Paroxetine for the prevention of depression induced by high-dose interferon alfa

A cognitive therapy conceptualization of panic disorder exacerbated by interferon treatment

This case conference presents a patient with von Willebrand disease, receiving year-long interferon treatment for hepatitis C. She was referred to C-L Psychiatry following a severe exacerbation of panic disorder. Our guest interviewer is Dr. Craig White, a Scottish cognitive therapist. The subsequent discussion outlines the treatment challenges of panic disorder that occurs when a patient is receiving interferon. A literature review evaluates psychological effects of interferon and biological mechanisms by which interferon may exacerbate anxiety and depression. A cognitive therapy conceptualization of interferon-induced exacerbation of panic disorder is proposed.

Endotoxin- or pro-inflammatory cytokine-induced sickness behavior as an animal model of depression: focus on anhedonia

In humans, exposure to endotoxins or pro-inflammatory cytokines induces a number of neuropsychological symptoms collectively referred to as 'flu-like syndrome'. The degree of overlap between flu-like syndrome and major depressive disorder is considerable and a close linkage between these has been predicted to arise due to hypersecretion of endogenous pro-inflammatory cytokines and activation of the hypothalamic pituitary adrenal axis. In animals, exposure to pro-inflammatory cytokines or endotoxins induces a 'sickness behavior' syndrome that is analogous to flu-like symptoms observed in human patients. The goal of the current paper is to review evidence implicating endotoxin- or cytokine-induced sickness behavior as an animal model of depression, with an emphasis on reduced consumption of highly palatable substances as a defining feature.

Cytokines as mediators of depression: what can we learn from animal studies?

It has recently been postulated that cytokines may cause depressive illness in man. This hypothesis is based on the following observations: 1. Treatment of patients with cytokines can produce symptoms of depression; 2. Activation of the immune system is observed in many depressed patients; 3. Depression occurs more frequently in those with medical disorders associated with immune dysfunction; 4. Activation of the immune system, and administration of endotoxin (LPS) or interleukin-1 (IL-1) to animals induces sickness behavior, which resembles depression, and chronic treatment with antidepressants has been shown to inhibit sickness behavior induced by LPS; 5. Several cytokines can activate the hypothalamo-pituitary-adrenocortical axis (HPAA), which is commonly activated in depressed patients; 6. Some cytokines activates cerebral noradrenergic systems, also commonly observed in depressed patients; 7. Some cytokines activate brain serotonergic systems, which have been implicated in major depressive illness and its treatment. The evidence for each of these tenets is reviewed and evaluated along with the effects of cytokines in classical animal tests of depression. Although certain sickness behaviors resemble the symptoms of depression, they are not identical and each has distinct features. Thus the value of sickness behavior as an animal model of major depressive disorder is limited, so that care should be taken in extrapolating results from the model to the human disorder. Nevertheless, the model may provide insight into the etiology and the mechanisms underlying some symptoms of major depressive disorder. It is concluded that immune activation and cytokines may be involved in depressive symptoms in some patients. However, cytokines do not appear to be essential mediators of depressive illness.

Mood disorders in the medically ill: scientific review and recommendations

OBJECTIVE

The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research.

DATA SOURCES

Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors.

STUDY SELECTION/DATA EXTRACTION

Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed.

CONCLUSIONS

A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Epidemiology and treatment of psychiatric conditions that develop after critical illness

PURPOSE

As a greater number of patients survive critical illness, there is increasing interest in accelerating patients' recovery after intensive care unit discharge. There is compelling evidence that psychiatric illnesses such as depression impair functional status in patients with chronic medical illnesses. Therefore, psychiatric conditions that develop after critical illness are a logical target for treatment or prevention strategies to improve recovery after critical illness.

RECENT FINDINGS

This is a new area of investigation for intensive care unit researchers. To date, most studies have focused on descriptive epidemiology of psychiatric conditions at varying times after intensive care unit discharge. Small randomized trials have shown that depression and posttraumatic stress symptoms can be reduced by interventions during or after mechanical ventilation, although the causal mechanisms leading to these improved outcomes are obscure. Promising results must be confirmed in additional trials. After acute myocardial infarction, large trials have found that psychosocial interventions started after hospital discharge are ineffective at preventing psychosocial impairment.

SUMMARY

Psychiatric symptoms and disorders affect 15%-35% of patients months after intensive care unit discharge. There is no consistent evidence that antidepressant medications are safe or effective in critically ill patients. Understanding the causal pathways that lead from acute medical stress to neuronal alterations and subsequent psychiatric symptoms will allow more precise targeting of preventive interventions.

The Goldman Consensus statement on depression in multiple sclerosis

BACKGROUND

In January 2002 the New York City Chapter of the National Multiple Sclerosis Society convened a panel of experts to review the issue of depressive affective disorders associated with multiple sclerosis (MS). This Consensus Conference was supported by a grant from the Goldman family of New York City.

RESULTS

The panel reviewed summaries of current epidemiologic, neurobiologic, and therapeutic studies having to do with depressive disorders among MS patient populations. Depressive disorders occur at high rates among patients with MS, and there is reason to believe that the immunopathology of the disease is involved in the clinical expression of affective disorders. The depressive syndromes of MS have a major, negative impact on quality of life for MS sufferers, but are treatable. At the present time, most MS patients with depression do not receive adequate recognition and treatment.

CONCLUSIONS

The Goldman Consensus Conference Study Group provides recommendations for improved screening, diagnosis, and clinical management for depressive affective disorders among patients suffering from MS.

Serotonin a la carte: supplementation with the serotonin precursor 5-hydroxytryptophan

This paper reviews the preclinical and clinical evidence regarding the use of the dietary supplement 5-hydroxytryptophan (5-HTP) for the treatment of depression. In the absence of supplementation with exogenous 5-HTP, the amount of endogenous 5-HTP available for serotonin synthesis depends on the availability of tryptophan and on the activity of various enzymes, especially tryptophan hydroxylase, indoleamine 2,3-dioxygenase, and tryptophan 2,3-dioxygenase (TDO). Factors affecting each of these are reviewed. The amount of 5-HTP reaching the central nervous system (CNS) is affected by the extent to which 5-HTP is converted to serotonin in the periphery. This conversion is controlled by the enzyme amino acid decarboxylase, which, in the periphery, can be blocked by peripheral decarboxylase inhibitors (PDIs) such as carbidopa. Preclinical and clinical evidence for the efficacy of 5-HTP for depression is reviewed, with emphasis on double-blind, placebo-controlled (DB-PC) trials. Safety issues with 5-HTP are also reviewed, with emphasis on eosinophilia myalgia syndrome (EMS) and serotonin syndrome.

Etanercept, anticytokines and mania

Cytokines influence multiple psychiatric and medical conditions. Proinflammatory cytokines are associated with depression. The novel treatment of autoimmune diseases with anticytokines presents a unique strategy to understand the role of cytokines in affective disorders. Specifically, because antidepressants can be associated with cycling into manic states, and antidepressants can be associated with resolution of cytokine-induced depression, then, hypothetically, the treatment of a vulnerable patient who has an affective disorder with an anticytokine could also result in cycling. The development of a manic episode is described in a patient with psoriatic arthritis who was treated with etanercept, a tumour necrosis factor-alpha antagonist.

Prevention of interferon-alpha associated depression in psychiatric risk patients with chronic hepatitis C

BACKGROUND/AIMS

Interferon-alpha (IFN-alpha) induced depression is a major limitation for the treatment of chronic hepatitis C, especially for patients with psychiatric disorders. We prospectively studied the efficacy of a pre-emptive treatment with the antidepressant citalopram to prevent depression during hepatitis C treatment with pegylated IFN-alpha-2b plus ribavirin.

METHODS

14 HCV infected patients with psychiatric disorders received a prophylactic medication with citalopram (20mg/day) before and during therapy with IFN-alpha. The incidence of major depression was compared with 22 HCV infected patients with psychiatric disorders (group B; n=11) and without psychiatric risk factors (group C; n=11), who underwent IFN-alpha treatment without a pre-emptive antidepressant therapy. Depression was diagnosed by DSM-IV criteria.

RESULTS

Pre-treatment of psychiatric patients with citalopram significantly reduced the incidence of major depression during the first 6 months of antiviral treatment as compared to the two control groups (group A 14% vs. 64% and 55% in group B and C; log-rank 6.89; df=2; P=0.032). Patients who developed symptoms of major depression during IFN therapy could also be improved by antidepressive treatment.

CONCLUSIONS

Our open label pilot study, though small, clearly indicates that IFN alpha induced depression in psychiatric risk patients can be ameliorated by both the use of antidepressants as well as by intensive psychiatric care. However, larger, double blind placebo controlled trials in other patient populations are required to confirm these preliminary findings.

Association between symptom distress and survival in outpatients seen in a palliative care cancer center

Clinical observation and preliminary reports suggest that higher scores for symptoms such as pain may be associated with shorter survival. We undertook a survival analysis to determine whether symptom expression in outpatients with complex cancer is related to the duration of their survival. Participants were 225 outpatients with cancer evaluated in our comprehensive cancer center for pain management or palliative care over a 10-week period ending June 2000. In addition to age and other clinical and demographic information, the patients completed the Anderson Symptom Assessment System (ASAS), which assesses pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath (dyspnea), appetite, sleep, and feeling of well-being on a 0-10 scale. Univariate analyses showed that higher symptoms of dyspnea, drowsiness, problems with appetite, and nausea were significantly associated with shorter survival whereas pain, depression and other ASAS items were not. In multivariate analyses, only higher levels of dyspnea and drowsiness showed a significant association (P=0.01 and P=0.02, respectively) with shorter survival. Knowledge about these symptoms may be important in formulating adaptive randomization techniques for clinical trials and for research concerning estimates of survival.

Interferon-induced depression: strategies in treatment

Interferon (IFN) is a pro-inflammatory cytokine that is widely used for the treatment of a number of disorders including viral infections, hematological proliferative disorders, and skin malignancies. Unfortunately, IFN frequently induced depression and has led to compromised tolerability with lowering of the dose of IFN and even discontinuation of treatment. Thus, it is imperative to diagnose IFN-induced depression early, evaluate whether this depression is associated with IFN-induced anemia or thyroid dysfunction, which can be corrected, and if necessary treat with antidepressants. IFN-induced depression is highly responsive to antidepressants with benefits occurring frequently at relatively low doses and after only a few weeks. Although SSRIs have mainly been studied, non-SSRIs appear to be effective also. Antidepressants have a number of risks and side effects that must be considered and may enter into the decision as to which antidepressant to choose. If IFN induces a depression in a patient with a bipolar disorder history, antidepressant treatment must include a mood stabilizer. In the case of vulnerable patients (e.g., those who have significant depressive symptoms prior to IFN or who have had an IFN-induced depression in the past) prophylactic antidepressant treatment appears to decrease the likelihood of having an IFN-induced depression. On the basis of known and effective treatment strategies, IFN-induced depression should not be an obstacle for continued treatment in most patient populations.

IDO and interferon-alpha-induced depressive symptoms: a shift in hypothesis from tryptophan depletion to neurotoxicity

Studies show that administration of interferon (IFN)-alpha causes a significant increase in depressive symptoms. The enzyme indoleamine 2,3-dioxygenase (IDO), which converts tryptophan (TRP) into kynurenine (KYN) and which is stimulated by proinflammatory cytokines, may be implicated in the development of IFN-alpha-induced depressive symptoms, first by decreasing the TRP availability to the brain and second by the induction of the KYN pathway resulting in the production of neurotoxic metabolites. Sixteen patients with chronic hepatitis C, free of psychiatric disorders and eligible for IFN-alpha treatment, were recruited. Depressive symptoms were measured using the Montgomery Asberg Depression Rating Scale (MADRS). Measurements of TRP, amino acids competing with TRP for entrance through the blood-brain barrier, KYN and kynurenic acid (KA), a neuroprotective metabolite, were performed using high-performance liquid chromatography. All assessments were carried out at baseline and 1, 2, 4, 8, 12 and 24 weeks after treatment was initiated. The MADRS score significantly increased during IFN-alpha treatment as did the KYN/TRP ratio, reflecting IDO activity, and the KYN/KA ratio, reflecting the neurotoxic challenge. The TRP/CAA (competing amino acids) ratio, reflecting TRP availability to the brain, did not significantly change during treatment. Total MADRS score was significantly associated over time with the KYN/KA ratio, but not with the TRP/CAA ratio. Although no support was found that IDO decreases TRP availability to the brain, this study does support a role for IDO activity in the pathophysiology of IFN-alpha-induced depressive symptoms, through its induction of neurotoxic KYN metabolites.

Hépatite C, Interféron α et dépression : principales hypothèses physiopathologiques

