|Fall 2007||Return to Outlook Main page >>|
I was asked to write this column to provide SBM members and psychologists-in-training exposure to a rather unique area of behavioral medicine in the field of hepatitis C. As a health psychologist working on the UNC multidisciplinary hepatitis C team, I apply psychosocial and behavioral principles to a novel area for behavioral medicine. In this article, I will provide some background into hepatitis C and the patient population with whom I work, as well as describe my role on the team. I end with my own story of how I came into this position, and hope that my example leads behavioral medicine neophytes to be proactive, passionate and persistent about career ambitions in ANY area of medicine.
A Primer on Hepatitis C
The hepatitis C virus (HCV) is a viral infection that can lead to chronic hepatitis C in up to 85% of patients who are exposed to the virus, and is the leading cause of cirrhosis and hepatocellular carcinoma. It is the most common blood-borne infection in the US with 4 million people infected; this is 5 times greater than the prevalence rate of HIV. HCV is responsible for 8-10 thousand deaths each year, and is the most common condition leading to liver transplantations. Chronic HCV is associated with mortality, morbidity, decreased quality of life, and increased healthcare utilization costs. Symptoms of HCV are often vague and diffuse, such as fatigue, weakness, aches and pains, itchy skin, and stomach pain. HCV, like HIV, is transmitted through exposure to contaminated blood. The most common mode of transmission is injection drug use, but it can also be contracted through blood transfusions prior to 1990, intranasal cocaine use, accidental needle sticks, sharing of razors and toothbrushes, unsterile tattoos or body-piercings, unprotected sex, and intranatally.
The treatment of choice for HCV is a combination of oral ribavirin and injectable pegylated interferon (IFN), which is also commonly used in the treatment of multiple sclerosis and malignant melanoma. Ostensibly if IFN treatment can eradicate the virus, damage to the liver can be minimized, and the risk of cirrhosis and liver cancer lowered. IFN treatment can clear HCV in 50-80% of patients. African-Americans have a much lower chance of viral clearance (~25%) and reasons for the racial discrepancy are not well understood. Unfortunately, IFN treatment can be associated with adverse side effects, such as flu-like symptoms, fatigue, weakness, nausea, rash, and cognitive and mood changes, and can lead to decreased quality of life in all aspects of functioning.
Pre-existing Mental Health and Substance Use Disorders (MH/SUD) and Interferon-Induced Mood Disorders
IFN-induced psychiatric symptoms are often the most concerning side effects for treating physicians. Depression, anxiety, irritability, cognitive disturbances, insomnia, suicidal ideation and attempts, psychosis, mania and relapse of substance abuse have all been reported. IFN-induced mood disturbance may hinder treatment adherence, may be associated with diminished rates of viral clearance, and has deleterious effects on quality of life. When these side effects cannot be managed, treatment can be reduced or discontinued.
Many patients with HCV have comorbid MH/SUD, and historically have not been considered eligible candidates for IFN therapy for fear of worsening their problems. However, more recent evidence suggests that previous MH/SUD is not necessarily a reliable predictor of the development of IFN-induced mood disturbance. Given the high rate of MH/SUD among HCV patients, and that these comorbidities do not necessarily translate into increased risk, then it no longer seems justified to withhold treatment from these individuals. Leaving this cohort untreated would worsen health disparities that already exist among persons with MH/SUD. Some programs are slowly but surely recognizing that novel solutions and models of care need to be implemented to effectively treat this large and challenging population. As a health psychologist with a multidisciplinary hepatology program, I am part of this larger goal to prepare and provide treatment to patients with MH/SUD, who otherwise may not have been given the opportunity to undergo treatment.
The Role of the Health Psychologist on a Multidisciplinary Hepatitis C Treatment Team
Because treatment is challenging and psychiatric disturbance is common, an essential part of my job is conducting psychological evaluations and interventions. After medical clearance from the hepatologist, I determine whether patients are psychologically stable and emotionally prepared to undergo treatment. I evaluate psychiatric and substance abuse history, and review social support, occupational and relational functioning, and expectations and concerns about treatment. Have patients addressed medical treatment with their employees? Do their spouses support the decision to undergo treatment? How do they normally cope with illness and fatigue? Patients with significant MH/SUD issues are required to be followed by a local mental health or addiction professional with whom I will collaborate if the patient’s functioning deteriorates. Another aspect of my job involves providing education and psychologically preparing patients to undergo treatment. Knowledge about treatment is often limited and anticipatory anxiety is high. I review pertinent information and guide them in conducting a risk-benefit analysis of treatment. For most non-cirrhotic patients where there is usually no urgency in starting treatment, I encourage them to consider their emotional, marital, and occupational stability so that treatment is initiated at the optimal time for themselves and their families. When patients appear too unstable to cope with the rigors of treatment, we discuss the barriers to initiating treatment, and I often assist in identifying resources in their community.
Once patients begin treatment, I follow those identified as high-risk for psychiatric issues. Mood disturbance is likely to occur within the first 5 months of treatment, so high-risk patients are monitored closely during this early phase. My follow-up clinics run concurrently with those of our treating clinicians, so patients are conveniently evaluated by both of us on the same day. Follow-up visits are spent re-evaluating mood functioning, symptomatology, and presence of suicidal ideation. I often find that my training as a health psychologist has equipped me with the expertise to aid patients with a wide array of physical and psychological issues that were either pre-existing, developed on treatment, or interfere with their ability to cope with treatment. For example, I may provide education and skills training in sleep hygiene, relaxation techniques, smoking cessation, medication adherence, coping and communication skills, behavioral activation for depression, or anger management. In a nutshell, many of these patients have considerable pre-existing emotional dysfunction and unhealthy lifestyle habits, and often these issues worsen on treatment. Thus, the opportunity to make small, yet positive, changes in patients’ lives is endless.
