Transcript Slide 1
Presented by William B. Lawson MD, PhD, DFAPA Professor and Chair Mansoor Malik, MD Assistant Professor Department of Psychiatry and Behavioral Sciences Howard University College of Medicine and Hospital
At the completion of this webinar each participant will be able to: Discuss the epidemiology of HIV in African Americans Explore the psychiatric complications associated with HIV in African Americans Understand the relationship between substance abuse and mental disorders to HIV in African Americans Discuss the diagnostic and treatment challenges seen in African Americans with substance abuse and mental disorders
Any manner of psychological or behavioral symptoms that causes an individual significant distress, impairs their ability to function in life, and/or significantly increases their risk of death, pain, disability, or loss of freedom. In addition, to be considered a psychiatric disorder, the symptoms must be more than the expected response to a particular event (e.g., normal grief after the loss of a loved one)
For the purpose of this presentation, we will focus on the following Psychiatric Disorders that African Americans experience most often:
Mood Disorders
Depression Bipolar Disorder Anxiety Disorders Post Traumatic Stress and other disorders Panic Disorder & Generalized Anxiety Disorder
Psychosis
Schizophrenia Schizoaffective Disorder Dementia
Striking disparities in mental health care for African Americans, Asian Americans and Pacific Islanders, Hispanics, and Native Americans 50% less likely to receive services than Whites Poorer quality of care (misdiagnosis, underuse, overuse) Underrepresented in mental health research Disparities impose greater disability burden on these affected population groups, which together constitute an emerging majority
US Department of Health and Human Services (2001) Mental health: culture, race, and ethnicity—a supplement to mental health: a report of the Surgeon General. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, Md
The number of AIDS cases per 100,000 African Americans is nine time greater than per 100,000 whites. African Americans account for 55 percent of all AIDS deaths, followed by Latinos who account for 14 percent. Survival after an AIDS diagnosis is lower for African Americans than any other racial or ethnic group. High risk behavior: unprotected sex and IV substance abuse accounts for most new cases Poorer response to HIV medications Lawson, W.B., Hutchinson, J., Reynolds, Diane, “ HIV/AIDS among African Americans ” in Psychiatric Aspects of HIV/AIDS. Eds. Fernandez, F. Ruiz, Pp 223-230, 2006, Lippincott Williams and Wilkins, Philadelphia, Pa.
H Ribaudo, K Smith, G Robbins, et al. Race Differences in the Efficacy of Initial ART on HIV Infection in Randomized Trials Undertaken by ACTG. 18th Conference on Retroviruses and Opportunistic Infections (CROI 2011). Boston. February 27-March 2, 2011
The prevalence of HIV is 7 times higher in patients with mental illness than in the general population.
Rates of HIV infection or AIDS among persons with serious mental illness in the United States is estimated to range between 5.2% and 22.9%.
Weiser SD et al., 2004
Majority of adults with severe mental illness (SMI) are sexually active Engage in high risk behaviors HIV risk correlated with psychiatric illness, substance use, and childhood abuse Decreased highly active antiretroviral therapy (HAART) utilization, adherence and viral suppression
Major Depression is common It is associated with morbidity and mortality (suicide) It is recognized as one the most important contributors to world wide suffering Bipolar disorder or manic depressive illness is less common but is strongly associated with high risk behavior: sexual recklessness, and substance abuse Risk factor for HIV Infection (Regier,1990; Reisner et al., 2009) 2.5 fold increase when CD4 cell <200 cells/mm³ (Lyketsos 1996)
Often under-recognized or misdiagnosed:
Referral bias Low cultural competence of mental health professionals cultural differences in the expression and tolerance of symptoms
Often undertreated
Use of crisis services (poorer prognoses) Use of alternative sources of help (faith, family, folk treatment) When help is sought from professionals, reliance on physicians in primary care settings rather then mental health specialists Primm, A.B. and Lawson, W.B. “ Disparities Among Ethnic Groups: African Americans ” in Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives; Eds. P. Ruiz and A. Primm, Wolters Kluver /Lippincott Williams & Wilkins, Baltimore, 2010, Pp19-29 Cultural Competence Standards. SAMHSA/EICHE; 2000.
