Title: Eleven Things About HIVAIDS Training Directors Need to Know and Teach Residents
1Eleven Things About HIV/AIDS Training Directors
Need to Know and Teach Residents
- Marshall Forstein, M.D.
- Adult Psychiatry Training Director, The Cambridge
Health Alliance, - Harvard Medical School
- Warren Liang, M.D.
- Psychiatry Training Director,
- University of Cincinnati School of Medicine
2Objectives
- To discuss why the teaching of HIV psychiatry is
important - To present some basic issues for training
directors to consider to insure HIV psychiatry is
part of the residency curriculum - To present suggestions for using the HIV/AIDS
Neuropsychiatric Curriculum in a residency program
3Context of the Pandemic
- Psychiatric patients at increased risk for HIV
- Patients who experience stigma and social
marginalization have decreased access to medical
as well as mental health care - Comorbid disorders are the norm, not the
exception - People with HIV have opportunities for increased
longevity but psychiatric disorders and social
stigma may preclude chronic management of the
disease
4HIV/AIDS as Paradigm understanding the interface
of Mind, Brain and Body
- Real value in preparing psychiatry residents for
clinical practice - Sexual and drug use risk assessment skills
- Neuropsychiatric screening and evaluation
- Application of co-morbid treatment options
- Managing complex medical/psychiatric disorders
- Enhancement of psychopharmacologic understanding
of drug-drug interactions - Application of principles and skills to other
neuropsychiatric disorders
5Applying the Bio-Psycho-Social Model
- BIO HIV invades the Central Nervous System soon
after infection - protean manifestations of neurological and
psychiatric disease - PSYCHO psychiatric disorders are increased in
people with HIV, and people with psychiatric
disorders have increased risks for acquiring HIV
infection - SOCIAL People with HIV disease continue to be
stigmatized, marginalized and have many social
problems that interfere with adequate mental
health and medical care
6Outline
- Evaluation Assessment
- 1. Stages of Change Model
- Diagnostic concerns
- 2. AIDS Mania
- 3. Neuro vs. Psych Disorders
- 4. CNS side effects of Sustiva
- 5. Hypogonadism and depression
- Treatment issues
- 6. AIDS Dementia
- 7. HIV Psychosis
- Psychopharmacology
- 8. Antipsychotics and HIV
- Drug interactions
- 9. P450 Drug Interactions
- 10. Ritonavir (Norvir) , and Ritonavir/lopinavir
( Kaletra) drug interactions - Lipodystrophy syndrome
- 11. Impact of metabolic changes on psychological
and social function
71. Stages of Change HIV Treatment Readiness
Adherence, Substance Abuse
- Psychiatrists role in assessment of HIV tx
readiness adherence becoming more recognized
integrated - HIV tx recommendations when starting HAART,
expectation to achieve 95 adherence with tx
regimes (i.e. achieve optimal outcomes - Psychiatric D/os, especially Mood, Anxiety,
Adjustment D/os significantly impact tx
readiness/adherence - Active Substance Abuse/Dependence, particularly
cocaine/crack, has a negative impact on
readiness/adherence
81. Stages of Change HIV Treatment Readiness
Adherence, Substance Abuse
- Transtheoretical Model (DiClemente Prochaska)
of Stages of Change can be incorporated into
psychiatric assessment tx of HIV pts with HIV
treatment concerns/ambivalence and/or substance
abuse - Stages of Change
- Precontemplation
- Contemplation
- Action
- Maintenance
- Termination or Relapse/recycle
91. Stages of Change to Assess HIV Treatment
Readiness Adherence, Substance Abuse
- Objective is Harm Reduction
- Assess stage, then help patient through
motivational interviewing/enhancement (Miller) to
work through the stages of change towards more
healthy adaptive behaviors self-beliefs/attitu
des
101. Stages of Change HIV Treatment Readiness
Adherence, Substance Abuse
- Conceptualized as a cycle engagement in tx as
essential - HIV Tx Readiness/Adherence
- r/o psychiatric d/o or substance abuse, rx
accordingly - pts may not be ready to start life-enhancing/savin
g tx, but will have greater understanding of
motivation - Substance Abuse/Dependence
- Model may be used by psychiatrists to engage pt,
and prepare for substance abuse tx or may be used
as part of substance abuse tx itself - Relapse seen as part of the cycle, not an
indication for tx termination
112. AIDS Mania
- Differs from idiopathic Bipolar Disorder in that
pt often has no personal or family h/o Bipolar
Disorder - Similar symptomatology DIG FAST, except mood
mood is usually more irritable than euphoric - Often associated with late-stage HIV disease/AIDS
or AIDS Dementia - Can be medication or drug-induced AZT, steroids,
stimulating illicit drugs (cocaine, CM, speed,
steroids) - May be associated with CNS involvement
