HAND Diagnostic Issues HAND Diagnostic Issues Addressing Mental - PowerPoint PPT Presentation

HAND Diagnostic Issues HAND Diagnostic Issues Addressing Mental Addressing Mental Health Health Dr. Adriana Carvalhal, MD, MSc, PhD University of Toronto –St. Michael’s Hospital

Disclosure Research: Canadian Institute Health Research (CIHR) - I Ontario HIV Treatment Network (OHTN) - I Company Abbvie Bristol-Myers Janssen Laboratories Squibb Canada Biotech Consulting I I I Speaking & I I Teaching Advisory I Board D – Relationship is considered directly relevant to the presentation. I – Relationship is NOT considered directly relevant to the presentation.

Introduction  Transition of HIV to a chronic disease  Challenges have changed with the advances in the treatment – shifted to the treatment of comorbidities  HIV-positive patients continue to face: • Extensive social challenges • Stigma and discrimination • Social isolation Heywood & Lyons, 2016

HIV and Psychiatric Disorders Risk Poor QoL HIV Psychiatric Disorders Severity Poor self-care Adherence Worse clinical outcomes Impairment in social and vocational functioning Use of health services Relf, MV et al. 2013. Carvalhal, et al. 2012.

Impact of Psychiatric Disorders In HIV Care HIV Retained Linked to HIV Viral On ART Infected Diagnosed Care in Care Suppression

Depression  Depression is the most common psychiatric disorder in HIV-infected patients  Lifetime prevalence is 20-45% (general population=9%)  Depression is the leading cause of disability and is associated with negative outcomes:  Low productivity  Medication non-adherence  Cognitive complaints  Comorbidities: a. Cardiovascular disease b. Stroke c. Diabetes d. Substance use e. Suicidality Hammond et al 2016 Murray et al 2013 Hees et al 2013

Why so high prevalence?  Direct effect of the virus on the immune system  High viral load  Symptoms burden  Emotional reaction to the diagnosis  Social stigma  Individuals with previous history Sowa et al 2016 Hammond et al 2016 Miller et at 2009

Depression and Cognitive Functioning Depression and Cognitive Functioning  Depression is associated with poor neurocognitive functions  Depressive symptoms predict cognitive complaints  Untreated depression affect cognition  “Resistant depression” can be symptom of HAND  Treatment for depression can improve cognitive symptoms  Best clinical practice to treat depression before referring patients to full neuropsychological assessment Cysique et al 2016 Carter et al 2003.

Screening for depression  Patients may not recognise or self-report Screening symptoms of depression 1  Some physicians may also be afraid to ask questions about psychological health Diagnosis  A wide variety of depression screening techniques are available 2  Most rely on self-reporting Monitoring  Some tools focus in physical symptoms  Most diagnose the severity rather than presence of depression 1. New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2010. Available at: http://cdn.hivguidelines.org/wp‐content/uploads/depression‐and‐mania‐posted‐10‐19‐2010.pdf. Last accessed July 2013. 2. Ramasubbu R et al. Ann Clin Psychiatr 2012;24:82 –90 .

Screening for depression  Many screening techniques can be performed in ≤ 10 minutes 1  Screening methods as short as two questions have been recommended 2  Questionnaire length does not impact accuracy 3 1. Ramasubbu R et al. Ann Clin Psychiatr 2012;24:82–90; 2. New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2010. Available at: http://cdn.hivguidelines.org/wp‐content/uploads/depression‐and‐mania‐posted‐10‐19‐2010.pdf. Last accessed July 2013; 3. Akena D et al. BMC Psychiatry 2012;12:187.

Screening for depression  Centre Epidemiological Studies – Depression – CES-D  Simple, quick and easy to interpret  Screening tools assess several somatic symptoms  Scoring > 16 Occasionally or a Rarely or none Some or a little Most or all the time (5-7 moderate amount of (less than 1 day) (1-2 days) days) time (3-4 days) I was bothered by things that usually don ’ t bother me. I felt hopeful about the future Radloff 1977

Confounding factors for the diagnosis of depression Confounding factors for the diagnosis of depression When diagnosing HIV patients with Screening depressive symptoms, it may be necessary to exclude the following possible causes: Diagnosis Bipolar disorder • Other Post-traumatic stress disorder • neuropsychiatric • HIV-associated dementia disorders • Alcohol and substance abuse Monitoring Endocrinological abnormalities • HIV-related HIV-related treatments • medical • Opportunistic and other infections conditions and (e.g. syphilis) treatments HIV-associated dementia • New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2010. Available at: http://cdn.hivguidelines.org/wp‐content/uploads/depression‐and‐mania‐posted‐10‐19‐2010.pdf. Last accessed July 2013.

Breaking Down the Siloes: Effective Multidisciplinary Team

Psychiatric Care for PHA at SMH Care in the Care in Primary Care at the Community Care Hospital Chan & Carvalhal, 2015 Carvalhal, 2015

HIV Care at St. Michael’s Hospital •  HIV care Primary care – HIV Program • Positive Care Program • Family physicians (5) • ID (5) • Nurse practitioner (1) • Hepatologist (1) • Psychiatrist (1) • Psychiatrist (1) • Social worker (1) • Nurse (3) • Dietician (1) • Dietician (1) • Pharmacist (1) • Physiotherapist (1) • Social worker (1) • Pharmacist (2)

HIV Care at St. Michael’s Hospital Care in the Community

HIV Care at St. Michael’s Hospital Casey House Casey House • 14 beds • Transition from hospital to community • Community services • SMH team: • ID • Psychiatrist

HIV Care at St. Michael’s Hospital McEwan Housing – McEwan Housing – Positive Service Positive Service Coordination Coordination • Intensive case management (15 – 20 clients/case manager) • Housing and fast track to engage in care • 100 patients in the program

HIV Care at St. Michael’s Hospital Complex Care Complex Care • Target population: • HIV-positive patients who are aging • Complex health issues • High service users • Cognitive disorders

In Summary 1. Despite many advances in the treatment of HIV infection, psychiatric disorders remain a challenge and a significant proportion of patients with HIV suffer from depression. 2. Psychiatric disorders create challenges for engagement in care and increase the likelihood of engaging in high risk behaviour. 3. Synergistic mechanisms between depression and HIV may be related to stress and immune dysfunction. 4. Depression is associated with negative outcomes such as low productivity, medication non-adherence and other comorbidities (e.g. cardiovascular disease, diabetes, and substance use). 5. Traditional models of delivery psychiatric care in HIV-infected patients do not work. We have to think “outside the box”. It is all about networks that we are able to develop.

HAND Diagnostic Issues HAND Diagnostic Issues Addressing Mental Addressing Mental Health Health Thank Y ou!