TREATING MENTAL ILLNESS IN THE HIV PATIENT
From the Ninth Annual HIV Conference: Building Strong Minds and Bodies, sponsored by the Carle Foundation
Hospital, Department of Continuing Medical Education
Glenn Treisman, MD, PhD, Associate Professor of Medicine, Associate Professor of Psychiatry and Behavioral
Sciences, and Director of AIDS Psychiatry Services, Johns Hopkins University School of Medicine, Baltimore
| Introduction: prevention of HIV infection cheaper than treatment, but treatment still cost-effective; however,
many patients go untreated because “it’s an unpopular epidemic of unpopular people”; patients at
speaker’s inner-city clinic tend to be African-American or Hispanic, poor, women, and/or drug addicts,
and all mentally ill; nobody wants to fund treatment for this type of population
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| Goals of speaker’s lecture: create sense of therapeutic optimism about this population of patients (about
whom, traditionally, there is great pessimism); illustrate that epidemic of HIV infection stoppable because
conditions that drive it can be treated; convince listeners that HIV epidemic is psychiatric epidemic;
defend psychiatry against bad reputation caused by practitioners of “alien-abduction psychiatry,” ie, notion
that mental illness due to dubious causes
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| Therapeutics vs diagnostics: about 1900, medicine began to shift from focusing on therapeutics to focusing on
diagnostics, which seeks underlying cause of disease based on scientific evidence; psychiatry did not
have scientific evidence available, so continued to focus on therapeutics and only recently has begun to
swing toward diagnostics; focus on therapeutics left door open for clinicians to promote treatments based
on quackery
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| HIV is psychiatric epidemic: speaker posits that mental illnesses drive risky behaviors that result in infection
and that HIV causes damage to brain that worsens mental illness, leading to vicious cycle; studies show
that >50% of people who present for care of HIV infection have psychiatric diagnosis other than substance
abuse, and 74% have substance abuse disorder; in speaker’s clinic, 75% of non-needle–using gay
men have substance abuse disorder, and 18% of patients have functional IQ <70 (which means they often
do not understand concept of “safe sex”)
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| Mental illness: “some things are diseases of brain” (eg, schizophrenia, bipolar illness, and major depression),
some are function of temperament (ie, introversion vs extroversion), some are disorders of behavior (ie,
addictions), and some are disorders due to negative life events (eg, rape, abusive parents, cultural environment
of hopelessness, indifference among institutional employees); well established that people with
mental illness more likely to get HIV infection, less likely to receive highly active antiretroviral treatment
(HAART), less likely to stay on HAART, less likely to achieve undetectable viral load, and have
higher mortality rate than people without mental illness; study showed that people with HIV infection
and mental illness who get even minimal psychiatric treatment less likely to die than those who do not
get psychiatric treatment (“this is the first study in the history of psychiatry to show a mortality advantage
for psychiatric treatment; psychiatric treatment in aggregate is so powerful that it prevents death in
this population of patients”)
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| Life experiences: patients may base assumptions about health care on their life experiences (eg, if health care
experience of patient negative, he or she may be suspicious of health care system and therefore not open
to treatment suggestions); once clinician understands patient’s experiences, with education and patience,
he or she may be able to change patient’s assumptions; speaker emphasizes that this approach to achieving
patient compliance not psychopharmacology, but rather psychotherapy
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| Major depression: necessary to distinguish between demoralization and major depression; demoralization is
temporary sadness in response to unhappy circumstance and responds to time, encouragement, support,
and therapeutic optimism; depression biologic in origin, caused by lesion in ascending mesolimbic
dopaminergic reward system of brain; ≈20% of patients with HIV infection have major depression
on first presentation, and ≈60% have it during lifetime; patients with major depression and HIV infection
likely noncompliant with treatment for HIV
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 | Identifying major depression: classic literature and Diagnostic and Statistical Manual of Mental Disorders
(DSM) state patients have down mood, feel sad, flat, or empty, have decreased vitality, and often feel
bad about themselves or guilty, but for various reasons, these manifestations also seen in people with
HIV infection; best single diagnostic feature for distinguishing major depression is presence of anhedonia;
some people able to continue to participate in routine activities even when anhedonic, others
cannot and usually stay in bed; third group, when depressed, seeks pleasure to point of engaging in
risky behaviors, including drug or alcohol addiction
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| Treatment: two thirds of patients get better on any antidepressant; all antidepressants work in people
with HIV infection, so select one with side effects individual patient can tolerate
