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489
Journal of Applied Sciences Research, 9(1): 489-497, 2013
ISSN 1819-544X
This is a refereed journal and all articles are professionally screened and reviewed
ORIGINAL ARTICLES
Hepatitis C and Depression: Does Hepatitis C Virus Chronic Patients need
Psychological support?
1
MetwallyAmmal M., 1Elmosalami Dalia M., 1Salama Somia I., 1Abdel Hameed A., 2Khalifa A.
and 1Hemeda Samia AR
1
2
Community Medicine Research Department, National Research Center, Giza, Egypt.
Child Health Department, National Research Center, Giza, Egypt.
ABSTRACT
Background: HCV is one of the most frequent infectious diseases with the highest number in Egypt.
Objective: To estimate the prevalence of depression among hepatitis C positive patients and identification of
some of the contributing factors for depression among Hepatitis C Virus (HCV) patients and its relation to
socio-demographic characteristics of the patients, treatment regimen, awareness/ perception of illness/ and HCV
stigma. Method: A descriptive cross sectional study was conducted in 10 National Treatment Reference Centers
of National Hepatology and Tropical Medicine Research Institutes of Ministry of Health hospitals along a
period of six months from September 2011 to March 2012. The present study included 540 cases; 359 males and
181 females. Depression was assessed by using short form Beck Depression Inventory. HCV patients
participating in this study were subjected to structured self administered questionnaire to collect personal data
(age, sex, address, their job, socioeconomic status, etc), patient knowledge about hepatitis C, attitude towards
hepatitis C (stigma) and history of alcoholism and drug abuse. Results: Males represented 66.9 % of the studied
group and females represent 33.1 %. The prevalence of depression was 26.7% among the HCV patients in
which 22.4 % of the studied HCV patients were diagnosed to have mild depressive symptoms, 3.2 % have
moderate depressive symptoms and 1.1 % have severe depressive symptoms. Female patients were found to
have a significantly higher level of depression (31.6%) versus males (24.3%) (P<0.05). Among the depressed
HCV patients a bigger proportion (49.0%) significantly reported not working as compared to the non- depressed
HCV patients (38.3%)(P<0.05). The non- depressed HCV patients have a higher score as regards their
knowledge about cause, complication and treatment of HCV if compared to the depressed HCV patients. But
difference is not statistically significant. Feeling with stigmatization was significantly reported by the depressed
HCV patients (25.4%) as compared to the non- depressed HCV group (8.5%)( p< 0.05). Conclusion: This study
reflects high frequency of undiagnosed depression in hepatitis C patients. Psychiatric assessment and early
intervention is mandatory in this population. Recommendation: HCV patients should be closely monitored for
exacerbation of depressive symptoms, so that treatment would be initiated promptly.
Key words: Hepatitis-C, Depression, Psychiatric Disorder.
Introduction
Hepatitis C poses a very significant health problem on a global scale (Hoofnagle, 1997). It is one of the
most frequent infectious diseases with the highest prevalence in Egypt (El-Zayadi, 2009). The World Health
Organization estimates that 3% of the world’s population (170 million people) is infected with hepatitis C virus
(Marcellin, 1999) and is at risk of developing liver cirrhosis and liver cancer (Davis et al., 2003).The prevalence
of an antibody to hepatitis C virus (anti-HCV) ranges from 22% in Egypt or Cameroon to 1.8% in the United
States to 0.8% in Germany (Alter, 1995, 1997, Alter et al., 1999 and Alter et al., 2006).
The reasons for the high prevalence of depression in persons with hepatitis C are not clear; these have been
hypothesized to arise from the disease itself, or from the high proportion of persons at risk for psychiatric
disorder among those affected by hepatitis C, or to the stigmatizing nature of the diagnosis (Capuron and Miller,
2004).
Progression from initial infection to liver cirrhosis and cancer can take 20–30 years; (Leone & Rizzetto,
2005 and Alazawi et al., 2010), thus complications from chronic HCV infection are, therefore, anticipated to
continue to increase (Patel et al., 2006), with rates of cirrhosis doubling, liver-related deaths tripling (Davis et
al., 2003). In addition, there are an increasing number of reports about the problem of chronic hepatitis C as the
"new plague of humanity" or the "shadow epidemic" in the media and the Internet. Similar to human
Corresponding Author: Dr Dalia M. Elmosalami, National Research Center, 12311 El Behoos Street, Doki, Giza, Egypt,
Tel: 01005230063; E-mail:[email protected]
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J. Appl. Sci. Res., 9(1): 489-497, 2013
immunodeficiency virus (HIV) infection, patients often estimate their infectious disease as fatal and stigmatic
(Williams, 1999).
Individuals face HCV as a chronic progressive disease that does not have a cure. The diagnosis of HCV can
have harmful effects on psychological well being. The emotional challenge becomes great, a person deals with a
chronic disease without letting it take over his or her life (Cornberg et al., 2002).
