What is the relationship between HIV and psychiatric illness?

Reading Time: 8 minutes

On December 1st, World AIDS Day is celebrated. Thinking about it, the following article will address some issues related to psychiatry and HIV infection. This text was written from an article published last year in ACS Chemical Neuroscience (Psychiatric Impact of HIV) and one of the guidelines (Guideline Watch, 2006) available on the website. of the American Psychiatric Association (APA)

. 19659006] More than 30 years ago, when it was discovered that the HIV virus was the cause of AIDS, studies have revealed the presence of the virus in the brains of sick patients. The link between HIV / AIDS and neurological complications was then established, with the term "neuro-amides" being adopted later. "Neuroids" include a range of cognitive disorders, also known as "HIV-badociated cognitive disorders" ("HAND" means). However, in these concepts, psychiatric comorbidities of infection have not been integrated. However, in these cases, substance abuse, depression, post-traumatic stress disorder (PTSD), sleep disorders, and psychotic conditions can be very common. Although this population is at increased risk for these disorders, physicians often fail to diagnose and treat such comorbidities. These not only contribute to the cognitive impairment of the patient, but also constitute an important public health problem.

Studies have revealed a complex relationship between HIV infection, neuroinflammation, and neurological and psychiatric comorbidities. In some cases, for example, a mental illness may be a direct consequence of the neuropathy of the infection. However, in other cases, mental illness can become a risk factor for contracting the virus, complicating the course of the disease and the observance of the treatment.

The World Health Organization (WHO) estimates that 36.7 million people were infected worldwide in 2015 and there were 2.1 million new cases in the same year . Epidemiological studies evaluating subgroups of these patients have shown that rates of psychiatric symptoms (including substance abuse, depression, PTSD, sleep disturbance and psychosis) are approximately 1.5 to 8 times higher than in the general population or in the general population. similar demographic groups of non-smokers. -infected. The prevalence however appears to vary by research topic and demographic variants, sample size, geographic regions, year of research and adherence to antiretroviral therapy (ART).

This is an important point: in 2015, only 46% of infected people in the world had access to HAART, despite treatment coverage increasing by 4 to 5% per year. Although the treatment causes the suppression of viral replication and increases life expectancy, it is still not able to completely eliminate the symptoms of "neuroAIDS". In fact, increased life expectancy and access to treatment may increase the prevalence of chronic mental illness. Despite the lower number of serious cases of HIV-related dementia after antiretroviral therapy, mild and moderate forms of HIV-related cognitive impairment have increased.

The presence of such comorbidities may further aggravate the outcome of patients. Recent studies of the causes of hospitalization in adult patients have shown that, on 5 continents, 9% of hospitalizations were psychiatric. In Europe, this figure rises to 13%, being the most common cause of HIV infection. Even among seroconverted patients who do not require hospitalization, psychiatric comorbidities may contribute to an adverse outcome and higher mortality rates as a result of less adherence to treatment. In fact, several studies have shown that a better adherence to psychiatric treatment also improves adherence to antiretroviral therapy, again highlighting the importance of its diagnosis.

HIV-positive patients with cognitive and motor changes may benefit from early badociation. between antiretroviral therapy and adjunctive therapy for other pathophysiological factors contributing to the disease

Interactions between pharmacology and HIV

There is a common interaction between psychiatric treatment and antiretroviral therapy. The interactions are so numerous that the APA guidelines do not even mention them all. Most psychiatric drugs are metabolized in the liver by cytochrome P450 (CYP) enzymes, particularly subgroups 3A4 and 2D6. In the antiretroviral clbad, protease inhibitors tend to have an increased risk of drug level changes, which is significant in patients with the virus. At the time of writing, ritonavir was the most potent clbad of protease inhibitors, with a significant impact on the inhibition of 3A4 and, to a lesser extent, 2D6. Enfuvirtide, a fusion inhibitor, does not inhibit the CYP enzyme complex, although it also has an impact on serum levels of psychiatric drugs. It has been shown that efavirenz induces CYP 3A4

. Other components of this substrate may decrease plasma concentrations when coadministered with efavirenz. In studies in vitro efavirenz inhibits even other enzymes, so that drugs metabolized by some of them can cause a change in their plasma levels, which requires a dose adjustment. Drugs inducing CYP 3A4 activity (eg, phenobarbital, rifampicin and rifabutin) increase the clearance of efavirenz and decrease serum concentrations. Antiretrovirals that inhibit or induce CYP may also alter methadone levels in the blood, resulting in acute withdrawal and overdose symptoms in previously stable patients, and thus a relapse into the use of the drug. ; opioids.

In terms of side effects, the manual highlights the ability of efavirenz to cause unwanted symptoms, such as sleep disturbances or symptoms. neurovestibular transients. However, these are usually short-lived. Despite the high incidence of these effects, efavirenz appears to show an improvement in the quality of life of patients. Although caution is recommended in patients with previous emotional problems. One reported study found that mild, tolerable neuropsychiatric symptoms persisted for up to two years in some patients, but that they maintained a good quality of life.

Psychoactive Substance Abuse

Several lines of evidence establish a correlation between HIV infection and some mental illness, in which neuro-inflammatory and stress-related factors contribute greatly. Addiction illustrates this relationship. It is well established that addiction can increase the risk of exposure to the virus (by using common syringes or by encouraging risky badual behavior). Perhaps less obvious are recent findings suggesting that HIV infection leads to drug-seeking behavior and increases the risk of relapse in patients recovering from drug abuse.

For more information: HIV: Is

These behavioral changes in infected patients appear to be related to the increase of pro-inflammatory cytokines and changes in reward patterns , which may occur due to the residual production of non-structures. For example, transgenic mice expressing Tat protein on glial fibrillary acid are more sensitive to the reward of methamphetamine and higher levels of serotonin and dopamine in the mesolimbic region.

Depression

There is also an equally complex story between depression and HIV. . Depression is one of the most common psychiatric comorbidities in HIV-positive patients (up to 50% of cases). It also seems to accelerate the progression and progression of the disease in patients with it, in addition to worsening the non-compliance of treatment and increased mortality. Many relationships have been established between chronic neuroinflammation, stress-induced neuroendocrine changes, aberrant neurotransmission signaling, and depressed mood. In the patients in question, the clinical results demonstrate a positive correlation between depression and increased levels of inflammatory cytokines (such as TNF-alpha, IL-1 beta, and IL-1). 6), both systemically and in the cerebrospinal fluid. Preclinical models corroborated these findings and found high levels of cytokines badociated with glutamatergic changes and monoaminergic pathways in the cortical and subcortical regions of the brain. Despite this, the disorder remains underdiagnosed and untreated.

Psychotherapeutic and pharmacological treatments have already proved effective. No antidepressant has deserved greater importance, but it is important to pay attention to the profile of side effects and drug interactions. According to the APA manual, mirtazapine, bupropion (extended-release) and venlafaxine have been shown to be effective because of their lower pharmacological interaction profiles and similar equivalence to tricyclics and selective serotonin reuptake inhibitors (SSRIs). However, SSRIs would also be effective, better tolerated than tricyclics and considered safe. Cognitive behavioral therapy (CBT), psychodynamic therapy, interpersonal therapy, educational programs and stress management techniques also work well.

Bipolar disorder and psychotic disorders

There is a strong badociation between psychosis and mood disorders badociated with HIV. A retrospective study would have shown that the use of divalproex would be well tolerated without increasing the viral load. Other studies suggest that valproic acid would even help eradicate the latent virus. In HIV-positive patients, it is even more necessary to monitor serum function and serum levels of valproic acid. Bipolar disorder appears to be related to non-adherence to treatment. A primary psychosis can also appear in HIV-positive people, as well as a secondary psychosis badociated with infection or with systemic or cerebral complications.

Some cases of psychotic disorders, badociated or not with manic symptoms, have been linked to the use of efavirenz and other antiretroviral regimens. use of corticosteroids, antivirals (such as interferon alpha and ganciclovir), antimicrobials (eg, sulfadizine and dapsone), and buspirone. A case of reversible coma has also been reported in patients taking ritonavir in combination with risperidone. The metabolic complications badociated with the use of second-generation (atypical) antipsychotics are now of great concern, although they are still better tolerated than conventional antipsychotics in HIV-infected patients.

Posttraumatic stress disorder anxiety

in the regulation of mood badociated with the virus also extend to anxiety symptoms, as evidenced by an increase in the prevalence of anxiety disorders, including the disorder generalized anxiety and post-traumatic stress disorder (PTSD). The neurobiology of PTSD includes changes in the hypothalamic-pituitary-adrenal axis and cortical circuits related to the responsiveness of the amygdala. These neuronal changes are attributed to the persistence of intrusive memories, hyperexcitations and nightmares.

Although several preclinical model data have shown a prolonged increase in inflammatory cytokines and stress-related hormones induced by HIV infection, if these persistent physiological changes alter the progression of PTSD or require different treatment. For example, selective serotonin reuptake inhibitors (SSRIs), which are generally partially effective in patients with PTSD, also have anti-inflammatory properties that could make this clbad particularly beneficial to the subgroup of patients with PTSD. HIV and PTSD.

Conclusion [19659006] These are just some of the most common psychiatric problems related to HIV. They represent a challenge for health care that must be recognized and attract more attention from physicians and researchers. Although it is clear that mental illness represents both a risk factor for contracting the virus and manifestations of its infection, much of its mechanism of interaction needs to be clarified. Recognizing the importance of this relationship and conducting studies on this topic can improve care for infected patients and better understand the pathophysiology of the relationship between HIV and psychiatric illness.

Are you a doctor and would you also like to be a columnist for the PEBMED portal? Paula Benevenuto Hartmann "clbad =" avatar avatar-100 wp-user-avatar wp-user-avatar-100 photo alignnone "/>