GUIDELINE

Management of mental health disorders in HIV-positive patients by the Southern African HIV Clinicians Society

G Jonsson (Chair), N Davies, C Freeman, J Joska, S Pahad, R Thom, K Thompson, N Woollett (Panel Members), J Furin, G Meintjes (Reviewers)

Mental Health Guidelines Committee, Southern African HIV Clinicians Society, Johannesburg, South Africa

Corresponding author: G Jonsson (gregory.jonsson@wits.ac.za)

Disclaimer. Specific recommendations provided in this document are intended only as a guide to clinical therapy, based on expert consensus and best current evidence. Treatment decisions for patients should be made by their responsible clinicians, with due consideration for individual circumstances. The most current version of this document should always be consulted.

These guidelines are intended as a reference document to assist HIV nurse and doctor clinicians in managing mental health disorders. It is intended to improve awareness, knowledge and capacity to support patients living with HIV and mental health disorders.

S Afr J HIV Med 2013;14(4):155-165. DOI:10.7196/SAJHIVMED.995

1. Introduction

‘There is no health without mental health’.1 , 2 Mental disorders are highly prevalent among people living with HIV/AIDS (PLWHA), with major depressive disorder (MDD) occurring almost twice as frequently among this group than in the general population.3 Mental disorders may increase an individual’s risk for HIV infection through increased social vulnerability, altered risk behaviour, associated substance misuse and loss of control within sexual relationships. Conversely, such disorders may also arise as a direct result of HIV neuro-invasion or psychosocial stressors, or due to complications of antiretroviral therapy (ART). 4 , 5

Despite their prevalence, mental disorders are often under-diagnosed or inadequately managed in PLWHA. The impact of untreated mental disorders on health outcomes is substantial. It is imperative that clinicians caring for HIV-positive individuals actively screen for, diagnose and manage mental disorders in this population.6

2. Overview of the guideline

This guideline is intended to improve primary care HIV clinicians’ knowledge and capacity to manage mental health disorders. It is also intended to heighten HIV clinicians’ awareness of the need to integrate HIV and mental healthcare within their daily practice.7

The following conditions and issues are addressed here:

• HIV testing in the context of mental disorders

• common mental disorders (CMDs)

• severe mental disorders (SMDs)

• HIV-associated neurocognitive disorders (HANDs)

• grief

• healthcare worker (HCW) burnout and vicarious trauma.

These guidelines do not encompass substance use disorders or triple diagnosis (HIV/mental disorder/substance use disorder), or mental disorders among children and adolescents; these topics will be covered in separate, future guidelines.

3. Principles of HIV testing in patients with mental disorders

• All patients with mental disorders (in-/out-patients, volun­tary/involuntary patients admitted under the Mental Health Care Act) should be offered HIV testing, HIV-prevention/risk-reduction education and access to condoms

• The presence of a mental disorder does not automatically equal incapacity to consent to HIV testing

• Capacity to consent to HIV testing must therefore be assessed on an individual basis, particularly in patients with SMDs

• For capacity to consent, patients should be able to:

• understand why they are being tested

• understand and report on the consequences of a negative or positive test result

• report how they are likely to respond to either result

• Patients should be included in decision-making about their HIV testing, as far as possible in all cases

• If the patient is assessed as being incapable of giving informed voluntary consent (e.g. active psychosis, dementia), then proxy consent may be sought

• Proxy consent

• Consent is given by someone else acting in the best interests of the patient, e.g. a senior clinician in charge of the case

• The reasons for testing and the process must be docu­mented carefully

• If the patient regains capacity, then disclosure of the results is paramount

• There may be a need to disclose the results to the carer, if the patient has irreversible neurocognitive impairment, with cognisance of potential stigma/discrimination

• Disclosure

• All medical information should be kept confidential at all times

• Information should preferably be released only with patient con­sent, unless the information is relevant to clinical management/medical aid pro­cedures

• The procedure to follow when testing for HIV in patients with mental disorders is shown in Fig. 1.8 , 9

4. Assessment and diagnosis of CMDs

The term ‘common mental disorder’, used to describe disorders that are highly prevalent in the general population (usually occurring at rates >10%), typically includes:

• depressive disorders

• anxiety disorders

• substance use disorders (not included in this guideline).10

Box 1 provides an overview of CMD pre­valence. In South Africa (SA), 26 - 38% of PLWHA have a CMD (v. 12.6% of the general population).6 CMDs have not decreased in prevalence with the introduction of ART.

4.1 Screening

Clinicians should screen routinely for CMDs, because patients rarely volunteer information about their mental state. Box 2 includes three questions to ask patients. Due to the high prevalence of gender-based violence (GBV) in SA, we recommend clinicians also incorporate screening for GBV.11

Box 2. Screening for depression and GBV Brief routine screening questions for depression • How have you been in the past month/since your last visit? • Have you been feeling more stressed than usual? • Have you been feeling down, low, heart-sore or depressed? Brief screening questions for GBV • How are things going in your relationship with your partner? • Have you ever been emotionally, sexually or physically victimised?

Certain patients may require more intensive screening, including:

• those at their first ART assessment

• those responding poorly to ART (detectable viral load (VL)/adherence issues)

• those exhibiting worrying behaviour (look­ing anxious/depressed, expressing sui­cidal ideation or self-harm).

Patients who respond positively to one of the brief screening questions should be administered a validated screening tool that is appropriate for primary healthcare settings, such as the Patient Health Questionnaire (PHQ)-9 (Fig. 2).12

4.2 Risk assessment

It is important to assess suicide risk. Clinicians should always ask about suicidal ideation in patients with depressive symptoms. High risk is indicated by:

• a clear plan for ending life

• an identified lethal method

• a previous suicide attempt

• a lack of social support

• severe (psychotic) depressive disorder.

See also the ‘SAD PERSONS’ scale (Fig. 3).13

4.3 Mental state assessment

Assessing the patient’s mental state is as important as a physical examination. Clini­cians should conduct and document a ‘mental state examination’ (Box 3) at each visit.

4.4 Depression in PLWHA (including MDD and less severe types)

Up to 25% of PLWHA in SA are thought to suffer from some form of depression during the course of the illness. Severe depression, also known as MDD, occurs in about 5 - 10% of patients, while minor depressive disorders are diagnosed in about 15 - 20%.6 , 10 Even mild depression can lead to erratic adherence, poor care engagement and ultimately to more serious outcomes. Major depression is diagnosed by the presence of five or more of the symptoms listed in section 4.4.1 for at least two weeks, while minor depression is diagnosed when fewer symptoms are present and/or for shorter periods.

4.4.1 Symptoms of depressive disorders

Depressive disorder is characterised by five or more of the following occurring together in a two-week period:

• EITHER: depressed mood almost all day every day

• OR: loss of interest or enjoyment of usually pleasurable activities for most of the day

• AND (occurring nearly every day):

• significant weight loss when not dieting or due to medical illness, or weight gain (e.g. >5% body weight change in a month), or decreased/increased appetite

• insomnia or hypersomnia

• psychomotor agitation or retardation (observ­able by others, not merely sub­ject­ive feelings of restlessness or of being slowed down)

• fatigue or loss of energy

• feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) – not merely self-reproach or guilt about being sick

• diminished ability to think or concen­trate, or indecisiveness (either by sub­jective account or as observed by others)

• recurrent thoughts of death (not just fear of dying), recurrent suicidal idea­tion without a specific plan, or a suicide attempt or a specific plan for committing suicide.14

Psychotic symptoms may occur in severe depressive disorders. These usually consist of delusions (guilt, nihilistic, of death, occasionally paranoid) and occasionally hallucinations (these are usually transient).

If the screen is positive for a CMD, conduct and document a mental state examination (see Box 3).

4.4.2 Differential diagnosis of depression

• Minor or sub-threshold depressive dis­orders are characterised by the presence of some symptoms, but do meet all criteria for MDD

• Major depression

• Adjustment disorder: a depressive reaction to psychosocial stressors including HIV diagnosis

• Bereavement (see section 7)

• Mood disorder secondary to a medical condition/substance, e.g. HIV, hypothyroidism, efavirenz (EFV), alcohol

• Bipolar disorder: there is usually history of a previous episode of elevated mood resulting in abnormal behaviour, e.g. reduced sleep, increased energy/libido/risk-taking, etc.

4.4.3 Management of MDD (moderate to severe depression according to the PHQ-9)

4.4.3.1 Hospitalisation

The patient requires hospitalisation:

• if there is a high suicide risk

• in complex cases: the presence of psychosis and/or minimal social support and/or a poor response to out-patient treatment and/or a diagnostic dilemma

• in complex medical comorbidity (to monitor antidepressant medi­cation)

• in the event of severe psychomotor retardation or no eating/drinking.

4.4.3.2 Initiation of antidepressant treatment

The initiation of antidepressant therapy in patients with CMDs is based on a step-wise approach, using the PHQ-9 as a guide to diagnosis, management and follow-up (Box 4). It is essential to remember that one ‘starts low and goes slow’ as patients with HIV/AIDS are often more sensitive to side-effects of medication.

4.4.5 Psychotherapy 15

• If available, patients should be referred for psychological assessment and treatment

• Evidence-based psychotherapy interventions for PLWHA and de­press­ion include:

• cognitive-behavioural therapy (CBT): a form of psychotherapy addressing dysfunctional emotions and maladaptive ideas through a goal-directed systematic process

• interpersonal therapy (IPT): a form of psychotherapy that is time-limited and encourages patients to regain control of mood and functioning through the therapeutic alliance

• group IPT (IPT-G): a form of therapy that employs the same basic structure and focus of individual IPT, though modified to capitalise on the group format

• Key determinants of successful therapy include the motivation of patients to attend multiple sessions and the access to clinics/times.

4.5 Anxiety disorders

Anxiety disorders in PLWHA are common. Some studies report that between 20% and 60% of HIV-positive adults suffer from some form of psychiatric disorder. The most recent general population study of the prevalence of mental disorders in SA was the SASH study, which reported a combined 12-month prevalence of depressive and anxiety disorders of 12.6%. 6 It is important to recognise and treat anxiety disorders as they have been associated with increased rates of poor treatment compliance and high-risk behaviour. Quality of life is also adversely affected by anxiety disorders (Table 1).

5. SMDs and HIV/AIDS

These disorders occur less frequently in the general population (usually at rates <5%) and include:

• schizophrenia

• bipolar mood disorder

• MDD with psychotic features.

Box 5 describes the prevalence and impact of SMDs.

5.1 Diagnosis of SMDs

SMDs in PLWHA can often be classified as ‘primary’ or ‘secondary’. Primary SMDs often occur prior to HIV infection while secondary SMDs arise as a consequence of HIV infection. Both are responsive to a combination of psychotropic medication and ART.

A careful approach will help to differentiate primary SMDs (with comorbid HIV) (Fig. 4a) from secondary SMDs resulting directly from HIV or an opportunistic infection (Fig. 4b).

Clinicians must:

• conduct a thorough history: presenting symptoms, temporal relation­ship to HIV diagnosis, family/past psychiatric history

• conduct a comprehensive physical and neurological examination: this is essential to exclude underlying medical causes for psychiatric symptoms, e.g. opportunistic infections (particularly CNS pathology – toxoplasmosis/tuberculosis or cryptococcal meningitis), delirium or medication side-effects

• perform the following investigations: vital signs, urine dipstix, blood glucose, full blood count (FBC), creatinine and estimated glomerular filtration rate (eGFR), CD4+ count, lumbar puncture; may also perform alanine transaminase (ALT)/liver function tests (LFTs), syphilis serology, thyroid stimulating hormone (TSH), VL testing and a computed tomography (CT) scan, if these are indicated on the basis of history and examination findings.

5.2 Management of SMDs

• Requires a multidisciplinary team approach, and where possible, integrated care including the involvement of community members and allied professionals

• Adherence support via treatment supporter/support groups and careful monitoring are key; patients should be educated/counselled regarding mental disorders and HIV to improve insight

• Poly-pharmacy (antidepressants, anticonvulsants, antipsychotics and ART): try as far as possible to rationalise to once daily dosing; patients on complex regimens should be reviewed regularly with a view to simplification

• Patients are more vulnerable to medication side-effects (e.g. extra-pyramidal side-effects while receiving antipsychotics) and should be monitored closely.

• See Table 2.

5.3 Starting ART in SMD: Use of EFV

Clinicians should follow standard national guidelines when initiating patients with SMDs on ART. EFV can often be used safely in patients with CMDs and in most with SMDs.17 Routinely avoiding EFV for fear of worsening psychosis/depression is not warranted, especially since EFV has a more favourable side-effect profile, lower pill burden and fewer drug-drug interactions with psychiatric medications than other available alternatives (nevirapine and lopinavir/ritonavir).

Milder neuropsychiatric side-effects of EFV (vivid dreams, dizziness), which typically resolve within 2 - 4 weeks, can be managed with re­assurance.18 Should a patient develop new-onset or worsening of pre-existing psychosis with a temporal relationship to EFV introduction, and the psychosis persists despite psycho-pharmacological management, then the clinician should consider switching from EFV to an alternative agent. If a patient cannot tolerate EFV side-effects, then it may be necessary to switch to an alternative ARV.

The use/initiation of EFV in patients who are currently psychotic or severely depressed remains controversial. If available, consider alternative regimens as there currently is no published literature on the outcomes of EFV in psychotic/depressed individuals. If alternatives are unavailable, contraindicated or involve significant drug-drug interactions, then initiate EFV and monitor carefully.

5.4 Diagnosis and management of secondary SMDs

It is helpful to establish whether the SMD (psychosis or manic epi­sode) is due to an underlying primary mental disorder or is secondary to HIV infection. Primary disorders require the initiation of psycho­tropic treatment and an assessment of whether HIV disease is currently contributing to the disorder. If patients do not meet National Department of Health (NDoH) criteria for ART initiation and are not considered to have HIV-associated SMD, then they can be referred to out-patient HIV services when discharged. Where the SMD is either thought to be secondary to HIV or where a primary SMD is being aggravated by HIV, ART and psychotropic treatment should be given in hospital.

5.5 SMDs secondary to HIV infection

• SMDs secondary to HIV infection are often associated with:

• cognitive impairment (memory deficits and psychomotor slowing)

• significant immune-compromise: stage III/IV WHO disease, CD4+ counts <350 cell/µl and/or high VLs

• some atypical mental state features, e.g. irritability, non-auditory hallucinations (i.e. visual or other), and a lack of personal or family history of mental disorders (i.e. no or little genetic loading)

• no/poor response to psychotropic treatment.

• Management includes:

• commencing ART in line with the NDoH guidelines

• using low-dose anti-psychotics (haloperidol, risperidone, quetia­pine) for psychosis

• patients with mania due to HIV may respond well to second-generation antipsychotics (SGAs) (risperidone, quetiapine, olanzapine, aripiprazole)

• considering mood stabilisers in persistently manic patients (consult with a psychiatrist).

