HIV psychiatry: HAND, depression, ART interactions, stigma, and capacity (MEQ)

(i) Syndrome map. Concurrent processes: (1) Major depressive episode — 7 weeks anhedonia, passive death wishes, functional impact, driving missed doses.^[3] (2) Prior neuropsychology with multi-domain impairment plus mild everyday impact is consistent with MND-range HAND (not ANI, which lacks functional interference; not necessarily HAD without marked disability) — CHARTER reminds that milder HAND persists on ART; reassess now with rebound viraemia and depression as confounders.^[1][2] (3) Efavirenz neuropsychiatric toxicity — temporal nightmares/insomnia after switch; classic spectrum includes anxiety, depression, and psychosis risk.^[6] (4) Internalised/enacted stigma — concealment and clinic avoidance as care barriers linked to adverse mental health outcomes.^[8] (5) Historical quetiapine + ritonavir interaction risk illustrates systems failure even if the booster is now stopped.^[7] Exclude delirium/CNS OI if new confusion or focal signs emerge with rebound viraemia.

(ii) Depression–adherence care. Depression associates with ART nonadherence in meta-analysis — treat both poles.^[3] Offer measurement-based antidepressant care integrated with HIV clinic pathways (Pence/SLAM DUNC tradition); randomised antidepressant treatment improves depression outcomes (HIV viral endpoints more nuanced — still treat).^[5] Add CBT-AD skills for mood and pill-taking behaviours.^[4] Example start (interaction-checked): sertraline 25–50 mg oral daily or escitalopram 5–10 mg oral daily, titrate to response, review 1–2 weekly early, monitor hyponatraemia/suicide risk.^[5][7]

(iii) ART pharmacology. Liaise with HIV team: consider switching off efavirenz for intolerable CNS effects while maintaining continuous ART cover to avoid resistance.^[6] Never restart high-dose quetiapine with boosters; Goodlet-level literacy — ritonavir/cobicistat raise CYP3A4-substrate psychotropics; use pharmacy interaction tools.^[7]

(iv) Capacity and suicide risk. Capacity is decision-specific for tomorrow's regimen choice: understand nature/risks/benefits/alternatives, appreciate, reason, communicate.^[9] Depression with hopelessness, severe insomnia/efavirenz effects, and cognitive impairment may impair appreciation — optimise sleep/mood/cognition, simplify information, teach-back, reassess; if incapacitous use local substitute decision law. Do not equate HIV or prior MND with global incapacity.^[9] Suicide: passive death wishes plus depression, stigma, and life stressors are a high-risk cluster — safety plan, means, urgent follow-up intensity.^[10]