HIV and Depression Learning Objectives Define what is

HIV and Depression

Learning Objectives • Define what is depression • Describe the relationship between depression and HIV/AIDS • List the symptoms of depression • Explain how to identify potential depression in our patients • Identify signs of substance abuse in our patients

Introduction § Many studies worldwide show evidence of increased psychological distress in people with HIV/AIDS § Increased rates of anxiety and depression: § Occurs at time of diagnosis/ disclosure to family members § Increased risk in those with painful physical symptoms of HIV/AIDS § HIV associated with stigma/ rejection by family members

Gaps in MHS in PLWHIV § Mental health conditions for PLHIV are under diagnosed and under treated § In resource-limited countries: § High burden of HIV/AIDS § Limited capacity of mental health care delivery § Detection of depression poor in HIV § WHO recommend that psychosocial needs of HIV+ve/ AIDS population should be integral to HIV services

What is Depression? § State of lowered mood, often accompanied by disturbances of sleep, energy, appetite, concentration, interest, and sexual drive

Depression and HIV/AIDS § Evidence that there are higher rates of HIV infection in depressed population § Increased risk taking behaviour § Social exclusion § Substance misuse § Cognitive deficits/ Impaired judgment § Mentally ill less likely to attend for screening and to attend follow up. Also have poorer quality of life and increased mortality

Depression and HIV/AIDS (contd. ) § Emerging evidence that depression is an independent risk factor for poor prognosis for those initiated on ARVs § HIV-positive have nearly twice the rate of major depression as HIV-negative § HIV with depressive disorders compared with HIV alone § Greater delays in medical treatment § Worse adherence to medical treatment § For women, higher mortality

Depression in PLWHIV § Increase in mortality rate among HIV-seropositive women and with disease progression in HIVseropositive men. § Depression associated with more rapid disease progression independent of demographics, psychosocial and clinical factors. § Patients with likely mood, anxiety, or substance use disorders were 2 x as likely to develop virologic failure and took 41% longer to achieve virologic supression.

Depressive Factors Asymptomatic Period: § “Slow Sentence” effect – unable to hope or plan, vigilant and fearful about self and others § Complex decision making (e. g. : who to inform? ) § Lifestyle changes § Reconsidering life plans § Preparations for death § Worries about financial and health security § Pressures of medical regimen

Depressive Factors (contd. ) Symptomatic Period: § Reduced independence § Fears about the future § Death anxiety § Concerns over body image § Changes in self-concept § Social isolation/conflictive relationships § Prejudice from others § Bereavement

Symptoms of depression For at least two weeks, the presence of at least two core symptoms: § Depressed mood (or irritable mood in children/adolescents) § Loss of interest or pleasure in activities (anhedonia) § Decreased energy or easily fatigued

Symptoms of depression (contd. ) During the last two weeks, at least three of the following: § Reduced concentration/attention § Reduced self esteem and self confidence § Ideas of guilt and unworthiness § Bleak and pessimistic view of the future § Ideas or acts of self harm or suicide § Disturbed sleep § Disturbed appetite

Symptoms of depression (contd. ) § The person has difficulties carrying out their usual work, school, social, or domestic activities § It does not occur secondary to a medical illness or a substance abuse problem

Screening for depression § § § § S I G E C A P S leep nterest uilt nergy oncentration ppetite sychomotor agitation/retardation uicide

Medication Side Effects § Steroids: mania or depression, paranoia § Efavirenz: decreased concentration, vivid dreams, may trigger onset of depression

Protective Factors § Positive social support § Optimism § Adaptive coping §Acceptance, planning, and active coping vs. denial and avoidance

The Flip Side § Fatalistic-pessimistic attitude is significant predictor of shorter survival time among men with AIDS § Use of extreme denial or extreme acceptance associated with accelerated disease course, while distraction is associated with slower course § People who remain socially isolated appear to show the fastest progression of disease

Depression and Adherence • Depression decreases adherence by: § Negatively influencing expectations and benefits about the efficacy of treatment § Increasing withdrawal and social isolation § Decreasing cognitive functioning and memory § Influencing dietary regimes § Decreasing energy for self care

What characterises ‘Super Survivors’? § Healthy self-care behaviors § Sense of connectedness § Sense of meaning and purpose § Maintaining perspective (cited in Antoni, 2000) 19

Depression and HIV Treatment – Psychological benefits § § § Decrease high risk behaviors Increase compliance Enhance quality of life Improve coping Increase utilization of health care services Lengthen survival time

Psychosocial/Behavioral Treatments § Support § Psychoeducation § Psychosocial § Cognitive-Behavioral § Existential 21

Supportive Therapy for Adherence to Antiretroviral Treatment (STAART) § Techniques to increase medication adherence and learn effective strategies to cope with stress and depression § Enhanced HIV treatment readiness § Reduced depressive symptoms in those who were depressed – (Balfour, Kowal, & Silverman, 2006) 22

Alcohol Use • CAGE screening questionnaire: § Have you ever thought you should CUT down? § Have you ever been ANGRY if someone criticised your drinking? § Have you ever felt GUILTY about your drinking? § Have you ever needed an EYE OPENER early in the morning? § 2 or more should lead to further referral assessment and referral 23

Key Messages § HIV positive people are at greater risk for depression § It’s important to screen our patients for symptoms of depression § Depression can affect a patient’s adherence to their treatment § Patient’s with depressive symptoms or substance abuse issues should be referred to the appropriate professionals 24