17th World Congress on Psychosomatic Medicine

[Guest guest]

> Friday December 12, 2003> 17th World Congress on Psychosomatic Medicine>> Symposium Number: SYMPCH0022OTHER CHRONIC DISEASE - E.G. ASTHMA, DIABETES,> OBESITY, RENAL, LIVER>> Psychosomatic Aspects in Liver Disease I: Chronic Hepatitis C>> Chair Abstract Number: SYMPCH0022>> (Chair) N W WITHERS; R C HILSABECK, P MALEK-AHMADI, D A HENSLEY,> (Discussant) TBD>> Hepatitis C (HCV) has been called the "psychiatric epidemic." Of 134> veterans with chronic HCV, most had a substance use disorder (96%),> psychiatric disorder (71%) or both (70%). 29% of the patients had PTSD.> Severe psychological symptoms were reported in 12% and could not becleared> for interferon therapy for HCV without stabilization. Aggression was> positively correlated with a substance use disorder or PTSD. Depressionwas> correlated with PTSD or lack of a partner. Higher anxiety was more likelyto> be reported by African American or Hispanic patients. Ethical dilemmas> include the selection of candidates and timing of interferon treatment.> Psychiatric side effects from interferon may be severe and lead to> discontinuation of therapy. Two main types of interferon-inducedpsychiatric> syndromes are described: mood disorders (including depression) andcognitive> impairment. Systematic studies on efficacy of pharmacological agents used> for these disorders are needed. In chronic liver disease (including HCV> engendered) neurocognitive dysfunction occurs in up to 50% of noncirrhotic> patients. Complex attention and concentration abilities are affectedearlier> in liver disease; problems with learning, psychomotor speed and mental> flexibility occur later, in cirrhotic patients. Early identification of> neurocognitive dysfunction may facilitate more rapid detection of hepatic> encephalopathy.>> Key Words: CHRONIC HEPATITIS C, NEUROCOGNITIVE, HEPATIC ENCEPHALOPATHY,> PTSD, AGGRESSION, INTERFERON, ANXIETY, PSYCHIATRIC EPIDEMIC, DEPRESSION>>> Speaker Abstract 1: SYMPCH0022-SP1>> N W WITHERS; R C HILSABECK;>> Hepatitis C (HCV) is the most common bloodborne infection in the US. The> initial survey of 3.9 million cases in the US is an underestimate; it did> not include those homeless, incarcerated or institutionalized due tomental> illness. In a dual diagnosis clinic, 48% are HCV positive and 11% are> coinfected (HIV/HCV). HCV, like HIV, poses clinical challenges as there is> no vaccine. 80% of those infected develop chronic disease. Treatment forHCV> (interferon/ribavirin) is expensive, lengthy, has significant sideeffects,> and is not always successful. Recently, the field of eligible patients has> expanded to include children, elderly, drug users in treatment, and> psychiatric patients. Patients experience distress at diagnosis of this> silent disease; and suffer from stigma. Side effects of interferon may be> disabling and there are no predictors for who will suffer. Decisionsinclude> the selection and timing of treatment. What is the best approach for> patients with conditions such as unstable psychiatric illness, addiction> without commitment to abstinence, HIV, head injury, obesity, psychosocial> instability, or incarceration? What are the consequences of treatment,> delayed treatment, or no treatment? Can patients provide informed consent,> since risks and outcomes are defined by research on limited study> populations? Cases are presented.>>> Speaker Abstract 2: SYMPCH0022-SP2>> R C HILSABECK;>> Chronic liver disease is a significant cause of morbidity and mortalityfor> persons between the ages of 25 and 55. With the epidemic of chronic> hepatitis C infection, this number is likely to increase over the next two> decades. Neurocognitive dysfunction is well documented in patients withend> stage liver disease as a relatively common complication is hepatic> encephalopathy. Recent research has shown that neurocognitive difficulties> are present in persons with mild fibrosis. Impaired performances have been> found in up to 50% of non-cirrhotic patients. Evidence suggests thatcomplex> attention and concentration abilities may be affected relatively earlierin> the disease process, while problems with learning, psychomotor speed, and> mental flexibility are affected more in cirrhotic patients. The pattern of> neurocognitive dysfunction consistently suggests involvement ofsubcortical> pathways such as the basal ganglia-thalamocortical circuit, which has been> supported by MR spectroscopy. Neurocognitive problems in patients with> chronic liver disease can result in reduced efficiency and accuracy in> performing household and job duties, leading to frustration, mood problems> and claims of disability. Patients experiencing episodes of hepatic> encephalopathy face possible coma and death. Identification of> neurocognitive dysfunction early in the disease process may facilitate> earlier identification and treatment of hepatic encephalopathy.