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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 • • • • Feeling like a burden Loss of dignity Guilt Grief over multiple losses • • • • 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 • • • • • TYPES SOURCE MOST COMMON OTHER TARGET ORGAN HIV & DIAGNOSIS • • • • • • 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 • • • • • • • • 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 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: – – – – – 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 • • • • • • 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 – – – – – – – – 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 • • • • 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 • • • • • 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