W1 The Psychiatry of AIDS Treisman

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W1 The Psychiatry of AIDS Treisman

  1. 1. Glenn Treisman MD PhD Johns Hopkins University
  2. 2. Disclosure of things that may have affected my views and this presentation <ul><li>I have accepted honoraria from Boehringer-Ingelheim for talks related to HIV and Psychiatry </li></ul><ul><li>I have been kicked off all the other drug company speakers lists because I will not use their slides </li></ul><ul><li>I still think this “Conflicts of Interest” thing is ridiculous, along with HIPAA and the insanity at the airports </li></ul><ul><li>I regularly accept payments from Johns Hopkins University </li></ul><ul><li>I think doctors are obligated to think critically </li></ul>
  3. 3. Objectives <ul><li>Is HIV a psychiatric epidemic? </li></ul><ul><li>Can we treat the psychiatric disorders that complicate the HIV epidemic? </li></ul><ul><li>Can clinicians integrate psychiatric treatment in to HIV treatment? </li></ul>
  4. 4. Prior research has shown that psychiatric patients <ul><li>Have increased risk of HIV </li></ul><ul><li>Are less likely to receive HAART </li></ul><ul><li>Are less likely to stay on HAART </li></ul><ul><li>Are less likely to get an undetectable viral load </li></ul><ul><li>Are more likely to die </li></ul>
  5. 5. More Rapid Discontinuation of ART in Depressed Persons Bangsberg DR et al. 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; December 16-21, 2001; Chicago, Ill. Abstract 1721. BDI  15 BDI  15-censored BDI<15 BDI<15-censored Months on highly active ART 70 60 50 40 30 20 10 0 Cumulative survival 1.0 .8 .6 .4 .2 0.0 P = 0.0001
  6. 6. Depression Decreases AIDS-Free Survival in Patients on ART <ul><li>HERS cohort: 765 participants </li></ul><ul><li>Longitudinal depression (CES-D): none, intermittent, chronic </li></ul><ul><li>Mortality predictors: depression, CD4 cell count, ART duration, age </li></ul>Ickovics JR et al. JAMA . 2001;285:1466-1474. Reprinted with permission. Total time in study (years) Cumulative survival 0 1 2 3 4 5 6 7 0.7 0.8 0.9 1.0 HIV-related mortality
  7. 7. DEFINITION OF GROUPS   Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463. Excluded Mental Disorder No Mental Disorder Mental Disorder Met 1 or 2 of 3 Criteria Psychiatric Diagnosis    Psychiatric Medication  Psychiatric Evaluation 
  8. 8. ASSOCIATION BETWEEN MENTAL D/O AND TIME TO HAART TIME IN YEARS PROBABILITY OF HAART THERAPY P=0.05 No Mental Disorder Mental Disorder 2 4 6 0 Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.
  9. 9. ASSOCIATION BETWEEN MENTAL DISORDER AND SURVIVAL TIME IN YEARS PROBABILITY OF SURVIVAL No Mental Disorder Mental Disorder P=0.10 Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.
  10. 10. Mental Illness depression demoralization substance abuse cognitive impairment AIDS impulsivity depression demoralization substance abuse cognitive impairment
  11. 11. HIV IS A PSYCHIATRIC EPIDEMIC <ul><li>HIV increases risk for psychiatric illness </li></ul><ul><li>psychiatric illness increases risk for HIV </li></ul><ul><li>effective treatment for psychiatric illness can improve patient outcome </li></ul><ul><li>effective treatment for psychiatric illness can decrease HIV transmission </li></ul>
  12. 12. Psychiatric disorders in new medical intakes <ul><li>Overall Axis I (non-substance abuse) 54 % </li></ul><ul><ul><li>Major depression 20 % </li></ul></ul><ul><ul><li>Adjustment disorder 18 % </li></ul></ul><ul><li>Substance Abuse 74 % </li></ul><ul><li>Cognitive Impairment 18 % </li></ul><ul><li>Personality disorder 26 %* </li></ul>* unpublished observation Lyketsos, C.G., Hutton, H., Fishman, M., Schwartz, J., Treisman, G. J ., Psychiatric morbidity on entry to an HIV primary care clinic. AIDS: 1996: 20(3): 131-144
  13. 13. The Four Perspectives McHugh and Slavney <ul><li>Disease </li></ul><ul><li>Temperament </li></ul><ul><li>Behavior </li></ul><ul><li>Life Story </li></ul>
  14. 14. Mental Illness depression demoralization substance abuse cognitive impairment AIDS impulsivity depression demoralization substance abuse cognitive impairment
  15. 15. Problems of life story <ul><li>An “assumptive” world </li></ul><ul><li>Assumptions provoke experience </li></ul><ul><li>Experience shapes assumptions </li></ul><ul><li>The medium of analysis of these experiences is “meaning” </li></ul><ul><li>Provides the “software operating system” for data and action </li></ul><ul><li>Can be “rescripted” or rewritten </li></ul>
  16. 16. Experience Meaning Assumption Behavior
  17. 17. Major Depression Demoralization (Depression in remission) Sub-syndromal Major Depression Dysthymia “ Minor Depression” “ Depressive Personality”
  18. 18. Differential Diagnosis of Depression DEPRESSION DELIRIUM DEMENTIA DEMORALIZATION
  19. 19. Depression diminishes <ul><li>Mood-the sense of baseline state of happiness that is usually present </li></ul><ul><li>Vital sense-the sense of being well, healthy, energetic, alert and able </li></ul><ul><li>Self Attitude-the sense of being good, of doing well, of effectiveness and utility to others </li></ul>
  20. 20. Anhedonia <ul><li>Loss of reward (pleasure, satiation or satisfaction) associated with behaviors </li></ul><ul><ul><li>Appetite Directed Behaviors </li></ul></ul><ul><ul><ul><li>Sleeping </li></ul></ul></ul><ul><ul><ul><li>Eating </li></ul></ul></ul><ul><ul><ul><li>Sex </li></ul></ul></ul><ul><ul><li>Function Directed Behaviors </li></ul></ul><ul><ul><ul><li>Work </li></ul></ul></ul><ul><ul><ul><li>Hobbies </li></ul></ul></ul><ul><ul><ul><li>Exercise </li></ul></ul></ul>
  21. 21. Disturbance of Neurophysiology <ul><li>Sleep </li></ul><ul><ul><li>EARLY MORNING AWAKENING </li></ul></ul><ul><ul><li>Difficulty falling asleep </li></ul></ul><ul><ul><li>Disrupted sleep architecture </li></ul></ul><ul><li>Appetite </li></ul><ul><ul><li>Change in food taste </li></ul></ul><ul><ul><li>Weight loss or gain </li></ul></ul><ul><ul><li>Immune function </li></ul></ul><ul><li>G.I. function </li></ul>
  22. 22. Depression stress demoralization CNS inflammation substance abuse subcortical injury cognitive impairment HIV impulsivity hopelessness carelessness demoralization substance abuse cognitive impairment
  23. 23. TIME OF AIDS DEPRESSION AS AIDS DEVELOPS MONTHS BEFORE AND AFTER AIDS P E R C E N T D E P R E S S E D 0 10 20 -48 -36 -24 -12 6 18 Lyketsos CG, et al. Am J Psychiatry. 1996;153:1430-1437.
