Comprehensive Approach Leads to Success Managing Psychiatric Disorders in People With HIV
A "coherent diagnostic and treatment approach" that draws on several disciplines is needed to successfully manage psychiatric disorders in people with HIV, according to a study that appears in today's Journal of the American Medical Association. According to doctors working at the Johns Hopkins Hospital AIDS Psychiatry Service in the Johns Hopkins HIV Clinic, the epidemiology of HIV/AIDS has shifted and people becoming infected today are more likely to have a psychiatric disorder that "prevents appropriate risk assessment and behavioral change, making them vulnerable to infection" and impairing their ability to obtain or comply with treatment. About three-quarters of the HIV patients at Hopkins' HIV Clinic have a substance abuse problem, and over half of all patients have another type of major psychiatric disorder. These disorders can be classified into four categories: brain diseases, personality disorders, disorders of motivated behavior (addictions) and problems stemming from life circumstances. A brief discussion of the four categories follows below:
- Brain diseases: Thought to stem from a "structural or functional brain lesion," brain diseases are the "most familiar" to medical professionals. Depression, characterized by sleep disturbances and a loss of pleasure in formerly satisfying activities, is most often seen. According to the authors, depression is often attributed to HIV itself and can be confused with AIDS dementia. They estimate that about 60% of people with HIV will experience a depressive episode at some point during the course of their illness. Depression can be treated with both pharmacotherapy and psychotherapy. The two treatments combined carry a success rate of about 85%, although antidepressant medications can interfere with antiretroviral drugs and must be closely monitored.
- Personality and temperament disorders: Patients with personality and temperament disorders typically exhibit "seemingly irrational and deliberately self-destructive" behaviors. They may have unstable emotions and are likely to get upset over "modest distress," which further intensifies their emotions. They may also find it difficult to focus on future consequences, making adherence to treatment a challenge. The authors recommend that doctors "[r]eframe all consequence avoidance, so it becomes a reward" and "appeal to the patient's cognitive side" rather than his or her emotional side whenever possible.
- Disorders of motivated behavior (addictions): Addictions increase the risk of transmission of HIV and "complicate" treatment for persons with the virus. Patients "must be removed from that apparatus that constantly reinforces their behavior" in order to overcome their addictions. Addiction treatment is difficult because of the "combination of habit, craving and circumstances," but a "team of determined clinicians" with a long-term plan can make headway.
- Extreme reactions to life circumstances: Initial HIV/AIDS diagnosis can cause depression and put patients at risk for suicide. Those with HIV are also more likely to face stigma and discrimination and to lose loved ones, leading to a sense of bereavement and demoralization. However, "[c]ompassionate caregivers can greatly improve demoralized patients' sense of hope and quality of life through counseling, support groups, family groups, family education programs, drop-in centers and advocacy programs," the authors state.