Psychiatric symptoms during interferon treatment for hepatitis C: experiences from a tertiary care hepatology centre

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

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

Prevalence and detection of neuropsychiatric adverse effects during hepatitis C treatment

BACKGROUND

Current treatment combinations for chronic hepatitis C virus infection still include pegylated interferon and ribavirin despite the new therapeutic options available. Interferon-based treatments are associated with a high incidence of adverse effects. Central nervous system events are among the most frequent adverse drug reactions and their influence on treatment adherence and effectiveness is controversial.

OBJECTIVE

The aim of the study was to evaluate neuropsychiatric adverse effects of interferon-based treatment for chronic hepatitis C in standard multidisciplinary clinical practice. Risk factors for these adverse effects and their impact on adherence and sustained viral response were also evaluated. Setting Ambulatory care pharmacy in coordination with the liver unit and the infectious diseases unit at a 650-bed tertiary university hospital.

METHODS

We included all consecutive patients with chronic hepatitis C who completed treatment with pegylated interferon and ribavirin between 2005 and 2013. All patients underwent a multidisciplinary follow-up during treatment.

MAIN OUTCOME MEASURES

Neuropsychiatric adverse effects were evaluated in relation to severity, management and outcome. The presence of anxiety and depression was evaluated by means of specific tests.

RESULTS

A total of 717 treatments in 679 patients were included. During treatment, we detected 1679 neuropsychiatric adverse effects in 618 patients (86.2 %), generating 1737 clinical interventions. Fifty-seven (3.3 %) neuropsychiatric adverse effects were severe and 2 (0.1 %) were life-threatening (suicidal attempts). Most neuropsychiatric adverse effects (1555 events, 92.6 %) resolved without sequelae. Psychiatric medication was required in 289 patients (40.3 %). Sustained viral response was achieved in 400 cases (55.8 %) and was associated with adherence (OR = 1.942, 95 % CI = 1.235-3.052, p = 0.004). A multivariate analysis did not show any relationship between neuropsychiatric adverse effects and treatment adherence or sustained viral response. A psychiatric history was a strong risk factor for depression, anxiety and other psychiatric disorders during treatment.

CONCLUSION

Neuropsychiatric adverse effects during interferon-based treatments in patients with chronic hepatitis C were common but mostly mild or moderate. Early detection and accurate multidisciplinary management avoided treatment discontinuation, ensuring adherence and attaining sustained viral response. The identified risk factors could be used to determine patients eligible for interferon-free combinations, thus optimizing health system economics.

Pegylated interferon pharmacokinetics and self-reported depressive symptoms during antiviral treatment for chronic hepatitis C

BACKGROUND

Pegylated interferon-2a (PegIFN-2a)+ribavirin treatment for chronic hepatitis C is often associated with depressive symptoms. Previous studies have failed to explore whether PegIFN-2a pharmacokinetic variability plays an etiologic role in PegIFN-2a-induced mood disorders. The objective of this investigation was to evaluate the association between trough PegIFN-2a concentration at treatment week 4 ("PegIFN-2a Cmin4") and an increase in depressive symptoms.

METHODS

Using data from Virahep-C, the association between PegIFN-2a Cmin4 and the following depression outcomes were evaluated using the Center for Epidemiological Studies-Depression scale (CES-D): (1) change in CES-D score from baseline to week 12; (2) greatest difference in CES-D score between baseline and weeks 4, 12, or 24; and (3) occurrence of severe depressive symptoms (CES-D greater than 23) at weeks 4, 12, or 24. One post-hoc analysis examined whether PegIFN-2a exposure during the first week of treatment was associated with change in CES-D score from baseline to week 4.

RESULTS

No significant associations between PegIFN-2a Cmin4 and the depression outcomes were observed (p>0.05). Exploratory analyses suggest a possible relationship between PegIFN-2a exposure during the first week of therapy and CES-D score change from baseline to week 4 (p=0.03).

CONCLUSIONS

PegIFN-2a concentration levels from baseline to week 4 do not predict the onset and severity of depressive symptoms during 24 weeks of antiviral therapy; however PegIFN-2a levels during the first week of treatment may predict depressive symptoms in the first 4 weeks, earlier than anticipated and warrants further exploration.

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

OBJECTIVES

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

BACKGROUND

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

STUDY

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

RESULTS

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

CONCLUSIONS

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

Adherence and completion in hepatitis C management: a systematic review

The complexity and challenge of Hepatitis C virus (HCV) medication therapy call for a comprehensive and integrated approach in management. This article includes an appraisal of the current state of the science in HCV management and the various models that support treatment completion and adherence. The patient undergoing HCV therapy may experience a wide range of symptoms such as anemia, depression, fatigue, and flu-like symptoms. These can constantly confront the patient's adherence and compliance with treatment. The article includes an analysis of the strengths, weaknesses, and limitations of the evidence. Future directions in research were also identified.

