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| ORIGINAL ARTICLE |
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| Year : 2014 | Volume
: 35
| Issue : 3 | Page : 179-186 |
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Depression in chronic hepatitis C patients and the role of cognitive behavioral therapy in its treatment
Eman R Elsafy, Wael Abu-Hendy, Haitham M Abouhashim, Heba A Fouad
Department of Psychiatry, Zagazig University, Zagazig, Egypt
| Date of Submission | 07-Apr-2014 |
| Date of Acceptance | 10-May-2014 |
| Date of Web Publication | 11-Nov-2014 |
Correspondence Address:
Eman R Elsafy
Department of Psychiatry, Faculty of Medicine, Zagazig University, Damietta Branch, Damietta
Egypt
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1110-1105.144351
Background
Hepatitis C is a major health problem in Egypt and worldwide. Hepatitis C is associated with an increased prevalence of psychiatric disorders, particularly depression. In addition, depression is one of the neuropsychiatric side effects of interferon (IFN) therapy. Although antidepressants have been proven to be effective in the treatment of depression in this patient population, the risk of hepatotoxicity and toxicity warrants the search for other treatment alternatives for depression, such as cognitive behavioral therapy (CBT).
Patients and methods
A sample of 100 hepatitis C-seropositive patients was divided into two groups: 50 IFN-treated patients and 50 patients not undergoing IFN treatment. All the patients were subjected to an assessment of detailed history and a physical examination and were evaluated for the presence of depression using the Structured Clinical Interview for DSM-IV axis I disorder (SCID-I), the Hamilton Rating Scale for Depression (HAM-D), and the Zagazig Depression Scale (ZDS). The patients who were diagnosed with depression received a course of CBT, and were tested using the same scales after completing the CBT and after 3 months of completing the therapy.
Results
Our data confirm the high rate of major depressive disorders among the population of patients with hepatitis C, with the prevalence of depression being higher in the group undergoing treatment with IFN (40%) than the untreated group (28%). Depression scores on both HAM-D and ZDS were higher in the IFN-receiving group. CBT intervention resulted in a marked decrease in ZDS and HAM-D scores over time in both the groups.
Conclusion
We concluded that a huge percentage of chronic hepatitis C patients develop depression, both those who undergo IFN treatment and those who did not receive any HCV treatment. CBT has been found to be an efficacious treatment for this adverse effect. Keywords: cognitive behavioral therapy, depression, hepatitis C
How to cite this article:
Elsafy ER, Abu-Hendy W, Abouhashim HM, Fouad HA. Depression in chronic hepatitis C patients and the role of cognitive behavioral therapy in its treatment. Egypt J Psychiatr 2014;35:179-86 |
How to cite this URL:
Elsafy ER, Abu-Hendy W, Abouhashim HM, Fouad HA. Depression in chronic hepatitis C patients and the role of cognitive behavioral therapy in its treatment. Egypt J Psychiatr [serial online] 2014 [cited 2023 Dec 11];35:179-86. Available from: https://new.ejpsy.eg.net//text.asp?2014/35/3/179/144351 |
| Introduction | |  |
Hepatitis C is a major significant health problem worldwide (Hoofnagle, 1997). Egypt has the highest prevalence of HCV worldwide (Abdel-Aziz et al., 2000; El-Sadawy et al., 2004). Like many chronic medical illnesses, hepatitis C is associated with an increased prevalence of psychiatric disorders (Bayliss et al., 1998), particularly depression. In addition, neuropsychiatric side effects develop in a huge percentage of patients (Hauser et al., 2000) who undergo interferon (IFN) therapy, including depression (Singh et al., 1997; Dieperink et al., 2000). The presence of depressive symptoms in patients with hepatitis C is significant because they have an adverse effect on the course of illness, with reduced treatment compliance and reduced quality of life (Dwight et al., 2000). Recent data have shown that depressive symptoms can be treated effectively in patients receiving IFNa/ribavirin treatment for chronic hepatitis C (CHC) (Horikawa et al., 2003). However, antidepressants rank fifth among drugs causing liver damage (Period Andrade et al., 2005). However, there is a lack of literature on the use and efficacy of cognitive behavioral therapy (CBT) for the treatment of depression in HCV, including IFN-induced depression.
| Aim of the work | | |
To study the prevalence of depression among patients with CHC and to study the role of CBT in the treatment of depression in these patients.
