HIV/AIDS and Mental Health
There are no community surveys in Zambia of the prevalence of mental
health problems in people with HIV, only personalised estimates from outpatient
and in-patient settings. Whether levels of mental health problems are
comparable with other medical conditions is also unknown. Similar to other serious illnesses, HIV is associated with
a wide range of mental health problems. Organic problems such as delirium are
common and are managed in the usual manner; however, a cause may be
particularly difficult to find because this is often multifactorial. Specific
HIV-related dementias have been described in detail elsewhere (Badkoobehi et al., 2006). Older individuals are at greater risk of
HIV-related cognitive impairment and dementia (Becker et al., 2004) and experience more social isolation (Meadows et al., 1998)
with improved survival and ageing cohorts, these problems may increase. Gender
and associated social consequences contribute to increased risk of mental
health problems (Gallego et al., 2000; Hutton and
Treisman, 2008). Previous contact with
psychiatric services, often because of substance misuse or personality problems,
is associated with an increased risk of mental health problems in people with
HIV (Gallego et al., 2000).
Disease progression and symptomatic disease are
associated with a greater risk of psychological morbidity. The risk may be highest
at diagnosis, when the manner of communication is important. Another time of
increased risk of mental health problems occurs when patients commence
antiretroviral medication; with their potential side effects, this time is also
associated with major health problems and chronic disabling symptoms (Gallego et al., 2000;
Hutton and Treisman, 2008).
Health workers in Zambia have for a long time encountered
neurologic and psychiatric complications in patients with human
immunodeficiency virus (HIV)
infection. This is not surprising since the HIV virus enters the central nervous system
(CNS) early in the course of the infection. HIV enters the CNS by
infecting macrophages and monocytes that then cross the blood brain barrier,
carrying the virus with them. Immunohistochemistry studies show that the virus
is most densely located in the basal ganglia, subcortical regions, and frontal
cortex. The major brain reservoirs for HIV infection and replication are microglia and macrophages.
Astrocytes can be infected but are not a site of active HIV replication. Accordingly, HIV-associated neurologic
complications are indirect effects of viral neurotoxins (viral proteins gp120
and tat) and neurotoxins released by infected or activated microglia,
macrophages, and astrocytes. In the brain, the virus invokes a neurotoxic[1]
inflammatory process. These neurotoxic agents create an inflammatory
environment by activating uninfected microglia and then proceed to injure
surrounding astrocytes and neurons. HIV does not directly infect the neuron, but the neuron is
damaged by the effects of various proinflammatory neurotoxins.
HIV
infection has so far been linked to:
·
Dementia[1],
·
psychosis,
·
anxiety syndromes,
·
mood disorders ,
·
Suicidality
and
·
Alcohol
dependence
In
addition, other HIV-associated
neuropsychiatric complications include the following:
- Minor cognitive motor disorder, which differs
from HAD in severity and degree of functional disability but may progress
to HAD.
- Neurobehavioral impairments (e.g., apathy,
depression, anxiety/agitation, sleep disturbance, hypomania).
- Myelopathy, which is functional disturbance
and/or pathologic change to the spinal cord.
- Aseptic meningitis.
Despite the decreasing incidence of HAD in
recent years, cognitive impairment is the most common CNS complication in people
with HIV/AIDS.
Delirium is the most common cognitive disorder in hospitalized
patients with AIDS.
The prompt diagnosis of cognitive impairment/dementia and delirium may
significantly decrease morbidity and mortality.
Anxiety Syndromes
and HIV/AIDS
As
one would expect, studies have shown that, among seropositive individuals,
there is a higher rate of that anxiety described by the DSM-IV as Generalized
Anxiety Disorder.
In fact studies have also shown that more than 40% of both seronegative and seropositive
homosexual men report episodes of clinical anxiety lasting from one to several
months, with the majority of onsets being related to seroconversions or
commencing after the advent of the AIDS pandemic.
In other words, it has been suggested that the very existence of HIV/AIDS is responsible for a
significant rise in prevalence rates for clinically diagnosable persistent
anxiety. Remarkably, a number of studies have shown that the rates of other
major anxiety disorders (panic disorder, obsessive compulsive disorder) do not
appear to be markedly above community standards in HIV seropositive individuals, even though HIV can be the
manifest content of these conditions. In its clinical dimensions, there is a
significant decrease in anxiety reported with both psychotherapy and
psychopharmacology.
