How Psychiatrists Can Contribute To Containment Of The Most Challenging Public Health Problem The World Has Faced On A Global Scale

In the United States, as in most other places in the world, psychiatric disorders are common and under-treated in HIV patients. For instance, less than one-third of the HCSUS sample was taking psychotropic medication, and significant disparities were found between African Americans and others in the prescription of medication for depression (Table 4.4).

The range of mental health issues encountered by HIV/AIDS care providers is broad (e.g., abuse of alcohol, cocaine, crystal methamphetamine; personality disorders; agitation; psychosis) and population-specific (e.g., adolescents, Latinas, people who are homeless or incarcerated). Because service delivery systems (medical care, mental health care, substance abuse treatment) are structured to work separately (historically due to different funding streams), efforts to navigate multiple systems often fail. Integrated HIV mental health care remains rare (Satriano et al., 2007), and comprehensive listings of regional HIV mental health service agencies do not exist. Patients may not themselves recognize the role that mental health problems are playing in their health (Messeri et al., 2002). As a result, HIV/AIDS medical service providers may be unable to integrate adequately HIV/ AIDS, mental health, and substance abuse treatment services, even through existing referral networks, let alone to diagnose and treat mental health disorders (Staab and Evans, 2001). Disentangling psychiatric, substance-related, and other comorbidities requires careful differential diagnosis and awareness that the table 4.4. HIV Cost and Services Utilization Study: Psychotropic Medications among 1489 HIV-Positive Medical Patients

• 27% took psychotropic medication:

• 21% antidepressants

• 5% antipsychotics

• 3% psychostimulants

• About half of patients with depressive disorders did not receive antidepressants; African Americans were over-represented.

presence of some disorders precludes making other diagnoses.

Yet there are important, basic principles that guide treating mental health problems in HIV illness that all psychiatrists should know (Cournosetal., 2005). These include taking into account multiple comorbidities and knowing how to prioritize their treatment; ruling out a new medical cause for any change in mental status (HIV related or not); starting with lower doses of psychotropic medication and slowly titrating them upward; checking for drug interactions and overlapping toxicities between psychotropics, antiretrovirals, and any other medications being taken (Psychiatric Medications and HIV Antiretrovirals: A Guide to Interactions for Clinicians, available at www.nynjaetc .org), including nonprescribed substances; and offering adherence support to patients whose cognitive or psychiatric symptoms interfere with regular medication taking.

We also can foster nonjudgmental prevention (with a wide range of safer-sex and drug use options according to the specific person's needs and lifestyle), educate HIV-infected patients about associated central nervous system problems, monitor psychiatric sequelae, adherence, and quality-of-life issues (e.g., sleep, sexual functioning), and assist in managing the psychosocial impact of the disease on infected people and their relatives.

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