Contents

Emotional Wellness

Emotional wellness is often overlooked. But as people with HIV live longer, healthier lives, their emotional health is increasingly important. Effective communication with healthcare providers about emotional wellness is key. Unhealthy stress, depression and anxiety are more common in people living with HIV than in the general population. Emotional issues can have multiple causes, including HIV infection and the medications used to treat it. There are many treatment options to improve emotional wellness, including self-help strategies, talk therapy and prescription medications.

Figuring out the cause

Some people living with HIV experience problems such as anxiety, depression, sleep disorders and nightmares, or cognitive challenges like foggy thinking, memory difficulties and loss of the ability to concentrate or focus. If you are experiencing these symptoms or have friends, family or coworkers telling you they are observing such symptoms in you, it is important to work with your healthcare provider, and possibly other health professionals, to obtain an accurate diagnosis and establish a treatment plan.

There are a number of possible causes of emotional issues in people living with HIV. Sometimes, multiple causes can interact to create problems, and these may or may not be associated with HIV and its treatments.

It is particularly important to discuss symptoms of anxiety or depression with your healthcare provider. It is normal to occasionally have feelings of worry or anxiety about different issues in your life. However, if anxiety persists, symptoms can intensify beyond general worrying and include irritability, changes in appetite and weight, difficulty falling or staying asleep and sexual problems. Anxiety is a health problem that can and should be treated. Moreover, if anxiety does not resolve, it can, in some cases, turn into depression.

People may say they are depressed when they experience sadness or “the blues.” Such short-term feelings are part of everyday life for most people. True clinical depression is a serious condition that has emotional, physical and behavioural effects, including long-term feelings of sadness, the inability to feel pleasure, disinterest in previously pleasurable activities, low self-esteem, the loss of the ability to concentrate on tasks, fatigue, poor quality of sleep, feelings of hopelessness and, in extreme cases, thoughts of suicide.

Many people living with HIV experience depression, anxiety or other mental health problems not caused by HIV but rather by their life experiences, lifestyle or biochemical imbalances in the brain. However, it is very important to remember that there are specific HIV-associated causes that should always be considered as you seek answers for depression and other emotional or mental health issues. If any of the following HIV-associated issues are contributing to your negative emotional or mental health symptoms, these issues will need to be addressed in order to restore your emotional health.

Antiretroviral drugs

Many antiretroviral medications can cause emotional or mental health problems as side effects. These side effects may diminish or disappear after a period of days, weeks or months, but can also remain long-term. In some cases, changing drugs may be the only option.

Integrase inhibitors are the most commonly used class of HIV drugs used to anchor a regimen. The vast majority of people have no problems with integrase inhibitors. However, in very rare cases, some people can develop feelings associated with anxiety or even mild depression when they start taking integrase inhibitors for the first time. Let your healthcare provider know if you develop these, or other, symptoms. In most cases, these symptoms disappear within a few weeks of starting a regimen of integrase inhibitors. 

Talk to your healthcare provider if these problems persist. If they do, one possibility may be changing your HIV drugs.

In the past, a drug most likely to be a cause of mental health problems was the non-nucleoside analogue efavirenz (Sustiva, in Atripla and generic formulations). However, this drug is seldom used for initiating treatment today.

Though it is unlikely, a person may sometimes develop feelings of anxiety or depression when starting a regimen. For these people, it may be useful to consider beginning a new regimen on a weekend or taking a few days off from work, since it can take a few days to get used to the drugs. Also, it is best to avoid alcohol and drugs when starting efavirenz because they can sometimes worsen anxiety or depression.

Although rare, serious psychiatric disorders have occurred in some people taking efavirenz, including severe depression, aggressive behaviour, delusions, paranoia, psychosis-like symptoms and suicide attempts. People with a prior history of psychiatric disorders appear to be at greater risk for these serious problems.

Nutrient deficiencies

Deficiencies of certain nutrients, especially vitamin D, vitamin B12 and other B vitamins, are common in people living with HIV and can cause a variety of emotional and mental health issues.

Vitamin D deficiency has been linked to an increased risk for depression. It is very important to get your vitamin D level tested regularly, and use supplements when necessary, to boost vitamin D to an optimal level. Studies have shown that vitamin D deficiency is a common problem in people living with HIV, so this is a possibility in anyone who has developed depression, especially in the winter when there is less exposure to sunlight. With proper supplementation, depression and associated problems caused by vitamin D deficiency can be reversed.  Note that it takes time for vitamin D levels in the blood to increase. Based on your level of vitamin D in the blood, your healthcare provider or pharmacist can advise you about dosing. 

Vitamin B12 has been shown in studies to be deficient in many people living with HIV, and the deficiency can begin early. Vitamin B12 deficiency can result in a deterioration of mental function that can cause symptoms such as foggy thinking, memory loss, confusion, disorientation and psychiatric disorders, including depression and paranoia. If you have developed such emotional or mental health symptoms, especially when combined with chronic fatigue, it is very possible that vitamin B12 deficiency could be a contributing factor. If you also have other symptoms that a B12 deficiency can cause, such as neuropathy, weakness and difficulty with balance or walking, it is possible that vitamin B12 deficiency is a problem. 

Other B vitamins are also sometimes deficient in people living with HIV. Deficiency of almost any individual B vitamin, or of the whole B complex, can cause anxiety, depression, lack of focus or difficulty concentrating. Most important in this regard is vitamin B6.  Always accompany an individual B vitamin supplement with another supplement that contains the whole B vitamin complex to maintain the proper balance of these important vitamins.

