AETC-NMC
   

Treatment of Mental Disorders in HIV-Infected Patients

The complex challenges of managing HIV-positive patients who are also experiencing one or more mental disorders suggest that these patients are best served by an integrated care program that includes treatment for their HIV disease, any comorbid mental disorders, and substance abuse when present. A number of studies have shown that, despite the risks of inadequate antiretroviral adherence that may accompany a mental disorder, patients experiencing mental disorders can be treated with HAART to achieve beneficial outcomes. [Himelhoch 2004, Mijch 2006, Walkup 2008]

Depending on the facilities and the communities in which they practice, mental health professionals should become as educated as possible in the medical management of HIV-infected patients. Some mental health practitioners will need to manage patients who present with mental health challenges related to the diagnosis, treatment, and socioeconomic implications of their HIV disease, including, potentially, HIV-related CNS dysfunction, substance abuse, and the coadministration of antiretrovirals and psychotropic medications. Therefore, mental healthcare workers may be called upon to simultaneously manage mental disorders, anticipate potential psychiatric effects of some antiretrovirals, make appropriate referrals for patients with severe mental disorders, and manage a host of other potential situations.

Cultural Competence

Moreover, all of these medical and therapeutic challenges take place in contexts that increasingly often require skills in culturally and linguistically sensitive patient care, including treatment of individuals from such diverse communities as men who have sex with men (MSM), injection drug users (IDUs), a wide range of ethnic and racial populations, women, young people, and older adults. Clinicians, mental healthcare workers, and other healthcare providers will, therefore, need to be prepared to provide appropriate services in a context that requires team approaches and knowledge that spans more than a single area of specialty. [Fernandez 2010]

This collaborative approach is discussed at length in a 1999 report, Mental Health Care for People Living with HIV/AIDS: A Practical Guide, issued by the Substance Abuse and Mental Health Services Administration (SAMHSA). The core challenges and recommended approaches are summarized in the report’s introduction, and they largely are still relevant today: [Acuff Mental]

To increase the likelihood of treatment adherence and to promote wellness, the provider must address client-specific concerns on many levels:

  • Social and Environmental Circumstances. These include poverty, access to care, family relationships, housing, financial needs, food, child care, transportation, and legal status. Such concerns may be further complicated by homelessness, incarceration, and prostitution.
  • Psychological Factors. These include stress; depression; anxiety; cognitive impairments due to HIV-associated dementia; psychosis; mania; preexisting serious mental illness, including schizophrenia and bipolar disorder; and poor judgment and impulsivity associated with personality disorders. Defense mechanisms, such as avoidance and denial, also may interfere with seeking and accepting treatment.
  • Biological Aspects. The health issues associated with HIV include the client’s medical condition; health of the immune system; symptoms and common opportunistic infections (e.g., of the brain); medications prescribed both prophylactically and for symptom relief; and co-existing chronic illnesses, such as diabetes, renal and liver disease, and high blood pressure.

Antiretroviral Drug-Drug Interactions

Some of the most commonly prescribed antiretrovirals can interact with a number of medications used to treat mental disorders, including some antidepressants and antipsychotics. Such interactions can lead to either increased or decreased levels of either the antiretroviral agent or the psychotropic medication, potentially resulting in inadequate therapy for either condition. Information regarding drug-drug interactions between antiretrovirals and numerous other categories of medications is available online from HIV InSite, a program of the University of California, San Francisco: http://hivinsite.ucsf.edu/insite?page=ar-00-02&post=9 and from Medscape: http://reference.medscape.com/drug-interactionchecker?src=ads. Both of these resources are updated regularly. In addition, the full prescribing information sheet available for all medications will indicate drug-drug interactions known at the time of publication.

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Howard University College of Medicine AIDS Education and Training Center - National Multicultural Center