Mental health care is HIV care! It is reasonable and feasible to screen for and treat mild to moderate cases of substance use disorder, depression, and anxiety in HIV primary care. Featuring audio from a live webinar presented by experts Kathleen Page, MD, and Glenn Treisman, MD, PhD, this case-based virtual Grand Rounds series explores practical strategies for integrating routine mental health screening, referral, and management into HIV care to support engagement, ART adherence, and overall outcomes for people living with HIV.
Mental health care is HIV care! It is reasonable and feasible to screen for and treat mild to moderate cases of substance use disorder, depression, and anxiety in HIV primary care. Featuring audio from a live webinar presented by experts Kathleen Page, MD, and Glenn Treisman, MD, PhD, this case-based virtual Grand Rounds series explores practical strategies for integrating mental health care into routine HIV clinical practice. Visit the program page to follow along with the downloadable slides and to view other related activities.
Topics covered include:
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Presenters:
Kathleen Page, MD
Professor of Medicine
Division of Infectious Diseases
Johns Hopkins School of Medicine
Baltimore, Maryland
Glenn J. Treisman, MD, PhD
Eugene Meyer III Professor of Psychiatry and Medicine
Departments of Psychiatry and Behavioral Sciences and Internal Medicine
Johns Hopkins Hospital
Baltimore, Maryland
This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
Screening for and Treating Substance Use Disorder, Depression, and Anxiety in Routine HIV Care
Introduction
Dr. Glenn Treisman (Johns Hopkins Hospital): Hello everybody. I'm Glenn Treisman. I'm a professor at Johns Hopkins. This is Dr. Page, my colleague, also a professor at Johns Hopkins. We work together in the HIV clinic, taking care of patients mostly who are vulnerable populations of underserved people. We thought that today would be fun to talk about the role of psychiatric illness and psychiatric treatment in the care of patients with HIV.
Dr. Page has worked with me in my HIV psychiatry clinic directly to learn about what I do. And she now works with a group of very vulnerable populations, both at Hopkins and in the health department, where she takes care of patients who have a lot of psychiatric illness. So, we thought we would talk about the kind of principles of what we do and why we do it. I hope this is fun for you. It's certainly fun for us. So, welcome. Welcome, Dr. Page. How are you?
Dr. Kathleen Page (Johns Hopkins School of Medicine): I'm fine. Thank you for having me, and thank you for the audience. I'm really excited to talk to you, Glenn, and to everyone. As Glenn says, I've been working with him for a long time. I'm an infectious disease physician by training, and I see patients in the HIV clinic, as well as in the community in a mobile clinic that tries to reach people who are generally very underserved.
Dr. Treisman: We do want to thank Decera for giving us this opportunity to talk to you. They have not influenced the content of the program in any way. Both Dr. Page and I are difficult enough that we would be hard to influence anyway.
I started this work back in 1988 when we noticed a huge amount of burnout in clinicians taking care of HIV patients at Johns Hopkins. And people asked me to come and try to understand what was going on with the clinicians. So, I was kind of hired as a psychiatrist for the doctors who were burning out. But we very quickly discovered the problem was that they had very little training in taking care of psychiatrically ill patients, and their patients were very psychiatrically ill, and they were overmatched by the psychiatric demands of the population of patients they were caring for. Things got a lot better when we integrated psychiatric care into HIV care.
Today we want to talk about implementing routine screening strategies in HIV care to ensure people who have mental health conditions are diagnosed promptly and treated. We want to integrate mental health care treatment and support at the HIV care provision, both within HIV practice and through timely referrals. And we want to reduce the barriers to treatment persistence and engagement in people care HIV experiencing mental health conditions.
What we can tell you up front is that people with psychiatric disorders are less likely to get diagnosed, less likely to get care, less likely to get an undetectable viral load, and more likely to die than matched controls. We've shown that many times, not just us, but lots of other people in many different clinical settings, psychiatric disorders are a huge barrier to care. Not just addictions, but all the psychiatric disorders. So, we wanted to talk about how to approach these patients.
Substance Use Disorder
Case 1
So, we want to start out by giving you a couple of cases. This is a 40-year-old woman living with HIV. She's had two missed follow-up appointments. She says her pain is out of control. Has a history of oxycodone prescriptions, now buying opiates on the street. Asked whether you can help them stop the opiates, and is not intoxicated at today's visit.
This is a pretty common thing in my clinic. I imagine Dr. Page sees a lot of patients like this. Back in the 2000 to 2015 era, we very much decided that the best way to approach pain was to just throw narcotics at it. And patients with acute pain injuries, like a broken hip, narcotics are great, but patients who have chronic pain syndromes, narcotics often make those worse over time. And so, we addicted a huge number of people to narcotics in Baltimore, a city where there was already a huge narcotic problem with addiction. And so, when people come to us, they've often been getting a combination of street opiates and prescribed opiates, bouncing around from place to place, trying to get them.
Unfortunately, this transition from - as you mentioned, from prescribed opiates to, you know, someone stops prescribing to street opiates is quite common. And - and in the era of fentanyl, that has become even more addictive and more difficult to - to - more dangerous and more difficult to stop.
Case 1: What Should Make You Pause?
So, things that you should think about are: are pain or withdrawal present during the visit? Is there a risk for antiviral adherence issues in terms of taking medicines, and missed visits, and potential overdose, and spreading HIV infection? Those are all things that you have to think about every time you see a patient like this.
Kathleen, when a patient walks in like this, what do you say to them?
Dr. Page: Yes, I think, well, first, this patient, in a way, we are already a little step ahead because if I read the case correctly, she actually wants to get off opiates. And so, that's already - she's - she's a little readier to - to get off the opiates, which as you mentioned, Glenn, that's not always the case. In many cases, people are on chronic opiates, and what they want is to get more. And so, that takes a little bit more of a conversation.
When the person is - is taking opiates, not expressing interest, at this point, they just want more, I usually start - like to start things with sort of open-ended questions, getting to know the - the patient and also why they're doing what they're doing. So, asking them, what are the opiates doing for you? I think when we ask a question like that, that often opens an opportunity to maybe clear up some misconceptions, for example, about the role of opioids in chronic pain. And then really start exploring whether they're even open to the possibility of tapering down and - and looking for other options that are safer and more evidence-based and - and will hopefully control their pain.
