Depression and HIV Disease

JANAC Vol. 14, No. 2, March/April 2003 ARTICLE 10.1177/1055329002250993 Valente / Depression and HIV Disease

Depression and HIV Disease Sharon M. Valente, RNCS, PhD, FAAN

Depressive disorders are common among 20% to 32% of people with HIV disease but are frequently unrecognized. Major depression is a recurring and disabling illness that typically responds to medications, cognitive psychotherapy, education, and social support. A large percentage of the emotional distress and major depression associated with HIV disease results from immunosuppression, treatment, and neuropsychiatric aspects of the disease. People with a history of intravenous drug use also have increased rates of depressive disorders. Untreated depression along with other comorbid conditions may increase costly clinic visits, hospitalizations, substance abuse, and risky behaviors and may reduce adherence to treatment and quality of life. HIV clinicians need not have psychiatric expertise to play a major role in detecting, screening, treating, and preventing major depression. Screening tools improve case finding and encourage early treatment. Effective treatments can reduce major depression in 80% to 90% of patients. Clinicians who mistake depressive signs and symptoms for those of HIV disease make a common error that increases morbidity and mortality. Key words: depression, HIV

Depression is one of the most common reasons for psychological evaluation and treatment of people living with HIV infection. The prevalence of major depression in HIV infection typically ranges from 22% to 36% (Bing et al., 2001; Fernando et al., 1998; Rabkin, Wagner, & Rabkin, 1999). Many psychological challenges accompany the diagnosis and progression of HIV disease (Antoni & Schneiderman, 1998). Among the most distressing events are receiving a diagnosis of HIV, learning of the death of a lover or friend with HIV, disease exacerbation, treatment

failure, and HIV symptoms without AIDS. Stressful life events may also increase depressive symptoms as well as alcohol and substance abuse. Inability to cope with rising stress can also usher in a loss of selfesteem. As stress increases, high-risk sexual behavior and other negative health behaviors may escalate. Depression complicates the treatment and physical status of a person with HIV disease. Although protease inhibitor antiretroviral medications decreased depression, rates of depressive symptoms continue among 46% to 52% of those in treatment (Low-Beer et al., 2000). Without treatment, depression sentences people to weeks and months of costly and needless emotional suffering. The costs of depression (hospital and outpatient treatment, medications, suicide, and lost productivity) exceeded $44 billion in 1990 (Simon, Von Korff, & Barlow, 1995). Thompson and Richardson (1999) found that depressed patients had higher costs of medical services compared with their nondepressed peers. Leslie and Rosenheck (1999) analyzed inpatient claims data and found that treating depression reduced inpatient costs per treated patient (44%). Furthermore, depression results in productivity losses via increased rates of absenteeism and short-term disability as well as impaired work performance (Thompson & Richardson, 1999). Saunders (1998) reported that regardless of the severity of their HIV disease, her study participants identified depression as the second or third most important and bothersome symptom they experienced. In Saunders’s (1998) study, Frederick articulately described his involvement with activities when he was depressed: Sharon M. Valente, RNCS, PhD, FAAN, is an assistant professor at the University of Southern California, Los Angeles, California.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 14, No. 2, March/April 2003, 41-51 DOI: 10.1177/1055329002250993 Copyright © 2003 Association of Nurses in AIDS Care

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(When I’m depressed), I cancel everything—I don’t go to my support group and I cancel my therapy. I don’t want to get cleaned up. I don’t want to go anyplace or do anything. I don’t really want to talk to anybody very much. Depression feels like—I stare at the ceiling, and I’m not motivated to do anything. I’m generally interested in a lot of things, but when I’m depressed I don’t feel like doing much of anything—it adds to my lethargy. It’s an “I don’t care syndrome” and I tell myself I just don’t have the energy to do what I need to be doing. Nurses and psychologists are often the first to detect the sadness, discouragement, guilt, hopelessness, and death wishes that often signal depression. Depressed patients challenge nurses to detect depression and to advocate for better symptom management. The nurse can offer empathic listening and supportive psychosocial counseling to improve coping, selfesteem, education, and social support. Untreated depression can lower life expectancy and treatment adherence, and is associated with an increased risk of cardiac disease, substance abuse, and suicide (Simon et al., 1995). In this article, we discuss major depression among people with HIV disease. Barriers to diagnosis, incidence, etiology, screening, and treatment of major depression are also described. The vignettes from the authors’ research, presented in Appendices A and B, illustrate typical depressed people with HIV. Because these patients are reluctant to spontaneously disclose their emotional distress unless they are asked, clinicians need skill in eliciting and detecting depressive symptoms. The clinical challenges are overcoming barriers to diagnosis, early detection, and differentiating the symptoms of depression from somatic symptoms of HIV disease.

Barriers to Diagnosis of Major Depression Common myths about depression constitute barriers to diagnosis and treatment. Depression is a common and expected reaction to a life-threatening diagnosis. Researchers report (Van Gorp & Buckingham, 1996) that not all people with

HIV are depressed, and empirical data suggest that treatment of depression improves medication adherence and motivation to improve health. If depression is bothersome, the patient will report this problem to the clinician. Both patients and clinicians alike hesitate to bring up the topic of emotional distress and tend to focus on physical problems. Patients fear that the clinician will discount emotional problems or will conclude that the patient is crazy. People with HIV disease often try to focus on the positive and display an optimistic attitude. Clinicians may hesitate to ask about depression because they feel they lack expertise with psychological issues. Neither Harold nor Freddy in their vignettes (see Appendices A and B) reported their depression to care providers, but both would confirm their depressive symptoms if asked. Suicide is an understandable choice for people with HIV disease. Although the current public and professional debate over the right to hasten death rages, depression may be the precipitant for suicidal thoughts. With treatment, these suicidal thoughts and death wishes often recede (Bongar et al., 1998; Marzuk et al., 1988). In his vignette, Harold was consistently suicidal and had several lethal plans for suicide but could not carry them out. According to the research data, depression in HIV populations is also highly correlated with desire for hastened death (Rosenfeld et al., 1999). The depressed patient’s poor cooperation with treatment may be considered evidence of laziness, manipulation, or attention seeking. Depression leaves little energy or motivation for self-care or cooperation. Low energy level, lack of interest in care, and negative responses resulting from depression are often misinterpreted and labeled as noncompliance. Clinicians may lack expertise in eliciting psychological symptoms. They may feel that the patient’s emotions are private, and they may feel ill at ease in talking about feelings, sadness, and hopelessness. Often, clinicians feel poorly prepared to respond empathically and therapeutically to depressed patients (Valente & Saunders, 2000).

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Incidence Most HIV-positive individuals appear to be psychologically resilient. However, Ciesla and Roberts (2001) conducted a meta-analysis of published studies examining depression and reported that the frequency of major depression was nearly 2 times higher in HIVpositive participants than in HIV-negative comparison participants. Rates of depression do not appear to be correlated with sexual orientation or stage of disease. Although the lifetime rate of major depressive disorder in the United States is 13% (Kessler, Stang, Wittchen, Stein, & Walters, 1999), it raises to 21% to 61% among seropositive men with intravenous drug use (Leslie & Rosenheck, 1999). The rates of depression among all terminally ill patients range from 13% to 26% (Martin & Jackson, 2000) as compared with rates of 22% to 32% among HIV-positive individuals.

Etiology and Pathophysiology of Depression The etiology of major depression is complex and poorly understood both in general and among HIVpositive individuals. The pathophysiology of major depressive disorder is most probably heterogeneous, and patients display diverse symptom profiles, ranging from anxiety to psychomotor retardation. Videbech (2000) studied a large population of patients and reported that increased cerebral blood flow in the hippocampus, measured using positron emission tomography technique, was highly correlated with these clinical dimensions. Because large-scale studies have been lacking, consensus regarding etiology and functional brain abnormalities in this disorder has not yet occurred (Videbech, 2001). Depression is also biologically based and associated with alterations in cortisol, testosterone, and serotonin metabolism. Neurotransmitters (e.g., norepinephrine, serotonin, and dopamine) regulate mood, movement, blood pressure, and postsynaptic impulse conduction. Nerve impulses cause presynaptic neuron vesicles to secrete these chemicals, which, across the neuronal synapse, connect to specific receptor sites and continue impulse co n d u ct i o n (Valent e & S aunders, 1997). Norepinephrine, serotonin, and dopamine excite transmission while gamma amino butyric acid system

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and other chemicals inhibit neurotransmission in the brain; a certain level of amines and/or receptor sensitivity to catecholamines regulates mood. A deficit in receptor sensitivity or a depletion in amine synthesis or storage leads to mood disorders (Tucker, 1996). Among HIV-positive individuals, depressive symptoms may follow the etiology described above and may also emerge because HIV infects the central nervous system and may damage neurons and impair cognition. Medication side effects and nutritional deficiencies as well as previous depression, losses, decreased social support, and advanced disease also increase predisposition to depression among HIVpositive individuals. Depression is also a common response to major life events (e.g., severely disrupted interpersonal relationships, life-threatening illness, death of loved ones, and profound threats to selfesteem). HIV-positive individuals report that their feelings of helplessness, hopelessness, loneliness, and utter despair can lead to clinical depression and suicide (Valente & Saunders, 1997).

Screening Nonpsychiatric clinicians often lack skill in detecting major depression. McDonald, Passik, Dugan, and Rosenfeld (1999, p. 396) found that nurses underestimated the level of depressive symptoms in patients who were moderately or severely depressed. “Nurses were most influenced by crying, depressed mood, and medical factors (e.g., anorexia, insomnia, constipation, fatigue) that are not reliable indicators of depression in a medically ill population.” Martin and Jackson (2000) reported in their study that most physicians and nurses detected only about 49% of depressed patients on a medical service, and only 2 (10%) patients received appropriate treatment for depression. In the vignette, Harold’s (see Appendix A) depression was not well evaluated, treated, or monitored. He was put on selective serotonin reuptake inhibitor (SSRI) antidepressants for 3 to 4 months, although 6 months to 1 year should be recommended and adherence monitored. Researchers (Bongar et al., 1998) recommend the use of reliable diagnostic criteria and screening tools to detect major depression. Often, screening instruments are available from pharmaceutical companies that carry antidepressant medications.

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Table 1.

Common Depression Screening Instruments, Characteristics, and Scoring for Adults

Instrument Yesavage (Sheikh & Yesavage, 1986) Beck Depression Inventory (BDI) Center for Epidemiological Studies–Depression Scale (Radloff, 1977) Hamilton Rating Scale (Corcoran & Fischer, 1987) Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1976)

Characteristics

Scoring

An easily administered 30-item tool with yes/no answers. A shorter form exists. It omits somatic symptoms and was specifically designed for elderly people. Patients rate cognitive, affective, and somatic symptoms on a brief, easily administered 21-item self-report scale. With high reliability and validity. A 20-question self-report scale with high reliability and discriminant validity. Gender bias may exist in some items. Scale has been used in general population and community samples of people with cancer. Clinicians rate 25 items from psychic and somatic clusters on a 5point scale (e.g., sadness, guilt, suicide, anorexia, insomnia, etc). Somatic items = 52% of total score. A 20-item true-false scale of self-report items about pessimism about the future. It differentiates suicide threats, attempters, and controls and has three factors, an internal consistency of .93 (Kuder-Richardson), and a 91% sensitivity for inpatients and 94% for outpatients.

Each yes answer accrues 1 point, and the score is totaled. For the long form, a score of 10 or less is normal. ≤10 = normal. Cognitive/affective items best indicate depression in medically ill. Total score is sum of 0 to 3 points per item. A cutoff of 16 or greater is used to identify major depression.

Gives more credit to somatic symptoms than the BDI and can give low specificity and false positive results. Measures different aspects than the BDI. One point for each item marked in the direction of pessimism. The sum indicates suicidality among adults, but reliability for adolescent minority females lacks verification.

SOURCE: Created by author and adapted from Valente and Saunders (1997).

