July 3, 2015
With appropriate support, people with HIV/AIDS can be helped to manage their depression effectively, according to a new study co-led by a researcher at UNC Gillings School of Global Public Health. However, effective depression treatment, even when combined with brief counseling about the importance of HIV medication adherence, did not lead to improvements in adherence or health outcomes, the study found.
Brian Wells Pence, PhD, associate professor of epidemiology at the Gillings School, co-led the study, which was published online July 1 in the journal AIDS.
In the clinical trial called Strategies to Link Antiretroviral and Antidepressant Management (SLAM DUNC), Pence and colleagues placed depression care managers in HIV clinics to guide HIV medical providers in prescribing antidepressants. The care managers monitored patients’ response to treatment and recommended additional antidepressant dose increases or treatment changes to the HIV provider as needed. They also provided up to three brief counseling sessions to patients to encourage HIV medication adherence.
The study randomized 304 HIV-infected adults from four U.S. clinics who were diagnosed with major depressive disorder. Patients were assigned either to have the care manager coordinate care with their usual HIV provider or to receive care only from their usual provider. By the end of the study, nearly 80 percent of patients in the care manager group were taking an antidepressant drug, compared with about 50 percent in the “usual care” group, and more patients in the care manager group were being prescribed a moderate or high dose of antidepressant.
In the study’s sixth month, suicidal thoughts in the care manager group had dropped by more than half, and patients in that group showed a clinically significant improvement in depressive symptoms. By 12 months, depression had improved in the usual care group, as well. Because of their faster response to treatment, patients in the care manager group experienced nearly a full additional month of depression-free days over the 12 months of the study, as compared to patients in the usual care group.
“Depression is quite common among patients in HIV care and is a big barrier to successful HIV treatment,” Pence said. “However, many HIV providers are not comfortable treating depression aggressively, and many patients have trouble accessing specialty mental health care. This study shows that, with the right support, HIV providers can manage depression safely and effectively as part of their patients’ regular care.”
Even though their symptoms of depression decreased, however, patients in the care manager group did no better than the usual care group at adhering to their HIV medication schedules, attending medical appointments, or in decreasing viral load (the amount of HIV in the bloodstream) or improving overall physical health.
“Medication adherence is a complex behavior that can be hard to change,” said Bradley Gaynes, MD, MPH, professor of psychiatry in the UNC School of Medicine and co-leader of the study. “Treating depression may be an important part of the puzzle, but may not be enough, even in combination with brief adherence counseling, to move the needle on HIV outcomes.”
Gaynes noted that in addition to major depression, four out of five study participants also had an anxiety, post-traumatic stress, or substance use disorder, which also can lead to challenges with adherence.
The study was funded by the National Institutes of Health’s National Institute of Mental Health and National Institute of Nursing Research. Participating sites included the University of North Carolina at Chapel Hill, Duke University, the University of Alabama at Birmingham, and the Warren-Vance Community Health Center in Henderson, N.C. Additional investigators at UNC included Evelyn B. Quinlivan, MD, associate professor of medicine, and Amy D. Heine, MSN, FNP, clinical instructor in the Division of Infectious Diseases, both in the UNC School of Medicine.