# Presentation: 571371

## MENTAL HEALTH AND HIV DISEASE

**Annelle B. Primm, MD, MPH**Director, Office of Minority and National AffairsAmerican Psychiatric Association**June 20, 2005**

**Notes:**
[TITLE SLIDE]  Greetings and introduction.

## Overview  

- Mental Health & Mental Illness
- Links between Mental Health & HIV/AIDS
- Relationship between Substance Abuse & HIV/AIDS
- Health & Mental Health Disparities & the Vicious Cycle
- Summary
- Vision for the Future

## Mental Health  

- Successful performance of mental function throughout the life cycle resulting in:
- Productive activity
- Fulfilling relationships
- Ability to adapt to change and cope with stress
- Foundation for thinking, communication skills, learning, emotional growth, resilience, and self-esteem

## Mental Illness

- Health conditions characterized by changes in:
- Thinking
- Mood
- Behavior (or some combination of these 3)
- Associated with distress and/or impaired functioning

## SG Report on MH - 2000

- Despite 20% prevalence, mental illnesses are undertreated
- Stigma is a major barrier to care
- Discrimination in insurance coverage
- Undertreatment of special populations children & youth, elderly, the 4 major ethnic and racial groups
- Important role for primary care physicians and other medical specialists

## It’s Not Over   

**It’s Not Over   **

**American Psychiatric Association**

- HIV can cause emotional distress and crisis
- HIV is a neurotropic virus that affects brain tissue
- HIV infection of the brain can lead to a wide spectrum of organic mental health disorders
- Neurocognitive impairment is common
- Missing diagnoses can lead to irreversible impairment

**HIV and Mental Health Issues**

**American Psychiatric Association**

- Complex drug regimens can result in mental health problems
- Substance use can increase HIV risk and mask underlying problems
- Mental health problems can interfere with treatment adherence

**HIV and Mental Health Issues ****(cont.)**** **** **

**American Psychiatric Association**

##   HIV and Mental Health Issues (cont.) 

- All populations are at risk
- Racial and ethnic minorities are disproportionately affected
- Left untreated, mental health problems can result in disabling consequences
- Can interfere with treatment adherence

**American Psychiatric Association**

##  Psychological Impact

- HIV is a chronic stressor
- HIV tests our coping skills
- HIV can precipitate mental distress
- HIV can lead to discrimination, fear,
- rejection, emotional trauma

**American Psychiatric Association**

## HIV’s Assault on the Brain 

**American Psychiatric Association**

## Spectrum of HIV-Related Disorders

- Neurocognitive Impairment
- Psychiatric Syndromes
- Somatic Syndromes

**American Psychiatric Association**

##   Neurocognitive Impairment

- Cognitive Functioning
- Behavioral Functioning
- Motor Functioning

**American Psychiatric Association**

##  Neurocognitive Impairment (cont.)

** ****Neurocognitive Impairment ****(cont.)**

- Most common illnesses include:
- HIV-associated Dementia
- Minor Cognitive-Motor Disorder

**American Psychiatric Association**

##   Psychiatric Disorders

- Most common illnesses include:
- Mood Disorders
- Substance Use
- Personality Disorders
- Adjustment Disorders
- Suicide Risk
- Anxiety Disorders

**American Psychiatric Association**

## Somatic Syndromes

- Pain Disorders
- Endocrine Disorders
- Medication Side Effects

**American Psychiatric Association**

## Substance Use

**American Psychiatric Association**

**Notes:**
Injection drug use is a risk behavior for 32% of people with AIDS in the United States. 
In addition to direct transmission through the sharing of needles, indirect transmission occurs through sexual contact with HIV-positive injection drug users. 
The use of noninjected drugs (alcohol and cocaine) increases risk for HIV because of its effect on decision making and sexual risk taking.  This is particularly important as we consider the issues among teenagers and young adults.

