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This document summarizes psychiatric disorders that are more prevalent in HIV-infected patients compared to the general population. It discusses how psychiatric illness can both increase the risk of HIV infection and negatively impact outcomes for HIV patients. Common psychiatric issues in HIV patients include depression, anxiety, substance abuse, and mania. Screening tools and treatment options are also reviewed.
![About These Slides ,[object Object],[object Object],[object Object],Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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- 1. Psychiatric Disorders in HIV-Infected Patients Glenn J. Treisman, MD, PhD Professor Department of Psychiatry and Behavioral Sciences and Internal Medicine Director of AIDS Psychiatry Johns Hopkins University School of Medicine Baltimore, Maryland This program is supported by an educational grant from
- 6. Mental illness Depression Demoralization Substance abuse Cognitive impairment HIV Impulsivity Depression Demoralization Substance abuse Cognitive impairment
- 9. Depression
- 13. Screening Instruments for Patients With Depression Screening Instrument Administration Items Measurements Primary Use Beck Depression Inventory (BDI) Self-report 20 Cognitive, somatic subscales Clinical Center for Epidemiological Studies-Depression (CES-D) Self-report 20 Cognitive, somatic subscales (cut scores for clinically relevant symptoms) Epidemiologic Hamilton Rating Scale for Depression (HAM-D) Clinician 17 Affective, vegetative subscales Research Hospital Anxiety and Depression Scale (HADS) Self-report 7 Screens depression and anxiety; excludes somatic symptoms Medical Patient Health Questionnaire-9 (PHQ-9) Depression Module Self-report 9 Keyed to DSM-IV depression diagnostic criteria; also somatic symptoms, anxiety disorders, alcohol and drug abuse Primary care
- 14. Depression Stress Demoralization CNS inflammation Substance abuse Subcortical injury Cognitive impairment HIV Impulsivity Hopelessness Carelessness Demoralization Substance abuse Cognitive impairment
- 23. Selecting an Antidepressant: Potential for Drug-Drug Interactions Crewe HK, et al. Br J Clin Pharmacol. 1992;34:262-265. Nemeroff CB, et al. Am J Psychiatry. 1996;153:311-320. von Moltke LL, et al. J Clin Psychopharmacol. 1994;14:1-4. von Motkle LL, et al. Clin Pharmacokinet. 1995;20(suppl 1):33. Potent P450 blockers: Potential for strong impact on metabolism of other drugs Low P450 blockers: Likely to have little impact on metabolism of other drugs Bupropion Citalopram Mirtazapine Venlafaxine Sertraline Methylphenidate Paroxetine Fluoxetine Fluvoxamine
- 25. Anxiety
- 28. Psychiatric Disorders and Nonadherence to ARVs *Adjusted for sex, race, age, education, employment, insurance, CD4+ cell count nadir, HIV status, ART, having a case manager. Tucker JS, et al. Am J Med. 2003;114:573-580. Disorder Odds Ratio* P Value Generalized anxiety disorder 2.4 (1.2-5.0) .02 Panic disorder 2.0 (1.4-3.0) < .001 Any psychiatric disorder 1.9 (1.4-2.6) < .001 Depression 1.7 (1.3-2.3) .001 Multiple disorders (OR per disorder) 1.4 (1.3-1.5) < .001 Dysthymia 1.3 (0.9-1.9) .17
- 30. Mania
- 32. Mania HIV High-risk behaviors
- 35. Substance Abuse
- 45. Issues Related to Antiretroviral Drugs
- 47. Psychiatric Agents Contraindicated With Antiretroviral Agents Anxiolytics Agent Interacting Antiretroviral Effect Antidepressants St John’s wort All ARVs ARV ↓ Alprazolam DLV Alprazolam ↑ Midazolam All PIs, DLV, EFV Midazolam ↑ Triazolam All PIs, DLV, EFV Triazolam ↑ Antipsychotics Pimozide All PIs, DLV Pimozide ↑
- 51. Psychiatric-ARV Interactions With Undefined Clinical Significance Anxiolytics Midazolam AUC ↑ 18% MVC Midazolam Desipramine AUC ↑ RTV Desipramine Effect ARV Agent Antidepressants Fluoxetine DLV DLV C min ↑ Fluoxetine RTV RTV AUC ↑ Fluoxetine NVP Fluoxetine AUC ↓ Paroxetine FPV Paroxetine AUC ↓ Sertraline EFV Sertraline AUC ↓, C max ↓, C min ↓ Mood Stabilizer Valproic acid LPV/RTV LPV/RTV AUC ↑ (nonsignificant)
