Depression%20and%20PTSD%20Treatments%20Improve%20HIV%20Treatment%20Outcome - PowerPoint PPT Presentation

About This Presentation
Title:

Depression%20and%20PTSD%20Treatments%20Improve%20HIV%20Treatment%20Outcome

Description:

1. To understand the relationship between the increasing prevalence of ... Stress alters cellular and humoral immune response. Kieclot-Glaser Proc Nat Acad Sci 1996 ... – PowerPoint PPT presentation

Number of Views:144
Avg rating:3.0/5.0
Slides: 61
Provided by: pwe94
Category:

less

Transcript and Presenter's Notes

Title: Depression%20and%20PTSD%20Treatments%20Improve%20HIV%20Treatment%20Outcome


1
Depression and PTSD Treatments Improve HIV
Treatment Outcome
  • Eric Avery, MD
  • Assistant Clinical Professor of Psychiatry
  • Director, HIV Psychiatry Services
  • The University of Texas Medical Branch
  • Galveston, Texas

2
Objectives
  • 1. To understand the relationship between the
    increasing prevalence of psychiatric disorders in
    HIV patients and the changing epidemiology of the
    epidemic.
  • 2. To review Depression and Post Traumatic
    Stress Disorder (PTSD)
  • Prevalence
  • Diagnosis
  • Impact on adherance and mortality
  • Treatment of Depression and PTSD
  • 3. To review HIV and psychiatric drug/drug
    interactions.

3
HIV is a Psychiatric Epidemic
  • Psychiatric illness increases risk for HIV.
  • HIV increases risk for psychiatric illness.
  • Effective treatment for psychiatric illness can
    improve patient outcome.
  • Effective treatment for psychiatric can decrease
    HIV transmission.

4
Psychiatric Illness Increases Risk of HIV
Infection
  • Substance Abuse.
  • Mood Disorders (Major Depression, Bipolor D/O)
  • Post Traumatic Stress Disorder (PTSD)
  • Psychotic Disorders
  • Impulsive behavior and personality factors

5
HIV Increases Risk for Psychiatric Illness
  • Increased major depression.
  • Increased mania.
  • HIV dementia (AIDS Dementia Complex).
  • Increased psychosocial stressors.

6
Depression
  • 1. Prevalence
  • 2. Diagnosis
  • 3. Impact on ARV Treatment
  • Initiation
  • Discontinuation
  • Adherance
  • 4. Impact on HIV Mortality
  • 5. Treatment of Depression

7
100 Patients with HIVHow many are depressed?
8
  • Depressed Mood and HIV
  • Name the 11 types
  • 1.
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11.
  • Why is the diagnosis important?

9
Differential Diagnosis of Depressed Moods in HIV
Patients
  • Despondency/demoralization.
  • Dysthymia (chronic low mood).
  • Adjustment disorder/minor depression.
  • Major depression, recurrent major depression.
  • General anxiety disorder.
  • Bipolar disorder -- depressed phase.
  • Organic mood disorder secondary depression
    (infections, medication side-effects, and mass
    lesions of CNS).
  • Malnourishment/weight loss associated with HIV.
  • Sleep disorder.
  • Psychoactive substance abuse.
  • Bereavement.

10
Depression Multicenter AIDS Cohort Study
Depressed
Time of AIDS Onset
55- 49- 43- 37-
31- 25- 19- 13-
7-12 0-6 0-6 7-12
13- 19- 60 54 48
42 36 30 24
18 mo mo mo
mo 18 24 mo mo
mo mo mo mo
mo mo
mo mo
Percentages of Multicenter AIDS Cohort Study
participants who met syndromal criteria for
depression, or who had a score of 22 or greater
on the Center for Epidemiologic Studies
Depression scale (CES-D) or 14 or greater on the
CES-D minus its somatic items (CES-D-NS), as
AIDS developed. Lyketos et al, Psych Ann 31 1
Jan 01
11
Depression and Progression to AIDS
PreHAARTLyketos, Hoover, Guccione et al JAMA
1993
  • MACS Cohort 1718 participants
  • 21 depressed at baseline
  • Cox proportional hazards analysis controlling for
    sociodemographics, CD4, AIDS related symptoms
  • Depression did not predict AIDS or death

12
Depression and Progression to Death
PreHAARTBurack, Barret, Stall, Chesney, Estrand,
Coates JAMA 1993
  • San Francisco Mens Health Study 277
    participants
  • 20 depressed at baseline
  • Cox proportional hazards analysis of progression
    to death
  • Depression predicted ARV use but not mortality

13
Depression and Progression to AIDS
PreHAARTMayne, Vittinghoff, Chesney, Barrett,
Coates Arch Int Med 1996
  • SF Mens Cohort 1032 participants over 102
    months
  • Cox proportional hazards with time dependent
    variables
  • 58 had significant depressive symptoms (CES-D)
  • Longitudinal measurement of depression every 6
    months
  • Predictors of Mortality
  • CD4 cell count
  • B2 microglobulin
  • P24 antigen
  • WHO HIV stage
  • Depression (RR1.67 Plt0.05)

14
Depression and Progression to AIDS
Post-HAARTIckovics, Hamburger, Vlahov et alJAMA
2001
  • HERS Cohort 765 Participants
  • Longitudinal depression (CES-D)
  • 42 chronic
  • 35 intermittent
  • 23 none
  • Mortality predictors depression (RR2), CD4,
    HAART duration, age

15
Depression, Mortality by CD4 and Viral load
Post-HAARTIckovics, Hamburger, Vlahov et alJAMA
2001
16
Why Does Depression Speed Progression to AIDS and
Death?
  • Stress alters cellular and humoral immune
    response
  • Kieclot-Glaser Proc Nat Acad Sci 1996
  • Vedhara Lancet 1999
  • Glaser Psychosom Med 1992
  • Jabaaij J Psychosom Res 1993
  • Glaser Ann NY Acad Sci 1998
  • Azciati Psychosomatics 2001
  • Delay in HAART initiation
  • Early HAART Discontinuation
  • Sub-optimal adherence to HAART

17
Depression and Delay in HAART InitiationFairfield
JGIM 1999
199 Patients New England Deaconnes with VLgt10,000
18
What Degree of AdherenceIs Needed to Prevent
Drug-Resistant Virus
Adherence to a PI-Containing Regimen
CorrelatesWith HIV RNA Response at 3 Months
100
80
60
Patients With HIV RNA lt400 ()
40
20
0
lt70
70-80
80-90
90-95
gt95
PI Adherence () (MEMScaps)
Paterson. 6th CROI 1999 Chicago. Abstract 92.
19
Depression Predicts Adherence to Non-HIV Treatment
20
Depression and HIV Medication Adherence
  • Singh AIDS Care 1996
  • Holzmer AIDS Patient Care STDs 1999
  • Peterson Annals Int Med 2000
  • Schulz 38th ICAAC 1998
  • Bangsberg 1721 41st ICAAC 2001

21
Depression is Under-Treated
  • 475 HIV men
  • 37 moderate-severe depressive symptoms
  • 40 of depressed received mental health care (12
    mo)
  • 3.4 of depressed received antidepressant
    medications (12 mo)
  • Katz et al AIDS Care 1996

22
Depression Diagnosis
23
Simple Depression Assessment
  • During the past month, have you often been
    bothered by feeling down, depressed, or hopeless?
  • Yes No
  • During the past month, have you often been
    bothered by having little interest or pleasure in
    doing things?
  • Yes No

If no to both, patient is unlikely to have
major depression. If yes to either, proceed
with the follow-up clinical interview.
Whooley MA, Simon GE. N Engl J Med, 2000.
24
Follow-up Interview for Diagnosis SIGECAPSS
  • S Sleep Disruption in sleep patterns nearly
    every day?
  • I Interests Decreased interest and pleasure in
    usual activities
  • G Guilt Feelings of worthlessness or guilt?
  • E Energy Decreased energy?
  • C Concentration Diminished ability to
    concentrate?
  • A Appetite Change in appetite or weight?
  • P Psychomotor Psychomoror retardation or
    agitation/irritable?
  • S Suicidal Recurrent thought of death or
    suicide?
  • S Sex drive Diminished sex drive?

