High rates of mental health and addiction care use in Ontario

• Ontario study finds people with HIV are more likely to use mental health services
• People with HIV are four times more likely to seek emergency mental health care
• Researchers recommend routine mental health screening for patients with HIV

Studies from several high-income countries suggest that issues related to mental health and addiction are higher among HIV-positive people than HIV-negative people. For instance, a recent study from the UK, which reviewed studies done since the year 2000, found that rates of depression, anxiety, difficulty sleeping and thoughts of self-harm were substantially greater among HIV-positive people than HIV-negative people.

In Ontario

A team of researchers at the University of Toronto investigated the use of mental health and addiction services by people with and without HIV in Ontario. They found that between the years 2013 and 2014, adults with HIV were more likely to use mental health and addiction care, obtained from primary care doctors and psychiatrists. HIV-positive people were also more likely to use mental health and addiction care via visits to a hospital emergency department.

The University of Toronto study is important for at least two reasons: It confirms that HIV-positive people have greater need for mental health and addiction services, and it provides a rationale to enhance the delivery of such services. Such enhancement can be part of a larger effort to strengthen the mental health and well-being of HIV-positive people and help prevent and treat addiction.

Study details

The researchers scoured many healthcare databases in Ontario, including those held by the Institute for Clinical and Evaluative Sciences (ICES), to compose a sample of 2,758,186 HIV-negative people and 5,095 HIV-positive people.

The researchers found that HIV-positive people (compared to HIV-negative people) in their study were more likely to have the following basic profile:

• male
• aged 35 to 55 years
• live in low-income neighbourhoods
• live in urban areas

The researchers also found that HIV-positive people were more likely to have the following conditions:

• asthma
• diabetes
• chronic obstructive pulmonary disease (COPD)
• congestive heart failure

Results—Focus on mental health and addiction

The researchers found that people with HIV were more likely to have been diagnosed with a range of mental health and addiction disorders, including the following:

Non-psychotic disorders (this category was largely driven by anxiety and depression but included many other mental health issues)

• HIV-positive people – 27%
• HIV-negative people – 22%

The researchers said that HIV-positive people “were more likely to have been diagnosed with multiple mental health and addiction disorders,” including the following:

A combination of psychotic and substance use disorders

• HIV-positive people – 5%
• HIV-negative people – 1%

Intensity of service use

When researchers took into account age and other factors, they found that, overall, HIV-positive people were more likely (compared to HIV-negative people) to do the following when seeking help for mental health and addiction:

• 1.5-fold more likely to visit family doctors
• three-fold more likely to visit psychiatrists
• nearly four-fold more likely to visit a hospital’s emergency department
• nearly five-fold more likely to be admitted to a hospital for psychiatric care

The researchers said that HIV-positive had “a higher intensity of service use” than HIV-negative people, regardless of the type of practitioner they sought.

Why is there a connection between HIV and mental health service need?

The reasons for the elevated rates of mental health and addiction care among HIV-positive people are complex. Past studies have found that having mental health and addiction issues can increase a person’s risk for acquiring HIV. The stress of living with HIV and the negative attitudes in the community that still dog this infection likely also play a role.

Although not specifically mentioned by the researchers, there are also biological issues involved in mental health. For instance, HIV infects cells of the immune system, some of which travel to and reside in the brain. These infected cells release chemical signals and viral proteins that can impair the functioning of the brain. Thus, early HIV diagnosis followed by an offer and initiation of HIV treatment (ART) and good adherence are all very important to maintaining overall health and brain health in particular.

An emerging area of research concerns chronic inflammation and its association with unfavourable mental health among some HIV-negative people. HIV infection results in elevated levels of inflammation and immune activation. ART can significantly reduce but does not eliminate HIV-associated inflammation and immune activation. It is possible that, over the long-term, chronic inflammation (and immune activation) may make some HIV-positive people more susceptible to mental health issues. 

In the present study, researchers were not able to access information about the different combinations of ART that participants were taking, their viral load test results or routine measures of inflammation.

Issues to consider

The Toronto research team found high rates of mental health and addiction services accessed via hospitals to be “concerning.” They made the following statement about this issue:

“It is possible that the severity of illness is greater [among HIV-positive people] relative to HIV-negative individuals, and more difficult to manage. Alternately, timely access to community-based services may be a challenge. Follow-up research interviewing persons who are HIV-positive and who face multiple intersecting barriers to care may explain these results.”

Socio-economic issues

The researchers noted that in their study there was an over-representation of HIV-positive people in low-income neighbourhoods. This suggests that they are disadvantaged. The researchers said: “Disadvantage can create multiple barriers to accessing mental health and addiction care, leading to delayed health-seeking, which may lead to crises that require acute care.” They added: “Having limited resources can also lead to food insecurity and a lack of stable housing, which can interfere with one’s ability to seek regular care, follow a treatment strategy and/or deal with medication side effects.”

The impact of complex diagnoses

The researchers noted that previous studies have found that people with multiple mental health diagnoses “have less social support and were less likely to attend scheduled sessions with care providers. These individuals may require more support to enhance their access to care and [adherence] with HIV and mental health and addiction treatment plans, particularly medications.”

Routine screening to identify issues early

The researchers said that “increasing routine screening in primary care for mental health and addiction conditions among HIV-positive patients can assist with early identification and linkage to specialty [care providers] with expertise in HIV who are willing to take patients with HIV.” Thus, they encourage doctors and nurses to do such routine screening.

Making access to care easier

The researchers suggested that health systems increase the availability of “integrated and client-centred models of care” that provide mental health and addiction services in the community. This would reduce the burden on patients who “have to navigate and coordinate care in separate healthcare sectors.”

Bear in mind

The University of Toronto study is a good step forward in a preliminary exploration of mental health and addiction service use among HIV-positive people. The study shows that there are high rates of mental health and addiction issues among HIV-positive people in Ontario. Furthermore, there was a relatively high rate of usage of hospital emergency departments, which is of interest to health policy planners. Such departments are generally overcrowded and not the best place to receive care for routine or chronic health problems unless there is a crisis or a time-sensitive medical issue. That people sought care in the emergency department underscores the need to make treatment for mental health and addiction issues more widely available in the community. More studies are needed to understand how to overcome barriers to the type of services needed so that the mental health, and ultimately quality of life, of HIV-positive people can be stabilized and improved.

Resources

Canadian Mental Health Association

Santé mentale – Le ministère de la Santé et des Services sociaux (MSSS)

HIV and emotional wellness

Mental health, substance use and HIV —TreatmentUpdate 219

U.S. researchers explore the impact of depression  —TreatmentUpdate 217

HIV and brain-related issues — TreatmentUpdate 204

—Sean R. Hosein

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