6. HIV-associated neurocognitive disorders

HIV-associated neuropathological disease presents with a characteristic sub-cortical deficit pattern including: psychomotor slowing, impaired memory, attention, language, executive functioning and behavioural apathy. In patients receiving ART, a mixed cortical-subcortical picture is observed (less psychomotor slowing, more executive function, language and visuo-spatial difficulties). Classification into various HAND categories (Box 6) is determined by the extent of neurological and functional impairment:

• mild neurocognitive disorder (MND)

• HIV-dementia (HIV-D).21

Box 6. MND v. HIV-D Incidence • HIV-D in untreated HIV: 35/1 000 person years • HIV-D in patients receiving ART: 3/1 000 person years Prevalence (SA) • MND, pre-ART: 42.4% • MND, while receiving ART: 25.4%22 Impact • HIV-associated neuro-invasion results in a spectrum of neurological effects, ranging from subclinical to advanced dementia • Milder (or subclinical) HAND, which often persists during ART, has significant effects on functional outcomes, e.g. poor adherence, unemployment • Increasing HIV testing uptake, earlier access to ART and adherence support will positively impact rates of HAND in HIV-positive populations

6.1 Screening

• Without screening (excluding HAND suffer­ers presenting to hospital with con­fusional states/psychosis), many patients with gradual neurodegenerative changes are undiagnosed due to infrequent self-reporting of functional impairment/ decline

• Such milder HAND needs to be detected as it may precede to further neurodegeneration that can potentially be prevented by ART

• In pre-ART patients with CD4+ counts >350 cells/µl, screening should be performed in wellness clinics approximately annually; patients with clear neurocognitive disorder should be referred for confirmation and initiation of ART

• At ART initiation, patients with cognitive problems may require additional treatment support; a baseline assessment allows track­ing over time of progress/recovery

• Once receiving ART, patients with HAND may require additional adherence support

• HAND may progress or fail to recover despite ART

• Should be offered as part of adherence support or may be offered annually, or where resources are limited, reserved for those with clinical problems (treatment failure, poor ad­her­ence, on-going depression, self-reported functional impair­ment).

6.2 Approaches to screening for HAND

• There is no globally accepted screening policy or practice

• An ultra-brief symptoms-based tool23 may detect more severe cases (see Table 3)

• Other tools proposed for use include:

• International HIV Dementia Scale (IHDS) (validated in SA) (http://www.europeanaidsclinicalsociety.org/Guidelines/G2_pC.htm)

• Montreal Cognitive Assessment (MOCA) (http://www.mocatest.org)

• the HIV-Dementia scale (http://www.turkpsikiyatri.org/arsiv/category/3-eng.html?...93:hiv-dementia)

• Cognitive Assessment Tool – Rapid Ver­sion (awaiting validation) (http://www.hivmentalhealth.co.za/.../Cognitive-Assessment-Tool-paper-version2.pdf)

• A positive screen does not equate to a diag­nosis of HAND; three further steps are required for clinical confirmation (Table 4).

6.3 Management (Fig. 5)

• Pre-ART, with confirmed HAND: comm­ence ART, irrespective of CD4+ count; engage family/partner for treatment support; and diagnose and treat confounding conditions

• Receiving ART, with HAND: usually mild/moderate disease but, with ageing popula­tions, more advanced disease may develop

• Routine VL monitoring with enhanced support, if adherence is poor

• Screen and treat comorbidities including age-related dementia

• Adjusting the ARV regimen to en­hance CNS penetration (CPE) is not recommended, as the evidence in this regard is conflicting

• Measure the cerebrospinal fluid VL if viral compartmentalisation is suspected (low CD4+ nadir, severe impairment, confusional symptoms, increased tone and psychomotor slowing despite viral suppression in plasma)

• Augmentation strategies, including meman­tine, are not recommended due to the lack of robust supporting evidence and cost

• Sodium valproate or lithium may be used if there is neuropsychiatric comorbidity.

