HIV-related depression.

While there is still much to be learned about depression in the context of HIV illness, studies over the past decade are generally reassuring. True, low-grade depressive symptoms are frequent among both HIV-positive and at-risk HIV-negative adults, but depressive disorders are the exception and not the rule, occurring in about 1 of 10 individuals. Similar to non-HIV populations, these depressive disorders are more likely to occur among those HIV-infected adults with severe personality problems, with a history of previous depressions, and with limited current social support. Although rates of depression may slightly increase with development of more severe physical symptoms, even then the clinician should not consider the presence of a depressive disorder as understandable, justified, and therefore "normal." Rather, depressive symptoms accompanied by suicidal ideation are signals for further evaluation and treatment. When antidepressant treatment is indicated, the weight of current evidence suggests that standard therapies can be safely and effectively prescribed for HIV-infected adults. For outpatients without severe physical illness, antidepressant medications are generally well tolerated in recommended dosages and do not increase immunosuppression. For those with more severe physical impairment, the adage for geriatric populations is applicable: "Start low and go slow." If lethargy and cognitive slowing is a major component of the depression, especially among those in later stages of disease, then psychostimulants may be helpful. When concerns about drug abuse preclude such a prescription, an activating antidepressant may be just as helpful to improve both mood and energy. For severe or refractory depressions, such as delusional affective disorders. ECT has been safely given to HIV-infected patients. And finally, accumulated clinical experience and a couple of systematic studies suggest that psychotherapy, alone or in combination with antidepressant drug therapy, can be remarkably beneficial. In sum, data support the fact that we have much to offer our depressed HIV-infected patients. Our task is to make sure that we identify their depressions when present and counter their feelings of hopelessness by ensuring that effective antidepressant treatments are provided.