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2 The Detecting and managing common child and adult mental health problems in HIV care -

3

4

5 Table of Contents

6 An introduction to mental health and HIV care What do we mean by mental health? - 5

7 - Why is mental health important to caring for people with HIV/AIDS

8 Mental health treatment - - 7

9 - What will the training teach you to do? - - 8

10 - respect

11 Exercises for Introduction Purpose: Instructions: Case Case 2

12 Communication Skills and Assessment

13

14 Communication skills and Assessment Module Objectives - A. Introduction to communication skills - B. Communication skills 1. Basic interviewing technique Knowing how to ask questions that are open-ended rather than closed-ended.

15 - - Making empathetic comments. 2. Starting a visit

16 Setting the agenda. - What if people go on and on? - -

17 3. When people seem to be asking for advice - C. Routine questions -

18 For adults and adolescents, ask the patient and partner, if they are accompanied by one and the patient gives permission: D. Assessment - -

19 1. History/background How does the patient look? - 3. How is the patient interacting with you?

20 4. How do they describe their mood? 5. What is their thinking like? Circumstantial speech Flight of ideas and loose associations Perseveration Thought blocking Perceptions

21 7. Alertness and awareness 8. The neurologic exam 9. Functioning Summary -

22 -

23 Exercises for Module 1 1. Communication skills role plays - 2. The brief mental status evaluation - -

24 -

25

26 Thought, perception, and memory problems

27

28 Thought, perception, and memory problems Module objectives - Introduction - - and general medical personnel. In addition, some of these problems can be signs of serious medical illness in people with HIV and thus they are important place to start talking about

29 Case to start off discussion A. Types of thought problems - - B. How these patients are noticed in ART care Changes in speech -

30 Changes in mood Changes in appearance and behavior Changes in thoughts and perceptions It is important to realize that these strange thoughts and behaviors may seem real to the person who is ill, but at the same time the person may realize that you will think them strange if they tell you, so they will not talk about their experiences or how much they are troubled. Hallucinations - Delusions-

31 - Somatic delusions can sometimes be hard to separate from medical symptoms such as pain and fatigue for which there isn t a ready medical explanation, but which are not symptoms of a thought problem. When symptoms or concerns are odd ( my inner body parts have been replaced by plastic ) they are more likely to be delusions. See the low mood module for information on somatic presentations of mental health problems and for an approach to medically unexplained symptoms that are not delusional. Problems - - C. Approach to treatment for thought, perception and memory disorder in primary care/hiv care -

32 - Delerium Thought problems that are part of medical illness (and especially delirium) are potential emergencies they usually mean that a person is very sick

33 Table 2.1: Opportunistic infections and tumors in HIV signs present signs - - tia - weeks weeks - -

34 See the substance module for what to do about alcohol withdrawal

35 - While the long-term treatment of the primary mental illnesses is different from the treatment of thought problems caused by medical illness, the initial treatment is often the same. -

36 - - -

37 Table 2.2: Choice of antipsychotic drugs gain increase ris-

38 Table 2.3: Antipsychotic drugs, side effects, and interactions - weeks

39 good rules include giving the medication time to take effect (once agitation has improved, days to weeks for psychotic symptoms to resolve) and using the lowest possible dose that seems effective

40

41 - -

42 D. Follow-up care E. Referral and consultation

43 - F. Summary Thought problems - - -

44 Memory problems

45 Exercises for Module 2 1. Thought problem terminology Cases to think about to differentiate dementia and delerium -

46 - - - diagnosis and treatment decisions - - -

47 4. Role plays to practice interviewing, differential diagnosis, and psychoeducation - - -

48

49 Figure 2.1 Thought, perception and memory problems - - -

50 Depression

51

52 Depression Module objectives - Introduction

53 - - - A. Types of disorders - Serious depression Milder forms

54 - - B. Presentations and detection in primary care/hiv care - Yakatlema Makatol Yikebdegnal Yakatilegnal Yiweregnal, yurania Wotiro yiyizegnal

55 Yikezekizegnal Bado yihonibgnal Wustus yimbochabichibignal - Because of what we said above about how common brief periods of depression can be after line is that the symptoms should have lasted for at least two weeks, and they should be causing a major change in what the person would normally be able to do. -

56 - Some of the most important symptoms of depression are ones that can be the most taboo or stigmatizing to talk about in front of others. Asking about these things in a non-private setting risks getting bad information, and harming the trust that you are hopefully building with the patient. Some of these symptoms can also seem shocking to clinicians, too. It can take practice to be able to ask about them. 55

57 C. Assessing suicidality SAD PERSONS S - A D 56

58 P E R S O N A S D. Treatment of depression in primary care/hiv care Special concern for suicidal individuals who may have taken an insecticide: - They may say they are suicidal and appear intoxicated or agitated - This is a medical emergency start plans for transfer to a hospital vated charcoal and atropine - Treat seizures if present 57

59

60

61 s g - -

62 Table 3.1- Antidepressant dosages and side effects week week - can be fatal in overdose; avoid use in suicidal patients

63 E. Follow-up and monitoring - F. Referral criteria -

64 G. Summary Depressive disorders - - -

65 Exercises for Module 3 1. Major symptoms of depression and suicidality diagnosis and treatment decisions - -

66

67 66

68

69 68

70 Anxiety and psychotrauma 69

71

72 Anxiety and psychotrauma Objectives for module A. Introduction - -

73 Case to start off discussion - B. Presentations and detection in primary care and ART - -

74

75 - How would you ask about these things among your patients? Which patients might you think of asking? This is a sensitive issue that we will practice in role plays. - - C. Approach to treatment in primary care - Thinking through anxiety treatment -

76 See the discussion of suicide in the depression module

77 - - - General treatment for most anxiety problems - 76

78 Anxiety related to traumatic stress Anxiety related to fear of HIV disclosure (or of other stigmatizing issues) - care

79 - - Obsessions and compulsions

80 Medications for anxiety 79

81 Table 4.1- Drugs for treating anxiety- dosages, side effects, and interactions (part 1)

82 Table 4.1- Drugs for treating anxiety- dosages, side effects, and interactions (part 1) - increase D. Follow-up and monitoring - -

83 E. Referral criteria: F. Summary- Anxiety and psychotrauma - - -

84 Exercises for Module 4 1. Major symptoms of anxiety problems 2. Major triggers of anxiety 3. Anxiety and living with HIV/AIDS Exercise 4: Initial assessment of ongoing violence. Purpose: Instruction:

85 diagnosis and treatment decisions

86 - 3. Role plays to practice interviewing, differential diagnosis, and psychoeducation

87 86 tween partners - - -

88 5 Substance use 87

89 88

90 5 Substance use Objectives for module 5 - A. Introduction - types of disorders and commonly used substances

91 Case to start discussion B. Background on the four substances Alcohol - - Early detection and intervention -

92 Cannabis/marijuana Khat/Chat

93 - - - Tobacco -

94 C. Presentations in ART/primary care Inhalants Being called a drunkard is a very serious and shameful thing in Ethiopia and many patients will not think that asking about drinking is something that should happen at a medical visit. So think about how you can approach this subject tactfully, and make a case that it is something important to discuss.

95 - - D. Approaches to treatment in primary care

96 - - Emergency care for alcohol withdrawal - 95

97 Table 5.1- Treatment of alcohol withdrawal

98 - - E. Follow-up and monitoring - F. Referral criteria - G. Summary Substance related disorders

99 - - 98

100 Exercises for Module 5 1. Major symptoms of substance problems Purpose: Instruction: - 2. Asking patients about substance abuse 3. Substance use and HIV diagnosis and treatment decisions - 99

101 5. Role plays to practice interviewing, differential diagnosis, and psychoeducation -

102

103

104 6 Epilepsy

105

106 6 Epilepsy Objectives for Module 6 - A. Types of disorders Table 6.1. Causes and beliefs about seizures and epilepsy Cause of seizures and epilepsy Traditional concepts

107 Case to start discussion B. Presentation/detection in primary care/art -

108 - Epilepsy is another stigmatized condition it is possible that family members who have seen someone have a seizure will not tell the person what happened. So asking for information from other family members is sensitive but often necessary. In Ethiopia, people frequently don t come for care for seizures until they have had the problem for years. nence -

109 nents - - Table 6.2 Characteristics of most common types of seizures

110 Table 6.3 Psychogenic versus generalized seizures Cause of seizures and epilepsy Psychogenic seizure Grand mal epilepsy Onset Tongue bite Incontinence Nocturnal occurrence Injuries Eyes Postictal state Recollecting events during the attack C. Approach to treatment in primary care/art - Emergencies and urgent issues

