Julie Adams

Association of Depression and Survival in Patients with Chronic Heart Failure over 12 Years

OBJECTIVE To examine the relationship between depression and survival in patients with chronic heart failure (HF) over a 12-year follow-up period. BACKGROUND The survival associated with depression has been demonstrated in HF patients for up to 7 years. Longer-term impact of depression on survival of these patients remains unknown. METHODS Prospectively conducted observational study examining adults with HF who were admitted to a cardiology service at Duke University Medical Center between March 1997 and June 2003 and completed the Beck depression inventory (BDI) scale. The national death index was queried for vital status. Cox proportional hazards modeling was used to determine the association of survival and depression. RESULTS During a mean follow-up of 1792.33 ± 1372.82 days (median 1600; range 0-4683), 733 of 985 participants with HF died of all causes, representing 80% of those with depression (BDI > 10) and 73% of those without (P = 0.01). Depression was significantly and persistently associated with decreased survival over follow-up (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.15-1.57), and was independent of conventional risk factors (HR 1.40, 95% CI 1.16-1.68). Furthermore, survival was inversely associated with depression severity (BDI (continuous) HR 1.02, 95% CI 1.006-1.025, P = 0.001). CONCLUSIONS The impact of co-morbid depression during the index hospitalization on significantly increased mortality of HF patients is strong and persists over 12 years. These findings suggest that more investigation is needed to understand the trajectory of depression and the mechanisms underlying the impact of depression as well as to identify effective management strategies for depression of patients with HF.

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.

Trauma history and depression predict incomplete adherence to antiretroviral therapies in a low income country.

Background As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care. Methodology The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART. Results Incomplete ART adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence. Discussion This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections.

The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial.

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.

Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults

Background In high income nations, traumatic life experiences such as childhood sexual abuse are much more common in people living with HIV/AIDS (PLWHA) than the general population, and trauma is associated with worse current health and functioning. Virtually no data exist on the prevalence or consequences of trauma for PLWHA in low income nations. Methodology/Principal Findings We recruited four cohorts of Tanzanian patients in established medical care for HIV infection (n = 228), individuals newly testing positive for HIV (n = 267), individuals testing negative for HIV at the same sites (n = 182), and a random sample of community-dwelling adults (n = 249). We assessed lifetime prevalence of traumatic experiences, recent stressful life events, and current mental health and health-related physical functioning. Those with established HIV infection reported a greater number of childhood and lifetime traumatic experiences (2.1 and 3.0 respectively) than the community cohort (1.8 and 2.3). Those with established HIV infection reported greater post-traumatic stress disorder (PTSD) symptomatology and worse current health-related physical functioning. Each additional lifetime traumatic experience was associated with increased PTSD symptomatology and worse functioning. Conclusions/Significance This study is the first to our knowledge in an HIV population from a low income nation to report the prevalence of a range of potentially traumatic life experiences compared to a matched community sample and to show that trauma history is associated with poorer health-related physical functioning. Our findings underscore the importance of considering psychosocial characteristics when planning to meet the health needs of PLWHA in low income countries.

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.

Correlates of HIV Testing Among Abused Women in South Africa

Gender-based violence increases a woman’s risk for HIV but little is known about her decision to get tested. We interviewed 97 women seeking abuse-related services from a nongovernmental organization (NGO) in Johannesburg, South Africa. Forty-six women (47%) had been tested for HIV. Caring for children (odds ratio [OR] = 0.27, 95% confidence interval [CI] = [0.07, 1.00]) and conversing with partner about HIV (OR = 0.13, 95% CI = [0.02, 0.85]) decreased odds of testing. Stronger risk-reduction intentions (OR = 1.27, 95% CI = [1.01, 1.60]) and seeking help from police (OR = 5.51, 95% CI = [1.18, 25.76]) increased odds of testing. Providing safe access to integrated services and testing may increase testing in this population. Infection with HIV is highly prevalent in South Africa where an estimated 16.2% of adults between the ages of 15 and 49 have the virus. The necessary first step to stemming the spread of HIV and receiving life-saving treatment is learning one’s HIV serostatus through testing. Many factors may contribute to someone’s risk of HIV infection and many barriers may prevent testing. One factor that does both is gender-based violence.

