Didactic Series. Depression in HIV/AIDS

Transcription

1 Didactic Series Depression in HIV/AIDS Lawrence M. Mc Glynn MD Clinical Associate Professor Stanford University School of Medicine San Jose AETC July 11, 2013 ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. 1

2 Learning Objectives 1) Etiology of depression in HIV/AIDS 2) Screening tools and creating the differential diagnosis 3) Treatment choices 2

3 Indirect Mechanisms of HIV Neuropathology Kaul, Garden and Lipton, Nature, 2001

4 HIV Effects in Subcortical Regions

5 Mood Disorders in HIV Clinical depression affects up to 22% of HIV+ patients Huge variations depending on population and presence of co-occurring substance abuse Dysthymia % prevalence Bipolar I % prevalence Orlando M, Burnma M, Beckman R, et al. Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV. Int J Methodsd Psychiatr Res 2002;11: Moore DJ, Posada C, Parikh M, et al. HIV-Infected Individuals with Co-occurring Bipolar Disorder Evidence Poor Antiretroviral and Psychiatric Medication Adherence. AIDS Behav. 30 October 2011.

6 HIV in Mood Disorders General population % prevalence of HIV in USA Unipolar Depressive Disorders: 1.4% Bipolar Disorder: Up to 10% Beyer JL, Taylor L, Gersing K, et al. Prevalence of HIV Infection in a General Psychiatric Outpatient Population Psychosomatics 2007; 48: Moore DJ, Posada C, Parikh M, et al. HIV-Infected Individuals with Co-occurring Bipolar Disorder Evidence Poor Antiretroviral and Psychiatric Medication Adherence. AIDS Behav. 30 October 2011.

7 Why Bother to Screen? Depression in HIV/AIDS is a significant predictor of worsening overall outcome Depression can contribute to poor cognitive functioning

8 MDD Criteria Specific symptoms, at least 5 of these 9, present nearly every day: Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) Decreased interest or pleasure in most activities, most of each day Significant weight change (5%) or change in appetite Change in sleep: Insomnia or hypersomnia Change in activity: Psychomotor agitation or retardation Fatigue or loss of energy Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt Concentration: diminished ability to think or concentrate, or more indecisiveness Suicidality: Thoughts of death or suicide, or has suicide plan

9 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 PHQ Are you depressed?

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11 PHQ-9

12 "Are you depressed?" Screening for depression in the terminally ill Am 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

13 What to do with a positive screen? Assess for suicidality

14 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

15 Risk History of suicide attempt(s) Diagnosable mental health disorder History of psychiatric treatment Substance use

16 Why Bother to Screen? Safety Establish a longitudinal record Suspicion of suicide can elicit emotions in the provider Is emotional decision making as precise as less emotion-based thinking?

17 Screening Tools Will you be able to sleep tonight? Multiple factors to consider which make screening a challenge Substance use Psychosocial stressors Temporal relationship to medications (e.g., efavirenz, IFN-α) Medical illness

18 SBQ-R (Osman et al)

19 What to do with a positive suicide screen? Hospitalize and continue workup For those deemed to be able to go home F/U asap to maintain continuity Telephone contact (to/from) Urgent referral to mental health Continue workup filling in gaps to complete the differential diagnosis

20 The Differential Diagnosis The creation of this crucial picture can involve the entire group

21 Causes of apparent mood changes in HIV Let s Think Primary Psychiatric Disorder (any axis) Acquired Medications (+/- prescribed) Illness (Consider HIV-related as CD4 drops) Infectious, inflammatory, metabolic, neoplastic, neurologic, idiopathic, toxin exposure Head/brain Injury (including CVA) Psychological causes Socioeconomic causes Combination of the above - biopsychosocial

22 Approaching the DDx Let s Act Medical work-up required Records review (establish temporal relationship) Psychosocial history Family history

23 Work-up (continued) Metabolic Sources Renal Hepatic (LFTs, ammonia level) Dyslipidemia Vitamin deficiencies (B12) Endocrine (testosterone, thyroid, DM) Hematologic Anemia

24 Work-up (continued) Infectious Periphery: WBC+diff, RPR, Hepatitis C, HIV viral load, tuberculosis, MAC UA Stool studies LP (including cryptococcal Ag, VDRL, Tb, JCV, EBV, CMV, HIV viral load CXR if indicated (e.g., hypoxemia) Imaging (MRI>CT) EEG if indicated

25 Rule-out (continued) Toxicities Efavirenz, zidovudine, IFN-α, corticosteroids Benzodiazepines, opioids Substance abuse (meth, alcohol, etc.) Drug-drug interactions

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28 Diagnosis Dictates Treatment Mood disorder due to <substance of choice> Consider substance abuse treatment Mood disorder due to <illness> Consider monitoring +/- mental health intervention and reassessing mood while illness is being treated Primary psychiatric disorder

29 How are people with HIV/AIDS and mood disorders viewed and treated across cultures? Cultural food for thought How are mood changes viewed?? Ethnic differences in mood treatment Who takes medications or uses psychotherapy? Who uses alternative therapies? eastern medicine, curanderos, herbals, acupuncture

30 Treatment Medications (mood +/- anxiety +/- psychosis) Therapy Exercise Diet Cosmetic Alternatives to Western Medicine

31 Pharmacotherapy - Depression SSRIs Paroxetine, fluoxetine most tested Fewest drug-drug interactions with citalopram, escitalopram SNRIs Venlafaxine, duloxetine Tricyclic antidepressants Imipramine, desipramine tested Side effects and interactions challenge their ease of use Mirtazapine, Bupropion may provide efficacy Stimulants (methylphenidate, dextroamphetamine)

32 Pharmacotherapy Bipolar Disorder Mood Stabilizers Lithium May provide neural protection in the brain Caution when administered with tenofovir Anticonvulsants Lamotrigine may benefit those with co-occurring neuropathy Valproic acid may cause anemia when administered with zidovudine Carbamazepine may cause deleterious drug-drug interaction and decreased white blood cell count Neuroleptics Caution with metabolic syndrome and cardiac conduction Caution with typical antipsychotics and extrapyramidal side effects

33 Prevention and Prophylaxis Antiretroviral and other medication selection Nutrition Psychotherapy Social support Exercise

34 Conclusions Mood disorders have a high prevalence among HIV+ patients Diagnosis involves ruling out a number of commonly cooccurring conditions Effective treatments are available Many patients living with mood disorders in poverty, rural areas, or of other cultures may go unnoticed and untreated

35 References Training materials and resources HIV Psychiatry Substance Abuse Drug Interactions