628 June 1988 Vol. 39 No. 6 Hospital and Community Psychiatry Response of HIV-Related Depression to Psychostimulants: Case Reports Francisco Fernandez, M.D. Joel K. Levy, Ph.D. Hilbene Galizzi, M.D. Four depressed and cognitively impaired patients with HI V-re- lateddisease bada marked tbera- peutic response to treatment with psycbostimulan:s. Use of dextro- amphetamine and methylpheni- date brought a prompt remission of depressive and cognitive dys- f unctions without adverse side ef- fects. The results suggest the need f orfurther evaluation of psycho- stimulants in the treatment of HIV patients whose depression proceedsfrom an affective distur- bance (either primary or second- aty) or from a specific organic mental disorder. The importance of neuropsychiatric assessment of depressed HIV patients is stressed, and diagnostic and treatment guidelines are given. Patients who are senopositive for the human immunodeficiency vi- fl’s (HIV) often exhibit a range of psychiatric disorders, of which on- ganic mental disorders, adjustment disorders, and depression are the most prevalent (1-4). Psychophar- Dr. Fernandez is assistant pro- fessor of psychiatry at Baylor College of Medicine and chief of the psychiatric consultation ser- vice at St. Luke’s Episcopal Hos- pital, 2-199, 6720 Bertner Aye- flue, Houston, Texas 77030. Dr. Levy is a neuropsychologist in the department of psychological services at the Institute for Re- habilitation and Research in Houston. Dr. Galizzi is a post- doctoral fellow in psychiatry at Baylor College of Medicine. macologic treatment of these dis- orders in HIV patients is usually avoided, as it is in other medically ill patients, because of the patients’ poor overall physical condition, the adverse side effects generally ascribed to psychotropic agents, and a historical bias (“pharmaco- logical Calvinism” [5]) against medical intervention for psycho- logical symptoms. The psychostimulants dextroam- phetamine and methylphenidate have gained some popularity in the past few years for treating second- any depressive disorders (6) in pa- tients who have a variety of medi- cal illnesses (7-10), specifically cancer patients (1 1-1 3). Treat- ment with psychostimulants is characterized by a rapid therapeu- tic response and the absence of significant side effects, in contrast to the prominent anticholinergic complaints and delayed efficacy of tnicycic antidepressants. It has been our clinical expeni- ence that HIV-infected patients who are depressed or who have cognitive impairment accompanied by a clinical depression frequently improve with aggressive stimulant therapy. Patients with HI V-related disease who manifest depression with on without cognitive impair- ment are particularly responsive to psychostimulants, with dramatic changes in appetite, energy, and higher cortical functions such as memory, affect, attention, and con- centration (14). We present the cases of four depressed patients treated with psychostimulants who are part of a prospective, longitudinal study of the psychiatric complications of HIV disease. In diagnosing de- pression in HIV-infected patients, we advocate an inclusive approach whereby no distinction is made as to whether the physical symptoms of depression proceeded primarily from the affective disturbance or the underlying HIV illness (1 5). The efficacy of psychostimulant treatment for HIV-related depres- sion or organic mental disorder plus depression was evaluated us- ing the Clinical Global Scale (16). Patients were rated as markedly improved when they experienced complete clinical remission of all depressive symptoms with psy- chostimulant treatment, as modem- ately improved when they im- proved in several symptom areas but did not achieve full remission, and as minimally improved if they evidenced a slight but definite rise in mood on energy accompanied by corresponding changes in cogni- tive capacity and interest in ambu- lation or in appetite. The four patients we have se- lected for this report are repre- sentative of the larger group under study and also accurately reflect our widen experience with psy- chostimulant therapy in HIV-in- fected patients. Case reports Case 1 . A 26-year-old homosexual man with AIDS-related complex (ARC) was referred for a baseline neurobehavioral evaluation before entering treatment in an expeni- mental protocol with diethyldith- iocarbamate (DTC). He had a pre- vious diagnosis of depression and was being treated with trazodone 600 mg daily with only a minimal response. Neuropsychological evaluation revealed only a mild memory deficit and conceptual confusion with visuospatial tasks. His electroencephalogram (EEG) was normal.