Utilizing Mental Health Assessments to Improve TB Outcomes

 

 

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Case History

A 48 year old Caucasian male was diagnosed with pulmonary tuberculosis in May 2006. The patient’s initial isolate was resistant to isoniazid, ethionamide, levofloxacin, ofloxacin, and moxifloxacin. The patient had a history of head injuries and a seizure disorder with reports of personality changes present since 1999. Patient was HIV and Hepatitis C positive. Previous history also included cocaine and alcohol dependence with IV drug use.

TB treatment was initiated, but complicated by elevated liver enzymes and multiple drug-drug interactions. A psychiatric evaluation was scheduled; however for unknown reasons patient did not follow through. The patient’s medications included Xanax 0.5 mg orally three times daily and Trazadone 150 mg orally as needed at bedtime as prescribed by his primary care physician. During TB treatment, the patient continued to drink alcohol when depressed causing liver enzymes to continue on an upward trend. TB medications were discontinued January 1, 2007 when liver enzymes were noted to be 8 times the upper limit of normal. At this time the patient was admitted for further evaluation and care.

Upon admission, the patient described himself as anxious, depressed, and as having severe mood swings with long periods of insomnia. A mental status evaluation revealed a cooperative, well-groomed individual with noticeably pressured speech, flight of ideas, and anxiety. After the complete psychiatric evaluation the patient was diagnosed with bipolar disorder and recommended to discontinue Trazadone and Xanax, noting the Trazadone may contribute to manic episodes. Consequently, Zyprexa was initiated as a mood stabilizer.

After the initiation of the Zyprexa, the patient appeared less anxious, happier, and with normalization of speech and thought processes. A weight gain of 12 lbs in six weeks and a good adherence to TB medications was also noted. No problems with alcohol or substance abuse were reported.

Background

Researchers note that there are many social and behavioral determinants involved in tuberculosis transmission, identification, and treatment success (1). Factors such as mental illness place individuals at high risk for treatment failure and poor adherence.

A multidisciplinary approach to care is the most effective strategy when caring for patients with co-morbidities including tuberculosis. Sharing patient information becomes a crucial factor in the provision of effective health care; especially at it relates to a patient’s TB treatment regimen and follow up care (1). Determination of the patient’s mental status as part of the initial evaluation to identify barriers to treatment leads to improved treatment outcomes. Measures for addressing co-existent mental health issues should be part of the patient’s case management plan.

An effective assessment tool, “The Mental Status Exam” or “MSE” is an examination of a patient’s mental status designed to test the cognitive ability, appearance, emotional mood, speech and thought patterns of an individual. The most commonly used test of cognitive functioning is the Folstein Mini-Mental Status Examination (MMSE), developed in 1975 (2). The purpose of a mental status examination is to assess the presence and extent of a person's mental impairment. The cognitive functions that are measured during the MSE include the person's sense of time, place, and personal identity; memory; speech; general intellectual level; mathematical ability; insight or judgment; and reasoning or problem-solving ability. The MMSE of Folstein evaluates five areas of mental status, namely, orientation, registration, attention and calculation, recall and language (2). All TB patients require an adequate mental status assessment before starting anti-tuberculosis therapy. Failure to properly diagnose and treat mental health issues prior to initiating TB therapy are associated with poor treatment outcomes.

Teaching Points

A complete MSE is more comprehensive and evaluates the following ten areas of functioning:

  • Appearance: The examiner notes the person's age, race, sex, civil status, and overall appearance. These features are significant because poor personal hygiene or grooming may reflect a loss of interest in self-care or physical inability to bathe or dress oneself.
  • Movement and behavior: The examiner observes the person's gait (manner of walking), posture, coordination, eye contact, facial expressions, and similar behaviors. Problems with walking or coordination may reflect a disorder of the central nervous system.
  • Affect: Affect refers to a person's outwardly observable emotional reactions. It may include either a lack of emotional response to an event or an overreaction.
  • Mood. Mood refers to the underlying emotional "atmosphere" or tone of the person's answers.
  • Speech: The examiner evaluates the volume of the person's voice, the rate or speed of speech, the length of answers to questions, the appropriateness and clarity of the answers, and similar characteristics.
  • Thought content: The examiner assesses what the patient is saying for indications of hallucinations, delusions, obsessions, symptoms of dissociation, or thoughts of suicide. Dissociation refers to the splitting-off of certain memories or mental processes from conscious awareness. Dissociative symptoms include feelings of unreality, depersonalization, and confusion about one's identity.
  • Thought process: Thought process refers to the logical connections between thoughts and their relevance to the main thread of conversation. Irrelevant detail, repeated words and phrases, interrupted thinking (thought blocking), and loose, illogical connections between thoughts, may be signs of a thought disorder.
  • Cognition: Cognition refers to the act or condition of knowing. The evaluation assesses the person's orientation (ability to locate himself or herself) with regard to time, place, and personal identity; long- and short-term memory; ability to perform simple arithmetic (counting backward by threes or sevens); general intellectual level or fund of knowledge (identifying the last five Presidents, or similar questions); ability to think abstractly (explaining a proverb); ability to name specified objects and read or write complete sentences; ability to understand and perform a task (showing the examiner how to combone's hair or throw a ball); ability to draw a simple map or copy a design or geometrical figure; ability to distinguish between right and left.
  • Judgment: The examiner asks the person what he or she would do about a common sense problem, such as running out of a prescription medication.
  • Insight: Insight refers to a person's ability to recognize a problem and understand its nature and severity.
  • Conditions such as mental illness place individuals at high risk fortreatment failure and poor adherence (2).
  • Measures for addressing mental health issues should be a part of the TB patient’s case management plan.
  • Ineffective mental health diagnosis and treatment is associated with poor treatment outcomes.
  • A multidisciplinary approach to care is an effective component when caring for patients with multiple co-morbidities including TB.

Footnotes

  1. Centers for Disease Control and Prevention. Tuberculosis Behavioral and Social Science Research Forum: Planting the Seeds for Future Research. Proceedings of the Tuberculosis Behavioral and Social Science Research Forum; December 10–11, 2003; Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2005.
  2. Frey, Rebecca, PhD. Gale Encyclopedia of Medicine. Gale Group, 2002.

Contributor: Adrianna Vasquez, MD
Researched and written by: Alisha Blair, LVN; Catalina Navarro, RN, BSN; Debbie Onofre, RN, BSN, Heartland National TB Center

TBeat :: Vol 4 :: Issue 1