Joe's POZ Blog

Depression: one of the most dreaded words in the English language. The word even sounds dismal and that pretty well sums up the effects of depression. Depression or severe depression, often called clinical depression, is a psychological disease that often goes undetected when it appears in conjunction with HIV infection. (For the sake of discussion I will simply refer to the disease as depression.) Too often, depression can be present, but often it may be attributed to feelings surrounding the HIV infection and excluded as a valid disease, in addition to the HIV infection. I believe it is a vastly under-diagnosed illness and its treatment is often portrayed as being more complicated that it has to be. It's an illness that I have suffered from for the past 15 years. I am disabled, not due to my HIV infection, but because I have clinical depression, as that is how I receive my disability insurance from Social Security.

Depression can devastate your life if left untreated and my hope is that is you see yourself here, you will consider being evaluated for depression. Depression is just that, depression. It is not being unhappy because you don't have a Porsche or did not win the lottery, as being unhappy is fleeting and soon forgotten. Depression hangs above you as a sword of Damocles, shrouding your existence in feelings of hopelessness and futility. If left untreated, it can drain the very essence from your being. It can be forever present, seldom witnessed by others; yet its effect remains unmistakable.

As with any disease, there are signs and in the interest of clarifying what depression is/is not, I present a list of the most common signs of depression.

You feel miserable and sad.

You feel exhausted a lot of the time with no energy.

You feel as if even the smallest tasks are sometimes impossible.

You seldom enjoy the things that you used to enjoy, you may be off sex or food or may 'comfort eat' to excess.

You feel very anxious sometimes

You don't want to see people or are scared to be left alone. Social activity may feel hard or impossible.

You find it difficult to think clearly.

You feel like a failure and/or feel guilty a lot of the time.

You feel a burden to others.

You sometimes feel that life is not worth living.

You can see no future. There is a loss of hope. You feel all you've ever done is make mistakes and that's all you will ever do.

You feel irritable or angry more than usual.

You feel you have no confidence.

You spend a lot of time thinking about what has gone wrong, what will go wrong or what is wrong about yourself as a person. You may also feel guilty sometimes about being critical of others.

You feel that life is unfair.

You have difficulty sleeping or wake up very early in the morning and can't sleep again. You seem to dream all night long and sometimes have disturbing dreams.

You feel that life has/is 'passing you by.'

You may have physical aches and pains, which appear to have no physical cause, such as back pain.

Using the signs above, they can be combined into symptoms that can represent clinical depression. If you have any of the following symptoms, generally five (or more), that have been present during the same 2-week period and represents a change from your previous functioning, you may have clinical depression.

Depressed mood most of the day, nearly every day, as indicated by feeling sad or empty or as an observation make by others (e.g. appears fearful).

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective report or observation made by others).

Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

If you have clinical depression, you will probably not experience all of the above signs, but will generally manifest at least half of them. They will usually persist for at least 2 weeks and may increase in intensity. I also include this list as education for others, because the effects of depression are far reaching and actually seem to be clearer when presented in a clinical fashion. Unfortunately the complexity of depression is what I think is the most insidious aspect of depression. It's so difficult to describe depression to others, to make them understand what you are experiencing, without sounding insane, even to yourself. How do you tell someone that you can go from loving life, to total isolation and back again within a four-hour time frame? Doesn't that sound awfully crazy to you? It does to me and I live it. But I suspect if you suffer from depression, what I have written might make perfect sense.

So let me take you on a voyage through my depression. The only reason I can describe this cycle, is because right now, I am on the outside looking back in. When I am mired in depression, I do not have much perception of anything, nor can I see issues clearly. The world looks bleak, there is little hope and what I wish for many times, is for all of it to simply go away. There are times, when the darkness becomes so black, that I have considered another existence. I have wondered if maybe death may not be so bad after all. But then again, I often do not really care because often, I simply cannot.

It's like being hypnotized, or as if you are being controlled by some type of puppet master. It can be quite surreal and the mood swings, within the same minute, hour or day, can be as wild as you can imagine. I have gone from happily married to divorce, in a matter of a few hours, on those days that the wiring just does not connect. It is all I can do to hold myself together, until the disconnect passes. I feel like I am witnessing a train wreck in progress, yet powerless to do anything about it. I often wonder if my actions expose my emotions, but since everything remains surreal, cognitive analysis is generally impossible. I know I feel funny, but I am unable to change those feelings, until they melt away on their own. Or at least I think I feel funny, but I can't always tell, because it also affects my perception of things and causes me to doubt my own abilities.

At the peak of my depression, I am wavering between reality and the realm of depression. When I can hold back the depression, my life continues, challenges intact, but continues nonetheless. But when I am depressed, it's like looking through a portal. I can still see my life, on the other side, but I am powerless to return to it, nor do I care to and that lack of caring or desire is ultimately what depression takes from you. It's not that you are simply unhappy, because you are not anything. You don't even feel sad or depressed per se, because you really don't feel anything. You begin to doubt your own sensibilities and often wonder just which way is up. Actually, I'm not even sure if any of this makes sense, but how do you describe the indescribable?

So now, take these periods of depression and try and formulate both a treatment plan for your depression and a health care plan for your HIV. Try and figure out how to take care of yourself, when you don't care about much of anything. Somehow you must find a way to compel yourself forward, but the amount of energy required always seems to be of inverse proportion, to what you want to accomplish. Just going to a doctor appointment, can wipe you out for three days. Add to that, your total lack of interest in anything, including food, your meds, exercise, etc. and you can be looking at some serious down time. And no, you just can't snap out of it, so don't ever be so asinine to suggest that to anyone who suffers from depression. Do you really think anyone would want depression? It is not something that can be controlled solely through willpower, nor does it indicate a weakness on the part of the sufferer.

Treating depression can be serious business and often requires a multiple approach including medications and therapy. The hard part though is identifying when you have depression, because when you have it, it does not just mean you are unhappy and you don't develop it over night. The best advice I can offer, is you should consider a mental health checkup if you notice a drastic change in your life, due to increasing indifference. I know it sounds like an oxymoron; seek help at the point where you have no interest in anything and be aware of that indifference, but it's the best I can offer. (This is the time, when your good friends' or partner, seeing you in these words, gently prods you to consider that you might be suffering from depression).

Also know, that you can maintain a wonderful life, assuming you diagnose and treat your depression. You need to see depression for what it is: a disease. Fortunately, it is a disease that can very often be treated successfully, often quite easily for mild to moderate depression, while clinical depression might require a more intense treatment. Medication can play an important part in treating depression, but some of the antidepressants can take from 2-3 weeks to be effective and you just have to tough out that initial wait. Also, on average, many people must go through up to 6 drugs before finding one that works for them. So if you are going to consider medications, please seek the guidance of a good psychiatrist in prescribing those medications, as most ID doctors are not that good at treating depression. But don't forget to review the drug recommendations with your ID doctor, because psychiatrists are usually not very familiar with all the possible reactions that antidepressants may have with HIV medications.

Therapy can also be an important form of treatment, but can present its own set of challenges. Assuming you find a good fit in a therapist, there is always the background work that you need to do, to bring them up to speed and for some of us, talking about private, intimate details can be a formidable challenge. But therapy remains one of the few things in life, where you will only get out of it, what you put into it. It isn't a test, there are no right or wrong answers, nor is there any shame in admitting you need some help with your mental health. Therapy also does not need to last forever. We possess more than one form of health, so consider mental health treatment and a therapist to be no different from your HIV infection and your ID doctor.

Through my experience with depression I have developed many tools that help me move through the dark times. Some are very simple, such as diverting my attention, or getting some exercise. Often a power-nap will clear the cobwebs or just remaining quiet for a period of time. Others can be difficult and take some time, but the goal is always to identify signs of your depression and work on the issues that may be contributing to them. A favorite tool of mine, is asking myself "what is the worst thing that can happen?", when I become especially anxious. And generally when I answer that question and process the meaning, the anxiety will diminish because depression always colors your perceptions. Whether or not these techniques would work for you, does not matter so much, as you realizing that you can develop tools to help you in treating your own depression.

Treating depression may not be easy, quick, and often not for the faint of heart. But in the end, you have no choice, but to treat it and for two simple reasons. The first, is that you cannot continue living with your depression and at some point, you will decide that you must address the problem head on. The second is that, at some point in your treatment, maybe after months of trying some antidepressants, or months of therapy, or both, you will wake up one morning and you will notice a marked change. Part of your being will once again emerge, from your depression and you will regain some of your interests and desires. Each day, those feelings will increase and as you regain your life, your essence will return. You'll remember all the things you need to do, which in itself is amazing, but you will also have the desire and energy to complete those tasks. Everything that you love and enjoy and hate and despise will return. You will slowly return to your own reality.

For the first time, in a very long time, you will be able to look back and see not only where you were, but how far you have come. You will have emerged from your depression and returned to your previous existence. When you reach that moment, you will understand how important both the necessity of and the journey itself truly are and the fruit of that labor, will be very sweet indeed.

Too many of us live under the cloud of depression and that is not necessary. I have decided to tell my story, because I know the damage that depression can do and all I ask is that if you see yourself in my words, that you consider a mental health checkup. Depression is an illness and nothing more. You don't deserve it, nor did you do anything wrong that caused you to develop depression. You don't have to swallow your pride to receive effective treatment, nor must you remain in the darkness.