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1 DOH92-DC-1030 ( ) Neuropsychiatric and Psychosocial Study of the HIV-I Infected: A Cross-sectional Nationwide Survey #1254 mingbeen@ntumc.org

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3 AIDS,, ; AIDS, HIV-1 (1) HIV-1 AIDS (2) (3) AIDS ( ) BSRS-5 DSM-IV 1604 index assessment % 33.9% 15.9% 7.3% 5.7% 4.9% 2.3% 3

4 1% dependent variable independent variables OR = 1.005; 95% C.I. = OR = ; 95% C.I. = OR = ; 95% C.I. = OR = ; 95% C.I. =

5 Research Data Archive, Center for Disease Control, The Executive Yuan, R.O.C. Readme file Project Title: Neuropsychiatric and Psychosocial Study of the HIV-I Infected: A Cross-sectional Nationwide Survey Project Number: DOH91-DC-1061 Executing Institute: National Taiwan University College of Medicine Principal Investigator(P.I.): Ming-Been Lee P.I. Position Title:Professor P.I. Institute: Department of Psychiatry Abstract The society, government and the professionals have paid much attention to the prevention and treatment of AIDS in Taiwan area. However, comprehensive care based on psychosocial, and psychiatric, and ethical aspects for the AIDS patients is still underdeveloped. Besides, the national wide survey of psychological distress and psychiatric morbidity of HIV-infected patients were never performed. The present study is a 2-year longitudinal cohort study that aims to understand the psychosomatic issues and psychiatric diagnosis of HIV infected patients by way of national survey. From this study, the national wide data on psychological, psychiatric and family aspects as well as the ethical issues of HIV-infected patients were disclosed. A series of reliable and valid measures was used to assess the psychological distress, cognitive function, and psychopathology. This study was designed to be a two stages survey study. The screening form of Brief Symptom Rating Scale BSRS-5 was served as screen tool in the first stage. The diagnosis of psychiatric morbidity was made by senior psychiatrists based on Mini International Neuropsychiatric Interview MINI in the second stage. During the two year period, 941 subjects with HIV-1 infection were recruited. Some of the subjects were followed up for 3 to 6 months. The study showed any kind of psychiatric morbidity occurred in 33.9% of our sample and the most frequent diagnosis was adjustment disorder with depressive mood 15.9%.Besides, the most prevalent psychological distress defined by BSRS-5 and reach the moderate severity and above was insomnia followed by depressive mood, anxiety, irritability, interpersonal sensitivity, suicidal ideation, pain, and dyspnea. The psychopathology was positively correlated with functional variables. The neuropsychological test Tail making B was significantly correlated with psychopathology and functional variables. In the logistic regression model, duration of HIV infection, suicidal ideation, dyspnea, pain were significantly correlated with psychiatric diagnosis. In addition to the survey of psychiatric morbidity, via in-depth interview in part of the samples, the main stressors were being diagnosed and the poor prognosis and family conflict. Using focus group discussion and questionnaire survey on the first line case managers revealed that they still need further training on the ethics, law and psychosocial aspects to take care of their registered clients. The present study implied that the psychosocial-ethical care including individual counseling, group/family support and patient-physician communication are rather important to improve the prognosis of the HIV-infected and the quality of health care on the AIDS patients. Key words: HIV-1 infected, Psychiatric morbidity, Risk factors, Prevalence, Medical ethics. 5

6 1980 George Engel Science biopsychosocial model trigger compliance behavioral modification biofeedback treatment 1980 AIDS ( Lee MB,1985;Lee MB et al,1990 ) 1981 retrovirus HIV HIV 6

7 HIV HIV 66% 7% 3% 3% HIV % 75% HIV HIV (Morin SF et al, 1984; Perry SW et al, 1984; Levy RM et al, 1985; Perry SW et al, 1986; Rundel JR et al, 1986; Beresford TP et al, 1986; Navia BA et al, 1987; Schmidt U et al, 1988; Butters N et al, 1990; Perry SW, 1990; Cefali FE, 1990; Dilley JW et al, 1992; Snyder S et al, 1992; Catalan J et al, 1992) HIV (Coates TJ et al, 1984;Temoshok L et al, 1989; Rabkin JG et al, 1991; Coates TJ et al, 1989;Ironson G et al, 1990; Capitanio JP et al, 1991; Goodkin K et al, 1992) AIDS D (delirium) (dementia) (depression) (demorale) 4D HIV (AIDS dementia complex ADC) 7

