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Chapter
14
Mental Health Disorders
Linda Frank,
PhD, MSN, ACRN
Glenn J. Treisman, MD, PhD
Niccolo D. Della Penna, MD
Overview
TOP
Why is it
important to address mental health disorders in persons living with
HIV?
HIV infection
increases the risk of developing psychiatric disorders, including
depression, mania, psychosis, and substance abuse (Treisman, 1999).
For patients with preexisting mental illness, a diagnosis of HIV
can significantly impact their ability to cope with HIV disease,
adhere to treatment regimens, and take advantage of support networks
and care systems, and can result in deterioration in their quality
of life. Individuals with previous histories of mood, cognitive,
or anxiety disorders may exhibit a reemergence or exacerbation of
symptoms. As persons with HIV/AIDS live longer and the focus of
care shifts from acute to chronic, the long-term psychological impact
of HIV disease becomes more apparent.
What common
HIV-related medical conditions have psychiatric symptoms?
It
is essential for primary care providers to be aware of the need
for a comprehensive evaluation of psychiatric symptoms in persons
with HIV disease. Many psychiatric symptoms can indicate an underlying
opportunistic disease or other condition (see Table 14-1).
What are
the most common mistakes made in mental health management of HIV-infected
patients?
Primary care
providers commonly 1) under-diagnose depression, 2) under-dose antidepressant
medications, 3) neglect substance use management and treatment,
4) stigmatize patients with psychiatric disorders, and 5) assume
that psychotherapy implies a lengthy and detailed conversation.
Table
14-1. HIV-Related Conditions That Can Present
With Psychiatric Symptoms
Type of
Problem |
Opportunistic
brain infections |
Toxoplasmosis,
cryptococcal meningitis, cytomegalovirus infection, tuberculosis,
progressive multifocal leukoencephalopathy, neurosyphilis |
Opportunistic
malignancies |
Lymphoma,
Kaposi sarcoma |
Metabolic
complications |
Fever,
anemia, blood infections, hypoxia, hypotestosteronism |
Drug
toxicity |
Corticosteroids,
alpha-interferon, efavirenz (EFV) |
Substance
abuse complications |
Recreational
drugs (cocaine, alcohol, methamphetamine, hallucinogens,
nitrate inhalant, opiates).
Prescribed
drugs (benzodiazepines, opiates, psychostimulants)
|
What conditions
warrant psychiatric consultation?
Providers should
obtain psychiatric consultation in 1) major depression refractory
to medication trials, 2) bipolar disorder, 3) schizophrenia, and
4) suicidal or homicidal thoughts.
Disorders
of Attention or Cognition
TOP
What are
the characteristics of delirium in patients with HIV infection?
Delirium, which
is a state of global derangement of cerebral function, occurs more
frequently in medically ill, brain injured, or metabolically unstable
patients. The clinical presentation and the differential diagnosis
in HIV patients are the same as in HIV noninfected individuals,
with the additional possibility that delirium is HIV-related. Presentation
may vary in the presence of psychomotor agitation or retardation.
Emotional changes are common and often unpredictable, and hallucinations
and delusions are frequently seen. Electroencephalography may show
diffuse slowing of the background alpha rhythm, which resolves as
confusion clears. The syndrome has an acute or sub-acute onset and
remits fairly rapidly once the underlying cause is treated.
How do you
manage delirium in patients with HIV infection?
Non-pharmacologic
treatments include identification and removal of the underlying
cause, reorientation of the patient (calendars, clocks, view of
outside world, and active engagement with staff members), and pharmacologic
management of behavior or psychosis. Low doses of high-potency antipsychotic
agents such as haloperidol are often useful. Newer, atypical antipsychotics
are currently being used with some success, but those with more
anticholinergic activity may worsen the condition. Benzodiazepines
should be used cautiously, as they may contribute to delirium in
some patients, except in cases of alcohol or benzodiazepine withdrawal
deliria. Physical restraint should be used as little as possible
as it often worsens delirium.
How do you
diagnose and treat minor cognitive-motor disorder (MCMD)?
MCMD is a less
severe neurocognitive disorder of earlier HIV infection, and the
symptoms are often overlooked because they may be very subtle. Cognitive
and motor slowing are most prominent and are often discovered as
a result of a minor complaint, such as taking longer to read a novel,
dysfunction when performing fine motor tasks, or an increased tendency
to stumble. Diagnosis is made by the finding of 2 or more of the
following symptoms for more than a month: impaired attention and
concentration, mental slowing, impaired memory, slowed movements,
lack of coordination, and changes in personality (irritability or
emotional lability). Some patients continue to have minor problems,
while others progress to frank dementia. Antiretroviral therapy
(ART) may be of some benefit in slowing progression, but this conclusion
is confounded by a lack of understanding of factors that lead some
patients to progress while others remain static.
How do you
diagnose and treat HIV-associated dementia?
HIV-associated
dementia presents with the typical triad of symptoms seen in other
subcortical dementias-memory and psychomotor speed impairments,
depressive symptoms, and movement disorders. Initially, patients
may notice slight problems with reading, comprehension, memory,
and mathematical skills. Patients later develop global dementia,
with marked impairments in naming, language, and praxis. Clouding
of consciousness is absent, and there is no evidence of another
cause. Motor symptoms are often subtle in early stages, including
occasional stumbling while walking or running, slowing of fine repetitive
movements, and slight tremor. There may be impaired saccadic eye
movements, dysdiadochokinesia, and hyperreflexia. Apathy is also
a common early symptom, often causing noticeable withdrawal from
social activity. A frank depressive syndrome also commonly develops,
typically with irritable mood and anhedonia instead of sadness and
crying spells. Sleep disturbances are quite common, as is weight
loss. Psychosis may develop in a significant number of patients
and generally presents with paranoid beliefs, although hallucinations
may exist. In 5%-8% of patients, a syndrome known as AIDS mania
develops in addition to the HIV-associated dementia. In later stages,
there may be frontal release signs and rather severe motor symptoms,
including marked difficulty in smooth limb movements, especially
in the lower extremities.
HIV dementia
is typically seen in late stages of illness, usually in patients
who have had a CD4 count nadir of <200 cells/mm3. Certain risk
factors have been associated with eventual development of HIV dementia,
namely, higher HIV RNA viral load, lower education level, older
age, anemia, illicit drug use, and female sex. Prognosis is rather
poor, with a rapidly progressive nature, usually ending in death
within 2 years.
Standard of
care is to ensure an optimal ART regimen and treat associated symptoms
aggressively. Depression can be treated with standard antidepressants,
and in some cases methylphenidate or other stimulants may be useful
in the treatment of apathy. Safety assessments should be performed
as with any other case of dementing illness.
What is
the relationship between psychosis and HIV?
Psychosis,
including schizophrenia, contributes to behaviors that may lead
to HIV infection, including higher rates of injection drug use,
unprotected sex, multiple sex partners, trading sex for money or
other goods, and sex while intoxicated (Cournos et al, 1994). Providers
who see patients with psychosis should be sensitive to the risk
of acquiring HIV and should screen patients carefully for risk behaviors.
Accumulating
evidence suggests that HIV infection may be directly linked to the
onset of psychosis. Psychosis can be a manifestation of delirium,
affective disorders, or schizophrenia, but can it occur in the absence
of these conditions. Estimates of the prevalence of new-onset psychosis
in patients with HIV range from 0.5%-15%, which is higher than in
the general population (Kendler et al, 1996; Sewell et al, 1994).
New-onset psychosis may also be a manifestation of HIV-associated
encephalopathy. History of substance abuse also is more common among
patients with psychosis.
How do you
treat HIV-infected patients with schizophrenia?
The principles
of treatment for HIV-infected patients with schizophrenia follow
the same basic principles as for any other patient with schizophrenia,
namely, control of symptoms with medications and psychosocial support
and rehabilitation. Quite often, patients require long-term treatment
and require various antipsychotic medications to control the delusions,
hallucinations, and overall level of disorganization.
Personality
Disorders
TOP
What is
the relationship between personality disorders and HIV infection?
