Depression and HIV

People often say that they are ‘depressed’ when they are feeling down or sad. Often this is probably a natural fluctuation in mood, or an appropriate reaction to a distressing event or situation – everyone will experience this at times.

However, depression is a recognised mental disorder and is treatable. Mental health professionals often talk about ‘clinical depression’ or ‘major depression’ when they are referring to this condition. It is characterised by being persistent and more severe than transient periods of sadness. It is thought that depression occurs much more frequently in people living with HIV than in the general population. Surveys of people living with HIV in the UK have shown that high numbers of HIV-positive people report experiencing depression and anxiety.

It is also worth remembering that some of the groups often affected by HIV – including gay men, ethnic minorities, women and transgender people – already have higher rates of depression than the general UK population. Some research suggests that people with HIV and hepatitis C co-infection also have high rates of depression.

One of the most common signs of depression is fatigue, tiredness and low energy. However, this fatigue or tiredness might be associated with some sort of physical condition, such as low testosterone levels or hypothyroidism. It’s essential you ask for a thorough physical check-up if you are struggling with low energy.

Some women who are pregnant or have recently given birth can be more prone to depressive symptoms – this generally starts very soon after the baby’s birth and only lasts a short time but it can also start during pregnancy or some time after the birth, and be more severe and longer lasting.

Later in life, women going through the menopause are at greater risk of mood swings and of depression. If this has an impact on your daily life, it’s worth telling your doctor. The main aim of treatments for the menopause is to relieve symptoms and improve quality of life.

Causes of depression vary, but can involve biological, psychological and social factors. Illness, stress and social problems often cause depression to develop. For example, the physical effects of HIV disease progression itself can trigger depression. Experiencing a number of significant losses in life in a short period of time can also trigger a depressive episode. It has also been suggested that some people may be vulnerable to developing depression and other mood disorders simply because of their genetic make-up. In many cases, however, there might be no obvious or identifiable cause for the depression.

Whatever the causes may be, depression can become very entrenched. It can even become dangerous if a person becomes suicidal. So, paying attention to the signs of depression and doing something about it can be life saving.

Depression is characterised by the presence of some or all of the following symptoms, for some or all of the time, and for a period of weeks or even months (rather than for a few hours or days): low mood, crying spells, apathy, irritability and difficulties with concentrating. Symptoms can also include constant fatigue, sleeping problems (difficulty in falling or staying asleep, or oversleeping constantly), and changes in eating habits (loss of appetite or an inability to control overeating).

A key feature of depression is the loss of pleasure in activities that are usually meaningful and enjoyable. Reduced sex drive, social withdrawal and isolation are also signs. Feelings of low self-worth and inappropriate or excessive feelings of guilt are also symptoms of depression which can include thoughts of death, self-harm, or suicide.

Feeling depressed can also affect how you feel about HIV treatment and your ability to take your drugs as prescribed (‘adherence’), so it’s important that you and your doctor talk about how you feel. Other staff at your HIV clinic can also help you with adherence if you are finding it hard.

Treatment for depression

It is important to get professional help if you think you are experiencing a number of these symptoms. Try talking to someone you trust – perhaps a friend, colleague, partner or family member – about how you feel and where you could get more support. You should not think that you are weak, unstable or ‘mad’. In fact, it’s a sign of strength that you are reaching out for some help to improve your situation.

Exercise can help with mild depression. It is something you can do yourself, but your GP may also be able to help by prescribing exercise and referring you to a programme at a local gym or health centre.

If depression is not treated, it will not go away permanently. The feelings may lessen, so that you feel better, but it’s likely that you will have another episode of depression in the future. Psychological treatments for depression are very effective and can reduce the chance of depression recurring.

If you think you need professional help, your GP or HIV doctor will be able to help. HIV doctors are very used to working with people who are experiencing depression. Many of the large HIV clinics have specialist mental health teams including psychiatrists, psychologists and mental health nurses. Your GP will also be able to help with diagnosis, treatment and referral to specialist services.

Seek help immediately if you are thinking of harming or killing yourself. Your GP should be able to arrange some immediate help during working hours. You can go to your local accident and emergency department at any time of day or night, where you will be able to see a mental health specialist for assessment and help.

If you suffer from depression, your doctor may recommend that you take antidepressant medication. These drugs relieve the symptoms of depression by correcting chemical imbalances in the brain. They do not cure depression but they help you with the symptoms so you can get into a better state to start helping yourself.

Drug treatment for depression

There are four main classes of antidepressant drugs:

• SSRIs (selective serotonin re-uptake inhibitors)
• tricyclics
• SNRIs (serotonin and noradrenaline re-uptake inhibitors, also called serotonin and norepinephrine re-uptake inhibitors)
• MAOIs (monoamine oxidase inhibitors).

If your doctor prescribes an antidepressant, it is most likely that it will be from the SSRI class. Drugs in this class, which includes fluoxetine (Prozac), have fewer side-effects and interactions with other medications. In particular, the antidepressant citalopram (Cipramil) is often used because it has few interactions with anti-HIV medications and generally doesn’t cause many side-effects. It’s important the doctor prescribing the antidepressant knows about any other drugs you take, including your HIV treatment. 

If your GP suggests that medication may be helpful to help improve your mood, it is a good idea to inform them if you are on HIV medication, to ensure that one drug does not reduce the absorption of the other. If this is difficult, make sure you inform your HIV consultant of any medication your GP has prescribed in case your HIV medication needs to be reviewed.

Antidepressants can take between two and 12 weeks to have a significant and lasting effect, and your dose may need to be increased for the drug to be effective. Like all medicines, they can have side-effects, although not everyone will experience them.

"Causes of depression vary, but can involve biological, psychological and social factors. "

The side-effects of SSRI antidepressants often occur in the first few weeks of taking them. Side-effects at this time can be particularly difficult to cope with because of the time the medication can take to relieve the symptoms of depression. Make sure you discuss any concerns about side-effects with your doctor.

The herbal antidepressant St John’s wort interacts with anti-HIV drugs in the protease inhibitor (PI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) classes, leading to low levels of the anti-HIV drugs in the blood and risking the development of drug-resistant HIV. For this reason, you must not take St John’s wort if you are taking a protease inhibitor or an NNRTI.

The length of time you need to take antidepressants will vary with your individual circumstances. You may start to feel a lot better a few weeks after you start taking them, but it is highly recommended that you remain on antidepressants for at least six months after you feel better.

It's important not to stop suddenly as withdrawal symptoms can be difficult to cope with. If you want to reduce your dosage of antidepressants, talk to your GP about gradually reducing the dose.

Antidepressants can be a vital tool in recovery from depression. But they are only one of the tools at your disposal. It’s often helpful to combine antidepressants with a ‘talking therapy’. There is evidence that talking therapies can be just as effective, or even more effective in some circumstances.

A good way to find a counsellor or therapist is to ask at your HIV clinic, another HIV organisation or GP surgery about their services or contacts they may have. Alternatively, you could find someone through personal recommendation or through a nationally recognised organisation (British Association for Counselling and Psychotherapy, United Kingdom Council for Psychotherapy or British Psychological Society). You can also refer yourself for free therapy through the NHS's Improving Access to Psychological Therapies initiative (England only).