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Mental Health Care

Updated December 2006

IX. PREVENTION OF SECONDARY DISEASE: MENTAL HEALTH CARE

HIV is a chronic stressor that places HIV-infected individuals, as well as their immediate and extended families, at risk for psychological distress and psychiatric disorders. Depression, anxiety, PTSD, cognitive impairment, and substance use are among the most common mental health disorders identified in the HIV-infected population. Psychosis is more common among HIV-infected patients who abuse substances, particularly stimulants, than in the general population. Table 1 lists specific crisis points and psychosocial factors that may precipitate mental distress in HIV-infected individuals and their families.

Table 1: Triggers That May Exacerbate Mental Distress for People With HIV Infection
  • Learning of HIV-positive status
  • Disclosure of HIV status to family and friends
  • Introduction of medication
  • Physical illness, new symptoms of disease, disease progression, AIDS diagnosis
  • Hospitalization (particularly first hospitalization)
  • Death of a significant other
  • Lifestyle changes, such as loss of job or income, end of relationship, relocation
  • Necessity of making end-of-life and permanency planning decisions

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A. Mental Health Screening in the Primary Care Setting

Recommendation:

The primary care clinician should conduct a mental health assessment at baseline and at least annually thereafter (see Tables 2, 3, and 4).

The role of the primary care clinician in caring for people who have both HIV infection and mental health disorders cannot be overemphasized. Because of the strong therapeutic alliances developed between primary care clinicians and patients, primary care clinicians are in a unique position to prevent, identify, and treat mental health disorders. Primary care clinicians may notice early signs of an underlying mental health disorder or cognitive disorder, such as difficulty with adherence to ARV medications; primary care clinicians also are often able to determine whether patients are developing or progressing to more serious conditions, such as suicidal ideation, depression, or anxiety disorder.

Denial, fear, and the stigma of mental illness may lead some patients to mask their psychological symptoms. Patients may be unaware of available treatment options, and they may avoid broaching the subject and asking for help. With routine mental health screening, primary care clinicians may uncover hidden mental distress. When conducting mental health screening, the clinician should indicate whether the disorder is active or in remission and whether the patient is currently engaged in mental health treatment.

Table 2: Primary Care Mental Health Screening
Screen all HIV-infected patients for mental health disorders at baseline and annually. Assess the following:

  • Cognitive impairment
  • Depression
  • Anxiety
  • Sleep habits and appetite
  • Post-traumatic stress disorder (PTSD)
  • Psychosocial status
  • Psychiatric history, including psychotropic medications
  • Alcohol and substance use
  • Suicidal/violent ideation



Table 3: Questions to Identify Mental Health Disorders
Cognitive Impairment1

  • Have you had difficulty reasoning and solving problems?
  • Have you forgotten things that have happened recently?
  • Have you had trouble keeping your attention on any activity for long?
  • Have you had difficulty doing activities involving concentration and thinking?

Depression
During the past month:

  • Have you experienced little interest or pleasure in doing things?
  • Have you felt down, depressed, or hopeless?

Anxiety

  • Do you often worry or feel nervous?
  • Are you often fearful of interacting with other people?
  • Do you ever feel jittery, short of breath, or like your heart is racing?
  • Do you ever feel as if you might lose control or fear that you may be “losing it”?

Sleep and Appetite

  • Do you have problems either falling asleep or staying asleep?
  • Do you have problems either with eating too much or too little?

PTSD
In your life, have you ever had any experience that was so upsetting, frightening, or horrible that you:

  • Have nightmares about it or think about it when you do not want to?
  • Try hard not to think about it or go out of your way to avoid situations that remind you of it?
  • Are constantly on guard, watchful, or easily startled?
  • Feel numb or detached from others, activities, or your surroundings?

Psychosocial Status

  • Where do you live?… How long have you lived there?
  • Where do you work?… How long have you worked there?
  • Do you have contact with family and friends?
  • Do you have a partner?
  • Do you feel safe in your current relationship?

Elements of Past Psychiatric History

  • Mental health diagnoses
  • Psychotropic medications
  • Past psychiatric hospitalizations
  • Contact information for mental health clinicians, if applicable

Suicide

  • See Figure 1



Studies conducted before the introduction of HAART indicated an increased risk of completed suicide in the HIV-infected population that was 7 to 36 times greater than that of the general population.2,3 More recent evidence suggests that suicide among HIV-infected patients may be mediated more often by factors other than HIV, including depression, alcohol, or other substance-related disorders. Research also suggests that suicide risk in HIV-infected patients may be higher than in populations with other chronic medical illnesses, such as cancer.4

Key Point:

A significant percentage of patients who commit suicide will have seen their primary care clinician in the month before their suicide. This underscores the importance of routine mental health screening in the primary care setting, which can help identify patients who are at risk for suicide and enable them to receive treatment for the underlying cause of their suicidal behavior.



Figure 1: Assessing and managing suicidal or violent patients
pr-prev-mhc-f1.jpg



Table 4: Alcohol and Substance Use Assessment*
Questions to Assess for Substance Use

  • Have you ever used any street drugs such as heroin, methamphetamine, ecstasy/MDMA, cocaine, crack, or marijuana?
  • When was the last time?
  • Are you interested now in any substance use services or treatment?

If the patient has a history of substance abuse, proceed with further evaluation and referral to treatment program or mental health specialist.
Questions to Assess for Alcohol Use
There are several tools available to screen for alcohol use. One simple and effective tool for identifying present or past use is the CAGE questionnaire. If the patient answers “yes” to two or more questions, it is suggestive of a problem, and the clinician should offer referral to appropriate services and should re-evaluate alcohol use at least quarterly.

  • Have you ever felt that you should CUT DOWN on your drinking?
  • Have people ANNOYED you by criticizing your drinking?
  • Have you ever felt bad or GUILTY about your drinking?
  • Have you ever had a drink first thing in the morning (an EYE OPENER) to steady your nerves or to get rid of a hangover?
* For additional screening tools and guidance for assessing substance and alcohol use in HIV-infected patients, refer to Screening and Ongoing Assessment for Substance Use.

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B. Referring Patients to Mental Health Services

Recommendations:

Clinicians should obtain an emergency evaluation for patients who present with acute psychosis and when there is a risk of violence to self or others.

Clinicians should be familiar with the resources available in the community to make the most appropriate referral when needed.

Primary care clinicians are often faced with the decision to observe, treat, or refer the patient to mental health services (see Table 5). Patients differ in their willingness to accept mental health referrals and may not follow through with care in a mental health setting. In some cases, it may take the primary care clinician months to convince patients of the need for care by a mental health professional. Mental health referrals and patients’ responses to the referral should be documented in the medical record.

Immediate referrals should be made in cases of acute psychosis and when there is a risk of violence to self or others.

Table 5: When to Refer to a Mental Health Professional
Emergent referral:

  • Risk of violence to self or others (suicidal/violent ideation)
  • Acute psychosis—general medical disorders, such as metabolic or cerebrovascular disorders, infections, head trauma or alcohol/drug intoxication, should be excluded in the emergency setting

Non-emergent referral:

  • Delusions
  • Hallucinations
  • Grandiosity/flight of ideas/loose association/disordered thinking
  • Inadequate response to mental health treatment initiated by the primary care clinician
  • Relapse of psychiatric symptoms while on treatment
  • Active substance use or relapse to substance use with mental disorder (refer to program for triply diagnosed patients)
  • Complex mental status evaluations become necessary or a patient’s behavior jeopardizes effective treatment

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C. Coordination of Care: Role of the Primary Care Clinician

Recommendation:

Primary care clinicians should notify the mental health care provider when there is a change in medical treatment, maintain communication with the mental health provider to monitor adherence, and document changes in mental health treatment.

Collaboration with mental health clinicians is essential in order to minimize fragmentation of care and enhance continuity and quality of care. The availability of mental health services varies from setting to setting, and this results in different levels of responsibilities for the primary care clinician when managing people with mental health disorders. Regardless of the setting, the goal is to make accurate mental health diagnoses, devise treatment plans, maintain mental health care, and collaborate with the treating mental health professionals.

Table 6 outlines the role of the primary care clinician when working with mental health care professionals. Patients who are under the care of mental health professionals may continue to experience emotional ups and downs, relapses, and suicidal ideation. Primary care clinicians should continue to monitor mental health and adherence to mental health treatment during routine office visits.

Table 6: The Role of the Primary Care Clinician When Coordinating Care With the Mental Health Professional
  • Ask patients follow-up questions regarding mental health, recovery, and treatment progress as a routine part of monitoring visits.
  • Include mental health issues in medical problem lists, progress notes, and corresponding medical assessments and plans.
  • Consider patients’ mental status, particularly suicidal and violent ideation and alcohol use or other substance use, before prescribing medications. For medications that can be lethal in overdose or otherwise misused by patients who are currently at risk for these behaviors, consider prescribing smaller quantities.
  • Clarify whether the mental health professional has prescribing privileges and/or access to a psychiatrist who will prescribe and monitor psychotropic medication as needed.
  • Monitor interactions between patients’ physical and mental conditions and the effects of psychotropic and other medications.
  • Maintain follow-up contact with patients’ mental health treatment program(s) to monitor adherence and document medication changes.
  • Consider active substance use or relapse to substance use as a factor in the above recommendations when appropriate.
  • Consider mental illness and/or substance use as possible underlying causes of unexplained signs or symptoms, laboratory abnormalities, changes in behavior, or adherence with medical treatment.

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REFERENCES

1. Knipples HM, Goodkin K, Weiss JJ, et al. The importance of cognitive self-report in early HIV-1 infection: Validation of a cognitive functional status subscale. AIDS 2002;16:259-267.

2. Marzuk PM, Tierney H, Tardiff K, et al. Increased risk of suicide in persons with AIDS. JAMA 1988;259:1333-1337.

3. Coté TR, Biggar RJ, Dannenberg AL. Risk of suicide among persons with AIDS: a national assessment. JAMA 1992;268:2066-2068.

4. Dannenberg AL, McNeil JG, Brundage JF, et al. Suicide and HIV infection. Mortality follow-up of 4147 HIV-seropositive military service applicants. JAMA 1996;276:1743-1746.

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