Mr. G, a 28-year-old heterosexual Puerto Rican man, is admitted to the hospital’s infectious diseases (ID) unit after 3 weeks of worsening bifrontal headaches. He has been treated as an outpatient for several years since becoming HIV-positive and was diagnosed with AIDS after an intracranial toxoplasmosis infection. Although he has not taken antiretrovirals for several months, Mr. G has adhered intermittently to his antiretroviral regimen and previously developed other opportunistic infections, including thrush and bacterial pneumonia.
Three days after Mr. G is admitted, ID clinicians become concerned that he appears severely depressed and request a psychiatric evaluation.
Psychiatric evaluation and diagnosis in patients with HIV can be a challenge because of:
- the myriad ways HIV can impact the CNS
- the proliferation of antiretroviral medications
- patients’ increasing lifespan as a result of highly active antiretroviral therapy (HAART)1
- the psychological repercussions of living with HIV infection.
In this case-based review, we outline a rational, 5-step approach to evaluating and diagnosing psychiatric symptoms in patients with HIV.
A wide differential diagnosis
Patients who are HIV-positive have disproportionately high rates of psychiatric disorders. One study of approximately 2,800 adults receiving care for HIV found that nearly one-half screened positive for major depression, dysthymia, generalized anxiety disorders, or panic attacks.2 Some psychiatric morbidity may be related to:
- the stress of having HIV
- stressors related to risk factors for acquiring HIV, including low socioeconomic status, homelessness, and discrimination and social stigma based on race and sexual orientation
- substance abuse, which is common among patients with HIV.2
Because of the range and variety of psychopathology encountered in HIV disease, keep a wide differential diagnosis in mind when evaluating patients with HIV.
A 5-step process can help you determine if symptoms in any patient—regardless of HIV status—are caused by a primary psychiatric disorder or CNS impairment (Box).
Table 1
HIV-associated CNS infections
| More common |
| Cryptococcus neoformans meningitis |
| Progressive multifocal leukoencephalopathy (polyomavirus JC) |
| Toxoplasma gondii |
| Less common |
| Aspergillosis |
| Coccidioidomycosis |
| Cytomegalovirus |
| Herpes simplex or varicella-zoster encephalitis |
| Histoplasmosis |
| Leptomeningeal tuberculosis |
| Source: References 5-8 |
Neuropsychiatric side effects of antiretroviral medications
| Medication | Potential side effect(s) |
|---|---|
| Abacavir | Depression, anxiety, psychosis |
| Amprenavir | Mood changes |
| Didanosine | Lethargy, nervousness, anxiety, confusion, sleep disturbances, mood disorders, psychosis |
| Efavirenz | Agitation, depersonalization, hallucinations, disturbed dreams, mood disorders, depression, suicidality, antisocial behavior, psychosis, catatonia, delirium |
| Enfuvirtide | Anxiety, depression |
| Indinavir | Mood changes |
| Lamivudine | Insomnia, mood disorders |
| Lopinavir+Ritonavir | Mood changes, agitation, anxiety |
| Nevirapine | Depression, cognitive impairment, psychosis |
| Ritonavir | Anxiety |
| Saquinavir | Depression, anxiety, sleep disturbances |
| Stavudine | Sleep disorders, mood disorders, delirium |
| Zalcitabine | Somnolence, impaired concentration, mood disorders, delirium |
| Zidovudine | Sleep disturbance, vivid dreams, agitation, mania, depression, psychotic symptoms, delirium |
| Source: References 9,10 | |
STEP 1 Perform initial exams
A careful diagnostic exam that includes a mental status examination with gross cognitive functioning testing is necessary to differentiate primary psychiatric disorders from HIV-related CNS pathology, including:
- HIV-associated dementia
- HIV-associated minor cognitive motor disorder (a less severe form of HIV-related cognitive and psychomotor impairment)
- opportunistic infections.
CASE CONTINUED
Mr. G sits in a chair alone in his room, looking out the window. He responds minimally to your initial greetings and has a staring expression and flat affect. Mr. G is calm and cooperative with the exam but has almost no spontaneous speech, answering questions with slow, imprecise 3- or 4-word responses. He is relaxed and does not seem guarded or paranoid.
Mr. G denies depressed mood or suicidal thinking and appears surprised to be asked about these symptoms. He also denies a history of manic or psychotic symptoms or problems with sleep, appetite, or energy. Bedside cognitive exam—focusing on alertness, orientation, attention, and memory—does not demonstrate any gross deficits.
Cognitive workup. Be vigilant for deficits in attention and orientation that might indicate an acute brain syndrome. In addition, look for discrepant patterns of symptoms or other features that may suggest CNS pathology. For example, Mr. G’s impoverished speech and lack of motivation—combined with a clear sensorium and lack of obvious patterns of mood, anxiety, or psychotic symptoms—suggest that a primary psychiatric disorder might not explain his presentation.
Although commonly used, the bedside Mini-Mental State Examination may be insensitive to cognitive deficits in HIV-associated dementia. The HIV-Dementia Scale is more sensitive to HIV’s typical subcortical features.
Physical workup. When evaluating symptoms in an immunocompromised patient at risk for opportunistic infections, it is important to conduct a comprehensive physical exam. Pay attention to evidence of secondary infection and to neurologic signs. Fever may suggest an opportunistic infection that could contribute to psychiatric symptoms. Immunocompromise in HIV may be associated with a variety of infectious meningitis forms, such as: