Adjustments in Hepatitis C Infection Roger A Wong BSc MRCPsych Brownlee Centre, Glasgow 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 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

1075 drug users in UK Heroin use 87% Brief Symptom Inventory 1075 drug users in UK Heroin use 87% Brief Symptom Inventory

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

National Veterans Affairs Database 1.9 million veterans admitted to hospital in USA between Hepatitis C infection 33,824 (1.8%) National Veterans Affairs Database 1.9 million veterans admitted to hospital in USA between Hepatitis C infection 33,824 (1.8%) El-Serag, Gastroenterology 2002;123

Psychiatric or substance misuse 86% Opiate use 48% Inpatient care for psychiatric or drug misuse disorder 31% Psychiatric or substance misuse 86% Opiate use 48% Inpatient care for psychiatric or drug misuse disorder 31%

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% 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%

Vietnam-era veterans HCV Infected HCV Negative Depression49%39% Anxiety41%33% Alcohol Dependence 78%46% Drug Use69%31%

“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

Psychological Morbidity 60% Depression 27% Previous psychiatric history 50% Psychiatric treatment within last year 41% Psychological Morbidity 60% Depression 27% Previous psychiatric history 50% 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 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.

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

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

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% 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

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

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

Neuropsychiatric Side Effects of Interferon-α Therapy Irritability Depression Insomnia Mania Suicide Irritability Depression Insomnia Mania Suicide

Incidence of Depression in Interferon Therapy NToolDepression 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 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 Commonest Cause of Drop Out from Interferon Treatment for Hepatitis C Neuropsychiatric Side Effects

Baseline psychiatric assessment Pre-treatment information, advice and support On-treatment monitoring and support Managing neuropsychiatric side effects Baseline psychiatric assessment Pre-treatment information, advice and support On-treatment monitoring and support Managing neuropsychiatric side effects

Dietetics BBV Specialist Nursing Occupational Therapy Pharmacy Psychiatry & Counselling Physiotherapy Sexual Health Social Work Dietetics BBV Specialist Nursing Occupational Therapy Pharmacy Psychiatry & Counselling Physiotherapy Sexual Health Social Work

Nurse-led Interferon Clinic Routine mood screening Clinical psychiatric assessment Nurse-led Interferon Clinic Routine mood screening 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. 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 Support Antidepressant medication Hypnotics Discontinuation of treatment Support Antidepressant medication Hypnotics Discontinuation of treatment

Living with Hepatitis C Infection Make informed decisions Identify relevant psychosocial and medical issues Access appropriate services Utilise appropriate help and support Make informed decisions Identify relevant psychosocial and medical issues Access appropriate services Utilise appropriate help and support

Managing Hepatitis C Infection Make informed decisions Identify relevant psychosocial and medical issues Access appropriate services Utilise appropriate help and support Make informed decisions Identify relevant psychosocial and medical issues Access appropriate services Utilise appropriate help and support Enable the individual to: