Highlights of the 2000 Institute on Psychiatric Services

The 2000 Institute on Psychiatric Services, held October 25-29 in Philadelphia, drew more than 2,100 participants to a varied program of more than 300 symposia, lectures, workshops, debates, and poster sessions. The unifying theme of the meeting, the American Psychiatric Association's 52nd annual fall conference on clinical care, was psychodynamic psychotherapy. Forty professional and advocacy organizations met in conjunction with the institute.

At the opening session, APA president Daniel B. Borenstein, M.D., noted that he selected psychodynamic psychotherapy as the theme of the institute because residents and training directors have expressed the need for additional training in psychotherapy, and examiners from the American Board of Psychiatry and Neurology have been concerned about the difficulty candidates have in formulating and describing appropriate psychotherapy—especially psychodynamic psychotherapy—as part of a treatment plan.

Dr. Borenstein discussed how the structure of APA will change in 2001 as it transitions from 501(c)3 nonprofit status to the less restrictive 501(c)6 status. "Under the revised structure," he said, "APA will provide significantly more financial assistance to state and district branch organizations to enhance their advocacy activities."

Under the APA umbrella will be three subsidiaries with 501(c)3 nonprofit status: the American Psychiatric Foundation (APF), the American Psychiatric Institute for Research and Education (APIRE), and American Psychiatric Publishing, Inc. (APPI—formerly American Psychiatric Press, Inc.). The mission of APIRE is to contribute to the scientific basis of psychiatric practice and policy, to strengthen the research infrastructure of psychiatry, to enhance psychiatric education and training and career development, to improve the quality of psychiatric care through research and training, and to provide national leadership of a collaborative effort in research and training areas that require academic institutions and practitioners. The mission of the APF is to improve the lives of patients and families and to improve the community by supporting education, advocacy, and research to advance the understanding, prevention, and treatment of mental disorders. The new APPI will consolidate all of APA's publishing activities except Psychiatric News.

Dr. Borenstein also spoke briefly about other APA activities. He noted that the Task Force on Competency in Graduate Education was appointed to help coordinate the development of the competencies that all psychiatric residents will soon be required to have. Psychiatric residency programs must demonstrate by January 2001 how they plan to incorporate the competencies into training. Many different groups are interested in this process, and APA hopes to serve a coordinating function among them.

APA launched a business initiative to help leaders in the business community analyze the effects of their current employee benefits structure. "Primarily we hope to increase access for their employees to high-quality psychiatric care," Dr. Borenstein said. Although restrictive managed care has produced decreases in insurance costs, many corporations have also seen increases in their disability payments and in absenteeism, sick days, and turnover. He noted that APA is in contact with dozens of corporations and that substantial discussions have been held with several. "We hope to have one or two prototype programs that we can use to show others how well it works if we improve the benefits."

The Commission on Public Policy, Litigation, and Advocacy is essentially a combination of APA's government relations activities and its public relations activities, plus it has the ability to either encourage or support litigation. "It gives us the flexibility to go in whatever direction we need to go [to address] issues that are brought to our attention," Dr. Borenstein said. Action plans will be developed to enable APA to assume a proactive position on certain issues rather than starting off in a reactive stance.

APA has also started meetings with 15 allied psychiatric organizations to form more cooperative working relationships with the leadership of the various groups. Meetings have been held twice, and the next will be held in May 2001.

"This is a very exciting time for psychiatry," Dr. Borenstein remarked in closing. "Research advances in neuroscience, genetics, and psychotropic medications are daily occurrences." APA's annual meeting in May in New Orleans will emphasize many of these new developments, as suggested by the theme Dr. Borenstein selected for the meeting: "Mind Meets Brain: Integrating Psychiatry, Psychoanalysis, and Neuroscience."

In a separate session, APA medical director Steven M. Mirin, M.D., discussed how APA aims to influence public policy related to the care of patients who have mental illness and substance use disorders. Despite the enormous progress made over the past two decades in the treatment of mental disorders, he said, numerous economic and social forces continue to impede patients' access to care for these disorders. Recent years have seen a general destigmatization of mental illness, in part as a result of media coverage of advances in neuroscience as well as of mental illnesses and their treatments. Dr. Mirin predicted that this destigmatization, combined with treatment advances, will increase the demand for mental health services.

