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

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsTable 10-18: Differential diagnosis of major depressive disorder (MDD)Disorder26 picasBipolar disorderGriefAdjustment disorder withdepressed moodOrganic mood disorderDementiaDeliriumMedication-induced,substance-induced mooddisordersDifferentiated from MDD by:Racing thoughts, increased energy, decreased need for sleep,irritability, hypersexuality (these may coexist with depressedmood in a mixed bipolar state)Onset associated with the loss; responsive to changes in theenvironment with less sadness or enjoyment; decreasing severityover time; preoccupation with deceased; “psychotic” symptomsrelated to deceased such as seeing, being visited by the deceased;rare suicidal intent although reunion fantasies may existSadness is rarely as profound; little anhedonia; no vegetativesymptoms; identifiable precipitant; responsive to environmentalchange; suicidal ideation and intent may still occurIdentifiable agent linked by time; less anhedonia or hopelessness;test for specific medical conditions such as TSH, B12, VDRLor RPR, CNS evaluation; no family historyLess concern with cognitive decline; more gradual changes; mayrespond with laughter; worse at night; specific neurologicaldeficits; CT scan often abnormalFluctuating mental status with altered level of consciousness;distractibility; inability to focus or sustain attention; dysarthricspeech; agitation; medical etiologyOnset with use of: steroids, anticholinergics, sedative-hypnotics,anticonvulsants, antiparkinsonians, beta-blockers, anti-TB meds;sympathomimetrics; azidothymidine, stavudine; all illicit drugs;urine toxicology screen; medication historyTSH, thyroid-stimulating hormone; VDRL/RPR, nontreponemal serologic tests for syphilis.Source: Kobayashi J. Psychiatric issues. In Anderson JR, ed. Guide to Clinical Care of Women with HIV. Rockville, Maryland: U.S.Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2001, p. 304.Affective Disorders in Children and AdolescentsRates of psychiatric disorders among HIV-positive children and adolescents are generally similarto those among adults. One study showed 85% had at least one Axis I diagnosis 54 and 53% hadhistory of psychiatric contact prior to their HIV diagnosis. Among adolescents, 34% had majordepression according to one study, 54 and 25% had major depressive disorder and high rates ofdistress in another. 55 Children and adolescents come to the attention of providers less withinternalizing disorders (depression and anxiety) than externalizing disorders (conduct-behavioraldisorders). 56226U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsDepression in children and adolescents must be evaluated in the context of HIV disease, thecognitive and emotional stage of development, and manifestations of HIV in the CNS. Suicidalitymust be thoroughly assessed and treated. One study showed 28% of HIV-positive adolescentsreported26a suicidepicasattempt. 57 Another study showed one third of HIV-positive adolescents requiredhospitalization because of a suicide attempt. 54 Children and adolescents may expresshopelessness over the future, fear of themselves or their infected parents dying, or being unableto participate with their peers as “normal” children due to physical or cognitive limitations.ManiaAs with depression, rates of mania increase as HIV disease progresses. Only 1 to 2% of patientswith early HIV experience a manic episode. Since this is only slightly higher than rates for maniain the general population, this may reflect the increased risk for infection with HIV due to hypersexuality,poor judgment and/or substance use that are associated with bipolar disorder. However,as HIV progresses to AIDS, 4 to 8% may have a manic episode. 58,59 In addition, mania inadvanced disease can be associated with cognitive changes or HIV dementia.AIDS-related mania can differ clinically from the true mania of bipolar disorder in that irritability,rather than true grandiose euphoria, is the core symptom. 60 Common symptoms of maniainclude the following:• Decreased sleep, increased activity• Increased talkativeness, pressured speech• Evidence of racing thoughts• Attention to unimportant or irrelevant activities• Grandiosity or inflated sense of self• Hallucinations or delusions• Increased goal-oriented activity• Psychomotor agitation• Excessive spending, or sexual activity without good judgmentThe clinical presentation of mania requires emergency psychiatric intervention, particularly ifpsychotic symptoms are present and judgment is impaired.Prescribed and illicit use of androgenic and/or anabolic steroids can cause or exacerbate maniaor hypomania and should be ruled out in the work-up of this symptom. Gancyclovir and dapsonehave also been associated with increased rates of mania.XTreatment of Mood DisordersTreatment of mood disorders must be tailored to the individual patient’s illness and circumstances.Although antidepressant medications are commonly prescribed by primary and palliativecare providers, referral to a psychiatrist should be made when the patient experiencessignificant side effects or does not respond to the psychopharmacological intervention. Clinicallydepressed patients with HIV have been shown to benefit from a therapeutic relationshipand from medications to alleviate depressive symptoms. 61 Additional studies have indicated thatsome types of psychotherapy and medications together may be more effective in treating depressionthan either one alone. 62 Additionally, management of psychotropic medications in thedebilitated, fragile AIDS patient may be difficult and warrant specialist consultation.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 227
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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Chapter 6.26 picasPulmonary Symptom
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 18.26 picasLegal and Financ
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Chapter 19.Palliative 26 picas Care
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DRUGS AND THERAPIES INDEXNOTES: Ent
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