Future Directions for Clinical and Research Opportunities
As with many other medical conditions such as heart disease, cancer, and HIV, a multidisciplinary approach to the treatment of HCV may well be the most effective strategy for treating patients with HCV. As the field has moved forward, a few HCV clinical researchers have encouraged integrative models of care that are equipped to handle the tri-morbidity of HCV, psychiatric and substance abuse disorders. The programs which are the most capable of treating this cohort often have psychiatrists, psychologists, or addiction specialists on staff. At this point, psychiatrists are the primary providers of mental health services. I know of very few psychologists working in the field of HCV, but I believe our contributions could mirror those made to other areas of medicine. Aside from psychiatric medication management, which falls under the purview of an HCV clinician or psychiatrist, the initial psychological evaluation, follow-up evaluations, and nonpharmacological interventions are all within a health psychologist’s expertise.
Studies addressing psychosocial issues of HCV and IFN treatment are virtually non-existent. The literature is much akin to HIV research in the late 1980s when the contributions of psychology were just beginning to be recognized. A recent literature search of HCV in PsychInfo illustrates this point. Only 500 articles were retrieved with a search term of “hepatitis C” while 26,000 articles were retrieved when searching for “HIV.” Combining the search terms “hepatitis C” and “interferon” the number of articles dropped to 130. Many articles that mention HCV are published in the addiction literature as a consequence of illicit drug use, but few articles have been published in journals oriented toward health psychology. This does not mean that those journals are not interested in publishing articles on the psychological factors of HCV and IFN, but rather it reflects that few psychologists are doing research in this area! There is also a dearth of posters and presentations on HCV at health psychology conferences—further attestation that the biopsychosocial issues of HCV and IFN treatment are under-explored by behavioral medicine researchers. Currently, most of the psych-oriented research on HCV has been conducted by psychiatrists interested in IFN-induced depression because it appears to be biochemically-induced, and it provides a patient population in which to study the cytokine-based theory of depression (interferon is a well-known proinflammatory cytokine).
Hepatitis C and IFN treatment offer a new medical arena in which to study the psychological, social, and behavioral aspects of disease and treatment. This field would be fruitful for psychologists interested in studying psychoimmunology, the activation of the HPA axis and development of depression. Psychologists working in the field of HIV would find many similarities between the two populations with regard to risk reduction interventions, medication adherence, co-morbidity of substance abuse and mood disorders, and social stigma. Psychologists working with cancer patients undergoing chemotherapy could easily translate knowledge about the benefits of social support and certain types of coping to researching these factors in treated patients. Essentially, an easy leap can be made from most psychological constructs and medical conditions to the field of hepatitis C research. My own research has involved reviewing the primary reasons patients are deferred from treatment, and determining the incidence rate of MH/SUD among HCV patients treated at our clinic. I am also working on projects to identify psychosocial predictors of IFN-induced mood disturbance, and to determine whether a psychosocial intervention can help MH/SUD patients become better candidates for treatment. These research projects are just the tip of the iceberg.
Connecting the Dots….
The trail from my starting point in behavioral medicine to my current position in hepatology is not obvious to a casual observer. A series of job opportunities, and being proactive, connected my graduate training to my current position. In graduate school, my area of interest was in cardiac rehabilitation; subsequently I took an internship position at UNC with the Heart and Lung Transplant Program to extend my experiences with this population. As a UNC intern, I took an elective rotation with the Liver and Kidney Transplant Program. From there, the transplant programs decided to create a two-year postdoctoral position that involved working with both transplant teams. During my postdoctoral training, I worked extensively with the Liver Transplant Program, becoming familiar with the biopsychosocial issues of liver disease. I became well-acquainted with members of the transplant team, comprised of hepatologists, transplant surgeons, nurses, and physician extenders. I initiated discussions with a few members of the medical and surgical teams regarding research opportunities, career development, and of course, funding. My discussions with the director of hepatology were fruitful, as he began to conceptualize how a psychologist trained as a clinician and a researcher might benefit and expand his HCV program. I continued to pursue these discussions, even writing a grant to demonstrate initiative, and Voila! A year later my faculty appointment was created.
For the past two years, I have enjoyed a rewarding position combining patient care and clinical research as a member of a multidisciplinary team in a hospital setting. What more could a health psychologist ask for? The take-home point is this: There are several possible paths to a career in health psychology, the most obvious of which is to search and interview for job positions that already exist. However, there are so many untapped opportunities where positions can be created for health psychologists in medical subspecialties. Many MDs in hospital settings who direct medical programs do not know what we do, or what we are capable of contributing. I encourage trainees to take initiative and start a dialogue about what you can offer patients, and more importantly, the medical team. Don’t be intimidated to start discussions with our MD counterparts; I have always found them interested and intrigued by what we can offer. Here’s a challenge: I can’t think of a disease or medical condition where psychosocial or behavioral factors are NOT relevant, can you?
For more information on hepatitis C, liver disease, and interferon treatment, the following references are recommended:
Donna Evon, PhD, is a Clinical Psychologist and Assistant Professor in the Department of Medicine, Division of GI and Hepatology, at the University of North Carolina in Chapel Hill. She has been a member of SBM for over 10 years.