mental health, hiv/aids and hcv coinfection - Pacific AIDS Network

64 Pages·2010·6.67 MB·English

RESOURCE GUIDE

CHAPTER THREE

PSYCHIATRY AND HIV/AIDS

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MENTAL HEALTH, HIV/AIDS AND HCV COINFECTION
Psychiatric Disorders Fact Sheet4

Psychiatric disorders are a barrier to medical care
and adherence to medications, and several studies
When it comes
have found that depression, stress and trauma can
lead to disease progression and increased to HIV/AIDS,
mortality.5,6,7,8 The power of mental health
mental health
treatment to reduce depression and anxiety,
improve adherence and HIV health outcomes and,
matters.

in turn, reduce the likelihood of death from AIDS-
related causes speaks to the vital role of mental
Diagnosis and
health care in the web of HIV care. 8.9.10.11
treatment of
People with serious mental illness are particularly
mental health
vulnerable to HIV infection as a result of the higher
prevalence among this group of a variety of factors, issues are essential
including poverty, homelessness, high-risk sexual
to the physical
activities, drug abuse, sexual abuse, and social
marginalization. Estimates of HIV infection rates
health and quality
among people with mental illness in the United
States vary widely from 3 percent to 23 percent; life for PWAs.
of
the average is about 7 percent. Their health
outcomes remain poor.12

4 Information for this section is from: http://hab.hrsa.gov/publications/may2009/default.htm
5
Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA.
2001;286:2857–64. 3Lesser, 2008.
6
Lesser, 2008.
7
Starace F, Ammassari A, Trotta MP, et al. Depression is a risk factor for suboptimal adherence to highly active
antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31(Suppl 3):S136–9.
8
Whetten K, Reif S, Whetten R, et al. Trauma, mental health, distrust, and stigma among HIV-positive persons:
implications for effective care. Psychosom Med. 2008;70:531–8.
8. Cook JA, Grey D, Burke J, et al. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-
positive women. Am J Public Health. 2004;94:1133–40.
9. Kalichman SC. Co-occurrence of treatment nonadherence and continued HIV transmission risk behaviors:
implications for positive prevention interventions. Psychosom Med. 2008;70:593–7.
10. Carrico AW, Antoni MH. Effects of psychological interventions on neuroendocrine hormone regulation and immune
status in HIV-positive persons: a review of randomized controlled trials. Psychosom Med. 2008;70:575–84.
11. Horberg MA, Silverberg MJ, Hurley LB, et al. Effects of depression and selective serotonin reuptake inhibitor use on
adherence to highly active antiretroviral therapy on clinical outcomes in HIV-infected patients. J Acquir Immun Defic
Syndr. 2008;47:384–90.
12. Weiser SD, Wolfe WR, Bangsberg DR. The HIV epidemic among individuals with mental illness in the United States.
Curr Infect Dis Rep. 2004;6:404–10

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RESOURCE GUIDE
HIV/AIDS PSYCHIATRY
A Review of Syndromes and Treatment
Stephen J. Fitzpatrick MD, FRCPC
HIV/AIDS PSYCHIATRY
Consultation-Liaison Psychiatry
A Review of Syndromes
St. Paul’s Hospital, Vancouver, BC
and Treatment:
Presentation
Clinical Associate Professor

Department of Psychiatry
as presented by Stephen
Faculty of Medicine
Fitzpatrick as the Keynote
University of British Columbia Address

Director
Program of Consultation-Liaison
Psychiatry
Department of Psychiatry
University of British Columbia

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MENTAL HEALTH, HIV/AIDS AND HCV COINFECTION

•TO UNDERSTAND THE •HUMAN RETROVIRUS IDENTIFIED IN
BIOLOGY OF HIV IN THE CNS 1984
•RNA PLUS REVERSE TRANSCRIPTASE
•TO REVIEW COMMON ENZYME
PSYCHIATRIC DISORDERS
ASSOCIATED WITH HIV •RAPID REPLICATION AND GENETIC
MUTATION
DISEASE AND THEIR
TREATMENT
•INFECTS BLOOD T-HELPER (CD4)
LYMPHOCYTES,
•TO REVIEW IMPORTANT LYMPHOID TISSUE AND CNS
INTERACTIONS BETWEEN
PSYCHOTROPIC AND
ANTIRETROVIRAL MEDICATIONS

