The Specialist Forum Volume 13 No 11 November 2013 | Page 15

HIV/AIDS

New psychiatric treatment
algorithms for HIV patients

S

tudies have shown that psychiatric disorders are more common
in patients with HIV, and that patients with psychiatric disorders
are more likely to engage in risky sex and substance abuse,
which increases their risk of contracting the disease.
The most common causes of psychiatric disorders in people living
with HIV include stress, the direct effect of HIV on the brain, side effects of HIV medication or drugs used to treat comorbidities such as
tuberculosis.
This is according to Drs John Joska, Kevin Stoloff and Eloise Reid
of the department of psychiatry and mental health at the University
of Cape Town and lead authors of the new GSH-HIV Mental Health
Group’s manuals for primary healthcare workers and psychotropic
prescribing in HIV for clinicians in HIV Care. The Department of Health
(DoH) has also developed a new algorithm for the treatment of psyciatric dis­ rders in HIV patients, which was released recently.
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of citalopran include its efficacy at a low dose (10mg) and the fact that
it has fewer drug interactions.
In patients with comorbid pain and/or sleep disorder, the authors
recom­ end the use of tricyclics (amitriptyline or imipramine) as monom
therapy. The recommended dose for amitriptyline is 25mg-150mg per
day (taken at night) and 75mg-150mg for imipramine. The authors
stress that amitriptyline is not recommended for patients with suicidal
tendencies.

Prevalence of psychiatric disorders
According to Drs Joska, Stoloff and Reid, research has shown that
more than 20% of HIV patients suffer from depression, 5% experience
manic episodes, more than 15% have substance abuse disorders and
a further 15% suffer from anxiety. In addition, between 15%-20% have
neurocognitive disorders, while 35% suffer from antiretroviral indused
disorders.

Prescribing psychotropics in HIV
Patients with HIV are ‘generally very sensitive to medication side effects’ because they often metabolise drugs slower, have less lean body
mass and have compromised blood brain functioning, according to the
authors.
It is therefore extremely important to start therapy at ‘low doses and
to go slow’. The authors also recommend that compex regiments (daily
doses versus twice daily) should be avoided, that drug interactions
should be anticipated and that the possible impact of medication on
the patient’s mood behavioural and cognitive functioning should be
considered.
In addition, the treatment of HIV and related conditions is crucial to
the success of psychiatric care. A multidisciplinary approach is therefore advised, and a clear distinction should be made between primary
and secondary psychiatric symptoms.

Depression
Before starting therapy, first determine whether or not the patient is suffering from mild-moderate or severe depression. If the patient suffers
from mild-moderate depression he/she should be referred for psychotherapy. A patient suffering from severe depression, should be started
on an antidepressant. The authors recommend the use of fluoxetine
if the patient is on first-line antiretroviral therapy (ART) or citalopram
for patients on second-line therapy. The latter should be initiated by a
psychatrist.
The advantages of using fluoxetine is that it is affordable, widely
available and safe in overdose. However, patients should be informed
that they might feel agitated during the first few days. The advantages
The Specialist Forum | November 2013

Venlafaxine – initiated by a psychiatrist – is recommended for patients with anxiety and/or for those who have not responded to selective serotonin reuptake inhibitors (SSRIs). The authors recommend that
patients are started on a dose of 37.5mg-225mg daily, but caution that
the dose needs to be reduced gradually when the symptoms are under
control.
The duration of treatment depends on the frequency of episodes. In
patients who have experienced only one episode, the recommended
duration of treatment is six months to a year, patients who have experienced two or three episodes, should be treated for two to three years,
while life-long treatment should be considered for those who have
experienced more than three depressive episodes.
The authors stress that the use of more than one antidepressant
should be avoided as it can lead to the onset of serotonin syndrome.
Symptoms inlcude pyrexia, sweating, diarrhoea, hyperfeflexia, myoclonus and seizures.

Anxiety
Anxiety can occur as part of depression or alone and can be classified
as either:
• Generalised anxiety disorder.
• Panic disorder.
• Phobia.
• Post-traumatic stress disorder.
• Obsessive-compulsive disorder.
Pharmacotherapy is recommended for patients who have experienced
symptoms for more than a month. The authors recommend the use
of fluoxetine in patients on first-line ART or citalopram in patients on
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