mental health screening tools for the hiv clinician
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Mental Health Screening Tools for the HIV Clinician
Lawrence M. Mc Glynn MDClinical Associate Professor
Stanford University
Faculty Medical DirectorSan Jose AETC
June 2013
Thanks
Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center
American Psychiatric Association – Office of HIV Psychiatry
Goals for Participants Understand which mental illnesses
present themselves more frequently in HIV
Identify risk factors for mental illness in HIV
Become familiar with screening tools for conditions which may affect the overall health of people living with HIV/AIDS
Grab a pencil and some scratch paper
Close your door; turn off your cell phone; no checking your email; no sleeping; kick back and let’s learn together
Types of Screening Tools Patient focused
Self administered Usually consist of questionnaires
Clinician administered to patient Questionnaires Labs Imaging Examinations (physical and mental status)
Includes simple observation Observer(s)
Testimonials from family, friends, coworkers, other providers
Why screening tools?
Relative objectivity (provider bias) Efficiency Lack of resources
Mental health timely availability Shows the patient that you are
considering all aspects of his/her life
Cognitive Dysfunction
As HIV enters the CNS at a very early stage of infection, a cascade of events leads to changes in multiple realms of cognition
Neuropsychological Domains
Verbal/Language Attention/concentration Working Memory Executive/Abstraction Memory (learning, recall) Speed of information processing Sensory-perceptual Motor skills
Associated Behavioral Disturbances
Apathy Depression Sleep disturbance Agitation/Mania Psychosis
HAND Classification
Asymptomatic NeurocognitiveImpairment (ANI)
Mild NeurocognitiveImpairment (MNI)
HIV-Associated Dementia (HAD)
No Functional Impairment
Mild Functional Impairment
Moderate to Severe Functional Impairment
1 SD
2 Domains
2 SD
2 Domains
NIMH, NINDS Panel, Neurology 2007; 69:1789-1799
1 SD
2 Domains
Prevalence of HAND based on New Criteria
NP Normal
(30-60%)
MNI
(20-30%)HAD
(5-20%)
Functional Impairment
ANI
(20-30%)
NIMH, NINDS Panel, Neurology 2007; 69:1789-1799
Risk and Protective Factors
Risk factors Age > 50 Survival duration Lower nadir CD4 T-cell counts Higher baseline viral load Gender (F)
Why Bother to Screen? MNI has been associated with poorer health
outcomes, possibly due poorer adherence to medications
Even mild HAND is associated with worse quality of life, difficulty obtaining employment and shorter survival
McGuire, Goodkin, and Douglas report that HAND independently predicts systemic morbidity and overall HIV mortality
Consider screening upon the initiation of cART and q6-12 months
Mind Exchange Working Group. CID Advance Access. Nov 2012.
The role of objective assessment General Practitioners ability to pick up dementia cases
Sensitivity 51.4% (“positive in disease”) Specificity 95.9% (“negative in health”)
Missed dementia more frequently in patients living alone
Over-diagnosed dementia more frequently in patients with mobility/hearing problems, and in the depressed
Miss nearly half of incident dementia cases Possible factors: GPs’ subjective views on dementia
(e.g., therapeutic nihilism, or suspected/feared stigmatization)
Conclusion: use objective tests
Pentzek M, Wollny A, Wiese B, et al. Apart from Nihilism and Stigma: What Influences GP’s accuracy in identifying incident dementia? Am J Geriatr Psychiatry 17:11, November 2009.
Screening Tools MMSE (not very sensitive, Crum et al.,
1993) HIV Dementia Scale (Power et al., 1995) International HIV Dementia Scale
(Sacktor et al., 2005) Montreal Cognitive Assessment (MoCA,
Overton et al. CROI 2011) MOS-IV
International HIV Dementia Scale (IHDS)
1. Memory-Registration
Give four words to recall (dog, hat, bean, red) – 1 second to say each.
Then ask the patient all four words after you have said them. Repeat words if the patient does not recall them all immediately. Tell the patient you will ask for recall of the words again a bit later.
2. Motor Speed
Have the patient tap the first two fingers of thenon-dominant hand as widely and as quickly aspossible.
4 = 15 in 5 seconds3 = 11-14 in 5 seconds2 = 7-10 in 5 seconds _____1 = 3-6 in 5 seconds0 = 0-2 in 5 seconds
3. Psychomotor Speed
Have the patient perform the following movements with the non-dominant hand as quickly as possible:
1) Clench hand in fist on flat surface. 2) Put hand flat on surface with palm down. 3) Put hand perpendicular to flat surface on the side of the 5th digit. Demonstrate and have patient perform twice for practice.
4 = 4 sequences in 10 seconds3 = 3 sequences in 10 seconds2 = 2 sequences in 10 seconds1 = 1 sequence in 10 seconds _____0 = unable to perform
4. Memory-Recall
Ask the patient to recall the four words. For words not recalled, prompt with a semantic clue as follows:
animal (dog); piece of clothing (hat); vegetable (bean); color (red).
Give 1 point for each word spontaneously recalled. Give 0.5 points for each correct answer after
prompting
Maximum – 4 points. _____
Total International HIV Dementia Scale Score
This is the sum of the scores on items 1-3. ____
The maximum possible score is 12 points.
A patient with a score of 10
should be evaluated further for possible dementia.
HIV Dementia ScaleMAXIMUM SCORE
PATIENT SCORE
TEST
MEMORY - REGISTRATIONGive 4 words to recall (dog, hat, green, peach) and 1 second to say each. Then ask the patient to repeat all 4 after you have said them.
4 ATTENTION/EXECUTIVE FUNCTIONAntisaccadic eye movements (20 commands): ____ errors out of 20 3 errors = 4; 4 errors = 3; 5 errors = 2; 6 errors = 1; 6 errors = 0
6 PSYCHOMOTOR SPEEDAsk patient to write the alphabet in uppercase letters horizontally across the page (use back of form) and record time: _____ seconds 21 sec = 6; 21.1-24 sec = 5; 24.1-27 sec = 4; 27.1-30 sec = 3; 30.1-33 sec = 2; 33.1-36 sec = 1; 36 sec = 0
4 MEMORY - RECALLAsk for the 4 words from MEMORY – REGISTRATION TEST above.Give 1 point for each correct. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); color (green); fruit (peach). Give ½ point for each correct word after prompting.
2 CONSTRUCTIONCopy the cube below. Record time _____ seconds 25 sec = 2; 25-35 sec = 1; 35 sec = 0
Adapted From: Power C et al.: HIV Dementia Scale: a rapid screening test. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1995;8:273-278. Used with permission.
Total score < 10: HAD 11-13: Mild cognitive impairment
Modified HIV Dementia ScaleMax Score
Pt. Score Task
Memory-Registration Give four words to recall (dog, hat, green, peach) - 1 second to say each. Then ask the patient all 4 after you have said them.)
6Psychomotor Speed Ask patient to write the alphabet in upper case letters horizontally across the page below and record time: ____ seconds.less than or equal to 21 sec = 6; 21.1 - 24 sec = 5; 24.1 - 27 sec = 4; 27.1 - 30 sec = 3; 30.1 - 33 sec = 2; 33.1 - 36 sec = 1; > 36 sec = 0)
4Memory - Recall Ask for 4 words from Registration above. Give 1 point for each correct. For words not recalled, prompt with a "semantic" clue, as follows: animal (dog); piece of clothing (hat), color (green), fruit (peach). Give 1/2 point for each correct after prompting
2 Construction Copy the cube below; record time: ____ seconds.(< 25 sec = 2; 25 - 35 sec = 1; > 35 sec = 0)
Total ScoreMax= 12
/12
< 7.5 may indicate dementia and should be evaluated by full battery if possible
MOCA
MOCA
MOCA
MOCA
MOCA
Cognitive Functional Status Sub-scale of MOS-HIV Scale of Wu et al.
4 questions, past 4 weeks: 1. Difficulty reasoning/problem solving? 2. Forget things (location; appointment)? 3.Trouble with keeping attention for long? 4. Difficulty with activities using
concentration / thinking? 6 pt. frequency scale: 1= all; 2=most; 3=good
bit; 4=some; 5=little; 6=none [cutoff < M= 4] Validated against NP overall
performance in the Netherlands; Good for busy clinicsKnippels, Goodkin, Weiss, et al., AIDS, 2002;16:259-267
Mathematical Screening
Cysique et al. Cognitive impairment is predicted to
occur when this expression is true
Step 1: Neuropsych performanceStep 2: Functional Impairment?
How To Assess Functional Impairment? Collateral Informant and
Objective ratings are most reliable IADL scale (Lawton) Driving Performance (Marcotte et
al.) Karnofsky, Finances, Medications
What to do with a positive screen?
Rule out other causes Always consider the biopsychosocial
model Treatment
Antiretrovirals Psychostimulants Other treatments being studied
Depression and Anxiety Depressed mood is one of the most
common complaints among people living with HIV
Given the high co-occurrence of HIV and PTSD, anxiety is also frequently seen
These disorders may present themselves as somatic complaints Headaches, GI complaints, weakness, fatigue,
insomnia, chest pain, shortness of breath Somatic complaints are not unusual in HIV/AIDS
even when the patient is mentally healthy
Epidemiology-Anxiety
15.8% of HIV+ have GAD (2.1% of general population
10.5% have Panic d/o (2.5% of gp) 37% of HIV+ women report “high
anxiety” Protective: relationship, older, vl BDL
Epidemiology-Depression
Lifetimes prevalence of depressive disorder in HIV as high as 22% (5-17% in general population)
Risk: African-american (M and W), MSM
Why Bother to Screen?
Depression in HIV/AIDS is a significant predictor of worsening overall outcome
Depression and anxiety can contribute to poor cognitive functioning
Screening Tools
Consider Endicott Criteria: reduce the weight of somatic symptoms (weight/appetite loss, sleep changes, agitation/retardation, fatigue, loss of concentration) in screening
HAD Are you depressed?
Anxiety questions
•I feel tense or wound up•I get a sort of frightened feeling as if something bad is about to happen•Worrying thoughts go through my mind•I can sit at ease and feel relaxed•I get a sort of frightened feeling like butterflies in the stomach•I feel restless and have to be on the move•I get sudden feelings of panic
•Cutoff score: 8
Depression Questions
•I still enjoy the things I used to enjoy•I can laugh and see the funny side of things•I feel cheerful•I feel as if I am slowed down•I have lost interest in my appearance•I look forward with enjoyment to things•I can enjoy a good book or radio or TV program
•Cutoff score: 8
"Are you depressed?" Screening for depression in the terminally illAm J Psychiatry 1997
Semi-structured diagnostic interviews for depression were administered to 197 patients receiving palliative care for advanced cancer
RESULTS: Single-item interview screening correctly identified the eventual diagnostic outcome of every patient, substantially outperforming the questionnaire and visual analog measures
PHQ-9
What to do with a positive screen?
Assess for suicidality R/o other causes (biopsychosocial
model) Refer to treatment (talk, med’s)
Suicidality
Epidemiology
Despite the development of cART, suicide rates among HIV+ individuals remain more than three times higher than in the general population.
AIDS PATIENT CARE and STDsVolume 26, Number 5, 2012
Risk
History of suicide attempt(s) Diagnosable mental health
disorder History of psychiatric treatment Substance use Anxiety sensitivity – cognitive
concerns
Why Bother to Screen?
Safety Establish a longitudinal record Suspicion of suicide can elicit
emotions in the provider Is emotional decision making as
precise as less emotion-based thinking?
Screening Tools Will you be able to sleep tonight? Multiple factors to consider which
make screening a challenge Substance use Psychosocial stressors Temporal relationship to medications
(e.g., efavirenz, IFN-α) Medical illness
SBQ-R (Osman et al)
What to do with a positive screen?
Hospitalize For those deemed to be able to go
home F/U asap; telephone contact (to/from) Urgent referral to mental health
PTSD Screening
The estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8–42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women
PC-PTSD
What to do with a positive screen
Screen for depression, anxiety, domestic violence, substance abuse and suicidality
Refer to mental health Therapy Medications based on symptoms
Substance abuse
Epidemiology
Only 19% of those with HIV had never used an illicit drug
1 in 4 of those with HIV in the USA report alcohol or drug use at a level warranting treatment
Why Bother to Screen?
Active substance use can lead to increased morbidity and mortality
Substances can interact with HIV medications
Screening Tools
Physical Exam Mental Status Exam CAGE questionnaire
CAGE
What to do with a positive screen? Establish safety
Prescribed medications which may pose a risk
Concurrent illnesses (e.g., HCV) Home, transportation Family responsibilities (children,
elderly) Discuss treatment options
Have referral information on hand
Domestic Violence
Facts For HIV+ women, the estimated rate of intimate partner
violence is 55.3% (95% CI 36.1–73.8%), which is more than twice the national rate. Early childhood abuse predicts future domestic violence (Machtinger et al)
Among MSW with HIV, childhood sexual abuse predicted post-traumatic stress disorder (PTSD), and less trust in medical providers (Whelten et al)
MSM with HIV and PTSD are more likely to miss appointments (Traeger et al)
Victims may be less likely to leave abusive situation In a sample of HIV+ individuals, 20.5% of the women,
11.5% of the MSM, and 7.5% of the MSW reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes (Zierler, Bozzette, et al)
Why Bother to Screen?
Safety of patient Safety of others
Family Friends Staff
Screening Tools
http://www.cdc.gov/ncipc/pub-res/images/ipvandsvscreening.pdf
What to do with a positive screen?
Assess for current safety Document Refer
Safe shelter Mental health
Report
The Great Imitators
Screen for other conditions which may mimic psychiatric disorders Hepatitis C - lab Syphilis - lab Drug Interactions – Pharm.D., website Adherence challenges Medication Adverse Effects Malnutrition/Dehydration
Axis II Flags
“Everyone” “No one” “Always” “Never”
The End
Thank you for taking care of our community!
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