The Infectious Disease Specialist and the Psychiatrist: Understanding the Psychiatric Issues in the Treatment of Hiv-infected Patients*

The extraordinarily high comorbidity of psychiatric disorders with human immunodeficiency virus (HIV) infection requires every member of the HIV health care team to be able to identify and understand how to treat these disorders. Two very different disorders with similar symptoms are demoralization and depression, which are highly prevalent in patients with HIV disease. Recognition and treatment of these conditions is essential to successful HIV drug therapy. Although many studies show the benefits of addressing psychiatric disorders in patient outcomes, funding for psychiatric services are not a priority in HIV patients, in part because these populations are often the disenfranchised of society. This article uses a case study to illustrate the effect of psychiatric disorders in HIV patient outcomes and shows how the psychiatrist is an integral member of the HIV health care team. (A more thorough description of the case has been published previously [Treisman GJ, et al. JAMA. 2001;286:2857-2864.]) In addition, methods the infectious disease specialist can use to recognize and possibly treat demoralization and depression in HIV-infected patients are discussed. (Advanced Studies in Medicine 2002;2(6):195-201) T he comorbidity of psychiatric illness in patients with human immunodeficiency virus (HIV) is astoundingly high. Of the HIV-infected patients at the Moore Clinic, the HIV clinic at Johns Hopkins Hospital in Baltimore, Maryland, 75% have a substance abuse disorder and 20% are significantly cognitively impaired, many with an intelligence quotient (IQ) of less than 70 (based on a 10-question screen that can predict IQ within approximately 10 points). More than half of these patients have a major mental illness other than substance abuse. Not surprisingly, these psychiatric disorders are an obstacle to treatment. Psychiatric disorders in HIV-infected patients have become more prevalent in the era of highly active antiretroviral therapy (HAART), as the patients receiving this type of treatment live longer, healthier lives and can shift their focus away from preparation for death and dying. Unfortunately, psychiatry remains marginalized in the treatment of HIV, and patients are usually only referred to the psychiatrist when they are considered intolerable and unruly, in the hopes that the psychiatrist can resolve the personality problems so that other members of the health care team can focus on their traditional province of health care. Although many of the patients appear to be difficult cases, an understanding of human personality, temperament, and the common psychiatric disorders in HIV-infected patients provides nonbehavioral specialists with key insights into methods of managing these patients. When infectious disease (ID) specialists begin to recognize and address the psychiatric comorbidities with HIV infection, the patient’s compliance with HAART PROCEEDINGS