Chronically mental ill patients have an increased risk of acquiring HIV through practicing risky sexual behaviors, abusing substances, and taking part in social networks that have a higher prevalence of HIV. Individuals with mental illness have variable knowledge of HIV risks and safer sex practices, with a diagnosis of schizophrenia being a specific predictor of having poor knowledge of such risks and practices. More importantly, increased knowledge of HIV risk behaviors does not translate to less risk behaviors on the part of individuals with mental illness. In fact, some studies have found that mentally ill individuals who practice risky behaviors had greater knowledge of HIV risks than those who did not (Chuang and Atkinson, 1996, McKinnon etal., 1996). Risk behaviors more common among psychiatric patients include multiple partners, partners with known HIV-positive status, substance use during sex, trading sex for money, drugs, or housing, and lack ofcondom use (Treisman and Angelino, 2004). Interestingly, compared to individuals with substance abuse alone, patients with severe mental illness and substance abuse have similar numbers of sexual partners and rates of unprotected oral, anal, and vaginal sex, but significantly increased rates of very high-risk behaviors, such as trading sex for money or gifts, being forced to have sex, having sex with intravenous drug users and persons with known HIVpositive status, and sharing needles (Dausey and Desai, 2003). Coercive sexual behavior and physical violence in particular have been shown to be frequent among chronically mental ill patients (Carey et al., 1997; Lamb, 1982). Many individuals with mental illness have unstable housing and finances, making access to condoms and clean works more difficult (McKinnon et al., 2002; Drake and Wallach, 1989).
Many providers use counseling about risk as the primary means of HIV prevention. Data on psychiatric patients indicate that, at baseline, persons with mental illness have more difficulty with behavior self-modification and furthermore, better knowledge of HIV prevention does not translate to behavior change (Carey etal., 1997). Thus, the HIV clinician and clinic need to provide knowledge as well as active interventions to facilitate behavior change. It is important to cover beliefs related to HIV risk, means of improving sexual or drug paraphernalia hygiene, negotiation of condom use, recognition of vulnerable emotional states, ways of avoiding risky behaviors, and sexual empowerment. Thorough screening must be done to identify individual risk factors. Patients with mental illness consistently underestimate the risk of their own behaviors (Carey et al., 1997). Helping patients to find other financial support or substance abuse treatment is critical to reduce the exchange of sex for money or drugs. Screening and treatment for victims of sexual abuse and assault should be addressed, since in one group of psychiatric outpatients, 13% reported being pressured for sex and 14% reported being coerced or forced into sex in the past year (Carey et al., 1997). Same-sex partnerships should be discussed in all settings, as some subgroups of mentally ill individuals have been shown to have increased rates of same-sex activity, particularly men (McKinnon et al., 2002).
Psychiatric treatment is especially important for individuals with psychosis, as there is a strong correlation between positive symptoms and high-risk behaviors. Successful reduction of positive symptoms of schizophrenia leads to a reduction in risk behaviors. Antidepressant therapy can be helpful, as individuals with depression may also engage in risky behavior because of a sense of hopelessness. It is critical that patients set goals toward healthy partnerships, and discuss what a healthy relationship entails, as many patients may never have experienced a stable romantic relationship. Having positive goals toward loving relationships also helps patients maintain a positive focus and appeals to reward-seeking extroverts; HIV risk counseling often focuses solely on risks and thus appeals less to extroverts who are less risk avoidant. Although HIV risk counseling can produce significant reductions in risk behavior after fewer than 10 treatment sessions (McKinnon et al., 2002), the practice of risk reduction fades over time, thus sessions that help maintain risk reduction may help to sustain subsequent benefits.
The importance of substance abuse treatment in the care of mentally ill patients with HIV/AIDS can not be emphasized enough. To maximize risk reduction, substance abuse should be addressed in all settings, including behavioral interventions, support for maintaining risk reduction, and medical and psychiatric appointments with health care professionals. Numerous studies have shown that patients with schizophrenia and other chronic mental illnesses have high rates of substance abuse, generally ranging from 40%-75% depending on the substances considered and method of ascertainment (Regier et al., 1990; Test et al., 1989; Miller and Tannenbaum, 1989; Toner et al., 1992; Caton et al., 1989; Horwath et al., 1996).
Various explanations have been given for the use of substances by psychiatric patients, one being that mentally ill patients self-medicate with substances in an attempt to alleviate symptoms or ameliorate side effects of medicines (Dixon et al., 1991; Test et al., 1989; Lamb, 1982; Mueser et al., 1990). Another theory is that chronically ill patients have disruptions ofsocial functioning and use substances as a means of connecting with others (Alterman et al., 1982), which has been supported by interviews with SMI patients that showed 44.4% of substance abusers cited "something to do with friends'' as a reason for their substance abuse (Test et al., 1989). Although these explanations help clinicians treat dually diagnosed patients, the fact remains that patients with severe mental illnesses use substances frequently and should be considered at greater risk for HIV.
Substance abuse affects every aspect of HIV/AIDS treatment. It worsens prognosis and compliance, interferes with the creation and maintenance of healthy social relationships, increases risk behaviors, and decreases judgment and insight (Drake and Wallach, 1989; McKinnon et al., 2002). Studies have shown that substance abuse or dependence concurrent with HIV/AIDS is associated with a more severe course of illness and poor medication compliance (RachBeisel et al., 1999). Thus substance abuse, by worsening psychiatric disorders, may cause more symptoms or worsen one's coping ability and lead to increased high-risk behavior. Intravenous drug use (IVDU) must be addressed, as any lifetime IVDU increases the risk of HIV infection from two- to ten-fold (Horwath et al., 1996). Five to 26 percent of psychiatric patients report prior injection and 1%-8% report IVDU in the past 3-12 months (Susser et al., 1996; Carey et al., 1997; Rosenberg et al., 2001). It is critical to inquire about IVDU at all visits, as IVDU among people with severe mental illness is often intermittent (McKinnon et al., 2002; Horwath et al., 1996). People with mental illness are more likely to be part of social networks that include intravenous drug users, increasing the risk of sexual transmission as well as IVDU-related infection.
Although abstinence from mood- or cognitive-altering substances is often considered the ideal, agonist-based therapies may provide a particularly effective form of treatment for opiate users. Metha-done maintenance therapy is highly useful in the management of opiate addiction among the chronically mentally ill. Adherence to a methadone program has been shown to decrease HIV risk behavior (Wong et al., 2003); it removes individuals from high-risk behaviors and environments while reducing motivation to seek IVDU in the community. It also keeps the individual actively participating in a treatment community. Individuals on methadone maintenance therapy demonstrate better adherence to highly active antiretroviral therapy (HAART), which decreases the overall cost of health care (Sambamoorthi et al., 2000). Methadone can be used by providers to give positive reinforcement for desired behaviors, such as rewarding a patient with take-home methadone after several months of negative toxicology screens. Meth-adone maintenance decreases drug-related morbidity and mortality and crime and improves patient function, leading to improved ability to participate in care. For patients who have failed abstinence-based treatment or are unwilling to attempt opiate cessation, methadone is a useful adjunct to HIV treatment.
Although IVDU often receives more attention in addressing HIV risk and care from providers, all forms of substance abuse contribute to risk and patient level of function. Alcohol, cocaine, and methamphetamine abuse are particularly important to address in HIV treatment, as their use is associated with high-risk sexual behaviors (McKinnon et al., 2002). Most importantly, substance abuse stands between the goals of HIV treatment and helping the patient with chronic mental illness as it demoralizes patients, prevents them from achieving stable living situations, work, and healthy relationships, and increases the severity of underlying psychiatric illness. Without the ability to achieve consistency and stability in life, patients have little opportunity to achieve consistent treatment adherence and improved functional outcome. Substance abuse among individuals with chronic mental illness is widespread, leads to practice of HIV risk be haviors, and is a poor prognostic factor for psychiatric treatment as well as HIV treatment.
Schizophrenia has a worldwide prevalence of about 1%. It is a lifelong disorder that usually has an onset in the teens and 20s for men and in the 20s and 30s for women, occurring with roughly equal prevalence in both sexes. Schizophrenia is a chronic condition that may be described as a disease of executive function, the ability to plan and carry out complex tasks using adaptability to internal and environmental cues. The essential deficit is the inability to plan and carry out complex tasks that require the ability to respond appropriately to certain variables, such as understanding and using social cues and organizing goal-directed behavior. As such, this disorganization interferes with treatment of medical conditions like HIV and the ability to manage risks and modify behaviors. Patients are thus predisposed to chaotic, unstable life situations and are vulnerable to sexual abuse, substance use, and dysfunctional relationships.
Schizophrenia is characterized by both positive and negative features. The more chronic and disabling negative features are often the least well understood by medical providers, and yet may most profoundly influence the relationship with the provider. These features were originally described by Bleuler in 1911, and are often referred to as the four "A's" of schizophrenia: flattened affect (a decrease in both expressed and experienced emotions), ambivalence, autism (an inability to make meaningful emotional connections with others), and loose associations. These features impede the ability of patients to "connect" with providers. They make patients ambivalent about all elements of treatment and make it hard for patients to engage with their providers.
The "positive" features include episodes of psychosis in which patients develop hallucinations (usually auditory), delusions (often paranoid and bizarre), and disordered thinking. These intrusive experiences are often disturbing and can lead to unpredictable and bizarre behavior that alienates patients from others and may be dangerous to the patient or others. These experiences and behaviors are considered positive symptoms because they add to the patient's otherwise normal experience. Over time, most patients develop apathy, withdraw from social functioning, and become increasingly disconnected in social interactions.
At an extreme, patients can be catatonic, living entirely in a separate mental world that others cannot access. This loss of connection leaves patients without emotional and social support and removes any motivation to achieve a better quality of life. Patients are often described as having been odd and withdrawn before the development of psychotic symptoms. The condition is a lifelong illness and is progressively disabling in most patients. It is associated with early mortality and increased morbidity.
Currently there is no significant difference between the pharmacologic treatment of schizophrenia in an HIV-infected individual and the treatment of an uninfected person. It is important to take into consideration interactions between HAART medications and antipsychotics; psychiatrists and HIV practitioners must work together closely during initiation of or changes in antiretroviral or antipsychotic treatment, as concomitant alterations in dosing may be needed. Many antipsychotics are associated with severe side effects, such as tardive dyskinesia and Parkinsonian syndromes known as extrapyramidal symptoms (EPS). They also have effects on metabolism, including weight gain, increased insulin resistance, and increased lipids that may complicate similar effects produced by antiviral medications. There may be drug interactions with antiviral treatment as well, although these remain unpredictable for the most part (Treisman and Angelino, 2004). Antipsychotic medications have been shown to be poorly adhered to by patients and may contribute to poor adherence to medications in general. It is unclear how much of this nonadherence is related to their mental health and how much is related to the medication side effects.
Treatment principles for patients with schizophrenia apply universally. They include medications for the control of hallucinations, delusions, thought disorders, and negative symptoms, as well as psychosocial rehabilitation for reintegration into the community. Studies have shown that adequate treatment of positive symptoms leads to significant reductions in HIV risk behaviors (McKinnon et al., 1996). The treatment of negative symptoms may help to motivate and engage the patient in treatment. Reality testing should be supported at all times, and the confrontation of delusional thoughts should be gentle and appropriately timed.
Patients should be given support for medication compliance. Substance abuse in particular leads to poor compliance in patients with schizophrenia
(Drake and Wallach, 1989). The incorporation of friends and family into the treatment plan can improve adherence to treatment and reinforce consistency of the treatment message, as well as provide support to these caregivers. Occasionally, issues arise because of delusions the schizophrenic patient has concerning the HIV infection itself. The most common of these is the belief that the patient does not have an HIV infection and that the situation is a hoax, created to monitor the patient's activity or somehow control the patient (Treisman and Angelino, 2004). Again, adequate antipsychotic treatment combined with a consistent but supportive message from the family, psychiatric team, and HIV team can address delusions and hallucinations that interfere with HIV treatment.
Bipolar disorder (previously called manic-depressive illness) is an illness that impacts the affective domain of one's mental health and accounts for many patients with severe mental illness. Often presenting with psychosis, this condition may be misdiagnosed as schizophrenia when severe. In the classic descriptions of manic-depressive illness, patients spend extended periods of time depressed, usually weeks to months at a time, followed by shorter periods when they are in an elevated, euphoric, and energized state, referred to as mania. Most often, patients cycle from one type of mood to the other, these cycles often interspersed with periods of normal moods but occasionally with intermediate mixed states that have features of both depressive and elevated mood states simultaneously or in rapid succession. The emotions and emotional changes in patients with bipolar disorder run their lives and can have a strong effect on their attitude toward treatment from minute to minute (Treisman and Angelino, 2004). Bipolar disorder is covered in more detail in Chapter 9 of this book.
In contrast to the bipolar disorder found in the general population, another type of mania appears to be specifically associated with late-stage HIV infection (CD4 count <200 per mm3), and it occurs in cognitive impairment or dementia (Kiburtz et al., 1991). This syndrome has been called ''AIDS mania'' and probably represents a related but different condition, as the patients show a lack of previous episodes or family history (Lyketsos et al., 1997). Clinically, patients with AIDS mania may be difficult to distinguish from those with delirium, because the sleep-wake cycle is often disturbed and patients show a good deal of confusion and cognitive impairment. For this reason, the workup begins with a careful evaluation of the causes of delirium. Patients with AIDS mania may differ clinically from those with familial bipolar disorder, as the predominant mood tends to be irritability rather than elation or euphoria. A review at a hospital AIDS clinic found that 8% of patients with AIDS experienced a manic syndrome at some point during the course of the illness (Lyketsos et al., 1993). Of these patients experiencing manic syndromes, half had no personal or family history of bipolar disorder and were more likely to have later stage AIDS. Personal or family history, imaging findings, and other clinical indicators may help to distinguish between AIDS mania and bipolar mania associated with AIDS (Lyketsos et al., 1993).
Depression is the most common psychiatric disorder and as such is common among individuals with HIV/ AIDS. A meta-analysis of studies reported active depression in 9.4% of individuals with HIV/AIDS compared with 5.2% in HIV-negative individuals (Ciesla and Roberts, 2001). Individuals with depression are predisposed to greater HIV/AIDS risk for several reasons. Higher HIV risk may result from a sense of hopelessness about the future. Additionally, persons with depression may seek to alleviate their symptoms with alcohol and other drugs. Alcohol abuse and dependence are prevalent among persons with depression. For patients with depression, alcohol use is a major source of HIV risk, as patients under the influence of alcohol are more likely to engage in risky sexual behaviors and IVDU because of decreased inhibition (McKinnon et al., 2002). Lack of memory and attention may distract depressed individuals from self-care and risk reduction behaviors. It can also keep patients from being diagnosed or entering treatment. Chronic depression, particularly when complicated by psychotic features, also adds to the population of patients with chronic and severe mental illness. This is particularly true when combined with chronic stimulant or alcohol use, leading to complex and difficult to understand symptoms at presentation.
Patients with major depression can be strongly resistant to HIV therapy. They may have difficulty engaging in treatment and maintaining treatment adherence. Because depressed patients feel hopeless, they are less likely to seek care or testing and counseling. It is difficult to engage depressed patients in treatment because they are preoccupied with negative ideas and low mood. Once involved in treatment, extra effort must be employed to maintain their engagement, because depression leads to low motivation and energy. This can be partially overcome through the use of incremental goals and rewards (Treisman and Angelino, 2004). Because depression causes decreased memory and concentration, patients have a more difficult time with medication adherence. Visual cues and memory aids may help improve adherence, and social support can improve morale and adherence. It is therefore necessary to treat depression concomitantly with HIV/AIDS if providers wish to succeed in viral suppression. Major depressive disorder is covered in further detail in Chapter 9 of this book.
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