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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Hepatitis C – The Next Psychiatric Epidemic?

By Andrew Angelino, M.D. and Glenn Treisman, M.D., Ph.D.

[Winter 2002; Vol. 28, No. 2; Pg 12-13]

If the AIDS epidemic has taught us anything, it is that there’s more to behavior than simple cognitive choice. Most people in the United States have been informed how to prevent contracting HIV. So who is still getting HIV? Many are people who are vulnerable to risky behaviors because of psychiatric illness. Who are they getting it from? HIV infected persons who are vulnerable to spread the virus, many because of psychiatric illnesses. As the epidemic rolls into its third decade, the fuel for the engine may have something to do with mental illnesses that interfere with a patient’s ability to conform to “safe” behavior. As psychiatrists, we must be prepared to provide the rationale for the necessity of mental health services for patients with serious infectious illnesses like HIV.

Major depression is a common psychiatric diagnosis, and serves as the prime example of how a mental illness may endanger lives by means other than suicide. A depressed patient may have lost many of the rewards that life has to offer due to profound anhedonia. This person may be at risk for trying drugs, some of which, like cocaine, produce powerful reinforcement in the brain. This may lead to further drug use and possible infection. Hopeless, depressed patients may not see a future, and therefore not take precautions to use sterile needles. Depression has been shown to be a major risk factor for non-adherence to highly-active antiretroviral therapy (HAART), leading to a higher titer of virus in the community available for transmission.

Schizophrenia and chronic mental illness also increase risk for infection, as evidenced by remarkably high HIV prevalence. Francine Cournos and her colleagues have shown that patients with chronic mental illness in New York engage in high-risk sexual and drug use behaviors, and that sexual activity may be coercive or involve exchange of sex for money, drugs or other goods. Even patients educated and aware of safer behavior often are unable to practice such behavior.

Patients with extraverted personality styles (predominantly DSM-IV cluster B) are not so motivated by the avoidance of a future consequence when there is an immediate reward to be had. This presents a particular risk when confronted with powerful reinforcers like cocaine or sex. The promise of the reward may be so great that the long-term consequences of not following safety precautions do not even register.

Drug addiction can lead to desperate measures in the face of withdrawal. Patients in the throes of addiction will resort to many unsafe behaviors to keep from feeling sick, such as sex for drugs or sharing a dose from a contaminated needle. Sometimes, while intoxicated, they may “slip” in a carefully practiced routine and not clean the needle well, or pick up someone else’s works.

Lastly, patients with difficulties arising out of their life circumstances are at risk for spreading the illness. Children raised in impoverished areas by a single parent might be at risk for diminished structure in their environment, and thus, might do poorly in school. They may see people in their neighborhoods involved in drug trafficking, making quite a living without education. One thing leads to another, and a demoralized teen quits school and pursues a life fraught with peril.

These descriptions are generalizations about how psychiatric disorders might lead to HIV infection. But the proof of the pudding is in the eating, as they say. One study showed a higher lifetime prevalence of major depression for subjects at risk for HIV infection who presented for serological testing, regardless of test results (almost 29% for men and 44% for women, compared to 2.3-4.4 % for men and 4.9-8.7% for women from the ECA samples). Other studies show a high prevalence of HIV in chronic mentally ill patients – 5.5% of an inpatient sample in New York, 75% of whom had schizophrenia. Several studies have shown high rates of personality disorders and extraverted traits in patients coming for STD or HIV treatment,. In the psychiatric-substance use disorder detox program at Johns Hopkins Bayview Medical Center, 49% of the first 150 patients did not graduate high school, 79% were unemployed and only 9% were in a stable relationship, demonstrating how life circumstances contribute to (and are affected by) risk behavior.

Using the HIV epidemic as a model for the interaction for psychiatric disorder and infectious disease risk, let us now turn our attention to hepatitis C.

There are four million people in the United States who are infected with hepatitis C-- four times as many as infected with HIV, and half of the patients infected with HIV are also infected with hepatitis C. More importantly, hepatitis C is easier to transmit with needle use than HIV, and there is currently epidemic spread in the IV drug-using population. The virus is often undetected for several years, as it seems to cause very low levels of liver damage until a critical mass is achieved. Further, since hepatitis produces very nonspecific symptoms at the onset, it is often overlooked very early in its course, and written off as other common ailments. Once the virus is very active, hepatic damage can be severe. On the positive side, treatment of hepatitis is now possible with the combination of interferon and ribavirin, and polyethylene glycol-linked interferon (which means longer half-life and less injections) has recently been approved. Combination treatment can result in eradication of the virus from the body, and such patients are probably “cured.” Treatment of hepatitis C with interferon alpha has increased the need for effective psychiatric care in these clinics as interferon induces a depressive syndrome in 30-40% of patients treated.

One disturbing element of this epidemic, however, is that it is being addressed by gastroenterologists and infectious disease specialists who have little experience in psychiatry, and who have decided that having a psychiatric disorder is a contraindication to interferon treatment. This means that the patients most likely to have and to spread hepatitis C are prevented from being treated for it. Furthermore, some patients who are treated and cured of their hepatitis C infection may, because of untreated psychiatric problems, continue high-risk behaviors and become re-infected. The experience doctors have is with patients who were infected by transfusion, while the current epidemic is related to mental illness driven behaviors. In our work, not one of the 12% of the patients presenting to the Bayview psychiatric detoxification who had hepatitis C (by report, we did not test for the infection) had ever had a transfusion.

Hepatitis C, along with hepatitis B and HIV, should be a topic of discussion for every psychiatrist treating any patient with any disorder that might conceivably put that patient at risk. Clinics that combine psychiatric services with medical services for the treatment of HIV-infected patients, such as the Moore Clinic at Johns Hopkins, have been extremely successful at improving the overall care of patients with mental illness vulnerabilities, and such clinics need to be developed for hepatitis patients. In this era of curious opinion that psychiatrists can be replaced by non-physician practitioners, expansion in this realm can only serve to demonstrate the unique ability of doctors to care for the whole patient, and thus improve our standing in the community of medicine. Psychiatrists who demonstrate cogent argument as to the value of psychiatry in the art of medicine, as is exemplified in these infectious diseases, are of great benefit to our profession.

Footnoted references available upon request.

Dr. Treisman and Dr. Angelino direct the Psychiatry Service at The Johns Hopkins Hospital Moore Clinic.