Title: Depression Symptoms and Antiretroviral Adherence in HIVPositive Clinic Patients
1Depression Symptoms and Antiretroviral Adherence
in HIV-Positive Clinic Patients
- Mark V. Bradley, M.D.
- Research Fellow, HIV Center for Clinical and
Behavioral Studies, New York State Psychiatric
Institute and Columbia University - HIV Center for Clinical and Behavioral Studies
- Grand Rounds June 26, 2008
2Background HIV and antiretroviral adherence
- The effectiveness of antiretroviral regimens
depends upon high levels of patient adherence. - Treatment failure is predicted by poor adherence
- High levels of adherence are required to ensure
virologic suppression and prevent resistant
strains (varies by regimen class type). - Most studies show that 40-60 of patients are
less than 90 adherent
3Determinants of Adherence
- Structural
- Housing
- Access to care
- Financial resources
- Transportation
- Medication Regimen Characteristics
- Complexity/Pill burden
- Side effects
- Individual-level factors
- Education and health literacy
- Physical symptoms
- Use of avoidant coping strategies
- Health beliefs
- Psychiatric symptoms/disorders
4Psychiatric disorders and ARV adherence
- Substance use disorders
- Intravenous drug use
- Marijuana
- Cocaine use including crack
- Problem alcohol use
- Methamphetamine
- Serious mental illness psychotic illnesses and
bipolar disorder - Anxiety disorders including PTSD
- Depressive symptoms / disorders
5Background Depression and HIV disease
- High prevalence of depressive disorders in HIV
samples - Depression predicts poorer medical outcomes in
HIV (Clinical progression, mortality), even after
controlling for adherence
6Depression and adherence
- Wagner et al, J Clin Epidemiol, 2001. 54 Suppl 1
p. S91-8. - Palepu et al, substance abuse treatment.
Addiction, 2004. 99(3) p. 361-8. - Barfod et al AIDS Patient Care STDS, 2005. 19(5)
p. 317-25. - Ammassari A., et al., Psychosomatics, 2004.
45(5) p. 394-402. - Arnsten et al, J Gen Intern Med, 2002. 17(5) p.
377-81. - Blanco et al, AIDS Res Hum Retroviruses, 2005.
21(8) p. 683-8. - Boarts et al, AIDS Behav, 2006.
- Carrieri et al., Int J Behav Med, 2003. 10(1) p.
1-14. - Catz et al., Health Psychol, 2000. 19(2) p.
124-33. - Gonzalez et al, Health Psychol, 2004. 23(4) p.
413-8. - Gordillo, et al Aids, 1999. 13(13) p. 1763-9.
- Murphy et al., Arch Pediatr Adolesc Med, 2005.
159(8) p. 764-70. - Holzemer et al., AIDS Patient Care STDS, 1999.
13(3) p. 185-97. - Reynolds et al., AIDS Behav, 2004. 8(2) p.
141-50. - Tucker et al., Am J Med, 2003. 114(7) p. 573-80.
- Waldrop-Valverde et al, Patient Care STDS, 2005.
19(5) p. 326-34.
- Depression is a robust predictor of nonadherence
across a range of studies and methodologies - Most of these studies have examined depression
symptoms rather than categorical diagnoses.
7Depression and adherence
- Cardiac disease and diabetes research has also
found that depression predicts poor medication
adherence
- Gehi, A., et al., Depression and medication
adherence in outpatients with coronary heart
disease findings from the Heart and Soul Study.
Arch Intern Med, 2005. 165(21) p. 2508-13. - Kalsekar, I.D., et al., Depression in patients
with type 2 diabetes impact on adherence to oral
hypoglycemic agents. Ann Pharmacother, 2006.
40(4) p. 605-11. - Lustman, P.J. and R.E. Clouse, Depression in
diabetic patients the relationship between mood
and glycemic control. J Diabetes Complications,
2005. 19(2) p. 113-22. - Barth, J., M. Schumacher, and C. Herrmann-Lingen,
Depression as a risk factor for mortality in
patients with coronary heart disease a
meta-analysis. Psychosom Med, 2004. 66(6) p.
802-13.
8Background Depression and adherence
- Two studies provide retrospective evidence that
treatment of depression improves adherence in
HIV populations (Yun et al, JAIDS 2005 Cook et
al, AIDS Care 2006) - Research in other medical illnesses (diabetes,
cardiocascular disease) have suggested
prospectively and retrospectively that treating
depression may improve adherence (Lustman, Arch
Gen Psychiatry 2006 Katon et al, Arch Intern Med
2005 ) -
9Background Study rationale
- To date, no published prospective research has
demonstrated that treating depression improves
adherence in HIV-positive depressed, nonadherent
medical patients. - The symptom threshold for adherence problems is
not known. - The time from depression response to adherence
improvement is not known. - The specific components of depression
symptomatology responsible for adherence failures
are not known.
