Transcript Pilot Integration of Mental Health Services into HIV

Pilot Integration of Mental Health Services
into HIV Treatment in Ethiopia
Henok Legesse (1) , Teketel Tegegn (2), Degu Jerene (1) Marion McNabb (1),,
Solomon Zewdu(1), Samuel Tilahun (3) and Lawrence Wissow (4)
Author affiliations:
(1) Johns Hopkins University, Technical Support for the Ethiopian HIV/AIDS ART Initiative, Ethiopia
(2) Amanuel Specialized Mental Health Hospital, Addis Ababa, Ethiopia
(3) The US Centers for Disease Prevention and Control, Addis Ababa, Ethiopia
(4) Johns Hopkins University, Baltimore, MD
ICASA
2011 Addis Ababa Ethiopia
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Outline
•Background
•Aim and Objectives
•Process and context
Preliminary results
•Key Challenges
•Suggested solutions
Conclusions and way forward
•Acknowledgements
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Background
Mental illnesses;
• lead to disability and
premature death
•leading NCD in terms of burden
•PLHIV are at increased risk and
vice versa
However, few ever receive the
Depression
Demoralization
Substance abuse
Cognitive impairment
Mental illness
HIV
Impulsivity
Depression
Demoralization
Substance abuse
Cognitive
impairment
treatment they need
Little experience with integrated
care
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Figure 1: Mental illness and HIV
Glenn J. Treisman, MD, PhD
Johns Hopkins University
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Prevalence in Survey Population
Psychiatric Disorder, %
.
HIV cases
General Population
Major depression
36.0
16.6
Dysthymic disorder
26.5
2.5
General anxiety disorder
15.8
5.7
Panic disorder
10.5
4.7
Any drug or alcohol use
disorder
50.1
27.8
In Ethiopia - 46.7% HIV cases has common mental disorder•The average prevalence of mental disorders in Ethiopia is 15% for
adults and 11% for children.
Bing EG, et al. Arch Gen Psychiatry. 2001;58:721-728. ;Burnam MA, et al. Arch Gen
Psychiatry. 2001;58:729-736. ; Kessler RC, et al. Arch Gen Psychiatry. 2005;62:617-627.
Deribew et al. BMC Infectious Diseases 2010, 10:201
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Aim and objectives
Overall aim: improve the survival, well-being, and function of children and
adults living with HIV
Objectives
1. Introduce integrated care for mental illness and HIV
2. Adapt and standardize an HIV focused mental health training package
3. Promote a desire among HCWs for further training and greater levels
of mental health treatment expertise
4. Complement ongoing mental health services in Ethiopia
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Process and context
Setting: Ethiopia (see Map)
Initiated by Hopkins University in 2009
Part of CDC/PEPFAR supported
comprehensive HIV program by JHU
TSEHAI *
Collaborative, US and Ethiopia experts
*Technical Support for the Ethiopian HIV/AIDS, ART Initiative (TSEHAI)
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The training material development
Began with a review of the literature
Combined with discussion, visits to sites
Consultative process of review and vetting
Draft materials reviewed by a team of
15 experts including :
Psychiatrists, clinical psychologist
Neurologist, HIV experts, and GPs
From:
Addis Ababa University
Amanuel Specialized Mental Health Hosp.
Other major psychiatric clinics
The Ministry of Health
The World Health Organization
Johns Hopkins University
These experts vetted on the materials
and their comments were incorporated
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The training approach, participants, and process
•Pilot TOT trainings were organized
•With CTS training for TOTs
•Other basic off site and onsite trainings
were also held
The training approach
Basically a 5-days training
Participatory approach Mainly
based on
Discussions
Case studies
role plays
 clinical attachment
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Approach to diagnosis, grouping into clusters
We opted for an approach that tried to be comprehensive across mental health conditions
in contrast to targeting a few priority conditions
Grouping problems into clusters (see next slide)
Our approach had multiple stages based on four main principles :
1. Try to set up an environment in which patients are most likely to express their concerns;
2. If those concerns fall into a recognizable cluster, start the diagnostic/treatment outline
appropriate to that cluster
3. If not, use a very abbreviated version of a mental status exam to identify a cluster with
which to start
4. Finally, depending on the severity of the patient's problems, provide a preliminary
treatment and make a follow-up plan. This plan can include getting consultation.
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Cluster name
Mental health conditions included
Thought ,perception and Conditions presenting with psychosis, including schizophrenia and
memory problems
mania; dementia; delirium
Depression
Major depression, adjustment disorder, suicidal ideation
Anxiety and psycho
trauma
Generalized anxiety, specific phobias, acute and post-traumatic
stress disorders (including response to child and intimate partner
violence)
Alcohol, tobacco and khat use/abuse
Substance use and
abuse
Epilepsy
Behavior and
developmental issues
among children
Living with HIV
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Evaluation of a first seizure, chronic seizure disorders, status
epileptics
Oppositional and conduct disorders, office evaluation for cognitive
and developmental problems among school-aged children
Demoralization, stigma, disclosure, functional problems that may
be associated with HIV-associated neurocognitive dysfunction
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Site selection and implementation
 Selected four
sites, in consultation with Regional Health Bureaus
and Ministry of Health
Two in Addis Ababa and two in Southern Region
Supplied job aids and registries
Regular mentoring by project staff and psychiatrists
Arranged HIV training for mental health professionals
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Preliminary results
ART provider uptake seems good
Varies with patient load and working conditions
Listening more, counseling more, less likely to refer low mood or anxiety
problems
MH treatment seems “natural” after training in HIV-related counseling
Led to activation of existing mental health nursing staff already on site
Previously not well linked to ART or working partly in non-MH role
Taking more visible role at site
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Common mental health problems detected/treated
Depression and anxiety, sleep problems, substance abuse most likely
to receive counseling and/or medication from ART providers
Seizures and psychotic symptoms more likely to be referred to MH
nurse
Locally important variations: home-brew alcohol in South, drug use
in city
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Key challenges
•Staff rotation and turnover
•Very high patient volume, short visits, over-burdened staff
•Need for brief screening tool
•Need for simpler and integrated M&E
•Lack of privacy for patient encounters
•Inconsistent availability of medications
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Suggested solutions
Develop Better “job aides” to cue providers and support patient counseling
Work with supply agencies to address medication issues
Work on strategies that improve staff retention and minimizes staff rotation
Work on developing simpler and integrated M and E tool
Continue supportive supervision/ongoing education
Build capacity MH nurses for both ongoing consultation and on-site trainings
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Conclusions and way forward
•Integrating mental health services into HIV care is feasible
•Participatory training approaches seem to work well
•Targeting a broad cluster of mental health conditions is more helpful than
focusing on a few conditions
•Non-specialists were able to detect and treat/refer common disorders
•The process led to re-activation of existing mental health nursing staff
•Address the challenges, share lessons and scale up
Acknowledgements
We would like to thank the following stakeholders for their key role in this
project
Federal Ministry of Health of Ethiopia
Addis Ababa University, School of Medicine, Department of Psychiatry
Amanuel Mental Specialized Hospital
Health Bureaus of Addis Ababa and Southern Region
Hospitals: ALERT, Zewditu Memorial, Arba Minch, and Yirgalem
JHU-CCP/AIDS Resource Center, Ethiopia
The World Health Organization, Ethiopia
This project was implemented under the CDC Cooperative Agreement to the
Johns Hopkins University School of Public Health ( CoAg # 5U2GPS000858)
funded by the PEPFAR.
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