Hepatitis C Treatment: Clinical Issues for Psychiatrists in the Post-Interferon Era

Real-world effectiveness and safety of direct-acting antivirals in hepatitis C virus patients with mental disorders

BACKGROUND

It is estimated that 58 million people worldwide are infected with the hepatitis C virus (HCV). Patients with severe psychiatric disorders could not be treated with previously available interferon-based therapies due to their unfavorable side effect profile. This has changed with the introduction of direct-acting antivirals (DAA), although their real-life tolerance and effectiveness in patients with different psychiatric disorders remain to be demonstrated.

AIM

To evaluate the effectiveness and safety of DAA in patients with various mental illnesses.

METHODS

This was a retrospective observational study encompassing 14272 patients treated with DAA for chronic hepatitis C in 22 Polish hepatology centers, including 942 individuals diagnosed with a mental disorder (anxiety disorder, bipolar affective disorder, depression, anxiety-depressive disorder, personality disorder, schizophrenia, sleep disorder, substance abuse disorder, and mental illness without a specific diagnosis). The safety and effectiveness of DAA in this group were compared to those in a group without psychiatric illness (n = 13330). Antiviral therapy was considered successful if serum ribonucleic acid (RNA) of HCV was undetectable 12 wk after its completion [sustained virologic response (SVR)]. Safety data, including the incidence of adverse events (AEs), serious AEs (SAEs), and deaths, and the frequency of treatment modification and discontinuation, were collected during therapy and up to 12 wk after treatment completion. The entire study population was included in the intent-to-treat (ITT) analysis. Per-protocol (PP) analysis concerned patients who underwent HCV RNA evaluation 12 wk after completing treatment.

RESULTS

Among patients with mental illness, there was a significantly higher percentage of men, treatment-naive patients, obese, human immunodeficiency virus and hepatitis B virus-coinfected, patients with cirrhosis, and those infected with genotype 3 (GT3) while infection with GT1b was more frequent in the population without psychiatric disorders. The cure rate calculated PP was not significantly different in the two groups analyzed, with a SVR of 96.9% and 97.7%, respectively. Although patients with bipolar disorder achieved a significantly lower SVR, the multivariate analysis excluded it as an independent predictor of treatment non-response. Male sex, GT3 infection, cirrhosis, and failure of previous therapy were identified as independent negative predictors. The percentage of patients who completed the planned therapy did not differ between groups with and without mental disorders. In six patients, symptoms of mental illness (depression, schizophrenia) worsened, of which two discontinued treatments for this reason. New episodes of sleep disorders occurred significantly more often in patients with mental disorders. Patients with mental illness were more frequently lost to follow-up (4.2% vs 2.5%).

CONCLUSION

DAA treatment is safe and effective in HCV-infected patients with mental disorders. No specific psychiatric diagnosis lowered the chance of successful antiviral treatment.

Patients with severe mental illness and hepatitis C virus infection benefit from new pangenotypic direct-acting antivirals: Results of a literature review

INTRODUCTION

Hepatitis C virus (HCV) infection is a global health problem that can results in cirrhosis, hepatocellular carcinoma and even death. HCV infection is 3-20-fold more prevalent among patients with versus without severe mental illness (SMI), such as major depressive disorder, personality disorder, bipolar disorder and schizophrenia. Treatment options for HCV were formerly based on pegylated interferon alpha, which is associated with neuropsychiatric adverse events, and this contributed to the exclusion of patients with SMI from HCV treatment, elimination programmes, and clinical trials. Moreover, the assumption of poor adherence, scant access to healthcare and the stigma and vulnerability of this population emerged as barriers and contributed to the low rates of treatment and efficacy.

METHODS

This paper reviews the literature published between December 2010 and December 2020 exploring the epidemiology of HCV in patients with SMI, and vice versa, the effect of HCV infection, barriers to the management of illness in these patients, and benefits of new therapeutic options with pangenotypic direct antiviral agents (DAAs).

RESULTS

The approval of DAAs has changed the paradigm of HCV infection treatment. DAAs have proven to be an equally efficacious and safe option that improves quality of life (QoL) in patients SMI.

CONCLUSIONS

Knowledge of the consequences of the HCV infection and the benefits of treatment with new pangenotypic DAAs among psychiatrists can increase screening, referral and treatment of HCV infection in patients with SMI.

Study protocol: a randomised, controlled trial of a nurse navigator program for the management of hepatitis C virus in patients with severe mental disorder

Background

To evaluate the impact of a nurse navigation program on treatment adherence and resolution of hepatitis C infection in patients with severe mental disorder.

