1. ANZJP Correspondence 687
Australian & New Zealand Journal of Psychiatry, 46(7)
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Efavirenz and psychosis:
Is there a link?
Todd G Manning
Monash Alfred Psychiatry Research Centre
(MAPrc), Alfred Hospital, Melbourne, Australia
Corresponding author:
Todd G Manning, Monash Alfred Psychiatry
Research Centre (MAPrc), Level 1, Old Baker
Building, Alfred Hospital, Melbourne,
VIC 3008, Australia.
Email: tgman2@student.monash.edu
DOI: 10.1177/0004867412450474
To the Editor
Recent advancements in the manage-
ment of HIV have led to a growing
number of ‘combination treatments’
with many antiretrovirals adminis-
tered in ‘once per day’ tablet forms
(Lochet et al., 2003). Atripla is one
example, containing emtricitabine,
tenofovir and efavirenz. Combination
drugs may create a risk of combined
side effects with difficulty identifying
which pharmaceutical constituent is
responsible for adverse events.
Atripla’s safety information lists
some potential psychiatric side effects
(Atripla, 2011) but does not separate
side effects by its drug components.
Existing literature suggests a broad
association between antiretroviral
drugs and acute psychosis (Kashuba,
2008) with more studies suggesting a
link between acute psychosis and efa-
virenz (Lochet et al., 2003; Poulsen
and Lublin, 2003; Zalila et al., 2010).
Mr C, a 38-year-old HIV and hepa-
titis C positive man, was admitted to
the psychiatry ward of a large metro-
politan hospital after 1 week of para-
noid ideation and persecutory
delusions. He believed that people
were following him and that drug
dealers wanted to murder him. He
had several aggressive responses to
these beliefs, including throwing a
brick through a neighbour’s window
and breaking into a stranger’s house.
Mr C’s symptoms coincided with the
initiation (2 weeks prior to admission)
of the antiretroviral regime, Atripla.
Mr C had no past psychiatric his-
tory and denied experiencing any
prior psychotic symptoms. He attrib-
uted the psychotic symptoms to his
antiretroviral medication.
Complicating his presentation was
a history of illicit drug use for 8 years.
His daily drug use prior to admission
included methamphetamine 1 g/day
IV, occasional oral gamma-hydroxybu-
tyric acid (GHB) and smoking canna-
bis. Urine drug testing on admission
confirmed the presence of both
amphetamines and cannabis.
Mr C’s Atripla had been ceased 2
days prior to admission and he was
commenced on 1 mg risperidone oral
twice daily. His HIV biochemistry
showed a CD4 count of 286 (16%)
and viral load of 162,237. Other inves-
tigations (apart from pre-existing HIV
and hepatitis C) and physical examina-
tion were normal.
Mr C improved rapidly over the
next 2 days, displaying a significant
reduction in paranoid ideation and
persecutory delusions. He was able to
identify that he had experienced a
brief psychotic illness. After a further
2 days he was discharged.
In consultation with his HIV spe-
cialist and with a viral load of 78,000,
Mr C. temporarily ceased taking
Atripla to minimize the possibility of
another psychiatric relapse. There
was no immediate plan to begin
another antiretroviral.
Three weeks after discharge, Mr C
had no psychiatric symptoms. He still
used illicit substances, as evidenced by
two urine drug tests, which both
detected amphetamines and cannabis.
He continued to take 1 mg oral risp-
eridone twice daily, and was not tak-
ing any antiretrovirals.
Mr C’s brief psychosis appears to
have been precipitated by Atripla
although HIV patients can experience
acute psychosis due to the CNS effects
and psychological impact of the dis-
ease itself. Nonetheless, this case high-
lights the need to consider the possible
psychiatric implications of taking com-
bined antiretroviral treatments, espe-
cially those containing efavirenz, when
considering differential diagnoses for
new-onset brief psychosis.
Funding
This research received no specific grant
from any funding agency in the public,
commercial, or not-for-profit sectors.
Declaration of interest
The author reports no conflict of interest.
The author alone is responsible for the
content and writing of the paper.
References
Atripla (2011) Patient information.
Available at: www.packageinserts.bms.
com/ppi/ppi_atripla.pdf (accessed 25
March 2012).
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2. 688 ANZJP Correspondence
Australian & New Zealand Journal of Psychiatry, 46(7)
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in patients with HIV-1 infection.
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in Pharmacy 5: 97–104.
Lochet P, Peyrière H, Lotthé A, et al.
(2003) Long-term assessment of
neuropsychiatric adverse reactions
associated with efavirenz. HIV Medicine
4: 62–66.
Poulsen HD and Lublin HK (2003)
Efavirenz-induced psychosis leading
to involuntary detention. AIDS 17:
451–453.
Zalila H, Elloumi H, Gaha N, et al.
(2010) Troubles psychotiques aigus
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88: 119–121.
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