Update On Psychiatric Aspects of Update On Psychiatric Aspects of Emerging Infectious DiseasesEmerging Infectious Diseases

(HIV, HCV, SARS and West Nile)(HIV, HCV, SARS and West Nile)

Eric Avery M.D.Eric Avery M.D.Associate Clinical Professor of PsychiatryAssociate Clinical Professor of PsychiatryAssociate Member, Institute for the Medical Associate Member, Institute for the Medical HumanitiesHumanitiesUniversity of Texas Medical BranchUniversity of Texas Medical BranchGalveston, TexasGalveston, Texas

At the conclusion of this presentation, the participantsAt the conclusion of this presentation, the participantsshould be able to: should be able to:

1.1. Describe the evolving trends in the care of the HIV+ patient Describe the evolving trends in the care of the HIV+ patient population and the implications for the role of the psychiatrist in population and the implications for the role of the psychiatrist in prevention and treatment.prevention and treatment.

2.2. Describe the psychiatric screening process and treatment of Describe the psychiatric screening process and treatment of psychiatric disorders in HCV patients.psychiatric disorders in HCV patients.

3.3. Recognize the neuropsychiatric manifestations of the WNV infected Recognize the neuropsychiatric manifestations of the WNV infected patient.patient.

4.4. Describe how the SARS outbreak in Canada defines the role of the Describe how the SARS outbreak in Canada defines the role of the psychiatrist in preparing for and participating in the treatment of psychiatrist in preparing for and participating in the treatment of emerging infectious diseases.emerging infectious diseases.

ObjectivesObjectives

HIV/AIDSHIV/AIDS

Objective:Objective:1.1. Describe the evolving Describe the evolving

trends in the care of the trends in the care of the HIV+ patient population HIV+ patient population and the implications for and the implications for the role of the the role of the psychiatrist in psychiatrist in prevention and prevention and treatment.treatment.

HIV Is a Psychiatric EpidemicHIV Is a Psychiatric Epidemic

Risk for HIVRisk for HIV

– Substance abuseSubstance abuse

– Major depressionMajor depression

– Impulsive behavior & Impulsive behavior & personality factorspersonality factors

– Cognitive impairmentCognitive impairment

HIV Infection Psychiatric Illness

Effective treatment of psychiatric illness may improve patient outcomes

Risk for psychiatric illnessRisk for psychiatric illness Major depressionMajor depression ManiaMania HIV dementia (AIDS dementia HIV dementia (AIDS dementia

complex)complex) Psychosocial stressorsPsychosocial stressors

The Psychiatry of The Psychiatry of AIDS:AIDS:

A Guide to Diagnosis and A Guide to Diagnosis and TreatmentTreatment

Glenn J. Treisman, M.D., Ph.D.Glenn J. Treisman, M.D., Ph.D.Andrew F. Angelino, M.D.Andrew F. Angelino, M.D.

The Johns Hopkins University Press The Johns Hopkins University Press 20042004

Primary Diagnosis of Patients at First Appointment for HIV Care (N=250)

Primary DiagnosisPrimary Diagnosis %%

Any Axis I psychiatric disturbance (other than Any Axis I psychiatric disturbance (other than substance use disordersubstance use disorder

54%54%

Major DepressionMajor Depression 20%20%

Adjustment Disorder (all types)Adjustment Disorder (all types) 18%18%

Cognitive ImpairmentCognitive Impairment 18%18%

Substance Use DisorderSubstance Use Disorder 74%74%

Personality DisorderPersonality Disorder 26%26%

Treisman 2004

Since the early 1990’s, thirteen studies of HIV Since the early 1990’s, thirteen studies of HIV infection among adults in psychiatric setting in infection among adults in psychiatric setting in the U.S. have been published in peer-reviewed the U.S. have been published in peer-reviewed literature.literature.

