Antidepressant Treatment Lacking in Patients With HIV
In patients with HIV, depression is linked to a range of negative clinical outcomes, including treatment adherence and mortality.
Approximately 2 in 5 HIV patients are in need of depression treatment with only about half of these patients actually receiving antidepressant treatment. These are the findings of a comprehensive study of a large, diverse sample of U.S. patients engaged in routine HIV care.
Depression in this population is linked to a range of negative clinical outcomes, including treatment adherence and mortality. Researchers analyzed the Center for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) database, which includes over 30,000 HIV-infected adults. Self-administered patient-reported outcomes (PROs) and the Patient Health Questionnaire-9 (PHQ-9) were used to measure depressive symptom severity.
Two analyses were conducted; a cross-sectional, 18-month period (July 2011 to December 2012) analysis and a prospective study of patients who were newly establishing HIV care at a CNICS site (ranging from 2005 to 2012).
Results of the cross-sectional study showed that 39% of patients had depression, with 16% having a PHQ-9 score of ≥10 (considered as likely major depression) and were not receiving antidepressants, while 9% who scored ≥10 were receiving antidepressants. Considering all patients with an indication for depression, 60% received treatment and 36% of these were in remission.
Among new CNICS patients, the estimate of those having an indication for depression treatment within the first 12 months was 44%. The estimated probability of starting an antidepressant within the first 12 months was 44% following a PHQ-9 score of ≥10, 17% following a PHQ-9 score <10, and 30% not immediately following a PHQ-9 screening.
Overall, the finding that the probability of receiving antidepressants among those who were eligible was 43% among new patients (prospective study), and 60% in the cross-sectional study. These findings are in line with previous, smaller studies from similar settings.
The authors write that their results suggest prescribers for HIV patients may be comfortable with initiating antidepressant medications but may not modify treatment when the depressive illness fails to respond to an initial dose. They posit that the creation of care models may be necessary to support primary care physicians in prescribing antidepressants to address this gap.
A growing movement of decentralizing depression care from mental health settings into primary care, including HIV primary care, may necessitate improved support for HIV providers in areas of depression, “particularly in cases that require titrating or changing antidepressant treatment regimens,” conclude the authors.
Cholera R, Pence BW, Bengtson AM, et al. Mind the gap: gaps in antidepressant treatment, treatment adjustments, and outcomes among patients in routine HIV care in a multisite U.S. clinical cohort [published online January 26, 2017]. PLoS One. doi: 10.1371/journal.pone.0166435