Mood Disorders Common Among HIV Patients

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine. Quetiapine or lamotrigine may be better than an antidepressant in these patients. Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. he said.

Psychotherapy should be considered, he said. “I think we're underprescribing psychotherapy in HIV.”

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Dr. Daroff reported having no relevant disclosures.

Few psychiatric drugs are contraindicated in patients on antiretrovirals.

Source DR. DAROFF

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff