Download - Pacific AIDS Education and Training Center

Mental Health Screening
Tools for the HIV Clinician
Lawrence M. Mc Glynn MD
Clinical Associate Professor
Stanford University
Faculty Medical Director
San Jose AETC
June 2013
Thanks
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Pacific AETC Staff and Faculty; San Jose
AIDS Education and Training Center
American Psychiatric Association –
Office of HIV Psychiatry
Goals for Participants
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Understand which mental illnesses
present themselves more frequently in
HIV
Identify risk factors for mental illness in
HIV
Become familiar with screening tools for
conditions which may affect the overall
health of people living with HIV/AIDS
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Grab a pencil and some scratch paper
Close your door; turn off your cell
phone; no checking your email; no
sleeping; kick back and let’s learn
together 
Types of Screening Tools
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Patient focused
 Self administered
 Usually consist of questionnaires
 Clinician administered to patient
 Questionnaires
 Labs
 Imaging
 Examinations (physical and mental status)
 Includes simple observation
Observer(s)
 Testimonials from family, friends, coworkers, other providers
Why screening tools?
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Relative objectivity (provider bias)
Efficiency
Lack of resources
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Mental health timely availability
Shows the patient that you are
considering all aspects of his/her life
Cognitive Dysfunction
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As HIV enters the CNS at a very early
stage of infection, a cascade of events
leads to changes in multiple realms of
cognition
Neuropsychological Domains
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Verbal/Language
Attention/concentration
Working Memory
Executive/Abstraction
Memory (learning, recall)
Speed of information processing
Sensory-perceptual
Motor skills
Associated Behavioral
Disturbances
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Apathy
Depression
Sleep disturbance
Agitation/Mania
Psychosis
HAND Classification
Asymptomatic Neurocognitive 1 SD
Impairment (ANI)
2 Domains
Mild Neurocognitive
Impairment (MNI)
HIV-Associated
Dementia (HAD)
1 SD
2 Domains
No Functional
Impairment
Mild Functional
Impairment
2 SD
Moderate to Severe Functional
2 Domains
Impairment
NIMH, NINDS Panel, Neurology 2007; 69:1789-1799
Prevalence of HAND based on
New Criteria
NP Normal
(30-60%)
ANI
(20-30%)
MNI
(20-30%)
HAD
(5-20%)
Functional Impairment
NIMH, NINDS Panel, Neurology 2007; 69:1789-1799
Risk and Protective Factors
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Risk factors
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Age > 50
Survival duration
Lower nadir CD4 T-cell counts
Higher baseline viral load
Gender (F)
Why Bother to Screen?
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MNI has been associated with poorer health
outcomes, possibly due poorer adherence to
medications
Even mild HAND is associated with worse quality of
life, difficulty obtaining employment and shorter
survival
McGuire, Goodkin, and Douglas report that HAND
independently predicts systemic morbidity and overall
HIV mortality
Consider screening upon the initiation of cART and
q6-12 months
Mind Exchange Working Group. CID Advance Access. Nov
2012.
The role of objective assessment
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General Practitioners ability to pick up dementia cases
 Sensitivity 51.4% (“positive in disease”)
 Specificity 95.9% (“negative in health”)
Missed dementia more frequently in patients living alone
Over-diagnosed dementia more frequently in patients
with mobility/hearing problems, and in the depressed
Miss nearly half of incident dementia cases
Possible factors: GPs’ subjective views on dementia
(e.g., therapeutic nihilism, or suspected/feared
stigmatization)
Conclusion: use objective tests
Pentzek M, Wollny A, Wiese B, et al. Apart from Nihilism and Stigma: What Influences GP’s
accuracy in identifying incident dementia? Am J Geriatr Psychiatry 17:11, November 2009.
Screening Tools
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MMSE (not very sensitive, Crum et al., 1993)
HIV Dementia Scale (Power et al., 1995)
International HIV Dementia Scale (Sacktor et
al., 2005)
Montreal Cognitive Assessment (MoCA,
Overton et al. CROI 2011)
MOS-IV
International HIV Dementia
Scale (IHDS)
1. Memory-Registration
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Give four words to recall
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(dog, hat, bean, red) – 1 second to say each.
Then ask the patient all four words after you
have said them. Repeat words if the patient
does not recall them all immediately. Tell the
patient you will ask for recall of the words
again a bit later.
2. Motor Speed
Have the patient tap the first two fingers of the
non-dominant hand as widely and as quickly as
possible.
4 = 15 in 5 seconds
3 = 11-14 in 5 seconds
2 = 7-10 in 5 seconds
1 = 3-6 in 5 seconds
0 = 0-2 in 5 seconds
_____
3. Psychomotor Speed
Have the patient perform the following movements with the nondominant hand as quickly as possible:
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1) Clench hand in fist on flat surface.
2) Put hand flat on surface with palm down.
3) Put hand perpendicular to flat surface on the side of the 5th digit.
Demonstrate and have patient perform twice for practice.
