Victimisation in the life of persons with severe mental illness in Uganda: a pluralistic qualitative study.

INTRODUCTION: Victimisation of persons with severe mental illness is recognised as an urgent global concern, with literature pointing to higher rates of violent victimisation of persons with severe mental illness than those of the general population. Yet, for low income countries, there is a huge gap in the literature on the risk, character and victims' in-depth experiences of victimisation of persons with severe mental illness. We explore the lived experiences and meanings of victimisation of persons with severe mental illness in Uganda, and discuss their implications for care of the mentally ill. METHODS: A pluralistic qualitative study was undertaken to explore victimisation among patients with severe mental illness. Patients who had suffered victimisation were purposively sampled from Butabika National Referral Mental Clinic and Masaka Regional Referral Hospital, following confirmation of symptom remission. In-depth interviews were held with 18 participants, comprising 13 females and 5 males from low to moderate socioeconomic status. Interpretative phenomenological analysis and thematic content analysis were conducted. RESULTS: Victimisation was exhibited in three main forms: (a) psychological, expressed in attitudes towards mentally ill family members as valueless and dispensable, and stigmatisation, (b) physical, as manifested in beatings, indoor confinement and tethering mostly by family members and (c) sexual victimisation, particularly rape. Also observed were victim's various responses that pointed to the negative impact of victimisation, including a heightened risk of suicide, social withdrawal, a sense of hatefulness and a predisposition to more victimisation. CONCLUSION: The family environment plays a predominant role in perpetrating victimisation of the mentally ill in some sub-Saharan African contexts such as Uganda. We propose a holistic framework for mental health interventions, incorporating biomedical but notably also social determinants of mental health, and targeted at improving familial relationships, social support and a sense of belongingness both within the family and the broader community.

Physical and psychiatric comorbidities among patients with severe mental illness as seen in Uganda.

While psychiatric and physical comorbidities in severe mental illness (SMI) have been associated with increased mortality and poor clinical outcomes, problem has received little attention in low- and middle-income countries (LMICs). This study established the prevalence of psychiatric (schizophrenia, bipolar affective disorder, and recurrent major depressive disorder) and physical (HIV/AIDS, syphilis, hypertension and obesity) comorbidities and associated factors among 1201 out-patients with SMI (schizophrenia, depression and bipolar affective disorder) attending care at two hospitals in Uganda. Participants completed an assessment battery including structured, standardised and locally translated instruments. SMIs were established using the MINI International Neuropsychiatric Interview version 7.2. We used logistic regression to determine the association between physical and psychiatric comorbidities and potential risk factors. Bipolar affective disorder was the most prevalent (66.4%) psychiatric diagnoses followed by schizophrenia (26.6%) and recurrent major depressive disorder (7.0%). Prevalence of psychiatric comorbidity was 9.1%, while physical disorder comorbidity was 42.6%. Specific comorbid physical disorders were hypertension (27.1%), obesity (13.8%), HIV/AIDS (8.2%) and syphilis (4.8%). Potentially modifiable factors independently significantly associated with psychiatric and physical comorbidities were: use of alcohol for both syphilis and hypertension comorbidities; and use of a mood stabilisers and khat in comorbidity with obesity. Only psychiatric comorbidity was positively associated with the negative outcomes of suicidality and risky sexual behaviour. The healthcare models for psychiatric care in LMICs such as Uganda should be optimised to address the high burden of psychiatric and physical comorbidities.

Prevalence, correlates for early neurological disorders and association with functioning among children and adolescents with HIV/AIDS in Uganda.