25
Beck Depression Inventory
Date__________________Name___________________
_______________________________ Marital
Status_______ Age____ Sex___Occupation_____
________________________________________
Education___________________________This
questionnaire consists of 21 groups of
statements. After reading each group of
statements carefully, circle the number (0,1,2 or
3) next to the one statement in each group which
best describes the way you have been feeling the
past week, including today. If several
statements within a group seem to apply equally
well, circle each one. Be sure to read all the
statements in each group before making your
choice.
  • 1 0 I do not feel sad.
  • 1 I feel sad.
  • 2 I am sad all the time and I cant snap out of
    it.
  • 3 I am so sad or unhappy that I cant stand it.
  • 2 0 I am not particularly discouraged about the
    future.
  • 1 I feel discouraged about the future.
  • 2 I feel I have nothing to look forward to.
  • 3 I feel that the future is hopeless and that
    things cannot improve.
  • 3 0 I do not feel like a failure.
  • 1 I feel I have failed more than the average
    person.
  • 2 As I look back on my life, all I can see is a
    lot of failures.
  • 3 I feel I am a complete failure as a person.
  • 8 0 I dont feel I am any worse than anybody
    else.
  • 1 I am critical of myself for may weaknesses or
    mistakes.
  • 2 I blame myself all the time for my faults.
  • 3 I blame myself for everything bad happens.
  • 9 0 I dont have any thoughts of killing myself.
  • 1 I have thoughts of killing myself, but I
    would not carry them out.
  • 2 I would like to kill myself.
  • 3 I would kill myself if I had the chance.
  • 10 0 I dont cry any more than usual.
  • 1 I cry more now than I used to.
  • 2 I cry all the time now.
  • 3 I used to be able to cry, but now I cant cry
    even though I want to.
  • To order forms 1-800-228-0752

26
Depression Treatment
27
Tricyclic Antidepressants Treatment of Depression
in HIV Individuals
28
  • Treatment of Depression With Other Agents
  • in HIV Individuals

Grinspoon 2000
29
SSRI Treatment of Depression in HIV Individuals
30
Side Effect/Toxicity Profile TCA vs SSRI
  • TCA
  • Narrow therapeutic window
  • Requires drug monitoring
  • Anticholinergic effects
  • Dry mouth, Constipation, dizziness, hypotension
  • 41 discontinue at 6 months
  • (Rabkin Amer J Psych 1994)
  • Pill burden
  • SSRI
  • Mild side effects
  • Anticholinergic, agitation/sedation, sexual
    dysfunction
  • Drug interactions (Rx ritonavir)
  • Bupropion - seizures

31
SSRI FDA Approvals
FDA approved to age 6 years
32
Half Lives of 4 SSRIs
33
Serotonin Discontinuation Syndrome
  • Somatic symptoms
  • Disequilibrium, dizziness, unsteadiness, vertigo
  • Feeling spacey, confusion, memory dysfunction
  • Flulike symptoms (myalgia, chills, fatigue,
    nausea)
  • Sensations of electric shocks, parethesia, tremor
  • Insomnia, overactivity, vivid dreams
  • Psychological symptoms
  • Agitation, anxiety, irritability
  • Mood lability, crying spells
  • Cognitive fog

34
Hepatic Isoenzyme Inhibition of the SSRIs
(Cytochrome P450)
35
HIV-Related Medications and Psychotropic Agents
Involving the Cytochrome P450 Isoenzyme
36
(No Transcript)
37
Staging HIV and Antidepressant TreatmentTreat
Depression First Whenever Possible
  • Depression is common
  • Depression is the strongest modifiable predictor
    of adherence to all medical therapy
  • Adherence is the strongest predictor of disease
    progression and death after CD4 cell count
  • Depression should be treated prior to starting
    antiretroviral therapy
  • Depression screen, CD4, VL
  • Patients with severe HIV disease may need
    concurrent initiation of antidepressant therapy
    and antiretroviral therapy

Bangsberg JGIM 199914446-8
38
Comorbid Mood and Anxiety Disorders
Panic Disorder 50 - 651
Generalized Anxiety Disorder
8- 391
Depression
Social Anxiety Disorder 702
PTSD 484
OCD 673
1 American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders. 4th
ed. Washington, DC American Psychiatric
Press 1994. 2 Van Ameringen M et al. J Affect
Disord. 19912193-99. 3 Rasmussen SA, Eisen JL.
J Clin Psychiatry. 199253(suppl)4-10. 4
Coryell W Et al. Am J Psychiatry 1988155895-898.
39
Post Traumatic Stress Disorder
  • Prevalence
  • Childhood abuse, PTSD and HIV risk behaviors
  • Proposed association between PTSD and HIV
    treatment nonadherance
  • Treatment of PTSD

40
PTSD Prevalence
  • Over half the U.S. population has been exposed to
    a severe trauma
  • 10-20 of trauma survivors will develop PTSD
  • Lifetime prevalence 8 overall. 12 in women
    (Kessler 1995)
  • Increased rates in HIV , incarcerated
  • Limited studies
  • HIV 30 (1/3 after HIV dx) (Kelly 1998)
  • Incarcerated women lifetime 33, current 15-22
    (Hutton 2001)
  • PTSD is the 5th most prevalent major psychiatric
    illness

41
Most Prevalent Anxiety Disorders in the General
Population
Lifetime Prevalence ()
Kessler et al, National Comorbidity Survey, 1994
Males Females
Hutton (2001) 177 Prison Women
Kelly (1998) 61 HIV Gay/Bi men
42
Comorbidity
  • Comorbid psychiatric illness is about 80
  • Patients with PTSD are 2 - 4X more likely to have
    depression, anxiety disorders or substance abuse
  • They are 90X more likely to have a somatization
    disorder

43
Common Traumatic Events
  • Witnessing injury/death
  • Sexual molestation/rape
  • Natural disaster/fire
  • Physical attack or abuse/threatened with a weapon
  • Life threatening accident
  • Combat

44
PTSD - Clinical Course
  • PTSD symptoms usually present within the first 3
    months following the trauma
  • Less frequently, symptoms may be delayed for
    months or years after the traumatic event
  • Symptoms of PTSD may persist for months or years
    after the trauma
  • Approximately 50 of all cases of PTSD are chronic

45
Connection Between Childhood Abuse and HIV
Infection
Reported Abuse Survivor Characteristics (N 52
HIV Adults Atlanta Social Service Agency)
Note. Survivor characteristic categories are not
independent.
Allers C. J Counsel Devel. 1991 70 309-13
46
Frequency of PTSD Disorders Among 177 Women
Prisoners in an HIV Risk Behavior Study
Compared with participants who did not have PTSD,
those with lifetime diagnosis of PTSD were 71
more likely to have engaged in anal sex and 56
more likely to have engaged in prostitution. The
association between lifetime PTSD and other HIV
risk behaviors were not significant in this study.
Hutton, Psych Services 2001, 52/4508-13
47
PTSD Predicts Adherence to Non-HIV Treatment
  • Survivors of Myocardial Infarction
  • 102 s/p MI
  • 10 PTSD (intrusion/avoidance)
  • significant association with decreased adherence
  • Shemesh Gen. Hosp. Psych 2000

48
PTSD is Under-Treated
  • 47 HIV women
  • 42 full, current PTSD
  • 59 not receiving mental health care
  • 22 partial PTSD
  • 78 not receiving mental health care
  • Martinez AIDS Patient Care and STDs 2002

49
PTSD Diagnosis
50
Screening questions
  • Have you ever had anything happen to you where
    you thought you would be seriously injured or
    might die?
  • Have you ever been in a life threatening
    accident? Fire? Disaster?
  • Have you ever been attacked or raped?
  • Have you ever seen these things happen to someone
    else?

51
If the answer to any of these questions is yes
  • Do you ever have nightmares about the event, or
    sometimes feel the same feelings you had when you
    were in the trauma?
  • Do you startle easily?
  • Do you try hard to avoid situations which remind
    you of the trauma?
  • How do you feel about your future?

