Transcript Depression Among People with HIV Infection Francine Cournos, MD

Depression Among People
with HIV Infection
Francine Cournos, M.D.
Professor of Clinical Psychiatry, Columbia University
Principal Investigator, New York/New Jersey AETC
[email protected]
There are no relationships to disclose.
June 2009
Depression: Dante vs. the DSM IV
Dante:
“I did not die
But yet I lost life’s breath
Imagine for yourself what I became
Deprived at once of both my life and death”
Dante’s Inferno
Translation by John Ciardi
Depression: Dante vs. the DSM IV
DSM IV Categories:
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Major depression –
severe sx + ≥ 2 weeks
Dysthymic disorder – moderate sx ≥ 2 years
Bipolar disorders
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Bipolar 1 – Major depression + mania
Bipolar 2 – Major depression + hypomania
Related disorders
- Cyclothymia
- Borderline Personality Disorder?
Adjustment disorder with depressed mood
Sub-threshold depressive symptoms
Major Depression: Key Points
• Depression is a physical and a mental illness
• Depression frequently presents in primary care
• Depression is very common among HIV+ people
• Depression is associated with increased morbidity and
mortality among HIV+ people (and for other illnesses)
• There are effective treatments for depression, but many
depressed HIV+ people never receive them
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
RAND HCSUS Study:
2,864 HIV-positive Medical Patients
Any Psychiatric Disorder:
•
•
•
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•
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Major depression
Dysthymia
Generalized anxiety disorder
Panic attack
Drug dependence
Problematic alcohol use
48%
36%
27%
16%
11%
13%
19%
Bing et al Arch. Gen. Psych. 2001
 Later studies showed elevated rates of PTSD.
Israelski et al, AIDS Care, 2007.
RAND HCSUS Study:
1,489 HIV-positive Medical Patients
• 27% took psychotropic medication :
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21% antidepressants
17% anxiolytics
5% antipsychotics
3% psychostimulants
• About half of patients with depressive disorders did
not receive antidepressants—African-Americans were
overrepresented.
• Depression is therefore common and undertreated
among HIV positive people in medical treatment.
Vitiello, et al, AJP, 2003
Depression and Mortality in
HIV+ Women
HERS cohort (Ickovics et al JAMA 2001): 765 HIV+ women at 4
sites followed for up to 7 years
– Mortality predictors: chronic depression, CD4 count,
HAART duration, age
– After adjusting for all other variables, women with
chronic depressive symptoms were twice as likely to die
as women with limited or no depressive symptoms
Depression and Mortality in
HIV+ Women
WIHS cohort: 2,059 HIV + women
• Replicated HERS results: Chronic depressive symptoms
associated with AIDS mortality (N = 1,716; Cook et al,
AJPH, 2004)
• Depression + illicit drug use, or recent drug use alone,
associated with decreased HAART utilization (N = 1,668;
Cook et al, JAIDS, 2002; N=1710; Cook, et al, Drug and
Alcohol Dependence, 2007)
The Effect of Depression Treatment on HIV
Medical Outcomes
• Use of antidepressants + MH therapy, or MH therapy alone,
associated with increased HAART utilization (N = 1,371; Cook,
et al, AIDS Care, 2006)
• Depression significantly worsens HAART adherence and HIV
viral control. Compliant SSRI use is associated with improved
HIV adherence and laboratory parameters (CD4 cell count
and viral load). (N= 3,359; Horberg, et al, JAIDS, 2008)
Summary: Depression and HIV
Progression
• Depression (and substance use disorders) are associated with nonadherence to HAART
• Controlling for adherence, depression remains associated with more
rapid progression of HIV and increased morbidity and mortality
• The treatment of depression improves medical outcomes
• The diagnosis and treatment of depression is an essential component of
HIV care
Screening for Depression:
PRIME-MD PHQ2
Over the last two weeks how often have you been bothered by any of
the following problems:
 Little interest or pleasure in doing things.
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0=Not at all
1=Several days
2=More than half the days
3=Nearly every day
 Feeling down, depressed or hopeless
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0=Not at all
1=Several days
2=More than half the days
3=Nearly every day
The higher the score the more likely the patient has depressive disorder
Kroenke et al, Med Care, 2003
Completed Suicide: A Fatal Outcome of Depression
(General Population)
Lifetime rate of completed suicide for major affective disorders =
10-15%
Risk Factors
White, male, older, single, unemployed, recent loss, access to lethal
weapons
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Previous history of suicide attempts, family history of suicide, victim of
abuse

In addition to depressive symptoms, severe anxiety, psychotic symptoms,
personality disorders, substance use, poor impulse control, detailed suicide
plan
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Severe medical illness especially with loss of functioning or intractable pain
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Qestions for Discussing Suicide
Questions:
-Do you feel unhappy and hopeless?
-Do you feel unable to face each day?
-Do you feel life is a burden?
-Do you feel life is not worth living?
-Do you feel like committing suicide?
Further questions:
-Have you made any plans to end your life?
-How are you planning to do it?
-Do you have the means to carry out suicide in your possession
(pills/guns/other method)?
-Have you considered when to do it?
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
TREATING
DEPRESSION
Barriers to Treating Depression
• Patient Level: stigma of mental illness; desire to be
strong and tough; there’s nothing wrong
• Intervention Level: the side effects of antidepressants
manifest before the therapeutic effects
• Provider Level: failure to screen, detect, discuss, treat
• System Level: limited funding/availability of mental
health services; lack of provider training
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Treatment of Depression in
People with HIV
 Modify contributing factors
 Psychotherapies
 Psychopharmacology
 Inpatient care (suicide risk, medical work-up, grave
disability)
 ECT
 Experimental brain stimulation treatments
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Depression:
Modify Contributing Factors
• Diagnose and treat underlying medical
illness
• Attempt to reduce the impact of
medication side effects and use of
substances
• Address psychosocial problems
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Brief Manualized Evidenced-Based
Psychotherapies for Depression
• Cognitive behavioral therapy (CBT) (negative
automatic thoughts)
• Interpersonal psychotherapy (IPT)
(interpersonal difficulties)
• Others (some include psychodynamic
strategies)
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Depression: When to Refer for
Urgent Psychiatric Evaluation
• Patient is suicidal and/or has just made a
suicide attempt
• Patient has symptoms of psychosis or severe
agitation (but rule out delirium)
• Patient has mixed depression and mania
Agents Used for Depression in
Patients with HIV
• Antidepressants
– SSRIs
– SNRIs
– TCA (tricyclic antidepressants )
– Other antidepressants
• Psychostimulants
• Hormonal treatment—check for / treat 
testosterone levels in men and women
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Antidepressants: SSRIs
• In general, SSRIs are well tolerated, safe, and have lower rates
of drug discontinuation in studies with HIV-infected patients –
all have equal efficacy
• SSRIs have proven efficacy in clinical trials with HIV+
depressed patients
• Drug interactions need to be considered with fluoxetine and
paroxetine
• Side effects: nausea, jitteriness, weight loss, insomnia, sexual
dysfunction
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Antidepressants: SSRIs
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Sertraline (Zoloft) 25 - 200 mg/day
Escitalopram (Lexapro) 10 – 20 mg/day
Citalopram (Celexa) 20 - 40 mg/day)
Fluoxetine (Prozac)* 10 - 60 mg/day
Paroxetine (Paxil)* 10 - 60 mg/day
*More likely to cause drug interactions
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Antidepressants: SNRIs
• Venlafaxine (Effexor) XR 75-300 mg qd
– useful in SSRI nonresponders
– extended release form preferable
– may decrease indinavir levels - significance unknown
• Mirtazapine (Remeron) 15-45 mg qHS
– very useful in patients with insomnia
• Duloxetine (Cymbalta) 20-60 mg qd
– effective for symptoms of physical pain associated with depression
– indicated for diabetic neuropathy
• Desvenlafaxine (Pristiq) 50mg
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extended release
American Psychiatric Association Practice Guidelines and other reference documents www.psych.org
Wainberg, et al. Psychiatric Medications and HIV Antiretrovirals: A Guide to Interactions for Clinicians,
second edition, New York/New Jersey AIDS Education & Training Center, HRSA, 2008.
Tricyclic Antidepressants: Potential
Useful Properties
• Anti-diarrhea
• Sedation
• Anti-neuropathic pain
• Can monitor correct dose by blood levels:
– imipramine, desipramine, nortriptyline
American Psychiatric Association Practice Guidelines and other reference
documents www.psych.org
Tricyclic Antidepressant /
Antiretroviral Drug Interactions
• Tricyclics (TCAs) are metabolized principally by CYP 2D6
• Ritonavir is a moderate inhibitor of CYP 2D6 & and may cause higher
blood levels of TCAs
• TCAs can delay cardiac conduction and cause arrhythmias, especially at
high levels
• EKG and plasma TCA monitoring is recommended when these drugs are
co-administered with ritonavir or other inhibitors of 2D6
• TCAs are dangerous in overdose--avoid giving large quantities to suicidal
patients
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Other Antidepressants
• Trazadone (Desyrel)
– good in low doses for sleep
– infrequently, arrhythmias and priaprism occur
– levels may be elevated by PIs
• Bupropion (Wellbutrin, Zyban)
– often chosen for low sexual side effects
– may cause anxiety or insomnia
– levels may be increased by efavirenz and protease inhibitors
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Wainberg, et al. Psychiatric Medications and HIV Antiretrovirals: A Guide to Interactions for
Clinicians, second edition, New York/New Jersey AIDS Education & Training Center, HRSA, 2008.
Bipolar Depression
• Check for history of mania or hypomania
(elevated/irritable mood, decreased need for sleep, high
energy, racing thoughts, pressured speech, self-importance,
risk taking behavior)
• Mood stabilizers are the treatment of choice
• Giving antidepressants alone can precipitate mania
American Psychiatric Association Practice Guidelines and other reference documents www.psych.org
Mood Stabilizers: Lithium and Anticonvulsants
with an Approved Indication
• Lithium carbonate (Eskalith, Lithobid)
– Use in lower doses or avoid with renal disease
• Divalproex sodium (Depakote)
– Can cause severe liver toxicity
– Can increase zidovudine levels – dosage
change not recommended but monitor for toxicity
• Valproic acid (Depakene)
– Can cause severe liver toxicity
– Can increase zidovudine levels – dosage
change not recommended but monitor for toxicity
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Wainberg, et al. Psychiatric Medications and HIV Antiretrovirals: A Guide to Interactions
for Clinicians, second edition, New York/New Jersey AIDS Education & Training Center,
HRSA, 2008.
Mood Stabilizers:
Anticonsulsants with an
Approved Indication
• Lamotrigine (Lamictal)
– Lamotrigine levels may be markedly decreased by lopinavir/ritonavir
• Oxcarbazepine (Trileptal)
• Carbamazepine (Tegretol + others)
– Avoid: may lower levels of PIs and NNRTIs
• Other anticonvulsants have been used but do
not have an approved indication
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Mood Stabilizers: Atypical Antipsychotics
with an Approved Indication for Bipolar
Disorder
• Aripiprazole (Abilify)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
Cautions: Interactions with PIs; metabolic complications
American Psychiatric Association Practice Guidelines and other reference
documents www.psych.org
HIV and Depression:
Other Considerations
• St. John’s Wort may lower levels of NNRTIs and protease
inhibitors – caution patients (it’s natural, but so is arsenic)
• HCV is a common comorbidity in HIV infected people; HCV
treatment (peginterferon alpha 2b + ribavirin) is associated
with depression.
American Psychiatric Association Practice Guidelines and other reference documents
www.psych.org
Wainberg, et al. Psychiatric Medications and HIV Antiretrovirals: A Guide to
Interactions for Clinicians, second edition, New York/New Jersey AIDS Education &
Training Center, HRSA, 2008.
Educational Resources on HIV and
Mental Health
• Local and national AETCs
• NYS AIDS Institute:
www.hivguidelines.org
• American Psychiatric Association Office of
HIV Psychiatry:
www.psych.org/AIDS
AETC National Programs
•
National Resource Center (FXB/UMDNJ)
– Provides virtual library of online training resources
for adaptation to meet local training needs
– www.aidsetc.org
•
Warmline/PEPline (UCSF)
– Telephone consultation for HIV clinical
management and post-exposure prophylaxis
management
– Warmline:
800-933-3413
PEPline:
888-448-4911
To schedule a Psychiatric Consultation please
contact James Satriano, PhD, at
[email protected]
OR 212/543-5591
To schedule a Training Activity, please contact
Dusty Hackler, MA, at
[email protected]
OR 212/543-6537
OR visit us on the web at:
www.columbia.edu/~fc15/