Feasibility of Integrated Depression Care in an HIV Clinic

Depression among people with HIV infection can lead to lower antiretroviral (ARV) therapy adherence, higher viral loads, lower CD4 cell counts, and increased mortality compared to those with HIV infection who are not depressed. Effective depression management can increase CD4 counts and decrease viral loads by improving ARV adherence. Collaborative depression care in HIV clinics using nurse care managers has shown promise as an effective management strategy. We developed an integrated approach to depression management in an HIV clinic using non–medically trained care managers (social workers) supervised by a psychiatrist as a way to further increase depression treatment options for HIV clinics, and we tested the model for feasibility and appropriateness. We implemented our approach in an outpatient infectious diseases clinic at a tertiary care hospital in Durham, North Carolina. The clinic staff consists of five full-time-equivalent physicians, one physician assistant, five nurses, and four social workers. The clinic has 1,760 patients with active HIV infection, representing most of the stable, returning clinic population. Patients are mostly male (70%), African American (56%) or Caucasian (37%), and between ages 30 and 59 (85%). A convenience sample of adult HIV-positive patients was screened with the self-administered nine-item Patient Health Questionnaire (PHQ-9). We selected patients with scores {grtr/eq }10, who gave informed consent and completed further baseline assessment with a psychiatrist. Participants with a confirmed diagnosis of major depressive disorder were eligible for inclusion in the study, whereas those with manic or psychotic history, acute suicidality, or current depression management were not. Key demographic and clinical data were also collected, including ARV prescription, adherence, and side effects. The care manager met with eligible participants to review clinical data and the PHQ-9 results. The care manager then used a guideline-concordant, antidepressant treatment algorithm that accounted for potential ARV interactions to determine individualized dosing recommendations. This served as decision support for the prescriber, who made the final treatment choice. Clinical data and PHQ-9 scores were examined during return visits at weeks 4, 8, and 12 by the care manager, who again used the algorithm to inform the prescriber, who made dose adjustments in collaboration with the participant. The care manager spoke with participants on the phone at weeks 2, 6, and 10 to assess for and manage incident side effects. The care manager met with the psychiatrist weekly to review each participant’s treatment course; the psychiatrist did not meet personally with participants after the baseline assessment. Participants whose depression had not remitted (PHQ-9 score <5) by week 12 and those with a clinical indication were referred for psychiatric care. A total of 144 patients were screened, of whom 45 (31%) screened positive for depression. Nineteen had excluding conditions (ten were receiving depression care, three patients declined, clinicians declined to refer three patients, two patients had manic history, and one did not have major depression), and 13 completed appointments before staff could approach them for enrollment. Thirteen (9% of total, 29% of positive screens) patients were enrolled. Participants’ mean±SD age was 38±8 years, and time since HIV diagnosis was 11±5 years. Most participants were men (N=9, 69%), single (N=8, 62%), and white (N=8, 62%). Over half self-identified as heterosexual (N=7, 54%). Most had attained at least a high school education (N=10, 77%) and were employed (N=7, 54%). Three (23%) were unemployed, and three (23%) were disabled. All participants had a concurrent anxiety disorder, and three (23%) had a substance use disorder. Algorithm fidelity was 91% (proportion of algorithm-indicated medication changes communicated by the care manager to prescribers). The care manager completed 72% of phone contacts and 82% of in-clinic visits. Nine participants (69%) completed 12 weeks of depression treatment. The mean±SD baseline PHQ-9 score was 17.62±5.47 (N=13). Scores among the nine completers decreased from 18.33±6.06 to 11.44±7.91, which was significant (t=2.73, df=8, p=.03). The intervention demonstrated reasonable feasibility in terms of identifying persons with depression, maintaining algorithm fidelity by the care manager, completion of study visits, and participant retention. Although the study was not powered to detect change in depressive symptoms, a decrease in PHQ-9 scores was observed. However, the mean score remained above the cut-off score for depression. The high prevalence of depression in the sample supports prior findings of increased prevalence in HIV relative to the general population. The presence of depression among individuals already receiving depression treatment suggests under treatment, and such individuals, as well as more women and persons from racial-ethnic minority groups, should be included in future research. Use of nonmedical care managers in integrated depression treatment models in HIV clinics deserves further study, particularly in clinics where nurse time may not be abundant.