Evidence Based Treatment

In youth with HIV infection, changes in mental status or the emergence of new cognitive or psychiatric disorders requires collaboration with the medical team to rule out any reversible and treatable causes. Therefore, the mental health consultant treating HIV-positive youth should be familiar with assessments of basic immune function and viral load and have a low threshold for ordering additional medical evaluations such as head imaging and cerebrospinal fluid examination and even antiretroviral drug resistance testing.

Although many children cope well and adapt, symptoms of depression such as fatigue, cognitive impairment, decreased social interaction and exploration, and anorexia may be in part derived from a cytokine/immunological response to HIV and its treatments (Miller 2009). It may only be possible to determine that antiretroviral medication is causing psychiatric side effects by evaluating the time course of psychiatric symptoms in relation to starting HIV medication regimens and by instituting trials of stopping treatment.

In general, the same psychotropic medications can be used in the HIV-infected child as in the general population. However, bone marrow suppression, hepatitis, and pancreatitis may cause treatment-limiting toxicities and affect metabolism of antiretrovirals, particularly protease inhibitors. Treatment with psychotropic medications is part of comprehensive multidisciplinary care and multimodal treatment to improve the quality of life for pe-diatric HIV/AIDS patients by decreasing discomfort and increasing functioning.

Important determining factors for pharmacological intervention are severity and duration of psychiatric symptoms and overall level of functional impairment. Symptomatic treatment includes pharmacological treatment of pain, movement disorders, seizures, spasticity, ADHD, and other psychiatric/ behavioral disorders in children with HIV-related CNS disease. Because the full gamut of developmental and childhood psychiatric disorders is seen in children and adolescents with HIV/AIDS, common treatment for clinical disorders is briefly discussed. The reader is also referred to Chapter 30, "Psycho-pharmacology in the Physically Ill Child." Adult psychiatric syndromes of adjustment disorder, major depression, anxiety, and delirium are seen in children as well. As in adults (Angelino and Treisman 2001), treatment of psychiatric syndromes in children and adolescents may improve outcomes.

A higher rate of psychotropic medication use and of psychiatric hospitalizations in HIV-infected children compared with uninfected control subjects has been reported (Gaughan et al. 2004). In addition, a high rate of psychotropic medication use (45%) in an HIV clinic cohort (N = 64; mean age, 15.3 years) has been reported, with psychostimulants and anti-depressants being most commonly prescribed and 30% of the sample receiving two or more psychotropic medications (Wiener et al. 2006).

Psychostimulants are often used to treat ADHD in children with HIV, although dosing is not well established and efficacy is variable. Often, higher dosages of stimulants are required to achieve scholastic benefit but need to be balanced against appetite loss, growth retardation, and insomnia, which are often significant issues for children with HIV. Clonidine, bupropion, and atomoxetine use in HIVpositive youth has also been described (Cesena et al. 1995; Pao and Wiener 2008). Treatment for behavioral disorders such as repetitive and persistent patterns of aggressive behaviors, serious violations of rules, and destruction of property (American Psy chiatric Association 1994) is directed at behavioral and parenting interventions. Medications such as atypical antipsychotics or mood stabilizers at low dosages are considered if behavioral dyscontrol is severe (Wiener et al. 2006).

For treatment of depression in HIV-positive youth, current treatment guidelines for the management of depression in children can be followed. Antidepressants, including tricyclic antidepressants as well as SSRIs and bupropion, have been used empirically, and off label in many cases, in youth with HIV (Pao and Wiener 2008). There is no evidence that one SSRI is more effective than another in HIV-positive youth. Citalopram or mirtazapine is used due to fewer side effects and less problematic drug-drug interactions. Mirtazapine may be used to promote weight gain and treat insomnia. Methyl-phenidate, which may also potentiate opiate treatment, may be useful for pain and depression in HIV (Walling and Pfefferbaum 1990).

Treatment options for bipolar disorder in HIVpositive youth include divalproex sodium when neutropenia is not a concern, other mood stabilizers such as lamotrigine, and, rarely, lithium (Kowatch and Delbello 2006). Similarly, drug-drug interactions, neutropenia, and hepatotoxicity are clinical management concerns.

Scharko (2006) described a case in which risperi-done was not effective and haloperidol was required to treat a delirium in the context of HIV dementia. Low-dosage typical and atypical antipsychotic medications may be useful in the treatment of AIDS dementia.

The treatment of pain in HIV-positive youth is very important and often involves a multimodal approach. The treatment goal must be to minimize pain and oversedation when possible. Pediatric pain management principles using age-appropriate assessment of all developmental ages should be applied and include a repertoire of nonpharmacologi-cal (such as distraction, relaxation, psychotherapies, and hypnosis) and pharmacological treatments (Duff 2003; Greco and Berde 2005).

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