Development of acute psychotic disorders and HIV-1 infection

Psychotic disorders in young adults with perinatally acquired HIV: a UK case series

BACKGROUND

Increasing numbers of children with perinatally acquired HIV (PaHIV) are transitioning into adult care. People living with behaviourally acquired HIV are known to be at more risk of psychosis than uninfected peers. Young adults living with PaHIV face numerous risk factors; biological: lifelong exposure to a neurotrophic virus, antiretroviral medication and immune dysfunction during brain development, and environmental; social deprivation, ethnicity-related discrimination, and migration-related issues. To date, there is little published data on the prevalence of psychotic illness in young people growing up with PaHIV.

METHODS

We conducted a retrospective case note review of all individuals with PaHIV aged over 18 years registered for follow up at a dedicated clinic in the UK (n = 184).

RESULTS

In total, 12/184 (6.5%), median age 23 years (interquartile range 21-26), had experienced at least one psychotic episode. The presentation and course of the psychotic episodes experienced by our cohort varied from short-lived symptoms to long term illness and nine (75%) appear to have developed a severe and enduring mental illness requiring long term care.

CONCLUSION

The prevalence of psychosis in our cohort was clearly above the lifetime prevalence of psychosis in UK individuals aged 16-34 years, which has been reported to be 0.5-1.0%. This highlights the importance of clinical vigilance regarding the mental health of young people growing up with PaHIV and the need to integrate direct access to mental health services within the HIV centres providing medical care.

Does Diagnosis Make a Difference? Estimating the Impact of an HIV Medication Adherence Intervention for Persons with Serious Mental Illness

The heightened risk of persons with serious mental illness to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Here we evaluate the interaction between psychiatric diagnosis and response to a community based-intervention targeted at treatment adherence in 236 HIV+ persons with co-occurring mental illness. To examine differential effectiveness of the intervention for categories of patient diagnosis, we reanalyzed the data after stratifying participants into two diagnostic groups: (1) participants with depressive disorders without psychosis and (2) participants with a psychotic or bipolar disorder. Outcomes included viral load and mental health quality of life (SF-12 Mental Health). We found that HIV+ persons with non-psychotic depressive disorders demonstrated a larger decrease in HIV viral load and more improvement in measures of mental health quality of life when compared to HIV+ persons with psychotic and bipolar disorders. We suggest that successful adherence interventions should be informed by psychiatric symptomatology.

TRIAL REGISTRATION

clinicaltrials.gov 29 identifier NCT00264823.

HIV prevalence among first-presentation psychotic patients

OBJECTIVES

First-episode psychosis is a frequent emergency department (ED) presentation that may potentially be secondary to an underlying life-threatening HIV-related condition. The aim of this study was to determine the prevalence of HIV infection in patients presenting with a first episode of psychosis.

METHODS

Medical records of 159 consecutive African, Asian, White and mixed ethnicity patients presenting to a tertiary academic hospital ED with a first episode of psychotic features were prospectively reviewed.

RESULTS

Of the 159 subjects, 63 (39.6%) were HIV positive. An underlying medical condition was the most common aetiology of psychosis in both HIV-positive (84.2%) and HIV-negative (35.4%) subjects, but was significantly more common in HIV-positive individuals (P < 0.001). Substance-induced psychotic disorders and other primary psychiatric disorders were significantly more common in subjects without HIV infection (P < 0.001 and P < 0.001, respectively). While there were more men in the HIV-negative group (66.7%), gender distribution was almost equal in the HIV-infected group (49.2% male). Overall, as well as in both groups, most subjects were of African race, were unemployed and had not completed high school.

CONCLUSIONS

Co-occurrence of HIV infection was a frequent finding in first-episode psychotic individuals residing in a high-prevalence HIV setting. These individuals are more likely to have an underlying medical condition precipitating the onset of psychosis, not to have been initiated on antiretroviral therapy and to present with a low CD4 cell count and high HIV viral load.

HIV-infection and psychiatric illnesses - A double edged sword that threatens the vision of a contained epidemic: The Greater Stockholm HIV Cohort Study

CONTEXT

The Greater Stockholm HIV Cohort Study is an initiative to provide longitudinal information regarding the health of people living with HIV.

OBJECTIVE

Our aim was to explore the prevalence of HIV and its association with psychiatric co-morbidities.

DESIGN, SETTING AND PARTICIPANTS

All patients with a recorded diagnosis of HIV (any position of the ICD-10 codes B20-B24) were identified during the period 2007-2014 and related to the total population in Stockholm by January 1, 2015, N = 2.21 million. The age at diagnosis, gender, and first occurrence of an HIV diagnosis was recorded. Analyses were done by age and gender. Prevalence of psychiatric co-morbidities amongst HIV patients were recorded.

MAIN OUTCOME MEASURES

Age-adjusted odds ratios with 95% confidence intervals were calculated with logistic regression for prevalent psychiatric co-morbidities in HIV infected individuals compared to the prevalence in the general population.

RESULTS

The total prevalence of HIV was 0.16%; females 0.10% (n = 1134) and males 0.21% (n = 2448). HIV-infected people were more frequently diagnosed with psychiatric illnesses and drug abuse. In females and males with HIV-diagnosis respectively, drug dependence disorder was 7.5 (7.76% vs 1.04%) and 5.1 (10.17% vs 1.98%) times higher, psychotic disorders were 6.3 (2.65% vs 0.42%) and 2.9 (1.43% vs 0.49%) times higher, bipolar disorder was 2.5 (1.41% vs 0.57%) and 3 (1.02% vs 0.34%) times higher, depression diagnosis was 1.5 (8.47% vs 5.82%) and 3.4 (10.17% vs 2.97%) higher, trauma-related disorder was 1.5 (6.00% vs 4.10%) respectively 2.9 (4.45% vs 1.56%) times higher, anxiety disorder was 1.2 (6.88% vs 5.72%) and 2.2 (6.54% vs 2.93%) times higher than in their non-infected peers.

CONCLUSION

Despite effective ART, many individuals with HIV have an impaired mental health and a history of drug abuse that may threaten the vision of a contained epidemic.

Anti-NMDAR antibodies in new-onset psychosis. Positive results in an HIV-infected patient

The role of neuronal surface autoantibodies (NSAs) in non-encephalitic psychosis is of recent and controversial interest. Most of the studies relating NSAs with psychosis are retrospective and only focused on the N-methyl-d-aspartate glutamate receptor (NMDAR). Our goal was to evaluate the prevalence of IgG antibodies against the NMDAR NR1 subunit (NMDAR-Abs) along with five additional NSAs in 61 first psychotic episode patients and 47 matched controls. We found two patients positive for NMDAR-Abs (3.3%). One of them was eventually considered to have been misdiagnosed and reclassified as encephalitis. The other met the criteria for bipolar I disorder, presented no neurological symptoms and had a comorbid HIV infection of vertical transmission. This is the first reported case of an HIV-infected patient with psychosis associated with NSAs. This study shows that patients presenting with clinically incomplete forms of anti-NMDAR encephalitis, with predominant or isolated psychiatric symptoms, can remain undetected if no ancillary tests are performed. To improve patient diagnosis and treatment of individuals with a first psychotic episode, more detailed neurological examinations might be needed. Further studies are required to better clarify the role of NSAs in the neuropsychiatric effects of HIV infection.

[The classifying criteria for the evaluation of the severity of the harm to health in the case of development of psychic health problems associated with HIV infection]

The objective of the present study was to develop the classifying criteria for the evaluation of the severity of the harm inflicted to human health that resulted in the development of mental disorders in response to subsequent HIV infection. The analysis of the available information about a rise in the prevalence of HIV infection and the high frequency of associated psychic disorders among the infected subjects gave evidence of the importance of this problem and the necessity to improve the existing statutory and legislative basis underlying the regulation of activities in this field. The scientifically substantiated criteria for the expert assessment of the severity of the harm to human health are proposed taking into consideration the clinical manifestations of psychic disorders.

Cognitive dysfunction among HIV positive and HIV negative patients with psychosis in Uganda

BACKGROUND

Cognitive impairment is an established phenomenon in HIV infected individuals and patients that have psychosis. However there is need to establish the severity of the impairment if patients are co morbid with both conditions.

AIM

To compare cognitive function among HIV positive individuals and HIV negative individuals with psychosis.

METHODS

We recruited patients with psychosis at two national referral hospitals. A standardized demographics questionnaire and psychiatric, physical, and laboratory assessments were conducted. Types of psychosis were diagnosed using the Mini International Neuropsychiatric Inventory-PLUS while cognitive functioning was determined using the Mini mental state examination (MMSE) and a neuropsychological test battery. Follow-up assessments on cognitive function and severity of psychiatric illness were performed at 3 and 6 months. Pairwise comparison and multivariable logistic regression analysis were used to determine the differences between the HIV positive and HIV negative individuals.

RESULTS

There were 156 HIV positive and 322 HIV negative participants. The mean age was 33 years for the HIV positive group and 29 years for the HIV negative group (p<0.001). The HIV positive individuals were almost three times (OR = 2.62 CI 95% 1.69-4.06) more likely to be cognitively impaired on the MMSE as well as the following cognitive tests:- WHO-UCLA Auditory Verbal Learning Test (OR 1.79, 95% CI 1.09-2.92), Verbal Fluency (OR 3.42, 95% CI 2.24-5.24), Color Trails 1 (OR 2.03, 95% CI 1.29-3.02) and Color Trails 2 (OR 3.50 95% 2.00-6.10) all p = 0.01. There was improvement in cognitive function at follow up; however the impairment remained higher for the HIV positive group (p<0.001).

CONCLUSION

Cognitive impairment in psychosis was worsened by HIV infection. Care plans to minimize the effect of this impairment should be structured for the management of individuals with HIV and psychosis.

Prenatal depression leading to postpartum psychosis

Postpartum psychosis is a mood disorder occurring up to 3 months after delivery. Incidence is one to two women every 1,000 live births. If not detected and appropriately treated in time, it may have detrimental effects on both the mother and her baby. We report a case of puerperal psychosis in a patient with a history of depression. We have also reviewed the relevant literature discussing prediction, management and differential diagnosis of postpartum psychosis. We emphasise the importance of early detection and provision of care to all women at risk of mental illness by multidisciplinary team, including GPs, obstetricians, midwives and perinatal mental health professionals.

Treatment considerations for psychiatric syndromes associated with HIV infection

Psychiatric syndromes associated with HIV disease were recognized early in the AIDS epidemic. Public education, new technologies and antiretroviral therapies have resulted in earlier recognition and therapautic interventions of HIV infection, improving the physical health for individuals living with HIV. While HIV-associated psychiatric symptoms have been recognized for more than 20 years, our understanding of the mechanisms underlying psychiatric symptoms among HIV-infected individuals and treatments for these symptoms have not kept pace with advances in HIV therapies. In this article, we discuss current knowledge of the psychiatric symptoms occurring with HIV disease, specifically mood, anxiety and psychotic disorders, evidence-based treatments and treatment considerations, new strategies for the treatments of psychiatric symptoms in HIV disease are also discussed.

Psychopharmacologic treatment of patients with HIV/AIDS

Psychiatric disorders are common among patients with HIV/AIDS, and psychopharmacologic treatment is a cornerstone of management. The efficacy of psychopharmacologic treatment for depression in HIV/AIDS is relatively well established. However, literature on the treatment of other disorders is limited, which means that we still must determine how standard treatment guidelines may need to be modified in consideration of several key aspects of HIV illness. These include the broad differential diagnosis for psychiatric symptoms and the potential for interactions between psychotropic medications and antiretroviral medications. This paper reviews the literature on psychopharmacologic treatments of key psychiatric disorders in HIV/AIDS as well as differential diagnosis and drug-drug interactions.

Psychopathology of first-episode psychosis in HIV-positive persons in comparison to first-episode schizophrenia: a neglected issue

This study aims to detect different psychopathological dimensions in first-episode psychoses with different underlying causes. We evaluated 22 subjects with first-episode psychosis, who differed in biological variables (HIV-positive versus HIV-negative) and who were compared by using the Structured Clinical Interview for DSM-III-Reviewer, the 18-item Brief Psychiatric Rating Scale (BPRS), the 17-item Hamilton Depression Rating Scale, the 14-item Hamilton Anxiety Rating Scale and the Mini-Mental State Examination. HIV-positive subjects had higher mean scores on the global BPRS and on the paranoid Positive and Negative Syndrome Scale subscale compared with HIV-negative subjects. Conversely, higher prevalence of affective and anxious symptoms was found in the HIV-negative patients in comparison to HIV-positives. HIV-positives had significantly greater attention/concentration impairment than HIV-negative persons. In conclusion, taking into account psychopathological dimensions may help psychiatrists in clinical decision-making regarding the differential diagnosis of psychotic symptoms. The psychopathological pattern of first-episode psychosis in HIV-positive patients may represent an 'elementary model' of acute psychosis characterized by paranoid delusions in the absence of the usual affective symptoms.

Acute psychotic symptoms in HIV-1 infected patients are associated with increased levels of kynurenic acid in cerebrospinal fluid

Human immunodeficiency virus type 1 (HIV-1) infection is associated with psychiatric complications including cognitive impairment, affective disorders, and psychosis. Previous studies have revealed a disturbed kynurenine metabolism in these patients leading to increased levels of neuroactive compounds acting at glutamatergic neurotransmission. Kynurenic acid (KYNA), one of these metabolites is a glutamate-receptor antagonist, preferentially blocking the glycine site of the N-methyl-d-aspartate (NMDA) receptor. Increased levels of brain KYNA have been suggested to induce a NMDA receptor hypofunction that is associated with psychotic symptoms. In the present study, we analyze the concentration of KYNA in the cerebrospinal fluid (CSF) from HIV-1 infected patients (n=22), including HIV-1 infected patients with psychotic symptoms (n=8) and HIV-1 infected patients without psychiatric symptoms (n=14). We found that HIV-1 infected patients had significantly higher median concentration of CSF KYNA (3.02nM) compared to healthy controls (1.17nM). Furthermore, CSF KYNA levels were significantly elevated in HIV-1 infected patients with psychotic symptoms (4.54nM) compared to patients with HIV-1 without psychiatric symptoms (2.28nM). Present results indicate that increased levels of CSF KYNA may be associated with development of psychotic symptoms in HIV-1 infected patients.

Psychosis related to neurological conditions: pro and cons of the dis- / mis-connectivity models of schizophrenia

Schizophrenia is still a condition with obscure causes and psychopathology. This paper aims to discuss the “disconnectivity” hypothesis in relation to some neurological conditions which are known to alter brain connectivity, as well as mimicking some aspects of the disorder. After a short historical introduction to the concept, we will examine the evidence for connectivity problems in schizophrenia, separating the anatomical level from the functional level. Then, we will discuss three different issues concerning connectivity: i) local reduction in connectivity without neuronal loss (within the gray matter); ii) reduction in or alteration of long-range connectivity (within the white matter); and iii) abnormal targets for connections. For each of these aspects, we will look at the conditions able to reproduce anomalies capable of increasing susceptibility to schizophrenia. We conclude that psychosis is more likely to occur: i) when long-range connectivity is concerned; ii) when lesions result in lengthening and scattering of conduction times; and iii) when there are high dopamine levels, shedding light on or adding weight to the idea of an interaction between dopamine and connectivity.

