Mental Health Screening Tools for the HIV Clinician

Lawrence M. Mc Glynn MDClinical Associate Professor

Stanford University

Faculty Medical DirectorSan Jose AETC

June 2013

Thanks

Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center

American Psychiatric Association – Office of HIV Psychiatry

Goals for Participants Understand which mental illnesses

present themselves more frequently in HIV

Identify risk factors for mental illness in HIV

Become familiar with screening tools for conditions which may affect the overall health of people living with HIV/AIDS

Grab a pencil and some scratch paper

Close your door; turn off your cell phone; no checking your email; no sleeping; kick back and let’s learn together

Types of Screening Tools Patient focused

Self administered Usually consist of questionnaires

Clinician administered to patient Questionnaires Labs Imaging Examinations (physical and mental status)

Includes simple observation Observer(s)

Testimonials from family, friends, coworkers, other providers

Why screening tools?

Relative objectivity (provider bias) Efficiency Lack of resources

Mental health timely availability Shows the patient that you are

considering all aspects of his/her life

Cognitive Dysfunction

As HIV enters the CNS at a very early stage of infection, a cascade of events leads to changes in multiple realms of cognition

Neuropsychological Domains

Verbal/Language Attention/concentration Working Memory Executive/Abstraction Memory (learning, recall) Speed of information processing Sensory-perceptual Motor skills

Associated Behavioral Disturbances

Apathy Depression Sleep disturbance Agitation/Mania Psychosis

HAND Classification

Asymptomatic NeurocognitiveImpairment (ANI)

Mild NeurocognitiveImpairment (MNI)

HIV-Associated Dementia (HAD)

No Functional Impairment

Mild Functional Impairment

Moderate to Severe Functional Impairment

1 SD

2 Domains

2 SD

2 Domains

NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

1 SD

2 Domains

Prevalence of HAND based on New Criteria

NP Normal

(30-60%)

MNI

(20-30%)HAD

(5-20%)

Functional Impairment

ANI

(20-30%)

NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

Risk and Protective Factors

Risk factors Age > 50 Survival duration Lower nadir CD4 T-cell counts Higher baseline viral load Gender (F)

Why Bother to Screen? MNI has been associated with poorer health

outcomes, possibly due poorer adherence to medications

Even mild HAND is associated with worse quality of life, difficulty obtaining employment and shorter survival

McGuire, Goodkin, and Douglas report that HAND independently predicts systemic morbidity and overall HIV mortality

Consider screening upon the initiation of cART and q6-12 months

Mind Exchange Working Group. CID Advance Access. Nov 2012.

The role of objective assessment General Practitioners ability to pick up dementia cases

Sensitivity 51.4% (“positive in disease”) Specificity 95.9% (“negative in health”)

Missed dementia more frequently in patients living alone

Over-diagnosed dementia more frequently in patients with mobility/hearing problems, and in the depressed

Miss nearly half of incident dementia cases Possible factors: GPs’ subjective views on dementia

(e.g., therapeutic nihilism, or suspected/feared stigmatization)

Conclusion: use objective tests

Pentzek M, Wollny A, Wiese B, et al. Apart from Nihilism and Stigma: What Influences GP’s accuracy in identifying incident dementia? Am J Geriatr Psychiatry 17:11, November 2009.

Screening Tools MMSE (not very sensitive, Crum et al.,

1993) HIV Dementia Scale (Power et al., 1995) International HIV Dementia Scale

(Sacktor et al., 2005) Montreal Cognitive Assessment (MoCA,

Overton et al. CROI 2011) MOS-IV

International HIV Dementia Scale (IHDS)

1. Memory-Registration

Give four words to recall (dog, hat, bean, red) – 1 second to say each.

Then ask the patient all four words after you have said them. Repeat words if the patient does not recall them all immediately. Tell the patient you will ask for recall of the words again a bit later.

2. Motor Speed

Have the patient tap the first two fingers of thenon-dominant hand as widely and as quickly aspossible.

4 = 15 in 5 seconds3 = 11-14 in 5 seconds2 = 7-10 in 5 seconds _____1 = 3-6 in 5 seconds0 = 0-2 in 5 seconds

3. Psychomotor Speed

Have the patient perform the following movements with the non-dominant hand as quickly as possible:

1) Clench hand in fist on flat surface. 2) Put hand flat on surface with palm down. 3) Put hand perpendicular to flat surface on the side of the 5th digit. Demonstrate and have patient perform twice for practice.

