Hepatitis C: How to manage mood during interferon treatment
Support patients through lengthy antiviral regimen.
Forty-eight weeks of treatment are recommended for patients with HCV genotype 1 (70% of patients) and 24 weeks for those with HCV genotypes 2 and 3 (15% to 25% patients).
Some patients—particularly those with genotype 1b—do not respond to IFN therapy. For nonresponders, repeated trials of longer duration or different types of IFN may be tried. Higher IFN dosages or more frequent administration are not viewed as beneficial.
Side effects. Sustained response rates 6 months after patients complete interferon treatment are:
Many of IFN’s early side effects are neurovegetative and overlap with psychiatric symptoms. The more specific psychiatric side effects of irritability, anxiety, insomnia, depression, and impaired concentration develop in 1 to 32 weeks of treatment (mean 12.1 weeks).19,20 Fatigue and depression are the main reasons 10% to 14% of outpatients in large randomized trials discontinue HCV treatment.21
Table 3
HCV testing protocols
| HCVab | If positive then do a HCV Riba |
| HCV Riba | If positive 2 bands or more, then do a HCV Genotype and HCV PCR |
| HCV Genotype | Genotype determines duration of treatment |
| HCV PCR Qualitative and/or Quantitative | Confirms presence of the virus |
| Liver biopsy | Determines the extent of liver damage from fibrosis or cirrhosis |
Case Continued: Preventing Relapse
During therapy, Mr. R completes the BDI and Fatigue Severity Scale (FSS) weekly. His pretreatment BDI score of 9 (normal) increases over time to 22 (mild to moderate depression), and his FSS scores range from 4 to 6, indicating fatigue sufficient to impair daily functioning. Medical and psychiatric staff address his symptoms during weekly treatment assessments.
After 12 weeks of treatment his viral levels are undetectable, but he develops severe fatigue and mild irritability that contribute to arguments with his wife. He is referred to supportive counseling, and citalopram is increased to 40 mg/d. His wife tests negative for HCV.
Monitor patients closely during IFN treatment, regardless of whether an antidepressant is prescribed. If depression abruptly worsens or mania emerges, IFN might need to be discontinued until the patient’s psychiatric disorder is stabilized. Adding an atypical antipsychotic—such as olanzapine, 10 to 20 mg/d—can help patients with psychosis, mania, mood lability, impulsivity, or irritability.22
For patients with substantial fatigue, we may supplement antidepressants with modafinil, 100 to 200 mg/d, which caused some improvement in an open trial as measured by the FSS.23 Support groups and cognitive-behavioral therapy have shown modest benefit.
Case Continued: Staying Healthy
Mr. R completes treatment, and his prognosis for remaining virus-free remains good. His fatigue and irritability resolve, and his BDI score returns to 9. One year later, he maintains a negative viral load. He periodically returns to his gastroenterologist for monitoring and continues in a chemical dependency relapse prevention program.
Mr. R acknowledges that his HCV-seronegative status motivates him to stay sober. Citalopram was withdrawn 1 month after he completed antiviral treatment, and his wife has not noted resurgent irritability. He has returned to work, and his supervisors report satisfactory task completion.
Related resources
- American Liver Foundation. www.liverfoundation.org.
- U.S. Centers for Disease Control and Prevention. Viral Hepatitis. www.cdc.gov/hepatitis.
- Hep C Connection. www.hepc-connection.org.
- Hepatitis C Support Project. www.hcvadvocate.org.
- National Institute of Mental Health. Depression. www.nimh.nih.gov/healthinformation/depressionmenu.cfm.
- U.S. Department of Veterans Affairs National Hepatitis C Program. www.hepatitis.va.gov.
- Bupropion • Wellbutrin
- Citalopram • Celexa
- Duloxetine • Cymbalta
- Fluoxetine • Prozac
- Modafinil • Provigil
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Venlafaxine • Effexor
Dr. Martin, Dr. Krahn, and Ms. Rosati report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Balan receives research grants from Novartis, Roche Pharmaceuticals, Schering-Plough, InterMune, SciClone Pharmaceuticals, and Human Genome Sciences.
