Depression during Interferon Treatment for Hepatitis C
Most of you who regular readers of this blog do not have to worry about this issue. But psychiatric patients are at greater risk of having Hep C. While 2% of the general population has Hep C, 20 % of persons with severe mental illness have Hep C. Regardless, any patient who faces treatment for the virus must also consider what is for many the most frightening side effect of interferon treatment–depression. Not everyone who is treated develops symptoms of depression that meet DSM-IV criteria for depression, but a significant proportion does. Data from various studies show that the rate of depression runs from 21% to 58 % with major depression developing at a mean of 12 weeks (range of 1 to 32 weeks). And those who don’t develop full syndromal criteria for Major Depression can struggle with subsyndromal depression. Manic symptoms such as elevated mood, irritability, insomnia, increased speech, racing thoughts etc can also emerge during treatment. Suicidal thoughts are concerningly high as well, effecting as many as 43% of patients in one study. Interestingly, however, not all studies have shown a correlation between previous psychiatric symptoms and the emergence of mood symptoms during Interferon treatment. In patients with a previous psychiatric history, the most common psychiatric side effects of treatment with interferon/ribavirin are irritability and anxiety (in 33-45%), insomnia (in 30-40%), depression (in 20-31%) and impaired concentration (in 10-17%). Aggressive behavior, psychosis and suicide was seen in less than 1%.
The mechanism behind the development of mood symptoms is not clear. It may possibly decrease CNS tryptophan level by disrupting the mechanism by which this serotonin building block is transported across the blood-brain barrier. Decreased serotonin would result in symptoms of depression and irritability. It may also act to disrupt central hormonal feedback systems or more directly alter neural functioning.
Should a prior history of psychiatric symptoms or fear of psychiatric complication prevent you from seeking treatment for Hep C. ABSOLUTELY NOT. When indicated, antiviral treatment should proceed. It is suggested that patients who have a past history of depression or are experiencing symptoms of depression should be put on antidepressants prophylactically to prevent treatment emergent worsening of their symptoms. While studies have shown that Celexa and Paxil are safe and effective, most antidepressants seem to be as well. I have used the SSRI’s and the dual-acting agents (Effexor and Cymbalta) and have also used Wellbutrin as an augmenting strategy in patients with resistent symptoms and/or a great deal of fatigue/concentration loss. It is really about being reasonably cautious. I would suggest that any patient who enters antiviral treatment should be seen by a counselor on a regular basis for the first few months (at least) of treatment. Regular screening for mood symptoms should occur and there should be a low threshold for referring a patient for a psychiatric consultation. Antiviral treatment for Hep C is so important for long term managment of this illness that psychiatric issues, or fear of psychiatric issues, should not be allowed to get in the way.
My thanks to Drs Martin, Krahn, and Balan and Rosati CRNP for their article in the November 2006 issue of Current Psychiatry from which the above statistics are derived.
–Dan Hartman, MD
