Mental Health Screening in HIV: Guideline and Commentary

Francine Cournos, MD

Jun 12, 2013

Mental Health Screening in HIV: Expert Commentary

Nothing is more frightening to many healthcare providers than being faced with patients who are exhibiting abnormal behavior. People who are obviously mentally impaired are often strongly discriminated against in medical care settings and often receive very poor healthcare, even when they have life-threatening medical emergencies.

Knowing how to assess people who present with abnormal mental states is a critical component of essential medical care. The Mental Health Screening Quick Reference Guide from the New York State Department of Health (NYS DOH) AIDS Institute can help clinicians in assessing the mental health status of HIV-infected patients.

The conditions that we label mental illnesses are on a continuum with physical illnesses, and this may be particularly important to consider in people with advanced HIV infection. For example, a change in mental status, especially when it is sudden and associated with confusion and a fluctuating level of consciousness, is highly suggestive of delirium. Delirium is a medical emergency with numerous causes, including liver failure, kidney failure, opportunistic infections, space-occupying lesions of the central nervous system, hypoxia, metabolic disturbances, a high fever of any cause, and HIV itself.

Therefore, the first step in assessing a patient's abnormal mental state is to evaluate the patient for serious medical conditions. This is true even if the patient has a known psychiatric history, because severely ill psychiatric patients often also present with serious untreated medical conditions. Note that evaluating agitated patients may require assistance from other hospital staff -- it is always important to ensure your own safety as well as that of the patient.

Also at the boundary of mental illness and medical illness is the large number of alcohol- and drug-related conditions. Alcohol withdrawal is a common cause of abnormal behavior and can result in death from seizures and hyperpyrexia if left untreated.

Another type of medical and psychiatric emergency is the patient who presents with or is imminently at risk for a suicide attempt. Those who have made attempts may need urgent medical treatment, and all require immediate supervision to prevent further harm. An effective screening and triage approach is essential to managing these patients.

Ultimately, however, the most common mental disorders seen in people with HIV infection are mood disorders; anxiety disorders, including post-traumatic stress disorder (PTSD); and alcohol or other substance use disorders. Indeed, key populations most at risk for HIV infection often have high rates of mental illness, even before becoming HIV infected. For example, men who have sex with men typically have higher rates of substance use, mood, and anxiety disorders compared with the general population, whereas sex workers, especially those who work outdoors, have high rates of substance use disorders and PTSD.

Biological, psychological, and psychosocial factors can influence the ways in which mental disorders can be caused by or exacerbated by HIV infection. Major depression is of particular importance and is best conceptualized as a medical comorbidity of HIV infection. The symptoms of depression are as much physical as they are mental, and some patients report few or no psychological disturbances but instead present with severe fatigue accompanied by numerous physical symptoms.

Emerging evidence suggests a bidirectional relationship between depression and inflammation, whereby one disorder makes the other more likely. This may help explain why approximately one third of patients with HIV infection suffer from major depression, and why major depression is associated with increased morbidity and mortality from HIV infection. In addition, because major depression is associated with failure to access and adhere to HIV care and treatment, it is clearly worthy of treatment in its own right in people with HIV, independent of its broader effects.

Finally, the direct effect of HIV on the brain can cause cognitive impairment. Although tools can be used to screen for HIV-associated dementia, much more common forms of milder or asymptomatic cognitive impairment can be more difficult to assess. A collaborative approach between primary care and mental health providers is critical to ensuring that full evaluations and neuropsychological testing are performed as needed.

Mental Health Screening in HIV

Editor's Note: This guideline was prepared by the New York State Department of Health (NYS DOH) AIDS Institute HIV Clinical Guidelines Program and was originally published in graphical format as Mental Health Screening: A Quick Reference Guide for HIV Primary Care Clinicians. A text-based version was developed by NYS DOH and has been published here.

Overview

People with HIV are more likely to experience mental health symptoms than are those in the general population.^[1] Depression, anxiety, 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 Mental Health Screening Quick Reference Guide may be used in the primary care setting to perform routine mental health assessment for HIV-infected patients.

