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Hepatitis C is a major public health concern, affecting almost 2% of the US population. While there are a number of innovative medications being researched, interferon is currently the cornerstone of treatment for this disease. The good news regarding interferon treatment is that success rates have climbed dramatically with the introduction of pegylated forms (trade names: Peg-Intron and Pegasys) and the addition of ribavirin. The not-so-good news is that interferons can cause significant side effects, including psychiatric side effects such as depression.
Depressive symptoms are very common with interferon treatment. Some studies show depression rates as high as forty percent; some clinicians assert that the rates of depression are higher. As opposed to the physical side effects of interferon treatment, psychiatric side effects such as depression tend to develop relatively slowly over weeks to months. In some cases, depression can get severe enough that an interferon patient starts thinking of suicide; while an uncommon event, it is certainly the most worrisome.
A diagnosis of depression is considered when several of these symptoms occur more days than not, over a two week period (see chart below). The problem with diagnosing depression in a patient taking interferon is that a number of the symptoms (such as problems sleeping and problems eating) are common side effects of interferon treatment. If these depressive symptoms start appearing together, especially when they last for days on end, most physicians would err on the side of caution and consider antidepressant treatment during interferon therapy. Fortunately, once the interferon is stopped, depressive symptoms tend to disappear over several months.
The way to minimize the chances of depression begins before a patient?s treatment with interferon. In the time before treatment begins, patients should concentrate on decreasing stress, getting plenty of rest, and starting an exercise plan with the doctor?s clearance. Going to support groups helps a patient remember that the treatment (and side effects) are not forever ? that there is ?light at the end of the tunnel?. The groups also can provide useful insight into what to expect from interferon and advice on treating most side effects. Finally, it is important to discuss timing of interferon treatment with the physician. If a stressful event is in the near future (marriage, divorce, taxes, etc.), waiting a bit until life is calmer is generally preferable before starting treatment.
Another potentially useful way to decrease depressive side effects is to start an antidepressant before starting interferon treatment ? even if the patient has never before had depressive symptoms. This strategy is used by some doctors to increase tolerability of the medication, and has some research evidence that supports it. There has also been evidence that ?brain fog? (confusion) and anxiety symptoms are decreased as well using this strategy. While any given antidepressant may have side effects, patients may prefer them to the possibility of depression.
All of the medications listed in the next two paragraphs are FDA approved for the treatment of depression. In general, these medications take several weeks at effective doses to provide maximum benefit. If a certain medication gives an intolerable side effect, another medication may not; in addition, if one medication doesn?t work on the depression, another one may be a good choice. The choice of medication is based on multiple factors; the decision should be made after assessment and collaboration with a physician.
Antidepressants called SSRIs (selective serotonin reuptake inhibitors) are commonly used for treating depression. The medications currently in this class include Prozac, Paxil, Zoloft, Celexa, and Lexapro. They are generally well-tolerated medications; side effects that can occur are stomach upset, diarrhea (which is usually brief), and problems with sexual interest or orgasm. Another medication, Wellbutrin, works on depression by increasing chemicals other than serotonin (dopamine and norepinephine, the brain?s adrenaline). Some people have insomnia or get a little anxious on this medication, and it may not be the best choice for a patient with both anxiety and depression. However, the medication has the benefit of not causing sexual problems in most people.
Two other medications (Effexor and Remeron) are ?dual action? and work both on serotonin and norepinephrine. They can be used as first choice, or they can be useful for patients who have not responded to or cannot tolerate an SSRI. Effexor at lower doses is very similar to the SSRIs; it gets significant norepinephrine activity at doses of 150mg or higher. Remeron can be helpful for the patient with sleep problems, nausea, and poor appetite in addition to depression or anxiety; for some patients, the sedation and appetite stimulation can be bothersome. There are reports that dual action medications may work more quickly than SSRIs, and that they may work better on resistant depression.
Generally, patients who start on antidepressants will need to continue taking them throughout the course of interferon therapy and for about six months afterwards. Interferon can cause big changes to the brain?s chemistry ? to the point where stopping an antidepressant too soon can cause depressive symptoms to reoccur. Continuing the antidepressant for several months afterwards helps the brain?s chemistries to renormalize; after six months or so, the medication can be safely tapered under a doctor?s supervision. Even with a doctor-supervised taper of medication, depressive symptoms may return on occasion. This recurrence may indicate a pre-existing depression that was never treated. In this case, the antidepressant can be increased back to its effective level.
Treatment with interferon can be challenging. However, by keeping a close watch on what the body and emotions are saying, most patients can successfully make it through this therapy.
CHART: symptoms of depression
Depressed mood and ?SIG-E-CAPS?
S Sleep changes
I Lack of Interest in activities
G Guilt or worthlessness
E Decrease in Energy
C Problems with Concentration
A Appetite changes
P Psychomotor changes (looking physically ?drained?)
S Thoughts of Suicide
