IX: PSYCHIATRIC ISSUES
Joyce Kobayashi, MD

I. OVERVIEW

The experience of being a woman who is HIV-positive must be examined from several perspectives: 1) from the perspective of the individual seropositive woman as she makes the journey through the common emotional milestones of HIV; 2) from the perspective of women as a group, because women, in contrast to men, tend to cope with HIV within the context of the relationships that are most important to their self-definition; and 3) from the perspective of the contemporary context of most HIV-positive women who are, on average, African American and Hispanic women living and needing to survive in poverty, in the midst of drugs and commonly with personal experiences of childhood sexual abuse or adult victimization through sexual or physical assault.

     The experience of the woman living with HIV may be affected by the emotional dynamics described by any or all of these three perspectives. The health care provider who is mindful of all three may be able to provide care with deeper understanding and more precise appreciation of her daily struggles with this disease.

     Even the asymptomatic phase of being seropositive should be managed and understood in these psychological dimensions. In fact, the experience of the asymptomatic phase of HIV is entirely emotional and psychological, rather than a disease characterized by physical symptoms. It can be an intense experience ranging from individual fears of stigma and suffering, to common concerns about rejection and abandonment by a partner, to a deep feeling about HIV as further victimization in the context of daily concerns about survival.

     Interventions by the health care provider during normal adjustment phases and common emotional transitions include skilled emotional support, education, and empathy, while maintaining awareness of the provider’s own reactions to the HIV-positive woman, her experiences, and her ways of coping.

     Accurate assessment might also indicate the need for referral to a substance treatment program or psychiatric evaluation, in addition to referral to programs of social support, housing, case management, and concrete services, depending on the needs of the individual. Care providers who focus on medication adherence without a comprehensive treatment plan addressing harm reduction and treatment for illicit drug use, psychiatric treatment for comorbid psychiatric conditions, and a full range of support services are likely to fail, leaving the HIV-positive woman with the feeling that her real sources of pain and suffering have been left unrecognized.

     When normal adjustment issues give way to formal psychiatric disorders, accurate diagnosis is essential, as are knowledge of appropriate treatment and awareness of potential drug-drug interactions, complemented by thorough assessment of suicide risk.

     This chapter will address this range of psychiatric issues relating to HIV disease in women and will make specific recommendations for provider and program response, evaluation, and management.

II. THREE PERSPECTIVES ON BEING A WOMAN WITH HIV

Emotional adjustment after learning that one is HIV-positive, coping with the demands of being HIV-positive in daily function, and becoming a patient for HIV care commonly follow a natural course of progression through stages. The milestones marking the transition from one stage to another are often powerful emotional experiences and should be understood as important opportunities for clinical intervention (see Table 9-1). Knowledge of these milestones will enable the health care provider to provide appropriate emotional support, education, and empathy.

     Reproductive decision making has not been included in Table 9-1 because discussion of this complex decision must be individually tailored to the current circumstances, both social and clinical, of the particular woman considering the variety of options now available. The decision to become pregnant is an important and emotional one and the health care provider should be ready to explore a variety of feelings with the patient within the emotionally intensified circumstances of seropositivity without a sense of pressure, before launching into current percentage rates of vertical transmission. (See Chapter VII on HIV and Reproduction.)

Contemporary psychiatric research on the developmental psychology of women suggests fundamental differences in the way women and men think about themselves (Gilligan, 1990), with significant implications for clinical practice. Although it may be speculative as to whether these differences are more evolutionary and transcultural or locally socialized and economic, an understanding of this perspective is likely to amplify sensitivity in working with HIV-seropositive women, whatever their ethnicity or racial background.

     While acknowledging that any generalization about gender is often wrong in the individual case, two overarching propositions derived from this research may help health care providers understand the ways HIV-positive women often differ from men in their adjustment to being seropositive or having AIDS. First, women more frequently define themselves in the context of their relationships to others. Second, whereas men may fear intimacy, women more often fear separation (Surrey, 1982).

     For example, it is not uncommon to hear HIV-positive men express fears about becoming dependent on others in the course of their illness, whereas HIV-positive women often tend to worry more about those who are dependent on them as their illness progresses. Of course, everyone fears being abandoned and left alone when they are dying. Although these differences may sound simple or obvious, in clinical practice the differences are striking.

     Men often lose self esteem if they are not able to continue working, or feel anger and may wish to distance themselves from others whom they feel obligated to support, whereas women more frequently lose self esteem if they are unable to continue taking care of others. Many HIV-positive women are single mothers and feel deep shame if they are unable to take care of their children or provide for them as they feel they should.

     Women may also accept being the target of anger or even abuse, or suppress their own anger, in order to avoid finding themselves alone. They may be more likely to end up in an abusive relationship if they have been abused in their childhood (see section C).

     There are subtleties in these differences that can guide the care provider in recognizing the adaptive and maladaptive aspects of these concerns for their female patients, and should inform their clinical approaches to seropositive women as they struggle with emotional adjustment to the vicissitudes of HIV-related illness.

     On the positive side, women who are coping with HIV/AIDS may be motivated to take care of others to the extent that they undertake major changes in their own behavior, such as giving up longstanding drug dependencies during pregnancy, or engaging in discussions about permanency planning that frighten them or that they would rather avoid. Other HIV-positive women may take on the responsibility of bringing their children or partners into medical care despite great distance or significant barriers (including their own fatigue or ill health). They may also demonstrate remarkable resourcefulness in seeking out additional avenues of support for others.

     The clinician who understands that the strength of this motivation often derives from a deeper level of self-definition and not simply a conventional wish to “do good” will realize the importance of pausing to show respect for the degree of caring the woman demonstrates in making this effort. These are clinical opportunities to build trust and strengthen an alliance around common concerns.

     The maladaptive side of similar situations for an HIV-positive woman may include starting or continuing to use drugs simply out of fear of losing a substance-using partner, staying in a dysfunctional or even abusive relationship because of anxiety about the loss of the relationship, feeling guilty about taking time away from responsibilities for others to address her own needs, or simply not being able to self-motivate and establish good self-care independently when “no one” will benefit from these efforts except herself.

     Women who have lived in poverty or have in multiple additional ways experienced powerlessness about their lives are even less convinced about self-efficacy or, at a deeper level, that they are “worth it.” Astute care providers understand that affirming or even “giving permission” for the seropositive woman to attend to her own needs may over time be more important than instructions about what specific health behaviors to follow. In certain circumstances, such as in negotiating safe sex with an unreceptive partner, the provider may even be more directive, without implying criticism about past behaviors, and encourage a woman to develop the necessary skills to be more assertive about her own health concerns.

     The practitioner who is able to establish a trusting relationship with the patient should also learn to feel comfortable with the fact that the strength of their relationship may help motivate the HIV-positive woman as much as lectures about viral load. Another provider may convey frustration or disappointment about a patient’s nonadherence to medication or some other medical recommendation, only to find that the patient does not return because she has personalized this as a rejection within the context of their relationship.

     The woman with AIDS who may feel guilty about taking any time for herself will feel much more supported by a health care provider who first acknowledges the importance of her concerns for taking care of others and then builds on that concern by gently reminding her she will not be able to continue unless she takes care of her own health first. This is most effectively done within the context of a relationship where the seropositive woman has felt her values have been respected, and where sufficient trust has been established that maladaptive behavior may be confronted by the provider, and yet be experienced as caring and supportive, rather than as rejection or criticism by the patient.

POVERTY

“The majority of women with AIDS in the United States are unemployed, and 83% live in households with incomes less than $10,000 per year. Only 14% are currently married, compared to 50% of all women in the United States, aged 15–44 years. Twenty-three (23%) of HIV-infected women live alone, 2% live in various facilities, and 1% are homeless. Approximately 50% have at least one child less than the age of 15 years. Similar to other population groups with AIDS in the United States, the majority of women with AIDS are from minority racial and ethnic groups, with African Americans comprising 57% of women with AIDS in the U.S., Latinas comprising 20% and Caucasians comprising 23%” (Barkan, 1998).

     The clinician should be as mindful of the devastating impact of poverty and intermittent homelessness on the person and personality, as of the physical sequelae of HIV. For many women who are working the streets, are constantly on the move in transient residences, or are feeling overwhelmed by the needs of their children, illicit drugs are sometimes the most available antidote. It is hard to make the medical treatment needs for HIV relevant unless the woman feels her provider recognizes and has some understanding of her daily struggles for survival. There are many concrete services such as transportation, child care, food programs, and housing that can increase the ability of these HIV-positive women to participate in their health care, amplified by the knowledge that their treatment team wants to address all issues fundamental to her survival and longevity.

