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Annotated Abstracts of Journal Articles
2013, 4th Quarter

HIV Psychiatry

Annotations by Oliver Freudenreich, MD, FAPM and Mary Ann Cohen, MD, FAPM
December 22, 2013

PUBLICATION #1 — HIV Psychiatry
Drug-Induced Long QT in Adult Psychiatric Inpatients: The 5-Year Cross-Sectional ECG Screening Outcome in Psychiatry Study

R Girardin F, Gex-Fabry M, Berney P, Shah D, Gaspoz JM, Dayer P
Am J Psychiatry 2013 Dec; 170(12):1468-76

This article is also reviewed this quarter by Chwastiak & Freudenreich under Serious Mental Illness.

ANNOTATION (Freudenreich & Cohen)

The Finding: In the ECG Screening Outcome in Psychiatry (ESOP) study, a drug-induced long QT interval (defined as > 500 msec) was associated with 7 drugs (including methadone, fluoxetine and citalopram/escitalopram) and 4 clinical conditions (T wave abnormalities, hypokalemia, HCV, and HIV infection).  Less than 1% of ECGs had a drug-induced long QT interval, and only 0.1% of patients developed torsades (but 20% of those had had a prolonged QT interval).

Strength and Weaknesses: The ESOP study uniformly coded all ECGs that were obtained routinely over a 5-year period at admission to a psychiatric hospital in Geneva.  Even though almost 7,000 ECGs were reviewed, the numbers of the outcomes of interest were small (and thus limited statistical power).  Also, this was a cross-sectional study in an inpatient population.

Relevance: This study should give practitioners of HIV psychiatry pause as they likely care for patients who have several of the identified risk factors (HIV infection by default but also use of methadone and use of antidepressants).  A screening ECG in HIV patients who require one of the psychiatric medications fingered in this report should be considered.  This would potentially prevent adding the last component risk factor needed to push a system towards torsades.


Objective: The authors aimed to determine the prevalence of drug-induced long QT at admission to a public psychiatric hospital and to document the associated factors using a cross-sectional approach.

Method: All ECG recordings over a 5-year period were reviewed for drug-induced long QT (heart-rate corrected QT ≥500 ms and certain or probable drug imputability) and associated conditions. Patients with drug-induced long QT (N=62) were compared with a sample of patients with normal ECG (N=143).

Results: Among 6,790 inpatients, 27.3% had abnormal ECG, 1.6% had long QT, and 0.9% qualified as drug-induced long QT case subjects. Sudden cardiac death was recorded in five patients, and torsade de pointes was recorded in seven other patients. Relative to comparison subjects, patients with drug-induced long QT had significantly higher frequencies of hypokalemia, hepatitis C virus (HCV) infection, HIV infection, and abnormal T wave morphology. Haloperidol, sertindole, clotiapine, phenothiazines, fluoxetine, citalopram (including escitalopram), and methadone were significantly more frequent in patients with drug-induced long QT. After adjustment for hypokalemia, HCV infection, HIV infection, and abnormal T wave morphology, the effects of haloperidol, clotiapine, phenothiazines, and citalopram (including escitalopram) remained statistically significant. Receiver operating characteristic curve analysis based on the number of endorsed factors per patient indicated that 85.5% of drug-induced long QT patients had two or more factors, whereas 81.1% of patients with normal ECG had fewer than two factors.

Conclusions: Drug-induced long QT and arrhythmia propensity substantially increase when specific psychotropic drugs are administered to patients with hypokalemia, abnormal T wave morphology, HCV infection, and HIV infection.

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PUBLICATION #2 — HIV Psychiatry
The effect of testosterone levels on mood in men: a review
Johnson JM, Nachtigall LB, Stern TA
Psychosomatics 2013 Nov-Dec; 54(6):509-14

ANNOTATION (Freudenreich & Cohen)

The Finding: Some but not all studies find a correlation between low testosterone levels and complaints typical for depression (low mood, irritability, libido) but not necessarily clinical depression. Testosterone replacement is not broadly beneficial but has been found to be effective in hypogonadal men with depression and in HIV/AIDS patients with depression.

