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Musisi hiv and mental illness Presentation Transcript

  • 1. HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE
    Prof SegganeMusisi MD, FRCP (C)
    Department Of Psychiatry
    Makerere University
    Global Mental Health and Africa: Opportunities, Challenges And Collaborations
    Mbarara University Of Science And Technology: Aug. 15th - 16th , 2011
  • 2. ACKNOWLEDGEMENTS
    MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY
    MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES
    ACADEMIC ALLIANCE FOR AIDS CARE AND PREVENTION IN AFRICA (IDI)
    UGANDAN MENTAL HEALTH ASSOCIATIONS:
    UPA, APRO, MHRC
    RESEARCH GRANTS:
    ARCH, ROGERS FOUNDATION, SIDA/SAREC, USHS, FULBRIGHT COMMISSION, NIH.
    MY STUDENTS AND RESEARCH COLLEAGUES
  • 3. Overview of Presentation:
    • History of The Epidemic
    • 4. Progression Of The Epidemic
    • 5. Nature & Extent Of The Mental Health Problems
    • 6. Etiological Factors
    • 7. The Mental Health Problems Themselves
    • 8. Mental Health Problems Of HIV/AIDS In Children
    • 9. Orphans & Caregivers
    • 10. HIV/AIDS Among The Elderly
    • 11. The Challenge
    • 12. Conclusions & Recommendations: The Future & Research
  • THE HIV/AIDS BURDEN IN AFRICA
  • 13. PROGRESSION OF THE EPIDEMIC
    STARTED IN EARLY 1980s
    MOST ADVANCED & SERIOUS IN SUB-SAHARAN AFRICA
    LINKED TO POVERTY & LOW EDUCATION
    70% OF PLWHA ARE IN SUB-SAHARAN AFRICA
    RAN ITS COURSE, PEAKED & HAS SHOWN DIFFERENT WAVES.
  • 14. OBSERVATIONS :THE AIDS WAVES
    EARLY 1980s – FIRST AIDS CASES
    INFECTION WAVE
    Very physically ill – Wasted : SLIM Disease
    Early death
    Ran mad : Bewitched (From Tanzania)
    DEATH WAVE
    Widows
    Orphans
    ORPHAN WAVE
    COTOs
    HIV-positive Adolescents
    THE ELDERLY HIV- POSITIVE WAVE
    Effect of HAART
    Effect Of Ageing
  • 15. IK Missoula 2003
  • 16. IK Missoula 2003
  • 17.
  • 18. WHY MENTAL HEALTH PROBLEMS OCCUR
    • SEXUAL DISEASE
    • 19. FAMILY DISCORD
    • 20. STIGMA (Cultural, Religious & Disease Factors)
    • 21. INFECTIOUS
    • 22. FATAL
    • 23. CHRONIC
    • 24. DISFIGURING
    • 25. INVOLVES CNS
    • 26. OPPORTUNISTIC INFECTIONS
    • 27. THE MEDICATIONS
  • THE MENTAL HEALTH PROBLEMS
    PREMORBID PSYCHOPATHOLOGY & ADJUSTMENT PROBLEMS
    PSYCHO-BEHAVIORAL PROBLEMS : PERSONALITY & SUBSTANCE ABUSE DISORDERS
    THE ANXIETY DISORDERS
    THE HIV-RELATED AFFECTIVE (MOOD) DISORDERS
    THE HIV-RELATED PSYCHOTIC PROBLEMS
    THE HIV-RELATED COGNITIVE DISORDERS
    HIV/AIDS MENTAL HEALTH PROBLEMS IN CHILDREN
    HIV-POSITIVE CHILDREN
    HIV-NEGATIVE ORPHANS
    FAMILY PROBLEMS
  • 28. PERSONALITY DISTURBENCES
    PREMORBID ADJUSTMENT
    PERSONALITY CHANGES
    Antisocial behaviour
    Irresponsibility
    Giving up
    Irresponsible Sexuality
  • 29. PREMORBID PSYCHOPATHOLOGY
    • PRE-EXISTING PSYCHIATRIC ILLNESS
    • 30. Bipolar Disorder
    • 31. Depression
    • 32. Schizophrenia
    • 33. MR
    • 34. SUBSTANCE ABUSE
    • 35. Alcohol
    • 36. Marijuana, Mayirungi
    • 37. IV Drug use
    • 38. HIGH HIV RISK POPULATIONS
    • 39. 4H Club
    • 40. Prostitutes & Truck drivers
    • 41. Professionals
    • 42. The War-affected
  • SUBSTANCE ABUSE->Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
    SUBSTANCE PERCENTAGE
    Alcohol 48
    Cigarettes 9
    Marijuana 2
    Pipe smoking 6
    None 35
    Partner Use Of Alcohol 54
  • 43. ADJUSTMENT AND REACTIVE DISORDERS
    ACUTE STRESS DISORDER
    SUICIDALITY
    ADJUSTMENT DISORDERS:
    WITH ANXIOUS MOOD
    WITH DEPRESSED MOOD
    WITH DISTURBENCE OF CONDUCT
    WITH MIXED FEATURES
  • 44. ANXIETY DISORDERS
    • ANXIETY DISORDER : ACUTE & RECURRENT
    • 45. Kuganda S. (2011): M.Med (Psychiatry)Thesis, MakCHS
    • 46. 6% Psychological Distress
    • 47. 27% Panic Attacks & 27% Generalised Anxiety Disorder
    • 48. Factors associated with Anxiety Disorder:
    • 49. Unemployment
    • 50. Poor Social Support
    • 51. Oral Thrush
    • 52. Other researchers : AIDS Phobia, OCD, PTSD
  • MOOD DISORDERS
    HIV-RELATED DEPRESSION
    Akena’s et al: (2010) African Journal Of Psychiatry Vol 13, No. 1
    F>M. Later age of onset. Negative F/H. Cognitive impairment. Widowhood.
