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Abstract and Introduction
Abstract
Background: Depression is a major barrier to HIV treatment outcomes.
Objective: To test whether antidepressant management decision support integrated into HIV care improves antiretroviral adherence and depression morbidity.
Design: Pseudo-cluster randomized trial.
Setting: Four US infectious diseases clinics.
Participants: HIV-infected adults with major depressive disorder.
Intervention: Measurement-based care (MBC) – depression care managers used systematic metrics to give HIV primary-care clinicians standardized antidepressant treatment recommendations.
Measurements: Primary – antiretroviral medication adherence (monthly unannounced telephone-based pill counts for 12 months). Primary time-point – 6 months. Secondary – depressive severity, depression remission, depression-free days, measured quarterly for 12 months.
Results: From 2010 to 2013, 149 participants were randomized to intervention and 155 to usual care. Participants were mostly men, Black, non-Hispanic, unemployed, and virally suppressed with high baseline self-reported antiretroviral adherence and depressive severity. Over follow-up, no differences between arms in antiretroviral adherence or other HIV outcomes were apparent. At 6 months, depressive severity was lower among intervention participants than usual care [mean difference −3.7, 95% confidence interval (CI) −5.6, −1.7], probability of depression remission was higher [risk difference 13%, 95% CI 1%, 25%), and suicidal ideation was lower (risk difference −18%, 95% CI −30%, −6%). By 12 months, the arms had comparable mental health outcomes. Intervention arm participants experienced an average of 29 (95% CI: 1–57) more depression-free days over 12 months.
Conclusion: In the largest trial of its kind among HIV-infected adults, MBC did not improve HIV outcomes, possibly because of high baseline adherence, but achieved clinically significant depression improvements and increased depression-free days. MBC may be an effective, resource-efficient approach to reducing depression morbidity among HIV patients.
Introduction
Depression is a major barrier to HIV care. Depressive disorders affect an estimated 20–30% of people living with HIV and are strongly associated with reduced antiretroviral medication adherence, virologic failure, and higher mortality rates.
Depressive disorders are cyclical, with approximately half of depressive episodes resolving within 12 months without treatment. However, evidence-based treatments such as antidepressants and psychotherapy are critical in speeding the time to recovery and reducing depression morbidity. Although such treatments have demonstrated efficacy for HIV-infected patients, this population still faces a large mental health treatment gap. Estimates suggest that among HIV-infected patients with depression, only one in five are receiving depression treatment and even fewer are receiving effective (rather than sub-therapeutic) treatment. Evidence is needed on the impact of pragmatic, efficient, evidence-based mental health service delivery strategies integrated within HIV primary care.
Despite the associations of depression with adverse HIV outcomes, the impact of effective depression treatment on these outcomes is unclear. Several observational studies as well as trials of counseling interventions have reported a positive association between receipt of depression treatment and antiretroviral adherence, while two recent randomized trials of medication-based depression treatment found no effect on antiretroviral adherence or other HIV outcomes. We report the results of a randomized trial to test the effect of measurement-based care (MBC) – a decision support model for antidepressant management integrated into HIV care, on HIV and mental health outcomes among HIV-infected adults with depression.
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