How should I evaluate and manage a 20-year-old HIV-positive man with a history of marijuana use disorder who presents with poor concentration and racing thoughts?

Evaluation and Management of a 20-Year-Old HIV-Positive Patient with Marijuana Use Disorder Presenting with Poor Concentration and Racing Thoughts

Immediate Psychiatric Screening

Screen this patient immediately for depression using the two-question screen: "During the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless?" and "During the past 2 weeks have you been bothered by little interest or pleasure in doing things?" 1

• If either answer is affirmative, follow up with: "Is this something with which you would like help?" 1
• Administer the PHQ-9 (Patient Health Questionnaire-9) for more comprehensive depression screening, with scores ≥10 requiring psychiatric referral (88% sensitivity and 88% specificity for major depression) 1
• Depression and anxiety are extremely common in people living with HIV, with psychiatric disorders present in 54% of HIV-infected patients presenting for medical care—rates 1.5 to 2 times higher than other medical clinics 2

Assess for Cannabis Withdrawal Syndrome vs. Active Cannabis Use

Determine whether symptoms represent cannabis withdrawal syndrome or complications of active cannabis use, as these require opposite management strategies. 3

If Patient Recently Stopped Cannabis:

• Cannabis withdrawal syndrome occurs 24-72 hours after cessation in heavy users, with symptoms including irritability, anxiety, insomnia, decreased appetite, restlessness, and difficulty concentrating 3
• Symptoms peak between days 2-6 and the acute phase lasts 1-2 weeks 3
• Patients consuming >1.5 g/day of inhaled cannabis or using >2-3 times daily are at highest risk 3
• Management: Provide supportive care with ondansetron for nausea if needed, avoid opioids entirely, and provide cannabis cessation counseling with psychological support for anxiety 3

If Patient Continues Active Cannabis Use:

• Assess for cannabinoid hyperemesis syndrome if there are any gastrointestinal symptoms, characterized by stereotypical episodic vomiting with compulsive hot water bathing behavior 3, 4
• Cannabis use itself can impair concentration and cognitive function, particularly in HIV-positive individuals where additive negative effects occur 5

Comprehensive Neurocognitive Assessment

Conduct a full neuropsychiatric evaluation including clinical history (ideally with observer/collateral account from family or friends), cognitive testing, and assessment for HIV-associated brain injury. 1

Key Elements to Assess:

• Cognitive symptoms: Document any changes in memory, reasoning speed, planning abilities, problem-solving, and attention difficulties—these questions from the Swiss HIV Cohort study are specifically validated for HIV populations 1
• Observer account: Obtain collateral history from family/friends to improve accuracy, as cognitive dysfunction can impair the patient's own insight into their deficits 1
• Distinguish from mood/substance effects: Cognitive symptoms can be transient and reactive to psychological stressors, depression, or substance use 1
• Rule out rapidly evolving symptoms: If symptoms are rapidly progressive, urgently investigate for CNS opportunistic infections, CD8 encephalitis, or symptomatic CSF HIV RNA escape 1, 6

Cognitive Testing and Investigations:

• Use standardized cognitive testing (HIV dementia scale or equivalent) to document baseline capacity 1
• Check CD4+ count and HIV viral load (plasma and ideally CSF if neurological concerns persist) 6
• Consider neuroimaging (MRI brain) if cognitive symptoms are severe, progressive, or accompanied by focal neurological signs 6
• Cognitive impairment in HIV requires abnormalities in at least two of three areas: cognitive symptoms, low performance on testing, and evidence of brain injury 1

Address Substance Use Disorder

Refer to addiction medicine or psychiatry specialists for comprehensive management of marijuana use disorder, as this is a critical barrier to optimal HIV care and cognitive function. 3, 4, 7

• Substance use disorders are present in an additional 22% of HIV-infected patients beyond those with other psychiatric disorders 2
• Cannabis cessation counseling combined with psychological support (cognitive behavioral therapy) is essential 3
• For patients with significant withdrawal symptoms who were consuming high amounts of cannabis, consider referral to specialists who can guide treatment with nabilone or nabiximols 3
• Avoid opioids entirely due to worsening of symptoms and high addiction risk 3

Optimize HIV Treatment and Monitor for Antiretroviral-Related Psychiatric Effects

Review current antiretroviral therapy regimen, as some agents (particularly efavirenz) can cause or worsen psychiatric and cognitive symptoms. 8

• Efavirenz causes serious psychiatric adverse events including severe depression (2.4%), suicidal ideation (0.7%), aggressive behavior, paranoid reactions, and manic reactions 8
• Efavirenz also causes central nervous system symptoms in 53% of patients including dizziness, insomnia, impaired concentration, somnolence, abnormal dreams, and hallucinations 8
• If patient is on efavirenz and experiencing these symptoms, discuss with HIV specialist about switching to alternative antiretroviral regimen 8
• Ensure antiretroviral therapy has good CNS penetration to suppress viral replication in the brain 6

Establish Multidisciplinary Care Team

This patient requires coordinated care between HIV medicine, psychiatry/addiction medicine, and ideally a behavioral health specialist embedded in primary care. 7, 9, 2

• Psychiatric disorders are barriers to medical care, communication with clinicians, and adherence to HIV treatment 7
• A psychiatric presence within HIV clinics (rather than external referral) is crucial given the 54% prevalence of psychiatric disorders in this population 2
• Motivational interviewing and cognitive behavioral therapy-based brief treatment should be initiated 9

Common Pitfalls to Avoid

• Do not attribute all cognitive symptoms to substance use alone—HIV-associated cognitive impairment, depression, and antiretroviral side effects must all be considered 1, 6, 8
• Do not miss cannabis withdrawal syndrome—it presents with anxiety and concentration difficulties that can be mistaken for primary psychiatric illness 3
• Do not overlook the need for collateral history—patients with cognitive dysfunction may lack insight into their deficits 1
• Do not delay psychiatric referral—untreated psychiatric disorders lead to poor HIV outcomes and treatment non-adherence 7, 2