who booklet 3

Mental Health and HIV/AIDS

Psychiatric Care in Anti-retroviral (ARV)Therapy (for second level care)

WHO Library Cataloguing-in-Publication Data

Psychiatric care in anti-retroviral (ARV) therapy : for second level care.

(Mental health and HIV/AIDS series)

1.HIV infections - complications 2.Acquired immunodeficiency syndrome - complications3.Anti-retroviral agents - adverse effects 4.Mental disorders - therapy 5.Psychotropicdrugs - therapeutic use 6.Guidelines I.World Health Organization II.Series.

ISBN 92 4 159308 3 (NLM classification: WC 503.7)ISSN 1814-750X

© World Health Organization 2005

All rights reserved. Publications of the World Health Organization can be obtained fromWHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland(tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requestsfor permission to reproduce or translate WHO publications – whether for sale or fornoncommercial distribution – should be addressed to WHO Press, at the above address(fax: +41 22 791 4806; email: [email protected]).

The designations employed and the presentation of the material in this publication donot imply the expression of any opinion whatsoever on the part of the World HealthOrganization concerning the legal status of any country, territory, city or area or of itsauthorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines onmaps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not implythat they are endorsed or recommended by the World Health Organization in preferenceto others of a similar nature that are not mentioned. Errors and omissions excepted, thenames of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information containedin this publication. However, the published material is being distributed without warrantyof any kind, either express or implied. The responsibility for the interpretation and use ofthe material lies with the reader. In no event shall the World Health Organization be liablefor damages arising from its use.

Printed in Johannesburg

Written by:

Dr Francine Cournos(New York State Psychiatric Institute/Columbia University, USA)

Dr Milton Wainberg(New York State Psychiatric Institute/Columbia University, USA)

Dr Ewald Horwath(New York State Psychiatric Institute/Columbia University, USA)

Mental health and HIV/AIDS series

This is module 3 in the Series ‘Mental Health and HIV/AIDS’.

Other modules are:-

1. Organization and systems support for mental health interventions in anti-retroviral (ARV) therapy programmes

2. Basic counselling guidelines for anti-retroviral (ARV) therapy programmes

4. Psychosocial support groups in anti-retroviral (ARV) therapy programmes

5. Psychotherapeutic interventions in anti-retroviral (ARV) therapy (for secondlevel care)

The WHO wishes to acknowledge the financial support of the European Unionthrough the National Department of Health in South Africa. Editorial assistance

was provided by Bobby Rodwell and lay-out and design by FontlineInternational.

Technical and advisory group for this series:

Dr Atalay ALEM (Addis Ababa University, Ethiopia)

Dr Jose BERTOLOTE (WHO, Switzerland)

Dr Jose CATALAN (Chelsea & Westminster Hospital United Kingdom)

Dr Pamela COLLINS (Columbia University and the New York State PsychiatricInstitute, USA)

Dr Francine COURNOS (New York State Psychiatric Institute, USA)

Prof Melvyn FREEMAN (Consultant to WHO, South Africa)

Dr Sandra GOVE, (WHO, Switzerland)

Dr Mark HALMAN (Saint Michael’s Hospital, University of Toronto, Canada)

Dr Kevin KELLY, (Centre for AIDS Development, Research and Evaluation, SouthAfrica)

Ms Ray LAZARUS (Perinatal HIV Research Unit, South Africa)

Dr Joseph MBATIA (Ministry of Health, Tanzania)

Prof Dan MKIZE (N Mandela Medical School, South Africa)

Dr Vikram PATEL (Sangath Centre, India)

Ms Kerry SALONER (Centre for the Study of AIDS, South Africa)

Mr Vernon SOLOMON (University of KwaZulu-Natal, South Africa)

Prof Leslie SWARTZ (Human Sciences Research Council South Africa)

Ms Annika SWEETLAND (Partners in Health, USA/Peru)

Dr Rita THOM (University of the Witwatersrand, South Africa)

Contents

Preface vi

Foreword vii

Care Pathways for District Level Hospitals/ Physicians: Delirium, Dementia,and Psychiatric Disorders 1

Delirium 2Dementia 4Suicide Risk 8Major depression 10Psychosis 12Anxiety disorder 14Alcohol withdrawal 16

Psychotropic Medications 18Antipsychotics 22Antidepressants 25Axiolytics 28Mood Stabilizers 32

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Preface

The AIDS epidemic is one of the most serious public health and social challengesthe world has ever faced. It not only destroys individuals, but also families,communities and the whole societal fabric. Worst hit are communities least ableto put in place appropriate measures for its containment and control. It is probablythe biggest hurdle to the attainment of the Millenium Development Goals.

As a bold measure to counteract it, WHO has launched the 3 by 5 Initiative that,while primarily aimed at providing treatment to millions of people in need of it,also aims at building the elements of the health system that will be needed todeliver it.

Therefore, treating mental disorders of people living with HIV/AIDS has hugehumanitarian, public health, and economic consequences; the same applies toproviding people in need with appropriate psychosocial support. This is not aneasy task, in view of the scarcity of human, technical and financial resources.

The present series is a contribution from the Department of Mental Health andSubstance Dependence to the WHO 3 by 5 Initiative, but also goes beyond that.Its production brought together experts on mental disorders in people with HIV/AIDS from around the world. They graciously contributed their knowledge, expertise,energy and enthusiasm to this endeavour. We are profoundly indebted to themall, as well as to the agencies and organizations to which they are connected. Thecontributors’ names are indicated in each of the modules in this series. A specialthanks goes to Prof Melvyn Freeman, who steered this illustrious group, sometimesthrough uncharted waters, with patience and efficiency.

Now, we make this material available, not as a finalized product, but rather as aworking tool, to be translated into local languages, adapted as needed, andimproved along the way. A set of specific learning/training instruments, relatedto this series will soon be released, as another contribution to the mammothtask of improving the skills of the human resources available and needed,particularly where the 3 by 5 Initiative is being rolled out. Comments, suggestionsand support are most welcome.

Dr Benedetto Saraceno, Director, Department of Mental Health andSubstance Abuse; World Health Organization

Dr Jim Kim, Director, Department of HIV/AIDS; World Health Organization

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Foreword

Among those affected by or at risk of acquiring HIV/AIDS are people with mentaldisorders. This happens primarily through two mechanisms:

(i) some mental disorders make people more vulnerable to infection with thevirus (e.g., intravenous drug use, alcohol abuse, major depression andpsychotic disorders, developmental disabilities, and other mental disordersthat impair judgement and decision-making) and more vulnerable to situationsthat increase the risk of passing the virus to others; and

(ii) some forms of HIV infection affect the brain thus creating clinical picturesthat initially resemble several different mental disorders.

Unfortunately the interplay between HIV/AIDS and mental disorders goes beyondthe mutual facilitation of occurrence. Perhaps the most relevant practical aspectof this interaction relates to adherence to treatment. It is well known that thepresence of an untreated mental disorder – particularly depression, psychoticand substance use disorders – considerably decreases adherence to thetreatment of any condition, including HIV/AIDS.

The failure of adhering to the proper regimen of anti-retroviral (ARV) treatmentcarries three major consequences. First, the expected benefit of the treatmentdoes not take place, the clinical situation worsens and mortality increases.Second, the irregularity of the intake of the ARVs brings new resistant strains ofthe virus, thus complicating its future control. Third, the interrupted or incompletecourse of treatment wastes money and other resources that could otherwisehave produced more cost-effective results in adherent patients.

In addition, being HIV-positive, or having someone with HIV/AIDS in the familycan be stressful for some people with HIV and for carers. In many countrieswhere HIV prevalence is high it is not infrequent to find more than one personwith HIV/AIDS in the same household, at the same time. The stress of living witha chronic illness or caring for an ill relative – even if it does not lead directly to amental disorder such as major depression – may result in a chain of psychosocialreactions that cause considerable pain and dysfunction. Such dysfunction and

viii

distress may decrease resistance and resilience to co-morbid conditions, andcontribute to reduced adherence to medical regimens.

José M. Bertolote, Coordinator

Management of Mental and Brain DisordersDepartment of Mental Health and Substance AbuseWorld Health Organization

1

Care Pathways for District Level Hospitals/Physicians: Delirium, Dementia, and

Psychiatric Disorders

Using This Table

Sequence

This table is intended to be used in the order in which the diagnoses appear.

Screens

The first column contains a screen for each disorder. If a screen is negative,proceed to the screen for the next diagnosis.

Diagnoses

The diagnoses covered are delirium, Alzheimer’s type dementia, HIV-associateddementia, suicide risk, major depression, psychoses and/or mania, anxietydisorder, and alcohol withdrawal. Mania and psychosis are listed together. Allanxiety disorders are listed together. More specific information about how todifferentiate these disorders can be found at the WHO website,www.mentalneurologicalprimarycare.org

Treatments, subsequent monitoring, and follow-up

This table lists major treatments. For general management, advice to families,and long-term follow-up care, see the WHO website,www.mentalneurologicalprimarycare.org

HIV-Infected Patients

It is important to keep in mind that HIV-infected patients have elevated rates ofdelirium, dementia, and psychiatric disorders. This may be due to pre-existingmental illnesses (especially alcohol and other substance use disorders), thedirect effects of HIV on the brain, opportunistic infections, and malignanciesseen in clinical stage 3 and 4 patients, and the side effects of antiretrovirals andother medications used to treat people with HIV related illness. Working withthese patients requires a very careful differential diagnosis, always looking fortreatable medical problems underlying mental status changes.

SCREEN IF SCREEN IS POSITIVE, DIAGNOSTIC CLASSIFY TREATMENTSCONTINUE CRITERIA AS

PATIENTREFERREDBECAUSE OF:

o Suddenconfusion/behaviorchange.

ASK FAMILY:

o When did itstart?

ASK PATIENT:

o Determine iforiented toplace,person, andtime.

EXAMINE:

o Is patientconfused,agitated, orapathetic?

ASSESS FOR:

o Disturbance of consciouslevel (for example,drowsiness, lethargy,alternately alert andlethargic);

o Inability to focus attention;

o Memory impairment;

o Suspiciousness, illusions,delusions, hallucinations;

o Incoherent speech; and

o Disturbed sleep or reversalof sleep pattern.

CONSIDER:

Physical causes

o Multiple medical illnesses;

o Alcohol and/or street drugscausing intoxication orwithdrawal;

o Disturbance ofconsciousnesswith reducedability to focus,sustain or shiftattention;

o A change incognition or thedevelopment of aperceptualdisturbance;

o The disturbancedeveloped overhours to daysand fluctuatesduring the courseof the day; and

o The disturbanceis caused by theconsequences ofa general medicalcondition (includ-ing alcohol/drugs,

DELIRIUM

DSM IV 293

ICD 10 F05

o Delirium requires manage-ment as a medical emer-gency;

o Take measures to preventharm to self or others (aconsequence of confusionand agitation);

o Give glucose, thiamine andfluids;

o Complete standard medicalevaluation and blood tests,including HIV testing;

o Hospitalise, if possible;

o If febrile, pay particularattention to possibility ofinfectious diseases (includingcerebral tuberculosis),dehydration, or alcoholwithdrawal;

o Follow WHO protocol forassessment of malaria;

3

o If acute head injury, assessfor skull fracture or intracra-nial bleed (see WHo proto-col); and

o Treat physical cause (sys-temic illness) or alcohol ordrug/ medication toxicity orwithdrawal;

o If HIV-related, stabilize andbegin ARV therapy withadherence support;

o If very agitated, give low dosesedation with haloperidol or,if HIV positive, use risperidolor another atypical antipsy-chotic, if available;

o Avoid diazepam or otherbenzodiazepines: mayworsen confusion andagitation; and

o Institute general manage-ment, advise family, andprovide follow-up. See thiswebsite:

www.mentalneurologicalprimarycare.org

o Medication toxicity orwithdrawal; and

o Acute head injury.

o Is patientfebrile?

medication,acute headinjury).



o Forgetful-ness anddecliningmentalfunctioningover time.

ASK FAMILY:

o Has therebeen achange inpersonalityor behavior?

o For howlong?

EXAMINE:

o Age ofpatient.Although itcan appear

ASSESS FOR:

o Orientation: ability to giveown name and address,names of accompanyingrelatives;

o Ability to name three objectsand recall them in threeminutes;

o Ability to carry out dailyroutines.;

o Apathy or emotional lability;

o Poor personal hygiene.

o Language disturbance(aphasia);

o Difficulty performing routinemotor tasks despite intactmotor function (apraxia);

o Failure to identify familiarobjects (agnosia); and

o Memory impair-ment; and

o One or more ofthe followingcognitive distur-bances:– Aphasia;– Apraxia;– Agnosia; and– Impaired

executivefunctioning.

and

o These cognitivedeficits impairfunctioning;

o Gradual onsetand continuingdecline; and

o Diagnosis ofexclusion.

DEMENTIA,

ALZHEIMER’STYPE

DSM – IV290

ICD 10 F03

o Conduct a full medical andlaboratory assessment toexclude a treatable cause(e.g. metabolic, endocrine,neoplasm, HIV), and treataccordingly;


www.mentalneurologicalprimarycare.org;

o If agitated or delusional,give low -dose haloperidolor another antipsychotic;

o If insomnia present, con-sider low-dose amitriptylineor low-dose antipsychotic;and

o If Alzheimer’s diagnosis ismade, consider anti-cholinesterase inhibitors, ifavailable.

5

earlier,Alzheimer ’sdiseaseusuallyoccurs inpeople over60 years old;and

o Patient mayappearnormal,apathetic, orunkempt atfirst glance.

o Executive function deficits(for example, abstractthinking and organisationalcapacity).

CONSIDER:

o Delirium – see Page 2;

o All other medical causes ofdementia which includescerebrovascular disease,Parkinson’s disease andHuntington’s disease;

o HIV Dementia – see below;and

o Depression with temporarilyimpaired cognitive function-ing (especially if elderly).



o Gradualonset ofmentalchanges thathave im-pairedfunctioning.

ASK PATIENT:

o Have youbeen testedfor HIV?

o What wasthe result?

EXAMINE:

o Is patient tooyoung tohave Alzhe-imer’s typedementia?

ASSESS FOR:

o Cognitive problems:– Slowed thinking;– Trouble concentrating;– Verbal memory

impairment;– Personality changes;– Difficulties with problem

solving; and– Impaired executive

functions.

o Motor problems:– Slowed movements;– Imbalance;– An abnormal gait; or– Weakness.

o Behavioral problems:– Apathy;– Social withdrawal; and– Emotional lability.

o Decrements in functioningsuch as difficulty with workor self care.

o Acquiredcognitiveabnormality in 2or moredomains:– impaired

attention;– concentration;– memory;– mental and

psychomotorslowing; and

– personalitychangecausingmarkedfunctionalimpairment.

o Acquiredabnormality inmotorperformance orbehavior, changein gait;

DEMENTIAHIVASSOCIATED

DSM IV294.9

ICD 10F02.4(022.0)

o Full medical assessment –see Dementia, Alzheimer’stype;

o Conduct HIV testing toestablish or confirm HIVseropositivity;

o Rule out other etiologiescommon in HIV diseases(e.g. CNS opportunisticinfections, metabolicproblems) and treataccordingly;

o Stabilise and begin ARVtherapy with adherencesupport;

o If depressed, considertreating with SSRI antide-pressant. If not available,use low-dose amitritryline;and

o If psychotic, manic, oragitated, use low-dose

7

antipsychotic, preferably anatypical antipsychotic.

If available, considerstandardised tests indicativeof HIV neuropsychiatricimpairment (e.g. Hopkins HIVscreen, non-dominant handgrooved peg board test).

CONSIDER:

o All other medical causes ofdementia.

o No clouding ofconsciousness orother confound-ing etiology and

o Diagnosis ofexclusion.



o Havingcontem-plated,threatened,or attemptedsuicide.

If currentattempt:

o Determinespecifics andpotentiallethality.

If no currentattempt:

ASK PATIENT

o Have you feltthat youwould bebetter off

ASSESS FOR:

o Current suicidal thoughts;

o Intent to act on suicidalthoughts;

o Presence of a specific planincluding time frame andpotential lethality;

o Whether the means havebeen obtained to carry outthe plan;

o All prior suicide attemptsand their potential lethality;

o Factors associated withsuicide risk:– Recent bad event;– Alcohol or substance

abuse;– Depression;– Psychosis;– Panic attacks;– Major psychiatricdiagnosis;

If current suicidethoughts, considerhigh risk for suicideif the patient:

o Has a plan andthe means;

o Has a current orprior potentiallylethal attempt;

o Is highlyagitated;

o Poses a threat ofviolence toothers; and

o Has multiplefactorsassociated withsuicide risk.

SUICIDERISK

ICD 10 X60-X89

o If high risk, ensure constantobservation and hospitaliseif possible;

o Attend to medical sequelaeof current attempt;

o Assess for major psychiatricdisorder and treataccordingly; and

o Institute generalmanagement, advise family,and provide follow-up. Seethis website:


9

dead or thatyou want topurposelyhurt your-self?

o Have youever at-temptedsuicide?

EXAMINE:

o Patientshowsphysicalevidence ofself-harm;and

o Patient looksdepressed,frightened oragitated.

– Family history;– Prior suicide attempt;– Prior violent acts;– Poor social support;– Chronic pain; and– Feelings of hopelessness.

o The greater the severity ofthe factors listed above, themore strongly they contrib-ute to suicide risk.



o Depressedor sad mood,loss ofpleasure andinterest, orlow energy.

ASK PATIENT:

o Do you feelsad,depressed orhopeless?

o Have youlost interest/pleasure in /energy to dothings youusuallyenjoy?

ASK THE PATIENT:

Over the last 2 weeks, haveyou been bothered by:

o Trouble falling or stayingasleep, or sleeping toomuch?

o Feeling tired or having littleenergy?

o Poor appetite or overeat-ing?

o Feeling bad about yourself,or that you are a failure, orhave let yourself or yourfamily down?

o Trouble concentrating onthings, such as cooking,reading, or watchingtelevision?

o Moving or speaking soslowly that other peoplecould have noticed? Or the

During the same 2-week period,patient has had:

o Nearly continu-ous depressedmood; or

o Markedly dimin-ished loss ofinterest or ofpleasure in usualactivities.

In addition, patienthas 3 (if both theabove present) or 4or more of thefollowing:

o Weight loss orgain;

o Consistentlysleeping toomuch or too little;

MAJORDEPRESSION

SingleEpisode

DSM IV296.2

ICD 10 F32

RecurrentEpisodes

DSM IV296.3

ICD 10 F33

o If suspect bipolar disorder,see Page 12;

o Ensure that standardmedical assessmentincludes thyroid tests;

o If symptons began followingrecent administration ofefavirenz (EFV), assess ifpatient can tolerate waitingto see if symptoms sponta-neously improve. If not,treat depression or considerARV regimen change;

o For mild to moderatesymptoms, considernonpharmacologicalinterventions;

o For moderate to severesymptoms, begin a TCAantidepressant or, ifavailable, an SSRI antidepressant. See psycho-tropic medication table;

11

o Institute generalmanagement, advise family,and provide follow-up. Seewebsite:

www.mentalneurologicalprimarycare.org;

o Monitor for increasedsuicide risk during earlyphases of medicationtreatment (patient maybecome activated or haveside effects that increaserisk);

o For first episode depression,continue antidepressant forsix months to one year;

o If 3 or more episodes ofdepression, continueantidepressant indefinitely;and

o If minor depression(symptoms do not meetcriteria), considercounseling or medicationdepending on level ofdistress or impairment.

o Have youever had apreviousepisode ofseveredepression?

EXAMINE:

o Patientappears sad,tearful,slowed downor restless.

opposite, being so fidgetyor restless that you havebeen moving around a lotmore than usual?

o Thoughts you would bebetter off dead or of hurtingyourself in some way?

ASSESS FOR:

o Accompanying complaints :– Dizziness;– Palpitations;– Physical aches and pains;– Sexual dysfunction; and– Anxiety;

o Physical disordersassociated with depressionthat require medicaltreatment; and

o Suicide risk, see Page 8.

o Can be observedas either agitatedor slowed down;

o Consistent lossof energy;

o Feelings ofworthlessness orguilt;

o Consistentproblemsthinking orconcentrating, orindecisiveness;

o Recurrentthoughts of deathor suicide orsuicide attemptor plan.

Consider whetherdepression issecondary to aphysical illnessor is part of abereavementreaction.


PATIENTREFERREDBECAUSE OF;

o Behavior thatis strange,frightening,or atypicallyimpulsive.

ASK PATIENT:

o Do you hearvoices ofpeople whoare not in theroom?

o Do you feelpeople aretrying toharm you?

o Have youever beenhospitalisedfor a psychi-atric illness?

ASSESS FOR:

o Bizarre ideas or fixedunrealistic beliefs;

o Disorganised thinking orspeech;

o Unusual or unnatural bodyposturing;

o Perceptual disturbances;

o Apprehension andconfusion;

o Disinhibited behavior; and

o Mood swings or lack ofappropriate emotion.

CONSIDER:

o Physical causes includingmedication, alcohol, streetdrugs, head trauma, andHIV infection.

o Criteria varydepending onwhether patienthas:– Brief psychotic

disorder;– Delusional

disorder;– Schizophrenia;– Schizoaffective

disorder; or– Other

psychoticdisorders;

o Depression maybe accompaniedby psychosis;

o Consider maniaif patient has:– Increased

energy andactivity;

– Elevated moodor irritability;

– Rapid speech;

PSYCHOSIS

and/or

MANIA(BIPOLARDISORDER)

PsychosisDSM IV 295ICD 10 F20– F29

BipolarDisorderDSM IV296AICD 10 F30– F31

o Take measures to preventharm to self or others;

o Assess for medical causes,including intoxication andtreat accordingly;

o Hospitalise if possible;

o Begin treatment withhaloperidol. If patient is HIV-positive, use risperidone oranother atypicalantipsychotic if available;

o If using haloperidol orchlorpromazine for agitationwith a clinical stage 3 or 4HIV-positive patient,consider augmentation withvery low dose diazepam todiminish risk of EPS. Seepsychotropic medicationtable;

o If psychosis persists orpatient has mania, refer forspecialty care;

13

EXAMINE:

o Is patientbehaving ina bizarre orthreateningmanner?

Always rule outdelirium, seePage 2.

– Loss ofinhibitions,includingfinancial andsexualinhibitions;

– Decreasedneed for sleep;and

– Increased selfimportance.

For furtherdiagnosticclarification seethis website:


o If specialty care notavailable for mania, andfollowing stabilisation withan antipsychotic, considerlithium, carbamazepine, orsodium valproate for furthertreatment and/orprophylaxis for mania. Seepsychotropic medicationtable; and





o Anxiety,fearfulness,avoidance ofordinarysituations,repetitiveritualisedbehaviors.

ASK PATIENT:

o Do you feelanxious,worried orstressedmost of thetime?

o Do yousometimessuddenly feelterrified forno obviousreason?

ASK THE PATIENT:

o Do you experience:– Pounding heart?– Sweating?– Trembling?– Shortness of breath?– Choking?– Dizziness?– Fear of dying?– Tingling or numbness;– Nausea and upset

stomach; and– Headaches.

o Are there specific thingsthat you are afraid of? Doyou go out of your way toavoid them?

o Do you have unwantedthoughts or images that youcannot get out of yourmind? How much does thisbother you?

o Are there rituals youperform to prevent harm to

o Criteria varydepending onwhether patienthas:– Generalised

anxietydisorder(GAD);

– Acute stressor post-traumaticstress disorder(ASD/PTSD);

– Panic disorder(Panic D/o);

– Obsessive –Compulsivedisorder(OCD); or

– Other anxietydisorders.

o Anxiety may becomorbid withdepression.

ANXIETYDISORDER

GADDSM IV300.02ICD 10F41.1

ASDDSM IV308.3ICD 10F43.0

PTSDDSM IV309.81ICD 10F43.0

o Assess for suicide risk , seePage 8;

o Rule out physical causes;

o Counsel on managinganxiety according to specificsituation. Consider specifictherapies if available (e.g.CBT);

o Teach patients slowbreathing and progressiverelaxation;

o If severe anxiety, considershort-term use of diazepam(up to 2 weeks) and longerterm use of an SSRIantidepressant; and

o Criteria for using medicationinclude:– Lack of improvement with

counseling;– Persistence of symptoms;– Comorbid depression;

15

o Do youfrequentlythink ordream aboutsomethingterrible thathappened toyou in thepast?

EXAMINE:

o Does patientappearfrightened,anxious, orrestless?

yourself or others or toreduce your anxiety (e.g.repetitive checking,washing, cleaning)? Dothey interfere with thingsyou need to get done?

CONSIDER:

o Physical causes of anxietyincluding cardiac problems,asthma, thyrotoxicosis,stimulant use.

PANIC D/oDSM IV300.01ICD 10F41.0

OCDDSM IV300.3ICD 10 F42

– Significant functionalimpairment; and

– Great subjective distress.



o Not feelingwell aftercutting downor stoppingregularheavydrinkingwithin thepast hours tofew days.

ASK PATIENTOR FAMILY:

o Confirmhistory ofregularheavyalcohol useprior tocutting downor stopping.

ASSESS FOR:

Mild to moderate symptomso Nervousness/anxiety/

shakiness;o Emotional lability;o Bad dreams;o Rapid heart rate;o Nausea and vomiting;o Sweating;o Paleness;o Clammy;o Hand tremors;o Insomnia; ando Difficulty concentrating.

Severe symptomso Confusion;o Hallucinations;o Agitation;o Fever;o Seizures; ando Memory disturbances.

o Cessation of (orreduction in)alcohol use thathas been heavyand prolonged;and

o Two or more ofthe followingoccurring withina few daysthereafter:– Automatic

hyperactivity;– Increased

hand tremor;– Insomnia;– Nausea or

vomiting;– Transient

visual, tactile,or auditoryhallucinationsor illusions;

– Psychomotoragitation;

– Anxiety; and

ALCOHOLWITHDRAWAL

DSM IV291.1

o Alcohol withdrawal is amedical emergency – followrecommendations fordelirium – Page 2 – andassess for other causes ofdelirium and other alcohol-related medical illnesses(e.g. liver failure);

o Give thiamine 100 mg PO,folate 1 mg PO, and amultivitamin every dayduring treatment for with-drawal; and

o Begin substitution treatmentwith diazepam, lorazepam,or carbamazepine. Seepsychotropic medicationtable for doses and taper.

17

– Grand malseizures.

18

Psychotropic Medications

Using this Table

Medications Listed

This table lists most psychotropic medications that are in the WHO modelformulary. It also includes some additional psychotropic medications which, ifavailable, are easier to administer to HIV infected patients, especially those whoare clinical stages 3 or 4 and those who are taking protease inhibitors as part ofan ARV regimen. Many other newer psychotropic medications are also suitablefor HIV-infected patients if they are available.

In some countries certain of the drugs listed below are not available, are onlyavailable at tertiary level or may be administered by registered psychiatristsonly. Practitioners at secondary level should be familiar with the regulations andrules that pertain to psychiatric medication in their country and prescribeaccordingly.

Side Effects and Cautions

This table does not list every possible side effect or caution. It focuses on themost serious and common ones. Very rare syndromes are not listed. Moredetailed information is available in the WHO model formulary and/or from onlineresources.

Disorders

This table covers psychotropic medications for the management of delirium,dementia, and common or serious psychiatric disorders. However, it does notaddress the treatment of chronic schizophrenia with long-acting injectablemedication.

Dosages

The dosages of medications are approximations, and need to be adjusted tothe patient in accordance with therapeutic response and tolerability. Patientswith chronic medical illnesses, including HIV, may be on multiple medications

19

that can affect the metabolism of the psychotropic drug being administered. Inthese patients, the basic rule is start low, go slow.

Interactions Between Psychotropic Drugs and Antiretroviral Medications

Information is often theoretical rather than clinically demonstrated in patients.Most psychotropic medications are well tolerated by patients on ARVs. Again,the general rule is start low, go slow.

Use of Multiple Psychotropic Medications

Always use caution when simultaneously prescribing more than one psychotropicmedication, whether from one or more classes. Many combinations areassociated with the potential for drug interactions and overlapping toxicities.Use the simplest possible psychotropic medication to stabilise and maintain apatient. If possible, check an online resource for drug interactions.

HIV Clinical Stage 3 and 4 Patients on Complex Medication Regimens

In addition to ARVs, many patients will be taking antimicrobial agents for theprevention and/or treatment of opportunistic infections. If possible, when addinga psychotropic medication to a complex regimen, check an online resource forpotential drug interactions and overlapping toxicities.

20

Terms, Definitions, and Descriptions

Term Abbreviation Definition and Description

Autonomic side Autonomic side effects due to muscariniceffects blockade (seen with antipsychotics and

TCAs) include orthostatic hypotension,sedation, dry mouth, blurred vision(disturbance of accommodation, increasedintraocular pressure), urinary retention,constipation, sexual dysfunction.

Extrapyramidal EPS EPS due to dopamine blockade (seen withside effects antipsychotics) include dystonias

(opisthotonus, oculogyric crises, torticollis),parkinsonism (masked facies, cogwheeling,tremor, gait disturbance, akinesia), andakathisia (restlessness and anxiety). Insevere form, EPS can be very frightening anduncomfortable for the patient.

Neuroleptic NMS Decreased consciousness, increased musclemalignant tone, autonomic dysfunction including fever,syndrome labile hypertension, tachycardia, tachypnea,

diaphoresis, and drooling. Muscle necrosismay cause myoglobinuric renal failure. NMSis a potentially fatal medical emergencyoccurring in about 1 percent of patientsexposed to antipsychotics. Discontinueantipsychotic and give supportive treatment,including hydration and cooling.

Nucleoside NRTI The NRTIs for HIV infection include abacavir,reverse didanosine (ddi), emtricitabine, lamivudinetranscriptase (3TC), stavudine (d4T), tenofovir, zalcitabineinhibitor (ddc), zidovudine (AZT, ZDV), and various

combinations of these medications in onepill.

Non-nucleoside NNRTI The NNRTIs for HIV include delavirdine,reverse efavirenz, nevirapine.transcriptaseinhibitor

Protease PI PIs for HIV include amprenavir, atazanivir,inhibitor fosamprenavir, indinovir, nelfinavir, ritonavir,

saquinivir, and combinations in whichritonavir is used to boost another PI.

21

Term Abbreviation Definition and Description

Selective SSRI The SSRI antidepressants include fluoxetine,serotonin sertraline, paroxetine, citalopram,reuptake escatalopram, fluvoxamine.inhibitor

Serotonin Caused by a hyperserotonergic state.syndrome Symptoms include: mental status changes

(euphoria, drowsiness, confusion, loss ofconsciousness), muscle abnormalities(sustained rapid eye movement, overreactionof the reflexes, abnormal movements of thefoot, clumsiness, restlessness, muscletwitching, rigidity, muscle contraction andrelaxation in the jaw) dizziness, sweating,fever, shivering, and diarrhea. Usually occursin patients taking more than one medicationthat increases serotonin. Difficult todistinguish from NMS since symptoms arevery similar. Can be fatal.

Discontinue the offending drugs and givesupportive measures including hydration andcooling.

Tricyclic TCA The TCA antidepressants includeantidepressant amitryptiline, imipramine, clomipramine,

nortryptyline, desipramine, doxepin, andprotriptyline.

Tardive TD Caused by prolonged dopamine blockadedyskinesia (seen with antipsychotics), TD is a syndrome

of abnormal involuntary movements, often ofthe mouth and tongue, but which may affectany part of the body, including the trunk andextremities. In rare cases, TD may affectrespiratory musculature and cause problemsbreathing. Discontinue antipsychotics ifpossible, which may or may not reverse TD.Vitamin E 800 I.U. daily may be beneficial.

Class: Antipsychotics

Indications: Antipsychotics can be used to treat psychotic disorders, mania and severe behavioral disturbances, such asagitation associated with delirium and dementia.

Medication: Dose: Dose: Serious and Cautions Main AntiretroviralName (Type) Healthy Adult Medically Ill, Common Side interactionsTablet sizes Elderly or HIV Effects

Clinical Stage 3or 4

Haloperidol(First generationtypicalantipsychotic).

Tablet sizes:

WHO modelformulary:2 mg.5 mg.

Other:0.5 mg.1 mg.10 mg.20 mg.

Start: 2 to 5 mgPO once or twicedaily.

Severeagitation:

5 mg IM andrepeat in onehour if needed.

Maintenance:2 to 20 mg daily.

Start:0.5 to 1 mg POonce or twicedaily.

Severeagitation:2 mg IM andrepeat in onehour if needed.If still agitated,consideraugmentationwith very lowdoses of ananxiolytic.


Serious, acute:EPS, NMS,arrhythmias,hypotension, heatstroke.

Seriouslong-term:NMS, TD

Other common:– Anxiety;– Drowsiness;– Lethargy;– Weight gain;– Autonomic

side effects;– Gynecom-astia;– Breast

tenderness;

Use withcaution ifhistory of NMSand in medicallyill.

Other:HIV ClinicalStage 3 or 4patients arevery sensitive toEPS. Inaddition, NMScan occur withindays, and TDcan occur withinweeks. Userisperidone ifpossible.

NNRTIs:No published data.

NRTIs:No published data

Proteaseinhibitors: Ritonavirmay increase bloodlevels of haloperidol:use low doses ofhaloperidol.

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Chlorpromazine(First generationtypicalantipsychotic)

Tablet sizes:WHO modelformulary:100 mg.

Other:10 mg.25 mg.50 mg.200 mg.

Start:25 mg 3 timesdaily or 75 mgpm

Severeagitation:25 to 50 mg IMand repeat every6 to 8 hours ifneeded.

Maintenance:100 to 300 mgdaily. May gohigher if needed.

Start:10 mg 3 timesdaily or 25 mgpm.

Severeagitation:12.5 to 25 mgIM and repeatevery 6 to 8hours if needed.

Maintenance:25 to 100 mgdaily.

Serious, acute:– Hypotension;– NMS;– EPS; and– Blood dyscrasias.

Seriouslong-term:NMS, TD.

Other common:Autonomic sideeffects, drowsiness.

Same cautionsas haloperidol.

AdditionalCautions:Avoid using withlithium:increased risk ofEPS.

Avoid using withfluoxetine orsertraline: risk ofQT prolongationand cardiacarrhythmias.NNRTIs:No publisheddata.


Proteaseinhibitors:Ritonavir mayincrease blood levelsof chlor-promazine.Use low doses ofchlorpromazine.

– Galactorrhea;and– Menstrual

irregularities.

Medication: Dose: Dose: Serious and Cautions Main AntiretroviralName (Type) Healthy Adult Medically Ill, Common Side interactionsTablet sizes Elderly or HIV Effects

Clinical Stage 3or 4

Risperidone(Atypicalantipsychotic).

Tablet sizes:WHO modelformulary:None.

Other:0.25 mg.0.5 mg.1 mg.2 mg.3 mg.4 mg.

Class: Antipsychotics

Medication: Dose: Dose: Medically Serious and Cautions Main AntiretroviralName (Type) Healthy Adult Ill, Elderly or Common Side interactionsTablet sizes HIV Clinical Effects

Stage 3 or 4

Start:1 to 2 mg POonce daily.

Increase:by 1 or 2 mgevery three toseven days.

Severeagitation:only oralpreparationavailable. Give 2mg PO. Repeatif needed in 3 to4 hours.


Start:0.25 to 0.5 mgPO once daily.

Increase:by 0.5 mg everythree to sevendays.

Severeagitation:only oralpreparationavailable. Give 1mg PO. Repeatif needed in 3 to4 hours.


Serious, acute:Hypotension, EPS(not common atlower doses),NMS.

Seriouslong-term:NMS, TD, diabetesmellitus.

Other common:Autonomic sideeffects, menstrualirregularities,weight gain.

Note: Studies withHIV clinical stage 3or 4 suggestpatients toleraterisperidone well.

Other:Use withcaution ifhistory of NMSand in medicallyill.


NRTIs:No published data.

Proteaseinhibitors:No published data.

25

Class: Antidepressants

Indications: Many antidepressants (e.g. SSRIs) can be used to treat both depressive and anxiety disorders. Antianxietydrugs such as benzodiazepines however, are not a treatment for depression. Low dose sedating antidepressants can beused for sleep.


Stage 3 or 4

Amitriptyline(TCA)


Other:10 mg.50 mg.75 mg.100 mg.150 mg.

Start: 50 mg pm

After 1 weekincrease to:75 mg pm.

After 3 weeksincrease to:25 mg am.75 mg pm.

Two weeks laterif inadequateresponse:50 mg am.100 mg pm.

Maximum dose:250 mg.

For insomnia:10 to 50 mg pm.

Start: 25 mg pm.

After 1 weekincrease to:25 mg am.25 mg pm.

After 3 weeksincrease to:25 mg am.50 mg pm.

Two weeks laterif inadequateresponse:25 mg am.75 mg pm.

Maximum dose:125 mg.

For insomnia:10 to 25 mg pm.

Serious:– Hypotension;– Arrhythmias;– Seizures; and– Mania.

Other common:Autonomic sideeffects,drowsiness, weightgain.

Contra-indications:– Recent

MyocardialInfarction;

– Arrhythmias;– Mania; and– Severe liver

disease.

Other:Give smallsupply if patientis suicidal. Riskof seriousarrhythmia inoverdose.



Protease inhibitors:Ritonavir increasesblood levels ofamitriptyline. Use lowdoses of amitriptyline.

If starting a proteaseinhibitor with apatient already onamitriptyline, halvethe amitriptylinedose, wait twoweeks, and titrateback up slowly astolerated.

Imipramine(TCA)

Tablet sizes:WHO modelformulary:None

Other:10 mg.25 mg.50 mg.



Stage 3 or 4

Same dosing asamitriptyline.

Same dosing asamitriptyline.

Same side effectsas amitriptyline.

Same cautionsas amitriptyline.

Same ARVinteractions asamitriptyline.

Ritonavir increasesblood levels ofimipramine; followsame procedure asfor amitriptyline.

Clomipramine(TCA)

Tablet sizes:WHO modelformulary:10 mg.25 mg.

Other:50 mg.75 mg.

Start: 25 mg POat bedtime.

Increase:in divided dosesby 25 mg every4 to 7 days to100-150 mg.

Maximumdose:250 mg.

Start: 10 mgPO at bedtime.

Increase:in divided dosesby 10 mg every4 to 7 days to50-75 mg.

Maximumdose:100 mg.

Same side effectsas amitriptyline.

Same cautionsas amitriptyline.

Same ARVinteractions asamitriptyline.

Ritonavir increasesblood levels ofclomipramine;follow sameprocedures as foramitriptyline.

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Fluoxetine(SSRI)




Stage 3 or 4

Start:10 to 20 mg POdaily.

Increase by:10 mg everythree weeks untiladequate clinicalresponse.

Maximumdose:60 mg.

Start:5 to 10 mg POdaily.

Increase by:10 mg everythree weeksuntil adequateclinicalresponse.

Maximumdose:40 mg.

Severe:Serotoninsyndrome, mania,severe rash.

Common:Autonomic sideeffects:– Nausea;– Headache;– Insomnia;– Anxiety;– Asthenia;– Diarrhea;– Tremor; and

rash.

Other:Use cautiouslywith othermedications thatelevate serotoninlevels (TCAs,lithium, MAOIs,another SSRI)and with ECT.



Proteaseinhibitors:Ritonavir mayincrease bloodlevels of fluoxetine;this is unlikely to beclinicallysignificant.

Sertraline(SSRI)



Class: Anxiolytics

Indications: Anxiolytics can be used to treat anxiety disorders and can be used briefly for sleep disorders.


Stage 3 or 4



Stage 3 or 4

Start: 25 to 50mg PO daily.


Maximumdose:200 mg.

Start:25 mg PO daily.


Maximumdose:150 mg.

Same side effectsas fluoxetine.

Same cautionsas withfluoxetine.



Protease inhibitors:Ritonavir mayincrease blood levelsof sertraline. This isunlikely to beclinically significant.

Diazepam(Benzodiazepine).

Start: 2 mg 1-2times daily.

Day six: Stop.Start: 1 to 2 mgonce to twice

Serious:– Respiratory

Precautions:NNRTIs: Nopublished data.

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depression;– Withdrawal

syndrome;– Hypotension;– Bradycardia;– Dependence; and– Abuse.

Common:– Drowsiness;– Fatigue;– Ataxia;– Confusion;– Diplopia;– Dysarthria;– Hypotension;– Vertigo; and– Blurred vision.

If patient is onproteaseinhibitors, usecautiously andwhere availablesubstitutelorazepam orbuspirone.

Other:Do not use inpregnant women.May causecongenitalanomalies,particularly whenused in the firsttrimester. Avoidin patients withcognitiveimpairment.


Proteaseinhibitors: Mayincrease diazepamlevels with resultanttoxicity includingexcessive sedationand respiratorydepression.Avoid diazepam.

Increase: ifneeded, individed dosesevery seven tofourteen days to10 to 20 mgdaily.

To treatalcoholwithdrawal:Day one: Startwith 4 to 20 mgP.O. up to fourtimes daily untilpatient is calm.

Day two: Givetwo-thirds of dayone dose.

Day three: Giveone half of daytwo dose.

Days four andfive: Continue toreduce dose.


Other:10 mg.

times daily.

Increase: to 5to 10 mg daily, ifneeded, individed dosesevery seven tofourteen days.

To treatalcoholwithdrawal:Use half thedoses recom-mended for ahealthy adult.Use specialcaution if patientis takingritonavir.

Lorazepam(Benzodiazepine).


Other:0.5 mg.1 mg.2 mg.

Class: Anxiolytics


Stage 3 or 4

Start:1 mg PO two tothree times daily.

Increase:to 6 to 10 mgdaily, if needed, individed doses.

Maximum dose:10 mg daily.

To treat alcoholwithdrawal: Daysone and two: Startwith 1 to 4 mg upto four times dailyuntil patient iscalm.Days three andfour: Give half ofday one dose.Day five: Give 2mg or less.Day six: Stop.

Start:0.5 mg PO onceto twice daily.

Increase:to 3 to 4 mgdaily, if needed,in divideddoses.

Maximumdose: 4 mgdaily.

To treatalcoholwithdrawal:Use half thedoses recom-mended for ahealthy adult.Safe to use withpatients onritonavir.

Same side effectsas Diazepam.

Same cautionsas Diazepam.Except safer touse withproteaseinhibitors



Proteaseinhibitors:No published data.Lorazepam ispreferable todiazepam due tolow risk of interac-tion with proteaseinhibitors.

31

Buspirone(NonBenzodiazepine).

Tablet sizes:WHO modelformulary:None

Other:5 mg.7.5 mg.10 mg.15 mg.30 mg.

Class: Anxiolytics


Stage 3 or 4

Start:10 mg PO two tothree times daily.

Increase:If needed by 5 mgevery three days.

Maximum dose:60 mg daily.

Note: May beless efficacaciousthanbenzodiazepinesfor treatinganxiety, butlacks addictivepotential.

Start:10 mg PO twoto three timesdaily.

Increase:If needed by 5mg every threedays.

Maximumdose:45 mg daily.

Serious:None reported.

Other common:– Dizziness;– Drowsiness;– Nausea and

vomiting;– Headache; and– Nervousness.

Use cautiouslywith othermedications thatelevate serotoninlevels (TCAs,lithium, MAOIs,SSRIs) and withECT.

Proteaseinhibitors:Protease inhibitorsmay increasebuspirone levels.Consider usinglower doses.

Class: Mood Stabilizers

Indications: Mood Stabilizers are used as monotherapy and in combination with other drugs for treatment of acute maniaand as maintenance treatment for bipolar disorder.


Stage 3 or 4

Lithium(Salt)



Start:600 mg PO individed doses.

Increase:300 mg eachweek andmonitor bloodlevel.

Maintain lithiumlevel in range:0.6 – 1.0 mEq/L

Consider slightlyhigher lithiumlevel up to 1.2mEq/L if neededfor efficacy and iflithium levels canbe obtainedregularly.

Not advisable.

If necessary,start:150 mg PO twotimes daily.

Increase:150 mg eachweek andmonitor bloodlevel

Maintainlithium level inrange:0.6 – 1.0 mEq/liter.

Serious:Coma; Seizures;Ventriculararrhythmia;Leucocytosis;Goiter; andBradycardia

Common:Tremor; Polyuria,;Diarrhea, Vomiting;Drowsiness; Muscleweakness;Arrhythmia;Anorexia; Nausea;Blurred vision; Drymouth; Fatigue;Acne; and Rash

Use if lithiumlevels can bemonitored andpatient is HIVnegative or HIVasymptomatic.Periodicallymonitor kidney andthyroid function.

Contra-indications:RenalImpairment.

Other: Do notuse in pregnantwomen, lithiummay causecongenitalanomalies.



Proteaseinhibitors:No published data.

33

SodiumValproate,Valproic Acidand DivalproexSodium(Anticonvulsant)


Other:125 mg.



Stage 3 or 4

Start:250 mg a.m.500 mg p.m.

Increase:by 200 mg every7 days untilclinical responseor therapeuticblood level.

Give in divideddoses.

Maximumdose:60 mg/kg/day

Desirablevalproate serumlevel:50-125 µg/mL.

Start:200 mg a.m.200 mg p.m.

Increase:by 200 mg every7 days untilclinical responseor therapeuticblood level.

Give in divideddoses.

Maximumdose:Assess bytolerability andclinical response.

Desirablevalproate serumlevel:50-125 µg/mL.

Serious:Hepatotoxicity (canbe fatal), pancreati-tis, SIADH,hyponatremia,blood dyscrasias,severe allergicreactions.

Common:Headache; Nausea;Vomiting;Somnolence;Dyspepsia;Dizziness; Diarrhea;Abdominal pain;Tremor; Alopecia;Appetite and weightincreases; Rash;Ataxia; Visualchanges; Blurredvision; andNystagmus

Other: Do notuse in pregnantwomen – maycause congenitalanomalies.

Use with cautionif liver disease,however, notcontraindicated.

If available,monitor serumlevels ofvalproate, liverfunction tests,and blood count.


NRTIs:Sodium Valproatemay elevate levelsof AZT

ProteaseInhibitors:No published data.

Carbamazepine(Anticonvulsant)

Tablet sizes:WHO modelformulary:100 mg200 mg.



Stage 3 or 4

Used forprophylaxis ofbipolar disorder.

Start:200 mg P.O. inp.m.

Increase:By 200 mg every3-4 days. Give individed doses upto 400 – 800 mg.

Maximum dose:1200 mg

To treat alcoholwithdrawal:Day one andtwo: Start with800 mg individed doses.

Used forprophylaxis ofbipolar disorder.

Start:100 mg P.O. inp.m.

Increase:By 100 mg every3-4 days. Givein divided dosesup to 300 – 600mg.

Maximumdose:800 mg

To treat alcoholwithdrawal:Use half thedoses recom-mended for ahealthy adult.

Serious:Hypersensitivityreaction; Seizures;Arrhythmias;Syncope; Blooddyscrasias;Hepatitis;Jaundice;Hyponatremia;SIADH; Waterintoxication;Severe allergicreactions; andPancreatitis.

Common:Dizziness;Drowsiness;Ataxia; Nausea;Vomiting;Abdominal pain;Blurred vision;Nystagmus;

Other: Do notuse in pregnantwomen; maycause congenitalanomalies.

If available,monitor serumlevels ofcarbamazepine,liver functiontests, and bloodcount.

Desirablecarbamazepineserum level:for maintenance6-10 µg/mL.

NNRTI:carbamazepinemay decreasedelavirdine levels.

Avoid using withefavirenz; maydecrease efavirenzlevels and efficacy.


ProteaseInhibitors:Avoid using withPIs; may decreasePIs levels andefficacy.Carbamazepinelevels can increaseor decrease withPIs.

35

Day three:Reduce to600 mg individed doses.

Days four:Reduce to400 mg individed doses.

Day five: Reduceto 200 mg individed doses.

Day six: Stop.

Confusion;Elevated liver;Transaminases;and Fatigue.

who booklet 3

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