Hepatitis C Treatments: Their Link to Depression

Hepatitis C Treatments: Their Link to Depression and Implications for the Social Worker The most commonly used treatment for patients suffering from Hepatitis C, a deadly liver disease, is the drug interferon combined with ribavirin. This treatment offers the most promise for a long-term positive prognosis. However, it has a known high rate for negative psychological side effects such as depression and other anxiety disorders.

Clinical psychology can offer some solutions to this problem, both in assessing those patients who have increased risk factors for depression such as substance abuse or a history of depression, and in offering treatments to help ease the occurrence and severity of depression. This study will assess the risk for depression among the general population of Hepatitis C patients on interferon therapy. Introduction Hepatitis C virus is the most common liver disease in the United States. Approximately 1.8% of the U.S.

population are infected, with approximately 74% of those persons chronically infected. Approximately 8-10 thousand people die each year from this disease (Darko, et. al., 2000). Although clinical trials indicate that Interferon/Ribavirin treatments produce significantly better clinical results in the long-term for hepatitis C patients, it is not recommended for those who have a history of depression. Many studies indicate that for people prone to depression ribavirin/interferon therapy can make their condition significantly worse (Mitchell, 2001).

This treatment can cause depression in as many as 25% of all people who use it (Boutiler and Hosein, 2000). Fortunately, it was found that this depression does respond to standard treatments for depression such as Prozac and other antidepressants (Boutiler and Hosein, 2000). Depression is a well-documented side effect of Interferon/Ribavirin treatment. Depression from Hepatitis C treatments can range from mild to severe. In some cases, the symptoms may be so severe that the person must decide between severe side effects and the continuance of a life-saving treatment.

Some severe cases have even been known to lead to suicide. The following research will assess past studies concerning the risk of depression for persons who have Hepatitis C and who are taking Interferon/Ribavirin treatments. Literature Review The most widely accepted treatment for Hepatitis C involves varying doses of the drug interferon or long acting Pegylated interferon combined with the drug ribavirin. This standard therapy is sold under the brand name Rebetron (Boutiler and Hosein, 2000).

It offers many possibilities for patients both newly diagnosed and for those who have had a relapse after interferon therapy (Mitchell, 2001). The exact mechanisms of how these drugs work against Hepatits C. are not known. However, this group of drugs is the most widely tested in clinical trials against the disease and are now considered standard therapy. Ribavirin has an action against some viruses. It is a synthetic drug and the mechanisms of how it works against Hepatitis C are not fully understood.

Ribavirin alone has not been found to be effective for the long-term. For this reason that it is used in combination with interferon or pegylated interferon. Interferon is found naturally in the body as a defense against viral infections. The interferon used to treat hepatitis C is a synthetic copy of the interferon found naturally in the body. It is thought that interferon works by stimulating the processes in cells that slow down the growth and reproduction of the virus.

Pegylated interferon is produced by attaching polyethylene glycol (PEG) molecules to interferon. This aids the interferon in several ways. It acts as a shield to the interferon so that the body cannot attack it and break it down as rapidly. PEG also makes the interferon molecule larger so that it remains in the blood longer and does not escape through the blood vessel walls as quickly into other parts of the body.

Pegylated interferon only needs to be injected once a week as opposed to three times a week for regular interferon (Mitchell, 2001). Ribavirin/interferon therapy shows positive results in the long-term from 31-49% above people using interferon alone (Mitchell, 2001). This therapy is the most effective treatment for Hepatitis C available today. There are two positions concerning Hepatitis C and depression.

The first is that patients with psychiatric disorders have a higher prevalence of Hepatitis C it is estimated that 74-100% of all intravenous drug users are infected with Hepatitis C (Fisher and others, 1997). The second is that patients with chronic Hepatitis C may have a higher incidence of depression (Yates and others, 1998). It is clear that high rate of depression occurs in Hepatitis C patients, however, the reasons for this depression are unclear. Two things stand out in the population of persons with Hepatitis C who are also depressed.

First, they are young and may have concerns over their long-term outcome. Many are between 30-40 years old (Alter and others, 1999). In addition, they tend to come from populations such as substance abusers, who tend to have a higher incidence of depression as compared to the normal population (Johnson and others, 1998). Depression can be a significant factor in the treatment of Hepatitis C (Dusheiko, 1997).

As Rebetron therapy is known to increase the symptoms of depression in persons taking this treatment (Capuron and Ravaud, 1999), it should be a consideration in the overall treatment plan for the patient. It may sometimes be difficult to distinguish pre-existing depression from that induced by the Rebetron (Johnson and others, 1998). Most studies conducted on the Hepatitis C patients have been conducted in tertiary care studies and may not reflect the result that would be obtained in the general population with the disease (Darko and others, 2000).

These results may contain a significant amount of sample bias due to the population chosen. Studies reproducing significantly high numbers of patients on Rebetron with depression are numerous and concurrent. Renault and others (1987) reports that psychiatric effects occur in 17% of all patients treated for Hepatitis C the severity of the depression changed across different studies and it is not known if the results obtained were from patients on similar dosages of interferon (Renault and others, (1987), Miyaika and others, (1998) and McHutchinson and others, (1998)).

It is not known if variations occurred as a result of higher and lower doses of interferon or if the duration of therapy had an effect (Renault et al., (1987), Miyaika et al., (1998) and McHutchinson et al., (1998)). The consistent factor across the studies examined is that patients with a history of depression are significantly more susceptible to interferon-induced depression than those without a psychiatric history (Dusheiko, 1997). Several studies confirm that interferon may worsen alcohol and substance abuse (Dusheiko, 1997).

Due to this factor, it is not known if interferon-induced depression in these patients is actually a relapse of alcohol or substance abuse (Darko et al., 2000). It would at first seem from the studies presented, that the connection between depression and interferon use is clear, however, several things must be considered when examining the studies presented. First, all of the studies used different exclusion criteria. Secondly, all of the studies used different scales and variables to assess depression.

It should be noted that depression induced by interferon is not unique to patients suffering from hepatitis C Depression is also seen in patients suffering from Hepatitis B, hairy cell leukemia, AIDS, melanoma and other similar diseases. Rates of depression ranges from 0-50% (Adams and others, (1994) and Misiani and others, (1994)). The exact physiology of Interferon Induced depression is not completely understood. It is believed from the pattern of personality changes that it may be a frontal-subcortical brain dysfunctional (Pavil and others, 1995).

Brown and others (1991) suggests that serotonin depletion might be responsible for the reported interferon-induced depression syndrome. Although the mechanism is unclear, it would seem as if altered seratonin levels are responsible for interferon induced depression. This would be consistent with the physiology associates with other forms of depression. Interferon-induced depression can be severe in some cases and can linger for some time after treatment has been discontinued.

Interferon-induced depression can lead to suicidal thoughts (Younossi, (1997) and Funikashi and others, (1998)) with the act being carried out in many cases (Janssen and others, (1994) and Rifflet and others (1998)). Depression does not always go away after Rebetron is discontinued and the patient must continue to undergo psychiatric monitoring and treatment. There is also a risk of switching patients from depression to mania with antidepressant therapy, which can also continue after the treatment is discontinued (Carpiniello and others, 1998).

Patients suffering from Interferon-induced depression may need psychological services long after Hepatitis C treatments have stopped. Despite a lack of published literature, there is a growing opinion that SSRIs may be the preferred agents for treating all types of depression, including interferon-induced depression. These agents appear to be safe and well tolerated in the patients with liver disease (Franco-Bronson, 1996). In McKeown (2001), persons with malignant skin cancer were given the antidepressant Paxil for two weeks before they started chemotherapy with high-dose interferon.

Only 11% developed depression compared with 45% of those who did not receive Paxil before interferon therapy (Mckeown, 2001). In Fried and others (2001), patients treated with pegylated interferon had fewer instances of depression than those treated with non-pegylated interferon and ribavirin. (Fried et al., 2001). Few studies exist using anti-depressants to pre-treat depression for those with Hepatitis C This reflects an older opinion among clinicians that depression is just part of Hepatitis C treatment and one that patients had to accept.

Recent developments suggest that depression may no longer need to be an accepted part of Hepatitis C treatments. Research Question Although this phenomenon is well documented, studies conducted on the subject have had several biases. Many of these studies were conducted in tertiary care facilities. Hepatitis C is highly prevalent among substance abusers. Many studies concerning depression associated with Interferon/Ribavirin treatment have been conducted among this population, which tends to have a higher incidence of depression as compared to the normal population.

It cannot therefore be determined if the results are applicable to the general population, including persons with Hepatitis C who are not substance abusers. So the question still remains as to whether Rebetron causes depression in the general population or if it is limited those who are prone to depression disorders. Studies need to be conducted among Hepatitis C patients who are not in the category of substance abusers or already depressed before taking interferon.

