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.


Acuff C, Archambeault J, Greenberg B, Hoeltzel J, McDaniel JS, Meyer Ph, Packer C, Parga fJ, Phillen MB, Ronhovde A, Saldarriaga M, Smith MJW, Stroff D, Wagner D (1999). Mental Health Care for People Living with or Affected by HIV/ AIDS: A Practical Guide. Substance Abuse and Mental Health Services Administration monograph (project no. 6031). Rockville, MD: Research Triangle Institute.

Alciati A, Fusi A, D'Arminio Monforte A, Coen M, Ferri A, and Mellado C (2001). New-onset delusions and hallucinations in patients infected with HIV. J Psy-chiatr Neurosci 26:229-324. Avins AL, Woods WJ, Lindan CP, Hudes ES, Clark W, and Hulley SB (1994). HIV infection and risk behaviors among heterosexuals in alcohol treatment programs. JAMA 271:515-518. Bartleth A and Ferrando SJ (2004). Identification and management of neurologic and psychiatric side effects associated with HIV and HAART. Medscape Retrieved April 25, 2007, from http://www.medscape .com/viewarticle/4700177.

Betz ME, Gebo KA, Barber E, Sklar P, Fleishman JA, Reilly ED, Mathews WC, for the HIV Research Network (2005). Patterns of diagnoses in hospital admissions in a multistate cohort of HIV-positive adults in 2001. Med Care 43:3-14.

Bing EG, Burnam A, Longshore D, Fleishman JA, Sherbourne CD, London AS, Turner BJ, Eggan F, Beckman R, Vitiello B, Morton SC, Orlando M, Bozzette SA, Ortiz-Barron L, and Shapiro M (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 58:721-728.

Blalock AC, Sharma SM, and McDaniel JS (2005). Anxiety disorders and HIV disease. In K Citron, M-J Brouillette, and A Beckett (eds.), HIV and Psychiatry: A Training and Resource Manual, second edition (pp. 120-127). Cambridge, UK: Cambridge University Press.

Boccellari AA, and Dilley JW (1992). Management and residential placement problems of patients with HIV-related cognitive impairment. Hosp Community Psychiatry 43:32-37.

Brown GR, Rundell JR, McManis SE, Kendall SN, Zachary R, and Temoshok L (1992). Prevalence of psychiatric disorders in early stages of HIV infection. Psychosom Med 54:588-601.

Ciesla JA, and Roberts JS (2001). Meta-analysis of the relationship between HIV-1 infection and risk for depressive disorders. Am J Psychiatry 158:725-730.

Cournos F, Empfield M, Horwath E, McKinnon K, Meyer I, Schrage H, Currie C, and Agosin B (1991). HIV seroprevalence among patients admitted to two psychiatric hospitals. Am J Psychiatry 148:12251230.

Cournos F, and McKinnon K (1997). HIV seropreva-lence among people with severe mental illness in the United States: a critical review. Clin Psychol Rev 17:259-269.

Cournos F, McKinnon K, and WainbergM (2005). What can mental health interventions contribute to the global struggle against HIV/AIDS? World Psychiatry 4:135-141.

de Ronchi D, Faranca I, Forti P, Ravaglia G, Borderi M, Manfredi R, and Volterra V (2000). Development of acute psychotic disorders and HIV-1 infection. Int J Psychiatry Med 30:173-183.

Dew MA, Becker JT, Sanchez J, Caldararo R, Lopez OL, Wess J, Dorst SK, and Banks G (1997). Prevalence and predictors of depressive, anxiety and substance use disorders in HIV-infected and unin-fected men: a longitudinal evaluation. Psychol Med


Dore GJ, Correll PK, Li Y, Kaldor JM, Cooper DA, and Brew BJ (1999). Changes to AIDS dementia complex in the era ofhighly active antiretroviral therapy.

AIDS 13:1249-1253.

Empfield M, Cournos F, Meyer I, McKinnon K, Horwath E, Silver M, Schrage H, and Herman R (1993). HIV seroprevalence among street homeless patients admitted to a psychiatric inpatient unit.

Am J Psychiatry 150:47-52.

Ferrando SJ, and Batki SL (2000). Substance abuse and HIV infection. New Dir Ment Health Serv 87: 57-67.

Ferrando S, Goggin K, Sewell M, Evans S, Fishman B, and Rabkin J (1998). Substance use disorders in gay/bisexual men with HIV and AIDS. Am J Addict 7:51-60.

Galvan FH, Bing EG, Fleishman JA, London AS, Caetano R, Burnam MA, Longshore D, Morton SC, Orlando M, and Shapiro M (2002). The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol 63:179-186.

Galvan FH, Burnam MA, and Bing EG (2003). Co-occurring psychiatric symptoms and drug dependence or heavy drinking among HIV-positive people.

J Psychoactive Drugs (SARC Suppl. 1):153-160.

Goodkin K, Forstein M, Beckett A, Bing EG, Cabaj RP, Cournos F, Etemad JG, Fernandez F, Fullilove MJ, Kertzner RM, Kobayashi JS, McDaniel JS, Nicols SE, O'Donnell JH (1996). HIV-related neuropsy-chiatric complications and treatments. In AIDS and HIV Disease: A Mental Health Perspective. Washington DC: AIDS Program Office, American Psychiatric Association.

Goodkin K, Wilkie FL, Concha J, Asthana D, Shapshak P, Douyon R, Fujimura RK, and LoPiccolo C (1997). Subtle neuropsychological impairment and minor cognitive-motor disorder in HIV-1 infection. Neuro-radiological, neurophysiological, neuroimmunolo-gical, and virological correlates. Neuroimaging Clin NAm 3:561-579.

Halstead S, Riccio M, Harlow P, Oretti R, and Thompson C (1988). Psychosis associated with HIV infection. Br J Psychiatry 153:618-623.

Harris MJ, Jeste DV, Gleghorn A, and Sewell DD (1991). New-onset psychosis in HIV-infected patients. J Clin Psychiatry 52:369-376.

Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE, Schuman P, Boland RJ, Moore J, for the HIV Epidemiology Research Study Group (2001). Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA 285:1466-1474.

Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, and Kendler KS (1994). Lifetime and 12-month prevalence of DSM III-R psychiatric disorders in the United States: results from the National Comorbidity Study. Arch Gen Psychiatry 51:8-19.

Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, and Leaf PJ (1996). The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatry 66:17-31.

Krakow DS, Galanter M, Dermatis H, and Westreich LM (1998). HIV risk factors in dually diagnosed patients. Am J Addict 7:74-80.

Kral AH, Bluthenthal RN, Booth RE, and Watters JK (1998). HIV seroprevalence among street-recruited injection drug and crack cocaine users in 16 US municipalities. Am J Public Health 88:108-113.

Lee HK, Travin S, and Bluestone H (1992). HIV-1 in inpatients. Hosp Community Psychiatry 43:181-182.

Mahler J, Yi D, Sacks M, Dermatis H, Stebinger A, Card C, and Perry S (1994). Undetected HIV infection among patients admitted to an alcohol rehabilitation unit. Am J Psychiatry 151:439-440.

May M (1990). Organic mental disorders in HIV-1 infection. AIDS 4:831-840.

McDaniel JS, and Blalock AC (2000). Mood and anxiety disorders. New Dir Ment Health Serv 87:51-56.

McKinnon K, and Cournos F (1998). HIV infection linked to substance use among hospitalized patients with severe mental illness. Psychiatr Serv 49:1269.

McKinnon K, and Rosner J (2000). Severe mental illness and HIV-AIDS. New Dir Ment Health Serv 87: 69-76.

McQuillan GM, Khare M, Karon JM, Schable CA, and Vlahov D (1997). Update on the seroepidemiology of human immunodeficiency virus in the United States household population: NHANES III, 19881994. J Aquir Immune Defic Syndr Hum Retrovirol 14:355-360.

Messeri PA, Abramson DM, Aidala AA, Lee F, and Lee G (2002). The impact of ancillary HIV services on engagement in medical care in New York City. AIDS Care 14 (Suppl 1):S15-29.

Meyer I, McKinnon K, Cournos F, Empfield M, Bavli S, Engel D, and Weinstock A (1993). HIV seropreva-lence among long-stay patients in a state psychiatric hospital. Hosp Community Psychiatry 44:282284.

Meyer JM (2003). Prevalence of hepatitis A, hepatitis B, and HIV among hepatitis C-seropositive state hospital patients: results from Oregon State Hospital.

J Clin Psychiatry 64:540-545.

Morrison MF, Petitto JM, Ten Have T, Gettes DR, Chiappini MS, Weber AL, Brinker-Spence P, Bauer RM, Douglas SD, and Evans DL (2002). Depressive and anxiety disorders in women with HIV infection. Am J Psychiatry 159:789-796.

National Institutes of Health Consensus Development Conference Panel (1997). Management of hepatitis C. Hepatology 26:2S-10S.

Navia BA, Jordan BD, and Price RW (1986). The AIDS dementia complex: I. Clinical features. Ann Neurol 19:517-524.

Neuenburg JK, Brodt HR, Herndier BG, Bickel M, Bacchetti P, Price RW, Grant RM, and Schlote W (2002). HIV-related neuropathology, 1985 to 1999: rising prevalence of HIV encephalopathy in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr 31:171-177.

Prier RE, McNeil JG, and Burge JR (1991). Inpatient psychiatric morbidity of HIV-infected soldiers. Hosp Community Psychiatry 42:619-623.

Rabkin JG (1996). Prevalence of psychiatric disorders in HIV illness. lnt Rev Psychiatry 8:157-166.

Rabkin JG, Ferrando SJ, Jacobsberg LB, and Fishman B (1997). Prevalence of axis I disorders in an AIDS cohort: a cross-sectional, controlled study. Compr Psychiatry 38:146-154.

Regier DA, Farmer ME, Rae S, Locke BZ, Keith SJ, Judd LL, and Goodwin FK (1990). Comorbidity of mental disorders with alcohol and other drug abuse.

JAMA 264:2511-2518.

Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, and Goodwin FK (1993). The de facto US mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 50:85-94.

Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, Constantine NT, Wol-ford GL, and Salyers MP (2001). Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 91:31-37.

Sacks MH, Dermatis H, Looser-Ott S, and Perry S (1992). Seroprevalence of HIV and risk factors for AIDS in psychiatric inpatients. Hosp Community Psychiatry 43:736-737.

Sacktor NC, Lyles RH, Skolasky RL, Anderson DE, McArthur JC, McFarlane G, Selnes OA, Becker JT, Cohen B, Wesch J, and Miller EN (1999). Combination antiretroviral therapy improves psychomo-tor speed performance in HIV-seropositive homosexual men: Multicenter AIDS Cohort Study (MACS). Neurology 52:1640-1647.

Satriano J, McKinnon K, and Adoff S (2007). HIV service provision for people with severe mental illness in outpatient mental health care settings in New York. J Prev Interv Community 33:95-108.

Schwartz-Watts D, Montgomery LD, and Morgan DW (1995). Seroprevalence of human immunodeficiency virus among inpatient pretrial detainees. Bull Am Acad Psychiatry Law 23:285-288.

Sewell MC, Goggin KJ, Rabkin JG, Ferrando SJ, Mc-Elhiney MC, and Evans S (2000). Anxiety syndromes and symptoms among men with AIDS: a longitudinal controlled study. Psychosomatics 41:294-300.

Silberstein C, Galanter M, Marmor M, Lifshutz H, and Krasinski K (1994). HIV-1 among inner city dually diagnosed inpatients. Am J Drug Alcohol Abuse 20: 101-131.

Simpson DM (1999). Human immunodeficiency virus-associated dementia: review ofpathogenesis, prophylaxis, and treatment studies of zidovudine therapy.

Clin Infect Dis 29:19-34.

Staab JP, and Evans DL (2001). A streamlined method for diagnosing common psychiatric disorders in primary care. Clin Cornerstone 3:1-9.

Stewart DL, Zuckerman CJ, and Ingle JM (1994). HIV seroprevalence in a chronic mentally ill population.

J Natl Med Assoc 86:519-523.

Stoff DM, Mitnick L, and Kalichman S (2004). Research issues in the multiple diagnoses of HIV/AIDS, mental illness and substance abuse. AIDS Care 16 (Suppl. 1):S1-S5.

Stolar A, Catalano G, Hakala S, Bright RP, and Fernandez F (2005). Mood disorders and psychosis in HIV. In K Citron, M-J Brouillette, and A Beckett (eds.), HIV and Psychiatry: A Training and Resource Manual, second edition (pp. 88-109). Cambridge, UK: Cambridge University Press.

Stoskopf CH, Kim YK, and Glover SH (2001). Dual diagnosis: HIV and mental illness, a population-based study. Community Ment Health J 37:469479.

Strober DR, Schwartz JAJ, McDaniel JS, and Abrams RF (1997). Depression and HIV disease: prevalence, correlates and treatment. Psychiatr Ann 27:372377.

Susser E, Valencia E, and Conover S (1993). Prevalence of HIV infection among psychiatric patients in a New York City men's shelter. Am J Public Health 83:568-570.

Susser E, Colson P, Jandorf L, Berkman A, Lavelle J, Fennig S, Waniek C, and Bromet E (1997). HIV infection among young adults with psychotic disorders. Am J Psychiatry 154:864-866.

Volavka J, Convit A, Czobor P, Dwyer R, O'Donnell J, and Ventura A (1991). HIV seroprevalence and risk behaviors in psychiatric inpatients. Psychiatr Res 39: 109-114.

Wainberg M, Cournos F McKinnon K, and Berkman A (2003). HIV and hepatitis C in patients with schizophrenia. In JM Meyer and HA Nasrallah (eds.), Medical Illness in Schizophrenia (pp. 115-140). Washington, DC: American Psychiatric Publishing.

White JL, Darko DF, Brown SJ, Miller JC, Hayduk R, Kelly T, and Mitler MM (1995). Early central nervous system response to HIV infection: sleep distortion and cognitive-motor decrements. AIDS 9: 1043-1050.

Wilkie FL, Eisdorfer C, Morgan R, Loewenstein DA, and Szapocznik J (1990). Cognition in early human immunodeficiency virus infection. Arch Neurol 47: 433-440.

Woods WJ, Lindan CP, Hudes ES, Boscarino JA, Clark W, and Avins AL (2000). HIV infection and risk behaviors in two cross-sectional surveys of heterosexuals in alcoholism treatment. J Stud Alcohol 61: 262-266.

An Addict's Guide To Freedom

An Addict's Guide To Freedom

Get All The Support And Guidance You Need To Be A Success At Understanding And Getting Rid Of Addictions. This Book Is One Of The Most Valuable Resources In The World When It Comes To New Ways To Understand Addicts And Get Rid Of Addictions.

Get My Free Ebook

Post a comment