This article was downloaded by: [York University Libraries] On: 27 December 2014, At: 03:55 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Psychiatric disorders associated with HIV disease a
J. Catalan & M. Riccio
b
a
Senior Lecturer in Liaison Psychiatry, Charing Cross & Westminster Medical School, Westminster Hospital , Horseferry Road, London, SW1 b
Consultant Psychiatrist, St Mary Abbots Hospital , Marloes Road, London, W8 SLQ, U.K. Published online: 25 Sep 2007.
To cite this article: J. Catalan & M. Riccio (1990) Psychiatric disorders associated with HIV disease, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 377-380, DOI: 10.1080/09540129008257757 To link to this article: http://dx.doi.org/10.1080/09540129008257757
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 4, 1990
377
Psychiatric disorders associated with HIV disease
Downloaded by [York University Libraries] at 03:55 27 December 2014
J. CATALAN' & M. RICCIO~ Senior Lecturer in Liaison Psychiatry, Charing Cross & Westminster Medical School, Westminster Hospital, Horsefeny Road, London S W l & Consultant Psychiatrist, St Mary Abbots Hospital, Marloes Road, London W 8 S L Q U.K.
Introduction Anyone naive enough to expect dramatic revelations or earth-shattering reports at the annual AIDS Conference would have been disappointed by the somewhat variable quality of the presentations and posters on the psychiatry of HIV infection. However, those concerned with seeking areas where consensus is being reached, or c h c i a n s or researchers wishing to make contact with the growing body of mental health workers involved in HIV related work, would have gone home with their expectations approaching some degree of fulfilment. Psychiatric presentations could be divided roughly into descriptive reports and intervention studies. Predictably, there were twice as many papers describing psychiamc problems as reports of treatment studies, proving how much harder it is to carry out proper evaluations of therapeutic approaches.
Descriptive studies Mood
A number of reports from different parts of the world and involving subjects belonging to different transmission groups reported no
statiSticaUy signifcant diferences in mood state between individuals with HIV infection and seronegative controls, and this was so regardless of HIV stage. Some of these reports were based on cross-sectional investigations while others involved longitudinal data. The transmission groups studied included gay men (Riccio et al., PSY 8 , Monterey; Kelly et al., ThB26; Chuang et al., SB361; Carter et ul., SB383); men with haemophilia (Catalan et al., PSY 1, Monterey); and intravenous drug users (Remien et al., SB363). Two other studies failed to find any significant correlations between measures of mood and other psychological indicators and immune variables (Perry et al., ThB27) and between psychological functioning and cerebrospinal fluid data (Rundell et al., SY 13, Monterey). By contrast, a similar number of papers reported the presence of significant di&ences between seropositives at various stages of disease and seronegatives; for example asymptomatic gay men compared with seronegatives (Carter et al., SB383); or symptomatic gay men compared with asymptomatics (Rosenberger et al., SB378). One paper reported higher levels of morbidity in intravenous drug users compared with gay men (Eich et al., SB376) while another found that intravenous drug users were more
Downloaded by [York University Libraries] at 03:55 27 December 2014
378
SAN FRANCISCO SUMMARIES: 1. CATALAN &
anxious than gay men, but gay men had higher levels of depression (Tempesta et al., ThB29); gay men with AIDS or ARC had greater levels of psychiatric morbidity than asymptomatics, and h s was also the case for those who were neurologically symptomatic or had low T4 levels (Fahy-Chandon er al., NPS 36, Monterey; Robertson et al., NPS 3 1,Monterey; Chessick et al., PSY 1 1 ,Monterey). Interestingly, a longitudinal report on the impact of being on a clinical trial showed that those subjects who bad enrolled in research had better psychological status than those who had declined to enter. There are many reasons that could account for the discrepancies between studies, including the size of the sample, the methods used to assess psychatric morbidity, and whether the subjects were part of a random cohort or selected individuals. It is possible too that the stage at whch individuals were assessed, and in particular the extent to whcb they were suffering from contemporary physical illness, may have also played a part. However, most stules seemed to suggest that asymptomatic individuals do not suffer greater psychological distress than seronegatives from a comparable transmission group. In addition, many reports suggested that symptomatic HIV disease, in particular when there are neurological symptoms and other major physical problems, is likely to be associated with psychological disturbance. It is important to remember, however, that even if there are few group differences, some individuals will experience psychological problems, and so it will be important to be able to identify those at risk (see below).