Imputability of thymic disorders caused by IFNalpha during the chronic Hepatitis C treatment -- hepatitis C and depression -- the infection by the hepatitis C virus (HCV) is a major public health concern since it affects 1.2% in the French population. Eighty percent of those contaminated by HCV keep bearing the virus chronically although they remain asymptomatic during many years. HCV infection is associated with psychiatric symptoms like depression. Together with other factors (eg the severity of hepatic condition), depression may induce significant impairment in quality of life. Conversely, some psychiatric conditions may increase the risk of HCV infection. In drug-addicted subjects using intravenous route, HCV contamination rate ranges from 74 to 100%. Compared with general population, a higher HCV contamination rate has also been noticed in some other subgroups of subjects (patients with alcohol abuse or dependence, with alcohol-induced hepatic disease and psychiatric inpatients). However, no valid explanation to this phenomenon has been established. Interferon alpha and depression - Interferons are a variety of cytokines naturally produced by human tissues and have also been synthesized for therapeutic purposes (treatment of a variety of cancers and viral infections). Many psychobehavioural symptoms are observed under IFNalpha treatment. Among them, mood disorders are known to occur early after entry into treatment and to be within the reach of preventive measures. The reported frequency of depression during IFNalpha treatment ranges from 0 to 37%. This variation reflects either methodological biases (eg differences in psychiatric assessment) or the heterogeneity of the population of patients accepted in therapeutic protocols. Note that the adjunction of ribavirine to IFNalpha in therapeutic protocols has not brought any changes in the depression frequency. The causal relationship between IFNalpha administration and the occurrence of mood disorders has been tackled by various recent research works focusing on the importance of the immune system in the pathophysiology of depression. Miscellaneous pathophysiological hypotheses -- nature of the psychobehavioural symptomatology -- in addition to depressive symptoms, IFNalpha treatment also induces various cognitive impairments and disruptions in EEG patterns. These symptoms are consistent with a mild subcortical dementia. Data resulting from pharmacological trials in humans and in animals are controversial (eg IFNalpha-induced symptoms being alleviated by both immune and antidepressant therapies). However, the debate about the nature of the psychobehavioural disorders observed under IFNalpha treatment might be no longer relevant in the light of recent theories which regard depression as a maladaptive response to a particular form of stress, namely a deep and diffuse feeling of sickness ("malaise"). These theoretical views ascribe the production of depressive symptoms to a disruption in the immune function, mediated by the variety of cytokines. The therapeutic effects of anti-depressive drugs are thus attributed to their analgesic properties, reducing the "malaise" feeling underlying depressive symptoms. Necessity of a second messanger -- accordingly to current pathophysiological theories, depression results from disorders of various CNS functions, mainly limbic, monaminergic and neuroendocrinal systems. Though, exogenous IFNalpha does not cross the blood-brain barrier when unscathed and an intermediary mechanism is necessary. First to be addressed is the cytokines system itself since it is composed of numerous different molecules interacting in an infinite number of possible combinations. Some of these cytokines (eg some interleukins) both are activated by IFNalpha and can reach CNS; they are good candidates for the role of second messenger mediating the induction of psychobehavioural disorders. Second, keeping in mind that serotonin is a monoaminergic neurotransmitter classically involved in depression pathophysiology, other works have demonstrated that IFNalpha modulates the peripheral activity of indolamine-dioxygenase -- a regulating enzyme of serotonin metabolism -- possibly through lymphocyte T CD4 activation. Third, other authors have postulated an immune-induced vagal mechanism to explain depression caused by IFNalpha. Action of IFNalpha on the neuroendocrine and on neuromodulating functions: monoaminergic hypothesis -- cytokines could have an influence on the mood through their modulating role on the serotoninergic system. IFNalpha treatment is reported to produce: 1) a decrease in tryptophan availability for serotonin synthesis, 2) a decrease in the 5-HIAA level in the LCR, and 3) a modification of the central serotoninergic receptors. Moreover, selective inhibitors of serotonin transporters are effective to treat or prevent depression caused by IFNalpha. Many studies support the serotonin-transporter hypothesis: in vitro, both IFNalpha and interleukine 4 (IL-4) increases the expression of serotonin transporter gene, IFNalpha increases in the production of IL-4 by mononucleus cells (not found in vivo). Serotoninergic system can also be altered by a peripheral action of IFNalpha on trytophan catabolism by activating a concurrent pathway (known as "kynurenine pathway") to serotonin synthesis. Finally, serotonin-mediated vulnerability to the psychobehavioural effects of IFNalpha could be underlain by a polymorphism of serotonin transporter gene. Concerning the other monoaminergic systems, IFNalpha seems to have an amphetamine-like effect at its first administration, followed by a decrease in dopaminergic tone with chronic administration. Dopaminergic depletion, subsequent to psychostimulant abuse for instance, results in severe depressive syndromes. Interactions between IFNalpha and noradrenergic system have also been reported. Neuroendocrinian hypothesis -- when administered through central or peripheral way, IFNalpha simulates/inhibits the corticotrope axis and alters endorphin system as shown by the induction of analgesia, catatonia and behavioural slowdown that can be suppressed by opioid antagonists. IFNalpha neurotoxic effects are successfully treated by naltrexone. Lastly, IFNalpha is known to cause disorders in thyroid function that are likely to contribute to the production or aggravation of mood disorders.

CONCLUSION

A better understanding of pathophysiologic mechanisms underlying psychiatric side-effects of IFNalpha is essential to extend access to treatment to some categories of patients that remain excluded from the protocols. A better management of those psychiatric side effects should help the clinician not to draw aside patients at risk, ie patients with depression, drug and alcohol addiction. Treating them in a pragmatic and careful way is a major issue, since this population represents a high percentage of the potential candidates for interferon therapy.

Exaggerated neuroinflammation and sickness behavior in aged mice following activation of the peripheral innate immune system

Acute cognitive impairment (i.e., delirium) is common in elderly emergency department patients and frequently results from infections that are unrelated to the central nervous system. Since activation of the peripheral innate immune system induces brain microglia to produce inflammatory cytokines that are responsible for behavioral deficits, we investigated if aging exacerbated neuroinflammation and sickness behavior after peripheral injection of lipopolysaccharide (LPS). Microarray analysis revealed a transcriptional profile indicating the presence of primed or activated microglia and increased inflammation in the aged brain. Furthermore, aged mice had a unique gene expression profile in the brain after an intraperitoneal injection of LPS, and the LPS-induced elevation in the brain inflammatory cytokines and oxidative stress was both exaggerated and prolonged compared with adults. Aged mice were anorectic longer and lost more weight than adults after peripheral LPS administration. Moreover, reductions in both locomotor and social behavior remained 24 h later in aged mice, when adults had fully recovered, and the exaggerated neuroinflammatory response in aged mice was not reliably paralleled by increased circulating cytokines in the periphery. Taken together, these data establish that activation of the peripheral innate immune system leads to exacerbated neuroinflammation in the aged as compared with adult mice. This dysregulated link between the peripheral and central innate immune system is likely to be involved in the severe behavioral deficits that frequently occur in older adults with systemic infections.

The role of immune system parameters in the relationship between depression and coronary artery disease

The relationship between depressive symptoms and coronary artery disease (CAD) is mediated in part by immune system parameters. This review describes research on the psychoneuroimmunological pathways accounting for the association between depression and CAD, and addresses conceptual and methodological issues. Relationships between central nervous system correlates of depression and immune system parameters are bidirectional and are mediated via neurohormonal and parasympathetic pathways. Evidence suggests that these associations can be affected by a) the clinical characteristics of depression (e.g., typical depression versus atypical depression and exhaustion), b) the duration and severity of depressive symptoms, and c) the stage of underlying CAD. Depressive symptoms are hypothesized to affect primarily the transition from stable CAD to acute coronary syndromes via plaque activation and prothrombotic processes, and may play an additional role in the response to injury at early stages of coronary atherosclerosis.

Treatment of hepatitis C

The combination of pegylated interferon alpha and ribavirin has improved treatment success rates in patients with hepatitis C with sustained response rates of just over 50% overall and more than 70% for those with genotypes 2 and 3. This article reviews the use of combination therapy, contraindications, factors influencing response and describes approaches to specific patient groups.

Stress, depression, and anhedonia: caveats concerning animal models

Numerous animal models of depression have been advanced, each having multiple attributes and some limitations. This review provides caveats concerning etiologically valid animal models of depression, focusing on characteristics of the depressive subtype being examined (e.g. typical vs atypical major depression, dysthymia, melancholia), and factors that contribute to the interindividual behavioral variability frequently evident in stressor-related behavioral paradigms. These include the stressor type (processive vs systemic stressors), and characteristics of the stressor (controllability, predictability, ambiguity, chronicity, intermittence), as well as organismic variables (genetic, age, sex), experiential variables (stressor history, early life events) and psychosocial and personality factors that moderate stressor reactivity. Finally, a model of depression is reviewed that evaluates the effects of stressors on hedonic processes, reflected by responding for rewarding brain stimulation. Anhedonia is a fundamental feature of depression, and assessment of stressor-related reductions in the rewarding value of brain stimulation, especially when coupled with other potential symptoms of depression, provides considerable face, construct and predictive validity. Stressful events markedly impact rewarding brain stimulation, and this effect varies across strains of mice differentially reactive to stressors, is modifiable by antidepressant treatments, and allows for analyses of the contribution of different brain regions to anhedonic processes. The paradigm is sensitive to several factors known to acts as moderators of stress responses, but analyses remain to be conducted with regard to several such variables.

