Depression, anxiety, post-traumatic stress, and alcohol-related problems among veterans with chronic hepatitis C

Relationship between anxiety sensitivity and post-traumatic stress symptoms in trauma-exposed adults: A meta-analysis

Given the high rate of trauma exposure among the general population, it is important to delineate the risk factors for post-traumatic stress disorder (PTSD). While historically implicated in panic disorder, anxiety sensitivity is increasingly found to play a role in PTSD. The present review investigated the size of the relationship between anxiety sensitivity and PTSD symptoms among trauma exposed adults. A systematic search on multiple electronic databases (PTSDpubs, CINAHL, MEDLINE and PsycINFO) generated a total of 1025 records, among which 52 (n = 15173) met study inclusion criteria and were included in our random effects meta-analysis. Our results indicated a medium effect size (r = .46, 95% CI =.41,.50) for the relationship between anxiety sensitivity and PTSD symptoms. There was significant between-study heterogeneity. Furthermore, sub-group analyses revealed that study design (cross-sectional vs. longitudinal) may significantly moderate the association between anxiety sensitivity and PTSD severity. No moderation effect was found for assessment of PTSD through interview versus questionnaire, interpersonal versus non-interpersonal trauma, or low versus high study quality. Such patterns of results are consistent with cognitive models of PTSD. Clinical implications, strengths and limitations of the review were discussed.

Pandemic Fatigue and Anxiety Sensitivity as Associated Factors With Posttraumatic Stress Symptoms Among University Students in South Korea During the Prolonged COVID-19 Pandemic

Objectives: The global impact of COVID-19 driven by new variants may add to the negative mental health consequences of the prolonged pandemic, including posttraumatic stress symptoms (PTSS). University students may be prone to develop a series of PTSS due to life plan disruptions as well as increased uncertainty caused by the pandemic. The purpose of this study was to assess the associations between pandemic fatigue, anxiety sensitivity (AS), and PTSS among university students in South Korea.

Methods: Using convenience sampling, 400 students participated in this cross-sectional online survey. Descriptive statistics and linear mixed models were used to examine factors associated with PTSS.

Results: About one-third (32.3%) of the participants reported clinically significant levels of PTSS. Multivariate analyses revealed that pandemic fatigue (β = 0.124, p < 0.001) and AS (β = 0.212, p < 0.001) were significantly associated with PTSS while controlling for other study variables.

Conclusion: Young adults who feel more fatigue related to the COVID-19 pandemic and with high AS should be given access to mental health resources to better manage their mental health and reduce PTSS.

Failure to replicate associations between Toxoplasma gondii or hepatitis C virus infection and personality traits

Background

Infections with Toxoplasma gondii (Toxo), a protozoan that can infect the brain, have been reported to alter behavior in rodents and humans; several investigators have related Toxo infection to personality traits such as novelty seeking in humans. We investigated human personality traits in relation to Toxo in Egypt, where such infection is common.

Results

In a community-based sample of Egyptian adults (N = 255), Toxo infection were indexed by levels of IgG antibodies. Viruses like hepatitis C virus (HCV) have also been associated with cognitive dysfunction and mood disorders; therefore, HCV antibody titers were also assayed for comparison. The antibody levels were analyzed in relation to the Arabic version of the NEO personality inventory (NEO-FFI-3), accounting for demographic variables. No significant correlations were noted with Toxo or HCV antibody levels, after co-varying for demographic and socio-economic factors and following corrections for multiple comparisons.

Conclusions

Infection with Toxo or HCV infection was not associated with variations in personality traits in a sample of Egyptian adults. The possible reasons for the discordance with prior reported associations are discussed.

Health care costs associated with hepatitis C virus infection in First Nations populations in Ontario: a retrospective matched cohort study

BACKGROUND

Colonization and marginalization have affected the risk for and experience of hepatitis C virus (HCV) infection for First Nations people in Canada. In partnership with the Ontario First Nations HIV/AIDS Education Circle, we estimated the publicly borne health care costs associated with HCV infection among Status First Nations people in Ontario.

METHODS

In this retrospective matched cohort study, we used linked health administrative databases to identify Status First Nations people in Ontario who tested positive for HCV antibodies or RNA between 2004 and 2014, and Status First Nations people who had no HCV testing records or only a negative test result (control group, matched 2:1 to case participants). We estimated total and net costs (difference between case and control participants) for 4 phases of care: prediagnosis (6 mo before HCV infection diagnosis), initial (after diagnosis), late (liver disease) and terminal (6 mo before death), until death or Dec. 31, 2017, whichever occurred first. We stratified costs by sex and residence within or outside of First Nations communities. All costs were measured in 2018 Canadian dollars.

RESULTS

From 2004 to 2014, 2197 people were diagnosed with HCV infection. The mean net total costs per 30 days of HCV infection were $348 (95% confidence interval [CI] $277 to $427) for the prediagnosis phase, $377 (95% CI $288 to $470) for the initial phase, $1768 (95% CI $1153 to $2427) for the late phase and $893 (95% CI -$1114 to $3149) for the terminal phase. After diagnosis of HCV infection, net costs varied considerably among those who resided within compared to outside of First Nations communities. Net costs were higher for females than for males except in the terminal phase.

INTERPRETATION

The costs per 30 days of HCV infection among Status First Nations people in Ontario increased substantially with progression to advanced liver disease and finally to death. These estimates will allow for planning and evaluation of provincial and territorial population-specific hepatitis C control efforts.

Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA.

AIMS

We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting.

METHODS

A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics.

RESULTS

One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services.

CONCLUSION

Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.

Anxiety sensitivity in the association between posttraumatic stress and substance use disorders: A systematic review

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No evidence-based, "gold standard" treatments for PTSD/SUD comorbidity are currently available. Thus, it is imperative to better understand cognitive-affective mechanisms, targetable via cognitive-behavioral intervention (i.e., malleable), that may be related to both disorders in order to improve the theory and treatment of PTSD/SUD. Anxiety sensitivity is a malleable cognitive-affective factor with relevance to both PTSD and SUD. This systematic review focused on the published literature on anxiety sensitivity and trauma/PTSD and substance use/SUD from 1966 - May 1, 2018, and includes a total of 35 manuscripts. The state of the literature, limitations, and future research directions are discussed.

A Randomized Trial of Off-Site Collaborative Care for Depression in Chronic Hepatitis C Virus

OBJECTIVE

To test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care.

DATA SOURCES/STUDY SETTING

Hepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals.

STUDY DESIGN

We compared off-site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (≥50 percent decrease in 20-item Hopkins Symptoms Checklist [SCL-20] score), remission (mean SCL-20 score, <0.5), and depression-free days (DFDs). Primary HCV outcome was receipt of HCV treatment.

DATA COLLECTION

Patient data were collected by self-report telephone surveys at baseline and 12 months, and from electronic medical records.

PRINCIPAL FINDINGS

Baseline screening identified 292 HCV-infected patients with depression, and 242 patients completed 12-month follow-up (82.9 percent). Intervention participants were more likely to report depression treatment response, remission, and more DFDs than usual care participants. Intervention participants were more likely to receive antiviral treatment; however, the difference was not statistically significant.

CONCLUSION

Off-site depression collaborative care improved depression outcomes in HCV patients and may serve as a model for collaboration between mental health and specialty physical health providers in other high co-occurring conditions.

Adapting a computer-delivered brief alcohol intervention for veterans with Hepatitis C

OBJECTIVE

This study adapted an existing computer-delivered brief alcohol intervention (cBAI) for use in Veterans with the hepatitis C virus (HCV) and examined its acceptability and feasibility in this patient population.

METHODS

A four-stage model consisting of initial pilot testing, qualitative interviews with key stakeholders, development of a beta version of the cBAI, and usability testing was used to achieve the study objectives.

RESULTS

In-depth interviews gathered feedback for modifying the cBAI, including adding HCV-related content such as the health effects of alcohol on liver functioning, immune system functioning, and management of HCV, a preference for concepts to be displayed through "newer looking" graphics, and limiting the use of text to convey key concepts. Results from usability testing indicated that the modified cBAI was acceptable and feasible for use in this patient population.

CONCLUSIONS

The development model used in this study is effective for gathering actionable feedback that can inform the development of a cBAI and can result in the development of an acceptable and feasible intervention for use in this population. Findings also have implications for developing computer-delivered interventions targeting behavior change more broadly.

Co-occurring Depression, Chronic Pain and Substance Use Disorders in People with Hepatitis C

Chronic infection with Hepatitis C virus (HCV) is common and can result in serious and sometimes fatal liver complications. The impact of HCV on the liver can be further complicated by medical and psychological comorbidities. Depression, substance use, and pain syndromes are frequent co-morbid conditions in people with HCV and diminish functioning, quality of life, and treatment compliance. Understanding the underlying biological mechanisms of these comorbid conditions within the context of HCV may help elucidate factors contributing to their co-occurrence, perhaps mediatedviapro-inflammatory cytokines. The current review provides a synthesis of the literature on depression, substance use disorders and chronic pain in the presence of HCV. The review includes studies conducted with both veteran and civilian populations. The implications for assessment and antiviral treatment of HCV will be considered.

Liver mortality attributable to chronic hepatitis C virus infection in Denmark and Scotland--using spontaneous resolvers as the benchmark comparator

Liver mortality among individuals with chronic hepatitis C (CHC) infection is common, but the relative contribution of CHC per se versus adverse health behaviors is uncertain. We explored data on spontaneous resolvers of hepatitis C virus (HCV) as a benchmark group to uncover the independent contribution of CHC on liver mortality. Using national HCV diagnosis and mortality registers from Denmark and Scotland, we calculated the liver mortality rate (LMR) for persons diagnosed with CHC infection (LMRchronic ) and spontaneously resolved infection (LMRresolved ), according to subgroups defined by age, sex, and drug use. Through these mortality rates, we determined subgroup-specific attributable fractions (AFs), defined as (LMRchronic - LMRresolved )/LMRchronic , and then calculated the total attributable fraction (TAF) as a weighted average of these AFs. Thus, the TAF represents the overall fraction (where 0.00 = not attributable at all; and 1.00 = entirely attributable) of liver mortality attributable to CHC in the diagnosed population. Our cohort comprised 7,005 and 21,729 persons diagnosed with HCV antibodies in Denmark and Scotland, respectively. Mean follow-up duration was 6.3-6.9 years. The TAF increased stepwise with age. It was lowest for death occurring at <45 years of age (0.21 in Denmark; 0.26 in Scotland), higher for death occurring at 45-59 years (0.69 in Denmark; 0.69 in Scotland), and highest for death at 60+years (0.92 in Denmark; 0.75 in Scotland). Overall, the TAF was 0.66 (95% confidence interval [CI]: 0.55-0.78) in Denmark and 0.55 (95% CI: 0.44-0.66) in Scotland.

CONCLUSIONS

In Denmark and Scotland, the majority of liver death in the CHC-diagnosed population can be attributed to CHC-nevertheless, an appreciable fraction cannot, cautioning that liver mortality in this population is a compound problem that can be reduced, but not solved, through antiviral therapy alone.

Psychiatric and substance use disorders co-morbidities and hepatitis C: Diagnostic and treatment implications

Chronic hepatitis C virus (HCV) viral infection is the most common blood-borne viral infection and approximately 2%-3% of the world’s population or 170-200 million people are infected. In the United States as many as 3-5 million people may have HCV. Psychiatric and substance use disorders (SUDs) are common co-morbid conditions found in people with HCV and are factors in predisposing people to HCV infection. Also, these co-morbidities are reasons that clinicians exclude people from antiviral therapy in spite of evidence that people with HCV and co-morbid psychiatric and SUD can be safely and effectively treated. Furthermore, the neuropsychiatric side effects of interferon (IFN), until recently the mainstay of antiviral therapy, have necessitated an appreciation and assessment of psychiatric co-morbidities present in people with HCV. The availability of new medications and IFN-free antiviral therapy medication combinations will shorten the duration of treatment and exposure to IFN and thus decrease the risk of neuropsychiatric side effects. This will have the consequence of dramatically altering the clinical landscape of HCV care and will increase the number of eligible treatment candidates as treatment of people with HCV and co-morbid psychiatric and SUDs will become increasingly viable. While economically developed countries will rely on expensive IFN-free antiviral therapy, less developed countries will likely continue to use IFN-based therapies at least until such time as IFN-free antiviral medications become generic. The current manuscript discusses the efficacy and viability of treating HCV in people with psychiatric and SUDs comorbidities, the treatment of the neuropsychiatric side effects of IFN -based therapies and the impact of new medications and new treatment options for HCV that offer the promise of increasing the availability of antiviral therapy in this vulnerable population.

The effect of stimulant use on antiviral treatment in an integrated hepatitis clinic

OBJECTIVE

The objective was to determine the impact of stimulant use on antiviral treatment for chronic hepatitis C patients in an integrated hepatitis clinic.

METHODS

A retrospective chart review of 449 consecutive patients seen in an integrated hepatitis clinic that included co-located mental health clinicians was performed. Psychiatric measures included drug use questionnaire, Beck Depression Inventory (BDI), Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C), urine drug screen and antiviral treatment outcomes. Patients with stimulant use were compared to patients with no drug use, other drug users and an unknown drug use group using χ(2) and analysis of variance tests.

RESULTS

Over 15% of hepatitis C patients presenting to the clinic were using stimulants. Stimulant users had higher BDI and AUDIT-C scores. They were more likely to be followed by a co-located mental health clinician than other groups and were just as likely to initiate and finish antiviral therapy.

CONCLUSIONS

Recent stimulant use is common in hepatitis C patients presenting to a hepatitis clinic. Stimulant users were more depressed and used alcohol to a greater degree than nonusers but were as likely to start antiviral therapy. An integrated mental health/medical care approach appears to be effective in addressing this difficult-to-treat population.

Evidence for a dysregulated immune system in the etiology of psychiatric disorders

There is extensive bi-directional communication between the brain and the immune system in both health and disease. In recent years, the role of an altered immune system in the etiology of major psychiatric disorders has become more apparent. Studies have demonstrated that some patients with major psychiatric disorders exhibit characteristic signs of immune dysregulation and that this may be a common pathophysiological mechanism that underlies the development and progression of these disorders. Furthermore, many psychiatric disorders are also often accompanied by chronic medical conditions related to immune dysfunction such as autoimmune diseases, diabetes and atherosclerosis. One of the major psychiatric disorders that has been associated with an altered immune system is schizophrenia, with approximately one third of patients with this disorder showing immunological abnormalities such as an altered cytokine profile in serum and cerebrospinal fluid. An altered cytokine profile is also found in a proportion of patients with major depressive disorder and is thought to be potentially related to the pathophysiology of this disorder. Emerging evidence suggests that altered immune parameters may also be implicated in the neurobiological etiology of autism spectrum disorders. Further support for a role of immune dysregulation in the pathophysiology of these psychiatric disorders comes from studies showing the immunomodulating effects of antipsychotics and antidepressants, and the mood altering effects of anti-inflammatory therapies. This review will not attempt to discuss all of the psychiatric disorders that have been associated with an augmented immune system, but will instead focus on several key disorders where dysregulation of this system has been implicated in their pathophysiology including depression, schizophrenia and autism spectrum disorder.

Poly I:C-induced activation of the immune response is accompanied by depression and anxiety-like behaviours, kynurenine pathway activation and reduced BDNF expression

In this study we characterised the ability of the viral mimetic poly I:C to induce a neuroinflammatory response and induce symptoms of depression and anxiety in rats. Furthermore, the ability of poly I:C to deplete central tryptophan and serotonin via induction of indolamine 2,3 dioxygenase (IDO), and also the ability of poly I:C to impact upon expression of the neurotrophin BDNF and its receptor TrkB were examined as potential mechanisms to link inflammation to depression. Poly I:C induced a neuroinflammatory response characterised by increased expression of IL-1β, IL-6, TNF-α and CD11b in frontal cortex and hippocampus. In the first 24h following poly I:C administration rats displayed sickness behaviour characterised by reduced locomotor activity and weight gain. Anhedonia measured using the saccharin preference test was used as an indicator of depressive behaviour, and poly I:C induced depressive behaviour that persisted for up to 72h following administration. Anxiety was measured using the open field test and anxious behaviour was observed 24h following poly I:C, a time-point when sickness behaviour had resolved. These behavioural changes were accompanied by decreased expression of BDNF and TrkB in hippocampus and frontal cortex. In addition, poly I:C increased central IDO expression and increased concentrations of tryptophan, and its metabolite kynurenine. However this activation of the kynurenine pathway did not result in reduced central serotonin concentrations. These findings suggest that depressive and anxiety-like behaviours elicited by poly I:C are associated with a reduction in BDNF signalling, and activation of the kynurenine pathway, but not a reduction in serotonin.

