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The Medical Director's Desk
Until the Crisis Is Over
Psychiatric News
Volume 39 Number 6 page 4-4
Anchor for JumpAnchor for JumpWe are facing a crisis. Now in the third decade of the AIDS pandemic, there is no end in sight. Since 1981 more than 28 million people have died of AIDS. Each day there are 14,000 new infections and 8,200 AIDS-related deaths. In the United States an estimated 850,000 to 950,000 people are living with HIV. Globally, a staggering 40 million people are infected with HIV, including 5 million individuals newly diagnosed in 2003 alone. The devastation caused by AIDS has surpassed even the most dismal predictions of the early 1980s.

No statistics, however alarming, can adequately convey the suffering and human trial these numbers represent. It is this knowledge that lies at the heart of APA’s response to the AIDS pandemic through the Office of HIV Psychiatry. We must do all we can to limit new infections and care for those infected by providing psychiatrists with the training, resources, and services needed to best respond to the challenges presented by AIDS and HIV infection—until the crisis is over.

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The involvement of psychiatrists in the diagnosis and treatment of AIDS and HIV infection is essential. Clinical experience and research provide substantial evidence that HIV directly infects the brain soon after initial infection, resulting in central nervous system impairment and neuropsychiatric disorders including HIV-1—associated dementia, minor cognitive-motor disorder, delirium, depression, and psychosis. Current antiretroviral treatments, while improving systemic health, show poor penetration into the brain, increasing the likelihood of cognitive-motor disorders. For those with pre-existing severe mental illness or significant substance abuse experience, the assessment of cognitive capacity is particularly complex.

Describing HIV as "a neuropsychiatric disease with systemic manifestations," Dr. Marshall Forstein, former chair of the APA Commission on AIDS, maintains that "HIV’s assault on the brain requires the participation of psychiatrists throughout the course of illness."

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Understanding psychiatrists’ unique role, APA established the Office of HIV Psychiatry. What began with a project steering committee and a single contract from the federal government has evolved into a mature, successful program. Its mission includes providing HIV-related training and education, developing curricula and clinical resources, ensuring appropriate psychiatric consultation, promoting collaboration with other specialties, ensuring adequate attention to the psychiatric and neuropsychiatric issues, and providing support to a network of psychiatrists and other mental health professionals working in the AIDS arena. Today this mission is achieved through the AIDS Education Project (AEP), APA Committee on AIDS, HIV Steering Committee of the American Psychiatric Institute for Research and Education (APIRE), APA staff, and collaboration with other medical and mental health specialty groups.

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Since 1987 the office, through funding from the Center for Mental Health Services (CMHS), has provided training and education to more than 26,000 psychiatrists, psychiatry residents, and mental health professionals. Trainings are based on a comprehensive curriculum whose topics range from central and peripheral nervous-system impairment to comorbidity and psychopharmacology.

Trainings are provided upon request at the local, regional, and national levels and are tailored to meet specific needs and interests of the participants. Training activities vary from one-hour grand-rounds lectures to full-day conferences and resident case discussions. Comprehensive training is also provided at APA’s two national conferences, the annual meeting and the Institute for Psychiatric Services.

The office also encourages the use of alternative training-delivery systems. For clinicians who prefer the convenience of self-paced learning, there are two online continuing medical education programs: "HIV and AIDS: An Overview for Psychiatric Physicians" and "Practice Guideline for the Treatment of Patients With HIV/AIDS." This year the office will initiate a distance-learning pilot program in rural and underserved areas. Funded through CMHS and dubbed iSite, the program will feature videoeducation, online discussions, and e-mail consultations.

The office takes pride in working with medical schools and psychiatry residency training programs to incorporate sufficient information and skill development on HIV into their curriculum. To date, the office has provided trainings to more than 1,600 residents at the request of training directors at more than 50 programs. This year, through CMHS funding, the office will also offer a minority medical student elective in HIV psychiatry. The program is designed to increase the number of racial and ethnic minorities entering HIV/AIDS clinical care and substance abuse services. This clinical rotation will provide intense training in HIV mental health, including neuropsychiatry.

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The office has just entered into a subcontract with Abt Associates to provide neuropsychiatric training to 21 community-based organizations engaged in meeting unmet mental health treatment needs of African-Americans, Hispanics/Latinos, and other racial and ethnic minorities. An APA curriculum developed to train nonphysicians to recognize psychiatric impairment in patients with HIV will provide the foundation for trainings.

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The office offers a variety of resources for those working in this field. Of particular interest is a nine-module curriculum detailing the neuropsychiatric dimensions of HIV infection. This curriculum includes discussion of the following: complications of the central nervous system, mood disorders, anxiety disorders, sleep disorders, pain syndromes, HIV among people with severe and persistent mental illness, substance use disorders, psychotic disorders, and drug interactions and toxicities.

Recognizing the need for psychiatrists to keep pace with current research and information, the office provides myriad resources:

• "Practice Guideline for the Treatment of Patients With HIV/AIDS" is a practical guide on the psychiatric management of patients with HIV/AIDS, representing a synthesis of current scientific knowledge and clinical practice.

• The Web site www.psych.org/AIDS offers a searchable resource database and access to guidelines, two CME programs, APA policy statements, fact sheets, and links to curricula and training information.

• Eight one-page summary sheets reflect the content of APA training modules.

Network Newsletter is a quarterly publication that lists funding sources and educational opportunities and provides information on recent research and clinical advances.

• "Neuropsychiatry and AIDS: The Impact of HIV on the Brain and Behavior" is a curriculum for nonmedical providers on the spectrum of cognitive and psychiatric disorders.

• Quick reference guides highlight prevalence, symptoms, diagnosis/differential, and treatment options for anxiety disorders, mood disorders, sleep disorders, pain syndromes, and substance use disorders.

• A number of position statements and guidelines are available on topics ranging from confidentiality and testing to inpatient and outpatient care to the management of neuropsychiatric impairment.

The office, whose annual budget is $278,844, is led by Director Carol Svoboda. She is assisted by Senior Project Manager Diane Pennessi and Training Manager Candice Peggs. Staff work collaboratively with the APA Committee on AIDS and the APIRE HIV Steering Committee. All programs are housed within APIRE and the APA Division of Research. Also essential to the overall structure and success of the office is the participation of a network of more than 500 psychiatrists, including 75 regional trainers committed to providing HIV/AIDS training to health and mental health care professionals across the country. Their time and commitment to resource development, training, and consultation are considered extremely valuable to the goals and objectives of the office.

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The goals of the Office of HIV Psychiatry have evolved over time to meet the changing needs and interests of the psychiatric community, as well as the demands presented by the epidemic. While much has been accomplished, much remains to be done. APA and the Office of HIV Psychiatry are well positioned and experienced in this arena and will continue to honor a commitment to quality HIV education and services for psychiatrists and quality care for all patients.

Feel free to e-mail your questions, comments, and suggestions to me at medicaldirector@psych.org.

Anchor for JumpAnchor for JumpWe are facing a crisis. Now in the third decade of the AIDS pandemic, there is no end in sight. Since 1981 more than 28 million people have died of AIDS. Each day there are 14,000 new infections and 8,200 AIDS-related deaths. In the United States an estimated 850,000 to 950,000 people are living with HIV. Globally, a staggering 40 million people are infected with HIV, including 5 million individuals newly diagnosed in 2003 alone. The devastation caused by AIDS has surpassed even the most dismal predictions of the early 1980s.

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