South African Journal of Psychology 2008 Freeman 489 500

7/28/2019 South African Journal of Psychology 2008 Freeman 489 500

1/13

http://sap.sagepub.com/South African Journal of Psychology

http://sap.sagepub.com/content/38/3/489The online version of this article can be found at:

DOI: 10.1177/008124630803800304

2008 38: 489South African Journal of PsychologyMelvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar and Kevin Kelly

Mental Disorder in People Living with HIV/Aids in South Africa

Published by:

http://www.sagepublications.com

On behalf of:

Psychological Society of South Africa

can be found at:South African Journal of PsychologyAdditional services and information for

http://sap.sagepub.com/cgi/alertsEmail Alerts:

http://sap.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://sap.sagepub.com/content/38/3/489.refs.htmlCitations:

What is This?

- Sep 1, 2008Version of Record>>

by guest on March 26, 2013sap.sagepub.comDownloaded from
http://sap.sagepub.com/http://sap.sagepub.com/http://sap.sagepub.com/http://sap.sagepub.com/content/38/3/489http://sap.sagepub.com/content/38/3/489http://www.sagepublications.com/http://www.psyssa.com/http://sap.sagepub.com/cgi/alertshttp://sap.sagepub.com/cgi/alertshttp://sap.sagepub.com/subscriptionshttp://sap.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://sap.sagepub.com/content/38/3/489.refs.htmlhttp://sap.sagepub.com/content/38/3/489.refs.htmlhttp://sap.sagepub.com/content/38/3/489.refs.htmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://sap.sagepub.com/content/38/3/489.full.pdfhttp://sap.sagepub.com/http://sap.sagepub.com/http://sap.sagepub.com/http://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://sap.sagepub.com/content/38/3/489.full.pdfhttp://sap.sagepub.com/content/38/3/489.refs.htmlhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsReprints.navhttp://sap.sagepub.com/subscriptionshttp://sap.sagepub.com/cgi/alertshttp://www.psyssa.com/http://www.sagepublications.com/http://sap.sagepub.com/content/38/3/489http://sap.sagepub.com/


2/13

Menta l d isorder in peop le l i v ing w i th HIV/A idsin Sou th A f r i caMelvyn FreemanHuman Sciences Research Council, 30 Urania S treet, Observatory, J ohannesburg, 2198,South Africamfreeman@ telkomsa.netNkulu leko NkomoHuman Sciences Research CouncilZuhayr KafaarSAAVI S ocio-behavioural Group, Department of Psychology, University of StellenboschKevin K el lyCADRE, Institute for Social and Economic Research, Rhodes UniversityWe investigate the prevalence of mental disorder in people living with HIV/AIDS in a developingcountry context and examine the relationship between the presence of mental disorder and variousindependent variables. Nine-hundred HIV positive people were interviewed in 18 recruitment sitesacross five provinces in South Africa, using a cross-culturally validated diagnostic instrument anda structured socio-demographic andhealth information questionnaire. Prevalence of mental disorderwas established using the Composite International Diagnostic Interview (CIDI). Chi-square, Fischerexact test, and binary logistic regression examined the relationship between mental health disordersand demographic characteristics, disease stage, CD4 count, and whether the person was on anti-retroviral treatment. A number of respondents (43.7%) were found to have a diagnosable mentaldisorder. Depression was the most common disorder (11.1% major and 29.9% mild depression),followed by alcohol abuse disorder (12.4%). The presence of mental disorder was significantlyassociated with gender, employment status, having children, and the clinical stage of the disease.Gender and the stage of disease were the best predictors of mental disorder. Rates of mentaldisorder were substantially higher inpeople living withHIV/AIDS than generally found in populationsin developing countries and similar to HIV positive groupings in developed countries. Viral impactson the brain, psychological reactions, and social conditions all contributed to the higher prevalencerates. Mental health interventions need to become a central part of comprehensive HIV/AIDS support, care, and treatment programmes.Keywords : CIDI; developing countries; HIV/AIDS; mental disorder prevalence; South Africa

Mental health interventions have not been systematically integrated into HIV/AIDS care and treatment programmes in most developing countr ies , including South Afr ica (Baingana, Thomas &Com blain, 20 05 ; Freema n, Patel , Col l ins & Ber tolote, 20 05 ; W H O , 200 5) . Important reasons forthis include a lack of resources for effective interventions, poor identification of mental disorders,st igma, and a low priorit isation of mental health in health services generally. Crit ically, planners ofHIV/AIDS programmes in developing countr ies appear unaware of HIV/AIDS/mental heal th co-morbidity and of the possibil i t ies of improving physical and mental health through mental healthintervent ions . Mo st mental heal th prevalence s tudies wi th people l iving wi th HIV /AIDS (PLH A) havebeen conducted in developed countries with low level or concentrated epidemics and caution isneeded when extrapolating findings to developing countries with generalised epidemics (Freeman,2 0 0 4 ; Freema n & Thorn, 2006 ) . For exam ple, co-morbidi ty of mental disorder and HIV infect ion canbe exp ected to be inflated in countries wh ere a relatively large numb er of infections are through intravenous drug use, since there is already co-morbidity of substance abuse and mental disorder. On the

Psychologic al Socie ty of South Afr ica . Al l r igh ts reserved . South Afr ican Journal of Psychology , 38(3) , pp . 489-500I SSN 0 0 8 1 - 2 4 6 3

mailto:[email protected]://sap.sagepub.com/http://sap.sagepub.com/http://sap.sagepub.com/mailto:[email protected]


3/13

Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin Kellyother hand correlations have been found between poverty and mental health and this could be influential in inflating me ntal disorder prevale nce in deve loping c oun tries. Altho ugh som e research onthe prevalence of mental disorder in people infected with HIV in developing countries has beenconducted, this is l imited. Collins and colleagues summarised 30 studies concerned with the mentalhealth conse que nce s of HIV in deve loping c ountries an d the result show s clearly the dearth of reliableand recent mental heal th epidemiology data (Col l ins, Holm an, Freeman & Patel , 200 6). The mentalhealth status of peo ple infected with HIV has consistently been found to be higher than in com mu nityor clinic samples, ranging from relatively mild distress to full-blown mental disorder (Catalan, 1999;Ferrando in Courno s & Forstein, 2000; Green & Smith, 200 4; Maj et al, 1994a; Maj et al., 1994b;Tostes, Chalub & Botega, 2004). Reasons for this have been found to include pre-morbid mentalcon dition s, the effects of the virus on the central nervous system, the psych olog ical im pacts of l ivingwith HI V/ AI DS , side-effects of me dication , and results of social st igma and discrim ination ( Freem anet al., 2005). Mood disorder has been found to be the most frequent psychiat r ic compl icat ionassociated wi th people wi th HIV/AIDS (Col l ins et / .2006; McDaniel & Blalock, 2000;) . Ameta-analysis of USA studies found that the prevalence of depression amongst HIV posit ive peoplewas twice that of the general populat ion (Ciesla & Roberts , 2001). Previous prevalence studies inSouth Africa, though using relatively sm all sample sizes, have found rates of depr ession of up to 60 %(Els et al., 1999; Olley et al., 2004) .

Anxiety disorders in studies in the USA range from negligible to around 40% (McDaniel &Blalock, 2000). Anxiety has been l inked to certain 'milestones' such as init ial diagnosis, firstopportunist ic infection, declining CD4 count and the onset or progression of AIDS defining i l lness.Antiretroviral therapy (ART) is reported as having had a significant impact on mental health whereit has been.available although there are as yet no published studies in developing countries based onobject ive assessment of mental heal th. Important ly, wi th AR T the progressive neuro psychiat r ic p rogression of HIV is diminished. Cross-sectional as well as longitudinal studies have shown decreaseddepression for peop le on AR T (Low -Beer, Yip, O 'Shaune ssy, Hogg & Montan er, 2000 ; Alciati et al.,2 0 0 1 ; Judd et al., 2000; Rabkin, Ferrando, Lon, Sewel l & McElhiney, 2000; Kal ichman, Graham,Luke & Aust in, 2002).

How ever a diagnosis of HIV rem ains "profoundly dist ressing" for most people (Green & Smith,2004) . People tend to have "new" problems and anxiet ies around forming relat ionships, disclosureand demoralisation around side-effects of medication.

The influence of factors such as age, gender, marital status, educ ation, soc io-eco nom ic statu s,CD4 count, stage of disease, whether the person has children, how the person was infected onmental health have received some attention in previous studies but have never been integrated andsystematically documented in a developing country context. In the present study we report thefindings of a mental health prevalence study of 900 HIV posit ive people in five provinces in SouthAfrica and examine characterist ics of co-morbidity, with a view to understanding the need to addressmental heal th needs in HIV care, support and t reatment intervent ions.M ETHODSC ontext of studyAt the t ime of study, HIV p reva lence in South Africa wa s estimated to be 1 6.2% in the 15 to 49 yea rsage group (Shisana et al., 2005).Whi le some people were receiving ant i -ret rovi ral therapy (ART),widespread roll-out of treatment was not in place.MeasuresThe Wo rld Mental Heal th Survey version of the Wo rld Heal th Organizat ion Com posi te In ternat ionalDiagnostic Interview (CIDI) was uti l ised. The CIDI is a comprehensive, fully structured diagnostic

49 0by guest on March 26, 2013sap.sagepub.comDownloaded from
http://sap.sagepub.com/http://sap.sagepub.com/http://sap.sagepub.com/


4/13

Mental disorder in people with HIV/AIDSinterview for the assessment of mental disorder. I t has been designed to be used by trained non-clinicians and (in i ts full form) diagn oses 22 m ental disord ers am ong st adults from different cultures(Kessler & stn, 2004). As part of the WHO world mental health survey the CIDI was adapted andused in 28 countries including South Africa. The South African adaptation which was translatedinto six local languag es for the WM H study, was uti lised here. Five langua ge versions we re used i .e. ,English, Zulu, Xhosa, Sotho and Afrikaans. For the purposes of this study 14 diagnostic categorieswith potential bearing on HIV/AIDS as well as screens for psychosis and personality disorder andsuicidali ty were measured. The DSM diagnostic system of categorisation of mental disorders wasut i l i sed. In addi t ion a socio-demographic ques t ionnaire was des igned and adminis tered and whereinformation was available and with the permission of the interviewee, relevant data (CD4 count anddisease stage) was extracted from patient f i les.P r o c e d u r eEthical clearance for the study was obtained from the Human Sciences Research Council (SouthAfrica) Ethics Committee. Interviewers previously trained in interview techniques received a furtherfour-day training, including administration of the CIDI, by an instructor accredited in i ts use.Participants were recruited either at public clinics, HIV 'wellness ' centres run by governmentor through non-government organisations of people l iving with HIV. There were 18 recruitment si tesacross five provinces in South Africa and a quota of 900 HIV posit ive people aged 18 years or olderwas targeted.The samp ling procedure w as purposive and des igned to cover rural, semi-urban, and urban pe ople who at the t ime of the interview were using or who would normally use the public health system.Subjects were stratif ied into four categories of length of t ime since HIV status was discovered.Consecutive attendees presenting at facil i t ies were approached to participate. Those that agreed tobe interviewed (less than 1% refused) were given opportunity to ask any further questions about thestudy before their signed informed consent was obtained.

Interviews were conducted in the hom e language s of par t icipants and took betwee n one and threehours depend ing on the num ber o f ' s ki p ' ques t ions in individual interviews and the abi li ty of par t ici pants to readily respond to questions.R E S U L T SS o c i o - d e m o g r a p h i c s o f p a r t i c i p a n t sTable 1 summ arises key socio-demo graphic character is tics of respond ents . The higher propor t ion ofwomen found in this sample is in part accounted for by the higher rates of women infected with HIVin the South Afr ican popu lat ion 2 0.2% of wom en com pared wi th 11.7% of men in the 1 5 - 4 9 yearage group (Shisana et al., 200 5) and by the fact that more w omen are diagnosed becau se they aretested at ante-natal services and referred for HIV interventions. Eighteen percent of participants(N = 160) were enrolled in anti-retroviral treatment programmes.Know l edge o f H I V pos i t i ve s t a t usEleven percent of respondents (N = 100) had found out that they were HIV posit ive within the 4months prior to the interview. Thirty-one percent (N = 270 ) had know n between 4 months and 1 year ,3 1 % (N = 271) between 1 and 3 years and 27 % (N = 237) had been diagnosed posit ive for longer than3 years. The majority of respondents believed that they had been infected by their regular partner(62%), while 2 1 % said i t had been throu gh sex wi th a casual par tner , 2% (13 responde nts) had beenraped and 12% did not know how they had been infected. Three percent bel ieved they had beeninfected through other means such as blood transfusions or drug use.

The majority of respondents found out their status after fall ing i l l (52%, N = 350), following

491



5/13

Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin KellyTable 1. Socio-demographic character is t ics of respondents

Variable Category n (% )GenderAge

Marital status

Schooling

Employment statusSocio-economicstatusChildren

MaleFemale18-2526-3536-45Over 45SingleMarried/living w ith partnerWidowedOtherNever been to schoolSome schooling but did not completeCompleted schoolingPost-school qualificationEmployed (full time)Employed (part time)UnemployedNot eno ugh m oney for basic things such as food and clothesMon ey for these basics but have no resources beyond seeingto basic needsHave most things but no luxury goods orHave childrenDo not have childrenmoney for holidays

235 (26)662 (74)144 (16)452(51)229 (26)68(6)651 (73)181 (20)37(4)27( 3 )28(3)668 (74)161(18)43( 5 )75(9)125 (14)685 (77)608 (68)264 (30)14.(2)690 (78)195 (22)

routine antenatal testing (19%, N= 128) or after disclosure of a positive status by a partner or child(1 2 %, N = 87). Few respondents (11%) found out that they were posit ive simply because they wereconcerned and went for testing. The staging of the disease and the CD4 count was obtained frompatient records and was available for 80% and 40% of people, respectively. Of these 30% (N = 213)were in s tage 1 (asymptomat ic-normal act ivi ty) , 37% (N = 235) in stage 2 (symptomatic-normalactivity), 22% (JV= 140) in stage 3 (bedridden 50% during last month). Fifty-five percent of people where CD4 count was available(180) had counts above 200 whi le 45% (146) had counts below 200.P revalence of mental disorde rThe prevalence of mental disorders found are given from Table 2. Given the dearth of theory regarding the prevalence of mental disorders in PLHAs, the research team chose to init ially test associations with Chi-square and Fischer exact test analysis (for bivariate factors). These were conductedwith regard to the presence of: (1) any diagnosis of mental disorder; and, as the two disorders withthe substantially highest prev alenc e rates; (2) depre ssion (major and minor com bine d); and (3)alcoh olabuse (depe nden t variables), in relation to the following variab les: gen der, age, marital status, education, emp loym ent, househ old situation, pro vinc e, prov ider type, whe ther the person had children , agesof children, period since knowledge of posit ive status, how infected, how status discovered, diseasestage, CD4 count and whether the person was on antiretroviral treatment.

Of the 14 variables measured, significant associations (p < 0.05) were found only with respectto the six variables included in Table 3. As is evident in Table 3, strong associations were apparentbetween the presence of any disorder and both employment status and stage of disease as well as49 2



6/13

Men tal disorder in peop le with HIV/AIDSTable 2. Prevalence of mental disorder

Mental disorderMajor depressive disorderMild depressive disorderAlcohol dependenceAlcohol abuse disorderDrug dependenceDrug abuseGeneral anxiety disorderPost Traumatic S tress DisorderPost Traumatic Stress Disorder (Event HIV )Panic disorderSocial PhobiaIntermittent Explosive DisorderAgoraphobiaPresence of any mental d isorder

Male n (% )24(10.2)66(28.1)13 (5.5)54 (23)3(1.3)12(5.1)2 (0.9)012(5.1)02 (0.9)9 (3.8)0116(49.4)

Female n (% )76(11.5)

202 (30.5)13(2)58 (8.8)05 (0.8)2 (0.3)6 (0.9)26 (3.91 (0.2)6 (0.9)26 (3.9)0273 (41.2)

Total (% ) (CI)11.1(9 .05-13.8)29 . 9 ( 26 . 91 - 32 . 89 )2 . 9 ( 1 . 8 - 4 . 0 )12.4(10.25-14.55)0.3 (-0.06 - 0.66)

1.9(1.01-2.79)0.4 ( -0 .01-0 .81)0 . 7 ( 0 . 16 - 1 . 24 )4 . 2 ( 2 . 89 - 5 . 51 )0 .1 ( -0 .11-0 .31)0 . 9 ( 0 . 28 - 1 . 52 )3 . 9 ( 2 . 72 - 5 . 28043 . 7 ( 40 . 46 - 46 . 94 )

Table 3. Variables associated wi th mental disorderVariable Presence of any disorder Depression Alcohol abusedf n df dfEmploym ent status 885Clinical stage of the 724diseaseGender 897

5 20.37** 8623 28.29*** 7241 4.31*

1 5.34*3 19.95***

Whether havechildrenHow infectedHow statusdiscovered

885 1 4.71"884 15.85*

862

897

884893

1 4.34*

1 32.08***

22.87*20.81"

/>


7/13

Melvyn Freeman, Nkululeko Nkom o, Zuhayr Kafaar, Kevin Kelly

Presence of any mentaldisorderDepressionAlcohol abuse disorder

Stage of diseaseGenderStage of diseaseGenderEmployment status

p< 0.0001p < 0.05p< 0.0001p< 0.001p < 0.05

Table 4. Associations with mental disorder from logistic regression analysesDependent variable Predictor Significance Odds Ratio (CI)

3.203 (1.784-5.752)1.599 (1.088-2.349)2.783 (1.574-4.920)2.932 (1.782-4.825)1.976 (1.020-3.830)

The following trends are evident in the Chi-square and logistic regression analyses: Ma les were more l ikely than females to exp erience a me ntal disorder. This is a reflection ofhigher levels of alcohol abuse, as in all other categories of mental disorder there was no significant gender difference. Unem ployed people were mo re l ikely to exper ience any mental disorder and have par t icularsusceptibil i ty to depression and alcohol abuse compared to their employed counterparts.Tho se with children were mo re l ikely to experien ce a me ntal disorder, but having children is notrelated to the presence of any particular disorder. Origin of infection is associated with both depression and alcohol use . Re spo nde nts who did notknow how they were infected were more l ikely to suffer from depression than those who knew no matter how they were infected. On the other hand a diagnosis of alcohol abuse was associated with having been infected by a casual partner. W ay of learning about status wa s related to alcoh ol abuse only. Res pon den ts who fell i ll andwent for care were more l ikely to have alcohol abuse disorder than those who found out fromother means .There was a strong relationship between stage of i l lness and presence of any disorder, and withdepression. Depression increased with stage of i l lness. Ge nde r (more men than wo me n) and stage of disease (later stage) we re the only significant pre dictors of the presence of any mental disorder in the regression analysis.

DISCUSS IONThe prevalenc e rate of 43 .7% of mental disorder amongst PLHAs confirms findings from extensivestudies in developed countries and more l imited data from developing countries that there is a highprev alen ce of mental disorde r in peo ple with HIV /AI D S. Results of the first 14 coun tries of the W orldMental Heal th Survey (WMHS), which used the same ins t rument as this s tudy to measure theprevalence of mental disorder (although each country had adaptations) and which included six less-developed countries, found prevalence rates of mental disorder in the general population (12 monthprevalence) ranging f rom 4 .3% to 26.4% (W HO , 200 4) . In the South Afr ican vers ion of the WorldM enta l Hea lth Survey that used the same version of the Comp osite Interna tional Diag nostic Interviewas this study (with the exception of the versio n of the instrument used for measu ring Pos t-Trau ma ticStress Disord er) an overall prev alenc e of me ntal disorder of 16.5% was found (Williams et al, 2008) .W hile i t is spuriou s to attr ibute the differences found in these two studies directly to the prese nce ofHIV, as socio-demographic var iables were not control led for and i t i s unknown how many peopleliving with HIV were also part of the general population survey, the differences in the findings ofthese studies suggest that PLHA are at least two and a half t imes more l ikely to suffer from mentaldisorder as mem bers of the general populat ion. Prev ious s tudies on the prevalence of mental disorderin South Africa using similar samples in terms of socio-economic status and rural/urban mix (though49 4



8/13

Mental disorder in people with HIV/AIDSusing different instruments) have found rates of mental disorder ranging from 10% - 25% (Parry,1996; Parry & Swartz,1997; Thorn, Zwi & Reinach, 1993) .Disease stage, time since diagnosis and CD4 countThere is conflicting evidence internationally of the association between HIV disease progression andmental disorder . Ickovics and col leagues concluded that depress ive symptoms are associated wi thlower CD4 count and disease progression but Evans and colleagues found no such relationship(Ickovics et al., 2001 ; Evans et al., 2002). In a South African study Moosa and colleagues found nosignificant differences in the CD4 counts between depressed and non-depressed groups of HIVinfected individuals (Moosa, Jeenah & Vorster, 2005).

In the prese nt study no significant asso ciations we re found betw een C D4 c ount and the pre senc eof a mental disorder. However, a very strong association was found between depression and diseasestage (p < 0.00 0). Wh ile in stages one and two men tal disord er differences were minim al (39.8 % and3 7 .2 %, respectively), at stage three 49.7% of respondents had identifiable psychiatric diagnoses andat stage four 68 .8% of respo nde nts were diagn osed with menta l disorde r. No a ssociations were foundbetween length of t ime since hearing the diagnosis and mental disorder.Reasons why the CD4 count did not correlate with the stage of disease as may have been anticipated and why correlations were found between mental disorder and the stage of disease but not CD4count are not clear. I t is possible that because CD4 counts are not tangible and visible, people withlower levels did not have negative psychological responses whereas their deteriorating conditionassociated with disease stage was experien ced as highly distressing. Further research is need ed.

GenderThere is l i t t le evidence of gender differences in population prevalence of mental disorder in generalpopulat ions (WHO, 2001) . However i t has been consis tent ly found that more women exper iencedepression and anxiety disorders than men with ratios varying from 1.5:1 to 2:1 whilst menexpe rience m ore alcoho l use disorders (W H O , 20 01 ). In this study me n indeed had significantly m orealcohol related problems than women. However levels of depression and anxiety were not significantly different. A num ber of authors hav e pointed to the significant add itional Stressors, and resultantdepre ssion, that wom en living with HIV /AID S ex perien ce, given their family and career roles (Mo rriso n et al., 2002; Hackl, Somlai, Kelly & Kalichman, 1997). So i t is somewhat surprising to find thatmen and women do not differ in the rate of mood disorders. I t is of interest to note that Olley andcolleagues made similar f indings (Olley et al., 2004) .

It may b e the case that HIV has physio logical effects leading directly to depre ssion in which casemen and wom en may be expecte d to be affected equally. Alternatively me n living with HIV m ay findit more difficult to cope with deteriorating physical health leading to heightened susceptibil i ty todepression. More research is needed to explain this uncharacterist ic f inding.Socio-economic statusThe relationship betw een so cio-ec ono mic status and mental disorder could not be tested as there weretoo few participants who were not impoverished to use as a basis of comparison. I t is important tonote however that poverty and HIV prevalence are related in South Africa and poverty and mentalhealth disorder are also related (Hargreaves, 2002; Shisana et al., 2005; Patel & Kleinman, 2003) .It may be the case that elevated mental disorder in HIV posit ive people is a consequence of povertyrather than HIV specifically. However given that previous mental health prevalence studies havefound m uch low er rates than this study, it is l ikely that pov erty and H IV/A IDS exac erbate each otherand in combination impact on mental health, leading to levels of mental disorder higher than areexpected for other very po or people or those who have HIV but are not poor. This vicious circle ma y

49 5by guest on March 26, 2013sap.sagepub.comDownloaded from


9/13

Melvyn Freeman, Nkululeko Nkomo , Zuhayr Kafaar, Kevin Kellybe further exac erbated by the possibil i ty that po or me ntal health can be both a risk factor for po vertyand HIV/A IDS as wel l as a consequence of both of them. High unemploym ent , HIV/A IDS and mentalhealth are l ikely intertwined in a complex cycle of mutual causali ty.E m p l o y m e n t s t a t u sMental disorder was significantly correlated with unemployment status. However i t was not possibleto ascer tain the extent to which unem ploym ent fol lowed rather than prece ded the per son 's HIV s tatus .However, given the official rate of 26% national unemployment (Statist ics South Africa, 2005), andthe 77% of unemployed people in this study, i t seems likely that highly elevated levels of unemployment in the sample, resulted from il l-health related to HIV disease and possibly employment discriminat ion.C h i l d r enPL HA who have children were significantly mo re l ikely to have a me ntal disord er than those that didnot (p< 0.05). I t seems likely that problems associated with caring for children and worries aboutwha t will happ en to the children with disease progressio n and possibly de ath, results in raised men taldisorder. Fu rtherm ore, f inancial burden of caring for children and associa ted stress ma y lead to higherlevels of disorder.H ow i n f ec t edPeo ple who though t they had beco me infected through a casual sexual partner were more l ikely tohave an alcohol abuse disorder than people infected through a long term partner or other ways (p


10/13

Mental disorder in people with HIV/AIDSA combinat ion of physiological and psychological reasons for the raised prevalence is highlyprobable .It is important also to bear in mind other reasons for the raised prevalence of mental disorder inPLHAs, bes ides physiological and psychological causes . Pover ty and adverse l iving condi t ions aswell as poor access to care and support services are themselves risk factors for poor mental healths tatus (Patel & Kleinman, 2003) .L i m i t a t i o n s o f s t u d yA direct control group was not available for comparison. Though the results can usefully be contrasted with those from the South African version of the World Mental Health Survey, as the sameinstruments were used and the trainers who trained the field workers were consistent, socio-demographic var iables were not control led. Moreover given the high prevalence of HIV in SouthAfrica i t could also be expected that a number of people assessed as part of the general populationsurvey were also HIV po sit ive. Hen ce while the prev alen ce rates found in this study are substantiallyhigher this cannot be di rect ly at t ributed to HIV/A IDS . Mo reove r though the s tudy des ign at temptedto determine the 'direction' of whether a mental disorder preceded or followed HIV infection, veryfew subjects had ever (before or after knowing they were infected with HIV) been diagnosed with amental disorder and hence determining what came first was not possible. Finally, while the studycovered the majority of South Africa's provinces and the recruitment of subjects was done in placeswhere most HIV infected people in South Africa are seen for care and support , this study is notrepresentative of all HIV infected people in South Africa.C O N C L U S I O NTh is study shows that peo ple l iving with HIV /AID S have high rates of me ntal disorde r. Thou gh therewere no matched controls in this study the prevalence found is substantially higher than previousgeneral population or clinic-based studies in South Africa (including studies of populations withsimilar socio-economic status). This f inding in a developing country with a generalised epidemic(HIV pre vale nce a mo ngst 15 - 49 year olds at 16.2% at t ime of study) replicates the findings of Bingand colleagues in a large scale study in the USA using the same instrument, where HIV prevalencewas 1% at the t ime of study (Bing et al., 2001; Karon et al., 1996; Shisana et al., 2005) .

In many developed countr ies mental heal th care and t reatment have been integrated into H IV/AID S prog ram me s. It is strongly suggested that sufficient eviden ce is now a vailable that the same isneeded in developing countr ies . Though the causal relat ionships between mental heal th and HIV/AIDS are complex, mental disorder is as much a direct corollary of the HIV epidemic as a numberof the well established physical consequences and requires similar attention. Moreover, adherenceto ART is l ikely to be affected by mental health status (Ammassari et al., 2004; Uldal l , Palmer ,W hetten & Me llins, 20 04 ). I t is crucial that governm ents, non -gove rnm ental o rganisation s and serviceplanners recognise mental health as a significant part of the HIV/AIDS pandemic and that relevantcare, suppor t and t reatment programmes become par t of the HIV/AIDS response.A C K N O W L E D G E M E N T SW e thank all the members of the HIV/AID S round table discuss ion group who reco mm ende d that thisresearch be condu cted and ass is ted in the init ial conceptual isat ion. W e thank Profs Dan M khize andSoraya Seedat for conducting the CIDI training and Sharon Kleintjes for training the interviewers.We also thank the research co-ordinators in the four provinces, the interviewers, and the clinics andnon-gov ernmen tal organizat ions where interviews were co nducted. F inal ly we thank al l those l ivingwith HIV /AIDS who al lowed themselves to be interviewed especially regarding emot ional ly sensitive issues.

497



11/13

Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin KellyR E F E R E N C E SAlciati, A., Starace, F., Scaramelli, B., Campaniello, M., Adriani, B., Me lleado, C , & Cargnel, A. (2001).Has there been a decrease in the prevalence of mood disorders in HIV-seropositive individuals sincethe introduction of combination therapy? European Psychiatry, 16, 491-496.Am massan, A ., Antinori, A., Aloisi, M.S., Trotta, M.P., M urri, R., Bartoli, L., d'Arminio Mo nforte, A., Wu,A.W., & Starace, F. (2004). Depressive symptoms, neurocognitive impairment, and ad herence tohighly active antiretroviral therapy among H IV infected p ersons. Psychosomatics, 45, 394-402.Baingana, F., Thomas, R., & Comblain, C. (2005). HIV/AIDS and Mental Health. World Bank.Bing, E.G., Burnam, M.A., Longshore, D., Fleishman, J.A., Sherbourne, C A ., L ondon, A.S ., Turner, B.J.,Eggan, F., Bechman , R., Vitiello, B., Mo rton, S .C , Orlando , M., Bozzette, S.A., Ortiz-Barron, L., &Shapiro, M. (2001). Psychiatric disorders and drug use am ong human immunodeficiencyvirus-infected adults in the United States. Archives of General Psychiatry, 58, 721-728.Catalan, J. (1999). Mental health and HIV infection. Psychological and psychiatric aspects. London: UCLPress.Ciesla, J.A., & Rob erts, J.E. (200 1). Meta-analysis of the relationship between H IV infection and risk fordepressive disorders. American Journal of Psychiatry, 158, 725-730.Collins, P.Y., Holman, A.R., Freeman, M ., & Patel, V. (2006). Wh at is the relevance of Mental health toHIV/AIDS Care and treatment Programs in Developing Countries? A systematic review. AIDS, 20 ,1571-1582.Cou rnos, F., & Forstein, M, (eds) (2000). What mental health practitioners need to know abo ut HIV and

AIDS. San Francisco: Jossey-Bass.Els, C , Boshoff, W., Scott, C , Strydom, W., Joubert, G., & Van der Rust, E. Psychiatric co-morbidity inSouth African HIV/AIDS. South African MedicalJourna l, 89, 992-995.Evans, D.L., Ten Hav e, T.R., Dou glas, S.D., Gettes, D.R., Morrison, M., C hiappini, M.S., Brinker-Spence ,P., Job , C , Mercer, D.E., Wang, Y.L., Cruess, D., Dub e, B., Dalen, E.A., Brown, T., Bauer, R., &Petitto, J.M. (20 02). Depression, distress and viral load, CD8 T lymphosytes and na tural killer cells inwomen w ith HIV infection. American Journal of Psychiatry, 159, 1752-1759.Ferrando, S. (2000 ). Diagnosis and Treatment of HIV-Associated N eurocognitive D isorders. In Courno s, F.,& Forstein, M (eds). Wha t mental health practitioners need to know about HIV and AIDS {pp. 25-35).San Francisco: Jossey-Bass.Freeman, M., Nko mo, N., Ntlabati, P., & Kleintjes, S. (2005). Coping psychologically with being HIVsero-positive: A study of lived experience, supporting and agg ravating actors. Cape Town: HSRCPress.Freeman, M ., & Thorn, R. (2006). Serious Mental Illness and HIV/AID S. South African Journal ofPsychiatry, 12, 2-8.Freeman, M.C ., Patel, V., Co llins, P.Y., & B ertolote, J.M. (200 5). Integrating mental health in globalinitiatives for H IV/AIDS . British Journal of Psychiatry, 187, 1-2.Freeman, M . (2004). HTV/AIDS in developing countries: heading towards a mental health and consequ entsocial disaster? South African Journal of Psychology, 34, 139-159.

Green, G., & Smith, R. (2004). The psychosocial and healthcare needs of HIV positive people in the UnitedKingdom: a review. HIV Medicine, 5, 5-46.Hackl, K., Som lai, A., Kelly, J., & Kalichman, S. (1997). Wom en living with HTV/AIDS: The D ualChallenge of being a Patient and Caregiver. Health and Social Work, 2 2(1), 53-62.Hargreaves, J.R. (200 2). Socio-economic status and risk of HIV infection in an urban popu lation of Kenya.Tropical Medicine and International Health, 7, 793-802.Ickovics, J.R., Ham burger, M.E., Vlahov, D., Schoe nbaum, E .E., Schuman, P., Boland, R.J., & Moo re, J.(2001). Mortality, CD4 cell count decline, and depressive symptoms among HIV seropositive women.Longitudinal analysis from the HIV E pidemiology research Study. Journal of the American MedicalAssociation, 285, 1466-1474.Judd, F., Cockram, A.M ., Komiti, A., Mijch, A.M ., Hoy, J.( & Bell, R. (2000). Depressive symptomsreduced in individuals with HIV/AIDS treated with highly active antiretroviral therapy: a longitudinalstudy. Australian and New Zea land Journal Of Psychiatry, 3 4, 1105-1 111.Kalichman, S. C , Graham, J., Luke, W., & Austin J. (2002). Perceptions of health care among persons living

498by guest on March 26, 2013sap.sagepub.comDownloaded from


12/13

Mental disorder in people with HIV/AIDSwith HIV/AIDS who are not receiving anti-retroviral medications. AIDS Patient Care and STDs, 16,233-240.Karon, I , Rosenburg, P., MsQuillan, G., Khare, M., Gwinn, M., & Petersen, L. (1996). Prevalence of HIVinfection in the United States, 1984 to 1992. Journal of the American Medical Association, 276,126-131.Kessler, R.C ., & stn, T.B. (2004). The W orld Mental H ealth (WMH ) Survey Initiative Version of theWorld Health Organization (W HO) C omposite International Diagnostic Instrument. InternationalJournal of Methods in Psychiatric Research, 33, 93-121.Low-Beer, S., Yip, B., O'Shaunessy, M., Hogg, R., & M ontaner, J. (2000). Adherence to triple therapy andviral load response. Journal of AIDS, 23 , 360-361.Maj, M., Janssen, R., Starace, F., Zaudig, M ., Satz, P., Sughondabirom, B ., Luabeya, M.A., Riede l, R.,Ndetei, D., & Calil, M. (1994a).WHO neuropsychiatric AIDS study, cross sectional phase I. Studydesign and psy chiatric findings. Archives of General Psychiatry, 51, 39-49.Maj, M., Satz, P., Janssen, R., Zaudig, M ., Starace, F., D'Elia, L., Sughondabirom, B., Mussa, M., Naber,D., & Ndetei, D. (1994b ). WHO neu ropsychiatric A IDS study, cross-sectional phase II.Neuropsychological and neurological findings. Archives of General Psychiatry, 51 , 51-61.

McD aniel, S & Blalock, A. (2000). Mood and anxiety disorders. In: Cournos, F., & Forstein, M. (eds). Whatmental health practitioners need to know abou t HIV and AIDS (pp. 51-56). San Francisco:Jossey-Bass.Moosa, Y., Jeenah, F., & Vorster, M. (2005). HIV in South Africa Depression and C D4 C ount. SouthAfrican Journal of Psychiatry, 11, 12-15.Morrison, M .F., Petitto, J.M., Ten Have, T., Gettes, D.R., Chiappini, M .S., Weber, A.L., Brinker-Spence,P., Bauer, R.M., Do uglas, S.D., Evans, D.L. (2002). Depressive and anxiety disorders in women withHIV infection. American Journal of Psychiatry, 159, 789-796.Olley, B.O., Gxamza, F., Seedat, S., Theron, H ., Stein, D., Taljaard, J., Reid, E., & Reuter, H. (2004 ).Psychopathology and coping in recently diagnosed HIV/AID S patients the role of gender. SouthAfrican Journal of Psychiatry, 10, 21-24.Parry, C , & Swartz, L. (1997). Psychiatric epidemiology. In Katzenellenbogen, J.M ., Joubert, G., & Abd oolKarim, S.S. (eds). Epidemiology. A manua l for South Africa (pp. 230-286). Cape Town: OxfordUniversity Press.Parry, C. (1996 ). A review of psychiatric epidemiology in Africa: strategies for increasing v alidity w henusing instruments cross-culturally. Transcultural Psychiatric Research Review, 33, 173-188.Patel, V., & Kleinman, A. (2003). Poverty and common mental disorders in developing c ountries. Bulletinof the World Health Organisation, 81, 609-615.Rabkin, J., Ferrando, S., Lon, S., Sewell, M., & McElhiney, M . (2000). Psychological effects of HAART : a2-year study. Psychosomatic Medicine, 62, 413-422.Prince, M., Patel, V., Saxena, S ., Ma j, M., Ma selko, J., Phillips, M.R. & Rah man, A . (2007). No healthwithout mental health. Lancet, 370, 859-877.Shisana, O., Rehle, T., Simbayi, L.C., Parker, W., Zuma, K., Bhana, A., Conn olly, C , Jooste, S., & Pillay,V. (2005). South African National HIV Prevalence, HIV Incidence, Behaviour and CommunicationsSurvey, 2005. Cape Town: HSRC press.Statistics South Africa. (2005). Labour orce Survey. Pretoria: Government P rinter.Thorn, R., Zwi, R., & Reinach, S. (1993). The prevalence of psychiatric disorders at a primary care clinic inSoweto, Johannesburg. South African Medical Journal, 83 , 650-653.Tostes, M.A., Chalub, M ., Botega, N.J. (2004). The qu ality of life of HIV-infected women is associated w ithpsychiatric m orbidity. AIDS Care, 16, 177-186.Uldall, K., Palmer, N., Whetten, K., & Mellins, C. (2004). Adherence In People Living with HIV/AIDS ,Mental Illness and Chemical Dependency A Review of The Literature. AIDS Care, 16, s71-s96.Williams D.R., Herman A., Stein, D J. , Heeringa S.G., Jackson P.B ., Moom al H. & Kessler R.C. (2008).12-Month Men tal Disorders in South Africa: Prevalence, Service Use and Demo graphic Co rrelates inthe Population-Based South African Stress and Health Study. Psychological Medicine, 38, 211-220.

World Health Organisation. (2005). Mental Health and HIV/AIDS. Organisation and Systems Support forMental Health Interventions in Anti-retroviral (A RV) Therapy program mes. Johannesburg: W HO.499



13/13

Melvyn Freeman, Nkululeko Nkomo , Zuhayr Kafaar, Kevin KellyWorld Health Organisation. (2001). Th e World Health Report 2001. Mental Health: New Understanding,

New Hope. Geneva: World Health Organisation.World Health Organisation. (200 4). World Mental Health Su rvey Consortium. Prevalence, Severity, andUnmet Need for Treatment of Mental Disorders in the World Health organisation World m ental HealthSurveys. Journal o f the American M edical Association, 291, 2581-2590.

500by guest on March 26, 2013sap.sagepub.comDownloaded from

South African Journal of Psychology 2008 Freeman 489 500

Documents

Transcript of South African Journal of Psychology 2008 Freeman 489 500