Addiction psychiatric assessment of veterans with chronic hepatitis C

Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129 and could not be cleared for interferon therapy for HCV without stabilization. Aggression was positively correlated with a substance use disorder or PTSD. Depression was correlated with PTSD or lack of a partner. Higher anxiety was more likely to be reported by African American or Hispanic patients. Ethical dilemmas include the selection of candidates and timing of interferon treatment. Psychiatric side effects from interferon may be severe and lead to discontinuation of therapy. Two main types of interferoninduced psychiatric syndromes are described: mood disorders (including depression) and cognitive impairment. Systematic studies on efficacy of pharmacological agents used for these disorders are needed. In chronic liver disease (including HCV engendered), neurocognitive dysfunction occurs in up to 50% of noncirrhotic patients. Complex attention and concentration abilities are affected earlier in liver disease; problems with learning, psychomotor speed, and mental flexibility occur later in cirrhotic patients. Early identification of neurocognitive dysfunction may facilitate more rapid detection of hepatic encephalopathy.

Ethical and psychosocial issues related to interferon alpha therapy for chronic hepatitis C Withers NW, Hilsabeck RC Hepatitis C (HCV) is the most common blood borne infection in the United States. The initial survey of 3.9 million cases in the United States is an underestimate; it did not include those homeless, incarcerated, or institutionalized due to mental illness. In a dual diagnosis clinic, 48% are HCV positive and 11% are coinfected (HIV/HCV). HCV, like HIV, poses clinical challenges as there is no vaccine. Eighty percent of those infected develop chronic disease. Treatment for HCV (interferon/ribavirin) is expensive, lengthy, has significant side effects, and is not always successful. Recently, the field of eligible patients has expanded to include children, elderly, drug users in treatment, and psychiatric patients. Patients experience distress at diagnosis of this silent disease and suffer from stigma. Side effects of interferon may be disabling and there are no predictors for who will suffer. Decisions include the selection and timing of treatment. What is the best approach for patients with conditions such as unstable psychiatric illness, addiction without commitment to abstinence, HIV, head injury, obesity, psychosocial instability, or incarceration? What are the consequences of treatment, delayed treatment, or no treatment? Can patients provide informed consent since risks and outcomes are defined by research on limited study populations? Cases are presented.

Neurocognitive changes in chronic liver disease Hilsabeck RC Chronic liver disease is a significant cause of morbidity and mortality for persons between the ages of 25 and 55. With the epidemic of chronic hepatitis C infection, this number is likely to increase over the next 2 decades. Neurocognitive dysfunction is well documented in patients with end stage liver disease, as a relatively common complication is hepatic encephalopathy. Recent research has shown that neurocognitive difficulties are present in persons with mild fibrosis. Impaired performances have been found in up to 50% of noncirrhotic patients. Evidence suggests that complex attention and concentration abilities may be affected relatively earlier in the disease process, while problems with learning, psychomotor speed, and mental flexibility are affected more in cirrhotic patients. The pattern of neurocognitive dysfunction consistently suggests involvement of subcortical pathways such as the basal ganglia – thalamocortical circuit, which has been supported by MR spectroscopy. Neurocognitive problems in patients with chronic liver disease can result in reduced efficiency and accuracy in performing household and job duties, leading to frustration, mood problems, and claims of disability. Patients experiencing episodes of hepatic encephalopathy face possible coma and death. Identification of neurocognitive dysfunction early in the

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disease process may facilitate earlier identification and treatment of hepatic encephalopathy.

Pharmacological management of interferon-induced psychiatric disorders Malek-Ahmadi P, Hilsabeck RC Pharmacological management of interferon-induced neuropsychiatric disorders in patients with hepatitis C. In recent years, a number of clinical studies have focused on the psychiatric symptoms associated with interferon (IFN) therapy. The severity of these symptoms may necessitate the discontinuation of IFN therapy. Therefore, early recognition and management of IFN-induced psychiatric symptoms are of paramount importance. Two main types of IFN-induced psychiatric syndromes are described. They include IFN-induced mood disorders and IFN-induced cognitive impairment. Management of these syndromes may require pharmacological interventions. The efficacy of antidepressants in IFN-induced depressive symptoms has not systematically been studied. A few case reports suggest that selective serotonin reuptake inhibitors ameliorate IFN-induced depression. Manic symptoms can be treated with antimanic agents. However, agents with hepatic biotransformation should be used with extreme caution in patients with abnormal liver function tests. There are a few studies concerning the pharmacological management of IFN-induced cognitive impairment. Future studies are needed to investigate the efficacy of pharmacological agents in IFN-induced cognitive dysfunction.

Addiction psychiatric assessment of veterans with chronic hepatitis C Hensley DA, Withers NW Twenty percent of chronic hepatitis C (HCV) patients develop cirrhosis without interferon therapy. Alcohol use may cause cirrhosis to progress more rapidly. As completion of interferon treatment is a desired clinical outcome, assessment of candidates’ substance use and psychiatric disorders is critical, with appropriate referral for substance abuse and psychiatric treatment. This study examines the scope of substance abuse and psychiatric illness in veterans with HCV. One hundred thirty-four male veterans referred to the HCV clinic had a mean age of 50, mean weight of 90.6 kg, and mean HCV level of 575,941. The majority had elevated ALT(SGPT) (77%), genotype la or lb (71%), and were noncirrhotic (92%). A majority of the patients had a psychiatric disorder (71%), substance use disorder (96%), or were dually diagnosed (70%). Point prevalences for psychiatric disorders were affective (42%), anxiety including PTSD (37%), and psychotic (7%). Eighty-four percent of patients had alcohol abuse or dependence; 78% met criteria for drug abuse or dependence. Patients with an alcohol use disorder were significantly more likely to have cirrhosis ( P < .001). The high incidence of substance use and psychiatric disorders in veterans with chronic HCV mandates that these patients have ongoing addiction psychiatric assessment, treatment, and stabilization before and during interferon therapy.

Aggression, depression, anxiety, and quality of life in veterans with chronic hepatitis C Hensley DA, Withers NW, Spira J Most veterans seeking treatment for chronic hepatitis C (HCV) have a substance use or psychiatric disorder or both. Psychiatric side effects are common with interferon treatment. An important objective is to determine which patients can be safely treated with interferon. One hundred thirty-four males were assessed using the Aggression Questionnaire (AQ), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and Quality of Life Inventory (QOL). Forty-five percent reported significant aggression. AQ scores were significantly influenced by the presence of an alcohol or