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Ask The Experts: Depression

September 1997


Is it only natural to be depressed if you're HIV-positive?

The answer, in brief, is "absolutely not." A series of studies conducted over the past 10 years consistently has shown that the vast majority of people with HIV illness, no matter what stage of illness they're at, are not clinically depressed. This was found to be the case both in cross-sectional studies, when people were evaluated for psychiatric disorders on a single occasion, and also in studies that interviewed the same people every six months over several years. Rates of current depressive disorder in nearly all of these studies are found to be in the range of 5 percent to 10 percent for non-intravenous drug users, and are the same for HIV sero-negative men and women from the same communities who were interviewed as well. That means that between 90 percent and 95 percent of HIV-positive people are not depressed at any given time. The term "clinical depression" as we use it refers to a persistent condition characterized by low mood, with or without loss of interest and pleasure in usual activities, and accompanied by several additional symptoms, all of which persist for most days, most of the day, for two weeks or longer.

The absence of a clinical depressive disorder does not necessarily mean that people are feeling consistently happy or cheerful. More than others, HIV-positive people tend to experience strong and changing emotions such as fear, anger, and certainly sadness, as well as positive moods such as hope, faith in the future, and a sense of meaning in their lives. However, being depressed is not only to be expected when you're HIV-positive, but if depression is identified, it certainly should be treated.

What treatments are available for depression?

Several treatments are available to people with HIV who suffer from depression, including standard antidepressants (e.g., Prozac, Zoloft, Paxil) and more innovative treatments such as psychostimulants and testosterone therapy, as well as psychotherapy such as cognitive behavioral or interpersonal therapy. While all of these treatments can alleviate depression and enhance quality of life in people with HIV illness, each has specific benefits and limitations which may make it more or less appropriate for a particular individual.

Research, including our own clinical trials of Tofranil (imipramine), Prozac (fluoxetine) and Zoloft (sertraline), has shown that standard antidepressants are effective in the treatment of depression in the context of HIV illness, though certain circumstances render a particular drug more appropriate. For example, Prozac and Zoloft are advantageous because of the need for fewer pills (one or two a day compared to five or six with Tofranil) and their greater safety margin regarding lethality of overdoses. Also, Prozac remains in the system longer after discontinuation, which may be selectively preferred for people whose health is currently unstable and who may require hospitalization in the near future, since temporary interruption of Prozac will have little impact on its efficacy. For someone who is experiencing HIV symptoms such as chronic diarrhea, Tofranil may be preferred because of its constipating side effect. While antidepressants do have side effects, our experience is that the majority of HIV patients find them tolerable and side effects that are reported are reversible and transient. It usually takes at least four to six weeks for a full effect to be achieved. Primary care physicians can successfully prescribe and manage these medications once the depression is brought to their attention, although not all are willing to do so.

The choice of whether or not to use an antidepressant is often a matter of personal preference. Some prefer antidepressants because they may view them as a more rapid treatment than psychotherapy or requiring less effort. Others are reluctant to add yet another medication to their health regimen, or are simply against using drugs to treat what they consider a psychological reaction; hence, they may prefer psychotherapy or a natural substance such as testosterone.

Although testosterone therapy is approved to treat sexual dysfunction, not depressed mood, our preliminary studies indicate that testosterone may be effective in treating depression. We are currently conducting a study in which we compare the relative benefits of testosterone and Prozac, which should further clarify the effects of testosterone on mood. In addition to its antidepressant effects, we have found that testosterone increases energy levels, helps to build muscle mass for those who are struggling with weight loss, and restores sex drive and erectile function. Research on the antidepressant effects of testosterone is new and limited; therefore, testosterone should not be considered the first line of treatment for depression. However, it is clear that testosterone therapy has tremendous potential to greatly improve the quality of life of people living with HIV, particularly for those with moderate to low testosterone levels who are experiencing many of the symptoms described above. Testosterone is currently FDA approved for men only; however, we are currently studying the effects of another hormonal agent, DHEA, on both men and women.

What if I struggle with fatigue as well as depression?

With standard antidepressants, mood may improve while lethargy and fatigue continue to persist, especially for those with advanced HIV illness. If fatigue is significantly hampering your mobility and overall functioning, psychostimulants such as Dexedrine (dextroamphetamine) and Ritalin (methylphenidate) may be your choice of treatment for both fatigue and low mood. The primary advantages to psychostimulants are their rapid onset of effect (usually two to three days in comparison to four to eight weeks for standard antidepressants) and activation properties (increase in energy). In our research with Dexedrine, the improved mood and energy level that patients reported often resulted in increased mobility and self-sufficiency that some patients described as transforming their lives. Patients reported being able to resume activity such as grocery shopping, cooking meals, seeing a movie with friends, or taking a long-awaited vacationóall of which are important to maintaining quality of life. We have just begun a study using Dexedrine to treat depression and fatigue in homebound as well as mobile AIDS patients, with the hope that treatment will help these patients regain a level of functioning that many feared would never return.

If you have a history of drug addiction, you should consider the potential that psychostimulants have for risk of abuse and dependence. However, there have been no reports of abuse or dependence on psychostimulant treatment in either HIV or non-HIV patients under medical supervision. Also, concerns surrounding loss of weight or appetite associated with psychostimulants have not been substantiated in our preliminary research or in other studies with HIV patients.

Protease Inhibitors and Antidepressants

The simultaneous use of both protease inhibitors (ritonavir, indinavir, saquinavir, nelfinavir) and psychotropic medications, including antidepressants, may alter the blood levels of these medications and subsequently the rate of adverse side effects and therapeutic efficacy. While in most cases the blood level of the psychotropic drug is raised (such as with the combination of ritonavir with benzodiazepines or Wellbutrin), there are exceptions such as the combination of indinavir and Serzone which increases the blood level of indinavir. These interaction effects call for greater surveillance of effects and side effects of both classes of drugs as dosage adjustments may be needed to achieve optimal therapeutic outcome.

(For further information on our ongoing studies, contact Dr. Rabkin at 212-543-5762 or Dr. Wagner at 212-543-5331.)

This article was provided by Body Positive. It is a part of the publication Body Positive.
See Also
Depression and HIV
Feeling Good Again: Mental Healthcare Works!
More on Depression and HIV/AIDS