Screening questionnaires detect depressive symptoms, establish a baseline, and gather objective evidence. Table 1 lists questionnaires to detect depression that are reliable, easily completed, and easily scored. Two of the most frequently used tests are the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies–Depression Scale (CES-D). The BDI (Wright, Thase, Beck, & Ludgate, 1993) contains 21 items about depression and two questions about suicide. Patients answer each question on the BDI by rating the severity of that symptom (e.g., weight loss, fatigue, anorexia, sadness, and thoughts of suicide). Another reliable and valid questionnaire, the CES-D, has 20 items. It is often used in community settings with people with cancer (Radloff, 1977). The Beck Hopelessness Scale (J. G. Beck & Stanley, 1997) evaluates suicide risk. When patients score above the norm on any screening questionnaire, a thorough assessment and a mental status evaluation with suicide risk is needed. Screening can also detect anxiety (e.g., generalized anxiety, panic disorder or social phobia, or substance abuse), which often accompanies depression in this population.

Evaluation A mental status evaluation explores symptoms, suicide risk, strengths, concerns, and identifies the nature,

duration, and precipitants of depression and other psychiatric symptoms. A Folstein mini–mental status exam helps detect dementia that mimics depression. Data from a patient’s history (e.g., stress, coping, mental health problems, substance use, medications, and caffeine) can suggest remediable causes of depression. Depression may stem from depressive side effects of medications (see Table 2), alcohol abuse, or electrolyte imbalance. Medications that precipitate depressive symptoms can often be changed. Clinicians need to rule out physical causes of depression such as medical conditions, substance abuse, and potential drug interactions. Sometimes, a drug, major life event, grief, bereavement, or physical abuse triggers depression (Valente & Saunders, 1997). In addition, an evaluation of suicide risk is essential.

Diagnosis Diagnosis of depression is challenging because many of the hallmarks of depressive disorders also emerge from medical disorders such as HIV. Hence, the somatic symptoms of depression are difficult to separate from the effects of HIV. Cognitive and mood symptoms (e.g., hopelessness, helplessness, guilt, low self-esteem, and anhedonia) most accurately and reliably signal major depression in medically ill patients. Clinicians and patients alike may discount emotional

Valente / Depression and HIV Disease Table 2.

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Medications With Depressive Side Effects

Classification Analgesics/ anti-inflammatory Anticonvulsants Antihypertensive agents Anti-infectives Antimicrobials Antineoplastics Anti-Parkinson agents Antiretrovirals Hormones Immunosupressives Neuroleptics Sedatives/tranquilizers Stimulants Other

Medications ibuprophen, indomethacin, baclofen, cocaine, opiates (morphine, codeine), pentazocine, phenacetin, phenylbutazone Carbamazepine, ethosuximide, phenobarbital, phenytoin, primidone Clonidine, guanethidine, hydralazine, hydrochlorothiazide, methyldopa, propranolol, reserpine, spironolactone Acyclovir, azidothymidine (AZT), cycloserine, ethionamide, isoniazid, metronidazole, trimethoprim/ sulfamethoxazole Ampicillin, cycloserine, dapsone, griseofulvin, metronidazole, nalidixic acid, nitrofurantoin, procaine penicillin, streptomycin, sulfonamide, tetracycline Alpha interferon, azathioprine, 6-azauridine, L-asparaginase, bleomycin, cisplatin, cyclophosphamide, doxorubicin, mithramycin, vinblastine sulfate, vincristine Amantadine, bromocriptine, levodopa Sustiva ACTH, corticosteroids, estrogens/oral contraceptives Corticosteroids Fluphenazine, haloperidol, prochlorperazine Barbiturates, chloral hydrate, diazepam, ethanol, flurazepam, major tranquilizers, triazolam, alprazolam Amphetamine (abuse), diethylpropion, fenfluramine (abuse), methylphenidate Metoclopramide hydrochloride

SOURCE: Adapted from Valente and Saunders (1997). NOTE: Bold indicates a high incidence of depression.

