Focus v10n9 depress

FOCUS

-A Guide to

AIDS

Research and Counseling

Volume 10 Number 9 August 1995

Depressive Disorder and HIV Disease: An Uncommon Association Judith G. Rabkin, PhD and Robert H. Remien, PhD Among patients with HIV infection, clinical depression is the most frequently observed psychiatric disorder, affecting between 4 percent and 14 percent of gay men and non-drug-using women, with higher rates among both infected and uninfected injection drug users. But while these rates demonstrate a connection between HIV disease and depression, it is not a direct one: despite the intuition that HIV disease might bring on depression, the evidence suggests that there is rarely a cause-and-effect relationship between the two. The majority of HIV-infected people with current depressive disorders have a history of depression that antedates HIV infection, and depression is not correlated with disease stage, T-helper cell count, or HIV-related medication use.

By reviewing the data on HIV disease and depression, this article seeks to dispel the belief that the two are inextricably linked. In doing so, it clarifies when and among whom HIV-related depression is likely to arise. In these cases, both psychotherapy and aggressive antidepressant treatment can be extremely effective.

Epidemiology: Scope of the Problem Early descriptive reports of psychiatric morbidity among those with HIV infection, which relied primarily on self-report rating scales and samples seen in medical settings, described exceptionally high rates of symptomatic depression and anxiety. More recent studies of community samples and research volunteers, using either symptom checklists or structured diagnostic instruments and trained pro-

fessional interviewers, have found rates among seropositive gay men to be approximately equal to their seronegative counterparts. When researchers compare rates for HIV-infected populations to general population rates, some investigators have found higher rates of depression, while others have not. Nevertheless, it has become increasingly clear that clinical depression is not the norm and therefore should not be expected among people with HIV disease.

At the same time, while transient mood states are not routinely recorded in epidemiologic studies, it is important to recognize that the majority of HIV-infected people are likely to experience periods of sadness and distress from time to time—particularly in relation to the illness or the death of friends. This is to be expected and is common. Therefore, the absence of a current depressive episode does not necessarily signify a total absence of distress.

Follow-up studies of HIV-infected men and women suggest that rates of depression do not increase over time. For example, a Chicago study of 436 subjects using self-rating scales to assess depressive symptoms found stable scores over a period of six bi-annual evaluations.1 A Cornell University study of 328 seropositive and seronegative, gay and heterosexual men and women found a decline in depressive symptom severity over time on both clinician and self-rated scales.2 There was no difference between infected and uninfected subjects on any occasion. A Columbia University study similarly failed to observe increased rates of depressive disorders among either seropositive or seronegative gay men followed over four years or among injection drug users surveyed at three semi-annual visits.3 Cross-sectional studies comparing symptomatic and asymptomatic men and

Editorial: Is Depression Normal?

Robert Marks, Editor There are two perceptual—and conceptually opposite—traps regarding depression and AIDS that may trick mental health and medical providers. The first is that depressive symptoms are a normal response to the harsh realities of HIV disease and therefore are not related to a clinical and treatable condition; the second is that the existence of any depressive symptoms indicates clinical depression and requires antidepressant treatment.

Depression versus Distress In this issue of FOCUS, Judith Rabkin and Robert Remien challenge these assumptions in a review the literature on depression and HIV disease. They report that clinical depression prevails among only a small group of people with HIV disease and that these individuals usually have a history of depression that predates HIV disease.

But it would be a mistake to interpret Rabkin and Remien’s

References 1. Joseph JG, Caumartin SM, Tal M, et al. Psychological functioning in a cohort of gay men at risk for AIDS: A three-year descriptive study.

Journal of Nervous and Mental Disease. 1990; 178(10): 607-615.

2. Perry S, Fishman B, Jacobsberg L, et al.

Relationships over one year between lymphocyte subsets and psychosocial variables among adults with infection by HIV. Archives of General Psychiatry. 1992; 49(5): 396-401.

3. Rabkin JG, Williams JBW, Remien RH, et al.

Depression, distress, lymphocyte subsets and HIV symptoms on two occasions in HIV2 FOCUS

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article as saying that people with HIV disease are free of angst. As FOCUS Editorial Consultant Michael Helquist points out, although HIV disease may not result in clinical depression for everyone who is infected, the series of distressing events can be so continual and unrelenting as to confound the distinction between a diagnosis of depression and distress.

In the second article in this issue, Bruce Victor briefly charts the complex relationship between sexual dysfunction and depression, focusing on the negative effects of the SSRI antidepressants (Prozac, Zoloft, and Paxil). These drugs, which have seemed to be so effective in improving mood among so many people, may not be as free of side effects as they appear to be. Most notably, they may cause sexual dysfunction, and sexual dysfunction itself may exacerbate depression.

Taken together, these three

women have resulted in inconsistent findings regarding rates of psychopathology. More recent reports have not found different rates of depression in samples at different stages of HIV illness The cumulative evidence does not support the notion that depression increases as HIV disease progresses.

Diagnosis of Depression Diagnosis may be complicated by the fact that both depression and HIV disease result in similar somatic or physical symptoms. Fatigue, lethargy, low libido, low appetite, and weight loss may be manifestations of either HIV-related illnesses or depressive disorder. In contrast, cognitive and affective symptoms—such as feeling sad, losing interest in formerly enjoyable activities, guilt, and irritability—are components of mood alone. In evaluating “interest,” for example, practitioners must distinguish between loss of physical energy and loss of interest per se. Clients might say that they have to

perspectives suggest that depression is complex, particularly for people with HIV disease. It is there and it isn’t; it may be clinical and treatable with drugs or it may be “distress,” which may respond to therapy, to social support, or simply to time; it may be acute or chronic, pre-existing or new, severe or incipient. The response to this complexity is careful assessment, and this assessment is crucial at the time of diagnosis.

Protecting the Therapeutic Process As Rabkin and Remien emphasize, clinical depression is treatable, and as Victor states, there are pharmacological alternatives and responses to SSRI-induced sexual dysfunction. But the SSRIs, as omnipotent as they seem, are specific drugs that respond to specific conditions: they will not relieve all forms of distress and may bring on more serious distress themselves.

They may also hide a client’s true distress from the therapist, potentially harming the therapeutic process and the client.

push themselves to do things, or that they have stopped engaging in formerly pleasurable activities, but this may be due to either depression, fatigue, or loss of physical functioning. For clarification, a therapist might ask, “If you had the energy, are there things you’d like to do today?”

Similarly, if reduced appetite and weight loss occur in the presence of medical problems—such as oral lesions, which make eating difficult, gastrointestinal disease, or antibiotics known to cause anorexia or nausea—these indicators would not be considered depressive symptoms if they were not also initiated, maintained, or exacerbated by depressed mood. Typically, clients can assist clinicians in making these distinctions. For example, ask the client, “If it were not for the lesions in your mouth, or the antibiotic you are taking, would you feel like eating?” With experience, the diagnosis of depression even in the context of severe medical illness can be done with greater confidence.

Risk Factors for Depression in HIV Illness What factors related to HIV disease are likely to be associated with depression?

Researchers have looked at a variety of factors including being gay, taking HIVrelated medications, being immune-suppressed, and being HIV-infected. None of these studies support the conclusion that HIV disease and depression are inherently associated with one another.

Studies of current and past psychopathology in community samples of gay men have revealed surprisingly high lifetime rates of depressive disorders, despite low rates of current depression.

Investigators at both Cornell and Columbia reported lifetime prevalence of depression in the range of 30 percent to 35 percent for gay men compared to 5 percent for the general population. Given the recurrent nature of depression, these findings suggest increased vulnerability to future episodes of depression in this group.

There appears to be no systematic published research regarding the effects on mood of any HIV-related medication or on the interactions between these medications and antidepressant drugs. Some published case reports suggest that zidovudine (ZDV; AZT) may be moodenhancing or mania-inducing, although occasionally clients report that ZDV causes depression. It is of course difficult to separate out the symbolism of initiating antiviral treatment from the chemical effects of the compound, or the effects of multiple HIV-related medications prescribed prophylactically or acutely as illness progresses. Overall, in view of the widespread use of these medications, especially ZDV, and the absence of documentation otherwise, the case reports may represent idiosyncratic rather than common mood effects.

