Nearly all HIV-positive people will experience ‘dysphoria’ – a negative disturbance in mood – at some stage. It can strike after their HIV diagnosis, as a result of some HIV-related conditions or because of the physical and mental strains that the virus places on us on a regular basis.

‘Feeling blue’ like this is normal and is usually just a transitory thing, but more serious depressive symptoms are estimated to have occurred in about 30 percent of the HIV-positive population at some stage¹ compared with about 7 percent of the general population. However a recent Australian study² suggests there’s been an improvement in these figures (a decrease to around 14 percent) possibly related to health improvements related to HAART.

Treating depression can be one thing but being aware that you are depressed is often half the battle. “Depression is insidious; it sneaks up on you,” Peter Hayes, a counsellor therapist of twenty years experience with the Melbourne Sexual Health Centre, told PL. “Being aware that you have the symptoms of depression can be half the battle in overcoming it.” A lot of HIV-positive people go to their doctor with vague symptoms, aches and pains, problems with their appetite or sleep and they wait for their doctor to make the diagnosis, he explained. There can be many reasons for these symptoms and depression may be one of them.

With GPs having to cope with complex HIV treatment and pathology results, they may not have the time in a 15-minute consultation to ask how you’re doing, so symptoms of depression can easily be missed. Added to this, some people feel embarrassed that they are not able to ‘pick themselves up and get on with it’ and are reluctant to admit this to their doctor.

“When patients are referred to me I make an extensive history which includes past and present coping strategies,” said Hayes. “I use a simple questionnaire which is then scored to help confirm depression and indicate how we proceed from there. [See the sidebar on this page for a checklist of the main symptoms of depression.] Some people can have a mixture of symptoms of anxiety and depression, which are often interrelated, and treatment can help reduce both.”

What caused the crisis?

“One of my aims in the psychotherapy sessions is to find out what precipitated the depression, what finally ‘sunk the boat’ for that person. People often manage to keep their head above water, so to speak, but then an unexpected issue tips them over the edge to a point of not being able to manage or they become depressed. Things like a relationship break-up, the loss of a job or not being able to make ends meet financially are all major stressors,” explained Hayes.

“Most people are able to regain their equilibrium after a period of supportive therapy and perhaps antidepressant medication. Others with more complex needs will benefit from the guidance of a psychiatrist. Encouragement to seek advice from perhaps a social worker, housing officer or peer support worker may be the key to recovery as they begin to appreciate that everything is not hopeless and a resolution can be found. To be able to talk the issues through with someone, without fear or judgment or dismissal with comments like, ‘It’s not really that bad’ is an important step to obtaining help.”

Isolation is a major issue for many of the clients Hayes sees. “The fear of disclosure of one’s HIV status can often lead to people cutting themselves off from the community, whether it be the HIV-positive community, the gay community or even family and friends who might have been good supports. This fear can be compounded when a person experiences the side effects of HIV treatments, such as lipodystrophy (particularly the facial changes) and feels they can’t disguise their status any longer. Or they come to see me because their health has deteriorated and suddenly they have to start taking treatments—this can be very confronting. They have put the HIV issue away in the ‘too hard basket’ until finally they have to face up to the possibility that they might get sick.”

Commencing HIV medications can be especially difficult, Hayes believes, as it is often the first time there is a daily reminder of being HIV-positive. For many people, the real hurdle is actually engaging with their HIV-positive peers – to be able to walk in the door of a Positive Living Centre and feel comfortable about receiving services there. Speaking to other positive people about how they managed is, says Hayes, “universally empowering.”

Role of antidepressants

People with serious depression will generally need to see a psychiatrist or a psychologist to help them to deal with feelings of hopelessness or despair, sometimes resulting in thoughts of suicide which stop them from functioning normally in their everyday lives.

Dr Steve Ellen is a senior psychiatrist with the Alfred Hospital in Melbourne with responsibility for looking after patients with HIV. “When depression gets really severe the balance of chemicals in the brain changes and medications are usually the only thing that helps,” he said. “Most people still require counselling or psychological therapies to help deal with the underlying causes. Medications alone work in about 65 percent of cases, but combined with psychological therapies, it goes up to about 80 percent.”

There are several issues you and your doctor should be aware of if considering antidepressant medication. For people with HIV who are on HAART drugs, it’s always important to be aware of the potential for any interaction between medications: double-check with your pharmacist if you are worried about these. Some of the latest antidepressants interfere less with sexual functioning, something some people are particularly concerned about. And for people with a history of depression it might be worth avoiding the antiretroviral efavirenz (Stocrin) because it can worsen depression. If it’s the best option for control of the virus, doctors need to watch for signs of depression and to treat it if it occurs.

“People with mild depression (the most common) don’t necessarily do so well with anti-depressants and if they are prepared to undergo supportive psychotherapy or be referred to a psychologist, I recommend it,” said Ellen. Cognitive Behavioural Therapy (CBT) is a popular psychotherapy for people with depression, which he says helps most people who try it.

Cognitive Behavioural Therapy

Michelle Earle, a clinical psychologist at the Alfred Hospital, explained what is involved with CBT. “It is a structured, focused approach to reduce a patient’s symptoms of depression. Patients commit to at least six sessions where the psychologist helps them look at their thinking patterns, feeling states and behaviour in a scientific way. This might involve a patient recording their thinking processes for a week – when is their mood low, what brings on thoughts of hopelessness or despair, what are the consequences for them when they feel low? Then the psychologist will examine these with patients to identify the patterns associated with their depression or anxiety and help to challenge these patterns.”

For example, Earle explained that if an individual believed that they were alone with their illness and this underpinned their depression, they might discuss the evidence for that and whether there was any evidence contrary which might offer hope. “There are very few people for whom things are all good or not good at all – a goal is to help the patient achieve some perspective and be able to master the patterns which lead to them being distressed.”

Alternatively, the psychologist might ask patients to monitor their feelings when undertaking certain activities – what things bring them the most pleasure in their everyday lives and can they increase the time they spend doing these things to counter their negative feelings? Finally, CBT also looks at behaviour: is the person spending too much time in bed, not getting out into the sunlight or not doing exercise each day (something which is known to aid stress management and mood)? The idea is to provide some tools to overcome depression and stop it recurring.

There’s usually no single intervention that works for everybody, said Earle. “There are lots of other approaches which psychologists use and often therapists will not just restrict themselves to one approach. The insight-oriented approaches can also be of benefit to people coping with a chronic illness, for instance.” These approaches look at people’s subjective experience, how they have adjusted to major life changes such as an HIV-positive diagnosis, or the grief and loss associated with illness and what meaning they can make of these changes.

“We have learned that it’s not what actually happens to you in your life that best predicts how you fare; it’s how you make sense of what happens to you that’s important. This approach is about helping people to make adjustments by looking at the ‘big picture’ of their lives.”

Inadequate mental health services

Steve Ellen acknowledges that the availability of mental health services in our country is generally poor. “Our public systems are under funded and don’t tend to do a great job with depression as they are more focused on schizophrenia and drug-related problems,” he said. “Depression is most commonly treated in general practice settings and by private psychiatrists and psychologists.” But GPs are often overrun and don’t have the time they need to deal with depression, although this is improving. Private psychiatrists are hard to access and are expensive (although they are covered by Medicare). Psychologists are even more expensive and, until recently, didn’t qualify for a Medicare rebate.

Fortunately there are HIV psychiatric services attached to major hospitals in a number of states. It’s possible to access a psychiatrist or psychologist through these for no fee – something which isn’t available for some other illnesses. Some community agencies, including AIDS Councils, also provide excellent counselling services. About 10 percent of Steve’s patients require in-hospital care, he said. Specialist inpatient and outpatient HIV psychiatry services attached to major treating HIV hospitals, clinics and GP practices would be desirable but, he said, “I think that will remain on my wish list for some time!”

The Alfred Hospital in Melbourne is planning an HIV Psychiatry Primary Mental Health Service to be located in the community to support GPs and clinics. It is to commence in the second half of 2006.

References

¹ Gibbie, Tania, Mijch Anne et al “Depression and Neurocognitive Performance in individuals with HIV/AIDS: Two Year Follow-Up” in press with JAIDS.

² ibid.

Are you depressed?

Based on the criteria developed by the American Psychiatric Association, there’s a possibility you may have major depression if, for at least two weeks, you’ve had…

*…at least one of these symptoms…*

1. Feeling depressed (down, sad, blue, hopeless) most of the day and almost every day.
2. Loss of interest in things that are usually interesting or pleasurable. (This can be partial or complete).

