Mental Health and HIV/AIDS

Published on Psychiatric Times

(http://www.psychiatrictimes.com)

Mental Health and HIV/AIDS

January 20, 2016 | CME [1], Anxiety [2], Comorbidity In Psychiatry [3], Depression [4], Schizophrenia
[5], Substance Use Disorder [6]
By Michael B. Blank, PhD [7]

An overview of the interface between HIV/AIDS infection and mental illness.

Premiere Date: January 20, 2016

Expiration Date: July 20, 2017

This activity offers CE credits for:

1. Physicians (CME)
2. Other
ACTIVITY GOAL
This article provides an overview of the interface between HIV/AIDS infection and mental illness.
LEARNING OBJECTIVES
At the end of this CE activity, participants should be able to:
Delineate the prevalence of HIV/AIDS in person with mental illness
Identify the primary mental health comorbidities associated with HIV/AIDS
Explain the role of substance abuse in the symptom to infection pathway
Identify treatment interventions for persons with comorbid HIV/AIDS and mental illness
TARGET AUDIENCE
This continuing medical education activity is intended for psychiatrists, psychologists, primary care
physicians, physician assistants, nurse practitioners, and other health care professionals who seek to
improve their care for patients with mental health disorders.
CREDIT INFORMATION
CME Credit (Physicians): This activity has been planned and implemented in accordance with the
Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME)
through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is
accredited by the ACCME to provide continuing medical education for physicians.
CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit.
Physicians should claim only the credit commensurate with the extent of their participation in the
activity.
Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of
participation for educational activities certified for 1.5 AMA PRA Category 1 Credit.
DISCLOSURE DECLARATION
It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific
rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any
relationships with commercial companies whose products or devices may be mentioned in faculty
presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has
evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous
content validation procedure, use of evidence-based data/research, and a multidisciplinary
peer-review process.
The following information is for participant information only. It is not assumed that these
relationships will have a negative impact on the presentations.
Michael B. Blank, PhD, reports that he has received support from the National Institutes of Health
(NIH), National Institute of Mental Health, National Institute of Child Health and Human Development,
National Institute of Allergy and Infectious Diseases (NIAID), CDC, and the American Psychological
Association.
Karl Goodkin, MD, (peer/content reviewer) reports that he has received support from the NIH and
NIAID and that he is a consultant for the American Academy of Neurology and the American
Psychiatric Association.
Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.
UNLABELED USE DISCLOSURE
Faculty of this CME/CE activity may include discussion of products or devices that are not currently

Page 1 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the
audience if they will be discussing off-label or investigational uses (any uses not approved by the
FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any
product outside of the FDA-labeled indications. Medical professionals should not utilize the
procedures, products, or diagnosis techniques discussed during this activity without evaluation of
their patient for contraindications or dangers of use.
Questions about this activity?
Call us at 877.CME.PROS (877.263.7767)
Every clinician who treats people with HIV/AIDS recognizes that co-occurring affective disorders (eg,
major depression, bipolar disorder), substance abuse disorders, cognitive disorders, psychotic
disorders, and/or anxiety disorders are also part of the picture. Often these patients have been
excluded from randomized clinical trials for new drugs and other treatments. As a result, there has
been a missed opportunity to provide informed guidance to clinicians who treat patients with these
comorbidities.
Persons with mental illness are at increased risk for contracting and transmitting HIV. This increased
risk is thought to be due to high rates of substance use, including injection drug use; risky sexual
behavior; sexual victimization; and prostitution. A recent study found a 4-fold increase in HIV
infections among persons receiving mental health care in a variety of treatment settings in
Philadelphia and Baltimore.1 Individuals were tested for HIV in university-based inpatient psychiatric
units (n = 288), where 5.9% were HIV-positive; in assertive community treatment programs (n =
273), where 5.1% were HIV-positive; and in community mental health centers (n = 501), where 4.0%
were infected. HIV infection was associated with being African American, gay, or bisexual; with
having hepatitis C virus co-infection; and with psychiatric symptom severity. The study suggests
routine HIV testing in all inpatient and outpatient mental health treatment settings.
When mental illness markedly compromises adherence to HIV treatment regimens, public health is
threatened: community viral load is increased, and treatment-resistant virus strains can develop.
The person with mental illness may therefore serve as a vector of HIV transmission. There is a
pressing need for improved continuity of care by detecting infections early, increasing access to HIV
treatment, and reinforcing treatment adherence so that people can maintain undetectable viral
loads.
Today, adverse outcomes from HIV infection are far from inevitable. People with mental illness and
HIV infection who receive good quality health care can achieve adherence rates comparable to those
in others. In fact, there is evidence that with appropriate supports, these patients can adhere to
treatment and may be less likely to discontinue antiretroviral therapy (ART).
Estimated prevalence
Risk factors associated with HIV infection among persons with mental illnesses mirror those in the
general population and include unprotected sex and injection drug use. The estimated prevalence of
HIV infection in patients with serious mental illness during the 1990s and early 2000s ranged from
1% to 23%.2,3 Prevalence estimates from these studies varied tremendously because of
methodological differences in sampling, particularly the reliance on convenience samples of high-risk
individuals in institutions or geographically restricted areas. Small sample sizes also compromised
these estimates.
An analysis of claims linked to the New Jersey HIV/AIDS registry showed that 5.7% of patients with
schizophrenia also had HIV infection.4 In another study, patients with schizophrenia spectrum
disorder were 1.5 times as likely to have HIV infection, and those with major affective disorder were
3.8 times as likely.5 Administrative medical records from a national sample from the Veterans
Administration (VA) also point to elevated rates of HIV infection in severely mentally ill patients.6
Estimates based on true epidemiological samples are rare. Perhaps because of shortcomings in
existing detection systems, these estimates are often limited in their ability to shed light on people
with more severe psychotic illnesses. A recent study using the National Epidemiologic Survey on
Alcohol and Related Conditions reported that men with HIV infection were significantly more likely to
have a range of diagnoses, compared with their HIV-negative counterparts.7 The prevalence of
12-month psychiatric disorders was stratified by gender to examine the increase in risk of a
psychiatric disorder as a function of the interaction between gender and HIV status. HIV-positive men
were more likely to have a mood disorder, MDD/dysthymia, any anxiety disorder, and a personality
disorder than men who did not have HIV infection. The same comparisons were not significant in
women.
The prevalence of HIV infection with comorbid psychiatric disorders may be underestimated because
of the likelihood that not all HIV diagnoses are captured. Those that are may not be reliably linked to

