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Download MENTAL HEALTH AND HIV An Overview
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MENTAL HEALTH AND HIV An Overview Karina K. Uldall, MD, MPH Department of Psychiatry University of Washington April 2003 An Overview • • • • • Psychosocial Issues Psychiatric Illness Substance Abuse Medication Interactions Neurologic Illness April 2003 Psychosocial Issues • Pre- versus Post-HAART – Acute to Chronic Illness • Population Characteristics – Marginalized, Access/Engagement, Comorbidity • Specific Cultural Issues – Meaning of Illness, Family/Community Role, Communication Patterns, Trust/Mistrust of System, Value of Autonomy April 2003 Aspects of HIV/AIDS • Increased services or support • Renewed spirituality • Healthier relationships • Priorities clarified • Conflicts resolved April 2003 • Stigma/discrimination • Social isolation • Fear of death or contagion • Loss of independence • Guilt • Grief over multiple losses Interventions • • • • • • • Accompaniment Advocacy Assessment Care Coordination Crisis Intervention Engagement Listening April 2003 • Patient/Family Education • Problem Solving • Referrals • Skills Building • Support Psychiatric Illness • • • • • HIV Associated Dementia Delirium Psychotic Disorders Mood Disorders Anxiety Disorders April 2003 HIV Associated Dementia • 15 – 20% of AIDS Patients • Cognitive, Motor, Mood/Personality Symptoms • CD4 count < 200 uL • CSF Viral Load > 10,000/ml, Beta-2microglobulin > 3.8 mg/dL • ARV combinations: AZT, AZT + 3TC, d4T + 3TC, Indinavir April 2003 Delirium • Disturbance of consciousness and attention • New onset cognitive or perceptual disturbance • Acute onset, fluctuating course • Underlying etiology – Fever, infection, trauma, metabolic, meds/drugs, other/multiple causes April 2003 Psychotic Disorders • Substance induced – intoxication or withdrawal • Medical illness/medication induced • Distinguished from delirium • Distinguished from late stage dementia April 2003 Mood Disorders • Bipolar disorder – 8% of outpatients • Major depressive episode – 20-35% lifetime • Substance induced – intoxication or withdrawal • Medical illness/medication induced • Distinguish from delirium – hyper/hypo • Distinguish from dementia April 2003 Anxiety Disorders • Panic disorder, PTSD, Adjustment disorder with anxiety – 2-38% of patients, depending on stage of illness • Substance induced – intoxication or withdrawal • Medical illness/medication induced – Untreated pain April 2003 Suicide Assessment • • • • • • Gender, age, ethnicity Family history Psychiatric illness Medical illness Behavior Lethality April 2003 Suicide Assessment • HIV/AIDS Risk Factors – Stage of disease – Number of losses – Social isolation – Disease progression/fear of progression – Uncontrolled pain – Experience with HIV-related suicide April 2003 Substance Abuse • • • • • Abuse versus dependence Co-morbid hepatitis C Relationship to risk behaviors Relationship to adherence Risk of adverse medication/drug events April 2003 Treatment • Psychotherapy – Supportive, interpersonal, cognitive-behavioral, group – Ongoing crises – Countertransference issues April 2003 • Medications – – – – – Antidepressants Stimulants Antipsychotics Antianxiety agents Mood stabilizers Medication Interactions • • • • • • Multiple medications Multiple medical illnesses Renal or hepatic disease Age Individual differences in liver metabolism Specific liver metabolism inhibitors/inducers April 2003 Choosing Medications • • • • • • • Adverse effects Possible interactions Metabolism via liver Elimination via liver, kidney or both Onset of action Duration of action “Less is better” April 2003 AIDS-Defining Neurologic Illnesses • CMV Encephalitis • Progressive Multifocal Leukoencephalopathy (PML) • Toxoplasma Encephalitis • Primary CNS Lymphoma • Cryptococcal Meningitis • Rarely TB Meningitis and Kaposi’s Sarcoma April 2003 Other CNS Disorders • • • • • Viral/Bacterial Meningitis Neurosyphilis Herpes Simplex Encephalitis Varicella-Zoster Encephalitis Rarely Histoplasmosis and Coccidiodomycosis April 2003 SUMMARY • • • • Document HIV status Determine degree of immunocompromise Thorough history and physical exam Diagnostic tests – CT/MR - Urine toxicology – LP - Blood alcohol level – Routine blood work – Neuropsychological testing April 2003 SUMMARY • • • • HIV related illness Other physical illness Medication toxicity Substance use • Primary psychiatric illness April 2003
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