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."

For more about hepatitis C, visit www.cdc.gov/nci dod/diseases/hepatitis/c/
index.htm or call 1-888-443-7232 (toll-free). About 4 million
Americans are infected with the hepatitis C virus, the leading cause
of liver transplants. Four in five will develop a lifelong chronic
infection.

Some 20 percent of chronic infections will lead to cirrhosis. People
with severe mental illness are about 11 times as likely to be infected.

Among them, the men are twice as likely to have the virus as the
women.

The severely mentally ill who are infected are far less likely to have
a regular source of medical care than those who aren't.

SOURCES: Five-Site Health and Risk Study/Psychiatric Services, June
2003; American Journal of Public Health, 2001; Centers for Disease
Control and Prevention

[sidebar]

TREATING THE LIVER, MONITORING THE MIND

In the June issue of Psychiatric Annals, devoted to hepatitis C,
experts Jennifer M. Loftis and Dr. Peter Hauser offer these
recommendations for doctors to manage depression during interferon
treatment for the virus:

_Obtain a complete psychiatric history, including a screening for
depression.

_Work with mental health care providers.

_Treat any pre-existing depression before starting interferon
treatment.

_Evaluate patients on interferon at least every two weeks for the
development of depression.

_If depression arises, treat with antidepressants known as selective
serotonin-reuptake inhibitors and continue to monitor mood symptoms.