Presented by William B. Lawson MD, PhD, DFAPA Professor and Chair Mansoor Malik, MD

1. Presented by William B. Lawson MD, PhD, DFAPA Professor and Chair Mansoor Malik, MD Assistant Professor Department of Psychiatry and Behavioral Sciences Howard University College of Medicine and Hospital The Triple Whammy: HIV, Psychiatric Disorders, African-AmericanPresented: August 10, 2011Updated on July 29, 2013

2. Learning Objectives • At the completion of this webinar each participant will be able to: • Discuss the epidemiology of HIV in African Americans • Explore the psychiatric complications associated with HIV in African Americans • Understand the relationship between substance abuse and mental disorders to HIV in African Americans • Discuss the diagnostic and treatment challenges seen in African Americans with substance abuse and mental disorders

3. PSYCHIATRIC DISORDER…..Definition Any manner of psychological or behavioral symptoms that causes an individual significant distress, impairs their ability to function in life, and/or significantly increases their risk of death, pain, disability, or loss of freedom. In addition, to be considered a psychiatric disorder, the symptoms must be more than the expected response to a particular event (e.g., normal grief after the loss of a loved one)

4. PSYCHIATRIC DISORDER…..Definition For the purpose of this presentation, we will focus on the following Psychiatric Disorders that African Americans experience most often: Mood Disorders Depression Bipolar Disorder Anxiety Disorders Post Traumatic Stress and other disorders Panic Disorder & Generalized Anxiety Disorder Psychosis Schizophrenia Schizoaffective Disorder Dementia

5. Surgeon General’s Report on Mental Health: Race, Culture, and Ethnicity • Striking disparities in mental health care for African Americans, Asian Americans and Pacific Islanders, Hispanics, and Native Americans • 50% less likely to receive services than Whites • Poorer quality of care (misdiagnosis, underuse, overuse) • Underrepresented in mental health research • Disparities impose greater disability burden on these affected population groups, which together constitute an emerging majority US Department of Health and Human Services (2001) Mental health: culture, race, and ethnicity—a supplement to mental health: a report of the Surgeon General. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, Md

6. HIV AND AFRICAN AMERICANS What Do We See?

8. HIV and African Americans • The number of AIDS cases per 100,000 African Americans is nine time greater than per 100,000 whites. • African Americans account for 55 percent of all AIDS deaths, followed by Latinos who account for 14 percent. • Survival after an AIDS diagnosis is lower for African Americans than any other racial or ethnic group. • High risk behavior: unprotected sex and IV substance abuse accounts for most new cases • Poorer response to HIV medications Lawson, W.B., Hutchinson, J., Reynolds, Diane, “HIV/AIDS among African Americans” in Psychiatric Aspects of HIV/AIDS. Eds. Fernandez, F. Ruiz, Pp 223-230, 2006, Lippincott Williams and Wilkins, Philadelphia, Pa. H Ribaudo, K Smith, G Robbins, et al. Race Differences in the Efficacy of Initial ART on HIV Infection in Randomized Trials Undertaken by ACTG. 18th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston. February 27-March 2, 2011

9. HIV AND MENTAL ILLNESS PSYCHIATRIC DISORDERS

10. Psychiatric Disorders Are a Risk Factor for HIV/AIDS • The prevalence of HIV is 7 times higher in patients with mental illness than in the general population. • Rates of HIV infection or AIDS among persons with serious mental illness in the United States is estimated to range between 5.2% and 22.9%. Weiser SD et al., 2004

11. HIV and Psychiatric Disorders • Majority of adults with severe mental illness (SMI) are sexually active • Engage in high risk behaviors • HIV risk correlated with psychiatric illness, substance use, and childhood abuse • Decreased highly active antiretroviral therapy (HAART) utilization, adherence and viral suppression

12. Mood Disorders • Major Depression is common • It is associated with morbidity and mortality (suicide) • It is recognized as one the most important contributors to world wide suffering • Bipolar disorder or manic depressive illness is less common but is strongly associated with high risk behavior: sexual recklessness, and substance abuse • Risk factor for HIV Infection (Regier,1990; Reisner et al., 2009) • 2.5 fold increase when CD4 cell <200 cells/mm³ (Lyketsos 1996)

13. African Americans and Depression • Often under-recognized or misdiagnosed: • Referral bias • Low cultural competence of mental health professionals • cultural differences in the expression and tolerance of symptoms • Often undertreated • Use of crisis services (poorer prognoses) • Use of alternative sources of help (faith, family, folk treatment) • When help is sought from professionals, reliance on physicians in primary care settings rather then mental health specialists Primm, A.B. and Lawson, W.B. “Disparities Among Ethnic Groups: African Americans” in Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives; Eds. P. Ruiz and A. Primm, Wolters Kluver /Lippincott Williams & Wilkins, Baltimore, 2010, Pp19-29 Cultural Competence Standards. SAMHSA/EICHE; 2000.

