----------------------------------------------------------------- Pubdate: Mon, 21 Jul 2003 Source: Centre Daily Times (PA) Copyright: 2003 Nittany Printing and Publishing Co., Inc. Author: Karen Patterson, The Dallas Morning News HEPATITIS C PLAGUES MENTALLY ILL AT RATE 10 TIMES NATIONAL AVERAGE DALLAS - ( KRT ) - It's as if psychiatric sickness weren't enough of a medical problem. A liver-threatening virus known as hepatitis C particularly plagues the mentally ill. And the standard treatment for the virus can fuel new mental problems or worsen existing ones. As a result, some psychiatrists - often a patient's only regular source of health care - are working to better understand their patients' treatment troubles and viral vulnerabilities. "There is a huge proportion of patients with schizophrenia and other chronic illnesses, in hospitals and out, who have chronic hepatitis C infection," Dr. Andrew Angelino said this spring in San Francisco, at a meeting of the American Psychiatric Association. His talk was titled: "Hepatitis C Infection: The Next Psychiatric Epidemic." Hepatitis C is taking a dramatic toll overall. Up to 10,000 U.S. deaths this year will be caused by liver disease resulting from infection with the virus. That figure, scientists say, could triple over the next 20 years. Although the virus is found in about 1.8 percent of Americans, it infects almost 20 percent of those with severe mental illness, research suggests. That's because people with mental illness or substance abuse problems are exposed to some key risks for the blood-borne virus. In the past, transfusions were a major vehicle for the spread of the virus, which can lurk in the body unrecognized for many years. Some people who caught the virus even decades ago may only now be finding out about it, as liver damage becomes evident. However, the blood supply has been overwhelmingly safe from hepatitis C since the early 1990s. Nowadays, the virus is generally transmitted through the use of intravenous drugs, such as heroin, and accidental needle sticks in health care workers. Sexual transmission is considered uncommon but possible. Injection drug use is responsible for about 70 percent of who's getting infected these days, said Angelino, an associate professor of psychiatry at the Johns Hopkins University School of Medicine. A 2001 study of severely mentally ill people, he noted, found that among those who had the virus, three-quarters were intravenous drug users. "Hepatitis C is really a psychiatric illness," Dr. Peter Hauser, clinical director of mental health at the Portland VA Medical Center, said in an interview. "New infections are caused increasingly by IV drug use. So that immediately puts it into the realm of psychiatry, or more generally, mental health." In research published last month, scientists scrutinized the connections between substance abuse, hepatitis C infection and severe mental illness. Drug use - particularly any history of needle use - was a major concern, although use of crack cocaine was also linked to higher hepatitis C risk. ( In prompting users to shrug off inhibitions, crack may encourage other high-risk behaviors, the scientists reasoned. ) The research, part of a multistate project called the Five-Site Health and Risk Study, noted that people with severe mental illness may be less able to afford their own drug needles or supplies to clean them. And they might not be able to learn to sterilize the paraphernalia or take part in needle exchanges, the scientists wrote in the journal Psychiatric Services. Impairments in thinking could also make it harder for some psychiatric patients to practice safe sex, project researchers noted. And such patients may have trouble recognizing their developing liver condition or affording a doctor's visit for a diagnosis. Other aspects of mental illness, too, may play a role in infection with hepatitis C ( as well as the AIDS virus, for instance ), the scientists wrote. The mentally ill are more likely to live in inner-city areas and to have spent time in jails or psychiatric hospitals - all homes to other high-risk people. The vast majority of people exposed to hepatitis C develop a lifelong infection. Some 70 percent of these chronic infections cause ongoing liver disease, according to the U.S. Centers for Disease Control and Prevention. Up to 20 percent of the chronically infected ultimately develop cirrhosis - scarring that is so severe it inhibits liver function - and about 3 percent develop liver cancer. Alcohol abuse can make matters worse.

The standard treatment for chronic hepatitis C is a combination of two drugs: alpha interferon ( as an injection ) and ribavirin ( in pill form ). The problem is, the regimen is extremely difficult to tolerate, even for the mentally hardy. Ribavirin, for instance, can cause anemia, leading to fatigue. And interferon can cause deep depression and cognitive problems, as well as severe physical ailments. "Every shot gives you something like a horrible flu," said Angelino, noting that interferon had been required three times a week but a new version of it is needed only weekly. Yet staying on the medicine as long as possible boosts its chance of success, he said. "In my little world, you are going to be asked to ... drag people kicking and screaming through 48 weeks of treatment." Because fighting hepatitis C is an arduous and expensive proposition, experts have worried that the mentally ill and substance abusers may not be up to the task. For instance, the CDC has advised treatment only after an addicted patient has been "clean" for six months. The thinking is that still-addicted patients are less likely to adhere to treatment, more likely to struggle with side effects and more likely to risk reinfection through dangerous habits, Angelino said. But he disagrees with that rationale, pointing out that there are all sorts of illnesses, such as diabetes and high blood pressure, where treatment isn't denied even though patients often don't adhere to it. Besides, he said, some evidence suggests that drug abusers and psychiatric patients stick with interferon treatment just fine, even when the interferon exacerbates existing depression. Meanwhile, the Physicians' Desk Reference, a manual for prescription drug use, indicates that people with a history of depression should not be candidates for interferon treatment. This irritated, and motivated, Hauser. "When you look at the data," he said, "there's nothing in the literature that suggests we should be doing one thing or the other, treating or not treating these people." Withholding treatment from patients is not something to be done without hard evidence, Hauser said. "Interferon is the only chance they have for getting their hepatitis C in remission." Moreover, said Angelino, depression often accompanies hepatitis C even without the influence of interferon. In fact, depression itself might be a risk factor for getting the virus, he suggested. "Quite possibly major depression leads patients to behaviors they wouldn't ordinarily do ... behaviors that put you at high risk of infection," Angelino said. More research funding is needed to explore the risks and benefits of treating patients' depression along with their liver disease, said Hauser, associate director of the Northwest Hepatitis C Resource Center, affiliated with the Portland VA clinic. "We really must begin to consider the whole person rather than just the liver," he said, adding that mental health care workers may be the best people to coordinate such care. "I think mental health providers have a very important role, a role that really hasn't been accentuated or examined." Mental health clinics are the primary avenue to the health care system for many people with severe mental illness, experts have noted. The Five-Site team supports integrated treatment of mental disorders and substance abuse to best fight addictions, and thus battle hepatitis C. Psychiatrists can be invaluable in detecting and preventing such infections, in helping people manage treatment and in getting myriad untreated patients ready for care, Hauser said. By treating a patient's alcoholism, for example, "we will make a difference; we will improve the outlook for their liver disease," he said. "Psychiatrists need to take some ownership."