Depression Among People with HIV Infection Francine Cournos, M.D. Professor of Clinical Psychiatry, Columbia University Principal Investigator, New York/New Jersey AETC fc15@columbia.edu There are no relationships to disclose. June 2009 - PowerPoint PPT Presentation

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Depression Among People with HIV Infection Francine Cournos, M.D. Professor of Clinical Psychiatry, Columbia University Principal Investigator, New York/New Jersey AETC fc15@columbia.edu There are no relationships to disclose. June 2009

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Title: Depression Among People with HIV Infection Francine Cournos, M.D. Professor of Clinical Psychiatry, Columbia University Principal Investigator, New York/New Jersey AETC fc15@columbia.edu There are no relationships to disclose. June 2009


1
Depression Among People with HIV Infection
Francine Cournos, M.D. Professor of Clinical
Psychiatry, Columbia University Principal
Investigator, New York/New Jersey
AETC fc15_at_columbia.edu There are no
relationships to disclose. June 2009
2
Depression Dante vs. the DSM IV
  • Dante
  • I did not die
  • But yet I lost lifes breath
  • Imagine for yourself what I became
  • Deprived at once of both my life and death
  • Dantes Inferno Translation by John Ciardi

3
Depression Dante vs. the DSM IV
  • DSM IV Categories
  • Major depression severe sx 2
    weeks
  • Dysthymic disorder moderate sx 2 years
  • Bipolar disorders
  • - Bipolar 1 Major depression mania
  • - Bipolar 2 Major depression hypomania
  • - Related disorders
  • - Cyclothymia
  • - Borderline Personality Disorder?
  • Adjustment disorder with depressed mood
  • Sub-threshold depressive symptoms

4
Major Depression Key Points
  • Depression is a physical and a mental illness
  • Depression frequently presents in primary care
  • Depression is very common among HIV people
  • Depression is associated with increased morbidity
    and mortality among HIV people (and for other
    illnesses)
  • There are effective treatments for depression,
    but many depressed HIV people never receive them
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

5
RAND HCSUS Study 2,864 HIV-positive Medical
Patients
  • Any Psychiatric Disorder 48
  • Major depression 36
  • Dysthymia 27
  • Generalized anxiety disorder 16
  • Panic attack 11
  • Drug dependence 13
  • Problematic alcohol use 19
  • Bing et al Arch. Gen. Psych. 2001
  • Later studies showed elevated rates of PTSD.
  • Israelski et al, AIDS Care, 2007.

6
RAND HCSUS Study 1,489 HIV-positive Medical
Patients
  • 27 took psychotropic medication
  • 21 antidepressants
  • 17 anxiolytics
  • 5 antipsychotics
  • 3 psychostimulants
  • About half of patients with depressive disorders
    did not receive antidepressantsAfrican-Americans
    were overrepresented.
  • Depression is therefore common and undertreated
    among HIV positive people in medical treatment.
  • Vitiello, et al, AJP, 2003

7
Depression and Mortality in HIV Women
HERS cohort (Ickovics et al JAMA 2001) 765 HIV
women at 4 sites followed for up to 7 years
  • Mortality predictors chronic depression, CD4
    count, HAART duration, age
  • After adjusting for all other variables, women
    with chronic depressive symptoms were twice as
    likely to die as women with limited or no
    depressive symptoms

8
Depression and Mortality in HIV Women
  • WIHS cohort 2,059 HIV women
  • Replicated HERS results Chronic depressive
    symptoms associated with AIDS mortality (N
    1,716 Cook et al, AJPH, 2004)
  • Depression illicit drug use, or recent drug use
    alone, associated with decreased HAART
    utilization (N 1,668 Cook et al, JAIDS, 2002
    N1710 Cook, et al, Drug and Alcohol Dependence,
    2007)

9
The Effect of Depression Treatment on HIV Medical
Outcomes
  • Use of antidepressants MH therapy, or MH
    therapy alone, associated with increased HAART
    utilization (N 1,371 Cook, et al, AIDS Care,
    2006)
  • Depression significantly worsens HAART adherence
    and HIV viral control. Compliant SSRI use is
    associated with improved HIV adherence and
    laboratory parameters (CD4 cell count and viral
    load). (N 3,359 Horberg, et al, JAIDS, 2008)

10
Summary Depression and HIV Progression
  • Depression (and substance use disorders) are
    associated with non-adherence to HAART
  • Controlling for adherence, depression remains
    associated with more rapid progression of HIV and
    increased morbidity and mortality
  • The treatment of depression improves medical
    outcomes
  • The diagnosis and treatment of depression is an
    essential component of HIV care

