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Psychiatric Disorders and Functioning in Hepatitis B Virus Carriers
Psychiatric Disorders and Functioning in Hepatitis B Virus Carriers FIGEN C. ATESCI, M.D., BANU C. CETIN, M.D. NALAN K. OGUZHANOGLU, M.D., FILIZ KARADAG, M.D. HUSEYIN TURGUT, M.D.
The authors compared asymptomatic hepatitis B virus carriers and healthy subjects in terms of their psychological state. Participants (43 asymptomatic hepatitis B virus carriers and 43 healthy comparison subjects) completed self-report questionnaires. Psychiatric disorders and psychosocial functioning were evaluated with structured clinical interviews and the Global Assessment of Functioning scale. Hepatitis B virus carriers were more likely to have psychiatric disorders than comparison subjects (30.2% vs. 11.6%). Also, carriers had significantly higher depression and anxiety scores and lower Global Assessment of Functioning scores than did comparison subjects. Worries about contamination and illnesses related to hepatitis B infection were associated with the presence of psychiatric disorder. The results suggest that asymptomatic hepatitis B virus carriers need emotional support. (Psychosomatics 2005; 46:142–147)
I
t has been estimated that there are more than 400 million people (or 5% of the world’s population) with some form of chronic hepatitis B virus infection. Hepatitis B has become one of the major causes of chronic hepatitis, cirrhosis, and hepatocellular carcinoma worldwide, and more than 1 million deaths are caused by hepatitis B each year.1 The distribution of hepatitis B infection in the world differs according to geographical zone, the zones being classified as low, moderate, and high endemic regions. Turkey belongs to the moderate endemic region, and there are approximately 4 million carriers in this country.2 The association between chronic physical disorders and psychiatric illnesses, particularly depression and anxi-
Received Dec. 5, 2003; revision received April 6, 2004; accepted May 26, 2004. From the Department of Psychiatry and the Department of Clinical Microbiology and Infectious Diseases, Pamukkale University Faculty of Medicine; and the Department of Clinical Microbiology and Infectious Diseases, Celal Bayar University Faculty of Medicine, Turkey. Address correspondence and reprint requests to Dr. Atesci, Faculty of Medicine, Psychiatry Department, Pamukkale University, Doktorlar Cad. Denizli, Turkey 20100; [email protected] (e-mail). Copyright 䉷 2005 The Academy of Psychosomatic Medicine.
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ety, has been shown in previous reports. Arthritis, cancer, lung disease, neurological disorder, heart disease, and physical handicap are strongly associated with psychiatric disorders.3–5 The chronic course of hepatitis B and the knowledge of hepatitis B-related diseases like cirrhosis and hepatocellular carcinoma might be predisposing factors for some kind of psychological disorders. Also, insufficient knowledge about the transmission modes of the virus may result in the isolation of the virus carriers, especially in their social and occupational life. Kunkel et al.6 observed that 46% of patients had depressive symptoms, and depression was also significantly associated with liver dysfunction and low psychosocial functioning in a heterogeneous group of patients with hepatitis B-related diseases (i.e., physically healthy carriers of the virus and patients with hepatocellular carcinoma and hepatic cirrhosis). Lok et al.7 studied the psychosocial impact of being a hepatitis B virus carrier in 40 British patients and reported that sexual, occupational, social, family, and physical aspects of their life were negatively affected in 90% of patients. Most of the problems were related to infectivity. Psychosomatics 46:2, March-April 2005
Atesci et al. To our knowledge, there has been no study reporting psychiatric morbidity in a homogeneous group of asymptomatic hepatitis B virus carriers. In this study we aimed to investigate the effect of being a hepatitis B virus carrier on psychological state (including psychiatric morbidity per standardized interview and DSM-IV), psychosocial functioning, and worries and behavior alterations related to infection. We expected that the standardized psychiatric evaluation of hepatitis B virus carriers may lead to a better understanding of the psychological characteristics and needs of this understudied population. METHOD This study was performed in Pamukkale University Faculty of Medicine Hospital with the participation of the Departments of Psychiatry and Clinical Microbiology and Infectious Diseases between April 2001–May 2002. Hepatitis B virus carriers (N⳱98) who were registered with the Clinical Microbiology and Infectious Diseases outpatient clinic were informed about the study by telephone call and invited for the interview. The study group comprised 43 asymptomatic hepatitis B virus carriers who voluntarily accepted to participate in the study. Serum liver enzymes were within the normal values, no human immunodeficiency virus (HIV) or hepatitis C virus infection was present, and there was no drug abuse. All of the carriers had been informed about the transmission modes and preventive measures concerning hepatitis B virus infection on their first admission to the outpatient clinic. The comparison group was selected from 43 healthy patients with the same gender and similar age who had been admitted to the Clinical Microbiology and Infectious Diseases outpatient clinic for preexposure hepatitis B virus prophylaxis. They had no known physical or psychiatric diseases nor were they users of any drugs. The first interview was carried out by a specialist in Clinical Microbiology and Infectious Diseases. All of the participants completed the self-report questionnaires, Beck Depression Inventory,8–10 and Spielberger’s State-Trait Anxiety Inventory.11–13 The hepatitis B and healthy subjects were interviewed individually by a psychiatrist with the Structured Clinical Interview for DSM-IV (SCID-I). Psychosocial functioning was examined with the DSM-IV Axis V Global Assessment of Functioning scale on the same day.14,15 Also, during the interview period the asymptomatic carriers were questioned about when they learned of their carrier status, how they reacted, and their behavior Psychosomatics 46:2, March-April 2005
and thoughts concerning their carrier status and axis IV DSM-IV psychosocial stressors. Data Collection Materials Beck Depression Inventory This inventory includes 21 items aimed to screen the signs of depression that occur in the vegetative, cognitive, motivational, and emotional fields.8 Validity and reliability studies have been performed for the Turkish form, and the cutoff score was accepted as 17.2,10 The total score ranges from 0 to 63. Spielberger’s State-Trait Anxiety Inventory This inventory is a self-reported measure of subjective anxiety.11 It comprises two 20-item scales; the state scale requires subjects to report current feelings of anxiety, and the trait scale measures longstanding background symptoms. The validity and reliability of the Turkish forms were carried out by Oner and Le Compte.12,13 Structured Clinical Interview for DSM-IV—Clinical Version This clinical interview inventory by First et al.14 was partially constructed toward assessing DSM-IV axis I diagnoses. It provides not only standardization in the evaluation process but also convenience in usage. Adaptation to Turkish and validity and reliability studies were performed by Ozkurkcugil et al.15 Global Assessment of Functioning Scale Axis V is a global assessment of functioning in which clinicians judge patients’ overall levels of functioning during a particular time. Functioning is considered a composition of three major areas: social, occupational, and psychological. The Global Assessment of Functioning scale is a 100-point scale, 100 representing the highest level of functioning in all areas.16 Psychometric properties of the instrument are described as adequate with evidence for moderate reliability (r⳱0.61–0.91).17 Statistical Analysis The statistical analysis was performed by SPSS version 10.0. Comparisons of group means were performed by Student’s t test or Mann-Whitney U test as the most appropriate for related data. Chi-square tests were used to evaluate the differences between groups for categorical variables. Pearson’s correlation analyses were used to examine the relationship between duration of hepatitis B virus carriage and scores on the Global Assessment of Funchttp://psy.psychiatryonline.org
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Psychopathology and Functioning in Hepatitis B Patients
TABLE 1.
Demographic Characteristics of Asymptomatic Hepatitis B Virus Carriers and Healthy Comparison Subjects Healthy Comparison Subjects (Nⴔ43)
Hepatitis B Virus Carriers (Nⴔ43) Characteristic Marital status Married Widowed Single Educational level Primary High University Occupation Employee Self-employed Housewife Retired University student
N
%
N
35 7 1
81.4 16.3 2.3
37 5 1
86.1 11.6 2.3
9 16 18
20.9 37.2 41.9
11 12 20
25.6 27.9 46.5
19 5 9 7 3
44.2 11.6 20.9 16.3 7.0
26 5 6 4 2
60.5 11.6 14.0 9.3 4.7
tioning, Beck Depression Inventory, and Spielberger’s State-Trait Anxiety Inventory. RESULTS The study consisted of 43 hepatitis B virus carriers and 43 comparison subjects, and both groups consisted of 22 women (51.2%) and 21 men (48.8%). The mean age of the carrier group was 38.8 years (SD⳱11.1) and that of the comparison group was 39.1 (SD⳱11.8) (Student’s t test, t⳱–1.37, df⳱84, p⬎0.50). No significant differences were found between the two groups with respect to sociodemographic variables (Table 1). Psychiatric disorders were detected in 13 (30.2%) of 43 subjects in the carrier group (Table 2). Two carriers with psychiatric disorders had additional chronic physical disorders like bronchial asthma and Parkinson’s disease. These two carriers had a history of depressive disorder. At the time of interview, one of them was diagnosed as suffering from major depressive disorder and the other as suffering from adjustment disorder with depressed mood. TABLE 2.
v2
df
p
0.389
2
0.82
0.877
2
0.64
2.707
4
0.60
Five participants from the comparison group (11.6%) had psychiatric disorders. Two of them were diagnosed with a major depressive disorder, one had generalized anxiety disorder, and the last two had anxiety disorder not otherwise specified. The frequency of the psychiatric disorders was significantly higher in the carrier group than in the comparison group (v2⳱4.49, df⳱1, p⬍0.05). Most of the carriers (41.9%, N⳱18) had learned of their hepatitis B virus infection 2–5 years before the interview. Psychiatric disorders were more frequent among the carriers who had learned of their hepatitis B virus infection within 3 months of the interview (Table 3). Twelve (27.9%) of 43 carriers had worries about contaminating their relatives and exhibited some behavior alterations. Some separated their plates from others, some closed their mouths when feeding their children or avoided kissing them even though the children were vaccinated, and some washed their vegetables repeatedly. Most of the carriers (70%)
TABLE 3.
Psychiatric Comorbidity by Length That Asymptomatic Hepatitis B Patients (Nⴔ43) Had Known Their Virus Carrier Status
Psychiatric Comorbidity Among Hepatitis B Virus Carriers (Nⴔ43)
Psychiatric Disorder
N
%
Major depressive disorder Anxiety disorder not otherwise specified Adjustment disorder with depressed mood Obsessive-compulsive disorder Adjustment disorder with anxious mood Dysthymic disorder Any psychiatric disorder
6 2 2 1 1 1 13
14.0 4.7 4.7 2.3 2.3 2.3 30.2
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Analysis
%
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Psychiatric Disorder Present Length of Known Hepatitis B Status
N
%
N
%
0–3 months 4–6 months 7 months to 2 years 2–5 years 6–10 years
5 2 11 18 7
11.6 4.7 25.6 41.9 16.3
3 0 3 5 2
60.0 0.0 27.3 27.8 28.6
Psychosomatics 46:2, March-April 2005
Atesci et al. demonstrated these kinds of behaviors, especially in the first 3 months after learning of hepatitis B virus carriage. Of the carriers, 14 (32.6%) had worries of illnesses related to hepatitis B infection. At the time of interview, carriers developing psychiatric disorders had more permanent worries about contamination (v2⳱1.03, df⳱1, p⬍0.05) and illnesses related to hepatitis B virus infection such as cirrhosis or hepatic cancer (v2⳱7.12, df⳱1, p⬍0.01) than did the others. When comparing the psychosocial functioning of carriers to the comparison group we excluded five carriers from the analyses because they had learned their status in the 3 months before the interview and were still in the adjustment period. The mean Global Assessment of Functioning scores of the carrier group were lower than those of the comparison group (76.86 [SD⳱9.25] versus 86.60 [SD⳱5.67], respectively; t⳱–4.46, df⳱84, p⬍0.001). Also, the mean Global Assessment of Functioning scores of carriers with psychiatric disorders (69.61 [SD⳱8.28]) were significantly lower than those of other carriers (80.00 [SD⳱7.87]) (Mann Whitney U test, z⳱–3.28, p⬍0.001). Stress factors were determined in seven carriers (16.3%): four had stress factors related to their primary supportive group, one to social factors, and the last two to other stress factors. Six of the cases with stress factors had a psychiatric disorder. Four of these cases were diagnosed with major depressive disorder (two had a death in the family, one had occupational problems, one had marriage problems), one was diagnosed as suffering from dysthymic disorder (death of father and brother as a result of hepatic failure), and the last was diagnosed with obsessive-compulsive disorder (death of father as a result of cirrhosis). Psychosocial stress factors were also found to be higher in carriers with psychiatric disorders (v2⳱12.2, df⳱1, p⬍0.01). There were no differences between male and female hepatitis B virus carriers in the presence of psychiatric diagnoses, stress factors, worries of contamination, or worries of hepatitis B virus-related illnesses. TABLE 4.
As presented in Table 4 the carrier group experienced significantly more depressive and anxiety symptoms than the comparison group according to mean Beck Depression Inventory and State-Trait Anxiety Inventory scores. Also, the carriers with psychiatric diagnosis had significantly higher Beck Depression Inventory scores (18.84 [SD⳱ 7.91]) than those without psychiatric diagnosis (8.96 [SD⳱ 5.08]) (z⳱–3.70, p⬍0.001, Mann Whitney U test). Moreover, relative to the healthy comparison subjects, the carriers without any psychiatric disorders had significantly higher scores on the Beck Depression Inventory (8.96 [SD⳱5.05]; z⳱–1.99, p⬍0.05) and the State-Trait Anxiety Inventory state scale (45.16 [SD⳱10.74]; z⳱–3.54, p⬍0.001) and trait scale (46.53 [SD⳱9.98]; z⳱–2.43, p⬍0.01). There were no significant correlations between duration of virus carriage and mean scores on the Beck Depression Inventory (r⳱0.25), State-Trait Anxiety Inventory state scale (r⳱0.20) or trait scale (r⳱0.06), or Global Assessment of Functioning (r⳱–0.11) (all p⬎0.05). There were no differences between male and female carriers in mean scores on the Beck Depression Inventory, State-Trait Anxiety Inventory, or Global Assessment of Functioning. Last, there were no significant correlations between length of education and mean scores on the Beck Depression Inventory (r⳱–0.16) or State-Trait Anxiety Inventory state scale (r⳱–0.10) or trait scale (r⳱0.03) (all p⬎0.05). DISCUSSION The results of the present study have suggested that psychiatric disorders have a considerable importance in asymptomatic hepatitis B virus carriers even in the absence of physical complaints or disabilities. The prevalence of psychiatric disorders varies between 10%–20% in community-based Turkish studies.18,19 Part of an international study planned and organized by the World Health Organization (WHO) found that in Turkey 17.6% of patients admitted for primary health care had an ICD-10 psychiatric
Symptoms of Depression and Anxiety Among Asymptomatic Hepatitis B Virus Carriers and Healthy Comparison Subjects Score Asymptomatic Hepatitis B Virus Carriers (Nⴔ43)
Healthy Comparison Subjects (Nⴔ43)
Analysis
Measure
Mean
SD
Mean
SD
t (dfⴔ41)
p
Beck Depression Inventory State-Trait Anxiety Inventory State score Trait score
11.95
7.53
6.93
5.56
3.51
0.001
45.72 47.62
9.34 9.34
36.34 40.86
12.35 8.33
3.89 3.54
0.001 0.001
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Psychopathology and Functioning in Hepatitis B Patients disorder.20 In the present study, the psychiatric disorder rate (30.2%) observed in the asymptomatic hepatitis B virus carriers was found to be higher than that of the comparison group (11.6%) and also than that of the sample drawn from community and primary health care patients as indicated in the WHO study.18–20 The rate of psychiatric disorders in our study group was similar to the rates among sufferers of chronic physical diseases (29%–40%) and chronic hepatitis C infection (22%–44%).3,21–24 It can be thought that, although physical limitations do not occur in asymptomatic hepatitis B virus carriers, the possibility of progression and the chronic nature of the situation lead to the perception of having a severe disease. The infectious character of hepatitis B, inadequate knowledge about transmission modes, and undue anxiety about transmissibility of the virus may lead to isolation of carriers.7 This social isolation might be one of the reasons for the higher rate of psychiatric disorders in the carriers. Furthermore, in our country hepatitis is stigmatized and seen as a fatal and infectious disease, requiring sufferers to avoid others. Thus, hepatitis B carrier status is perceived by our society as synonymous with having a chronic disease that will result in cirrhosis or death. A study performed in the United States indicated that hepatitis C patients experienced stigmatization as though they were lepers.25 Stigmatization in this study was associated with higher anxiety, depression, a worsened quality of life, and difficulty with coping. In our study, the high rates of psychiatric disorder in hepatitis B virus carriers may be related to the frightening and potentially stigmatizing nature of hepatitis B. In contrast, a Turkish study examining the effect of chronic hepatitis B on the psychological state of children found no difference between asymptomatic carrier patients and comparison group children with respect to anxiety and depression scores.26 This could be explained by the absence of symptoms and having sufficient information about their status; it could also be explained by the society protecting children from stigmatization. Our hepatitis B patients have experienced significantly more anxiety and depression relative to the comparison subjects, as indicated by higher anxiety and depression scores, and showed lower functioning than the comparison subjects. Depression especially was a major problem in carriers with psychiatric diagnosis, and major depressive disorders constituted 46.1% of all psychiatric diagnoses (N⳱6 of 13). As reported in Lok et al.’s study,7 worries about infectivity and the negatively affected social, family, and occupational lives of hepatitis B virus carriers were also present among our cases. The ongoing anxiety and 146
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depressive symptoms may play a disturbing role in functioning. During the interviews, we observed that articulation of worries about hepatitis B virus-related diseases (61.5%) and the feelings of threat concerning loss of physical health contributed considerably to the development of depression in hepatitis B virus carriers. These worries were prominent in the first 3 months after learning of hepatitis B virus carriage. As a result, we may say that this period comprises an acceptance and adjustment period. The carriers had been informed about hepatitis B virus infection transmission modes and preventive measures. Although this information might have caused reduced worries of infectivity, it might also lead to a distorted cognition, which is “I am ill and will be more ill in time.” Actually, it may be expected that the worries about infectivity and the threat of losing health may decrease in the course of time, but this condition was not observed in hepatitis B virus carriers who developed psychiatric disorders. The continuation of these worries and its association with depression have been demonstrated in Kunkel et al.’s study.6 Their heterogeneous sample was different from ours and included a range of patients from healthy carriers to those with hepatocellular cancer. Thus, it can be said that the threat of losing health is independent of time and current status. As indicated by the lower Global Assessment of Functioning scores in our carrier group relative to those of the comparison group, the overall functioning of the carriers was affected negatively. This situation probably originated from worries about hepatitis B virus infection and from psychiatric disorders. Members of the group of hepatitis B carriers with psychiatric diagnoses were more likely to report a stressful life event. Also, two carriers had additional chronic physical disorders and histories of depressive disorders before learning of hepatitis B virus infection. Such psychosocial stressors can be considered as contributing factors in developing a predisposition to psychiatric disorders in our carrier group. In conclusion, our study showed that 30.2% of the hepatitis B virus carriers studied met the criteria for a DSM-IV psychiatric disorder. The present study is limited by its small size and possible selection bias: carriers who have already suffered from emotional problems would be more likely to participate in a study evaluating participants for possible psychiatric problems. Nevertheless, we believe that our findings do provide some information about the psychological state of this population and that it requires more consideration. To the best of our knowledge, the present study is set apart from previous studies by two methodological advantages, which are the use of structured psyPsychosomatics 46:2, March-April 2005
Atesci et al. chiatric interviews for determining psychiatric morbidity and the homogeneity of the hepatitis B virus carriers studied. However, our results need to be replicated in larger populations in order to improve their generalizability. As a conclusion, psychiatric morbidity, and particu-
larly depression, seems an important problem for hepatitis B virus carriers, negatively affecting the patients’ overall functioning and quality of life. Multidisciplinary evaluation incorporating psychiatry and liaison services is a necessity for this population.
References