     In the book Women, Poverty and AIDS (Farmer, 1996), which contains a comprehensive discussion of these issues, Shayne and Kaplan state that “safe sex is an economic compromise for many poor women who rely on sex as a source of employment, as a means to establish ownership or proprietary rights in relationships, or as a means of getting tangible supports, generally short in supply” (Shayne, 1991).

     Most women with AIDS in the United States are unemployed minority women living in poverty, often as single mothers, and frequently without easy access to medical care. Poverty and the related experiences of racism, sexism, and stigmatization are the predominant themes in their lives. This may leave these women with the feeling that their medical teams are simply adding to their burdens by admonishing them to adhere to complicated medical recommendations such as antiretroviral medications. In one study investigating ways to improve health care utilization by inquiring about needs for services, a sample of two groups of HIV-positive women, from a needle exchange program and a correctional facility, all indicated that “shelter and food/clothing ranked first among unmet needs for services” (Thompson, 1995).

     A source of income is not traditionally conceptualized as within the realm of medical treatment, but it certainly becomes a major factor in medical illness and cannot be ignored. Many women who have substance abuse disorders with psychiatric comorbidity may qualify for entitlement programs that they have not explored. Vocational rehabilitation programs often entail medical or psychiatric referrals. Although housing is not traditionally considered part of medical care, it too is a major factor in medical illness and should be considered. For example, residential programs that require substance abuse treatment contracts should be made available when feasible. Treatment teams should consider this dimension of care in making a comprehensive plan to encourage antiretroviral medication adherence.

CHILDHOOD SEXUAL ABUSE AND ADULT VICTIMIZATION

Sexual abuse, sexual assault, and domestic violence are experienced within the lifetimes of a significant portion of American women regardless of their economic status or ethnicity. When childhood sexual abuse is defined as physical contact of a sexual nature with children under 14 years of age, estimates range from 28% to 36% (Wyatt, 1986). Childhood abuse research is limited by the methodology of self-report, sampling, and definitional issues, but shows remarkably consistent high lifetime prevalence rates for women who are HIV-positive or at risk for HIV, for both childhood sexual abuse and adult sexual assault. In turn, these are associated with multiple HIV transmission and risk behaviors.

     In a study of 186 HIV-positive or at-risk individuals, 28% of the women (and 15% of the men) had been sexually abused during childhood. The female survivors of sexual abuse were significantly more likely to work as prostitutes, become pregnant during teenage years, abuse alcohol or tranquilizers, and were less likely to finish high school (Zierler, 1991).

     A recent study of 1645 subjects enrolled in the Women’s Interagency HIV Study (Cohen, 2000) found that among both HIV-positive and seronegative, at-risk women two out of every three women (67% and 66%, respectively) had experienced domestic violence during their lifetimes, and almost one out of three (31% and 27%, respectively) had been sexually abused as children. There was no significant difference in prevalence associated with race, ethnicity, education level, or marital status, although domestic violence was more frequently reported among older, unmarried, unemployed women.

Early sexual abuse was strongly associated with increased HIV risk behaviors:

• using drugs
  
• having more than 10 male sexual partners
  
• having male partners at risk for HIV infection
  
• exchanging sex for drugs, money, or shelter
  

     Sexual assault for adult women has been estimated to be two to four times as likely in women who were survivors of childhood sexual abuse. In a study of 327 women with or at risk for HIV, Zierler (1991) found that 35% of women with HIV were sexually assaulted as adults. Forty-five percent of women who reported rape as adults had been sexually abused during childhood or as teenagers. Among women with HIV, adult rape experiences were associated with:

• more sexual partners
  
• unprotected sex involving drugs
  
• earlier age of injection drug use
  
• teen pregnancy
  
• sexually transmitted diseases
  
• gynecologic surgery
  

     Similar results were found in a study of street-recruited women from three different major urban sites, with demographics similar to a large portion of the female HIV-positive population: 114/918 women (12%) reported they had been sexually assaulted in the previous 12 mo. In comparison with those who were not sexually assaulted, this study (Wong, 1993) found that rape was associated with:

• higher rates of sex for drug exchanges (79% vs. 37%)
  
• reporting more than 100 lifetime sex partners (55% vs. 18%)
  
• smoking crack (86% vs. 55%)
  
• twice the likelihood of being infected with HIV and syphilis

     In another study, of 40 HIV-positive women seeking medical care in one survey, a trauma history was reported by 95%: 63% reported sexual abuse and 70% reported physical abuse (Nelson, 1996).

