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Psychiatric Issues in Adolescents with HIV/AIDS Ann M. Usitalo, PhD UF CARES University of Florida/Jacksonville Center for HIV/AIDS Research, Education & Service Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation. Objectives • Describe the spectrum of psychiatric illness in HIV infected children and adolescents. • Discuss the impact of psychiatric illness on the management of their HIV infection. • Discuss specific signs and symptoms of psychiatric disease in this population that would allow early recognition. • Discuss the different management strategies available including psychosocial and behavioral health interventions. HIV/AIDS as…. • Youth driven (13-24 years of age) • 14% new HIV infections in 2006 & increasing • 50% of all STDs • Mental health driven • Risky behaviors higher among psychiatrically ill • HIV infection increases risk of mental health problems • Impacting racial/ethnic minorities, females • > 60% African-American • ~ 20% Hispanic/Latino • 37% female HIV Epidemic in 2011 • Better prognosis overall • Co-morbidities • Increased emphasis upon • Adherence • Medication interactions and side effects • Levels of social/economic support • Stigmatization • High for HIV and mental health • Synergistic stigmas Threats to Emotional Well Being • • • • • • • • Coping with physical illness Concerns about prognosis Disruptions of social and academic functioning Concerns about body image Social stigma and isolation Disclosure fears Losses Sexual relationships & peer pressure Socioecological Systems Health Care Financing Priorities Clinic Home Cultural or Community Beliefs About Illness Attitudes Toward Adolescents Social Network Parents Siblings Adolescent Cognitions Attributes Health Status Family Illness Neighborhood Peers School General Economic Conditions Perinatally Infected Behaviorally Infected Psychiatric Disorders Risk Behaviors I have the most difficulty addressing the following with my adolescent patients…. 1. Sexual abuse 2. Suicidal ideation 3. MSM/Transgender sexual issues 4. Death, end-of-life issues RISK FACTORS FOR PSYCHIATRIC DISORDERS & HIV Characteristics of 91 HIV-infected youth in southern urban HIV clinic Demographics Number Male 32 Female 59 African-American 86 Heterosexual activity 69 Homosexual activity 16 Bisexual activity 2 (Kadivar, Garvie, Sinnock, Heston, & Flynn, 2006) % 35% 65% 95% 76% 18% 2% Psychosocial Experiences Characteristic N % STDs Abuse by parents Parental substance abuse Known someone with HIV Juvenile justice Sexual abuse 62 42 42 38 37 37 68% 46% 46% 42% 41% 41% Psychosocial Experiences Characteristic N % Marijuana use Abandonment/Neglect Runaway Depression- past & current Unstable housing Tobacco use Loss/death 30 27 26 25 25 25 22 33% 30% 29% 27% 27% 27% 24% Summary of Psychosocial Profile • “Samantha” • Chaotic environment • High levels parental substance abuse (46%) & abandonment • Reduced parental/adult monitoring • Sexual abuse • Early initiation of sexual activity (<13 yrs) • Higher incarcerations, school drop-out • High rates of depression, loss Developmental Issues • Adolescent brain as a “work in progress” • Higher order, abstract thinking • Planning • Impulse control • • • • Pubertal development Perceptions of immortality Identity exploration Peers & social functioning Personal Attributes • • • • Cognitions Emotional regulation/dysregulation Sexual abuse Personality traits • Sensation seeking • Impulsivity • Achievement motivation Mental Health • Emergence of psychiatric problems during adolescence • Externalizing (aggression/delinquency) • Internalizing (depression/anxiety) • Direct link between psychiatric issues & increased risk behaviors • Sexual activity • Unprotected sex • Alcohol and drug use (Benton, 2010; Donenberg & Pao, 2003 & 2005; Lehrer, Shrier, & Gortmaker, 2006) Sexual Minority Youth • 68% of HIV diagnoses aged 13-24 (2008) • Rates of emotional and behavioral problems higher • Increased suicidality • Family and/or peer rejection • Verbal and physical abuse • Increased stigmatization (Lam, Naar-King, &Wright, 2007; Marhefka, et al., 2009; Morrison & L’Heureux, 2001; Safren& Heimber, 1999) Perinatally Infected Adolescents • Disclosure • Maternal status • Own status • Treatment “burn out” • Loss and bereavement • Parent • Peers • Etiology of HIV • Complicated emotions • Anger, guilt, shame, ambivalence PSYCHIATRIC DIAGNOSES & RELATED ISSUES Jessica is a 16 yo female who presents with significant drug/alcohol use, social isolation, irritability, & risky sexual behavior. Which of the following is your #1 r/o diagnosis? 