Causes/Relationship of Mental Health Problems in HIV&AIDS
• Manifestations of mental disorders in HIV & AIDS are multiple and these may be due to:
The virus (HIV) invasion of the brain resulting in acute inflammation, and
degenerative changes
Sero-conversion from non-clinical to clinical AIDS stage
Physical changes associated with the diseases progression are
Progressive weight loss
Skin rashes
Subtle loss of functional ability in daily activities
Opportunistic infections including
Tuberculosis
Cryptococcal infection
Toxoplasmosis
Cytomegalovirus (CMV)
Varicella zoster virus (VZV)
PML (progressive multifocal leukencephalopathy)
HIV dementia
Neurosyphilis
Secondary spread of cancer such as Lymphoma and KS
News of positive HIV test result
Intoxication (alcohol or other drugs)
Co-morbid mental health disorders such as depression, anxiety, bipolar and
schizophrenia
Psychosocial and environmental factors such as
Stress stigma and discrimination
Unemployment
Bereavement
Family separations (single parent)
Orphanage
Social economic reasons
Mental Health Problems in HIV and AIDS
The nature of HIV physical symptoms, relentless progressive course together with the
reactions of other people explain why emotional distress is common in patients with HIV
infection.
Groups at high risk haemophilia and drug abusers may have other psychological or
neuropsychiatric problems in addition to symptoms of organic brain HIV infection thus
complicate the picture.
Neuropsychiatry problems and other psychosocial disorders may occur at any stage of the
disease progression.
Furthermore, effects of HIV infection in the family are significant where the partner and/or
children also suffer from the infection.
Social and cultural differences are both considerable because of the public fears of the
condition and stigma.
HIV and AIDS Encephalopathy
Causes
• HIV invasion of the brain tissue results in acute inflammation and degenerative changes
• Opportunistic infections including tuberculosis, cryptococcal and toxoplasmosis
• Secondary spread of cancer such as Lymphoma and KS
Clinical Features
• Vomiting
• Irritability
• Photophobia
• Neck stiffness
• Papilloedema
• Variable pyrexia
• Disturbance of consciousness from mild somnolence to coma
• Delirium may be the main picture
• Epileptic fits can occur
Management
• All HIV patients with CNS problems must be referred to hospitals for proper evaluation,
investigations and treatment.
History
• Family members and friends may provide the vital information needed but carefully
observe confidentiality
• Review of systems may lend insight to the nature of the process such as meningismus,
headache or focal neurological deficits
• The past medical history is of particular importance
• Medication list prescribed, over the counter, and illicit drugs must be obtained.
Physical Examination
• Centered on evidence of organ dysfunction and opportunistic infections.
• Additional neurological findings may have dramatic clinical impact.
Laboratory Investigations
• CD4 count
• Renal function tests
• Liver function tests
• Blood culture
• Sputum gram stain
• ZN stain
• Complete blood count
• Electrolytes
• CSF investigations
• Stool and urine culture
• Lumbar puncture is contraindicated for suspected case of increased intracranial pressure
and in brain hemorrhages.
• All these investigations are done at a referral hospital or in CTC where laboratory
facilities are adequately available.
Treatment
• Refer to CTC for the following therapy
• First identify what the cause of the mental health status change is, then:
Anti-retroviral therapy with drugs which can penetrate into the CNS
Treatment should aim at full viral suppression for longest time with the least toxicity
Adequate nutrition, rest, regular exercise, stop alcohol use and refraining from other
drug use, output/input chart, vitals monitoring, catheterization and iv line
Active manage of opportunistic infection or other problem if present
Management of HIV and Mental Illness
• Adherence to medications (ARVs, antidepressant, antipsychotics) for a person who is
suffering from mental illness is difficult to achieve
• Mentally ill patients may have no or poor insight or are incapacitated
• Family, friends, social workers need to accompany patients to CTC and psychiatry units
• Adherence plan should be followed
• Antidepressants e.g. Amitriptyline, Imipramine, dose of 25- 75 mg per day interacts with
Lopinavir and Ritonavir
• These ARVs increase antidepressant levels in serum
• Antidepressant are used in treating
Depression
Phobias
Anxiety
• Serotonin specific re-uptake inhibitors e.g. Fluoxetine dose of 10- 20 mg per day is
recommended in patients on ARVs.
• Nevirapine decreases antidepressant levels
• Antidepressant increase levels of Efavirenz, Indinavir, Lopinavir and Ritonavir
• Efavirenz can cause CNS side effects such as
Vivid dreams
Nightmares
Vertigo
Confusion
Severe side effects can be acute psychosis and would avoid use of efavirenz in a
patient with serious mental health issues (such as bipolar or schizophrenia)
• These symptoms are often mild and transient.
• Patients may benefit from assurance, but if the patient is not able to understand and has
marked elevation of psychiatric symptoms that CTC counselor, will change Efavirenz to
Nevirapine.
• Anti epileptic (anticonvlsions) medication Tegretol i.e. carbamezapine, and
antipsychotics such phenothiazides i.e. largatil, haloperidol, may cause liver toxicity
(hepatotoxicity).
• These may interact with ARVs retinovir which is also potentially hepatotoxic.
• Liver function test are necessary in these condition and immediate changing of drugs is
recommended.
• Drug abusers and alcohol dependants can have liver function test (hepatic enzymes
transaminase) elevations.
• Drug addicts may also have been suffering from residual Hepatitis B antibodies due to
sharing of intravenous needles.
• ARVs that may interact or cause hepatotoxicity to drug addicts who show symptoms of
hepato-biliary tract, should be shifted to less toxic ARVs if available or monitor very
carefully for toxicity.
Adverse Effects of Efavirenz (EFV)
• CNC Toxicity
Very frequent (52%) usually lasts 2-4 weeks
Dizziness, headache, insomnia, depression, impaired concentration, agitation, strange
dreams or nightmares, somnolence
• Only 2% serious psychiatric symptoms
Depression
Delusion
Mania
Suicidal thoughts
• Higher risk if history of mental illness/substance abuse
• Avoid in patients with psychiatric disorders
Efavirenz Central Nervous System Toxicity Management
• Inform patients very well and reassure
• Bedtime dosing
• Avoid driving the car in beginning
• Avoid alcohol
• Use agenda, inform friends to remember appointments
• Expose to pleasant activity before sleeping to reduce nightmares
• If serious psychiatric symptoms refer to higher level for possible replacement of EFV
with NVP
Other HIV Neuropsychiatric Conditions
AIDS Dementia Complex (ADC)
• Patients present with sub cortical encephalitis resulting in progressive sub-cortical
dementia without focal neurological sign
• Development of sub-cortical dementia is a bad prognostic sign where death may occur
within 6 months if not on ARV therapy
• 30% of HIV infected individual develop HIV associated dementia
• The CD4 count is often below 200 cells/mm3
Clinical Features
• Apathy or lethargy
• Social withdrawal
• Hyper-reflexia
• Paraesthesias and increased muscle tone
• Cognitive dysfunctions which include
Concentration and memory deficits
Inattention and later on mutism
• Motor deficits including
Motor inco-ordination
Ataxia, spastic gait and later paraplegia
Management
• Similar treatment as in HIV encephalopathy
• HAART therapy is the management of choice for HIV dementia
HIV and AIDS Associated Delirium
• Risk Factors for Developing Delirium in HIV
Advanced stage of the HIV and AIDS
Substance abuse intoxication and/or overdose
Malignancies of the central nervous system
Drug interactions in AIDS patients taking multiple medication
High fever from any cause
Seizures (convulsions)
Treatment
• The treatment of HIV-associated delirium includes typical management of delirium in
organic psychiatric disorders and HIV management as in HIV encephalopathy.
Psychosocial Reaction to HIV and AIDS
• Patients with HIV have many psychosocial reactions which include
Depression
Anxiety disorders
Substance abuse
Diagnostic Features of Depression
• Depressed mood
• Decreased interest in activities
• Anhedonia (loss of the capacity to experience pleasure)
• Fatigue
• Weight loss
• Impaired ability of mental concentration
• Recurrent thoughts of death and hopelessness
• Profound sense of not well disproportionate to medical condition
Diagnostic Challenges
• Misconception that depression in HIV is normal.
• Overlapping symptoms such as fatigue, weight loss and insomnia may be due to
depression or physical illness such as HIV.
• Chronic pain and chronic physical syndromes co-morbid with mood disorders.
• Medication-related depression and anxiety may pose challenges in the diagnosis.
• Substance abuse may be associated with depression hence adding more challenges.
Management
• Mainstay of treatment is antidepressants like (amitriptyline 25-50 mg per day, to start
with. Then the dose can be slowly increased to 100-150mg a day.
• Start at low dose and increase slowly a dose of around 100-150mg daily
• Avoid overmedication and side effect
• Black Tanzanian patients respond well to a lower than recommended doses
• Common early side effects to amitryptiline are dry mouth, urinary retention. More severe
side effects include arrhythmias, delirium.
• Serotonin selective reuptake inhibitors (SSRIs) e.g., fluoxetine are preferable especially
in elderly patients. And for these there is also a need for starting at lower dosing that is
later on raised.
o Fluoxetine – 20mg daily
Neuropsychiatric Manifestation of HIV
Scenario
Frida is 31 years old HIV positive woman presents with weakness on the left side of the
body for 5 days. She has been complaining of fever and throbbing headache which is
intermittent for more than one month and she is not taking any medication. Physical
examination revealed sad mood, irritability, confusion, with increased muscle tone.
Paralyzed left arm and leg, herpes zoster scar on left side of the chest.
Answers
1. What could be the cause of confusion to Frida?
• HIV and AIDS Encephalophathy
• Brain tissue damage due to stroke or infection such as (Toxoplasmosis, cryptococcosis,
TB meningitis, PML)
2. What kind of mental disorder is Frida suffering from?
• AIDS dementia complex
• Depression
• Delirium (confusion)
3. How will you manage Frida?
Management
History
• Family members and friends may provide the vital information needed while carefully
observing confidentiality
• Review of systems my lend insight to the nature of the process (meningismus, headache
or focal neurological deficits)
• The past medical history is of particular importance
• Medication list prescribed, over the counter, and illicit drugs must be obtained
Physical Examination
• Centered on evidence of organ dysfunction and opportunistic infections.
• Additional neurological findings may have dramatic clinical impact.
Laboratory Investigation
• CD4 count
• Renal function tests
• Liver function tests
• Blood culture
• Sputum gram stain (if available)
• ZN stain
• Complete blood count
• Electrolytes
• CSF investigations
• Lumbar puncture is contraindicated for suspected case of increased intracranial pressure
and in brain hemorrhages
• All these investigations are done at a referral hospital or in CTC where laboratory
facilities are adequately available
Treatment
• Refer to CTC for farther evaluation and initiation of treatment
• Need to identify underlying cause of her paralysis before initiation of any HIV specific
medications. If acute bacterial meningitis is suspected- give appropriate IV antibiotics
first before transfer.
• Anti-retroviral therapy with drugs which can penetrate into the CNS when able to take
them
Treatment should aim at full viral suppression for the longest time with the least
toxicity
Adequate nutrition, rest, regular exercise, stop alcohol use and refraining from other
drug use, output/input chart, vitals monitoring, catheterization and IV line
Manage opportunistic infection
REFFERNCES;
Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed. Oxford: McGraw Hill
Davidson, S (2006). Principles and practice of medicine 20th Ed. Churchill: Livingstone.
Kumar
& Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.
Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold
Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford
Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.
Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF
Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby
Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.
0 Comments