Psychosocial Factors that Affect TB Treatment. Catalina Navarro, RN, BSN March 19, TB Nurse Case Management March 17 19, 2015 San Antonio, Texas

Transcription

1 Psychosocial Factors that Affect TB Treatment Catalina Navarro, RN, BSN March 19, 2015 TB Nurse Case Management March 17 19, 2015 San Antonio, Texas EXCELLENCE EXPERTISE INNOVATION Catalina Navarro, RN, BSN has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Psychosocial Factors that Affect TB Treatment Nurse Case Management March 19, 2015 Catalina B. Navarro RN, BSN Nurse Consultant/Educator TB is Still a Social Disease TB Control is not only going to be conditional in significant medical advances, it will also depend upon to address the social determinants of TB, as well as the risk factors that mediate the effect of socioeconomic conditions on TB. These include mal or undernutrition, crowded living conditions, HIV infection, smoking, abuse of alcohol and other drugs, diabetes and mental illness. The International Journal of TB and Lung Disease. Editorial Mario Raviglione, June

3 Overview Addressing psychosocial factors and mental health needs is necessary to ensure positive treatment outcomes. Homelessness Substance abuse Mental Illness Socioeconomic status Homelessness Homelessness is not easily defined Temporary circumstance Homeless people are three to six times more likely to become ill than housed people (National Health Care for the Homeless Council, 2008) 3

4 Homelessness Among the homeless population the incident of TB is high due to: Lack of access to health care service Increase number of undetected cases Delay in diagnosis Reluctance to consult health services Poor health understanding Poor Health Understanding Challenges Low literacy level May not be literate Low disease comprehension level May not understand medical terms (adverse reactions) Available resources May not know where to turn for medical help Language barriers May not understand related materials 4

5 Transient population May move out of your jurisdiction patients who move are much more likely to default than patients who do not move Communication and coordination are especially important for these patients 5

6 Substance Abuse Tobacco Alcohol Illicit drugs Tobacco Use Approximately 13% of the TB cases in the world each year may be attributable to tobacco exposure. Smokers may have a much better chance of quitting with a support program Tobacco cessation must become an integral part of all TB control programs. Systematic Reviews and Meta analyses evaluating tuberculosis and cigarette smoking 6

7 Tobacco Use Association between Tobacco Smoking and Active Tuberculosis in Taiwan Hsien Ho et al AJRCCM 2009, 180; 475 Prospective cohort study in Taiwan: 17,699 participants, Current smoking associated with twofold increased risk of active TB Association stronger for patients < 65 years Significant dose response relations Cigarettes per day Years of smoking Pack years Drug Used and TB Oeltmann et al. Arch Intern Med. 2009;169(2):

8 How You Assess Substance Abuse in Your TB Patient? CAGE Substance and Drug Abuse Screening Tool Have you ever felt you should cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking? Have you ever had a drink or used drugs first thin in the morning, to steady your nerves, or to get rid of a hangover? Substance and Drug Abuse CAGE Questions Yes = 1 No = 0 Interpretation: Score of >1 is considered significant Suggest a referral to a professional addiction counselor A higher score, strong indication of alcohol or drug problem 8

9 Alcohol Use and TB Treatment Hepatotoxicity Drug induced hepatitis Association between heavy ETOH use and TB ETOH weakens the immune system which increases risk of TB Heavy ETOH use has been linked to Higher reinfection rate Lack of treatment adherence Development of drug resistant TB BMC Public Health 2009, 9:450 Mental Illness 9

10 10

11 TB is a Unique and Painful Experience Research has shown that people affected by TB are more likely to develop mental and psychological problems than people not affected by the disease Patients believe that TB is always an interruption in life Physically, psychologically, economically and socially After the initial shock from diagnosis the is a period of denial followed by Resignation and depression TB research and treatment; 2013;Article ID Psychological Factors of TB Fear, shock, denial, anger, guilt, stigma and shame are typical feelings after diagnosis Perception as an incurable disease Lead to denial and treatment rejection Fear/guilt of infecting family members 11

12 Case of Chinese Patient Came to USA (Plano) to visit his son and take care of the grandchildren Diagnosed with MDR TB Son and 1 y.o grandson also Dx. also MDR TB cases Pt. admitted to TCID (Home sick, language barriers, missed Chinese food was abandoned by the family No visits, no interaction with family D/C from TCID one year later to the airport to flight to China Relationships Between Mental Disorders and TB are Complex Mental disorders are associated with High risk of TB acquisition and transmission Poor adherence to anti TB treatment Diagnosis of TB increases the risk of Mental illness TB research and treatment;2013;article ID

