Hepatitis C

Hepatitis C is an increasingly common disease. Up to 90% of patients who have injected illicit drugs and between 7% and 10% of individuals who received blood or blood products prior to 1992 test positive for hepatitis C. Other risk factors include: 1) history of multiple sexual partners (though hepatitis C is much less readily transmittable sexually than the hepatitis B virus); 2) chronic hemodialysis treatment; 3) being the child of a hepatitis C positive woman; 4) tattoos or body piercings; and 5) needle stick accidents. Hepatitis C should also be suspected in anyone with unexplained elevated serum alanine aminotransferase (ALT) levels or signs of liver disease, such as jaundice or hepatomegaly.
Acute hepatitis C infection often does not come to clinical attention. Patients may experience nonspecific symptoms such as malaise, abdominal pain, and nausea. A few have jaundice. Acute hepatitis C infection progresses to chronic hepatitis C in approximately 75% of patients. It is chronic hepatitis C that is of chief concern to psychiatrists, especially those who work with chemically dependent populations.
The screening test for hepatitis C is the ELISA test for antibody to the hepatitis C virus (anti-HVC), which can sometimes give false-positive results. The confirmatory test is HCV RNA, which can distinguish between past and active infection. The recombinant immunoblot assay is no longer commonly used as a confirmatory test.
Patients with hepatitis C should be referred to an internist or GI specialist for further assessment, which in selected cases may include liver biopsy. Liver biopsy can be helpful in determining if the patient is likely to progress to cirrhosis, which occurs in about 20% of individuals with chronic hepatitis C, typically over a period of 20-40 years.

Treatment of hepatitis C is an evolving field. All patients with hepatitis C should be advised to abstain from alcohol, which accelerates the progression to cirrhosis and reduces the response to HCV treatments. Prime candidates for drug therapy include patients with persistently elevated ALT readings, detectable HCV RNA levels, and appropriate liver biopsy results [“liver biopsy results (if available) that show portal or bridging fibrosis or at least moderate inflammation or necrosis”]2. For those patients who are candidates for drug therapy, the current standard regime is weekly subcutaneous pegylated interferon alpha plus oral ribavarin for six to twelve months, depending on HCV genotype. The response rate is approximately 50% but varies depending on HCV genotype. Common side effects of ribavarin include hemolytic anemia, fatigue, irritability, and rash. Side effects of interferon include fatigue, flu-like syndrome, nausea, headaches, and depression. Suicidal ideation and suicide attempts have also been reported. Selective serotonin reuptake inhibitors have been used to treat interferon associated depression. If psychiatric side effects are severe, antiviral treatment may need to be discontinued.

REFERENCES
1. American College of Physicians. PIER (Physician’s Information and Education Resource) module for Hepatitis C. Available online at http://pier.acponline.org/physicians/diseases/d163/d163-pdf.html
2. Park JS, Dieterich DT. Chronic Hepatitis C: Latest Diagnosis and Treatment Guidelines. ConsultantLive.com 2006. Available online at http://consultantlive.com/article/showArticle.jhtml?articleID=184429289