Clinical Education Initiative Support@ceitraining.org INTRODUCTION TO HIV PSYCHIATRY Speaker: Hansel Arroyo, MD 3/1/2017
Introduction to HIV Psychiatry [video transcript] 00:00:07 - So we're gonna be talking about, sort of like an introduction to HIV psychiatry. I know I have a little bit less time. I'm happy to go over anything in particular. 00:00:19 I have nothing to disclose. Some of the objectives are to understand the central role of psychiatric issues in the assessment, presentation, and management of individuals with HIV. Describe some of the clinical manifestations and be familiar with some of the theories of biological underpinnings. 00:00:36 Why is it that we talk, I tell this to my residents, fellows, why is it that we talk about HIV psychiatry? And the main reason is that we see a higher prevalence in the general population of psychiatric disorders, specifically depression, mania, and anxiety, so the mood disorders, at a higher rate, around 60% more, so in the general population we're around the 30%. And this has direct effects on things like adherence to ART, a very lower quality of life, higher healthcare costs, increased risk of suicide, especially with depression, more rapid progression of HIV, that's been reported, worse health outcomes, and increased mortality. 00:01:21 The good thing is that, you know, even for the case that we were discussing just now, is that patients who do engage in mental health services, where there is something as supportive therapy, psychotherapy, or med management, actually do better, right? Their adherence to ART is improved, and some studies even document those as much as double, are twice as likely to be more adherent to med regiments. 00:01:51 So, I want us to think of psychiatric disorders in this context, not just the psychological components of it, but more of the biological components of how is HIV actually causing, promoting, perpetuating psychiatric disorders, or the other way around, right? So we see that, early on, we have CNS penetration of the virus, we have a separate reservoir of virus in our central nervous system. And we don't go tapping patients, unless there's a specific indication, but we do know that peripheral viral load and CNS viral load, opposite there tends to be some difference at times. Then also the virus has some predilections for subcortical structures, so once it enters the CNS, it'll have predilections for subcortical structures, mostly basal ganglia, which means that patients may develop things like difficulty with executive functioning, and that's really crucial because executive functions are the ability to plan and be able to complete tasks. So it's not surprising that, especially in my experience, that perineum infected will have difficulty with keeping appointments, taking their medication, being able to organize themselves, especially in the teen years, or your frontal lobe is not super developed, and then on top of 1
that you have subcortical structure damage or can have subcortical structure damage. This also involves other things like movement disorders, that we see in HIV dementia. 00:03:30 One of the most common conditions that we see, delirium, HIV-associated dementia, the most common really are major depressive disorder, bipolar disorder. There used to be this thing called AIDS mania, it's more common in the 80s and 90s, it's really not well-reported anymore. I've never seen it, but it was, in the absence of having a history of bipolar disorder or a family history of mood disorder, patients in the late stages of AIDS would develop manic-like symptoms. It would be chronic and non-remitting. We also see schizophrenia, we also see lots of substance abuse, anxiety, and PTSD. These are the most common psychiatric diagnoses. 00:04:13 I'm just going to go over depression, the mood disorders, and the psychotic disorders, just as a summary. We see that HIV creates a risk of depression. When there's direct damage to the subcortical brain areas, or through chronic stress, chronic stress raises your basal cortisol level, which changes the volume in your amygdala, which then can, is linked to depressive states. You see up to 2.5 fold increase in rates of depression. And also, for us to think of depression as a vector for HIV, a risk for HIV transmission. And that, I mean, patients are more likely to engage in risk behavior, use controlled substances, have problems negotiating, using protection if they are depressed or anxious, or psychotic. So let's think of psychiatric disorders as a vector. 00:05:13 Mania, I mentioned AIDS mania before, which is less common, but bipolar disorder, there is a higher, it's like one or two percent in those living with HIV, and then up to eight percent in those with AIDS. It's more associated with lower CD4 counts as well. 00:05:32 Anxiety, higher risk of anxiety, up to, prevalence, 10 to 72 percent, general anxiety disorder, panic disorders. Anxiety has been very closely linked to, also, increased basal cortisol levels, which causes decreasing immune function, disruption of your HPA axis, decreased adherence, increased risky behavior, and increased substance abuse. Patients tend to self-medicate, especially if they're having anxiety that is more chronic and not like point anxiety. 