Depressive and anxiety disorders in chronic hepatitis C patients: reliability and validity of the Patient Health Questionnaire

Depression and anxiety in patients with hepatitis C virus (HCV) infection influence their health-related quality of life and their adherence to antiviral treatment.

OBJECTIVE

To study the psychometric properties of the Patient Health Questionnaire (PHQ) as a screening instrument for depression and anxiety in HCV patients.

METHODS

Criterion validity, using the structured clinical interview for DSM-IV-Axis I (SCID-I) to diagnose depression and anxiety disorders as diagnostic standard, was evaluated for both summed and algorithm-based PHQ in 500 HCV patients. Correlations with quality of life (Short-Form-36 Health Survey; SF-36) and severity of illness (Hospital Anxiety and Depression Scale; HADS) were calculated to assess construct validity. Test-retest reliability and patients' reaction to the PHQ were assessed in 120 HCV patients.

RESULTS

Twenty-three percent of patients (N=114) had a psychiatric disorder (any depressive disorder=18.2%; major depressive disorder=6.4%; generalized anxiety disorder=7.0% and panic disorder=5.8%). The questionnaire demonstrated good test-retest reliability for any depressive disorder (k=.847), major depressive disorder (k=.784), generalized anxiety disorder (k=.787), panic disorder (k=.848), and for any psychiatric disorder (k=.847). There was good agreement between PHQ and SCID-I diagnoses (for any PHQ disorder, k=.821; overall accuracy=90.43%, sensitivity=83.84%; specificity=97.01%). Patients with any PHQ disorder had higher impairment on the SF-36 (p<.001). HADS depression and anxiety scores showed high correlations with PHQ depression (p<.001) and anxiety (p<.001) scores respectively. PHQ administration was well accepted by 97% of patients.

CONCLUSIONS

The Spanish version of the PHQ is a reliable, valid, and useful screening instrument to detect depression, generalized anxiety and panic disorders in HCV patients.

Irritability: an underappreciated side effect of interferon treatment for chronic hepatitis C?

AIM AND OBJECTIVES

The research literature was reviewed with the aim of answering the question 'is irritability an underappreciated side effect of interferon and ribavirin treatment for hepatitis C'.

BACKGROUND

The majority of information regarding interferon treatment identifies depression as the main psychological side effect. However, clinical observation and patient reports suggest that irritability, not depression, is the predominant side effect.

DESIGN

The literature review included research and discussion papers. Data bases were searched using the keywords interferon and hepatitis C in combination with one of the following: side effects, depression, mood alteration/change, irritability, anger, impulse control, psychiatric side effects or neuropsychiatric side effects.

RESULTS

The review revealed a gap in the literature regarding interferon-related irritability. Whereas depression was well researched and described, irritability was afforded little research time. However, where irritability was assessed, it was found to occur to a significant degree. Issues identified were difficulty defining and categorising irritability; lack of irritability-specific assessment tools and failure of depression rating scales to adequately discern irritable mood; and the confounding effect of physiological side effects on mood alteration. Relevance to clinical practice. Underappreciation and underrecognition of irritability have implications for clinical practice. Good research is the foundation for evidence-based practice; therefore, the possibility exists that, based on current research evidence, patients may not be receiving a standard care that adequately addresses the entirety of the side effect spectrum.

CONCLUSION

Irritability is an underappreciated psychological side effect of interferon therapy. Although irritability is recognised as a side effect of interferon, there is considerable discordance between clinical observation, patient reports and research evidence as reported in the literature.

Barriers to accessing care in patients with chronic hepatitis C: the impact of depression

BACKGROUND

Patients with hepatitis C viral (HCV) may perceive barriers to accessing speciality care for HCV, and these barriers may be related to depressive symptoms.

AIM

To evaluate the relationship between barriers to care, demographics, and depressive symptoms.

METHODS

A cross-sectional analysis of 126 patients referred for HCV at two speciality HCV clinics. Barriers to care, depressive symptoms and sociodemographics were measured using standardized instruments. A retrospective chart review was conducted to collect clinical outcome data.

RESULTS

Depressive symptoms were reported in 26%. Common barriers included lack of personal financial resources; lack of HCV knowledge in the community; lack of professionals competent in HCV care; stigmatization of HCV; and long distances to clinics offering care. After we controlled for sociodemographics, depression accounted for an additional 7-18% of variability in all barriers (all p values <0.01). Lower depression, marital and employment status were associated with subsequent receipt of HCV treatment in 38% (45/120) of patients; perceived barriers were not.

