Antidepressants versus Interpersonal Psychotherapy in Treating Depression in HIV-Positive Patients

Article excerpt

In 2001, a meta-analysis of previously published studies found the frequency of depression among HIV-positive individuals to be almost twice that of HIV-negative individuals. (1) In 2005, Yun et al. reported a lifetime prevalence rate of depression of 22-45% compared with 15% for the general population. (2) Similiarly, other studies also reported prevalence rates ranging from 2% to 50% in HIV-positive patients. (3-5) It is evident that depression is a common co-morbid psychiatric diagnosis among HIV-positive individuals. The varying prevalence rates reported are probably explained by variations in study population and design, with differences in age, sex, education, ethnicity, stages of HIV/AIDS and diagnosis of depression.

Clinical research had documented a relationship between depression and cell-mediated immunity resulting in alterations in key parameters of cellular immunity, thereby accelerating the course of HIV and AIDS. (6) Although the exact neurobiological mechanisms remain unknown, there is a considerable body of knowledge implicating alterations in CD4, CD8 and NK cells. (7-9) Other potential immune mechanisms include an effect on C-reactive protein, interleukin-2, interleukin-6 and tumour necrosis factor-alpha. Depression is also a risk factor for non-adherence to highly active antiretroviral therapy. (10-13)

On the positive side, there are data showing that currently available treatments (pharmacotherapy and psychotherapy) are effective in the treatment of co-morbid depression and prevent the abovementioned negative sequelae. With regard to pharmacotherapy, tricyclic antidepressants (imipramine and amitriptyline) have been associated with 74-89% response rates in HIV patients. (14-16) However, 30% of responders discontinued use after 6 months' follow-up owing to side-effects such as constipation, hypotension, headache, weight gain and sexual dysfunction. (17) Selective serotonin reuptake inhibitors (SSRIs), although not more efficacious (64-100% response rates), are tolerated better than tricyclics. (18-20) Emerging data suggest that the newer antidepressants such as escitalopram, (21,22) reboxetine, (23,24) nefazodone, (25) venlafaxine, (26) mirtazapine (27-29) and buproprion (30-32) are promising alternatives. Two recent meta-analyses of clinical trial results concluded that antidepressant medications are statistically superior to placebo in their overall effect. (33,34)

There are a number of different psychotherapies for depression, which may be provided to individuals or to groups. Research suggests that cognitive behavioural therapy (CBT) can perform as well as antidepressants in treating patients with moderate to severe depression. (35) However, interpersonal psychotherapy (IPT) was developed as a focused, time-limited treatment for its most common target syndrome, depression, and its efficacy has been established in a number of empirical studies. (36-39)

Despite the prevalence of HIV and AIDS in South Africa reaching pandemic proportions, very few studies have been published on co-morbid depression. Much of the work has mainly been done in the West, hence the need for this study. This study was conducted at the Perinatal HIV Research Unit, a research unit of the University of the Witwatersrand based in Soweto at Chris Hani Baragwanath Hospital, on a group of HIV-positive patients with depression who were receiving antiretroviral treatment. The source of the participants may introduce a bias, and the results therefore cannot be generalised. The objectives of this report (part of a larger study) were to describe the socio-demographic characteristics of the patients, and their response to treatment with either an antidepressant or psychotherapy.

Methods

This was a prospective, randomised, controlled and open-labelled study. The sampling was a convenience sampling as it included patients attending the HIV clinic. Volunteers included in the study were 18 years and older and had a Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnosis of a major depressive disorder (no specifiers). …