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 ProblemsFor longer-term or chronic anxiety disorders, maintenance with antidepressants may help avoidthe use of potentially addictive agents, and are generally effective for generalized anxiety disorder,panic disorder, obsessive compulsive disorder, and social phobia. Venlafaxine is effective forgeneral26anxietypicasdisorder, usually well tolerated in people with HIV, and has few interactions withother HIV medications, although sexual side effects may interfere with the person’s willingnessto continue the medication. All of the SSRIs as well can cause significant sexual and gastrointestinalside effects sufficient to cause patients to be non-adherent. Anticipating such side effectsand starting with lower than typical doses may help alleviate these problems and allow patientsto accommodate more easily to the medications.Adding buproprion to a regimen of other antidepressants to help counter the sexual side effectsmay enhance adherence. However, buproprion alone is not usually sufficient to treat anxiety,and is stimulating, so caution must be used in adding it into the regimen in anxious patients.Using long-acting (SR) formulations, and simply anticipating the potential problems will oftencomfort patients enough for them to try tolerating the medications. Buspirone may be effectivefor GAD but requires several weeks of bid-tid dosing to be effective.Medications which are most effective in treatment of OCD include the SSRIs, particularlyfluvoxamine, sertraline, and fluoxetine. These are typically required in higher dosages than fordepression. Anafronil, strongly anticholinergic, is effective for OCD but not well tolerated in theperson with HIV.The SSRIs and some mood stabilizers may be useful for diminishing the physiological responsesassociated with PTSD.Cognitive behavioral therapy may be particularly useful in addressing the underlying distortedthinking, irrational thinking, and maladaptive behavior. Specific techniques that address particularanxiety syndromes, short-term psychoeducational groups, individual therapy and ongoingtherapy groups all may be useful in reducing anxiety symptoms.Anxiety Disorders in Children and AdolescentsAnxiety symptoms and disorders occur more frequently in HIV-positive than HIV-negative children.68,69 Anxiety in children may focus on life span, how they contracted HIV and health concerns.Ruminations about death may be excessive and disabling. Physiological changes, such asshortness of breath, gastrointestinal symptoms, or neurological problems may compound theseconcerns. The extent to which psychological functioning is affected varies with the cognitiveand developmental stage of the child.As in adults, treatment includes anti-anxiety medication and psychotherapy. Clinically, SSRIsare used for long-term anxiety and BZs for short-term, situation anxiety. Teaching children touse deep breathing exercises, progressive muscle relaxation and guided imagery may relievesymptoms and provide some sense of mastery to children feeling out of control of their feelingsand bodily functions.236U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau