Drug treatment of depression in HIV-positive patients: Safety considerations

Safe and effective treatment of major depression, one of the most common comorbid conditions in individuals infected with HIV, significantly lowers morbidity and mortality from HIV disease. However, optimal treatment of both conditions is complicated by interactions between the disease processes as well as the pharmacological agents used to treat them. In patients with HIV it may be difficult to distinguish major depression from other physiological and emotional states that present with similar symptoms. Accurate diagnosis of major depression is thus complex and essential to preventing inappropriate exposure of patients to potentially harmful psychotropic medications. This review outlines important initial steps in making this diagnosis. All patients with HIV should be screened for depression by their medical providers and referred to a psychiatrist for full evaluation when necessary. The mainstay of treatment for major depression in patients with HIV disease is pharmacotherapy. Depressed patients with HIV respond to the same wide variety of antidepressant-class medications as depressed patients without HIV, including tricyclic antidepressants, paroxetine, fluoxetine and trazodone. Notably, new studies have also shown that some psychiatric medications can inhibit HIV replication. No particular antidepressant medication is superior for the treatment of depressed HIV-infected patients; however, the most important component of treatment of major depression in HIV-disease is patient adherence, which is highly influenced by antidepressant adverse effects. This review outlines adverse effects of antidepressant-class medications that are of particular concern in HIV-infected patients and describes pharmacological strategies for overcoming these potential barriers to medication adherence. This review also describes situations in which some adverse effects of antidepressant-class medications may be safely exploited to benefit depressed patients with HIV disease. Potential interactions between antidepressant-class medications and HIV medications, as well as pharmacological treatment strategies for treating the psychiatric adverse effects of HIV medications, are also discussed.