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•PSYCHIATRIC
•SEXUAL BEHAVIOURS WITH MOOD DISORDERS
EXCHANGE OF BODY BIPOLAR, DEPRESSION, DYSTHYMIA
FLUIDS
PSYCHOTIC DISORDERS
SCHIZOPHRENIA, SCHIZOAFFECTIVE
•INJECTION DRUG USE
PERSONALITY DISORDERS
•BLOOD TRANSFUSION BNOARRCDIESRSLISINTEIC, ,H DISETPREINODNEICN,T , ANTISOCIAL
•PERINATAL •SUBSTANCE USE / ABUSE /
DEPENDENCE
•SOCIAL / GEOGRAPHICAL / FINANCIAL
FACTORS

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•3-6 WEEKS AFTER INFECTION •USUALLY LASTS FOR YEARS
•BURST OF REPLICATION AND WIDE •BALANCE BETWEEN VIRUS
DISSEMINATION OF VIRUS REPLICATION/INFECTION OF NEW CD4
CELLS VS PRODUCTION OF NEW CD4 CELLS
•NON-SPECIFIC FLU-LIKE SYMPTOMS
• 10 BILLION VIRUS PARTICLES PRODUCED
•BODY MOUNTS MASSIVE IMMUNE RESPONSE DHOAIULYRS- PLASMA VIRUS HALF-LIFE OF 6
PRODUCES ANTIBODIES
POSITIVE SEROCONVERSION AND
POSITIVE HIV TEST •NOT A DORMANT STATE

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Biology
HIV creates chronic, progressive, inflammatory CNS
disease
Viral load, CD4 count provide a ‗cross-sectional
•PRODUCTION CANNOT KEEP UP WITH snapshot‘
DESTRUCTION AND REPLICATION
Serum and CSF viral dynamics may differ
•FATIGUED IMMUNE RESPONSE SYSTEM Neuronal dysfunction –neurotoxins, chronic
inflammatory state, cytokine and chemokine
•CD4 < 200 release
Apoptosis ( programmed cell death ) in sub-cortical
•OPPORTUNISTIC INFECTIONS ARISE white matter, basal ganglia and frontal lobes

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MENTAL HEALTH, HIV/AIDS AND HCV COINFECTION

ANTIVIRAL THERAPY TARGETS DURING THE
HIV REPLICATION CYCLE
•EARLY PENETRATION INTO CNS (DAY 16) VIA
MACROPHAGES
ACROSS BLOOD-BRAIN BARRIER
• VIRUS INFECTS MACROPHAGES AND
MICROGLIAL CELLS, NOT
NEURONS
•NEUROTOXINS AND CHRONIC INFLAMMATORY
RESPONSE
NEURONAL DYSFUNCTION/DEATH
•CNS IS A RESERVOIR WITH SEPARATE VIRAL
DYNAMICS FROM
PERIPHERAL BLOOD
•BRAIN/LIMBIC SYSTEM DYSFUNCTION MOOD
SYMPTOMS,
SLEEP DISTURBANCE, MEMORY AND
CONCENTRATION
COMPLAINTS, MENTAL SLOWING, AGITATION

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• DRUG-DRUG INTERACTIONS • NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS NRTI’s
•LIVER TOXICITY
• NUCLEOTIDE REVERSE TRANSCRIPTASE
•DEGREE OF DRUG CNS PENETRATION INHIBITORS NtRTI’s
•CO-INFECTION WITH HEPATITIS C • PROTEASE INHIBITORS
INTERFERON TREATMENT PI’s
•SIDE EFFECTS OF ARV THERAPY • NONNUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS
NNRTI’s
• RIBONUCLEOTIDE REDUCTASE INHIBITORS

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RESOURCE GUIDE

 Combination therapy most popular
One pill = 3 or 4 ARV’s
Atripla
Truvada
Kivexa
Raltegravir
Maraviroc
Etravirine

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Challenges
-PROTEASE INHIBITORS GENERALLY INHIBIT METABOLISM OF  What am I treating?
PSYCHOTROPIC MEDS, ESPECIALLY BUPROPRION,
 What does the patient report as a problem?
BENZODIAZEPINES AND CLOZAPINE
 What do other people report as a problem?
-MONITOR DOSES, SIDE-EFFECTS, CLINICAL RESPONSE
 Adherence to ARV RX
-RITONAVIR (NORVIR)) AND RITONAVIR / LOPINAVIR (KALETRA)  Substances
REQUIRES MOST MONITORING
 Drug interactions
-EFAVIRENZ (SUSTIVA) HAS UP TO 34% CNS PENETRATION
 Delirium
–-FREQUENT CNS / PSYCHIATRIC MANIFESTATIONS
–-CAN HAVE ACUTE ONSET OF MOOD SHIFT, AGITATION,  Vague symptoms
SUICIDALITY
 What is the problem?