1. Shaw-Stiffel TA: Chronic hepatitis, in Principles and Practice of Infectious Diseases, 5th ed. Edited by Mandell GL, Bennett JE, Dolin R. Philadelphia, Churchill Livingstone, 2000, pp 1297–1331 2. Tasyaran MA: Epidemiology of hepatitis B virus infection, in Viral Hepatit 2001. Edited by Kilicturgay K, Badur S. Istanbul, 2000, pp 121–129 [Turkish] 3. Wells KB, Golding JM, Burnam MA: Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry 1988; 145:976–981 4. Harter M, Reuter K, Aschenbrenner A, Schretzmann B, Marschner N, Hasenburg A, Weis J: Psychiatric disorders and associated factors in cancer: results of an interview study with patients in inpatient, rehabilitation and outpatient treatment. Eur J Cancer 2001; 37:1385–1393 5. Kell B, Burnett P, Judd F: Measuring psychological adjustment to HIV infection. Int J Psychiatry Med 2000; 30:41–59 6. Kunkel EJS, Kim JS, Hann HW: Depression in Korean immigrants with hepatitis B and related liver diseases. Psychosomatics 2000; 41:472–480 7. Lok ASF, van Leeuwen DJ, Thomas HC, Sherlock S: Psychosocial impact of chronic infection with hepatitis B virus on British patients. Genitourin Med 1985; 61:279–282 8. Beck AT: An inventory measuring depression. Arch Gen Psychiatry 1961; 4:561–571 9. Tegin B: Cognitive disorders in depression: an investigation according to Beck model (Ph.D Thesis). Ankara, Hacettepe University, 1980 [Turkish] 10. Hisli N: Reliability and validity of Beck depression inventory on college students. Turkish Psychological Review 1989; 7:3–13 [Turkish] 11. Spielberger CD, Gorsuch RL, Lushene RE: Manual for State-Trait Anxiety Inventory. Palo Alto, Calif, Consulting Psychology Press, 1970 12. Oner N, Le Compte A: Manual of State and Trait Anxiety Inventory. Istanbul, Bogazici University, 1985 [Turkish] 13. Le Compte WA, Oner N: Development of the Turkish edition of the State-Trait Anxiety Inventory, in Cross Cultural Anxiety. Edited by Spielberger CD, Guerrero D. Washington, DC, Hemisphere Publishing Corporation, 1976, pp 51–68 14. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clini-
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cal Interview for DSM-IV Clinical Version (SCID-I/CD). Washington, DC, American Psychiatric Press, 1997 15. Ozkurkcugil A, Aydemir O, Yildiz M: Adaptation to Turkish and reliability study of Structured Clinical Interview for Axial I disorders. Ilac¸ ve Tedavi Dergisi 1999; 12:233–236 [Turkish] 16. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994 17. Endicott J, Spitzer R, Fleiss J, Cohen J: The Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 1976; 33:766–771 18. Kuey L, Ustun TB, Gulec C: A study that examine the epidemiology of psychiatric disorders in Turkey. Toplum ve Hekim 1987; 44:16–30 [Turkish] ¨ gel K: Social psychiatry, in Basic Psychiatry. Edited by Gu¨lec¸ 19. O C, Koroglu E. Ankara, Physicians Publication, 1998, pp 1319– 1328 ¨ zgen G: A field study of the psychiatric 20. Rezaki M, Kaplan I, O disorders in primary health care. Turk J Psychiatry 1995; 6:3–11 [Turkish] 21. Minagawa H, Uchitomi Y, Yamawaki S: Psychiatric Morbidity in terminally ill cancer patients. Cancer 1996; 78:1131–1137 22. Ozmen E, Aydemir O, Icelli I: The distribution of psychiatric diagnoses in patients with physical diseases. Ege Psikiyatri Su¨rekli Yayınları Konsu¨ltasyon Liyezon Psikiyatrisi II, 1997; 285–298 [Turkish] 23. Lehman CL, Cheung RC: Depression, anxiety, post-traumatic stress, and alcohol-related problems among veterans with chronic hepatitis C. Am J Gastroenterol 2002; 97:2640–2646 24. Kraus MR, Schafer A, Csef H, Scheurlen M, Faller H: Emotional state, coping styles, and somatic variables in patients with chronic hepatitis C. Psychosomatics 2000; 41:377–378 25. Zickmund S, Ho EY, Masuda M, Ippolito L, LaBrecque DR: “They treated me like a leper”: stigmatization and the quality of life of patients with hepatitis C. J Gen Intern Med 2003; 18:835– 844 26. Arslan N, Buyukgebiz B, Ozturk Y, Akay AP: Depression and anxiety in chronic hepatitis B: effect of hepatitis B virus infection on psychological state in childhood. Turk J Pediatr 2003; 45:26– 28
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The authors compared asymptomatic hepatitis B virus carriers and healthy subjects in terms of their psychological state. Participants (43 asymptomatic hepatitis B virus carriers and 43 healthy comparison subjects) completed self-report questionnaires. Psychiatric disorders and psychosocial functioning were evaluated with structured clinical interviews and the Global Assessment of Functioning scale. Hepatitis B virus carriers were more likely to have psychiatric disorders than comparison subjects (30.2% vs. 11.6%). Also, carriers had significantly higher depression and anxiety scores and lower Global Assessment of Functioning scores than did comparison subjects. Worries about contamination and illnesses related to hepatitis B infection were associated with the presence of psychiatric disorder. The results suggest that asymptomatic hepatitis B virus carriers need emotional support. (Psychosomatics 2005; 46:142–147)
I
t has been estimated that there are more than 400 million people (or 5% of the world’s population) with some form of chronic hepatitis B virus infection. Hepatitis B has become one of the major causes of chronic hepatitis, cirrhosis, and hepatocellular carcinoma worldwide, and more than 1 million deaths are caused by hepatitis B each year.1 The distribution of hepatitis B infection in the world differs according to geographical zone, the zones being classified as low, moderate, and high endemic regions. Turkey belongs to the moderate endemic region, and there are approximately 4 million carriers in this country.2 The association between chronic physical disorders and psychiatric illnesses, particularly depression and anxi-
Received Dec. 5, 2003; revision received April 6, 2004; accepted May 26, 2004. From the Department of Psychiatry and the Department of Clinical Microbiology and Infectious Diseases, Pamukkale University Faculty of Medicine; and the Department of Clinical Microbiology and Infectious Diseases, Celal Bayar University Faculty of Medicine, Turkey. Address correspondence and reprint requests to Dr. Atesci, Faculty of Medicine, Psychiatry Department, Pamukkale University, Doktorlar Cad. Denizli, Turkey 20100; [email protected] (e-mail). Copyright 䉷 2005 The Academy of Psychosomatic Medicine.
