Depression during treatment with interferon alpha

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.

Childhood Adversity and Current Stress are related to Pro- and Anti-inflammatory Cytokines in Major Depression

BACKGROUND

Stress during early childhood, for example as a result of maltreatment, can predict inflammation in adulthood. The association of depression with inflammation and current and long-term stress resulting from childhood maltreatment and threatening experiences in the past year has not yet been studied. Therefore, we assessed these variables in a group of patients with major depressive disorder (MDD) and measured levels of the pro-inflammatory cytokine IL-6 and the anti-inflammatory cytokine IL-10. High levels of IL-6 are associated with depression and of IL-10 with stress.

METHODS

We included 44 patients who fulfilled DSM-IV diagnostic criteria for MDD and 44 age- and gender-matched healthy controls. We used Cohen's Perceived Stress Scale (PSS), the list of life-threatening experiences questionnaire (LTE-Q) and the childhood trauma questionnaire (CTQ) to assess the level of stress and analyzed IL-6 and IL-10 cytokines in venous blood plasma.

RESULTS

The patient group showed significantly higher scores on the maltreatment scale LTE-Q (2.7 vs. 1.1; P = 0.001, and the stress scales CTQ (emotional abuse; P = 0.048 and physical neglect; P = 0.002) and PSS (35.2 vs 15.5; P < 0.001) as well as significantly higher levels of IL-6 (1.5pg/ml vs. 0.9pg/ml; P = 0.012). They also had significantly higher levels of IL-10 (1.1pg/ml vs. 0.7pg/ml; P < 0.001). Higher actual stress levels were associated with childhood maltreatment and higher IL-6 (tau = 0.004) and IL-10 (tau = 0.027) levels.

LIMITATIONS

The results need to be replicated in a larger sample, and the study did not evaluate causal relationships. Although the assessment of childhood trauma was retrospective, the CTQ is a well-established assessment instrument.

CONCLUSIONS

The patients with MDD in this study showed an immune activation in response to stress. This study highlights the association of childhood trauma and current and long-term stress with an increased immune activation in MDD.

Association of Baseline Sleep Quality With Trajectories of Depressive Symptoms in Patients Undergoing Interferon Treatment

OBJECTIVE

Some patients with hepatitis C starting interferon-α (IFN-α) therapy experience depression, although many patients do not develop depressive symptoms. We have found that poor sleep is associated with increased depressive symptoms on average. It is unknown whether this association holds generally or is driven by a specific, distinct subgroup. This investigation first determined whether patterns of change in depressive symptoms form clinically meaningful, distinct subgroups and then tested the extent to which sleep disturbances are associated with a less favorable depression trajectory.

METHOD

Group-based trajectory modeling was used on 124 patients with hepatitis C who started IFN-α therapy. The Pittsburgh Sleep Quality Index (PSQI) assessed pretreatment sleep, the Beck Depression Inventory minus the sleep question assessed depression over time, and the Structured Clinical Interview for DSM-IV provided categorical diagnoses.

RESULTS

Three distinct subgroups were found, where each subgroup shared similar patterns of depressive symptoms over time. The groups were characterized as "nondepressed," "slow increase," and "rapid increase." The nondepressed subgroup (44.4%) experienced low depressive symptoms with little change over time. In comparison, all rapid increasers (11.3%) were diagnosed as having a mood disorder by 12 weeks of treatment. The PSQI was strongly associated with group membership, where the odds of developing a rapid increase was elevated 39% for every unit-score increase in the PSQI compared with individuals who remained nondepressed (odds ratio = 1.39, 95% confidence interval = 1.07-1.80, adjusted for depression at baseline).

CONCLUSIONS

Only a distinct subpopulation of people is notably vulnerable to a developing a rapid increase in depression symptoms during IFN-α therapy. This group may be identifiable by their markedly poor sleep before IFN-α therapy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Labile anger during interferon alfa treatment is associated with a polymorphism in tumor necrosis factor alpha

OBJECTIVE

Inflammatory cytokines may influence both labile anger and depression. Both psychiatric conditions can occur during interferon alfa-based treatments. Evidence also indicates a central nervous system role for tumor necrosis factor alpha (TNF-alpha), whose expression may be increased by interferon alfa. A polymorphism in the promoter region of TNF-alpha has been associated with various inflammatory illnesses. We therefore hypothesized that this TNF-alpha polymorphism would influence susceptibility to psychiatric symptoms during interferon alfa therapy.

METHODS

One hundred five patients with hepatitis C, initially without active major depression (major depressive disorder), were treated with interferon alfa and then prospectively monitored using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Beck Depression Inventory II, the Anger Irritability and Assault Questionnaire, and circulating TNF-alpha levels. The A-308G polymorphism (rs1800629) was determined using the 5'-nuclease assay. Repeated-measure mixed-effect analyses compared changes in symptoms over time.

