Psychiatric disorder in HIV infection

Beneficial and Adverse Effects of cART Affect Neurocognitive Function in HIV-1 Infection: Balancing Viral Suppression against Neuronal Stress and Injury

HIV-associated neurocognitive disorders (HAND) persist despite the successful introduction of combination antiretroviral therapy (cART). While insufficient concentration of certain antiretrovirals (ARV) may lead to incomplete viral suppression in the brain, many ARVs are found to cause neuropsychiatric adverse effects, indicating their penetration into the central nervous system (CNS). Several lines of evidence suggest shared critical roles of oxidative and endoplasmic reticulum stress, compromised neuronal energy homeostasis, and autophagy in the promotion of neuronal dysfunction associated with both HIV-1 infection and long-term cART or ARV use. As the lifespans of HIV patients are increased, unique challenges have surfaced. Longer lives convey prolonged exposure of the CNS to viral toxins, neurotoxic ARVs, polypharmacy with prescribed or illicit drug use, and age-related diseases. All of these factors can contribute to increased risks for the development of neuropsychiatric conditions and cognitive impairment, which can significantly impact patient well-being, cART adherence, and overall health outcome. Strategies to increase the penetration of cART into the brain to lower viral toxicity may detrimentally increase ARV neurotoxicity and neuropsychiatric adverse effects. As clinicians attempt to control peripheral viremia in an aging population of HIV-infected patients, they must navigate an increasingly complex myriad of comorbidities, pharmacogenetics, drug-drug interactions, and psychiatric and cognitive dysfunction. Here we review in comparison to the neuropathological effects of HIV-1 the available information on neuropsychiatric adverse effects and neurotoxicity of clinically used ARV and cART. It appears altogether that future cART aiming at controlling HIV-1 in the CNS and preventing HAND will require an intricate balancing act of suppressing viral replication while minimizing neurotoxicity, impairment of neurocognition, and neuropsychiatric adverse effects. Graphical abstract Schematic summary of the effects exerted on the brain and neurocognitive function by HIV-1 infection, comorbidities, psychostimulatory, illicit drugs, therapeutic drugs, such as antiretrovirals, the resulting polypharmacy and aging, as well as the potential interactions of all these factors.

Effects of Antiretroviral Therapy and Depressive Symptoms on All-Cause Mortality Among HIV-Infected Women

Depression affects up to 30% of human immunodeficiency virus (HIV)-infected individuals. We estimated joint effects of antiretroviral therapy (ART) initiation and depressive symptoms on time to death using a joint marginal structural model and data from a cohort of HIV-infected women from the Women's Interagency HIV Study (conducted in the United States) from 1998-2011. Among 848 women contributing 6,721 years of follow-up, 194 participants died during follow-up, resulting in a crude mortality rate of 2.9 per 100 women-years. Cumulative mortality curves indicated greatest mortality for women who reported depressive symptoms and had not initiated ART. The hazard ratio for depressive symptoms was 3.38 (95% confidence interval (CI): 2.15, 5.33) and for ART was 0.47 (95% CI: 0.31, 0.70). Using a reference category of women without depressive symptoms who had initiated ART, the hazard ratio for women with depressive symptoms who had initiated ART was 3.60 (95% CI: 2.02, 6.43). For women without depressive symptoms who had not started ART, the hazard ratio was 2.36 (95% CI: 1.16, 4.81). Among women reporting depressive symptoms who had not started ART, the hazard ratio was 7.47 (95% CI: 3.91, 14.3). We found a protective effect of ART initiation on mortality, as well as a harmful effect of depressive symptoms, in a cohort of HIV-infected women.

Mind the Gap: Gaps in Antidepressant Treatment, Treatment Adjustments, and Outcomes among Patients in Routine HIV Care in a Multisite U.S. Clinical Cohort

BACKGROUND

Depression affects 20-30% of HIV-infected patients and is associated with worse HIV outcomes. Although effective depression treatment is available, depression is largely untreated or undertreated in this population.

METHODS

We quantified gaps in antidepressant treatment, treatment adjustments, and outcomes among US patients in routine HIV care in the nationally distributed CNICS observational clinical cohort. This cohort combines detailed clinical data with regular, self-reported depressive severity assessments (Patient Health Questionnaire-9, PHQ-9). We considered whether participants with likely depression received antidepressants, whether participants on antidepressants with persistently high depressive symptoms received timely dose adjustments, and whether participants achieved depression remission. We considered a cross-sectional analysis (6,219 participants in care in 2011-2012) and a prospective analysis (2,936 participants newly initiating CNICS care when PHQ-9 screening was active).

