Update On Psychiatric Aspects of Emerging Infectious Diseases (HIV, HCV, SARS and West Nile)

1. Update On Psychiatric Aspects of Emerging Infectious Diseases(HIV, HCV, SARS and West Nile) Eric Avery M.D. Associate Clinical Professor of Psychiatry Associate Member, Institute for the Medical Humanities University of Texas Medical Branch Galveston, Texas

2. Objectives At the conclusion of this presentation, the participants should be able to: • Describe the evolving trends in the care of the HIV+ patient population and the implications for the role of the psychiatrist in prevention and treatment. • Describe the psychiatric screening process and treatment of psychiatric disorders in HCV patients. • Recognize the neuropsychiatric manifestations of the WNV infected patient. • Describe how the SARS outbreak in Canada defines the role of the psychiatrist in preparing for and participating in the treatment of emerging infectious diseases.

3. HIV/AIDS Objective: • Describe the evolving trends in the care of the HIV+ patient population and the implications for the role of the psychiatrist in prevention and treatment.

8.  Risk for HIV Substance abuse Major depression Impulsive behavior & personality factors Cognitive impairment HIV Infection Psychiatric Illness HIV Is a Psychiatric Epidemic •  Risk for psychiatric illness •  Major depression •  Mania • HIV dementia (AIDS dementia complex) •  Psychosocial stressors Effective treatment of psychiatric illness may improve patient outcomes

9. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment Glenn J. Treisman, M.D., Ph.D.Andrew F. Angelino, M.D. The Johns Hopkins University Press 2004

10. Primary Diagnosis of Patients at First Appointment for HIV Care (N=250) Treisman 2004

11. HIV Among People with Chronic Mental Illness • Since the early 1990’s, thirteen studies of HIV infection among adults in psychiatric setting in the U.S. have been published in peer-reviewed literature. • These studies show a combined HIV seroprevalence of 6.9%. • Urban centers 5% • Smaller cities 1.7% • U.S. Population HIV infection rate 0.4% McKinnon, 2002

12. Depression: Multicenter AIDS Cohort Study % Depressed Time of AIDS Onset 0-6 0-6 7-12 7-12 55-60 49-54 43-48 37-42 31-36 25-30 19-24 13-18 13-18 19-24 Time (months) Before AIDS diagnosis After AIDS diagnosis Percentages of Multicenter AIDS Cohort Study participants who met syndromal criteria for depression, or who had a score of 22 or greater on the Center for Epidemiologic Studies Depression scale (CES-D) or 14 or greater on the CES-D minus its “somatic” items (CES-D-NS), as AIDS developed. Lyketos et al, Psych Ann 31: 1 Jan 01

13. Depression and Progression to AIDS: Pre-HAARTShafer, Delorenze, Satariano, WinkelsteinAnn Epi 1996 • San Francisco Men’s Health Study: 395 participants • 34% depressed at baseline (different baseline than Burrack) • Depression at baseline predicted death

14. Depression and Progression to AIDS: Post-HAART HIV-Related Mortality 1.0 • HERS Cohort: 765 Participants • Longitudinal depression (CES-D) • 42% chronic • 35% intermittent • 23% limited or none • Mortality predictors: depression (RR=2), CD4, HAART duration, age 0.9 Cumulative Survival 0.8 0.7 0 1 2 3 4 5 6 7 Total Time in Study (y) Ickovics, Hamburger, Vlahov et al JAMA 2001

15. 1 0 I do not feel sad. 1 I feel sad. 2 I am sad all the time and I can’t snap out of it. 3 I am so sad or unhappy that I can’t stand it. 2 0 I am not particularly discouraged about the future. 1 I feel discouraged about the future. 2 I feel I have nothing to look forward to. 3 I feel that the future is hopeless and that things cannot improve. 3 0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failures. 3 I feel I am a complete failure as a person. 8 0 I don’t feel I am any worse than anybody else. 1 I am critical of myself for may weaknesses or mistakes. 2 I blame myself all the time for my faults. 3 I blame myself for everything bad happens. 9 0 I don’t have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance. 10 0 I don’t cry any more than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I used to be able to cry, but now I can’t cry even though I want to. Beck Depression InventoryDate__________________Name:_________________________________________________ Marital Status:_______ Age:___ Sex:___ Occupation:___________________________________________ Education:___________________________This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number (0,1,2 or 3) next to the one statement in each group which best describes the way you have been feeling the past week, including today. If several statements within a group seem to apply equally well, circle each one. Be sure to read all the statements in each group before making your choice. To order forms: 1-800-228-0752

