The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsThe diagnosis and treatment of psychiatric disorders is essential to the well-being of a personinfected by HIV. Depression, for example, has been associated with shorter survival times inHIV-infected men26 picas50 and women. Appropriate mental health care is also essential if patients areto engage in treatment and sustain sobriety and protective sexual practices.It is never appropriate to assume that a psychiatric symptom is merely an “understandable”emotional reaction to a particular situation. Table 10-17 lists some common misperceptions inthis regard.Mood DisordersMood disorders are associated with substance use, impaired quality of life, mental suffering,suicide, poor adherence to antiretroviral regimens and increased risk for behaviors such asmultiple sexual partners and drug use that transmit HIV. 51DepressionStudies show that depressive disorders are very common but underdiagnosed and undertreatedin HIV infection. 52,53 Depressive symptoms increase over the course of HIV illness, especiallyafter the onset of AIDS. These increases are not necessarily associated with HAD or MCMD.Depression must be differentiated from many other conditions common in HIV which are presentedin Table 10-18. Major depression is never a “normal” response to a particular situation. Itmust be approached with the same rigor as any other medical illness.Patients often feel that they are depressed for good reason, or that they feel fatigued and sadbecause they are sick. Providers must understand and make clear that depression is a treatablemedical illness that responds well to both psychotherapy and medications. Somatic symptoms,such as fatigue, trouble sleeping, decreased appetite or sexual drive, and mental slowing arealso symptoms of HIV-related cognitive disorders. Symptoms of anhedonia, guilty feelings, sadnessand loss of hope may be helpful in distinguishing depression from cognitive impairment.XDepression at the End of LifeEven at the end of life, depression is a disorder that requires treatment, and should never beconsidered a normal response to illness or dying. Patients who are not clinically depressed maytalk about the sadness of leaving others behind, of dying, or of fear of the unknown. Depressedpatients near the end of life will likely have flattened affect or an inability to respond appropriatelyto loved ones, or might be withdrawn and mute. When in doubt, using low dosepsychostimulants may be very helpful in reducing the depression, and increasing cognitive functioneven in the last weeks of life. In the agitated or anxious patient very low doses of risperidone(.25 to 1mg) or olanzapine (1.25 to 5mg) may be a helpful treatment.Providers must distinguish between depression and grief. While sadness may be present in bothconditions, grief is a normal reaction to loss or impending loss. Further, grief may manifestdifferently across cultures. Anticipating the loss of function and quality of life, and acknowledgingan impending death, can appear to observers like depression. Grief, however, is often accompaniedby powerful and profound affective states and crying, while severe depression appearsmore like an emotional paralysis, with patients often unable to mobilize any affect other thanhopelessness.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 225