So, I think, like I said, starting with what's bothering you the most, what are you trying to treat with these opiates, and how do we think of other alternatives, is a good way to start.
And then the other thing is, I guess there's the spectrum. People will say, "I just want opiates. Give me opiates." The other - the person who said, "I want to get off them. We can talk about sort of strategies for that." And sometimes people are on opiates, but they don't actually tell you anything more than that. And what you're getting is clues that something else is going on.
And so, in this case, this patient has had missed appointments. And - and again, all of these little clues open up possibilities for exploring. So, when someone misses an appointment, you know, asking them what happened, what was going on in your life? I'm hypothesizing if she was using street drugs, there may have been reasons why she wasn't able to come in. But that again opens up the conversation and - and really relates back to the part, you know, that we as HIV providers are very familiar with, right? So, this is what we do.
As HIV infectious disease providers, we're often very focused on the HIV viral load and the risk of HIV, depending on this person, if she has HIV or not, but HIV acquisition or HIV transmission, harm reduction, the risk of - of infections related to injection drug use if that's what she's doing.
And those are all really important things to explore, but I think fundamentally at the beginning, you just have to understand where the patient is and where the - the priorities and where we can sort of have a way to influence that.
Dr. Treisman: Right. I think another structural question is, is this a patient who's coming for care? That is, they're new to us, and they've been out of -they've been kicked out of another practice, or they haven't gotten HIV care at all. They've only been getting narcotics at some pain clinic, and now they're kicked out for missing appointments or for dirty urine, or because somebody's just tired of them, or because they're too demanding or they're not demanding enough.
And sometimes it's worth calling whatever doctor they've been seeing to find out the reality of why they're there.
Dr. Page: Yeah.
Dr. Treisman: It's very useful to know if you can get the information why the person is seeing you now, after they've been cared for someplace else for a long time, especially if it's been going well for a while. So, often, patients say, "Well, the only thing that helps me is narcotics. When I'm on narcotics, I can do this, and I can do that, and I can do this. When I don't have narcotics, I can't do anything." And then you call the primary doctor, and the doctor says, "No, no, they haven't worked in years. And when they get narcotics, they just use more narcotics." So, being able to - being able to reflect back the fact that their narcotics are not helping them but are hurting them is very useful.
Patients will come in on a high dose of narcotics and say their pain is 10 out of 10, and they've had narcotics that day. Say, "Well, if your pain is 10, narcotics are not helping you," because there's no higher - there's no higher number than 10.
Dr. Page: Yeah. Yeah, absolutely. And then I think, you know, as you mentioned, the patient is there. So, that already is an opportunity. They - they came in. And so, you know, while - while we may not be able to do everything we want at that one visit, at least we can start talking about what - what possible options there are in terms of tapering the narcotics, alternatives for pain control, the need perhaps for MOUD or - or something like buprenorphine as she tapers off. And then, again, addressing the risk of overdose and some of the things are, you know, making sure she has naloxone, making sure that, you know, that she - if she's using, she's not using alone, that she's not sharing needles if - if she is injecting, et cetera. So, those are all things that can be easily done early in that - in that first visit.
Dr. Treisman: And then how long do you spend with an average incoming patient for this first visit?
Dr. Page: I think we get 30 minutes, which may be less than - than you guys get with a new patient as a - as a provider. And I think 30 minutes is - is probably generous in - in our clinic for a new patient. I recognize that many people have time limitations in - in what the new visit template may look like in various practices. I do think though, that, you know, while we all would love to have an hour, 30 minutes does give you enough time to - to really start exploring some of these questions.
You may not be able to resolve everything, but I'm a really big fan of sort of close follow-up. So, you start a conversation, you do, you know, some of the basic assessment regarding the type of use, what they're using, what other drugs they may be using, how they're using, as well as some other sort of assessment of their mental health, because so many things go hand-in-hand. And sometimes it's really hard, especially for us primary care providers, to really disentangle what's the active drug use versus something else going on, but at least starting to explore that. And then doing some of the basics: harm reduction, if the person is really ready to start something, you know, to start tapering, then you could do that. But I think the key is establishing that rapport in a non-judgmental way. You know, telling the patient we're here to - to work with you, but we have to work together. It's like a two-way thing to get you where you need to be, and then - and then close follow-up to - to me feels fundamental as someone like her who seems ready to taper cannot be seen in three months. She needs to be seen fairly frequently so that we can really start doing that work.
Case 1: Targeted Questions for Substance Use Disorder
Dr. Treisman: So, this is things that you might want to ask people: what substances they're using, how much, and how often.
Are you using opiates to treat pain, withdrawal, craving, or anxiety?
What happens if you try not to use opiates?
Any overdose naloxone use for potential fentanyl exposure.
And then use of alcohol or benzodiazepines. And how is use of opiates affecting their antiviral treatment, their visits, their housing, their safety, their relationships, their ability to make a living, and their ability to survive? And those are important questions, I think, to ask.
It takes me about 45 minutes to do a new patient, going as fast as I can. And often because of the way my clinic is set up on Mondays, I can spend more time with a patient, and other people can see patients who are coming. And I - I will spend a long time with a new patient if I have to, to try to get them engaged with us. Often, they've lapsed in terms of their HIV care. I - I always check their medical status as well as their substance abuse status when they come. So, a person like this, I would want to know, do - do they have an undetectable load or not? Even if they say they're taking treatment, often they have lapsed in their care.
Dr. Page: Yeah. And a lot of them, you know, to your last point about just asking more broadly about safety and a number of other things, you know, especially illicit drug use from the street often goes hand in hand with, you know, transactional sex, really unsafe situations for - for men and women. And so, again, integrating sort of a holistic approach where you're talking about that, but also checking for hepatitis C, hepatitis B, STIs. If people have wounds, often wounds from injection are the thing that really hurts and is stigmatizing, and people really care about. And so, I often find that - that addressing the wounds is sort of a really good way of - of establishing rapport and really demonstrating to patients that we really are there for them and trying to care for whatever it is that - that is bothering them the most at that time.
