Managing Mental Health and Substance Abuse In HIV Patients

July 6, 2022

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This transcript has been edited for clarity.

Michael Saag, MD: Hello. I’m Dr Michael Saag, and welcome to Medscape InDiscussion: HIV. Today we’re talking about managing mental health and substance abuse in patients with HIV. I picked this topic because these issues interfere with many patients’ ability to adhere consistently to their antiretroviral regimens. Here’s a case to illustrate: A 29-year-old man was diagnosed with HIV 6 years ago. His viral load is usually undetectable, but he has spikes in his HIV RNA associated with heroin use. He has been through rehab several times. His last viral load was undetectable, but now he has missed two clinic appointments over the last 4 months. My guest today is Dr Glenn Treisman, who’s professor of medicine, psychiatry, and pharmacology at Johns Hopkins University. Glenn is one of the first HIV psychiatrists in the US, has written a textbook on this topic, and works in the Hopkins HIV clinic, actively providing psychiatric care in the Bartlett Clinic. On a personal note, I feel like I learn more about the practice of psychiatry in a 1-hour lecture from Glenn treatment than from an entire clerkship in medical school. Welcome, GT!

Glenn J. Treisman, MD, PhD: Thank you, “Saag Meister.”

Saag: Let’s get started. Maybe we can have you just describe that scene in your career where you realized that you were going to be an HIV psychiatrist.

Treisman: I was drafted to go down to the HIV clinic when the previous psychiatrists who had been there each quit in sequence. So I was sent there. But after I had worked there for 2 years, I really felt like I couldn’t leave because the need was so great. We have a very large clinic and we were seeing as many patients as we could possibly see, and they were quite psychiatrically ill. Turns out that there’s a huge amount of psychiatric disorder in the population of patients in the HIV clinic.

Saag: Describe those for me. What are the top three or four things that you deal with every day?

Treisman: Probably 30% of our patients have mood disorders — depending on what your ascertainment method is. But if you say the general population is 4% in the HIV clinic, it’s 25%-30%. Similarly, hepatitis C — in fact, anything that causes inflammation of the brain causes affective disorders. You see the same thing in lupus patients, for instance; there’s a huge increase in depression. Second thing we see a lot of is addiction. Obviously, people get infected because they’re addicted and people get addicted because they’re infected. So the huge frequency of addiction, even in non-needle–using gay men at the very beginning of the epidemic, we saw more than 70% of people with a substance use–related problem in our clinic. That’s not people referred to me. That’s the whole clinic. Substance abuse is a very big problem in our population. The third problem that we have in our clinic, and it speaks particularly to being in East Baltimore, is our patients have had horrendous lives. There are very high rates of posttraumatic stress disorder (PTSD), trauma, and negative experiences. Most of the patients have become profoundly demoralized by what they’ve gone through in their life. They really see no way out. They’ve been treated in the prison system and they’ve been treated here and there, and they really don’t have much hope for getting better. The fourth thing we see a lot of is people with temperamental problems. And is there a particular kind of person? You and I have talked about this, but some of our patients really focus on the now — their feelings — and what they want and avoiding consequences, the future and what they need to do. That kind of temperament makes you vulnerable to getting infected with HIV and also makes you hard to treat.

Part of the reason I ended up staying in the HIV clinic, to reflect on your earlier question, is the providers don’t have any training in how to deal with those kinds of problems. What they really needed was to learn how to interact more successfully. And one of the main examples is patients in our clinic as a general rule are reward-sensitive rather than consequence-averse. You can divide the population of the world up into this normal distribution of people who are very consequence-averse, like my accountant, average people. Then few are very reward-sensitive, like the average car salesman who’s focused entirely on getting the car sold now. If you imagine the world is made up of people like that, our patients tend to come from the reward-sensitive side. They do what feels good in the now, and clinicians, as a rule, are consequence-averse. We study so we won’t flunk. We say we study because we want to get an A. We’re lying. We do our medical records so we won’t get dinged. We fill out our forms. We pay our taxes because we don’t like consequences. We don’t want our patients to die. We check the labs obsessively because we don’t want to miss something, and our motivation is often avoiding consequences. So when you put those two things together, you get this weird disconnect in which you say to patients, “If you don’t stop doing this, something bad will happen.” You’re saying it to a person who’s come in with some new horrendous infection because they haven’t taken their HIV medicines because they didn’t feel like it.