BACKGROUND: The aim of this study was to determine the prevalence of neurological disorders and their associated correlates and relations with clinical and behavioural problems among children and adolescents with HIV/AIDS (CA-HIV). METHODS: This study involved a sample of 1070 CA-HIV/caregiver dyads who were evaluated at their 6-month follow-up visit as part of their participation in the longitudinal study, 'Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)'. Participants completed an extensive battery of measures that included a standardized DSM-5- referenced rating scale, the parent version (5-18 years) of the Child and Adolescent Symptom Inventory-5 (CASI-5). Using logistic regression, we estimated the prevalence of neurological disorders and characterised their associations with negative clinical and behavioural factors. RESULTS: The overall prevalence of at least one neurological disorders was 18.5% (n = 198; 95% CI, 16.2-20.8). Enuresis / encopresis was the most common (10%), followed by motor/vocal tics (5.3%); probable epilepsy was the least prevalent (4%). Correlates associated with neurological disorders were in two domains: socio-demographic factors (age, ethnicity and staying in rural areas) and HIV-related factors (baseline viral load suppression). Enuresis/encopresis was associated with psychiatric comorbidity. Neurological disorders were associated with earlier onset of sexual intercourse (adjusted OR 4.06, 95% CI 1.26-13.1, P = 0.02). CONCLUSIONS: Neurological disorders impact lives of many children and adolescents with HIV/AIDS. There is an urgent need to integrate the delivery of mental and neurological health services into routine clinical care for children and adolescents with HIV/AIDS in sub-Saharan Africa.

Prevalence and correlates for ADHD and relation with social and academic functioning among children and adolescents with HIV/AIDS in Uganda.

BACKGROUND: Aim of this study was to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD), its associated correlates and relations with clinical and behavioural problems among children and adolescents with HIV/AIDS (CA-HIV) attending five HIV clinics in central and South Western Uganda. METHODS: This study used a quantitative design that involved a random sample of 1339 children and adolescents with HIV and their caregivers. The Participants completed an extensive battery of measures including a standardized DSM-5 referenced rating scale, the parent version (5-18 years) of the Child and Adolescent Symptom Inventory-5 (CASI-5). Using logistic regression, we estimated the prevalence of ADHD and presentations, correlates and its impact on negative clinical and behavioural factors. RESULTS: The overall prevalence of ADHD was 6% (n = 81; 95%CI, 4.8-7.5%). The predominantly inattentive presentation was the most common (3.7%) whereas the combined presentation was the least prevalent (0.7%). Several correlates were associated with ADHD: socio-demographic (age, sex and socio-economic status); caregiver (caregiver psychological distress and marginally, caregiver educational attainment); child's psychosocial environment (quality of child-caregiver relationship, history of physical abuse and marginally, orphanhood); and HIV illness parameters (marginally, CD4 counts). ADHD was associated with poor academic performance, school disciplinary problems and early onset of sexual intercourse. CONCLUSIONS: ADHD impacts the lives of many CA-HIV and is associated with poorer academic performance and earlier onset of sexual intercourse. There is an urgent need to integrate the delivery of mental health services into routine clinical care for CA-HIV in Sub-Saharan Africa.

A 'hidden problem': Nature, prevalence and factors associated with sexual dysfunction in persons living with HIV/AIDS in Uganda.

BACKGROUND: We conducted a clinic-based cross-sectional survey among 710 people living with HIV/AIDS in stable 'sexual' relationships in central and southwestern Uganda. Although sexual function is rarely discussed due to the private nature of sexual life. Yet, sexual problems may predispose to negative health and social outcomes including marital conflict. Among individuals living with HIV/AIDS, sexual function and dysfunction have hardly been studied especially in sub-Saharan Africa. In this study, we aimed to determine the nature, prevalence and factors associated with sexual dysfunction (SD) among people living with HIV/AIDS (PLWHA) in Uganda. METHODS: We conducted a clinic based cross sectional survey among 710 PLWHA in stable 'sexual' relationships in central region and southwestern Uganda. We collected data on socio-demographic characteristics (age, highest educational attainment, religion, food security, employment, income level, marital status and socio-economic status); psychiatric problems (major depressive disorder, suicidality and HIV-related neurocognitive impairment); psychosocial factors (maladaptive coping styles, negative life events, social support, resilience, HIV stigma); and clinical factors (CD4 counts, body weight, height, HIV clinical stage, treatment adherence). RESULTS: Sexual dysfunction (SD) was more prevalent in women (38.7%) than men (17.6%) and majority (89.3% of men and 66.3% of women) did not seek help for the SD. Among men, being of a religion other than Christianity was significantly associated with SD (OR = 5.30, 95%CI 1.60-17.51, p = 0.006). Among women, older age (> 45 years) (OR = 2.96, 95%CI 1.82-4.79, p<0.01), being widowed (OR = 1.80, 95%CI 1.03-3.12, p = 0.051) or being separated from the spouse (OR = 1.69, 95% CI 1.09-2.59, p = 0.051) were significantly associated with SD. Depressive symptoms were significantly associated with SD in both men (OR = 0.27, 95%CI 0.74-0.99) and women (OR = 1.61, 95%CI 1.04-2.48, p = 0.032). In women, high CD4 count (OR = 1.42, 95% CI 1-2.01, p = 0.05) was associated with SD. CONCLUSION: Sexual dysfunction has considerable prevalence among PLWHA in Uganda. It is associated with socio-demographic, psychiatric and clinical illness factors. To further improve the quality of life of PLWHA, they should be screened for sexual dysfunction as part of routine assessment.

A Qualitative Exploration of Causes of Depression among Persons Living with HIV Receiving Antiretroviral Therapy in Uganda: Implications for Policy.

Introduction: Depression is the fourth leading cause of the global disease burden and worsens the outcome of comorbidities including HIV/AIDS. Depression is particularly problematic among persons living with HIV in sub-Saharan Africa where scarcity of cost-effective interventions is compounded by inadequate understanding of the disease. We examine risk factors for depression among persons living with HIV undergoing antiretroviral treatment in Uganda and discuss policy implications. Methods: A qualitative study using a narrative approach was conducted, the formative phase of a large study to develop a model for integrating depression management into routine HIV care in Uganda. Participants were purposively sampled at four public health facilities in Mpigi District. In-depth interviews were conducted with four clinicians, three supervisors, and 11 persons living with HIV and suffering from depression, as were three focus group discussions with lay health workers. Exit interviews were conducted with 17 persons living with HIV who completed/interrupted depression treatment but had not been interviewed. Only data collected from persons living with HIV and lay health workers were analysed for the purpose of this paper. A narrative thematic approach was used in data analysis. Findings. There were several pathways through which lack of family social support reportedly led to depression: worries about disclosure in discordant relationships, false perceptions of social support, stigmatisation and discrimination, and domestic violence. Economic/poverty and other causes were identified, but their role was less significant or moderated by family social support. Conclusion: Family social support plays a dominant role-both directly and indirectly-in influencing depression risk. We propose the mainstreaming of formal psychosocial support and a shift from individual to family-focused counselling that targets both persons living with HIV and their family.

Physical and sexual victimization of persons with severe mental illness seeking care in central and southwestern Uganda.

