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Mental Health Screening Tools for the HIV Clinician. Lawrence M. Mc Glynn MD Clinical Associate Professor Stanford University Faculty Medical Director San Jose AETC June 2013. Thanks. Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center

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Mental health screening tools for the hiv clinician

Mental Health Screening Tools for the HIV Clinician

Lawrence M. Mc Glynn MD

Clinical Associate Professor

Stanford University

Faculty Medical Director

San Jose AETC

June 2013


  • Pacific AETC Staff and Faculty; San Jose AIDS Education and Training Center

  • American Psychiatric Association – Office of HIV Psychiatry

Goals for participants
Goals for Participants

  • Understand which mental illnesses present themselves more frequently in HIV

  • Identify risk factors for mental illness in HIV

  • Become familiar with screening tools for conditions which may affect the overall health of people living with HIV/AIDS

Types of screening tools
Types of Screening Tools

  • Patient focused

    • Self administered

      • Usually consist of questionnaires

    • Clinician administered to patient

      • Questionnaires

      • Labs

      • Imaging

      • Examinations (physical and mental status)

        • Includes simple observation

  • Observer(s)

    • Testimonials from family, friends, coworkers, other providers

Why screening tools
Why screening tools?

  • Relative objectivity (provider bias)

  • Efficiency

  • Lack of resources

    • Mental health timely availability

  • Shows the patient that you are considering all aspects of his/her life

Cognitive dysfunction
Cognitive Dysfunction

  • As HIV enters the CNS at a very early stage of infection, a cascade of events leads to changes in multiple realms of cognition

Neuropsychological domains
Neuropsychological Domains

  • Verbal/Language

  • Attention/concentration

  • Working Memory

  • Executive/Abstraction

  • Memory (learning, recall)

  • Speed of information processing

  • Sensory-perceptual

  • Motor skills

Associated behavioral disturbances
Associated Behavioral Disturbances



Sleep disturbance



Hand classification
HAND Classification

Asymptomatic Neurocognitive

Impairment (ANI)

1 SD

No Functional


2 Domains

Mild Neurocognitive

Impairment (MNI)

Mild Functional


1 SD

2 Domains

Moderate to Severe Functional


2 SD


Dementia (HAD)

2 Domains

NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

Prevalence of hand based on new criteria
Prevalence of HAND based on New Criteria

NP Normal








Functional Impairment

NIMH, NINDS Panel, Neurology 2007; 69:1789-1799

Risk and protective factors
Risk and Protective Factors

  • Risk factors

    • Age > 50

    • Survival duration

    • Lower nadir CD4 T-cell counts

    • Higher baseline viral load

    • Gender (F)

Why bother to screen
Why Bother to Screen?

  • MNI has been associated with poorer health outcomes, possibly due poorer adherence to medications

  • Even mild HAND is associated with worse quality of life, difficulty obtaining employment and shorter survival

  • McGuire, Goodkin, and Douglas report that HAND independently predicts systemic morbidity and overall HIV mortality

  • Consider screening upon the initiation of cART and q6-12 months

Mind Exchange Working Group. CID Advance Access. Nov 2012.

The role of objective assessment

  • General Practitioners ability to pick up dementia cases

    • Sensitivity 51.4% (“positive in disease”)

    • Specificity 95.9% (“negative in health”)

  • Missed dementia more frequently in patients living alone

  • Over-diagnosed dementia more frequently in patients with mobility/hearing problems, and in the depressed

  • Miss nearly half of incident dementia cases

  • Possible factors: GPs’ subjective views on dementia (e.g., therapeutic nihilism, or suspected/feared stigmatization)

  • Conclusion: use objective tests

Pentzek M, Wollny A, Wiese B, et al. Apart from Nihilism and Stigma: What Influences GP’s accuracy in identifying incident dementia? Am J Geriatr Psychiatry 17:11, November 2009.

Screening tools
Screening Tools

  • MMSE (not very sensitive, Crum et al., 1993)

  • HIV Dementia Scale (Power et al., 1995)

  • International HIV Dementia Scale (Sacktor et al., 2005)

  • Montreal Cognitive Assessment (MoCA, Overton et al. CROI 2011)

  • MOS-IV

1 memory registration
1. Memory-Registration

Give four words to recall

(dog, hat, bean, red) – 1 second to say each.

Then ask the patient all four words after you have said them. Repeat words if the patient does not recall them all immediately. Tell the patient you will ask for recall of the words again a bit later.

2 motor speed
2. Motor Speed

Have the patient tap the first two fingers of the

non-dominant hand as widely and as quickly as


4 = 15 in 5 seconds

3 = 11-14 in 5 seconds

2 = 7-10 in 5 seconds _____

1 = 3-6 in 5 seconds

0 = 0-2 in 5 seconds

3 psychomotor speed
3. Psychomotor Speed

Have the patient perform the following movements with the non-dominant hand as quickly as possible:

1) Clench hand in fist on flat surface.

