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 Problemsmay cause side effects and will not hasten a clinical response. Many patients who are in recoverymay be reluctant to take antidepressants because they believe that mind-altering substancesmust be habit-forming. The patient must be educated and supplied with information aboutdepression,26 picasits treatment, and the differences between antidepressants and benzodiazepines ornarcotics.Because they can present with similar symptoms (poor concentration, memory impairment,fatigue and/or mental slowing), depression and other mood disorders must be differentiatedfrom MCMD or HAD. Psychostimulants are well tolerated in the medically ill patient and maytreat symptoms of both depression and cognitive impairment. As depression and cognitive impairmentoften co-exist in advanced HIV, psychostimulants may be used alone or in conjunctionwith an antidepressant. 63 Mood may improve significantly in the hypogonadal patient (male orfemale) with correction of the underlying androgen deficiency. 64People with HIV may be particularly sensitive to side effects of antidepressants. Starting withlow doses and anticipating side effects for the patient increases his or her ability to tolerate themedication. It is important to allow a reasonable period of time to assess effectiveness of aparticular medication and dose.Psychological support is very important in adherence to antidepressants and other medications.Some clinical suggestions in this regard are as follows:• Start low and go slowly in dosing psychiatric medications. Increase medsaccording to the half-life and time-to-reach-steady-state to avoid overshootingtherapeutic levels.• Anticipate side effects, and suggest that most of the time they maysubside in time.• Encourage patient to call health care provider four to five days after startingmedication to report how well it is being tolerated, and what side effectsare present.• Dose sedating antidepressants one to two hours before sleep time to helpinitiate sleep. Taking medications right at bedtime does not give them timeto be absorbed and to reach peak sedating levels.Treatment for mood disorders in children and adolescents also includes psychotropic medicationsand a variety of psychological and psychosocial interventions. Medications for mood disordersin children and adolescents with HIV have not been well studied, although the SSRIs areused clinically. Individual, group and family therapy are effective in treating issues specific toHIV in adolescents, such as future goals, intimacy issues and self esteem. In the later stages ofdisease, preparation for disability and death may require intensive, multidisciplinary approaches.Suicide EvaluationSuicidal ideation must always be taken seriously. Table 10-20 contains important elements inevaluating suicide risk. Attempts increase under the influence of psychoactive substances andalcohol and in the midst of a delirium or psychosis. 65230U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau