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

Adjustments in Hepatitis C Infection

Adjustments in Hepatitis C Infection

Roger A Wong BSc MRCPsychBrownlee Centre, Glasgow

Roger A Wong BSc MRCPsychBrownlee 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 2000Marsden 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 1992 - 1999

Hepatitis C infection 33,824 (1.8%)

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;123El-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

Depression

49% 39%

Anxiety 41% 33%Alcohol

Dependence

78% 46%

Drug Use 69% 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.”

“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 1998J. 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.

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.

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

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


Post-Test Discussion in Hepatitis C Screening

Post-Test Discussion in Hepatitis C Screening

• Communicate result clearly

• Explain implications of result

• Identify relevant issues for follow-up/referral


• Communicate result clearly

• Explain implications of result

• Identify relevant issues for follow-up/referral


Identified Psychological and Social Problems in Hepatitis C Antibody

Positive Clients


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 unpublishedAudit of referrals to V. Lynch, Hep C Counsellor, Brownlee Centre 1999 unpublished


Positive Clients


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%


Positive Clients


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

Neuropsychiatric Side Effects of Interferon-α

Therapy

• Irritability

• Depression

• Insomnia

• Mania

• Suicide

• Irritability

• Depression

• Insomnia

• Mania

• Suicide

Incidence of Depression in

Interferon TherapyN 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 2003Horikawa N General Hospital Psychiatry 2003Bonaccorso S Journal of Affective Disorders 2002Hauser P Molecular Psychiatry 2002

Kraus MR Journal of Clinical Psychiatry 2003Horikawa N General Hospital Psychiatry 2003Bonaccorso S Journal of Affective Disorders 2002Hauser 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

DieteticsBBV Specialist NursingOccupational Therapy

PharmacyPsychiatry & Counselling

PhysiotherapySexual HealthSocial Work

DieteticsBBV Specialist NursingOccupational Therapy

PharmacyPsychiatry & Counselling

PhysiotherapySexual HealthSocial 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

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 InfectionLiving with Hepatitis C Infection

• Make informed decisions

• Identify relevant psychosocial and medical issues

• Access appropriate services

• Utilise appropriate help and support





Managing Hepatitis C InfectionManaging Hepatitis C Infection









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