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| HIV itself causes brain damage: specifically, subcortical damage, which provokes depression; data show depression
causes risky behaviors that lead to HIV infection, and as it advances, HIV infection causes depression
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| Temperament: “this is something we have an endowment”; speaker proposes that personality disorder is
“dimensional trait, like height, like IQ, like many other endowments”
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| Introversion vs extroversion: introvert focuses on future rather than present, on functions rather than feelings,
and on avoiding consequences rather than getting rewards; extrovert focuses on present, on feelings,
and on rewards; many noncompliant patients extroverts, preferring, for example, to buy
cigarettes rather than HIV medication, or to stay in bed rather than attend clinic; extroverts do not want
to take medication that makes them feel bad now in order not to feel worse in future; instead of telling
patient about future consequences of noncompliance, clinician must find rewards for compliance in
present
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| Dealing with extroverts: extroverts often confuse “need” with “want” or “like” (eg, patient insists he
needs cigarettes but does not need HIV medication); they often refuse to recognize that tolerating mild
side effects of HIV medication now may lessen or eliminate dire side effects of HIV infection later
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| “Addiction is not a disease”: but “also not a choice”; speaker acknowledges biologic component to addiction,
but opines that it is primarily behavior disorder, and 12-step programs are behavior-modification therapy
(“you never sent anybody to a 12-step program and their schizophrenia, their lupus, or their herpes
was cured”); addicts enjoy taking substances that make them feel better and do not consider short- or
long-term consequences; if offered medication such as naltrexone that eliminates high from heroin, addict
declines; speaker notes that pills do not work for addiction as they do for medical illnesses, and
only successful treatment for addiction is changing patient’s behavior
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| What substance abusers need: short-term detoxification (generally available) and long-term treatment
(generally not available); clinicians must advocate for patients at all levels of government
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| Clinicians must: “stop talking about alien abduction and start talking like doctors”; stop fighting about psychotherapy
vs medications; recognize efficacy of treatment and demand that it be available to all patients,
even indigents; advocate for “people who have no voice” (ie, mentally ill); politicians reluctant to embrace
benefit programs for poor “because it’s an 8-year solution and the average politician has a 4-year
shelf life”; practitioners must make clear to politicians that treatment cost-effective and prevention even
more cost-effective; clinicians must learn to be “therapeutic optimists who can set limits”; clinician, not
patient, must determine best treatment for each patient and refuse to provide drugs that patients merely
want
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| Conclusion: “if you treat your patients like dying people for whom there’s no hope and make them comfortable,
they will die”; but if treated like people for whom there is hope and who need to be directed to get
well, many will get better
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| Where to start prevention? many studies of prevention done, but most do not show efficacy, mainly because
they offered point interventions for specific populations; also, populations not stratified, eg, people
with HIV infection and depression, those with HIV infection and personality disorder, those with
HIV and addiction, and so forth; without that kind of coherence, intervention trial cannot be designed
that will show positive results; to date, no one willing to prepare this kind of trial because it requires
large numbers of patients, takes lots of time, and is expensive
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| What role does stigma attached to psychiatric care play in whether patients with HIV infection get psychiatric
care? very big role in that many patients with HIV infection decline psychiatric care because
of stigma; speaker’s clinic has medical doctors and psychiatrists in same facility, but many clinics do
not, making it cumbersome for patients to receive both kinds of treatment; also, his clinic has been in
community for long time, has become accepted by patients and community as natural part of environment,
removing some of stigma; many patients bring other people in for treatment; overall, only ≈20%
of patients with HIV infection avail themselves of any mental health services, and speaker thinks if
more clinics were set up like his, it would reduce much of stigma attached to getting mental health services
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Educational Objectives
| The goal of this program is to educate the listener about treating mental illness in patients with HIV infection.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. State why mental health care is often not available to patients with HIV infection.
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| 2. Explain how a few practitioners have given a bad name to psychiatry by promoting “alien-abduction
psychiatry.”
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| 3. Discuss why it is important for psychiatry to redeem its tarnished reputation.
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| 4. Describe the 4 types of influences that may lead to mental disorders and to patients’ not seeking psychiatric
care.
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| 5. Explain the rationale for the premise that addiction is not a disease but rather a behavior disorder.
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Suggested Reading
Angelino AF et al: Management of psychiatric disorders in patients infected with human immunodeficiency
virus. Clin Infect Dis 33:847, 2001; Bagchi A et al: Use of antipsychotic medications among HIV-infected individuals
with schizophrenia. Schizophr Res 71:435, 2004; Cournos F et al: Schizophrenia and comorbid human
immunodeficiency virus or hepatitis C virus. J Clin Psychiatry 66(Suppl 6):27, 2005; Erbelding EJ et al:
The prevalence of psychiatric disorders in sexually transmitted disease clinic patients and their association
with sexually transmitted disease risk. Sex Transm Dis 31:8, 2004; Haller DL et al: Suicidal ideation among
psychiatric patients with HIV: psychiatric morbidity and quality of life. AIDS Behav 7:101, 2003; Himelhoch
S et al: Does the presence of a current psychiatric disorder in AIDS patients affect the initiation of antiretroviral
treatment and duration of therapy? J Acquir Immune Defic Syndr 37:1457, 2004; Hutton HE et al: Understanding
the role of personality in HIV risk behaviors: implications for prevention and treatment. Hopkins
HIV Rep 13:5, 2001; Kalichman SC et al: Distinguishing between overlapping somatic symptoms of depression
and HIV disease in people living with HIV-AIDS. J Nerv Ment Dis 188:662, 2000; Kilbourne AM et al:
General medical and psychiatric comorbidity among HIV-infected veterans in the post-HAART era. J Clin
Epidemiol 54(Suppl 1):S22, 2001; Klinkenberg WD et al: Mental disorders and drug abuse in persons living
with HIV/AIDS. AIDS Care 16 Suppl 1:S22, 2004; Kresina TF et al: Addressing the need for treatment paradigms
for drug-abusing patients with multiple morbidities. Clin Infect Dis 38 Suppl 5:S398, 2004; Ladd GT et
al: Antisocial personality in treatment-seeking cocaine abusers: Psychosocial functioning and HIV risk. J
Subst Abuse Treat 24:323, 2003; Palmer NB et al: Psychiatric and social barriers to HIV medication adherence
in a triply diagnosed methadone population. AIDS Patient Care STDS 17:635, 2003; Pieper AA et al: Drug
treatment of depression in HIV-positive patients: safety considerations. Drug Saf 28:753, 2005; Ruiz P et al:
Psychiatric considerations in the diagnosis, treatment, and prevention of HIV/AIDS. J Psychiatr Pract 6:129,
2000; Sambamoorthi U et al: Antidepressant treatment and health services utilization among HIV-infected
medicaid patients diagnosed with depression. J Gen Intern Med 15:311, 2000; Treisman GJ et al: Neurologic
and psychiatric complications of antiretroviral agents. AIDS 16:1201, 2002; Treisman GJ et al: Psychiatric issues
in the management of patients with HIV infection. JAMA 286:2857, 2001; Trobst KK et al: Personality
psychology and problem behaviors: HIV risk and the five-factor model. J Pers 68:1233, 2000; Tsao JC et al:
Stability of anxiety and depression in a national sample of adults with human immunodeficiency virus. J
Nerv Ment Dis 192:111, 2004; Turrina C et al: Depressive disorders and personality variables in HIV positive
and negative intravenous drug-users. J Affect Disord 65:45, 2001; Wilkinson D et al: Population-based interventions
for reducing sexually transmitted infections, including HIV infection. Cochrane Database Syst
Rev:CD001220, 2001; Woody GE et al: HIV risk reduction in the National Institute on Drug Abuse Cocaine
Collaborative Treatment Study. J Acquir Immune Defic Syndr 33:82, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, Dr. Treisman reported nothing to disclose.
Dr. Triesman was recorded at The Ninth Annual HIV Conference: Building Strong Minds and Bodies, presented
September 27, 2005, in Urbana, Illinois, and sponsored by the Carle Foundation Hospital, Department of
Continuing Medical Education. The Audio-Digest Foundation thanks Dr. Triesman and the Carle Foundation
Hospital for their cooperation in the production of this program.
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