Scandinavian Journal of Infectious Diseases, 2014; 46: 566–572
ORIGINAL ARTICLE
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Depressive symptoms are frequent among drug users, but not associated with hepatitis C infection
LONE W. MADSEN1, THILDE FABRICIUS1, SIMON HJERRILD2, THOMAS M. HANSEN1, BELINDA K. MÖSSNER1, INGE BIRKEMOSE3, MERETE SKAMLING4 & PEER B. CHRISTENSEN1 From the 1Department of Infectious Diseases, Odense University Hospital, Denmark, 2Department for Affective Disorders, Aarhus University Hospital, Denmark, 3Drug Treatment Centre of Odense, Denmark, and 4Drug Treatment Centre of Svendborg, Denmark
Abstract Aim: To compare the prevalence and severity of depressive symptoms among drug users with and without hepatitis C virus (HCV) infection. Methods: This was a cross-sectional survey study carried out at the 2 major drug treatment centres on the island of Funen, Denmark. Participants were drug users presenting to the 2 treatment centres. Individuals with chronic hepatitis B virus or HIV infection were excluded. Participants completed the Major Depression Inventory (MDI) questionnaire when presenting at the centres. Patients with MDI scores indicating severe depression (total MDI score ⱖ 35) were referred for treatment evaluation. Hepatitis C status was classified by the presence of anti-HCV as a marker of HCV exposure and HCV-RNA as a marker of ongoing infection. Results: Two hundred and sixty-eight patients were included, of whom 235 (88%) had complete serological testing; 100 (43%, 95% confidence interval (CI) 36–49%) had chronic hepatitis C. The median MDI score was 22 (interquartile range 12–33); 32% (95% CI 26–39%) had a score compatible with depression and 14% (95% CI 10–19%) were rated as severe depression. Depression was not associated with hepatitis C (HCV-infected 29%, non-infected 35%; p ⫽ 0.25). Forty-one percent (11/27) of the evaluated participants started antidepressant treatment. Conclusions: Our study demonstrated a high prevalence of depressive symptoms among drug users, but this was not more frequent among HCV-infected patients. The high overall prevalence of depression underlines the relevance of screening for depression in patients who are drug users.
Keywords: Hepatitis C, depression, drug users
Introduction Symptoms of depression such as fatigue, decreased cognition function, sleep disturbances, and low mood are frequent in patients with hepatitis C [1–4]. It has been suggested that the hepatitis C virus (HCV) per se contributes causally by infecting the human central nervous system [5–7], since current evidence indicates that HCV crosses the blood–brain barrier and subsequently replicates in microglia leading to low-grade neuroinflammation through the production of pro-inflammatory cytokines [6,7]. Further, a study has shown an association between depression and HCV in patients who have never been exposed
to previous interferon-alpha treatment, or drug and alcohol abuse [8]. However, the majority of HCV patients in the Western world have been infected through intravenous drug use [9], and drug users also have a high prevalence of mood disorders [10]. An association between HCV and depression has also been demonstrated among heroin users on methadone treatment using the Beck Depression Inventory (BDI) [11]. The identification of depression prior to hepatitis C treatment with interferon-alpha is clinically important. A recent meta-analysis found that 1 out of 4 developed a depressive disorder during interferon-alpha
Correspondence: L. W. Madsen, Department of Infectious Diseases Q, Odense University Hospital, Building 1, 2nd Floor, Penthouse block 6, Sdr Boulevard 29, 5000 Odense C, Denmark. Tel: ⫹ 45 65414294. Fax: ⫹ 45 66117418. E-mail: [email protected] (Received 30 September 2013 ; accepted 11 April 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.918274
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Depression and hepatitis C treatment. Predictive variables for the development of depression were female gender, history of depression or psychiatric disorder, and low educational level [12]. Furthermore, prophylactic treatment with selective serotonin reuptake inhibitors (SSRI) has been shown to prevent depression during interferon-alpha treatment, even in patients without depression before the initiation of antiviral treatment [13]. The identification of patients with sub-syndromal depressive symptoms could lead to a more intensive management during antiviral treatment. Our hypothesis was that depressive symptoms would be more prevalent among HCV-infected patients. The aim of this study was to compare the prevalence and severity of depressive symptoms as measured by the Major Depression Inventory (MDI) in a population of drug users with and without HCV infection. Materials and methods A cross-sectional survey was performed among drug users attending 2 major methadone treatment centres in Denmark during the winter of 2010/2011. The treatment centres cover a population of approximately 240,000 inhabitants and are the only places that provide substitution treatment in primary care. The 2 centres have a capacity of approximately 664 drug users, and the staff includes social workers, nurses, and doctors specialized in addictive medicine and psychiatry. Drug users were approached by the study team when presenting for treatment at the centre. After signing informed consent, the participants completed
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a validated Danish version of the MDI questionnaire alone or assisted by the study team. The MDI is a 10-item dual function self-rating depression scale that generates a probable depression diagnosis based on either the International Classification of Diseases 10th edition (ICD-10) or the Diagnostic and Statistical Manual 4th edition (DSM-IV) symptom criteria, and the total score serves as a measure of depression severity [14–17]. A total score of 20–26 points indicates mild depression, 27–35 points indicates moderate depression, and a total score of more than 35 points indicates severe depression. According to an algorithm of major and minor symptoms, the patient may be classified as having mild, moderate, or severe depression according to the ICD-10 classification (see footnote to Table I) [14,16]. The MDI form has previously been used to diagnose depression in hepatitis C patients and was found to be suitable for monitoring depression during interferon-based treatment [18]. We classified depression according to the algorithm for the presence of major and minor symptoms as per the ICD-10 classification. In addition, we analyzed the results with a depression classification based on the total MDI score. In addition to the MDI forms, information on substitution treatment, psychotropic drug consumption, previous psychiatric hospitalization, and alcohol consumption was obtained from the treatment centre and hospital records. All participants had a previous drug addiction and the majority were abusing a multitude of drugs. Some of the patients had a current drug abuse prob-
Table I. Presence of depressive symptoms among 235 drug users according to HCV status. HCV MDI question 1. Have you felt low in spirits or sad? 2. Have you lost interest in your daily activities? 3. Have you felt lacking in energy and strength? 4. Have you felt less self-confident? 5. Have you had a bad conscience or feelings of guilt? 6. Have you felt that life wasn’t worth living? 7. Have you had difficulty in concentrating, e.g. when reading the newspaper or watching TV? 8a. Have you felt very restless? 8b. Have you felt subdued or slowed down? 9. Have you had trouble sleeping at night? 10a. Have you suffered from reduced appetite? 10b. Have you suffered from increased appetite?
Infected 2 3 3 1 1 0.5 1 2 1 3 1 0
Not infectedb
p-Value
(1–3.8) (1–4) (1–4) (0–3) (0–3) (0–2) (0–3)
2 3 3 2 2 1 1
(1–4) (1–4) (2–5) (0–4) (0–4) (0–3) (0–3)
0.772 0.739 0.222 0.283 0.096 0.424 0.166
(1–3) (0–3) (0–4) (0–4) (0–1)
3 2 3 2 0
(1–4) (0–4) (1–5) (0–4) (0–1)
0.094 0.019 0.203 0.729 0.914
HCV, hepatitis C virus; MIDI, Major Depression Inventory. aResults given as median (interquartile range); 0: at no time, 5: all of the time (recall period 14 days). Algorithm for classification according to the presence of major symptoms (questions 1–3 ⬎ 3) and minor symptom (questions 4–10 ⬎ 2): mild depression ⫽ 2 major and 2 minor; moderate depression ⫽ 2 major and 4 minor; severe depression ⫽ 3 major and 5 minor. bSum of past HCV and never HCV infection.
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lem and if the patient appeared intoxicated, they were denied access to the treatment centres. There was no distinction between previous or current drug abuse. Participants with MDI scores suggesting severe depression and patients who the study team believed needed further medical assessment were referred for further diagnostic and treatment evaluation. HCV status was assessed by testing for anti-HCV as a marker of HCV exposure and HCV-RNA as a marker of ongoing infection. Patients with hepatitis B virus or HIV infections (HBsAg or anti-HIV positives) were excluded from the study. Less than 5% of HCV-infected patients had previously been treated for HCV. The few patients with a cured infection were not distinguished from those patients with spontaneous HCV clearance, and no patients receiving interferon treatment were included in the study. Data were analyzed using Stata version 12 (StataCorp LP, College Station, TX, USA). Univariate associations were tested with non-parametric tests (Fisher’s exact test, Chi-square test, or Mann–Whitney test, as appropriate) and a 2-sided p-value of ⬍ 0.05 was considered significant. Multivariate analysis was done by logistic regression with MDI depression as the outcome and HCV as the independent variable and including clinically and statistically significant covariates in a full model. Insignificant variables were eliminated, however variables that changed the odds ratio (OR) of the HCV association were maintained in the model regardless of significance. Due to the population size, interaction terms were not included in the model. The study was approved by the local ethics committee (S-VF-20060078) and the Danish Data Protection Agency (2010-41-5149).
Results We obtained MDI forms from a total of 287 participants, corresponding to 43% of 664 drug users attending the centres over a period of 6 months from October 2010 to March 2011. We excluded 17 repeat MDI forms from drug users who entered the study twice and 10 incomplete forms; also excluded were 9 participants who were co-infected with HBV or HIV and 33 persons with incomplete hepatitis C status (Figure 1). Non-participants did not differ significantly by age or gender, but information related to hepatitis C infection and symptoms of depression were only available for participants. Among the remaining 235 participants, 175 (74%, 95% confidence interval (CI) 68–80%) were men and the median age was 45 y (interquartile range (IQR) 37–51 y). Chronic hepatitis C was found in 100 participants (43%, 95% CI 36–49%) (HCV-RNA positive); 55 participants (23%, 95% CI 18–29%) had a former infection (antiHCV-positive, HCV-RNA-negative) and 80 (34%, 95% CI 28–40%) had not been infected with HCV (anti-HCV negative). Opioid substitution was given to 98% (231/235), of whom 86% received methadone, with no difference according to HCV status or MDI score. The MDI questionnaire was completed individually by 49% of the participants and with the assistance of the study team by 51%. Scores were not statistically different between these 2 groups, however 117 participants who did not report whether they were assisted with completing the form had EXCLUDED
664 drug users affiliated to a drug treatment centre
377 (57%) not present or declined participation
17 duplicates 10 incomplete forms 9 coinfected
304 MDI forms from 287 (43%) drug users
33 no HCV RNA test
268 included
235 (88%) known HCV status
100 (43%) Chronic HCV
55 (23%) Past HCV Figure 1. Study flow diagram.
80 (34%) Never HCV
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Depression and hepatitis C lower MDI scores (median 21 for non-reporters versus 25 for non-assisted and 29 for assisted; p ⫽ 0.01). The median MDI total score was 22 (IQR 12–33, range 0–50). An MDI score suggesting depression (ⱖ 20) was found in 133 (57%, 95% CI 51–64%), of whom 50 (21%, 95% CI 16–27%) had a score compatible with severe depression (Table II). When utilizing the diagnostic algorithm in the MDI, 32% (95% CI 26–39%) of the participants had depression according to the ICD-10 criteria and 14% (95% CI 10–19%) were severe. Fifty-one percent of the participants with depression had a psychiatric diagnosis. Among the 76 patients who were diagnosed with depression according to the MDI, 29% had previously been diagnosed with depression, 24% with anxiety, and 3% with schizophrenia (Table III). In a univariate analysis, the use of illegal drugs during methadone treatment was associated with ICD-10 depression (Table IV). Young age, illegal drug use, and use of benzodiazepines were associated with higher total MDI scores (data not shown). In contrast, HCV infection was not associated with depressive symptoms. In fact, HCV-infected drug users had a lower prevalence of depression than the uninfected, although the difference was not statistically significant (Tables IV and V). The lack of association between depressive symptoms and hepatitis C was found both for the algorithm classification and MDI total score. HCV-infected drug users did not score higher than non-infected substance abusers on any of the items in the MDI (Table I). The symptom ‘tiredness’ (item 3: “Have you felt
lacking in energy and strength?”) has often been associated with HCV infection in the literature, but for neither this nor the combination of all ‘somatic’ symptoms (questions 3 and 7–10) or ‘cognitive’ symptoms (questions 1, 2, and 4–6) did we find an association with HCV infection. The only variable associated with HCV infection was alcohol abuse (Table V). The use of prescribed drugs against mood disorders was frequent. Overall, 54% (127/235) used antidepressant drugs and 20% (47) used 2 or more classes of these drugs. Use was numerically higher among depressed drug uses, and for benzodiazepines this was close to significance (p ⫽ 0.06, Table IV). In contrast, no association was found between drugs prescribed for mood disorders and hepatitis C status (Table V). In a multivariate logistic regression analysis with depression defined by the MDI algorithm as the outcome and hepatitis C infection, age, gender, use of benzodiazepines, illicit drug use, and alcohol abuse as independent variables, only the use of benzodiazepines was significantly associated with depression (Table IV). Chronic hepatitis C was close to significance (p ⫽ 0.054), but the association was negative: the HCV-infected tended to have lower MDI scores than the non-infected. By backwards elimination of insignificant variables, no other variables became associated with depression and no OR changed ⬎ 10% of the value in the full model. As a result of the MDI screening, 92/268 (34%) were referred for further evaluation. Twenty-seven participants had a psychiatric evaluation by the doctors at the treatment centres, of whom 41% (11/27) started antidepressant treatment and 15% (4/27) were referred to a psychiatrist.
Table II. Major Depression Inventory (MDI) score among 235 drug users.
Total MDI score 0–19 (normal) 20–26 (mild depression) 27–34 (moderate depression) 35–50 (severe depression) Total
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Number
%
102 34 49 50 235
43.5 14.5 20.9 21.3 100
Symptom severity (algorithm classification) No depression Mild depression Moderate depression Severe depression
Number 159 11 33 32 235
% 67.7 4.7 14.0 13.6 100
Table III. Psychiatric diagnosis associated with depression.
Participants with ⱖ 1 previous psychiatric diagnosis Depression Schizophrenia Anxiety Attention deficit/hyperactivity disorder (ADHD) Opioid use, unspecified Obsessive-compulsive disorder (OCD) Psychosis Post-traumatic stress disorder (PTSD)
Depression
No depression
51% 29% 3% 24% 3% 5% 1% 1% 7%
40% 25% 4% 19% 2% 4% 3% 3% 3%
(39/76) (22/76) (2/76) (18/76) (2/76) (4/76) (1/76) (1/76) (5/76)
(64/159) (40/159) (7/159) (30/159) (3/159) (6/159) (4/159) (5/159) (4/159)
p-Value 0.12 0.53 0.72 0.39 0.66 0.73 1.00 0.67 0.15
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Table IV. Factors associated with any depression according to the Major Depression Inventory (MDI) algorithm score. Univariate analysis
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MDI algorithm score % of total (n) Age, y, median (IQR) Men HCV-RNA-positive Anti-HCV-positive Any psychotropic Antidepressant Benzodiazepine Antipsychotic Other psychotropic Admission to psychiatric ward ever Substitution treatment Use of illegal drugs during substitution treatment Alcohol abuse ever
Depression (n ⫽ 76)
No depression (n ⫽ 159)
32% (76) 42 (37–48) 70% (53/76) 38% (29/76) 62% (47/76) 74% (46/68) 13% (9/68) 45% (29/68) 22% (15/68) 4% (3/68) 35% (26/74) 86% (65/76) 90% (63/70)
68% 46 77% 45% 68% 64% 12% 24% 24% 5% 33% 87% 76%
39% (23/59)
33% (42/129)
Logistic regression analysis
p-Value
(159) (37–52) (122/159) (71/159) (108/159) (81/127) (15/127) (30/127) (30/127) (6/127) (52/157) (138/159) (107/140)
OR Univariate
OR Multivariate
95% CI
p-Value
0.97 1.07 0.53
0.96 1.41 0.47
(0.92–1.01) (0.6–3.3) (0.2–1.01)
0.10 0.43 0.05
2.43
2.7
(1.3–6.0)
0.01
3.48
3.1
(0.8–12)
0.09
1.50
1.4
(0.7–3.1)
0.38
0.16 0.10 0.27 0.40 0.38 0.64 0.82 0.06 0.86 1.00 0.77 0.84 0.03 0.41
OR, odds ratio; CI, confidence interval; IQR, interquartile range; HCV, hepatitis C virus.
Table V. Factors associated with HCV infection.
% of total (n) Age, y, median (IQR) Men MDI total score ⬍ 20 (no depression) 20–26 (mild depression) 27–35 (moderate depression) ⬎ 35 (severe depression) Depression severity (MDI algorithm) No depression Mild depression Moderate depression Severe depression Any psychoactive drugs Antidepressants Benzodiazepines Antipsychotic drugs Other psychoactive drugs Admission to psychiatric ward Substitution treatment Use of illegal drug during substitution treatment Alcohol abuse
HCV present
HCV past
HCV never
(HCV-RNA-positive)
(anti-HCV-positive, HCV-RNA-negative)
(anti-HCV-negative)
43% (100) 47 (37–51) 71% (71/100)
23% (55) 46 (40–51) 71% (39/55)
34% (80) 41 (35–48) 81% (65/80)
45% 19% 25% 11%
(45/100) (19/100) (25/100) (11/100)
45% 13% 18% 24%
(25/55) (7/55) (10/55) (13/55)
40% 10% 24% 26%
71% 8% 9% 12% 67% 11% 38% 22% 4% 36% 100% 82% 43%
(71/100) (8/100) (9/100) (12/100) (57/85) (9/85) (32/85) (19/85) (3/85) (35/98) (100/100) (72/88) (38/89)
67% 2% 15% 16% 70% 11% 37% 22% 7% 35% 100% 78% 33%
(37/55) (1/55) (8/55) (9/55) (32/46) (5/46) (17/46) (17/46) (3/46) (19/55) (55/55) (36/46) (13/40)
64% (51/80) 3% (2/80) 20% (16/80) 14% (11/80) 59% (38/64) 16% (10/64) 25% (16/64) 25/16/64 5% (3/64) 30% (24/78) 95% (76/80) 82% (62/76) 24% (14/59)
p-Value
0.12 0.36 0.11
(32/80) (8/80) (19/80) (21/80) 0.25
0.62 0.66 0.26 0.87 0.73 0.67 0.13 0.86 0.03
HCV, hepatitis C virus; IQR, interquartile range; MDI, Major Depression Inventory. p-Value for HCV present versus HCV past and HCV never combined.
