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Pushing back against challenges to mental health and emotional wellness

There are many biological and psychological factors faced by people living with HIV that can from time to time challenge their sense of mental health and emotional well-being. Researchers have found that people living with chronic conditions such as HIV are at increased risk for experiencing mental and emotional health issues. These issues reduce a person’s ability to engage in the daily work of looking after him or herself.

Different studies have found different rates of depression among HIV-positive people; however, overall rates of depression are generally higher than among HIV-negative people.

Psychosocial support plays a vital role in acting as a buffer against stress. Counselling can make people more resilient by enabling them to deal with past trauma and by teaching helpful responses to difficult situations.

Biological issues

HIV can cause changes to the way brain cells process and send chemical signals to each other. Also, due to the ongoing inflammation incited by HIV and only partially suppressed by ART, the brain may benefit from additional doctor-recommended or prescribed therapy from time to time, including the following:

  • regular aerobic exercise (several times weekly)
  • relaxation practices – yoga, meditation, Tai Chi
  • counselling – on an individual basis or with a group
  • treating underlying mental health and emotional issues such as anxiety, depression, mood swings and addiction

All of these steps can go a long way to helping HIV-positive people lead longer and healthier lives and improve their quality of life.

In some cases it may be necessary for family doctors, nurses and pharmacists to refer patients to different healthcare providers as appropriate, including the following:

  • social workers
  • psychologists
  • psychiatrists

Anxiety

Researchers have found that anxiety—including such symptoms as excess worry, episodes of panic, nervousness, paralyzing fear—can occur in some HIV-positive people. Anxiety can also occur as part of the spectrum of depressive illness.

If left untreated, persistent anxiety can degrade a person’s quality of life and affect their energy and ability to have restful sleep.

If you think that you might suffer from anxiety, speak to your doctor to get help.

Anxiety can be successfully managed with one or more of the following:

  • counselling
  • stress reduction and relaxation techniques (as mentioned earlier in this report)
  • temporary use of anti-anxiety medicines or antidepressants

Bipolar disorder

Also called manic depressive illness, bipolar disorder causes “unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks,” according to mental health experts. Furthermore, these experts add that “symptoms of bipolar disorder can be quite severe and can result in a manic state where thinking and judgment are severely impaired.” Some researchers suggest that rates of bipolar disorder are elevated among HIV-positive people.

People living with bipolar disorder can go through periods of high energy for weeks or months and can have symptoms such as the following:

  • little need for sleep
  • poor concentration (easily distracted by irrelevant events)
  • impulsive behaviour, such as extended bouts of substance use (including alcohol), increased sexual activity, uncontrolled spending
  • changes in mood
  • excessive talking

After a period of weeks or months the affected person may become depressed and experience symptoms such as the following:

  • unexpected lack of energy
  • difficulty concentrating
  • poor memory
  • feelings of unexpected sadness, guilt or hopelessness
  • losing pleasure in activities that were once fun
  • difficulty falling or staying asleep or sleeping too much
  • avoiding friends

If you have these or other symptoms suggestive of bipolar disorder, contact your doctor right away.

Diagnosis of bipolar disorder can only be done by a healthcare professional. There are many treatment options for bipolar disorder and the goals of treatment are to minimize shifts in mood and enable people to become functional.

People with bipolar disorder are at high risk for severe depression and thoughts of self-harm. In such cases, preventing suicide with medication becomes an important short-term goal.

According to American psychiatrist Daniel Hall-Flavin, approaches to the treatment of bipolar disorder can include the following groups of medicines:

  • mood stabilizers – lithium
  • some anti-seizure drugs (valproic acid, carbamazepine, lamotrigine)

Some doctors and patients also find another class of drugs called antipsychotics helpful for bipolar disorder. These can include the following drugs:

  • quetiapine (Seroquel)
  • olanzapine (Zyprexa)
  • risperidone (Risperdal)
  • aripiprazole (Abilify)
  • ziprasidone (Zeldox, Geodon)
  • asenapine (Saphris)

According to Dr. Hall-Flavin, antipsychotics can be helpful in cases where persistent depression or mania occur despite the use of mood stabilizers. Antipsychotics may be used either alone or in combination with a mood stabilizer.

In cases of persistent depression despite the use of a mood stabilizer or antipsychotic, doctors may then also add an antidepressant to a person’s regimen. However, antidepressants need to be used cautiously, as they may inadvertently trigger an episode of mania in susceptible people.

In addition to medications, and depending on the severity of illness, doctors may recommend the following courses of action:

  • a temporary stay in a hospital or regular visits to a hospital where the response to treatment is monitored
  • lifestyle changes – healthier eating, more regular exercise

Successfully managing bipolar illness takes time and patience to find the right drug or combinations of drugs. Dose adjustments or other changes to medications may be necessary from time to time to avoid or minimize side effects.

Depression

It is normal to feel temporary and mild sadness after learning about unfortunate events that have happened to friends and loved ones. However, in some people, sadness can persist for more than a few weeks and can lead to a serious condition called depression. This can be caused by psychological issues, biological issues or a combination of factors.

Not everyone with depression will have the same signs and symptoms, so trying to self-diagnose depression is tricky and can lead to problems. The best person to help you diagnose depression is your doctor.

According to the U.S. National Institute of Mental Health, people with depression can experience some or all of the following:

  • feeling sad
  • feeling hopeless, anxious or guilty
  • getting easily irritated or angry
  • feeling tired without having expended energy
  • difficulty concentrating
  • difficulty making decisions
  • memory problems
  • difficulty falling asleep or staying asleep
  • waking up prematurely in the early morning
  • unexpected muscle pain, cramps, headache
  • sudden changes in appetite that result in weight loss or gain
  • loss of interest in regular activities, including sex

If you think you may be suffering from depression, talk to your doctor as soon as possible.

Medical factors that can affect a person’s mood can include the following:

  • abnormal levels of thyroid hormone
  • less-than-normal levels of testosterone in men
  • presence of type 2 diabetes
  • untreated hepatitis C virus infection
  • exposure to certain anti-HIV medicines, particularly efavirenz (sold as Sustiva, Stocrin and found in Atripla)
  • exposure to biological agents that affect the immune system, such as interferons (sometimes used in the treatment of hepatitis C) and interleukins

Major depression

If depression is left untreated it can become severe, leading to major depression. In such cases, some people may develop additional feelings such as thoughts of self-harm or suicide. If this occurs do the following right away:

  • call your doctor
  • if your doctor is not immediately available go to the emergency room of the nearest hospital right away
  • if you are unable to get yourself right away to the emergency room of the nearest hospital, dial emergency services at 911

There are many therapies for depression and your doctor can help you find one that is right for you. It may take some time to find the right medication or dosage that is best for you, so some patience is necessary. Doctors and their patients have found that using a combination of approaches, such as counselling and antidepressants, can be very useful.

—Sean R. Hosein

Resources

HIV and Emotional Wellness – CATIE’s guide to how people with HIV can cultivate their emotional well-being

Canadian Mental Health Association

Strengthening the aging brain – TreatmentUpdate

Good for the brain—advice from neuroscientists – TreatmentUpdate

Mindfulness-based therapy found helpful for stress and the immune system – CATIE News

REFERENCES:

  1. Reus V.I. (2012). Chapter 391. Mental Disorders. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), Harrison’s Principles of Internal Medicine, 18e.
  2. Schmidt KL. Emergency Medicine: Care of the HIV-positive patient in the emergency department in the era of highly active antiretroviral therapy (HAART). In: Tintinalli JE. eds. Tintinalli’s Emergency Medicine Online Updates. New York, NY: McGraw-Hill; 2011.
  3. Blank MB, Himelhoch S, Walkup J, et al. Treatment considerations for HIV-infected individuals with severe mental illness. Current HIV/AIDS Reports. 2013 Dec;10(4):371-9.