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HIV AND PSYCHIATRIC ILLNESS
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Karina K. Uldall, MD, MPH
Department of Psychiatry
HIV/AIDS Research Program
University of Washington
April 2003
OVERVIEW
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AIDS Defining Neurological Illnesses
Other CNS Disorders
Psychiatric Illness in HIV/AIDS
Diagnosis and Treatment
April 2003
AIDS DEFINING NEUROLOGICAL
ILLNESS
• CMV Encephalitis
• Progressive Multifocal
Leukoencephalopathy (PML)
• Toxoplasma Encephalitis
• Primary CNS Lymphoma
• Cryptococcal Meningitis
• Rarely TB Meningitis and Kaposi’s
Sarcoma
April 2003
CMV ENCEPHALITIS
• Disorientation, confusion, apathy
• Psychomotor retardation, lethargy, cranial
nerve abnormalities
• Abrupt onset, short course
• CD4 count < 50/uL
• Diagnosed via CSF PCR
• Treated with foscarnet, ganciclovir, both
• Survival less than 2 months
April 2003
PROGRESSIVE MULTIFOCAL
LEUKOENCEPHALOPATHY
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Occurs in approximately 4% of patients
Focal weakness, visual loss
10% spontaneously improve
CD4 count < 100/uL
Diagnosed via CSF JC virus PCR
No clear treatment
Survival 1 to 4 months
April 2003
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 < 200/uL
• Contrast scan - multiple enhancing
lesions, basal ganglia, gray-white junction
• Treated with pyrimethamine/sulfadiazine
April 2003
PRIMARY CNS LYMPHOMA
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Approximately 3-5% of HIV patients
Second most common CNS mass in AIDS
Presentation depends on location of tumor
CD4 count < 100/uL
Contrast scan - usually single lesion noted
Treated with radiation
Survival 2 to 6 months
April 2003
CRYPTOCOCCAL MENINGITIS
• Occurs in approximately 7% of HIV
patients
• Fever, headache, cognitive changes
• Insidious onset spanning 2 to 4 weeks
• CD4 count < 100/uL
• Diagnosed via CSF culture, India ink stain
• Treated with amphotericin B and
fluconazole
April 2003
OTHER CNS DISORDERS
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Bacterial/Viral Meningitis
Neurosyphilis
Herpes Simplex Encephalitis
Varicella-Zoster Encephalitis
Rarely Histoplasmosis and
Coccidiodomycosis
April 2003
PSYCHIATRIC ILLNESS IN HIV/AIDS
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HIV Associated Dementia (HAD)
Delirium
Psychotic Disorders
Mood Disorders
Anxiety Disorders
Substance Abuse and Dependence
April 2003
HIV ASSOCIATED DEMENTIA
• 15-20% of AIDS patients
• Combination of motor, cognitive and
mood/personality changes
• Insidious onset, CD4 count < 200/ul
• CSF Beta-2-microglobulin > 3.8 mg/dL,
HIV-1 RNA >10,000/ml
• AZT, AZT+3TC, d4T+3TC, Indinavir
April 2003
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)
April 2003
DELIRIUM
• Common in later stages of disease, 3060% 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
April 2003
PSYCHOTIC DISORDERS
• Substance induced during intoxication or
withdrawal
• Medical illness induced
– must be distinguished from delirium
– late stage HIV associated dementia
April 2003
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
April 2003
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
April 2003
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
April 2003
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
April 2003
SUICIDE ASSESSMENT
• Gender
• Age
• Ethnicity
April 2003
M>F
15-25 years and > 45 years
men; > 55 years women
Caucasian (Black, Hispanic,
Native American)
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
April 2003
SUICIDE ASSESSMENT
• Behavioral factors
– Changes in behavior
– Messages saying goodbye
– Social isolation
• Lethality
– Access to means
– Method of attempt
– Possibility of rescue
April 2003
-Thorough plan
-Prior attempts
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
April 2003
SUICIDE INTERVENTIONS
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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
April 2003
TREATMENT
• Psychotherapy
– supportive, interpersonal, cognitivebehavioral, group, psychoeducational
– ongoing risk of crises
– countertransference issues
• homophobia, sex, substance use, existential
beliefs, rescue fantasies, identification, therapeutic
nihilism, guilt, fear of contagion
April 2003
TREATMENT
• Pharmacotherapy
– Antidepressants
• SSRIs
• TCAs
• Other
Paroxetine, Sertraline, Fluoxetine
Nortriptyline, Desipramine
Nefazodone, Venlafaxine, Mirtazapine
– Stimulants
• Methylphenidate
• Dextroamphetamine
– Testosterone
April 2003
TREATMENT
• Pharmacotherapy
– Antipsychotics
• typical
• atypical
haloperidol
risperidone, olanzapine
– Antianxiety agents
• benzodiazepines
– Mood stabilizers
• lithium, valproic acid, carbamazepine
April 2003
MEDICATION INTERACTIONS
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Multiple medications
Multiple medical illnesses
Renal or hepatic disease
Elderly
Individual differences in liver metabolism
Specific liver metabolism inhibitors
April 2003
CHOOSING MEDICATIONS
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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”
April 2003
SUMMARY
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Document HIV status
Determine level of immunocompromise
Thorough history and physical exam
Diagnostic tests
– CT/MR
-Urine tox screen/BAL
– LP
– Neuropsychological testing
April 2003
SUMMARY
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HIV-related illness
Other “physical” disorder
Medication toxicity
Substance use
Primary psychiatric illness
April 2003