10/20/2016. University of California, San Francisco

Transcription

1 James A. Bourgeois, O.D., M.D. Clinical Professor, Director, Psychosomatic Medicine Department of Psychiatry/Langley Porter Psychiatric Institute/Weill Institute for Neurosciences University of California, San Francisco 1 Grant support for HIV: Black Health Center of Excellence, Psychiatry Consultant, 8%. UCSF 360 Positive Care Program Funding Organization: San Francisco Department of Public Health, Funding Source: Ryan White Part A/General Fund, Contract Number: BPHC Sub Contract Amount: $134,292, February 2015 June 2018 (anticipated) No commercial support/no off label medication use Book royalties upcoming: Bourgeois JA, Cohen MA, Grimaldi J, Levenson JA, Moghimi Y, Fisher W, Tran D: Models of Care for Persons with HIV and Cohen MA, Bourgeois JA, Fisher W, Tran D: How to Establish an Integrated Ambulatory Care Program Co located in an HIV Clinic. In Cohen MA, Gorman JM, Jacobson JM, Volberding P, Letendre S, Eds. Comprehensive Textbook of AIDS Psychiatry A Paradigm for Integrated Care. Oxford University Press, New York NY (in press). 2 At end of presentation, attendees with be able to Discuss psychiatric and systemic illness co mrbidity in psychiatric illness Describe use of psychiatric rating instruments in HIV clinical practice Articulate safety considerations in psychotropic prescribing Describe laboratory monitoring for HIV patients on psychotropic medications Acute suicidal ideation (SI)/homicidal ideation (HI)/psychosis Assessment of psychiatric co morbidity Diagnostic clarity Atypicality Failure of first/second line treatments leading to nees for third/fourth line treatment Problematic medication side effects Drug drug interactions (DDI) Systemic medical/psychiatry complexity 3 4 1

2 Recall that delirium can manifest any psychiatric symptoms Temporal relationships among illness and symptoms e.g., post CVA/Parkinson s/thyroid/rheumatologic Confront substance use as a separate problem Empirical treatment of presenting symptoms after substance detoxification period Substance abuse treatment and continued sobriety offers greater clarity on attribution of illness Be alert to substance abuse recurrence itself predisposing to symptomatic recurrence Patient Health Questionnaire 9 (PHQ 9) for depression. Major depression 10 or more Hamilton Depression Inventory (Ham D). Major depression 16 or more Generalized Anxiety Disorder 7 (GAD 7). Generalized anxiety disorder 10 or more. Montreal Cognitive Assessment (MoCA). Intact cognitive status 26 or more. 5 6 Very common in primary care esp HIV/HCV Other psychiatric co morbidity is common Severe cases cognitive status can be compromised, leading to overlap with dementia presentation, increased delirium risk Often present to PCP with SOMATIC, not CNS symptoms (sleep, appetite, pain, nonspecific) Co morbid depression and systemic illness = much increased GENERAL MEDICAL utilization 7 30 woman. HIV x 5 years, stable on ARVs till recently 2 months depressed mood, poor sleep, poor appetite, low energy, poor concentration, not functioning well at work/home, not interested, lately hopeless, less medication adherence, some vague thoughts of suicide Uses alcohol to self medicate mood state Exam: Dysphoric, tearful, hopeless, retardation, no SI, no psychosis, PHQ9 16, GAD7 6, MoCA

3 SIADH from SSRI Check Uosm/Sosm/UNa All SSRI and serotonergic psych meds can do this D/c SSRI IMMEDIATELY and monitor THEN switch to lower risk medication (SNRI/mirtazapine) WITH MONITORING or no risk medication (bupropion) Full dose, full compliance x 2 months Dose increases NET q2w First line SSRI or other class Second line switch class (Psychiatric consultation) Third line augmentation (e.g., combos, T3, antipsychotic, anticonvulsant, Li) Fourth line robust combos (e.g., 3 antidepressants at full doses), transcranial magnetic stimulation (TMS), ECT 9 10 Tonic (e.g., GAD, hyperthyroid, steroids) vs episodic (panic disorder, phobic disorders) Systemic list is broad hyperthyroidism, pheochromocytoma, hypoglycemia, hyperadrenocorticism, CHF, PE, arrhythmia, COPD, pneumonia, hyperventilation B12 deficiency, porphyria, neoplasm, vestibular disease, encephalitis 35 HIV + M, chronically anxious, insomnia, nonspecific physical complaints, poor sleep, uses THC/EtOH for anxiolysis, wants BZPs, no discrete panic attacks. Exam. Non tearful, non melancholic, anxious, mild psychomotor agitation, no SI HI psychosis, GAD 7 15 PHQ 9 5, MoCA

4 For GAD, SSRI/other antidepressant Buspirone Caution re: chronic BZPs (long T1/2 e.g., clonazepam, preferred), do not use if active substance abuse Psychotic disorder Schizophrenia, schizoaffective disorder, drug or illness induced psychotic disorder Psychotic symptoms of other psychiatric disorder ( secondary ); e.g., delirium, dementia, bipolar disorder, melancholic depression Psychosis due to substance intoxication/use, systemic/other CNS illness, systemic medications M, HIV+, onset AH/paranoid delusions insidiously, gradual social withdrawal, unable to work, go to school, isolative/frightened. Uses methamphetamine and marijuana. Exam. Anxiously blunted, perplexed affect, scanning the room, poor eye contact, delusions/ah of seeing the Illuminati controlling my mind and the whole world, suicidal to escape this, GAD 7 12, PHQ9 13, MoCA 22 Antipsychotic agents Atypical are now typical Block D2 and 5HT2 variably D2 blockade high for risperidone and ziprasidone, moderate for olanzapine, low for quetiapine and clozapine

5 Discrete mood periodic (manic/depressive) episodes Not just irritability without mood periodicity Distinguish from drug induced states/steroids/immunomodulators Need acute and maintenance treatment Classify as: (1) Classic euphoric mania Lithium, VPA, AAP (2) Bipolar II or bipolar depression Lamotrigine/other anticonvulsant, quetiapine, olanzapine/fluoxetine combo (3) Prominent psychosis atypical antipsychotic (4) Mixed state VPA/AAP Antidepressants (controversial, not monotherapy), only with mood stabilization first WM, HIV +. Manic and depressive mood episodes since age 20, many hospitalizations, strong FHx bipolar disorder Abuse of alcohol, stimulants, others, but in recovery at this time Maintenance lithium Comes to clinic for maintenance and monitoring He is on lithium 1200 mg per day What labs do you want for monitoring? Lithium level, Renal panel, TSH, Ca++ Liver enzymes Vitamin D Vitamin B12 Ammonia

6 ALWAYS renal panel with Li level No combo with NSAIDs, diuretics, ACE inhibitors Do not use in DM Caution re dehydration 68 WF, HIV+ stable in treatment, compliant No hx HIV dementia No vascular disease risk factors Insidious onset memory loss x 2 years Word finding problems, anomia, disorganized No depression/psychosis MoCA 20 Pleasant, circumstantial, perseverative, poor recall for recent > distant No psychosis/si/hi LOC full CT ventriculomegaly/atrophy/white matter disease Reassurance Avoid BZP/anti ACh/opioids Donepezil Memantine Antipsychotic

7 These psychiatric illnesses are common in primary care, including HIV population Primary care management with PRN psychiatric consultation can manage most of these Medication monitoring and toxicity management is an important part of outpatient care Philip et al. Expert Opin Pharmacother 2010; 11: Emul et al. Neuropsych Dis Treat 2015; 11: Vancampfort at al. World Psychiatry 2015; 14: Lally et al. Br Med Bull 2015; 114: Foussais et al. Can J Psychiatry 2010; 55: Chan et al. MJA Open 2012; 1Suppl4:44 47 Matsunaga et al. Int J Neuropsychopharm2015:1 11 Connolly et al. Prim Care Companion CNS Disord 2011; 13:PCC.10r1097 Gaynes et al. Psychiatric Serv 2009; 60: Healthnet.umassmed.edu/mhealth/HAMD.pdf Patient.info/doctor/generalised anxiety disorderassessment gad 7 Farukawa TA: J Psychosom Res 2010;68:581 9 Mitchell AJ: Curr Opinion Psychiatry 2012;25: