Some persons with HIV and AIDS do not have a psychiatric disorder, while others have multiple complex psychiatric disorders that are responses to illness or treatments or are associated with HIV/AIDS (such as HAND) or other medical illnesses and treatments (such as hepatitis C, cirrhosis, end-stage liver disease, HIV nephropathy, end-stage renal disease, anemia, coronary artery disease, and cancer). See this article at CurrentPsychiatry.com for case studies of HIV patients with delirium, depression, posttraumatic stress disorder (PTSD), and substance dependence.
Mood disorders. Depression is common among persons with HIV. Demoralization and bereavement may masquerade as depression and can complicate diagnosis and treatment. Depression and other mood disorders may be related to stigma and AIDSism as well as to biologic, psychological, social, and genetic factors. Because suicide is prevalent among persons with HIV and AIDS,13 every patient with HIV should be evaluated for depression and suicidal ideation.
PTSD is prevalent among persons with HIV. It is a risky diagnosis because it is associated with a sense of a foreshortened future, which leads to a lack of adequate self-care, poor adherence to medical care, risky behaviors, and comorbid substance dependence to help numb the pain of trauma.14,15 Persons with PTSD may have difficulty trusting clinicians and other authority figures if their trauma was a high-betrayal trauma, such as incest or military trauma.14,15
In patients with HIV, PTSD often is overlooked because it may be overshadowed by other psychiatric diagnoses. Intimate partner violence, history of childhood trauma, and childhood sexual abuse are risk factors for HIV infection and PTSD. Increased severity of HIV-related PTSD symptoms is associated with having a greater number of HIV-related physical symptoms, history of pre-HIV trauma, decreased social support, increased perception of stigma, and negative life events.
PTSD also is associated with nonadherence to risk reduction strategies and medical care.14,15 Diagnosis is further complicated by repression or retrograde amnesia of traumatic events and difficulties forming trusting relationships and disclosing HIV status to sexual partners or potential sexual partners because of fear of rejection.
Substance use disorders. Dependence on alcohol and other drugs complicates and perpetuates the HIV pandemic. Sharing needles and other drug paraphernalia is instrumental in HIV transmission. The indirect effects of alcohol and substance abuse include:
• the impact of intimate partner violence, child abuse, neglect, and/or abandonment
• development of PTSD in adults, with early childhood trauma leading to repeating their own history
• lack of self-care
• unhealthy partner choices
• use of drugs and alcohol to numb the pain associated with trauma.
Persons who are using alcohol or other drugs may have difficulty attending to their health, and substance dependence may prevent persons at risk from seeking HIV testing.
Intoxication from alcohol and drug use frequently leads to inappropriate partner choice, violent and coercive sexual behaviors, and lack of condom use. Substance dependence also may lead individuals to exchange sex for drugs and to fail to adhere to safer sexual practices or use sterile drug paraphernalia.
Treating persons with HIV/AIDS
Several organizations publish evidence-based clinical guidelines for treating depression, anxiety, substance abuse, and other psychiatric disorders in patients with HIV/AIDS. One such set of guidelines is available from the New York State Department of Health AIDS Institute at www.hivguidelines.org. As is the case with patients who do not have HIV, psychotherapy and pharmacotherapy are common first-line treatments.
Psychotherapy. Patients with HIV/AIDS with psychiatric comorbidities generally respond well to psychotherapeutic treatments.16,17 The choice of therapy needs to be tailored to the needs of individuals, couples, and families coping with AIDS. Options include:
• individual, couple, family, and group psychotherapy
• crisis intervention
• 12-step programs (Alcohol Anonymous, Narcotics Anonymous, etc.)
• adult survivors of child abuse programs (www.ascasupport.org), groups, and workbooks
• palliative psychiatry
• bereavement therapy
• spiritual support
• relaxation response
• wellness interventions such as exercise, yoga, keeping a journal, writing a life narrative, reading, artwork, movement therapy, listening to music or books on tape, and working on crossword puzzles and jigsaw puzzles.
Psychopharmacotherapy. Accurate diagnosis and awareness of drug-drug and drug-illness interactions are important when treating patients with HIV/AIDS; consult resources in the literature18 and online resources that are updated regularly (see Related Resources). Because persons with AIDS are particularly vulnerable to extrapyramidal and anticholinergic side effects of psychotropics, the principle start very low and go very slow is critical. For patients who are opioid-dependent, be cautious when prescribing medications that are cytochrome P450 3A4 inducers—such as carbamazepine, efavirenz, nevirapine, and ritonavir—because these medications can lower methadone levels in persons receiving agonist treatment and might lead to opioid withdrawal symptoms, discontinuation of ARVs, or relapse to opioids.18 When a person with AIDS is experiencing pain and is on a maintenance dose of methadone for heroin withdrawal, pain should be treated as a separate problem with additional opioids. Methadone for relapse prevention will target opioid tolerance needs and prevent withdrawal but will not provide analgesia for pain.