HIV and Psychiatric Illness

December 1, 2007

Most estimates suggest that there are just over a million persons living with HIV/AIDS in the United States. According to CDC data, between 2001 and 2005, an average of 37,127 new cases of HIV infection, HIV infection and later AIDS, and concurrent HIV infection and AIDS were diagnosed each year.

Most estimates suggest that there are just over a million persons living with HIV/AIDS in the United States.1 According to CDC data, between 2001 and 2005, an average of 37,127 new cases of HIV infection, HIV infection and later AIDS, and concurrent HIV infection and AIDS were diagnosed each year.2 Injection drug use, male-to-male sexual contact in men and adolescent boys, and high-risk heterosexual contact in women and adolescent girls are the 3 most common routes of transmission.2 Among individuals with psychiatric illness, injection drug use and other high-risk behaviors contribute significantly to high rates of HIV infection.

In the early 1980s, a number of young men died of infections that were usually only seen in immune-compromised patients. Over the next several years, the HIV virus was identified, characterized, and found to be an RNA virus that was only transmitted by intimate contact, most commonly sex and shared needles. The public health response to the epidemic seemed obvious at the time, and a campaign to educate people at risk about the use of condoms and clean needles was launched. It was surprising to many public health officials that the epidemic continued but less surprising to those who worked in mental health areas and already knew how difficult it is to change behaviors.

The devastation that originally brought mental health professionals to HIV clinics to help with the losses and sadness related to patient deaths gave way to the need for mental health professionals to treat the psychiatric disorders that were associated with the continued high-risk behaviors in psychiatric subpopulations. Depression, mania, impulsivity, substance abuse, intoxication, cognitive impairment, and personality vulnerabilities are all associated with risk of HIV infection.

As an example, in the HIV clinic at Johns Hopkins, which serves about 3000 predominantly indigent and minority patients, we evaluated all new patients coming for medical care in the early 1990s and found that 54% had an Axis I disorder other than substance abuse, and that 74% had a substance use disorder. There were high rates of major depression (20%) and cognitive impairment (18%).3 Later work showed that chronically mentally ill patients were at increased risk for HIV infection. The seroprevalence of HIV infection among the mentally ill is estimated to be 3.1%,4 much higher than the seroprevalence estimate of 0.3% in the general US population.5

Data from the National Treatment Improvement Evaluation Study indicate that the prevalence of HIV among patients with dual diagnoses of severe mental illness and substance abuse is 4.7%, which is much higher than the prevalence of 2.4% in patients with a single diagnosis of substance abuse.6 Patients with dual diagnoses are more than twice as likely to have HIV infection as patients who have a single diagnosis. This is true of older patients as well as younger. In a national sample of veterans in the Veterans Affairs health system in the 2002 fiscal year, researchers determined that the prevalence of HIV infection was twice as high among patients with severe mental illness as it was in patients who did not have severe mental illness.7

In the mid-1990s came the discovery that combination therapy could essentially halt the progression of HIV infection; thus, HIV infection became a chronic disease. This development was a miraculous reversal of the inevitable fatal course that patients had faced only months earlier. The problem was that patients had to take 90% of their medications to prevent progression and the development of viral resistance, and many patients were unable to adhere to the requirements of treatment. Research quickly confirmed that the same psychiatric risk factors that increased transmission of HIV also interfered with the adherence to treatment with antiretroviral cocktails.

Not only does mental illness increase the risk of infection with HIV, but the presence of HIV/AIDS increases the lifetime prevalence of psychiatric illness.8 The relationship between HIV/ AIDS and psychiatric illness increases the severity of illness in either case, with resultant exacerbation of other medical comorbidities. The diagnosis and management of psychiatric illness in HIV/ AIDS is complicated by patient nonadherence to psychiatric treatment and/or HIV treatment.

Depression

Major depressive disorder (MDD) is a common and well-studied psychiatric disorder in patients who are HIV positive. During their lifetime, 22% to 45% of patients living with HIV/AIDS will experience depression compared with 5% to 17% of the general population.9,10 The diagnosis of depression in the context of HIV/AIDS can be a challenge because symptoms of fatigue, decreased appetite and libido, and poor memory are also symptoms of HIV infection. In particular, this is of more importance in older persons with HIV/ AIDS.11 No difference exists between the lifetime prevalence of depression among young and older individuals with HIV/AIDS; in the general population, current and lifetime depression decrease with age.12

Depression is intimately related to HIV infection. Patients with MDD tend to have increased risk-taking behavior and substance use. HIV transmission or acquisition is more likely to result from risky behavior in depressed individuals than in those who are not depressed. Risky behavior includes increased number of lifetime sex partners, having sex with injection drug users, having sex while intoxicated, and having sex for money or drugs.13 Psychiatric patients with depressive disorders who are substance abusers are at higher risk for HIV infection than are psychiatric patients with another diagnosis.14

HIV infection increases the risk of depression. While depressive symptoms may appear as a reaction to a new diagnosis of HIV infection,15 there is also evidence that advancing HIV infection increases depression directly.16

A proposed mechanism of the interrelationship between HIV infection and MDD might be a decrease in cobalamin in the brain associated with HIV infection, which increases the risk of MDD. This is also associated with supression of natural killer cells and CD8 T cells, thereby worsening HIV infection.17 Another suggested mechanism is that HIV infection increases the risk of depression by reducing serotonergic transmission in the brain.18

Depression is also associated with higher rates of nonadherence to medication regimens.19,20 Symptoms of depression, such as apathy, lack of interest in self-care, and loss of concentration may result in patients ignoring symptoms and not keeping clinical appointments, which in turn, may contribute to disease progression and increased mortality. When clinical correlates of HIV infection are controlled for, patients who are depressed have a 2-fold increase in mortality.21 Similarly, improved outcomes, such as increased CD4+ cell counts, decreased hospitalization, and AIDS-related mortality are associated with adherence to medication schedules.22,23

There is no evidence that one antidepressant is superior to another in treating MDD in HIV/AIDS patients, but there is ample evidence that antidepressants are effective in these patients.

Psychosis

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

Anxiety disorders

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.

Future direction

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.

References:

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