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1. Psychiatric management

The development of a psychiatric treatment plan for patients with HIV infection requires thoughtful and comprehensive consideration of the biopsychosocial context of the illness. Treatment decisions must balance standard recommendations for psychiatric conditions against the medical stage of HIV illness and up-to-date information about available medical interventions targeted at the underlying HIV infection. At the same time, psychiatrists should be aware that emotional reactions and conflicts can interfere with a patient's ability to follow medical recommendations and thus have a profound effect on physical status. Psychiatrists should carefully consider possible medical causes of psychiatric symptoms and whether a medical workup is indicated to rule out a potentially life-threatening illness due to HIV or HIV-related illness. Organ malfunction, synergism of side effects of drugs, and drug-drug interactions are important factors to address in the management of patients.

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a) Establish and maintain a therapeutic alliance

Establishing an alliance involves, in part, recognition of a patient's understanding of his or her stage of illness and an evaluation of how he or she is coping with it. The exploration of cultural/ethnic beliefs regarding psychiatric and HIV illnesses can also contribute to the formation of a solid alliance. Because of the potential for the patient to feel shame and stigma associated with HIV infection and the sensitive nature of discussing risk behavior, psychiatrists should be supportive and not judgmental to encourage trust.

Issues of confidentiality should be reviewed with the patient, and the patient should be asked to consider the psychiatrist's role in assisting with the process of disclosure of HIV status to appropriate persons (94). In establishing a therapeutic alliance, it is important to discuss with the patient whether he or she wants to extend the treatment relationship to include selected communication with the family or significant other(s). Lastly, given the importance of the therapeutic alliance and the emotional impact of issues related to HIV, the psychiatrist should be aware of transference and countertransference feelings as well as personal attitudes about HIV infection and how the patient acquired the virus.

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b) Collaborate and coordinate care with other mental health and medical providers

Managing the health care needs of a patient with HIV infection can be challenging due to the complex nature of the illness. Psychiatrists must be aware that the illness changes over time and has many different clinical manifestations. In addition, because information about HIV-related treatment is constantly evolving, psychiatrists may feel that their fund of knowledge about the most current interventions, such as antiretroviral medications, is inadequate. To keep up to date and to provide good clinical care, it is essential to collaborate with other physicians in infectious disease, primary care, and other disciplines.

Discussions of drug-drug interactions and the close monitoring and workup of unexplained somatic or psychiatric symptoms are examples of how psychiatrists and primary care physicians can assist each other in providing high-quality comprehensive care. Patients should specify their agreement for the exchange of specific information between the psychiatrist and other clinicians in a written release of information. It is often appropriate to use a multidisciplinary team approach when managing a patient with HIV, especially as the disease becomes more advanced. Access to both general medical and specialty care may need to be addressed.

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c) Diagnose and treat all associated psychiatric disorders

A number of surveys of persons with HIV infection have shown an elevated premorbid rate of psychiatric disorders when compared to rates in the general population. In addition, psychiatric disorders can develop during any stage of HIV illness.

Psychiatric treatment of patients with HIV infection should include active monitoring of substance abuse, since it is often associated with risk behaviors that can lead to further transmission of HIV. Clinicians must not assume that patients who have relatively good immune functioning have no risk for CNS HIV disorders. Thorough evaluation and accurate diagnosis are key to selecting the appropriate intervention, whether it is risk reduction counseling, neuropsychological testing, or the use of psychotropic and antiretroviral medications.

There are no data to suggest that the psychotherapeutic management of patients with HIV infection should be different from that of other patients. Many clinicians use a variety of approaches (e.g., both time-limited and longer-term individual and group psychotherapy) and psychotherapeutic models (e.g., cognitive behavior, supportive, interpersonal, or psychodynamic/psychoanalytic).

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d) Facilitate adherence to overall treatment plan

Adherence to a treatment regimen is profoundly important for patients with HIV infection. Research has demonstrated that less than 95% adherence to antiretroviral medications results in the development of viral resistance (95). Translated into actual practice, if medication doses are taken twice a day, a patient cannot miss more than one dose every 10 days.

Because comorbid psychiatric disorders, such as substance abuse or depression, have been shown to adversely affect patients' compliance with a complicated treatment regimen, psychiatrists and patients should actively discuss adherence to both psychotropic and HIV medications (96). Psychoeducational approaches are especially useful, since they reinforce the importance of adherence, support appropriate help-seeking, and identify barriers to adherence. Some patients who are unable to modify their behavior after educational approaches may be helped by intensive psychodynamic psychotherapy. If indicated, outreach efforts with public health nurses and services can be used to provide adherence assistance.

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e) Provide education about psychological, psychiatric, and neuropsychiatric disorders

Mental health problems can occur at any stage of HIV illness (e.g., around the time of serologic testing) (97), or they could be precipitated by the onset of somatic symptoms. Preexisting psychiatric disorders or personality traits may be exacerbated by the onset of HIV illness. Patients may seek mental health services on their own, but it is not uncommon for other clinicians to request psychiatric consultation for patients who are in crisis or who have psychiatric symptoms.

It is often the psychiatrist's role to educate other clinicians and patients about the neuropsychiatric complications of HIV infection and to initiate and encourage treatment of current or emergent psychiatric disorders. When seeing a patient in consultation, it is important to gather history about cognitive or motor symptoms and conduct a mental status screening examination to determine whether neurocognitive deficits are present (see Section III.B.2.a on screening exams).

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f) Provide risk reduction strategies to further minimize the spread of HIV

Psychiatrists are obligated to assess the risk for HIV transmission from their HIV-infected patients to others and to provide risk reduction counseling. This task should be a long-term treatment priority, since many HIV-infected individuals continue risk behaviors. Risk assessment should be repeated when there are changes in the patient's clinical status or social situation, such as the onset of binge drug or alcohol use or new sexual relationships. Psychotherapy may help some individuals who are unaware of motivations that promote ongoing risk behavior. When a psychiatrist cannot provide the specific risk reduction intervention that is indicated for a patient, he or she should refer patients to resources such as HIV/AIDS service organizations and support the intervention when initiated.

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g) Maximize psychological and social/adaptive functioning

Biomedical interventions have stemmed the progression of HIV illness so that its course has increasingly resembled that of other chronic medical illnesses. Therefore, maximizing psychosocial functioning is relevant to the long-term social and economic impact of HIV infection. Psychiatrists can enhance a patient's functioning by helping him or her cope with the illness. Psychiatrists should ask about and be aware of a patient's use of alternative or complementary treatments, including herbal remedies.

Assessment of social supports, utilization of appropriate community-based services, and resolution of financial and occupational concerns are all potential fruitful domains of inquiry. Many patients find support groups for persons with HIV infection helpful in coping with their illness, whereas others may prefer individual, couples, or family therapy.

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h) Role of religion/spirituality

Inquiry about the spiritual beliefs and religious faith of a person with HIV infection should be a regular part of a psychiatric assessment and treatment planning, since they can be an important source of support for many with HIV/AIDS. Facing a serious illness often serves as a catalyst for a search for meaning and a renewal of spiritual beliefs and practices. A person's religious history includes not only current beliefs and practices but also religious traditions of one's family of origin and ethnic culture.

Religious congregations have had different, sometimes negative, responses to the spiritual needs of members with HIV/AIDS that often correspond to the core beliefs of the faith communities (98). Many ethnic minorities find the religious community or body of the church to be the network that most effectively addresses their need for support in crises.