2) Put hand flat on surface with palm down.

3) Put hand perpendicular to flat surface on the side of the 5th digit.

Demonstrate and have patient perform twice for practice.

4 = 4 sequences in 10 seconds

3 = 3 sequences in 10 seconds

2 = 2 sequences in 10 seconds

1 = 1 sequence in 10 seconds _____

0 = unable to perform

4 memory recall
4. Memory-Recall

Ask the patient to recall the four words. For words not recalled, prompt with a semantic clue as follows:

animal (dog); piece of clothing (hat); vegetable (bean); color (red).

Give 1 point for each word spontaneously recalled.

Give 0.5 points for each correct answer after prompting

Maximum – 4 points. _____

Total international hiv dementia scale score
Total International HIV Dementia Scale Score

This is the sum of the scores on items 1-3. ____

The maximum possible score is 12 points.

A patient with a score of 10

should be evaluated further for possible dementia.

Hiv dementia scale
HIV Dementia Scale





Give 4 words to recall (dog, hat, green, peach) and 1 second to say each. Then ask the patient to repeat all 4 after you have said them.



Antisaccadic eye movements (20 commands): ____ errors out of 20

 3 errors = 4; 4 errors = 3; 5 errors = 2; 6 errors = 1;  6 errors = 0


Ask patient to write the alphabet in uppercase letters horizontally across the page (use back of form) and record time: _____ seconds

 21 sec = 6; 21.1-24 sec = 5; 24.1-27 sec = 4; 27.1-30 sec = 3; 30.1-33 sec = 2; 33.1-36 sec = 1; 36 sec = 0




Ask for the 4 words from MEMORY – REGISTRATION TEST above.

Give 1 point for each correct. For words not recalled, prompt with a semantic clue as follows: animal (dog); piece of clothing (hat); color (green); fruit (peach). Give ½ point for each correct word after prompting.



Copy the cube below. Record time _____ seconds

 25 sec = 2; 25-35 sec = 1; 35 sec = 0

Total score < 10: HAD 11-13: Mild cognitive impairment

Adapted From: Power C et al.: HIV Dementia Scale: a rapid screening test. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology 1995;8:273-278. Used with permission.

Cognitive functional status sub scale of mos hiv scale of wu et al
Cognitive Functional Status Sub-scale of MOS-HIV Scale of Wu et al.

4 questions, past 4 weeks:

1. Difficulty reasoning/problem solving?

2. Forget things (location; appointment)?

3.Trouble with keeping attention for long?

4. Difficulty with activities using concentration / thinking?

6 pt. frequency scale: 1= all; 2=most; 3=good bit; 4=some; 5=little; 6=none [cutoff < M= 4]

Validated against NP overall performance in the Netherlands; Good for busy clinics

Knippels, Goodkin, Weiss, et al., AIDS, 2002;16:259-267

Mathematical screening
Mathematical Screening

  • Cysique et al.

  • Cognitive impairment is predicted to occur when this expression is true

Step 1 neuropsych performance step 2 functional impairment

Step 1: Neuropsych performanceStep 2: Functional Impairment?

How to assess functional impairment
How To Assess Functional Impairment?

  • Collateral Informant and Objective ratings are most reliable

    • IADL scale (Lawton)

    • Driving Performance (Marcotte et al.)

  • Karnofsky, Finances, Medications

What to do with a positive screen
What to do with a positive screen?

  • Rule out other causes

    • Always consider the biopsychosocial model

  • Treatment

    • Antiretrovirals

    • Psychostimulants

    • Other treatments being studied

Depression and anxiety
Depression and Anxiety

  • Depressed mood is one of the most common complaints among people living with HIV

  • Given the high co-occurrence of HIV and PTSD, anxiety is also frequently seen

  • These disorders may present themselves as somatic complaints

    • Headaches, GI complaints, weakness, fatigue, insomnia, chest pain, shortness of breath

    • Somatic complaints are not unusual in HIV/AIDS even when the patient is mentally healthy

Epidemiology anxiety

  • 15.8% of HIV+ have GAD (2.1% of general population

  • 10.5% have Panic d/o (2.5% of gp)

  • 37% of HIV+ women report “high anxiety”

    • Protective: relationship, older, vl BDL

Epidemiology depression

  • Lifetimes prevalence of depressive disorder in HIV as high as 22% (5-17% in general population)

  • Risk: African-american (M and W), MSM

Why bother to screen1
Why Bother to Screen?

  • Depression in HIV/AIDS is a significant predictor of worsening overall outcome

  • Depression and anxiety can contribute to poor cognitive functioning

Screening tools1
Screening Tools

  • Consider Endicott Criteria: reduce the weight of somatic symptoms (weight/appetite loss, sleep changes, agitation/retardation, fatigue, loss of concentration) in screening

  • HAD

  • Are you depressed?

Anxiety questions
Anxiety questions

  • I feel tense or wound up

  • I get a sort of frightened feeling as if something bad is about to happen

  • Worrying thoughts go through my mind

  • I can sit at ease and feel relaxed

  • I get a sort of frightened feeling like butterflies in the stomach

  • I feel restless and have to be on the move

  • I get sudden feelings of panic

  • Cutoff score: 8

Depression questions
Depression Questions

  • I still enjoy the things I used to enjoy

  • I can laugh and see the funny side of things

  • I feel cheerful

  • I feel as if I am slowed down

  • I have lost interest in my appearance

  • I look forward with enjoyment to things

  • I can enjoy a good book or radio or TV program

  • Cutoff score: 8

Are you depressed screening for depression in the terminally ill am j psychiatry 1997
"Are you depressed?" Screening for depression in the terminally illAm J Psychiatry 1997

  • Semi-structured diagnostic interviews for depression were administered to 197 patients receiving palliative care for advanced cancer

  • RESULTS: Single-item interview screening correctly identified the eventual diagnostic outcome of every patient, substantially outperforming the questionnaire and visual analog measures

What to do with a positive screen1
What to do with a positive screen?

  • Assess for suicidality

  • R/o other causes (biopsychosocial model)

  • Refer to treatment (talk, med’s)


  • Despite the development of cART, suicide rates among HIV+ individuals remain more than three times higher than in the general population.


Volume 26, Number 5, 2012


  • History of suicide attempt(s)

  • Diagnosable mental health disorder

  • History of psychiatric treatment

  • Substance use

  • Anxiety sensitivity – cognitive concerns

Why bother to screen2
Why Bother to Screen?

  • Safety

  • Establish a longitudinal record

  • Suspicion of suicide can elicit emotions in the provider

    • Is emotional decision making as precise as less emotion-based thinking?

Screening tools2
Screening Tools

  • Will you be able to sleep tonight?

  • Multiple factors to consider which make screening a challenge

    • Substance use

    • Psychosocial stressors

    • Temporal relationship to medications (e.g., efavirenz, IFN-α)

    • Medical illness

What to do with a positive screen2
What to do with a positive screen?

  • Hospitalize

  • For those deemed to be able to go home

    • F/U asap; telephone contact (to/from)

    • Urgent referral to mental health

Ptsd screening
PTSD Screening

  • The estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8–42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women

What to do with a positive screen3
What to do with a positive screen

  • Screen for depression, anxiety, domestic violence, substance abuse and suicidality

  • Refer to mental health

    • Therapy

    • Medications based on symptoms


  • Only 19% of those with HIV had never used an illicit drug

  • 1 in 4 of those with HIV in the USA report alcohol or drug use at a level warranting treatment

Why bother to screen3
Why Bother to Screen?

  • Active substance use can lead to increased morbidity and mortality

  • Substances can interact with HIV medications

Screening tools3
Screening Tools

  • Physical Exam

  • Mental Status Exam

  • CAGE questionnaire

What to do with a positive screen4
What to do with a positive screen?

  • Establish safety

    • Prescribed medications which may pose a risk

    • Concurrent illnesses (e.g., HCV)

    • Home, transportation

    • Family responsibilities (children, elderly)

  • Discuss treatment options

    • Have referral information on hand


  • For HIV+ women, the estimated rate of intimate partner violence is 55.3% (95% CI 36.1–73.8%), which is more than twice the national rate. Early childhood abuse predicts future domestic violence (Machtinger et al)

  • Among MSW with HIV, childhood sexual abuse predicted post-traumatic stress disorder (PTSD), and less trust in medical providers (Whelten et al)

  • MSM with HIV and PTSD are more likely to miss appointments (Traeger et al)

  • Victims may be less likely to leave abusive situation

  • In a sample of HIV+ individuals, 20.5% of the women, 11.5% of the MSM, and 7.5% of the MSW reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes (Zierler, Bozzette, et al)

Why bother to screen4
Why Bother to Screen?

  • Safety of patient

  • Safety of others

    • Family

    • Friends

    • Staff

Http www cdc gov ncipc pub res images ipvandsvscreening pdf

What to do with a positive screen5
What to do with a positive screen?

  • Assess for current safety

  • Document

  • Refer

    • Safe shelter

    • Mental health

  • Report

The great imitators
The Great Imitators

  • Screen for other conditions which may mimic psychiatric disorders

    • Hepatitis C - lab

    • Syphilis - lab

    • Drug Interactions – Pharm.D., website

    • Adherence challenges

    • Medication Adverse Effects

    • Malnutrition/Dehydration

Axis ii flags
Axis II Flags

  • “Everyone”

  • “No one”

  • “Always”

  • “Never”

The end
The End

  • Thank you for taking care of our community!