HIV AND PSYCHIATRIC ILLNESS

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HIV AND PSYCHIATRIC ILLNESS

• Karina K. Uldall, MD, MPH
• Department of Psychiatry
• HIV/AIDS Research Program
• University of Washington

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OVERVIEW

• AIDS Defining Neurological Illnesses
• Other CNS Disorders
• Psychiatric Illness in HIV/AIDS
• Diagnosis and Treatment

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AIDS DEFINING NEUROLOGICAL ILLNESS

• CMV Encephalitis
• Progressive Multifocal Leukoencephalopathy (PML)
• Toxoplasma Encephalitis
• Primary CNS Lymphoma
• Cryptococcal Meningitis
• Rarely TB Meningitis and Kaposis Sarcoma

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CMV ENCEPHALITIS

• Disorientation, confusion, apathy
• Psychomotor retardation, lethargy, cranial nerve
  abnormalities
• Abrupt onset, short course
• CD4 count lt 50/uL
• Diagnosed via CSF PCR
• Treated with foscarnet, ganciclovir, both
• Survival less than 2 months

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PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

• Occurs in approximately 4 of patients
• Focal weakness, visual loss
• 10 spontaneously improve
• CD4 count lt 100/uL
• Diagnosed via CSF JC virus PCR
• No clear treatment
• Survival 1 to 4 months

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TOXOPLASMA ENCEPHALITIS

• Approximately 10 of HIV patients, most common
  CNS mass in AIDS (60)
• Activation of previous infection
• Fever, headache, weakness, visual symptoms,
  seizures, cognitive changes
• CD4 count lt 200/uL
• Contrast scan - multiple enhancing lesions, basal
  ganglia, gray-white junction
• Treated with pyrimethamine/sulfadiazine

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PRIMARY CNS LYMPHOMA

• Approximately 3-5 of HIV patients
• Second most common CNS mass in AIDS
• Presentation depends on location of tumor
• CD4 count lt 100/uL
• Contrast scan - usually single lesion noted
• Treated with radiation
• Survival 2 to 6 months

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CRYPTOCOCCAL MENINGITIS

• Occurs in approximately 7 of HIV patients
• Fever, headache, cognitive changes
• Insidious onset spanning 2 to 4 weeks
• CD4 count lt 100/uL
• Diagnosed via CSF culture, India ink stain
• Treated with amphotericin B and fluconazole

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OTHER CNS DISORDERS

• Bacterial/Viral Meningitis
• Neurosyphilis
• Herpes Simplex Encephalitis
• Varicella-Zoster Encephalitis
• Rarely Histoplasmosis and Coccidiodomycosis

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PSYCHIATRIC ILLNESS IN HIV/AIDS

• HIV Associated Dementia (HAD)
• Delirium
• Psychotic Disorders
• Mood Disorders
• Anxiety Disorders
• Substance Abuse and Dependence

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HIV ASSOCIATED DEMENTIA

• 15-20 of AIDS patients
• Combination of motor, cognitive and
  mood/personality changes
• Insidious onset, CD4 count lt 200/ul
• CSF Beta-2-microglobulin gt 3.8 mg/dL, HIV-1 RNA
  gt10,000/ml
• AZT, AZT3TC, d4T3TC, Indinavir

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DELIRIUM

• Disturbance of consciousness with attention
  problems
• Change in cognition or development of a
  perceptual disturbance
• Acute onset with fluctuating course
• Underlying etiology
• fever/infection, trauma, metabolic, meds/drugs,
  other cause(s)

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DELIRIUM

• Common in later stages of disease, 30-60 of
  patients
• Often confused with dementia and depression
• Associated with poor outcomes - mortality, long
  term care, longer hospitalization
• Treatment of choice is haloperidol unless
  etiology is alcohol/benzodiazepine withdrawal

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PSYCHOTIC DISORDERS

• Substance induced during intoxication or
  withdrawal
• Medical illness induced
• must be distinguished from delirium
• late stage HIV associated dementia

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MOOD DISORDERS

• Bipolar disorder - 8 of outpatients
• Major depressive episode
• 6-10 current and 20-35 lifetime
• similar to other medically ill populations
• Substance induced mood disorder
• Medical illness induced
• must distinguish from dementia, hypoactive or
  hyperactive delirium

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ANXIETY DISORDERS

• 2 to 38 of patients depending on stage of
  illness
• Panic disorder
• Adjustment disorder
• Substance induced due to intoxication or
  withdrawal
• Medical illness induced, e.g. untreated pain

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SUBSTANCE ABUSE AND DEPENDENCE

• Abuse
• recurrent use in setting of failure at work, home
  or school
• use in physically hazardous settings
• recurrent legal problems
• recurrent social or interpersonal problems

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SUBSTANCE ABUSE AND DEPENDENCE

• Dependence
• tolerance/withdrawal
• larger amounts/longer period of time
• unable to cut down or control use
• time spent obtaining drug or recovering from it
• love, work or play compromised
• use in setting of physical/psychological problems

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SUICIDE ASSESSMENT

• Gender M gt F
• Age 15-25 years and gt 45 years men gt 55
  years women
• Ethnicity Caucasian (Black, Hispanic, Native
  American)

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SUICIDE ASSESSMENT

• Family history
• suicide, early parental loss, mood disorder,
  chaos
• Psychiatric illness
• auditory hallucinations, mood disorder, substance
  use, prior attempts
• Medical illness
• acute v chronic, terminal, pain, medications

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SUICIDE ASSESSMENT

• Behavioral factors
• Changes in behavior
• Messages saying goodbye
• Social isolation
• Lethality
• Access to means -Thorough plan
• Method of attempt -Prior attempts
• Possibility of rescue

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SUICIDE ASSESSMENT

• HIV/AIDS Risk Factors
• Stage of disease
• Number of AIDS related losses
• Social isolation
• Disease progression/fear of progression
• Uncontrolled pain
• Experience with HIV-related suicide

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SUICIDE INTERVENTIONS

• Medication/hospitalization
• Address contributing factors
• Encourage expression of feelings/thoughts
• Promote sense of self control
• Build alternative coping strategies
• Educate patient and family
• Develop a crisis plan

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TREATMENT

• Psychotherapy
• supportive, interpersonal, cognitive-behavioral,
  group, psychoeducational
• ongoing risk of crises
• countertransference issues
• homophobia, sex, substance use, existential
  beliefs, rescue fantasies, identification,
  therapeutic nihilism, guilt, fear of contagion

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TREATMENT

• Pharmacotherapy
• Antidepressants
• SSRIs Paroxetine, Sertraline, Fluoxetine
• TCAs Nortriptyline, Desipramine
• Other Nefazodone, Venlafaxine, Mirtazapine
• Stimulants
• Methylphenidate
• Dextroamphetamine
• Testosterone

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TREATMENT

• Pharmacotherapy
• Antipsychotics
• typical haloperidol
• atypical risperidone, olanzapine
• Antianxiety agents
• benzodiazepines
• Mood stabilizers
• lithium, valproic acid, carbamazepine

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MEDICATION INTERACTIONS

• Multiple medications
• Multiple medical illnesses
• Renal or hepatic disease
• Elderly
• Individual differences in liver metabolism
• Specific liver metabolism inhibitors

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CHOOSING MEDICATIONS

• Adverse effects
• Interactions with other medications/drugs
• Metabolism via liver
• Elimination via liver or kidney or both
• Time to expected onset of action
• Expected duration of action
• Less is better

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SUMMARY

• Document HIV status
• Determine level of immunocompromise
• Thorough history and physical exam
• Diagnostic tests
• CT/MR -Urine tox screen/BAL
• LP
• Neuropsychological testing

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SUMMARY

• HIV-related illness
• Other physical disorder
• Medication toxicity
• Substance use
• Primary psychiatric illness