Integration of mental health services into HIV healthcare facilities among Thai adolescents and young adults living with HIV

Abstract

Introduction To assess the burden of depression, anxiety and suicidality; and to determine the impact of integrated mental health and HIV services on treatment outcomes among Thai adolescents and young adults living with HIV (AYHIV). Methods A multicentre prospective cohort study was conducted among AYHIV (15 to 25 years), and age‐ and sex‐matched HIV‐uninfected adolescents and young adults (HUAY). The Patient Health Questionnaire 9‐item (PHQ‐9) and Generalized Anxiety Disorder 7‐item scales (GAD‐7) were used as screening tools for depressive and anxiety symptoms respectively. History of lifetime and recent suicidal ideations/attempts were ascertained. Elevated mental health screening scores were defined as having either significant depressive symptoms (PHQ‐9 ≥9), significant anxiety symptoms (GAD‐7 ≥10) or suicidality (lifetime; and recent [within two weeks]). Participants meeting these criteria were referred to psychiatrists for confirmatory diagnosis and mental health services. Follow‐up assessment with PHQ‐9 and GAD‐7 was performed one year after psychiatric referral. Results From February to April 2018, 150 AYHIV and 150 HUAY were enrolled, median age was 19.0 (IQR:16.8 to 21.8) years and 56% lived in urban areas. Among AYHIV, 73% had HIV RNA <50 copies/mL, and median CD4 count was 580 (IQR:376 to 744) cells/mm 3 . At enrolment, 31 AYHIV (21%; 95%CI:14% to 28%) had elevated mental health screening scores; 17 (11%) significant depressive symptoms, 11 (7%) significant anxiety symptoms and 21 (14%) suicidality. Seven AYHIV (5%) had all three co‐existing conditions. These prevalences were not substantially different from HUAY. Urban living increased risk, whereas older age decreased risk of elevated mental health screening scores ( p < 0.05). All AYHIV with elevated mental health screening scores were referred to study psychiatrists, and 19 (13%; 95%CI: 8% to 19%) had psychiatrist‐confirmed mental health disorders (MHDs), including adjustment disorder (n = 5), major depression (n = 4), anxiety disorders (n = 2), post‐traumatic stress disorder (n = 1) and mixed MHDs (n = 4). One year after psychiatric referral, 42% of AYHIV who received mental health services demonstrated an absence of significant mental health symptoms from the reassessments, and 26% had an improved score. Conclusions With the significant burden of MHDs among AYHIV, an integration of mental health services, including mental health screenings, and psychiatric consultation and referral, is critically needed and should be scaled up in HIV healthcare facilities.

Depression and Anxiety in Youth and Young Adults Living with HIV: Frequency and Associated Factors in Thai Setting

“…9,10 In contrast to the data in youth, there have been few studies addressing depression and anxiety in adolescents living with HIV in the Asian context, with only one recent study revealing the rate of significant anxiety or depressive symptoms at about 20%, comparable to the rate in HIV-uninfected youths. 11,12 Due to differences in stage of psychosocial development between youth and young adults, they have distinct developmental tasks resulting in unique psychological and emotional changes. We hypothesized that the factors associated with depression and anxiety in the two groups may be different.…”

HIV and suicide risk across adolescence and young adulthood: an examination of socio‐demographic, contextual and psychosocial risk factors for attempted suicide in a longitudinal cohort of ageing adolescents affected by HIV living in the New York City Area

“…Prior study of suicidality among AYA affected by HIV has found mixed results. Three cross‐sectional studies (from England, Thailand and South Africa) found no differences in suicide risk between AYALPHIV versus those without HIV [ 46 , 47 , 48 ]. Conversely, our current and prior work in the United States [ 50 ] and a study in Rwanda [ 49 ] both found an increased risk of suicidality among AYALPHIV compared to AYA without HIV.…”

“…A recent systematic review and meta‐analysis found that PLWHIV, median age 39 years, had a 100‐fold higher risk of dying by suicide than people not living with HIV, with an even higher risk for people living with AIDS [ 42 ]. While risk factors for suicide in the general population of AYA are well documented [ 43 , 44 , 45 ], few studies have examined suicidality among AYA living with perinatally acquired HIV (AYALPHIV) [ 24 ] and those that have showed mixed results [ 46 , 47 , 48 , 49 , 50 ].…”

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

“…Professional support where available 70 Support healthcare staff to understand mental health 20 PRIME modelintegration into primary care 71 Routine mental health screening 72,73 Training healthcare staff in mhGAP 71,74 Simple, immediate referral systems 20 There is emerging evidence of effective mental health services for adolescents living with HIV, including interventions promoting positive mental health or preventing onset of mental health disorders, as well as broader-based psychosocial interventions aimed at promoting adherence and engagement in care, or reducing risk behaviour. 75 A meta-analysis of psychosocial interventions for adolescents living with HIV found small to moderate benefits on improved adherence to ART and reduced viral load, 76 leading to a strong recommendation of psychosocial interventions for young people living with HIV.…”

“…104 In contexts where there are human and financial resources available, integrating screening and referral to qualified psychiatric or psychological staff is beneficial for adolescents experiencing acute distress. 70 However, there remains severe scarcity of psychiatric professionals in the Global South, with 1.4 mental health workers per 100,000 population in the African WHO region, 105 and almost no adolescent inpatient wards. An innovative model for addressing this generalised mental health gap is the Programme for Improving Mental health care (PRIME), 71 which worked with Ministries of Health and partners in five LMIC countries to integrate evidence-based psychosocial and pharmacological interventions into existing primary healthcare systems, using WHO's mhGAP guidelines.…”