Methods

An open, randomized, controlled trial with blinded outcome assessment. The intervention group will engage in a nurse navigation program designed by mental health nurses. The program involves active screening for patients with severe mental disorder. The patients and caregivers included in the program will receive information, training, support and guidance throughout the treatment and recovery process, which involves different healthcare professionals and units. The control group will receive the standard of care, which includes follow-up by a family physician, referral to the hepatologist, serological testing, new referral to the hepatologist, onset of treatment, and follow-up. Multidisciplinary care will be provided along a coordinated and seamless clinical pathway led by a nurse navigator.

The primary endpoints are total recovery (hepatitis C cure) and treatment adherence. Occurrence of symptoms of schizophrenia and health-related quality of life will be also recorded. Follow-up of patients will be performed three and six months after the administration of antiviral treatment.

The study was authorised by the Ethics Committee of Malaga in December 2021. Funding was approved in March 2021.

Discussion

If this intervention is proven to be effective in improving treatment access and adherence, it will represent a step forward in addressing a chronic health issue that is 16 times more prevalent in the population with severe mental disease. Finally, this intervention may lead to the detection of undertreated HCV infection in this population of patients.

Trial registration

This protocol has been registered in ClinicalTrials.gov with identifier code NCT04891445 on May 18, 2021.

Hepatitis C virus in people with serious mental illness: An analysis of the care cascade at a tertiary health service with a pilot 'identify and treat' strategy

BACKGROUND

People with serious mental illness (SMI) are underserved from a hepatitis C Virus (HCV) screening and treatment perspective.

AIMS

To examine the HCV care cascade in people with SMI and to pilot a supported HCV treatment integration program.

METHODS

HCV prevalence was retrospectively analysed from 4,492 consecutive individuals admitted to a tertiary hospital mental health service between January 2017 and December 2018. Sub-cohort analysis of screening patterns and predictors of seropositive infection was performed. Referral pathways and community care integration were analysed for HCV positive individuals, and a prospective community-based 'identify and treat' HCV program was assessed.

RESULTS

Screening for HCV had been performed in 18.6% (835/4,492) of the cohort. Seroprevalence was 4.6% (207/4,492). HCV seropositivity was associated with age > 40-years (OR = 9.30, CI 3.69-23.45, p <0.01), injecting drug use (IDU) (OR = 24.26, CI 8.99-65.43, p <0.01), and previous incarceration (OR = 12.26, 4.51-33.31, p <0.01). In a cohort of treatment-eligible individuals, 43.3% (90/208) had neither been referred to specialist services or general practitioners for HCV management. Amongst those referred to specialist services, 64.7% (57/88) did not attend scheduled follow-up, and 48.3% (15/31) of attendees were lost to follow-up. Through an intensified community access program, 10 people were successfully treated for HCV, though 22 could not be engaged.

CONCLUSION

People with SMI are underserved by traditional models of HCV healthcare. Intensified community-based support can partially bolster the treatment cascade, though investment in innovative screening and management strategies are required to achieve healthcare parity. This article is protected by copyright. All rights reserved.

Depression in patients with chronic hepatitis-C treated with direct-acting antivirals: A real-world prospective observational study

BACKGROUND

Direct-acting antiviral (DAAs) therapy showed high safety and efficacy profile in patients with chronic hepatitis C (CHC) particularly those with previous or current psychiatric illness. The aim of this study was to evaluate the incidence and potential risk factors of depression and psychological distress following DAAs therapy in CHC euthymic Egyptian patients with no previous or current diagnosis of any psychiatric disorders.

METHODS

This is a prospective study that included 126 patients diagnosed with chronic hepatitis C virus genotype-4. Patients were candidate for DAAs therapy and were recruited consecutively (convenient sample) from the viral hepatitis center, Department of Endemic medicine, Kasr Al-Ainy Hospitals, Cairo University. Symptom Checklist 90-R, Beck Depression Inventory (BDI) and Structured Clinical Interview for DSM-IV (SCID IV) were performed at baseline and at 12 weeks post-treatment with DAAs.

RESULTS

Forty-seven patients were included in the final analysis. Depression severity increased after treatment as BDI scores increased significantly than baseline scores (p= < 0.001). About one third of patients (32%) had moderate to severe depression. All Symptom Checklist-90 scores showed significant increase after treatment.

LIMITATIONS

Dropout rate of patients for the 12 weeks post-treatment assessment was 33.8%.

CONCLUSION

Depression and psychological distress can occur with DAAs treatments. Close psychosocial assessment and patient monitoring are still needed.

Effectiveness and safety of direct-acting antivirals in hepatitis C infected patients with mental disorders: Results in real clinical practice

The aim of this study is to analyze the effectiveness and safety of direct-acting antivirals (DAAs) in psychiatric patients with chronic hepatitis C (CHC). Secondary objectives included adherence and drug-drug interaction (DDIs) evaluations. Prospective observational comparative study carried out during 3 years. Psychiatric patients were included and mental illness classified by a psychiatric team based on clinical records. Main effectiveness and safety variables were sustained virologic response (SVR) at posttreatment week 12 (SVR12) and rate of on-treatment serious drug-related adverse events (AEs), respectively. A total of 242 psychiatric and 900 nonpsychiatric patients were included. SVR12 by intention-to-treat (ITT) analysis of psychiatric vs nonpsychiatric patients was 92.6% (95% confidence interval [CI], 89.1-96.1) vs 96.2% (95% CI, 94.9-97.5) (P = .02). SVR12 by modified-ITT analysis was 97.8% (95% CI, 95.0-99.3) vs 98.4% (95% CI, 97.5-99.3) (P = .74). 92.2% of psychiatric patients with mental disorders secondary to multiple drug use (MDSDU) and 93.0% of psychiatric patients without MDSDU vs 96.2% of nonpsychiatric patients reached SVR12 (P = .05 and P = .20, respectively). The percentage of adherent patients to DAAs did not show differences between cohorts (P = .08). 30.2% of psychiatric patients and 27.6% of nonpsychiatric patients presented clinically relevant DDIs (P = .47). 1.7% vs 0.8% of psychiatric vs nonpsychiatric patients developed serious AEs (P = .39); no serious psychiatric AEs were present. DAAs have shown a slightly lower effectiveness in psychiatric patients with CHC, as a result of loss of follow up, which justifies the need for integrated and multidisciplinary health care teams. DAAs safety, adherence, and DDIs, however, are similar to that of nonpsychiatric patients.

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

Hepatitis C Pretreatment Profile and Gender Differences: Cognition and Disease Severity Effects

Background

The hepatitis C virus (HCV) is known to infect the brain, however, the findings based on associated neuropsychiatric syndrome are controversial and the association itself remains unclear. Gender research in HCV infection is limited, failing to integrate the role of gender differences in neurocognitive syndrome. The aim of this study was to characterize psychological and neurocognitive profiles in HCV-infected patients before treatment and to explore gender differences in those profiles, as well as the impact of disease severity.

Methods

A total of 86 patients diagnosed with chronic hepatitis C were included. Depression and anxiety were assessed using Hamilton anxiety scale (HAM-A), Hamilton depression scale (HAM-D), Beck Depression Inventory (BDI). For cognition, a neuropsychological battery to measure attention, concentration and memory was used, and executive function components validated for the Portuguese population was also used before starting treatment. To identify the disease severity, platelet ratio index, and FibroScan^® were used.

Results

A statistically significant gender effect was found on HAM-A (B = 0.64, CI: 0.17–1.11) and HAM-D (B = 0.62, CI: 0.14–1.09), with women scoring higher compared to men. Regarding neuropsychological scores, significant differences between gender were identified in executive functions measured by Trail Making Test (TMT B) (B = 0.48, CI: 0.02–0.97), TMT B-A (B = 0.26, CI: −39.2 to −3.7) and in digit span total (B = −0.52, CI: −1.0 to −0.04), with women performing worse than men. Controlling for years of substance dependence, TMT-B and TMT B-A showed significant gender differences. Regarding the presence or absence of substance dependence, only HAM-A and HAM-D remained significant. For categorical variables, Digit Span Total was also influenced by gender, with women being more likely to be impaired: odds ratio (OR) = 7.07, CI: 2.04–24.45), and a trend was observed for Digit Span Backward (OR = 3.57, CI: 1.31–9.75). No significant differences were found between disease severity and neurocognitive performance.

Conclusion

Data suggest that gender has an influence on depression, anxiety and cognitive functions with women showing greater impairment compared with men. This effect seems to be influenced by substance dependence.

Hepatitis C treatment outcomes among homeless-experienced individuals at a community health centre in Boston

BACKGROUND

Hepatitis C virus (HCV) infection prevalence is high among adults who experience homelessness but data on HCV treatment outcomes are limited in this population. We examined HCV treatment engagement and outcomes in a cohort of homeless-experienced adults treated through an innovative community-based primary care program in Boston, Massachusetts, USA.

