When I lived in Minnesota a couple of years ago, it seemed that I could get just about anything for my HIV-positive clients. Need insurance? No problem! Housing? Let’s get started. HIV medicine? Be there soon. Prozac? What?? . . . Mental health medicine??? . . . auughhh. Now, that is a problem. It can still be a problem.

Since Gerry has been on leave of absence, I have been taking a number of peer counseling calls. It feels like a number of our callers are having problems getting help with their mental health medicines as well as finding places to go for help. There seems to be a barrier for HIV-positive folks as well as HIV-affected folks. I have had callers tell me that they don’t even want to call a mental health provider because they are ashamed. They are ashamed of the stigma that society places on mental health. They are ashamed of living with HIV. They are ashamed of the double stigma. Sometimes our society seems to do better with an illness that they can "see." You can’t see mental health, so it comes across as something frightening because it is unknown and untouchable.

I know that when I decided to go to a therapist in 1994, it was the hardest thing I had ever done. I had known since high school that I was depressed (dysthymia to be exact), but was too ashamed to do anything about it. I was going to be a social worker. I was supposed to be stable so that I could take care of other people. How could I possibly be eligible to provide social services when I may be experiencing problems myself?

You see, I was buying into the stigma. I will tell you that going to a therapist and starting on anti-depressants was the best thing that I ever did for myself. I remember telling someone that "this is what it must be like to feel normal." (OK, I think I just came "out.") I have been on medication since 1994 and feel better than ever. It is sad to me that people are still so ashamed of making that first call and continue to live unhappy lives. There is help out there and people do not have to be miserable. As a matter of fact, I found the majority of the information and resources for this article by searching the internet.

Before I get started talking about "mental health," I would like to start with a definition of mental illness. The National Alliance for the Mentally Ill defines it as "a disorder of the brain that disrupts a person’s thinking, feeling, moods, and ability to relate to others. Just as diabetes is a disorder of the pancreas, mental illnesses are brain disorders that often result in a diminished capacity for coping with the ordinary demands of life. Mental illness is not the result of personal weakness, lack of character, or poor upbringing. These brain disorders are treatable."

In a recent survey regarding the causes of mental illness:

• 71% believed that mental illness is caused by emotional weakness.

• 65% believed that mental illness is caused by bad parenting.

• 35% believed that mental illness is caused by sinful or immoral behavior.

• 43% believed that mental illness is brought on in some way by the individual.

This is very sad information and, most importantly, it is all completely untrue. I am going to focus the rest of the article on depression because many of my peers with HIV have commented that this is a universal feeling that just about everyone has experienced at one time or another.

Depression

In 1997, Dr. Mary Romeyn wrote that depression has been reported in 4 to 14% of people living with HIV. One long-term study evaluating men with HIV disease at six-month intervals for eight years reported that over 50% met the criteria for clinical depression at least once during that time. In the medication literature, depression has been associated infrequently with many medications commonly used by people with HIV disease, including AZT (Retrovir), acyclovir (Zovirax), sulfonamide antibiotics, anticonvulsant, narcotics and isoniazid (INH).

In the Spring of 1999, Dr. Trisdale reported that clinical depression can be mistaken for advancing HIV disease, over half of all people with HIV are likely to end up with clinical depression, women (HIV+ or HIV-) are twice as likely to suffer from depression as men, and that clinical depression is one of the leading causes of non-adherence to HIV medications.

So, what is depression? Depression is not something that lasts a day or two. It is a feeling that can last for months or even years. It affects changes in your body chemistry and your brain. It can change your outlook on life. Some of the symptoms can be: fatigue; no energy or motivation; loss of interest in sex; insomnia; no appetite; loss of interest or pleasure in activities; irritability; social withdrawal; frequent crying; loss of concentration or memory problems; a persistent sad, anxious or "empty" mood; sleeping too little or sleeping too much; feeling guilty, hopeless or worthless; or thoughts of death or suicide. Also, there are different types of depression -- make sure that you find out what type you have so you can be treated appropriately.

What are the causes of clinical depression?

People with depression typically have too little or too much of certain brain chemicals, called "neurotransmitters." These brain chemicals may cause, or contribute to, clinical depression.

Clinical depression is more likely to occur with certain illnesses, such as cancer, stroke, heart disease, Parkinson’s , diabetes, HIV. This is referred to as "co-occurring depression."

Some medications can actually cause clinical depression. It is important to tell your doctor about all of the medicine you are taking. It would be helpful to have a conversation with your doctor if you suspect that any of your medications are causing depression so a plan can be put in to place to resolve the depressive symptoms.

People with negative thinking patterns (low self-esteem, worrying too much or feeling they have little control over life events) are more likely to develop clinical depression. Difficult life events -- divorce, financial problems, moving to a new place, the death of a loved one, or a loss -- may trigger an episode of clinical depression.

What are some of the risk factors for major depression in HIV-positive or at-risk populations?

• Previous depression or family history of depression.

• Alcohol, IV drug or other substance use.

• Loss of social supports.

• Multiple losses.

What are some HIV-related conditions that mimic depression?

1. Pneumocystis: shortness of breath, lethargy, fever, cough.

2. Toxoplasmosis: headache, depression, social withdrawal.

3. Cryptococcal Meningitis: headache, fever, depression.

4. HIV-Associated Dementia: memory loss, social withdrawal, personality change.

5. Lymphoma, PML: withdrawal, depression, focal neurologic changes.

How can you treat it?

