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Archives of Clinical Psychiatry (São Paulo)

Print version ISSN 0101-6083On-line version ISSN 1806-938X

Arch. Clin. Psychiatry (São Paulo) vol.45 no.6 São Paulo Nov./Dec. 2018 

Letter to the Editor

A fatal case of bipolar disorder and comorbid hepatitis C

Desislava A. Ignatova1 

Georgi N. Onchev1 

1Department of Psychiatry and Clinical Psychology, Medical University of Sofia, Sofia, Bulgaria

Dear Editor,

Bipolar disorder is associated with an increased risk of substance use disorders and hepatitis C virus (HCV) infection1. The prevalence of HCV in bipolar patients is 5 to 13-fold higher than in the general population, presenting a major clinical and therapeutic challenge2. We report a case of a patient with bipolar disorder, a history of heroin addiction, and HCV related cirrhosis with fatal outcome.


Mr. A was a 44-year-old married white male, an artist, who was diagnosed with bipolar disorder in his late adolescence. He had recurrent manic or mixed psychotic episodes, effectively treated with antipsychotics and mood stabilizers. During a ten-year period of intravenous heroin misuse and dependency, he contracted HCV and subsequently developed liver cirrhosis. Induction of psychotic exacerbation hindered specific HCV infection treatment, which continued with hepatoprotectors and diuretics with poor adherence. The patient's timeline is presented in Figure 1.

Figure 1 History of the patient. 

The last psychiatric admission of Mr. A was at the age of 44. He presented with insomnia, elevated mood, megalomania, delusions, dysphoria, and lack of insight. Anaemia, thrombocytopenia, hypoalbuminemia, ascites and elevated transaminases were present. Zuclopenthixol resolved the psychiatric symptoms and the patient was referred to the hepatology department. A follow-up after one year was scheduled. The patient's wife reported that he had died. He had been in stable mood following discharge and discontinued the psychiatric treatment. The improvement in the mental state improved the compliance with the somatic treatment and regimen, which led to temporary stabilization of the somatic state. However, his somatic condition deteriorated and he died from liver failure 3 months prior to the scheduled follow-up at the age of 45.


Individuals with severe mental illness are estimated to die approximately 25 years earlier than the general population and up to 60% of the premature deaths are due to general medical conditions3. Chronic HCV infection is a major concern, with an estimated infection rate up to 10-23.3% in bipolar patients as compared to 1.8% in the general population4. The risk of liver cirrhosis is between 15 and 30% within 20 years5 but risky social environment, high- risk behaviors, and non-compliance can aggravate the condition in bipolar patients2.

New and highly effective therapies for chronic HCV infection are present, however access to treatment remains limited and psychiatric patients still suffer stigmatization6,7. Mental disorders were previously seen as contraindications against the use of interferon alfa and ribavirin in patients with chronic hepatitis C, as cases of mania and psychosis induced after initiation of treatment or upon withdrawal have been reported8,9. Current guidelines state that all HCV-infected patients should receive treatment, with patients with life-threatening conditions not expected to survive beyond 1 year being the only exclusion7.

The case highlights the importance of an integrated model for clinical management of patients with comorbid HCV infection and bipolar disorder. An interdisciplinary approach and education of the patient are required in order to ensure the adequate treatment and compliance and prevent fatal outcomes10.

Institution where the study was conducted: Department of Psychiatry and Clinical Psychology Medical University of Sofia, St. G. Sofiyski 1, Sofia 1431, Bulgaria


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Received: July 19, 2018; Accepted: October 30, 2018

Address for correspondence: Desislava Ignatova, Department of Psychiatry and Clinical Psychology, Medical University Sofia, St. G. Sofiyski 1, Sofia 1431, Bulgaria. Telephone: +359887825250, fax. +35929230680. E-mail:

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