14. Mental Health Seeking Behaviors by African Americans *Psychologist, psychiatrist, or social worker; †Mental health specialist, general medical provider, other professional (nurse, occupational therapist, other health professional, minister, priest, rabbi, counselor), spiritualist, herbalist, natural therapist, or faith healer. SE = standard error. Sources: 1. Neighbors HW. Comm Mental Health J. 1984;20:169-181. 2. Office of the Surgeon General. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health, a Report of the Surgeon General. Rockville, MD: US Dept of Health and Human Services; 2001. Available at: http://www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-3613.pdf. Accessed April 24, 2006. Despite symptoms of distress, treatment is delayed or not sought1 Treatment sought from non–mental health professionals1

15. Recognizing Depression: Cultural Issues • In many West African countries • No single word for depression • Guilt is rare, shame is common • In U.S., rather than sadness, African Americans expressions include: • Somatization • Denial • Irritability • “Falling out” • Failure to disclose inner feelings • Healthy paranoia • John Henryism • Angry Black Woman • Depression is thought to be • Inconsistent with African American resilience • Inconsistent with religious beliefs

16. Depression-relatedComplaints

17. Medication Treatment and Interactions: Considerations for AA Patients with HIV/AIDS • Antidepressants • Key Interactions with ART: • Fluvoxamine (Luvox) AVOID • Nefazodone (Serzone) • AVOID or dose cautiously • Bupropion (Wellbutrin, Zyban) • @ 400 mg, dose cautiously with ritonavir

18. Medication Treatment and Interactions: Considerations for AA Patients with HIV/AIDS • Antidepressants • Tricyclic antidepressants • Generally well tolerated with antiretrovirals • Nortriptyline & desipramine (secondary amines) • Narrow metabolism at 2D6 • Levels can be elevated by other medications • Get a blood level if in doubt • SSRIs and Dual-action agents: • Well tolerated without adjusting dose • Few interactions

19. Bipolar • Prevalence of bipolar disorder in HIV infection is 10 times higher than in general population • Stress of HIV infection exacerbates pre-existing bipolar disorder – complicating adherence • Increased risk of HIV infection • Impulsivity, poor judgment, & libido changes all part of mood episodes • More than half are substance abusers (Lyketsos 1993)

20. Bipolar • Treatment • Not well studied with mostly anecdotal case reports • Depakote (VPA) well tolerated • Avoid with impaired hepatic function • Risk anemia with AZT • Lithium • Conflicting reports of good response (increases WBC) versus intolerable side effects • Tegretol (carbamazepine) • Second generation (atypical) antipsychotics all have indication as mood stabilizers, well tolerated and effective for psychotic sx’s

21. Case Study: Mood Depression • Ms. D, a 33 year-old Nigerian woman who recently returned from Africa is 3 ½ months pregnant. She also has an 8-year-old son. She was diagnosed with HIV in 3 years ago. She has no income, is living with friends, and has debt from when she left the United States. • She says she practiced safe sex and tested regularly; however, she had one incident where the condom broke. Her CD4+ is 1130 and she has an undetectable viral load. She feels there is no need for her to take medicine because she is afraid that her family will find out that she has HIV and she will have no place to stay. She feels guilty about this situation and reports feelings of worthlessness and fatigue all the time.

22. Questions • How you evaluate her further for possible psychiatric complications? • How will you evaluate her risk of self harm? • What can you tell her about HIV medications and pregnancy? • Which HIV medication(s) should she avoid? • What advice would you give her about HIV related stigma?

23. POST TRAUMATIC STRESS AND OTHER ANXIETY DISORDERS

24. ANXIETY DISORDERS IN AFRICAN AMERICANS • One of the most common mental disorders • PTSD and phobias may be more common in African Americans than other racial and ethnic minority groups • Often under recognized and misdiagnosed • PTSD more likely in African American combat veterans and from the stressors of inner city Lawson, W.B.“Anxiety disorders in African Americans and other ethnic minorities” in Stress-induced and Fear Circuitry Disorders-Advancing the research agenda for DSM-V: Eds. G Andrews, D.S.Charney, P.J. Sirovatka, D.A. Regier, Arlington, VA, US: American Psychiatric Publishing, Inc., 2009. pp. 139-144

25. Post Traumatic Stress Disorder • Greatly increased rates • 42% HIV+ women, County Medical Clinics (Cottler 2001) • 30% pts develop in reaction to HIV diagnosis (Kelley 1998) • Predicts lower CD4 counts (Lutgendorf 1997)

26. Post Traumatic Stress Disorder • SSRIs show 50% improvement in sx • prefer to use sertraline (Zoloft) or citalopram (Celexa) • Prazosin often used for intrusive nightmares • Psychotherapy effective, using variety of approaches (CBT, Abreaction, Supportive)

27. Other Anxiety Disorders • Panic Disorder & Generalized Anxiety Disorder • > 4 times more prevalent (Bing 2001) • Affects accessing primary care, adherence to treatment, and quality of life • Especially agoraphobic/housebound • Responds well to treatment

28. Medication Treatment and Interactions • Treatments of Choice: • SSRI’s • Anxiolytics Avoid • Alprazolam (Xanax) • Triazolam (Halcion) • Midazolam (Versed)

29. Medication Treatment and Interactions • Anxiolytics • Safest to use glucuronidated benzodiazepines: • Lorazepam (Ativan) • Temazepam (Restoril) • Oxazepam (Serax) Caution with buspirone (Buspar), and dosing of other benzodiazepines with ART

30. SCHIZOPHRENIA AND OTHER PSYCHOSES

31. Schizophrenia in African Americans • Thought to be common but often over-diagnosed • Disorders with better prognosis overlooked • INPATIENT CARE • More likely to be admitted to inpatient care • More likely to be referred to the correctional system • More likely to be involuntarily committed • More likely to be over medicated • More likely to leave against medical advice • OUTPATIENT CARE • More likely to be referred for medication only or to the emergency room • More likely to be terminated early Flaherty & Meagher 1980; Lawson 1994; Lindsey et al. 1989; Paul & Menditto 1992; Soloff and Turner, 1982; Strakowski et al. 1995)

32. Schizophrenia • Patients with chronic mental illness at increased risk for HIV infection • Prevalence rates 2 to 10% • Medical providers often do not test for HIV • Incorrectly assume pts not sexually active • Substance abuse significant co-morbidity • Pts do not implement HIV risk behavior knowledge • Providers feel such patients are poor candidates for treatment

33. Schizophrenia • Treatment • Coordinate between medical & psychiatric providers as much as possible • Typical or 1st generation antipsychotics • Increase risk of EPS & tardivedyskinesia • Atypical or 2nd generation antipsychotics are preferred but risk weight gain: • Olanzapine (Zyprexa) > risperidone (Risperdal) & quetiapine (Seroquel) > ziprasidone (Geodon) & aripiprazole (Abilify) • *Note: clozapine (Clozaril) contraindicated

34. Medication Interactions Antipsychotics: • For use with ritonavir, start with low dose • Haloperidol (Haldol) (risk EPS & TD) • Avoid chlorpromazine (Thorazine), thioridazine (Mellaril) • Olanzapine (Zyprexa) • Aripiprazole (Abilify) • Avoid pimozide (Orap)

35. Chronically and Severe Mentally Ill Patients • Chronically and Severe Mentally Ill: • Bipolar, schizophrenic, schizoaffective • At increased risk of HIV infection • Less adherent to medical & psychiatric care • Often must receive care across systems • Community Mental Health system not integrated with Primary Care, Medical Clinics, or Hospitals • Concomittent substance abuse treatment programs are the most effective but integrated programs are uncommon

36. Schizophrenia • Substance-induced psychosis • Least studied & most resistant to treatment • Methamphetamine > cocaine > hallucinogen • Possibly increased susceptibility in patients with later stage HIV infection (C3)

37. Case Study • Ms. L has a triple diagnosis: HIV+, paranoid schizophrenia, and alcoholism. She was referred to you by her social worker. She is not taking any medications for either HIV or her mental diagnosis. She refused to take them. • Her social worker, doctor, and you have all notice her psychosis as she speaks and rambles. She lives in a group home, and has become friends with Mr. J, who lives there also. • She drinks a couple of half-pints of hard liquor every day. She has started threatening Mr. J that if he doesn’t have sex with her, she will accuse him of raping her. Her lab results show her CD4+ count is 130 and her viral load is 500,000.

