Intern Emerg Med DOI 10.1007/s11739-014-1175-3
EM - ORIGINAL
Mental disorders and HIV infection in the emergency department: epidemiology and gender differences Giada Melis • Giorgio Pia • Ilenia Piras Massimo Tusconi
•
Received: 2 November 2014 / Accepted: 5 December 2014 Ó SIMI 2014
Abstract The management of patients with HIV infection who have comorbidity with psychiatric disorders, is a problem that is encountered relatively frequently in Emergency Departments. This retrospective study aims to evaluate the characteristics of HIV-infected patients who have been admitted for mental disorders and other conditions to an Emergency Department (ED) of Sardinia, Italy, in 2013. Regarding the associated psychiatric condition (25.5 % of total sample) 46.3 % had mood disorders, 38.9 % psychotic disorders and 14.8 % anxiety disorders, with no significant gender differences (p = 0.329). The analysis of the sample showed drug abuse in 29.2 %. A concomitant infection with HBV or HCV was found in the history of almost half of the patients. Only in 24.5 % of cases was there a drug treatment in administered urgently, and an admission to hospital was necessary in 34.3 % of the total sample of patients. Among the admissions, 70.4 % were admitted to a department of infectious diseases, but of these, only 54.4 % had at the admission to the ED signs of acute infection. The management of those who had gained access to emergency services required not only the management of acute disease, but also consideration of which would be the most appropriate department to solve the G. Melis Ph.D Training Program in Physiopathology, University of Sassari, Sassari, Italy G. Pia I. Piras Emergency Department Holy Trinity Hospital ASL Cagliari, Cagliari, Italy M. Tusconi (&) Department of Public Health, Clinical and Molecular Medicine - Section of Psychiatry, University of Cagliari, Cagliari, Italy e-mail: [email protected]
main problem (infection, fever, agitation, decompensated cirrhosis). Poor patient compliance often makes it difficult to manage, as the analysis of the data shows, a relevant percentage of patients appeared to leave before completion. Keywords HIV Psychiatry Emergency Urgency Comorbidity Compliance
Introduction The management of patients with HIV infection who have comorbidity with psychiatric disorders, is a problem that is encountered relatively frequently in the ED. This retrospective study aims to evaluate the characteristics of HIVinfected patients who have been admitted to an ED in Sardinia, Italy, in 2013, for mental disorders and other conditions. Persistent and progressive changes in emotional and cognitive functions can be caused by viral infections. Behavior can be altered by the viral-induced disequilibrium in neuronal network functioning, and can potentially accentuate or even precipitate a psychiatric condition in the context of an emotional disorder. Scientific literature indicates that the biologic mediators of psychiatric illnesses and those of HIV-related neuropathogenesis can target the same brain structures, receptor systems and neurocircuitry in the central nervous system [1]. Emergency departments are often the first admission point for patients with HIV infection. State of agitation or other mental disorders may be the main initial presentations or an important concomitant factor for this cohort of patients. In this setting, it is necessary for there to be team work and a collaboration of emergency physician, psychiatrist, psychologist, nurse and other professionals. This cooperation is necessitated by the complexity of HIV infection, the associated psychiatric
123
Intern Emerg Med
complications and the frequent presence of substance abuse, and is needed for the successful screening of patients and for providing careful and rational treatment [2]. Nevertheless, studies provide evidence to the high frequency with which medical disorders may exacerbate or cause psychiatric symptoms or mental disorders. The ED may become involved because of psychological factors related to the HIV infection or in the process of proving such a diagnosis. AIDS patients can face emotive issues brought on by the medical illness, the prospect of death, and the reactions of other persons. Many of those at risk for HIV infection have already suffered prejudice, and the addition of such a diagnosis frequently precipitates crises related to job loss, social ostracism, and difficulties obtaining medical services. In the early stages of this medical condition, during adaptation to such a serious illness, the large majority of patients show psychiatric symptoms, such as adjustment disorder or depression [3]. Knowledge about the characteristics of such patients coming to the ED is fundamental for better understanding of their clinical conditions, and to improve service delivery in this setting. HIV-positive patients face multiple issues in coping with their illness, often needing psychiatric and emergency care [4].
patients without any urgency. On the basis of the color, the urgency of treatment was determined. We included in the sample patients of all ages who were admitted to the ED who had acute intoxications from psychopharmacological medications, alcohol and drugs of abuse, such as cocaine or heroin. According to Italian laws, due to the strictures of the laws for the protection of privacy, an evaluation via urine test can be carried out only in case of a specific request from the Magistracy, and with the patient’s consent if responsive, or, in case of unconsciousness, for diagnostic purposes only; in all other cases the assessment must mandatorily be carried out with the medical history alone. We also evaluated the patients for comorbidity and demographic characteristics. The level of statistical significance was placed to a value of ‘‘p’’ equal to or less than 0.05 for two-tailed hypothesis (p B 0.05). It has been decided to compare nominal data by the use of crosstabs, based on the evaluation of the Pearson v2 test (Chi square) and Fisher’s Exact test to adapt statistical analysis to the sample size; data expressed as continuous variables were instead treated using the Student’s ‘‘t’’ test for independent samples. The results obtained on the basis of the analysis of the sample have been reported with the aid of tables and discussed by comparison with the actual available literature. Statistical analyses were done using IBM SPSSÒ 22.0 [6].
Methods The sample was selected at triage by choosing as the main problem at entrance, a state of agitation or acute intoxication (n = 1245), or other symptoms or disorders not defined at the time of access to the ED (n = 12,125). From an initial sample of 13,370 patients, representing 38.8 % of total visits to the ED (n = 34,468), a cohort of 216 cases with a clinical history of HIV infection has been selected. We were not able to evaluate the incidence of previously unknown HIV among psychiatric patients, since the patients assessed in this study came to a general Emergency Department and not to a psychiatric emergency ED [4]. We decided to perform the study, on a large cohort of patients referred to a first level Emergency and Acceptance Department, in Holy Trinity Hospital, Cagliari, Italy. A consecutive sample of patients in 2013 was observed. A retrospective review of patients registered as ‘‘intoxication’’ and ‘‘state of agitation’’ as the chief complaint at triage, was defined. An expert nurse assigned a gravity and priority code at the admission to the ED, based on the clinical history of the patient. The assessment of the disease severity of patient on admission to the ED was made on the basis of guidelines of the Italian Ministry of Health [5]. Red Code was assigned to patients with a critical state of impairment of vital functions, Yellow Code for average critical state, Green Code for uncritical, and Code White to
123
Results The sample is composed of 170 men (78.7 % of total, mean age = 45.4 ± 6.8,) and 46 women (21.3 % of total, mean age = 44.5 ± 4.5) (t = 1.076, df = 108.9, p = 0.284,) these data have been confirmed by the Mann–Whitney U test for independent samples (p = 0.136). 59.3 % of patients (n = 128) were assigned a triage priority code green (m = 47.2 %, f = 12.0 %,) and 34.7 % (n = 75) a code yellow (m = 26.4 %, f = 8.3 %) (p = 0.187) (Table 1). Regarding the associated psychiatric condition (25.5 % of total sample), 46.3 % had mood disorders, 38.9 % psychotic disorders and 14.8 % anxiety disorders, with no significant gender differences (p = 0.329) (Table 2). Often there was failure to document the mental status at triage, because of a lack of compliance of the patients. The most frequent process deficiencies in the medical evaluation were in the neurological or psychiatric examination. The analysis of the sample showed that 29.2 % (m = 26.4 %, f = 2.8 %) declared drug abuse, while 70.8 % (m = 52.3 %, f = 18.5 %) reported no drugs (p = 0.007) (Table 3). A comorbidity infection with HBV or HCV was found in the history in 54.6 % (m = 44.9 %, f = 9.7 %) of patients (Table 4). Only 24.5 % (n = 53) was there administered any drug treatment in urgency (Pre-Hospital/
Intern Emerg Med Table 1 Triage code assignment
Triage
Male (n, %)
Female (n, %)
Tot (n, %)
Triage. Code White
9 (4.2)
–
9 (4.2)
Triage. Code Green
102 (47.2)
26 (12.0)
128 (59.2)
Triage. Code Yellow
57 (26.4)
18 (8.3) 75 (34.8)
Triage. Code Red
2 (0.9)
2 (0.9)
4 (1.8)
Total
170 (78.7)
46 (21.3)
216 (100.0 %)
ED) and an admission to hospital was necessary in 34.3 % of the total. About a third of the cohort (37.5 %, n = 81) were admitted to the hospital. Regarding the disposition of these patients, in most cases patients were admitted to medical or surgery units, while only a relatively small percentage were admitted to departments of Psychiatry. 70.4 % (n = 57) of the patients were admitted to an Infectious Diseases Department, of these, 78.9 % (n = 45) were men and 21.1 % (n = 12) women.; Only 54.4 % had at time of admission to the Emergency Department signs of acute infection, such as fever, pneumonia, and other clinical conditions. 16.0 % (n = 13) were hospitalized in Psychiatry, with equal proportions between men and women. 2.5 % were admitted to Internal Medicine, 1.2 % to Gastroenterology, 1.2 % to Cardiology, 1.2 % to Neurosurgery, 1.2 % to Emergency Surgery, 1.2 % to Maxillofacial Surgery, 1.2 % to Geriatrics, and 2.5 % were held in the ED in the (Short Intensive Observation Unit of the Emergency Department) (p = 0.114) (Table 5). The poor patient compliance often makes it difficult to manage, as the analysis of the data shows, so that 16.2 % of patients (n = 35) appeared to be gone from the emergency room before physical examination or have completed the expected diagnostic process.
Discussion The limitations of this study are first due to its nature as a retrospective study, and second, the setting of the observation is not ideal, because of comorbidity with emergency condition. There is a high prevalence of substance abuse and psychiatric disorders among HIV-infected individuals. Table 2 Comorbidities between HIV and mental disorders
Comorbidities
Anxiety disorders Mood disorders Psychotic disorders Total
Male (n, %)
5 (9.3)
v2 test
df
p value
4.803
3
0.187
Importantly, drug and alcohol-use disorders are frequently comorbid with mental disorders as well as depression, anxiety and other psychiatric disorders. Not only do these disorders increase the risk of contracting HIV, but they have also been linked with decreased highly active antiretroviral therapy (HAART) utilization, compliance and virological suppression. The literature evaluating the relationship between substance abuse and HIV outcomes has mainly focused on injection drug abusers, although there has been increasing interest in alcohol, cocaine, hashish and marijuana. Similarly, the psychiatric and psychological literature has focused primarily on mood disorders, with a lesser focus on anxiety or severe mental illness as psychosis. To date, there is little literature evaluating the association between co-occurring HIV, substance abuse and mental illness on HAART uptake, drug compliance and virological suppression. Interventions to improve compliance in these populations have demonstrated a varied efficacy [7]. Nevertheless, the HIV infection prevalence rate in psychiatric EDs is comparable to that in outpatient Psychiatry. In addition to human immunodeficiency virus type 1 (HIV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV) are major sources of public health burden. Several studies show the percentage of comorbidity between these viral infections. HBV, HCV, and HIV-1 share models of transmission, and are relatively prevalent among certain population groups, as injective drug users [8]. Drug use, especially the injection of drugs, has been associated with many of the most severe worldwide HIV epidemics. HIV-infected drug users have increased the prevalence of medical and psychiatric diseases that result in increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. The Female (n, %)
3 (5.6)
Tot (n, %)
v2 test
df
p value
2.224
2
0.329
8 (14.8)
9 (16.7)
16 (29.6)
25 (46.3)
11 (20.4) 25 (46.3)
10 (18.5) 29 (53.7)
21 (38.9) 54 (100.0 %)
123
Intern Emerg Med Table 3 Drugs of abuse
Substance
Male (n, %)
Drugs of abuse
Table 4 Comorbidities between HIV and hepatitis
57 (26.4)
Tot (n, %)
6 (2.8)
113 (52.3)
40 (18.5)
153 (70.8)
Total
170 (78.7)
46 (21.3)
216 (100.0 %)
Hepatitis
Male (n, %)
Female (n, %)
HBV or HCV positive
97 (44.9)
21 (9.7)
HBV or HCV negative
73 (33.8)
25 (11.6)
170 (78.7)
46 (21.3)
range and number of these comorbid disorders complicate treatment and diagnosis, resulting in several issues in providing comprehensive care. HIV-infected drug abusers accessing antiretroviral therapy (ART) have worse clinical outcomes than people living with HIV/AIDS who do not use any drugs. Medical and psychiatric comorbidities may complicate care and must be simultaneously addressed to achieve similar health outcome [9]. HIV patients show frequent rehospitalization and lack of compliance with treatments. Several studies show a highly significant correlation between poor compliance with medication and frequent rehospitalization. Compared with the general psychiatric patient population frequently hospitalized, these patients are younger and with a chronic psychiatric illness [10]. Research recently has found that HIV may be an independent risk factor for many medical illnesses including chronic obstructive pulmonary disease. After adjusting for other known risk factors, including age and smoking, it has been demonstrated that HIV-positive
v2 test
df
p value
7.354
1
0.007
63 (29.2)
No abuse
Total
Table 5 Diagnosis at the admission
Female (n, %)
Tot (n, %)
df
p value
1.901
1
0.168
118 (54.6) 98 (45.4) 216 (100.0 %)
patients may be 50–60 % more likely to develop clinical conditions [11]. Psychological comorbidity is associated with noncompliance with antiretroviral medication. It has not yet been clearly demonstrated whether treatment of identified psychological morbidity can lead to improved antiretroviral medication adherence and to a better medical outcome [12]. Patients with concomitant mental disorders generally have been found to have worse prognoses and to be more difficult to treat than those with diagnoses of either a substance abuse or mental disorder [13, 14]. HIV patients appear to have poor compliance with their antiviral treatments; all psychotic patients seem to have poor compliance with antipsychotic therapy. We refer in this case to patients who have both conditions, and thus appear to have an even worse compliance; in fact, the simultaneous presence of both conditions provides a worsening not equal to the sum of difficulties, but with a quadratic reduction. Patients often leave before completion at a time when they are perceived as medical patients and not yet deemed to have psychosis.
