Impact of Hepatitis on Mental Health and Addiction Recovery

Foreign. The 2021 Wellness Retreat is an opportunity for clinicians and non clinicians to enjoy fall in Tennessee and maybe even a leaf change while you take a deep dive into learning about the mind, body connection and strategies for improving your overall well being. Up to 21 CEUs will be available for clinicians, but again you don't need to be a clinician to attend. The retreat is being held October 20th through 23rd at Cumberland Mountain State park and is limited to 60 people to allow me to have plenty of time to interact with everyone. Go to allce.comwellness to see the detailed schedule and download the registration form. I look forward to seeing you there. I'd like to welcome everybody to today's presentation on the impact of hepatitis on recovery. This is based in part on Samsa Tip Fitness 53. That's the substance Abuse and Mental Health Services Administration Treatment Improvement Protocol 53. Now you can find that if you go to the SAMSA web store and look at their tips that it is downloadable as a PDF for free. I don't know if you can order print copies anymore. I think they started doing away with that, but you definitely can get the entire PDF if you want to and it's also available online Oopsies Today we're going to learn about hepatitis and its prevalence, identify the consequences of hepatitis, and explore the impact of hepatitis on mental and and physical health to a little bit and effective interventions that we as counselors, social workers, pastors can engage. Hepatitis refers to an inflammatory condition of the liver that can be caused by a viral infection. That's what we normally think about when we think hepatitis. We think hepatitis A, B, C, D, E. But there are other kinds of hepatitis. There is autoimmune hepatitis, which is just like it sounds like anything that has ITIS at the end means inflammation and HEPA mean in this context means liver or hepatic liver. So what we're talking about is liver inflammation and autoimmune disorders have at their core inflammation. So this happens to be inflammation of the liver. And the liver can be inflamed as a secondary result of the use of drugs, toxins or alcohol. The liver is one of our body's filters for gunk. You know, it helps clear out some of the pathogens in the body. And when the liver is bombarded with things like alcohol that are inflammatory or other toxins, it's going to create an inflammatory response. So those types of things can cause hepatitis as a result of ingestion. Interestingly now this is kind of where the the counselors kick in. Mood disorders were present in 3, 38% of patients with viral hepatitis. I couldn't find any data on any of the other types of hepatitis, but what we were looking at was those with viral hepatitis. 38% of patients had mood disorders, 30% were diagnosed with personality disorders, 19% PTSD, other anxiety disorders, 9% and 17% had had psychotic disorders. Now this typically would be towards the end looking at like schizophrenia, not depression with psychotic features. But it is important to recognize that a lot of people with hepatitis are going to have concurrent mood issues. It could be something that predated the hepatitis, or it could be partially as a result of the hepatitis. And, and we're going to talk about ways that hepatitis might contribute to mood symptoms, aside from just the fact that the person is trying to wrap their head around the fact that they may be living with a chronic condition. Hepatitis B, for example, is a chronic condition. They haven't found a way to cure it yet. Hepatitis C they actually do have treatments for. But I'm getting ahead of myself. Although alcohol use disorders were found in 86% of this patient population, so a lot of this patient population has an alcohol use disorder and may end up developing viral hepatitis because alcohol use disorders suppress the immune system and make people more susceptible to viral hepatitis. And that's not even talking about, you know, alcohol involved hepatitis. But intravenous drug use was present in only 28% of this population. That's still a lot of freaking people that have co occurring issues with hepatitis. So it's important if you're working with any behavioral health diagnosis to recognize the fact that hepatitis may be a confounding issue for people. Diabetes, which we now know does have some autoimmune components to it. Diabetes, they found, can lead to cirrhosis of the liver, which is, you know, a inflammation and then hardening basically of the liver. So we want to recognize that our patients with diabetes may be at risk for hepatic dysfunction. Over 10,000 people come to BetterHelp every day looking for a counselor. BetterHelp makes it easy for you to move your practice online and focus on what you love most, helping others. Better Help's easy to use platform takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18,000 therapists at better Help helping to improve people's mental health and lives. So what does the liver do? It filters out toxins from your body and it helps excrete toxins. Now this, this part here is a little bit technical. I guess more. More like your chemistry course. But it's important. Ammonium is produced when the proteins break down. Some of this ammonium is shuttled to the brain where it's used to make glutamine. The rest of it is shunted out and excreted through out of the body. If the liver malfunctions, it causes an excess amount of ammonium to be created or to build up and therefore an excess amount of glutamine, which can trigger something called hepatic encephalopathy. What we know about this, if you've been in my other classes where we've talked about neurotransmitters, glutamine or becomes glutamate. And glutamate is one of your main excitatory neurotransmitters. When there is excess amounts of. When there are excess amounts of glutamate in the brain, it creates an environment that is neurotoxic. It's an too hot, if you will, for the neurons to survive. So you start seeing cell death. So that's why we start having problems in the brain. When the glutamate builds up, when the glutamine and ammonia, you know, wherever, whatever part, whatever place you are in that process starts to build up. As it gets too uncomfortable for the neurons to survive, you start to see inflammation. And as more inflammation happens, then you start seeing neuronal death. Hepatic hepatic encephalopathy. I'm having difficulty talking today. Is when there is swelling in the brain as a result of the backup of these chemicals from the liver. The liver also helps break down carbohydrates, fats, cholesterol, and proteins. Who knew the liver was involved in digestion? When the liver is not functioning well, then your body cannot make use of the nutrients that you ingest nearly as effectively. As someone who has a healthier functioning liver. You know from other classes that what we eat is the forms, the raw materials that our body uses to make our hormones, to make our neurotransmitters, to keep our immune system functioning, all that stuff. So if you're getting a bunch of nutrients in, but your body can only use half of it because it's not as effective at breaking down those foods, then you may end up with a nutrient deficit. So it's important to have anybody who has liver dysfunction, whether it is cirrhosis or hepatitis or whatever the label is, to make sure that they're regularly being evaluated by their primary for. For their nutritional status. The liver also activates Enzymes essential to bodily functions. And we don't need to go into all of those. But the takeaway is if these enzymes, which are sort of like catalysts for a lot of bodily functions, if they are not activating, then our body system is not going to function as effectively. Think about trying to drive a car if all of its spark plugs aren't working. Storage of glyco, glycogen, which is blood sugar, basically minerals and vitamins. So it's a warehouse as well. And if it starts getting inflamed, if it starts breaking down where it can't store as much, then the body may not have the reserves it needs for emergencies. It synthesizes blood proteins such as albumin, which serves as an antioxidant, eliminating free radicals that contribute to depression. So that's another big issue. If the body does not has too much, too many free radicals build up, it leads to oxidative stress. Oxidative stress leads to inflammation. Inflammation, especially systemic inflammation, is associated with worsening of autoimmune conditions as well as depression and even anxiety. So it's important. Another reason why the liver is an important organ in mental health and behavioral health recovery. We need to help the body function as effectively as possible. And it also synthesizes clotting factors, which I haven't found any direct correlation to clotting factors and mood, but I figured I'd put it in there for you. So, types of hepatitis. You have your viral hepatitis. Hepatitis A usually lasts less than two months. About 10 to 15% of symptomatic people have prolonged or relapsing diseases for up to six months. But it does not become a chronic long term infection. So hepatitis A is something that actually a lot of people used to end up getting. And I believe there's a vaccination for it now. But it's something that is not going to be a long term problem for people. Hepatitis B, on the other hand, about 90% of infants with hepatitis B go on to develop chronic infection, which is why they do hepatitis vaccinations now. Whereas only 2% to 6% of people who get hepatitis B as adults become chronically infected and have an increased risk of liver cancer. If you work in health care, which I think most of you do, you've probably been offered the hepatitis B series and that is to help you prevent getting hepatitis B. But if you haven't had it yet, if you, if you're an adult and you haven't had hepatitis B yet, it is important to recognize that even if you're exposed to it, because I know we all get that bloodborne pathogens training. Only about 2 to 6% of adults who contract hepatitis B become chronically infected. Now, that's not to say you should avoid your universal precautions or avoid getting the vaccination, but it is a little dose of reality here. So if you do get exposed, you don't go into automatic panic. You know, you have, you can take steps to do what you need to do to prevent it from becoming an issue in terms of hepatitis C. Once diagnosed, most people with hepatitis C can be cured in eight to 12 weeks, reducing their liver cancer risk by 75%. Inflammation causes a lot of changes in the body that predispose people to a higher risk of cancer. Inflammation in the liver predisposes them to a much higher risk of liver cancer. So people with hepatitis really want to get that hepatitis dealt with. Not only so they can effectively process nutrients and reduce their inflammation and have more energy and all that stuff, but also to reduce the risk of cancer and it is curable. Although the treatment window, and we're going to talk about that pretty significantly here, the treatment window or protocol for hepatitis C can be kind of rough and people may need a lot of support to maintain treatment compliance during hepatitis C treatment. Now, hepatitis D can only be contracted by someone with hepatitis B and hepatitis E is spread through ingestion of feces from infected people. And most people who contract hepatitis E, just like with hepatitis A, tend to have a full recovery. This is hepatitis awareness month, so you can go on the CDC website and find all kinds of fact sheets about hepatitis if you want to learn more about all the different types of viral hepatitis. Interestingly, they don't have much on there about autoimmune or alcoholic hepatitis, which are both also significant issues in the United States, at least, I don't know about other countries. So what are the side effects of hepatitis? We know what the liver does, we know the hepatitis means there's inflammation. So what are some of the side effects? When the liver is inflamed, it activates those pro inflammatory cytokines. You hear me lament about those dagum things all the time. And that inflammation, that increase in systemic inflammation may directly lead to the development of depression via central nervous system effects, including fatigue, anhedonia, social isolation, psychomotor slowing, decreased appetite and libido hyperalgesia, meaning people feel their, their pain tolerance is lowered, sleep disturbance and neurocognitive impairment, pro inflammatory cytokines, increases in those are associated with all of these symptoms. So when people have inflammation, they often react a little bit differently. But let's think about how this is protective in a way. If an animal is sick, and I know we're evolved past animals, but let's just go back to basics. If an organism, let's say that is sick, if they're not feeling well, if they've got inflammation, does it behoove them to be out there in the middle of everybody expending a lot of energy where they're vulnerable? Or does it behoove them to isolate themselves so they're safe and reduce their energy output so their body can focus the energy on recovery? It makes sense. All of these symptoms, although unpleasant, make sense when the body is fighting off an illness, an infection, a problem that some of these things may happen. Major depression occurs in nearly 25% of untreated hepatitis C patients. Now, that's HCV, stands for hepatitis C virus. So it is important to recognize that some of your patients may not realize they have hepatitis. They may not be having. I mean, by the time you get to the point of cirrhosis and swelling and all that kind of stuff, where they may recognize they've got problems, you're. You're pretty far down the line. Which is why an annual physical that does a full blood panel and looks at liver enzymes is so important, because these things can be picked up very easily on blood, in blood work and addressed. Hepatitis infection may result in cognitive impairment prior to the development of cirrhosis and may be unrelated to a history of illicit drug use or. Or mood disorders in some patients. So this cognitive impairment can be caused by the inflammatory cytokines and, and may happen before you get that problem that we talked about earlier with the hepatic encephalopathy. Just simply these significant increase in inflammatory cytokines in the body may lead to cognitive impairment, even if the person did not use drugs or have a mood disorder prior to this happening and they don't have cirrhosis yet. Sleep disturbances, not. This was one thing I learned. Sleep disturbances affect about 50% of people with hepatitis C. And we do know that sleep disturbances can and usually do worsen other behavioral health issues. When you don't get enough sleep, your circadian rhythms get out of whack. Circadian rhythms get out of whack. It alters your hormones, your thyroid hormones, your gonadal hormones, your cortisol levels, and when it peaks and when it goes down, it alters your melatonin levels, it alters your hunger and satiation hormones. Circadian rhythms are involved in just about everything that keeps your body humming along. So it is really, really important that people get good quality sleep and maintain their circadian rhythms. Now the reasons for the sleep disturbances are varied, but it is important to recognize that it is a very common side effect, especially in people with advanced levels of hepatitis where they've got abdominal swelling, you see more instances of sleep, sleep apnea and pain and discomfort than in people who are in early stages. But we don't want to ignore this because good quality sleep enhances the immune system and helps the body help itself recover hepatitis Medications Interferon Alpha now my daddy when had melanoma and Interferon Alpha is one of the main medications for melanoma treatment. It is a vicious medication, so it is important to recognize and not minimize what's going on. When people are using Interferon Alpha. It can cause depression, delirium, irritability and even mania in people or hypomania in people. So it's important to encourage people to be aware of their mood and cognitive symptoms when they're taking the medication. And so we can help them develop a strategy to cope with those symptoms until their 12 week treatment period is over. Interferon Alpha activates your CNS opioid receptors which, well, this may be another issue for people who have a history of opioid misuse. But a lot of other drugs of abuse also activate those endogenous opioid recept endogenous opioids. So you want to recognize that people who have a history of substance misuse may have a slightly different reaction than others. Interferon Alpha may damage neurons by causing cerebral edema, increasing free radicals and promoting glutamate release, causing excitotoxic cell death. So Interferon Alpha actually does increase that HPA axis and increase that neurotoxic environment Some, unfortunately it's a necessary, if you will, or unavoidable side effect of interferon treatment. Baseline depression or anxiety even when subclinical predicts the development of psychiatric morbidity during Interferon Alpha treatment. If you have a client that you're seeing right now who just got diagnosed and they haven't started treatment yet, but you just got diagnosed for hepatitis, but you know that they have a history, maybe it's a childhood history, but they have a history of depressive disorder or anxiety disorder, even social anxiety disorder, the likelihood of them developing psychiatric comorbidities while they're in during the treatment phase is pretty high. So preparing them for that, creating a plan with them to help them Increase their mindfulness, reduce any unnecessary stressors, prevent as many vulnerabilities as possible, and have a plan to deal with those symptoms, recognizing that, you know, some days are not going to be a days, they may not even be C days. So how can they be compassionate towards themselves? Interferon alpha induces the enzyme indolamine 2,3 dioxygenase, or IDO, which causes a diversion of the metabolism of tryptophan away from serotonin. This is another major issue. Serotonin, remember, is involved not only in regulating your mood, which, you know, that's first line for depression. So if your body is not breaking down tryptophan to make serotonin, then guess what, you may, or the person may become serotonin deficient. But that's only one issue. If the serotonin levels become imbalanced compared to what the person is used to, what the that person's brain is used to. Serotonin is also involved in heart rate, respiration, energy, libido, hunger, satiation, sleep. Remember, serotonin's broken down to make melatonin to help people sleep. So if they're serotonin deficient, they're probably also going to have sleep problems. Unfortunately, interferon alpha is still the gold standard for treatment of hepatitis C. But it is important to educate the clients about what to expect or, you know, the, the spectrum of what to expect. Not everybody has all these symptoms, but if they do start having them, that they can recognize them early, advocate with their treating physician, advocate with you to help them develop cognitive behavioral strategies, whatever we can do in order to maximize their quality of life during that treatment period. Irritability is a classic symptom of mania and a common adverse effect of interferon alpha. With 20% of patients demonstrating manic or hypomanic symptoms at some time during the six months of treatment. So I guess some people are on treatment for up to six months. It is important to be aware of this. 20% of patients, so even someone who is, has never had a bipolar episode in their life, may end up developing some hyp, manic or hypomanic symptoms. And we want to, you know, very carefully assess this because it doesn't necessarily mean that they've developed quote, unquote, bipolar disorder. It may just be a side effect of the medication. But it can be really freaky for people if they've never had a manic episode before the first time they do have one. Up to 77%. That's a lot. 77% of patients receiving interferon A plus some other medications for hepatitis C report fatigue during treatment more often than not. Obviously 77% report fatigue and depressive symptoms. Then you've got 20% that report irritability, hypomania, mania. They're not necessarily mutually exclusive. Some people have fatigue and hypomania at the same time. They have what looks like a mixed episode. But fatigue is often one of the most debilitating symptoms for a lot of clients to deal with. They just, I mean, it feels like they are trudging with a 50 pound rucksack on their back. Just getting literally standing up feels incredibly difficult. And they may just lay in bed in the morning for, you know, 10, 15, 30 minutes going, crap, I've got to move. Remember, if you've probably worked with clients with major depressive disorder, and a lot of them, unfortunately we don't have it listed in the dsm, which I think is a shame. It's a travesty. That really explains that people with clinical depression often, you know, they feel a lot heavier. There's that psychomotor retardation, but there's also an increase in, in pain, a decrease in pain tolerance, if you will. So just getting up, not only does it feel heavy, it can hurt. And, and part of that is the body's reaction. Part of that is a result of decreased serotonin. Serotonin is involved in your pain threshold as well. So we do want to recognize this. There are things that people can do. You know, obviously if somebody is going through an intensive treatment for hepatitis, you want to work with the multidisciplinary team. But there are certain essential oils, for example, and certain activities that they can do that can help naturally increase levels of their endocannabinoids, their endogenous opioids, dopamine and serotonin. A lot of that involves doing things that are pleasurable and smelling things that are pleasurable that make them feel calmer, happier. Obviously with the essential oils, even if they're just inhaling them, you'd still want to check with the medical providers first to make sure there's no weird contraindications. Treatments. Antidepressants, particularly SSRIs, have meant shown significant effectiveness in treating depressive symptoms in both treatment related and non treatment related depression. Why is this? Well, we can hypothesize, we don't know for sure. I mean, I couldn't find any articles that could say this is exactly why this happens, but. So let's talk about treatment related depression. When people are undergoing treatment, they have that issue where the body is not breaking down tryptophan to make serotonin. So their body's not making enough serotonin compared to what it's used to making. So when you give somebody an ssri, it says, okay, we don't have as much serotonin as we normally do, so we're not going to let it leave the synaptic space as quickly. That's what SSRI is, selective serotonin reuptake inhibitor. It keeps the serotonin in that synaptic space longer so it can do more. If you've ironing, I guess that's the thing that I can liken it to. You know, if you're ironing, if you pass the iron over really quickly, it may get out some of those easy wrinkles. But if you keep it there on the cloth for longer, not so long that you burn it, but for longer, it can help really set in a crease. When my husband was in law enforcement, I used to have to iron his uniforms all the time and set those creases. And you couldn't just do it real quick, you had to leave it there. So it needed more heat for longer. When people don't have enough serotonin, leaving the serotonin in that space for longer is like leaving the iron on the crease for longer. It helps it have a more intense effect. Effect, basically. And that's really oversimplified. But so that can be one effect or one reason why antidepressants can be very helpful for treatment related depression. Because you're actually countering the effect of that whole tryptophan boondoggle. Non treatment related depression. Remember we talked earlier about how hep. The liver is responsible for breaking down the food you eat or helping break down the food you eat in order to make those nutrients available to be used to make neurotransmitters and those sorts of things. So people who have hepatitis may be suffering from a deficiency in neurotransmitters because of a nutrient deficiency. They may be suffering from a depressive symptoms as a result of increased inflammation, which SSRIs in some cases have been found to help with that. So it is interesting to take a look at, you know, what are all the reasons somebody may be having these depressive symptoms as a result of liver dysfunction and or as a result of the medication. So we can get a bigger picture, a more well rounded picture of all of the things that are influencing their mood and behavioral health and overall energy levels so we can help them understand it a little bit better and cope with it, we want to provide health education to help clients understand their diagnosis, their prognosis, and their treatment plan. It's important. Even though interferon alpha is a bugger and a half, it is so important for them to be treatment compliant. Otherwise they're not going to recover and they're going to have worsening problems, likely with their liver. Dietary support as mental health clinicians, social workers, dietary support is generally not in our scope of practice, so we cannot legally recommend foods for people to eat. However, we can make sure that they're coordinating with their nutritionist. A lot of physicians that treat hepatitis do have a dietitian or nutritionist on staff because what people are eating during this time is that important. But we can also, we can refer them to good websites so they can learn about healthy eating. You know, the US Government has a bunch of those different. The USDA website is a good place to get some overview information. We want to help people build support systems and that is means among their family as well as among people who are also living with hepatitis. Now, that may be people who have hepatitis. It may be a support group for people going through treatment for hepatitis C. You know, there are a variety of different types of support groups out there. There are also support groups for people who have loved ones with hepatitis and loved ones that are going through treatment with, for hepatitis C because it does shake up the family. If, you know, caregiver, partner 1 develops hepatitis and starts going through this treatment, they are often kind of basically on bed rest for 12 weeks. They may be able to get up and do some work. Some people, you know, are able to go through and continue working, but, you know, it is really hard. And going to work 40 hours a week wipes them out. And a lot of people can't even do that during that period. So it is important to recognize that the family needs to understand what's going on, needs to understand that the person's not belingering when they say, you know what? I can't, I, I can't get up. I can't help folding the laundry. I, I can't. I can barely just keep my eyes open right now. There may be some grief, some anger from the family because that person is not able to participate as much. There may be some anxiety from the family because they don' the diagnosis and they're worried that their loved one is going to die. So education's important. Building a plan, helping people understand, especially in the case of hep C treatment, that this is a. Generally it's a 12 week protocol. So during that 12 weeks, it's going to be rough. However, you know, when that 12 weeks is over, the person will likely gradually return to a more normal for them, level of activity. We want to help people develop a plan to prevent infecting others and causing themselves further liver damage in terms of infecting others with the hepatitis that are transmittable through saliva, through blood. You know, obviously you want to work with the person or have the physician work with the person to identify ways that hepatitis is transmitted through the saliva and the blood and things that they need to do to keep their family members safe and then for them, for preventing further liver damage. Like, you know, a lot of doctors will say, you know, no to the Tylenol during this period. Tylenol is really hard on your liver, and the alcohol is another substance and other substances may be very hard on the liver. So the doctor may be requiring or requesting certain changes. Now, if you've got somebody, let's just stack the deck against this poor person. If they've got hepatitis C and they are struggling with alcoholism, in order to go through treatment, they are going to have to get clean. They're going to have to go through detox. And it's foolhardy to think that going through detox for 3, 7 days, however long it takes the person to get the alcohol out of their system and get medically stable is. Is it because we have what's called post acute withdrawal syndrome, which is basically the brain takes a lot longer to rebalance itself, even after the. The substance is out of the body. It takes the brain up to a year to 18 months for some people to really rebalance. So the person, while they're going through this treatment that may be experiencing cravings, may be experiencing withdrawals, may be at high risk of relapse. Some physicians, according to the SAMSA tip, will not even initiate hepatitis treatment with someone until they have six months of sobriety under their belt. You can argue both sides of this coin. They've shown that people that are on hepatitis treatment typically don't have much higher of a rate of relapse than people who aren't on treatment. Um, in some cases, people reported that the treatment itself was the reason they didn't relapse, because they knew it was medically contraindicated. So it is important to talk with the person to encourage them to advocate for themselves to know the research. And a lot of that they go over in the SAMSA tip. But suffice it to say that if somebody is freshly detoxed from alcohol and, or has a history of substance misuse or substance abuse. Remaining clean during the 12 week period of treatment can be really, really difficult and they'll need extra support. We want to help people by providing some motivational enhancement and practical management of their side effects for fatigue. You know, what can they do? Encouraging them to use effective time management skills, Write down the things that have to be done, what is it that you have to do each day or each week? And, and that is what you need to focus on. And then encourage them, if they can, to try to let everything else go until treatment is over. You know, thinking of treatment as their full time job and recovering their liver as their full time job and anything else is just what getting the basics done, like paying the bills. If they have to do that, okay. If somebody else in the family can do that, even better because bills usually bring stress and they don't need extra stress. In addition to that, helping them maintain their sleep hygiene, feeling fatigued all the time, and with a psycho psychomotor slowing that they may experience, they may want to sit inside all the time, watch TV in the dark. You know, it can really mess with their circadian rhythms. They may want to take a lot of naps during the day. The more naps they take, especially long naps, if they're getting into a deep level of sleep, it's going to mess up their nighttime sleep. So their sleep quantity may be really high, but their sleep quality is likely very low. And what we're shooting for is good sleep quality for ideally 8 to 10 hours during the treatment phase. So we want to help people figure out what are some things that are contributing to your fatigue. And yes, you can sleep too much irritability. And this can be people being cranky because they don't feel well. It can be mood liability because they don't feel well, because their neurotransmitters are a little bit wonky because their serotonin may be low. Or it could be irritability, like agitation, hypomania, whatever it looks like for them, encourage them to be descriptive. When you say you're irritable, what does that look like? And then help them identify strategies. If they've ever had a manic or hypomanic episode. It's important to identify what are some risk factors when you're in those episodes. Do you typically go on spending sprees? Are you more impulsive or what is it? That could be what high risk behaviors might be a problem if you become irritable and, and help them develop a Plan to address that. Maybe during treatment they take all of their credit cards. I had one client do this, not during hepatitis treatment, but just as a matter of course. She took all of her credit cards and she froze them in a block of ice in the freezer, and if she ever needed them. By the time that block of ice thawed out, the urge to buy whatever it was that she wanted to impulsively buy had generally passed. But, you know, if it was something like her car broke down, she would have to wait a little while. But she still had the ability, she hadn't actually cut the cards. You can also, if you have a trusted friend or a safe deposit box in a bank, put credit cards there. So again, there's still, the accounts are still open, but you can't access, Access them at 2 in the morning when you're watching QVC or something. All of those things are things to be prepared for if there's the slightest risk or concern of somebody having a manic or hypomanic episode and they've never had one before, making sure they know what it looks like and have a plan for how to deal with it. Because you don't know, especially with interferon, a treatment, you don't exactly know what it's going