It has been suggested but not demonstrated that HIV itself causes mood changes and that HIV-associated dementia induces depression. However, there is little evidence to support either of these

Treatment of depression in the general population is one of psychiatry’s success stories, and there is no evidence that it should be different for people with HIV disease.

positive homosexual men. Archives of General Psychiatry.

1991; 48(2): 111-119.

4. Stern Y, Marder K, Bell K, et al.

Multidisciplinary baseline assessment of homosexual men with and without HIV infection: III. Neurologic and neuropsychologic findings. Archives of General Psychiatry.

1991; 48(2): 131-138.

5. Evans D, Lesserman J, Perkins D. Stressrelated reduction of natural killer cells in HIV. Presentation from the VII International Conference on AIDS, Florence, Italy, June 1991.

6. Kessler RC, Foster C, Joseph J, et al.

Stressful life events and symptom onset in HIV infection.

American Journal of Psychiatry. 1991; 148(6): 733-738.

7. Stein M, Miller AH, Trestman RL. Depression, the immune system and health and illness: Findings in search of meaning. Archives of General Psychiatry.

1991; 48(2): 171-177.

hypotheses. A study of HIV-infected men did not find depressed mood to be associated with early subtle cognitive changes.4 Apathy, rather than sadness, appears to be the predominant affect in HIV-associated dementia.

Finally, published studies on the relationship between depression and HIVrelated immune compromise continue to offer inconsistent results. Some investigators have reported an association between depression and the decline in T-helper cell count. In contrast, a longitudinal study of 113 seropositive gay men found no relationship between syndromal depression, psychiatric distress, or psychosocial stressors and immune status or HIV illness stage.3 Greater distress was not associated with greater immunosuppression or more advanced illness stage, either concurrently or over time. Other studies also support this conclusion.5,6 Overall, the weight of the evidence does not support “a measurable or substantial effect” of psychosocial factors such as depression or stress “on [enumerative measures of] the immune system in relation to physical disorders such as AIDS” using the endpoints of medical outcome and death.7 With the advent of more direct measures of viral load such as polymerase chain reaction (PCR) and branch DNA, further study may be worthwhile.

Treatment Research Treatment of depression in the general population is one of psychiatry’s success stories, and there is no evidence that it should be different for people with HIV disease. While limited, published research on antidepressant treatment for seropositive clients together with extensive clinical experience suggests that HIV-infected depressed patients respond as their uninfected counterparts to both antidepressant medications and brief, focused psychotherapies.8 Tricyclic antidepressants, serotonin re-uptake inhibitors, and psychostimulants have all been shown to be effective in this population. Preliminary evidence suggests that testosterone replacement therapy may also have positive mood effects. In a study of men with advanced immunosuppression and clinical symptoms of hypogonadism (low testosterone levels), 69 percent of those who complained of depressed mood showed clear-cut mood improvement after eight weeks of treatment.9 Psychotherapy is also an effective approach to depression, particularly in 3 FOCUS

August 1995

8. Markowitz JC, Rabkin JG, Perry SW. Treating depression in HIV+ patients. AIDS. 1994; 8(4): 403-412.

9. Rabkin JG, Rabkin R, Wagner G. Testosterone replacement therapy in HIV illness. General Hospital Psychiatry.

1995; 17(1):37-42.

Authors Judith G. Rabkin. PhD is Professor of Clinical Psychology in Psychiatry at the College of Physicians and Surgeons, Columbia University, and a Research Scientist at New York State Psychiatric Institute. She is coauthor, with Dr. Remien, of Good Doctors/Good Patients: Partners in HIV Treatment (NCM Publishers, Inc., 1994).

Robert H. Remien, PhD is Assistant Professor of Clinical Psychology in Psychiatry at the College of Physicians and Surgeons, Columbia University, and a Research Scientist at New York State Psychiatric Institute.

terms of adjusting to a seropositive status—a process that requires integrating new information into an existing identity.

This process necessarily includes questioning assumptions about life, redefining priorities, establishing new goals, and acquiring new skills. It is an effort that takes time and can also evoke a sequence of grief, loss, and rage in the patient.