     In addition, multiple studies have established a relationship between childhood sexual abuse in women and adult-onset depression (Weiss, 1999). Of interest is that HIV-positive and at-risk women both have higher rates of depression than the general population, although depression increases with physical symptoms. There is also evidence that a range of psychiatric disorders are more prevalent in women and are associated with childhood sexual abuse:

• bulimia nervosa
  
• panic disorder with agoraphobia
  
• generalized anxiety disorder
  
• borderline personality disorder
  
• adult-onset depression

     There are major implications from these findings for medical care, psychiatric and substance treatment, and HIV prevention efforts. A significant segment of the HIV-positive and at-risk female population have experienced childhood sexual abuse and/or sexual assault as an adult and their feelings about their disease, their likelihood of continuing high-risk transmission behaviors, their methods of coping (such as the use of substances), and their relationship to the health care system are seen through the prism of those experiences.

     Medical care, treatment, and prevention efforts should be conceptualized with attention to the important impact of violence and trauma in the lives of these women (Fullilove, 1992b). When individuals whom these women were supposed to be able to trust have victimized them, it is not surprising that health care providers will have to very consciously earn their trust. Lack of trust, low self esteem, and feelings of powerlessness are frequently experienced by these women. Supportive measures such as having a female health care provider, participating in women’s support groups, getting supportive therapy or treatment with psychiatric medications, using social resources, or receiving vocational rehabilitation can increase trust and self esteem and ultimately empower them. Education about prevention should also be a part of medical treatment when there is high risk for continuing transmission behaviors.

     It is also important to be aware that women with a history of childhood sexual abuse may be susceptible to a variety of misperceptions. A directive style of recommending medical treatment, for example, may be perceived as coercive by women sensitized through past experiences. A treatment with major side effects or a surgical procedure may be experienced as abusive intrusions in their lives or bodies. A friendly relationship with a health care provider may take on unwarranted sexual overtones. Efforts at health education may not be heard when the individual is suddenly lost in thought or actually dissociating because of suddenly being overwhelmed by memories of abuse. Pain may be amplified because of experiences of physical abuse and might be dismissed as drug-seeking.

     Clinicians, in turn, may have particular responses to these women and should understand their vulnerability to unproductive “countertransferential” reactions such as either being provoked into being the anticipated abusive figure, or feeling compelled to rescue the individual. Responses of the clinician are more specifically addressed later in this chapter.

     Finally, it must be noted that the clinician must ask in order to know. A simple and direct question may be used, such as, “Would you mind if I ask if you have ever been the victim of physical or sexual abuse?” or “Has anyone ever hurt you physically or abused you sexually?” This should routinely be asked as a pertinent part of the medical history. If there is a positive response, the details need not be explored. If there is a negative response, the possibility of an abuse history should nevertheless be kept in mind. With regard to the possibility of domestic violence, the clinician can ask, “Is there anyone in your life right now who makes you feel unsafe?” If there is a positive response, the details should be explored.

ILLICIT DRUG USE

Women with HIV who are impoverished and struggling with sequelae of childhood abuse and adult victimization are also frequently struggling under the burden of significant substance use, which is often further complicated by psychiatric comorbidity. Whether or not they are etiologically related, each factor can exacerbate the other and relapses, in turn, are often associated with increased medical morbidity. Medical providers who consider a substance-using HIV-positive woman an inappropriate candidate for multiple drug anti-retroviral medication should consider clinical efforts to assure that she is enrolled in substance abuse treatment as a specific part of the treatment plan.

     Although it is beyond the scope of this chapter to explore the range of studies addressing substance use among HIV-positive women, a few have been selected for discussion. (Also see Chapter X on Substance Abuse.)

• There is a high rate of psychiatric comorbidity among HIV-positive women who use substances.