The concept of spirituality goes beyond religious considerations to encompass multidimensional and existential perspectives that are important in maintaining well-being for many persons with HIV infection. It is not uncommon for persons with HIV/AIDS to seek alternative modes of spiritual expression, such as meditation. An assessment of the spiritual needs of a patient involves questions around the person's concept of God, sources of strength and hope, significance of practices and rituals, and perceived relationship between spiritual beliefs and health status (99). Information gathered may help caregivers assist patients to better cope with their illness at all stages but particularly as a patient nears death.

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i) Prepare for issues of disability, death, and dying

As HIV illness advances, a psychiatrist may be asked to help evaluate the need for reasonable work or school accommodations or the ability to return to work in line with the Americans With Disabilities Act. Patients with minor children may need assistance with disclosure of illness and the establishment of a custody plan in the event of parental death from AIDS. Psychotherapy may be very helpful in reducing the emotional distress and turmoil activated by approaching death.

The fundamental right of a patient with advancing HIV illness to make treatment decisions can be supported when issues relating to disability, death, and dying are discussed by the appropriate parties in a timely and ongoing fashion. Discussions about preferences for care should be initiated by physicians, since it has been reported that only 36% of patients with AIDS had spoken with their physician about their preferred treatment (100). It is recommended that patients with HIV infection draw up a living will to guide end-of-life decisions in addition to a durable power of attorney. Copies of these documents should be placed in a patient's medical charts and in the files of their primary and specialty physicians.

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j) Advice to significant others/family regarding sources of care and support

The HIV patient's significant others—partner, family, and friends—are often collaborative partners in care and support who often shoulder a significant share of the clinical day-to-day care of an acutely or terminally ill patient with AIDS. They also are a rich source of collateral information about the clinical status of the patient. The psychiatrist needs to take care that the patient has given consent before speaking directly with family and significant others.

Intimate involvement with the patient and his or her illness can lead to mental health difficulties for the significant others as well. Referral to support groups for significant others affected by HIV may be helpful, as can encouragement to participate in HIV/AIDS advocacy organizations. Both can provide emotional validation and a degree of respite for a significant other. Some significant others and family members may be best served by referral for psychiatric evaluation and treatment, including individual or family therapy.

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2. Diagnosis and treatment of disorders requiring specific psychiatric intervention

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a) Dementia and the spectrum of cognitive disorders

Cognitive complaints are not uncommon among psychiatric patients in general, but the evaluation of such complaints in a patient with HIV infection requires a comprehensive psychiatric assessment, formulation of a differential diagnosis, and possible medical workup. Symptoms of early cognitive changes due to HIV can be subtle and can differ from symptoms associated with cortical dementia such as Alzheimer's. For example, HIV-associated dementia, due to its subcortical localization, more commonly presents with psychomotor slowing rather than deficits in language or visual recognition. Psychiatrists need to be aware of these differences in clinical phenomenology in order to identify HIV-associated dementia at early stages.

The widely used Mini-Mental State (101) is not sensitive in picking up early HIV-associated cognitive motor symptoms. Alternative screening examinations have been proposed that identify symptoms more likely to be present with subcortical dementia (102–105). Psychiatrists should become familiar with the available screening examinations for cognitive motor impairment that are more specific for subcortical symptoms (Table 14). It has been found that patient self-assessment of cognitive status is not reliable (106). Therefore, psychiatrists should administer a baseline screening examination on every patient with HIV infection and plan to readminister the test on a regular basis as part of the treatment plan. If there is evidence of early cognitive impairment, formal neuropsychological testing is useful to more comprehensively document cognitive dysfunction as well as areas of relative cognitive strength.

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Table Reference Number
Table 14. Screening Examinations for HIV-Associated Cognitive Motor Dysfunction

Once cognitive deficits are identified, the psychiatrist should work in collaboration with infectious disease specialists, neurologists, or primary care clinicians to develop a plan for further workup. A magnetic resonance imaging scan often reveals no abnormality in patients with early dementia, so this technique is not useful in providing specific confirmation of HIV-associated dementia. The overall immunological status of the patient should be assessed if not already known.

