AIDS Community Research Initiative of America (ACRIA) - Summer 2006

Within the last decade, the medical and psychiatric communities have begun to recognize a subgroup of people with HIV who suffer from severe persistent mental illness and substance use disorders. In spite of the challenges and barriers to providing quality health care to these patients, the health service community has developed and designed effective health care and supportive service programs for this triply diagnosed population. This article is a review of the different approaches to care and the best practices that have been developed to effectively offer care to this unique population.

What is a Triple Diagnosis?
The term "triple diagnosis" has been used from the onset of the AIDS epidemic, when intravenous or other injecting drug use was first seen as a major risk factor for HIV. The term arose from the earlier "dual diagnosis," which referred to a patient with severe persistent mental illness (SPMI) and a substance use disorder (SUD). A triply diagnosed patient also suffers from another medical problem or chronic physical condition. The term was created to describe a new breed of patients with complex medical and other social care needs who required specialized health care services that were virtually nonexistent at the time.

Triply diagnosed patients are overrepresented in many treatment settings because of their unusually severe and chronic symptoms. For instance, a 1994 study (Lyketsos) of 50 randomly chosen people with HIV who accessed Johns Hopkins AIDS Services found that 44% had a diagnosis of current or previous substance use disorder, and 24% had both a primary psychiatric diagnosis and substance use disorder.

Triply diagnosed patients can pose significant barriers to treatment because they may have a tendency to act on strong, impulsive feelings rather than following carefully considered treatment instructions. Their behavior can be driven by the transient, immediate rewards of drug use rather than by future consequences. Some studies have found that these clients may become easily bored. They tend to "want what they want when they want it", rather than what they need and when it may be good for them.

Mood disorders, especially major depression, are also found in these patients, with studies estimating a prevalence of 15% to 30%. Diagnosing affective disorders in drug users, however, can be difficult and controversial. The controversy stems from the problem of determining the relationship between drug use and mood disorders. In order to precisely diagnose a drug user with a primary mood disorder, some mental health professionals believe that observation over a period of abstinence in a confined environment is necessary. Others believe that treatment can be started even if the patient is not abstinent. It may also be difficult to determine whether an individual's symptoms meet the full criteria for major depression. Finally, AIDS itself can lead to changes in mental status or a new psychiatric or cognitive disorder, such as dementia, delirium, cognitive disorders, anxiety, or even psychotic disorders.

Providers should also be aware that active drug users may have difficulty managing potentially addictive psychotropic medications, or may feel the need to sell their medications, which could lead to incarceration. This should not be used as a reason to deny treatment, but mental health practitioners should carefully evaluate and screen for alternatives to psychotropic meds for certain at-risk patients.

Harm Reduction
The harm reduction approach acknowledges that a person may continue to use substances, but employs several strategies to ensure a level of safety for the patient. Methadone maintenance treatment, needle/syringe education and bleach distribution, legal clean needle purchase, and needle exchange programs are examples of harm reduction strategies.

Care providers should become familiar with the "transtheoretical stages of change" in order to evaluate a patient's readiness to change unhealthy behaviors effectively. During precontemplation, the patient has no intention of changing the behavior. In the contemplation stage, she or he is thinking about change but remains ambivalent. In the preparation stage, the patient has decided to change and is taking initial steps to obtain treatment. During the action phase, the patient is modifying his or her behavior, environment, and circumstances in order to stop the behavior. Finally, in the maintenance phase, the patient works to prevent relapse into old behaviors.

Harm reduction strategies can be employed within the therapeutic alliance that is normally developed in the delivery of health care. To start, a nonjudgmental and empathetic approach is critical when interviewing the patient. Moving from comfortable topics of discussion (employment, family, friends, hobbies) to questions about drug use and sexual behavior is a technique that can be employed during the initial stages of treatment. Maintaining confidentiality is also a vital part of building a therapeutic alliance, especially when accessing other sources of information such as medical records, family members, friends, and other health care providers.

Harm reduction recognizes patients' motivation and readiness to become involved in their health care needs. In the event alcohol or other drugs are identified as barriers to safer behaviors, the clinician should counsel the patient to reduce or avoid substance use prior to engaging in sex, or refer him or her to prevention case management for more specialized risk reduction. The provider can often assist the patient in identifying methods for reducing HIV transmission risk, including those that do not require abstaining from alcohol and drug use. Of course, this requires that clinicians discuss substance use, including steroid use, with their patients, and reinforce their understanding of the adverse effects that these drugs can have on the body and the immune system.

Care of the Triply Diagnosed
There is no set protocol for working with triply diagnosed patients. As a first step, however, providers need to create a safe environment and supportive structure for the patient in which the necessary drug treatment history can be obtained. Properly worded assessment forms can provide critical answers. These can contain questions concerning the length of time in detoxification, outpatient drug treatment, methadone maintenance programs, AA/NA meetings, and residential drug treatment programs. This information is helpful in ascertaining the client's perception of which methods of treatment have been successful and which have failed. Questions related to drug craving, loss of control of drug use, withdrawal symptoms, medical complications, and impairment in psychosocial functioning can also be part of the process of building a therapeutic alliance.