Page 2 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
confirmed HIV-positive tests within administrative databases. When a more direct case
ascertainment strategy was used, HIV infection was observed in 10.1% of patients.3 These findings
indicate some serious shortcomings in patient care, which suggests that persons with mental illness
are likely underserved with regard to identification of HIV.
A lack of treatment guidelines
Relatively few guidelines have been developed for clinicians who treat persons with HIV infection and
mental illness. These guidelines are listed in Table 1. Note that the 2000 and 2010 guidelines from
the American Psychiatric Association may already be outdated.8,9
A web-based survey of members from the Organization of AIDS Psychiatry sought to identify
common use of psychopharmacology.10 With a response rate of only 39% (n = 69), the findings
should be interpreted with caution, but treatment trends were observed: first-line treatment for
depression: escitalopram/citalopram; for psychosis and secondary mania: quetiapine; and for
anxiety: clonazepam.
A national survey of members of the American Academy of HIV Medicine focused on the initiation of
ART for patients with comorbid HIV infection and schizophrenia.11 The results showed that clinicians
recognized the importance of recommending ART to patients as well as avoiding antiretroviral
medications with known neuropsychiatric adverse effects. Such studies have led to an effort to
develop biopsychosocial curricular components of residency training for psychiatrists.12
Major depression and affective disorders
Depression and other affective disorders are common comorbidities of all chronic illnesses including
HIV infection, and they provide particular clinical challenges. They often interfere with adherence to
ART as well as with other aspects of self-care, virologic and immunologic outcomes, and quality of
life.
Depression is the most common psychiatric comorbidity with HIV infection.13 A meta-analysis was
undertaken to evaluate the relationship between depression and HIV medication adherence to
determine the overall effect size and to examine potential methodological and measurement
moderators.14 Depression was significantly associated with nonadherence; larger effects were found
for studies that collected data via interviews versus self-administered questionnaires.14 Larger effect
sizes were also found when depression was considered along a continuum of severity rather than as
a dichotomous variable. No differences in effect sizes were found for cross-sectional versus
longitudinal studies. Assessment for depression, even at subclinical levels, as well as treatments for
depression should be included in all HIV behavioral interventions. Table 2 lists common treatments
for depression in people with HIV infection.
The estimated prevalence of MDD among patients with HIV/AIDS ranges from 20% to 37%more
than 3 times the rate in the general population.13 Like other chronic and life-threatening illnesses,
HIV/AIDS can be stressful to manage, and people who live with this infection are particularly
vulnerable to depression and other affective disorders. The life-threatening nature of HIV infection
itself may instigate fears of impending mortality. Moreover, the medical sequelae of HIV infection
such as HIV-associated neurocognitive disorders, associated opportunistic infections, and the
adverse effects of ART can mimic symptoms of depression (ie, fatigue, problems concentrating,
somatic symptoms, decreased appetite/weight loss).
From a cognitive-behavioral perspective, these physical symptoms can be part of a cycle of
continued depression. Other factors that might account for the high level of depression and other
affective disorders are unique to HIV. Specifically, people with HIV/AIDS disproportionately belong to
socially disadvantaged and marginalized populations who are already at risk for depression because
of their racial, ethnic, or sexual minority status, poverty, current or prior substance use, sex work,
and/or trauma.
Depression rates do not appear to decline with age in HIV-positive populations as they do in the
general population. This is important because as many as one-quarter of all US adults who are
HIV-positive are now aged 50 years or older. As people live longer as a result of medical advances,
depression in a gradually aging HIV cohort will remain an issue that needs to be addressed clinically
and accounted for in HIV research. While there is evidence that the presence of severe psychiatric
illness can negatively affect HIV careparticularly medication adherencestudies also underline the
importance of individualized assessment and the potential positive impact of good psychiatric and
substance abuse care.
Carrico and colleagues15 used a mobile outreach van to recruit a probability sample of homeless and
unstably housed men. Those who tested positive for HIV were screened for mental illnesses.
Participants receiving ART were compared with those eligible for ART but not receiving it. Mental
health treatment in the past 90 days significantly increased the likelihood of receiving ART. No

