David J. Grelotti

Placebo by proxy

Clinicians’ and family members’ feelings and perceptions about a treatment may influence their judgments about its effectiveness

Development and validation of a Haitian Creole screening instrument for depression

Developing mental health care capacity in postearthquake Haiti is hampered by the lack of assessments that include culturally bound idioms Haitians use when discussing emotional distress. The current paper describes a novel emic-etic approach to developing a depression screening for Partners in Health/Zanmi Lasante. In Study 1 Haitian key informants were asked to classify symptoms and describe categories within a pool of symptoms of common mental disorders. Study 2 tested the symptom set that best approximated depression in a sample of depressed and not depressed Haitians in order to select items for the screening tool. The resulting 13-item instrument produced scores with high internal reliability that were sensitive to culturally informed diagnoses, and interpretations with construct and concurrent validity (vis-à-vis functional impairment). Discussion focuses on the appropriate use of this tool and integrating emic perspectives into developing psychological assessments globally. The screening tool is provided as an Appendix.

Pretreatment antiretroviral exposure from recreational use

The international community has overcome many obstacles in making HIV antiretroviral (ARV) medication available globally, but ARV resistance in treatment-naive individuals remains an implementation challenge. The subject of many recent reports,1-3 worries abound that pretreatment ARV resistance is related to treatment failure and that further increases in the rates of pretreatment ARV resistance might “jeopardise the global HIV response”.1,2 Largely attributed to transmitted resistance, pretreatment ARV exposure such as inadequate treatment outside of sanctioned care networks is believed to be a contributing factor.3 While investigating HIV-risk behaviour in South Africa,4 we learned of a preventable form of pretreatment ARV exposure that has gone largely unreported and may accelerate rates of pretreatment ARV resistance: the recreational use of ARVs referred to by our informants as “whoonga”. Whereas whoonga has received significant media attention since 2010, the first and only report in the medical literature documenting the recreational use of ARVs appeared years earlier from the United States. In discussions with HIV-infected individuals in Miami about prescription drug diversion, Inciardi and colleagues learned that some individuals abuse efavirenz for its “intoxicating” effects and use ritonavir to enhance the effects of illicit drugs such as methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA/ecstasy).5 Claims about the psychoactive effects of these ARVs are supported by scientific case reports.6,7 Similar ARV abuse patterns in South Africa have been reported in the social science literature and news media. Larkan and colleagues provide an account of individuals smoking efavirenz in Western Cape and summarise media reports that ARVs are combined with illicit drugs such as opiates, methamphetamine, and/or marijuana to make drug cocktails.8 Whoonga, believed to be one such cocktail, brought media attention to the problem of recreational ARV use in Kwazulu-Natal because of its addictive potential, its association with criminal activity, and the challenge it posed to ARV rollout.9 Even local experts who maintain that whoonga is heroin and does not contain ARVs acknowledge that a number of South African drug abusers use ARVs recreationally.10 Although essentially a substance abuse problem, the implications for HIV treatment are broad. For example, diversion of ARVs, in addition to impacting adherence, reduces ARV supply and limits access to treatment. Criminal behaviour related to diversion of ARVs endangers patients and healthcare providers while deterring others from seeking care. Finally, the recreational use of ARVs further stigmatises HIV-infected patients and their communities and may undermine donor willingness to fund ARV treatment.8 In addition to these impacts, when untreated HIV-infected individuals are exposed to ARVs recreationally, they are at risk for acquiring resistance.8 Mutations conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as efavirenz are among the most common in individuals with pretreatment ARV resistance.1-3 Interestingly, serum concentrations of ARVs including efavirenz have been detected in some HIV-infected individuals with pretreatment ARV resistance who deny prior history of ARV treatment.3 To help explain some of these findings, researchers may wish to inquire specifically about recreational ARV use or use of drug cocktails when assessing pretreatment ARV exposure. Expanding pretreatment ARV resistance screening will help to minimize the risk that this form of pretreatment ARV exposure poses; however, a comprehensive strategy to investigate this problem also involves expanding substance abuse research. Existing substance abuse surveillance methods have not reported on the phenomenon,11,12 and they may need to be improved if we are to understand the extent of pretreatment ARV exposure from recreational ARV use. Systematic research is also needed to explore the chemical makeup of South African street drugs, the abuse liability of ARVs, and the bioavailability and likelihood of developing resistance when ARVs are smoked or otherwise administered inappropriately. Given the high prevalence and complex medical, psychosocial, and political context of HIV in southern Africa, it is important that treatment strategies adapt to emerging issues like recreational ARV use. We may decrease the recreational use of ARVs, decrease drug diversion, and improve adherence to HIV treatment if we avoid ARVs used recreationally when developing ARV treatment guidelines or distribute ARVs to patients in a way that minimizes the potential for misuse. The recreational use of ARVs also serves as a reminder that ARV treatment is not synonymous with HIV treatment and demonstrates the importance of access to effective community-based mental health and substance abuse services.

