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:
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Mood Disorders
 Depression
 Bipolar Disorder
 Anxiety Disorders
 Post Traumatic Stress and other disorders
 Panic Disorder & Generalized Anxiety Disorder
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Psychosis
 Schizophrenia
 Schizoaffective Disorder
 Dementia
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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
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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
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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
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The prevalence of HIV is 7 times higher in
patients with mental illness than in the
general population.
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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
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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
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(Lyketsos 1996)
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Often under-recognized or misdiagnosed:
 Referral bias
 Low cultural competence of mental health professionals
 cultural differences in the expression and tolerance of symptoms
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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.
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Despite symptoms of distress, treatment is delayed or not sought1
Treatment sought from non–mental health professionals1
Use of Mental Health Services by African Americans (N = 1011)2
Mental Health Specialist*
% (SE)
Any Provider†
% (SE)
Mood Disorder
15.6 (3.5)
28.7 (4.5)
Anxiety Disorder
12.6 (2.4)
25.6 (5.3)
12-Month Disorder
*Psychologist, psychiatrist, or social worker; †Mental health specialist, general medical provider, other professional (nurse, occupational therapist, other health professional,
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.
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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
Culture
“Nerves” and headaches
Latino
Weakness, tiredness,
“imbalance”
Asian
“Heartbroken”
Native American
Bad nerves, “evil”
African American
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Antidepressants
 Key Interactions with ART:
▪ Fluvoxamine (Luvox)
AVOID
▪ Nefazodone (Serzone)
▪ AVOID or dose cautiously
▪ Bupropion (Wellbutrin, Zyban)
▪ @ 400 mg, dose cautiously with ritonavir
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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
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Prevalence of bipolar disorder in HIV infection is 10 times
higher than in general population
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Stress of HIV infection exacerbates pre-existing bipolar
disorder – complicating adherence
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Increased risk of HIV infection
 Impulsivity, poor judgment, & libido changes all part of
mood episodes
 More than half are substance abusers
(Lyketsos 1993)
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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) versus
intolerable side effects
 Tegretol (carbamazepine)
▪ Second generation (atypical) antipsychotics all have indication as
mood stabilizers, well tolerated and effective for psychotic sx’s
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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.
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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
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Lawson, W.B. “Anxiety disorders in African Americans and other ethnic minorities” in Stress-induced and Fear Circuitry Disorders-Advancing the
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
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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)
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SSRIs show 50% improvement in sx
 prefer to use sertraline (Zoloft) or citalopram (Celexa)
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Prazosin often used for intrusive nightmares
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Psychotherapy effective, using variety of
approaches (CBT, Abreaction, Supportive)
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Panic Disorder & Generalized Anxiety Disorder
 > 4 times more prevalent
(Bing 2001)
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Affects accessing primary care, adherence to
treatment, and quality of life
 Especially agoraphobic/housebound
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Responds well to treatment
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Treatments of Choice:
 SSRI’s
 Anxiolytics
Avoid
 Alprazolam (Xanax)
 Triazolam (Halcion)
 Midazolam (Versed)
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Anxiolytics
 Safest to use glucuronidated benzodiazepines:
▪ Lorazepam (Ativan)
▪ Temazepam (Restoril)
▪ Oxazepam (Serax)
Caution with buspirone (Buspar), and dosing of other
benzodiazepines with ART
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Thought to be common but often over-diagnosed
Disorders with better prognosis overlooked
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INPATIENT CARE
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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
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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)
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Patients with chronic mental illness at
increased risk for HIV infection
 Prevalence rates 2 to 10%
 Medical providers often do not test for HIV
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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
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Treatment
 Coordinate between medical & psychiatric providers as
much as possible
 Typical or 1st generation antipsychotics
▪ Increase risk of EPS & tardive dyskinesia
 Atypical or 2nd generation antipsychotics are preferred but
risk weight gain:
 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)
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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
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Substance-induced psychosis
 Least studied & most resistant to treatment
 Methamphetamine > cocaine > hallucinogen
 Possibly increased susceptibility in patients with
later stage HIV infection (C3)
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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.
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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.
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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?
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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
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Risk Factors
 Seroconversion illness
 Anemia
 Vitamin deficiencies (B6, B12)
 Low CD4 count
 High CSF HIV viral Load
 ETOH, cocaine & amphetamine
 Depression
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Often misdiagnosed or ignored in African Americans
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Delays in treatment of a preventable condition
often occurs
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General disparities in health care contribute to
treatable cognitive impairments that may be
misdiagnosed as dementia
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Mild Manifestation
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1) At least 2 of: impaired
attention, concentration,
memory, mental &
psychomotor slowing,
personality change
2) Rule out other cause
 MCMD
Minor Cognitive Motor Disorder
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Severe Manifestation*
 HAD
HIV Associated Dementia
*functional impairment
Diagnostic Criteria
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Diagnostic Criteria
1) Acquired cognitive abnormality*
2) Acquired motor abnormality*
3) rule out other cause
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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)
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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
Use of Services
Visits
 Acceptability
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 Cultural
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 Language/literacy
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Primary care
Specialty
Emergency
 Attitudes, beliefs
 Preferences
 Health behavior
Procedures
 Preventive
 Diagnostic
 Education/income
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 Involvement in care
Structural
 Availability
 Appointments
 How organized
 Transportation
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
Financial
 Insurance coverage
 Reimbursement levels
 Public support
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.
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Genuine sensitivity, understanding, respectful and
nonjudgmental in dealing with people whose
cultural practice differs from your own.
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Flexible and skillful in responding and adapting to
different circumstances and within different
contexts
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Incorporate an understanding of the needs of the
target patient populations and designs services
accordingly.
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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
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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
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The platinum rule: Treat others the way they want to be treated
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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;94:10071016.)

[Regarding depression]… wouldn’t say I don’t pray, I would
say don’t just pray. I would say, admit you have an illness…
like other illnesses, put yourself in treatment, and stay in
prayer.”
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“[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.”
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“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 ”
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Changing epidemic with significant impact
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Challenging illness & patient population
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Team approach, multidisciplinary care
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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. Latino (Hispanic) - “Nerves” and headaches
B. Asian - Weakness, tiredness, “imbalance”
C. Native American - “Heartbroken”
D. African American- Bad nerves, “evil”
E. 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?
More likely to be referred to outpatient care
More likely to be referred to the correctional
system
C. More likely to be involuntarily committed
D. More likely to be over medicated
E. More likely to leave against medical advice
A.
B.

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 7th Street NW, 2nd Floor
Washington, DC 20001
202-865-8146 (Office)
202-667-1382 (Fax)
Goulda Downer, Ph.D., RD, LN, CNS
Principle Investigator/Project Director (AETC-NMC)
www.AETCNMC.org
HRSA Grant Number: U2THA19645
64