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Who's afraid of the Big Bad Wolf? Mental health for general HIV nurses.


Mental health and HIV are natural partners. Since the start of the epidemic in the 1980s, HIV and mental health services have worked side by side but today many mental health services have been drastically cut, are threatened with closure or have closed down permanently. However, mental health remains a huge issue, perhaps now more than ever, as people are living longer with HIV yet the discrimination and stigma continues; meanwhile, new health threats such as neurocognitive disorders and cancer are increasing, which may lead to more psychological problems.

'What do you need?', a survey report from social research group Sigma Research, found that 72% of people living with HIV surveyed had had problems managing depression or anxiety in the previous year, and a third of those had not received any help to address these problems. A similar proportion of people living with HIV reported troubles with self-confidence and self-esteem--and an even higher number had not received any help for these issues. The same research highlighted that anxiety and depression, self-esteem, sleep and sex are the areas of life that pose problems to the greatest number of people living with HIV in the UK [1].

For some, their mental health problems predate their HIV diagnosis, with issues such as personality and bipolar disorders and depression. In some cases, it is these mental health problems that have led them to become HIV positive, especially if accompanied by drug or alcohol addiction. For others, mental health issues have resulted from their HIV diagnosis, or from antiretroviral therapy or other medication. People living with HIV can lead healthy lives; however, many have some degree of psychological or emotional troubles. Think about the people you care for ... how many of them at times have shown emotional distress or depression? How many have ongoing mental health issues that may be obvious or hidden? For any general nurse in HIV, working with patients with mental health issues is a daily occurrence--yet do we even think about it? Do we feel skilled and able to manage? Or is it now a fact of HIV care that, unless there is an acute mental health episode or a patient is so depressed they become suicidal, we rarely think about how we will react and manage the situation?

Where to start?

Barker [2] claims that mental illness and mental health are 'two expressions fundamental to psychiatric and mental health nursing--[but they] possess no clear, accepted definition', and he suggests that nursing should be geared to focusing on human responses to some very special human problems. We all go in for stereotyping, and being told that a patient is low in mood, depressed, suicidal or has schizophrenia, bipolar or personality disorder can bring up a lot of thoughts, emotions and anxieties before we even meet them. Obtaining as good a history as possible and researching the issues is an important start. There is a wealth of information out there. Clinic letters from psychology or psychiatry services, or speaking to those involved in caring for the patient's mental health, can help you put the illness into some perspective. Is this what we, as general nurses, would call holistic nursing?--that is, treating the patient as an individual with unique problems. It has been stated that general nurses ignore mental health factors in patient care and that psychiatric nurses neglect physical aspects of health [3]. It has also been observed that general nurses often feel unsure what to do when faced with patients with psychological problems and often withdraw from interaction with them. What can we do to reverse this tendency?

The issues and where they began

HIV is complex and can impose a significant psychological burden. In a meeting of South African Mental Health Services in 2007 Professor Melvyn Freeman stated, 'a number of studies from across the globe suggest that mental health issues are on the rise in people who have HIV and AIDS', adding that twice as many people with HIV have mental health issues than people without the disease. Freeman also commented, 'When you look at the higher rates among HIV-infected people, you have to ask the question: is this because they had a prior condition and their vulnerability led to their infection or is it that, because they have contracted HIV, it has mental impact on them, and, therefore, this raises the numbers of people living with HIV who have mental disorders. This is a complex issue and I would like to suggest that both are true: that it's very likely that mental disorder is both a risk factor and a consequence of HIV'.

As patients adjust to the impact of their HIV diagnosis, they can suffer from depression and anxiety as they face the difficulties of living with a chronic life-threatening illness, such as a perceived shortened life expectancy, potentially complicated drug regimens, stigma, and the potential loss of social support, family or friends. A third of HIV-positive gay men have post-traumatic stress disorder: events including starting treatment, HIV-related illness, and witnessing an HIV-related death were all linked to the development of symptoms associated with post-traumatic stress disorder. Emotional responses to such events rather than actual physical threat--were associated with the development of symptoms of posttraumatic stress [4].

HIV infection can also have direct effects on the central nervous system and cause neuropsychiatric complications including HIV encephalopathy, depression, mania, cognitive disorder and dementia. Throw in drug and/or alcohol use and the problems become heightened. However, at times patients find themselves being batted between services. Perhaps because healthcare staff are not always sufficiently trained, or able to see the big picture, HIV services may place the onus onto mental health, whereas mental health think that HIV services are at the forefront of care--while the patient is stuck in the middle and may feel unsupported by all involved.

The significance of psychological support has finally been highlighted with the publication of the Standards for psychological support for adults living with HIV (2011) [5] which, instead of focusing upon the physical manifestations of HIV and mental health, now gives a clear framework and guidance for supporting people living with HIV with their psychological and mental health issues.

What can you do?

What are our concerns about HIV and mental health? What are we afraid of? Could it be the fear of the unknown, of dealing with people who have the potential to be unpredictable, aggressive or emotionally labile? Or is it that fear of not knowing what to say? As general nurses, we should be good listeners but sometimes this may not be enough. General nurses are mostly terribly practical people, offering a pill to take away the pain, a dressing for a wound or a comforting hand--but how do we mend a broken mind or help those who are so depressed they want to end their lives? Our fear may lie in not knowing what the next course of action is, whether the patient will be safe, or what therapy they can access to enable them to lead healthier, emotionally stable lives.


The following pointers can be used to help:

Be prepared and know your limits. As much as possible, avoid situations that make you wary or anxious, as this may be obvious to the patient. On occasions where this cannot be avoided, try to be as prepared as you possibly can. If there is any doubt, see the patient with a nursing colleague present or arrange a joint visit with a mental health professional. Bouncing ideas off others and checking whether you were reading the situation right is important. One person's 'manic' is another person's 'excited', so being able to discuss your thoughts and share experiences is vital. If you are seeing a patient at home, find out who else will be there, and whether or not they are aware of the diagnosis and history--we have all had stilted, covert conversations when we avoid naming the condition and talk with raised eyebrows and knowing nods, and such situations are best avoided.

Treat everyone as a person first. Common sense? Yes! Approach adults with mental health issues in the same way you would relate to anyone holistically with respect, with appropriate boundaries, and with an understanding of that person's life. Assess the patient as thoroughly as possible and be as inquisitive as possible without causing anxiety to the patient. If they are happy for you to talk to their partners, family or friends, then utilise this resource, as they may be able to give you the bigger picture. Think about how you phrase questions--the 'mental illness' tag is a hard one to bear. Asking if a patient has had a mental health issue in the past may not elicit an honest response. However, getting to the bottom of someone's emotional state is vital--how many people have had adverse reactions to medications because they failed to disclose a past history of depression or mental illness?

Don't jump to conclusions. It may be easy to put every incident down to mental illness but there may be other causes, including obvious ones like excessive drug or alcohol use, or a new recreational drug. Equally, other causes that can cause signs and symptoms of confusion, slurring, or hallucinations could include blood toxicities, side effects of new medications or overdosing with medication, for example, double-dosing with Fentanyl patches or confusion over Oramorph doses. Explore obvious possibilities first and, if there is no clear cause, consider other options.

Be open, honest and non-judgmental. Adults -with mental illness have long been the victims of severe social stigmas, based on the assumption that they had a moral deficiency [6]. It should therefore be a given for any nurse to work in a way that is open, honest and non-judgmental. However, we all have stereotypes and fears that may impinge on how we work with patients. Although it may be hard to shake our preconceptions, for us to be effective we must try to put these aside. While some patients will amaze you, some will strengthen what you felt before--so acknowledge this. Being honest may also mean admitting that you are unsure what to do next and need to seek expert advice; or that you are anxious or worried about a patient, and sometimes this is all that needs to be said.

Take HIV out of it. For some patients their mental health issues were around long before the HIV diagnosis, so getting to know their history and what has worked and not worked before is important. Take advice from professionals, even though it may go against what you have been taught as a general nurse and may be hard to work with. For example, some people with personality disorders may respond better to very clear-cut boundaries, such as setting tight timings for meetings, not answering the phone out of hours or offering only objective, practical advice. However, for others, antiretroviral therapy or HIV itself may be the root cause of the mental health issues and may feature large in the patient's life--so have an awareness of how HIV fits into the whole picture.

Seek help and education. Get to know your local mental health service and what they offer. Do they have a crisis resolution team and how do you access the emergency psychiatric unit? What are their referral criteria and how do you refer to them? There may be a clinical nurse specialist or a psychiatric nurse with an interest in HIV. Look to see if there are sessions offering an introduction to mental health, or a module at the local college/university. Or you could offer some reciprocal training with local mental health staff, such as HIV awareness or HIV update sessions. In the late 1980s and 1990s, HIV training was part of statutory training within many NHS trusts but now it may only be of interest if a unit has had an issue with a patient, so be on hand to offer support and they may do the same for you. Network and collaborate as much as you can. Most trusts will have statutory training on the management of aggression or conflict resolution which may give you the tools you need.

Know the law. The Mental Health Act can be scary so get know what the main points are, what are 'sections' and what do they mean? Even a basic knowledge will better equip you to know when a patient may require more structured help.

And finally ... Yes, on some occasions you may feel that you have failed a patient or situation, or be concerned that you have put yourself at risk. However, try to use this experience and learn from it. Formulate strategies and use the support of colleagues, clinical supervision and your appraisal to move forward.


[1.] Weatherburn P, Keogh P, Reid D et al. What do you need? 2007-2008: findings from a national survey of people diagnosed with HIV. Sigma Research, London, 2009. Available at: (accessed February 2012).

[2.] Barker P. Psychiatric and Mental Health Nursing. Arnold, London, 2003.

[3.] Castledine G. General nurses must ensure they have mental health skills. British Journal of Nursing, 2004, 13, 683.

[4.] Theuninck AC, Lake N, Gibson S et al. HIV-related posttraumatic stress disorder: investigating the traumatic events. AIDS Patient Care and STDs, 2010, 24, 485-491.

[5.] British Psychological Society/British HIV Association/Medical Foundation for AIDS and Sexual Health. Standards for psychological support for adults living with HIV. Published November 2011, available at: standards_for_psychological_support_for_adults_living_with_HIV.pdf (accessed February 2012).

[6.] Lin AMR. Mental health overview. In Edwards R ed.) Encyclopedia of Social Work. National Association of Social Workers, Washington DC, 1995.

Shaun Watson

Clinical Nurse Specialist (HIV Community), Hammersmith and Fulham Primary Care Trust, London, UK

Correspondence: Shaun Watson

Clinical Nurse Specialist, 4th floor

56 Dean Street

London W1D 6AQ, UK
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Author:Watson, Shaun
Publication:HIV Nursing
Article Type:Report
Geographic Code:4EUUK
Date:Mar 22, 2012
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