Managing HIVRelated Depression in a Hospital Based OutPatient Psychiatric Department: The Mount Sina

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Managing HIV-Related Depression in a Hospital
Based Out-Patient Psychiatric Department The
Mount Sinai Experience

• Peter L. DeRoche MD, FRCP(C)
• Director, Clinic for HIV-Related Concerns
• Department of Psychiatry
• Mt. Sinai Hospital

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Clinic for HIV-Related Concerns

• Started in 1986 by Drs. Stephen Woo and Mary
  Seeman
• Funded in 1989 and 1991
• Services expanded and adjusted as epidemic
  evolved
• 7 part-time psychiatrists, 2 full-time
  psychotherapists, 1 part-time couple and family
  therapist, 1 part-time occupational therapist,
  full-time secretary/receptionist

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Clinic for HIV-Related Concerns

• Consultation
• Psychiatric assessment
• Multi-disciplinary psychiatric management of
  major mental illnesses
• Individual psychotherapy
• Couple and family therapy
• Group psychotherapy
• Mindfulness-based stress reduction
• Narrative therapy
• Art therapy

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Clinic for HIV-Related Concerns

• 250 intakes per year
• 500 patient visits per month
• 250 active patients
• 85 MSM, primarily gay men
• A developing Womens Program service for women,
  by women

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Clinic for HIV-Related Concerns

• Research
• Screening instruments for early neuro-cognitive
  decline
• Comparing efficacy of models of brief
  psychotherapy intervention
• Impact of St. Johns Wort on depression in HIV
• Role for Mindfulness-Based Stress Reduction
• Role for Art Therapy
• Role for Narrative Therapy

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Self-reported psychiatric symptoms. (Horwath
2002)
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MSM receiving diagnosis at time of assessment.
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• Social realities of HIV (burden of illness)
• Impact on career, income, housing
• Privacy, disclosure and discrimination
• Impact on relationships (family, life partner,
  social network)
• Impact on intimacy, sex relationships
• Stigmatization marginalization, isolation
• Multiple losses
• Impact of treatment

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• Not everybody has the same experience with HIV
• The experience of a life event (eg diagnosis with
  HIV), and how one copes with that event, is
  determined/influenced by previous life events.
• Formative years may be associated with shame,
  stigmatization and marginalization
• Development of low self esteem, low self worth
  and self as unlovable
• Interpersonal difficulties can result eg longing
  for intimacy but feeling unworthy or not trusting

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• Focus of treatment on pre-existing problems which
  compromise capacity to cope. Eg
• Impact childhood trauma
• Experiences with marginalization and
  stigmatization

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• Diagnosing strategies
• DSM IV depressions
• Major depressive disorder
• Dystymia
• Bipolar Affective Disorder
• Adjustment disorder
• Personality disorder
• Substance use or dependency disorders
• Sub-syndromal depression
• Limits of diagnosing

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Role for medications

• Evidenced-based practice
• Facilitate psychotherapy and social interventions
• Limitation of medications
• Influences of personality
• Influences of substance use
• Medication management of psychiatric disorders is
  informed by psychodynamic theory
• Relationship with the prescriber is critical in
  determining adherence
• The healing power of the relationship independent
  of the medications

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• Multitude of influences which complicate
  treatment and can limit response to treatment.

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Goals

• Living a more engaged, productive life in the
  context of illness
• Ericksons 7th and 8th stages
• Generativity vs self absorption
• Integrity vs despair

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Couple and Family Therapy

• Conflicts in primary relationships can cause or
  contribute to depression
• Depression can cause or aggravate conflicts in
  primary relationships

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Interpersonal Group Therapy

• As distinct from peer support
• A here and now focus on interpersonal
  relationships.
• Interpersonal problems are played out
  spontaneously in the group and examined
  therapeutically.

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Crisis Intervention

• To return the individual to a prior level of
  functioning.
• Facilitates expression of affect.
• Seeks to help understand the meaning of the
  event.
• Explores options for active coping.

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Individual Psychotherapy

• Distinction from counseling ?
• Focus on pre-existing problems which compromise
  capacity to cope. Eg
• Impact childhood trauma
• Experiences with marginalization and
  stigmatization

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Psychodynamic Psychotherapy

• The dynamic tension
• neurosis
• defence
• The role of the unconscious
• free association
• dreams
• transference
• Developmental years are a major focus of therapy.

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Psychodynamic Psychotherapy

• To develop insight into the influence of past
  experiences on the way one thinks about oneself,
  others and the world around.
• To understand dysfunctional patterns of thinking
  or behaviour which have developed as a result of
  these experiences
• To develop acceptance of the past.
• To connect legitimate feelings to what happened
  in the past, moving from self-blame to anger to
  grief to resolution.
• To disengage from the wounding experiences in
  order to engage in the present and future
  possibilities.
• To engage in healthier and more Self supportive
  ways of living in the world.

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Cognitive/Behavioural Therapy (CBT)

• Designed specifically for the treatment of
  depression and anxiety.
• Based on the assumption that mood is determined
  by thought and that depression and anxiety result
  from dysfunctional thought patterns.
• Therapy seeks to identify dysfunctional thought
  patterns, change them and reduce symptoms.

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Elements of Cognitive/Behavioural Psychotherapy
(CBT)

• Anxiety and depression are perpetuated by
  focusing on negative thought patterns a vicious
  cycle.
• A depressed person emphasizes the negative and
  tends to undervalue the positive.
• Therapy identifies cognitive distortions eg
  black and white thinking, predicting the
  future, operating on assumptions.
• Therapy helps individual look at emotions and
  events in more rational and balanced way.
• Facilitates acknowledgement of the positive in
  life and helps find ways to keep awareness of the
  positive in the individuals life.

