Antidepressant Rx in HIV Care

Antidepressant management can be integrated into HIV care, leading to clinically significant depression improvements and increased depression-free days, according to a new randomized trial.

Depression is a major barrier to HIV care. Depressive disorders affect an estimated 20% to 30% of people living with HIV and are strongly associated with reduced antiretroviral medication adherence, virologic failure, and higher mortality rates, stated the authors, led by Brian W. Pence, PhD, MPH, Associate Professor, Department of Epidemiology, Gillings School of Global Public Health in Chapel Hill, NC.

HIV-infected patients face a large mental health treatment gap. “Estimates suggest that among HIV-infected patients with depression, only one in five are receiving depression treatment and even fewer are receiving effective (rather than sub-therapeutic) treatment,” the researchers stated.

They conducted a randomized trial to test the effect of measurement-based care (MBC), a decision support model for antidepressant management integrated into HIV care, on HIV and mental health outcomes among 304 HIV-infected adults with depression. Participants were mostly men, Black, non-Hispanic, unemployed, and virally suppressed, with high baseline self-reported antiretroviral adherence and depressive severity.

The researchers randomized 149 participants to intervention and 155 participants to usual care. The results show no differences between the two groups in antiretroviral adherence or other HIV outcomes.

At 6 months, depressive severity was lower among intervention participants than usual care, the probability of depression remission was higher and suicidal ideation was lower.

By 12 months, both groups had comparable mental health outcomes. However, the intervention group experienced an average of 29 more depression-free days. By shortening the course of depressive episodes, the intervention led to nearly an additional month of depression-free days over the 12 months of the study, they noted.

“MBC depression management approach was effectively integrated in four HIV clinics, with high uptake of antidepressants and timely dose escalation in the intervention arm,” the researchers stated. They suspect that MBC did not improve HIV outcomes because of high baseline adherence.

Their results are similar to two other randomized trials of antidepressant-focused depression treatment strategies, which reported substantial improvements in mental health measures, but no effect on HIV-related measures.

Other studies show depression treatment can improve HIV outcomes. Three trials of cognitive behavioral therapy for depression with integrated adherence counseling showed improvements in both depression and adherence among adults with HIV and depression. A meta-analysis of 29 studies encompassing more than 12,000 individuals estimated that depression treatment improved the odds of satisfactory antiretroviral adherence by 83%.

In conclusion, the researchers stated: “New care models that build on the success of collaborative depression treatment, in general primary care, are critically needed to address the large mental health treatment gap among people living with HIV. Models such as MBC efficiently leverage clinic staff time to provide antidepressant prescription decision support to HIV medical providers.”

They believe their trial demonstrates that a “real-world strategy can significantly shorten the course of depressive illness for HIV patients and reduce overall morbidity from depression.”