Scores on a standard depression scale fell by half during 12 months of antiretroviral therapy (ART) in 281 previously untreated adults with HIV. Lack of health insurance boosted 12-month depression scores, but treatment with efavirenz (Sustiva, Stocrin) did not.
Depression remains highly prevalent in diverse HIV populations. Research shows that depression leads to poor antiretroviral adherence and to greater HIV-related morbidity and mortality. Some work links treatment with efavirenz to depression and suicidality, but other research does not confirm this association.
To assess the impact of depression before ART and factors related to continued depression during ART, researchers from the University of Alabama at Birmingham (UAB) conducted a retrospective study of patients starting their first antiretroviral regimen between January 2007 and December 2012. The UAB team used medical records to gather scores on the Patient Health Questionnaire depression scale (PHQ-9) and relevant sociodemographic data before ART began and during treatment. The researchers classified patients into two groups: major depression (PHQ-9 score ≥10) or mild or no depression (PHQ-9 ≥9). They compared pre-ART scores with scores closest to 12 months after ART began. Multivariate logistic regression explored relationships between 12-month depression and sociodemographic and clinical variables.
The 281 patients assessed averaged 36 years in age. Most were men (83%), men who have sex with men (61%) and black (61%). Eighty-seven participants (31%) had depression before starting ART and 59 (21%) had depression at treatment month 12. Median PHQ-9 score was significantly higher before ART (6.0, interquartile range [IQR] 2 to 11) than at 12 months (3.0, IQR 0 to 8) (P < .001). Median pre-ART and 12-month PHQ-9 scores were 4.3 and 2.0 for patients starting efavirenz and 8.0 and 4.0 for those starting a non-efavirenz regimen. Among the 87 people with pre-ART depression, 37 (43%) remained depressed on treatment.
Odds of depression were twice higher before ART than at treatment month 12 (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.3 to 3.6). Multivariable analysis adjusted for channeling bias (avoiding efavirenz in patients with or at risk for depression) figured that odds of depression at 12 months were eight-fold higher in people with pre-ART depression (OR 8.1, 95% CI 3.9 to 16.8, P < .001) and more than two-fold higher in people without insurance (OR 2.6, 95% CI 1.2 to 5.7, P = .02). Compared with patients younger than 30 years old, those older than 45 had nearly tripled odds of depression (OR 2.9, 95% CI 1.0 to 8.5, P = .05). Treatment with efavirenz did not boost chances of depression at 12 months (OR 0.9, 95% CI 0.4 to 1.8). Neither sex nor race affected depression risk.
The researchers believe their results "emphasize the need for comprehensive HIV care, including ART prescription and mental services ... to optimize health outcomes."
Depression screening is routine for new patients at the UAB HIV clinic. But depression remains underdiagnosed and undertreated in most HIV populations. Analyzing U.S. studies, other investigators estimated that only 45% of HIV patients with major depressive disorder are recognized clinically, only 40% of those receive treatment, only 40% of that group receives adequate treatment and only 70% of the last group achieves remission. Effective treatment of depression is well established, these HIV depression experts note, but "successful treatment of depression in HIV patients is a rare event due to shortcomings in clinical recognition, treatment initiation, and treatment adequacy."
Mark Mascolini writes about HIV infection.