to look like. Isolation, well, when you are fatigued, when it is difficult for you to move around, when it's heavy and it hurts to do anything, then it is important to, to figure out how can you reduce your sense of isolation, how can you increase your sense of connectedness? When we feel connected, we have increased levels of oxytocin, which are very helpful for pain management as well as helping regulate some of our other neurotransmitters. Having a pet can be helpful. You know, if you have an emotional support animal, that can be very helpful. Having people you can call, people you can text, people who will drop by. Some people feel very isolated and some people get very isolated when they get a hepatitis diagnosis because there is so much misinformation out there about hepatitis that people are afraid to be around somebody with hepatitis. So it's important to educate the patient about, again, about how hepatitis can be transmitted so they can explain to other people and even provide them handouts so they have it from the CDC horse's mouth, so to speak. That way people don't feel as anxious being around the person with hepatitis. Sleep impairment. We already talked about how that partly because of alterations in serotonin, partly because of pain, partly because of fatigue and alterations and circadian rhythms, there's A lot of reasons sleep could be impaired. So it's important to help the person develop a strategy so they feel empowered to get the best sleep possible for them at that point in time. They may need to end up being can't, can't put words together today. Sorry y'. All. They may end up needing to be referred back to their primary care or their treating physician, who may end up issuing a referral for a sleep study. That's generally rare if the sleep impairment happens as a result exclusively during the treatment window. But it may happen hyperalgesia, and this is one of the ones that people don't, aren't aware of, aren't, you know, expecting to happen. And it's important to recognize that it is real. People may start having pain, they can hyperalgesia. Sometimes it may be painful even to wear clothing or even to be touched by other people. Now a lot of times that will go, go away. There are just periods during the day or times when it happens or maybe for a full day, but it doesn't last ongoing. But they may experience more pain just in general. Weird pains, more pains, moving pains. It's important for them to feel like they know when they should call their doctor. It's important for the doctor hopefully to be sympathetic to that person's concerns if they start having these weird pains, you know, they already know that their liver's inflamed. So they can have a fair amount of health anxiety at that, at that point in time helping them, them to develop strategies to handle the hyperalgesia. What can you do to help yourself feel better? And part of it will depend on what hyperalgesia looks like for that person. If it is like I was talking about, where the skin becomes tender to the touch, you know, it just really, it is painful when people touch them. Okay, what do you need to do? Are there certain materials that feel better against your skin? What can you do to reduce your pain? There are, there's guided imagery, there's meditation, there's lots of non pharmacological pain management techniques that also can be used if they're feeling more aches and pains and things. But remember that pain is often an indication that something is wonky in the factory and it could just be a side effect of the medication and the, the hepatitis, or it could be something more, which is again, why the, it's ideal to have a physician or the doctor's nurse who can field those questions if the person is concerned. Loss of appetite is very common in people who have a lot of inflammation. And when people are sick, a lot of times they lose their appetite. It's important that they still continue to get nutrients to get nutrition. Malnutrition is going to reduce the immune system and it's going to make it harder for the system to recover. Recognition of the time limited nature of treatment, and you can do this very simply with a calendar and just xing off the days. You can have a countdown timer on your mobile device. There are a lot of different things that you can do to celebrate each day that passes. I had one client that I don't know what you call them. It's a construction paper garland is what we used to call them. But she took pieces of strips of construction paper and made little rings and connected them all so it was a chain. And each day she would rip off one of the little rings in the chain. And the last day of treatment, she had obviously one ring left. And she really enjoyed the tearing up that last ring. But encourage people to, instead of seeing it as something they're dreading and looking and going, oh my gosh, I've got, you know, 40 more days left. Encouraging them, this is one of the few times we have them look backwards and see how far they've come. Wow, you're already, you know, six weeks into it or whatever. Trying to do math in my head this quickly just doesn't work. But encouraging them to recognize you're more than halfway through or you're this far through. Help them reframe symptoms as the body doing its job. As I gave you the analogy earlier, you know, how do these symptoms make sense? How does fatigue make sense? Well, it makes sense that the body's using all of its energy right now to try to help you get better. So let's let us do it. Let's let it do its job. Instead of trying to do six other things and steal energy from your immune system, keep throwing energy at that immune