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Interpersonal Psychotherapy (IPT)

• Designed specifically for the treatment of
  depression.
• Links the depression to changes in the persons
  life, eg role transitional, grief.
• Labels the depression as an illness but seeks to
  normalize the experience.
• Therapy very much focused on helping the
  individual re-engage in productive and meaningful
  activity, particularly interpersonal.

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Elements of Interpersonal Psychotherapy (IPT)

• Validate depression as a legitimate emotional
  reaction to the experience of living with HIV.
• Emphasize the proven value of re-engaging in
  productive, meaningful activity, particularly
  that which involves the interpersonal, as
  curative of depression.
• Explore and help work through the barriers the
  patient anticipates in doing this.

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Short-Term vs. Long-Term, open-ended

• Biases
• Chronic, recurring or successive problems.

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• Certain psychotherapies work better in specific
  disorders and with certain patients
• Most therapist utilize an eclectic approach
  determined by the therapists skill set and the
  patients particular needs and set of
  experiences.
• Therapist characteristics predicting successful
  psychotherapy outcomes (Rogers)
• Accurate empathy
• Non-possessive warmth
• Genuineness

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Staff development

• Analytically-oriented therapy, longer-term and
  shorter-term models
• Cognitive/Behavioural, Interpersonal
• Systems theory
• Occupational therapy
• Focusing, Mindfulness
• Creative writing
• Art Therapy

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Mindfulness-Based Stress Reduction

• developed for patients with chronic medical
  conditions, anxiety and chronic pain
• based on Buddhist mindfulness meditation
  practices
• evidence-based approach

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Mindfulness Based Stress Reduction Program
Structure

• 8-week training group led by trained practitioner
  (Buddhist meditation)
• 20 participants per group
• 3-hour sessions
• 1 day-long silent retreat
• approx. 1 hour homework, 6 days per week

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Mindfulness Based Stress Reduction techniques

• Guided meditations
• Eg loving kindness
• Focus on movement of breath, body scanning
• Non-judgemental awareness of intrusive thoughts,
  sensations
• Yoga practice

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Mindfulness Based Stress Reduction - goals

• Systematic training in how to focus attention and
  reduce influence of distracting thoughts,
  environmental stimuli and bodily sensations
• Unhooking from worry and rumination
• Enhancing capacity for curiosity about ones
  self, openness to the realities in ones life and
  acceptance of the self and the experiences life
  presents
• Increased compassion for the self

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Mindfulness Based Stress Reduction - benefits

• Increases psychological mindedness.
• Improvement on measures of worry rumination.
• Decreases anxiety depression.
• Reduction in symptoms of pain.

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Narrative TherapyTheory

• A persons verbal description of self and history
  may be unelaborated, unrevealing, rambling,
  inconclusive, interrupted, broken or disjointed.
• In psychotherapy a therapist talks with the
  client to help develop a coherent, logical and
  concise description of the problematic
  experiences.
• Goal is to develop understanding and empowerment
  through insight and working through.

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Narrative TherapyStructure

• 16 week group intervention.
• Each week a topic or theme is introduced eg
  write about a place or write about something
  you observed or experienced as a child.
• The intervention is the writing of personal
  stories (narratives) and sharing them with
  other group members during the group meetings.
• When a story is read, the personal life of the
  participant is not discussed rather the
  facilitators encourage discussion about the
  story.
• The participant learns to write a coherent story
  about himself/herself which can be understood by
  others (autobiographical/narrative competence)

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Narrative Therapy

• An opportunity to write and share stories with
  others who live with HIV in a confidential
  setting.
• Fosters creative problem solving resulting in
  enhanced life enjoyment, a change in perspective
  on experiences, develops tools for expression and
  helps navigate the impact of illness on their
  lives.

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Narrative Therapy Impact on Physical and Mental
Health

• Drops in physician visits
• Positive impact on immune function
• Reduced emotional distress
• Reduction in symptoms of illness
• More positive attitudes towards the self

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Art Therapy

• Psychotherapy is based primarily on a verbal
  process
• Stigmatization, secrecy, and extreme anxiety
  associated with unresolved adverse experiences
  can limit cognitive and verbal processing
• This may make it difficult to begin and sustain
  treatment using talk therapy

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Art Therapy

• Art helps express feelings that are difficult to
  put into words, thereby releasing feelings in a
  safe and acceptable way and promoting spontaneity
  and creativity
• Greater awareness provided through art therapy
  can increase active coping, such as problem
  solving and more effective utilization of social
  support
• Even when awareness and insight remain low, the
  process of expression through art can alleviate
  symptoms of anxiety, intrusive memories, and
  pre-occupation

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Art Therapy

• 30 of participants in a previous group therapy
  intervention could not tolerate the group
  experience
• The current intervention is one-on-one for
  individuals with significant symptoms of distress
  related to traumatic events in the past (eg
  childhood sexual abuse, discrimination/stigmatizat
  ion, diagnosis of HIV)

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Art Therapy

• 10 sessions of structured art therapy
• A theme is presented and the client chooses the
  medium to work with
• The client develops increased capacity to step
  back from the emotional impact of self
  reflection, to create a structure and boundaries
  emotionally so that the experience is a safer
  one.
• A gradual freedom in emotional expression and
  trust in the therapist to participate in the
  expression of affect.

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pderoche_at_mtsinai.on.ca