MENTAL HEALTH AND HIV
An Overview
Karina K. Uldall, MD, MPH
Department of Psychiatry
University of Washington
April 2003
An Overview
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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
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Accompaniment
Advocacy
Assessment
Care Coordination
Crisis Intervention
Engagement
Listening
April 2003
• Patient/Family
Education
• Problem Solving
• Referrals
• Skills Building
• Support
Psychiatric Illness
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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
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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
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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
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Antidepressants
Stimulants
Antipsychotics
Antianxiety agents
Mood stabilizers
Medication Interactions
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Multiple medications
Multiple medical illnesses
Renal or hepatic disease
Age
Individual differences in liver metabolism
Specific liver metabolism
inhibitors/inducers
April 2003
Choosing Medications
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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
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Viral/Bacterial Meningitis
Neurosyphilis
Herpes Simplex Encephalitis
Varicella-Zoster Encephalitis
Rarely Histoplasmosis and
Coccidiodomycosis
April 2003
SUMMARY
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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
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HIV related illness
Other physical illness
Medication toxicity
Substance use
• Primary psychiatric illness
April 2003