Depression and HIV/AIDS

Introduction

Research has enabled many men and women, and young people living with human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), to lead fuller, more productive lives. As with other serious illnesses such as cancer, heart disease or stroke, however, HIV often can be accompanied by depression, an illness that can affect mind, mood, body and behavior. Treatment for depression helps people manage both diseases, thus enhancing survival and quality of life.

Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated. Although as many as one in three persons with HIV may suffer from depression,¹ the warning signs of depression are often misinterpreted. People with HIV, their families and friends, and even their physicians may assume that depressive symptoms are an inevitable reaction to being diagnosed with HIV. But depression is a separate illness that can and should be treated, even when a person is undergoing treatment for HIV or AIDS. Some of the symptoms of depression could be related to HIV, specific HIV-related disorders, or medication side effects. However, a skilled health professional will recognize the symptoms of depression and inquire about their duration and severity, diagnose the disorder, and suggest appropriate treatment.

Depression Facts

Depression is a serious medical condition that affects thoughts, feelings, and the ability to function in everyday life. Depression can occur at any age. NIMH-sponsored studies estimate that 6 percent of 9- to 17-year-olds in the U.S. and almost 10 percent of American adults, or about 19 million people age 18 and older, experience some form of depression every year.^2,3 Although available therapies alleviate symptoms in over 80 percent of those treated, less than half of people with depression get the help they need.^3,4

Depression results from abnormal functioning of the brain. The causes of depression are currently a matter of intense research. An interaction between genetic predisposition and life history appear to determine a person's level of risk. Episodes of depression may then be triggered by stress, difficult life events, side effects of medications, or the effects of HIV on the brain. Whatever its origins, depression can limit the energy needed to keep focused on staying healthy, and research shows that it may accelerate HIV's progression to AIDS.^5,6

HIV/AIDS Facts

AIDS was first reported in the United States in 1981 and has since become a major worldwide epidemic. AIDS is caused by the human immunodeficiency virus (HIV). By killing or damaging cells of the body's immune system, HIV progressively destroys the body's ability to fight infections and certain cancers (http://www.nci.nih.gov/).

The term AIDS applies to the most advanced stages of HIV infection. More than 700,000 cases of AIDS have been reported in the United States since 1981, and as many as 900,000 Americans may be infected with HIV.^7,8 The epidemic is growing most rapidly among women and minority populations.⁹

HIV is spread most commonly by having sex with an infected partner. HIV also is spread through contact with infected blood, which frequently occurs among injection drug users who share needles or syringes contaminated with blood from someone infected with the virus. Women with HIV can transmit the virus to their babies during pregnancy, birth, or breast-feeding. However, if the mother takes the drug AZT during pregnancy, she can reduce significantly the chances that her baby will be infected with HIV.

Many people do not develop any symptoms when they first become infected with HIV. Some people, however, have a flu-like illness within a month or two after exposure to the virus. More persistent or severe symptoms may not surface for a decade or more after HIV first enters the body in adults, or within two years in children born with HIV infection. This period of "asymptomatic" (without symptoms) infection is highly individual. During the asymptomatic period, however, the virus is actively multiplying, infecting, and killing cells of the immune system, and people are highly infectious.

As the immune system deteriorates, a variety of complications start to take over. For many people, their first sign of infection is large lymph nodes or "swollen glands" that may be enlarged for more than three months. Other symptoms often experienced months to years before the onset of AIDS include:

• Lack of energy
• Weight loss
• Frequent fevers and sweats
• Persistent or frequent yeast infections (oral or vaginal)
• Persistent skin rashes or flaky skin
• Pelvic inflammatory disease in women that does not respond to treatment
• Short-term memory loss

Many people are so debilitated by the symptoms of AIDS that they cannot hold steady employment or do household chores. Other people with AIDS may experience phases of intense life-threatening illness followed by phases in which they function normally.

Because early HIV infection often causes no symptoms, a doctor or other health care worker usually can diagnose it by testing a person's blood for the presence of antibodies (disease-fighting proteins) to HIV. HIV antibodies generally do not reach levels in the blood which the doctor can see until one to three months following infection, and it may take the antibodies as long as six months to be produced in quantities large enough to show up in standard blood tests. Therefore, people exposed to the virus should get an HIV test within this time period.

Over the past 10 years, researchers have developed antiretroviral drugs to fight both HIV infection and its associated infections and cancers. Currently available drugs do not cure people of HIV infection or AIDS, however, and they all have side effects that can be severe. Because no vaccine for HIV is available, the only way to prevent infection by the virus is to avoid behaviors that put a person at risk of infection, such as sharing needles and having unprotected sex.

Get Treatment for Depression

While there are many different treatments for depression, they must be carefully chosen by a trained professional based on the circumstances of the person and family. Prescription antidepressant medications are generally well-tolerated and safe for people with HIV. There are, however, possible interactions among some of the medications and side effects that require careful monitoring. Specific types of psychotherapy, or "talk" therapy, also can relieve depression.

Some individuals with HIV attempt to treat their depression with herbal remedies. However, use of herbal supplements of any kind should be discussed with a physician before they are tried. Scientists recently discovered that St. John's wort, an herbal remedy sold over-the-counter and promoted as a treatment for mild depression, can have harmful interactions with other medications, including those prescribed for HIV. In particular, St. John's wort reduces blood levels of the protease inhibitor indinavir (Crixivan®) and probably the other protease inhibitor drugs as well. If taken together, the combination could allow the AIDS virus to rebound, perhaps in a drug-resistant form. (See the alert on the NIMH Web site: http://www.nimh.nih.gov/events/stjohnwort.cfm.)

Treatment for depression in the context of HIV or AIDS should be managed by a mental health professional—for example, a psychiatrist, psychologist, or clinical social worker—who is in close communication with the physician providing the HIV/AIDS treatment. This is especially important when antidepressant medication is prescribed, so that potentially harmful drug interactions can be avoided. In some cases, a mental health professional that specializes in treating individuals with depression and co-occurring physical illnesses such as HIV/AIDS may be available. People with HIV/AIDS who develop depression, as well as people in treatment for depression who subsequently contract HIV, should make sure to tell any physician they visit about the full range of medications they are taking.

Recovery from depression takes time. Medications for depression can take several weeks to work and may need to be combined with ongoing psychotherapy. Not everyone responds to treatment in the same way. Prescriptions and dosing may need to be adjusted. No matter how advanced the HIV, however, the person does not have to suffer from depression. Treatment can be effective.

It takes more than access to good medical care for persons living with HIV to stay healthy. A positive outlook, determination and discipline are also required to deal with the stresses of avoiding high-risk behaviors, keeping up with the latest scientific advances, adhering to complicated medication regimens, reshuffling schedules for doctor visits, and grieving over the death of loved ones.

Other mental disorders, such as bipolar disorder (manic-depressive illness) and anxiety disorders, may occur in people with HIV or AIDS, and they too can be effectively treated. For more information about these and other mental illnesses, contact NIMH.

Remember, depression is a treatable disorder of the brain. Depression can be treated in addition to whatever other illnesses a person might have, including HIV. If you think you may be depressed or know someone who is, don't lose hope. Seek help for depression.

References

¹Bing EG, Burnam MA, Longshore D, et al. The estimated prevalence of psychiatric disorders, drug use and drug dependence among people with HIV disease in the United States: results from the HIV Cost and Services Utilization Study. Archives of General Psychiatry, in press.

²Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865-77.

³Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993; 50(2): 85-94.

⁴National Advisory Mental Health Council. Health care reform for Americans with severe mental illnesses. American Journal of Psychiatry, 1993; 150(10): 1447-65.

⁵Leserman J, Petitto JM, Perkins DO, et al. Severe stress, depressive symptoms, and changes in lymphocyte subsets in human immunodeficiency virus-infected men. Archives of General Psychiatry, 1997; 54(3): 279-85.

⁶Page-Shafer K, Delorenze GN, Satariano W, et al. Comorbidity and survival in HIV-infected men in the San Francisco Men's Health Survey. Annals of Epidemiology, 1996; 6(5): 420-30.

⁷Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report, 2000; 12(1): 1-44.

⁸Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR, 1999; 48(RR-13): 1-27, 29-31.

⁹Centers for Disease Control and Prevention (CDC). HIV Prevention Strategic Plan Through 2005. Draft, September 2000.

Source: National Institute of Mental Health. NIH Publication No. 02-5005