Implementation of Collaborative Care for Depression in HIV Primary Care

Abstract

Background. Patients living with HIV have high reported rates of depression and untreated depression has been associated with lower rates of engagement to HIV care as well as adherence to medication. Access to mental health services remains a challenge nationally. Novel approaches to providing expert mental health care are desperately needed. Methods. The collaborative care model includes routine, systematic screening for depression, behavioral health coordination, scheduled re-measurement of symptoms when present using a standardized scale, stepped measurement-based care, and expert psychiatric case review. As part of the Health Resources and Services Administration-funded Practice Transformation Initiative, we are implementing the collaborative care for depression care in our large, urban HIV clinic. Results. The intervention is active among half of the providers, and 791 patients were screened in the first 9 months. Of those patients, 167 patients had moderate or severe depressive symptoms. High or very high levels of social isolation were present among 84% of patients with depressive symptoms. One-third of patients had additional assessment by the care coordinator, developed a self-management plan and received recommendations for medication and/or psychotherapy by the collaborating psychiatrist. Rescreening has occurred among 52 of the 167 patients, with 28 reporting resolution of symptoms. Conclusion. Despite current depressive symptoms, patients have been reluctant to engage with the care coordinator. Barriers noted include patient denial, mistrust of new staff, perceived stigma, reporting an existing mental health provider, addiction issues, transportation, and having a functional phone. Nonetheless, routine screening is identifying previously undiagnosed depression as well as under-treatment of previously diagnosed depression. Rescreening offers opportunities to engage patients and build rapport when symptoms persist. Rates of comorbid psychiatry diagnoses are common and highlight the complexities of treating this population.