Effect of interferon-alpha treatment of chronic hepatitis C on health-related quality of life

Burden of psychological symptoms and disorders among individuals with hepatitis B: a systematic review, meta-analysis and meta-regression

Introduction

Hepatitis B is a highly contagious viral infection that has long been a significant global health concern. Given its adverse effects on the course of the disease, evaluating psychiatric outcomes is important. Despite indications of an increased risk of psychological outcomes among those with hepatitis B, the extent of this association remains unclear.

Methods

This PRISMA-adherent systematic review (PROSPERO: CRD42024564246) searched PubMed, Embase, Cochrane, and PsycINFO for all studies evaluating the prevalence and risk of anxiety and depressive symptoms in individuals with hepatitis B. Random effects meta-analyses and meta-regression were used for primary analysis.

Results

A total of 31 studies were included. We identified a high prevalence of depressive symptoms (Proportion=19%, 95% CI: 11-31) and anxiety (Proportion=30%, 95% CI: 18-45) among individuals with hepatitis B. There was also a significantly increased risk of depressive symptoms (RR=1.45, 95% CI: 1.00-2.09, P=0.049) and anxiety (RR=1.40, 95% CI: 1.11-1.78) in individuals with hepatitis B compared to controls. Subgroup analyses indicated that older age and chronic hepatitis B infection were associated with a higher prevalence of anxiety and depressive symptoms. The systematic review found that being single, unemployed, having a lower income, a lower education level, high comorbidities, and a family history of mental illness were significant risk factors for poorer psychological outcomes.

Conclusion

Our study highlights an increased vulnerability to anxiety and depressive symptoms among individuals with hepatitis B. We emphasize the urgent need for early detection and additional support for this at-risk group.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024564246.

Direct antiviral agents for chronic hepatitis C virus infection improve health-related quality of life significantly in the long term

Introduction

Direct antiviral agents (DAAs) are new drugs for the treatment of chronic hepatitis C virus (HCV) infection. These drugs are very effective and well tolerated. HCV can cause liver disease as well as extrahepatic manifestations, including a profound negative impact on health-related quality of life (HRQL).

Aim of the study

To evaluate HRQL in the long term (> 6 months after finishing treatment) after successful treatment with DAAs. To the best of our knowledge, this is the first study that evaluates quality of life in the long term after DAA treatment.

Material and methods

This is an observational study which included 100 patients treated with DAAs for chronic HCV infection between January 2015 and August 2018. Patients were assigned randomly. The average time after finishing treatment was 29.96 months. The Liver Disease Symptom Index (LDSI) 2.0 Questionnaire was used to evaluate quality of life before and after treatment.

Results

Seven of 9 parameters of the LDSI 2.0 Questionnaire showed significant improvement in the long term after successful treatment with DAAs. Two parameters (arthralgia and jaundice) did not improve significantly. Quality of life improved in both males and females similarly. Improvement did not correlate with the severity of liver fibrosis.

Conclusions

Treatment with DAAs improves HRQL significantly in the long term.

Cognitive impairment in patients with chronic hepatitis treated with interferon alpha (IFNα): results from a prospective study

Background.

Treatment with low-dose interferon alpha (IFN-α) is often associated with neuropsychiatric side effects. In addition to depression and anxiety, IFN-α associated cognitive impairment significantly affects patient’s mental health and quality of life.

Aims of the study.

To measure possible effects of low-dose IFN-α on cognitive functioning and its relationship to the development of depression and anxiety.

Method.

We prospectively followed 38 patients with a chronic hepatitis B or C by neuropsychological tests and psychiatric self-rating scales during 12 weeks of low-dose treatment with IFN-α.

Results.

Before IFN-α treatment, neuropsychological tests as well as self-ratings in the Beck’s Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS) and the Self-Report Symptom Inventory 90 Items-Revised (SCL-90-R) were within the normal range. Following 12 weeks of treatment with IFN-α resulted in a slight, but significant increase in depression scores. Neuropsychological assessment after 12 weeks of IFN-α treatment showed a significant decrease of the immediate recall in the Auditory-Verbal Learning Test (AVLT) and a significant reduction of words recited in the Controlled Oral Word Association Test (COWA). Cognitive impairment did not significantly correlate with depressive symptoms or anxiety.

Conclusion.

Our results indicate that even low-dose IFN-α induces cognitive impairment independent from depressive symptoms, which might be related to functional disturbances in the prefrontal cortex and the hippocampus. We suggest close monitoring of cognitive function during IFN-α treatment of chronic hepatitis.

Outcomes and costs of treating hepatitis C patients with second-generation direct-acting antivirals: results from the German Hepatitis C-Registry

OBJECTIVE

Chronic hepatitis C virus infection is associated with a significant health burden. Long-term consequences are the development of liver cirrhosis and hepatocellular carcinoma. The introduction of direct-acting antivirals (DAA) has led to an increase in sustained virologic response rates (SVR), but is accompanied by higher treatment costs. The aim of this study was to assess the outcomes and costs of treating hepatitis C virus infected patients with DAAs in clinical practice in Germany.

PATIENTS AND METHODS

Data were derived from a noninterventional study including a pharmacoeconomic subset of 2673 patients with genotypes 1 and 3 who initiated and completed treatment between February 2014 and February 2017. Sociodemographic and clinical parameters as well as resource utilization were collected using a web-based data recording system. Costs were calculated using official remuneration schemes.

RESULTS

The mean age of the patients was 54.6 years; 48% were men. 93.5% of all patients achieved an SVR. The average total treatment costs were &OV0556;67 979 (&OV0556;67 131 medication costs, &OV0556;824 ambulatory care, &OV0556;24 hospital costs). The average costs per SVR of &OV0556;72 705 were calculated. Differences in SVR and costs according to genotype, treatment regimen, treatment experience, and cirrhosis were observed. Quality-of-life data showed no or a minimal decrease during treatment.

CONCLUSION

This analysis confirms high SVR rates for newly introduced DAAs in a real-world setting. Costs per SVR estimated are comparable to first-generation DAA. Given the fact that the costs for the currently used treatment regimens have declined, it can be assumed that the costs per SVR have also decreased. Our insight into real-world outcomes and costs can serve as a basis for a comparison with the mentioned newly introduced treatment regimens.

Socioeconomic Vulnerability to Depressive Symptoms in Patients with Chronic Hepatitis B

Depression is considered one of the most prevalent psychiatric disorders among patients with hepatitis B virus (HBV)-related liver disease and has adverse effects on the disease progression. However, there is a scarcity of studies contributing to the assessement of depression in hepatitis B patients. There is also little research into risk factors, particularly underlying socio-economic factors in Vietnam where the prevalence of hepatitis B is high. This study aimed to examine depression and identify whether differences in socio-economic status is related to the level of depression amongst chronic hepatitis B patients. A cross-sectional study was conducted on 298 patients with chronic hepatitis B at The Chronic Hepatitis Clinic in the Viet-Tiep Hospital, Hai Phong, Vietnam. The Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 dimensions-5 levels (EQ-5D-5L) were used to assess the severity of depression and health-related quality of life (HRQOL). Of chronic hepatitis B patients, 37.5% experienced depressive symptoms and most of them suffered minimal depressive symptoms (31.4%). According to the result of the multivariate logistic regression model, we found that higher age, lower income level, unemployement, living with spouse/partners were positively associated with having depression. Furthermore, having physical health problems and lower health-related quality of life were also related to a higher risk of depression. We recommend family support, financial support and active participation in consultation should be conducted during treatment to improve the quality of life and the emotional state of HBV patients.

