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Psychiatric Complications of HIV Disease

Psychiatric syndromes that can complicate HIV disease include depression, anxiety/panic disorder, delirium, psychosis, mania and dementia. The underlying organic cause for all of these symptoms is usually HIV-associated organic brain disease. In other patients the primary causative factors may be situational stressors, genetic predispositions, substance abuse.

Psychiatric complications are among the most treatable complications of HIV disease.

Specific Syndromes:


Rule out Rx side effect

Overlap with symptoms of HIV disease (eg, fatigue and libido)

Choosing an anti-depressant:

 avoid and exploit side-effects

in general, avoid sedating, very anticholinergic TCAs (eg, Elavil)

the SSRIs are generally better tolerated but have a high incidence of sexual dysfunction side-effects (5-10% per published data, >20% in my experience)

Bupropion (Wellbutrin) less likely to cause sexual dysfunction but must be taken bid-tid, and is relatively contraindicated in patients with seizure disorders.

stimulants may be useful, especially in patients with disabling morning fatigue or concomitant cognitive dysfunction.

Anxiety/Panic Disorders:

Anxiety may present as memory impairment or fatigue.

Panic attacks can mimic neurologic and cardiopulmonary syndromes.

Treatment strategy for anxiety: determine whether short (eg, alprazolam, lorazepam) vs. long- acting (clonazapam) anxiolytics are indicated.

Treatment strategy for panic attacks: if chronic/frequent, both an antidepressant (for long term prevention) and an anxiolytic (for short term stabilization) indicated.


Rule out Rx effect (eg, steroids), metabolic abnormalities (eg, hypoglyiemia), hypoxemia, Primary CNS disease, substance abuse.

Treat with midpotency neuroleptics (and possibly shot-acting benzodiazapines) (eg, Trilafon), and mileau management.


Organic vs. functional - similar presentation.

Same differential diagnosis and treatment principals as delirium.


Commonly seen late in HIM disease, as a complication of organic brain disease. Also, commonly complicates high-dose steroid use (eg, for early PCP).

Treatment: stabilize initially with mid-potency neuroleptics (eg, Trilafon); stop/taper steroids or other contributing reeds as promptly as possible; if long-term treatment needed, avoid lithium, consider valproic acid (Depekoate is the best tolerated formulation) or carbamazapine.

Organic Brain Disease:

Probably underlies/copresents with most HIV-associated mood/cognitive disturbances.

High-dose (800 mg/day) AZT therapy may help reverse cognitive defects

Selected Antidepressants