All HIV-infected patients should receive baseline and ongoing assessment of the following^a:

• Mental health disorders:

  • Depression (every visit)

  • Anxiety (at least annually)

  • PTSD (at least annually)

• Cognitive function (at least annually)

• Sleep habits and appetite (every visit)

• Psychosocial status (at least annually)

• Suicidal/violent ideation (every visit)

• Alcohol and substance use (at least annually) ^b

aFor most patients, mental health screening requires approximately 10-20 minutes.

bAt-risk drug and alcohol users should be screened more frequently to identify escalation of present levels of use or harmful consequences from use.

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 (ie, psychiatrists, psychologists, clinical social workers, and psychiatric nurse practitioners).

Assessments and Screenings

Assessment for Depression, Anxiety, and PTSD

A brief screening tool, such as the Patient Health Questionnaire (PHQ-2), may be used for routine depression screening. Annual mental health screening for depression, anxiety, and PTSD can be performed with the Substance Abuse/Mental Illness Symptoms Screener (SAMISS) questionnaire,^[2] which is a comprehensive mental health screening tool that has been validated in HIV-infected patients. A positive screen from these tools should prompt further evaluation by a member of the healthcare team and, if necessary, referral to a mental health provider.

For the PHQ-2 and other screening tools, see Mental Health Screening Tools. For questions from the SAMISS questionnaire that can be used for annual assessment, see the Mental Health Screening Quick Reference Guide.

Assessment of Cognitive Function

Early motor and cognitive slowing may be detected with the International HIV Dementia Scale, which can be administered by nonneurologists and has been validated in HIV-infected patients.^[3] To access the International HIV Dementia Scale, refer to Mental Health Screening Tools.

Assessment of Sleep and Appetite

Sleep and appetite are important elements of a mental health assessment. Insomnia occurs frequently in HIV-infected patients and during all stages of HIV disease,^[4] and weight loss is a strong predictor of HIV disease progression.^[5] Resources for sleep and appetite include:

• Mental Health Screening Tools;

• Somatic Symptoms; and

• Insomnia Screening and Treatment Quick Reference Guide.

Substance Use Screening

A positive screen from any one of the following tools indicates the need for additional evaluation for substance use disorders:

• Single Alcohol Screening Question;

• The Two-Item Conjoint Screen (TICS); or

• CAGE-AID (CAGE-Adapted to Include Drugs).

For these and other available tools, see the Substance Use Screening Quick Reference Guide. For additional information on substance use screening, see Screening and Ongoing Assessment for Substance Use.

Screening for and Management of Acute Suicidal or Violent Ideation or Behavior

The following algorithm can be used in the HIV primary care setting to screen for the risk for acute suicidal or violent ideation or behavior.

Algorithm for screening for the risk for acute suicidal or violent ideation or behavior.

Considerations for Mental Health Referral

Successful mental health referral involves communication between medical and mental health providers, as well as patient education. Referral to a mental health provider is warranted when a patient presents with:

• Risk for violence to self or others;

• Psychosis, including delusions, hallucinations, flight of ideas, and disordered thinking;

• Poor response or relapse of psychiatric symptoms while receiving medication/treatment; or

• Active substance abuse or relapse to substance use with mental health disorder.*

*Refer to a program for dually diagnosed patients.

Additional Considerations

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 a sexually transmitted disease, introduction of antiretroviral medications, or AIDS diagnosis;

• Hospitalization (particularly first hospitalization);

• Life changes (eg, death of a significant other, end of relationship, job loss); or

• Necessity of making end-of-life permanency-planning decisions.

Elements of a Psychosocial Assessment

The following assessment may help determine the need for additional support:

• Stability of housing,* employment, and 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.

Prescribing Considerations

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.

References

1. Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58:721-728. Abstract

2. Pence BW, Gaynes BN, Whetten K, Eron JJ Jr, Ryder RW, Miller WC. 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. Abstract

3. 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. Abstract

4. Reid S, Dwyer J. Insomnia in HIV infection: a systematic review of prevalence, correlates, and management. Psychosom Med. 2005;67:260-269. Abstract

5. Colecraft E. HIV/AIDS: nutritional implications and impact on human development. Proc Nutr Soc. 2008;67:109-113. Abstract

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