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Depression rate drops during first year of antiretroviral therapy.

In a group of HI V-positive people starting antiretroviral therapy, * chances of depression fell sharply in the first year of treatment. (1) A score indicating level of depression dropped by half--from 6 to 3--during the first year of antiretroviral therapy.

Depression--feeling very sad or hopeless much of the time--is not just a mood or a feeling: It's a serious illness that can be assessed with standard tests and often responds to treatment. Analysis of a group representing everyone in care for HIV in the United States determined that more than 1 in 3 HIV-positive people have depression. (2) Almost half of these people with depression did not have a diagnosis of depression in their medical file, meaning many of them never discussed depression with their HIV care provider. A study of 2596 people with or without HIV calculated that the HIV group had almost a doubled risk of major depression. (3)

Research has linked depression to poor antiretroviral pill taking and to worsening HIV infection and death. (4) Depression can make it harder to work, harder to sleep, and harder to enjoy the good things in life.

A team at the University of Alabama at Birmingham conducted this study to measure changes in depression rate and severity during the first 12 months of antiretroviral therapy and to identify factors linked to depression after 12 months of therapy.

* How the study worked. The study focused on adults starting their first antiretroviral combination between January 2007 and December 2012. Everyone received care at the University of Alabama at Birmingham HIV clinic. The researchers checked clinic records to gather information on these people (like age and race) and to note their scores on a standard depression test.

This test, the Patient Health Questionnaire depression scale (PHQ-9), can be used to determine whether a person has mild, moderate, moderately severe, or severe depression. (5) For this study the researchers divided people into those with major depression (score 10 or higher) or mild or no depression (score 9 or lower). You can see the PHQ-9 by clicking on the link following reference 6.

For each person, the researchers recorded PHQ-9 scores at two points: (1) in the year before they started antiretroviral therapy and (2) at the point closest to 12 months after they started antiretroviral therapy. Then the investigators used a standard statistical test to identify personal and health-related factors linked to depression after 12 months of antiretroviral therapy. This statistical test pinpoints individual factors related to depression, no matter what other risk factors a person may have.

* What the study found. The study included 281 people, 48 (17%) of them women, 170 (60%) black, and 111 (40%) white. While 38% of the study group were younger than 30 years old, 41% were 30 to 45 and 21% were older than 45. Records showed that 8% of the group had public health insurance (like Medicaid or Medicare), 44% had private insurance, and 48% had no insurance.

Among the 281 study participants, 196 (70%) had mild or no depression and 85 (30%) had major depression. Eighty-seven people (31%) had depression before ever starting antiretroviral therapy. That number dropped to 59 (21%) with depression after 12 months of therapy. Among the 87 people with depression before therapy, only 37 (43%) still had depression while taking antiretroviral therapy.

The median (midpoint) depression score fell from 6 before antiretroviral therapy began to 3 after 12 months of therapy. This drop is highly statistically significant, meaning that chance cannot explain the difference. Risk of depression was more than 2 times higher before antiretroviral therapy than during therapy.

The multifactor statistical analysis determined that three factors made depression more likely after 12 months of antiretroviral therapy (Figure 1). People with major depression before antiretroviral therapy had an 8 times higher chance of depression after 12 months of therapy, when compared with people who had no depression or mild depression before therapy. Compared with people younger than 30, those older than 45 had almost a 3 times higher chance of depression after 12 months of antiretroviral therapy. And compared with people who had private health insurance, those with no health insurance had a 2.6 times higher chance of depression during antiretroviral therapy.

The same statistical analysis found no evidence linking the antiretroviral efavirenz to depression. Efavirenz is also called Sustiva and is part of the 3-in-l pill Atripla. Some earlier research linked efavirenz to depression, but other research did not. Results of the new study support the argument that efavirenz does not lead to depression.

* What the findings mean for you. Depression--a "persistent sad, anxious, or 'empty' mood"'--is a serious illness. The National Institute of Mental Health says depression can cause "severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working."' Yet people are sometimes reluctant to discuss depression with their providers. People with HIV and their providers should work together to determine if a person has depression, because depression can be treated successfully with counseling, medication, or both.

A study of a large US HIV group figured that one third had major depression. (2) Results of the new study agree with that estimate, finding that almost 1 in 3 HIV-positive people had major depression before they started their first antiretroviral therapy. But after about 12 months of therapy, the proportion of people with depression had dropped to 1 in 5. At the same time, depression severity fell by half in this HIV group.

These findings do not mean antiretroviral therapy itself relieves depression. Rather, the lower depression rate after antiretroviral therapy began may indicate that being in care for HIV infection and having contact with health professionals helps people overcome depression. The study also found that people without health insurance had more than a doubled risk of depression.

If you think you may have depression, you can look at the National Institute of Mental Health list of depression signs and symptoms (Table 1). If you have some of these feelings most of the clay for at least 2 weeks, you may have depression and you should talk about it with your HIV provider.


(1.) Eaton EF, Gravett RM, Tamhane AR, Mugavero MJ. Antiretroviral therapy initiation and changes in self-reported depression. Clin Infect Dis. 2017; 64:1791 -1794.

(2.) Asch SM, Kilbourne AM, Gifford AL, et al. LTnderdiagnosis of depression in HIV: who are we missing?/ Gen Intern Med. 2003; 18:450-460.

(3.) Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001; 158:725-730.

(4.) Villes V, Spire B, Lewden C, et al; ANRS CO-8 APROCO-COPILOTE Study Group. The effect of depressive symptoms at ART initiation on HIV clinical progression and mortality: implications in clinical practice. Antiiir Ther. 2007; 12:1067-1074.

(5.) Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure./ Gen Intern Med. 2001; 16:606-613.

(6.) LIS Preventive Services Task Force. Patient Health Questionnaire (PHQ-9).

(7.) National Institutes of Health. National Institute of Mental Health. Depression.

* Words in bold are defined in the Technical Word List at the end of this issue of HIV Treatment Alerts.
Table 1. Signs and symptoms of depression

If you have been experiencing some of the following signs and
symptoms most of the day, nearly every day, for at least two weeks,
you may be suffering from depression:

* Persistent sad, anxious, or "empty" mood
* Feelings of hopelessness, or pessimism
* Irritability
* Feelings of guilt, worthlessness, or helplessness
* Loss of interest or pleasure in hobbies and activities
* Decreased energy or fatigue
* Moving or talking more slowly
* Feeling restless or having trouble sitting still
* Difficulty concentrating, remembering, or making decisions
* Difficulty sleeping, early-morning awakening, or oversleeping
* Changes in appetite or weight
* Thoughts of death or suicide, or suicide attempts
* Aches or pains, headaches, cramps, or digestive problems without a
  clear physical cause and/or that do not ease even with treatment

Source: National Institutes of Health. National Institute of Mental
Health. Depression. Signs and symptoms.


Figure 1. Three factors made
depression after 12 months of
antiretroviral therapy (ART)
more likely: depression before
ART began, being older than
45 versus younger than 30, and
having no health insurance versus
having private health insurance.

Factors predicting depression on ART

Times higher chance of depression

Depression before ART   8.1
Older than 45           2.9
No insurance            2.6

Note: Table made from bar graph.
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Publication:HIV Treatment: ALERTS!
Date:Sep 1, 2017
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