| DEPRESSION: DIAGNOSIS AND MANAGEMENT |
Significance
- Higher prevalence of depression in HIV-infected patients (20-40% versus 7% in general population) due to stigma, sexual dysfunction, side effects of cART, co-morbidities
- Significant disability associated with depression
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| Screening and diagnosis |
| Who ? |
How to screen ? |
How to diagnose |
Risk population
- Positive history of depression in family
- Depressive episode in personal history
- Older age
- Adolescence
- Patients with history of drug addiction, psychiatric, neurologic or severe somatic co-morbidity
- Use of EFV
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- Screen every 1-2 years
- Two main questions:
- Did you feel frequently depressed, sad and without hope in the last months?
- Were you uninterested in undertaking something in the last month?
- Special symptoms in men:
- Stressed, burn out, angry outbursts, coping through work or alcohol
- Rule out organic cause (hypothyroidism, Addison’s disease, non-HIV drugs, Vit B12 deficiency)
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Symptoms – evaluate regularly with screening questions
- A. At least 2 weeks of depressed mood OR
- B. loss of interest OR
- C. diminished sense of pleasure
PLUS 4 of 7 of the following:
- Weight change of ≥ 5% in one month or a persistent change of appetite,
- insomnia or hypersomnia in most days,
- changes in psychomotor state,
- fatigue,
- feelings of guilt and worthlessness,
- diminished concentration and decisiveness,
- suicidal ideation or a suicide attempt
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| Management |
| Degree of depression |
Number of symptoms
(see diagnosis: A-C + 1-7) |
Treatment |
Refer to expert |
| No |
< 4 |
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| Mild |
4 |
problem focused consultation, consider antidepressive treatment i, recommend physical activity |
- Severe depression
- Depression not responding to treatment
- Suicidal ideation
- Complex situations such as drug addiction, anxiety disorders, personality disorders, dementia, acute severe life event
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| Intermediate |
5-6 |
start antidepressive treatment i, consider referral |
| Severe |
> 6 |
refer to expert |
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| i |
Maximum effectiveness reached after 10 weeks, one episode usually 6 months treatment;
optimize treatment, i.e. increase dosage or change drug if side effects;
partial or no response after 4-6 weeks of antidepressant treatment at adequate dosage: reassess diagnosis;
depression in persons ≥ 65 years generally requires relatively low doses of antidepressants;
preferred antidepressants for HIV-infected patients: sertralin, paroxetin, venlafaxine, citalopram, mirtazapin, but also other antidepressants may be given. Citalopram may be preferred because of low interactions. For classification, doses, safety and side effects of antidepressants, see
www.europeanaidsclinicalsociety.org/guide/index.htm.
For interactions with antidepressants see www.hiv-druginteractions.org and www.europeanaidsclinicalsociety.org/guide/index.htm |
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