Admissions
Male (n, %)
Female (n, %)
Tot (n, %)
Infectious diseases
45 (55.6)
12 (14.8)
57 (70.4)
Psychiatry
7 (8.6)
6 (7.4)
13 (16.0)
Internal medicine
2 (2.5)
–
2 (2.5)
Gastroenterology
1 (1.2)
–
1 (1.2)
Cardiology
v2 test
–
1 (1.2)
1 (1.2)
Neurosurgery
1 (1.2)
–
1 (1.2)
Emergency surgery
1 (1.2)
–
1 (1.2)
Geriatrics
1 (1.2)
–
1 (1.2)
Maxillofacial surgery
1 (1.2)
–
1 (1.2)
SIOU of the ED
1 (1.2)
1 (1.2)
59 (72.8)
22 (27.2)
2 (2.5)
(Short intensive observation Unit of the Emergency Department) Total
123
81 (100.0 %)
v2 test
df p value
14.255
9
0.114
Intern Emerg Med
In Sardinia, psychiatric patients are usually managed with an integrated system that includes a synergy of mental health centers, which operate with outpatients, EDs and psychiatric units. In Italy, since 1978, there are no more long-term care units for psychiatric patients (Italian Laws, Law May 13, 1978, n. 180, ‘‘Law Basaglia’’) [15]; due to the limitations of the resources available to hospitals often there is no possibility for all psychiatric patients to be admitted to the appropriate department, and therefore other units are used to admit them. Based on the data obtained it could be considered to strengthen the psychiatric units, so that if there are minor medical problems, they can be managed at the psychiatric services by internists on staff there, but if they have major medical problems, they will be admitted to a medical unit, almost universally to the medical service, unless their major medical problem is trauma or surgical. A psychiatrist will consult with these services. The management of those accessing emergency services requires not only the management of acute disease, but also considering the most appropriate department to solve the main problem (infection, fever, agitation, decompensated cirrhosis). In addition to higher mortality, the hospitalization costs of these kinds of patients are also substantially higher. More precise description of HIVpositive patients visiting psychiatric EDs may help elucidate the needs of this population and help plan for improvements in care in this setting. Based on this observational cross-sectional study, there should be a longitudinal study carried out with a sample standardized for age, gender, and psychiatric comorbidity to assess what is the recurrence rate of psychopathology in patients with HIV infection. The clinical data in fact suggest frequent admissions to ED of these patients, and that a numerical estimate could better direct any measures concerning the management of efficient use of hospital resources. Acknowledgments The authors thank all physicians and nurses of the Emergency Department for their contributions to this study. Conflict of interest
The authors declare no conflicts of interest.
