1. A Cross-cultural Comparison of Psychological Distress among Individuals with HIV/AIDS Enbal Shacham, PhD, MEd 1 Michael Reece, PhD, MPH 2 Patrick Monahan, PhD 3 Tania Basta, PhD, MPH 4 1 Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 2 Department of Applied Health Science, Indiana University-Bloomington 3 Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 4 School of Health Sciences, Ohio University, Athens, OH

2. Collaborators Moi University School of Medicine/AMPATH Otieno Omollo, MD W.D. Owino Ong’or, MD Claris Ojwang Indiana University, USA Michael Reece, Ph.D., MPH Violet Yebei, MA Patrick Monahan, Ph.D.

3. HIV and Psychological Distress  Levels of psychological distress have been shown to vary through the HIV disease continuum (Perry et al., 1990; Atkinson & Grant, 1994; Judd et al., 2000) –Depression –Anxiety –Lack of perceived control –Elevated stress levels –Death-related issues  Lower levels of psychological distress have been documented to increase health-protective behaviors (Paterson et al., 2000; Suarez et al., 2001; Arnsten et al., 2002) –Safer sex practices –Serostatus disclosure to sex partner(s) –Adherence to medication –Engagement and adherence to medical care

4. Cross-Cultural Assessment  Little is known about the levels of psychological distress in sub-Saharan Africa –Translation and cross-translation of established instruments assist measurement in new cultures Somatization has been commonly documented (Kirmayer, 1993; Ice & Yogo, 2006) Depression has been screened in some samples (Ice & Yogo, 2006; Kaaya et al., 2002; Uwakwe, 2003) –Understanding differences in expression of psychological distress has potential to impact medical practice, and form how mental health systems are developed

5. AMPATH  Adult HIV prevalence in Kenya estimated at 5.2%  Indiana University and Moi University Schools of Medicine partnership  Academic Model for the Prevention and Treatment of HIV/AIDS Services offered: –HIV treatment –HIV prevention –Psychosocial support

6. Study Samples HIV-infected population  Self-enrolled mental health care Individual, couple, group therapy (Atlanta, Georgia) Psychosocial support groups (Eldoret, Kenya) Randomly selected from samples  Georgia (n = 581) May 2004-May 2006 60% of the cases selected (n = 339)  Kenya (n =397) November 2005 75% of the cases selected (n = 294)

7. Study Design  Cross-sectional assessments Baseline measures between May 2004 and May 2006 (Atlanta) One week period November 2005 (Kenya) Study approved by Institutional Review Board of Indiana University- Bloomington and Institutional Research Ethics Committee, Kenya

8. Measures  Demographic characteristics –Age –Gender –Tribal affiliation/Race/Ethnicity –Relationship status –Number of children –Employment status –Highest level of education attained  HIV-related characteristics –Latest CD4 count –Length of time with HIV and/or AIDS diagnosis

9. Measures  Psychological Distress Symptoms –Brief Symptom Inventory (BSI) –53 item questionnaire –Measures symptoms of psychological distress by dimensions: Anxiety Depression Hostility Interpersonal sensitivity Obsessive-Compulsive Paranoid ideation Phobic anxiety Psychoticism Somatization Global severity index –Caseness refers to a cut off t-score > 63 that symptoms suggest further psychiatric evaluation

10. Participant Characteristics Kenya (n = 294) Georgia (n = 334) n%n%p Female21673.58525.10.001 African Americann/a19256.6 Hispanic/Latinon/a5516.2 MeanSDMeanSDp Age36.28.041.68.80.001

11. Relationship Status Kenya (n = 294) Georgia (n = 334) n%n%p Married11438.8319.10.001 Divorced279.24212.4 Single6923.519858.4 Significant other/partner41.45415.9 Widow8027.282.4

12. Employment Status Kenya (n = 294) Georgia (n = 334) n%n%p Full time3010.14915.30.001 Part time248.13711.5 Unemployed20869.89830.5 Disabilityn/a 11836.8

