Hepatitis C plagues mentally
ill at rate 10 times national average
BY KAREN PATTERSON
The Dallas Morning News
Mon, Jul. 21, 2003
... "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."
... 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."
... 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."
© 2003, The Dallas Morning News
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