MENTAL HEALTH AND HIVAn Overview

Karina K. Uldall, MD, MPH

Department of Psychiatry

University of Washington

An Overview

• Psychosocial Issues

• Psychiatric Illness

• Substance Abuse

• Medication Interactions

• Neurologic Illness

Psychosocial Issues

• Pre- versus Post-HAART– Acute to Chronic Illness

• Population Characteristics– Marginalized, Access/Engagement, Co-

morbidity

• Specific Cultural Issues– Meaning of Illness, Family/Community Role,

Communication Patterns, Trust/Mistrust of System, Value of Autonomy

Aspects of HIV/AIDS

• Increased services or support

• Renewed spirituality• Healthier

relationships• Priorities clarified• Conflicts resolved

• 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

• Patient/Family Education

• Problem Solving• Referrals• Skills Building• Support

Psychiatric Illness

• HIV Associated Dementia

• Delirium

• Psychotic Disorders

• Mood Disorders

• Anxiety Disorders

HIV Associated Dementia

• 15 – 20% of AIDS Patients

• Cognitive, Motor, Mood/Personality Symptoms

• CD4 count < 200 uL

• CSF Viral Load > 10,000/ml, Beta-2-microglobulin > 3.8 mg/dL

• ARV combinations: AZT, AZT + 3TC, d4T + 3TC, Indinavir

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

Psychotic Disorders

• Substance induced – intoxication or withdrawal

• Medical illness/medication induced

• Distinguished from delirium

• Distinguished from late stage dementia

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

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

Suicide Assessment

• Gender, age, ethnicity

• Family history

• Psychiatric illness

• Medical illness

• Behavior

• Lethality

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

Substance Abuse

• Abuse versus dependence

• Co-morbid hepatitis C

• Relationship to risk behaviors

• Relationship to adherence

• Risk of adverse medication/drug events

Treatment

• Psychotherapy– Supportive,

interpersonal, cognitive-behavioral, group

– Ongoing crises– Countertransference

issues

• 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

Choosing Medications

• Adverse effects

• Possible interactions

• Metabolism via liver

• Elimination via liver, kidney or both

• Onset of action

• Duration of action

• “Less is better”

AIDS-Defining Neurologic Illnesses

• CMV Encephalitis

• Progressive Multifocal Leukoencephalopathy (PML)

• Toxoplasma Encephalitis

• Primary CNS Lymphoma

• Cryptococcal Meningitis

• Rarely TB Meningitis and Kaposi’s Sarcoma

Other CNS Disorders

• Viral/Bacterial Meningitis

• Neurosyphilis

• Herpes Simplex Encephalitis

• Varicella-Zoster Encephalitis

• Rarely Histoplasmosis and Coccidiodomycosis

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

SUMMARY

• HIV related illness

• Other physical illness

• Medication toxicity

• Substance use

• Primary psychiatric illness