Mental Health Screening in the Primary Care Setting
The primary care clinician should conduct a mental health assessment at baseline and at least annually thereafter (see Tables 2, 3, and 4 below).
Table 2 Primary Care Mental Health Screening
Screen all human immunodeficiency virus (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
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Table 3 Questions to Identify Mental Health Disorders
Cognitive Impairment
- 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?
Post-Traumatic Stress Disorder (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 in the original guideline document
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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.
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/methylenedioxymethamphetamine (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.
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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?
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*For additional screening tools and guidance for assessing substance and alcohol use in HIV-infected patients, refer to the National Guideline Clearinghouse summary of the New York State Health Department's guideline, Screening and Ongoing Assessment for Substance Use.
Referring Patients to Mental Health Services
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.
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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Coordination of Care: Role of the Primary Care Clinician
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.
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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