Patients and methods
Patients
The present study was carried out on 100 patients with CHC recruited from among outpatients attending the intrinsic medicine clinic in Zagazig university hospital and patients seeking antiviral treatment for HCV at an urban hospital-based primary care clinic (Al-Ahrar hospital) during the period from January 2010 to September 2011.
The study participants were divided into two groups:
(1) A group of 50 patients diagnosed with CHC and not undergoing IFN treatment (either on the waiting list for IFN treatment or not candidates for antiviral treatment).
(2) A group of 50 patients diagnosed with CHC and undergoing treatment with peg-IFNa and ribavirin.
Inclusion criteria
In order to be eligible to receive antiviral treatment, all patients had to fulfill the treatment inclusion criteria:
(1) At least 18 years of age.
(2) HCV antibody positive and detectable HCV RNA in serum. CHC is defined as the presence of antibody to HCV with intermittent or persistent abnormal liver function tests for more than 6 months (or the presence of viremia for those with persistently normal liver function tests).
Patients had to fulfill additional eligibility criteria in order to participate in the study:
(3) Education level at least literate (able to read and write fluently).
(4) In addition, the patients in the IFN group had to complete at least 8 weeks of treatment.
Exclusion criteria
Patients were excluded from the study if they had.
(1) Advanced liver cirrhosis (child stage B or C), coinfection (hepatitis B virus or HIV), or severe internal diseases or any medical illness affecting the central nervous system.
(2) Active intravenous drug use or alcohol abuse.
(3) Currently taking an antidepressant medication.
(4) Currently suicidal or psychotic.
(5) The intention to relocate from the study area in the next 6 months.
Methods
Following the baseline interview, the 100 study participants were assessed using the following:
Screening measure for depression by the Zagazig Depression Scale (ZDS)
(1) Psychiatric case interview: including previous history and family history.
(2) Structured Clinical Interview for DSM-IV axis I disorder (SCID-I).
(3) Hamilton Rating Scale for Depression (HAM-D).
(4) Neurological and physical examination to exclude any medical illness affecting the central nervous system.
The patients who were diagnosed with depressive disorders (HAM-D score >7) from both groups were scheduled to receive a CBT course and were tested using the same scales after completing the CBT and after 3 months of completing the therapy.
| Results | | |
Participant characteristics
The mean age of the participants was 42.8 ± 8.2 years, 23% of whom were women and 77% were men. Thirty-four percent were unemployed or housewives, 50% were manual workers, and 16% were employees. Twenty-five percent of the participants were single, 70% were married, 2% were widowers, and 3% were divorced. Thirty-one percent of participants had a previous history of psychiatric disorders and 17% had a family history of psychiatric disorders. Forty-six percent of the participants were living in urban areas and 54% were living in rural areas ([Table 1]). | Table 1 Sociodemographic data of a sample of chronic hepatitis C patients
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Detection of depression
Thirty-four percent of the participants in this study were diagnosed with depression. The mean score of the HAM-D scale of all the participants in this study was 8.57 ± 6.2 and the mean score of ZDS was 12.08 ± 9.7. Patients diagnosed with depression had a mean score of 15.73 ± 5.2 on the HAM-D scale and a mean score of 23.21 ± 9.3 on the ZDS scale, whereas the nondepressed patients had a mean score of 4.88 ± 1.6 on the HAM-D scale and a mean score of 6.35 ± 1.9 on the ZDS scale ([Table 2]). Twenty of the 50 patients (40%) who received IFN developed major depressive disorder, compared with 14 (28%) of the 50 patients in the non-IFN-receiving group ([Table 3]).The groups of patients who received IFN had significantly higher HAM-D and ZDS scores than those who did not receive IFN ([Table 4]). The G2 group had significantly higher mean scores for both HAM-D and ZDS than G1 at baseline ([Table 5]). Patients with hepatitis C receiving pegylated IFN-a (peg IFNa) and ribavirin had a higher frequency of severe depression in comparison with patients with hepatitis C who were not receiving IFN, whereas the non-IFN-receiving group showed a higher frequency of mild depression compared with the IFN-receiving group ([Figure 1]). | Table 2 Prevalence of depression, and comparison of Hamilton rating scale for depression and the zagazig depression scale among a sample of chronic hepatitis C patients
