Clinical Manual for Management of the HIV-Infected ... - myCME.com

8–8 | Clinical Manual for Management of the HIV-Infected Adult/2006
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Tricyclic antidepressants may be effective, but in
general have a higher risk of adverse effects than
SSRIs and are dangerous if overdosed.
Treatment may involve antidepressant combinations,
including psychostimulants.
Patients with prominent insomnia may benefit from
the addition of trazodone 25-50 mg, given 1-2 hours
before bedtime.
St. John's wort is an herbal antidepressant that is
contraindicated for use with protease inhibitors
and nonnucleoside reverse transcriptase inhibitors.
St. John's wort can significantly decrease serum
concentrations of these HIV medications.
Patient Education
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Providers should explain to patients that illness
(physical or emotional) is not a character flaw or a
moral or spiritual weakness. It is an expected aspect
of HIV infection. Sadness is a normal part of life,
but major depression is always abnormal and often
can be alleviated with medication, therapy, or both.
Antidepressants typically are given for a long time,
usually for a year or longer, to help patients with the
chemical imbalances associated with depression.
When starting an antidepressant medication,
patients should expect that it will take 2-4 weeks for
them to notice any improvement. Their symptoms
should continue to decrease over the following
weeks. If they do not have much improvement in
symptoms, their providers may choose to adjust the
dosage of the medication or to change medications.
Patients must continue taking their medications so
that the symptoms of depression do not return.
Some patients develop problems with sexual
function while they are taking antidepressants. They
should report any problems to their prescribers.
Patients should note the major symptoms of
depression and be aware of what factors led them to
seek treatment. They will need to monitor themselves
for recurrences and get help if the symptoms come
back. Providers should explain to patients that if they
notice changes in their sleep, appetite, mood, activity
level, or concentration, or if they notice fatigue,
isolation, sadness or helplessness, it is time to get
help.
References
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American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. Washington:
American Psychiatric Association; 1994.
Ickovics JR, Hamburger ME, Vlahov D, et al.
Mortality, CD4 cell count decline, and depressive
symptoms among HIV-seropositive women: longitudinal
analysis from the HIV Epidemiology Research Study.
JAMA. 2001 Mar 21;285(11):1466-74.
Leserman J, Petitto JM, Perkins DO, et al. Severe
stress, depressive symptoms, and changes in lymphocyte
subsets in human immunodeficiency virus-infected men.
A 2-year follow-up study. Arch Gen Psychiatry. 1997
Mar;54(3):279-85.
Mayne TJ, Vittinghoff E, Chesney MA, et al.
Depressive affect and survival among gay and bisexual
men infected with HIV. Arch Intern Med. 1996 Oct
28;156(19):2233-8.
Motivala SJ, Hurwitz BE, Llabre MM, et al.
Psychological distress is associated with decreased
memory helper T-cell and B-cell counts in pre-AIDS
HIV seropositive men and women but only in those
with low viral load. Psychosom Med. 2003 Jul-
Aug;65(4):627-35.
Schatzberg AF, Nemeroff CB, eds. Textbook
of Psychopharmacology. Washington: American
Psychiatric Press Inc.; 1998:257-263, 1017.
Stober DR, Schwartz JAJ, McDaniel JS, et al.
Depression and HIV disease: prevalence, correlates and
treatment. Psychiatric Annals 1997:27(5):372-377.