Download Mental Health in HIV Patients

Psychiatric issues in HIV
infected patients
DR SEDDIGH
• More rapid, fatal course of disease
• Emphasis on treating opportunistic
infectison and providing palliative care
• Quality of life affected by various
symptoms
• More chronic disease course
• Complex treatment regimen with many
adverse effects
• Prognostic uncertainty
Negative Aspects of HIV/AIDS
• Stigma/Discrimination
• Estrangement from
family/community
• Fear of contagion
• Fear of death
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Feeling like a burden
Loss of dignity
Guilt
Grief over multiple
losses
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‫سندرم نقص ايمني ‪ -‬اكتسابي (‪ )AIDS‬و اختالالت وابسته به آن به‬
‫همراه اعتياد ‪ ،‬ماهيت مراقبت هاي بهداشتي را در سراسر دنيا تغيير‬
‫داده است ‪ .‬تيم هاي بهداشت رواني در سه زمينه با مشكل ‪AIDS‬‬
‫درگير هستند ‪:‬‬
‫‪ -1‬عوارض مغزي و عصبي‬
‫‪ -2‬سندرم هاي روانپزشكي كالسيك (اضطراب ‪ ،‬افسردگي ‪،‬‬
‫سايكوز ) و اختالالت وابسته به ‪HIV‬‬
‫‪ -3‬كمك به جامعه و بيمار و خانواده او با اثرات اجتماعي و آموزش‬
‫در مورد رفتارهاي جنسي و سوء مصرف مواد‬
• It is not surprising for the general public, as well as
healthcare professionals, to assume that HIV
diagnosis may lead to acute distress including
anxiety, depression, or suicide (Green et al., 1996).
‫اين پديده جديد از طيف وسيعي تشكيل شده است كه‬
‫در يك قطب آن سندرم ههاي شديد مرتبط با ‪AIDS‬‬
‫و در قطب ديگر ‪ ،‬عفونت هاي بدون عالمت مطرح‬
‫است و اين بيماران نسبت به تمام اختالالت طبي‬
‫ديگر نظير عفونت ‪ ،‬تومور و سندرم هاي عصبي ‪-‬‬
‫رواني ‪ ،‬آسيب پذير هستند ‪ .‬باالخره اين بيماران از‬
‫يك طرف به خاطر بيماري و عوارض جسمي آن و‬
‫از طرف ديگر به خاطر اثرات و استرس هاي‬
‫اجتماعي ‪ -‬رواني آن در رنج هستند كه حمايت هاي‬
‫اجتماعي و درماني را طلب مي كند‬
• This concern was confirmed in the literature showing
a high prevalence of emotional distress,
psychopathology, and suicide among HIV-infected
people (Perry et al., 1984; Faulstich, 1987; Marzuk et
al., 1988; Chuang et al., 1989; Dew et al., 1990).
• After 29 years of HIV epidemic, 40,000 new cases
are being diagnosed annually in the USA.
• The fact that HIV infection is being spread by people
who are not aware of their serostatus underscores
the need to increase the number of people who know
their HIV serostatus (Janssen et al., 2001).
• How can we achieve this objective without causing
undue emotional distress as we contemplate the
possibility of making HIV Rapid tests available over
the counter?
HIV & TRANSMISSION
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TYPES
SOURCE
MOST COMMON
OTHER
TARGET ORGAN
HIV & DIAGNOSIS
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•
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•
•
•
METHOD
ELISA
WESTERN BLOT
SEROCONVERSION
HIGH RISK GROUPS
CONSOULTATION (PRE TEST/POST
TEST)
‫عالئم باليني ‪AIDS‬‬
‫• عوارض و عالئم باليني غير عصبي‬
‫• عوارض عصبي و روانپزشكي‬
Opportunistic infections and neoplasm
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•
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•
•
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Influ-like syndrome
Cerebral Toxo
TB
Crypto
CMV retinitis/encephalitis
PML
Other viral/fungal/protozoal CNS infections
Tumors: CNS lymphoma, metastatic lymphoma
and Kaposi
Biology of HIV infection in the
CNS
• VIRUS KNOWN TO ENTER THE BRAIN
EARLY AND REMAIN SEQUESTERED, AT
LEAST IN MICROGLIA.
• NO PRODUCTIVE NEURONAL INFECTION
– NEURONS DO NOT HAVE CD4 RECEPTORS
• NEURONAL LOSS LIKELY IMMUNEMEDIATED
– INFECTED MACROPHAGE-ASTROCYTE
HIV and Psychiatric Illness
• HIV increases risk for psychiatric illness
• Psychiatric illness increases risk for HIV
• Effective treatment for psychiatric illness
can improve patient outcome
• Effective treatment for psychiatric illness
can decrease HIV transmission
Depression
Demoralization
Substance abuse
Cognitive impairment
Mental illness
HIV
Impulsivity
Depression
Demoralization
Substance abuse
Cognitive impairment
Primary CNS Infection by HIV
• A. Neurological
•
•
•
•
HIV Associated neurological deficit (HAND)
Delirium
Aseptic meningitis
Vacuolar myelopathy
B: Psychiatric disorders:
Psychotic and mood disorders due to a general
medical condition
• HIV Associated Neurocognitive
disorders (HAND)
Cognitive Screening Work-up
1. Mini-Mental Status Exam
– Insensitive
– Higher cut offs may be useful (<26/30 should be suspect)
2. HIV Dementia Scale
– Concerns regarding reliability and validity
– Cut off <10 of total 16 points
3. Mental Alternation test
4. Executive interview
5. Cognitive Neuroscreen: Trail making tests (A and B) and the
Digit symbol task which together assess the speed of
information processing
6. International HIV dementia scale
Risk Factors for HAND



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Host genetic factors
 Apolipoprotein
 CCL2 (MCP-1) and CCR2 polymorphisms (may influence production of chemokines)
 TNF-α receptor polymorphisms (may influence production of TNF-α
Extremes of age (younger than 15 years of age and older than 50 years of age are at higher risk
Unsuppressed HIV-1 RNA in plasma or cerebrospinal fluid
CD4+ cell count < 200 cells/mm³
Platelet decline (a decline of approximately > 25%increases risk of HAND by 50%)
TNF, tumor necrosis factor
Neurocognitive Functions
Affected by HIV
• Driving
• Employment
• Treatment adherence
• Risk behavior
Employment Status and
Neuropsychological Function
HIV+ and HIV- Women
50
% Employed
40
30
H
20
10
0
HIV-
HIV+
HIV+ ABNL NP
*
NL NP
Martin et al, JINS 2000
70
NP Performance and
Antiretroviral Therapy
% NP Impaired
60
p < .01
50
40
30
20
HIV-
HIV+
ART
Richardson et al., JINS 2002
HIV+
NO ART
‫آنسفالوپاتي ‪HIV‬‬
‫• نوعي آنسفاليت تحت حاد است كه به دمانس تحت قشري پيشرونده‬
‫بدون نشانه هاي عصبي موضعي منجر ميشود ‪ .‬فقدان عالئم قشري‬
‫كالسيك (آفازي ) تا مراحل بيماري از عالئم اين اختالل است ‪ .‬در‬
‫اين بيماران تغييرات خلقي شديد و تغييرات شخصيتي ‪ ،‬مسائل‬
‫مربوط به حافظه و تمركز و درجاتي از كندي رواني ‪ -‬حركتي ‪،‬‬
‫فقدان احساس ‪ ،‬حواس پرتي ‪ ،‬كونفوزيون ‪ ،‬احساس ناخوشي ‪ ،‬فقدان‬
‫لذت و مردم گريزي كه با افسردگي اشتباه مي شود ‪ ،‬عارض مي‬
‫گردد ‪ .‬آنسفالوپاتي ‪ HIV‬به صورت دليريوم تظاهر مي كند كه دوره‬
‫هاي شبه مانيا و اسكيزوفرنياي خود را نشان مي دهد ‪ .‬وجود عالئم‬
‫حركتي مربوط به دمانس تحت قشري مشتمل بر تشديد رفلكس هاي ‪،‬‬
‫آتاكسي اسپاستيك راه رفتن ‪ ،‬پاراپارزي و افزايش قواي ذهني ‪ ،‬جلب‬
‫توجه مي كند ‪.‬‬
‫دليريوم‬
‫• عللي كه باعث دمانس در مبتاليان به ‪ HIV‬مي گردد باعث‬
‫دليريوم به صورت افزايش فعاليت يا كاهش فعاليت مي شود‬
‫كه نيازمند درمان عالمتي و درمان علل زمينه اي است ‪.‬‬
‫• ‪Delirium is the most common cognitive‬‬
‫‪disorder in hospitalized patients with HIV.‬‬
HIV Associated Dementia
(HAD)
• HAD presents with typical symptoms seen in
other sub-cortical dementias. Following find
some early symptoms patients may present with:
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Memory & psychomotor speed impairments
Depressive episode
Movement disorders
Difficulty with reading and comprehending material
Difficulties with performing mathematical functions
HIV Associated Dementia
(HAD)
• Early HAD differs from Alzheimer's disease in
that HAD is more likely to present with behavior
changes and progress more rapidly.
