Medically stable patient with hepatitis C

1. Obtain History , Physical

• Past psychiatric history
• Family psychiatric history
• Current medications

2. Conduct mental status examination

3. Administer

• Depression screening tool
(BDI, PRIME-MD, or CES-D)
• PSTD Screen
• AUDIT-C
• Drug use questionnaire
• Urine drug screen

• BDI, PTSD screen, AUDIT-C & Drug use questionnaire are included in this appendix of this toolkit

• Other depression screening tools are available on the internet

• Check with your laboratory to determine what drugs are included in a routine Urine Drug Screen (UDS). It is advised to include opioids (both natural, such as morphine, and synthetic, such as oxycodone & methadone), amphetamines, cocaine, and benzodiazepines

Current serious suicide ideation or suicide plan, OR history of psychosis or bipolar disorder?

• 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.

Current depressive disorder
(as demonstrated by)?

• BDI > 18
• Meets DSM-IV criteria for major depression
• Currently receiving treatment for depression?
• Positive Screen for PTSD

• 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

Possible Substance Use Disorder (SUD)?

• AUDIT - C>4
• > Five times lifetime drug use for recreational drugs
• Positive UDS for non-prescribed]
• Injection drug use in the past 6 months
• Positive breath or blood alcohol at clinic visit

History of diagnosis or treatment for SUD

• 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

High risk for developing MH or SUD disorders during antiviral treatment?

• BDI score 6 - 18

Currently drinking >2 drinks/day

• History of PTSD
• History of two or more past psychiatric diagnoses

• 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.

• Monitor neuropsychiatric symptoms with standardized scale every 2 - 4 weeks for at least 12 weeks or throughout antiviral treatment

• Periodically reassess substance use