Depression and HIV

October 2003     View PDF     En español
Reprinted from www.aidsmeds.com, US

What medications are used to treat depression?

A number of different drugs (logically referred to as antidepressants) are used to treat depression. Antidepressants belong to several different categories. They affect the function of certain neurotransmitters (chemical messengers) in the brain, although the process is not completely understood.

The medications that currently are most widely used to treat both major depression and dysthymia belong to a category referred to as SSRIs, “selective serotonin reuptake inhibitors.” They take their name from the effect they have on certain chemicals in the brain known as serotonin, which are believed to play a role in causing depression.

BRAND NAME	GENERIC NAME
There are currently seven SSRIs available in the United States: These pills can come in different shapes & colors, based on dose and/or manufacturer.
Prozac	fluoxetine
Paxil	paroxetine
Zoloft	sertraline
Luvox	fluvoxamine
Celexa	citalopram
Anafranil	clomipramine
Lexapro	escitalopram
Three other drugs that are currently available affect both serotonin and other chemicals in the brain:
Effexor	venlafaxine
Serzone	nefazodone
Remeron	mirtazapine
An additional drug is widely used to treat both major depression and dysthymia. This drug directly affects chemicals in the brain other than serotonin, mainly noradreneline.
Wellbutrin	bupropion

 

For reasons that are not understood, some people respond to one drug and do not respond to another drug in the same class. Additionally, the severity of side effects of each drug varies from person to person. Therefore, if you do not get better after trying one drug or have unacceptable side effects, you are still likely to respond well to another antidepressant. Occasionally, people respond best to a combination of medications and may, in actual fact, have fewer side effects.

These antidepressants are generally the first choice for treating both dysthymia and major depression. They are as effective as the older drugs used to treat depression, and have fewer and less serious potential side effects.

How safe are these drugs medically?
Generally these drugs are very safe. The antidepressants listed above have not been used long enough to study very long-term side effects. However, they are closely related to an older class of antidepressants that have been used for about forty years with no significant long-term adverse reactions. In addition, these drugs are safer for people who may have suicidal impulses; it is very hard for a person to kill themselves with an overdose of these drugs alone.

How do these antidepressants differ?
All of these drugs appear to be equally effective in treating both major depression and dysthymia, though there are insufficient data available to make a clear-cut comparison. They vary primarily in terms of side effects, and you and your psychiatrist will make the decision on which drug to use based largely on these side effects.

What are the side effects of these drugs?
Almost all medications have a wide variety of possible side effects, and this is true of the SSRIs and Wellbutrin. As with other drugs, only a few of these side effects are common. However, there is tremendous variation in response to medication. Do not hesitate to report any possible side effects to your psychiatrist and/or doctor, even if they are not typical of the drug you have been given.

The following is intended to be a general overview of the more common side effects. It is not a complete listing of all potential side effects:

Sexual side effects
The most common side effect of Prozac, Zoloft, Paxil, Celexa, Effexor and Luvox is sexual dysfunction. People are highly variable in how they respond to these sexual side effects. The most common sexual side effect is delayed orgasm. The next most common is decreased libido that is, sexual desire. A small proportion of men develop problems getting an erection. Delayed orgasm can range anywhere in severity from just noticeable to complete inability to achieve orgasm. Its impact on sex varies. It may prolong sex in a pleasurable way, or it may significantly inhibit pleasure. The orgasm itself may feel different.

Consequently, some people find the sexual side effects of these drugs tolerable while others find them extremely disturbing and discontinue medication or switch to another drug. These side effects reverse when the medication is stopped.

Sexual side effects occur in both women and men, although most of the clinical studies have been done on men. There is disagreement on what percentage of patients develop these side effects; possibly up to 75% of patients who take these drugs develop some sexual side effects. In some people the side effects disappear after a few weeks on the drug. Although inadequate data are available, Wellbutrin, Serzone, Effexor, and Remeron appear to have fewer sexual side effects, and Wellbutrin in combination with other drugs may even decrease sexual side effects.

Sexual desire may be diminished, or absent. Sometimes spontaneous thoughts of sex lessen or disappear while sexual response to external stimulus is well maintained.

Erectile problems when they do occur generally respond well to treatment with Viagra, Levitra or Cialis.

Assessing the sexual side effects of these drugs in women is somewhat difficult. Because of the cultural prejudices, discussions (especially with male doctors) about sexual side effects are often omitted, insufficiently detailed or followed up in subsequent visits, or considered unimportant.

Sometimes people don’t care about sexual function when depressed. Since loss of sexual desire is a symptom of depression, some people who start these medications report an improvement in their sex lives despite delayed orgasm. Remember, however, that as your depression lessens, sex may become more important and sexual side effects more bothersome. At this point, you should feel free to raise this issue with your doctor.

