Treatment considerations for the client with interferon-alpha-induced depression.

Abstract

This column offers a question-and-answer forum to help nurses maintain their knowledge of advances in prescribing and psychopharmacology, and implications for safe psychiatric care. Do you have a question related to prescribing psychotropic medications? Send it to the Editor, Mary Paquette, at: mary@artwindows.com. ********** Question: I am a primary care provider and am concerned about the neuropsychiatric side effects of interferon in a client who has been treated for 2 months. His major complaints included depression, lethargy, concentration difficulties, agitation, and sleeplessness. He has a negative history of psychiatric symptoms or treatment prior to being followed up for hepatitis C (HCV). What is the most appropriate strategy for treating clients with interferon-alpha-induced depression? Deborah Antai-Otong responds- Understanding the association among hepatitis C, interferon, and depression is essential to the effective treatment of HCV. Clients treated with interferon-alpha (IFN-alpha), an immunomodulatory cytokine, are frequently susceptible to depression and other mood disorders (Fattovich et al., 1996; Horikawa, Yamazaki, Izumi, & Uchihara, 2003; Valentine, Meyers, Ling, Richelson, & Hauser, 1998; Yates & Gleason, 1998). Prevalence, time course, risk factors, and treatment of IFN-alpha-depression remain obscure. The pathogenesis of IFN-alpha depression is unclear; various hypotheses suggested include its actions on complex mechanisms such as neuroendocrine (e.g., increased serum cortisol levels) and neurotransmitter systems (e.g., dopamine, serotonin, norepinephrine) (Capuron et al., 2003; Maes, 1995, 1999; Valentine et al.). Further, additional data indicate IFN-alpha may play a role in the activation of the inflammatory response system (IRS) and induce production of proinflammatory cycokines, such as interleukon-1 (1L-l), IL-6 (known to stimulate release of corticotrophin-releasing factor), and IFNC [alpha]] (Maes, 1995, 1999). Other posits about the link between IFN-alpha and depression is its effects on tryptophan and subsequent neurotransmitter systems. Major symptoms of IFN-alpha-induced depression are outlined in Table 1. Treatment Considerations Initial treatment involves three important steps: 1. Forming a collaborative relationship with the consulting primary care provider or hepatologist, and formulating a holistic treatment plan that integrates psychiatric treatment and medical management. 2. Establishing an optimal treatment plan is based on a therapeutic nurse-client relationship. 3. Performing a comprehensive psychiatric evaluation that involves queries about the onset of symptoms pre and post initiation of treatment, personal and family history of mood disorders, psychiatric and substance abuse histories, and mental status examination. Clients must be assessed for suicidality initially and throughout treatment. Once a definitive diagnosis of IFN-alpha-induced depression is established, pharmacological and psychotherapeutic interventions must be initiated. Although there is a paucity of data involving controlled studies of antidepressant treatment in people with IFN-alpha-depression, case reports have shown promising results. Case reports indicate that an array of pharmacological agents such as selective serotonin reuptake inhibitors (SSRIs) have shown efficacy in reducing the central nervous system side effect of IFN-alpha therapy (Levenson & Fallon, 1993; Valentine et al., 1998; Van Thiel et al., 1998). Dose ranges for antidepressants are similar to the treatment of depressive episodes and are influenced by the client's liver function status. It is imperative to monitor liver function tests prior to and throughout the course of antidepressant treatment. Major benefits of SSRIs (e.g., fluoxetine, paroxetine, citalopram) include their activating properties and rapid symptom resolution (e. …