Whoonga and the Abuse and Diversion of Antiretrovirals in Soweto, South Africa

Media reports have described recreational use of HIV antiretroviral medication in South Africa, but little has been written about this phenomenon in the scientific literature. We present original, qualitative data from eight semi-structured interviews that characterize recreational antiretroviral use in Soweto, South Africa. Participants reported that antiretrovirals, likely efavirenz, are crushed, mixed with illicit drugs (in a mixture known as whoonga), and smoked. They described medications being stolen from patients and expressed concern that antiretroviral abuse jeopardized the safety of both patients and users. Further studies are needed to understand the prevalence, patterns, and consequences of antiretroviral abuse and diversion.

Even more mountains: challenges to implementing mental health services in resource-limited settings.

Mwen te swe anpil (“I sweat a lot”) when I moved to Haiti after child and adolescent psychiatry training for a global mental health fellowship at Partners In Health (PIH). The blazing Caribbean sun was a lot to sweat, but so too was the task at hand. Alongside Haitian physicians and psychologists, we worked to improve mental health services for patients and families that hitherto had little access to psychiatric care. While on the ground, we learned ways to address the challenges of providing mental health care in a resource-limited setting culturally quite distinct from the United States.

High burden of mental illness and low utilization of care among school-going youth in Central Haiti: A window into the youth mental health treatment gap in a low-income country

Background: The mental health treatment gap for youth in low- and middle-income countries (LMICs) is substantial; strategies for redress are urgently needed to mitigate the serious health and social consequences of untreated mental illness in youth. Aims: To estimate the burden of major depressive episode (MDE) and posttraumatic stress disorder (PTSD) as well as utilization of care among Haitian youth in order to describe the mental health treatment gap in a LMIC setting. Methods: We estimated the point prevalence of MDE, PTSD, and subthreshold variants in a school-based sample of youth (n = 120, ages 18–22 years) using a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID)-based interview and examined treatment utilization among those receiving one of these diagnoses. We assessed additional psychopathology with self-report measures to examine validity of study diagnostic assignments. Results: The combined prevalence of full-syndrome or subthreshold MDE or PTSD was high (36.7%). A large majority of affected individuals (88.6%) had accessed no mental health services in the health sector, and 36.4% had accessed no care of any kind in either the health or folk sectors in the past year. Conclusion: Findings demonstrate a high mental health burden among Haiti’s youth and that many youth with MDE and PTSD are not accessing mental health care.

Formative research on a teacher accompaniment model to promote youth mental health in Haiti: Relevance to mental health task-sharing in low-resource school settings

Background: Task-sharing with teachers to promote youth mental health is a promising but underdeveloped strategy in improving care access in low-income countries. Aims: To assess feasibility, acceptability and utility of the teacher accompaniment phase of a school-based Teacher-Accompagnateur Pilot Study (TAPS) in Haiti. Methods: We assigned student participants, aged 18–22 years (n = 120), to teacher participants (n = 22) within four Haitian schools; we instructed participants to arrange meetings with their assigned counterparts to discuss mental health treatment, academic skills, and/or well-being. We measured student and teacher perceived feasibility, acceptability and utility of meetings with self-report Likert-style questions. We examined overall program feasibility by the percentage of students with a documented meeting, acceptability by a composite measure of student satisfaction and utility by the percentage with identified mental health need who discussed treatment with a teacher. Results: Favorable ratings support feasibility, acceptability and utility of teacher-accompagnateur meetings with students. The majority of students (54%) met with a teacher. Among students with an identified mental disorder, 43.2% discussed treatment during a meeting. Conclusion: This accompaniment approach to mental health task-sharing with teachers provided a school-based opportunity for students with mental health need to discuss treatment and has potential relevance to other low-income settings.

