Major depression and risk of depressive symptomatology associated with short-term and low-dose interferon-alpha treatment

Major depression and the biological hallmarks of aging

Major depressive disorder (MDD) is characterized by psychological and physiological manifestations contributing to the disease severity and outcome. In recent years, several lines of evidence have suggested that individuals with MDD have an elevated risk of age-related adverse outcomes across the lifespan. This review provided evidence of a significant overlap between the biological abnormalities in MDD and biological changes commonly observed during the aging process (i.e., hallmarks of biological aging). Based on such evidence, we formulate a mechanistic model showing how abnormalities in the hallmarks of biological aging can be a common denominator and mediate the elevated risk of age-related health outcomes commonly observed in MDD. Finally, we proposed a roadmap for novel studies to investigate the intersection between the biology of aging and MDD, including the use of geroscience-guided interventions, such as senolytics, to delay or improve major depression by targeting biological aging.

Remote Assessment of Disease and Relapse in Major Depressive Disorder (RADAR-MDD): recruitment, retention, and data availability in a longitudinal remote measurement study

BACKGROUND

Major Depressive Disorder (MDD) is prevalent, often chronic, and requires ongoing monitoring of symptoms to track response to treatment and identify early indicators of relapse. Remote Measurement Technologies (RMT) provide an opportunity to transform the measurement and management of MDD, via data collected from inbuilt smartphone sensors and wearable devices alongside app-based questionnaires and tasks. A key question for the field is the extent to which participants can adhere to research protocols and the completeness of data collected. We aimed to describe drop out and data completeness in a naturalistic multimodal longitudinal RMT study, in people with a history of recurrent MDD. We further aimed to determine whether those experiencing a depressive relapse at baseline contributed less complete data.

METHODS

Remote Assessment of Disease and Relapse - Major Depressive Disorder (RADAR-MDD) is a multi-centre, prospective observational cohort study conducted as part of the Remote Assessment of Disease and Relapse - Central Nervous System (RADAR-CNS) program. People with a history of MDD were provided with a wrist-worn wearable device, and smartphone apps designed to: a) collect data from smartphone sensors; and b) deliver questionnaires, speech tasks, and cognitive assessments. Participants were followed-up for a minimum of 11 months and maximum of 24 months.

RESULTS

Individuals with a history of MDD (n = 623) were enrolled in the study,. We report 80% completion rates for primary outcome assessments across all follow-up timepoints. 79.8% of people participated for the maximum amount of time available and 20.2% withdrew prematurely. We found no evidence of an association between the severity of depression symptoms at baseline and the availability of data. In total, 110 participants had > 50% data available across all data types.

CONCLUSIONS

RADAR-MDD is the largest multimodal RMT study in the field of mental health. Here, we have shown that collecting RMT data from a clinical population is feasible. We found comparable levels of data availability in active and passive forms of data collection, demonstrating that both are feasible in this patient group.

Interferon-alpha-induced depression: Comparisons between early- and late-onset subgroups and with patients with major depressive disorder

Interferon (IFN)-alpha, until recently the standard treatment of hepatitis C virus (HCV) infection, is associated with a significant risk of major depressive episode (MDE, or IFN-alpha-induced depression). However, it is little studied the comparisons of clinical manifestations between IFN-alpha-induced depression and major depressive disorder (MDD). In addition, IFN-alpha induces different neuroinflammation and neuroendocrine status throughput the HCV treatment course; however, the clinical presentations have never been compared between early-onset and later-onset IFN-alpha-induced depression. We assessed 200 HCV patients starting IFN-alpha therapy bi-weekly for 24 weeks, with the structured interview for confirmation of diagnosis of IFN-alpha-induced depression and with clinical rating scales for depressive symptoms and neuropsychiatric symptoms. Subjects developed IFN-alpha-induced depression (n = 59, 30%) during the first 6 weeks of IFN-alpha therapy were defined as the early-onset group (n = 32), while those developed depression after the 6th week were defined as the late-onset group (n = 27). A matched group of MDD patients (n = 60) was used to compare specific clusters of depressive symptoms with early- and late-onset IFN-alpha-induced depression. Compared to the matched group of MDD patients, IFN-alpha-induced depression was significantly associated with more somatic symptoms and fewer symptoms of mood, anxiety and negative cognition. More somatic symptoms were also found in those who became clinically depressed at early stage of IFN-alpha therapy. We suggest that the specific somatic features of interferon-alpha-induced depression, and especially of early-onset depression, characterise individuals who are more sensitive to cytokines-induced changes in mood.

Reduced frontal activation during verbal fluency task in chronic hepatitis C patients with interferon-based therapy as measured by near-infrared spectroscopy

AIM

Psychiatric side-effects are the main reason for discontinuation of interferon (IFN)-based therapy. Recent developments in near-infrared spectroscopy (NIRS) have enabled non-invasive clarification of brain functions in psychiatric disorders. We prospectively evaluated brain activation in 20 chronic hepatitis C patients with or without IFN-based therapy by using NIRS during a verbal fluency task (VFT).

METHODS

The relative concentrations of oxygenated hemoglobin were measured while patients completed a questionnaire survey at the start of treatment and at 4 and 12 weeks during treatment, using NIRS.

RESULTS

The VFT performance did not change among the two groups. Patients with IFN-based therapy showed significantly lower activation during VFT in frontal channels at 12 weeks than those at the start of treatment and control (P < 0.05). Their Center for Epidemiologic Studies Depression Scale scores were significantly higher at 12 weeks than those at the start of treatment, although major depressive symptoms were not found (8.3 ± 7.9 vs. 13.2 ± 6.0, P < 0.001).

CONCLUSION

The decrease in oxygenated hemoglobin concentrations of the frontal lobe detected using NIRS in this study reflects hypofunction of the frontal lobe. This functional decline that was caused by IFN-based therapy may be associated with the prodromal phase of depression.

DEPRESSIVE EPISODE INCIDENCE IN PATIENTS WITH CHRONIC HEPATITIS C TREATED WITH PEGYLATED INTERFERON AND RIBAVIRIN

BACKGROUND

The effectiveness of antiviral therapy with pegylated interferon and ribavirin for chronic hepatitis C is far from ideal and presents several adverse events. Among such events, there is the depressive episode that can even lead to treatment discontinuity.

OBJECTIVE

Analyze the incidence of depressive episodes in patients with chronic hepatitis C treated with pegylated interferon (IFN-PEG) and ribavirin, as well as the possible factors associated with its occurrence and its impact on patients' sustained virological response.

METHODS

People with chronic hepatitis C undergoing antiviral therapy were interviewed at the baseline, at the 4th, 12th, 24th and 48th treatment weeks and 4 weeks after the end of it, using the HADS scale for tracking the depressive episode. Patients with HADS ≥9 were subjected to Beck Depression Inventory (BDI-II) to grade the episode. Clinical, sociodemographic, laboratorial and histological variables were obtained to identify factors related to the onset of depression. The sustained virological response rate (negative HCV-RNA 6 months after end of therapy) was compared among patients with and without depressive symptoms.

RESULTS

The study comprised 32 patients, most men (59%) with mean age of 54±11.13 years old. Genotype non-1 was prevalent (56%) and 81% of the patients were non-cirrhotic. The depressive episode was diagnosed in 25% of the patients and the peak incidence was found in the 12th treatment week. The depressive episode was moderate in 87% of the patients and only one patient abandoned the treatment. None of the analyzed factors was associated with depressive episode onset. A trend was observed in female patients ( P =0.08). The sustained virological response rate was of 75% and 67% in patients with and without depressive episode, respectively ( P =0.66).

CONCLUSION

The incidence of depressive episodes in patients with chronic hepatitis C undergoing antiviral therapy was of 25% and the 12th treatment week was the most critical one. The presence of depressive episode did not affect the sustained virological response rate.