11
Screening for Depression PRIME-MD PHQ2
  • Over the last two weeks how often have you been
    bothered by any of the following problems
  • Little interest or pleasure in doing things.
  • 0Not at all
  • 1Several days
  • 2More than half the days
  • 3Nearly every day
  • Feeling down, depressed or hopeless
  • 0Not at all
  • 1Several days
  • 2More than half the days
  • 3Nearly every day
  • The higher the score the more likely the patient
    has depressive disorder
  • Kroenke et al, Med Care, 2003

12
Completed Suicide A Fatal Outcome of
Depression (General Population)
  • Lifetime rate of completed suicide for major
    affective disorders 10-15
  • Risk Factors
  • White, male, older, single, unemployed, recent
    loss, access to lethal weapons
  • Previous history of suicide attempts, family
    history of suicide, victim of abuse
  • In addition to depressive symptoms, severe
    anxiety, psychotic symptoms, personality
    disorders, substance use, poor impulse control,
    detailed suicide plan
  • Severe medical illness especially with loss of
    functioning or intractable pain
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

13
Qestions for Discussing Suicide
  • Questions
  • -Do you feel unhappy and hopeless?
  • -Do you feel unable to face each day?
  • -Do you feel life is a burden?
  • -Do you feel life is not worth living?
  • -Do you feel like committing suicide?
  • Further questions
  • -Have you made any plans to end your life?
  • -How are you planning to do it?
  • -Do you have the means to carry out suicide in
    your possession (pills/guns/other method)?
  • -Have you considered when to do it?
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

14
TREATING DEPRESSION
15
Barriers to Treating Depression
  • Patient Level stigma of mental illness desire
    to be strong and tough theres nothing wrong
  • Intervention Level the side effects of
    antidepressants manifest before the therapeutic
    effects
  • Provider Level failure to screen, detect,
    discuss, treat
  • System Level limited funding/availability of
    mental health services lack of provider training
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

16
Treatment of Depression in People with HIV
  • Modify contributing factors
  • Psychotherapies
  • Psychopharmacology
  • Inpatient care (suicide risk, medical work-up,
    grave disability)
  • ECT
  • Experimental brain stimulation treatments
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

17
Depression Modify Contributing Factors
  • Diagnose and treat underlying medical illness
  • Attempt to reduce the impact of medication side
    effects and use of substances
  • Address psychosocial problems
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

18
Brief Manualized Evidenced-Based Psychotherapies
for Depression
  • Cognitive behavioral therapy (CBT) (negative
    automatic thoughts)
  • Interpersonal psychotherapy (IPT) (interpersonal
    difficulties)
  • Others (some include psychodynamic strategies)
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

19
Depression When to Refer for Urgent Psychiatric
Evaluation
  • Patient is suicidal and/or has just made a
    suicide attempt
  • Patient has symptoms of psychosis or severe
    agitation (but rule out delirium)
  • Patient has mixed depression and mania

20
Agents Used for Depression in Patients with HIV
  • Antidepressants
  • SSRIs
  • SNRIs
  • TCA (tricyclic antidepressants )
  • Other antidepressants
  • Psychostimulants
  • Hormonal treatmentcheck for / treat ?
    testosterone levels in men and women
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

21
Antidepressants SSRIs
  • In general, SSRIs are well tolerated, safe, and
    have lower rates of drug discontinuation in
    studies with HIV-infected patients all have
    equal efficacy
  • SSRIs have proven efficacy in clinical trials
    with HIV depressed patients
  • Drug interactions need to be considered with
    fluoxetine and paroxetine
  • Side effects nausea, jitteriness, weight loss,
    insomnia, sexual dysfunction
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

22
Antidepressants SSRIs
  • Sertraline (Zoloft) 25 - 200 mg/day
  • Escitalopram (Lexapro) 10 20 mg/day
  • Citalopram (Celexa) 20 - 40 mg/day)
  • Fluoxetine (Prozac) 10 - 60 mg/day
  • Paroxetine (Paxil) 10 - 60 mg/day
  • More likely to cause drug interactions
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

23
Antidepressants SNRIs
  • Venlafaxine (Effexor) XR 75-300 mg qd
  • useful in SSRI nonresponders
  • extended release form preferable
  • may decrease indinavir levels - significance
    unknown
  • Mirtazapine (Remeron) 15-45 mg qHS
  • very useful in patients with insomnia
  • Duloxetine (Cymbalta) 20-60 mg qd
  • effective for symptoms of physical pain
    associated with depression
  • indicated for diabetic neuropathy
  • Desvenlafaxine (Pristiq) 50mg
  • extended release
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

24
Tricyclic Antidepressants Potential Useful
Properties
  • Anti-diarrhea
  • Sedation
  • Anti-neuropathic pain
  • Can monitor correct dose by blood levels
  • imipramine, desipramine, nortriptyline
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