Despite symptoms of distress, treatment is delayed or not sought 1 Treatment sought from non–mental health professionals 1
Use of Mental Health Services by African Americans (N = 1011) 2 12-Month Disorder
Mood Disorder
Mental Health Specialist* % (SE)
15.6 (3.5)
Any Provider † % (SE)
28.7 (4.5) Anxiety Disorder 12.6 (2.4) 25.6 (5.3) *Psychologist, psychiatrist, or social worker; † Mental health specialist, general medical provider, other professional (nurse, occupational therapist, other health professio nal, minister, priest, rabbi, counselor), spiritualist, herbalist, natural therapist, or faith healer. SE = standard error.
Sources:
1. Neighbors HW.
Comm Mental Health J.
1984;20:169-181. 2. Office of the Surgeon General.
Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health, a Report of the Surgeon General.
Rockville, MD: US Dept of Health and Human Services; 2001. Available at: http://www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-3613.pdf. Accessed April 24, 2006.
In many West African countries
No single word for depression Guilt is rare, shame is common
In U.S., rather than sadness, African Americans expressions include:
Somatization Denial Irritability “ Falling out ” Failure to disclose inner feelings Healthy paranoia John Henryism Angry Black Woman
Depression is thought to be
Inconsistent with African American resilience Inconsistent with religious beliefs
Complaints
“
Nerves
”
and headaches Weakness, tiredness,
“
imbalance
” “
Heartbroken
”
Bad nerves,
“
evil
”
Culture
Latino Asian Native American African American
Antidepressants
Key Interactions with ART: ▪ Fluvoxamine (Luvox) ▪ ▪ Nefazodone (Serzone) ▪ AVOID or dose cautiously Bupropion (Wellbutrin, Zyban) ▪
AVOID @ 400 mg, dose cautiously with ritonavir
Antidepressants
Tricyclic antidepressants ▪ Generally well tolerated with antiretrovirals ▪ Nortriptyline & desipramine (secondary amines) ▪ Narrow metabolism at 2D6 ▪ ▪ Levels can be elevated by other medications Get a blood level if in doubt SSRIs and Dual-action agents: ▪ Well tolerated without adjusting dose ▪ Few interactions
Prevalence of bipolar disorder in HIV infection is 10 times higher than in general population Stress of HIV infection exacerbates pre-existing bipolar disorder – complicating adherence Increased risk of HIV infection Impulsivity, poor judgment, & libido changes all part of mood episodes More than half are substance abusers
(Lyketsos 1993)
Treatment
Not well studied with mostly anecdotal case reports Depakote (VPA) well tolerated ▪ Avoid with impaired hepatic function ▪ Risk anemia with AZT Lithium ▪ Conflicting reports of good response (increases WBC) intolerable side effects versus Tegretol (carbamazepine) ▪ Second generation (atypical) antipsychotics all have indication as mood stabilizers, well tolerated and effective for psychotic sx ’ s
Ms. D, a 33 year-old Nigerian woman who recently returned from Africa is 3 ½ months pregnant. She also has an 8-year-old son. She was diagnosed with HIV in 3 years ago. She has no income, is living with friends, and has debt from when she left the United States. She says she practiced safe sex and tested regularly; however, she had one incident where the condom broke. Her CD4+ is 1130 and she has an undetectable viral load. She feels there is no need for her to take medicine because she is afraid that her family will find out that she has HIV and she will have no place to stay. She feels guilty about this situation and reports feelings of worthlessness and fatigue all the time.
1.
How you evaluate her further for possible psychiatric complications?
2.
How will you evaluate her risk of self harm? 3.
What can you tell her about HIV medications and pregnancy? 4.
Which HIV medication(s) should she avoid? 5.
What advice would you give her about HIV related stigma?
