HIV and Mental Health: Psychiatry and Depression - PowerPoint Presentation

1. HIV and Mental Health:Psychiatry and DepressionFrancine Cournos, MDProfessor of Clinical PsychiatryCo-Principal InvestigatorColumbia UniversityNortheast/Caribbean AETCNew York, New YorkDr Cournos has no relevant financial affiliations to disclose. (Updated 04/19/21)Planner/Reviewer Financial Disclosures:Planner/Reviewer 1 has no relevant financial affiliations to disclose. (03/16/21)Planner/Reviewer 2 has no relevant financial affiliations to disclose. (04/27/21)

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5. Navigating the WebinarPoll QuestionsA separate window will show the poll questionChoose your response for the pollResponses will be displayed after the poll closesHow to Submit QuestionsSubmit questions using the Q&A buttonYour first and last name must be indicated in order to have questions addressedGenerally, most questions will be answered at the end of the webinar. We apologize in advance if we are not able to address all questions

6. Poll 1Do you currently screen for depression using PHQ-2 or PHQ-9?Yes, I use PHQ-2Yes, I use PHQ-9Yes, I use PHQ-2 and, if positive, I administer the PHQ-9 I screen for depression using a different instrumentI do not screen for depressionDoes not apply

7. HIV and Mental Health:Psychiatry and DepressionFrancine Cournos, MDProfessor of Clinical PsychiatryCo-Principal InvestigatorColumbia UniversityNortheast/Caribbean AETCNew York, New YorkDr Cournos has no relevant financial affiliations to disclose. (Updated 04/19/21)Planner/Reviewer Financial Disclosures:Planner/Reviewer 1 has no relevant financial affiliations to disclose. (03/16/21)Planner/Reviewer 2 has no relevant financial affiliations to disclose. (04/27/21)

8. Describe the approach to the differential diagnosis and management of depression among people with HIVDevelop strategies for managing some of the comorbidities that commonly complicate the treatment of depression in people with HIVConsider models for integrating the treatment of depression with HIV care that best fits your treatment settingLearning Objectives

9. Pretest Question #1Mr. B is a 35-year-old man who was first diagnosed with HIV infection 4 years ago and has adhered well to his antiretroviral medication regimen with a consistently suppressed viral load. Two months ago, Mr. B’s partner broke up with him, and at his visit today he tearfully talks about how sad he’s been since then and how difficult it is for him to concentrate at work. You administer a PHQ-9 screen for depression which shows severe depressive symptoms. Mr. B is amenable to taking an antidepressant medication. Which of these statements is NOT TRUE? If Mr. B is having an episode of major depression, an antidepressant will have a one in three chance of achieving remission.If Mr. B takes as antidepressant, he could develop mania.A diagnosis of major depression can be made based on Mr. B’s high PHQ-9 score.A trial-and-error approach will likely be needed when selecting an antidepressant for Mr. B.If Mr. B improves on his antidepressant but still has symptoms, adding psychotherapy may be a good next step.

10. Pretest Question #2Ms. A is a 29-year-old woman who just been diagnosed with HIV infection. On intake to your HIV clinic, Ms. A has a CD4 cell count of 180, so you’re concerned about her already advanced disease. Screening assessments show Ms. A currently has both severe depressive symptoms and high daily alcohol consumption. You want Ms. A to have the best chance of achieving and sustaining viral suppression, so you decide an optimal approach is to begin antiretroviral treatment while simultaneously: Beginning treatment for her alcohol use disorder with an understanding that Ms. A’s depressive symptoms are likely to improve once she’s drinking less Offering an adherence intervention while mapping out an approach to treating Ms. A’s depression and heavy alcohol use Beginning treatment for Ms. A’s depression while taking a harm reduction approach to her alcohol useSimultaneously beginning optimal evidence-based treatments for Ms. A’s depressive disorder and her alcohol use disorder

11. Estimated Prevalence of Psychiatric Disorders among People in Treatment for HIVCournos, McKinnon, Wainberg, in Comprehensive Textbook of AIDS Psychiatry: A Paradigm for Integrated Care, 2017

12. Treating depressive illness currently involves more trial and error and more uncertainty than treating HIV infectionPsychiatry has no biological tests for the diagnosis of depression (nothing equivalent to detecting HIV or its associated antibody responses) Psychiatry has no biological tests for selecting antidepressants (no phenotype, genotype, resistance testing, etc.) The idea that its simple to screen for and treat depression is not yet trueThe brain is the body’s most unique and least understood organ (which is why psychiatry is both difficult and fascinating)Strategies for Treating Depressive Illness vs. Strategies for Treating HIV Infection