Suicidal ideas and behaawur A report of military personnel with HIV infection found similar levels of suicidal ideation or history of deliberate self-harm in the last year to seronegative personnel with alcoholism receiving treatment (Drexler et al., SB388), while a paper from Milan found that amongst seropositive individuals admit-
M.RlCCIO
ted to psychiatric units nearly 30% were found to have a history of deliberate selfharm, compared with only 7% amongst seronegatives (Zamperetti et al., SB387). Gay men with HIV infection at lfferent stages of disease were found to have the same lifetime prevalence of suicidal thoughts, history of deliberate self-harm and other indicators of suicidal ideation as seronegative gay men, while both seropositives and seronegatives differed markedly from heterosexual controls who had much lower levels of suicidal ideadbehaviour (Atkinson et al., SB384). Those with a positive lifetime history of suicidal ideas/behaviour were more likely to lack social supports and tended to cope with the problems by avoidance (Gutierrez et al., SB386). By contrast, a study from New York involving individuals with HIV infection attenlng a psychiatric outpatient clinic found lower prevalence of suicidal thoughts and acts (self or family) in inlviduals with AIDS compared with those at other stages of lsease (Orr et al., ThB30). However, there were some methodological problems in t h ~ spaper which casts doubt over the finlngs.
Akohol and substance we, coping style and other
No differences were reported in consumption of alcohol and other substances in symptomatic gay men compared with asymptomatic (Rosenberger er al., SB378) or in asymptomatics seropositives when cornpared with seronegatives (Jadresic et al., PSY 2, Monterey). A longitudinal study of gay men with HIV infection described how asymptomatics tended to identify positive aspects in their lives while minimizing some adverse events, but knowledge about decline in T4 levels was associated with an increase in negative views about oneself (Hart er al., SB371). In men with haemophilia, potentially maladaptive coping techniques were identified in asymptomatic seropositives compared with seronegatives (Catalan er al., PSY 1 , Mon-
PSYCHIATRIC DISORDERS ASSOCIATED WITH HIV DISEASE
terey). By contrast with last year's conference, there were few reports on sexual dysfunction in HIV infection, except in the case of men with haemophilia (Catalan et al., PSY 1, Monterey).
Downloaded by [York University Libraries] at 03:55 27 December 2014
HIV infection in psychianic settings Anonymized testing for HIV infection in an' acute psychiatric unit in New York found 7.8% to be seropositive (Sacks et al., SB368) and a similar study from Milan concerned with acute psychiatric patients who had given their consent for testing found 6% prevalence (Zamperetti et al., SB387). In Germany, amongst patients with HIV infection referred to a psychiatrist nearly 30% were found to suffer from major depression, while only 1% had a psychotic illness, usually an organic brain syndrome (Naber et al., PSY 10, Monterey), while a paper from Australia found 36% of patients with HIV admitted to a psychiatric unit to be suffering from mania (Smith, PSY 3, Monterey). In a report from Brazil, 13% of psychiatric emergencies were HIV patients (Tostes, SB397), mostly consisting of organic brain syndrome.
379
mother before the age of 18 years and a history of physical and sexual abuse (Rundell et al., SB362). Poor active coping and the use of avoidance or escape as coping mechanisms was associated with psychiatric disturbance in gay men with AIDS, both cross-sectionally and longitudinally (Reed et al., ThB25). Finally, death within 12 months of diagnosis was more likely to occur in blacks, those with no social supports and those experiencing increasing levels of distress (Redo et al., SB372).
Treatment Psychological interventions Cognitive-bchavioural treatment was found to be more effective than no treatment for individuals with HIV infection both by the end of treatment and at 6-month follow up (Garcia-Huete, SB396) and an 8-week educational/support group was found to be better than a wait group in terms of reduction in stress levels and an increase in active coping, but not in relation to the practice of safer sex (Moulton et al., SB400). There was also an intriguing report of the use of meditation and other stress management techniques, but the results were marred by poor methodology (Earl et al., ThB28).