Hypothesis Studies concerning the incidence of depression among persons who have Hepatitis C and are being treated with interferon has been confined to those who already have a natural tendency to depression. This research will confirm that these results, not only apply to the groups previously found to have this tendency, but that they will apply to the general population of Hepatitis C patients as well, including those who are not substance abusers or who have no other factors pre-disposing them to depression.

Methodology The sample population for this group will include eight persons who are members of a Hepatitis C Support group in Broward County Florida. These persons will be screened for conditions predisposing them to depression. The sample size is small and therefore will be similar to a case study.

The study will be conducted using a survey to determine if the persons are on Rebetron or Pegylated interferon therapy for hepatitis C it will determine if they have ever had depression in the past or have conditions that predispose them to depression, prior to receiving interferon treatment for Hepatitis C it will assess whether they are currently depressed, are being treated for depression, or have stopped taking interferon as a result of depression. Data analysis will use standard statistical procedures to validate the data and determine correlation coefficients.

It is expected that the small ample size will make the data contain sample bias and that it will only give preliminary data, which could be used to design a larger study with a larger sample size in the future. The data may contain a certain amount of bias, as all of these persons are in the same location and have been working together for some time.

It is expected that the qualitative results of the survey will be of more value than the quantitative results due to the small sample size. Findings Due to the known effect of interferon on seratonin levels and the known effects of this chemical on mood, it can be expected that this study will reveal that approximately 25-30% of the patients on interferon will have or have had experienced depression as a result of the therapy. This will include those who have discontinued interferon therapy due to depression.

These results would be consistent with previous studies conducted on the effects of interferon-induced depression. Limitations The primary limitation of this study, will be the ability to generalize the results to the general population of Hepatitis C patients on Rebetron or Pegylated interferon. The sample size is small and will not be easily applied to the general population. In addition, different results may be obtained in a more randomly selectes population, comprised of persons in various locations.

It will also not be determined if all of the patients are on the same dosage of interferon or how long they have been being treated with interferon. These factors may influence the results. For this reason, this study the results will be treated as preliminary, in lieu of results obtained in more controlled settings such as a hospital from a sample pool of patients on known dosages of interferon.

This type of controlled study is beyond the scope of this study due to laws prohibiting the release of medical information from medical facilities. Implications Interferon-induced depression has wide implications for those in the social work field. Due to the high rate of interferon-induced depression and the severity of some cases, it is important that a professional from the field of psychology be included in the treatment team of Hepatitis C patients.

This professional will be important in determining pre-existing risk factors in the patient and in helping to offset any negative psychological effects from the treatment. Standard drug therapies have been used to prevent depression in patients undergoing interferon treatment. A social worker could be of help by providing group therapy and support for those on interferon therapy.

A social worker in this case may be a valuable member of the team in assessing the severity of side effects and could be of assistance in preventing the side effects from becoming more severe or being hidden from the doctor. A group therapy program could be beneficial in providing information and support for those taking interferon and may be one of the most important tools for preventing suicide from interferon-induced therapy. This study will help to determine if these types of services would be helpful for these patients.

Interferon-induced depression is a known side effect of Hepatitis C treatments. It has along history of being either not treated at all or dismissed as a normal part of treatment. Depression can severely effect the quality of a patient's life and can sometimes be fatal. Patients at particular risk should be screened and monitored closely for sign of new or worsening depression. Treatment is available for these patients and they do not have to suffer needlessly.

Often physicians tend to either mis-diagnose the signs of depression, or dismiss them in lieu of physical symptoms. They are trained to diagnose the body and often could obtain beneficial results for the patient by referring them to specialists in the field of psychology. It is the goal of every disease treatment to enhance the quality of life of the patient. Quality of life goes beyond physical symptoms and in order to maintain a better quality of life, it is necessary to attend to the patient's mental condition as well.

An interdisciplinary approach to medicine could be helpful, no only in the treatment of interferon-induced depression, but could be useful in the treatment of other diseases as well. A person's well-being is influenced by their attitudes and outlook on life. Maintaining a positive outlook on life could have a positive outcome on the medical side of the treatment and long-term prognosis of the patient. The benefits of including a psychological professional as part of the treatment team could have significant effects on their life.

Medicine and psychology need to work more closely than they have in the past. The maximum benefit for the patient can only be obtained if this is done. Works Cited Adams, F, Quesada JR, Gutterman JU. (1984) Neuropsychiatric manifestations.