symptoms or attribute them to HIV or doubt that emotional symptoms exist unless they have objective evidence. Major depression occurs when either depressed mood or markedly diminished pleasure in most activities and six other symptoms (e.g., significant weight loss, insomnia or hypersomnia, fatigue, worthlessness or excessive guilt, psychomotor retardation or agitation, thoughts of death and/or suicide, and diminished concentration) occur daily for 2 weeks (American Psychiatric Association, 1994). Depression must cause clinically meaningful impairment, be unrelated to physiological effects of a general medical condition or substance, and not occur within 2 months of the death of a loved one. When people have a life-threatening illness such as HIV disease or cancer, the somatic symptoms (e.g., weight loss, fatigue, anorexia, insomnia) may stem from either the physical disorder or depression. The psychological symptoms (e.g., sadness and anhedonia) more reliably indicate major depression in medically ill populations than somatic symptoms. Depressed or sad mood should be differentiated from feeling physically down; lack of interest in activities

should not be confused with pain or symptoms that reduce activity, and feelings of worthlessness should be differentiated from changes in body image or disappointment at lowered performance due to HIV. If the patient has many of these symptoms but not enough to qualify for a diagnosis of major depression, the patient may have an atypical depression or another depressive disorder with less intense symptoms. In the vignettes, both Freddy and Harold satisfy the criteria for major depression with 3 months of somatic, cognitive, and mood symptoms. Treatment effectively relieves 80% to 90% of major depression (Bongar et al., 1998). In the process of establishing a diagnosis of depression, the clinician needs to consider whether the symptoms might be caused by drug use including alcohol, cocaine, and crystal methamphetamine and cognitive disorders such as dementia or acute confusion.

Treatment Modalities Managing depression involves addressing psychosocial and biomedical issues, medications, psychotherapy, and education. Antidepressants are a

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mainstay of treatment, and the challenge is to match the patient and the side-effect profile. Because HIV disease is a life-threatening illness, the person may contemplate feelings of doom, anger, fear, and the need to make major changes in lifestyle. Coping with the psychosocial aspects may involve disclosing the diagnosis, changing sexual practices, managing guilt over transmitting infection, and fear of death. Counseling and education also focus on denial, distress, risky behavior, self-efficacy, control, coping strategies, and social support. Many people with HIV disease face painful stigma from friends, colleagues, and family. Harold (see Appendix A) felt that his friends, colleagues, and family had demeaned him and wished he were dead. He coped with his pain, isolation, and loneliness with alcohol and crack.

Antidepressant Medications Antidepressant medications reduce depression for roughly 80% of people. Common drugs are SSRIs, tricyclic antidepressants, and monoamine oxidase inhibitors, which may be used when other drugs fail and have more side effects and dietary restrictions. Medications aim to reduce the depressive symptoms with the fewest side effects (Silverman, 1998). SSRIs. First marketed in the United States in 1989, fluoxetine became one of the most prescribed medications with its prompt action and low side-effect profile. SSRIs are the cornerstone of treatment for adult depression, account for the largest market share of antidepressants, and have comparable efficacy to other new antidepressants and tricyclics. SSRIs are approved for major depression, panic disorder, social phobia (paroxetine), post-traumatic stress disorder (sertraline), and generalized anxiety disorder (venlafaxine). Most patients tolerate SSRIs well, and the initial side effects (e.g., hyperactivity, insomnia, nausea, headache) subside in a few weeks (See Table 2). People using SSRIs need to report sexual (e.g., impaired libido or ejaculation) and other side effects. SSRIs are safer than tricyclics for suicidal patients partly because an overdose of SSRI medication is not lethal. Clinicians can select the antidepressant so its side effects (e.g., sedation) reduce bothersome symptoms

(e.g., insomnia). Tricyclic antidepressants (TCA) can also relieve neuropathic pain. Clinicians need a baseline electrocardiogram for those older than age 45 before prescribing TCAs, which can cause conduction defects. Patients need education about TCAs, management of immediate side effects (e.g., sedation, orthostatic hypotension), and reminders that the therapeutic effects may take 2 to 3 weeks. If one medication produces bothersome side effects, clinicians can prescribe another. Alternative medications have included stimulants, lithium carbonate, anticonvulsants, and hormones. Electroconvulsive therapy (ECT) is also a safe and effective treatment. However, Geddes and Butler (2002) found no adequate systematic review of possible adverse cognitive effects of ECT. ECT produces some amnesia for the 6 months before and after treatment. Typically, ECT is useful when medications are ineffective, contraindicated, or unacceptable and when the patient has suicidal or psychotic features (Geddes & Butler, 2001). But follow-up with antidepressant medications is typical.

