Awareness and knowledge of integrated counselling and testing centres (ICTC) counsellors about depression among people with human immunodeficiency virus (HIV): A descriptive study from Karnataka

Abstract

Background:

Depression among people living with human immunodeficiency virus (PLHIV) is highly prevalent and it is associated with increased morbidity, poor adherence to antiretroviral therapy, and poor psychosocial outcomes. To address this, integrated counselling and testing centres (ICTC) counsellors provide psychosocial support to PLHIV.

Materials and Methods:

This descriptive study aims to assess the awareness and knowledge of ICTC counsellors about depression and its management. A total of 338 (n = 452) ICTC counsellors participated in the study. A demographic data sheet and a semi-structured questionnaire were used to collect data.

Results:

More than half of the participants reported that biochemical imbalances cause depression. 71.60% and 79.59% of participants reported that depression was common among PLHIV and required immediate attention. 92.60% of counsellors reported that a combination of counselling and medication would be effective to treat depression. 86.98% and 81.95% of counsellors were confident and actively screened for depression among PLHIV, and 78.11% of counsellors had access to a psychiatrist. In contrast. One-third of participants had difficulties working with PLHIV, and 55.56% of participants expressed that addressing issues of PLHIVs’ depression to be left to mental health professionals.

Conclusion:

ICTC counsellors had adequate knowledge about depression and its symptoms. However, lack of knowledge on intervention strategies, time constraints and work targets are significant barriers. These findings suggest that training on mental illness screening; brief intervention strategies may help counsellors to assist PLHIV in overcoming depression complications.

Depression is the most common psychiatric condition among people living with human immunodeficiency virus (PLHIV), with its prevalence varying from 22% to 71%.[1] Despite the high prevalence, depression often remains undiagnosed, and negatively affecting the quality of life of sufferers.[2] The unrecognised depression leads to psychiatric morbidity, contributes to high-risk behaviour and nonadherence to antiretroviral therapy.[3,4] PLHIV with depression struggles to handle daily life situations and finds difficulty in relationships with spouses and family members.[5] Fear of transmission to others, changes in the pattern of sexuality and emotional intimacy, stigma and discrimination, lack of social support, financial constraints, substance use and loneliness lead to poor health outcomes.[6,7] In India, 57% of PLHIV were non-adherent to antiretroviral therapy (ART), and 17.22% were lost to follow-up due to drug use, psychiatric conditions, and stigma.[8,9,10] The lack of trained mental health professionals appears to be a significant barrier to addressing the psychiatric and psychosocial problems of PLHIV.[11] This condition indicates the necessity of psychosocial intervention.

Integrated counselling and testing centres (ICTC) counsellors regularly contact PLHIV to offer social and emotional support to ameliorate their health.[12] ICTC counsellors are involved in pre- and post-HIV test counselling, educating PLHIV about high-risk behaviours, signs and symptoms of sexually transmitted infections, and reproductive tract infections, emphasising treatment initiation, adherence to medications and risk reduction.[13] However, common psychiatric problems and psychosocial issues are unaddressed during their visits to ICTC centres.[14] In this context, training ICTC counsellors about major and minor mental disorders and their management strategies will enhance the ability of counsellors to conduct the mental health screening of PLHIV in regular clinical follow-up and offer psychosocial interventions and referral services for mental health problems.

MATERIALS AND METHODS

The current study was conducted as a part of the counsellor’s training programme on delivering psychosocial intervention modules for common mental disorders (CMDs) among women living with HIV/AIDS by the National institute of mental health and neurosciences, Bengaluru. The training programme was intended to develop a psychosocial intervention for CMDs among women living with HIV/AIDS, and capacity building of ICTC counsellors in delivering the psychosocial intervention. This half-day training programme was conducted with the permission of the Karnataka AIDS prevention society during the ICTC counsellors’ monthly review meeting at the District AIDS prevention and control unit in 30 districts of Karnataka. A total of 338 out of 452 counsellors with postgraduation either in social work or psychology participated in the monthly review meeting and all of them were invited to the study between January 2018 and 2019 after obtaining written informed consent.

Tools

The study used a demographic data sheet to collect information about age, education, place of work, years of experience in HIV counselling, and participation in any mental health training programme.

To assess awareness and knowledge, the researchers adopted a self-administered questionnaire from published articles on awareness and knowledge about depression and its management among PLHIV.[15,16,17,18] Further, the questionnaire was content validated by five experts with experience in the mental health field. This instrument is a three-point Likert scale (agree, neutral and disagree) consisting of 28 items and five domains such as 1) etiology of depression in PLHIV, 2) importance of depression in PLHIV, 3) knowledge of depression in PLHIV, 4) ability and willingness of ICTC counsellor to manage depression and 5) access to mental health professionals.

Statistical analysis

Descriptive statistics such as mean, standard deviation and frequency distribution were used to describe the data and analysis was done through Statistical Package for Social Sciences version 20.0.

Permission and ethical approval

The study has obtained permission and approval from the Karnataka state AIDS prevention society and institutional ethics committee.

RESULTS

Socio-demographic characteristics of the sample

Most participants were male (61.83%), and the mean age was 37 years (SD ± 5.35). All of them had studied postgraduate either in social work or in psychology. The mean years of experience as a counsellor was 9.33 (SD ± 4.08). The majority (58%) of participants had no prior experience of working with people with mental illness, and 55.62% had obtained mental health training during their postgraduation.

The participants had varied opinions about the causes of depression among PLHIV. Even though 53.55% believed biochemical changes as the cause, 58.28% thought recent misfortune could be the reason for depression. Further, 73.08% considered depression a personal weakness, and 60.65% agreed that PLHIV took the blame on them for the depression. More than one-third of counsellors (35.21%) felt that depression in PLHIV complicates the situation and made their work challenging [Table 1].

Table 1.

Etiology of depression in PLHIV

Etiology of depression in PLHIV	Agree % (n=338)	Neutral % (n=338)	Disagree % (n=338)
Depression is a result of biochemical changes	53.55	16.27	30.18
Recent misfortunes are the cause of depression	58.28	17.46	24.26
People who develop depression usually have only themselves to blame	60.65	19.53	19.82
Depression is a sign of personal weakness	73.08	8.88	18.05
It is difficult to work with PLHIV who have depression	35.21	9.76	55.03

Most participants agreed that depression was common among PLHIV (71.60%) and worsened their somatic symptoms (81.07%). Further, nearly half of the participants reported that mental health was less emphasised than physical health problems. Most participants (71.06%) agreed that depression causes risky behaviour, failure of ART (49.70%) and dropout of care (74.56%) [Table 2].

Table 2.

Importance of depression in PLHIV

Importance of depression in PLHIV	Agree % (n=338)	Neutral % (n=338)	Disagree % (n=338)
Depression is common among PLHIV	71.60	11.24	17.16
Among PLHIV, mental health problems are less important than physical health problems	49.70	9.76	40.53
Depression in PLHIV needs concern and attention	79.59	13.31	7.10
Depression worsens somatic symptoms in PLHIV	81.07	13.02	5.92
PLHIV with depression are less likely to be adherent to antiretroviral therapy	73.67	9.47	16.86
PLHIV who are depressed are more likely to engage in risky behaviours	71.60	14.79	13.61
PLHIV with depression are more likely to have antiretroviral treatment failure	49.70	15.68	34.62
PLHIV who are depressed are more likely to drop out of care	74.56	15.98	9.47

Most participants agreed that depression was a treatable psychiatric condition (94.38%). It must be treated with a combination of counselling and medications (92.60%) before it worsens (89.64%) [Table 3].

Table 3.

Knowledge of depression

Knowledge of depression	Agree % (n=338)	Neutral % (n=338)	Disagree % (n=338)
Depression is treatable	94.38	4.44	1.18
Depression needs to be treated before it worsens	89.64	7.40	2.96
Counselling is enough to treat depression	65.68	11.54	22.78
Medication is enough to treat depression	32.84	17.16	50.00
Medication and counselling are an excellent combination to treat depression	92.60	3.85	3.55

Most participants (81.95%) screened for depression in their patients. Half of the participants attended training on mental health. Time constraints (46.45%) and lack of knowledge (44.38%) were significant barriers to assisting PLHIV with depression. Most participants were confident (92.60%) in their ability (86.98%) to counsel PLHIV with depression and discuss mental health problems (91.42%). However, one-third of the participants felt that it was inappropriate for a clinician to bring up mental health problems with PLHIV [Table 4].

Table 4.

Ability and willingness of ICTC counsellors to manage depression

Ability and willingness of ICTC counsellors to manage depression	Agree % (n=338)	Neutral % (n=338)	Disagree % (n=338)
I actively look for depression among PLHIV	81.95	10.95	7.10
Time constraints prevent me from helping PLHIV with depression	46.45	21.30	32.25
I attended formal training on mental health disorder	56.21	16.57	27.22
Lack of knowledge/training about depression prevents me from helping PLHIV with depression	44.38	19.23	36.39
I am confident in my ability to help PLHIV with depression	92.60	5.33	2.07
I am confident in my ability to counsel PLHIV with depression	86.98	8.88	4.14
I am comfortable discussing mental health problems with PLHIV	91.42	5.03	3.55
It is generally inappropriate in India to discuss mental health problems with patients	32.54	18.05	49.41

Most participants had access to a psychiatrist and other mental health professionals (78.11%). More than half the participants reported that diagnosing and managing depression in PLHIV are the duty of psychiatrists and other mental health specialists (55.92%).

DISCUSSION

Mental illness is one of the leading causes of disability among PLHIV. Nearly 50% of people with mental illness, including PLHIV, do not receive adequate mental health care.[19] Most PLHIV has been stigmatised at the community and family level, and those identified with mental illness may experience double stigma.[20] In India, as low as 0.6 psychiatrists, 0.4 psychiatric nurses, 0.3 psychiatric social workers, and clinical psychologists are available for one lakh population.[21] In addition, the shortage of trained mental health professionals also contributes PLIHIV’s burden in low and middle-income countries.[22] As the prevalence of depression is relatively high among PLHIV,[23] it is necessary to use the service of ICTC counsellors to address the mental health problems of PLHIV. Our study showed that counsellors’ understanding is in line with the existing research findings that mental health problems such as CMDs, posttraumatic stress disorder, alcoholism, and depression are common among PLHIV.[24,25,26,27]

Further, counsellors reported that depression among PLHIV could lead to poor adherence to ART treatment, drop out of care and worsening of HIV condition. Similar findings were obtained from a study on depression and associated factors among people with HIV.[28] These findings indicate that the ICTC counsellors had a fair understanding of the psychiatric comorbid conditions including depression and management. The reason behind is that all counsellors had either postgraduation in psychology or social work, and these two disciplines comprise papers on counselling.[29] In addition, previous working experience in the mental health field also could have contributed to gaining knowledge about HIV/AIDS and depression among PLHIV.[30]

The counsellors identified depression as a critical comorbid psychiatric condition among PLHIV. However, more than half of the counsellors reported that recent misfortune, personal weakness, and PLHIV themselves were responsible for their depression. A similar kind of varied response regarding the causes of depression was found among ICTC counsellors in another study from India.[31] Studies among nursing students and general hospital staff, including counsellors, reported poor knowledge and negative attitude towards PLHIV.[32,33] Despite the adequate knowledge of depression among counsellors, the varied responses show that continued mental health awareness training for counsellors is needed to improve their understanding and to change their attitude as well.

Our study showed that more than half of the counsellors were chosen both pharmacological and non-pharmacological (medication and counselling) treatment options that are good for treating depression. As counsellors are involved in pre- and post-test counselling, prevention and health education, psychosocial support, referrals, and monitoring of PLHIV, they might have witnessed the efficacy of the combination approach.[13,34] In addition, they also obtained supervision and training in counselling and psychosocial services.[35,36] The job experience, training, and supervision have helped counsellors to develop a biopsychosocial perspective and to realise the importance of an integrated approach to address depression complications.[37]

The counsellors were comfortable discussing mental health issues with PLHIV and were confident in counselling them to manage their depression. In contrast, more than half of the participants reported that addressing mental health issues is the job of mental health professionals. Time constraints and lack of formal training about the treatment and other interventions for depression were significant barriers to dealing with depression among PLHIV. A south Indian study on the job perception of ICTC counsellors reported that lack of time and support, administrative and clerical work, and work targets were barriers to helping PLHIV.[34] Developing brief assessment tools, training and supervision on screening, brief intervention and access to referral services might help counsellors address mental health issues effectively.[38] Therefore, the study recommends that National AIDS control organisation and state-level AIDS prevention societies encourage counsellors to conduct mental health screenings for PLHIV. Therefore, they can access mental health care and can minimise adverse HIV outcomes.[23]

Strengths and limitations of the study

The current study covered 338 ICTC counsellors from 30 ICTC centres in Karnataka. The study results can be generalisable to the intended professionals. The researchers visited each centre and collected data directly so the counsellors could clarify doubts in the study questionnaire, reducing errors in data collection. However, the questionnaires used in the study were not standardised, and thus the researchers had limitations in performing appropriate inferential statistical analyses. Keeping the limitations apart, this is one of the studies focusing on the awareness and knowledge of the ICTC counsellors towards addressing depression among PLHIV.

CONCLUSION

The study suggests that the ICTC counsellors’ understanding of depression among PLHIV is fair. They acknowledged the importance of both pharmacological and non-pharmacological treatment for depression. However, lack of time and support, administrative work, and inadequate training on managing depression are barriers which prevent ICTC counellors from offering quality mental health services to PLHIV.

Financial support and sponsorship

The training programme on psychosocial intervention on common mental health problems was funded by the National Health Mission, Government of Karnataka. To conduct the present study and in data collection and analysis, the funding agency did not participate.

Conflicts of interest

There are no conflicts of interest.