March #57 : Beat The Blues - by Maia Szalavitz

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March 2000

Beat The Blues

by Maia Szalavitz

It doesn’t take a brain surgeon to defeat depression. But you do have to get yourself help

Depressed people often resist getting treatment, and HIVers are no exception. In addition to “I’m not crazy,” “It’s my own fault I’m miserable,” “Nothing’s gonna help” and other routine rationalizations, HIVers have a special zinger to fling at folks who tell them to get over it: “You’d be miserable, too, with a life-threatening virus.” Well, get over it—untreated depression has serious health effects and can even shorten your life, not to mention just being a big bummer. What might surprise the downcast is the news that depression is very treatable.

One common but often-overlooked cause of depression in men (and some women) with HIV is low testosterone. So HIVers should have their levels checked as part of any evaluation for depression. A study at Columbia University found that three-quarters of HIV positive men with major depression who had deficient or even “low normal” testosterone levels showed improvement “equal to that achieved with standard antidepressants” when given supplements of the hormone.

Other contributors to depression are overall malnutrition or deficiencies of B vitamins (especially B-6 and B-12), very common in HIVers. And since nutrient-level blood tests are unreliable, eating better and adding a potent B complex plus extra B-12 (by nasal gel or injection) are worth trying.

If the depression is diagnosed as mild or moderate, everything from psychotherapy to exercise to pets can help. The main issue is: Can you mobilize to take these actions? If you can get yourself to your support group, the gym or the dog run, all well and good. But if, as Emily Carter describes in “Woman on the Verge,”even finding a pair of clean socks in the morning (or late afternoon) looms as an overwhelming task—you may need to start an antidepressant.

Phil Bialer, MD, who started the AIDS psychiatry unit at Beth Israel Medical Center in New York City, advises that even before you shop for St. John’s Wort or start a daily jogging routine, first get a psychological evaluation. “It’s a very complicated illness,” Bialer says. “It’s important to have a mental health worker as part of your treatment team.” Many practitioners recommend weekly visits with a psychiatrist, psychologist or social worker for four weeks, with at least one 30-minute consult every month thereafter. Ongoing monitoring is especially important if your treatment of choice is pharmacological.

The chart on the opposite page features the best available meds and techniques to battle the blues. Whether picking and sticking to one or mixing and matching, keep your doctor or therapist informed. Bring this chart to your next visit and discuss your preferences. “I feel confident that for almost 90 percent of my patients, we can find something that works,” Bialer says.


RESOURCES
These are great guides to your adventure in brain chemistry:

  • The HIV Drug Book, compiled by Project Inform (Pocket Books/New York City); The Handbook of Psychiatric Drugs, by Bernard Salzman, MD (Henry Holt & Co./NYC)
  • The Essential Guide to Psychiatric Drugs, by Jack Gorman, MD (St. Martin’s Griffin/NYC)
  • Beyond Prozac: Brain-Toxic Lifestyles, Natural Antidotes and New Generation Antidepressants, by Michael J. Norden, MD (ReganBooks/NYC)
  •  “Depression” chapter of The Encyclopedia of Natural Medicine, by Michael Murray, ND, and Joseph Pizzorno, ND (Prima Publishing/Rocklin, CA).

Other information sources:

  • Educational materials and interactive assessment tools for patients and physicians: Mediconsult’s Depression Center, www.mediconsult.com/defeatdepression
  • Online support groups for depression and FAQs (frequently asked questions) about the condition: www.firelily.com/support
  • HIV buyers clubs that offer info and discount prices on supplements: Direct Access to Alternative Information Resources (DAAIR), 888.951.5433, www.daair.org, PWA Health Group, 212.255.0520, www.aidsinfonyc.org/pwahg
  • Information on Bach Flower Remedies: Flower Essence Society, 530.265.9163, www.flowersociety.org



TREATMENT: Selective serotonin reuptake inhibitorS (SSRIs) Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram)
BENEFITS: Generally fewer side effects than tricyclic antidepressants.
CAUTIONS: Can cause loss of sexual desire and function, appetite suppression and headaches. Some on the drugs feel “speeded up”; others, slowed down and fatigued. Watch for interactions with HIV meds, particularly ritonavir (Norvir).

TREATMENT: Tricyclic antidepreSsants Norpramin (desipramine), Pamelor (nortriptyline), Tofranil (imipramine), Sinequan (doxepine)
BENEFITS: Also can help with chronic pain, reduce insomnia, increase appetite.
CAUTIONS: Side effects such as sedation, constipation, dry mouth, irregular heart beat. Watch for interactions with HIV meds, particularly ritonavir.


TREATMENT: Other antidepressants Serzone (nefazodone), Remeron (mirtazapine), Wellbutrin (buproprion), Effexor(venlafaxine), Desyrel (trazodone)
BENEFITS: Serzone and Remeron particularly helpful with sleep, and (along with Wellbutrin) reduce sexual function less than do SSRIs or Effexor. Wellbutrin helps in quitting smoking. Remeron may cause weight gain.
CAUTIONS: Effexor may cause agitation, insomnia and sexual dysfunction. Desyrel may cause painful erection requiring medical help. Wellbutrin in high doses or with ritonavir may cause seizures. Watch for interactions with other HIV meds.


TREATMENT: Psychostimulants Ritalin (methylphenidate),Dexedrine (dextroamphetamine),Cylert (pemoline)
BENEFITS: Work almost immediately. Help with fatigue and mood. Also useful for attention deficit disorder, which can be a part of depression.
CAUTIONS: Risk of dependence, but need not be avoided by all with addiction history. Can cause insomnia, appetite loss, overstimulation, increased heart rate and post-dosing fatigue.


TREATMENT: Testosterone replacement (patches or creams preferred; injections not recommended)
BENEFITS: Many cases of HIV-related depression and loss of sex drive are related to low testosterone levels.
CAUTIONS: Requires blood test to determine testosterone level (see “Raging Hormones,” April 1999). If dose too high, can have such side effects as aggression or (for women) masculinization.

TREATMENT: Interpersonal psychotherapy
BENEFITS: Research on HIVers finds that this therapy works. Improves relationships, coping.
CAUTIONS: Severe depression may require drugs as well.

TREATMENT: Cognitive or behavioral psychotherapy
BENEFITS: Has the most research support of all talk therapies for improving mood.
CAUTIONS: Severe depression may require drugs as well.

TREATMENT: support groups (in-person or online)
BENEFITS: Studies show that in-person support improves mental and physical health; those in similar situations can offer new insights and coping skills.
CAUTIONS: In-person: if you’re too depressed to go out, not a useful resource. Online: no data on antidepressant value; lacks full benefit of human contact.

TREATMENT: Acupuncture
BENEFITS: Two controlled studies show dramatic improvements, plus relief from anxiety-related symptoms.
CAUTIONS: Full benefit requires once- or twice-weekly visits to acupuncturist for a period of time.

TREATMENT: St. John’s Wort herb (most potent forms: freeze-dried flower and leafor 0.3% hypericin extract)
BENEFITS: According to numerous controlled European studies, generally as effective as some antidepressant drugs for mild to moderate depression, with far less toxicity.
CAUTIONS: High doses can induce painful sensitivity to sunlight. Can’t use with SSRIs or MAO inhibitors. Use with caution in combo with protease inhibitors and NNRTIs. Varying quality.*

TREATMENT: SAMe  S-adenosyl-methionine, an amino acid derivative)
BENEFITS: European research finds that this nutrient, important to brain and liver function, can have antidepressant effects.
CAUTIONS: No evidence of toxicity, but little data in general. Expensive, varying quality.*

TREATMENT: Bach flower remedies(essences from 38 flowering plants, diluted in an alcohol base, taken in a cup of water; several indicated for various types of depression; can be used in combos)
BENEFITS: According to many alternative practitioners, can balance negative feelings and stress, and may help reduce emotional barriers to health maintenance; effects occur any time from immediately to two weeks; nontoxic; inexpensive; FDA-regulated for quality control.
CAUTIONS: No data showing effectiveness for depression. For those with alcohol sensitivity, need to
further dilute in water (which doesn’t reduce effectiveness).

TREATMENT: Good diet and nutrient supplementS (esp. B-6 & B-12)
BENEFITS: If depression has a nutritional cause, can help. No side effects.
CAUTIONS: Supplements mean taking yet more pills, or in the case of B-12, nasal gel or injections.

TREATMENT: Exercise (such as yoga, running, bicycling, swimming or even walking)
BENEFITS: Releases body’s natural pain-relievers, boosts mood and promotes relaxation.
CAUTIONS: Can cause fatigue if too strenuous. May be difficult to do if depression has undercut your self-motivation.

TREATMENT: Pet ownership
BENEFITS: Pets provide unconditional love; research shows people with pets live longer, have better moods and more normal blood pressure.
CAUTIONS: Need care, food.





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