Ethical standards All human and animal studies have been approved by the appropriate ethics committee and have, therefore,
been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
References 1. Kopnisky KL, Bao J, Lin YW (2007) Neurobiology of HIV, psychiatric and substance abuse comorbidity research: workshop report. Brain Behav Immun 21(4):428–441 2. Lyketsos CG, Fishman M, Treisman G (1995) Psychiatric issues and emergencies in HIV infection. Emerg Med Clin N Am 13(1):163–177 3. Ellison JM, Hughes DH, White KA (1989) An emergency psychiatry update. Psychiatric Serv 40(3):250–260 4. Bennett WM, Joesch J, Mazur M, Roy-Byrne P (2009) Characteristics of HIV-positive patients treated in a psychiatric emergency department. Psychiatric Serv 60(3):398–401 5. Italian Minister of Health. Accordo tra il Ministro della salute, le Regioni e le Province autonome: ‘‘Triage intraospedaliero (valutazione gravita` all’ingresso) e chirurgia della mano e microchirurgia nel sistema dell’emergenza-urgenza sanitaria’’, 2001, October, 25 (G. U. N. 285, 2001, December, 7th) 6. SPSS, Inc., Chicago, IL, USA 7. Chander G, Himelhoch S, Moore RD (2006) Substance abuse and psychiatric disorders in HIV positive patients. Drugs 66(6):769–789 8. Kelen GD, Green GB, Purcell RH, Chan DW, Qaqish BF, Sivertson KT, Quinn TC (1992) Hepatitis B and hepatitis C in emergency department patients. N Engl J Med 326(21): 1399–1404 9. Altice FL, Kamarulzaman A, Soriano VV, Schechter M, Friedland GH (2010) Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet 376(9738):367–387 10. Green JH (1988) Frequent rehospitalization and noncompliance with treatment. Hosp Community Psychiatry 39(9):963 11. Venkat A, Piontkowsky DM, Cooney RR, Srivastava AK, Suares GA, Heidelberger CP (2008) Care of the HIV-positive patient in the emergency department in the era of highly active antiretroviral therapy. Ann Emerg Med 52(3):274–285 12. Sternhell PS, Corr MJ (2002) Psychiatric morbidity and adherence to antiretroviral medication in patients with HIV/AIDS. Aust N Z J Psychiatry 36(4):528–533 13. Dausey DJ, Desai RA (2003) Psychiatric comorbidity and the prevalence of HIV infection in a sample of patients in treatment for substance abuse. J Nerv Ment Dis 191(1):10–17 14. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (1995) Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52(12):1048–1060 15. Italian Laws. Legge 13 maggio 1978, n. 180, ‘‘Legge Basaglia’’
123
EM - ORIGINAL
Mental disorders and HIV infection in the emergency department: epidemiology and gender differences Giada Melis • Giorgio Pia • Ilenia Piras Massimo Tusconi
•
Received: 2 November 2014 / Accepted: 5 December 2014 Ó SIMI 2014
Abstract The management of patients with HIV infection who have comorbidity with psychiatric disorders, is a problem that is encountered relatively frequently in Emergency Departments. This retrospective study aims to evaluate the characteristics of HIV-infected patients who have been admitted for mental disorders and other conditions to an Emergency Department (ED) of Sardinia, Italy, in 2013. Regarding the associated psychiatric condition (25.5 % of total sample) 46.3 % had mood disorders, 38.9 % psychotic disorders and 14.8 % anxiety disorders, with no significant gender differences (p = 0.329). The analysis of the sample showed drug abuse in 29.2 %. A concomitant infection with HBV or HCV was found in the history of almost half of the patients. Only in 24.5 % of cases was there a drug treatment in administered urgently, and an admission to hospital was necessary in 34.3 % of the total sample of patients. Among the admissions, 70.4 % were admitted to a department of infectious diseases, but of these, only 54.4 % had at the admission to the ED signs of acute infection. The management of those who had gained access to emergency services required not only the management of acute disease, but also consideration of which would be the most appropriate department to solve the G. Melis Ph.D Training Program in Physiopathology, University of Sassari, Sassari, Italy G. Pia I. Piras Emergency Department Holy Trinity Hospital ASL Cagliari, Cagliari, Italy M. Tusconi (&) Department of Public Health, Clinical and Molecular Medicine - Section of Psychiatry, University of Cagliari, Cagliari, Italy e-mail: [email protected]
main problem (infection, fever, agitation, decompensated cirrhosis). Poor patient compliance often makes it difficult to manage, as the analysis of the data shows, a relevant percentage of patients appeared to leave before completion. Keywords HIV Psychiatry Emergency Urgency Comorbidity Compliance
Introduction The management of patients with HIV infection who have comorbidity with psychiatric disorders, is a problem that is encountered relatively frequently in the ED. This retrospective study aims to evaluate the characteristics of HIVinfected patients who have been admitted to an ED in Sardinia, Italy, in 2013, for mental disorders and other conditions. Persistent and progressive changes in emotional and cognitive functions can be caused by viral infections. Behavior can be altered by the viral-induced disequilibrium in neuronal network functioning, and can potentially accentuate or even precipitate a psychiatric condition in the context of an emotional disorder. Scientific literature indicates that the biologic mediators of psychiatric illnesses and those of HIV-related neuropathogenesis can target the same brain structures, receptor systems and neurocircuitry in the central nervous system [1]. Emergency departments are often the first admission point for patients with HIV infection. State of agitation or other mental disorders may be the main initial presentations or an important concomitant factor for this cohort of patients. In this setting, it is necessary for there to be team work and a collaboration of emergency physician, psychiatrist, psychologist, nurse and other professionals. This cooperation is necessitated by the complexity of HIV infection, the associated psychiatric
123
Intern Emerg Med
complications and the frequent presence of substance abuse, and is needed for the successful screening of patients and for providing careful and rational treatment [2]. Nevertheless, studies provide evidence to the high frequency with which medical disorders may exacerbate or cause psychiatric symptoms or mental disorders. The ED may become involved because of psychological factors related to the HIV infection or in the process of proving such a diagnosis. AIDS patients can face emotive issues brought on by the medical illness, the prospect of death, and the reactions of other persons. Many of those at risk for HIV infection have already suffered prejudice, and the addition of such a diagnosis frequently precipitates crises related to job loss, social ostracism, and difficulties obtaining medical services. In the early stages of this medical condition, during adaptation to such a serious illness, the large majority of patients show psychiatric symptoms, such as adjustment disorder or depression [3]. Knowledge about the characteristics of such patients coming to the ED is fundamental for better understanding of their clinical conditions, and to improve service delivery in this setting. HIV-positive patients face multiple issues in coping with their illness, often needing psychiatric and emergency care [4].