• Examples of these include: Have you ever felt you wanted to cut down on your drinking or drug use?
• Have you ever been criticized about drinking or using?
• Have you ever felt any sense of guilt about your drinking or drug use?
• Have you ever begun drinking or using first thing upon awakening?

These sample questions are potentially less harmful and intrusive when trying to understand the patient's own perception about their use.

Performing a complete physical examination, including a careful search for physical evidence of drug use, is a necessity. Injection marks, scars, burns, nasal septum erosion or perforation, skin abscesses, cellulitis, and other soft-tissue infections should be part of the examination. In addition, careful evaluation of markers of alcohol use, including hepatospleno-megaly, ascites, and physical trauma, should be considered. For the mental health provider, a careful neurological assessment, including a complete mental status examination, is essential to assess the presence of both substance intoxication and the neuropsychiatric manifestations of AIDS.

Early studies supported a cautious approach when treating the triply diagnosed. These studies argued that the multiple medical problems associated with chronic substance use could affect HIV disease progression. A 1992 study (Selwyn, PA) found that substance users with HIV were at higher risk for developing bacterial infections such as pneumonia, sepsis, soft tissue infections and endocarditis than HIV-negative drug users. A 1994 study (O'Connor, PG) showed that tuberculosis and hepatitis C infection were common in this population. But a surprising number of other studies have shown that continuing substance use does not accelerate HIV disease progression in people who are not taking HIV medications.

In addition, neurological symptoms can surface when HIV infection and substance abuse overlap. For instance, both AIDS dementia and drug intoxication can lead to apathy, disorientation, aggression, and an altered level of consciousness, and drug withdrawal can lead to seizures and symptoms of depression.

Because of these potential complications, some physicians were reluctant to prescribe any treatment until the patient had stopped all substance use and had a psychiatric evaluation. The stigma of mental illness and substance abuse effectively prevented some physicians from prescribing needed medication regimens. Physicians still face difficulty choosing which HIV medications to prescribe when psychotropic medications are also being taken. They may be concerned about potential side effects and adherence difficulties, and triply diagnosed patients may refuse treatment and decide not to adhere to any drug protocols. Despite this level of frustration, recent studies provide some useful recommendations. For instance, ID specialists can consult colleagues or use charts and computer programs to check for potential drug interactions. Physicians should not simply avoid treating patients aggressively out of fear of potential drug interactions.

The continuing medical care of active drug users also presents challenges. A 2002 study (Arici, C) found that active drug users, along with people who had higher CD4 counts, were less likely than others to return for follow-up medical care visits. While there is a common assumption that substance use is associated with poor antiretroviral medication adherence, studies have found contradictory results on this issue. Certainly, many active users are able to adhere to HIV medications, and substance use alone should not be a reason to deny HIV treatment. High-risk sexual behaviors can also be common in drug users, increasing the risk of STDs for both them and their partners. In addition, the physical symptoms of HIV infection can mirror those of substance abuse and withdrawal, including malaise, fatigue, weight loss, fever, diarrhea, and night sweats.

Coordinating Care
The clinician should assess if the patient is ready for referral to treatment services. For instance, if the client is using injection drugs, the emphasis should be on evaluating his or her knowledge of the risk of acquiring HIV or other infections (such as endocarditis and hepatitis C) through sharing needles and other injection equipment. The clinician should also evaluate each patient's readiness to change his or her drug injection practices and make referrals to syringe exchange programs, substance abuse treatment programs, relapse prevention programs, or other sources of ongoing support.

Collaboration and coordination of care with a variety of medical, substance use treatment, social service, complementary therapies, chaplaincy, and mental health providers is critical to ensure that appropriate specialty care is provided to triply diagnosed clients. In such instances, providers should find this approach useful to find and share their knowledge about the most appropriate clinical interventions. Managing adherence is profoundly important for the triply diagnosed, as it is for anyone with HIV. Medical and mental health providers should actively discuss with patients adherence to both psychotropic medication and HIV medications. If the clinical site permits, medication monitoring or directly observed therapy may be an option.

Linking to Other Services
Another useful strategy is linking patients to outpatient programs that offer specialty health care services, such as support groups that address the specific social and health needs. Referral to an outpatient or inpatient drug treatment facility should be done carefully, with the provider chosen to address the complex needs of the individual patient. For instance, certain drug treatment programs that use a therapeutic community model may not be effective in addressing the needs of a triply diagnosed person.

Finally, although religion and spirituality often play a significant role in the lives of people with HIV, providers generally do not assess or explore patients' spiritual beliefs and their impact on their ability to cope with multiple medical and mental health illnesses. Providers should not be afraid to ask questions about a patient's concept of God, sources of strength and hope, and the significance of religious practices and rituals in their lives.

Although caring for the triply diagnosed continues to be a growing challenge, employing these best practices can be the key to providing care to this medically fragile but complex population. The health care establishment has made significant strides in addressing the needs of the triply diagnosed. But just as the mental health community once developed programs for the dual diagnosed patient, the HIV/AIDS community must now strategize and advocate for the triply diagnosed, who deserve a uniform and replicable model for treatment and care.

Hans Desnoyers is the Executive Director of Adult Day Health Care at Housing Works in the West Village.

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