Like many chronic medical illnesses, hepatitis C is associated with an increased prevalence of psychiatric
disorder (Yates and Gleason, 1998), particularly depression. The presence of depressive symptoms in hepatitis C
is important because they have an adverse effect on the course of illness, with amplification of physical
symptoms, functional impairment, reduced treatment compliance and reduced quality of life (Dwight et al.,
2000). In addition, treatment for hepatitis C involves interferon, which has neuropsychiatric side effects.
Psychiatric disorder is the main reason for delay or discontinuation of interferon treatment (Zdilar et al., 2000).
Successful medical treatment of hepatitis C therefore requires detection and management of depression both
before and during treatment (Dwight et al., 2000).
Depression is a particularly common side effect that may occur in up to 60% of patients, and in some rare
cases, it may be associated with deliberate self-harm or suicide attempts (Dieperink and Willenbring, 2000).
Identification of the risk factors that lead to neuropsychiatric side effects and the associated low adherence rates
may help identify patients at risk who may then benefit from additional psychological assessment and support
(Janssen et al., 1994 and Fukunishi et al., 1998).
Interferon-α, currently used for the treatment of hepatitis C, is associated with a substantially elevated risk
of depression. However, not everyone who takes this drug becomes depressed, so it is important to understand
what particular factors may make some individuals more ‘at risk’ of developing depression than others
(Kimberley et al., 2011).
In this study we interviewed a group of patients with hepatitis C to estimate the prevalence of psychiatric
disorder and to identify factors associated with increased risk of depression.
Methods:
The current study is a cross sectional descriptive study. Data collection was carried out along a period of six
months from September 2011 to March 2012. The study population included HCV patients in 21 National
Treatment Reference Centers of National Hepatology and Tropical Medicine Research Institutes of MOH
hospitals, from which 10 centers are selected randomly. The study group included 540 cases; 359 males and 181
females (≈ 50 patients/ Center). We calculated the sample size depending on: Prevalence of depression =22%
Confidence interval = 90% Margin of error = 5% Design effect = 2 Percentage of loss =10%. So sample size of
540 students will fulfill the above criteria.
HCV patients participating in this study were subjected to structured self administered questionnaire to
collect personal data (age, sex, address, their job, socioeconomic status, etc), patient knowledge about hepatitis
C, attitude towards hepatitis C (stigma) short form Beck Depression Inventory (Beck et al., 1974). For the short
form of the Beck Depression Inventory, 0-10 indicates that the patient is not depressed; 12-18 depressed; 20+
severely depressed.
Data analysis:
Data entry and analysis were done using statistical package for the social sciences software (SPSS) program
version 18 and suitable statistical tools were applied. Frequency tables were used to describe qualitative data and
chi-square was used as the test of statistical significance to detect difference between groups. Significant values
were considered at p < 0.05.
Results:
Around one quarter (22.4 %) of the studied HCV patients was diagnosed to have mild depressive
symptoms, 3.2 % have moderate depressive symptoms and 1.1% have severe depressive symptoms. HCV
females reported significantly higher level of mild, moderate and severe depression (24.3%, 4.5% and 2.8%
respectively) compared to males (21.5%, 2.5% and 0.3% respectively). Higher proportion (39.2%) of the
depressed HCV patients was females versus (30.9%) of the non-depressed group with no significant difference
(Chart 1). Among the depressed HCV patients a bigger proportion (49.0%) significantly reported not working as
compared to the non-depressed HCV patients (38.3%). On the other hand there was no significant difference
between depressed and non-depressed groups as regards age, years since HCV was diagnosed, marriage state
and education (table 1). Comparison between depressed and non-depressed HCV patients as regards their
knowledge, attitude towards HCV, treatment and complications, history of alcoholism and drug abuse was
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J. Appl. Sci. Res., 9(1): 489-497, 2013
illustrated in table 2. The non-depressed HCV patients have a higher score as regards their knowledge about
cause, complication and treatment of HCV if compared to the depressed HCV patients. But difference is not
statistically significant. Feeling with stigmatization was significantly reported by the depressed HCV patients
(25.4%) as compared to the non- depressed HCV group (8.5%)( p< 0.05). Higher proportion of the depressed
HCV patients had took treatment for hepatitis C and continued their treatment (69.5% and 77.9% respectively)
versus the non- depressed group (61.3% and 77.5% respectively) but the difference is not significant. There was
no significant difference between depressed and non- depressed groups as regards alcoholism and drug abuse.
Different degrees of social withdrawal, fear of change in body image, retardation in work, easy fatigability and
loss of appetite were significantly reported by females as compared to males (p< 0.05). On the other hand there
was no so significant difference between males and females as regards sadness, hopeless from future, sense of
failure, dissatisfaction, guilt, dislike of self and suicidal ideation (table 3).
Chart 1: Prevalence of depressive symptoms of the studied HCV patients according to sex (P value = 0.022).