Absolute and relative contraindications to pegylated-interferon or ribavirin in the US general patient population with chronic hepatitis C: results from a US database of over 45 000 HCV-infected, evaluated patients

BACKGROUND

Chronic hepatitis C (HCV) treatment with pegylated-interferon (PEG-IFN)/ribavirin (RBV) is often limited by preexisting medical, psychiatric and psychosocial contraindications. However, limited data exist in general patient populations.

AIM

To evaluate the percentage of HCV-infected patients in the general US population who may have contraindications to PEG-IFN/RBV.

METHODS

The General Electric (GE) Centricity dataset was used to screen the US population between 2004 and 2009 for HCV infection and contraindications to PEG-IFN/RBV. HCV diagnosis and contraindications were identified using ICD-9-CM codes or laboratory values. Only patients with an encounter 180 days prior to HCV diagnosis were included. Demographic differences were calculated using Pearson's chi-squared test. Frequencies and percentages for absolute and relative contraindications to PEG-IFN and/or RBV were determined and proportions and rates/1000 person-months were calculated.

RESULTS

A total of 15 561 021 patients were screened, and 45 690 (0.3%) were HCV-positive and were evaluated. Those with contraindications were significantly younger, female, White, not currently married and receiving Medicare or Medicaid coverage (all P < 0.0001). 17.3% had at least one contraindication to PEG-IFN/RBV (5.5 events/1000 person-months); bipolar disorder (6.5%), anaemia (Hgb < 10 g/dL; 5.9%), pregnancy (1.9%) and neutropenia (neutrophils <750 cells/mm(3) ; 1.2%) were most frequently cited.

CONCLUSIONS

Approximately, 17% of HCV-infected patients in the general US population had at least one contraindication to PEG-IFN/RBV. Most contraindications were relative and potentially modifiable. Clinical assessment of contraindications as relative and/or modifiable should be considered and used to determine if patients could benefit from current PEG-IFN-containing triple therapy or future PEG-IFN- or RBV-free regimens.

Hepatitis C infection, antiviral treatment and mental health: a European expert consensus statement

Mental health problems frequently occur in chronic infection with the hepatitis C virus (HCV) and during antiviral treatment with pegylated interferon-alpha (PegIFNα) and ribavirin. Depression is one of the most important complications during antiviral treatment of chronic hepatitis C infection. However, an increased prevalence of depression, fatigue, and cognitive disturbances has also been reported in untreated HCV-positive patients. Patients with psychiatric disorders or drug addiction also have an increased risk of HCV infection. Furthermore, because of possible drug-drug interactions, new antivirals administered together with PegIFNα and ribavirin may complicate psychiatric side effect management, even if no specific psychiatric adverse events are known so far for these new drugs. The European liver patient's organization (ELPA) organised a European expert conference to review the literature and develop expert recommendations for the management of mental health problems in HCV infected patients. This paper results from the output of the 2011 EASL meeting and subsequent dialogue with patient groups and relevant experts in Europe. It summarises the current knowledge of HCV infection and the brain; prevalence, course, and neurobiology of IFN-α associated psychiatric side effects; possible risk factors for IFN-α associated depression and suicide attempts; psychiatric management of HCV infected patients before and during antiviral treatment; prevention of IFN- α associated psychiatric side effects; and psychiatric aspects of the new antivirals. The summarised current knowledge about mental health changes before and during antiviral treatment should improve interdisciplinary management of HCV infected patients.

Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users

OBJECTIVES

We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users.

METHODS

This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics.

RESULTS

The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network.

CONCLUSIONS

One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.

Psychiatric management of the hepatitis C patient

Patients with hepatitis C virus (HCV) infection have a higher prevalence of psychiatric illness compared with the general US population, and the prevalence of HCV infection in patients with severe mental illness ranges between 8% and 19%, which is four to nine times that of the general US population (1.8%). Given the association between HCV infection and psychiatric illness, gastroenterologists are on the front line of identifying comorbid psychiatric and substance use disorders and conducting a psychosocial pretreatment risk-benefit assessment for HCV infection. The use of interferon-alpha (IFN)-based therapies in combination with ribavirin (RBV) to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of both HCV patients with and those without a preexisting history of psychiatric illness. Consequently, gastroenterologists have been reluctant to engage patients with HCV and comorbid psychiatric illness in antiviral treatment due to concerns about exacerbating or precipitating neuropsychiatric symptoms. Despite the clinical challenge that HCV treatment of patients with comorbid HCV and psychiatric illness presents, recent research indicates that HCV treatments can be safely administered to patients with psychiatric illness provided that there is a comprehensive pretreatment assessment, a risk-benefit analysis, and ongoing follow-up of neuropsychiatric symptoms during antiviral therapy. The process of pretreatment assessment involves screening patients for psychiatric and substance use disorders, educating patients about the treatment process, and addressing available psychosocial support. Most psychotropic medications (antidepressants, mood stabilizers, antipsychotics, and neuroleptics) are thought to be safe to use in the management of patients with HCV and psychiatric illness and for the management of IFN- and RBV-induced neuropsychiatric adverse effects. Nonetheless, the prophylactic use of psychotropic medications to prevent IFN- and RBV-induced neuropsychiatric adverse effects remains a controversial topic. The use of IFN and RBV in patients with HCV and severe mental illness can be done safely with expert psychiatric follow-up. In this review, we discuss the process of pretreatment assessment of patients with HCV and psychiatric illness and specifically address IFN- and RBV-induced depression in patients receiving HCV treatment.

Correlates of hazardous drinking among Veterans with and without hepatitis C

Hazardous drinking is a major barrier to antiviral treatment eligibility among hepatitis C (HCV) patients. We evaluated differences in substance-related coping, drinking-related consequences, and importance and confidence in ability to change alcohol use among hazardous drinkers with and without HCV (N = 554; 93.5% male). We examined group differences between HCV+ patients (n = 43) and their negative HCV counterparts (n = 511). Results indicate a higher percentage of HCV+ patients report using substances to cope with possible symptoms of PTSD (P < .05) and depression (P < .01), and endorse more lifetime drinking-related negative consequences than HCV patients (P < .01). Furthermore, HCV+ patients place greater importance on changing alcohol use (P < .01) but report less confidence in their ability to change (P < .01). Use of brief assessment and feedback with skills-based interventions to decrease alcohol use may be well-received by HCV+ patients.

Changes in depressive symptoms and impact on treatment course among hepatitis C patients undergoing interferon-α and ribavirin therapy: a prospective evaluation

OBJECTIVES

Accounting for severity of depressive symptoms at baseline (pretreatment), this study describes (i) depressive symptom change over the course of antiviral treatment among patients with hepatitis C virus (HCV), and (ii) the relationship of such symptom change to treatment duration and response.

METHODS

Depressive symptoms, measured with the Beck Depression Inventory (BDI), were examined prospectively among 129 HCV patients (95% male) who endorsed minimal (n=91), mild (n=28), or moderate depressive symptoms (n=10) prior to commencement of antiviral therapy. Assessments were obtained at baseline, 2 weeks, 4 weeks, and thereafter at 4-week intervals until treatment was discontinued or completed.

RESULTS

The average depression score of the participants prior to commencing treatment was 7.4 (minimal depression). Depressive symptoms increased over the course of treatment, with average scores of 12.6 (mild depression) at the final assessment at the end of treatment. Patients with mild depressive symptoms at baseline demonstrated the greatest increase (M(increase)=12.7) and the greatest change (M(Δ)=5.8) in depressive symptoms from baseline to treatment completion. Patients who were minimally depressed at baseline completed the least amount of treatment (74%). Likewise, minimally depressed patients were less likely than mildly and moderately depressed patients to attain an antiviral treatment response.

CONCLUSIONS

Depressive symptoms may worsen during antiviral therapy among patients with HCV. Notable changes in patients with subclinical depressive symptoms at baseline may be of significant concern, as the present work suggests that their depressive symptom changes are the most unstable. Thus, findings suggest that the degree of within treatment symptom change may be a more useful predictor (compared with baseline depression status) of ability to tolerate treatment. As the findings of the present study are preliminary, we urge further research and replication before drawing firm conclusions.

