Spotlight: Interview With Eric Avery, M.D.
HEPP Report interview with Eric Avery*, M.D., Assistant Clinical Professor of Psychiatry and Director of HIV Psychiatric Services, University of Texas Medical Branch, Galveston, Texas.
Q: Tell us about your work in correctional health care.
A: Until early last year, I worked in the Carol Young Medical Facility, a minimum security Texas Department of Criminal Justice facility near Galveston. It's a "step-down" medical facility for several hundred women who come for their medical appointments at the University of Texas Medical Branch at Galveston (UTMB). A large number of these women have HIV.
Q: What were some of the most challenging aspects of your work with inmates?
A: I had to learn how to listen to their stories about their childhood and adulthood physical, sexual, verbal and emotional abuse. For many of these women, prison was a retraumatization. Since there was little I could do to change where they lived, we had to focus on how they did their time.
Q: What were some of the most common mental disorders that you encountered in your correctional experience?
A: Substance abuse or dependence, in remission because of incarceration, was epidemic. Major depression was common. I couldn't believe how often I diagnosed Post-traumatic Stress Disorder (PTSD) in these women compared to my "free world" work in the HIV Clinic at UTMB. Sometimes the stories of childhood abuse are such a problem that patients would tell me them in their first visits. But in others, to ask questions about childhood abuse instantly puts the patient in a flashback so I'm really careful. Since in abuse situations the survivor has felt out of control of what is happening, it's important for the patient to feel that they control what and how they disclose the trauma. I often use a childhood abuse questionnaire that I give to the patient with instructions that they control if and how they complete it. If they can fill it out, they can bring it to the next session. If they can't complete it, that's ok too. Then again, perhaps months later after treatment, we might revisit this traumatic part of their history.
Q: In your experience, how did these disorders impact upon the ability of patients to adhere to therapy?
A: Depressed and hopeless patients aren't really motivated to take on the challenges of HIV treatment. But the Infectious Disease/HIV physician who worked in the facility had a really good reputation with these women. That was one of the keys to why these women have done so well. I worked with this doctor in the HIV Clinic at UTMB so we both could reinforce what the other was doing.
One of the most crippling aspects of PTSD is the belief that the future is hopeless, that at any moment another trauma will happen. Certainly bad stuff can happen in a prison setting and there can be a lot of bad news if you've got chronic medical disorders like HIV, HCV and breast cancer. Add these medical problems to a life of trauma and you have to work really hard to overcome the hopelessness.
Getting these women on an SSRI like Sertraline, and keeping them on it for a long time helped a lot with the depression, PTSD and medical adherence. For many of these women with HIV who'd been hopelessly on street drugs and living waiting to die, getting them to understand they could control their viral loads by what they did with their medical and psychiatric care - well, it was a transformational experience for many of them. Watching this was one of the best parts of my job.
Q: Could you tell us a little about your current situation at the HCV clinic?
A: In my prison job, I saw many women co-infected with HIV and HCV but only a few were on treatment for HCV. ALTs were followed but a lot of women were released before they'd meet criteria for HCV treatment. In the free world, I've worked for several years in a hepatitis clinic. If a patient with HCV has a history of depression or other psychiatric disorders, I'm consulted to evaluate them before they begin their treatment with pegylated interferon and ribavirin because psychiatric disorders can come back with a vengeance while on HCV treatment.
Q: What kinds of psychiatric problems do you see there?
A: The G.I. physicians have gotten comfortable diagnosing and treating depression in HCV patients so I am referred more complicated patients. Like in the prison, these patients have histories of substance abuse and dependence. Interestingly, many have stopped years ago and now are facing HCV. Of those still using drugs, benzodiazepine abuse and alcohol are more common than problems with cocaine. I'm evaluating and treating more and more Bipolar I and II patients.
What really concerns me is who I'm not seeing in the hepatitis clinic. I don't see co-infected HIV/HCV patients in this clinic. And I'm not seeing any patients referred from the psychiatry wards and psychiatric clinics. When I do weekend coverage on the inpatient psychiatric wards I'm stunned to see how many of these patients now are HCV-positive. In Houston, investigators at Baylor College of Medicine discovered that 16.9% of institutionalized psychiatric patients tested positive for HCV.
Because of the neuropsychiatric side effects of HCV treatment, most of these patients will not be treated. This is an emerging problem and the psychiatric profession hasn't figured out that their patients are the ones disproportionately getting infected with HIV and HCV. My worst-case scenario is that future psychiatric clinics will have HIV and hepatitis physicians working in them providing care, instead of the other way around.
Q: How do you manage patients with depression? What are your first- and second-line agents? What complications do you watch for?
A: I use all antidepressants in patients with HIV and HCV. Certainly the first-line agents are the SSRIs. I frequently use Sertraline (Zoloft), Paroxetine (Paxil) as my first choice for patients with depression and PTSD. In patients with medical problems the rule is to start low, so with Sertraline, I start with 25 mg in the morning, and then increase to 50 mg. You can increase up to 200 mg but I'd be looking up drug-drug interactions with the HIV medications as I increased the dose. I start Paxil with 10 mg but, because it has no metabolites, a non-adherent patient can get discontinuation symptoms if they suddenly stop it, so I counsel patients about this.
Prozac is now generic and cheaper so the prison liked me to use it. It's a really good antidepressant. Its primary metabolite's half-life is 14 days. In non-adherent patients this can be a benefit. But, if the patient has bad side effects, they'll last for a long time. It also has more drug-drug interactions, so I am watching for this when I use it in HIV-infected patients.
In patients with liver disease, I'm always careful with how I dose psychiatric medications. Again the rule is go low and increase slowly. But I tell physicians who treat HIV and HCV not to be afraid to prescribe antidepressants. Their patients will be more adherent with medical treatment if they are not depressed. They should become familiar with a few of them and use them. If they can't improve their patients' depression, then they should send them on to the psychiatrist.
This article was provided by Brown Medical School. It is a part of the publication HEPP Report.