During this process, people living with HIV disease typically experience a wide range of emotional reactions to the actual, as well as the anticipated, events in their lives. They may feel hopeful, calm, and connected one day, and pessimistic, fearful, and alienated on another. Psychotherapy can validate this wide range of feelings as normal and can provide a safe environment in which clients can express emotion, allowing them to “ride the roller coaster” without “falling apart.”

There are specific times in the course of HIV disease during which clients are particularly vulnerable to acute distress: the confirmation of HIV infection, the initial onset of physical symptoms, a sudden decline in T-helper cell count, the first opportunistic infection. While time-limited psychotherapy and antidepressant medication are effective in responding to this distress, they do not assure sustained well-being. Given the unpredictable nature of HIV progression, it is prudent for therapists to encourage clients to maintain contact and return to treatment during difficult times.

To treat HIV-related depression effectively, therapists need to be flexible in terms of availability during illness episodes, willingness to make home or hospital visits, and the scope of their

attention during late stage illness when partners, close friends, or family members may also be at the bedside. They must also be prepared to talk about progressive physical decline, approaching death, and the circumstances of dying.

Clinicians have remarked upon the surprisingly gratifying nature of working with HIV-infected patients. As the awareness of a foreshortened life may be associated with grief and depression, it may also help patients to focus on what is important, and to motivate efforts to accomplish goals and reach clarity about concerns that really matter. Even if we cannot prolong life, we can help make life worth living.

Conclusion It is understandable that therapists might assume that people faced with disability, pain, and a threat to life might become depressed. But the presumption that all or even most people with HIV disease suffer from clinical depression is wrong and does a disservice to clients.

The data show that depression is neither more common among people with HIV infection nor likely to increase as HIV disease progresses.

While HIV-infected individuals may experience distress during the course of disease, depression is not “normal” for them. This is important for two reasons. It implies that people with HIV disease are more psychologically resilient than we may assume, and it suggests that when clinical depression does arise in a client, therapists should not dismiss it as usual and understandable but should instead treat it aggressively.

Clearinghouse: Depression References Alegria M, Vera M, Freeman DH Jr, et al.

HIV infection, risk behaviors, and depressive symptoms among Puerto Rican sex workers. American Journal of Public Health. 1994; 84(12): 2000-2002.

Atkinson JH, Grant I. Natural history of neuropsychiatric manifestations of HIV disease. Psychiatric Clinics of North America. 1994; 17(1): 17-33.

Drebing CE, Van Gorp WG, Hinkin C, et al.

Confounding factors in the measurement of depression in HIV. Journal of Personality Assessment. 1994; 62(1): 68-83.

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Harker JO, Satz P, DeL-Jones F. Measurement of depression and neuropsychological impairment in HIV-1 infection. Neuropsychology. 1995; 9(1): 110-117.

Herbert TB, Cohen S. Depression and immunity: A meta-analytic review.

Psychological Bulletin. 1993; 113(3): 472-486.

Kessler RC, Foster C, Joseph J, et al.

Stressful life events and symptom onset in HIV infection. American Journal of Psychiatry. 1991; 148(6): 733-738.

Jadresic D, Riccio M, Hawkins DA, et al.

Long-term impact of HIV diagnosis on mood and substance use—St. Stephen’s cohort study. International Journal of STD and AIDS. 1994; 5(4): 248-52.

Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with human immunodeficiency virus (HIV) infection using the Beck Depression Inventory: Disease processes and other potential confounds. Journal of Personality Assessment. 1995; 64(1): 86-100.

Perry SW. HIV-related depression.

Research Publications—Association for Research in Nervous and Mental Disease. 1994; 72: 223-238.

Rabkin JG, Rabkin R, Harrison W, et al.

Effect of imipramine on mood and

Depression, Antidepressants, and Sexual Function Bruce S. Victor, MD Allopathic medicine involves a series of trade-offs: the message to the patient is that one needs to endure a series of “side effects” as seeming payment for the salutary effects of a medication that relieves a more distressing problem. Before the advent of the new class of serotoninenhancing drugs, the somatic price for alleviating major depression was a plethora of discomforts, ranging from dry mouth to constipation, that came with tricyclic antidepressants. By contrast, the advent of the selective serotonin reuptake inhibitors (SSRIs)— fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and their progeny— seemed to promise relief without sacrifice.

