Introduction

Mental health issues are difficult territory for any healthcare provider. The situation becomes exponentially more complex when the patient is incarcerated and HIV is added to the mix. The multifactorial etiology of mental illness makes diagnosis and management of these patients quite challenging. Treatment is further complicated by factors such as potential medication side effects and interactions and mental status changes due to opportunistic infections.

Psychiatric problems in the correctional setting are more prevalent and often more severe than seen in the general population (1). The overall prevalence of psychiatric disorders among inmates ranges from 30-70%; contributing to this high prevalence is co-occurring substance use disorders (about 60%) and neurocognitive disorders (about 50%). The neurocognitive disorders often have multiple etiologies, including acquired brain injury (ABI) and the long-term consequences of substance abuse. In addition, neurocognitive disorders can complicate the management of other concurrent illnesses. Unfortunately, these disorders combine to reduce the likelihood that a patient will adhere to treatment (2).

Factors contributing to the high prevalence of psychiatric and neuropsychiatric disorders in correctional populations should be carefully considered when treating incarcerated patients. Education, adaptive coping skills, and a strong support network are essential for protecting individuals from significant mental health problems. Incarcerated men and women tend to represent a marginalized sector of the general population, who also have very poor social support networks and lower levels of education.

Women often present with additional psychosocial factors. More than 60% of incarcerated women report histories of sexual abuse, and an even greater number approaching 90% report physical abuse (3). This abuse history has been linked to a number of mental illnesses, including substance abuse, personality disorders, affective disorders, and post-traumatic stress disorders. The extent of severe, prolonged physical and sexual abuse histories among incarcerated men is likely to be similar and to contribute to the high prevalence of mental illness among them.

These primary (antecedent to HIV infection) mental health issues play a critical role in determining whether a person will become infected with HIV, will adhere to a long term medication regimen, and will engage in risk factors for the development of other health problems. Thus, managing mental illness is an important part of providing HIV and medical care to incarcerated populations.

Depression

One of the most relevant and underdiagnosed mental health issues among inmates with HIV is depression. Depression is common, potentially life threatening, and generally treatable. Depression is several times more prevalent among people with HIV than among the general population; prevalence of depressed mood approaches 80% and 10-15% have diagnosed major depression (4). Co-morbid mental illness among HIV-infected prisoners is concentrated in even higher numbers due to co-existing substance use disorders among prisoners. While the etiology of depression may be multifactorial, including primary depression, depression from substance abuse, post-traumatic stress, or issues surrounding reasons for incarceration, nonetheless, depression must be diagnosed and effectively treated to ensure adequate health outcomes. Rates of self-reported depressed mood tend to be highest immediately prior to HIV testing and while waiting for results (5).

Additionally, for individuals undergoing HIV testing, symptoms of depression may be enhanced, particularly in facilities where HIV testing is mandatory. Psychiatric support and crisis intervention may be most required at these times. As patients begin to accommodate to their changing health status, depressive issues may diminish over time, only to reemerge at transition points in the disease.

Depression is thought to be related to damage to, or alterations in the functioning of subcortical brain structures (6). Increased rates of depression have been seen in several neurologic disorders that differentially affect subcortical structures, such as Parkinson's disease, Huntington's disease, and HIV/AIDS. While depression (due to situational factors) can certainly cause a patient to be distractible, irritable, forgetful, disorganized, apathetic and slow, these behaviors may also be symptomatic of the neurocognitive changes associated with subcortical neurologic disorders. Unfortunately, traditional treatments for depression may be less than optimally effective in patients with subcortical neurological disorders.

Cognitive Function

Although many healthcare providers may think of the evaluation of cognitive functioning as being outside the purview of mental health, it is actually an integral part of a mental health evaluation. Further, it is often extremely difficult for physicians to distinguish the behavioral aspects of depression from the consequences of subcortical neurocognitive impairment. In patients with HIV, neurocognitive disorders increase with the presence of psychiatric symptoms, CD4<200, a history of poor medication adherence, and a history of prior neurologic insults (substance abuse, trauma, stroke, etc). Although these patients frequently appear to be depressed, uncooperative, and out of step with the environment, they may in reality be having difficulty comprehending and consistently tracking the changes and demands of the prison setting. Thus, patients with HIV may have symptoms that make differentiating depression from subcortical impairment more challenging, especially since existing screening tools are insensitive to measuring a difference.

Inmates with unrecognized cognitive impairment as a result of HIV may be emotionally labile and behaviorally unpredictable, inviting attacks from other inmates and punishment/retaliation from correctional officers who fail to understand the behavioral impetus. They may receive punishment for rule infractions that they were never entirely capable of understanding or remembering. They may refuse medication, either intermittently or consistently, because of an inability to understand and/or remember the consequences of non-adherence. They may be asked to make decisions about their medical treatment or day to day lives that they are no longer cognitively competent to make. The implications of impaired decision making ability in a prison setting, whether or not it is due to HIV, are enormous due to the unpredictability, complexity, and potential for violence in correctional facilities. Thus, any inmate with non-adherence to medications or health care should be carefully screened for co-existing mental illness.

