Can antidepressants prevent interferon-alpha-induced depression? A review of the literature

Bacterial Lipopolysaccharide Increases Serotonin Metabolism in Both Medial Prefrontal Cortex and Nucleus Accumbens in Male Wild Type Rats, but Not in Serotonin Transporter Knockout Rats

It is well known that bacterial lipopolysaccharides (LPS) both increases proinflammatory cytokines and produces sickness behavior, including fatigue and anhedonia (i.e., the inability to experience pleasure). Previously, we have shown that intraperitoneally (i.p.) administered LPS increased extracellular monoamine metabolite levels in the nucleus accumbens (NAc) and medial prefrontal cortex (mPFC), which was completely, or at least partly, prevented by pretreatment with a triple reuptake inhibitor that also blocks the serotonin (5-HT) transporter (SERT). This suggests indirectly, that LPS may enhance SERT transporter activity, and consequently, increase removal of 5-HT from the synaptic cleft, and increase metabolism of 5-HT. In the present study, we focus more specifically on the role of SERT in this increased metabolism by using rats, that differ in SERT expression. Therefore, the effects of an intraperitoneal LPS injection on extracellular concentrations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) were investigated by in vivo microdialysis in the NAc and mPFC of wild type (SERT^+/+), heterozygous (SERT^+/−) and knockout (SERT^−/−) rats. Here, we show that LPS-induced 5-HIAA formation in male rats, is significantly increased in SERT^+/+ rats in both the NAc and mPFC, whereas this increase is partly or totally abolished in SERT^+/− and SERT^−/− rats, respectively. Thus, the present study supports the hypothesis that systemic LPS in male rats increases SERT function and consequently enhances 5-HT uptake and metabolism in both the NAc and mPFC.

Multimethod assessment of baseline depression and relationship to hepatitis C treatment discontinuation

Objective The primary study objective is to determine which measures of depression are associated with early discontinuation of hepatitis C virus infection treatment and to determine which measure best characterizes the depression that develops during treatment. Methods Seventy-eight treatment-naïve subjects who initiated pegylated interferon/ribavirin treatment for hepatitis C virus infection were included. Baseline depression was assessed with the Structured Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the Hamilton Depression Rating Scale, and the Beck Depression Inventory-II. The latter two measures were repeated at treatment weeks 12 and 24. Results Depression scores, as measured by the three instruments, lacked adequate consistency. Baseline depression as measured by the Beck Depression Inventory-II, but not by the other scales, was associated with early treatment discontinuation at weeks 12 and 24. Changes in depression during treatment were restricted to somatic symptoms. Of those who completed treatment, those who were not depressed at baseline tended to demonstrate significant depression increases during treatment. Conclusion The Beck Depression Inventory-II is recommended to assess depression prior to hepatitis C virus infection treatment. Somatic symptoms of depression should be monitored during treatment. Baseline depression as measured by the Beck Depression Inventory-II was associated with early treatment discontinuation. The Beck Depression Inventory-II, Structured Interview for DSM-IV, and Hamilton Depression Rating Scale yielded results that were not consistent with each other in this sample. Future research should focus on standardizing depression assessment in medically ill populations to identify measures that predict treatment discontinuation.

Neurological and Neuropsychiatric Adverse Effects of Dermatologic Medications

Severe, recalcitrant dermatologic conditions often require systemic treatment. Although efficacious, these medications have been associated with wide-ranging adverse reactions. Some are reversible, predictable, and either dose-dependent or treatment length-dependent, while others are unpredictable, irreversible, and potentially fatal. This review examines the neuropsychiatric adverse effects associated with US FDA-approved medications for treatment of the following dermatologic pathologies that typically require systemic therapy: autoimmune dermatoses, acne, psoriasis, and melanoma. A search of the literature was performed, with adverse effects ranging from mild headaches and neuropathy to severe encephalopathies. The medications associated with the most serious reactions were those used to treat psoriasis, especially the older non-biologic medications such as cyclosporine A and methotrexate. Given the importance of these systemic dermatologic therapies in treating severe, recalcitrant conditions, and the wide variety of potentially serious neuropsychiatric adverse effects of these medications, neurologists, psychiatrists, dermatologists, oncologists, and primary care providers must be aware of the potential for these neuropsychiatric adverse reactions to allow for appropriate counseling, management, and medication withdrawal.

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

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

Depression and anxiety in patients receiving interferon-alpha: The role of illness perceptions

Development of psychiatric symptoms during interferon-alpha therapy may be influenced by psychological factors. We examined illness perceptions using the Revised Illness Perceptions Questionnaire in 55 patients with chronic hepatitis C virus infection, due to receive interferon-alpha. The Hospital Anxiety and Depression Scale was used to assess the development of symptoms. Negative identity, consequences and emotional representation beliefs were significantly associated with both higher depression and anxiety scores. Negative illness perceptions play a predictive role in the development of interferon-alpha-induced psychiatric symptoms.

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

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

Social support decreases depressogenic effect of low-dose interferon alpha treatment in melanoma patients

OBJECTIVE

The most frequent serious psychological side effect of immune therapies is depression. In the present study, we tested whether social support, as a positive environmental effect, is able to moderate depression or anxiety symptoms in melanoma patients during adjuvant low-dose interferon treatment.

METHODS

Hundred and twenty-seven melanoma patients with negative psychiatric history were included in our longitudinal study and followed up for one year. Depression and anxiety symptoms were measured six times during treatment: at baseline, at 1st, 3rd, 6th, 9th and 12th month of the therapy. In addition, social support was investigated with the Social Dimension Scale.

RESULTS

Depressive symptoms significantly increased during the 12-month follow-up period (p<0.001). However, social support significantly moderated the depressogenic effect of low-dose interferon treatment (p<0.001). Patients with better social support showed attenuated increase of depression. Anxiety showed no significant changes during the low-dose interferon treatment (p=0.230). Social support had no moderating effect on anxiety symptoms (p=0.745) during the follow up.

DISCUSSION

Our data provide evidence that social support and interferon alpha treatment significantly interact in the development of depression. In addition, our study emphasises that enhancement of social support can reduce depressogenic side effects and increase compliance during adjuvant interferon treatment, and thus, psychological screening and psychooncological counselling should be incorporated in the treatment protocol.

Specific serotonin reuptake inhibitors prevent interferon-α-induced depression in patients with hepatitis C: a meta-analysis

BACKGROUND & AIMS

Interferon-α (IFN-α)-induced depression is a major complication to treatment of chronic hepatitis C virus (HCV) infection. Specific serotonin reuptake inhibitors (SSRIs) can be used to treat depression, but it is not clear whether they can prevent depression in patients receiving IFN therapy for chronic HCV infection.

METHODS

We performed a meta-analysis by searching the Cochrane Library, PubMed, and EMBASE databases through 2013 for published results from randomized, placebo-controlled trials evaluating the utility of SSRIs in preventing IFN-induced depression in HCV patients. We analyzed data from 7 studies with a total of 662 patients. The incidence of IFN-induced major depression and depression severity were defined as primary outcomes. Sustained virologic response, completion of antiviral therapy, and tolerability were considered secondary outcomes.

RESULTS

A meta-analysis of IFN-induced major depression revealed that prophylactic SSRIs reduced the risk of depression, compared with placebo (relative risk [RR], 0.56; 95% confidence interval [CI], 0.37-0.84; P = .005). Proportions of patients achieving a sustained virologic response (RR, 1.02; 95% CI, 0.79-1.32; P = .87) and completing antiviral therapy (RR, 0.98; 95% CI, 0.66-1.44; P = .91) were similar between patients given SSRIs and controls. Prophylactic SSRIs were tolerated in patients with HCV during treatment.

CONCLUSIONS

On the basis of a meta-analysis of 7 randomized controlled trials, prophylactic administration of SSRIs to patients with HCV significantly lowered the incidence of IFN-induced major depression, compared with placebo, and the SSRIs were well tolerated.

Fluoxetine a novel anti-hepatitis C virus agent via ROS-, JNK-, and PPARβ/γ-dependent pathways