system. And take care of yourself. Be compassionate with yourself. If you're having irritability or feeling like you're wanting to isolate, how does that make sense? And what can you do if it's a symptom that is unpleasant for you? You know, maybe you, you're an extrovert. You really hate feeling isolated all the time, but you don't have the energy to get out. Well, your body's trying to conserve energy to help you recover. So how can you both meet your social needs and conserve your energy at the same time? As I mentioned before, remember post acute withdrawal syndrome for people who were abusing substances or even misusing substances prior to the beginning of treatment. And I do have a video on post acute withdrawal syndrome on the YouTube channel that, that you can watch if you're interested in it. But the gist of it is that people may have symptoms of withdrawal sporadically for the next 12 to 18 months, depending on how heavily they were using, how effective their body is at recovering, how long they used, etc. So we do want to recognize that people can be going along just bebopping, having a great old time, thinking, oh, I'm feeling much better, not having any cravings and then all of a sudden for no apparent reason, they start suddenly start having dreams about the drug use or cravings or they feel really depressed and like, just like they did when they were in or just came out of detox. And that is unfortunately normal. If people are prepared for this, then they can have a plan for how to handle it if and when they do have a upsurgence of pause symptoms. The liver is involved in managing blood sugar, production of antioxidants to reduce inflammation, filtering out toxins that can contribute to inflammation and the it's involved in the creation of neurotransmitters. Interferon alpha treatment, as well as hepatitis itself can contribute to anxiety, irritability, mania, depression and grief. Many clients benefit and before I go on, grief is one we really didn't talk about a lot. But even if we're talking about someone who has hepatitis C who has to go through this 12 week treatment, there can be a grieving process for them because they feel guilty for having to basically go on hiatus for three months from their family and their work obligations. And they may grieve the fact that their body is not healthy at this point in time. Now, yes, chances are they'll make a full recovery and you know, there's all sunshine and rainbows on the other end. But that quarter of a year is, can be really tough and there can be a lot of emotions associated with it and frustration when during that period they can't do the things that they want to do or they feel they should be doing. Many clients benefit from a combination of health education, motivational enhancement and development of a risk reduction plan so they don't spread it and they don't make theirs worse and cognitive restructuring. So there's a lot of things as clinicians that we can do now. Let me show you a couple of those since we do have another minute or so. The division of Viral Hepatitis, Hepatitis Awareness Month. You can go here and you can find out about each type of hepat hepatitis. It talks about how hepatitis A, for example, is found in the stool and blood of people who are infected. CDC recommends pregnant women, men who have sex with men, people who inject drugs, household and sexual contacts of someone infected or anyone born or whose parents were born in areas where hepatitis B is common. Get tested for hepatitis B. Hepatitis B is very contagious, but you don't get it by shaking hands. You get it by swapping bodily fluids. So you don't want to drink out of the same glasses just in case the person has, you know, well, the saliva is going to get into the drink. You don't want to drink out of the same glasses. You don't want to share utensils, you don't want to share razors, or definitely don't share needles. And, you know, practice a safe sex. There are, you know, modifications you can make to prevent transmission. But it is important to be cognizant of how whatever type of hepatitis the client has, how that particular type of hepatitis is spread. For example, hepatitis C. Most people become in hepatitis infected with hepatitis by sharing needles or syringes or equipment to inject drugs. But again, people who are struggling with alcoholism often have a very reduced immune system, their liver, as is at risk, and they can much more easily develop hepatitis B or C. Are there any more questions? Those were all great questions. And like I said, you can go to cdc.gov I don't know how long it'll last, but May is hepatitis awareness month. So it is a great time to find those cute little handouts that the government has already paid money to create. Deficient. Did I say that? Deficiency in certain neurotransmitters can lead to inflammation of the liver. Neurotransmitters are partially involved in regulating inflammation. What's more important or the. The more greater impact of neurotransmitters is when that HPA axis is overly activated. Glutamate, your main excitatory, excitatory neurotransmitter, can become in excess, and that can contribute to systemic inflammation. And it's more systemic than necessarily just in the liver. And yes, hepatitis can cause a deficiency of nutrients needed for your body to make certain neurotransmitters. So problems with the liver, just like problems with the kidneys and, and the GI tract, can all contribute to neurotransmitter imbalances that can contribute to cognitive and emotional and behavioral dysfunction. Well, thank you all for being here and I really appreciate it, and I will see you on Tuesday.