Dr. Treisman: Yeah. Getting them - getting them engaged.
Dr. Page: Yeah.
Case 1: Screening Tools for Substance Use Disorder
Dr. Treisman: So, these are screeners that NIDA uses for substance use. I recommend that you spend the time and get the history, not just use a screener for - for addiction. The time it takes to do one of these screeners is a little bit shorter, but you're going to end up in order to take adequate care of the patient doing the history anyway. So, these tools are available, though you can download them from the NIDA website.
It's nice if - if you can get somebody who is doing the vital signs to run these screeners in your clinic so that you - the person comes in having been screened, because occasionally, people have a substance use problem and they don't ask for opiates, they - they ask for something else. And if you don't ask the question, you don't find out. So, these screeners can be useful in somebody who's coming in who - who isn't really interested in trying to get opiates from you, but is using opiates nonetheless. And I think they're worth knowing about.
Dr. Page: I would agree that they're sort of good at intake. Sometimes the MAs are using them, and it may normalize sort of that we ask about this for everyone, but - but these are questions, if you look at the screeners that all of us as clinicians are asking about anyway, more in a conversational style and - and usually asking, you know, again open-ended questions and really is more inviting than just filling a checklist. Let's see.
Case 1: What HIV Clinicians Can Do for Substance Use Disorder
Dr. Treisman: So, one of the things we can do to help patients with substance use disorders. I think the issue of non-judgmental language is key. Addictions are a disorder, and they're no different than any disorder in terms of people don't ask to be drug addicts. Many of them experiment with medications or drugs early on in their lives, and they don't really understand the pull of addiction. And before they know it, they're addicted or dependent. And addictions are not - not a choice. I apologize to Nancy Reagan, but it's not a choice these people make. Nobody says, "I think I'd like to be addicted to heroin."
We discuss ways to keep them safe. I don't use the term harm reduction. I use the term getting you safe, keeping you safe, trying to keep you from coming to harm.
We screen people for STIs, hepatitis C, hepatitis B, and then referring people to pain specialists rather than dismissing the concern. People have pain. I've had part of the reason my career is as complicated is that I got interested in the pain in our patients in our clinic, and have become a pain expert because most pain clinics in Baltimore used to just give people narcotics. And that's less so now, but it's very hard for them to find a person who's an expert at neuropathic pain or post-herpetic neuralgia or - or the kinds of pain syndromes that people get after severe injuries.
So, I refer people to pain specialists, particularly if there's somebody I think that can help them, but a lot of pain clinics are run by anesthesiologists. Good at blocking something or acute pain, but not very good at chronic neuropathic pain.
We always provide people with naloxone and overdose prevention. We offer buprenorphine for patients. One of the things that's an issue is that some patients who were the actual problem is that they have severe chronic pain. Buprenorphine, as much as it's a great drug, is a narcotic. And people have opiate mediated hyperalgesia, the buprenorphine can keep their pain going or worsen it. It doesn't worsen it more than other opiates. It is probably less of a problem than other opiates, but sometimes to get their pain better, you have to get them off all narcotics.
And then you're thinking about instead of buprenorphine, something like naltrexone, which doesn't make their pain worse, and is a - is an available, incredibly easy to use, available as a long-acting drug. The problem is it's not reinforcing. So, patients who are looking for that thing that they get from narcotics don't get anything from the naltrexone.
Case 1: Manage vs Refer for Substance-Use Disorder
Manage versus refer for substance use disorder. It's reasonable to manage people in the clinic when there's no acute intoxication or sedation, person is relatively stable. The health care provider can provide naloxone and harm reduction. The opiate use path- medically assisted treatment pathways available or can be arranged. And pain in HIV can be coordinated.
Times when you really need to get outside help is when the person is intoxicated to the point where they really can't tell you what's going on. They're psychiatrically unstable. They have a high overdose risk. They're using complex pharmacological cocktails of medications, drugs, pregnancy, need for methadone or higher-level care, and pain needing to be managed by a pain specialist.
It is not that hard to learn to manage chronic pain, but it is demanding, and it took years to learn. So, I think that most people have to have a person that they can go to when they have a person with real chronic pain as a primary part of their disorder.
Kathleen, do you feel comfortable managing chronic pain in these patients?
Dr. Page: I can take a first stab, and I will, but I think I often do need help and will call for help. But I - I agree with you, Glenn, that my experience has been that most pain clinics are sort of more focused on like very specific pain syndromes and not so much the chronic pain. And so, I think the - the challenge is really getting a patient, like the patient that we're talking about really to buy into the to - to the concept that the narcotics are actually making the pain worse, and trying to get her off. Many of the patients and this is, you know- so, aside from chronic pain, you know, most of the patients that I see, especially in - in the community setting where really these are people who are using very high doses of fentanyl all day long. But as you said, Glenn, they - they started, maybe they started years ago because someone prescribed an opiate or something, or maybe they were experimenting because they were young and they thought it would be fun, but it's, for the most part, almost 100% none of them find it fun anymore. Very few are truly getting a real high. And most of them will tell me that the reason they use is that they just feel so sick if they don't. So, really, the issue managing the withdrawal and figuring out alternatives for that is sort of a huge step in that direction.
And this is where buprenorphine can come very handy. Although, you know, I also think, we have to set realistic expectations with patients. It is not that easy. Like, I think promising people you will never have withdrawal. We're going to put you on buprenorphine, and that's it, is not really the truth.
For many people, getting on it and getting on a stable dose takes a little bit of time. And just tinkering on the right dosing and - and getting their body adjusted. I think it's important that we recognize these - these medications are amazing. They can really help, but - but they - they take a lot, like patients have to put in a lot to be able to get on them, and - and we should support them in that - in that journey, recognizing that this is a really difficult illness that often took many years for people to get there, and it doesn't resolve overnight. And there's a lot of ups and downs sometimes in those journeys; people who do great and then suddenly relapse, and we just have to be there for them non-judgmentally and ready to - to help in whichever way we can. But to answer your specific question, I handle some chronic pain, and often, I need help.
