Viral Hepatitis in Hawai‘i – Differing Perspectives
III. Perspectives of Physicians
B. Management Hepatitis in Patients with Psychiatric and Substance Abuse Disorders:
William Haning MD and Nancy Withers MD, MPH
pp. 8-9
Hepatitis C has been termed a ‘psychiatric epidemic’ in that it is estimated that 20% of severely mentally ill patients have HCV, which is about ten times the prevalence in the general US population.6 Individuals with psychiatric and substance abuse disorders have a much greater risk of developing chronic liver disease including chronic HCV and fatty liver disease than the general population. Many psychiatric patients often develop metabolic syndromes in adulthood due to factors such as diet, lifestyle, and medications, which can lead to nonalcoholic fatty liver disease. The aggressive pharmacotherapy required for management of hepatitis C has emphasized that these medications carry some psychiatric risk, e.g. mood disorders and aggravation of substance abuse. As a result, primary, secondary, and tertiary prevention strategies are the shared responsibilities of the general psychiatrist, addictionist, and general practitioner. These include: 1) reduction of risk for other causes of hepatitis; 2) management of transmissibility of hepatitis; 3) pharmacological suppression of hepatic injury; and 4) management of psychiatric co-morbidity, primarily mood disorders, from the combination of hepatitis and hepatitis therapy.
Common psychiatric and substance abuse disorder co-morbidities accompanying hepatitis C treatment are mood disorders such as depression and hypomania, cognitive disorders such as paranoia and psychosis, delirium which can progress from disorientation to confusion to a comatose state, anxiety, sleep disorders, exacerbation of existing personality disorders, and pathological bereavement. Huckans et al.7 demonstrated that individuals with and without a history of substance abuse disorders cleared the HCV virus at similar rates, and indicated that patients with co-morbid substance abuse disorders and HCV are capable of successfully completing a course of antiviral therapy. Currently, there are no reliable predictors to determine which individuals might suffer from severe psychiatric side effects, although pre-treatment screenings including Alcohol Use Disorders Identification Test (AUDIT-C), the Beck Depression Inventory, Beck Anxiety Inventory, and the Aggression Questionnaire can stabilize and guide the course of treatment and monitoring. Just as HIV disease was originally dismissed as an illness of gays, prostitutes, and drug addicts, hepatitis C has also taken on the association with drug addiction. That population, frequently not seen as deserving of any particular attention, and certainly not any priority in epidemiological management, has difficulty speaking for itself, or more correctly, in being heard. Unique challenges in treating individuals with substance abuse and psychiatric disorders and HCV include increased risk for liver disease, identification of safe pharmacotherapy, and availability of adequate treatment facilities.
Increased Risk for Liver Disease
Individuals with substance abuse disorders are at a 40% higher risk for chronic HCV from intravenous or intranasal drug abuse than the general population, and often have co-morbid alcoholic and/or nonalcoholic fatty liver disease. According to Swartz et al.6 only 54% of those with severe mental illness and HCV infection have a regular source of medical care. General hepatitis C education explaining the ‘silent epidemic’ is an important aspect in reducing the risk of infection for this subgroup of patients. Specifically, it is important to educate patients about 1) the impact of alcohol use and importance of sobriety, 2) drug abuse and dependence as a means of re-infection, 3) effects of other medications such as acetaminophen and ibuprofen on liver function, 4) transmission of the disease, 5) discussion of health behaviors including the importance of exercise and nutrition as they relate to the risk of fatty liver disease, and 6) making sure patients are aware of vaccinations for hepatitis A and B if they are not protected. In addition, psychiatrist and primary care provider integration to monitor lab results, weight, risk of metabolic syndrome and hyperlipidemia, and treatment and monitoring of interferon and ribavirin for those with chronic HCV are important tools in managing patient care.
Identification of Safe Pharmacotherapy
In the mid-1990s, gastroenterologists were often reluctant to initiate interferon and ribavirin therapy for psychiatric patients with chronic hepatitis C because of their concern about noncompliance, symptom instability, and even risk of suicide. At that time, it was known that interferon could induce serious neuropsychiatric symptoms and worsen pre-existing conditions. Current treatment of chronic hepatitis C involves the use of interferon and ribavirin for 24 to 48 weeks, depending on the viral genotype, and still has the potential to worsen pre-existing psychiatric symptoms and even cause new symptoms and unpleasant side effects to occur. This treatment, which may be effective in curing hepatitis C in a percentage of patients when administered consistently, might also place the individual at risk for relapse to prior substance dependence, and has the potential to induce symptoms such as depression, aggression or agitation, and anxiety. In addition, insomnia, fatigue, cognitive impairment (“mind fog”), and pain exacerbation have been reported. Interferon-alfa induced depression is a major limitation for the treatment of chronic hepatitis C, especially for patients with psychiatric disorders. Prophylactic treatment to prevent depression during HCV therapy using citalopram (Celexa) and paroxetine (Paxil) have been shown to significantly reduce the incidence of major depression during the first 6 months of antiviral treatment compared to control groups.8 Mirtazapine (Remeron) is also a recommended first line antidepressant to consider in treatment. Institutional screening and regular monthly monitoring of affective and cognitive status using standardized instruments such as the Hamilton Depression Index and Brief Psychiatric Rating Scale are recommended to monitor the effects of treatment. The principal pharmacokinetic considerations in setting an antidepressant’s dose are inhibiting the metabolism of medications that use the cytochrome P450 CYP 2D6 system, thus raising serum concentrations. Particularly affected are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, as well as the tetracyclic antidepressant mirtazapine.
