Clinical Manual for Management of the HIV-Infected ... - myCME.com

Depression
Background
Major depression is a cause of significant morbidity
among people with HIV disease. Management of this
condition may be complicated by its multifactorial
etiology. A diagnosis of HIV may not only cause
psychological crisis, but may also complicate underlying
psychological or psychiatric problems (eg, preexisting
depression, anxiety, or substance abuse). In addition,
direct viral infection of the central nervous system (CNS)
can cause several neuropsychiatric syndromes. Finally,
both constitutional disease and medications can impair
neurologic function and mood.
The clinician’s task is 4-fold:
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Maintain a high index of suspicion for depression
and screen frequently for mood disorders.
Elicit any history of psychiatric diagnoses or
treatment.
Rule out organic causes of mood or functional
alterations.
Refer for appropriate psychiatric evaluation and
psychosocial support, including substance abuse
counselors and domestic violence service providers.
Patients with untreated depression experience
substantial morbidity and may become self-destructive
or suicidal. They are also at continuing risk for unsafe
behaviors that may lead to HIV transmission.
Major depression in persons with comorbid medical
illness, including HIV infection, has been associated
with numerous adverse events, such as the following:
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Decreased survival
Impaired quality of life
Decreased treatment adherence
Longer hospital stays
Increased risk behaviors
Suicide
Although depression occurs independently of physical
symptoms, recent research has concluded that it is
associated with higher mortality rates in HIV-infected
individuals. Stress and depressive symptoms, especially
when they occur jointly, are associated with diminished
immune defenses in HIV-infected individuals.
S: Subjective
Section 8—Neuropsychiatric Disorders | 8–5
The patient may complain of the following:
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Appetite changes with weight changes (increase or
decrease)
Decreased ability to concentrate
Depressed mood, sadness, hopelessness
Diminished interest or pleasure in activities
Fatigue or loss of energy
Feelings of worthlessness or guilt
Insomnia or hypersomnia
Psychomotor agitation or retardation
Recurrent thoughts of death or suicide
History
Inquire about the symptoms listed above, and about
associated symptoms. If 5 of these symptoms occur on
most days for at least 2 weeks, a clinically significant
major affective disorder is present and requires
intervention. Depressed mood or diminished interest or
pleasure must be 1 of the 5 symptoms present.
Take a careful history of the timing of symptoms, their
relationship to life events (eg, HIV testing, loss of a
friend) and any other physical changes noted along
with the mood changes. Elicit personal and family
histories of depression or suicidal behavior. Probe for
suicidal thoughts, plans, and materials to execute the
plans. Inquire about hallucinations, paranoia, and other
symptoms. Take a thorough history of medication use
and substance abuse.
O: Objective
Perform mental status examination, including
affect, mood, orientation, appearance, agitation, or
psychomotor slowing; perform neurologic examination
if appropriate.