A prospective study of the incidence and open-label treatment of interferon-induced major depressive disorder in patients with hepatitis C

The immune-mediated alteration of serotonin and glutamate: towards an integrated view of depression

Beside the well-known deficiency in serotonergic neurotransmission as pathophysiological correlate of major depression (MD), recent evidence points to a pivotal role of increased glutamate receptor activation as well. However, cause and interaction of these neurotransmitter alterations are not understood. In this review, we present a hypothesis integrating current concepts of neurotransmission and hypothalamus-pituitary-adrenal (HPA) axis dysregulation with findings on immunological alterations and alterations in brain morphology in MD. An immune activation including increased production of proinflammatory cytokines has repeatedly been described in MD. Proinflammatory cytokines such as interleukin-2, interferon-gamma, or tumor necrosis factor-alpha activate the tryptophan- and serotonin-degrading enzyme indoleamine 2,3-dioxygenase (IDO). Depressive states during inflammatory somatic disorders are also associated with increased proinflammatory cytokines and increased consumption of tryptophan via activation of IDO. An enhanced consumption of serotonin and its precursor tryptophan through IDO activation could well explain the reduced availability of serotonergic neurotransmission in MD. An increased activation of IDO and its subsequent enzyme kynurenine monooxygenase by proinflammatory cytokines, moreover, leads to an enhanced production of quinolinic acid, a strong agonist of the glutamatergic N-methyl-D-aspartate receptor. In inflammatory states of the central nervous system, IDO is mainly activated in microglial cells, which preferentially metabolize tryptophan to the NMDA receptor agonist quinolinic acid, whereas astrocytes - counteracting this metabolism due to the lack of an enzyme of this metabolism - have been observed to be reduced in MD. Therefore the type 1/type 2 immune response imbalance, associated with an astrocyte/microglia imbalance, leads to serotonergic deficiency and glutamatergic overproduction. Astrocytes are further strongly involved in re-uptake and metabolic conversion of glutamate. The reduced number of astrocytes could contribute to both, a diminished counterregulation of IDO activity in microglia and an altered glutamatergic neurotransmission. Further search for antidepressant agents should take into account anti-inflammatory drugs, for example, cyclooxygenase-2 inhibitors, might exert antidepressant effects by acting on serotonergic deficiency, glutamatergic hyperfunction and antagonizing neurotoxic effects of quinolinic acid.

Trend of depression and the use of psychiatric medications in U.S. Veterans with hepatitis C during interferon-based therapy

OBJECTIVES

Interferon-based therapy in patients with HCV infection may cause new psychiatric symptoms or worsening of existing psychiatric conditions. The aim of this study was to evaluate the trend of depression, and the use and the effect of psychiatric medications during interferon therapy.

METHODS

Patients with HCV were evaluated at our clinic following a standardized template to collect clinical and psychiatric data at baseline, weeks 2, 4, 8, 12, and every 6 wk thereafter. Depression was measured at each visit by obtaining the CES-D (Center for Epidemiologic Studies-Depression) score. A PMI was defined as the addition or increase in the dose of a psychiatric medication.

RESULTS

During interferon therapy, patients with psychiatric history (N = 46) had minor fluctuation in the CES-D score compared to baseline, while patients without psychiatric history (N = 33) had significant increase in their CES-D score, were more likely to require PMIs with antidepressants (63.6%vs 39.1%, respectively; P= 0.04), and they required the first PMI with sedatives/hypnotics earlier (4.1 wk vs 8.9 wk after starting interferon, respectively; P= 0.01). PMIs in the two groups resulted in significant decrease in CES-D score at 4-6 wk and 8-12 wk post-PMIs, but it continued to be higher than baseline. The overall sustained viral response was 47%.

CONCLUSION

Hepatitis C patients with stable psychiatric history can be successfully treated with interferon-based therapy if followed closely by a multidisciplinary team that includes specialists in hepatitis C and behavioral health.

A randomized trial of paroxetine to prevent interferon-alpha-induced depression in patients with hepatitis C

BACKGROUND

Interferon-alpha-(IFN-alpha) induced depression presents a challenge when treating patients with the hepatitis C virus (HCV). Depression occurs in approximately one-third of patients during antiviral therapy and can lead to reduction in treatment dosage or discontinuation of treatment, thus reducing the likelihood of clearing HCV infection. This study examined the efficacy of paroxetine in preventing the development of depression during antiviral therapy.

METHODS

In a double-blind, placebo-controlled study, 33 patients with HCV were randomly assigned to paroxetine or placebo prior to antiviral therapy. Patients were evaluated for psychiatric symptoms prior, during, and six months after antiviral therapy.

RESULTS

The rate of IFN-alpha-induced depression for the entire sample was 33.3%. The prophylactic use of paroxetine did not decrease the likelihood of IFN-alpha-induced depression (35.7% in the paroxetine group vs. 31.6% in the placebo group). However, in 10 of 11 patients who developed IFN-alpha-induced depression and entered the rescue arm of the study, open-label treatment with paroxetine helped reduce symptoms of depression. Group assignment did not appear to impact antiviral therapy completion rates, as a similar proportion of patients from each group completed treatment.

LIMITATIONS

The antiviral treatment was changed during the trial and aspects of the sample limit the generalizability of the results.

CONCLUSION

A prophylactic approach to interferon-alpha-induced depression may not be indicated in patients with HCV infection.

Incidence of psychiatric side effects during pegylated interferon- alpha retreatment in nonresponder hepatitis C virus-infected patients

OBJECTIVE

Evaluate the incidence of mental disorders using pegylated interferon plus ribavirin retreatment in nonresponder hepatitis C virus-infected patients.