##  Substance Use (cont.)

- Substance abuse most likely to cause symptoms of cognitive impairment
- Symptoms will mimic psychiatric and biologic disorders
- Substance abuse may result in secondary psychiatric disorders and related cognitive impairment
- Substance abuse may lead to permanent cognitive impairment that may predate HIV

**American Psychiatric Association**

## Substance abuse can interfere with rational decision making
Substance abuse can interfere with treatment adherence
Substance abuse may lead to high risk behavior
TB and Hepatitis C are common among substance abusers

- Substance abuse can interfere with rational decision making
- Substance abuse can interfere with treatment adherence
- Substance abuse may lead to high risk behavior
- TB and Hepatitis C are common among substance abusers

**American Psychiatric Association**

## High rate of HIV infection among persons with serious mental illness who are also substance abusers
HIV/AIDS sufferers often turn to alcohol or drugs to manage their disease
Teenagers often experiment with drugs and alcohol

- High rate of HIV infection among persons with serious mental illness who are also substance abusers
- HIV/AIDS sufferers often turn to alcohol or drugs to manage their disease
- Teenagers often experiment with drugs and alcohol

**American Psychiatric Association**

## Populations at Risk

**American Psychiatric Association**

## Ethnic & Racial Disparities

- Mental Illness affects all
- Striking disparities in MH Care for 4 major ethnic & racial groups
- Less likely to receive services
- Poorer quality of care
- Underrepresented in MH research
- Disparities impose great disability burden on these populations
- 		SG Report on MH, Supplement of Culture, Race & Ethnicity, 2002

## Factors Affecting Service Use

**Racism**
**Discrimination**
**Economic  impoverishment**
**Mistrust**
**Fear**
**Cultural and social influences**
**Biological, psychological and environmental factors**

**U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001**

## High Need Populations

**Homeless**
**Corrections**
**Alcohol & Drug Abuse**
**Refugees**
**Victims of Trauma**
**Homicide**
**Foster Care**

**U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001**

## IOM Report: Unequal Treatment

- Racial and ethnic disparities exist regardless of SES:
- Higher morbidity and mortality from the leading causes of death (CV disease, Diabetes, HIV/AIDS, etc.)
- Poorer quality of care
- Worse outcomes – “Death gap”

## The Death Gap

- African Americans:  Heart disease and stroke, cancer (breast, lung and prostate), diabetes, infant mortality, HIV/AIDS
- Asian Americans and Pacific Islanders: tuberculosis, stroke, cervical cancer
- Hispanics:  diabetes, uncontrolled hypertension, HIV/AIDS
- American Indians and Alaska Natives:  diabetes, infant mortality

## Personal/Family
acceptability
cultural
language/literacy
attitudes, beliefs
preferences
involvement in care
health behavior 
education/income
Structural
availability
appointments
how organized
transportation
Financial
insurance coverage
reimbursement levels
public support

- Personal/Family
- acceptability
- cultural
- language/literacy
- attitudes, beliefs
- preferences
- involvement in care
- health behavior
- education/income
- Structural
- availability
- appointments
- how organized
- transportation
- Financial
- insurance coverage
- reimbursement levels
- public support

- Visits
- primary care
- specialty
- emergency
- Procedures
- preventive
- diagnostic
- therapeutic

- Quality of providers
- cultural competence
- communication skills
- medical knowledge
- technical skills
- bias/stereotyping
- Appropriateness of care
- Efficacy of treatment
- Patient adherence

- Health Status
- mortality
- morbidity
- well-being
- functioning
- Equity of Services
- Patient Views of Care
- experiences
- satisfaction
- effective partnership

***Barriers***

***Use of Services***

***Mediators***

***Outcomes***

- Modified From Access to Health Care in America 10 , From Cooper LA, Hill MN, and Powe NR. JGIM 2002; 477-486

**Barriers and Mediators to Equitable Health Care for Racial and Ethnic Groups**

## Vicious Cycle 

**Substance **
**Abuse**

**Poor Physical Health**

**Poverty & Homelessness**

**Mental Illness**

**      ****Violence & Incarceration**

## DSM IV - Major Depression

- Sadness or irritability
- Loss of interest in activities
- Appetite or weight change
- Sleep disturbance
- Guilt, low self worth, hopelessness
- Inability to concentrate
- Fatigue or loss of energy
- Restlessness or slowed activity
- Thoughts of suicide or death

## Prevalence of Depressive Episodes 	

- 				Lifetime		One year
- Sex:
- 	Men			3.6*			2.2*
- 	Women			8.7			5.0
- Ethnicity:
- 	White			6.6*			3.7
- 	Black			4.4			3.3
- 	Hispanic			5.6			3.9

**(Psychiatric Disorders in America, 1991)**

##  Underdiagnosis of Depression

*Source: NHANES III, Scott Levin, PDDA*

## Depression Related Complaints

-            _Complaints_			       _Culture_
- “nerves” and headaches	   	    Latino
-  weakness, “imbalance”		    Asian
- “heartbroken”		     		   Amer. Indian
-  angry, “evil”				   African Amer.

