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December 2010, Volume 60, Issue 12

Opinion and Debate

Mood disorder associated with gastrointestinal and liver diseases: Are there many challenges?

Amin A. Muhammad Gadit  ( Memorial University of Newfoundland, Canada. )

With the high prevalence of hepatitis and other gastrointestinal illness in the country, we come across the mental health consequences of such medical problems. The major issues are with depression and anxiety. It is quite understandable that physical illnesses bring in with them stress that is intrinsic by virtue of the serious nature of medical illness, the socio-economical repercussions and the uncertain prognosis in terms of the nature of illness. The major mental health problem that these patients are referred with is depression that can be of moderate to severe intensity. Depression in itself is a separate clinical entity that calls for treatment. This becomes challenging for mental health professional in a number of ways, first to educate the patient that there is another illness to be dealt with, the type of tailored psychotherapy that the individual person would need and above all, the biological treatment in terms of its suitability, side effects and interaction with the medications already been prescribed for the medical condition in question. One particular drug is notoriously known for inducing depression is Interferon. Here the challenge for management of depression becomes more acute. However, there are a number of success stories that are quite encouraging. Though several experts claim that antiviral therapy should not be given to HCV patients having psychiatric problems, this has proven wrong in clinical trials as SSRI (selective serotonin uptake inhibitors) have proven effective.1
Reviewing the evidence of associations between depression and Hepatitis C and Interferon treatment and its association with immune mechanism effective treatment with the use of anti-depressants has been recommended in a study.2
Asnis et al3 in their study emphasized on the finding of depression prior to interferon therapy that could contribute to the propensity to develop depression during treatment. They also wondered whether pegylation of interferon would lead to reduced potential to induce depression. The effective use of nortriptyline in patient with simultaneous interferon treatment proved to be highly beneficial in a reported case.4
Paroxetine has been tried successfully for interferon associated depression in a study.5 In a case series, Imipramine, Sertraline, Paroxetine were administered with successful outcome in interferon related depression.6 It has been advocated that selection of antidepressant agent in medically ill patients require careful assessment in terms of physiological vulnerabilities, potential for drug interactions and patient\'s primary symptoms, newer drugs like Bupropion, and Venlafaxine have simplified the treatment of depression while refractory cases can be managed with electroconvulsive therapy.7 It has also been noted that the effects of antidepressant therapy are reversed by initiation of interferon. It was suggested that ECT is more likely than SSRIs to be effective in interferon-induced major depression.8 A study conducted in Pakistan on 100 patients revealed that among those who were on interferon therapy, 47% had depression before and after taking interferon. Among these 6% reported suicidal ideation, none of these HCV positive cases were on antidepressants or either referred for psychiatric evaluation.9 The aforementioned study does not go further to address the problem of depression among these patients. Psychotherapy may also play a major role especially the cognitive Behavioural and the supportive type but tailoring it according to the needs for individual personality profile can be challenging. Education for the patient in terms of understanding the dynamics of both physical and mental health issues and its management is an essential task for the treating physician. A simultaneous follow up by both specialties is another important step to follow. Despite all these, a number of issues remain on the horizon like: to discontinue the interferon or reducing the dose, compliance by the patient, selection of appropriate antidepressant, monitoring the side effects of both types of medications, caution for any drug-drug interaction and ways to keep the communication intact between medical consultant and the psychiatrist for ongoing review of the patient\'s condition. This year, the World Federation for Mental Health (WFMH) has emphasized on collaborative care for both mental and physical illnesses. In many instances, both types of illnesses are interwoven and treatment of one in isolation does not bring total well-being to the patients. Can we afford to ignore this fact?


1.Horsmans Y. Interferon-induced depression in chronic hepatitis C. J Antimicrobial Chemotherapy 2006; 58: 711-3.
2.Angelino AF, Treisman GJ. Evidence-informed assessment and treatment of depression in HCV and interferon-treated patients. Int Review Psychiat 2005; 17: 471-6.
3.Asnis GM, De La G, Richard H. Interferon-Induced Depression in Chronic Hepatitis C: A Review of its Prevalence, Risk Factors, Biology, and Treatment Approaches. J Clin Gastroenterol 2006; 40: 322-35.
4.Goldman LS. Successful treatment of interferon alfa-induced mood disorder with Nortriptyline-letter. Psychosomatics 1994; 35: 412-3.
5.Kraus MR, Schafer A, Faller H, Csef H, Scheurlen M. Paroxetine for the treatment of interferon-alpha-induced depression in chronic hepatitis C. Alimentary Pharmacol Therapeutics 2002; 16: 1091-9.
6.Gleason OC, Yates WR. Five cases of interferon-alpha-induced depression treated with antidepressant therapy. Psychosomatics 1999; 40: 510-2.
7.Beliles K, Stoudemire A. Psychopharmacologic treatment of depression in the medically ill. Psychosomatics 1998; 39: S2-S19.
8.McAllister-Williams RH, Young AH. Antidepressant response reversed by interferon. Br J Psychiatry 2000; 176: 93.
9.Majeed S, Memon A, Abidi MA. Frequency of depression among Hepatitis C patients. KUST Med J 2009; 1: 42-5.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: