Mental health service settings vary in their ability to offer HIV-related interventions, and the range of services available may not yet be meeting the needs of people with severe mental illness (McKinnon et al. 1999). With respect to HCV, Mendel and Ryan's preliminary findings suggest that patients with these psychiatric disorders often are thought "not good candidates" for HCV treatment, with several HIV clinics implementing policies excluding patients with serious psychiatric histories from HCV treatment despite the lack of evidence to support their concerns about maintaining adherence or triggering a major psychiatric event. One medical director at a clinic in a large hospital was willing to engage severely mentally ill patients in HCV treatment, but only if they were under heavily supervised mental health care. Implementing such arrangements could be helpful in initiating treatment and conducting mental health evaluations of candidates already on HCV treatment.
People with serious mental illness usually can undergo HIV counseling and antibody testing without inordinate distress or worsening of their psychiatric symptoms (Oquendo and Tricarico 1996). Clinicians can use their clinical judgment to determine when a patient's psychiatric condition permits optimal coping with any result, although HIV testing often can proceed when a patient is in the hospital for treatment of an acute episode. In fact, appropriate testing of inpatients has some advantages if the entire process can be completed before hospital discharge. (This is more likely now that the newly approved rapid test is available.) In these cases, staff can ensure that patients receive posttest counseling and follow-up appointments and can address any worsening of the patient's psychiatric condition in the event of a distressing test result.
Clinicians have an important role in helping their patients understand the implications of either a negative or a positive HIV antibody test result. Involvement in pretest counseling can ensure that patients have the capacity to give consent to testing; prepare themselves for the stress related to waiting for the result and the consequences of learning it; and appropriately anticipate, prevent, or manage exacerbations of psychiatric symptoms.
Voluntary HIV testing is the norm for people with serious mental illness so that those who are HIV positive can seek treatment and change their risk behaviors and yet be protected against discrimination. The capacity to consent to testing hinges on the ability to understand the information being conveyed and to draw reasonable conclusions from it. People with serious mental illness are considered to have this capacity unless an assessment determines otherwise, in which case consent may be given by a person who is legally authorized to do so. Informed consent for HIV antibody testing should include an explanation of the test, its purpose, the meaning of the results, and the benefits of early diagnosis and medical intervention. In addition, explanation should be given of the voluntary nature of the test, the individual's right to withdraw consent at any time, the availability of anonymous testing, and confidentiality and the circumstances under which test results may be disclosed with or without the individual's agreement.
The first step in the HIV counseling and testing process is to obtain a risk history. Rather than asking, "Have you ever...?" asking "How often have you...?" is more likely to elicit useful risk information without raising a patient's defenses by implying that the clinician will judge such behaviors negatively or consider them unusual.
The point of the risk assessment is to elicit behaviorally specific information about patients' sexual behaviors and drug use. Most patients, when queried in a direct and nonjudgmental way, are cooperative and forthcoming. The ease the clinician demonstrates in discussing sex and drug use will set the anxiety level for the patient, and normalizing any patient discomfort can create a more relaxed tone.
Clinicians should ensure that patients are referred for HIV testing on a regular basis whenever a patient asks for it, and when a patient has current or past risk behaviors, is pregnant, has physical signs suggestive of HIV infection or AIDS, has psychiatric symptoms that suggest CNS dysfunction, or has a positive PPD (Mantoux) tuberculin test and resides in an area endemic for HIV.
Screening for hepatitis viruses at mental health and substance abuse agencies appears to be spotty, as is screening for most medical problems. Mental health agencies that have established medical services on-site (e.g., inpatient units or shelters with co-located primary care clinics) may screen automatically for HCV and sometimes hepatitis B virus in routine laboratory examinations. In the vast majority of mental health agencies lacking on-site medical services, providers know about HCV infection only if patients self-report having been diagnosed or if they are in such advanced stages as to manifest signs of liver failure (e.g., spider angiomata, jaundice, ascites).
The initial diagnosis of HIV infection may occur when a patient first becomes infected, in advanced AIDS, or at any time in between. Shock and disbelief may be followed by depression, anxiety, and fear in adjusting to having contracted a serious and still potentially deadly illness. In many nonindustrialized countries AIDS remains a rapidly terminal condition. Untreated depression and hopelessness may be associated with continuing risk behavior, even suicidal ideation (Liberman et al. 1986). Like serious mental illness, HIV and AIDS can be highly stigmatizing, possibly resulting in rejection, abandonment, and further social isolation. If a worsening of psychiatric symptoms follows the initial HIV diagnosis, the most effective intervention is individual counseling and supportive therapy geared to both the current mental status of the patient and his or her knowledge and understanding of HIV infection (Broder et al. 1994).
Legal regulations or guidelines for confidentiality and the disclosure of HIV- or AIDS-related information are in place in many countries and can set the stage for upholding humane and responsible individual and public health standards. Contact notification by physicians may not be required, but legal statutes may allow doctors or public health officers to notify the contact themselves if they determine that a patient will not inform a contact who is at significant risk. Laws that are applicable to the locality should be consulted in making decisions that involve confidentiality and contact notification.
Testing for HCV can occur at any point and does not require a special consent. Nonetheless, it remains important to explain the test result to patients found to be HCV positive and to refer such patients for further evaluation and, as appropriate, hepatitis A and B virus immunization.
For HIV-infected psychiatric patients who are asymptomatic, supportive groups may encourage behavioral change and promote ways to preserve physical health in the community and within the psychiatric setting. This kind of group intervention can prevent worsening of psychiatric symptoms and provide a sense of community that can decrease social isolation, reinforce safer peer norms, and encourage altruism, which appeals to ego strengths and gives patients a sense of worth and accomplishment.
Although most outpatient agencies in New York City, an early epicenter, distribute HIV educational material, half or fewer of these service settings provide risk reduction interventions, conduct risk assessments, offer pre- and posttest counseling, or hold support groups for HIV-positive patients. The reason for this may be unmet needs for training, reported by 84% of agencies that serve between 1 and 10 persons with HIV infection annually and have staff members already trained in providing at least one HIV-related service. Services may be directed at patients on the basis of their suspected or presumed risks rather than on the basis of a thorough risk assessment (McKinnon et al. 1999, 2001). These findings are echoed in other United States regions (e.g., Brunette et al. 2000) and may suggest how to improve service delivery systems in other AIDS-endemic areas where resources allow for comprehensive care.
Clinicians may be in the best position to help their patients access HIV testing, treatment, and prevention opportunities. They can employ many strategies to help their patients determine their risk of acquiring or transmitting the AIDS virus; to prevent new infections, to promote healthier behaviors; and to reduce the impact of HIV-related illness on this vulnerable population. They also are uniquely qualified to help their patients manage the many medications required to maintain their psychiatric and physical health.
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