8 ( subacute encephalitis SE) HIV (nonfocal or HIV encephalopathy) 1983 Snider SE 1984 Nielsen SE HIV ` Shaw 1985 HIV HIV ADC HIV 40% 10% 70-80% ADC ( ) ( ) ( ) ( ) (microfocal demyelination) HIV (existential plight) 8

9 (planning for death) ARC 1986 Tross ARC 75% ARC 50% ARC (uncertainty) HIV 1987 HIV 162 ( ) 19 DSM -R

10 33 (GSI ) 58 HIV 20 10

11 (1) HIV-1 (2) ( ) (3) (4) HIV-1 AIDS HIV-1 AIDS 11

12 HIV-1 AIDS HIV-1 AIDS BSRS-5 BSRS-5 Chinese Health Questionare: CHQ % 70% Cheng TA et al, CHQ CHQ general medical condition psychiatric morbidity Brief Symptom Rating Scale: BSRS GSI Cronbach Alpha BSRS GSI

13 Cronbach Alpha receiver operating characteristic (ROC) analysis psychiatric morbidity 78.9% 74.3% 8 - BSRS-5 Mini International Neuropsychiatric Interview MINI Mini International Neuropsychiatric Interview MINI DSM-IV ICD-10 Axis I David Sheehan Yves Lecrubier DSM-III-R SCID-P ICD-10 CIDI 20 DSM-III-R SCID-P ICD-10 CIDI Sheehan Sheehan Sheehan Function Inventory Trail Making Test sub - cortical dementia 13

14 Finger Taping Test, Trail Making Test, A B Partington & Leiter, 1949 A B Trail Making Test A 1 25 Trail Making Test B 1 A 2 B 3 - C-.. speed for attention, sequencing, mental flexibility, visual search, motor function SPSS 8.0 Frequencies Cronbach alpha Student s t test α Fisher s exact test Pearson s product moment Mann-Whitney test α 0.05 Kendall tau logistic regression odds ratio 14

15 1604 index assessment % % Table Table ± ±37.09 Table BSRS % 10.5% 9.6% 7.4 % 6.1% 3.8% 2.9% 0.8% Table Table 3.1 to BSRS GSI Cronbach Alpha receiver operating characteristic (ROC) analysis psychiatric morbdity 78.9% 74.3% 8 - BSRS ± % 33.9% 27.8% 22.7% Table Mini International Neuropsychiatric Interview MINI 15

16 DSM-IV ICD-10 Axis I 36.2% BSRS-5 BSRS % 81.3% 20% Table 5.1 logistic regression dependent variable independent variables OR = 1.005; 95% C.I. = OR = ; 95% C.I. = OR = ; 95% C.I. = OR = ; 95% C.I. = Table % 33.9% 15.9% 7.3% 5.7% 4.9% 2.3% 1% Table BSRS-5 BSRS-5 r = to 0.596; all p < Table 6.1 Table 6.2 Table

17 Trail Making Test Trail Making Test - BSRS-5 sub - cortical dementia Finger Taping Test, Trail Making Test, A B 37 A Trail Making Test A B Trail Making Test B BSRS Trail B r = 0.437; p = BSRS-5 r = 0.579; p < Trail A r = 0.362; p = BSRS 34% 26% 34%

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19 % 33.9% 1% BSRS % HIV HIV sub-clinic HIV Trail B teat HIV HIV AIDS Dementia Complex (ADC) HIV neuron glial cell sub-cortical area psychomotor executive function alogia abulia delirium HIV 19

20 HIV blood brain barrier HIV HIV DSM-IIIR Mini International Neuropsychiatric Interview MINI 36.2% 20

21 existential plight planning for death acquired immunodeficiency syndrome AIDS human immunodeficiency virus, HIV 21