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 | Table 3 Comparison between the prevalence of depression in the group of patients receiving interferon and in the group of patients not receiving interferon
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 | Table 4 Comparison between the Hamilton rating scale for depression and the zagazig depression Scale in the mean scores of the group of patients who were receiving interferon and those who were not receiving interferon
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 | Table 5 Comparison of the mean and SD scores of the Hamilton rating scale for depression and the zagazig
depression scale between G1 and G2 before starting cognitive behavioral therapy
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Role of cognitive behavioral therapy in the treatment of depressive disorders
In the group of patients with hepatitis C not receiving IFN, patients who developed depression were significantly older than those who did not. In addition, significantly more women than men developed depression. Also, significantly more patients who developed depression were unemployed than those who did not. Significantly more patients who developed depression were single than those did not. Finally, patients who developed depression had significantly higher ratio of a positive previous history of mood disorders than those who did not ([Table 6]). | Table 6 Comparison of different sociodemographic factors between depressed and nondepressed patients who were not receiving interferon
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In the group of patients with hepatitis C receiving pegylated IFNa (peg IFNa) and ribavirin, significantly more women (63.6%) than men (33.3%) developed depression (P = 0.05). Depressed patients were significantly more likely to have a history of mood disorders (35.1%) than those who did not (3.3%). There were no statistically significant differences in occupational status (unemployment), education, family history of psychiatric disorders, or area of residence ([Table 7]). | Table 7 Comparison of different sociodemographic factors between depressed and nondepressed patients in the group of patients receiving interferon
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A statistically significant difference was found between the means and SDs of HAM-D and ZDS scores of G1 and G2 at baseline, after completion of therapy, and 3 months later ([Table 8]). | Table 8 Comparison between Hamilton rating scale for depression and zagazig depression scale at baseline, 3 months, and after 6 months of follow-up between G1 and G2
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A highly statistically significant difference in the mean score of HAM-D was found in G1 before and after the CBT course and after 6 months of follow-up ([Table 9]). Similarly, a statistically significant difference was found in G2 in the mean scores of HAM-D before and after the CBT course (t = 2.09 and P = 0.009) and after 6 months of follow-up (t = 2.2 and P = 0.009) ([Table 9]). A highly statistically significant difference was found in G1 in the mean scores of ZDS before and after the CBT course (t = 4.3 and P < 0.001) and after 6 months of follow-up (t = 5.3 and P < 0.001) ([Table 11]). A statistically significant difference in the mean scores of ZDS was found before and after the CBT course (t = 4.20 and P ≤ 0.001), and after 6 months of follow-up in G2 (t = 4.70 and P = 0.01) ([Table 12]). | Table 9 Mean differences in repeated Hamilton rating scale for depression measures in group G1 at baseline, after 3 months, and after 6 months of follow-up
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| Discussion | | |
Detection of depressive disorders
In agreement with studies on patients with other chronic medical illnesses (Katon, 1987), we found significant levels of depression in patients with CHC, both treated and untreated with IFN therapy. Depression was found in 34% of our patients ([Table 2]). This finding is in agreement with that of ElSerag et al. (2002), who found that patients infected with HCV have a high prevalence of psychiatric disorders, irrespective of whether they received HCV antiviral treatments.
In the non-IFN-receiving group, depression was found in 28% of patients with CHC ([Table 3]). This finding is in agreement with other studies that used a standardized psychiatric interview (Lee et al., 1997; Dwight et al., 2000; Mulder et al., 2000; Golden et al., 2005) that reported depression in 28% of patients. Similarly, Elshahawi et al. (2011) found a 30% prevalence of depression in a sample of Egyptian patients with CHC virus. However, some studies have reported a higher frequency of depression, for example, Mohammad et al. (2012) found depression in 57% of CHC patients. This variation may be attributed to the different study designs (retrospective vs. prospective studies) or reliance on self-administered scales rather than a formal psychiatric assessment.
In the IFN-receiving group, depression was diagnosed in 40% of patients ([Table 4]). This finding is in agreement with that of Elshahawi et al. (2011), who reported a prevalence of 42% of depression in patients with CHC undergoing IFN treatment. Our observation is also in agreement with early studies that reported that IFN-induced depression ranges from 3 to 48%, depending on the instrument used, age group, time from the start of therapy, and sex (Bonaccorso et al., 2002; Yawn et al., 2008; Baranyi et al., 2011). A few reports have reported a possible increase in depressive symptoms up to 77% after IFNa treatment (Falasca et al., 2009).
Although depression was more prevalent in patients who received IFN, there was no significant difference between the two groups in the number of patients who were diagnosed with depression (P = 0.21) ([Table 3]). This may be attributed to the small sample size.
Nevertheless, both HAM-D and ZDS scores were significantly elevated in the IFN-receiving group ([Table 4]) compared with chronic hepatitis patients not undergoing IFN treatment. These findings are in agreement with an earlier report of Elshahawi et al. (2011), who found that the beck depression inventory (BDI) scores were highly significantly elevated in the IFN-receiving group in comparison with the non-IFN-receiving group.
Comparison of the severity of depression using the HAM-D showed that the patients who did not receive IFN had a higher frequency of moderate depression, whereas the patients who received IFN treatment had a higher frequency of mild depression ([Figure 1]). These findings are in agreement with those of Elshahawi et al. (2011), who found that the BDI score was significantly higher in CHC patients who received IFN treatment compared with those who did not. Similarly, patients who received IFN therapy had a higher frequency of severe depression, in contrast to IFN-free patients who were more likely to have mild depression. | Figure 1: Comparison of the severity of depression between the group of patients receiving interferon and the group of patients not receiving interferon (IFN) according to the Hamilton Depression Scal e.
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Risk factors of depression
In the CHC patients not receiving IFN, the following risk factors were identified as presented in [Table 6].
In the present study, depressive disorders were significantly more common in female than male patients (the percentage of depressed men was 21.1% compared with 50% in women), in agreement with earlier results obtained by Golden et al. (2005). However, Dwight et al. (2000) found no significant relation between sex and development of depression in CHC patients. In addition, patients who developed depression were significantly older (mean age 48 years) than those who did not (mean age 40 years). Also, significantly more patients who developed depression were unemployed than (57.1%) than those who did not (22.2%), in agreement with the finding of Ataei et al. (2010), who reported unemployment as a risk factor for the development of depression in CHC patients. We also found that significantly more patients who developed depression were single than those did not (13.8%). These findings are in agreement with those of Erim et al. (2010), who found that participants who were single had higher depression values (P = 0.05) compared with married patients.
We also found that a previous history of mood disorders was significantly correlated to the development of depression in HCV patents not undergoing IFN treatment (P = 0.01). This finding is in agreement with studies on patients with medical conditions that showed an increased risk of depression in patients with a previous history of mood disorders (Rajasekaran et al., 2005; Richardson et al., 2006).
Depression in the chronic hepatitis C patients receiving interferon
Although previous studies have suggested that IFN-induced depression was associated with risk factors related to IFNa treatment such as the dose, duration, and mode of IFNa delivery Kraus et al., 2003, we could not study this factor because all patients included in our study were on the same treatment regimen in terms of the dose, duration, and mode of delivery. The following possible risk factors for the development of depression in CHC patients undergoing IFN treatment were found in the present study ([Table 7]):
In the present study, depressive disorders were significantly more common in female than male patients (the percentage of depressed men was 33.3% compared with 63.6% among women, in agreement with earlier results (Gallegos-Orozco et al., 2003; Gohier et al., 2003). However, other studies did not find any differences in the PEG-IFNa-associated depression in terms of the sex of the participants. (Bonaccorso et al., 2002; Martin-Santos et al., 2008).
In the present study, there was no significant difference in age between patients who developed depression and those who did not. This finding is in agreement with that of other studies (Kraus et al., 2003; Martin-Santos et al., 2008). However, some studies have found that young age was associated with the development of depression (Castera et al., 2006; Evon et al., 2009).
The lack of consensus on the impact of sociodemographic data on the development of IFN-induced depression may be attributed to the differences in sample size and different screening methods.
In the present study, a previous history of psychiatric disorder was significantly correlated with the development of depression in the group of patients undergoing IFN treatment (P < 0.005). This finding is in agreement with that of other studies. Castera et al. (2002) found that a history of mood disorders was predictive of depression. Castellvi et al. (2009) found that patients who developed depression were significantly more likely to have a history of psychiatric disorders (58%) than those who did not (30%). However, few reports have failed to find an evidence that a previous history of psychiatric disorders was a risk factor (Hauser et al., 2002; Horikawa et al., 2003; Martin-Santos et al., 2008). This variation may be attributed to the presence of other risk factors or protective factors and the type of psychometric approach used in diagnosis.
Role of cognitive behavioral therapy in the treatment of depressive disorders
The main finding in this study was that the 12-session CBT for the treatment of depression tested in the current study resulted in a relatively marked decrease over time in the observed mean scores of ZDS and HAM-D both in CHC patients receiving IFN therapy and in those who were not receiving IFN ([Table 8]). In addition, the CBT intervention resulted in significant differences over time in the HAM-D mean scores in both depressed patients not receiving IFN treatment ([Table 9]) and depressed patients receiving IFN treatment ([Table 10]). There were also significant differences over time in the ZDS mean scores both in depressed patients not receiving IFN treatment ([Table 11]) and in depressed patients receiving IFN treatment ([Table 12]). | Table 10 Mean differences in repeated Hamilton rating scale for depression measures in G2 at baseline, after 3 months, and after 6 months of follow-up
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 | Table 11 Mean difference in repeated zagazig depression scale measures in G1 at baseline, after 3 months, and after 6 months of follow-up
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 | Table 12 Mean differences in repeated zagazig depression scale measures in group G2 at baseline, after 3 months, and after 6 months of follow-up
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Our findings are in agreement with the results of a randomized trial conducted on a group of methadone maintenance patients with CHC who were undergoing IFN treatment (Ramsey et al., 2011). In that study, the group of patients who received CBT showed a greater decrease in their BDI and HAM-D scores than the standard care group. A similar finding was obtained by Lang et al. (2003), who conducted a small retrospective survey of HepC patients treated with IFN and had depression. Antidepressants and psychotherapy were found to improve their treatment compliance. However, the study was not randomized and it applied supportive psychotherapy together with pharmacological treatment. Only one study has examined the role of CBT in treating depressed patients with hepatitis B not undergoing IFN treatment. Fengmei et al. (2009) found CBT to be an effective treatment in depression in a group of hepatitis B patients[37].
| Conclusion | | |
We concluded that a considerable percentage of CHC patients developed depression, both those who were undergoing IFN treatment and those who were not receiving any HCV treatment. CBT was found to be an effective treatment for this adverse effect.
| Recommendation | | |
Our study may provide a basis for the possible future therapeutic use of psychotherapy, in particular CBT, in the treatment of IFN-induced depression and depression associated with chronic hepatitis. More studies into the efficacy of psychotherapy are required. Randomized-controlled trials are clearly warranted. It is recommended to start a psychiatric assessment at the beginning of therapy to identify early predictors of depression.
| Acknowledgements | | |
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]
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