Dr. Treisman: Yeah. Going back to one of the things that you said, which is that people are - are just - they're using now to keep from being sick. While that's absolutely true, the other thing to know is that almost all of our patients at one time or another have been off opiates.
Dr. Page: Mm-hmm.
Dr. Treisman: Even though they'll say they don't do it to get high anymore, once they get off opiates, that high starts to nag at them, and they're at high risk, and they don't realize what a big role the addictive part of the drugs is playing, the chronic use.
So, describing addiction is a process to people and making them understand that - that being addicted to drugs isn't just about avoiding feeling sick, because when you were off, you weren't sick, and people will often relapse - if you take the history, they'll describe, "Yeah, I was off for about six months, but then I went to my high school reunion," or I went to visit my friend Joe, or I went to a wedding, or I was hanging around with this girl or this guy, "and we were using." And they relapse.
So, you have to talk to people about all the different opiate stuff, all the different addiction stuff, changing people, places, and things, changing - looking at triggers and maintaining sobriety.
And drugs aren't something people are giving up. What they're doing is they're getting sober rather than giving up something. And that's an incredibly important thing to think about in patients with addictions, because most patients with addiction tend to think about drugs as something that they get, and they tend to think about going off of drugs is something they're giving up. They're not really giving up going - giving up drugs, they're giving up a lot of misery, and they're giving up an addiction. And they're - they're - what they're getting is sober. And the idea of getting sobriety as an accomplishment is something that you get as a tangible thing that you have that changes your life. Very hard for people to understand without a lot of explanation and just input.
Depression
Case 2
So, this is our second case. This is a 38-year-old man living with HIV who comes for routine follow-up. His viral load is undetectable. He has a 20-pound weight gain since his last visit. His relationship is strained, and he has lower libido. And he stopped exercising and seeing friends.
This is a fairly common scenario, and we see this kind of - we see this kind of problem fairly regularly where someone comes in with this kind of story. They've been doing well, and now something is not going well.
Case 2: What Should Make You Pause?
Things that should make you spend a little time with this case are the loss of usual activities. Like he's not exercising. And so, I mentioned here that his weight loss and his relationship is strained, and his lower libido. Those kinds of changes are signals that something is very wrong. And people will say, "I'm not seeing my friends, I'm not doing social things. I stopped going to the gym. And I know I should go, but when I try to go, I don't feel like it." I often will say to somebody, "What's the most fun thing you can do?" And they'll tell you, and you say, "Have you done that recently?" And they haven't.
Weight and libido change, and social withdrawal are big markers. And these are markers of a condition called major depression where people's circuitry for the reward in the brain, your ascending mesolimbic dopamine pathway, the "Yeah," circuit in your brain gets turned off and it makes people much more vulnerable to drugs, to relapse, but it also makes people's lives kind of fall apart and often results in damage to their relationships and other things.
Case 2: Targeted Questions and Screening for Depression
So, targeted questions and screening for depression. I think the core of depression is anhedonia, the loss of rewards. What still feels enjoyable? Has sleep, appetite, energy, or concentration changed?
Any alcohol or substance use? Many patients will say, "Yeah, I noticed I've been drinking more. I notice I've been smoking marijuana," or "I've been borrowing my friends' narcotics."
Then history of mania or hypomania. History of periods where people feel like they have more than their usual energy, can do more than usual, stay up at night, don't need to sleep for a week at a time, get a lot done.
The reason for asking that question is that it changes how you treat depression. Patients with mania very seldom come in. They're enjoying being manic. Patients with depression come in because their episode of mania is now resolved, and now they're in an extended depression.
And then thoughts of suicidality or self-harm. It's an important question. Suicide, we think, is preventable in lots of people. Part of the problem is that unless you push people, they often won't tell you about it. So, you have to ask people directly, "Have you thought about killing yourself? Do you feel like giving up? Is it not worth it?" Questions like that are very important.
Owen’s Perspective: Why Asking Matters
So, this is a patient talking about his diagnosis, HIV, as a young adult, and substance use and severe depression.
As you listen, you might consider: what a clinician might miss if they focus only on virus or viral suppression. How can routine questions about mood, substance abuse, and safety create an opening for support? And what should happen next when people disclose that they're not okay?
[Audio playing]
Owen: So, with mental health combined with the HIV to start, it was rough. I would say more so due to me being diagnosed at 19 and just graduating high school. It was really hard situation because at that time, I was a substance abuser as well. So, that kind of collided with everything, and I was suicidal. And I actually tried to commit suicide when I was 19, turning 20, finding out about my status. And through Whitman-Walker, I ended up getting into what they called the day program for those that were just like newly diagnosed. It helped me to better understand myself and to be more comfortable with who I am and around people. Yet it's still kind of was tormenting to know that this is something that I will have to carry for the rest of my life. My primary care doctor, Megan over at Whitman-Walker, which she's been by my side for the past 20 years of me knowing, has been very helpful.
Speaker: Is there any message for somebody who helps treat HIV? If they're not sure if they should ask the people that they see about their mental health?
Owen: I think the first question should always be, "How are you doing?" And not just in a state of - of finding out where they are in their health status. We should always ask someone how their day is going, because we never know what a person is facing at that particular time. Be mentally disturbed, no one asks you how you're doing, it can be bothersome. So, I think it's just making sure that the other person is, like, mentally okay with just simple questions. "How are you doing? How are you feeling?" And "How can I help?" If there is a way they can help.
[Audio ends]
Dr. Treisman: So, when you talk to people about suicide, one of the things clinicians are worried about is: what do I do if this person says that they're suicidal or that they're feeling a danger to themselves, or they might kill themselves? They might deliberately take an overdose. They might just buy a triple dose of narcotic today and end it all.
When you hear that, you have an obligation to try to help that person. And I think that we're all very anxious about people not wanting to go to the ER, not wanting to get an emergency assessment. But people sometimes need an emergency assessment, and some people need to go to the ER, and it's not - it may not be comfortable, but it's important that they go.
I've had many people who were very reticent to go to the ER for evaluation. I always call the emergency room if I'm sending a patient, explain why I'm sending them, explain my concerns, and encourage them to have a low - by the time I'm sending someone to the ER, they should have a low threshold for admitting that person for a couple of days' evaluation to see if they have a depression that's easily ameliorated or not.
Patients, when you call the ER while they're sitting there, they're very encouraged by that, that you care about them enough to spend the time.
Kathleen, I'm sure you see patients who come in feeling suicidal. What's the - what's the Page approach?
Dr. Page: So, I think very similar to yours, you know, the, you know, as we ask these questions, I guess there's different grades. Some people have had sort of passive suicide thoughts, but, as you sort of ask a little more questions, they don't really have a plan. And they - they often will like say, actually, no. I mean, maybe occasional times, but I'm not thinking about it. But I think the key there is really making sure that they're not trying to tell you something to avoid going to the ED when they really need to.
And so, if there's any concern, I - I will, like you, encourage the patient to go to the ED. And - and really again, so much of it has to do with engagement. I think if they realize how much - how much importance I'm giving to this - I'm giving it as much importance as if they were telling me that they were having chest pain in the clinic. When - if someone has chest pain in the clinic, I would immediately send them to the ED, get an EKG, et cetera. This is - this is a type of level of importance that we need to give to these conversations.
And chest pain, I wouldn't just like say, "Okay, go to the ED, good luck." I would actually arrange for that to happen in front of them and make sure they're safe until they get there. I would - I do the same thing for - for this. And I think most of us would for the - for - for things that are life-threatening. So, this is exactly the same as someone who comes in with chest pain, with shortness of breath, et cetera, et cetera. And I don't really see a difference in terms of our ability to do that as providers, regardless of whether we're psychiatrists or primary care, et cetera.
So, thankfully, it doesn't happen that often, but it does happen. And when it does happen, it's sort of like you pause everything else you're doing to focus on that.
Dr. Treisman: There are different laws in different states, but in general, in every state in the United States, there is a way to - to make patients go to the ER if you're really concerned whether they want to go or not. It's not necessarily a voluntary thing. If you're worried that someone will kill themselves and you don't get them to the ER, you have a financial liability and a vulnerability to a lawsuit. And it's very important to try to get people the help they need.
So, sometimes I say, "Look, you have to go. You don't ever want to go. You have to go. I'm too nervous about it. You can come back and tell me I was stupid, but go and get evaluated, please." And the relationship that you've already started with the person will help encourage them to do that, and can be very effective in getting people to go get the help they need.
Dr. Page: And most patients are very grateful afterwards because even if - if, you know, just having that pause and being, you know, admitted for a couple of days can help sort of reset. Obviously, if someone is suicidal, they are in serious trouble. And so, that, I think - every time I've done it, patients have come back to thank me and have not been upset. So, they may be upset in the moment, but they're okay afterwards.
Dr. Treisman: So, screening tools for depression. There are a lot of them. The PHQ-9 is better. And if it's positive, you can ask about suicidal ideas. But I, again, for depression, I think that it's important to ask the questions. And since you're going to ask the questions anyway, the question of a screener becomes less important unless you can get someone to do a PHQ-9 for the patient before they come into your office. Then it becomes useful because it can trigger a conversation that is really important. Moving to the top of your list rather than the bottom.
So, I think people should ask the questions about whether or not you have anhedonia, whether you've lost pleasure in things, whether you have a sleep disturbance, whether you're as social as you ordinarily would be, whether you're enjoying things as much as you ordinarily would, whether you're as active as you ordinarily would be, and whether you're seeing the world in a - in a negative way.
And you can ask those questions as fast as you can do a PHQ-9. But if you have people come in with a PHQ-9 already scored, and you - and it's - it triggers you thinking about, "Well, I got to do the mental health screening questions on this patient more than I would otherwise," then it becomes very useful.
One of the problems with the depression screening is that in environments where they've tested this, depression screening, if it's positive, doesn't automatically give Dr. Page an extra 10 minutes to talk to the patient. She doesn't get an extra dollar to - to do the depression assessment. She doesn't get an extra dollar for treating depression. In fact, it intrudes into the time she would spend doing medical care. And so, a lot of places, people ignore the depression screeners because they're too busy doing the other things. And they don't trigger a change in people's interactions with the patient. And I think that's pretty tragic because suicide is expensive and relapse is expensive, and transmission of HIV care - HIV virus is expensive.
So, if you can prevent those things by - by - by being effective in treating their depression and knowing about it, you really save the - the system a lot of money, and yet the system does not provide for this care very well. So, it's a big problem for us.
Dr. Page: One thing I would say, though, to piggyback on that, Glenn, is that, for example, in this patient, you know, to me it feels as an HIV provider, I have to say that it's rare that mental health is not part of the key, the main plate of - of the visit. In other words, mental health really impacts so many things. So, if we look back at this patient, their HIV viral load was suppressed, and so, you would think, "Okay, check the box. I'm an HIV provider. Everything's good." But they had gained 20 pounds. They're telling you that they're not feeling well. And so, you know, I could, again, go through the, you know, if you're only focused on the somatic things, maybe I could spend 30 minutes of my visit or 20 minutes or whatever I have just talking to them about diet and eating healthy, which, honestly, would be missing the point because if they're depressed, that's what's happening.
And so, you know, as a - as a patient that we just heard speak really doesn't take that long early on at the beginning of the visit to just ask people, how are they doing, how are they feeling, what's changed in their life? And that can really help direct that because if - if they truly are - if they're depressed, they may not come and tell you I'm depressed and suicidal, but that is going to come up early in the visit. And if that's what's happening, that really should direct most of the visit, and that will impact their - their physical health as well. And you know, in this case, this patient was suppressed, but - but he - he may not be for long if we keep the depression unattended.
So, you know, I guess I'm reiterating some of what Glenn you've said. It feels like when you see a checklist of things that you have to ask, it seems like it's one more checklist, but I really would encourage everyone to think about asking them about how people are doing without thinking really of checklists. We - we have internalized, like we know what questions to ask about depression or anxiety without really having to look at a checklist.
The checklist can be helpful later on to follow patients. And if someone can do it, sometimes the MAs can integrate it into their flow, and they can do it, and you can see what the score has done over time. But - but really asking about mental health early in an HIV visit seems to me like fundamental and not that hard to do.
