Lack of Collaboration Hinders Hepatitis C Diagnosis

The diagnosis of hepatitis C virus (HCV) in persons who have a psychiatric or substance abuse disorder is a significant challenge, not only to the patients, but also to their psychiatrist. Experts today say that those challenges can be most readily met by a closely integrated collaborative care model that simultaneously addresses both the mental health and general medical concerns of the patient.

Diagnosis of HCV is in itself a challenge, said Marvin Swartz, M.D., a professor of psychiatry and behavioral sciences at Duke University. Swartz was a collaborator in a five-site seroprevalence study documenting high rates of infection with HCV in persons with severe mental illness and addictive disorders (see Original article: story on facing page).

“First, you have very vague symptoms, and it is something that requires pretty careful medical follow-up to be detected,” Swartz told Psychiatric News. “You have to ask the right questions to first even know whether a person is at risk. Then, you have to do appropriate lab work and follow up with appropriate referral for treatment for HCV.”

However, several studies have indicated that the number one reason for a “hepatologist”—a gastroenterologist who specializes in the management of liver diseases—to deny a patient the best available treatment is a past or current psychiatric or drug abuse disorder. Unfortunately, persons with psychiatric disorders and drug abuse problems are at great risk to develop HCV. Studies have indicated that as many as 85 percent of those who have used intravenous drugs of abuse are HCV positive, and most won’t know it because they may remain asymptomatic for decades.

“The good news is there are fairly effective treatments for HCV,” noted Mark Willenbring, M.D., a professor of psychiatry at the University of Minnesota and director of the Minneapolis Veterans Affairs Hepatitis Resource Center. “The bad news is that hardly anyone is getting that treatment. And that is where the role of the psychiatrist, and in particular the addiction psychiatrist, is absolutely critical, in increasing the proportion of patients who are able to receive treatment.”

Willenbring frequently speaks on the treatment of persons with mental and addictive disorders with HCV, including a medical update presentation at the recent annual meeting of the American Academy of Addiction Psychiatry.

“Overall, 70 percent to 80 percent of patients are commonly excluded [from the best available treatment], and mental and addictive disorders are the most common reason,” Willenbring noted. The very unfortunate corollary to that, he added, is that neuropsychiatric symptoms—including affective symptoms and cognitive changes—are common in patients who have untreated HCV.

To make matters even worse, both Swartz and Willenbring emphasized, the most effective treatment available for HCV—24 to 48 weeks of injectible interferon and antiviral medications—is associated with neuropsychiatric side effects such as depression, anxiety, and cognitive and behavioral changes. Studies have indicated that 30 percent of patients treated with interferon develop depression, usually within the first to third month of treatment.

The depression can be severe, Willenbring noted, and related suicides have been reported. Less commonly, treatment-emergent cases of anxiety, mania, and even psychosis have been reported. Beyond that, he added, other common side effects include fatigue, malaise, muscle and joint pains, and insomnia, leaving the patient “feeling like they’ve had the flu for a year.”

Nonetheless, treatment can be successful at actually eradicating the virus from the patient’s body with studies documenting no virus in as many as 50 percent to 60 percent of cases. Without treatment, HCV becomes chronic in about 75 percent of those acutely infected. Around 20 percent of those lead to cirrhosis and liver failure, and about 6 percent to liver cancer.

“You put all of this together,” Swartz said, “and it really raises some significant concerns about treatment of severely mentally ill patients with hepatitis C. Number one, is the patient even capable of being compliant with a regimen that is long term and expensive, and has lots of significant side effects? And number two, is the treatment going to exacerbate or induce depressive symptoms that could be hard to manage?”

Indeed, Willenbring said, the threshold for excluding patients from effective treatment for HCV has been very low, “and that is where the role of the psychiatrist has been so critical. We can offer the support and co-management that are required for these patients to get treatment and make the hepatologist feel a lot more secure and willing to go ahead and treat.”

Swartz said that a close relationship with primary care providers is essential to making sure patients with HCV receive and successfully complete treatment with interferon and antiviral medications.

“There are some models of pretty good teamwork between hepatologists and psychiatrists, and then there are some pretty good models of primary care psychiatry, which is what has been happening in the VA, and that is a good first step,” Swartz said. “But outside of the VA, I think that kind of collaborative care is less common.”

Willenbring’s clinic at the Minneapolis VA involves “a close relationship between HCV staff and the mental health/addictive disorders treatment staff.” Within the clinic staff, roles are clearly defined, as are protocols for referral in both directions between hepatology and psychiatry. Primary management of patients within the chronic hepatitis clinic is jointly monitored by a medical nurse practitioner and a psychiatric clinical nurse specialist with a team of consulting hepatologists, psychiatrists, and addiction specialists.

All patients who come into the Minneapolis center are screened for depression (using the Beck Depression Inventory) at baseline and then every two to four weeks as they go through treatment with interferon and antiviral medication. Conversely, all patients with psychiatric and substance abuse disorders are screened for hepatitis, immunized for both hepatitis A and B, and closely monitored for signs of liver dysfunction.

“Clearly,” Willenbring said, “co-management of care between HCV and mental and addictive providers is the key to success, and with co-management, patients with co-occurring disorders can be successfully treated.” ▪