April 2003 HIV AND PSYCHIATRIC ILLNESS Karina K. Uldall, MD, MPH Department of Psychiatry HIV/AIDS Research Program University of Washington.

April 2003April 2003

HIV AND PSYCHIATRIC ILLNESSHIV AND PSYCHIATRIC ILLNESS

• Karina K. Uldall, MD, MPH

• Department of Psychiatry

• HIV/AIDS Research Program

• University of Washington

April 2003April 2003

OVERVIEWOVERVIEW

• AIDS Defining Neurological Illnesses

• Other CNS Disorders

• Psychiatric Illness in HIV/AIDS

• Diagnosis and Treatment

April 2003April 2003

AIDS DEFINING NEUROLOGICAL AIDS DEFINING NEUROLOGICAL ILLNESSILLNESS

• CMV Encephalitis

• Progressive Multifocal Leukoencephalopathy (PML)

• Toxoplasma Encephalitis

• Primary CNS Lymphoma

• Cryptococcal Meningitis

• Rarely TB Meningitis and Kaposi’s Sarcoma

April 2003April 2003

CMV ENCEPHALITISCMV ENCEPHALITIS

• Disorientation, confusion, apathy

• Psychomotor retardation, lethargy, cranial nerve abnormalities

• Abrupt onset, short course

• CD4 count < 50/uL

• Diagnosed via CSF PCR

• Treated with foscarnet, ganciclovir, both

• Survival less than 2 months

April 2003April 2003

PROGRESSIVE MULTIFOCAL PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHYLEUKOENCEPHALOPATHY

• Occurs in approximately 4% of patients

• Focal weakness, visual loss

• 10% spontaneously improve

• CD4 count < 100/uL

• Diagnosed via CSF JC virus PCR

• No clear treatment

• Survival 1 to 4 months

April 2003April 2003

TOXOPLASMA TOXOPLASMA ENCEPHALITISENCEPHALITIS

• Approximately 10% of HIV patients, most common CNS mass in AIDS (60%)

• Activation of previous infection • Fever, headache, weakness, visual

symptoms, seizures, cognitive changes• CD4 count < 200/uL• Contrast scan - multiple enhancing lesions,

basal ganglia, gray-white junction• Treated with pyrimethamine/sulfadiazine

April 2003April 2003

PRIMARY CNS LYMPHOMAPRIMARY CNS LYMPHOMA

• Approximately 3-5% of HIV patients

• Second most common CNS mass in AIDS

• Presentation depends on location of tumor

• CD4 count < 100/uL

• Contrast scan - usually single lesion noted

• Treated with radiation

• Survival 2 to 6 months

April 2003April 2003

CRYPTOCOCCAL MENINGITISCRYPTOCOCCAL MENINGITIS

• Occurs in approximately 7% of HIV patients

• Fever, headache, cognitive changes

• Insidious onset spanning 2 to 4 weeks

• CD4 count < 100/uL

• Diagnosed via CSF culture, India ink stain

• Treated with amphotericin B and fluconazole

April 2003April 2003

OTHER CNS DISORDERSOTHER CNS DISORDERS

• Bacterial/Viral Meningitis

• Neurosyphilis

• Herpes Simplex Encephalitis

• Varicella-Zoster Encephalitis

• Rarely Histoplasmosis and Coccidiodomycosis

April 2003April 2003

PSYCHIATRIC ILLNESS IN HIV/AIDSPSYCHIATRIC ILLNESS IN HIV/AIDS

• HIV Associated Dementia (HAD)

• Delirium

• Psychotic Disorders

• Mood Disorders

• Anxiety Disorders

• Substance Abuse and Dependence

April 2003April 2003

HIV ASSOCIATED DEMENTIAHIV ASSOCIATED DEMENTIA

• 15-20% of AIDS patients

• Combination of motor, cognitive and mood/personality changes

• Insidious onset, CD4 count < 200/ul

• CSF Beta-2-microglobulin > 3.8 mg/dL, HIV-1 RNA >10,000/ml

• AZT, AZT+3TC, d4T+3TC, Indinavir

April 2003April 2003

DELIRIUMDELIRIUM

• Disturbance of consciousness with attention problems

• Change in cognition or development of a perceptual disturbance

• Acute onset with fluctuating course

• Underlying etiology– fever/infection, trauma, metabolic,

meds/drugs, other cause(s)

April 2003April 2003

DELIRIUMDELIRIUM

• Common in later stages of disease, 30-60% of patients

• Often confused with dementia and depression

• Associated with poor outcomes - mortality, long term care, longer hospitalization

• Treatment of choice is haloperidol unless etiology is alcohol/benzodiazepine withdrawal

April 2003April 2003

PSYCHOTIC DISORDERSPSYCHOTIC DISORDERS

• Substance induced during intoxication or withdrawal

• Medical illness induced – must be distinguished from delirium– late stage HIV associated dementia

April 2003April 2003

MOOD DISORDERSMOOD DISORDERS

• Bipolar disorder - 8% of outpatients

• Major depressive episode– 6-10% current and 20-35% lifetime– similar to other medically ill populations

• Substance induced mood disorder

• Medical illness induced– must distinguish from dementia, hypoactive or

hyperactive delirium

April 2003April 2003

ANXIETY DISORDERSANXIETY DISORDERS

• 2 to 38% of patients depending on stage of illness

• Panic disorder

• Adjustment disorder

• Substance induced due to intoxication or withdrawal

• Medical illness induced, e.g. untreated pain

April 2003April 2003

SUBSTANCE ABUSE AND SUBSTANCE ABUSE AND DEPENDENCEDEPENDENCE

• Abuse– recurrent use in setting of failure at work,

home or school– use in physically hazardous settings– recurrent legal problems– recurrent social or interpersonal problems

April 2003April 2003

SUBSTANCE ABUSE AND SUBSTANCE ABUSE AND DEPENDENCEDEPENDENCE

• Dependence– tolerance/withdrawal– larger amounts/longer period of time– unable to cut down or control use– time spent obtaining drug or recovering from it– love, work or play compromised– use in setting of physical/psychological

problems

April 2003April 2003

SUICIDE ASSESSMENTSUICIDE ASSESSMENT

• Gender M > F

• Age 15-25 years and > 45 years men; > 55 years

women

• Ethnicity Caucasian (Black, Hispanic, Native American)

April 2003April 2003

SUICIDE ASSESSMENTSUICIDE ASSESSMENT

• Family history– suicide, early parental loss, mood disorder,

chaos

• Psychiatric illness– auditory hallucinations, mood disorder,

substance use, prior attempts

• Medical illness– acute v chronic, terminal, pain, medications

April 2003April 2003

SUICIDE ASSESSMENTSUICIDE ASSESSMENT

• Behavioral factors– Changes in behavior– Messages saying goodbye– Social isolation

• Lethality– Access to means -Thorough plan– Method of attempt -Prior attempts– Possibility of rescue

April 2003April 2003

SUICIDE ASSESSMENTSUICIDE ASSESSMENT

• HIV/AIDS Risk Factors– Stage of disease– Number of AIDS related losses– Social isolation– Disease progression/fear of progression– Uncontrolled pain– Experience with HIV-related suicide

April 2003April 2003

SUICIDE INTERVENTIONSSUICIDE INTERVENTIONS

• Medication/hospitalization

• Address contributing factors

• Encourage expression of feelings/thoughts

• Promote sense of self control

• Build alternative coping strategies

• Educate patient and family

• Develop a crisis plan

April 2003April 2003

TREATMENTTREATMENT

• Psychotherapy– supportive, interpersonal, cognitive-

behavioral, group, psychoeducational– ongoing risk of crises– countertransference issues

• homophobia, sex, substance use, existential beliefs, rescue fantasies, identification, therapeutic nihilism, guilt, fear of contagion

April 2003April 2003

TREATMENTTREATMENT

• Pharmacotherapy– Antidepressants

• SSRIs Paroxetine, Sertraline, Fluoxetine• TCAs Nortriptyline, Desipramine• Other Nefazodone, Venlafaxine, Mirtazapine

– Stimulants• Methylphenidate• Dextroamphetamine

– Testosterone

April 2003April 2003

TREATMENTTREATMENT

• Pharmacotherapy– Antipsychotics

• typical haloperidol• atypical risperidone, olanzapine

– Antianxiety agents• benzodiazepines

– Mood stabilizers• lithium, valproic acid, carbamazepine

April 2003April 2003

MEDICATION INTERACTIONSMEDICATION INTERACTIONS

• Multiple medications

• Multiple medical illnesses

• Renal or hepatic disease

• Elderly

• Individual differences in liver metabolism

• Specific liver metabolism inhibitors

April 2003April 2003

CHOOSING MEDICATIONSCHOOSING MEDICATIONS

• Adverse effects

• Interactions with other medications/drugs

• Metabolism via liver

• Elimination via liver or kidney or both

• Time to expected onset of action

• Expected duration of action

• “Less is better”

April 2003April 2003

SUMMARYSUMMARY

• Document HIV status

• Determine level of immunocompromise

• Thorough history and physical exam

• Diagnostic tests– CT/MR -Urine tox screen/BAL– LP– Neuropsychological testing

April 2003April 2003

SUMMARYSUMMARY

• HIV-related illness

• Other “physical” disorder

• Medication toxicity

• Substance use

• Primary psychiatric illness