Table 1: Comparison between Depressed and Non- depressed HCV Patients as Regards Socio-Demographic Characteristics.
Nondepressed
HCV Depressed HCV patients (n= Total
Socio-Demographic
patients (n= 396)
144)
(n= 540)
Characteristics
No. %
No. %
No. %
Sex
Males
274(69.1)
88(60.8)
362(66.9)
Females
122(30.9)
56(39.2)
178(33.1)
Age:
4(0.7)
2(1.4)
2(0.5)
<20
84(15.5)
23(16.1)
61(15.3)
20112(20.7)
24(16.8)
88(22.2)
30189(35.0)
54(37.1)
135(34.2)
40118(21.9)
35(24.5)
83(20.9)
5033(6.2)
6(4.2)
27(6.9)
≥ 60
Mean age
42.2 ± 11.3
42.6 ± 11.6
42.4±11.4
Years since HCV diagnosed
211(39.1)
52(36.4)
159(40.0)
< 1 year
280(51.8)
82(56.6)
198(50.0)
142(7.9)
9(6.3)
33(8.4)
104(0.7)
1(0.7)
3(0.8)
203(0.6)
0(0.0)
3(0.8)
≥ 30
Mean years
4.3 ±6.1
3.6 ±4.3
4.1 ±5.7
Marriage state
Single
37(9.5)
18(12.6)
55(10.3)
Married
340(85.9)
116(80.4)
456(84.5)
Divorced
7(1.5)
5(3.5)
12(2.1)
Widow
12(3.1)
5(3.5)
17(3.2)
Education
163(29.9)
52(35.2)
111(28.0)
1. Illiterate
67(12.4)
20(14.1)
47(11.8)
2. Read and write
44(8.1)
10(7.0)
34(8.5)
3. Primary
33(6.2)
11(7.7)
22(5.7)
4. Preparatory
167(31.1)
35(24.6)
132(33.4)
5. Secondary or equivalent
6. University or more
66(12.2)
16(11.3)
50(12.6)
Employment
1. Not working
152(38.3)
70(49.0)
222(41.1)
2. Working
244(61.7)
74(51.0)
318(58.9)
P value
0.071
0.062
0.564
0.336
0.311
0.026
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J. Appl. Sci. Res., 9(1): 489-497, 2013
Table 2: Knowledge, Attitude, History of Alcoholism and Drug Abuse among Depressed and Non- depressed HCV Patients.
HCV patients
Variable
Non- depressed
Depressed
Total
P value
(n= 396)
(n= 144)
(n= 540)
No. %
No. %
No. %
Knowledge about hepatitis C cause
- Right knowledge (virus)
- Wrong knowledge
255(64.3)
85(58.7)
340(62.8)
0.142
141(35.7)
59(41.3)
200(37.2)
Knowledge of methods of infection (16
questions)
11.0± 2.4
10.7±2.5
10.9±2.5
0.246
Mean score
Knowledge
of
symptoms
(10
5.6±2.6
6.3±2.2
5.8±2.5
0.003
questions)Mean score
Knowledge about complications
< 50%
50%-75%
330 (83.4)
130 (90.2)
460 (85.2)
>75%
24 (6.1)
3 (2.1)
27 (5.0)
0.134
Mean score*(7 questions)
42 (10.5)
11 (7.7)
53 (9.7)
4.9±2.2
4.6±2.4
4.8 ± 2.3
Knowledge about treatment
< 50%
79(19.9)
40(28.0)
119(22.1)
50%-75%
114(28.9)
42(29.4)
156(29.0)
>75%
203(51.2)
62(42.7)
265(48.9) 4.1±1.2
0.941
Mean score*(6 questions)
4.1±1.2
4.1±1.1
Knowledge about incubation period
357(90.1)
125(87.4)
482(89.3)
0.428
Knowledge about early detection of
363(91.8)
128(89.5)
492(91.2)
0.393
disease
Knowledge about presence of vaccine
172(43.6)
59(41.3)
232(43.0)
0.693
Methods of prevention
0.335
Mean score (8 questions)
2.8±1.6
3.1±2.1
2.2±1.9
Total knowledge score
30.7±7.0
30.7±6.6
30.7±6.9
0.98
Stigmatizing
Yes
33(8.5)
36(25.40)
69(13.0)
0.000
No
363(91.5)
108(74.6)
471(87.0)
Took treatment
Yes
243(61.3)
100(69.5)
343(63.6)
0.086
No
153(38.7)
44(30.5)
197(36.4)
Continuity of treatment
Yes
307(77.5)
112(77.9)
419(77.6)
0.934
No
89(22.5)
32(22.1)
121(22.4)
Alcoholism
Yes
10(2.6)
3(2.1)
13(2.5)
0.745
No
386(97.4)
141(97.9)
527(97.5)
Drug abuse
Yes
2(0.5)
1(0.7)
3(0.6)
0.813
No
394(99.5)
143(99.3)
537(99.4)
*P>0.05
Table 3: Some Symptoms of Depression of the Studied HCV Patients according to sex.
