For Wendy, a recovering injecting
drug user, HIV diagnosis feels like a final blow to an already shattered life. The
news thrusts her into a profound depression; she can’t eat or sleep yet can
hardly get out of bed. She starts having thoughts that the neighbours know her
HIV status and has used heroin to calm her fears. She broods on how she might
kill herself. A nurse specialist with mental health training spots her major depression
the next time Wendy is able to make herself go to the clinic. She refers her to
the liaison psychiatrist, who prescribes an antidepressant and sets up some
sessions with a specialist trauma therapist. There Wendy is able to start
talking about the abuse she suffered as a child, and starts pulling her life
Level 4 covers
specialist mental health support provided by psychiatrists, clinical psychologists
and specialist psychotherapists. It may or may not be HIV-specific: it depends
on local provision but also on how directly the mental health condition and the
HIV are bound up with each other.
[The Standards] are about what needs to be there in order to ensure that wherever a person with HIV enters the system, there will be psychological support. Liz Shaw, Consultant clinical psychologist, St Ann's Hospital, London
Gibson, however, says that providing a specialist team containing experts in
both HIV and mental health means that they can sometimes work with people who
aren’t being helped by standard mental health provision: “We deal with a lot of
people who are difficult characters and who have been diagnosed with
personality disorders – meaning that, by definition, psychological support is
difficult to provide. But we’ll hold them because we know that, if they don’t
engage with the HIV clinic, their health will be at risk.”
specialist team can help in situations where mental health and substance-misuse
problems are bound up with each other, “whereas, in other settings, people tend
to get sent to addiction services and told to stop using first before the
mental health issues that may have led them to take drugs get sorted out.”
of mental illness, Stuart adds, means that psychologists have a useful role in explaining patients to other healthcare
practitioners. “Doctors can sometimes have this naive expectation that if they
tell a patient they must do something
to get well, such as take their pills, they’ll go and do it. Psychologists can
help to explain why some patients don’t seem to act in their own interest.”
tricky areas that practitioners at all four levels need to take into account.
One is the ability to listen for indications that the person is at risk of
suicide, harming themselves or others.
is how to take into account organic and neurological illness, including HIV-related
cognitive impairment. Originally the standards were going to exclude
neurological problems, but given that dementia and depression, for instance, may
imitate each other or coincide, a requirement for cognitive screening is now
included. Members of the writing group are pondering if there is still a need
for guidelines covering diagnosis and treatment of HIV cognitive impairment.
standards – currently a 61-page document, though efforts are being made to slim
it down – may look daunting to a healthcare practitioner who isn’t a mental
health or HIV specialist. One aspect of the recommendations is to identify
existing simple, validated, screening tools – standard questions, for instance
– that can be used with relatively little advance training and which will at
least provide some indication as to who might need onward referral.
are, of course, being implemented at a time when mental health services are
being cut back. The service provided by one interviewee for this piece was
under threat of a complete funding cut, while the other had experienced 75%
cuts to local provision in the last year.
probably not before time that we had, set down in black and white, the range of
services that can make living with HIV not just possible – but bearable.
Update 17 November 2011: The published standards document is now available on the British HIV Assocation website: http://www.bhiva.org/StandardsForPsychologicalSupport.aspx