Anxiety Disorders in HIV and Aging (11/19/17)

  • Other causes for anxiety (including comorbid conditions and medications) must be ruled out when evaluating for anxiety in HIV
  • Non-pharmacological approaches for treating anxiety in HIV are preferred, particularly for older adults because of polypharmacy and increased risk for drug-drug interactions
  • If medications are necessary, SSRIs are preferred over benzodiazepines as they have fewer adverse consequences.
  • Benzodiazepines may be appropriate for acute control of anxiety and short- to intermediate acting benzodiazepines with no active metabolites are preferred. 
  • Non-benzodiazepine agents are preferred for longer-term anxiety control, when longer-term pharmacotherapy is judged to be warranted.

In contrast to other comorbid disorders in PLWH such as HIV associated neurocognitive disorders (HAND), depressive disorders, and substance use disorders, anxiety disorders have been less examined despite their high prevalence in HIV as compared to HIV-uninfected counterparts[1]. Anxiety disorders may be present prior to an HIV diagnosis or may present as a consequence of an HIV diagnosis[2]. When evaluating for anxiety disorders in HIV, general medical causes of anxiety must be ruled out, such as fever, dehydration, opportunistic infections, and delirium and dementia as well as medications that can cause anxiety (e.g., efavirenz, interferon, corticosteroids).

While the prevalence of anxiety and related disorders is reported to be higher in PLWH than the general population, comparison of prevalence rates must be done so with caution, given differences in measurement and criteria across the limited literature as well as differences in samples[3-5]. Estimated rates of anxiety disorders in HIV are reported to be as high as 25%, and perhaps even higher in high risk subpopulations such as those with comorbid substance disorders[6, 7]. Furthermore, anxiety symptoms may be as high as 70% [8]. Adjustment disorder is frequently noted after initial diagnosis of HIV infection and may be the most common psychiatric disorder manifesting primarily with anxious mood. Generalized anxiety disorder (GAD) and panic disorder have been documented in 15.8% and 10.5% of HIV seropositive persons versus 2.1% and 2.5% of the general population, respectively[7, 9-11]. Post-traumatic stress disorder (PTSD) has also been reported at a higher rate among the HIV infected[1, 12]. There are mixed findings on gender and risk for anxiety in HIV[1, 7, 8, 10, 13].

Given the unique challenges and burdens of aging with HIV, including discrimination, social isolation[14-16] physical comorbidities, and higher prevalence of HAND, it might be expected that older adults with HIV may experience higher rates of anxiety symptoms and disorders than their younger and HIV-negative counterparts[17]. However, research to date has not confirmed this. In a study examining age differences, the rate of anxiety disorders (panic disorder, GAD, and PTSD) were found to be somewhat more frequent in younger patients (at 22.5% and 16.1%) vs. older patients (at  17.7% and 6.6%, respectively)[18]. These findings are consistent with research in the general population showing that the prevalence of psychiatric disorders tends to decrease slightly with age[5]. Similarly, a recent 2016 study[17] in a large well-characterized sample found that the frequency of both 12-month and lifetime diagnoses of panic disorder and GAD were comparable among older and younger individuals living with HIV. Possible explanations for this are better coping skills and resilience in older people living with HIV as well as perhaps processing negative emotions differently[19].

While not specific to older adults living with HIV, findings in HIV populations have shown negative health outcomes are associated with anxiety symptoms and disorders[1, 13, 20-22]. Anxiety symptoms have been specifically noted to threaten adherence measured by missed ARV doses, although older age was associated independently with a greater likelihood of maintaining the schedule of taking ARVs[6, 7, 22-24].  In one recent study, 47% of patients demonstrated significant anxiety symptoms. Patients showing such anxiety symptoms had a high number of ARV switches (i.e., were at the fourth line or more)[25]. The Brandt et al. study[17] also found in their overall PLWH sample that those with both neurocognitive impairment and anxiety disorders were at the highest risk for functional impairment. In a study of older veterans living with HIV, history of anxiety diagnosis was more prevalent in those patients reporting participating in mental health treatment versus those who were not[26].

Psychopharmacotherapy for anxiety disorders in HIV infected persons should be avoided when non-pharmacological approaches are available, particularly for older patients because of increased rates of polypharmacy and greater risk for drug-drug interactions[27] (Department of Health and Human Services). Non-pharmacological approaches include psychotherapy, cognitive behavioral therapy, guided imagery, progressive muscular relaxation training, self-hypnosis, biofeedback, physical exercise, and other such behavioral techniques. However, it may be useful to employ psychopharmacotherapy in low doses to support the older patient’s sense of control and autonomy. The most common anxiolytic therapies used ─ benzodiazepines ─ are sedating, interact with alcohol and some protease inhibitors, and foster dependence. If needed, on an ongoing basis, SSRIs are generally preferred to benzodiazepines. For short-term treatment, short-to intermediate-acting benzodiazepines with no active metabolites, such as lorazepam and oxazepam, may be employed. Buspirone is an option to consider that is non-sedating, safe in overdose, and has low abuse potential, although it does suffer from a delay in onset of action. Other options with no abuse potential include hydroxyzine, diphenhydramine, pregabalin and the nutritional supplement, valerian.   The first two agents should be used with caution due to their anti-cholinergic side effects especially in older adults.

Updated 11/2017

by Pariya Fazeli PhD

References

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