HIV Translating Initiatives for Depression Into Effective Solutions
Condition: HIV, Depression
MeSH terms: Depression; Depressive Disorder
Study type: Interventional

Summary: 
      This study is a randomized trial designed to test and refine a collaborative care model for
      treating depression in VA patients with HIV.
    

Detailed description: 
      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, the
      investigators 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. The investigators 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.
    

Intervention name(s): Collaborative Care Interventions
Intervention type(s): Behavioral
Intervention description(s): 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 CPRS. 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.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: HIV, depression; patient care management; patient care team