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Depression and PTSD Treatments Improve HIV Treatment Outcome. Eric Avery, MD Assistant Clinical Professor of Psychiatry Director, HIV Psychiatry Services The University of Texas Medical Branch Galveston, Texas. Objectives.

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Depression and ptsd treatments improve hiv treatment outcome

Depression and PTSD Treatments Improve HIV Treatment Outcome

Eric Avery, MD

Assistant Clinical Professor of Psychiatry

Director, HIV Psychiatry Services

The University of Texas Medical Branch

Galveston, Texas


1. To understand the relationship between the increasing prevalence of psychiatric disorders in HIV patients and the changing epidemiology of the epidemic.

2. To review Depression and Post Traumatic Stress Disorder (PTSD):



Impact on adherance and mortality

Treatment of Depression and PTSD

3. To review HIV and psychiatric drug/drug interactions.

Hiv is a psychiatric epidemic
HIV is a Psychiatric Epidemic

  • Psychiatric illness increases risk for HIV.

  • HIV increases risk for psychiatric illness.

  • Effective treatment for psychiatric illness can improve patient outcome.

  • Effective treatment for psychiatric can decrease HIV transmission.

Psychiatric illness increases risk of hiv infection
Psychiatric Illness Increases Risk of HIV Infection

  • Substance Abuse.

  • Mood Disorders (Major Depression, Bipolor D/O)

  • Post Traumatic Stress Disorder (PTSD)

  • Psychotic Disorders

  • Impulsive behavior and personality factors

Hiv increases risk for psychiatric illness
HIV Increases Risk for Psychiatric Illness

  • Increased major depression.

  • Increased mania.

  • HIV dementia (AIDS Dementia Complex).

  • Increased psychosocial stressors.


1. Prevalence

2. Diagnosis

3. Impact on ARV Treatment:

  • Initiation

  • Discontinuation

  • Adherance

    4. Impact on HIV Mortality

    5. Treatment of Depression

100 patients with hiv how many are depressed
100 Patients with HIVHow many are depressed?

Depressed Mood and HIV:

Name the 11 types:












Why is the diagnosis important?

Differential diagnosis of depressed moods in hiv patients
Differential Diagnosis of Depressed Moods in HIV Patients

  • Despondency/demoralization.

  • Dysthymia (chronic low mood).

  • Adjustment disorder/minor depression.

  • Major depression, recurrent major depression.

  • General anxiety disorder.

  • Bipolar disorder -- depressed phase.

  • Organic mood disorder “secondary depression” (infections, medication side-effects, and mass lesions of CNS).

  • Malnourishment/weight loss associated with HIV.

  • Sleep disorder.

  • Psychoactive substance abuse.

  • Bereavement.

Depression: Multicenter AIDS Cohort Study

% Depressed

Time of AIDS Onset

55- 49- 43- 37- 31- 25- 19- 13- 7-12 0-6 0-6 7-12 13- 19-

60 54 48 42 36 30 24 18 mo mo mo mo 18 24

mo mo mo mo mo mo mo mo mo mo

Percentages of Multicenter AIDS Cohort Study participants who met syndromal criteria for depression, or who had a score of 22 or greater on the Center for Epidemiologic Studies Depression scale (CES-D) or 14 or greater on the CES-D minus its “somatic” items (CES-D-NS), as AIDS developed.

Lyketos et al, Psych Ann 31: 1 Jan 01

Depression and progression to aids prehaart lyketos hoover guccione et al jama 1993
Depression and Progression to AIDS – PreHAARTLyketos, Hoover, Guccione et al JAMA 1993

  • MACS Cohort: 1718 participants

  • 21% depressed at baseline

  • Cox proportional hazards analysis controlling for sociodemographics, CD4, AIDS related symptoms

  • Depression did not predict AIDS or death

Depression and progression to death prehaart burack barret stall chesney estrand coates jama 1993
Depression and Progression to Death – PreHAARTBurack, Barret, Stall, Chesney, Estrand, Coates JAMA 1993

  • San Francisco Men’s Health Study: 277 participants

  • 20% depressed at baseline

  • Cox proportional hazards analysis of progression to death

  • Depression predicted ARV use but not mortality

Depression and Progression to AIDS – PreHAARTMayne, Vittinghoff, Chesney, Barrett, Coates Arch Int Med 1996

  • SF Men’s Cohort: 1032 participants over 102 months

  • Cox proportional hazards with time dependent variables

  • 58% had significant depressive symptoms (CES-D)

