The good news about HIV-related depression is "you don't have to live with it," says Glenn Wagner, PhD, a research scientist at the New York State Psychiatric Institute. Wagner advises, "Recognize when you're struggling with a low mood that's affecting your life. Then talk to a doctor or mental-health professional." It's crucial to determine whether the cause if medication, chronic illness, nutritional deficiencies, pre-existing depression, untreated grief from multiple loss, or some combination. The goal of treating depression is to alleviate overwhelming feelings of sadness, hopelessness or unworthiness that can distort your ability to cope with HIV and its consequences. Familiarize yourself with the various options: Psychological, physical, nutritional, alternative and pharmacological. The kind of treatments you choose will depend on several factors-aside from what's available and affordable-including your depression's cause, length and intensity. None of these treatments is a magic bullet; all have benefits and limitations. Your treatment regimen will be as unique as you are.
The chart below provides only a quick guide to some of the most commonly used treatment options for HIV-related depression, based on interviews with numerous professionals. Take it with you when seeing a health practitioner. But since she or he may not be familiar with all approaches and there is a wide range of opinions, it pays to do your own reading. Before making a decision, ask yourself, "Am I really comfortable with this approach?"
If you see a therapist you find helpful, it's important to maintain some contact after your course of treatment and return during difficult times. And if you take psychotherapeutic drugs, careful monitoring is essential (see "Listening to Prozac" below).
Treatment: Support groups (seek group whose members hold positive attitudes about surviving AIDS) Benefits: Share feelings and emotions with others; learn from experiences of peers in a supportive social setting Limitations: Not recommended for major depressive episodes Resources: Local AIDS organizations, hospitals and AIDS newsletters
Treatment: Psychotherapy (group or individual) (seek therapist with positive attitude about surviving AIDS) Benefits: Helps resolve personal/emotional conflicts Limitations: Can be expensive; long-term treatment sometimes required to obtain benefits Resources: Therapists or community mental-health clinics that offer sliding fees or accept Medicaid
Treatment: Exercise (such as yoga, stretching, walking, running, bicycling or swimming) Benefits: Releases endorphins, which boost mood; promotes relaxation; may boost immune function Limitations: Can cause fatigue if too strenuous Resources: Local Y's, health clubs, exercise physiologist, personal trainer, classes for PWAs
Treatment: Bach flower remedies: Essences from 38 flowering plants, diluted in alcohol base, taken in cup of water; several indicated for various types of depression; up to six remedies can be taken in combination Benefits: Balances negative feelings and stress; may help reduce emotional
barriers to health; effects occur any time from immediately to within
two weeks; no physical dependencies; nontoxic; inexpensive;
FDA-regulated for quality control Limitations: If you don't have an alternative practitioner, use books to help choose best remedies for your problems; for those with alcohol sensitivity, need to further dilute in water. Resources: Information: Ellon, USA 516.593.2206; Bach Flower Therapy Theory and Practice, by Mechthild Scheffer (Thorsons/Rochester, Vermont) Products: Health-food stores; discount mail-order: L&H Vitamins, 800.221.1152.
Treatment: Hypericin (herbal extract of St. John's wort) Benefits: Approved and used in Europe for years as a "natural" antidepressant; also may have antiviral properties (against HIV and other viruses) Limitations: St. John's wort tablets only potent enough for antidepressant, but not for antiviral, effect; more potent hypericin form is more expensive and can induce painful sensitivity to sunlight Resources: Information: Direct AIDS Alternative Information Resources (DAAIR) 888.951.5433 Products: PWA buyers clubs and health-food stores
Treatment: Good diet and nutrient supplementation, especially high-potency B-complex, extra B-6 and B-12 (possibly including injections) Benefits: Can reverse depression caused by nutrient deficiencies, perhaps avoiding the need for antidepressants; toxicity is very rare Limitations: Nutrient-rich diet should accompany supplementation to help ensure optimal nutrient status for health maintenance Resources: Information: Carl Vogel Center, 202.638.0750; DAAIR, 888.951.5433; Products: PWA buyers club, health-food stores or pharmacies
Treatment: Testosterone-replacement therapy (injections, patches or creams) Benefits: Can improve depressed mood, sex drive and energy; may help reverse wasting Limitations: Usually requires blood test to determine level before starting; can have side effects; therapies for women less researched Resources: Glenn Wagner, PhD, New York State Psychiatric Instititue, 212.960.2331; Program for Wellness Restoration, 713.526.5883
Luvox (fluvoxamine) (approved in Europe for depression; can be prescribed off-label in U.S.)
Benefits: Generally less serious side effects than tricyclic and older drugs; Luvox may cause less sexual dysfunction Limitations: May decrease sexual function, cause appetite suppression, lose effectiveness with extended use, and have harmful interactions with protease inhibitors, especially ritonavir; Prozac has been reported to induce agitation and suicidal thoughts and actions Resources: Psychiatrist or physician, preferably one up-to-date on antidepressant therapy and HIV infection. Information: 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./New York City)
Benefits: Serzone and Remeron are most likely to improve sleep; Effexor is more effective for treatment-resistant cases and has less drug-interaction problems; Serzone, Remeron and Wellbutrin generally avoid sexual side effects; Trazadone is used as adjunct to improve response Limitations: Effexor may cause agitation, blood-pressure increases and insomnia; Wellbutrin may cause agitation and stimulant-like side effects; Serzone and Remeron may cause sedation; Remeron is too new for in-depth studies Resources: Same as above
Treatment: Tricyclic Antidepressants
Benefits: May help reduce peripheral-neuropathy pain, insomnia and increase appetite; Vivactil is less sedating than other tricyclics Limitations: Can cause sedation, constipation, dry mouth and irregular heart beat; may dangerously interact with protease inhibitors, especially ritonavir Resources: Same as above
Benefits: Rapid effects (within a week); can improve mood and energy Limitations: Risk of abuse and dependence, especially for those with history of drug abuse; can produce overstimulation, insomnia, loss of appetite, increased heart rate, rebound fatigue Resources: Same as above; also study of Dexedrine for PWAs underway at New York State Psychiatric Institute, 212.960.2331
LISTENING TO PROZAC
With any antidepressant, stay tuned for troublesome side effects
By Stuart Timmons
Despondent from watching his immune system and legal career simultaneously slide down the drain, Robert Doyle began taking Prozac in 1992. It enabled him to think clearly enough to retire, relocate and make other major decisions. But within a few months, he faced an unexpected problem: "I wanted to have an erection before I died."
Doyle had joined the ranks of those suffering adverse side effects from anti-depressants. Problems ranging from minor drowsiness to outright psychosis are possible side effects of the various antidepressants. Depending on the drug, nausea, jitteriness, insomnia or forgetfulness can accompany mood stabilization. The sexual dysfunction Doyle suffered may be experienced as delayed climax, erection difficulty or reduced interest in sex.
Problematic side effects intrude upon "15 percent to 20 percent of patients, and that's a generous, fair estimate," says Los Angeles psychiatrist Dr. Duane McWaine, who specializes in psychopharmacology and HIV. But counselor Linda Hoag, also LA-based, observes problems in more than 50 percent of her clients, including those with HIV.
In some cases, side effects can be worse than the original depression. As Doyle's internist shifted him from Prozac to Zoloft to Pamelor, he found each had major drawbacks. By last July, his latest, Serzone, was changed to Effexor. "Two days into the transition I began feeling very agitated. By day three I had this horrible feeling of wanting to crawl out of my skin." By the fourth day strong suicidal urges drove him to a psychiatric ward. "I'm still paying off that bill, but I know it saved my life." Most psychiatrists, such as Dr. Dan Karasic of the AIDS Clinic at San Francisco General Hospital, insist that such experiences are rare. "SSRIs [selective serotonin reuptake inhibitors] are great drugs and are, overall, the safest," he says (see chart).
But psychiatrist Dr. Peter Breggin, director of the Center for the Study of Psychiatry and Psychology in Bethesda, Maryland and coauthor (with his wife, Ginger) of Talking Back to Prozac: What Doctors Aren't Telling You About Today's Most Controversial Drug (St. Martin's/New York City), argues strongly against America's most popular antidepressant. "I have been involved with cases where patients with no history of suicide attempts killed themselves or tried to do so," he says. FDA records show hundreds of complaints, though none are verified, of suicidal or homicidal behavior among people taking Prozac but manufacturer Eli Lilly strongly denies the drug caused these incidents.
The most likely way to catch side effects early is adequate monitoring of medication by a professional. Ideally, PWAs on antidepressants should use a team approach, seeing both a psychiatrist and a psychotherapist in addition to their primary-care physician.
Opinions on needed levels of monitoring vary. Many practitioners recommend weekly visits for the first four weeks, with at least one 30-minute consult at least every month thereafter (the less stable the patient, the more frequent the checkups). But patients are commonly monitored as little at 15 minutes every three months. And the advents of HMOs-which often scrimp on monitoring-has further eroded access to care. Doyle, now on Paxil, never saw a psychiatrist until after he hospitalized himself, a fate shared by many PWAs. So enlist your psychiatrist or physician as an ally in pressuring your HMO to authorize needed visits.
Another important caution: Beware of drug interactions. "I used to be comfortable saying that antidepressants had no bothersome interactions with HIV meds," McWaine says. But protease inhibitors, especially ritonavir (Norvir), inhibit liver metabolism of many drugs. So before a patient starts a protease inhibitor, some doctors cut antidepressant dosage at least in half, then adjust from there. Since ritonavir may increase the blood concentration of tricyclics to dangerous-even fatal-levels, physicians often establish an antidepressant blood level as a baseline before adding other drugs.
The only protection may lie in consumer activism. Linda Hoag urges depressed PWAs to "hassle the doctor about dosage. Keep up with side effects. Don't be afraid to complain if you're uncomfortable, physically or mentally." After the transitional period is complete, Hoag adds, "The patient has to evaluate the big question: Is it worth it?"