38. Questions 1. How will you treat her psychiatric complications? 2. What kind of support or resources can you get for yourself? 3. What is the next step if she continues to refuse treatment?

39. DEMENTIA AND COGNITIVE IMPAIRMENT

40. Dementia • CNS Infection • 10% AIDS pts present with neurological dx • 75% AIDS pts: brain pathology at autopsy • gliosis, white matter pallor & multinucleated giant cells • HIV-Associated Dementia (HAD) & Minor Cognitive Motor Disorder (MCMD) predict shorter survival

41. Dementia • Risk Factors • Seroconversion illness • Anemia • Vitamin deficiencies (B6, B12) • Low CD4 count • High CSF HIV viral Load • ETOH, cocaine & amphetamine • Depression

42. Dementia • Often misdiagnosed or ignored in African Americans • Delays in treatment of a preventable condition often occurs • General disparities in health care contribute to treatable cognitive impairments that may be misdiagnosed as dementia

43. Mild Manifestation MCMD Minor Cognitive Motor Disorder Severe Manifestation* HAD HIV Associated Dementia *functional impairment Diagnostic Criteria 1) At least 2 of: impaired attention, concentration, memory, mental & psychomotor slowing, personality change 2) Rule out other cause Diagnostic Criteria 1) Acquired cognitive abnormality* 2) Acquired motor abnormality* 3) rule out other cause Dementia

44. Dementia • With effective ART, incidence of CNS OIs dropped significantly, since early 1990’s • 2/3 decreased incidence HAD (Saktor 1999) • 75% decrease CMV & lymphoma on autopsy • However 60% with some evidence of HIV encephalopathy on autopsy (Neuenburg 2002)

45. Medication Treatment and Interaction • Treatment • Most effective treatment is ART • Raises question of lumbar puncture to confirm effectiveness on CSF HIV viral load • Slows progression of dementia (Ferrando 1998) • Reversed periventricular white matter changes seen on MRI scan in some cases

46. OTHER IMPORTANT FACTORS IN PROVIDING CULTURALLY COMPETENT CARE TO AFRICAN AMERICANS WITH PSYCHIATRIC DISORDERS AND HIV

47. Barriers and Mediators to Equitable Health Care for Multicultural Groups Barriers Mediators Outcomes Use of Services Personal/Family • Acceptability • Cultural • Language/literacy • Attitudes, beliefs • Preferences • Involvement in care • Health behavior • Education/income Structural • Availability • Appointments • How organized • Transportation Financial • Insurance coverage • Reimbursement levels • Public support Visits • Primary care • Specialty • Emergency Procedures • Preventive • Diagnostic • Therapeutic Quality of providers • Cultural competence • Communication skills • Medical knowledge • Technical skills • Bias/stereotyping • Appropriateness of care • Efficacy of treatment • Patient adherence Health Status • Mortality • Morbidity • Well-being • Functioning Equity of Services Patient Views of Care • Experiences • Satisfaction • Effective partnership Modified from Institute of Medicine. Access to Health Care in America: A Model for Monitoring Access. Washington, DC: National Academy Press; 1993. Cooper LA, Hill MN, Powe NR. J Gen Internal Med. 2002;477-486.

48. MULTICULTURAL GROUPS: Facilitating Culturally Competent Clinical Care • Knowledgeable about cultural values and beliefs of the patient and applying that understanding in a health context. • Genuine sensitivity, understanding, respectful and nonjudgmental in dealing with people whose cultural practice differs from your own. • Flexible and skillful in responding and adapting to different circumstances and within different contexts

49. MULTICULTURAL GROUPS: Facilitating Culturally Competent Clinical Care • Incorporate an understanding of the needs of the target patient populations and designs services accordingly. • Culturally accessible service delivery, in essence, “opens the door” to services for all patients.

50. MULTICULTURAL GROUPS: Facilitating Culturally Competent Clinical Care • Culture and ethnicity are products of both personal history and wider situational, political, social, political, geographic and economic factors • Factors related to culture and ethnicity shape: • the way people interact with a health care system; • their participation in programs of prevention and health promotion; • their access to health information and services • their health-related choices and decisions; • their understanding of and priorities re: health and illness, • help seeking behavior and adherence to treatment