One of the most common mental disorders PTSD and phobias may be more common in African Americans than other racial and ethnic minority groups Often under recognized and misdiagnosed PTSD more likely in African American combat veterans and from the stressors of inner city
Lawson, W.B.
research agenda for DSM-V: Eds. G Andrews, D.S.Charney, P.J. Sirovatka, D.A. Regier, Arlington, VA, US: American Psychiatric Publishing, Inc., 2009. pp. 139-144
“
Anxiety disorders in African Americans and other ethnic minorities
”
in Stress-induced and Fear Circuitry Disorders-Advancing the
Greatly increased rates
42% HIV+ women, County Medical Clinics (Cottler 2001) 30% pts develop in reaction to HIV diagnosis (Kelley 1998) Predicts lower CD4 counts (Lutgendorf 1997)
SSRIs show 50% improvement in sx prefer to use sertraline (Zoloft) or citalopram (Celexa) Prazosin often used for intrusive nightmares Psychotherapy effective, using variety of approaches (CBT, Abreaction, Supportive)
Panic Disorder & Generalized Anxiety Disorder > 4 times more prevalent (Bing 2001) Affects accessing primary care, adherence to treatment, and quality of life Especially agoraphobic/housebound Responds well to treatment
Treatments of Choice:
SSRI ’ s Anxiolytics
Avoid
Alprazolam (Xanax) Triazolam (Halcion) Midazolam (Versed)
Anxiolytics
▪ ▪ Safest to use glucuronidated benzodiazepines: ▪ Lorazepam (Ativan) Temazepam (Restoril) Oxazepam (Serax) Caution with buspirone (Buspar), and dosing of other benzodiazepines with ART
Thought to be common but often over-diagnosed Disorders with better prognosis overlooked
INPATIENT CARE
More likely to be admitted to inpatient care More likely to be referred to the correctional system More likely to be involuntarily committed More likely to be over medicated More likely to leave against medical advice
OUTPATIENT CARE
More likely to be referred for medication only or to the emergency room More likely to be terminated early
Flaherty & Meagher 1980; Lawson 1994; Lindsey et al. 1989; Paul & Menditto 1992; Soloff and Turner, 1982; Strakowski et al. 1995)
Patients with chronic mental illness at increased risk for HIV infection
Prevalence rates 2 to 10% Medical providers often do not test for HIV Incorrectly assume pts not sexually active Substance abuse significant co-morbidity Pts do not implement HIV risk behavior knowledge Providers feel such patients are poor candidates for treatment
Treatment
Coordinate between medical & psychiatric providers as much as possible Typical or 1 st ▪ generation antipsychotics Increase risk of EPS & tardive dyskinesia Atypical or 2 risk weight gain: nd generation antipsychotics are preferred but Olanzapine (Zyprexa) > risperidone (Risperdal) & quetiapine (Seroquel) > ziprasidone (Geodon) & aripiprazole (Abilify) *Note: clozapine (Clozaril) contraindicated
Antipsychotics:
For use with ritonavir, start with low dose
Haloperidol (Haldol) (risk EPS & TD) ▪ Avoid chlorpromazine (Thorazine), thioridazine (Mellaril)
Olanzapine (Zyprexa)
Aripiprazole (Abilify)
▪ Avoid pimozide (Orap)
Chronically and Severe Mentally Ill:
Bipolar, schizophrenic, schizoaffective ▪ At increased risk of HIV infection ▪ Less adherent to medical & psychiatric care Often must receive care across systems ▪ Community Mental Health system not integrated with Primary Care, Medical Clinics, or Hospitals ▪ Concomittent substance abuse treatment programs are the most effective but integrated programs are uncommon
Substance-induced psychosis
Least studied & most resistant to treatment Methamphetamine > cocaine > hallucinogen Possibly increased susceptibility in patients with later stage HIV infection (C3)
Ms. L has a triple diagnosis: HIV+, paranoid schizophrenia, and alcoholism. She was referred to you by her social worker. She is not taking any medications for either HIV or her mental diagnosis. She refused to take them. Her social worker, doctor, and you have all notice her psychosis as she speaks and rambles. She lives in a group home, and has become friends with Mr. J, who lives there also. She drinks a couple of half-pints of hard liquor every day. She has started threatening Mr. J that if he doesn ’ t have sex with her, she will accuse him of raping her. Her lab results show her CD4+ count is 130 and her viral load is 500,000.
