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Center for Substance Abuse Treatment. Addressing Viral Hepatitis in People With Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2011. (Treatment Improvement Protocol (TIP) Series, No. 53.)

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Addressing Viral Hepatitis in People With Substance Use Disorders.

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Appendix FMental Health Treatment Considerations for People Who Have Chronic Viral Hepatitis C

Mental illness and hepatitis frequently co-occur (Rosenberg et al., 2001; Rosenberg et al., 2003). People who have mental illness are at greater risk than the general public for exposure to infectious diseases, including chronic hepatitis (Rosenberg et al., 2001). For instance, in a study of veterans with hepatitis C, Fireman, Indest, Blackwell, Whitehead, and Hauser (2005) found that 93 percent of subjects had one or more psychiatric or substance use disorders at the time of or before the study.

Behavioral health conditions are not absolute contraindications for chronic hepatitis treatment. As healthcare providers increasingly consider treating hepatitis in patients with mental disorders, they might turn to behavioral health providers to assess their patients for readiness for antiviral treatment. In addition, behavioral health treatment providers might have clients who have chronic hepatitis and who require support through the lengthy and challenging hepatitis treatment process.

Behavioral Health Counseling

Goldsmith and Hauser (2003) advocate the participation of an informed behavioral health treatment provider in a client’s antiviral treatment for chronic hepatitis. They assert that, to provide effective support in the treatment process, behavioral health treatment providers need to know:

  • The natural history of hepatitis C virus infection (see Chapter 1 in this Treatment Improvement Protocol [TIP]).
  • Standard treatment for chronic hepatitis (Chapter 5).
  • Common adverse effects of treatment (Chapter 5).
  • How to manage side effects of treatment (Appendix D).
  • How to work with high-risk populations (Chapters 4, 5, and 6).
  • How to manage (particularly with psychotropic medications) a client’s mood and cognitive changes that might result from antiviral treatment (see below).

Behavioral health treatment providers can partner with healthcare providers to help patients with chronic hepatitis get evaluated for treatment (see Chapter 3) and adhere to treatment (Chapter 6). Psychiatrists are especially well suited to monitor patients being treated for hepatitis for psychiatric side effects of treatment (Straits-Tröster, Sloan, & Dominitz, 2003).

Issues Clients Who Have Chronic Hepatitis B or C Might Bring to Counseling

Treatment for chronic hepatitis is challenging for most people. Behavioral health treatment providers might have clients who need assistance with making psychological adjustments to having a chronic disease (e.g., coping with a chronic disease, learning about hepatitis, making healthful lifestyle changes) and making decisions related to having hepatitis (e.g., whether/how to disclose the condition to others, deciding on whether to undertake antiviral therapy, adhering to the treatment regimen). Helping clients make medical decisions about hepatitis treatment is the subject of Chapter 4. Chapter 6 of this TIP includes the following relevant topics:

  • Using effective counseling strategies, including motivational approaches
  • Ensuring safety of the counselor
  • Providing reliable information about hepatitis
  • Building the therapeutic relationship
  • Helping clients understand their diagnoses
  • Incorporating client needs in substance abuse treatment planning
  • Developing a plan to prevent infecting others and to prevent further liver damage
  • Using motivational approaches
  • Confronting the social ramifications of disclosing hepatitis status
  • Addressing relapse
  • Building support systems
  • Providing effective case management

Patients with baseline depression, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), or other behavioral health conditions might face additional challenges that come with the neuropsychiatric side effects of hepatitis treatment, such as worsening of their symptoms, or relapse. Therefore, the issue of readiness for treatment is particularly relevant for mental health care professionals.

Readiness for Treatment

Many clients who have mental illnesses do not receive hepatitis pharmacotherapy because they are not prepared (in their view or in a care provider’s view) to successfully complete the regimen. For example, some healthcare providers might defer treatment until an individual’s mental illness, such as depression, can be stabilized. Individuals might choose to defer treatment until they are in stable housing or until they have built strong support networks.

Little information is available on how frequently clients receive a second referral for chronic hepatitis treatment if they are initially deferred but later become eligible for treatment. One study reported that none of the 306 patients who deferred had a second referral for treatment (Yawn, Wollan, Gazzuola, & Kim, 2002). A more recent study reported that of 111 patients deferred for psychiatric issues (including psychiatric instability and suicidal ideation), 53 percent received a followup referral, of which only 18 percent (20 individuals) were ultimately treated (Evon et al., 2007). These rates suggest that, if treatment for hepatitis is deferred at the initial assessment, few clients have opportunities to receive treatment after they become eligible.

In addition, although some clients might have healthcare providers who defer hepatitis treatment because of the client’s behavioral health issues, some data suggest that some individuals do not follow through with steps necessary to get treatment (Butt, Wagener, Shakil, & Ahmad, 2005).

Behavioral health treatment providers can help clients who are currently ineligible for hepatitis treatment become eligible. For example, they can motivate clients to attend medical appointments. Helping a client become ready for treatment can take several months (Scheft & Fontenette, 2005). Behavioral health treatment providers can work with a client’s healthcare provider and advocate a referral for hepatitis treatment when clients are ready.

An expanded psychiatric evaluation can enhance the assessment of client readiness for hepatitis treatment (Scheft & Fontenette, 2005; Silberbogen, Mori, & Sogg, 2005). Silberbogen et al. (2005) developed a structured interview to help determine a client’s readiness for treatment. Facets of the structured interview include the following:

  • Hepatitis C history
  • Social support network
  • Understanding of chronic hepatitis C and its treatment
  • History of motivation and adherence to treatment
  • Psychiatric history
  • Mental status exam

Tools that might assist the psychiatric assessment include the following:

  • Beck Anxiety Inventory
  • Beck Depression Inventory
  • Bipolar Spectrum Diagnostic Scale
  • Brief Psychiatric Rating Scale
  • Center for Epidemiologic Studies Depression Scale
  • Geriatric Depression Scale
  • Major Depression Inventory
  • Mood Disorders Questionnaire
  • Montgomery Asberg Depression Rating Scale
  • Post-Traumatic Stress Disorder Checklist (civilian version)
  • Quick Inventory of Depressive Symptoms
  • State-Trait Anxiety Inventory
  • Young Mania Rating Scale
  • Zung Self-Rating Depression Scale

An important part of the expanded assessment is screening for substance use disorders. Tools to assess substance use disorders include the following:

  • Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
  • Alcohol Use Disorders Identification Test (AUDIT)
  • Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)
  • CAGE Adapted to Include Drugs (CAGE-AID)
  • Drug Abuse Screening Test
  • Michigan Alcoholism Screening Test (MAST) (MAST-G for older adults)
  • Patient Health Questionnaire (PHQ9)

Pharmacological approaches (see the section on Medications for People Who Have Behavioral Health Disorders, below) and nonpharmacological approaches (see Chapter 6) might be beneficial for helping the client become ready for treatment of hepatitis.

Effects of Antiviral Treatment for Chronic Hepatitis on Behavioral Health

People who never had problems with anxiety, depression, or irritability might experience these as a result of treatment for chronic hepatitis, and stable patients with previous mental health problems might have exacerbations. Some early symptoms of treatment-related depression might also mimic opioid withdrawal. This can complicate clinical management for the large subset of patients with chronic hepatitis C who have a history of opioid injection drug use (Schaefer & Mauss, 2008).

In a review article by Robaeys and Buntinx (2005), neurobehavioral changes leading to depression often begin by the eighth week of antiviral therapy, which coincides with the peak time for quitting medication treatment. Addressing mental health symptoms is important to antiviral treatment success because close adherence to and completion of multiple-week therapy are required for achieving treatment success (Sylvestre & Clements, 2007).

