1. Mental Health in HIV Patients

2. Objectives
To become aware of the prevalence of HIV in the mental health patient
To understand risk behaviors of mental health patients infected with HIV
To obtain current prevention tactics in mental health patients infected with HIV
To discuss interactions with psychiatric medications and antiretrovirals

3. What is the prevalence of HIV infection in people who suffer from chronic mental illness?
A recent study of waste blood from 350 samples in a New York psychiatric unit revealed that 7% were HIV+.
Another study, which used a questionnaire to assess risk factors for HIV, showed that HIV-seroprevalence was 0.6% in the lowest-risk group, but increased to 14.4% among the high-risk groups of psychiatric patients.

4. Risk Factors
A New York study of 25 inpatients and outpatients with schizophrenia revealed that 44% had been sexually active during the preceding six months, and 62% of those who had been sexually active had had multiple partners.
Sexual activity has been shown to be associated with
greater psychopathology.
Having multiple sexual partners is associated with a younger age, a lower level of functioning, and the presence of positive symptoms of schizophrenia.

5. Risk factors http://www.cpa-apc.org/Publications/HIV/ment-ill.pdf
This Canadian study (Chuang and Atkinson 1996), conducted in 1995, revealed similar results (Table 10.1). In this study, which looked at 151 patients with a diagnosis of schizophrenia or mood disorder, more than 50% of the study subjects had been sexually active in the past year; 16% had had sex with someone they knew less than 24 hours; 33% would “give in” to their partner’s desire not to use a condom; and 17% had had sex with more than one partner in the past year.

6. No, knowledge does not necessarily translate into behavior change.
Do patients who are well informed about HIV infection and its transmission change their behavior accordingly?
No, knowledge does not necessarily translate into behavior change.
Health behavior change is a function of:
perceived susceptibility to the disease
perceived seriousness of the disease
knowledge about the disease and its prevention
motivation to change, leading to a plan for action
skills to engage in risk reduction
environmental resources (for example, condoms)

7. What factors affect the ability of people with chronic mental illness to protect themselves against HIV infection?
Lack of information.
Lack of perception of being at risk for HIV infection.
Social cost of prevention may be perceived as too high.
Low self-esteem and fear of rejection.
Lack of faith in their ability to negotiate safer-sex practices.
Chronically mental ill women tend to be more vulnerable to exploitation by partners.
Impulsive behavior.
Decreased judgment secondary to personality disorder, mania, psychosis, or concomitant substance use.
Financial difficulties that may lead people with chronic mental
illness to trade sex for money or accommodation.
Chaotic lifestyle that may include multiple sexual partners.

8. Psychiatric Illnesses Associated with HIV
HIV Associated Dementia
Psychotic Disorders
Affective Disorders
Anxiety Disorders

9. Affective Disorders Major Depression Bipolar Disorder
Clinical Depression is the most commonly observed mental health disorder among HIV-infected patients, effecting up to 20% of patients. The prevalence may even be greater in those who are substance abusers.
Major Depression has a life time prevalence of about 15% and as high as 25% in women. Not infected with HIV
There is a higher incidence of depression in primary care patients and in medical inpatients.
Major depression has a higher incidence in singles and those without close interpersonal relationships.

10. Depression in HIV Patients
Depressive symptoms have been associated with increased risky behaviors, non-compliance to treatment, & shortened survival.
Failure to recognize and treat depression endangers both the patient and the community.
These patients are at a higher risk
for co-morbid disorders.
Co-morbid disorders include: other psychiatric disorders, poly-substance abuse. Alcohol, methamphetamine abuse, cocaine abuse as well as abuse of cannabis.

11. Depression in HIV Patients
Symptoms of Depression which would warrant a Psychiatric Consult
Depressed mood (stated by the patient or observed by the clinician)
Anhedonia (loss of interest or pleasure)
Feelings of guilt
Suicidal thoughts
Insomnia (middle insomnia)
A change in one’s weight
Attention or concentration problems
Decreased energy
Psychomotor agitation or retardation
Middle insomnia is waking up in the middle of the night and having difficulty falling back to sleep. They may have terminal insomnia which is waking up to early and not being able to return to sleep.
The weight change has to be 5% or greater either increased or decreased in one month.

12. Depression in HIV Patients
Many HIV patients will not report these symptoms, instead they will demonstrate behaviors changes
Behavior changes that would indicate a depressive episode
Non-Compliance with treatment regime
Difficulty making life choices
Ruminating thoughts
An inability to perform daily activities
Somatic complaints
Acting out behaviors

13. Depression in HIV Patients
Screening for Depression
Clinicians should screen for depression as part of the annual physical & whenever indicated
Simply asking patients, are you depressed have been shown to be effective.
Asking such questions as, during the past month have you often felt down, depressed or hopeless?
What do you enjoy doing these days?
Most of all do not be afraid to ask for a psychiatric consultation! Early intervention with psychotherapies and medication management have proven to be most effective in treating those who suffer from depression

14. Depression in HIV Patients
Early detection and intervention with psychotherapy and medication management has been proven to be the most effective treatment for those who suffer from depression.

15. Bipolar Disorder in HIV Patients
Bipolar Disorder is very difficult to treat and if untreated, the progression of the illness increase the risk of being infected with HIV.
Symptoms of Bipolar Mania
The lack of need for sleep
Poor impulse control
Sexually acting out
Excessive shopping (a disregard to paying bills)
Expansive thoughts
Irritable mood
Hyper-verbal speech
Psychomotor agitation

16. Bipolar Disorder in HIV Patients
Patients who present in a manic episode require immediate treatment, most likely hospitalization.
They are more likely to act out sexually with a disregard for their own safety as well as, the safety of others; by not practicing safer-sex.
Studies have indicated the prevalence of bipolar patients to be between 4% to 8%.

17. Bipolar Disorder in HIV Patients
Most Bipolar patients first symptom of mania is the decreased need for sleep with an abundance of energy.
It is important for the clinician to assess the individuals need for sleep, energy level and and signs of distorted thinking. This can be done on an annual basis or as indicated.
If in doubt, ask for a Psychiatric Consult.

18. Anxiety Disorders in HIV Patients
Anxiety disorders have been reported to be as high as 50% in HIV infected individuals.
Those who suffer from anxiety are 50% more likely to suffer from a major depressive episode.
Untreated anxiety has proven to diminish the effectiveness of the immune system, increases the use of substance
abuse, increase non-compliance
with treatment, and increased visits
to local emergency rooms.
By treating those depressed with a chronic illness, patients gain a sense of self, feel enjoyment and a desire do to the things they love, help them to regain a sense of accomplishment in social and occupational settings.

19. Anxiety Disorders in HIV Patients
Panic Disorder has been reported to affect around 2.4 million Americans.
PTSD has been reported to affect 5.2 million Americans, 30% of these individuals are war veterans.
OCD has been reported to affect 3.3 million Americans.
Generalized anxiety has been reported to affect 4 million Americans all according to the USSG.

20. Anxiety Disorders in HIV Patients
Symptoms of General Anxiety Disorder
Heart palpitations
Restlessness or feeling keyed up
Easily fatigued
Irritability
Muscle tension
Sleep disturbances
Somatic symptoms
Exaggerated startle response

21. Anxiety Disorders in HIV Patients
Patients who are diagnosed with HIV are at risk to develop anxiety if they are:
Newly diagnosed individuals
The patient becomes symptomatic
The patient receives news of a declining CD4 count or elevated viral load
At the onset of AIDS
When faced with disclosing of HIV
When dealing with relationship implications

22. Anxiety Disorders in HIV Patients
During these delicate times, clinicians need to evaluate for signs and symptoms of anxiety. Requesting a psychiatric consult if appropriate.
Assessing for anxiety can be as simple as asking the patient if they worry and what do they worry about.

23. Anxiety Disorders in HIV Patients
PTSD has a lifetime prevalence of 1.3% to 7.8% in the general population and a higher incidence in those infected with HIV.
Trauma has been associated with diminishing the immune system and increasing the risk for infections.
Psychological effects of PTSD may be manifested in increased risk-taking behaviors such as increase substance abuse, poor eating habits, & unsafe sexual behaviors.
Serotonin, norepinepherine and dopamine

24. Anxiety Disorders in HIV Patients
May experience episodes of depression, social isolation, trust or attachment issues, & uncontrollable rages.
An onset of PTSD may be triggered following news of testing positive.
This may occur in the form of denial, followed by nightmares, or as intrusive thoughts regarding the stigma of being HIV.

25. Anxiety Disorders in HIV Patients
Patients with PTSD may experience a disruption in the ordinary integration of consciousness, memory, or identity; also known as dissociation. Clinicians can screen for PTSD by assessing for history of trauma and the length of time symptoms have been present. Refer to Psychiatry if warranted.
Symptoms must be present for at least one year.

26. Anxiety Disorders in HIV Patients
Panic Disorder seems to be more common in HIV disease.
Patients who suffer from panic disorder are likely to present with following symptoms:
Accelerated heart rate, palpitations
Sweating
Trembling
Sensation of shortness of breath
Chest pain
Fear of dying or losing control
Numbness or tingling

27. Anxiety Disorders in HIV Patients
Panic Disorder can be triggered in the same manner of anxiety. These situations are more associated with provoking anxiety.
Newly diagnosed patients
Progression of the HIV illness
Dealing with the social implications of being diagnosed with HIV
Relationship issues

28. Anxiety Disorders in HIV Patients
Once again it is important for the clinician to educate the patient, assess the patient for panic disorder on a regular basis and refer or initiate treatment if warranted.
Quick response from the clinician helps to decrease an exacerbation of either the mental health aspect of HIV, the physical component of the illness or both.

29. Anxiety Disorders in HIV Patients
Obsessive-Compulsive Disorder (OCD). These patients tend to be more difficult to diagnosis. They are often aware of their behaviors and go to great lengths to hide their pathology.
However if untreated, these symptoms can impair ones medical treatment, ability to maintain gainful employment, & increases social isolation.

30. Anxiety Disorders in HIV Patients
Patients with OCD suffer from either obsessions, compulsion or both.
Signs of obsessions
Recurrent and persistent thoughts, they ruminate over minor issues which cause significant impairment of one’s life.

31. Anxiety Disorders in HIV Patients
Signs of compulsion, which are easier to recognize.
Repetitive behaviors such as, hand washing, ordering, checking, praying, counting, & repeating words silently.

32. Anxiety Disorders in HIV Patients
All of the anxiety disorders have the potential to effect the care of the patients with HIV. Recognizing individual symptoms and initiating treatment, or referring for psychiatric consultation increases the patient’s compliance to treatment, improved outcomes, decreased hospitalizations, and increases the communication clinicians have with these patients.
Assessing for anxiety symptoms on an annual basis or as indicated is suggested.

33. Psychotic Disorders in HIV Patients
Estimates of the prevalence of new-onset psychosis in patients with HIV range from 0.5% to 15%. This is higher then the incidence of psychosis in the general population.
Psychosis, inclusive of schizophrenia, schizoaffective, delusional disorder, brief psychotic episode, and other psychotic disorders contribute to behaviors which may lead to HIV infection.

34. Psychotic Disorders in HIV Patients
These behaviors include:
Higher rates of injection drug use
Unprotected sex
Multiple sex partners
Trading sex for money, drugs or other goods
Increased use of alcohol

35. Psychotic Disorders in HIV Patients
Evidence suggests that HIV infection may directly be linked to the onset of a psychotic episode.
New onset psychosis may also be a manifestation of HIV associated encephalopathy.
Early diagnosis and intervention is a key role in determining the outcome of one’s treatment. Treatment for these individuals follows the same guidelines as for those who suffer from psychotic features without HIV.

36. HIV Associated Dementia (HAD)
HAD presents with typical symptoms seen in other sub-cortical dementias. Following find some early symptoms patients may present with:
Memory & psychomotor speed impairments
Depressive episode
Movement disorders
Difficulty with reading and comprehending material
Difficulties with performing mathematical functions

37. HIV Associated Dementia (HAD)
Early HAD differs from Alzheimer's disease in that HAD is more likely to present with behavior changes and progress more rapidly.
Use of the modified HIV Dementia Scale is more ideal for aiding clinicians in diagnosing HAD. It takes about five minutes to administer in the clinic setting.

38. HIV Associated Dementia (HAD)
Despite the decreasing prevalence of HAD in recent years; due to the advances in treatment of HIV illness, cognitive impairment continues to be the most common CNS complication in people with HIV/AIDS. Delirium is the most common cognitive disorder in hospitalized patients with HIV.
Prompt diagnosis may significantly decrease morbidity and mortality.
This is most likely do to the progression of the illness

39. How to minimize the risk of HIV infection?
Regular detailed assessment
of sexual and drug risk
behaviors i.e. needle
sharing, anonymous sex, multiple sexual partners, and
unsafe sex.
Raise AIDS consciousness i.e. AIDS education as part of individual or group therapy.
Confront people with chronic
mental illness about high-risk
activities.
Help patients become more
assertive in saying “no” to
unsafe sex and high-risk
activities, such as the use of
street drugs or alcohol.
Learn to be more comfortable talking about specific topics such as homosexual behavior,
high-risk sexual activities.

40. Psychiatric Medications and HIV Antiretrovirals

41. Summary
It is well documented that HIV infection increases the risk of mental health disorders, including depressive episodes, mania, psychotic disorders, and substance abuse.
Patients who have a preexisting mental health condition, a diagnosis of HIV can significantly impact one’s ability to cope with HIV disease process, adhere to treatment plans, utilize support networks and other care systems, and can result in deterioration in one’s quality of life.

42. Summary
As individuals living with HIV/AIDS live longer, the long term psychological impact of HIV disease becomes more apparent.
Early detection of mental health illness in those infected with HIV leads to early interventions. Early treatment increases one’s quality of life and is essential in the over all care of these patients.