Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial^†

† Portions of this paper were presented earlier in poster form at the Conference on Retroviruses and Opportunistic Infections, Boston, Massachusetts USA, March 2014.

ABSTRACT

Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.

KEYWORDS:

• Depression
• substance abuse
• HIV
• syndemics
• directly observed therapy

Acknowledgements

We thank Judith Rabkin for critical input on the design of the study, and Kathleen Ragland for assistance with data management.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

† Portions of this paper were presented earlier in poster form at the Conference on Retroviruses and Opportunistic Infections, Boston, Massachusetts USA, March 2014.

Additional information

Funding

This study was funded by the U.S. National Institutes of Health (NIH) [grant number R01MH063011] (PI: Bangsberg). The Research in Access to Care for the Homeless cohort, from whom some of the study participants were drawn, was funded by the NIH [grant number R01MH054907] (PI: Bangsberg). Members of the research team also acknowledge the following additional funding support from the NIH: [grant number T32MH017119] (Grelotti), [grant number K23MH096620] (Tsai), and [grant number K24MH087227] (Bangsberg). HIV RNA kits were donated by Roche. Study doses of Prozac Weekly(R) were donated by Eil Lilly from 2002 through 2005. No funding source was involved in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.