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MENTAL HEALTH, HIV/AIDS AND HCV COINFECTION

– SLEEP DISORDERS
– ADJUSTMENT DISORDERS
– COGNITIVE DISORDERS
– ANXIETY DISORDERS •HIV -ASSOCIATED MINOR COGNITIVE MOTOR
DISORDER H-MCMD
– MOOD DISORDERS •HIV -ASSOCIATED DEMENTIA COMPLEX H-ADC
•DEPRESSION
– SUBSTANCE ABUSE / DEPENDENCE
•MANIA / HYPOMANIA
– DELIRIUM
– PSYCHOTIC DISORDERS
•SCHIZOPHRENIA
•SCHIZOAFFECTIVE
•BRIEF PSYCHOSIS

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- VERY COMMON
- FREQUENT CO-MORBIDITY
- ELEVATED PREVALENCE OF PSYCHIATRIC DISORDERS
- POLYPHARMACY
PRE-HIV INFECTION
- DYNAMICS OF ACUTE AND CHRONIC MEDICAL DISEASE
-ALL PERSONS WITH HIV WILL DEVELOP AT LEAST ONE
PSYCHIATRIC DISORDER OVER COURSE OF DISEASE
-SOCIALLY MARGINALIZED, LIMITED SUPPORT, ISOLATION
FROM FAMILY
- BIO-PSYCHO-SOCIAL MODEL

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RESOURCE GUIDE

–EDUCATE RE:
– IMPROVE QUALITY OF LIFE
•RISK REDUCTION
•SEXUAL BEHAVIOURS
– FACILITATE ADHERENCE •CO-INFECTION
– ADVOCATE RE:
– INCREASE LEVEL OF FUNCTION
•DISABILITY
•FAMILY
– DECREASE HEALTH CARE COSTS •BUREAUCRACY
– IMPROVE RELATIONSHIPS – ADDRESS DEATH AND DYING ISSUES

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Depression
 Most common disorder
–THINK GERIATRIC BRAIN
•START LOW, GO SLOW  Cascade of negative consequences
 Under recognized, under treated
–BALANCE RISKS AND BENEFITS
 Normalization of Sx by others
–POLYPHARMACY
 Overlap of HIV physical Sx with mood Sx
–REVIEW CD4, VIRAL LOAD, ANTIRETROVIRAL (ARV)  Anhedonia, diurnal variation, early cognitive decline
MEDS, OTHER MEDICATIONS, LFTS  Responsive to Rx

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MENTAL HEALTH, HIV/AIDS AND HCV COINFECTION

Depression Rx Augmentation
 SRI’s  Common
 SSNRI’s  Effective
 Buproprion  Multiple choices –other AD’s, Lithium, T3 (Cytomel),
 Psychostimulants psychostimulants, atypicals
 Mirtazepine  Caution -Drug-drug interations
 ECT
 No TCA’s, MAOI’s –exceptions include
 Pain
 Sleep
 Augmentation

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MEDICATIONS FOR
BIPOLAR DISORDERS
BIPOLAR DISORDERS
 lithium
 PRE-EXISTING BIPOLAR DISORDER BECOMES MORE FRAGILE WITH  valproic acid (EPIVAL)
HIV
 gabapentin (NEURONTIN)
 NEW ONSET MORE LIKELY ASSOCIATED WITH CNS HIV DISEASE OR
SUBSTANCE USE THAN FAMILY/PERSONAL HISTORY  atypical antipsychotics
 ? RECENT CHANGE IN ARVs  avoid carbamazepine (TEGRETOL) and clozapine
 bone marrow suppression
 MAY DO WELL WITH SUBTHERAPEUTIC DOSES
 ? lamotrigine (LAMICTAL) - Steven’s-Johnson Syndome
 ? topiramate (TOPAMAX)

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