Psychosocial oncology: Supportive care for the cancer patient

Increasing attention is being paid to the emotional and psychosocial needs of cancer patients. As a result of huge advances in early detection and in treatment modalities, there now are millions of cancer survivors in the United States. There has been a realization that cancer survivors have distinct psychosocial needs. As cancer survivors live longer, reduction of psychological distress has been recognized as being an important part of having an improved quality of life. There have been numerous changes in the field of psychosocial oncology since it first began 25 years ago. Guidelines now exist for the definition of distress and decision trees are available for making the appropriate referrals. Advances in pharmacologic treatment for depression and anxiety have made it possible to decrease distress and increase coping in cancer patients undergoing treatment as well as in cancer survivors. Numerous individual and group therapies have demonstrated effectiveness in improving mood and quality of life in cancer patients and those at high risk for developing cancer. Due to the forthright efforts of cancer patients, there are now many organizations and list serves (e-mailing lists) that cancer survivors can turn to for help before, during, and after cancer treatment. Finally, with the rapid expansion of the internet not only are there websites available as resources, but also the creation of interactive online support is becoming a reality. One of the most important issues in providing supportive care to cancer patients in the future is to meet the individual needs of patients and provide the type of psychological therapy that will work best for them.

Factors associated with the initiation of alpha-interferon treatment in Medicaid patients diagnosed with hepatitis C

We aimed to determine rates of treatment with alpha-interferon medication in patients diagnosed with hepatitis C virus (HCV), to ascertain the prevalence of selected conditions that could influence initiation of interferon treatment, and to examine the association between the presence of these conditions and interferon treatment. A nested case-control design was used in California Medicaid (Medi-Cal) claims data covering the period from 1 January 1996 to 30 June 2002. Interferon-treated cases and non-treated controls were selected in a 1 : 2 ratio that matched the length of the observation period and year of index HCV diagnosis. Predictor variables examined in bivariate and multivariate analyses included demographics, substance abuse and dependence, psychotropic drug use, selected chronic conditions and medical utilization. The proportion of eligible subjects diagnosed with HCV and treated with interferon ranged from 10.7 to 13.9%. There were 529 treated cases that met the eligibility criteria and 1058 non-treated HCV patients selected as controls. Multivariate factors that increased the likelihood of treatment were a liver biopsy, a diagnosis of mild liver disease, a diagnosis of psoriasis, antidepressant use and classification of race/ethnicity as 'other'. A decreased likelihood of treatment was linked to age > or =65 years, a diagnosis of kidney disease, one to four emergency visits and five or more emergency visits. The proportion of patients receiving interferon treatment in the Medi-Cal-insured population was low compared with published rates in HCV patients in other general medical settings. The diverse factors linked to initiation of HCV therapy raise compelling questions for further research.

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Cognition in liver disease

BACKGROUND

Cognitive dysfunction has been observed in a range of liver diseases including chronic hepatitis C virus, alcoholic liver disease, primary biliary cirrhosis and Wilson's disease. Such dysfunction may range from mild cognitive changes to overt hepatic encephalopathy, and represents a significant complication of liver disease that may negatively impact the patient's quality of life, and normal activities of daily living (e.g., driving).

METHOD

This article reviews the published evidence relating to cognitive dysfunction in liver disease.

OUTCOME

Issues of definition, diagnosis, epidemiology, aetiology, treatment and outcome are discussed. Particular attention is devoted to identifying the mild cognitive changes that occur in liver diseases of different aetiology.

Cytokines and major depression

In the research field of psychoneuroimmunology, accumulating evidence has indicated the existence of reciprocal communication pathways between nervous, endocrine and immune systems. In this respect, there has been increasing interest in the putative involvement of the immune system in psychiatric disorders. In the present review, the role of proinflammatory cytokines, such as interleukin (IL)-1, tumour necrosis factor (TNF)-alpha and interferon (IFN)-gamma, in the aetiology and pathophysiology of major depression, is discussed. The 'cytokine hypothesis of depression' implies that proinflammatory cytokines, acting as neuromodulators, represent the key factor in the (central) mediation of the behavioural, neuroendocrine and neurochemical features of depressive disorders. This view is supported by various findings. Several medical illnesses, which are characterised by chronic inflammatory responses, e.g. rheumatoid arthritis, have been reported to be accompanied by depression. In addition, administration of proinflammatory cytokines, e.g. in cancer or hepatitis C therapies, has been found to induce depressive symptomatology. Administration of proinflammatory cytokines in animals induces 'sickness behaviour', which is a pattern of behavioural alterations that is very similar to the behavioural symptoms of depression in humans. The central action of cytokines may also account for the hypothalamic-pituitary-adrenal (HPA) axis hyperactivity that is frequently observed in depressive disorders, as proinflammatory cytokines may cause HPA axis hyperactivity by disturbing the negative feedback inhibition of circulating corticosteroids (CSs) on the HPA axis. Concerning the deficiency in serotonergic (5-HT) neurotransmission that is concomitant with major depression, cytokines may reduce 5-HT levels by lowering the availability of its precursor tryptophan (TRP) through activation of the TRP-metabolising enzyme indoleamine-2,3-dioxygenase (IDO). Although the central effects of proinflammatory cytokines appear to be able to account for most of the symptoms occurring in depression, it remains to be established whether cytokines play a causal role in depressive illness or represent epiphenomena without major significance.

Interferon-induced depression: prevalence and management

BACKGROUND

Interferon-induced depression ranges from 0 to 50%. Interferon schedule and a history of psychiatric illnesses are not enough to predict who will develop symptoms and who will not.

AIMS

To assess the prevalence of depression during interferon therapy; to test whether Minnesota Multiphasic Personality Inventory is useful in clinical practice for the early identification of patients at risk of depression; whether and how the depression can be cured.

PATIENTS

One hundred and eighty-five patients treated with interferon and ribavirin for chronic hepatitis C.

METHODS

Before therapy, all patients underwent a Minnesota Multiphasic Personality Inventory and a clinical examination, specifically for the identification of depressive symptoms.

RESULTS

Thirty-one patients developed a psychiatric disorder, 11 of them requiring treatment with anti-depressant drugs. Among the 18 patients with Minnesota Multiphasic Personality Inventory positive tests, 16 developed a psychiatric disorder, 8 of them a severe disorder (sensitivity of 0.58; 0.73 for severe disorders). Among the 154 who did not develop psychiatric side effects, 152 had a negative Minnesota Multiphasic Personality Inventory (specificity: 0.99). Severe psychiatric disorders were successfully treated with anti-depressant drugs.