- Risperidone has been shown to be effective in
treating AIDS Mania, with minimal adverse effects
123. Neuropsychiatric vs. Psychiatric Disorders
- Neuropsychiatric syndromes may be confused with
Psychiatric Disorders, especially Mood Disorders - Neuropsychiatric syndrome complaints may mimic
- Depression apathy, memory changes,
sleep/energy/appetite changes, functional
impairment, low mood, social withdrawal, paranoia - Mania restlessness, distractibility, memory
changes, decreased sleep, irritability, impaired
judgment, paranoia
133. Neuropsychiatric vs. Psychiatric Disorders
- Psychiatric Disorders commonly associated with
HIV/AIDS - Mood Disorders
- Adjustment Disorders
- Anxiety Disorders
- Psychotic Disorders
- Substance Abuse Disorders
- Pain Disorders
143. Neuropsychiatric vs. Psychiatric Disorders
- HIV Neuropsychiatric complications include
- AIDS Dementia (HIV-1 associated Dementia)
- Minor Cognitive-Motor Disorder (MCMD aka Minor
AIDS Dementia) - Delirium
- Amnestic Disorders
15Minor Cognitive-Motor Disorder
- American Academy of Neurology, 1991
- Two of
- Impaired attention/concentration
- Mental slowing
- Impaired memory
- Slowed movements
- Impaired coordination
- Personality change/irritability/lability
- Neuro exam (impaired SPEM, hyperreflexia,
frontal release, slowed RAM, ataxia)
16HIV Cognitive Disorders
- Classification by American Neurological
Association - Minor Cognitive Motor Disorder
- 14 of patients with early HIV
- 24 of patients with late HIV
- HIV-Associated Dementia
- Comparable to CDC-defined HIV encephalopathy
- 7-10 of patients with late HIV (21 pre-HAART)
173. Neuropsychiatric vs. Psychiatric Disorders
- Distinguishing Neuropsychiatric vs. Psych D/os
- Prominent memory and cognitive (executive
functioning, task completion) difficulties - Problems with motor function (visuospatial
difficulties, impaired coordination) - Speech/language problems (aphasias, parapraxis)
- Fluctuating levels of consciousness/alertness
acute disorientation - New onset psychosis (particularly visual other
non-auditory hallucinations) - Personality changes
18Distinguishing Neuropsychiatric vs. Psych D/os
- Assessment includes
- careful history mental status
- neurological exam, neurological work-up may
include neuroimaging, LP, labwork, - neuropsychological testing
- Differential diagnosis includes
- CNS complications (HAD, MCMD, delirium,
infections, lymphoma) - Medical conditions (endocrine, metabolic
disorders) - Medication-induced disorders
- Substance-related disorders
194. Psychiatric/CNS Side Effects of efavirenz
(Sustiva)
- Efavirenz, a non-nucleoside reverse transcriptase
inhibitor (NNRTI), may be used as part of a HAART
regimen - Similar to steroids in the range of psychiatric
symptoms which may be induced
204. Psychiatric/CNS Side Effects of efavirenz
(Sustiva)
- Psychiatric side effects are common
- Controlled trial of 1,008 pts taking efavirenz,
635 experienced significant psychiatric adverse
effects requiring intervention - Psychiatric s/es include severe depression,
mania, suicidal ideation, paranoia, psychosis,
anxiety - CNS s/es include drowsiness, insomnia (/-
abnormal dreams), impaired concentration
215. Hypogonadism and Depression
- When evaluating depressive disorders (Major
Depressive D/o, Dsythymic D/o, Depressive D/o
NOS, Adjustment D/o w/depressed mood) in HIV
men, check testosterone levels, r/o hypogonadism - HIV men have a greater risk of
hypotestosteronism than the general population - Tx of hypotestosteronism consists of testosterone
replacement (Androderm, Androgel,
Depo-Testosterone), in addition to tx for
depression
225. Hypogonadism and Depression
- The jury is out about any association between
hormones levels and depression in women - Hypotestosteronism in HIV transgendered
depressed patients (male-to-female) must be
evaluated treated on a case-by-case basis
236. AIDS Dementia (HIV-1 Associated Dementia aka
HAD)
- Tx primarily consists of antiretroviral
medication - Subcortical dementia with deficits in affect
(dysphoria, blunted), behavior, cognition and
motor function - Cannot be diagnosed using Mini-Mental Status Exam
- Use HIV Dementia Scale, Memorial Sloan Kettering
Rating Scale, Blessed Dementia Scale,
Neuropsychological Testing - Medication management (which may include
psychostimulants, neuroprotective
anti-inflammatory mediators, immunostimulants,
nutritional interventions) with vigilance towards
monitoring adherence, symptomatic tx
(psychosis, insomnia, aggression, memory problems)
247. HIV Psychosis
- Often more difficult to treat than other forms of
psychosis, both diagnostically
pharmacologically - Etiology of HIV Psychosis
- Psychosis arising in HIV pt with a pre-existing
psychotic disorder - HIV-1 infection, or secondary opportunistic
