1. April 2003 MENTAL HEALTH AND HIV An Overview Karina K. Uldall, MD, MPH Department of Psychiatry University of Washington

2. April 2003 An Overview Psychosocial Issues Psychiatric Illness Substance Abuse Medication Interactions Neurologic Illness

3. April 2003 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

4. April 2003 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

5. April 2003 Interventions Accompaniment Advocacy Assessment Care Coordination Crisis Intervention Engagement Listening Patient/Family Education Problem Solving Referrals Skills Building Support

6. April 2003 Psychiatric Illness HIV Associated Dementia Delirium Psychotic Disorders Mood Disorders Anxiety Disorders

7. 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-2- microglobulin > 3.8 mg/dL ARV combinations: AZT, AZT + 3TC, d4T + 3TC, Indinavir

8. 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

9. April 2003 Psychotic Disorders Substance induced – intoxication or withdrawal Medical illness/medication induced Distinguished from delirium Distinguished from late stage dementia

10. 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

11. 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

12. April 2003 Suicide Assessment Gender, age, ethnicity Family history Psychiatric illness Medical illness Behavior Lethality

13. 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

14. April 2003 Substance Abuse Abuse versus dependence Co-morbid hepatitis C Relationship to risk behaviors Relationship to adherence Risk of adverse medication/drug events

15. April 2003 Treatment Psychotherapy –Supportive, interpersonal, cognitive-behavioral, group –Ongoing crises –Countertransference issues Medications –Antidepressants –Stimulants –Antipsychotics –Antianxiety agents –Mood stabilizers

16. April 2003 Medication Interactions Multiple medications Multiple medical illnesses Renal or hepatic disease Age Individual differences in liver metabolism Specific liver metabolism inhibitors/inducers

17. 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”

18. 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

19. April 2003 Other CNS Disorders Viral/Bacterial Meningitis Neurosyphilis Herpes Simplex Encephalitis Varicella-Zoster Encephalitis Rarely Histoplasmosis and Coccidiodomycosis

20. 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

21. April 2003 SUMMARY HIV related illness Other physical illness Medication toxicity Substance use Primary psychiatric illness