Mental health screening tools for the hiv clinician
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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 Jose AETC June 2013. Thanks. Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center

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Mental health screening tools for the hiv clinician

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


Thanks

Thanks

  • Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center

  • American Psychiatric Association – Office of HIV Psychiatry


Goals for participants

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


Mental health screening tools for the hiv clinician

  • 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 


Types of screening tools

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


Why screening tools

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


Cognitive dysfunction

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


Neuropsychological domains

Neuropsychological Domains

  • Verbal/Language

  • Attention/concentration

  • Working Memory

  • Executive/Abstraction

  • Memory (learning, recall)

  • Speed of information processing

  • Sensory-perceptual

  • Motor skills


Associated behavioral disturbances

Associated Behavioral Disturbances

Apathy

Depression

Sleep disturbance

Agitation/Mania

Psychosis


Hand classification

HAND Classification

Asymptomatic Neurocognitive

Impairment (ANI)

1 SD

No Functional

Impairment

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; 69:1789-1799


Prevalence of hand based on new criteria

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; 69:1789-1799


Risk and protective factors

Risk and Protective Factors

  • Risk factors

    • Age > 50

    • Survival duration

    • Lower nadir CD4 T-cell counts

    • Higher baseline viral load

    • Gender (F)


Why bother to screen

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.


Mental health screening tools for the hiv clinician

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.


Screening tools

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


International hiv dementia scale ihds

International HIV Dementia Scale (IHDS)


1 memory registration

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.


2 motor speed

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


3 psychomotor speed

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


4 memory recall

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. _____


Total international hiv dementia scale score

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.


Hiv dementia scale

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

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

6

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

Total score < 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 1995;8:273-278. Used with permission.


Modified hiv dementia scale

Modified HIV Dementia Scale


Mental health screening tools for the hiv clinician

MOCA


Mental health screening tools for the hiv clinician

MOCA


Mental health screening tools for the hiv clinician

MOCA


Mental health screening tools for the hiv clinician

MOCA


Mental health screening tools for the hiv clinician

MOCA


Cognitive functional status sub scale of mos hiv scale of wu et al

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


Mathematical screening

Mathematical Screening

  • Cysique et al.

  • Cognitive impairment is predicted to occur when this expression is true


Step 1 neuropsych performance step 2 functional impairment

Step 1: Neuropsych performanceStep 2: Functional Impairment?


How to assess functional impairment

How To Assess Functional Impairment?

  • Collateral Informant and Objective ratings are most reliable

    • IADL scale (Lawton)

    • Driving Performance (Marcotte et al.)

  • Karnofsky, Finances, Medications


What to do with a positive screen

What to do with a positive screen?

  • Rule out other causes

    • Always consider the biopsychosocial model

  • Treatment

    • Antiretrovirals

    • Psychostimulants

    • Other treatments being studied


Depression and anxiety

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


Epidemiology anxiety

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


Epidemiology depression

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


Why bother to screen1

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


Screening tools1

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?


Anxiety questions

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


Depression questions

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


Are you depressed screening for depression in the terminally ill am j psychiatry 1997

"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


Mental health screening tools for the hiv clinician

PHQ-9


What to do with a positive screen1

What to do with a positive screen?

  • Assess for suicidality

  • R/o other causes (biopsychosocial model)

  • Refer to treatment (talk, med’s)


Suicidality

Suicidality


Epidemiology

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


Mental health screening tools for the hiv clinician

Risk

  • History of suicide attempt(s)

  • Diagnosable mental health disorder

  • History of psychiatric treatment

  • Substance use

  • Anxiety sensitivity – cognitive concerns


Why bother to screen2

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?


Screening tools2

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


Sbq r osman et al

SBQ-R (Osman et al)


What to do with a positive screen2

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


Ptsd screening

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


Pc ptsd

PC-PTSD


What to do with a positive screen3

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


Substance abuse

Substance abuse


Epidemiology1

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


Why bother to screen3

Why Bother to Screen?

  • Active substance use can lead to increased morbidity and mortality

  • Substances can interact with HIV medications


Screening tools3

Screening Tools

  • Physical Exam

  • Mental Status Exam

  • CAGE questionnaire


Mental health screening tools for the hiv clinician

CAGE


What to do with a positive screen4

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


Domestic violence

Domestic Violence


Facts

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)


Why bother to screen4

Why Bother to Screen?

  • Safety of patient

  • Safety of others

    • Family

    • Friends

    • Staff


Screening tools4

Screening Tools


Http www cdc gov ncipc pub res images ipvandsvscreening pdf

http://www.cdc.gov/ncipc/pub-res/images/ipvandsvscreening.pdf


What to do with a positive screen5

What to do with a positive screen?

  • Assess for current safety

  • Document

  • Refer

    • Safe shelter

    • Mental health

  • Report


The great imitators

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


Axis ii flags

Axis II Flags

  • “Everyone”

  • “No one”

  • “Always”

  • “Never”


The end

The End

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