Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors.

A global survey of National Tuberculosis Program (NTP) directors. To assess the perceived mental health needs of persons with tuberculosis (TB), current practices, and receptivity to integrating evidence-based mental and substance use treatment into national TB guidelines. Semi-structured survey of NTP directors from 26 countries of all income levels using a standardized questionnaire. Of the 26 countries, 21 were classified as high incidence and/or burden countries for TB, TB and human immunodeficiency virus coinfection, and/or drug-resistant TB. Two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. If effective and low-cost integrated care models were available, 17 NTP directors felt that it was highly likely, and five somewhat likely, that their NTPs would integrate mental health treatment into national TB guidelines and services. The main perceived barriers to service integration were limited capacity, not recognizing mental health as a problem, insufficient resources, and TB-related social stigma. NTPs currently do not address mental disorders as part of routine practice. Nevertheless, receptivity is high, which creates a ripe opportunity to integrate the management of TB and mental disorders into the policies and guidelines of NTPs worldwide. .

Addressing the tuberculosis-depression syndemic to end the tuberculosis epidemic.

Tuberculosis (TB) and depression act synergistically via social, behavioral, and biological mechanisms to magnify the burden of disease. Clinical depression is a common, under-recognized, yet treatable condition that, if comorbid with TB, is associated with increased morbidity, mortality, community TB transmission, and drug resistance. Depression may increase risk of TB reactivation, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment because of poverty, undernutrition, immunosuppression, and/or negative coping behaviors, including substance abuse. Tuberculous infection and/or disease reactivation may precipitate depression as a result of the inflammatory response and/or dysregulation of the hypothalamic-pituitary-adrenal axis. Clinical depression may also be triggered by TB-related stigma, exacerbating other underlying social vulnerabilities, and/or may be attributed to the side effects of anti-tuberculosis treatment. Depression may negatively impact health behaviors such as diet, health care seeking, medication adherence, and/or treatment completion, posing a significant challenge for global TB elimination. As several of the core symptoms of TB and depression overlap, depression often goes unrecognized in individuals with active TB, or is dismissed as a normative reaction to situational stress. We used evidence to reframe TB and depression comorbidity as the 'TB-depression syndemic', and identified critical research gaps to further elucidate the underlying mechanisms. The World Health Organization's Global End TB Strategy calls for integrated patient-centered care and prevention linked to social protection and innovative research. It will require multidisciplinary approaches that consider conditions such as TB and depression together, rather than as separate problems and diseases, to end the global TB epidemic.

Subtypes of depressive symptoms and inflammatory biomarkers: An exploratory study on a sample of HIV-positive patients.

Depressive symptoms cause major impairment and may accelerate HIV progression despite the use of antiretroviral medication. The somatic symptoms criteria for HIV infection and depression partially overlap, which can make differential diagnosis challenging. Because of chronic inflammation caused by HIV infection, HIV-positive patients may develop somatic and affective-cognitive symptoms of depression. Inflammation-related depression is primarily characterized with severe somatic symptoms such as fatigue and sleep disturbance. This study sought to explore the patterns of somatic and cognitive-affective depressive symptoms that characterize HIV-positive patients. Our specific aims were (1) to identify subtypes of depressive symptoms in a sample of HIV-positive patients; and (2) to test the subtypes' difference on inflammatory and HIV disease progression biomarkers. HIV-positive men and women (N=102) with and without depressive symptoms were randomly selected from an Italian HIV clinic. Depressive symptoms (PHQ-9), viral load (VL), CD4+, Il-6, TNF-α, and monocytes were assessed. The three subtypes formed using Latent Class Analysis (LCA) identified patients with (1) severe cognitive-affective and somatic depressive symptoms; (2) severe/moderate somatic symptoms; and (3) absent or low depressive symptoms. The subtype with severe/moderate somatic symptoms was characterized with elevated levels of Il-6 and monocytes. No difference on HIV progression biomarkers was found. The subtypes of depressive symptoms might help differentiating depressive symptoms from HIV- and inflammatory-related somatic symptoms. When present, cognitive-affective and/or somatic symptoms cause significant impairment to patients' lives and thus warrant further assessment and treatment.

A low-cost, sustainable intervention for drinking reduction in the HIV primary care setting.

Excess drinking poses multiple substantial health risks to HIV-infected individuals. However, no published intervention studies have focused on drinking reduction as the main outcome in HIV primary care patients. An intervention in this setting must place minimal demands on pressured staff and resources. This pilot study tested such an intervention, which consisted of brief Motivational Interviewing (MI) and HealthCall, an automated daily telephone self-monitoring system based on Interactive Voice Response (IVR), designed to extend and enhance the effects of brief MI. Thirty-one patients entered the study, received a 30-minute MI and were instructed in daily use of the IVR system. They received graphical feedback on their daily drinking from the HealthCall database after 30 days. A statistically significant decrease in drinking was found over time, both as reported in daily IVR calls (beta = - 0.01, se 0.01, p=.03) and in follow-up interviews (beta = - 0.04, se 0.12, p=.02) at 60 days. The proportion of daily calls made supported the feasibility of the intervention. The results indicate that HealthCall is acceptable to a disadvantaged HIV patient population, and preliminary data support the efficacy of this intervention in reducing harmful drinking among HIV primary care patients.

HIV/AIDS preparedness in mental health care agencies with high and low substance use disorder caseloads.

PURPOSE: The Columbia University HIV Mental Health Training Project, created to improve the mental health workforce's AIDS preparedness in New York and neighboring states, sought to compare the perceived HIV-related needs and capacities of mental health care providers in settings where clients with substance use disorders predominated versus those where clients with substance use disorders were the minority of the agencies' caseload. METHODS: The first consecutive 67 mental health care agencies that requested HIV/AIDS training between March 2000 and January 2001 completed a written needs assessment describing their HIV-related services and training needs. RESULTS: Agencies with higher substance abuse caseloads were significantly more likely than others to have large HIV/AIDS caseloads, to be currently providing condoms to clients, and to rate staff comfort with sexual identity issues as well as drug-related issues as good. Overall, agencies that had received previous training in specific topic areas (e.g., HIV risk assessment) were significantly more likely than others to provide those services. Even so, in all settings, significant gaps in service provision were found. IMPLICATIONS: Two decades into the AIDS epidemic, mental health care agencies, especially those treating smaller caseloads of patients with substance use disorders, may not be providing sufficient services to meet their clients' HIV-related needs.

Essential medical facts for mental health practitioners.

New information about the life cycle of HIV, new HIV-specific laboratory tests, and newer antiretroviral medications have transformed the management of HIV illness. Knowledge about these changes will help mental health providers better understand the latest medical issues affecting their HIV-infected patients, which will assist them in providing better care.

Adherence to treatment.

Since the advent of highly active antiretroviral therapy, the issue of strict adherence has become increasingly important. This chapter examines how the mental health provider can employ a multimodal approach to promoting patient adherence, which increases the chances of success.

The Hispanic, gay, lesbian, bisexual and HIV-infected experience in health care.

This presentation, relying both on personal experience and an array of studies, surveys the problems minorities face in trying to obtain adequate health care. From another viewpoint, these are problems that physicians have in trying to provide health care to persons they do not understand and cannot really see or hear. And the problems multiply when the patient is a minority in more than one sense. The gay, Hispanic, HIV+ patient, for example, is removed from the average physician's comprehension to a degree that is itself almost incomprehensible. Treating patients as they ought to be treated requires that physicians overcome many layers of prejudice and unfounded assumptions. Failure to overcome such prejudices distorts medical practice.