METHOD

The Mini-International Neuropsychiatric Interview (MINI) was used to evaluate 30 hepatitis C virus-infected interferon-nonresponder patients at baseline and following 4, 12 and 24 weeks of pegylated interferon retreatment.

RESULTS

During the pegylated interferon/ribavirin retreatment, 5(16.6%) patients developed psychiatric side effects: 3(10%) were diagnosed with major depressive disorder, 1(3.3%) had a brief psychotic disorder and 1(3.3%) presented with panic attacks.

CONCLUSION

This is the first prospective study evaluating the incidence of neuropsychiatric side effects during interferon retreatment of hepatitis C virus-infected patients, suggesting that the risk of acquiring serious psychiatric symptoms during retreatment with interferon-alpha (IFN-alpha) may not be higher than during the first antiviral therapy. This finding challenges the hypothesis that during a second treatment with IFN-alpha, patients with hepatitis C may be at greater risk for neuropsychiatric side effects than naïve patients.

Preventing relapse of major depression during interferon-alpha therapy for hepatitis C--A pilot study

Depression is common in hepatitis C, exacerbated by interferon, and is a major reason for discontinuing interferon therapy. We aimed to determine (1) whether patients with a history of major depression could complete a course of peginterferon alpha-2a and ribavirin if pretreated with escitalopram and (2) the relapse rate of depression during the course of therapy in these subjects. Ten patients were enrolled in the study and treated with escitalopram. The Hamilton Depression Rating Scale (Ham-D) and other psychiatric scales were administered throughout the study. There were no statistically significant increases in mean Ham-D scores. No subjects were discontinued from the study due to depression relapse. Nine of 10 subjects maintained remission of depression throughout the study. We conclude that pretreatment with escitalopram in subjects with major depressive disorder in remission may prevent recurrence of major depression during a course of interferon and ribavirin therapy for hepatitis C.

Depression following pegylated interferon-alpha: characteristics and vulnerability

OBJECTIVE

Interferon-alpha2 (IFN-alpha) injections may be capable of triggering depression in some individuals. The first objective was to further characterize this depression and, secondly, to examine whether pre-treatment temperament was correlated with subsequent vulnerability to IFN-alpha.

METHODS

Twenty-three initially euthymic adults undergoing year-long PEG-IFN-alpha treatment for hepatitis C were evaluated at baseline and then prospectively monitored using both the Structured Clinical Interview for DSM-IV (SCID) and self-report questionnaires.

RESULTS

A major depressive episode developed within 3 months in 39%. Principal component analysis of the change in self-report scores after 1 month of treatment demonstrated three orthogonal factors: (i) a specific increase in depression as manifested in the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS), (ii) an increase in hostility and anxiety, (iii) and a generalized combination of worse symptoms including somatic symptoms on the Symptom Check List (SCL-90). BDI at 1 month was predicted by baseline BDI (r=0.76, P=.004). Hostility at 1 month was predicted by low baseline agreeableness (r=0.75, P=.01). Controlling for baseline BDI scores, categorical major depression was predicted by combined high baseline neuroticism and low agreeableness (combined r=0.66, P=.03).

CONCLUSION

These initial results (i) support the depressogenic nature of IFN-alpha treatment in a subset of vulnerable individuals, (ii) indicate that some individuals are also independently vulnerable to worsened hostility, and (iii) suggest that it may be possible to clinically predict these vulnerabilities in initially euthymic subjects.

Chronic hepatitis C virus infection: a review for pharmacists

OBJECTIVE

To review the epidemiology, pathophysiology, and therapeutics of chronic hepatitis C virus (HCV) infection, focusing on patient counseling and adverse effects, to serve as a resource for pharmacists in multiple patient care settings.

DATA SOURCES

Published articles identified through Medline using search terms such as hepatitis C virus, hepacivirus, ribavirin, interferon alfa-2a, or interferon alfa-2b. Therapeutic guidelines retrieved from www.guidelines.gov and the Centers for Disease Control and Prevention (CDC). Additional resources identified from personal bibliographies collected by the author and bibliographies from gathered articles.

STUDY SELECTION

By the author.

DATA EXTRACTION

By the author.

DATA SYNTHESIS

HCV is a blood-borne pathogen affecting an estimated 4 million Americans and 170 million people worldwide. An estimated two-thirds to three-fourths of those infected with HCV have not been diagnosed, and in the next 10 to 20 years, the number of patients diagnosed with HCV is likely to increase. Thus, the health care community, including pharmacists, needs to be educated about the disease, how it is spread, and the details related to treatment of HCV. The standard therapy for HCV is combination therapy with pegylated interferon and ribavirin. This therapy has a varied rate of response that improves with medication adherence. Adherence is often reduced as a result of adverse effects of therapy. In this article, a basic review of HCV is provided, as well as a thorough discussion of strategies to reduce the incidence and severity of adverse effects related to therapy.

CONCLUSION

Pharmacists have an important role in educating other health care practitioners and the community about HCV, providing injection training and medication and adverse effect counseling for patients initiating therapy, and engaging in follow-up and monitoring of patients to encourage therapeutic success by improving medication adherence and patient tolerance of adverse effects.

Interferon-induced depression in hepatitis C: an update

Hepatitis C is a global epidemic, and its costs in both lives and health care expenditures continue to rise. The only approved treatment for this disease, interferon-alpha (IFN), causes treatment-emergent depression in more than one quarter of all patients who take it. Newer preparations of IFN have been developed to increase its antiviral efficacy, but the incidence of treatment-emergent depression has not decreased. The data on the epidemiology and risk factors for interferon-induced depression are reviewed in an effort to delineate its standing as a unique psychiatric disorder. In addition, evidence-based treatment approaches are outlined, including the potential efficacy of preinterferon prophylactic treatment with antidepressants.

The widely-used anti-viral drug interferon-alpha induces depressive- and anxiogenic-like effects in healthy rats

Interferon-alpha (IFN-alpha) is a naturally occurring human cytokine that is a key therapy in the treatment of several viral diseases and cancers. However, treatment can produce significant neuropsychiatric and neurotoxic adverse events, including depression and anxiety. Here we investigated the effects of a clinically-comparable treatment regime of IFN-alpha on depressive- and anxiety-like behaviour in rats; and also examined frontal-cortical and hippocampal BDNF levels. Rats treated with IFN-alpha for four weeks showed significant increases in depressive- and anxiety-like behaviour. Further experimental investigation revealed that hedonic dysregulation (stronger preference for a sweet solution) did not emerge until the second week of treatment, and became more persistent as treatment progressed. No significant IFN-alpha-induced changes in BDNF levels were found. These results indicate that the affective deficits seen in patients may be modelled in healthy animals. This model may represent a novel tool to investigate the extent of and mechanisms underlying the IFN-alpha psychiatric syndrome.

Paroxetine for prevention of depressive symptoms induced by interferon-alpha and ribavirin for hepatitis C

BACKGROUND

Whether antidepressants prevent depression during interferon-alpha/ribavirin treatment for hepatitis C virus infection has yet to be established.

AIM

To investigate the use of paroxetine in a prospective, double-blind, placebo-controlled study for this indication.

METHODS

Sixty-one hepatitis C virus-infected patients were randomly assigned to the antidepressant, paroxetine (n = 28), or placebo (n = 33), begun 2 weeks before and continued for 24 weeks during interferon-alpha/ribavirin treatment. Primary endpoints included development of major depression and severity of depressive symptoms measured by the Montgomery Asberg Depression Rating Scale (MADRS).

RESULTS

Rates of major depression during the study were low (17%) and did not differ between groups. Nevertheless, using published MADRS cut-off scores, the percent of subjects who met criteria for mild, moderate or severe depression during interferon-alpha/ribavirin therapy was significantly lower in paroxetine- vs. placebo-treated subjects (P = 0.02, Fisher's exact test). Assignment to paroxetine was also associated with significantly reduced depressive symptom severity. This effect was largely accounted for by participants with depression scores above the median (MADRS > 3) at baseline in whom paroxetine was associated with a maximal reduction in MADRS scores of 10.3 (95% CI: 2.1-18.5) compared with placebo at 20 weeks (P < 0.01). Study limitations included a small sample size and high drop-out rate.

CONCLUSION

This double-blind, placebo-controlled trial provides preliminary data in support of antidepressant pre-treatment in hepatitis C virus patients with elevated depressive symptoms at baseline.

Interferon-α effects are exaggerated when administered on a psychosocial stressor backdrop: Cytokine, corticosterone and brain monoamine variations

Immunotherapy involving interferon-alpha (IFN-alpha) treatment is often accompanied by symptoms of depressive illness. These effects may stem from the direct actions of the cytokine, or may be unique to individuals undergoing considerable strain. In two experiments using CD-1 mice, we demonstrate that intraperitoneal administration of IFN-alpha dose dependently influences plasma corticosterone and sickness behaviors, and modestly influences norepinephrine turnover in brain. However, when mice are exposed to a psychosocial stressor (social disruption by transferring mice from isolated to grouped conditions, and to a moderate extent a transfer from grouped housing to isolation), the effects of IFN-alpha on sickness, plasma corticosterone and hippocampal norepinephrine, as well as on the levels of circulating IL-6, TNF-alpha and IL-10 (but not IL-1beta or IFN-gamma) are greatly augmented. It is suggested that the depressive effects of immunotherapy in humans likewise reflects the synergistic actions of the cytokine and the ongoing distress experienced by patients.

Influence of the type of pegylated interferon on the onset of depressive and neuropsychiatric symptoms in HIV-HCV coinfected patients

This is a prospective observational comparative 48-week study to assess the impact of the different types of Peg-IFN on depressive and neuropsychiatric symptoms during treatment in HIV-HCV coinfected patients. Thirty-one patients treated with Peg-IFN alpha-2b 1.5 microg/kg/w plus ribavirine (RBV) (Peg-IFN alpha-2b Group) and 32 patients receiving Peg-IFN alpha-2a 180 microg/w plus RBV (Peg-IFN alpha-2a Group) were included. Depressive and neuropsychiatric symptoms, quality of life and adherence were assessed. Fifteen subjects (23%) discontinued therapy (p = 0.3, between groups). Overall, 37 patients presented mild to moderate depressive symptoms, 9 moderate to severe and 3 severe, without differences between groups. Patients in Peg-IFN alpha-2b reported higher fatigue and dizziness at weeks 12 (p < 0.05) and 24 (p < 0.05), and irritability and memory loss at week 24 (p < 0.05) with respect to Peg-IFN alpha-2a Group. At week 12, role functioning, general health perception, vitality, emotional role, mental health and the summary areas of physical health and mental health were lower in Peg-IFN alpha-2b Group (p < 0.05). The same was observed in physical functioning (p = 0.05) and role functioning, general health perception, emotional role and mental health (p < 0.001) at week 24. Three months after finishing treatment, no patient had depressive or neuropsychiatric symptoms, and quality of life improved. Antiretroviral adherence was low but adherence to anti-HCV therapy remained high in both groups. According to our data, Peg-IFN alpha-2a and Peg-IFN alpha-2b exert a similar impact on the overall rate of depressive symptoms, although patients treated with Peg-IFN alpha-2a experience less fatigue and fewer neuropsychiatric symptoms and a lower impairment in their physical and mental quality of life.

