HIV and Psychiatric Illness
By Edward Hammond, MD, MPH and Glenn J. Treisman, MD, PhD |
December 1, 2007
Dr Hammond is a clinical research fellow in psychiatry and neurology at the Johns Hopkins School of Medicine, Baltimore. He reports no conflicts of interest concerning the subject matter of this article. Dr Treisman is associate professor of psychiatry at Johns Hopkins School of Medicine and director of AIDS psychiatry at the Johns Hopkins Hospital. He reports that he is on the Speakers' Bureau of Boehringer Ingelheim.
New-onset psychosis is a serious complication of HIV infection and develops more frequently in severely immunocompromised patients. The incidence of first psychotic episodes in patients who are HIV-positive is estimated to range from less than 1% to as high as 15%.24 The pathogenesis of new-onset psychosis in HIV infection is not clearly understood, and the condition is not clearly distinguished from delirium. First-episode psychosis in HIV-positive individuals is frequently associated with paranoid delusions and in a small study of 18 patients was found to be associated with more negative symptoms and positive paranoia but less anxiety and affective distress.25
Psychosis in HIV-positive patients has been associated with illicit drug use, affective disorders, cognitive impairment, dementia, and untreated HIV infection.26 High mortality rates have been reported in HIV-infected patients with psychosis.27 Patients who are HIV-positive have significantly higher rates of psychotic disorders than do controls.24 This may be because patients with schizophrenia are at increased risk for contracting HIV because of their poor understanding of risk behaviors.28
Comorbidity of schizophrenia and HIV infection is a predictor of worse prognosis for both illnesses.29 Individuals with schizophrenia are at increased risk for mortality and may receive less attention from health care workers.30 In addition, these patients are less likely to comply with medical care.A recent con- tradictory finding to our present knowledge, and the first such report, suggests that patients with schizophrenia in the Veterans Affairs health system have a statistically significant 51% decrease in the risk of HIV infection in the absence of substance use disorder.7 Acute psychosis has also been reported to occur as an adverse effect of antiretroviral medications.31
Neuroleptic medications are usually effective in resolving psychosis. Patients with HIV/AIDS who are taking neuroleptics must be monitored closely for the extrapyramidal syndrome (EPS). Patients with AIDS have a greater risk of EPS as an adverse effect than do other medically ill patients.32,33 At low dosages, atypical antipsychotics have been shown to lead to improvements in psychosis in patients infected with HIV without causing EPS.28 Clinicians also need to monitor patients closely for overlapping toxicity between antipsychotic and antiretroviral medications.28
The relationship between anxiety disorders and HIV infection has received less attention than mood disorders and schizophrenia in HIV infection. The prevalence of anxiety disorders in HIV is estimated to be about 38%.34 A review of a national HIV-positive population determined a probable diagnosis of generalized anxiety disorder (GAD) in 15.8%, panic disorder (PD) in 10.5%, and both GAD and PD in 5% of patients.35 In HIV-infected patients, anxiety is associated with a significant negative impact on health-related quality of life.36
A study of the stability of anxiety disorders and depression in a national sample of adults determined that HIV symptom count at diagnosis was a significant predictor of GAD, MDD, PD, and dysthymia.37 Unfortunately, early access to antiretroviral therapy did not reduce the risk of any of these conditions. An increase in HIV symptom count from baseline to follow-up is linked to a 27% increase in risk for GAD.37 In a multivariate analysis, HIV-infected patients with anxiety symptoms were determined to have more than a 5-fold increased risk of suboptimal adherence.38
Posttraumatic stress disorder (PTSD) is more prevalent in the HIV-infected population than in the general population. PTSD and depression account for the variance in antiretroviral therapy adherence.39 PTSD is also associated with faster progression of HIV/AIDS.40 Nilsson Schönnesson and colleagues38 determined that PTSD in patients with HIV was associated with an increased risk of suboptimal adherence to schedule instructions in a multivariate analysis.38 Patients with PTSD had 48% higher odds of being suboptimally adherent to dose instructions.
Lastly, the diagnosis of PD is a good predictor of pain in HIV infection. A cardinal feature of PD is to interpret relatively harmless symptoms of anxiety as catastrophic events. This is not beneficial to HIV-infected patients, who may misinterpret symptoms, thereby worsening any anxiety disorder.
Other psychiatric diagnoses
Although beyond the scope of this article, personality disorders, addictions, and aversive life experiences increase the risk for HIV infection and worsen the problem of poor adherence to antiretroviral drug regimens, which is a critical factor in the treatment of the whole patient. Personality disorders place patients at increased risk for both HIV infection and nonadherence to treatment. Personality disorders often result in decreased access to care because of patient factors and because of health care providers' reactions to difficult personalities.
Behaviors involved in addictions and intoxication with addictive drugs increase the risk of infection and nonadherence, as well as the likelihood of engaging in high-risk sex and prostitution. Patients who experience negative encounters with agencies and health care providers are less trusting and less likely to access care. Indigent and disenfranchised populations are also less likely to access and benefit from medical care.
An ideal model of integrated care should include treatment for HIV infection, substance use, and mental illness, along with provision of social rehabilitation and psychotherapy in a single clinical setting. Although our clinic lacks funding and resources, we have been able to show improved outcomes for patients treated for psychiatric illnesses.41
There is good evidence that the HIV epidemic is in part driven by untreated psychiatric conditions, and that treatment improves outcomes and decreases risks. Those in the field of psychiatry must advocate for better resources for the vulnerable and undertreated people with psychiatric conditions who are infected with HIV/AIDS and die because of a lack of psychiatric care. Such care would help stop the epidemic, improve quality of life, and save money in the long run. In the face of the evidence that the psychiatric conditions our patients have are treatable and that with treatment, outcomes improve and the risk of spreading HIV decreases, to ignore the need for the treatment simply makes no sense and undermines our own health and well-being.
Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference; June 2005; Atlanta. Abstract 595.2.
HIV/AIDS Surveillance Reports, 2005, Revised June 2007. Available at: http://www.cdc.gov/hiv/topics/surveillance/
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