Depression and HIV
In everyday conversation, people say they are depressed when they are feeling unhappy, down, blue, sad, or hopeless. Almost everyone has experienced these emotions, and if you have HIV disease, you may have reason to be anxious or depressed at times. These feelings are just one part of everyday life for most people.
However, if the feelings are overwhelming or persistent, you may benefit from psychological evaluation and treatment. Depression of this type can be effectively reduced or even eliminated with (often relatively simple) treatment. Professional intervention in serious depression can reduce suffering and improve the quality of life.
In the United States today, psychological symptoms are organized into diagnostic categories written by the American Psychiatric Association (APA) and currently known as DSM 4 criteria. These categories are pragmatic constructs and do not capture the richness of mental and emotional life. However, they are useful in determining whether medication might reduce your symptoms and, if so, which medications should be tried.
There are several sub-categories of depression. The most common are major depression and dysthymia.
Basic criteria for major depression are (literally) one symptom from column A and four symptoms from column B, lasting for at least two weeks.
Besides the criteria listed above, you may experience some of the following problems if you are depressed:
One of the common symptoms of depression is a feeling of hopelessness. If you are seriously depressed, you may feel that it is impossible to get help and that you will never feel better. You may feel that you have always been in this mental state. This hopelessness can lead to failure to get help. If friends comment on your depression or suggest that you get professional help, take them seriously.
Major depression can be a dangerous disorder. You may neglect to take necessary medication for HIV or skip doctor's appointments. You may take risks sexually that would be unacceptable to you in a non-depressed period of time. At its worst, it can lead to suicide.
If someone in your immediate family has had an episode of severe depression, studies indicate that you probably face an increased risk of developing this kind of depression.
I Feel Depressed Most of the Time, but I Manage to Function on a Daily Basis. Is There Help for This Kind of Depression?
Yes. Dysthymic disorder is a term used in psychiatry to describe an ongoing depression that may not be as severe as a major depressive disorder, but is chronic, often lasting for years and, for some people, as long as they can remember.
The symptoms may be similar to that of major depressive disorder, but milder that is, fewer and less severe symptoms. The diagnosis is usually made when the symptoms have lasted for at least two years.
Following are the American Psychiatric Association's DSM 4 criteria for dysthymia: Feeling unhappy or "down" most of the time on most days, AND, while depressed, at least two of the following symptoms are present:
People with dysthymia are able to work and generally conduct their lives, but often feel irritable, are chronically unhappy with themselves, unable to enjoy things, and may feel that life is not very worthwhile.
Major depressions often do get better on their own, but this can take at least six months or a year and some symptoms may persist for much longer. Adequate treatment can often shorten the period of time that you are suffering to a few weeks or less. Getting help may keep you from losing a job, a relationship or even your life.
Dysthymia can be life-long, and many people who have episodes of major depression also suffer from dysthymia.
If depression is intense and interferes significantly with your daily life for a period of time (major depression), or if you are functioning adequately but feeling depressed for months at a time (dysthymia), you should seek help from a mental health professional. You should always seek help if you are suicidal or neglecting necessary medical care.
Yes. This is one of the reasons that your psychiatrist needs to take a careful history. For example, HIV-positive men can have low testosterone levels which may cause decreased energy, loss of sexual desire, and feelings of depression. You can determine your testosterone level with a simple blood test, and should receive testosterone replacement if your level is abnormally low.
Sustiva, an drug used to treat HIV, can cause a variety of psychological side effects. If your depression coincides with starting Sustiva and becomes severe or lasts more than a few weeks, you should consider switching to another anti-HIV drug to see if the depression improves.
In advanced symptomatic HIV disease, a number of opportunistic infections (OIs) as well as HIV itself can affect the brain so as to produce symptoms of depression. Antidepressant medication may still be indicated, but the underlying problem should be diagnosed first and treated if possible.
Psychotherapy is helpful in treating depression. If you are depressed, it is crucial that you have someone to listen to your feelings, provide support, and help you understand what is troubling you. Although friends, lovers, and family may serve some of these functions, it is best to have a well-trained, more objective mental health professional provide you with help. Supportive talk therapy need not be lengthy.
Support groups are also useful for many HIV-positive people with dysthymia. Talking with people who share and really understand your problems often reduces feelings of isolation and despair.