*…and at least four of these symptoms…*

1. Loss of appetite and/or weight loss without diet or medical cause or increase in appetite and/or undesired weight gain.
2. Insomnia (waking up early and not being able to fall back to sleep; difficulty falling asleep) or sleeping too much.
3. Being slowed down physically or mentally. You or other people notice that it takes you longer than usual to accomplish activities.
4. Being agitated (restless, can’t sit still, pacing, wringing hands, rubbing head).
5. Fatigue; loss of energy.
6. Feeling excessively guilty or worthless.
7. Difficulty in concentrating. Feeling that your thinking is slowed down. Increased difficulty in making small decisions.
8. Persistent thoughts about death and/or suicide.

If you are depressed

The most important things you can do is to talk to someone about it – your close friends, your family, your GP, your counsellor. Most people find it very difficult dealing with depression on their own and they shouldn’t have to. There are counselling and psychotherapy services available in each capital city and in most rural areas. See the Broadsheet on the back page of Positive Living for services in your state.

It is important to raise any concerns about mood changes with your GP. Depression should be treated as a medical problem like any other and sometimes mood changes can be a symptom of other medical conditions.

Try to maintain or increase social activities. Talk to friends and family. Many people withdraw from others when feeling down which only makes the depression worse.

Exercise has been proven to help people with depression. A regular gym routine is good but simply walking around the block can help a lot too.

Try to maintain your normal sleep-wake cycle, eat well and limit late nights.

Engage in pleasurable and distracting activities like reading, meditation, gardening, listening to music.

Limit or abstain from alcohol or recreational drugs. Alcohol is a depressant and while it might be commonly used as a coping mechanism, is likely to cause long-term problems if you start to depend upon it. Recreational drugs are known to cause depression several days after use, and people on antidepressants should not take ecstasy or amphetamines at all due to the risk serious drug interactions. Drugs like marijuana and alcohol also limit the effectiveness of treatments and so prolong the depression.

Thanks to Tania Gibbie from the Alfred Hospital, Melbourne for help with this list.

Robert’s story

Robert is a health professional who has been HIV-positive since 1985 and has experienced several AIDS-defining illnesses during the 1990s. Robert’s awareness of his mental health is acute, as he has just experienced a serious bout of depression involving visits to a counsellor and a psychiatrist who prescribed antidepressant drugs.

“It has been a rough period in my life but the psychotherapy helped me to get an understanding of the way my mind works, and the role that my past history has played in my thoughts. Along with the antidepressants which have really picked up my mood, finding a therapist who I could trust has helped bring me through a dark time.”

As Robert found in his psychotherapy, periods of change or upheaval can bring depression for some people and this has been Robert’s experience. Very early on in his life he remembers going through depression when he thought his conservative father wouldn’t accept him being gay. Later in life when he became HIV-positive, it was revealing the news to his then boyfriend which set it off again – the boyfriend’s rejection of his status hurt him deeply as did the general stigmatising of positive people by society then – it was only finding a very supportive gay GP that got him through his great feelings of loneliness.

As a health professional, Robert has only been too aware of the stigmatising of patients with mental illness by other professionals and he was cautious about letting anyone know if he had been through any depression. “If you’re hiding personal details about previous mental health episodes and your HIV status on top of that, you can get to a lonely place. Finding a few real friends or soul mates who won’t judge you or tell others can really make the difference. I found that in a partner who was also HIV-positive and for a number of years we planned our lives together. Things were going well but when we split a year or so ago my dreams about where my life was going seemed to fall apart.

“On top of that of course I have been dealing with the ageing process. There is no doubt that HIV and its treatments cause people to age faster – when I look in the mirror and compare myself with my brothers and sisters who are similar ages, I look much older. The lipoatrophy from the drugs has not been kind to me and the thought of losing one’s youth and attractiveness – of not being able to pick up at the bars anymore – has caused me some despair. When recently I became run down from doing too many hours at my work, I had a serious mental collapse. I was reluctant to find help but when I started to think suicidal thoughts and to actually think about carrying it out, I knew I had to see a mental health professional.

“Fortunately I found someone I got on well with and I’ve made some significant changes to my life. I’ve decided to simplify everything I do down to the things that really give me pleasure – I don’t have to do things for others all the time like I used to. I’ve learnt to prioritise the things I want to achieve every day so I don’t get overwhelmed or upset if I don’t do everything. I’ve nurtured a couple of special relationships and made sure I haven’t remained isolated from others like I was.”

Robert also found that antidepressants helped in his case. “After three weeks on the mirtazapine I started to feel so much better. I could concentrate, observe things around me more fully and even listen more closely to my friends. My psychiatrist selected it partly because it doesn’t interfere with sexual performance and it has worked well for me.”