4 = 4 sequences in 10 seconds
3 = 3 sequences in 10 seconds
2 = 2 sequences in 10 seconds
1 = 1 sequence in 10 seconds
0 = unable to perform
_____
4. Memory-Recall
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Ask the patient to recall the four words. For words
not recalled, prompt with a semantic clue as follows:
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animal (dog); piece of clothing (hat); vegetable (bean);
color (red).
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Give 1 point for each word spontaneously recalled.
Give 0.5 points for each correct answer after
prompting
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Maximum – 4 points.
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_____
Total International HIV Dementia
Scale Score
This is the sum of the scores on items 1-3. ____
The maximum possible score is 12 points.
A patient with a score of
 10
should be evaluated further for possible dementia.
HIV Dementia Scale
MAXIMUM
SCORE
PATIENT
SCORE
TEST
MEMORY - REGISTRATION
Give 4 words to recall (dog, hat, green, peach) and 1 second to say
each. Then ask the patient to repeat all 4 after you have said them.
4
ATTENTION/EXECUTIVE FUNCTION
Antisaccadic eye movements (20 commands): ____ errors out of 20
 3 errors = 4; 4 errors = 3; 5 errors = 2; 6 errors = 1;  6 errors = 0
6
PSYCHOMOTOR SPEED
Ask patient to write the alphabet in uppercase letters horizontally across
the page (use back of form) and record time: _____ seconds
 21 sec = 6; 21.1-24 sec = 5; 24.1-27 sec = 4; 27.1-30 sec = 3; 30.1-33 sec =
2; 33.1-36 sec = 1; 36 sec = 0
MEMORY - RECALL
Ask for the 4 words from MEMORY – REGISTRATION TEST above.
Give 1 point for each correct. For words not recalled, prompt with a
semantic clue as follows: animal (dog); piece of clothing (hat); color
(green); fruit (peach). Give ½ point for each correct word after prompting.
4
2
CONSTRUCTION
Copy the cube below. Record time _____ seconds
 25 sec = 2; 25-35 sec = 1; 35 sec = 0
Total score < 10: HAD
11-13: Mild cognitive impairment
Adapted From: Power C et al.: HIV Dementia Scale: a rapid screening test. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology
1995;8:273-278. Used with permission.
Modified HIV Dementia Scale
Max Score Pt. Score
Task
Memory-Registration Give four words to recall (dog, hat, green,
peach) - 1 second to say each. Then ask the patient all 4 after you
have said them.)
Psychomotor Speed Ask patient to write the alphabet in upper
case letters horizontally across the page below and record time:
____ seconds.
less than or equal to 21 sec = 6; 21.1 - 24 sec = 5; 24.1 - 27 sec =
4; 27.1 - 30 sec = 3; 30.1 - 33 sec = 2; 33.1 - 36 sec = 1; > 36 sec
= 0)
6
Memory - Recall Ask for 4 words from Registration above. Give 1
point for each correct. For words not recalled, prompt with a
"semantic" clue, as follows: animal (dog); piece of clothing (hat),
color (green), fruit (peach). Give 1/2 point for each correct after
prompting
4
2
Total Score
Max= 12
Construction Copy the cube below; record time: ____ seconds.
(< 25 sec = 2; 25 - 35 sec = 1; > 35 sec = 0)
/12
< 7.5 may indicate dementia and should be evaluated by full
battery if possible
MOCA
MOCA
MOCA
MOCA
MOCA
Cognitive Functional Status Sub-scale of
MOS-HIV Scale of Wu et al.
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4 questions, past 4 weeks:
1. Difficulty reasoning/problem solving?
 2. Forget things (location; appointment)?
 3.Trouble with keeping attention for long?
 4. Difficulty with activities using concentration /
thinking?
6 pt. frequency scale: 1= all; 2=most; 3=good bit;
4=some; 5=little; 6=none [cutoff < M= 4]
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Validated against NP overall performance in
the Netherlands; Good for busy clinics
Knippels, Goodkin, Weiss, et al., AIDS, 2002;16:259-267
Mathematical Screening
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Cysique et al.
Cognitive impairment is predicted to
occur when this expression is true
Step 1: Neuropsych
performance
Step 2: Functional
Impairment?
How To Assess Functional
Impairment?
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Collateral Informant and
Objective ratings are most
reliable
IADL scale (Lawton)
 Driving Performance (Marcotte et
al.)
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Karnofsky, Finances, Medications
What to do with a positive
screen?
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Rule out other causes
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Always consider the biopsychosocial model
Treatment
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Antiretrovirals
Psychostimulants
Other treatments being studied
Depression and Anxiety
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Depressed mood is one of the most common
complaints among people living with HIV
Given the high co-occurrence of HIV and
PTSD, anxiety is also frequently seen
These disorders may present themselves as
somatic complaints
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Headaches, GI complaints, weakness, fatigue,
insomnia, chest pain, shortness of breath
Somatic complaints are not unusual in HIV/AIDS
even when the patient is mentally healthy
Epidemiology-Anxiety
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15.8% of HIV+ have GAD (2.1% of
general population
10.5% have Panic d/o (2.5% of gp)
37% of HIV+ women report “high
anxiety”
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Protective: relationship, older, vl BDL
Epidemiology-Depression
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Lifetimes prevalence of depressive
disorder in HIV as high as 22% (5-17%
in general population)
Risk: African-american (M and W), MSM
Why Bother to Screen?
