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The Positive Side Spring 2003 Lady Sings the Blues When grief, illness or plain-old hard times turn into a prolonged depression, your health and survival could be at stake. So right when you want to crawl under the covers for good, it’s time to ask for help — and get diagnosed. by David Coop Life with HIV isn’t exactly easy. It can mean struggling with illness or drug side effects, grieving for friends or family lost to the disease, and facing a future where everything from jobs to relationships is more difficult than it was before you were diagnosed. Any of these experiences is likely to fill you with intense sadness at times — a natural, if painful, part of the coping process. But a recent survey showed that people with HIV and AIDS (PHAs) are particularly vulnerable to sorrow, anxiety or grief turning into a prolonged, paralyzing depression (every day for more than two weeks with no let-up) — a state in which your emotions can begin to damage your health. The survey of 136 HIV doctors, by the International Association of Physicians in AIDS Care (IAPAC), found that 80% of their patients with HIV suffer from depression or anxiety — more than 10 times higher than common estimates of depression in the population at large. (Other studies have found that women are more likely to experience depression than men, possibly because of the increased stress they often face as caregivers.) And yet, in a related IAPAC survey of 235 PHAs, only 62% reported that their doctors ever asked them about their mental health. This data means two things: One, if you think depression can’t happen to you, think again. And two, right when you’re feeling the most down, you may have to be the one to reach out for help. The problem I’ve found in my years as a psychotherapist is that while physical illness usually prompts people to seek professional help, people often view depression as self-imposed weakness — especially those raised to keep a stiff upper lip. I’ve often heard patients say, “I just need to snap out of this and think positively” or “I have only myself to blame.” Well, it’s not so simple. Real depression is extremely complex. It involves changes in your mood that are so severe and prolonged that you really can’t “snap out of it” on your own. In the middle of a depression you can become so preoccupied with your own feelings that you lose the ability to see the world objectively. You can feel completely worthless, hopeless and unable to ask for help. Embarrassment, shame and guilt can often make your low mood sink even lower. You can endlessly replay “old tapes,” second-guessing all your past choices — for PHAs, this can mean beating yourself up about the circumstances of your infection or past risk behaviours. Depression is the opposite of seeing the world through rose-coloured glasses; instead, everything looks gray. Even when friends or family are trying to help, their comments may seem critical, painful or frightening. As result, you may pull further into your shell, shutting out the world. One Canadian psychotherapist (she asked not to be named, to protect the confidentiality of her patients) who’s been treating PHAs since 1987 says that depression among women with HIV has its own particular patterns. She sees more “anxious depression” rather than “hopeless depression” in women, who are often overwhelmed trying to cope with their own illness and the illness of a child. This can mean more feelings of anxiety and guilt, often accompanied by eating or sleeping too much. Many women, she says, struggle with “a great deal of enormous sadness over losses, and how to cope with that and get on with life,” while others struggle with the loss of physical attraction stemming from lipodystrophy — the skinny arms and legs, sunken cheeks, and large breasts and belly that can be a side effect of some HIV medications and perhaps even the disease itself. Regardless of gender, many of her patients with HIV struggle with the image that the disease is now supposed to be “chronic and controllable,” but the reality of fatigue, side effects and financial pressures means “you can’t really go back to your former life.” As well, there are stages in living with HIV when the likelihood of depression may be worse, including after initial diagnosis, after developing serious physical illness, or after the death of friends and loved ones. If any of these stresses push you into a real depression, your health may suffer. You may stop eating and sleeping well or taking your HIV medicines on time or making it to doctors’ appointments — all recipes for a health disaster. At worst, some people experiencing depression take their own lives. So for your own health, and the well-being of the people closest to you, if you suspect you may be on the slippery slope to depression, talk with your doctor. He or she may be able to refer you to a psychotherapist. Diagnosis When you’re in a depression, it can feel inescapable — but in fact there are a variety of ways to treat it. A holistic approach might include such basic steps as regularizing your routine and getting more exercise, along with prescribed medications, vitamins and supplements, counselling or therapy and social support. But the first step is diagnosis — and that can be somewhat complicated for PHAs. Risk factors Research has shown that some things can make people vulnerable to depression or make depression worse. Health care professionals call these “risk factors.” They include:
Symptoms Psychotherapists and family physicians will typically look for the following symptoms in distinguishing between regular sorrow or worry and chronic depression:
PHAs can suffer from a host of HIV-related medical problems that mimic or overlap with many of these symptoms of depression. So a crucial first step is to identify — and treat — any physical causes. Talk with your doctor about getting tested for the following:
Encourage your doctor to look into whether any of the medications you’re taking may be a factor, as a few can actually cause depression — or related symptoms, such as difficulty concentrating — in some people. Some meds known to cause depression or depression-like symptoms include:
Testing At this point, your health care provider may choose to use some standardized tests to help determine whether you are clinically depressed. One reliable tool is a brief multiple-choice questionnaire called the “Beck Depression Inventory.” Try not to be intimidated by these tests. Answer honestly, and the results can greatly help you and your caregiver plan your care and monitor your progress. Taking steps If you and your physician or psychotherapist come to the conclusion that you are experiencing depression, here are some simple tips that may help you start to feel better:
Meeting with a professional trained to treat depression can help in a variety of ways:
Cognitive/behavioural therapy (CBT) has the strongest data showing a benefit in decreasing symptoms of depression among PHAs. CBT is based on the premise that you largely feel the way that you think, so it’s useful to become aware of underlying thought processes that may be making your depression worse. CBT helps you identify these thoughts and the situations that trigger them, so you and your therapist can then develop more reassuring thought patterns. This, in turn, will contribute to positive lifestyle changes. CBT does not try to turn you into a positive-thinking Pollyanna! Rather, it helps you acknowledge the legitimacy of the health threats and emotional struggles that you face, while allowing you to put them in context. To find a psychotherapist, you can ask your family physician for a referral. You could also ask your HIV clinic or local AIDS organization whether they keep referral lists. Keep in mind that of the professions that typically do psychotherapy (psychiatry, psychology and social work), only psychiatrists may prescribe antidepressant medications. Ultimately, the most important thing is to choose a therapist whom you feel comfortable with and “click” with — if you feel you can only open up to a woman, trust your instincts. Make sure you pick someone who is willing to answer any of your questions without rushing you or being defensive. Remember: If you’re feeling suicidal, call your local crisis help-line or go immediately to the nearest emergency — don’t wait for a therapy appointment! Antidepressants Both the rate of depression and the severity of side effects of antidepressants may increase with the severity of HIV disease, but people may benefit from these drugs at any stage of disease. In certain circumstances, PHAs may be more sensitive to the effects of antidepressants and may therefore require lower dosing. Women may also require relatively lower doses of antidepressants than a man would, because of their relatively smaller body sizes, which may cause them to achieve higher levels of antidepressants in their blood. This particularly applies to women who may be underweight by virtue of their HIV disease. It should be noted that the potential effects of antidepressants on a fetus need to be considered when treating pregnant women, but there are some antidepressants that are considered safe for pregnant women. The first-line antidepressants for PHAs — and the most commonly prescribed overall — are known as “selective serotonin uptake inhibitors” (SSRIs), a group that includes such drugs as Prozac, Zoloft, Paxil, Celexa and Luvox. SSRIs make available more of your body’s natural serotonin, a neurotransmitter (signal-carrying chemical) that helps your body regulate mood — resulting in greater feelings of calm, well-being and happiness. Many PHAs swear by their SSRIs, but a few cautions: Some SSRIs cause side effects, including gastrointestinal upset and decreased sex drive, and some interact with HIV meds (for instance, the protease inhibitor ritonavir, or Norvir, increases the level of SSRIs in the blood). Check with your doctor or pharmacist about possible drug interactions. Some antidepressants, like Celexa, interact least with anti-HIV meds. A second category of antidepressants, known as “tricyclics” (Norpramin, Elavil, Pamelor, Tofranil and Sinequan), are also used to treat chronic pain. A third category is known as MAO inhibitors. These are not commonly prescribed due to the large number of drug interactions and dietary restrictions. Other antidepressants with different chemical structures from SSRIs and tricyclics include Serzone, Remeron, Effexor, Wellbutrin and Buproprion. Sometimes you may have to try more than one antidepressant before you find the right fit, so don’t be discouraged. Antidepressants are non-addictive — unlike tranquilizers, such as Valium, which are highly addictive — and can be safely used for long periods of time. Many antidepressants decrease anxiety as well as depression, particularly important for many women with HIV. That IAPAC survey found that HIV doctors are more likely to prescribe antidepressants than any other intervention for depression, but keep this in mind: Research has shown that antidepressants are most effective when combined with psychotherapy. If you’re considering taking an antidepressant, make sure that your doctor knows about your HIV status, as well as any medications, supplements or herbal products that you’re taking. This is because mixing some supplements, such as herbs, with antidepressants can cause dangerous side effects. If possible, see a specialist who knows how to best co-manage HIV disease and depression. COMPLEMENTARY THERAPIES For more info on these supplements, go to www.daair.org. Omega-3 fatty acids: Major studies have shown that high doses of omega-3 fatty acids may reduce symptoms of depression — possibly by spiking serotonin levels. Salmon oil capsules are a good source of omega-3s. B-vitamin complex: If your depression is related in part to vitamin deficiencies, adding this supplement to your diet can make a difference, particularly with anxiety. B6 is particularly important for women. SAMe: European research finds that this nutrient (S-adenosyl-methionine, an amino acid derivative), important to brain and liver function, can have antidepressant effects — but so far, the data is slim. Bach Flower Remedies: Many alternative health practitioners say that this tincture of essences from 38 flowering plants helps lift depression. It’s nontoxic, but there’s no data showing effectiveness. 5HTP: This is a form of the amino acid tryptophan, which your brain uses to make serotonin. Yoga, massage, meditation and mindfulness techniques: These complementary therapies have shown some benefit in countering symptoms of mild depression. Acupuncture: Two controlled studies have shown dramatic improvements in depression, plus relief from anxiety-related symptoms. Warnings: St. John’s wort used to be very popular with PHAs for treating depression. But it is now known that this herb interacts with many HIV meds — affecting the blood levels of several protease inhibitors and non-nukes as well as heart medicines — and therefore should be used with extreme caution and only after consultation with a licensed physician. Kava is also often taken for antidepressant and sedative effects. But this herb has been shown to cause severe liver toxicity. Health Canada recommends that it not be used. POST-PARTUM DEPRESSION Post-partum depression (PPD) — depression after giving birth — does not present in the same way in every woman. Studies have shown that up to 80% of women experience a mild form of depression shortly after their baby is born, but a smaller percentage can experience more severe symptoms, which include:
The exact cause of PPD is unknown, although some of the risk factors are similar to those already discussed in this article. Certainly, the issues associated with deciding whether to take antiretroviral therapy during pregnancy and the fears around your baby having HIV could contribute to PPD. Also, because so many HIV+ mothers are single parents or facing the prospects of single parenthood through death or abandonment, it is understandable how the new responsibilities that come with parenthood could be overwhelming. Because PPD can be so serious, it is very important if you are pregnant or contemplating pregnancy to take preventive steps to ensure you have a good support network in place. Research shows that social support both from personal and professional sources can buffer you against many stresses that might otherwise result in depression. | |
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Decisions about particular medical treatments should always be made in consultation with a qualified medical practitioner who is knowledgeable about HIV-related illness and the treatments in question. MORE | |