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Mental Health Screening Tools for the HIV Clinician Lawrence M. Mc Glynn MD Clinical Associate Professor Stanford University Faculty Medical Director San.

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Presentation on theme: "Mental Health Screening Tools for the HIV Clinician Lawrence M. Mc Glynn MD Clinical Associate Professor Stanford University Faculty Medical Director San."— Presentation transcript:

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 let’s 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) Mild Neurocognitive Impairment (MNI) HIV-Associated Dementia (HAD) No Functional Impairment Mild Functional Impairment Moderate to Severe Functional Impairment 1 SD 2 Domains 2 SD 2 Domains NIMH, NINDS Panel, Neurology 2007; 69:1789-1799 1 SD 2 Domains

11 Prevalence of HAND based on New Criteria NP Normal (30-60%) MNI (20-30%) HAD (5-20%) Functional Impairment ANI (20-30%) NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

12 Risk and Protective Factors Risk factors Age > 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 GP’s accuracy in identifying incident dementia? Am J Geriatr Psychiatry 17:11, 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)


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 MAXIMUM SCORE PATIENT SCORE TEST MEMORY - REGISTRATION Give 4 words to recall (dog, hat, green, peach) and 1 second to say each. Then ask the patient to repeat all 4 after you have said them. 4 ATTENTION/EXECUTIVE FUNCTION Antisaccadic eye movements (20 commands): ____ errors out of 20  3 errors = 4; 4 errors = 3; 5 errors = 2; 6 errors = 1;  6 errors = 0 6 PSYCHOMOTOR SPEED Ask patient to write the alphabet in uppercase letters horizontally across the page (use back of form) and record time: _____ seconds  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;  36 sec = 0 4 MEMORY - RECALL Ask for the 4 words from MEMORY – REGISTRATION TEST 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 ½ point for each correct word after prompting. 2 CONSTRUCTION Copy the cube below. Record time _____ seconds  25 sec = 2; 25-35 sec = 1;  35 sec = 0 Adapted From: Power C et al.: HIV Dementia Scale: a rapid screening test. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1995;8:273-278. Used with permission. Total score < 10: HAD 11-13: Mild cognitive impairment

24 Modified HIV Dementia Scale Max Score Pt. ScoreTask 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; > 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. ( 35 sec = 0) Total Score Max= 12/12 < 7.5 may indicate dementia and should be evaluated by full battery if possible







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; 2=most; 3=good bit; 4=some; 5=little; 6=none [cutoff < M= 4] Validated against NP overall performance in the Netherlands; Good for busy clinics Knippels, Goodkin, Weiss, et al., AIDS, 2002;16:259-267

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

33 Step 1: Neuropsych performance Step 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


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?


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 ill Am 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


48 What to do with a positive screen? Assess for suicidality R/o other causes (biopsychosocial model) Refer to treatment (talk, med’s)

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- α) 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 18.8–42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women


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


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 36.1–73.8%), 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


70 res/images/ipvandsvscreening.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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