Case: A 36-Year-Old HIV-infected Man with History of Depression

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?

Because the patient’s depression presentation is similar to that of past episodes (recurrent depression) and because he is HIV asymptomatic and off antidepressant medication, restarting the same antidepressant, escitalopram, without further assessment and workup, is warranted.
Prior to restarting the antidepressant, the one necessary further step is to perform a validated depression screen in order to assess the severity of his depression and to follow the patient’s progress more objectively.
Conduct a depression screen and a complete medical workup, including assessment of thyroid function, testosterone, syphilis, and hepatitis C laboratory screens. Pending the results, initiate escitalopram in the patient to treat his depression.
Conduct a depression screen and a complete medical workup, including assessment of thyroid function, testosterone, syphilis, and hepatitis C laboratory screens. Hold off on restarting escitalopram in order to review the results of these tests first.

Question 2 of 4

Case Presentation (Continued)

The patient screens positive for depression (PHQ-9: 16) and reports no increase in alcohol or drug use lately. He denies suicidal ideation and psychotic symptoms, and he does not have a history of mania.

Until results of the laboratory tests are back, the practitioner restarts escitalopram 10 mg daily (this was the previously effective dose) to begin to treat his depression and prevent further deterioration and problems at work.

The patient’s thyroid function, testosterone level, and syphilis and hepatitis C virus (HCV) laboratory test results are all within normal limits, as are the results of other routine laboratory tests.

The practitioner sets up a plan to monitor the patient’s antidepressant response by phone. At 2 weeks he calls in to report some improvement. One month later he calls again but this time reports that his improvement has dissipated. The practitioner increases the escitalopram dose to 20 mg and makes an appointment to see him again in 4 weeks. The patient arrives late for his scheduled appointment, looks unkempt, and indicates that he is still not better. When asked how he is coping, he reports worrying about missing a few days at work after he did not get much sleep. When asked if anything helps him to sleep, he states: “After a while I get out of bed. I might take a drink and look out the window. When I feel sleepy again I go back to bed. I think I’d feel much better if I could get a good night’s sleep.”

Clinical Decision Point B

What is the optimal next step to take in helping your patient?

Switch to the antidepressant citalopram because the escitalopram is not working.
Assess the patient for alcohol and drug use, because such use might be interfering with the patient’s improvement.
Add a sleep medication to the patient’s regimen because sleep deprivation may be contributing to his continued low mood.
Taper the escitalopram because it is not working and schedule the patient to return in 2 weeks to begin a trial of another antidepressant.

Question 3 of 4

Case Presentation (Continued)

The practitioner decides to conduct a more detailed assessment of the patient’s alcohol and drug use using the TICS.[42] The patient scores positive for alcohol but 0 for drugs. Using the AUDIT for further alcohol screening reveals that for the past few months the patient has been drinking almost daily, anywhere from 3 to 4 drinks per night, and has an AUDIT score of 17, which is consistent with alcohol use disorder. A brief counseling conversation with the patient addresses the pros and cons of the current drinking behavior (using motivational interviewing). The high possibility of alcohol contributing to the depression or lack of response to treatment and difficulty functioning at work yields a plan for the patient to try to abstain or reduce his drinking to no more than 1 or 2 drinks per night not every night (maximum of 4 or 5 drinks/week), for the next 2 weeks.

Two weeks later the patient calls the practitioner as planned and reports marked improvement of his depression and energy level. His teaching is going well and he is enjoying it again. He reports that it is a relief to be back to his usual level of functioning and he feels motivated to continue to moderate his drinking and consume no more than 2 drinks a day on Friday and Saturday nights only.

Understanding that recurrent depression requires chronic pharmacologic treatment, the practitioner and the patient agree on a long-term plan for him to continue taking the current antidepressant treatment and moderate his alcohol use as already described. The practitioner continues to see him every 3 months and he remains stable (back to his baseline) for the next couple of visits.

However, during a routine visit 12 months later, the patient again arrives late and looks unkempt, and he reports that his mood remains good but he has started to notice slowness and mild problems with concentration that frighten him and make him once again feel concerned about his teaching job. The practitioner repeats the medical workup as described above, reassessing the patient’s laboratory values and alcohol and drug use. There are no notable findings. The practitioner suspects that the patient may be displaying the cognitive manifestations of HIV infection, and refers him to neuropsychological testing to clarify the extent of his problem. However, the patient will need to wait 3 months for the next appointment.

Clinical Decision Point C

While waiting for neuropsychological testing to take place, the clinical approach is likely to be best guided by:

Administering the Mini Mental State Examination (MMSE).
Administering the HIV dementia scale (HDS) to confirm a diagnosis of mild neurocognitive disorder.
Discontinuing escitalopram to determine whether the cognitive changes he is experiencing are due to the adverse effects of his antidepressant medication.
Use the information that the patient has already given you to make a tentative diagnosis of mild neurocognitive disorder.

Question 4 of 4

Add or switch to a non-SSRI antidepressant to provide a more potent treatment of the depression, as escitalopram may not be working.
Because of this patient’s history of substance use, prescribing a psychostimulant is contraindicated.
Starting a psychostimulant, such as methylphenidate, can help deal with the patient’s slowness and decreased concentration.
Meet with the patient and his partner to help them prepare for the inevitable reality of rapid cognitive decline and progression to full HAD.

Case: A 36-Year-Old HIV-infected Man with History of Depression