Mental Health Screening in HIV: Guideline and Commentary

Francine Cournos, MD


June 12, 2013

In This Article

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.