HIV Digest	HIV Digest Archive

As part of a larger series about fatigue and HIV, AIDS Treatment News recently asked Lisa Capaldini about treating depression in HIV positive patients. Her remarks include:

"My experience is that antidepressants are as effective in treating biological depression in people with HIV disease as in HIV-negative people. Two major issues in using antidepressant therapy in people with HIV are (1) to make sure you are not missing hypogonadism (characterized by fatigue, decreased libido, concentration/mood problems), and (2) to choose an antidepressant with full knowledge of its side effect profile....

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Sexual dysfunction

"By class, probably the most frequently prescribed antidepressants today are in the SSRI category (selective serotonin re-uptake inhibitors). These are drugs that affect the level of serotonin in the brain-- Prozac, Zoloft, Paxil, and Luvox. The main disadvantage of this class of drugs is that they tend to cause sexual dysfunction (decreased libido, trouble getting physically aroused, or most commonly trouble "getting stuck," as it were, before climax). These problems often get better over time, and if they do not, the patient can be switched to a different antidepressant.

"Bupropion, or Wellbutrin, is the least likely of the newer antidepressants to cause sexual dysfunction, and is taken twice a day.

"Effexor is midway between Wellbutrin and SSRIs with regard to sexual dysfunction.

"Serzone (nefazodone) is not as likely to cause sexual dysfunction as the SSRIs, but tends to cause sleepiness during the day in a fair number of people. It does tend to help people gain weight, which is a good thing if they are having trouble with appetite or weight loss.

"Remeron is like Serzone in that it tends to cause sleepiness and weight gain, although the published data suggests that these side effects tend to be more short-lived with Remeron.

No instant results

"Patients starting an antidepressant should know that for the first two weeks they are most likely to have the side effects, but the antidepressant effects typically do not begin for two to four weeks. Patients need to understand that they will not get instant results. If after four weeks there is no effect and also no side effects, then the doctor may increase the dose and check again in another three weeks or so....

"Unlike many other drugs that act in the brain, antidepressants are not addictive or mind-altering in a recreational sense. Patients in recovery are often concerned about this. But in fact these drugs do not sell on the street; there is no market because they do not make people euphoric.

"For many patients, psychotherapy works as well as or better than medications. For some patients, face to face contact with another human being feels like a better way to work through depression problems. The obstacles are financial and logistical; therapy may run $100 a week, and most managed care plans cover it incompletely....

"Many recreational drugs are depressogenic, that is, they can cause depression. For example, large amounts of alcohol can cause depression, as can most other street drugs....

Possible interactions

"A newer issue with antidepressants is drug interactions between these drugs and combination-therapy antiretrovirals. While all protease inhibitors and NNRTIs [non-nucleoside reverse transcriptase inhibitors, for example nevirapine or delavirdine] have potential drug interactions with many antidepressants, the major drug interaction problems with antiretrovirals are with ritonavir and delavirdine. These two antivirals are powerful inhibitors of the P450 enzyme system, which metabolizes many antidepressants. If you are on one of those two drugs, your doctor needs to either avoid certain antidepressants, or to prescribe them in lower than typical doses, taking care to check drug levels for those drugs which have tests available, like the tricyclics....

"If a patient is on either ritonavir or delavirdine, I would not prescribe Wellbutrin (because when that drug's levels get very high there is a possibility of a seizure), or tricyclics (as these can cause serious cardiac rhythm disturbances when their levels are high).

"The tricyclics can be safely used with antiretrovirals other than ritonavir or delavirdine, but their blood levels should be monitored closely, and initial dosing should be low and adjusted upward based on drug levels.

"For other antivirals and HIV therapies, I do not routinely adjust or modify antidepressant dosing. Patients and doctors should not be inappropriately spooked by some of the warnings about drug interactions; some companies have speculated that their drug may increase the levels of other drugs, based on theoretical, non-clinical data, and have translated these speculations into specific warnings.

"I am all for being cautious, but think that in some cases the caution has been overstated."

Editor's Note: from AIDS Treatment News