Clients with mental illness who decide to undergo treatment for chronic hepatitis will require regular psychiatric monitoring. In addition, treatment adherence might be enhanced with the following supports:

  • Psychosocial interventions
  • Medication, therapy, or both to manage anger, anxiety, irritability, depression, or other side effects of interferon treatment
  • Support groups to combat social isolation and discrimination resulting from a hepatitis diagnosis
  • Support to prevent relapse to substance use
  • Motivational therapy to inspire changes in daily life that support antiviral treatment
  • Education on how to prevent transmission of the hepatitis C virus

For patients with risk factors for depression (e.g., personal or family history of depression, suicide attempts, alcohol abuse, poor sleep quality) preemptive treatment with selective serotonin reuptake inhibitors (SSRIs) has been used as a prevention strategy (Schaefer & Mauss, 2008). Concurrent use of interpersonal psychotherapy, behavioral psychotherapies, and psychosocial support might also be beneficial to these clients (American Psychiatric Association, 2010; Wilson, Castillo, & Batey, 2010).

Preexisting psychiatric medication regimens might need modification during hepatitis treatment. For example, a patient with bipolar disorder who takes valproic acid might need to change to a mood stabilizing medication that is less toxic to the liver while on antiviral therapy. A patient who was previously stable on an SSRI might need an increased dosage or a medication change. Psychiatric medications and care might need to continue for at least 6 to 12 weeks after antiviral treatment is completed because mood disorders, neurocognitive changes, and other psychological problems might persist (Schaefer & Mauss, 2008).

With pretreatment screening to determine need for medication, continuous monitoring, and individualized treatment, patients with preexisting or emerging mental health problems might be able to mitigate the adverse IFN-alpha psychiatric side effects, complete treatment, and achieve sustained viral response. These positive outcomes have been reported with collaborative care provided by multidisciplinary management teams that include healthcare providers, psychologists, psychiatrists, addiction specialists, and other behavioral health workers (Belfiori et al., 2009; Guadagnino et al., 2007; Schaefer et al., 2003; Sylvestre & Clements, 2007).

Medications for People Who Have Behavioral Health Disorders

Affective Disorders

Depression is common among patients who require antiviral treatment of chronic hepatitis C (Schaefer & Mauss, 2008). Others can develop major depression during the course of antiviral treatment. The medications most commonly prescribed for depression include SSRIs (e.g., fluoxetine, citalopram, sertraline, paroxetine, escitalopram), serotonin and nor-ephedrine reuptake inhibitors (e.g., duloxetine, venlafaxine), and the chemically unique bupropion. Older antidepressant medications (e.g., monoamine oxidase inhibitors, tricyclics) are less often prescribed because they have more side effects and drug interactions (National Institute of Mental Health [NIMH], 2008). Depression screening scales that rely on patient self-reporting can be used, but the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria (APA, 2000) and clinical evaluation are essential to guide treatment decisions.

Bipolar disorder is another affective disorder in which patients cycle through alternating episodes of depression and mania. Patients are treated with mood stabilizers (e.g., carbamazepine, lamotrigine, lithium, oxcarbazepine, valproic acid). Antidepressants are sometimes added to mood stabilizers to treat symptoms of depression in bipolar disorder, but these medications need to be used with great care because of the risk of exacerbating manic symptoms and/or inducing suicidality (NIMH, 2008). Atypical antipsychotics (e.g., aripiprazole, clozaril, olanzapine, risperidone, ziprasidone) are sometimes added to treat depression or bipolar disorder.

Anxiety Disorders

Anxiety disorders include obsessive-compulsive disorder, PTSD, generalized anxiety disorder, panic disorder, social phobia, and others (APA, 2000). When patients undergoing treatment for chronic hepatitis exhibit symptoms related to anxiety disorders, it is important to determine whether symptoms are related to the psychological demands of coping with a chronic disease, whether they are due to the rigors of treatment, or whether they are an exacerbation of a preexisting condition so that appropriate pharmacological and non-pharmacological treatments can be arranged. Cognitive behavioral therapy is frequently used for the treatment of anxiety disorders and can improve symptoms significantly within a short timeframe. Other nonpharmacological treatments include group therapy, systematic desensitization, acupuncture, and biofeedback.