CONCLUSIONS

Depression is independently associated with perceived barriers to care. Higher depressive scores, but not perceived barriers, were associated with nontreatment. Healthcare providers who diagnose HCV need to be cognizant of numerous perceived barriers to accessing HCV care, and the impact that depression may have on these perceptions and receipt of treatment.

Predictors of early treatment discontinuation among patients with genotype 1 hepatitis C and implications for viral eradication

BACKGROUND & AIMS

A significant proportion of patients with hepatitis C virus (HCV) infection discontinue antiviral treatment prematurely. Risk factors for discontinuation before 48 weeks among patients with genotype 1 HCV vary over the course of therapy. We investigated the rates and risk factors for treatment discontinuation within 12 weeks, 12-24 weeks, and 24-48 weeks.

METHODS

We retrospectively evaluated data from all Veterans Affairs (VA) patients with genotype 1 HCV who initiated pegylated interferon and ribavirin therapy from 2002-2007 (n = 11,019). We accounted for appropriate discontinuation because of viral nonresponse.

RESULTS

Overall, 53% of patients completed at least 38.4 weeks of therapy (80% of the projected 48 weeks), 16.5% discontinued early in the setting of viral nonresponse, and 30.9% discontinued despite viral response or in the absence of virologic data. Cirrhosis, diabetes, pretreatment substance use disorder, hemoglobin, and lack of hematopoietic growth factor use independently predicted discontinuation before 12 weeks (P < .05 for all). Among patients with documented early virologic responses, higher baseline levels of creatinine, depression, and lack of growth factor use predicted discontinuation from 12-24 weeks. No factors independently predicted discontinuation from 24-48 weeks among patients responding to treatment at 24 weeks.

CONCLUSIONS

Early discontinuation of antiviral therapy is common. Use of growth factors was the strongest independent predictor of treatment retention before 24 weeks and should be evaluated prospectively. Early interventions may also be warranted for other risk factors for early discontinuation, such as pre-existing substance use, depression, cirrhosis, or diabetes.

Prospective analysis of depression during peginterferon and ribavirin therapy of chronic hepatitis C: results of the Virahep-C study

OBJECTIVES

Combination therapy for chronic hepatitis C is associated with depression, which may lead to worse treatment outcomes. The objectives of this study were to determine the association between patient characteristics and depression before and during treatment and to evaluate the relationship between depression and treatment outcomes.

METHODS

Prospective data from the Viral Resistance to Antiviral Therapy of Chronic Hepatitis C (Virahep-C) study were analyzed (191 African Americans, 203 Caucasians). Depression was defined as a score of >23 on the Center for Epidemiologic Studies Depression (CES-D) scale. Scores were taken before treatment, at weeks 4, 12, and 24 of treatment, and 24 weeks after treatment ended. Baseline social support was measured using the Medical Outcomes Study (MOS) Social Support Survey. Associations between baseline patient characteristics and incident depression were assessed with discrete-time Cox proportional hazards models.

RESULTS

At baseline, 47 (12%) participants had CES-D scores 23. Univariable analyses indicated that several patient characteristics were associated with baseline depression, including lower social support (P<0.0001). On treatment, these patients were more likely to have psychiatric adverse events (AEs) or start new antidepressants (45 vs. 28%, P=0.02) and to have had early treatment discontinuation (38 vs.13%, P<0.0001); however, sustained virological response (SVR) rates were similar (38 vs. 40%, P=0.79) to those of participants without baseline depression. The incidence of new-onset depression was 26% by 24 weeks. One-third of patients were started on antidepressants, and no patients attempted suicide. Multivariable analyses indicated that new-onset depression was significantly associated with younger age (P=0.04), lower social support (P<0.001), and "feeling depressed, sad, or blue" (P=0.008). Patients who developed depression during treatment were more likely to have a psychiatric AE or begin antidepressants (44 vs. 23%, P<0.001) but had lower rates of treatment discontinuation (6 vs. 15%, P=0.02) and comparable rates of SVR compared with patients without depression (47 vs. 38%, P=0.16). There were no differences in the frequency of pretreatment or new-onset depression between African-American and Caucasian participants in this study.

CONCLUSIONS

In this large prospective analysis, baseline and new-onset depression were associated with patient characteristics and treatment outcomes; however, SVR rates did not differ between depressed and nondepressed patients. The relationship of lower baseline social support with depressive symptoms warrants further investigation.