Special Edition of Medicine
Chest: Detection and Treatment of Depression
by Glen Pietrandoni, R.Ph.
Depression is not unique to
any individual or group. Depression can affect the mind, body,
mood and behavior of anyone. As in the general population,
some HIV-positive patients are at higher risk for clinical
depression. Patients with a previous history or family history
of depression are at higher risk, as well as those who are
dealing with alcohol or substance abuse. Women also are at
higher risk, as compared to men.
How do you know if you are
experiencing clinical depression or just having a bad hair
day? Symptoms of depression include changes in sleep patterns,
changes in eating habits, loss of interest in activities,
excessive or inappropriate guilt, lack of energy or motivation,
inability to concentrate, apathy, agitation, depressed mood,
and suicidal thoughts. Most experts agree that to be considered
clinically depressed, at least five of these symptoms must
be present all day for at least two weeks, and include either
a lack of interest in activities or depressed mood as one
of the symptoms. Studies indicate that depression is somewhat
difficult to diagnose in people living with HIV/AIDS. Many
of the symptoms of depression like fatigue, appetite changes,
or problems sleeping can resemble manifestations of HIV. Some
opportunistic infections like toxoplasmosis, cryptococcal
meningitis and HIV related dementia, as well as medications
used to treat opportunistic infections can affect one’s mood
or ability to function normally. Antiretroviral drugs can
have side effects causing agitation, depressed mood (AZT /
Retrovir), or sleep disturbances (Sustiva). For these reasons,
health care providers must be careful in determining if depression
in clients is being caused by medical or drug related issues.
Like HIV disease, depression
has stigma attached to it. Seeking help and discussing problems
openly is uncomfortable for most people. Even people who have
support systems and excellent health care benefits may refuse
or be reluctant to seek assistance for depression because
of perceived stigma. For this reason, many people turn to
self-medication to help deal with feelings of depression.
It is important to be aware
that some substances, including alcohol, cocaine, ecstasy,
crystal and ketamine, that people use to help cope with depression
can exaggerate the condition. In addition, withdrawal from
alcohol will have depression-like symptoms. While street and
party drugs can provide temporary escape from depression,
they can also accelerate progression of HIV disease. Herbal
and over the counter remedies can help treat depression, but
may have unwanted drug interactions with antiretroviral drugs.
If not treated, depression
can impact the course of HIV disease. Stress and depression
can result in a slight decline of CD4 + Tcells cells and compromise
the body’s immune function. Depression can also cause apathy,
self-neglect and forgetfulness that may result in poor adherence
to antiretroviral drugs and complementary therapies.
None the less, there is hope
for individuals living with HIV/AIDS who are also coping with
depression. Treatments are available to reduce symptoms of
depression and improve the quality of life. Psychotherapy
(counseling), pharmacotherapy (drugs) and a combination of
both are the standard of care. However, the goal of medication—prescription
and alternative—used to treat depression is intended to return
you to “normal” rather than make you numb to your feelings.
The most common class of
drugs used for depression today are called SSRIs (selective
serotonin re-uptake inhibitors). Drugs in the SSRI class are
Prozac, Paxil, Zoloft, Luvox, Celexa, and Anafranil. Sexual
side effects are common with some of these drugs, and may
include delayed orgasm, problems getting an erection, and
decreased interest in sex. When people are depressed, a decreased
interest in sex is not uncommon. If the antidepressant drugs
are effective, the sexual side effects may subside. Viagra
does seem to help reduce the erectile problems caused by the
antidepressant drugs. Cyclic antidepressants are also used
today to a lesser extent. These drugs include amitryptyline
(Elavil), nortriptyline and doxepin. Amitriptyline is also
used to treat peripheral neuropathy. Sedation, dry mouth and
constipation are often seen as side effects with cyclic antidepressants.
Wellbutrin, Serzone, Effexor and Remeron are other drugs effective
in the treatment of depression in HIV-positive individuals.
Wellbutrin (buproprion, Zyban) may be prescribed to help stop
smoking. Weight gain often occurs with antidepressants, but
can be a welcomed side effect.
Treatment of depression with
prescription drugs in HIV may be slightly different then in
the general population mainly due to possible drug interactions
with the antiretroviral therapies. Most of the antidepressant
drugs are safe to take with antiretrovirals with a few exceptions.
Ritonovir (Norvir) and Lopinavir/r (Kaletra) may increase
blood levels of Wellbutrin. This interaction may lead to increased
risk of seizures and should be used with caution. Other side
effects include insomnia, agitation, or sedation. This can
get confusing because depression itself causes these problems.
Because all of these drugs
have side effects, your doctor may need to try different combinations
to find one that is both effective and free of unwanted adverse
effects. It is important to communicate any benefits and problems
you experience to your health care provider, so that they
may be able to fine-tune your treatment. Talk to your physician
or health care provider if problems get worse or are difficult
to adapt to. Antidepressants are usually started at low doses
and then increased as necessary. In most cases, improvement
of side effects and benefits of these drugs can take between
two-to-six weeks before full effect can be assessed. After
six months of successful results, your provider may want to
discontinue the medication. If depression reoccurs, the drugs
can be restarted.
Other drugs can also be used
to improve feelings of well being in depressed individuals.
Stimulants like methylphenidate (Ritalin) and androgens like
testosterone can be prescribed. Benefits include more rapid
results and fewer side effects over antidepressant drugs.
Androgens can help put weight on patients who have wasting
syndrome. However, stimulants can also cause unwanted weight
loss and anxiety. As with any form of therapy, talk with your
physician or healthcare provider before taking any medication
for depression.
Glen Pietrandoni is
director of Clinical Pharmacy Services for the Walgreen Specialty
Pharmacy, focusing on HIV, located in the Howard Brown Health
Center of Chicago.
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Preventing Depression
by Charles E. Clifton
Nearly ten percent
of the U.S. population, or about 19 million American
adults, suffer from depression, according to the National
Institute of Mental Health (NIMH). A bout of major depression
can last several weeks to several years, and have devastating
impact on one’s health and personal life. Depression
not only compromises a person’s ability to function
normally but can alter relationships with friends and
family. The NIMH also reports that depression is the
number one cause of suicide.
Depression is not a
side effect of HIV disease. However, depression is more
widespread in people living with HIV, as compared to
HIV-negative individuals, due to higher instances of
social discrimination, economic inequalities and a lack
of institutional support.
Prevention
There is no blueprint
to prevent the onset of depression. Biological makeup
causes some people to be more susceptible to depression
than others, just as the psychosocial issues of living
with HIV impact everyone differently. No one’s life
is empty of conflict, stress and obstacles. The goal
is learning how to successfully manage issues when they
do arise. Here are just a few suggestions from Shaun
Bourget, M.A., M.F.T., a licensed marriage and family
therapist in the Los Angeles area, that could potentially
help improve the quality of your life when dealing with
feelings of depression:
• Try to accept
that loss is part of life
• Don’t be afraid
to reach out and accept help and support from others
• Accept that
we can’t control everything around us
• Make better,
more informed choices that create less turmoil for you
• Stop being
so critical of yourself, and of others
• Acknowledge
the good in you, stop beating yourself up
• If you’re good
at caring for others, add yourself to that mix
Therapy—“Just get
over it.”
For most people depression
is a passing mood. And with time, most people do “just
get over it.” However, for others, depression is a debilitating
chronic illness with potentially severe consequences.
Popping a pill a couple times a day may help shorten
episodes of depression, but they do not help you understand
the causes or cope with situations. Professional counseling
(therapists and psychiatrists) can help evaluate and
reduce symptoms, shorten episodes of depression, and
prevent relapse. Sometimes medications are not needed
at all. The most common goals of therapy are:
• provide a safe
environment
• assess the
need for medication
• improve problem
solving and coping skills
• resolve issues
of loss and correct irrational/negative thoughts
• improve self-esteem
• improve eating
and sleeping patterns
• educate and
encourage involvement of support persons
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