Becoming a TB Nurse Expert San Antonio, Texas July 30-31, 2008 Psychosocial Factors in a TB Patient Adriana Vasquez, MD July 30, 2008 TUBERCULOSIS and MENTAL ILLNESS Adriana Vasquez, MD Staff physician at TCID 1
Bipolar disorder Case presentation # 1 48y/o Caucasian man with AIDS, HCV, seizure disorder, several head injuries post an assault. Reported personality changes since 1999 History of cocaine and alcohol dependence, IVDU methamphetamine use Diagnosed with PTB May 2006, isolate resistant to INH, ethionamide, levofloxacin, ofloxacin, moxifloxacin TB treatment as outpatient complicated by elevated liver function test, multiple drug-drug interactions 2
Case presentation #1 Several treatment interruptions due to abnormal LFT s TB meds. were discontinued on 1/8/07 because LFT s 8 times normal Taking xanax 0.5mg PO TID and trazodone 150 mg at bed time prn, as outpatient prescribed by primary care provider. Was drinking when felt depressed Had prior psych evaluation but did not follow through 1/29/07 admitted to TCID Mental status assessment Described himself as anxious with mood swings, including long bursts of depression and periods of insomnia, Rapid thoughts, distractibility, being pushy, poor impulse control (at one time had $100k credit card debt and filed bankruptcy). Had prior suicide attempt as young adult 3
Mental status assessment Groomed, high kinetics, cooperative Speech: pressure, quite hyper verbal, flight of ideas, difficult to obtain a clear history from Mood: anxious. Psych diagnosis and treatment Diagnosed with Bipolar disorder Psychiatrist recommended to DISCONTINUE trazodone as this can contribute to mania symptoms and xanax Zyprexa was initiated as mood stabilizer (less interactions with some of his meds ) 4
Response to treatment Less anxious, calmer, normal speech, no flight of ideas, happier Insomnia resolved Weight gain, 12 lb in six weeks Decrease Impulsivity Able to make better choices life and health wise Good compliance with tb and medical treatment Better judgment No alcohol or substance abuse incidents Case presentation # 2 26y/o Caucasian, homeless female with h/o bipolar disorder, off psychotropic medications for 2 years Reported personality changes since age 20 Used crack, cocaine, ETOH every day for 18 months prior to TCID hospitalization Delivered a healthy baby 9/2006 5
Case presentation # 2 Complained of fever, cough, anorexia, weight loss during last trimester of pregnancy CXR post partum bilateral cavitary infiltrates Diagnosed with pansusceptible Tb 10/2007 Admitted to TCID 12/2007 for TB treatment in the setting of HOMELESNESS, UNTREATED MENTAL ILLNESS AND SUBSTANCE ABUSE Mental status assessment Reported episodes of depression, tearful, low energy alternating with episodes of spending money irrationally and feeling every thing was good Groomed, cooperative, high kinetics Speech: pressure, hyper verbal, Mood: anxious 6
Psychiatric treatment Patient required regular psychiatric evaluations and medication adjustments throughout hospitalization Was started on depakote ER as mood stabilizer to prevent mania/depression Depakote serum levels were followed and doses adjusted accordingly Patient was actively involved in substance abuse treatment, AA meetings since hospital admission Response to treatment Was sobered and intended to remained sober after hospital discharge Mood swings resolved Good compliance with tb and psychiatric treatment Weight gain, 40 lb Completed in-patient Tb treatment successfully Obtained full time job upon TB treatment completion. Employer described her as a very hard worker, responsible and efficient. 7
BIPOLAR DISORDER Is a mood disorder characterized by mood swings from mania to depression, which have a tendency to recur and subside spontaneously. Mood swings may be cyclic, often starting with mania that ends in deep depression Symptoms of Depression Prolonged sadness Significant changes in appetite and sleep patterns Irritability, anger, worry, agitation, anxiety Pessimism, indifference 8
Symptoms of Depression Loss of energy Feelings of guilt, worthlessness Inability to concentrate Unexplained aches and pains Recurring thoughts of death and suicide No pleasure on activities enjoyed previously Symptoms of mania Increased physical and mental activity and energy Exaggerated optimism and self-confidence Excessive irritability, aggressive behavior Decreased need for sleep without fatigue inflated self-esteem Excessive irresponsible behavior pattern Increased social or sexual activity 9
Symptoms of mania Impulsiveness, poor judgment, distractibility Flight of ideas Excessive involvement in pleasurable activities with painful consequences (spending, unsafe sex with multiple partners, alcohol and drugs) False beliefs (delusions) Hallucinations Diagnosis of Bipolar Disorder Psychiatric history of mood swings Observation of current behavior and mood are critical in diagnosing this disorder Obtaining information from family members regarding patient s behavior Physical exam and lab tests (thyroid and drug screen) may be performed to rule out other causes for the symptoms. Patients are at increased risk of substance abuse 10
Treatment of Bipolar Disorder Hospitalization may be required to control symptoms and for the safety of the patient Mainstay of treatment are mood-stabilizing medications ( valproic acid, lithium, carbamazepine) which are effective for both the manic and depressive phases as well as in preventing recurrence. Treatment of Bipolar Disorder Mood stabilizers should be given before antidepressants to prevent mania Psychotherapy 11