     In a study of a population of HIV-positive individuals on methadone, 79% were found to have a current DSM-III-R Axis I psychiatric disorder and nearly two thirds had two or more concurrent disorders (Batki, 1996). If psychiatric and substance use treatment are not offered at the same time, a relapse in one condition can often destabilize the other, such as with crack use and bipolar disorder, or with injection drug use and posttraumatic stress disorder (PTSD). Investigators using a National Survey of Veterans found that the combination of substance abuse and PTSD increased the rate of HIV infection almost 12-fold, compared with those without either disorder (Hoff, 1997). Psychiatric evaluation and treatment should accompany substance treatment when there is comorbidity; this combination has been shown to be effective (Lyketsos, 1997).

• As many as one third of HIV-infected women exposed to HIV through heterosexual contact use noninjection drugs and engage in high-risk behaviors.

     Analysis of data from 2270 questionnaires administered to HIV-infected women from 12 state or local health departments over 5 years focused on the 488 (21%) who used noninjection drugs only.

• 36% of crack users, 11% of primarily marijuana users, and 7% of primarily cocaine users had received money for sex in the past five years
• 66% of crack users, 37% of primarily cocaine users, and 41% of primarily marijuana users had had a sexually transmitted disease (Kacanek, 1996).

• Crack cocaine use results in increased HIV exposure and HIV-positive status in multiple ways.

     Comparing a national sample of 796 high-frequency (daily during the previous month) and 855 low-frequency (1–10 days during the previous month) crack-using women, high-frequency users were more likely to be infected with HIV (14.2% vs. 5.8%), had six times the number of sex partners (13 vs. 2.4), were more than three-fold as likely to have sex while high, were nine times more likely to trade sex for drugs or money, and were about 50% more likely to have had unprotected oral sex, as compared with low-frequency users (Klein, 1997).

     It is likely that one of the most important interventions for preventing further HIV transmission in the seropositive woman who continues to use crack is substance abuse treatment combined with needed psychiatric and other concrete services.

• Women injection drug users (IDUs) frequently borrow injection works or follow as a second user with shared needles, increasing the risk of HIV transmission.

• New York neighborhood with high HIV seroprevalence: Among 286 women IDUs who had been injecting drugs an average of 14 years and on an average had injected 55 times per month during the past 12 months, 48% reported having borrowed used injection works. Women who had someone to talk to were less likely to have borrowed injection works (p<.05) (Abdul-Quader, 1993).
• San Francisco Needle Exchange Programs: Among 150 female IDUs, younger women (< 30 yr) were more likely to be Caucasian, have an IDU parent, start injecting at an early age and share needles and inject second when sharing with a main partner (74% vs. 38%) (Lum, 1998). Needle exchange programs have been found to be effective in preventing HIV exposure and reducing transmission of HIV among injection drug users (Stephen, 1995; Kaplan 1996).
• IDUs in England: In a study of 181 IDUs in two cities, analyzing 547 injection episodes, women received previously used injecting equipment significantly more often than men (Bennett, 2000).

• HIV-positive women with substance abuse problems have high utilization of emergency services, low utilization of health services, and HIV-positive women in general tend to have lower rates of utilization of antiretrovirals and opportunistic infection prophylaxis.

     Seropositive individuals who use drugs are more likely to be without a primary care provider and use emergency medical services than people with AIDS who do not use drugs (Mauskopf, 1994). Injection drug users either tend to delay initiation of treatment (Broers, 1994) or have less access to antiretroviral medications as a group (Shapiro, 1999). In women with < 200 CD4/mm³ at a baseline visit, utilization of antiretroviral medication was only 49%, and prophylaxis for opportunistic infections, 58% (Solomon, 1996). People who use injection drugs are often not diagnosed as HIV positive until they are symptomatic (Hu, 1995).

III. NEED FOR MULTISERVICE CLINICAL PROGRAMS

As the above discussions indicate, many HIV-positive women have multiple diagnoses and require a variety of services to be adequately supported through this illness. Many HIV-positive women are living in poverty or as sex workers, often while still addicted to drugs. A large percentage of seropositive women are also struggling with the multiple sequelae of childhood sexual abuse and may have formal psychiatric disorders.

     The varied needs of these HIV-positive women require specific multiser-vice program components (Morrow, 1997) and care provider training as listed below for good comprehensive care. Clinical issues for these diverse subpopu-lations of HIV-positive women with complex histories and comorbidities can be managed best through such programs, which are responsive to both their clinical and concrete needs. Some of these services may be available through community-based AIDS service organizations and require close coordination with medical care.

     Optimally, treatment for formal psychiatric and substance use disorders, which will be discussed below, would be available on site (Kobayashi, 2000) and be integrated with primary medical care. Savings from emergency room visits and hospitalizations prevented help offset the labor-intensive costs of these multiservice programs; if a broad array of services is not provided for these populations with such a complex layering of needs, routine medical care will generally be complicated by intermittent follow-up, medication nonadher-ence, or frequent presentations in crisis in emergency room settings.

IV. PSYCHIATRIC DISORDERS

A number of formal psychiatric disorders among women with HIV infection require diagnosis and treatment. Women with HIV as well as women at risk for HIV have higher lifetime prevalence of major depressive disorder, PTSD, and borderline personality disorder than the general population. If women with these disorders do not receive appropriate treatment, their participation in medical follow-up or their ability to adhere to complicated medication regimens can be compromised.

     Seropositive women with untreated psychiatric disorders associated with impulsive or self-destructive tendencies may also engage in high-risk transmission behaviors, potentially infecting others or being exposed to other sexually transmitted diseases themselves. Abuse histories frequently leave them susceptible to feelings of learned helplessness or powerlessness in sexual situations, which may result in high-risk behaviors, inability to negotiate safe sex, or exchanging sex for drugs (Fullilove, 1992a).

     Women across cultures and around the world have lifetime incidence rates of major depressive disorders twice that of men. In the United States, the incidence of major depression in the general population is approximately 10–15% (American Psychiatric Association, 1994). Among a sample of 234 African American men who have sex with men (159 HIV-positive and 75 HIV-negative) and African American women (100 HIV-positive and 35 HIV-negative), there was a high prevalence of anxiety spectrum disorders (38%) and mood disorders (23%) in both samples, and signifcant rates of PTSD (50%) among the women (Myers, 1999).

     Major depressive disorders may be missed as care providers project their own feelings and think “I’d be depressed too, under those circumstances.” Once diagnosed, these disorders are often undermedicated with doses of antidepressant medication that are too low to ensure a clinical response. Substance disorders are sometimes missed as contributors to the depression, and bipolar disorder is often not recognized when depression is the presenting symptom.

     For the clinician who is treating HIV-positive women, there are a number of specific psychiatric issues to consider. Women who are incarcerated have a higher prevalence of psychiatric disorders and substance use disorders than women in the general population or even men who are incarcerated. The chronically mentally ill have higher rates of HIV than the general population in high seroprevalence areas (Cournos, 1997). Psychotic symptoms also need to be differentiated from delirium in any HIV-positive individual. Central nervous system (CNS) causes of change in mood and mental status should be ruled out, although there is now evidence that there is less HIV-related neuro-physiologic dysfunction among those using protease inhibitors (Ferrando, 1998). (The differential diagnoses of minor cognitive motor disorder, HIV-associated dementia, and other CNS diseases such as cryptococcus, syphilis, herpes, CNS lymphoma, progressive multifocal leukoencephalopathy, toxoplas-mosis and other conditions are beyond the scope of this chapter.) Although initial rates of suicide were much higher than in the general population in the early days of the epidemic, it is likely that these rates are decreasing (Marzuk, 1997). Suicidal ideation may be used defensively, as a reminder that the individual still retains ultimate control over their illness; these cases should be differentiated from those women who are actively suicidal.

     Some of the clinical misperceptions that get in the way of evaluating these disorders are listed in Table 9-4, along with reminders for complete assessment. For the complete diagnostic criteria of each disorder, see the DSM-IV of the American Psychiatric Association (1994).

V. DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER

The diagnosis of a major depressive disorder should focus on “anhedonia,” or the loss of pleasure in all activities, rather than sadness alone. The sadness of grief, for example, can be as profound, but is often accompanied by moments of pleasure or even laughter as the most acute grief subsides. Sadness from other sources, such as major disappointments, is also responsive to environmental change such as an enjoyable activity, and the mood would be quickly reversed if the source of the disappointment were to change. This is not the case in a major depressive episode, where the world has no joy regardless of the activity or turn of events, where the outlook is gloom and doom regardless of the likelihood of positive events, and where there can be obsessive rumination on past wrongs or regrets that are impossible to balance with any feelings of accomplishment or hope. The mood is often worst in the morning, whereas the sadness of adjusting to difficult or stressful events tends to worsen over the course of the day and the new day is often filled with more hope. Hopelessness indicates severe depression and is the most consistent predictor of completed suicides; suicidal ideation is associated with both depressive and bipolar mood disorders.

