A decade or more ago, psychiatrists and mental health professionals began to see an alarming number of cases of infection with human immunodeficiency virus (HIV) among patients with psychiatric and substance abuse disorders. Indeed, the issue was significant enough that in the following years, the phenomenon led to the subspecialty HIV/AIDS psychiatry.
Today, physicians are beginning to recognize there is a far more common viral predator seemingly targeting that same population of patients—the hepatitis C virus (HCV). And a series of new research reports indicates it has its own devastating consequences.
"If you look at our research, you see that both in the literal sense of prevalence and in the sense of disease burden, hepatitis C actually turns out to be a much bigger problem than HIV," said Stanley Rosenberg, Ph.D., a professor of psychiatry at New Hampshire-Dartmouth Psychiatric Research Center at Dartmouth Medical School.
Rosenberg headed a multicenter research group focusing on HIV and HCV infection in persons with severe mental illness. The research led to the publication of a special section containing numerous reports on the topic in the June issue of the APA journal Psychiatric Services.
In an extensive interview with Psychiatric News, Rosenberg detailed how the group began looking into the issue of HIV infection in patients with severe mental illness some seven to 10 years ago.
"The big issue then was what appeared to be a huge prevalence of HIV among those with severe mental illness," Rosenberg said. "We reviewed a great deal of literature, and there were certainly some things that made even the reporters of [the data] say that we really need to be cautious here," before determining whether there is any conclusive link between HIV and psychiatric illness.
The early studies, Rosenberg added, largely reported data from people who lived in known high-risk geographic areas and engaged in behaviors known to heighten risk.
"We were concerned because a lot of the studies had information drawn only from blood samples, for example, of people who were going into the hospital," he said. That made his team wonder whether the study samples were representative of the overall population. "It simply wasn’t very well linked by age, by gender, by race or ethnicity, or by risky behaviors. So the whole thing really—HIV in the severely mentally ill—was still a mystery."
Rosenberg and his colleagues set out to do a larger study of the problem "in which we could link all of the variables. What were the histories of the people: drug abuse, risky sexual behaviors, and so on—whatever the issues could be that might account for the apparent connection between severe mental illness and HIV," Rosenberg said. "There simply is no inherent thing about having a psychotic disorder that is going to give you HIV. So we wanted to know where the real links were."
In addition to attempting to determine prevalence of the viruses, Rosenberg and his colleagues also tried to identify key risk factors for infection among those with serious mental illness.
The five centers studied a mixture of smaller, more rural populations (New Hampshire and North Carolina) and larger, urban populations (Hartford and Bridgeport, Conn., along with Baltimore). Investigators assessed a total of 969 individuals with severe mental illness for the presence of HIV or hepatitis. In addition, each was interviewed regarding sociodemographic characteristics, substance abuse, risk behaviors for sexually transmitted diseases (STD), STD history, and general health care.
The investigators confirmed in the Psychiatric Services special section that "risk for HIV infection is markedly elevated for persons with severe mental illness." The HIV prevalence was 3.1 percent, nearly nine times the overall rate for the general U.S. population.
"The most surprising finding," Rosenberg wrote in the lead article, "was that HCV prevalence was 19.6 percent of, or approximately 11 times, the overall population rate."
More specifically, the group found that the prevalence of HCV was higher in metropolitan areas (25.4 percent) than in the rural areas studied (10.6 percent).
Fully 30 percent of patients assessed were positive for either hepatitis, HIV, or both, and nearly half of patients with a dual diagnosis (a severe mental illness and a substance abuse disorder) were positive. Of those patients who acknowledged injecting drugs of abuse at least once, close to two-thirds tested positive for HCV.
"What we found in this study," Rosenberg stressed, "was that people whose blood was HIV positive knew they had HIV. But the people that were positive for HCV were shocked and blown away; they didn’t know they had it, and they didn’t know what it was. They were simply asymptomatic."
And therein, Rosenberg emphasized, lies the danger.
"If they don’t know they are infected, they can’t get the help that they need—either from the mental health side or from a liver specialist—to get treatment to begin with or to proceed through treatment," Rosenberg said.
Treatment is involved, long term, and expensive, Rosenberg noted. However untreated, HCV can progress to cirrhosis, liver failure, and liver cancer.
Best practice recommendations for the treatment of people with HCV involve extensive treatment—lasting up to one year—with pegylated interferons (Roche’s Pegasys and others) and an antiviral medication, most commonly ribaviran (Schering Plough’s Rebetol and others). But complicating the matter even further are reports that interferon treatment is associated with neuropsychiatric side effects, including depression (see story on page 39).
The more fundamental issue, however, is identifying patients who need treatment to begin with, Rosenberg said.
"Surely, what you are supposed to do is screen people for risk factors—drug abuse and risky sexual behaviors—and then ultimately order lab tests, if warranted," he noted.
Rosenberg and his colleagues, in a Psychiatric Services paper with Mary Brunette, M.D., an assistant professor of psychiatry at Dartmouth, as lead author recommended a list of fundamental services that all psychiatrists should incorporate in their practices:
• Screen all patients for substance abuse and sexual risk factors.
• Test for HIV and hepatitis B and C.
• Immunize against hepatitis A and B.
• Counsel patients on risk reduction and pursue substance abuse treatment.
• Refer and support infected patients for medical assessment and treatment.
"Within psychiatry though," Rosenberg said, treatment of hepatitis in patients with mental illness "is still controversial due largely to the treatment burden being high with side effects and complications as well as cost. All of these things together make it pretty formidable; so if you are a busy psychiatrist, you may not have much of a sense of either familiarity or confidence in detection and treatment of hepatitis C."
The Psychiatric Services special section is posted on the Web at http://ps.psychiatryonline.org under the June issue. ▪