HAND Diagnostic Issues Addressing Mental Health. Dr. Adriana Carvalhal, MD, MSc, PhD University of Toronto St. Michael s Hospital

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1 HAND Diagnostic Issues Addressing Mental Health Dr. Adriana Carvalhal, MD, MSc, PhD University of Toronto St. Michael s Hospital

2 Disclosure Research: Canadian Institute Health Research (CIHR) - I Ontario HIV Treatment Network (OHTN) - I Company Abbvie Laboratories Bristol-Myers Squibb Canada Janssen Biotech Consulting I I I Speaking & Teaching Advisory Board I I I D Relationship is considered directly relevant to the presentation. I Relationship is NOT considered directly relevant to the presentation.

3 Introduction Transition of HIV to a chronic disease Challenges have changed with the advances in the treatment shifted to the treatment of comorbidities HIV-positive patients continue to face: Extensive social challenges Stigma and discrimination Social isolation Heywood & Lyons, 2016

4 HIV and Psychiatric Disorders Risk Poor QoL HIV Psychiatric Disorders Severity Poor self-care Adherence Worse clinical outcomes Impairment in social and vocational functioning Use of health services Relf, MV et al Carvalhal, et al

5 Impact of Psychiatric Disorders In HIV Care HIV Infected HIV Diagnosed Linked to Care Retained in Care On ART Viral Suppression

6 Depression Depression is the most common psychiatric disorder in HIV-infected patients Lifetime prevalence is 20-45% (general population=9%) Depression is the leading cause of disability and is associated with negative outcomes: Low productivity Medication non-adherence Cognitive complaints Comorbidities: a. Cardiovascular disease b. Stroke c. Diabetes d. Substance use e. Suicidality Hammond et al 2016 Murray et al 2013 Hees et al 2013

7 Why so high prevalence? Direct effect of the virus on the immune system High viral load Symptoms burden Emotional reaction to the diagnosis Social stigma Individuals with previous history Sowa et al 2016 Hammond et al 2016 Miller et at 2009

8 Depression and Cognitive Functioning Depression is associated with poor neurocognitive functions Depressive symptoms predict cognitive complaints Untreated depression affect cognition Resistant depression can be symptom of HAND Treatment for depression can improve cognitive symptoms Best clinical practice to treat depression before referring patients to full neuropsychological assessment Cysique et al 2016 Carter et al 2003.

9 Screening for depression Screening Diagnosis Monitoring Patients may not recognise or self-report symptoms of depression 1 Some physicians may also be afraid to ask questions about psychological health A wide variety of depression screening techniques are available 2 Most rely on self-reporting Some tools focus in physical symptoms Most diagnose the severity rather than presence of depression 1. New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; Available at: content/uploads/depression and mania posted pdf. Last accessed July Ramasubbu R et al. Ann Clin Psychiatr 2012;24:82 90.

Screening for depression Many screening techniques can be performed in 10 minutes 1 Screening methods as short as two questions have been recommended 2 Questionnaire length does not impact accuracy 3

10 Screening for depression Many screening techniques can be performed in 10 minutes 1 Screening methods as short as two questions have been recommended 2 Questionnaire length does not impact accuracy 3 1. Ramasubbu R et al. Ann Clin Psychiatr 2012;24:82 90; 2. New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; Available at: content/uploads/depression and mania posted pdf. Last accessed July 2013; 3. Akena D et al. BMC Psychiatry 2012;12:187.

11 Screening for depression Centre Epidemiological Studies Depression CES-D Simple, quick and easy to interpret Screening tools assess several somatic symptoms Scoring > 16 Rarely or none (less than 1 day) Some or a little (1-2 days) Occasionally or a moderate amount of time (3-4 days) Most or all the time (5-7 days) I was bothered by things that usually don t bother me. I felt hopeful about the future Radloff 1977

12 Confounding factors for the diagnosis of depression Screening When diagnosing HIV patients with depressive symptoms, it may be necessary to exclude the following possible causes: Diagnosis Monitoring Other neuropsychiatric disorders HIV-related medical conditions and treatments Bipolar disorder Post-traumatic stress disorder HIV-associated dementia Alcohol and substance abuse Endocrinological abnormalities HIV-related treatments Opportunistic and other infections (e.g. syphilis) HIV-associated dementia New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; Available at: content/uploads/depression and mania posted pdf. Last accessed July 2013.

13 Breaking Down the Siloes: Effective Multidisciplinary Team

14 Psychiatric Care for PHA at SMH Care at the Hospital Care in Primary Care Care in the Community Chan & Carvalhal, 2015 Carvalhal, 2015

15 HIV Care at St. Michael s Hospital HIV care Positive Care Program ID (5) Hepatologist (1) Psychiatrist (1) Nurse (3) Dietician (1) Physiotherapist (1) Social worker (1) Pharmacist (2) Primary care HIV Program Family physicians (5) Nurse practitioner (1) Psychiatrist (1) Social worker (1) Dietician (1) Pharmacist (1)

16 HIV Care at St. Michael s Hospital Care in the Community

17 HIV Care at St. Michael s Hospital Casey House 14 beds Transition from hospital to community Community services SMH team: ID Psychiatrist

18 HIV Care at St. Michael s Hospital McEwan Housing Positive Service Coordination Intensive case management (15 20 clients/case manager) Housing and fast track to engage in care 100 patients in the program

19 HIV Care at St. Michael s Hospital Complex Care Target population: HIV-positive patients who are aging Complex health issues High service users Cognitive disorders

20 In Summary 1. Despite many advances in the treatment of HIV infection, psychiatric disorders remain a challenge and a significant proportion of patients with HIV suffer from depression. 2. Psychiatric disorders create challenges for engagement in care and increase the likelihood of engaging in high risk behaviour. 3. Synergistic mechanisms between depression and HIV may be related to stress and immune dysfunction. 4. Depression is associated with negative outcomes such as low productivity, medication non-adherence and other comorbidities (e.g. cardiovascular disease, diabetes, and substance use). 5. Traditional models of delivery psychiatric care in HIV-infected patients do not work. We have to think outside the box. It is all about networks that we are able to develop.

21 HAND Diagnostic Issues Addressing Mental Health Thank You!

Differential diagnosis between depression and neurocognitive impairment in HIV-infected persons

Differential diagnosis between depression and neurocognitive impairment in HIV-infected persons Dr. Adriana Carvalhal, MD, MSc, PhD University of Toronto - Canada Disclosure Research: Canadian Institute