MENTAL HEALTH AND HIV An Overview

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MENTAL HEALTH AND HIVAn Overview

• Karina K. Uldall, MD, MPH
• Department of Psychiatry
• University of Washington

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An Overview

• Psychosocial Issues
• Psychiatric Illness
• Substance Abuse
• Medication Interactions
• Neurologic Illness

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Psychosocial Issues

• Pre- versus Post-HAART
• Acute to Chronic Illness
• Population Characteristics
• Marginalized, Access/Engagement, Co-morbidity
• Specific Cultural Issues
• Meaning of Illness, Family/Community Role,
  Communication Patterns, Trust/Mistrust of System,
  Value of Autonomy

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Aspects of HIV/AIDS

• Increased services or support
• Renewed spirituality
• Healthier relationships
• Priorities clarified
• Conflicts resolved

• Stigma/discrimination
• Social isolation
• Fear of death or contagion
• Loss of independence
• Guilt
• Grief over multiple losses

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Interventions

• Accompaniment
• Advocacy
• Assessment
• Care Coordination
• Crisis Intervention
• Engagement
• Listening

• Patient/Family Education
• Problem Solving
• Referrals
• Skills Building
• Support

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Psychiatric Illness

• HIV Associated Dementia
• Delirium
• Psychotic Disorders
• Mood Disorders
• Anxiety Disorders

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HIV Associated Dementia

• 15 20 of AIDS Patients
• Cognitive, Motor, Mood/Personality Symptoms
• CD4 count lt 200 uL
• CSF Viral Load gt 10,000/ml, Beta-2-microglobulin
  gt 3.8 mg/dL
• ARV combinations AZT, AZT 3TC, d4T 3TC,
  Indinavir

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Delirium

• Disturbance of consciousness and attention
• New onset cognitive or perceptual disturbance
• Acute onset, fluctuating course
• Underlying etiology
• Fever, infection, trauma, metabolic, meds/drugs,
  other/multiple causes

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Psychotic Disorders

• Substance induced intoxication or withdrawal
• Medical illness/medication induced
• Distinguished from delirium
• Distinguished from late stage dementia

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Mood Disorders

• Bipolar disorder 8 of outpatients
• Major depressive episode 20-35 lifetime
• Substance induced intoxication or withdrawal
• Medical illness/medication induced
• Distinguish from delirium hyper/hypo
• Distinguish from dementia

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Anxiety Disorders

• Panic disorder, PTSD, Adjustment disorder with
  anxiety 2-38 of patients, depending on stage
  of illness
• Substance induced intoxication or withdrawal
• Medical illness/medication induced
• Untreated pain

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Suicide Assessment

• Gender, age, ethnicity
• Family history
• Psychiatric illness
• Medical illness
• Behavior
• Lethality

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Suicide Assessment

• HIV/AIDS Risk Factors
• Stage of disease
• Number of losses
• Social isolation
• Disease progression/fear of progression
• Uncontrolled pain
• Experience with HIV-related suicide

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Substance Abuse

• Abuse versus dependence
• Co-morbid hepatitis C
• Relationship to risk behaviors
• Relationship to adherence
• Risk of adverse medication/drug events

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Treatment

• Psychotherapy
• Supportive, interpersonal, cognitive-behavioral,
  group
• Ongoing crises
• Countertransference issues

• Medications
• Antidepressants
• Stimulants
• Antipsychotics
• Antianxiety agents
• Mood stabilizers

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Medication Interactions

• Multiple medications
• Multiple medical illnesses
• Renal or hepatic disease
• Age
• Individual differences in liver metabolism
• Specific liver metabolism inhibitors/inducers

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Choosing Medications

• Adverse effects
• Possible interactions
• Metabolism via liver
• Elimination via liver, kidney or both
• Onset of action
• Duration of action
• Less is better

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AIDS-Defining Neurologic Illnesses

• CMV Encephalitis
• Progressive Multifocal Leukoencephalopathy (PML)
• Toxoplasma Encephalitis
• Primary CNS Lymphoma
• Cryptococcal Meningitis
• Rarely TB Meningitis and Kaposis Sarcoma

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Other CNS Disorders

• Viral/Bacterial Meningitis
• Neurosyphilis
• Herpes Simplex Encephalitis
• Varicella-Zoster Encephalitis
• Rarely Histoplasmosis and Coccidiodomycosis

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SUMMARY

• Document HIV status
• Determine degree of immunocompromise
• Thorough history and physical exam
• Diagnostic tests
• CT/MR - Urine toxicology
• LP - Blood alcohol level
• Routine blood work
• Neuropsychological testing

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SUMMARY

• HIV related illness
• Other physical illness
• Medication toxicity
• Substance use
• Primary psychiatric illness