Aim of the study is to explore the perceived impact of mental illness, reported coping strategies and reported needs of family members of mentally ill patients attending the Parirenyatwa Annexe Psychiatry Unit in Harare, Zimbabwe.

Background: Survival of children and adolescents with HIV/AIDS has greatly improved with antiretroviral treatment. These young people now live with a chronic, rather than a fatal disease, which has brought into focus issues of quality of life, including the emotional and behavioral wellbeing of those living with the disease. HIV infection is associated with poor mental health and a high prevalence of behavioral and emotional problems in affected adolescents. Despite this burden of emotional and behavioral problems, the majority of HIV care services in sub-Saharan Africa do not have mental health care services specifically targeting adolescents with HIV. In order to address mental health in this population, it is important to explore their explanatory models to understand aspects such as how they view their symptoms, and what treatment or support they prefer. At the present time, research is scarce regarding explanatory models of mental disorders in HIV-positive adolescents and no study has been conducted in Uganda. This study aimed to address this gap by exploring the explanatory models of mental disorders and perceived daily life challenges in HIV-infected adolescents who had been diagnosed with a common mental disorder. Methods: This qualitative study was nested in a longitudinal epidemiological study that investigated prevalence, incidence and risk factors for mental health problems in HIV-infected children and adolescents in rural and urban Uganda. In-depth interviews were conducted with adolescents aged 12 to 17 years who had been diagnosed with depression, anxiety or attention deficit hyperactivity disorder (ADHD). Case vignettes were used to enable adolescents to talk about their experiences and daily life challenges. Written consent and assent were sought from caregivers and adolescents respectively. Data were processed and analyzed thematically. NVivo-11 was used to manage data for analysis. Results: Twenty-one adolescents participated in the study. Most adolescents (9/21) in the study were living with their grandparents. Twelve were in primary school and 4 had dropped out. The main findings were: (i) the adolescents had not been informed about their mental disorder diagnoses and none viewed their symptoms as illness, (ii) they attributed their symptoms to daily life problems, such as poverty and interpersonal relationship problems, and did not mention biomedical or spiritual causes, (iii) they thought that their symptoms would improve with time, and financial and emotional support were also important. Conclusion: The findings of this study highlight the need for action at the mental health policy and practice levels. The main areas for such intervention include mental health literacy, screening and intervention in healthcare settings, and psychosocial interventions in community and school settings for affected adolescents and their caregivers.

Includes abstract. Includes bibliographical references.

A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Community Psychology) in the Department of Psychology University of Zululand, South Africa, 2003. / The state has committed itself to the integration of mental health and primary health care services in order to utilise resources more efficiently and to provide comprehensive care to the population. Primary health care nurses are generally lacking in mental health skills. The provision of training for them has been identified as being essential if integration is to succeed. The various provinces have differed from each other in their approaches to integration and training. In Kwa Zulu-Natal, no training programs had been introduced by the provincial health authorities until recently. This study aimed to provide a training program in child mental health for primary health care nurses in the Ugu region. A group of fourteen nurses were trained in the diagnosis and management of four frequently occurring child mental health problems. Their knowledge prior to training was assessed and compared to that of a group of psychiatric nurses and a group of primary care nurses undergoing training in a general mental health program conducted by the Department of Health. Their attitude towards integration was also compared to that of the group of psychiatric nurses. It was found that prior to training, both groups of primary care nurses knew significantly less about these conditions than did the group of trained psychiatric nurses. After training, the group that had been trained in the writer's program were found to have improved their knowledge to a level similar to that of the psychiatric nurses. The group undergoing training in the department's program made no significant gains in knowledge when compared to the other two groups. It was concluded that the department's program may be deficient in certain aspects and needs to be reviewed. Both primary health care nurses and trained psychiatric nurses anticipate various problems related to the proposed integration of services. It is argued that for integration to be successful these concerns and issues need to be urgently addressed.

A dissertation submitted to the Faculty of Education in partial fulfillment of the requirements for the Degree of Masters in Educational Psychology in the Department of Educational Psychology & Special Needs Education at the University Of Zululand, 2017 / The aim of this study was to assess the mental health status of school going adolescents on ART. The objectives of the study being to establish the status of mental health before and after these adolescents are placed on ART. A literature study was done in order to determine the feasibility of the study and in order to strengthen the need for such information to be known. A qualitative approach was used so as to gain insight into the topic. Data was collected using face to face interviews and an interview guide was prepared to guide the discussions between the researcher and the participants. The data collected was thematically analysed and the results were presented using the research questions and the themes that emerged in answering those questions. Themes and sub-themes that emerged included compliance; fear of disclosing; normalisation of life with HIV; acceptance and support from family; fear of rejection, stigma and discrimination; institutional support; morally judged. Since participants were young when they tested mental health changes occurred once their status was disclosed to them. The adolescents have unresolved mental health issues and which become unknown to the healthcare workers due to ineffective communication. Participants were still preoccupied with the thought that they will be on ARVs for the rest of their lives. Key problems faced by the adolescents included preoccupation about the future, fear of stigma and discrimination and reject from society. There were no feelings of anger towards their caregivers once their status was disclosed to them. Only feelings of fear and confusion were raised which were quickly addressed by caregivers. Recommendations were included to address the concerns highlighted in the study and these included a need to address factors such as disclosure, stigma and discrimination as these directly and indirectly have an impact on the mental health of HIV positive adolescents and follow-up research needs to be done to document the lives of adolescents post admission in the ART programme.

