• Depression and mania in patients with HIV/AIDS (updated online 2005 Mar). In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 1-20.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

• Human immunodeficiency virus (HIV) infection
• Mental disorders in HIV-infected patients:
  • Depression
  • Mania

Diagnosis
Evaluation
Management
Screening
Treatment

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Psychiatry

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments

To provide guidelines for diagnosis and treatment of depression and mania in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in primary care settings

Patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)

Depression (Screening, Diagnosis, Treatment)

1. Screening for depression using one of the screening tool options
2. Use of Diagnostic and Statistical Manual of Mental Disorders - IV (DSM-IV) criteria
3. Paying specific attention to patients taking interferon-alpha and those with changes in body fat
4. Antidepressant medications:
   • Selective serotonin reuptake inhibitors
   • Novel antidepressants
   • Tricyclic antidepressants
   • Psychostimulants
5. Psychotherapy
6. Alternative therapies (e.g., St. John's Wort)
7. Follow-up

Mania (Screening, Diagnosis, Treatment)

1. Use of DSM-IV diagnostic criteria for mania
2. Prompt referral of patients experiencing mania for psychiatric consultation
3. Medications
4. Combination of psychotherapy with medication

• Effectiveness of screening techniques in detecting unrecognized depression
• Effectiveness of interventions to treat depression

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person 3 to 4 times per year, and otherwise conduct business through monthly conference calls.

Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Depression

Screening for Depression

Clinicians should screen for depression as part of the annual mental health assessment and whenever symptoms suggest its presence.

See the original guideline document for screening techniques, symptoms of depression, and behavioral changes that may be indications of an underlying depressive disorder.

HIV-infected patients do not become depressed simply because their disease progresses; however, it is particularly important to screen for depression during the crisis points noted below.

Crisis Points for HIV-Infected Persons

• Learning of HIV-positive status
• Disclosure of HIV status to family and friends
• Introduction of medication
• Occurrence of any physical illness
• Recognition of new symptoms/progression of disease (e.g., major decrease in CD4 cells, increase in viral load)
• Necessity of hospitalization (particularly the first hospitalization)
• Death of a significant other
• Diagnosis of AIDS
• A return to a higher level of functioning (e.g., re-entry into job market/school, giving up entitlements)
• Major life changes (e.g., childbirth, pregnancy, loss of job, end of relationship, relocation)
• Necessity of making end-of-life and permanency planning decisions

Diagnosis

Clinicians should use the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) to diagnose depression (see table below).

Depression and Co-Existing Medical Conditions

The primary care clinician should work closely with a psychiatrist throughout the course of treatment if depressive symptoms are associated with medication, and the benefit of continuing the medication outweighs the risk. In these situations, antidepressant therapy should be considered.

Key Point

Patients co-infected with hepatitis C virus (HCV), patients receiving treatment with interferon, and patients with disfiguring side effects of highly active antiretroviral therapy (HAART), particularly body fat changes, are more prone to develop depressive symptoms.

Depression in Patients with Human Immunodeficiency Virus (HIV)/Hepatitis C Co-Infection

Clinicians who prescribe interferon-alpha should screen patients for depression at least every 4 weeks while they are receiving treatment (Hauser et al., 2002).

Clinicians who prescribe interferon-alpha should consult with a psychiatrist when treating patients with a history of psychiatric disorders, including depression and substance use.

Key Point

There is a growing amount of evidence that a history of psychiatric disorders, such as depression, does not necessarily increase the risk of developing depression while receiving interferon.

Depression in Patients Experiencing Body Fat Changes

Clinicians should assess mood at every visit in patients who develop changes in body fat.

Key Point

Patients report that clinicians minimize the importance of body fat changes.

Management of HIV-infected Patients with Depression

Clinicians should implement interventions, such as medications or psychotherapy, for patients with moderate to severe depression or mild depression that does not resolve in 2 to 4 weeks.

Referral

Patients at high risk for suicide or other violent behavior should be referred for immediate psychiatric intervention.

Antidepressant Medications

Clinicians should individualize therapy, considering drug-drug interactions with HIV-related medications, presence of comorbid psychiatric disorder(s), presenting symptoms, and side effect profile.

