HIV Psychiatry

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Outline
I. HIV and Mental illness
- an overview

II. Milestones of HIV disease and psychiatric

disorders

III. Major psychiatric disorders in HIV

a. Psychosis
b. Mood disorders- mania, depression
c. Anxiety disorders
d. HAND
e. Delirium
I. HIV and Mental illness
- an overview

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HIV and Psychiatric Illness
A. HIV increases the risk for psychiatric
illness

B. Psychiatric illness increases the risk for

HIV

C. Mental illness can affect management of

HIV disease and vice versa

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A. HIV increases risk for
psychiatric illness

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Ethiopia
Oromia region: 46.7% HIV cases also have common mental
disorders

39.3% of the children had behavioral and emotional

problems(ART clinic).

In USA HIV pts General population

Major depression 36.0 16.6

Dysthymic disorder 26.5 2.5
General anxiety disorder 15.8 5.7
 1. Primary – due to direct effect of HIV virus
or immune reaction to it
HIV-1 neuroinvasion

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2. Secondary to compromised
immunity
Infections
Toxoplasmosis
Cryptococcus meningitis
Cytomegaly virus encephalitis
Progressive Multifocal
Leukoencephalitis (PML)
Neoplasms
Lymphoma
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3. Due to psychosocial factors

Stressors leading to break down in coping

capacity which occurs
Seroconversion, onset of physical
symptoms, HIV-related bereavement

Stigmatization

Loss of employment or inability to work –

financially disadvantaged

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4. Treatment related
Medications used to treat
•HIV (ART)
•Opportunistic infections
•Co-morbid medical illnesses
Drug-drug interactions

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B. Psychiatric illness increases
risk for HIV

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• Poor judgment and decision making

– Impaired accurate risk assessment and
promote sexual involvement with risky
partners.

• Decreased impulse control may reduce

motivation to use condoms.

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• Poor assertiveness skills and poor

negotiation skills
Condom use

• Low self-esteem may lead to sexual

exploitation.

• Difficulty maintaining relationships and

poor relationship quality may lead to
non-monogamous relationships.

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C. Effect of psychiatric disorders on
management of HIV infection

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1. Delayed initiation of treatment

– Poor or inadequate access to health
care systems
– Stigma on the part of the health care
worker

2. Poor adherence to ARV

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3. Side effects and Drug-interactions

• Neuropsychiatric side effects of ARV
drugs limit the choice of ARV in those
with mental illness
Individuals with a history of mental
health problems may be at an
increased risk of developing such
complications
• Drug interactions between psychotropic
and HIV medications will also influence
the choice of ARV in those with mental
illness

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II. Milestones of HIV disease
and psychiatric disorders

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.

Milestones of HIV Disease

• HIV testing and news • Onset of AIDS- .

of HIV positive defining illness

status • Initiation of multi-
• Disclosure of HIV drug regimen
status • Bereavement
• Appearance of first • Onset of functional
illness symptoms disabilities
• Declining CD 4 • Onset of cognitive
counts and disorders
increasing viral load

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a. Decision to test for HIV – fear-denial

b. News of HIV positive status

• Initially reaction
• Anger, shock, or denial,
– Guilty feeling
– Feelings of loneliness and isolation
– Feelings of grief and loss
Adjustment disorder
Depression
Anxiety
 .

c. Disclosure of HIV status

Fear of telling others about HIV diagnosis -
greatest burdens
– HIV - very misunderstood condition - Can
only be acquired in immoral ways??
– Fear of stigma and rejection
– Lead “double lives” in -always hiding
something
– Can lead to unprotected sexual activity
– Decision who to tell, how and when to
tell
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d. Appearance of first illness symptoms and

initiation of ART
– Psychological disturbances are relatively
absent during asymptomatic stage
– Early symptomatic phase- uncertainity
about the future – somatization, anxiety,
intrusive worries
– Onset of ART medication - worries
about adverse effects of drugs
– Development of AIDs – dysphoric mood,
helplessness, anhedonia, rejection
sensitivity, suicidality
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e. Loss
 Bereavement – HIV related death
• Partner , friend
 Onset of functional disabilities
• Cognitive impairment
• Loss of job
III. Major psychiatric disorders in
HIV
1. Psychosis
2. Depression
3. Anxiety disorders
4. Neurocognitive disorders
5. Delirium

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1. HIV and Psychosis

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Rate of psychosis in HIV: 0.5 – 15%

Psychotic symptoms -independent of HIV

• Past history or family history of psychosis.
• Substance use/withdrawal syndromes

Psychotic symptoms secondary to HIV effect

• Psychosis is usually a later stage
complications of HIV/AIDS
– Towards the end of the middle stage and
in the late stage of IV
..