CONCLUSIONS

Psychiatric side effects are easy to see during interferon therapy. A psychiatric evaluation should be considered on all patients before treatment. If depression develops, it should be treated aggressively, and selective serotonin re-uptake inhibitors are the anti-depressants of choice.

Prophylactic SSRI during interferon alpha re-therapy in patients with chronic hepatitis C and a history of interferon-induced depression

Only limited data are available on selective serotonin re-uptake inhibitor (SSRI) prophylaxis for antiviral re-treatment in hepatitis C patients with previous interferon-induced major depressive episodes. Therefore, we investigated the efficacy and safety of secondary SSRI prophylaxis in these patients. In a prospective and longitudinal study, repeated psychometric testing (Hospital Anxiety and Depression Scale) was performed before, during, and after antiviral re-treatment. Chronic hepatitis C virus (HCV)-infected patients, who had been psychometrically monitored during an unsuccessful previous antiviral therapy, and had developed major depression were included. Interferon re-therapy with SSRI prophylaxis was started (n = 8). The reference group was comprised of HCV patients without a history of interferon-associated depression and also a group who were previously unsuccessfully treated with interferon and were re-treated without SSRI prophylaxis (n = 9). All patients receiving SSRI prophylaxis were able to complete interferon re-therapy as scheduled. As in the first therapeutic course, depression scores were significantly elevated during re-treatment also (P < 0.001). Depression scores were significantly lower (P =0.036) during interferon re-therapy with SSRI prophylaxis. Reference group subjects showed similar depression scores during first therapy and re-therapy (P > 0.05). In conclusion, hepatitis C patients with a history of interferon-induced major depression can be successfully re-treated with peginterferon/ribavirin and concomitant SSRI prophylaxis. In these patients, SSRI prophylaxis is safe and efficacious and should be considered, if antiviral re-therapy is indicated.

Impact of adherence on the outcome of antiviral therapy for chronic hepatitis C

Nearly 4 million people in the United States have evidence of hepatitis C infection (HCV), representing a significant cause of cirrhosis and liver cancer as well a major burden to our healthcare systems and society. Antiviral therapy can successfully eradicate HCV over the long term, potentially reducing the risk of progression and improving patients' quality of life. The currently preferred HCV treatment is a combination of pegylated interferon alfa and ribavirin, which can achieve an overall sustained viral eradication rate of 55%. The duration of this treatment is typically determined by HCV genotype and the patient's early virologic response to the antiviral regimen. Evidence has accumulated over the past few years to indicate that close adherence to the optimal antiviral regimen can enhance sustained virologic response. But optimal treatment outcomes require diligence and careful management of side effects related to combination therapy. Although reducing the dose of pegylated interferon alfa, ribavirin, or both can effectively treat side effects, suboptimal doses of this regimen, especially ribavirin, may negatively affect virologic response. An alternative strategy is to use growth factors to treat cytopenias. This strategy can obviate dose reductions while potentially improving patients' quality of life. Patient support seems especially important early after the initiation of antiviral therapy. Encouraging study findings involving the growth factors, epoetin alfa and darbepoetin alfa, suggest improved anemia and quality of life while maintaining the optimal ribavirin dose. Future work should be aimed at providing stronger evidence for the use of these "supportive products" during anti-HCV therapy. As we strive to develop better treatment options for our HCV patients, the importance of adhering to the treatment regimen continues to play a central role. Effective side effect management is crucial for the success of this treatment because adherence is negatively affected by side effects related to the antiviral regimen. By identifying and addressing the important side effects of combination therapy for HCV, adherence to treatment can be improved and optimal outcomes can be achieved.

5-Hydroxytryptophan plus SSRIs for interferon-induced depression: Synergistic mechanisms for normalizing synaptic serotonin

Interferon-alpha (IFN) is widely used in the treatment of certain cancers and viral infections, including hepatitis C (HCV). Unfortunately, depression is a common side effect of IFN therapy, affecting approximately a third of HCV patients receiving IFN therapy. Studies have shown that selective serotonin reuptake inhibitors (SSRIs) can effectively treat IFN-induced depression in only 63-75% of cases. For the remaining percentage, depression often necessitates dose reduction of or discontinuation from IFN therapy. Emerging evidence indicates that IFN may cause depression by affecting brain serotonin. IFN has been shown to increase serotonin reuptake and to decrease serotonin synthesis. We hypothesize that SSRIs are not fully effective because they affect only serotonin reuptake, not serotonin synthesis, and that effective treatment must address both uptake and synthesis. 5-Hydroxytryptophan (5-HTP) effectively increases central nervous system synthesis of serotonin. It is the immediate precursor of serotonin and is widely available as a dietary supplement, which is well absorbed after an oral dose. Several double-blind studies have shown 5-HTP to be effective in the treatment of nondrug-induced depression. We hypothesize that patients who become depressed on IFN will respond to the synergistic combination of SSRIs plus 5-HTP.

Medical illness and comorbidities in drug users: implications for addiction pharmacotherapy treatment

Providing effective medical care to those with substance use disorders can be a challenge to clinicians. In this article, we briefly summarize issues that occur frequently in the medical treatment of substance users. The focus of this article is twofold. The first is to briefly summarize common co-occurring medical illnesses in those manifesting substance use disorders with an emphasis on issues related to providing effective treatment for these diseases in this population. Using specific examples of frequently occurring comorbid medical illness in substance users, including infectious diseases (hepatitis C and HIV disease), sexually transmitted diseases, and pregnancy as examples, the complexities of medical care for this population is demonstrated. Second, this article addresses some of the difficulties encountered in pharmacotherapy aimed specifically at treatment of substance use disorders. For example, difficulties in managing concomitant opiate therapy in those requiring medications for medical illness that may have strong and adverse interactions with opiates are addressed. Adverse events reported for some substance use disorder pharmacotherapies are also highlighted. We conclude with a brief review of models of care that have been effective in addressing the needs of this challenging population that can provide additional means for enhancing the clinical care of substance users.

Depression during pegylated interferon-alpha plus ribavirin therapy: prevalence and prediction

BACKGROUND

Interferon-alpha (IFN-alpha) plus ribavirin is used to treat hepatitis C virus (HCV) infection and is associated with a high rate of depression. Newer, pegylated preparations of IFN-alpha have a longer half-life, require once-per-week dosing, and may be associated with reduced neuropsychiatric burden. Limited data exist on depression during pegylated IFN-alpha therapy.

METHOD

Depressive symptoms were assessed using the Zung Self-Rating Depression Scale (SDS) in 162 HCV-infected patients at baseline and after 4, 8, 12, and 24 weeks of treatment with pegylated IFN alpha-2b (PEG IFN) plus weight-based (N = 86) versus standard dose (N = 76) ribavirin. Data were collected from March 2001 to April 2003.

RESULTS

Compared with baseline, mean SDS index scores were significantly increased by week 4 and remained elevated throughout the study. Thirty-nine percent of the sample experienced moderate to severe depressive symptoms (SDS index score > or = 60) at some point during PEG IFN/ribavirin therapy. Baseline depression scores significantly predicted severity of depressive symptoms during PEG IFN/ribavirin treatment (simple regression analysis: Y = 0.55X + 32.7, p < .0001). In addition, assignment to weight-based ribavirin treatment and history of depression were associated with increased likelihood of developing moderate to severe depressive symptoms (odds ratio [OR] = 2.7, 95% CI = 1.3 to 5.6, p < .01, and OR = 3.3, 95% CI = 1.3 to 8.1, p < .01, respectively).

