1. The Triply Diagnosed Patient: Prevention and Care Milton L. Wainberg, M.D. Columbia University HIV Mental Health Training Project New York State Psychiatric Institute A Local Performance Site of the New York / New Jersey AIDS Education and Training Center mlw35@columbia.edu

2. Definitions and Background

3. Triply Diagnosed Patients: Who They Are and Why These Disorders Travel Together Majority: Majority: Alcohol / substance use disorders and HIV with comorbid depressive, anxiety, personality disorders. Minority: Minority: Recurrent psychotic disorders (schizophrenia, mania, depression with psychosis, psychosis NOS) with comorbid alcohol / substance use disorders and HIV.

4. u National U.S. health survey: Adults with depression and anxiety disorders (GAD, PD) were more likely to engage in HIV risk behavior than those without these disorders. u National U.S. study of substance use programs: Adults with both psychiatric and substance abuse disorders have higher rates of HIV infection than those with substance abuse disorders alone. Majority Population of Triply Diagnosed Patients: Some Findings

5. u 27% took psychotropic medication in 1996: –21% antidepressants –17% anxiolytics –5% antipsychotics –3% psychostimulants u About half of patients with depressive disorders did not receive antidepressants. u Psychiatric disorders are common and undertreated. RAND HCSUS Study: 1,489 HIV-positive Medical Patients

6. Psychosis & Mania Diagnostic and Treatment Issues

7. u Prior to infection: –Elevated rates of HIV infection in psychiatric patients with psychotic disorders : seroprevalence 1% - 23%, associated with AOD use, unsafe sex, institutionalization –Substance use, (e.g. hallucinogens, amphetamines, cocaine, ecstasy) associated with both psychotic symptoms and HIV risk. When Psychosis / Mania Occur in the Course of HIV Infection

8. u With asymptomatic infection: –HIV invades the brain at initial infection –Not known if HIV by itself increases biological vulnerability to certain mental illnesses When Psychosis / Mania Occur in the Course of HIV Infection

9. u With symptomatic illness: –Can occur at the initial presentation of symptomatic HIV illness –Concern is differential diagnosis: »Complication of substance use / withdrawal, medical illness, metabolic disturbances, neuropsychiatric manifestations of HIV (e.g., HAD), side effects of HIV-related medications, etc.

10. Psychosis/Mania: Differential Diagnosis due to a General Medical Condition u HIV associated dementia u Psychoneurotoxicities –Steroids –Nucleoside antiretrovirals –NNRTI –Gancyclovir –Sympathomimetics –Antidepressants –Cocaine, amphetamines u Opportunistic infections –Toxoplasmosis –Cryptococcal meningitis –CNS lymphoma –Neurosyphillis –Herpes –B12 deficiency (megaloblastic madness)

11. Psychosis u Common underlying causes –Medical conditions / treatments associated with CNS dysfunction –Illicit drugs –Depression / mania with psychosis –Schizophrenia / related disorders u Psychosis in medical settings is associated with under treatment by providers

12. Use of Antipsychotic Medications in Patients with HIV Infection u Antipsychotic medications maintain efficacy in the presence of HIV neuropsychiatric manifestations u Problems that may arise –Increased sensitivity to side effects –Overlapping toxicities –Drug interactions (often theoretical) –Liver toxicity among patients co-infected with hepatitis viruses u In advanced HIV disease, follow rule as with elderly: start low, go slow

13. “Typical” First-Generation Antipsychotics u Haloperidol most commonly prescribed u Low doses useful in delirium u In advanced HIV infection:  extrapyramidal side effects, including rapid onset tardive dyskinesia and neuroleptic malignant syndrome

14. “Atypical” Second-Generation Antipsychotics u Zyprexa / olanzapine:  risk diabetes u Clozaril / clozapine:  risk diabetes; bone marrow suppression;  risk seizures on ritonavir / other Pis u Geodon / ziprasidone:  QT interval— caution with drugs that also have this effect (e.g., protease inhibitors, ketoconazole)

15. Mania: Treatment u Psychopharmacology –Antipsychotics at lower doses –Mood stabilizers: »Lithium »Anticonvulsants—consider side effects, toxicities, and drug interactions –Benzodiazepines as adjunct u Electroconvulsive therapy (ECT)