Purpose: This study established the prevalence of physical and sexual victimization, associated factors and psychosocial consequences of victimization among 1,201 out-patients with severe mental illness at Butabika and Masaka hospitals in Uganda. Methods: Participants completed structured, standardized and locally translated instruments. Physical and sexual victimization was assessed using the modified adverse life events module of the European Para-suicide Interview Schedule. We used logistic regression to determine the association between victimization, the associated factors and psychosocial consequences. Results: The prevalence of physical abuse was 34.1% and that of sexual victimization was 21.9%. The age group of > = 50 years (aOR 1.02;95% CI 0.62-1.66; p = 0.048) was more likely to have suffered physical victimization, while living in a rural area was protective against physical (aOR 0.59; 95% CI 0.46-0.76; p = <0.001) and sexual (aOR 0.48, 95% CI 0.35-0.65; p < 0.001) victimization. High socioeconomic status (SES) (aOR 0.56; 95% CI 0.34-0.92; p = <0.001) was protective against physical victimization. Females were more likely to have been sexually victimized (aOR 3.38; 95% CI 2.47-4.64; p = <0.001), while being a Muslim (aOR 0.60; 95% CI 0.39-0.90; p = 0.045) was protective against sexual victimization. Risky sexual behavior was a negative outcome associated with physical (aOR 2.19; 95% CI 1.66-2.90; p = <0.001) and sexual (aOR 3.09; 95% CI 2.25-4.23; p < 0.001) victimization. Mental health stigma was a negative outcome associated with physical (aOR 1.03; 95% CI 1.01-1.05; p < 0.001) and sexual (aOR 1.03; 95% CI 1.01-1.05; p = 0.002) victimization. Poor adherence to oral anti-psychotic medications was a negative outcome associated with physical (aOR 1.51; 95% CI 1.13-2.00; p = 0.006) and sexual (aOR 1.39; 95% CI 0.99-1.94; p = 0.044) victimization. Conclusion: There is a high burden of physical and sexual victimization among people with SMI in central Uganda. There is need to put in place and evaluate complex interventions for improving detection and response to abusive experiences within mental health services. Public health practitioners, policymakers, and legislators should act to protect the health and rights of people with SMI in resource poor settings.

Prevalence, Risk Factors, and Negative Outcomes of Anxiety and Depressive Disorders among HIV-Infected Children and Adolescents in Uganda: CHAKA Study 2014-2017.

Background: Children and adolescents infected with HIV/AIDS (CA-HIV) experience a considerable burden of depressive and anxiety disorders that have a tendency to persist into adulthood. The aim of this study was to determine the prevalence of anxiety, depression, and their clinical correlates among children and adolescents with HIV/AIDS (CA-HIV) in Uganda. Methods: A random sample of 1339 CA-HIV (ages 5-18 years) and their caregivers completed a standardized DSM-5-referenced psychiatric rating scale, the Child and Adolescent Symptom Inventory-5 (CASI-5). The prevalence of "anxiety and depression" was estimated at 95% confidence intervals. Logistic and ordinal regression models were fitted for the clinical correlates and clinical outcomes. Results: The overall prevalence of "any anxiety and depressive disorders" was 13.7% at 95% CI (based upon the symptom count criteria); 4.0% (95% CI) met the clinical psychiatric disorder criteria (both symptom count and functional impairment criteria). Anxiety disorder was more prevalent (9%, 95% CI) than depression (6.4%, 95% CI). Correlates of "anxiety and depressive disorders" included age of the child, caregiver' psychological distress, caregivers' age, child-caregiver relationship, and child's current CD4 count (aOR1.00, 95% CI 1.02-1.05; p = 0.021). Anxiety disorders (aOR 2.58, 95% CI 1.16-5.42; p = 0.02) and depressive disorders (aOR 2.47, 95% CI 1.93-6.52; p = 0.041) were also associated with hospital admissions. Limitations. Analyses were cross-sectional; we cannot comment on the causal directions. The results are entirely based upon caregiver' reports. Conclusions: There is an urgent need to integrate mental health services into routine HIV care for CA-HIV in sub-Saharan Africa.

Effect of suicidality on clinical and behavioural outcomes in HIV positive adults in Uganda.

INTRODUCTION: Suicidality is a risk of a person committing suicide often characterized by suicidal ideation, intent or attempts. Despite the high burden of suicidality among individuals living with HIV and HAIDS, there is paucity of data on the impact of suicidality on clinical (such as CD4 counts and HIV disease progression) and behavioural outcomes (such as adherence to HIV Medications). Cross-sectional investigations of these associations are often complicated by bidirectional causal relationships and hence the need for longitudinal study designs. We conducted a cohort study to determine the impact of suicidality on clinical and behavioural outcomes among adults living with HIV/AIDS in Uganda. MATERIALS AND METHODS: We conducted the study among 1099 ART naïve adults living with HIV/AIDS in Uganda. Data were collected at three time points: baseline, 6 and 12 months. Multiple regression and discrete time survival models were used to determine the relationship between suicidality and indices of HIV outcomes. RESULTS: Majority of the participants were female and the participant mean age was 35 years. Most of them (73%) had primary or no formal education. The proportion of participants with suicidality decreased from 2.9% at baseline to roughly 1% both at month 6 and month 12. Of the investigated clinical and behavioural outcomes, baseline suicidality only had a negative impact on missing a dose of ART where the odds of missing a dose of ART were 8.25 (95% CI 2.45-27.71, p>0.01) times higher for participants with suicidality compared to those without suicidality. The following outcomes were not significantly impacted by baseline suicidality: HIV clinical stage, CD4 count and risky sexual behaviour. CONCLUSIONS: The fact that baseline suicidality significantly negatively impacted ART adherence calls for the incorporation of psychosocial interventions to target indices of psychological distress such as suicidality to improve HIV related outcomes.

Anxiety disorders and asthma among adolescents in Uganda: role of early-life exposures.

The reasons for the positive association between anxiety disorders and asthma are unknown. We investigated the possible role of shared exposures in early life. We conducted a case-control study among adolescents (age 12-17 years) with and without asthma in urban Uganda, as part of a larger asthma case-control study. Anxiety disorders were diagnosed by psychiatric clinical officers. We focused on generalised anxiety disorder (GAD), panic disorder and social anxiety disorder. Asthma was doctor-diagnosed by study clinicians. We used questionnaires to collect data on early-life exposures. The data were analysed using multiple logistic regression. We enrolled 162 adolescents; 73 of them had asthma. Adolescents with asthma were more likely to have any of the three anxiety disorders studied (46.6%) than adolescents without asthma (21.4%) (adjusted OR (aOR) 2.68, 95% CI 1.30-5.53). The association was strong for GAD (aOR 4.49, 95% CI 1.48-13.56) and panic disorder (aOR 5.43, 95% CI 2.11-14.02), but not for social anxiety disorder. The early-life risk factors associated with anxiety disorders among adolescents were similar to asthma risk factors previously published, including urban residence at birth (aOR 3.42, 95% CI 1.29-9.09) and during most of the first 5 years of life (aOR 2.87, 95% CI 1.07-7.66), father's tertiary education (aOR 2.09, 95% CI 1.00-4.37), and adolescent's history of other allergy-related diseases (aOR 4.64, 95% CI 1.66-13.00). We confirm a positive association between anxiety disorders and asthma among adolescents in urban Uganda. The early-life risk factors associated with anxiety disorders among adolescents were similar to those for asthma in the same age group, suggesting shared underlying environmental exposures.

Prevalence and risk factors for youth suicidality among perinatally infected youths living with HIV/AIDS in Uganda: the CHAKA study.

BACKGROUND: Research from high income countries indicates that suicide is a major mental health care concern and a leading cause of preventable deaths among children and adolescents. Proper assessment and management of youth suicidality is crucial in suicide prevention, but little is known about its prevalence and associated risk factors in Sub-Saharan Africa. In low income countries there is an increased risk of suicide among persons with HIV/AIDS even in the presence of the highly active antiretroviral therapy. OBJECTIVE: To determine the prevalence of and risk factors for youth suicidality among perinatally infected youth living with HIV/AIDS in Uganda. METHODS: We studied 392 HIV positive children (5-11 years) and adolescents (12-17 years) and their caregivers in Kampala and Masaka districts. Caregivers were administered the suicide assessment section of the MINI International Psychiatric Interview. Socio-demographic characteristics, psychiatric diagnoses, and psychosocial and clinical factors were assessed and suicidality (suicidal ideation and or suicidal attempt) was the outcome variable. Logistic regression was used to calculate odds ratios adjusting for study site and sex at 95% confidence intervals. RESULTS: Caregivers reported a suicidality rate of 10.7% (CI 8-14.1) in the past one month with higher rates among urban female (12.4%, CI 8.6-17.7) than male (8.7%, CI 5.4-13.8) youth. Lifetime prevalence of attempted suicide was 2.3% (n = 9, CI 1.2-4.4) with the highest rates among urban female youth. Among children, caregivers reported a lifetime prevalence of attempted suicide of 1.5%. The self-reported rate of attempted suicide in the past month was 1.8% (n = 7, CI 0.8-3.7) with lifetime prevalence of 2.8% (n = 11, CI 1.6-5.0). The most common methods used during suicide attempts were cutting, taking overdose of HIV medications, use of organophosphates, hanging, stabbing and self-starvation. Clinical correlates of suicidality were low socioeconomic status (OR = 2.27, CI 1.06-4.87, p = 0.04), HIV felt stigma (OR = 2.10, CI 1.04-3.00, p = 0.02), and major depressive disorder (OR = 1.80, CI 0.48-2.10, p = 0.04). Attention-deficit/hyperactivity disorder was protective against suicidality (OR = 0.41, CI 0.18-0.92, p = 0.04). CONCLUSION: The one-month prevalence of suicidality among CA-HIV was 10.7%.

Exploration of the understanding and etiology of ADHD in HIV/AIDS as observed by adolescents with HIV/AIDS, caregivers and health workers- using case vignettes.

BACKGROUND: Attention-Deficit / Hyperactivity Disorder (ADHD) is one of the most prevalent behavioural disorder among children and adolescents with HIV infection (CA-HIV). OBJECTIVE: To explore the explanations used by adolescents with HIV/AIDS, caregivers and health workers to understand and explain ADHD in HIV/AIDS. METHODS: This was a qualitative sub-study nested within a larger research project whose focus was on mental health among HIV infected children and adolescents in Kampala and Masaka, Uganda (CHAKA study, 2014-2017). Participants were recruited from five study sites: two in Kampala and three in Masaka. We purposively sampled 10 ADHD adolescent-caregiver dyads equally divided between the Masaka and Kampala sites, age groups and gender. Semi-structured interviews were carried out within 12 months of baseline. Ten HIV health workers (two from each study site) participated. The ten health workers were assessed about their knowledge related to psychiatric disorders (especially ADHD in HIV/AIDS), services available for such clients and gaps in service provision for CA-HIV with behavioural / emotional disorders. Participants were recruited over one month. Taped interviews were transcribed and preliminary coding categories generated based on the research questions. Broad categories of related codes were then generated to derive a coding framework. Thematic analyses were conducted to elicit common themes emerging from the transcripts. RESULTS: Explanations used by respondents to express their understanding related to ADHD among CA-HIV included; psychosocial stressors, biomedical manifestations, personal traits and supernaturalism, which affected health seeking behaviour. CONCLUSION: In contexts similar to those in Uganda, treatment approaches for ADHD among HIV positive CA-HIV should consider the explanations provided by CA-HIV, caregivers to CA-HIV and HIV health workers.

Cross-cultural adaptation of the Child and Adolescent Symptom Inventory-5 (CASI-5) for use in central and south-western Uganda: the CHAKA project.

Our study was to examine the applicability of translating and culturally adapting the Child and Adolescent Symptom Inventory-5 (CASI-5) for use in Uganda. This process followed guidelines recommended by the International Test Commission. A number of the CASI-5 concepts needed to be revised to capture the idioms for emotional, behavioural disorders and individual functioning among children and adolescents in Uganda. Our experience is that before introduction into another culture, psychological assessment instruments should undergo an adaptation process such as as the one used.