Page 3 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
significant impact on the odds of receiving ART was found for a current mental illness, but among
those taking ART, mental illness was associated with a 6 times higher viral load. The authors
concluded that providing psychiatric treatment to impoverished HIV-infected people could help
optimize health outcomes.
Psychotherapeutic interventions may be well suited to address the psychosocial difficulties as well as
the distress associated with HIV. Of note, telephone-based cognitive behavioral therapy (CBT) has
emerged as a feasible, acceptable, and effective treatment for major depression. Himelhoch and
colleagues16 developed a manualized telephone-based CBT intervention and compared it with
face-to-face therapy among 34 low-income, urban-dwelling patients with HIV/AIDS. The primary
outcome was reduced depression; medication adherence was the secondary outcome. No
differences were found for reductions in depressive symptoms; however, better treatment adherence
was seen in the telephone-based CBT group. This study suggests that telephone-based CBT may be
an alternative to standard treatment.
A Brazilian study found a high incidence of bipolar disorder in patients with HIV/AIDS.17 Adults with
HIV infection were assessed using the Mood Disorder Questionnaire: 13.2% (n = 26) of study
participants screened positive for bipolar disorder, and the diagnosis was confirmed in 8.1% (n =
16). This represents almost a 4-fold higher prevalence than in the general population. Factors
associated with bipolar diagnoses were sex with commercial sex workers, sex outside a primary
relationship, alcohol use disorders, and illicit drug use. Not surprisingly, the most common
psychiatric comorbidity among persons with bipolar disorder was substance abuse (61.5%).
A US study examined HIV transmission risk behavior among 63 people with HIV/AIDS comorbid with
bipolar disorder, MDD, or no mood disorder; half also had a substance use disorder.18 Participants
who had HIV/AIDS and bipolar disorder were more likely to report unprotected intercourse with
HIV-negative partners and poorer adherence to ART. In multivariate models, bipolar disorder and
substance-use disorder were independent predictors of both risk behaviors. Patients with bipolar
disorder need to be carefully evaluated and referred to HIV prevention services to reduce HIV
transmission risk behaviors.
Anxiety disorders
As many as 16% to 36% of persons with HIV infection have anxiety disorders.19 The HIV Cost and
Services Utilization Study showed that 16% of HIV-infected individuals met criteria for generalized
anxiety disorder and that 10.5% met criteria for panic attacks.20 Adjustment disorder with anxious
mood was the most common, followed by generalized anxiety disorder and panic disorder; anxiety
disorders are also a common comorbidity with depression. Although SSRIs are effective for anxiety
disorders, Vitiello and colleagues21 found that 63% of the medications prescribed for anxiety among
HIV-infected individuals were benzodiazepines. That finding is of some concern because of the high
rates of substance abuse among HIV-infected persons and the potential for abuse of
benzodiazepines. Approaches to the treatment of anxiety comorbid with HIV infection are listed in
Table 3.
Among persons who are HIV-positive, the rate of lifetime PTSD and the incidence of HIV-related PTSD
were estimated to be 54% and 40%, respectively.22 However, these estimates should be interpreted
with caution, since they are based on only 85 patients with recently diagnosed HIV infection who
participated in a cross-sectional study of lifetime rates of PTSD and HIV-related PTSD. Although there
seems to be a high co-occurrence of PTSD and its harmful effects in HIV-infected individuals, there is
relatively little research on treating PTSD in this population. Prolonged exposure therapy is a
well-supported psychotherapeutic treatment for PTSD and has demonstrated efficacy in a wide range
of trauma populations. More research, however, is needed to see if it is effective in treating PTSD
comorbid with HIV/AIDS.
Schizophrenia
HIV risk is complex in schizophrenia, in which the onset of the illness is typically in late adolescence
and early adulthood in both men and womenduring the same developmental period in which
sexuality and sexual behaviors typically increase in importance and frequency. This dynamic
combined with the increased vulnerability to abuse and exploitation of persons with schizophrenia
spectrum disorder makes these persons particularly susceptible to contracting and transmitting HIV
and other infectious diseases.
Antipsychotics are standard treatment for psychotic symptoms in people with HIV/AIDS. The
atypicals are more effective and have fewer extrapyramidal effects than traditional antipsychotic
medications, such as haloperidol or thioridazine. However, many of the atypical antipsychotics are
associated with an increased risk of obesity and metabolic syndrome that can potentially lead to
cardiovascular disease and diabetes. This situation is aggravated by the fact that ART has also been

