Transcript Adjustments in Hepatitis C Infection

Adjustments in Hepatitis C
Infection
Roger A Wong BSc MRCPsych
Brownlee Centre, Glasgow
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
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Heroin use 87%
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Brief Symptom Inventory
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Anxiety 32.3%
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Depression 29.7%
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Psychiatric treatment in last 2 years 20%
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Suicidal thoughts in last 3 months 29%
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 2002;123
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Psychiatric or substance misuse 86%
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Opiate use 48%
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Inpatient care for psychiatric or drug misuse
disorder 31%
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Substance use with other psychiatric comorbidity 16,828 50%
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Depression 14,210 42%
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Anxiety 11,946 35%
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Substance use without other psychiatric
comorbidity 10,286 30%
Vietnam-era
veterans
HCV
Infected
HCV
Negative
Depression
49%
39%
Anxiety
41%
33%
78%
46%
69%
31%
Alcohol
Dependence
Drug Use
“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%
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Depression 27%
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Previous psychiatric history 50%
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Psychiatric treatment within last year 41%
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.
Those drug users who seek testing should be offered wellinformed 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.
“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.”
Pre-Test Discussion in Hepatitis C
Screening
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Obtain informed consent
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Explain possible test results
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Prepare for possible positive result
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Advise on reducing risks of transmission
Post-Test Discussion in Hepatitis C
Screening
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Communicate result clearly
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Explain implications of result
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Identify relevant issues for follow-up/referral
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Advise on reducing risks of transmission
Identified Psychological and Social
Problems in Hepatitis C Antibody Positive
Clients
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Poor self-image/confidence 58%
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Information on Hepatitis C 52%
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“Coming to terms with the condition” 47.5%
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Transmission 46.5%
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Family/relationship difficulties 43.75%
Audit of referrals to V. Lynch, Hep C Counsellor, Brownlee Centre 1999 unpublished
Identified Psychological and Social
Problems in Hepatitis C Antibody Positive
Clients
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Substance misuse alcohol/drugs 40%
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Mood swings 33.75%
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Bouts of depression/depressed 30%
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Former IVDU 27.5%
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General fatigue/apathy 27%
Identified Psychological and Social
Problems in Hepatitis C Antibody Positive
Clients
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Suicidal thoughts 22.5%
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Social isolation 22%
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Housing problems 16.5%
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Attempted suicide/self-harm 9.5%
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Coping with treatment 6.25%
Neuropsychiatric Side Effects
of Interferon-α Therapy
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Irritability
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Depression
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Insomnia
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Mania
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Suicide
Incidence of
Depression in
Interferon Therapy
N
Tool
Depression
Horikawa N
99
DSM-IV
23.2%
Hauser P
39
BDI
33%
Kraus MR
84
HAD
35%
Bonaccorso S
30
DSM-IV
40.7%
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
Commonest Cause of Drop Out from Interferon Treatment
for Hepatitis C
Neuropsychiatric Side Effects
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Baseline psychiatric assessment
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Pre-treatment information, advice and support
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On-treatment monitoring and support
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Managing neuropsychiatric side effects
Dietetics
BBV Specialist Nursing
Occupational Therapy
Pharmacy
Psychiatry & Counselling
Physiotherapy
Sexual Health
Social Work
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Nurse-led Interferon Clinic
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Routine mood screening
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Clinical psychiatric assessment
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.
Management of the Neuropsychiatric
Side Effects of Interferon Therapy
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Support
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Antidepressant medication
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Hypnotics
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Discontinuation of treatment
Living with Hepatitis C Infection
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Make informed decisions
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Identify relevant psychosocial and medical
issues
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Access appropriate services
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Utilise appropriate help and support
Managing Hepatitis C Infection
Enable the individual to:
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Make informed decisions
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Identify relevant psychosocial and medical
issues
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Access appropriate services
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Utilise appropriate help and support