These studies show a combined HIV These studies show a combined HIV seroprevalence of 6.9%.seroprevalence of 6.9%.– Urban centers 5%Urban centers 5%– Smaller cities 1.7%Smaller cities 1.7%

U.S. Population HIV infection rate 0.4%U.S. Population HIV infection rate 0.4%

HIV Among People with Chronic HIV Among People with Chronic Mental IllnessMental Illness

McKinnon, 2002

0

5

10

15

20

25

30

SYNDROMAL

CES - D>=22

CES-D-NS>=14

Time of AIDS Onset

Percentages of Multicenter AIDS Cohort Study participants who met syndromal criteria for depression, or who had a score of 22 or greater on the Center for Epidemiologic Studies Depression scale (CES-D) or 14 or greater on the CES-D minus its “somatic” items (CES-D-NS), as AIDS developed.

% D

epre

ssed

Depression: Multicenter AIDS Cohort StudyDepression: Multicenter AIDS Cohort Study

Lyketos et al, Psych Ann 31: 1 Jan 01

55-60

49-54

43-48

37-42

31-36

25-30

19-24

13-18

7-12

0-6

0-6

7-12

13-18

19-24

Time (months)Before AIDS diagnosis After AIDS diagnosis

San Francisco Men’s San Francisco Men’s Health Study: 395 Health Study: 395 participantsparticipants

34% depressed at 34% depressed at baseline (different baseline (different baseline than Burrack)baseline than Burrack)

Depression at baseline Depression at baseline predicted deathpredicted death

Depression and Progression to AIDS: Pre-HAARTDepression and Progression to AIDS: Pre-HAARTShafer, Delorenze, Satariano, WinkelsteinShafer, Delorenze, Satariano, WinkelsteinAnn Epi 1996Ann Epi 1996

Depression and Progression to AIDS: Depression and Progression to AIDS: Post-HAARTPost-HAART

HERS Cohort: 765 HERS Cohort: 765 ParticipantsParticipants

Longitudinal depression Longitudinal depression (CES-D)(CES-D)– 42% chronic42% chronic

– 35% intermittent35% intermittent

– 23% limited or none23% limited or none

Mortality predictors: Mortality predictors: depression (RR=2), CD4, depression (RR=2), CD4, HAART duration, ageHAART duration, age

Ickovics, Hamburger, Vlahov et al JAMA 2001

0 1 2 3 4 5 6 7

0.7

0.8

0.9

1.0HIV-Related Mortality

Total Time in Study (y)

Cu

mu

lati

ve S

urv

ival

Beck Depression InventoryBeck Depression Inventory Date__________________Date__________________

Name:_________________________________________________ Marital Status:_______ Age:___ Sex:___ Name:_________________________________________________ Marital Status:_______ Age:___ Sex:___ Occupation:___________________________________________ Education:___________________________Occupation:___________________________________________ Education:___________________________This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number (0,1,2 or 3) next to the one statement in each group which best describes the way you have been the number (0,1,2 or 3) next to the one statement in each group which best describes the way you have been feeling the past week, including today. If several statements within a group seem to apply equally well, circle feeling the past week, including today. If several statements within a group seem to apply equally well, circle each one. Be sure to read all the statements in each group before making your choice.each one. Be sure to read all the statements in each group before making your choice.

11 0 I do not feel sad.0 I do not feel sad.1 I feel sad.1 I feel sad.2 I am sad all the time and I can’t snap 2 I am sad all the time and I can’t snap out of it. out of it.3 I am so sad or unhappy that I can’t 3 I am so sad or unhappy that I can’t stand it. stand it.

22 0 I am not particularly discouraged about0 I am not particularly discouraged about the future. the future.1 I feel discouraged about the future.1 I feel discouraged about the future.2 I feel I have nothing to look forward to.2 I feel I have nothing to look forward to.3 I feel that the future is hopeless and that3 I feel that the future is hopeless and that things cannot improve. things cannot improve.

33 0 I do not feel like a failure.0 I do not feel like a failure.1 I feel I have failed more than the average1 I feel I have failed more than the average person. person.2 As I look back on my life, all I can see 2 As I look back on my life, all I can see is a lot of failures. is a lot of failures.3 I feel I am a complete failure as a person.3 I feel I am a complete failure as a person.

88 0 I don’t feel I am any worse than anybody0 I don’t feel I am any worse than anybody else. else.1 I am critical of myself for may 1 I am critical of myself for may weaknesses or mistakes. weaknesses or mistakes.2 I blame myself all the time for my faults.2 I blame myself all the time for my faults.3 I blame myself for everything bad 3 I blame myself for everything bad happens. happens.

99 0 I don’t have any thoughts of killing 0 I don’t have any thoughts of killing myself. myself.1 I have thoughts of killing myself, but 1 I have thoughts of killing myself, but I would not carry them out. I would not carry them out.2 I would like to kill myself.2 I would like to kill myself.3 I would kill myself if I had the chance.3 I would kill myself if I had the chance.

1010 0 I don’t cry any more than usual.0 I don’t cry any more than usual.1 I cry more now than I used to.1 I cry more now than I used to.2 I cry all the time now.2 I cry all the time now.3 I used to be able to cry, but now I 3 I used to be able to cry, but now I can’t cry even though I want to. can’t cry even though I want to.

To order forms: 1-800-228-0752

Hirschfeld et al (2000)

Mood Disorder QuestionnaireMood Disorder Questionnaire

Mood Disorder Diagnostic Data for HIV PatientUTMB AIDS Clinical Care & Research Clinic

Patients (N=159) %

DSM IV Bipolar Diagnosis 48 30.2%

Bipolar I 29 18.2%

Bipolar II 11 6.9%

Bipolar NOS 5 3.1%

Cyclothymia 2 1.3%

Mood disorder, secondary to a general medical condition 3 1.9%

Mood Disorder, NOS 4 2.5%

Major Depressive Disorder 69 43.4%

Dysthymic Disorder 3 1.9%

Substance Induced Mood Disorder 7 4.4%

Includes Bipolar I, Bipolar II, Bipolar NOS, Cyclothymia

MDQ Sensitivity and Specificity Data for HIV UTMB ACCRP Clinic

Sensitivity Specificity

DSM IV Bipolar Diagnosis 62.50% 78.40%

Bipolar I 72.40% 74.60%

Bipolar II 36.40% 66.20%

Bipolar NOS 60% 66.90%

Cyclothymia 50% 66.20%

Mood disorder, secondary to a general medical condition 33.30% 66.00%

Mood Disorder, NOS 0.00% 65.21%

Major Depressive Disorder 23.20% 57.80%

Dysthymic Disorder 33.30% 66.00%

Substance Induced Mood Disorder 14.30% 65.10%

N=159

M.B. Molded paper woodcut on handmade paper28 ¼” x 23” edition: 10

HIV and Post Traumatic Stress Disorder

E.D. 04/23/99 Molded paper woodcut on handmade paper28 ¼” x 23” edition: 10

Post Traumatic Stress DisorderPost Traumatic Stress Disorder

Over half the U.S. population has been exposed to a Over half the U.S. population has been exposed to a severe traumasevere trauma

10-20% of trauma survivors will develop PTSD10-20% of trauma survivors will develop PTSD Lifetime prevalence 8% overall. 12% in womenLifetime prevalence 8% overall. 12% in women

– Increased rates in HIV +, incarceratedIncreased rates in HIV +, incarcerated

– Limited studies: Limited studies: HIV + 30% (1/3 after HIV dx)HIV + 30% (1/3 after HIV dx) Incarcerated women lifetime 33%, current 15-22%Incarcerated women lifetime 33%, current 15-22%

PTSD is the 5th most prevalent major psychiatric PTSD is the 5th most prevalent major psychiatric illnessillness

0

4

8

12

16

20

24

28

32

SocialAnxiety

Disorder

PTSD GAD Panic OCD

Lif

etim

e P

reva

len

ce (

%)

Males Females

Hutton (2001) 177 Prison Women

Kelly (1998) 61 HIV+ Gay/Bi men

Kessler et al, National Comorbidity Survey, 1994

Most Prevalent Anxiety Disorders Most Prevalent Anxiety Disorders in the General Populationin the General Population

Frequency of PTSD Disorders Among 177 Frequency of PTSD Disorders Among 177 Women Prisoners in an HIV Risk Behavior Women Prisoners in an HIV Risk Behavior StudyStudy

Hutton, Psych Services 2001, 52/4:508-13

Women prisonersWomen prisoners

DisorderDisorderPercentage amongPercentage amonggeneral populationgeneral populationNN %%

Posttraumatic stress disorderPosttraumatic stress disorder11

LifetimeLifetime 5959 3333 1-141-14CurrentCurrent 2727 1515 <1<1

Compared with participants who did not have PTSD, those with lifetime diagnosis of PTSD were 71% more likely to have engaged in anal sex and 56% more likely to have engaged in prostitution. The association between lifetime PTSD and other HIV risk behaviors were not significant in this study.

1.1. The majority of persons who become infected in the United States engage The majority of persons who become infected in the United States engage in high rates of risky behaviors that are associated with the vulnerabilities in high rates of risky behaviors that are associated with the vulnerabilities seen in psychiatric disorders. Our patients are disproportionately being seen in psychiatric disorders. Our patients are disproportionately being infected.infected.

2.2. Psychiatric disorders decrease patients’ ability to gain access to medical Psychiatric disorders decrease patients’ ability to gain access to medical care because these disorders disorganize patients often making them feel care because these disorders disorganize patients often making them feel hopeless and because medical care of psychiatric patients in complex and hopeless and because medical care of psychiatric patients in complex and time consuming.time consuming.

3.3. Mentally ill persons are economically disadvantaged, often being “carved Mentally ill persons are economically disadvantaged, often being “carved out” by managed care organizations, resulting in fragmented care.out” by managed care organizations, resulting in fragmented care.

4.4. Psychiatric disorders have a negative effect on a person’s adherence to Psychiatric disorders have a negative effect on a person’s adherence to medical care.medical care.

Why AIDS Psychiatry?Why AIDS Psychiatry?

Treisman 2004

The effective treatment of psychiatric disorders decreases the risk of The effective treatment of psychiatric disorders decreases the risk of getting HIV and for those already infected, improves function, quality of getting HIV and for those already infected, improves function, quality of life and adherence to medical treatment. life and adherence to medical treatment.

Hepatits CHepatits C

Objective:Objective:2.2. Describe the psychiatric Describe the psychiatric

screening process and screening process and treatment of psychiatric treatment of psychiatric disorders in HCV disorders in HCV patients.patients.

Corcoran Museum of ArtCorcoran Museum of ArtWashington D.C.Washington D.C.

LIVER DIE: A Print Action for HealthLIVER DIE: A Print Action for Health

March 31 – April 3, 2005

LIVER DIE Medical Care in the Art MuseumLIVER DIE Medical Care in the Art Museum

LIVER DIE Participants: Rae Johnson, R.N., John Hogan, M.D., Eric Avery, M.D.LIVER DIE Participants: Rae Johnson, R.N., John Hogan, M.D., Eric Avery, M.D.

Hepatitis C Prevalence Across Varied Study Samples

Sample ScreenedSample Screened N ScreenedN Screened Hepatitis C Hepatitis C Antibody + Antibody + PrevalencePrevalence

Low-income young women, aged 18-29 Low-income young women, aged 18-29 northern California population-based samplenorthern California population-based sample

1,7071,707 25%25%

Veterans undergoing phlebotomy at VAMCs Veterans undergoing phlebotomy at VAMCs on March 17, 1999on March 17, 1999

26,10226,102 6.6%6.6%

Public mental health patients with severe Public mental health patients with severe mental illnessmental illness

751751 16.1%16.1%

Correctional facilities inmates (1997 Correctional facilities inmates (1997 estimate)estimate)

1,784,0001,784,000 17% - 25%17% - 25%

Opioid maintenance treatment program Opioid maintenance treatment program patients, Sacramento, Californiapatients, Sacramento, California

460460 87.4%87.4%

Older intravenous drug users in six US citiesOlder intravenous drug users in six US cities 1,7171,717 89% - 100%89% - 100%

Psychiatric Annals 33:6. JUN 2003

Psychiatric and Substance Use Comorbidity Among Northwest Veterans Tested for HCV AntibodyNovember 1996 to August 2000

Diagnostic ICD-9 Code Category Associated with Diagnostic ICD-9 Code Category Associated with Inpatient or Outpatient Clinical Contacts in Past 4 YearsInpatient or Outpatient Clinical Contacts in Past 4 Years

HCV +HCV +

(N=5,406)(N=5,406)

Any psychiatric or substance use disorder diagnosisAny psychiatric or substance use disorder diagnosis 78%78%

Drug use disorderDrug use disorder 68%68%

Alcohol use disorderAlcohol use disorder 57%57%

Depressive disorderDepressive disorder 26%26%

Posttraumatic stress disorderPosttraumatic stress disorder 29%29%

PsychosisPsychosis 14%14%

Bipolar disorderBipolar disorder 4.8%4.8%

HomelessHomeless 32%32%

Psychiatric Annals 33:6. JUN 2003

83/95 (50% male) tested for HCV83/95 (50% male) tested for HCV14/83 HCV+ = 16.9%14/83 HCV+ = 16.9%

Psychiatric Diagnoses/HCV+Psychiatric Diagnoses/HCV+

Depression 31%Depression 31%Bipolar 10%Bipolar 10%Psychosis 8.8%Psychosis 8.8%Cluster B 36.8%Cluster B 36.8%No Axis II 10%No Axis II 10%

Substance abuse, previous STD, physical and sexual abuse and Substance abuse, previous STD, physical and sexual abuse and homelessness had statistically significant associations with homelessness had statistically significant associations with HCV+.HCV+.

HCV Among Institutionalized Mentally Ill Patients: HCV Among Institutionalized Mentally Ill Patients: Ben Taub, HoustonBen Taub, Houston

41 Patients on RS3A, 3B, 3C41 Patients on RS3A, 3B, 3C

6/30 = 20% HCV+6/30 = 20% HCV+

Of 11 inpatients without ALT test, perhaps 1-3 would test HCV+Of 11 inpatients without ALT test, perhaps 1-3 would test HCV+

HCV Among Institutionalized Mentally Ill Patients: HCV Among Institutionalized Mentally Ill Patients: R. Sealy, UTMBR. Sealy, UTMBApril 24-25, 2005April 24-25, 2005

ALT (30)ALT (30) HCV+HCV+ HCV-HCV- No HCV TestNo HCV Test

↑ ↑ ALT (6)ALT (6) 55 33 00

NL ALT (24)NL ALT (24) 11 44 1010

TotalTotal 66 1414 1010

Clinical and Laboratory events associated with hepatitis C virus infection. Clinical Virology, 2002.

Acute Acute hepatitishepatitis

Chronic active Chronic active hepatitishepatitis

CirrhosisCirrhosis HCCHCC

0 3m 6m 9m 12m 5y 10y 15y 20y 25y

HCV RNA

EventsALT

anti-HCV

SYMPTOMS

Months // Year//

At risk, check ALT. If increased, hepatitis screen. (CDC.gov)At risk, check ALT. If increased, hepatitis screen. (CDC.gov)

If -, HCV prevention (Harm Reduction)If -, HCV prevention (Harm Reduction)If +, education to decrease transmissionIf +, education to decrease transmissionIf +, refer to Hepatitis Clinic/specialistIf +, refer to Hepatitis Clinic/specialistIf +, no HCV Tx until Comorbid psychiatric problems treatedIf +, no HCV Tx until Comorbid psychiatric problems treated

+ Motivator = Want HCV TX?+ Motivator = Want HCV TX?- Motivator = you will get sicker if you are not treated - Motivator = you will get sicker if you are not treated

To Test or Not to Test?To Test or Not to Test?

1.1. Because depression my be as high as 50% in IFN-treated Because depression my be as high as 50% in IFN-treated patients:patients:

• Inform patient about risk of depressionInform patient about risk of depression• Educate on how to recognize symptomsEducate on how to recognize symptoms• Explain depression treatment optionsExplain depression treatment options

2.2. Before INF treatment, psychiatric evaluation for patients Before INF treatment, psychiatric evaluation for patients

with:with:• Current episode of depression or history of depression (mood Current episode of depression or history of depression (mood

swings)swings)• History of psychiatric hospitalizationHistory of psychiatric hospitalization• History of substance abuse or dependenceHistory of substance abuse or dependence• Family history of depression or suicide attemptsFamily history of depression or suicide attempts

