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Managing Patients with complex social, mental health and addiction issues

HIV and mental health in Ontario

Dr. Evan Collins, a staff psychiatrist at the Immunodeficiency Clinic of the University Health Network, provided an overview of Ontario research about the mental health of people living with HIV. Mental health conditions are the most common comorbid conditions affecting people living with HIV. An OHIP database study (Kendall CE et al, 2014) showed that more than 40% of people living with HIV also live with a mental health condition.

Further information from the OHTN Cohort Study (Choi et al, 2016) suggests that there are significant gaps in mental health care for people living with HIV. In the cohort, 28% of people were identified as experiencing clinical depression. Within this group, 56% had past histories of depression, as well as high levels of recreational drug use and alcohol use. However, only 50% of depressed participants were receiving mental health services. (Note: This figure may be an underestimate, since the study could not measure the use of community mental health services at AIDS service organizations.) Most importantly, only 50% of those receiving mental health care were receiving care in accordance with accepted standards. LGBT individuals, people with low incomes, and non-native English speakers were less likely to receive adequate care.

Dr. Collins explained that experiences of childhood adversity (such as abuse, parental addiction, or family separation) have a profound effect on mental and physical health – particularly among people living with HIV. Surveys of OHTN Cohort Study participants show that 71% report more than one type of childhood adversity, compared to 49% of the general Canadian population. The more types of childhood adversity a person has faced, the higher the likelihood of depression. Increased levels of childhood adversity also reduce measures of overall mental health and health-related quality of life and correlate with reduced retention in care and other physical health measures.

Key message: Depression and other mental health issues are major challenges to the well-being of people living with HIV.

Strategies for treating depression among people living with HIV

Dr. Conall O’Cleirigh, a clinical psychologist at Massachusetts General Hospital, evaluates ways of treating depression among people living with HIV. His talk focused on three studies using cognitive behavioural therapy (CBT). CBT is a relatively short-term therapy that focuses on how a person is thinking and feeling, and teaches ways of responding to negative thoughts.

Dr. O’Cleirigh’s research began with studies on helping people adhere to antiretroviral therapy (ART). With collaborator Steven Safren, Dr. O’Cleirigh observed that one of the biggest predictors of a struggle with adherence was a diagnosis of depression. Accordingly, they developed a 12-session CBT course that was fully integrated into an ART adherence program. Dr. O’Cleirigh has since been involved in three studies of this therapy:

  • An initial trial of 45 men and women living with HIV and struggling with ART adherence who had been diagnosed with depression (Safren et al, 2009).
  • The Target trial of HIV-positive people diagnosed with depression who were also involved in substance abuse treatment for opioid addiction and receiving ART (Safren et al, 2012).
  • The Triad trial of diverse participants all of whom were HIV-positive, on ART, and diagnosed with depression; this trial compared CBT therapy to individualized supportive psychotherapy or the adherence intervention alone (Safren et al, 2016).

In all trials, CBT significantly increased adherence to ART by 10-12% and significantly decreased depression. Gains persisted for 12 months following completion of the therapy. The Target trial demonstrated that this type of therapy could be integrated into substance abuse therapy. The Triad trial revealed that this therapy was as effective as individualized therapy in reducing depression and improving adherence.

The CBT therapy used in these trials is described in a therapist’s guide and work book entitled Coping with Chronic Illness: A Cognitive-Behavioral Approach for Adherence. It is now being evaluated in other settings in Africa and the USA.

Key message: Cognitive behavioural therapy can help reduce depression and enhance adherence to antiretroviral therapy in people living with HIV.

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