Discussion In this cross-sectional survey of depressive symptoms among drug users attending drug treatment centres, we found that a high proportion of the participants reported the presence of significant depressive symptoms, but these were not more frequent among HCV-infected drug users as compared to the
non-infected. Both in univariate and multivariate analysis, HCV-infected participants had numerically lower depression scores than the non-infected. Our results do not support the hypothesis that HCV per se increases depressive symptoms. Our study had several weaknesses: First, the MDI has not been evaluated previously among drug users,
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Depression and hepatitis C and participants in our study were not systematically evaluated by a psychiatrist, thus we cannot conclude that all drug users identified as depressed fulfilled the ICD-10 or DSM-IV criteria of depression. In addition, a diagnosis of depression cannot be established using a screening instrument like the MDI. However, 41% of participants with high MDI scores who were further evaluated were prescribed antidepressants, suggesting that depression was diagnosed by their treating physician. Second, the relative depressogenic contribution of HCV might be significantly diminished in patients with active substance abuse and potential psychiatric and somatic co-morbidities, as suggested by the high prevalence of depressive symptoms in this group. Third, the 2 functions of the MDI (total sum versus categorical ICD-10 diagnosis) differed considerably in their prevalence estimates of depression in the sample (Table IV). We believe that the MDI algorithm was most comparable to depression as defined by ICD-10, but the use of the total MDI sum to define depression did not change our findings. Fourth, the low participation rate in the study constitutes a limitation, albeit we could not detect any demographic bias in non-participants and the high median score among the participants made it less likely that drug users with depressive symptoms were selectively excluded from the study. Fifth, the MDI does not permit a more precise description and classification of the depressive symptoms into, for example, bipolar depression or a recurrent brief depressive episode [19,20]. Due to the above limitations, it is difficult to estimate the prevalence of depression in this particular population. However, the primary aim of our study was to elucidate the association between HCV and depressive symptomatology, and we found the MDI an appropriate tool for this purpose. Since most depression scales have been developed in patients with primary depression, it has been argued that the applicability of these rating scales in patients with co-morbid somatic diseases (e.g. HCV) might be reduced [21–23] and potentially lead to diagnostic inflation. A recent study showed that HCV patients had increased somatic item scores on the BDI [24], however we did not find any association between somatic item scores in the MDI and hepatitis C status. An increased prevalence of depression has been reported in patients with chronic hepatitis C [2,3,25–27]. Since a significant proportion of HCV infections remain undiagnosed [28], the increased prevalence of depression among HCV outpatients could be due to the fact that a high proportion were diagnosed in the first place due to psychiatric or somatic complaints [29]. This fact is underlined by similar proportions of fatigue in healthy blood donors with and without HCV [30]. Several studies have found no differences in depressive symptomatology in patients with HCV antibodies with or
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without active viral replication (HCV-RNA) [31,32]. Additionally, knowledge of the HCV diagnosis can be considered a significant psychological stressor [33,34], and the associated stigmatization [35] appears to be associated with depressive symptoms [36]. Patients with substance abuse generally have a high prevalence of psychiatric co-morbidity, especially depression [37]. Batki et al. studied psychiatric morbidity in HCV patients on methadone replacement therapy and found that approximately 20% fulfilled the DSM-IV criteria for a mood disorder [38,39]; they also found that the median BDI score was in the mild depression range and was a significant predictor of health-related quality of life [38]. Another study found major depression according to the DSM-IV criteria in 37% of injection drug users with acute HCV, and a total of 59% had depression [40]. It is therefore likely that the estimated prevalence of depression derived from the MDI total score may be too high due to item contamination from, for example, drug use or physical disorders. Using the MDI algorithm to diagnose depression yielded prevalence rates in the vicinity of known rates of depression from studies using structured clinical interviews. This finding suggests that the algorithm-based diagnosis could be the most correct estimate, but this remains to be validated. The MDI score has been evaluated previously in a study of the general Danish population [15]. The mean MDI score was 7.2, 4.1% were classified as having depression according to ICD-10, and 3% received medical treatment for mental disorders. In a study among patients undergoing treatment for hepatitis C (of whom 72% were infected by injecting drug use), the mean MDI at baseline was 13, 6% had major depression, and 8% received antidepressants, compared to our study with a mean MDI of 23, 14% with major depression, and 12% using antidepressants [18]. Thus hepatitis C patients reported higher MDI scores than the general population, but substantially lower than the participants in our study (Table IV). We found a high prevalence of depressive symptoms among drug users, but depressive symptoms were not increased in drug users with hepatitis C, thus our study does not support the hypothesis that hepatitis C increases depressive symptoms in this population. Due to the high prevalence of depression in drug users, we suggest that screening for depression prior to treatment for hepatitis C is a useful strategy; in this way depression can be identified and treated before interferon-based antiviral treatment is commenced and patients in need of a more intensive management during treatment can also be identified.
Declaration of interest: This study was not funded. All authors have no financial interest to disclose.
