Jeffrey G. Miller, D.N.P., APNP, ACRN
Jeffrey G. Miller, D.N.P., APNP, ACRN
Association of Nurses in AIDS Care

Mental health is a state of overall well-being that can be negatively impacted by stressors such as isolation, trauma, or the death of a loved one. Compared with the general population, people living with HIV are more likely to develop conditions such as depression, anxiety, mania, and substance use disorder. As a result, HIV nurses are often helping their patients grapple with two interlinked diagnosis of HIV and mental illness.

"All nurses are mental health nurses," said Jeffrey G. Miller, D.N.P., APNP, ACRN, speaking about his 30 years of experience treating HIV and comorbid health concerns on Nov. 2 at the 2017 Association of Nurses in AIDS Care (ANAC) conference. During Miller's presentation, he reviewed the importance of understanding that mental health, like HIV, is treatable with a combination-treatment approach comprising therapy, support groups, and medication management.

"Every nurse needs to realize that he or she is a mental health nurse," agreed Joseph De Santis, Ph.D., ARNP, ACRN, FAAN, assistant professor at the University of Miami School of Nursing and Health Studies. "No matter what you're dealing with with a patient ... it has a mental health component."

In addition, De Santis added, "nurses have a lot of the skills they need to provide mental health care [such as] listening, letting someone talk, hearing someone's story, and helping patients prioritize and problem solve."

The Link Between HIV and Mental Health

HIV and mental health conditions are linked for a variety of reasons. First, a diagnosis of HIV is stressful in and of itself, with HIV-positive people more than twice as likely to suffer from depression compared with those who are HIV negative, according to the National Institutes of Health.

Second, some mental illnesses can cause people to engage in behavior that increases the risk of contracting HIV. For example, Miller explained, people with mania -- a form of mental illness marked by week-long periods of euphoria and delusions -- think that they're invincible and may engage in "hyper sexual" behavior without protection.

Third, HIV and mental illnesses disproportionately affect marginalized people who lack resources to effectively treat their illness.

Related: At ANAC, Nurses Unpack the Importance of Emotional Intimacy in Providing High-Quality Care

"A lot of the people we see in the Ryan White clinics particularly are multiple diagnosed," said William L. Holzemer, Ph.D., RN, FAAN, dean at the Rutgers School of Nursing in Newark, New Jersey. "Then, you overlay the mental health, which is huge, let alone the depression from being HIV positive. Then, there's all the [cultural] 'isms', the homophobia, racial issues, etc."

HIV and mental health conditions can also negatively play off each other after diagnosis, explained Miller during his talk.

For example, all people dealing with anxiety and panic attacks have real, physiological responses during these episodes. Often these physiological responses can affect the immune system, "and it's not going to work as well as it was prior to" the episode, said Miller. For HIV-positive people with compromised immune systems, these episodes are more dangerous.

In addition, substance abuse and addiction, one of the major mental health issues that clinicians deal with on a daily basis, negatively affect the immune system.

Common Disorders and How to Treat Them

According to Miller's presentation at ANAC, nearly all common mental health illnesses should be treated with a combination of individual talk therapy, group therapy, support groups, and medication.

Common mental illnesses include mood disorders such as depression and anxiety, mania and bipolar disorder; psychotic conditions such as schizophrenia and hallucinations; and substance use disorders.

"All treatment will be combination therapy, regardless of the mental illness diagnosis," Miller said. When considering the best treatment for various conditions, mental health providers can't rely on blood work and laboratory tests.

Instead, "we so depend on the information we get from our patients," said Miller. "We're trying to put together a puzzle, and we rely on our patients to give us all the pieces."

That's why, when it comes to treatment, trust, empathy, and patience are paramount. For example, for people suffering from substance use disorder, "we can't give up on people in recovery. ... [; w]hen they're addicted and they've gone through 15 detoxes, we still have to hope that the 16th will be the charm."

In addition, it's important to keep in mind that many psychotic illnesses such as schizophrenia are adaptive mechanisms that patients developed at an early age to cope with trauma.

Addressing the ANAC audience, Miller said, "I'm talking to the choir here about being judgmental, [but it's important not to] judge someone because of their substance use or their thought process, because there's a whole story underneath there."

When considering medication, it's important to know which medications work best with HIV meds, he added. For example, for anxiety and depression, a class of drugs called selective serotonin reuptake inhibitors (SSRIs) "interact well with the HIV medications," said Miller.

Creating Safe Spaces & Mitigating Stigma

HIV nurses are well aware of the stigma surrounding an HIV diagnosis, but the stigma surrounding mental illness can, in some ways, be even more difficult to navigate. Patients often resent the idea of being "crazy enough" to take medication, Miller explained.

There are some practical tips for keeping patients engaged in their mental health treatment, such as pulling a mental health provider into the office for a warm hand-off. Another suggestion from the room at Miller's ANAC presentation was to re-label the mental health provider's job description from "therapist" to "integrated health provider" to reduce the stigma associated with therapy.

"Work with patients to remove stigma of medication therapy," said Miller. One way to explain mental illness to patients is to describe it as "an imbalance, like diabetes," he suggested.

Ultimately, some patients may not want to engage in their own mental health care right away. In those cases, the best thing a nurse can do is to create a safe space in which patients feel comfortable bringing up issues when they're ready.

HIV nurses shouldn't be afraid to don the label of mental health provider, said De Santis. "Nobody understands the patient like a nurse [does]," he said.

Many nurses may "think they're not qualified to deal with some of the psycho-social or mental health issues, but I think they are. I really think they are," said De Santis.