CONCLUSIONS

Development of moderate to severe depressive symptoms occurred frequently during PEG IFN/ribavirin treatment and was predicted by baseline depression scores and higher doses of ribavirin. History of major depressive disorder was also a significant predictive factor, but only through association with elevated baseline depression status. All of these factors can be evaluated and addressed to limit neuropsychiatric morbidity during HCV treatment.

Platelet MAO activity during treatment with pegylated interferon-alfa in melanoma patients

Depression and cognitive disturbance are well-known neuropsychiatric side effects of therapy with interferon-alfa (IFN-alfa). Aggression and irritability are also reported as side effects. Probably, central nervous system (CNS) serotonergic dysfunction is one of the underlying pathophysiological mechanisms of IFN-alfa-induced neuropsychiatric toxicity. Platelet activity of monoamine oxidase-B (MAO; EC1.4.3.4) is a possible indicator of central serotonergic function. Moreover, low platelet MAO activity is linked to impulsiveness, addiction and personality disorder. In this exploratory study in 17 high-risk melanoma patients, platelet counts, whole blood MAO, and platelet MAO activity were measured before and during therapy with IFN-alfa. Patients were randomized to treatment either with pegylated IFN-alfa (PEG-IFN-alfa) once a week at a dose of 6 microg/kg/week subcuteanously (s.c.) during 8 weeks, followed by a maintenance treatment of 3 microg/kg/week s.c. for a total of 5 years, or to observation only. Blood samples were taken at baseline, 4 and 8 weeks and 3 months. During treatment with IFN-alfa, platelet counts decreased at 4 and 8 weeks and 3 months, while platelet MAO activity increased, both compared to baseline and compared to non-treated controls. Compared to non-treated controls, platelet MAO activity increased with 86.4% (95 CI: 52.9-127.2). No significant changes in platelet MAO activity were observed in the control group. This indicates that platelet MAO activity is influenced by IFN-alfa. Since platelet MAO activity is a model for CNS MAO-B activity, it may be speculated that CNS MAO-B activity will also be increased. This could influence serotonin (5-HT) metabolism and thereby contribute to the development of psychiatric disturbance. However, a preferential inhibition of platelet production cannot be ruled out. Hypothetically, the antiproliferative effects of IFN-alfa could interfere more strongly with the synthesis of platelets than with the synthesis of mitochondria. In that case, increased platelet MAO activity reflects an increased number of mitochondria per platelet.

Major depressive disorder with psychotic features induced by interferon-alpha treatment for hepatitis C in a polydrug abuser

Infectious diseases, especially hepatitis C, are prevalent among drug abusers. Interferon-alpha (IFN-alpha) is the pharmacological treatment of choice for this condition. Patients being treated with IFN-alpha can be expected to experience such psychiatric side-effects as development of depression, mania, irritability, changes in personality, hallucinations or delirium. In addition, certain patients are considered to be at greater risk of developing neuropsychiatric side-effects. Individuals meeting the following criteria are particularly vulnerable: over 40 years of age; having central nervous system abnormalities; a previous neurological or psychiatric history; a past familial psychiatric history; use of narcotics or having alcohol or substance use disorders; being HIV-positive; coadministration of other cytokines; receiving high doses of IFN-alpha (> 6 million units). We report the case of a 29-year-old patient with chronic non-active hepatitis C, a previous psychiatric history of polydrug abuse (cannabis, heroin and illegal use of the psychotropic drug biperiden) and anxiety disorder. Two weeks after the initiation of IFN-alpha treatment, he developed fatigue, sleeplessness and persecutory delusions. The patient responded partially to the discontinuation of the IFN-alpha treatment. Due to the presence of three risk factors in this patient, he was considered to belong to the group of patients being 'at high risk' of developing neuropsychiatric side-effects. This is the first case report of major depressive disorder with psychotic features in such a 'high-risk patient'. This case report may prompt other research by showing the importance of the close monitoring, and the prevention of the progression of IFN-alpha-related psychiatric disorders in 'a high-risk patient'.

Neuropsychiatric adverse effects of interferon-alpha: recognition and management

Recombinant preparations of the cytokine interferon (IFN)-alpha are increasingly used to treat a number of medical conditions, including chronic viral hepatitis and several malignancies. Although frequently effective, IFN alpha induces a variety of neuropsychiatric adverse effects, including an acute confusional state that develops rapidly after initiation of high-dose IFN alpha, a depressive syndrome that develops more slowly over weeks to months of treatment, and manic conditions most often characterised by extreme irritability and agitation, but also occasionally by euphoria. Acute IFN alpha-induced confusional states are typically characterised by disorientation, lethargy, somnolence, psychomotor retardation, difficulties with speaking and writing, parkinsonism and psychotic symptoms. Strategies for managing delirium should be employed, including treatment of contributing medical conditions, use of either typical or atypical antipsychotic agents and avoidance of medications likely to worsen mental status. Significant depressive symptoms occur in 21-58% of patients receiving IFN alpha, with symptoms typically manifesting over the first several months of treatment. The most replicated risk factor for developing depression is the presence of mood and anxiety symptoms prior to treatment. Other potential, but less frequently replicated, risk factors include a past history of major depression, being female and increasing IFN alpha dosage and treatment duration. The available data support two approaches to the pharmacological management of IFN alpha-induced depression: antidepressant pretreatment or symptomatic treatment once IFN alpha has been initiated. Pretreatment might be best reserved for patients already receiving antidepressants or for patients who endorse depression or anxiety symptoms of mild or greater severity prior to therapy. Several recent studies demonstrate that antidepressants effectively treat IFN alpha-induced depression once it has developed, allowing the vast majority of subjects to complete treatment successfully. Recent data suggest that IFN alpha-induced depression may be composed of two overlapping syndromes: a depression-specific syndrome characterised by mood, anxiety and cognitive complaints, and a neurovegetative syndrome characterised by fatigue, anorexia, pain and psychomotor slowing. Depression-specific symptoms are highly responsive to serotonergic antidepressants, whereas neurovegetative symptoms are significantly less responsive to these agents. These symptoms may be more effectively treated by agents that modulate catecholaminergic functioning, such as combined serotonin-noradrenaline (norepinephrine) antidepressants, bupropion, psychostimulants or modafinil. Additional factors to consider in selecting an antidepressant include potential drug-drug interactions and adverse effect profile. Finally, IFN alpha appears capable of inducing manic symptoms. Mania, especially when severe, is a clinical emergency. When this occurs, IFN alpha and antidepressants should be stopped, an emergency psychiatric consultation should be obtained, and treatment with a mood stabilizer should be initiated.

