Acute Psychosis and Emergency Referrals
After excluding or treating urgent medical conditions, clinicians should refer patients in acute psychiatric distress and those with suicidal or violent ideation for immediate psychiatric evaluation.
Clinicians should be able to recognize the signs and symptoms of delirium and refer patients presenting with such symptoms immediately to the hospital.
Diagnosis of Severe and Persistent Mental Illness (SPMI)
Differential Diagnosis
Clinicians should assess patients for any treatable underlying medical or neurologic conditions, including those attributable to medications that could cause or exacerbate a mental health condition.
Diagnosis
Clinicians should refer patients for a psychiatric evaluation when patients present with symptoms of psychosis that are not attributable to delirium or dementia.
Treatment and Management of Patients with SPMI
Developing a Treatment Plan and Coordination of Care
Clinicians should investigate the mental health history of patients with SPMI and contact the last known treating psychiatrist.
Clinicians should determine whether patients with SPMI are receiving mental health care. For patients who are receiving mental health care, clinicians should coordinate with their mental health providers. If the patient is not receiving mental health care, the clinician should refer him/her for such care.
Clinicians and mental health care providers should collaborate to develop a step-by-step treatment plan that delineates the frequency of follow-up visits with both providers as well as the frequency of contacts between providers to reevaluate effectiveness of the overall medical and mental health treatment.
Patients with SPMI Who Refuse Psychiatric Care
Psychotropic Management
When managing psychotropic treatment of SPMI patients who refuse psychiatric care:
- The primary care clinician should consult with a psychiatrist within the healthcare team if available, both initially and if assistance is required over time, when prescribing or changing psychotropic medications
- If a psychiatrist is not available within the healthcare team, the primary care clinician should consider creating an ongoing "silent partnership" with a psychiatrist outside of the healthcare team that maintains the confidentiality of the patient's identity but enables the clinician to consult about the patient's psychotropic medications.
Nonpharmacologic Mental Health Management
When managing the nonpharmacologic aspects of mental health care for SPMI patients who refuse psychiatric care:
- The primary care clinician should consult with a licensed mental health professional within the healthcare team if available (e.g., psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse) on an ongoing basis, such as during team meetings, regarding the patient's treatment but
- If a mental health professional is not available for regular consultation within the team setting, the primary care clinician should consider creating an ongoing "silent partnership" outside of the healthcare team that maintains the confidentiality of the patient's identity but enables the clinician to consult with a licensed mental health professional.
Key Point:
According to Health Insurance Portability and Accountability Act (HIPAA) regulations, the patient's identity cannot be shared with the silent partner without the patient's consent in most cases. These regulations may vary according to the type of facility. For specific information about HIPAA, refer to the New York State Department of Health's HIPAA Information Center.
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Engaging the Patient with SPMI in Care
Clinicians should attempt to engage human immunodeficiency virus (HIV)-infected patients with SPMI in a partnership of care.
Clinicians should not attempt to argue or change the delusional belief systems of patients with SPMI.
Clinicians should help all members of the staff develop and enhance their skills for working with patients with SPMI.
Key Point:
Attempting to show patients with SPMI the illogic of their beliefs is counterproductive in establishing a partnership in treatment and could ultimately frustrate both the clinician and patient.
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| Table. General Guidelines for Interacting with Patients with
Severe and Persistent Mental Illness |
- Become familiar with the person behind the illness; attempt to connect on a personal level.
- Keep in mind that patients with SPMI are rarely physically violent*; potential for violence should be assessed on a case-by-case basis.
- Be as straightforward as possible; do not be evasive or overly protective with medical information; the tendency of some patients with SPMI to be suspicious may be exacerbated by a clinician's evasiveness.
- Create a structured environment; patients with SPMI respond best when they know what is expected of them.
- Do not try to change the belief systems of patients; delusional beliefs often do not prevent patients from understanding and following medical instructions.
- Give them space; if they want to disengage in conversation, let them.
