1. Chapter 8 Depression and Human Immunodeficiency Virus Francine Cournos, MD Karen McKinnon, MA Mark Bradley, MD Copyright © 2011. World Psychiatric Association

2. 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 Copyright © 2011. World Psychiatric Association2

3. 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 Copyright © 2011. World Psychiatric Association3

4. 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 Copyright © 2011. World Psychiatric Association4

5. 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 Copyright © 2011. World Psychiatric Association 5

6. 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 6 Copyright © 2011. World Psychiatric Association

7. 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. Copyright © 2011. World Psychiatric Association7

8. 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 Copyright © 2011. World Psychiatric Association8

9. 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. Copyright © 2011. World Psychiatric Association9