13 Why is TB so Prevalent Among those with Mental Illness? TB and mental illness have common associations Homelessness Alcohol/substance abuse/tobacco Poor health care access General hospital Psychiatry; 2013; 35: Risk of Mental Illness in TB Patients Up to 70% of TB patients have mental illness A study in Peru found rates of depression and anxiety at 52.2% and 8.7% among MDRTB patients Prevalence of depression correlates with Disease severity and duration Co infection with HIV may increase the risk of depression by up to 70% General hospital Psychiatry; 2013; 35:

14 Why Depression and Anxiety are Common in TB Patients? Life disruption leads to emotional difficulties Symptoms of TB and depression overlap Weakness, fatigue, loss of appetite and energy TB medications can cause agitation, confusion, depression and psychosis Depression can lead to further disability and interfere with treatment Case Study College Student Life disruption 21 y.o female from India In Florida studying in college (Student Visa) Diagnosed with pneumonia pending Chest X ray Visit a friend in Houston Chest X ray taken Diagnosed with TB.. MDR TB Admitted to TCID In Texas, no family support, no friends, visa to be expired 14

15 Challenges and Responses Challenges 1. Under or misdiagnosis Some symptoms are overlapping Misconception about situational distress vs. Clinical illness Conflating poverty/illness with depression 2. Not integrated onto standard protocols 3. Low priority/limited services available 4. Limited evidence base for best practices 15

16 Responses 1. Assessment and screening Situational vs. clinical distress? 2. Intervention Supportive Problem solving Motivational interviewing/harm reduction Clinical Psychotherapeutic intervention (group or individual) Psychopharmacology & TB drug interactions 3. Health/Mental health system integration Case Management Strategies Identify barriers to treatment and competing priorities Develop an individualized care plan Referrals to substance abuse counselors Referrals to AA programs Psychological or Psychiatric evaluations may be required Hospitalization often required to successfully treat patient with mental illness and TB 16

17 Potential Drug Drug Interactions Between Rifampin and Psychotropic Medications Consider increasing dose of psychotropic medications or change rifampin to rifabutin to decrease drug interaction How to Recognized a Mental Health Problem? 17

18 Mental Health Assessment Tool MENTAL HEALTH ASSESSMENT TOOL NON SPECIFIC MENTAL HEALTH ASSESSMENT CHECK LIST Depression Disorder Suicide-Self Harm Bipolar Disorder Substance Abuse-Drug Abuse (CAGE) Behavior Appearance Speech Mood and Affect Sensorium Bipolar Disorder Screening Black Dog Institute s Self Test Have you been too depressed to work, or only able to work with difficulty? Do you experience ups as well as downs with your mood? Are your ups wired or hyper more than when you are just happy? Seek referral if patient answer yes to all 3 questions Black Dog Institute. (2011). Self-test for bipolar disorder. Retrieved from 18

19 Socio Economic Factors Socio Economic Factors 31 50% of patients have financial difficulties 11% of children with TB affected parents abandoned schooling and 8% took up work Present late in the disease when cure is less likely and more costly Choose between continuing treatment and working Chang B.Quality of life in TB: A review of English literature 19

20 Case Study Case Study :Medical History 38 y/o male with History of cirrhosis, hepatitis B and C, AIDS Substance abuse 18 years in penitentiary for 9 10 robberies Post traumatic stress Physical and emotional abuse by mother and brothers Worked as a prostitute in Las Vegas at 15 years of age Admitted to TCID June 15, 2011 for treatment of PTB, non cavitary pan susceptible under court order 40 20

21 Complications During Hospitalization Patient became increasingly agitated over time with inpatient treatment Refused to talk to psychiatrist Refused Seroquel, but took all TB medications Became increasingly combative, violent, and disruptive with other patients and staff Refused to sleep for four days and discussed escape plans 41 Escalating Aggressive Behavior Hit walls, destroyed four glass monitors and six alcohol dispensers Threatened and cursed staff and patients Pushed staff members and slapped patients Everyone was horrified Patient jumped from the second floor (about 15 ft) Patient ran away, but security caught him 21

22 Diagnosis and Management Bipolar, antisocial and borderline personality disorders, uncontrolled Patient was sent to mental hospital for 2 weeks Required physical restraints at Psych Hospital, IM medication was given Returned to TCID after 2 weeks Wrote an apology letter Was sorry for his bad behavior Behavior was appropriate and respectful Took his TB and psychotropic medication 43 Psychotherapy Treatment Stress and anger management skills No specific medications Can treat associate symptoms Mood stabilizers Antidepressants Anti anxiety Antipsychotic 4 22

23 Conclusions Mental illness is very prevalent amongst patients with TB and visa versa Failure to diagnose and treat mental illness in TB patients leads to poor adherence and TB treatment failure Mental illness leads to unemployment, substance abuse, homelessness HIV and TB Be aware of drug drug interactions between rifampin and psychotropic medications TB can cause depression and as providers we can help patients by promoting a supportive environment and treating them with compassion and respect 45 23

24 Share stories 24