HIV and depression

Related Terms

Acquired immune deficiency syndrome, acquired immunodeficiency syndrome, AIDS, antidepressants, antiretroviral therapy, apathy, ART, bipolar disorder, clinical depression, behavioral problems, cognitive psychotherapy, depression, depressive disorder, emotional imbalance, genetic predisposition, HIV, human immunodeficiency, immunocompromised, interpersonal psychotherapy, low self-esteem, major depressive disorder, MAOIs, MDD, mental status evaluation, monoamine oxidase inhibitors, neurochemicals, neurotransmitter, postpartum depression, psychiatric disorder, psychiatrist, psychologist, psychology, psychotherapy, serotonin, SAD, seasonal affective disorder, SSRIs, suicide, TCAs, tricyclic antidepressants, zidovudine.

Background

Depression, a mental illness that causes many emotional, physical, and behavioral problems, is characterized by feelings of sadness, low self-esteem, loss of pleasure, apathy, and sometimes, difficulty functioning. When these problems persist for at least two weeks and interfere with daily activities, it is classified as clinical depression, which is also called major depressive disorder (MDD).
Patients who have MDD may experience single or recurrent episodes of depression. MDD may be mild, major or severe. The two primary symptoms of clinical depression are depressed mood and loss of interest in daily activities.
Depression is the most common psychiatric (mental) disorder among HIV patients. Some researchers estimate that 22-45% of HIV patients suffer from depression, compared to 15% of the general population. However, other researchers report no significant difference in depression rates among HIV-positive and HIV-negative patients. After controlling for factors like substance abuse or demographic information (like sexual orientation), the differences in prevalence are unclear. Therefore, researchers are uncertain whether HIV and depression are correlated.
Recovery from depression takes time. Treatment varies among patients. Patients may receive psychotherapy and/or antidepressant medications (such as Zoloft? or Elavil?). Antidepressants can take several weeks to begin working. Not everyone responds to treatment the same way. Therefore, prescriptions and dosing may need to be adjusted, depending on how the patient responds to treatment.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

AIDS Health Project .
American Psychiatric Association. .
National Institute of Mental Health. .
Natural Standard: The Authority on Integrative Medicine. .
San Francisco AIDS Foundation. .
Yun LW, Maravi M, Kobayashi JS, et al. Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir Immune Defic Syndr. 2005 Apr 1;38(4):432-8. .

Causes

General: A variety of physical, genetic, environmental, and emotional factors seem to be involved in causing clinical depression in HIV patients. One or more of the following factors may contribute to the development of depression.
Alcohol and other drugs: Alcohol and other drugs may have a negative effect on an individual's mood. Depressed individuals who abuse alcohol, benzodiazepine-based tranquilizers, and sleeping medications may experience prolonged or more severe forms of depression.
Birth: Some women experience postpartum depression, which occurs within two years of giving birth.
Environmental factors: Environmental factors, including the death of a friend, family member or pet, abandonment, rejection, neglect, chronic illness, poverty, financial difficulties, traumatic events, as well as physical, psychological, or sexual abuse may increase the likelihood of developing depression or trigger episodes of depression. In addition, individuals who live with someone who suffers from depression may have an increased risk of developing depression.
Heredity: Researchers believe that certain people are born with a genetic predisposition to developing depression.
HIV: Some studies have shown that HIV patients are more likely to develop depression than non-infected individuals. However, after controlling for factors like substance abuse and sexual orientation, the differences are unclear. This is because many HIV patients have other risk factors in addition to HIV infection. For instance, studies have shown that homosexual men have high lifetime rates (about 30-35%) of depressive disorders.
Researchers have also proposed that HIV itself induces mood changes in patients. Some experts also suggest that HIV-associated dementia may lead to depression. However, neither of these hypotheses has been scientifically proven. According to studies, apathy, rather than sadness, appears to be the predominant effect in HIV-associated dementia.
Some researchers have suggested that individuals with weakened immune systems, including HIV patients, are more likely to develop depression than healthy individuals. However, this correlation has not been proven. Some studies have found an association between depression and low CD4 cell counts (immune system cells that HIV primarily infects and destroys), while other studies have found no relationship.
HIV medications: Several case reports suggest that the antiretroviral drug zidovudine (ZDV) may be mood-enhancing or mania-inducing. However, there are currently no available studies on the effects of antiretrovirals on mood in HIV patients.
Physiological: Brain imaging technologies show that the neural circuits responsible for regulating moods, thought, sleep, appetite, and behavior do not function properly in patients who suffer from depression. In addition, important neurotransmitters (chemicals used by nerve cells to communicate) are unbalanced in patients who are depressed. Patients who suffer from depression have low levels of serotonin (chemical messenger in the brain that affects emotions, behavior, and thought). However, the reason for this imbalance is not completely understood.
Psychological factors: Low self-esteem is associated with depression. However, it is unclear whether low self-esteem causes depression, or if it is a symptom of depression.
Seasonal changes: Seasonal changes may worsen or trigger episodes of depression in some individuals. Seasonal affective disorder (SAD), also known as winter disorder, is a form of depression that occurs during the winter months.
Stress: Individuals who experience long-term physical or emotional stress may have an increased risk of developing depression. Stress causes increases in the hormone cortisol, which may lead to neurochemical imbalances.

Symptoms

General: Because both depression and HIV cause similar symptoms, the condition is difficult to diagnose in HIV patients. The most common symptoms of depression include a loss of interest in daily activities that were once enjoyed and depressed mood. Other common symptoms include persistent sad, or anxious moods, feelings of hopelessness, pessimism, guilt, worthlessness, helplessness, low self esteem, decreased energy, fatigue, difficulty concentrating, difficulty remembering, indecisiveness, insomnia, early-morning awakening or oversleeping, appetite and/or weight changes, thoughts of death or suicide or suicide attempts, restlessness and irritability.
Melancholic symptoms: Patients who have depression may experience melancholic symptoms characterized by a loss of pleasure and interest in most daily activities, failure to react to pleasurable stimuli, depressed mood (especially in the early morning), excessive weight loss, and excessive guilt.
Atypical symptoms: Atypical symptoms, despite the name, are common among patients who suffer from depression. Atypical symptoms include mood reactivity, significant weight gain or increased appetite, excessive sleeping or tiredness, leaden paralysis, and significant social impairment.
Psychotic symptoms: Some patients may experience psychotic symptoms, which may include hallucinations (seeing or hearing things that are not there) or delusions (lost sense of reality).

Diagnosis

General: Diagnosing depression may be difficult in HIV patients because the symptoms of depression and HIV infection are often similar. For instance, fatigue, lethargy, low libido, low appetite, and weight loss may be symptoms of either HIV-related illnesses or depressive disorder. Clinical depression is diagnosed after a complete physical and psychological examination. Patients who are diagnosed with depression should be referred to mental health professionals for treatment.
Physical examination: A physical examination is conducted to rule out other possible causes of depression symptoms. If depression is suspected, a healthcare provider will recommend a psychological exam with a mental health professional.
Psychological examination: A psychological examination includes a complete history of the patient's symptoms, as well as medical and family history. Individuals who have a family history of depression are more likely to develop depression than those who do not. A mental status evaluation is also conducted to assess the severity of psychological symptoms and problems.

Treatment

General: Treatment for depression varies considerably among patients. Most patients receive a combination of medications and therapy. Prescription antidepressants (like serotonin-reuptake inhibitors, tricyclic antidepressants and monoamine oxidase inhibitors) are generally well tolerated and safe for patients who have HIV and depression. Lifestyle changes may also be beneficial.
Since HIV patients typically receive antiretroviral therapy (anti-HIV drugs), patients should tell their healthcare providers, including psychiatrists, if they are taking any drugs (prescription or over-the-counter), herbs or supplements. Psychotherapy (talk therapy) may also help relieve symptoms of depression.
Serotonin-reuptake Inhibitors (SSRIs): Serotonin-reuptake inhibitors (SSRIs) are antidepressants that increase the amount of the neurochemical serotonin in the brain. This helps improve the patient's mood and energy levels. Commonly prescribed SSRIs include fluoxetine (Prozac?), paroxetine (Paxil?), sertraline (Zoloft?), citalopram (Celexa?), and fluvoxamine (Luvox?). SSRIs may cause side effects such as nausea, sexual dysfunction (including reduced desire or orgasm difficulties), headache, diarrhea, agitation, nervousness, rash, restlessness, increased sweating, weight gain, drowsiness, or insomnia
Tricyclic antidepressants (TCAs): Tricyclic antidepressants (TCAs) increase the level of norepinephrine in the brain synapses. They may also increase serotonin levels in the brain. This class of drugs was the standard of care before SSRIs were introduced. Today, these drugs are typically used to treat moderate to severe depression. Commonly prescribed TCAs include amitriptyline (Elavil?), protriptyline (Vivactil?), desipramine (Norpramin?), nortriptyline (Aventyl? or Pamelor?), trimipramine (Surmontil?), and perphenazine (Triavil?). TCAs may cause side effects such as dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness, drowsiness, skin rash, and weight gain or weight loss.
Monoamine oxidase inhibitors (MAOIs): Monoamine oxidase inhibitors (MAOIs) were the first antidepressants developed. These drugs are prescribed when other antidepressant medication has failed because MAOIs can cause serious side effects, including high blood pressure. MAOIs elevate the levels of neurochemicals in the brain synapses by inhibiting an enzyme called monoamine oxidase. Monoamine oxidase breaks down neurochemicals, including norepinephrine. When monoamine oxidase is inhibited, the norepinephrine is not broken down. As a result, higher levels of norepinephrine are present in the brain. Commonly prescribed MAOIs include phenelzine (Nardil?) and tranylcypromine (Parnate?).
The most serious side effect associated with MAOIs is high blood pressure. Other side effects may include drowsiness, constipation, nausea, diarrhea, stomach upset, fatigue, dry mouth, dizziness, low blood pressure, lightheadedness, decreased urine output, decreased sexual function, sleep disturbances, muscle twitching, weight gain, blurred vision, headache, increased appetite, restlessness, shakiness, trembling, weakness, or increased sweating.
Psychotherapy: Many forms of psychotherapy have been used to treat HIV patients who suffer from depression. Interpersonal psychotherapy focuses on the patient's disturbed personal relationships that both cause and aggravate the depression. Cognitive/behavioral therapy may help patients change their negative ways of thinking and behaving that are associated with depression. Psychodynamic psychotherapy focuses on introspection and reflection. This type of therapy is used to help the patient express his/her true feelings.
Psychosocial interventions: Psychosocial interventions commonly used for depression include cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy.
Cognitive behavioral therapy helps patients with depression change inappropriate or negative thought patterns and behaviors associated with the illness. Cognitive behavioral therapy helps patients understand more about their illness, deal with feelings of hopelessness and guilt, help resolve family conflicts that arise, gain better control over impulses and moods, and assist in decision-making.
Psychoeducation involves teaching people with depression about the illness and treatment and how to recognize signs of relapse so that early interventions can be made before a full-blown episode occurs. Psychoeducation also may be helpful for family members.
Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the patient's symptoms. Family and friends of an individual with depression must be familiar with the signs and symptoms of the disease.
Interpersonal and social rhythm therapy helps people with depression improve their interpersonal relationships and also helps them regularize their own daily routines. Regular daily routines and sleep schedules may help protect against episodes of depression.
As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.
Lifestyle: Proper nutrition and regular exercise may improve the mental health of individuals who suffer from depression. Since isolation may contribute to symptoms of depression, especially in HIV patients who may feel stigmatized because of their illness, patients are encouraged to participate in social activities with friends and/or family members. Patients are also encouraged to maintain regular sleeping schedules. Too much or too little sleep may exacerbate symptoms of depression.

