Download 2009-03 Beyond101 Davis

HIV Beyond 101
I. Jean Davis, PhD, DC, PA , AAHIVS
Assistant Professor, Dept. Internal Medicine
Charles Drew University of Medicine and Science
University of California, Los Angeles
Co-Principal Investigator & Director,
Pacific and National Minority AIDS Education & Training
Centers
March 4, 2009
HIV & Mental Health:
A Complex Issue
Poor Medical and/or
Psychosocial
Outcomes
HIVMental Illness
Mental IllnessHIV
Mental IllnessHIV
Mental illness
HIV & Mental Health
Individuals who are HIV-infected often
experience psychosocial and medical
challenges such as:
•
•
•
•
•
social isolation
depression
traumatic life events
medication side effects
comorbid illnesses
HIV & Effects on CNS
The infection itself has direct effects on the
central nervous system, causing:
•
•
•
•
•
•
neuropsychiatric complications
depression
mania
cognitive disorder
frank dementia
(often in combination)
HIV & Mental Health
• Individuals with mental illnesses are
more at risk for HIV and AIDS due to:
– disadvantaged social status and poverty
– higher rates of substance abuse
– homelessness/unstable housing
• Individuals with serious chronic mental
illnesses in US have a high
seroprevalence of HIV (5–7%)
HIV & Mental Health
• Availability of more effective HIV treatments has
reduced mortality  more people living with HIV in US,
as incidence of new cases decreases
• Despite advances in the treatment of HIV, there
continues to be unexplained variability in the course of
this disease
• Psychosocial factors, such as chronic depression and
stressful events, can affect clinical and immunological
progression of HIV/AIDS, even with decreasing
prevalence of opportunistic infections (don’t fully
understand biological mechanisms)
HIV-infected patients experience
significantly more stress than the
general population
• Some stress-related psychiatric disorders are
commonly undetected and untreated in HIV
health care settings
– PTSD: 30-50% prevalence; more than ½
untreated
– Acute stress disorder: maybe 30% prevalence
– Depression
• Depressive symptoms highly prevalent among
people living with HIV/AIDS
– especially among women who are infected
HIV-infected patients experience
significantly more stress than the
general population
• In a national probability sample of HIV-positive
men and women in the USA, the 1-year
prevalence of major depression was 36% and
that of generalized anxiety disorder was 16%
(5 & 8x more than the general population)
• A large cross-cultural case control study found
that rates of depressive disorders and
depression symptoms were higher in
symptomatic HIV-positive people than nonsymptomatic and non-infected in Bangkok,
Kinshasa, Nairobi and Sao Paulo
HIV-infected patients experience
significantly more stress than the
general population
In one study of 210 HIV-infected patients in two county-based HIV
primary care clinics in CA:
•
•
•
•
•
•
•
•
38% had depression
34% had PTSD
43% had Acute Stress Disorder
38% had 2 or more disorders
20% had all met criteria for all 3 diagnoses
Women had more ASD than men
African Americans and white non-Latino patients were more likely
to have ASD than Latinos or other patients
43% of those with at least 1 diagnosis were not receiving
concurrent mental health care treatment
Women with HIV more prone to
emotional distress than men with HIV
Factors associated with emotional distress and
mental health problems in women:
• Younger age, more social conflict, less social
support, lower perception of health, and more
HIV worry were associated with higher
depressive symptom scores
• Factors most often affecting various mood
states included public housing,
unemployment, social conflict, and worry about
having HIV
Psychiatric outpatients & Sexually
Transmitted Infections (STIs)
In one study of 464 psychiatric outpatients:
• 38% reported a lifetime history of one or more
STIs
– Patients with a lifetime STI history were more
knowledgeable about HIV, expressed stronger
intentions to use condoms, and perceived
themselves to be at greater risk for HIV
BUT
– Those with a past STI were also more likely to
report sex with multiple partners and reported
more frequent unprotected sex in the past 3
months
Summary
•
Important to understand relationship between mental health and
HIV in order to reduce the number of persons affected by the
epidemic (by addressing mental health), and to improve the
mental health and quality of life of those who are HIV infected.
