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Controversy over using benzodiazepines in a human immunodeficiency virus (HIV)-positive population to relieve sleep and anxiety has not been addressed in the literature. Serious problems with diazepam abuse emerged in a psychiatric outpatient clinic for a predominately HIV-positive and illicit drug-using population, which led to a review of patient characteristics and prescribing policies and to a systematic problem-solving effort. The patients originally prescribed diazepam were significantly more likely to be on methadone and have histories of intravenous drug use compared with the patients not on benzodiazepines. Thus, the patients asking for diazepam are likely to have histories of substance abuse and have a high potential for abusing the medication. The authors found that diazepam can be discontinued without causing a significantly greater drop-out rate in that group.

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A 29-year-old single Puerto Rican woman with AIDS was admitted to the Medical Service for pneumonia, seen by the Psychiatric Consultation Service, an eventually transferred to the Inpatient Psychiatric Unit with several possible psychiatric diagnoses including major depression, HIV dementia, delirium, and posttraumatic stress disorder. These possibly coexisting and interacting syndromes are discussed by three psychiatrists, one of whom is also a board-certified neurologist. This case illustrates the combined contribution of organic and psychological factor to complex behavioral disorders, which are increasingly common in HIV infection.

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The evolution of central nervous system (CNS) impairments associated with human immunodeficiency virus (HIV) infection was assessed by a prospective, longitudinal study of patients in a methadone maintenance clinic. At a mean of 47 months after baseline testing, which included physical exams, HIV antibody testing and a neuropsychological (NP) screening battery, 121 subjects received a second NP assessment. Forty subjects (33%) who were seropositive at baseline showed statistically significant declines in NP function over the 4 years compared with 81 seronegatives, on the Finger Tapping and Trail Making B tests. This relatively long-term follow-up suggests that subtle cognitive deficits develop over time and can be identified early, but their course is slow and appears generally to parallel that of non-CNS symptoms/signs of HIV infection.

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The authors conducted a study to examine the association between neuropsychological markers of central nervous system impairment and systemic human immunodeficiency virus (HIV) disease progression in a sample of 64 HIV-positive asymptomatic patients who were followed for a median of 45.6 months. Patients with poorer baseline scores on the Halstead-Reitan Trail-Making A neuropsychological test developed HIV-related systemic symptoms earlier over the study period than patients with the higher scores on the same test (P < 0.05). Subclinical neuropsychological dysfunction in otherwise asymptomatic HIV-infected individuals may be a harbinger of progressive HIV-related immunologic dysfunction.

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Current suicidality and many other characteristics were assessed in 183-patients in the various stages of HIV infection who were referred to a specialized HIV-related psychiatric clinic. Intravenous drug use was the most common HIV risk factor. Patients with AIDS had significantly less current suicidal ideation than patients with AIDS-related complex and asymptomatic HIV positivity. The lower suicidality in AIDS patients was independent of age, gender, HIV risk group, and source of referral. Possible explanations of this association include denial, refocusing of life goals in AIDS patients, and psychological changes related to central nervous system impairment.

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Among psychiatric consultation patients, 322 AIDS patients were significantly less suicidal than 82 other HIV-positive patients and were comparable in suicidality to 1,086 patients with negative or unknown HIV status. AIDS patients had significantly more organic mental disorders. Organicity, denial, acceptance, and/or preoccupation with a fatal illness may reduce suicidality in AIDS patients.

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The frequency of a psychiatric consultation being requested to assess a patients' capacity to give informed consent varies among institutions, with most recent surveys reporting a frequency of between 3% and 8% of all consultations. At Montefiore Medical Center, a hospital policy was interpreted as mandating such consultations for all patients with possible or even definite lack of decisional capacity. From 1987 to 1988, 55% of all psychiatric consultations in the institution were for consent. Only 9% of the consent patients seen had an Axis I diagnosis other than organic mental syndrome (OMS). Because many of these consultations were believed to be unnecessary, with patient clearly able or unable to give consent, the consultation service worked first with administration to modify the guidelines, and then educated the medical and nursing staff as to when consultation was indicated. With this program, the number of consent consultations fell from 958 in 1988 to 177 in 1990, representing a major saving of staff time and third-party billings. In this era of cost containment and outside review of professional practices, psychiatrists must take responsibility for identifying areas where patient services and billings for them are not justified by clinical indications.

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Demographic and clinical data were recorded for 324 patients who visited an AIDS-related psychiatric outpatient clinic over a three-year period. Seventy-five percent of the patients had a diagnosis of AIDS, AIDS-related complex, or asymptomatic HIV seropositivity. Intravenous drug use and heterosexual relations were the most common HIV transmission risk factors. Seventy-three percent of the patients were black or Hispanic; 51 percent were female. In all stages of HIV infection, adjustment disorder was the most common diagnosis; one third to one half of the patients had substance abuse diagnoses. Only 5 percent were diagnosed with dementia, with the incidence highest (12 percent) in patients with AIDS. On the basis of their experience with the clinic, the authors discuss issues that have proved important in the treatment of patients with the triple diagnoses of medical illness, mental illness, and substance abuse.

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A unique and novel Clinical Information System has been set up to link all of the Psychiatric Emergency Rooms in The Bronx, New York. The system is designed from a clinician's perspective and it is an inexpensive system using personal computers. This new system of information exchange utilizes two interesting aspects of applying computer technology to assist clinicians: 1) use of a scannable medical record form to speed the input of data; and, 2) information exchange among many emergency rooms via a dial up access to a central database.

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A prospective longitudinal study of neuropsychological and psychosocial functioning in a methadone-maintained population was initiated to test the hypothesis that cognitive impairments may be present early in the course of HIV infection, before the onset of other physical symptoms. A total of 220 methadone-clinic patients without evidence of HIV-related illnesses were given baseline psychological screening tests, as well as serological testing for HIV antibodies. At baseline, 83 (38%) had antibodies to HIV and 137 (62%) did not. On initial testing, controlling for race/ethnicity, age, sex and drug use, the seropositives were more cognitively impaired than the seronegatives. The differences were statistically significant for three subtests on univariate analysis: finger tapping (dominant), digit span (forward) and similarities. Ninety-one patients whose current serological status was known were given follow-up neuropsychological and psychosocial assessments after a mean interval of 7.4 months from baseline testing. At follow-up, seropositives continued to be more cognitively impaired than seronegatives, but there was no deterioration in the performance of the initial seropositives over the time interval.

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Every clinical service must record certain data about its patient care activities. In low-volume services, such as Psychiatric Inpatient Services, with perhaps 20-30 admissions per month, and an average patient stay of 2-4 weeks, a large amount of data on each patient can be obtained during the contact time with the patient. On the other hand, very large-volume psychiatric services, such as Emergency and Consultation-Liaison (C-L) Services, may not need or be able to gather such a large amount of data on every patient seen. This article describes the development of a brief, optically scannable, and computerized minimal data base form for patients seen by a very large division of C-L Psychiatry. The system is feasible and easily auditable for completeness and reliability. This data base has already served many important functions beyond providing an administrative statistical summary of services rendered. It is presented as a model for the development of similarly efficient data collection methods for other high-volume psychiatric services.

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To identify similarities and differences between AIDS patients and non-AIDS patients, all psychiatric consultations done in one year in a large voluntary general hospital were reviewed. A total of 93 consultations were done on 67 AIDS patients and 138 consultations were done on 121 comparably aged patients without AIDS. The most common AIDS risk factor was intravenous drug use. The AIDS patients were more likely to be Hispanic and male than were the non-AIDS patients. The AIDS group was also more likely to have a diagnosis of organic mental disorder, particularly dementia. There were no other differences in Axis I diagnoses, including depression, substance abuse, and adjustment disorder. Suicidal risk was no greater in the AIDS patients than in the non-AIDS patients. Axis II diagnoses were made more often in the non-AIDS patients, who also required more one-to-one nursing supervision. Consultation in AIDS patients took more staff time, and AIDS patients were more likely to have required one or more repeat consultations within the period of the study, thus creating a heavier burden on consultation staff. Although these predominantly heterosexual, Hispanic, and drug-using hospitalized AIDS patients do not show significantly higher rates of psychiatric morbidity than other, non-AIDS patients, except for more organic mental disorders, AIDS seems to create a much higher demand for psychiatric consultation services.

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To test the hypothesis that cognitive impairment may be present early in the course of HTLV-III/LAV infection, intravenous drug abusers (IDVAs) without overt symptoms of AIDS related illness were tested with standard neuropsychological and psychosocial measures. This study is the baseline for a prospective longitudinal study of the natural history of HTLV-III/LAV infection in this high risk population. Of 211 subjects initially evaluated, 70 (33%) were HTLV-III/LAV seropositive and 141 (67%) were seronegative. At the baseline, by univariate analysis, the seropositive IVDAs were significantly (p less than .05) more impaired than seronegatives on 4 of 8 measures: Finger Tapping--dominant, hand, Digit Span Forward, Trail making A and WAIS-Similarities. However, by multivariate analysis the seropositives were significantly more impaired only on the WAIS-Similarities and Wechsler--Associative Learning tests. Multiple factors such as drug use and psychological stress may have influenced test performance. These preliminary results, however, suggest that seropositive IVDAs may show evidence of impaired neuropsychological function even in the absence of AIDS related symptoms and are consistent with the hypothesis of the early neurotropism of HTLV-III/LAV.

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