Personality
disorders represent extremes of normal personality characteristics
and are disabling conditions. Clinical observation suggests that
patients with personality disorders who are highly extroverted and
highly neurotic are most prone to engage in HIV risk behavior. These
individuals are preoccupied by and act upon their feelings, and
their actions tend to be unpredictable and inconsistent. Past experience
and future consequences have little salience in decisionmaking for
individuals who are ruled by feeling; the present is paramount.
Their overarching goal is to achieve immediate pleasure or removal
of pain, regardless of circumstances. Patients are more fixed upon
the reward of sex and remarkably inattentive to the STDs they may
acquire. In addition, substance abuse is more likely a comorbidity
with these patients. Injection drug use is markedly more common
because the experience is much more intense and pleasurable. Thus,
patients with personality disorders are at risk for HIV infection,
and if they are already HIV-positive they are at risk for transmitting
HIV to others. Management of patients with personality disorders
includes encouraging a focus on thoughts rather than feelings, use
of a behavioral contract, emphasis on constructive rewards, use
of relapse prevention strategies, and coordination with additional
health and psychosocial care providers.
Mood
Disorders
TOP
What are
characteristics of adjustment disorders in patients with HIV?
Adjustment
disorders are common emotional responses to HIV and often account
for the "hopeful highs" and "helpless lows"
experienced by some patients. These reactions are typically situational
and transient, but reflect significant distress in the patient.
Adjustment issues vary according to a variety of factors in addition
to stage of illness, risk factors, socieoeconomic status, level
of education, characteristics of support networks, and comorbid
psychiatric disorders. Adjustment reactions are most likely to occur
at the time of significant medical events, especially during transition
points in the illness. These conditions typically are accompanied
by less severe depression and/or anxiety than are classic mood disorders.
Treatment is usually non-pharmacologic and includes promotion of
a structured environment, reassurance, engagement of the patient
in the treatment process, close monitoring for progression of symptoms,
and supportive counseling and psychotherapy.
How do you
diagnose bipolar disorder in patients with HIV?
Bipolar disorder,
also known as manic-depressive illness, is a condition in which
patients classically alternate between extended episodes of depression
and briefer periods of hypomania or mania with increased mood, increased
energy, increased confidence, and grandiose ideas. Manic episodes
are associated with increased rates of substance abuse and impulsive
behavior, and there has been speculation that bipolar disorder may
be a risk factor for HIV infection. AIDS-related mania appears to
be specifically associated with late-stage HIV infection and is
associated with cognitive impairment and a lack of previous episodes
or family history. The history will usually reveal progressive cognitive
decline prior to the onset of mania. Irritable mood is more typical
than euphoria, and prominent psychomotor slowing may replace the
expected hyperactivity of mania, complicating the diagnosis. The
presentation is usually quite severe in its course. AIDS mania appears
to be more characteristically chronic, has few spontaneous remissions,
and readily relapses with cessation of treatment (Lyketsos et al,
1997).
How
do you treat bipolar disorder in patients with HIV?
The treatment
of mania in early-stage HIV infection is responsive to mood stabilizing
medications, particularly lithium, valproic acid, and carbamazepine.
Antipsychotic agents, particularly atypical agents, are often utilized
in the acute phase as well. These medications decrease manic symptoms
and may prevent recurrence. Treatment strategies may be somewhat
different in advanced HIV disease. AIDS mania may respond to treatment
with antipsychotics alone. In general, patients are often exquisitely
sensitive to dosage changes that might otherwise seem trivial. Few
data exist for the newer anticonvulsants such as gabapentin and
lamotrigine, and these medications should be used sparingly. The
major problem with lithium in AIDS patients has been rapid fluctuations
in blood level, even when on previously stable doses. Lithium intoxication
is not uncommon in this setting. Valproic acid has been successfully
used when titrating to usual therapeutic serum levels of 50-100
ng/dL. Hepatotoxicity may significantly limit treatment, particularly
in the setting of chronic viral hepatitis or severe hepatic Mycobacterium
avium complex infiltration. Hematopoietic abnormalities may also
occur, requiring close monitoring of white blood cell and platelet
levels. Carbamazepine may be effective but is poorly tolerated because
of sedation and potential for bone marrow suppression in combination
with antiviral medications and viral burden. Patients with late-stage
HIV are also significantly affected by toxic side effects of antipsychotic
medications, and a much lower dosage may be required than in other
settings.
