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Psychiatric disorders among veterans with hepatitis C infection
Reported by Jules Levin
  GASTROENTEROLOGY 2002;123:476-482 Hashem B. El-Serag, M.D., M.P.H., The Houston Veterans Affairs Medical Center
This study highlights the concern that HCV/HIV coinfected patients may be more likely to have psychiatric and emotional disorders due to IVDU, alcohol use, and chaotic life histories. Treating HCV-infected patients with interferon can result in neuropsychiatric side effects, mostly as depression and, rarely, mania. These problems may make it more difficult to manage HCV in coinfected patients, and may make adherence to therapy more difficult. With proper and adequate counseling and support programs many of the individuals can respond well to therapy as reported by Diana Sylvestri in her well received study presented at DDW Conference in 2002. The data from this study can be found at the NATAP website DDW Conference report. As well, The NIH Consensus Conference Report 2002, also available on the NATAP website, supports not excluding IVDUs from HCV therapy, and supports the importance of treating these communities and in developing support services to encourage treatment and improve responses to therapy. The problem is that there is little of these programs and services ongoing at this point in time.
The presence of psychiatric, drug-, and alcohol-use disorders in hepatitis C virus (HCV)-infected patients may influence their management and prognosis. The frequency and the risk for these disorders among HCV-infected patients are unknown. We identified all HCV-infected veteran patients who were hospitalized during 1992-1999 and searched the inpatient and outpatient computerized files for predefined psychiatric, drug-, and/or alcohol-use disorders. We then performed a case-control study among Vietnam veterans; controls without HCV were randomly chosen from hospitalized patients. Results: We identified 33,824 HCV-infected patients, in whom 86.4% had at least one past or present psychiatric, drug-, or alcohol-use disorder recorded. However, only 31% had active disorders as defined by hospitalization to psychiatric or drug-detoxification bed sections. There were 22,341 HCV-infected patients from the Vietnam period of service (cases) who were compared with 43,267 patients without HCV (controls). Cases were more likely to have depressive disorders (49.5% vs. 39.1%), posttraumatic stress disorder (PTSD) (33.5% vs. 24.5%), psychosis (23.7% vs. 20.9%), bipolar disorder (16.0% vs. 12.6%), anxiety disorders (40.8% vs. 32.9%), alcohol (77.6% vs. 45.0%), and drug-use disorders (69.4% vs. 31.1%). In multivariable regression analyses that adjust for age, sex, and ethnicity, drug use, alcohol-use, depression, PTSD, and anxiety remained strongly associated with HCV.
The authors concluded that several psychiatric, drug-, and alcohol-use disorders are commonly found among HCV-infected veterans compared with those who are not infected. At least one third of these patients have active disorders. A multidisciplinary approach to the management of HCV-infected patients is needed.
These results show some of the obstacles encountered in managing HCV-infected patients and the potential difficulty in enrolling and maintaining patients in antiviral treatment regimens that were found to be of good efficacy in randomized controlled trials. Conversely, effectiveness of HCV therapy outside these settings may be more difficult to achieve. At least 3 recent studies have highlighted this issue. In the first, it was reported that 242 of 557 patients (43.4%) initially referred to the HCV clinic at the St. Louis VA did not keep their appointments. Of the remaining 242 HCV-infected patients that were observed, at least 64 (26%) had active psychiatric or drug-use disorders. In another study from a teaching hospital in Cleveland, 72% of 293 HCV-positive patients were not treated for the following reasons: 37% did not adhere to evaluation procedures, 34% had medical or psychiatric contraindications, and 13% had ongoing substance or alcohol abuse. Some of the observed results may represent confounding by substance use and alcohol disorders given the well-known association between substance use and alcohol and other psychiatric disorders. There are other explanations, not related to confounding by substance/alcohol use, for the higher frequency of psychiatric disorders among HCV-infected patients. Patients with psychiatric disorders were more likely to have high-risk behavior such as intravenous drug use17 and unprotected sex with multiple sexual partners, which increased their risk for HCV acquisition. However, we are unable in this analysis to determine to what degree psychiatric disorders predispose to substance use.
Several factors may affect the generalizability of the current results. First, the strong association seen in this study of hospitalized veterans may not be present in outpatient samples. However, there were no differences between cases with HCV and controls in the priority of listing psychiatric diagnoses (primary vs. secondary diagnoses) or the place where the diagnosis was made (inpatient vs. outpatient). Second, the proportion of patients in cases and controls with psychiatric diagnosis is higher in the veteran population than in nonveteran populations.17,32 Third, the study sample was composed almost entirely of men. For these reasons, caution must be exercised before extrapolating the prevalence results to non-VA populations. However, we believe that because of the case-control design, the odds ratios probably would be similar in non-VA populations.
The authors concluded that we have shown that psychiatric disorders including drug use and alcohol use are very common among hospitalized veterans with HCV; however, these results may not be applicable to other HCV-infected populations. We suggest that health care providers should screen HCV-infected persons for these disorders and consider screening persons with these disorders for HCV infection. A multidisciplinary approach to subsequent management including counseling, drug and alcohol treatment and rehabilitation, as well as appropriate referral, should be an integral part of HCV management programs. Future studies assessing the impact of these psychiatric disorders on the clinical course of HCV are warranted
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