     In addition to depressed mood and anhedonia, often with a sense of hopelessness, a variety of vegetative or biologic symptoms should be explored: low energy and psychomotor retardation; sleep disturbance (hypersomnia or insomnia), frequently with early morning awakening around 2:00 AM to 4:00 AM; appetite disturbance (hyperphagia or hypophagia) usually accompanied by loss of appetite and enjoyment of food regardless of the amount actually consumed; and constipation. Finally, there may be cognitive changes such as decreased attention and concentration (see Table 9-5), social withdrawal and tendency toward isolative behavior, preoccupation with guilt or regrets, obsessive rumination, diminished range of affect, uncharacteristic irritability, and increased use of substances of abuse. A family history of mood disorders is often present. In the most severe cases, psychotic symptoms such as delusions and hallucinations can be present. The fact that a constellation of depressive symptoms develop together over a course of weeks or months helps differentiate major depressive disorders from similar disturbances related to medical illnesses. A combination of psychotherapy and antidepressant medication has been shown to be therapeutic for HIV-positive patients with depressive symptoms (Markowitz, 1998).

VI. PSYCHOPHARMACOLOGY FOR THE HIV-POSITIVE WOMAN: GENERAL GUIDELINES

Numerous studies have indicated that psychotropic medications are safe for HIV-positive individuals and do not adversely affect the immune system (Fer-rando, 1999; Rabkin 1999). While specific medications and dosing will be discussed later, the following general guidelines should be kept in mind when approaching psychotropic medications with the seropositive woman:

• Start low, go slow: Low dosing, slow upward titration as with geriatric patients.
  
• Always expect the unexpected: HIV-positive patients often experience unusual side effects, or common side effects at low doses, or complicated drug-drug interactions.
  
• Dynamic monitoring: Changes in weight, metabolism, other medications, or medical illness episodes require frequent updating and reevaluating dosing ranges.
  
• Interdisciplinary coordination: Psychiatrists should be in regular communication with primary health care providers, and vice versa, about clinical updates, dosing changes, major medical events.
  
• Suspect substances: Depression may be complicated by alcohol, anxiety by withdrawal syndromes, mania by psychostimulants; patients often forget that, when their consumption has decreased, their CNS sensitivity to the effects of these substances increases over time.
  
• Amplify psychotropic medication adherence: Use medication boxes, simple regimens, written instructions, coordination with antiretroviral therapies, and patient education.
  
• The primary cytochrome P450 systems at issue for psychiatric medications are Cyp2D6 and Cyp3A4: The major cytochrome P450 drug-drug interactions to keep in mind are: ritonavir may increase levels of benzodi-azepines, desipramine and selective serotonin reuptake inhibitors (2D6), or nefazadone (3A4); venlafaxine (and St. John’s wort) may decrease indinavir concentration; nevirapine may decrease methadone levels; methadone increases zidovudine levels; valproate increases the level of zidovudine. (See Chapter XIV on Pharmacologic Considerations in HIV-infected Pregnant Patients for more information on drug-drug interactions.)
  

     A complete discussion of psychotropic medications (including complete side effect profiles) is beyond the scope of this chapter; however, the following medications are useful for the practitioner wishing to initiate psychotropic medications, with dosage ranges for common indications (modifed from Schatzberg, 1998).

     Common potential side effects of all of the antidepressant medications include agitation, irritability, sedation, sexual dysfunction, weight gain, headache, gastrointestinal distress, dry mouth, and potentiation of mania. Side effects of antipsychotics include cognitive slowing, the extrapyramidal symptoms of dystonia and akathisia with long-term risk of dyskinesia; with the newer “atypical” antipsychotics, hyperprolactinemia may occur; and with olanzapine in particular, significant weight gain. There are discontinuation syndromes with paroxetine and venlafaxine; these drugs should be tapered. There are sedation and cognitive effects: tolerance, dependence, and withdrawal syndromes, including rebound anxiety, with the benzodiazepines, especially with alprazolam.

     Patients who require multiple medications, have severe side effects, have multiple diagnoses, or are not responding routinely or at routine doses should be referred for psychiatric evaluation.

