Transcript Cognitive Behavioral Skills Training Intervention

The Triply Diagnosed Patient:
Prevention and Care
Milton L. Wainberg, M.D.
Columbia University
HIV Mental Health Training Project
New York State Psychiatric Institute
A Local Performance Site of the New York / New Jersey
AIDS Education and Training Center
[email protected]
Definitions and Background
Triply Diagnosed Patients:
Who They Are and Why These
Disorders Travel Together
• Majority:
Alcohol / substance use disorders and HIV with
comorbid depressive, anxiety, personality disorders.
• Minority:
Recurrent psychotic disorders (schizophrenia,
mania, depression with psychosis, psychosis NOS)
with comorbid alcohol / substance use disorders and
HIV.
Majority Population of Triply
Diagnosed Patients: Some Findings
National
U.S. health survey: Adults with
depression and anxiety disorders (GAD,
PD) were more likely to engage in HIV risk
behavior than those without these
disorders.
National U.S. study of substance use
programs: Adults with both psychiatric and
substance abuse disorders have higher
rates of HIV infection than those with
substance abuse disorders alone.
RAND HCSUS Study:
1,489 HIV-positive Medical Patients
27%
took psychotropic medication in
1996:
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21% antidepressants
17% anxiolytics
5% antipsychotics
3% psychostimulants
About
half of patients with depressive
disorders did not receive
antidepressants.
Psychiatric disorders are common and
undertreated.
Psychosis & Mania
Diagnostic and Treatment
Issues
When Psychosis / Mania Occur
in the Course of HIV Infection
Prior to infection:
–Elevated rates of HIV infection in psychiatric
patients with psychotic disorders :
seroprevalence 1% - 23%, associated with
AOD use, unsafe sex, institutionalization
–Substance use, (e.g. hallucinogens,
amphetamines, cocaine, ecstasy)
associated with both psychotic symptoms
and HIV risk.
When Psychosis / Mania Occur in
the Course of HIV Infection
With
asymptomatic infection:
–HIV invades the brain at initial infection
–Not known if HIV by itself increases
biological vulnerability to certain mental
illnesses
When Psychosis / Mania Occur in the
Course of HIV Infection
With
symptomatic illness:
–Can occur at the initial presentation of
symptomatic HIV illness
–Concern is differential diagnosis:
»Complication of substance use /
withdrawal, medical illness, metabolic
disturbances, neuropsychiatric
manifestations of HIV (e.g., HAD), side
effects of HIV-related medications, etc.
Psychosis/Mania: Differential Diagnosis
due to a General Medical Condition
 HIV
associated dementia
 Psychoneurotoxicities
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Steroids
Nucleoside antiretrovirals
NNRTI
Gancyclovir
Sympathomimetics
Antidepressants
Cocaine, amphetamines
 Opportunistic infections
– Toxoplasmosis
– Cryptococcal meningitis
– CNS lymphoma
– Neurosyphillis
– Herpes
– B12 deficiency (megaloblastic
madness)
Psychosis
Common
underlying causes
– Medical conditions / treatments associated
with CNS dysfunction
– Illicit drugs
– Depression / mania with psychosis
– Schizophrenia / related disorders
Psychosis
in medical settings
is associated with under
treatment by providers
Use of Antipsychotic Medications in
Patients with HIV Infection
Antipsychotic
medications maintain efficacy
in the presence of HIV neuropsychiatric
manifestations
Problems that may arise
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In
Increased sensitivity to side effects
Overlapping toxicities
Drug interactions (often theoretical)
Liver toxicity among patients co-infected with hepatitis viruses
advanced HIV disease, follow rule as with
elderly: start low, go slow
“Typical” First-Generation
Antipsychotics
Haloperidol
most commonly prescribed
Low doses useful in delirium
In advanced HIV infection:
extrapyramidal side effects, including
rapid onset tardive dyskinesia and
neuroleptic malignant syndrome
“Atypical” Second-Generation
Antipsychotics
/ olanzapine: risk diabetes
Clozaril / clozapine: risk diabetes;
bone marrow suppression; risk
seizures on ritonavir / other Pis
Geodon / ziprasidone: QT interval—
caution with drugs that also have this
effect (e.g., protease inhibitors,
ketoconazole)
Zyprexa
Mania: Treatment
Psychopharmacology
– Antipsychotics at lower doses
– Mood stabilizers:
» Lithium
» Anticonvulsants—consider side effects, toxicities,
and drug interactions
– Benzodiazepines as adjunct
Electroconvulsive
therapy (ECT)
HIV Among People with
Severe Mental Illness:
Summary of U.S. Studies
HIV Among People with Severe Mental
Illness: Summary of U.S. Studies
 Rates
of HIV Infection (1%-23%) > general population
  Rates of unsafe sexual behavior
  Rates of co-morbid alcohol/drug use: 20-75%
 Intermittent IDU:
– 1%-8% recent
– 4%-26% lifetime
 HIV
Infection Rates by Type of Drug Use
– Injected drugs
– Non-Injected drugs
– Alcohol only
33.8%
15.4%
10.9%
HIV Among People with Severe Mental
Illness: Summary of U.S. Studies
♦ Sexual risk behaviors associated with drug use:
♦ sex with IDU partners
♦ sex in exchange for money / drugs
♦ impaired judgment and reduced impulse control while
high: unsafe sexual activity while high on alcohol /
drugs
♦ Drug use is associated with rates of STIs and
HCV/HBV
♦ Prevention and treatment of an alcohol /
substance use disorder is an HIV risk reduction
strategy
Harm Reduction: Creating Stable Change
Transtheoretical Model*
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse & Recycle
* Prochaska & Diclemente
Outcomes of Cognitive Behavioral Skills Training
Intervention for Psychiatric Patients:
Summary of Studies on Sexual Risk Reduction
AIDS knowledge
 Self efficacy / intention to change
 Condom use
Number of partners
Episodes of Unprotected sex