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[20] Carta MG, Angst J, Moro MF, Mura G, Hardoy MC, Balestrieri C, et al. Association of chronic hepatitis C with recurrent brief depression. J Affect Disord 2012;141:361–6. [21] Hilsabeck RC, Webb AL, Stern SL. Depression and fatigue: challenging comorbidities in HCV-infected patients. Curr Hepat Rep 2007;6:153–9. [22] Trask PC. Assessment of depression in cancer patients. J Natl Cancer Inst Monogr 2004;(32):80–92. [23] Patterson AL, Morasco BJ, Fuller BE, Indest DW, Loftis JM, Hauser P. Screening for depression in patients with hepatitis C using the Beck Depression Inventory-II: do somatic symptoms compromise validity? Gen Hosp Psychiatry 2011;33:354–62. [24] Rifai MA, Rosenstein DL. Hepatitis C and psychiatry. Focus 2005;3:194–202. [25] Fontana RJ, Bieliauskas LA, Back-Madruga C, Lindsay KL, Kronfol Z, Lok AS, et al. Cognitive function in hepatitis C patients with advanced fibrosis enrolled in the HALT-C trial. J Hepatol 2005;43:614–22. [26] Gallegos-Orozco JF, Fuentes AP, Gerardo Argueta J, Pérez-Pruna C, Hinojosa-Becerril C, Sixtos-Alonso MS, et al. Health-related quality of life and depression in patients with chronic hepatitis C. Arch Med Res 2003; 34:124–9. [27] Christensen PB, Hay G, Jepsen P, Omland LH, Just SA, Krarup HB, et al. Hepatitis C prevalence in Denmark—an estimate based on multiple national registers. BMC Infect Dis 2012;12:178. [28] Wessely S, Pariante C. Fatigue, depression and chronic hepatitis C infection. Psychol Med 2002;32:1–10. [29] Hoofnagle JH. Hepatitis C: the clinical spectrum of disease. Hepatology 1997;26:15S–20S. [30] Coughlan B, Sheehan J, Hickey A, Crowe J. Psychological wellbeing and quality of life in women with an iatrogenic hepatitis C virus infection. Br J Health Psychol 2002;7(Pt 1):105–16. [31] Helbling B, Overbeck K, Gonvers JJ, Malinverni R, Dufour JF, Borovicka J, et al. Host- rather than virus-related factors reduce health-related quality of life in hepatitis C virus infection. Gut 2008;57:1597–603. [32] Castera L, Constant A, Bernard PH, de Ledinghen V, Couzigou P. Psychological impact of chronic hepatitis C: comparison with other stressful life events and chronic diseases. World J Gastroenterol 2006;12:1545–50. [33] Rodger AJ, Jolley D, Thompson SC, Lanigan A, Crofts N. The impact of diagnosis of hepatitis C virus on quality of life. Hepatology 1999;30:1299–301. [34] Zickmund S, Ho EY, Masuda M, Ippolito L, LaBrecque DR. “They treated me like a leper.” Stigmatization and the quality of life of patients with hepatitis C. J Gen Intern Med 2003;18:835–44. [35] Golden J, Conroy RM, O’Dwyer AM, Golden D, Hardouin JB. Illness-related stigma, mood and adjustment to illness in persons with hepatitis C. Soc Sci Med 2006;63:3188–98. [36] Swendsen JD, Merikangas KR. The comorbidity of depression and substance use disorders. Clin Psychol Rev 2000; 20:173–89. [37] Batki SL, Canfield KM, Smyth E, Ploutz-Snyder R. Health-related quality of life in methadone maintenance patients with untreated hepatitis C virus infection. Drug Alcohol Depend 2009;101:176–82. [38] Batki SL, Canfield KM, Ploutz-Snyder R. Psychiatric and substance use disorders among methadone maintenance patients with chronic hepatitis C infection: effects on eligibility for hepatitis C treatment. Am J Addict 2011;20:312–8. [39] Holtzheimer PE, Veitengruber J, Wang CC, Krows M, Thiede H, Wald A, et al. Utility of the Beck Depression Inventory to screen for and track depression in injection drug users seeking hepatitis C treatment. Gen Hosp Psychiatry 2010;32:426–32.
ORIGINAL ARTICLE
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Depressive symptoms are frequent among drug users, but not associated with hepatitis C infection
LONE W. MADSEN1, THILDE FABRICIUS1, SIMON HJERRILD2, THOMAS M. HANSEN1, BELINDA K. MÖSSNER1, INGE BIRKEMOSE3, MERETE SKAMLING4 & PEER B. CHRISTENSEN1 From the 1Department of Infectious Diseases, Odense University Hospital, Denmark, 2Department for Affective Disorders, Aarhus University Hospital, Denmark, 3Drug Treatment Centre of Odense, Denmark, and 4Drug Treatment Centre of Svendborg, Denmark
Abstract Aim: To compare the prevalence and severity of depressive symptoms among drug users with and without hepatitis C virus (HCV) infection. Methods: This was a cross-sectional survey study carried out at the 2 major drug treatment centres on the island of Funen, Denmark. Participants were drug users presenting to the 2 treatment centres. Individuals with chronic hepatitis B virus or HIV infection were excluded. Participants completed the Major Depression Inventory (MDI) questionnaire when presenting at the centres. Patients with MDI scores indicating severe depression (total MDI score ⱖ 35) were referred for treatment evaluation. Hepatitis C status was classified by the presence of anti-HCV as a marker of HCV exposure and HCV-RNA as a marker of ongoing infection. Results: Two hundred and sixty-eight patients were included, of whom 235 (88%) had complete serological testing; 100 (43%, 95% confidence interval (CI) 36–49%) had chronic hepatitis C. The median MDI score was 22 (interquartile range 12–33); 32% (95% CI 26–39%) had a score compatible with depression and 14% (95% CI 10–19%) were rated as severe depression. Depression was not associated with hepatitis C (HCV-infected 29%, non-infected 35%; p ⫽ 0.25). Forty-one percent (11/27) of the evaluated participants started antidepressant treatment. Conclusions: Our study demonstrated a high prevalence of depressive symptoms among drug users, but this was not more frequent among HCV-infected patients. The high overall prevalence of depression underlines the relevance of screening for depression in patients who are drug users.
Keywords: Hepatitis C, depression, drug users
Introduction Symptoms of depression such as fatigue, decreased cognition function, sleep disturbances, and low mood are frequent in patients with hepatitis C [1–4]. It has been suggested that the hepatitis C virus (HCV) per se contributes causally by infecting the human central nervous system [5–7], since current evidence indicates that HCV crosses the blood–brain barrier and subsequently replicates in microglia leading to low-grade neuroinflammation through the production of pro-inflammatory cytokines [6,7]. Further, a study has shown an association between depression and HCV in patients who have never been exposed
to previous interferon-alpha treatment, or drug and alcohol abuse [8]. However, the majority of HCV patients in the Western world have been infected through intravenous drug use [9], and drug users also have a high prevalence of mood disorders [10]. An association between HCV and depression has also been demonstrated among heroin users on methadone treatment using the Beck Depression Inventory (BDI) [11]. The identification of depression prior to hepatitis C treatment with interferon-alpha is clinically important. A recent meta-analysis found that 1 out of 4 developed a depressive disorder during interferon-alpha
Correspondence: L. W. Madsen, Department of Infectious Diseases Q, Odense University Hospital, Building 1, 2nd Floor, Penthouse block 6, Sdr Boulevard 29, 5000 Odense C, Denmark. Tel: ⫹ 45 65414294. Fax: ⫹ 45 66117418. E-mail: [email protected] (Received 30 September 2013 ; accepted 11 April 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.918274
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Depression and hepatitis C treatment. Predictive variables for the development of depression were female gender, history of depression or psychiatric disorder, and low educational level [12]. Furthermore, prophylactic treatment with selective serotonin reuptake inhibitors (SSRI) has been shown to prevent depression during interferon-alpha treatment, even in patients without depression before the initiation of antiviral treatment [13]. The identification of patients with sub-syndromal depressive symptoms could lead to a more intensive management during antiviral treatment. Our hypothesis was that depressive symptoms would be more prevalent among HCV-infected patients. The aim of this study was to compare the prevalence and severity of depressive symptoms as measured by the Major Depression Inventory (MDI) in a population of drug users with and without HCV infection. Materials and methods A cross-sectional survey was performed among drug users attending 2 major methadone treatment centres in Denmark during the winter of 2010/2011. The treatment centres cover a population of approximately 240,000 inhabitants and are the only places that provide substitution treatment in primary care. The 2 centres have a capacity of approximately 664 drug users, and the staff includes social workers, nurses, and doctors specialized in addictive medicine and psychiatry. Drug users were approached by the study team when presenting for treatment at the centre. After signing informed consent, the participants completed
