Facing Depression in HIV

Written by David Goldenberg, MD

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Depression is perhaps the most widely studied psychiatric complication of any medical illness, including HIV. Many people, doctors and patients alike, think of depression as a natural consequence of having a chronic or terminal illness. Yet being depressed is not part and parcel of being ill or facing an illness. In fact, people meet the emotional challenges and adjustments of illness in a myriad of ways. Major depression is a potentially severe complication of HIV. This article reviews what major depression is, how to recognize it, and various forms of treatment.

What is Major Depressive Disorder?

Major depression, also called major depressive disorder (MDD), is a clinical illness far more serious than daily parlance would suggest. Everyone's said or heard someone say, "I'm depressed today." This is usually not major depression, but rather a temporary feeling of sadness, discouragement, or grief, which everyone has from time to time. These mild versions of depressive symptoms are familiar to most people and make up the experiences of everyday life.

Most everyone has felt sad, grumpy, or irritable, been distracted or disinterested, not felt like eating, or indulged in excessive eating or sleeping as a reaction to bad news or events. Major depression includes these symptoms and a subjective experience of being sad, unhappy, or dissatisfied, but these feelings are magnified, persistent, and nearly unremitting. They are not passing feelings, but instead they seep into every area of life and rob the individual of the ability to experience pleasure and joy, of desires and motivations. The perspective of the person who suffers major depression is so distorted that the proverbial glass is not only half-empty, but will never be full and may even be broken and dangerous.

Major depressive disorder as a clinical disorder is defined in the Diagnostic and Statistical Manual (DSM-IV). The DSM-IV identifies different clinical entities comprised of groups of symptoms that are statistically validated and reproducible. This system was developed for use by researchers to provide consistency in nomenclature. Thus, when one research describes major depression, other researchers know that this involves certain symptoms and, for the most part, implies certain generally agreed upon potential biological and psychological etiologies, family history profiles, prognosis and response to certain treatments. The DSM-IV is the reference most commonly used to make a psychiatric diagnosis.

Diagnosis of MDD

The diagnosis of major depressive disorder generally must be made by a trained medical professional and requires the presence of at least five of nine symptoms occurring together, most of the time for a period of at least two weeks. The person must experience depressed mood and/or markedly diminished interest or pleasure in activities; and three or four (for a total of five symptoms) of the following:

Significant unintentional weight loss or gain
Sleep disturbance including insomnia or hypersomnia
Psychomotor retardation (a slowing in thinking or movement) or agitation
Loss of energy or fatigue
Feelings of worthlessness or excessive or inappropriate guilt
Decreased concentration
Recurrent thoughts of death or suicide

Thoughts of death and suicide alarm many people. Most people who are diagnosed with a chronic and potentially life-threatening illness have increased thoughts of death during the course of their adjustment, or repeated adjustment, to their illness or diagnosis. It is often a natural part of facing one's mortality. If these thoughts are pervasive, unrelenting, intrusive, or even particularly bothersome, then it is wise to seek mental-health consultation and treatment. Thoughts of suicide can reflect an individual's desire to gain control in the face of loss of control because of illness. These thoughts, however, may be a sign of a more severe depression and also merit professional evaluation. If the thoughts are accompanied by a plan and intent to act on them, a severe depression is more likely and urgent psychiatric evaluation is indicated. Researchers have studied suicide and the desire for death in people with HIV and they have concluded that in the overwhelming majority of cases, these thoughts and feelings change when the person is treated for depression.

Physical symptoms of major depression

It is important to note that the symptoms of MDD include not only mood- and emotion-related symptoms, but also cognitive and somatic, or physical, symptoms. Indeed, diagnosing major depression in the context of a medical illness like HIV disease can be complicated by the presence of physical symptoms. Thus, when making the diagnosis of major depression in a person with HIV, it is important that the doctor be very familiar with the physical manifestations of HIV disease as well as with the manifestations of depression.

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