Ask the HIV Specialist: Peace of Mind

Q: I've been HIV-positive for 12 years. My viral load is undetectable and I have a good T-cell count. Ever since I was diagnosed, however, I have experienced deep depression. My life is a mess with a recent job loss, money problems, a dysfunctional relationship, and I'm still not out about being gay or HIV-positive. My doctor keeps trying different antidepressants and sleeping pills, but nothing seems to work. A friend recommended a psychiatrist and he prescribed yet another antidepressant without even asking me what other drugs I'm taking. Is there any danger of these antidepressants interfering with my HIV meds? Is there any one antidepressant known to be effective for people with HIV? Help! I'm at the end of my rope!

A: First of all, Hang in there! YOu've asked three questions: 1) Can psychiatric and HIV medicines interact in a bad way; 2) Is there a "preferred" antidepressant for people with HIV; and 3) What do we do about depression, anyway? To those, I might also add 4) Can certain HIV treatments have a psychiatric effect?

Question 1: Yes, there can be interactions between HIV drugs and psychiatric medicines that could produce undesirable side effects. Also, the herbal antidepressant St. John's wort can lower the blood levels of many HIV medicines, so we never use that herb for HIV patients on treatment.

Question 4: The HIV drug efavirenz (found in Sustiva and Atripla) can definitely affect the mood; if there are significant pre-existing mood problems in a patient, I often will choose a different HIV medicine for them. Isentress (raltegravir) has also been found to worsen depression in patients already on antidepressants; it's not clear if that's due to the Isentress interacting with their psychiatric meds or a direct mood-depressive effect of the Isentress.

Any HIV patient needing psychiatric prescriptions should work with a provider familiar with all of these issues. When I have a patient who works with a psychiatrist, I speak to that provider to make sure he's aware of the possible drug interactions with HIV medicines. Drug interactions can be very serious; it's essential that psychiatrists review your entire drug list before prescribing something for you.

Question 2: There's no "one-size-fits-all" antidepressant for HIV patients, any more than there is a "one-size-fits-all" HIV cocktail. The "right" antidepressant for a patient depends on many different factors, such as the type of depression, the presence of insomnia, other medical conditions they might have, etc. But, that said, at San Francisco General Hospital, where I trained, we usually used Celexa (citalopram) as a first choice, because it generally lacked interactions with the common HIV drugs, and was available as a less-expensive generic. Lexapro (escitalopram) is a newer medicine that similarly lacks drug interactions and rates very favorably for effectiveness and lack of side effects when compared to other antidepressants.

But this gets to Question 3: How do we know that a medication is what your depression needs, anyway? You mention that you've been depressed ever since you were diagnosed HIV-positive, but were you depressed before? You mention a host of stressors, including "a recent job loss, money problems, a dysfunctional relationship, and I'm still not out about being gay or HIV-positive." Those last two facts seem especially important: Living in one closet can be extremely depressing, let alone living in two. I have no doubt that the closeted status is also a factor in the relationship difficulties.

With the underlying issues in your life, there's no pill that's going to erase your depression. What I would strongly recommend is finding a cognitive-behavioral psychotherapist to work with you, to clarify how your life circumstances are creating your depression, and to explore how to address those factors. Also, you might check out Loving What Is, by Byron Katie. While many might be skeptical, her technique is easily learned in just a few minutes, has been found to be very effective by many academic psychotherapists, and is free if you check it out from the library. Self-help from a book is no substitute for working with a qualified therapist, but it may help while you're looking for one.

Rick Loftus, M.D., A.A.H.I.V.S., is Associate Program Director for the internal medicine residency program at Eisenhower Medical Center, and has a private practice in Palm Springs, California.