Treating mental problems also helps HIV treatment 

Therapy along with medical treatment works best 

Mental illnesses have had a great impact on the AIDS epidemic, and new research shows that providing psychiatric treatment to HIV-infected patients who have a psychiatric comorbidity will produce better treatment outcomes, a researcher says.

"A lot of data show that antiretrovirals are less likely to be taken by patients who have mental illness, and patients with comorbid mental illness are less likely to have antiretrovirals," says Glenn J. Treisman, MD, PhD, an associate professor of internal medicine and an associate professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine in Baltimore.

HIV clinicians at Johns Hopkins discovered early in the AIDS epidemic that a high percentage of people presenting for HIV care also had psychiatric problems, including depression, personality problems, addictions, bipolar disorder, and schizophrenia, he says.

Psychiatric illness can lead to greater risk behaviors for HIV infection, and data show once someone is infected, a psychiatric comorbidity is likely to exacerbate HIV disease, Treisman notes.

"We already have data to show psychiatric disorders have a bad impact on compliance with highly active antiretroviral treatment (HAART)," he says. "And there are good data to show that HIV infection increases the likelihood and severity of depression."

The good news is that HIV-infected patients who receive psychiatric treatment have better outcomes, Treisman adds.

Psychiatric treatment should include both medications and psychotherapy to be most effective, he says.

"Without therapy, they don’t take the medications and respond as well," Treisman explains. "We think it’s important to be on antidepressants and psychotherapy at the same time."

Johns Hopkins has a psychiatric treatment model for HIV-infected patients that includes substance abuse treatment for those with addictions, group therapy, and individual therapy, he says.

The psychiatric service is comprehensive, intensive, and expensive except when the cost of not providing the treatment is taken into consideration, Treisman notes.

"Mental illnesses are driving the HIV epidemic, and if we don’t treat them, they are a vector into the epidemic and an impediment to treatment," he says. "Treatment allows HAART to have the best chance to work and ultimately saves money."

For example, last year, Treisman treated a patient, who had been congenitally infected with HIV, who had been in and out of hospitals for months. Each hospital episode resulted in costs of $10,000 to $30,000. Finally, the patient was referred to the psychiatry department where the patient was treated for three months as an inpatient, he recalls.

While the three-month cost was $90,000, it has already produced a savings in health care resources because the patient has not been hospitalized in the six months since being discharged, Treisman points out.

The patient now is functioning normally and is back in school, he adds.

"It’s much cheaper in the long run to treat a patient like that for three months and have the patient then take HAART, maintain an undetectable viral load, and practice safer sex," Treisman says.

The two main obstacles to HIV clinicians referring mentally ill patients to psychiatric services are the prevalent attitude that certain personality disorders and psychiatric illnesses cannot be treated, and the short-term public health strategy of limiting funds for treatments that prevent health care problems rather than react to them, he says.

"The public has taken the view that these are untreatable disorders, but that’s not true," adds Treisman. "It’s not like giving someone penicillin, but it is like treating someone after a stroke: The person can be rehabilitated and can dramatically improve, but may never be 100%."

Likewise, it’s a mistake to believe that people who abuse substances always will return to the substances after substance use treatment, because at least one-third of these patients will stay off drugs or alcohol if they receive long-term treatment, he says.

To the other issue of short-sighted health care resources, Treisman says this is an irrational approach in a nation as wealthy as the United States.

Treisman has co-authored a book, published this summer, about psychiatric disorders and AIDS. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment, published by the Johns Hopkins University Press, offers a model for psychiatric care of HIV-infected patients.