Integrative therapies

Strong scientific evidence:
Music therapy: Music has been referred to as an ancient tool of healing. Many different forms of music intervention have been used to reduce depression and anxiety in a variety of medical conditions and medical procedures. There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects for mood enhancement. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood. Music therapy is generally known to be safe.
Sage: Sage has long been suggested as a possible therapy for mood enhancement. Several trials provide evidence for this use of sage, even in stressful situations. Additional study is needed to confirm these findings and determine the best dose.
Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.
St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions, with the most common modern-day use being the treatment of depression. St. John's wort has been extensively studied in Europe over the last two decades, with more recent research in the United States. Short-term studies (one to three months) suggest that St. John's wort is more effective than placebo (sugar pill), and equally effective as tricyclic antidepressants (TCAs) in the treatment of mild-to-moderate depressive disorder. Comparisons to the more commonly prescribed selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (Prozac?) or sertraline (Zoloft?), are more limited. However, other data suggest that St. John's wort may be just as effective as SSRIs with fewer side effects. Safety concerns exist as with most conventional and complementary therapies. Studies of St. John's wort for severe depression have not provided clear evidence of effectiveness.
In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. Avoid with protease inhibitors like indinavir (Crixivan?) and non-nucleoside reverse transcriptase inhibitors like nevirapine (Viramune?). St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
Good scientific evidence:
5-hydroxytryptophan (5-HTP): Supplement use of 5-HTP may help balance serotonin in the body. Serotonin is the brain chemical associated with sleep, mood, movement, eating and nervousness. While cells outside the brain, such as platelets in the blood and some cells in the intestine, produce and utilize serotonin, all serotonin used by brain cells must be made within the neurons themselves. When serotonin is not properly constructed within the brain, the result can be irritability, aggression, impatience, anxiety and depression. The results of numerous studies in humans suggest that 5-HTP may aid in the treatment of depression. However, it is not known whether 5-HTP is as effective as commonly prescribed antidepressant drugs.
Caution is advised when taking 5-HTP supplements, as numerous adverse effects including drug interactions are possible. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. It involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy may be an effective intervention for hospitalized, suicidal adolescents. There is evidence that it can be used to aid in developing a sense of identity and optimism about the future. It may also aid in relaxation and willingness to communicate, and may result in shorter hospitalization.
Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
Dehydroepiandoseterone (DHEA): DHEA is a hormone made in the human body that serves as precursor to male and female sex hormones (androgens and estrogens). The majority of clinical trials investigating the effect of DHEA on depression support its use for this purpose under the guidance of a healthcare provider. Further research is needed to confirm these results.
Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Avoid if allergic to DHEA. Side effects may include fatigue, nasal congestion, headache, acne, or rapid/irregular heartbeats. In women, the most common side effects are abnormal menses, emotional changes, headache, and insomnia. Individuals with a history of abnormal heart rhythms, blood clots or hypercoagulability, and those with a history of liver disease, should avoid DHEA supplements. Patients who are taking antidepressants should avoid DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders or anticoagulants (blood thinners), or drugs, herbs, or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
Hypnotherapy, hypnosis: Hypnosis appears effective in the treatment of psychosomatic disorders. Additional research is needed to support this finding.
Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
Music therapy: There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood. Music therapy is generally known to be safe.
Phenylalanine: In early human study, L-phenylalanine, DL-phenylalanine, and D-phenylalanine were shown to reduce symptoms associated with depression. However, high quality clinical trials are needed for better assessment of the antidepressant effectiveness of various forms of phenylalanine dietary supplements.
Use cautiously in patients taking monoamine oxidase inhibitors (MAOIs), or in patients with hypertension, anxiety disorders, psychiatric disorders, or sleep disorders. Avoid in patients with Parkinson's disease or tardive dyskinesia. Avoid in patients with hypersensitivity to phenylalanine or with phenylketonuria (PKU).
Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). A broad range of psychotherapies have been shown to be effective for the treatment of mild to moderate depression, ante- and postpartum depression, and depression in children. Although prescription medication is the most effective treatment for bipolar disorder, psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior.
Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.
St. John's wort: Well-designed studies have investigated the effect of St. John's wort on symptoms associated with somatoform disorders. The results suggest St. John's wort may be effective in this population. Further well-designed clinical trials would add to this information and allow recommendations to be made.
