Psychiatric Issues in Adolescents with HIV/AIDS

1. Psychiatric Issues in Adolescents with HIV/AIDS Ann M. Usitalo, PhD UF CARES University of Florida/Jacksonville Center for HIV/AIDS Research, Education & Service

2. Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there areno conflicts of interest represented in the presentation.

3. Objectives • Describe the spectrum of psychiatric illness in HIV infected children and adolescents. • Discuss the impact of psychiatric illness on the management of their HIV infection. • Discuss specific signs and symptoms of psychiatric disease in this population that would allow early recognition. • Discuss the different management strategies available including psychosocial and behavioral health interventions.

4. HIV/AIDS as…. • Youth driven (13-24 years of age) • 14% new HIV infections in 2006 & increasing • 50% of all STDs • Mental health driven • Risky behaviors higher among psychiatrically ill • HIV infection increases risk of mental health problems • Impacting racial/ethnic minorities, females • > 60% African-American • ~ 20% Hispanic/Latino • 37% female

7. HIV Epidemic in 2011 • Better prognosis overall • Co-morbidities • Increased emphasis upon • Adherence • Medication interactions and side effects • Levels of social/economic support • Stigmatization • High for HIV and mental health • Synergistic stigmas

8. Threats to Emotional Well Being • Coping with physical illness • Concerns about prognosis • Disruptions of social and academic functioning • Concerns about body image • Social stigma and isolation • Disclosure fears • Losses • Sexual relationships & peer pressure

9. Socioecological Systems Health Care Financing Priorities Attitudes Toward Adolescents Social Network Peers Clinic Parents Siblings Cognitions Attributes Health Status Adolescent Home School Cultural or Community Beliefs About Illness General Economic Conditions Family Illness Neighborhood

11. I have the most difficulty addressing the following with my adolescent patients…. • Sexual abuse • Suicidal ideation • MSM/Transgender sexual issues • Death, end-of-life issues

12. Risk Factors for Psychiatric Disorders & HIV

13. Characteristics of 91 HIV-infected youth in southern urban HIV clinic DemographicsNumber% Male32 35% Female59 65% African-American 8695% Heterosexual activity 6976% Homosexual activity 1618% Bisexual activity 2 2% (Kadivar, Garvie, Sinnock, Heston, & Flynn, 2006)

14. Psychosocial Experiences CharacteristicN% STDs 62 68% Abuse by parents 42 46% Parental substance abuse 42 46% Known someone with HIV 38 42% Juvenile justice 37 41% Sexual abuse 37 41%

15. Psychosocial Experiences CharacteristicN% Marijuana use 30 33% Abandonment/Neglect 27 30% Runaway 26 29% Depression- past & current 25 27% Unstable housing 25 27% Tobacco use 25 27% Loss/death 22 24%

16. Summary of Psychosocial Profile • “Samantha” • Chaotic environment • High levels parental substance abuse (46%) & abandonment • Reduced parental/adult monitoring • Sexual abuse • Early initiation of sexual activity (<13 yrs) • Higher incarcerations, school drop-out • High rates of depression, loss

17. Developmental Issues • Adolescent brain as a “work in progress” • Higher order, abstract thinking • Planning • Impulse control • Pubertal development • Perceptions of immortality • Identity exploration • Peers & social functioning

18. Personal Attributes • Cognitions • Emotional regulation/dysregulation • Sexual abuse • Personality traits • Sensation seeking • Impulsivity • Achievement motivation

20. Mental Health • Emergence of psychiatric problems during adolescence • Externalizing (aggression/delinquency) • Internalizing (depression/anxiety) • Direct link between psychiatric issues & increased risk behaviors • Sexual activity • Unprotected sex • Alcohol and drug use (Benton, 2010; Donenberg & Pao, 2003 & 2005; Lehrer, Shrier, & Gortmaker, 2006)

21. Sexual Minority Youth • 68% of HIV diagnoses aged 13-24 (2008) • Rates of emotional and behavioral problems higher • Increased suicidality • Family and/or peer rejection • Verbal and physical abuse • Increased stigmatization (Lam, Naar-King, &Wright, 2007; Marhefka, et al., 2009; Morrison & L’Heureux, 2001; Safren& Heimber, 1999)

