Case: A 36-Year-Old HIV-infected Man with History of Depression
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Question 1 of 4
A 36-year-old African American man has been provided HIV-related care for the past year, and presents today for a routine quarterly visit. He has been infected with HIV for 15 years and is being successfully treated with fixed-dose combination tenofovir, emtricitabine, and efavirenz. The patient’s most recent CD4+ cell count is 630/µL, and his plasma HIV RNA value is below the level of detection. Before starting antiretroviral treatment, he had a CD4+ cell count of 202/µL (nadir) and a plasma HIV RNA value of 182,000 copies/mL. He has remained asymptomatic.
The patient’s medical history is unremarkable apart from HIV infection and a history of recurrent depression successfully treated in the past with the selective serotonin reuptake inhibitor (SSRI) antidepressant escitalopram. Several family members have also been diagnosed and successfully treated for depression. The patient has not taken antidepressants in more than a year. His clinic visits typically involve assessing adherence issues and safer sex behaviors, as well as screening for depression.
The patient lives alone and has a supportive environment. For the past year, he has been in a monogamous relationship with a male partner who is reportedly HIV seronegative. The patient is employed as an elementary school teacher and is proud of his work. He is very organized, never misses appointments, is very well-related during his appointments with the practitioner, and always dresses meticulously. He is an occasional alcohol user and has a history of sporadic ecstasy use in his twenties.
During this visit, the practitioner reviews the patient’s medical history and medication list, and he reports that for the last 2 months he has begun feeling depressed again and cannot identify any triggers. As with previous depressive episodes, it began with mild sadness, lack of motivation to engage in pleasurable activities (anhedonia), decreased energy, middle-night and early-morning awakening, and mild memory difficulties. At first he thought his depression was stress related. However, when school closed for its annual spring break and he took a 1-week vacation, he did not feel any better. He has had no suicidal ideation or major life changes because of his depression. He is still able to work but says that it takes much more effort to get through the day and that he is not performing at his peak. A routine physical examination is unremarkable. The practitioner mentions the possibility of switching to an efavirenz-free antiretroviral regimen, but the patient states he trusts his current regimen and that his episodes of depression began before he took efavirenz. The practitioner decides to accept the patient’s perspective and keep the antiretroviral regimen as is.
Clinical Decision Point A
What is the optimal initial approach to this patient’s complaints?CorrectIncorrect
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