Screening for Mental Health Disorders

Distinguishing depression from subcortical neurocognitive impairment is difficult in a clinical interview. Fortunately, brief screening instruments are available to quickly identify patients with HIV who may be experiencing cognitive changes as well as affective disorders. The Mini Mental State Examination (MMSE) (7) is widely used as a quick cognitive screen, however, it screens for cortical signs, rather than the subcortical problems usually associated with HIV-related changes. The Johns Hopkins HIV Dementia Scale is an excellent alternative (See HEPPigram, page 6). It is brief, easy to administer and interpret, and freely available on the Internet at http://www.iapac.org/clinmgt/mh/demscale.html. It screens short term memory, concentration, and processing speed. While these areas may show some impairment in patients with moderate to severe depression, the cut off for considering dementia is sufficiently low to reduce the probability of false positive results. Another test is the Center for Epidemiologic Studies-Depression test (CES-D), which is shown in Figure 1. In general, screening should not occur immediately after intake into the facility as substance abuse or reaction to incarceration may overestimate the number of individuals with depression.

Regardless of whether HIV-infected prisoners have depressed affect secondary to depression or impaired neurocognitive changes, a trial of antidepressant therapy is indicated. In general, a trial with selective serotonin reuptake inhibitors (SSRIs) is likely to provide the best attempt at treatment. This class of drugs have few interactions with existing antiretrovirals (see HIV 101, page 7) and unlike tricyclic anti-depressants, tend not to suppress cognitive function.

Other mental Illnesses

Other conditions to be considered among HIV-infected inmates who present with a depressed mood or evidence of behavioral problems include bipolar disorder and schizophrenia. One study found that 2-4.3% of all inmates have bipolar disorder, and 2.3-3.9% of all inmates are schizophrenic (8). In their discussion, the authors suggest these numbers may be underestimates. This condition, if misdiagnosed and treated with antidepressants rather than mood stabilizing medications, may result in episodes of mania that may lead to behavioral infractions or inability to adhere to medication regimens. (See Table 1) In some cases, the symptoms may be subtle. Moreover, some patients with thought disorders (e.g. schizophrenia) go clinically undetected because these individuals have become quite skilled at "covering" their mental illness. (For an indepth review of other mental illnesses, see reference 2, Stevens et al, 2000.)

Conclusion

The range of psychiatric disorders that are seen in a correctional population is broad. The prevalence of all psychiatric disorders is higher in an incarcerated population than in the general population (1) , and some disorders are even more likely in an HIV-infected population. Depression is the most frequently encountered psychiatric disorder, both in and out of prison. Treatable and common, depressive symptoms also suggest potential additional complications in HIV-infected individuals. The symptoms of depression can overlap with and mimic the signs of subcortical impairment that is seen in HIV patients. In order to effectively treat symptoms, manage behavior, and promote optimal autonomy in the correctional setting, physicians must begin to erase the imaginary boundary between the mental health and neurocognitive consequences of this complex disease.

* Speaker’s Bureau: Bristol-Myers Squibb

Table 1

References

1. The Health Status of Soon-to-be-Released Inmates. National Commission on Correctional Healthcare and National Institute of Justice joint project. Meeting of the Expert Panel on Communicable Disease, June 14015, 1999, Chicago, IL.

2. Stevens VM, Neel JL, Baker DL. "Psychosis and nonadherence in an HIV-seropositive patient.", AIDS Reader, 2000; 10(10):596-601.

3. Browne A, Miller B, Maguin E. International J Law Psychiatry: Special Issue: Current Issues in Law and Psychiatry, July 1999

4. Boccellari, A., Dilley, J., and Shore, M. "Neuropsychiatric aspects of AIDS dementia complex: A report on a clinical series.", Neurotoxicology 1988 Fall;9(3):381-9

5. Bix B, Glosser G, Holmes W, Ballas C, Meritz M, Hutelmeyer C, and Turner J. "Relationship between psychiatric disease and neuropsychological impairment in HIV seropositive individuals.", J Int Neuropsychol Soc 1995 Nov;1(6):581-8.

6. Cummings J. "The neuroanatomy of depression.", J Clin Psychiatry 1993 Nov;54 Suppl:14-20.

7. Folstein M, Folstein S, and McHugh P. ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician.", Journal of Psychiatric Research, 1975 Nov;12(3):189-98.

8. HEPP News interview with Robert Greifinger, correctional health care consultant. HEPP News, December 1999; 2(11): 4. (Please see: pdf version of this issue, page 4.)

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©1997,1998,1999,2000,2001. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.

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