RESULTS

The cross-sectional sample was 87% male, 53% Caucasian, 25% African American, and 18% Hispanic; the prospective sample was similar. In both samples, 39-44% had likely depression, with 44-60% of those receiving antidepressants. Of participants receiving antidepressants, 20-26% experienced persistently high depressive symptoms; only a small minority of those received antidepressant dose adjustments. Overall, 35-40% of participants on antidepressants achieved full depression remission. Remission among participants with persistently high depressive symptoms was rare regardless of dose adjustments.

CONCLUSIONS

In this large, diverse cohort of US patients engaged in routine HIV care, we observed large gaps in antidepressant treatment, timely dose adjustment to address persistently high depressive symptoms, and antidepressant treatment outcomes. These results highlight the importance of more effective pharmacologic depression treatment models for HIV-infected patients.

Depression and HIV risk among men who have sex with men in Tanzania

Studies have shown high rates of depression among men who have sex with men (MSM) in developed countries. Studies have also shown association between depression and HIV risk among MSM. However, very little research has been done on depression among African MSM. We assessed depression and HIV risk among a sample of MSM in Tanzania. We reviewed data on 205 MSM who were recruited from two Tanzanian cities using the respondent driven sampling method. Demographic and behavioral data were collected using a structured questionnaire. HIV and sexually transmitted infections data were determined from biological tests. Depression scores were assessed using the Patient Health Questionnaire (PHQ-9). For the analysis, depression scores were dichotomized as depressed (PHQ > 4) and not depressed (PHQ ≤ 4). Bivariate and multivariable Poisson regression analyses were conducted to assess factors associated with depression. The prevalence of depression in the sample was 46.3%. The mean (±SD) age of the sample was 25 (±5) years. In bivariate analysis, depression was associated with self-identifying as gay (p = .001), being HIV positive (p < .001: <8% of MSM knew they were HIV infected) and having a high number of sexual partners in the last 6 months (p = .001). Depression was also associated with sexual (p = .007), physical (p = .003) and verbal (p < .001) abuse. In the Poisson regression analysis, depression was associated with verbal abuse (APR = 1.91, CI = 1.30-2.81). Depression rates were high among MSM in Tanzania. It is also associated with abuse, HIV and HIV risk behaviors. Thus, reducing the risk of depression may be helpful in reducing the risk of HIV among MSM in Africa. We recommend the colocation of mental health and HIV preventive services as a cost-effective means of addressing both depression and HIV risk among MSM in Africa.

Excess burden of depression among HIV-infected persons receiving medical care in the united states: data from the medical monitoring project and the behavioral risk factor surveillance system

Background

With increased life expectancy for HIV-infected persons, there is concern regarding comorbid depression because of its common occurrence and association with behaviors that may facilitate HIV transmission. Our objectives were to estimate the prevalence of current depression among HIV-infected persons receiving care and assess the burden of major depression, relative to that in the general population.

Methods and Findings

We used data from the Medical Monitoring Project (MMP) and the Behavioral Risk Factors Surveillance System (BRFSS). The eight-item Patient Health Questionnaire was used to identify depression. To assess the burden of major depression among HIV-infected persons receiving care, we compared the prevalence of current major depression between the MMP and BRFSS populations using stratified analyses that simultaneously controlled for gender and, in turn, each of the potentially confounding demographic factors of age, race/ethnicity, education, and income. Each unadjusted comparison was summarized as a prevalence ratio (PR), and each of the adjusted comparisons was summarized as a standardized prevalence ratio (SPR). Among HIV-infected persons receiving care, the prevalence of a current episode of major depression and other depression, respectively, was 12.4% (95% CI: 11.2, 13.7) and 13.2% (95% CI: 12.0%, 14.4%). Overall, the PR comparing the prevalence of current major depression between HIV-infected persons receiving care and the general population was 3.1. When controlling for gender and each of the factors age, race/ethnicity, and education, the SPR (3.3, 3.0, and 2.9, respectively) was similar to the PR. However, when controlling for gender and annual household income, the SPR decreased to 1.5.

Conclusions

Depression remains a common comorbidity among HIV-infected persons. The overall excess burden among HIV-infected persons receiving care is about three-times that among the general population and is associated with differences in annual household income between the two populations. Relevant efforts are needed to reduce this burden.

Depression Among HIV-infected Patients in Korea: Assessment of Clinical Significance and Risk Factors

BACKGROUND

With prolonged life expectancies, mental illness has emerged as a disabling disorder among people with HIV.