Diet, vitamins (particularly B-12), sunlight, exercise, psychotherapy, medication, support groups or alternative treatments. Important: St. John’s Wort, which is often used as a natural remedy for depression, can have a bad interaction with indinavir (Crixivan). Ritonavir (Norvir), as well as other protease inhibitors, can also interact (and result in side effects) with prescription antidepressants, so make sure that you talk with your doctor and your pharmacist before you start taking new mental health medicines.

How can you manage medication side effects?

1) Dry mouth

• Chewing sugarless gum or sucking on hard candy.
• Good oral hygiene (frequent brushing and flossing).
• Frequent or regular dental check-ups.
• Artificial saliva preparation.
• Sialor, Saliment Organiden, 1% solution of plocarpine to promote salivation or produce a feeling of wetness in the mouth.

2) Nausea

• Take medications at mealtime or bedtime.
• Anti-nausea drugs (Gravol, Stemetil).

3) Diarrhea

• Apple juice or agents like kaopectate.
• Immodium.

4) Drowsiness

• Take medicine at bedtime.
• Increase caffeine intake, especially in the morning.

5) Hand tremor

• Take medication with food.
• Lower doses of benzodiazepines.
• Inderal.

6) Constipation

• Natural laxatives and bulking agents, (bran, juices) and an adequate fluid intake.
• Milk of magnesia.
• Metamucil.

Tips for starting on anti-depressants when you are living with HIV:

• Rule out causes of medical illness that may present as depressive symptoms. Again, many symptoms of depression may actually be HIV-related problems. Review all currently prescribed medications. Evaluate for any possible drug-drug interactions.

• Address issues of alcohol and substance use/dependence. Consider how you currently tolerate medications (i.e. side effects). SSRIs (Selective sertonin reuptake inhibitors) may provide equal effectiveness with few side effects compared to TCA (Tricyclic antidepressants).

• If you are experencing depression and neuropathy, this may indicate the use of TCAs, as these may augment neuropathic symptoms. In advanced HIV disease, stimulants may improve mood, energy, alertness and cognitive ability.

• The presence of depression and weight loss may indicate the use of Remeron, which both stimulates appetite and increases weight.

• For those with low testosterone levels, testosterone replacement may improve depressive symptoms.

• Educate yourself about depression. As with HIV, KNOWLEDGE = POWER.

You can enjoy life! With recognition and treatment, depression can be overcome. Remember, National Depression Screening Day is October 5th.

Resources

Local: (in the Atlanta, Georgia area)

AIDS Survival Project
404-874-7926
Peer counseling, information and referral.

Positive Impact
404-589-9040
Individual counseling, support groups, and play therapy for children.

National Mental Health Association of Georgia
404-527-7175
Advocacy, education and training, research direct services.

NAMI Georgia
770-234-0855
Information, referral, support groups.

Mental Health Insurance Hotline
404-978-0316
800-933-9896
If your benefits, insurance, or managed care plan is presenting obstacles to needed mental health services call the hotline!

National

National Mental Health Information Center
800-969-NMHA
Information on mental illnesses and treatment, and referrals for local treatment centers.
TTY Line: 800-433-5959

National Depressive and Manic Depressive Association
800-82-NDMDA

National Foundation for Depressive Illness
800-248-4344

Depression, Awareness, Recognition, and Treatment (DART)
800-421-4211

American Psychiatric Association
202-682-6000

NIMH, Clinical Trials
301-443-4513

Grief Recovery Institute
800-445-4808

Patient Assistance Programs (Doctors only)
List of companies who offer free medicine
Pharmaceutical Manufacturers Association
800-762-4636

Free Medication Programs

Some pharmaceutical companies offer free medications to low-income families. They require a doctor’s consent and proof of financial status. Depending on what your insurance covers, you may be able to apply. Some companies may prefer to speak directly with your doctor. Here is a list of medications with corresponding companies that feature patient assistance programs and their contact numbers.

Asendin	Lederle Laboratories	703-706-5933
BuSpar	Bristol-Myers Squibb Co.	800-736-0003
Calan	Searle	800-542-2526
Clozaril	Novartis Pharmaceuticals	800-227-2254
Compazine	Smith Kline Beecham Phar.	800-546-0420
Depakote	Abbott Laboratories	800-441-4987
Desyrel	Bristol-Myers Squibb	800-736-0003
Effexor	Wyeth-Ayerst Laboratories	800-568-9938
Elavil	Zeneca Parmaceutical	800-424-3727
Haldol	Ortho-McNeil	800-797-7737
Isoptin	Knoll Pharmaceutical	800-524-2474
Klonopin	Roche Laboratories	800-285-4484
Lithobid	Solvay	800-788-9277
Loxitane	Lederle Laboratories	703-706-5933
Luvox	Solvay	800-788-9277
Navane	Pfizer, Inc.	800-646-4455
Norpramin	Hoechst Marion Roussel	800-221-4025
Paxil	Smith Kline Beecham	800-546-0420
Prolixin	Bristol-Myers Squibb	800-736-0003
Prozac	Eli Lilly and Co.	800-545-6962
Remeron	Organon	800-241-8812
Risperdal	Janssen Pharm.	609-730-2000
Serentil	Boehringer I. Pharm.	800-556-8317
Serzone	Bristol-Myers Squibb Co.	800-736-0003
Sinequan	Pfizer, Inc.	800-646-4455
Surmontil	Wyeth-Ayerst Lab.	800-568-9938
Tegretol	Novartis Phar	800-277-2254
Trilafon	Schering Laboratories	800-656-9485
Valium	Roche Lab.	800-285-4484
Wellbutrin	Glaxo Wellcome	800-722-9294
Zoloft	Pfizer, Inc.	800-646-4455
Zyprexa	Eli Lilly & Co.	800-545-6962