Psychiatric Disorders

Epidemiologic studies of patients infected with HIV and AIDS show a high lifetime prevalence of psychiatric disorders compared to the general population. Persons at highest risk for HIV infection (i.e., injected drug users and homosexual men) frequently suffer from mood disturbances prior to contracting HIV. Infection with HIV produces brain injury and is associated with a variety of CNS and metabolic disturbances that can produce psychiatric symptoms. HIV infection is also a significant psychosocial stressor, leading to social isolation, poverty, and hopelessness.

Evaluation of psychiatric symptoms in the emergency department should focus on an aggressive search for underlying organic causes of the acute presentation. 19 Delirium suggests the presence of a primary physiologic disease; the workup should include laboratory studies, neuroimaging, and lumbar puncture. The differential diagnosis includes CNS and toxic-metabolic derangements. Frequently, a period of observation may be required if a patient is found to be intoxicated or experiencing withdrawal symptoms.

AIDS psychosis is poorly understood. Patients may present with psychiatric symptoms, such as hallucinations, delusions, or other abnormal behavioral changes. The cause is unclear, and treatment has been identical to that for other psychoses. Acute episodes require admission.

Depression occurs in 20 percent of patients, most commonly in those with lower CD4 counts.20 Depressive illnesses are often responsive to hospitalization and psychosocial intervention. Antidepressant therapy may be considered if symptoms of depression continue longer than 2 weeks. However, due to the increased propensity to develop medication side effects, close patient monitoring is required. Patients with suicidal ideation usually require inpatient psychiatric management.

An increased incidence of mania is observed in both the early and late stages of HIV. Late-stage mania is closely associated with dementia and carries a poor prognosis.

Management of HIV-positive patients with psychiatric complaints must include attention to violent behavior and suicidality. Assessment and stabilization may require physical restraints and acute pharmacologic intervention. Neuroleptics and benzodiazepines may be used in combination. Haloperidol and diazepam are often used; alternatives include droperidol (which has a rapid onset and short half-life) and lorazepam (which offers improved intramuscular absorption). 21

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