Making sense of mental health


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In response to concerns around the high prevalence of depression and anxiety experienced by people with HIV, Positive Life NSW facilitated a community consultation with the aims of uncovering the mental health needs of people with HIV, their resilience or otherwise in meeting challenges & the barriers to achieving good mental health. Kathy Triffitt (Manager, Health Promotion, Positive Life NSW) outlines the consultation process and outcomes from the service provider forum which considered the implications for community & clinical interventions, care & support, advocacy & health promotion.

This presentation was given at the AFAO Positive Services Forum 2012.

Published in: Health & Medicine
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Making sense of mental health

  1. 1. BackgroundInvestigate – mental health needs of people with HIV barriers to achieving good mental health resilience or otherwise in meeting mental health challenges assessment and management of mental health to identify gaps in services.
  2. 2. Background Focus on depression and anxiety Consistent with a preventative approach - early detection and intervention - risk management approach Feed into the advocacy and health promotion work of Positive Life NSW Provide feedback on mental health needs to service provides.
  3. 3. Literature review People with HIV are more vulnerable to affective disorders, including depression Newman, C et al, (2009) found that gay men are at high risk of major depression, but that HIV status is not independently associated with major depression. - higher rates of depression associated with factors such as socio-economic hardship, isolation and withdrawal.
  4. 4. Literature ReviewFutures 6* reported that in the six months prior to completingthe survey: 27.0% of respondents said they had taken prescribed medication for depression This is considerably higher than the 5.9% of the Australian population who reported taking antidepressants in the (previous two weeks) in the national Health Survey [Australian Bureau of Statistics, 2009]. 28.6%) of respondents reported taking medicine prescribed for anxiety *Grierson, J, Poer, J, Pitts, M, Croy, S, Clement, T, Thorpe, R, and McDonald, K (2009) HIV Futures 6: Making Positive Lives Count, monograph series number 74, The Australian Research Centre in Sex, Health and Society, Latrobe University, Melbourne, Australia.
  5. 5. Futures data% PLWHA taking Rx in last 6 months for depression and anxiety 35 30 25 20 Depression 15 Anxiety 10 5 0 F1. F2. F3. F4. F5. F6. 1998 2000 2002 2004 2006 2009
  6. 6. Literature Review Cooke et al, [2004]; Whettan et al, (2008) found HIV- positive women were twice as likely as men to be depressed (this is also observed in women who do not have HIV) McDonald et al, (2005) Futures 4 reported: - 29.9% of women were diagnosed with depression - more than three quarters of these women reported HIV- related health conditions and 38.4% had been diagnosed with a major health condition other than HIV (the most common Hep C).
  7. 7. Other FactorsPsychosocial impact of living long-term with HIV: - loss of social networks (loss of relationships, friendships and social connectedness; inability to make new relationships) - “lost expectations and opportunities” (e.g. career,earning capacity, or sense of future or longevity, quality of life)
  8. 8. Other Factors Mid 1996 with the introduction of HAART options changed dramatically (“adjust to a new way of living with HIV”; dramatic shift from planning short term to planning for a future with little information on how to do this). We were given our lives back but no one told us how to plan long-term. Many struggled to rebuild their lives. Terry (GETTING ON WITH IT AGAIN - Living longer with HIV, Positive Life NSW, 2008) We have missed the crux of rebuilding people’s lives. That’s what got lost and a lot of people are stuck in limbo. They’re stuck because they’ve got financial constraints. They’re stuck because their financial constraints bring a smaller world to them […]. Michael (GETTING ON WITH IT AGAIN - Living longer with HIV, Positive Life NSW, 2008)
  9. 9. Other Factors Daily living for many people with HIV (in Australia) includes interactions between growing older (premature ageing) and living with other health conditions (e.g. cancer, diabetes, heart disease).
  10. 10. Community Consultation Twenty people with HIV: - 13 gay men (recruited via community media) - 7 women (recruited through NAPWA Women’s Network, Positive Life and ACON Women & Families Project) Semi-structured interviews Discussion group?
  11. 11. Demographic Profile Respondent Age:
  12. 12. Demographic Profile Where respondents live: - Men (inner city, Sydney; inner west and western suburbs) - Women (inner city Sydney, western suburbs, Central coast NSW) When respondents were diagnosed: - 2 women and 4 men diagnosed over the last 12 months – 3 years; with other participants diagnosed between 5-10 years and over 10 years.
  13. 13. Demographic Profile Employment: NB There is no significant difference between the profiles of people working, studying and those on the DSP in relations to the issues identified in the recommendations.
  14. 14.  Interplay between Mental Health and HIV Is HIV the cause or are there other factors (e.g. prior condition)? - 80% reported a pre-history of mental health (namely depression and anxiety) - 45% identified a family history of depressionIt was not clearly identified in this consultation what is HIV-related, pre-dates HIV or is exacerbated by an HIV diagnosis.
  15. 15. Recommendations Intervention, care and support (both in community (workforce) and clinical settings) Advocacy Health promotion Research
  16. 16. Recommendations Intervention, care and support (both in community (workforce) and clinical settings)(e) CommunityIncrease the capacity of peer support/ community developmentworkers and others working directly with HIV-positive people to: - recognise the signs and symptoms of depression and anxiety - develop ‘first aid strategies’ for dealing with mental health crisis - know where to get help and refer people
  17. 17. RecommendationsKey considerations: give priority to early intervention and preventive measures (develop a risk management approach) recognise the mental health impact of: - specific HIV-related events (including the experience of diagnosis, disease progression, starting treatments) - life changing events acknowledge the stigma of mental health, which may prevent people from speaking about mental health concerns and seeking treatment.
  18. 18. RecommendationsServices and programs need to: support a strengths-based approach to service provision: focus on individual strengths and resources to achieve goals rather than programs planned around ‘welfare dependency’ ensure they are providing a responsive peer support program for all people with HIV which not only addresses social isolation, but also other opportunities to build resilience support an integrated wellbeing framework (e.g. Healthy Life Plus or Poz Quest)
  19. 19. RecommendationsServices and programs need to: inform people on strategies to get the best outcomes from the therapeutic relationship: - finding the right therapeutic match - therapeutic goals provide information on where to get help/ financial support build individual capacities to talk about depression and anxiety address notable gaps in peer support (e.g. women and newly diagnosed)
  20. 20. RecommendationsServices and programs need to: support the sharing of personal strategies and perspectives on mental health ensure mental health and problematic drug (crystal)/ alcohol use) are positioned within an AOD framework provide more opportunities for people with HIV to participate in volunteering both within and outside of HIV.
  21. 21. Recommendations(b) Clinical Assess the capacity of GPs in high caseload clinics to provide ideal levels of mental health assessment and support (Newman et al, 2009) Tailor mental health interventions to meet individual needs Provide mental health screening at particular points in a person’s life, such as starting treatment, significant personal or family event, diagnosis of other health conditions. - A risk management approach may prevent anxiety and depression from escalating into something, which requires an intensive intervention.
  22. 22. Recommendations(b) Clinical Assess people diagnosed with heart disease or diabetes for depression and anxiety. While other illnesses are treated depression may not be accounted for or even diagnosed. Also unexplained depression may be accounted for if tested for diabetes or heart disease. - Weiser et al, (2004) found only 1 in 4 people have depression alone; a person diagnosed with depression has other chronic conditions. - Nearly 50% of people with asthma may also experience depression; and depression is twice as prevalent among people with diabetes as it is in the general population (Anderson et al, [2001])
  23. 23. RecommendationsTreatment for depression/ anxiety: 70% reported low treatment adherence (psychological interventions) Reasons included: - inappropriate referrals, finding the right support - poor understanding of the therapeutic relationship (goals etc) - confidentiality issues - ability to attend appointments (study, childcare, work commitments) - cultural appropriateness (lack of empathy) - financial constraints - finding a psychologist/psychiatrist who will bulk bill - loss of confidence in services
  24. 24. RecommendationsLow treatment uptake for depression/anxiety: 70% reported low treatment uptake (e.g. antidepressants) Reasons included: - libido - body shape change - pre-history of treatments (side effects)
  25. 25. Recommendations(c) Advocacy Advocate for Medicare funded Chronic Disease Management, GP Management Plans and Team Care arrangements to: - incorporate flexibility - provide mental health support, particularly access to affordable mental health providers, access to therapists and counsellors for less intensive or preventive/ maintenance of mental health conditions such as anxiety and other social disorders.
  26. 26. Recommendations(c) Advocacy Advocate for more flexible hours in clinical and community mental health settings Work with mental health professionals and governing bodies (Mental Health Association of NSW) to improve knowledge of and access to bulk billing services.
  27. 27. Recommendations(d) Health Promotion Raise awareness of the importance of early intervention and treatment Promote positive representations to reduce stigma and ‘normalise’ the experiences of mental health Produce resources on strategies to get the best outcomes from the therapeutic relationship: - finding the right therapeutic match - goals of psychological interventions (e.g. the differences between cognitive behavioural therapy, counselling and psychiatry) - identifying triggers for depression and anxiety - where to find support.
  28. 28. Recommendations(e) Research Advocate for social research on mental health (wellbeing and resilience,adapting and coping) and also the sociological and emotional impacts of HIV on women Surveys such as Futures tend to select out people with cognitive disability/mental health issues/psychiatric disability/ABI. We lack evidence re service gaps for people with mental health issues (and other cognitive impairments). There are few studies in Australia on positive mental health and its effects, including coping, competence, support seeking and adjustment.
  29. 29. Forum RecommendationsCommunity WorkforceOver the next two years what can be done to build the capacity of theworkforce? Main emphasis of discussion: build professional relationships between mental health and HIV services that are not only driven by acute care service needs but focus also on the emerging demand for prevention interventions and early response systems.
  30. 30. Forum RecommendationsCommunity Workforce Improve the capacity of the HIV worker to respond to mental health needs Improve the capacity of the mental health worker to respond to HIV needs Ensure service providers in both sectors have sufficient mental health and HIV expertise to assess and refer effectively.
  31. 31. Forum RecommendationsAdvocacyWhat are the key advocacy priorities? How do we achieve these over the next two years? Need to revisit the subject with a focus on systemic advocacy and policy as opposed to individual advocacy Medicare Funded chronic disease management: highly relevant for people ageing with HIV. Need for GP clinic practice nurses to be trained re the issues, including sensitivity training for dealing with older HIV positive people with mental health/cognitive problems.
  32. 32. Forum RecommendationsAdvocacy Mental health plans need to be coordinated with chronic disease management – all should be seamless and mainstreamed. Community organisations – AIDS Councils and PLHIV orgs - need to engage with Medicare Locals and Local Hospital Networks re service delivery issues for PLHIV. Confusion re mental illness/ABI/intellectual disability is rife in community orgs. Serious impacts re referrals and engaging with clients. Need for training/ professional development.
  33. 33. Forum RecommendationsAdvocacy In terms of management plans, probable that GPs and practice nurses coordinating care are unaware of range of services available – survey of practitioner/providers would be good. Consider relationships with mainstream services (e.g. CALD, Pozhets, rural, priority populations). How?
  34. 34. Forum RecommendationsClinicalWhat can be done to improve levels of mental health assessment, careand treatment to prevent depression and anxiety from escalating? All clinicians need to increase knowledge of mental health assessment GP referral database to mental health workers (including counsellors, clinical psychologists, mental health nurses and social workers) with experience working with PLWH/ A w/anxiety and/or depression. Database would also provide information re: Medicare mental health benefits/ Allied Health; Registration body (i.e. APS, ACA, PACFA, etc) and status (active, inactive, etc).
  35. 35. Forum RecommendationsClinical Time requirement for assessment (needs at least 1.5 hours), not a few questions at the end of a GP consultation Modify A1use of MSE section guidelines Flu MH r/v’s – clinicians; use of standardised assessment and psychometric testing (e.g. DASS, K10)
  36. 36. Forum RecommendationsClinical Online assessment/ treatment – CBT (e.g. Mood-gym (ANU); CRUFAD (SVH)) Work closely with the individual’s needs (ask what they want or what they think helps them?) Gap in services – requiring support not necessarily appropriate for MH services, particularly for socially isolated individuals Recovery model for HIV/mental health care Flexibility re contact with services (e.g. email; mobile)
  37. 37. We would like to thank all the people who have beenwilling to take part in this consultation. It is an act ofgenerosity on their part to share their experiences withus. For more information