16. Mood Disorder Questionnaire Hirschfeld et al (2000)

19. HIV and Post Traumatic Stress Disorder M.B. Molded paper woodcut on handmade paper28 ¼” x 23” edition: 10 E.D. 04/23/99 Molded paper woodcut on handmade paper28 ¼” x 23” edition: 10

20. Post Traumatic Stress Disorder • Over half the U.S. population has been exposed to a severe trauma • 10-20% of trauma survivors will develop PTSD • Lifetime prevalence 8% overall. 12% in women • Increased rates in HIV +, incarcerated • Limited studies: • HIV + 30% (1/3 after HIV dx) • Incarcerated women lifetime 33%, current 15-22% • PTSD is the 5th most prevalent major psychiatric illness

21. Most Prevalent Anxiety Disorders in the General Population Males Females Hutton (2001) 177 Prison Women Kelly (1998) 61 HIV+ Gay/Bi men Lifetime Prevalence (%) Kessler et al, National Comorbidity Survey, 1994

22. Frequency of PTSD Disorders Among 177 Women Prisoners in an HIV Risk Behavior Study Women prisoners Percentage amonggeneral population Disorder N % Posttraumatic stress disorder1Lifetime 59 33 1-14 Current 27 15 <1 Compared with participants who did not have PTSD, those with lifetime diagnosis of PTSD were 71% more likely to have engaged in anal sex and 56% more likely to have engaged in prostitution. The association between lifetime PTSD and other HIV risk behaviors were not significant in this study. Hutton, Psych Services 2001, 52/4:508-13

23. Why AIDS Psychiatry? • The majority of persons who become infected in the United States engage in high rates of risky behaviors that are associated with the vulnerabilities seen in psychiatric disorders. Our patients are disproportionately being infected. • Psychiatric disorders decrease patients’ ability to gain access to medical care because these disorders disorganize patients often making them feel hopeless and because medical care of psychiatric patients in complex and time consuming. • Mentally ill persons are economically disadvantaged, often being “carved out” by managed care organizations, resulting in fragmented care. • Psychiatric disorders have a negative effect on a person’s adherence to medical care. The effective treatment of psychiatric disorders decreases the risk of getting HIV and for those already infected, improves function, quality of life and adherence to medical treatment. Treisman 2004

24. Hepatits C Objective: • Describe the psychiatric screening process and treatment of psychiatric disorders in HCV patients.

25. Corcoran Museum of ArtWashington D.C.

26. LIVER DIE: A Print Action for Health March 31 – April 3, 2005

27. LIVER DIE Medical Care in the Art Museum

28. LIVER DIE Participants: Rae Johnson, R.N., John Hogan, M.D., Eric Avery, M.D.

30. Hepatitis C Prevalence Across Varied Study Samples Psychiatric Annals 33:6. JUN 2003

31. Psychiatric and Substance Use Comorbidity Among Northwest Veterans Tested for HCV AntibodyNovember 1996 to August 2000 Psychiatric Annals 33:6. JUN 2003

32. HCV Among Institutionalized Mentally Ill Patients: Ben Taub, Houston 83/95 (50% male) tested for HCV 14/83 HCV+ = 16.9% Psychiatric Diagnoses/HCV+ Depression 31% Bipolar 10% Psychosis 8.8% Cluster B 36.8% No Axis II 10% Substance abuse, previous STD, physical and sexual abuse and homelessness had statistically significant associations with HCV+.

33. HCV Among Institutionalized Mentally Ill Patients: R. Sealy, UTMBApril 24-25, 2005 41 Patients on RS3A, 3B, 3C 6/30 = 20% HCV+ Of 11 inpatients without ALT test, perhaps 1-3 would test HCV+

34. Events ALT anti-HCV HCV RNA SYMPTOMS // Months // Year Clinical and Laboratory events associated with hepatitis C virus infection. Clinical Virology, 2002.

