04 - Depression

Depression

804 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 10 Although most psychotropic agents are thought to be safe in PLWH, definitive data are lacking in many cases. PLWH may be more sensitive to higher doses, adverse effects and to interactions.2 Patients with advanced HIV disease are particularly more likely to suffer exaggerated adverse reactions to psychotropic medication. HIV treatment advances and mental health Treatment of HIV infection has evolved in recent years to include long-­acting injectable antiretroviral therapy (ART) (e.g. cabotegravir/rilpivirine)3 aiming to improve adherence to and persistence with treatment.3 Ensuring continuous ART is crucial for a number of reasons including the fact that inflammation associated with untreated HIV can worsen pre-­existing cognitive decline in people with psychosis. Successful treatment with ART is associated with a lower risk of mental health disorders.4 In those at high risk of psychiatric relapse and poor compliance with medicines, long-­acting injections of both antipsychotics and antiretrovirals are available and could be used concurrently. Psychotic illness For most PLWH and comorbid psychosis, treatment is similar to that used in people without HIV5 but with some specific considerations. PLWH are more susceptible to extrapyramidal side effects (EPSEs) because HIV, a neurotropic virus, enters the brain and replicates in the basal ganglia leading to dopaminergic neuronal loss.6 In addition to this, both HIV and ART are implicated in metabolic abnormalities, hyperlipidaemia, weight gain and insulin resistance.7 Use of second-­generation antipsychotics (SGAs) in PLWH has been shown to increase the cardiovascular risk and metabolic complications compared with those not on SGAs.8 Likewise, QT interval prolongation can be a complication of HIV progression, HIV comorbidities and use of antiretrovirals as well as antipsychotics.9 Pharmacokinetic interactions should be considered and are discussed further in this section. SGAs are clearly first-­line options for the treatment of psychosis in PLWH although close physical health monitoring is essential, as is the use of preventative measures if required. Clozapine is a treatment option in PLWH10–12 and comorbid treatment-­resistant schizophrenia. Haematological abnormalities, including leukopenia, neutropenia, lymphopenia, thrombocytopenia and anaemias, are frequent complications of HIV13 as well as ART. Clozapine treatment may be erroneously interrupted if these are considered as clozapine-­induced, with detrimental consequences for the treatment of both HIV and psychosis. The safe and effective management of the additive haematological, metabolic and cardiovascular effects of clozapine and ART and complex pharmacokinetic interactions require the close collaboration of specialist medical teams and pharmacists. Clozapine may also be helpful in the treatment of individuals with HIV-­associated psychosis with drug-­induced parkinsonism.14 Depression Depression is the most common mental health disorder in PLWH, with prevalence estimated to be between 14% and 78%.1 Depressive symptoms can be a consequence of HIV infection or ART or of a pre-­existing disorder. Untreated depression in PLWH is associated with reduced viral suppression and faster HIV illness progression.15 Antidepressants