25
Tricyclic Antidepressant / Antiretroviral Drug
Interactions
  • Tricyclics (TCAs) are metabolized principally by
    CYP 2D6
  • Ritonavir is a moderate inhibitor of CYP 2D6
    and may cause higher blood levels of TCAs
  • TCAs can delay cardiac conduction and cause
    arrhythmias, especially at high levels
  • EKG and plasma TCA monitoring is recommended when
    these drugs are co-administered with ritonavir or
    other inhibitors of 2D6
  • TCAs are dangerous in overdose--avoid giving
    large quantities to suicidal patients
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

26
Other Antidepressants
  • Trazadone (Desyrel)
  • good in low doses for sleep
  • infrequently, arrhythmias and priaprism occur
  • levels may be elevated by PIs
  • Bupropion (Wellbutrin, Zyban)
  • often chosen for low sexual side effects
  • may cause anxiety or insomnia
  • levels may be increased by efavirenz and protease
    inhibitors
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org
  • Wainberg, et al. Psychiatric Medications and HIV
    Antiretrovirals A Guide to Interactions for
    Clinicians, second edition, New York/New Jersey
    AIDS Education Training Center, HRSA, 2008.

27
Bipolar Depression
  • Check for history of mania or hypomania
    (elevated/irritable mood, decreased need for
    sleep, high energy, racing thoughts, pressured
    speech, self-importance, risk taking behavior)
  • Mood stabilizers are the treatment of choice
  • Giving antidepressants alone can precipitate
    mania
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

28
Mood Stabilizers Lithium and Anticonvulsants
with an Approved Indication
  • Lithium carbonate (Eskalith, Lithobid)
  • Use in lower doses or avoid with renal disease
  • Divalproex sodium (Depakote)
  • Can cause severe liver toxicity
  • Can increase zidovudine levels dosage
  • change not recommended but monitor for toxicity
  • Valproic acid (Depakene)
  • Can cause severe liver toxicity
  • Can increase zidovudine levels dosage
  • change not recommended but monitor for toxicity
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org
  • Wainberg, et al. Psychiatric Medications and HIV
    Antiretrovirals A Guide to Interactions for
    Clinicians, second edition, New York/New Jersey
    AIDS Education Training Center, HRSA, 2008.

29
Mood Stabilizers Anticonsulsants with an
Approved Indication
  • Lamotrigine (Lamictal)
  • Lamotrigine levels may be markedly decreased by
    lopinavir/ritonavir
  • Oxcarbazepine (Trileptal)
  • Carbamazepine (Tegretol others)
  • Avoid may lower levels of PIs and NNRTIs
  • Other anticonvulsants have been used but do not
    have an approved indication
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

30
Mood Stabilizers Atypical Antipsychotics with
an Approved Indication for Bipolar Disorder
  • Aripiprazole (Abilify)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)
  • Risperidone (Risperdal)
  • Ziprasidone (Geodon)
  • Cautions Interactions with PIs metabolic
    complications
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org

31
HIV and Depression Other Considerations
  • St. Johns Wort may lower levels of NNRTIs and
    protease inhibitors caution patients (its
    natural, but so is arsenic)
  • HCV is a common comorbidity in HIV infected
    people HCV treatment (peginterferon alpha 2b
    ribavirin) is associated with depression.
  • American Psychiatric Association Practice
    Guidelines and other reference documents
    www.psych.org
  • Wainberg, et al. Psychiatric Medications and HIV
    Antiretrovirals A Guide to Interactions for
    Clinicians, second edition, New York/New Jersey
    AIDS Education Training Center, HRSA, 2008.

32
Educational Resources on HIV and Mental Health
  • Local and national AETCs
  • NYS AIDS Institute www.hivguidelines.org
  • American Psychiatric Association Office of HIV
    Psychiatry www.psych.org/AIDS

33
AETC National Programs
  • National Resource Center (FXB/UMDNJ)
  • Provides virtual library of online training
    resources for adaptation to meet local training
    needs
  • www.aidsetc.org
  • Warmline/PEPline (UCSF)
  • Telephone consultation for HIV clinical
    management and post-exposure prophylaxis
    management
  • Warmline 800-933-3413
  • PEPline 888-448-4911

34
To schedule a Psychiatric Consultation please
contact James Satriano, PhD, at SATRIAN_at_PI.CPMC.C
OLUMBIA.EDU OR 212/543-5591 To schedule a
Training Activity, please contact Dusty Hackler,
MA, at DRA2107_at_COLUMBIA.EDU OR
212/543-6537 OR visit us on the web
at www.columbia.edu/fc15/
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