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*The low incidence of violence applies to all disorders associated with SPMI. However, comorbid substance use increases the risk of violence in these patients (see the National Guideline Clearinghouse (NGC) summary of the New York State Department of Health (NYSDOH) guideline, Suicidality and Violence in Patients with HIV/AIDS).
| Table. Maintaining the SPMI Patient in Care |
- Assess patients' psychosocial status regularly—housing, employment and/or social security disability benefits, health insurance, family and partner contacts, stability of relationships, including domestic violence screening.
- Ask follow-up questions of patients regarding mental health and treatment progress as a routine part of clinic visits.
- Monitor interactions between patients' physical and mental conditions and the effects of psychotropic and other medications.
- Make referrals to mental health care if the patient is not receiving mental health care.
- Monitor adherence to recommended mental health treatment, including psychotropic medications, appointments with mental health providers, and attendance in support groups.
- Include mental health diagnoses among other medical data, assessments, and plans.
- Consider patients' mental status before prescribing antiretroviral (ARV) medications.
- Maintain follow-up phone contact with patients' mental health treatment programs, including notifying programs of medication changes.
- Monitor patients' potential barriers to adherence to ARV therapy when applicable (refer to the NGC summary of the NYSODH guideline, Adherence to Antiretroviral Therapy among HIV-Infected Patients with Mental Health Disorders).
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Key Point:
Adherence to treatment can be enhanced when appointments are scheduled at times when the needs of patients with SPMI are best accommodated.
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ARV Therapy and Adherence
Clinicians should initiate ARV therapy only after the patient's basic needs have been adequately addressed, including receipt of social support services and stabilization of mental status through effective treatment of psychiatric symptoms.
Clinicians should discuss potential side effects of psychotropic medications, as well as their potential interactions with ARV therapy and other medications. If side effects or interactions occur, clinicians and patients should discuss how they will be managed.
Clinicians should note all medications in the medical record, including psychotropic medications that patients with SPMI are receiving.
Risk Reduction Counseling and Substance Use Referral
| Table. Identification and Management of Risk in Patients with SPMI |
| Risk |
Management Recommendation |
| Coerced or forced sex |
- Intensive risk-reduction counseling that includes skills training in detecting and avoiding situations that increase risk for sexual violence
- Rape crisis services* when patients present immediately after an episode of coerced sex
- Referral for domestic violence services when appropriate
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| Inconsistent use of barrier protection |
- Intensive risk-reduction counseling, including the importance of effective barrier protection to avoid HIV transmission
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| Trading sex for money or drugs |
- Assistance with applying for benefits for food and housing and other services for which they might be eligible to reduce the likelihood of trading sex
- Intensive risk-reduction counseling, including the importance of effective barrier protection to avoid HIV transmission
- Referral for substance use treatment; in particular, injection drug users enrolled in methadone or buprenorphine programs are less likely to engage in high-risk behaviors such as unprotected sex or needle sharing; they are also more likely to adhere to HIV-related treatment and medication regimens**
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*Examples of such services include crisis counseling and emergency contraception.
** Refer to the NGC summary of the NYSDOH Substance Use Guideline, Working with the Active User.
Sexual Risk Behaviors
Clinicians should determine whether sexually active patients with SPMI have experienced or are at risk for coerced or forced sex.
Clinicians should educate patients, including those with SPMI, about safe-sex practices when discussing HIV risk reduction.
Substance Use
Clinicians should make appropriate referrals, including consulting a mentally ill chemical abuser (MICA) specialist, when substance use disorders are identified in SPMI patients.
Clinicians should screen all HIV-infected patients for past and present substance use at baseline and at least annually.
Patients at Risk for Violence
Clinicians should clearly instruct medical support staff about how to manage emergencies involving patients with potential or actual violent behavior toward self or others.
Mental Health Services and Programs
Clinicians should have access to information regarding follow-up for patients with SPMI, including assisted outpatient treatment and intensive case management, which can be obtained by calling 1-800-HEALTHNET.