13. Education Kenya (n = 294) Georgia (n = 334) Levelsn% n% None 165.4 1st-6th grade 102.9 Standard 1-3 196.4 7th-11th grade 6719.8 Standard 4-8 12040.3 High school graduate 8926.3 Form 1-2 4414.8 Some college 10430.7 Form 3-4 9431.5 College graduate 5215.3 University 51.7 Some graduate school 133.8

14. HIV-related Characteristics KenyaGeorgia n% n%p Diagnosed with AIDS13043.6 9929.20.001 nMeanSDnMeanSDp Length of time with HIV (months)26528.529.930898.874.10.001 Length of time with AIDS (months)12320.219.98186.3142.60.001 CD4 cell count/mm 3 253419.2557227352.9214.10.001

15. BSI Scores by Dimension (Raw scores) KenyaGeorgia nMeanSDnMeanSDp Anxiety2541.10.93061.51.10.001 Depression2461.0 3061.61.10.001 Interpersonal sensitivity2541.21.03051.41.20.002 Hostility2600.90.83061.10.90.11 Obsessive-compulsive2481.30.93061.71.10.001 Paranoid ideation2571.51.03061.51.00.85 Phobic anxiety2630.8 3060.91.00.78 Psychoticism2601.00.83051.31.00.001 Somatization2501.10.83061.21.00.47 Global severity index1441.00.73061.40.90.001

16. BSI Scores by Dimension (T-score) KenyaGeorgia nMeanSDnMeanSDp Anxiety25443.39.430648.811.30.001 Depression24642.39.330649.410.10.001 Hostility25447.39.330549.89.60.002 Interpersonal sensitivity26045.59.730649.211.10.001 Obsessive-compulsive24847.19.630651.211.50.001 Paranoid ideation25753.29.030654.09.40.32 Phobic anxiety26350.58.230650.610.40.89 Psychoticism26047.49.430551.710.60.001 Somatization25053.59.130655.210.40.04 Global severity index14445.110.130651.412.00.001

17. Proportion of Sample which Meet “Caseness” (t > 63) KenyaGeorgia n%n% Anxiety52.04113.4 Depression62.43712.1 Hostility124.7289.2 Interpersonal sensitivity93.54514.7 Obsessive-compulsive93.64815.7 Paranoid ideation4316.75518.0 Phobic anxiety166.14314.1 Psychoticism135.04414.4 Somatization3313.27424.2 Global severity index42.85718.6

18. BSI “Caseness” by Dimension KenyaGeorgia nMeanSDnMeanSDp Anxiety565.82.24167.54.50.41 Depression666.02.53766.63.10.66 Hostility1266.44.42868.15.40.34 Interpersonal sensitivity967.43.74566.63.50.50 Obsessive-compulsive968.24.54869.05.40.70 Paranoid ideation4366.02.95567.84.20.01 Phobic anxiety1666.11.54367.34.70.34 Psychoticism1367.23.84469.04.60.20 Somatization3367.63.87468.64.30.25 Global severity index469.05.55769.54.90.85

19. Participant Summary  Kenyan sample was –Younger and female –Married and widowed (rather than single or partnered) –Higher rates of unemployment –Lower levels of education attainment –Shorter time with HIV and AIDS –More reported being diagnosed with AIDS –Mimic national epidemics

20. Psychological Distress Summary  Georgian sample significantly higher than Kenyan sample among: –Anxiety –Depression –Interpersonal sensitivity –Obsessive compulsivity –Psychoticism –Global severity index Hostility and somatization were significantly higher when accounting for gender and norming sample (t-scores)

21. Caseness “Caseness” for paranoid ideation and somatization occur most often with both Kenyan and Georgian sample Higher levels of paranoid ideation occur among the Georgian sample

22. Conclusions Similarities of extreme psychological distress occur among these samples –Somatization Similar to previous findings regarding lower education in African sample –Paranoid ideation Previous findings similar with African American samples –Question symptom expression and disorder definition

23. Conclusions Psychological distress may be expressed differently across populations living with the same disease Highlights the need to understand how symptoms are expressed to when developing systems of care and subsequently providing services to those in these populations