• Use of the modified HIV Dementia Scale is more
ideal for aiding clinicians in diagnosing HAD. It
takes about five minutes to administer in the
clinic setting.
HIV Associated Dementia
(HAD)
• Despite the decreasing prevalence of HAD in
recent years; due to the advances in treatment
of HIV illness, cognitive impairment continues to
be the most common CNS complication in
people with HIV/AIDS. Prompt diagnosis may
significantly decrease morbidity and mortality.
‫اختالالت اضطرابي‬
‫• بيماران مبتال به عفونت ‪ HIV‬و ‪ AIDS‬به هر نوع اختالل‬
‫اضطرابي مبتال مي شوند ‪ ،‬اضطراب منتشر ‪ ،‬اختالل استرس پس‬
‫از سانحه و اختالل وسواس جبري نيز شايع هستند ‪.‬‬
‫• اضطراب يك احساس ناخوشايند و نامتناسب است كه معموال با‬
‫عالئم فيزيولوژيك همراه است ‪ .‬در اضطراي ‪ ،‬سندرم هاي‬
‫گوناگوني به صورت غالب خود را نشان مي دهند ‪ .‬شيوع انواع‬
‫اختالالت اضطرابي در ‪ HIV‬حدود ‪ %2 - %28‬است ‪.‬‬
‫عوامل اضطراب زا در ‪HIV , AIDS‬‬
‫• تهديد جدي زندگي با يك بيماري مزمن و كشنده عوامل تنش‬
‫زايي رواني ‪ -‬اجتماعي‬
‫• مرگ دوستان و افرادي كه بيمار به آنها وابسته است ‪.‬‬
Anxiety Disorders in HIV
Patients
• Patients who are diagnosed with HIV are at risk
to develop anxiety if they are:
– Newly diagnosed individuals
– The patient becomes symptomatic
– The patient receives news of a declining CD4 count
or elevated viral load
– At the onset of AIDS
– When faced with disclosing of HIV
– When dealing with relationship implications
Anxiety Disorders in HIV
Patients
• PTSD has a lifetime prevalence of 1.3% to 7.8%
in the general population and a higher incidence
in those infected with HIV.
• Trauma has been associated with diminishing
the immune system and increasing the risk for
infections.
• Psychological effects of PTSD may be
manifested in increased risk-taking behaviors
such as increase substance abuse, poor eating
habits, & unsafe sexual behaviors.
‫افسردگي و اختالل خلقي ‪:‬‬
‫• شايع ترين علل مشاوره روان پزشكي جهت بيماران ‪HIV‬‬
‫است ‪ %4-40 .‬بيماران از اين بيماري ‪ ،‬رنج مي برند ‪.‬‬
‫افسردگي ‪ HIV,AIDS‬علل مختلف دارد كه هر كدام از‬
‫علل زمينه اي‬
‫• درمان خاص خود را دارد با پيشرفت بيماري احتمال‬
‫افسردگي اساسي افزايش مي يابد ‪ .‬با درمان هاي‬
‫اختصاصي اين افسردگي بهبود مي يابد ‪.‬‬
Depression in HIV Patients
• Depressive symptoms have been associated
with increased risky behaviors, non-compliance
to treatment, & shortened survival.
• Failure to recognize and treat depression
endangers both the patient and the community.
• These patients are at a higher risk
for co-morbid disorders.
Depression in HIV Patients
• Symptoms of Depression which would
warrant a Psychiatric Consult
– Depressed mood (stated by the patient or
observed by the clinician)
– Anhedonia (loss of interest or pleasure)
– Feelings of guilt
– Suicidal thoughts
– Insomnia (middle insomnia)
– A change in one’s weight
– Attention or concentration problems
– Decreased energy
– Psychomotor agitation or retardation
Depression in HIV Patients
• Many HIV patients will not report these
symptoms, instead they will demonstrate
behaviors changes
• Behavior changes that would indicate a
depressive episode
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Non-Compliance with treatment regime
Difficulty making life choices
Ruminating thoughts
An inability to perform daily activities
Somatic complaints
Acting out behaviors
Depression in HIV Patients
• Screening for Depression
– Clinicians should screen for depression as part of the
annual physical & whenever indicated
– Simply asking patients, are you depressed have been
shown to be effective.
– Asking such questions as, during the past month
have you often felt down, depressed or hopeless?
– What do you enjoy doing these days?
Depression in HIV Patients
• Early detection and intervention with
psychotherapy and medication
management has been proven to be the
most effective treatment for those who
suffer from depression.
• Suicide and HIV
• Suicide is the 8th leading cause of death in the
United States and accounts for an average of 30,000
deaths per year. The total number of deaths has
changed little over time (Mann, 2002).
• Suicide rate in persons with cancer is two to 4 times
that of the general population. The rate in persons
with AIDS is 66 times that of the general population
(Mann, 2002).
• More than 90% of suicide victims have a diagnosable
psychiatric illness (Isometsa et al., 1995)
Suicide
• Perry et al. (1990) assessed suicidal
ideation among 244 men and 57
women. Subjects filled the Beck
Depression Inventory 2 weeks before
and 1 week and 2 months after
notification.
•
Suicide
•
Score
Suicide Indeation Among 49 HIV+ AND 252
HIV35
30
25
20
15
10
5
0
HIV+
HIV-
2 weeks
before
1 week after
1 month
after
Time of Follow up
Suicide
• However, the symptoms development of
HIV or the presence of severe
depression may lead to suicide.
Mania
High-risk behaviors
HIV
Mania in HIV-Infected Patients
• Can occur in conjunction with bipolar
disorder or HIV infection of the brain
• HIV-associated mania different from mania
with bipolar disorder
– Late, secondary affective disorder
– Associated more often with personal or family
history of mood disorder
– More irritability, less hypertalkativeness, more
psychomotor slowing and cognitive
impairment
Bipolar Disorder in HIV Patients
Bipolar Disorder is very difficult to treat and if
untreated, the progression of the illness increase
the risk of being infected with HIV.
Symptoms of Bipolar Mania
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–
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The lack of need for sleep
Poor impulse control
Sexually acting out
Excessive shopping (a disregard to paying bills)
Expansive thoughts
Irritable mood
Hyper-verbal speech
Psychomotor agitation
Bipolar Disorder in HIV
Patients
• Patients who present in a manic episode require
immediate treatment, most likely hospitalization.
• They are more likely to act out sexually with a
disregard for their own safety as well as, the
safety of others; by not practicing safer-sex.
• Studies have indicated the prevalence of bipolar
patients to be between 4% to 8%.
Bipolar Disorder in HIV
Patients
• Most Bipolar patients first symptom of mania is
the decreased need for sleep with an
abundance of energy.
• It is important for the clinician to assess the
individuals need for sleep, energy level and and
signs of distorted thinking. This can be done on
an annual basis or as indicated.
• If in doubt, ask for a Psychiatric Consult.
