Psychiatric Issues in HCV-Infected Veterans Must Be Managed With Underlying Disease

by U.S. Medicine

May 19, 2011

Managing the physical disease alone is not enough with veterans infected with hepatitis C and who also have high rates of mental health conditions. Addressing the psychiatric issues is especially critical when interferon-based therapies—where depression is a contraindicatio—are the preferred treatment, or when evaluating a patient for a liver transplant, according to experts at the VHA.

In 2008, about 56% of veterans diagnosed with chronic HCV were depressed, 26%, were diagnosed with PTSD and 33% were identified as having other neuroses or anxiety disorders, according to a VA report issued last year, State of Care for Veterans with Chronic Hepatitis C.

HCV-graphs.jpg“A team-based multidisciplinary care [system] can help these patients with these disorders receive treatment,” said Eric Dieperink, MD, a staff psychiatrist at the Minneapolis VA Medical Center and co-director of the VA Hepatitis C Resource Center located there, one of four VA resource centers.

“I think VA is at the forefront of these team-based models.”

Psychological evaluations are needed for patients to determine their suitability for HCV antiviral treatment or liver transplant. Mental health care providers on the team are also able to help address issues such as determining whether patients who complain of fatigue, one of the symptoms of HCV, are actually suffering from depression or both conditions.

Psychological support is also needed for HCV patients with end-stage disease. “You tend to see the full spectrum of the impact of Hepatitis C, not only around antiviral treatment, but also at the latter stages as well,” said Dieperink.

HCV Care Was Issue at Forum

The coordination of care for HCV patients was touched upon at a 2008 forum convened by the VA’s Public Health Strategic Health Care Group (PHSHG). At the forum, VA providers were asked for feedback about their experiences in diagnosing and treating HCV.

Participants complained that the level of communication across various departments is often insufficient to manage a complex chronic disease such as HCV infection. They also identified a need to coordinate with substance use disorder services and mental health services, according to a report on the forum.

“Patients with histories of mental illness and/or substance abuse, who also present with hepatitis C risk factors, need HCV screening,” the report stated. “Providers of these services must be able to assess risk factors associated with HCV infection and provide or arrange for prevention, screening, and treatment.”

VA’s four Hepatitis C Resource Centers have been working closely with VA’s Public Health Strategic Health Care Group to develop best practices in hepatitis C prevention, clinical care, patient and provider education, and program evaluation for VA and have developed resources regarding multidisciplinary care.

The resource centers have offered training on creating a multidisciplinary care system in prior years as well as providing interventions for HCV-infected veterans who use alcohol.

Dieperink, who has been treating psychiatric issues in Hepatitis C patients for the last 12 years, said he a team-based multidisciplinary approach to HCV care has been beneficial at the Minneapolis VA Medical Center. “It becomes much more efficient care then it might otherwise be,” he said. “It takes time to develop, but it can be quite successful with these kinds of complex medical, psychiatric patients.”

Two Studies Test Telephone Support

The side effect profile of interferon makes it difficult for patients to maintain treatment, especially when the medication can compound depression in patients already susceptible to it. Amy Silberbogen, PhD, a clinical psychologist with the Jamaica Plain Campus VA Medical Center, has had some success in counseling HCV patient through their treatment.

“One of the main reasons why patients drop out of interferon treatment or get terminated prematurely is because of the negative side effects—often times psychiatric side effects,” Silberbogen said. “If you are able to stabilize the patient’s psychiatric status then more patients may be able to finish interferon.”

In this seven-week pilot study participants were randomized to either a telephone-based cognitive behavioral self-management treatment or usual care that did not include the intervention. Participants receiving the intervention received one face-to-face session and six telephone calls to help improve or stabilize their psychological symptoms when they were being treated with interferon.

While the results for the small HCV/Interferon pilot study had not yet been released, she said the results were promising. “We found that those in who were randomized to the telephone-based cognitive behavioral self-management treatment demonstrated either stable or improved psychological outcomes, while those randomized to treatment as usual demonstrated worsening psychological outcomes,” she said. “And, this is when they were taking antiviral treatment, a combination of medications that can have many neuropsychiatric side effects.”

The study included eight participants in the intervention group and nine in the treatment as usual group.

No results are available yet in another study being conducted by Silberbogen. In a study involving veterans with comorbid diagnoses of PTSD and HCV, she tested and compared the efficacy of two cognitive behavioral interventions. One of the interventions was delivered face-to-face and the other by telephone.

Reaching patients with PTSD is important because they may have problems managing their underlying disease or avoiding risky health behaviors, Silberbogen noted.

“What we know about patients with PTSD is that the research really shows that patients with PTSD are likely to not engage in self care practices, they engage in higher risk behaviors like smoking and substance abuse and they engage in fewer preventive healthy behaviors,” she said.

The interventions consisted of five sessions designed to help veterans with quality of life issues, self-care, motivation to engage in health care and psychological distress. Silberbogen and her team hypothesized that both the telephone and face-to-face interventions would improve outcomes over care delivered without an intervention, but that participants would be more satisfied with the telephone intervention.

She said researchers expected telephone support to be preferable because of the convenience and the avoidance of issues such as the cost to come to the hospital, geographical barriers and stigma associated with seeking mental health care.

What does the typical patient with HCV look like in the VA?

In 2008, the typical veteran with chronic HCV was white, 56 years old, male, with a history of co-morbidities including hypertension and depression, according to VA’s November 2010 report State of Care for Veterans with Chronic Hepatitis C.

The report, produced by VA’s Public Health Strategic Healthcare Group, characterizes the state of care of the population of Veterans with chronic hepatitis C within VHA. “The first step in providing responsive care is to learn about the affected population,” the report stated.

According to the report, between 2000 and 2008, 287,410 Veterans in VHA care screened positive for antibodies to HCV and 189,065 were identified with chronic HCV infection. In 2008, VHA clinicians cared for over 147,000 veterans with chronic HCV.

While the majority of veterans with chronic HCV were men, the VHA provides care to more than 4,200 women veterans with chronic HCV. The number of HCV infected female veterans may increase as the percentage of female veterans in VHA increases, the report stated.

The report also stated that the mean age of veterans with chronic HCV has increased from 49.8 to 56.3 years. In 2008, 88% of veterans with chronic HCV in VHA care were age 50 or older and more than one in four Veterans with chronic HCV was over the age of 60. The impact of HCV disease on the long-term management of other chronic conditions common in the elderly and vice versa is still largely unknown, the report stated.

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