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Mental Health Screening Tools for the HIV Clinician

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Title: HIV-Associated Neurocognitive Disorders (HAND) Author: RENTEX Last modified by: Stanford University Created Date: 5/8/2008 1:41:09 PM Document presentation format – PowerPoint PPT presentation

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Title: Mental Health Screening Tools for the HIV Clinician


1
Mental Health Screening Tools for the HIV
Clinician
  • Lawrence M. Mc Glynn MD
  • Clinical Associate Professor
  • Stanford University
  • Faculty Medical Director
  • San Jose AETC
  • June 2013

2
Thanks
  • Pacific AETC Staff and Faculty San Jose AIDS
    Education and Training Center
  • American Psychiatric Association Office of HIV
    Psychiatry

3
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

4
  • Grab a pencil and some scratch paper
  • Close your door turn off your cell phone no
    checking your email no sleeping kick back and
    lets learn together ?

5
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

6
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

7
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

8
Neuropsychological Domains
  • Verbal/Language
  • Attention/concentration
  • Working Memory
  • Executive/Abstraction
  • Memory (learning, recall)
  • Speed of information processing
  • Sensory-perceptual
  • Motor skills

9
Associated Behavioral Disturbances
  • Apathy
  • Depression
  • Sleep disturbance
  • Agitation/Mania
  • Psychosis

10
HAND Classification
Asymptomatic Neurocognitive Impairment (ANI)
No Functional Impairment
1 SD
2 Domains
Mild Neurocognitive Impairment (MNI)
Mild Functional Impairment
1 SD
2 Domains
Moderate to Severe Functional Impairment
2 SD
HIV-Associated Dementia (HAD)
2 Domains
NIMH, NINDS Panel, Neurology 2007 691789-1799
11
Prevalence of HAND based on New Criteria
NP Normal (30-60)
MNI (20-30)
ANI (20-30)
HAD (5-20)
Functional Impairment
NIMH, NINDS Panel, Neurology 2007 691789-1799
12
Risk and Protective Factors
  • Risk factors
  • Age gt 50
  • Survival duration
  • Lower nadir CD4 T-cell counts
  • Higher baseline viral load
  • Gender (F)

13
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.
14
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 GPs
accuracy in identifying incident dementia? Am J
Geriatr Psychiatry 1711, November 2009.
15
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

16
International HIV Dementia Scale (IHDS)
17
(No Transcript)
18
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.

19
2. Motor Speed
  • Have the patient tap the first two fingers of the
  • non-dominant hand as widely and as quickly as
  • possible.
  • 4 15 in 5 seconds
  • 3 11-14 in 5 seconds
  • 2 7-10 in 5 seconds _____
  • 1 3-6 in 5 seconds
  • 0 0-2 in 5 seconds

20
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 seconds
  • 3 3 sequences in 10 seconds
  • 2 2 sequences in 10 seconds
  • 1 1 sequence in 10 seconds _____
  • 0 unable to perform

21
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. _____

22
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.

23
HIV Dementia Scale
Total score lt 10 HAD 11-13 Mild cognitive
impairment
Adapted From Power C et al. HIV Dementia
Scale a rapid screening test. Journal of
Acquired Immune Deficiency Syndrome and Human
Retrovirology 19958273-278. Used with
permission.
24
Modified HIV Dementia Scale
Max 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.)
6 Psychomotor 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 gt 36 sec 0)
4 Memory - 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.(lt 25 sec 2 25 - 35 sec 1 gt 35 sec 0)
Total Score Max 12 /12 lt 7.5 may indicate dementia and should be evaluated by full battery if possible


25
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26
MOCA
27
MOCA
28
MOCA
29
MOCA
30
MOCA
31
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 2most 3good
    bit 4some 5little 6none cutoff lt M 4
  • Validated against NP overall performance in the
    Netherlands Good for busy clinics
  • Knippels, Goodkin, Weiss, et al., AIDS,
    200216259-267

32
Mathematical Screening
  • Cysique et al.
  • Cognitive impairment is predicted to occur when
    this expression is true

33
Step 1 Neuropsych performanceStep 2
Functional Impairment?
34
How To Assess Functional Impairment?
  • Collateral Informant and Objective ratings are
    most reliable
  • IADL scale (Lawton)
  • Driving Performance (Marcotte et al.)
  • Karnofsky, Finances, Medications

35
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36
What to do with a positive screen?
  • Rule out other causes
  • Always consider the biopsychosocial model
  • Treatment
  • Antiretrovirals
  • Psychostimulants
  • Other treatments being studied

37
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

38
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

39
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

40
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

41
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?

42
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43
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

44
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

45
"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

46
PHQ-9
47
(No Transcript)
48
What to do with a positive screen?
  • Assess for suicidality
  • R/o other causes (biopsychosocial model)
  • Refer to treatment (talk, meds)

49
Suicidality
50
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 STDs Volume 26, Number 5,
2012
51
Risk
  • History of suicide attempt(s)
  • Diagnosable mental health disorder
  • History of psychiatric treatment
  • Substance use
  • Anxiety sensitivity cognitive concerns

52
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?

53
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-a)
  • Medical illness

54
SBQ-R (Osman et al)
55
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

56
PTSD Screening
  • The estimated rate of recent PTSD among
    HIV-positive women is 30.0 (95 CI 18.842.7),
    which is over five-times the rate of recent PTSD
    reported in a national sample of women

57
PC-PTSD
58
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

59
Substance abuse
60
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

61
Why Bother to Screen?
  • Active substance use can lead to increased
    morbidity and mortality
  • Substances can interact with HIV medications

62
Screening Tools
  • Physical Exam
  • Mental Status Exam
  • CAGE questionnaire

63
CAGE
64
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

65
Domestic Violence
66
Facts
  • For HIV women, the estimated rate of intimate
    partner violence is 55.3 (95 CI 36.173.8),
    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)

67
Why Bother to Screen?
  • Safety of patient
  • Safety of others
  • Family
  • Friends
  • Staff

68
Screening Tools
69
(No Transcript)
70
http//www.cdc.gov/ncipc/pub-res/images/ipvandsvsc
reening.pdf
71
What to do with a positive screen?
  • Assess for current safety
  • Document
  • Refer
  • Safe shelter
  • Mental health
  • Report

72
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

73
Axis II Flags
  • Everyone
  • No one
  • Always
  • Never

74
The End
  • Thank you for taking care of our community!
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