Adjustments in Hepatitis C Infection

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Adjustments in Hepatitis C Infection

• Roger A Wong BSc MRCPsych
• Brownlee Centre, Glasgow

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Psychiatric symptoms among clients seeking
treatment for drug dependence. Intake data from
the National Treatment Outcome Research Study J
Marsden et al. National Addiction Centre, London
Marsden J British Journal of Psychiatry 2000
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• 1075 drug users in UK
• Heroin use 87
• Brief Symptom Inventory

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• Anxiety 32.3
• Depression 29.7
• Psychiatric treatment in last 2 years 20
• Suicidal thoughts in last 3 months 29

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National Veterans Affairs Database 1.9 million
veterans admitted to hospital in USA between 1992
- 1999 Hepatitis C infection 33,824 (1.8)
El-Serag, Gastroenterology 2002123
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• Psychiatric or substance misuse 86
• Opiate use 48
• Inpatient care for psychiatric or drug misuse
  disorder 31

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• Substance use with other psychiatric co-morbidity
  16,828 50
• Depression 14,210 42
• Anxiety 11,946 35
• Substance use without other psychiatric
  comorbidity 10,286 30

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Vietnam-era veterans HCV Infected HCV Negative
Depression 49 39
Anxiety 41 33
Alcohol Dependence 78 46
Drug Use 69 31
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A study to determine the extent of psychological
morbidity occurring in persons with a diagnosis
of Hepatitis C virus infection, attending a
specialist outpatient clinic.
J. Fraser, Master of Public Health Degree,
University of Glasgow 1998
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• Psychological Morbidity 60
• Depression 27
• Previous psychiatric history 50
• Psychiatric treatment within last year 41

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Because of the potential implications of a
positive diagnosis of hepatitis C virus infection
(including the knowledge that it can cause a
chronic disease from which the person can develop
long term symptoms, with the risk of death in a
minority), all tests should be preceded by
careful information and advice so that the
implications of the testing are clearly
understood. It is very important to recognise the
anxiety this subject can create for the drug
user. Those drug users who seek testing should be
offered well-informed advice, and be made aware
of the implications of both a positive result and
of a negative result, to provide a basis for
giving informed consent.
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Those drug users who seek testing should be
offered well-informed advice, and be made aware
of the implications of both a positive result and
of a negative result, to provide a basis for
giving informed consent. A wide range of health
professionals in both primary and specialist
substance misuse services are appropriate to
deliver hepatitis C antibody pre- and post-test
information, advice and discussion, as well as
arranging onward assessment and care for those
with positive results.
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You must obtain consent from patients before
testing for a serious communicable
disease,... The information you provide when
seeking consent should be appropriate to the
circumstances and to the nature of the condition
or conditions being tested for....you must make
sure that the patient is given appropriate
information about the implications of the test,
and appropriate time to consider and discuss
them.
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Pre-Test Discussion in Hepatitis C Screening

• Obtain informed consent
• Explain possible test results
• Prepare for possible positive result
• Advise on reducing risks of transmission

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Post-Test Discussion in Hepatitis C Screening

• Communicate result clearly
• Explain implications of result
• Identify relevant issues for follow-up/referral
• Advise on reducing risks of transmission

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Identified Psychological and Social Problems in
Hepatitis C Antibody Positive Clients

• Poor self-image/confidence 58
• Information on Hepatitis C 52
• Coming to terms with the condition 47.5
• Transmission 46.5
• Family/relationship difficulties 43.75

Audit of referrals to V. Lynch, Hep C Counsellor,
Brownlee Centre 1999 unpublished
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Identified Psychological and Social Problems in
Hepatitis C Antibody Positive Clients

• Substance misuse alcohol/drugs 40
• Mood swings 33.75
• Bouts of depression/depressed 30
• Former IVDU 27.5
• General fatigue/apathy 27

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Identified Psychological and Social Problems in
Hepatitis C Antibody Positive Clients

• Suicidal thoughts 22.5
• Social isolation 22
• Housing problems 16.5
• Attempted suicide/self-harm 9.5
• Coping with treatment 6.25

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Neuropsychiatric Side Effects of Interferon-a
Therapy

• Irritability
• Depression
• Insomnia
• Mania
• Suicide

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Kraus MR Journal of Clinical Psychiatry
2003 Horikawa N General Hospital Psychiatry
2003 Bonaccorso S Journal of Affective Disorders
2002 Hauser P Molecular Psychiatry 2002
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Commonest Cause of Drop Out from Interferon
Treatment for Hepatitis C Neuropsychiatric Side
Effects
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• Baseline psychiatric assessment
• Pre-treatment information, advice and support
• On-treatment monitoring and support
• Managing neuropsychiatric side effects

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Dietetics BBV Specialist Nursing Occupational
Therapy Pharmacy Psychiatry Counselling Physioth
erapy Sexual Health Social Work
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• Nurse-led Interferon Clinic
• Routine mood screening
• Clinical psychiatric assessment

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A Systematic Guide for the Management of
Depression in Primary Care DSM-IV
criteria Major depression is Over the last 2
weeks five of the following features should be
present of which one or more should be 1.
depressed mood most of the day nearly every day
2. loss of interest or pleasure in almost all
activities most of the day nearly every day and
the remaining (the total to make at least five)
from any of the following 3. significant weight
loss or gain (more than 5 change in 1 month) or
an increase or decrease in appetite nearly every
day 4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down) 6. fatigue or loss of energy nearly
every day 7. feelings of worthlessness or
excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self
reproach about being sick) 8. diminished ability
to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or
observation of others) 9. recurrent thoughts of
death (not just fear of dying), recurrent
suicidal ideation without a specific plan or a
suicide attempt or a specific plan for committing
suicide. And the symptoms cause clinically
significant distress or impairment in
occupational or other "important areas of
functioning. BUT It cannot be established that
an organic factor initiated and maintained the
disturbance . The disturbance is not a normal
reaction to the death of a loved one (morbid
preoccupation with worthlessness, suicidal
ideation, marked functional impairment or
psychomotor retardation, or prolonged duration
suggest bereavement complicated by major
depression) At no time during the disturbance
have there been delusions or hallucinations for
as long as two weeks in the absence of prominent
mood symptoms (i.e. before the mood symptoms
developed or after they have remitted). Not super
imposed on schizophrenia, schizophreniform
disorder, delusional disorder or psychotic
disorder not superimposed on schizophrenia.
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Management of the Neuropsychiatric Side Effects
of Interferon Therapy

• Support
• Antidepressant medication
• Hypnotics
• Discontinuation of treatment

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Living with Hepatitis C Infection

• Make informed decisions
• Identify relevant psychosocial and medical issues
• Access appropriate services
• Utilise appropriate help and support

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Managing Hepatitis C Infection

• Make informed decisions
• Identify relevant psychosocial and medical issues
• Access appropriate services
• Utilise appropriate help and support

Enable the individual to