Male
Female
Symptoms
(n= 359)
(n= 181)
No.
%
No.
%
Sadness
I
do
not
feel
sad. 119(33.2)
50(27.7)
I
feel
sad 183(50.8)
88(48.6)
- I am sad all the time and I can't snap out of it. 38(10.6)
27(14.7)
- I am so sad and unhappy that I can't stand it.
19(5.3)
16(9.0)
Hopeless from future (Pessimism)
-I am not particularly discouraged about the future. 238(66.2)
114(62.7)
I
feel
discouraged
about
the
future. 89(24.9)
43(23.7)
- I feel I have nothing to look forward to. 12(3.4)
12(6.8)
- I feel the future is hopeless and that things cannot 20(5.6)
12(6.8)
improve.
Sense of failure
-I
do
not
feel
like
a
failure. 297(82.7)
135(74.6)
-I feel I have failed more than the average person. 48(13.4)
29(15.8)
-As I look back on my life, all I can see is a lot of 5(1.4)
7(4.0)
failures.
9(2.5)
10(5.6)
-I feel I am a complete failure as a person.
Dissatisfaction
-I get as much satisfaction out of things as I used to. 276(76.8)
138(76.3)
-I don't enjoy things the way I used to.
Total
(n= 540)
No.
%
169(31.4)
271(50.1)
65(12.0)
35(6.5)
P value
0.142
352(65.0)
132(24.5)
24(4.5)
32(6.0)
0.300
432(80.0)
77(14.2)
12(2.2)
19(3.6)
0.042
414(76.6)
0.107
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J. Appl. Sci. Res., 9(1): 489-497, 2013
Symptoms
-I don't get real satisfaction out of anything anymore.
-I am dissatisfied or bored with everything.
Guilt
-I
don't
feel
particularly
guilty
-I feel guilty a good part of the time.
-I feel quite guilty most of the time.
-I feel guilty all of the time.
Dislike of self
-I
don't
feel
disappointed
in
myself.
-I
am
disappointed
in
myself.
-I
am
disgusted
with
myself.
-I hate myself.
Suicidal ideation
-I don't have any thoughts of killing myself.
-I have thoughts of killing myself, but I would not carry
them
out.
-I
would
like
to
kill
myself.
-I would kill myself if I had the chance.
Social withdrawal
-I have not lost interest in other people.
-I am less interested in other people than I used to be.
-I have lost most of my interest in other people.
-I have lost all of my interest in other people.
Indecisiveness
-I make decisions about as well as I ever could.
-I put off making decisions more than I used to.
-I have greater difficulty in making decisions more than
I
used
to.
-I can't make decisions at all anymore.
Change in body image
-I don't feel that I look any worse than I used to.
-I am worried that I am looking old or unattractive.
-I feel that there are permanent changes in my
appearance that make me look unattractive.
-I believe that I look ugly.
Retardation
-I can work about as well as before.
-It takes an extra effort to get started at doing
something.
-I have to push myself very hard to do anything.
-I can't do any work at all.
Fatigability
-I
don't
get
more
tired
than
usual.
-I get tired more easily than I used to.
-I get tired from doing almost anything.
-I am too tired to do anything
Loss of appetite
My
appetite
is
no
worse
than
usual.
-My appetite is not as good as it used to be.
-My
appetite
is
much
worse
now.
-I have no appetite at all anymore.
Male
(n= 359)
No.
%
68(19.0)
8(2.2)
Female
(n= 181)
No.
%
27(14.7)
9(5.1)
Total
(n= 540)
No.
%
95(17.6)
17(3.2)
7(2.0)
7(4.0)
14(2.6)
283(78.8)
50(14.0)
24(6.7)
2(0.6)
146(80.8)
25(13.6)
10(5.6)
0(0.0)
429(79.4)
75(13.8)
34(6.4)
2(0.4)
300(83.5)
44(12.3)
10(2.8)
5(1.4)
141(78.0)
31(16.9)
2(1.1)
7(4.0)
441(81.7)
75(13.8)
12(2.2)
12(2.2)
343(95.5)
11(3.1)
168(93.2)
12(6.2)
511(94.8)
23(4.1)
5(1.4)
0(0.0)
0(0.0)
1(0.6)
5(0.9)
1(0.2)
256(71.2)
81(22.6)
112(61.6)
45(24.9)
368(68.0)
126(23.4)
16(4.5)
6(1.7)
16(9.0)
8(4.5)
32(6.0)
14(2.6)
244(67.9)
80(22.3)
29(8.1)
115(63.3)
42(23.2)
14(7.9)
359(66.4)
122(22.6)
43(8.0)
6(1.7)
10(5.6)
16(3.0)
180(50.0)
150(41.9)
64(35.6)
92(50.8)
244(45.2)
242(44.9)
26(7.3)
22(11.9)
48(8.8)
3(0.8)
3(1.7)
6(1.1)
89(24.9)
181(50.3)
24(13.0)
107(59.3)
113(20.9)
288(53.3)
63(17.6)
37(20.3)
100(18.5)
26(7.3)
13(7.3)
39(7.3)
64(17.9)
212(58.9)
57(15.9)
26(7.3)
15(7.9)
97(53.7)
53(29.4)
16(9.0)
79(14.6)
309(57.2)
110(20.4)
42(7.9)
126(35.2)
170(47.2)
50(14.0)
13(3.6)
41(22.6)
86(47.5)
41(22.6)
13(7.3)
167(31.0)
256(47.3)
91(16.8)
26(4.9)
P value
0.736
0.065
0.060
0.022
0.083
0.011
0.016
0.000
0002
Discussion:
Hepatitis C is and will remain for some time a major health problem in Egypt and the entire continent of
Africa. This infection can lead to an acute or silent course of liver disease, progressing from liver impairment to
cirrhosis and decompensated liver failure or hepatocellular carcinoma in a 20–30-year period (Attia, 1998).
Besides the late clinical sequelae of chronic liver disease, such as cirrhosis and hepatocellular carcinoma, a high
prevalence of depressive symptom has been reported (Forton et al., 2001 and Fontana et al., 2002). Surprisingly,
the number of people with comorbid HVC and depressive disorder (including minor depression) increased
significantly between 1995 and 2005 from 18% to over 35% of all people with diagnosed HVC (Yawn et al.,
2008).
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J. Appl. Sci. Res., 9(1): 489-497, 2013
Depression is the most common psychiatric disorder. Data from western countries reported that the
prevalence of depression is 15- 17 % of the population, perhaps as 25 percent for women (Nimesh and Mohan,
2006). In this study, depression is reported in 26.7% of patients in which 22.4 % of the studied HCV patients
were diagnosed to have mild depressive symptoms, 3.2 % have moderate depressive symptoms and 1.1 % have
severe depressive symptoms according to Beck Depression Inventory. Earlier researches showed a range
between 28 and 35% (Golden et al., 2005 and Yawn et al., 2008). This proves the impact of chronic hepatitis C
(CHC) as a potent trigger for depression. This rate (26.7%) was slightly higher than the rate (24%) observed in a
retrospective study by Lee et al., (1997) where depression, unrelated interferon therapy, was the most common
associated disorder in CHC. Kenny-Walsh (1999) reported a 16% prevalence of depressed mood noted in the
medical charts of 376 Irish women with iatrogenic hepatitis C and Dwight et al., (2000) using a standardized
psychiatric interview, found a 28% prevalence in 50 patients. This result is similar to other international studies
that registered depression in 10 to 40% patients with chronic hepatitis C (Grothe et al., 2005, Orru and Pariante,
2005 and Majeed et al., 2009).
Several demographic factors potentially impact on the development of depression
including age,
gender, and education level, years since HCV diagnosed, marital state (Williams et al., 2007). In the current
study 60.1% of the depressed pt were >40 years with no significant difference between the mean age of the
depressed and non- depressed groups (40 years). Both Castera (2006) and Evon (2009) and their coworkers
stated that patients who developed depression were significantly younger (mean age 43) than those who did not
(mean age 48). On the other hand, Michael and his colleagues (2000) reported that HCV patients (>50 years)
were significantly more depressed as coping mechanism of religiousness was positively correlated with age.
Also, Horikawa and his coworkers (2003) found that age is a risk factor in their study where 23.2% of patients
developed depression was advanced age.
As regards gender, HCV females reported significantly higher level of mild, moderate and severe
depression (24.3%, 4.5% and 2.8% respectively) compared to males (21.5%, 2.5% and 0.3% respectively). This
agrees with Gohier and his coworkers (2003) who found that Sixty-four percent of women developed a
depression on treatment. Also Su and his colleagues (2010) stated that significantly more women (52.4%) than
men (23.8%) developed a depression on treatment.
In the current study, there was no significant difference between depressed and non- depressed groups as
regard education. On the other hand, Martin-Santos and his colleagues (2008) found that those people with only
a primary education level (ie, lower levels of education) were significantly more likely to develop a depressive
disorder. Meanwhile, among the depressed HCV patients a bigger proportion (49.0%) significantly reported not
working as compared to the non- depressed HCV patients (38.3%). Negative correlation was found between
depression and employment (-0.104). This agrees with studies that found employment to be an area of major
stress for the HCV patient and his families (Zickmund et al., 2003 and Blasiole et al., 2006).
In the current study there was no significant difference between depressed and non- depressed groups as
years since HCV diagnosed but Michael et al. (2000) study showed that patients with recently diagnosed
hepatitis C had significantly lower scores for depression than patients with a longer time interval since initial
diagnosis. The last subgroup of patients shows the lowest levels of problem-solving behavior.
