We are pleased to introduce this special issue of CNS Spectrums on neuropsychiatry and human immunodeficiency virus infection. The study of psychiatric manifestations of HIV has been at the forefront of research since the early 1980s. Although information has accumulated in the past 20 years, there is still a great deal to be learned. This issue includes four comprehensive reviews of the literature in the area of HIV research. The first two papers outline the prior research examining the prevalence and effects of psychiatric symptoms in HIV-positive (HIV+) individuals. The other papers summarize the research examining the effectiveness of pharmacologic and nonpharmacologic interventions in treating these psychiatric symptoms. All four articles consider the impact of these psychiatric symptoms (or their treatments) on both the psychological and physical health of HIV+ individuals. They also help delineate some of the underlying physiologic mechanisms involved in this process that perhaps may subsequently influence the course of HIV disease.

Jane Leserman, PhD, reviews and evaluates the literature on the impact of stressors, depression, and the use of specific adverse coping strategies on alterations in immune function and disease progression among HIV+ individuals. Leserman describes a number of findings generated from the Coping in Health and Illness Project and points out that there is substantial evidence that stressful life events, depressive symptoms, and passive coping strategies can lead to immune impairments during HIV disease. She discusses some of the underlying physiological mechanisms, particularly alterations in the hypothalamic-pituitary-adrenal axis, which might mediate the relationship between psychosocial factors, immune system functioning, and disease status. The author concludes that by further understanding the impact of stress, depression, adverse coping strategies, and alterations in hormonal systems on immune function, researchers will develop a greater account of how these important factors may influence HIV progression and survival.

What is the role of stress and coping in changes in immunologic and clinical indicators of human immunodeficiency virus disease progression? There is substantial evidence that stressful life events and passive coping strategies, such as denial, may have a detrimental effect on HIV disease progression. Given the harmful effects of stress and passive coping, the author reviews the limited research testing the efficacy of interventions, such as cognitive-behavioral therapies for HIV-infected persons. Finally, in trying to understand psychoimmune relationships in HIV, the evidence is examined for the mediating and direct effects of cortisol, a hormone associated with stress, on HIV disease progression. Delineating the role of psychosocial factors and cortisol on HIV disease progression may aid in the development of new interventions for this devastating disease.

Does stress management affect psychological and immune functioning in persons with human immunodeficiency virus infections? Stress-management techniques, such as relaxation training and imagery, cognitive restructuring, coping-skills training, and interpersonal-skills training, may reduce anxiety, depression, and social isolation in HIV-infected persons by lowering physical tension and increasing a sense of control and self-efficacy. A psychoneuroimmunologic model is proposed wherein these psychological changes are hypothesized to be accompanied by an improved ability to regulate neuroendocrine functioning, which in turn may be associated with a partial normalization of immune system functions such as lymphocyte proliferation and cytotoxicity, providing more efficient surveillance of latent viruses that may contribute directly to increased HIV replication and generate opportunistic infections or cancer if left unchecked. Such a normalization of stress-associated immune system decrements are hypothesized to forestall or minimize increases in viral load and expression of clinical symptoms. This model is useful for testing the factors contributing to the health effects of stress-management interventions in HIV-infected persons. In this context, one general research strategy for testing the effects of stress-management interventions is to target them toward the more prevalent psychosocial challenges that HIV-infected people face at various points in the disease process; enroll an HIV-infected population (eg, HIV-positive homosexual and bisexual men) into a randomized trial; and monitor changes in cognitive, affective, behavioral, and social factors in parallel with hormonal, immunologic, viral, and clinical changes over the course of time. This article will review the major psychoneuroimmunologic findings that have emerged using this paradigm and suggest future research directions and clinical applications.

Can psychological factors, such as depression, affect human immunodeficiency virus progession? HIV infection is viewed as a chronic illness in which those infected often confront a number of emotional challenges and physical health and disease-related issues. Over the past 20 years, there has been increasing evidence that depression and other mood-related disturbances are commonly observed among HIV-positive individuals. There is also mounting data showing that depressive symptoms might further impact upon specific elements of immune system functioning and influence quality of life and health status. This paper will highlight studies examining the prevalence of depression during HIV infection and review some of the evidence examining the impact of depressive symptoms on immune function and HIV disease progression.

How can neuropsychiatric disorders and syndromes be underdiagnosed and inadequately treated in individuals infected with human immunodeficiency virus? Depression in particular is among the most prevalent diagnoses and there is a solid foundation of data from controlled clinical studies that has begun to examine the efficacy of various antidepressants in HIV-infected persons. This article summarizes essential findings pertaining to the use of psychotropic medications to treat depression and other neuropsychiatric disorders in the context of immunodeficiency. This includes discussion of clinically significant treatment considerations (eg, efficacy, side effects, drug-drug interactions) derived from the existing literature. Taken together, there is compelling evidence that psychopharmacologic intervention can improve the quality of life of mentally ill HIV-infected individuals.