Depression in HIV+ people is very common due to the virus itself, its health implications and complications, and the virus's and HIV medications affect on certain body and brain chemicals.
HIV and depression often go hand-in-hand. Isolation, occupational disability, alterations in body image, bereavement, loss of friends, debilitation, effects of the HIV virus on the brain, and the knowledge of having a terminal illness... they can all contribute. And so do the drugs that combat HIV, especially when their side effects are worse than the conditions they're supposed to remedy.
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.
The diagnosis of MDD 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.
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 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.
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.
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.
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.
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.
I personally have suffered from MDD on two different occasions. Through medication and therapy, I was able to get back on stable ground and once again live a productive life. I hope that anyone reading my story will seek help if they find themselves while reading this.
I know if it hadn't been for a great support group, family, friends and healthcare professionals; I would not be here today.
My thanks go out to all those that have supported me.