Nonpharmacological Interventions Education Combined cognitive-behavioral therapy, education, counseling, and self-management techniques effectively treat depression. Education helps the client understand the disorder and develop coping strategies. Take-home materials that are found in psychological catalogs, local bookstores, or libraries include audiotapes and videotapes or computer programs to help clients learn relaxation, breathing, assertiveness, and selfcalming skills. Treatment often includes skill training and increased resources to help cope with unemployment or disability. Many undergraduate psychiatric nursing texts describe cognitive behavioral techniques, and nurses in inpatient and ambulatory care settings can use these in addition to education, relaxation, training, and skill building. Education can also help families and supportive others provide effective support and encourage constructive activities. In the vignettes of Harold and Freddy, (Appendices A and B), the supportive others needed to learn not to increase dependence unnecessarily and to help both

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men be as independent as possible. Education can also clarify which symptoms were related to depression and which symptoms might be discussed with his physician because treatment for HIV-related fatigue might need to be considered. The experienced clinician or advanced practice nurse will be more likely to provide individual and group therapy using cognitive behavioral therapy and other modalities. Cognitive Therapy Evidence shows that cognitive psychotherapy with antidepressants has been more effective than either treatment alone (Geddes & Butler, 2002). Cognitive therapy is an effective, directive, time-limited approach to helping change irrational thoughts, assumptions, and beliefs (J. G. Beck & Stanley, 1997). Depression arises from a negative view of the world and from automatic and negative thinking patterns (e.g., the future is bleak, the world is barren, and the self is worthless) (J. G. Beck & Stanley, 1997). Cognitive therapy explains how irrational and negative thinking patterns (e.g., “I have to be perfect or no one will love me”) lead to depression. Irrational fears about death, being unloved, or survivor guilt may cause needless distress and can interfere with treatment and quality of life (e.g., “If I tell them I’m depressed, they will lock me up”). Cognitive reframing helps the patient review the automatic thoughts and learn to control these thoughts by distraction, discussion, positive self-talk, or relaxation. Cognitive therapy focuses on here and now, problem solving, and rational thinking. It can help a group or individual meet psychological, educational, and social support needs (Greenberger & Pedesky, 1995; Wright et al., 1993). Cognitive therapy includes discussing negative or irrational thoughts that influence disclosure of HIV status, end-of-life issues, survivor guilt, and sexual behavior. Cognitive distortions often surround the potential risk of telling family and loved ones of an HIV diagnosis and the fears of rejection and abandonment. Such secrets cause intense pain, distress, and alienation and sharing the issue in group sessions reduces alienation and invites stories of coping. Some people have never disclosed their diagnosis except to their treating physician and have not talked with others who are HIV infected. Patients can benefit

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from using cognitive techniques to reexamine fears such as fear of telling their families of the diagnosis. Cognitive appraisal involves identifying typical irrational beliefs and automatic thought patterns such as overgeneralizing (e.g., “Pain medications never work”), personalizing, catastrophizing (e.g., “My family will reject me and I’ll die alone”), and forming negative conclusions (Padesky & Greenberger, 1995). People can learn to correct overgeneralizations or catastrophic expectations (e.g., “No one will love me if they know I’m HIV positive”) (Greenberger & Pedesky, 1995). Cognitive techniques include questioning idiosyncratic meanings, reevaluating automatic conclusions, examining options and alternatives, and reattributing responsibility for things beyond one’s control. Most patients also need to talk about their feelings, values, and perceptions related to death and dying. Themes of loss emerge when people talk about giving up their occupation, financial resources, homes, and pastimes. Unresolved grief often relates to friends’ deaths and end-of-life preferences. Experiences with a friend’s death open the discussion of end-of-life options (e.g., living will) to ensure that one’s choices about life support, feeding tubes, and ventilators are heeded. Patients may also report feeling stigmatized, alienated, or judged negatively by caregivers. Some people are sensitive to a caregiver’s distance, failure to shake hands, and attitude (e.g., “He never looks at me, just asks questions and faces the computer”) and interpret these as caustic, judgmental, painful narcissistic injuries, and nonprofessional. The painful sense of rejection in these encounters needs to be recognized and validated, and the validation may open the discussion to ways of coping. Group outpatient therapy helps individuals with significant psychological symptoms and needs. In a meta-analysis, groups were at least as effective and sometimes more effective than individual treatment and more efficient because more patients are treated for the same cost (Ciesla & Roberts, 2001). Health-Promoting Activities Lovejoy and Matteis (1997) suggested that patients contemplate and participate in health-promoting activities (e.g., exercise, nutrition, and graded task management), set realistic goals, and recognize their