16.2 Delirium and HIV/AIDS
Delirium is the most common neuropsychiatric complication in
hospitalized patients with AIDS. Delirium may be life-threatening and requires immediate medical
attention. Occasionally, patients may present with early signs of delirium in
the primary care setting. Thus, it is essential that health workers be able to
recognize the signs and symptoms and refer patients to the hospital
immediately. In these cases, the clinician should then contact the emergency
department to follow-up with the disposition of the patient.
The
following patients are at risk for developing delirium:
- Those in advanced stages of immunosuppression.
- Those with a history of opportunistic infections,
substance use, head/brain injuries, or episodes of delirium.
- Those with HAD or infections and malignancies of
the CNS
·
Health
workers should assess for delirium
when there is a sudden change in a patient’s cognitive functioning,
consciousness, or behavior.
·
The hallmarks of delirium are an impairment of consciousness, with a
reduced ability to focus or sustain or shift attention, and changes in
cognition or development of perceptual disturbances that are not explained by a
preexisting dementia. These disturbances may develop over a short period of
time, and the symptoms may fluctuate in severity. Delirium is generally a direct physiologic consequence of a
medical condition.
Management of
Patients With HIV Delirium
Treatment
of delirium in patients with HIV/AIDS is based on the same principles used for treatment of delirium in patients with
other medical illnesses. Correcting the underlying conditions that have led to delirium is the
primary treatment. Symptoms such as confusion or agitation can be treated by
using low doses of neuroleptics (e.g., haloperidol[1] or
risperidone). If symptoms of agitation put the patient or others at risk and
are not controlled by low doses of antipsychotics, adding low doses of
lorazepam may achieve sedation. Psychiatric consultation may be helpful in
management.
Mood Disorders
Rates of major depression are
about twice the average for seropositive individuals. It should be noted that
this puts HIV/AIDS in the range found
for other chronic medical illnesses. In hospitalized HIV patients, as with non-HIV hospitalized patients,
rates are much higher and may approach 40%. It is important to note that the
somatic and neurologic symptoms may complicate a differential diagnosis in more
advanced HIV
patients. For them, the clinician should focus for differential diagnosis on
saddened mood, distinct loss of pleasure or interest and feelings of
worthlessness. Suicidality, especially in patients with advanced AIDS who are not
responding to combination therapy, poses a special problem for the clinician.
It is recommended that clinician pose herself the question of human dignity
versus human life. In any case, suicidality based on a sense of failure or
sinfulness should be seen as a diagnostic indicator. Major depression is
sometimes accompanied by disturbances of higher cognitive functions, including
memory and concentration. Evidence suggests that such complaints are just
as likely to be neurologically based, associated for example with AIDS-related
dementia. Common mental status examinations are relatively insensitive to
neurological impairment; health workers should refer patients to experts for
neurological testing. Barring neurological sources, the symptoms of
depression respond significantly to both psychotherapy and psychopharmacology.
“Secondary” mania (an organic mood disorder related to some neurological
diseases, e.g. meningitis or to pharmacological interventions such as AZT) may
appear in HIV
illness. Its treatment is often palliative pharmacology. Otherwise mania
does not appear to be appreciably more common for persons with HIV.
Psychotic
Disorders
With the following
significant exception, psychotic disorders are not particularly prominent among
people with HIV/AIDS. Full-blown psychosis may appear in
late stages of AIDS
with a prevalence rate of up to 5%. Loosening of associations,
hallucinations and even elaborate delusions are common. The diagnosis of
such persons is complicated by prominent disturbances of mood. Moreover,
the emergence of psychotic symptoms is prognostic of death within the
succeeding year. The fear of this condition, far from universal, but well know
in the HIV/AIDS community, is itself
a significant source of depression and anxiety. Psychosis associated with HIV infection is more
responsive to neuroleptic treatment than to psychotherapy.
AIDS dementia complex (ADC)
This
is a metabolic encephalopathy induced by HIV infection and fuelled by immune
activation of brain macrophages and microglia (Gray et al., 2000). These cells
are actively infected with HIV and secrete neurotoxins of both host and viral
origin. The essential features of ADC are disabling cognitive impairment
accompanied by motor dysfunction, speech problems and behavioural change.
Cognitive impairment is characterised by mental slowness, trouble with memory and
poor concentration. Motor symptoms include a loss of fine motor control leading
to clumsiness, poor balance and tremors. Behavioural changes may include apathy,
lethargy and diminished emotional responses and spontaneity. Histopathologically,
it is identified by the infiltration of monocytes and macrophages into the central
nervous system (CNS), gliosis, pallor of myelin sheaths, abnormalities of dendritic
processes and neuronal loss (Adle-Biassette, et al., 1995;
Gray et al., 2000).
AIDS
dementia complex
(ADC) encompasses cognitive deficits, behavioural changes, and motor
involvement. Those affected may manifest deficits in each of the 3 aspects at
varying severity. Some may present primarily with cognitive changes such
as slowed processing of information captured by neuropsychological testing.
Others may present to the psychiatrist for behavioural management. Others may
be affected by motor symptoms such as unsteady gait, tremor, or weakness. In
2007, Antinori et al (2007) proposed more refined criteria for diagnosing
cognitive impairment associated with HIV. They proposed 3 entities: asymptomatic neurocognitive
impairment (ANI), HIV-associated
mild neurocognitive disorder (MND), and HIV-associated dementia
(HAD). Standardized neuropsychological testing was required to assess the
following domains of cognition: language, attention, executive function,
memory, speed of information processing, and perceptual and motor skills.
In order to make one of the above diagnoses, patients have to have no other
etiology of dementia
and not have the confounding effect of substance use or psychiatric illness
(Antinorri et al., 2007).
The
AIDS Dementia Complex is one of
the most common and clinically important CNS complications of late HIV-1 infection. It is a
source of great morbidity and, when severe, is associated with limited
survival. While its pathogenesis remains enigmatic in several important
aspects, ADC is generally thought to be caused by HIV-1 itself, rather than to another
opportunistic infection (Price, 1998). HIV can cross the blood-brain barrier and enter the central
nervous system through virus-infected macrophages. Hence a significant
proportion of HIV-infected
persons will develop this neurologically based cognitive disorder. For some
that will entail subtle impairments in cognitive function (attention deficits,
slower processing of information.) Less commonly, and specifically with frank AIDS, some will develop
more pronounced cognitive deficits (including linguistic disturbances and
psychomotor slowing.) Some patients with this dementia become severely
withdrawn and uncommunicative. Occasionally, this dementia progresses to psychosis and delirium.
The dementia associated with HIV can develop over weeks or
chronically over years. Symptoms may be similar to those associated with other
types of dementia and include decreased short-term memory, decreased attention
and concentration; disturbance in word finding, decelerated thought processing,
psychomotor retardation (slowed movement), impaired reasoning and intellect,
and, in advanced disease, impaired visual-spatial function. Personality changes
and mood disturbances such as depression may occur. Less commonly, manic
symptoms (agitation, irritability, impulsivity, and excessive talkativeness)
and psychosis (hallucinations, delusions, irrational suspiciousness, or
paranoia) may be present. Motor deficits are also a part of the HIV-related
dementia syndrome and may include muscle weakness, increased or decreased
muscle tone, spasticity movements, muscle rigidity or ―cog wheeling, and over
or under- reactive reflexes.
HIV- Related dementia is treatable. That
is, symptoms may be reduced generally with anti-retroviral therapy (ARV).
Specific symptoms of the dementia syndrome may be addressed with particular
treatments as well. For example, if agitation has developed and is severe, low
dose high-potency antipsychotic may be used (e.g. haloperidol 2-5mg po or IM
every 4 hours as needed until agitation subsides). Low dose antipsychotic may
be used if hallucinations are present as well. Antidepressants are helpful in
treating associated depression. Benzodiazepines that are metabolized by the
body in a relatively short period (i.e. with short half-lives such as diazepam
and lorazepam) may be useful for anxiety and insomnia. However, it is important
to be aware that benzodiazepines have also been associated with uninhibited
behaviour (i.e. disinhibition) and cognitive impairment and should be used short-term
and in the lowest effective doses.
CNS infections and
tumours
Individuals with significant HIV disease may be prone to
central nervous system (CNS) infections and tumours that can present with a
combination of neurological and psychiatric symptoms. These conditions are
outlined in detail below and include neurosyphilis, cryptococcal meningitis,
toxoplasmosis, cytomegalovirus (CMV) encephalitis, aseptic meningitis,
progressive multifocal leukoencephalopathy (PML), and CNS lymphoma.
Neurosyphilis
Syphilis is an infection caused by the spirochete, Treponema
pallidum, and has several stages of disease. The primary stage is characterized
by enlarged lymph nodes in the groin region and a painless ―chancre or sore
that may be located on the genitals. This may disappear without treatment but
secondary syphilis characterized by fever, swollen lymph nodes, rash, and
genital lesions may appear after approximately 2 years. During this stage
syphilitic meningitis with headache, nausea, stiff neck, and occasional cranial
nerve deficits may occur. However, more commonly, there are no neurological
symptoms but diagnostic tests analyzing spinal fluid may be abnormal. The
latent or next phase is also characterized by abnormal diagnostic blood tests
and minimal clinical symptoms.
The last stage or tertiary phase is when neurosyphilis
(syphilis affecting brain tissue) occurs. During this phase other organs
including the heart and eyes may be affected as well. Neurosyphilis may present
with or with-out symptoms, however diagnostic tests (of spinal fluid) remain
abnormal. Syphilis in this stage may cause meningitis or a stroke. There may
also be syphilitic dementia associated with seizures, mania, agitation, and grandiose
delusional thoughts. Tabes dorsalis (ataxia/loss of balance, lower extremity
paresthesia and paresis, hyporeflexia, incontinence, and sharp pains) may
occur. ―Gummas or degenerated brain tissue surrounded by thick, fibre-like
tissue may, on rare occasion, lead to a space-occupying brain mass.
Syphilis may be suspected or detected through tests including
VDRL (Venereal Disease Research Laboratory), RPR (rapid plasma reagent), MH-ATP
(microhemiagglutination – assay for treponema pallidum), and FTA (fluorescent
treponemal antibody). In some instances lumbar puncture may be indicated.
Treatment with antibiotics (e.g. penicillin) is effective.
Cryptococcal Meningitis
Cryptococcus neoformans is a fungus that commonly causes
meningitis (swelling of the protective outer-sheath of the brain) in AIDS
patients. Symptoms may occur within days or weeks. Early symptoms may be fever,
lethargy, persistent, progressive headache; seizure and delirium may occur.
Stiff neck typically associated with other types of meningitis is not
necessarily present. Some individuals may develop focal neurological symptoms
including paralysis of cranial nerves causing blindness and deafness, partial
muscle weakness, and over-active reflexes.
Treated or untreated, the disease may
progress to produce complications including seizure, stroke, swelling of the
brain, and coma. Permanent nerve damage and dementia may be long-lasting
complications. Cryptococcus is detected usually by analyzing blood and spinal
fluid for presence of the fungus. Antifungal antibiotics are used as treatment.
Cytomegalovirus (CMV) Encephalitis
CMV belongs to the family of Herpes viruses
and in addition to neurological disease is associated with disease of the eyes,
lungs, oesophagus, intestines, and adrenal gland. Neuropsychiatric
manifestations of CMV include primarily encephalitis (global swelling or
inflammation of brain tissue). Symptoms associated with encephalitis include
fever, headache, lethargy, delirium, dementia, seizure, and coma. Occasionally
facial and ocular cranial nerve impairments and weakness of the lower limbs
occurs. A definitive diagnosis is made through brain biopsy (analysis of a
sample of brain tissue). The recommended treatment is antiviral medication
(e.g. intravenous gancyclovir).
Aseptic Meningitis
A form of meningitis may occur where no pathogen or germ is
evident on diagnostic analysis (i.e. no bacteria evident in spinal fluid). This
has been referred to as aseptic meningitis. Symptoms may emerge within days to
weeks and include headache with or without stiff neck or fever, lethargy and
delirium. Rarely impairment of the cranial nerve that controls movements of the
facial muscles occurs. If available, a
CT or MRI will indicate inflammation of the tissues that make up a protective
sheath enveloping the brain (meninges) and analysis of the spinal fluid will be
abnormal. There is no specific treatment
– however the condition may resolve on its own. Supportive measures (e.g. IV
fluid), ARV therapy, pain medication, and steroids are used empirically.
HIV
related dementia
The specific symptoms and treatments for
depression, anxiety disorders, adjustment disorder, and substance abuse are
outlined in previous chapters. Regarding psychiatric medication therapy, drugs
that are less likely to interfere with or potentiate the side effects of
anti-retroviral medicines should be prescribed.
Psychological Issues
Fear, uncertainty, anger, and guilt are emotions often
experienced by individuals infected by HIV.
Patients may be fearful and uncertain about the effect the virus will
have on their bodies and their lives in general. They may fear subsequent
medical tests, losing the capacity to function independently, losing the
support of friends and family, and death. Providing individuals education and
information can reduce fear and uncertainty. For example, directly teaching or
referring patients to healthcare providers who can teach them about test procedures,
medications and recognizing symptoms of illness early can help individuals feel
in greater control of their circumstances. In addition helping patients
identify reliable supports (family, friends, clergy, therapist, etc…) can allay
fears of abandonment.
Anger is common and may be rooted in a sense of
unfairness. That is, an individual may feel that he or she has been unduly
afflicted. Anger may also stem from a fear of losing control of one‘s life or a
fear of social stigma, rejection, or abandonment. It will be important to help
the patient understand that having anger is alright and a natural human
response. The issue is how the anger is managed. Helping the patient identify
and utilize constructive, productive mechanisms for discharging anger is
imperative.
Guilt
is another emotion that is
often experienced by individuals infected with HIV. A person with HIV may feel
that he or she has brought the virus onto him or herself and should be blamed
and punished. Some experience guilt about introducing HIV into the lives of
others. They may feel that they have created burden and distress for spouses,
partners, parents, children, or friends. Individuals burdened with overwhelming
guilt, should be counselled on how to detach negativity and punishment from the
virus. Help them understand that, in reality, the virus has nothing to do with
punishment. Anyone, ―good or ―bad, has the potential to become infected. In
addition, reinforce patients‘self esteem and sense of worth. Having the
patients remind themselves of who they are outside of having HIV can bolster
self confidence and esteem. Having them recall what people who love them (i.e.
family, partners, and friends) like about them can reinforce self esteem.
Loss of control
As HIV disease progresses, one may need to rely on others to
manage activities of daily living such as cooking, cleaning, bathing, dressing,
feeding, and administration of medications. A loss of independence and control
may be emotionally problematic for individuals who have been accustomed to and
taken great pride in providing for themselves. There may be a great effect on
self-esteem and self-worth that can lead to anxiety and depression. Help
patients control and take responsibility for what they can. If it is clear that
one is able to bathe or feed himself or herself, encourage him or her to do so.
Reassurance and reinforcement for what they can do may potentially help them to
accept and feel less powerless about what they can‘t do. Caregivers often feel
helpless because the patient remains ill despite their intervention or support.
Caregivers should allow patients to take the lead on expressing what feels like
too much or too little help. Those caring for individuals with HIV disease may
find it useful to listen without necessarily providing advice to resolve a
problem. Attending to non-verbal clues and keeping an open channel of communication
could be useful at times.
Essentials of Diagnosis
- Marked acquired impairment of at least two
ability domains of cognitive function (e.g. memory, attention): typically,
the impairment is in multiple domains, especially in learning, information
processing and concentration/attention. The cognitive impairment is
ascertained by medical history, mental status examination or
neuropsychological testing.
- Cognitive impairments interfere markedly with
day-to-day functioning.
- Cognitive impairments are present for at least
one month.
- Cognitive impairments do not meet the criteria
for delirium, or if delirium is present, dementia was diagnosed when delirium was
not present.
- No evidence of another, pre-existing aetiology
that could explain the dementia
(e.g. another CNS infection, CNS neoplasm, cerebrovascular disease,
pre-existing neurological disease, severe substance abuse compatible with
CNS disorder.
Mortality/Morbidity
ADC
causes a significant increase in the overall morbidity due to AIDS.
- The increase in morbidity results from a
combination of factors, including the increased number of
hospitalizations, increased duration of hospital stays, and decreased life
expectancy compared with AIDS patients who do not have dementia. In the pre-HAART era, AIDS patients who had
untreated ADC had an average life span of 6 months, which was
significantly less than that for AIDS patients without dementia. This has now increased to 38 months for ADC
patients in the Western hemisphere who have been on a stable regimen of
HAART (McArthur, 2004).
- The overall psychosocial and emotional burden on
the family and friends of such patients is tremendous, far beyond that of
a cognitively intact patient with AIDS.
- Patients with cognitive difficulties have
problems with compliance and adherence to their medication regimen.
Because of their neuropsychiatric problems, these patients are likely to
be less inhibited and are more prone to HIV-related risk behaviour like
unprotected intercourse, and they therefore pose a greater risk of
transmission of the virus.
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