Like a blanket of pure white snow following a storm, the new year can sparkle with the opportunity for a fresh start. After summing up what was good, bad and ugly about the past year, the new year lets us plan to live differently. Despite our good intentions though, New Year’s resolutions can have a dark side—as sometimes even the cheeriest of people become stressed and discouraged because the goals they set for themselves prove all too quickly to be unattainable. And, for those who experience clinical depression on top of the usual holiday stress, just the thought of setting positive goals for the new year can seem futile. For those with the deep blues, a time that should be about new starts and new hope can turn into one of the darkest days of the year.

Richard Prendes, a 36-year-old corporate travel expert from San Jose who has been HIV positive since 1997, says that trying to make New Year’s resolutions when he was depressed was “hard, if not impossible. I would try to set goals, but the truth is that when the depression was there, [the] motivation was gone.”

Your reaction to societal pressure to clean up your act this January may be a very good barometer of where you fall on a scale that ranges from normal holiday stress to major depression—a condition that afflicts as many as 37 percent of people living with HIV. Experts say that lacking motivation is one of the distinct warning signs of depression. If even thinking about setting new goals makes you want to curl up into a ball in a dark room, it’s a good idea to seek professional help. But how can you tell the difference between the insidious tendrils of a major depression and the effects of a post-holiday hangover?

While it’s normal to have an emotional reaction to the holidays and the dwindling hours of daylight that crop up each December, experts say that if you’re feeling crummy most of the day, every day, for a period greater than several weeks, it could be a sign of a much more serious problem. This is especially significant for people with HIV, who have rates of depression at least twice as high as those in the general public.

Fortunately, depression is highly treatable. There is a wide variety of methods ranging from talk therapy to medication that have proven successful, even in people with HIV. The issue is not whether treatment works, but whether people will pursue a cure for the blues. Experts say only half of all people who suffer with depression seek out and receive the medical help they need. Lisa Razzano, PhD, an associate professor of psychiatry at the University of Illinois at Chicago, understands some people’s reluctance to admit that they’re struggling with depression and to seek professional help. She says, “The stigma around mental illness is as bad as the stigma around HIV.”

Fighting that stigma is one New Year’s resolution that people who are experiencing depression should strive to keep. Step one is admitting to yourself that the funk you’ve been fighting for weeks isn’t going away on its own. If that seems difficult, remember that you’re not alone. There are thousands of others who’ve felt the same way—and they’ve gotten better. With the awareness and determination on your part, you will find the courage to ask for the help you need. When you do, 2008 could just turn out to be one of the best years of your life.

Holiday Stew
In the months leading up to January, a combination of stressful ingredients can reach a boiling point, resulting in a stew of awful feelings. Nadia Damm, PsyD, a clinical psychologist with the AIDS Resource Center of Wisconsin, in Milwaukee, says, “Because [the holidays] are a time for rejoicing with family and friends, I think that [people with HIV] have a greater awareness of their social isolation. There’s increased stress, fatigue, financial constraints…. Often times conflict with family and friends are brought to the fore, because [you’re] spending more time with them. There may also be unrealistic expectations during the holidays, about what they should be like, that can lead to more depression.”

Joel Kaylor, who at 63 years old has been living with HIV since at least 1989, is painfully familiar with the melancholy that the holidays can inspire. He says, “When we decorate our Christmas tree we always put the ornaments on first that were given to us by friends who died of AIDS. I never used to cry while decorating a Christmas tree. Now Christmas is one of the saddest days of the year.”

Dealing with this kind of stress and loss is enough to bring even the most optimistic person down a little. So how is a person supposed to know if the malaise they’re feeling is related to the holidays that recently passed or something more serious? That’s where an expert comes in handy.

Diagnosing Depression
There is a formal list of symptoms that psychiatrists and psychologists use to diagnose depression. Some of the symptoms included in that list are changes in sleep and eating patterns, and persistent feelings of guilt, hopelessness and helplessness. (For a thorough list of symptoms and treatments for depression see the AIDSmeds lesson on HIV & Depression).

When evaluating a person with depressive symptoms, most experts attempt to distinguish between the stress of certain life events—like first testing HIV positive or dealing with holiday stress—and clinical depression. Disliking the catchall term “depression,” some experts differentiate between emotional reactions to life stressors (which they call “demoralization”) and the more serious disorder of clinical depression. Damm and Razzano both say one key way to distinguish between the two is the intensity and duration of the symptoms and encourage anyone suffering from symptoms of depression to tell their health care provider(s).

In an article published in a December supplement of Clinical Infectious Diseases, Glenn Treisman and Andrew Angelino, from the psychiatric department at Johns Hopkins University in Baltimore, wrote that there are two primary symptoms that are often absent in demoralization but common in clinical depression. These are the loss of pleasure or reward coming from activities that a person would otherwise enjoy, and consistently waking much earlier in the morning than intended.

When asked to describe what clinical depression felt like, Paul, a chef who tested positive in 1985 and moved to Melbourne, Australia, not long ago (he asked that his last name not be used), says, “The joyous light of living seems to disappear and it seems as if I’m living in a dense fog.”

Another characteristic that often describes both depression and a person’s life after being diagnosed with HIV is isolation from the family and friends who would typically be relied upon for support. After testing positive in 1997, Prendes stopped all the activities that had formerly given his life meaning and purpose. He says, “I basically went to work, came home—and that was my life. Inside I was completely dead, but I didn’t realize it because I wasn’t crying and feeling sorry for myself.”

Head Help
Razzano and Damm highly recommend seeking help first from your primary health care provider. This is especially important for people living with HIV, as there are some conditions, such as low levels of testosterone, that can mimic many of the symptoms of depression, especially fatigue and decreased libido. Checking for low testosterone levels can rule out such factors.

Treatment for the most serious forms of depression often involves some kind of talk therapy with a specialist—such as a psychotherapist or psychiatrist—or medication. In a comprehensive review of studies on depression in HIV published in the August/September Topics in HIV Medicine, Bunmi Olatunji, PhD, and his colleagues found that treatment with two types of therapy, both interpersonal psychotherapy and cognitive behavioral therapy, were highly effective at reducing depressive symptoms in people with HIV. They also found studies showing that up to 75 percent of those who took the antidepressant drugs fluoxetine (Prozac) or imipramine had reductions in depressive symptoms. Several studies in the general population have found that the combination of talk therapy and antidepressants works best.

Unfortunately, many people feel reluctant to seek professional help. “When you say, ‘I’m going to refer you to an orthopedic doctor for your knee,’ everyone says, ‘Great! They’re an expert in knee problems,’” says Razzano, “But when you say, ‘I’m going to refer you to a psychiatrist, because they’re an expert in your brain and emotions,’ people say, ‘I don’t need to see a psychiatrist!’”

And if feeling blue all the time isn’t bad enough to cause you to seek help, there are some very practical reasons to get treatment. In the December 2007 online edition of the Journal of Acquired Immune Deficiency Syndromes, Michael Horberg, MD, from Kaiser Permanente in Oakland, CA, found that of 3,359 people whose records were examined, 42 percent had a diagnosis of depression, and that those who were depressed were significantly less likely to have good adherence to their HIV medications than people who weren’t depressed. But when Horberg’s team looked at a group of the depressed patients who were prescribed and took a selective serotonin re-uptake inhibitor (SSRI) antidepressant appropriately, they had even better adherence to their HIV meds than people who weren’t depressed, and higher CD4 counts than people who were depressed but not taking an antidepressant. In short, untreated depression can have a direct negative impact on your overall health.

Though seeking help from a specialist is a must for anyone who is seriously depressed, it’s not the only way out. Prendes feels that the antidepressant medication he is receiving has helped him, but also points to the fact that he decided to reengage socially with the kinds of activities that used to make him feel good. Not only did he recently come out as HIV positive to his coworkers on World AIDS Day, he also volunteers as a speaker for a local AIDS service organization (ASO) and joined the Positive Pedalers to train for the California AIDS Ride.

Strength in Numbers
What many people who are depressed don’t realize is how many other people have experienced exactly what they’re going through. Razzano says, “Depression has been noted by the World Health Organization to be the number-one disabling condition worldwide.”

And when it comes to HIV, rates of depression have been found to be at least twice as high as in the general population. Thus, the chance of encountering other people with HIV who have suffered from and possibly conquered depression is very high. The first step out of the isolation is admitting to yourself that you’ve got a problem; the second step is telling another person with the knowledge and experience to help you.

Resolving to remedy social isolation is a step most people can take—and it’s one of the best things a person with depression can do, say Razzano and Damm.

Razzano isn’t too keen on the traditional forms of New Year’s resolutions; she says the classic ones like quitting smoking, eating right and losing weight are “doomed for failure,” especially for people struggling with depression.

Instead, she recommends resolutions that can’t be “measured in pounds,” such as doing more AIDS advocacy or volunteer work. She recommends “participating in a march, or helping a mailing campaign, or something like that at the place you receive services, or be a mentor or peer for someone who is newly diagnosed.”

Damm agrees, saying that at her agency they highly encourage people to get involved in volunteering, because, “giving back can increase self-esteem, because you’re helping other people, which can help you feel better about yourself. Also, it can help you get out of yourself.”

Paul, who lives in Australia and uses the Internet to keep up with friends and family in the United States, also touts the benefits of connecting with others. “I keep the voices of other HIV-positive people with me as an inspiration, “ he says.

Kaylor reached out in desperation when his partner was dying and his depression got deep. On the advice of a neighbor, he joined a support group at his local ASO. He calls that group “the most profound experience of my life.” He learned a number of key lessons in that group, and among the most important he says were “taking care of yourself, asking for help when you need it, and assembling a group of friends.”

For those who don’t have a local support group, the Internet can be another way of connecting with and receiving support from your peers. Kaylor, Prendes and Angeloni have all used the Community Forums on AIDSmeds.com to connect with others.

Prendes, who feels like he’s “living proof” of how much better things can become after dealing with depression, says, “Don’t waste time thinking that there’s no hope. I wasted 10 years of my life thinking that no matter what I did I would never feel the same as I did before I tested positive, but I was wrong…. There’s a lot of life left and there are a lot of [wonderful] things you can do.”