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Within the general population and among persons infected with HIV, women have a higher rate of depression than men. Approximately 50% of women with HIV—nearly double that of men with HIV—have characteristics consistent with depressive symptoms or disorders.[147,148] In addition, 1 in 5 women with HIV meet the classification for major depressive disorders compared with 1 in 20 women without HIV. Although the diagnosis of depression in women with HIV is common, the underlying etiologies of the depression diagnosis often require formal psychiatric or mental health counseling to overcome the disorder. Given the frequency of depression in this population, depression screening should be incorporated into routine clinical care. Screening tools such as the Edinburgh Postnatal Depression Scale may be useful in detecting antenatal depression in women with HIV. Depression is sometimes associated with domestic violence and therefore screening for past or ongoing intimate partner violence may also be clinically relevant.[151,152]
Effect of Depression on ARV Treatment and Overall Clinical Outcomes
Depression may[147,153] or may not[154-157] affect immunologic recovery following initiation of ART. Individuals with depression may have a diminished virologic response and time to virologic suppression may be increased. Access to pharmacologic and psychiatric therapy increases the use of ART among women with HIV with depression. In addition, there is a significant association between intimate partner violence and the incidence of HIV infection among women. Furthermore, women with HIV infection who are exposed to intimate partner violence have lower rates of adherence to ARV treatment, particularly those who score lower on resilience assessment tests. Clinicians should be mindful of potential exposure to domestic violence in all women at entry to care, when adherence patterns change, and if concern for depression emerges. Women should be made aware and linked to appropriate support services.
Women with depression have increased rates of all-cause and AIDS-related mortality and new AIDS-defining illnesses. Untreated depression may result in higher rates of STDs and substance abuse.[164,165] Depression has also been shown to correlate with decreased cognitive function in women with HIV. Individuals who are receiving ongoing treatment for depressive disorders appear to have similar responses to ART, supporting the concurrent treatment of HIV and depression.[160,167]
Neuropsychiatric complications related to the use of ARV medications, ranging from vestibular symptoms and sleep disorders to frank psychosis, have been documented in several case reports of various complications with zidovudine,[168-170] abacavir,[171,172] and nevirapine, although the most extensive body of literature details neuropsychiatric effects of efavirenz.[174-179] Some of these studies have suggested that individuals with a history of mental health problems may be at an increased risk of developing such complications of efavirenz use; however, the studies are contradictory and inconclusive. Regardless, preexisting depression is not a contraindication for efavirenz use, although many providers may be hesitant to use efavirenz in women with a diagnosis of depression. If used, vigilant observation for the development of psychiatric problems when initiating therapy with efavirenz-containing regimens is advised in women with a history of mental health problems.
Treatment of Depression in Women With HIV
Efficacy trials of antidepressant use in women with HIV are lacking. In a study that included mostly men with HIV (83%), depressed patients compliant with selective serotonin reuptake inhibitor (SSRI) use adhered to their ART regimens and achieved viral control that was statistically similar to nondepressed patients with HIV receiving ART. Furthermore, depressed patients compliant with SSRI treatment had statistically significantly greater immunologic responses when compared with depressed patients who were noncompliant with their SSRI regimen. Before initiating any antidepressant agent in women receiving ART, care must be taken to make sure there are no metabolic interactions that may increase adverse events or diminish the efficacy of either agent.
Although depression is a common mental health issue in women with HIV, there is a growing body of evidence demonstrating the efficacy of ART in improving depressive symptoms.[181,182] Moreover, treating depression improves HIV outcomes. Therefore, positive mental health and HIV outcomes can be achieved when the 2 diagnoses are addressed concurrently. Ongoing screening for depression should be used in the clinical setting with referral for appropriate mental health intervention when indicated.