Suggested Approach for Assessing and Suggested Approach for Assessing and Managing INF-Induced Depression Managing INF-Induced Depression

3.3. If depressed when evaluated for INF treatmentIf depressed when evaluated for INF treatment • Treat the depression first, then INFTreat the depression first, then INF

4.4. When monitoring the patient for depression during INF:When monitoring the patient for depression during INF:

• Use a screening instrumentUse a screening instrument• Patient minimize to continue INFPatient minimize to continue INF• If depressed, treat aggressively with SSRIIf depressed, treat aggressively with SSRI• If depressed and not responding, INF can be decreasedIf depressed and not responding, INF can be decreased• If depression is severe (suicidal/psychotic) IFN discontinued If depression is severe (suicidal/psychotic) IFN discontinued • +/- need for psychiatric admission +/- need for psychiatric admission

NIH Concensus Conference 1997NIH Concensus Conference 1997Zdilar Hepatology 2000 Zdilar Hepatology 2000

Suggested Approach for Assessing and Suggested Approach for Assessing and Managing INF-Induced Depression Managing INF-Induced Depression

Paroxetine for the Prevention of Depression Induced by Paroxetine for the Prevention of Depression Induced by

High-dose Interferon AlfaHigh-dose Interferon Alfa

Research Question: Pretreatment of HCV Research Question: Pretreatment of HCV Patients at Risk for Depression with SSRI?Patients at Risk for Depression with SSRI?

Musselman NEJM 2001

West Nile VirusWest Nile Virus

Objective:Objective:3.3. Recognize the Recognize the

neuropsychiatric neuropsychiatric manifestations of the manifestations of the WNV infected patient.WNV infected patient.

http://www.cdc.gov/ncidod/dvbid/westnile/surv&control04Maps.htm

20042004

http://www.cdc.gov/ncidod/dvbid/westnile/surv&control04Maps.htm

Isolated 1937 in West Nile district of UgandaIsolated 1937 in West Nile district of Uganda

Outbreaks in Africa and the Middle East caused “West Nile Outbreaks in Africa and the Middle East caused “West Nile Fever”-- non-specific and self-limited viral illness Fever”-- non-specific and self-limited viral illness – Outbreak in South Africa in mid-1970s had 18,000 cases with no reports Outbreak in South Africa in mid-1970s had 18,000 cases with no reports

of encephalitis and no deathsof encephalitis and no deaths

Major change in virulence appeared in later outbreaks:Major change in virulence appeared in later outbreaks:– Romania (1996), Russia (1999), Israel (2000) Romania (1996), Russia (1999), Israel (2000) – Western hemisphere (1999-present)Western hemisphere (1999-present)

Unprecedented rates of encephalitis and mortality indicate Unprecedented rates of encephalitis and mortality indicate evolution of a new strain with greater neurotropism and evolution of a new strain with greater neurotropism and neurovirulenceneurovirulence

West Nile VirusWest Nile Virus

Incubation period – 2-21 days after infection Incubation period – 2-21 days after infection (generally 2-6 days in WN fever).(generally 2-6 days in WN fever).

Those requiring hospitalization generally Those requiring hospitalization generally complain of:complain of:– Fever –GI complaints (diarrhea) –confusionFever –GI complaints (diarrhea) –confusion– headache –myalgia –malaise –rashheadache –myalgia –malaise –rash– fatiguefatigue

WNV Clinical PresentationWNV Clinical Presentation

Most striking feature and greatest concern is invasive Most striking feature and greatest concern is invasive neurologic disease.neurologic disease.

Neurologic disease ranges from meningitis to Neurologic disease ranges from meningitis to movement disorders to acute flaccid paralysis movement disorders to acute flaccid paralysis resembling poliomyelitis.resembling poliomyelitis.