Suicide is the worst outcome of major depressive disorder, and treatment of modifiable risk factors (anxiety, insomnia, agitation, psychotic symptoms, and substance abuse) are recommended in addition to treating the depressive episode (APA, 2010).

Some of the medications that are used to treat depression and bipolar disorder might increase the risk of suicidal thoughts and behaviors (U.S. Food and Drug Administration, 2009). All clients should be screened for risk of suicide. People at risk for suicide should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behaviors, or unusual changes in mood or behavior (NIMH, 2008). More information can be found in TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (Center for Substance Abuse Treatment, 2009b). Other materials are available at the National Suicide Prevention Lifeline (

Treating Patients With Hepatitis C and Serious Mental Illness

Adults with a serious mental illness (SMI) are people ages 18 and older who, at any time during a given year, have a diagnosable mental, behavioral, or emotional disorder that meets the criteria of DSM-IV-TR (APA, 2000) and that results in functional impairment which substantially interferes with or limits one or more major life activities (Substance Abuse and Mental Health Services Administration [SAMHSA], 1999).

Whether SMIs such as psychotic disorders and major mood disorders should be contraindications to undergoing antiviral therapy for hepatitis C is controversial. The American Psychiatric Association (APA, 2010) states that SMIs are not necessarily contraindications to antiviral treatment. Psychotic symptoms (hallucinations and delusions) make effective coping with a chronic infectious disease difficult, increase patient risk of suicide, and might make adherence with complex antiviral regimens impossible. Patients with psychotic symptoms frequently need antipsychotic medications (e.g., aripiprazole, chlorpromazine, clozaril, fluphenazine, haloperidol, olanzapine, paliperidone, perphenazine, quetiapine, risperidone, ziprasidone) alone or in combination with other medications (NIMH, 2008). These complex psychiatric medication treatment regimens can be difficult to manage during antiviral treatment. Patients with depression frequently experience increased depressive symptoms during antiviral treatment (Ghany et al., 2009). This increase in symptoms has not been reported for patients with schizophrenia (Huckans, Mitchell, & Pavawalla 2010); however, this has not been well studied.

Antiviral therapy can be successful for chronic hepatitis C patients with SMIs but often requires expert psychiatric management and close monitoring by clinical staff. Intensive case management by a behavioral health case manager might be needed to support treatment adherence, make and monitor treatment appointments, and assist with housing, food, and employment needs. More frequent physician appointments might be needed for laboratory monitoring of liver function and to detect any dangerous medication interactions. The decision to treat needs to consider the social support network and the availability of social services, as well as the patient’s abilities.

Drug Interactions

A combined medication regimen consisting of pegylated interferon and ribavirin is the standard of care for chronic hepatitis C (Ghany et al., 2009). Both antiviral drugs have side effects and potential toxicities, but they have few specific interactions with medications used to treat behavioral health disorders (see Exhibit F-1). Interferon has no clinically significant interactions with methadone used to treat opioid addiction; however, its potential interaction with buprenorphine has not been adequately studied to identify such interactions. Ribavirin’s potential interactions with methadone or buprenorphine have also not been studied indepth and are unknown (McCance-Katz, Sullivan, & Nallani, 2009). Ribavirin does not interact adversely with any medications listed in Exhibit F-1. The patient should be monitored closely for any adverse effects or drug interactions when receiving medications that are metabolized by the liver.

Exhibit F-1. Potential Interactions Among Medications Used to Treat Chronic Hepatitis and Behavioral Health Conditions.

Exhibit F-1

Potential Interactions Among Medications Used to Treat Chronic Hepatitis and Behavioral Health Conditions.


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