111 Prolonged seizures: Treatment of seizures if the cause can t be determined or treated separately

112 - - Treatment of psychogenic seizures - -

113 Table 6.4 Medications for seizures: doses, side effects, and interactions Drugs Dose range Side effects Interactions - - pecia Table 6.4. Medications for different types of seizures Type of seizure Anmesia

114 D. Special conditions in epilepsy 2. Febrile seizures (young children) 1. Status epilepticus

115 3. Epilepsy, contraception, and pregnancy Depression and epilepsy 5. HIV and epilepsy - -

116 E. Case management and long-term follow-up F. Referral criteria

117 G. Summary - Epilepsy -

118 Exercises for Module 6 1. Causes of epilepsy Purpose: Instruction: 2. Review types of seizures Purpose: Instruction: - 3. Epilepsy quiz Purpose: Instruction:

119 guide diagnosis and treatment decisions - - -

120

121

122 7 Behavior and developmental issues in children and adolescents

123

124 7 Behavior and developmental issues in children and adolescents Objectives for module 7 gies A. Introduction See the depression and anxiety modules for information about treating those concerns in children and adolescents.

125 - Cases to start off discussion - B. Presentation in primary care/art treatment

126 In Ethiopia and many other countries, children who are shy and quiet are seen as good, so their problems may be overlooked. Physical punishment is also seen as useful and acceptable. So think about how to tactfully bring these subjects up. -

127 C. Treatment in primary care/art setting 1. Physical injury to the child: - 2. Sexual injury to the child: 3. Physical or emotional violence between parents: 4. Suicidal ideation: 5. Especially in very young children, 6. Childhood psychotic symptoms: -

128 - In children, with the exception of emotional trauma, consider severe psychotic-like symptoms to be most likely caused by a medical problem or intoxication. - -

129 Table 7.1. Ten Questions for detection of child developmental disability

130 In many parts of the world, ADHD is considered to be the most common childhood mental health problem, but in Ethiopia it is not recognized as often. ADHD has both cognitive (thinking) and task. Children with ADHD can be very forgetful, lose things, and have a lot of trouble keeping their mind on one task, especially if it needs a lot of mental effort (such as school work). They can be easily distracted from their work by noises or the presence of others. Boys more than girls with ADHD can also have trouble sitting still, though this usually gets better by adolescence (the thinking problems may not). The behavioral counseling we talk about below can help children with ADHD, but in more severe cases medication stimulants seems more effective. These medications are not currently available in Ethiopia. -

131 - -

132 - - - Table 7.2 Antipsychotics medications for children D. Follow-up and monitoring weeks

133 E. Referal criteria F. Summary of child behavior and development problems

134 Exercises for module 7-1. Asking about behavior problems in children Purpose: Instruction: 2. Causes of behavior problems in children Purpose: Instruction: 3. Developmental assessment Purpose: diagnosis and treatment decisions Instructions: -

135

136 ing? - pieces - -

137

138 8 Living with HIV

139

140 8 Living with HIV Module 8: Living with HIV Objectives for module 8 A. Introduction - B. Reaction to the diagnosis

141 C. Stigma and disclosure

142 - Disclosure to HIV+ children: -

143 C. Mild impairment of cognitive functioning - - One aspect of HAND that can be particularly troubling is that the combination of brain problems tends to make people unconsciously shy away from new situations and challenges. This can be a barrier to accessing new programs and treatments that may be helpful, and can be frustrating to both the patient and clinicians, neither of whom can really understand the source of the reluctance.

144 - - Summary points for this module -

145 Exercises for module 8 diagnosis and treatment decisions Instructions Role plays to practice interviewing, differential diagnosis, and psychoeducation Instructions - -

146 - -

147

148 9 Implementation issues and putting it all together

149

150 9 Implementation issues and putting it all together Objectives for module 9 Introduction A. The work plan for integrating mental health into ART visits - -

151 Figure 9.1. Flow chart for a patient newly thought to have a mental health problem

152 Figure 9.2. Flow chart for returning patients known to have a mental health problem -

153 - - B. Ethical/procedural issues for mental health - - -

154 C. Monitoring and evaluation - Table 9.1. The monitoring and evaluation framework A Comprehensive M&E Framework cancer?

155 Draft register

156 D. What else is needed to be able to increase attention to mental health in ART services?

157 E. What follow-up training and refreshers should be offered?

158 Exercises for module 9 Purpose: Instruction: 2. Creating an action plan for your own clinical site Purpose: Instruction:

159 Bibliography/selected readings from recent publications about mental health in Ethiopia

160 - -

161

162