title: Mind the Gap: Gaps in Antidepressant Treatment, Treatment Adjustments, and Outcomes among Patients in Routine HIV Care in a Multisite U.S. Clinical Cohort.
abstract: Depression affects 20-30% of HIV-infected patients and is associated with worse HIV outcomes. Although effective depression treatment is available, depression is largely untreated or undertreated in this population.
  
  
  
  We quantified gaps in antidepressant treatment, treatment adjustments, and outcomes among US patients in routine HIV care in the nationally distributed CNICS observational clinical cohort. This cohort combines detailed clinical data with regular, self-reported depressive severity assessments (Patient Health Questionnaire-9, PHQ-9). We considered whether participants with likely depression received antidepressants, whether participants on antidepressants with persistently high depressive symptoms received timely dose adjustments, and whether participants achieved depression remission. We considered a cross-sectional analysis (6,219 participants in care in 2011-2012) and a prospective analysis (2,936 participants newly initiating CNICS care when PHQ-9 screening was active).
  
  
  
  The cross-sectional sample was 87% male, 53% Caucasian, 25% African American, and 18% Hispanic; the prospective sample was similar. In both samples, 39-44% had likely depression, with 44-60% of those receiving antidepressants. Of participants receiving antidepressants, 20-26% experienced persistently high depressive symptoms; only a small minority of those received antidepressant dose adjustments. Overall, 35-40% of participants on antidepressants achieved full depression remission. Remission among participants with persistently high depressive symptoms was rare regardless of dose adjustments.
  
  
  
  In this large, diverse cohort of US patients engaged in routine HIV care, we observed large gaps in antidepressant treatment, timely dose adjustment to address persistently high depressive symptoms, and antidepressant treatment outcomes. These results highlight the importance of more effective pharmacologic depression treatment models for HIV-infected patients.
authors.affiliation: UNC School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Rushina
authors.initials: R
authors.lastname: Cholera
authors.affiliation: Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pence
authors.affiliation: Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Angela M
authors.initials: AM
authors.lastname: Bengtson
authors.affiliation: Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States of America.
authors.forename: Heidi M
authors.initials: HM
authors.lastname: Crane
authors.affiliation: HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States of America.
authors.forename: Katerina
authors.initials: K
authors.lastname: Christopoulos
authors.affiliation: Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Cole
authors.affiliation: Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States of America.
authors.forename: Rob
authors.initials: R
authors.lastname: Fredericksen
authors.affiliation: Department of Psychiatry, School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Bradley N
authors.initials: BN
authors.lastname: Gaynes
authors.affiliation: Division of Infectious Diseases, Department of Medicine, School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Amy
authors.initials: A
authors.lastname: Heine
authors.affiliation: UCSD, Department of Medicine, School of Medicine, University of California, San Diego, San Diego, CA, United States of America.
authors.forename: W Christopher
authors.initials: WC
authors.lastname: Mathews
authors.affiliation: Harvard Medical School/Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America.|The Fenway Institute, Fenway Health, Boston, MA, United States of America.|Harvard School of Public Health, Department of Epidemiology, Boston, MA, United States of America.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Mimiaga
authors.affiliation: Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States of America.
authors.forename: Richard
authors.initials: R
authors.lastname: Moore
authors.affiliation: Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.|Division of Infectious Diseases, Department of Medicine, School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill NC, United States of America.
authors.forename: Sonia
authors.initials: S
authors.lastname: Napravnik
authors.affiliation: Harvard Medical School/Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States of America.|The Fenway Institute, Fenway Health, Boston, MA, United States of America.
authors.forename: Conall
authors.initials: C
authors.lastname: O'Clerigh
authors.affiliation: Department of Psychology, University of Miami, Miami FL, United States of America.
authors.forename: Steven
authors.initials: S
authors.lastname: Safren
authors.affiliation: Department of Medicine and UAB Center for AIDS Research, University of Alabama at Birmingham, Birmingham AL, United States of America.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mugavero
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D003863:Depression / Q000150:complications / Q000188:drug therapy* / Q000523:psychology* / Q000821:virology; D059026:Diagnostic Self Evaluation; D004334:Drug Administration Schedule; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy / Q000523:psychology* / Q000821:virology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012074:Remission Induction; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents; D000928:Antidepressive Agents