Depression Depresses HIV Treatment Response

By Michael Smith
OAKLAND, Calif., Dec. 21 -- More than four in every 10 HIV patients are clinically depressed, a condition that affects how well they respond to anti-HIV drugs, researchers here found.
The good news, however, is that treatment with selective serotonin reuptake inhibitors (SSRIs) appears to restore the benefit of highly active antiretroviral therapy (HAART), according to Michael Horberg, M.D., director of HIV/AIDS for Kaiser Permanente.
In a retrospective analysis of a cohort of 3,359 HIV patients, 42% also had a diagnosis of depression and 36% of those were using SSRIs, Dr. Horberg and colleagues reported online in the Journal of Acquired Immune Deficiency Syndromes.
"The take-home point here is that there is a very high prevalence of depression among HIV patients," Dr. Horberg said.
"All HIV patients should be screened for depression," he said, and if it's found, "treatment for depression -- not just with SSRIs -- should be considered concomitantly, because one helps the other."
The researchers analyzed health records of HIV patients in eight states, enrolled in the Kaiser Permanente and Group Health Cooperative HMOs, who began a new HAART regimen from January 2000 through December 2003.
Of the 3,359 patients who met the criteria, 1,961 had not been diagnosed with depression and served as a control group.
The researchers found:
Depression was associated with significantly decreased odds of achieving 90% or better adherence to HAART. The odds ratio was 0.81, with a 95% confidence interval from 0.70 to 0.98, which was significant at P=0.03.
The condition was also associated with significantly lower odds of a serum HIV RNA level of less than 500 copies per milliliter. The odds ratio was 0.77, with a 95% confidence interval from 0.62 to 0.95, which was significant at P=0.02.
The impact of depression on viral load might just be a function of poorer adherence to HAART, but interestingly, Dr. Horberg and colleagues found, the negative association persisted even when depressed patients were taking their HAART medication properly.
In a multivariable analysis taking HAART adherence into account, depressed patients were 12% less likely to get below the 500-copy level, a difference that remained significant at P=0.05, the researchers reported.
The finding implies that depression itself has an impact on the effect of HAART, over and above any possible impact on adherence, Dr. Horberg said.
Dr. Horberg said he and colleagues were puzzled by one finding, that there appeared to be little benefit of SSRIs among depressed patients who had been on HAART and were switched to a new regimen -- with the addition of an SSRI -- during the study period.
There might simply have been too few patients (428) to see an effect, Dr. Horberg said. But equally, those patients might have been severely depressed or perhaps using an SSRI that was not effective for them.
"We couldn't look at the degree of severity," he said.
The study was limited by its retrospective design, but Dr. Horberg said he and colleagues are planning a prospective study to confirm the findings.
The study was supported by the Garfield Memorial Research Fund of Kaiser Permanente. Dr. Horberg is an employee of the company.
Primary source: Journal of Acquired Immune Deficiency SyndromesSource reference:Horberg MA, et al "Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients" J Acquir Immune Defic Syndr 2007.