Addressing Psychosocial Comorbidities among HIV-Infected Youth
Many HIV-infected adolescents suffer from poor mental health or psychiatric illness that may be treatable with psychoactive medications. Results from studies on children and adolescents living with HIV indicate increased incidence of mental disorders in this population; and poor mental health can itself be a risk factor for acquiring HIV.57 One study among perinatally infected youth found that 40% had one or more anxiety disorder, 21% had attention deficit hyperactivity, 13% had one or more behavioral disorder, and 11% had oppositional defiant disorder. 42 These disorders, in addition to mood disorders, may require treatment with psychotropic medications.
Because many psychotropic drugs are metabolized via the cytochrome P450 family of enzymes, there is a large potential for drug interactions with ARVs that inhibit or induce these metabolic pathways. These interactions can be bidirectional, as some antidepressants also inhibit cytochrome P2D6. For example, fluoxetine was shown to increase the area under the plasma concentration-time curve (AUC) of ritonavir by approximately 20%. 58
Close monitoring of the patient by the psychiatrist and the clinician will assure that adverse effects are noted early and that changes in the treatment plan occur appropriately (see Toolbox for resources on common psychoactive-ARV drug interactions). Clinicians also should be sensitive to the concerns that family members may have regarding the possible toxic effects of psychoactive medications, and should provide culturally informed guidance regarding the safety of medication regimens.
The key drug categories and corresponding medications that are commonly used in the treatment of HIV-infected youth are as follows:
- Sleep aids: zolpidem (Ambien), eszopiclone (Lunesta), diphenhydramine (Benadryl)
- Antidepressants: citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), bupropion (Wellbutrin), duloxetine (Cymbalta)
- Antianxiety drugs: lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), buspirone (BuSpar)
- Mood stabilizers: lithium, divalproex (Depakote)
- Antipsychotics/Mood stabilizers: olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel)
- Psychostimulants: methylphenidate (Ritalin), dextroamphetamine + amphetamine (Adderall)
In addition to medications used to treat psychiatric disorders, clinicians should be aware of the interactions between HIV medications and recreational substances that are commonly reported among adolescents, including alcohol, marijuana, MDMA ("ecstasy," "E," "X"), methamphetamine ("crystal," "crank," "Tina"), cocaine ("snow," "crack"), and other drugs (see Toolbox for resources).
- Mellins CA, Brackis-Cott E, Dolezal C, et al. Psychiatric disorders in youth with perinatally acquired human immunodeficiency virus infection. Pediatr Infect Dis J. 2006 May;25(5):432-7.
- Dilley J, DeCarlo P. How Does Mental Health Affect HIV Prevention? Center for AIDS Prevention Studies Fact Sheet. 2001.
- Interactions between HIV and Psychiatric Medications. Medscape HIV/AIDS; August 1, 1999. [Registration required]