Mental Health & HIV

Keith Haas, MSW, CSWUniversity of Kentucky

Lexington, KY

A Biopsychosocial Perspective

o Mental illnesses are medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others, and daily functioning.

o Not related to a person’s character—brain based disorder!o Fall on a continuum of severity o Affects 1 in 5 families in Americao Most likely to strike in adolescence and young adulthoodo Untreated mental illness costs over 100 billion dollars a year in lost

wages, disability, incarceration, substance abuse, etc.

A Biopsychosocial Perspective

Mental Illness is not just a biological phenomenon It is the result of an interplay/interaction between

complex factors, including:Genetic predisposition A person’s beliefs, thought patterns, emotional

characteristics, and behavior patternsFamily of origin, current relationships, SES (poverty),

culture, race, religionEarly experiences of trauma

A Biopsychosocial Perspective

The DSM uses a multi-axial system to diagnose/code mental illnesses

Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disordersDepression, anxiety, phobias, schizophrenia, ADHD, Autism,

Substance abuse Axis II: underlying pervasive or personality conditions, as well as

mental retardationNarcissistic PD, Borderline PD, Histrionic PD, etc.

Axis III: acute medical conditions and physical disorders Brain injury, dementia, diabetes, HIV

Axis IV: psychosocial and environmental factors contributing to the disorder

The most common disorders among PLWHA and their symptoms

Study of HIV patients at Johns Hopkins clinic (N=250) showing up for 1st appt:54% Axis I (not including SA)18% adjustment disorder20% major depression18% cognitive impairment74% substance abuse disorder26% personality disorder

The most common disorders among PLWHA and their symptoms

Clinical Depression Affects approximately 20% of patientsIncreases transmission risk and complicates tx

• Poor appetite• Insomnia/hypersomnia• Low energy/fatigue• Low self-esteem• Poor concentration• Feelings of hopelessness

The most common disorders among PLWHA and their symptoms

Anxiety DisordersApproximately 20% of patientsFrequently co-occurs with depressionIncludes PTSD, general phobias, and panic, OCDMore common in those w/ limited social support

• Restlessness• Easily fatigued• Excessive worry• Irritability • Sleep disturbance• Somatic manifestations

The most common disorders among PLWHA and their symptoms

• Personality Disorders• Enduring patterns of inner experience and behavior, that have

existed since at least adolescence or early adulthood• Negatively affects functioning in multiple areas of life• Most common among HIV-infected are borderline and antisocial

disorder• Behaviors are not adaptive, don’t fit current circumstances

• Demanding, entitled

• Complaining

• Irrational

• Perceive relationships to be closer than appropriate

• Extreme anger when things don’t go their way

The most common disorders among PLWHA and their symptoms

AIDS related dementia/Cognitive disorderHIV affects the brain & CNS

• Memory loss, slurred speech, loss of physical abilities, etc.

Contributes to depression and other mood disorders, such as acute mania and anxiety disorders

May refuse to take medications

The most common disorders among PLWHA and their symptoms

Mentally ill patients are likely to self-medicateSA creates biochemical instabilitySymptoms of addiction mimic disease symptoms

Withdrawals (e.g. tremors, weight loss, sweats, panic)Affects mood & behavior

HIV diagnosis can sometimes be the “bottom”

The most common disorders among PLWHA and their symptoms

May impair one’s judgment and/or self-esteemMore likely to engage in risky activityChaotic lifestyle Substance dependency/sex workLess likely to negotiate safety

May make one more vulnerable to victimizationWomen MR/DDCognitive deficits

Case

Wendy: 48 y.o. female Serious trauma history; exposed to alcoholism, DV and sexual abuse in

childhood.

Struggled with anxiety, depression and involved in DV relationships

in early adulthood Diagnosed w/ HIV in 2001—most likely transmission through

victimization

Has difficulty following through with visits due to depression, anxiety.

Depression/AnxietyDifficulties with stigma, stress associated with

illnessAIDS Dementia/CNS Opportunistic Infections

ForgetfulnessConfusionSlurred speechMuscle weaknessClumsiness

Things that can exacerbate mental illness/substance abuse

DiagnosisDisclosureHospitalizationGrief/LossNew Medication End of life decision makingLifestyle changes

Case

Jack: 37 y.o. maleBefore diagnosis, functioning relatively well, no hx of

serious mental illness/addictionDiagnosed HIV+; partner had hidden his own + status, thus

putting Terry at risk of infectionAfter diagnosis, reports severe anxiety and panic attacks,

depression, and unresolved anger, grief and loss.Difficulties in coping with stress associated with this

diagnosis.Alcohol use increases from occasional use to near daily

use, in an attempt to cope with stress.

DepressionDemoralization

Substance AbuseCognitive

impairment

ImpulsivityDepression

DemoralizationSubstance Abuse

Cognitive impairment

Mental Illness HIV/AIDS

Mental health disorders make our patients feel disorganized and hopeless

MH disorders make medical (and dental!) treatment more difficult

MH treatment is expensive, time consuming, and difficult to access

Care is fragmentedIMPACTS ADHERENCE

Barriers to adherence:Active substance abuse –consistent predictor of

poor adherenceFluctuations in cognitive functionPessimism, apathy, poor coping stylesDepression & AnxietyFear of stigmatization/victimization/mistrust

Predictors of adherence: Social supportConfidenceBeliefs & knowledge about medication Trust in provider/relationships with providerRegimen that “fits” with daily activities

Stabilize mental healthDetox from substance abuse and achieve sobriety

or reduce negative impacts of useImprove quality of lifeFeel better—live better—live longer!Decrease transmission of HIV

You are privy to information that many people don’t have

How you respond to your patient will impact social experience of the illness

Pts are less likely to disclose mental illness and/or substance abuse b/c of stigma

How do I ask about mental health and substance abuse?• Ensure confidentiality• Eliminate stigma

• “I ask all of my patients…”

• Express concern• “I am concerned about you because you missed your

last appointment. Is there anything that I can help you with?”

• Screen--don’t diagnose• Only a licensed mental health professional can make

a diagnosis. • Familiarize yourself with reliable screening tools

Screening tools

Mental HealthPatient Health Questionnaire (PHQ-9) General Health Questionnaire

Substance AbuseMost common tool is the CAGE:

Have you ever tried to cut-down?

Have you become annoyed when others ask about your using?

Have you ever had guilt over your substance use?

Do you need an eye-opener?

Services

• Primary Care

• Psychiatric Care (Medicaid)

• Community Mental Health Centers

• NAMI

• Ryan White Programs Part B

• Care Coordination Program

• Mental health services

Questions? Comments? Concerns?

Thank You!

Keith Haas, MSW, CSW

University of Kentucky

Bluegrass Care Clinic

740 S. Limestone St. 5D

Lexington, KY 40536

859-218-3815

Keith.Haas@uky.edu