22 % 16.7% HIV HIV HIV HIV Finger Taping Test, Trail Making Test, HIV 22

23 stress management 23

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25 Neuropsychiatry 1990;2: Grant I, Atkinson JH: Neurogenic and psychogenic behavioral correlates of HIV infection. Immunologic Mechanisms in Neurologic and Psychiatric Disease 1990; Harris C, Small CB, Klein RS, et al: Immunodeficiency in female sexual partners of men with the acquired immunodeficiency syndrome. N Engl J Med 1983; 308: Hintz S, Kuck J, Peterkin JJ, et al: Depression in the context of human immunodeficiency virus infection: implications for treatment. J Clin Psychiatry 1990; 51: Holland JC, Tross S: The psychosocial and neuropsychiatric sequelae of the acquired immunodeficiency syndrome and related disorders. Ann Intern Med 1985; 103: Holmes VF, Fernandez F, Levy JK: Psychostimulant response in AIDS-related complex patients. J Clin Psychiatry 1989; 50: Hwu HG, Yeung SY: Psychiatric diagnostic assessment: establishment and inter-rater reliability. Chin Psychiatry 1988;2: [In Chinese; English abstract] 30. Ironson G, LaPerriere A, Antoni M, O'Hearn P, Schneiderman N et al: Changes in immune and psychological measures as a function of anticipationand reaction to news of HIV-1 antibody status. Psychosom Med 1190;52: Janssen RS, Saykin AJ, Cannon L, et al: Neurological and neuropsychological manifestations of HIV-1 infection: association with AIDS-related complex but not asymptomatic HIV-1 infection. Ann Neurol 1989; 26: Lee MB, Yeh EK, Tsai MT, Chen CY: Consultation psychiatry: clinical issues, trends, and evaluation. J Formosan Med Assoc 1982;81: Lee MB:Psychiatric disorders in hospitalized cancer patients: A study of 135 referrals with matched controls. J Formosan Med Assoc 1985; 84: Lee MB, Rin H, Lin HN, Huang MG: A follow-up study of psychiatric outpatients with neurotic disorders. Report of National Science Council (ROC), NSC H002-13, 1987.[In Chinese; English abstract] 35. Lee MB, Lee YJ, Yen LL, Lin MH, Lue BH: Reliability and validity of using a brief psychiatric rating scale in clinical practice. J Formosan Med Assoc 1990;89: Lee MB, Lee YJ: A cross-sectional epidemiological study of psychiatric comorbidity in hospitalized medically ill. Chinese Psychiatry 1990a;4: Lee MB, Lee YJ: Coping strategies and associated psychosocial features of the hospitalized medically ill. Chinese Psychiatry 1990b;4: Lee MB, et al: Psychosomatic study on the HIV-1 infected. Report of Deoartment of Health DOH 82-DC-026, Lyketsos CG, Hanson A, Fishman M, McHugh PR, Treisman GJ: Screening for psychiatric morbidity in a medical outpatient clinic for HIV infection: the need for a psychiatric presence. Intern J Psychiatry Med 1994; 24: Maj M: Psychiatric aspects of HIV-1 infection and AIDS. Psychol Medicine 1990;20: Marotta R, Perry S: Early neuropsychological dysfunction caused by human immunodeficiency virus. J Neuropsychiatry Clin Neurosci 1989; 1: McArthur MC, Cohen BA, Selnes OA, et al: Low prevalence of neurological and neuropsychological abnormalities in otherwise healthy HIV-1 infected individuals: results from the Multicenter AIDS Cohort Study. Ann Neurol 1989; 26: Miller EN, Selnes OA, McArthur JC, et al: Neuropsychological performance in HIV-linfected homosexual men: the Multicenter AIDS Cohort Study (MACS). Neurology 1990; 40: Morin SF, Charles KA, Malyon AK: The psychological impact of AIDS on gay men. Am Psychologist 1984; 39: Munson R.:AIDS and its issues. In: Intervention and Reflection Basic Issues in 25