Key Point

As in other vulnerable populations, the concept "start low, go slow" remains the cornerstone of psychiatric medication prescribing for HIV-infected patients.

Refer to Table 6-3 in the original guideline document for a list of commonly used antidepressants.

Refer to Appendix I in the "Companion Documents" field for dosing information, side effect profile, and drug-drug interactions.

Selective Serotonin Reuptake Inhibitors (SSRI) and Novel Antidepressant Medications

Clinicians should ask patients who are receiving SSRIs about sexual side effects.

Clinicians should monitor patients for suicidal ideation during the initiation phase of SSRI treatment. Clinicians should consider discontinuing medication in patients whose depression is persistently worse or whose emergent suicidality is severe, abrupt in onset, or was not part of the presenting symptoms.

Tricyclic Antidepressants

Clinicians should monitor serum drug levels to ensure appropriate dosing of tricyclic antidepressants when there are concerns about adherence, absorption, or drug interactions.

Psychotherapy

Clinicians should refer patients for psychotherapy in the following situations:

• When basic supportive psychoeducational interventions are deemed ineffective in alleviating mood symptoms
• When patients with depressive symptoms refuse (or prefer not to take) recommended psychotropic medication
• When situational events precipitate mild to moderate depressive symptoms
• When patients appear to have difficulty accepting the diagnosis of a mood disorder (especially when this appears to cause high-risk behavior or non-adherence to medication)
• When patients request a referral

Key Point

Combining psychotherapy with antidepressant and mood-stabilizing medications is the most effective treatment option for many patients. If treatment with medications is not possible (e.g., some patients in recovery are opposed to taking psychotropic medications), psychotherapy alone may be as effective as medication in cases of mild to moderate depression.

Alternative Therapies for Depression

Clinicians should inform patients who decide to use alternative treatments of the following:

• Drug interactions and toxicities may occur.
• These treatments may take longer to be effective.
• These medications are not well studied.

Clinicians should inform patients that concomitant use of St. John's Wort with protease inhibitors (PIs) or non-nucleoside reverse transcriptase inhibitors (NNRTIs) is contraindicated because it may lead to subtherapeutic antiretroviral (ARV) drug concentrations.

Treatment Follow-Up

After initiating treatment, clinicians should schedule a brief visit or phone conversation every 1 to 2 weeks to support adherence, assess response and side effects, and remind the patient that it may take 3 weeks or longer for mood to improve. After 3 to 4 weeks, the clinician should perform an in-person assessment of symptom improvement.

During the maintenance phase of treatment with antidepressant medication, clinicians should schedule a brief visit every 4 to 12 weeks to assess adherence, sustained therapeutic response, and side effects.

After referring patients to another provider for medication or psychotherapy, primary care clinicians should schedule a brief visit or phone conversation within 1 to 4 weeks after the referral to ensure that the patient followed through (Simon at al., 2004).

Clinicians should encourage patients who experience recurrent depression to remain on medication indefinitely.

Primary care clinicians should maintain ongoing coordination of care with the patient's mental health care provider.

Mania

Clinicians should immediately refer patients experiencing mania for psychiatric evaluation and care.

Diagnosis

Clinicians should consult with or refer patients to a psychiatrist when there is doubt concerning the diagnosis.

Clinicians should consult with or refer patients to a psychiatrist when it is not clear whether patients are hypomanic or depressed.

Clinicians should use the DSM-IV diagnostic criteria for mania (see table below).

Management of HIV-Infected Patients with Mania

Until patients with mania are stabilized, clinicians should maintain consultation with a psychiatrist or the patient should be under psychiatric care.

Medications

Key Point

Treating hypomanic patients with antidepressants may lead to a full-blown episode of mania.

Refer to Table 6-5 in the original guideline document for commonly used medications to treat mania.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• Appropriate screening, diagnosis, and treatment of depression and mania in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)
• Simple screening techniques tested in a general primary care setting have been shown to be effective in detecting unrecognized depression.
• Mild depression may resolve within 2 to 4 weeks with support and education alone. For some patients, medication alone may be sufficient to ease their depression; for others, the combination of medication and psychotherapy will provide a more effective and perhaps faster response.

