Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial.
OBJECTIVE
We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.


METHODS
We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).


RESULTS
The intervention reduced depression symptom severity (b = -1.97; 95% confidence interval [CI] = -0.85, -3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.


CONCLUSIONS
Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.
Langley Porter Psychiatric Institute, University of California, San Francisco, CA, USA. atsai@hsph.harvard.edu
Alexander C
AC
Tsai
Dan H
DH
Karasic
Gwendolyn P
GP
Hammer
Edwin D
ED
Charlebois
Kathy
K
Ragland
Andrew R
AR
Moss
James L
JL
Sorensen
James W
JW
Dilley
David R
DR
Bangsberg
D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D018687:Antidepressive Agents, Second-Generation / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology; D015331:Cohort Studies; D003866:Depressive Disorder / Q000188:drug therapy*; D005260:Female; D005473:Fluoxetine / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006678:HIV / Q000302:isolation & purification; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D012495:San Francisco; D012720:Severity of Illness Index; D016896:Treatment Outcome; D019562:Viral Load / Q000187:drug effects
D044966:Anti-Retroviral Agents; D018687:Antidepressive Agents, Second-Generation; D005473:Fluoxetine