Download Triggers for depressed mood in a diverse sample of

Triggers for Depressed Mood in a Diverse Sample of HIV-positive Patients with Comorbid Depressive Disorders
Angela R. Wendorf, Jessica Jardas, Erin Moore, Samantha Bilkey, and Katie E. Mosack
University of Wisconsin-Milwaukee
Background & Significance:
Interpersonal Stressors (Including Stigma,Discrimination, and Losses)
•Depression, which is prevalent among HIV+ individuals, has been associated with nonadherence to ARV medication, substance
abuse, increases in risky sex behavior, increased rates of progression to AIDS, and increased mortality.
(Catz et al., 2000; Remien et al., 2003; Singh et al, 1996; Chandler, Himelhoch, & Moore, 2006; Leserman, et al., 1999,
Ickovics et al., 2001; Lima et al., 2007)
•The relationship between depression and HIV is likely bidirectional. Being diagnosed with HIV may lead to depression and
depression may lead to maladaptive behaviors (e.g., risky sex-taking and injection drug use) that result in HIV infection.
(Hutton et al., 2004; Stein et al, 2003)
•Although quantitative research on HIV and depression has been conducted (Olatunji et al, 2006; Rabkin, 2008), we know little
about what it is like to live with the comorbid conditions.
•The purpose of this study was to explore the experience of living with comorbid HIV and depression, and specifically, how HIV
affects, and is affected by, the experience of being depressed.
Levels of depression increase when P experiences conflict in interpersonal relationships.
•“Some people are very, very afraid of HIV… and the way that they - the way that some people have shunned me in a way triggers
my depression.
•“I think a lot of HIV people who are depressed feel that no one understands and no one’s willing to help them.”
•“My nieces and my nephew are very important to me, and…they know that Uncle’s sick, but they don’t know that its HIV. And, I’m
kinda scared for them to know… like my nephew, like he’s my pride and joy, ‘cause he’s my only nephew. And, he said ‘Uncle, why do
you take all those pills?’ So I was kinda stunned. I said, ‘Well, Uncle’s sick so he’s gotta take these pills.’ ‘Well, when are you gonna
stop taking them?’ And it just, it…it kinda broke my heart, not to be able to give him an answer. Not to be able to tell him, ‘Uncle’s
gonna have to take these pills the rest of his life…’”
Methods:
Perceived negative changes in one’s appearance due to the effects of HIV and medications significantly often negatively
influenced participants’ mood.
•“You notice little things happening to your body. I have like, um, on my legs-my legs were usually clear –a rash developed which
left scars, well that puts me depressed because I notice physical changes in my body that wasn’t there before.”
•“This goes back to the depression, knowing that you have to look at [these infections and rashes] and treat this stuff and medicate
this stuff, you start looking at your appearance. And seeing how your appearance…starts to drop and you don’t look as…fatty in the
cheeks that you used to look…you just start noticing stuff that you thought were good attributes, are no longer good attributes. So
you start thinking about, ‘How do I fix this? How do I fix that? How do I put weight on? How do I make myself look the way I used
to?’ I can’t put on weight, so my appearance is just like deteriorating, dropping, more and more every day.”
•Semi-structured interviews were conducted with 21 HIV+ men and women diagnosed with comorbid depressive disorders who
were recruited from outpatient specialty HIV clinics.
•The data were part of a larger qualitative study investigating mechanisms by which depressed mood may influence adherence.
•Data were analyzed in accordance with principles of Grounded Theory.
Participants:
Sociodemographics
• N=21
• Gender: M=14, F=7
• Race/ethnicity:
• African American (15), White (4), Biracial (1)
• Age: 44 yrs (range = 33-60 yrs, SD=7)
• Household income per month:
• Majority of participants’ reported < $1000/month
• Education:
• n=8 < HS degree
• n=4 = HS degree
• n=9 > HS degree
HIV:
• Average time since HIV diagnosis:
• 11 years (Range: 1993-2005, SD=3)
• Current stage of disease:
• HIV-positive (17)
• AIDS (4)
Depression:
• Diagnoses
• MDD (n=2)
• MDD and Dysthymia (n=15)
• MDD partial remission (n=3)
• Minor Depression (n=1)
• Treatment
• Currently on antidepressant treatment (n=17)
Findings:
•Themes related to visual and mental reminders of HIV medications, rumination about being HIV-positive, attending
medical appointments and receiving poor test results, interpersonal stressors, changes in appearance, experiencing side
effects from HIV medications, and dysfunctional/unhelpful beliefs about treatment and health emerged from the data.
•Descriptions of each thematic category are provided below.
Visual and Mental Reminders of HIV Medications:
Simply viewing or taking medications, as well as considering the meaning of these medications often triggers depression
•“When I’m getting [my HIV medications] together, and I can actually visually see all these bottles spread out across my table…it
bothers me, I’m tired of it.”
Rumination About Being HIV-Positive:
Repetitive thinking about one’s experience being HIV-positive and the emotional burdens associated can trigger depression
•“Just…thinking of my position, where I am in life is depressing to me, I'm not where I think I should be, I don’t have the things,
my life’s not going where I feel that I want it to go. I think HIV has a lot to do with it.”
•“It depresses me….because usually I’m a healthy person and I hate having to deal with the doctors and the medical situation that
comes part of it. I’m upset because I know that my life is altered.”
Attending Medical Appointments and Receiving Poor Test Results:
Participants’ perceptions of negative test results and the implication for their long-term health may trigger depression
•“Usually when I come from the doctor I’m depressed. They say, “Well this is up, and this is down, and you need to do this and
you need to do that...’ And when I leave the doctor’s office, I’m usually depressed for about the next day or two.”
Experiencing Physical Symptoms (Due to HIV) and Functional Limitation as a Consequence of HIV:
Perceptions of the impact of functional limitation and intrusive HIV-related symptoms tends to trigger depression.
•“I wanted to go for a walk the other day, I couldn’t…my legs were just way too tired…I get depressed about that. And it all stems
from being HIV positive. ‘If I wasn’t, I wouldn’t have neuropathy, I wouldn’t have this’ and then I start to cry, and – just little
things, I mean, a walk? Why would you get depressed about a walk? But I do.”
Changes in Appearance
Experiencing Side Effects from HIV Medications:
Intrusive side effects of the HIV medication can trigger depression., and can interfere with one’s ability to cope with depression.
•“But the side effects of the medication… it’s just that I know it’s affecting my system, and that makes me even more depressed. It gets
me down ‘cause I have to take it anyway. Knowing I wish I didn’t have to take it, but I have to take it.”
•“The side effects [were] something that really kept me down too because if I had to take some medication, then I’m gonna have
these side effects [amd] I’m not gonna be able to deal with them. How can I deal with them – I’m dealing with my depression, I’m
dealing with this medication – how is it gonna affect this medication? How is it gonna – it’s gonna affect my thinking, already – I’m
already – can’t even handle what I’m dealing with now, how am I gonna deal with this?”
Dysfunctional/Unhelpful Beliefs About Treatment and Health:
Maladaptive beliefs about participants’ own health, their treatment, and long-term health can trigger depressed mood.
•“Sure. I’m gonna die. It’s inevitable. I mean, everyone eventually will die. However, I have a bigger – I got a greater chance of
dying sooner. And I’m not ready to go. So, usually that – the whole death thing. (laughs)”
•“[Sometimes I think] that I’ve been given a death sentence, basically. Some people say, “You know, you could live 20 years!” But
some people don’t, and I think I got that in the back of my mind. You know? So, it affects a lot of things. It really triggers my
depression sometimes.”
Conclusions:
•The context of depressed mood among HIV-positive patients is complex
•Triggers for depressed mood included reminders of being HIV-positive in several contexts, including private and medical settings
•Triggers for depressed mood involve cognition, physical symptoms, and behaviors
Recommendations and Implications for Assessment and Treatment:
•Clinicians and other health professionals working collaboratively with HIV-positive patients should assess triggers for depression that
span multiple domains, including intrapersonal, interpersonal, and structural contexts
•The utilization of cognitive-behavioral strategies and interventions are recommended, to work with patients to modify maladaptive
beliefs pertaining to patients’ triggers for depressed mood
.
References
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Chandler, G., Himelhoch, S., Moore R.D. (2006). Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy. Drugs, 66,769–789.
Hutton, H.E., Lyketsos, C.G., Zenilman, J.M., Thompson, R.E., & Erbelding, E.J. (2004). Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic. American
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Ickovics, J.R., Hamburger, M.E., Vlahov, D., Schoenbaum, E.E., Schuman, P., Boland, R.J., & Moore, J. (2001). Mortality, CD4 cell count decline, and depressive symptoms among HIVseropositive women. Journal of the American Medical Association, 285, 1466-1474.
Leserman, J., Jackson, E.D., Petitto J.M., Golden, R.N., Silva, S.G., Perkins, D.O., Cai, J., Folds, J.D., & Evans, D.L. (1999). Progression to AIDS: the effects of stress, depressive symptoms, and
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Olatunji, B.O., Mimiaga, M.J., O’Cleiright, C.O., & Safren, S.A. A review of treatment studies of depression in HIV. International AIDS Society, 14, 112-124.
Rabkin, 2008. HIV and depression: 2008 review and update. Current HIV/AIDS Reports, 5, 163-171.
Remien, R.H., Hirky, A.E., Johnson, M.O., Weinhardt, L.S., Whitter, D., Giang, M.L.(2003). Adherence to medication treatment: A qualitative study of facilitators and barriers among a diverse
sample of HIV+ men and women in four U.S. cities. AIDS & Behavior, 7, 61-72.
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Acknowledgements:
•This research was supported, in part,
by APA Cyber Mentor funding
(Mosack, PI).
•Many thanks to UWM Patient
Advocacy and Research Lab Coding
Team.
•This research would not have been
possible without the participants who
were so willing to share their
experiences with us.