As regards HCV patients' knowledge about hepatitis C in the current study, the HCV patients had a 60% of
the right answer from total knowledge. No sig different between depressed and non-depressed patient. The nondepressed HCV patients have a higher score as regards their knowledge about cause, symptoms, complication
and treatment of HCV if compared to the depressed HCV patients. But difference is not statistically significant.
This is may be right as orientation of the patient with the disease will help him to know cope with it.
There are three broad classes of hypothesis for the reason of depression among HCV patients. Some authors
have postulated that the disease process involved in hepatitis C gives rise to psychiatric morbidity. Others have
rightly pointed out that persons with hepatitis C come from population subgroups that carry a high risk of
psychiatric disorder. Finally, a third line of reasoning has suggested that disease labeling, with the stigma that
this entails, is responsible for the increased rates of morbidity (Jeannette and Anne, 2005).
In the current study, higher proportion of the depressed HCV patients had took treatment for hepatitis C and
continued their treatment (69.5% and 77.9% respectively) versus the non- depressed group (61.3% and 77.5%
respectively) but the difference is not significant. This goes parallel with the study which showed that the
prevalence of depression in the interferon-receiving group was 42% and 30% in the noninterferon-receiving
group (Elshahawi et al., 2011). Many postulated theories have described the mechanism of IFN-induced
depression. Among them is alteration of tryptophan metabolism into quinolinic acid (Wichwers and Maes,
2004) and activation of the hypothalamic pituitary adrenal axis resulting in increase of stress peptides (Cai et al.,
2005).
Feeling with stigmatization was significantly reported by the depressed HCV patients (25.4%) as compared
to the non- depressed HCV group (8.5%)( p< 0.05). This agrees with Zickmund et al., (2003) who found that
HCV patients reported having experienced stigmatization; this was associated with higher depression and worse
495
J. Appl. Sci. Res., 9(1): 489-497, 2013
quality of life. This goes parallel with the hypotheses proposes that the stigma involved in the diagnosis of
hepatitis C is central to the reduced psychological well-being found in patients. The link between alcohol,
intravenous drug use, and liver disease frequently trigger reactions in others that that the disease may well be a
consequence of inappropriate behavior; thus casting the shadow of stigmatization over patients.
Patients described three major reasons for feeling stigmatized. First, they felt others confused or associated
HCV with HIV/AIDS. Second, given the commonly perceived link between blood- borne diseases such as
HIV/AIDS and sexual transmission, patients were frequently viewed as sexually promiscuous. Finally, many
patients were automatically seen as drug users (Zickmund et al., 2003).
It should be borne in mind that this is a cross-sectional study. For this reason, the direction of association
between some of the risk factors and depression may be in either direction. For example, it may be that those
who are most stigmatized are most vulnerable to depression, or it may be that a sense of stigma is heightened by
the cognitive distortions of depression.
In the current study, different degrees of social withdrawal, fear of change in body image, retardation in
work, easy fatigability and loss of appetite were significantly reported by females as compared to males (p<
0.05). On the other hand there was no so significant difference between males and females as regards sadness,
hopeless from future, sense of failure, dissatisfaction, guilt, dislike of self and suicidal ideation.
Our results confirm the importance of experience of HCV illness as predictor of depression. In particular,
illness related stigma, work adjustment, and impact of depressive symptoms were all associated with increased
risk.
Conclusions:
This study shows a higher frequency of depression in hepatitis C. It also corroborates presence of
depression among patients who did not take any treatment showing that depression is also caused by the disease
process itself. Psychiatric assessment and early intervention is mandatory in this population.
Recommendation:
We recommend that all HCV patients undergoing antiviral therapy be closely monitored for exacerbation of
depressive symptoms. If a patient develops clinically significant depression, treatment should be initiated
promptly. Health authorities should take active part in organizing awareness programs among public regarding
routes of transmission, prevention and treatment of the disease.
Acknowledgements
This study was conducted through a project that was supported financially by the Science and Technology
Development Fund (STDF), Egypt, Grant No 1774. The authors express their thanks and appreciation to the
funding agency. Assessment of the Need for Psychological and Psychiatric Intervention among Hepatitis C
Virus Chronic Patients along six governorates of Egypt would not be possible without the collaborative effort of
National Treatment Reference Centers of National Hepatology and Tropical Medicine Research Institutes of
Ministry of Health (MOH) hospitals with the research team of the National Research Center
We give sincere thanks to the head of gastroenterology and Hepatology departments within the National
Treatment Reference Centers of MOH along six governorates of Egypt: Benisuef and Assuit as representative to
urban and rural upper Egypt, Dakhlya and Gharbya as representative to urban and rural lower Egypt, Cairo as
representative to middle Egypt and Ismailia as representative to canal region, and to the National Committee for
the Control of Viral Hepatitis. Special thanks to all patients for their willing participation and cooperation.
References
Alazawi, W., M. Cunningham, J. Dearden and G. Foster, 2010. Systematic review: outcome of compensated
cirrhosis due to chronic hepatitis C infection. Aliment Pharmacol Ther., 32(3): 344-355.
Alter, M., 1995. Epidemiology of hepatitis C in the West. Seminars in Liver Disease, 15: 5-14
Alter, M., 1997. Epidemiology of hepatitis C. Hepatology, 26: 62S-65S.
Alter, M., D. Kruszon-Moran and O. Nainan, 1999. The prevalence of hepatitis C virus infection in the United
States, 1988 through 1994. N Eng J Med., 341: 556-562.
Alter, M., G. Armstrong A. Wasley, E. Simard, G. McQuillan and W. Kuhnert, 2006. The prevalence of
hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. May 16;144(10): 70514.
496
J. Appl. Sci. Res., 9(1): 489-497, 2013
Attia, M., 1998. Prevalence of hepatitis B and C in Egypt and Africa Antivir Ther., 3: 1-9.
Bayliss, M., B. Gandek, K. Bungay, D. Sugano and M. Hsu, 1998. questionnaire to assess the generic and
disease-specific health outcomes of patients with chronic hepatitis C. Qual Life Res., 7(1): 39-55.
Beck, A., W. Rial and K. Rickets, 1974. Short form of depression inventory: cross-validation. Psychol Rep.,
34(3): 1184-6.
Blasiole, J., L. Shinkunas, D. LaBrecque, R. Arnold and S. Zickmund, 2006. Mental and physical symptoms
associated with lower social support for patients with hepatic C. World J Gastroenterol., 12(29): 4665-4672.
Cai, W., V. Khaoustov, Q. Xie, T. Pan, W. Le and B. Yoffe, 2005. Interferon-alpha-induced modulation of
glucocorticoid and serotonin receptors as a mechanism of depression J Hepatol., 42: 880-887.
Capuron, L. and A. Miller, 2004. Cytokines and psychopathology: lessons from interferon-alpha. Biol
Psychiatry. 56(11): 819-824.
Castera, L., A. Constant, C. Henry, 2006. Impact on adherence and sustained virological response of psychiatric
side effects during peginterferon and ribavirin therapy for chronic hepatitis C. Aliment Pharmacol Ther.,
24(8): 1223-1230.
Cornberg, M., H. Wedmeyer and M. Manns, 2002. Treatment of chronic hepatitis C with pegylated interferon
and ribaverin Curr Gastroenterol Rep., 4: 23-30.
Davis, G., J. Albright, S. Cook, D. Rosenberg, 2003. Projecting future complications of chronic hepatitis C in
the United States. Liver Transpl., 9(4): 331-338.
Dieperink, E. and M. Willenbring, 2000. Neuropsychiatric symptoms associated with hepatitis C and interferon
alpha: a review. Am J Psychiatry., 157(6): 867-876.
Dwight, M., K. Kowdley, J. Russo, P. Ciechanowski, A. Larson and W. Katon, 2000. Depression, fatigue, and
functional disability in patients with chronic hepatitis C. J Psychosom Res., 49(5): 311-7.
Elshahawi, H., M. Hussein and A. Allam, 2011. Depression comorbidity in patients with chronic hepatitis C and
its possible relation to treatment outcome. Middle East Current Psychiatry, 18: 23-28.
El-Zayadi, A., 2009. Hepatitis C comorbidities affecting the course and response to therapy World
Gasteroenterol., 15: 4993-4999.
Evon, D., D. Ramcharran, S. Belle, N. Terrault, R. Fontana and M. Fried, 2009. Prospective analysis of
depression during peginterferon and ribavirin therapy of chronic hepatitis C: results of the Virahep-C study.
Am J Gastroenterol., 104(12): 2949-2958.
Fontana, R., S. Schwartz, A. Gebremariam, A. Lok and C. Moyer, 2002. Emotional distress during interferonalpha-2B and ribaverin treatment of chronic hepatits C Pscyhosomatics, 42: 378-385.
Forton, D., J. Allsop, J. Main, G. Foster, H. Thomas and S. Taylor Robinson, 2001. Evidence for a cerebral
effect of hepatits C virus Lancet., 358: 38-39.
Fukunishi, K., H. Tanaka and J. Maruyama, 1998. Burns in a suicide attempt related to psychiatric side effects
of interferon. Burns., 24(6): 581-583.
Gohier, B., J. Goeb, K. Rannou-Dubas, I. Fouchard, P. Cales and J. Garre, 2003. Hepatitis C, alpha interferon,
anxiety and depression disorders: a prospective study of 71 patients. World J Biol Psychiatry., 4(3): 115118.
Golden, J., A. O'Dwyer and R. Conroy, 2005. Depression and anxiety in patients with hepatitis C: prevalence,
detection rates and risk factors Gen Hosp Pscyhiatry., 27: 431-438.
