Psychosomatics 40:321-324, August 1999
© 1999 The Academy of Psychosomatic Medine
Delivering Mental Health Care to HIV-Positive Individuals
A Comparison of Two Models
Maria F. Gomez, M.D.,
David A. Klein, M.D.,
Shara Sand, Psy.D.,
Mari Marconi, M.S.W., and
Mary Alice O'Dowd, M.D.
Received November 20, 1997; revised November 24, 1998; accepted December 4, 1998. From the Department of Psychiatry and the Department of Social Work, Montefiore Medical Center, Bronx, New York. Address correspondence and reprint requests to Dr. O'Dowd, Director, Consultation-Liaison, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467.
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ABSTRACT
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Data on initial psychiatric evaluations performed in 1995 were compared to assess whether psychiatric consultation for human immunodeficiency virus (HIV)-positive/acquired immunodeficiency syndrome (AIDS) patients provided on-site in an infectious disease (ID) clinic improved compliance and were preferred by staff to evaluations performed in a specialized AIDS psychiatric program. Compliance with initial appointments remained below 50% in both settings, but more patients seen in the ID clinic had received prior psychiatric treatment and medication and they were more likely to receive a psychotropic prescription at this initial visit. The ID clinic staff preferred on-site consultations. Stationing psychiatric consultants in the ID clinic may reach a more impaired population but did not improve compliance with the initial visit.
Key Words: AIDS/HIV • Health Services
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INTRODUCTION
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The interrelationship between human immunodeficiency virus (HIV) infection and mental illness is a complex one, with HIV infection adding stress to the already compromised coping skills of the mentally ill, while mental illness itself may increase risk behaviors and thus predispose the affected person to HIV infection. Several studies have found a substantial proportion of the chronically mentally ill report engaging in HIV risk behaviors.1–3 As a result, surveys of psychiatric patients in a variety of urban settings have found rates of HIV infection ranging from 5% to 25%, with patients often unaware of their HIV status.4–7 Approaching the problem from another direction, surveys of psychiatric illness in persons attending HIV-positive/infectious disease (ID) clinics have found a high prevalence of psychiatric disorders, often antedating any knowledge of HIV infection. McDaniel et al.8 found that more than 50% of the 56 ID clinic patients interviewed had had psychiatric histories before HIV testing, while Perry and his colleagues found lifetime rates of mood disorder higher in subjects at self-perceived risk for HIV infection than rates reported from epidemiologic catchment area surveys.9 Other studies have found either higher rates of personality disorder in HIV-positive persons or more severe personality disorders,10–12 suggesting the possibility of greater difficulty for such persons in coping with HIV infection and greater challenges for the health care professional trying to provide care to them. Substance use disorders, either as primary HIV risk factors or comorbid with psychiatric disorders and further impairing judgment about risk behaviors, are also obviously common in an HIV-positive population, and substance abuse may even be more severe in this population.13,14 The final area of interaction is the possibility of the HIV infection causing new psychiatric disorders. In addition to acquired immunodeficiency syndrome (AIDS) dementia complex, with behavioral manifestations that may require psychiatric evaluation and/or care,15 a number of authors have reported the onset of psychosis or mood disorders in the later stages of HIV infection.16,17 Patients may also experience symptoms related to anxiety or depression at any stage of HIV infection.18,19
This complex series of interaction suggests that substantial numbers of HIV-positive persons will need psychiatric care over the course of their infection. Several models for delivering such care have been described. In some settings, the HIV-positive patients receive mental health care in the general psychiatric care system, alongside other patients with mental health needs and without any particular linkage with their medical care.20 In the second model, specialized HIV care programs have been set up within a department of psychiatry, with function similar to other psychiatry services but with the providers closely linked to the primary medical care providers through formal and informal contacts.19 The third model stations the mental health care provider on a permanent or part-time basis in the primary care/ID clinic, with the goal of a more complete integration of services and greater ease of providing care to a difficult patient population.21
At Montefiore Medical Center, a 700-bed, tertiary-care hospital in a geographic area of high HIV seroprevalence, a specialized HIV mental health clinic, staffed by psychiatrists and psychologists from the consultation-liaison (C–L) service, has been in operation since 1987. The clinic, called the Psychiatry AIDS Connected Ambulatory Program (PACAP) and the population it serves have been previously described.19 In brief, the HIV population is evenly divided between men and women, slightly more than half are Hispanic, and intravenous drug use and heterosexual transmission are the predominant HIV risk factors. The overall demographics of the population in the ID clinic, the primary referral source, are similar, although slightly more of the ID patients (58%) are male. Integration of the mental health services with those of the ID/AIDS team has been achieved over the years through participation in team rounds, case conferences, and more informal contact.