Page 4 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
linked to an increased risk of metabolic syndrome. It may be advisable to use typical antipsychotic
agents for people who are on ART. Specific, evidence-based treatment guidelines are needed, based
on biological and behavioral studies of the treatment of schizophrenia spectrum disorders among
individuals also in treatment for HIV/AIDS, to improve psychiatric, behavioral, and medical outcomes.
Table 4 lists common treatments for comorbid schizophrenia and HIV.
Substance abuse
The interaction between symptoms of mental illness, substance abuse, and HIV risk behaviors is
complex and recursive. The symptom to infection pathway needs to be understood in the context of
multiple environmental and behavioral factors. As with any life-threatening chronic illness, an HIV
diagnosis often brings depression and anxiety with it. Furthermore, the virus itself has direct
neurotoxic effects that can result in HIV-associated neurocognitive disordera complex syndrome
characterized by a wide variety of neurological and performance deficits.
The severity of mental illness symptoms has been associated with a higher risk of HIV infection. In
one study, baseline data on 228 HIV-positive and 281 HIV-negative participants from 2 clinical trials
were used.23 Years to HIV diagnosis served as the primary endpoint. A Colorado Symptom Index (CSI)
score of at least 30 was associated with a 47% increased risk of HIV infection (P < .01). This study
established a basis for using CSI scores to identify a vulnerable subgroup within the community of
persons with serious mental illness. Further studies might develop effective approaches to mitigate
psychiatric symptoms in order to examine the impact on HIV-transmission risky behaviors. It seems
probable that effective mental health treatment and substance abuse treatment will be effective HIV
prevention.
There is compelling evidence that substance abuse profoundly raises the risk of HIV infection in
people with mental illness. In a large sample of patients with schizophrenia spectrum disorders
treated through the VA system, Himelhoch and colleagues6 found that schizophrenia and comorbid
substance abuse markedly increased the risk of HIV infection. In the absence of substance use,
persons with schizophrenia were at lower risk for HIV infection than the general VA population.
Prince and colleagues24 had similar results. Using Medicaid claims, the researchers examined new
HIV diagnoses among patients with serious mental illness. Logistic regression and Cox regression
revealed that 24% of persons with a mood disorder were hospitalized, and 24% of that group were
re-hospitalized within a 3-month period. Comorbid substance abuse accounted for 36% of the initial
hospitalizations and 50% of readmissions. These results suggest that comorbid HIV infection, mental
illness, and substance abuse should be treated within a multidisciplinary partnership that includes
mental health, infectious disease, and substance abuse professionals.
The findings from Cournos and colleagues25 suggest that a mental illness diagnosis in the absence of
a substance abuse diagnosis is not highly associated with increased risk of HIV/AIDS. Substance
abuse and symptoms of mental illness are relapsing and remitting. Therefore, relying on the
presence or absence of one or another diagnosis at a given point fails to take a lifespan
developmental view of mental illness and substance abuse.
Medication monitoring and drug-drug interactions
When prescribing psychotropic medication in the context of ART, it is important to monitor for
untoward adverse effects, as well as to consider possible drug-drug interactions. For example,
atypical antipsychotics increase the risk of metabolic syndrome, including weight gain,
hyperglycemia, and hyperlipidemia. Similar symptoms associated with the metabolic syndrome are
also associated with treatment with antiretroviral medications. Monitoring of weight, fasting blood
glucose, and lipid profiles is integral to treatment for people who take any of these medications. Any
drug-drug interactions between antiretroviral medications and psychotropic medications need to be
identified. For example, specific benzodiazepines may be contraindicated when taken with protease
inhibitors, and care must be taken when prescribing methadone in the presence of specific
non-nucleoside reverse-transcriptase inhibitors. A careful history about the use of over-the-counter
medications and herbal remedies is also recommended. In particular, St Johns wort may be
contraindicated when used in conjunction with ART.
Tailored treatment and nurse health navigators
Preventing AIDS Through Health for HIV Positive (PATH+) persons was a regimen management
intervention study for persons who also had a serious mental illness.26 An adaptive treatment design
implemented through an intervention cascade was used to gear the intensity (and expense) of the
intervention to adherence. A nurse health navigator (NHN) provided in-home consultations and
coordinated medical and mental health services for 1 year. The protocol included a meeting with the
patient at least once a week. Participants in the intervention group received psycho-education along
with pillboxes and beeping watches. In addition, the NHN coordinated physician and other

Page 5 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
appointments for the patient and would accompany the patient if there was a problem with a
medication, communication, or other issues that needed attention.
Adherence to HIV and psychiatric medications was calculated weekly. If adherence fell below 80%,
the intervention cascade was implemented until adherence was maintained equal to or above 80%
for 3 weeks. The intervention cascade represented a gradual increase in intensity and included
activation of social networks, the use of reminder beepers with alphanumeric displays, and prepaid
cellular phones to encourage participants to follow their regimen. If all else failed, the final step in
the intervention cascade was directly observed therapy.
A total of 238 community-dwelling, HIV-positive patients with a serious mental illness were enrolled
in the study. The main outcome measures were viral load and CD4 count. Assessments were
conducted at baseline and at 3, 6, 12, and 24 months. Participants were followed for 12 months after
the intervention ended in order to examine any recidivism. The results of the PATH+ study showed
that with appropriate support, persons with a mental illness and HIV infection can successfully
adhere to treatment and achieve improvements in health-related quality of life and biomarker health
status indicators.
Conclusion
This article provides a brief overview of the interface between HIV infection and mental illness. The
interested reader can peruse the cited references and a growing literature as well as the practice
guidelines for additional information.
Other complexities involving HIV care and mental health include HIV-associated neurocognitive
disorders that are increasingly recognized in clinical practice, but which are beyond the scope of this
article. Treatment of HIV infection has come a long way since the epidemic first emerged, and
thankfully the infection is rapidly becoming a manageable chronic illness. As with other chronic
illnesses, HIV infection has specific psychiatric sequelae that are coming into sharper focus.
We still have a long way to go in terms of treatment options, updated guidelines, and tailored health
services. Screening for depression and anxiety should occur at each infectious disease visit, and
consultation and referral to specialty mental health providers should be seamless. The public health
response to HIV infection and AIDS may be the finest example of the triumph of science and
medicine over disease. In less than 4 decades we have managed to shift HIV infection from a disease
of unknown origin that resulted in rapid decline and death, to a manageable chronic illness for which
inoculation and cure are being sought.
There are successes to draw on, and perhaps nowhere have the positive impact and
cost-effectiveness of prevention been so thoroughly demonstrated and accepted as in science-based
HIV programs. The focus now needs to be on the co-occurrence of mental illness and HIV infection,
along with the need to increase attention to the mental health risk and needs of HIV-positive
persons.
CME POST-TEST
Post-tests, credit request forms, and activity evaluations must be completed online at
www.cmeoutfitters.com/PT (requires free account activation), and participants can print their
certificate or statement of credit immediately (80% pass rate required). This Web site supports all
browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy,
visit www.neurosciencecme.com/technical.asp.
PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE
MONTH OF ACTIVITY ISSUE AND FOR A YEAR AFTER.