1. Social phobia/anxiety 2. PTSD 3. Major depressive disorder 4. Primary substance abuse disorder Psychiatric Epidemiology • Prevalence high (25% to 85%) • Both perinatally and behaviorally infected • 10%-20% in general adolescent population • Affected youth with rates similar to HIV + • Increased psychiatric hospitalizations • Most common diagnoses • • • • • Depression Anxiety disorders Attention-deficit/Hyperactivity (ADHD) Behavioral problems Substance abuse (Mellins, Brackis-Cott, Dolezal & Abrams, 2006; Mellins, et al., 2009; Scharko, 2006) Depression • • • • NOT “normal” in chronic illness Prevalence 47% “Jennifer” Symptoms • Depressed mood or anger/irritability - 2 weeks • Loss of interest • Neurovegetative symptoms • • • • Poor sleep Appetite changes Diminished libido Problems with attention, concentration • Feelings of guilt, worthlessness • Suicidal ideation Depression (cont’d) • 2x more frequent in females • Overlapping symptoms with HIV • • • • • Appetite changes Sleep disturbance Decreased energy Slowed motor movements Multiple somatic complaints • Psychosocial stress significant • Stigma, discrimination, poverty, violence • Relationship & disclosure issues Bipolar Disorder(s) • Not being “moody” • Mania/hypomania • Elevated or irritable mood • Poor judgment • Drug use • Impulsivity • Racing thoughts • Risky sexual behavior • Cyclothymia • Stress of HIV exacerbates bipolar disorder • Adherence poor • Family history • In adults with HIV, prevalence 10x higher than general population Anxiety Disorders • Prevalence 24%-49% overall • Generalized Anxiety • Persistent, excessive worry • Illness • Panic Disorder • Panic attacks • Fear of subsequent attacks and implications or consequences • Behavioral change • Agoraphobia • Specific phobias Social Phobia • “Benjamin”, “Kathy” • Fear of social situations, scrutiny • Fear others judge them as anxious, weak, crazy, stupid • Avoidance of social, public situations • Exacerbated by • Internalized stigma of illness • Weight loss, lipodystrophy • Self-medication with drugs, alcohol PTSD/PTSS • Prevalence 13%-23% (Benton, 2010) • Trauma related to life events, diagnosis, medical procedures • Rape and sexual violence • 68% women & 35% men with HIV after age 15 • Physical abuse as child • 34% women, 27% men • Witnessing violence at home & community • Symptoms • Flashbacks, depression, social/emotional isolation, poor emotional regulation, irritability, anger • Substance use, sexual risk taking Schizophrenia & Thought Disorders • “Edward” • Emerges in late adolescence • Positive symptoms • Delusions, hallucinations, agitation, suspiciousness • Negative symptoms • Social withdrawal, non-communicative, lack of initiative • Cognitive • Poor attention, concentration, information processing • Estimated 2-10% adult PLWHA • Can be triggered by substance use ADHD • 25%+ of youth with HIV • Primary symptoms • • • • Impulsivity Hyperactivity Distractibility Inattentiveness • Etiology linked to • • • • Genetics Biological adversity Psychosocial adversity Neurobiology Behavioral Issues • Oppositional- Defiant Disorder • • • • • Negativistic, hostile, defiant behavior Loses temper Argues with adults Deliberately defies authority Angry, resentful, spiteful • Conduct Disorder • • • • Aggression Destruction of property Deceitfulness or theft Serious violations of rules • Behavioral problems, “acting up”, “out of control” • Prevalence 