1. What I Have Learned in 25 Years of HIV and Hepatitis C Psychiatry FORMATTED: 11/17/15 New Orleans, Louisiana: December 15-17, 2015 Glenn J. Treisman, MD, PhD Eugene Meyer III Professor of Psychiatry and Medicine The Johns Hopkins Medical Institutions Baltimore, Maryland

2. Slide 2 of 75 Experience Meaning Assumption Behavior

3. Slide 3 of 75 Major DepressionDemoralization Anhedonia (Pervasive loss of rewards from activity) AM insomnia Family history Similar episodes Disrupted life course Unresponsive to positive events Distractible from loss (Maintains rewards from activity) Initial insomnia No family history Unique episode Stable life course Responsive to positive events

4. Slide 4 of 75 Depression stress demoralization CNS inflammation drug effects substance abuse subcortical injury cognitive impairment HIV impulsivity hopelessness carelessness demoralization substance abuse cognitive impairment

5. Slide 5 of 75 Simplified model of disposition Percent of population Introversion Punishment avoidant Future directed Function directed Extraversion Reward directed Present directed Feeling directed

6. Slide 6 of 75 Abnormal Illness Behavior Behaviors associated with illness that have been conditioned to continue in the absence of the initiating stimulus

7. Slide 7 of 75 Examples of reinforcers in abnormal illness behavior Positive reinforcers – Disability payments – Attention from spouses, family, doctors, lawyers – Ability to express prohibited feelings – Possibility of “lump sum” payments Negative reinforcers – Relief from stress, expectations and criticism – Relief from pain and discomfort

8. Slide 8 of 75 Increased patient satisfaction correlates with increased mortality The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Fenton JJ, Jerant AF, Bertakis KD, Franks P. Arch Intern Med. 2012 Mar 12;172(5):405-11.

9. Slide 9 of 75 Solutions The art of medicine cannot yet be mechanized and we must defend it Integrated care is better care Saving money in the short run has not succeeded HIV and Hepatitis C are transmitted by psychiatric vectors, and can be stopped