People with HIV are more likely to experience mental health symptoms than those in the general population [Bing et al. 2001]. Depression, anxiety, post-traumatic stress disorder (PTSD), and cognitive impairment are among the most common disorders. Risk for suicide or violence may be present. Any sudden change in cognitive function, consciousness, or behavior should prompt immediate assessment for delirium caused by an acute medical complication.
The complexity of mental health diagnosis and treatment in the setting of HIV often requires a collaborative approach between primary care and mental health providers. (Mental health providers include psychiatrists, psychologists, clinical social workers, and psychiatric nurse practitioners.)
Screening: For most patients, mental health screening requires approximately 10-20 minutes.
Referral: Refer to a mental health provider when a patient presents with:
- Risk for violence to self or others (see algorithm)
- Psychosis, including delusions, hallucinations, flight of ideas, disordered thinking
- Poor response or relapse of psychiatric symptoms while receiving medication/treatment
- Active substance abuse or relapse to substance use with mental health disorder (Refer to a program for dually diagnosed patients.)
Successful mental health referral involves communication between medical and mental health providers, as well as patient education.
Depression, Anxiety, and PTSD
Assessment: A brief screening tool, such as the PHQ-2, may be used for routine depression screening. For annual mental health screening, an answer of “yes” to any one of the following questions from the SAMISS questionnaire [Pence et al. 2005] should prompt further evaluation by a member of the healthcare team and, if necessary, referral to a mental health provider.
Questions to identify depression:
- In the past year, were you ever on medication or antidepressants for depression or nerve problems?
- In the past year, was there ever a time when you felt sad, blue, or depressed for more than 2 weeks in a row?
- In the past year, was there ever a time lasting more than 2 weeks when you lost interest in most things like hobbies, work, or activities that usually give you pleasure?
Questions to identify anxiety:
- In the past year, did you ever have a period lasting more than 1 month when most of the time you felt worried and anxious?
- In the past year, did you have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy when most people would not be afraid or anxious?
- In the past year, did you ever have a spell or an attack when for no reason your heart suddenly started to race, you felt faint, or you couldn’t catch your breath?
Questions to identify post-traumatic stress disorder (PTSD):
- During your lifetime, as a child, or adult, have you experienced or witnessed traumatic event(s) that involved harm to yourself or to others?
- If “yes”: In the past year, have you been troubled by flashbacks, nightmares, or thoughts of the trauma?
- In the past 3 months, have you experienced any event(s) or received information that was so upsetting it affected how you cope with everyday life?
Question to identify mania:
- In the past year, when not high or intoxicated, did you ever feel extremely energetic or irritable and more talkative than usual?
Note: Questions have been reprinted by permission of Wolters Kluwer Health.
The International HIV Dementia Scale is a validated brief screening instrument that can be administered by non-neurologists and may detect early motor and cognitive slowing.
Cognitive Function Screening Tools: International HIV Dementia Scale (IHDS)
Memory-Registration: Give 4 words to recall (dog, hat, bean, red) — 1 second to say each. Then ask the patient all 4 words after you have said them. Repeat the words if the patient does not recall them all immediately. Tell the patient you will ask for recall of the words again a bit later.
- Motor Speed: Have the patient tap the first two fingers of the non-dominant hand as widely and as quickly as possible.
- 4 = 15 in 5 seconds
- 3 = 11-14 in 5 seconds
- 2 = 7-10 in 5 seconds
- 1 = 3-6 in 5 seconds
- 0 = 0-2 in 5 seconds
- Psychomotor Speed: Have the patient perform the following movements with the non-dominant hand as quickly as possible: 1) Clench hand in fist on flat surface. 2) Put hand flat on surface with palm down. 3) Put perpendicular to flat surface on the side of the 5th digit.
Demonstrate and have the patient perform twice for practice.
- 4 = 4 sequences in 10 seconds
- 3 = 3 sequences in 10 seconds
- 2 = 2 sequences in 10 seconds
- 1 = 1 sequence in 10 seconds
- 0 = unable to perform
- Memory-Recall: Ask the patient to recall the 4 words. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); vegetable (bean); color (red).
