w1 the psychiatry of aids treisman
TRANSCRIPT
Glenn Treisman MD PhDJohns Hopkins University
Disclosure of things that may have affected my views and this presentation
I have accepted honoraria from Boehringer-Ingelheim for I have accepted honoraria from Boehringer-Ingelheim for talks related to HIV and Psychiatrytalks related to HIV and Psychiatry
I have been kicked off all the other drug company speakers I have been kicked off all the other drug company speakers lists because I will not use their slideslists because I will not use their slides
I still think this “Conflicts of Interest” thing is ridiculous, I still think this “Conflicts of Interest” thing is ridiculous, along with HIPAA and the insanity at the airportsalong with HIPAA and the insanity at the airports
I regularly accept payments from Johns Hopkins I regularly accept payments from Johns Hopkins UniversityUniversity
I think doctors are obligated to think criticallyI think doctors are obligated to think critically
Objectives
Is HIV a psychiatric epidemic?Is HIV a psychiatric epidemic? Can we treat the psychiatric disorders that Can we treat the psychiatric disorders that
complicate the HIV epidemic?complicate the HIV epidemic? Can clinicians integrate psychiatric Can clinicians integrate psychiatric
treatment in to HIV treatment?treatment in to HIV treatment?
Prior research has shown that psychiatric patients Have increased risk of HIVHave increased risk of HIV Are less likely to receive HAARTAre less likely to receive HAART Are less likely to stay on HAARTAre less likely to stay on HAART Are less likely to get an undetectable viral Are less likely to get an undetectable viral
loadload Are more likely to dieAre more likely to die
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.
BDI15BDI15-censored
BDI<15BDI<15-censored
Months on highly active ART706050403020100
Cumulative survival
1.0
.8
.6
.4
.2
0.0P = 0.0001
Depression Decreases AIDS-Free Survival in Patients on ART
HERS cohort: 765 participantsHERS cohort: 765 participants Longitudinal depression Longitudinal depression
(CES-D): none, (CES-D): none, intermittent, chronicintermittent, chronic
Mortality predictors: Mortality predictors: depression, CD4 cell depression, CD4 cell count, ART duration, agecount, ART duration, age
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 70.7
0.8
0.9
1.0HIV-related mortality
DEFINITION OF GROUPSExcludedExcluded
Mental Mental DisorderDisorder
No MentalNo MentalDisorderDisorder
Mental DisorderMental DisorderMet 1 or 2 of 3 Met 1 or 2 of 3
CriteriaCriteria
PsychiatricPsychiatricDiagnosisDiagnosis PsychiatricPsychiatricMedicationMedication PsychiatricPsychiatricEvaluationEvaluation
Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.
ASSOCIATION BETWEEN MENTAL D/O AND TIME TO HAART
TIME IN YEARS
PR
OB
AB
ILIT
Y O
F H
AA
RT
TH
ER
AP
Y
P=0.05
No Mental Disorder
Mental Disorder
2 4 60
Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.
ASSOCIATION BETWEEN MENTAL DISORDER AND SURVIVAL
TIME IN YEARS
PR
OB
AB
ILIT
Y O
F S
UR
VIV
AL
No Mental Disorder
Mental Disorder
P=0.10
Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.
Mental Illness
depressiondemoralizationsubstance abuse
cognitive impairment
AIDS
impulsivitydepression
demoralizationsubstance abuse
cognitive impairment
HIV IS A PSYCHIATRIC EPIDEMIC
• HIV increases risk for psychiatric illness
• psychiatric illness increases risk for HIV
• effective treatment for psychiatric illness can improve patient outcome
• effective treatment for psychiatric illness can decrease HIV transmission
Psychiatric disorders in new medical intakes
Overall Axis I Overall Axis I (non-substance abuse)(non-substance abuse) 54 %54 % Major depressionMajor depression 20 %20 % Adjustment disorderAdjustment disorder 18 %18 %
Substance AbuseSubstance Abuse 74 %74 % Cognitive ImpairmentCognitive Impairment 18 %18 % Personality disorderPersonality disorder 26 %*26 %*
* 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
The Four Perspectives McHugh and
Slavney
DiseaseDiseaseTemperamentTemperamentBehaviorBehaviorLife StoryLife Story
Mental Illness
depressiondemoralizationsubstance abuse
cognitive impairment
AIDS
impulsivitydepression
demoralizationsubstance abuse
cognitive impairment
Problems of life story
An “assumptive” worldAn “assumptive” world Assumptions provoke experienceAssumptions provoke experience Experience shapes assumptionsExperience shapes assumptions The medium of analysis of these The medium of analysis of these
experiences is “meaning”experiences is “meaning” Provides the “software operating system” Provides the “software operating system”
for data and actionfor data and action Can be “rescripted” or rewrittenCan be “rescripted” or rewritten
Experience
Meaning
Assumption
Behavior
Major Depression Demoralization
(Depression in remission)
Sub-syndromal Major Depression
Dysthymia
“Minor Depression”
“Depressive Personality”
Differential Diagnosis of Depression
DEPRESSIONDELIRIUMDEMENTIADEMORALIZATION
Depression diminishes
Mood-the sense of baseline state of Mood-the sense of baseline state of happiness that is usually presenthappiness that is usually present
Vital sense-the sense of being well, healthy, Vital sense-the sense of being well, healthy, energetic, alert and ableenergetic, alert and able
Self Attitude-the sense of being good, of Self Attitude-the sense of being good, of doing well, of effectiveness and utility to doing well, of effectiveness and utility to othersothers
Anhedonia Loss of reward Loss of reward (pleasure, satiation or satisfaction)(pleasure, satiation or satisfaction) associated with associated with
behaviorsbehaviors Appetite Directed BehaviorsAppetite Directed Behaviors
Sleeping Sleeping Eating Eating SexSex
Function Directed BehaviorsFunction Directed Behaviors Work Work HobbiesHobbies ExerciseExercise
Disturbance of Neurophysiology
SleepSleep
EARLY MORNING AWAKENINGEARLY MORNING AWAKENING Difficulty falling asleepDifficulty falling asleep Disrupted sleep architectureDisrupted sleep architecture
AppetiteAppetite
Change in food tasteChange in food taste Weight loss or gainWeight loss or gain Immune functionImmune function
G.I. functionG.I. function
Depression
stressdemoralization
CNS inflammationsubstance abusesubcortical injury
cognitive impairment
HIV
impulsivityhopelessnesscarelessness
demoralizationsubstance abuse
cognitive impairment
TIME OF AIDS
DEPRESSION AS AIDS DEVELOPS
MONTHS BEFORE AND AFTER AIDS
PERCENT DEPRESSED
0
10
20
-48 -36 -24 -12 6 18
Lyketsos CG, et al. Am J Psychiatry. 1996;153:1430-1437.
Differential Diagnosis of Depression
DEPRESSIONDELIRIUMDEMENTIADEMORALIZATION
Pharmacotherapy
• poor sleep
• weight loss
• anxiety
• G.I. disturbance
DesipramineNortriptyline
• hypersomnia
• weight gain
• suicide potential
• chronicity
CitalopramEscitalopram FluoxetineParoxetineSertralineVenlafaxineDesvenlafaxine
Failure from side effects
Lithium augmentationCombination Antidepressants
Thyroid, Pindolol, Antipsychotic augmentation
Failure after adequate trial
NEXT DRUG
BupropionNefazodoneMAOI'sTrazodoneMirtazepineAtomoxetine??
0
100
DEMENTIA SUBSTANCEUSE
PERSONALITYDISORDER
COMPLIANT OVERALL
Full
Partial
None
Treatment of DepressionOutcome 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
Mania
HIV
CASE STUDY OF PATIENTS WITH HIV AND MANIA
NEGATIVEHISTORY
(N=7)
33.6
7 male
4 gay/2 IDU
6/6
all AIDS
all
POSITIVEHISTORY
(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
The Four Perspectives McHugh and
Slavney
DiseaseDiseaseTemperamentTemperamentBehaviorBehaviorLife StoryLife Story
It is much more important to It is much more important to know what sort of patient know what sort of patient has a disease than what sort has a disease than what sort of disease a patient has.of disease a patient has.
William OslerWilliam Osler
Simplified model of disposition
Percent of population
IntroversionIntroversion
Punishment avoidant Punishment avoidant Future directedFuture directedFunction directedFunction directed
ExtraversionExtraversion
Reward directed Reward directed Present directedPresent directedFeeling directedFeeling directed
• Population-Disposition
Introversion-Extroversion
Stability-Instability
introversion extroversion
stable
unstable
sanguine
choleric
phlegmatic
melancholy
Motivated Behavior The cycle of driveThe cycle of drive
CravingCraving BehaviorBehavior ReinforcementReinforcement SatiationSatiation
Environmental ExposureEnvironmental Exposure
Parental and societal inputParental and societal input Biological FactorsBiological Factors
genetic contributiongenetic contribution ? errors in drive, object specificity, or gross pathology? errors in drive, object specificity, or gross pathology
Law of effect
……probability of a behavior can be probability of a behavior can be increased or decreased depending on its increased or decreased depending on its immediate consequence.immediate consequence.Thorndyke 1913Thorndyke 1913
Behaviorenvironmental exposure environmental response
Behavior
positiveincrease
negativedecrease
Internal “drive” (craving)
Behavior
Reward-Reinforcement
Satiation
environmental exposure environmental response
temperamentlife experience
disease
Motivated Behavior
Internal “drive” (craving)
Behavior
Satiation
environmental exposure environmental response
temperamentlife experience
disease
Motivated Behavior
Reward-Reinforcement