Hepatitis C plagues mentally ill at rate 10 times national average

... "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."

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