The Darwinian concept of stress: benefits of allostasis and costs of allostatic load and the trade-offs in health and disease

Why do we get the stress-related diseases we do? Why do some people have flare ups of autoimmune disease, whereas others suffer from melancholic depression during a stressful period in their life? In the present review possible explanations will be given by using different levels of analysis. First, we explain in evolutionary terms why different organisms adopt different behavioral strategies to cope with stress. It has become clear that natural selection maintains a balance of different traits preserving genes for high aggression (Hawks) and low aggression (Doves) within a population. The existence of these personality types (Hawks-Doves) is widespread in the animal kingdom, not only between males and females but also within the same gender across species. Second, proximate (causal) explanations are given for the different stress responses and how they work. Hawks and Doves differ in underlying physiology and these differences are associated with their respective behavioral strategies; for example, bold Hawks preferentially adopt the fight-flight response when establishing a new territory or defending an existing territory, while cautious Doves show the freeze-hide response to adapt to threats in their environment. Thus, adaptive processes that actively maintain stability through change (allostasis) depend on the personality type and the associated stress responses. Third, we describe how the expression of the various stress responses can result in specific benefits to the organism. Fourth, we discuss how the benefits of allostasis and the costs of adaptation (allostatic load) lead to different trade-offs in health and disease, thereby reinforcing a Darwinian concept of stress. Collectively, this provides some explanation of why individuals may differ in their vulnerability to different stress-related diseases and how this relates to the range of personality types, especially aggressive Hawks and non-aggressive Doves in a population. A conceptual framework is presented showing that Hawks, due to inefficient management of mediators of allostasis, are more likely to be violent, to develop impulse control disorders, hypertension, cardiac arrhythmias, sudden death, atypical depression, chronic fatigue states and inflammation. In contrast, Doves, due to the greater release of mediators of allostasis (surplus), are more susceptible to anxiety disorders, metabolic syndromes, melancholic depression, psychotic states and infection.

Cytokines and psychopathology: lessons from interferon-alpha

Interferon-alpha is a potent inducer of the cytokine network and is notorious for causing behavioral alterations. Studies on interferon-alpha-treated patients reveal at least two distinct syndromes: 1) a mood/cognitive syndrome that appears late during interferon-alpha therapy is responsive to antidepressants and is associated with activation of neuroendocrine pathways and altered serotonin metabolism; and 2) a neurovegetative syndrome characterized by psychomotor slowing, and fatigue that appears early during interferon-alpha treatment is antidepressant nonresponsive and may be mediated by alterations in basal ganglia dopamine metabolism. Findings from interferon-alpha may provide important clues regarding the pathophysiology and treatment of cytokine-induced behavioral changes in medically ill patients, while also potentially modeling the development of neuropsychiatric symptoms in patients without medical disorders.

The management of side-effects during therapy for hepatitis C

The results of interferon and ribavirin combination therapy for chronic hepatitis C infection have substantially improved in recent years, such that the majority of patients in randomized-controlled trials now achieve a sustained virological response. However, adverse effects are commonplace, often disabling and may lead to interruption or cessation of therapy with subsequent loss of efficacy. Constitutional, neuropsychiatric and haematological reactions have proved particularly troublesome. In this review, we discuss these adverse effects in more detail and highlight recent advances in their management.

Clinical trials in late life: new science in old paradigms

This article, based on a Lawton Award Lecture, addresses the subject of the need to enhance the evidence base in our field in order to influence processes of policy development. Four issues are identified as critical to this: theory-driven targets of public health significance, use of appropriate and sophisticated approaches to research design and statistical modeling, development of instruments and measures, and conclusions that make a difference. Incentives are discussed with particular attention to regulatory approaches. A broad view of research is taken, with examples from studies of Alzheimer's disease and depression in late life. I conclude that new approaches to methodology will enhance our capacity to translate exciting new findings from the basic sciences into the development of therapeutics and that this will, in turn, enhance our capacity to inform the development of public policy.

The phenomenology and treatment of interferon-induced depression

Interferon (IFN)-alpha, IFN-beta, and IFN-gamma are currently available for the treatment of malignancies, viral infections (e.g., hepatitis C virus), multiple sclerosis (MS), and skin conditions. In addition to their therapeutic effects, IFNs commonly cause various side effects. Most common among the side effects of IFN are "flu-like" symptoms such as chills, fever, and muscle soreness. However, IFN can also cause significant neuropsychiatric side effects, particularly symptoms of depression. A literature search was conducted in order to summarize current information on (1) the frequency, characteristics, and risk factors of IFN-induced depression, (2) possible biochemical mechanisms associated with IFN-induced depression, and (3) the treatment strategies for IFN-induced depression. Review of the literature suggests that symptoms of depression induced by IFN therapy, in particular IFN-alpha therapy, are common and can limit the treatment utility, often necessitating discontinuation of IFN therapy or the use of psychopharmacologic agents. Depression is also a suspected side effect of therapy with IFN-beta and IFN-gamma; however, the association has not been as convincingly confirmed. Importantly, IFNs affect neurochemical pathways putatively involved in the etiology of depression. While these depressive side effects usually resolve after the completion of IFN therapy, they can persist or reappear with dose escalations. It is recommended that health care providers, patients and their families be informed about the potential risk of the psychiatric disturbances that can occur with IFN-alpha therapy. Screening and monitoring, ideally using symptom rating scales for depression, and early antidepressant treatment intervention appear necessary to optimize IFN therapy for the majority of patients.

Psychiatric issues in older cancer patients

Although many patients are surviving longer than in the past, a cancer diagnosis may shatter the dream of a dignified old age for elderly patients. Cancer diagnosis and treatment often produce psychologic stresses resulting from the actual symptoms of the disease, as well as perceptions of the disease and its stigma. Concerns related to cancer have particular meaning for aging individuals who undergo these situations in the context of retirement, widowhood, other medical disabilities and other losses. Today, patients and families are more interested in treatment issues, and quality of life, both during and after treatment. In this article we discuss late life depression, anxiety and delirium as they relate to elderly patients coping with cancer.

Combination immunotherapy with a CpG oligonucleotide (1018 ISS) and rituximab in patients with non-Hodgkin lymphoma: increased interferon-alpha/beta-inducible gene expression, without significant toxicity

CpG oligodeoxynucleotides (CpG-ODNs) affect innate and adaptive immune responses, including antigen presentation, costimulatory molecule expression, dendritic cell maturation, and induction of cytokines enhancing antibody-dependent cell-mediated cytotoxicity (ADCC). We conducted a phase 1 study evaluating 4 dose levels of a CpG-ODN (1018 ISS) with rituximab in 20 patients with relapsed non-Hodgkin lymphoma (NHL). Patients received CpG once a week for 4 weeks beginning after the second of 4 rituximab infusions. Adverse events were minimal. Quantitative polymerase chain reaction (PCR) measurements of a panel of genes inducible by CpG-ODN and interferons were performed on blood samples collected before and 24 hours after CpG. A dose-related increase was measured in the expression of several interferon-inducible genes after CpG and correlated with serum levels of 2'-5' oligoadenylate synthetase (OAS), a validated interferon response marker. Genes induced selectively by interferon-gamma (IFN-gamma) were not significantly induced by CpG. In conclusion, we have defined a set of gene expression markers that provide a sensitive measure of biologic responses of patients to CpG therapy in a dose-related manner. Moreover, all the genes significantly induced by this CpG are regulated by type 1 interferons, providing insight into the dominant immune mechanisms in humans. CpG treatment resulted in no significant toxicity, providing rationale for further testing of this exciting combination immunotherapy approach to NHL.

