No Abstract.South African Psychiatry Review Vol. 10 (2) 2007: pp.83-8

Bracken, C

Janse Van Rensburg, B

English

AJOL - African Journals Online

South African Psychiatry Review • May 2007 83IntroductionThe referral of service users with acute psychiatric symptomsto psychiatric units for assessment or admission who are HIVpositive has become a fairly routine experience over the pastcouple of years. Although a literature on the nature andtreatment of acute psychiatric symptoms in relation to HIVexists (involving  North American, British and Europeansamples)1-9,  published data on the psychiatric presentationand acute management of South African HIV positive serviceusers is lacking. Highly Active Anti-Retroviral Treatment(HAART) was made available in certain hospitals in GautengProvince (South Africa) in April 2004 (including Helen JosephHospital, the site of the current study). The current study ofservice users tested for HIV status while admitted to the acutepsychiatric unit of Helen Joseph Hospital was undertakenabout six months after the initial “roll out” of HAART. Thestudy aimed to provide both an  overview of the predominantfeatures of the clinical presentation, the acute management ofHIV positive psychiatric inpatients in a typical South Africanacute psychiatry admission unit, as well as identify furtherresearch objectives in this group of service users. MethodA retrospective clinical audit of service users tested for HIVstatus and admitted to Ward 2 of Helen Joseph Hospital wasundertaken for a one year period September 2003 to August2004, in order to establish the demographic, clinical,management and functional profile of this group. The generalclinical and management profile of these South African HIVpositive service users was then compared with availableliterature reports on the clinical presentation andmanagement of such service users in comparable settings.ORIGINAL S Afr Psychiatry Rev 2007;10:83-85Correspondence:Dr B Janse Van RensburgDivision of Psychiatry, Faculty of Health Sciences, University of theWitwatersrand, 7 York Rd. Parktown 2193, Johannesburg, South Africae-mail: bernardj@gpg.gov.zaAcute psychiatric in-patientstested for HIV status: a clinical profileB janse van Rensburg, C BrackenDivision of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg.ABSTRACTObjective: To obtain a retrospective profile of the clinical presentation, inpatient management and their initial access to HAARTof service users tested for HIV status while admitted to an acute bed psychiatric unit. Method: A retrospective clinical audit ofHIV positive service users’ discharge data sets was undertaken for the year September 2003 to August 2004. Data wascompared with exisiting literature. Results: During the study period a total of 443 service users were admitted of whom 17.4%(n=77) were tested for HIV status. Of these, 7.7% (n=34) of the total admissions tested positive. Presenting psychiatric symptomsincluded elevated mood, psychosis, disorganized behavior, confusion, aggression and mutism. The most common DSM IVdiagnoses were mood disorder or psychosis due to general medical condition. Predominantly risperidone and haloperidol incombination with valproate were used in treatment and at relatively high dosages. Conclusion: Amongst HIV positive serviceusers acute psychiatric symptoms almost exclusively consisted of associated psychosis or manic symptoms rather thandepression. The clinically successful addition of valproate to antipsychotic medication in 50% of cases in this study requiresfurther research to establish if it could also be recommended on the basis of empirical findings. Service users’ capacity toadhere to strict treatment regimes might have been affected if not supervised, in view of their generally low global assessmentof functioning (GAF) scores on discharge. Keywords: HIV/AIDS; Psychiatric symptoms; Inpatient managementReceived: 11-11-2005Accepted: 24-05-2006South African Psychiatry Review • May 2007 84The data available for the clinical review consisted of the casesummaries completed by the attending clinician ondischarge. This discharge data set was designed for thepurpose of the study to reflect the minimum informationrequired from the user file and included the followingvariables: (1) age, gender and race; (2) suburb/district oforigin; (3) length of stay; (4) reason for admission; (5)compliance; (6) substance abuse; (7) investigations; (8)inpatient treatment; (9) DSM IV multi-axial diagnosticformulation; and (10) referral. Compliance or adherence inthese case summaries was merely indicated as “yes” or “no”and referred mainly to the history of compliance topsychiatric medication prescribed immediately prior toadmission. DSM IV diagnoses stated in the discharge datawere regarded as the most likely “working diagnoses” madein the operational scenario of an acute psychiatric unit afterroutine medical and psychiatric examination and investigationduring admission. No structured interview procedures wereapplied as part of the study to verify the criteria for diagnosesmade. ResultsDuring this one year period, a total of 443 service users wereadmitted to Ward 2 for psychiatric assessment and treatment.Of these, only 17.4% (n=77) of the total number of serviceusers’ were tested for HIV status either prior to or duringadmission. Of these 7.7% (n=34) of the total number ofservice users tested positive and 43 negative. Demographic profile of HIV positive users Age - 10-19 years (n=1); 20-29 years (n=10); 30-39 years(n=18); 40-49 years (n=3); 50-59 years (n=2);  Gender - 12male; 22 female; Ethnicity - 30 black, 3 colored, 1 white;Average length of stay - 29.3 days; Areas of origin of users inthis study included suburbs in and around Johannesburg butalso two users each from Kwazulu-Natal and Lesotho. Clinical profile of HIV positive users Reasons for admission stated in the discharge summariesincluded psychosis, confusion, restlessness, aggression,inappropriate or disruptive or disorganized behavior,previous post partum psychosis, elevated mood, relapse,neuro-syphilis and depressed mood.  Substance abuse wasconfirmed to play a role in the admission of 40% of serviceusers. Adherence – Ten service users were regarded ascompliant on their psychiatric treatment prior to and duringtheir stay, eleven were regarded as non compliant with thenotion that it contributed to their admission, while adherenceor compliance was unknown or not indicated in 13 of the 34cases. Investigations - CD4 counts obtained ranged from 10 to674 million/l and the general medical work-up did not includea routine brain scan, LP or EEG. Routine multi-axial diagnosesformulated on discharge included AXIS I - mood disorder dueto general medical condition (n=4), psychosis and mooddisorder due to general medical condition (n=3), psychosisdue to general medical condition (n=23), bipolar mooddisorder (n=1), delirium (n=1) and schizophrenia (n-2). Co-morbidity on AXIS I included dementia (n=7); cannabis abuse(n=1); bipolar mood disorder (n=1) and major depressivedisorder (n=1). AXIS III diagnoses included epilepsy (n=2),tuberculosis (n=5), meningo-encephalitis (n=1), chickenpox(n=1), upper respiratory tract infection (n=2) and neuro-syphilis (n=1). Management profile of HIV positive users Treatment choices included antipsychotics such asrisperidone (n=8), haloperidol (n=19), trifluoperazine (n=3)fluopenthixol deconoate (n=4) and mood stabilizers,specifically sodium valproate (n=17, in 50% of the serviceusers). The most frequent combinations used were valproateand haloperidol or valproate and risperidone. Antipsychoticswere usually administered at a somewhat higher dosagerange, at the equivalent of haloperidol 7.5mg per day. Theclinical impression from the case discharge data was thatonce the mood stabilizer was added, service users tended tosettle sooner and that valproate was added to patients whodid not show an initial response to antipsychotic medicationalone. Follow-up arrangements included referrals tocommunity psychiatry clinics (n=12) and Helen JosephHospital out patients (n=13) for review of their continuedpsychiatric management, while seven users were referred forextended inpatient care to Tara, Sterkfontein and LifeEsidimeni hospitals. Two service users did not return afterleave of absence.Functional profile of HIV positive users The Global Assessment of Functioning (GAF) scale reflectedon Axis V of the multi-axial formulation, remained low tomoderate in most patients, even on discharge. Some patientswere severely compromised due to concomitant dementiaand required ongoing full-time care and supervision. Discussion The relatively low figure of 17.4 % (n=77) of hospitalisedusers tested for HIV status during the period of study wasmainly due to existing ethical concerns about obtainingconsent for testing in this population of service users. Thisgiven that their capacity to consent was regarded to becompromised in terms of their understanding of the benefit oftesting. To obtain a more comprehensive picture of HIVpositive users presenting with acute psychiatric symptoms,this obstacle in any study design will have to be resolved. However, studies reviewed on the psychiatric features ofthe acute presentation of HIV positive service users, mostlyreported on even smaller study populations.1-9 These studiesincluded those by Vogel-Scibilia et al1, Buhrich et al2 Halsteadet al3, Harris at al4, Sewell et al5 and Alciati et al6. The firstgroup reported in 1988 on 13 cases of HIV infectionpresenting as psychosis in a literature review of HIV andpsychiatry.1 The clinical features, with which these patientspresented, included paranoid delusions, acute mania,auditory hallucinations and catatonia. Diagnoses madeincluded schizophreniform illness, organic hallucinosis and/ororganic delusional syndrome, as well as organic affectivesyndrome and organic mental syndrome (unspecified). Mostof these cases also had some finding consistent with anincipient dementing process. Buhrich et al (1988) reported onthree psychotic patients, one with AIDS and two with AIDS-related complex (ARC).2 From these cases they concludedthat HIV may produce symptoms indistinguishable from thoseseen in the functional psychoses. These three cases did notdemonstrate any impaired cognition during their psychosis.ORIGINAL S Afr Psychiatry Rev 2007;10:83-85South African Psychiatry Review • May 2007 85Halstead et al (1988) reported on another 5 cases ofpsychiatric illness presenting as functional psychosis in malesubjects with HIV infection.3 They argued that sufficientevidence did not exist that HIV may itself cause symptoms offunctional psychosis, especially in view of the low incidence ofpsychosis observed in their health district’s HIV positivepopulation at the time. The fourth review examined theclinical information of 124 HIV-infected patients followed upover a 6-year period.4 Fifty seven of them were referred forpsychiatric assessment and twelve had acute or sub-acutesymptoms of psychosis such as delusions, hallucinations,bizarre behavior, mood and affective disturbances. Onadmission some of these patients received a primarypsychiatric diagnosis, but the diagnoses were later revised toAIDS encephalitis, cryptococcal meningitis and “organicpsychosis”. Sewell et al (1994) evaluated 20 HIV-infected menwho presented with new onset psychosis, which wereregarded, at least in part, as a manifestation of an HIV-associated encephalopathy.5 Alciati’s group (2001) assessedthe relationship between HIV-associated psychotic symptomsand demographic, psychopathological and medical variablesby comparing 26 patients with cerebral opportunisticinfections or metabolic encephalopathy, with patients withoutit.6 They concluded that “organic” symptoms of psychosis inthose infected with HIV are related to the systemic andcerebral complications of HIV infection rather than to thepsychotic process itself. According to the literature, in the presence of subsequentwidespread use of HAART in European and North Americancountries, antidepressant medication rather than anti-psychotic medication seems to have become the norm. Thisbeing for the treatment of associated depressive conditionsrather than psychosis which appears to be a less commonclinical presentation in these regions. In a large NorthAmerican study, 20.9% of patients were on antidepressantmedication and only 4.7% on antipsychotics. With 61.9% ofpatients in this study on HAART, similar proportions of thosetreated with antidepressants or antipsychotics were found forboth those on or off HAART.7 Although no empirical evidencecan be drawn from the current study, the clinical impressionexists that our local acute psychiatric inpatient HIV positivestudy population responded more favorably to a combinationof treatment of haloperidol or risperidone with valproate,rather than on one of these agents alone. Such treatmentswere against a background of predominantly psychoticpresentations. With regard to the use of valproate in themanagement of these users, Rachbeisel and Weintraubreported on the successful treatment with valproic acid ofmanic symptoms in two patients with HIV infection asopposed to lithium - where side effects at therapeutic doseswas a concern, and as opposed to carbamazepine - whereinduction of liver enzymes with decreased effectiveness ofHAART was a concern.8 Another retrospective chart reviewstudy of patients treated from 1994 to 1998 found no evidenceof an increased viral load in eleven patients on valproatealthough observations in vitro indicated that valproate maystimulate replication of HIV-1 and cytomegaloviruses.9 Noadverse effect on viral load was seen in nine out of theseeleven patients who were on valproate and HAART. Confirmation of service users’ HIV status in the currentstudy did clarify available treatment options including accessto HAART. According to hospital policy at the time of the study,the only objective factor determining access to HAART wasthe CD4 count, which had to be less than 200 million/l. In ourstudy group, CD4 values ranged from 10 to 647 million/l and11 of our users had a count of less than 200 million/l. Theseusers therefore qualified for access and were referred to thelocal HAART clinic. Although the majority of inpatient serviceusers in this study were regarded by attending clinicians tohave a possible reduced capacity to comply with theirmedical and psychiatric treatment, policy on access to anti-retroviral treatment did not exclude them as long as aresponsible treatment partner was able to partake in thesupervision of treatment.ConclusionsThe clinical experience at Helen Joseph Hospital with HIVpositive service users who presented with acute psychiatricsymptoms was still almost exclusively that of associatedpsychosis or manic symptoms rather than depression, as wasmore commonly reported in the North American context. In our experience, an anti-psychotic in combination withvalproate was most often used in the acute treatment ofelevated mood and psychotic symptoms. Some support forthe use of valproic acid on its own or in combination withantipsychotics was forthcoming from the reviewed literature. In view of the expected ongoing burden of HIV positiveusers presenting with acute psychiatric symptoms, furtherstudy of these clinical impressions should be conducted toachieve empiric clarity on the presentation and appropriatetreatment of HIV associated psychosis in a South Africancontext. Further research is also necessary on the outcome ofHAART in psychiatric service users in relation to their longer-term adherence. References1. Vogel-Scibilia SE, Mulsant BH, Keshavan MS. HIV InfectionPresenting as   Psychosis: A Critique. Acta Psychiatri Scandinavia1988; 78:625-6562. Buhrich N, Cooper DA, Freed E. HIV Infection Associated withSymptoms Indistinguishable from Functional Psychosis. BritishJournal of Psychiatry, 1988; 152: 649-653 3. Halstead S, Riccio M, Harlow P, Oretti R, Thompson C. PsychosisAssociated with HIV Infection. British Journal of Psychiatry; 1988:153:618-6234. Harris MJ, Jeste DV, Gleghorn A, Sewell DD. New-Onset Psychosis inHIV-Infected Patients. Journal of Clinical Psychiatry; 1991 52(9) 369-3765. Sewell DD, Jeste DV, Atkinson JH, Heaton RK, et al. HIV-AssociatedPsychosis: A Study of 20 Cases. Americam Journal of Psychiatry1994; 151(2): 237-2426. Alciati A, Fusi A, D’Arminio Monforte A, Colmegna F, Valli I, MelladoC. New-onset Delusions and Hallucinations in patients infected withHIV. Journal of Psychiatry & Neuroscience 2001; 26 (3), 229-2347. Vietiello B, Burnam MA, Bing E, Beckman R, Shapiro MF. Use ofpsychotropic medications among HIV infected patients in theUnited States. American Journal of Psychiatry 2003; 160 (3):547-5548. Rachbeisel JA, Weintraub E. Valproic Acid Treatment of AIDS-Related Mania. Journal of Clinical Psychiatry 1997; 58 (9): 406-4079. Maggi JD, Halman MH. The effect of divalproex sodium on viralload: a retrospective review of HIV positive patients with manicsyndromes. Canadian Journal of Psychiatry 2001; 46:359-362ORIGINAL S Afr Psychiatry Rev 2007;10:83-85

Acute psychiatric in-patients tested for HIV status: a clinical  profile

https://www.ajol.info/index.php/ajpsy/article/download/30238/5719

Acute psychiatric in-patients tested for HIV status: a clinical profile

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online