Update%20On%20Psychiatric%20Aspects%20of%20Emerging%20Infectious%20Diseases%20(HIV,%20HCV,%20SARS%20and%20West%20Nile)

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Update On Psychiatric Aspects of Emerging
Infectious Diseases(HIV, HCV, SARS and West Nile)

• Eric Avery M.D.
• Associate Clinical Professor of Psychiatry
• Associate Member, Institute for the Medical
  Humanities
• University of Texas Medical Branch
• Galveston, Texas

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Objectives

• At the conclusion of this presentation, the
  participants
• should be able to
• Describe the evolving trends in the care of the
  HIV patient population and the implications for
  the role of the psychiatrist in prevention and
  treatment.
• Describe the psychiatric screening process and
  treatment of psychiatric disorders in HCV
  patients.
• Recognize the neuropsychiatric manifestations of
  the WNV infected patient.
• Describe how the SARS outbreak in Canada defines
  the role of the psychiatrist in preparing for and
  participating in the treatment of emerging
  infectious diseases.

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• HIV/AIDS
• Objective
• Describe the evolving trends in the care of the
  HIV patient population and the implications for
  the role of the psychiatrist in prevention and
  treatment.

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HIV Is a Psychiatric Epidemic

• ? Risk for HIV
• Substance abuse
• Major depression
• Impulsive behavior personality factors
• Cognitive impairment

• ? Risk for psychiatric illness
• ? Major depression
• ? Mania
• HIV dementia (AIDS dementia complex)
• ? Psychosocial stressors

Effective treatment of psychiatric illness may
improve patient outcomes
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• The Psychiatry of AIDS
• A Guide to Diagnosis and Treatment
• Glenn J. Treisman, M.D., Ph.D.Andrew F.
  Angelino, M.D.
• The Johns Hopkins University Press 2004

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Primary Diagnosis of Patients at First
Appointment for HIV Care (N250)
Primary Diagnosis
Any Axis I psychiatric disturbance (other than substance use disorder 54
Major Depression 20
Adjustment Disorder (all types) 18
Cognitive Impairment 18
Substance Use Disorder 74
Personality Disorder 26
Treisman 2004
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HIV Among People with Chronic Mental Illness

• Since the early 1990s, thirteen studies of HIV
  infection among adults in psychiatric setting in
  the U.S. have been published in peer-reviewed
  literature.
• These studies show a combined HIV seroprevalence
  of 6.9.
• Urban centers 5
• Smaller cities 1.7
• U.S. Population HIV infection rate 0.4

McKinnon, 2002
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Depression Multicenter AIDS Cohort Study
Depressed
Time of AIDS Onset
0-6
0-6
7-12
7-12
55-60
49-54
43-48
37-42
31-36
25-30
19-24
13-18
13-18
19-24
Time (months)
Before AIDS diagnosis
After AIDS diagnosis
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
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Depression and Progression to AIDS
Pre-HAARTShafer, Delorenze, Satariano,
WinkelsteinAnn Epi 1996

• San Francisco Mens Health Study 395
  participants
• 34 depressed at baseline (different baseline
  than Burrack)
• Depression at baseline predicted death

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Depression and Progression to AIDS Post-HAART
HIV-Related Mortality
1.0

• HERS Cohort 765 Participants
• Longitudinal depression (CES-D)
• 42 chronic
• 35 intermittent
• 23 limited or none
• Mortality predictors depression (RR2), CD4,
  HAART duration, age

0.9
Cumulative Survival
0.8
0.7
0
1
2
3
4
5
6
7
Total Time in Study (y)
Ickovics, Hamburger, Vlahov et al JAMA 2001
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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
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Mood Disorder Questionnaire
Hirschfeld et al (2000)
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Mood Disorder Diagnostic Data for HIV PatientUTMB AIDS Clinical Care Research Clinic Mood Disorder Diagnostic Data for HIV PatientUTMB AIDS Clinical Care Research Clinic Mood Disorder Diagnostic Data for HIV PatientUTMB AIDS Clinical Care Research Clinic
Patients (N159)
DSM IV Bipolar Diagnosis 48 30.2
Bipolar I 29 18.2
Bipolar II 11 6.9
Bipolar NOS 5 3.1
Cyclothymia 2 1.3
Mood disorder, secondary to a general medical condition 3 1.9
Mood Disorder, NOS 4 2.5
Major Depressive Disorder 69 43.4
Dysthymic Disorder 3 1.9
Substance Induced Mood Disorder 7 4.4
Includes Bipolar I, Bipolar II, Bipolar NOS, Cyclothymia Includes Bipolar I, Bipolar II, Bipolar NOS, Cyclothymia
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MDQ Sensitivity and Specificity Data for HIV UTMB ACCRP Clinic MDQ Sensitivity and Specificity Data for HIV UTMB ACCRP Clinic MDQ Sensitivity and Specificity Data for HIV UTMB ACCRP Clinic
Sensitivity Specificity
DSM IV Bipolar Diagnosis 62.50 78.40
Bipolar I 72.40 74.60
Bipolar II 36.40 66.20
Bipolar NOS 60 66.90
Cyclothymia 50 66.20
Mood disorder, secondary to a general medical condition 33.30 66.00
Mood Disorder, NOS 0.00 65.21
Major Depressive Disorder 23.20 57.80
Dysthymic Disorder 33.30 66.00
Substance Induced Mood Disorder 14.30 65.10
N159
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HIV and Post Traumatic Stress Disorder
M.B. Molded paper woodcut on handmade paper28
¼ x 23 edition 10
E.D. 04/23/99 Molded paper woodcut on handmade
paper28 ¼ x 23 edition 10
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Post Traumatic Stress Disorder

• 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
• Increased rates in HIV , incarcerated
• Limited studies
• HIV 30 (1/3 after HIV dx)
• Incarcerated women lifetime 33, current 15-22
• PTSD is the 5th most prevalent major psychiatric
  illness

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Most Prevalent Anxiety Disorders in the General
Population
Males Females
Hutton (2001) 177 Prison Women
Kelly (1998) 61 HIV Gay/Bi men
Lifetime Prevalence ()
Kessler et al, National Comorbidity Survey, 1994
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Frequency of PTSD Disorders Among 177 Women
Prisoners in an HIV Risk Behavior Study
Women prisoners
Percentage amonggeneral population
Disorder
N

Posttraumatic stress disorder1 Lifetime 59 33 1-
14 Current 27 15 lt1
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
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Why AIDS Psychiatry?

1. The majority of persons who become infected in
   the United States engage in high rates of risky
   behaviors that are associated with the
   vulnerabilities seen in psychiatric disorders.
   Our patients are disproportionately being
   infected.
2. Psychiatric disorders decrease patients ability
   to gain access to medical care because these
   disorders disorganize patients often making them
   feel hopeless and because medical care of
   psychiatric patients in complex and time
   consuming.
3. Mentally ill persons are economically
   disadvantaged, often being carved out by
   managed care organizations, resulting in
   fragmented care.
4. Psychiatric disorders have a negative effect on a
   persons adherence to medical care.

The effective treatment of psychiatric disorders
decreases the risk of getting HIV and for those
already infected, improves function, quality of
life and adherence to medical treatment.
Treisman 2004
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• Hepatits C
• Objective
• Describe the psychiatric screening process and
  treatment of psychiatric disorders in HCV
  patients.

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Corcoran Museum of ArtWashington D.C.
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LIVER DIE A Print Action for Health
March 31 April 3, 2005
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LIVER DIE Medical Care in the Art Museum
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LIVER DIE Participants Rae Johnson, R.N., John
Hogan, M.D., Eric Avery, M.D.
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Hepatitis C Prevalence Across Varied Study Samples
Sample Screened N Screened Hepatitis C Antibody Prevalence
Low-income young women, aged 18-29 northern California population-based sample 1,707 25
Veterans undergoing phlebotomy at VAMCs on March 17, 1999 26,102 6.6
Public mental health patients with severe mental illness 751 16.1
Correctional facilities inmates (1997 estimate) 1,784,000 17 - 25
Opioid maintenance treatment program patients, Sacramento, California 460 87.4
Older intravenous drug users in six US cities 1,717 89 - 100
Psychiatric Annals 336. JUN 2003
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Psychiatric and Substance Use Comorbidity Among
Northwest Veterans Tested for HCV
AntibodyNovember 1996 to August 2000
Diagnostic ICD-9 Code Category Associated with Inpatient or Outpatient Clinical Contacts in Past 4 Years HCV (N5,406)
Any psychiatric or substance use disorder diagnosis 78
Drug use disorder 68
Alcohol use disorder 57
Depressive disorder 26
Posttraumatic stress disorder 29
Psychosis 14
Bipolar disorder 4.8
Homeless 32
Psychiatric Annals 336. JUN 2003
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HCV Among Institutionalized Mentally Ill
Patients Ben Taub, Houston

• 83/95 (50 male) tested for HCV
• 14/83 HCV 16.9
• Psychiatric Diagnoses/HCV
• Depression 31
• Bipolar 10
• Psychosis 8.8
• Cluster B 36.8
• No Axis II 10
• Substance abuse, previous STD, physical and
  sexual abuse and homelessness had statistically
  significant associations with HCV.