At the same time, however, rising costs will result in the imposition of tighter controls on access to care and on the type, intensity, and duration of care that people receive. These controls will be applied by payers and by managed care intermediaries in both the public and private sectors, and they will be in place for some time to come. Issues that still need to be addressed include discriminatory limitations on Medicare reimbursement for outpatient treatment, access to mental health and substance abuse treatment in state Medicaid programs, and controls on the type and frequency of care delivered in managed care networks. These issues will not be resolved soon, but APA can take certain steps to affect the direction the debate takes.

The appropriate role of a professional organization such as APA in attempting to influence these aspects of mental health policy is multifaceted, Dr. Mirin said. One of APA's goals is to educate professionals, policy makers, and the public on the value of mental health care. Skepticism about mental health care is supported by stigma as well as by the paucity of outcomes data. In combination, these two factors make APA's educational task a difficult one. In addition, he noted, the field in general—and perhaps APA in particular—needs to develop the ability to communicate more effectively to a variety of audiences, not just to the mental health community.

It is also appropriate for APA to undertake legislative initiatives, both at the federal level and in all the state capitals, on behalf of patients as well as on behalf of the profession. Much of this effort will be in direct lobbying, which, Dr. Mirin pointed out, really needs to begin at the grass roots. "Last-minute letter-writing is helpful, but relationships are more helpful."

APA also intends to take the lead in developing and disseminating standards of care, practice guidelines, quality indicators, and other measures that define what standards caregivers should adhere to and what standards organized care systems should adhere to. Policy makers, payers, and patients are demanding accountability for clinical and fiscal outcomes of care. Without valid and reliable measures of outcome and measures of quality, Dr. Mirin pointed out, payers and legislators will differentiate among providers solely on the basis of cost. "Evidence-based practice is preferable to having legislators and accountants dictate how care should be rendered."

In addition, APA has a leading role in refining nosology and diagnostic precision in psychiatry. The development of the Diagnostic and Statistical Manual of Mental Disorders went a long way toward improving these areas, and a few years from now DSM-V will go even further, Dr. Mirin said. Of particular interest in future revisions will be consideration of how a particular illness is manifested at different stages of the life course and the incorporation of advances in neuroscience and molecular genetics into the diagnostic and treatment array.

Dr. Mirin pointed out that supporting the training of future clinicians, teachers, and researchers is a professional responsibility and part of APA's mission. APA also needs to step up its efforts to assist psychiatrists in launching and sustaining research careers. Over the past 15 years psychiatry has moved from tenth place in National Institutes of Health research funding among all the medical specialties to second place. However, much of the research is conducted by nonphysicians, as the supply of physician-scientists has not kept pace with the research funding stream.

APA will continue to advocate for greater government support of research. "Research and the knowledge born of research is the lifeblood of our field," Dr. Mirin said. "Tremendous advances in basic and clinical research over the past two decades have contributed enormously to our ability to care for patients." Every spring APA convenes the Academic Consortium—chairs of departments from across the country, researchers, center directors—to join patient advocacy groups to advocate for public and private support for basic, clinical, and health services research. Dr. Mirin noted that APA is engaged in additional advocacy efforts with strategic allies—the National Alliance for the Mentaly Ill, the National Mental Health Association, the National Depressive and Manic-Depressive Association—as well as other medical associations, such as the American Medical Association and state medical associations.

APA carries out numerous media and public affairs activities, said Dr. Mirin, and one of its strategic goals is to develop and disseminate information on key clinical issues. In addition to translation of research into improvements of clinical care, other issues arise in the public arena on which APA speaks out. For example, APA has spoken out to correct misinformation about homosexuality and AIDS, methadone treatment, and electroconvulsive therapy.

How to make dynamic psychotherapy work

The American Academy of Psychoanalysis held a symposium on making psychodynamic psychotherapy work in various practice settings and patient groups.