  • Longitudinal measurement of depression every 6 months

  • Predictors of Mortality

    • CD4 cell count

    • B2 microglobulin

    • P24 antigen

    • WHO HIV stage

    • Depression (RR=1.67 P<0.05)

Depression and progression to aids post haart ickovics hamburger vlahov et al jama 2001
Depression and Progression to AIDS: Post-HAARTIckovics, Hamburger, Vlahov et alJAMA 2001

  • HERS Cohort: 765 Participants

  • Longitudinal depression (CES-D)

    • 42% chronic

    • 35% intermittent

    • 23% none

  • Mortality predictors: depression (RR=2), CD4, HAART duration, age

Depression mortality by cd4 and viral load post haart ickovics hamburger vlahov et al jama 2001
Depression, Mortality by CD4 and Viral load: Post-HAARTIckovics, Hamburger, Vlahov et alJAMA 2001

Why does depression speed progression to aids and death
Why Does Depression Speed Progression to AIDS and Death?

  • Stress alters cellular and humoral immune response

    • Kieclot-Glaser Proc Nat Acad Sci 1996

    • Vedhara Lancet 1999

    • Glaser Psychosom Med 1992

    • Jabaaij J Psychosom Res 1993

    • Glaser Ann NY Acad Sci 1998

    • Azciati Psychosomatics 2001

  • Delay in HAART initiation

  • Early HAART Discontinuation

  • Sub-optimal adherence to HAART

  • Depression and delay in haart initiation fairfield jgim 1999



    95% CI

    p Value

    CD4 cell count





    1.61, 4.17




    3.57, 33.33


    Tenfold increase in initial        elevated viral load


    0.45, 0.98


    History of pneumocystis


    0.37, 0.90


    Depression (53%)


    1.03, 2.13


    History of injection drug use


    1.35, 5.56


    Model adjusted for calendar date of first elevated viral load.

    Depression and Delay in HAART InitiationFairfield JGIM 1999

    199 Patients New England Deaconnes with VL>10,000

    What degree of adherence is needed to prevent drug resistant virus
    What Degree of AdherenceIs Needed to PreventDrug-Resistant Virus

    Adherence to a PI-Containing Regimen CorrelatesWith HIV RNA Response at 3 Months




    Patients With HIV RNA <400 (%)









    PI Adherence (%) (MEMScaps)

    Paterson. 6th CROI; 1999; Chicago. Abstract 92.

    Depression predicts adherence to non hiv treatment



    Psychosom Med


    General medicine


    J Fam Pract


    Aspirin for angina


    Behavioral Med


    Renal diet




    ESRD Diet


    Psychol Reports


    ESRD Diet


    Health psychol


    ESRD Medical Regimen


    Ped Neph


    Cyclosporine Renal Transplant




    Cyclosporine Renal Transplant


    Trans Proc


    Rheum arthritis treatment plan


    Pt Ed Counsel


    Oral cytoxan








    Depression Predicts Adherence to Non-HIV Treatment

    Depression and hiv medication adherence
    Depression and HIV Medication Adherence

    • Singh AIDS Care 1996

    • Holzmer AIDS Patient Care STDs 1999

    • Peterson Annals Int Med 2000

    • Schulz 38th ICAAC 1998

    • Bangsberg #1721 41st ICAAC 2001

    Depression is under treated
    Depression is Under-Treated

    • 475 HIV+ men

    • 37% moderate-severe depressive symptoms

      • 40% of depressed received mental health care (12 mo)

      • 3.4% of depressed received antidepressant medications (12 mo)

        Katz et al AIDS Care 1996

    Simple depression assessment
    Simple Depression Assessment

    • During the past month, have you often been bothered by feeling down, depressed, or hopeless?

    • Yes No

    • During the past month, have you often been bothered by having little interest or pleasure in doing things?

    • Yes No

    If “no” to both, patient is unlikely to have major depression.

    If “yes” to either, proceed with the follow-up clinical interview.

    Whooley MA, Simon GE. N Engl J Med, 2000.

    Follow up interview for diagnosis sigecapss
    Follow-up Interview for Diagnosis: SIGECAPSS

    SSleep Disruption in sleep patterns nearly every day?

    I Interests Decreased interest and pleasure in usual activities

    G Guilt Feelings of worthlessness or guilt?

    E Energy Decreased energy?

    C Concentration Diminished ability to concentrate?

    AAppetite Change in appetite or weight?

    PPsychomotor Psychomoror retardation or agitation/irritable?