10Pilot study Methods
- Naturalistic design
- Following depressed, antiretroviral nonadherent
HIV clinic patients who have recently started or
optimized treatment for depression - Monitoring their depressive symptoms and
antiretroviral adherence as they continue
antidepressant treatment.
11Methods Sample
- HIV adult patients
- Referred to study based on history of depression
and/or nonadherence - Recent initiation or change in antidepressant
treatment (medication switch, titration, or
augmentation) or initiation of psychotherapy - Followed in one of three HIV medical or mental
health clinics at Columbia Med Ctr., or the
Center for Special Studies at Cornell.
12Methods Eligibility criteria
- Currently on antiretrovirals
- Meet the criteria for Major Depressive Disorder,
Minor Depressive Disorder, or Dysthymic Disorder
(SCID) - Demonstrates lt80 adherence at baseline
- Does not meet criteria for substance use disorder
in the past month - Fluent in English
- No h/o bipolar disorder
13Methods Measures
- Adherence
- Chesneys ACTG Follow-Up Questionnaire for
Adherence to Antiretroviral Medications - Visual Analog Scale
- Pill Count
- Viral load
- Depression
- Hamilton Depression Scale
- Depression Module of the SCID
14Methods Measures/co-variates
- Substance use HIV Center Substance Use
Questionnaire (potential depression-nonadherence
mediator) - Cognition
- Rey Verbal Learning Test
- WAIS Letter-Number Sequence
- Stroop
- Color Trails A and B
- Controlled Oral Word Association
- WAIS Test of Adult Reading
15Assessment timeline
16Methods Analytic Plan
- Linear regression models to examining
associations between changes in adherence scores
and changes in HAM-D scores, controlling for
substance use at each time point. - Generalized estimating equations will be used to
account for within-subject correlation across the
three time points. - In secondary analyses, we will examine
relationships between specific depression
symptoms (such as depressed mood, insomnia, and
anergia) and adherence
17Recruitment feasibility
- Recruitment procedures commenced in November,
2007 - Recruitment represented a major challenge to this
study - The intersection of specific eligibility criteria
in several domains resulted in many patients
being screened out of the study - Depressive disorder
- lt80 adherent in past 4 days - 1 week
- Recent onset/change in depression treatment
- Fluent in English
- Not actively using substances
- No history of bipolar disorder
- No psychotic symptoms
18Recruitment feasibility
- Many patients identified and treated for
depression demonstrate good adherence - Many patients systematically identified as
nonadherent by their clinicians also demonstrate
other exlusionary features, especially active
substance use and comorbid psychopathology
19Preliminary findings Sample
-
- 9 participants recruited to date
20Preliminary findings Baseline Depression and
Adherence Scores
21Preliminary Findings
- 4 participants have completed to date.
- These subjects have overall demonstrated some
evidence of improvement in adherence which
occurred alongside improvements in depression
scores - 2 participants have not followed up after
baseline due to re-emergent, severe substance use
problems - 3 participants remain in the process of data
collection
22Preliminary resultsCompleters
23Preliminary conclusions (1)
- Depressed, nonadherent HIV-positive patients
demonstrate a degree of psychosocial complexity
and comorbidity that makes recruitment
challenging. - Studies designed to examine this population may
require a degree of tolerance for this
complexity, rather than highly restrictive
eligibility criteria
24Preliminary conclusions (2)
- When substance use disorders are not an active
issue, individual cases suggest that treating
depressive disorders may be one method for
improving adherence in depressed patients - Future research will require larger samples and
longer follow-up periods in order to elucidate
relationships between depression treatment and
adherence changes.
25Acknowledgements
- This study has been funded by the HIV Centers
Pilot Studies Program and by the Columbia
Department of Psychiatry Frontier Fund. - Dr. Bradley is supported by a training grant from
NIMH (T32 MH19139 Behavioral Sciences Research
in HIV Infection Principal Investigator, Anke A.
Ehrhardt Ph.D. Training Director Theo Sandfort,
Ph.D.). - The HIV Center for Clinical and Behavioral
Studies at the New York State Psychiatric
Institute and Columbia University is supported by
a grant from NIMH (P30-MH43520 Principal
Investigator Anke A. Ehrhardt Ph.D.).
26Acknowledgements
- Mentor
- Robert H. Remien, PhD
- Study Advisors
- Judith G. Rabkin, PhD
- Milton Wainberg, MD
- Cheng-Shiun Leu, PhD
- HIV Center Expertise
- Patricia Warne, PhD
- Katherine Elkington, PhD
- Research Assistant
- Elizabeth Arias, MA
- Harkness-6
- Karen Brudney, MD
- Noga Shalev, MD
- Anne Skomorowsky, MD
- Lucy Ann Wicks Clinic
- Joan Storey, PhD
- Vera Smith, PhD
- Alexandra Bloom, PhD
- Elizabeth Wade, PhD
- Center for Special Studies
- Todd P. Loftus, MD
- Joseph F. Murray, MD