Saag: Can you think of a good example of when that played out in your practice?

Treisman: My favorite quote of all time is the patient who said to me, “You know, Dr Treisman, I’ve been very nervous lately because I’ve been buying cocaine from a guy who shot me.” I said, “Why do you buy cocaine from a guy who shot you?” He said, “Well, because he has cocaine.” I said, “Look, I really like prime rib. You can tell by looking at me. But if I went to the prime rib restaurant and the maître d’ shot me, I wouldn’t go there anymore.” He said, “Yeah, with an attitude like that, Dr Treisman, you could miss out on some really good meat.” And he’s right. But I’m focused on avoiding consequences and they’re focused on getting what they need.

Saag: Yeah. How would you define a personality disorder? We kind of know it when we see it. But how would an average clinician know that they’re dealing with somebody like that?

Treisman: Elements of temperament are, like I said, dimensionally distributed. How do you know when someone’s a genius vs a high IQ? There aren’t categorical dividers. Instead, there’s this dimension. If you get far enough out on that dimension and you’re the right kind of person, if you’re not taught how to cope with your feelings and how to cope with your impulses, you develop a disorder. One thing that I often mention is think about a person who’s willing to work 365 days a year for 10 hours a day without any vacation, any weekends off. That’s an average addict. I wouldn’t do that. You wouldn’t do that. I’m not sure I could do that. They can do it because living in the now, they can focus on what needs to be done. And those same people, if you took them out of being a drug addict and put them in a different environment, taught them some coping skills, they can be tremendously successful as many people who are extroverts are.

Saag: Let’s break each down for the people who are depressed. We have a lot of options there. But as you pointed out many times, it’s a depressed person who’s undiagnosed that has the most difficulty, right? Because people who are depressed and on treatment do better because they are able to attend to things. For people who have a substance use problem like this guy in our case — he’s been in rehab several times and he falls off the wagon. When he does, you know it because he doesn’t show up for his visits, his viral load shoots back up. Let’s focus on that case for a minute. How would you approach his care in your clinic?

Treisman: Addictions are a misunderstood element. The first thing to know is that it’s unlike a disease, and everybody wants to call addictions a disease, and on the test, that’s the right answer. But they are somewhat different than a disease because if you have an opportunity to take a pill for schizophrenia that would cure you, you would. The average heroin addict will not take naltrexone, which would essentially cure them of their heroin addiction, because they don’t want to give it up. People want to give up their diseases. People with behavioral problems like addiction don’t want to give up their behavior. They don’t want to stop. They know they need to stop. But it’s very hard to stop and these things have a habit. The problem is the patients will say to you, “I have to work away at this every second of every hour of every day, or I find myself right back where I was.” When treating addiction, you have to help people change their habits but they can’t stop using drugs. What you do is start doing something else. The idea that you’re going to quit drugs without replacing them with some other set of habits, you can’t do it. You have to give people a new habit: going to meetings, working on rehabilitation, filling up their life with useful things. Those steps — when you explain them to patients with addiction, what you’re saying has a lot of teeth to it. What I say to patients is, “You’re going to not want to come here on a day when you don’t feel like coming, but you can miss any day that you’d miss going out to cop when you were using.” They say, “Well, I never missed a day; even in a blizzard, I would go out to cop,” and I say “Good, so even in a blizzard, you’re going to come to the clinic.” The idea that you’re going to change how you assess what’s important, those little cognitive-behavioral changes: What’s important? What do I need to do? How do I structure my day? Those things really change substance abuse disorders, and they continue to use even though life’s beating the crap out of them. At some point they say, “This is too terrible.” So you kind of have to get people over the line to where they say this is too terrible. We call that confrontation with the smile or conversion. People get the idea that they have to change. The second thing is structuring the change in a way that replaces old habits with new behaviors. The third thing to understand is that it’s a relapsing disorder. When the patients relapse, you just pick them up, brush them off, put them back on the road. You see many people try to get sober, the people who succeed getting sober are the people who try over and over again and don’t give up. When you don’t give up, eventually you will get sober and your life will get to be better. One of the other things I say to the residents is, “Anything good that happens, it’s because they’re working on their sobriety; anything bad that happens, it’s because of when they used to use drugs.” What you do is you’re emphasizing how negative the impact of drug use is and how positive the impact of sobriety is. They quickly see that they’ll say, “Yeah, for those 3 weeks, my life was way better.” “For those 3 months, my life was way better.” Then if you can get them in to see you — and you have to see them a lot… Part of the problem is that we tend to see our patients every 3 months. Patients who are addicted to drugs, I see them every week. I often have them come to clinic 3 times a week to go to group. We’re seeing them a lot and there’s a there’s a mesh of people saying, “Oh, you got to get back on track, you got to get back on track.” If they use even 1 day and they come the next day, we can get them better again. So it’s a relapsing disorder; you have to be banging away at it long-term.

