Depression and PTSD Treatments Improve Depression and PTSD Treatments Improve HIV Treatment OutcomeHIV Treatment Outcome

Eric Avery, MD

Assistant Clinical Professor of Psychiatry

Director, HIV Psychiatry Services

The University of Texas Medical Branch

Galveston, Texas

ObjectivesObjectives

1. To understand the relationship between the increasing prevalence of psychiatric disorders in HIV patients and the changing epidemiology of the epidemic.

2. To review Depression and Post Traumatic Stress Disorder (PTSD):

Prevalence

Diagnosis

Impact on adherance and mortality

Treatment of Depression and PTSD

3. To review HIV and psychiatric drug/drug interactions.

HIV is a Psychiatric EpidemicHIV is a Psychiatric Epidemic

• Psychiatric illness increases risk for HIV.

• HIV increases risk for psychiatric illness.

• Effective treatment for psychiatric illness can improve patient outcome.

• Effective treatment for psychiatric can decrease HIV transmission.

Psychiatric Illness Increases Risk of HIV Psychiatric Illness Increases Risk of HIV InfectionInfection• Substance Abuse.

• Mood Disorders (Major Depression, Bipolor D/O)

• Post Traumatic Stress Disorder (PTSD)

• Psychotic Disorders

• Impulsive behavior and personality factors

HIV Increases Risk for Psychiatric IllnessHIV Increases Risk for Psychiatric Illness

• Increased major depression.

• Increased mania.

• HIV dementia (AIDS Dementia Complex).

• Increased psychosocial stressors.

DepressionDepression1. Prevalence

2. Diagnosis

3. Impact on ARV Treatment:• Initiation

• Discontinuation

• Adherance

4. Impact on HIV Mortality

5. Treatment of Depression

100 Patients with HIV100 Patients with HIV

How many are depressed?How many are depressed?

Depressed Mood and HIV:Name the 11 types:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.Why is the diagnosis important?

Differential Diagnosis of Depressed Moods in HIV PatientsDifferential Diagnosis of Depressed Moods in HIV Patients

•Despondency/demoralization.

•Dysthymia (chronic low mood).

•Adjustment disorder/minor depression.

•Major depression, recurrent major depression.

•General anxiety disorder.

•Bipolar disorder -- depressed phase.

•Organic mood disorder “secondary depression” (infections, medication side-effects, and mass lesions of CNS).

•Malnourishment/weight loss associated with HIV.

•Sleep disorder.

•Psychoactive substance abuse.

•Bereavement.

0

5

10

15

20

25

30SYNDROMAL

CES - D>=22

CES-D-NS>=14

Time of AIDS Onset

55- 49- 43- 37- 31- 25- 19- 13- 7-12 0-6 0-6 7-12 13- 19-

60 54 48 42 36 30 24 18 mo mo mo mo 18 24

mo mo mo mo mo mo mo mo mo mo

Percentages of Multicenter AIDS Cohort Study participants who met syndromal criteria for depression, or who had a score of 22 or greater on the Center for Epidemiologic Studies Depression scale (CES-D) or 14 or greater on the CES-D minus its “somatic” items (CES-D-NS), as AIDS developed.

Lyketos et al, Psych Ann 31: 1 Jan 01

% D

epre

ssed

Depression: Multicenter AIDS Cohort StudyDepression: Multicenter AIDS Cohort Study

Depression and Progression to AIDS – PreHAARTDepression and Progression to AIDS – PreHAARTLyketos, Hoover, Guccione et al Lyketos, Hoover, Guccione et al

JAMA 1993JAMA 1993

• MACS Cohort: 1718 participants

• 21% depressed at baseline

• Cox proportional hazards analysis controlling for sociodemographics, CD4, AIDS related symptoms

• Depression did not predict AIDS or death

Depression and Progression to Death – PreHAARTDepression and Progression to Death – PreHAARTBurack, Barret, Stall, Chesney, Estrand, Coates Burack, Barret, Stall, Chesney, Estrand, Coates

JAMA 1993JAMA 1993

• San Francisco Men’s Health Study: 277 participants

• 20% depressed at baseline

• Cox proportional hazards analysis of progression to death

• Depression predicted ARV use but not mortality

Depression and Progression to AIDS – PreHAARTDepression and Progression to AIDS – PreHAARTMayne, Vittinghoff, Chesney, Barrett, Coates Mayne, Vittinghoff, Chesney, Barrett, Coates

Arch Int Med 1996Arch Int Med 1996

• SF Men’s Cohort: 1032 participants over 102 months • Cox proportional hazards with time dependent variables• 58% had significant depressive symptoms (CES-D)• Longitudinal measurement of depression every 6 months• Predictors of Mortality

– CD4 cell count– B2 microglobulin– P24 antigen– WHO HIV stage– Depression (RR=1.67 P<0.05)

Depression and Progression to AIDS: Post-HAARTDepression and Progression to AIDS: Post-HAARTIckovics, Hamburger, Vlahov et alIckovics, Hamburger, Vlahov et al

JAMA 2001JAMA 2001

• HERS Cohort: 765 Participants

• Longitudinal depression (CES-D)– 42% chronic– 35% intermittent– 23% none

• Mortality predictors: depression (RR=2), CD4, HAART duration, age

Depression, Mortality by CD4 and Viral load: Depression, Mortality by CD4 and Viral load: Post-HAARTPost-HAART

Ickovics, Hamburger, Vlahov et alIckovics, Hamburger, Vlahov et alJAMA 2001JAMA 2001

Why Does Depression Speed Why Does Depression Speed Progression to AIDS and Death?Progression to AIDS and Death?

• Stress alters cellular and humoral immune response• Kieclot-Glaser Proc Nat Acad Sci 1996• Vedhara Lancet 1999• Glaser Psychosom Med 1992• Jabaaij J Psychosom Res 1993• Glaser Ann NY Acad Sci 1998• Azciati Psychosomatics 2001

• Delay in HAART initiation• Early HAART Discontinuation• Sub-optimal adherence to HAART

Factor Hazard 95% CI p Value

CD4 cell count

<200 1.00      

200-500 2.63 1.61, 4.17 <.001

>500 11.11 3.57, 33.33 <.001

Tenfold increase in initial        elevated viral load 0.66 0.45, 0.98 .038

History of pneumocystis 0.57 0.37, 0.90 .016

Depression (53%) 1.49 1.03, 2.13 .032

History of injection drug use 2.70 1.35, 5.56 .005

Model adjusted for calendar date of first elevated viral load.

Depression and Delay in HAART InitiationDepression and Delay in HAART InitiationFairfield JGIM 1999Fairfield JGIM 1999

199 Patients New England Deaconnes with VL>10,000

Adherence to a PI-Containing Regimen CorrelatesWith HIV RNA Response at 3 Months

Pat

ien

ts W

ith

HIV

RN

A <

400

(%)

0

20

40

60

80

100

<70 70-80 80-90 90-95 >95

PI Adherence (%) (MEMScaps)

Paterson. 6th CROI; 1999; Chicago. Abstract 92.

What Degree of AdherenceWhat Degree of AdherenceIs Needed to PreventIs Needed to Prevent Drug-Resistant VirusDrug-Resistant Virus

Depression Predicts Adherence to Non-HIV Treatment

1996DrugsCochraneAsthma

1994Ped NephBrownbridgeESRD Medical Regimen

1991Trans ProcRodriguezCyclosporine Renal Transplant

1993TransplantationKileyCyclosporine Renal Transplant

1990CancerLebovitsOral cytoxan

1992

1991

1998

1993

1998

1992

1999

Pt Ed Counsel

Health psychol

Psychol Reports

Transplantation

Behavioral Med

J Fam Pract

Psychosom Med

TaalRheum arthritis treatment plan

SchniederESRD Diet

KatzESRD Diet

De-NourRenal diet

CarneyAspirin for angina

BotelhoGeneral medicine

IrvineAmiodarone

Depression and HIV Medication Depression and HIV Medication AdherenceAdherence

• Singh AIDS Care 1996

• Holzmer AIDS Patient Care STDs 1999

• Peterson Annals Int Med 2000

• Schulz 38th ICAAC 1998

• Bangsberg #1721 41st ICAAC 2001

Depression is Under-TreatedDepression is Under-Treated

• 475 HIV+ men

• 37% moderate-severe depressive symptoms– 40% of depressed received mental health care (12 mo)– 3.4% of depressed received antidepressant

medications (12 mo)

