Anxiety, Depression, and HIV PHASE, Canadian Psychological Association and Health Canada Module Developed by Lynda J. Phillips, Ph.D., C.Psych. Division of Clinical Psychology, Department of Psychiatry, University of Alberta Hospital, Edmonton Alberta

1 It’s Normal to be Upset

2 It’s normal to be upset Feeling upset can happen anytime. About 40-60% of HIV+ people experience an adjustment reaction that subsequently goes away. The incidence of clinical depression and anxiety disorders is only slightly higher for people with HIV than for people in the general population.

3 HIV Events Can Trigger Distress

4 HIV events can trigger distress. HIV testing HIV diagnosis First opportunistic infection Viral load and T4 count Diminishing and lost functions Fear of disclosure Getting healthier Becoming ill Frustrations with treatment Confronting losses and death Concerns about negotiating safer sex and/or needle use

5 It can be hard to tell what causes symptoms of depression.

6 Is it HIV? Another illness? Medication? Environment? Vegetative symptoms can be exaggerated in medical illness. Be mindful of person’s prior coping and vulnerabilities. The psychological and emotional results of vegetative symptoms. Sometimes psychological issues lead to vegetative symptoms.

7 Clinical depression is more than the blues.

8 Signs and symptoms of clinical depression Differentiate severity and duration of symptoms Risk factors for clinical depression

9 Risk factors for depression Prior episode of major depression Personality disorder Limited social support Bereavement Presence of AIDS-related signs and symptoms Alcohol or substance abuse Anxiety disorder Family history of suicide History of depression in a family member

10 Effective treatment for clinical depression is often more than Prozac

11 Effective treatment for clinical depression is often more than Prozac n Role of medication n Role of psychological intervention n Teamwork, accessing community resources and support

12 Selective Serotonin Reuptake Inhibitors (SSRIs) - Prozac (fluoxetine) - Luvox (fluvoxamine) - Zoloft (sertraline) - Paxil (paroxetine)

13 Depression and HIV Most HIV counsellors (e.g., Kalichman, 1996; O’Connor, 1997; Winiarski, 1997) suggest that the emotional/affective and cognitive components (e.g., sadness, crying, lack of pleasure or interest, negativistic beliefs, suicidal ideation or plans) provide the most important information when assessing for depression in HIV-positive people. Many neuro-vegetative symptoms (e.g., insomnia, weight loss, and decreased appetite, energy and sexual drive) may be related to depression, but they may also be related to HIV disease.

14 Help! My client is suicidal. Discussing suicide Ethical issues How to intervene Adapting treatment with suicidal clients

15 Help! My client is suicidal. àDiscussing suicide àEthical issues àHow to intervene àAdapting treatment with suicidal clients

16 Help! My client is suicidal. àDiscussing suicide àEthical issues àHow to intervene àAdapting treatment with suicidal clients

17 Help! My client is suicidal. àDiscussing suicide àEthical issues àHow to intervene àAdapting treatment with suicidal clients

18 CASE STUDY (Depressive Symptoms) “Struggling with HIV Issues in Lois’s Family” Lois, age 29, was diagnosed HIV-positive five years ago, when she gave birth to a baby. She now lives on social assistance with her three sons, Max - 2 years, Tony - 5 years and Joel - 8 years of age. Lois was infected by Robert, her common-law bisexual partner and father of the three boys, who died with AIDS- related Lymphoma ten months ago. The middle child, Tony, is HIV- positive. He has recently returned home from the hospital and is recovering from Esophageal Candidiasis. (continued on next page)

19 CASE STUDY (Depressive Symptoms) “Struggling with HIV Issues in Lois’ Family” (continued form previous page) Lois was the primary care giver throughout Robert’s final stage and is finding it difficult to cope with her children’s needs, the aftermath of their father’s death, and her own HIV status. She requests counselling and sees you because of insomnia, suppressed appetite, low energy, uncontrollable crying, apathy, withdrawal, and feelings of hopelessness.

20 Questions for Discussion Re: Case Study (Lois) 1. What issues or difficulties could be contributing to the client’s symptoms? 2. How would you and your client determine therapeutic goals? 3. How would you intervene or work with the client? 4. What referrals would you suggest or offer?

21 An anxiety disorder is more than being worried.

22 An anxiety disorder is more than being worried. It’s normal to worry and experience some anxiety when living with HIV. Some HIV medications can cause anxiety. The severity and duration of symptoms. The signs and symptoms of anxiety disorders (DSM-IV).

23 Anxiety and HIV Mild to moderate anxiety is very common. HIV- positive clients will often request psychological intervention to deal with symptoms – worries, agitation, shakiness, insomnia, irritability, feeling on edge or hypervigilant, muscle tension, difficulty concentrating, or concerns about the many uncertainties and unpredictabilities of living with HIV disease.

24 Features of an anxiety disorder (Based on DSM-IV) A.Excessive anxiety and worry (apprehensive expectation) occur more days than not for at least six months. B.The person finds it difficult to control the worry. C.The anxiety and worry are associated with three (or more) of the following six symptoms: 1)restlessness or feeling keyed up or on edge 2)being easily fatigued 3)difficulty concentrating or mind going blank 4) irritability 5)muscle tension 6)sleep disturbance (difficulty falling or staying asleep, or restless or unsatisfying sleep). D.The anxiety, worry, or physical symptoms cause clinically significant stress or impairment in social, occupational, or other important areas of functioning.

25 Treatment for anxiety is generally more than reassurance and support (but not always!).

26 Treatment for anxiety is generally more than reassurance and support (but not always): The Role of Reassurance and Support Psychoeducational material – addressing gaps in knowledge Using CBT techniques Relaxation Biofeedback Thought stopping Lifestyle issues Medication

27 Anxiety and HIV Not all clients are readily able to identify the cause of their anxieties. Often the therapist can assist with an exploration or uncovering, and at times the insight is sufficient to relieve symptoms. Take the time to understand a client’s concerns. Sometimes a listening ear, together with acceptance and reassurance, is exactly what is needed.

28 CASE STUDY “Fred Feels Anxious and Alone” Fred, 24 years old, and Bill moved in together six years ago. Bill was diagnosed HIV-positive while he was hospitalized for pneumonia (PCP) about a year following their union. Shortly afterwards, Fred received positive test results. Bill died with PML at the age of 32, ten months following his diagnosis. Fred was referred to you by his HIV specialist for bereavement counselling. Continued on next page

29 CASE STUDY “Fred feels anxious and alone” (continued from previous page) Fred presented as an attractive, talkative, restless young European man, very teary and “on edge.” He explained that Bill was his one and only sexual partner and that he was deeply and truly in love with him. He described symptoms that you thought could be indicative of an anxiety disorder. He impressed you as someone who was prone to anxiety, often overwhelmed by worries and concerns, and very private – particularly regarding the cause of his partner’s death and his own HIV status. Fred had informed only his immediate family of his own HIV status. Unfortunately, he received little support from them and was feeling very alone.

30 Questions for Discussion Re: Case Study (Fred) 1. What issues or difficulties could be contributing to the client’s symptoms? 2. How would you and your client determine therapeutic goals? 3. How would you intervene or work with the client? 4. What referrals would you suggest or offer?