Troubles neuropsychiatriques chez les patients infectés par le VIH et rôle de l'efavirenz

Efavirenz has now become commonly used to treat HIV infection. Neuropsychiatric disorders have been reported in patients treated with efavirenz. Several factors often make it hard to determine the cause of these disorders: HIV infected patients take many different drugs, they may suffer from various organ diseases, and may also be heavily affected by problems in their everyday life. The French experts group working on neuropsychiatric side effects of efavirenz has undertaken a review of these disorders with the aim to identify: (1) semiology, (2) epidemiology in the global population, in HIV infected patients, and in patients treated with efavirenz. The expert group suggests recommendations to manage these disorders.

Psychological burden in the era of HAART: impact of selenium therapy

OBJECTIVE

To determine the impact of nutritional (selenium) chemoprevention on levels of psychological burden (anxiety, depression, and mood state) in HIV/AIDS.

METHOD

A randomized, double-blind, placebo-controlled selenium therapy (200 microg/day) trial was conducted in HIV+ drug users from 1998-2000. Psychosocial measures (STAI-State and Trait anxiety, BDI-depression, and POMS- mood state), clinical status (CD4 cell count, viral load), and plasma selenium levels were determined at baseline and compared with measurements obtained at the 12-month evaluation in 63 participants (32 men, 31 women).

RESULTS

The majority of the study participants reported elevated levels of both State (68%) and Trait (70%) anxiety. Approximately 25% reported overall mood distress (POMS > 60) and moderate depression (BDI > 20). Psychological burden was not influenced by current drug use, antiretroviral treatment, or viral load. At the 12-month evaluation, participants who received selenium reported increased vigor (p = 0.004) and had less anxiety (State, p = 0.05 and Trait, p = 0.02), compared to the placebo-treated individuals. No apparent selenium-related affect on depression or distress was observed. The risk for state anxiety was almost four times higher, and nearly nine times greater for trait anxiety in the placebo-treated group, controlling for antiretroviral therapy, CD4 cell decline (> 50 cells) and years of education.

CONCLUSIONS

Selenium therapy may be a beneficial treatment to decrease anxiety in HIV+ drug users who exhibit a high prevalence of psychological burden.

Antiretroviral therapy-induced psychosis: case report and brief review of the literature

OBJECTIVE

We present a case of psychosis in an individual with known HIV infection whose symptoms developed approximately 1 month following the commencement of combination antiretroviral therapy consisting of abacavir (ABC), nevirapine and combivir. She presented with severe persecutory delusions, accompanied by mutism, posturing and catatonia. Following cessation of therapy and the introduction of a low-dose antipsychotic, her mental state resolved to a stable premorbid level, and no further disturbances of behaviour were noted. Furthermore, when re-challenged with the above combination minus ABC, there were no further episodes of psychosis. It is proposed that the aetiology of the psychosis was related to her antiretroviral therapy.

METHODS

Cessation of antiretroviral medication and initiation of antipsychotic medication with appropriate monitoring and assessment.

RESULTS

Subjective and objective improvements in psychotic symptoms and presentation.

CONCLUSION

The current case suggests that sudden onset psychotic disturbances in HIV-infected individuals in the absence of other known organic or other causal factors could be related to treatment with antiretroviral therapy, and that cessation of this can markedly improve psychiatric morbidity. Furthermore, treatment with antipsychotic medication can lead to alleviation of psychotic symptoms and enable the re-introduction of antiretroviral medication.

Corticosteroids, immune suppression, and psychosis

The role of the immune system in psychiatric symptoms has been an area of much interest for many years. This review discusses medications and medical illnesses associated with immune system dysfunction, and their relationship to psychiatric symptoms, particularly psychosis. Medical illnesses including HIV infection, systemic lupus erythematosus (SLE), and Cushing's disease are all associated with psychiatric symptoms. In addition, high dosages of prescription corticosteroids (eg, prednisone and dexamethasone) are associated with mood changes, cognitive deficits, and even psychosis. However, the role of the immune system in mediating the psychiatric disturbances with each of these conditions is not clear. Directions for further research and treatment considerations are discussed.