Mental Health Practice Guidelines

The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.

Guideline Title

The role of the primary care practitioner in assessing and treating mental health in persons with HIV. Mental health care for people with HIV infection.

Bibliographic Source(s)

The role of the primary care practitioner in assessing and treating mental health in persons with HIV. In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 1-12.

Guideline Status

This is the current release of the guideline.

Disease/Condition(s)

Human immunodeficiency virus (HIV) infection Psychiatric disorders associated with HIV Mood disorders Substance use disorders Personality disorders Adjustment disorders Cognitive disorders Depression Suicide risk Anxiety disorders

Guideline Category

EvaluationManagementTreatment

Clinical Specialty

Allergy and ImmunologyFamily PracticeInfectious DiseasesInternal MedicinePsychiatry

Intended Users

Advanced Practice NursesHealth Care ProvidersPatientsPhysician AssistantsPhysiciansPublic Health DepartmentsSocial WorkersSubstance Use Disorders Treatment Providers

Guideline Objective(s)

To outline the role of primary care practitioners in assessing and treating mental health in persons with human immunodeficiency virus (HIV)

Target Population

Human immunodeficiency virus (HIV)-infected persons

Interventions and Practices Considered

Coordination of care among primary care practitioners, patients, mental health clinicians, case managers, and others involved in care Assessment of specific and general factors that may trigger or exacerbate mental distress in human immunodeficiency virus (HIV)-infected patients Providing substance-using HIV-infected patients with appropriate services and referrals Coordination of care with methadone program Psychotropic medications and assessment of adherence or reasons for non-adherence to the medications Consultation with and/or referral to a psychiatrist or mental health programs Counseling patients about safer sex practices

Major Outcomes Considered

Not stated

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person 3 to 4 times per year, and otherwise conduct business through monthly conference calls. Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

