Depressive disorders are 'under recognized and under treated' in people with HIV/AIDS

People living with HIV/AIDS are at increased risk of depressive disorders. But all too often, these conditions go unrecognized or untreated, suggests a literature review in the May/June issue of Harvard Review of Psychiatry.

Proper diagnosis and management are essential to reduce negative health effects of depression in patients with HIV/AIDS, according to the report by Gustavo C. Medeiros, MD, of University of Texas Southwestern Medical Center, Dallas, and colleagues. Based on an analysis of 125 research publications, "We provide evidence-based recommendations to improve assessment and management of depressive disorders in seropositive persons," the researchers write.

Diagnosis and Treatment of Depression in Patients with HIV/AIDS

People with HIV/AIDS are at higher risk of depression than the general population—including a two- to four-fold increase in the risk of major depressive disorder (MDD). Depressive disorders are linked to negative health outcomes including poorer compliance with antiretroviral therapy, lower immune function (CD4 cell count), and a higher mortality rate. Dr. Medeiros and colleagues seek to provide an "updated, practical, and global overview" of depression in HIV/AIDS, focusing on:

Assessment and diagnosis. "Depressive disorders are vastly underdiagnosed in HIV/AIDS," according to the authors. Patient assessment is complex due to the overlap between depression and HIV/AIDS symptoms, including fatigue, insomnia, and reduced appetite. Making the correct diagnosis is essential for providing the appropriate treatment.

In addition to MDD, depressive symptoms in patients with HIV/AIDS may be due to other medical conditions, medications or addictive substances, adjustment disorder, or other psychiatric disorders. Other contributing factors may include direct brain damage caused by HIV, as well as psychosocial factors such as chronic stress, HIV-related stigma, and social isolation.

Treatment. Many if not most patients with HIV/AIDS do not receive recommended treatment for depression. One study reported that only seven percent of HIV-positive patients with MDD had access to adequate treatment. Selective serotonin reuptake inhibitors (SSRIs) are the first-choice medications; other antidepressants may be used but require close monitoring for side effects and drug interactions. Other helpful treatments include individual or group psychotherapy. It's also essential to ensure proper management of HIV/AIDS and related medical conditions.

Special challenges. Studies have found that persons with HIV/AIDS have low adherence to recommended treatment for depression—possibly related to HIV-related stigma and feelings of shame. The combination of depression and HIV/AIDS is strongly linked to suicide, with rates eight to ten times higher than in the general population. Depression also poses special challenges in adolescents and older adults with HIV/AIDS.

The article includes detailed information on the differential diagnosis of MDD and other forms of depression, key points related to the use of antidepressant medications, and 'clinical pearls' in managing depressive disorders in patients with HIV/AIDS. Dr. Medeiros and colleagues conclude: "Evidence-based recommendations are available for improving the assessment and management of depression in seropositive persons, and they should be implemented in real-life practice to improve outcomes."