SAN FRANCISCO – Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.
“It's one of the only objective measures I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center. Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.
Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug instead of adding one, he said. (See box.)
Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.
In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were escitalopram, citalopram, sertraline, and mirtazapine, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were unchanged, but Dr. Daroff would not generally initiate treatment with escitalopram because the other agents were available in generic form.
Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase reverse transcriptase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.
If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania. Quetiapine or lamotrigine may be a better choice than an antidepressant in these patients, he said.
Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV and anxiety are often “exquisitely sensitive to side effects,” he advised.
Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”
Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.
The review (Psychosom. Med. 2008;70:575–84) and other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in these patients, Dr. Daroff said.
The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” added Dr. Daroff.
He reported having no relevant disclosures.
Psychotherapy is underprescribed in HIV patients and should be considered a part of the overall therapeutic approach, Dr. Robert B. Daroff Jr. says.
Source Courtesy Patricia Reed
Side Effects of Antiretrovirals
Didanosine: Nervousness, anxiety, confusion, insomnia.
Lamivudine: Insomnia, mania.
Stavudine: Confusion, depression, anxiety, mania, insomnia.
Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.
Raltegravir: May worsen preexisting depression.
Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.
Source: Dr. Daroff