May was Mental Health Awareness month. How aware of mental health issues are we in our own lives as well as in those we treat every day? As HIV care providers, how often do we hear “I am so down,” “I haven’t had fun in so long,” or “I’m so stressed.” Often in our patient’s lives everything becomes a problem, so do we truly recognize the stress they may be experiencing? With clinic visits becoming shorter and patient volume growing larger, checking in on a person’s mood often falls by the wayside.
Studies vary on the prevalence (0 – 80%) but most agree the incidence of depression in the HIV-infected population is similar to other chronic illnesses. If this is correct, 25-30% of our patients meet the criteria for Major Depression. Many more transiently feel “down” and could benefit from intervention of some sort, which may vary from some type of interpersonal therapy to psychopharmacologic intervention. Screening tools become an important part of the patient visit to identify those who need further interventions. Many tools are available and should be chosen based on ease of administration, and time for completion. A short list includes Beck Depression Inventory -II (BDI-II), Brief Symptom Inventory (BSI), and the Patient Health Questionnaire (PHQ-9). In states with Medicaid expansion and more aggressive Affordable Care Act rollout, the ability to intervene has increased. For states without Medicaid expansion and fewer resources, mental health services remain status quo. Therefore, in states without Medicaid expansion, it behooves the Primary Care Provider (PCP) to learn about and use these resources. Waiting for the initial psychiatric or therapy appointment to intervene is a waste of valuable therapeutic time. Utilizing self-report screening tools allows providers to determine who needs further attention. Referring case managers familiar with mental health issues then provides another level of support. They can further assess the individual during the visit, and make treatment recommendations for the provider to intervene.
In these situations, it is important to for the PCP to understand how to use a few antidepressants/anti-anxiety medications. There are many relatively safe medications that have few interactions with antiretrovirals. It is also important to know where the HIV-infected individual can be referred locally for therapy, as not all interventions need to be pharmacologic. Starting medications may be sufficient without need for psychiatric referrals. Following up with tools that assess progress on each visit or a phone call can help determine more intensive intervention (psychiatric referral). For example, both the Beck Depression Inventory –II, and the Patient Health Questionnaire have been validated for interval use demonstrating progress of treatment.
Treatment of mental health issues (specifically depression) is important for effective treatment of HIV. With few treatment options, Primary Care Providers need to take more of a lead with treatment to assure positive patient outcomes.