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The Triply Diagnosed Patient: Prevention and Care Milton L. Wainberg, M.D. Columbia University HIV Mental Health Training Project New York State Psychiatric Institute A Local Performance Site of the New York / New Jersey AIDS Education and Training Center [email protected] Definitions and Background Triply Diagnosed Patients: Who They Are and Why These Disorders Travel Together • Majority: Alcohol / substance use disorders and HIV with comorbid depressive, anxiety, personality disorders. • Minority: Recurrent psychotic disorders (schizophrenia, mania, depression with psychosis, psychosis NOS) with comorbid alcohol / substance use disorders and HIV. Majority Population of Triply Diagnosed Patients: Some Findings National U.S. health survey: Adults with depression and anxiety disorders (GAD, PD) were more likely to engage in HIV risk behavior than those without these disorders. National U.S. study of substance use programs: Adults with both psychiatric and substance abuse disorders have higher rates of HIV infection than those with substance abuse disorders alone. RAND HCSUS Study: 1,489 HIV-positive Medical Patients 27% took psychotropic medication in 1996: – – – – 21% antidepressants 17% anxiolytics 5% antipsychotics 3% psychostimulants About half of patients with depressive disorders did not receive antidepressants. Psychiatric disorders are common and undertreated. Psychosis & Mania Diagnostic and Treatment Issues When Psychosis / Mania Occur in the Course of HIV Infection Prior to infection: –Elevated rates of HIV infection in psychiatric patients with psychotic disorders : seroprevalence 1% - 23%, associated with AOD use, unsafe sex, institutionalization –Substance use, (e.g. hallucinogens, amphetamines, cocaine, ecstasy) associated with both psychotic symptoms and HIV risk. When Psychosis / Mania Occur in the Course of HIV Infection With asymptomatic infection: –HIV invades the brain at initial infection –Not known if HIV by itself increases biological vulnerability to certain mental illnesses When Psychosis / Mania Occur in the Course of HIV Infection With symptomatic illness: –Can occur at the initial presentation of symptomatic HIV illness –Concern is differential diagnosis: »Complication of substance use / withdrawal, medical illness, metabolic disturbances, neuropsychiatric manifestations of HIV (e.g., HAD), side effects of HIV-related medications, etc. Psychosis/Mania: Differential Diagnosis due to a General Medical Condition HIV associated dementia Psychoneurotoxicities – – – – – – – Steroids Nucleoside antiretrovirals NNRTI Gancyclovir Sympathomimetics Antidepressants Cocaine, amphetamines Opportunistic infections – Toxoplasmosis – Cryptococcal meningitis – CNS lymphoma – Neurosyphillis – Herpes – B12 deficiency (megaloblastic madness) Psychosis Common underlying causes – Medical conditions / treatments associated with CNS dysfunction – Illicit drugs – Depression / mania with psychosis – Schizophrenia / related disorders Psychosis in medical settings is associated with under treatment by providers Use of Antipsychotic Medications in Patients with HIV Infection Antipsychotic medications maintain efficacy in the presence of HIV neuropsychiatric manifestations Problems that may arise – – – – In Increased sensitivity to side effects Overlapping toxicities Drug interactions (often theoretical) Liver toxicity among patients co-infected with hepatitis viruses advanced HIV disease, follow rule as with elderly: start low, go slow “Typical” First-Generation Antipsychotics Haloperidol most commonly prescribed Low doses useful in delirium In advanced HIV infection: extrapyramidal side effects, including rapid onset tardive dyskinesia and neuroleptic malignant syndrome “Atypical” Second-Generation Antipsychotics / olanzapine: risk diabetes Clozaril / clozapine: risk diabetes; bone marrow suppression; risk seizures on ritonavir / other Pis Geodon / ziprasidone: QT interval— caution with drugs that also have this effect (e.g., protease inhibitors, ketoconazole) Zyprexa Mania: Treatment Psychopharmacology – Antipsychotics at lower doses – Mood stabilizers: » Lithium » Anticonvulsants—consider side effects, toxicities, and drug interactions – Benzodiazepines as adjunct Electroconvulsive therapy (ECT) HIV Among People with Severe Mental Illness: Summary of U.S. Studies HIV Among People with Severe Mental Illness: Summary of U.S. Studies Rates of HIV Infection (1%-23%) > general population Rates of unsafe sexual behavior Rates of co-morbid alcohol/drug use: 20-75% Intermittent IDU: – 1%-8% recent – 4%-26% lifetime HIV Infection Rates by Type of Drug Use – Injected drugs – Non-Injected drugs – Alcohol only 33.8% 15.4% 10.9% HIV Among People with Severe Mental Illness: Summary of U.S. Studies ♦ Sexual risk behaviors associated with drug use: ♦ sex with IDU partners ♦ sex in exchange for money / drugs ♦ impaired judgment and reduced impulse control while high: unsafe sexual activity while high on alcohol / drugs ♦ Drug use is associated with rates of STIs and HCV/HBV ♦ Prevention and treatment of an alcohol / substance use disorder is an HIV risk reduction strategy Harm Reduction: Creating Stable Change Transtheoretical Model* Precontemplation Contemplation Preparation Action Maintenance Relapse & Recycle * Prochaska & Diclemente Outcomes of Cognitive Behavioral Skills Training Intervention for Psychiatric Patients: Summary of Studies on Sexual Risk Reduction AIDS knowledge Self efficacy / intention to change Condom use Number of partners Episodes of Unprotected sex Reducing Sexual Risk: Suggested Modifications for People with Severe Mental Illness Adjust language used by staff to match verbal skills, cognitive functioning, cultural values of patients Keep goals simple and realistic Be more repetitive Provide more maintenance sessions Take into account your patients’ stages of change Adherence Psychiatric Illness and Adherence Substance use, depression, and other mental illnesses can undermine adherence: Treat these disorders Creating stable life conditions enhances adherence Patient’s readiness to adhere must be individually assessed Consider adherence support Strategies for Improving Adherence Therapeutic alliance Patient education Treating substance abuse Treating psychiatric disorders Memory aids Observed medication administration Integrated care Outreach (“Inreach”) Incentives—offer what is desired Substance Use AOD Treatment for HIV+ Patients: Medical Model: – if patient is doing worse: increase the treatment Traditional Substance Abuse Treatment – if client is doing worse: discharge from treatment Public Health Model: – patient seen as vector of infection; keep patient in treatment at all costs Traditional Substance Abuse Treatment – avoid “enabling”; labeling; tell client what to do; monitor clients’ urines / bloods Harm Reduction Model – reduce harm around use; keep patient in treatment at all costs; clientoriented approach; personal responsibility AOD Users and HIV Medical Care AOD Users less likely to be tested and diagnosed More likely to develop OIs and complications Less likely to have access to medical care Less likely to be offered optimal treatments Less likely to adhere if offered HAART Modified from Frontline Forum: Clinical Symposia Highlights in HIV, May, 1999, cited by A. Vinciquerra, SUNY UMU, 2001, Drug Interactions: HIV+ AOD Users Psychiatric medications + drugs of abuse + HIV medications + medications to treat substance used disorders = Drug Interactions Track new information on websites such as – HIV InSite (http://hivinsite.ucsf.edu) – HIV Drug Interaction Guides by the NY NJ AETC Before we get to the conclusions… Close your eyes Close your eyes again The Miriam Acevedo Syndrome Common Treatment Dilemmas Adequate access to and integration of mental health and substance use services. Maintaining adherence in patients with three chronic relapsing disorders. Provider countertransference reactions to “self-destructive” and “manipulative” patient behaviors. Balancing harm reduction approaches with sensible limit-setting. A Couple of Words About Our Work… Get to know your patients, understand them – feel free to ask! Know your role – know what is “None of your business!” (religion, sexuality, politics, etc.) Adjust to them, not the other way around – if uncomfortable, get supervision We all have experience prejudices – connect with that However, not over identify – at times the medicine can be worst than the disease! Thanks!
