Psychiatric and substance use disorders co-morbidities and hepatitis C: Diagnostic and treatment implications

Abstract

Chronic hepatitis C virus (HCV) viral infection is the most common blood-borne viral infection and approximately 2%-3% of the world's population or 170-200 million people are infected. In the United States as many as 3-5 million people may have HCV. Psychiatric and substance use disorders (SUDs) are common co-morbid conditions found in people with HCV and are factors in predisposing people to HCV infection. Also, these co-morbidities are reasons that clinicians exclude people from antiviral therapy in spite of evidence that people with HCV and co-morbid psychiatric and SUD can be safely and effectively treated. Furthermore, the neuropsychiatric side effects of interferon (IFN), until recently the mainstay of antiviral therapy, have necessitated an appreciation and assessment of psychiatric co-morbidities present in people with HCV. The availability of new medications and IFN-free antiviral therapy medication combinations will shorten the duration of treatment and exposure to IFN and thus decrease the risk of neuropsychiatric side effects. This will have the consequence of dramatically altering the clinical landscape of HCV care and will increase the number of eligible treatment candidates as treatment of people with HCV and co-morbid psychiatric and SUDs will become increasingly viable. While economically developed countries will rely on expensive IFN-free antiviral therapy, less developed countries will likely continue to use IFN-based therapies at least until such time as IFN-free antiviral medications become generic. The current manuscript discusses the efficacy and viability of treating HCV in people with psychiatric and SUDs comorbidities, the treatment of the neuropsychiatric side effects of IFN -based therapies and the impact of new medications and new treatment options for HCV that offer the promise of increasing the availability of antiviral therapy in this vulnerable population.

Efficacy and safety of glecaprevir/pibrentasvir in patients with chronic HCV infection and psychiatric disorders: An integrated analysis

“…Adherence among patients with chronic HCV infection and comorbid psychiatric disorders remains a concern despite the advent of IFN‐free DAA treatments. Lower adherence is hypothesized due to cases of severe, untreated psychiatric disorders and higher rates of comorbid substance use disorders ; however, DAA regimens have shown similarly high adherence rates in clinical trials among patient populations traditionally considered to be at‐risk for nonadherence including patients with psychiatric disorders, people who inject drugs and patients on stable opioid substitution therapy . In its clinical trial programme, overall adherence to G/P regimens has been reported at >95% with comparable rates among patients with psychiatric disorders, people who inject drugs and patients on stable opioid substitution therapy .…”

“…Chronic hepatitis C virus infection is associated with neuropsychiatric disorders in up to 50% of cases . Historically, patients with comorbid psychiatric disorders were less likely to receive HCV treatment since interferon (IFN)‐based regimens can induce depression and other neuropsychiatric manifestations including insomnia, irritability and mood changes . Treatment adherence among this patient population was also a concern due to IFN's psychiatric side effect profile and perceived risks of lower adherence in patients with psychiatric and/or substance use disorders .…”

“…Historically, patients with comorbid psychiatric disorders were less likely to receive HCV treatment since interferon (IFN)‐based regimens can induce depression and other neuropsychiatric manifestations including insomnia, irritability and mood changes . Treatment adherence among this patient population was also a concern due to IFN's psychiatric side effect profile and perceived risks of lower adherence in patients with psychiatric and/or substance use disorders . Yet, fatigue and psychological issues contribute significantly to quality‐of‐life (QoL) impairments in patients with chronic HCV infection, both of which can be improved by the achievement of sustained virologic response (SVR) …”

“…Based on these data, recent HCV treatment guidelines recommend DAA regimens without any restrictions based on psychiatric comorbidities . However, there has been more limited use of DAAs in patients with psychiatric disorders in both late phase trials and clinical practice potentially due to concerns about treatment adherence and drug–drug interactions (DDIs) with neuropsychiatric co‐medications . Thus, there is an unmet need to better understand the impact of psychiatric disorders on the treatment adherence, efficacy and safety of DAA regimens.…”

Co-occurring Depression, Chronic Pain and Substance Use Disorders in People with Hepatitis C

“…It is also critical to note the implications of utilizing newer antiviral drugs in the context of HCV and common comorbidities. The development of new medications, including direct acting antiviral agents (DAA) that are used to treat HCV has allowed providers to treat people who have or are at risk for pain, depression, and SUD and otherwise would have been excluded from antiviral treatment [133]. Telaprevir, simeprevir and sofosbuvir in combination with IFN therapy can significantly decrease treatment duration without exacerbating side effects of interferon therapy, such as depressive symptomatology and muscle aches.…”