1.
How will you treat her psychiatric complications?
2.
What kind of support or resources can you get for yourself?
3.
What is the next step if she continues to refuse treatment?
CNS Infection
10% AIDS pts present with neurological dx 75% AIDS pts: brain pathology at autopsy ▪ gliosis, white matter pallor & multinucleated giant cells HIV-Associated Dementia (HAD) & Minor Cognitive Motor Disorder (MCMD) predict shorter survival
Risk Factors
Seroconversion illness Anemia Vitamin deficiencies (B6, B12) Low CD4 count High CSF HIV viral Load ETOH, cocaine & amphetamine Depression
Often misdiagnosed or ignored in African Americans Delays in treatment of a preventable condition often occurs General disparities in health care contribute to treatable cognitive impairments that may be misdiagnosed as dementia
Mild Manifestation MCMD Minor Cognitive Motor Disorder Severe Manifestation* HAD HIV Associated Dementia
*functional impairment
Diagnostic Criteria 1) At least 2 of: impaired attention, concentration, memory, mental & psychomotor slowing, personality change 2) Rule out other cause Diagnostic Criteria 1) Acquired cognitive abnormality* 2) Acquired motor abnormality* 3) rule out other cause
With effective ART, incidence of CNS OIs dropped significantly, since early 1990
’
s
2/3 decreased incidence HAD (Saktor 1999) 75% decrease CMV & lymphoma on autopsy However 60% with some evidence of HIV encephalopathy on autopsy (Neuenburg 2002)
Treatment
Most effective treatment is ART ▪ Raises question of lumbar puncture to confirm effectiveness on CSF HIV viral load Slows progression of dementia (Ferrando 1998) Reversed periventricular white matter changes seen on MRI scan in some cases
Barriers Personal/Family
Acceptability Cultural Language/literacy Attitudes, beliefs Preferences Involvement in care Health behavior Education/income
Structural
Availability Appointments How organized Transportation
Financial
Insurance coverage Reimbursement levels Public support
Use of Services Visits
Primary care Specialty Emergency
Procedures
Preventive Diagnostic Therapeutic
Mediators Quality of providers
Cultural competence Communication skills Medical knowledge Technical skills Bias/stereotyping Appropriateness of care Efficacy of treatment Patient adherence
Outcomes Health Status
Mortality Morbidity Well-being Functioning
Equity of Services Patient Views of Care
Experiences Satisfaction Effective partnership Modified from Institute of Medicine.
Access to Health Care in America: A Model for Monitoring Access
. Washington, DC: National Academy Press; 1993. Cooper LA, Hill MN, Powe NR.
J Gen Internal Med
. 2002;477-486.
Knowledgeable about cultural values and beliefs of the patient and applying that understanding in a health context. Genuine sensitivity, understanding, respectful and nonjudgmental in dealing with people whose cultural practice differs from your own.
Flexible and skillful in responding and adapting to different circumstances and within different contexts
Incorporate an understanding of the needs of the target patient populations and designs services accordingly.
Culturally accessible service delivery, in essence, “ opens the door ” to services for all patients.
Culture and ethnicity are products of both personal history and wider situational, political, social, political, geographic and economic factors
Factors related to culture and ethnicity shape:
the way people interact with a health care system; their participation in programs of prevention and health promotion; their access to health information and services their health-related choices and decisions; their understanding of and priorities re: health and illness, help seeking behavior and adherence to treatment
Encourage patients to ask questions about their illness, to bring an advocate along with them, and to be an active participant in the health care encounter The platinum rule: Treat others the way they want to be treated No matter what your differences are, taking the time to listen, understand, and communicate clearly and showing patients you care will engender trust Trust is the key to establishing an effective patient–health professional partnership and optimal outcomes in depression care and medical care in general Educate patients about depression and strategies to manage it (health literacy)
Use videotapes and other literacy-level–neutral resources
Guide to a Healthy Mind, Celebrating Life, Gray & Blue, and
Black & Blue
Black & Blue features AA adults describing their own depression as a medical syndrome Emphasizes the importance of early recognition and treatment Increases awareness of negative consequences of untreated depression Provides information on where to get help Evaluation of the video showed changed attitudes toward depression in the areas of depression as a medical illness, stigma, spirituality, and treatment with antidepressants (Primm et al. JNMA. 2002;94:1007 1016.)
