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HIV-Associated Psychiatric Disorders

Depression in HIV-Infected Patients

A. The incidence of depression in HIV infection is 7-10%, and the risk is particularly high immediately before and after HIV testing. A patient's risk of suicide is elevated in the immediate weeks or months after HIV antibody testing.

B. AZT, acyclovir, interferon INH and sulfonamides can cause neuropsychiatric problems such as depression or delirium.

C. Patients with depression should be screened carefully for substance use because substance use or withdrawal can cause depression and psychomotor agitation.

D. Chronic pain can cause depression and anxiety. Chronic headache due to HIV encephalitis, or chronic extremity pain due to peripheral neuropathy are common causes of pain. Optimization of pain control may bring improvement in the psychiatric disease.

E. Some symptoms of depression, such as fatigue, are common manifestations of HIV infection itself.

F. Diagnostic Criteria for Major Depressive Episode

Anhedonia

Depressed mood

Difficulty in depression thinking or concentrating

Fatigue or anergy

Feelings of depression guilt or worthlessness

Psychomotor slowing

Significant and HIV-associated psychiatric disorders, HIV, AIDS, depression unintentional change in weight

Sleep disturbances

Suicidal ideation

G. Diagnostic Evaluation: Imaging studies and screening for cryptococcal disease and syphilis with serological testing should be undertaken if symptoms suggest the presence of a CNS disorder (headache, focal neurological symptoms, signs of frontal lobe disease).

H. Treatment of Depression

1. Psychiatric referral of the depressed patient may be appropriate if suicidal ideation is strong.



2. The choice of antidepressant depends largely on what adverse effects the person is likely to tolerate.



3. Tricyclic Agents



a. Desipramine, which is the least sedating TCA, and nortriptyline, which is the least anticholinergic TCA, are useful agents because they have minimal side effects.



b. A tricyclic agent such as amitriptyline (Elavil) may be helpful for patients who have difficulty sleeping, although anticholinergic effects can also occur.



c. Many HIV-infected patients have dermatitis and pruritus, and these patients can benefit from an antidepressant that also has antihistaminic effects. Doxepin is a sedating TCA that has substantial antihistamine effects.



d. The tricyclics are useful in treating the chronic pain of peripheral neuropathy, which is a common side effect of some antiretroviral agents.



e. Because TCAs can cause conduction defects, a baseline EKG should be obtained in patients older than 45 or in any patient with cardiac disease.



f. Only small quantities of tricyclics should be prescribed at one time if the patient is a suicide risk because the average 7-10 day supply of a tricyclic antidepressant may be a lethal dose.