16. HIV Among People with Severe Mental Illness: Summary of U.S. Studies

17. u Rates of HIV Infection (1%-23%) > general population u  Rates of unsafe sexual behavior u  Rates of co-morbid alcohol/drug use: 20-75% u Intermittent IDU: –1%-8% recent –4%-26% lifetime u HIV Infection Rates by Type of Drug Use –Injected drugs33.8% –Non-Injected drugs15.4% –Alcohol only10.9% HIV Among People with Severe Mental Illness: Summary of U.S. Studies

18. ♦Sexual risk behaviors associated with drug use: ♦sex with IDU partners ♦sex in exchange for money / drugs ♦impaired judgment and reduced impulse control while high: unsafe sexual activity while high on alcohol / drugs ♦Drug use is associated with  rates of STIs and HCV/HBV ♦Prevention and treatment of an alcohol / substance use disorder is an HIV risk reduction strategy HIV Among People with Severe Mental Illness: Summary of U.S. Studies

19. Harm Reduction: Creating Stable Change Transtheoretical Model* * Prochaska & Diclemente

20. Outcomes of Cognitive Behavioral Skills Training Intervention for Psychiatric Patients: Summary of Studies on Sexual Risk Reduction   AIDS knowledge   Self efficacy / intention to change   Condom use   Number of partners   Episodes of Unprotected sex

21. Reducing Sexual Risk: Suggested Modifications for People with Severe Mental Illness u Adjust language used by staff to match verbal skills, cognitive functioning, cultural values of patients u Keep goals simple and realistic u Be more repetitive u Provide more maintenance sessions u Take into account your patients’ stages of change

22. Adherence

23. Psychiatric Illness and Adherence u Substance use, depression, and other mental illnesses can undermine adherence: Treat these disorders u Creating stable life conditions enhances adherence u Patient’s readiness to adhere must be individually assessed u Consider adherence support

24. Strategies for Improving Adherence u Therapeutic alliance u Patient education u Treating substance abuse u Treating psychiatric disorders u Memory aids u Observed medication administration u Integrated care u Outreach (“Inreach”) u Incentives—offer what is desired

25. Substance Use

26. AOD Treatment for HIV+ Patients: u Medical Model: –if patient is doing worse: increase the treatment u Traditional Substance Abuse Treatment –if client is doing worse: discharge from treatment u Public Health Model: –patient seen as vector of infection; keep patient in treatment at all costs u Traditional Substance Abuse Treatment –avoid “enabling”; labeling; tell client what to do; monitor clients’ urines / bloods u Harm Reduction Model –reduce harm around use; keep patient in treatment at all costs; client- oriented approach; personal responsibility

27. AOD Users and HIV Medical Care u AOD Users less likely to be tested and diagnosed u More likely to develop OIs and complications u Less likely to have access to medical care u Less likely to be offered optimal treatments u Less likely to adhere if offered HAART Modified from Frontline Forum: Clinical Symposia Highlights in HIV, May, 1999, cited by A. Vinciquerra, SUNY UMU, 2001,

28. Drug Interactions: HIV+ AOD Users Psychiatric medications + drugs of abuse + HIV medications + medications to treat substance used disorders = Drug Interactions u Track new information on websites such as –HIV InSite (http://hivinsite.ucsf.edu) –HIV Drug Interaction Guides by the NY NJ AETC

29. Before we get to the conclusions… u Close your eyes u Close your eyes again u The Miriam Acevedo Syndrome

30. Common Treatment Dilemmas u Adequate access to and integration of mental health and substance use services. u Maintaining adherence in patients with three chronic relapsing disorders. u Provider countertransference reactions to “self-destructive” and “manipulative” patient behaviors. u Balancing harm reduction approaches with sensible limit-setting.

31. A Couple of Words About Our Work… u Get to know your patients, understand them – feel free to ask! u Know your role – know what is “None of your business!” (religion, sexuality, politics, etc.) u Adjust to them, not the other way around – if uncomfortable, get supervision u We all have experience prejudices – connect with that u However, not over identify – at times the medicine can be worst than the disease!

32. Thanks!