patients without any urgency. On the basis of the color, the urgency of treatment was determined. We included in the sample patients of all ages who were admitted to the ED who had acute intoxications from psychopharmacological medications, alcohol and drugs of abuse, such as cocaine or heroin. According to Italian laws, due to the strictures of the laws for the protection of privacy, an evaluation via urine test can be carried out only in case of a specific request from the Magistracy, and with the patient’s consent if responsive, or, in case of unconsciousness, for diagnostic purposes only; in all other cases the assessment must mandatorily be carried out with the medical history alone. We also evaluated the patients for comorbidity and demographic characteristics. The level of statistical significance was placed to a value of ‘‘p’’ equal to or less than 0.05 for two-tailed hypothesis (p B 0.05). It has been decided to compare nominal data by the use of crosstabs, based on the evaluation of the Pearson v2 test (Chi square) and Fisher’s Exact test to adapt statistical analysis to the sample size; data expressed as continuous variables were instead treated using the Student’s ‘‘t’’ test for independent samples. The results obtained on the basis of the analysis of the sample have been reported with the aid of tables and discussed by comparison with the actual available literature. Statistical analyses were done using IBM SPSSÒ 22.0 [6].
Methods The sample was selected at triage by choosing as the main problem at entrance, a state of agitation or acute intoxication (n = 1245), or other symptoms or disorders not defined at the time of access to the ED (n = 12,125). From an initial sample of 13,370 patients, representing 38.8 % of total visits to the ED (n = 34,468), a cohort of 216 cases with a clinical history of HIV infection has been selected. We were not able to evaluate the incidence of previously unknown HIV among psychiatric patients, since the patients assessed in this study came to a general Emergency Department and not to a psychiatric emergency ED [4]. We decided to perform the study, on a large cohort of patients referred to a first level Emergency and Acceptance Department, in Holy Trinity Hospital, Cagliari, Italy. A consecutive sample of patients in 2013 was observed. A retrospective review of patients registered as ‘‘intoxication’’ and ‘‘state of agitation’’ as the chief complaint at triage, was defined. An expert nurse assigned a gravity and priority code at the admission to the ED, based on the clinical history of the patient. The assessment of the disease severity of patient on admission to the ED was made on the basis of guidelines of the Italian Ministry of Health [5]. Red Code was assigned to patients with a critical state of impairment of vital functions, Yellow Code for average critical state, Green Code for uncritical, and Code White to
123
Results The sample is composed of 170 men (78.7 % of total, mean age = 45.4 ± 6.8,) and 46 women (21.3 % of total, mean age = 44.5 ± 4.5) (t = 1.076, df = 108.9, p = 0.284,) these data have been confirmed by the Mann–Whitney U test for independent samples (p = 0.136). 59.3 % of patients (n = 128) were assigned a triage priority code green (m = 47.2 %, f = 12.0 %,) and 34.7 % (n = 75) a code yellow (m = 26.4 %, f = 8.3 %) (p = 0.187) (Table 1). Regarding the associated psychiatric condition (25.5 % of total sample), 46.3 % had mood disorders, 38.9 % psychotic disorders and 14.8 % anxiety disorders, with no significant gender differences (p = 0.329) (Table 2). Often there was failure to document the mental status at triage, because of a lack of compliance of the patients. The most frequent process deficiencies in the medical evaluation were in the neurological or psychiatric examination. The analysis of the sample showed that 29.2 % (m = 26.4 %, f = 2.8 %) declared drug abuse, while 70.8 % (m = 52.3 %, f = 18.5 %) reported no drugs (p = 0.007) (Table 3). A comorbidity infection with HBV or HCV was found in the history in 54.6 % (m = 44.9 %, f = 9.7 %) of patients (Table 4). Only 24.5 % (n = 53) was there administered any drug treatment in urgency (Pre-Hospital/
Intern Emerg Med Table 1 Triage code assignment
Triage
Male (n, %)
Female (n, %)
Tot (n, %)
Triage. Code White
9 (4.2)
–
9 (4.2)
Triage. Code Green
102 (47.2)
26 (12.0)
128 (59.2)
Triage. Code Yellow
57 (26.4)
18 (8.3) 75 (34.8)
Triage. Code Red
2 (0.9)
2 (0.9)
4 (1.8)
Total
170 (78.7)
46 (21.3)
216 (100.0 %)