11%-13% (Mellins, Brackis-Cott, Dolezal, Abrams, 2006) Neurocognitive Functioning • “Bethany” • CNS manifestations of HIV • Neurotoxic, inflammatory response • Opportunistic infections • Encephalopathy • Consequences • Poor attention, executive functioning, memory • Problems with visuomotor & spatial learning • Impaired expressive and receptive language skills • HIV medication • Neuropsychological testing • Educational interventions Substance Abuse • Prevalence high • 14% total (aged 12-18); 22% > 15 (Williams, et al., 2010) • 47% alcohol, 37% cannabis aged16-24 (Naar-King, et al., 2010) • Associated with • • • • • • ADHD Conduct disorder Oppositional defiant disorder Depression Self-efficacy Parental substance use Personality Disorders Long-standing patterns of thought, behavior, and emotions that are maladaptive for the individual or for people around him or her. • Etiology • Physiological/biological predisposition plus • Social/psychological experiences • Risk to self & others • Impulsivity, risk taking, self-destructive • Difficult to treat • Chaotic, demanding, manipulative • If under 18, must be present for 1 year • Make life miserable for those around them Personality Disorders • Cluster A • Paranoid, schizoid, schizotypal • Cluster B • Borderline • Unstable relationships & emotions, impulsivity, parasuicidal behaviors • Antisocial (must be > 18 years old) • Aggressive, pervasive disregard for & violation of rights of others • Histrionic • Sexually seductive, self-dramatization, needs to be center of attention • Narcissistic • Exaggerated self-importance, entitled, exploitative • Cluster C • Avoidant, dependent, passive-aggressive, obsessive-compulsive Jessica is a 16 yo female who presents with significant drug/alcohol use, social isolation, irritability, & risky sexual behavior. Which of the following is NOW your #1 r/o diagnosis? 1. Social phobia/anxiety 2. PTSD 3. Major depressive disorder 4. Primary substance abuse disorder Consequences of Psychiatric Illness • • • • • • • • Poor adherence Early onset sexual activity More unprotected intercourse Multiple sexual partners More STDs Increased drug or alcohol use Quality of life poorer Treatment outcome poorer Sexual Behavior • Internalizing (depression, anxiety) • Decreased assertiveness • Early sexual initiation • Less able to negotiate safe sex • Externalizing behaviors • More frequent sexual involvement • Multiple partners • Higher rates of “exchange” sex • Sex as basic biological drive • Relief from distress in self-soothing behaviors • Unprotected sex • Substance use - which increases unprotected sex Drawing IT Out: 1st International HIV/AIDS Cartoon Exhibition in New York City. World AIDS Day, December 1, 2006 International Planned Parenthood Federation/Western Hemisphere Region, Government of Brazil and UNAIDS Artist: Vascoli, Country: Brazil ASSESSMENT & TREATMENT Assessment • Biopsychosocial & developmental context • Multiple sources of information • Adolescent, school, family, PCP • • • • Family psychiatric history Life events and stressors School, job functioning Identify strengths as well as issues • Screening • “Triage” process • Use reliable and validated instrument(s) • Diagnostic Interview Schedule for Children (DISC) • Clinical or psychiatric interview • Comprehensive assessment • Interview, testing, school records • Current medical status and medications • Efavirenz (Kenedi & Goforth, 2011) • Aware of side effects • Evaluation must be ongoing Evaluate Symptoms & Behaviors • • • • • • • Depressed affect Anxiety Suicidal tendencies Alcohol and drug use problems Unusual or bizarre thoughts Anger and aggression Intellectual and neuropsychological deficits • Self-injurious behaviors Treatment Treatment • Stigma of mental health diagnosis • <50% overall receive appropriate treatment • Pharmacological treatment • • • • Drug-drug interactions Metabolic complications Side effects Resistance to more medication • Therapy • Individual, family, group www.nynjaetc.org • Cognitive-behavioral, motivational