How do you
diagnose major depressive disorder in patients with HIV?
Several lines
of evidence suggest that HIV is a causal factor in depression, and
that depression is a causal factor in HIV-related morbidity (Ciesla
and Roberts, 2001). Differentiating appropriate sadness from pathologic
depression may be difficult in the person infected with HIV. Psychomotor
retardation and apathy of AIDS dementia complex may be confused
with depression, but will often improve in patients who are on combination
antiretroviral treatment. Organic mood disorders may also have symptoms
similar to major depression and are responsive to antidepressant
medication.
Table 14-2. Risk Factors for Depression
- History
of prior mood disorder
- History
of substance abuse or active substance use
- Prior
suicide attempt
- History
of anxiety disorder
- Family
history of depression or suicide
- Inadequate
social support
- Nondisclosure
of HIV status
- Multiple
losses
- Advancing
illness
- Treatment
failure
|
Depression
is underrecognized, underdiagnosed, and undertreated (see Table
14-2). At the same time, it is important for providers to consider
alternative diagnostic possibilities for depressive symptomatology
(see Table 14-3).
Table
14-3. Differential Diagnosis of
Major Depression
- Nonpathologic
states of grief and mourning
- Dysthymia
- Delirium
- Dementia
- Demoralization
- Substance
intoxication
- Substance
withdrawal
- CNS
injury or infection
- Acute
medical illness
|
What
are the pharmacologic treatment options for major depression?
Pharmacotherapy
is the mainstay of treatment for major depression (see Table 14-4).
No single antidepressant has been found to be superior in treating
HIV-infected patients as a group. Patient adherence to regimens
is critical, and those who take adequate doses of antidepressants
have the best chance of improving. A general rule is to start with
low doses of any medication, titrating up to a full dose slowly,
in order to minimize early side effects that may act as obstacles
to adherence.
Table
14-4. Medications to Treat Depression in HIV Disease
nortriptyline
(Pamelor)
|
10-25
mg qhs |
50-150
mg qhs |
70-125
ng/dL |
Promotes
sleep, weight gain, decreases diarrhea |
Fluconazole,
lopinavir/ritonavir, and ritonavir increase nortriptyline levels.
|
desipramine
(Norpramin)
|
10-25
mg qhs |
50-200
mg qhs |
>125
ng/dL |
Promotes
sleep, weight gain, decreases diarrhea |
Lopinavir/ritonavir
and ritonavir increase desipramine levels. |
imipramine
(Tofranil)
|
10-25
mg qhs |
100-300
mg qhs |
>225
ng/dL |
Promotes
sleep, weight gain, decreases diarrhea |
Lopinavir/ritonavir
and ritonavir increase imipramine levels. |
amitriptyline
(Elavil)
|
10-25
mg qhs |
100-300
mg qhs |
200-250
ng/dL |
Promotes
sleep, weight gain, decreases diarrhea |
Lopinavir/ritonavir
and ritonavir increase amitriptyline levels. |
clomipramine
(Anafranil)
|
25
mg qhs |
100-200
mg qhs |
150-400
ng/dL |
Promotes
sleep, weight gain, decreases diarrhea |
Lopinavir/ritonavir
and ritonavir increase clomipramine levels. |
doxepin
(Sinequan)
|
10-25
mg qhs |
150-250
mg qhs |
100-250
ng/dL |
Promotes
sleep, weight gain, decreases diarrhea |
lopinavir/ritonavir
and ritonavir increase doxepin levels. |
fluoxetine
(Prozac)
|
10
mg qam |
20
mg qam |
unclear |
Activating,
energizing |
Amprenavir,
delavirdine, efavirenz, indinivir, lopinavir/ritonavir, nelfinavir,
ritonavir, and saquinavir increase HIV medication levels.
Nevirapine decreases fluoxetine levels. |
sertraline
(Zoloft)
|
25-50
mg qam |
50-150
mg qam |
unclear |
|
Lopinavir/ritonavir
and ritonavir increase sertraline levels. |
citalopram
(Celexa)
|
20
mg qam |
20-60
mg qam |
unclear |
|
Lopinavir/ritonavir
and ritonavir increase citalopram levels. |
paroxetine
(Paxil)
|
10
mg qhs |
20-40
mg qhs |
unclear |
Mildly
sedating |
Lopinavir/ritonavir
and ritonavir increase paroxetine levels. |
fluvoxamine
(Luvox
|
50
mg qhs |
150-250
mg qhs |
unclear |
Mildly
sedating |
Amprenavir,
delavirdine, efavirenz, indinavir, lopinavir/ritonavir, nelfinavir,
ritonavir and saquinivir increase HIV medication levels.
Nevirapine decreases fluvoxamine levels.
|
venlafaxine
(Effexor)
|
37.5
mg qam |
75-300
mg qam |
unclear |
|
Lopinavir/ritonavir
and ritonavir increase venlafaxine levels. |
mirtazepine
(Remeron)
|
7.5-15
mg qhs |
15-45
mg qhs |
unclear |
Promotes
sleep, weight gain |
|
nefazodone
(Serzone)
|
50
mg bid |
300-400
mg/d
in divided doses
|
unclear |
Mildly
sedating |
Efavirenz
and indinavir increase HIV medication levels. |
trazodone
(Desyrel)
|
50-100
mg qhs |
50-150
mg qhs for sleep
200-600 mg qhs for depression
|
unclear |
Promotes
sleep |
Lopinavir/ritonavir
and ritonavir increase trazodone levels. |
bupropion
(Wellbutrin)
|
100
mg qam |
150-400
mg/d
in divided doses
|
unclear |
Activating,
no sexual side effects |
|
The first week
of treatment usually determines whether a patient will be able to
tolerate the medication at all. Following this period, the dosage
should be increased slowly to either a typical therapeutic dose
or serum level, when appropriate. Patients should be encouraged
to wait as long as possible for the therapeutic effect, which may
take at least 6 weeks to achieve. Close monitoring for side effects
should be done at every visit, and the side effects treated whenever
possible. For example, insomnia because of selective serotonin reuptake
inhibitor (SSRI) use may respond well to low doses of trazodone.
Constipation from tricyclic antidepressants is often relieved by
increasing water and fiber intake. Sexual side effects from SSRIs
are common and may be treated with sildenafil in some, or by drug
holidays, switching to bupropion, and addition of buspirone, cyproheptadine,
or ginkgo biloba.
For patients
showing only partial response to antidepressant medications after
an adequate trial period, several other agents are often useful
for augmentation strategies. The best studied is lithium, yet its
side-effect profile often prevents use in the HIV setting. Olanzapine,
risperidone, and pindolol have also been reported to be effective
augmenting agents, as well as addition of a second antidepressant,
other mood stabilizers, trazodone, methylphenidate, benzodiazepines,
sleep deprivation, and phototherapy.
If no benefit
is gained from the primary antidepressant, even after augmentation,
a new primary agent should be chosen and similarly titrated slowly,
and augmented if necessary. There is evidence to suggest that a
response may be seen from 1 drug where none was seen from another
in the same class.
What are
the nonpharmacologic treatments for major depression?
Psychotherapy
is an integral part of the treatment of major depression. Treatment
with medication plus psychotherapy has been shown to be more effective
for patients than either modality alone. Patients often require
education about the disease nature of their depression, encouragement,
and therapeutic optimism that the treatments will work. Medical
providers who keep the concept of psychotherapy in mind will structure
their interactions with patients to slowly empower and enable the
patients to take control of their lives, thus relying on their providers
less and less.
Anxiety
Disorders
TOP
How do you
diagnose anxiety disorder in patients with HIV infection?
Anxiety disorder,
which can include generalized anxiety disorder, panic disorder,
obsessive-compulsive disorder, and post-traumatic stress disorder,
is a common response to the stressors of HIV infection at any stage.
