The Psychiatry of HIV Infection

Dr Ajay NihalaniMD,MRCPsych

www.nihalaniclinics.com,www.drnihalanipsychiatristdelhi.com

Mental Disorders in HIV infection

Similar to other potentially serious conditions

Include…normal psychological reactionsEg.shock,denial,distress

Abnormal responses..suicidal behavior and major depressionNeuropsychiatric complications eg dementiaHIV infected individuals at increased risk of developing mental health problemsh/o psychological & social difficulties prior to acquiring HIVSOCIAL STIGMA associated with HIV/AIDS adds to the physical consequences

Factors associated with development of mental disorders in HIVHIV related factors---notofication of HIV infection,decline in health,AIDS diagnosis,disabling symptoms.h/o psychiatric problemsLack of social supportsAvoidance & Denial as a habitual way of copingExposure to grief d/t AIDS & other adverse life eventsPersonal characteristics:age,reduced brain reserve,gender.

Types of mental disorders in HIV/AIDSAbnormal psychological reactions-adjustment disorders,manifestations of personality disorderMood and other disorders-major depression,suicidal bahaviour,manic episodes,sexual dysfunction,anxiety disorders,obsessive compulsive disorder,eating disorders,Organic brain syndromes—acute and subacute brain syndromes,HIV ass. Dementia,HIV associated minor cognitive impairementMental disorders in partners and relativesAbnormal beliefs in people seeking testing for HIV

Abnormal psychological reactionsAnxiety,Insomnia,Depressive Sx.Adjustment disorder in 30%Personality disorder manifestations….eg avoidant,dependent,narcissistic,histrionicWorsened by substance misuse

Mood Disorders

Depression prevalene 80%..often unrecognized or insufficiently treated

Mania…inherent & iatrogenic causes,underlying BPAD

New onset mania in severe symptomatic disease is predictive of reduced survival

Sexual dysfunction…psychological,organic,iatrogenic

Organic brain Syndromes Sec. to immune suppression…opportunistic infections,progressive multifocal leucoencephalopathy,cerebral lymphoma\Delirium…acute and subacute d/t systemic disorder,sec complx

HIV DementiaSubstantial memory and intellectual declineMarked psychomotor slowingMotor abnormalitiesDevelops over a rel short period of time,associated with poor prognosis

Minor cognitive disorder Poorer memory &attention,slower information processing,difficulty with abstract thinking

Mental disorders of partners and relativesAdapt to the changed relationshipIncreased dependencyDeclining healthFear of infectionSocial stigma

Abnormal beliefs in people seeking testing for HIVRemain concerned,convinced they are seropositiveSeek repeated testingMay point to underlying neurotic disorders,inadequate information,mistaken attitudes to delusions

Assessment of Mental Health ProblemsRecognition by those involved in treatment and care

Avoidance of attributing it to the diseaseOr as a normal &understandable reaction Avoidance of negative attitudes

InterventionsEnsuring appropriate counseling Pretest ….significance of the procedure

Post test….outcome

Risk reduction counseling

Use of psychoeducational techniques,psychotherapy,psychopharmacological interventions

Agent Psychiatric side-effects

For additional information see Everall et al, 2004, and the following websites: Clinical Care Options for HIV (www.clinicaloptions.com/hiv); the National AIDS Manual (www.aidsmap.com); AIDSinfo (AIDSinfo.nih.gov). Protease inhibitors Amprenavir Mood changesIndinavir Mood changesLopinavir+ritonavir Mood changes, agitation, anxietyNelfinavir None reportedRitonavir AnxietySaquinavir Depression, anxiety, sleep disturbancesAtazanavir Depression, insomniaFosamprenavir None reportedNucleoside reverse transcriptase inhibitors (NRTIs) Abacavir None reported

DidanosineLethargy, nervousness, anxiety, confusion, sleep disturbances, mood disorders, psychosis

Lamivudine Insomnia, mood disordersStavudine Sleep and mood disorders, delirium

ZalcitabineSomnolence, impaired concentration, mood disorders, delirium

Zidovudine

Sleep disturbance, vivid dreams, agitation, mania and depression, psychotic symptoms, delirium

Coformulated NRTIs Zidovudine+lamivudine See aboveZidovudine+lamivudine+ abacavir See aboveNucleotide reverse transcriptase inhibitors (NtRTI) Tenofovir None reportedNon-nucleoside reverse transcriptase inhibitors (NNRTIs) Delavirdine None reported

Efavirenz

Agitation, depersonalisation, hallucinations, disturbed dreams, mood disorders, depression, suicidality, antisocial behaviour, psychosis, catatonia, delirium

Nevirapine None reportedFusion or entry inhibitors Enfuvirtide Anxiety, depression

Common psychiatric side-effects of licensed antiretroviral agents

Lord,I'm glad I can talk to you. You’re always there - even when my head is somewhere else. Sometimes I feel overwhelmed ashamed, afraid to face the future.It’s hard living with a stigma. It’s not what people say. It’s what they don't say. It’s the knowing smiles, and the sheepish looks. They all add up to a feeling of accusation.Lord, I’m glad I can talk to you Nothing surprises you. You’ve been where I’ve been You’ve felt the discrimination Experienced the betrayal the hurt the name calling the whispering in corners the prejudice.Lord, You make me feel whole again You include me in You make me feel understood Your extravagant generosity leaves me speechless. Words fail me as I try to say Thank you You draw me You give me a place in the picture You tell me I belong even when I can't believe.Lord, you’re unbelievable!

Thank You