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Principal Investigator, New York/New Jersey AETC
About 30% of people receiving care and treatment for HIV infection have major depression. But is it best to conceptualize major depression as a mental illness or a medical illness? If you wake up in a bad mood but your body feels fine, you are very unlikely to have major depression. Physical symptoms, such as severe fatigue and disturbances of sleep and appetite, are part of the diagnostic criteria for major depression, and other physical complaints, such as dizziness, palpitations and gastrointestinal disturbances, are very common. Major depression also worsens pain by lowering the pain threshold. For all these reasons many people with major depression think they are physically ill and seek medical rather than psychiatric attention.
Recent evidence suggests that there may be a bidirectional relationship between depression and inflammation, and that immune responses release certain cytokines that also appear in major depression. This may help explain why there are such high rates of depression among people with HIV or tuberculosis infection, and why depression is such a common response to interferon treatment for Hepatitis C.
Depression can be a component of many medical disorders. Perhaps the best-known illnesses are hypothyroidism and pancreatic cancer, but there’s a long list of conditions that can present with depression. For that reason a thorough medical assessment is always in order.
If the patient’s medical workup is negative, some clinicians feel the problem is in the patient’s head and that there are no further steps to be taken. This approach disempowers clinicians and does a disservice to patients. Major depression is the second leading cause of years of life lost to disability throughout the world and is classified by the World Health Organization as more disabling than AIDS, heart failure, and most other diseases. If we think of major depression as a medical problem it becomes the domain of all clinicians and the patient has a better chance of getting treated.
It’s easy to screen for major depression and there are many effective treatments. Because patients are often uncomfortable with mental health referrals it works best if the HIV clinician can screen for depression and prescribe antidepressants in uncomplicated cases.
The PHQ-2 and the PHQ-9 are commonly used screening instruments that can be readily accessed online. These instruments are free, come with are scoring instructions and have been translated into more than 80 languages. The PHQ-2 is a simple two-question screen and, if positive, the clinician can go on to the full PHQ-9 screen which has a suggested cut off score for beginning antidepressants and can also be used to monitor patients’ progress.
While there are many antidepressants, the HIV clinician can focus on learning how to prescribe a few of them and refer patients to a psychiatrist or psychiatric nurse practitioner if there’s no improvement or severe side effects occur. SSRI antidepressants have been the most studied among people with HIV infection and they are all efficacious. It’s best to avoid paroxetine in women of reproductive age because it’s category D for use in pregnancy. If possible, refer patients who have bipolar depression (these patients need a mood stabilizer, not an antidepressant) or those who may be suicidal, homicidal or otherwise complex to specialty mental health services.
There are effective evidence-based manualized psychotherapies for depression. In mild to moderate depression these therapies often work without the use of antidepressants. People who have been disabled by depression may need therapy for the rehabilitative purpose of restoring normal functioning. When available offering both medication and psychotherapy can be the most effective treatment.
What are your thoughts about treating major depression as a medical comorbidity of HIV infection?