True anxiety disorders tend to be less prevalent than depressive
disorders, particularly at later stages of HIV infection. Anxiety
is often a component of major depression, and further history should
be ascertained for patients presenting with symptoms of panic or
anxiety. Anxiety may also be due to substance use, and neurologic
and physical impairment.
What are
pharmacologic treatments for HIV-infected patients with anxiety?
Physicians
must aggressively screen for major depression in patients presenting
with anxiety symptoms, because both conditions often coexist. In
particular, anxiety is a frequent symptom of major depression. Antidepressant
medications are very effective in most cases.
In particularly
debilitating cases, however, anxiolytic medications can be used
for time-limited intervention and in low doses. Exclusion of patients
with comorbid substance abuse is essential prior to initiation of
anxiolytic medication, because of the abuse liability. Medications
with a short half-life should be very cautiously used, as dependence
may easily develop over a short period of usage. Particular attention
should be given to the issues of hepatic function and choice of
anxiolytic. Lorazepam, oxazepam, and temazepam avoid hepatic glucuronide
conjugation by means of an alternate metabolic pathway and should
be chosen as first-line medications for patients with HIV-associated
liver dysfunction, as in patients with viral hepatitis.
What are
nonpharmacologic treatments for HIV-infected patients with anxiety?
Specific advantages
to utilizing nonpharmacologic intervention for anxiety include a
decrease in pill burden, decrease in CNS sedation and cognitive
impairment, lack of drug-drug interaction, and avoiding polypharmacy.
Some interventions are 1) muscle relaxation, 2) meditation techniques,
3) psychotherapy, 4) exercise, 5) biofeedback, 6) behavioral techniques,
7) guided imagery, and 8) cognitive therapy.
Suggested
Resources
TOP
Lyketsos CG,
Hanson A, Fishman M, McHugh PR, Treisman GJ. "Screening for
psychiatric morbidity in a medical outpatient clinic for HIV infection:
the need for a psychiatric presence." Int J Psychiatr Med.
1994;24:103-113.
Angelino AF,
Treisman GJ. "Management of psychiatric disorders in patients
infected with human immunodeficiency virus." Clin Infect
Dis. 2001;33:847-856.
Treisman G,
Fishman M, Schwartz J, Hutton H, Lyketsos C. "Mood disorders
in HIV infection." Depress Anxiety. 1998;7:178-187.
Ickovics JR,
Hamburger ME, Vlahov D, et al. "Mortality, CD4 cell count decline,
and depressive symptoms among HIV-seropositive women: Longitudinal
analysis from the HIV Epidemiology Research Study." JAMA.
2001;285:1466-1474.
Lyketsos CG,
Hoover DR, Guccione M, et al. "Changes in depressive symptoms
as AIDS develops." Am J Psychiatry. 1996;153:1430-1437.
Sher KJ, Trull
TJ. "Substance use disorder and personality disorder."
Current Psychiatry Reports. 2002;4:25-29.
References
TOP
Ciesla JA,
Roberts JE. "Meta-analysis of the relationship between HIV
infection and risk for depressive disorders." Am J Psychiatry.
2001;158:725-730.
Cournos F,
Guido JR, Coomaraswamy S, Meyer-Bahlburg H, Sugden R, Horwath E.
"Sexual activity and risk of HIV infection among patients with
schizophrenia." Am J Psychiatry. 1994;151:228-232.
Kendler KS,
Gallagher TJ, Abelson JM, Kessler RC. "Lifetime prevalence,
demographic risk factors, and diagnostic vulnerability of nonaffective
psychosis as assessed in a US community sample." The National
Comorbidity Survey. Arch Gen Psychiatry. 1996; 53:1022-1031.
Lyketsos CG,
Schwartz J, Fishman M, Treisman G. "AIDS mania." J
Neuropsychiatry Clin Neurosci. 1997;9:277-279.
Sewell DD,
Jeste DV, Atkinson JH, et al. "HIV-associated psychosis: a
study of 20 cases." San Diego HIV Neurobehavioral Research
Center Group. Am J Psychiatry. 1994;151:237-242.
Treisman GJ.
"AIDS education for psychiatrists." Primary Psychiatry.
1999;6:71-73.
|