In addition to treatment, other steps can be taken to improve the outcomes of HCV-infected patients with psychiatric and substance abuse disorders. Discussions with the patient and caretakers/family can be initiated well before treatment begins to explain the potential side effects of the antiviral treatment so that plans can be made to increase the psychosocial support of the patient. Optimal timing of the treatment can be discussed in order to reduce stress on the patient and caretakers. Close mental health monitoring and co-management of patients with HCV clinicians, including screening questionnaires, interviews, medication management and cognitive therapy are strategies that will assist in successful treatment of patients with mental health issues who are undergoing interferon and ribavirin therapies.
Availability of Facilities for Management and Care
The single population most afflicted by viral hepatitis is found in the methadone maintenance treatment facilities (MMTFs), which are the end point for many opioid dependence issues. Estimates of prevalence in this population are surprisingly consistent, with point prevalence of hepatitis B in 2007 at 20%, and hepatitis C at 80%.9 However, institutional and systemic responses have been restricted by diminishing reimbursement for such facilities and the resultant diminution of counseling, rehabilitation, and allied health services. As a result there is limited availability of adequate substance abuse disorder treatment facilities for the identified chronic hepatitis population. In 2007 there were two MMTFs in Honolulu on O‘ahu and one in Hilo on the Big Island, and day treatment programs on Kaua‘i and Moloka‘i, with limited residential treatment on Maui. Thus, geographic proximity to such a center is a major factor in getting proper treatment. The increasing availability of buprenorphine, a new narcotic agonist therapy that has been shown to be useful in managing the dependence needs of an opioid addict, is an accessible improvement that provides support for methadone treatment, although some individuals on high doses of methadone may be resistant to this therapy.
Although substance abuse treatment programs are an important point of contact to provide health services to diagnose, treat, and prevent transmission of hepatitis, one study found that only 28.9% of programs in the United States offered HCV treatment either on-site or via referral, and that very few offer comprehensive hepatitis vaccination services.10 A chronic hepatitis diagnosis for many individuals produces grief equivalent with anticipated death, which can lead to pathological mourning, and absence or reduction in hope. The efficacy in obtaining substance use disorder treatment for patients with chronic hepatitis lies in the potential for increased adherence to medications and to epidemic control measures. An individual whose expectation of death is high may place more reliance on the quality of the remaining life; and if convinced that life will be both short and unpleasant, there is little basis for treatment adherence. Treatment of the substance use disorder can improve both, and in so doing, enhance HCV treatment adherence. One proposal to consider is providing head of the line privileges for substance abuse disorder treatment for those with hepatitis, analogous to that provided for those with HIV disease. Equally, the role of social engagement cannot be over-emphasized. As depression is the most prevalent disorder in management of both the HCV population and those who are dependent on opioids, and as the behavioral management of depression emphasizes counterphobic behaviors (e.g. getting out of bed early despite somnolence, interacting with people in spite of social avoidance and isolation) a great opportunity is missed if these patients are not actively engaged in community recovery programs. Whether through 12-step-based recovery groups, social enterprises by allied agencies, or occupational rehabilitation and training, interaction with a healthier population of goal-directed individuals is central to chronic disease management. It addresses the spiritual core of the human animal, the requirement for human relatedness. An operational example would be walking through an Alcoholics Anonymous or Narcotics Anonymous weekly schedule with the patient, identifying likely compatible groups, and groups close to home or work, and marking routes of travel to attend the meetings.
Coordination of care between psychiatrists and hepatitis clinics is the standard of care at the Veteran’s Administration Hospital, and ideally the mental health provider or addiction specialist screens patients before treatment and meets with patients at each hepatitis clinic visit. This model can be seen in a number of Hawai‘i community health centers, including Waikiki Health Center, Kalihi-Palama Health Center and the Queen Emma Clinics which all have Infectious Diseases specialists and often Gastroenterologists available. Private clinics such as the Liver Center also offer combined support. All successful settings seem to require one champion for integrative management who correctly perceives the issue as a chronic disease with multi-systems expression, inclusive of behavioral, neurological, and social elements. This advocate need not be a psychiatrist, or even a physician.
In summary, public health interventions to improve access to hepatitis testing, treatment, and prevention are needed at the community level to provide assistance and incentives for patients with psychiatric and substance use disorders.
