Psych consult often is necessary
A national survey indicates that it’s fairly common for HIV physicians to identify depression and similar symptoms in HIV-infected patients. A telephone survey conducted in October, of 136 United States AIDS physicians, found that 84.3% reported that their HIV-positive patients suffered from depressive symptoms, says Ewald Horwath, MD, director of the Washington Heights Community Service Inpatient Unit at the New York State Psychiatric Institute in New York City. He is the author of the study, which appeared in the October issue of International Association of Physicians in AIDS Care.
"The physicians were a fairly experienced group," he says. "About 60% of them saw more than 20 HIV-infected patients a week, and a majority of them, about 70%, had more than 10 years experience in the field." About one-third of the physicians were infectious disease doctors, and 40% were internal medicine physicians.
Horwath presented the survey results at the Infectious Disease Society of America conference, held in late October in Chicago. The survey was conducted by telephone, with a follow-up in which the person surveyed completed a paper or web site reply form that was returned to the surveyor, he says.
The survey highlights how commonly HIV/ AIDS patients have problems that go beyond their infection, Horwath says. "Oftentimes, a patient with AIDS walks into a doctor’s office, and it’s almost as if they come in with AIDS written on their forehead — the disease becomes the patient. The important thing to remember is that although the patient has AIDS, which implies immune problems and opportunistic infections, etc., they also are quite likely to suffer from psychological and psychiatric problems, including depression."
Their depression may be in response to their disease or to their history before infection, or to the stress that results from antiretroviral treatment, Horwath notes.
The surveyed physicians also were asked about diagnosing and treating depressive symptoms, and 95% said they routinely screen for symptoms of depression. In most cases, the HIV clinicians had a variety of strategies for treating depression, and these included prescribing antidepressants, referring patients for a psychiatric consultation, and sometimes switching antiretroviral therapy when a particular drug was likely the cause of the symptom, he explains.
"In particular, efavirenz was identified as one of the drugs associated with a large risk of psychiatric and central nervous system side effects," Horwath says. Physicians surveyed also reported that common problems among HIV patients included anxiety, headaches, lethargy, and insomnia. About 87% of the doctors attributed some of these symptoms to one of the antiretroviral agents, he adds.
The causes of the symptoms may vary widely. For example, headaches are very common among medical patients of all types as well as among HIV patients, and they can be caused by a variety of different factors. "It’s a common symptom in people who are depressed and among people who have various types of central nervous symptoms," Horwath says. "OIs [opportunistic infections] — like toxoplasmosis and meningitis — can present with headaches, and even HIV itself can cause headaches, especially very early after infection." Since each symptom has a potentially complicated causality, it’s important to take a patient’s history and investigate the various possibilities, he advises.
While the survey couldn’t determine the cause of symptoms, it did show that physicians often are aware of the possibility of mental health problems and they will identify them and either evaluate the patients themselves or refer patients for evaluation.
"One of the tricky things about treating AIDS is that one is often faced with a variety of symptoms that can be either medical or psychiatric, and you don’t know the cause because the patient has so many things going on," Horwath notes. "The average HIV patient is taking antiretroviral drugs, has OIs, may have a history of substance abuse and a pre-existing psychiatric disorder."
So when clinicians first see a patient who presents with symptoms of depression, they may not know what causes the symptoms and they’ll have to start an evaluation process, he says.
"About 70% of the doctors said they rely on psychiatric consultation," Horwath adds. "So a consultative relationship between the psychiatrist and infectious disease specialist or internist is something we believe is an important element of treating patients with HIV." Horwath says he hopes HIV clinicians will realize from the survey’s findings that they need to screen patients for mental health problems and then possibly refer patients to a psychiatrist, psychologist, or another mental health professional for evaluation.
"They need to think of possible medical causes for the symptoms, and these could include opportunistic infections, medication side effects, and potential psychological issues, like stresses from the illness and other problems the patients experience," he adds.
The New York State Psychiatric Institute has been involved with the Columbia University HIV Mental Health Training Project, which began its work in 1998 as a collaborative effort to work with mental health providers and mental health agencies that are interested in learning more about HIV and mental health issues. "So we have a group of people, including myself and other psychiatrists and psychologists, who are experienced in the area and go out and train other professionals about it," Horwath says.
The training includes lectures, interactive workshops, and discussions of risk behaviors and how to get patients to talk about HIV and some of the things they’ve done to put themselves at risk for infection, he adds. "We talk about what we refer to as triply-diagnosed patients, which are those with HIV infection, substance abuse problems, and psychiatric disorders. We talk about how to manage patients with that complicated combination, which is quite common actually."