More than 20% of chronic hepatitis C (CHC) patients receiving interferon-alpha (IFN-α)-based anti-hepatitis C virus (HCV) therapy experienced significant depression, which was relieved by treatment with fluoxetine. However, whether and how fluoxetine affected directly the anti-HCV therapy remained unclear. Here, we demonstrated that fluoxetine inhibited HCV infection and blocked the production of reactive oxygen species (ROS) and lipid accumulation in Huh7.5 cells. Fluoxetine facilitated the IFN-α-mediated antiviral actions via activations of signal transducer and activator of transcription (STAT)-1 and c-Jun amino-terminal kinases (JNK). Alternatively, fluoxetine elevated peroxisome proliferator-activated receptor (PPAR) response element activity under HCV infection. The inhibitory effects of fluoxetine on HCV infection and lipid accumulation, but not production of ROS, were partially reversed by the PPAR-β, -γ, and JNK antagonists. Furthermore, fluoxetine intervention to the IFN-α-2b regimen facilitated to reduce HCV titer and alanine transaminase level for CHC patients. Therefore, fluoxetine intervention to the IFN-α-2b regimen improved the efficacy of anti-HCV treatment, which might be related to blockades of ROS generation and lipid accumulation and activation of host antiviral JNK/STAT-1 and PPARβ/γ signals.

Serotonin-1A receptor CC genotype is associated with persistent depression related to interferon-alpha in hepatitis C patients

OBJECTIVE

The aim of this study is to investigate the development of depression during interferon-alpha (IFN-α) therapy and the variations in the expression of the serotonin receptor (5-HTR) and transporter (5-HTT) in hepatitis C patients.

METHOD

Hepatitis C patients (n=277) were given the Mini International Neuropsychiatric Interview at the end of IFN-α therapy. Three polymorphisms were genotyped: the serotonin transporter repeat length polymorphic region [5-HTT gene-linked polymorphic region (5-HTTLPR)], as well as SNPs rs25531 and rs6295, located within the 5-HTTLPR and the transcriptional control region of the 5-HTR1A gene, respectively.

RESULTS

The diagnosis of current depression, which was associated with IFN-α-related depression (P<.001), demonstrated a statistically significant association with the CC genotype of the 5-HTR1A gene (odds ratio=5.57, 95% confidence interval=1.61-19.24, P=.007).

CONCLUSIONS

Persistent depression may represent a more specific type of IFN-α-related psychopathology. Future studies need to investigate the genetic risk factors for vulnerability associated with persistent depression. Limitations, such as the study's cross-sectional design, small sample size and retrospective assessment of IFN-α-induced depression diagnosis, must be taken into account while interpreting the results found in this study.

Longitudinal effects of selective serotonin reuptake inhibitor therapy and cytokine-related depression on hepatitis C viral logs during antiviral therapy

OBJECTIVES

The aim of this study was to determine the longitudinal effects of selective serotonin reuptake inhibitor (SSRI) therapy and cytokine-related depression on levels of hepatitis C virus (HCV) during treatment with combination therapy.

BACKGROUND

Prior studies have investigated the association between cytokine-related depression and sustained virological response, but it is unknown whether anti-inflammatory properties of SSRIs used to treat cytokine-related depression inadvertently contravene proinflammatory properties of pegylated interferon (Peg-IFN), in effect reducing therapeutic efficacy.

STUDY

In a retrospective cohort design, patients being treated with Peg-IFN or interferon in combination with ribavirin at a gastroenterology clinic were followed from initiation of therapy until 24 weeks after the completion of therapy. Sustained virological response and rate of decline of HCV RNA levels were compared among patients with SSRI therapy and cytokine-related depression.

RESULTS

Selective serotonin reuptake inhibitor therapy and cytokine-related depression did not adversely impact the proportion of patients achieving sustained virological response. In a multivariate longitudinal analysis, the mean slope of HCV RNA levels declined faster over time in patients without cytokine-related depression in comparison to patients with cytokine-related depression (P = 0.05), and the mean slope of HCV RNA levels declined similarly over time in patients with and without SSRI therapy.

CONCLUSIONS

In this retrospective cohort, SSRI therapy did not interfere with immune activation dynamics of Peg-IFN/ribavirin, and patients without cytokine-related depression developed quicker responses and suppressed HCV replication more favorably over time.

Interferon-induced depression in patients with hepatitis C: an epidemiologic study

Objective To assess the incidence rate and severity of depressive symptoms in different time points (12, 24 and 48 weeks) in Brazilian patients with HCV treated with PEG IFN plus ribavirin. Methods We conducted an observational prospective study using the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression Scale (CES-D). Results Fifty patients were included. The assessments with either scale showed the highest score of depressive symptoms in the 24th week of treatment; the mean BDI score before treatment was 6.5 ± 5.3 and the mean CES-D was 10.9 ± 7.8. After 24 weeks, the mean BDI was 16.1 ± 10.2 and mean CES-D was 18.6 ± 13.0; 46% were diagnosed with depression according to combined BDI and CES-D scores. The somatic/psychomotor subscales were highly correlated with overall scale scores . Subjects with history of substance and alcohol abuse had higher risk for IFN-induced depression. Conclusion Treatment with PEG IFN was associated with a high incidence rate of depressive symptoms in this sample of Brazilian patients, as measured by CES-D and BDI. Alcohol and substance abuse increase the risk of PEG IFN-induced depression.

Lipopolysaccharide increases degradation of central monoamines: an in vivo microdialysis study in the nucleus accumbens and medial prefrontal cortex of mice

Peripheral administration of lipopolysaccharide (LPS) in rodents induces anhedonia, i.e. the inability to experience pleasure. Recently, we reported that serotonin transporter (SERT) function is required for LPS-induced anhedonia. Less is known about the effect of LPS on the biological activity of dopamine transporters (DAT) and norepinephrine transporters (NET). Therefore, in vivo microdialysis was performed in the nucleus accumbens and medial prefrontal cortex of C57BL6/J mice exposed to saline or LPS (133 µg/kg i.p.). To investigate the possible involvement of different monoamine transporters, the triple reuptake inhibitor DOV 216,303 or saline was i.p. injected 30 min before the saline/LPS injection. The dose of LPS, shown to decrease responding for brain stimulation reward in mice, significantly increased extracellular levels of monoamine metabolites (5-HIAA, DOPAC and HVA) in the nucleus accumbens and medial prefrontal cortex. Remarkably, DOV 216,303 abolished LPS-induced DOPAC and HVA formation in the nucleus accumbens, suggesting that LPS increases DAT activity in this brain area. DOV 216,303 also inhibited LPS-induced DOPAC and HVA formation in the medial prefrontal cortex. Since DAT density is very low in this brain structure, reuptake of DA predominantly takes place via NET, suggesting that LPS increases DAT and NET activity in the medial prefrontal cortex. Furthermore, DOV 216,303 pretreatment prevented LPS-induced 5-HIAA formation only in the medial prefrontal cortex, indicating that LPS increases prefrontal SERT activity. In conclusion, the present findings suggest that peripheral LPS increases DAT activity in the nucleus accumbens and increases NET and SERT activity in the medial prefrontal cortex of mice.

Antidepressant pretreatment for the prevention of interferon alfa-associated depression: a systematic review and meta-analysis

BACKGROUND

Depression is a major complication during treatment with interferon alfa (IFN-α).

AIM

The aim of this study was to clarify whether preemptive antidepressant treatment can reduce the incidence and severity of IFN-associated depression.

METHOD

Based on a systematic review of the literature up to July 2012, a meta-analysis of the data from 8 trials investigating patients with malignant melanoma or hepatitis C was performed. The influence of antidepressants on the incidence of major depression and depression severity was defined as the primary outcome and the influence of somatic disorder, psychiatric comorbidity, type of antidepressants, type of IFN, and possible effects on treatment outcome as secondary outcome criteria.

RESULTS

Antidepressant pretreatment reduced the overall incidence of major depression during IFN treatment in all patients (odds ratio = 0.42; 95% confidence interval, 0.26-0.68; p < 0.001, n = 589) and was associated with lower mean depression scores after 12 weeks of IFN treatment (g = -0.37; 95% confidence interval -0.59 to -0.18; p < 0.001, n = 375). For patients with hepatitis C virus infection, antidepressants reduced the incidence of major depression (odds ratio = 0.38; 95% confidence interval 0.22-0.66; p < 0.001, n = 549) and the mean depression scores after 24 weeks of IFN treatment (g = -0.50; 95% confidence interval -0.70 to -0.29; p < 0.001, n = 335). The effects of selective serotonin reuptake inhibitors on the incidence and severity of depression were not dependent on pre-existing psychiatric disorders.

CONCLUSION

Antidepressant pretreatment with selective serotonin reuptake inhibitors lowers the incidence and severity of IFN-associated depression in patients with chronic hepatitis C infection or malignant melanoma.