Saag: It takes an enormous amount of patience and persistence, right? That’s what you’re very good at. I was in clinic with you several years ago, and I remember a case where you set up a program where they came in every day. What I remember most about it was — it goes back to what you’re saying… Their life wasn’t going very well. They said they needed — I forget what it was. It might have been Valium. It might have been a narcotic, but you said, “Okay, we’re going to set this up so that you come in every day and pick up your medicine and you have to show me that this medicine is helping you.” Can you walk us through briefly what that scene is like?

Treisman: It’s a common scenario for people who have become dependent on opiates — not necessarily addicted, just dependent. But you can be addicted as well. People say, “I need my narcotics,” and I say, “Fine, how are they helping you?” They’ll give me a long list of things that the narcotics help with that are all nonsense, but they’ll give me the list and I’ll say, “Okay, you come every day, pick up your narcotics. And each day you bring me something that you’ve been able to accomplish that day that the narcotics helped you accomplish.” And each day it’s a struggle. Then you go to once a week, and if they mess up, you go back to every day and then you go to once a month. People are getting a month’s worth at a time. Then if they run out early, they have to come back every day again. You do that for a year or 2. During that process, they get busier and busier with their life and they finally say, “You know, I have to get off these narcotics because they’re interfering with my work or my life or what I’m trying to do,” or, “I can’t get an erection because of the narcotics.” But they start to see the narcotics as an impairment rather than an asset. Patients will tell you when it’s time for them to get off. Pushing people from, let’s say, oral oxy to Suboxone, often as an intermediary step, is very helpful for a lot of people because if you’re using Suboxone, you can go buy a bunch of narcotics on the street and you can’t get high because you’re on Suboxone.

Saag: For the folks who are on narcotics long-term, there’s consequences beyond just the addiction right in terms of it causes depression as well, right?

Treisman: Or it worsens depression.

Saag: It interferes with, as you taught me, the mesolimbic dopaminergic pathway, right? Maybe you can describe to us how that works and what exactly is happening when you treat depression.

Treisman: There is a circuit in your brain that gives you a “yeah” from things. You know, we go to a basketball game together and your team scores, you get a little “yeah.” And it’s so powerful that I get a “yeah” just from seeing you. That circuit is what makes us get out of bed every morning. That’s the ascending mesolimbic dopamine reward circuit. It’s what makes us go. When people get depressed periodically, that turns off in about probably 4% — it may be 5% — of the population gets that condition, where periodically, that circuit just shuts off for no reason. Chronic illness will make it much more common. Inflammatory illness will make it much more common. Chronic viral infection will make it much more common. A variety of dysautonomia problems like gastrointestinal (GI) dysmotility make it much more common, so we see increases in certain subpopulations of that problem of not enough “yeah.” When you turn that circuit back on, people get rewards. People who are depressed and more like getting addicted because nothing is rewarding. Nothing gives them a “yeah,” except maybe drugs, which directly release dopamine in your brain and give you a “yeah.” Opioidergic pathways in your brain, benzodiazepinergic pathways, GABAergic pathways in your brain — and stimulants directly modulate that pathway. If you mess with that, that pathway is much less likely to recover. So often we can’t get people better until they’re off narcotics, off benzos, and they say it makes me feel better. It does make them feel better, but it makes them worse. Even though it makes them feel better in the short run.