Interferon-alpha-induced depressive symptoms are related to changes in the cytokine network but not to cortisol

OBJECTIVE

Proinflammatory cytokines have the potential to activate the hypothalamo-pituitary-adrenocortical (HPA) axis, and HPA axis hyperactivity is also encountered in depression. Therefore, the induction of depressive symptoms by interferon-alpha (IFN-alpha) may be mediated by changes in the cytokine network and the HPA axis.

METHODS

In 17 hepatitis C patients undergoing IFN-alpha treatment, depressive symptoms were measured using the Montgomery-Asberg Depression Rating Scale (MADRS). In addition, serum cytokine concentrations were measured. Saliva was collected five times over the course of a day in order to assess daily average cortisol (DAC) and awakening response. Assessments were carried out at baseline and six later time points after starting treatment.

RESULTS

During treatment, the increases in the MADRS were significantly and positively correlated with soluble interleukin (IL)-2 receptor, tumor necrosis factor alpha (TNF-alpha), and IL-6. There were no significant associations between the DAC or cortisol awakening response with the MADRS score.

CONCLUSION

Results suggest a clear connection between IFN-alpha-induced depressive symptoms and cytokine concentrations, but not cortisol.

Interferon alpha therapy for hepatitis C: treatment completion and response rates among patients with substance use disorders

Background

Individuals with substance use disorders (SUDs) are at increased risk for hepatitis C viral infection (HCV), and few studies have explored their treatment responses empirically. The objective of this study was to assess interferon alpha therapy (IFN) completion and response rates among patients with HCV who had a history of comorbid SUDs. More data is needed to inform treatment strategies and guidelines for these patients. Using a medical record database, information was retrospectively collected on 307,437 veterans seen in the Veterans Integrated Service Network 20 (VISN 20) of the Veterans Healthcare Administration (VHA) between 1998 and 2003. For patients treated with any type of IFN (including regular or pegylated IFN) or combination therapy (IFN and ribavirin) who had a known HCV genotype, IFN completion and response rates were compared among patients with a history of SUD (SUD+ Group) and patients without a history of SUD (SUD- Group).

Results

Odds ratio analyses revealed that compared with the SUD- Group, the SUD+ Group was equally likely to complete IFN therapy if they had genotypes 2 and 3 (73.1% vs. 68.0%), and if they had genotypes 1 and 4 (39.5% vs. 39.9%). Within the sample of all patients who began IFN therapy, the SUD- and SUD+ groups were similarly likely to achieve an end of treatment response (genotypes 2 and 3, 52.8% vs. 54.3%; genotypes 1 and 4, 24.5% vs. 24.8%) and a sustained viral response (genotypes 2 and 3, 42.6% vs. 41.1%; genotypes 1 and 4: 16.0% vs. 22.3%).

Conclusion

Individuals with and without a history of SUD responded to antiviral therapy for HCV at similar rates. Collectively, these findings suggest that patients who have co-morbid SUD and HCV diagnoses can successfully complete a course of antiviral therapy.

Methodological approaches in the assessment of interferon-alfa-induced depression in patients with chronic hepatitis C - a critical review

In recent years, research on interferon (IFN)-induced depressive symptoms in antivirally treated patients suffering from chronic hepatitis C (CHC) has considerably intensified. Profound scientific knowledge of this complication is of great relevance with regard to adherence, compliance, and premature therapy discontinuation. Presently, there is considerable variability of both, the frequency and extent of IFN-induced depression reported in different cohorts of patients. The aim of the presented study was to systematically review recent literature of research within this field; and particularly (1) to identify to what extent methodological bias contributed to inconsistent results in different studies, (2) to critically appraise methods and results of studies published so far, and (3) to suggest directions for future work, especially with respect to alternative and improved methodological approaches. The results of this critical review suggest that the variability of findings seem to be largely due to different study populations, treatment regimens, methodological approaches, and sometimes arbitrary or at least poorly defined choice of screening instruments for depression, particularly criteria for clinically relevant depression (cut-off criteria). Study designs and methodological approaches to investigate IFN-alfa-induced depression in patients with CHC have been incoherent. Future research in this field needs agreement on the use of standardized assessment of IFN-induced depression in CHC. Furthermore, objective criteria and guidelines for the treatment of IFN-induced depression in these patients are needed in clinical practice.

Impact on adherence and sustained virological response of psychiatric side effects during peginterferon and ribavirin therapy for chronic hepatitis C

BACKGROUND

The psychiatric side effects of interferon, often responsible for dose reduction or treatment discontinuation, represent a major limitation in the treatment of chronic hepatitis C (CHC).

AIM

To prospectively assess the impact on adherence and sustained virological response (SVR) of the occurrence of psychiatric side effects during peginterferon and ribavirin therapy for CHC.

METHODS

Ninety-eight consecutive treatment-naïve CHC patients receiving a standard course of peginterferon plus ribavirin were systematically screened for psychiatric side effects, using DSM-IV, at baseline and both during and after treatment.

RESULTS

Psychiatric side effects occurred in 38 patients (39%), mostly within the first 12 weeks (87%), and always consisted of mood disorders. Overall, 68% of patients achieved an SVR (71% of patients with mood disorders and 68% of those without; P = N.S.). Peginterferon and ribavirin dose reductions did not differ between patients with mood disorders and those without (46% vs. 37%, respectively; P = N.S. and 13% vs. 22%, respectively; P = N.S.). Anti-viral therapy had to be discontinued in four patients (nonresponse: two, hyperthyroidism: one, psychiatric event: one).

CONCLUSION

Early detection and appropriate management of psychiatric side effects during peginterferon and ribavirin therapy for CHC allow optimizing adherence and virological efficacy.

Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users

Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities.

Integrating services for injection drug users infected with hepatitis C virus with methadone maintenance treatment: challenges and opportunities

Despite the high prevalence of hepatitis C virus (HCV) infection among drug users enrolled in methadone maintenance treatment programs, few drug users are being treated with combination therapy. The most significant barrier to treatment is lack of access to comprehensive HCV-related care. We describe a pilot program to integrate care for HCV infection with substance abuse treatment in a setting of maintenance treatment with methadone. This on-site, multidisciplinary model of care includes comprehensive screening and treatment for HCV infection, assessment of eligibility, counseling with regard to substance abuse, psychiatric services, HCV support groups, directly observed therapy, and enhanced linkages to a tertiary care system for diagnostic procedures. Our approach has led to high levels of adherence, with liver biopsy and substantial rates of initiation of antiviral therapy. Two cases illustrate the successful application of this model to patients with HCV infection complicated by active substance abuse and psychiatric comorbidity.

Mental and physical symptoms associated with lower social support for patients with hepatitis C

AIM: To systematically examine the impact of the hepatitis C virus (HCV) diagnosis on patients’ level of social support in a large-scale study.

METHODS: Patients evaluated and treated for HCV in a tertiary referral center were enrolled in a cross-sectional study. Demographic data, functional and emotional status as measured by the Hospital Anxiety and Depression Scale (HAD) and the Sickness Impact Profile (SIP), severity of liver disease, mode of acquisition, and physical and psychiatric comorbidities were collected from patients or abstracted from the medical record. All participants completed a semi-structured interview, addressing questions of social support.

RESULTS: A total of 342 patients (mean age 45.2 years; 37% women) were enrolled. Ninety-two (27%) patients described lower levels of support by family and friends. Nearly half of the participants (45%) noted the loss of at least one relationship due to the disease. Fears related to transmitting the disease (25%) were common and often associated with ignorance or even discrimination by others (19%). Nearly one fifth of the patients did not share information about their disease with others to avoid being stigmatized. Lower levels of social support were significantly associated with living alone, being unemployed, being excluded from antiviral therapy, having psychiatric comorbidities, contracting HCV through intravenous drug use, having high levels of anxiety and depression as measured by the HAD and negative mood state as measured by the SIP. Patients reporting lower levels of social support also noted more physical symptoms as measured by the SIP.

CONCLUSION: Patients with hepatitis C often face significant social problems, ranging from social isolation to familial stress. The most common concerns reflect a limited insight of patients and their relatives and friends about the disease, the risk factors for its spread, and about potential consequences. Our data suggest that educational interventions targeting support persons and the stressors identified in our findings may lessen or alleviate the social strains patients with hepatitis C experience.

Mental and physical symptoms associated with lower social support for patients with hepatitis C

AIM: To systematically examine the impact of the hepatitis C virus (HCV) diagnosis on patients’ level of social support in a large-scale study.

METHODS: Patients evaluated and treated for HCV in a tertiary referral center were enrolled in a cross-sectional study. Demographic data, functional and emotional status as measured by the Hospital Anxiety and Depression Scale (HAD) and the Sickness Impact Profile (SIP), severity of liver disease, mode of acquisition, and physical and psychiatric comorbidities were collected from patients or abstracted from the medical record. All participants completed a semi-structured interview, addressing questions of social support.

RESULTS: A total of 342 patients (mean age 45.2 years; 37% women) were enrolled. Ninety-two (27%) patients described lower levels of support by family and friends. Nearly half of the participants (45%) noted the loss of at least one relationship due to the disease. Fears related to transmitting the disease (25%) were common and often associated with ignorance or even discrimination by others (19%). Nearly one fifth of the patients did not share information about their disease with others to avoid being stigmatized. Lower levels of social support were significantly associated with living alone, being unemployed, being excluded from antiviral therapy, having psychiatric comorbidities, contracting HCV through intravenous drug use, having high levels of anxiety and depression as measured by the HAD and negative mood state as measured by the SIP. Patients reporting lower levels of social support also noted more physical symptoms as measured by the SIP.

CONCLUSION: Patients with hepatitis C often face significant social problems, ranging from social isolation to familial stress. The most common concerns reflect a limited insight of patients and their relatives and friends about the disease, the risk factors for its spread, and about potential consequences. Our data suggest that educational interventions targeting support persons and the stressors identified in our findings may lessen or alleviate the social strains patients with hepatitis C experience.

An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist

Liver disease is a common cause of morbidity and mortality in the United States and elsewhere. Arising from infectious, hereditary, or toxin-induced sources, the detection of liver disease often requires a high index of suspicion. Clinical presentations are highly variable and are often accompanied by neuropsychiatric symptoms. This fact, along with an increased incidence of liver disease among patients with primary psychiatric disorders and the presence of varied drug use, complicates the tasks of providing care to patients with liver disease. To assist the consultation-liaison psychiatrist, the authors present the first of a two-part series focused on psychiatric issues in liver disease.

Baseline immune activation as a risk factor for the onset of depression during interferon-alpha treatment

BACKGROUND

Major depression has been associated cross-sectionally with increased cell-mediated immune activation but causality has been difficult to establish. This study prospectively investigated the hypothesis that baseline level of immune activation predicts the development of depression during interferon-alpha (IFN-alpha) treatment.

METHODS

Sixteen hepatitis C patients without psychiatric disorder underwent IFN-alpha treatment. Proinflammatory and anti-inflammatory cytokines were determined before starting treatment. Presence of a major depressive disorder (MDD) was assessed at baseline and several times during treatment.