26 Medical Ethics. 5th ed. Washington: Wadworth Publishing Company, 1996: 205~ Namir S, Wolcott DL, Fawzy FI: Social support and HIV spectrum disease: clinical and research perspectives. Psychiatr Med 1989; 7: Navia BA, Jordan BD, Price RW: The dementia complex: I. clinical features. Ann Neurol 1986; 19: Nichols SE: Psychosocial reations of persons with the acquired immunodeficiency syndrome. Ann Intern Med 1985; 103: O'Down MA, Natali C, Orr D, et al: Characteristics of patients attending an HIV-related psychiatric clinic. Hosp Community Psychiatry 1991; 42: Ostrow D, Grant I, Atkinson H: Assessment and management of the AIDS patient with neuropsychiatric disturbances. J Clin psychiatry 1988; 49:5(suppl): Ostrow DG et al: Public health policy and bioethical issues in AIDS. In: Behavioral Aspects of AIDS Perry S, Fishman B, Jacobsberg L, et al: Effectiveness of psychoeducational interventions in reducing emotional distress after human immunodeficiency virus antibody testing. Arch Gen Psychiatry 1991; 48: Perry SW: Organic mental disorders caused by HIV: update on early diagnosis and treatment. Am J Psychiatry 1990; 147: Perry SW, Jacobsen P: Neuropsychiatric manifestations of AIDS-spectrum disorders. Hosp Community Psychiatry 1986; 37: Perry SW, Jacobsberg LB, Fishman B, Weiler PH, Gold JWM, Frances AJ: Psychological responses to serological testing for HIV. AIDS. 1990;4: Perry SW, Tross S: Psychiatric problems of AIDS inpatients at the New York Hospital:Preliminary report. Public Health Rep 1984; 99: Perry SW, Markowitz J: Psychiatric interventions for AIDS spectrum disorders. Hosp Community Psychiatry 1986; 37: Pfeiffer E: A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriat Soc 1975;23: Rabkin JG, Williams JBW, Remien RR, Goetz RR, Kertzner R, Gorman JM: Depression, lymphocyte subsets, and human immunodeficiency virus symptoms on two occasions in HIV-positive homosexual man. Arch Gen Psychiatry 1991;48: Regier DA, Boyd JH, Burke JD, et al: One-month prevalence of mental disorders in the United States. Arch Gen Psychiatry 1988; 45: Robins LN, Helzer JE, Weissman MM, et al: Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984; 41: Rosenberger PH, Bornstein RA, Nasrallah HA, Para MF, Whitaker CC, Fass RJ, Rice RR Jr: Psychopathology in human immunodeficiency virus infection: lifetime and current assessment. Compr Psychiatry 1993; 34: Rundell JR, Kyle KM, Brown GR, Thomason JL: Risk factors for suicide attempts in a human immunodeficiency virus screening program. Psychosomatics 1992; 33: Seedhouse D, Lovett O: Practical Medical Ethics. Johnwiley & Sons, NewYork, Smilkstein G, Ashworth C, Montano D: Validity and reliability of the family function. J Fam Prac 1982;15: Targ EF, Karasic DH, Diefenbach PN, Anderson DA, Bystritsky A, Fawzy FI: Structured group therapy and fluoxetine to treat depression in HIV-positive persons. Psychosomatics 1994; 35: Thomas WF:AIDS-Related psychiatric disorder. Br J Psychiatry 1987; 151: Treisman GJ, Lyketsos CG, Fishman M, Hanson AL, Rosenblatt A, McHugh PR: Psychiatric care for patients with HIV infection: The varying perspectives. 26

27 Psychosomatics 1993; 34: Tross S, Hirsch DA: Psychological distress and neuropsychological complications of HIV infection and AIDS. Am Psychologist 1988; 43: Tseng MC, Lee MB, Lee YJ: Psychiatriic problems of hospitalized AIDS patients. Chinese Psychiatry 1992;6: Weisman AD: Coping with illness. In: Hackett TP, Cassem NH eds. Handbook of General Hospital Psychiatry. Saint Louis: C.V. Mosby Comp, 1978: Wiener PK, Schwartz MA, O'Connell RA: Characteristics of HIV-infected patients in an inpatient psychiatric setting. Psychosomatics 1994; 35: Wolcott DL, Fawzy FI, Namir S: Clinical management of psychiatric disorders in HIV spectrum disease. Psychiatr Med 1989; 7: Wolcott DL, Dilley JW, Mitsuyasu RT: Psychiatric aspects of acquired immune deficiency syndrome. in Kaplan HI, Sandock BJ ed: Comprehensive textbook of Psychiatry 5th ed. Baltimore: Williams & Wilkins 1989; Wolf TM, Balson PM, Dralle PW, Gaumer RH, Morse EV, Williams MH, Simon PM: A biopsychosocial examination of symptomatic and asymptomatic HIV-infected patients. Int'l J Psychiatry in Medicine, 1991;2: Wolf TM, Balson PM, Morse EV, Simon PM, Gaumer RH, Dralle PW, Williams MH: Relationship of coping style to Affective state and perceived social support in asymptomatic and symptomatic HIV-infected persons: Implications for clinical Management. J Clin Psychiatry. 1991;52:

28 Table 1.1 Basic data: sex Frequency Percent Male Female Total Table 1.2 Basic data: education level Frequency Percent Elementary school Junior high school Senior high school Occupational high school College Postgraduate school Total Table 1.3 Basic data: year and month of first assessment Frequency Percent

29 Total

30 Table 2: Distribution of symptom Table 2.1 Distribution of symptom: anxiety Frequency Percent Not at all A little bit Moderately Quite a bit Extremely Total Table 2.2 Distribution of symptom: depression Frequency Percent Not at all A little bit Moderately Quite a bit Extremely Total Table 2.3 Distribution of symptom: anger Frequency Percent Not at all A little bit Moderately Quite a bit Extremely Total Table 2.4 Distribution of symptom: inferiority Frequency Percent Not at all A little bit Moderately Quite a bit Extremely Total Table 2.5 Distribution of symptom: insomnia 30

