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 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