Strength and Weaknesses: Even though this topic is clinically important the literature is hampered by numerous yet small studies leading to inconsistent findings. Optimal testosterone cut-offs are not well established for people over age 60.

Relevance: Male HIV patients are one clinical subgroup where the detection and treatment of low testosterone in the setting of dysthmia/depression (even without overt hypogonadism) is supported by the literature. Checking total (morning) testosterone levels in the aforementioned scenarios should be considered. As always, the risks of testosterone treatment should be taken into account before treating.


Background: The effects of both high and low levels of testosterone are wide ranging and can include changes in mood, often overlapping with symptoms of mood disorders.

Objective: We sought to review the literature on the correlation of high and low levels of testosterone on mood disorders in men.

Results: Based on limited studies, high levels of testosterone are related to increased rates of depression as well as hypomania, whereas low levels of testosterone are related to depressive disorders in certain subpopulations of patients. There is insufficient evidence to conclude that low testosterone level routinely leads to major depressive disorder in men.

Conclusions: Physicians should consider screening for low testosterone levels in certain subgroups of depressed men.

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PUBLICATION #3 — HIV Psychiatry
HIV Testing and Risk Behaviors Among Gay, Bisexual, and Other Men Who Have Sex with Men – United States
Centers for Disease Control and Prevention (CDC)
MMWR Morb Mortal Wkly Rep 2013 Nov 29; 62(47):958-62

ANNOTATION (Freudenreich & Cohen)

This is an important epidemiological report from the CDC that finds 1) that the majority of new HIV diagnoses in the US in 2011 were among MSM (in all but one state), and 2) that unprotected anal sex at least once in the past 12 months increased from 48% in 2005 to 57% in 2011.  These findings matter with regards to prevention of new infections which have remained stubbornly high and stable.  At a minimum, patients with MSM should receive annual HIV testing (more frequent testing as often as every 3 months might be needed in some patients).  Efforts to reduce high-risk sexual behaviours including unprotected sex need to accompany better screening.

ABSTRACT (PubMed)  [ed: paragraph breaks inserted]

The burden of human immunodeficiency virus (HIV) is high among gay, bisexual, and other men who have sex with men (MSM). High HIV prevalence, lack of awareness of HIV-positive status, unprotected anal sex, and increased viral load among HIV-positive MSM not on antiretroviral treatment contribute substantially to new infections among this population.

CDC analyzed data from the National HIV Surveillance System (NHSS) to estimate the percentage of HIV diagnoses among MSM by area of residence and data from the National HIV Behavioral Surveillance System (NHBS) to estimate unprotected anal sex in the past 12 months among MSM in 2005, 2008, and 2011; unprotected discordant anal sex at last sex (i.e., with a partner of opposite or unknown HIV status) in 2008 and 2011; and HIV testing history and the percentage HIV-positive but unaware of their HIV status by the time since their last HIV test in 2011. This report describes the results of these analyses.

In all but two states, the majority of new HIV diagnoses were among MSM in 2011. Unprotected anal sex at least once in the past 12 months increased from 48% in 2005 to 57% in 2011 (p<0.001). The percentage engaging in unprotected discordant anal sex was 13% in 2008 and 2011. In 2011, 33% of HIV-positive but unaware MSM reported unprotected discordant anal sex. Among MSM with negative or unknown HIV status, 67% had an HIV test in the past 12 months. Among those tested recently, the percentage HIV-positive but unaware of their infection was 4%, 5%, and 7% among those tested in the past ≤3, 4-6, and 7-12 months, respectively. Expanded efforts are needed to reduce HIV risk behaviors and to promote at least annual HIV testing among MSM.

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