Katz et al AIDS Care 1996Katz et al AIDS Care 1996

Depression: DiagnosisDepression: Diagnosis

Simple Depression Assessment1. During the past month, have

you often been bothered by feeling down, depressed, or hopeless?

Yes No

If “no” to both, patient is unlikely to have major depression.

If “yes” to either, proceed with the follow-up clinical interview.

2. During the past month, have you often been bothered by having little interest or pleasure in doing things?

Yes No

Whooley MA, Simon GE. N Engl J Med, 2000.

Follow-up Interview for Diagnosis: Follow-up Interview for Diagnosis: SIGECAPSSSIGECAPSS

SS Sleep Disruption in sleep patterns nearly every day?

II Interests Decreased interest and pleasure in usual activities

GG Guilt Feelings of worthlessness or guilt?

EE Energy Decreased energy?

CC Concentration Diminished ability to concentrate?

AA Appetite Change in appetite or weight?

PP Psychomotor Psychomoror retardation or agitation/irritable?

SS Suicidal Recurrent thought of death or suicide?

SS Sex drive Diminished sex drive?

Beck Depression Inventory Beck Depression Inventory Date__________________Date__________________Name:__________________________________________________ Marital Status:_______ Age:____ Sex:___Name:__________________________________________________ Marital Status:_______ Age:____ Sex:___Occupation:_____________________________________________ Education:___________________________Occupation:_____________________________________________ Education:___________________________This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number (0,1,2 or This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number (0,1,2 or 3) next to the one statement in each group which 3) next to the one statement in each group which bestbest describes the way you have been feeling the describes the way you have been feeling the past week, including todaypast week, including today. If . If several statements within a group seem to apply equally well, circle each one. several statements within a group seem to apply equally well, circle each one. Be sure to read all the statements in each group Be sure to read all the statements in each group before making your choice.before making your choice.

1 0 I do not feel sad.

1 I feel sad.

2 I am sad all the time and I can’t snap out of it.

3 I am so sad or unhappy that I can’t stand it.

2 0 I am not particularly discouraged about the future.

1 I feel discouraged about the future.

2 I feel I have nothing to look forward to.

3 I feel that the future is hopeless and that things cannot improve.

3 0 I do not feel like a failure.

1 I feel I have failed more than the average person.

2 As I look back on my life, all I can see is a lot of failures.

3 I feel I am a complete failure as a person.

8 0 I don’t feel I am any worse than anybody else.

1 I am critical of myself for may weaknesses or mistakes.

2 I blame myself all the time for my faults.

3 I blame myself for everything bad happens.

9 0 I don’t have any thoughts of killing myself.

1 I have thoughts of killing myself, but I would not carry them out.

2 I would like to kill myself.

3 I would kill myself if I had the chance.

10 0 I don’t cry any more than usual.

1 I cry more now than I used to.

2 I cry all the time now.

3 I used to be able to cry, but now I can’t cry even though I want to.

To order forms: 1-800-228-0752

Depression: TreatmentDepression: Treatment

Tricyclic Antidepressants Treatment of Tricyclic Antidepressants Treatment of Depression in HIV+ IndividualsDepression in HIV+ Individuals

1999Dep and Anxiety

Schwartz50%Desipramine

1998Am J PsychElliot87%Imipramine

1994Am J PsychRabkin74% Imipramine

YearJournalAuthorResponseMedication

Treatment of Depression With Other AgentsTreatment of Depression With Other Agents

in HIV+ Individuals in HIV+ Individuals

YearJournalAuthorResponseDrug

2000

2000

1999

J Clin Endo Metab

GrinspoonTestosterone (Sx decrease)