‫روانپريشی‬
‫•‬
‫•‬
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‫•‬
‫شيوع روانپريشی درمراحل انتهايي ‪AIDS‬‬
‫(حدود ‪ ) %1-5‬است ‪.‬‬
‫عالئم باليني ‪:‬‬
‫توهم و هذيان و رفتارهاي غريب و غير عادي وجود‬
‫دارد ‪ .‬روانپريشی ممكن است به علت بيماري زمينه‬
‫اي مثل پارانوئيد يا اسكيزوفرن باشد يا ثانوي به‬
‫اختالل طبي مثل عارضه دارويي يا به خاطر خود‬
‫‪ AIDS‬باشد ‪.‬‬
‫علل جنون در بيماران مبتال به ‪HIV‬‬
‫•‬
‫•‬
‫•‬
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‫اختالالت روانشناختي اوليه (اسكيزوفرني ‪ ،‬اختالل دو‬
‫قطبي )‬
‫ثانويه به مصرف مواد مخدر‬
‫مسموميت عصبي ‪ -‬رواني ثانويه به مصرف داروهاي ضد‬
‫ويروس ‪ ،‬شيمي درماني ‪ ،‬استروئيدها ثانويه به اختالالت‬
‫‪CNS‬‬
‫مجموعه ايدز ‪ -‬زوال عقل (دمانس )‬
‫زوال عقل ناشي از عفونت هاي فرصت طلب و سرطان‬
‫ها‬
Psychotic Disorders in HIV
Patients
• Estimates of the prevalence of new-onset
psychosis in patients with HIV range from
0.5% to 15%. This is higher then the
incidence of psychosis in the general
population.
Psychotic Disorders in HIV
Patients
• Evidence suggests that HIV infection may
directly be linked to the onset of a psychotic
episode.
• New onset psychosis may also be a
manifestation of HIV associated encephalopathy.
• Early diagnosis and intervention is a key role in
determining the outcome of one’s treatment.
Treatment for these individuals follows the same
guidelines as for those who suffer from psychotic
features without HIV.
‫بي خوابي ‪:‬‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫اغلب بيماران از مشكل خواب شكايت مي كنند ‪.‬‬
‫علل بي خوابي ‪:‬‬
‫‪ -1‬اضطراب‬
‫‪ -2‬افسردگي‬
‫‪ -3‬عفونت ‪HIV‬‬
‫‪ -4‬عوارض داروها‬
‫از نظر باليني بي خوابي مي تواند به صورت بي خوابي اوليه و‬
‫ابتداي خواب يا انتهاي خواب يا كل خواب تظاهر كند ‪.‬‬
‫اعتياد و وابستگي به مواد و دارو در بيماران‬
‫‪AIDS‬مبتال به‬
‫• شيوع اعتياد و وابستگي دارويي در اين بيماران باال است ‪.‬‬
‫در سطح كشور بيش از نيمي از بيماران (‪ )%65‬كه به‬
‫تازگي تشخيص ‪ HIV‬آنها مطرح است اعتياد دارويي دارند‬
‫‪.‬‬
• THE TRIPLY DIAGNOSED PATIENT:
HIV INFECTION, MENTAL ILLNESS &
ALCOHOL / OTHER DRUG USE (AOD)
DISORDERS
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 therefore
common and undertreated.
HIV Among People with Severe Mental
Illness: Summary of Studies
•
•
•
•
Rates of HIV Infection (3%-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%
Role of Substance Use in HIV
Spread
• Injection (IV, IM, SQ, etc.) with contaminated
injecting equipment
– not just syringe/needle, but spoon, cottons, etc.
• Non-injection blood exchange, e.g. intranasal
use
• Other non-injection drug and alcohol use is also
associated with higher risk for HIV
• Risky sexual behavior related to AOD use
– effects on libido; disinhibition; sex for drugs exchange
• WORRIED WELL POPULATION
Medication Effects
• Steroids: mania or depression
• Interferon: neurasthenia fatigue syndrome,
depression
• Interleukin-2: depression, disorientation,
confusion and coma
• Zidovudine: mania, depression
• Vinblastine: depression, cognitive impairment
• Efavirenz: decreased concentration,
depression, nervousness, nightmares
WITH THANKS
FOR YOUR ATTENTION