A middle-aged woman with chronic hepatitis C is referred for psychiatric clearance before starting antiviral therapy.
“Ms. A” is a 56-year-old, married homemaker with chronic hepatitis C who was recommended for treatment with interferon-alpha (IFN-α) after her liver biopsy demonstrated a fibrotic score of 4/6. Because she had a history of excessive alcohol use, she was referred for psychiatric clearance before starting antiviral therapy. From the age of 21, Ms. A drank most days of the week, sometimes until she passed out asleep. She had a history of driving under the influence, of multiple attempts to stop drinking (resulting in mild agitation and insomnia but no other withdrawal problems), and of frequently feeling hung over. At age 55, she was diagnosed with hepatitis C during routine screening of liver function tests by her primary care physician. Her physician strongly recommended that she stop drinking, and a few months later, she successfully did so. Her only withdrawal symptom was insomnia. Other than a few experiments with marijuana and psychedelics in the early 1970s and past abuse of methaqualone to help sleep, no other drug use was noted.
At her initial psychiatric evaluation, Ms. A had already been completely abstinent from alcohol for 5 months. She did have a sense of being a failure in life, with poor self-esteem; however, she denied most other depression symptoms. Her Montgomery-Åsberg Depression Rating Scale (MADRS) score was 4 (minimal depressive symptoms). She endorsed having had one episode, 10 years earlier, in which she had notably low mood, anhedonia, weight loss, fatigue, passive death wish, insomnia, and an increased sense of being guilty. This resolved in about 1 year without treatment. There was no history of anxious, psychotic, or manic episodes. Her marriage of 30 years was stable, her 26-year-old son was now independent, and she volunteered several days a week delivering food to the elderly. She was recently started on metformin for fatty liver and occasionally took ibuprofen for carpal tunnel syndrome pain. Her only other medications were daily multivitamin, iron, and vitamin E supplements. Because of her past history of alcohol abuse, she was reluctant to start any medications for occasional insomnia.
After a 6-month waiting period for financial reasons, Ms. A was started on a 6-month course of weekly subcutaneous pegylated interferon-α2A injections (180 μg), daily ribavirin (1200 mg), and daily telepravir (2250 mg). Within 1 month, her viral levels were undetectable. However, she soon had worsening fatigue along with pancytopenia. Her hemoglobin level went from 14.9 to 6.9. She was given two units of packed red blood cells and an injection of epoetin alpha, and her ribavirin was briefly held. Her anemia and fatigue improved, but by week 8 of treatment, she reported increased depression and suicidal ideation. Her hepatologist prescribed citalopram (20 mg) and a small dose of amitriptyline (10 mg) for sleep. She was fearful of taking these medications, however, and did not start them. She was referred for a psychiatric reevaluation. By that time, her MADRS score was 19 (consistent with moderate depression) with increased suicidal ideation.