Depression: Screening, Diagnosis and Management

Significance

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

Screening and diagnosis of depression

Who?

  • Consider screening at each routine HIV clinic visit, 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 neurocognitive impairment, see Algorithm for Diagnosis and Management of NCI
    • Socially isolated

How to Screen?

  • Two 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?
  • Rule out other medical conditions (such as hypothyroidism, hypogonadism, Cushing’s syndrome, vitamin B12 deficiency)
  • Rule out depressive symptoms associated with ART (such as EFV) and non-ART medication (such as corticosteroids)

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(i)

Assessment of the risk of suicide should be done with the following questions:

  • Are these just ideas?
  • Are they intrusive and how many?
  • How much control do you have over these ideas?
  • Have you made a plan?
  • Are you about to take action?

i  EFV has been associated with a higher risk of suicidal ideation

Management of depression

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 person has suicidal ideation or psychotic symptoms (delusions or hallucinations)

In case of complex situations such as drug addiction, anxiety disorders, personality disorders, dementia, acute severe life events

Clinical improvement with antidepressants may take up to 4 weeks; there is no need to change antidepressants before this time. Dose increment of antidepressant may be considered
Intermediate 5-6 Start antidepressive
treatment(i, ii, iii)
Severe > 6 Refer to expert (essential)(iv)
  1. See Drug-drug Interactions between Antidepressants and ARVs 
  2. There is an increased risk of suicide and serious traffic accident in the first 15 days of antidepressant treatment;
    frequent monitoring in groups 5 and 6 is required during this period
  3. In groups 4, 5 and 6, psychotherapeutic follow-up (e.g. cognitive behavioral therapy CBT) may be indicated (consult with expert advice)
  4. Mental health professionals should always be consulted if there is a risk of suicide

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