- 52. Psychiatric-ARV Interactions With Undefined Clinical Significance (cont’d) Effect ARV Agent Opiates Buprenorphine EFV Buprenorphine AUC ↓, C min ↓ Methadone ddI ddI AUC ↑; R-methadone not affected Methadone d4T d4T AUC ↓; R-methadone not affected Methadone APV R-methadone AUC↓ 13%; S-methadone AUC ↓ 37% Methadone NFV S-methadone AUC ↓; R-methadone AUC not affected Methadone RTV R-methadone AUC ↓ 36%; S-methadone AUC ↓ 25% Methadone SQV R-methadone AUC ↓ 20%
Editor's Notes
- The Women’s Interagency HIV study (WIHS) is a prospective cohort study of women in 5 US cities (Chicago, Los Angeles, San Francisco, New York, and Washington DC). In 1994 and 1995, 2628 women were enrolled. Of these, 2059 were HIV-1 seropositive and 569 were seronegative. The first study in the table included 961 HIV-positive women with a median of 5.1 years of follow-up after the initiation of ART. Continuous HAART use strongly predicted virologic, immunologic, and clinical response. Depression was associated with poorer virologic response, immunologic failure, AIDS-defining illness, and death (all causes) Current drug use was associated with AIDS-defining illness and death from AIDS The second study in the table examined the effect of treatment for depression on adherence to ART in 1371 depressed HIV-positive women 599 (44%) of these women reported use of an antidepressant. 39% of the antidepressants were SSRIs, 26% were tricyclics, and 28% were atypicals. Antidepressant use alone was not significantly associated with use of HAART, although there was a trend (p=0.109). 923 (67%) of the women reported seeing a mental health counselor. Antidepressants plus therapy and therapy alone were both significantly associated with an increased likelihood of using HAART (P=0.009 and P=0.021, respectively). The third study in the table examined the predictors and consequences of interruption and discontinuation of HAART in 873 HIV-positive men in the Multicenter AIDS Cohort Study (MACS). Interruption of ART was predicted by younger age, black race, geographical location, higher HIV RNA level, depression, less time on ART, lower medication adherence, and not using 3TC Discontinuation of ART was predicted by younger age, higher HIV RNA level, depression, and ABC or LPV use HIV RNA increases occurred in 5% of patients who interrupted treatment for 7 or fewer days or who remained on continuous ART HIV RNA increases occurred in 37.5% of patients with longer interruptions and 70.5% who discontinued ART; these patients also experienced decreases in CD4 counts References Anastos K, Schneider MF, Gange SJ, et al; for the Women's Interagency HIV Study Collaborative Group. The association of race, sociodemographic, and behavioral characteristics with response to highly active antiretroviral therapy in women. J Acquir Immune Defic Syndr. 2005;39:537-544. Cook JA, Grey D, Burke-Miller J, et al. Effects of treated and untreated depressive symptoms on highly active antiretroviral therapy use in a US multi-site cohort of HIV-positive women. AIDS Care. 2006;18:93-100. Li X, Margolick JB, Conover CS, et al. Interruption and discontinuation of highly active antiretroviral therapy in the multicenter AIDS cohort study. J Acquir Immune Defic Syndr. 2005;38:320-328.
- In a retrospective cohort study in Denver, 1713 HIV-positive patients were studied For more information about this study, see the Capsule Summary at http://www.clinicaloptions.com/HIV/Journal%20Options/Articles/Yun-JAIDS-2005-04/Capsule.aspx.
- The Veterans Aging (VA) Cohort Study is an observational study of HIV+ and matched HIV- veterans in care at 8 sites. The study described here (n=2702) examined the association between missed doses of medication on a particular day and alcohol use 56% of the responders were abstainers (no alcohol in past 30 days), 34.5% were non-binge drinkers (alcohol in past 30 days, 4 or fewer standard drinks per day), and 8.9% were binge drinkers (at least five standard drinks on at least one day in past 30 days) Self-reported alcohol consumption was associated with missed doses Reference Braithwaite RS, McGinnis KA, Conigliaro J, et al. A temporal and dose-response association between alcohol consumption and medication adherence among veterans in care. Alcohol Clin Exp Res. 2005;29:1190-1197.
- No changes….RSM