In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. Avoid with protease inhibitors like indinavir (Crixivan?) and non-nucleoside reverse transcriptase inhibitors like nevirapine (Viramune?). St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several human studies support the use of yoga for depression in both children and adults. Although this preliminary research is promising, better studies are needed.
Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
Unclear or conflicting scientific evidence:
Acupressure, shiatsu: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Several studies suggest that acupressure therapy may be effective for depression. Further research is needed.
With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. A small number of studies have sought to compare acupuncture with medications used in depression. More studies are needed on this use.
Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (such as asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary research suggests that lavender (Lavendula officinalis) aromatherapy may be helpful as an adjunct to prescription medications used for depression. Additional research is necessary before a conclusion can be made.
Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. Early evidence suggests that a traditional Ayurvedic formula containing extracts of four Indian herbs, Ashvatha, Kapikachu, Dhanvayasa, and Bhuriphali, may have benefits similar to conventional anti-depressant medication. Further studies are needed to confirm the effects of this ayurvedic preparation for mild to moderate depression.
Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.
Bach flower remedies: Depression is one of the major uses of Bach flower remedies. Currently, there is a lack of high-quality clinical trials that have investigated the use of Bach flower remedies for major depressive disorder. Higher quality research is needed in this area. Back flower remedies should not be used in lieu of more proven therapies.
Chasteberry: There is limited evidence suggesting possible benefits of chasteberry in the alleviation of symptoms of pre-menstrual dysphoric disorder (PMDD). Further evidence is necessary before a conclusion can be drawn.
Avoid if allergic or hypersensitive to members of the Vitex (Verbenaceae) family or any chasteberry components. When taken in recommended doses, chasteberry appears to be well tolerated with few side effects. Use cautiously in patients taking oral contraceptives or hormone replacement therapy. Use cautiously with dopamine agonists or antagonists. Avoid with hormone sensitive cancers or conditions (like ovarian cancer or breast cancer). Avoid if pregnant, breastfeeding or if undergoing in vitro fertilization.
Chromium: Early studies show that chromium picolinate may improve symptoms of depression in people with atypical depression. Further research is needed before a recommendation can be made.
Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, a weakened immune system (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, or stroke or in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.
Coleus: Limited studies have assessed the efficacy of coleus in the treatment of depression. High quality clinical trials are warranted.
Avoid if allergic or hypersensitive to coleus. Use cautiously with antidepressants, blood pressure drugs, blood-thinners, pain relievers, anticoagulants, blood sugar drugs, bronchodilators, heart drugs (like anti-arrhythmics), drugs dependent on stomach pH (like ketoconazole), thyroid drugs, bladderwrack, garlic, ginkgo, St. John's wort, and other herbs or supplements with similar effects.
Creatine: Early research suggests a potential beneficial of creatine supplements in depression. Large, well-designed studies are needed.
Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix?)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.
Feldenkrais method?: Early research revealed improved mood among participants who enrolled in a one-year program that included the Feldenkrais Method?. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method?.
Folate: Folic acid or folate deficiency has been found among many individuals suffering from depression and has been linked to poor response to antidepressant therapies. Folate supplements have been used for enhancing treatment response to antidepressants. Limited clinical research suggests that folic acid is not effective as a replacement for conventional antidepressant therapy. Blood tests can determine if an individual is low in vitamins such as folic acid.
Folate appears to be well tolerated in recommended doses. Avoid if allergic or hypersensitive to folate or any of the product ingredients. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.
Ginkgo: Preliminary study suggests that ginkgo (Ginkgo biloba) may not be effective for depression and seasonal affective disorder (SAD). Other research in elderly patients with depression shows possible minor benefits. Ginkgo may help in decreasing sexual side effects such as loss of libido in individuals taking antidepressants. Overall, there is not enough evidence to form a clear conclusion. It remains unclear if ginkgo is effective for improving mood in post-menopausal women. Further well-designed research is needed as existing study reports conflicting evidence.
Caution is advised when taking ginkgo supplements as numerous adverse effects and drug interactions are possible. Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak, or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (such as aspirin or warfarin) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
Ginseng: A review of several studies suggested that ginseng may improve mood in post-menopausal women. Additional studies are needed before a conclusion can be made.
Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
Guarana: Caffeine, the active ingredient in guarana, may have positive effects on mood enhancement. Caffeine may increase alertness and feelings of well-being and improve performance on sustained attention tasks and simulated driving performance. Slow release caffeine consumption has been correlated with a decrease in calmness and an increase in sleep onset latency.