ED) and an admission to hospital was necessary in 34.3 % of the total. About a third of the cohort (37.5 %, n = 81) were admitted to the hospital. Regarding the disposition of these patients, in most cases patients were admitted to medical or surgery units, while only a relatively small percentage were admitted to departments of Psychiatry. 70.4 % (n = 57) of the patients were admitted to an Infectious Diseases Department, of these, 78.9 % (n = 45) were men and 21.1 % (n = 12) women.; Only 54.4 % had at time of admission to the Emergency Department signs of acute infection, such as fever, pneumonia, and other clinical conditions. 16.0 % (n = 13) were hospitalized in Psychiatry, with equal proportions between men and women. 2.5 % were admitted to Internal Medicine, 1.2 % to Gastroenterology, 1.2 % to Cardiology, 1.2 % to Neurosurgery, 1.2 % to Emergency Surgery, 1.2 % to Maxillofacial Surgery, 1.2 % to Geriatrics, and 2.5 % were held in the ED in the (Short Intensive Observation Unit of the Emergency Department) (p = 0.114) (Table 5). The poor patient compliance often makes it difficult to manage, as the analysis of the data shows, so that 16.2 % of patients (n = 35) appeared to be gone from the emergency room before physical examination or have completed the expected diagnostic process.
Discussion The limitations of this study are first due to its nature as a retrospective study, and second, the setting of the observation is not ideal, because of comorbidity with emergency condition. There is a high prevalence of substance abuse and psychiatric disorders among HIV-infected individuals. Table 2 Comorbidities between HIV and mental disorders
Comorbidities
Anxiety disorders Mood disorders Psychotic disorders Total
Male (n, %)
5 (9.3)
v2 test
df
p value
4.803
3
0.187
Importantly, drug and alcohol-use disorders are frequently comorbid with mental disorders as well as depression, anxiety and other psychiatric disorders. Not only do these disorders increase the risk of contracting HIV, but they have also been linked with decreased highly active antiretroviral therapy (HAART) utilization, compliance and virological suppression. The literature evaluating the relationship between substance abuse and HIV outcomes has mainly focused on injection drug abusers, although there has been increasing interest in alcohol, cocaine, hashish and marijuana. Similarly, the psychiatric and psychological literature has focused primarily on mood disorders, with a lesser focus on anxiety or severe mental illness as psychosis. To date, there is little literature evaluating the association between co-occurring HIV, substance abuse and mental illness on HAART uptake, drug compliance and virological suppression. Interventions to improve compliance in these populations have demonstrated a varied efficacy [7]. Nevertheless, the HIV infection prevalence rate in psychiatric EDs is comparable to that in outpatient Psychiatry. In addition to human immunodeficiency virus type 1 (HIV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV) are major sources of public health burden. Several studies show the percentage of comorbidity between these viral infections. HBV, HCV, and HIV-1 share models of transmission, and are relatively prevalent among certain population groups, as injective drug users [8]. Drug use, especially the injection of drugs, has been associated with many of the most severe worldwide HIV epidemics. HIV-infected drug users have increased the prevalence of medical and psychiatric diseases that result in increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. The Female (n, %)
3 (5.6)
Tot (n, %)
v2 test
df
p value
2.224
2
0.329
8 (14.8)
9 (16.7)
16 (29.6)
25 (46.3)
11 (20.4) 25 (46.3)
10 (18.5) 29 (53.7)
21 (38.9) 54 (100.0 %)
123
Intern Emerg Med Table 3 Drugs of abuse
Substance
Male (n, %)
Drugs of abuse
Table 4 Comorbidities between HIV and hepatitis
57 (26.4)
Tot (n, %)
6 (2.8)
113 (52.3)
40 (18.5)
153 (70.8)
Total
170 (78.7)
46 (21.3)
216 (100.0 %)
Hepatitis
Male (n, %)
Female (n, %)
HBV or HCV positive
97 (44.9)
21 (9.7)
HBV or HCV negative
73 (33.8)
25 (11.6)
170 (78.7)
46 (21.3)
range and number of these comorbid disorders complicate treatment and diagnosis, resulting in several issues in providing comprehensive care. HIV-infected drug abusers accessing antiretroviral therapy (ART) have worse clinical outcomes than people living with HIV/AIDS who do not use any drugs. Medical and psychiatric comorbidities may complicate care and must be simultaneously addressed to achieve similar health outcome [9]. HIV patients show frequent rehospitalization and lack of compliance with treatments. Several studies show a highly significant correlation between poor compliance with medication and frequent rehospitalization. Compared with the general psychiatric patient population frequently hospitalized, these patients are younger and with a chronic psychiatric illness [10]. Research recently has found that HIV may be an independent risk factor for many medical illnesses including chronic obstructive pulmonary disease. After adjusting for other known risk factors, including age and smoking, it has been demonstrated that HIV-positive