General Recommendations Mental health care for the person with human immunodeficiency virus (HIV) infection should be a collaborative effort involving primary care practitioners, patients, mental health clinicians, case managers, and also, when appropriate, substance abuse counselors or domestic violence service providers. The stage of HIV infection and the severity of the psychiatric disorder should determine whether the medical practitioner or the psychiatrist should be the primary care practitioner. Care should be coordinated between medical and psychiatric practitioners, and primary care practitioners should assist mental health clinicians in coordinating ongoing care when patients are referred to a mental health treatment program. Practitioners should develop and maintain the necessary skills to recognize and address the psychiatric disorders commonly associated with HIV and the factors that may trigger distress in persons living with HIV. Psychological Impact of HIV Practitioners should be aware of specific and general factors that may trigger or exacerbate mental distress or psychological disorders in HIV-infected persons and their families (refer to the table below). CRISIS POINTS FOR HIV-INFECTED PERSONS Learning of HIV-positive status Disclosure of HIV status to family and friends Introduction of medication Occurrence of any physical illness Recognition of new symptoms/progression of disease (e.g., major drop in CD4 cells, rise in viral load) Necessity of hospitalization (particularly the first hospitalization) Death of a significant other Diagnosis of AIDS Changes in major aspects of lifestyle (e.g., loss of job, end of relationship, relocation) Necessity of making end-of-life and permanency planning decisions Mentally III Substance Users Primary care practitioners should provide their substance-using patients with information about appropriate substance use-related services and, if necessary, make referrals (see Appendix IV in the "Companion Documents" field. For patients who are enrolled in a methadone treatment program and complain of drug withdrawal symptoms after starting highly active antiretroviral therapy (HAART) or other medications, coordination of care with their methadone program should be maintained so that dosage adjustments can be considered. General Issues Organic Contributions To Aberrant Behavior Direct drug influence: drug intoxication; drug withdrawal (or a combination*); drug-related delirium HIV-related central nervous system (CNS) disorders: toxoplasmosis; cryptococcosis; progressive multifocal leukoencephalopathy (PML); lymphoma; HIV dementia Underlying chronic brain disorders or developmental disorders (sometimes secondary to fetal alcohol syndrome or malnutrition): mental retardation; minimal brain dysfunction; dementia. Psychiatric illness: psychotic disorders; affective disorders; anxiety disorders; personality disorders. Other: infection; fever; hypoxia; anemia; subdural hematoma; delirium of any etiology (e.g., electrolyte imbalance, glucose imbalance); hepatic encephalopathy. *Because cocaine intoxication and sedative withdrawal are often hard to differentiate, cocaine users are often at risk for undiagnosed sedative withdrawal due to the use of sedatives in heavy doses to "come down" from cocaine. Management Issues HIV-infected mentally ill, chemical-abusing (MICA) patients with insomnia, low energy, anxiety, and pain (which can be primary symptoms or symptoms of drug withdrawal) should be referred to an addiction specialist or psychiatrist for assessment and treatment. Prescriptions for a controlled substance can be written by a primary care practitioner unless the prescriptions are part of a coordinated plan of care agreed upon by the medical practitioner and the psychiatrist. Practitioners should realize that drug users, because of their high tolerance, often require larger doses of sedatives and opioids for treatment purposes than other patients. Medications Known to Induce Enzymes and Decrease Methadone Levels Carbamazepine Nelfinavir Pentazocine Phenobarbital Phenytoin Rifabutin Rifampin Rifapentine Psychiatric Disorders Primary care practitioners should have sufficient expertise to recognize and to treat appropriately the psychiatric disorders commonly associated with HIV and acquired immune deficiency syndrome (AIDS). For patients with more severe mental illness, services based in the mental health system may be necessary. Psychotropic Medications To provide comprehensive care, primary care professionals should be familiar with the commonly prescribed psychotropic medications and should be confident in their use of these medications. Specifically, primary care practitioners should understand how these agents work, their side effects, and for whom they work best. Primary care practitioners, in addition, should be aware of how these medications may interact with HIV-related drugs (see Appendix I in the "Companion Documents" field). Adherence Practitioners should carefully assess adherence and reasons for non-adherence on a case-by-case basis. For patients with HIV and mental illness who do not adhere fully or who refuse treatment, close coordination between the primary care practitioner and psychiatrist should be maintained. Referral or Consultation The practitioner should familiarize him/herself with the resources available in the community to make the most appropriate referral (see Appendix IV in the "Companion Documents" field). Consultation with a psychiatrist, psychologist, nurse practitioner, or certified social worker is appropriate when the patient refuses treatment, when advice is needed in regard to the patient's needs for psychotherapy, or if the patient needs a complete psychiatric evaluation or assessment in regard to his/her risk of suicide. When the practitioner is in need of information concerning psychotropic medications, a psychiatrist or nurse practitioner with expertise in psychiatry should be consulted. When there is a concern about the presence of serious mental illness in a patient, the most appropriate referral is to a psychiatrist. Practitioners should contact a psychiatric service to establish intensive case management for mentally ill patients requiring such care, particularly if the patient uses substances. Practitioners should opt for referral or consultation when unfamiliar with the patient's needs for prescription of psychotropic medications, assessment of mental status, or further management of the mental condition. The primary care practitioner should routinely consider mental health aspects of care when treating patients who are also being cared for by a mental health provider (see table below). Practitioners should maintain ongoing communication with psychiatric personnel to provide optimal care. The Role of the Primary Care Practitioner When Working in Coordination with the Mental Health Provider Ask follow-up questions of patients regarding mental health and treatment progress as a routine part of office visits. Include mental health issues in medical problem lists and progress notes and in corresponding medical assessments and plans. Consider patients' mental status, particularly suicidal ideas and alcohol use or other substance use, before prescribing medications. Monitor interactions between patients' physical and mental conditions and the effects of psychotropic and other medications. Maintain follow-up phone contact with patients' mental health treatment programs, including notifying programs of medication changes. Monitor patients' attendance and missed appointments. Consider substance use as a factor in the above recommendations when appropriate. Consider mental illness and/or substance use as possible underlying causes when unexplained signs (e.g., weight loss), symptoms, or laboratory abnormalities become apparent or when there are changes in behavior or adherence with medical treatment. Treatment Programs Refer to the original guideline document for a discussion of the types of treatment programs, including outpatient mental health programs, community support programs, and emergency programs. Risk Reduction Mentally ill patients should be counseled on how to reduce their risk of HIV infection and how to avoid infecting their partners. Patients will benefit from education regarding safer sex practices, including how to use condoms and other barrier methods.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Potential Benefits

Because of the unique role of primary care practitioners in the health care system, they can help prevent or treat psychiatric illness and maximize psychologic health in patients with human immunodeficiency virus (HIV).

Potential Harms

Refer to Appendix I in the "Companion Document" field for information on potential interactions between human immunodeficiency virus (HIV)-related medications and psychotropic medications.

Contraindications

Refer to Appendix I in the "Companion Documents" field for information on contraindications between human immunodeficiency virus (HIV)-related medications and psychotropic medications.

Description of Implementation Strategy

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening, or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below. Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience. Define target audience (providers, consumers, support service providers). Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)? Define implementation methods. What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)? Determine appropriate implementation processes. What steps need to be taken to make these activities happen? What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)? What necessary processes are external to the organization (e.g., meetings with external groups, conferences)? Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion? Monitor progress. What is the flow of activities associated with the implementation process and which can be tracked to monitor the process? Evaluate. Did the processes and strategies work? Were the guidelines implemented? What could be improved in future endeavors?

Implementation Tools

ResourcesFor information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Living with Illness

IOM Domain

EffectivenessPatient-centeredness

Bibliographic Source(s)

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2001 Mar

Guideline Developer(s)

New York State Department of Health - State/Local Government Agency [U.S.]

Source(s) of Funding

New York State Department of Health

Guideline Committee

Mental Health Guidelines Committee

Composition of Group that Authored the Guideline

Committee Chair: John Grimaldi, MD, Assistant Professor of Clinical Psychiatry, Sanford Weill-Cornell University Medical College, New York, New York, Chief Psychiatrist of David Rodgers Unit, Center for Special Studies, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York Committee Vice-Chair: Francine Cournos, MD, Professor of Clinical Psychiatry, Columbia University, New York State Psychiatric Institute - Unit 112, New York, NY AIDS Institute Liaison: L. Jeannine Bookhardt-Murray, MD, Director, HIV/AIDS Care, Morris Heights Health Center, Bronx, NY AIDS Institute: Teresa C. Armon, RN, MS, Coordinator - Mental Health Initiative, Bureau of Community Support Services, New York State Department of Health AIDS Institute, Albany, NY; Josh Sparber, New York State Department of Health AIDS Institute Committee Members: Philip A. Bialer, MD, Associate Professor of Clinical Psychiatry, Albert Einstein College of Medicine, Chief, Division of Consultation-Liaison Psychiatry, Beth Israel Medical Center, New York, NY; John Budin, MD, Director, Mental Health Services, ID Clinic, Montefiore Medical Center, Bronx, NY, Clinical Instructor in Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York; Mary Ann Cohen, MD, Director, AIDS Psychiatry, Mount Sinai Medical Center, Associate Professor of Psychiatry, Mount Sinai Medical Center, New York, New York; Barbara A. Conanan, RN, MS, Program Director, SRO/Homeless Program, Department of Community Medicine, Saint Vincents Catholic Medical Centers - St. Vincent's Manhattan, New York, New York; Marc Johnson, MD, Assistant Professor of Medicine, Mount Sinai School of Medicine, New York, New York, Attending Physician, New York Hospital Queens, Flushing, New York, Physician in Charge, New York Hospital - Queens Primary Care at ACQC, Rego Park, New York; Henry McCurtis, MD, Acting Director of Psychology, Harlem Hospital Center, New York, New York; Yiu Kee Ng, MD (Warren), Special Needs Clinic, VC4E, New York Presbyterian Hospital, New York, NY; Francine Rainone, PhD, DO, Director, Community Palliative Care, Montefiore Medical Center, Bronx, New York Liaisons: Frank Machlica, MA, MSW, CSW, Senior Mental Health Consultant, New York City Department of Mental Health, Mental Retardation & Alcoholism Services, Bureau of Strategic Planning, New York, NY; James Satriano, PhD, Assistant Professor of Clinical Psychology, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, Director, HIV/AIDS Programs, New York State Office of Mental Health, New York, New York; Milton Wainberg, Title 1 Liaison

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 5 Penn Plaza, New York, NY 10001; Telephone: (212) 268-6108

Availability of Companion Documents

The following are available: HIV clinical practice guidelines. New York (NY): New York State Department of Health; 2003. 36 p. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Appendix I: interactions between HIV-related medications and psychotropic medications: indications and contraindications. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Appendix II: HIV-related causes of psychiatric symptoms: differential diagnosis. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Appendix III: rating scales. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Appendix IV: mental health care resources in New York State. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Appendix V: syringe access resources in New York State. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Appendix VI: permanency planning and transitional services. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 5 Penn Plaza, New York, NY 10001; Telephone: (212) 268-6108

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on May 4, 2005.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer. See the New York State Department of Health AIDS Institute Web site for terms of use.

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