4 = 4 sequences in 10 seconds3 = 3 sequences in 10 seconds2 = 2 sequences in 10 seconds1 = 1 sequence in 10 seconds _____0 = unable to perform

4. Memory-Recall

Ask the patient to recall the four words. For words not recalled, prompt with a semantic clue as follows:

animal (dog); piece of clothing (hat); vegetable (bean); color (red).

Give 1 point for each word spontaneously recalled. Give 0.5 points for each correct answer after

prompting

Maximum – 4 points. _____

Total International HIV Dementia Scale Score

This is the sum of the scores on items 1-3. ____

The maximum possible score is 12 points.

A patient with a score of 10

should be evaluated further for possible dementia.

HIV Dementia ScaleMAXIMUM SCORE

PATIENT SCORE

TEST

    MEMORY - REGISTRATIONGive 4 words to recall (dog, hat, green, peach) and 1 second to say each. Then ask the patient to repeat all 4 after you have said them.

4   ATTENTION/EXECUTIVE FUNCTIONAntisaccadic eye movements (20 commands): ____ errors out of 20 3 errors = 4; 4 errors = 3; 5 errors = 2; 6 errors = 1; 6 errors = 0

6   PSYCHOMOTOR SPEEDAsk patient to write the alphabet in uppercase letters horizontally across the page (use back of form) and record time: _____ seconds 21 sec = 6; 21.1-24 sec = 5; 24.1-27 sec = 4; 27.1-30 sec = 3; 30.1-33 sec = 2; 33.1-36 sec = 1; 36 sec = 0

4   MEMORY - RECALLAsk for the 4 words from MEMORY – REGISTRATION TEST above.Give 1 point for each correct. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); color (green); fruit (peach). Give ½ point for each correct word after prompting.

2   CONSTRUCTIONCopy the cube below. Record time _____ seconds 25 sec = 2; 25-35 sec = 1; 35 sec = 0

Adapted From: Power C et al.: HIV Dementia Scale: a rapid screening test. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1995;8:273-278. Used with permission.

Total score < 10: HAD 11-13: Mild cognitive impairment

Modified HIV Dementia ScaleMax Score

Pt. Score Task

Memory-Registration Give four words to recall (dog, hat, green, peach) - 1 second to say each. Then ask the patient all 4 after you have said them.)

6Psychomotor Speed Ask patient to write the alphabet in upper case letters horizontally across the page below and record time: ____ seconds.less than or equal to 21 sec = 6; 21.1 - 24 sec = 5; 24.1 - 27 sec = 4; 27.1 - 30 sec = 3; 30.1 - 33 sec = 2; 33.1 - 36 sec = 1; > 36 sec = 0)

4Memory - Recall Ask for 4 words from Registration above. Give 1 point for each correct. For words not recalled, prompt with a "semantic" clue, as follows: animal (dog); piece of clothing (hat), color (green), fruit (peach). Give 1/2 point for each correct after prompting

2 Construction Copy the cube below; record time: ____ seconds.(< 25 sec = 2; 25 - 35 sec = 1; > 35 sec = 0)

Total ScoreMax= 12

/12

< 7.5 may indicate dementia and should be evaluated by full battery if possible

MOCA

MOCA

MOCA

MOCA

MOCA

Cognitive Functional Status Sub-scale of MOS-HIV Scale of Wu et al.

4 questions, past 4 weeks: 1. Difficulty reasoning/problem solving? 2. Forget things (location; appointment)? 3.Trouble with keeping attention for long? 4. Difficulty with activities using

concentration / thinking? 6 pt. frequency scale: 1= all; 2=most; 3=good

bit; 4=some; 5=little; 6=none [cutoff < M= 4] Validated against NP overall

performance in the Netherlands; Good for busy clinicsKnippels, Goodkin, Weiss, et al., AIDS, 2002;16:259-267

Mathematical Screening

Cysique et al. Cognitive impairment is predicted to

occur when this expression is true

Step 1: Neuropsych performanceStep 2: Functional Impairment?

How To Assess Functional Impairment? Collateral Informant and

Objective ratings are most reliable IADL scale (Lawton) Driving Performance (Marcotte et

al.) Karnofsky, Finances, Medications

What to do with a positive screen?

