Abstract: Prevalence of major depressive disorder runs 2 to 3 times higher in people with HIV infection than in the general population. Yet depression often goes undiagnosed or untreated in HIV populations. One analysis calculated that fewer than half of depression cases get recognized clinically in people with HIV, only 18% get treated, only 7% get treated adequately, and only 5% achieve remission through treatment. Depressive symptoms may affect two thirds of people with newly diagnosed HIV infection. Research in US and Swiss cohorts links depression to greater HIV mortality and all-cause mortality. Diverse studies document the baneful impact of depression on antiretroviral adherence and, at least partly in consequence, on CD4-cell and virologic response to antiretroviral therapy. Treating depression with selective serotonin reuptake inhibitors (SSRIs) ameliorates the impact of depression on these outcomes.
More than 1 in 3 people infected with HIV in the United States has major depressive disorder, according to analysis of a national probability sample of people in care.1 But almost half of the 488 people with major depressive disorder determined by the Composite International Diagnostic Interview, 45%, did not have a depression diagnosis in their medical record. An 8-site US study of 803 HIV-positive people with mental health and substance abuse disorders found that only 59% received any mental health treatment in the past 3 months.2 And among 551 people diagnosed with mood disorders, only 40% took an antidepressant. In a Veterans Administration analysis of 434 HIV-positive and 298 HIV-negative veterans with test-determined depression, only 38% of the HIV group and 34% of the HIV-negative group took a selective serotonin reuptake inhibitor (SSRI).3 Fewer than half in each group got an SSRI or mental health counseling.
More than 1 in 3 people infected with HIV in the United States has major depressive disorder, according to analysis of a national probability sample of people in care.1
HIV depression experts at Duke University and other centers recently underlined three troubling facts about depression care in HIV populations:4
- Although highly prevalent in people with HIV, depression remains widely unrecognized.
- When recognized clinically, depression often goes untreated.
- When treated, the therapeutic strategy typically does not follow best-practices guidelines.
Duke's Brian Pence and depression collaborators4 collected and parsed data from the cited studies1,2 and others to describe a depression treatment cascade for people with HIV. The end of the cascade looks more like a trickle. They calculated that of all cases of major depressive disorder in 1 year, only 45% are recognized clinically, only 40% of those recognized get treated, only 40% of those treated are treated adequately, and 70% of those treated adequately achieve remission. To state these estimates another way, only 18% of HIV-positive people with major depressive disorder get treated, only 7% receive adequate treatment, and only 5% emerge from their depression (Figure 1). That means 82% of HIV-positive people with depression receive no treatment, 93% do not get adequate treatment, and 95% do not attain remission.
One Estimate of HIV Depression Care Cascade
Figure 1. According to a recent estimate of the major depressive disorder care cascade in people with HIV infection, fewer than half of cases get recognized clinically, only 18% get treated, only 7% get treated adequately, and only 5% achieve remission through treatment.4
Credit: Teresa B. Southwell/The Center for AIDS Information & Advocacy
How can healthcare professionals coax more flow through this ever-narrowing HIV depression care cascade? Pence and colleagues propose working collaboratively on multiple cascade steps, for example, "combining routine depression screening with collaborative care models that give HIV providers decision support in prescribing and adjusting antidepressants within the HIV 'medical home.'"4 (See the three models of such support.) This issue of RITA! aims to abet this process by helping clinicians understand (1) depression prevalence and clinical impact in people with HIV, (2) risk factors and keys to screening for and diagnosing depression, and (3) effective treatment.
Depression Rate 2 to 3 Times Higher With HIV
Major depressive disorder affects 17% of US adults in their lifetime, according to the 2001-2003 National Comorbidity Survey of 9282 people.5 Depression prevalence in people with HIV may stand 2 or 3 times higher, depending on the population studied and how depression is determined.
A 2001 comparison of a nationally representative sample of 2864 HIV-positive US adults and 22,181 people in the National Household Survey on Drug Abuse charted nearly a 5 times higher prevalence of major depression in the HIV group (36.0% versus 7.6%).6 In other HIV populations, prevalence of major depressive disorder or moderate to major depression has ranged from 26% among 212 people in Denmark,7 to 28% among 4422 people in the Swiss HIV Cohort Study,8 to 38% among 210 people in California.9 Depressive symptoms affected 15.7% of 2863 HIV-positive people in Western Europe and Canada10 and 48.8% of 690 people in Italy.11 Among 180 people with newly diagnosed HIV infection in Houston, 67% had depressive symptoms.12
Centers for Disease Control and Prevention (CDC) researchers used the simple 8-item Patient Health Questionnaire to identify current major depression in a nationally representative sample of 4168 people in care for HIV infection in 2009.13 They compared that prevalence with the rate in 267,584 people in the Behavioral Risk Factors Surveillance System. Current major depression affected 12% of adults with HIV, a prevalence 3.1-fold higher than current major depression in the general population. That prevalence ratio changed little in analyses controlled for age, race/ethnicity, or education. Controlling for both female gender and lower annual household income cut the prevalence ratio to 1.5 (95% confidence interval [CI] 1.4 to 1.7).
A 2001 meta-analysis of 10 studies comparing prevalence of major depressive disorder in 2596 HIV-positive or negative men who have sex with men (MSM) calculated an aggregated prevalence of 9.4% in men with HIV versus 5.2% in men without HIV.14 Those rates translated into a doubled chance of major depressive disorder in MSM with HIV (odds ratio [OR] 1.99, 95% CI 1.32 to 3.00). None of the individual studies -- reported from 1988 through 1998 in the United States, Canada, Australia, and Japan -- found higher odds of major depressive disorder in men with HIV, probably because none of the studies had enough participants to yield the needed statistical power to show a doubled chance of depression.
Fewer studies address depression incidence in people with HIV. Among 4422 people without a history of psychiatric disorders or depression in the Swiss HIV Cohort Study, depression developed at a rate of 3.9 cases per 100 person-years.8 A comparison of 297 HIV-positive men and 90 HIV-negative men in the HIV Neurobehavioral Research Center at the University of California, San Diego focused on men who did not have major depression, anxiety, or substance dependence when starting 2 years of follow-up.15 Men with symptomatic HIV disease proved significantly more likely to have a major depressive episode during those 2 years than asymptomatic HIV-positive men or HIV-negative men (about 40% versus 20%).
Research also shows that high proportions of people with HIV ponder suicide and sometimes attempt it. A review of studies published from 1995 through 2015 figured that 13.6% to 31% of HIV-positive people think about suicide and 3.9% to 32.7% try it.16 Analysis of 1560 HIV-positive people in the US CHARTER cohort determined that 26% thought about suicide and 13% tried it.17