Medication with antidepressants is the quickest way to relieve major depression and is definitely indicated for severe depression that is associated with suicidal thoughts and/or major disruption of functioning. Appropriate medication can relieve symptoms and allows you to go on with your life. In general, two thirds of patients with a major depressive disorder will respond positively to the use of medication within two weeks to two months. Most of the rest will get better when they try another antidepressant. Major depression is one of the most treatable of medical conditions.
Medication also works for dysthymia. Although the improvement may look less dramatic than in major depression, it can lead to a meaningful improvement in your life.
The best treatment for both major depression and dysthymia is a combination of medication and talk therapy. Numerous studies show that both psychotherapy and medication are very effective in treating depression. A recent study (and a great deal of clinical experience) indicates that probably a combination of the two is most effective in treating depression.
Aren't Antidepressants Just "Happy Pills" That Will Cover Up the Real Problem and Keep Me From Solving It?
No. If you are not depressed and take antidepressants, they will not improve your mood or functioning. People who are significantly depressed often lack the perspective and energy to understand and deal with underlying problems. Many therapists report that patients who are treated with antidepressants make more progress in talk therapy because they have the ability to grapple with emotional and practical problems when the depression is lessened with medication.
Aren't Psychiatric Drugs Only for People With Severe Mental Illness?
It is a common fear that taking medication means you are "crazy," or that medication will sedate you into being a zombie, change your identity as a person, or disarm appropriate anger at social injustice. These fears are unrealistic. Psychoactive drugs are useful for people with a wide range of problems, not just people who are "crazy." People who are generally well functioning psychologically can have on-and-off periods of depression, particularly when confronting the stress of HIV disease. There is no reason why you should suffer such distress when safe, effective medication can reduce the burden you have been forced to carry.
When a major source of stress is present, such as HIV-related problems, you may tend to accept depression as inevitable, understandable, and unchangeable and, therefore, inappropriate for medication-oriented treatment. However, just because a source of stress is known, doesn't mean medical treatment should be ruled out. We understand an arm can be fractured because of the stress of a fall; but we still set the bone in a cast.
While some drugs used to treat severely disturbed people are sedating, the drugs normally prescribed for milder problems are not. Drugs used to treat depression generally restore you to normal mood rather than blunting or blurring all feelings or robbing you of emotion or passion. A small number of people do experience a sense of apathy or flatness on some antidepressants. In this case, a different antidepressant could be tried that may not have the same effect.
Like other drugs, psychoactive medications have some side effects. Many of these side effects are typically noticeable when you start treatment, and diminish or disappear after a few weeks, though some may be more persistent. When prescribed correctly, psychoactive drugs do not dull your intelligence or your ability to perceive reality.
Depression inhibits your ability to see the world clearly and act effectively. By reducing anxiety and depression, drugs help some people clarify their thinking and become more active.
A number of different drugs (logically referred to as antidepressants) are used to treat depression. Antidepressants belong to several different categories. They affect the function of certain neurotransmitters (chemical messengers) in the brain, although the process is not completely understood.
The medications that currently are most widely used to treat both major depression and dysthymia belong to a category referred to as SSRIs, "selective serotonin reuptake inhibitors." They take their name from the effect they have on certain chemicals in the brain known as serotonin, which are believed to play a role in causing depression.
For reasons that are not understood, some people respond to one drug and do not respond to another drug in the same class. Additionally, the severity of side effects of each drug varies from person to person. Therefore, if you do not get better after trying one drug or have unacceptable side effects, you are still likely to respond well to another antidepressant. Occasionally, people respond best to a combination of medications and may, in actual fact, have fewer side effects.
These antidepressants are generally the first choice for treating both dysthymia and major depression. They are as effective as the older drugs used to treat depression, and have fewer and less serious potential side effects.
How Safe Are These Drugs Medically?
Generally these drugs are very safe. The antidepressants listed above have not been used long enough to study very long-term side effects. However, they are closely related to an older class of antidepressants that have been used for about forty years with no significant long-term adverse reactions. In addition, these drugs are safer for people who may have suicidal impulses; it is very hard for a person to kill themselves with an overdose of these drugs alone.
How Do These Antidepressants Differ?
All of these drugs appear to be equally effective in treating both major depression and dysthymia, though there are insufficient data available to make a clear-cut comparison. They vary primarily in terms of side effects, and you and your psychiatrist will make the decision on which drug to use based largely on these side effects.
What Are the Side Effects of These Drugs?
Almost all medications have a wide variety of possible side effects, and this is true of the SSRIs and Wellbutrin. As with other drugs, only a few of these side effects are common. However, there is tremendous variation in response to medication. Do not hesitate to report any possible side effects to your psychiatrist and/or doctor, even if they are not typical of the drug you have been given.
The following is intended to be a general overview of the more common side effects. It is not a complete listing of all potential side effects:
How Fast Do These Drugs Work and How Long Should I Take Them?
Antidepressants are usually started at a low dosage and then increased. Significant improvement should occur in two to six weeks after taking a therapeutic dose of the drug. Do not expect it to work immediately, although some people feel better within a few days. If one antidepressant does not work, another may be effective. Inadequate dosage or inadequate length of time on the drug is the most common cause of treatment failure.
Antidepressant medications are usually taken for four to six months. If depression recurs when the medication is stopped, these antidepressants may be taken on an indefinite basis.
Are These Drugs Used to Treat Other Problems?
The SSRI drugs and Wellbutrin are also used to treat a number of other psychiatric problems including panic disorder, social phobia, and obsessive-compulsive disorder.
Do Any of These Drugs Interact With Anti-HIV Drugs or Have Unusual Effects on Someone Who Has HIV Disease? How Will They Affect My Immune System?
In general, there is no problem in taking one of this group of antidepressants in combination with anti-HIV medication. However, if you are taking the protease inhibitors Norvir (ritonavir) or Kaletra (lopinavir + ritonavir), you should be particularly cautious. Ritonavir acts in a way that increases the amount of certain other drugs in the body. This is particularly problematic with Wellbutrin, because the drug can cause seizures if the dose is too high. Ritonavir may increase the development of anxiety and agitation as a side effect of Serzone. It is generally not a problem with the other antidepressants, though you may require a lower dose than typical. Your psychiatrist should know what other medications you are taking. If s/he is not an expert in treating patients with HIV, s/he should consult with your HIV doctor to make sure no combination is harmful.
If you have advanced symptomatic HIV disease, you may be more likely to develop side effects from various medications. Your psychiatrist should work in close consultation with your HIV physician.
Some people who are depressed treat themselves with St. John's Wort (hypericum perforatum), an herbal supplement available without prescription in health food stores. You may consider it preferable to one of the prescribed medications because of the ease of obtaining it and because it is seen as "natural". It is probably an effective antidepressant for some people and has been widely used in Europe. However, few studies have been done on the use of St. John's Wort for serious depression; the strength of pills varies from manufacturer to manufacturer; and, like other medications, it has side effects. Most importantly, St. John's Wort can reduce the amount of various anti-HIV drugs in the body to an ineffective level. This interaction can happen with all the currently marketed Protease Inhibitors (PIs) and Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs). The FDA letter of recommendation about use of St. John's Wort and anti-HIV drugs can be seen by clicking here.
There is no evidence that use of antidepressant medication suppresses or improves immune system functioning.
A group of drugs referred to as cyclic antidepressants are also commonly used for treating major depressive episodes. They are extremely effective; their efficacy equals that of the newer antidepressants and in some situations they may be preferable. In past years they were the first line treatment for major depression, however, they have more side effects than SSRIs and now are usually used for patients who do not respond to SSRIs.
These cyclic antidepressant medications vary primarily by side effects. Some are more sedative than others-that is, they make you feel sleepy or fall asleep. This can be useful if you are suffering from insomnia or troubling if it interferes with your daily activities.
Anticholinergic Side Effects
These drugs have what are referred to as anticholinergic side effects, some drugs more than others. These side effects include dry mouth, constipation, blurred near vision, and difficulty in urinating. Dry mouth is the most frequent symptom. Sucking on hard candies, especially citrus-flavored ones (preferably sugar-free ones for the sake of your teeth) can alleviate it.
Sometimes cyclic antidepressants cause a drop in blood pressure associated with change in posture that can lead to fainting or dizziness. This is referred to as orthostatic hypotension. Standing up slowly after being in a prone or squatting position can help prevent this.
Other Side Effects
Monoamine oxidase inhibitors (MAOIs) are antidepressants generally used for patients who have not responded to other antidepressant drugs. They are not usually the first choice but can be very effective and seem to work well in certain patients who are considered to have atypical depressions. They are particularly useful for people who have depression combined with panic disorder, although other antidepressants work for this purpose also. The following MAOIs have comparable effectiveness and similar side effects:
MAOIs have significant side effects. They provoke dangerously high blood pressure when combined with a substance known as tyramine, which is contained in some food, beverages, and drugs. If you take MAOIs, you must avoid liver, cheese pizza, Chianti wine, certain beers and cheeses, herring, bologna and some other sausages, and a number of other foods as well as many cough and cold medications. Any meat you eat must be fresh. Coffee and chocolate should be consumed only in small amounts. If you take MAOIs you must get a dietary restriction list from your doctor. If you eat a "forbidden" food with no problem, you may still develop a severe reaction if you eat that food again.
Psychostimulants, like those listed below, are useful in patients with severe medical illness and especially for people those who are withdrawn and apathetic. They are occasionally used for physically healthy depressed people who do not respond to other medication. They are energizing and work more rapidly than cyclic depressants or MAOIs.
Dexedrine appears to be more effective than Ritalin. Cylert occasionally causes serious liver damage and may be particularly risky for people taking multiple drugs for HIV infection.
Side effects are jitters, insomnia, and loss of appetite and these medications can be addictive. When used for recreational purposes, these drugs have a high potential for abuse and addiction, which is why they are not widely prescribed. This problem may be outweighed by their utility in seriously ill patients (those with major symptomatic medical problems). An overdose may lead to paranoid episodes with loss of ability to judge reality.
It is best to get antidepressants from a psychiatrist although, if this is not possible, your regular physician can prescribe antidepressants. Effective medication depends on correct diagnosis. Diagnosis of psychological symptoms requires specialized training and prescribing psychoactive drugs optimally requires experience. Proper dosage can be critical, and the choice of effective drugs can be subtle. Therefore, a psychiatrist is the best physician to prescribe antidepressants.
It is important to see a psychiatrist who is well trained and up-to-date on the use of psychoactive drugs. Psychiatrists who specialize in the use of medication are called psycho-pharmacologists. Psycho-pharmacologists are more likely to choose the most suitable drug for you and are more likely to prescribe appropriate doses. They are trained to have an organized strategy for trying different drugs if the first is not successful.
A psychiatrist or psycho-pharmacologist who has experience in treating patients with HIV disease will give you the best advice. This is less important if you are physically asymptomatic and more important if you have major medical symptoms. If you see a psychiatrist for a medication consultation, you should be able to give him or her a clear picture of your current and past illnesses and medications. It is useful to have the psychiatrist talk to your physician, especially if the psychiatrist does not have extensive experience in treating people with HIV disease. If you live in a large metropolitan area, you should be able to locate a psychiatrist who is experienced in treating people with HIV infection.
If your physician cannot give you a referral to a psychiatrist, you can request a list of possible referrals from the psychiatry department of the major medical center in your area, particularly if it affiliated with a medical school. AIDS organizations may be able to refer you to psychiatrists as well.
If you are unable for any reason, financial or otherwise, to see a psychiatrist, you may get antidepressants from your regular physician. Often this is a successful approach since many people respond well to the first drug they are given for depression and have few complications. This has become less problematic since the SSRIs are usually less complicated to prescribe than older antidepressants. However, your regular doctor may lack the expertise and the time to make a careful assessment. Physicians (and even some psychiatrists) inexperienced with medication sometimes prescribe antidepressant or antianxiety drugs at doses that are not ideal. Non-specialists may also give up if the first medication does not work. If you are treated for depression by your regular physician and do not respond, you should make every effort to see a psychiatrist rather than give up.
If you are in therapy with a well-trained psychologist or social worker, s/he will be able to make a preliminary diagnosis of depression and refer you to a psychiatrist. At that point the therapist and psychiatrist will consult and work with you collaboratively. If you are not already in therapy, the psychiatrist should refer you to a non-medical therapist for talk therapy. Some psychiatrists provide both medication and talk therapy.