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a validated Danish version of the MDI questionnaire alone or assisted by the study team. The MDI is a 10-item dual function self-rating depression scale that generates a probable depression diagnosis based on either the International Classification of Diseases 10th edition (ICD-10) or the Diagnostic and Statistical Manual 4th edition (DSM-IV) symptom criteria, and the total score serves as a measure of depression severity [14–17]. A total score of 20–26 points indicates mild depression, 27–35 points indicates moderate depression, and a total score of more than 35 points indicates severe depression. According to an algorithm of major and minor symptoms, the patient may be classified as having mild, moderate, or severe depression according to the ICD-10 classification (see footnote to Table I) [14,16]. The MDI form has previously been used to diagnose depression in hepatitis C patients and was found to be suitable for monitoring depression during interferon-based treatment [18]. We classified depression according to the algorithm for the presence of major and minor symptoms as per the ICD-10 classification. In addition, we analyzed the results with a depression classification based on the total MDI score. In addition to the MDI forms, information on substitution treatment, psychotropic drug consumption, previous psychiatric hospitalization, and alcohol consumption was obtained from the treatment centre and hospital records. All participants had a previous drug addiction and the majority were abusing a multitude of drugs. Some of the patients had a current drug abuse prob-
Table I. Presence of depressive symptoms among 235 drug users according to HCV status. HCV MDI question 1. Have you felt low in spirits or sad? 2. Have you lost interest in your daily activities? 3. Have you felt lacking in energy and strength? 4. Have you felt less self-confident? 5. Have you had a bad conscience or feelings of guilt? 6. Have you felt that life wasn’t worth living? 7. Have you had difficulty in concentrating, e.g. when reading the newspaper or watching TV? 8a. Have you felt very restless? 8b. Have you felt subdued or slowed down? 9. Have you had trouble sleeping at night? 10a. Have you suffered from reduced appetite? 10b. Have you suffered from increased appetite?
Infected 2 3 3 1 1 0.5 1 2 1 3 1 0
Not infectedb
p-Value
(1–3.8) (1–4) (1–4) (0–3) (0–3) (0–2) (0–3)
2 3 3 2 2 1 1
(1–4) (1–4) (2–5) (0–4) (0–4) (0–3) (0–3)
0.772 0.739 0.222 0.283 0.096 0.424 0.166
(1–3) (0–3) (0–4) (0–4) (0–1)
3 2 3 2 0
(1–4) (0–4) (1–5) (0–4) (0–1)
0.094 0.019 0.203 0.729 0.914
HCV, hepatitis C virus; MIDI, Major Depression Inventory. aResults given as median (interquartile range); 0: at no time, 5: all of the time (recall period 14 days). Algorithm for classification according to the presence of major symptoms (questions 1–3 ⬎ 3) and minor symptom (questions 4–10 ⬎ 2): mild depression ⫽ 2 major and 2 minor; moderate depression ⫽ 2 major and 4 minor; severe depression ⫽ 3 major and 5 minor. bSum of past HCV and never HCV infection.
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lem and if the patient appeared intoxicated, they were denied access to the treatment centres. There was no distinction between previous or current drug abuse. Participants with MDI scores suggesting severe depression and patients who the study team believed needed further medical assessment were referred for further diagnostic and treatment evaluation. HCV status was assessed by testing for anti-HCV as a marker of HCV exposure and HCV-RNA as a marker of ongoing infection. Patients with hepatitis B virus or HIV infections (HBsAg or anti-HIV positives) were excluded from the study. Less than 5% of HCV-infected patients had previously been treated for HCV. The few patients with a cured infection were not distinguished from those patients with spontaneous HCV clearance, and no patients receiving interferon treatment were included in the study. Data were analyzed using Stata version 12 (StataCorp LP, College Station, TX, USA). Univariate associations were tested with non-parametric tests (Fisher’s exact test, Chi-square test, or Mann–Whitney test, as appropriate) and a 2-sided p-value of ⬍ 0.05 was considered significant. Multivariate analysis was done by logistic regression with MDI depression as the outcome and HCV as the independent variable and including clinically and statistically significant covariates in a full model. Insignificant variables were eliminated, however variables that changed the odds ratio (OR) of the HCV association were maintained in the model regardless of significance. Due to the population size, interaction terms were not included in the model. The study was approved by the local ethics committee (S-VF-20060078) and the Danish Data Protection Agency (2010-41-5149).
Results We obtained MDI forms from a total of 287 participants, corresponding to 43% of 664 drug users attending the centres over a period of 6 months from October 2010 to March 2011. We excluded 17 repeat MDI forms from drug users who entered the study twice and 10 incomplete forms; also excluded were 9 participants who were co-infected with HBV or HIV and 33 persons with incomplete hepatitis C status (Figure 1). Non-participants did not differ significantly by age or gender, but information related to hepatitis C infection and symptoms of depression were only available for participants. Among the remaining 235 participants, 175 (74%, 95% confidence interval (CI) 68–80%) were men and the median age was 45 y (interquartile range (IQR) 37–51 y). Chronic hepatitis C was found in 100 participants (43%, 95% CI 36–49%) (HCV-RNA positive); 55 participants (23%, 95% CI 18–29%) had a former infection (antiHCV-positive, HCV-RNA-negative) and 80 (34%, 95% CI 28–40%) had not been infected with HCV (anti-HCV negative). Opioid substitution was given to 98% (231/235), of whom 86% received methadone, with no difference according to HCV status or MDI score. The MDI questionnaire was completed individually by 49% of the participants and with the assistance of the study team by 51%. Scores were not statistically different between these 2 groups, however 117 participants who did not report whether they were assisted with completing the form had EXCLUDED
664 drug users affiliated to a drug treatment centre
377 (57%) not present or declined participation
17 duplicates 10 incomplete forms 9 coinfected
304 MDI forms from 287 (43%) drug users
33 no HCV RNA test
268 included
235 (88%) known HCV status
100 (43%) Chronic HCV
55 (23%) Past HCV Figure 1. Study flow diagram.
80 (34%) Never HCV
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Depression and hepatitis C lower MDI scores (median 21 for non-reporters versus 25 for non-assisted and 29 for assisted; p ⫽ 0.01). The median MDI total score was 22 (IQR 12–33, range 0–50). An MDI score suggesting depression (ⱖ 20) was found in 133 (57%, 95% CI 51–64%), of whom 50 (21%, 95% CI 16–27%) had a score compatible with severe depression (Table II). When utilizing the diagnostic algorithm in the MDI, 32% (95% CI 26–39%) of the participants had depression according to the ICD-10 criteria and 14% (95% CI 10–19%) were severe. Fifty-one percent of the participants with depression had a psychiatric diagnosis. Among the 76 patients who were diagnosed with depression according to the MDI, 29% had previously been diagnosed with depression, 24% with anxiety, and 3% with schizophrenia (Table III). In a univariate analysis, the use of illegal drugs during methadone treatment was associated with ICD-10 depression (Table IV). Young age, illegal drug use, and use of benzodiazepines were associated with higher total MDI scores (data not shown). In contrast, HCV infection was not associated with depressive symptoms. In fact, HCV-infected drug users had a lower prevalence of depression than the uninfected, although the difference was not statistically significant (Tables IV and V). The lack of association between depressive symptoms and hepatitis C was found both for the algorithm classification and MDI total score. HCV-infected drug users did not score higher than non-infected substance abusers on any of the items in the MDI (Table I). The symptom ‘tiredness’ (item 3: “Have you felt
lacking in energy and strength?”) has often been associated with HCV infection in the literature, but for neither this nor the combination of all ‘somatic’ symptoms (questions 3 and 7–10) or ‘cognitive’ symptoms (questions 1, 2, and 4–6) did we find an association with HCV infection. The only variable associated with HCV infection was alcohol abuse (Table V). The use of prescribed drugs against mood disorders was frequent. Overall, 54% (127/235) used antidepressant drugs and 20% (47) used 2 or more classes of these drugs. Use was numerically higher among depressed drug uses, and for benzodiazepines this was close to significance (p ⫽ 0.06, Table IV). In contrast, no association was found between drugs prescribed for mood disorders and hepatitis C status (Table V). In a multivariate logistic regression analysis with depression defined by the MDI algorithm as the outcome and hepatitis C infection, age, gender, use of benzodiazepines, illicit drug use, and alcohol abuse as independent variables, only the use of benzodiazepines was significantly associated with depression (Table IV). Chronic hepatitis C was close to significance (p ⫽ 0.054), but the association was negative: the HCV-infected tended to have lower MDI scores than the non-infected. By backwards elimination of insignificant variables, no other variables became associated with depression and no OR changed ⬎ 10% of the value in the full model. As a result of the MDI screening, 92/268 (34%) were referred for further evaluation. Twenty-seven participants had a psychiatric evaluation by the doctors at the treatment centres, of whom 41% (11/27) started antidepressant treatment and 15% (4/27) were referred to a psychiatrist.
Table II. Major Depression Inventory (MDI) score among 235 drug users.
Total MDI score 0–19 (normal) 20–26 (mild depression) 27–34 (moderate depression) 35–50 (severe depression) Total
569
Number
%
102 34 49 50 235
43.5 14.5 20.9 21.3 100
Symptom severity (algorithm classification) No depression Mild depression Moderate depression Severe depression
Number 159 11 33 32 235
% 67.7 4.7 14.0 13.6 100
Table III. Psychiatric diagnosis associated with depression.
Participants with ⱖ 1 previous psychiatric diagnosis Depression Schizophrenia Anxiety Attention deficit/hyperactivity disorder (ADHD) Opioid use, unspecified Obsessive-compulsive disorder (OCD) Psychosis Post-traumatic stress disorder (PTSD)
Depression
No depression
51% 29% 3% 24% 3% 5% 1% 1% 7%
40% 25% 4% 19% 2% 4% 3% 3% 3%
(39/76) (22/76) (2/76) (18/76) (2/76) (4/76) (1/76) (1/76) (5/76)
(64/159) (40/159) (7/159) (30/159) (3/159) (6/159) (4/159) (5/159) (4/159)
p-Value 0.12 0.53 0.72 0.39 0.66 0.73 1.00 0.67 0.15
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Table IV. Factors associated with any depression according to the Major Depression Inventory (MDI) algorithm score. Univariate analysis
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MDI algorithm score % of total (n) Age, y, median (IQR) Men HCV-RNA-positive Anti-HCV-positive Any psychotropic Antidepressant Benzodiazepine Antipsychotic Other psychotropic Admission to psychiatric ward ever Substitution treatment Use of illegal drugs during substitution treatment Alcohol abuse ever
Depression (n ⫽ 76)
No depression (n ⫽ 159)
32% (76) 42 (37–48) 70% (53/76) 38% (29/76) 62% (47/76) 74% (46/68) 13% (9/68) 45% (29/68) 22% (15/68) 4% (3/68) 35% (26/74) 86% (65/76) 90% (63/70)
68% 46 77% 45% 68% 64% 12% 24% 24% 5% 33% 87% 76%
39% (23/59)
33% (42/129)
Logistic regression analysis
p-Value
(159) (37–52) (122/159) (71/159) (108/159) (81/127) (15/127) (30/127) (30/127) (6/127) (52/157) (138/159) (107/140)
OR Univariate
OR Multivariate
95% CI
p-Value
0.97 1.07 0.53
0.96 1.41 0.47
(0.92–1.01) (0.6–3.3) (0.2–1.01)
0.10 0.43 0.05
2.43
2.7
(1.3–6.0)
0.01
3.48
3.1
(0.8–12)
0.09
1.50
1.4
(0.7–3.1)
0.38
0.16 0.10 0.27 0.40 0.38 0.64 0.82 0.06 0.86 1.00 0.77 0.84 0.03 0.41
OR, odds ratio; CI, confidence interval; IQR, interquartile range; HCV, hepatitis C virus.
Table V. Factors associated with HCV infection.
% of total (n) Age, y, median (IQR) Men MDI total score ⬍ 20 (no depression) 20–26 (mild depression) 27–35 (moderate depression) ⬎ 35 (severe depression) Depression severity (MDI algorithm) No depression Mild depression Moderate depression Severe depression Any psychoactive drugs Antidepressants Benzodiazepines Antipsychotic drugs Other psychoactive drugs Admission to psychiatric ward Substitution treatment Use of illegal drug during substitution treatment Alcohol abuse
HCV present
HCV past
HCV never
(HCV-RNA-positive)
(anti-HCV-positive, HCV-RNA-negative)
(anti-HCV-negative)
43% (100) 47 (37–51) 71% (71/100)
23% (55) 46 (40–51) 71% (39/55)
34% (80) 41 (35–48) 81% (65/80)
45% 19% 25% 11%
(45/100) (19/100) (25/100) (11/100)
45% 13% 18% 24%
(25/55) (7/55) (10/55) (13/55)
40% 10% 24% 26%
71% 8% 9% 12% 67% 11% 38% 22% 4% 36% 100% 82% 43%
(71/100) (8/100) (9/100) (12/100) (57/85) (9/85) (32/85) (19/85) (3/85) (35/98) (100/100) (72/88) (38/89)
67% 2% 15% 16% 70% 11% 37% 22% 7% 35% 100% 78% 33%
(37/55) (1/55) (8/55) (9/55) (32/46) (5/46) (17/46) (17/46) (3/46) (19/55) (55/55) (36/46) (13/40)
64% (51/80) 3% (2/80) 20% (16/80) 14% (11/80) 59% (38/64) 16% (10/64) 25% (16/64) 25/16/64 5% (3/64) 30% (24/78) 95% (76/80) 82% (62/76) 24% (14/59)
p-Value
0.12 0.36 0.11
(32/80) (8/80) (19/80) (21/80) 0.25
0.62 0.66 0.26 0.87 0.73 0.67 0.13 0.86 0.03
HCV, hepatitis C virus; IQR, interquartile range; MDI, Major Depression Inventory. p-Value for HCV present versus HCV past and HCV never combined.
Discussion In this cross-sectional survey of depressive symptoms among drug users attending drug treatment centres, we found that a high proportion of the participants reported the presence of significant depressive symptoms, but these were not more frequent among HCV-infected drug users as compared to the
non-infected. Both in univariate and multivariate analysis, HCV-infected participants had numerically lower depression scores than the non-infected. Our results do not support the hypothesis that HCV per se increases depressive symptoms. Our study had several weaknesses: First, the MDI has not been evaluated previously among drug users,
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Depression and hepatitis C and participants in our study were not systematically evaluated by a psychiatrist, thus we cannot conclude that all drug users identified as depressed fulfilled the ICD-10 or DSM-IV criteria of depression. In addition, a diagnosis of depression cannot be established using a screening instrument like the MDI. However, 41% of participants with high MDI scores who were further evaluated were prescribed antidepressants, suggesting that depression was diagnosed by their treating physician. Second, the relative depressogenic contribution of HCV might be significantly diminished in patients with active substance abuse and potential psychiatric and somatic co-morbidities, as suggested by the high prevalence of depressive symptoms in this group. Third, the 2 functions of the MDI (total sum versus categorical ICD-10 diagnosis) differed considerably in their prevalence estimates of depression in the sample (Table IV). We believe that the MDI algorithm was most comparable to depression as defined by ICD-10, but the use of the total MDI sum to define depression did not change our findings. Fourth, the low participation rate in the study constitutes a limitation, albeit we could not detect any demographic bias in non-participants and the high median score among the participants made it less likely that drug users with depressive symptoms were selectively excluded from the study. Fifth, the MDI does not permit a more precise description and classification of the depressive symptoms into, for example, bipolar depression or a recurrent brief depressive episode [19,20]. Due to the above limitations, it is difficult to estimate the prevalence of depression in this particular population. However, the primary aim of our study was to elucidate the association between HCV and depressive symptomatology, and we found the MDI an appropriate tool for this purpose. Since most depression scales have been developed in patients with primary depression, it has been argued that the applicability of these rating scales in patients with co-morbid somatic diseases (e.g. HCV) might be reduced [21–23] and potentially lead to diagnostic inflation. A recent study showed that HCV patients had increased somatic item scores on the BDI [24], however we did not find any association between somatic item scores in the MDI and hepatitis C status. An increased prevalence of depression has been reported in patients with chronic hepatitis C [2,3,25–27]. Since a significant proportion of HCV infections remain undiagnosed [28], the increased prevalence of depression among HCV outpatients could be due to the fact that a high proportion were diagnosed in the first place due to psychiatric or somatic complaints [29]. This fact is underlined by similar proportions of fatigue in healthy blood donors with and without HCV [30]. Several studies have found no differences in depressive symptomatology in patients with HCV antibodies with or
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without active viral replication (HCV-RNA) [31,32]. Additionally, knowledge of the HCV diagnosis can be considered a significant psychological stressor [33,34], and the associated stigmatization [35] appears to be associated with depressive symptoms [36]. Patients with substance abuse generally have a high prevalence of psychiatric co-morbidity, especially depression [37]. Batki et al. studied psychiatric morbidity in HCV patients on methadone replacement therapy and found that approximately 20% fulfilled the DSM-IV criteria for a mood disorder [38,39]; they also found that the median BDI score was in the mild depression range and was a significant predictor of health-related quality of life [38]. Another study found major depression according to the DSM-IV criteria in 37% of injection drug users with acute HCV, and a total of 59% had depression [40]. It is therefore likely that the estimated prevalence of depression derived from the MDI total score may be too high due to item contamination from, for example, drug use or physical disorders. Using the MDI algorithm to diagnose depression yielded prevalence rates in the vicinity of known rates of depression from studies using structured clinical interviews. This finding suggests that the algorithm-based diagnosis could be the most correct estimate, but this remains to be validated. The MDI score has been evaluated previously in a study of the general Danish population [15]. The mean MDI score was 7.2, 4.1% were classified as having depression according to ICD-10, and 3% received medical treatment for mental disorders. In a study among patients undergoing treatment for hepatitis C (of whom 72% were infected by injecting drug use), the mean MDI at baseline was 13, 6% had major depression, and 8% received antidepressants, compared to our study with a mean MDI of 23, 14% with major depression, and 12% using antidepressants [18]. Thus hepatitis C patients reported higher MDI scores than the general population, but substantially lower than the participants in our study (Table IV). We found a high prevalence of depressive symptoms among drug users, but depressive symptoms were not increased in drug users with hepatitis C, thus our study does not support the hypothesis that hepatitis C increases depressive symptoms in this population. Due to the high prevalence of depression in drug users, we suggest that screening for depression prior to treatment for hepatitis C is a useful strategy; in this way depression can be identified and treated before interferon-based antiviral treatment is commenced and patients in need of a more intensive management during treatment can also be identified.
Declaration of interest: This study was not funded. All authors have no financial interest to disclose.
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