Things you need to know about HIV Psychiatry

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Things you need to know about HIV Psychiatry

• German Molina, M.D.
• Assistant Professor of Clinical Psychiatry
• University of Miami

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In perspective Death by AIDS lt13 yrs
old 5,071 gt13 yrs old
496,598MSMgtIVUgtMSM/IVUgtHETFemale causes
IVUgtHET
3
Living with HIV/AIDS lt13 yrs old 3,219
gt13 yrs old 308,914Bl not HISPgtWT not
HISPgtHISPMSMgtIVUgtHETgtMSM/IVUFemale causes
HETgtIDU
4
In FloridaLiving with HIV lt13 yrs old
244 gt13 yrs old 28,945
Total 29,189Living with AIDS lt13 yrs
old 408 gt13 yrs old 40,607
Total 41,015
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In FloridaLiving with HIV and AIDS Total
70,204
AndWorldwide 42 millions.
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HIV is a Psychiatric Epidemic

• HIV increases risk for psychiatric illness
• Psychiatric illness increases risk for HIV
• Effective treatment for psychiatric illness can
  improve patient outcome
• Effective treatment for psychiatric illness can
  decrease HIV transmission

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Aspects to be considered

• Neuropsychiatric complications
• Psychiatric manifestations
• Treatment considerations

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Neuropsychiatric Complications
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HIV is a neurotropic virus
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Neuropsychiatric complications

• CNS OIs (Non-viral)
• CNS OIs (Viral)
• Systemic/metabolic complications
• Substance-induced complications
• Medication side effects
• Neurocognitive disorders

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OIs of the CNS (Non-Viral)

• Cerebral Toxoplasmosis
• Cryptococcal Meningitis
• Tuberculous (TB) Meningitis
• Atypical TB (MAI) Infection
• Candida Infection
• Neurosyphillis

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OIs of the CNS (Viral)

• Cytomegalovirus (CMV)
• Herpes Simplex Virus
• Progressive Multifocal Leukoencephalopathy (PML)
• Varicella-Zoster Virus

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CNS Neoplasms

• Primary CNS Lymphoma
• Secondary CNS Lymphoma
• Kaposis Sarcoma

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Systemic/Metabolic Complications

• Hypoxemia
• Electrolyte Disturbance (Dehydration)
• Fever
• Septicemia
• Uremia
• Hepatic Encephalopathy
• Anemia

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Psychoactive Substance-Induced CNS Complications

• Alcohol
• Amphetamines
• Cannabis
• Cocaine
• Hallucinogens

• Inhalants
• Sedative-Hypnotics
• Opiates

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Medication Side Effects

• Steroids mania or depression, paranoia
• Interferon neurasthenia fatigue syndrome,
  depresion and hypomania
• Interleukin 2 depression, disorientation,
  confusion, coma
• Efavirenz decreased concentration, vivid dreams,
  depression
• Pentamidine anxiety

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HIV-AssociatedNeurocognitive Disorders

• Minor Cognitive motor disorder (MCMD)
• HIV-Associated Dementia (not ADC)
• Delirium

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HIV-AssociatedMinor Cognitive Motor Disorder

• Mild syndrome of motor and/or cognitive
  dysfunction
• Minimal impairment in functioning
• Significant marker for reduced survival

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HIV-Associated Dementia

• The most frequent single neurologic of AIDS

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HIV-Associated Dementia

• Abnormality in two or more cognitive domains
  causing functional impairment
• Impaired motor performance or decline in
  motivation or emotional control
• No clouding of consciousness (Delirium)
• No confounding etiology

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HIV-Associated Dementia (HAD)Most common
presenting clinical symptoms - memory
impairment - gait difficulty - mental
slowing - depressive symptoms (social
withdrawal and lack of interest)
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HADLate Manifestations

• Global cognitive dysfuntion
• Mutism
• Aphasia
• Amnestic features
• Frontal lobe dysfunction

• Weakness
• Spasticity
• Dyskinesias
• Ataxia
• Myoclonus
• Seizures
• Coma

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HIV-Associated Delirium

• Prevalence 43 - 65 (AIDS)
• Most common psychiatric dx in hospitalized
  critically ill patients with AIDS
• Associated with increased medical morbidity and
  mortality

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Psychiatric manifestations
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HIV-Associated Psychiatric Complications

• Mood disorders
• Substance Abuse
• Anxiety disorders
• Adjustment disorders
• Psychotic disorders
• Pain syndromes
• Sleep disorders

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Major Depression is the most commonly observed
psychiatric disorder among persons with HIV
infection.Point prevalence of 8-67Can be
higher in the medically ill
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Depression and HIVRisk Factors

• Prior history of depression
• Psychoactive substance use
• Unemployment
• Lack of social support
• Use of avoidance coping strategies
• Perceived HIV-related physical symptoms
• Multiple losses

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Depression and HIVDiagnosis

• Asymptomatic stage of illness
• Symptomatic HIV disease
• Physical indicators of mood disturbance

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Depression and HIVDifferential DxTake
special consideration when low CD4
-HIV-neurocognitive disorders (MCMD HAD)
-CNS OIs and neoplasms
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Depression and HIVDifferential Dx

• Substance use
• Medication effects
• Endocrine abnormalities (hypogonadism, adrenals,
  thyroid)
• Nutritional (B-12 deficiency)

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Depression and HIVTreatment

• Optimal management includes psychological and
  psychopharmacological interventions
• Pharmacotherapy is mainstayall antidepressants
  are equally effective

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Depression and HIVTreatment - Psychological

• Cognitive-behavioral therapy
• Interpersonal therapy
• Behavioral therapy
• Brief psychotherapy
• Short-term dynamic psychotherapy
• Supportive psychotherapy
• Group psychotherapy

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Depression and HIVTreatment Psychological
benefits

• Decrease high risk behaviors
• Increase compliance
• Enhance quality of life
• Improve coping
• Decrease utilization of health care services
• Lengthen survival time (?)

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Depression and HIVTreatment - Psychopharmacology

• Start with lower dose
• Titrate slowly
• Lower maintenance
• Drug-drug interactions
• Side effect profiles
  
  
  
  

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Depression and HIVTreatment - Psychopharmacology

• TCAs
• SSRIs
• SNRIs (Venl, Nefaz)
• Atypicals (Bup, Mirt)
• MAOIs

• Psychostimulants
• ECT
• Vagal Nerve Stimulation
• TMS

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Depression and HIVTreatment - Duration

• First episode 6 9 months beyond resolution of
  symptoms
• Three or more episodes consider tx for life

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Depression and HIVSuicide

• Completed suicide 17 37-fold increase
  (1985-1987)
• Ideation at serologic testing, at pivotal
  disease points and in HIV without AIDS
  

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Depression and HIVSuicidality Risk Factors

• Prior attempt
• African American, Hispanic men
• Ages 25 54
• Family Hx of suicidal attempts
• Psychiatric Hx
• Drug/Alcohol abuse or dependence
• Higher levels of distress, hopelessness

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Depression and HIVSuicidality - continued

• More reported HIV symptoms
• Multiple losses
• Unsettled sexual identity
• Poorly controlled pain
• Psychosocial stressors
• Stage of HIV disease
• Cognitive dysfunction

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HAART and Neurocognitive Disorders

• Protease inhibitors have poor blood-brain barrier
  penetration
• CNS reservoir
• Progression of neuropsychiatric complications
  with reduced peripheral viral load??