The Neuropsychiatric Symptoms of AIDS

To the Editor: As the director of a medical psychiatry unit, I have faced a common clinical problem in patients who have been diagnosed with AIDS that is complicated by neuropsychiatric symptoms. Patients with AIDS have been shown to benefit from the use of antiviral agents. Unfortunately, if they have variable compliance, they may develop resistant strains of the HIV virus, which complicate their treatment and have the potential to be introduced into the population. Therefore, it is common practice to discontinue treatment with antiviral agents for patients who are noncompliant (1–4).

Patients with AIDS suffer from a wide array of neuropsychiatric symptoms that can include depression, psychosis, anxiety, and cognitive impairment. Over the course of the illness, these develop in a majority of patients to varying degrees. They can contribute to noncompliance unless they are diagnosed and treated aggressively. I have treated a significant number of patients who trace their noncompliance to psychiatric symptoms as opposed to the typical side effects of antiviral agents.

Our institution’s infectious disease service is often hesitant to initiate antiviral therapy in patients with current or past psychiatric symptoms for fear of noncompliance. This is clearly a circular argument, because if the disease is allowed to progress, patients are more likely to have cognitive impairment or psychiatric symptoms that will impair their compliance. We are often aware that psychiatric patients are given less than optimal care because of stereotypes and the discomfort they elicit in health care providers. Our institution has tried to educate our medical colleagues about this conundrum; yet, this has yielded no significant changes in standard practice (5–7).

We are making clear advances in treating psychiatric syndromes in patients with chronic medical and neurological illnesses. The situation is similar to the one I experienced over the last 15 years in regard to basal ganglia disease, stroke, dementia, and demyelinating illness. We did not recognize or treat the psychiatric comorbidity in these conditions. Currently, there is a wide appreciation for depression, psychosis, and anxiety in these conditions, and they are aggressively treated. It is incumbent on individual psychiatrists and the psychiatric community to educate our colleagues in this area. It is a sad commentary that patients who already have so much going against them may be deprived of life-prolonging treatment because of a lack of awareness of the psychiatric complications of their illness. It is hoped that in 10 years or less we will be able to see the same appreciation of the psychiatric comorbidity of AIDS. With this may come the effective treatment of psychiatric comorbidity and improved compliance with antiviral therapy, with prolonged life expectancy.