Trauma, dissociation, and antiretroviral adherence among persons living with HIV/AIDS

BACKGROUND

There are approximately 1,000,000 persons living with HIV/AIDS (PLH) in the United States; to reduce rates of new infection and curb disease progression, adherence to HIV medication among PLH is critical. Despite elevated trauma rates in PLH, no studies to date have investigated the relationship between dissociation, a specific symptom of trauma, and HIV medication adherence. We hypothesized that Post-Traumatic Stress Disorder (PTSD) symptoms would be associated with lower adherence, and that dissociation would moderate this relationship.

METHODS

Forty-three individuals with HIV were recruited from community-based clinics to participate in a cross-sectional study. The relationship of trauma, dissociation, and their interaction to the probability of antiretroviral adherence was assessed using a hierarchical binary logistic regression analysis.

RESULTS

Among 38 eligible participants, greater PTSD was associated with lower odds of adherence (OR = .92, p < .05). Dissociation moderated the effect of PTSD on adherence, resulting in lower odds of adherence (OR = .95, p < .05). PTSD symptoms were significantly associated with lower odds of adherence in individuals reporting high levels of dissociation (OR = .86, p < .05) but not in those reporting low levels of dissociation (OR = 1.02, p > .05).

CONCLUSIONS

This is the first study to demonstrate a relationship between dissociation and medication adherence. Findings are discussed in the context of clinical management of PLH with trauma histories and the need for interventions targeting dissociative symptomatology to optimize adherence.

The effect of anxiety sensitivity on alcohol consumption among individuals with comorbid alcohol dependence and posttraumatic stress disorder

Existing research has shown that anxiety sensitivity (AS) is positively associated with alcohol use, and that individuals with high AS use alcohol to avoid or escape negative affect associated with aversive stimuli. The current study investigated the associations between AS and drinking behavior among individuals with comorbid alcohol dependence and posttraumatic stress disorder (PTSD). We assessed baseline PTSD symptoms, AS, and drinking behavior among 151 participants enrolled in a randomized clinical trial for alcohol dependence. We hypothesized that AS would moderate the association between PTSD symptoms and drinking behavior, with PTSD symptoms being more strongly associated with drinking behavior among individuals with high AS. Results showed that AS was strongly associated with PTSD (r = .48) and moderately associated with drinking behavior (r = .18). As predicted, the interaction of AS with severity of PTSD symptoms was associated with frequency of drinking; however, contrary to our hypothesis, PTSD symptoms were more strongly associated with drinking behavior among individuals with relatively low AS. The implication of the present results for treatment of both PTSD and alcohol dependence are discussed.

Influencing factors of healthcare-seeking behaviors in Taiwanese patients with hepatitis C

The purpose of this study was to determine factors that influence the frequency of hospital clinic visits for hepatitis C patients in Taiwan and identify data related to healthcare-seeking behaviors of patients by using a developed questionnaire based on the Health Belief Model. Consistent clinic visits for follow-up and treatment are required of the hepatitis C patient to be compliant with therapy guidelines. Recent studies targeted only Western communities in which hepatitis C is nonepidemic, unlike hepatitis C virus-endemic regions of Taiwan where patients may exhibit 10-20 times higher seroprevalence. Influences on hospital clinic visit attendance were identified as educational level, income, and aspartate aminotransferase level at diagnosis. Perceived benefits from and barriers to action were similar among the 390 evaluable subjects at various frequencies of hospital clinic visits (both p > .05); however, subjects who visited the hospital clinic between 1 and 6 months exhibited significantly higher scores of perceived susceptibility to disease and severity of disease than those who visited the hospital clinic at 7-9 months or less often (all p ≤ .001). Findings lay the foundation for future studies to address strategies to increase compliance with treatment regimens for Taiwanese patients with hepatitis C.

Effects of recognizing depression with a standardized questionnaire (CES-D) versus patient reporting of depression after a single-standardized question on the outcomes of treatment for hepatitis C with pegylated interferon-α-2b and ribavirin

BACKGROUND

Depression may worsen during antiviral treatment for hepatitis C virus, resulting in noncompliance treatment.

AIM

The aim was to compare the response and compliance rates between the groups of veteran patients using two different methods of identifying depression, either the Centers for Epidemiology Studies for Depression Scale (group A) questionnaire or the report of symptoms of depression after a single-standardized question by the health care provider (group B).

METHODS

One hundred and twenty-nine patients were randomly assigned to the two groups before the treatment.

RESULTS

No statistical differences were noted in baseline characteristics between the groups. Depression was common in both the groups. No difference between initial Centers for Epidemiologic Studies Depression Scale scores and diagnosis of depression between the two groups was noted. Furthermore, the number of patients diagnosed with depression during the treatment was similar in each group. There were no significant differences between the groups in rates of sustained viral response (30% group A, 35% group B) or in rates of overall compliance with patients receiving more than 90% of prescribed PegIntronA therapy (44% group A, 39% group B), and ribavirin (32% group A and 37% group B).

CONCLUSION

The use of the Centers for Epidemiology Studies for Depression Scale questionnaire to recognize depression had no significant advantage over patient reporting of depression symptoms after a single-standardized question on the hepatitis C virus clearance and the treatment compliance rates in veteran populations.

Psychiatric care of the patient with hepatitis C: a review of the literature

CONTEXT

Approximately 1.8% of the US population is chronically infected with the hepatitis C virus (HCV). The prevalence rates of psychiatric illness in patients with HCV infection are higher than those rates in the general US population, and the prevalence of HCV infection in patients with severe mental illness may be as high as 9 times that of the general US population. Primary care physicians and psychiatrists are on the forefront of identifying patients with psychiatric illness who are at risk for HCV infection and can screen for HCV infection. This review summarizes the psychiatric implications of HCV infection and strategies for the management of interferon alfa-induced neuropsychiatric adverse effects.

EVIDENCE ACQUISITION

English-language studies were identified by computerized searches using the term hepatitis C psychiatric between 1972 and 2009, and further references were obtained from bibliographies of the reviewed articles. Relevant references were reviewed by the authors and included the basis of significance and applicability to practicing psychiatrists and internists.

RESULTS

Since primary care physicians and psychiatrists are sometimes the only medical link for patients with psychiatric illness, they are expected to provide posttest counseling for their patients with HCV and psychiatric illness. The task of conducting a psychiatric and psychosocial pretreatment risk-benefit assessment to determine whether or not to treat HCV infection is increasingly delegated to primary care providers as well as psychiatrists. The use of interferon alfa-based therapies to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of HCV patients with and without a preexisting history of psychiatric illness. Primary care physicians and psychiatrists are frequently asked to assist in the management of these neuropsychiatric adverse effects and evaluate the risks and benefits of using prophylactic psychotropics.

CONCLUSIONS

Despite the clinical challenge that interferon alfa treatment for patients with comorbid HCV and psychiatric illness presents, recent research indicates that interferon alfa can be safely administered to HCV-infected patients with psychiatric disorders provided there is a comprehensive pretreatment assessment, a risk-benefit analysis, and intensive ongoing medical and psychiatric follow-up.

Psychosocial issues and mental health treatment recommendations for patients with hepatitis C

BACKGROUND

Mental health needs of patients with HCV are increasingly being addressed in medical contexts.

OBJECTIVE

The authors review the psychosocial issues relevant to patients with hepatitis C and provide mental health treatment recommendations.

FINDINGS

Patients with HCV are faced with a number of challenges, including adjustment to a chronic medical illness, management of symptoms and treatment side effects, and making and maintaining lifestyle changes. Given these issues, mental health clinicians have the opportunity to make a significant contribution to patient care.

CONCLUSION

After reviewing the relevant research on these psychosocial issues, the authors have identified areas in which clinicians can intervene; these include adjustment to having a chronic medical illness, coping with stigma and relationship changes, management of side effects, and implementing healthy lifestyle changes.

Psychiatric and substance use disorders comorbidities in veterans with hepatitis C virus and HIV coinfection

PURPOSE OF REVIEW

A growing number of veterans in the Veterans Health Administration are coinfected with HIV and hepatitis C virus. This review covers timely research relative to comorbid conditions that are common in this population including psychiatric diagnoses, substance use disorders and neurocognitive problems.

RECENT FINDINGS

Current literature on the psychiatric, substance use disorders and cognitive problems of the coinfected population show that not only are rates of morbidity higher in the coinfected population but that this affects antiviral treatments as well. There is new evidence that brain injuries and infiltration of the virus into the central nervous system may be responsible for cognitive dysfunction. Cotesting, particularly in hepatitis C infected individuals, is not done routinely despite shared risk factors.

SUMMARY

With this understanding of the comorbidities of the coinfected population, integrated healthcare models involving mental health, internal medicine, substance abuse treatment and internal medicine are crucial to work with these medically and psychologically complex patients.

Clinical management of HIV/hepatitis C virus coinfection

PURPOSE

The purpose of this study was to review the current management of hepatitis C virus (HCV) in persons coinfected with HIV.

DATA SOURCES

Comprehensive review of current scientific literature derived from electronic databases, article bibliographies, and conference abstracts.

CONCLUSIONS

HCV treatment is feasible in the individual coinfected with HIV; however, therapy is complex and requires intensive monitoring and support to achieve the outcome of viral eradication. New strategies to improve HCV treatment rates, adherence to therapy, and virological response rates are needed in this patient population.

IMPLICATIONS FOR PRACTICE

Nurse practitioners are crucial to the management of the HIV/HCV-coinfected patient. This patient population requires detailed clinical monitoring, education, side effect management, and strategies to improve adherence to therapy.

Hepatitis C and poor quality of life: is it the virus or the patient?

Hepatitis C is a systemic disease that has many extrahepatic manifestations in addition to hepatic inflammation and fibrosis, some of which may result in a poor health-related quality of life (HRQOL). Fatigue is perhaps the most frequent and disabling extrahepatic symptom of hepatitis C virus (HCV), reported in almost one-half of all chronically infected individuals. Many other factors are associated with a poor quality of life in patients with HCV, including a number of physical and psychological factors. The objective of this article is to review the association between HCV and impaired HRQOL due to fatigue and psychological disturbances.

Management of chronic hepatitis C in veterans: the potential of integrated care models

The prevalence of hepatitis C virus (HCV) infection is higher among veterans than nonveterans, but only about 14% of all identified infected veterans have ever received antiviral therapy. High rates of comorbid psychiatric and substance use disorders are major barriers to receiving antiviral treatment for veterans, and characteristics associated with poor virologic response are more common in this population. However, accumulating evidence indicates that patients with psychiatric and substance use disorders can successfully receive interferon-based antiviral therapies in an integrated or multidisciplinary health-care setting. The broad aims of integrated care models include reducing fragmentation and improving continuity and coordination of care. Although, to date, there are no randomized controlled trials of specific care models for patients with HCV, studies of integrated care for other chronic diseases suggest several strategies for optimizing outcomes for patients with HCV. Components of an HCV clinic incorporating these principles have been tested in a nonrandomized setting and include routine screening of all patients for psychiatric and substance use disorder risk factors, collaboration with mental health providers within the HCV clinic, following a defined integrated medical/psychiatric clinical protocol, provision of ongoing integrated support during antiviral treatment or retreatment, and educating patients on principles of chronic disease self-management.

The effect of pegylated interferon-alpha2b and ribavirin on posttraumatic stress disorder symptoms

BACKGROUND

Patients with chronic psychiatric diagnoses have a prevalence of chronic hepatitis C (HCV) approximately 11 times higher than the general American population. Posttraumatic stress disorder (PTSD) is particularly common among HCV patients.

OBJECTIVE

The authors describe the effect of treatment with pegylated-interferon-alpha(2b) (IFN) and ribavirin for patients with HCV on their posttraumatic stress disorder (PTSD) symptoms.

METHOD

Sixteen patients with HCV and combat-related PTSD were followed for 24 weeks and assessed with self-report measures of PTSD, hostility, and depression.

RESULTS

Depression and Resentment scores significantly increased in five patients treated with IFN and ribavirin, but no significant differences were found in PTSD scores when compared with 11 control patients.

CONCLUSION

The results suggest that patients with PTSD and HCV can be safely treated with anti-viral therapies when they are given appropriate psychiatric care.

Outcome of screening for hepatitis C virus infection based on risk factors

OBJECTIVES

Screening for hepatitis C virus (HCV) infection in individuals at increased risk is currently recommended by most, but not all, health authorities. This study identifies outcomes of individuals diagnosed through a screening program targeting high-risk patients.

METHODS

Veterans presenting for care in VA facilities are assessed for HCV risk factors by a questionnaire. Those with a risk factor are offered anti-HCV testing. Between October 1998 and May 2004, 25,701 patients were assessed and 8,471 patients had a risk factor for HCV. Patients diagnosed through the screening program were assessed per study protocol.

RESULTS

The prevalence of a positive HCV antibody in veterans who identified a risk factor was 7.3% (95% CI 6.6-8.0%). Among those diagnosed through the screening program (N = 260), 47% had chronic hepatitis C. Among patients with chronic HCV, 18% had evidence of advanced liver disease (stage III/IV on biopsy or clinical cirrhosis) while 34% had persistently normal alanine aminotransferase (ALT). Two-thirds of individuals who underwent liver biopsy had minimal or no fibrosis. About half (47%) of the screen-detected patients with chronic HCV were treatment candidates. Forty-four percent were not immediate candidates secondary to medical or psychiatric comorbidities or active substance abuse. Twenty-two patients (8%) had died after a median follow-up of 911 days. Two were liver-related deaths.

CONCLUSION

Screening for hepatitis C in persons at high risk can lead to early identification of individuals at risk for progressive liver disease who may benefit from antiviral therapy and counseling to reduce HCV-related liver injury.

Views of hepatitis C virus patients delayed from treatment for psychiatric reasons

For patients with chronic hepatitis C virus, certain psychiatric disorders are contraindications for antiviral therapy with interferon-alpha (IFN). Although these conditions delay a significant portion of patients from beginning therapy, no one has yet portrayed the views of these patients. A qualitative analysis, drawing upon semi-structured interviews, was developed to generate hypotheses regarding patient views of the treatment disposition process, and to generate strategies for increasing the portion of treatment-eligible patients. Two focus groups were conducted: one for patients delayed from treatment due to current or recent depression, and one for patients delayed due to current or recent alcohol use. A grounded theory analysis of the interview data were conducted. Patients were generally satisfied with the decision-making process, based largely on education from, and trust in, physicians. Upon learning their diagnosis, patients reported making healthy behaviour changes regarding alcohol, diet, exercise and herbal remedies. Some patients reported that requiring a period of alcohol abstinence was excessive, as they believed that they could discontinue alcohol use immediately, if so instructed by a physician. Patients seemed to over-interpret the likelihood of suicide during interferon-alpha (IFN) therapy. Current or recent psychiatric morbidity delays many patients from beginning interferon therapy. Nonetheless, this may be an optimal time for physicians to encourage healthy behaviours including abstinence from alcohol. Also, physicians may need to extensively assess the use of herbal remedies by patients. To help patients make judgments about beginning therapy, physicians should focus upon risk communication regarding the likelihood of suicide on therapy with interferon.

Positive CAGE screen correlates with cirrhosis in veterans with chronic hepatitis C

The current study examines the relationship between problem alcohol use and severity of liver disease by self-administered questionnaires using both the CAGE questionnaire and beverage-specific quantity-frequency questions. The cohort consisted of 38 patients with cirrhosis (10 with decompensated liver disease) and 62 with mild fibrosis (stage 0-1), of comparable mean age and estimated duration of infection. Although mean alcohol consumption was similar in both groups, a positive CAGE screen (defined as two or more affirmative answers) was significantly more common among cirrhotics (OR = 5.24; 95% CI, 1.78-15.39) and tended to be associated with decompensated liver disease (OR = 13.3; 95% CI, 0.67-256) among cirrhotics. In multivariate analysis, only inflammatory grade on liver biopsy (OR = 67.7; 95% CI, 10.6-431) and positive CAGE score (OR = 8.09; 95% CI, 1.15-57.1) were independent predictors of cirrhosis. These findings suggest that the CAGE questionnaire predicts advanced liver disease better than daily or lifetime drinking measures.

Reasons why patients infected with chronic hepatitis C virus choose to defer treatment: do they alter their decision with time?

