J. Stephen McDaniel

An assessment of rates of psychiatric morbidity and functioning in HIV disease

This study examined demography, rates of psychopathology, and functional impairment in HIV-seropositive women and men in a large, urban, public outpatient infectious disease clinic. Fifty-three percent of the women and 70% of the men met Structural Clinical Interview for DSM-III-R criteria for psychiatric disorders. Current mood disorders were the most frequent diagnoses, followed by psychoactive substance abuse/dependence disorders and psychotic disorders. Seventy-six percent of the women and 90% of the men had previous psychiatric histories, including 59% of the women and 55% of the men who had psychiatric histories prior to their knowledge of HIV seroconversion. Depressed subjects reported significant impairment in physical, social, and role functioning. Similarly, impairment in physical functioning was highly correlated with self-reported anxiety symptoms. These data suggest considerable past and current psychiatric comorbidity in HIV-infected individuals seeking medical care, and draw attention to the need for recognition and aggressive psychiatric treatment, particularly for those depressed and anxious patients with impaired functioning.

Double-blind comparison of fluoxetine and desipramine in the treatment of depressed women with advanced HIV disease: a pilot study.

A double‐blind, placebo‐controlled study was conducted to assess the relative efficacy and tolerability of fluoxetine and desipramine in depressed, human immunodeficiency virus (HIV)‐positive women. Although difficulty in the recruitment and retention of participants led to insufficient power to detect differences between treatment groups, results indicated that participants experienced improvement in their depression. However, for most women, significant depressive symptoms remained after 6 weeks of treatment. In addition, although most participants reported at least one adverse event after treatment began, most of the side effects, regardless of treatment condition, were mild to moderate in severity. Important barriers to study participation and completion are discussed, as well as suggestions for increasing the involvement of depressed, HIV‐positive women in future treatment studies. Depression and Anxiety 9:70–74, 1999.

Severe mental illness and HIV-related medical and neuropsychiatric sequelae.

Medical and neuropsychiatric sequelae of HIV infection present a spectrum of diagnostic and treatment challenges to mental health clinicians. Both HIV and the many opportunistic infections that manifest in patients due to their immunocompromised state also can affect the central nervous system (CNS). Thus, mental health clinicians need to be familiar with the diagnosis and management of HIV-related medical and psychiatric complications. This article provides an overview of the CNS-related manifestations resulting from HIV disease, including HIV-related dementia, psychotic disorders, delirium, CNS opportunistic infections and tumors, systemic abnormalities, psychoactive substances, and the adverse effects of certain medical treatments. Treatment strategies for individuals with HIV disease and comorbid severe mental illness are outlined and recommendations for future research are offered.

A National, Randomized Survey of HIV/AIDS Knowledge and Attitudes Among Psychiatrists in Training

Given the broad spectrum of medical and psychiatric complications associated with HIV (human immunodeficiency virus) disease, HIV-related education is an important curriculum topic for all physicians. This study examined the HIV-related knowledge and attitudes among psychiatrists in training to evaluate their training needs. A survey instrument was developed containing 15 knowledge items, 15 attitude items, demographic items, and questions concerning how HIV/AIDS (acquired immunodeficiency syndrome) affected residency choice and self-perception of training needs. The questionnaire was mailed to 2,252 psychiatrists in training randomly selected and stratified by American Psychiatric Association district and postgraduate training year. The sample consisted of 825 respondents representing 37% of the initial pool. Knowledge was most lacking in areas dealing with HIV-related neuropsychiatric complications and issues concerning HIV/AIDS and special populations. In general, the respondents expressed positive attitudes about HIV-related issues; however, three items correctly endorsed by fewer than 75% of the sample dealt specifically with the management of neuropsychiatric complications, working with dying patients, and the range of normal sexuality. Targeted HIV-related education is needed for psychiatrists in training and particularly should encompass neuropsychiatric syndromes and issues of special populations.

Clinical management of psychiatric disorders in patients with HIV disease.

HIV disease presents considerable challenges that can affect adjustment and health-related behaviors. This article provides an overview of clinical considerations in the treatment of comorbid psychiatric disorders and problems in adjustment in HIV patients. First, the research literature is reviewed with respect to biomedical, intrapersonal, and psychosocial factors associated with HIV-related psychological adjustment and psychiatric complications. Next, a brief description is presented regarding prevalence and types of co-occurring psychiatric disorders seen in HIV patients. The article concludes with a discussion of clinical assessment and treatment considerations for psychiatric clinicians who work with HIV patients.

Terminal cardiomyopathy, splitting, and borderline personality organization

A 63-year-old married man with idiopathic terminal cardiomyopathy was admitted to the medical service for treatment of advanced heart failure. A psychiatric consultation was requested to assist the medical treatment team in dealing with the patients abusive behavior. The case is presented and discussed within the context of understanding the borderline personality in the medical setting.

An Association between Increased Concentrations of Cerebrospinal Fluid Dopamine Sulfate and Higher Negative Symptom Scores in Patients with Schizophrenia and Schizoaffective Disorder

There has been much speculation as to the role of dopamine in the etiology and/or manifestation of positive and negative symptoms. Traditionally, cerebrospinal fluid (CSP) concentrations of homovanillic acid (HVA) has been used as an index of central dopaminergic activity. Relea~l dopamine is metabolized to HVA, by catechol-O-methyltransferase (COMT) and monoamine oxidase (MAO) (Cooper et al 1991). A review of the CSF HVA literature, however, reveals no consistent correlations between HVA and schizophrenic symptomatoiogy (reviewed by Pickax et al ! 9907. Yet there is sufficient data to suggest that dopamine activity is abnormal in schizophrenia (Davis et al 19917. Therefore the evaluation of other putative measures of dopamine release or metabolism seems warranted. Released dopamine is also converted to dopamine sulfate (DASO47 by the enzyme phenolsulphotransferase (PST7 (Jenner and Rose, 1973). in the brain, it appears that the sulfoconjugation of dopamine occurs primarily outside of dopaminergic neurons (Tyce et al 1988). Therefore CSF DASO~ concentrations may reflect an important alternate route of dopamine metabolism. Assessment of PST-dependent DASO4 independently, or in re-