METHODS

We conducted a retrospective chart review of individuals referred for HCV treatment at Boston Health Care for the Homeless Program (BHCHP) from January 2014 to March 2017. We assessed HCV treatment initiation, treatment completion, sustained virologic response (SVR), and reinfection rates. We conducted univariate and multivariable logistic regression analyses to examine the predictors of these outcomes.

RESULTS

Of 510 referred for HCV treatment, 210 (41.1%) did not initiate treatment, principally because of being lost to follow-up (N = 93) or having superseding social issues (N = 49). Of 300 who initiated treatment, 80% were male, 52.3% were non-white, and 29% were homeless. Over half (58.6%) had a history of opioid use disorder (OUD). Twenty percent had cirrhosis. Treatment was completed by 285 (95.0%) individuals, and 255 (85.0%) achieved SVR. In multivariable analyses, individuals with bipolar disorder (OR 0.38, 95% CI 0.15-0.99), treated (OR 0.36, 95% CI 0.14-0.96) or untreated (OR 0.18, 95% CI 0.05-0.57) OUD, or on-treatment insurance change (OR 0.16, 95% CI 0.04-0.67) were less likely to achieve SVR, while individuals living with HIV (OR 10.43, 95% CI 1.33-81.96) were more likely to achieve SVR. Among 126 individuals with post-SVR follow-up data, 27 reinfections were identified during 206 person-years of follow up (rate 13.1 per 100 person-years).

CONCLUSION

Homeless-experienced individuals initiating HCV treatment in a community-based program achieved high rates of treatment completion and SVR, but a large proportion did not initiate treatment. Individuals with OUD experienced lower but still substantial rates of cure. Treatment strategies targeting homeless-experienced people should focus on improving initial engagement and minimizing reinfection risk following treatment.

Impact of treatment with direct-acting antivirals on anxiety and depression in chronic hepatitis C

BACKGROUND AND AIM

Treatment of hepatitis C with direct-acting antiviral agents (DAA) has few side effects. Although pivotal studies suggested that DAA were safe in patients with psychiatric diseases who could not be treated with previous antiviral therapies, their effects on anxiety and depression have not yet been analysed in clinical practice. The aim of our study was to analyse anxiety and depression in the setting of DAA treatment in a clinical practice series.

METHODS

All patients starting DAA treatment between November 1, 2014 and October 31, 2015 were eligible. Patients completed the Hospital Anxiety and Depression scale at different times during treatment. The results were plotted on line graphs and evaluated using a linear regression model with repeated measures.

RESULTS

One hundred and forty-five patients were included (11% with major psychiatric disorders; 32% on psychiatric treatment). Sustained virologic response (SVR) was achieved in 97.3% of cases. Anxiety and depression measures did not differ between time points. No differences between patients on psychiatric treatment or with advanced fibrosis or cirrhosis were found at any time point analysed.

CONCLUSION

DAA treatment had no impact on anxiety or depression during or after chronic hepatitis C infection treatment, even in high-risk patients with major psychiatric disorders.

Evaluating psychiatric outcomes associated with direct-acting antiviral treatment in veterans with hepatitis C infection

Introduction:

Approximately 70% of veterans with hepatitis C virus infection have at least one psychiatric illness. The advent of direct-acting antiviral (DAA) therapy provided an alternative to interferon-alpha regimens and revolutionized treatment, however, the extent of psychiatric effects attributed to these agents are unclear. The primary objective of this pilot study was to prospectively analyze psychiatric outcomes, specifically depression, in veterans with hepatitis C virus infection who are initiated on DAA therapy.

Methods:

In this single center, prospective cohort study, psychiatric outcomes were analyzed using Patient Health Questionnaire assessments at baseline and weeks 4, 8, and 12 of complete DAA treatment. Outcome analysis were stratified based on specific DAA therapy and preexisting mental illness (mental health [MH] subjects and non-MH subjects), with a sub-analysis of major depressive disorder patients.

Results:

Analysis included 48 patients, majority males (96%), with a mean age of 59.4 years (±8.0). Twenty-four (50%) patients had a preexisting MH diagnosis, with major depressive disorder being the most common MH diagnosis (50%, n = 12). Despite a trend toward improvement, no significant changes in questionnaire scores after 12 weeks of DAA therapy were observed for all patient groups (P > .05). Neither MH subjects nor non-MH subjects displayed a significant change in questionnaire scores from baseline to end of treatment (P > .05). No patients required acute psychiatric interventions during DAA treatment.