Facms associated with psychiatric morbidity There was a fair amount of consistency both in cross-sectional and longitudinal studies in relation to factors likely to be associated with psychiatric disorder. For example, studies of depression in AIDS found that mood disturbance was more likely in women, the unemployed, those lacking in social support or those with high levels of physical symptoms (Fleishman et al., SB391), and in those black or hispanic origins, no social supports and declining neuropsychological performance (Schmidt et al., SB381). In early HIV infection, depression was found to be associated with the absence of social supports (Turner et al., SB380), while psychiatric disorder in asymptomatic gay men was associated with past psychiatric history, death of
Physical methods of treatment Not surprisingly, imipramine was found to be better than placebo for the treatment of depression in people with HIV infection (Manning et al., ThB32), and the findings from a 10-patient study were used to support a claim that Buspirone was better than placebo for the treatment of anxiety (Hirsch et al., SB395). There were anecdotal references to the use of psycho-stimulants (Ostrow, Monterey), and it was suggested that asymptomatic individuals responded better to anti-depressants than those with ARC/ AIDS (Peterkin et al., SB389), and there was a report about five patients whose depression improved after AZT,but no infor-
380
SAN FRANCISCO SU5hURIE.S: J. CATALAN &
mation was given about changes in the patients’ physical state as a result of treatment, and the likely contribution of such clinical improvement to changes in mood (Perkins et al., SB392).
Downloaded by [York University Libraries] at 03:55 27 December 2014
Therapist/patient issues A paper from Brazil asked the question of whether women with HIV infection, in particular those who had acquired it from a bisexual husband, would accept counselling by a male therapist (Carvalho-Net0 et al., SB403). About half of the women were prepared to be counselled by a male and a significant number refused to attend. The problems that gay therapists experience when dealing with gay men with HIV dlsease were discussed on the basis of mformation given by a small number of therapists (Cadwell, SB404) and a report on patients’ views about decision making and information in relation to their condition highlighted the need for further work in this area (Gerbert et uf., SB401).
Psychological interoentions and medical preaments This is a neglected area of research which deserved attention. One small study showed the value of identifying individuals who
M.RICCIO
either as a result of psychological problems or memory impairment are likely to have problems coping with self-treatment with foscarnet using a Hickman line. The report showed how identification and intensive educational and supportive interventions resulted in increased compliance and satisfaction with treatment (Williams et al., SB406). The importance of providing information and support to individuals participating in treatment trials before, during and after the trial was completed was highlighted in a descriptive report a package of techniques used to increase compliance (Bennett et al., SB408).
Conclusions While there is a move towards consensus in many of the descriptive studies of psychiatric morbidity in HIV disease, there are still areas of discrepancy, and there are significant gaps in our knowledge, for example as regards the prevalence of major psychiatric syndromes such as mania or schizophrenic like dlnesses, or the lack of good data for some transmission groups such as women and drug users. Much needs to be done in terms of treatment studies both psychological and physical, and also in relation to provision of services, their value and their cost-efficacy.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Psychiatric disorders associated with HIV disease a
J. Catalan & M. Riccio
b
a
Senior Lecturer in Liaison Psychiatry, Charing Cross & Westminster Medical School, Westminster Hospital , Horseferry Road, London, SW1 b
Consultant Psychiatrist, St Mary Abbots Hospital , Marloes Road, London, W8 SLQ, U.K. Published online: 25 Sep 2007.
To cite this article: J. Catalan & M. Riccio (1990) Psychiatric disorders associated with HIV disease, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 377-380, DOI: 10.1080/09540129008257757 To link to this article: http://dx.doi.org/10.1080/09540129008257757
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 4, 1990
377
Psychiatric disorders associated with HIV disease
Downloaded by [York University Libraries] at 03:55 27 December 2014
J. CATALAN' & M. RICCIO~ Senior Lecturer in Liaison Psychiatry, Charing Cross & Westminster Medical School, Westminster Hospital, Horsefeny Road, London S W l & Consultant Psychiatrist, St Mary Abbots Hospital, Marloes Road, London W 8 S L Q U.K.
Introduction Anyone naive enough to expect dramatic revelations or earth-shattering reports at the annual AIDS Conference would have been disappointed by the somewhat variable quality of the presentations and posters on the psychiatry of HIV infection. However, those concerned with seeking areas where consensus is being reached, or c h c i a n s or researchers wishing to make contact with the growing body of mental health workers involved in HIV related work, would have gone home with their expectations approaching some degree of fulfilment. Psychiatric presentations could be divided roughly into descriptive reports and intervention studies. Predictably, there were twice as many papers describing psychiamc problems as reports of treatment studies, proving how much harder it is to carry out proper evaluations of therapeutic approaches.
