Melvyn Freeman

Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations.

Shekhar Saxena and colleagues summarize the recent WHO Mental Health Gap Action Programme (mhGAP) intervention guide that provides evidence-based management recommendations for mental, neurological, and substance use (MNS) disorders.

Factors associated with prevalence of mental disorder in people living with HIV/AIDS in South Africa.

Abstract The study examines the association between the presence of mental disorder and a range of independent variables. A sample of 900 HIV-positive individuals was administered the Composite International Diagnostic Interview to determine the presence of selected mental disorders. A structured interview assessed support received and factors that may contribute to mental disorder. Overall prevalence of mental disorder was 43.7%—though higher in Stage 3 (49.7%) and in Stage 4 (68%) of the disease. Eighteen percent of respondents were receiving antiretroviral treatment. Having had pre- and post-test counselling was not related to mental disorder; nor were the number of sessions, the professional status of the counsellor and perceived helpfulness of counselling. Being in an HIV support group was related to presence of a mental disorder, although the frequency of attendance was not. Although most of those who disclosed their HIV status found the experience helpful there was a significant positive association between presence of a mental disorder and having disclosed HIV-positive status. Although being a member of an association for people with HIV/AIDS and being religious was perceived as helpful, neither was statistically associated with the presence of mental disorder. Discrimination by community and family and isolation were related to mental disorder. Death of a significant other due to AIDS was related to mental disorder. The findings suggest a strong need for provision of psychiatric care as part of AIDS care as well as strengthening of support services.

Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers

Abstract Increasing numbers of orphaned and vulnerable children resulting from AIDS deaths requires practical placement strategies. While the extended family is regarded as both the most likely and the preferred option by most key planners and organizations, warnings of the limitations of this alternative have been increasing. This study assessed the views of 1400 adults (both current and prospective caregivers) regarding the placement of children. Most current caregivers believed that either their partner (30%), a grandparent (25%) or another family member (33%) would look after the child/children if they were no longer able to. However, 12% of parents could not identify a carer or predicted only a bleak future for their children. There was strong willingness amongst adults of various relational proximity to take in children if required to −71% of both fathers and grandparents, 63% of siblings and 23% of best friends said they would take in children. Nonetheless this research suggests that the willingness may not necessarily be translated into reality. Most prospective caregivers identified significant additional stressors (most importantly financial) and expressed a strong need for assistance if they were to take in additional children. The HIV status of the child is also likely to sway placement decisions for some people. Nonetheless opportunities to keep children in families are clearly high, but people will need considerable help to realize this potential. For some children alternatives other than the extended family will be required

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio‐environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual‐focused, health system‐focused, and community level and policy‐focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

HIV / AIDS in developing countries : heading towards a mental health and consequent social disaster?

The HIV/AIDS pandemic will have massive implications for mental health in sub-Saharan Africa. While research in developed countries is quite advanced in this area, and while some of this research is relevant and important in developing countries, understanding and dealing with a disease of relatively low prevalence and which is mostly under control is vastly different from the considerations required of a growing epidemic which seems likely to kill a significant proportion of the population. The mental health implications of HIV/AIDS will be felt by individuals, families, communities and society as a whole. This article looks at the mental health of people who are unsure of their HIV status, people diagnosed as HIV-positive, the family and caregivers of HIV-positive individuals, people left behind following AIDS deaths and of society as a whole. Given the magnitude and pervasiveness of HIV, it is argued that the mental health ‘whole’ will be far greater than the sum of the parts. This means that much more research and interventions will have to be put in place in order to obviate a potential mental health and social ‘disaster’.

Mental Disorder in People Living with HIV/Aids in South Africa

We investigate the prevalence of mental disorder in people living with HIV/AIDS in a developing country context and examine the relationship between the presence of mental disorder and various independent variables. Nine-hundred HIV positive people were interviewed in 18 recruitment sites across five provinces in South Africa, using a cross-culturally validated diagnostic instrument and a structured socio-demographic and health information questionnaire. Prevalence of mental disorder was established using the Composite International Diagnostic Interview (CIDI). Chi-square, Fischer exact test, and binary logistic regression examined the relationship between mental health disorders and demographic characteristics, disease stage, CD4 count, and whether the person was on anti-retroviral treatment. A number of respondents (43.7%) were found to have a diagnosable mental disorder. Depression was the most common disorder (11.1% major and 29.9% mild depression), followed by alcohol abuse disorder (12.4%). The presence of mental disorder was significantly associated with gender, employment status, having children, and the clinical stage of the disease. Gender and the stage of disease were the best predictors of mental disorder. Rates of mental disorder were substantially higher in people living with HIV/AIDS than generally found in populations in developing countries and similar to HIV positive groupings in developed countries. Viral impacts on the brain, psychological reactions, and social conditions all contributed to the higher prevalence rates. Mental health interventions need to become a central part of comprehensive HIV/AIDS support, care, and treatment programmes.

Assistance needed for the integration of orphaned and vulnerable children – views of South African family and community members

Guardianship within families is often regarded as the most viable and preferred option for orphaned and vulnerable children (OVC). However, this will place a considerably increased burden on the new caregivers of these children. This study examines whether assistance to prospective families would incline them towards incorporating children and, if so, what would act as ‘threshold’ incentives for them. Adults (N = 1 400) in diverse locations and of various ‘relational proximity’ to children were interviewed in three high HIV/AIDS prevalence provinces in South Africa. Close relatives were more inclined to take in children and would generally require lower levels of assistance than more distanced adults. Nonetheless, for most poor families, no matter their relation to the child, help is critical. More distanced families, friends and strangers also showed a strong willingness to incorporate children - provided they receive sufficient help. For all categories, the greater the assistance the more likely they would be to take in children.While direct financial assistance was important, assistance with education-related costs and having a trained and caring person come in ‘now and then’ to help were also significant factors. The age and HIV status of the child were viewed as important intervening factors in deciding whether or not to take in an additional child/ren by some people.