• Refer to mental health service (if no current MH provider), or consult with current MH provider prior to consideration of antiviral treatment.

• Serious suicide ideation or a suicide plan are medical emergencies. Follow local mandates regarding possible emergency hold orders.

• Refer to mental health service (if no current MH provider), or consult with current MH provider, if possible.

• If MH services are not readily accessible, consider treatment with antidepressant after ruling out bipolar disorder.

• Assure depression is properly managed prior to proceeding with antiviral treatment.

• Obtain additional alcohol/drug use history.

• Educate about effects of substance use & methods of avoiding becoming infected or spreading infection.

• Advise to cut down or quit (conduct brief intervention).

• If meets DSMIV criteria for SUD (Appendix G), refer to specialty substance use disorder services.

• More information is available at the VA Office of Quality and Performance.

• Obtain additional alcohol/drug use and psychiatric history.

• Recommend abstinence from alcohol and recreational drugs.

• Consider whether referral to MH services is indicated.

• Educate about neuropsychiatric effects of antiviral treatment.

• Safety & efficacy of prophylactic treatment vs. symptom-triggered treatment for depression symptoms not established.

• Discuss options with patient and agree on plan.