Mental health training for secondary school teachers in Haiti: a mixed methods, prospective, formative research study of feasibility, acceptability, and effectiveness in knowledge acquisition

Background Engagement and training of educators in student mental health holds promise for promoting access to care as a task sharing strategy but has not been well-studied in low-income regions. Methods We used a prospective and convergent mixed methods design to evaluate a customized school mental health 2½ day training for teachers in rural Haiti (n = 22) as the initial component of formative research developing a school-based intervention to promote student mental health. Training prepared teachers to respond to student mental health needs by providing psychoeducational and practical support to facilitate access to care. We examined level of participation and evaluated feasibility, acceptability, and perceived effectiveness by calculating mean scores on self-report Likert-style items eliciting participant experience. We examined effectiveness of the training on improving mental health knowledge and attitudes by comparing mean scores on an assessment administered pre- and post-training. Finally, we examined self-report written open-ended responses and focus group discussion (FGD) interview data bearing on perceived feasibility, acceptability, and effectiveness to contextualize participant ratings of training and to identify recommendations for enhancing the utility of mental health training locally for educators. Results Mean scores of knowledge and attitudes significantly improved between the pre-test and post-tests; e.g., knowledge improved from 58% correct at baseline to 68% correct on the second post-test (p = 0.039). Mean ratings of the training were favorable across all categories and FGD data demonstrated widespread participant endorsement of training acceptability and effectiveness; participants recommended extending the duration and number of training sessions. Conclusions Findings support feasibility, acceptability, and a limited scope of effectiveness of brief mental health training for secondary school teachers in Haiti. Further development of approaches to engage teachers in promoting school mental health through training is warranted.

Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States

Importance Depression commonly affects adults with HIV and complicates the management of HIV. Depression among individuals with HIV tends to be chronic and cyclical, but the association of this chronicity with HIV outcomes (and the related potential for screening and intervention to shorten depressive episodes) has received little attention. Objective To examine the association between increased chronicity of depression and multiple HIV care continuum indicators (HIV appointment attendance, treatment failure, and mortality). Design, Setting, and Participants The study comprised an observational clinical cohort of 5927 patients with 2 or more assessments of depressive severity who were receiving HIV primary care at 6 geographically dispersed US academic medical centers from September 22, 2005, to August 6, 2015. Main Outcomes and Measures Missing a scheduled HIV primary care visit, detectable HIV RNA viral load (≥75 copies/mL), and all-cause mortality. Consecutive depressive severity measures were converted into a time-updated measure: percentage of days with depression (PDD), following established methods for determining depression-free days. Results During 10 767 person-years of follow-up, the 5927 participants (5000 men, 926 women, and 1 intersex individual; median age, 44 years [range, 35-50 years]) had a median PDD of 14% (interquartile range, 0%-48%). During follow-up, 10 361 of 55 040 scheduled visits (18.8%) were missed, 6191 of 28 455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years. Percentage of days with depression showed a dose-response relationship with each outcome. Each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment (risk ratio, 1.08; 95% CI, 1.05-1.11), a 5% increase in the risk of a detectable viral load (risk ratio, 1.05; 95% CI, 1.01-1.09), and a 19% increase in the mortality hazard (hazard ratio, 1.19; 95% CI, 1.05-1.36). These estimates imply that, compared with patients who spent no follow-up time with depression (PDD, 0%), those who spent the entire follow-up time with depression (PDD, 100%) faced a 37% increased risk of missing appointments (risk ratio, 1.37; 95% CI, 1.22-1.53), a 23% increased risk of a detectable viral load (risk ratio, 1.23; 95% CI, 1.06-1.43), and a doubled mortality rate (hazard ratio, 2.02; 95% CI, 1.20-3.42). Conclusions and Relevance Greater chronicity of depression increased the likelihood of failure at multiple points along the HIV care continuum. Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes. Clinic-level trials of protocols to promptly identify and appropriately treat depression among adults living with HIV should be conducted to understand the effect of such protocols on shortening the course and preventing the recurrence of depressive illness and improving clinical outcomes.

Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial†

ABSTRACT Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.