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Treatment Contracts for Patients With Hepatitis C, Psychiatric Illness, and Substance Abuse

Received October 27, 2000; revised February 15, 2001; accepted March 2, 2001. From the Department of Psychiatry, Johns Hopkins Bayview Medical Center D2East, 4940 Eastern Avenue, Baltimore, Maryland 21224. Address reprint requests to Dr. Gallucci.

Key Words: Hepatitis • Substance Abuse • Comorbidity

Epidemiologic studies have demonstrated high prevalence and incidence rates for hepatitis C infection in the general population.^1–6 More recently, studies have attempted to define the rates of infection in populations with substance abuse and in dually diagnosed patients with substance abuse and mental illness.^7–9 New treatments for hepatitis C have emerged and include a combination of interferon- and ribavirin.^10–13 A recent review describes the neuropsychiatric manifestations of hepatitis C infection and interferon- treatment.¹⁴ Although symptoms of depression have been associated with hepatitis C infection,¹⁵ affective symptoms and other neuropsychiatric problems can be exacerbated in patients with hepatitis C who are undergoing treatment with interferon-.^16–18

Patients with a psychiatric illness or substance abuse and hepatitis C may contemplate treatment with an interferon-/ribavirin regimen. More frequently, patients and their medical health care providers ask mental health providers whether interferon treatment for hepatitis C is a safe treatment for an individual with an existing psychiatric illness and/or substance abuse disorder. Although some investigations suggest low risk for serious psychiatric symptoms for patients being treated with interferon-,^19,20 other studies have reported high rates of psychiatric side effects from this treatment.

The following case illustrates the importance of establishing a partnership among patients and their psychiatric and medical health care providers when deciding to institute hepatitis treatment. The use of treatment contracts with patients may be particularly helpful for patients with dual-diagnosis of psychiatric illness and substance abuse to ensure compliance and allow monitoring for adverse treatment effects from interferon- (see Treatment Contract).

Case Report

Ms. A. was a 38-year-old woman referred by the emergency room to our clinic for treatment of substance abuse and depression. Her psychiatric history includes two previous admissions to state psychiatric hospitals approximately 15 years ago and multiple admissions to drug rehabilitation programs. She had tried a variety of medication for treatment of depression but did not remain on medication long enough to have a satisfactory effect. She was admitted to our mental illness/substance abuse program (MISA) and received a diagnosis of mood disorder, not otherwise specified. Ms. A. also met criteria for a diagnosis of cocaine dependence. She was prescribed paroxetine (Paxil; 20 mg/day) and was to receive supportive psychotherapy. Two months after admission to the MISA program Ms. A. was still using cocaine and attending therapy irregularly. Her mood was not stable and she reported auditory hallucinations. A diagnosis of substance-induced psychotic disorder was considered. She was subsequently prescribed olanzapine (Zyprexa; 2.5 mg/day). The next day, after a cocaine binge, Ms. A. took all her olanzapine and was again seen in the emergency room where she was treated for an overdose attempt.

During this time, Ms. A. was diagnosed with hepatitis C, and treatment alternatives were considered. Her primary care physician was hesitant to prescribe interferon and ribavirin because of her history of depression and poor compliance with treatment. The patient entered a 2-week inpatient rehabilitation program and was able to remain drug-free for 6 weeks after discharge. Her olanzapine was restarted secondary to continued complaints of auditory hallucinations. Psychotherapy was resumed. To maximize safe treatment for hepatitis, we decided that a contract should be developed and agreed upon by Ms. A., her psychiatric team, and her primary care physician.

Ms. A. had multiple relapses to substance use, several medication overdoses, and brief hospitalizations. She entered a psychosocial program that provided daily individual and group therapies. Her olanzapine was eventually discontinued, but Ms. A. continued to complain of auditory hallucination and paranoid thoughts despite abstinence from cocaine. She was treated with mood stabilizers and quetiapine (Seroquel).

Ms. A. has been compliant with treatment and appears more focused in her individual and group therapies. She attends Narcotics Anonymous meetings regularly and participates in substance-treatment groups at the psychosocial program. She has maintained nearly 3 months of sobriety and will soon begin interferon/ribavirin treatment for hepatitis C.

Discussion

Hepatitis C infection has become a major public health concern. High prevalence and incidence rates in populations with mental illness and substance abuse have been recognized. Because hepatitis C infection as well as its treatment with interferon- and ribavirin may cause or exacerbate psychiatric illness and precipitate suicide attempts,²¹ patients and their medical health care providers have sought the advice of the psychiatric team for management of these patients.

We have found treatment contracts to be useful in guiding hepatitis C treatment in patients who may be especially vulnerable to the neuropsychiatric consequence of hepatitis C or its treatment or who have a history of noncompliance or continued substance abuse that can complicate their care.^21–26

The use of treatment contracts has been helpful to improve adherence to a variety of complicated treatment regimens. For example, contracts have been shown to be helpful in the management of antituberculosis therapy and other infectious diseases. In addition, protocols have been established for selection of patients for liver transplant based on a patient's willingness to remain abstinent from alcohol.²⁶

This case report illustrates how a contract can help patients and their health care providers to establish treatment guidelines before starting hepatitis treatment. Although Ms. A. was initially unsuccessful in adhering to the conditions of the contract, she was able to continue with her psychiatric and substance abuse treatment. Eventually, improved compliance and abstinence from substances have enabled her to begin treatment for hepatitis C.

Elements of the treatment contract should include the condition that the patient not use illicit drugs or alcohol. Substance use may complicate neuropsychiatric symptoms, compromise compliance with both psychiatric and hepatitis treatment, and exacerbate medical problems. The use of random toxicology screens may be helpful for monitoring adherence to this condition of treatment. Patients should also be asked to comply with treatment for depression, anxiety or other psychiatric symptoms. Treatment may consist of pharmacotherapy, psychotherapy, or a combination of treatments.

Patients receiving medication will be required to take all psychotropic medications as prescribed. Visits for individual and/or group psychotherapy can be useful to monitor the patient's mental status, provide support during the often difficult-to-tolerate hepatitis treatment, and allow for medication adjustments, if indicated. Patients should agree to keep all scheduled appointments.

The contract should also include the condition that the patient be compliant with the hepatitis treatment. Response to treatment can be evaluated by the somatic provider during the course of treatment with interferon- or interferon-/ribavirin combination treatment. Communication between the psychiatric team and primary care physician (or infectious disease specialist) is crucial for ongoing assessment of the patient's adherence to the contract, mental status, and response to hepatitis treatment. Adjustments to psychiatric or hepatitis treatment may be necessary if psychiatric symptoms occur or the patient relapses to alcohol or substance abuse.

Finally, the contract should acknowledge that the patient is aware of the various risks and benefits involved in hepatitis treatment, especially as pertains to the potential effects on mood and suicide risk.

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Appendix

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