- Give 1 point for each word spontaneously recalled
- Give 0.5 point for each correct answer after prompting
- Maximum — 4 points
Total International HIV Dementia Scale Score: This is the sum of the scores on items 1-3. The maximum possible score is 12. Patients with a score of ≤10 should be evaluated further for possible dementia.
Reprinted with permission of Wolters Kluwer Health. Sacktor NC, Wong M, Nakasujja N, et al. The International HIV Dementia Scale: A new rapid screening test for HIV dementia. AIDS 2005;19:1367-1374
Sleep and Appetite
Insomnia occurs frequently in HIV-infected patients and during all stages of HIV disease [Reid and Dwyer 2005], and weight loss is a strong predictor of HIV disease progression [Colecraft 2008].
Additional resource: Insomnia Screening and Treatment (Quick Reference Guide)
Substance Use Screening
A positive screen with any one of the following tools indicates the need for additional evaluation. Many more tools are available. For additional information, see NYSDOH AI Substance Use Guidelines.
Single Alcohol Screening Question
“How many times in the past year have you had x or more drinks in 1 day?”
Where x = 4 for women and x = 5 for men, and one or more heavy drinking days in the past year is considered a positive screen.
Reprinted from the National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide, 2005.
The Two-Item Conjoint Screen (TICS)
“In the last year, have you ever drunk or used drugs more than you meant to?”
“Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?”
Where ≥1 positive may be suggestive of a problem.
Reproduced by permission of the American Board of Family Medicine. Brown RL, Leonard T, Saunders LA, et al. A two-item conjoint screen for alcohol and other drug problems. J Am Board Fam Pract 2001;14:95-106. Copyright © 2001, JABFM Online by American Board of Family Medicine.
CAGE-AID (CAGE-Adapted to Include Drugs)
“Have you ever felt the need to cut down on your use of alcohol or drugs?”
“Has anyone annoyed you by criticizing your use of alcohol or drugs?”
“Have you ever felt guilty because of something you’ve done while drinking or using drugs?”
“Have you ever taken a drink or used drugs to steady your nerves or get over a hangover (eye-opener)?”
Where a total of ≥2 may be suggestive of a problem.
Reproduced by permission of the Wisconsin Medical Society; cited from Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in primary care practice. Wisconsin Medical Journal 1995;94:135-140.
Acute Suicidal or Violent Ideation or Behavior
HIV-Related Triggers of Mental Distress
Clinicians should be aware of triggers that can cause mental distress, such as:
- Learning of HIV status and disclosure to sex partners, family, and friends
- Physical illness, diagnosis of an STI, introduction of ART medications, AIDS diagnosis
- Hospitalization (particularly first hospitalization)
- Life changes (death of a significant other, end of relationship, job loss)
- Necessity of making end-of-life permanency-planning decisions
Elements of Pyschosocial Assessment
The following assessment may help determine the need for additional support:
- Stability of housing,* employment, government assistance, and level of education
- Support network and safety:
- Does the patient have contact with family and friends? …Are they aware of the patient’s HIV status?
- Does the patient have a partner?…Is the patient afraid of his/her partner or someone else close?
- Legal issues, including end-of-life arrangements
*Contact information, housing, and support network should be closely monitored for patients with unstable living situations.
Use of full prescribing information, knowledge of drug-drug interactions, and patient education are important components of effective psychopharmacologic treatment. Consultation with a psychiatrist experienced in HIV treatment may be warranted. Consultation for providers in New York State can be obtained at Columbia University HIV Mental Health Training Project: HIV Mental Health Warmline (1-212-543-5413).
Bing EG, Burnam MA, Longshore D, et al. Arch Gen Psychiatry 2001;58:721-728.
Colecraft E. Proc Nutr Soc 2008;67:109-113.
Pence BW, et al. Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients. J Acquir Immune Defic Syndr 2005;40:434-444.
Reid S, Dwyer J. Psychosom Med 2005;67:260-269.