Prevalence of Major Depression and Its Associations With Demographic and Clinical Characteristics and Quality of Life in Chinese Patients With HBV-related Liver Diseases

BACKGROUND

There are no data about the frequency of major depression in patients with liver disease related to Hepatitis B virus (HBV) in China. This study examined the prevalence of major depression and its clinical correlates and association with quality of life (QOL) in patients with HBV-related liver diseases.

METHOD

Altogether 634 patients with HBV-related liver diseases met study entry criteria and completed the survey. The diagnosis of major depression was established with the Mini International Neuropsychiatric Interview (MINI). Socio-demographic and clinical characteristics, Global Assessment of Functioning (GAF) and QOL were measured.

RESULTS

The prevalence of major depression was 6.4%. Multivariable logistic regression analyses revealed that insomnia (P=0.01, OR=5.5, 95%CI=1.4-21.6) and global functioning (P<0.001, OR=0.6, 95% CI=0.5-0.7) were independently associated with major depression. Major depression was associated with both poor physical (F _{(1, 634)}=4.0, P=0.04) and mental QOL (F _{(1, 634)}=26.2, P<0.001).

CONCLUSIONS

Given the negative impact of depression on patients' QOL, more attempts should be made to identify and treat it in HBV-related diseases.

Interferon α Therapy in Patients with Chronic Hepatitis C Infection: Quality of Life and Depression

Health-related quality of life was examined in 49 patients with hepatitis C virus with no psychiatric history who received interferon (IFN)-α treatment. Quality of life was assessed at baseline, at 3-time points during IFN-α therapy and at 1-6 month follow-up, using SF-36. Hepatitis C virus patients showed poorer physical functioning and better social and mental functioning than a normal population. Significant decreases from baseline SF-36 scores were observed at an early phase of treatment. Six patients developed major depression during IFN-α treatment. At baseline, they had reported more bodily pain than patients who did not develop depression during treatment. Planned contrasts revealed that worsening in some dimensions of quality of life at 2 months was greater in depressed than in non-depressed patients. Results suggest that depressive symptoms should be accurately monitored during IFN-α therapy even in patients with no psychiatric history, especially if they present with bodily pain.

Natural history of hepatitis C

There has long been evidence that hepatitis C can lead to persistent infection in a high proportion of infected individuals, and can progress to chronic liver disease, cirrhosis and hepatocellular carcinoma (HCC). The transition from acute to chronic hepatitis C is usually sub-clinical. Accurate studies of the time course for clearance of acute hepatitis C are difficult to carry out because of the silent onset of the acute disease. The likelihood of spontaneous HCV resolution is associated with several genetic factors, including IL28B inheritance and the DQB1*0301 allele of the major histocompatibility complex class II. Most data suggest that resolution in the acute phase without progression to chronic disease is not accompanied by significant disease, but minor histological lesions have been observed in anti-HCV positive, HCV RNA negative individuals. The risk of reinfection remains a possibility after clearance of acute hepatitis C. High rates of sexually-transmitted infection are being reported in HIV positive men who have sex with men (MSM). Chronic infection with HCV is the leading cause of end-stage liver disease, hepatocellular carcinoma (HCC) and liver related death in the Western world. The natural history of the chronic disease remains incompletely defined. It is generally a slowly progressive disease characterized by persistent hepatic inflammation, leading to the development of cirrhosis in approximately 10-20% of patients over 20-30 years of HCV infection. However, the published data indicate varying progression rates to cirrhosis. Overall, once cirrhosis has developed there is a 1-5% annual risk of HCC and a 3-6% annual risk of hepatic decompensation. Following an episode of decompensation the risk of death in the following year is between 15% and 20%. The high number of chronically infected individuals, the burden of disease, and the absence of a vaccine indicates that treatment will form part of the disease control but the impact, effectiveness and outcomes of treatment in various groups remain uncertain. Several studies and meta-analysis have concluded that eradication of HCV with antiviral therapy reduces the risk of HCC in patients with chronic hepatitis C, independent of fibrosis stage, but the risk is not eliminated.

Quantifying serotonin transporters by PET with [11C]-DASB before and after interferon-α treatment

BACKGROUND

Interferon-α (IFN-α) therapy is frequently associated with disabling depression, fatigue, and related neuropsychiatric effects. Although depression in major depressive disorder is associated with low serotonin transporter binding, animal models suggest that IFN-associated mood effects are linked to increased presynaptic serotonin transporter binding. This study tested the hypotheses that IFN administration to human subjects increases presynaptic serotonin binding activity, and that this effect correlates with incident depression symptoms.

METHODS

Positron emission tomography (PET) scans using [11C]-DASB were obtained for nine hepatitis C patients before and after IFN-α treatment for 8 weeks. Serotonin transporter binding was estimated using the likelihood estimation in graphical analysis (LEGA) model and measured as the volume of distribution (VT) divided by the free fraction of ligand (fP). Depression was measured with the Structured Clinical Interview for DSM-IV Diagnosis (SCID) and the Hamilton Rating Scale for Depression (HAM-D).

RESULTS

Compared to pre-IFN treatment values, changes in serotonin transporter binding and depression symptoms were not significant. There was no correlation between changes in serotonin transporter binding and depression symptoms.

LIMITATIONS

The study is limited by small sample size, minimal effect on observed mood symptoms within the sample, and brief duration of follow-up.

CONCLUSION

These findings do not support the hypothesis of an IFN-induced change in serotonin transporter function as the cause of incident depressive symptoms in patients treated with IFN-α. Additional study of these possible relationships should be of longer duration and include more subjects with more pronounced changes in mood.

A Preliminary Study on the Relationship between Platelet Serotonin Transporter Functionality, Depression, and Fatigue in Patients with Untreated Chronic Hepatitis C

Objective and Methods. Although the interaction between fatigue and depression in patients with chronic hepatitis C infection (HCV) has been recognized, the biological correlates of this observation have yet to be reported. We addressed this issue by examining serotonin transporter- (SERT-) driven [(14)C]-serotonin uptake rate (SUR) and serotonin content in platelets of 65 untreated HCV patients and 65 healthy control subjects (HCS). All patients completed report questionnaires for fatigue, depression, and general psychopathology. Structured interviews were conducted by a board-certified psychiatrist. Results. Whereas 36 of the patients experienced fatigue of moderate-to-severe intensity, only 16 reported symptoms of depression (BDI score > 10). Mean SUR in patients with depressive symptoms was significantly higher relative to the HCS, corresponding to a large Cohen's effect size of d = 1.45 (95% CI = 0.66-1.83). Patients who rated their fatigue to have a marked impact on mood and activity displayed a moderate relationship between the BDI score and SUR (n = 18, r = 0.563, P = 0.015), which becomes stronger after controlling for age, gender, and thrombocytopenia (r part = 0.710, P = 0.003). In the univariate analysis, high fatigue interference score, thrombocytopenia, and high SUR were all significant predictors of depression. Conclusions. High SERT activity could be implicated in the expression of depressive symptoms especially in a subgroup of HCV patients who are feeling fatigue as markedly distressing.

