Transcript Depression and Human Immunodeficiency Virus

Chapter 8
Depression and Human
Immunodeficiency Virus
Francine Cournos, MD
Karen McKinnon, MA
Mark Bradley, MD
Copyright © 2011. World Psychiatric Association
Importance of Identifying and Treating
Depression in HIV-positive patients
• Studies throughout the world show that depression is common
among people with human immunodeficiency virus (HIV).
• Learning that one has a chronic, potentially fatal illness may
precipitate the onset of depressive symptoms.
• HIV is a neurotropic virus that enters the central nervous system at
the time of initial infection and persists there, and the virus itself may
cause depressive symptoms.
• Negative affective states, particularly depression and anxiety, have
been consistently associated with sexually risky behaviours,
including a lower likelihood of condom use and proper condom use
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Importance of Identifying and Treating
Depression in HIV-positive patients (Cont’d)
• Studies show that depression is associated with reduced use of
antiretroviral therapy, more rapid progression to AIDS, and early
mortality.
• Depressed patients treated with antidepressants are more adherent
to antiretroviral therapy than those with untreated depression, and
demonstrate greater improvement in adherence after initiation of
antidepressant treatment compared with untreated depressed
patients over similar time intervals after their index diagnosis of
depression.
• People with HIV infection have an increased risk of suicide when
compared to the general population.
Cook et al. 2006; Hong et al. 2007; Yun et al. 2005
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Common Psychiatric Co-morbidities
• Co-morbid psychiatric conditions are common among individuals who
have depression and HIV.
• HIV care providers often have difficulty recognising and helping their
patients manage these psychiatric problems.
• In developed countries, substance use disorders are the most
common co-occurring psychiatric disorders among people with
depression and HIV/AIDS.
• Individuals with dual psychiatric and substance use disorders may be
at higher risk for HIV infection than those with either disorder alone
• Thus, in clinical settings of any kind it is prudent to screen patients
with one type of psychiatric disorder for other psychiatric disorders.
Ferrando and Batki 2000
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Differential Diagnosis
• Diagnosing depression in HIV requires a careful differential diagnosis to rule out
treatable medical disorders.
• Distinguishing somatic symptoms of depression from somatic symptoms related to HIV
illness and its treatment can be challenging.
• Neuropsychiatric complications of the direct effects of HIV in the brain become more
frequent as illness advances and require a thorough differential diagnosis for other
possible medical causes including:
– Opportunistic infections
– Metabolic problems
– Side effects of antiretroviral agents
• Depression must be distinguished from grief, demoralisation, and the apathy
associated with dementia.
• Depression and cognitive impairment often co-exist and depression should be treated
under those circumstances.
• It is also essential to rule out intoxication or withdrawal
Bartlett and Ferrando, 2006; Bartlett and Gallant 2007
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Prescribing Antidepressants in HIV/AIDS
Treatment
• Patients with advanced HIV infection are often more sensitive to medication side
effects.
• Drug interactions become a consideration when patients are taking antiretroviral
therapy or treatments for other associated diseases.
• In many resource-limited countries, this includes treatment of tuberculosis.
• Few well-controlled trials that included a significant number of patients have been
conducted but smaller studies of antidepressants conducted with varying degrees of
rigor and at various stages of HIV illness have demonstrated efficacy for:
– Many of the tricyclic antidepressants
– All of the common selective serotonin reuptake inhibitors (SSRIs)
– Mirtazapine
– Bupropion
– Dextroamphetamine
Cozza et al. 2008
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Prescribing Antidepressants in HIV/AIDS
Treatment (Cont’d)
• The major concerns when prescribing antidepressants to medically ill patients and/or
those taking HIV-related medications are drug interactions and overlapping toxicities
• The latter is especially worrisome in patients with pre-existing liver disease, often from
alcohol misuse and/or HCV infection, which are common problems among people with
HIV infection.
• Medications for TB, another common co-morbidity may interact with antidepressants
and/or antiretrovirals.
• Most drug interactions are predicted theoretically; results may differ in vivo.
• In general, in initiating antidepressant treatment in a patient receiving protease
inhibitors, it is best to start low and slowly raise the dose of any antidepressant
medication. There is in vivo evidence that ritonavir, alone or when used to boost
another PI, increases tricyclic antidepressant levels.
• Although it is less common, certain protease inhibitors may decrease levels of
particular antidepressants.
• Use online resources to check for interactions whenever possible.
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Other Effective Treatments for Depression in
Patients with HIV/AIDS
• Certain brief psychotherapies, such as interpersonal psychotherapy
and cognitive behavioural therapy, as well as psychoeducational
programs have shown good results in treating depression and
enhancing coping in resource-poor countries where antidepressants
may not be readily available for people living with HIV
• In developed countries, where patients with HIV are frequently taking
multiple medications, having such non-medication options can be
desirable.
Bolton et al. 2003; Olley, 2006
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Conclusions
• Screening and provision of psychosocial and medication
interventions for depression should be part of comprehensive HIV
care.
• Primary care efforts to improve outcomes in the course of HIV
disease should include effective management of psychiatric
conditions, including depression, since successful intervention for
these conditions may reduce the risk of morbidity and mortality in
HIV/AIDS.
• Addressing depression in patients with HIV may result in better
treatment outcomes, enhanced quality of life, and decreased HIV
transmission.
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