Avoid if allergic/hypersensitivite to guarana (Paullinia cupana), caffeine, tannins or species of the Sapindaceae family. Avoid with hypertension, psychological or psychiatric disorders, liver impairment, and arrhythmias. Avoid with other stimulatory agents, especially ephedra. Use cautiously with breast disease, impaired kidney function, diabetes, pre-existing mitral valve prolapse, iron deficiency, gastric or duodenal ulcers, bleeding disorders, glaucoma, or if at risk for osteoporosis. Use cautiously if undergoing electroconvulsive therapy (ECT). Avoid if pregnant or breastfeeding.
Healing touch (HT): Preliminary data suggests that a series of healing touch (HT) sessions over time may reduce depression. However, data are insufficient to form definitive conclusions, and studies of better design are needed. HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.
Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. It is an elaborate system focused on healing and "purifying" the mind, body, and emotions. There is preliminary evidence that Kundlini yoga practice may be of benefit in depression. More trials are needed to establish whether this is a viable therapy for depression before a recommendation can be made.
Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, or with poor memory or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis or cervical spondylitis. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.
Lavender: Preliminary research suggests that lavender may be helpful as an adjunct to prescription medications for mild-to-moderate depression. Additional research is necessary before a conclusion can be made.
Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
L-carnitine: L-carnitine (also known as acetyl-L-carnitine) is an antioxidant and may help blood flow as well as neurological function. Although the results are promising there is currently insufficient evidence to support the use of acetyl-L-carnitine in the treatment of depression. Well-designed clinical trials with adequate subject number are required.
Caution is advised when taking acetyl-L-carnitine supplements as numerous adverse effects including drug interactions are possible. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Massage is relaxing and may decrease stress. There is currently insufficient evidence to determine if massage is beneficial in patients with depression. Additional research is necessary in order to form a scientifically based recommendation.
Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery or blood clots. Use cautiously if history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
Meditation: There is currently not enough scientific evidence to suggest the effectiveness of meditation for mood enhancement. Some forms of meditation may prevent relapse in patients who have had bouts of major depression. More studies are needed.
Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
Melatonin: Melatonin has been suggested for the improvement of sleep disturbances in depression, although research is limited in this area. There are several small, brief studies of melatonin in patients with seasonal affective disorder (SAD). This research is not well designed or reported, and further study is necessary before a clear conclusion can be reached.
Melatonin is not to be used for extended periods of time. Caution is advised when taking melatonin supplements as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Use cautiously with drugs broken down by the liver, sedative drugs (Ambien?), barbiturates, narcotics, antidepressants, alcohol, drugs that increase the risk of bleeding such as warfarin (Coumadin?), non-steroidal anti-inflammatories (ibuprofen or naproxen), drugs that affect blood pressure (atenolol), drugs that lower levels of vitamin B6 in the body (such as birth control pills, hormone replacement therapy, or loop diuretics), diazepam, verapamil, temazepam, somatostatin, drugs that alter blood sugar levels (insulin), caffeine, succinylcholine, methamphetamine, isoniazid or herbs or supplements with similar effects (such as 5-HTP, Ginkgo biloba,garlic, saw palmetto, vitamin B12, chasteberry, arginine, DHEA, and Echinacea).
Omega-3 fatty acids, fish oil, alpha-linolenic acid: Essential fatty acids (including omega-3 fatty acids) have many roles in the body, including proper nerve and brain function. There have been several studies on the use of omega-3 fatty acids in depression; however, not enough reliable evidence is available to form a clear conclusion.
Omega-3 fatty acids found in fish oils are normally used. It is important to choose quality fish oil supplements, as heavy metals have been reported in some fish oil supplements. The label should say if the product has been tested for heavy metal contamination (such as lead and mercury). Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/breastfeeding women to a single six-ounce meal per week, and in young children to less than two ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/breastfeeding women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
Prayer, distant healing: Early study suggests that psychiatric inpatients may benefit from anonymous distant healing intention for depression. Additional research is needed.
Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers.
Psychotherapy: Telephone-administered cognitive-behavioral therapy may help treat depression for multiple sclerosis patients, although more study is needed in this area. Short-term psychotherapy for psychosomatic conditions may not be as effective as long-term psychotherapy. More research needs to be done to evaluate these approaches. Psychotherapy may help seasonal affective disorder (SAD). Further study is needed to confirm early results.
Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.
Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated. Qi gong has been studied in elderly patients to assess if it helped with depression in those with chronic physical illnesses. Results were inconclusive, and further research is needed before a recommendation can be made. Qi gong may be used as an adjunct to more proven therapies.
Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders. In cases of potentially serious conditions, Qi gong should not be used as the only treatment instead of more proven therapies, and should not delay the time it takes to see an appropriate healthcare provider.
Reflexology: Reflexology may provide some benefits to patients suffering from depression. However, results from numerous studies have been inconsistent. Further research is needed.
Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
Reiki: Reiki is a Buddhist practice that is approximately 2,500 years old. It is used for stress reduction and relaxation and is administered by "laying on hands" and moving around the "energy" of the body. There is evidence that Reiki may reduce symptoms of depression. Additional research is needed.
Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.
Relaxation therapy: Relaxation therapy includes self-control relaxation, paced respiration, and deep breathing. There is promising early evidence from human trials supporting the use of relaxation to reduce symptoms of depression,although effects appear to be short-lived. Better quality research is necessary before a firm conclusion can be drawn.
Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
Riboflavin (Vitamin B2): Riboflavin is a water-soluble vitamin, which is involved in many processes in the body, and is necessary for normal cell function, growth, and energy production. Adequate nutrient supplementation with riboflavin may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins, including riboflavin, has been reported to improve depression in patients taking tricyclic antidepressants.
Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as being safe during pregnancy and breastfeeding. The U.S. recommended dietary allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women; the RDA during pregnancy is 1.4 milligrams daily, and 1.6 milligrams during breastfeeding.
SAMe: S-adenosylmethionine, or SAMe, is normally formed in the body from the essential amino acid methionine. SAMe supplements are used in depression and mood disorders. SAMe has been studied for use in depression for many decades. However, the majority of trials that have been performed have significant methodological flaws limiting their clinical usefulness. A small number of randomized placebo controlled trials suggest an antidepressant effect that is greater than that observed with placebo. Although some studies have suggested that SAMe has a more rapid onset of action in depression than tricyclic antidepressants (TCAs), it is uncertain whether these effects result in improved patient outcomes. Large randomized placebo controlled trials that compare SAMe to other antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) are needed. Until these trials are available, it is difficult to justify the use of SAMe in patients with depression since there are many effective antidepressants available to this patient population.
Caution should be used when taking SAMe supplements as drug interactions are possible. Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety disorders, or in women in their third trimester of pregnancy. Avoid with bipolar disorder. Avoid during the first trimester of pregnancy or if breastfeeding.
St. John's wort: Studies of St. John's wort for severe depressive disorder have not provided clear evidence of effectiveness. Additionally, despite some promising early data, there is currently not enough evidence to recommend St. John's wort for Seasonal Affective Disorder (SAD). Additional study is needed.
In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. Avoid with protease inhibitors like indinavir (Crixivan?) and non-nucleoside reverse transcriptase inhibitors like nevirapine (Viramune?). St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
Tai Chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility and strength. Preliminary research suggests that tai chi may help alleviate depression. Patients may experience improved mood as a result of tai chi practice. Additional research is needed.
Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and in patients with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while practicing tai chi may increase the risk of injury.
Therapeutic touch: Therapeutic touch may offer some benefits when used with standard therapies to treat depression. More research is needed.
Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
Valerian: There is currently not enough available scientific evidence on the use of valerian for depression.
Use with caution if allergic to members of the Valerianaceaefamily. Avoid if driving or operating heavy machinery, as it may cause drowsiness. Avoid with liver disease. Avoid if pregnant or breastfeeding.
Vitamin B6 (Pyridoxine): Some research suggests that pyridoxine supplementation alone or in combination with high doses of other B vitamins may help with depression. Pyridoxine helps increase the "calming" neurochemicals serotonin and gamma amino butyric acid (GABA) levels in the blood, possibly benefiting people in dysphoric mental states. Well-designed clinical trials are needed to confirm potential benefit. Vitamin B6 may be found in a multivitamin or a B-complex vitamin supplement.
Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). The RDA for pregnant women is 1.9 milligrams per day. For relief of severe nausea in early pregnancy, 30-75 milligrams has been used daily. There is some concern that high-dose pyridoxine taken by a pregnant mother can cause seizures in a newborn. The RDA in breastfeeding women is 2 milligrams per day. Use cautiously if pregnant or breastfeeding.
Vitamin D: In limited available study, vitamin D was found to be better than light therapy in the treatment of seasonal affective disorder (SAD). Further studies are necessary to confirm these findings.
Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.
Fair negative scientific evidence:
Psychotherapy: Several studies suggest that patients with psychotic depression are probably not good candidates for psychotherapy and that medication remains the optimal treatment. More research is needed to determine how psychotherapy may be of benefit in psychotic depression.
Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.

