Mental Health Issues in HIV and HepatitisMental Health Issues in HIV and Hepatitis Ira B. Wilson,...
Transcript of Mental Health Issues in HIV and HepatitisMental Health Issues in HIV and Hepatitis Ira B. Wilson,...
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Mental Health Issues in HIV and Hepatitis
Ira B. Wilson, MD, MSc
Professor of Health Services, Policy & Practice
and Professor of Medicine
Brown University School of Public Health
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Learning ObjectivesUpon completion of this presentation, learners should be better able to:
• Understand HIV and mental health in the broader context of our health care system
• Appreciate the prevalence and impact of mental health problems in persons with HIV
• Understand the special problems posed by persons with HIV, HCV, and mental health problems
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Faculty and Planning Committee DisclosuresPlease consult your program book.
There will be no off-label/investigational uses discussed in this presentation.
No conflicts
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Goals
• Mental health disorders: broader context
• Epidemiology of mental disorders in HIV
• Impact of mental disorders in HIV care
• HIV & Depression
• HIV & SMI
• HIV and Hepatitis C
• Summary
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Goals
• Focus on adults in the US
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CONTEXT: MENTAL HEALTH DISORDERS IN THE US
Broader Context
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Social Determinants
• Poverty
• Poor education
• Violence
• Discrimination based on race, ethnicity, sexual preference
• Poor access to health care
• Distrust of social institutions including our health care system
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Importance of Mental Health in HIV Care
• Burden of suffering: individuals and those close to them
• Difficulties participating in all aspects of HIV care
• Risk of transmission
• Financial costs
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PHP 310, 201515
JAMA, 310(6): 591-608, 2013
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PHP 310, 201516
JAMA, 310(6): 591-608, 2013
The disability-adjusted life year (DALY) is a
measure of overall disease burden, expressed as
the number of years lost due to ill-health,
disability or early death.
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PHP 310, 201517
JAMA, 310(6): 591-608, 2013
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PHP 310, 201519
JAMA, 310(6): 591-608, 2013
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PHP 310, 201520
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EPIDEMIOLOGY OF MENTAL HEALTH DISORDERS IN HIV
PHP 310, 2015 21
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Methods: Bing et al.
• National probability sample
• 91% in-person interviews
• Michigan Composite International Diagnostic Interview brief screener (DSM III-R criteria)
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http://www.rand.org/pubs/research_briefs/RB9300/index1.html
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DEPRESSION
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Gonzalez et al, J Acquir Immune Defic Syndr 2011;58:181–187
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The relationship between depression and
HIV treatment nonadherence is consistent
across samples and over time, is not limited
to those with clinical depression, and is not
inflated by self-report bias. Our results
suggest that interventions aimed at reducing
depressive symptom severity, even at
subclinical levels, should be a behavioral
research priority.
Gonzalez et al, J Acquir Immune Defic Syndr 2011;58:181–187
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Wagner et al.
• National data from MACH14 dataset
– 14 studies that used electronic adherence monitoring methods
• 25% mild to moderate depression
• 18% had severe depression
• Mean adherence was 69%
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The relationship between global continuous
depression and nonadherence was statistically
significant, but relatively weak compared to that of
cognitive depressive symptoms and severe
depression, which appear to pose strong challenges
to adherence and call for the need for early detection
and treatment of depression.
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Depression Treatment
• Often can be done in primary care setting
• Severe and treatment resistant depression often requires collaboration with MH providers
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SERIOUS MENTAL ILLNESS
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Serious Mental Illness (SMI)
• Serious Mental Illness (SMI): Substantial disorder of thought, mood, perception, orientation or memory, any which grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. This includes, but is not necessarily limited to, diagnoses of schizophrenia, schizoaffective disorder, psychotic conditions not otherwise specified, bipolar disorder, and severe depressive disorders.
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SMI and HIV: Epidemiology
• Prevalence: from convenience samples, administrative data, remnant blood samples in MH treatment settings
• No really good data, but rates of HIV given SMI, and rates of SMI given HIV are probably at least 2x higher than in non-HIV infected population
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SMI and HIV: Broad Challenges
• MH care is in low supply generally, particularly for those with Medicaid and the uninsured
• When SMI care is available, often poorly integrated with primary care or other kinds of “physical health” care
• Models of care for SMI and other less severe MH care should probably differ
• Medicaid programs are increasingly aware of these issues
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SMI and HIV: Specific Issues
• Linkage to and engagement with care
• Adherence to HIV and MH medications
• Drug-drug interactions: newer antipsychotics produce obesity and metabolic complications, synergizing with ARVs (PI’s) that can have similar effects
• Lack of evidence based guidelines
• Key: be aware of the very special issues and challenges presented by persons with SMI
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HCV AND MENTAL ILLNESS
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HIV & HCV: Epidemiology
• In the US, at least 16% of PLWA also have HCV1
• Most cases related to injection drug use
• HCV is now one of the most frequent causes of comorbidity and mortality
• Liver disease second most common cause of death in HIV
• HIV accelerates the course of HCV, so early treatment is critical
1Sherman et al, CID 2002 (34): 831
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HCV & HIV … and Mental Disorders
• Primary etiology is injecting drugs
• Many persons who inject drugs (PWID) have comorbid mental diagnoses
• Overlap of HIV, HCV, and MH disorders
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Summary
• Broader context of weak care systems for persons with behavioral disorders in the US
• Because behavioral disorders affect the organ of cognition, it makes all aspects of care more difficult: from diagnosis to linkage to engagement to adherence to pharmacological issues
• Difficult but important challenge for primary HIV care providers
• Different care models needed
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