13. Depressive illness is one of the most frightening and disabling of all illnesses, as described below:“I did not die, and yet I lost life’s breath. Imagine for yourself what I became, deprived at once of both my life and death.” (Dante Alighieri, The Inferno, translated by John Ciardi. Dante was born in1265 and the DSM (1) was born in 1952, so Dante had no official DSM diagnoses. But his descriptions of depressive illness are extraordinary!)“I lay down fully dressed in nice clothes, in the mud…and I didn’t care about standing up ever again.” (Andrew Solomon, The Anatomy of Melancholy, The New Yorker)Successfully treating depressive illness gives people their lives back. Given the Frustrations of Treating Depressive Illness, Why Is Persevering So Important?

14. Depressive symptoms are ubiquitousDepressive symptoms can occur as part of ALMOST ANY serious medical illness or neurological condition Depressive symptoms can occur as part of ALMOST ANY other psychiatric diagnosis or as part of ordinary distressRuling out numerous other medical and psychiatric conditions is key to settling on a diagnosis of depressive illnessDepressive Symptoms vs Depressive Illness

15. Even though it’s naïve to screen patients for depressive symptoms without understanding the broad differential diagnosis for these symptoms, doing so is a common practice.A positive screen for depressive symptoms CANNOT BY ITSELF be used to make a psychiatric diagnosis.The SARS-CoV-2 pandemic has magnified this concern as we confront elevated rates of distress in the entire U.S. population (although the presenter observed similarly high rates of distress while doing HIV-related mental health work in parts of sub-Saharan Africa). This talk is primarily about depressive disorders as defined in the DSM-5, and not about depressive symptoms.Differential Diagnosis of Depressive Symptoms

16. Distinguish Between Mental Distress And Mental Disorders Mental DistressCan occur in response to any adversity (including COVID-19).Often does not meet criteria for a psychiatric diagnosis or require specialized mental health interventions. Often responds well to supportive strategies.Mental DisordersUsually cause either persistent severe subjective distress and/or functional impairment. Meet recognized diagnostic criteria (ICD, DSM).Call for evidenced informed mental health interventions such as medication and psychotherapy.

17. The Patient Health Questionnaire-2 (PHQ-2): Two questionsThe Patient Health Questionnaire-9 (PHQ-9): Nine questionsA combination of the PHQ-2 and PHQ-9The PHQ-2 and PHQ-9 are:Quick to completeFree of charge to use and/or reproduceWell-studiedAvailable in multiple languagesThe PHQ-2 and PHQ-9 can be accessed via the National HIV Curriculum and scored at that site using automatic calculators (Tools and Calculators); This site also offers extensive information about the sensitivity and specificity of these tools (Module 2, Lesson 5). Access these materials at www.aidsetc.org/nhc The Two Most Commonly Used Screening Tools Used to Assess for Depressive Symptoms

18. Depressive disorders, which include:Major depression (the major focus of this talk)Persistent depressive disorder (includes what was previously called dysthymia)Bipolar disorders, which include: Bipolar 1 (mania is/has been present)Bipolar 2 (hypomania is/has been present)Cyclothymia (does not meet full criteria for bipolar 1 or 2)Depression As an Illness Is Found in Two Types of Psychiatric Disorders

19. Major Depression is Best Conceptualized as aMedical Co-morbidity of HIV InfectionAFFECTIVEDepressed moodLoss of interestGuilt, worthlessnessHopelessnessSuicidal ideationSOMATICAppetite/Weight lossSleep disturbanceAgitation/retardationFatigueLoss of concentrationMajor depression among people with HIV is associated with increased mortality and worse outcomes along the entire HIV care continuum.