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ety, has been shown in previous reports. Arthritis, cancer, lung disease, neurological disorder, heart disease, and physical handicap are strongly associated with psychiatric disorders.3–5 The chronic course of hepatitis B and the knowledge of hepatitis B-related diseases like cirrhosis and hepatocellular carcinoma might be predisposing factors for some kind of psychological disorders. Also, insufficient knowledge about the transmission modes of the virus may result in the isolation of the virus carriers, especially in their social and occupational life. Kunkel et al.6 observed that 46% of patients had depressive symptoms, and depression was also significantly associated with liver dysfunction and low psychosocial functioning in a heterogeneous group of patients with hepatitis B-related diseases (i.e., physically healthy carriers of the virus and patients with hepatocellular carcinoma and hepatic cirrhosis). Lok et al.7 studied the psychosocial impact of being a hepatitis B virus carrier in 40 British patients and reported that sexual, occupational, social, family, and physical aspects of their life were negatively affected in 90% of patients. Most of the problems were related to infectivity. Psychosomatics 46:2, March-April 2005
Atesci et al. To our knowledge, there has been no study reporting psychiatric morbidity in a homogeneous group of asymptomatic hepatitis B virus carriers. In this study we aimed to investigate the effect of being a hepatitis B virus carrier on psychological state (including psychiatric morbidity per standardized interview and DSM-IV), psychosocial functioning, and worries and behavior alterations related to infection. We expected that the standardized psychiatric evaluation of hepatitis B virus carriers may lead to a better understanding of the psychological characteristics and needs of this understudied population. METHOD This study was performed in Pamukkale University Faculty of Medicine Hospital with the participation of the Departments of Psychiatry and Clinical Microbiology and Infectious Diseases between April 2001–May 2002. Hepatitis B virus carriers (N⳱98) who were registered with the Clinical Microbiology and Infectious Diseases outpatient clinic were informed about the study by telephone call and invited for the interview. The study group comprised 43 asymptomatic hepatitis B virus carriers who voluntarily accepted to participate in the study. Serum liver enzymes were within the normal values, no human immunodeficiency virus (HIV) or hepatitis C virus infection was present, and there was no drug abuse. All of the carriers had been informed about the transmission modes and preventive measures concerning hepatitis B virus infection on their first admission to the outpatient clinic. The comparison group was selected from 43 healthy patients with the same gender and similar age who had been admitted to the Clinical Microbiology and Infectious Diseases outpatient clinic for preexposure hepatitis B virus prophylaxis. They had no known physical or psychiatric diseases nor were they users of any drugs. The first interview was carried out by a specialist in Clinical Microbiology and Infectious Diseases. All of the participants completed the self-report questionnaires, Beck Depression Inventory,8–10 and Spielberger’s State-Trait Anxiety Inventory.11–13 The hepatitis B and healthy subjects were interviewed individually by a psychiatrist with the Structured Clinical Interview for DSM-IV (SCID-I). Psychosocial functioning was examined with the DSM-IV Axis V Global Assessment of Functioning scale on the same day.14,15 Also, during the interview period the asymptomatic carriers were questioned about when they learned of their carrier status, how they reacted, and their behavior Psychosomatics 46:2, March-April 2005
and thoughts concerning their carrier status and axis IV DSM-IV psychosocial stressors. Data Collection Materials Beck Depression Inventory This inventory includes 21 items aimed to screen the signs of depression that occur in the vegetative, cognitive, motivational, and emotional fields.8 Validity and reliability studies have been performed for the Turkish form, and the cutoff score was accepted as 17.2,10 The total score ranges from 0 to 63. Spielberger’s State-Trait Anxiety Inventory This inventory is a self-reported measure of subjective anxiety.11 It comprises two 20-item scales; the state scale requires subjects to report current feelings of anxiety, and the trait scale measures longstanding background symptoms. The validity and reliability of the Turkish forms were carried out by Oner and Le Compte.12,13 Structured Clinical Interview for DSM-IV—Clinical Version This clinical interview inventory by First et al.14 was partially constructed toward assessing DSM-IV axis I diagnoses. It provides not only standardization in the evaluation process but also convenience in usage. Adaptation to Turkish and validity and reliability studies were performed by Ozkurkcugil et al.15 Global Assessment of Functioning Scale Axis V is a global assessment of functioning in which clinicians judge patients’ overall levels of functioning during a particular time. Functioning is considered a composition of three major areas: social, occupational, and psychological. The Global Assessment of Functioning scale is a 100-point scale, 100 representing the highest level of functioning in all areas.16 Psychometric properties of the instrument are described as adequate with evidence for moderate reliability (r⳱0.61–0.91).17 Statistical Analysis The statistical analysis was performed by SPSS version 10.0. Comparisons of group means were performed by Student’s t test or Mann-Whitney U test as the most appropriate for related data. Chi-square tests were used to evaluate the differences between groups for categorical variables. Pearson’s correlation analyses were used to examine the relationship between duration of hepatitis B virus carriage and scores on the Global Assessment of Funchttp://psy.psychiatryonline.org
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Psychopathology and Functioning in Hepatitis B Patients
TABLE 1.
Demographic Characteristics of Asymptomatic Hepatitis B Virus Carriers and Healthy Comparison Subjects Healthy Comparison Subjects (Nⴔ43)
Hepatitis B Virus Carriers (Nⴔ43) Characteristic Marital status Married Widowed Single Educational level Primary High University Occupation Employee Self-employed Housewife Retired University student
N
%
N
35 7 1
81.4 16.3 2.3
37 5 1
86.1 11.6 2.3
9 16 18
20.9 37.2 41.9
11 12 20
25.6 27.9 46.5
19 5 9 7 3
44.2 11.6 20.9 16.3 7.0
26 5 6 4 2
60.5 11.6 14.0 9.3 4.7
tioning, Beck Depression Inventory, and Spielberger’s State-Trait Anxiety Inventory. RESULTS The study consisted of 43 hepatitis B virus carriers and 43 comparison subjects, and both groups consisted of 22 women (51.2%) and 21 men (48.8%). The mean age of the carrier group was 38.8 years (SD⳱11.1) and that of the comparison group was 39.1 (SD⳱11.8) (Student’s t test, t⳱–1.37, df⳱84, p⬎0.50). No significant differences were found between the two groups with respect to sociodemographic variables (Table 1). Psychiatric disorders were detected in 13 (30.2%) of 43 subjects in the carrier group (Table 2). Two carriers with psychiatric disorders had additional chronic physical disorders like bronchial asthma and Parkinson’s disease. These two carriers had a history of depressive disorder. At the time of interview, one of them was diagnosed as suffering from major depressive disorder and the other as suffering from adjustment disorder with depressed mood. TABLE 2.
v2
df
p
0.389
2
0.82
0.877
2
0.64
2.707
4
0.60
Five participants from the comparison group (11.6%) had psychiatric disorders. Two of them were diagnosed with a major depressive disorder, one had generalized anxiety disorder, and the last two had anxiety disorder not otherwise specified. The frequency of the psychiatric disorders was significantly higher in the carrier group than in the comparison group (v2⳱4.49, df⳱1, p⬍0.05). Most of the carriers (41.9%, N⳱18) had learned of their hepatitis B virus infection 2–5 years before the interview. Psychiatric disorders were more frequent among the carriers who had learned of their hepatitis B virus infection within 3 months of the interview (Table 3). Twelve (27.9%) of 43 carriers had worries about contaminating their relatives and exhibited some behavior alterations. Some separated their plates from others, some closed their mouths when feeding their children or avoided kissing them even though the children were vaccinated, and some washed their vegetables repeatedly. Most of the carriers (70%)
TABLE 3.
Psychiatric Comorbidity by Length That Asymptomatic Hepatitis B Patients (Nⴔ43) Had Known Their Virus Carrier Status
Psychiatric Comorbidity Among Hepatitis B Virus Carriers (Nⴔ43)
Psychiatric Disorder
N
%
Major depressive disorder Anxiety disorder not otherwise specified Adjustment disorder with depressed mood Obsessive-compulsive disorder Adjustment disorder with anxious mood Dysthymic disorder Any psychiatric disorder
6 2 2 1 1 1 13
14.0 4.7 4.7 2.3 2.3 2.3 30.2
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Analysis
%
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Psychiatric Disorder Present Length of Known Hepatitis B Status
N
%
N
%
0–3 months 4–6 months 7 months to 2 years 2–5 years 6–10 years
5 2 11 18 7
11.6 4.7 25.6 41.9 16.3
3 0 3 5 2
60.0 0.0 27.3 27.8 28.6
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Atesci et al. demonstrated these kinds of behaviors, especially in the first 3 months after learning of hepatitis B virus carriage. Of the carriers, 14 (32.6%) had worries of illnesses related to hepatitis B infection. At the time of interview, carriers developing psychiatric disorders had more permanent worries about contamination (v2⳱1.03, df⳱1, p⬍0.05) and illnesses related to hepatitis B virus infection such as cirrhosis or hepatic cancer (v2⳱7.12, df⳱1, p⬍0.01) than did the others. When comparing the psychosocial functioning of carriers to the comparison group we excluded five carriers from the analyses because they had learned their status in the 3 months before the interview and were still in the adjustment period. The mean Global Assessment of Functioning scores of the carrier group were lower than those of the comparison group (76.86 [SD⳱9.25] versus 86.60 [SD⳱5.67], respectively; t⳱–4.46, df⳱84, p⬍0.001). Also, the mean Global Assessment of Functioning scores of carriers with psychiatric disorders (69.61 [SD⳱8.28]) were significantly lower than those of other carriers (80.00 [SD⳱7.87]) (Mann Whitney U test, z⳱–3.28, p⬍0.001). Stress factors were determined in seven carriers (16.3%): four had stress factors related to their primary supportive group, one to social factors, and the last two to other stress factors. Six of the cases with stress factors had a psychiatric disorder. Four of these cases were diagnosed with major depressive disorder (two had a death in the family, one had occupational problems, one had marriage problems), one was diagnosed as suffering from dysthymic disorder (death of father and brother as a result of hepatic failure), and the last was diagnosed with obsessive-compulsive disorder (death of father as a result of cirrhosis). Psychosocial stress factors were also found to be higher in carriers with psychiatric disorders (v2⳱12.2, df⳱1, p⬍0.01). There were no differences between male and female hepatitis B virus carriers in the presence of psychiatric diagnoses, stress factors, worries of contamination, or worries of hepatitis B virus-related illnesses. TABLE 4.
As presented in Table 4 the carrier group experienced significantly more depressive and anxiety symptoms than the comparison group according to mean Beck Depression Inventory and State-Trait Anxiety Inventory scores. Also, the carriers with psychiatric diagnosis had significantly higher Beck Depression Inventory scores (18.84 [SD⳱ 7.91]) than those without psychiatric diagnosis (8.96 [SD⳱ 5.08]) (z⳱–3.70, p⬍0.001, Mann Whitney U test). Moreover, relative to the healthy comparison subjects, the carriers without any psychiatric disorders had significantly higher scores on the Beck Depression Inventory (8.96 [SD⳱5.05]; z⳱–1.99, p⬍0.05) and the State-Trait Anxiety Inventory state scale (45.16 [SD⳱10.74]; z⳱–3.54, p⬍0.001) and trait scale (46.53 [SD⳱9.98]; z⳱–2.43, p⬍0.01). There were no significant correlations between duration of virus carriage and mean scores on the Beck Depression Inventory (r⳱0.25), State-Trait Anxiety Inventory state scale (r⳱0.20) or trait scale (r⳱0.06), or Global Assessment of Functioning (r⳱–0.11) (all p⬎0.05). There were no differences between male and female carriers in mean scores on the Beck Depression Inventory, State-Trait Anxiety Inventory, or Global Assessment of Functioning. Last, there were no significant correlations between length of education and mean scores on the Beck Depression Inventory (r⳱–0.16) or State-Trait Anxiety Inventory state scale (r⳱–0.10) or trait scale (r⳱0.03) (all p⬎0.05). DISCUSSION The results of the present study have suggested that psychiatric disorders have a considerable importance in asymptomatic hepatitis B virus carriers even in the absence of physical complaints or disabilities. The prevalence of psychiatric disorders varies between 10%–20% in community-based Turkish studies.18,19 Part of an international study planned and organized by the World Health Organization (WHO) found that in Turkey 17.6% of patients admitted for primary health care had an ICD-10 psychiatric
Symptoms of Depression and Anxiety Among Asymptomatic Hepatitis B Virus Carriers and Healthy Comparison Subjects Score Asymptomatic Hepatitis B Virus Carriers (Nⴔ43)
Healthy Comparison Subjects (Nⴔ43)
Analysis
Measure
Mean
SD
Mean
SD
t (dfⴔ41)
p
Beck Depression Inventory State-Trait Anxiety Inventory State score Trait score
11.95
7.53
6.93
5.56
3.51
0.001
45.72 47.62
9.34 9.34
36.34 40.86
12.35 8.33
3.89 3.54
0.001 0.001
Psychosomatics 46:2, March-April 2005
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Psychopathology and Functioning in Hepatitis B Patients disorder.20 In the present study, the psychiatric disorder rate (30.2%) observed in the asymptomatic hepatitis B virus carriers was found to be higher than that of the comparison group (11.6%) and also than that of the sample drawn from community and primary health care patients as indicated in the WHO study.18–20 The rate of psychiatric disorders in our study group was similar to the rates among sufferers of chronic physical diseases (29%–40%) and chronic hepatitis C infection (22%–44%).3,21–24 It can be thought that, although physical limitations do not occur in asymptomatic hepatitis B virus carriers, the possibility of progression and the chronic nature of the situation lead to the perception of having a severe disease. The infectious character of hepatitis B, inadequate knowledge about transmission modes, and undue anxiety about transmissibility of the virus may lead to isolation of carriers.7 This social isolation might be one of the reasons for the higher rate of psychiatric disorders in the carriers. Furthermore, in our country hepatitis is stigmatized and seen as a fatal and infectious disease, requiring sufferers to avoid others. Thus, hepatitis B carrier status is perceived by our society as synonymous with having a chronic disease that will result in cirrhosis or death. A study performed in the United States indicated that hepatitis C patients experienced stigmatization as though they were lepers.25 Stigmatization in this study was associated with higher anxiety, depression, a worsened quality of life, and difficulty with coping. In our study, the high rates of psychiatric disorder in hepatitis B virus carriers may be related to the frightening and potentially stigmatizing nature of hepatitis B. In contrast, a Turkish study examining the effect of chronic hepatitis B on the psychological state of children found no difference between asymptomatic carrier patients and comparison group children with respect to anxiety and depression scores.26 This could be explained by the absence of symptoms and having sufficient information about their status; it could also be explained by the society protecting children from stigmatization. Our hepatitis B patients have experienced significantly more anxiety and depression relative to the comparison subjects, as indicated by higher anxiety and depression scores, and showed lower functioning than the comparison subjects. Depression especially was a major problem in carriers with psychiatric diagnosis, and major depressive disorders constituted 46.1% of all psychiatric diagnoses (N⳱6 of 13). As reported in Lok et al.’s study,7 worries about infectivity and the negatively affected social, family, and occupational lives of hepatitis B virus carriers were also present among our cases. The ongoing anxiety and 146
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depressive symptoms may play a disturbing role in functioning. During the interviews, we observed that articulation of worries about hepatitis B virus-related diseases (61.5%) and the feelings of threat concerning loss of physical health contributed considerably to the development of depression in hepatitis B virus carriers. These worries were prominent in the first 3 months after learning of hepatitis B virus carriage. As a result, we may say that this period comprises an acceptance and adjustment period. The carriers had been informed about hepatitis B virus infection transmission modes and preventive measures. Although this information might have caused reduced worries of infectivity, it might also lead to a distorted cognition, which is “I am ill and will be more ill in time.” Actually, it may be expected that the worries about infectivity and the threat of losing health may decrease in the course of time, but this condition was not observed in hepatitis B virus carriers who developed psychiatric disorders. The continuation of these worries and its association with depression have been demonstrated in Kunkel et al.’s study.6 Their heterogeneous sample was different from ours and included a range of patients from healthy carriers to those with hepatocellular cancer. Thus, it can be said that the threat of losing health is independent of time and current status. As indicated by the lower Global Assessment of Functioning scores in our carrier group relative to those of the comparison group, the overall functioning of the carriers was affected negatively. This situation probably originated from worries about hepatitis B virus infection and from psychiatric disorders. Members of the group of hepatitis B carriers with psychiatric diagnoses were more likely to report a stressful life event. Also, two carriers had additional chronic physical disorders and histories of depressive disorders before learning of hepatitis B virus infection. Such psychosocial stressors can be considered as contributing factors in developing a predisposition to psychiatric disorders in our carrier group. In conclusion, our study showed that 30.2% of the hepatitis B virus carriers studied met the criteria for a DSM-IV psychiatric disorder. The present study is limited by its small size and possible selection bias: carriers who have already suffered from emotional problems would be more likely to participate in a study evaluating participants for possible psychiatric problems. Nevertheless, we believe that our findings do provide some information about the psychological state of this population and that it requires more consideration. To the best of our knowledge, the present study is set apart from previous studies by two methodological advantages, which are the use of structured psyPsychosomatics 46:2, March-April 2005
Atesci et al. chiatric interviews for determining psychiatric morbidity and the homogeneity of the hepatitis B virus carriers studied. However, our results need to be replicated in larger populations in order to improve their generalizability. As a conclusion, psychiatric morbidity, and particu-
larly depression, seems an important problem for hepatitis B virus carriers, negatively affecting the patients’ overall functioning and quality of life. Multidisciplinary evaluation incorporating psychiatry and liaison services is a necessity for this population.
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