Depression in Older Adults With HIV
In ACRIA's 2006 study of HIV in 1,000 New York City residents over the age of 50 (ROAH: Research on Older Adults with HIV), it was found that the number of people reporting significant symptoms of depression was 13 times higher than that found in the city's general population. As this older population steadily increases and ages (in NYC 30% of all people living with HIV are over 50 and 70% are over 40), there is a critical need to address this treatable disease. Why are there such high levels of depression in older people with HIV? And more important, why is the health care system not more responsive to this medical need? While many illnesses are common to both HIV and aging, the lack of focus on the management of depression is disturbing.
The impact of depression on the immune system has been well established. Stress and depression can have harmful effects on cellular immunity, including those aspects of the immune system affected by HIV. According to Leserman (2003), elevated symptoms of depression are associated with faster progression to AIDS. Another study found that depressive symptoms, especially in the presence of severe stress, are associated with decreases in CD4 cell count and declines in lymphocytes (Kopnisky, 2004). Moreover, it has been theorized that cortisol, which is elevated during periods of stress, may affect HIV viral replication, as well as certain immune system responses. Some studies show that severe life stress, if combined with high glucocorticoid activity, can lower circulating lymphocyte populations, which may then alter the immune system's defense against infections (Petitto et al., 2000).
The precise relationships between stressors, depression, and the immune system remains a puzzle, but understanding the role of psychosocial factors on HIV disease progression may aid in the development of new interventions to better manage HIV. There is a psychoimmune dynamic that affects health and that is the basis for such complementary therapies as relaxation, massage, visualization, and meditation. And since the incidence of depression increases with age, along with a decrease in the response of the immune system, it is clear that the treatment of depression can lead to better management of HIV as well as all of the illnesses of aging.
Since depression rates increase with age, the management of depression in the older adult HIV population becomes even more of a priority in order to maximize immune function, which decreases with age. What are the barriers to treatment? Older adults are less likely than younger people to seek treatment for depression. Often there is a failure to recognize the symptoms of depression, and there may be a perception that being depressed is simply a characteristic of aging rather than an illness. Further, people can be depressed without feeling sad. Rather, the depressive disorder in the aging population may be expressed more by agitation and irritability, and in physical terms such as vague complaints of aches and pains or gastrointestinal upset.
Older adults may continue to regard depression as shameful or a sign of weakness that should not be acknowledged -- even to physicians. Physicians, in turn, often fail to ask the questions that will identify and diagnose depression in their patients. And there is too often the belief that nothing can be done for older people with ample reason to be depressed. That attitude seems to be why depression is given short shrift by those who care for people living with HIV: "You should be depressed."
Older HIV-positive adults who are depressed are more likely to have financial problems, have fewer people to turn to for support, lack critical HIV-related information, live alone, have thoughts of suicide, and experience greater levels of stigma related to HIV and aging as compared to older adults with HIV who are not depressed. Depression may interfere with adherence to treatment, doctor visits, participation in social activities, and personal relationships.
In ROAH, depression symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D). This is one of the primary standardized tools used to assess depression. People with scores below 16 are not considered depressed; scores between 16 and 27 indicate moderate levels of depression and would typically correspond with a clinical depression diagnosis; and scores of 28 and above indicate severe levels of depression. ROAH participants' scores ranged from 0 to 52. The mean CES-D score was 20.3: 36% of the participants were not depressed (scored less than 16), while 38% were moderately depressed (scored 16-27), and 26% could be categorized as severely depressed (scored 28+).
ROAH found no differences between males and females, but there were significant differences between the ethnic groups, with Latinos having higher levels of depression than Blacks. The White group's score placed them between Latinos and Blacks. The aging HIV-positive adults in ROAH experienced significant levels of depression, at a rate almost 13 times higher than the general New York City population. Regardless of the measure used, other studies have also shown that older adults with HIV are more likely to experience symptoms of depression than younger HIV-positive people and older HIV-negative adults.
There is no single evident reason why these numbers are so high. ROAH participants are receiving care, with access to myriad support modalities for the management of depressive disorders. One reason may be the difficulty in diagnosing depression when symptoms are not typical or are easily confused with a physical ailment. Too often, treating physicians are focused on HIV and see depressive symptoms as an expected reaction of a person living with HIV. The mental health needs of this growing group of adults can be overlooked. In the era of effective antiretroviral medications, it is important for health care providers to be prepared to assess and treat the physical and mental health conditions that aging adults present. In fact, the co-occurrence of HIV and depression is a formula for continued distress of the immune system. The effectiveness of ARV treatment also may have caused health care providers to view depression as a less significant illness, assigning it a low priority and treating it less aggressively.
Substance use is a contributing factor to the high rates of depression in the older adult population living with HIV. The use of substances to self-treat depression are common. In addition, the stigma of HIV combines with the stigma of depression to make seeking help for depression even more of a challenge. The ROAH study found that 54% of the older adults studied use illicit substances or alcohol on a regular basis. This can precipitate depression, increase the magnitude of the depression, or mask symptoms so the depression is not identified by care providers. Add to these factors our findings that 70% of ROAH participants live alone, many are disconnected from their biological families, and few have spouses or partners, and the high incidence of depression is not surprising.
In the ROAH study, 42% of respondents said the emotional support they had received was inadequate to their needs. This pattern of unmet need is similar to studies that examined diverse groups of older adults. However, the magnitude of need -- particularly the need for emotional support -- is higher for older adults with HIV than for other older New Yorkers. Taken together, the findings from ROAH describe a population at risk. These older adults may not be able to obtain the needed support to age successfully. The high levels of unmet need for emotional support and significant evidence of loneliness reflect a certain distance from loved ones, either physically or emotionally. One of the possible causes for this estrangement is the powerful stigma related both to HIV/AIDS and to aging. Add to this the large numbers of people with untreated depression and the need to provide directed guidance for the management of the emotional needs of this population becomes clear.
Treatment is needed. More important, effective sustained treatment is needed. And as with HIV, adherence to treatment regimens for depression is critical. This can become a challenging management task for both clients and care providers as older adults also begin to need treatments for coronary conditions, arthritis, osteoporosis, CNS and PNS pathologies, and other illnesses associated with aging. Many studies report that individuals with depression are less adherent when taking their anti-HIV medications. Since non-adherence ranks as one of the strongest predictors of progression to AIDS, it would seem that targeting depression would reduce that progression. A small difference in adherence can significantly affect whether a person avoids progressing to an AIDS diagnosis (Bangsberg, 2001).
The level of untreated depression in the older adult HIV population is alarmingly large, highlighting the real needs of the growing and aging HIV population. Competent care must acknowledge that we treat not merely a virus, but an entire person, especially as a social being. Medical care and services must be patient-centered. There are rigorous follow-up standards used when a person begins HAART; similar follow-ups are critical when treating depression.
The impact of treating depression extends far beyond managing HIV. The successful management of depression improves an individual's ability to engage in social and community support networks. This is particularly important for the older adult with HIV who has been isolated and marginalized by their service providers and their communities, who are without the social support networks that are vital to people as they age. Care for those with HIV needs to be examined so that it is inclusive of all health and social needs.
Stephen Karpiak is ACRIA's Associate Director for Research.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication ACRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.