Tumour necrosis factor-α inhibitor therapy in chronic physical illness: A systematic review and meta-analysis of the effect on depression and anxiety

OBJECTIVE

Depression is more common among individuals with chronic physical illness than in the general population. New treatments for severe and chronic inflammatory conditions which inhibit tumour necrosis factor alpha (TNF-α), a pro-inflammatory cytokine, may be able to shed some light on the role of inflammatory mediators in depression. This systematic review and meta-analysis of randomised controlled trials determined the effects of TNF-α inhibitor therapy on depression and anxiety in people with chronic physical illness.

METHODS

Seven databases were searched from inception to January 2014: AMED, Central, Cochrane Database of Systematic Reviews, CINAHL, Embase, MEDLINE, and PsycINFO. Articles were screened for inclusion independently by two reviewers. Data extraction and appraisal were conducted by one reviewer and checked by a second. Random-effects meta-analyses were performed.

RESULTS

Six randomised controlled trials (reported in seven articles) met eligibility criteria and were included in the final review. In total 2540 participants were enrolled across the trials, with participants presenting with rheumatoid arthritis (n=3 trials), psoriasis (n=2) or ankylosing spondylitis (n=1). Meta-analyses, using standardised mean differences, showed evidence of small reductions in depression (-0.24; 95% CI -0.33 to -0.14; p<0.001), and anxiety (-0.17; 95% CI -0.31 to -0.02; p=0.02).

CONCLUSION

TNF-α inhibitor therapy reduces depression in people with chronic disease though the effects are small. Whilst this is consistent with inflammation contributing to the development of depression, further studies investigating a more detailed timeline of changes in depression, inflammatory biomarkers and disease activity status are required.

Central administration of murine interferon-α induces depressive-like behavioral, brain cytokine and neurochemical alterations in mice: a mini-review and original experiments

A role for pro-inflammatory cytokines and their neuroinflammatory signaling cascades in depressive pathology has increasingly gained acceptance. In this regard, several lines of evidence suggested that interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) can provoke neurochemical and hormonal changes akin to those associated with psychological stressors, and that these cytokines also induce sickness behaviors that resemble some of the neurovegetative features of depression. Similarly, human depressed patients often display marked changes of pro-inflammatory cytokine levels and immune cell activity. Perhaps more germane in the analysis of the cytokine-depression connection, reports of humans undergoing interferon-α (IFN-α) treatment for certain cancers or viral infections have indicated that the pro-inflammatory cytokine caused signs of major depression in a substantial subset of those treated. In the present investigation, we demonstrated that acute or repeated infusion of IFN-α into the lateral ventricles provoked depressive-like behavior and concomitant changes in serotonin (5-HT) and mRNA expression of particular 5-HT receptors and pro-inflammatory cytokines. These actions were less evident following administration directly into the prefrontal cortex and not apparent at all when administered to the dorsal raphe nucleus. The data are discussed in relation to the induction of depression elicited by IFN-α, and are presented in the context of a mini-review that highlights potential mechanisms through which the cytokine might act to promote psychomotor and affective disturbances and interact with stressors.

The puzzle of depression and acute coronary syndrome: reviewing the role of acute inflammation

The relationship between depression and coronary heart disease is well-established, but causal mechanisms are poorly understood. The aim of this review is to stimulate different ways of viewing the relationship between depression and adverse outcomes following acute coronary syndrome (ACS) and coronary artery bypass graft (CABG) surgery patients. We present an argument for depression in ACS and CABG patients being a qualitatively distinct form from that observed in psychiatric populations. This is based on three features: (1) depression developing after cardiac events has been linked in many studies to poorer outcomes than recurrent depression; (2) somatic symptoms of depression following cardiac events are particularly cardiotoxic; (3) depression following an ACS does not respond well to antidepressant treatments. We propose that inflammation is a common causal process responsible in part both for the development of depressive symptoms and for adverse cardiac outcomes, and we draw parallels with inflammation-induced sickness behaviour. Clinical implications of our observations are discussed along with suggestions for further work to advance the field.

Uncoupling protein 2 knockout exacerbates depression-like behaviors in mice via enhancing inflammatory response

Mitochondrial uncoupling protein 2 (UCP2) has been recognized as an important protein to regulate reactive oxygen species (ROS) production. The absence of UCP2 has the potential to promote ROS accumulation and thereby induces oxidative damages and inflammatory response. Increasing evidence strongly reveals that depression is accompanied by oxidative stress, so the present study was to investigate the impacts of UCP2 on the etiology of depression. Wild-type and UCP2 knockout mice were used to establish chronic mild stress (CMS)-induced anhedonia model of depression. The results showed that CMS led to more severe depressive responses in UCP2 knockout mice, characterized by exacerbated depression-like behaviors, increased corticosterone level and significant loss of weight. Moreover, CMS resulted in a higher mortality in UCP2 knockout mice. Our further study showed that UCP2 knockout enhanced CMS-induced activation of nuclear factor κB (NF-κB) p65 and increased mRNA expression of tumor necrosis factor alpha (TNF-α) in hypothalamus. And the levels of TNF-α of serum and spleen in UCP2 knockout mice are remarkably enhanced by CMS, even under basal conditions. Therefore, our findings suggest that UCP2 knockout-induced inflammation may contribute to the development of depressive symptoms.

Depression, cytokines and experimental pain: evidence for sex-related association patterns

BACKGROUND

There is robust evidence that altered neural-immune interactions including increased levels of proinflammatory cytokines are involved in both the pathogenesis of depression and altered pain processing. Proinflammatory cytokines induce sickness behavior, a constellation of symptoms that bears a strong similarity to those of depression. A feature of sickness behavior is enhanced pain sensitivity and it has been suggested that proinflammatory cytokines interact with pain processing directly and via several neurobiological pathways. Previous research indicates that depression and pain are closely related. We investigated the association between proinflammatory cytokines and experimental pain in major depression.

METHODS

Psychopathological variables, pressure pain thresholds (PPT) and concentrations of tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were measured in 37 outpatients with major depression and 48 healthy controls.

RESULTS

Compared with controls, depressed patients exhibited significantly higher levels of TNF-α and significantly decreased PPT indicating enhanced pain sensitivity. The group differences were robust when adjusting for sex and body mass index, although sex was significantly related to PPT. No group difference was observed in IL-6. PPT correlated significantly with TNF-α in women but not in men.

LIMITATIONS

Because of the cross-sectional design, causality of the relation between TNF-α and pain cannot be determined. Results should be considered preliminary given the small sample size.

CONCLUSION

The present findings suggest that increased pain sensitivity in depression may be linked to increased TNF-α concentration. The absence of this association in men is discussed in terms of pain-related psychobiological sex differences.

Suicide risk in hepatitis C and during interferon-alpha therapy: a review and clinical update

Chronic hepatitis C (CHC) affects over 170 million individuals worldwide and is a growing public health concern. Despite the availability of CHC treatment, specifically interferon-α and ribavirin, treatment of CHC is limited by concerns about psychiatric side effects including risks of suicide. Although depression has been the focus of neuropsychiatric complications from interferon-alpha (IFNα), emerging evidence has contributed to our understanding of IFNα-induced suicidal ideation and attempts. Using Pubmed, we performed a literature review of all English articles published between 1989 and April 1, 2010 on suicide in untreated and IFNα-treated patients with CHC. References in all identified review articles were scanned and included in our review. A total of 17 articles were identified. Studies have suggested that the first 12 weeks of IFNα therapy are the high-risk period. Moreover, the emergence of suicidal ideation can be linked to neuropsychiatric abnormalities, specifically serotonin depletion. Pretreatment with antidepressant treatment should be reserved for high-risk groups, as this may reduce the risk of depression and thus decrease the suicide risk indirectly. Although there is a paucity of literature on suicide and suicide risk during IFNα therapy for CHC, recent studies on IFNα-induced depression have provided some potential insights into suicide in this patient population. Further research examining the effects of pharmacological and nonpharmacological interventions on suicide risk during IFNα treatment is needed.

Depression: a repair response to stress-induced neuronal microdamage that can grade into a chronic neuroinflammatory condition?

Depression is a major contributor to the global burden of disease and disability, yet it is poorly understood. Here we review data supporting a novel theoretical model for the biology of depression. In this model, a stressful life event leads to microdamage in the brain. This damage triggers an injury repair response consisting of a neuroinflammatory phase to clear cellular debris and a spontaneous tissue regeneration phase involving neurotrophins and neurogenesis. During healing, released inflammatory mediators trigger sickness behavior and psychological pain via mechanisms similar to those that produce physical pain during wound healing. The depression remits if the neuronal injury repair process resolves successfully. Importantly, however, the acute psychological pain and neuroinflammation often transition to chronicity and develop into pathological depressive states. This hypothesis for depression explains substantially more data than alternative models, including why emerging data show that analgesic, anti-inflammatory, pro-neurogenic and pro-neurotrophic treatments have antidepressant effects. Thus, an acute depressive episode can be conceptualized as a normally self-limiting but highly error-prone process of recuperation from stress-triggered neuronal microdamage.

Sustained elevation of serum interleukin-6 and relative insensitivity to hydrocortisone differentiates posttraumatic stress disorder with and without depression

BACKGROUND

Elevated levels of proinflammatory cytokines, especially interleukin-6 (IL-6), can mediate the greater risk for cardiovascular disease in individuals with posttraumatic stress disorder (PTSD), particularly in those with comorbid major depressive disorder (MDD). However, IL-6 levels are not consistently elevated in either PTSD or MDD. Although PTSD is associated with supersensitivity to glucocorticoids; prior studies have not evaluated the effect of comorbid MDD.

METHODS

Serum IL-6 levels were measured hourly between 7:00 pm and 7:00 am in individuals with PTSD with comorbid MDD (PTSD + MDD) (n = 9) and compared with those with PTSD without MDD (PTSD - MDD) (n = 9) and nontraumatized healthy control subjects (n = 14). Group differences in serum IL-6, plasma adrenocorticotropic hormone (ACTH), and plasma cortisol response to 30 mg of intravenous hydrocortisone were evaluated using linear mixed models.

RESULTS

Only subjects with PTSD + MDD exhibited higher, overnight serum IL-6 levels compared with individuals with PTSD - MDD (p < .01) and healthy control subjects (p < .001). Peak overnight IL-6 levels positively correlated with severity of PTSD (r = .56, p < .01) and depressive symptoms (r = .54, p < .01). Hydrocortisone administration significantly reduced IL-6 levels in both PTSD groups; however, IL-6 levels in PTSD + MDD were higher than both PTSD - MDD (p < .05) and healthy control subjects (p < .01). Following hydrocortisone administration, there was a greater reduction in levels of ACTH in PTSD - MDD compared with control subjects (p < .01).

CONCLUSIONS

Sustained elevations of overnight IL-6 levels and relatively decreased sensitivity to hydrocortisone distinguish PTSD + MDD from PTSD - MDD. Novel strategies that decrease IL-6 levels offer a new direction in the prevention and treatment of PTSD and associated comorbid medical illnesses.

Psychobiological differences between depression and somatization

BACKGROUND

Comorbidity studies have shown that depression and somatization (multiple somatoform symptoms) often overlap. Therefore it has been suggested to classify at least some patients with somatization syndromes under the category of depressive disorders. We wanted to investigate whether psychobiological investigations confirm the lumping of somatization and depression, or whether psychobiological pathways favor distinguishing these disorders.

METHOD

An overview is presented summarizing psychobiological studies including patients with depression and/or somatization-associated syndromes. We focus on the following topics: heritability, polymorphisms in special candidate genes, immune activation, hypothalamic-pituitary-adrenal (HPA) axis reactivity, serotonergic pathways, monoamino acids, and fatty acid concentrations.

RESULTS

Immunological activation seems to be associated with specific features of somatoform disorders, namely, sickness behavior and pain thresholds. Genetic factors can also contribute to somatic complaints, e.g., via serotonergic pathways, HPA-axis response, immune activation, and other biological systems that contribute to the self-description of not being healthy. Some results indicate that psychobiological aspects of depression and somatization overlap in part (e.g., the relevance of serotonergic pathways), but there is clearly more evidence for discrepancies of psychobiological pathways in depression and somatization (e.g., the relevance of proinflammatory immune processes; HPA-axis activity; monoamino acid availability; omega-3-concentration; the role of triallelic subtypes of 5-HTTLPR).

CONCLUSION

Many psychobiological pathways act differently in depression and somatization. These differences in psychobiology favor the distinction of these syndromes in classification approaches.

Managing depression during hepatitis C treatment

OBJECTIVE

The prevalence of hepatitis C virus (HCV) infection in Canada is estimated to be 1% and expected to increase during the next decade. Mental illness, particularly depression, is common among HCV-infected patients and remains an obstacle to interferon-alpha (IFN-alpha) treatment. We summarize the risk factors for interferon-alpha-induced major depressive disorder (IFN-alpha-MDD) in HCV patients and the evidence for antidepressant prophylaxis and symptomatic antidepressant treatment of depression.

METHODS

We searched MEDLINE, EMBASE, and CINAHL for randomized controlled or quasi-experimental trials evaluating antidepressant prophylactic and symptomatic treatment approaches for depression emerging during IFN-alpha treatment. Manual searches of references listed in review articles, case series, and anecdotal reports supplemented our literature search.

RESULTS

A total of 9 trials involving prophylactic and symptomatic treatment approaches for IFN-alpha-MDD are summarized in our review. Antidepressant pretreatment is beneficial for patients with elevated baseline depressive symptoms and a preexisting history of IFN-alpha-MDD. Although limited evidence exists for several antidepressant agents, much of the evidence suggests that selective serotonin reuptake inhibitors (SSRIs) are safe and efficacious in treating depressive symptoms secondary to IFN-alpha therapy.

CONCLUSION

Both antidepressant pretreatment and symptomatic treatment are viable strategies for treating IFN-alpha-MDD. Improved treatment outcomes and early identification of depression during HCV treatment can be achieved using an integrated medical and mental health treatment approach.

Depressive symptomatology is associated with decreased interleukin-1 beta and increased interleukin-1 receptor antagonist levels in males

Previous studies with selected patient populations have suggested that cytokines, the immune system messengers, may play a role in the aetiology of depression. However, the data concerning the increase or decrease of the plasma cytokine levels in depression is controversial and the effects of the medications and type of depression are largely unknown. We studied the connections between plasma interleukin-1 beta (IL-1 beta) and interleukin 1 receptor antagonist (IL-1RA) levels, and depressive symptomatology measured with the Beck Depression. Inventory in a large, middle-aged population-based sample collected from Central Finland. In addition, the effects of various medications and type of depressive symptomatology on the cytokine levels were scrutinized. In the whole study population, IL-1RA levels were higher in the subgroup with depressive symptomatology. In the males with depressive symptomatology, higher IL-1RA levels and lower interleukin-1 beta levels were observed as compared with the non-depressed males. The IL-1RA/IL-1 beta ratio was significantly higher in males with depressive symptomatology. The IL-1RA levels were also higher and IL-1 beta levels lower in the depressed females, but the trend was not significant. The elevated IL-1RA-levels and IL-1RA/IL-1 beta ratio suggest a role for cytokines in the pathogenesis of depression. The higher IL-1RA levels may reflect an endogenous repairing process against depression.

Differences in depressive thoughts between major depressive disorder, IFN-alpha-induced depression, and depressive disorders among cancer patients

OBJECTIVE

The objective of this study is to test the hypothesis that there are differences in the distribution of negative thoughts among major depressive disorders (MDD), depressive disorders among cancer patients, and IFN-alpha-induced depression.

METHODS

Twenty-three patients affected by MDD, 25 cancer patients affected by depressive disorders (20 MDD), and 19 patients affected by IFN-alpha-induced depression satisfying MDD criteria were evaluated using the 17-item Hamilton Depression Rating Scale and the 13-item Beck Depression Inventory.

RESULTS

Sense of guilt was higher among MDD patients (56.5%) and was lower among cancer patients (4%) (P<.0001). Sense of failure, dissatisfaction, and self-dislike were higher among MDD patients than among IFN-alpha patients (P<.0001).

CONCLUSIONS

In our study, patients affected by MDD present a different pattern of symptoms in comparison with patients affected by IFN-alpha-induced depression and depressive disorders. In particular, core depressive thoughts were less frequent in the last two conditions.

Early prediction of major depression in chronic hepatitis C patients during peg-interferon α-2b treatment by assessment of vegetative-depressive symptoms after four weeks

AIM: To study the predictive value of the vegetative-depressive symptoms of the Zung Depression Rating Scale for the occurrence of depression during treatment with peg-interferon α-2b of chronic hepatitis C (CHC) patients.

METHODS: The predictive value of vegetative-depressive symptoms at 4 wk of treatment for the occurrence of a subsequent diagnosis of major depressive disorder (MDD) was studied in CHC patients infected after substance use in a prospective, multi-center treatment trial in Belgium. The presence of vegetative-depressive symptoms was assessed using the Zung Scale before and 4 wk after the start of antiviral treatment.

RESULTS: Out of 49 eligible patients, 19 (39%) developed MDD. The area under the ROC curve of the vegetative Zung subscale was 0.73, P = 0.004. The sensitivity at a cut-point of > 15/35 was 95% (95% CI: 74-100). The positive predictive value equalled 44% (95% CI: 29-60).

CONCLUSION: In this group of Belgian CHC patients infected after substance use, antiviral treatment caused a considerable risk of depression. Seven vegetative-depressive symptoms of the Zung scale at wk 4 of treatment predicted 95% of all emerging depressions, at a price of 56% false positive test results.

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.

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.

Kynurenine pathway in major depression: evidence of impaired neuroprotection

The neurodegeneration hypothesis proposed major depression as a consequence of the imbalance between neuroprotective and neurodegenerative metabolites in the kynurenine pathway. To test the hypothesis, plasma tryptophan and kynurenine pathway metabolites were studied in 58 patients with major depression and 189 normal controls. The mean tryptophan breakdown index was higher (p=0.036), and mean kynurenic acid concentration and mean neuroprotective ratios were lower, in depressed patients (p=0.003 and 0.003, respectively). In receiver operating characteristic analysis, the kynurenic acid concentrations and the neuroprotective ratio showed clear discrimination between depressed patients and controls with area under the curve 79% and 76.3% respectively. The neuroprotective ratio did not change after treatment in those with repeated episodes of depression but it increased significantly (p=0.044) in those with first episodes. The results suggested that the reduction in neuroprotective markers, which indicated an impaired neuroprotection, might play an important role in pathophysiology of major depression.

Depression and anxiety

Anxiety and depression are common in patients with cancer and in palliative care settings. These symptoms can be reactive to the illness or can be related to the direct physiologic effects of the disease or to drug therapies. Effective treatment of these symptoms includes both psychopharmacologic and psychotherapeutic approaches. The newer antidepressants, anxiolytics, and hypnotics are better tolerated and can be continued safely if necessary, or they can be reduced and discontinued as symptoms improve.

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.