In a 300-person trial, depression care managers helping HIV providers pick appropriate antidepressants significantly relieved depression when compared with usual care. But the measurement-based care plan they used had no impact on antiretroviral adherence or other HIV outcomes.
About one-quarter of HIV-positive people have depression, which affects antiretroviral adherence, virologic response and mortality. Yet only an estimated one-fifth of HIV-positive people with depression receive treatment for that illness. Researchers at four U.S. HIV clinics conducted this trial to test measurement-based care (MBC) in relieving depression.
The investigators randomized 304 study participants with confirmed major depressive disorder to either treatment as usual or MBC, in which depression care managers work with HIV providers to select appropriate antidepressant therapy with an evidence-based algorithm. All study participants were taking antiretroviral therapy, and none had two or more antidepressant treatment failures in clinical trials
The MBC and usual-care groups averaged respectively 42.8 and 44.9 years in age, 75% and 64% men, 56% and 68% black, and 36% and 25% white. Three-quarters of both groups were unemployed. Depression severity on the HAM-D test averaged 20.3 in the MBC group and 19.9 in the usual-care group. About 40% in both study arms were already taking antidepressants. During the trial antidepressant prescription and moderate/high dosing rose in both arms but "more rapidly and substantially" in the MBC intervention arm.
Six months after randomization, the groups did not differ in antiretroviral adherence measured by unannounced phone-based pill count or self-report. Nor did the groups differ in viral load, appointment attendance or HIV-related symptoms.
After six months the intervention group had significantly lower depressive severity (mean difference -3.7 on the Patient Health Questionnaire-9, 95% confidence interval [CI] -5.6 to -1.7), a 13% greater probability of depression remission and an 18% lower rate of suicidal ideation. Through 12 months of follow-up, improvements in the control arm evened response rates by these measures. But at 12 months the intervention group had an average 29 more depression-free days (95% CI 1 to 57).
In contrast to the results of this trial, a 29-study meta-analysis involving more than 12,000 people determined that treating depression improved chances of antiretroviral adherence by 83%. The researchers suggest that the trial participants' high baseline antiretroviral adherence could explain failure of the MBC intervention to improve adherence in this study -- "potentially introducing a ceiling effect on HIV outcomes."
The authors stress that health workers successfully integrated the MBC management approach into the four HIV clinics. The intervention promoted "high uptake of antidepressants and timely dose escalation."
They believe that "real-world" strategies like MBC "that build on the success of collaborative depression treatment, in general primary care, are critically needed to address the large mental health treatment gap among people living with HIV."
Mark Mascolini is a freelance writer focused on HIV infection.