Facing Depression in HIV

Depression is perhaps the most widely studied psychiatric complication of any medical illness, including HIV. Many people, doctors and patients alike, think of depression as a natural consequence of having a chronic or terminal illness. Yet being depressed is not part and parcel of being ill or facing an illness. In fact, people meet the emotional challenges and adjustments of illness in a myriad of ways. Major depression is a potentially severe complication of HIV. This article reviews what major depression is, how to recognize it, and various forms of treatment.

What is Major Depressive Disorder?

Major depression, also called major depressive disorder (MDD), is a clinical illness far more serious than daily parlance would suggest. Everyone's said or heard someone say, "I'm depressed today." This is usually not major depression, but rather a temporary feeling of sadness, discouragement, or grief, which everyone has from time to time. These mild versions of depressive symptoms are familiar to most people and make up the experiences of everyday life. Most everyone has felt sad, grumpy, or irritable, been distracted or disinterested, not felt like eating, or indulged in excessive eating or sleeping as a reaction to bad news or events. Major depression includes these symptoms and a subjective experience of being sad, unhappy, or dissatisfied, but these feelings are magnified, persistent, and nearly unremitting. They are not passing feelings, but instead they seep into every area of life and rob the individual of the ability to experience pleasure and joy, of desires and motivations. The perspective of the person who suffers major depression is so distorted that the proverbial glass is not only half-empty, but will never be full and may even be broken and dangerous.

Major depressive disorder as a clinical disorder is defined in the Diagnostic and Statistical Manual (DSM-IV). The DSM-IV identifies different clinical entities comprised of groups of symptoms that are statistically validated and reproducible. This system was developed for use by researchers to provide consistency in nomenclature. Thus, when one research describes major depression, other researchers know that this involves certain symptoms and, for the most part, implies certain generally agreed upon potential biological and psychological etiologies, family history profiles, prognosis and response to certain treatments. The DSM-IV is the reference most commonly used to make a psychiatric diagnosis.

Diagnosis of MDD

The diagnosis of major depressive disorder generally must be made by a trained medical professional and requires the presence of at least five of nine symptoms occurring together, most of the time for a period of at least two weeks. The person must experience depressed mood and/or markedly diminished interest or pleasure in activities; and three or four (for a total of five symptoms) of the following:

• Significant unintentional weight loss or gain
• Sleep disturbance including insomnia or hypersomnia
• Psychomotor retardation (a slowing in thinking or movement) or agitation
• Loss of energy or fatigue
• Feelings of worthlessness or excessive or inappropriate guilt
• Decreased concentration
• Recurrent thoughts of death or suicide

Thoughts of death and suicide alarm many people. Most people who are diagnosed with a chronic and potentially life-threatening illness have increased thoughts of death during the course of their adjustment, or repeated adjustment, to their illness or diagnosis. It is often a natural part of facing one's mortality. If these thoughts are pervasive, unrelenting, intrusive, or even particularly bothersome, then it is wise to seek mental-health consultation and treatment. Thoughts of suicide can reflect an individual's desire to gain control in the face of loss of control because of illness. These thoughts, however, may be a sign of a more severe depression and also merit professional evaluation. If the thoughts are accompanied by a plan and intent to act on them, a severe depression is more likely and urgent psychiatric evaluation is indicated. Researchers have studied suicide and the desire for death in people with HIV and they have concluded that in the overwhelming majority of cases, these thoughts and feelings change when the person is treated for depression.

Physical symptoms of major depression

It is important to note that the symptoms of MDD include not only mood- and emotion-related symptoms, but also cognitive and somatic, or physical, symptoms. Indeed, diagnosing major depression in the context of a medical illness like HIV disease can be complicated by the presence of physical symptoms. Thus, when making the diagnosis of major depression in a person with HIV, it is important that the doctor be very familiar with the physical manifestations of HIV disease as well as with the manifestations of depression.

The diagnosis of MDD in the context of a medical illness is the subject of a fair amount of study among consultation-liaison (C-L) psychiatrists (psychiatrists who specialize in working with people with medical illnesses). Clearly, physical symptoms from an illness can be mistaken for physical symptoms from depression. There are several ways of approaching this problem. The symptoms that can be attributed to a medical illness can be included in the diagnosis, thus leading to overdiagnosis of depression, or they can be excluded, thus risking underdiagnosis. A third approach to control for over- or underdiagnosis is to substitute other signs for symptoms that can be attributed to the underlying illness. For example, a tearful or depressed appearance can be substituted for appetite or weight change. Specific substitutions, known as the Endicott Substitution Criteria, have been researched but are not standardized like the DSM-IV criteria. In studies of the various approaches to diagnosis, it seems that the most important factor is that the physician or mental health provider is very familiar with the physical, neuropsychiatric, and psychological manifestations of the illness

HIV-related illnesses that mimic symptoms of major depression

Because major depression has so many physical manifestations, there are, in fact, certain physical conditions that mimic major depression. Common culprits in HIV disease include anemia (significantly low red blood cell count or hemoglobin) and, in men, hypogonadism (significantly low testosterone). When there are concomitant affective (mood) symptoms that resolve with treatment of the underlying condition (such as getting a transfusion for anemia), then the person is generally considered to have a mood disorder secondary to a general medical condition and not major depression. HIV itself does not cause MDD, but complications, such as a very high viral load, often contribute to illness feelings that may mimic MDD.

Under these circumstances, how is the person with HIV supposed to know if he or she has major depression? In its severe forms, MDD is usually easy to identify. But often issues like stigma and prejudice, and even simply lack of information serve as obstacles to identifying the problem. Frequently, behaviors that reflect low self-esteem, shame, and guilt often increase the chances of high-risk activities. These activities, such as drug and alcohol use, and unsafe and high-risk sex, may be attempts to ward off or defend against the unpleasant feelings of depression. Many people seek an emotional escape or a feeling of disinhibition through drugs, alcohol, and sex. An honest, but often difficult, appraisal of the role these behaviors have in your life may reveal an underlying depressive disorder.

Seeking Help and Getting Treatment

Where is the person with MDD to seek help? Remember that MDD is a clinical disorder and not a natural consequence of illness or diagnosis, but it will complicate your ability to get and adhere to treatment. Thus, when seeking information or help, a consultation with your primary care provider is a good place to start. Providing information and asking a healthcare professional for his opinion is part of your job as a patient. He can help begin an evaluation that may lead to more specialized care from a mental health professional. Most primary care providers are comfortable referring their patients to a small number of mental health professionals who they know and recommend. Feel free to ask for a recommendation. Of course, seeking treatment directly from an individual therapist or a mental health clinic is a good alternative. It is quite reasonable to seek out a consultation, as opposed to committing to treatment, from a mental health professional who can help determine if you are experiencing major depression and what treatment or combination of treatments might be right for you.

If you are suffering from severe major depression, you may need medications to break the downward cycle and to recover from this illness. There are, however, other potential treatments if you really don't want to take medications or you try them and can't tolerate them. Psychotherapy, where you discuss your problems and potential solutions, is an excellent treatment for depression, particularly in its mild to moderate forms. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are two types of psychotherapy that have been studied in people with HIV or AIDS and have been shown to be effective.

Finding a therapist When looking for a therapist, many people feel intimidated and don't know where to begin. In addition to the referral sources mentioned above, be creative. Ask your friends or family, if you're comfortable with sharing your need with them, or ask some of the services available at many community-based organizations (CBOs) such as Gay Men's Health Crisis (GHMC) or the Gay and Lesbian Community Center. There are resources available for all types of people. You may be concerned about whether or not their mental health professional will be familiar with the issues associated with HIV. At this point in the epidemic, there are mental health professionals who sub-specialize in treating people with HIV, so it is possible, but not essential, to find such a therapist. While a specialist in HIV-related depression is not absolutely essential, it is extremely important to seek a therapist at least somewhat familiar with, if not an expert in, the physical and emotional complications of HIV, and also familiar with the environments and cultures which comprise high-risk populations. Often, those at risk for HIV are more vulnerable to issues of stigma and thus more reluctant to seek mental healthcare. Many potential patients or clients are concerned that, in seeking therapy or a consultation, they will be confronted with some of the traditional, but antiquated, prejudices of the mental health profession, such as prejudices against homosexuality. It is definitely outside the mainstream of accepted clinical practice to view homosexuality pathological or to try to change and individual's sexual orientation. Doing so is counter-therapeutic and often leads to worsening of depressive symptoms.

When consulting with a mental health professional, it is important to consider several factors. Foremost, you should feel that the person is a good listener. If your therapist doesn't hear you, you'll get nowhere. You should feel comfortable being with the therapist. That person should be able to answer your questions, be open to your theories and ideas, ask good questions that stimulate your thinking and self-reflection and be someone with whom you feel you can work and can trust. Therapy is a collaborative effort. It is reasonable to interview several candidates to be your therapist. Note, however, that it's probably your issue if, after more than a small handful of candidates, you can't find anyone to work with.

Antidepressants

Combining psychotherapy with medication is generally considered the optimal treatment for depression. Quite often, medication is the most readily accessible treatment for most people with HIV and a depressive disorder. Many of the currently available antidepressants have been studied in people with HIV or AIDS and all have been shown to be safe and effective. A primary care provider can often initiate treatment with an antidepressant. Ongoing treatment should, however, be supervised by a psychiatrist familiar with HIV treatments and potential pharmacologic interactions. Only people with a medical degree, an MD, can prescribe medications. If you're working with a psychologist (PhD) or social work therapist (LCSW), that person should have a working relationship with a psychiatrist who is available to you for medication consultation.

The decision to seek medication treatment should be collaborative, but it's not unusual for the HIV-positive individual in psychotherapy to resist taking steps that could lead to going on yet another medication. Consider your initial consultation with a psychiatrist as information gathering. Get her opinions about your problems and how medications may be helpful. Feel open about discussing this information with your regular therapist. Because so many people with HIV are on some form of antidepressant, many people prefer to work with a psychiatrist, as opposed to a psychologist, as a way of minimizing their number of providers. Most psychiatrists also do psychotherapy and are quite interested in providing this service in combination with medication management.

Conclusion

Major depression is a serious clinical disorder. It is not part of having HIV, but in mild forms, some of its signs and symptoms may reflect a natural adjustment to HIV as a diagnosis or illness. As with many illnesses, early detection usually leads to more rapid and complete treatment. In the end, getting treatment is your choice. The mode or combination of treatments you choose is also your choice. If your are uncertain about your feelings, changes in emotions, energy, or interests, having thoughts of death or suicide, open up to your healthcare provider. Listen to your friends and family when they say, "Maybe you should seek treatment." The information and help you get may greatly add to your quality of life or even save your life.

A board-certified psychiatrist, Dr. David Goldenberg is a staff psychiatrist at the Center for Special Studies (CSS), the HIV/AIDS clinic at the New York Presbyterian Hospital of Cornell University. He specializes in the psychiatric and psychological complications of HIV and cancer.