Posted December 2007 — Currently Under Revision
Patients with severe and persistent mental illness (SPMI) are commonly diagnosed with psychotic disorders, such as schizophrenia and schizoaffective disorder, and often have current or past experiences of hallucinations or delusions. SPMI diagnoses can also include mood disorders, such as bipolar disorder, or personality disorders, such as borderline personality disorder, which may or may not be associated with psychotic symptoms (see Depression and Mania in Patients With HIV/AIDS and Personality Disorders in Patients With HIV/AIDS).
These patients often have impairments in social and occupational functioning that can result in social isolation and reliance on governmental economic supports. Fluctuations in mental health status, impairments in cognitive function, and lack of insight into having a mental illness may interfere with the patient’s ability to follow directions and to adhere to both HIV and mental health treatment (see Adherence to Antiretroviral Therapy Among HIV-Infected Patients With Mental Health Disorders). Such considerations often require extra time and coordination of clinicians.
Studies documenting HIV infection rates among people with SPMI began to appear in the literature in the early to mid-1990s. Reported rates of HIV infection in these patients varied widely, from a low of 4% to a high of 23%. Most of these studies were conducted on New York City inpatient psychiatric units. The lowest reported rate of infection (4%) was found among patients who had been hospitalized for at least 1 year in a state psychiatric facility and represented those with the most chronic mental health disorders. Among patients admitted to psychiatric units, excluding those with a primary substance use disorder, the rates of HIV infection ranged from 5.5% to 8.9%. Infection rates ranged from 16.3% to 22.9% among mentally ill and chemically abusing (MICA) patients who were admitted to special units for the treatment of combined diagnoses of SPMI and alcohol or other substance use disorders.1
Table 1 provides definitions of terms used in this chapter that may not be familiar in all primary care settings but that are commonly used among mental health professionals who manage patients with SPMI.
II. ACUTE PSYCHOSIS AND EMERGENCY REFERRALS
After excluding or treating urgent medical conditions, clinicians should refer patients in acute psychiatric distress and those with suicidal or violent ideation for immediate psychiatric evaluation.
Clinicians should be able to recognize the signs and symptoms of delirium and refer patients presenting with such symptoms immediately to the hospital.
Patients with SPMI may present with either acute or chronic symptoms of illness. A person in an acute psychotic state will likely be very agitated and may pose a danger to him/herself or others. After addressing any life-threatening medical conditions, clinicians should refer patients exhibiting these types of behaviors for immediate psychiatric evaluation. If the symptoms are caused by interruption of psychotropic medications, resumption of these medications under the supervision of a psychiatrist may result in effective and timely stabilization of psychiatric symptoms. Patients presenting with delirium may have a severe and life-threatening neurologic or medical complication and should be sent immediately to the hospital (see Cognitive Disorders and HIV/AIDS and the Adults Guidelines: Neurologic Complications of HIV Infection).
Psychotic illnesses are assumed to be primarily the result of neurotransmitter imbalances in the brain; however, psychotic disorders can also result from reactions to outside stressors or medications. These reactive psychoses are uncommon but do occur. They can be characterized by abrupt onset resulting from a severe stressor or the initiation of new medication. Acute psychotic episodes without a precipitant may or may not indicate a more chronic mental illness.
III. DIAGNOSIS OF SPMI
A. Differential Diagnosis
Clinicians should assess patients for any treatable underlying medical or neurologic conditions, including those attributable to medications, that could cause or exacerbate a mental health condition.
The differential diagnosis of an altered mental status is especially important in the presence of HIV infection because the virus itself is neurotropic and some of the opportunistic infections common in HIV-infected patients involve the central nervous system. Drug reactions to ARV medication may also result in psychiatric symptoms.
In addition to elevated rates of HIV infection, comorbidity with other medical conditions has also been reported in patients with SPMI. These include diabetes, hyperlipidemia, cardiovascular disease, obesity, malignant neoplasms, hepatitis C, osteoporosis, hyperprolactinemia, and irritable bowel syndrome.2 The side effects of antipsychotic medications contribute to some of these problems. However, clinicians may mistake physical complaints as psychosomatic symptoms. Several studies have shown that the detection rate of physical illness among people with mental health disorders is poor. Many of these undetected physical illnesses were found to be exacerbating or causing the patient’s mental health disorder.3
Clinicians should refer patients for a psychiatric evaluation when patients present with symptoms of psychosis that are not attributable to delirium or dementia.
Mental health professionals distinguish among positive, negative, and cognitive symptoms of psychosis (see Table 2). The positive symptoms are those most easily recognized by the clinician and include bizarre delusions and hallucinations. The positive symptoms are the most amenable to psychotropic treatment. Negative symptoms are more difficult to discern and treat. Patients with positive or negative symptoms that are not attributable to delirium or dementia should be referred for psychiatric assessment to clarify the patient’s diagnosis and treatment. Cognitive symptoms require careful assessment, particularly to distinguish between symptoms related to an underlying medical etiology from those associated with SPMI.
Cognitive symptoms may also result from mental retardation. This diagnosis can often be obtained from family members and other caretakers. There is usually a history of special schooling, and school records often contain IQ information. Clinicians should assess how these patients process information that is given to them. This can be performed by asking patients to explain in their own words what the clinician has told them. Of note, mental retardation also falls under Diagnostic and Statistical Manual IV-Text Revision Axis II disorders (see Table 3).
IV. TREATMENT AND MANAGEMENT OF PATIENTS WITH SPMI
A. Developing a Treatment Plan and Coordination of Care
Clinicians should investigate the mental health history of patients with SPMI and contact the last known treating psychiatrist.
Clinicians should determine whether patients with SPMI are receiving mental health care. For patients who are receiving mental health care, clinicians should coordinate with their mental health providers. If the patient is not receiving mental health care, the clinician should refer him/her for such care.
Clinicians and mental health care providers should collaborate to develop a step-by-step treatment plan that delineates the frequency of follow-up visits with both providers as well as the frequency of contacts between providers to reevaluate effectiveness of the overall medical and mental health treatment.
Patients with chronic SPMI often have a documented history of mental health treatment and also may have experienced episodes of acute psychosis. Clinicians should investigate a patient’s prior mental health treatment and contact the last known treating psychiatrist.
The importance of coordination of care between SPMI patients’ primary care clinicians and mental health providers cannot be overstated. A comprehensive treatment plan to coordinate mental health and medical care should be established in conjunction with a mental health provider.
B. Patients With SPMI Who Refuse Psychiatric Care
When managing psychotropic treatment of SPMI patients who refuse psychiatric care:
- The primary care clinician should consult with a psychiatrist within the healthcare team if available, both initially and if assistance is required over time, when prescribing or changing psychotropic medications
- If a psychiatrist is not available within the healthcare team, the primary care clinician should consider creating an ongoing “silent partnership” with a psychiatrist outside of the healthcare team that maintains the confidentiality of the patient’s identity but enables the clinician to consult about the patient’s psychotropic medications
Nonpharmacologic Mental Health Management
When managing the nonpharmacologic aspects of mental health care for SPMI patients who refuse psychiatric care:
- The primary care clinician should consult with a licensed mental health professional within the healthcare team if available (e.g., psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse) on an ongoing basis, such as during team meetings, regarding the patient’s treatment but
- If a mental health professional is not available for regular consultation within the team setting, the primary care clinician should consider creating an ongoing “silent partnership” outside of the healthcare team that maintains the confidentiality of the patient’s identity but enables the clinician to consult with a licensed mental health professional
When patients with SPMI do not agree to mental health evaluation and treatment by a mental health professional, the primary care clinician should consult with a psychiatrist, both initially and if assistance is required over time, when prescribing or changing psychotropic medications. If the healthcare team includes a licensed mental health professional (i.e., psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse), then the primary care clinician should consult with that team member on an ongoing basis regarding the patient’s treatment. Alternatively, the primary care clinician can establish a “silent partnership” outside of the team setting with a licensed mental health professional who can help the clinician develop a treatment strategy for the patient. Because psychiatrists are physicians and are familiar with medical illnesses and their treatment, as well as drug-drug interactions, initial consultation with a psychiatrist would be ideal for the primary care clinician to establish the patient’s overall care. If it is not possible to coordinate the patient’s overall care with a psychiatrist thereafter, then the medical provider should coordinate care with a licensed mental health professional in the primary role as silent partner for the nonpharmacologic aspects of the patient’s mental health care.
According to Health Insurance Portability and Accountability Act (HIPAA) regulations, the patient’s identity cannot be shared with the silent partner without the patient’s consent in most cases. These regulations may vary according to the type of facility. For specific information about HIPAA, refer to the New York State Department of Health’s HIPAA Information Center.
C. Engaging the Patient With SPMI in Care
Clinicians should attempt to engage HIV-infected patients with SPMI in a partnership of care.
Clinicians should not attempt to argue or change the delusional belief systems of patients with SPMI.
Clinicians should help all members of the staff develop and enhance their skills for working with patients with SPMI.
Many clinicians encounter patients with SPMI in their clinical practice. Some general guidelines for interacting with these patients in a partnership of care are listed in Table 4. If asked directly by the patient whether the clinician agrees with the patient’s beliefs, the clinician should respectfully explain that he/she see things differently but understands the patient’s concerns.
Attempting to show patients with SPMI the illogic of their beliefs is counterproductive in establishing a partnership in treatment and could ultimately frustrate both the clinician and patient.
People with SPMI may talk aloud to themselves, neglect their hygiene, or interact with others in a manner that may be perceived as odd or inappropriate. They may experience delusions, or perceptions that either have no basis in fact or are not held by the general population. However, patients with SPMI have capacity for reality-testing in other areas. Many of these patients can follow information and instructions for managing physical illness, particularly when their care takes place in a structured clinic setting and the staff conveys the message that their intent is to provide as much information as possible and to assist the patient in obtaining optimal medical care (see Table 5). Clinicians should help all members of the staff develop and enhance their skills for working with patients with SPMI.
Clinicians and medical staff should be clear and respectful when giving patients information about their medical conditions and the strategies for the treatment of their conditions. The more open and direct the communication, the more likely the patient will accept a partnership of care. For example:
Your doctor will see you first, although you may have to wait 15 to 30 minutes because he/she is a bit backed up today. After your visit, the nurse will review your medications and answer any questions you may have about your medical care. You may also be asked to go to the lab for blood work.
Other patients may not react well to patients with SPMI, particularly during an acute episode, which can be distressing to other patients, both with and without SPMI. Clinicians should consider arranging clinic visits that minimize social stimulation, scheduling them early or late in the day and allowing extra time to coordinate the comprehensive care that these individuals frequently require.
Adherence to treatment can be enhanced when appointments are scheduled at times when the needs of patients with SPMI are best accommodated.
D. ART and Adherence
Clinicians should initiate ART only after the patient’s basic needs have been adequately addressed, including receipt of social support services and stabilization of mental status through effective treatment of psychiatric symptoms.
Clinicians should discuss potential side effects of psychotropic medications, as well as their potential interactions with ART and other medications. If side effects or interactions occur, clinicians and patients should discuss how they will be managed.
Clinicians should note all medications in the medical record, including psychotropic medications, that patients with SPMI are receiving.
Patients with severe mental health disorders should not be discriminated against when ARV treatment is considered. The likelihood of good adherence can be maximized by first addressing patients’ basic needs through their receipt of social support services when psychosocial challenges such as housing and income instability are present. Stabilization of psychiatric symptoms to the greatest extent possible is also necessary before initiation of ART.
Patients with severe affective disorders, such as bipolar disorder, have been found to have lower rates of adherence and to require increased efforts by care providers to overcome adherence barriers. By contrast, a retrospective study of Medicaid data has determined that patients with schizophrenia may be as adherent to ART as those without a serious mental health disorder, a finding that could reflect the benefit of integrating these patients into the healthcare system.4
Adherence also can be enhanced when patients with SPMI are educated about their ARV treatment, including the potential side effects of psychotropic medications, as well as their potential interactions with ART and other medications. If side effects or interactions occur, clinicians and patients should discuss how they will be managed (see Adherence to Antiretroviral Therapy Among HIV-Infected Patients With Mental Health Disorders).
E. Risk Reduction Counseling and Substance Use Referral
Patients with SPMI are at risk for sexual abuse and behaviors that can increase HIV transmission, including unprotected sex and injection drug use. Risk-reduction counseling and referral can address the risk factors that sexually active patients with SPMI often face (see Table 6).
1. Sexual Risk Behaviors
Clinicians should determine whether sexually active patients with SPMI have experienced or are at risk for coerced or forced sex.
Clinicians should educate patients, including those with SPMI, about safe-sex practices when discussing HIV risk reduction.
Multiple sex partners are common among sexually active SPMI patients. One-third to one-half of sexually active psychiatric inpatients and outpatients have had multiple sex partners within the previous year. The sexual behavior of patients with SPMI can be secondary to the symptoms of a mental health disorder, such as hypersexuality during acute mania, and is also often characterized by a lack of condom use. These individuals are consequently at increased risk for transmitting HIV or, because the HIV status of sex partners is often unknown,5 becoming reinfected. Of particular concern are the high reported rates of coerced or forced sex among psychiatric outpatients. In one study, 14% reported that they were pressured into unwanted sex or otherwise sexually victimized in the previous year.6 It is important to educate patients about the risk of HIV transmission through unprotected sex. In addition, social services, including those for domestic violence, also may be necessary to address the heightened risks that these patients may experience.
2. Substance Use
Clinicians should make appropriate referrals, including consulting a MICA specialist, when substance use disorders are identified in SPMI patients.
Clinicians should screen all HIV-infected patients for past and present substance use at baseline and at least annually.
Substance use disorders co-occur significantly among SPMI patients. Published reports estimate the co-occurrence to be approximately 50% over the course of the lifetime. Substance use may cause or exacerbate psychotic symptoms. The use of alcohol and other drugs is thought to contribute to HIV risk by increasing sexual desire, disinhibition of sexual behavior, promulgating trade of sex for money or drugs, and interfering with the use of safer sex practices. Among sexually active psychiatric inpatients and outpatients, 15% to 45% have reported intoxication with alcohol or other substances during sex in the past 6 to 12 months. Trading sex for drugs or for money to buy drugs within the past year was reported by 12% to 69% of sexually active patients. Unprotected sex with an injection drug user known to be HIV-infected in the previous 1 to 12 months was reported by 3% to 13% of psychiatric inpatients and outpatients.7
Trading sex for money or drugs was more than three times as likely among patients with schizophrenia than among those with other diagnoses and more than five times as likely among those with certain positive symptoms, such as delusions.8
Active substance or alcohol use is one of the few relatively consistent predictors of poor adherence to HIV treatment.9,10 As such, clinicians should make appropriate referrals, including consulting a MICA specialist, when substance use disorders are identified in SPMI patients.
F. Patients at Risk for Violence
Clinicians should clearly instruct medical support staff about how to manage emergencies involving patients with potential or actual violent behavior toward self or others.
Patients with SPMI are at increased risk for suicide but are rarely violent toward others. Although some literature has shown an increase in violent tendencies for some subgroups of mental health patients, with comorbid substance use being the strongest association, most people with SPMI are nonviolent and respond eagerly to offers of help. However, people with SPMI are often suspicious, because of either the disorder itself or their experience with how others treat and react to them. Clinicians should be as straightforward as possible to dispel patient suspicion.
In the event that a patient with SPMI becomes threatening, the office or clinic should have a clearly stated plan for managing such emergencies. Such a plan may include protocols for contacting emergency services, escorting other patients from the area, safely isolating the patient from other patients, and ensuring that no one stands between the potentially violent patient and the exit.
V. MENTAL HEALTH SERVICES AND PROGRAMS
Clinicians should have access to information regarding follow-up for patients with SPMI, including assisted outpatient treatment and intensive case management.
Mental health programs for people with SPMI may be located in hospital settings or in outpatient clinics in the community. Hospital-based psychiatric emergency departments are often best-suited to assess agitated patients and refer them to inpatient care if needed. Most hospital-based care is short-term because of the limited number of available long-term hospital beds. Many different organizations provide routine outpatient services. In addition, a variety of day programs are available where patients participate in groups focused on social, occupational, and self-management skills. Most commonly, psychotropic medication is prescribed by a psychiatrist, and other forms of therapy are conducted by social workers, psychologists, nurses, and other counselors. Programs for MICA patients combine mental health care with treatment for alcohol and other substance use disorders. Housing programs are also available for SPMI patients and offer a spectrum of supervision, from intensive to minimal.
Additional programs, such as intensive case management and assisted outpatient treatment, are also available to patients with SPMI. Intensive case management assigns the patient to a specialized case manager who carries a limited number of clients on his/her caseload in order to provide these patients with greater access and a higher level of care. Assisted outpatient treatment is provided through Kendra’s Law, which mandates psychiatric treatment for patients with serious mental health disorders who are unlikely to survive safely in the community without supervision. These services assess the needs of patients and connect patients with programs that can address those needs. For information regarding Kendra’s Law, refer to: http://bi.omh.ny.gov/aot/about
Support groups held in the community or within the psychiatric setting increase interaction between patients and their peers, which can decrease patients’ social isolation and help with self-management, including reduction in risk behaviors and maintaining or improving their physical health.
Resources are available in New York State for clinicians seeking assistance in caring for patients with SPMI. The New York State Office of Mental Health offers the Assertive Community Treatment (ACT) program, which is designed to offer services for patients with SPMI. A directory for providers is available at http://bi.omh.ny.gov/act/team_directory. New York City providers may also receive referrals through the Mobile Crisis Team by calling 1-800-LIFENET (1-800-543-3638).
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