PSYCHOPHARMACOLOGICAL CHALLENGES FOR HIV/AIDS PATIENTS WITH A HISTORY OF SUBSTANCE USE DISORDER EXPERIENCING PSYCHOTIC DEPRESSION

Abstract Background The intersection of HIV/AIDS, substance use disorders, and depression represents a complex and pressing challenge within the realm of healthcare and clinical psychiatry (Berger-Greenstein et al., 2007). While significant progress has been made in the management of HIV/AIDS and in understanding the physiological and psychosocial aspects of substance use and depression, the co-occurrence of these conditions in HIV-positive individuals poses unique and multifaceted difficulties (Medeiros et al., 2020). Addressing these psychopharmacological challenges is essential to provide comprehensive and effective care for HIV/AIDS patients with a history of substance use experiencing depression. Aims & Objectives To provide insights into the complexities of medication management for the HIV patients, considering their unique clinical needs and potential interactions between psychopharmaceuticals and antiretroviral therapies (ART). Method We present a case report with a discussion using relevant literature. Results A 38-year-old male patient living with HIV/AIDS, had a history of multiple drug use disorder (opioid, methamphetamine, and benzodiazepine). The patient reported severe depressive symptoms with psychotic features, all of which significantly impaired his quality of life. He was prescribed ART (tenofovir, lamivudine, and abacavir) and psychopharmacological treatment (quetiapine to address his cravings, sertraline as his antidepressant, aripiprazole as an adjuvant for the antidepressant, and clonazepam). Efforts were made to simplify his drug regimen, but the patient's cravings increased when quetiapine was discontinued, and his depression worsened despite increasing the dose of sertraline when aripiprazole was stopped. Clozapine was introduced to replace quetiapine and aripiprazole, and the patient's condition improved. Fortunately, there is no interaction between ART and the other medications used. Discussion & Conclusion Existing studies have reported a high prevalence of HIV/AIDS patients experiencing substance use and depression problems, with one report even noting a percentage as high as 73% (Berger-Greenstein et al., 2007). Treating this population is exceptionally challenging due to the influence of psychosocial support, neurocognitive functioning, drug interactions, and medication side effects (Medeiros et al., 2020; Millar et al., 2017)). The use of clozapine in the treatment of depression in HIV patients is a subject of ongoing research and clinical discussion. Depression in individuals with HIV/AIDS can be complex and multifactorial, often related to a combination of medical, psychological, and social factors. The use of clozapine or other atypical antipsychotics for depression in HIV patients may be considered in specific situations, especially when depression is treatment-resistant and accompanied by psychotic features (Ranjan and Meltzer, 1996). Furthermore, clozapine is also deemed effective in reducing cravings in patients with substance use disorder (Teixeira et al., 2022; Brunette et al., 2006). However, this decision should be made by a healthcare provider experienced in treating psychiatric conditions in the context of HIV/AIDS. Treatment decisions should be based on a thorough assessment of the individual's specific case and should consider factors such as co-occurring substance use disorders, other medications the patient may be taking, and potential interactions with ART. References Berger-Greenstein, J. A., Cuevas, C. A., Brady, S. M., Trezza, G., Richardson, M. A., & Keane, T. M. (2007). Major depression in patients with HIV/AIDS and substance abuse. AIDS Patient Care and STDs, 21(12), 942-955. Medeiros, G. C., Smith, F. A., Trivedi, M. H., & Beach, S. R. (2020). Depressive disorders in HIV/AIDS: A clinically focused narrative review. Harvard Review of Psychiatry, 28(3), 146-158. Millar, B. M., Starks, T. J., Gurung, S., & Parsons, J. T. (2017). The Impact of Comorbidities, Depression, and Substance Use Problems on Quality of Life Among Older Adults Living With HIV. AIDS and Behavior, 21(6), 1684-1690. Ranjan, R., & Meltzer, H. Y. (1996). Acute and long-term effectiveness of clozapine in treatment- resistant psychotic depression. Biological Psychiatry, 40(4), 253-258. Teixeira, J., Alexandre, S., Cunha, C., Raposo, F., Costa, J. P. (2022). Impact of clozapine as the mainstay therapeutic approach to schizophrenia and substance use disorder: A retrospective inpatient analysis. Psychiatry Research Communications, 2(3), 100056. ISSN 2772-5987. Brunette, M. F., Drake, R. E., Xie, H., McHugo, G. J., & Green, A. I. (2006). Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders. Schizophrenia bulletin, 32(4), 637–643.