00:06:10 Psychosis, psychosis can be primary or secondary. When I say psychosis, I mean schizophrenia, I mean schizo affective disorder. Schizophrenia contributes to high-risk behavior, whether it's to engage in unprotected sex, trade sex for money, sex while intoxicated. Schizophrenia has a high risk of suicide, and I think I'm going to mention the last point here, which is, it's been reported where people living with HIV have a tendency to have more extrapyramidal side effects from antipsychotics. So these are your Seroquels, Abilify, Haldol, medications that are commonly used to treat psychosis and bipolar disorder, cause these medications essentially block dopamine in the subcortical areas which are already 2
somewhat affected, and they tend to develop tardive dyskinesia or EPS. So in the case that we were discussing, you would have to go to higher doses of Seroquel to be able to treat the specific symptoms, but you would also have to monitor for rigidity, cogwheeling, and other movement disorders that could develop. 00:07:21 We always have to rule out other conditions that could mimic psychiatric conditions, whether it's medications, we know that Efavirenz has, 50% of patients will develop some neuropsychiatric symptoms. We have to rule out CNS malignancies, opportunistic infections, drugs. 00:07:45 And so I think for this part of the talk, I want to use depression as a model for psychiatric disorders, and see how, what is, these morphistic correlations between patients living with HIV and psychiatric disorder. 00:08:03 We know the cardinal symptoms of depression, decreased mood, low energy, then we have what we call the neurovegetative symptoms of depression, which are poor energy, fluctuations in sleep, appetite, somatic body functions. A lot of patients come into the office complaining of headaches and abdominal pain, and you do a full assessment, it turns out that it's just a depressive episode occurring. Fatigue, fatigue is important. Fatigue is actually associated more with depression than HIV disease progression. So if a patient continuously complains of fatigue, that should raise a flag for whether a depressive episode is actually happening. 00:08:42 Other than the things I mentioned, like increased basal cortisol levels and subcortical structure damage, depression, or HIV, can cause other things, like lower testosterone levels, that can present itself like depression. Posterior pituitary function is often abnormal, which creates an affinity for SIADH. All of our SSRIs can cause SIADH, that's something to be mindful about. 00:09:08 I mentioned the elevated basal cortisol. Okay, so two minutes left. So there's this connection, there's biological components for psychiatric disorders. Is it the genes, is it the environment, is it stress, is it all of it? 00:09:27 And some of the newer data has demonstrated that, depression, we think of, now, depression as sort of this chronic inflammatory disease, and Dr. Silvia Alboni, she's doing this research in Europe right now in which they've linked HIV itself as a chronic inflammatory disease, activating cytokines, activating hemokines, that are closely linked to developing things like depression and anxiety. 00:10:05 3
So we've associated interleukin 18, which is closely associated with depression, with schizophrenia, with anxiety, and it's just sort of activated through chronic states of stress. So these are some of the ideologies that we're now associating with HIV and psychiatric disorders. 00:10:26 We're thinking of it as sort of a chronic state of inflammatory stress. So here we see, what is this cycle, why does psychiatry, has to be, or should be, closely involved with the care of a lot of our patients? Because psychiatric conditions can increase impulsivity, risk behavior, substance abuse, cognitive impairment, poor adherence, which can either be a vector for HIV transmission, it could be a vector for HIV acquisition, which also has its effect on the body. And it can cause demoralization, decrease quality of life, social isolation, more substance abuse, more cognitive impairment. 00:11:08 I guess this last slide, I kind of really powered through that. This last slide, I also don't want to diminish the other more psychological effects of HIV, that HIV can have, more psychodynamic themes that are not uncommon during sessions, of shame, guilt, feeling dirty, development of adjustment disorders, bereavement, the loss of one's health, the loss of an ideal future, fatigue, suicide, and insomnia's very common. [Dr. Urbina] - Thank you very much for that overview. [end] 4