HIV/AIDS has reached pandemic proportions in South Africa. The National HIV and Syphilis Seroprevalence Survey (1) revealed that in 2004 there were about 5.3 million people living with HIV/AIDS in South Africa; 26.5% of all pregnant women tested positive for HIV, and there were more than 1 500 new infections daily. Worldwide, UNAIDS estimated that at the end of 2003, 1.1% of adults between the ages of 15 and 49 years were living with HIV/AIDS, 3 million adults and children had died of AIDS, and 15 million children had been orphaned. (2)
Prevalence of depression
Worldwide, depression is exceedingly common in the general population, with lifetime prevalence rates ranging from 9% to 20%. (3) Depression is twice as common in women (20%) compared with men (10%). (4) In patients with chronic medical diseases the rates are higher, at 15-36%. (5) Depression also appears to occur frequently among HIV/AIDS patients, emerging soon after diagnosis or during the course of illness, with major depressive disorder being the most common disorder. (6)
Being diagnosed with a stigmatising disorder, experience of severe physical symptoms, and loss of relationships or work as a result of the diagnosis may all contribute to the development of HIV/AIDS-associated depression. (7) Depression may also be secondary to neuropathology caused by HIV/AIDS itself. (8) The distinction between major depressive disorder and mood disorder due to HIV disease can be difficult, since both result in similar symptoms. Fatigue, lethargy, low libido, diminished appetite and weight loss may be manifestations of either HIV-related illnesses or depressive disorder. In contrast, cognitive symptoms, feeling sad, losing interest in formerly enjoyable activities, guilt, and irritability are usually aspects of mood affliction.
The prevalence of depressive disorders in HIV-positive patients varies widely in the literature, ranging from 0% to 47.8%. (6,9-11) In clinical samples the rates range from 2% to 35%, (12,13) while rates vary from 30% to 60% in community samples. (14,15) Yet other studies that compared rates of depressive disorders in HIV-positive and negative patients (matched for gender, sexual orientation and drug use) concluded that HIV infection is not associated with a higher rate of the disorder. (16,17) However, a meta-analysis of some of these published studies by Ciesla et al. (18) concluded that HIV-positive individuals have nearly twice the likelihood of having had a recent episode of major depressive disorder compared with HIV-negative individuals. This is probably a better estimate, as the study considered differences between groups for a number of potentially important factors such as gender, mode of transmission, access to quality health care, socio-economic status and advances in the treatment of HIV infection.
Treatment of depression
Treatment of depression in HIV-positive patients has received little systematic study, (19) even though medication tolerance and potential medication interactions in such patients may influence the effectiveness and safety of antidepressant medication. (20) Double-blind, randomised, placebo-controlled trials of imipramine, (21,22) fluoxetine (23) and paroxetine (24) have shown response rates ranging from 45% to 80%, with a placebo response of up to 48%. Despite these significant effects of medication, attrition rates were as high as 55%. By the end of 6 months more than one-third of responders had discontinued imipramine because of troublesome anticholinergic side-effects (such as dry mouth, fatigue, and muscle aches). Although tricyclic antidepressants produced significant response rates, adverse effects limit their usefulness. Selective serotonin re-uptake inhibitors (SSRIs), although not more efficacious, are more tolerable and have greater overall effectiveness. (25) In addition to the absence of anticholinergic side-effects, SSRIs are safer in overdose than the tricyclic antidepressants, which is an advantage in HIV patients given their higher risk of suicidal ideation. …