In recent years, however, it has become increasingly apparent that the SSRIs cause significant adverse effects to sexual functioning: studies suggest that as many as 50 percent of patients taking SSRIs suffer from some sort of sexual dysfunction. While sexual side effects certainly occurred with the tricyclic antidepressants and with monoamine oxidase inhibitors, the seeming ubiquity of the SSRIs brings the issue of sexual side effects to the forefront.

Medications can reverse the sexual dysfunction caused by antidepressants such as Prozac, Zoloft, and Paxil.

The relationship between depression and sexual functioning can be complex. It is well-known that loss of sexual interest can be a manifestation of a major depressive disorder—and that effective antidepressant treatment can restore sexual interest and function. In addition, for many people who are strongly identified with their sexual function, any interference with it might cause feelings of sadness, grief, and loss of self-esteem, which are themselves depressive symptoms. The loss of sexual function for whatever reason also heightens fears of abandonment in current relationships as well as raises anxiety and, at times, feelings of hopelessness regarding the forging of future relationships.

Sexual Side Effects Both sexual function and mood depend upon the right amount of neurotransmitters as well as the balance between these neurological chemical messengers. The significant neurotransmitters for both mood and sexual function include serotonin, noradrenaline, acetylcholine, and dopamine. The SSRIs promote, in particular, the transmission of serotonin, which is especially important in mood stabilization. The enhancement of serotonergic function, however, can potentially lead to sexual side effects.

Antidepressant medication can affect sexual functioning in a number of different ways. First, any of these medications can decrease libido significantly, sometimes to the point of elimination. This effect can be seen in both men and women. Second, any class of antidepressants can lead to erectile difficulties among men. While erectile failure is gen-

enumerative measures of immune status in depressed patients with HIV illness. American Journal of Psychiatry.

1994; 151(4): 516-523.

negative illness-related network interactions to depressive mood. Social Science and Medicine. 1994; 39(11): 1555-1563.

Rabkin JG, Rabkin R, Wagner G. Effects of fluoxetine on mood and immune status in depressed patients with HIV illness. Journal of Clinical Psychiatry.

1994; 55(3): 92-97.

Targ EF, Karasic DH, Diefenbach PN, et al. Structured group therapy and fluoxetine to treat depression in HIVpositive persons. Psychosomatics.

1994; 35(2): 132-137.

Rabkin JG, Wagner G, Rabkin R. Effects of sertraline on mood and immune status in patients with major depression and HIV illness: An open trial.

Journal of Clinical Psychiatry. 1994; 55(10): 433-439.

Valente SM, Saunders JM. Management of suicidal patients with HIV disease.

Journal of the Association of Nurses in AIDS Care. 1994; 5(6): 19-29.

Siegel K, Raveis VH, Karus D. Psychological well-being of gay men with AIDS: Contribution of positive and

George Harrison, MD, UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884, 415-502-4818.

David Ostrow, MD, PhD, Community Health Behavior Program, University of Wisconsin, 1202 North Prospect Avenue, Milwaukee, WI 53202, 414287-4680.

Judith G. Rabkin, PhD, New York State Psychiatric Institute—Unit 35, 722 West 168th Street, New York, NY 10032, 212960-5762.

Robert H. Remien, PhD, HIV Center for Clinical and Behavioral Studies, 722 West 168th Street, New York, NY 10032, 212-960-2375.

Contacts See also references cited in articles in this issue.

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References Balon R, Yeregani V, Pohl R, et al. Sexual dysfunction during antidepressant treatment. Journal of Clinical Psychiatry.

1993; 54(6): 209-212.

Feder R. Reversal of antidepressant activity by cyproheptadine in three patients.

Journal of Clinical Psychiatry. 1991; 52(4): 163-164.

Herman J, Brotman A, Pollack M, et al.

Fluoxetine-induced sexual dysfunction.

Journal of Clinical Psychiatry. 1990; 51(1): 25-27.

Segraves R. Overview of sexual dysfunction complicating the treatment of depression: Effects of psychotropic drugs on human erection and ejaculation. Journal of Clinical Psychiatry.

1992; 4(2): 4-10.

Zajecka J, Fawcett J, Schaff M, et al. The role of serotonin in sexual dysfunction: Fluoxetine associated orgasm dysfunction.

Journal of Clinical Psychiatry. 1991; 52(2):66-68.

Jacobsen F. SSRIinduced sexual dysfunction. American Society of Clinical Psychopharmacology.

Progress Notes. 1994; 5: 1-4.

Authors Bruce S. Victor, MD is Director of Clinical Pharmacology at California-Pacific Medical Center in San Francisco and Associate Clinical Professor of Psychiatry at the University of California San Francisco. He has written and lectured widely on the assessment and treatment of mood disorders.

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erally the rule, at least one antidepressant, Trazadone, has been associated with priapism—persistent, abnormal erection— in a small but significant number of men.

Finally, these medications can cause profound difficulties not only in achieving orgasm, but also in orgasmic enjoyment.

In men, this last effect ranges from ejaculatory delay or absence to a decrease in the sensation of orgasm.

Before the advent of the SSRIs, it was thought that sexual side effects resulted from the inhibition of other neurotransmitters such as acetylcholine and, to a certain extent, noradrenaline. However, recent research appears to support the idea that the facilitation of serotonin-based systems may also be responsible for these side effects. Part of this reasoning comes from the clinical evidence that drugs that block serotonin transmission seem to be at least partially effective in restoring previous levels of sexual functioning.

Treatment of Sexual Dysfunction For some individuals, sexual dysfunction may be remedied merely by lowering antidepressant dosages. The obvious risk inherent in this approach is that the therapeutic effect of the medication may be decreased or lost, and there are many people for whom this is not an acceptable risk.

However, there are medications that can reverse sexual dysfunction. Perhaps the two most commonly used ones are cyproheptadine (Periactin) and yohimbine (Yocon). The former is actually a serotonin antagonist which was found to be effective in diminishing sexual side effects especially from the SSRIs. However, because it is a histamine blocker, it can be profoundly sedating and this effect often becomes predominant. Patients will voice their impatience with a remedy that they are instructed to take one hour before sexual activity only to be asleep within 20 minutes of ingestion. Further, in some instances, cyproheptadine, probably because of its serotonin-blocking effects, has also been reported to reverse the actual antidepressant or anti-obsessive effect of the SSRI itself.

Yohimbine enhances the transmission of epinephrine—another neurotransmitter—which, in turn, enhances sexual functioning presumably by increasing inflow of blood to erectile tissue and enhances sexual desire by increasing the activation of the cerebral cortex. While there has been no report that yohimbene reverses the salutary effects of antidepressant

medication, it may increase levels of panic anxiety in those patients susceptible to it.

It should also be noted that more frequent dosing is necessary if the target symptom is loss of libido rather than orgasmic or erectile difficulty.

Other biochemical stratagems have been applied to sexual dysfunction.

Because it is possible that the newer SSRIs block the activity of dopamine—another neurotransmitter—agents such as amantadine (Symmetrel), bromcriptine (Parlodel), and buspirone (Buspar), which enhance both dopamine and serotonin transmission, have been shown to have some effect in reducing sexual side effects of the SSRIs. Finally, because the newer antidepressants might exhibit a small anticholinergic effect that could have an adverse effect on sexual functioning, bethanecol (Urechline), which enhances transmission of choline, has also been reported to have some benefit.

For those patients for whom antidepressant dose reduction or administration of one of the antidotes described above does not work, switching antidepressants may be effective. One study reported significant improvement in sexual response when inpatients taking fluoxetine (Prozac) discontinued this medication in favor of the nonserotonergic, mildly dopamineenhancing antidepressant buproprion (Wellbutrin).

Conclusion The dramatic sexual side effects of medications that are seen as the great biochemical hope to depression is cruelly ironic. Given the ubiquity of depression where one of the cardinal symptoms is hopelessness, especially in the context of HIV disease, providers must handle the decline or loss of sexual functioning with both creativity and compassion.

Comments and Submissions We invite readers to send letters responding to articles published in FOCUS or dealing with current AIDS research and counseling issues. We also encourage readers to submit article proposals, including a summary of the idea and a detailed outline of the article. Send correspondence to: Editor, FOCUS UCSF AIDS Health Project, Box 0884 San Francisco, CA 94143-0884

Recent Reports Immunity, Bereavement, and Depression Kemeny ME, Winer H, Taylor SE, et al. Repeated bereavement, depressed mood, and immune parameters in HIV seropositive and seronegative gay men. Health Psychology. 1994; 13(1): 14-24.

(University of California, Los Angeles.)

Depressed mood may be a co-factor for HIV progression, but the relationship between bereavement and the immune system remains unclear, according to a small study of a Los Angeles subset of the MultiCenter AIDS Cohort Study (MACS). The study correlated depressed mood and immune parameters associated with HIV progression in nonbereaved seropositive men; however these correlations were inexplicably absent among seropositive men who had experienced the loss of a close friend to AIDS. Forty-five gay men who had lost one or more close friends in the past year to AIDS were matched by age and serostatus to 45 men who had not experienced recent loss.

The mean age of the sample was 38 and 39 years old, and all of the men were White. The Profile of Mood States (POMS) was used to assess “depressed mood” (not clinical depression), and most individuals did not report abnormally high levels of depressed mood.

Depression scores did relate to HIV status and bereavement, but in a surprising way. Among nonbereaved subjects, HIV-infected men had a statistically significant lower average depression score than uninfected men. Bereaved seropositive and seronegative men reported approximately the same average scores.

Correlating HIV status, bereavement, and depressed mood with immune parameters produced equally puzzling results. Among nonbereaved seropositive men, high depression scores were associated with predictable immunological changes related to advanced HIV infection, including significantly lower T-helper cell counts and T-killer cell counts.

But bereaved seropositive men exhibited no immune changes associated with depressed mood.

Among bereaved seronegative men, higher depression scores were correlated only with a lower percentage of CD16 NK (natural killer) cells, which is linked to HIV progression; there were no significant correlations for nonbereaved men.

Women with depressive symptoms were more likely than other women to engage in HIV-related risk behaviors.

Researchers hypothesized that a high POMS score in a bereaved individual may represent a grief response instead of depressed mood, a distinction that may be crucial to understanding the physiological effects of bereavement. The difference in results of bereaved and nonbereaved HIV positive men could also be explained if biological effects of bereavement are mitigated by psychological adaptation when repeated loss occurs.

Hopelessness and Injection Drug Use Steer RA, Iguchi MY, Platt JJ. Hopelessness in IV drug users not in treatment and seeking testing and counselling. Drug and Alcohol Dependence. 1994; 34(2): 99-103. (University of Medicine and Dentistry of New Jersey; and Hahnemann University, Philadelphia.)

According to a large clinical study, injection drug users seeking antibody testing had surprisingly low overall levels of hopelessness, given the probability of HIV infection via drug use.

Hopelessness, defined as “negative expectancies about the future,” is a symptom of depression and has been linked to suicidal behavior and ideation. Past studies comparing overall levels of hopelessness with HIV infection status have found no relationship between the two.

A sample of 2,379 injection drug users was evaluated using the Beck Hopelessness Scale (BHS)—which rates overall hopelessness on a scale of 0 to 20—for three dimensions of hopelessness: resignation to the futility of changing the future; rejection of the possibility of a better future; and acceptance of the inevitability of a hopeless future. Of the sample, 75 percent were men and 25 percent were women; and 78 percent were African American, 14 percent were Hispanic, and 8 percent were White. All of the participants sought HIV antibody testing and counseling, but none knew their serostatus when evaluated and none were in drug treatment.

Overall, 17.8 percent of the participants reported total BHS scores above nine, indicating risk for eventual suicide, and 24.5 percent reported current suicide ideation on the evaluation. Researchers theorized that seeking testing and counseling may have contributed to a sense of hope about the future.

Risk and Depression in Black Women Orr ST, Celentano DD, Santelli J, et al. Depressive symptoms and risk factors for HIV acquisition among black women attending urban health centers in Baltimore. AIDS Education and Prevention.

1994; 6(3): 230-236. (Johns Hopkins University; and Baltimore City Health Department.)

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FOCUS A Guide to

AIDS

Research and Counseling

Executive Editor; Director, AIDS Health Project James W. Dilley, MD Editor Robert Marks Staff Writer John Tighe Founding Editor; Advisor Michael Helquist Medical Advisor Stephen Follansbee, MD Marketing Michal Longfelder Design Saul Rosenfield Production Jennifer Cohen Stephan Peura Kelly Van Noord Circulation Sandra Kriletich Interns Julie Balovich Shirley Gibson Mark Kuhnle FOCUS is a monthly publication of the AIDS Health Project, affiliated with the University of California San Francisco.

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A Baltimore study of women’s health centers found that women with depressive symptoms were significantly more likely than women without depressive symptoms to engage in HIV-related risk behaviors.

The predominantly African-American sample of 173 women was comprised of clients from two Baltimore health centers in economically disadvantaged areas of the city. Participants responded to a brief questionnaire assessing risk factors and depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D scores above 16 indicate significant depressive symptoms.

Approximately half of the sample scored 16 or higher on the CES-D, with a median score of 15. Women who scored 16 or higher reported more risk exposure through their sex partners than did the women with scores of 15 or lower.

Distress in Homosexually Black Americans Cochran SD, Mays VM. Depressive distress among homosexually active African American men and women. American Journal of Psychiatry. 1994; 151(4): 524-529. (California State University, Northridge; and University of California, Los Angeles.)

Homosexually active African Americans experience higher levels of depressive distress than have been shown in previous studies of African Americans and White gay men, according to a large Los Angeles survey of gay and bisexual men and women.

The survey used the CES-D and a scale rating the frequency of life problems, including suicidal thoughts. Researchers received responses from 603 women and 829 men, all African-American. Of this sample, 84 percent of the women and 80 percent of the men stated that they considered themselves to be gay or lesbian; 11 percent of the women and 14 percent of the men considered themselves bisexual; and 5 percent of both the women and the men identified themselves as neither homosexual or bisexual, but currently homosexually active.

Based on the results of previous surveys, subjects reported unexpectedly high levels of depressive distress. The mean CES-D score in this survey was 13.6, in contrast to earlier studies that ranged from 9.9 to 11.5. Female respondents had an estimated mean score of 14.7. Male respondents had a total mean score of 12.8 with four subgroup scores: 16.7 for symptomatic HIVinfected men, 12.8 for asymptomatic HIV-infected men, 12.7 for uninfected men, and 11.4 for men whose HIV infection status was unknown. Symptomatic HIVinfected men also reported the highest prevalence of suicidal thoughts.

Depression in Low HIV Prevalence Areas Perkins DO, Stern RA, Golden RN, et al. Mood disorders in HIV infection: Prevalence and risk factors in a nonepicenter of the AIDS epidemic.

American Journal of Psychiatry. 1994; 151(2): 233236. (University of North Carolina, Chapel Hill; and University of Florida, Gainesville.)

As has been shown among people in AIDS epicenters, a North Carolina study found that major depression was common among both seronegative and asymptomatic seropositive gay men in an area of low HIV prevalence.

The Coping in Health and Illness Project investigated neuropsychiatric, psychosocial, and psychoimmunological aspects of HIV infection among 169 subjects—71 seronegative gay men and 98 asymptomatic seropositive gay men. Most subjects in both groups were White.

Among the HIV-infected participants, 8 percent suffered from major depression at the time of the study; and 3 percent of the uninfected participants had current major depression. The lifetime prevalence of major depression, a significant risk factor for current depression, was 29 percent of the HIV-infected sample and 45 percent of the uninfected sample. A community sample showed 2 percent prevalence of major depression in the general population, with a lifetime prevalence of 3 percent.

Next Month Drug abuse and treatment often arise in some way for women with HIV disease. Yet most drug treatment approaches rely on models developed by men and for men. In the September issue of FOCUS, Gillian Walker, ACSW of the Ackerman Institute in New York identifies some of the short-comings faced by women with HIV disease who access traditional drug treatment programs. She focuses her discussion on a family-centered therapeutic approach that is more tailored to the lives of these women.

Also in the August issue, Suzanne Ostermann, a consultant on substance abuse treatment who is based in southern California, critiques programs for women from a historical perspective.

She looks at factors such as the traditions of Alcoholics Anonymous, the bias in government funding, and the trend toward cost containment and relates them to inappropriate treatment for HIV-infected women.

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