Mood disorder associated with gastrointestinal and liver diseases: are there many challenges?
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ABSTRACT: Objective: To assess and compare the severity of depression in chronic hepatitis B (CHB), chronic hepatitis C (CHC) and healthy subjects. Study Design: Comparative study. Place and Duration of Study: Shifa International Hospital, Islamabad from July 2011 to February 2012. Methodology: A total of 206 subjects were divided in three groups. Group-I (chronic hepatitis C, n = 95), group-II (chronic hepatitis B, n = 29) and group-III (healthy subjects, n = 82). They were matched for age, gender and socioeconomic status and were compared for frequency and severity of depression as measured by Hospital Anxiety and Depression Scale (HADS). Results: Some degree of depression was noted in all groups. Frequency of depression was 72.6% in group-I, 58.6% in group-II and 37.8% in group-III (p value < 0.001). Conclusion: Both CHC and CHB had high frequency of some degree of depression. Hepatitis C patients had more depressive features than CHB. It is worthwhile to do more close mental health observation in them. A multidisciplinary team including a psychiatric specialist can help in this approach.Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 10/2012; 22(10):632-4.
With the high prevalence of hepatitis and other
gastrointestinal illness in the country, we come across the
mental health consequences of such medical problems. The
major issues are with depression and anxiety. It is quite
understandable that physical illnesses bring in with them
stress that is intrinsic by virtue of the serious nature of
medical illness, the socio-economical repercussions and the
uncertain prognosis in terms of the nature of illness. The
major mental health problem that these patients are referred
with is depression that can be of moderate to severe
intensity. Depression in itself is a separate clinical entity
that calls for treatment. This becomes challenging for
mental health professional in a number of ways, first to
educate the patient that there is another illness to be dealt
with, the type of tailored psychotherapy that the individual
person would need and above all, the biological treatment in
terms of its suitability, side effects and interaction with the
medications already been prescribed for the medical
condition in question. One particular drug is notoriously
known for inducing depression is Interferon. Here the
challenge for management of depression becomes more
acute. However, there are a number of success stories that
are quite encouraging. Though several experts claim that
antiviral therapy should not be given to HCV patients
having psychiatric problems, this has proven wrong in
clinical trials as SSRI (selective serotonin uptake inhibitors)
have proven effective.1
Reviewing the evidence of associations between
depression and Hepatitis C and Interferon treatment and its
association with immune mechanism effective treatment
with the use of anti-depressants has been recommended in a
Asnis et al3in their study emphasized on the finding
of depression prior to interferon therapy that could
contribute to the propensity to develop depression during
treatment. They also wondered whether pegylation of
interferon would lead to reduced potential to induce
depression. The effective use of nortriptyline in patient with
simultaneous interferon treatment proved to be highly
beneficial in a reported case.4
Paroxetine has been tried successfully for interferon
associated depression in a study.5In a case series,
Imipramine, Sertraline, Paroxetine were administered with
successful outcome in interferon related depression.6It has
been advocated that selection of antidepressant agent in
medically ill patients require careful assessment in terms of
physiological vulnerabilities, potential for drug interactions
and patient's primary symptoms, newer drugs like
Bupropion, and Venlafaxine have simplified the treatment
of depression while refractory cases can be managed with
electroconvulsive therapy.7It has also been noted that the
effects of antidepressant therapy are reversed by initiation
of interferon. It was suggested that ECT is more likely than
SSRIs to be effective in interferon-induced major
depression.8A study conducted in Pakistan on 100 patients
revealed that among those who were on interferon therapy,
47% had depression before and after taking interferon.
Among these 6% reported suicidal ideation, none of these
HCV positive cases were on antidepressants or either
referred for psychiatric evaluation.9The aforementioned
study does not go further to address the problem of
depression among these patients. Psychotherapy may also
play a major role especially the cognitive Behavioural and
the supportive type but tailoring it according to the needs for
individual personality profile can be challenging. Education
for the patient in terms of understanding the dynamics of
both physical and mental health issues and its management
is an essential task for the treating physician. A
simultaneous follow up by both specialties is another
important step to follow. Despite all these, a number of
issues remain on the horizon like: to discontinue the
interferon or reducing the dose, compliance by the patient,
selection of appropriate antidepressant, monitoring the side
effects of both types of medications, caution for any drug-
drug interaction and ways to keep the communication intact
between medical consultant and the psychiatrist for ongoing
review of the patient's condition. This year, the World
Federation for Mental Health (WFMH) has emphasized on
collaborative care for both mental and physical illnesses. In
many instances, both types of illnesses are interwoven and
treatment of one in isolation does not bring total well-being
to the patients. Can we afford to ignore this fact?
1.Horsmans Y. Interferon-induced depression in chronic hepatitis C. J
Antimicrobial Chemotherapy 2006; 58: 711-3.
1064J Pak Med Assoc
Opinion and Debate
Mood disorder associated with gastrointestinal and
liver diseases: Are there many challenges?
Amin A. Muhammad Gadit
Memorial University of Newfoundland, Canada.
2. Angelino AF, Treisman GJ. Evidence-informed assessment and treatment of
depression in HCV and interferon-treated patients. Int Review Psychiat 2005;
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Hepatitis C: A Review of its Prevalence, Risk Factors, Biology, and Treatment
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4. Goldman LS. Successful treatment of interferon alfa-induced mood disorder
with Nortriptyline-letter. Psychosomatics 1994; 35: 412-3.
5. Kraus MR, Schafer A, Faller H, Csef H, Scheurlen M. Paroxetine for the
treatment of interferon-alpha-induced depression in chronic hepatitis C.
Alimentary Pharmacol Therapeutics 2002; 16: 1091-9.
6.Gleason OC, Yates WR. Five cases of interferon-alpha-induced
depression treated with antidepressant therapy. Psychosomatics 1999;
7. Beliles K, Stoudemire A. Psychopharmacologic treatment of depression in the
medically ill. Psychosomatics 1998; 39: S2-S19.
8.McAllister-Williams RH, Young AH. Antidepressant response reversed by
interferon. Br J Psychiatry 2000; 176: 93.
9. Majeed S, Memon A, Abidi MA. Frequency of depression among Hepatitis C
patients. KUST Med J 2009; 1: 42-5.
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