Jack Drescher, M.D., supervising psychoanalyst at the William Alanson White Institute and clinical assistant professor of psychiatry at the State University of New York, Brooklyn, discussed the role of mutual play in psychodynamic psychotherapy and presented an illustrative case study of a patient with bipolar disorder. In classical psychoanalytic theory, Dr. Drescher noted, interpretation has a privileged position, and for many psychoanalysts, analyzability is based on the narrow criterion of receptivity to interpretation. However, this view overlooks the issue of what conditions make interpretation possible.

Dr. Drescher cited the perspective of Winnicott, who held that it is not interpretation but mutual play between patient and therapist that lies at the center of psychoanalytic technique. "When there is mutual playing, then interpretation, according to accepted psychoanalytic principles, can carry the therapeutic work forward," he said. If a patient is unable to play, then the therapist's efforts at the outset must be "directed toward bringing the patient from a state of not being able to play into a state of being able to play."

In his case study, Dr. Drescher described the principal difficulties of working with "Eve" and emphasized some of ways in which he himself had to adapt. "She both challenged my usual way of doing treatment and still challenges my thinking about psychoanalysis and psychotherapy," he said. Although Eve was perfectly capable of playing, he found that he and Eve played by different rules. Therapy became increasingly successful as they both learned and adapted to each other's rules.

Joseph P. Merlino, M.D., director of the ambulatory and community medicine service at the Bellevue Hospital Center and clinical professor of psychiatry at the New York University School of Medicine in New York City, presented a paper illustrating his use of a basic psychodynamic tool in some of his work with mentally ill homeless persons—dream analysis. Asking about their dreams early on, he found, helped in the formation of a therapeutic alliance. They were surprised that a psychiatrist was actually interested in hearing about what they thought and dreamed, he said, and they became engaged more readily than with the mental status checklist approach to interviewing. "Dream exploration can also expedite the uncovering of significant dynamic issues—very important given the short amount of time available to working with this patient group."

Talking about their dreams interested the patients and conveyed a sense of the psychiatrist's interest in them. Dr. Merlino said it gave him the opportunity to provide some useful psychoeducation to patients and to collaborate with them in understanding their current dilemma or distress.

Psychotherapy in the field

The International Society for the Psychological Treatments of Schizophrenia and the Other Psychoses (ISPS) held a symposium on psychotherapy in the field entitled "Out of Psychosis and Into Life." ISPS is a group of mental health professionals that has been meeting on a regular basis for nearly 50 years. The symposium focused on the element of "relatedness" or "connectedness," often altered or absent in patients with schizophrenia, as a key factor in reestablishing the links that constitute a healthy life.

Michael D. Robbins, M.D., associate clinical professor of psychiatry at the University of California, San Francisco, discussed language and communication in schizophrenia. While working with a patient who had a long history of chronic schizophrenia, Dr. Robbins became frustrated by his inability to understand her when she spoke "schizophrenese," as he dubbed it. He resolved to study her language to see if he could come to understand her. The patient herself was intrigued, and at times, at Dr. Robbins' prompting, she engaged with the question of why she used schizophrenese rather than ordinary language.

It is not unreasonable to think of schizophrenese as a language, Dr. Robbins said, as it generally adheres to rules of syntax and grammar and the speaker's intent is to communicate. Interpreting the language is no simple matter, however, although with prompting the patient with schizophrenia may be able to restate his or her underlying thoughts in ordinary language. Using quotations from his patient's speech and writings, Dr. Robbins provided translations illustrating the interpretive use of reflection, metaphor, and symbolism and pointing out some of the unique aspects of the language of schizophrenia.

Schizophrenese is similar syntactically to ordinary language, Dr. Robbins noted, but in its semantic and pragmatic aspects, it is qualitatively different. From the semantic standpoint, the patient with schizophrenia "lacks the capability to distinguish words from things, body states, and actions." Hence in schizophrenese words are used as though they were identical to the things they ordinarily refer to, to actions on those things, or to the mediating semantic processes involved.

From the pragmatic standpoint, the patient with schizophrenia uses schizophrenese to create and maintain distance from self and others. "Schizophrenese serves to create omnipotent delusions of control over a psyche that is indistinguishable from the world," he said. "It is felt by its user to possess the power to undo, reverse, and eliminate intolerable reality, both past and present." Dr. Robbins quoted his patient on her use of schizophrenese: "I get away to a place where my own words are real, but other people aren't. I can't be touched by them. I guess I'm finding a Closetland, a private place where I can escape to my own words to avoid other people's touch."

This pragmatic is at odds with that of the therapist, Dr. Robbins pointed out. "If the therapist approaches the schizophrenic with the implicit assumption that their languages are qualitatively similar, and with the related belief that schizophrenese can be empathically decoded, then the therapist will be indulging in an illusion of his or her own that matches the patient's sense of omnipotence." Only after the two recognize that they speak different languages and "initiate a dialogue consisting of simultaneous translations" can effective psychotherapy begin—and it must begin with work on the patient's developing an observing, thoughtful, reflective self and forming a communicative alliance with the other.

Joel Kanter, M.S.W., senior case manager at Fairfax City Health Services in Takoma Park, Maryland, discussed the role of what he calls the transitional participant in the treatment of patients with schizophrenia. Mr. Kanter cited the work of Donald and Clare Winnicott as the background for his thinking about how mental health workers in community care can serve as transitional participants to address what Werner Mendel referred to as "the failure of historicity" among patients with schizophrenia—that is, the inability to carry one's personal history through to new relationships and experiences.

In community care, case managers and other professionals often are directly involved in many aspects of their patients' lives. "In this way we move beyond the traditional psychotherapist's role as an outside observer in the patient's life to becoming an actual participant," Mr. Kanter noted. The case manager may interact with a large number of people in the patient's life—doctors, pharmacists, parole officers, landlords, and so on—and typically sees the patient more frequently than anyone else does. As the transitional participant, the case manager not only can provide a certain degree of interpersonal continuity for the patient but also can help the patient to integrate his or her experience.

The cultural aspects of trauma and torture

Many of the estimated 15 to 20 million refugees worldwide are at risk for mental health problems. Most of them were victims of psychological and physical trauma in their own country, and as refugees they face the stress of dislocation—often abrupt—to overcrowded, underserved refugee camps or to countries where the language and lifestyle are vastly different from their own.

Stevan M. Weine, M.D., co-director of the Project on Genocide, Psychiatry, and Witnessing in Chicago, described an access and intervention program designed to help Kosovar refugee families adapt to the demands of their new situation and to connect with existing service organizations. From his experience with a similar program for Bosnian refugees and through extensive discussions with Kosovar refugees in Germany, Dr. Weine knew that the impetus for help seeking would have to come from within the Kosovar community.

The extended family is by far the most important social unit in Kosovar culture. It provides support and guidance to the individual in almost every aspect of his or her life. The program consisted of organizing groups of families to meet in a very informal, relaxed atmosphere. The groups were mediated exclusively by trained Kosovar facilitators, and no professionals were present. People were encouraged to talk about their experiences, but the tone was kept upbeat and positive.

Initial results indicate the program was successful in helping families be more supportive and communicative among themselves and with other families and in helping them link up with existing services. Although mental health issues were never discussed in the group meetings or even within the family, individuals were made aware of the fact that help was available, and many sought treatment.

Dr. Weine feels that family-focused prevention and intervention groups are a valid and feasible response to the needs of refugees. They are especially effective in reaching people who otherwise would not access the mental health care system.

Jack Saul, Ph.D., director of the International Studies Center at New York University, also recognizes the power of cultural and family connections in treating and healing victims of political violence and torture. An estimated 100,000 torture survivors live in New York City alone. These individuals need the resources and resilience of families and communities to rebuild their lives and recover from trauma and massive loss.

Using the experience gained through years of treating Holocaust victims, Dr. Saul works to create consortiums of community projects in which trained bicultural workers help individuals develop social networks. The projects teach community members how to conduct their own needs assessments, identify their most important psychosocial needs, and come up with creative interventions. In this social context, individuals can connect with other people, develop trust, and talk about the concerns in their lives.

To open much-needed public discourse on the issues of refugees and torture, Dr. Saul works with the media and the arts community. A theatre group originally set up to teach INS interviewers how to talk sensitively with torture survivors now meets with groups of refugees. From the refugees' experiences, the actors develop improvisational plays around themes of loss, violence, separation, survival guilt, and safety. This approach acquaints the public with the realities of political violence and at the same time allows the survivors to externalize their traumatic memories and process and channel their emotions into creative work.

Eugenio M. Rothe, M.D., of the University of Miami, found ample evidence of posttruamatic stress disorder (PTSD) among Cuban children placed in the refugee camp at Guantanamo during the 1994 boat lift. The trauma of the children's boat journey was escalated by overcrowded, unhygienic living conditions in the camp, where violence, lack of privacy, overt sexual activity, substandard food, and extreme weather conditions were common and basic services were few. The barbed wire that surrounded the camp was a recurring theme in the children's art work.

In a clinical population of 285 preschool through adolescent children in the camp, Dr. Rothe found a lot of crying and sleep problems in the preschoolers and severe aggressive behavior and suicidality in the older children. Preexisting psychiatric conditions in these children were three times those of the normal population, and somatic symptoms such as asthma and epilepsy were much more common. Six months after the refugees had been relocated to Miami, almost 70 percent of the children who had not sought help in the camp reported symptoms of PTSD.

Microbes and mental illness

Disease is caused by the interaction between some life situation, some environmental situation, and one or more vulnerabilities, noted Robert C. Bransfield, M.D., who has a private practice in Red Bank, New Jersey. He described the ongoing arms war between human beings and microbes and the link between infectious disease and symptoms of mental illness.

In a normal state of health, we have ten times as many bacterial cells as human cells in our body. More than 500 species of bacteria live in the normal human colon, and 400 live in the mouth.

Microbes reproduce many times more rapidly than human beings, so they can evolve quickly and adapt to changing situations. As we develop new defenses, microbes develop new ways to penetrate them. Many pathogens can live dormant in the body for years—or even generations—and then manifest themselves under opportunistic conditions. We cannot eradicate microbes—we can only hope to keep them at bay with a healthy immune system.

In any given year, 51 million Americans suffer from some form of mental illness, any number of which may be associated with an infectious disease. Strep, tick-borne diseases, Hong Kong flu, and the Coxsackie virus may cause obsessive-compulsive disorders and attention-deficit hyperactivity disorder. Infection trauma to the brain can cause cognitive dysfunction and emotional dysregulation, depending on where it occurs; for example, damage to the stimulatory side of the brain may produce apathy, while damage to the inhibitory side may result in loss of impulse control and aggressive outbursts. Trauma to the central nervous system alters gene transcription, neurochemistry, and neural architecture.

Genetic predisposition, individual vulnerability, and the timing of infection onset can affect the outcome of the disease. An infection may result in asthma or attention-deficit disorder in a child, but the same infection in an adult may result in chronic fatigue syndrome or dementia. Furthermore, some diseases may be the result of several microbes working synergistically. Some theories suggest that chronic fatigue syndrome, AIDS, tick-borne diseases, and even multiple sclerosis are caused by the interaction of different microbes.

A classic example of the link between microbes and symptoms of mental illness is Lyme disease. In addition to debilitating physical symptoms, Lyme disease, which is caused by the spirochete Borrelia burgdorferi,may produce anxiety, depression, confusion, aggressive behavior, mild to moderate cognitive deficits, fatigue, memory loss, and irritability.

Lyme disease is traditionally treated with antibiotics, but a particular problem in the treatment process is the recurrence of symptoms. Brian A. Fallon, M.D., associate professor of psychiatry at Columbia University, presented case studies in which some patients responded to antibiotics, only to suffer additional or more severe symptoms weeks or months later. Other patients showed dramatic improvement with high doses of antibiotics administered over a long period. When a patient experiences symptom relief with antibiotic treatment, a good case can be made to resume or increase the treatment if symptoms recur.

Factors that complicate the detection of Lyme disease include the sheer number of possible physical and psychiatric symptoms, the variability of symptoms between patients, and the ambiguity of diagnostic tests such as the ELISA and the Western blot. Positive test results do not necessarily indicate an active infection, but negative results cannot necessarily rule it out.

Dr. Fallon encourages mental health professionals to ask their patients about specific symptoms that may point to an acute or chronic infection. Atypical psychiatric disturbances and atypical responses to psychotropic drugs may also indicate the presence of an infectious disease such as Lyme.

Diseases such as schizophrenia, which have traditionally been considered genetic in origin, are increasingly being studied in the context of environmental factors such as perinatal infection and anoxia. Robert H. Yolken, M.D., of Johns Hopkins University, pointed to several studies that indicate a correlation between schizophrenia and seasonality of birth and to an increased rate of the disease among immigrants. European studies show evidence of retroviruses in about 30 percent of individuals in the very early onset of schizophrenia. Dr. Yolken is especially interested in the development of diagnostic laboratory tests for psychiatric illnesses such as schizophrenia.

Patient treatment and care in the third decade of HIV-AIDS

The scope of interest in the treatment and care of HIV and AIDS patients was evident in both the large number and the professional diversity of attendees at a full-day session on these issues.

In a clinical update, J. Stephen McDaniel, M.D., of the Emory University School of Medicine, reported that by the end of 1999, a total of 700,000 cases of AIDS and 430,000 AIDS-related deaths had been recorded in the United States. Estimates extrapolated from various testing sites around the country indicate that 900,000 to one million persons are currently infected with HIV and that a significant portion of these individuals have not been tested and may be unaware that they are infected.

Between 1996 and 1997, the U.S. death rate from HIV infection and AIDS dropped 42 percent, but between 1997 and 1998 it declined only 20 percent. The annual U.S. HIV infection rate dropped by 27 percent from the 1980s to late 1990s, but the infection rate is increasing at an alarming rate among African Americans, Hispanics, and women. One in four new cases of HIV infection in the United States befalls someone younger than 22 years of age.

Worldwide, 18.8 million adults and children had died from AIDS by the end of 1999. More than 34 million persons were living with HIV infection at the end of 1999, and almost five and a half million of them—15,000 per day—were newly infected in that year alone. Ninety-five percent of all persons with HIV infection and AIDS live in developing countries.

The gap between resource-rich and resource-poor countries is an emerging psychosocial issue associated with the HIV-AIDS epidemic. Francine Cournos, M.D., of the New York Psychiatric Institute, presented World Health Organization figures showing that by the end of 1999, a cumulative total of more than 13 million children between the ages of 10 and 14 years had been orphaned by AIDS worldwide. More than 90 percent of these children are from sub-Saharan Africa.

Among the AIDS-related problems faced by resource-poor countries are the rapid spread of HIV infection, changing demographics—especially the growing number of orphaned children—limited HIV education even among health care workers, limited treatment resources, and scant assistance from resource-rich countries.

Dr. McDaniel stressed the clinical importance of recognizing HIV as a neurotropic and neuropathic virus. The virus enters the brain and crosses the blood-brain barrier within days to weeks after initial infection. Residual HIV replicates in "anatomically privileged sanctuaries" such as the central nervous system (CNS) and the urogenital tract, where antiretroviral penetration and correlation with peripheral tissue are poor. Substantial viral replication may be occurring in these areas even in the absence of detectable peripheral loads.

Autopsy studies have revealed that 75 to 90 percent of AIDS patients have postmortem evidence of CNS disease, according to Marshall Forstein, M.D., of Harvard University. CNS dysfunctions that are related to primary HIV infection include HIV-associated dementia and minor cognitive-motor disorder, which manifest themselves in affective, behavioral, cognitive, and motor impairments.

An estimated 40 to 60 percent of persons with HIV infection experience depression, anxiety disorder, adjustment disorder, and drug abuse, yet attempts to refer these patients to behavioral health care providers often prove unsuccessful. Patients are often mistrustful of the mental health system, and they are not prepared to recognize or accept the fact that they may have a mental health problem. Many patients form a relationship with their primary care provider and are reluctant to engage with another health care provider. On the other hand, patients who indicate a need and willingness to get mental health services may not receive them.

Bryce McLaughlin, M.D., of Temple University, and Susan Spencer, L.S.W., a private practitioner in Philadelphia, described an initiative in Philadelphia designed to integrate mental health care with primary care. The goal of the program is to develop behavioral health services at HIV primary care sites. The pilot program, based on a similar initiative in New Orleans, provides for behavioral health care professionals to be on-site at primary care facilities and to be fully integrated members of the treatment team. The program is currently operating at two of six prospective sites.

Among the implementation issues that emerged during the development of the program were buy-in from the various systems, licensure approval, patient documentation, provider training, and reimbursement. Health care professionals who might be considering a similar program were advised to expect unexpected barriers, to think creatively, and to load up on patience. The results of the New Orleans program prove that the challenges can be overcome and success is achievable.

Among the recent medical breakthroughs that offer marked improvements in the way the disease is being diagnosed and treated are the HIV RNA viral load assay, which can be used as a marker of disease progression and as a tool for clinical decision making; the antiretroviral drugs, including protease inhibitors; genotype and phenotype testing to determine drug resistance; and strategic treatment initiatives.

New therapies have resulted in declines in AIDS mortality, decreasing morbidity and hospitalization, and fewer incidents of general opportunistic illnesses. However, issues of adherence, dosing, and drug-drug interactions, as well as the physical and psychological effects of the psychotropic drugs, are still major concerns.

Furthermore, these breakthroughs may be a contributing factor in one of the troubling trends noted above—the slower decline of the U.S. death rate—because they foster the belief, especially among young people, that the disease can be easily treated or even cured. This false sense of security may lead to a relaxation of safe sex and drug use practices, a decreased incentive to be tested for HIV infection, and a delay in seeking treatment.

Additional areas of medical and public health concern are the lack of access to care and treatment among minorities, women, and the uninsured; a patient's inability to adhere to—and consequently, the failure of—treatment, and the emergence of drug-resistant HIV strains.

A recurring theme throughout the presentation was the fact that mental health care providers have a prominent role to play in HIV risk and prevention education, in promoting and facilitating testing and access to care, in encouraging adherence to medication, and in helping individuals adjust to the profound emotional impact of AIDS.

Immigration and mental health

Javier I. Escobar, M.D., professor and chair of the department of psychiatry of the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey, described findings about the mental health of Latin American immigrants. Despite significant socioeconomic disadvantages, he said, recent Latino immigrants, particularly those from Mexico, seem to fare better than Latinos who were born in the United States, and in many cases they also fare better than the U.S. general population.

Dr. Escobar noted that the traditional view of immigration in psychiatric epidemiology, and in psychiatry in general, was that "being born outside the United States was bad for you, immigration made it worse, and the only way to heal those deficiencies was to become Americanized, or acculturated." This view was supported by data showing that immigrants were disproportionately impaired and that impairment decreased with successive generations.

In the 1980s Dr. Escobar and his colleagues as well as other groups began to examine the prevalence of major psychiatric disorders by level of acculturation and place of birth. They found that illness increased with level of acculturation and that the prevalence of mental disorders was higher among those born in the United States. Mexican Americans born in Mexico had a significantly lower level of many psychiatric disorders—anxiety disorders, affective disorders, and substance use disorders—and the differences held across the sexes and across sociodemographic levels.

In physical health, too, those born in Mexico are better off. Even after taking into account potential confounding factors, "the fact remains that this difference is highly statistically significant, suggesting that there is something protective in these ethnic affiliations."

More research will be required to explain this paradox, Dr. Escobar said, but several factors stand out as likely candidates. Healthier habits appear to be important, and kin networks and family support is a critical factor; with acculturation comes a decline in the stability of the family. The set of expectations is very different between immigrants and nonimmigrants, and this too may play a role.