Because the staff in the ID clinic felt the wait of several weeks or more for an outpatient screening in PACAP was sometimes too long for a patient in crisis, in 1995, the C–L attending physicians and fellows began setting aside one morning a week to do on-site psychiatric evaluations in the ID clinic. Choice of referral site was left to the ID staff, but it was agreed that patients needing more urgent assessment would be "fast-tracked" to the ID clinic evaluation, whereas patients whose need for care seemed less urgent would be referred to PACAP. In all cases, the patients were made aware that referral to a psychiatrist was being made and that the appointment they were being given was for a psychiatric evaluation. The information was most often provided and reinforced by the ID clinic social workers who also followed up on missed appointments. As the unkept appointment rate in the PACAP clinic had always been disappointingly high, averaging close to 50% for initial appointments, it was hoped that stationing the psychiatrist in the ID clinic would remove any barrier to care that might arise from having the psychiatric clinic in a different building and overcome some of the resistance or stigma associated with psychiatric care and clinics. It was anticipated that this would improve compliance with the initial psychiatric visit, thus improving delivery of care and making more effective use of psychiatric time. It was also anticipated that having the psychiatric assessment immediately available in the chart would make it more useful to the primary care staff. Informal feedback to the referring staff would also be facilitated by having psychiatric and medical staff at the same site.
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METHODS
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To assess whether psychiatric consultations provided on-site in an ID clinic improved patient compliance and were seen as more useful by staff than those provided in an off-site, more traditional, although specialized, psychiatric clinic (PACAP), data on all initial appointments kept at both sites in 1995 were reviewed. Demographics, diagnoses, prior psychiatric diagnoses and treatment, and current treatment recommendations were reviewed. All clinical assessments were made by using the same data-collection sheets and a semistructured interview. The majority of the assessments at both sites was performed by the same staff members (MFG, DAK, SS, and MAO'D). After 1 year's experience, the referring clinicians were given a questionnaire and asked to compare their experience with the two models and to assess which model better met their patients' needs.
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RESULTS
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During the year studied, 134 patients were scheduled for initial psychiatric appointments in PACAP and 101 initial appointments were scheduled in the ID clinic. The percentage of appointments kept in both settings was almost identical (47.8% PACAP, 48.5% ID: Table 1). Although there was a trend toward the patients seen in ID having more advanced HIV disease and being more likely to have had prior psychiatric treatment, these differences were not significant (Table 2). The ID clinic patients evaluated tended to be more likely to receive a diagnosis of any depressive disorder or substance abuse and less likely to receive a diagnosis of adjustment disorder, but again these differences were not significant. The differences approaching significance were only for the diagnosis of substance abuse. Overall, the ID patients were more likely than the PACAP patients to receive a prescription (P=0.001) (Table 3), with antidepressants the only class of medication prescribed significantly more often for the ID clinic patients (P=0.013). The medical staff questionnaire indicated greater satisfaction with the ID assessments and a preference for on-site care.
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DISCUSSION
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Providing psychiatric evaluations to an HIV-positive patient population in their primary care clinic did not improve compliance with the initial visit. There was no difference in the percentage of patients keeping initial appointments in the two settings studied. The consideration that stationing psychiatrists in the ID clinic might allow better use of psychiatry time did not appear to be validated by this 1-year review. However, there was a trend toward the patients who were seen for an initial psychiatric evaluation in ID clinic being more seriously ill, both medically, as determined by stage of HIV infection, and psychiatrically, based on report of prior psychotropic medication and treatment. Since psychiatric evaluation and services had been available to these persons through PACAP before ID clinic evaluation, and some patients seen in ID had actually missed prior PACAP appointments, it is possible to hypothesize that these impaired persons were more able to use services provided in the primary care site. The presumption of more serious psychiatric illness in these persons is confirmed by the significantly greater use of medication by the consultants performing the initial evaluations in the ID clinic setting. It is not surprising that the medical staff preferred the on-site evaluations, with the evaluation immediately part of the medical record and with the increased availability of informal "curb-side" consultation.
Obviously, looking only at compliance with initial appointments does not give a complete assessment of compliance. Many patients in both sites missed several appointments before finally accessing care. Beyond that initial appointment, there are further issues of compliance, such as with ongoing care and with medication recommendations. In addition, in the ID clinic, it was hoped that the primary care doctors would take a greater role in medication management for some patients after the initial psychiatric assessment and medication recommendations. However, this possible benefit produces another barrier to patient compliance with psychiatric recommendations, as physician concordance with psychiatric consultants' diagnostic and treatment recommendations has long been known to vary.22,23 However, such a detailed look at compliance in these populations over time is beyond the scope of this article.
In the face of the growing AIDS population seen at ID clinics, and because of improved patient survival times and a shift in emphasis from inpatient to outpatient medical care, the availability of both models of care may help to meet the needs of a wider range of patients. However, in view of the continued high rate of unkept appointments in the primary care site, double-booking, which is used by the ID primary care staff, may be helpful if psychiatrist time is to be used effectively in a medical outpatient setting (Holland JC, personal communication, 1996).
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ABSTRACT
INTRODUCTION
