Introduction to Mental Health Care for People Living with or Affected by HIV/AIDS: A Practical Guide

An excerpt follows from Mental Health Care for People Living with or Affected by HIV/AIDS: A Practical Guide. The guide was developed through the collaboration of the Substance Abuse and Mental Health Services Administrations Center for Mental Health Services, the National Institutes of Health's National Institute of Mental Health, and the Health Resources and Services Administrations HIV/AIDS Bureau.

Psychiatric & Neurologic Conditions

There are several neuropsychiatric complications associated with HIV infection. These complications have numerous etiologies. Awareness of them will assist clinicians in appropriate client assessment, referral, and treatment. In almost all cases, access to a clinician with skills in neuropsychiatric assessment and treatment is essential.

Neuropsychiatric conditions are rarely isolated occurrences. Instead, they generally occur in conjunction with other medical, mental health, and substance abuse problems. These complications, particularly when left untreated, are associated with increased morbidity and mortality, impaired quality of life, and numerous psychosocial challenges, such as nonadherence with the treatment regimen. The complexity of these conditions should encourage all mental health clinicians to incorporate multidisciplinary approaches to client-centered care.

For the purposes of this Practical Guide, neuropsychiatric complications are categorized as follows:

" Disorders attributed to HIV in the brain

" Disorders due to medical complications of HIV infection

" Psychiatric disorders

" Serious mental illness

For each of these conditions, comprehensive management strategies require skilled interventions that utilize psychotropic medication management, medical treatment, behavioral management, and psychosocial care.

Disorders Attributed to HIV in the Brain

HIV-Associated Dementia (HAD). Clients who develop HAD generally will experience abnormalities in their cognitive and motor abilities that significantly impair their ability to function effectively. HAD signals progression to AIDS for those HIV-positive persons not yet meeting AIDS-defining criteria. Generally, HAD occurs in later stages of HIV infection, and debilitating symptoms may progress over time. Pharmacological treatments include antiretroviral therapies and psychotropic medications. This condition cannot be diagnosed when a client is simultaneously experiencing delirium (see below). Screening instruments that may be helpful in diagnosing HAD include the Mini-Mental State Examination (Folstein et al, 1975) and the HIV Dementia Scale (Power et al, 1995).

Minor Motor-Cognitive Disorder (MMCD). Clients who develop MMCD will experience mild and sometimes subtle decrements in their motor or cognitive functioning. Examples include clients who have slight difficulty coordinating finger or hand movements, but not to the extent that use of their fingers or hands is severely limited. Similarly, clients may develop mild impairments in memory, but not to the extent that their impairment is noticeable by others. MMCD does not necessarily progress to HAD.

Delirium. This neuropsychiatric disorder is characterized by a disturbance of consciousness (i.e., reduced clarity or awareness of ones environment) with reduced ability to sustain attention. Delirium is accompanied by memory problems and perceptual disturbances, such as illusions (e.g., misinterpreting objects or persons as something else). The condition develops over hours to days and fluctuates throughout the day. Delirium is the most common neuropsychiatric complication in hospitalized persons with HIV who are severely ill. A screening instrument helpful in diagnosing delirium is the Mini-Mental State Examination (Folstein et al, 1975).

Treatment. Primary treatment for these conditions attributed to HIV in the brain consists of medical management (e.g., psychotropic and antiretroviral agents) in combination with psychotherapeutic and support services.

Disorders Due to Medical Complications of HIV Infection

The course of HIV infection may include medical complications that create changes in ones mental status that mimic more common psychiatric conditions, such as depression, mania, anxiety, and psychosis. The most critical feature of treatment is accurate diagnosis and treatment of the medical causes. Although psychotropic medications often are warranted for symptom relief, at least temporarily, overall management should focus on treating the underlying medical complication(s). When these conditions occur, coordinated care with medical providers is absolutely essential.

These complications highlight the need for clinicians to be aware of and knowledgeable about clients medications and substance use patterns and to be suspicious of major changes in mental status, particularly among clients with more advanced illness or those on many medications.

Treatment. Primary treatment for these conditions due to complications of HIV infection relies on treatment of the underlying medical etiology.

Possible Underlying Causes of Common Medical Complications Associated with HIV

Opportunistic brain infections

Opportunistic cancers

Metabolic complications

Drug-to-drug toxic interactions

Psychoactive substance use complications

Prescribed