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Mental Health Screening Tools for the HIV Clinician

Mental Health Screening Tools for the HIV Clinician. Lawrence M. Mc Glynn MD Clinical Associate Professor Stanford University Faculty Medical Director San Jose AETC June 2013. Thanks. Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center

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Mental Health Screening Tools for the HIV Clinician

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  1. Mental Health Screening Tools for the HIV Clinician Lawrence M. Mc Glynn MD Clinical Associate Professor Stanford University Faculty Medical Director San Jose AETC June 2013

  2. Thanks • Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center • American Psychiatric Association – Office of HIV Psychiatry

  3. Goals for Participants • Understand which mental illnesses present themselves more frequently in HIV • Identify risk factors for mental illness in HIV • Become familiar with screening tools for conditions which may affect the overall health of people living with HIV/AIDS

  4. Grab a pencil and some scratch paper • Close your door; turn off your cell phone; no checking your email; no sleeping; kick back and let’s learn together 

  5. Types of Screening Tools • Patient focused • Self administered • Usually consist of questionnaires • Clinician administered to patient • Questionnaires • Labs • Imaging • Examinations (physical and mental status) • Includes simple observation • Observer(s) • Testimonials from family, friends, coworkers, other providers

  6. Why screening tools? • Relative objectivity (provider bias) • Efficiency • Lack of resources • Mental health timely availability • Shows the patient that you are considering all aspects of his/her life

  7. Cognitive Dysfunction • As HIV enters the CNS at a very early stage of infection, a cascade of events leads to changes in multiple realms of cognition

  8. Neuropsychological Domains • Verbal/Language • Attention/concentration • Working Memory • Executive/Abstraction • Memory (learning, recall) • Speed of information processing • Sensory-perceptual • Motor skills

  9. Associated Behavioral Disturbances Apathy Depression Sleep disturbance Agitation/Mania Psychosis

  10. HAND Classification Asymptomatic Neurocognitive Impairment (ANI) 1 SD No Functional Impairment 2 Domains Mild Neurocognitive Impairment (MNI) Mild Functional Impairment 1 SD 2 Domains Moderate to Severe Functional Impairment 2 SD HIV-Associated Dementia (HAD) 2 Domains NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

  11. Prevalence of HAND based on New Criteria NP Normal (30-60%) MNI (20-30%) ANI (20-30%) HAD (5-20%) Functional Impairment NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

  12. Risk and Protective Factors • Risk factors • Age > 50 • Survival duration • Lower nadir CD4 T-cell counts • Higher baseline viral load • Gender (F)

  13. Why Bother to Screen? • MNI has been associated with poorer health outcomes, possibly due poorer adherence to medications • Even mild HAND is associated with worse quality of life, difficulty obtaining employment and shorter survival • McGuire, Goodkin, and Douglas report that HAND independently predicts systemic morbidity and overall HIV mortality • Consider screening upon the initiation of cART and q6-12 months Mind Exchange Working Group. CID Advance Access. Nov 2012.

  14. The role of objective assessment • General Practitioners ability to pick up dementia cases • Sensitivity 51.4% (“positive in disease”) • Specificity 95.9% (“negative in health”) • Missed dementia more frequently in patients living alone • Over-diagnosed dementia more frequently in patients with mobility/hearing problems, and in the depressed • Miss nearly half of incident dementia cases • Possible factors: GPs’ subjective views on dementia (e.g., therapeutic nihilism, or suspected/feared stigmatization) • Conclusion: use objective tests Pentzek M, Wollny A, Wiese B, et al. Apart from Nihilism and Stigma: What Influences GP’s accuracy in identifying incident dementia? Am J Geriatr Psychiatry 17:11, November 2009.

  15. Screening Tools • MMSE (not very sensitive, Crum et al., 1993) • HIV Dementia Scale (Power et al., 1995) • International HIV Dementia Scale (Sacktor et al., 2005) • Montreal Cognitive Assessment (MoCA, Overton et al. CROI 2011) • MOS-IV

  16. International HIV Dementia Scale (IHDS)

  17. 1. Memory-Registration Give four words to recall (dog, hat, bean, red) – 1 second to say each. Then ask the patient all four words after you have said them. Repeat words if the patient does not recall them all immediately. Tell the patient you will ask for recall of the words again a bit later.

  18. 2. Motor Speed Have the patient tap the first two fingers of the non-dominant hand as widely and as quickly as possible. 4 = 15 in 5 seconds 3 = 11-14 in 5 seconds 2 = 7-10 in 5 seconds _____ 1 = 3-6 in 5 seconds 0 = 0-2 in 5 seconds

  19. 3. Psychomotor Speed Have the patient perform the following movements with the non-dominant hand as quickly as possible: 1) Clench hand in fist on flat surface. 2) Put hand flat on surface with palm down. 3) Put hand perpendicular to flat surface on the side of the 5th digit. Demonstrate and have patient perform twice for practice. 4 = 4 sequences in 10 seconds 3 = 3 sequences in 10 seconds 2 = 2 sequences in 10 seconds 1 = 1 sequence in 10 seconds _____ 0 = unable to perform

  20. 4. Memory-Recall Ask the patient to recall the four words. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); vegetable (bean); color (red). Give 1 point for each word spontaneously recalled. Give 0.5 points for each correct answer after prompting Maximum – 4 points. _____

  21. Total International HIV Dementia Scale Score This is the sum of the scores on items 1-3. ____ The maximum possible score is 12 points. A patient with a score of 10 should be evaluated further for possible dementia.