7. Grief and loss in the context of HIV

Grief is a normal, non-pathological response to any type of loss, not just death. The grief response is highly individualised as it is influ­enced by individual, cultural, religious, familial, community and societal factors. Grief arising from a loss related to HIV may be particularly complicated; complicated grief is defined as a prolonged period of intensified grief symptoms that disrupt daily functioning.24

7.1 Screening

• Screen for common symptoms of grief:

• emotional: enduring sadness, shock, anger, anxiety, loneliness, yearning, guilt, fear, withdrawal, feeling worthless, apathy, irritability, appetite disturbances

• physical: fatigue, tightness in the chest, shortness of breath, lack of energy, numbness, nausea, body aches, panic attacks, insomnia

• psychological/cognitive: disbelief, con­fu­sion, sense of presence, lack of concen­tration, auditory hallucinations (hearing the voice of the deceased), intrusive thoughts, anxiety about death, mental fatigue

• spiritual distress: questioning faith or the meaning of being a survivor

• Explore the nature and relationship of the loss/death and its impact

• Assess if the grief reaction is appropriate for the setting/cultural context

• Assess the griever’s coping style, support network, and previous experiences of loss or death

• Assess for barriers to effective grieving, e.g. a lack of support, multiple losses, mental health issues, a complex relationship with the deceased, the manner of death, etc.

• The screening of children and adolescents needs to be age-appropriate and cognisant of the multiple subsequent losses that can arise following parental/caregiver death, e.g. separation from siblings, new school/friends, new home, etc.

• Clinicians may have trouble distinguishing grief and bereavement from depression (see Table 5; refer to Fig. 6 for the management of acute grief and bereavement)

8. Burnout and vicarious trauma

HCWs may also experience emotional and psychological effects from exposure to cumulative challenges within the health sector. While taking care of oneself is a prerequisite to taking good care of others, stigma persists for HCWs acknowledging burnout and vicarious trauma. Table 6 highlights key symptoms indicative of burnout and vicarious trauma.29

8.1 Burnout

• Prolonged involvement in emotionally demanding situations results in gradual progression towards: (i) emotional ex­haus­tion; (ii) depersonalisation; and (iii) a re­­duc­ed personal accomplishment and commit­ment to one’s profession

• Risk factors include: a high patient load; difficult patient circumstances; HCW em­­pathy, own experiences, age, training, lack of control and failure to care for oneself; and organisational characteristics (a lack of support/recognition/fairness, low salaries)

• Failure to recognise burnout may lead to depression or chronic fatigue27

• Burnout can be assessed officially using the Maslach Burnout Inventory (MBI) (http://www.mindgarden.com/products/mbi.htm) or the Oldenburg Burnout Inventory (OBI) (http://www.bma.org.uk/burnoutquestionnaire ).

8.2 Vicarious trauma

Repeated exposure to patients’ traumatic stories may result in intrusive imagery, avoidance/hyperarousal, experiencing symp­toms similar to the patients’ trauma response (confusion, tearfulness, iso­lation, anger, irrita­bility, powerlessness, hope­less­ness), increased vulnerability and/or sur­vivor guilt.28

8.3 Management

• The individual clinician can manage burnout by following the 3 ‘r’ approach:30

• recognise: watch carefully for signs of burnout

• reverse: undo damage by using stress-management techniques and employing support from fellow HCW and family

• resilience: build resilience to stress by looking after your physical and mental health

• When recovering from burnout: slow down; re-evaluate goals and priorities; and get support.

Conflict of interest. All expert panel members completed and submitted conflict of interest disclosure forms. Disclosure information represents the previous three years (updated 15 November 2013) and includes relationships with pharmaceutical companies and medical aids. C Freeman has received support to attend a conference from Bristol-Myers Squibb; G Jonsson has received support to attend conferences from Janssen-Cilag, research support from Bristol-Myers Squibb and honoraria for speaking engagements from Toga Laboratories; J Joska has received an in-kind donation to support research from Norgine Pharmaceutircals and honoraria for speaking engagements from Sanofi Aventis; and G Meintjes has received honoraria for speaking engagements from Sanofi Aventis and serves as a consultant for Aid for AIDS. N Davies, J Furin, S Pahad, R Thom, K Thompson and N Woollett report no conflicts of interest.   

Acknowledgement. This work is supported and funded by the Southern African HIV Clinicians Society through an educational grant from Atlantic Philanthropies.

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