Depression and fatigue must be properly investigated and managed in HCV patients in order to improve HRQL. WHOQOL-BREF proved to be a useful instrument to assess HRQL in HCV patients.

rESUMoA vitamina B12, ou cianocobalamina, desempenha importantes funções metabólicas e neurotróficas. Sua deficiência está associada a distúrbios hematológicos, neurológicos e psiquiátricos. É relatado o caso de uma paciente com depressão refratária ao tratamento com antidepressivos que melhorou somente após a detecção e o tratamento da deficiência de vitamina B12. Esse relato ilustra a importância de o psiquiatra considerar causas secundárias de depressão em casos refratários. . É interessante notar que, segundo alguns trabalhos, níveis mais elevados de vitamina B12 estiveram associados a melhores resultados em pacientes com depressão maior tratados com antidepressivos 2 . Neste relato, descreveu-se o caso de uma paciente com transtorno depressivo refratário ao tratamento psicofarmacológico tradicional, que evoluiu com remissão dos sintomas depressivos logo após a correção de deficiência de vitamina B12. rElato DE CaSoTrata-se de paciente de 42 anos, do sexo feminino, solteira, sem filhos, católica, com primeiro grau completo, desempregada há cerca de seis meses, período em que interrompeu o trabalho que desempenhava como auxiliar de serviços gerais a fim de cuidar do pai que estava doente. A paciente solicitou ao seu clínico-geral um encaminhamento para acompanhamento psiquiátrico, pois persistia com sintomas depressivos a despeito do uso de amitriptilina na dose de 50 mg/dia,

564www.scielo.br/rsbmt I www.rsbmt.org.br Revista da Sociedade Brasileira de Medicina Tropical 47(5):564-572, Sep-Oct, 2014http://dx.doi. org/10.1590/0037-8682-0147-2014 Major Article ABSTRACT Introduction: The prevalence of sexual dysfunction (SD) and dissatisfaction with sexual life (DSL) in patients with chronic hepatitis C virus infection (CHC) was jointly investigated via a thorough psychopathological analysis, which included dimensions such as fatigue, impulsiveness, psychiatric comorbidity, health-related quality of life (HRQL) and sociodemographic and clinical characteristics. Methods: Male and female CHC patients from an outpatient referral center were assessed using the Brief Fatigue Inventory, the Barrat Impulsiveness Scale, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale, the Hamilton Anxiety Scale (HAM-A), and the World Health Organization Quality of Life Scale-Brief Version (WHOQOL-BREF). Structured psychiatric interviews were performed according to the Mini-International Neuropsychiatric Interview. SD was assessed based on specifi c items in the BDI (item 21) and the HAM-A (item 12). DSL was assessed based on a specifi c question in the WHOQOL-BREF (item 21). Multivariate analysis was performed according to an ordinal linear regression model in which SD and DSL were considered as outcome variables. Results: SD was reported by 60 (57.1%) of the patients according to the results of the BDI and by 54 (51.4%) of the patients according to the results of the HAM-A. SD was associated with older age, female gender, viral genotype 2 or 3, interferon-α use, impulsiveness, depressive symptoms, antidepressant and benzodiazepine use, and lower HRQL. DSL was reported by 34 (32.4%) of the patients and was associated with depressive symptoms, anxiety symptoms, antidepressant use, and lower HRQL. Conclusions: The prevalence of SD and DSL in CHC patients was high and was associated with factors, such as depressive symptoms and antidepressant use. Screening and managing these conditions represent signifi cant steps toward improving medical assistance and the HRQL of CHC patients.

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Objective: Major depression (MD) is a condition associated with both hepatitis C virus (HCV) infection and pegylated interferon (IFN)-α treatment. IFN induces a depressive syndrome that is associated with an inflammatory profile. We aimed to investigate whether there is any specific alteration in plasma biomarkers associated with MD. Methods: HCV-monoinfected patients, with and without IFN treatment, were followed up for 18 months and went through structured psychiatric evaluation. We assessed plasma levels of brain-derived neurotrophic factor, tumor necrosis factor (TNF) and its soluble type 1 and type 2 receptors (sTNFR1 and sTNFR2, respectively), and adipokines (adiponectin, leptin and resistin) using ELISA. Results: Among the 50 patients included in the study, 14 were treated with IFN during the follow-up. Being older, not married, presenting higher body mass index, higher liver inflammatory activity, lower baseline adiponectin levels and use of IFN were associated with MD development. Higher levels of sTNFR1 during IFN treatment were associated with sustained virological response. The lack of a control group without HCV infection did not allow any assumption of a biomarker change exclusively due to the infection itself. Conclusion: Adiponectin may be a resilience biomarker for MD in HCV-infected patients.

Pegylated interferon-alpha combined with ribavirin is the current gold standard treatment for chronic hepatitis C. Illicit drug dependence is not a rare co-morbidity among chronic hepatitis C population, what can make antiviral treatment an outmost challenge. Despite high sustained virological response rate following antiviral treatment, serious psychiatric adverse reactions may occur, like depression and suicide attempt. We report a patient with recurrent depressive disorder, previous history of suicide attempt and illicit drug dependence. We discuss the singularities and challenges of managing this patient in order to complete the antiviral treatment. Key-Words: Interferon-alpha, chronic hepatitis C, depression, suicide attempt, drug addiction. . Due to these liver complications, CHC is among the most common causes of liver transplantation [3]. The antiviral treatment of CHC with a combination of pegylated interferon-α (IFN-α) and ribavirin (RBV) is the current standard care resulting in sustained virological response in 45% to 80% of patients [4][5].It is recognized that psychiatric patients have higher rates of sexually and bloodborne transmitted infections, including CHC. A recent review study [6] showed wide variability of CHC prevalence rates in the psychiatric population. Some researchers in the United States have found CHC exposure rates as high as 38%, and others as low as 8.2%. The lowest CHC rates in psychiatric patients were found in developing countries, 2.6% [7] and 5.7% [8] in Brazil, and 6.8% in Taiwan [9]. It is worth reminding that the estimated prevalence of CHC in the general population of the Brazilian municipality of São Paulo [10] is 1.4%. Drug dependence should also be considered as a possible factor associated to increased risk for CHC [7].Furthermore, depressive symptoms secondary to IFN-α treatment occurs in approximately 10%-40% of patients [11] and they are a major cause of drug interruption with a negative impact in treatment response rates. Suicidal ideation and attempt are considered reasons for prompt treatment interruption. However it might be possible to complete treatment in selected patients with careful multidisciplinary approach. Herein we describe a case on which we managed to finish a 48-week combined treatment in an HCV-infected patient with depression and drug dependence that attempted suicide on week 11. Case ReportIn October 2006, a 46-year-old man was referred for treatment evaluation at a public university-based service of infectious diseases (CTR-DIP Orestes Diniz-SMSA-BH/ UFMG) in Belo Horizonte, Minas Gerais, Brazil. He was diagnosed with HCV infection two years earlier, but was asymptomatic and denied any previous symptoms related to either acute or chronic hepatitis.The patient had a previous history of illicit drug use, including intravenous cocaine and inhaled crack since 18 years old. He alleged that he had quit illicit drug use four months earlier. He reported alcohol intake until a month earlier and had a history of 35 pack-years of smoking. The patient r...