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Depression and HIV: the search for solutions in sub-Saharan Africa

Many people with HIV worldwide suffer from some form of mental health problem. Although antiretroviral therapy has drastically reduced HIV-related death and disability, reports of the psychiatric repercussions of HIV are on the increase.

In high-income countries, HIV-related depression – the most common mental health problem in HIV-positive people – was recognised early in the AIDS epidemic as a factor that affects treatment outcomes. Yet it is only recently that the issue has drawn attention in sub-Saharan Africa, where research has found that one in three people living with HIV suffers from depression.

Addressing co-occuring mental health problems is a necessary step in controlling the HIV epidemic. But mental health care is not yet part of the HIV care package in the region.

There are efforts to change this. Our research shows how group psychotherapy interventions that give HIV-positive people emotional and social support, as well as positive coping and income-generating skills, can make a difference.

The link between mental health and HIV

There are biological, psychological and social factors that can cause mental health problems in HIV-positive people.

Depression is the natural grief response to being diagnosed with a terminal illness and to the chronic disability that may arise from it. It can also be linked to the stigma and discrimination associated with the illness. And new psychiatric symptoms and syndromes may occur as the virus affects the brain, or because of opportunistic diseases or treatment side-effects.

Mental health issues can, in turn, influence treatment outcomes. Co-morbid depression may affect motivation to seek HIV treatment or adhere to antiretroviral therapy.

It is also linked to behaviour that may facilitate HIV transmission. People commonly internalise negative stereotypes, expecting discrimination and devaluing themselves. This can interfere with their ability to choose sexual partners and negotiate safer sexual behaviour.

Depression is also associated with reduced coping capacity, poor HIV-related disease prognosis, diminished quality of life, greater social burden, increased health-care costs and higher mortality.

Our research focused on rural primary care settings in Uganda where we developed a group support psychotherapy model to treat depression. Group support psychotherapy treats depression by providing emotional and social support, and teaching positive coping and income-generating skills.

HIV-positive people suffering from depression met in eight weekly, gender-specific sessions. They were provided with information about depression and HIV. They were guided to share personal problems and taught problem-solving and coping skills. These included how to deal with anxiety and unhelpful ways of thinking, and basic livelihood skills.

High level of engagement

Unlike previous studies of group psychotherapy for depression in sub-Saharan Africa, the participants in our group support psychotherapy sessions were eager to engage in the process. More than 80% attended six or more sessions. Given the stigma attached to HIV and mental illness, this was surprising.

There are three possible explanations for the programme’s success.

First, the target community was involved in developing the model. Group support psychotherapy had also been piloted prior to the study and word had spread in the community about its benefits.

Second, trained mental health workers created a safe environment in which the participants could experience the therapeutic processes of group therapy. For example, facilitators reported that all participants had powerful cathartic experiences. Such catharsis has been shown to result in immediate and long-lasting change.

As sessions progressed, group members also began to provide feedback and support each other, during therapy and later, in their livelihood groups. The opportunity to help others, or altruism, has been shown to restore a sense of significance and increase self esteem.

Third, unlike other psychotherapeutic interventions, facilitators taught income-generating skills to mitigate poverty, which has been shown to be a potent risk factor for depression.

Addressing depression in resource-poor settings

Our study provides the first evidence of the success of this kind of group intervention in breaking the negative cycle of poverty and poor mental health in a resource-poor setting.

Six months after the programme ended, 80% of participants said the intervention had reduced their depression and motivated them to make positive changes in their lives.

Our findings also suggest that it is possible to roll out this kind of treatment in poorly resourced rural areas. Non-mental health professionals can be trained to deliver psychotherapeutic interventions in places where it is not possible to employ sufficient numbers of mental health providers.

The shifting of mental health-related tasks from health professionals to para-professionals or non-health professionals has been well-documented in non-HIV populations.

But less is known about the effectiveness of such a shift in HIV-positive populations. We now have evidence that specialists at tertiary institutions can train mid-level mental health workers to effectively deliver group support psychotherapy.

Looking ahead

We plan to expand capacity at primary health-care centres in three districts in northern Uganda. This will allow for depression diagnosis and treatment for those receiving HIV services at these centres.

Strategies include developing tailored training curricula to teach non-specialised health workers to recognise depression and employ group support psychotherapy in its treatment.

They will also be trained to teach lay health workers to deliver group support psychotherapy to HIV-positive people. This will make first-line treatments more widely accessible and sustainable.

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