W1 The Psychiatry of AIDS Treisman

Glenn Treisman MD PhD Johns Hopkins University

Disclosure of things that may have affected my views and this presentation ,[object Object],[object Object],[object Object],[object Object],[object Object]

Objectives ,[object Object],[object Object],[object Object]

Prior research has shown that psychiatric patients ,[object Object],[object Object],[object Object],[object Object],[object Object]

More Rapid Discontinuation of ART in Depressed Persons Bangsberg DR et al. 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; December 16-21, 2001; Chicago, Ill. Abstract 1721. BDI  15 BDI  15-censored BDI<15 BDI<15-censored Months on highly active ART 70 60 50 40 30 20 10 0 Cumulative survival 1.0 .8 .6 .4 .2 0.0 P = 0.0001

Depression Decreases AIDS-Free Survival in Patients on ART ,[object Object],[object Object],[object Object],Ickovics JR et al. JAMA . 2001;285:1466-1474. Reprinted with permission. Total time in study (years) Cumulative survival 0 1 2 3 4 5 6 7 0.7 0.8 0.9 1.0 HIV-related mortality

DEFINITION OF GROUPS   Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463. Excluded Mental Disorder No Mental Disorder Mental Disorder Met 1 or 2 of 3 Criteria Psychiatric Diagnosis    Psychiatric Medication  Psychiatric Evaluation 

ASSOCIATION BETWEEN MENTAL D/O AND TIME TO HAART TIME IN YEARS PROBABILITY OF HAART THERAPY P=0.05 No Mental Disorder Mental Disorder 2 4 6 0 Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.

ASSOCIATION BETWEEN MENTAL DISORDER AND SURVIVAL TIME IN YEARS PROBABILITY OF SURVIVAL No Mental Disorder Mental Disorder P=0.10 Himelhoch S, et al. J Acquir Immune Defic Syndr. 2004;37:1457-1463.

Mental Illness depression demoralization substance abuse cognitive impairment AIDS impulsivity depression demoralization substance abuse cognitive impairment

HIV IS A PSYCHIATRIC EPIDEMIC ,[object Object],[object Object],[object Object],[object Object]

Psychiatric disorders in new medical intakes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],* unpublished observation Lyketsos, C.G., Hutton, H., Fishman, M., Schwartz, J., Treisman, G. J ., Psychiatric morbidity on entry to an HIV primary care clinic. AIDS: 1996: 20(3): 131-144

The Four Perspectives McHugh and Slavney ,[object Object],[object Object],[object Object],[object Object]

Problems of life story ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Experience Meaning Assumption Behavior

Major Depression Demoralization (Depression in remission) Sub-syndromal Major Depression Dysthymia “ Minor Depression” “ Depressive Personality”

Differential Diagnosis of Depression DEPRESSION DELIRIUM DEMENTIA DEMORALIZATION

Depression diminishes ,[object Object],[object Object],[object Object]

Anhedonia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Disturbance of Neurophysiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Depression stress demoralization CNS inflammation substance abuse subcortical injury cognitive impairment HIV impulsivity hopelessness carelessness demoralization substance abuse cognitive impairment

TIME OF AIDS DEPRESSION AS AIDS DEVELOPS MONTHS BEFORE AND AFTER AIDS P E R C E N T D E P R E S S E D 0 10 20 -48 -36 -24 -12 6 18 Lyketsos CG, et al. Am J Psychiatry. 1996;153:1430-1437.

Pharmacotherapy ,[object Object],[object Object],[object Object],[object Object],Desipramine Nortriptyline ,[object Object],[object Object],[object Object],[object Object],Citalopram Escitalopram Fluoxetine Paroxetine Sertraline Venlafaxine Desvenlafaxine Failure from side effects Lithium augmentation Combination Antidepressants Thyroid, Pindolol, Antipsychotic augmentation Failure after adequate trial NEXT DRUG Bupropion Nefazodone MAOI's Trazodone Mirtazepine Atomoxetine??

0 100 DEMENTIA SUBSTANCE USE PERSONALITY DISORDER COMPLIANT OVERALL Full Partial None Treatment of Depression Outcome by Diagnosis Lyketsos, C. G., Fishman, M., Hutton, H., Cox, T., Hobbs, S., Spoeler, C., Hunt, W., Driscoll, J., Treisman, G. J ., The effectiveness of psychiatric treatment for HIV infected patients, Psychosomatics: 1997: 38:423-432

CASE STUDY OF PATIENTS WITH HIV AND MANIA NEGATIVE HISTORY (N=7) 33.6 7 male 4 gay/2 IDU 6/6 all AIDS all POSITIVE HISTORY (N=7) 36.0 5 male 4 IDU/3 gay 2/7 2 AIDS/5 HIV+ none AGE SEX RISK FACTOR CD4<100 * STAGE * DEMENTIA * * p<0.05 by fisher's exact test

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Simplified model of disposition Percent of population ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],Introversion-Extroversion Stability- Instability

introversion extroversion stable unstable sanguine choleric phlegmatic melancholy

Motivated Behavior ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Law of effect ,[object Object]

Behavior environmental exposure environmental response Behavior positive increase negative decrease

Internal “drive” (craving) Behavior Reward-Reinforcement Satiation environmental exposure environmental response temperament life experience disease Motivated Behavior

Internal “drive” (craving) Behavior Satiation environmental exposure environmental response temperament life experience disease Motivated Behavior Reward-Reinforcement

W1 The Psychiatry of AIDS Treisman

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