Contribution of functional neuroimaging to understanding neuropsychiatric side effects of interferon in hepatitis C

Patients with hepatitis C who are treated with interferon may develop neuropsychiatric symptoms, including fatigue and depression. The authors discuss the potential use of functional neuroimaging in the identification and treatment of these patients. The authors provide an overview of functional neuroimaging studies of fatigue and depressive symptoms in various medical and psychiatric conditions and suggest future directions for research that may increase understanding of the specific neural substrates of neuropsychiatric side effects associated with hepatitis C and interferon treatment. This knowledge may help consultation-liaison psychiatrists identify patients at high risk for developing side effects related to hepatitis C and interferon, which would allow for implementation of validated strategies for prophylactic treatment of these patients.

Injection drug use and the hepatitis C virus: considerations for a targeted treatment approach--the case study of Canada

Infection with the hepatitis C virus (HCV) is a major public health burden in Canada and globally. The literature shows that injection drug use is currently the primary transmission route for HCV, and that a majority of injection drug users (IDUs) are currently infected with HCV in Canada. This article first reviews the burden of HCV within IDU populations and the transmission risks and the treatment implications specific to IDUs. Traditionally, IDUs have been excluded from HCV treatment unless abstaining from illicit drug use. However, recent research suggests that categorical exclusion is not medically necessary. A series of key questions about the feasibility of offering HCV treatment to IDUs in the specific Canadian context are considered, including concerns related to the motivation of treatment for IDUs, treatment delivery, treatment side effects, HCV reinfection, and the social environment. The article concludes that treatment of HCV-infected illicit drug users is both feasible and may be necessary to reduce transmission and adverse outcomes in this high-risk population.

Visual side effects of pegylated interferon during therapy for chronic hepatitis C infection

Ocular toxicity, including retinopathy, optic neuropathy and ocular loss, has been infrequently (<1%) reported as a potentially serious adverse event associated with standard interferon therapy. The new pegylated interferons have improved pharmacokinetics which translates to better antiviral efficacy, however, this improved pharmacokinetic profile also has the potential to alter the frequency and extent of their adverse events. We describe a case of chronic hepatitis C infection that developed visual complaints after one month of pegylated interferon, and retinopathy confirmed on ophthalmologic examination. We place our report in context with a review of the literature related to visual complications associated with interferon therapy. From our compilation of case reports, it is apparent that variable doses and duration of interferon therapy have been associated with ocular toxicity, which in turn suggests an idiosyncratic drug reaction. In as much as this adverse event is unpredictable, and its frequency undefined with pegylated interferon therapy, further surveillance will be required for patients undergoing pegylated-interferon therapy. Although ocular toxicity is uncommon, it should be emphasized that it can occur any time after the start of interferon therapy, and physicians now treating chronic hepatitis C patients with pegylated interferon must be aware of this potentially serious adverse event.

Depressive Symptoms after Initiation of Interferon Therapy in Human Immunodeficiency Virus-Infected Patients with Chronic Hepatitis C

Background

Interferon alpha (IFN-α) therapy for chronic hepatitis C (CHC) infection is commonly associated with neuropsychiatric side effects including depressive symptomatology. In this study, we evaluated the incidence and management of depressive symptoms during IFN-α therapy in HIV-infected patients with CHC.

Methods

HIV-infected patients with CHC who began IFN-α and ribavirin therapy during the recruitment period April 2001 to April 2003 were included in the study. Patients with a history of major depressive disorder were excluded.

Results

Of 113 co-infected patients who started IFN-α therapy during the recruitment period, 45 (40%) developed symptoms of depression (sadness, tiredness and apathy). Twenty of them (44%) were treated with citalopram, a selective serotonin re-uptake inhibitor, resulting in a significant improvement in their symptoms. Most of the patients (60%) showed depressive side effects in the first 3 months after initiation of IFN-α. In addition, during the study, three patients developed psychotic symptoms and one committed suicide.

Conclusions

The incidence of depressive symptoms in patients with HIV/HCV co-infection treated with IFN-α is high. Most of the depressive symptoms were not severe and improved with antidepressant therapy, without reduction or cessation of IFN-α therapy. During the first weeks after initiating IFN-α therapy for HIV/HCV co-infection, close assessment of psychiatric symptoms is recommended. Early treatment of these side effects with antidepressants would help avoid early dropouts from interferon therapy.

Neuropsychological dysfunction associated with cancer and cancer therapies: a conceptual review of an emerging target

Neuropsychological dysfunction associated with cancer and cancer treatment is a growing concern. Methodological limitations permeate the corpus of research in this area and have limited our understanding of the multifactorial nature of this process. The following review provides a summary of the current state of knowledge and highlights future directions.

Peginterferon alfa-2a: A review of approved and investigational uses

BACKGROUND

In October 2002, the US Food and Drug Administration approved peginterferon alfa-2a for the management of chronic hepatitis C virus (HCV) infection. The addition of polyethylene glycol (PEG) moiety to the interferon (IFN) molecule results in a product with altered pharmacokinetic properties.

OBJECTIVE

The aim of this article is to review the pharmacology, medications interactions, adverse events (AEs), and approved or investigational uses of PEG-IFN alfa-2a for viral hepatitis and oncologic conditions.

METHODS

Relevant articles were identified through searches of MEDLINE (1980-July 2003) and EMBASE (1980-July 2003). Search terms included, but were not limited to, peginterferon alfa-2a, pharmacokinetics, pharmacology, pharmacodynamics, and therapeutic use, as well as terms for specific disease states and AEs. Further publications were identified from citations of resulting papers.

RESULTS

Pegylation of IFN alfa-2a results in major changes in the pharmacokinetics of the product. Absorption is prolonged and serum concentrations are sustained over the dosing regimen. PEG-IFN alfa-2a has been shown to be more effective with or without ribavirin (RBV), in the management of treatment-naive patients with chronic HCV infection, than unmodified IFN alfa-2a with or without RBV. Results in other disease states are still preliminary. AEs are similar, in incidence and severity, to those occurring with unmodified IFN. They include earlier hematologic symptoms and fewer influenza-like symptoms. Drug-drug interactions are the same as those occurring with the unmodified IFN product.

CONCLUSIONS

The pharmacokinetic profile of IFN alfa-2a is improved by pegylation, which enables less frequent administration and results in improved efficacy with a similar side-effect profile. Combination of PEG-IFN alfa-2a with RBV is associated with a greater chance of achieving a sustained virologic response in treatment-naive patients with chronic HCV, compared with unmodified IFN alfa-2a/RBV combinations. Documentation of efficacy in other conditions awaits results of controlled clinical trials.

Drug-induced depression: a systematic review to inform clinical practice

BACKGROUND

Certain medications may contribute to the etiology of depressive symptoms and disorders. Research in this area, however, has been hampered by methodological and conceptual problems. This review had two objectives: to identify evidence linking medical drugs to depressive symptoms and disorders, and to summarize this evidence in a clinically meaningful way.

METHODS

Electronic literature searches were performed and studies were reviewed with reference to critical methodological features.

RESULTS

No medications causing the typical major depressive syndrome were identified. Evidence was found linking corticosteroids, interferon-alpha, interleukin-2, gonadotropin-releasing hormone agonists, mefloquine, progestin-releasing implanted contraceptives and propranolol to the etiology of atypical depressive syndromes.

CONCLUSIONS

A small number of drugs have been shown capable of inducing depressive symptoms. Drug-induced depression appears to differ symptomatically from classical major depression.