Discussion:

Treatment with DAA therapy was not associated with psychiatric decompensation. Data from this pilot study supports the safe utilization of DAA therapy in hepatitis C virus patients with preexisting MH illness as it appears to be devoid of depressive and psychiatric side effects.

Psychosocial and Neurocognitive Factors Associated With Hepatitis C - Implications for Future Health and Wellbeing

Background: Hepatitis C virus (HCV) infection involves changes not only from the point of view of physical health, but also emotional, and social that have a significant impact on the quality of life of these patients. According to the literature review, it seems that there is an important association between psychosocial factors, in particular on a cognitive level and disease progression. The aim of this mini-review is to summarize recent literature looking at the associations between psychosocial and neurocognitive factors and HCV. Methods: PubMed/Medline was systematically searched for psychosocial and neurocognitive factors associated with hepatitis C, treatment adherence, and patient wellbeing. Results: Patients present with a range of extrahepatic symptoms including fatigue, anxiety, depression, and neurocognitive dysfunction. HCV's impact on quality of life and wellbeing has serious clinical and social implications. Conclusion: Hepatitis C and its management continue to have a profound impact on health and psychologic wellbeing. Considering the serious extrahepatic implications for individuals, it is imperative that healthcare professionals pay close attention to psychosocial and neurocognitive factors. The focus on combined clinical approaches could enhance understanding about the health and social impacts of hepatitis C along the life course.

The Effect of Psychosocial Factors on Success Rates of Hepatitis C Treatment

OBJECTIVE

Our study was to determine which psychosocial factors interfere with patients reaching sustained virologic response (SVR), a marker for hepatitis C virus eradication.

METHODS

A retrospective chart review was performed between January 6, 2015 and February 24, 2016. The primary outcome was to assess which social and psychological factors may interfere with patients reaching SVR. SVR was defined as having an undetectable viral load 12 weeks after the completion of the treatment regimen. Bivariate analysis was followed by a multivariate logistic regression analysis to determine significant factors for SVR. Depression and generalized anxiety disorder were included.

RESULTS

A total of 204 patients completed treatment within the designated time frame and were included in the final analysis. Social or home support was associated with SVR (odds ratio = 7.0, p = 0.02). Cocaine use was also a significant factor predicting SVR. Historical cocaine use compared with active cocaine use during treatment was associated with an odds ratio of SVR of 39.3 (p = 0.04). Interestingly, historical cocaine use vs no history of cocaine use did not influence SVR. No history of depression or generalized anxiety disorder was associated with a higher rate of SVR (odds ratio = 10.4, p = 0.05). No depression/generalized anxiety disorder compared with untreated depression/generalized anxiety disorder was associated with a 13.1 times greater rate of SVR (p = 0.04).

CONCLUSION

It is important to recognize and address psychosocial factors related to mental illness and active cocaine addictions before hepatitis C virus treatment. Furthermore, patients without home or social support are at greater risk for failing treatment, thus strategies to provide support during treatment are necessary.

Co-infection with HIV associated with reduced vulnerability to symptoms of depression during antiviral treatment for hepatitis C

In this prospective study, we examined new-onset major depressive disorder (MDD) and the differential expression of depressive symptoms in a sample of 132 HCV mono-infected and 40 HIV/HCV co-infected patients initiating pegylated interferon-based treatment, including protease inhibitor therapy. The semi-structured clinical interview (SCID-I) was used to assess MDD. Severity of depressive symptoms was assessed using the Hamilton Depression Rating Scale. Of the total sample, 60 patients (34.9%) developed SCID-I defined MDD during antiviral treatment. The proportion of HCV mono- and HIV/HCV patients developing MDD during treatment was not significantly different (37.9% vs. 25%; p=0.185). In both groups, there was a significant increase in HAMD total score from baseline to week 4, and a significant decrease between week 24 and 6 months post-treatment cessation. The greatest increase was observed in the symptoms of the neurovegetative syndrome. HCV mono-infected patients reported higher scores than co-infected patients, particularly impaired activity and somatic symptoms, but the differences were only significant at week 12. The finding that co-infected patients appear less vulnerable to the development of depressive symptoms during HCV treatment than HCV mono-infected patients warrants further exploration, including a thorough analysis of the biological and psychosocial factors associated with this emergence.