Case 2: What HIV Clinicians Can Do for Depression
Dr. Treisman: So, what HIV clinicians can do for depression? Look at their adherence because often when people are depressed, their adherence drops off. Think about drug addiction and alcohol use. People, when they're depressed, will use more, but start antidepressants.
Basic depression care usually starts with an SSRI antidepressant. They're incredibly easy to use. Give a decent dose. Don't - don't give people subtherapeutic doses of drugs. It's like giving people not enough penicillin because their urinary tract infection is mild. You still have to kill the bugs. You still have to get therapeutic.
But if they don't have a bipolar history, it's fairly easy to use an SSRI. And all of them are effective. And even in severe depression, an SSRI can do the trick if you get people on it and start following up quickly. So, I see people the next week and then maybe two to four weeks if they're doing well after one week.
And talk to people about counselling and psychotherapy and support, because people do better if they're talking about this when they're going through it. And cognitive behavioral therapy is a useful adjunct to antidepressants. Supportive psychotherapy can be a very useful adjunct. And you want to get your patient through this and get them better.
Often patients respond within a few weeks. They're often much better within a few weeks. And especially if they haven't had a lot of history treatment-wise. If they've had a lot of treatment in the past, it hasn't been effective, sometimes when you see them, you're going to want to ask for help with a difficult patient. I don't think Dr. Page would hesitate to call me up and say, "This person's been on five different antidepressants. Nothing's ever gotten them better. I'm seeing them now. They look sick. What should I do? What are some tricks?" Because I know a lot of tricks to get people better.
Dr. Page: Yeah. Exactly right. I think for most bread-and-butter early, we can start it. But when people are not responding, maybe need augmentation or have had complex history of nothing working, absolutely, call a lifeline, call a friend. And, you know, one thing I appreciate about our practice, and - and Glenn, you specifically, is that, you know, sometimes it may be hard - in your practice, it's easy to get patients in Monday afternoons, but I recognize not everyone has that luxury of having psychiatrists on site, but I think just you know, having a psychiatrist friend who you can at least run a case by is incredibly helpful and hopefully all of you can find someone to do so.
Case 2: Manage vs Refer for Depression
Dr. Treisman: So, should you manage or refer people with depression? It's reasonable when it's mild to moderate, when there's no suicidal intent, there's no psychosis or mania. People with depression can get psychotic. They will tell you that their bowels have died and they can smell them rotting. They will tell you that they're already dead. They will tell you that they're dying. And they're - they're unshakeable in those ideas. Or they'll hear voices saying, "You're a bad person." Critical voices, voices telling them that they smell, voices telling them that they're dying. And the patient can follow up, and drug interactions, adverse events are fairly straightforward.
Refer or escalate when the patient is unresponsive to treatment. There are suicidal feelings, psychosis, bipolar disorder or severe impairment, diagnostic uncertainty, complex use - substance use, or need for specialty psychotherapy or pharmacological management.
And that's nice, that "Refer or escalate when..." but if you're in a setting where psychiatry is - is sparsely available as it is in Baltimore, you may have to get good by calling people up and asking what to do. I coach a lot of people on how to treat our hard-to-treat patients. If Dr. Page already has a relationship with the patient, they're more likely to listen to her than to me anyway. So, if she has a relationship with a patient and they're not better on an SSRI or SNRI, I might say, "Okay, give them nortriptyline and here's how to do it." And that - that - that can be very helpful because getting psychiatric care for people now has become very difficult. And some places, plenty of resources; some places have very few resources. And how good you have to be at that depends partly on where you are.
So, let's see. I'm going to take questions now. Please type in your questions.
How do you decide between tapering only versus buprenorphine? So, if the patient's primary problem is really chronic pain, and all that's happening is they're using opiates to try to manage a chronic pain problem. I try to get them off opiates completely. If the primary problem is that they've gotten addicted to opiates and it's an addiction problem or a dependence on opiate problem, then I'm much more likely to use buprenorphine.
Buprenorphine is safe, it - it works well, it decreases opiate craving. Very hard to overdose on street drugs when you're on buprenorphine because the opiate-blocking properties of buprenorphine help protect patients from overdose with fentanyl. So, once people are on buprenorphine, they're actually safer than they are when they're getting just traditional opiates. So, I like buprenorphine for that.
And I agree with Kathleen, when you can get someone on long-acting buprenorphine those patients tend to do well, and they have a very - a considerably different life.
One of the problems with these interventions is that people tend not to stick with them. And if their depression is not adequately treated, or their personality issues aren't addressed, or their circumstances aren't addressed, they'll often relapse to depression and relapse to substance use. And so, it's important to treat the whole person and not just their addiction, because addiction is one of those things.
So, if you look at the long-term studies, people are more likely to stay on methadone than buprenorphine, and they're more likely to stay on buprenorphine than on naltrexone. But if they do stay on naltrexone, they do really well. So, just a question of can you get the person to stick with what you're doing? And that's an issue.
Anxiety
Case 3
Dr. Treisman: So, this is a 60-year-old man living with well-controlled HIV. He has hepatitis C co-infection. He missed repeat labs and abdominal ultrasound after abnormal liver tests. He has a liver mass with a concern for hepatocellular carcinoma. He says he intends to follow through, but has constant worry about scans and uses marijuana daily to calm down.
Case 3: What Should Make You Pause?
What should you think about? What should make you pause?
Avoidance that threatens routine medical follow-up? Worry tied to hepatitis C care and cancer, preventing a completed oncology workup.
Missed appointments despite confirming substance use to calm down and isolation.
So, this is another case where you have to think about why is this person having so much anxiety, and what are you going to do about it. And what can you do to help this person get the care they need?
Case 3: Targeted Questions for Anxiety
There we go. So, what worries you most before a visit or scan? Do you have panic attacks? How often does it worry you to keep from care? How are sleep and concentration going on? Any depression or suicidal thoughts? Any substance use to manage anxiety?