Reducing Sexual Risk: Suggested
Modifications for People with Severe
Mental Illness
Adjust
language used by staff to match
verbal skills, cognitive functioning, cultural
values of patients
Keep goals simple and realistic
Be more repetitive
Provide more maintenance sessions
Take into account your patients’ stages of
change
Adherence
Psychiatric Illness and Adherence
Substance
use, depression, and
other mental illnesses can
undermine adherence: Treat these
disorders
Creating stable life conditions
enhances adherence
Patient’s readiness to adhere
must be individually assessed
Consider adherence support
Strategies for Improving Adherence
 Therapeutic
alliance
 Patient education
 Treating substance abuse
 Treating psychiatric disorders
 Memory aids
 Observed medication administration
 Integrated care
 Outreach (“Inreach”)
 Incentives—offer what is desired
Substance Use
AOD Treatment for HIV+ Patients:

Medical Model:
– if patient is doing worse: increase the treatment

Traditional Substance Abuse Treatment
– if client is doing worse: discharge from treatment
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Public Health Model:
– patient seen as vector of infection; keep patient in treatment at all
costs
 Traditional Substance Abuse Treatment
– avoid “enabling”; labeling; tell client what to do; monitor clients’
urines / bloods

Harm Reduction Model
– reduce harm around use; keep patient in treatment at all costs; clientoriented approach; personal responsibility
AOD Users and HIV Medical Care
 AOD
Users less likely to be tested and
diagnosed
 More likely to develop OIs and
complications
 Less likely to have access to medical care
 Less likely to be offered optimal
treatments
 Less likely to adhere if offered HAART
Modified from Frontline Forum: Clinical Symposia Highlights in HIV, May, 1999, cited by A. Vinciquerra, SUNY UMU, 2001,
Drug Interactions: HIV+ AOD Users
Psychiatric medications
+ drugs of abuse
+ HIV medications
+ medications to treat substance used
disorders
= Drug Interactions
 Track new information on websites such
as
– HIV InSite (http://hivinsite.ucsf.edu)
– HIV Drug Interaction Guides by the NY NJ AETC
Before we get to the
conclusions…
Close your eyes
 Close your eyes again
 The Miriam Acevedo Syndrome

Common Treatment Dilemmas
 Adequate
access to and integration of
mental health and substance use services.
 Maintaining adherence in patients with
three chronic relapsing disorders.
 Provider countertransference reactions to
“self-destructive” and “manipulative”
patient behaviors.
 Balancing harm reduction approaches with
sensible limit-setting.
A Couple of Words About Our Work…
Get to know your patients, understand them – feel
free to ask!
 Know your role – know what is “None of your
business!” (religion, sexuality, politics, etc.)
 Adjust to them, not the other way around – if
uncomfortable, get supervision
 We all have experience prejudices – connect with
that
 However, not over identify – at times the medicine
can be worst than the disease!

Thanks!