Management of common psychiatric conditions in the HIV-positive population

Abstract

Presentation and management of psychiatric illness in HIV-infected patients can pose a challenge for clinicians. Psychiatric illness can exist premorbidly or result from the progression and treatment of HIV infection, influencing the course of the illness both through behavior and putative biological factors. Mood disorders, anxiety, psychosis, delirium, dementia, and substance abuse disorders all factor heavily into the care of HIV-infected patients. Management, however, continues to draw on small and skewed datasets, and remains largely an extrapolation from seronegative patient experience. The following is a discussion of treatment considerations derived from recent literature, as well as a consideration of judgments that clinicians may make in the absence of available data. The use of antidepressants, stimulants, mood stabilizers, and antipsychotics is discussed, as are precautions that must be taken with the HIV population when using these medications, not only because of side effect vulnerability, but because of significant drug-drug interactions.

Longitudinal Study of Emerging Mental Health Concerns in Youth Perinatally Infected With HIV and Peer Comparisons

“…The potential for interactions between psychotropic and HIV drugs requires expertise in both areas for effective clinical management. 62,63 Transitioning youth with PHIV to adult care providers is fraught with many clinical concerns as mental health issues are often chronic. 64,65 For example, many (41%) of our youth with PHIV who met Symptom Cutoff criteria at study entry also met criteria during follow-up.…”

Neurobehavioral Manifestations of Human Immunodeficiency Virus/AIDS

“…Due to the lower incidence of anticholinergic side effects, SSRIs such as fluoxetine and paroxetine are typically used as first line agents while TCADs are sometimes used for patients with both depression and neuropathic pain. The atypical antidepressant bupropion, which has been studied in open label trials, can have significant interactions with the ART drugs ritonavir and efavirenz, and cannot be used in patients with seizure disorders 16 . Modafinil, a psychostimulant, reduced fatigue in HIV+ patients in a RCT 17 , although its effects on other MDD symptoms was unclear.…”

“…HIV mania may improve with an approach that combines resolution of the underlying CNS process, use of a mood stabilizing drug, and/or addition of an anti-psychotic drug. For example, the mood stabilizer and anti-epileptic drug valproic acid has been used to successfully treat mania in HIV+ patients 16 . The disadvantages to valproic acid use are as follows: valproic acid is metabolized in the liver, and liver disease is common in HIV+ persons; further, valproic acid has interactions with many ART drugs 22,23 .…”

“…Atypical antipsychotics, such as risperidone, clozapine, ziprasidone, quetiapine and olanzapine are frequently used to manage psychosis in HIV+ patients 28,29 ; however, they are associated with development of metabolic syndrome, cardiac problems and obesity, and may require dose adjustment if they are used with the protease inhibitor ritonavir 30,31 . Interactions between clozapine and ritonavir may increase clozapine levels leading to bone marrow toxicity 16 .…”

“…The groups treated with low dose haloperidol and chlorpromazine demonstrated improvement (although mild extrapyramidal symptoms were noted) but patients treated with lorazepam suffered a significant increase in their delirium, to such a degree that the lorazepam arm of the study was terminated. Open-label studies and case reports suggest that the atypical antipsychotics clozapine, risperidone, and ziprasidone benefit AIDS patients with psychosis and/or delirium 16 . Some would argue that the use of older, D2-blocking antipsychotics should be avoided as first-line treatment in AIDS patients, due to reports of neuroleptic malignant syndrome and extrapyramidal movement disorders 26 .…”