31 Frequency Percent Not at all A little bit Moderately Quite a bit Extremely Total Table 2.6 Distribution of symptom: dyspnea Frequency Percent Valid Percent Cumulative Percent Not at all A little bit Moderately Quite a bit Extremely Total Missing Table 2.7 Distribution of symptom: pain Frequency Percent Valid Percent Cumulative Percent Not at all A little bit Moderately Quite a bit Extremely Total Missing

32 Table 2.8 Distribution of suicidal ideation Frequency Percent Valid Percent Cumulative Percent Not at all A little bit Moderately Quite a bit Extremely Total Missing

33 Table 3: Descriptive Statistics Table 3.1 Descriptive statistics of other clinical measurements AGE DURA BSRS5_1 BSRS5_2 BSRS5_3 N Missing Mean Std. Deviation Skewness Std. Error of Skewness Kurtosis Std. Error of Kurtosis Table 3.2 Descriptive statistics of other clinical measurements Trail A Trail B Social function Family function Work ability N Missing Mean Std. Deviation Skewness Std. Error of Skewness Kurtosis Std. Error of Kurtosis

34 Table 4: Psychiatric Morbidity at Three Waves of Assessments Table 4.1 Proportion of psychiatric diagnosis defined by BSRS-5 total scores 6 at the index assessment Frequency Percent Valid Percent Cumulative Percent < Total Table 4.2 Proportion of psychiatric diagnosis defined by BSRS-5 total scores 6 at six months after index assessment Frequency Percent Valid Percent Cumulative Percent < Total Missing Table 4.3 Proportion of psychiatric diagnosis defined by BSRS-5 total scores 6 at one year after index assessment Frequency Percent Valid Percent Cumulative Percent < Total Missing

35 Table 5: Diagnosis, Validity, and Predictors Table 5.1 BSRS-5 categories and psychiatric diagnosis cross tabulation Psychiatric Diagnosis Total No Yes Count BSRS-5 Total < 6 6 % within BSRS % 27.4% 100.0% % within psychiatric Dx 81.3% 44.4% 66.2% Count % within BSRS % 67.2% 100.0% % within psychiatric Dx 18.7% 55.6% 33.8% Count % within BSRS % 40.9% 100.0% % within psychiatric Dx 100.0% 100.0% 100.0% Chi-Square = , p, Table 5.2 Logistic regression model of psychiatric diagnosis defined by BSRS-5 with clinical variables as predictors 95% CI for Exp(B) Variable B S.E. Sig R Exp(B) Lower Upper Age Duration of illness Dyspnea Pain Suicidal ideation Dependent variable = psychiatric morbidity defined by BSRS-5 (cutoff point >=6) Nagelkerke - R^2 =.181 Number of selected cases:941 Number rejected because of missing data: 361 Number of cases included in the analysis:

36 Table 5.3 Psychiatric diagnoses confirmed by Mini International Neuropsychiatric Interview Diagnosis by MINI N % Dementia due to HIV disease 2.3 Phobia 3.4 Hypochondriasis 4.5 Adjustment disorder with mixed disturbance of emotions and conduct 4.5 Anxiety disorder, NOS 6.8 Major depressive disorder Dysthymic disorder Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder unspecified Adjustment disorder with depressed mood No formal psychiatric diagnosis Total Missing system 192 Total

37 Table 6: Correlation Analysis Table 6.1 Correlations between three waves of BSRS-5 total scores BSRS5_1 BSRS5_2 BSRS5_3 Pearson Correlation BSRS5_1 Sig. (2-tailed) N Pearson Correlation BSRS5_2 Sig. (2-tailed) N Pearson Correlation BSRS5_3 Sig. (2-tailed) N Table 6.2 Correlations between dimensions of Sheehan Functional Scale and BSRS-5 total scores BSRS5_1 Social function Family function Work ability BSRS5_1 Social Family function function Work ability Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N

38 Table 6.3 Correlations between associated psychical symptom and functions Social Family function function Work ability Dyspnes Pain Pearson Social Correlation function Sig. (2-tailed) N Pearson Family Correlation function Sig. (2-tailed) N Pearson Correlation Work ability Sig. (2-tailed) N Pearson Correlation Dyspnea Sig. (2-tailed) N Pearson Correlation Pain Sig. (2-tailed) N

39 Table 6.4 Correlations between functions, BSRS-5 total scores and neuropsychological test Social function Family function Work ability Trail A Trail B BSRS5_1 Social function Family function Work ability Trail A Trail B BSRS5_1 Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N

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