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TITLE PAGE201046232539


									Managing HIV-Related Depression in
a Hospital Based Out-Patient
Psychiatric Department: The Mount
Sinai Experience

Peter L. DeRoche MD, FRCP(C)
Director, Clinic for HIV-Related Concerns
Department of Psychiatry
Mt. Sinai Hospital
Clinic for HIV-Related
   Started in 1986 by Drs. Stephen Woo and
    Mary Seeman
   Funded in 1989 and 1991
   Services expanded and adjusted as
    epidemic evolved
   7 part-time psychiatrists, 2 full-time
    psychotherapists, 1 part-time couple and
    family therapist, 1 part-time occupational
    therapist, full-time secretary/receptionist
Clinic for HIV-Related
   Consultation
   Psychiatric assessment
   Multi-disciplinary psychiatric management of major
    mental illnesses
   Individual psychotherapy
   Couple and family therapy
   Group psychotherapy
   Mindfulness-based stress reduction
   Narrative therapy
   Art therapy
Clinic for HIV-Related
   250 intakes per year
   500 patient visits per month
   250 active patients
   85% MSM, primarily gay men
   A developing Women’s Program –
    service for women, by women
Clinic for HIV-Related
   Research
    – Screening instruments for early neuro-cognitive
    – Comparing efficacy of models of brief
      psychotherapy intervention
    – Impact of St. John’s Wort on depression in HIV
    – Role for Mindfulness-Based Stress Reduction
    – Role for Art Therapy
    – Role for Narrative Therapy
Self-reported psychiatric
symptoms. (Horwath 2002)
 70                 65
 50                            48
                                          43           41           40           40
  0   Depression   Anxiety   Insomnia   Lethargy   Irritability   Impaired   Mood Swings
MSM: % receiving diagnosis at
    time of assessment.


    10                              8                     7
                                             5     6
         Maj.   Subst.   Dysth. Adj. Dis.   BAD   Oth.   Anx.
         Dep.                                     Dep.   Dis.






     1.00        2.00       3.00        4.00

            Number of Problem Domains
   Social realities of HIV (burden of illness)
    – Impact on career, income, housing
    – Privacy, disclosure and discrimination
    – Impact on relationships (family, life partner,
      social network)
    – Impact on intimacy, sex relationships
    – Stigmatization – marginalization, isolation
    – Multiple losses
    – Impact of treatment
   Not everybody has the same experience with HIV
   The experience of a life event (eg diagnosis with
    HIV), and how one copes with that event, is
    determined/influenced by previous life events.
   Formative years may be associated with shame,
    stigmatization and marginalization –
   Development of low self esteem, low self worth and
    self as unlovable
   Interpersonal difficulties can result eg longing for
    intimacy but feeling unworthy or not trusting
   Focus of treatment on pre-existing
    problems which compromise capacity
    to cope. Eg:
    - Impact childhood trauma
    - Experiences with marginalization and
   Diagnosing strategies
    – DSM IV depressions
          Major depressive disorder
          Dystymia
          Bipolar Affective Disorder
          Adjustment disorder
    – Personality disorder
    – Substance use or dependency disorders
   “Sub-syndromal” depression
   Limits of diagnosing
Role for medications
   Evidenced-based practice
   Facilitate psychotherapy and social interventions
   Limitation of medications
   Influences of personality
   Influences of substance use
   Medication management of psychiatric disorders is
    informed by psychodynamic theory
    – Relationship with the prescriber is critical in determining
    – The healing power of the relationship independent of the
   Multitude of influences which
    complicate treatment and can limit
    response to treatment.

   Living a more engaged, productive life
    in the context of illness
   Erickson’s 7th and 8th stages
    – “Generativity vs self absorption”
    – “Integrity vs despair”
Couple and Family Therapy

   Conflicts in primary relationships can
    cause or contribute to depression
   Depression can cause or aggravate
    conflicts in primary relationships
Interpersonal Group
   As distinct from peer support
   A “here and now” focus on
    interpersonal relationships.
   Interpersonal problems are played out
    spontaneously in the group and
    examined therapeutically.
Crisis Intervention

   To return the individual to a prior level
    of functioning.
   Facilitates expression of affect.
   Seeks to help understand the meaning
    of the event.
   Explores options for active coping.
Individual Psychotherapy

   Distinction from counseling ?
   Focus on pre-existing problems which
    compromise capacity to cope. Eg:
    - Impact childhood trauma
    - Experiences with marginalization and
Psychodynamic Psychotherapy

   The “dynamic” tension
    – neurosis
    – defence
   The role of the unconscious
    – “free association”
    – dreams
    – “transference”
   Developmental years are a major focus of
Psychodynamic Psychotherapy

   To develop insight into the influence of past experiences on
    the way one thinks about oneself, others and the world
   To understand dysfunctional patterns of thinking or behaviour
    which have developed as a result of these experiences
   To develop acceptance of the past.
   To connect legitimate feelings to what happened in the past,
    moving from self-blame to anger to grief to resolution.
   To disengage from the wounding experiences in order to
    engage in the present and future possibilities.
   To engage in healthier and more Self supportive ways of living
    in the world.
Cognitive/Behavioural Therapy (CBT)

   Designed specifically for the treatment of
    depression and anxiety.
   Based on the assumption that mood is
    determined by thought and that depression
    and anxiety result from dysfunctional
    thought patterns.
   Therapy seeks to identify dysfunctional
    thought patterns, change them and reduce
Elements of Cognitive/Behavioural
Psychotherapy (CBT):

   Anxiety and depression are perpetuated by focusing
    on negative thought patterns; a “vicious cycle”.
   A depressed person emphasizes the negative and
    tends to undervalue the positive.
   Therapy identifies cognitive distortions eg “black
    and white thinking”, “predicting the future”,
    “operating on assumptions”.
   Therapy helps individual look at emotions and
    events in more rational and balanced way.
   Facilitates acknowledgement of the positive in life
    and helps find ways to keep awareness of the
    positive in the individual’s life.
Psychotherapy (IPT)
   Designed specifically for the treatment of
   Links the depression to changes in the
    person’s life, eg role transitional, grief.
   Labels the depression as an illness but
    seeks to normalize the experience.
   Therapy very much focused on helping the
    individual re-engage in productive and
    meaningful activity, particularly
Elements of Interpersonal
Psychotherapy (IPT):
   Validate depression as a legitimate
    emotional reaction to the experience of
    living with HIV.
   Emphasize the proven value of re-engaging
    in productive, meaningful activity,
    particularly that which involves the
    interpersonal, as curative of depression.
   Explore and help work through the barriers
    the patient anticipates in doing this.
Short-Term vs. Long-
Term, open-ended
   Biases
   Chronic, recurring or successive
   Certain psychotherapies work better in specific
    disorders and with certain patients
   Most therapist utilize an “eclectic” approach
    determined by the therapist’s skill set and the
    patient’s particular needs and set of experiences.
   Therapist characteristics predicting successful
    psychotherapy outcomes (Rogers):
    – Accurate empathy
    – Non-possessive warmth
    – Genuineness
Staff development

   Analytically-oriented therapy, longer-term
    and shorter-term models
   Cognitive/Behavioural, Interpersonal
   Systems theory
   Occupational therapy
   Focusing, Mindfulness
   Creative writing
   Art Therapy
Mindfulness-Based Stress
   developed for patients with chronic
    medical conditions, anxiety and
    chronic pain
   based on Buddhist mindfulness
    meditation practices
   evidence-based approach
Mindfulness Based Stress
Reduction – Program Structure
   8-week training group led by trained
    practitioner (Buddhist meditation)

   20 participants per group

   3-hour sessions

   1 day-long silent retreat

   approx. 1 hour homework, 6 days per week
Mindfulness Based Stress
Reduction – techniques
   Guided meditations
    – Eg “loving kindness”
   Focus on movement of breath, body
   Non-judgemental awareness of
    intrusive thoughts, sensations
   Yoga practice
Mindfulness Based Stress
Reduction - goals
   Systematic training in how to focus
    attention and reduce influence of
    distracting thoughts, environmental
    stimuli and bodily sensations
   Unhooking from worry and rumination
   Enhancing capacity for curiosity about one’s
    self, openness to the realities in one’s life
    and acceptance of the self and the
    experiences life presents
   Increased compassion for the self
Mindfulness Based Stress
Reduction - benefits
1.   Increases “psychological
2.   Improvement on measures of worry
     & rumination.
3.   Decreases anxiety & depression.
4.   Reduction in symptoms of pain.
Narrative Therapy:
   A person’s verbal description of self and
    history may be unelaborated, unrevealing,
    rambling, inconclusive, interrupted, broken
    or disjointed.
   In psychotherapy a therapist talks with the
    client to help develop a coherent, logical
    and concise description of the problematic
   Goal is to develop understanding and
    empowerment through insight and working
Narrative Therapy:
   16 week group intervention.
   Each week a topic or theme is introduced eg “write about a
    place” or “write about something you observed or experienced
    as a child”.
   The intervention is the writing of personal stories
    (“narratives”) and sharing them with other group members
    during the group meetings.
   When a story is read, the personal life of the participant is not
    discussed; rather the facilitators encourage discussion about
    the story.
   The participant learns to write a coherent story about
    himself/herself which can be understood by others
    (“autobiographical/narrative competence”)
Narrative Therapy

   An opportunity to write and share stories
    with others who live with HIV in a
    confidential setting.
   Fosters creative problem solving resulting in
    enhanced life enjoyment, a change in
    perspective on experiences, develops tools
    for expression and helps navigate the
    impact of illness on their lives.
Narrative Therapy:
Impact on Physical and Mental Health

   Drops in physician visits
   Positive impact on immune function
   Reduced emotional distress
   Reduction in symptoms of illness
   More positive attitudes towards the
Art Therapy

   Psychotherapy is based primarily on a
    verbal process
   Stigmatization, secrecy, and extreme
    anxiety associated with unresolved
    adverse experiences can limit cognitive
    and verbal processing
   This may make it difficult to begin and
    sustain treatment using talk therapy
Art Therapy
   Art helps express feelings that are difficult to put
    into words, thereby releasing feelings in a safe and
    acceptable way and promoting spontaneity and
   Greater awareness provided through art therapy
    can increase active coping, such as problem solving
    and more effective utilization of social support
   Even when awareness and insight remain low, the
    process of expression through art can alleviate
    symptoms of anxiety, intrusive memories, and pre-
Art Therapy

   30% of participants in a previous group
    therapy intervention could not tolerate the
    group experience
   The current intervention is one-on-one for
    individuals with significant symptoms of
    distress related to traumatic events in the
    past (eg childhood sexual abuse,
    discrimination/stigmatization, diagnosis of
Art Therapy
   10 sessions of structured art therapy
   A theme is presented and the client chooses
    the medium to work with
   The client develops increased capacity to
    step back from the emotional impact of self
    reflection, to create a structure and
    boundaries emotionally so that the
    experience is a safer one.
   A gradual freedom in emotional expression
    and trust in the therapist to participate in
    the expression of affect.

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