• Glenn J. Treisman, M.D., Ph.D.

Dr. Treisman addressed the issues of mental health and substance use in the HIV-infected population, particularly the question of whether or not to treat those who are dually and triply diagnosed.

He quoted rates of major mental illness among the HIV infected as high as 54%, prevalence of substance use as high as 75% and of cognitive impairment as high as 20%. He stressed the evolution of the epidemic from one affecting those engaging in particular behaviors, to one affecting those willing to engage in the same behavior knowing the risks involved.

Dr. Treisman noted the lack of a treatment algorithm with this population, stressing instead the need to individualize care. He did discuss three major factors amenable to treatment that affect overall outcome and response to HIV therapies. These are depression, substance use, and demoralization.

The only factor repeatedly identified in non-adherence to medication regimens is major depression, yet depression remains woefully under-recognized. When diagnosed, it is eminently treatable with antidepressants, 60% of patients improving clinically on the initial antidepressant regimen.

Substance use and addiction is also treatable. He describes his own experience at Johns Hopkins where, with limited resources, they are able to get one-third of heroin users off heroin, one-third of cocaine users off cocaine, and one-third of alcohol abusers off alcohol. He describes the process as one of time, energy and continual intervention that costs money but, over the long term, saves much more than it costs. He stressed the need to treat all substance users since it is impossible to predict who will and who will not respond to therapy.

Finally, Dr. Treisman addressed the demoralization affecting this population. The message given to most substance-using and mentally ill people with HIV is a sense of hopelessness. Instead of this, what they need is support, therapeutic options, and a sense of hope. Dr. Treisman makes a compelling argument for incorporating psychiatric care, on-site whenever possible, into comprehensive HIV care programs.