    Frequent medical illnesses. Severer sleep & appetite disturbances. Guilt.
    HIV-RELATED MANIA
    Nakimuli et al: (2006) Am J. Psychiatry 163: 8
    F>M. Later age of onset. Severer Psychosis. Negative F/H. Cognitive impairment. Widowhood
    BIPOLAR DISORDER
    Nakimuli et al: (2008) Psychosomatics Journal 49:530-534
    Early onset: Bipolar I; Later onset: Secondary mania. Quick Rx response
  • 53. PSYCHOTIC DISORDERS
    HIV-RELATED PSYCHOSIS:
    SCHIZOPHRENIA-LIKE
    PARANOID
    MIXED
    PRE-EXISTING SCHIZOPHRENIA
    Maling’s et al: (2011). AIDS Care, Vol. 23, No. 2, 171-178
    18.4% Prevalence in First Episode Psychosis
    F>M; Older age of onset (41 years). More auditory, visual & tactile hallucinations. More likely to remit.
  • 54. DISORDERS OF COGNITION
    HIV-RELATED DELIRIUM
    • Musisi et al.(2000): Makerere Medical School Journal
    40% of all C-L referrals. Early & Late stages of HIV/AIDS. Se/CRAG
    • Lukwago et al. (2009): Delirium. In Psychiatric Problems Of HIV/AIDS & Their Management In Africa. Fountain Publishers
    38% of ER attendees at Mulago Hospital. Associated with OI & ↑ viremia
    HIV ASSOCIATED DEMENTIA
    • Sactor N, Nakasujja N et al (2005): AIDS 19:1367-1374
    • 55. The IHDS can screen for Dementia in Uganda/Africa
    • 56. 31% prevalence Of Dementia: Cognitive impairment ↓ with HAART
    • 57. Question: When can we start HAART with CD4>200?
    • 58. Nakasujja N et al(2010): BMC Psychiatry 10:44
    Depressive & cognitive symptoms are common in HIV/AIDS
    Cognitive deficits persist despite adequate treatment for depression
  • 59. FAMILY PROBLEMS
    FAMILY TYPES AND CONJUGAL PRACTICES AMONG HIV-POSITIVE CLIENTS IN CARE IN UGANDA IN PAST 5 YEARS :
    ->Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
    • 64% started off in monogamous unions, 28% got separated/divorced & 10% got into visiting unions with many partners,
    • 60. About 60% reported having lived in visiting unions at one point
    • 61. Conclusion: Considerable flexibility, variability and volatility of marital unions & conjugal practices among the HIV-positive TASO clients.
    DISCORDANT COUPLES: 10%
    WIDOWS: 30%
  • 62. DISCLOSURE OF HIV STATUS TO PARTNERLwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
  • 63. CONDOM USELwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
  • 64. PARTNER VIOLENCELwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
  • 65. HIV/AIDS AND CHILDREN(Wakhweya et al, 2000)
     ORPHANS
    >2 million orphans in Uganda, >14 million orphans in Africa
    Types of Orphans:
    Paternal orphans (50%)
    Double orphans (30%)
    Maternal Orphans (20%)
    Classification Of AIDS orphans:
    HIV-positive orphans
    Have all the neuropsychiatric disorders, many physical illnesses associated with HIV + psychosocial problems
    HIV-negative orphans
    Have only psychosocial problems but no major disorders
    Elderly caretakers (30%), Child-headed households
    Poverty , Prostitution, Destitution
    Mother to Child Transmission (25%)
    >90% of infected children are orphans
    >60% are in stage III of illness by 10 yrs
  • 66. Impact Of HIV/AIDS-related Parental Death On Children’s Home Life
    Increased:
    . Poverty
    . Household responsibility
    . Psychosocial distress
    . Vulnerability to sexual & labor abuse,
    . Stigma and isolation
    . Hunger and malnutrition
    Reduced:
    - Access to food
    - Access to health services
    - Access to school
    - Material goods : clothes, supplies
    - Guidance, protection, and love
  • 67. HIV-POSITIVE CHILDREN IN UGANDA.- Musisi S & Kinyanda E (2009), East African Medical Journal, Vol. 86, No. 1, 16-24.
