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This overview delves into psychosocial issues, psychiatric illness, substance abuse, and medication interactions in HIV/AIDS patients, emphasizing the importance of support services, spirituality, and relationships in coping with the disease. It discusses psychiatric disorders such as HIV-associated dementia, delirium, psychotic disorders, mood disorders, and anxiety disorders, highlighting assessment criteria and treatment options like psychotherapy and medications. Moreover, it addresses the significance of suicide assessment, substance abuse, and medication interactions. The summary outlines key steps in evaluating and managing neurologic illnesses related to HIV and emphasizes the importance of comprehensive diagnostic tests.
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MENTAL HEALTH AND HIVAn 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 • 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
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
Accompaniment Advocacy Assessment Care Coordination Crisis Intervention Engagement Listening Patient/Family Education Problem Solving Referrals Skills Building Support Interventions
Psychiatric Illness • HIV Associated Dementia • Delirium • Psychotic Disorders • Mood Disorders • Anxiety Disorders
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
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
Psychotic Disorders • Substance induced – intoxication or withdrawal • Medical illness/medication induced • Distinguished from delirium • Distinguished from late stage dementia
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
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
Suicide Assessment • Gender, age, ethnicity • Family history • Psychiatric illness • Medical illness • Behavior • Lethality
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
Substance Abuse • Abuse versus dependence • Co-morbid hepatitis C • Relationship to risk behaviors • Relationship to adherence • Risk of adverse medication/drug events
Psychotherapy Supportive, interpersonal, cognitive-behavioral, group Ongoing crises Countertransference issues Medications Antidepressants Stimulants Antipsychotics Antianxiety agents Mood stabilizers Treatment
Medication Interactions • Multiple medications • Multiple medical illnesses • Renal or hepatic disease • Age • Individual differences in liver metabolism • Specific liver metabolism inhibitors/inducers
Choosing Medications • Adverse effects • Possible interactions • Metabolism via liver • Elimination via liver, kidney or both • Onset of action • Duration of action • “Less is better”
AIDS-Defining Neurologic Illnesses • CMV Encephalitis • Progressive Multifocal Leukoencephalopathy (PML) • Toxoplasma Encephalitis • Primary CNS Lymphoma • Cryptococcal Meningitis • Rarely TB Meningitis and Kaposi’s Sarcoma
Other CNS Disorders • Viral/Bacterial Meningitis • Neurosyphilis • Herpes Simplex Encephalitis • Varicella-Zoster Encephalitis • Rarely Histoplasmosis and Coccidiodomycosis
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
SUMMARY • HIV related illness • Other physical illness • Medication toxicity • Substance use • Primary psychiatric illness