Untreated HIV

In advanced, untreated HIV, certain opportunistic infections, as well as HIV itself, can affect the brain in a way that causes symptoms of depression, memory loss and other serious mental and emotional health symptoms. If your CD4 count is low and symptoms like this become noticeable, be sure to discuss this with your healthcare provider right away. Such symptoms could be an important sign of another infection for which treatment is urgently needed. If you are not currently on antiretroviral therapy, beginning effective treatment will be very important to control the virus and help restore your immune system.

Hormone changes and deficiencies

Testosterone deficiency frequently causes depression, fatigue and loss of sexual desire in people living with HIV. The appropriate use of transdermal testosterone patches or gels to return testosterone to optimal levels (testosterone replacement therapy) can help eliminate depression and fatigue if testosterone deficiency is the cause. 

It is possible for the hormonal changes that occur during and around menopause to cause depression or anxiety. Testing hormone levels of estrogen, followed by discussion with your healthcare provider of what can be appropriate for hormone replacement therapy is, very important.

Thyroid hormone deficiency (called hypothyroidism) is a problem for some people living with HIV. It can cause fatigue, depression, foggy thinking and difficulties with focus and concentration. For trans people, thyroid function can also be impacted by gender-affirming hormone therapies. Talk to your healthcare provider about whether thyroid function tests should be a part of your regular blood tests. In people who have low thyroid hormone levels, restoring their thyroid hormones to optimal levels can create mental focus and physical energy, though it may take weeks to months of supplementation before these levels return to normal. Hormones tend to work slowly, so patience is necessary.

Reducing stress

Stress may be causing your anxiety or depression. Many people face stressors in their relationships, finances and work. Living with HIV or other chronic conditions can add to that stress. Stress can be managed in many ways, including counselling with a mental health professional. Some people also find it helpful to speak with a traditional healer or engage in a healing cultural practice.  If you start any complementary or alternative therapies, check with healthcare provider or pharmacist about any potential drug interactions.

There are many simple self-help techniques that can help deal with anxiety, including:

  • Deep, slow breathing – Concentrate on taking slow, steady breaths. Breathe in to the count of four, pause and breathe out to the count of four. Repeat. Find some time every day to focus on your breath and slow it down.
  • Relaxing – Tense up each muscle in your body, one at a time, then release it to see how a relaxed muscle feels. A hot bath with aromatherapy oils or Epsom salts, or getting a massage, also helps to relax muscles.
  • Laughing – Studies show that laughter reduces stress.
  • Living in the present – Life with HIV can be all about living in the past with regrets or in the future with worry about what lies ahead. Find some time every day to try to let go of the past and future and live in the moment.
  • Appreciating the good things – Every day, try to count five things in your life that you are grateful for. This reinforces a positive attitude.
  • Problem solving – If the source of your stress is something you have control over, try to address it and eliminate the root cause.
  • Talking about your fears – Keeping your fears bottled up makes them worse. Find a friend, a counsellor or an Elder you can talk to about your biggest fears and worries.
  • Learning about stress reduction – Many complementary therapies teach relaxation and stress reduction. Some community organizations offer free massage, yoga and meditation classes.

Eating, sleeping, exercising and socializing

A healthy lifestyle contributes to mental and emotional health. Eating a nutrient-rich and healthy diet is important for mental and physical health. Many studies have shown that regular exercise can help to improve mood and counter anxiety, stress and depression. Getting a good night’s sleep is also very important for maintaining a good mood in general, as well as for ensuring that you have sufficient energy to address your health and well-being.

Socializing with friends and family, and finding social support, can contribute significantly to emotional wellness, too. People who are isolated or have little social support are more likely to experience depression and anxiety. Making the effort to socialize, or joining a peer support group, can be very helpful for restoring and maintaining good emotional health.

Seeking professional help

In addition to finding support within your circle of family and friends, you may want to reach out to healthcare providers. A good place to start is with your family healthcare provider or HIV specialist. They can work to uncover any medical causes and refer you to mental health professionals, such as counsellors, psychologists or psychiatrists, for more help.

Talk therapy, either one-on-one or in a group, can be very effective in dealing with emotional problems. If you are feeling emotionally unwell, it is crucial that you have someone to listen to you, understand your feelings, give you support and help you understand what is troubling you. In some cases, antidepressant medication may also be part of the solution. Your healthcare provider can advise you about this.

Using antidepressant therapies

Antidepressant medications may help to treat depression, anxiety and other mental health issues common in people living with HIV. There are many different antidepressant medications available today, and you may need to try more than one to find the medication that works best for you.

Medications that are most commonly used today for the treatment of depression are called selective serotonin reuptake inhibitors (SSRIs). They work on serotonin, the brain’s “happiness chemical.” Because it is a serotonin precursor, 5-HTP (5-hydroxy-tryptophan, related to tryptophan) may also work for countering depression. Many people have found that combining 5-HTP supplementation with other emotional wellness strategies is a successful solution for depression. However, 5-HTP should never be taken by people who are also taking medicines to treat depression or anxiety. The combination of 5-HTP and medicines for anxiety or depression can cause serious or life-threatening interactions.

Be sure to tell your pharmacist or healthcare provider about all the medications, (including over-the-counter drugs), supplements and herbal therapies that you take. These products can interact with your antiretroviral drugs, causing them to become less effective, or increasing the risk of experiencing side effects.

The herb St. John’s wort is used by some people as an antidepressant. However, it is not as potent as some prescription antidepressants. St. John’s wort can interact with many medications, including antiretroviral drugs, lowering or raising their levels and causing side effects in some cases or weakening the effect of HIV treatment. It should never be used without first consulting with your healthcare provider about ways to safely manage your depression. Also, if you are taking St. John’s wort, always speak to your pharmacist regarding the possibility of drug interactions.