HIV Translating Initiatives for Depression Into Effective Solutions

Background: Depression is the most common mental disorder in HIV infected patients. Despite
the availability of efficacious treatments for depression, evidence suggests that it is
under-diagnosed and under-treated in routine HIV care. To address this problem, we will
adapt and implement a collaborative stepped-care model for depression treatment in HIV
clinics. This proposal builds on past success of the TIDES/WAVES programs used in VA primary
care. The project (HI-TIDES or HIV Translating Initiatives for Depression into Effective
Solutions) will implement the primary care collaborative care model for depression treatment
in HIV clinics using evidence-based implementation strategies. Objectives: The objectives of
this proposal are to: 1) Develop and evaluate the process of adapting, implementing, and
sustaining collaborative care for depression in VA HIV clinics, 2) Compare the quality of
depression care and the clinical effectiveness of HI-TIDES to usual care in the HIV clinics,
and 3) Evaluate the cost-effectiveness of patients assigned to HI-TIDES relative to patients
assigned to usual care in HIV clinics. Methods: The implementation framework for this
proposal is primarily informed by the Rogers diffusion of innovation model, Simpson Transfer
Model, and the PRECEDE model. The VA and American Psychiatric Association Practice
Guidelines inform the stepped care collaborative model intervention as source documents for
summarizing the evidence for depression treatment for the general population. An expert
panel will be convened to rate the quality of available evidence for depression treatment in
the context of HIV. Patients will be recruited from VA HIV clinics: Little Rock, Atlanta,
and Houston. The intervention will be randomized at the level of the patient. We expect to
recruit a total of 140 intervention and 140 usual care patients. Patients in the
intervention group will be supported by a depression collaborative care team that will
include a depression nurse care manager, clinical pharmacist, and psychiatrist. The
depression nurse care manager will evaluate depression symptom severity, antidepressant side
effects, depression and HIV medication adherence every two weeks over the phone during the
acute phase of treatment and will record these results in the VA electronic medical record.
After a 50% improvement in depression severity, the intervention subject will move into the
continuation phase of treatment and the patient will be contacted every four weeks by the
depression nurse case manager. A formative evaluation will occur during start-up and
throughout the implementation of the intervention. A summative evaluation will document the
effectiveness and cost-effectiveness of the intervention using an intent to treat analysis
plan. Findings: No results at this time. Status: Start-up activities. Impact: The proposed
study is highly relevant to the VA and the veterans it serves for many reasons. First, the
majority of VA patients with HIV are not seen in the primary care clinics and therefore will
not benefit from VA's efforts in primary care settings to improve depression identification
and treatment. Second, in addition to the negative outcomes of depression generally,
depression in HIV patients is associated with additional negative outcomes including
accelerated HIV disease progression, decreased immune system functioning, and premature
death. Third, directly moving collaborative depression care from primary care clinics to HIV
clinics is likely to fail for several reasons including the comorbidities associated with
depressed HIV patient and the potential for drug-drug interactions. The proposed project
will address these gaps and provide effectiveness and cost-effectiveness analyses to inform
decisions about larger scale implementation of the HI-TIDES intervention.

Inclusion Criteria:

1. current 9-item Patient Health Questionnaire (PHQ-9) score of 10 or more and

2. current treatment in the HIV clinic.

Exclusion Criteria:

1. patients who do not have access to a telephone,

2. patients with current suicidal ideation,

3. patients with significant cognitive impairment as indicated by a score < 10 on the
HIV Dementia Scale, and

4. patients with a chart diagnosis of schizophrenia.