Treatment of AIDS in a Psychiatric Setting

Treatment staff in psychiatric facilities must meet new diagnostic and treatment challenges as more patients with an AIDS-related syndrome are admitted to their institutions. Staff probably will encounter two categories of patients with AIDS-related syndromes requiring treatment: functional, which is adjustment disorder; and organic brain syndrome, which includes major depression, dementia, and delirium. Health care professionals dealing with these people must respond to legal and ethical questions surrounding the diagnosis and plan of care. This article examines treatment issues, and legal and ethical questions that often arise in the delivery of care to psychiatric patients with an AIDS-related syndrome. Specific areas addressed include care of the psychotic patient, compulsory testing, and confidentiality of information. The article presents some suggested basic guidelines for working with patients with AIDS.     

Treatment of Psychiatric Disorders in Children and Adolescents with HIV/AIDS

We could not have predicted that HIV/AIDS would become one of our greatest public health challenges worldwide when the first cases were identified in the 1980s. More than 22 million people have died from the disease, and HIV is now the seventh-leading cause of death in the United States among 15- to 24-year-olds. At the beginning of this pandemic, most HIV infections of youth were acquired congenitally. Prenatal screening of pregnant women, early detection, and antiretroviral therapies have reduced mother-to-child transmission. Children born with HIV infections are now young adults living with HIV, while other adolescents are acquiring HIV primarily through high-risk behaviors. Associations between psychiatric symptoms and poor health outcomes have been recognized among adults. Few studies have examined these factors among youth. We review what is known about psychiatric syndromes among HIV-positive youth, and their treatments.     

Psychopharmacological Treatment of Patients with HIV and AIDS

Psychopharmacological treatment of patients with HIV/AIDS is an important aspect of managing distress and enhancing quality of life. This article reviews the psychopharmacological management of depression, anxiety, mania, and psychosis in the context of HIV/AIDS, with a discussion of psychotropic–antiretroviral drug interactions. While psychopharmacological management of HIV/AIDS patients may be complex, there is a substantial amount of clinical and research information describing both conventional and novel approaches that are safe and effective.     

Exploring Individual Factors Associated with Critical Incidents in a Secure Psychiatric Setting: A Preliminary Study

This study explored individual factors associated with critical incidents that required professional intervention. Critical incidents were defined as holding someone against their will (i.e., hostage-taking), rooftop demonstrations and isolating oneself from others (i.e., barricades). Participants were from a high secure psychiatric hospital. All had a known history of having engaged in critical incidents. They were compared with a matched sample from the same hospital with no such history. Thirty-four patients were recruited, 16 in the study group and 18 in the comparison group. Extraversion, agreeableness and an impulsive/careless problem-solving style were noted in those who perpetrated critical incidents. Personality and problem solving were variables distinguishing the perpetrators of critical incidents. Future research exploring in more detail the individual factors associated with involvement in critical incidents is suggested.     

Psychiatric morbidity and adherence to antiretroviral medication in patients with HIV/AIDS

OBJECTIVE: To determine whether psychological morbidity is associated with poor compliance with antiretroviral medication in HIV-positive subjects. METHOD: This is a cross-sectional survey of patients attending a public HIV clinic in Sydney. Volunteers completed a survey which gathered data on substance use, psychological distress, attitudes to illness and medication, and self-reported medication adherence. Psychological morbidity was assessed using the 28 question General Health Questionnaire, GHQ-28, and adherence was assessed using a combination of direct self-report and indirect questions. RESULTS: Forty-four per cent of subjects were identified as suffering psychological disorder on the GHQ. They reported significantly poorer adherence to antiretroviral medication than subjects not identified as 'cases' (odds ratio 4.5). Expressed scepticism about medication and previous use of psychotropics was also associated with poor adherence. CONCLUSIONS: Psychological morbidity is associated with poor adherence to antiretroviral medication. It is not known whether treatment of identified psychological morbidity leads to improved antiretroviral medication adherence and better medical outcome. A longitudinal study could help answer this question.     

Perceived Mental Illness Stigma and HIV Risk Behaviors Among Adult Psychiatric Outpatients in Rio de Janeiro,Brazil

We examined the associations between perceived mental illness stigma and HIV risk and protective behaviors among adults with severe mental illness (SMI) in Rio de Janeiro, Brazil. We measured mental illness stigma across three domains (“Personal Experiences,” “Perceived Attractiveness,” and “Relationship Discrimination”), and examined the relationship between experiences of stigma in each domain and HIV risk and protective behaviors over the past 3 months in 98 outpatients with SMI. Those who reported greater “Relationship Discrimination” stigma were significantly more likely to be sexually active and to have unprotected sex; they were significantly less likely to report deliberately having fewer partners as a way to protect themselves from HIV. The role of stigma in unprotected sexual behavior should be examined further and considered in any HIV prevention intervention for people with SMI.     

Psychiatric considerations in the diagnosis, treatment, and prevention of HIV/AIDS

HIV/AIDS has the unfortunate distinction of being one of the most devastating epidemics of the twentieth century. By the end of June, 1999, 420,201 deaths in persons with AIDS had been reported in the United States. While HIV/AIDS patients are currently living longer as a result of more effective and complex treatments, no vaccination or cure has yet been discovered. Over the years, the HIV/AIDS epidemic has become multifactorial and currently affects several different special population groups. Individuals who are at high risk for becoming infected with HIV or who already suffer from HIV/AIDS can benefit greatly from the interventions of psychiatrists or other mental health professionals. It is important that psychiatrists collaborate very closely with infectious disease specialists in the management of HIV/AIDS and its psychological sequelae. The authors describe the psychiatric conditions that most often occur in association with HIV/AIDS: mood disorders, anxiety disorders, substance-related disorders, psychotic disorders, insomnia and sleep disorders, delirium, dementia, and pain syndromes. We present guidelines for diagnosis and psychopharmacological and psychotherapeutic treatment of these disorders in patients with HIV/AIDS. The article concludes with a discussion of prevention strategies that can be used in a mental health treatment setting and special issues related to treating HIV/AIDS in certain special population groups.     

Demographic Characteristics and Employment Among People with Severe Mental Illness in a Multisite Study

People with psychiatric disabilities experience disproportionately high rates of unemployment. As research evidence is mounting regarding effective vocational programs, interest is growing in identifying subgroup variations. Data from a multisite research and demonstration program were analyzed to identify demographic characteristics associated with employment outcomes, after adjusting for the effects of program, services, and study site. Longitudinal analyses found that people with more recent work history, younger age, and higher education were more likely to achieve competitive employment and to work more hours per month, while race and gender effects varied by employment outcome. Results provide strong evidence of demographic subgroup variation and need.Jane K. Burke-Miller, Judith A. Cook, Dennis D. Grey, Lisa A. Razzano, and Amanda Taylor are affiliated with the Center on Mental Health Services Research and Policy at the University of Illinois at Chicago. Crystal R. Blyler is affiliated with the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, MD. H. Stephen Leff is affiliated with the Human Services Research Institute, Cambridge, MA. Paul B. Gold is affiliated with the Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina. Richard W. Goldberg is affiliated with the Department of Psychiatry, University of Maryland. Kim T. Mueser is affiliated with the New Hampshire-Dartmouth Psychiatric Research Center, Dartmouth Medical School. William L. Cook is affiliated with the Department of Psychiatry, Maine Medical Center. Sue K. Hoppe was affiliated with the University of Texas Health Sciences Center San Antonio, Department of Psychiatry at the time of the study. Michelle Stewart was affiliated with the Community Rehabilitation Division, University of Arizona at the time of the study. Laura Blankertz was affiliated with Matrix Research Institute, Philadelphia, PA at the time of the study. Kenn Dudek is affiliated with Fountain House, New York, NY. Martha Ann Carey was affiliated with the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, MD at the time of the study.This research was funded by Cooperative Agreement No. SM51820 from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, as part of the Employment Intervention Demonstration Program (EIDP).     

Implementing a Violence Risk Screening Protocol in a Civil Psychiatric Setting: Preliminary Results and Clinical Policy Implications

Comprehensive violence risk assessment can require substantial time and resources, which may be challenging for an already strapped public mental health system. Herein, we describe a naturalistic study of the Fordham Risk Screening Tool (“FRST”), a violence risk screening instrument designed to quickly identify individuals for whom thorough violence risk assessment would be advisable. All patients admitted to one of three state hospitals during the study period received FRST screening and HCR-20^V3 risk assessment. The FRST reliably and accurately identified individuals deemed high risk by the HCR-20^V3. The implications of these findings, and the broader clinical policy choices are reviewed.     

Sexual HIV Transmission and Antiretroviral Therapy: A Prospective Cohort Study of Behavioral Risk Factors Among Men and Women Living with HIV/AIDS

Background  

Using antiretroviral therapies for HIV prevention relies on patient adherence and avoidance of co-occurring sexually transmitted infections.     

Crisis Visits and Psychiatric Hospitalizations Among Patients Attending a Community Clinic in Rural Southern California

Ethnic minorities from disadvantaged socioeconomic backgrounds report increased utilization of mental health emergency services; however findings have been inconsistent across ethnic/racial groups. In this study we describe patients who present to a rural crisis unit in Southern California, examine rates of psychiatric hospitalizations across ethnic/racial groups, and investigate factors that are associated with increased psychiatric hospitalizations in this sample. This is a retrospective study of 451 racially and ethnically diverse patients attending a crisis unit in Imperial County, California. Chart review and data abstraction methods were used to characterize the sample and identify factors associated with psychiatric crises and subsequent hospitalizations. The sample was predominantly Latino/Hispanic (58.5%). Based on chart review, common psychosocial stressors which prompted a crisis center visit were: (a) financial problems; (b) homelessness; (c) partner or family conflict; (d) physical and health problems; (e) problems at school/work; (f) medication compliance; (g) aggressive behavior; (h) delusional behavior; (i) addiction and (j) anxiety/depression. Bivariate analyses revealed that Hispanics had a disproportionately lower rate of psychiatric hospitalizations while African Americans had a higher rate. Multivariate analyses which included demographic, clinical and psychosocial stressor variables revealed that being African American, having a psychotic disorder, and presenting as gravely disabled were associated with a higher likelihood of hospitalization while partner/family conflict was associated with a lesser likelihood in this rural community. These data elucidate the need for longitudinal studies to understand the interactions between psychosocial stressors, ethnicity and social support as determinants of psychiatric hospitalizations.     

National Differences in Predictors of Suicide Among Young and Elderly Citizens: Linking Societal Predictors to Psychological Factors

ABSTRACT

Suicide is usually conceptualized as arising either because of social phenomena or individual dynamics. In this study, these approaches were combined by analyzing suicide rates of younger people aged 15–24 and elderly aged 65–74 from 54 nations using societal variables in conjunction with psychological measures of citizen characteristics as mediators. A mediated analysis showed that psychological citizen factors, like home satisfaction and happiness, mediated the impact of societal variables, like the sex ratio, in predicting suicide rates. We found different psychological and societal predictors for young and elderly suicides, with elderly suicide rates being much more predictable. An age-responsive Durkheimian framework focusing on the dynamics of social integration at different ages was used to interpret these results.     

The Prevalence of Suicidal Ideation and Attempt Among Young People with HIV/AIDS: a Systematic Review and Meta-Analysis

Psychiatric Quarterly - Studies have suggested that suicidal ideation and attempt are highly prevalent among young people with HIV/AIDS and have been linked with increased risk of complete suicide....     

Reasons for Nonadherence to Psychiatric Medication and Cardiovascular Risk Factors Treatment Among Latino Bipolar Disorder Patients Living in Puerto Rico: A Qualitative Study

Latinos with bipolar disorder (BD) have a high rate of nonadherence to psychiatric medication and treatment for other medical conditions such as cardiovascular disease (CVD) risk factors than non-Latinos with BD. The aim of this study is to identify patients’ perspectives on the reasons for nonadherence to psychiatric medication and for CVD risk factors conditions in outpatients with BD. Three focus group sessions were held for a total of 22 adults ranging from 23 to 60 years old. Participants had BD, Type I/II and CVD risk factors. Audio-recordings of focus groups were transcribed and a content analysis was performed. Reasons identified as barriers to adherence were somewhat different for BD medications in comparison to CVD risk factors suggesting the need for integrated interventions targeting these barriers to adherence for both BD and CVD risk factors.     

Prior Experiences of Behavioral Health Treatment among Uninsured Young Adults Served in a Psychiatric Crisis Setting

This study qualitatively explored the past treatment experiences of uninsured young adults who sought public emergency psychiatric care. Qualitative interviews were conducted with a racially diverse sample of 55 young adults (ages 18–25) using a semi-structured interview guide, and analyzed using a team-based open coding approach. Findings emerged in three broad areas—provider-related factors, treatment-related factors, and environmental factors. Young adults talked about the importance of providers respecting and listening to them, the perceived advantages and disadvantages of therapy and medication treatment, and aspects of the environment that resulted in positive and negative experiences, particularly in inpatient settings. Providers need to convey respect and caring that transcends job duties and provide tangible skills and supports.     

Comorbid Psychiatric Disorders and Predictors of Pain Management Program Success in Patients With Chronic Pain

BACKGROUND: This prospective investigation assessed success rates of a pain management program for patients with and without DSM-III-R Axis I and II psychiatric disorders. METHOD: Subjects included 40 consecutive patients with chronic pain who were referred to a physical therapy-oriented, "standard" pain management program. Serial ratings of pain levels were measured via a visual analogue scale (VAS) at baseline, weekly throughout a 12-week program, and during a follow-up interval 1 month after completion of the program. Weekly reports of hours of gainful employment were recorded. VAS scores and number of hours worked per week were combined into a measure of pain improvement. This dependent variable was used to compare groups of patients across psychiatric disorders diagnosed via the Diagnostic Interview Schedule (DIS). Percentages of patients in each diagnostic group who met minimal criteria for improvement were computed and compared. A chi-square analysis was conducted on success rates between patients with and without any Axis I disorder, any Axis II disorder, and any substance abuse/dependence disorder. RESULTS: Overall, 70% of patients (N = 28) were found to have a DIS psychiatric disorder. There were differences in improvement between patients with and without Axis I disorders and between those with and without Axis II disorders. The presence of a diagnosis was associated with significantly lower improvement rates (p <.05). CONCLUSION: Patients with chronic pain enrolled in this clinic had a high prevalence of comorbid psychiatric disorders, and these comorbid patients were less likely to improve with standard chronic pain treatment. In a population of patients seeking treatment for chronic pain, these results suggest a need for detection and diagnosis of psychiatric disorders and further research on the efficacy of psychiatric treatment interventions in chronic pain management.     

脑膜瘤组织VEGF／VPF、KDR的表达及意义

目的研究脑膜瘤血管生成及瘤周脑水肿与VEGF/VPF及其受体KDR的关系。方法采用Northern印迹分子杂交和免疫组化技术检测47例脑膜瘤组织VEGF/VPFmRNA、VEGF/VPF和KDR蛋白表达,分析其与微血管密度(MVD)和瘤周脑水肿度DPTBE的关系。结果47例脑膜瘤均表达4.2Kb的VEGF/VPFmRNA片段,VEGF/VPF蛋白表达与其mRNA的表达一致,80.9%的肿瘤KDR蛋白表达阳性,VEGF/VPF和KDR分别定位于脑膜瘤瘤细胞和血管内皮细胞胞浆。VEGF/VPFmRNA表达与脑膜瘤MVD和DPTBE呈正相关r=0.67,P<0.01r=0.54,P<0.01;KDR阳性组脑膜瘤VEGF/VPFmRNA表达水平、MVD、DPTBE均显著高于KDR阴性组(P<0.01)。结论脑膜瘤细胞可产生VEGF/VPF,通过KDR介导促肿瘤血管生成和增加血管通透性,在脑膜瘤瘤周脑水肿的发生发展过程中起重要作用。     

Special Section: Psychiatric Dimensions of HIV and AIDS in the 21st Century: Introduction

Psychiatric Quarterly -