  22. HIV Dementia Scale MAXIMUM SCORE PATIENT SCORE TEST MEMORY - REGISTRATION Give 4 words to recall (dog, hat, green, peach) and 1 second to say each. Then ask the patient to repeat all 4 after you have said them. 4 ATTENTION/EXECUTIVE FUNCTION Antisaccadic eye movements (20 commands): ____ errors out of 20  3 errors = 4; 4 errors = 3; 5 errors = 2; 6 errors = 1;  6 errors = 0 PSYCHOMOTOR SPEED Ask patient to write the alphabet in uppercase letters horizontally across the page (use back of form) and record time: _____ seconds  21 sec = 6; 21.1-24 sec = 5; 24.1-27 sec = 4; 27.1-30 sec = 3; 30.1-33 sec = 2; 33.1-36 sec = 1; 36 sec = 0 6 4 MEMORY - RECALL Ask for the 4 words from MEMORY – REGISTRATION TEST above. Give 1 point for each correct. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); color (green); fruit (peach). Give ½ point for each correct word after prompting. 2 CONSTRUCTION Copy the cube below. Record time _____ seconds  25 sec = 2; 25-35 sec = 1; 35 sec = 0 Total score < 10: HAD 11-13: Mild cognitive impairment Adapted From: Power C et al.: HIV Dementia Scale: a rapid screening test. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1995;8:273-278. Used with permission.

  23. Modified HIV Dementia Scale

  24. MOCA

  25. MOCA

  26. MOCA

  27. MOCA

  28. MOCA

  29. Cognitive Functional Status Sub-scale of MOS-HIV Scale of Wu et al. 4 questions, past 4 weeks: 1. Difficulty reasoning/problem solving? 2. Forget things (location; appointment)? 3.Trouble with keeping attention for long? 4. Difficulty with activities using concentration / thinking? 6 pt. frequency scale: 1= all; 2=most; 3=good bit; 4=some; 5=little; 6=none [cutoff < M= 4] Validated against NP overall performance in the Netherlands; Good for busy clinics Knippels, Goodkin, Weiss, et al., AIDS, 2002;16:259-267

  30. Mathematical Screening • Cysique et al. • Cognitive impairment is predicted to occur when this expression is true

  31. Step 1: Neuropsych performanceStep 2: Functional Impairment?

  32. How To Assess Functional Impairment? • Collateral Informant and Objective ratings are most reliable • IADL scale (Lawton) • Driving Performance (Marcotte et al.) • Karnofsky, Finances, Medications

  33. What to do with a positive screen? • Rule out other causes • Always consider the biopsychosocial model • Treatment • Antiretrovirals • Psychostimulants • Other treatments being studied

  34. Depression and Anxiety • Depressed mood is one of the most common complaints among people living with HIV • Given the high co-occurrence of HIV and PTSD, anxiety is also frequently seen • These disorders may present themselves as somatic complaints • Headaches, GI complaints, weakness, fatigue, insomnia, chest pain, shortness of breath • Somatic complaints are not unusual in HIV/AIDS even when the patient is mentally healthy

  35. Epidemiology-Anxiety • 15.8% of HIV+ have GAD (2.1% of general population • 10.5% have Panic d/o (2.5% of gp) • 37% of HIV+ women report “high anxiety” • Protective: relationship, older, vl BDL

  36. Epidemiology-Depression • Lifetimes prevalence of depressive disorder in HIV as high as 22% (5-17% in general population) • Risk: African-american (M and W), MSM

  37. Why Bother to Screen? • Depression in HIV/AIDS is a significant predictor of worsening overall outcome • Depression and anxiety can contribute to poor cognitive functioning

  38. Screening Tools • Consider Endicott Criteria: reduce the weight of somatic symptoms (weight/appetite loss, sleep changes, agitation/retardation, fatigue, loss of concentration) in screening • HAD • Are you depressed?

  39. Anxiety questions • I feel tense or wound up • I get a sort of frightened feeling as if something bad is about to happen • Worrying thoughts go through my mind • I can sit at ease and feel relaxed • I get a sort of frightened feeling like butterflies in the stomach • I feel restless and have to be on the move • I get sudden feelings of panic • Cutoff score: 8

  40. Depression Questions • I still enjoy the things I used to enjoy • I can laugh and see the funny side of things • I feel cheerful • I feel as if I am slowed down • I have lost interest in my appearance • I look forward with enjoyment to things • I can enjoy a good book or radio or TV program • Cutoff score: 8

  41. "Are you depressed?" Screening for depression in the terminally illAm J Psychiatry 1997 • Semi-structured diagnostic interviews for depression were administered to 197 patients receiving palliative care for advanced cancer • RESULTS: Single-item interview screening correctly identified the eventual diagnostic outcome of every patient, substantially outperforming the questionnaire and visual analog measures

  42. PHQ-9

  43. What to do with a positive screen? • Assess for suicidality • R/o other causes (biopsychosocial model) • Refer to treatment (talk, med’s)

  44. Suicidality

  45. Epidemiology • Despite the development of cART, suicide rates among HIV+ individuals remain more than three times higher than in the general population. AIDS PATIENT CARE and STDs Volume 26, Number 5, 2012

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