Descriptive studies Mood
A number of reports from different parts of the world and involving subjects belonging to different transmission groups reported no
statiSticaUy signifcant diferences in mood state between individuals with HIV infection and seronegative controls, and this was so regardless of HIV stage. Some of these reports were based on cross-sectional investigations while others involved longitudinal data. The transmission groups studied included gay men (Riccio et al., PSY 8 , Monterey; Kelly et al., ThB26; Chuang et al., SB361; Carter et ul., SB383); men with haemophilia (Catalan et al., PSY 1, Monterey); and intravenous drug users (Remien et al., SB363). Two other studies failed to find any significant correlations between measures of mood and other psychological indicators and immune variables (Perry et al., ThB27) and between psychological functioning and cerebrospinal fluid data (Rundell et al., SY 13, Monterey). By contrast, a similar number of papers reported the presence of significant di&ences between seropositives at various stages of disease and seronegatives; for example asymptomatic gay men compared with seronegatives (Carter et al., SB383); or symptomatic gay men compared with asymptomatics (Rosenberger et al., SB378). One paper reported higher levels of morbidity in intravenous drug users compared with gay men (Eich et al., SB376) while another found that intravenous drug users were more
Downloaded by [York University Libraries] at 03:55 27 December 2014
378
SAN FRANCISCO SUMMARIES: 1. CATALAN &
anxious than gay men, but gay men had higher levels of depression (Tempesta et al., ThB29); gay men with AIDS or ARC had greater levels of psychiatric morbidity than asymptomatics, and h s was also the case for those who were neurologically symptomatic or had low T4 levels (Fahy-Chandon er al., NPS 36, Monterey; Robertson et al., NPS 3 1,Monterey; Chessick et al., PSY 1 1 ,Monterey). Interestingly, a longitudinal report on the impact of being on a clinical trial showed that those subjects who bad enrolled in research had better psychological status than those who had declined to enter. There are many reasons that could account for the discrepancies between studies, including the size of the sample, the methods used to assess psychatric morbidity, and whether the subjects were part of a random cohort or selected individuals. It is possible too that the stage at whch individuals were assessed, and in particular the extent to whcb they were suffering from contemporary physical illness, may have also played a part. However, most stules seemed to suggest that asymptomatic individuals do not suffer greater psychological distress than seronegatives from a comparable transmission group. In addition, many reports suggested that symptomatic HIV disease, in particular when there are neurological symptoms and other major physical problems, is likely to be associated with psychological disturbance. It is important to remember, however, that even if there are few group differences, some individuals will experience psychological problems, and so it will be important to be able to identify those at risk (see below).
Suicidal ideas and behaawur A report of military personnel with HIV infection found similar levels of suicidal ideation or history of deliberate self-harm in the last year to seronegative personnel with alcoholism receiving treatment (Drexler et al., SB388), while a paper from Milan found that amongst seropositive individuals admit-
M.RlCCIO
ted to psychiatric units nearly 30% were found to have a history of deliberate selfharm, compared with only 7% amongst seronegatives (Zamperetti et al., SB387). Gay men with HIV infection at lfferent stages of disease were found to have the same lifetime prevalence of suicidal thoughts, history of deliberate self-harm and other indicators of suicidal ideation as seronegative gay men, while both seropositives and seronegatives differed markedly from heterosexual controls who had much lower levels of suicidal ideadbehaviour (Atkinson et al., SB384). Those with a positive lifetime history of suicidal ideas/behaviour were more likely to lack social supports and tended to cope with the problems by avoidance (Gutierrez et al., SB386). By contrast, a study from New York involving individuals with HIV infection attenlng a psychiatric outpatient clinic found lower prevalence of suicidal thoughts and acts (self or family) in inlviduals with AIDS compared with those at other stages of lsease (Orr et al., ThB30). However, there were some methodological problems in t h ~ spaper which casts doubt over the finlngs.
Akohol and substance we, coping style and other
No differences were reported in consumption of alcohol and other substances in symptomatic gay men compared with asymptomatic (Rosenberger er al., SB378) or in asymptomatics seropositives when cornpared with seronegatives (Jadresic et al., PSY 2, Monterey). A longitudinal study of gay men with HIV infection described how asymptomatics tended to identify positive aspects in their lives while minimizing some adverse events, but knowledge about decline in T4 levels was associated with an increase in negative views about oneself (Hart er al., SB371). In men with haemophilia, potentially maladaptive coping techniques were identified in asymptomatic seropositives compared with seronegatives (Catalan er al., PSY 1 , Mon-
PSYCHIATRIC DISORDERS ASSOCIATED WITH HIV DISEASE
terey). By contrast with last year's conference, there were few reports on sexual dysfunction in HIV infection, except in the case of men with haemophilia (Catalan et al., PSY 1, Monterey).
