Kelly Cozza, MD, DFAPA, FACLP
Associate Professor, Dept of Psychiatry. Director, Psychiatry Clerkship, & Scientist, CSTS
Uniformed Services University of the Health Sciences
Washington, District of Columbia
HIV/AIDS is estimated to be among the most frequent global causes of disease burden, despite recent advances in its treatment and management, particularly when co-morbid with Major Depressive Disorder (MDD). MDD is more prevalent among HIV-infected individuals than in the general population, with estimated prevalence rates varying from 2% to as high as 60% in certain subpopulations, such as in women or socially disadvantaged persons. The introduction of effective antiretroviral therapy (ART) in regions with access to HIV care and medications has changed the impact and course of HIV infection from a rapidly debilitating and deadly disease into a chronic, manageable illness with a long-term life perspective. Effective treatment of co-morbid MDD assumes even more importance in order to improve quality of life. Unfortunately, MDD is often not recognized and managed in persons with HIV and may not be adequately treated because of fear of side effects of psychotropics, concern about potential drug-drug interactions, and the role of several confounding factors, particularly HIV-associated neurocognitive disorders.
The pathogenic basis for the association of MDD and HIV-infection remains to be clarified. Potential etiologies may include the disruption of immune-balance, since HIV induces activation of inflammatory mediators such as cytokines, chemokine receptors, extracellular matrix-degrading enzymes, and glutamate receptor-mediated excitotoxicity. Pro-inflammatory cytokines, including interleukin (IL) 1, IL-6, IL-18, IL-12, IL-23, tumor necrosis factor (TNF)-a and IFN-a, and chemokines like monocyte chemoattractant protein (MCP)-1, are among the cytokines likely to play an important role in the development and treatment of MDD. HIV-associated inflammatory mediators may play an additive or compounding role with MDD-associated pro-inflammatory cytokines in facilitating the development of depressive symptoms as well as the response (or lack thereof) to treatment. The identification of MDD biomarkers such as pro-inflammatory cytokines in HIV-infected persons may improve diagnostic and therapeutic strategies for MDD in these patients, potentially increasing adherence to ART, improving quality of life, and decreasing morbidity and mortality.
In this symposium we will provide an update on the role of inflammation and immune function in HIV and depression. Luis Pereira, MD, will introduce the symposium by providing an overview of research supporting the impact of immune functioning in HIV. Mark Bradley, MD, will review existing evidence on the role of inflammation in establishing MDD-HIV comorbidity. Jordi Blanch, MD, will then address the challenging task of correctly diagnosing MDD comorbid with HIV infection, reviewing reliable tools for differential diagnosis. Silvia Ferrari, MD, will summarize preliminary results of a multi-center research designed to identify immune biomarkers of MDD in patients newly diagnosed with HIV. The session will conclude with an audience question-and-answer and panel discussion, focusing on the opportunities and challenges posed to psychiatrists by the evidence presented.