MATERIALS AND METHODS

This study was conducted to assess the prevalence of depression and its risk factors among Korean patients with HIV infections. Eighty-two HIV-infected patients completed structured questionnaires including the Beck Depression Inventory and the State-Trait Anxiety Inventory. Subjects with depression were compared to those without depression in terms of demographics, comorbidities, CD4 T-cell count, RNA copy numbers, highly active antiretroviral therapy (HAART) regimens, and adherence.

RESULTS

The estimated depression rate was 21% (17 of 82 subjects). Comorbidities (47% vs. 20%, P = 0.01) and unemployment (65% vs. 31%, P = 0.02) were risk factors for depression. Depressive patients were more likely to be anxious (71% vs. 29%, P < 0.01), to frequently miss clinical appointments each year (P = 0.04), and to have higher cumulative time lost to follow-up per month (P <0.01) compared to non-depressive patients. Only three depressive patients were referred to neuropsychologists.

CONCLUSIONS

More than 20% of the Korean HIV patients in this study suffered from depression associated with poor adherence. Considering the low level of recognition of depression by clinicians, risk factor-based active assessment is recommended to manage depression properly in HIV-infected patients.

Treating depression within the HIV "medical home": a guided algorithm for antidepressant management by HIV clinicians

People living with HIV/AIDS (PLWHA) suffer increased depression prevalence compared to the general population, which negatively impacts antiretroviral (ART) adherence and HIV-related outcomes leading to morbidity and mortality. Yet depression in this population often goes undiagnosed and untreated. The current project sought to design an evidence-based approach to integrate depression care in HIV clinics. The model chosen, measurement-based care (MBC), is based on existing guidelines and the largest randomized trial of depression treatment. MBC was adapted to clinical realities of HIV care for use in a randomized controlled effectiveness trial of depression management at three academic HIV clinics. The adaptation accounts for drug-drug interactions critical to ongoing ART effectiveness and can be delivered by a multidisciplinary team of nonmental health providers. A treatment algorithm was developed that enables clinically supervised, nonphysician depression care managers (DCMs) to track and monitor antidepressant tolerability and treatment response while supporting nonpsychiatric prescribers with antidepressant choice and dosing. Quality of care is ensured through weekly supervision of DCMs by psychiatrists. Key areas of flexibility that have been important in implementation have included flexibility in timing of assessments, accommodation of divergence between algorithm recommendations and provider decisions, and accommodation of delays in implementing treatment plans. This adaptation of the MBC model to HIV care has accounted for critical antidepressant-antiretroviral interactions and facilitated the provision of quality antidepressant management within the HIV medical home.

Prevalence and predictors of major depression in HIV-infected patients on antiretroviral therapy in Bamenda, a semi-urban center in Cameroon

Recent blue-ribbon panel reports have concluded that HIV treatment programs in less wealthy countries must integrate mental health identification and treatment into normal HIV clinical care and that research on mental health and HIV in these settings should be a high priority. We assessed the epidemiology of depression in HIV patients on antiretroviral therapy in a small urban setting in Cameroon by administering a structured interview for depression to 400 patients consecutively attending the Bamenda Regional Hospital AIDS Treatment Center. One in five participants met lifetime criteria for MDD, and 7% had MDD within the prior year. Only 33% had ever spoken with a health professional about depression, and 12% reported ever having received depression treatment that was helpful or effective. Over 2/3 with past-year MDD had severe or very severe episodes. The number of prior depressive episodes and the number of HIV symptoms were the strongest predictors of past-year MDD. The prevalence of MDD in Cameroon is as high as that of other HIV-associated conditions, such as tuberculosis and Hepatitis B virus, whose care is incorporated into World Health Organization guidelines. The management of depression needs to be incorporated in HIV-care guidelines in Cameroon and other similar settings.

Assessing the effect of Measurement-Based Care depression treatment on HIV medication adherence and health outcomes: rationale and design of the SLAM DUNC Study

Depression affects 20-30% of people living with HIV/AIDS (PLWHA) in the U.S. and predicts greater sexual risk behaviors, lower antiretroviral (ARV) medication adherence, and worse clinical outcomes. Yet little experimental evidence addresses the critical clinical question of whether depression treatment improves ARV adherence and clinical outcomes in PLWHA with depression. The Strategies to Link Antidepressant and Antiretroviral Management at Duke, UAB, and UNC (SLAM DUNC) Study is a randomized clinical effectiveness trial funded by the National Institute for Mental Health. The objective of SLAM DUNC is to test whether a depression treatment program integrated into routine HIV clinical care affects ARV adherence. PLWHA with depression (n=390) are randomized to enhanced usual care or a depression treatment model called Measurement-Based Care (MBC). MBC deploys a clinically supervised Depression Care Manager (DCM) to provide evidence-based antidepressant treatment recommendations to a non-psychiatric prescribing provider, guided by systematic and ongoing measures of depressive symptoms and side effects. MBC has limited time requirements and the DCM role can be effectively filled by a range of personnel given appropriate training and supervision, enhancing replicability. In SLAM DUNC, MBC is integrated into HIV care to support HIV providers in antidepressant prescription and management. The primary endpoint is ARV adherence measured by unannounced telephone-based pill counts at 6 months with follow-up to 12 months and secondary endpoints including viral load, health care utilization, and depressive severity. Important outcomes of this study will be evidence of the effectiveness of MBC in treating depression in PLWHA and improving HIV-related outcomes.

Contributors to neuropsychological impairment in HIV-infected and HIV-uninfected opiate-dependent patients

Neuropsychological (NP) impairment is multiply determined among HIV-infected and HIV-uninfected individuals who are also dually diagnosed with depression and who use illicit substances. The purpose of the present study was to assess the impact of HIV status, depression, and problematic substance use on NP performance. A total of 160 opiate-dependent outpatients undergoing methadone maintenance (80 HIV-infected, 80 HIV-uninfected) completed diagnostic and NP evaluations. Raw scores from individual NP tests were converted to Z scores relative to standard norms and were averaged to form a composite score. HIV-infected participants had significantly lower overall NP performance--as well as lower performance on tests of attention, motor speed, and verbal memory--than HIV-uninfected participants. In multiple regression analyses considering the role of depression and substance use, only HIV status emerged as a significant predictor of NP impairment. These findings confirm NP impairment in HIV-infected substance abusing patients independent of comorbid depression and severity of substance use.

The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS

Potent antiretroviral therapy (ART) has transformed HIV from a death sentence to a chronic illness. Accordingly, the goal of HIV care has shifted from delaying death to achieving optimal health outcomes through ART treatment. ART treatment success hinges on medication adherence. Extensive research has demonstrated that the primary barriers to ART adherence include mental illness, especially depression and substance abuse, as well as histories of traumatic experiences such as childhood sexual and physical abuse. These psychosocial factors are highly prevalent in people living with HIV/AIDS (PLWHA) and predict poor ART adherence, increased sexual risk behaviours, ART treatment failure, HIV disease progression and higher mortality rates. The efficacy of standard mental health interventions, such as antidepressant treatment and psychotherapy, has been well-defined, and a small but growing body of research demonstrates the potential for such interventions to improve ART adherence and reduce sexual risk behaviours. Despite this evidence, mental disorders in PLWHA frequently go undiagnosed and untreated. Challenges to the provision of mental healthcare for PLWHA in HIV clinical settings include time and resource constraints, lack of expertise in psychiatric diagnosis and treatment, and lack of available mental health referral services. Future research should prioritize the evaluation of mental health interventions that are cost-effective and feasible for widespread integration into HIV clinical care; the impact of such interventions on ART adherence and clinical outcomes; and interventions to identify individuals with histories of traumatic experiences and to elucidate the mechanisms through which such histories pose barriers to effective HIV treatment.

The impact of alcohol use on depressive symptoms in human immunodeficiency virus-infected patients

AIMS

To examine the impact of alcohol use on depressive symptoms in human immunodeficiency virus (HIV)-infected patients.

DESIGN

Data were collected at 6-month intervals and analyzed to evaluate the association between alcohol dependence and consumption on depressive symptoms using longitudinal mixed-effects regression models controlling for specified covariates.

MEASUREMENTS

The two independent variables were current alcohol dependence assessed using the Composite International Diagnostic Interview (CIDI) and past month consumption (heavy versus not heavy drinking) using a validated calendar-based method. The primary outcome was depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale (CES-D).

PARTICIPANTS

HIV-infected adults with current or past alcohol problems.

FINDINGS

Alcohol dependence and heavy alcohol use were significantly associated with higher CES-D scores in unadjusted models. In adjusted analyses, the association of current alcohol dependence persisted [mean difference in CES-D was 3.49 for dependence versus non-dependence; 95% confidence interval (CI): 1.76-5.22]; however, the effect of heavy drinking was no longer statistically significant (mean difference in CES-D was 1.04 for heavy versus not heavy drinking; 95% CI: -0.24-2.32).

CONCLUSIONS

Alcohol use is associated with more depressive symptoms in HIV-infected patients with alcohol problems. This association remains significant after adjusting for potential confounders only when alcohol use meets the criteria for alcohol dependence.

Major depression in patients with HIV/AIDS and substance abuse

Previous research has been inconsistent in documenting a strong relationship between depression and HIV/AIDS, although a recent meta-analysis of studies examining this issue indicates that rates of depression are modestly higher for this population. For the current study, conducted from 2001-2004, we sought to examine rates and types of depressive symptoms in a cohort of patients receiving HIV care at two urban medical centers. These patients were participants in an intervention study examining adherence and mental health in persons triply diagnosed with psychiatric disorders, substance use disorders, and HIV/AIDS. Nearly three quarters of these participants were people of color, two thirds described their sexual orientation as heterosexual, and the vast majority were unemployed. We sought to examine the relationship of depression to patients' adherence to antiretroviral medication regimens (highly active antiretroviral therapy [HAART]). Results obtained from structured clinical interviews and self-report questionnaires indicated that study participants experienced high rates of depressive symptoms, and that 72.9% of participants met criteria for major depressive disorder (MDD). The results of this study offer a detailed view of the incidence and nature of MDDs and depressive symptoms for an urban sample of substance-abusing adults with HIV/AIDS. Given the degree to which depressive symptoms and MDD appear to be prevalent for this group, as well as the observation that these symptoms are amenable to treatment, future research should focus on identifying helpful strategies and interventions for treating these symptoms, effective ways of providing linkages to care, and ways in which standardized assessment and treatment protocols might be adapted to better suit this population.

Exposure to HIV in Brazilian adolescents: the impact of psychiatric symptomatology

OBJECTIVES

To examine associations between psychiatric symptomatology and HIV-positive status in adolescents who sought HIV testing at a public health center in Brazil.

METHOD

In a cross-sectional study, 388 adolescents assessed for their HIV status were also evaluated for psychiatric symptomatology using the Symptom Checklist-90-R (SCL-90-R). The impact of potential confounding variables such as risk behaviors was ascertained using the Brazilian version of the Risk Assessment Battery (RAB).

RESULTS

Overall seropositivity rate was 6.2%. Seropositives had significantly higher scores in all dimensions of psychiatric symptomatology in the SCL-90-R (P < 0.05 and effect sizes > 0.5 in all dimensions). In multiple analyses, with the inclusion of 3 composite variables (sex-risk, drug-risk, and psychiatric symptomatology), only psychiatric symptoms were associated with positive HIV status (OR = 1.88, CI95% = 1.06-3.34; P = 0.032).

CONCLUSIONS

Our findings suggest that amongst young people asking for HIV testing in Brazil, seropositivity is associated with psychological symptoms and that screening for the latter would therefore be appropriate in this context.

Increased health care utilization and increased antiretroviral use in HIV-infected individuals with mental health disorders

OBJECTIVES

The aims of the study were to describe the prevalence and associations of mental health disorder (MHD) among a cohort of HIV-infected patients attending the Victorian HIV/AIDS Service between 1984 and 2000, and to examine whether antiretroviral therapy use or mortality was influenced by MHD (defined as a record of service provision by psychiatric services on the Victorian Psychiatric Case Register). It was hypothesized that HIV-positive individuals with MHD would have poorer treatment outcomes, reduced responses to highly active antiretroviral therapy (HAART) and increased mortality compared with those without MHD.

METHODS

This is a retrospective cohort of 2981 individuals (73% of the Victorian population diagnosed with HIV infection) captured on an HIV database which was electronically matched with the public Victorian Psychiatric Case Register (VPCR) (accounting for 95% of public system psychiatry service provision). The prevalence, dates and recorded specifics of mental health disorders at the time of the electronic match on 1 June 2000 are described. The association with recorded MHD, gender, age, AIDS illness, HIV exposure category, duration and type of antiviral therapy, treatment era (prior to 1986, post-1987 and pre-HAART, and post-HAART) on hospitalization and mortality at 1 September 2001 was assessed.

RESULTS

Five hundred and twenty-five individuals (17.6% of the Victorian HIV-positive population) were recorded with MHD, most frequently coded as attributable to substance dependence/abuse or affective disorder. MHD was diagnosed prior to HIV in 33% and, of those diagnosed after HIV, 93.8% were recorded more than 1 year after the HIV diagnosis. Schizophrenia was recorded in 6% of the population with MHD. Hospitalizations for both psychiatric and nonpsychiatric illness were more frequent in those with MHD (relative risk 5.4; 95% confidence interval 3.7, 8.2). The total number of antiretrovirals used (median 6.4 agents vs 5.5 agents) was greater in those with MHD. When adjusted for antiretroviral treatment era, HIV exposure category, CD4 cell count and antiretroviral therapy, survival was not affected by MHD.

CONCLUSIONS

MHD is frequent in this population with HIV infection and is associated with increased healthcare utilization but not with reduced survival.

