Depression: Screening, Diagnosis, Management

Significance

  • A higher prevalence of depression is reported in PLWH described in 20-40% versus 7% in general population
  • Significant disability and poorer HIV treatment outcomes are associated with depression
  • Depressive disorders are often associated with a significant anxiety and poor overall wellbeing

Screening and Diagnosis

Who?

  • Screening of all PLWH recommended in view of the high prevalence of depression
  • Populations at particularly high risk
    • Positive history of depression in family
    • Depressive episode in personal history
    • Older age
    • Adolescence
    • Persons with history of drug addiction, psychiatric, neurologic or severe somatic co-morbidity
    • Use of EFV
    • Use of neurotropic and recreational drugs
    • As part of investigation of neuro-cognitive impairment, see Algorithm for Diagnosis and Management of NCI

How to Screen?

  • Screen every 1-2 years
  • Two main questions:
  1. Have you often felt depressed, sad or without hope in the last few months?
  2. Have you lost interest in activities that you usually enjoy?
  • Specific symptoms in men:
    • Stressed, burn out, angry outbursts, coping through work or alcohol
  • Rule out organic cause (such as hypothyroidism, hypogonadism, Addison’s disease, non-HIV drugs, vitamin B12 deficiency)

How to Diagnose?

  • Symptoms – evaluate regularly
  1. At least 2 weeks of depressed mood OR
  2. Loss of interest OR
  3. Diminished sense of pleasure

PLUS 4 out of 7 of the following:

    1. Weight change of ≥ 5% in one month or a persistent change of appetite
    2. Insomnia or hypersomnia on most days
    3. Changes in speed of thought and movement
    4. Fatigue
    5. Feelings of guilt and worthlessness
    6. Diminished concentration and decisiveness
    7. Suicidal ideation or a suicide attempt (EFV has been associated with a higher risk of suicidal ideation)

    Management

    Degree Number of symptoms
    (see above section "How to Diagnose?")
    Treatment Consultation with expert
    No < 4 No  
    Mild 4 - Problem-focused
    consultation
    - Consider
    antidepressive treatment(i)
    - Recommend physical activity
    • Always if treating doctor is unfamiliar with use of antidepressants
    • If depression not responding to treatment
    • If the person has suicidal ideation
    • In case of complex situations such as drug addiction, anxiety disorders, personality disorders, dementia, acute severe life events
    Intermediate 5-6 - Start antidepressive
    treatment(i)
    Severe > 6 Refer to expert (essential)

     

    1. See Drug-drug Interactions between Antidepressants and ARVs

    If a person is diagnosed with depression switching off EFV to another third ARV drug according to switch rules is recommended