20. There’s no “penicillin” for depression.We largely treat patients by trial and error, monitoring tolerability to side effects and degree of improvement.Response to treatment (>50% reduction of symptoms) is a much less desirable outcome than remission from depressive illness (few or no symptoms).Depressive symptoms that persist pose a risk for relapse. Aim to Achieve Remission of Depressive Illness, Not Just Improvement

21. STAR*D is the largest and most inclusive clinical trial ever conducted on the treatment of non-psychotic unipolar major depression.This multisite, multistep, prospective, randomized, federally funded clinical trial enrolled about 4000 patients, many with medical and psychiatric co-morbidities.The were four sequenced treatment steps in the algorithm. The first step for everyone was treatment with the SSRI antidepressant citalopram. Treatment of Unipolar Major Depression The STAR*D Study: Overview

22. There were two endpoints: response (>50% reduction of symptoms) and remission (few or no symptoms).If citalopram treatment was not successful, step two contained seven options for either augmentation (with another medication or cognitive behavioral therapy) or switching to another antidepressant.If step two failed there were further options in steps three and four.Since 2003, hundreds of papers have been published about the STAR*D results.Treatment of Unipolar Major Depression The STAR*D Study: Overview

23. Seven Step 2 options: Switch to options: sertraline, or bupropion-SR, or venlafaxine-XR, or cognitive psychotherapy; orAdd-on options: bupropion-SR or cognitive psychotherapy or buspironeTwo Step 3 options: Add lithium or triiodothyronine (T3)Step 4 options: Switch to the monoamine oxidase inhibitor tranylcypromine or the combination of venlafaxine-XR and mirtazapine Treatment of Unipolar Major Depression The STAR*D Study: Level 2, 3, 4 Optionshttps://www.nimh.nih.gov/funding/clinical-research/practical/stard/allmedicationlevels.shtml

24. Rates of acute remission (few or no symptoms): Step 1: 37%Step 2: 31%Step 3: 14%Step 4: 13% Rates of response (>50% reduction of symptoms): Step 1: 49%Step 2: 29%Step 3: 17%Step 4: 16%Rates of medication intolerance, relapse and dropout are not shown in this slide. Treatment of Unipolar Major Depression The STAR*D Study: ResultsRush et. al., Am J Psychiatry, 2006

25. It is valuable for prescribers in primary/HIV care to know how to use several antidepressants and be willing to switch patients from one to another depending on patient outcomes (symptom improvement and tolerance of side effects). If the patient does not improve sufficiently after two trials, refer to mental health specialty care.Other reasons to refer to specialty care include bipolar depression, psychotic depression, risk for suicide and/or violence, and diagnostic uncertainty.Treatment of Unipolar Major Depression The STAR*D Study: Implications

26. Brain stimulation treatments: Electroconvulsive therapy (ECT) was the first such treatment, but now there are two other FDA approved treatments, vagus nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS).Ketamine, an agent used primarily by veterinarians for anesthesia (and as a drug of abuse), was recently approved by the FDA for refractory depression; must be used with specific safeguards.Patients with refractory depression should always be referred to the next level of care.There are Treatments For Depressive Disorders that Are Refractory to Usual Psychotropic Medications

27. Bipolar depression accounts for most of the time that people with bipolar disorder spend unwell.This may help explain why, in primary care, over 3 in 20 patients diagnosed with a depressive disorder have an unrecognized bipolar disorder. First line pharmacologic treatment of bipolar depression is mood stabilizers (lithium, anticonvulsants, atypical antipsychotics), whereas for major depression it’s antidepressants.Giving antidepressants alone to people with bipolar depression works poorly and may precipitate mania. Distinguish Between Major Depression and Bipolar DepressionMcIntyre, et al, Curr Med Res Opin, 2019; Devaney, et al, Gen Hosp Psych, 2019

28. There are no brief screens for bipolar disorder. The Mood Disorders Questionnaire (MDQ) is available but has 13 items. Ask if the patient or a close relative has ever been told s/he has manic-depressive illness or bipolar disorder?” Consider a few questions from the MDQ (based on the DSM-5):Has there ever been a period of time when you were not your usual self, and you had much more energy than usual?” Has there ever been a period of time when you got much less sleep than usual and found you didn’t really miss it?If you get yes answers to any of the above questions, you might consider completing the MDQ (www.aidsetc.org/nhc) and/or referring the patient for a diagnostic evaluation.Diagnosing Bipolar Disorder

29. On average, bipolar disorders are more severe illnesses than depressive disorders. This was one reason for the creation of two separate categories for these conditions in the DSM-5. Many people with bipolar disorder need lifetime ongoing management for this condition to maximize social/occupational functioning and well being. Evidence shows that intensive psychotherapy helps.Despite the associated disabilities, there’s a long list of famous artists, fiction writers, inventors, politicians etc. with bipolar disorder.People with bipolar disorder are most amenable to treatment during the depressive phase of the illness. Those who feel euphoric and energized during (hypo)mania often reject care while in that state.Managing Bipolar Disorder

