ADDRESSING MENTAL HEALTH ISSUES SUPPORTS ADHERENCE
The experiences of the Medication Support Team (MST) at Chase-Brexton illustrate the impact of mental health issues on the initiation of and adherence to HAART. MST Coordinator Tracey Salaam recounts the experience of a patient who confronted severe anxiety as he prepared to begin therapy. A mental health patient for many years, the patient had been HIV positive for 3 months when his primary care doctors recommended HAART. “Mentally, he could understand why it was so important, but he had so much anxiety about treatment and his concerns that it would throw him off the stability he had attained in his mental health,” said Salaam.
Chase-Brexton’s multidisciplinary MST works closely with patients to ensure that they are ready and equipped to begin treatment. Salaam met with this patient at least six times over 3 months to address his anxiety, but he was still not ready. In addition to Salaam, the patient’s therapist and psychiatrist were involved, but no one ever pushed the patient to begin HAART.
With a strong support team in place, the patient did eventually begin treatment, although not without anxiety. He spent 15 minutes on the sidewalk in front of the building sweating profusely before his appointments. The prep work paid off, however—the patient has now been on treatment for 18 months and has an undetectable viral load. Salaam attributes the patient’s success in part to his ability to sustain a regimented medication routine, a skill that came from years of taking medications to stabilize his mental health.
“The medication regimen can be very stressful. Our patients may be asking themselves,
‘Am I taking the medications correctly?’ and ‘What will my results show?’”
According to Haltiwanger, the patient’s anxiety about medication was not uncommon. “The medication regimen can be very stressful,” he says. “Our patients may be asking themselves, ‘Am I taking the medications correctly?’ and ‘What will my results show?’ and those issues can cause tremendous anxiety.”
One strategy Chase-Brexton uses to provide support is “Club Med”—a biweekly support group led by a health and behavioral psychologist. At group meetings, participants fill their pillboxes, support one another in their efforts to be adherent, and discuss issues they are confronting. “We focus on the benefits of HIV medications and strategies to stay healthy. We also talk about anything and everything they want, and some of the topics that come up are addictions, depression, loneliness, stress management, and suicide,” says Salaam.
These kinds of struggles are real. One member with a history of drug addiction was clean when she started on HAART. When it became obvious that she was abusing drugs again, Salaam, her case manager, her primary care provider, and staff at the local methadone clinic talked with her about the importance of maintaining her medication regimen. When the patient was 2 weeks late picking up her medications and had relapsed on heroin, the team decided that it was in her best interest to stop the medications. “She was on a very fragile regimen and risked developing drug resistance in a short window,” said Salaam. “We are here to support her now and when she is ready to resume treatment.”
| MOOD DISORDERS33 | |
|---|---|
| Major depression | A disabling condition characterized by a persistent sad mood; a diminished sense of well-being; and feelings of guilt, anxiety, or self-loathing. Symptoms interfere with a person’s ability to work, sleep, study, eat, and enjoy once-pleasurable activities, and they prevent normal functioning. |
| Dysthymia | Chronic, mild depression that can prevent normal functioning and persists for at least 2 years in adults or 1 year in children. |
| Bipolar disorder | Dramatic mood swings from overly “high,” irritable, or both to sad and hopeless, and then back again, often with periods of normal mood in between. The periods of highs and lows are called episodes of mania and depression, respectively. |
| ANXIETY DISORDERS34 | |
| Generalized anxiety disorder | Chronic anxiety, exaggerated worry, and tension accompanied by a variety of physical symptoms. |
| Panic disorder | Unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. |
| Posttraumatic stress disorder | Persistent frightening thoughts and memories of a terrifying event or ordeal in which grave physical harm occurred or was threatened. Symptoms include sleep problems and feelings of detachment or numbness. |
| OTHER | |
| Adjustment disorders | A psychological response from an identifiable stressor or group of stressors that causes significant emotional or behavioral symptoms, including anxiety and depressed mood, but does not meet criteria for more specific disorders.35 |
| DHIV-associated dementia or AIDS dementia complex | Progressive illness that is the result of HIV’s impact on the central nervous system. May affect behavior, cognition, mood, and motor skills. Patients may develop ambulation or gait problems, mania, panic, psychosis, social isolation, or anxiety.36,37 |
| Personality disorders | A group of mental disorders characterized by inflexibility, rigidity, and inability to respond to the changes and demands of life. People with personality disorders tend to have a narrow view of the world and find it difficult to participate in social activities.38 |
| Substance abuse | Abuse or dependence on anything that is ingested to produce a high, alter one’s senses, or otherwise affect functioning.39 |
The MST team also pays close attention to the mental health–related side effects of the anti-HIV medications. For example, some medications can exacerbate ADHD and bipolar disorder. “In matching patients up with a medication regimen, it is important to screen for those medications that may impact or trigger their mental health issues as well as [for] those that may interact with antidepressants,” says Salaam. HIV medications and psychiatric medications may interact or be contraindicated and should therefore be chosen with consideration for adverse effects and potential interactions.40,41 (See the online resources box for a guide to interactions.)