Depression, anxiety and cognitive performance each improved
significantly in people cured of hepatitis C, Indian researchers report in the Journal
of Viral Hepatitis.
Anxiety and depression are frequently reported by people
with hepatitis C at all stages of liver disease. Neurocognitive impairment –
including slowed mental processing speed and reaction times, reduced attention
span and verbal fluency, and impaired memory – may affect up to half of people
with hepatitis C. Hepatic encephalopathy, a decline in brain function seen in
late-stage liver disease when the liver can no longer remove toxins from the
blood, is a more severe form of neurocognitive impairment.
Although anxiety and depression may be direct effects of
viral infection, social stigma associated with hepatitis C or with using drugs
can also lead to mental health problems in people with hepatitis C. Substance
use may also reflect underlying mental health conditions.
A disease or infection affecting the brain.
The Indian state of Punjab provides treatment for hepatitis
C and comprehensive health care at 25 decentralised clinics. The Punjab public
health treatment model uses a pangenotypic regimen, either
sofosbuvir/daclatasvir for people without cirrhosis or sofosbuvir/velpatasvir
for people with cirrhosis.
Researchers at Chandigarh University recruited 385 people
who started treatment between June 2018 and March 2020, to assess the impact of
hepatitis C cure on mental health conditions and neurocognitive functioning.
Study participants were 76% male with a mean age of 39
years. Unsafe injections (59%), surgery (75) and injecting drug use (5%) were
the most frequently identified sources of infection. Most of the cohort were
literate (82%) and 38% had completed high school. Twenty-one per cent of the
study cohort had cirrhosis and 6% had major depressive disorder.
Study participants exhibited substantial cognitive
impairment at baseline, regardless of cirrhosis status, when compared to
healthy controls or people with non-alcoholic fatty liver disease. On the
Stroop test of concentration, attention and processing skills, for example, the
median score in healthy controls was 68%, compared to 47% in people with
hepatitis C. On the visual memory test, healthy controls scored a median of
6.6, compared to 5.1 in people with hepatitis C.
Substantially inferior scores on tests for cognitive function
were also evident in people with hepatitis C when compared to the control group
of people with non-alcoholic fatty liver disease, suggesting that impairments
in cognitive function are a consequence of viral infection rather than liver
The hepatitis C cure rate was 87% in participants without
cirrhosis and 91% in participants with cirrhosis. Just under two-thirds (63%)
of participants with cirrhosis received treatment for 24 weeks. The remainder
were treated for 12 weeks.
Treatment success was associated with full adherence in
participants with cirrhosis.
Study participants were assessed for depression, anxiety and
health-related quality of life using validated scoring instruments. They
underwent computer-based tests for visual and verbal memory, attention,
visual-motor speed, arithmetic and reaction times. All tests were carried out
at baseline and 12 weeks after the completion of treatment and the results were
compared with healthy controls and a control group of people with non-alcoholic
fatty liver disease.
People who were cured of hepatitis C experienced significant
improvements in depression, anxiety and cognitive function, whereas those who
were not cured experienced no change or deterioration in various measures.
Depression scores fell by 7% on a 40-point scale where 40 is
extreme depression and 10 or below reflects normal mood changes. In contrast
depression scores rose by 28 points in those who were not cured.
Anxiety scores fell by 15% in people who were cured but rose
by 12% in those who were not cured.
But whereas depression and anxiety may reflect individual
psychological responses to the outcome of treatment rather than physiological
changes as a result of treatment, cognitive changes may occur independent of
changes in mood or anxiety.
People who were cured of hepatitis C showed significant
improvements in reaction time, visual memory, concentration, attention and
processing skills (measured by the Stroop test) and short term and working
memory (measured by the digit span test). In contrast, scores on these tests
deteriorated in people who were not cured.
The study did not find substantial gender differences in
depression, anxiety or neurocognitive test scores, in either cured or uncured
The study authors say the study demonstrates that hepatitis
C is associated with cognitive impairment and clearing hepatitis C results in
improved cognitive functioning and reduction in depression and anxiety. They
say that theirs is the largest prospective cohort study of neurocognitive
changes after hepatitis C treatment to date, recruiting almost ten times as
many participants as any previous study, and its findings are strengthened by
the exclusion of people with a prior history of hepatic encephalopathy.