June 2009
Reviewer: Jeff C. Huffman, MD
Psychosomatics 2009; 50(1):30-37
Background: Hepatitis C (HCV) is an important chronic medical condition that has available treatments. Prior small or uncontrolled studies have found elevated rates of HCV among patients with serious mental illness, but a large, well-controlled prevalence study had not been completed.Methods: This was a cross-sectional study of veterans who received a diagnosis of bipolar disorder (N=65,983) or schizophrenia (N=89,189) from VA providers during fiscal year 2002, using the National Psychosis Registry, an ongoing registry of VA patients who have received such diagnoses. A comparison group of randomly-selected VA patients (N=67,965) without bipolar disorder or schizophrenia was obtained utilizing VA databases; in all three groups, patients had at least three visit-days over the year to ensure adequate opportunity for the HCV diagnosis to be recorded. For all subjects, demographic variables were recorded and presence or absence of a recorded substance use disorder diagnosis was also noted.Results: Unadjusted for covariables, recorded rates of HCV were 8.1% in patients with bipolar disorder, 7.1% in schizophrenia, and 2.5% in the comparison group. When other variables (e.g., age, race, gender, homelessness, substance use disorder, though other SES variables not available) were also considered, having a substance use disorder was the greatest ‘predictor’ of HCV (adjusted odds ratio [OR] of over 5), and patients with bipolar disorder or schizophrenia who did not have a substance use disorder had a small but significant increase in HCV risk (bipolar disorder OR 1.64 [95% confidence interval: 1.51-1.78], schizophrenia OR 1.47 [1.36-1.59]). Patients with co-occurring substance use disorders and bipolar disorder/schizophrenia had the highest risk of all.Discussion: Again, these results are not necessarily surprising, but underscore the high prevalence of HCV—an important and transmissible medical condition—among patients with serious mental illness. Substance abuse certainly is the greatest risk factor, but bipolar disorder and schizophrenia were also associated with HCV above and beyond these effects of substance abuse. It may be the case that impaired judgment/impulsivity associated with these illnesses may lead to behaviors (promiscuity/unprotected sexual activity, using personal care items of infected persons) that might lead to transmission of HCV. Indeed, the fact that HCV was more common in bipolar disorder than in schizophrenia might be related to the impulsivity seen in mania/hypomania. This article also reinforces the utility of electronic medical records, since the VA system’s electronic record has HCV come up in each treatment plan, making it much less likely that this diagnosis (and monitoring of illness) gets lost in the cracks.One might reasonably ask: since there is no definitive cure for HCV, and since a major treatment for HCV (interferon) is not often given to patients with serious mood disorders or psychotic illness due to neuropsychiatric side effects, why is this information important? This is a key question and indeed lowers to some degree the priority of these findings.
However, a focus on primary prevention of HCV in mental health clinics (e.g., screening/education programs) may protect some patients from getting HCV in the first place—this may be especially important given that this population is less likely to get treatment of HCV if they contract this illness. In addition, knowledge of having HCV may motivate some patients to get treatment for substance use disorders, and may allow for education to family and other contacts to avoid transmission of HCV. Finally, with appropriate monitoring for mood and psychotic symptoms, some patients with serious mental illness may be candidates for interferon treatment of their HCV, and psychiatrists may help to advocate for patients when this seems appropriate (e.g., in patients whose illness has been stable, who are reliable in follow-up, and whose HCV illness appears to be leading to hepatic impairment).
So, in short, this report should prompt us to consider checking HCV status on our patients with serious mental illness (especially with a substance use disorder or other risk factors)—and at least as importantly, to check HAV/HBV/HIV status for such patients since they can receive vaccinations for HAV/HBV and treatment for HIV—or to ensure that their general medical physicians are checking for these important medical conditions.