22. Perinatally Infected Adolescents • Disclosure • Maternal status • Own status • Treatment “burn out” • Loss and bereavement • Parent • Peers • Etiology of HIV • Complicated emotions • Anger, guilt, shame, ambivalence

23. PSYCHIATRIC DIAGNOSES & RELATED ISSUES

24. Jessica is a 16 yo female who presents with significant drug/alcohol use, social isolation, irritability, & risky sexual behavior. Which of the following is your #1 r/o diagnosis? • Social phobia/anxiety • PTSD • Major depressive disorder • Primary substance abuse disorder

25. Psychiatric Epidemiology • Prevalence high (25% to 85%) • Both perinatally and behaviorally infected • 10%-20% in general adolescent population • Affected youth with rates similar to HIV + • Increased psychiatric hospitalizations • Most common diagnoses • Depression • Anxiety disorders • Attention-deficit/Hyperactivity (ADHD) • Behavioral problems • Substance abuse (Mellins, Brackis-Cott, Dolezal & Abrams, 2006; Mellins, et al., 2009; Scharko, 2006)

26. Depression NOT “normal” in chronic illness Prevalence 47% “Jennifer” Symptoms Depressed mood or anger/irritability - 2 weeks Loss of interest Neurovegetative symptoms Poor sleep Appetite changes Diminished libido Problems with attention, concentration Feelings of guilt, worthlessness Suicidal ideation

27. Depression (cont’d) • 2x more frequent in females • Overlapping symptoms with HIV • Appetite changes • Sleep disturbance • Decreased energy • Slowed motor movements • Multiple somatic complaints • Psychosocial stress significant • Stigma, discrimination, poverty, violence • Relationship & disclosure issues

28. Bipolar Disorder(s) Not being “moody” Mania/hypomania Elevated or irritable mood • Impulsivity Poor judgment • Racing thoughts Drug use • Risky sexual behavior Cyclothymia Stress of HIV exacerbates bipolar disorder Adherence poor Family history In adults with HIV, prevalence 10x higher than general population

29. Anxiety Disorders Prevalence 24%-49% overall Generalized Anxiety Persistent, excessive worry Illness Panic Disorder Panic attacks Fear of subsequent attacks and implications or consequences Behavioral change Agoraphobia Specific phobias

30. Social Phobia • “Benjamin”, “Kathy” • Fear of social situations, scrutiny • Fear others judge them as anxious, weak, crazy, stupid • Avoidance of social, public situations • Exacerbated by • Internalized stigma of illness • Weight loss, lipodystrophy • Self-medication with drugs, alcohol

31. Prevalence 13%-23% (Benton, 2010) Trauma related to life events, diagnosis, medical procedures Rape and sexual violence 68% women & 35% men with HIV after age 15 Physical abuse as child 34% women, 27% men Witnessing violence at home & community Symptoms Flashbacks, depression, social/emotional isolation, poor emotional regulation, irritability, anger Substance use, sexual risk taking PTSD/PTSS

32. Schizophrenia & Thought Disorders “Edward” Emerges in late adolescence Positive symptoms Delusions, hallucinations, agitation, suspiciousness Negative symptoms Social withdrawal, non-communicative, lack of initiative Cognitive Poor attention, concentration, information processing Estimated 2-10% adult PLWHA Can be triggered by substance use

33. ADHD • 25%+ of youth with HIV • Primary symptoms • Impulsivity • Hyperactivity • Distractibility • Inattentiveness • Etiology linked to • Genetics • Biological adversity • Psychosocial adversity • Neurobiology

34. Behavioral Issues • Oppositional- Defiant Disorder • Negativistic, hostile, defiant behavior • Loses temper • Argues with adults • Deliberately defies authority • Angry, resentful, spiteful • Conduct Disorder • Aggression • Destruction of property • Deceitfulness or theft • Serious violations of rules • Behavioral problems, “acting up”, “out of control” • Prevalence 11%-13% (Mellins, Brackis-Cott, Dolezal, Abrams, 2006)

35. Neurocognitive Functioning • “Bethany” • CNS manifestations of HIV • Neurotoxic, inflammatory response • Opportunistic infections • Encephalopathy • Consequences • Poor attention, executive functioning, memory • Problems with visuomotor & spatial learning • Impaired expressive and receptive language skills • HIV medication • Neuropsychological testing • Educational interventions

36. Prevalence high 14% total (aged 12-18); 22% > 15 (Williams, et al., 2010) 47% alcohol, 37% cannabis aged16-24 (Naar-King, et al., 2010) Associated with ADHD Conduct disorder Oppositional defiant disorder Depression Self-efficacy Parental substance use Substance Abuse

37. Personality Disorders Long-standing patterns of thought, behavior, and emotions that are maladaptive for the individual or for people around him or her. • Etiology • Physiological/biological predisposition plus • Social/psychological experiences • Risk to self & others • Impulsivity, risk taking, self-destructive • Difficult to treat • Chaotic, demanding, manipulative • If under 18, must be present for 1 year • Make life miserable for those around them

38. Personality Disorders Cluster A Paranoid, schizoid, schizotypal Cluster B Borderline Unstable relationships & emotions, impulsivity, parasuicidal behaviors Antisocial (must be > 18 years old) Aggressive, pervasive disregard for & violation of rights of others Histrionic Sexually seductive, self-dramatization, needs to be center of attention Narcissistic Exaggerated self-importance, entitled, exploitative Cluster C Avoidant, dependent, passive-aggressive, obsessive-compulsive

39. Jessica is a 16 yo female who presents with significant drug/alcohol use, social isolation, irritability, & risky sexual behavior. Which of the following is NOW your #1 r/o diagnosis? • Social phobia/anxiety • PTSD • Major depressive disorder • Primary substance abuse disorder

40. Consequences of Psychiatric Illness • Poor adherence • Early onset sexual activity • More unprotected intercourse • Multiple sexual partners • More STDs • Increased drug or alcohol use • Quality of life poorer • Treatment outcome poorer

41. Internalizing (depression, anxiety) Decreased assertiveness Early sexual initiation Less able to negotiate safe sex Externalizing behaviors More frequent sexual involvement Multiple partners Higher rates of “exchange” sex Sex as basic biological drive Relief from distress in self-soothing behaviors Unprotected sex Substance use - which increases unprotected sex Sexual Behavior

43. Drawing IT Out: 1st International HIV/AIDS Cartoon Exhibition in New York City. World AIDS Day, December 1, 2006 International Planned Parenthood Federation/Western Hemisphere Region, Government of Brazil and UNAIDS Artist: Vascoli, Country: Brazil

44. Assessment & Treatment

45. Assessment • Biopsychosocial & developmental context • Multiple sources of information • Adolescent, school, family, PCP • Family psychiatric history • Life events and stressors • School, job functioning • Identify strengths as well as issues

46. Screening • “Triage” process • Use reliable and validated instrument(s) • Diagnostic Interview Schedule for Children (DISC) • Clinical or psychiatric interview • Comprehensive assessment • Interview, testing, school records • Current medical status and medications • Efavirenz (Kenedi & Goforth, 2011) • Aware of side effects • Evaluation must be ongoing

47. Evaluate Symptoms & Behaviors • Depressed affect • Anxiety • Suicidal tendencies • Alcohol and drug use problems • Unusual or bizarre thoughts • Anger and aggression • Intellectual and neuropsychological deficits • Self-injurious behaviors

48. Treatment

49. Treatment • Stigma of mental health diagnosis • <50% overall receive appropriate treatment • Pharmacological treatment • Drug-drug interactions • Metabolic complications • Side effects • Resistance to more medication • Therapy • Individual, family, group • Cognitive-behavioral, motivational interviewing, multisystemic therapy, social support/groups www.nynjaetc.org

50. Pharmacological Treatment • Same medications as HIV- adolescents • Little known about specific effects in HIV+ • Antidepressants/Anxiety disorders • SSRIs • Psychostimulants • Few drug-drug interactions • Antipsychotics • Second-generation antipsychotics related to elevated cholesteral (Kapetanovic et al., 2010)