Refer to Appendix I in the "Companion Document" field for side effect profile and drug-drug interactions.

Refer to Appendix I in the "Companion Document" field for contraindications between human immunodeficiency virus (HIV)-related medications and psychotropic medications.

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening, or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below.

• Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience.
• Define target audience (providers, consumers, support service providers).
  • Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)?
• Define implementation methods.
  • What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)?
• Determine appropriate implementation processes.
  • What steps need to be taken to make these activities happen?
  • What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)?
  • What necessary processes are external to the organization (e.g., meetings with external groups, conferences)?
  • Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion?
• Monitor progress.
  • What is the flow of activities associated with the implementation process and which can be tracked to monitor the process?
• Evaluate.
  • Did the processes and strategies work? Were the guidelines implemented?
  • What could be improved in future endeavors?

Getting Better
Living with Illness

Effectiveness

• Depression and mania in patients with HIV/AIDS (updated online 2005 Mar). In: Mental health care for people with HIV infection: HIV clinical guidelines for the primary care practitioner. New York (NY): New York State Department of Health; 2001 Mar. p. 1-20.

Not applicable: The guideline was not adapted from another source.

2005 Feb

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Mental Health Guidelines Committee

Committee Chair: John Grimaldi, MD, Assistant Professor of Clinical Psychiatry, Sanford Weill-Cornell University Medical College, New York, New York, Chief Psychiatrist of David Rodgers Unit, Center for Special Studies, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York

Committee Vice-Chair: Francine Cournos, MD, Professor of Clinical Psychiatry, Columbia University, New York State Psychiatric Institute - Unit 112, New York, NY

AIDS Institute Liaison: L. Jeannine Bookhardt-Murray, MD, Director, HIV/AIDS Care, Morris Heights Health Center, Bronx, NY

AIDS Institute: Teresa C. Armon, RN, MS, Coordinator - Mental Health Initiative, Bureau of Community Support Services, New York State Department of Health AIDS Institute, Albany, NY; Josh Sparber, New York State Department of Health AIDS Institute

Committee Members: Philip A. Bialer, MD, Associate Professor of Clinical Psychiatry, Albert Einstein College of Medicine, Chief, Division of Consultation-Liaison Psychiatry, Beth Israel Medical Center, New York, NY; John Budin, MD, Director, Mental Health Services, ID Clinic, Montefiore Medical Center, Bronx, NY, Clinical Instructor in Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York; Mary Ann Cohen, MD, Director, AIDS Psychiatry, Mount Sinai Medical Center, Associate Professor of Psychiatry, Mount Sinai Medical Center, New York, New York; Barbara A. Conanan, RN, MS, Program Director, SRO/Homeless Program, Department of Community Medicine, Saint Vincents Catholic Medical Centers - St. Vincent's Manhattan, New York, New York; Marc Johnson, MD, Assistant Professor of Medicine, Mount Sinai School of Medicine, New York, New York, Attending Physician, New York Hospital Queens, Flushing, New York, Physician in Charge, New York Hospital - Queens Primary Care at ACQC, Rego Park, New York; Henry McCurtis, MD, Acting Director of Psychology, Harlem Hospital Center, New York, New York; Yiu Kee Ng, MD (Warren), Special Needs Clinic, VC4E, New York Presbyterian Hospital, New York, NY; Francine Rainone, PhD, DO, Director, Community Palliative Care, Montefiore Medical Center, Bronx, New York

Liaisons: Frank Machlica, MA, MSW, CSW, Senior Mental Health Consultant, New York City Department of Mental Health, Mental Retardation & Alcoholism Services, Bureau of Strategic Planning, New York, NY; James Satriano, PhD, Assistant Professor of Clinical Psychology, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, Director, HIV/AIDS Programs, New York State Office of Mental Health, New York, New York; Milton Wainberg, Title 1 Liaison

Not stated

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

None available

This NGC summary was completed by ECRI on May 5, 2005. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.