SAN JUAN, P.R. – Depression was not significantly associated with heroin or cocaine use for methadone maintenance patients infected with hepatitis C, according to a study presented at the annual meeting of the American Academy of Addiction Psychiatry.
“Depression has been associated with increased substance use in some previous studies of drug users, but patients with hepatitis C infection may be somewhat different,” Steven L. Batki, M.D., said in an interview. Neuropsychiatric effects of the disease itself are a possible explanation.
“The bottom line is that in our sample, past or current depression was not significantly correlated with substance use over the past year,” he said.
The only significant association noted in the study was lower alcohol use in the previous 12 months for participants who met criteria for current major depression or who reported a history of depression.
Patients with substance use disorders are a difficult population for whom to provide hepatitis C treatment. “Substance abuse is often a barrier to access to medical care for hepatitis C. Better treatment for mental disorders in patients with substance use problems would likely increase access and adherence to hepatitis C treatment,” said Dr. Batki, professor of psychiatry at the State University of New York, Syracuse, where he is also director of the Veterans Affairs Center for Integrated Healthcare.
About 80% of injection drug users in the Syracuse area are infected with the hepatitis C virus. The 82 patients interviewed for the study in 2001 and 2003 in central New York reported “considerable recent substance use,” Dr. Batki said.
More than 60% of hepatitis C patients in methadone treatment reported heroin and/or cocaine use during the previous year, and more than 50% reported alcohol use. In addition, nearly 50% met DSM-IV diagnostic criteria for a major depressive disorder.
The mean age of study participants was 42 years: 62% of participants were male, and 62% were white. A total of 72% reported mental health problems. At the time of the survey, 55% were being treated for depression, and 55% had a Beck Depression Inventory score greater than 15. In addition, 66% reported a history of depression, including 31% who had been hospitalized for depression at some point. The National Institute on Drug Abuse funded the study.
Methadone patients come to treatment for months or years but often do not have consistent medical or psychiatric care. Substance users have often had hepatitis C for many years and therefore are at high risk for long-term morbidity from infection, cirrhosis, and liver failure. “When you find hepatitis C infected patients in a substance abuse program, these are people in their 40s, usually infected for 20 years or more,” he said.
Historically, patients with substance use and psychiatric disorders were systematically barred from hepatitis C treatment, Dr. Batki said.
Although 2002 guidelines from a National Institutes of Health Consensus Development Conference removed the strict rules against offering hepatitis C treatment to these patients, “there has not yet been any widespread change in practice,” he said.
“My concern, as with HIV and tuberculosis, is that too little is being done to bring the medical treatment to where the patients are,” Dr. Batki said.
With that in mind, he is now performing a National Institute on Drug Abuse-funded randomized controlled trial to see whether hepatitis C treatment offered on site in methadone programs improves outcomes compared with routine care in community GI clinics.
The study also seeks to assess the sustained virologic response after initiation of hepatitis C treatment and to follow the development of any neuropsychiatric symptoms before, during, and after treatment.