EFFECTS OF CARE GIVER COUNSELLING ON DEPRESSION AMONG PEOPLE LIVING WITH HIV/AIDS ATTENDING FEDERAL MEDICAL CENTRE, IDO-EKITI.

Summary

 

There is a pandemic of HIV/AIDS all over the world and a new trend is seen in the management of this disease with the advent of highly active antiretroviral therapy, and more advancement in medicine, patients now live longer with the disease.

These facts have brought about the challenges of managing chronic complications of this condition. The chronic complication of interest in this study is depression.

Depression is a chronic complication that affects every stage of management of this condition. Furthermore, attending physicians are increasingly aware of its adverse effect on the management of HIV/AIDS patients. There is an increased urge to add some pills to the already high pill load of these patients in order to manage depression; but pill load is of a concern to both the patient and the physicians.

This study thus looked into the effect of caregiver counselling and follow up on depression among People Living with HIV/AIDS (PLWHA) attending Federal Medical Centre Ido-Ekiti with the aim of reducing the burden of the disease in PLWHA.

An experimental study was performed on 64 depressed HIV patients (32 intervention group and 32 in the control group). These 64 respondents were randomly screened out of 351 respondents using Zung’s self-rating depression scale. On-phone counselling was done for the caregiver of the experimental group for 1 months. Then a post intervention assessment was done for both intervention and control groups.

The age of the studied subjects ranged between 21-80years with a mean age of 41.53 (±9.06) . One hundred and forty-nine of the 351 subjects (42.5%) were found to have one form of depression or the other. Furthermore 57.5% are not depressed 17.1% had mild depression,

10.3% had moderate depression and 15.1% had severe depression. One hundred and two

(29.1%) of the respondents came from a severely dysfunctional family, 193(55.0%) from a moderately dysfunctional family and 56 (16%) from a highly functional family. In this study family functioning had a direct relationship with the presence of depression. After the intervention with caregiver counselling, 59.4% of the depressed patients in the intervention group recovered from depression as opposed to 3.2% in the control group.  Therefore, there is a statistically significant effect of caregiver counselling on depression among PLWHA with a P-value of <0.001.

A large proportion of PLWHA goes about with depression. Care giver counselling proved to be effective in the management of depression in this study without the necessity of adding antidepressant pills.

The key findings are as follows

The percentage of the intervention group that suffered severe depression reduced from 40.6% to 6.2% after the intervention as opposed to a marginal reduction of 34.4% to 31.2% in the control group.

A very strong statistically significant effect was found for the use of caregiver counselling to intervene in the management of depression among PLWHA. The intervention programme in this study resulted in significant improvement of depression in the study group. This is likely the only reason why more than half of the respondents experienced resolution of depression, because no other intervention was given to that group.

The attending physician could do well by involving caregivers of PLWHA in the management of these patients. Programmes of co-management with caregivers, care giver counselling and education could be undertaken periodically to improve the psychological well being of these patients.

TABLE OF CONTENTS

Title Page                                                                                                                    i

Declaration                                                                                                                 ii

Certification          iii Dedication          iv

Acknowlegdement                                                                                                      v

Table of Contents                                                                                                        vi

List of Abbreviations                                                                                                  vii-ix

List of Tables and Figures                                                                                          x

Summary                                                                                                                    1

Chapter One: Introduction                                                                                          3

Chapter Two: Literature Review                                                                                10

Chapter Three: Materials and Methods                                                                      43

Chapter Four: Results                                                                                                 60

Chapter Five: Discussion and Conclusion                                                                 75

Recommendations and Limitations                                                                            80

References                                                                                                                  82

Appendices                                                                                                                 93

Questionnaire                                                                                                 93

Subject Information Sheet and Informed Consent                                         99

Counselling Prototype used for counselling of each care giver                                 100

 

CHAPTER ONE

1.0. INTRODUCTION

Human Immunodeficiency Virus (HIV) types derived from primate lentiviruses are the aetiologic agents of AIDS. The illness was first described in 1981 and HIV1 was isolated by the end of 1983.¹ The disease was first recognised in the United States of America as a strange illness among a small number of gay men in 1981.² By 1982, the condition had acquired a number of names which included gay-related immune deficiency syndrome (GRID), gay cancer, community-acquired immune dysfunction and gay compromise syndrome.² The Centre for Disease Control and prevention (CDC) used the term Acquired Immune Deficiency Syndrome (AIDS) for the first time in September 1982.² The first two cases of HIV and AIDS in Nigeria were identified in 1985 and were reported at an international AIDS conference in 1986.³ Once infected, an individual remains infected for the rest of his/her life, hence the chronic nature of the disease. HIV is a retrovirus, a member of the lentivirus genus, and it exhibits many of the physiochemical features typical of the family.

