Adherence Strategies

Antidepressant treatment may improve adherence

Routine depression screening recommended

While surveying long-term data of HIV-infected people, an investigator was struck by how commonly HIV patients were diagnosed with depression.

This observation led to a study of depression and medication adherence among HIV-infected patients seen in urban health settings between 1997 and 2001, says Lourdes Yun, MD, MSPH, epidemiologist with the Denver Health TB Clinic.

"Adherence of antiretroviral drugs is a big issue because of the big regimens with their side effects," she says. "We started to think about if depression had anything to do with adherence to antiretroviral therapy."

Investigators measured data already collected from 1,713 HIV-infected patients, and found that 57% were depressed. Of those diagnosed as depressed, 46% received antidepressant medication, and 52% received antiretroviral treatment.1

The observational study found that people who have HIV and who are receiving antidepressant treatment for depression have a higher adherence to their antiretroviral drugs than do those who are diagnosed as depressed, but who do not receive antidepressant treatment, Yun says.

"So we recommend more routine screening of depression among HIV patients, and among those found to have depression, we recommend antidepressant therapy," she explains. "We need to be really aware that depression is a common diagnosis among HIV patients, and when they’re found to be depressed, antidepressants can improve adherence to antiretroviral therapy."

A prospective study would be a good way to confirm these findings, Yun notes.

"It’d be nice to follow those patients and see if prospectively patients found to be depressed and if put on antidepressant therapy will improve therapy," she says.

In defining depression for the purposes of the study, investigators relied on several pieces of information, including whether the primary physician diagnosed a patient with depression and used the appropriate ICD-9 code. In other instances, physicians referred patients to a psychiatrist where a diagnosis was made, or the physician failed to make the diagnosis of depression, but prescribed the patient antidepressant medication, Yun explains.

"Anyone prescribed an antidepressant medication was described as depressed," she says.

Although using pharmacy prescription refill data is not an ideal way to measure adherence, this was the best method available to investigators, Yun notes.

"There is some validity in using this method," she says. "We took all the patients on antiretroviral therapy, and we measured when was the first time the patient picked up an antidepressant drug and when was the last time the patient ever picked up a prescription, and that was our numerator."

The denominator was how many times the patient had the prescription filled, so if someone was 100% adherent, they would in a period of 12 months pick up the prescription 12 times, Yun adds.

An important take-home message from the study is that it’s very important to screen HIV patients for depression because it such a common diagnosis in this population, she points out.

"We should look more carefully at every single HIV patient and assess depression," Yun says. "Our recommendation is we should look at outpatients and specifically those who are not adherent and go back to see if some psychiatric issue is affecting their antiretroviral adherence."

In clinics where this is possible, HIV patients should be referred to a psychiatrist, perhaps on the second visit, she adds.

While not all patients who are depressed will need antidepressant medication, this prescription appears to be of benefit to many and appears to benefit antiretroviral adherence, Yun concludes.

Reference

  1. Yun LW, Maravi M, Kobayashi JS, et al. Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir Immune Defic Syndr 2005; 38(4):432-438.