## Depression in Adolescents 

- Acting out, conduct problems
- Loss of interest - enjoying nothing
- Feeling slowed down or “keyed up”
- Sense of hopelessness
- Social isolation or dropping out of activities
- Declining academic performance
- Substance abuse

## Depression in Seniors

- Physical complaints: headaches, stomach aches, backaches
- Sadness is not a common complaint
- Hopelessness
- Anxiety
- Loss of ability to feel pleasure
- Slowness of movement
- Lack of interest in personal care								Gallo et al, 1999

## Depression & Other Diseases

- HIV/AIDS
- Heart Disease & Stroke
- Arthritis and Chronic Pain Syndromes
- Respiratory Disorders
- Sickle Cell Disease
- Cancer
*	**	**	**	**	*
*	**	*

## Mental Illness & Substance Abuse

- High risk of substance use disorders in people with anxiety disorders, mood disorders & schizophrenia
- Increase risk for:
**Poor coping skills**
**Homelessness & Poverty**
**Incarceration**
**Violence**
**Suicide**
**Poor coping**

## Drug Treatment Gap

- 3.9 million people need drug treatment services for whom no services are available
- Women & children < 1/3 of all admissions
- Race is a main factor in admission to treatment outside criminal justice system
- Admissions nationwide are linked to insurance status:
- 62% are White
- 24% are African American
- <13% are Latino
- Caught in the Net:  The Impact of Drug Policies on Women & Families, www. Fairlaws4families.org

## MI, SA & Incarceration

- Poor minority communities are targets for aggressive policing efforts
- Mental illness and substance abuse predispose to incarceration for minor offenses
- High rates of illicit substance abuse and the war on drugs lead to high arrest rates
- Jails & prisons are hotbeds of HIV transmission

## Trends in Corrections

- African Americans are 13% of the U.S. population and over 50% of those incarcerated
- Latinos are the fastest growing minority group in the U.S. and in the justice system
- American Indians’ migration patterns and high rates of behavioral disorders lead to increased risk of contact with corrections
- Asian Americans’ and Pacific Islanders’ contact with the justice system is likely to increase significantly in the next two decades

## SAMHSA Priorities Matrix 2003

- Vision: A Life in the Community for Everyone
- Mission:  Building Resilience & Facilitating Recovery
- Programs/Issues – eg., co-occurring disorders, substance abuse treatment, homelessness, HIV/AIDS and hepatitis, criminal justice
- Cross-Cutting Principle:  Cultural Competency/Eliminating Disparities

## The President’s Freedom Commission on MH

- Achieving the Promise:  Transforming Mental Health Care in America - Recommendations
- Improve access to quality care that is culturally competent
- States to address ethnic and racial disparities & increased diversity in mental health workforce

## Summary

- Mental Illness is a risk factor for and consequence of HIV/AIDS
- Co-occurring mental Illness & substance Abuse is a common pathway to HIV/AIDS exposure
- Integrated treatment of MI & SA can improve HIV/AIDS adherence & outcome
- Ethnic & Racial Disparities in HIV/AIDS, MH & SA Care are a lethal combination

## Vision for the Future

- Improve public awareness of mental health problems in people with HIV/AIDS
- Increase awareness of effective treatment for HIV, MI & SA
- Promote prevention, early detection, & access to care including integrated care
- Increase funding for treatment and research

## Vision for the Future

- Ensure supply of mental health services & providers
- Parity in the way we provide services
- Community-based approaches
- Culturally-competent clinicians
- Tailor treatment to age, gender, race, ethnicity & culture