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MENTAL HEALTH AND HIV An Overview

MENTAL HEALTH AND HIV An 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

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MENTAL HEALTH AND HIV An Overview

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  1. MENTAL HEALTH AND HIVAn Overview Karina K. Uldall, MD, MPH Department of Psychiatry University of Washington

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

  3. 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. 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 Aspects of HIV/AIDS

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

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

  7. 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. 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. Psychotic Disorders • Substance induced – intoxication or withdrawal • Medical illness/medication induced • Distinguished from delirium • Distinguished from late stage dementia

  10. 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. 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. Suicide Assessment • Gender, age, ethnicity • Family history • Psychiatric illness • Medical illness • Behavior • Lethality

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

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

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

  17. 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. 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. Other CNS Disorders • Viral/Bacterial Meningitis • Neurosyphilis • Herpes Simplex Encephalitis • Varicella-Zoster Encephalitis • Rarely Histoplasmosis and Coccidiodomycosis

  20. 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. SUMMARY • HIV related illness • Other physical illness • Medication toxicity • Substance use • Primary psychiatric illness

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