Insomnia and agitation
Prozac, Zoloft, Paxil, Luvox, Celexa and especially Wellbutrin frequently cause insomnia and a sense of restlessness, agitation, or nervousness that may range from mild to severe. Other drugs occasionally cause this. Again, occurrence of this side effect varies from person to person. It usually gets better after a few weeks and some psychiatrists prescribe sleep or anti-anxiety medication to use until these symptoms remit. With some people, the agitation may be severe enough to lead to discontinuation of the drugs.

Sedation
All of these medications occasionally cause sleepiness in some people. With Remeron and Serzone this is a frequent problem. However, since both of these drugs can be taken once a day before bedtime, some people find this effect helpful.

Weight gain and loss
Only Remeron has been proven to lead to weight gain, however there is a lack of long-term studies of this issue. Prozac, Zoloft, Paxil, Luvox, and Wellbutrin cause temporary loss of appetite and consequent weight loss when they are started. Many patients describe weight gain with all the SSRIs.

Other side effects
Prozac, Zoloft, Paxil, Luvox, Celexa, Effexor and Wellbutrin all may cause temporary nausea, stomachache, diarrhea, or headache. Generally these symptoms are mild and disappear after a few days to weeks.

Remeron and Zoloft may increase cholesterol levels.
Effexor may cause constipation and dry mouth and it causes high blood pressure in about 5% of people who take the drug. This happens in the higher dose range and is usually minimal.
Wellbutrin can cause seizures. This has occurred in less than 1% of people who take the drug. If you have a previous history of seizure disorders you should not take Wellbutrin and you should not take more than 200mg at one time or 450mg per day.

Anafranil tends to cause more anticholinergic side effects (dry mouth constipation, blurring of vision, difficulty urinating) and orthostatic hypotension (a drop in blood pressure after standing up which may cause dizziness or faintness) than other drugs.

Celexa, a relatively new drug, may cause the fewest side effects, including sexual ones, although the drug has not been used long enough to be sure of this.

How fast do these drugs work and how long should I take them?
Antidepressants are usually started at a low dosage and then increased. Significant improvement should occur in two to six weeks after taking a therapeutic dose of the drug. Do not expect it to work immediately, although some people feel better within a few days. If one antidepressant does not work, another may be effective. Inadequate dosage or inadequate length of time on the drug is the most common cause of treatment failure.

Antidepressant medications are usually taken for four to six months. If depression recurs when the medication is stopped, these antidepressants may be taken on an indefinite basis.

Are these drugs used to treat other problems?
The SSRI drugs and Wellbutrin are also used to treat a number of other psychiatric problems including panic disorder, social phobia, and obsessive-compulsive disorder.

Do any of these drugs interact with anti-HIV drugs or have unusual effects on someone who has HIV disease? How will they affect my immune system?
In general, there is no problem in taking one of this group of antidepressants in combination with anti-HIV medication. However, if you are taking the protease inhibitors Norvir (ritonavir) or Kaletra (lopinavir + ritonavir), you should be particularly cautious. Ritonavir acts in a way that increases the amount of certain other drugs in the body. This is particularly problematic with Wellbutrin, because the drug can cause seizures if the dose is too high. Ritonavir may increase the development of anxiety and agitation as a side effect of Serzone. It is generally not a problem with the other antidepressants, though you may require a lower dose than typical. Your psychiatrist should know what other medications you are taking. If s/he is not an expert in treating patients with HIV, s/he should consult with your HIV doctor to make sure no combination is harmful.

If you have advanced symptomatic HIV disease, you may be more likely to develop side effects from various medications. Your psychiatrist should work in close consultation with your HIV physician.

Some people who are depressed treat themselves with St. John’s Wort (Hypericum perforatum), an herbal supplement available without prescription in health food stores. You may consider it preferable to one of the prescribed medications because of the ease of obtaining it and because it is seen as “natural.” It is probably an effective antidepressant for some people and has been widely used in Europe. However, few studies have been done on the use of St. John’s Wort for serious depression; the strength of pills varies from manufacturer to manufacturer; and, like other medications, it has side effects. Most importantly, St. John’s Wort can reduce the amount of various anti-HIV drugs in the body to an ineffective level. This interaction can happen with all the currently marketed Protease Inhibitors (PIs) and Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs). The FDA letter of recommendation about use of St. John’s Wort and anti-HIV drugs can be seen by clicking here.

There is no evidence that use of antidepressant medication suppresses or improves immune system functioning.

Possible treatments

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What if SSRIs don't work?