Lipopolysaccharide-induced anhedonia is abolished in male serotonin transporter knockout rats: an intracranial self-stimulation study

A growing body of evidence suggests that pro-inflammatory cytokines contribute to the pathogenesis of depression. Previously, it has been shown that cytokines (e.g. interferon-α therapy) induce major depression in humans. In addition, administration of the cytokine-inducer lipopolysaccharide (LPS) provokes anhedonia (i.e. the inability to experience pleasure) in rodents. Furthermore, serum pro-inflammatory cytokine levels are increased in depressed patients. Nevertheless, the etiology of cytokine-induced depression is largely unknown. Previously, it has been shown that selective serotonin re-uptake inhibitors decrease serum pro-inflammatory cytokine levels and that pro-inflammatory cytokines increase activity of the serotonin transporter (SERT). The purpose of this study was to explore the effect of partial and complete lack of the SERT in LPS-induced anhedonia assessed in the intracranial self-stimulation (ICSS) paradigm. A single intraperitoneal injection of LPS was used to induce a pro-inflammatory immune response in male serotonin transporter wild type (SERT(+/+)), heterozygous (SERT(+/-)) and knockout (SERT(-/-)) rats. Body weight and ICSS thresholds were measured daily. Although LPS reduced body weight in all genotypes, loss of body weight was less pronounced in SERT(-/-) compared to SERT(+/+) rats. Remarkably, LPS-induced anhedonia was totally abolished in SERT(-/-) rats and as expected was still present in SERT(+/+) and to a lesser extent in SERT(+/-) rats. Therefore, it is concluded that an intact SERT function is needed for pro-inflammatory cytokine-induced anhedonia and weight loss in rats.

Self-efficacy for coping with cancer in melanoma patients: its association with physical fatigue and depression

OBJECTIVE

The purpose of this study was to explore the impact of self-efficacy for coping with cancer (SECC) on physical fatigue and depressive symptoms in melanoma patients, in comparison with objective factors, such as treatment with interferon-alpha (IFN-α) and medical and sociodemographic variables. Current literature shows that psychological distress in melanoma patients is generally moderate, that they experience high quality of life, and that symptoms of depression and fatigue have been mostly associated with adjuvant IFN-α treatment

METHODS

A total of 175 melanoma patients, stages Ib-IIIc with and without low-dose IFN-α therapy, completed surveys on SECC, depression, and fatigue. Two hierarchical regression analyses were conducted to explore the predictive role of objective factors (first step: tumor stage, time since diagnosis, and current IFN-α treatment; second step: age and gender) in conjunction with the subjective factor of SECC (third step) on physical fatigue and depression.

RESULTS

Regression analysis revealed no significant effect of IFN-α treatment upon depression. Current IFN-α treatment was predictive of higher fatigue scores, however. The highest predictive effect by far was obtained for SECC, indicating higher fatigue and depression in patients with lower SECC.

CONCLUSIONS

The findings suggest that the treatment with IFN-α is mainly accompanied by physical fatigue in melanoma patients rather than by mood changes. Most notably, the potential influence of increased SECC on reducing both physical fatigue and depression is suggested by the data, indicating the importance of self-efficacy enhancing interventions in the psycho-oncological support of melanoma patients.

The place of immunotherapy in the management of HCV-induced vasculitis: an update

Patients with chronic hepatitis C virus (HCV) can develop systemic cryoglobulinemic vasculitis. Combination of pegylated-interferon α and ribavirin is the first-line treatment of this condition. However, in case of severe or life-threatening manifestations, absence of a virological response, or autonomized vasculitis, immunotherapy (alone or in addition to the antiviral regimen) is necessary. Rituximab is to date the only biologic with a sufficient level of evidence to support its use in this indication. Several studies have demonstrated that rituximab is highly effective when cryoglobulinaemic vasculitis is refractory to antiviral regimen, that association of rituximab with antiviral regimen may induce a better and faster clinical remission, and, recently, that rituximab is more efficient than traditional immunosuppressive treatments. Some issues with regard to the optimal dose of rituximab or its use as maintenance treatment remain unsolved. Interestingly, in balance with this anti-inflammatory strategy, a recent pilot study reported the significant expansion of circulating regulatory T lymphocytes with concomitant clinical improvement in patients with refractory HCV-induced cryoglobulinaemic vasculitis using low dose of subcutaneous interleukin-2. This paper provides an updated overview on the place of immunotherapy, especially biologics, in the management of HCV-induced cryoglobulinaemic vasculitis.

Understanding clinical risk decision making regarding development of depression during interferon-alpha treatment for hepatitis-C: a qualitative interview study

BACKGROUND

Hepatitis C virus (HCV) affects 170 million worldwide. Currently, around 30% of patients receiving interferon-alpha (IFN-α) treatment for HCV experience clinically significant depression. Effective and timely detection of depression is crucial to ensuring appropriate treatment and support. However, little is known about how clinical nurse specialists identify patients at risk of developing interferon-alpha-induced depression, and monitor those receiving antiviral treatment for the occurrence of depression.

OBJECTIVE

This study aimed to gain an in-depth understanding of staff experience of, and attitudes towards, the identification and monitoring of interferon-alpha-induced-depression and the decision-making process concerning the use of liaison psychiatry and other clinical services.

DESIGN

A qualitative interview study was conducted among clinical staff involved in the care of patients with hepatitis C, using the perspective of naturalistic decision making.

SETTINGS

Outpatient liver clinics in three large teaching hospitals in South London, the United Kingdom.

PARTICIPANTS

All clinical nurse specialists from the three outpatient liver clinics were included. All were involved directly in the care of patients receiving interferon-alpha treatment and had at least one year experience (mean 6.4 years, range 1-11 years) in this field.

METHODS

Semi-structured face-to-face interviews were conducted between 2010 and 2011. Data collection and analysis were carried out iteratively to ensure the reliability of the analysis using the constant comparison method.

RESULTS

Staff used verbal and non-verbal cues when assessing risks of patients developing depression before and during IFN-α treatment. Major sources of uncertainty were patient engagement and familiarity, referrals to psychiatrists, language barriers, and distinguishing between psychological and physical symptoms. Good rapport with patients and good communication among multidisciplinary professional groups were key strategies identified to reduce uncertainty.

CONCLUSION

Current methods of identifying vulnerable patients rely on the availability of clinical experts and good communication within a multidisciplinary team. Detection and management of depression in this population is complex, however, various strategies are employed by nurses to overcome difficulties when making decisions regarding patient welfare. Current clinical practices should be taken into account when developing new tools and methods.

Hepatitis C treatment and erotomania

The emergence of psychosis during antiviral therapy for hepatitis C is a rare side effect poorly understood in terms of etiopathogenesis, clinical features and prognosis. Erotomania is a rare psychotic syndrome characterized by the presence of a delusion: the patient (usually a female) is loved by a specific man. We present a patient who began a clinical picture of erotomania that involved his doctor a few days after treatment of interferon and ribavirin was started. He stalked his doctor, forcing the police and the court to intervene. Nevertheless, once antipsychotic treatment was established, symptoms remitted, and the patient continued antiviral treatment successfully.

Lack of association of indoleamine 2,3-dioxygenase polymorphisms with interferon-alpha-related depression in hepatitis C

BACKGROUND

Major depression is a frequent adverse effect of interferon-alpha (IFN-α) therapy. Although the indoleamine 2,3-dioxygenase (IDO) enzyme seems to be involved in the pathophysiology of IFN-α-induced depression, no pharmacogenetic study has investigated whether variation in the IDO gene modifies vulnerability to this adverse effect.

METHODS

A cross-sectional study assessing 277 hepatitis C patients recruited in two specialized outpatient clinics of Brazil. They were interviewed with the Mini International Neuropsychiatric Interview (MINI) approximately 1 month after the end of IFN-α plus ribavirin therapy. Genomic DNA of individuals was extracted from venous blood. Three IDO single-nucleotide polymorphisms (SNPs) were genotyped (rs3824259; rs10089084 and rs35099072).

RESULTS

MINI indicated that 21.3% of the sample met criteria for a major depressive episode during the course of IFN-α therapy. No association with the diagnosis of a major depressive episode during the course of IFN-α therapy was observed genotype or allele-wise (p>0.05). Current major depression and/or current anxiety disorder was significantly associated with IFN-α-related depression (p<0.005). However, gender, age, route of infection, result of the antiviral treatment, past history of substance use disorders, depression or any other psychiatric disorder showed no association with IFN-α-related depression (p>0.05).

CONCLUSIONS

Our results suggest no influence of the variants in the IDO gene and the diagnosis of interferon-α-related depression in the Brazilian population. Interferon-α-related depression may impose persistent psychopathology on at least 15% of the depressed patients even 2 years after antiviral therapy termination. The cross-sectional design is a limitation of our study, predisposing memory bias. Prospective pharmacogenetic studies are warranted to continue investigation of the impact of IDO polymorphisms on the development of IFN-α-induced depression.