Mary Ann Cohen and David Chao

All severe and complex medical illnesses have psychosocial and psychological aspects and meanings, and may have associated psychiatric diagnoses. Every patient with a severe and complex medical illness referred for psychiatric evaluation deserves a thorough and comprehensive biopsychosocial assessment. For persons with HIV and AIDS, a thorough and comprehensive assessment has far-reaching implications not only for competent and coordinated care but also for adherence to medical treatment and risk reduction, as well as public health. Psychiatric disorders are associated with inadequate adherence to risk reduction, medical care, and antiretroviral therapy. While adherence to medical care for most medical illnesses has major meaning to patients, loved ones, and families, adherence to medical care for HIV and AIDS has major implications for reduction of HIV transmission and prevention of emergence of drug-resistant HIV viral strains. Most persons with HIV and AIDS have psychiatric disorders (Stoff et al., 2004) and can benefit from psychiatric consultation and care. The rates of HIV infection are also higher among persons with serious mental illness (Blank et al., 2002).

In 1967 Lipowski provided a classification of commonly encountered problems at the medical-psychiatric interface that is still relevant to AIDS psychiatry today. These problems (with a modification of the fifth item, discussed in Chapter 1 of this book) include psychiatric presentation ofmedical illness, psychiatric complications of medical illnesses or treatments, psychological response to medical illness or treatments, medical presentation of psychiatric illness or treatments, and comorbid medical and psychiatric illness. These five problems have been illustrated with casevignettes in Chapter 1. Somepersons withHIVand AIDS have no psychiatric disorder, while others have a multiplicity of complex psychiatric disorders that are responses to illness or treatments or are associated with HIV/AIDS (such as HIV-associated dementia) or co-morbid medical illnesses and treatments (such as hepatitis C, cirrhosis, or HIV nephropathy and end-stage renal disease). Persons with HIV and AIDS may also have comorbid psychiatric disorders that are co-occurring and may be unrelated to HIV (such as schizophrenia or bipolar disorder). The complexity of AIDS psychiatric consultation is illustrated in an article (Freedman et al., 1994) with the title "Depression, HIV Dementia, Delirium, Posttraumatic Stress Disorder (or All of the Above).''

Comprehensive psychiatric evaluations can provide diagnoses, inform treatment, and mitigate anguish, distress, depression, anxiety, and substance use in persons with HIV and AIDS. Furthermore, thorough and comprehensive assessment is crucial because HIV has an affinity for brain and neural tissue and can cause central nervous system (CNS) complications even in healthy seropositive individuals. These complications are described in Chapters 10, 17, and 19 of this book. Because of potential CNS complications as well as the multiplicity of other severe and complex medical illnesses in persons with HIV and AIDS (Huang et al., 2006), every person who is referred for a psychiatric consultation needs a full biopsychoso-cial evaluation. In this chapter, we provide a basic approach to persons with HIV and AIDS who are referred to an AIDS psychiatrist and a template for a comprehensive psychiatric evaluation. Neuropsycho-logical evaluation can be a valuable adjunct in some persons with HIV and AIDS and is covered in Chapter 7.

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