So, in psychiatry, we have these two conditions, anxiety and depression, that we - we refer to that include two different things. The symptom of being depressed or the condition of major depression. The symptom of being anxious or a condition that's an anxiety condition. And so, the things that we're asking here is your anxiety being caused by panic disorder, which is if people have a panic attack in the scanner, they're going to have to be practically sedated to get the scanner again. If they have panic attacks at all - the panic attacks are terrifying. First time people have them, they usually end up in the ER thinking they're having a heart attack - they will be able to tell you when they had their first panic attack, where they were, what was happening. "I was in the grocery store, and I was in the canned foods aisle in front of the peas when it happened." It's so severe. They last a relatively short time, but the anxiety persists for hours afterwards.
And panic attacks are terrifying to patients. You do want to diagnose them because they're really treatable, even - even fairly easily treatable in most people. Depression will provoke anxiety in lots of people. So, you have to try and distinguish between a primary anxious disorder and a depressive anxiety disorder.
The other primary anxiety disorder is OCD, and you have to ask about OCD as an issue. And the other thing you have to ask about is you have to think about whether or not the person is taking benzodiazepines, because the easiest way to not be anxious is to take a sedative, hypnotic drug like alcohol or a benzodiazepine. And if you take those when they wear off, you're more anxious. And so, you have to ask people if they're on those drugs because if they're - if they're taking those medications, they're going to get really anxious as they wear off. And the more of them they take, the worse they get.
Case 3: Screening Tools for Anxiety
You can act, you can use the GAD-7, which is like a PHQ-9. I don't use the GAD-2. It's two questions. I don't believe you can screen for anything in two questions. But again, I think that screening is best done by people before the patient is seen by you. And with - with a message to you that they screen positive for this or that, so you can ask the questions. I think that's the right way to do screening for anything. You shouldn't be doing screening. You should be asking the questions.
So, those are some screening tools for anxiety.
Case 3: What HIV Clinicians Can Do for Anxiety
What can you do? Is anxiety driving missed care? You can track people's response to treatment. Use reminder calls. Coordinate labs. Consider SNRIs - SNRIs or buspirone. Avoid benzodiazepines because they generally make people worse over time, although they'll make people instantly better when they take them.
Cognitive behavioral therapy or counselling is very useful. This is probably a situation where most people are anxious, have depression. But if they really don't have depression, cognitive behavioral therapy probably will get them as better as we can do in terms of medicines. But often people have occult depression masquerading as anxiety and they do really well on SSRIs and SNRIs.
Case 3: Manage vs Refer for Anxiety
It's reasonable to manage anxiety in HIV clinic when it's mild, when there's no suicidality, psychosis or mania when the person can come for treatment and medication choices are fairly straightforward and care navigation can reduce avoidance. So, helping people get into the clinic means calling them and reminding them, telling them how important it is for you to see them, telling them how much you care, encouraging them to come.
Panic attacks prevent care. You really want to get help with that or you want to treat it if you know how to treat it.
Suicidality, you need to get people the same kind of treatment. Avoidance of medical treatment, you need to get people better. Active substance use, we talked about. Failure or partial response to first-line treatment and need for psychotherapy around medical distress. Sometimes people need specific forms of cognitive behavioral therapy to manage their medical anxiety. And those people, useful to have somebody help you with them.
Kathleen, what did I miss?
Dr. Page: No, I think that's - that's, you know, nothing really. But I would say that this is a fairly common scenario that, you know, especially, I feel like nowadays, one of the things I like to ask is sort of, how are you doing? Are you stressed out? How stressed are you? So many people have anxiety in different ways. And as you mentioned, there's the symptom of anxiety, which we probably all have at some point, and then there's an anxiety disorder that's actually disrupting your life and affecting, in this case, medical treatment.
And I think that is actually fairly common in our clinic. And I see it manifest in different ways. So, in this case that we had is a patient who maybe had a lot of anxiety, potentially maybe panic attacks associated with a scan, or just worried about the result of the scan. And - and this patient has a pretty serious condition that we're worried about.
I also sometimes see patients, you know, especially in the era of MyChart, where all the results come back to them in yellow, and they can't tell what's actually truly alarming from a medical standpoint or not. And that can cause anxiety in people who are already prone to anxiety. And so, sort of having conversations with patients about what the results mean, et cetera.
And then the avoidances also manifest a lot in, for example, you know, people who don't want to do health maintenance things; they don't want to do their mammogram because they're so afraid of what the result is going to show, or they don't come for labs because they're afraid of what the labs will show. And again, you know, it's easy sometimes to dismiss all of these things and say, "Well, the patient is just not showing up." But unless you really ask and find out what's - what's actually driving that, you may actually find out that the patient really is suffering pretty significantly from anxiety that's affecting this, but many other aspects of their lives.
And so, again, just because we live in an anxious world, we shouldn't just assume that anxiety is normal in everyone, and really start exploring. Like, what - what is it that - where is it more than just a symptom that, you know, someone is anxious today, but not tomorrow, versus someone who really, truly has an anxiety disorder that's disabling in many ways and can lead to many other complications, substance use, et cetera?
This patient is - actually, this is a question for you, Glenn. I - I feel like more and more I hear patients taking marijuana for anxiety. They feel like it - they say it helps. So, I'm curious how - what you think about that because I personally, I have my opinion, but I'm asking. I wonder what you're thinking.
Dr. Treisman: Yeah. So, the problem is that when it wears off -
Dr. Page: Yeah.
Dr. Treisman: - then the anxiety tends to be worse. And a subset of people, the more exposed they are to marijuana, the more anxiety they get as a direct result. So, people seem to - many people seem to develop an intense irritability, anxiety, agitation from repeated exposures to marijuana. Although they internally feel better, everybody else doesn't see them as better, and sometimes confronting them about that is really helpful.
But, you know, any SSRI works pretty well. They're all good for treating panic attacks, and they will decrease anxiety, particularly if it's being caused by depression. And they're very easy to use. If they were hard to use, I think it would be tougher, but they're easy to use.
Dr. Page: Yeah, I think that's - it's really great for us as primary care HIV providers because SSRIs really, there's - there's so many options with - with great tolerability. And, you know, often they kill two birds with one stone for those patients that have both things, depression and anxiety. And so, it really is part of our wheelhouse to be comfortable. Maybe we don't have to know all of them, but at least comfortable with a few of them and be able to start, escalate dosing, et cetera.
Dr. Treisman: One of the things that is a problem is that people who are introverted healthcare providers tend to be anxious by their nature. It makes us worry about our patients, makes us wonder whether we did the right thing. It makes us better at our jobs. And our anxiety is part of what is effective. Anxiety is a symptom, but it's also an emotional driver of behavior. And it can be a very positive emotional driver behavior, but it can be very destructive. And so, you have to try to figure out what's normal for that person. And if they're not an anxious person and they're getting anxious for no good reason, then you have to start thinking about whether or not they have a mood disorder that's affecting them.
Dr. Page: Exactly.
Dr. Treisman: So, let's see. Questions about these things we just did. There's a question about anxiety. Which SSRI is best?
So, all the SSRIs that have been looked at in trials have approximately equal efficacy for treating anxiety and depression. They're all about the same. So, everybody has their favorite. We tend to give too low a dose, increase the dose. Some drugs that are SNRIs, like venlafaxine, will increase anxiety in some people. And so, you have to think about that and people. But otherwise, they're all pretty good. And pick one that you feel comfortable about.
Some have advantages. Like fluoxetine is a very long half-life. Other drugs have a relatively short half-life. Some drugs have more drug interactions, some have less. There are not a lot of drug interactions with antidepression drugs that make you worry about HIV. So, the HIV drugs and the antidepressants don't have much drug-drug interaction that's worrisome. So, it doesn't matter too much which SNRI you use.
Dr. Page: Yeah, I think, Glenn, you can tell me if I'm doing this right or not, but one thing that is helpful for me: many patients that are coming with depression or anxiety have actually been on medicines before, have maybe had - had episodes before. And if something has worked for them before, which sometimes, you know, if I ask them, they'll tell me that worked and that didn't work, I'll go with what worked, and it often does the trick.
Dr. Treisman: So, if somebody in their family has the same problem and got better on that medicine, that's a reasonable reason to pick something over something else. And also, if they say, "Well, I'm not going to take that," pick something else.
Dr. Page: Yeah, exactly. Exactly.
Dr. Treisman: "My friend - my friend took that, and they ended up in the psychiatric hospital, and they probably got manic." But we'll probably start with something different for you.
And if people say they've had a very bad experience with an SNRI, they probably got into a manic state or a mixed state where they have elements of both depression and mania mix. It's a very awful feeling where you have sort of an energized misery, and that will make people very reluctant to take an SSRI. And if you hear that, you want to get a more comprehensive evaluation and somebody who's good at it.
Dr. Page: Yeah. So, I would say, though, just in general for the audience, I think it's just fundamental, it's part of HIV care, is to address mental health, and that so many - there's so much that we can do at the primary or HIV care level. First of all, the first thing is to ask and recognize, and be able to - to open up the conversation.
As Glenn said, often we're the people who've - this is one of the nice things about HIV care that we get to know people over years. And so, we have that rapport with patients, and - and often, we may be the best people to initiate treatment because they trust us, and we know them, and we can ask these questions.
And then, you know, if we need to refer, we can refer. If we don't have a referral place, definitely, I advocate having a friendly psychiatrist that you can ask for help because, again, if we have a relationship with a patient and the rapport, we may be the best people to - to sort of escalate treatment as long as we have the right guidance and -and support in the back end.
So, I'm sure a lot of you guys are doing this already, and so, hopefully, this is helpful. But - but I think more than anything, just hope you all feel empowered to do this and not to be afraid of whatever you find out because we can handle whatever comes our way.
Dr. Treisman: In terms of dosing SSRIs, some people advocate the start low and go up slowly. And I think that's a very reasonable approach to giving people any medication. So, often people will start at a half dose. And the key with SSRI is not to just stay at that half dose, but to push people up to where the drug is therapeutic because more people relapse on low doses, and when they relapse, the drug might not work when you go up on the dose. So, I try to push people up to a therapeutic dose of an SNRI - of an SSRI, rather.
Dr. Page: Glenn, I guess I'm going to ask a question, but as we are seeing more older patients in our HIV clinic, do you - I mean, I generally use that approach of sort of starts low and then sort of follow patients closely to - to go up. And I feel like the first week is just to make sure they don't have many side effects, and then go up. But anything that - that - that you do differently or we should be doing differently in people who are just much older, like I'm talking about like in their 80s, et cetera?
Dr. Treisman: Yeah. I do the same thing you just said. I start with a low dose, go up every week by a small amount until they're at therapeutic dose. So, if somebody, for instance, is going to get fluoxetine, I'm going to give them between 20 and 30 for most people. I'll start at 5 or 10, especially in a person who's older, who I'm worried about sundowning or has some cognitive limitation. I'll start on a lower dose.
And sometimes you might - you might decide that you want to use a particular medication because someone is older. For instance, paroxetine is an SSRI drug that has a little bit of anticholinergic side effects and probably isn't ideal for somebody who has cognitive limitation compared to a regular one that doesn't have that.
Well, again, I want to thank you all for coming. I hope this was helpful to you, Kathleen. You're the greatest. Like always, I love working with you, and thank you for working with me. I want to thank Decera for - for setting this up, and for arranging it, and for the sponsorship from pharma. That was very helpful to make this happen. I appreciate it. So, we look forward to -
Dr. Page: I want to thank you, Glenn, for - for doing this with me. I always learn something new from you, and - and for being so gracious, both in helping me take care of the patients and helping me - allowing me to shadow you and learn from you even as I'm, you know, pretty advanced in my career. But I feel like, you know, this is the fun of medicine; we always get to learn more and more for our patients. And thank you. And thank you, Decera, for inviting us to do this. And thank you for the audience. I think - I hope this was helpful.
Dr. Treisman: I was - it's an interesting thing. I think our patients as a group are very underserved, and they push us to become - they push us to become experts at more than what we - than what we bargained for.
Dr. Page: Yeah. I think once, especially because so many of our patients have a mistrust of the medical system. And so, once they develop rapport with - with one of us, it sort of like, it - it behooves us to do as much as we can and get the help we can when we can, when we need to.
Dr. Treisman: All right. Well, thank you all.