Why Are Mental Disorders the Missing Link to Providing Effective HIV Prevention, Care & Treatment

1. Why Are Mental Disorders the Missing Link to Providing Effective HIV Prevention, Care & Treatment A Summary of the Research Francine Cournos, M.D.Milton Wainberg, M.D.July 24, 2012

2. Years of Life Lost to Disability (YLD) • 5 out of 10 of the most disabling illnesses in the world are mental illnesses. • Depression tops the list at #1 for both adults and adolescents. • Other illnesses among the most disabling are alcohol use disorders, schizophrenia, bipolar disorder and drug use disorders. • This is the case in low, middle and high income countries. WHO, Global Burden of Disease, 2008 Update

3. 5 Mental Illnesses Are among the Top 10 Causes of Years Lost to Disability (YLD) Worldwide WHO, Global Burden of Disease, 2008 Update

4. Why is Mental Illness Such a Common Cause of Disability? • Mental disorders are relatively common. • They usually begin early in life and often persist. • The severe stigma of mental illnesses interferes with treating them. • Untreated severe depression and acute psychosis are classified as more disabling than untreated AIDS, tuberculosis, congestive heart failure and malaria • The prevention, detection and treatment of mental illness remains a low priority, including in the international HIV community. WHO, Global Burden of Disease, 2008 Update, and other references

5. Mental Illnesses precede HIV infection in most-at-risk populations • IDU: High rates of alcohol/substance use disorders and depression • MSM: Elevated rates of alcohol/substance use disorders, depression and anxiety disorders • Sex Workers: Elevated rates of addictive disorders, suicidal ideation and posttraumatic stress disorder • Primary HIV prevention involves reaching special populations with high rates of mental illness

6. Mental Illnesses have been identified as a major contributor to HIV-related risk behaviors across studies PrimaryHIV prevention—Alcohol/substance use disorders, depression and other severe mental illnesses are associated with sexual risk behavior and drug injection among those who are HIV negative. Secondary HIV prevention—Alcohol/substance use disorders, depression and other severe mental disorders are associated with transmission risk behaviors among those who are HIV positive.

7. Psychosocial Support/Structural Interventions Are Protective of Health Strength of Psychosocial Support/Structural Interventions Weak Strong More Physical and Mental Illness Less Physical and Mental Illness Structural Interventions include food, $, transportation, indoor plumbing, etc.

8. However, Illnesses Still Occurand Need Treatment • In the case of HIV disease, there is international funding and efforts to provide care and treatment regardless of the available level of psychosocial support and structural interventions. • In the case of mental illnesses, the wrong assumption is often made that they can be managed solely through psychosocial support and structural interventions. • Mental illnesses, like physical illnesses, need specific treatment when they occur.

9. AFFECTIVE Depressed mood Loss of interest Guilt, worthlessness Hopelessness Suicidal ideation SOMATIC Appetite/Weight loss Sleep disturbance Agitation/retardation Fatigue Loss of concentration Depression is aMedical Co-morbidity of HIV Infection DepressionInflammation

10. Depression Is One of the Most Frequent Medical Co-morbidities of HIV Infection • Depression is the most common mental disorder and on average is present in 30%-50% of HIV+ people in HIV care and treatment settings. • Depression rates vary by study design (e.g. population, severity threshold, measurement tools, etc); they range from 0%-80%. • People living with HIV and chronic depressive symptoms have a two times greater risk of dying than people living with HIV who are not depressed. • Sherr et. al., Psychology, Health and Medicine, 2011 and other references

11. Depression and HIV-related Mortality HERS cohort: 765 HIV+ women at 4 sites in U.S. followed for up to 7 years • Mortality predictors: chronic depression, CD4 count, antiretroviral treatment duration, age • After adjusting for all other variables, women with chronic depressive symptoms were twice as likely to die as women with limited or no depressive symptoms. Results repeated in other U.S. studies Cook et al., Am J Public Health, 2004 Ickovics et al., JAMA, 2001

12. Depression and HIV-related Mortality • 996 HIV+ pregnant women in Tanzania followed for 6-8 years without antiretroviral treatment (vitamin supplementation study, 1995 – 2003) • WHO clinical stage I (82%) and stage II (17%) • 31% died during follow-up • Depression associated with • A 60% increase risk of progressing to clinical stage III/IV disease • A greater than two-fold increased risk of death • Antelman et al., JAIDS, 2007

13. Depression and HIV Care and Treatment • Untreated depression is associated with failure to access HIV care and treatment. • Untreated depression is associated with failure to adhere to HIV care and treatment. • These facts call for early detection and treatment of depression. • Yet, international funding for HIV care and treatment has not routinely included the screening and treatment of depression as part of HIV care.

14. Associations Between DepressionTreatment and Antiretroviral Use and Outcomes • Conversely, participating in treatment for depression among HIV+ people is associated with better outcomes. • Use of antidepressants + mental health therapy, or mental health therapy alone, associated with increased antiretroviral utilization (N = 1,371) • Compliant SSRI use associated with improved HIV adherence and laboratory parameters (CD4 cell count and viral load) Cook et al., AIDS Care, 2006,Horberg et al., JAIDS, 2008

15. Following Severe Depression, Alcohol Use Disorder Is the Next Most Disabling Mental Illness • Inaddition to causing disability, having an alcohol use disorder or using alcohol in a hazardous way (including before sex) increases the risk of acquiring HIV. • Among HIV positive people, heavy drinking predicts: • poor medication adherence • HIV progression • liver damage and end stage liver disease • overall mortality Chander et al, J Acquir Immune Defic Syndr. 2006 and other references

16. The Good News: Mental Illness can be successfully screened for and treated • Depression and other mental illnesses, including alcohol and substance use disorders, can be successfully screened for and treated in primary care and HIV care. • There are well developed guidelines for accomplishing screening and treatment of mental illnesses. • Treatments for mental illnesses compare favorably to treatments for other chronic diseases. • Successful treatments for mental illness include medications and psychotherapies

17. Further Good News: Similar Outcomes are Accomplished among those with Psychotic Disorders • People in care for psychotic disorders (such as schizophrenia) respond well to HIV prevention strategies and reduce their risk behaviors. • People in care for psychotic disorders are as adherent to antiretroviral treatment as the general population. • In Sub-Saharan Africa there are successful models for delivering HIV testing, care and treatment within psychiatric institutions.

18. In Summary • Affordable and effective interventions for preventing, screening and treating prevalent and disabling mental illnesses are available. • These interventions have been shown to improve health outcomes for people living with HIV and can be delivered by providers in HIV care and primary care settings. • Despite these compelling facts, very little international or country level HIV-related funding is devoted to screening for and treating mental illnesses.

19. Where To From Here? • We can’t ignore mental illnesses and expect to provide effective HIV prevention and treatment. • Each one of us is needed to change the current neglect of mental illnesses. How do we advocate successfully? • Our panelists will present successful examples for integrating mental health care with HIV care and treatment.