v2 test
df
p value
7.354
1
0.007
63 (29.2)
No abuse
Total
Table 5 Diagnosis at the admission
Female (n, %)
Tot (n, %)
df
p value
1.901
1
0.168
118 (54.6) 98 (45.4) 216 (100.0 %)
patients may be 50–60 % more likely to develop clinical conditions [11]. Psychological comorbidity is associated with noncompliance with antiretroviral medication. It has not yet been clearly demonstrated whether treatment of identified psychological morbidity can lead to improved antiretroviral medication adherence and to a better medical outcome [12]. Patients with concomitant mental disorders generally have been found to have worse prognoses and to be more difficult to treat than those with diagnoses of either a substance abuse or mental disorder [13, 14]. HIV patients appear to have poor compliance with their antiviral treatments; all psychotic patients seem to have poor compliance with antipsychotic therapy. We refer in this case to patients who have both conditions, and thus appear to have an even worse compliance; in fact, the simultaneous presence of both conditions provides a worsening not equal to the sum of difficulties, but with a quadratic reduction. Patients often leave before completion at a time when they are perceived as medical patients and not yet deemed to have psychosis.
Admissions
Male (n, %)
Female (n, %)
Tot (n, %)
Infectious diseases
45 (55.6)
12 (14.8)
57 (70.4)
Psychiatry
7 (8.6)
6 (7.4)
13 (16.0)
Internal medicine
2 (2.5)
–
2 (2.5)
Gastroenterology
1 (1.2)
–
1 (1.2)
Cardiology
v2 test
–
1 (1.2)
1 (1.2)
Neurosurgery
1 (1.2)
–
1 (1.2)
Emergency surgery
1 (1.2)
–
1 (1.2)
Geriatrics
1 (1.2)
–
1 (1.2)
Maxillofacial surgery
1 (1.2)
–
1 (1.2)
SIOU of the ED
1 (1.2)
1 (1.2)
59 (72.8)
22 (27.2)
2 (2.5)
(Short intensive observation Unit of the Emergency Department) Total
123
81 (100.0 %)
v2 test
df p value
14.255
9
0.114
Intern Emerg Med
In Sardinia, psychiatric patients are usually managed with an integrated system that includes a synergy of mental health centers, which operate with outpatients, EDs and psychiatric units. In Italy, since 1978, there are no more long-term care units for psychiatric patients (Italian Laws, Law May 13, 1978, n. 180, ‘‘Law Basaglia’’) [15]; due to the limitations of the resources available to hospitals often there is no possibility for all psychiatric patients to be admitted to the appropriate department, and therefore other units are used to admit them. Based on the data obtained it could be considered to strengthen the psychiatric units, so that if there are minor medical problems, they can be managed at the psychiatric services by internists on staff there, but if they have major medical problems, they will be admitted to a medical unit, almost universally to the medical service, unless their major medical problem is trauma or surgical. A psychiatrist will consult with these services. The management of those accessing emergency services requires not only the management of acute disease, but also considering the most appropriate department to solve the main problem (infection, fever, agitation, decompensated cirrhosis). In addition to higher mortality, the hospitalization costs of these kinds of patients are also substantially higher. More precise description of HIVpositive patients visiting psychiatric EDs may help elucidate the needs of this population and help plan for improvements in care in this setting. Based on this observational cross-sectional study, there should be a longitudinal study carried out with a sample standardized for age, gender, and psychiatric comorbidity to assess what is the recurrence rate of psychopathology in patients with HIV infection. The clinical data in fact suggest frequent admissions to ED of these patients, and that a numerical estimate could better direct any measures concerning the management of efficient use of hospital resources. Acknowledgments The authors thank all physicians and nurses of the Emergency Department for their contributions to this study. Conflict of interest
The authors declare no conflicts of interest.
Ethical standards All human and animal studies have been approved by the appropriate ethics committee and have, therefore,
been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
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