Clinicians, researchers starting to understand impact of depression
Study shows that depressed HIV patients cost more
Recent research drives home the point that HIV patients are at risk for becoming depressed, and their progression to AIDS may be affected by their psychological status and the level of stress in their lives. Also, untreated depression in HIV patients results in higher medical care costs, a study has shown.
"HIV intrudes on your life, has financial costs, and affects your sex life," says Margaret Chesney, PhD, professor of medicine at the University of California San Francisco (UCSF).
"So the persons living with HIV and their closest family and friends and providers all tend to become at times overwhelmed by this," Chesney explains. "Sometimes it’s depression; sometimes it’s just being stressed or having a depressed mood."
Data confirm it
While clinicians may have been alert to this problem through anecdotal evidence and intuition previously, now there’s a growing body of research confirming their suspicions that HIV patients fare worse when they are depressed or under excessive stress.
"There’s beginning to be an outpouring of data that psychological factors affect disease progression in HIV," says Jane Leserman, PhD, research associate professor of psychiatry at the University of North Carolina School of Medicine in Chapel Hill.
Other research shows a high rate of depression among older adults with HIV.
"About 54% of older adults with HIV infection have some form of depression, whether mild, moderate, or severe," says Timothy Heckman, PhD, associate professor of psychology at Ohio University in Athens. "This is higher than in the general population of HIV patients," Heckman adds.
Two trends make this finding more alarming, Heckman notes. First, the success of antiretroviral medications in extending the lives of HIV patients means it is likely many of the people who become infected while in their 20s and 30s will live until their late 50s and 60s. Second, there is an increase in HIV infection among older adults.
Together, those trends indicate that clinicians need to be aware that their older patients are at greater risk for depression and that their younger patients may face an increasing risk as they age.
"I’m very concerned about not just extending the life expectancy of people with HIV, but also improving their quality of life," Heckman says.
Watch for depression at diagnosis
A University of Florida researcher has found that HIV patients are particularly prone to develop depression at two specific times: right after they receive their HIV diagnosis and when their symptoms first appear, explains Gail Ironson, MD, PhD, professor of psychology and psychiatry at the University of Miami in Coral Gables, FL.
"So a physician should be on the lookout for that," Ironson says, "and also ask patients if they have had any particularly difficult stressors in the last six months, any major stressful events in their lives."
Although the prospects of a longer and healthier life now exist for HIV patients, the disease still carries a stigma, and depression is common among those who are infected, says Jerry Durham, PhD, RN, FAAN, dean and professor at the Barnes College of Nursing at the University of Missouri in St. Louis.
"HIV is a life-threatening condition, and it carries with it a sense of loss and the potential of not having a very good outcome," Durham says.
Treating depression, whether through a variety of cognitive and behavioral therapy interventions, stress management, support groups, or medications often is necessary.
Untreated depression is associated with higher medical costs for HIV patients than is treatment with antidepressants, according to a study published this year in the Journal of General Internal Medicine.
The study assessed antidepressant treatment and health services utilization among Medicaid patients who had HIV and were diagnosed with depression. The patients who were treated with antidepressants had significantly lower monthly medical care expenses and were more likely to receive appropriate HIV care.1
The study concludes that depression is a major health risk for people with HIV and is associated with a variety of other problems, including lowered immune response, disease progression to AIDS, shorter survival, increased disability, and a lower quality of life.1
Leserman has been studying how psychological factors impact the immune system and disease process in HIV patients. The preliminary findings indicate that psychosocial status and neuroendocrine functioning might lead to the acceleration of HIV disease.2
"Often when we think about HIV, we focus only on the biological aspects of illness, and the psychological aspects are only thought about in terms of whether someone has a major psychiatric disorder," Leserman says. "In our study, we find psychological factors may be important in terms of disease progression."
Researchers asked adult homosexual men with HIV to fill out questionnaires about the stresses that had occurred in their lives within the past six months. "We took their blood at a certain time in the morning and did neuropsychological and psychiatric evaluations," she says. Investigators measured the men’s social support and coping mechanisms based on their answers to the questionnaire, and they measured stress levels based on an objective scale that rated various life stressors.
"So if their dearest friend had died, it received a higher rating than if an acquaintance had died," she explains. "Our rating was based on the idea of how would the typical person, given these circumstances, assess this, rather than using the men’s own rating, which was biased."
Researchers viewed stress as something that could affect the men’s health even when the men downplayed its importance. "A lot of people are just stoic, and if you ask them how stressful an event was, they say it wasn’t so bad, and yet they’re suffering," Leserman says. "And other people say they’re stressed no matter what’s happening to them — they might just get a traffic ticket and that’s the biggest stress."
The men answered questions about how satisfied they were with their social support and how they coped with the prospect of developing AIDS and watching their disease grow worse. They were given choices among their answers, such as "I pretend it’s not real" or "I pretend it’s not happening." Those types of responses indicated their level of denial about the disease.
Blood tests revealed their cortisol measures, which tended to predict which men would have a faster progression to AIDS, Leserman says.
"Cortisol is associated with lowering the immune system, and it might have had a direct effect on immune response," she says. "There are not too many good studies on cortisol, and the research is controversial."
Some findings show that high cortisol levels are harmful, while others have not reached that conclusion. "Our own findings showed that cortisol was not a very beneficial hormone for these men," Leserman says.
References
1. Sambamoorthi U, Walkup J, Olfson M, Crystal S. Antidepressant treatment and health services utilization among HIV-infected Medicaid patients diagnosed with depression. J Gen Int Med 2000; 15:311-320.
2. Leserman J, Petitto JM, Golden RN, et al. Impact of stressful life events, depression, social support, coping, and cortisol on progression to AIDS. Am J Psychiatry 2000; 1,578:1,221-1,228.
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