Grothe, B., R. Dutton, N. Jones, J. Bodenlos, M. Ancona and J. Brantley, 2005. Validation of the Beck
Depression Inventory-II in a low-income African American sample of medical outpatients. Psychol Assess.,
17: 110-4.
Hoofnagle, J., 1997. Hepatitis C: the clinical spectrum of disease. Hepatology; 26(3 Suppl 1): 15S-20S.
Horikawa, N., T. Yamazaki, N. Izumi and M. Uchihara, 2003. Incidence and clinical course of major depression
in patients with chronic hepatitis type C undergoing interferon-alpha therapy: a prospective study. Gen
Hosp Psychiatry., 25(1): 34-38.
Janssen, H., J. Brouwer, S. Schalm, 1994. Suicide associated with alfa-interferon therapy for chronic viral
hepatitis. J Hepatol., 21(2): 241-243.
Jeannette, G. and M. Anne, 2005. Depression and anxiety in patients with hepatitis C: prevalence, detection,
rates and risk factors, General Hospital Psychiatry, 27: 431-438.
Kenny-Walsh, E., 1999. Clinical outcomes after hepatitis C infection from contaminated anti-D immune
globulin. Irish Hepatology Research Group. N Engl J Med., 340(16): 1228-33.
Kimberley, J. N. Suzanne, O. Cliona and M. Shane, 2011. Risk factors for the development of depression in
patients with hepatitis C taking interferon-α. Neuropsychiatr Dis Treat., 7: 275-292.
Lee, D., H. Jamal and F. Regenstein, 1997. Morbidity of chronic hepatitis C as seen in a tertiary care medical
center. Digestive Diseases and Sciences, 42: 186-191.
497
J. Appl. Sci. Res., 9(1): 489-497, 2013
Leone, N. and M. Rizzetto, 2005. Natural history of hepatitis C virus infection: from chronic hepatitis to
cirrhosis, to hepatocellular carcinoma. Minerva Gastroenterol Dietol., 51(1): 31-46.
Majeed, S., A. Memon and M. Abdi, 2009. Frequency of Depression Among Hepatitis C Patients. KUST Med
J., 1(2): 42-5.
Marcellin, P., 1999. Hepatitis C. The clinical spectrum of the disease. J Hepatol., 31(Suppl 1): 9-16.
Martin-Santos, R., C. Diez-Quevedo and P. Castellvi, 2008. De novo depression and anxiety disorders and
influence on adherence during peginterferon-alpha-2a and ribavirin treatment in patients with hepatitis C.
Aliment Pharmacol Ther., 27(3): 257-265.
Michael, R. S. Arne, S. Michael and F. Hermann, 2000. Emotional State, Coping Styles, and Somatic Variables
in Patients With Chronic Hepatitis C. Pschosomatics, 41: 377-384.
Nimesh, G. and I. Mohan, 2006. Regional Health Forum WHO South-East Asia Region, 5(1).
Orru, M. and C. Pariante, 2005. Depression and liver diseases. Dig Liver Dis., 37: 564-5.
Patel, K., A. Muir and J. McHutchison, 2006. Diagnosis and treatment of chronic hepatitis C infection. BMJ.,
332(7548): 1013-1017.
Su, K., S. Huang and C. Peng, 2010. Phospholipase A2 and cyclooxygenase 2 genes influence the risk of
interferon-alpha-induced depression by regulating polyunsaturated fatty acids levels. Biol Psychiatry.,
67(6): 550-557.
Wichwers, M. and M. Maes, 2004. The role of indoleamine 2,3-dioxygenase (IDO) in the pathophysiology of
interferon-a-induced depression J Psychiatry Neurosci., 29: 11-17.
Williams, D., H. Gonzalez and H. Neighbors, 2007. Prevalence and distribution of major depressive disorder in
African Americans, Caribbean Blacks, and Non-Hispanic Whites. Arch Gen Psychiatry., 64: 305-315.
Williams, S., 1999. Hepatitis C testing at home. Newsweek.
Yates, W. and O. Gleason, 1998. Hepatitis C and depression. Depress Anxiety., 7(4): 188-93.
Yawn, B., L. Rocca and P. Wollen, 2008. 10-year trends in the diagnosis and treatment of hepatitis C and
concomitant mental health disorders: 1995 to2005 Prim Care Companion J Clin Psychiatry., 10: 349-354.
Zdilar, D., K. Franco-Bronson, N. Buchler, J. Locala and Z. Younossi, 2000. Hepatitis C: interferon alfa, and
depression. Hepatology., 31(6): 1207-11.
Zickmund, S., E. Ho, M. Masuda, L. Ippolito and D. LaBrecque, 2003. "They treated me like a
leper".Stigmatization and the quality of life of patients with hepatitis.J Gen Intern Med., 18(10): 835-844.