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Psychiatric Complications and Psychosocial Issues in HIV Disease

The psychiatric complications of AIDS---depression, anxiety/panic disorder, delirium, mania, psychosis and organic brain disease are common and very treatable. The incidence of these syndromes increases with non-psychiatric HIV disease progression. Medically sicker patients are more apt to have psychiatric complications.

Depression

Recent observational studies have suggested that the prevalence of depression in HIV-positive persons ranges between 4 percent and 14 percent, compared to a general population prevalence of approximately 5 percent.

The overlap problem has also been noted in diagnosing depression in the geriatric population where many of these symptoms can been seen with aging or co-morbid medical disease.

Another significant methodologic problem in diagnosing depression in patients with HIV disease is the overlap between symptoms of organic brain disease and primary depression. These symptoms can include anhedonia, decreased libido and blunted affect. In some patients, it appears that the organic brain disease and the depression.

A major barrier to the effective diagnosis of depression in the medically ill is the understandable but incorrect notion that depression is a situationally appropriate response to medical disease. For example, many providers may believe that they, too, might be depressed were they facing the losses involved in having HIV disease.

Anxiety/Panic Disorder

HIV-positive patients commonly experience anxiety and, when this is chronic, it can be extremely disabling. Symptoms of anxiety include trouble falling asleep, impaired concentration, fatigue, and psychomotor agitation. Medications often may cause anxiety; these include corticosteroids, nonsteroidal antiinflammatory drugs, and high-dose sulfonamide therapy. Anxiety also can be caused by substance use withdrawal. All patients with new anxiety should be screened carefully for substance use or drug withdrawal.

Discrete intense episodes of anxiety that include a constellation of physical symptoms such as dizziness, chest pain, shortness of breath, paresthesias of the fingers, toes and lips, and a sense of impending doom are called panic attacks. Medically ill patients have an increased incidence of panic attacks relative to the general population.

Delirium

Delirium is a life-threatening complication of many medical diseases including HIV disease. The causes of delirium are many and diverse and, therefore, an inclusive diagnostic approach should be undertaken initially.

Mania

Mania is a disorder of mood characterized by persistently grandiose or irritable moods with less need for sleep, psychomotor agitation, inflated self esteem, and pursuit of pleasurable activities with impaired judgment.

Carbamazapine (Tegretol) also may be useful, but some experts are concerned about the possibility of Tegretol causing bone marrow suppression in patients with HIV disease who are already receiving marrow suppressives.

Psychosis

HIV-positive patients may exhibit symptoms of psychosis that are indistinguishable from primary functional disorders. Symptoms of these psychotic disorders include hallucinations, delusions, flight of ideas, and paranoid delusions.

Treatment. Because of the risk of neuroleptic malignant syndrome and increased frequency and severity of extrapyramidal symptoms seen with high-potency neuroleptic medicines in people with advanced HIV disease, mid-potency neuroleptic medicines such as Trilafon are generally the best treatment for HIV-associated psychosis. While low-potency neuroleptics such as Thorazine and Mellaril may be useful to help the patient sleep.

Organic Brain Disease/Dementia

HIV-associated organic brain disease is often the organic substrate underlying the psychiatric syndromes previously discussed. There is a great deal of overlap between patients with HIV-associated organic brain disease.