February 21, 2018
For patients living with HIV, depression is common. A new study links greater time spent depressed with increased likelihood of missing medical appointments, increased risk of HIV treatment failure and higher mortality rates. These were the findings of a new study co-authored by several researchers in the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health.
The full study, titled “Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States,” was published online Feb. 21 by JAMA Psychiatry.
Co-authors associated with the Gillings School are Brian W. Pence, PhD, lead author and associate professor, Jon C. Mills, PhD, postdoctoral scholar, Tiffany L. Breger, MSPH, doctoral candidate, and Bradley N. Gaynes, MD, adjunct professor, all in the Department of Epidemiology, as well as Angela M. Bengston, PhD, a former postdoctoral scholar at UNC Gillings who now holds a faculty position at Brown University.
“A number of studies have found that people living with HIV who also have depression experience worse health outcomes than those without depression,” said Pence. “Almost all of this literature, though, puts people in either a ‘depressed’ bin or a ‘not depressed’ bin, even though we know there is a lot of variation in the severity, duration and recurrence of depression over time.”
To examine the specific relationship between increased time spent depressed and multiple important HIV care outcomes – including HIV appointment attendance, treatment failure and mortality – Pence and his colleagues analyzed an observational clinical cohort of 5,927 adults receiving HIV primary care at six geographically dispersed academic medical centers in the United States. Over time, participants completed multiple depressive severity assessments, which the researchers converted into a measure of “percent of days with depression (PDD).”
Over 10,767 person-years of follow-up, participants spent a median of 14 percent of their days living with depression.
“We’re unlikely to ever prevent all depression. So, we need measurement approaches that help us understand the impact of shortening exposure to depression rather than eliminating it entirely,” Pence explained. “This study implemented a novel approach to characterizing the cumulative burden of depression over time. We found that even a modest increase in the proportion of time spent depressed is related in a dose-response fashion to increased likelihood of missing HIV medical appointments, increased risk of failing HIV treatment and higher mortality rates.”
In terms of “dose-response,” each 25 percent increase in the percent of days spent depressed led to an eight percent increase in the no-show risk for scheduled appointments, a five percent increase in the risk of a detectable viral load and a 19 percent increase in the mortality hazard.
Furthermore, the estimates showed that compared to those who spent no follow-up time depressed (PDD=0%), participants who spent the entire follow-up time depressed (PDD=100%) faced a 37 percent increased risk of missing appointments, a 23 percent increased risk of a detectable viral load, and a doubled mortality rate.
“Additional time spent depressed elevates the likelihood of failure at multiple points along the HIV care continuum,” said Pence. “Even modest increases led to clinically meaningful upticks in negative outcomes. The implication is that regular depression screening and rapid, evidence-based treatment – by shortening the duration of depression – hold the potential to have a meaningful impact on HIV outcomes.”
The study authors recommend that next steps include clinic-level trials of protocols to promptly identify and appropriately treat depression among adults living with HIV.