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Received July 3, 2002; revision received Jan. 3, 2003; accepted Jan. 22, 2003. From the Mount Sinai Medical Center. Address reprint requests to Dr. Hoffman, AIDS Center, Box 1009, Mount Sinai Medical Center, One Gustave Levy Place, New York, NY 10029. Copyright 2003 The Academy of Psychosomatic Medicine. Four million people in the United States and over 100 million worldwide are estimated to have hepatitis C infection. The modes of transmission of HIV and hepatitis C virus are similar, and coinfection is common, especially among intravenous drug users. Among HIV-positive patients, approximately 30%–50% are coinfected with hepatitis C. Approximately 70%–80% of those exposed to hepatitis C develop chronic infection. Although interferon has been the principal treatment for chronic hepatitis C for more than 10 years, treatment is complicated by its neurotoxic and psychiatric side effects. Several case reports have described depression and suicidal ideation in patients receiving interferon for hepatitis C. Three reports have documented psychosis in HIV-negative patients receiving interferon , but to our knowledge no reports to date have described psychosis in HIV-positive patients receiving interferon treatment for comorbid hepatitis C. All patients described in this study were enrolled at the Mount Sinai School of Medicine subsite of Hepatitis Resource Network 002, a multicenter trial of interferon 2b and ribavirin therapy in individuals coinfected with hepatitis C and HIV. Patients in this study were given ribavirin, 400 mg b.i.d., and were randomly assigned to receive interferon either daily or three times per week in a subcutaneous dose of 3 million units. At our subsite, all patients were screened for current depression and suicidality before enrollment and were followed throughout the study by a psychiatrist. The study was approved by the Mount Sinai School of Medicine Institutional Review Board. Table 1 describes the immunological parameters and antiretroviral therapy at study entry as well as treatment outcomes. In our case series, four out of six patients with comorbid hepatitis C and HIV developed psychosis during interferon therapy. While all four of the patients who developed psychosis had prior histories of mood and substance use disorders, none had a previous history of psychosis. None of the patients engaged in substance abuse during interferon therapy. This is the first case series of new-onset psychosis in patients with comorbid HIV and hepatitis C during treatment with interferon .

We present this medical-psychiatric case discussion to illustrate the psychodynamic aspects of nonadherence in a woman with AIDS. Our patient sustained severe, repeated abandonment and brutal emotional, physical and sexual trauma throughout her early and later childhood and adult life. Her care was considerably complicated by the sequelae of trauma including difficulty with trust and posttraumatic stress disorder. The additional problem of HIV dementia compounded the patient's nonadherence to treatment. We present a multidisciplinary biopsychosocial approach that enabled the patient to engage in both medical and psychiatric care.

The purpose of this study was to assess the prevalence of distress, anxiety, and depression in persons with human immunodeficiency virus (HIV) infection and determine the feasibility of screening in an urban HIV primary care setting. A convenience sample of 101 patients in the waiting room of an acquired immunodeficiency syndrome clinic completed two questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Distress Thermometer. The patient's demographic, medical, and psychiatric histories were obtained through chart review. The results of the Distress Thermometer revealed that 72.3% had a score of 5 or greater, demonstrating high distress. The results of the HADS revealed that 70.3% had high anxiety, with a score of 7 or greater. On the HADS depression questions, 45.5% had a score of 7 or greater, indicating depression. Analysis of the total HADS scores, including anxiety and depression, revealed that 53.5% had a score of greater than 15 and were experiencing significant distress. Patients with high viral loads were more likely to be distressed (P < 0.0005). Patients with high viral loads were also more likely to have higher anxiety or depression scores on the HADS. Patients who had CD4 counts higher than 500/mm(3) were less likely to be depressed. This study demonstrates a high prevalence of distress, anxiety, and depression among persons with HIV. The HADS and the Distress Thermometer showed a good correlation with each other (P < 0.0005), and these questionnaires can provide a simple and efficient method for rapid screening in an HIV clinic setting.