Prognosis Mood stabilizing medications can prevent recurrence of symptoms Patients often stop psychotropic medications as soon as they feel better Suicide in both phases is a real risk Complications Disruption of relationships, work and finances Alcohol and substance abuse are common 12
SCHIZOPHRENIA Case presentation # 3 55 y/o white male with schizophrenia Resides at boarding home in Medina County, site of a recent TB outbreak 70 pts newly diagnosed with LTBI, 4 TB suspects, 2 active cases (treated at TCID) Positive PPD, cavitary infiltrates on CXR, sputum AFB smears and cultures from 4/06 positive for mtb, pan susceptible 13
Case presentation # 3 Started on RIPE 4/06 as outpatient Refused ALL RIPE doses for 6 weeks Admitted to TCID 6/2/05 under court order for TB treatment in the setting of severe mental illness Mental status assessment Very delusional (false beliefs ) Delusions varied in nature Grandiose ( wealth) Paranoid (Patient reported being poisoned by medications, people stealing his ideas and working with the CIA on a plot to kill him) 14
Mental status assessment Speech: hyper verbal, high volume Mood: mildly elevated No suicidal or homicidal ideation Distractible Psychiatric diagnosis and treatment Chronic schizophrenia, psychosis Unlikely to become substantially less psychotic given duration of illness and compliance issues Required 3 psychiatric evaluations during first month at TCID Required several adjustments on psychotropic meds 15
Hospital course Refused CXR, blood draws, medications, sputum multiple times You are killing me with so many pills I do not have TB I will get bruises, gangrene if I give blood I will get lung cancer, brain cancer if I get a CXR You are putting LSD on the food Complications of TB treatment AST, ALT 14 times above normal 8 weeks after admission while on Rifampin, PZA, INH (refused monthly blood work for 2 months) Was treated with a liver friendly regimen ( IM amikacin, levofloxacin and ethambutol) for 5 months Never had a CXR done during 10 months hospitalization at TCID Nurses offered TB meds Multiple times until he finally took them Refused sputum samples first 3 hospital months 16
Complications of TB treatment Security had to be called on several occasions before blood draws, IM injections to back up staff Treatment outcome With time, patient became more compliant with TB medications, procedures (giving sputum, blood samples) Remained delusional througout hospitalization Completed in-patient TB treatment successfully 17
What is schizophrenia? Chronic, severe, disabling brain disorder Interferes with a person s ability to think clearly, distinguish fantasy from reality, manage emotions, make decisions and relate to others Affects 2 million American adults Affects 1% adults older than 18 Symptoms of schizophrenia Positive Symptoms Negative Symptoms Cognitive Symptoms 18
Positive Symptoms Hallucinations and delusions ( lost of contact with reality). Delusions are false beliefs, others are reading their minds and plotting against them Hallucinations is something a person sees or hears that no one else can see or hear, patients hear voices that order them to do things. Catatonic Schizophrenia 19
Negative symptoms Flat affect (immobile facial expression) Lack of pleasure in everyday life Diminished ability to initiate and sustained planned activities Speak infrequently Neglect basic hygiene, need help with every day activities. Cognitive Symptoms Problems with working memory Inability to sustain attention Poor executive functioning (ability to absorb, interpret and make decisions based on information given) 20
DEPRESSION Case presentation # 4 30 y/o hispanic male, alcohol dependent, admitted to TCID for recurrent PTB 2006 Treated for TB for 9 months 2002 History of alcohol related seizures, withdrawal, delirium Had severe anorexia, generalized weakness 21
Hospital course Loss 8 lb (wt down from 100 to 92 lb) during first 2 hospital months Disliked hospital food and refused to eat it Refused to get out of the room kept the room dark Was very quiet Mental Status Evaluation Cachectic, alert, oriented x 3 Denied sadness, crying spells, suicidal ideation Admitted anorexia, anhedonia (no pleasure on activities enjoyed previously) 22
Diagnosis and Treatment Depression Alcohol dependence Remeron 30 mg PO daily Response to treatment Appetite improved, gained about 25 lb Became more active Interacted more with other patients and staff ( asked the staff how are you doing today) Looked happier Better understanding of disease process and importance to take TB treatment until completion 23
Symptoms of Depression Loss of energy Feelings of guilt, worthlessness Inability to concentrate Unexplained aches and pains Recurring thoughts of death and suicide No pleasure on activities enjoyed previously Significant changes in appetite and sleep patterns Prolonged sadness Treatment Serotonin reuptake inhibitors Remeron, has appetite stimulant effect useful in cachectic patients with chronic illnesses such as tuberculosis 24
Conclusion Every TB patient needs a good mental status assessment Mental illness leads to unemployment, substance abuse, homelessness and TB Failure to diagnose and treat mental illness leads to poor compliance and TB treatment failure Hospitalization is often required to successfully treat patients with mental illness and TB 25