    SSuicidal Recurrent thought of death or suicide?

    SSex drive Diminished sex drive?

    1 0I do not feel sad.

    1I feel sad.

    2I am sad all the time and I can’t snap out of it.

    3I am so sad or unhappy that I can’t stand it.

    20I am not particularly discouraged about the future.

    1I feel discouraged about the future.

    2I feel I have nothing to look forward to.

    3I feel that the future is hopeless and that things cannot improve.

    30I do not feel like a failure.

    1I feel I have failed more than the average person.

    2As I look back on my life, all I can see is a lot of failures.

    3 I feel I am a complete failure as a person.

    8 0 I don’t feel I am any worse than anybody else.

    1 I am critical of myself for may weaknesses or mistakes.

    2 I blame myself all the time for my faults.

    3 I blame myself for everything bad happens.

    90 I don’t have any thoughts of killing myself.

    1 I have thoughts of killing myself, but I would not carry them out.

    2 I would like to kill myself.

    3 I would kill myself if I had the chance.

    100 I don’t cry any more than usual.

    1 I cry more now than I used to.

    2 I cry all the time now.

    3 I used to be able to cry, but now I can’t cry even though I want to.

    To order forms: 1-800-228-0752

    Beck Depression Inventory Date__________________Name:__________________________________________________ Marital Status:_______ Age:____ Sex:___Occupation:_____________________________________________ Education:___________________________This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number (0,1,2 or 3) next to the one statement in each group which best describes the way you have been feeling the past week, including today. If several statements within a group seem to apply equally well, circle each one. Be sure to read all the statements in each group before making your choice.

    Tricyclic antidepressants treatment of depression in hiv individuals









    Am J Psych





    Am J Psych





    Dep and Anxiety


    Tricyclic Antidepressants Treatment of Depression in HIV+ Individuals

    Treatment of Depression With Other Agents

    in HIV+ Individuals









    J Clin Psych





    Arch Gen Psych


    Testosterone (Sx decrease)


    J Clin Endo Metab


    Grinspoon 2000

    Ssri treatment of depression in hiv individuals









    J Clin Psych





    J Clin Psych





    Am J Psych





    Gen Hosp Psych





    Dep and Anxiety






    J Clin Psych





    Gen Hosp Psyh





    J Clin Psych





    Gen Hosp Psych


    SSRI Treatment of Depression in HIV+ Individuals

    Side effect toxicity profile tca vs ssri


    Narrow therapeutic window

    Requires drug monitoring

    Anticholinergic effects

    Dry mouth, Constipation, dizziness, hypotension

    41% discontinue at 6 months

    (Rabkin Amer J Psych 1994)

    Pill burden


    Mild side effects

    Anticholinergic, agitation/sedation, sexual dysfunction

    Drug interactions (Rx + ritonavir)

    Bupropion - seizures

    Side Effect/Toxicity Profile TCA vs SSRI

    Ssri fda approvals
    SSRI FDA Approvals

    * FDA approved to age 6 years;

    Serotonin discontinuation syndrome
    Serotonin Discontinuation Syndrome

    • Somatic symptoms

      • Disequilibrium, dizziness, unsteadiness, vertigo

      • Feeling “spacey”, confusion, memory dysfunction

      • Flulike symptoms (myalgia, chills, fatigue, nausea)

      • Sensations of electric shocks, parethesia, tremor

      • Insomnia, overactivity, vivid dreams

    • Psychological symptoms

      • Agitation, anxiety, irritability

      • Mood lability, crying spells

      • Cognitive fog

    Staging hiv and antidepressant treatment treat depression first whenever possible
    Staging HIV and Antidepressant Treatment: the Cytochrome P450 IsoenzymeTreat Depression First Whenever Possible

    • Depression is common

    • Depression is the strongest modifiable predictor of adherence to all medical therapy

    • Adherence is the strongest predictor of disease progression and death after CD4 cell count

    • Depression should be treated prior to starting antiretroviral therapy

      • Depression screen, CD4, VL

    • Patients with severe HIV disease may need concurrent initiation of antidepressant therapy and antiretroviral therapy

    Bangsberg JGIM 1999;14:446-8

    Comorbid mood and anxiety disorders
    Comorbid Mood and Anxiety Disorders the Cytochrome P450 Isoenzyme

    Panic Disorder 50% - 65%1

    Generalized Anxiety Disorder 8%- 39%1


    Social Anxiety Disorder 70%2

    PTSD 48%4

    OCD 67%3

    1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC;

    American Psychiatric Press; 1994.

    2 Van Ameringen M et al. J Affect Disord. 1991;21:93-99.

    3 Rasmussen SA, Eisen JL. J Clin Psychiatry. 1992;53(suppl):4-10.

    4 Coryell W Et al. Am J Psychiatry 1988;155:895-898.

    Post traumatic stress disorder
    Post Traumatic Stress Disorder the Cytochrome P450 Isoenzyme

    • Prevalence

    • Childhood abuse, PTSD and HIV risk behaviors

    • Proposed association between PTSD and HIV treatment nonadherance

    • Treatment of PTSD

    Ptsd prevalence
    PTSD Prevalence the Cytochrome P450 Isoenzyme

    • Over half the U.S. population has been exposed to a severe trauma

    • 10-20% of trauma survivors will develop PTSD

    • Lifetime prevalence 8% overall. 12% in women (Kessler 1995)

      • Increased rates in HIV +, incarcerated

      • Limited studies:

        • HIV + 30% (1/3 after HIV dx) (Kelly 1998)

        • Incarcerated women lifetime 33%, current 15-22% (Hutton 2001)

    • PTSD is the 5th most prevalent major psychiatric illness

    Most prevalent anxiety disorders in the general population
    Most Prevalent Anxiety Disorders in the General Population the Cytochrome P450 Isoenzyme

    Lifetime Prevalence (%)

    Kessler et al, National Comorbidity Survey, 1994


    Hutton (2001) 177 Prison Women

    Kelly (1998) 61 HIV+ Gay/Bi men

    Comorbidity the Cytochrome P450 Isoenzyme

    • Comorbid psychiatric illness is about 80%

    • Patients with PTSD are 2 - 4X more likely to have depression, anxiety disorders or substance abuse

    • They are 90X more likely to have a somatization disorder

    Common traumatic events
    Common Traumatic Events the Cytochrome P450 Isoenzyme

    • Witnessing injury/death

    • Sexual molestation/rape

    • Natural disaster/fire

    • Physical attack or abuse/threatened with a weapon

    • Life threatening accident

    • Combat

    Ptsd clinical course
    PTSD - Clinical Course the Cytochrome P450 Isoenzyme

    • PTSD symptoms usually present within the first 3 months following the trauma

      • Less frequently, symptoms may be delayed for months or years after the traumatic event

      • Symptoms of PTSD may persist for months or years after the trauma

  • Approximately 50% of all cases of PTSD are chronic

  • Connection between childhood abuse and hiv infection
    Connection Between Childhood Abuse and HIV Infection the Cytochrome P450 Isoenzyme

    Reported Abuse & Survivor Characteristics (N= 52 HIV +Adults Atlanta Social Service Agency)

    Note. Survivor characteristic categories are not independent.

    Allers C. J Counsel Devel. 1991; 70: 309-13

    Frequency of ptsd disorders among 177 women prisoners in an hiv risk behavior study
    Frequency of PTSD Disorders Among 177 Women Prisoners in an HIV Risk Behavior Study

    Compared with participants who did not have PTSD, those with lifetime diagnosis of PTSD were 71% more likely to have engaged in anal sex and 56% more likely to have engaged in prostitution. The association between lifetime PTSD and other HIV risk behaviors were not significant in this study.

    Hutton, Psych Services 2001, 52/4:508-13

    Ptsd predicts adherence to non hiv treatment
    PTSD Predicts Adherence to Non-HIV Treatment HIV Risk Behavior Study

    Survivors of Myocardial Infarction

    • 102 s/p MI

    • 10% PTSD (intrusion/avoidance)

      • significant association with decreased adherence

        Shemesh Gen. Hosp. Psych 2000

    Ptsd is under treated
    PTSD is Under-Treated HIV Risk Behavior Study

    47 HIV+ women

    • 42% full, current PTSD

      • 59% not receiving mental health care

    • 22% partial PTSD

      • 78% not receiving mental health care

        Martinez AIDS Patient Care and STDs 2002

    Ptsd diagnosis
    PTSD: Diagnosis HIV Risk Behavior Study

    Screening questions
    Screening questions HIV Risk Behavior Study

    • Have you ever had anything happen to you where you thought you would be seriously injured or might die?

    • Have you ever been in a life threatening accident? Fire? Disaster?

    • Have you ever been attacked or raped?

    • Have you ever seen these things happen to someone else?

    If the answer to any of these questions is yes
    If the answer to any of these questions is “yes” HIV Risk Behavior Study

    • Do you ever have nightmares about the event, or sometimes feel the same feelings you had when you were in the trauma?

    • Do you startle easily?

    • Do you try hard to avoid situations which remind you of the trauma?

    • How do you feel about your future?

    Yes or No? HIV Risk Behavior Study

      Have you experienced or witnessed a life-

    threatening event that caused intense fear

    Do you re-experience the event in at least one of

    the following ways?

      Repeated, distressing memories and/or

    Yes No dreams?

     Acting or feeling as if the event were

    Yes No happening again (flashbacks or a sense of

    reliving it)?

      Intense physical and/or emotional distress

    Yes No when you are exposed to things that remind

    you of the event?

    Do you avoid reminders of the event and feel numb, compared to

    the way you felt before, in three or more of the following ways?

      Problems concentrating?

    Yes No

      Feeling “on guard”?

    Yes No

      An exaggerated startle response?

    Yes No

      Do your symptoms interfere with your daily life?

    Yes No

      Have you symptoms lasted at least 1 month?

    Yes No

    Having more than one illness at the same time can make it more

    difficult to diagnose and treat the different conditions. Illnesses

    that sometimes complicate PTSD include depression and

    substance abuse. To see if you have other problems that may

    need treatment, please complete the following questions.

    HOW CAN I TELL IF I HAVE PTSD?PTSD is a serious, yet treatable medical disorder. It is not a sign of personal weakness. If you think you may have PTSD, answer the following questions and show this checklist to your health care professional

    Consensus Guidelines: J Clin Psych 1999

    Ptsd treatment
    PTSD: Treatment HIV Risk Behavior Study

    Psychotherapeutic interventions
    Psychotherapeutic Interventions HIV Risk Behavior Study

    • Acute PTSD

      • mild: Psychotherapy

      • severe: Psycho therapy and medication

    • Chronic PTSD

      • mild: Psychotherapy first or + medication

      • severe: Psychotherapy first or + medication

        If comorbid (eg: depression / bipolor / other anxiety DO)

      • medication plus psychotherapy

    • Most effective: cognitive behavioral therapy (CBT) and exposure therapy

    • Patients are encouraged to confront anxiety provoking triggers, decrease avoidance, and practice stress reducing strategies

    • When referring patients, seek therapists with expertise in CBT and BT

      Consensus Guidelines J. Clin. Psychiatry 1999

    Pharmacological interventions antidepressants
    Pharmacological Interventions: HIV Risk Behavior StudyAntidepressants

    Positive Controlled Trials:


    • amitryptaline (Elavil)

    • imipramine ((Tofranil)


    • phenelzine (Nardil)


    • fluoxetine (Prozac): civilians only

    • sertraline (Zoloft): (Paxil): FDA indication

    • paroxetine (Paxil)

    Benzodiazepines HIV Risk Behavior Study

    • Should NOT be first line

    • May exacerbate

      • Dissociation

      • Substance abuse

      • Disinhibition

    • Best used as an augment

    Pharmacological steps for ptsd
    Pharmacological Steps for PTSD HIV Risk Behavior Study

    • Start with and SSRI

    • Initiate with a low dose, half of what would start for depression

    • Titrate to a high dose

    • Once patient improves, maintain dosage for at least a year

    Pharmacotherapy steps for ptsd
    Pharmacotherapy Steps for PTSD HIV Risk Behavior Study

    • If no response or intolerant to SSRI:

      • Venlafaxine

      • Nefazadone

      • A tricyclic antidepressant

    • If all else fails, consider a monoamine oxidase inhibitor

    Reasonable augmentations
    Reasonable augmentations HIV Risk Behavior Study

    • Anticonvulsants: for dissociation, explosiveness, mood lability

    • Autonomic blockers: for SNS overactivity

    • Benzodiazepines or Buspirone: for excessive anxiety

    • Neuroleptics: for poor impulse control

    • Sedating antidepressants (Trazadone): for insomnia

    Summary HIV Risk Behavior Study

    • Psychiatric disorders, especially depression and PTSD are common in HIV patients.

    • Depression is the strongest modifiable predictor of adherence to all medical therapy.

    • Adherence is the strongest predictor of disease progression and death after CD4 count.

    • Depression should be treated prior to starting antiretroviral therapy. When in doubt, treat.

    • The behavioral manifestations of PTSD contribute to problems of HIV treatment adherance.

      • Difficulty recognizing harm

      • Difficulty developing self protective mechanism

      • Compulsive need to repeat the trauma

      • Sense of foreshortened future