infections, may precipitate psychosis - Comorbid substance abuse may induce psychosis
- Psychosis may be induced by medications used to
HIV infection or OIs
257. HIV Psychosis
- Treatment with antipsychotic medications
adjunctive medications can be problematic - Use of benzodiazepines for adjunctive tx may lead
to adverse effects such as paradoxical agitation,
greater cognitive difficulties /or dependence
268. Antipsychotic Medication HIV
- In HIV patients
- Tx with traditional high-potency antipsychotic
medications, may lead to greater risk for
extrapyramidal side effects (dystonic rxns,
parkinsonian syndrome, akathisia, akinesia, TD,
catatonia, NMS) - Tx with low-potency antipsychotic medications,
including atypicals, may be more associated with
anticholinergic side effects (which may
exacerbate delirium) - rule of thumb start low (i.e. reduce initial
dose by 50) and go slow
279. Cytochrome P450 Drug Interactions
- All Protease Inhibitors (PIs) Non-Nucleoside
Reverse Transcriptase Inhibitors (NNRTIs) are
substrates of cytochrome P450 - Therapeutic concerns some psychotropic
medications (i.e. TCAs) and antiretrovirals
(ARVs) may have narrow therapeutic indices
(including PIs NNRTIs) - Drug interactions b/n psychotropic medications
ARVs may lead to resistance to not just the
specific ARV, but all within the same drug class
28PI Drug Drug Interactions
- PI inhibition of 3A can lead to Fentanyl
toxicity( a substrate for 3A ) - Ritonavir induces glucuronyl transferase (which
metabolizes benzodiazepines), leading to
decreased bioavailability of a benzo - 3A inhibition by nefazodone and PIs lead to
increased levels of benzos and sildenafil
299. Cytochrome P450 Drug Interactions
- P450 Inhibitors (by level of potency)
- Significant ritonavir
- Moderate indinavir, nelfinavir, amprenavir,
delaviridine - Weak saquinavir
- P450 Inducer nevirapine (3A4)
- P450 Inhibitor Inducer efavirenz (Sustiva)
3A4 - Co-administration of NNRTIs (efavirenz,
delaviridine, nevirapine) and certain
psychotropic medications (fluoxetine,
fluvoxamine, nefazodone) may lead to toxic levels
of NNRTIs
3010. Drug-drug Interactions and Norvir Kaletra
- lopinavir/ritonavir (Kaletra) , is the only
combination PI, having ritonavir (Norvir ) as
one of its components - Ritonavir (Norvir ) is the ARV with the most
potential for clinically significant psychotropic
drug interactions - Ritonavir is a potent cytochrome P450 3A4, 2D6,
2C9, 2C19, 2A6, 1A2 2E1 inhibitor - As with antipsychotic medications, when combining
Norvir or Kaletra with psychotropics, it is
safer to start low go slow
3110. Drug-drug Interactions and Ritonavir (Norvir
) Ritonavir/lopinavir (Kaletra)
- Psychotropics contraindicated due to risk of
toxically increased drug levels - clozapine, pimozide (incr. risk of QT interval
prolongation), midazolam triazolam (incr. Risk
CNS depression) - Psychotropics with risk of increased drug levels
reduce initial dose by at least 50 - TCAs, SSRI, bupropion, venlafaxine, maprotiline,
trazodone, haloperidol, risperidone,
thioridazine, chlorpromazine, ziprasidone,
aripiprazole, buspirone, lamotrigine, zolpidem,
diazepam, flurazepam - nefazodone, sertraline (greater risk, reduce
initial dose by 70) - Psychotropics that may cause toxic Norvir or
Kaletra drug levels via metabolic inhibition - fluvoxamine, nefazodone, paroxetine, sertraline,
venlafaxine, olanzapine, perphenazine,
thioridazine
3211. HIV-Associated Lipodystrophy
- body shape and metabolic abnormalities
- 3 main categories
- most obvious altered fat deposits
- Subcutaneous fat shrinks in the arms, legs and
face - thin limbs with bulging veins
- facial wrinkling with hollow cheeks
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3411.HIV-Associated Lipodystrophy
- new fat bulges
- between and above the shoulder blades (dorsal
cervical fat pads or "buffalo hump") - abdominal cavity, surrounding the internal organs
(truncal adiposity or "protease paunch") - Breast enlargement also occurs, mostly in women
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3711. HIV-Associated Lipodystrophy
- More common changes in fat metabolism
- Hyperlipidemia
- Hyperglycemia
- because fat cells are processing less glucose
into fat stores - Insulin production may rise to increase the
removal of sugar from the blood - elevated production may or may not successfully
keep sugar levels below normal - "insulin resistance
3811. Psychological Responses to Physiological/
Metabolic Changes
- HIV- related lipodystrophy syndrome
- Managing Adherence to Anti-HIV meds
- Ambivalence
- Uncertainty
- Delayed gratification
- Grieving and Loss
39Acknowledgments
- Khakasa Wapenyi, MD
- Joseph Murray, MD
- Milton Wainberg, MD
- Arkady Bilenko, MD
- Wade Leon, NP
- Francine Cournos, MD
- Candice Peggs
- Steve Ferrando, MD