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 ProblemsTable 10-25: Pharmacologic Agents Used for Sleep Disturbance in HIV (continued)Desipramine 10 to 100mg Anticholinergic alpha May promote sleep(Norpramin) blocking Blood levels (>125ng/dl)26 picasUseful for neuropathyNortriptyline 10 to 100mg Anticholinergic alpha May promote sleep(Pamelor) blocking Blood levels (70 to 125ng/dl)Useful for neuropathyDoxepin 10 to 50mg Sedation May be useful in(Sinequan) at hs Anticholinergic alpha asymptomaticsblockingUseful for neuropathyConfusion in medically illAmitriptyline 10 to 100mg Sedation May be useful in(Elavil) Anticholinergic alpha asymptomaticsblockingUseful for neuropathyConfusion in medically illAntihistamines 10 to 50mg Sedation in AM May be useful in mildly(hydroxyzine, at hs Anticholinergic effects anxious patients withdiphenhydramine) Confusion in medically ill initial insomniaNot usually effectivelong-termXSubstance Use DisordersSubstance use disorders complicate the psychiatric diagnosis and treatment of many patientswith HIV. (See Chapter 11: Substance Use Problems.) Patients with a triple diagnosis ofHIV, psychiatric disorder, and substance use are at increased risk for poor access to care, pooradherence to medical treatments and increased psychological distress leading to increasedmorbidity and mortality.Substance-using patients, including those receiving methadone maintenance treatment (MMT),have high rates of prior psychiatric morbidity and suicidal ideation. 76 Screening for substanceabuse and psychiatric disorders should be routine.Psychiatric Treatment of HIV-Positive Substance UsersThe diagnosis and treatment of drug users with HIV is complicated by multiple risks for neuropsychiatricdisturbance. Acute and chronic effects of alcohol and substances of abuse, methadone,head trauma, and HIV itself can each and in combination cause significant mental statusimpairments. Problems secondary to past trauma or substance use can be differentiated fromcurrent use and HIV neurocognitive effects by serial assessments. Past brain injury or substanceabuse would not continue to cause increasing CNS impairment. Current substance use, CNSinfection, or HIV related cognitive impairment would continue to show decrements of functionover time.There are few studies to show the safety or efficacy of pharmacological treatment of psychiatricdisorders in substance-using patients with HIV. Safety, abuse potential and adherence capacitymust all be considered when prescribing medications for cognitive or psychiatric disorders.Likewise, the capacity for adherence to antiretrovirals often impacts the decision to start orcontinue anti-HIV medications.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 239