Health-related quality of life in genotype 1 treatment-naïve chronic hepatitis C patients receiving telaprevir combination treatment in the ADVANCE study

BACKGROUND

Chronic hepatitis C virus (HCV) infection and its treatment impact patients' health-related quality of life (HRQL).

AIM

To report on treatment impact and predictors of HRQL among treatment-naïve patients with genotype 1 chronic HCV infection who received 12-week telaprevir (T) with 24 (T12PR24) or 48 weeks (T12PR48) peginterferon alpha-2a/ribavirin (PR), or 48 weeks of PR in the ADVANCE study.

METHODS

The EQ-5D-3L (EQ-5D) questionnaire (index range: 0-1) was completed at baseline and weeks 4, 12, 24, 36, 48 and 72. Patients indicated their health state on five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Descriptive statistics for the EQ-5D index and descriptive system and area under the curve from baseline to week 12 were calculated. Predictors of EQ-5D index were identified using multivariate analyses.

RESULTS

Data from 722 patients were included. The mean EQ-5D index decreased during the first 12 weeks and returned to baseline by week 72 (T12PR24 by week 36) across treatments. In multivariate analysis, sustained virological response (SVR) at week 72 was associated (P < 0.0001) with improved EQ-5D index [mean; SVR+ (0.90), SVR- (0.86)], a 4% difference, within the published range of minimal clinically important difference.

CONCLUSIONS

Post hoc analyses of data from ADVANCE suggested that HRQL worsened during the first 12 weeks of therapy and returned to baseline by week 72 across treatments. Improvements were observed early following completion of a 24-week treatment (T12PR24). Telaprevir combination therapy was associated with slightly higher reductions in HRQL during the first 12 weeks (vs. PR). SVR was a statistically significant and meaningful predictor of HRQL at week 72.

Predictors of mental and physical health in non-cirrhotic patients with viral hepatitis: a case control study

OBJECTIVE

To identify independent predictors of mental and physical health in patients with viral hepatitis.

METHODS

Hepatitis C (HCV) and hepatitis B (HBV) infected patients, and community control subjects with equal age and sex distribution were recruited. All subjects filled in personal characteristics questionnaire, Hospital Anxiety and Depression Scale (HADS), Iowa Fatigue Scale (IFS), and Medical Outcomes Survey Short Form-12 (SF-12). All patients had measurement of routine laboratory values, and some had recent liver biopsy. Regression analyses were used to identify predictors of physical and mental health.

RESULTS

One hundred eighty nine subjects (162 males, 27 females, for each group N=63) with mean (±SD) age of 39±11years were included. Anxiety and depression were important predictors of SF-12 (and its subscales MCS and PCS) and IFS scores, whereas IFS scores independently predicted HADS, PCS, MCS, and SF-12 scores. After controlling for confounders, HCV infection was independently associated with impairment of physical health. Moreover, creatinine showed an inverse strong relation with fatigue. Genotype 3a of HCV was independently associated with depressed and anxious states, whereas higher inflammation grade was significantly related to depression. Marital status, non-psychiatric comorbidities, and history of alcohol abuse also predicted health scores in the patients. Adjusted R(2)s for linear models were 0.571 to 0.709, whereas areas under the receiver operating characteristic (ROC) curve for logistic models were 0.90 to 0.93.

CONCLUSION

In viral hepatitis patients, besides mental and medical comorbidities, marital status, and alcohol abuse, HCV infection itself is associated with impaired physical and possibly mental health.

Tobacco and other factors have a negative impact on quality of life in hepatitis C patients

Hepatitis C virus (HCV) is known to adversely affect general, social, emotional and mental health domains. This study was designed to identify variables that may be associated with these measurable outcomes. We conducted a cross-sectional retrospective review of demographic and clinical data from 800 patients with HCV evaluated between January 1998 and November 2007. Data were collected using a standardized questionnaire filled out by the patients at the first encounter. Variables evaluated included fibrosis stages (i.e. FS0/1/2 vs FS3/4), demographics, comorbid health conditions, tobacco and alcohol use, high-risk social behaviours and laboratory data. Variables assessed were depression, fatigue, problems sleeping and loss of interest in sex. Statistical analysis was performed using univariate and multivariate logistic regression. Depression (29.3%) in our HCV study population was associated with female gender, tobacco use, hyperlipidemia, history of heavy alcohol use and intravenous drug use. Fatigue (44.6%) was associated with end-stage renal disease, past and current tobacco use and current alcohol use. Difficulty sleeping (13.8%) was associated with past and current tobacco use, current alcohol use and diabetes. Loss of interest in sex (7.7%) was associated with current tobacco use, multiple risk factors for HCV and age at time of evaluation. Fibrosis stage (FS) also had a significant positive association with alcohol use (OR 2.61; P = 0.003) and tobacco use (OR 2.00; P = 0.002). Smoking and alcohol use have a significant negative impact on the presence of depression, fatigue, difficulty sleeping and loss of interest in sex in HCV patients. Practitioners should be aware of these associations, particularly tobacco use, which significantly and negatively impacted every variable evaluated.

Psychological and biological mechanisms of cytokine induced depression

Depression is frequently seen in patients with medical illnesses yet the link between medical illnesses and depression remains unclear. There is increasing data to suggest that the array of depressive symptoms experienced by the medically-ill may involve inflammation. The activation of the immune system and the subsequent release of innate immune products such as cytokines can have important effects on behaviour. The treatment of choice for chronic viral hepatitis C, interferon-alpha IFN-α, acutely induces the production and release of other innate immune cytokines, and has been indicated to cause clinically significant depression in 30% of patients receiving treatment. This in turn can impair quality of life and affect treatment compliance. We and others use IFN-α induced depression as a model to identify alterations in psychological and biological pathways that predispose to depression in the medically-ill, and thus provide an explanatory link between inflammation and the subsequent behavioural changes. In this editorial, we aim to describe the main biological pathways involved in IFN-induced depression and to discuss psychological, clinical and biological factors that have been found to predict those who will develop more severe psychiatric symptoms during treatment with IFN-α. Among these, particular attention would be given to psychological traits, genetic polymorphisms regulating inflammation and serotonergic function, and changes in plasma levels of pro-inflammatory cytokines.

Risk factors for the development of depression in patients with hepatitis C taking interferon-α

Interferon-α, currently used for the treatment of hepatitis C, is associated with a substantially elevated risk of depression. However, not everyone who takes this drug becomes depressed, so it is important to understand what particular factors may make some individuals more 'at risk' of developing depression than others. Currently there is no consensus as to why interferon-induced depression occurs and the range of putative risk factors is wide and diverse. The identification of risk factors prior to treatment may allow identification of patients who will become depressed on interferon, allowing the possibility of improved treatment support and rates of treatment adherence. Here, we consolidate and review the literature on risk factors, and we discuss the potential confounds within the research examined in order to better isolate the risk factors that may be important in the development of depression in these patients and which might help predict patients likely to become depressed on treatment. We suggest that interactions between psychobehavioral, genetic, and biological risk factors are of particular importance in the occurrence of depression in patients with hepatitis C taking interferon-α.

What can post-mortem studies tell us about the pathoetiology of suicide?

Suicide is a major public health concern; however, its neurobiology is unclear. Post-mortem brain tissue obtained from suicide victims and normal controls offers a useful method for studying the neurobiology of suicide. Despite several limitations, these studies have offered important leads in the neurobiology of suicide. In this article, we discuss some important findings resulting from these studies, focusing on serotonergic mechanisms, signal transduction systems, neuroendocrine studies and immune function abnormalities in suicide. These studies suggest that abnormalities of certain receptor subtypes, components of signaling systems such as protein kinase C and protein kinase A, transcription factors such as cyclic AMP response element-binding protein and neurotrophins may play an important role in the pathophysiology of suicide. These studies also suggest abnormalities of hypothalamic-pituitary-adrenal axis system components, feedback mechanisms and cytokines, which are chemical mediators of the immune functions. Post-mortem brain tissue offers an opportunity for future studies, such as genetic and epigenetic studies.

Thymosin alpha 1 for treatment of hepatitis C virus: promise and proof

The hepatitis C virus (HCV) is a global public health problem, with chronic infection leading to development of cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC). Treatment of HCV is suboptimal with overall response rates of slightly greater than 50% when patients are treated with pegylated interferon alfa and ribavirin. Thymosin alpha 1 (Talpha1; TA-1) is an immunomodulatory peptide with intrinsic activities that might improve treatment outcomes for HCV by incorporation of this agent in current treatment paradigms. An extensive body of literature supports a possible role for this agent in difficult to treat populations. However, clinical trials to date have failed to conclusively support the role of TA-1 in combination interferon-based therapies. Therefore, the promise of TA-1 adjunctive therapy for HCV remains, but the proof will require investment in large randomized clinical trials of appropriate patient populations.

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

OBJECTIVE

To review the literature about the efficacy of antidepressant prophylaxis during interferon-alpha (IFN-alpha) therapy.

METHOD

We have performed a database search in PUBMED and ISI Web of Knowledge (1980-August 2009) for the available literature. The keywords "prevention" or "prophylaxis", and "depression", and "interferon", and "antidepressant" or "antidepressive agents" were used.

RESULTS

The six eligible studies comprise three randomized controlled trials, two in hepatitis C virus (HCV) patients and one in individuals with melanoma, and three open-label studies with HCV patients. The results of the randomized controlled trials suggest that antidepressant prophylaxis may blunt the magnitude of depressive symptoms in HCV patients and raise the rates of treatment completion. In melanoma patients, this preventive strategy may reduce the incidence of depression during IFN-alpha treatment. In addition, the open-label studies with HCV patients suggest that this strategy may reduce the onset of major depression in specific samples (current psychiatric diagnosis, major depression in remission, past history of IFN-alpha-induced depression) on IFN-alpha (re-)treatment.

CONCLUSIONS

In the face of so few trials about the usefulness of prophylaxis with antidepressants before IFN-alpha treatment, there is not enough information to sufficiently and widely support this strategy to prevent depression. However, this approach may, nonetheless, bring some beneficial outcomes, if applied to specific patient groups.

Effect of long-term late-evening snack on health-related quality of life in cirrhotic patients

AIM

In patients with liver cirrhosis, abnormal energy metabolism induces low health-related quality of life (HRQOL) scores. However, late-evening snack (LES) prevents morning starvation in cirrhotic patients. Our aim is to assess the effect of long-term LES on HRQOL in cirrhotic patients, using the 36-item Short Form (SF-36) health survey.

METHODS

Thirty-nine cirrhotic patients classified as Child-Pugh grade A were recruited. The patients were randomly divided into two groups: 24 were assigned to the non-LES group and 15 to the LES group. SF-36 scores, anthropometric data and serum biochemical parameters were examined in the non-LES and LES groups at 0, 6 and 12 months.

RESULTS

Neither anthropometric data nor laboratory data showed significant differences between the non-LES and the LES groups at 0, 6 and 12 months. The role-emotional (RE) HRQOL scores at 6 months and mental health (MH) scores at 6 and 12 months were significantly reduced from the baseline level in the non-LES group. In contrast, these scores remained unchanged in the LES group. General health perception (GH) scores at 12 months, RE at 6 months and MH at 6 and 12 months in the LES group were significantly higher than those of the non-LES group.

CONCLUSION

Long-term LES administration may be helpful in maintaining higher HRQOL in patients with cirrhosis.

Changes in quality of life and sexual health are associated with low-dose peginterferon therapy and disease progression in patients with chronic hepatitis C

BACKGROUND

Primary analysis of the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (HALT-C) Trial showed long-term peginterferon therapy did not reduce complications in patients with chronic hepatitis C and advanced fibrosis or cirrhosis.

AIM

To assess the effects of long-term peginterferon therapy and disease progression on health-related quality of life (HRQOL), symptoms and sexual health in HALT-C patients.

METHODS

A total of 517 HALT-C patients received peginterferon alfa-2a (90 microg/week); 532 received no additional treatment for 3.5 years. Patients were followed up for outcomes of death, hepatocellular carcinoma and hepatic decompensation. Sexual health, SF-36 scores and symptoms were serially assessed by repeated-measures analyses of covariance.

RESULTS

Patients with cirrhosis (n = 427) reported lower general well-being and more fatigue (P < 0.001) than patients with fibrosis (n = 622). Physical scores declined significantly over time, independent of treatment, and patients with cirrhosis reported lower scores. Vitality scores were lower in those with cirrhosis, and treated patients experienced a greater decline over time than untreated patients; HRQOL rebounded after treatment ended. Patients with a clinical outcome had significantly greater declines in all SF-36 and symptom scores. Among men, Sexual Health scores were significantly worse in treated patients and in those with a clinical outcome.

CONCLUSION

Clinical progression of chronic hepatitis C and maintenance peginterferon therapy led to worsening of symptoms, HRQOL and, in men, sexual health in a large patient cohort followed up over 4 years (NCT00006164).

Psychosocial issues and mental health treatment recommendations for patients with hepatitis C

BACKGROUND

Mental health needs of patients with HCV are increasingly being addressed in medical contexts.

OBJECTIVE

The authors review the psychosocial issues relevant to patients with hepatitis C and provide mental health treatment recommendations.

FINDINGS

Patients with HCV are faced with a number of challenges, including adjustment to a chronic medical illness, management of symptoms and treatment side effects, and making and maintaining lifestyle changes. Given these issues, mental health clinicians have the opportunity to make a significant contribution to patient care.

CONCLUSION

After reviewing the relevant research on these psychosocial issues, the authors have identified areas in which clinicians can intervene; these include adjustment to having a chronic medical illness, coping with stigma and relationship changes, management of side effects, and implementing healthy lifestyle changes.

Psychiatric problems in patients infected with hepatitis C before and during antiviral treatment with interferon-alpha: a review

OBJECTIVE

Neuropsychiatric symptoms are common in patients with chronic hepatitis C (CHC) and can potentially be exacerbated by interferon-alpha treatment. Such symptoms can contribute to problems with treatment adherence, which can significantly compromise epidemiological virus control. This review summarizes current knowledge about the etiology, course, and management of neuropsychiatric symptoms in patients with CHC.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULTS

Psychopathological syndromes that occur during interferon-alpha treatment frequently have atypical features that may complicate their recognition using standard diagnostic criteria. In addition, prospective studies in this area often exclude patients with psychiatric disorders and have methodological disparities that make it difficult to develop guidelines for management of psychiatric side effects induced by interferon-alpha. Despite the high prevalence of chronic hepatitis C virus (HCV) infection in patients with psychiatric and substance use disorders, neuropsychiatric concerns often lead to the exclusion of such patients from interferon-alpha treatment, inappropriately depriving them of the potential benefits of this therapy.

CONCLUSION

Consultation-liaison psychiatrists should become familiar with the clinical spectrum of presentations associated with HCV infection as well as with related neuropsychiatric symptoms in order to promote the creation of multidisciplinary teams who specialize in the care of patients with HCV infections. More studies are needed to define neuropsychiatric syndromes that can be induced by interferon-alpha and to clarify best assessment and treatment procedures for these syndromes. It is also important to create and evaluate psychoeducational programs for all patients with chronic HCV infections, even those with low risk of complications, in order to promote adherence to therapy and optimize patients' quality of life.

Quality of life is not related with liver disease severity but with anemia, malnutrition, and depression in HCV-infected hemodialysis patients

Hepatitis C virus (HCV) infection may deteriorate quality of life. The relationship between HCV infection and quality of life in hemodialysis (HD) patients is unknown. The demographic characteristics, comorbidities, biochemical parameters, and Malnutrition-Inflammation Score (MIS) were recorded. Child-Pugh classification, Beck Depression Inventory, and SF-36 were performed. Liver histopathology was examined. Thirty-two patients (21 Child-Pugh-A, 11 Child-Pugh-B) were included. There was high-grade portal necroinflammatory activity in 14, high-grade lobular necroinflammatory activity in 26, and hepatic fibrosis in 19 patients. Three patients had cirrhosis. Patients with a high stage of liver fibrosis had lower social functioning scores than patient with a low stage of fibrosis (P= 0.011). The only correlation was between aspartate aminotransferase and the physical function subscale (r=-0.395, P= 0.025). None of the SF-36 scores differed between Child-Pugh A and B patients. Instead, most of the SF-36 subscale and summary scores were related with hemoglobin, albumin, MIS and Beck Depression Score. Quality of life in HCV-infected HD patients was independent of liver disease severity anchors, but was correlated with anemia, malnutrition, and depression.

Occurrence, course and risk factors of depression during antiviral treatment for chronic hepatitis C in patients with inherited bleeding disorders: a prospective study

Treatment of hepatitis C virus (HCV) consists of pegylated interferon (IFN)-alpha and ribavirin for 24 or 48 weeks. An important side-effect of IFN-alpha is depression. The occurrence, course and risk factors of depression during antiviral treatment were studied prospectively in HCV patients with inherited bleeding disorders. The Beck Depression Inventory, indicating no, mild, moderate or severe depression, was administered to 47 patients before starting therapy, after 4, 12, 24 and 48 weeks of treatment, and 4 weeks after cessation of therapy. At baseline, five patients (11%) had mild depression. Depression worsened during treatment in three of these patients. In all five patients, (mild) depression persisted 4 weeks after treatment. Of the remaining 42 patients, 23 (55%) developed depression during treatment (14 mild, eight moderate and one severe), mostly (78%) during the first 12 weeks. Four weeks after cessation of treatment, three of 23 patients still had mild depression. The only independent risk factor for development of depression was a history of depression or other psychiatric problems (odds ratio 9.7). For patients with inherited bleeding disorders, depression is a significant, mostly transient, problem during HCV treatment. We recommend close monitoring of patients, especially those with previous psychiatric problems, to ensure adequate detection and treatment of depression during antiviral therapy.

Living with hepatitis C: qualitative interviews with hepatitis C-infected veterans

BACKGROUND

Chronic hepatitis C (HCV) infection affects millions of people in the USA and prevalence rates are higher in US veterans. The consequences of HCV infection include reduced quality of life, liver damage, and reduced longevity.

OBJECTIVE

Our objective was to describe the experiences of US veterans living with chronic HCV infection and use this information in the development of an HCV self-management intervention.

METHODS

Twenty-two male HCV-infected veterans completed qualitative interviews. Participants were recruited via flyers and hepatitis C clinic providers at a major VA medical center. Participants were asked about their medical history, being diagnosed with HCV, and general experiences living with HCV.

RESULTS

The study gathered the following findings: the impact of HCV on interpersonal relationships was pronounced, recovery from substance use disorders and getting care for HCV were connected, receiving the HCV diagnosis was more troubling to non-IV drug users, participants had misconceptions about HCV and its treatment, psychological problems were prevalent as were barriers to participating in antiviral treatment and HCV care in general.

CONCLUSION

The themes derived from our analysis indicate that affected veterans may benefit from interventions or support to improve HCV-related health education, social/relationship issues, psychological issues, and exploration of the connection between substance use recovery and motivation to get care for HCV infection.

Factors associated with quality of life in chronic hepatitis C patients who received interferon plus ribavirin therapy

BACKGROUND/PURPOSE

Antiviral treatment leading to impaired quality of life in chronic hepatitis C patients has been reported in the West. To promote high quality care, we explored the quality of life in Taiwanese chronic hepatitis C patients treated with antiviral therapy by means of comparing quality of life, social support and its factors.

METHODS

One hundred and fifteen patients with chronic hepatitis C, enrolled from hospitals in Central Taiwan, were treated with interferon plus ribavirin. A structured questionnaire was used for data collection, including the Hepatitis Quality of Life Questionnaire (HQLQ), Inventory of Socially Supportive Behaviors (ISSB) and clinical demographics. The data were analyzed by the methods of means, correlation and regression.

RESULTS

The study patients included 60 men (52.2%) and 55 women (47.8%), with 98 (85.2%) older than 40 years. The drug expenses of 71 (61.7%) patients were paid for by the Bureau of National Health Insurance of Taiwan. The patients had a low mean HQLQ score of 58.13 +/- 17.21. Three scales which had HQLQ scores below 50 were general health perceptions (49.39), vitality (49.32) and role disability: physical (47.48). The mean ISSB score was 71.15 +/- 19.61. Only financial stress (p = 0.006) had significant difference in HQLQ. Treatment duration (r = -0.23) correlated negatively with the general health domain of HQLQ, and tangible support (r = -0.21) correlated negatively with HQLQ scales. Financial stress and tangible support were significant predicting variables for HQLQ.

CONCLUSION

The study found that patients with chronic hepatitis C who received interferon plus ribavirin therapy had poor quality of life during the treatment period. There was significant difference among patients with different financial stress, and a negative relationship between tangible support and hepatitis quality of life. Financial stress and tangible support are predictors of quality of life for all subjects. The results of this study might assist healthcare personnel to comprehend the quality of life and its related factors in patients with chronic hepatitis C treated with antiviral therapy.

