This set of slides was part of a presentation made at the amfAR National HIV/AIDS Update Conference in Miami, Fla., on April 4, 2003.
It is intended to be an overview of some of the important issues surrounding the psychiatric and neuropsychiatric manifestations of HIV infection. It is not an exhaustive or complete review of this subject area, which would be beyond the scope of a presentation such as this.
The importance of an awareness of psychiatric symptoms is highlighted by the results of a survey sponsored by the International Association of Physicians in AIDS Care (IAPAC). It showed that some 80 percent of respondents with HIV infection had experienced symptoms of depression, but that only about one-third of their physicians had assessed them for psychiatric symptoms without being prompted by the patient. This indicates the need to increase the awareness of physicians and other healthcare professionals about the prevalence of psychiatric symptoms and disorders among those with HIV infection.
A study at Columbia University underlined the importance of identifying psychiatric disorder, substance abuse and parenting stress. This study showed that single, minority mothers were less likely to adhere to their antiretroviral medication regimen if they had a psychiatric disorder, substance abuse or were experiencing parenting stress. Treatment settings need to identify these problems and be able to provide treatment and support in order to assure a better HIV treatment outcome.
The presentation goes on to review some of the important neuropsychiatric manifestations of HIV infection, such as HIV-associated dementia (HAD), minor cognitive motor disorder (MCMD), toxoplasmosis, and cryptococcal meningitis. Other psychiatric problems that manifest during HIV infection include psychotic and mood disorders. Some psychiatric symptoms may be side effects of antiretroviral medications. Such psychiatric side effects are most commonly seen with efavirenz, and in some cases may include serious symptoms, such as hallucinations and depression.
The presentation outlines some features of a work-up for a HIV-infected person presenting with new onset psychiatric symptoms. Several treatment interventions are reviewed, including the beneficial effects of antiretroviral medications, which have resulted in a lower prevalence of severe HIV-associated dementia, and lower incidence of CNS toxoplasmosis and cryptococcal meningitis. Issues regarding the central nervous system (CNS) penetration of HAART remain to be clarified.
Finally, a brief overview is presented on the use of psychostimulants and antidepressants to manage early symptoms of HAD and depression.
Ewald Horwath, M.D. is Associate Clinical Professor of Psychiatry College of Physicians and Surgeons at Columbia University.