Consultation for medication with a psychiatrist for medication generally involves several closely spaced visits (usually weekly) with a psychiatrist while you start medication, and then occasional more widely spaced visits to monitor your progress on the drug. Your contact with the psychiatrist will not be as frequent or regular as visits for psychotherapy.
Many recreational drugs can cause depression or anxiety; this includes alcohol or alcohol withdrawal, amphetamines, cocaine, ecstasy, crystal, and ketamine (Special K). We lack adequate scientific data about the relationship between depression and recreational drug use, but do have significant understanding based on clinical experience.
Depression may lead you to seek relief in the use of alcohol or other recreational drugs. In turn, these drugs may cause or exacerbate depression. If you are taking antidepressants and extensively using recreational drugs, it will decrease your chances of getting better. You need to seek help in reducing drug use as well as getting direct treatment for the depression.
It is important to be honest with your psychiatrist about the extent of your recreational drug use. You have a need and right to report this without receiving a morally judgmental response.
The drug Ecstasy affects the serotonin system, the same neurotransmitters that are affected by antidepressants. There is growing reason to fear that Ecstasy may have very long-term effects that may ultimately bring on depression and anxiety problems. For some individuals, it may not take much Ecstasy use for this to occur.
It is emotionally helpful to understand your psychological state and to identify current sources of stress and the influence of your own particular history and conflicts in depression. Therapy helps lessen depression and may prevent its recurrence. Both psychotherapy and support groups provide you with a chance to talk about upsetting feelings, to feel the comfort of being understood, and to alleviate anxiety and depression at times of particular stress.
Psychotherapy is actually a disparate group of techniques designed to improve emotional well being, and usually involve some kind of verbal dialogue between patient and therapist. Because of the broad range of practices described as psychotherapy it is impossible to discuss the use and efficacy of therapy in a brief fashion. Furthermore, because the human mind and emotions are so complex, it is extremely difficult to develop objective measures for judging the utility of therapy. Therapy even within the same "school of thought" varies tremendously from practitioner to practitioner.
Some kinds of therapy currently in use are psychoanalysis, psychoanalytically oriented psychotherapy, family and couple therapy, group therapy, cognitive therapy, and behavior therapy. These therapies are based on divergent views of the mind, behavior, and the pathways of change.
A tremendous problem with psychotherapy is the cost. Because it is often an ongoing activity, the fees can mount up. Some insurance policies pay for some therapy, but usually this covers a limited amount of the cost. Some therapy at low-cost or covered by Medicaid is available through clinics (usually associated with hospitals, medical centers, and social service agencies).
It is difficult to give advice on how to find a therapist. The referral you get will depend on the point of view and experience of the person who gives you the referral. Obviously, you should seek a referral to psychotherapy from a person you trust. Good sources of referrals include your medical doctor, the psychiatry department of a well-respected hospital or medical school, or perhaps a local AIDS organization.
Anyone can call himself or herself a psychotherapist; there are no legal requirements to use this title. Many therapists practicing in the United States are either psychiatrists, social workers, or psychologists. All three do psychotherapy; only psychiatrists prescribe medication. Training within each of these groups varies widely; some clinicians in each category are highly trained while others have little specific training in the practice of psychotherapy. State licensing is required for each of these professions. This means that if you see a licensed psychiatrist, social worker, or psychologist, you have the reassurance of knowing that they have met some standard of education and ethical practice. However, the requirements are variable and merely being licensed is no proof of competence.
You are entitled to ask therapists about their training, credentials, experience, and therapeutic approach. You should not expect personal information or a long detailed discussion of therapeutic philosophy. This is generally seen as counterproductive for the therapy.
You may need to interview several therapists to find one with whom you feel comfortable. Following is a list of attributes to look for in a therapist:
You are entitled to total confidentiality from your therapist. This means that a therapist can never communicate any information about you to anyone without your explicit permission. This includes doctors, insurance companies, and family members. The only exception is if you are in danger of physically hurting yourself or someone else in which case your therapist is required by law to communicate this information in order to prevent this.
There should never be any sexual activity between therapist and patient. Frank discussion of sex is part of many therapies, but sexual activity in therapy is always inappropriate. If this occurs in your therapy, you should discontinue therapy and report your therapist's behavior to the relevant professional organization.
Laura Pinsky is a psychotherapist in private practice and at the Columbia University Counseling and Psychological Services. Reprinted from www.aidsmeds.com.
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