Pharmacologic treatment of HIV-associated dementia consists of intervening with potent antiretroviral therapy that targets the underlying HIV infection with consideration of whether the agents adequately penetrate the CNS. For comorbid conditions such as depression, psychiatrists should consider prescribing antidepressant medications as they would for other medically ill patients. Last, for management of symptoms associated with HIV-associated dementia (e.g., agitation or fatigue), medications such as antipsychotic or stimulant agents, respectively, should be considered.

Psychotherapy may be helpful for patients with mild to moderate dementia in order to help them understand, mourn, and adapt to this new impairment of functioning. Both medications and psychotherapy can thus improve the quality of life both for persons with HIV-related cognitive disorders and their significant others while also improving overall clinical outcomes.

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b) Delirium

The evaluation of the cause of delirium in an HIV-infected patient requires the psychiatrist to be alert to multiple possible etiologic factors and be knowledgeable about specific diseases that are associated with HIV infection. Examples are hypoxemia due to Pneumocystis carinii pneumonia, uremia due to HIV nephropathy, or elevated ammonia levels due to cirrhosis. One of the most important factors is the multiple medications that HIV patients typically take, which often cause delirium or contribute to delirious states because of drug-drug interactions. Problems arising from such toxicity are often reversible. Patients with AIDS who reside in either nursing homes or assisted living facilities or who have been hospitalized and who develop delirium have been shown to have significantly shorter survival than AIDS patients without delirium (107, 108). HIV-associated delirium may present with symptoms that resemble classic mania or drug intoxication, thereby bringing patients to the attention of a psychiatrist for evaluation. Delirium in the context of HIV infection should be evaluated like delirium with other medical conditions (47). A psychiatrist should advocate for a complete medical/neurological evaluation for patients with HIV infection who present with an acute onset of psychiatric symptoms with no previous psychiatric history. A complete workup should include a toxicology screen, thorough neurological examination, laboratory evaluation, and brain imaging studies. A comprehensive assessment for infectious processes should be conducted and may entail lumbar puncture.

Management of delirium in the context of HIV infection includes judicious use of antipsychotic medications for symptoms of agitation or perceptual abnormalities such as hallucinations. Many clinicians use the newer, atypical antipsychotic agents due to their lower side effect profile.

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c) Mood disorders

The management of disturbances in mood such as depression or mania for patients with HIV infection is similar to that for other patients with medical comorbidity. Fatigue and insomnia, frequent complaints in otherwise asymptomatic patients, are likely related to psychological disturbances such as major depressive disorder (109). In addition, the overall medical status of the patient should be assessed to take into account possible effects of concurrent illness or side effects of medications such as efavirenz. Psychiatrists should know all medications that a patient is taking. Choice of an antidepressant or mood-stabilizing agent may be influenced by the antiretroviral regimen in place, and doses may need to be adjusted if drug-drug interactions are likely. Psychotherapy should be recommended when indicated.

Manic syndromes are difficult to treat in HIV-infected patients for several reasons. First, mania may result from HIV infection (secondary mania) (33), AIDS-associated brain infections, neoplasms, or treatment with medications like steroids. In addition, manic syndromes can be related to comorbid substance use disorders, and case reports have documented manic symptoms induced by the antiretroviral agents didanosine and zidovudine (110, 111). Patients who experience their first manic episode later in the course of their HIV disease are less likely to have personal or family histories of mood disorders and are more likely to have dementia or neurocognitive slowing (34). Although the prevalence and incidence of mania associated with HIV are not well described, treatment studies suggest that traditional antimanic agents are effective and tolerated.

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d) Substance use disorders

In the United States, substance use disorders are prevalent in the population of persons with or at risk for HIV infection, and treatment is a high priority. Because drug- and alcohol-dependent HIV-infected patients form a large reservoir for HIV in the United States, and because behavior that risks transmission of HIV is often associated with concomitant substance use, psychiatrists should be aware that by treating substance abuse, they may well be preventing HIV infection (112). Unfortunately, the number of injection drug users in the United States outnumbers the available treatment slots.