RESULTS

Baseline soluble interleukin-2 receptor (sIL-2r), interleukin-6 (IL-6), and interleukin-10 (IL-10) concentrations were significantly increased in the five subjects that developed MDD during treatment compared with those that did not, with standardized effect sizes of 1.08, 1.16, and 1.25, respectively, controlling for marijuana use, cigarette smoking, and baseline level of depressive symptoms.

CONCLUSIONS

Results suggest that increased immune activation, rather than an epiphenomenon, is a causal risk factor for the development of MDD.

Current therapy of hepatitis C

Hepatitis C is a mild disease, with most infected people unaware that they have it. Worldwide, 170 million people are infected, and therefore the burden of morbidity and mortality is significant (decompensated liver cirrhosis and hepatocellular carcinoma). The treatment of patients with hepatitis C has significantly improved over the past few years, such that high sustained virological responses can be obtained: >80% in genotypes 2 and 3 and >50% in genotype 1. Treatment in genotypes 2 and 3 should be considered in all patients, whereas in genotype 1 the decision has to be based on the presence of fibrosis in the liver biopsy and general patient characteristics. Guidelines for antiviral therapy are given in this overview.

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.

Hepatitis C Treatment for People With Severe Mental Illness

Over 4 million people in the United States are chronically infected with hepatitis C virus (HCV), and, if untreated, over 20% of these will progress to more serious disease. Persons with severe mental illness (SMI) have markedly elevated rates of HCV infection, but treatment of persons with SMI and HCV has been controversial. Effective antiviral treatment is available, but side effects include depression and other neuropsychiatric symptoms. This article reviews the available data on neuropsychiatric side effects of interferon (IFN) treatment, discusses the limitations of the current research, and makes recommendations regarding HCV treatment in persons with SMI.

Traitements complémentaires de l’hépatite chronique virale C

Pegylated interferon and ribavirin combination therapy represent the standard-of-care treatment for chronic hepatitis C, that allows to cure more than half of the patients. However, the success of this bitherapy is in balance with numerous side effects, especially hematologic and psychiatric. This review is focused on complementary treatments (erythropoietin, G-CSF, vitamin E, glutathion, ursodeoxycholic acid and antidepressants) likely to bring a benefit in maintaining adequate interferon and ribavirin dosages and in improving quality of life. This analysis has been performed by using the Medline(R) data base and with data from laboratories which commercialized these molecules. Erythropoietin, G-CSF and antidepressants are the best tools to optimize the bitherapy in its dose and its duration while privileging the quality of life of HCV-infected patients.

[Interferon-alpha-induced psychiatric side effects in patients with chronic viral hepatitis: a prospective, observational, controlled study]

AIMS

Patients with chronic viral hepatitis suffer from a high prevalence of psychiatric problems. Furthermore, the treatment for chronic viral hepatitis, with interferon (IFN) alpha, induces the occurrence of further psychopathological symptoms. The authors examined whether patients with a pre-existing psychiatric diagnosis had more severe IFN alpha-induced psychiatric adverse effects, and whether they were more likely to interrupt the IFN alpha therapy, compared with control patients with no pre-existing psychiatric diagnosis. They also examined the psychopharmacological management of the interferon-alpha-induced psychiatric side effects.

METHODS

The authors studied prospectively 60 patients with chronic hepatitis B or C in Cagliari, Italy. Patients underwent psychiatric assessment before starting interferon alpha and monthly throughout the therapy.

RESULTS

After adjusting for the baseline psychopathology, there was no statistically significant difference in interferon-alpha-induced psychiatric adverse effects between patients with a pre-existing psychiatric diagnosis and controls. There was also no evidence that psychiatric cases were more likely than controls to interrupt the IFN alpha therapy because of psychiatric side effects. Moreover, there was no difference in the psychiatric adverse effects severe enough to require psychopharmacological treatment. Finally, psychopharmacological management successfully treated psychiatric symptoms induced by the IFN alpha.

CONCLUSIONS

Patients with a pre-existing psychiatric diagnosis do not have a specific vulnerability to interferon-alpha-induced psychiatric adverse effects.

Selective serotonin re-uptake inhibitors and the risk of bleeding

Despite their safety, selective serotonin re-uptake inhibitors (SSRIs) are associated with bleeding. The authors critically reviewed the medical literature on SSRIs to identify subgroups of patients at risk of bleeding complications. The authors performed a literature search using MEDLINE from 1966 to 1st September 2004 using; 'haemorrhage, serotonin uptake inhibitors and antidepressive agents' as search terms and followed up on citations in each paper that was relevant to SSRI associated bleeding. The authors reviewed 7 retrospective analytical studies and 24 case reports of bleeding in 43 different people. Analytical studies support an association between SSRI consumption and upper gastrointestinal (GI) bleeding and perioperative bleeding. Little evidence links SSRI use with intracerebral haemorrhage. The risk of GI bleeding appeared to be highest among patients consuming SSRIs with NSAIDs. Combining aspirin or NSAIDs with SSRIs may further increase the risk of bleeding. Clinicians should caution patients about combining SSRIs with aspirin or NSAIDs. Pharmacotherapy to reduce the risk of GI bleeding should be considered in high risk patients.

Evidence-informed assessment and treatment of depression in HCV and interferon-treated patients

More than 4 million people are currently infected with Hepatitis C an RNA virus that may ultimately result in complete hepatic failure and is often a silent infection until late in the course of disease. Hepatitis C patients have increased rates of major depression (as well as substance abuse) and treatment of hepatitis with interferon, the current standard treatment, provokes episodes of depression in as many as a third of patients treated. Immune-dysfunction mediated mechanisms for the depression in these patients have been proposed and have increasing experimental support. The resulting depression has interfered with treatment for many patients, but several standard treatments for depression have been shown to be effective in patients with interferon-associated depression, suggesting that this should not be a barrier to effective treatment. In this paper, we review the evidence for associations between depression and Hepatitis C and interferon treatment, as well as the evidence supporting an immune mechanism for the association, and finally the data showing effective treatment and recommendations for prophylactic use of anti-depressants.

Neurobehavioral effects of interferon therapy

Interferon (IFN) therapy is associated with neuropsychiatric side effects including cognitive dysfunction and mood syndromes of varying severity. These problems are the most common causes of treatment discontinuation. Dose and duration of treatment influence risk of IFN-induced side effects. Rates of IFN-induced depression vary, but approach 50% in recent studies. Presence and severity of depressive symptoms at or before treatment predicts development of mood disorders during IFN therapy. Several possible endocrine and neurotransmitter perturbations may be responsible for IFN neurotoxicity, with recent research suggesting different symptoms clusters are related to different underlying mechanisms. The interpretation of these clusters has been influenced by subjective versus objective evaluation of cognitive function. Effective management of IFN-induced neuropsychiatric side effects should involve pretreatment screening and interval assessment during therapy. Antipsychotic and psychostimulant drugs may be used against cognitive dysfunction. Antidepressants have been shown to be effective against IFN-induced depression and can be very valuable in support of adequate or completed therapy.

Hepatitis C virus treatment decision-making in the context of HIV co-infection: the role of medical, behavioral and mental health factors in assessing treatment readiness

Hepatitis C virus (HCV)-related liver disease is among the leading causes of mortality among HIV patients, yet very few co-infected patients receive pegylated-interferon and ribavirin combination therapy, the standard of care for chronic HCV. Whereas factors related to the provider, patient and clinic setting all contribute to HCV treatment decision-making, the decision of the provider to recommend or defer treatment is perhaps the most critical determinant of whether a patient receives treatment. This paper reviews the literature related to the medical, behavioral and mental health variables that contribute to providers' assessment of treatment readiness, and associations with treatment response, adherence and retention. A greater understanding of the multilevel factors contributing to HCV treatment decision-making, as well as patient characteristics that predict treatment outcome and adherence, can inform the development of interventions aimed at improving HCV care for HIV patients.

Interferon-induced depression and cognitive impairment in hepatitis C virus patients: a 72 week prospective study

OBJECTIVES

This study assessed the rates and course of depressive symptomatology and neurocognitive deficits in hepatitis C virus (HCV) patients undergoing interferon treatment, and explored possible predictors of depression and neurocognitive deficits.

DESIGN

In order to obtain objective assessments of depression, and to evaluate cognitive impairment, a 72-week prospective study, comprising 48 weeks of treatment and 24 weeks of post-treatment follow-up was utilized.

METHODS

A total of 50 HCV patients were assessed at baseline, and 14 times during pegylated interferon plus ribavirin treatment. Patients were also assessed on four timepoints after the termination of treatment. All patients have previously been treated for hepatitis C infection with interferon and were judged to be treatment resistant in these treatments. Depression was assessed using the Center for Epidemiological Studies Depression (CES-D) questionnaire, and patients were interviewed regarding problems with memory, attention and concentration.

RESULTS

Eighty-two per cent of interferon-treated patients developed severe enough depressive symptoms to meet the CES-D criteria for possible major depressive disorder (MDD). Possible MDD onset was most frequent by the first week of treatment, and almost all possible MDD cases were observed by week 8. More severe depressive symptoms at baseline were associated with higher depressive symptoms during interferon treatment. Thirty per cent of patients complained about cognitive problems. In half of these patients cognitive impairments were still reported after the termination of treatment. There was no association between depression during interferon treatment and subjective cognitive complaints.

CONCLUSIONS

The findings suggest that depression and cognitive impairments are frequent and persistent side-effects of interferon treatment in treatment-resistant patients.

The pathogenesis of clinical depression: stressor- and cytokine-induced alterations of neuroplasticity

Stressful events promote neurochemical changes that may be involved in the provocation of depressive disorder. In addition to neuroendocrine substrates (e.g. corticotropin releasing hormone, and corticoids) and central neurotransmitters (serotonin and GABA), alterations of neuronal plasticity or even neuronal survival may play a role in depression. Indeed, depression and chronic stressor exposure typically reduce levels of growth factors, including brain-derived neurotrophic factor and anti-apoptotic factors (e.g. bcl-2), as well as impair processes of neuronal branching and neurogenesis. Although such effects may result from elevated corticoids, they may also stem from activation of the inflammatory immune system, particularly the immune signaling cytokines. In fact, several proinflammatory cytokines, such as interleukin-1, tumor necrosis factor-alpha and interferon-gamma, influence neuronal functioning through processes involving apoptosis, excitotoxicity, oxidative stress and metabolic derangement. Support for the involvement of cytokines in depression comes from studies showing their elevation in severe depressive illness and following stressor exposure, and that cytokine immunotherapy (e.g. interferon-alpha) elicited depressive symptoms that were amenable to antidepressant treatment. It is suggested that stressors and cytokines share a common ability to impair neuronal plasticity and at the same time altering neurotransmission, ultimately contributing to depression. Thus, depressive illness may be considered a disorder of neuroplasticity as well as one of neurochemical imbalances, and cytokines may act as mediators of both aspects of this illness.

Major depressive episode with psychotic features induced by pegylated interferon-alpha-2b and ribavirin treatment

Recent evidence has demonstrated the efficacy of pegylated interferon-alpha (IFN-alpha) in treating hepatitis C virus infection. Neuropsychiatric complications commonly occur during the course of IFN treatment, with depressive symptoms usually appearing within the first 12 weeks. Few cases of the pegylated interferon-alpha-induced psychosis and depression have been reported compared to standard interferon-alpha therapy. We report the first case of a major depressive episode with psychotic features induced by pegylated IFN-alpha-2b and ribavirin in the last 2 weeks of therapy.

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.

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.

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.

Interferon-alpha-induced modulation of glucocorticoid and serotonin receptors as a mechanism of depression

BACKGROUND/AIMS

The mechanism of interferon (IFN)-alpha-induced depression remains poorly understood. Recently, modulation of glucocorticoid receptor (GR) and serotonin receptor 1A (5-HTR1A) were implicated in mechanism(s) leading to depression. To gain insight into this mechanism, we assessed the effect of IFN-alpha on the modulation of GR and 5-HTR1A expression.

METHODS

Hepatoblastoma, myelocyte-derived and T cell leukemia-derived cell lines were treated with titrated doses of IFN-alpha for different incubation times and analyzed by Western blot, RT-PCR, and microarrays. Dose- and time-dependent decreases of proteins and mRNA levels of GR and 5-HTR1A were observed.

RESULTS

The expression of GR and 5-HTR1A in cells treated for 6 days decreased by 74 and 72%, respectively. Recovery was observed following IFN-alpha withdrawal. Co-incubation with tricyclic antidepressants (desipramine) or serotonin reuptake inhibitors (fluoxetine) attenuated the effect of IFN-alpha on GR or 5-HTR1A. GR and 5-HTR1A were unaffected by treatment with either IFN-gamma or tauroursodeoxycholic acid (TUDCA). However, the effect of IFN-alpha on GR was abolished when used in combination with TUDCA.

CONCLUSIONS

In conclusion, IFN-alpha downregulated GR and 5-HTR1A levels in cell lines. These levels of GR and 5-HTR1A, following IFN-alpha-induced downregulation, recovered after withdrawal of IFN-alpha or addition of desipramine or fluoxetine. These data provide insights regarding pathogenesis of IFN-alpha-induced depression.

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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Major depressive disorder in hepatitis C: an open-label trial of escitalopram

BACKGROUND

Depression is a common condition associated with hepatitis C and may be induced by interferon alfa, the primary treatment for hepatitis C. Depression is also a major barrier to the initiation of such treatment. This study examined the effect of escitalopram on measures of depression, quality of life, and tests of liver function in subjects with comorbid hepatitis C and depression.

METHOD

Subjects with DSM-IV major depressive disorder and hepatitis C were included in this open-label study. The recruitment period was from October 2002 through February 2004. Treatment status with regard to interferon therapy was neither an inclusion nor an exclusion criterion. Subjects received escitalopram for 8 weeks starting at 10 mg/day. Dosage adjustments up to 20 mg/day were made after week 4, as deemed clinically necessary. Scores on the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impressions-Severity of Illness scale (CGI-S) and results of liver function tests (AST, ALT, GGT) were obtained at baseline, 2 weeks, 4 weeks, and 8 weeks. Medical Outcomes Study Short Form Health Survey (SF-36) ratings and Hopkins Symptom Checklist-90-Revised (SCL-90-R) scores were obtained at baseline and week 8.

RESULTS

Eighteen subjects (12 female, 6 male) participated in this study. The mean daily dose of escitalopram at endpoint was 12.78 mg. Mean HAM-D-17 scores decreased significantly with treatment (t = 8.535, df = 17, p < .0001). Statistically significant improvement was also demonstrated on many subscales of the SF-36, the SCL-90-R, and the CGI-S. Tests of liver function showed no significant changes.

CONCLUSION

These results suggest that depression in patients with hepatitis C may be effectively and safely treated with escitalopram.

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.

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.

Mood, cognition and EEG changes during interferon alpha (alpha-IFN) treatment for chronic hepatitis C

BACKGROUND

This study is aim to investigate concurrent long-term psychiatric, cognitive and neurophysiological measures of alpha-IFN neurotoxicity in the treatment of chronic viral hepatitis.

METHODS

Twenty patients with HCV hepatitis were enrolled while treated with alpha-IFN (3-6 MU t.i.w. for 6-12 months). Neurotoxicity was evaluated by psychiatric [Hamilton Depression Rating Scale (HAM-D), Hamilton Scale for Anxiety (HAM-A), Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI-Y)], complete cognitive and neurophysiological assessments (EEG spectral analysis, P300). Patients were assessed at baseline (t0), 2 (t1) and 6 months (t2) since the beginning of therapy.

RESULTS

Depression scores significantly increased (HAM-D: t0=4.4+/-2.6; t1=8.9+/-3.9, p<0.001; and t2=7.7+/-3.8, p<0.001). A concurrent increase was shown also for anxiety (HAM-A: t0=6.0+/-3.2; t1=9.6+/-4.5, p<0.005; and t2=9.1+/-4.5, p<0.005). Significant neurophysiological effects were also detected: increase of alpha power (p<0.05) in frontal derivations, reduction of the mean dominant frequency (p<0.005) and increase of theta power (p<0.05) in parietal derivations. In contrast, no significant cognitive changes occurred.

LIMITATIONS

The study was performed on a relative small sample of patients mainly with observational intentions. Biological data (e.g. blood cytokines samples) are not available: they could have given useful information about biological mechanisms related to the alterations observed.

CONCLUSIONS

Alpha-IFN treatment caused a time-dependent induction of symptoms of mild depression, concurrent anxiety and EEG changes. These psychiatric and neurophysiological changes can better explain the pharmacological profile of alpha-IFN and could help to address research on at risk population and, particularly, during pegylated-IFN therapy.