SLAM DUNC 2012 Accomplishments

In a partnership between CHPIR, Duke University’s Center for Health Policy and Infectious Diseases Clinic, and the Department of Psychiatry and Infectious Diseases Clinic at UNC at Chapel Hill, SLAM DUNC integrates a depression treatment and brief medication adherence counseling intervention into clinical care at four HIV clinics, employing randomized controlled trials to assess whether, relative to usual care, the intervention leads to improved HIV medication adherence. The depression treatment intervention uses a model known as Measurement-Based Care which equips Care Coordinators with systematic measurement tools, a decision algorithm, and psychiatric backup and trains them to provide decision support to HIV clinicians to implement, monitor, and adjust antidepressant therapy.

In 2012, SLAM DUNC acquired three new team members, Scotty Elliott (Depression Care Manager at Duke ID clinic), Elise Nelson (Interviewer), Marcus Hawley (Interviewer), in addition to expanding to a fourth site at the Northern Outreach Clinic in Henderson, NC. Here, 89 of the 133 active participants have successfully completed the study.

SLAM DUNC staff—Assistant Professor, Dr. Brian Pence; Project Coordinator, Quinn Williams; and Associate Professor, Dr. Nathan Theilman—disseminated their research findings by publishing two peer-reviewed articles with one currently in press, as well as through two presentations of SLAM DUNC research at the 7^th International Conference on HIV Treatment Adherence in Miami, FL.

Publications and Presentations

• Pence BW, O’Donnell JK, Gaynes BN.  “The depression treatment cascade in primary care: A public health perspective.”  Current Psychiatry Reports. 2012; 14(4): 328-35.  PMCID: PMC3410049.

ABSTRACT: Major depressive disorder (MDD) is common and costly. Primary care remains a major access point for depression treatment, yet the successful clinical resolution of depression in primary care is uncommon. The clinical response to depression suffers from a “treatment cascade”: the affected individual must access health care, be recognized clinically, initiate treatment, receive adequate treatment, and respond to treatment. Major gaps currently exist in primary care at each step along this treatment continuum. We estimate that 12.5% of primary care patients have had MDD in the past year; of those with MDD, 47% are recognized clinically, 24% receive any treatment, 9% receive adequate treatment, and 6% achieve remission. Simulations suggest that only by targeting multiple steps along the depression treatment continuum (e.g. routine screening combined with collaborative care models to support initiation and maintenance of evidence-based depression treatment) can overall remission rates for primary care patients be substantially improved.

• Pence BW, Gaynes BN, Williams Q, Modi R, Adams J, Quinlivan EB, Heine A, Thielman N, Mugavero MJ. “Assessing the effect of Measurement-Based Care depression treatment on HIV medication adherence and health outcomes: Rationale and design of the SLAM DUNC Study.” Contemporary Clinical Trials:33(4):828-38, 2012. PMCID: PMC3361555.

ABSTRACT: Depression affects 20-30% of people living with HIV/AIDS (PLWHA) in the U.S. and predicts greater sexual risk behaviors, lower antiretroviral (ARV) medication adherence, and worse clinical outcomes. Yet little experimental evidence addresses the critical clinical question of whether depression treatment improves ARV adherence and clinical outcomes in PLWHA with depression. The Strategies to Link Antidepressant and Antiretroviral Management at Duke, UAB, and UNC (SLAM DUNC) Study is a randomized clinical effectiveness trial funded by the National Institute for Mental Health. The objective of SLAM DUNC is to test whether a depression treatment program integrated into routine HIV clinical care affects ARV adherence. PLWHA with depression (n=390) are randomized to enhanced usual care or a depression treatment model called Measurement-Based Care (MBC). MBC deploys a clinically supervised Depression Care Manager (DCM) to provide evidence-based antidepressant treatment recommendations to a non-psychiatric prescribing provider, guided by systematic and ongoing measures of depressive symptoms and side effects. MBC has limited time requirements and the DCM role can be effectively filled by a range of personnel given appropriate training and supervision, enhancing replicability. In SLAM DUNC, MBC is integrated into HIV care to support HIV providers in antidepressant prescription and management. The primary endpoint is ARV adherence measured by unannounced telephone-based pill counts at 6 months with follow-up to 12 months and secondary endpoints including viral load, health care utilization, and depressive severity. Important outcomes of this study will be evidence of the effectiveness of MBC in treating depression in PLWHA and improving HIV-related outcomes.

• Pence BW, O’Donnell JK, Gaynes BN.  “Falling through the cracks: the gaps between depression prevalence, diagnosis, treatment, and response in HIV care.” AIDS 26(5):656-8, 2012. Presented at 7^th International Conference on HIV Treatment Adherence, Miami, FL, June 2012.
• Quinn Williams, MSW; Brian Pence, PhD, MPH; Julie Adams MD, MPH; Amy Heine, MSN, FNP; Bradley Gaynes, MD, MPH. “Monthly assessments of stressful life events in HIV patients participating in an adherence trial” Presented at 7^thInternational Conference on HIV Treatment Adherence, Miami, FL, June 2012.