– West Nile – CNS 2,863 (29%) of 9,858 cases reported to West Nile – CNS 2,863 (29%) of 9,858 cases reported to CDC in 2003 were neuroinvasiveCDC in 2003 were neuroinvasive

– Risk Factors:Risk Factors: ImmunocompromisedImmunocompromised OlderOlder Male genderMale gender

WNV Clinical SyndromesWNV Clinical Syndromes

~80%Asymptomatic

~20%“West Nile Fever”

<1%CNS

disease

~10% fatal(<0.1% of total infections)

WNV Human Infection “Iceberg”WNV Human Infection “Iceberg”

1 CNS disease case=

~150 total infections

Very crude estimates

Follow-up Features in 16 Patients After Acute Follow-up Features in 16 Patients After Acute WNV-CNS in LouisianaWNV-CNS in Louisiana

Patients:Patients:– 5 meningitis5 meningitis– 8 encephalitis8 encephalitis– 3 poliomyelitis – like3 poliomyelitis – like

Clinical Features:Clinical Features:– Tremor (94%)Tremor (94%)– Myoclonus (31%)Myoclonus (31%)– Parkinsonism (69%)Parkinsonism (69%)– Balance and gait (19%)Balance and gait (19%)

All had altered mental status, the most common were behavioral or personality All had altered mental status, the most common were behavioral or personality changes, including irritability, confusion or disorientation.changes, including irritability, confusion or disorientation.

Sejvar JAMA 2003

Female patient is HIV+, lives in Beaumont, Texas areaFemale patient is HIV+, lives in Beaumont, Texas area

““New observations of CTs decrease motor and cog. Skills: Ct New observations of CTs decrease motor and cog. Skills: Ct increasing confused, motor skills slower i.e. unable to tie shoe, increasing confused, motor skills slower i.e. unable to tie shoe, slow getting out of bed, unable to find her way to my office room slow getting out of bed, unable to find her way to my office room – then lost in room didn’t know what to do. Her mom reports – then lost in room didn’t know what to do. Her mom reports onset of change abt 1 wk prior to appt.onset of change abt 1 wk prior to appt.

Also: Ct sent home from job due to inability to carry out assigned Also: Ct sent home from job due to inability to carry out assigned duties that she has done routinely for 15 years.duties that she has done routinely for 15 years.

Please evaluate - although oriented x3 Ct. drastic change in cog. Please evaluate - although oriented x3 Ct. drastic change in cog. and motor skills have me very concerned.”and motor skills have me very concerned.”

4/6/05 FAX From Clinical Social Worker to My Office4/6/05 FAX From Clinical Social Worker to My Office

““In mosquito season, fever and altered mental In mosquito season, fever and altered mental status, think West Nile”status, think West Nile”

Infectious Disease FacultyInfectious Disease Faculty

UTMB 2005UTMB 2005

SARSSARS

Objective:Objective:4.4. Describe how the SARS Describe how the SARS

outbreak in Canada outbreak in Canada defines the role of the defines the role of the psychiatrist in preparing psychiatrist in preparing for and participating in for and participating in the treatment of the treatment of emerging infectious emerging infectious diseases.diseases.

C. J. and Susan Peters Taiwan 2004C. J. and Susan Peters Taiwan 2004

EPIDEMIOLOGYEPIDEMIOLOGY

Reservoir/SourcesReservoir/Sources

Global SpreadGlobal Spread

SARSSARS

EPIDEMIOLOGYEPIDEMIOLOGY Reservoirs/SourcesReservoirs/Sources

– HospitalsHospitals PatientsPatients Healthcare workersHealthcare workers VisitorsVisitors

– Person with SARS in householdsPerson with SARS in households– Person with SARS in the communityPerson with SARS in the community

Persons with SARS unknown to the community or authoritiesPersons with SARS unknown to the community or authorities

SARSSARS

PREVENTION AND CONTROL IN HEALTHCAREPREVENTION AND CONTROL IN HEALTHCARE Isolation of cases Isolation of cases (suspect cases, probable (suspect cases, probable cases, confirmed cases)cases, confirmed cases)

– Protection of healthcare Protection of healthcare workers (HCWs)workers (HCWs)

All Barrier Precautions (ABP)All Barrier Precautions (ABP)– N95 mask (fit tested)N95 mask (fit tested)– GogglesGoggles– GownGown– GlovesGloves

SARSSARS

> 15,000 Voluntary Quarantine> 15,000 Voluntary Quarantine Web based survey (Impact of Events Scale –R, CES-D)Web based survey (Impact of Events Scale –R, CES-D)

129 Respondents (68% Health Care Workers)129 Respondents (68% Health Care Workers)– 66% Home Quarantine66% Home Quarantine

– 34% Work Quarantine34% Work Quarantine

Psychological Effects of SARS Psychological Effects of SARS Quarantine Toronto, CanadaQuarantine Toronto, Canada

Hawryluck E.I.D. 2004

CES-DCES-D

<16<16

>16>16

IES-RIES-R

<20<20>20>20

No (%)No (%)

84 (68.8)84 (68.8)

38 (31.2)38 (31.2)

86 (71.1)86 (71.1)

35 (28.9)35 (28.9)

>10 days quarantine>10 days quarantine>PTSD if + Depression>PTSD if + Depression>PTSD with less income>PTSD with less income

33 patients (40% Health Care Workers) (4-8 33 patients (40% Health Care Workers) (4-8 weeks after Dx SARS)weeks after Dx SARS)

58% PTSD (mean IES-R 24.8)58% PTSD (mean IES-R 24.8)61% Depression61% Depression48% PTSD + Depression48% PTSD + Depression

Psychiatric Assessment of SARS Psychiatric Assessment of SARS Survivors Toronto, CanadaSurvivors Toronto, Canada

Jancin Clin Psy News 2003

1.1. By infecting health care workers at a high rate, SARS By infecting health care workers at a high rate, SARS presented enormous challenges:presented enormous challenges:

– Adequate staffingAdequate staffing– Physicians, nurses avoided caring for infected patientsPhysicians, nurses avoided caring for infected patients– Penalties/incentivesPenalties/incentives

2.2. Long-term effect for health care staffing because of report of Long-term effect for health care staffing because of report of

psychological problems:psychological problems:– Toronto – departure from the health professions and declining Toronto – departure from the health professions and declining

enrollment in training programsenrollment in training programs

3.3. Policies need to be developed on the appropriate site for Policies need to be developed on the appropriate site for quarantine for individuals who have mental illness, mental quarantine for individuals who have mental illness, mental retardation and substance abuse problems.retardation and substance abuse problems.

Quarantine and Isolation: Lessons Learned from SARSQuarantine and Isolation: Lessons Learned from SARSCDC and Institute for Bioethics, Health Policy and Law CDC and Institute for Bioethics, Health Policy and Law

University of Lousiville School of Medicine University of Lousiville School of Medicine www.instituteforbioethics.com

From: Whitmore, RonSent: Friday, April 22, 2005 3:50 pmTo: Avery, Eric NSubject: respirator fit testing

You are due, or soon will be due, for retesting or have never been tested for N95 respirator use. Please complete the attached questionnaire and send it to Employee Health (route 1161) for review. You will be notified for scheduling when approved.

Ron Whitmore

Asbestos Program AdministratorRespiratory Protection Program AdministratorEnvironmental Health & Safety1302 Mechanic St., Ste. 2.112Galveston, TX 77555-1111phone 409-772-8491

1.1. As the As the HIVHIV and and HCVHCV epidemics epidemics continue to evolve, psychiatric patients continue to evolve, psychiatric patients are being disproportionately infected. are being disproportionately infected. Psychiatrist are in the frontline of Psychiatrist are in the frontline of HIV/HCV prevention and in treating the HIV/HCV prevention and in treating the psychiatric comorbidities which psychiatric comorbidities which complicate patients care.complicate patients care.

2.2. In patients with altered mental status and In patients with altered mental status and behavioral changes during mosquito behavioral changes during mosquito season, season, West Nile – CNSWest Nile – CNS should be in should be in the diagnostic differential. Psychiatrists the diagnostic differential. Psychiatrists will play a role in the rehabilitation of will play a role in the rehabilitation of these patients.these patients.

3.3. Because of the impact Because of the impact SARSSARS had on had on communities, individuals and health care communities, individuals and health care workers, psychiatrists should play a role workers, psychiatrists should play a role in the response planning for in the response planning for Emerging Emerging Infectious Diseases.Infectious Diseases.

Summary:Summary:

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