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negative and distorted perceptions. Depending on the person’s level of activity, phone calls, Internet communications, music, and dial-a-prayer can be supportive. Diverse strategies such as restorative yoga and meditation can improve well-being. Aerobic exercise is an approach that has reduced depressive symptoms. Initially, Freddy (see Appendix A) was not interested in anything and just wanted to die. The nurse discovered that he had been interested in computer e-mail and art but worried that the peripheral neuropathy might interfere with art work. With some encouragement, he was willing to meet with a computer coach to teach him email and an art therapist who could help him with art work. The art therapist was part of a volunteer organization that helps people with life-threatening illnesses.

Table 3.

Research-Based Clues to Suicide

Psychiatric diagnosis: depressive illness Alcoholism, drug abuse Suicide ideas, messages, talk, preparation Prior suicide attempts Lethal methods Isolation, living alone, loss of support Hopelessness, cognitive rigidity Being an older, White male Modeling suicide in the family, genetics Work problems, economics, occupation Marital problems, family pathology Stress, life events Anger, aggression, irritability Physical illness: (e.g., cancer, cardiorespiratory disorders, HIV positive, renal dialysis) SOURCE: See Bongar et al. (1998) and Valente (1994).

Monitoring Suicide Risk Depression in HIV populations is also highly correlated with desire for hastened death (Rosenfeld et al., 1999). Clinicians need to vigilantly monitor suicide risk among high-risk groups (e.g., people with depression, HIV disease, cancer, substance abuse, and other psychiatric disorders) (Bongar et al., 1998). Clinicians need to evaluate suicide clues and messages (e.g., comments about or threats of suicide) that reflect suicide risk. Table 3 presents research-based clues to suicide. About 80% of patients tell a nurse or physician before they attempt suicide (Bongar et al., 1998). However, many clinicians may not recognize the seriousness of these threats. Verbal suicide messages communicate a distressing situation or a strong emotional state (e.g., love and hate) and often suggest a restricted cognitive state in which the person cannot consider alternatives. Suicide messages may be direct (“I can’t live with this dyspnea anymore; how much morphine will end my suffering?”) or indirect (e.g., “I may go to Oregon or contact Dr. Kevorkian”) (Valente, 1994). Retrospective studies provide scant information about suicide among the terminally ill. Chochinov (2000) found that 44% (89 of 200) of terminally ill patients occasionally wished that death would come soon, and 9% reported a serious and pervasive wish to die. The desire for death is often linked with uncontrolled physical pain or distressing symptoms and poor social support, and for 59% of patients, it is linked with depression. Emanuel et al. (2002) found that 25% of

patients with a life-threatening diagnosis thought of asking their physician for euthanasia or assisted suicide. J. G. Beck and Stanley (1997) asserted that feelings of hopelessness about the future are the best indicator of suicide.

Summary Major depression can be a recurring and disabling illness that typically responds to brief cognitive psychotherapy, antidepressants, and social support. It is one of the most commonly overlooked psychiatric disorders associated with diagnosis and treatment of HIV disease. Major depression may occur twice as often in HIV-positive individuals as in the general population and 22% to 61% more often among HIV-positive individuals who are intravenous drug users. Although depression is common among those with HIV disease, many clinicians neglect to ask patients about depressive signs and symptoms, including suicidal ideas and threats. Diagnosis is also overlooked because patients may be too embarrassed to report emotional symptoms. Untreated depression can lower life expectancy, treatment adherence, or immune function and can increase the risk of suicide. Routine use of screening measures helps detect those at risk for depression. Evaluation of depression rests on a review of history, symptoms, mental status, and screening tests; an understanding of how the patient is responding to the

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HIV disease; and its treatment. Evaluating hopelessness and negative thinking patterns is important. Although research data are scant, studies suggest that approximately 15% to 20% of people with a chronic medical illness will commit suicide, and the rates in patients with HIV and AIDS have been higher (Marzuk et al., 1988). Therefore, monitoring suicide risk is essential. Depression responds well to a combination of antidepressant medications, cognitive psychotherapy, and social support. All members of the HIV treatment team can use cognitive strategies and education to help people to recognize and reduce automatic negative thinking patterns and suicidal ideas.

Appendix A Vignette of Harold Harold is a charming and articulate 45-year-old African American gay man with HIV disease who loves art, literature, music, golf, gourmet food, and travel. He grew up in the South where church, status, masculinity, and family were the center of life. He always felt isolated in a family in which he was constantly criticized, manipulated, and demeaned. He left home early to find freedom and supportive friends. He always yearned for empathic parents who loved and accepted him. He is self-sufficient and completed college, but he feels isolated and alienated and struggles with major depression. He has been treated with antidepressant drugs but not psychotherapy. Many of his close friends and family have died. He feels he has not worked to his potential, and due to alcohol and drug abuse, he has lost his home and art collection. He has few friends and feels depressed, sad, alone, and anxious. He feels aggressive occasionally and worries that he might not be able to control his angry impulses. He says it is difficult to go to work and church and that he just goes through the motions. He is not sure that life is worth living. When he takes drugs and drinks, he does not feel depressed, but now that he has been sober for a few months, he feels more immobilized by his depression (Valente & Saunders, 1996).

Course of Treatment Harold was diagnosed with HIV about 10 years ago when his T cells were very low and he nearly died from pneumonia. However, he responded to antiretroviral and

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protease inhibitor medications that increased his T cells and stabilized his viral load.

Psychosocial Data Harold hoped that the treatment, faith, and a sense of humor would sustain him and he could “turn it over to God” and be healed. He thought of the HIV as a test of faith. However, he was unhappy when he had to quit work and was eager to return to work. He had not told his family of his HIV disease because “they are very fundamental Christians who won’t understand and don’t need to know. I don’t want them to have to take care of me.” He was a private man who told few others of his disease, but he thought he might tell his brother. He thought that the HIV disease caused his fatigue, sadness, and depression and initially did not think his depression was treatable. As his depression worsened, he became more afraid of being a burden on his family, felt hopeless, and thought about suicide as a way out of suffering.

Evaluation and Management of Major Depression Harold scored a 35 on the Beck Depression Inventory (BDI) and endorsed the two suicide items. Subsequently, his depression was confirmed by his symptoms during a clinical interview. He wanted to know about treatments for depression with counseling and medications. He began antidepressants and cognitive psychotherapy. Harold responded well to cognitive therapy and clarified the notion that if he were a better Christian, he would not be punished for these symptoms. His major therapeutic work related to grief, family relationships, sadness, suicidal ideas, and end-of-life issues.

Outcomes With therapy and antidepressants, Harold’s symptoms and BDI score decreased to 12. With a course of selective serotonin reuptake inhibitors, education, and cognitive therapy, his laughter, sense of humor, and energy returned. He returned to work. His suicide risk decreased over time. He said he no longer wanted to kill himself. He returned to participating in activities he enjoyed, joined a men’s support group, and became an active volunteer with the local men’s chorus and maintained close contact with his family. Unfortunately, when he improved, he was taken off the antidepressants prematurely, and his symptoms returned.

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Appendix B Vignette of Freddy Freddy is a 52-year-old Caucasian man with HIV disease who lives alone and has a full-time attendant. Freddy has advanced chronic obstructive pulmonary disease and diabetes. He relies on oxygen. His leg and back pain and peripheral neuropathy keep him immobilized, he smokes constantly, and he wants help to commit suicide. Freddy does not take his HIV medications, and he filters what he tells his physicians. He also has memory loss and poor short-term memory. Because most of his friends and lovers have died, he has few contacts. Despite his efforts, he has not gotten enough drugs to die by an overdose. He avoids telling physicians about his unresolved grief, depression, and suicidal ideas, fearing that they might hospitalize him in a psychiatric unit. His case manager is working to get his pain, depression, and neurological symptoms evaluated and treated. Freddy wishes he could fly to Oregon and apply for assisted suicide (Valente & Saunders, 1996).

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