Rule out other causes Always consider the biopsychosocial

model Treatment

Antiretrovirals Psychostimulants Other treatments being studied

Depression and Anxiety Depressed mood is one of the most

common complaints among people living with HIV

Given the high co-occurrence of HIV and PTSD, anxiety is also frequently seen

These disorders may present themselves as somatic complaints Headaches, GI complaints, weakness, fatigue,

insomnia, chest pain, shortness of breath Somatic complaints are not unusual in HIV/AIDS

even when the patient is mentally healthy

Epidemiology-Anxiety

15.8% of HIV+ have GAD (2.1% of general population

10.5% have Panic d/o (2.5% of gp) 37% of HIV+ women report “high

anxiety” Protective: relationship, older, vl BDL

Epidemiology-Depression

Lifetimes prevalence of depressive disorder in HIV as high as 22% (5-17% in general population)

Risk: African-american (M and W), MSM

Why Bother to Screen?

Depression in HIV/AIDS is a significant predictor of worsening overall outcome

Depression and anxiety can contribute to poor cognitive functioning

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 Are you depressed?

Anxiety questions

•I feel tense or wound up•I get a sort of frightened feeling as if something bad is about to happen•Worrying thoughts go through my mind•I can sit at ease and feel relaxed•I get a sort of frightened feeling like butterflies in the stomach•I feel restless and have to be on the move•I get sudden feelings of panic

•Cutoff score: 8

Depression Questions

•I still enjoy the things I used to enjoy•I can laugh and see the funny side of things•I feel cheerful•I feel as if I am slowed down•I have lost interest in my appearance•I look forward with enjoyment to things•I can enjoy a good book or radio or TV program

•Cutoff score: 8

"Are you depressed?" Screening for depression in the terminally illAm 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

PHQ-9

What to do with a positive screen?

Assess for suicidality R/o other causes (biopsychosocial

model) Refer to treatment (talk, med’s)

Suicidality

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 STDsVolume 26, Number 5, 2012

Risk

History of suicide attempt(s) Diagnosable mental health

disorder History of psychiatric treatment Substance use Anxiety sensitivity – cognitive

concerns

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?

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

SBQ-R (Osman et al)

What to do with a positive screen?

Hospitalize For those deemed to be able to go

home F/U asap; telephone contact (to/from) Urgent referral to mental health

PTSD Screening

The estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8–42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women

PC-PTSD

What to do with a positive screen

Screen for depression, anxiety, domestic violence, substance abuse and suicidality

Refer to mental health Therapy Medications based on symptoms

Substance abuse

Epidemiology

Only 19% of those with HIV had never used an illicit drug

1 in 4 of those with HIV in the USA report alcohol or drug use at a level warranting treatment

Why Bother to Screen?

Active substance use can lead to increased morbidity and mortality

Substances can interact with HIV medications

Screening Tools

Physical Exam Mental Status Exam CAGE questionnaire

CAGE

What to do with a positive screen? Establish safety

Prescribed medications which may pose a risk

Concurrent illnesses (e.g., HCV) Home, transportation Family responsibilities (children,

elderly) Discuss treatment options

Have referral information on hand

Domestic Violence

Facts For HIV+ women, the estimated rate of intimate partner

violence is 55.3% (95% CI 36.1–73.8%), which is more than twice the national rate. Early childhood abuse predicts future domestic violence (Machtinger et al)

Among MSW with HIV, childhood sexual abuse predicted post-traumatic stress disorder (PTSD), and less trust in medical providers (Whelten et al)

MSM with HIV and PTSD are more likely to miss appointments (Traeger et al)

Victims may be less likely to leave abusive situation In a sample of HIV+ individuals, 20.5% of the women,

11.5% of the MSM, and 7.5% of the MSW reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes (Zierler, Bozzette, et al)

Why Bother to Screen?

Safety of patient Safety of others

Family Friends Staff

Screening Tools

http://www.cdc.gov/ncipc/pub-res/images/ipvandsvscreening.pdf

What to do with a positive screen?

Assess for current safety Document Refer

Safe shelter Mental health

Report

The Great Imitators

Screen for other conditions which may mimic psychiatric disorders Hepatitis C - lab Syphilis - lab Drug Interactions – Pharm.D., website Adherence challenges Medication Adverse Effects Malnutrition/Dehydration

Axis II Flags

“Everyone” “No one” “Always” “Never”

The End

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