Trend of depression and the use of psychiatric medications in U.S. Veterans with hepatitis C during interferon-based therapy.

OBJECTIVES: Interferon-based therapy in patients with HCV infection may cause new psychiatric symptoms or worsening of existing psychiatric conditions. The aim of this study was to evaluate the trend of depression, and the use and the effect of psychiatric medications during interferon therapy. METHODS: Patients with HCV were evaluated at our clinic following a standardized template to collect clinical and psychiatric data at baseline, weeks 2, 4, 8, 12, and every 6 wk thereafter. Depression was measured at each visit by obtaining the CES-D (Center for Epidemiologic Studies-Depression) score. A PMI was defined as the addition or increase in the dose of a psychiatric medication. RESULTS: During interferon therapy, patients with psychiatric history (N = 46) had minor fluctuation in the CES-D score compared to baseline, while patients without psychiatric history (N = 33) had significant increase in their CES-D score, were more likely to require PMIs with antidepressants (63.6%vs 39.1%, respectively; P= 0.04), and they required the first PMI with sedatives/hypnotics earlier (4.1 wk vs 8.9 wk after starting interferon, respectively; P= 0.01). PMIs in the two groups resulted in significant decrease in CES-D score at 4-6 wk and 8-12 wk post-PMIs, but it continued to be higher than baseline. The overall sustained viral response was 47%. CONCLUSION: Hepatitis C patients with stable psychiatric history can be successfully treated with interferon-based therapy if followed closely by a multidisciplinary team that includes specialists in hepatitis C and behavioral health.

The cost-effectiveness of two strategies for vaccinating US veterans with hepatitis C virus infection against hepatitis A and hepatitis B viruses.

OBJECTIVES: Although hepatitis A and B vaccinations are recommended for patients with chronic hepatitis C virus (HCV), the ideal vaccination strategy has not been determined. Our objective was to model the cost-effectiveness of two strategies for vaccinating patients with HCV infection against hepatitis A (HAV) and hepatitis B (HBV) viruses. The strategies evaluated were: universal vaccination with the combined HAV and HBV vaccine, and selective vaccination based on immunity determined by blood testing. METHODS: A decision tree model was constructed to compare the cost-effectiveness of the two vaccination strategies from the New Mexico Veterans Affairs Health Care System (NMVAHCS) perspective. A retrospective review of all HCV patients (2517 subjects) at the NMVAHCS was performed to extract prevalence of immunity to HAV and HBV, and prevalence of decompensated liver disease. Literature review was performed to obtain other probabilities for the model. Only direct medical costs were considered; the effectiveness measure was the number of patients immune to both HAV and HBV. Sensitivity analyses were performed to test robustness of the results to changes in input variables. All costs were in 2004 US dollars. RESULTS: The selective strategy was less costly but less effective, with a cost-effectiveness ratio of 105 dollars per patient immune to HAV and HBV. The universal strategy was more effective but more expensive with a cost-effectiveness ratio of 112 dollars per patient immune to HAV and HBV. Compared with the selective strategy, universal strategy was associated with an incremental cost-effectiveness (ICE) ratio of 154 dollars per additional patient immune to HAV and HBV. The universal strategy would become more cost-effective if 1) the cost of combined vaccine was reduced to less than 30.75 dollars (9.7% reduction), 2) the cost of HBV vaccine increased to greater than 34.50 dollars (25% increase), 3) the cost of blood tests for immunity increased to more than 25.25 dollars (23% increase), or (4) the prevalence of anti-HBs decreased to less than 24%. CONCLUSIONS: The selective vaccination strategy for HAV and HBV in our sample of patients with HCV is more cost-effective. However, the universal strategy is more effective and its ICE is minimal, thus it may be worth the additional cost.