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HAND Diagnostic Issues HAND Diagnostic Issues Addressing Mental Addressing Mental Health Health

• Dr. Adriana Carvalhal, MD, MSc, PhD

University of Toronto –St. Michael’s Hospital

Company Abbvie Laboratories Bristol-Myers Squibb Canada Janssen Biotech Consulting I I I Speaking & Teaching I I Advisory Board I

D – Relationship is considered directly relevant to the presentation. I – Relationship is NOT considered directly relevant to the presentation.

Research: Canadian Institute Health Research (CIHR) - I Ontario HIV Treatment Network (OHTN) - I

Disclosure

Introduction

• Transition of HIV to a chronic disease
• Challenges have changed with the advances

in the treatment – shifted to the treatment

• f comorbidities
• HIV-positive patients continue to face:
• Extensive social challenges
• Stigma and discrimination
• Social isolation

Heywood & Lyons, 2016

Relf, MV et al. 2013. Carvalhal, et al. 2012.

HIV

Psychiatric Disorders

Risk Poor QoL

Severity Poor self-care Adherence Worse clinical outcomes Impairment in social and vocational functioning Use of health services

HIV and Psychiatric Disorders

HIV Infected

HIV

Diagnosed

Linked to Care Retained in Care On ART

Viral

Suppression

In HIV Care

Impact of Psychiatric Disorders

Depression

 Depression is the most common psychiatric disorder in HIV-infected patients  Lifetime prevalence is 20-45% (general population=9%)  Depression is the leading cause of disability and is associated with negative outcomes:

 Low productivity  Medication non-adherence  Cognitive complaints  Comorbidities:

• a. Cardiovascular disease
• b. Stroke
• c. Diabetes
• d. Substance use
• e. Suicidality

Hammond et al 2016 Murray et al 2013 Hees et al 2013

Why so high prevalence?

 Direct effect of the virus on the immune system  High viral load  Symptoms burden  Emotional reaction to the diagnosis  Social stigma  Individuals with previous history

Sowa et al 2016 Hammond et al 2016 Miller et at 2009

 Depression is associated with poor neurocognitive functions  Depressive symptoms predict cognitive complaints  Untreated depression affect cognition

 “Resistant depression” can be symptom of HAND

 Treatment for depression can improve cognitive symptoms  Best clinical practice to treat depression before referring patients to full neuropsychological assessment

Cysique et al 2016 Carter et al 2003.

Depression and Cognitive Functioning Depression and Cognitive Functioning

 Patients may not recognise or self-report symptoms of depression1

 Some physicians may also be afraid to ask questions about psychological health

 A wide variety of depression screening techniques are available2

 Most rely on self-reporting  Some tools focus in physical symptoms  Most diagnose the severity rather than presence of depression

Screening Diagnosis Monitoring

• 1. New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2010.

Available at: http://cdn.hivguidelines.org/wp‐content/uploads/depression‐and‐mania‐posted‐10‐19‐2010.pdf. Last accessed July 2013.

• 2. Ramasubbu R et al. Ann Clin Psychiatr 2012;24:82–90.

Screening for depression

 Many screening techniques can be performed in ≤10 minutes1

 Screening methods as short as two questions have been recommended2  Questionnaire length does not impact accuracy3

• 1. Ramasubbu R et al. Ann Clin Psychiatr 2012;24:82–90;
• 2. New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2010.

Available at: http://cdn.hivguidelines.org/wp‐content/uploads/depression‐and‐mania‐posted‐10‐19‐2010.pdf. Last accessed July 2013;

• 3. Akena D et al. BMC Psychiatry 2012;12:187.

Screening for depression

Screening for depression

 Centre Epidemiological Studies – Depression – CES-D  Simple, quick and easy to interpret  Screening tools assess several somatic symptoms  Scoring > 16

Radloff 1977

Rarely or none (less than 1 day) Some or a little (1-2 days) Occasionally or a moderate amount of time (3-4 days) Most or all the time (5-7 days) I was bothered by things that usually don’t bother me. I felt hopeful about the future

When diagnosing HIV patients with depressive symptoms, it may be necessary to exclude the following possible causes:

Other neuropsychiatric disorders

• Bipolar disorder
• Post-traumatic stress disorder
• HIV-associated dementia
• Alcohol and substance abuse

HIV-related medical conditions and treatments

• Endocrinological abnormalities
• HIV-related treatments
• Opportunistic and other infections

(e.g. syphilis)

• HIV-associated dementia

New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York (NY): New York State Department of Health; 2010. Available at: http://cdn.hivguidelines.org/wp‐content/uploads/depression‐and‐mania‐posted‐10‐19‐2010.pdf. Last accessed July 2013.

Screening Diagnosis Monitoring Confounding factors for the diagnosis of depression Confounding factors for the diagnosis of depression

Breaking Down the Siloes: Effective Multidisciplinary Team

Psychiatric Care for PHA at SMH Care at the Hospital Care in Primary Care Care in the Community

Chan & Carvalhal, 2015 Carvalhal, 2015

HIV Care at St. Michael’s Hospital

 HIV care

• Positive Care Program
• ID (5)
• Hepatologist (1)
• Psychiatrist (1)
• Nurse (3)
• Dietician (1)
• Physiotherapist (1)
• Social worker (1)
• Pharmacist (2)
• Primary care – HIV

Program

• Family physicians (5)
• Nurse practitioner (1)
• Psychiatrist (1)
• Social worker (1)
• Dietician (1)
• Pharmacist (1)

Care in the Community

HIV Care at St. Michael’s Hospital

Casey House Casey House

• 14 beds
• Transition from hospital to

community

• Community services
• SMH team:
• ID
• Psychiatrist

HIV Care at St. Michael’s Hospital

McEwan Housing – McEwan Housing – Positive Service Positive Service Coordination Coordination

• Intensive case management (15 –

20 clients/case manager)

• Housing and fast track to engage

in care

• 100 patients in the program

HIV Care at St. Michael’s Hospital

Complex Care Complex Care

• Target population:
• HIV-positive patients who

are aging

• Complex health issues
• High service users
• Cognitive disorders

HIV Care at St. Michael’s Hospital

In Summary

1. Despite many advances in the treatment of HIV infection, psychiatric disorders remain a challenge and a significant proportion of patients with HIV suffer from depression. 2. Psychiatric disorders create challenges for engagement in care and increase the likelihood of engaging in high risk behaviour. 3. Synergistic mechanisms between depression and HIV may be related to stress and immune dysfunction. 4. Depression is associated with negative outcomes such as low productivity, medication non-adherence and other comorbidities (e.g. cardiovascular disease, diabetes, and substance use). 5. Traditional models of delivery psychiatric care in HIV-infected patients do not work. We have to think “outside the box”. It is all about networks that we are able to develop.

HAND Diagnostic Issues HAND Diagnostic Issues Addressing Mental Addressing Mental Health Health

Thank Y

• u!