30. Many Exceptional People Have Had Bipolar Disorder: Artists

31. Winston Churchill was the Prime Minister of the UK who achieved victory during World War II. He was diagnosed with bipolar disorder in middle age and openly referred to his depression as his “black dog”. He wrote voluminously and won the Nobel Prize in Literature in 1953.Many Exceptional People Have Had Bipolar Disorder: Politicians and Writers

32. Alvin Ailey was a renowned modern dancer and choreographer whose bipolar disorder was aggravated by his drinking and drug use. He died of AIDS in 1989, but his work lives on through the Alvin Ailey American Dance Theater.Many Exceptional People Have/Had Bipolar Disorder: Dancers and Entertainers

33. Psychiatric disorders carry a high degree of comorbidity with one another: Alcohol and other substance use disorders are common co-morbidities of depressive illnessesWe have yet to understand if there’s an underlying biological vulnerability that could help explain why these diagnoses frequently travel togetherSiloed services for mental illness and substance use disorders are a major barrier to good behavioral health careMost people with alcohol/substance use disorders receive no treatment for these conditionsAlcohol/substance use co-morbidity

34. In general, outcomes tend to be significantly worse among patients diagnosed as having both major depressive disorder and an alcohol/substance use disorder, compared with patients who have only one of these diagnoses.A review of studies among people with bipolar disorders shows a 42% prevalence of alcohol use disorders, a 20% prevalence of cannabis use disorders and a 17% prevalence of other illicit drug use disorders. Iqbal et al, Focus (Am Psychiatr Publ). Spring 2019; Hunt, et al, J Affect Disord, 2016 Alcohol/substance use co-morbidity

35. Alcohol and substance use disorders tend to be one of the most problematic of psychiatric comorbidities among people with depressive illness and HIV because of their added negative impact on morbidity, mortality, and outcomes along the HIV care continuum.In this case, two disorders = two treatments Affective disorders and alcohol/substance use disorders each require their own treatment because treating only one condition doesn’t usually result in sufficient improvement of the other condition.Alcohol/substance use co-morbidity

36. Screening Tools with Calculators:The National HIV Curriculum Has Tools to Rapidly Screen for Substance Use Disorders: www.aidsetc.org/nhcNow available only in the text

37. Treating Distress vs. Disorder Is Best Understood With the WHO Pyramid of Mental Health ServicesMental DistressCan occur in response to any adversity (including COVID-19).Often does not meet criteria for a psychiatric diagnosis or require specialized mental health interventions. Often responds well to supportive strategies.Mental DisordersUsually cause either persistent severe subjective distress and/or functional impairment. Meet recognized diagnostic criteria (ICD, DSM).Call for evidenced informed mental health interventions such as medication and psychotherapy.

38. The World Health Organization (WHO) Pyramid of Mental Health Services

39. There aren’t enough behavioral health providers in the US to refer everyone with depressive symptoms to specialized care.For mild symptoms, self-care and informal supports at lower levels of care on the WHO pyramid can improve mood and protect against distress progressing to illness.For those with diagnosed and treated depressive illnesses, these supports help to maintain remission.During the COVID-19 pandemic, we have been bombarded with advice about accessing these levels of care: coping strategies, maintaining a routine, eating and sleeping well, meditation, exercise, listening to music, virtual socialization, productive and pleasurable activities, reducing exposure to the news, etc., etc.Activating Care along the WHO Pyramid of Mental Health Services for Distress

40. Self care is essential with any chronic illness, including depressive and bipolar disorders. Depressive and bipolar disorders often occur in relapsing cycles, and self care can reduce the frequency of relapse. Informal care can address the social determinants of health (food, shelter, income support, etc.), which also reduces the risk of relapse. Specialty care can assist with stabilizing patients with depressive disorders who are being followed in HIV care.Activating Care along the WHO Pyramid of Mental Health Services for Depressive Illnesses

41. The World Health Organization (WHO) Pyramid of Mental Health Services

42. General outcomesRelief of suffering and improved quality of lifeReduced disability and cognitive dysfunctionIncreased ability to functionReduced mortality due to suicide or medical illnessHIV specific outcomesImproved rates of viral suppressionReduced HIV-related morbidity and mortalityWhat Are the Hoped-for Outcomes in the Successful Treatment of Depressive Illness

