FINDING PEOPLE WHO NEED SUPPORT

Before PLWHA can be linked to the mental health care they need, those who have mental health issues must be identified. Two screening tools developed specifically for PLWHA are aimed at working efficiently in busy clinical or support service settings.

One tool is the HIV/AIDS Bureau’s Client Diagnostic Questionnaire (CDQ). The CDQ was developed through the Special Projects of National Significance Program for use in various service sites, including medical clinics, multiservice community organizations, and homeless shelters. The questionnaire, which takes 15 to 20 minutes to complete, can be administered by staff with no mental health training. It screens for depression, anxiety disorder, and psychosis as well as for alcohol and drug abuse or dependence.

The drop-in center at the Native American Health Center in San Francisco offers culturally rich activities, caring staff, and holistic approaches to care to address clients’ physical as well as mental health needs.

The baseline assessment indicates PLWHA who need either further assessment or direct referral to treatment by a clinician. Research on the CDQ’s effectiveness found that it identified 90 percent of clients with clinically significant mental health needs.24 Ordering information for the free CDQ and the related training manual is available here.

Another useful tool is a 16-question form known as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS), which has proved its effectiveness as a frontline screening tool.25 The questions take less than 15 minutes to administer, so patients who screen positive are also advised to undergo a confirmatory psychiatric evaluation.26 English- and Spanish-language versions of the SAMISS, together with the answer keys, can be downloaded here. Exit Disclaimer

Data from the HCSUS also identified certain characteristics that may predict a greater likelihood of mental health issues. An analysis of a subsample from the HCSUS found that those most likely to screen positive for mental illness

  • Were under age 35,
  • Lived alone or with a nonromantic partner,
  • Were unemployed or disabled,
  • Experienced more HIV-related symptoms, or
  • Used illicit drugs other than marijuana.27

Severity of HIV disease did not play a role in the findings, although women in the study who showed signs of mental illness were more likely to have advanced disease or need income assistance.28

More recent data from the North Carolina study echoed the association between younger age and mental illness and also found that mental illness rates were higher among Whites and patients with higher viral loads.29

People working with or supporting PLWHA should be on the lookout for other signs of mental health difficulties, such as missed appointments or abruptly changing or stopping medications. Specific triggers that may lead to mental distress include the following:

  • Learning of one’s HIV-positive status
  • Disclosure of one’s HIV status to family and friends
  • Introduction of medication
  • Occurrence of any physical illness
  • Recognition of new symptoms or progression of disease (e.g., a major drop in CD4 cells, an increase in viral load)
  • Necessity of hospitalization (particularly the first hospitalization)
  • Death of a significant other or anniversaries of loved ones’ deaths
  • Holidays
  • Diagnosis of AIDS
  • Changes in major aspects of lifestyle (e.g., job loss, end of relationship, relocation)
  • Need to make end-of-life and permanency planning decisions.30,31
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REFERENCES
  1. Lesser J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70:539–45.
  2. Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA. 2001;286:2857–64. 3Lesser, 2008.
  3. Lesser, 2008.
  4. Starace F, Ammassari A, Trotta MP, et al. Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31(Suppl 3):S136–9.
  5. Whetten K, Reif S, Whetten R, et al. Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care. Psychosom Med. 2008;70:531–8.
  6. Cook JA, Grey D, Burke J, et al. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health. 2004;94:1133–40.
  7. Kalichman SC. Co-occurrence of treatment nonadherence and continued HIV transmission risk behaviors: implications for positive prevention interventions. Psychosom Med. 2008;70:593–7.
  8. Carrico AW, Antoni MH. Effects of psychological interventions on neuroendocrine hormone regulation and immune status in HIV-positive persons: a review of randomized controlled trials. Psychosom Med. 2008;70:575–84.
  9. Horberg MA, Silverberg MJ, Hurley LB, et al. Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy on clinical outcomes in HIV-infected patients. J Acquir Immun Defic Syndr. 2008;47:384–90.
  10. Bing EG, Burnam A, Longshore D, et al. Psychiatric disorders and drug use among HIV-infected adults in the US. Arch Gen Psychiatry. 2001;58:721–8.
  11. Lesser, 2008.
  12. New York State Department of Health. Suicidality and violence in patients with HIV/AIDS. 2007. Accessed October 30, 2008.
  13. Whetten K, Reif S, Napravnik S, et al. Substance abuse and symptoms of mental illness among HIV-positive persons in the Southeast. South Med J. 2005;98:9–14.
  14. Whetten et al, 2008.
  15. Weiser SD, Wolfe WR, Bangsberg DR. The HIV epidemic among individuals with mental illness in the United States. Curr Infect Dis Rep. 2004;6:404–10.
  16. National Alliance of State and Territorial AIDS Directors. Mental Health Issue Brief: HIV and mental health: the challenges of dual diagnosis. 2005. Accessed October 15, 2008.
  17. Treisman et al, 2001.
  18. Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158:725–30.
  19. Horberg et al, 2008.
  20. Horberg et al, 2008.
  21. Treisman et al, 2001.
  22. Clare DM, Kissane DW. Demoralization: its phenomenology and importance. Aust NZ J Psychiatry. 2002;36:733–42.
  23. Treisman et al, 2001.
  24. HIV/AIDS Bureau, Health Resources and Services Bureau. Tools for grantees: The Client Diagnostic Questionnaire (CDQ). n.d. Accessed October 21, 2008.
  25. Pence BW, Gaynes BN, Whetten K, et al. Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients. J Aquir Immune Defic Syndr. 2005;40:434–44.
  26. Pence et al, 2005.
  27. RAND Corporation. Mental health and substance abuse among people with HIV: lessons from HCSUS. Santa Monica, CA: Author; 2007. Accessed October 15, 2008.
  28. RAND Corporation, 2007.
  29. Whetten et al., 2005.
  30. New York State Department of Health. Mental health care for people with HIV Infection: HIV clinical guidelines for the primary care practitioner. Table 1-1: crisis points for HIV-infected persons. 2001.
  31. Personal communication, Armando Smith, Chief Program Officer, Vital Bridges, October 2008.
  32. New York State Department of Health. The role of the primary care practitioner in assessing and treating mental health in persons with HIV. 2001 Accessed November 3, 2008.
  33. National Institute of Mental Health. Depression. 2007. Accessed November 3, 2008.
  34. National Institute of Mental Health. Anxiety disorders. 2008. Accessed November 3, 2008.
  35. Clare & Kissane, 2002.
  36. New York State Department of Health. Cognitive disorders and HIV/AIDS: minor cognitive disorder, HIV-associated dementia, and delirium. 2007. Accessed November 3, 2008.
  37. Coffey, S, Ed. AIDS Education and Training Centers National Resource Center. Clinical manual for management of the HIV-infected adult. 2006. Accessed November 3, 2008.
  38. Mental Health America. Fact sheet: personality disorders. 2006. Accessed November 3, 2008.
  39. AllPsych Online. Psychiatric disorders: substance related disorders. Accessed November 3, 2008.
  40. Smith, personal communication, 2008.
  41. New York/New Jersey AETC. Psychiatric medications and HIV antiretrovirals: a guide to interactions for clinicians. 2008. Accessed November 3, 2008.
  42. Emlet CA. An examination of the social networks and social isolation in older and younger adults living with HIV/AIDS. Health Soc Work. 2006;31:299–308.
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