Need Additional CME Credit?

Check Out These CME Activities Hurry, Some Expire Soon!
A Practical Update on Neuroimaging for Psychiatric Disorders
by Robin A. Hurley, MD, FANPA, Shiv Patel, MD, DABR, and Katherine Taber, PhD, FANPA
Expiration date: February 20, 2016.
http://www.psychiatrictimes.com/cme/practical-update-neuroimaging-psychi...

Clinical Issues and Strategies Associated With Smoking Cessation

by Stephen E. Hall, MD and Judith J. Prochaska, PhD, MPH
Expiration date: March 20, 2016.
http://www.psychiatrictimes.com/cme/clinical-issues-and-strategies-assoc...

Tips, Cautions, and Successes in Treating Bipolar Patients With Lithium

by Ralph J. Koek, MD

Page 6 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
Expiration date: April 20, 2016.
http://www.psychiatrictimes.com/cme/tips-cautions-and-successes-treating...

Table 2 Sample treatment options for

depression

Table 1 Treatment guidelines for people with

HIV/AIDS

Table 3 Sample treatment options for anxiety Table 4 Sample treatments for schizophrenia
Disclosures:
Associate Professor of Psychology, Department of Psychiatry, Perelman School of Medicine,
University of Pennsylvania, Philadelphia

References:
1. Blank MB, Himelhoch SS, Balaji AB, et al. A multisite study of the prevalence of HIV using rapid
testing in mental health settings. Am J Pub Health. 2014;104:2377-2384.

2. Susser E, Valencia E, Conover S. Prevalence of HIV infection among psychiatric patients in a New
York City mens shelter. Am J Pub Health. 1993;83:568-570.

3. Rothbard AB, Blank MB, Staab JP, et al. Previously undetected metabolic syndromes and infectious
diseases among psychiatric inpatients. Psychiatr Serv. 2009;60:534-537.

4. Kessler RC, Birnbaum H, Demler O, et al. Prevalence and correlates of nonaffective psychosis:
results from NCS-R. Biol Psychiatry. 2005;57:108S-109S.

5. Blank MB, Mandell DS, Aiken L, Hadley TR. Co-occurrence of HIV and serious mental illness among
Medicaid recipients. Psychiatr Serv. 2002;53:868-873.

6. Himelhoch S, McCarthy JF, Ganoczy D, et al. Understanding associations between serious mental
illness and HIV among patients in the VA health system. Psychiatr Serv. 2007;58:1165-1172.

Page 7 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
7. Lopes M, Olfson M, Rabkin J, et al. Gender, HIV status, and psychiatric disorders: results from the
National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry.
2012;73:384-391.

8. McDaniel JS, Brown L, Cournos F, et al. Practice guideline for the treatment of patients with
HIV/AIDS; 2000.
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/hivaids.pdf.
Accessed November 23, 2015.

9. Forstein M, Cournos F, Douaihy A, et al. Guideline watch: practice guideline for the treatment of
patients with HIV/AIDS; 2010.
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/hivaids-watch.pdf.
Accessed November 23, 2015.

10. Freudenreich O, Goforth HW, Cozza KL, et al. Psychiatric treatment of persons with HIV/AIDS: an
HIV-psychiatry consensus survey of current practices. Psychosomatics. 2010;51:480-488.

11. Himelhoch S, Powe NR, Breakey W, Gebo KA. Schizophrenia, AIDS and the decision to prescribe
HAART: results of a national survey of HIV clinicians. J Prev Interv Commun. 2007;33:109-120.

12. Cohen MA, Forstein M. A biopsychosocial approach to HIV/AIDS education for psychiatry
residents. Acad Psychiatry. 2012;36:479-486.

13. Simoni JM, Safren SA, Manhart LE, et al. Challenges in addressing depression in HIV research:
assessment, cultural context, and methods. AIDS Behav. 2011;15:376-388.

14. Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment
nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011;58:181-187.

15. Carrico AW, Bangsberg DR, Weiser SD, et al. Psychiatric correlates of HAART utilization and viral
load among HIV-positive impoverished persons. AIDS (London). 2011;25:1113-1118.

16. Himelhoch S, Medoff D, Maxfield J, et al. Telephone-based cognitive behavioral therapy targeting
major depression among urban dwelling, low income people living with HIV/AIDS: results of a
randomized controlled trial. AIDS Behav. 2013;17:2756-2764.

17. de Sousa GW, da Silva Carneiro AH, Barreto Rebouas D, et al. Prevalence of bipolar disorder in
a HIV-infected outpatient population. AIDS Care. 2013;25:1499-1503.

18. Meade CS, Bevilacqua LA, Key MD. Bipolar disorder is associated with HIV transmission risk
behavior among patients in treatment for HIV. AIDS Behav. 2012;16:2267-2271.

19. Chander G, Himelhoch S, Moore RD. Substance abuse and psychiatric disorders in HIV-positive
patients. Drugs. 2006;66:769-789.

20. Tsao JC, Dobalian A, Moreau C, Dobalian K. Stability of anxiety and depression in a national
sample of adults with human immunodeficiency virus. J Nerv Ment Dis. 2004;192:111-118.

21. Vitiello B, Burnam MA, Bing EG, et al. Use of psychotropic medications among HIV-infected
patients in the United States. Am J Psychiatry. 2003;160:547-554.

22. Martin L, Kagee A. Lifetime and HIV-related PTSD among persons recently diagnosed with HIV.
AIDS Behav. 2011;15:125-131.

23. Wu ES, Rothbard A, Blank MB. Using psychiatric symptomatology to assess risk for HIV infection
in individuals with severe mental illness. Community Ment Health J. 2011;47:672-678.

24. Prince JD, Walkup J, Akincigil A, et al. Serious mental illness and risk of new HIV/AIDS diagnoses:
an analysis of Medicaid beneficiaries in eight states. Psychiatr Serv. 2012;63:1032-1038.

Page 8 of 9
 Mental Health and HIV/AIDS
Published on Psychiatric Times
(http://www.psychiatrictimes.com)

25. Cournos F, Guimares MD, Wainberg ML. HIV/AIDS and serious mental illness: a risky conclusion.
Psychiatr Serv. 2012;63:1261-1262.

26. Hanrahan NP, Wu E, Kelly D, et al. Randomized clinical trial of the effectiveness of a home-based
advanced practice psychiatric nurse intervention: outcomes for individuals with serious mental
illness and HIV. Nurs Res Pract. 2011. http://www.hindawi.com/journals/nrp/2011/840248/. Accessed
November 23, 2015.

Source URL: http://www.psychiatrictimes.com/cme/mental-health-and-hivaids

Links:
[1] http://www.psychiatrictimes.com/cme
[2] http://www.psychiatrictimes.com/anxiety
[3] http://www.psychiatrictimes.com/comorbidity-psychiatry
[4] http://www.psychiatrictimes.com/depression
[5] http://www.psychiatrictimes.com/schizophrenia
[6] http://www.psychiatrictimes.com/substance-use-disorder
[7] http://www.psychiatrictimes.com/authors/michael-b-blank-phd

Page 9 of 9