Depression following pegylated interferon-alpha: characteristics and vulnerability

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of chronic hepatitis C on health-related quality of life in homeless and marginally housed individuals with HIV

Although infection with Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) frequently co-exist, there has been little research to determine the effects of HIV/HCV co-infection on health-related quality of life (HRQOL). We performed a cross-sectional analysis of baseline data from 216 participants enrolled in a community based study of HIV-infected homeless and marginally housed individuals, using multivariable linear regression analysis to determine if co-infection with HCV was independently associated with lower short-form 36 (SF-36) questionnaire scores. We found that individuals with HCV had significantly lower mean SF-36 scores in the domains of physical functioning, bodily pain, social functioning and role limitation due to emotional health, and that HIV/HCV co-infection was independently associated with a lower physical component score but not a lower mental component score after controlling for numerous covariates. These results suggest that co-infection with HCV may have an adverse effect on HRQOL among homeless and marginally housed individuals with HIV.

Psychiatric morbidity and its effect on the quality of life of patients with chronic hepatitis B and hepatitis C

OBJECTIVE

The primary aim of our study was to determine the prevalence of psychiatric morbidity in a cohort of consecutive chronic hepatitis patients not receiving antiviral therapy. The secondary aim of our study was to determine if psychiatric morbidity, type of hepatitis, and the level of depression correlated with health-related quality of life (HRQL).

METHODS

The study was conducted in collaboration with Hepatology and Infectious Disease Clinics at three-major university hospitals. One hundred seven patients who met the criteria for being diagnosed with either chronic hepatitis B or C, had non-cirrhotic compensated liver disease, had not received antiviral treatment in the preceding 6 months, and had no accompanying physical illness were included in the study. The Structured Clinical Interview for DSM-IV Axis I Disorders, the Short Form--36 for measuring HRQL, and semi-structured interviews for assessing psychosocial variables were used. Sixty-seven healthy adults formed the control group.

RESULTS

43.9% of the patients had hepatitis B, 56.1% hepatitis C. A psychiatric diagnosis was made in 48.6%, of which 15% was depression. No significant difference was found in the rate of psychiatric diagnosis between hepatitis B and hepatitis C patients. Hepatitis B and C patients were found to vary significantly (p < 0.001) from the control group on all subcategories of quality of life criteria. Psychiatric morbidity (mainly depression) was the major variable on lowering HRQL (p = 0.000).

CONCLUSIONS

Chronic hepatitis B and C patients presented a high rate of psychiatric disorder. HRQL was significantly decreased in patients with psychiatric morbidity.

The effects of HCV infection and management on health-related quality of life

Infection with HCV leads to an array of symptoms that compromise health-related quality of life (HRQL). Chronic hepatitis C is treated primarily with pegylated interferon (peg-IFN) and an inosine 5' monophosphate dehydrogenase inhibitor, ribavirin (RBV), with the goal of achieving a sustained virologic response (SVR). SVR reduces the rate of hepatic fibrosis and other disease-related complications and, in turn, increases HRQL. Although combination therapy with peg-IFN and RBV produces SVRs in more than 50% of treated patients, it is associated with side effects that can reduce short-term HRQL, can lead to dose reductions and discontinuations, and may impair treatment response. Fatigue and depression are common symptoms of chronic HCV infection that may also be caused by IFN-based therapy. Hemolytic anemia and IFN-mediated bone marrow suppression are well-known consequences of IFN/RBV therapy, often resulting in dose reductions or discontinuations, and have the potential to affect SVR rates. Management of these symptoms is vital to successful outcomes and generally relies on therapy that is adjunctive to the primary treatment of the viral infection itself. Several new drugs with the potential to increase SVR rates without compromising HRQL are in development.

CONCLUSION

The relationship of chronic HCV infection, treatment, and HRQL is complex. Successful treatment of chronic hepatitis C requires an understanding of the intricacies of this relationship and appropriate management of treatment-related symptoms.

Health-related quality of life in patients with chronic hepatitis C and advanced fibrosis

BACKGROUND/AIMS

Although the antiviral and histological benefits of peginterferon/ribavirin therapy are well established, the effects on health-related quality of life (HRQOL) and sexual health are less certain. This study assessed HRQOL and sexual health in patients with advanced fibrosis or cirrhosis in the HALT-C Trial.

METHODS

Subjects completed SF-36 and sexual health questionnaires prior to and after 24 weeks of peginterferon/ribavirin therapy (n=1144). Three hundred and seventy-three (33%) subjects were HCV RNA negative at week 20 and continued therapy through week 48; 258 were seen at week 72. One hundred and eighty achieved sustained virological responses (SVR) and 78 relapsed.

RESULTS

At baseline, patients had poorer scores for all eight SF-36 domains compared to healthy controls. Patients with cirrhosis had lower HRQOL scores than those with bridging fibrosis, as did patients with higher depression scores. SVR patients had significant improvements in seven domains, whereas relapsers had significant worsening in one domain. Sexual scores improved in SVR patients and decreased in relapsers (p=0.03). In multivariate analyses, improvements in HRQOL and sexual scores were significantly associated with SVR but were less striking in patients with lower depression scores.

CONCLUSIONS

Achievement of SVR after peginterferon/ribavirin therapy improves HRQOL and sexual health in chronic hepatitis C patients with advanced fibrosis or cirrhosis.

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

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

Impaired health-related quality of life in patients with chronic hepatitis C and persistently normal aminotransferase levels

A significant impact of hepatitis C virus (HCV) infection on health-related quality of life (HRQOL) has been previously described. However, comprehensive data on the quality of life in patients with chronic hepatitis C and persistently normal aminotransferase levels (PNAL) are currently not available. One hundred fifteen patients with chronic hepatitis C (45 with persistently normal aminotransferases and 70 with elevated aminotransferases) and 50 healthy subjects were enrolled. Emotional and psychological states were assessed by Profile of Mood States (POMS) scale and HRQOL was assessed by the 'Everyday Life' questionnaire (EDLQ), a validated questionnaire related to the SF-36 Health Survey. An impairment in HRQOL was observed in patients with chronic hepatitis C showing PNAL compared with healthy subjects with significant differences for the factor scores depression and anger in the POMS scale as well as for the items body, relationship to partner, self-confidence and zest of life in the EDLQ. No differences in any questionnaire were observed between patients with chronic hepatitis C showing PNAL or elevated aminotransferase levels except of a worse mean level for factor score anger in POMS scale in patients with persistently normal aminotransferases. No association of quality of life with severity of liver disease was found. Impairment of HRQOL by chronic infection with HCV is similar in patients with PNAL and those with elevated aminotransferase levels.

