Director's Letter

We know that improving health care means more than meeting physical needs. For people living with HIV/AIDS (PLWHA), who have higher rates of depression and substance abuse than the general public, treating mental health disorders is especially critical.

Depression rates for HIV-positive people are as high as 60 percent; yet, one-half of all PLWHA with depression go undiagnosed and untreated. We’ve got the means to do better. Screening tools like HRSA’s Client Diagnostic Questionnaire can help detect potential signs of risk, such as social isolation and alcohol dependence. By closely monitoring patients at critical times, such as at the start of antiretroviral treatment, we can aid them at the onset of mental health issues. Because the sooner we see warning signs, the sooner we can act.

Let’s remember, too, that treatment regimens only go so far in treating mental illness—relationships matter, too. By providing support groups and strengthening patient–provider bonds, we can boost retention for people at risk, improving patients’ bodies and minds in the process.

Deborah Parham Hopson
HRSA Associate Administrator for HIV/AIDS

DIAGNOSING and TREATING DEPRESSION

Major depression is the most common mental health disorder among PLWHA; estimates are that about 60 percent of PLWHA will have a depressive episode at some time during their illness.16,17 Strong evidence indicates that HIV infection is associated with greater risk of major depressive disorder, although a review of research also found that most PLWHA appear to be psychologically resilient.18

One challenge in linking patients with depression to care is the attitude of providers. “Too often, we see providers not using medications to treat depression because they are putting themselves in their patients’ shoes and the depression makes sense to them,” says David Haltiwanger, clinical psychologist at Chase-Brexton Health Services, a Ryan White HIV/AIDS Program grantee in Baltimore. “It is crucial that patients be medicated based on their symptoms for depression, not on the reason for depression.”

Recent research reflects the tremendous importance of identifying and treating depression in PLWHA. A retrospective study of more than 3,000 patients found strong evidence that depression without treatment using the class of antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) decreased the odds of both achieving adherence to highly active antiretroviral therapy (HAART) and lowering viral load.19

Conversely, patients with depression who were prescribed and adhered to SSRIs had HAART adherence rates and viral loads similar to those of patients without depression. In addition, among patients with depression, those taking SSRIs showed significantly greater increases in CD4 T-cell counts than did patients not taking SSRIs. Especially noteworthy, the evidence indicated that the improvements in viral load among patients on SSRIs were not solely attributable to HAART adherence, implying that depression itself may affect viral control.20

Depression vs. Demoralization

Depressed* Demoralized*
Persistent inability to experience pleasure from normally pleasurable life events Characterized by a “welling up of grief”
Cannot be distracted by and enjoy pleasant activities Can be distracted by and enjoy pleasant activities
Feel worst in the morning; mood improves during the day Feel best in the morning; mood worsens during the day
Difficulty staying asleep Difficulty falling asleep

Although the high prevalence of depression among PLWHA is well documented, clinicians at Johns Hopkins University’s Moore Clinic describe an equally prevalent condition among their patients known as demoralization.21 Common among people with physical and mental illness, demoralization is characterized by existential despair, hopelessness, helplessness, and loss of meaning and purpose in life.22

Although it shares many of the symptoms of depression, demoralization has key differences that affect its symptoms and the course of treatment; correct diagnosis is made trickier because the two disorders can coexist. Unlike depression, demoralization is not a brain disease but an adjustment disorder caused by recent events or ongoing life circumstances.

According to the Hopkins team, clients with major depression respond well to antidepressants, whereas those with demoralization may not. Clients who are demoralized, however, do respond well to psychotherapy, support groups, encouragement, drop-in centers, education, and time.23

*Note: These are generalized statements; patient symptoms may vary.
Source: Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA. 2001;286:2857–64.

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REFERENCES
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  2. Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA. 2001;286:2857–64. 3Lesser, 2008.
  3. Lesser, 2008.
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