35. To Test or Not to Test? At risk, check ALT. If increased, hepatitis screen. (CDC.gov) If -, HCV prevention (Harm Reduction) If +, education to decrease transmission If +, refer to Hepatitis Clinic/specialist If +, no HCV Tx until Comorbid psychiatric problems treated + Motivator = Want HCV TX? - Motivator = you will get sicker if you are not treated

36. Suggested Approach for Assessing and Managing INF-Induced Depression • Because depression my be as high as 50% in IFN-treated patients: • Inform patient about risk of depression • Educate on how to recognize symptoms • Explain depression treatment options • Before INF treatment, psychiatric evaluation for patients with: • Current episode of depression or history of depression (mood swings) • History of psychiatric hospitalization • History of substance abuse or dependence • Family history of depression or suicide attempts

37. Suggested Approach for Assessing and Managing INF-Induced Depression • If depressed when evaluated for INF treatment • Treat the depression first, then INF • When monitoring the patient for depression during INF: • Use a screening instrument • Patient minimize to continue INF • If depressed, treat aggressively with SSRI • If depressed and not responding, INF can be decreased • If depression is severe (suicidal/psychotic) IFN discontinued • +/- need for psychiatric admission NIH Concensus Conference 1997 Zdilar Hepatology 2000

38. Research Question: Pretreatment of HCV Patients at Risk for Depression with SSRI? Paroxetine for the Prevention of Depression Induced by High-dose Interferon Alfa Musselman NEJM 2001

39. West Nile Virus Objective: • Recognize the neuropsychiatric manifestations of the WNV infected patient.

40. http://www.cdc.gov/ncidod/dvbid/westnile/surv&control04Maps.htmhttp://www.cdc.gov/ncidod/dvbid/westnile/surv&control04Maps.htm

41. 2004 http://www.cdc.gov/ncidod/dvbid/westnile/surv&control04Maps.htm

42. West Nile Virus • Isolated 1937 in West Nile district of Uganda • Outbreaks in Africa and the Middle East caused “West Nile Fever”-- non-specific and self-limited viral illness • Outbreak in South Africa in mid-1970s had 18,000 cases with no reports of encephalitis and no deaths • Major change in virulence appeared in later outbreaks: • Romania (1996), Russia (1999), Israel (2000) • Western hemisphere (1999-present) • Unprecedented rates of encephalitis and mortality indicate evolution of a new strain with greater neurotropism and neurovirulence

43. WNV Clinical Presentation • Incubation period – 2-21 days after infection (generally 2-6 days in WN fever). • Those requiring hospitalization generally complain of: • Fever –GI complaints (diarrhea) –confusion • headache –myalgia –malaise –rash • fatigue

44. WNV Clinical Syndromes • Most striking feature and greatest concern is invasive neurologic disease. • Neurologic disease ranges from meningitis to movement disorders to acute flaccid paralysis resembling poliomyelitis. • West Nile – CNS 2,863 (29%) of 9,858 cases reported to CDC in 2003 were neuroinvasive • Risk Factors: • Immunocompromised • Older • Male gender

45. WNV Human Infection “Iceberg” ~10% fatal (<0.1% of total infections) 1 CNS disease case = ~150 total infections <1% CNS disease Very crude estimates ~20% “West Nile Fever” ~80% Asymptomatic

46. Follow-up Features in 16 Patients After Acute WNV-CNS in Louisiana Patients: • 5 meningitis • 8 encephalitis • 3 poliomyelitis – like Clinical Features: • Tremor (94%) • Myoclonus (31%) • Parkinsonism (69%) • Balance and gait (19%) All had altered mental status, the most common were behavioral or personality changes, including irritability, confusion or disorientation. Sejvar JAMA 2003

47. 4/6/05 FAX From Clinical Social Worker to My Office Female patient is HIV+, lives in Beaumont, Texas area “New observations of CTs decrease motor and cog. Skills: Ct increasing confused, motor skills slower i.e. unable to tie shoe, slow getting out of bed, unable to find her way to my office room – then lost in room didn’t know what to do. Her mom reports onset of change abt 1 wk prior to appt. Also: Ct sent home from job due to inability to carry out assigned duties that she has done routinely for 15 years. Please evaluate - although oriented x3 Ct. drastic change in cog. and motor skills have me very concerned.”

48. “In mosquito season, fever and altered mental status, think West Nile” Infectious Disease Faculty UTMB 2005

49. SARS Objective: • Describe how the SARS outbreak in Canada defines the role of the psychiatrist in preparing for and participating in the treatment of emerging infectious diseases.

50. C. J. and Susan Peters Taiwan 2004