HIV MENTAL HEALTH TREATMENT ISSUES HIV and Clinical Depression

Why is clinical depression a concern for those A number of HIV medications can also have side-effects that who are HIV + can cause depression and other psychological symptoms, as Mood disorders, particularly depression, are the most outlined in the table below. common psychiatric complication associated with HIV disease. Although some studies suggest that depression is HIV Medication May trigger no more common among HIV+ people than in those at risk Interleukin Depression, disorientation, for HIV infection, a large meta-analysis of 10 studies found confusion and coma HIV+ people had twice the risk for depression than those Steroids Mania or depression who were at risk for HIV but were not actually infected. Efavirenz (Sustiva) Decreased concentration, One study estimated the lifetime prevalence of depressive depression, nervousness, nightmares disorders in HIV+ individuals to range as high as 22%, Stavudine (Zerit, d4T) Depression or mania, asthenia compared to lifetime estimates of 5% to 17% and current major depression diagnoses of only 3% to 10% in the Zidovudine (Retrovir, AZT) Mania, depression general population. Interferon Neurasthenia fatigue syndrome, depression Groups at heightened risk for HIV—African-American men Zalcitabine (Hivid) Depression, cognitive impairment and women, gay and bisexual men of all races—may have higher risk for depression, which may lead to increased risk Vinblastine Depression, cognitive impairment behavior. How can a clinician differentiate depression Depression can also be a consequence of HIV-induced brain from other complications of HIV? injury or antiretroviral medication. Symptoms of true clinical depression come in two Who is at risk for depression? categories: affective and somatic. Affective symptoms include depressed mood, loss of interest in normally HIV+ individuals who have not disclosed their seropositive pleasurable activities, feelings of guilt or worthlessness, status, have lost loved ones to HIV, or are themselves in an hopelessness or suicidal ideation. Somatic symptoms advancing stage of the illness are at serious risk. Treatment include loss of weight or appetite, sleep disturbances, failure, and even treatment success, should also be agitation/retardation, fatigue and loss of concentration. considered risk factors for depression. Some symptoms of clinical depression (e.g., fatigue) can be Does HIV cause depression? “explained away” as the effects of HIV and the medications Many health care professionals believe that an HIV+ used to treat it. But the fatigue that accompanies depression diagnosis will naturally result in depression. Although the will include a true loss of interest (as opposed to simply loss diagnosis will certainly trigger anxiety and distress— of ability) in formerly enjoyable activities. sometimes so severe it impairs functioning and may even lead to suicide—this kind of situation-specific emotional It’s challenging to differentiate clinical depression from the response is not the same as depression. A person distressed effects of HIV, the side-effects of treatment and even other by an HIV diagnosis may indeed need treatment, most illnesses, all of which can affect mood. The surest way to likely for an adjustment reaction, but the distress will finding the difference is in how someone responds to respond to supportive and other types of psychotherapy depression treatment. Conditions that are not actually rather than medications. depression will respond poorly to antidepressant treatment.

HIV can damage subcortical areas of the brain and produce What kind of treatment is appropriate for an HIV dementia, resulting in states that are mistaken for HIV+ person suffering from clinical depression? clinical depression. HIV+ patients can also experience other The same treatments used with depression in the general medical and endocrine abnormalities that can create mood population are effective in treating depression in HIV+ disturbances. Systemic illnesses secondary to HIV people. All the treatment options listed in the following infection—such as hepatitis, pneumocystis carinii table should be considered specifically for pneumonia and endocrinopathes can all look like patients’ stage of illness and their particular HIV depression. Malnourishment, specifically with deficiencies treatment plan. in vitamins B6 and B12, also mimics depression. Psychopharmacology must include monitoring for drug-drug How important is it for HIV+ people to get needed interactions, especially the actions of HIV medications that treatment for depression? can change the body’s absorption of antidepressants, HIV+ patients with depressive symptoms will benefit from competition for protein binding affects, and induction/ treatment beyond getting relief from the depression. In fact, inhibition of CP450, which can alter drug levels. studies suggest that depressed HIV+ patients who are given Depression Advantages Drawbacks treatment may be more likely to adhere to, and benefit from, Therapy their treatment. Antidepressant therapy for treatment of SSRIs (Prozac, Relatively easly to use Increased GI activity, depression has actually been associated with a significantly Paxil, Zoloft) and well-tolerated by anorgasmia, akathisia, lower monthly cost of medical care services. most patients. apathy, anxiety, and when toxic, a seroto- nin syndrome. Recent research suggests that social support is highly Bupropion Rarely causes sexual Contraindicated in associated with better treatment adherence for individuals (Wellbutrin) dysfunction. patients with unstable with depression or anxiety. seizure disorder; mul- tiple divided dosings. A physician treating any HIV+ patient who is depressed must Venlafaxine Raises CNS levels of Initial stimulant side (Effexor) both serotonin and effects may disturb weigh the benefits of treatment—and the potential to relieve norpinephrine; well- some patients, may symptoms of depression—against the side-effects of the tolerated as first-line increase blood pres- chosen treatment and the likelihood of adverse drug-drug agent or in patients sure in hypertensives; interactions. Each patient, and each case, is individual, and refractory to other GI side effects (also antidepressants. common with an- must be approached as such. Treatment for depression can tiretrovirals). make a significant difference in the physical and emotional Trazodone Can be used as seda- May cause sedation in well-being of individuals living with HIV. (Desyrel) tive at low doses. a.m. at 50-100 mg when taken at night; 1/7000 incidence of References priapism. Tricyclics Weight gain and con- Weight gain, constipa- American Psychiatric Association. Practice guideline for the stipation can be helpful tion, orthostatic hypo- treatment of patients with HIV/AIDS. American Journal of with marked weight tension, dry mouth, Psychiatry (suupl). 2000. 157(11). loss or diarrhea. Seda- sedation. Can be lethal tion is useful with in overdose. Capaldini, Lisa. Depression and HIV Disease A highly treatable insomnia. Marked complication of HIV infection. HIV Newsline 1[6]. 1995. benefit on neuropathic pain, common in ad- Sambamoorthi U, Walkup J, Olfson M, Crystal S. Antidepressant vanced HIV disease (AIDS). treatment and health services utilization among HIV-infected Hormones Can be very helpful in Off-label for treating medicaid patients diagnosed with depression. Journal of General (testosterone, alleviating fatigue, depression, side ef- Internal Medicine. 2000;15 (5):311-320. DHEA) anorexia, and dimin- fects with hormone ished libido, particular- treatment impact Woodward EN, Pantalone DW. The role of social support and ly in patients with biological functions. negative affect in medication adherence for HIV-infected men who hypogonadism. have sex with men, Journal of the Association of Nurses in AIDS Electroconvulsive May be especially Electroconvulsive Care 2011 Dec 29 (Epub ahead of print). Therapy useful for patients too therapy is associated ______medically ill to tolerate with confusion just antidepressants or in after the treatment is severely suicidal, administered, and About this Fact Sheet psychotic, or treatment there is a greater like- resistant patients. May lihood of confusion in This fact sheet was revised by John-Manuel Andriote, based on an play a role in pregnant cases where a patient earlier version by Kerry Flynn Roy in collaboration with the APA depressed patients. has a coexisting CNS Commission on AIDS. For more information contact American disease. Psychiatric Association, Office of HIV Psychiatry, 1000 Wilson Psychotherapies Can effectively address May need to be used Blvd., Suite 1825, Arlington, VA 22209; phone: 703.907.8668; fax: quality of life issues, in combination with 703.907.1089; or e-mail [email protected]. Visit our web site at other emotional issues psychopharmacology www.psychiatry.org/AIDS. related to HIV. for optimal effective- ness.

Once an HIV+ patient is diagnosed with clinical depression, the clinician should be mindful that the individual’s risk of suicide is higher than in the general population, and that this is true at all stages of HIV disease.

As always, clinicians are advised to take a conservative approach to pharmacology, “start low and go slow” with dosage, particularly for patients with advanced HIV disease (AIDS).