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


1
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

2
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.

3
  • 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.

4
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5
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7
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8
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
9
  • 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

10
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
11
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
12
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
13
Depression and Progression to AIDS
Pre-HAART Shafer, Delorenze, Satariano,
Winkelstein Ann Epi 1996
  • San Francisco Mens Health Study 395
    participants
  • 34 depressed at baseline (different baseline
    than Burrack)
  • Depression at baseline predicted death

14
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
15
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
16
Mood Disorder Questionnaire
Hirschfeld et al (2000)
17
Mood Disorder Diagnostic Data for HIV Patient UTMB AIDS Clinical Care Research Clinic Mood Disorder Diagnostic Data for HIV Patient UTMB AIDS Clinical Care Research Clinic Mood Disorder Diagnostic Data for HIV Patient UTMB 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
18
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
19
HIV and Post Traumatic Stress Disorder
M.B. Molded paper woodcut on handmade paper 28
¼ x 23 edition 10
E.D. 04/23/99 Molded paper woodcut on handmade
paper 28 ¼ x 23 edition 10
20
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

21
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
22
Frequency of PTSD Disorders Among 177 Women
Prisoners in an HIV Risk Behavior Study
Women prisoners
Percentage among general 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
23
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
24
  • Hepatits C
  • Objective
  • Describe the psychiatric screening process and
    treatment of psychiatric disorders in HCV
    patients.

25
Corcoran Museum of Art Washington D.C.
26
LIVER DIE A Print Action for Health
March 31 April 3, 2005
27
LIVER DIE Medical Care in the Art Museum
28
LIVER DIE Participants Rae Johnson, R.N., John
Hogan, M.D., Eric Avery, M.D.
29
(No Transcript)
30
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
31
Psychiatric and Substance Use Comorbidity Among
Northwest Veterans Tested for HCV
Antibody November 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
32
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.

33
HCV Among Institutionalized Mentally Ill
Patients R. Sealy, UTMB April 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
34
Acute hepatitis Chronic active hepatitis Cirrhosis HCC
Clinical and Laboratory events associated with
hepatitis C virus infection. Clinical Virology,
2002.
35
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

36
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

37
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

38
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
39
  • West Nile Virus
  • Objective
  • Recognize the neuropsychiatric manifestations of
    the WNV infected patient.

40
http//www.cdc.gov/ncidod/dvbid/westnile/survcont
rol04Maps.htm
41
2004
http//www.cdc.gov/ncidod/dvbid/westnile/survcont
rol04Maps.htm
42
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

43
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

44
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

45
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
46
  • 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
47
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.

48
  • In mosquito season, fever and altered mental
    status, think West Nile
  • Infectious Disease Faculty
  • UTMB 2005

49
  • 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.

50
C. J. and Susan Peters
Taiwan 2004
51
SARS
  • EPIDEMIOLOGY
  • Reservoir/Sources
  • Global Spread

52
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

53
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

54
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 quarantine gtPTSD if Depression gtPTSD
with less income
Hawryluck E.I.D. 2004
55
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
56
Quarantine and Isolation Lessons Learned from
SARS CDC 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.

57
  • From Whitmore, Ron Sent Friday, April 22, 2005
    350 pm To Avery, Eric N Subject 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 Administrator Respiratory
    Protection Program Administrator Environmental
    Health Safety 1302 Mechanic St., Ste.
    2.112 Galveston, TX 77555-1111 phone 409-772-8491

58
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.

59
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