43. People with HIV appear to achieve comparable outcomes with depression treatments as the general population.Evidence is mixed regarding whether successful treatment of depressive illness by itself is associated with improved rates of viral suppression; the use of specific adherence interventions is advisable.Evidence is not available regarding whether the successful treatment of depressive illness reverses the shortened life span of people with both chronic depression and HIV What Is the Evidence for Improved Outcomes if Depressive Illness in Treated Successfully

44. Current approaches to care integration vary widelySome HIV programs have great behavioral health care integration, some have no integration at all, and most still struggle with adequately treating depression.There are well researched models for integrating the treatment of depression into primary/HIV care, but they are infrequently implemented successfully. Approaches to Integrating the Diagnosis and Treatment of Depressive Illnesses with HIV Care

45. Standard Framework for Care IntegrationSAMHSA-HRSA CIHDoherty et al, 2013

46. For the most part, each disorder requires its own treatment.There are many models for integrating treatment, but one size does not fit all. Make the most of your own unique circumstances. Influential factors include urban vs. rural sites, the availability of human resources, variations in health insurance, etc.The COVID-19 pandemic has vastly increased the use of virtual visits. Lessons learned could be applied to improve care integration.Strategies for Providing Care to People with Multiple Diagnoses: General principles

47. Health care provider training is not designed to address the brain and the body as an integrated system.The stigma of mental illness/substance use pervades health care provider education.Fear of abnormal behavior is used to construct an artificial separation between the brain and the body. Health care providers often believe taking care of people with substance use disorders or other mental illnesses is not their job.Reflecting on Why It’s So Difficult to Integrate Physical and Mental Health Care

48. The brain controls life’s essential involuntary bodily functions, such as breathing and heart rate.The brain tells the body what voluntary physical actions it must take to survive, such as eating or running away. The body provides continuous feedback to the brain, such as my stomach is full, or my muscles are tired.The brain and the body are a single system. But Physical and Mental Disorders Travel Together Because the Brain and the Body Are One

49. A gut feelingA lump in my throatA knot in my stomachMy heart skipped a beatChills ran down my spine(Strong) Emotions Are Expressions of Brain/Body Integration It took my breath awayI had a sinking feelingIt made my blood boilI was frozen in placeFeeling faint; fainting

50. Unhealthy Behaviors Account for More Premature Deaths in the US than Any Other FactorMcGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

51. If we could overcome the profound problems that separate the treatment for diseases of the body from the treatment for diseases of the brain and mind (such as stigma; treatment siloes; fragmented licensing, information sharing and health insurance systems; etc.), this could be one important step toward reversing the current trend of the U.S. simultaneously spending more money on healthcare than many other high-income countries but seeing worse morbidity and mortality. A Closing Thought

52. Posttest Question #1Mr. B is a 35-year-old man who was first diagnosed with HIV infection 4 years ago and has adhered well to his antiretroviral medication regimen with a consistently suppressed viral load. Two months ago, Mr. B’s partner broke up with him, and at his visit today he tearfully talks about how sad he’s been since then and how difficult it is for him to concentrate at work. You administer a PHQ-9 screen for depression which shows severe depressive symptoms. Mr. B is amenable to taking an antidepressant medication. Which of these statements is NOT TRUE? If Mr. B is having an episode of major depression, an antidepressant will have a one in three chance of achieving remission.If Mr. B takes as antidepressant, he could develop mania.A diagnosis of major depression can be made based on Mr. B’s high PHQ-9 score.A trial-and-error approach will likely be needed when selecting an antidepressant for Mr. B.If Mr. B improves on his antidepressant but still has symptoms, adding psychotherapy may be a good next step.

53. Posttest Question #2Ms. A is a 29-year-old woman who just been diagnosed with HIV infection. On intake to your HIV clinic, Ms. A has a CD4 cell count of 180, so you’re concerned about her already advanced disease. Screening assessments show Ms. A currently has both severe depressive symptoms and high daily alcohol consumption. You want Ms. A to have the best chance of achieving and sustaining viral suppression, so you decide an optimal approach is to begin antiretroviral treatment while simultaneously: Beginning treatment for her alcohol use disorder with an understanding that Ms. A’s depressive symptoms are likely to improve once she’s drinking less Offering an adherence intervention while mapping out an approach to treating Ms. A’s depression and heavy alcohol use Beginning treatment for Ms. A’s depression while taking a harm reduction approach to her alcohol useSimultaneously beginning optimal evidence-based treatments for Ms. A’s depressive disorder and her alcohol use disorder

54. Submit questions using the Q&A button.Question-and-Answer Session