VII. EVALUATION OF SUICIDE RISK

Women are significantly more likely to attempt suicide than men, whereas men are significantly more likely to complete the suicide by a male:female ratio of at least 4:1. Caucasians commit suicide at twice the rate of African Americans and Hispanics. It is estimated that 90% of individuals have a psychiatric disorder at the time of suicide, 45–79% of those have major depression. Fifteen percent of individuals with a mood disorder commit suicide (Buzan, 1996).

     Women more commonly attempt suicide by overdose, whereas men use more violent means such as firearms or hanging. Women who have few social supports, have been widowed or divorced, or who have a history of sexual abuse are at increased risk for suicide. Women with children attempt suicide less frequently. Any risk factor is increased by the presence of alcohol, psychosis, or an organic mental syndrome.

     As mentioned, it is likely that suicide rates are decreasing among HIV-positive individuals. This may be due to antiretroviral therapies, which can improve organic mood disorders and cognitive function (Ferrando, 1998), in addition to increasing longevity and hope.

     To assess suicide risk, the clinician must inquire about it. This does not increase the likelihood an individual will attempt suicide. The clinician should practice a standard way of asking, such as “Have you ever had thoughts of hurting yourself?” or “. . . of ending your life?” or “Do you ever feel that life is not worth living?”

VIII. CARE PROVIDER ISSUES

One of the most important relationships the seropositive woman has is the relationship with her health care provider. The dynamics of this relationship can have significant impact on the experience of the HIV-positive woman, and the woman will be affected not only by what the clinician communicates about HIV disease and treatment, but by how the information is communicated and how the provider relates to the HIV-positive woman herself.

     Whether or not it is conscious, health care providers may experience different reactions to HIV-positive women than to seropositive men. As previously discussed, it has been estimated that one out of every three women in the United States has experienced a sexual assault, from childhood sexual abuse to rape. This is even more common among women in poverty, where the HIV epidemic increasingly resides.

     Women who have been victims of abuse or assault may provoke a variety of reactions in care providers, the most common of which is frustration and disapproval of the substance use that many women use to distance themselves from their trauma. Male or female care providers may find it particularly difficult not to be angry or put off with the substance-using woman who is pregnant or who has children.

     Providers may also collude with the seropositive woman’s feelings of powerlessness and try to take control over things she can actually handle with sufficient support; protective concerns and anger at an abusing partner may tempt the caring provider to cross professional boundaries and try to rescue the patient.

     The provider may feel anger when the woman’s sense of powerlessness, particularly in sexual situations, results in submitting repeatedly to unsafe sex. They may unknowingly continue the trail of abuse by not allowing her concerns to be heard or by providing inadequate pain control, often in response to provocative and insistent behavior on the part of the patient, which provokes the clinician to try to assert control. It is important to stop to consider the powerful drive for self-preservation that leads women with few options to try to neutralize or forget painful memories with drugs or alcohol. Pregnancy and motherhood do not automatically erase these feelings.

     As with other medical populations, nonadherence with medications or medical follow-up can be personalized by providers as lack of commitment, clinical failure, or an affront to their good intentions, rather than adherence to different priorities. Appointments missed to take care of children or because of problems with transportation may be misinterpreted as not caring about medical follow-up.

     Frank disregard or avoidance of medical treatment, on the other hand, may be mistakenly excused without exploring the real meaning of the behaviors. Care providers often assume that a woman is missing visits because she is overwhelmed with the care of her children, when she is actually angry at a particular provider, or so frightened about the illness that she avoids treatment so as not to be confronted with it. Initiating multiple medications may be the point at which she is forced to break through the denial and confront her illness.

     For the woman health care provider, the experience of taking care of HIV-positive women can be both more rewarding and more depleting than general medical or HIV care. Personal identification with the patient may work positively to increase empathy, or negatively to increase projection of one’s own values and expectations on the individual. Female providers may also experience amplified grief, through personal identification, concern for orphaned children, or because of the death of a patient with whom they developed a genuine connection. Providers who are either prone to experience patient deaths as their own clinical failures, or who have deep compassion for the suffering of their patients, may be vulnerable to experiencing professional burnout, particularly if subjected to multiple, sequential losses. The practitioner who can cope with these challenges, however, may find personal and professional satisfaction in providing a combination of important services to a subpopulation of women who remain profoundly underserved.

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