Hepatitis C: How to manage mood during interferon treatment

Current Psychiatry. 2006 November;05(11):69-79

November 1, 2006|Psychiatry

Kari A. Martin, MD

Support patients through lengthy antiviral regimen.

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Hepatitis C: Risk of infection and disease progression

HCV affects 2% of the U.S. population but 20% of persons with severe mental illness
Average annual new infections declined to 36,000 in 1996 from a high of 230,000 in the 1980s, which for reasons that are unclear correlates with a decrease in cases among IV drug users
Progression of HCV infection is the leading cause of liver transplants in the United States
Persons infected with HCV are at an increased risk for disease progression if they drink alcohol (>2 drinks/day for men under age 65, >1 drink/day for nonpregnant women and all persons over age 66), are age >40 years at time of infection, or are HIV-positive
Deaths from acute liver failure are rare
Chronic HCV infection causes 8,000 to 10,000 deaths per year

Source: References 24 and 25

Whether or not patients with a psychiatric history are at increased risk, the incidence of neuropsychiatric effects with IFN remains high (Table 2) and warrants attention.^8-11

Psychiatric assessment. Assess all IFN candidates for present or past psychiatric disorders, including:

depression
suicidal thoughts (in one study, 43% of patients on IFN therapy reported suicidal ideation)¹²
bipolar disorder (selective serotonin reuptake inhibitors [SSRIs] could induce mania or aggravate cycling)
chemical dependency (substance abuse may represent the patient’s attempt to self-medicate underlying mood and anxiety symptoms).

Perform a baseline psychiatric exam to evaluate the patient’s emotional suitability for treatment and to screen for depression, anxiety disorders, posttraumatic stress disorder, bipolar disorder, and personality disorders. Evaluate the patient’s social support system, which may be augmented with group or individual therapy if deficient. Assess for depression and other psychiatric symptoms periodically and in some cases weekly during antiviral therapy.

Case Continued: Getting Ready

Although Mr. R no longer uses street drugs, he tells the psychiatrist he drinks 2 to 3 beers nightly. Because alcohol use stresses a compromised liver and could undermine IFN therapy’s effectiveness, he agrees to complete a chemical dependency program, demonstrate 6 months of sobriety before starting HCV treatment, and enroll in a chemical dependency relapse prevention program where unannounced drug and alcohol screenings are conducted.

As his IFN treatment approaches, Mr. R agrees to begin prophylactic citalopram, 20 mg/d, because he may be at increased risk for IFN-induced depression. Although Mr. R’s past depressive episodes responded well to fluoxetine, the psychiatrist chooses citalopram during IFN treatment because of its lower risk of drug-drug interactions.

Alcohol and IFN. Continued alcohol use can accelerate HCV-induced liver disease and reduce the likelihood of viral clearance with IFN treatment. One study showed that individuals who enrolled in a substance abuse treatment program were more likely to complete HCV treatment.¹³

This study also reported that HCV-seropositive patients were more likely to complete a 28-day chemical dependency treatment and remain abstinent 6 months after program discharge, compared with HCV-seronegative patients.¹³ This suggests that a chronic hepatitis C diagnosis motivates patients to address chemical dependency as a pre-requisite for hepatitis C treatment.

Table 2

Psychiatric side effects with interferon/ribavirin treatment*

Side effect	Prevalence
Irritability, anxiety	33% to 45%
Insomnia	30% to 40%
Depression	20% to 31%
Impaired concentration	10% to 17%
Aggressive behavior
Psychotic disorder
Suicide
* In patients without a history of psychiatric disorders
Source: References 19 and 20

Prophylactic antidepressants can be used in patients with a history of depressive episodes or baseline Beck Depression Inventory (BDI) scores >10. Prophylaxis is quite tolerable compared with IFN-induced depression, which has an insidious onset and can be associated with aggression, suicide risk, and interferon discontinuation.

Start antidepressants 2 to 4 weeks before antiviral therapy begins to allow the medication to reach therapeutic efficacy. SSRIs such as paroxetine, 10 to 50 mg/d, and citalopram, 20 to 40 mg/d, have been reported to be effective and do not interact with HCV therapies.^5,14 In our experience, dual-action antidepressants such as duloxetine, venlafaxine, or bupropion also can be beneficial.

IFN Treatment Protocol

Mr. R begins a 48-week IFN protocol. To maximize the treatment’s effectiveness, he is given long-acting pegylated interferon, 180 mcg injected weekly, and takes oral ribavirin, 600 mg twice daily.

IFN plus ribavirin. The mainstay of HCV therapy is IFN, a cytokine immunotherapeutic agent. A long-acting IFN administered weekly—called pegylated because the compound is bound to polyethylene glycol—doubles the sustained viral response rate and is now widely used.

Pegylated interferon is often combined with ribavirin—an oral nucleoside analog that has been shown to improve outcomes. Ribavirin increases the risk of hemolysis, however, which mandates frequent blood count monitoring. The NIH recommends pegylated interferon and ribavirin for patients with:

detectable HCV RNA viral loads >50 copies per ml of blood
liver biopsy with portal or bridging fibrosis
and at least moderate inflammation and necrosis.

References