Arch Gen Psych

Rabkin74%Testosterone

J Clin PsychWagner73%Dextroamphetamine

Grinspoon 2000

SSRI Treatment of Depression in SSRI Treatment of Depression in HIV+ IndividualsHIV+ Individuals

YearJournalAuthorResponseMedication

1997

1999

1997

1999

1999

1997

1998

1998

1994

Gen Hosp PsychFerrando86%Paroxetine

J Clin PsychElliot73%Nefazodone

Gen Hosp PsyhFerrando86%Sertraline

J Clin PsychFerrando78%Fluoxetine/

Sertraline

Dep and AnxietySchwartz75%Fluoxetine

Gen Hosp PsychFerrando90%Fluoxetine

Am J PsychElliot67%Fluoxetine

J Clin PsychZisook64%Fluoxetine

J Clin PsychRabkin83%Fluoxetine

Side Effect/Toxicity Profile Side Effect/Toxicity Profile TCA vs SSRITCA vs SSRI

TCA• Narrow therapeutic window

– Requires drug monitoring

• Anticholinergic effects– Dry mouth, Constipation,

dizziness, hypotension

– 41% discontinue at 6 months• (Rabkin Amer J Psych 1994)

• Pill burden

SSRI• Mild side effects

– Anticholinergic, agitation/sedation, sexual dysfunction

• Drug interactions (Rx + ritonavir)

• Bupropion - seizures

SSRI FDA ApprovalsSSRI FDA Approvals

SSRI Fluoxetine Sertraline* Paroxetine Citalopram

Majordepression

+ + + +

OCD + + + -

PanicDisorder

- + + -

GAD - - + -

SocialAnxietyDisorder

- Filedwith FDA

+ -

PTSD - + + -

* FDA approved to age 6 years;

Half Lives of 4 SSRIsHalf Lives of 4 SSRIs

SSRI Parent Drug Metabolite

Fluoxetine 2 – 4 days 10 – 14 days – 100%active

Sertraline 26 hours 62 – 104 hours –20% active

Paroxetine 20 hours None

Citalopram 35 hours None

Serotonin Discontinuation SyndromeSerotonin Discontinuation Syndrome

• Somatic symptoms– Disequilibrium, dizziness, unsteadiness, vertigo

– Feeling “spacey”, confusion, memory dysfunction

– Flulike symptoms (myalgia, chills, fatigue, nausea)

– Sensations of electric shocks, parethesia, tremor

– Insomnia, overactivity, vivid dreams

• Psychological symptoms– Agitation, anxiety, irritability

– Mood lability, crying spells

– Cognitive fog

Hepatic Isoenzyme Inhibition of the SSRIs Hepatic Isoenzyme Inhibition of the SSRIs (Cytochrome P450)(Cytochrome P450)

2D6 3A4 1A2

Fluoxetine +++ + -

Sertraline + - -

Paroxetine +++ - -

Citalopram - - -

HIV-Related Medications and Psychotropic Agents Involving the Cytochrome HIV-Related Medications and Psychotropic Agents Involving the Cytochrome P450 IsoenzymeP450 Isoenzyme

CytochromeP450Isoenzyme

HIVmedicationsPrimarilyMetabolizedby Isoenzyme

PsychotropicMedicationsPrimarilyMetabolized byIsoenzyme

Common HIV-Related Medicationsthat InhibitIsoenzyme

Possible ClinicalImplications ofIsoenzyme Inhibition

Common HIV-Related Medicationsthat InduceIsoenzyme

PossibleClinicalImplicationsof IsoenzymeInduction

3A4

2D6

PIRitonovirAmprenavirIndinavirSaquinavir

NNRTIDelavirdineEfavirenzNevirapine

RitonovirDelavirdineEfavirenz

BenzodiazepinesBuspironeCitalopramCarbamazepineNefazodoneTrazodoneSertralineRisperdal (minor)

MirtazapineFluoxetineParoxetineSertralineFluvoxamineTricyclicantidepressantsVenlafaxineNeuroleptics, typicaland atypicalOlonzepine (minor)Risperidone

Protease inhibitors(especially ritonavir)DelavirdineClarithromycinErthromycinItraconazoleKetoconazoleMacrolide antibioticsFluoxetineParoxetine (weak)Valproic Acid (weak)

Protease inhibitors(especially ritonavir& nelfinavir)Resperdal (weak)Sertraline (weak)FluoxetineCitaloprain (weak)Paroxetine (weak)Valproic Acid

Increased plasmalevels and increasedside effects; forbenzodiazepines,sedation & decreasedrespiratory drive

Increased plasmalevels and increasedside effects; fortricyclicantidepressants,potential increasedrisk for cardiacconduction delay

NivirapineEfavirenzGlucocorticoidsRifampinRifabutin

Efavirenz

Decreasedplasma levelsofpsychotropicmedications& decreasedeffectiveness

Dose Ranges and Interactions With Human Immunodeficiency Virus (HIV) Medications of Commonly Used Antidepressants* Antidepressant Usual Dosage Range Interaction with HIV Medications

Nortriptyline 50-150 mg at bedtime (therapeutic serum level 50-150 mg ng/dL)

Fluconazole, lopinavir-ritonavir, and ritonavir increase nortriptyline levels

Desipramine 50-300 mg at bedtime (therapeutic serum level > 125 ng/dL)

Lopinavir-ritonavir and ritonavir increase desipramine levels

Fluoxetine 10-30 mg in the morning Fluoxetine increases amprenavir, delavirdine, efavirenz, indinavir, lopinavir-ritonavir, ritonavir, nelfinavir, and saquinavir level; nevirapine decreases fluoxetine levels

Sertraline 50-200 mg in the morning Lopinavir-ritonavir and ritonavir increase sertraline levels

Paroxetine 10-40 mg at bedtime Lopinavir-ritonavir and ritonavir increase paroxetine levels

Citalopram 20-60 mg in the morning Lopinavir-ritonavir and ritonavir increase citalopram levels

Nefazodone 300-600 mg/d in divided doses Nefazodone increases efavirenz and indinavir levels

Venlafaxine XR 75-300 mg in the morning Lopinavir-ritonavir and ritonavir increase venlafaxine levels

Mirtazepine 7.5-45 mg at bedtime No known interactions

Bupropion SR 100-400 mg/d in divided doses No known interactions

Staging HIV and Antidepressant Treatment:Staging HIV and Antidepressant Treatment:Treat Depression First Whenever PossibleTreat Depression First Whenever Possible

• Depression is common• Depression is the strongest modifiable predictor of

adherence to all medical therapy• Adherence is the strongest predictor of disease progression

and death after CD4 cell count• Depression should be treated prior to starting antiretroviral

therapy– Depression screen, CD4, VL

• Patients with severe HIV disease may need concurrent initiation of antidepressant therapy and antiretroviral therapy

Bangsberg JGIM 1999;14:446-8

Comorbid Mood and Anxiety DisordersComorbid Mood and Anxiety Disorders

Panic Disorder 50% - 65%1

Social Anxiety Disorder

70%2

OCD 67%3

PTSD 48%4

Generalized Anxiety Disorder

8%- 39%1

Depression

1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC;

American Psychiatric Press; 1994.

2 Van Ameringen M et al. J Affect Disord. 1991;21:93-99.

3 Rasmussen SA, Eisen JL. J Clin Psychiatry. 1992;53(suppl):4-10.

4 Coryell W Et al. Am J Psychiatry 1988;155:895-898.

Post Traumatic Stress DisorderPost Traumatic Stress Disorder

• Prevalence

• Childhood abuse, PTSD and HIV risk behaviors

• Proposed association between PTSD and HIV treatment nonadherance

• Treatment of PTSD

PTSD PrevalencePTSD Prevalence• Over half the U.S. population has been exposed to a severe trauma

• 10-20% of trauma survivors will develop PTSD

• Lifetime prevalence 8% overall. 12% in women (Kessler 1995)

– Increased rates in HIV +, incarcerated

– Limited studies: • HIV + 30% (1/3 after HIV dx) (Kelly 1998)

• Incarcerated women lifetime 33%, current 15-22% (Hutton 2001)

• PTSD is the 5th most prevalent major psychiatric illness

Most Prevalent Anxiety Disorders in the Most Prevalent Anxiety Disorders in the General PopulationGeneral Population

-3

1

5

9

13

17

21

25

29

33

Social AnxietyDisorder

PTSD GAD Panic OCD

Lif

etim

e P

reva

len

ce (

%)

Males Females

Hutton (2001) 177 Prison Women

Kelly (1998) 61 HIV+ Gay/Bi men

Kessler et al, National Comorbidity Survey, 1994

ComorbidityComorbidity

• Comorbid psychiatric illness is about 80%

• Patients with PTSD are 2 - 4X more likely to have depression, anxiety disorders or substance abuse

• They are 90X more likely to have a somatization disorder

Common Traumatic EventsCommon Traumatic Events

• Witnessing injury/death

• Sexual molestation/rape

• Natural disaster/fire

• Physical attack or abuse/threatened with a weapon

• Life threatening accident

• Combat

PTSD - Clinical CoursePTSD - Clinical Course

• PTSD symptoms usually present within the first 3 months following the trauma

• Less frequently, symptoms may be delayed for months or years after the traumatic event

• Symptoms of PTSD may persist for months or years after the trauma

• Approximately 50% of all cases of PTSD are chronic

Connection Between Childhood Abuse and HIV InfectionConnection Between Childhood Abuse and HIV Infection

SurvivorCharacteristics

Reported Abuse

Total Nonsexual-Physical Sexual No Abuse

(N=52) % (N=12) % (N=22) % (N=18) %

Revictimized 34 65 10 83 18 82 6 33

Sexuallycompulsive

20 38 6 50 11 50 3 17

Chronicallydepressed

29 56 6 50 17 77 6 33

Alcohol/drugabusing

37 71 10 83 19 86 8 44

Note. Survivor characteristic categories are not independent.

Allers C. J Counsel Devel. 1991; 70: 309-13

Reported Abuse & Survivor Characteristics (N= 52 HIV +Adults Atlanta Social Service Agency)Reported Abuse & Survivor Characteristics (N= 52 HIV +Adults Atlanta Social Service Agency)

Frequency of PTSD Disorders Among 177 Women Frequency of PTSD Disorders Among 177 Women Prisoners in an HIV Risk Behavior StudyPrisoners in an HIV Risk Behavior Study

Women prisonersDisorder N % Percentage among general populationPosttraumatic stress disorder 1 Lifetime Current

5927

3315

1-14<1

Hutton, Psych Services 2001, 52/4:508-13

Compared with participants who did not have PTSD, those with lifetime diagnosis of PTSD were 71% more likely to have engaged in anal sex and 56% more likely to have engaged in prostitution. The association between lifetime PTSD and other HIV risk behaviors were not significant in this study.

PTSD Predicts Adherence to Non-HIV TreatmentPTSD Predicts Adherence to Non-HIV Treatment

Survivors of Myocardial Infarction

• 102 s/p MI• 10% PTSD (intrusion/avoidance)

– significant association with decreased adherence

Shemesh Gen. Hosp. Psych 2000

PTSD is Under-TreatedPTSD is Under-Treated

47 HIV+ women

• 42% full, current PTSD– 59% not receiving mental health care

• 22% partial PTSD– 78% not receiving mental health care

Martinez AIDS Patient Care and STDs 2002

PTSD: DiagnosisPTSD: Diagnosis

Screening questionsScreening questions

• Have you ever had anything happen to you where you thought you would be seriously injured or might die?

• Have you ever been in a life threatening accident? Fire? Disaster?

• Have you ever been attacked or raped?

• Have you ever seen these things happen to someone else?

If the answer to any of these questions is “yes”If the answer to any of these questions is “yes”

• Do you ever have nightmares about the event, or sometimes feel the same feelings you had when you were in the trauma?