Lifestyle changes and beliefs regarding disease severity in patients with chronic hepatitis C

The aim of this prospective study was to investigate beliefs regarding disease severity and lifestyle changes following hepatitis C diagnosis in patients with chronic hepatitis C (CHC). One hundred and eighty-five consecutive CHC patients were interviewed by means of self-questionnaires exploring several aspects of their disease. Most patients (93%) identified cirrhosis and liver cancer as the two main complications of CHC. More than half of patients (59%) thought that CHC was always associated with a fatal outcome whereas 3% thought that they would stay healthy. HCV viral load was the most commonly reported factor associated with disease severity. Sex life changes were reported by 107 patients (58%) whereas dietary intake changes were reported by 88 patients (48%). In multivariate analysis, changes in sex life were associated with male gender [odds ratio (OR): 2.57, 95% CI: 1.30-5.08, P < 0.007], perceived disease severity (OR: 1.02, 95% CI: 1.00-1.03, P < 0.03) and anxiety (OR: 1.05, 95% CI: 1.01-1.08, P < 0.003), whereas changes in dietary intake were associated with age (OR: 1.04, 95% CI: 1.02-1.08, P < 0.003) and anxiety (OR: 1.04, 95% CI: 1.01-1.08, P < 0.006). Our results show the considerable impact of CHC diagnosis on patients' lifestyle. They emphasize the need for improving CHC patient counselling in order to avoid unnecessary sex life and dietary intake changes.

Neuropsychiatric complications after liver transplantation: role of immunosuppression and hepatitis C

Neuropsychiatric complications are an important source of morbidity following orthotopic liver transplantation. Etiology of liver disease and type of immunosuppression are possible related factors. The aim of this study was to describe the prevalence of neuropsychiatric complications after liver transplantation, the role of immunosuppression, and the association between these and specific liver diseases such as hepatitis C. One hundred twenty-eight patients with liver transplants were studied. Tacrolimus was the primary immunosuppressant in 101 patients and cyclosporine in 27 patients. Seventy-five complications in 49 patients (38.2%) were reported. In 43 patients, the etiology was associated with immunosuppression: 36 on tacrolimus and 7 on cyclosporine (P = 0.34). Seventeen and four-tenths percent of patients with hepatitis C and 4.6% of patients without hepatitis C developed depression (P = 0.02). There is no difference between types of primary immunosuppression and neuropsychiatric complications. There is a significantly greater incidence of depression in patients transplanted for hepatitis C.

Quality of life and cost-effectiveness of anti-HCV therapy in HIV-infected patients

Quality of life studies in chronic hepatitis C using specific questionnaires have been performed in mono-infected patients; however, these studies have just begun in HIV-HCV co-infected patients. The questionnaires used in mono-infected patients are not well adapted for co-infected patients and need to be redesigned. Typically, co-infected patients have multiple symptoms that may be attributable to HIV, to HCV, to a combination of both diseases or even to side effects related to drug therapy. These patients usually need substitutive therapy to manage side effects related to HCV therapy, particularly anaemia, leukopenia and depression. There are no cost-effectiveness studies published on the current HCV standard therapy with pegylated interferon and ribavirin. However, there is some research on the old standard interferon and ribavirin, which shows that HCV therapy is cost-effective. Cost-effectiveness studies in co-infected patients will have to take into account variables that do not affect mono-infected patients, such as the different levels of CD4, the increase in the fibrosis progression rate and the use of other expensive drugs for the management of side effects. Currently, the literature does not provide adequate information on the effect of HCV infection on the quality of life of HIV-HCV co-infected patients or the most cost-effective HCV therapy.

Improvement in quality of life measures in patients with refractory hepatitis C, responding to re-treatment with Pegylated interferon alpha -2b and ribavirin

BACKGROUND

In this paper, we report the health related quality of life (HRQOL) data from patients with hepatitis C viral infection (HCV) who were refractory to prior therapy and had re-treatment with a combination of Pegylated interferon alpha-2b and ribavirin. We hypothesized that the HRQOL will improve in those patients who attain sustained viral response similar to naïve patients undergoing treatment for HCV.

METHODS

HRQOL data was obtained from 152 patients enrolled into a randomized study for re-treatment of HCV refractory to prior therapy with interferon alpha-2b in combination with ribavirin. The treatment protocol was for 48 weeks and had a high and low dose arm. The HRQOL data was collected at baseline, weeks 24 and 48 of treatment, and at 24 week follow-up after treatment. A repeated measures statistical model was used for comparing the HRQOL domain scores between the responders and non-responders and the treatment groups. The responders and non-responders were also compared to the age and sex adjusted national mean scores.

RESULTS

Twenty-five of the 152 (17%) patients achieved a sustained viral response. At baseline, HRQOL is lower in HCV patients compared to national norms. The norm based HRQOL domain scores for the different domains of the SF-36 instrument were as follows: physical functioning = 47.13, role-physical = 46.87, bodily pain = 48.00, general health = 44.01, vitality = 45.39, social functioning = 47.05, role-emotional = 48.88, mental health = 48.76, physical component score 43.26 and mental component score = 46.17. The scores decreased during therapy in those who would be responders and non-responders, but the pattern of change was different. During the treatment, the HRQOL domain scores of responders decrease notably in the domain of vitality. At week 48 vitality scores were worst in responders. 5 of the 8 domain scores were lower compared to baseline in non-responders. At 24 weeks post treatment follow up, HRQOL in those refractory patients who respond to re-treatment tended to be better than the national average in the domains of vitality (p = .06), social functioning (p = .06) and role-emotional (p = .03) while the non-responders improved their scores in domains of physical function and bodily pain.

CONCLUSION

We conclude that patients who are to be responders and non-responders behave differently in terms of the HRQOL domain scores when re-treated with a combination of interferon alpha 2b and ribavirin. The responders sustained a significant decrease in the domain score of vitality while 5 of the 8 domain scores decrease in non-responders at the end of treatment. At the end of follow up, in responders, the HRQOL score tended to be better than the national average notably in the domains of role-emotional, vitality and social functioning. On the other hand, in non-responders, the domain scores of physical function improve, while that of role-emotional worsened.

Psychological impact of chronic hepatitis C: Comparison with other stressful life events and chronic diseases

AIM: To examine the psychological impact of chronic hepatitis C (CHC) diagnosis in a large cohort of CHC patients as compared with other stressful life events and chronic diseases carrying a risk of life-threatening complications.

METHODS: One hundred and eighty-five outpatients with compensated CHC were asked to self-grade, using a 100-mm visual analogue scale (VAS), the degree of stress caused by the learning of CHC diagnosis and the perceived severity of their disease. Diagnosis-related stress was compared to four other stressful life events and perceived CHC severity was compared to four other common chronic diseases.

RESULTS: Learning of CHC diagnosis was considered a major stressful event (mean ± SD scores: 72 ± 25), significantly less than death of a loved-one (89 ± 13, P < 0.0001) and divorce (78 ± 23, P < 0.007), but more than job dismissal (68 ± 30, P < 0.04) and home removal (26 ± 24, P < 0.0001). CHC was considered a severe disease (74 ± 19), after AIDS (94 ± 08, P < 0.001) and cancer (91 ± 11, P < 0.001), but before diabetes (66 ± 23, P < 0.001) and hypertension (62 ± 20, P < 0.001). Perceived CHC severity was not related to the actual severity of liver disease, assessed according to Metavir fibrosis score. In multivariate analysis, diagnosis-related stress was related to perceived disease severity (P < 0.001), trait anxiety (P < 0.001) and infection through blood transfusion (P < 0.001).

CONCLUSION: Our results show the considerable psychological and emotional burden that a diagnosis of CHC represents, even in the absence of significant liver disease. They should be taken into account when announcing a diagnosis of CHC in order to reduce its negative effects.

Hepatitis C Treatment for People With Severe Mental Illness

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

Treatment of chronic hepatitis C patients with persistently normal alanine aminotransferase levels with the combination of peginterferon alpha-2a (40 kDa) plus ribavirin: impact on health-related quality of life

BACKGROUND

Peginterferon alpha-2a (40 kDa) plus ribavirin is equally effective in chronic hepatitis C patients with normal or elevated alanine aminotransferase (ALT) values. This analysis, in patients with normal ALT levels, compared health-related quality of life (HRQoL) measurements between untreated control patients and treated patients grouped by virological response. HRQoL in the present population was also compared with HRQoL in patients with elevated ALT levels, observed in a previous study.

METHODS

A total of 491 patients with persistently normal ALT levels were randomized to peginterferon alpha-2a (40 kDa)/ribavirin for 24 (group A) or 48 weeks (group B) or no treatment for 72 weeks (group C). Quality of life was assessed with valid instruments (self-administered Short Form (SF)-36 Health Survey and Fatigue Severity Scale).

RESULTS

In groups A and B, patients with sustained virological responses after combination therapy had significantly better quality of life and less fatigue than patients without sustained responses. Differences were significant for five SF-36 domains, the SF-36 Physical Component score and both Fatigue Severity Scale scores. Viral clearance was not observed in any untreated patients (group C). Comparison with data from elevated ALT patients revealed little difference in baseline quality of life, although normal ALT patients had significantly higher scores related to mental health than elevated ALT patients.

CONCLUSIONS

Eradication of HCV with peginterferon alpha-2a (40 kDa) plus ribavirin is associated with better quality of life and less fatigue in normal ALT patients. These patient benefits, coupled with the high probability of eradicating HCV, should be considered in making decisions about treating this population.

Psychological status and depression in patients with liver cirrhosis

BACKGROUND

Previous studies reported an impairment of both the physical and mental dimensions of quality of life in patients with cirrhosis. Very few data are available on the psychological impact of the disease and its relation to liver function.

AIM

To measure the psychological status of patients with cirrhosis in relation to the severity of the liver impairment.

PATIENTS AND METHODS

One hundred and fifty-six patients with cirrhosis were studied. Two questionnaires (the Beck Depression Inventory and the Psychological General Well-Being Index) were self-administered in random order. Clinical and laboratory data were collected using standardised forms.

RESULTS

The global score of Psychological General Well-Being Index was severely reduced compared to Italian population norm. Among individual domains, the more severely affected was General Health, the less compromised was Positive Well-Being. A negative relation was found between Child-Pugh score (a comprehensive measure of disease severity) and global Psychological General Well-Being Index and several individual subscales. The Beck Depression Inventory scores were indicative of a depressed mood in over 50% of patients, in relation to the presence of clinical symptoms.

CONCLUSIONS

Patients with cirrhosis have signs of psychological distress and depression, as assessed by Beck Depression Inventory and Psychological General Well-Being Index, in relation to the severity of liver disease. Accordingly, a non-negligible number of patients warrant treatment.

Hépatite C, Interféron α et dépression : principales hypothèses physiopathologiques

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

CONCLUSION

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

Impact of hepatitis C on health related quality of life: a systematic review and quantitative assessment

Hepatitis C virus (HCV) diminishes health related quality of life (HRQOL), and it is now common to measure HRQOL in clinical trials. We sought to summarize the HRQOL data in HCV, and to establish the minimally clinically important difference (MCID) in HRQOL scores in HCV. We performed a systematic review to identify relevant studies, and converted HRQOL data from each study into clinically interpretable statistics. An expert panel used a modified Delphi technique to estimate the MCID in HCV. We found that patients with HCV scored lower than controls across all scales of the SF-36. Patients achieving sustained virological response (SVR) scored higher across all scales versus patients without SVR, especially in the physical health domains. HRQOL differences did not correspond with differences in liver histology or ALT levels. Based upon the published data, the expert panel concluded that the SF-36 vitality scale was most relevant in patients with HCV, and generated a mean MCID of 4.2 points on this scale. In conclusion, patients with HCV have a clinically significant decrement in HRQOL versus controls, and physical HRQOL improves in patients achieving SVR but not in those without SVR. The data further suggest that traditional outcomes fail to capture the full spectrum of illness related to chronic HCV. A difference of 4.2 points on the SF-36 vitality scale can be used as an estimate of the MCID in HCV, and this value may be used as the basis for power calculations in clinical trials evaluating HRQOL. Supplementary material for this article can be found on the HEPATOLOGY website (http://www.interscience.wiley.com/jpages/0270-9139/suppmat/index.html).

A Clarified Conceptual Meaning of Hepatitis C-Related Depression

A clarified conceptual meaning of depression in individuals with hepatitis C virus infection is proposed based on a critical review of literature. Moving beyond an exclusively biomedical perspective, depression in hepatitis C is explained by a cluster of factors that incorporate physiological, psychological, and social dimensions. Symptom experience, stigma, and uncertainty are factors that span the complex nature of depression in individuals with hepatitis C. This broadened perspective incorporates individual and societal values and beliefs regarding hepatitis C and encompasses the multidimensional complexity of depression in hepatitis C. Hepatitis C-related depression presents an enormous challenge for nurses because of its interference with treatment adherence and significant negative impact on the individual's quality of life. Nursing theorists, researchers, and clinicians may benefit from a clear conceptual understanding of the unique nature of depression in this growing segment of the U.S. population. This clarified conceptual meaning needs to be validated through qualitative, quantitative, and longitudinal studies with this population. It is hoped that future theorists, researchers, and practitioners will contribute to our conceptual understanding, resulting in improved quality of life for this special population.

Estimation of utilities for chronic hepatitis C from SF-36 scores

OBJECTIVES

Utilities are the recommended health-related quality of life (HRQOL) measure for cost-effectiveness studies. The aim of this study was to estimate utilities for chronic hepatitis C health states from published studies reporting Short Form-36 (SF-36) quality-of-life scores.

METHODS

A systematic review of published studies was undertaken. Articles were eligible for review if direct HRQOL assessment using the SF-36 in a chronic hepatitis C population was reported. SF-36 data were grouped according to hepatitis C virus (HCV) treatment status at baseline, stage of liver disease, association with comorbidity, and HCV treatment response. The SF-36 scores were then transformed into utilities using three different methods.

RESULTS

Using Nichol's method, the estimated SF-36 mean utilities were 0.87 for sustained virological response (SVR) to interferon-based treatment, 0.82 for untreated chronic hepatitis C, 0.81 for precirrhosis, 0.76 for compensated cirrhosis, 0.69 for decompensated cirrhosis, 0.67 for hepatocellular carcinoma (HCC), and 0.77 for liver transplant. Other methods showed differences across comparison groups (e.g., treated vs untreated) but absolute scores differed substantially by translation method. SF-36 utilities for different stages of liver disease varied considerably from expert estimates but comparable to direct patient-elicited utilities.

CONCLUSIONS

Application of SF-36 translation methods facilitate use of large existing datasets to generate community-weighted utilities for cost-effectiveness analyses, an important consideration in the absence of large studies of direct patient-elicited utilities in chronic hepatitis C.

Interferon-induced depression: prevalence and management

BACKGROUND

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

AIMS

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

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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