HIV and Mental Health Considerations when treating clients with HIV and mental health - PowerPoint Presentation

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HIV and Mental Health

Considerations when treating clients with HIV and mental health disorders

Justin Kerr, RN, MS, PMHNP-BC

“Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his

community.” (WHO.gov)

Mental illness can be defined as “ongoing signs and symptoms cause stress and affect your ability to function.” (mayoclinic.org)

Mental Health and Mental Illness

Mood disordersAnxiety disorders

Psychotic/thought disorders

Personality disordersSubstance use disorders

Some of the major groups of mental illness

Presence of a chronic psychiatric disorder that results in substantial functional impairment (

Hobkirk

, Towe, Lion, Meade 2015)Typically includes: Psychotic disorders, Bipolar disorder, Recurrent Major Depressive Disorder

Not many studies examine associations between HIV and non-depression severe mental illness.

Severe mental illness (SMI)

In a sample of adults receiving care for HIV in the United States, nearly half of the sample screened positive for a mental disorder; nearly 40% reported using illicit substance use other than marijuana; more than 12% screened positive for substance dependence (Bing, 2001)

Of that sample, one third screened positive for major depression

Documented

seroprevalence

rates range from 3% to 23% among people living with a severe mental illness (Weiser, Wolfe &

Bansberg

, 2004)

Prevalence of HIV among persons with SMI was 5.9% in psychiatric inpatient units, 5.1% in intensive outpatient case management programs, and 3.9% in community mental health centers (Blank et al, 2014)

Prevalence of HIV among person with SMI in African counties range from 11 to 27%

Important statistics

Higher risk of HIV transmission and higher mortality rate than general population

Tested more frequently than general population, but prescribed ART less often than non-SMI population

Some evidence to support that risk is directly influenced by psychiatric symptomsTransmission risk is more complex and influenced by individual, social, and system factors

HIV transmission risk factors among SMI population

- Homelessness

Experience of sexual violence

Early sexual debut Substance use during sex L

ifetime illicit substance use

S

ex work

HIV transmission risk factors among SMI population

Mood disorders are the most common psychiatric complication associated with HIV

HIV diagnosis does not necessarily lead to a mood disorder

Possible medical causes for mood disturbances: subcortical damage from HIV infection, systemic illness secondary to HIV infection (ex pneumonia), endocrine abnormality, vitamin deficiencies

HIV and Mood Disorders

Interleukin:

Depression, disorientation, confusion and coma

Steroids: Mania or depressionEfavirenz (Sustiva

):

Decreased concentration, depression, nervousness, nightmares

Stavudine

(

Zerit

, d4T): Depression or mania, astheniaZidovudine (Retrovir, AZT): Mania, depressionInterferon: Neurasthenia fatigue syndrome, depression

Zalcitabine

(

Hivid

):

Depression, cognitive impairment

Vinblastine:

Depression, cognitive impairment

ART and mental health side effects

SSRIs

Citalopram; Fluoxetine; Sertraline; Paroxetine; Fluvoxamine

SNRIsLevomilnacipran; Venlafaxine; DuloxetineNDRIs

Buproprion

MAOIs

Selegine

TCAs

Amitriptyline; Nortriptyline

Atypical/2nd generation antipsychoticsMood stabilizers/antiepileptics

Novel agents

Vortioxetine

(

Trintellix

)

Mirtazapine (

Remeron

)Trazodone (

Desyrel

)Vilazodone (Viibryd)

Psychopharmacology for depression

Fluoxetine increased levels of

Delavirdine

around 50%Efavirenz and Nevirapine may reduce Vilazodone

Efavirenz

may reduce Sertraline

Ritonavir may increase level of SSRIs

Fluvoxamine increases level of all Protease Inhibitors

All Protease Inhibitors increase

Vilazodone levelsDuranavir/ritonavir decreases Sertraline and Paroxetine levels

Some anti-depressant and ART interactions

Atypical antipsychoticsMood stabilizers

Lithium

LamotrigineValproateCarbamazepine/Oxcarbamazepine

Topiramate

Psychopharmacology for Bipolar

Monitor for zidovudine toxicity if a client is also on

Valproic

acidLamotrigine levels are decreased when treated with RitonavirCarbamazepine and Oxcarbazepine may reduce Elvitegravir levels

Carbamazepine may decrease levels of PIs

Ritonavir increases Carbamazepine levels

Some mood stabilizer and ART interactions

HIV positive individuals with, and without, substance use disorders have increased risk of schizophrenia and acute psychosis

People with HIV who have schizophrenia have substantially increased mortality

Factors contributing to psychosis among people with HIV include: direct effect of HIV on CNS, opportunistic infections, CNS neoplasm, medications, substance use disorder

HIV and Psychosis

Differentiating between primary psychosis and HIV-related psychosis

HIV-related psychosis is usually associated with eventual remission of psychosis, smaller doses of antipsychotics, are treated with antipsychotics for a shorter duration, more likely to have a full re-mission

HIV-related psychosis is more likely to occur in later stage of HIV-infection Several reports of

Efavirenz

-induced psychosis

Some reports on

Nevirapine

and

ZidovudinHIV and Psychosis

First Generation/Typical

Include: Haloperidol*; Chlorpromazine;

Perphenazine; Fluphenazine*; Promethazine; Loxapine;

Pimozide

Second Generation/Atypical

Include

: Clozapine; Olanzapine*;

Quetiapine; Risperidone*;

Paliperidone*; Iloperidone; Ziprasidone; Lurasidone; Aripiprazole*; Asenapine

Recently approved medications include:

Brexpiprazole

(

Rexulti

)

* = come in long-acting injectable

Psychopharmacology for Psychosis

Pimozide is contraindicated in combination with Protease Inhibitors d/t

qT

prolongationSome Antipsychotic and ART interactions