SLAM DUNC3,9 and other trials10,11 in HIV populations used response-driven algorithms interpreted by nonphysicians to guide depression management. Can these algorithms be adapted to clinical practice?
The algorithm we used in SLAM DUNC3 was heavily based on what was used in the original STAR*D depression trial in primary care 10 years ago.13 It's an adaptation of a standard chronic disease management approach to managing depression, and that algorithm was designed for use in primary care. The Depression Management Tool Kit, a great resource from the MacArthur Foundation, details the same approach using the PHQ-9 [see page 20 of reference 5] and offers primary care clinicians other practical guides to depression screening, diagnosis, and treatment.5 The University of Washington also has a toolkit for collaborative care for depression that presents many of these same elements.14 We have also published our adaptation of the approach for HIV care so others can use it.9
In SLAM DUNC we specifically looked carefully at interactions between antiretrovirals and antidepressants, but there really weren't many interactions to be very concerned about. So the principles present in the toolkits available are just as applicable to HIV clinical care.
The really key aspect of these algorithms is the emphasis on measuring depressive symptom severity regularly -- in particular about 4 weeks after any new prescription or dose adjustment -- to see if the treatment is working. If the patient is still depressed, the treatment plan probably needs to be adjusted. One of the big gaps in primary care and other nonpsychiatric management of depression is that an antidepressant may be started, but it may be many months before there's any sort of assessment of whether it's helping. Several scales, like the PHQ-9 for example, are well validated as tools that can measure depressive severity and guide treatment adjustment decisions.
What other issues should HIV clinicians be aware of in caring for people with depression?
I think there are great lessons to be learned from the experience of primary care over the last 10 to 15 years in expanding depression identification and treatment. That primary care model could be very helpful in structuring depression management in the HIV clinic.
We know depression is highly prevalent in people with HIV infection; we know that it can be identified reliably; and we know that much of it can be managed well in the HIV clinical home with the algorithms we discussed. At the same time we know that many HIV-positive patients don't have access to good mental health care elsewhere. Even though we really wish they could all be treated by a psychiatrist or a specialty mental health clinic, that's simply not the reality for many of these patients. There's a real opportunity within HIV clinical care to greatly improve quality of life for a substantial proportion of patients and at the same time try to head off some of the disengagement from care, poor adherence, disease progression, and poor clinical outcomes -- all consequences that have been linked to depression. I think there's opportunity for movement in improving primary HIV care of depression.
|High Depression Rates With HIV -- and Its Scathing Clinical Impact|
|Depression Risk Factors With HIV -- Plus Screening and Diagnosis Keys|
|When and How to Treat Depression -- and How to Make It Easier|
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