[Regarding depression]… wouldn say don
’
t say I don
’
t pray, I would prayer.
” ’
t just pray. I would say, admit you have an illness… like other illnesses, put yourself in treatment, and stay in
“
[Admitting to having depression] was a hard thing for me to do because it hurt that image, that image of being a proud, strong, black man, it really did.
” “
Being the spiritual young man that I am, I would go to God [for treatment of depression], and you know what God
’
s gonna do, he
’
s gonna send you to a doctor…people have to come to understand that it
’
s a medical illness
”
Changing epidemic with significant impact
Challenging illness & patient population
Team approach, multidisciplinary care
Ethnopharmacologic considerations
Which of the following statements about African Americans is incorrect?
A.
B.
C.
D.
Anxiety disorders are one of the most common mental disorders PTSD and phobias may be more common than other racial and ethnic minority groups Anxiety disorders are often readily recognized but diagnosed PTSD more likely in combat veterans and from the stressors of inner city
Cultural expressions for depression-related complaints may include: (choose all that apply):
A.
B.
C.
D.
E.
Latino (Hispanic) “
Nerves
”
and headaches
Asian - Weakness, tiredness, “
imbalance
” Native American “
Heartbroken
” African American- Bad nerves, “
evil
” None of the above
The prevalence of HIV is 7 times higher in patients with mental illness than in the general population.
True False
Which of the following statements about adults with Severe
Mental Illness is incorrect?
A.
B.
C.
D.
Majority of adults with severe mental illness (SMI) engage in high risk behaviors For adults with severe mental illness (SMI), HIV risk is correlated with psychiatric illness, substance use, but not childhood abuse Decreased highly active antiretroviral therapy (HAART) utilization, adherence and viral suppression are often seen in adults with sever mental illness The majority of adults with severe mental illness (SMI) are sexually active
Which of the following statements about African Americans with Schizophrenia is incorrect?
A.
B.
C.
D.
E.
More likely to be referred to outpatient care More likely to be referred to the correctional system More likely to be involuntarily committed More likely to be over medicated More likely to leave against medical advice
Lawson, W.B., Hutchinson, J., Reynolds, Diane, “ HIV/AIDS among African Americans ” in Psychiatric Aspects of HIV/AIDS. Eds. Fernandez, F. Ruiz, Pp 223-230, 2006, Lippincott Williams and Wilkins, Philadelphia, Pa.
Sullivan, G., Koegel, P., Kanouse, D. E., Cournos, F., McKinnon, K., Young, A. S., & Bean, D. (1999). HIV and People with Serious Mental Illness: The Public Sector ’ s Role in Reducing HIV Risk and Improving Care. Psychiatric Services, 50, 648-652 Managing Mentally and Physically Challenged HIV Patients: Journal of the National Medical Association , Dec 2009 by Farhat, Faria , Daftary, Monika N , Downer, Goulda A , Momin, Fatima
Goulda Downer, Ph.D., RD, LN, CNS - Principle Investigator/Project Director (AETC-NMC) Keith W. Crawford, R.Ph., Ph.D.
I Jean Davis, PhD, PA, AAHIVS Michael R. Noss, DO Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN
1840 7 th Street NW, 2 nd 202-667-1382 (Fax) Floor Washington, DC 20001 202-865-8146 (Office)
Goulda Downer, Ph.D., RD, LN, CNS
Principle Investigator/Project Director (AETC-NMC)
www.AETCNMC.org
HRSA Grant Number: U2THA19645 64