Prevention

Adhering to medical treatments, including medication and therapy, may help reduce the risk of experiencing recurrent depression.
Having a strong support system of family and friends may help prevent an individual from developing depression or experiencing a relapse.
Patients should learn to recognize the early symptoms of depression relapse.
Proper nutrition and regular exercise may improve the mental health of individuals who suffer from depression.
Since isolation may contribute to symptoms of depression, especially in HIV patients who may feel stigmatized because of their illness, patients are encouraged to participate in social activities with friends and/or family members.
Patients are also encouraged to maintain regular sleeping schedules. Too much or too little sleep may exacerbate symptoms of depression.

Complications

Suicidal thoughts may accompany depression. Anyone who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.
Untreated depression among HIV patients has been associated with reduced adherence to antiretroviral therapy (anti-HIV drugs). These drugs are less effective when not taken exactly as prescribed. Also, forgetting to take medication or taking it at the wrong time may lead to drug resistance, which can worsen the patient's prognosis and limit future treatment options. One study found that HIV patients who suffered from depression and received antidepressants were more likely to adhere to their antiretroviral therapy regimens.
Patients who suffer from depression and are not receiving treatment may also suffer from a diminished quality-of life because they no longer enjoy activities that were once pleasurable.
Depression may make it difficult for individuals to maintain healthy interpersonal relationships.

Other types of depression

Bipolar disorder I: Bipolar disorder (formerly called manic depression) is characterized by an alternating pattern of emotional highs (mania) and lows (depression). Bipolar I disorder involves one or more manic or mixed episodes, and often one or more major depressive episodes. A depressive episode may last for several weeks or months. Between episodes of bipolar I disorder, there may be periods of normal functioning. Symptoms may also be related to seasonal changes.
Bipolar disorder II: Bipolar II disorder involves one or more major depressive episodes along with at least one hypomanic episode. Hypomanic episodes have symptoms similar to manic episodes, but they are less severe. There may be periods of normal functioning between episodes of bipolar II disorder. Symptoms may also be related to seasonal changes.
Dysthymia: Dysthymia is a long-term, mild form of depression that lasts for at least two years. Symptoms are generally less severe than major depression. Dysthymia often begins during adolescence and continues throughout life. It is possible for patients with dysthymia to also develop major depressive episodes in the future. When this occurs, the condition is known as double depression.
Hypomania: Hypomania is a milder, less dramatic form of mania. A person may feel good, and may think that he or she is getting more things done. However, the good feeling can change into full-blown mania or depression at any time.
Postpartum depression: Postpartum depression, also known as post-natal depression, is clinical depression that develops in women within two years of giving birth.
Premenstrual dysphoriais: Premenstrual dysphoriais occurs when women experience recurrent depressive symptoms that are associated with menstrual cycles.
Seasonal affective disorder (SAD): Seasonal affective disorder (SAD), also known as winter depression, is a cyclic form of depression that occurs during the winter months.

When to consult a healthcare provider

Individuals who continually feel sad or irritable.
Individuals who notice significant changes in sleep habits, appetite, and energy levels.
Individuals who have difficulty thinking, concentrating, and remembering.
Individuals who no longer enjoy activities that were once pleasurable.
Individuals who experience feelings of guilt, worthlessness, hopelessness, and emptiness.
Individuals who have recurrent thoughts of death or suicide.
Individuals who experience persistent physical symptoms like headaches, digestive problems, and chronic pain that do not respond to treatment.