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Depression in HIV/AIDS is a significant
predictor of worsening overall outcome
Depression and anxiety can contribute
to poor cognitive functioning
Screening Tools
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Consider Endicott Criteria: reduce the
weight of somatic symptoms
(weight/appetite loss, sleep changes,
agitation/retardation, fatigue, loss of
concentration) in screening
HAD
Are you depressed?
Anxiety questions
•I feel tense or wound up
•I get a sort of frightened feeling as if something bad is
about to happen
•Worrying thoughts go through my mind
•I can sit at ease and feel relaxed
•I get a sort of frightened feeling like butterflies in the
stomach
•I feel restless and have to be on the move
•I get sudden feelings of panic
•Cutoff score: 8
Depression Questions
•I still enjoy the things I used to enjoy
•I can laugh and see the funny side of things
•I feel cheerful
•I feel as if I am slowed down
•I have lost interest in my appearance
•I look forward with enjoyment to things
•I can enjoy a good book or radio or TV program
•Cutoff score: 8
"Are you depressed?"
Screening for depression in the terminally ill
Am J Psychiatry 1997
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Semi-structured diagnostic interviews for
depression were administered to 197 patients
receiving palliative care for advanced cancer
RESULTS: Single-item interview screening
correctly identified the eventual diagnostic
outcome of every patient, substantially
outperforming the questionnaire and visual
analog measures
PHQ-9
What to do with a positive
screen?
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Assess for suicidality
R/o other causes (biopsychosocial
model)
Refer to treatment (talk, med’s)
Suicidality
Epidemiology
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Despite the development of cART,
suicide rates among HIV+ individuals
remain more than three times higher
than in the general population.
AIDS PATIENT CARE and STDs
Volume 26, Number 5, 2012
Risk
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History of suicide attempt(s)
Diagnosable mental health disorder
History of psychiatric treatment
Substance use
Anxiety sensitivity – cognitive concerns
Why Bother to Screen?
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Safety
Establish a longitudinal record
Suspicion of suicide can elicit emotions
in the provider
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Is emotional decision making as precise as
less emotion-based thinking?
Screening Tools
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Will you be able to sleep tonight?
Multiple factors to consider which make
screening a challenge
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Substance use
Psychosocial stressors
Temporal relationship to medications (e.g.,
efavirenz, IFN-α)
Medical illness
SBQ-R (Osman et al)
What to do with a positive
screen?
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Hospitalize
For those deemed to be able to go
home
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F/U asap; telephone contact (to/from)
Urgent referral to mental health
PTSD Screening
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The estimated rate of recent PTSD
among HIV-positive women is 30.0%
(95% CI 18.8–42.7%), which is over
five-times the rate of recent PTSD
reported in a national sample of women
PC-PTSD
What to do with a positive
screen
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Screen for depression, anxiety, domestic
violence, substance abuse and
suicidality
Refer to mental health
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Therapy
Medications based on symptoms
Substance abuse
Epidemiology
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Only 19% of those with HIV had never
used an illicit drug
1 in 4 of those with HIV in the USA
report alcohol or drug use at a level
warranting treatment
Why Bother to Screen?
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Active substance use can lead to
increased morbidity and mortality
Substances can interact with HIV
medications
Screening Tools
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Physical Exam
Mental Status Exam
CAGE questionnaire
CAGE
What to do with a positive
screen?
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Establish safety
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Prescribed medications which may pose a
risk
Concurrent illnesses (e.g., HCV)
Home, transportation
Family responsibilities (children, elderly)
Discuss treatment options
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Have referral information on hand
Domestic Violence
Facts
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For HIV+ women, the estimated rate of intimate partner
violence is 55.3% (95% CI 36.1–73.8%), which is more than
twice the national rate. Early childhood abuse predicts future
domestic violence (Machtinger et al)
Among MSW with HIV, childhood sexual abuse predicted posttraumatic stress disorder (PTSD), and less trust in medical
providers (Whelten et al)
MSM with HIV and PTSD are more likely to miss appointments
(Traeger et al)
Victims may be less likely to leave abusive situation
In a sample of HIV+ individuals, 20.5% of the women, 11.5%
of the MSM, and 7.5% of the MSW reported physical harm since
diagnosis, of whom nearly half reported HIV-seropositive status
as a cause of violent episodes (Zierler, Bozzette, et al)
Why Bother to Screen?
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Safety of patient
Safety of others
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Family
Friends
Staff
Screening Tools
http://www.cdc.gov/ncipc/pubres/images/ipvandsvscreening.pdf
What to do with a positive
screen?
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Assess for current safety
Document
Refer
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Safe shelter
Mental health
Report
The Great Imitators
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Screen for other conditions which may
mimic psychiatric disorders
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Hepatitis C - lab
Syphilis - lab
Drug Interactions – Pharm.D., website
Adherence challenges
Medication Adverse Effects
Malnutrition/Dehydration
Axis II Flags
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“Everyone”
“No one”
“Always”
“Never”
The End
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Thank you for taking care of our
community!