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Psychiatric Disorders in HIV-infected Patients

Delirium

Delirium is the clinical manifestation of a CNS metabolic disturbance. Systemic illness, CNS infection or neoplasm, and medications may cause delirium in advanced HIV disease. Hypoxia, dehydration, sepsis, renal failure, hyponatremia, hypercalcemia, and hypoglycemia can cause delirium. Delirium may be caused by HIV encephalopathy, cryptococcal meningitis, neurosyphilis, progressive multifocal leukoencephalopathy, herpes encephalitis, cytomegalovirus encephalitis, disseminated toxoplasmosis, lymphoma, and

Medications associated with delirium. Anticholinergics, antihistamines, sedatives, opioids and antibiotics (cephalosporins and amphotericin B, antineoplastics) can cause delirium. Delirium may be the result of intoxication or withdrawal from abused substances, including alcohol, stimulants, hallucinogens, sedatives, and

Early symptoms of delirium include irritability and sleep-wake cycle alterations. A later symptom of delirium is rapid onset of fluctuating level of consciousness, with markedly poor attention and disorganized thought and speech. Orientation and memory are often impaired. Illusions may be present. The patient may be

Treatment of delirium

Treatment consists of treatment of the underlying disease process and identification of medications contributing to the confusional state.

Olanzapine ( Zyprexa), an "atypical" neuroleptic with a very low incidence of extrapyramidal symptoms, is effective for treatment of agitation accompanying delirium. Treatment should start at 2.5 mg bid or 5 mg qhs, and increasing up to 20 mg po qhs as , an "atypical" neuroleptic with a very low incidence of extrapyramidal symptoms, is effective for treatment of agitation accompanying delirium. Treatment should start at 2.5 mg bid or 5 mg qhs, and increasing up to 20 mg po qhs as

Risperidone ( Risperdal) is also effective and well-tolerated, starting at 0.5 twice a is also effective and well-tolerated, starting at 0.5 twice a

Haloperidol ( Haldol) may be used at low doses (0.5 to 2.0 mg 2 times a day) when intravenous administration is necessary. Extrapyramidal side effects are common. Additional may be used at low doses (0.5 to 2.0 mg 2 times a day) when intravenous administration is necessary. Extrapyramidal side effects are common. Additional

Cognitive impairment and dementia

Neurocognitive impairment is common in persons with advanced HIV disease. Early symptoms include poor concentration, psychomotor slowing, difficulty with complex sequential motor activity, apathy, and

Treatment of dementia consists of treatment of the underlying organic cause. Multidrug regimens to lower serum viral load, which include protease inhibitors, often will slow progression and may even reverse HIV

Depression

Major depressive disorder is a common psychiatric diagnosis in HIV-infected patients. Symptoms include depressed mood, changes in sleep and/or appetite and weight, fatigue, loss of interest or pleasure in daily activities, psychomotor slowing or agitation, feelings of worthlessness or guilt, poor concentration,

Treatment with a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine ( Prozac), sertraline (Zoloft), paroxetine (Paxil), or fluvoxamine ( Luvox) is recommended. SSRIs are very safe in overdose and lack the anticholinergic and orthostatic side effects of tricyclic antidepressants (TCAs). Initial treatment consists of 10 mg of paroxetine or fluoxetine, or 50 mg sertraline, increasing as necessary to 40 mg paroxetine or fluoxetine or 200 mg sertraline.

SSRIs are generally well tolerated, but they may cause nausea, jitteriness, weight loss, insomnia, and sexual dysfunction. These side effects frequently diminish if dosage is reduced or with time.

Bupropion ( Wellbutrin) is a stimulating antidepressant, without the sexual dysfunction of SSRI's, but with a small risk of seizures. The slow release form (Wellbutrin SR) has reduced seizure risk, and is well tolerated. Wellbutrin SR (dose 100 to 200 mg bid) is often used in SSRI nonresponders and in patients who discontinue SSRIs due to sexual dysfunction. is a stimulating antidepressant, without the sexual dysfunction of SSRI's, but with a small risk of seizures. The slow release form (Wellbutrin SR) has reduced seizure risk, and is well tolerated. Wellbutrin SR (dose 100 to 200 mg bid) is often used in SSRI nonresponders and in patients who discontinue SSRIs due to sexual dysfunction.

Venlafaxine ( Effexor) has a side effect profile similar to SSRIs, but may be useful in SSRI nonresponders (starting dose 37.5 bid, or 75 mg qd of the slow release form, Effexor XR). has a side effect profile similar to SSRIs, but may be useful in SSRI nonresponders (starting dose 37.5 bid, or 75 mg qd of the slow release form, Effexor XR).

Tricyclic antidepressant agents are useful for treating peripheral neuropathy pain and depression. They may be effective for those patients who cannot tolerate or who do not respond to SSRIs. TCAs with greater anticholinergic and orthostatic side effects (amitriptyline [Elavil]) should be avoided. A TCA with lower incidence of side effects, such as desipramine ( Norpramin) and nortriptyline ( Pamelor), is

Nortriptyline ( Pamelor) is mildly sedating; dosage is 50 to 150 mg at bedtime. Desipramine ( is mildly sedating; dosage is 50 to 150 mg at bedtime. Desipramine ( Norpramin) is somewhat stimulating; its 100- to 300-mg dose may be taken either in the morning or at bedtime.

Insomnia associated with depression often responds to trazodone ( associated with depression often responds to trazodone ( Desyrel, 50 mg every night, increasing if necessary to 150 to 300 mg every night). Side effects of morning grogginess and orthostatic hypotension. In depressed patients with persistent insomnia, trazodone

Apathetic withdrawal in patients with advanced HIV disease may improve with methylphenidate (Ritalin)