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Mental Health/Substance Use – Diagnostic Tools

Diagnostic Tools

Evaluation of substance use and dependence in people living with HIV

Substance use and dependence has implications for the management of PLWHIV; however, under-reporting of illicit substance use is common. As such, all individuals diagnosed with HIV should be screened for substance use and dependence.1

Assessment (complete history and physical examination) should take place:2

  • at initial patient evaluation for HIV infection
  • before initiation of combined antiretroviral therapy (ART)
  • every 6–12 months during follow-up

A substance use and treatment history includes:1

  • substances used (including alcohol and combinations of drugs), and age at first use
  • modes of drug administration
  • lifetime, recent and current use
  • changes in drug effects over time
  • history of tolerance, overdose and withdrawal
  • periods of abstinence and attempts to quit
  • complications of substance use (e.g. hepatitis, abscesses)
  • current problems, including severity of dependence
  • types and outcomes of previous treatment for drug dependence

Evaluation of psychological morbidity

Mental health comorbidities occur in 25% to 50% of injecting drug users (IDUs) with HIV. A psychosocial assessment, undertaken at initial evaluation, should focus on:1

  • any source of instability that may undermine adherence to treatment
  • depression and other mood disorders
    • adherence to highly active antiretroviral therapy (HAART) has been reported to be greater among depressed PLWHIV who adhere to antidepressant treatment compared with those who do not adhere to it, or do not receive it (see Treatment section)3
  • other psychiatric problems

Assessment tools

Substance and alcohol use and dependence

Any screening of an individual patient’s substance use or dependence must be voluntary and fully informed, with explanation for the need to understand the individual’s past or present substance use.

  • In Europe, the preferred screening and assessment instrument for substance use and dependence is the European version of the Addiction Severity Index (EuropASI).1
    • the EuropASI asks questions on several areas of life, including health, employment, alcohol and drug use, criminal activities, family and social relationships, and psychological health
    • some questions ask about the past 30 days or past 6 months, others span the patient’s entire lifetime
    • the questions are asked by a physician and it takes around an hour to complete the interview

Psychosocial assessment

Standardised screening tools have been developed for the general population to improve the detection of psychological illness, including:

  • Brief Psychiatric Rating Scale (BPRS)7
    • it is simple to administer, consisting of 24 psychiatric symptoms whose severity can be scored on a scale of 0–7, where 0 is ‘not present’ and 7 is ‘extremely severe’
    • the scores reflect the condition of the patient at the time of the assessment
  • Montgomery Asberg Depression Rating Scale (MADRS)8
    • a 10-item checklist (scored on a scale of 0–6) that evaluates the patient’s condition at the time of the interview
    • this tool is considered particularly useful for physically ill patients1

Download the quick reference guide for mental health screening, from New York State Department of Health



  1. World Health Organization. HIV/AIDS Treatment and Care. Clinical Protocols for the WHO European Region, 2007.  Accessed 25 October 2011.
  2. European AIDS Clinical Society. Guidelines, Version 6.0. Accessed 12 October 2011.
  3. Yun L, Maravi M, Kobayashi JS, Barton PL, Davidson AJ. Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir Immune Deficiency Syndr 2005;38(4):432–438.
  4. Ewing JA. Detecting alcoholism: The CAGE questionnaire. JAMA 1984;252:1905–1907.
  5. Babor TF, Biddle-Higgins JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care, 2001. Geneva, Switzerland: World Health Organization.
  6. National Institute of Alcohol Abuse and Alcoholism. Assessing alcohol problems, 2003
  7. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychiatric Reports 1962;10:799–812. Accessed on 01 November 2011.
  8. Montgomery S, Asberg M. A new depression scale designed to be sensitive to change.  Br J Psychiatry 1979;134:382–389.