Psychiatric Issues in the Management of Patients With HIV Infection [Treisman GJ et al. JAMA 2001;286:2857] The authors review the experience with the AIDS Psychiatry Service at the Johns Hopkins Moore Clinic. This review concerns the HIV-associated issues with the four main categories of psychiatric disorders: Brain diseases, personality disorders, addiction and problems with life circumstances.

Psychiatric diseases associated with HIV: Major depression is the greatest concern because it is common, devastating, and responds well to treatment with antidepressant drugs. The authors note that about 20% of patients who present to the AIDS Psychiatry Service have major depression and they estimate that about 60% of HIV-infected patients have a depressive episode at some time during their illness. The major source of confusion in diagnosis is an "adjustment disorder" which is characterized as "demoralization." Patients with major depression are considered to have brain disease whereas demoralization is a response to life circumstances. The former responds well to antidepressants, but demoralization probably responds best to psychotherapy. The authors report that antidepressant therapy with psychotherapy provides benefit to 85% of patients and restores half of them to baseline [Psychosomatics 1997;38:423]. The use of antidepressants is complicated by the drug interactions associated with HAART, which have been described in detail previously by these authors [CID 2001;33:847]. The following two tables provide a comparison of depression vs. demoralization and a summary of the most important antidepressant agents with dosage and major interactions, which generally reflect competition for, or induction of the P450 enzymes.

There are two additional dimensions to depression that are important to emphasize: First, depression is associated with poor adherence to HAART [Ann Intern Med 2000;133:21]; second, there is the confusion distinguishing depression from AIDS dementia. AIDS dementia is a subcortical dementia, which produces a flat apathetic state and is best treated with HAART.

Personality disorders: The authors characterize two personality dimensions, stability-instability and introversion-extroversion, both of which exert influence on and can cause difficulties with a patients' adherence to treatment regimens. The authors note that most health workers are introverts making them, "consequence-avoidant," but most HIV-infected patients are extroverts who tend to be insensitive to consequences. This difference often poses difficulties with effective communication. The authors state that the goal of therapy is "a series of gradual behavior changes sustained over several years."

Addictions: This is sometimes referred to as "motivated behavior," to encompass both biologic and volitional aspects. Management of substance abuse requires a team of clinicians.

Problems with life circumstances: This category includes demoralization and risk of suicide. The interventions with the best results are counseling, support groups, family groups, drop in centers and advocacy programs. Severe demoralization usually requires psychotherapy by a trained provider.

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