Lady Sings the Blues

PLUSAromatherapy Blend

PLUSWomen’s Words: Brigitte Charbonneau, Leahann, Andrea Rudd

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 selfimposed 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 behaviors. 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:

• a history of depression before HIV diagnosis
• alcohol or substance (ab)use
• an anxiety disorder
• a family history in which a mother, father or sibling has any of the above
• a family history of suicide
• inadequate social support

The fact that PHAs may experience many stressful life events in a short period of time — related to social factors such as the difficulty of disclosing to others and the potential for rejection, the experience of stigma and discrimination as a result of HIV status, the loss of physical health and energy, and the deaths of friends and loved ones — can also increase the likelihood of depression.

Symptoms

Psychotherapists and family physicians will typically look for the following symptoms in distinguishing between regular sorrow or worry and chronic depression:

• A “down,” very low or irritable mood, sometimes with outbursts of crying or anger triggered by minor incidents.
• Not being able to take pleasure in activities of daily living. Things that used to make you smile or distract you no longer give you joy.
• Not caring about anything. “What’s the point? I’m going to die anyway” becomes your response to a new challenge.
• Appetite loss, not attributable to a medical problem or drug side effect.
• Difficulty falling or staying asleep, not attributable to a prescribed or recreational drug.
• Loss of sex drive, not attributable to medication or HIV-related illness.
• Fatigue. Even getting out of bed or doing a tiny task has become difficult.
• Difficulty concentrating or remembering things. Tasks that you could do before without much thought now require all your attention to complete.
• Difficulty making even small decisions. You find yourself in the drugstore for a long time just trying to choose a new shampoo.
• Feeling useless or worthless, a global feeling like “everything I do is wrong.”
• Social withdrawal, removing yourself from family, friends or others whom you would normally see.
• Thoughts of killing yourself.

Physical and other causes

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:

• anemia (can cause fatigue)
• sex hormone levels (hormone imbalances can diminish your sex drive)
• thyroid levels (women have a higher incidence of hypothyroidism, a common, treatable glandular disorder which can cause depression)
• HIV-related brain damage (can cause problems with memory and concentration)

Overall, the same diagnoses that apply to men also apply to women, but women can additionally have unique causes of depression. Physicians treating women should be careful to identify any relationship between depression and the following:

• menstruation
• pregnancy
• the perinatal period (around giving birth)
• the post-partum period (after giving birth)
• the perimenopausal period (around menopause)

Once you’ve taken steps to treat these physical problems, your doctor or therapist can better diagnose — and treat — depression. Consider avoiding recreational drugs, alcohol and caffeine, which may disrupt your sleep cycle and cause fatigue.

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:

• efavirenz (Sustiva, an antiretroviral)
• interferon (used to treat hepatitis C)
• acyclovir (Zovirax, used to treat herpes and shingles)
• co-trimoxazole (used for PCP prophylaxis)
• steroids (used to treat wasting)
• ethionmide (Trecator) and isoniazid (both used to treat TB)
• birth control pills or hormone replacement therapy
• muscle relaxants like Baclofen

Tell your doctor about all the meds you’re taking, so he or she can assess their relevance when diagnosing your depression.

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:

• Accept the fact that you may be depressed. (You may already have while reading this article.)
• Seek professional help. Sometimes well-meaning friends will try to talk you out of your depression, without fully understanding the causes.
• Break the cycle of depression by developing small goals that you can gradually build on as you gain confidence and your mood improves. Try to:
  • Go to bed and wake up at the same time each day.
  • Wash your face, brush your teeth, comb your hair and get dressed each morning.
  • Get out of your home each day for a short walk or outing.
  • Engage in activities that you can stop or start easily, such as light exercise or a shopping trip. (Exercise can release endorphins and adrenaline in your body that contribute to feelings of well-being, and a little retail therapy never hurts.)
  • Choose a few friends or family members who are the easiest to be around and have short but frequent contacts with them.
  • Avoid alcohol, recreational drugs and caffeine, as these have been shown to make depression worse in the long run. (A caution: If you’re already taking an antidepressant, even mild use of alcohol or recreational drugs can substantially reduce the medicine’s efficacy.)

Counselling and therapy

Meeting with a professional trained to treat depression can help in a variety of ways:

• It can help you explore the reasons why you became depressed as well as the best ways to cope with your depression.
• It can help you minimize risk factors that might make your depression worse.
• It can provide a “sounding board” to help you regain feelings of control.

There are many kinds of therapy, from HIV support groups to one-on-one meetings with a psychotherapist. Therapists use different techniques to help you with your depression. Some use an expressive approach that helps you identify and vent your feelings. Others use an insight-oriented approach that helps you look at patterns of relationships over your life history and how they affect you today. Others focus more on problem-solving or behaviour change.

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.