    • 97% of HIV-infected children are orphans
    • 68. >60% are in stage III of illness by 10 yrs
    • 69. They manifest major psychiatric disorders:
    Anxiety (58.5%) Depression,(42%)
    • Psychosis, (30%) Mania(7.2%)
    • 70. HPE (4.9%) Seizures(8.5%)
    • 71. Suicide, (20%) , Substance Abuse(4.8%).
    • 72. Somatoform Disorders (18.3%)
    • 73. No special services are available for them.
  • The Psychosocial Problems Of Orphans (Musisi S, Kinyanda E, Nakasujja N (2007): African Health Sciences Journal, 7(4)
    Emotionally needy - No parental guidance, love, support, & security
    Are materially deprived, abused, isolated & neglected,
    Lack Scholastic materials, Fees, Food, Clothing , Shelter, Protection.
    Need Role Modeling , Social & Vocational Skills, and Health care.
    Live in poverty & exploitation (labor, sexual, spiritual & inheritances)
    Lack family & individual counseling / support & community resources
    Live in Fear & engage in survival behavior: –
    Girls: Prostitution, early marriage or domestic help for girls.
    Boys: Street children with petty theft , child labor & fights
    Have high rates of depression, suicide & substance abuse
  • 74. Shelter: To build and/or repair houses
  • 75. Psycosocial Interventions: Care, Protection, Schooling
  • 76. School fees, scholastic materials and LUNCH
  • 77. Contributing to a better future…
  • 78. ELDERLY HIV-POSITIVES
    NEW WAVE & INCREASING
    ↑ STIGMA, ↑ SECRECY, with ↓ACCESS TO CARE
    MULTIPLE PHYSICAL & MENTAL PROBLEMS
    HAD Vs OTHER DEMENTIAs
    SEXUALLY ACTIVE, SOME HAD >1 PARTNER. FEW USED CONDOMS
    ↓ SOCIAL SUPPORT, ARV TREATMENT & CLINIC ATTENDANCE
    NO SPECIFICALLY TARGETTED PREVENTION PROGRAMS
    LAXITY OF CARE ON THE PART OF THE STAFF
  • 79. Elderly HIV-Positive Age Distribution (N=118)
  • 80. The Elderly Sexual Behavior (last 3 months)
  • 81. The Challenge in Uganda’s HIV/AIDS Care:
    • The Apparent Absence of Mental Health In HIV-care
    • 82. Problems In Scaling Up HIV care
    • 83. Adherence, Resistance: The role of mental health
    • 84. Substance Abuse
    • 85. Unreached Pockets Of Infection : The marginalised (Trauma , mentally ill, elderly, orphans, disabled)
    • 86. Interventions & Policy
  • THE FUTURE
    INTEGRATED MENTAL HEALTH IN ALL HIV CARE PROGRAMS.
    ORPHAN POLICY :
    ORPHAN REGISTRY, LEGAL PROTECTION,
    CHILDRENS AID SERVICES
    LEGAL GUARDIANSHIP,
    SCHOOLING,SHELTER, HEALTHCARE FOOD SECURITY
    CHILD PSYCHOLOGY & GUIDANCE,
    DISTRICT RUN FAMILY SERVICES
    RESEARCH INTO :
    HIV CARE FOR THE ELDERLY,
    LONG TERM OUTCOME OF MENTAL HEALTH DISORDERS OF HIV/AIDS,
    COMFOUNDING MENTAL HEALTRH FACTORS IN HIV CARE IN UGANDA,
    TASK SHIFTING APPROACH TO MENTAL HEALTH CARE PROVISION IN PHC HIV SETTINGS
    ADHERENCE & MENTAL HEALTH SERVICES IN HARD TO REACH HIV COMMUNITIES
    MENTAL HEALTH INITIATIVES TO ENHANCE THE SCALE UP OF HIV CARE IN UGANDA
  • 87. LETS MOVE FORWARD IN PARTNERSHIP