>> Key Words: CHRONIC LIVER DISEASE, HEPATITIS C, COGNITIVE DYSFUNCTION,> CIRRHOSIS, BASAL GANGLIA-THALAMOCORTICAL CIRCUIT, SUBCORTICAL PATHWAYS,> HEPATIC ENCEPHALOPATHY, ATTENTION, CONCENTRATION, MILD FIBROSIS (TITLE:> NEUROCOGNITIVE CHANGES IN CHRONIC LIVER DISEASE)>>> Speaker Abstract 3: SYMPCH0022-SP3>> P MALEK-AHMADI; R C HILSABECK;>> Pharmacological Management of Interferon-Induced NeuropsychiatricDisorders> in Patients with Hepatitis C In recent years a number of clinical studies> have focused on the psychiatric symptoms associated with interferon (IFN)> therapy. The severity of these symptoms may necessitate discontinuation of> IFN therapy. Therefore, early recognition and management of IFN-induced> psychiatric symptoms are of paramount importance. Two main types of> IFN-induced psychiatric syndromes are described. They include IFN-induced> mood disorders and IFN-induced cognitive impairment. Management of these> syndromes may require pharmacological interventions. The efficacy of> antidepressants in IFN-induced depressive symptoms has not systematically> been studied. A few case reports suggest that selective serotoninre-uptake> inhibitors ameliorate IFN-induced depression. Manic symptoms can betreated> with anti-manic agents. However, agents with hepatic biotransformation> should be used with extreme caution in patients with abnormal liverfunction> tests. There are a few studies concerning the pharmacological managementof> IFN-induced cognitive impairment. Future studies are needed to investigate> the efficacy of pharmacological agents in IFN-induced cognitivedysfunction.>> Key Words: INTERFERON, COGNITIVE DYSFUNCTION, HEPATITIS C, MOOD DISORDERS,> INTERFERON-INDUCED COGNITIVE DISORDER, INTERFERON-INDUCED MOOD DISORDER,> SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS, HEPATIC BIOTRANSFORMATION>>> Speaker Abstract 4: SYMPCH0022-SP4>> D A HENSLEY; N W WITHERS;>> 20% of chronic hepatitis C (HCV) patients develop cirrhosis without> interferon therapy. Alcohol use may cause cirrhosis to progress more> rapidly. As completion of interferon treatment is a desired clinical> outcome, assessment of candidates' substance use and psychiatric disorders> is critical, with appropriate referral for substance abuse and psychiatric> treatment. This study examines the scope of substance abuse andpsychiatric> illness in veterans with HCV. 134 male veterans referred to the HCV clinic> had a mean age of 50, mean weight of 90.6 kg, and mean HCV level of575,941.> The majority had elevated ALT(SGPT) (77%); genotype 1a or 1b (71%) andwere> non-cirrhotic (92%). A majority of the patients had a psychiatric disorder> (71%), substance use disorder (96%) or were dually diagnosed (70%). Point> prevalences for psychiatric disorders were; affective (42%), anxiety> including PTSD (37%), and psychotic (7%). 84% of patients had alcoholabuse> or dependence; 78% met criteria for drug abuse or dependence. Patientswith> an alcohol use disorder were significantly more likely to have cirrhosis> (p<.001). The high incidence of substance use and psychiatric disorders in> veterans with chronic HCV mandates that these patients have ongoing> addiction psychiatric assessment, treatment and stabilization before and> during interferon therapy.>> Key Words: CHRONIC HEPATITIS C, CIRRHOSIS, ALCOHOL DEPENDENCE, ANXIETY,> PTSD, DEPRESSION, AGGRESSION, INTERFERON THERAPY, DUAL DIAGNOSIS, DRUG> DEPENDENCE>>> Speaker Abstract 5: SYMPCH0022-SP5>> D A HENSLEY; N W WITHERS; J SPIRA;>> Most veterans seeking treatment for chronic hepatitis C (HCV) have a> substance use or psychiatric disorder or both. Psychiatric side effectsare> common with interferon treatment. An important objective is to determine> which patients can be safely treated with interferon. 134 males were> assessed using the Aggression Questionnaire (AQ), Beck DepressionInventory> (BDI), Beck Anxiety Inventory, and Quality of Life Inventory (QOL). 45%> reported significant aggression. AQ scores were significantly influencedby> the presence of an alcohol or substance use disorder, PTSD, or receiving> psychiatric care. 45% had significant depression. BDI scores were> significantly higher in patients with PTSD, receiving psychiatric care, or> who reported not having a partner. 54% of patients had significant anxiety> symptoms. Higher anxiety was more likely to be reported by patients whowere> African American or Hispanic or receiving mental health care. 41% reporteda> low or very low QOL. A portion of patients had severe symptoms: aggression> (3.9%), depression (11.6%), or anxiety (8.8%), 27.5% reported a very low> QOL. Veterans presenting for HCV treatment have a high frequency of> clinically significant, active psychological symptoms. It is recommended> that patients with severe symptoms (12% in this study) be stabilized with> psychiatric intervention before interferon treatment.>> Key Words: (TITLE: AGGRESSION, DEPRESSION, ANXIETY AND QUALITY OF LIFE IN> VETERANS WITH CHRONIC HEPATITIS C) AGGRESSION, DEPRESSION, ANXIETY,QUALITY> OF LIFE, CHRONIC HEPATITIS C, PTSD>>