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James W. Dilley, MD Clinical Professor, Psychiatry UCSF AIDS Health Project

Psychological/Psychiatric Challenges Across the Spectrum of HIV Disease University of Hawaii June 30, 2003. James W. Dilley, MD Clinical Professor, Psychiatry UCSF AIDS Health Project UCSF School of Medicine. “I’m at Risk and should be tested”. What does HIV have to do with me?

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James W. Dilley, MD Clinical Professor, Psychiatry UCSF AIDS Health Project

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  1. Psychological/Psychiatric ChallengesAcross the Spectrum of HIV DiseaseUniversity of HawaiiJune 30, 2003 James W. Dilley, MD Clinical Professor, Psychiatry UCSF AIDS Health Project UCSF School of Medicine

  2. “I’m at Risk and should be tested” • What does HIV have to do with me? • Requires Behavioral self-examination • How has HIV affected others in my life? • Am I too afraid or not afraid enough?

  3. “I’m a person living with HIV” • Affective: Numbing vs. Flooding Living with uncertainty • Cognitive: What does this mean for me? Understanding HIV Disease Becoming a “Patient” • Behavioral: Protecting self and others Lifestyle changes • Social: Disclosure—who, what do I tell? Belonging to a “new group”

  4. “I’m told I should go on treatment, but I feel fine!” • How to decide? • Medication Issues: when and what to start • Managing side effects and adherence

  5. “I’m a person with AIDS” • Managing physical symptoms • More meds • Facing progression/disability • Withdrawing from life

  6. “I’m dying” • End of life issues: Denial vs. Acceptance • “Taking care of business”

  7. Prevalence of MH Disorders among People with HIV/AIDSn = 1489 Vitiello et al. AJPsych 2003, 160:547-54 from “HIV Cost and Services Utilization Study—1996”

  8. Depression in HIV • Most common dx in outpatient setting • Concern re: diagnosis in medically ill . • Emphasize cognitive/affective vs. neurovegetative signs/sxs • Assoc with ê CD4, soc support and é phys limitations and HIV sx • Excellent pharmacologic response • Give benefit of the doubt

  9. Pharmacotherapy of Depression in HIV

  10. Depression & Testosterone • 50% of men with Sx HIV/AIDS have deficiency and sx of hypogonadism: • Fatigue • Decreased libido • Decreased appetite • Decreased mood

  11. HIV produces at diff rates in CNS vs. plsma Diff phen/genotypes: esp later in disease All ARV’s not = in treating CNS cx May result in peripheral success (pVL) but central failure CNS: HIV’s Most Important Sanctuary Site

  12. HIV Neuropathogenesis Early and continuous seeding Importance of Blood Brain Barrier

  13. Cognitive Functions A. Memory Short-term vs. delayed B. Concentration, Calculation and Constructional Ability C. Personality Change: alteration or accentuation of pre-morbid traits D. Language E. Judgement “Reasonable plans”

  14. Early Manifestations of HAD • Cognitive Memory Loss (names, historical details, etc.) Impaired Concentration (difficulty reading, loses track of conversation) Mental slowing (“not as quick,” less verbal) Confusion (time, especially)

  15. Early Manifestations of HAD (continued) • Behavioral Apathy, withdrawal, “depression” Agitation, hallucination • Motor Unsteady gait Bilateral leg weakness Tremor Loss of fine motor coordination

  16. Late Manifestations • Cognitive global dementia in all spheres confusion and distractability slow verbal responsiveness • Behavioral vacant stare disinhibition and restlessness organic psychosis

  17. Late Manifestations (cont.) • Motor general slowing truncal ataxia weakness: legs > arms pyramidal tract signs: spasticity, hyperreflexia

  18. Effect of HAART • Significant changes in the epidemiology of CNS disorders since HAART • In Sx illness • Studies are more consistent with subcortical dementia • In asx illness, NP findings are inconsistent • > Length of battery>NP deficits • Significance clinically is unclear

  19. Pathological Findings in CNS of AIDS Patients at Autopsy N = 1597 1984-1987 (No therapy) 1988-1994 (monotherapy) 1995-1996 (dual comb. therapy) 1997-2000 (triple comb. therapy) Vago L., et al. AIDS 2002, 16:1925-28

  20. Medical Rx of HAD 1. Aggressive ARV: neuroprotective 2. Use combinations of 3, 4 or more Should include: • AZT, D4T, 3TC, Abac-NRTI • Nevirapine, Efavirenz-NNRTI • Indinavir - PI (best BBB penetrance)

  21. Psychopharmacology in HIV Disease Consider geriatric dosing - “start low and go slow” Look for low-anticholinergic meds ConsiderPay special attention to Ritonavir (NORVIR - strong CYP3A4 inhibitor) Overall, anti-HIV meds are not problematic

  22. Ritonavir (Norvir)(Potent inhibitor of CP450, esp. 2D6 and 3A4) 1. AdjustAnti-depressants SSRI’s - initially  by 1/2 TCA’s - initially  by 1/2 to 1/3 Nefazodone and St. John’s Wort 2. Avoid Benzodiazepines Anti-psychotics Clonazepam (Klonopin) Clozapine Alprazolam (Xanax) Pimozide Diazepam (Valium) Flurazepam (Dalmane) Triazolam (Halcion) Zolpidem (Ambien) 2. Allow Temazepam (Restoril) Oxazepam (Serax) Lorazepam (Ativan) Bupropion (Wellbutrin)

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