This study was designed to determine the percentage of treatment-naïve patients infected with chronic hepatitis C virus who make an informed choice to forego (defer) treatment with pegylated interferon regimens in the absence of any medical, psychosocial, or other contraindications, and to reassess their decision by using a questionnaire at least 1 year later. Patient charts dating from 2001 were retrieved and retrospectively analyzed for the following data: patient age, gender, race, hepatitis C viral load, genotype, liver biopsy results, hepatic imaging results, peak alanine aminotransferase (ALT) levels, comorbid conditions, source of infection, estimated duration of infection, and reasons given by the patient for declining pegylated interferon-based treatment at the time of their consultation. A questionnaire survey sought to determine their satisfaction with their initial decision. Of 446 patient charts reviewed, 280 patients were treatment-naïve and were judged to have no contraindications to receiving interferon-based therapy. Of these, 115 (41%) opted to defer treatment and are the subject of this analysis. Women declining therapy outnumbered men by approximately 3 to 2. Middle-aged patients (45-55 years) were most likely to choose expectant therapy compared with older or younger individuals. The proportion of African American patients who deferred therapy (48%) was higher than non-African American patients (36.6%). More than 90% of the patients choosing to be followed were genotype 1. Peak ALT values were normal in 37% and <2X upper limits of normal (ULN) in another 40%. The estimated duration of chronic hepatitis C infection was >16 years in approximately three-quarters of individuals. The most common source of their infection was intravenous drug use followed by transfusion-related. The most common reason for opting not to receive treatment, given by nearly two-thirds of patients, was the asymptomatic nature of their infection coupled with their concern about side effects of the medications. Approximately 10% had unfavorable social situations, including a lack of support or health insurance, that precluded receiving therapy (despite the availability of indigent care programs offered by the pharmaceutical manufacturers). Only five patients (4.3%) cited doubts about efficacy as the main reason that they did not want to be treated. The questionnaire survey at 1 year found that 79% of the patients confirmed their ongoing satisfaction with their initial decision to decline treatment, and another 10.6% indicated that they were still "moderately satisfied" with their decision and unlikely to change it in the near-future. Only six patients (7%) voiced their current dissatisfaction with expectant management and expressed the desire to have a follow-up discussion about treatment options. Of the remaining three patients (3.5%), two had already started treatment and one was deceased (of non-liver-related causes). A significant proportion of patients infected with hepatitis C virus who are otherwise eligible for therapy opt to defer treatment (41% overall in our series, with African American patients deferring in a higher proportion than non-African American patients). Nearly all of our patients were genotype 1 with clinically and histologically mild hepatitis of reasonably long duration. Our questionnaire survey found that most remained satisfied with their decision to defer treatment at the present time. Few patients cited a perceived low rate of efficacy of pegylated interferon and ribavirin therapy as the principal reason that they chose not to initiate treatment.

Psychiatric morbidity and its effect on the quality of life of patients with chronic hepatitis B and hepatitis C

OBJECTIVE

The primary aim of our study was to determine the prevalence of psychiatric morbidity in a cohort of consecutive chronic hepatitis patients not receiving antiviral therapy. The secondary aim of our study was to determine if psychiatric morbidity, type of hepatitis, and the level of depression correlated with health-related quality of life (HRQL).

METHODS

The study was conducted in collaboration with Hepatology and Infectious Disease Clinics at three-major university hospitals. One hundred seven patients who met the criteria for being diagnosed with either chronic hepatitis B or C, had non-cirrhotic compensated liver disease, had not received antiviral treatment in the preceding 6 months, and had no accompanying physical illness were included in the study. The Structured Clinical Interview for DSM-IV Axis I Disorders, the Short Form--36 for measuring HRQL, and semi-structured interviews for assessing psychosocial variables were used. Sixty-seven healthy adults formed the control group.

RESULTS

43.9% of the patients had hepatitis B, 56.1% hepatitis C. A psychiatric diagnosis was made in 48.6%, of which 15% was depression. No significant difference was found in the rate of psychiatric diagnosis between hepatitis B and hepatitis C patients. Hepatitis B and C patients were found to vary significantly (p < 0.001) from the control group on all subcategories of quality of life criteria. Psychiatric morbidity (mainly depression) was the major variable on lowering HRQL (p = 0.000).

CONCLUSIONS

Chronic hepatitis B and C patients presented a high rate of psychiatric disorder. HRQL was significantly decreased in patients with psychiatric morbidity.

Psychiatric comorbidity does not predict interferon treatment completion rates in hepatitis C seropositive veterans

GOALS

The aim of this study was to evaluate the impact of common psychiatric disorders on treatment completion of antiviral therapy prescribed to a series of hepatitis C virus (HCV) positive US veterans.

BACKGROUND

Clinical experience suggests that preexisting psychiatric conditions may adversely affect the ability to tolerate combination antiviral therapy in patients with HCV infection.

STUDY

We performed a retrospective chart review of 130 HCV positive veterans treated with combination antiviral therapy [interferon (IFN)/ribavirin] at VA San Diego from 2000 to 2004. We examined baseline psychiatric and substance use diagnoses, as well as demographic and comorbid medical disease variables for all patients started on treatment.

RESULTS

Thirteen percent of patients in our cohort required treatment discontinuation for neuropsychiatric adverse effects. There was no association between treatment completion and any specific psychiatric diagnosis, baseline use of antidepressants, history of substance abuse/dependence, or combined psychiatric and substance use diagnoses for patient groups receiving either standard or pegylated IFN plus ribavirin therapies. Psychiatric and substance use disorders were not associated with dropout due to neuropsychiatric adverse effects. Baseline comorbid medical disorders also did not predict treatment completion. However, higher body weight did predict likelihood of treatment completion, especially for those > or =100 kg compared with thinner subjects (odds ratio=2.90; P=0.037).

CONCLUSIONS

In this cohort of veterans, prior psychiatric or substance use history did not predict completion of recommended IFN/ribavirin treatment. These findings suggest that a larger pool of veterans with psychiatric or substance use disorders may be considered candidates for antiviral therapy when provided with multidisciplinary support.

Addressing tri-morbidity (hepatitis C, psychiatric disorders, and substance use): the importance of routine mental health screening as a component of a comanagement model of care

BACKGROUND

Recent studies suggest that most patients with hepatitis C virus (HCV) infection commonly present to medical clinics with active psychiatric and substance use disorders. However, routine screening for these disorders is generally not done.

OBJECTIVES

The purpose of our study was to assess prospectively the frequency of psychiatric and substance use disorders in patients presenting for initial assessment of a positive HCV antibody test result.

METHODS

A sample of 293 patients represented the majority of patients scheduled for their initial hepatology clinic visit at the Portland Veterans Affairs Medical Center between September 2002 and September 2003. The patient screening questionnaire, Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and the Beck Depression Inventory (BDI-II) were administered to all patients.

RESULTS

At screening, 93% of the patients had a current or past history of at least 1 psychiatric disorder, and 73% had >or=2 disorders. The most common disorders included depression (81%), posttraumatic stress disorder (62%), any substance use disorder (58%), bipolar disorder (20%), and other psychotic disorders (17%). One hundred two patients (35%) had baseline BDI-II scores in the moderate-to-severe range of depression (>19), and 61 (21%) had AUDIT-C scores indicating current heavy alcohol use (>or=4).

CONCLUSIONS

Psychiatric and substance use disorders are highly prevalent among veterans with chronic hepatitis C. Thirty-five percent have significant symptoms of depression before the initiation of treatment with interferon (IFN). Routine screening for underlying psychiatric and substance use disorders and early treatment intervention before initiating antiviral therapy is essential to prevent worsening of depression and to optimize the outcome of treatment with IFN. Comanagement treatment models involving mental health care may expand the pool of patients eligible to receive treatment with IFN, as well as enhance treatment outcomes.

Integrated psychiatric/medical care in a chronic hepatitis C clinic: effect on antiviral treatment evaluation and outcomes

OBJECTIVES

Psychiatric and substance use disorders are common in hepatitis C patients and represent barriers to antiviral treatment. We evaluated the effect of integrating psychiatric and medical care on evaluation for and initiation of antiviral treatment in a cohort of 184 patients with chronic hepatitis C.

METHODS

Integrated care consisted of screening for psychiatric problems with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), Beck Depression Inventory (BDI), Urine Drug Screen (UDS), and Primary Care Posttraumatic Stress Disorder (PC-PTSD) screens, referral based on specified cutoff scores to an established mental health (MH) provider, to a colocated psychiatric clinical nurse specialist (PCNS), or both. Data were collected retrospectively by chart review.

RESULTS

Most patients (149/184, 81.0%) had at least one positive screen, 25.5% had a positive UDS. Among patients with positive screens, 38.3% had established MH providers, 47.0% had no MH provider and were referred to the PCNS, and 15.0% refused any psychiatric referral. Patients receiving integrated care with a colocated PCNS were significantly more likely to complete evaluation for and start antiviral treatment than other patients with positive screens, and at a rate similar to that of patients with negative screens. Patients with positive screens followed by any MH provider had significantly greater adherence to antiviral therapy than patients without positive screens.

CONCLUSION

An integrated MH and medical approach was associated with rates of antiviral therapy recommendation and initiation similar to patients without risks for psychiatric or substance use problems. MH care was associated with improved adherence to antiviral therapy. Integrated care offers promise as an approach for addressing psychiatric comorbidity in this traditionally difficult to treat population.

Hepatitis C infection is associated with depressive symptoms in HIV-infected adults with alcohol problems

OBJECTIVES

Depression is common in persons with HIV infection and with alcohol problems, and it has important prognostic implications. Neurocognitive dysfunction has been reported with chronic hepatitis C virus (HCV) infection. We hypothesized that HCV infection is associated with more depressive symptoms in HIV-infected persons with a history of alcohol problems.

METHODS

We performed a cross-sectional analysis of baseline data from a prospective cohort study of 391 HIV-infected subjects with a history of alcohol problems, of whom 59% were HCV antibody (Ab) positive and 49% were HCV RNA-positive. We assessed depressive symptoms (Center for Epidemiologic Studies Depression [CES-D]) and past month alcohol consumption. In the primary analysis, we evaluated whether there were more depressive symptoms in HCV Ab-positive and RNA-positive subjects in unadjusted analyses and adjusting for alcohol consumption, gender, age, race, CD4 count, homelessness, drug dependence, and medical comorbidity.

RESULTS

Mean CES-D scores were higher in subjects who were HCV Ab-positive compared with those who were HCV Ab-negative (24.3 vs 19.0; p < 0.001). In adjusted analyses, the difference in CES-D scores between HCV Ab-positive and Ab-negative subjects persisted (24.0 vs 19.0; p < 0.001). Unadjusted mean CES-D scores were also significantly higher in HCV RNA-positive subjects compared with those who were RNA-negative, and the difference remained significant (24.6 vs 19.3; p < 0.001) in adjusted analyses.

CONCLUSIONS

HCV/HIV coinfected persons with a history of alcohol problems have more depressive symptoms than those without HCV, and this association is unexplained by a variety of population characteristics. These data suggest that HCV may have a direct effect on neuropsychiatric function.

The impact of chronic hepatitis C and comorbid psychiatric illnesses on health-related quality of life

GOALS

To determine the relative impact of chronic hepatitis C (CHC) and comorbid psychiatric illness on the health-related quality of life (HRQoL).

BACKGROUND

Psychiatric conditions are more common among patients with CHC but their relative influence on HRQoL is not well understood.

STUDY

We identified 864 veterans who had previously completed a veteran-specific HRQoL questionnaire (SF-36V) as part of the 1999 VA Large Health Survey with known HCV antibody (anti-HCV) status before the survey. For 201 anti-HCV(+) and 663 anti-HCV(-) patients, we compared the HRQoL status and the prevalence of 6 major psychiatric diagnoses. We conducted multiple regression analyses to measure the effect of anti-HCV status and psychiatric comorbidity.

RESULTS

Compared with the anti-HCV(-) group, anti-HCV(+) veterans were more likely to have alcohol dependence (P<0.001), depression (P=0.01), or posttraumatic stress disorder (PTSD) (P<0.004). The anti-HCV(+) group also reported lower HRQoL on 4 of the 8 SF-36V subscales (P<0.01) and the mental component summary scale (P<0.001). Even after adjusting for demographic variables and comorbid psychiatric illness, anti-HCV(+) patients reported a significantly lower mental component summary score (P<0.01) than did anti-HCV(-) patients. Multiple regression analysis found that depression and PTSD predicted lower HRQoL scores for all 8 HRQoL subscales (P<0.01) and both the physical (P<0.001) and mental component (P<0.03) summary scales independent of anti-HCV status.

CONCLUSIONS

The HRQoL is significantly impaired in veterans with CHC, particularly the mental health components of HRQoL. In contrast, comorbid depression and PTSD are associated with both lower physical and mental components of HRQol, independent of CHC.

Psychiatric and substance use disorders in individuals with hepatitis C: epidemiology and management

Hepatitis C virus (HCV) infection is a major health concern in the US as well as in other countries worldwide. Treatment issues and disease management strategies are complicated by the extremely high rate of psychiatric and substance use disorders in those who have HCV. The majority of new and existing cases of HCV are related to injection drug use and, in this population, the prevalence of psychiatric comorbidity is high. Optimally, all patients with HCV should be screened for psychiatric and substance use disorders before initiation of antiviral therapy. If a patient screens positive, he or she should be referred to a mental healthcare provider or addiction specialist, assessed for the presence of a psychiatric or substance use disorder, and appropriately treated prior to initiation of antiviral (i.e. interferon) therapy. Although interferon-based therapies can lead to severe neuropsychiatric adverse effects, including in rare instances suicide, evidence suggests that many patients with comorbid psychiatric and substance use diagnoses can be treated safely and effectively using comanagement strategies. However, most patients with HCV are not treated with antiviral therapy. Therefore, we must expand our definition of HCV 'treatment' to include treatment of the comorbid psychiatric and substance use disorders that accompany HCV infection and precede antiviral therapy. This paper reviews the epidemiology and management of psychiatric and substance use disorders in patients with HCV, the issue of psychiatric and substance use disorders as contraindications for antiviral therapy, and current treatment strategies for HCV patients with these comorbid conditions.

Interferon-induced depression in chronic hepatitis C: a review of its prevalence, risk factors, biology, and treatment approaches

Hepatitis C viral infection is a global health problem that affects approximately 4 million people in the United States. Combination treatment with pegylated interferon (IFN)-alpha plus ribavirin has been shown to be most effective in treating patients with chronic hepatitis C (CHC). Despite its efficacy, one of the most common side effects of this regimen is depression. Whereas IFN-alpha has been found to induce depression in chronic myelogenous leukemia, melanoma, and renal cell carcinoma, CHC patients may be especially prone to develop IFN-induced depression. This review includes a summary of differences between IFN-alpha and IFN-beta and addresses whether pegylation of IFN (versus nonpegylated IFN) gives rise to a treatment with reduced potential to induce depressive symptoms. Consideration is also given to evidence showing that treatment with ribavirin may contribute to IFN-induced depression. Thyroid disorders and anemia (as well as other medical conditions) have also been associated with IFN exposure and may account for some incidences of depression in CHC patients. Evidence is reviewed indicating that prior psychiatric and mood disorders (especially previous episodes of major depressive disorder), just prior to IFN treatment, contribute to the propensity to develop depression during treatment. In addition, a brief description is provided of potential biological mechanisms of IFN-induced depression (ie, monoamines, hypothalamic-pituitary-adrenocortical [HPA] axis, proinflammatory cytokines, peptidases, intercellular adhesion molecule-1, and nitric oxide). Finally, a discussion is provided on the use of antidepressants as a preventative versus restorative treatment, including a commentary on risks of using antidepressants in this patient population.

Psychological impact of chronic hepatitis C: Comparison with other stressful life events and chronic diseases

AIM: To examine the psychological impact of chronic hepatitis C (CHC) diagnosis in a large cohort of CHC patients as compared with other stressful life events and chronic diseases carrying a risk of life-threatening complications.

METHODS: One hundred and eighty-five outpatients with compensated CHC were asked to self-grade, using a 100-mm visual analogue scale (VAS), the degree of stress caused by the learning of CHC diagnosis and the perceived severity of their disease. Diagnosis-related stress was compared to four other stressful life events and perceived CHC severity was compared to four other common chronic diseases.

RESULTS: Learning of CHC diagnosis was considered a major stressful event (mean ± SD scores: 72 ± 25), significantly less than death of a loved-one (89 ± 13, P < 0.0001) and divorce (78 ± 23, P < 0.007), but more than job dismissal (68 ± 30, P < 0.04) and home removal (26 ± 24, P < 0.0001). CHC was considered a severe disease (74 ± 19), after AIDS (94 ± 08, P < 0.001) and cancer (91 ± 11, P < 0.001), but before diabetes (66 ± 23, P < 0.001) and hypertension (62 ± 20, P < 0.001). Perceived CHC severity was not related to the actual severity of liver disease, assessed according to Metavir fibrosis score. In multivariate analysis, diagnosis-related stress was related to perceived disease severity (P < 0.001), trait anxiety (P < 0.001) and infection through blood transfusion (P < 0.001).

CONCLUSION: Our results show the considerable psychological and emotional burden that a diagnosis of CHC represents, even in the absence of significant liver disease. They should be taken into account when announcing a diagnosis of CHC in order to reduce its negative effects.

Infecções virais e depressão

OBJETIVO: A associação entre depressão e viroses é estudada há quase dois séculos, com resultados conflitantes. O objetivo deste trabalho é fazer uma análise crítica dos estudos existentes na literatura sobre essa relação. MÉTODOS: A pesquisa bibliográfica utilizou as fontes eletrônicas de busca MEDLINE e LILACS (1966 a agosto 2005). As referências dos artigos foram utilizadas como fonte adicional de consulta. RESULTADOS: Foram abordados os trabalhos que trataram da associação entre depressão e os vírus HIV, HCV, EBV, influenza, HSV, HBV, HAV, BDV e HTLV. A relação entre HIV e depressão mostrou-se bem documentada na literatura. Existem indícios de que a prevalência desse transtorno nos indivíduos infectados pelo HIV seja maior que a encontrada nos soronegativos. Além disso, estudos constataram que a depressão está associada a pior prognóstico da infecção. Quanto à associação entre HCV e depressão, os trabalhos sugeriram maior prevalência desse transtorno psiquiátrico nos portadores do HCV comparados à população geral. Não existem evidências científicas suficientes para dar suporte à relação entre os demais vírus e depressão. CONCLUSÃO: As associações mais bem fundamentadas foram aquelas entre depressão e os vírus HIV e HCV. A relação entre as demais viroses e depressão precisa ser mais bem estudada, e trabalhos com delineamento adequado se fazem necessários.

Integrated hepatitis C virus treatment: addressing comorbid substance use disorders and HIV infection

OBJECTIVES

To examine hepatitis C virus (HCV) and HIV testing patterns within the Northwest Veterans Integrated Service Network (VISN 20).

METHODS

Using a comprehensive VISN 20 database, we retrospectively reviewed medical records of 293,445 veterans.

RESULTS

32.8% of patients were tested for HCV, 5.5% were tested for HIV, and 4.3% were co-tested. Of those tested, 12.3% were HCV positive, 5.4% were HIV positive, and 1.6% were co-infected. 79.1% of HIV-positive patients were tested for HCV, 29.2% of whom tested positive. 34.8% of HCV-positive patients were tested for HIV, 4.9% of whom tested positive. Of those tested, HCV-positive patients were significantly more likely than HCV-negative patients to test positive for HIV; HIV-positive patients were no more likely to test positive for HCV than HIV-negative patients. HIV-positive patients with substance use disorders (SUD) were significantly more likely to test HCV positive than those without. Within the total sample, veterans with SUD were significantly more likely to be tested for both diseases and to test positive for HCV but not HIV. After controlling for other categories of SUD, veterans with a history of cocaine abuse compared with those without were at an increased risk of HIV infection and co-infection.

CONCLUSION

79.1% of HIV-positive but only 34.8% of HCV-positive veterans were co-tested, suggesting barriers to HIV testing may exist in VISN 20. Results also indicate that HCV-positive patients are at increased risk for HIV infection and that HIV-positive patients with SUD are at increased risk of HCV infection; routine co-testing for these patients is therefore warranted. Given significant co-infection rates, HCV and HIV screening and testing should be increasingly integrated. Increased infection rates among patients with SUD also warrant integration of HCV and HIV screening and testing into mental health and addiction programmes.

Physical and psychosocial contributors to quality of life in veterans with hepatitis C not on antiviral therapy

BACKGROUND AND AIMS

Treatment-naive hepatitis C virus (HCV)-infected patients report impaired health-related quality of life (HRQOL), although causes are unclear. Psychosocial factors may be major determinants of HRQOL.

METHODS

We administered a general (Short Form-36; SF-36) and a liver-specific (Chronic Liver Disease Questionnaire; CLDQ) HRQOL measure to 62 HCV-infected veterans being considered for antiviral therapy. Psychosocial assessment included the Structured Clinical Interview for DSM-IV Axis I Disorders/Non-Patient (SCID-I/NP), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Abbreviated Cook-Medley (ACM) anger measure, and Medical Outcomes Study Social Support Measure (SSM). We examined the potential determinants of HRQOL, including psychosocial measures, demographic measures (age, sex, race/ethnicity), clinical measures (presence of cirrhosis, comorbid medical conditions), and viral data (quantitative PCR).

RESULTS

SF-36 scores were significantly lower in HCV-infected patients than published U.S. population norms but similar to those reported by previous studies of HCV-infected samples. CLDQ scores were very similar to those reported by previous studies. Demographic, clinical, and viral indicators were not statistically associated with HRQOL, and neither was the presence of a substance abuse or psychotic disorder. Lower BDI-II and BAI scores were associated with better general and disease-specific HRQOL. Lower SSM scores were associated with lower scores on SF-36 but not CLDQ; however, this effect did not persist in multiple linear regression analyses. In these, BDI-II was the strongest independent predictor of both SF-36 and CLDQ.

CONCLUSIONS

Psychosocial factors, especially depression, are strong indicators of impaired HRQOL for HCV-infected veterans not receiving antiviral therapy. Screening and treatment of psychosocial factors is recommended.

Prospective multicenter study of eligibility for antiviral therapy among 4,084 U.S. veterans with chronic hepatitis C virus infection

BACKGROUND

Many veterans may not be candidates for hepatitis C virus (HCV) treatment due to contraindications to therapy. The aims of this study were to determine the proportion of HCV-infected veterans who were eligible for interferon alfa and ribavirin therapy and to evaluate barriers to HCV treatment.

METHODS

We prospectively enrolled 4,084 veterans who were referred for HCV treatment over a 1-yr period at 24 Veterans Affairs (VA) Medical Centers. Treatment candidacy was assessed using standardized criteria and the opinion of the treating clinician.

RESULTS

Overall, 32.2% (95% CI, 30.8-33.7%) were candidates for HCV treatment according to standardized criteria, whereas 40.7% (95% CI, 39.2-42.3%) were candidates in the opinion of the treating clinician. Multivariable analysis identified ongoing substance abuse (OR = 17.68; 95% CI, 12.24-25.53), comorbid medical disease (OR = 9.62; 95% CI, 6.85-13.50), psychiatric disease (OR = 9.45; 95% CI, 6.70-13.32), and advanced liver disease (OR = 8.43; 95% CI, 4.42-16.06) as the strongest predictors of not being a treatment candidate. Among patients who were considered treatment candidates, 76.2% (95% CI, 74.0-78.3%) agreed to be treated and multivariable analysis showed that persons >/=50 yr of age (OR = 1.37; 95% CI, 1.07-1.76) and those with >50 lifetime sexual partners (OR = 1.44; 95% CI, 1.08-1.93) were more likely to decline treatment.

CONCLUSIONS

The majority of veteran patients are not suitable candidates for HCV treatment because of substance abuse, psychiatric disease, and comorbid medical disease, and many who are candidates decline therapy. Multidisciplinary collaboration is needed to overcome barriers to HCV therapy in this population.

Management of hepatitis C virus in special populations: patient and treatment considerations

The most common chronic blood-borne infection in the United States is caused by hepatitis C virus. An estimated 3.9 million people (1.8%) in the United States have been infected with the hepatitis C virus, excluding certain subpopulations who are at high risk for hepatitis C virus infection. Among these subpopulations are an estimated 255,000 (15%) of prison inmates and 175,000 (22%) of homeless people. Prevalence of hepatitis C virus infection is also high among veterans (6.6% overall and even higher among homeless veterans). The single most important risk factor for hepatitis C virus infection is injection drug use; up to 90% of illicit injection drug users are infected with hepatitis C virus. This review describes the prevalence of hepatitis C virus in special populations and discusses the treatment options for patients with severe disease, transplant recipients, and patients at high risk for infection. Close monitoring and management of therapeutic side effects are required to assist these patients in adhering to therapy.