52
HOW CAN I TELL IF I HAVE PTSD?PTSD is a serious,
yet treatable medical disorder. It is not a sign
of personal weakness. If you think you may have
PTSD, answer the following questions and show
this checklist to your health care professional
  • Yes or No?
  • ? ? Have you experienced or witnessed
    a life-
  • threatening event that
    caused intense fear
  • Do you re-experience the event in at least
    one of
  • the following ways?
  • ? ? Repeated, distressing
    memories and/or
  • Yes No dreams?
  • ? ? Acting or feeling as
    if the event were
  • Yes No happening again
    (flashbacks or a sense of
  • reliving it)?
  • ? ? Intense physical and/or
    emotional distress
  • Yes No when you are exposed
    to things that remind
  • you of the
    event?
  • Do you avoid reminders of the event and feel
    numb, compared to
  • ? ? Problems concentrating?
  • Yes No
  • ? ? Feeling on guard?
  • Yes No
  • ? ? An exaggerated startle response?
  • Yes No
  • ? ? Do your symptoms interfere with your
    daily life?
  • Yes No
  • ? ? Have you symptoms lasted at least 1
    month?
  • Yes No
  • Having more than one illness at the same time can
    make it more
  • difficult to diagnose and treat the different
    conditions. Illnesses
  • that sometimes complicate PTSD include depression
    and
  • substance abuse. To see if you have other
    problems that may

Consensus Guidelines J Clin Psych 1999
53
PTSD Treatment
54
Psychotherapeutic Interventions
  • Acute PTSD
  • mild Psychotherapy
  • severe Psycho therapy and medication
  • Chronic PTSD
  • mild Psychotherapy first or medication
  • severe Psychotherapy first or medication
  • If comorbid (eg depression / bipolor / other
    anxiety DO)
  • medication plus psychotherapy
  • Most effective cognitive behavioral therapy
    (CBT) and exposure therapy
  • Patients are encouraged to confront anxiety
    provoking triggers, decrease avoidance, and
    practice stress reducing strategies
  • When referring patients, seek therapists with
    expertise in CBT and BT
  • Consensus Guidelines J. Clin. Psychiatry 1999

55
Pharmacological InterventionsAntidepressants
  • Positive Controlled Trials
  • TCAs
  • amitryptaline (Elavil)
  • imipramine ((Tofranil)
  • MAOIs
  • phenelzine (Nardil)
  • SSRIs
  • fluoxetine (Prozac) civilians only
  • sertraline (Zoloft) (Paxil) FDA indication
  • paroxetine (Paxil)

56
Benzodiazepines
  • Should NOT be first line
  • May exacerbate
  • Dissociation
  • Substance abuse
  • Disinhibition
  • Best used as an augment

57
Pharmacological Steps for PTSD
  • Start with and SSRI
  • Initiate with a low dose, half of what would
    start for depression
  • Titrate to a high dose
  • Once patient improves, maintain dosage for at
    least a year

58
Pharmacotherapy Steps for PTSD
  • If no response or intolerant to SSRI
  • Venlafaxine
  • Nefazadone
  • A tricyclic antidepressant
  • If all else fails, consider a monoamine oxidase
    inhibitor

59
Reasonable augmentations
  • Anticonvulsants for dissociation,
    explosiveness, mood lability
  • Autonomic blockers for SNS overactivity
  • Benzodiazepines or Buspirone for excessive
    anxiety
  • Neuroleptics for poor impulse control
  • Sedating antidepressants (Trazadone) for
    insomnia

60
Summary
  • Psychiatric disorders, especially depression and
    PTSD are common in HIV patients.
  • Depression is the strongest modifiable predictor
    of adherence to all medical therapy.
  • Adherence is the strongest predictor of disease
    progression and death after CD4 count.
  • Depression should be treated prior to starting
    antiretroviral therapy. When in doubt, treat.
  • The behavioral manifestations of PTSD contribute
    to problems of HIV treatment adherance.
  • Difficulty recognizing harm
  • Difficulty developing self protective mechanism
  • Compulsive need to repeat the trauma
  • Sense of foreshortened future
Write a Comment
User Comments (0)
About PowerShow.com