• Do you startle easily?

• Do you try hard to avoid situations which remind you of the trauma?

• How do you feel about your future?

HOW CAN I TELL IF I HAVE PTSD?HOW CAN I TELL IF I HAVE PTSD?PTSD is a serious, yet treatable medical disorder. It is not a sign of personal weakness. If you think you may have PTSD, answer the following questions and show this checklist to your health care professional

Yes or No? Have you experienced or witnessed a life-

threatening event that caused intense fear

Do you re-experience the event in at least one of

the following ways?

Repeated, distressing memories and/or

Yes No dreams?

Acting or feeling as if the event were

Yes No happening again (flashbacks or a sense of

reliving it)?

Intense physical and/or emotional distress

Yes No when you are exposed to things that remind

you of the event?

Do you avoid reminders of the event and feel numb, compared to

the way you felt before, in three or more of the following ways?

Problems concentrating?

Yes No

Feeling “on guard”?

Yes No

An exaggerated startle response?

Yes No

Do your symptoms interfere with your daily life?

Yes No

Have you symptoms lasted at least 1 month?

Yes No

Having more than one illness at the same time can make it more

difficult to diagnose and treat the different conditions. Illnesses

that sometimes complicate PTSD include depression and

substance abuse. To see if you have other problems that may

need treatment, please complete the following questions.

Consensus Guidelines: J Clin Psych 1999

PTSD: TreatmentPTSD: Treatment

Psychotherapeutic InterventionsPsychotherapeutic Interventions• Acute PTSD

– mild: Psychotherapy

– severe: Psycho therapy and medication

• Chronic PTSD– mild: Psychotherapy first or + medication

– severe: Psychotherapy first or + medication

If comorbid (eg: depression / bipolor / other anxiety DO)– medication plus psychotherapy

• Most effective: cognitive behavioral therapy (CBT) and exposure therapy

• Patients are encouraged to confront anxiety provoking triggers, decrease avoidance, and practice stress reducing strategies

• When referring patients, seek therapists with expertise in CBT and BTConsensus Guidelines J. Clin. Psychiatry 1999

Pharmacological Interventions:Pharmacological Interventions:AntidepressantsAntidepressants

Positive Controlled Trials:

TCAs• amitryptaline (Elavil)

• imipramine ((Tofranil)

MAOIs• phenelzine (Nardil)

SSRIs• fluoxetine (Prozac): civilians only

• sertraline (Zoloft): (Paxil): FDA indication

• paroxetine (Paxil)

BenzodiazepinesBenzodiazepines

• Should NOT be first line

• May exacerbate– Dissociation

– Substance abuse

– Disinhibition

• Best used as an augment

Pharmacological Steps for PTSDPharmacological Steps for PTSD

• Start with and SSRI

• Initiate with a low dose, half of what would start for depression

• Titrate to a high dose

• Once patient improves, maintain dosage for at least a year

Pharmacotherapy Steps for PTSDPharmacotherapy Steps for PTSD

• If no response or intolerant to SSRI:

– Venlafaxine

– Nefazadone

– A tricyclic antidepressant

• If all else fails, consider a monoamine oxidase inhibitor

Reasonable augmentationsReasonable augmentations

• Anticonvulsants: for dissociation, explosiveness, mood lability

• Autonomic blockers: for SNS overactivity

• Benzodiazepines or Buspirone: for excessive anxiety

• Neuroleptics: for poor impulse control

• Sedating antidepressants (Trazadone): for insomnia

SummarySummary1. Psychiatric disorders, especially depression and PTSD are

common in HIV patients.

2. Depression is the strongest modifiable predictor of adherence to all medical therapy.

3. Adherence is the strongest predictor of disease progression and death after CD4 count.

4. Depression should be treated prior to starting antiretroviral therapy. When in doubt, treat.

5. The behavioral manifestations of PTSD contribute to problems of HIV treatment adherance.

• Difficulty recognizing harm

• Difficulty developing self protective mechanism

• Compulsive need to repeat the trauma

• Sense of foreshortened future