The virus persists indefinitely in infected hosts though it may be present at very low levels. The viruses have high mutation rates and different mutants are selected under different conditions (host factors, immune responses, tissue types.¹) The viral infection progresses slowly through specific stages.² It may take years for disease to develop. Infected hosts usually produce antibodies but they do not clear the infection. In other words, the persistence of the virus in the host becomes life-long.⁴ The time between HIV infection and death depends on a number of related factors with therapeutic management with anti-HIV medications being the most important. Related to this are factors such as how soon anti-HIV treatment was commenced and whether or not such treatment was faithfully maintained over long period of time. HIV infection passes through a series of steps or stages before eventually turning into AIDS,⁵ where AIDS indicates the highly advanced form of the HIV disease.⁵

Over the past 27 years, 25 million people have died from AIDS⁵. AIDS causes debilitating illnesses and premature death in the infected individuals especially during their prime years.⁵ The effect of this is devastating both on the immediate families and on the communities.⁶  When HIV kills or damages cells of the body's immune systems, it progressively destroys the body's ability to fight infections and certain cancers.⁷

Breaking the news to anybody that he / she is HIV positive sounds like a death sentence. It affects the mental health of the patient with its attendant effects on morbidity and mortality. People with HIV/AIDS are subjected to numerous stressors that can impact their mental health which can negatively affect compliance with medications, which in turn affects morbidity and mortality. In busy clinics, or with unwary staff, depression in HIV/AIDS may be readily overlooked, down-played or completely go undetected. Depression is a mental state involving alterations in mood and characterised by feelings of sadness, despair, and discouragement.⁸ It is the lowering of mood beyond the normal range of ups and downs encountered in normal life which is sustained over time and to such a degree that the person's quality of life is significantly impaired.^8,9  Depression is a serious medical condition that affects thoughts, feelings and the ability to function in everyday life. It can affect any age bracket. In addition, it is well documented that chronic diseases such as hypertension, diabetes mellitus, stroke and HIV infection predispose people to depression.¹⁰ When a person has both depression and a chronic physical health problem, functional impairment is likely to be greater than if he/she only has either depression or a physical health problem.¹⁰ Depression is approximately two to three times more common in patients with a chronic physical health problem (prevalence of about 20 %) than in people who have good physical health.¹⁰ Depression in PLWHA has consistently been reported to be higher than the 12  ̶ 15 % rate reported for the general population. Furthermore, depression in this population is largely untreated. Estimates suggest that this co-morbid condition of HIV affects 10  ̶ 50 % of PLWHA.⁸ Improvement in health care delivery has enabled many men and women and young people living with HIV/AIDS live longer and productive life.⁷ As with other chronic illnesses such as cancer, heart diseases and stroke, HIV/AIDS too can be accompanied by depression. Treatment for depression helps people manage both diseases, thus enhancing survival and good quality of life.¹

Depression is the most frequently observed psychiatric disorder among HIV/AIDS patients.¹⁰ In addition, there are vivid pieces of evidence that support the fact that gender affects the development of psychiatric morbidity among HIV positive individuals. In a study, over 15.87

% of HIV positive women and 10 % of HIV negative women have current major depression. These figures, however, approach twice the value for HIV positive men¹¹. However, the prevalence of depression worldwide ranges from 20-70 %.¹²  There is significant association between depressive symptoms and mortality with women who reported chronic depressive symptoms being two times more likely to die than women with limited symptoms after controlling for various confounding factors.¹¹

The management of depression in PLWHA is of paramount importance since depression is capable of negatively impacting medication adherence. For instance, a depressive patient may not be well motivated to take his/her drugs.

Depression is a pressing problem at this point in the epidemic of HIV/AIDS especially because the HIV population is aging and the incidence of depression increases with age. The main cause of depression among PLWHA is stigmatization and the fact that the disease is terminal in nature.

Poor health related quality of life in Nigerian subjects living with HIV was associated with depression e.g. lower educational and socio-economic levels, and poor social support.⁴ If social support could be encouraged in the management of depression in PLWHA, the outcome of management may improve.

In patients with HIV/AIDS in Nigeria when one member of a family has the disease the whole family is called ‘’AIDS family’’ by other villagers.¹³ Studies have shown that disclosure of HIV positive status can however result in greater social support, which in turn has positive effect on psychological wellbeing.¹⁴ Family and friends already affect patient self-management since daily eating, physical activities and even stress management happen in the settings of social activities and relationships.¹⁵ By extension, improving family support and social relationships may translate to improved outcome of management of depression among people living with HIV/AIDS.

Over 50 per cent of people with chronic disease like diabetes or heart disease report that their families are involved with planning which foods are best for their health and about 30 per cent of families get involved with patient medication taking and self-testing.¹⁶ There is extensive research that proves conclusively that family support, education and psycho education improve both patient outcomes and family functioning in both medical and

psychiatric illnesses.^15,17-19

Hence, this is to be verified in the case of HIV patients. Clinical experience holds that families influence and are influenced by the health of their members, and that family-oriented primary care can lead to improved health for both the individual patient and the family as a whole.^{19, 20} In Africa, the rich cultural and family ties could be explored to manage patients with depression in chronic diseases like HIV/AIDS and this may have positive impact on the outcomes.

Family oriented care may not be possible if there are no gate-ways into the family. This gateway could be somebody who is most concerned about the patient’s health condition. These people are termed collaborators or care givers.²¹ Family oriented questions will bring out these care givers.

The term care giver refers to unpaid family member, friend, or neighbour who provides care to an individual who has an acute or chronic condition.²²They could be called family care givers or informal care givers. Recent survey estimates there are 44 million care givers over the age of 18years.²²

Furthermore, care givers spend substantial amounts of their time interacting with their care recipients, while providing care in a wide range of activities.²² On average, informal care givers devote 4.3years to this work while dealing with a chronic illness. This is a day in day out responsibility and more than half of family care givers provide 8 hours of care or more weekly and one in five provides more than 40 hours per week.²²

Family care givers often feel unprepared to provide care, they have inadequate knowledge to deliver proper care and receive little guidance from the formal health care provider.²² Family care givers function as advocates and provide physical, emotional and financial support frequently without training and often without recognition or support. Without the multitude of these unpaid family care-givers, many people would live in institutions.²³ How can we as health care providers provide education and support for these caregivers? This question could be answer in this study.

 

1.1.  JUSTIFICATION FOR THE STUDY

Depression is one of the most common psychological problems affecting nearly everyone either through personal experience (affective losses, incurable disease and rejection of any sorts) or through depression in a family member.¹⁵ Over 67 % of Nigerian adults above 45years experience a period of clinical depression.²⁴

It is a common statement in the HIV clinic at Federal Medical Centre Ido-Ekiti that patients have defaulted but nobody has actually considered the fact that the patients might default due to depression or even suicide in extreme cases. These affected patients often have moody appearances, paucity of speech and many of them are not forthcoming at discussions in the clinic. Presently, social workers are doing a great job of motivating the patients; they visit patients at home to identify with them, encourage them to join support groups and more often than not encourage them to take their drugs. Unfortunately this approach is increasingly failing because most patients do not want to be visited at home because of the stigma associated with the disease. In fact, majority of the patients give fake names and addresses in the clinic making them difficult to be traced. Despite the availability of antiretroviral drugs and treatment, the care and support of people living with HIV/AIDS has continued to be a major challenge, with greater impact not only on the people living with the disease but also on those who care for them. The care and support of this group might not be adequate if health workers do not recognize and encourage the role of informal care givers. This study will establish the correlation between depression and CD4 count in the subjects attending HIV clinic of the centre. Furthermore an additional pill in the form of antidepressant may complicate the already cumbersome HAART, but the rich socio-cultural heritage in Nigeria viz the informal care giver which is left unutilized could be utilized in the management of this co-morbidity.

From this type of study, more information will be available on the ways this population could be effectively managed. The influence of the family care giver in the outcome of treatment will be revealed and the importance of patient education will be re-emphasised. The current prevalence of the co-morbidity in this centre will be available and this can be used by policy makers to influence intervention in the management of the co-morbidity. Programmes of health workers' education on psychiatric illness, family oriented interviews and care giver counselling, could be engineered from the result of this type of study.

This study will contribute to the existing knowledge on effect of family support and care giver support and education on treatment outcomes of PLWHA. It will also add to the body of knowledge in the management of chronic illnesses like depression.

 

1.2.   GENERAL OBJECTIVES:

To determine the effect of caregiver counselling on depression among people living with HIV/AIDS with a view to reducing the burden of depression in the study population.

 

1.3.   SPECIFIC OBJECTIVES

1. To determine the pattern of depression among PLWHA attending Federal Medical

Centre Ido-Ekiti

2. To determine the relationship between family functioning and depression among

PLWHA

3. To determine the relationship between CD4 count and depression; and between BMI and depression among PLWHA
4. To determine the effect of care giver counselling on depression among depressed PLWHA

EFFECTS OF CARE GIVER COUNSELLING ON DEPRESSION AMONG PEOPLE LIVING WITH HIV/AIDS ATTENDING FEDERAL MEDICAL CENTRE, IDO-EKITI.

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