Suicidal Ideation is Associated with Limited Engagement in HIV Care.

PHQ-9 data from persons living with HIV (PLWH, n = 4099) being screened for depression in three clinics in the southeastern USA were used to determine the prevalence of suicidal ideation (SI). SI was reported by 352 (8.6 %); associated with <3 years since HIV diagnosis (1.69; 95 %CI 1.35, 2.13), and HIV RNA >50 copies/ml (1.70, 95 %CI 1.35, 2.14). Data from PLWH enrolled in a depression treatment study were used to determine the association between moderate-to-high risk SI (severity) and SI frequency reported on PHQ-9 screening. Over forty percent of persons reporting that SI occurred on "more than half the days" (by the PHQ-9) were assessed as having a moderate-to-high risk for suicide completion during the Mini International Neuropsychiatric Interview. SI, including moderate-to-high risk SI, remains a significant comorbid problem for PLWH who are not fully stabilized in care (as indicated by detectable HIV RNA or HIV diagnosis for less than 3 years).

Psychiatric comorbidity in depressed HIV-infected individuals: common and clinically consequential.

OBJECTIVE: To report on the prevalence of psychiatric comorbidity and its association with illness severity in depressed HIV patients. METHODS: As part of a multi-site randomized controlled trial of depression treatment for HIV patients, 304 participants meeting criteria for current Major Depressive Disorder (MDD) were assessed for other mood, anxiety and substance use disorders with the Mini-International Neuropsychiatric Interview, a structured psychiatric diagnostic interview. We also assessed baseline adherence, risk, and health measures. RESULTS: Complicated depressive illness was common. Only 18% of participants experienced MDD with no comorbid psychiatric diagnoses; 49% had comorbid dysthymia, 62% had ≥1 comorbid anxiety disorder, and 28% had a comorbid substance use disorder. Self-reported antiretroviral adherence did not differ by the presence of psychiatric comorbidity. However, psychiatric comorbidity was associated with worse physical health and functioning: compared to those with MDD alone, individuals with ≥1 comorbidity reported more HIV symptoms (5.1 vs. 4.1, P=.01), and worse mental health-related quality of life on the SF-12 (29 vs. 35, P<.01). CONCLUSION: For HIV patients with MDD, chronic depression and psychiatric comorbidity are strikingly common, and this complexity is associated with greater HIV disease severity and worse quality of life. Appreciating this comorbidity can help clinicians better target those at risk of harder-to-treat HIV disease, and underscores the challenge of treating depression in this population.

When "need plus supply" does not equal demand: challenges in uptake of depression treatment in HIV clinical care.

OBJECTIVE: Depression is common among patients in HIV care and is associated with worse HIV-related health behaviors and outcomes. Effective depression treatment is available, yet depression remains widely underdiagnosed and undertreated in HIV care. METHODS: As part of a multisite, randomized trial of depression treatment in HIV clinical care, the proportion of positive depression screens that resulted in study enrollment and reasons for nonenrollment were examined. RESULTS: Over 33 months, patients completed 9,765 depression screens; 19% were positive for depression, and of these 88% were assessed for study eligibility. Of assessed positive screens, 11% resulted in study enrollment. Nonenrollment after a positive screen was sometimes dictated by the study eligibility criteria, but it was often related to potentially modifiable provider- or patient-level barriers. CONCLUSIONS: Addressing patient- and provider-level barriers to engaging in depression treatment will be critical to maximize the reach of depression treatment services for HIV patients.

Implementation of PHQ-9 depression screening for HIV-infected patients in a real-world setting.

The prevalence of depression is 20%-30% for people living with HIV, and while it is associated with poorer adherence to antiretrovirals, it is often unrecognized by medical providers. Although it has been challenging for some health care settings to develop consistent depression screening mechanisms, it is feasible to create screening protocols using the nine-item Patient Health Questionnaire (PHQ-9). Establishing a depression screening and response protocol is an iterative process that involves preparing staff, determining screening frequency, and developing procedures for response and appropriate medical record documentation. While there are multiple issues and potential challenges during implementation, it is possible to incorporate systematic depression screening into HIV primary care in a manner that achieves staff buy-in, minimizes patient burden, streamlines communication, and efficiently uses the resources available in the medical setting.