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HCV Among Institutionalized Mentally Ill
Patients R. Sealy, UTMBApril 24-25, 2005

• 41 Patients on RS3A, 3B, 3C
• 6/30 20 HCV
• Of 11 inpatients without ALT test, perhaps 1-3
  would test HCV

ALT (30) HCV HCV- No HCV Test
? ALT (6) 5 3 0
NL ALT (24) 1 4 10
Total 6 14 10
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Acute hepatitis Chronic active hepatitis Cirrhosis HCC
Clinical and Laboratory events associated with
hepatitis C virus infection. Clinical Virology,
2002.
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To Test or Not to Test?

• At risk, check ALT. If increased, hepatitis
  screen. (CDC.gov)
• If -, HCV prevention (Harm Reduction)
• If , education to decrease transmission
• If , refer to Hepatitis Clinic/specialist
• If , no HCV Tx until Comorbid psychiatric
  problems treated
• Motivator Want HCV TX?
• - Motivator you will get sicker if you are not
  treated

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Suggested Approach for Assessing and Managing
INF-Induced Depression

• Because depression my be as high as 50 in
  IFN-treated patients
• Inform patient about risk of depression
• Educate on how to recognize symptoms
• Explain depression treatment options
• Before INF treatment, psychiatric evaluation for
  patients with
• Current episode of depression or history of
  depression (mood swings)
• History of psychiatric hospitalization
• History of substance abuse or dependence
• Family history of depression or suicide attempts

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Suggested Approach for Assessing and Managing
INF-Induced Depression

• If depressed when evaluated for INF treatment
• Treat the depression first, then INF
• When monitoring the patient for depression during
  INF
• Use a screening instrument
• Patient minimize to continue INF
• If depressed, treat aggressively with SSRI
• If depressed and not responding, INF can be
  decreased
• If depression is severe (suicidal/psychotic) IFN
  discontinued
• /- need for psychiatric admission
• NIH Concensus Conference 1997
• Zdilar Hepatology 2000

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Research Question Pretreatment of HCV Patients
at Risk for Depression with SSRI?

• Paroxetine for the Prevention of Depression
  Induced by High-dose Interferon Alfa

Musselman NEJM 2001
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• West Nile Virus
• Objective
• Recognize the neuropsychiatric manifestations of
  the WNV infected patient.

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http//www.cdc.gov/ncidod/dvbid/westnile/survcont
rol04Maps.htm
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2004
http//www.cdc.gov/ncidod/dvbid/westnile/survcont
rol04Maps.htm
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West Nile Virus

• Isolated 1937 in West Nile district of Uganda
• Outbreaks in Africa and the Middle East caused
  West Nile Fever-- non-specific and self-limited
  viral illness
• Outbreak in South Africa in mid-1970s had 18,000
  cases with no reports of encephalitis and no
  deaths
• Major change in virulence appeared in later
  outbreaks
• Romania (1996), Russia (1999), Israel (2000)
• Western hemisphere (1999-present)
• Unprecedented rates of encephalitis and mortality
  indicate evolution of a new strain with greater
  neurotropism and neurovirulence

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WNV Clinical Presentation

• Incubation period 2-21 days after infection
  (generally 2-6 days in WN fever).
• Those requiring hospitalization generally
  complain of
• Fever GI complaints (diarrhea) confusion
• headache myalgia malaise rash
• fatigue

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WNV Clinical Syndromes

• Most striking feature and greatest concern is
  invasive neurologic disease.
• Neurologic disease ranges from meningitis to
  movement disorders to acute flaccid paralysis
  resembling poliomyelitis.
• West Nile CNS 2,863 (29) of 9,858 cases
  reported to CDC in 2003 were neuroinvasive
• Risk Factors
• Immunocompromised
• Older
• Male gender

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WNV Human Infection Iceberg
10 fatal (lt0.1 of total infections)
1 CNS disease case 150 total infections
lt1 CNS disease
Very crude estimates
20 West Nile Fever
80 Asymptomatic
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• Follow-up Features in 16 Patients After Acute
  WNV-CNS in Louisiana
• Patients
• 5 meningitis
• 8 encephalitis
• 3 poliomyelitis like
• Clinical Features
• Tremor (94)
• Myoclonus (31)
• Parkinsonism (69)
• Balance and gait (19)
• All had altered mental status, the most common
  were behavioral or personality changes, including
  irritability, confusion or disorientation.

Sejvar JAMA 2003
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4/6/05 FAX From Clinical Social Worker to My
Office

• Female patient is HIV, lives in Beaumont, Texas
  area
• New observations of CTs decrease motor and cog.
  Skills Ct increasing confused, motor skills
  slower i.e. unable to tie shoe, slow getting out
  of bed, unable to find her way to my office room
  then lost in room didnt know what to do. Her
  mom reports onset of change abt 1 wk prior to
  appt.
• Also Ct sent home from job due to inability to
  carry out assigned duties that she has done
  routinely for 15 years.
• Please evaluate - although oriented x3 Ct.
  drastic change in cog. and motor skills have me
  very concerned.

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• In mosquito season, fever and altered mental
  status, think West Nile
• Infectious Disease Faculty
• UTMB 2005

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• SARS
• Objective
• Describe how the SARS outbreak in Canada defines
  the role of the psychiatrist in preparing for and
  participating in the treatment of emerging
  infectious diseases.

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C. J. and Susan Peters
Taiwan 2004
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SARS

• EPIDEMIOLOGY
• Reservoir/Sources
• Global Spread

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SARS

• EPIDEMIOLOGY
• Reservoirs/Sources
• Hospitals
• Patients
• Healthcare workers
• Visitors
• Person with SARS in households
• Person with SARS in the community
• Persons with SARS unknown to the community or
  authorities

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SARS

• PREVENTION AND CONTROL IN HEALTHCARE
• Isolation of cases
• (suspect cases, probable
• cases, confirmed cases)
• Protection of healthcare
• workers (HCWs)
• All Barrier Precautions (ABP)
• N95 mask (fit tested)
• Goggles
• Gown
• Gloves

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Psychological Effects of SARS Quarantine Toronto,
Canada

• gt 15,000 Voluntary Quarantine
• Web based survey (Impact of Events Scale R,
  CES-D)
• 129 Respondents (68 Health Care Workers)
• 66 Home Quarantine
• 34 Work Quarantine

CES-D lt16 gt16 IES-R lt20 gt20 No () 84 (68.8) 38 (31.2) 86 (71.1) 35 (28.9)
gt10 days quarantinegtPTSD if DepressiongtPTSD
with less income
Hawryluck E.I.D. 2004
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Psychiatric Assessment of SARS Survivors Toronto,
Canada

• 33 patients (40 Health Care Workers) (4-8 weeks
  after Dx SARS)
• 58 PTSD (mean IES-R 24.8)
• 61 Depression
• 48 PTSD Depression

Jancin Clin Psy News 2003
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Quarantine and Isolation Lessons Learned from
SARSCDC and Institute for Bioethics, Health
Policy and Law University of Lousiville School
of Medicine www.instituteforbioethics.com

• By infecting health care workers at a high rate,
  SARS presented enormous challenges
• Adequate staffing
• Physicians, nurses avoided caring for infected
  patients
• Penalties/incentives
• Long-term effect for health care staffing because
  of report of psychological problems
• Toronto departure from the health professions
  and declining enrollment in training programs
• Policies need to be developed on the appropriate
  site for quarantine for individuals who have
  mental illness, mental retardation and substance
  abuse problems.

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• From Whitmore, RonSent Friday, April 22, 2005
  350 pmTo Avery, Eric NSubject respirator fit
  testing
• You are due, or soon will be due, for retesting
  or have never been tested for N95 respirator use.
  Please complete the attached questionnaire and
  send it to Employee Health (route 1161) for
  review. You will be notified for scheduling when
  approved.
• Ron Whitmore
• Asbestos Program AdministratorRespiratory
  Protection Program AdministratorEnvironmental
  Health Safety1302 Mechanic St., Ste.
  2.112Galveston, TX 77555-1111phone [phone]

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Summary

• As the HIV and HCV epidemics continue to evolve,
  psychiatric patients are being disproportionately
  infected. Psychiatrist are in the frontline of
  HIV/HCV prevention and in treating the
  psychiatric comorbidities which complicate
  patients care.
• In patients with altered mental status and
  behavioral changes during mosquito season, West
  Nile CNS should be in the diagnostic
  differential. Psychiatrists will play a role in
  the rehabilitation of these patients.
• Because of the impact SARS had on communities,
  individuals and health care workers,
  psychiatrists should play a role in the response
  planning for Emerging Infectious Diseases.

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