Treatment with methadone or LAAM (113) can be an important treatment component for persons with opiate dependence. Since the quality of such programs varies, psychiatrists should help identify the best program for their patients. Factors that often indicate higher quality include the use of higher doses of methadone or LAAM and a close working relationship with primary medical clinicians and associated psychosocial services. It should be noted that doses of methadone may need to be increased or decreased in accordance with the use of specific antiretroviral agents that can have an impact on the metabolism of methadone.

Psychiatrists may be primary providers of care in a variety of clinical settings for HIV-infected patients who also have a substance use disorder. Psychiatrists should either provide treatment for their patients with comorbid substance abuse or collaborate with high-quality substance abuse programs. Substance use disorders themselves are often associated with comorbid psychiatric disorders such as anxiety, depression, and psychotic symptoms. Treatment of these comorbid conditions can help stabilize patients who are attempting to achieve sobriety or abstinence.

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e) Anxiety disorders

Many problems involving anxiety symptoms can arise in relationship to HIV illness. An example of a clinical anxiety problem without HIV infection is AIDS phobia. For persons infected with HIV, there are numerous points at various stages of the illness when anxiety about the future, physical symptoms, or clinical decisions can become overwhelming. Psychotherapeutic approaches to situational anxiety can help patients work through intense affects and provide a structure within which sound decisions can be made.

Anxiety disorders can precede HIV infection or arise as its consequence. Treatment of anxiety disorders among HIV-infected patients has not been well studied; thus, psychiatrists should apply standard pharmacologic treatments for anxiety disorders with caution. For instance, many benzodiazepines are contraindicated when patients are taking protease inhibitors, particularly ritonavir, since predicted pharmacokinetics suggest blood levels of these psychotropic agents will be greatly elevated. Thus, benzodiazepines should be given as a short-term intervention in most instances. Psychiatrists may need to adjust medication doses and consider medical setbacks when treating patients with prominent anxiety symptoms. Psychotherapy may be effective in managing anxiety while reducing the need for medications. PTSD is a possible outcome of sexual assault or abuse and may be a focus of clinical treatment for some patients with HIV infection.

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f) Psychotic disorders

Psychotic symptoms in the context of HIV infection, particularly at advanced stages of illness, do not necessarily indicate a primary psychotic disorder, such as schizophrenia, but may arise from causes ranging from opportunistic infections, mania, HIV-associated dementia, or delirium. Evaluation of new-onset psychosis requires a careful medical/neurological workup.

There is no literature to suggest that the use of antipsychotic medication needs to be modified for HIV-infected patients who have good immune functioning and are not taking antiretroviral medication. For patients taking antiretroviral medications, it is important to be aware of drug-drug interactions and overlapping toxicities. In particular, the use of clozapine is problematic with both ritonavir and zidovudine, the former because ritonavir may elevate blood levels of clozapine, the latter because clozapine and zidovudine can each cause significant bone marrow suppression.

In late-stage HIV infection, atypical antipsychotic medications are the first-line treatment because standard neuroleptic medications have been associated with very severe and difficult-to-treat extrapyramidal side effects. Also, in late-stage HIV illness, the lowest effective dose of any atypical antipsychotic medication should be given, since lower doses are sufficient to achieve efficacy and necessary to help prevent side effects.

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g) Adjustment disorders

These disorders are interspersed among other diagnostic categories and are differentiated on the basis of onset after an identifiable stressor. Adjustment disorders are associated with significant emotional or behavioral symptoms. Although they may arise from stressful life events such as testing HIV-antibody positive, they may indicate a subsyndromal state that will evolve into a severe psychiatric disorder if left untreated. Various forms of psychotherapy may be indicated to prevent progression to a more severe psychiatric disturbance.

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h) Sleep disorders

Sleep complaints are common in HIV patients in psychiatric treatment. Sleep disturbances may arise from a psychiatric disorder such as depression or stem from complications of HIV infection. For instance, because pain is a frequent accompaniment of HIV-related illness and is often treatable, clinicians should intervene to alleviate pain that causes sleep disturbance. The antiretroviral medication efavirenz is associated with a high incidence of vivid dreams and nightmares.

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i) Disorders of infancy, childhood, and adolescence

The presenting psychiatric problems of HIV illness in children depend upon factors such as the age and developmental stage of the child, HIV clinical stage, psychosocial situation, and individual vulnerabilities for psychiatric disorders. Although there are few studies in this area, psychiatric disorders are common among infected youth, with rates of about 30% for mood disorders and 25% for attention deficit hyperactivity disorder (114, 115). As mood and anxiety disorders are more likely to be overlooked by caregivers than disorders with prominent behavioral manifestations (externalizing disorders), extra vigilance is required by the psychiatrist.

Just as the standard of care for HIV intervention has changed for adults, so have the treatments for children infected with HIV. Children have increased survival rates and slower progression to AIDS with the use of antiretroviral medications.

Psychiatrists, especially child and adolescent psychiatrists, need to help support children who survive to adolescence to negotiate this complex developmental stage. Psychotherapy may be of particular help for adolescents who are dealing with issues of developing sexuality. For some adolescents, sexuality may be a reminder of their infection. For others, sexual risk behavior may be a reenactment of parental behaviors, a method of mastering their trauma, or a response to their anger concerning their ill health. Substance abuse is frequent (33% in one study) and is likely to involve multiple drug use (116). The issues of risk behavior and autonomy have implications for HIV prevention, adherence to treatment, and effective coping with chronic illness. The family's understanding and capacity to respond in a supportive manner are essential—these adaptations will not only help the child or adolescent cope with the attendant biopsychosocial adversity, they may also influence morbidity and mortality. The importance of family dynamics for children and adolescents with chronic illness and handicapping conditions has long been recognized (117, 118).

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j) HIV-associated syndromes with psychiatric implications

In the case of somatic syndromes that exist at the interface of medical and psychiatric disorders, psychiatrists can serve to integrate treatment approaches and promote interdisciplinary and interspecialty dialogue. Symptoms such as fatigue, weight loss, pain, and sexual dysfunction can be associated with HIV illness as well as psychiatric disorders. It is useful to avoid all-or-nothing, mind or body, approaches when evaluating such nonspecific symptoms. Good communication between psychiatrists and other physicians leads to better treatment decisions. Principles of palliative care apply when a patient is terminally ill and desires treatment that focuses on comfort and symptom relief.

Wasting syndrome generally occurs in patients with more advanced HIV illness and can be related to a number of physiologic disturbances, such as progressive HIV disease, hypogonadism, and gastrointestinal malabsorption. Loss of lean body mass is a strong predictor of increased mortality due to AIDS (119). Wasting is defined as loss of >10% of ideal body weight.

Fatigue is a common, often chronic symptom in HIV disease, frequently associated with depressed mood and physical disability, particularly among patients with more advanced HIV infection or AIDS (120–122).

Patients report pain at all stages of HIV illness, but complaints tend to be more frequent and more intense at advanced stages of systemic illness (123, 124). Common painful symptoms stem from headaches, herpetic lesions, peripheral neuropathy, back pain, throat pain, arthralgias, and muscle and abdominal pain (125).

Sexual dysfunction has been reported to occur in both men and women with HIV infection. In men, hypogonadism can be treated with testosterone replacement (126). As a rule, testosterone more effectively treats diminished libido than erectile dysfunction.

Table Reference Number
Table 14. Screening Examinations for HIV-Associated Cognitive Motor Dysfunction

References

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