  24. 24. Differential Diagnosis of Depression DEPRESSION DELIRIUM DEMENTIA DEMORALIZATION
  25. 25. Pharmacotherapy <ul><li>poor sleep </li></ul><ul><li>weight loss </li></ul><ul><li>anxiety </li></ul><ul><li>G.I. disturbance </li></ul>Desipramine Nortriptyline <ul><li>hypersomnia </li></ul><ul><li>weight gain </li></ul><ul><li>suicide potential </li></ul><ul><li>chronicity </li></ul>Citalopram Escitalopram Fluoxetine Paroxetine Sertraline Venlafaxine Desvenlafaxine Failure from side effects Lithium augmentation Combination Antidepressants Thyroid, Pindolol, Antipsychotic augmentation Failure after adequate trial NEXT DRUG Bupropion Nefazodone MAOI's Trazodone Mirtazepine Atomoxetine??
  26. 26. 0 100 DEMENTIA SUBSTANCE USE PERSONALITY DISORDER COMPLIANT OVERALL Full Partial None Treatment of Depression Outcome by Diagnosis Lyketsos, C. G., Fishman, M., Hutton, H., Cox, T., Hobbs, S., Spoeler, C., Hunt, W., Driscoll, J., Treisman, G. J ., The effectiveness of psychiatric treatment for HIV infected patients, Psychosomatics: 1997: 38:423-432
  27. 27. Mania HIV
  28. 28. CASE STUDY OF PATIENTS WITH HIV AND MANIA NEGATIVE HISTORY (N=7) 33.6 7 male 4 gay/2 IDU 6/6 all AIDS all POSITIVE HISTORY (N=7) 36.0 5 male 4 IDU/3 gay 2/7 2 AIDS/5 HIV+ none AGE SEX RISK FACTOR CD4<100 * STAGE * DEMENTIA * * p<0.05 by fisher's exact test
  29. 29. The Four Perspectives McHugh and Slavney <ul><li>Disease </li></ul><ul><li>Temperament </li></ul><ul><li>Behavior </li></ul><ul><li>Life Story </li></ul>
  30. 30. <ul><li>It is much more important to know what sort of patient has a disease than what sort of disease a patient has. </li></ul><ul><ul><ul><ul><ul><li>William Osler </li></ul></ul></ul></ul></ul>
  31. 31. Simplified model of disposition Percent of population <ul><li>Introversion </li></ul><ul><li>Punishment avoidant </li></ul><ul><li>Future directed </li></ul><ul><li>Function directed </li></ul><ul><li>Extraversion </li></ul><ul><li>Reward directed </li></ul><ul><li>Present directed </li></ul><ul><li>Feeling directed </li></ul>
  32. 32. <ul><li>Population-Disposition </li></ul>Introversion-Extroversion Stability- Instability
  33. 33. introversion extroversion stable unstable sanguine choleric phlegmatic melancholy
  34. 34. Motivated Behavior <ul><li>The cycle of drive </li></ul><ul><ul><li>Craving </li></ul></ul><ul><ul><li>Behavior </li></ul></ul><ul><ul><li>Reinforcement </li></ul></ul><ul><ul><li>Satiation </li></ul></ul><ul><li>Environmental Exposure </li></ul><ul><ul><li>Parental and societal input </li></ul></ul><ul><li>Biological Factors </li></ul><ul><ul><li>genetic contribution </li></ul></ul><ul><ul><li>? errors in drive, object specificity, or gross pathology </li></ul></ul>
  35. 35. Law of effect <ul><li>… probability of a behavior can be increased or decreased depending on its immediate consequence. Thorndyke 1913 </li></ul>
  36. 36. Behavior environmental exposure environmental response Behavior positive increase negative decrease
  37. 37. Internal “drive” (craving) Behavior Reward-Reinforcement Satiation environmental exposure environmental response temperament life experience disease Motivated Behavior
  38. 38. Internal “drive” (craving) Behavior Satiation environmental exposure environmental response temperament life experience disease Motivated Behavior Reward-Reinforcement
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