In primary care, physicians commonly miss between one-half and two-thirds of patients who screen positive for depression using accepted scales. (Source: https://www.ncbi.nlm.nih.gov/pubmed/2184790) Moreover, patients are often hesitant to mention mood issues to their physicians. Depressive symptoms, such as fatigue or poor appetite, are easily attributable to HIV infection or medications (Source: http://www.natap.org/2001/dec/122101_1.htm), making additional inquiry into such symptoms important. Untreated, depression can undermine HIV treatment by contributing to poor medication adherence, self-care skills, and an increased risk of morbidity and mortality. If the HIV Physician does recognize a patient with depressive symptoms and needs to refer them to psychiatry, long wait times may exacerbate the patient’s symptoms.
In a collaborative care model, the HIV physician doesn’t have to rely on the patient to express symptoms of depression or refer a patient to the long wait for psychiatric care. Instead, all patients are screened annually in the clinic for depressive symptoms using the Patient Health Questionnaire (PHQ-2/PHQ-9) as a part of the patient’s health maintenance items. The Medical Assistant (MA) enters the PHQ-2/PHQ-9 results into the Electronic Medical Record (EMR) during intake. Patients with depressive symptoms are flagged in the EMR, and the MA notifies a Behavioral Health Care Manager (BHM). The BHM assesses symptoms further and shares insights with the HIV provider, who may initiate medication immediately in parallel with expert consultation for depression treatment by the Consulting Psychiatrist (CP). Additionally, the BHM will follow up with the patient regularly for emotional support and ensure needs are being met.
The CP provides the HIV physician with the medication recommendation through the EMR. The HIV physician prescribes the antidepressant. A Case Consultation Formulation is available for reference, addressing differential diagnosis and the appropriate treatment for each. It provides the HIV physician with antidepressant dosing recommendations, side effects, and treatment considerations. The MIDUS Algorithm was created to allow HIV physicians and BHMs the ability to quickly identify the next steps to take for patients with different PHQ-9 scores to progress towards remission.
HIV physician responsibilities:
- Incorporate BHM into the care team
- Provide time and space for BHM to meet with patients in the clinic
- Review consultation notes and prescribe psychiatric medications as recommended by the CP (typically antidepressants though with time, some HIV physicians and CP add additional medications to their repertoire)