Facing Depression in HIV

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The diagnosis of MDD in the context of a medical illness is the subject of a fair amount of study among consultation-liaison (C-L) psychiatrists (psychiatrists who specialize in working with people with medical illnesses). Clearly, physical symptoms from an illness can be mistaken for physical symptoms from depression. There are several ways of approaching this problem. The symptoms that can be attributed to a medical illness can be included in the diagnosis, thus leading to overdiagnosis of depression, or they can be excluded, thus risking underdiagnosis. A third approach to control for over- or underdiagnosis is to substitute other signs for symptoms that can be attributed to the underlying illness. For example, a tearful or depressed appearance can be substituted for appetite or weight change. Specific substitutions, known as the Endicott Substitution Criteria, have been researched but are not standardized like the DSM-IV criteria. In studies of the various approaches to diagnosis, it seems that the most important factor is that the physician or mental health provider is very familiar with the physical, neuropsychiatric, and psychological manifestations of the illness

HIV-related illnesses that mimic symptoms of major depression

Because major depression has so many physical manifestations, there are, in fact, certain physical conditions that mimic major depression. Common culprits in HIV disease include anemia (significantly low red blood cell count or hemoglobin) and, in men, hypogonadism (significantly low testosterone). When there are concomitant affective (mood) symptoms that resolve with treatment of the underlying condition (such as getting a transfusion for anemia), then the person is generally considered to have a mood disorder secondary to a general medical condition and not major depression. HIV itself does not cause MDD, but complications, such as a very high viral load, often contribute to illness feelings that may mimic MDD.

Under these circumstances, how is the person with HIV supposed to know if he or she has major depression? In its severe forms, MDD is usually easy to identify. But often issues like stigma and prejudice, and even simply lack of information serve as obstacles to identifying the problem. Frequently, behaviors that reflect low self-esteem, shame, and guilt often increase the chances of high-risk activities. These activities, such as drug and alcohol use, and unsafe and high-risk sex, may be attempts to ward off or defend against the unpleasant feelings of depression. Many people seek an emotional escape or a feeling of disinhibition through drugs, alcohol, and sex. An honest, but often difficult, appraisal of the role these behaviors have in your life may reveal an underlying depressive disorder.

Seeking Help and Getting Treatment

Where is the person with MDD to seek help? Remember that MDD is a clinical disorder and not a natural consequence of illness or diagnosis, but it will complicate your ability to get and adhere to treatment. Thus, when seeking information or help, a consultation with your primary care provider is a good place to start. Providing information and asking a healthcare professional for his opinion is part of your job as a patient. He can help begin an evaluation that may lead to more specialized care from a mental health professional. Most primary care providers are comfortable referring their patients to a small number of mental health professionals who they know and recommend. Feel free to ask for a recommendation. Of course, seeking treatment directly from an individual therapist or a mental health clinic is a good alternative. It is quite reasonable to seek out a consultation, as opposed to committing to treatment, from a mental health professional who can help determine if you are experiencing major depression and what treatment or combination of treatments might be right for you.

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If you are suffering from severe major depression, you may need medications to break the downward cycle and to recover from this illness. There are, however, other potential treatments if you really don't want to take medications or you try them and can't tolerate them. Psychotherapy, where you discuss your problems and potential solutions, is an excellent treatment for depression, particularly in its mild to moderate forms. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are two types of psychotherapy that have been studied in people with HIV or AIDS and have been shown to be effective.

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Last updated: 10/05

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