Clinical features
• Usually rapid onset – over hours or days
• Change of level of consciousness - arousal
is suppressed or fluctuating
• Hallucination: more Visual than auditory
• Delusion: Less fixed, fleeting
• Mood symptoms -tended to occur
prominently and frequently(depression,
euphoria, mixed)
• Cognitive impairment has also been
consistently described as a feature of HIV-
associated psychosis
Treatment of psychosis in HIV
Pharmacological treatment of HIV patients
• Does not differ much from that of other
populations

• Increased propensity to develop EPS and to

have drug-drug interactions

• Atypical antipsychotics have a lesser risk of

side effects (EPS) than the typical
antipsychotics
2-HIV and Depression

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Depression –
• Major cause of distress in patients with HIV
and AIDS
• Frequently underdiagnosed and
undertreated
• The most frequently occurring psychiatric
disorder in HIV patients

Prevalence
• HIV Exceed rates in the general population
- to 50 %( 80%).
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Clinical Presentations

AFFECTIVE SOMATIC
 Depressed mood  Loss of appetite
 Loss of interest  Weight loss
 Guilt, worthlessness  loss of libido
 Hopelessness  Sleep disturbance
 Thoughts of death  Fatigue, anergia
 Suicidal ideation  Loss of concentration

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Detecting Depression could be hard

• The somatic symptoms of depression may
be confused with opportunistic infections
– Physical illness produces vegetative
symptoms, similar to depression.
• Psychological distress is a normal feature
of being physically ill or in the dying
process.
• Stigma of psychiatric issues could cause
patient’s reluctance to talk about it.

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Suicide
Predictable times with increased Risk for Suicide
1. When they are first diagnosed with HIV

2. When their medical condition deteriorates

 A drop in CD4 counts,
 An opportunistic infection,
 Hospitalization, in times of pain
 onset of treatment with HAART

3. When there are losses,

 Death of friends, death of a partner
 Loss of employment; Rejection
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Treatment
Antidepressants: Selective Serotonin
Reuptake Inhibitors – SSRIs;Tricyclic
Antidepressants – TCA
-Selective Serotonin Reuptake Inhibitors (SSRIs)
-Tricyclic Antidepressants(TCA)
• Any medication must be carefully
monitored: CNS effects likely
• Consider drug-drug interactions

Psychoeducation/ psychotherapy

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3. HIV and Anxiety Disorder

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Anxiety disorders - in HIV

• Anxiety disorders are common in HIV

infection
• Prevalence of anxiety disorders-2-40%
• Disease-related events and stages
(Milestones) of disease progression are
associated with the onset/ worsening of
anxiety symptoms

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1.Generalized Anxiety Disorder (GAD)

2.Panic disorder
3.Phobias
4.Obsessive-compulsive disorder (OCD)
5.PTSD
6.Adjustment disorder with anxiety

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Clinical features
Autonomic/Somatic Symptoms .

• Chest pain • Hyperventilation

• Choking sensation • Muscle tension
• Diarrhea • Nausea
• Diaphoresis • Palpitations
• Dyspnea • Parasthesias
• Fatigue • Tachycardia
• Flushing • Vertigo
• Headache • Vomiting

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Treatment - two modes of treatment

1. Non-pharmacologic treatment
a. Psychoeducation
b. Psychotherapy

2. Drug treatment
– Benzodiazepines
– SSRI’s
– Tricyclic agents

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4. HAND – (HIV-Associated
Neurocognitive Disorders)

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Domains of Cognition
• Attention/working memory
• Abstraction/executive- organization,
decision making, judgment
• Memory (learning; recall)
• Speed of information processing
• Sensory-perceptual
• Motor skills

* Neuropsychological tests
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Neurodegeneration in HAND
1. Viral proteins released from infected monocyte-
derived cells cause neuronal death through direct
interaction of viral proteins with neurons

2. Factors released by non-neuronal cells as part

of an inflammatory response to viral particles. e.g.
gp120, Tat, and Vpr quinolinic, etc.
(Some are neuroprotective role, and others
neurotoxic)
HIV-induced inflammation-associated
neurodegeneration
• Chemokine/cytokine effects
• Increased Excitotoxicity
• Oxidative stress
* Not mutually exclusive
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1.HIV-associated asymptomatic neurocognitive

impairment (ANI)
Acquired impairment in cognitive functioning with
no interference to everyday functioning

2. HIV-1-associated mild neurocognitive disorder

(MND)
Acquired impairment in cognitive functioning with
at least mild interference in daily functioning

3. HIV-1-associated dementia (HAD)

Marked acquired impairment in cognitive
functioning with marked interference with
day-to-day functioning
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Treatment

• HAART- mainstay of treatment

• Psychostimulants -
methylphenidate/Ritalin- DA agonist

• Current trials and considerations

 Minocycline: anti-inflammatory
 Memantine: anti-excitotoxicity
 Selegiline: antioxidant
5. HIV and Delirium

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HIV and Delirium
• Cumulative prevalence of delirium in HIV -
up to 65%

• Etiologies include opportunistic infections,

tumors and different medications used in
HIV infected patients

• No remarkable difference in clinical

manifestations
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Treatment
Delirium may be fatal-should be thoroughly
investigated and managed intensively

1. The primary goal - treat the underlying

cause.
2. Provide physical, sensory, and
environmental support
3. Pharmacotherapy
• Antipsychotics :
• For sleep problem or agitation:
benzodiazepines
• Opioids : when delirium is secondary to
severe pain, dyspnea