Affective disorders in patients with HIV infection: impact of antiretroviral therapy

At the beginning of the AIDS pandemic, affective disorders (such as depressed mood) were seen in a considerable number of HIV-1-infected individuals. These disorders were a result of the poor physical condition of the patients, brain involvement by the virus (e.g. encephalopathy) or a reaction to disadvantageous living conditions (losing friends, jobs, etc.). In the era of highly active antiretroviral therapy (HAART), mental illness related to physical weakness is declining, as is the incidence of HIV-1-associated encephalopathy. However, depressed mood and fatigue caused by efavirenz (a standard component of HAART) is becoming increasingly important, particularly in individuals who are infected long-term with HIV-1. Whatever the cause of affective disorders, their presence has been shown to negatively influence adherence to HAART and HIV-1 disease progression. Specialist knowledge of HIV-1 infection, and HAART and its psychiatric complications (particularly in subgroups of patients such as drug abusers and older people), is needed to care adequately for patients. Furthermore, prospective studies are needed to more fully differentiate between the various aetiologies of affective disorders seen in individuals living with HIV/AIDS and to determine their incidence and prevalence. Such information is important to ensure that affective disorders are recognised and adequately treated, which will in turn improve the efficacy of HAART.

Infecções virais e depressão

OBJETIVO: A associação entre depressão e viroses é estudada há quase dois séculos, com resultados conflitantes. O objetivo deste trabalho é fazer uma análise crítica dos estudos existentes na literatura sobre essa relação. MÉTODOS: A pesquisa bibliográfica utilizou as fontes eletrônicas de busca MEDLINE e LILACS (1966 a agosto 2005). As referências dos artigos foram utilizadas como fonte adicional de consulta. RESULTADOS: Foram abordados os trabalhos que trataram da associação entre depressão e os vírus HIV, HCV, EBV, influenza, HSV, HBV, HAV, BDV e HTLV. A relação entre HIV e depressão mostrou-se bem documentada na literatura. Existem indícios de que a prevalência desse transtorno nos indivíduos infectados pelo HIV seja maior que a encontrada nos soronegativos. Além disso, estudos constataram que a depressão está associada a pior prognóstico da infecção. Quanto à associação entre HCV e depressão, os trabalhos sugeriram maior prevalência desse transtorno psiquiátrico nos portadores do HCV comparados à população geral. Não existem evidências científicas suficientes para dar suporte à relação entre os demais vírus e depressão. CONCLUSÃO: As associações mais bem fundamentadas foram aquelas entre depressão e os vírus HIV e HCV. A relação entre as demais viroses e depressão precisa ser mais bem estudada, e trabalhos com delineamento adequado se fazem necessários.

Life stress and adherence to antiretroviral therapy among HIV-positive individuals: a preliminary investigation

The present study sought to investigate the impact of life stress on treatment adherence and viral load of HIV-positive individuals. Three different aspects of life stress were examined in this investigation (perceived stress, acute life events unrelated to the HIV illness, and HIV-related acute life events). Furthermore, we examined whether these relationships were moderated by depressive severity, self-esteem, and neuroticism. Participants (n = 24) were treatment- seeking HIV-positive individuals who completed a series of questionnaires for this investigation. The majority of the participants in this sample were middle-aged, Caucasian males who identified themselves as either homosexual or bisexual, had contracted HIV via sexual contact, and met criteria for AIDS (mean CD4 count = 324). This sample was highly self-selected and varied from the county HIV-positive population in terms of gender, ethnicity, and HIV risk factor. Information on their adherence and viral load was collected from their medical records 6 to 9 months after completion of the psychological measurements. Results indicated that perceived stress, but not acute events, prospectively predicted adherence. Moreover, marginal trends suggested that depressive symptoms and neuroticism moderated the effect of perceived stress on adherence. Neither perceived stress nor acute life events were associated with viral load.

Sexual risk behaviors and substance use among alcohol abusing HIV-positive men who have sex with men

An ethnically diverse sample (79.0% men of color) of HIV seropositive (HIV+) men who have sex with men (MSM) with alcohol use disorders from the New York City metropolitan area was recruited from a variety of settings frequented by such men. Data were collected using quantitative assessments and calendar based techniques at the baseline assessment of a longitudinal study assessing the relationship between alcohol and substance use and sexual risk behaviors as well as alcohol use and HIV disease progression. Data were selected on a sample of 253 HIV+ MSM (mean age = 38.55, SD = 6.73). Of these, the majority of participants (80.2%, n=203) reported engaging in sexual behaviors with casual partners. In terms of sexual behaviors that put partners at greatest risk for HIV transmission, unprotected anal insertive intercourse was most likely to occur with unknown status casual partners (46.8%, n=95) than with either HIV negative casual partners (19.2%, n=39) or with HIV+ casual partners (40.8%, n=83). Further, bivariate analyses indicated significant relationships between the use of several substances and sexual behaviors that put partners at greatest risk for HIV transmission, as well as a significant positive relationship between drinks per drinking day and viral load.

Antidepressant Treatment Improves Adherence to Antiretroviral Therapy Among Depressed HIV-Infected Patients

BACKGROUND

Antiretroviral regimens for HIV-infected patients require strict adherence. Untreated depression has been associated with medication nonadherence. We proposed to evaluate the effect of antidepressant treatment (ADT) on antiretroviral adherence.

METHODS

Data were retrieved for HIV-infected patients seen at an urban health care setting (1997-2001) from chart review and administrative and pharmacy files. Antiretroviral adherence was determined for depressed patients stratified by receipt of and adherence to ADT. Antiretroviral adherence was compared before and after initiation of ADT.

RESULTS

Of 1713 HIV-infected patients, 57% were depressed; of those, 46% and 52% received ADT and antiretroviral treatment, respectively. Antiretroviral adherence was lower among depressed patients not on ADT (vs. those on ADT; P = 0.012). Adherence to antiretroviral treatment was higher among patients adherent to ADT (vs. those nonadherent to antidepressant treatment; P = 0.0014). Antiretroviral adherence improved over a 6-month period for adherent, nonadherent, and nonprescribed ADT groups; however, the mean pre- versus post-6-month change in antiretroviral adherence was significantly greater for those prescribed antidepressants.

CONCLUSIONS

Depression was common, and antiretroviral adherence was higher for depressed patients prescribed and adherent to ADT compared with those neither prescribed nor adherent to ADT. Attention to diagnosis and treatment of depressive disorders in this population may improve antiretroviral adherence and ultimate survival.

Stability of anxiety and depression in a national sample of adults with human immunodeficiency virus

We examined the stability of anxiety and depression in a national sample of patients with human immunodeficiency virus (HIV) using data from the HIV Cost and Services Utilization Study. We also investigated risk factors for developing new cases of anxiety and depression. Analyses were conducted using multiple logistic regressions to control for key demographic and clinical factors. Our results showed a general stability of these psychiatric conditions across 6 months, with no dramatic increase in new cases. Overall prevalence declined over time, but a subgroup of patients, particularly those with major depression, evidenced persistent psychopathology. Having a high baseline HIV symptom count and a growing number of HIV symptoms significantly increased the likelihood of anxiety and depression persisting to follow-up and of developing new such cases. Our findings indicate that living with HIV does not necessarily lead to increased psychiatric distress but that palliation of HIV symptoms is paramount to patients' mental health.

Underdiagnosis of depression in HIV: who are we missing?

OBJECTIVE

To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV.

DESIGN

Cross-sectional survey.

PATIENTS/PARTICIPANTS

National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data.

MEASUREMENTS AND MAIN RESULTS

We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P <.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P <.01) and those with >or=3 outpatient visits (P <.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers.

CONCLUSIONS

Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.

Resourcefulness and self-care in pregnant women with HIV

The human immunodeficiency virus (HIV) has caused suffering in the lives of humans worldwide. Pregnant Thai women now constitute the fastest-growing segment of individuals diagnosed with HIV/AIDS. Few studies have looked at self-care or resourcefulness among pregnant women with HIV. Using Rosenbaum's theory of learned resourcefulness, this study examined the direct effects of depression and resourcefulness on prenatal self-care as well as the mediating effects of resourcefulness on depression and self-care. A model testing study with 153 pregnant Thai women compared the effects of depression and resourcefulness on prenatal self-care in HIV-positive and HIV-negative groups. Regression analyses indicated direct effects of depression and resourcefulness on prenatal self-care. The effect of depression on prenatal self-care was mediated by resourcefulness. HIV status did not predict prenatal self-care. The findings on the relationships of depression, resourcefulness, and prenatal self-care can help nurses provide effective services to pregnant Thai women, including counseling on self-care.

Neurocognitive Manifestations of Human Immunodeficiency Virus

Is human immunodeficiency virus still a terminal condition? Recent advances in treatment have significantly reduced both mortality and morbidity associated with HIV, but these treatments have not been successful in eradicating the virus itself. As such, HIV has evolved into a chronic condition that is complicated by neurocognitive factors. Cognitive difficulties associated with HIV are characterized by a subcortical pattern with primary deficits in information processing speed and psychomotor speed. These deficits interfere with the ability of patients to complete important instrumental activities of daily living even in the absence of dementia. Treatment of HIV improves neurocognitive functioning, but the regimens are complex and patient adherence is critical. Cognitive factors can negatively impact treatment adherence, which in turn results in poorer immunological, cognitive, and psychiatric outcome. This cycle emphasizes the important interrelationships between symptom expression and treatment outcome in patients with HIV. The nature of these relationships will change with further developments in treatment regimens such as once-daily dosing. Less complex treatment approaches should improve health outcome as well as provide additional opportunities to further understand the impact of HIV on brain function.

Depression among Patients with HIV/AIDS: A Treatment Dilemma

Increased longevity of HIV-infected individuals due to expanding pharmacological research allows a longer period of time for mood disorders to come to medical attention. A longer period of time exists in which the treatment of depression can make a difference in the quality of life, function, and course of HIV infection. Many HIV-related symptoms and concurrent treatment regimens can complicate the choices made regarding mood disorder treatments. Certain HIV/AIDS patients are at greater risk for developing depression, such as those with substance abuse/dependence. Differentiation between the clinical presentation of depression in the general population versus the HIV/AIDS population is important. Although differentiating between symptoms of depression, somatic complaints, and cognitive deficits may be difficult, specific symptoms in HIV-infected individuals prevail. Substantial evidence suggests that antidepressant therapy and psychotherapy are effective in most HIV-positive patients with major depression. One of the greatest difficulties in drug selection for the HIV-infected population is the avoidance of clinically significant drug-drug interactions between antidepressants and antiretrovirals. Evaluating the tolerability of antidepressant medications is also an important factor of effective treatment. This article attempts to clarify all the aforementioned issues pertaining to treatment choices in HIVinfected individuals suffering from depression.

Imidazoline receptor proteins are decreased in the hippocampus of individuals with major depression

BACKGROUND

A downregulation of I(2)-imidazoline binding sites has been reported in frontal cortices of depressed suicide victims, according to I(2)-radioligand binding and confirmed by Western blotting. We now report Western blots of imidazoline receptor proteins in hippocampi of subjects with and without depression at the time of death.

METHODS

Postmortem diagnoses were obtained from 17 cases of Axis I major depressive disorder and 17 cases without Axis I psychopathology. No psychotropic compounds were found in body fluids. Hippocampi were removed, sectioned, and assessed histologically. Throughout the analysis, each major depressive disorder sample was paired with a sample from a psychiatrically healthy subject based on equivalent life spans and postmortem delays. The antiserum was identical to that used in previous studies that reported a downregulation of cortical 29/30-kd imidazoline receptor-binding proteins in depression.

RESULTS

A triad of imidazoline receptor-binding protein bands (40-50 kd) was detected in the human hippocampus. Subjects with major depressive disorder had significantly less intensity in each imidazoline receptor-binding proteins band compared with control subjects (p =. 01 for overall bands).

CONCLUSIONS

The present results can be aligned with previous reports of downregulation of I(2)-radioligand binding sites in both cortices and platelets of depressed patients.

Psychological effects of HAART: a 2-year study

OBJECTIVE

The objectives of this study were to evaluate the psychological consequences of combination antiretroviral treatment in terms of mood, hope, and life satisfaction in men with symptomatic human immunodeficiency virus (HIV) infection or acquired immune deficiency syndrome and to compare those whose health improved with those whose health did not improve.

METHODS

One hundred seventy-three HIV+ gay or bisexual men with symptomatic HIV illness (40% nonwhite) were evaluated semiannually in a university-affiliated research program between July 1995 and December 1997. The primary outcome measures were the Structured Clinical Interview for DSM-IV, Beck Depression Inventory, Endicott Quality of Life Enjoyment and Satisfaction Questionnaire, and Beck Hopelessness Scale.

RESULTS

Psychological distress in this sample was mild to moderate at baseline. During the first 2 years that highly active antiretroviral therapy became widely available, we observed a statistically significant but clinically modest reduction in distress in the sample as a whole, with significant covariates of CD4 cell count, HIV symptoms, and social support in a mixed-effects model. Rates of clinical depression declined. However, this generalized mental health improvement was not related to individual medical improvement of markers of HIV illness progression; those classified as improved were no more likely than those who remained unimproved to report greater declines in measures of distress and hopelessness. Number of self-reported physical symptoms were directly related to distress levels.

CONCLUSIONS

A cohort effect was observed, with overall psychological improvement. Physical symptoms were more strongly related to psychological distress than were laboratory markers. Consequently, those whose CD4 cell count and HIV RNA viral load reflected successful treatment were no more likely than others to be relieved of the psychological burdens of illness.