Suicidality is a major public health issue and is more common among people with disabilities. However, relatively little is known about the context and specifics of suicidality among adults with disabilities compared to their peers without disabilities. This dissertation presents three different analyses of suicidality and disability using a sample of American adults. Chapter I introduces the topic and dataset. Chapter II presents an analysis of the internal consistency, mean scores, and response patterns on the Suicidal Behavior Questionnaire—Revised (SBQ-R) by disability status in order to establish the internal of the measure in people with disabilities and explore the uniformity of suicidality in people with and without disabilities. Participants with disabilities tended to more frequently endorse response choices consistent with increased past, current, and perceived future suicidality. Chapter III presents an analysis of the relationship between suicidality, disability, and psychiatric disability. Disability remained a significant predictor of suicidality even when depressive symptoms were included in the analysis, and psychiatric disability predicted greater suicidality within the disability subsample, even when depressive symptoms were controlled for via statistical analysis. Chapter IV presents an analysis of suicidality and disability within the context of both depressive symptoms and sociodemographic risk and protective factors for suicidality. Participants with disabilities experienced more sociodemographic risk factors than participants without disabilities; however, disability status remained a significant predictor of suicidality even when sociodemographic risk and protective factors, as well as depressive symptoms, were included in the analysis. Chapter V summarizes and concludes the dissertation, including our consistent and major finding that disability is linked to significantly higher suicidality, even when depression and sociodemographic risk factor are accounted for in statistical analysis.

ABSTRACT Background: Tremendous progress has been achieved in the treatment for HIV/AIDS since the 1980s. This significant improvement and progress in HIV treatment has largely been attributed to antiretroviral therapy (ART). Non-adherence to ART commonly causes ART treatment failure and the development of drugresistant strains of HIV, resulting in increased mortality. Common mental disorders have been found to be strongly associated with non-adherence. In Malawi, where HIV is prevalent, there is a paucity of studies on how common mental disorders are associated with non-adherence. The present study aimed at examining the association between depression, anxiety and alcohol use disorder symptoms and ART adherence among people living with HIV/AIDS (PLWHA) attending an HIV clinic in Blantyre, Malawi. Methods: This was a facility-based quantitative study with a cross-sectional descriptive design with 213 PLWHA attending an HIV clinic. The participants completed a survey consisting of demographics and mental health disorders symptoms screening tools, namely the 9-item Patient Health Questionnaire (PHQ9) for depression symptoms, the Generalized Anxiety Disorder 7-item scale (GAD-7) for anxiety symptoms and the Alcohol Use Disorders Identification Test (AUDIT) for alcohol use and related harms. ART adherence was assessed using pill count, a self-report measure and a combined measure of both pill count and self-report adherence. Results: The prevalence of depressive symptoms among the participants was 32%, 26% for anxiety symptoms and 16% of participants reported any life-time alcohol use. The majority of participants (75.6%) were found to have good pill count-based adherence while only 41.7% and 33.2% of participants reported good adherence on the self-report and combined measures respectively. The results showed that older participants were more likely to self-report good adherence than younger participants (OR=1.03; 95%CI=1.01-1.06, p-value=0.050). The participants who scored higher on the AUDIT were less likely to self-report good adherence to ART (OR=0.88; 95% CI=0.78-1.00, p-value=0.050). Side-effects were statistically significantly associated with both pill-count and combined adherence. The participants that experienced side effects from the treatment were less likely to be adherent on pill count (OR=0.19; 95% CI=0.07-0.53, p-value=0.001) and the combined adherence measure (OR=0.45; 95% CI=0.24-0.83, pvalue=0.011). Alcohol use was again significantly associated with combined adherence. The participants who reported ever having used alcohol were less likely to be adherent to ART on the combined adherence measure (OR=0.51; 95% CI=0.29-0.93, p-value=0.026). No statistically significant association between depressive and anxiety symptoms and ART adherence was found. Conclusion: The findings show that symptoms of common mental disorders were highly prevalent among PLWHA. Alcohol use, younger age group and experiencing side-effects from ART were significantly associated with ART non-adherence. Further research is required to investigate how depression and anxiety is associated with ART adherence among PLWHA in a Malawian population using larger sample sizes. The current study also highlights the need to routinely screen PLWHA for mental health problems. Further research using advanced designs, such as randomized clinical trials incorporating implementation science approaches, is also needed to evaluate the feasibility and effectiveness of integrating mental health services into HIV care in Malawi.

Background The Transgender Clinic at Groote Schuur Hospital (GSH) – a large government funded academic hospital in Cape Town, South Africa - assists with the mental health assessment of transgender individuals and facilitates access to other gender affirming services, such as hormone therapy, plastic and reconstructive surgery, psychosocial, and legal services. Objectives This clinical audit aimed to gain a clearer understanding of the service and areas within the service which could be improved. To this end the general compliance of the clinical services of the multidisciplinary team (MDT) as recommended by the World Professional Association for Transgender Health 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH SOC 7) was assessed. In addition, an analysis of the demographic and clinical characteristics of individuals attending the clinic and a review of waiting times and distance travelled to attend the clinic, was conducted. Methods The study was a clinical audit without a repeat data collection cycle. Participants included the MDT members working at GSH's Transgender Unit and individuals attending the Transgender Clinic from September 2018 to December 2019 (n = 50). All 11 MDT members were invited to participate in the study and were required to complete a data collection sheet related to their competency and experience. Data collection with respect to services provided, and waiting times for services, was captured from clinician administered standardized historytaking and assessment booklets and patient hospital folder reviews. Results All members of the MDT who participated met the WPATH SOC 7 competency requirements. The mean age of the individuals attending the GSH Transgender Clinic was 28 years. Forty-eight percent were employed, 36% unemployed and 16% full time scholars. The 7 mean waiting time for an initial appointment with mental health was 75 days, 73 days for endocrinology and 255 days for plastic surgery. Non- attendance at initial appointment was a factor across gender affirming services – 18% mental health service, 20.5% endocrinology and 27% plastic surgery. Forty-two percent of individuals screened positive for a co-occurring mental health condition with a third of these individuals having more than one mental health disorder. Mood and anxiety disorders co-occurred together most frequently. Seventy-five percent of individuals with an untreated or partially treated mental health concern were provided a therapeutic intervention at the time of initial assessment. The introduction of laboratory investigations being performed prior to the initial appointment with endocrinology resulted in a significant improvement in waiting time to the initiation of hormone therapy. Conclusion WPATH SOC 7 competency requirements were met by the GSH Transgender clinical team. Inconsistencies were found in the documentation of WPATH SOC 7 recommended clinician tasks within the mental health and endocrinology service. This is secondary to the layout of the standardized history taking and assessment booklet, and documentation of certain tasks being clinician dependent. Limited hospital resources and subsequent understaffing, long waiting times for appointments and gender-affirming surgery and lack of access to other services (e.g. fertility services) result in continued barriers to gender-affirming care.

The central premise of this thesis was that pain is a problem in persons living with HIV/AIDS (PLWHA), that this pain is biopsychosocial in nature, and as such may have different characteristics in different sub-groups. It was also hypothesised that pain in PLWHA can be effectively managed using a biopsychosocial treatment.

Indiana University-Purdue University Indianapolis (IUPUI) / Persons with opioid use disorder (OUD) often receive intensive outpatient treatment (IOT) but these programs are associated with low rates of completion and high rates of relapse. Enhancing patient activation - taking an active role in one’s healthcare - would likely improve outcomes for persons with OUD in IOT. The overarching purpose of this dissertation is to describe how persons with OUD experience IOT, especially regarding activation. The dissertation includes three components. The first is an integrative review of 29 studies of activation in persons with mental health disorders generally. Results revealed that activation was related to several heath and treatment-related factors and some interventions, most notably educational programs, increased activation. The second and third components were based on interviews with 14 persons who had been enrolled in an IOT program in academic health centers. The second component was a constructivist grounded theory study conducted to describe the process people undergo as they participate in an IOT program. Participants described a process of connecting and disconnecting that included eight stages: (1) connecting with drugs, (2) disconnecting from everyday life, (3) connecting with the IOT program, (4) connecting with others in the IOT program, (5) disconnecting from drugs, (6) reconnecting with others, (7) reconnecting with self, and (8) disconnecting from the IOT program. The third component was a qualitative descriptive study conducted to describe types of instances in which persons play an active role in their IOT (activation). Participants described six types of instances: (1) making and enacting one’s own treatment decisions, (2) actively engaging in treatment planning with staff, (3) choosing to actively engage in groups, (4) making a commitment to treatment, (5) taking responsibility for one’s own recovery, and (6) taking actions to avoid relapse. The results of this dissertation will inform the development of strategies to enhance activation among persons with OUD in IOT with the goal of improving engagement and program outcomes.