interviewing, multisystemic therapy, social support/groups Pharmacological Treatment • Same medications as HIV- adolescents • Little known about specific effects in HIV+ • Antidepressants/Anxiety disorders • SSRIs • Psychostimulants • Few drug-drug interactions • Antipsychotics • Second-generation antipsychotics related to elevated cholesteral (Kapetanovic et al., 2010) Pharmacological Treatment • Drug-drug interactions (examples) • Metabolized by Cytochrome P450 system or liver Drug Name Interactions with HAART Citalopram (Celexa) Fluoxetine (Prozac) & fluvoxamine (Luvox) Lopinavir/r, ritonavir citalopram levels levels of amprenavir, delavirdine, efavirenz, indinavir, lopinavir/r, nelfinavir, ritonavir, saquinavir; Nevirapin fluoxetine levels Paroxetine (Paxil) Lopinavir/r, ritonavir paroxetine levels Sertraline (Zoloft) Lopinavir/r, ritonavir sertraline levels (Benton, 2010) Effective Interventions • What is the problem? • Brief interventions for discrete behaviors • Motivational Interviewing • Substance use • Therapy or medication for mental health problem • Risk reduction vs. elimination • Treatment based on client’s needs & goals • Any harm reduction is valuable • Use comprehensive, multidisciplinary approach for complex problems Cognitive-Behavorial Therapy • Strong evidence for efficacy in • • • • Depression Anxiety disorders PTSD With/without medication, depending on issue • Is NOT • Being a “Pollyanna” • Just giving advice on “what to do” • It IS • A name for many similar therapies • A collaborative effort to change one’s thoughts and behaviors in order to feel better and obtain goals Motivational Interviewing (Miller & Rollnick, 2002) Client-centered yet directive method for enhancing intrinsic motivation to change by exploring & resolving client ambivalence • Basic principles • • • • Expressing empathy Developing discrepancy Rolling with resistance Supporting self-efficacy • Effective in sexual & behavioral risk reduction, substance abuse • Treatment adherence in HIV • Participation in therapy Multisystemic Therapy (MST) • Intensive, home-based family therapy • Designed for adolescents with delinquent behavior • Evidence for use in delinquency, substance abuse, psychiatric emergencies, HIV medication adherence (Ellis, Naar-King, Cunningham, & Secord, 2006) • Social-ecological and family systems theories • Sample targets: • Adolescent – Oppositionality • Family – Disorganization, lack of supervision • Community – Poor relationships with providers, schools Information, Motivation, Behavioral Skills Prevention Adherence Information Prevention Adherence Motivation Prevention Adherence Behavioral Skills Health Outcomes Prevention Adherence Behavior Moderating Factors: Psychological health, living situation, access to care, substance use, etc. (Adapted from Fisher, et al., 2006) Viral load CD4 Subjective & Objective physical & Mental health status Additional Approaches • Social support and group therapy • Overcome social isolation, stigmatization • Active, problem-focused coping strategies for controllable stressors • Social support and coping skills for PLH and affected adolescents (Rotheram-Borus et al., 2003) • Less depression, fewer conduct problems • Fewer teenage pregnancies • Decreased parental substance use, dependence After completing your initial screening interview with Jessica, your next step would be 1. Offer support & ask her to return in 2 weeks 2. Prescribe an antidepressant 3. Refer for full psychiatric evaluation 4. Encourage her to attend the peer support group 5. Use MI to address substance use & risky behaviors Summary • High rates of psychiatric illness, mental health problems • Socioecological framework important • Awareness and ongoing evaluation crucial • Effective pharmacological and therapeutic interventions do exist (*References available upon request) Thanks to the patients and staff of the Rainbow Center & UF CARES (UF Center for AIDS Research, Education & Service) Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.