Downloaded by [York University Libraries] at 03:55 27 December 2014
HIV infection in psychianic settings Anonymized testing for HIV infection in an' acute psychiatric unit in New York found 7.8% to be seropositive (Sacks et al., SB368) and a similar study from Milan concerned with acute psychiatric patients who had given their consent for testing found 6% prevalence (Zamperetti et al., SB387). In Germany, amongst patients with HIV infection referred to a psychiatrist nearly 30% were found to suffer from major depression, while only 1% had a psychotic illness, usually an organic brain syndrome (Naber et al., PSY 10, Monterey), while a paper from Australia found 36% of patients with HIV admitted to a psychiatric unit to be suffering from mania (Smith, PSY 3, Monterey). In a report from Brazil, 13% of psychiatric emergencies were HIV patients (Tostes, SB397), mostly consisting of organic brain syndrome.
379
mother before the age of 18 years and a history of physical and sexual abuse (Rundell et al., SB362). Poor active coping and the use of avoidance or escape as coping mechanisms was associated with psychiatric disturbance in gay men with AIDS, both cross-sectionally and longitudinally (Reed et al., ThB25). Finally, death within 12 months of diagnosis was more likely to occur in blacks, those with no social supports and those experiencing increasing levels of distress (Redo et al., SB372).
Treatment Psychological interventions Cognitive-bchavioural treatment was found to be more effective than no treatment for individuals with HIV infection both by the end of treatment and at 6-month follow up (Garcia-Huete, SB396) and an 8-week educational/support group was found to be better than a wait group in terms of reduction in stress levels and an increase in active coping, but not in relation to the practice of safer sex (Moulton et al., SB400). There was also an intriguing report of the use of meditation and other stress management techniques, but the results were marred by poor methodology (Earl et al., ThB28).
Facms associated with psychiatric morbidity There was a fair amount of consistency both in cross-sectional and longitudinal studies in relation to factors likely to be associated with psychiatric disorder. For example, studies of depression in AIDS found that mood disturbance was more likely in women, the unemployed, those lacking in social support or those with high levels of physical symptoms (Fleishman et al., SB391), and in those black or hispanic origins, no social supports and declining neuropsychological performance (Schmidt et al., SB381). In early HIV infection, depression was found to be associated with the absence of social supports (Turner et al., SB380), while psychiatric disorder in asymptomatic gay men was associated with past psychiatric history, death of
Physical methods of treatment Not surprisingly, imipramine was found to be better than placebo for the treatment of depression in people with HIV infection (Manning et al., ThB32), and the findings from a 10-patient study were used to support a claim that Buspirone was better than placebo for the treatment of anxiety (Hirsch et al., SB395). There were anecdotal references to the use of psycho-stimulants (Ostrow, Monterey), and it was suggested that asymptomatic individuals responded better to anti-depressants than those with ARC/ AIDS (Peterkin et al., SB389), and there was a report about five patients whose depression improved after AZT,but no infor-
380
SAN FRANCISCO SU5hURIE.S: J. CATALAN &
mation was given about changes in the patients’ physical state as a result of treatment, and the likely contribution of such clinical improvement to changes in mood (Perkins et al., SB392).
Downloaded by [York University Libraries] at 03:55 27 December 2014
Therapist/patient issues A paper from Brazil asked the question of whether women with HIV infection, in particular those who had acquired it from a bisexual husband, would accept counselling by a male therapist (Carvalho-Net0 et al., SB403). About half of the women were prepared to be counselled by a male and a significant number refused to attend. The problems that gay therapists experience when dealing with gay men with HIV dlsease were discussed on the basis of mformation given by a small number of therapists (Cadwell, SB404) and a report on patients’ views about decision making and information in relation to their condition highlighted the need for further work in this area (Gerbert et uf., SB401).
Psychological interoentions and medical preaments This is a neglected area of research which deserved attention. One small study showed the value of identifying individuals who
M.RICCIO
either as a result of psychological problems or memory impairment are likely to have problems coping with self-treatment with foscarnet using a Hickman line. The report showed how identification and intensive educational and supportive interventions resulted in increased compliance and satisfaction with treatment (Williams et al., SB406). The importance of providing information and support to individuals participating in treatment trials before, during and after the trial was completed was highlighted in a descriptive report a package of techniques used to increase compliance (Bennett et al., SB408).
Conclusions While there is a move towards consensus in many of the descriptive studies of psychiatric morbidity in HIV disease, there are still areas of discrepancy, and there are significant gaps in our knowledge, for example as regards the prevalence of major psychiatric syndromes such as mania or schizophrenic like dlnesses, or the lack of good data for some transmission groups such as women and drug users. Much needs to be done in terms of treatment studies both psychological and physical, and also in relation to provision of services, their value and their cost-efficacy.