RESULT

Beck Depression Inventory II score increased during interferon alfa therapy (F = 6.2; P < 0.001), with 27% developing MDD. The TNF-alpha A allele was associated with worsened labile anger (F = 2.5; P < 0.05) and fatigue (F = 2.9; P < 0.05) during treatment but not with major depression incidence (chi = 0.0; P = 0.99) or increased Beck Depression Inventory II (F = 1.2; P = 0.31). Labile anger was not predicted by the serotonin transporter polymorphism (F = 0.8; P = 0.59).

DISCUSSION

During treatment with an exogenous cytokine, vulnerability to worsening labile anger-distinct from major depression-is associated with genetic variability in TNF-alpha. This has implications both for patients being treated with interferon alfa and our understanding of genetic vulnerability for different subtypes of dysphoric and mood disorders.

Poor sleep quality predicts onset of either major depression or subsyndromal depression with irritability during interferon-alpha treatment

Major depressive disorder (MDD) often occurs during pegylated IFN-alpha2 (IFN-alpha) treatment. Identifying who is at risk for MDD in this population is essential, and epidemiological studies suggest that sleep may be related to depression risk. Controlling for pre-existing depression symptoms, we therefore examined whether sleep quality prior to IFN-alpha treatment would predict subsequent MDD incidence during IFN-alpha treatment. Adults with hepatitis C but without current clinical MDD (n=86) were evaluated prior to IFN-alpha treatment and then prospectively monitored during treatment using self-report measures of sleep quality (PSQI), depression (BDI), and anger and irritability (AIAQ), as well as with Structured Clinical Interviews for DSM-IV Axis I Disorders (SCID-I). During IFN-alpha treatment, 19% developed MDD, 19% developed subsyndromal depression with irritability, and one developed mania. Controlling for baseline depression symptoms and past history of depression, patients with worse sleep quality (PSQI > or = 10) prior to treatment had a significantly shorter time until they developed MDD or any severe psychiatric problem. These findings may have important implications for understanding, predicting, and possibly preventing depression, particularly in individuals treated with IFN-alpha.

High rates of sustained virological response in hepatitis C virus-infected injection drug users receiving directly observed therapy with peginterferon alpha-2a (40KD) (PEGASYS) and once-daily ribavirin

This retrospective study evaluated the efficacy and tolerability of directly observed therapy with peginterferon alfa-2a and once-daily ribavirin (RBV) for chronic hepatitis C in 49 opioid-addicted injection drug users (IDUs) participating in a drug treatment program at a specialized outpatient center. Patients also received prophylactic citalopram to minimize the risk of interferon-induced depression. Patients had daily access to and support from specialist physicians, nurses and counseling services at the center, and a 24-hour helpline. Sustained virological response was achieved by 48 of 49 patients (98%) overall, including 20 of 21 (95%) hepatitis C virus (HCV) Genotype 1/4-infected patients and 28 of 28 (100%) Genotype 2/3-infected patients. Treatment was well tolerated, and no unexpected side effects of peginterferon treatment were seen. The safety profile of once-daily RBV was not different from twice-daily dosing. Decline in hemoglobin levels was similar to those reported in clinical trials including once-daily RBV and did not lead to dose reduction or treatment withdrawal. Our data demonstrate that HCV-infected IDUs on stable L-polamidone (methadone) or buprenorphine maintenance can be successfully and safely treated with peginterferon alfa-2a and RBV in an optimal substitution setting.

Major depression during interferon-alpha treatment: vulnerability and prevention

Major Depressive Disorder (MDD) during interferons (IFN-α) treatment can occur within a few months of therapy, and shares many homologies with other forms of MDD, Most patients are resilient to the side effect ofinterferon-induced depression (IFN-MDD), but 15% to 40% are vulnerable. Several studies have employed antidepressants to prevent the incidence of an IFN-MDD episode, and the results suggest that prophylactic antidepressants may be specifically useful in those with pre-existing subthreshold depressive symptoms andlor a history of prior MDD episodes. Several other potential markers of vulnerability for IFN-MDD have been implicated in assessments of nondepressed patients before they start IFN-α These include poor sleep quality, premorbid elevations in inflammatory cytokines, genetic polymorphisms in the serotonin system, personality, and social support. The interplay of these factors strongly predicts who is at risk for IFN-MDD, and indicates several potentially modifiable targets for the personalized prevention of IFN-MDD,

Psychiatric care of the patient with hepatitis C: a review of the literature

CONTEXT

Approximately 1.8% of the US population is chronically infected with the hepatitis C virus (HCV). The prevalence rates of psychiatric illness in patients with HCV infection are higher than those rates in the general US population, and the prevalence of HCV infection in patients with severe mental illness may be as high as 9 times that of the general US population. Primary care physicians and psychiatrists are on the forefront of identifying patients with psychiatric illness who are at risk for HCV infection and can screen for HCV infection. This review summarizes the psychiatric implications of HCV infection and strategies for the management of interferon alfa-induced neuropsychiatric adverse effects.

EVIDENCE ACQUISITION

English-language studies were identified by computerized searches using the term hepatitis C psychiatric between 1972 and 2009, and further references were obtained from bibliographies of the reviewed articles. Relevant references were reviewed by the authors and included the basis of significance and applicability to practicing psychiatrists and internists.

RESULTS

Since primary care physicians and psychiatrists are sometimes the only medical link for patients with psychiatric illness, they are expected to provide posttest counseling for their patients with HCV and psychiatric illness. The task of conducting a psychiatric and psychosocial pretreatment risk-benefit assessment to determine whether or not to treat HCV infection is increasingly delegated to primary care providers as well as psychiatrists. The use of interferon alfa-based therapies to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of HCV patients with and without a preexisting history of psychiatric illness. Primary care physicians and psychiatrists are frequently asked to assist in the management of these neuropsychiatric adverse effects and evaluate the risks and benefits of using prophylactic psychotropics.

CONCLUSIONS

Despite the clinical challenge that interferon alfa treatment for patients with comorbid HCV and psychiatric illness presents, recent research indicates that interferon alfa can be safely administered to HCV-infected patients with psychiatric disorders provided there is a comprehensive pretreatment assessment, a risk-benefit analysis, and intensive ongoing medical and psychiatric follow-up.

Cytokine-induced depression during IFN-alpha treatment: the role of IL-6 and sleep quality

Depressive symptoms, poor sleep quality, and systemic markers of inflammation (e.g., interleukin (IL)-6) are frequently associated. Interferon-alpha (IFN-alpha) therapy results in Major Depressive Disorder (MDD) in some people, offering the possibility to elucidate the relationship of MDD to sleep and inflammation during treatment. In particular, delineating the temporal relations among these factors could help inform their causal relationships. To this end, a cohort of 95 non-depressed hepatitis C patients was followed prospectively for four consecutive months during IFN-alpha therapy. We found that higher pre-treatment levels of circulating IL-6 predicted incidence of MDD (X(2)(1)=7.7; p<0.05). Time-lagged mixed-effect analyses supported uni-directional associations in which IL-6 predicted next month's PSQI scores (F(47,11.6)=78.4; p<0.0005), and PSQI scores predicted next month's depressive Beck Depression Inventory-II (BDI) scores (F(16,22.6)=3.4; p<0.005). In addition, on any given month of treatment, IL-6 levels predicted BDI symptoms the following month (F(16,97.5)=7.3; p<0.0005), and conversely BDI predicted next month's IL-6 (F(14,7.4)=5.2; p<0.05) - providing evidence for a positive feedback relationship between depressive symptoms and systemic inflammation. These data provide further evidence that high levels of inflammation and poor sleep quality may be risk factors for IFN-alpha induced depression. Furthermore, these findings highlight the complex temporal relationships that exist among sleep, depression, and inflammation, and support the need for further prospective investigations to elucidate the dynamics that underlie depression during IFN-alpha treatment.

Cancer Chemotherapy-Related Symptoms: Evidence to Suggest a Role for Proinflammatory Cytokines

PURPOSE/OBJECTIVES

To provide an overview of the evidence that supports a role for the proinflammatory cytokines interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6) in the etiology of cancer chemotherapy-related symptoms.

DATA SOURCES

Electronic nursing, psychology, and medicine databases; online meeting abstracts; and personal experimental observations.

DATA SYNTHESIS

Substantial evidence implicates the proinflammatory cytokines IL-1beta, TNF-alpha, and IL-6 in the etiology of chemotherapy-related anorexia, cachexia, anemia, pain, sleep disturbance, fatigue, and depression.

CONCLUSIONS

Further investigation into the role of these cytokines in the genesis of chemotherapy-related symptoms is warranted. The development of appropriate animal models likely will be key to understanding the relationship among cancer chemotherapy, proinflammatory cytokines, and symptoms.

IMPLICATIONS FOR NURSING

Nurses traditionally have been leaders in symptom management. The symptoms experienced by patients undergoing chemotherapy have a profound negative impact on quality of life and patients' ability to receive prescribed treatments. An understanding of potential mechanisms underlying the physiologic and behavioral consequences of chemotherapy administration will aid nurses in the development of interventions to effectively manage chemotherapy-related symptoms.

L’interféron β1-a IM ne modifie pas le fonctionnement psychologique global de patients atteints de sclérose en plaques rémittente pendant les premiers mois de traitement

INTRODUCTION

Psychological troubles are common in multiple sclerosis but their underlying etiology is still controversial.

METHODS

The objective of this open, non comparative, multicenter study was to assess changes in global psychological functioning in new multiple sclerosis patients during the first 3 months of treatment with intramuscular interferon beta-1a once weekly (Avonex). This functioning was rated every 4 weeks with the GAF (Global Assessment Functioning) scale. Depression measured on MADRS (Montgomery & Asberg Depression Rating Scale), clinical global impression (CGI) on patients'psychological status and clinical as well as biological tolerance were also assessed every 4 weeks.

RESULTS

Five hundred and ninety-nine patients (71.4 percent women), aged 39.4 years were included. No clinically significant difference in mean GAF score between baseline and the end of the first 3 months of interferon beta-1a IM treatment (main evaluation outcome) was found. Similar results were obtained on MADRS scale.

CONCLUSION

No clinically significant alteration of global psychological functioning, including symptoms of depression, was observed during the first 3 months of treatment with interferon beta-1a IM.