Mental health—a bridge not so far
Authors: Lorraine Sherr
Journal: The Lancet Global Health (2017)

The world now faces the next step in HIV management. We are in an era beyond treatment and viral suppression. The widespread roll out of antiretroviral treatment and good HIV testing programmes within pregnancy might substantially change vertical transmission rates globally. Lifelong treatment and innovations, such as those financed by the Global Fund, provide a pathway— indeed a lifeline—for survival. Yet, the scars of an epidemic are deep. Exposure to trauma and loss can affect children and youth for many years. Interventions for such trauma are improving, but recent reviews suggest a need for more solid evidence.1Baxter C Abdool Karim S Combination HIV prevention options for young women in Africa.Afr J AIDS Res. 2016; 15: 109-121Crossref PubMed Scopus (25) Google Scholar In The Lancet Global Health, Tonya Thurman and colleagues' study2Thurman TR Luckett BG Nice J Spyrelis A Taylor TM Effect of a bereavement support group on female adolescents' psychological health: a randomised controlled trial in South Africa.Lancet Glob Health. 2017; (published online April 24)http://dx.doi.org/10.1016/S2214-109X(17)30146-8PubMed Google Scholar provides a randomised controlled evaluation of an intervention for bereaved adolescent girls in South Africa. As such, it marks an important shift in the evidence base and contributes to the growing provision in this area as well as providing usable tools. Mental health effects of the HIV epidemic are not only a key consideration, but might have been neglected especially in contexts of greatest resource constraints. The infrastructure and provision of mental health services in low-income and middle-income settings needs urgent attention. This study—despite specific limitations—is a clear example of potential provision and a way forward. The study showed effective impacts of a brief therapeutic intervention, including significantly lower intrusive grief, depression, and behaviour problems, and higher support. The intervention was confined to those who were willing to be included. However, it is well established in the psychological therapies that motivation and willingness for support is a pre-requisite for successful intervention. The study was confined to adolescent girls—again clearly noting a gap for adolescent boys who might have equal need, but could require adjusted interventions and different strategies to both reach them and to do so effectively. There is a growing body of evidence showing the efficacy of complex interventions3Thurman TR Kidman R Carton TW Chiroro P Psychological and behavioral interventions to reduce HIV risk: evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa.AIDS Care. 2016; 28: 8-15Crossref PubMed Scopus (28) Google Scholar for improving wellbeing and reducing adolescent risk behaviour.4van der Heijden I Abrahams N Sinclair D Psychosocial group interventions to improve psychological well-being in adults living with HIV.Cochrane Database Syst Rev. 2017; 3 (CD010806)PubMed Google Scholar A recent Cochrane review5Ramaiya MK Sullivan KA O' Donnell K Cunningham CK Shayo AM Mmbaga BT Dow DE A qualitative exploration of the mental health and psychosocial contexts of HIV-positive adolescents in Tanzania.PLoS One. 2016; 11: e0165936Crossref Scopus (38) Google Scholar identified only 16 quality trials of psychological interventions for adults affected by HIV. The evidence base for adolescents is even less robust. Emerging reports show the nature of mental health burden experienced by adolescents6Jani N Vu L Kay L Habtamu K Kalibala S Reducing HIV-related risk and mental health problems through a client-centred psychosocial intervention for vulnerable adolescents in Addis Ababa, Ethiopia.J Int AIDS Soc. 2016; 19: 20832Crossref PubMed Scopus (12) Google Scholar and forms of effective provision, such as client centred approaches in Ethiopia.7Caserta TA Pirttilä-Backman AM Punamäki RL Stigma, marginalization and psychosocial well-being of orphans in Rwanda: exploring the mediation role of social support.AIDS Care. 2016; 28: 736-744Crossref PubMed Scopus (11) Google Scholar This study adds to the evidence base—especially for adolescents where the data are much more limited.8Sherr L Yakubovich AR Skeen S Cluver LD Hensels IS Macedo A Tomlinson M How effective is help on the doorstep? A longitudinal evaluation of community-based organisation support.PLoS One. 2016; 11: e0151305Crossref Scopus (17) Google Scholar It marks the importance of the mental health burden of bereavement on adolescents—especially heightened by the many parental deaths within high endemic HIV settings. The study also explored the links between mental health and behaviour and showed how a brief intervention could reduce intrusive grief as well as reduce adult reported behavioural problems. As such, this small study is an example of the next generation of vital interventions. Acknowledgement of mental health issues is needed—especially in children and youth, and an active attempt needs to be made to measure this and to provide responsive pathways for redress. Evidence based interventions that are theory driven and accessible within the local culture are do-able and do not need to rely on imported interventions—especially when those are costly. Many bereaved children and youth reside in the community and have little recourse to good psychosocial support, despite the fact that such care has been shown to be of benefit.9Gillies D Maiocchi L Bhandari AP Taylor F Gray C O'Brien L Psychological therapies for children and adolescents exposed to trauma.Cochrane Database Syst Rev. 2016; 10 (CD012371)PubMed Google Scholar This study highlights group interventions as a cost-effective quality support provision. In low-income and low-resource settings, the urgency of physical survival, the presence of dire poverty, and the absence of skilled services and infrastructure has often resulted in a focus on physical survival. The time has now come for mental health to be given adequate attention. This will require investment in infrastructure and personnel. It will also require an approach to care that incorporates the importance of mental health. Bereavement provision for survivors of HIV-related deaths might reduce as treatment reduces death rates. However, many communities are still carrying the burden of HIV within their midst and interventions that can ameliorate suffering, depression, and emotional burden are sorely needed. I declare no competing interests. Effect of a bereavement support group on female adolescents' psychological health: a randomised controlled trial in South AfricaShort-term, structured, theory-based support groups with contextually relevant content show promise in mitigating psychological and behavioural problems among bereaved adolescents. Abangane is replicable in resource limited settings, using freely available curriculum materials, existing programme structures, and appropriately trained personnel to implement it. Full-Text PDF Open Access