Saag: The take-home point is, as you’ve taught me, the idea is to learn about a couple of these — become comfortable with them. If those aren’t working for this individual patient, that’s when you do a referral to the psychiatrist for more detailed involvement.

Treisman: Yeah. Three bullet points are depression is insidious, and the patients will explain it away as being caused by their life. A Hopkins medical student said to me, “My girlfriend broke up with me and I got depressed.” This is a tall, handsome, straight-A Hopkins medical student going into ophthalmology. Nobody would break up with him. And a genuinely nice guy to boot. I said, “No, no. You got depressed and that’s why your girlfriend broke up with you.” On Wellbutrin, his girlfriend wanted to get back together; his grades went back up from C’s to A’s, and everything was firing on all eight. But his life story explanation — I got depressed because my girlfriend broke up with me — is how most people see it. You have to look for the stigmata of depression in your patient without being drawn into their explanation of why they got depressed and then persuade them that turning that circuit back on is going to make things better because they resist it. They say, “No, no, I just need to… I just need to get through this difficult time.” No, you need to get your mood disorder treated. And when you take a careful history and you listen to the patient carefully, you can reflect back on them all the events of their life where they were diverted by their affective episodes.

Saag: Our time is rapidly melting away, but I think we’ve covered exactly what I wanted to cover in terms of what are the types of things that interfere with a patient’s ability to take their medicine or keep their clinic appointments. It’s the four things you mentioned. It’s an affective mood disorder, most often depression. It’s PTSD, which is a whole different set of treatments, but usually therapy through talk and group — that type of thing.

Treisman: I would say I would broaden that not just PTSD, but people who had lives that have demoralized them. Circumstances that have demoralized them. They’ve run into the idea that life can’t get better, and you have to remoralize them.

Saag: Finally, personality disorders, which to me is the toughest because we can’t change people’s personality. I remember vividly when you asked one of our students, or in one of the lectures you said, “Give me a definition of a personality disorder,” and they came up with all these DSM-3, -4, or -5 — whatever. And you said, “The way you know that somebody has a personality disorder is…

Treisman: …everybody in the clinic is fighting and the patient isn’t getting blamed or you hate them.”

Saag: Right? You see their name on the board and you say, “Gosh, I hope they don’t show up this week.”

Treisman: That’s right.

Saag: Those are the toughest.

Treisman: Right. But the key to remember is they’re exquisitely reward-sensitive as a group and you are exquisitely consequence-averse. You speak in consequences and you have to learn to speak in rewards. If you do this thing, this good thing will happen. That’s salient to them, and your approval is very important to patients. You don’t realize it, but your positive regard is often what keeps patients coming back to your clinic and they want your positive regard. So you make a big fuss over each incremental thing they do that’s good, and you kind of ignore the stuff they do that’s negative, What helps them is to say, “You did this good thing this week and wow, look at how it paid off,” or “I’m so proud of you,” and never be afraid to say how positively you regard some accomplishment of your patient. Because that’s what drives many patients is the reward. Whereas if you’re consequence-averse, you don’t want your doctor to say, “Wow, let’s give you a standing ovation. Your blood pressure is under control.” You want to just get out of there. My patients need a standing ovation.

Saag: I’ve seen that work over and over again as I’ve learned from you over the last 25, 30 years — I’ve lost track. Dr Treisman, thank you for being with us. It’s been an illuminating 25 minutes and hopefully this series will continue. We’ll bring you back and we’ll dig into some of these a little bit more in depth. But for now, we’ll sign off and thank you. Do you have any parting words for us in the last?

Treisman: No, Dr Saag. You are a wonderful colleague and you’ve been a great help to me and my work. I appreciate you more than you know and I very much appreciate getting be part of this series.

Saag: Thank you so much, GT, and thanks for your friendship and education to me personally over the last several decades.