•
Important to understand the behavioral mechanisms
associated with HIV disease progression and how they may
mediate the impact of psychosocial factors on disease
progression
•
Interventions for psychiatric conditions will lead to improved
healthcare outcomes for patients with HIV/AIDS and mental
health disorders.
– Patients with HIV/AIDS and depression who received
antidepressants were more adherent to antiretroviral
treatment than those who did not receive antidepressant
medication
What can be done to
address the problems?
•
•
•
Primary healthcare of patients with HIV/AIDS could be improved
by more regular use of tools to routinely screen and diagnose
mental health disorders related to traumatic life events
Need for STI/HIV risk reduction interventions in psychiatric
settings, particularly for patients with high-risk profiles
•
Mental Health Services need to become an integral part of HIV
care
•
Need more information and better dissemination of information
about what psychological and psychiatric treatments might be
beneficial for HIV-infected persons presenting with depression,
past history of trauma and Post Traumatic Stress Disorder
“No health without
mental health”
•
Mental disorders increase risk for communicable and
non-communicable diseases
•
Many health conditions increase the risk for mental
disorders
•
Co-morbidity complicates help-seeking, diagnosis, and
treatment and influences prognosis
•
Health services are not provided equitably to people
with mental disorders
Case Study: Howard
• 48 year-old male
• Recently released after being incarcerated for possession of
cocaine
• No income or insurance
• Tested positive 8 years ago while in a methadone program
• Has had intermittent medical care
• Reports that he is staying with “a friend”
• Was on antiretroviral therapy while incarcerated
• Shows up at your clinic asking about housing
What are some of the issues a case manager should
explore during the psychosocial assessment?
Case Study: Lydia
• 32 year-old African American female
• Diagnosed with HIV following testing during a routine
gynecological exam
• Recently separated from her husband, has 3 schoolage children
• Employed as a nurse’s aide
• Living with her mother and grandmother while saving to
be able to afford her “own place”
What are some of the issues a case manager should
explore during the psychosocial assessment?
References
•
•
•
•
•
•
•
•
Barton, P.L., Kobayashi, J.S., Maravi, M., & Yun, L.W.H. (2005). Antidepressant treatment
improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir
Immune Defic Syndr, 38, 432-438.
Blank, Michael B. and Eisenberg, Marlene M. (2007) HIV and Mental Illness',Journal of
Prevention & Intervention in the Community,33:1,1-4.
Gore-Felton, C. & Koopman, C. (2008). Behavioral Mediation of the Relationship Between
Psychosocial Factors andHIV Disease Progression. Psychosomatic Medicine 70:569–574
Israelski, D. M., Prentiss, D. E., Lubega, S., Balmas, G., Garcia, P., Muhammad, M., Cummings,
S. and Koopman, C.(2007) Psychiatric co-morbidity in vulnerable populations receiving primary
care for HIV/AIDS',AIDS Care,19:2,220-225
Leserman, J. (2008). Role of Depression, Stress, and Trauma in HIV Disease Progression.
Psychosomatic Medicine 70:539–545
Miles, Margaret Shandor, Holditch-Davis, Diane, Pedersen, Cort, Eron Jr., Joseph J. and
Schwartz, Todd (2007) Emotional Distress in African American Women with HIV', Journal of
Prevention & Intervention in the Community,33:1,35-50
Prince, M., Patel, V., Saxena, S., Maj, M. Maselko, J., Phillips, M.R., Rahman, A. (2007). No
health without mental health. The Lancet 370 September 8, 859-877.
Vanable, Peter A., Carey, Michael P., Carey, Kate B. and Maisto, Stephen A. (2007). Differences
in HIV-Related Knowledge, Attitudes, and Behavior Among Psychiatric Outpatients with and
Without a History of a Sexually Transmitted Infection,Journal of Prevention & Intervention in the
Community,33:1,79 — 94
Acknowledgement:
Alison Hamilton, Ph.D.
UCLA Integrated Substance Abuse
Programs
[email protected]