Individuals with severe mental illness (SMI) are at particular risk for the transmission of blood-borne infections and the implications for prevention and treatment are profound. This article reviews the literature findings on the relationship between SMI and hepatitis C virus (HCV), describes findings comparing individuals with and without SMI on their HCV serostatus, and discusses the implications of these findings for hepatitis prevention and intervention.
BACKGROUND AND SIGNIFICANCE
It is estimated there are approximately 4 million people infected with HCV making it the most common chronic bloodbome infection in the United States.1 A majority of those infected develop chronic active hepatitis and are infectious to others. Approximately one-fifth of infected individuals without intervention develop cirrhosis, hepatocellular carcinoma, or both. The number of annual deaths due to HCV liver failure has been predicted to rise from less than 9,000 in 2003 to greater than 28,000 by 2008.2 While approximately 1 .8% of the general population is HCV infected,1 recent data collected by a National Institute of Mental Health-funded multi-site study suggests that 20% of adults with SMI are infected - an almost 1 1-fold increase.3 Moreover, most people with SMI are unaware of their HCV infection.3 Access to and use of somatic care among people with SMI is deficient.4 Understanding the reasons for high prevalence fates of HCV among individuals with SMl is critical to the design of effective prevention and intervention strategies.
Demographic Characteristics of the Serious Mental Illness (SMI) and Soup Kitchen Samples
The association between SMI and human immunodeficiency virus (HlV) infection was noticed in the late 1980s and replicated by several research groups.5 It was not until the late 1990s that a similar awareness of the increased rates of HCV among individuals with SMI was documented.3 In an analysis of risk factors for HCV, Essock et al. identified geographic location, gender, and substance abuse as associated risks for HCV infection above and beyond the more direct activities of risky drug and sexual practices.6
There is a strong relationship between substance use disorders and HCV infection. An estimated 60% of HCV transmission in thé United States is attributed to injection drug use.7 The most efficient routes of transmission for HCV are either through the transfusion of contaminated blood products or the use of contaminated drug paraphernalia,8-9 and these routes are even more efficient than for HTV.
The context of an individual's substance use affects probability of contracting HCV. Urban centers with high rates of substance use disorders and HCV infection increase the incidence of new infections among drug users; however, studies of HCV and injection drug use independent of locale have shown prevalence rates between 65% and 90%.y·10 In a Baltimore, Maryland study of injection drug users with less than 1 year of intravenous drug use 64.7% were HCV positive.11
The high rate of co-occurring substance use disorders among individuals with SMI, coupled with its association with risky drug use behaviors for HCV transmission, warrants special consideration. Studies of individuals with SMI consistently demonstrate high prevalence rates of co-occurring substance use disorders. One half of individuals diagnosed with schizophrenia meet lifetime criteria for a substance use disorder.12 Furthermore, individuals with schizophrenia are 4.6 times more likely to meet substance use disorder criteria and those with affective disorders are 2.6 times more likely.13 With the most direct route Of HCV transmission being intravenous injection, it is alarming that individuals with SMI are estimated to have lifetime intravenous drug use rates between 5% and 35%. H In their study of SMI, Rosenberg et al. found that the presence of a substance use disorder, lifetime intravenous drug use, sniffing or snorting drugs, trading sex for drugs, gifts, or money, and sharing needles were all significantly correlated (P < .001) with the seroprevalence of HCV infection.3
In addition to injection drug use, people with SMI appear to be at higher risk for blood-borne infections through other routes of transmission. Multiple sexual partners, high-risk partners, infrequent condom use, homosexual activity in males, trading sex for material gain, and engaging in sex while using psychoactive substances have all been documented as risk behaviors frequently found within SMI populations.14·15 These practices will affect future rates of hepatitis B (HBV) and HIV infection in addition to HCV. Although the types of behavior leading to hepatitis infection in people with SMI are similar to those in the general population, understanding the specific sources of their increased rate of infection is of paramount importance.
Modeling has failed to identify specific features of psychiatric impairment that put individuals with SMI at risk, for infection.16 It appears that substance abuse and related high-risk drug practices may explain most of the variance in rates. The use of crack cocaine among people with SMI has emerged as a particularly risky behavior for this population.17 Factors such as socioeconomic status and residence in urban settings may have a profound influence on exposure and subsequent risk. Using a soup kitchen comparison group provides an opportunity to compare rates of infection and rates of high-risk behavior to individuals with SMI.
Infectious Disease Rates of Samples
A parent study investigated 969 subjects with SMI at five community sites in the United States. Sampling and main research procedures for that study have been reported previously,318 This article discusses a subset of subjects from that parent study receiving services from a community mental health center in Baltimore, Maryland (N = 141) and a contemporaneous sample of non-SMI individuals drawn from a Baltimore soup kitchen (N = 304).
STUDY SUBJECTS FOR SMI GROUP
Outpatient clients with a chart diagnosis of schizophrenia spectrum disorder were randomly selected from a pool of patients within the University of Maryland Lead Agency community mental health programs. A total of 527 potential subjects were identified and 200 patients were selected and approached. Women were oversampled to achieve equal numbers to men for analytic purposes. Recruitment began on June 4, 1997 and was completed on September 14, 1998. Because potential subjects refused or were unavailable, the researchers moved further down the randomized list to obtain a sample of 141 (75 male, 66 female) subjects. During the recruitment period, 43 of the potential subjects stopped receiving outpatient services, and 8 died.
STUDY SUBJECTS FOR SOUP KITCHEN SAMPLE
Over a 1-year period from April 24, 1998 to April 7, 1999, 304 subjects were recruited as they queued up for lunch at a soup kitchen in inner city Baltimore. Using a random selection process, potential subjects were asked to participate in a health risk survey and blood sampling, in return for which they would be compensated for their time. If subjects were interested, a trained research assistant recorded the individual's name and demographics (gender, race, and age). Willing subjects were screened for serious mental illnesses after eating their meal.
The screening consisted of seven questions from the Psychiatric Epidemiology Research Interview19 screen out any person who possibly suffered from SMI, including schizophrenia, schizoaffective disorder, and bipolar disorder; four questions from the Beck Depression Inventory20 to identify individuals with major affective disorders; and two questions (psychiatric hospitalizations, psychotropic medication use) used in the state of Maryland to define serious mental illness.
During the 1-year enrollment period, 861 individuals at the soup kitchen were approached. Of this group, 39% passed the mental health screening, 36% were screened out, 11% did not return to be screened, and 13% on further consideratiofi, refused to participate. To obtain equal numbers of men and women, women were oversampled at the soup kitchen.
Following informed consent, both groups of subjects responded to standardized interviews, including questions on sociodemographic characteristics, substance use, and specific risk behavior for blood-borne diseases (eg, needle use)· Subjects also received pretest counseling for HIV/ AIDS, and then provided blood specimens through venipuncture. Details regarding laboratory analyses of blood can be found in Rosenberg et al.3 All subjects were paid a participation fee of $35 and attempts were made to provide subjects with test results, post-test counseling, and (when appropriate) referral for treatment with medical providers. These procedures and all informed consent forms were approved by the University of Maryland School of Medicine Institutional Review Board.
Current alcohol and drug use (cocaine, cannabis) disorders were identified with the Dartmouth Assessment of Lifestyle Instrument.21 This is an 18item screening tool with high classification accuracy for current abuse of alcohol, cannabis, and cocaine, it was specifically developed and validated for individuals with SMIs and serves as a proxy measure for substance use disorders in our soup kitchen sample. It may underreport opiate abuse and dependence. Drug and sexual practices were assessed using a survey of high-risk activity.
Table 1 (page 396) shows that there were no differences between the two groups in terms of gender, race, and educational status. The soup kitchen sample is significantly younger.
Table 2 (page 397) shows that rates of the measured infectious diseases are higher in the soup kitchen sample. Hepatitis C virus infection is significantly greater in the soup kitchen sample compared to the community mental health sample P - .00Oi). The differences between HBV and HLTV infection in the two groups are significant (P = .014 and P = .003, respectively).
Table 3 (page 399) shows high rates of high-risk drug and sexual behavior in both groups. Compared to the SMl group, the souo kitchen, cample, repotted significantly higher rates of lifetime needle use, sharing needles with friends, and sniffing drugs. Although not significantly different, both groups endorsed high rates of risky sexual behavior. As measured by the Dartmouth Assessment of Lifestyle Instrument, the soup kitchen sample also had significantly higher rates of both drug and alcohol use disorder. In preliminary analyses, high-risk behaviors in both groups were associated with HCV infection. Among those who were HCV-positive 72% of the SMI sample endorsed a lifetime use of needles, compared with 89% of the soup kitchen sample and 88% of the SMI sample with HCV reported lifetime sharing of needles, compared to 91% of the HCV-positive soup kitchen sample.
This data supports previous research showing that individuals with SMI are at high risk for HCV, as well as HBV and HIV infection. The fact that a contemporaneous group of subjects drawn from an urban soup kitchen had such high rates of infection is alarming. Impoverished residents in our urban cities, will carry the burden of these infections for years to come. Related health care costs will be staggering.
Risk factors associated with HCV seroprevalence in other studies were greater in the soup kitchen sample.3·6 Additional analyses is required to ascertain if these behaviors have a relatively higher risk for HCV infection in either population. Attendance at the soup kitchen defines a population of individuals without access to adequate food and shelter. Homelessness may prove to be a significant factor associated with HCV risk. The high rates of substance use disorders in both samples are consistent with previous research and suggest a nexus for the spread of infectious diseases exists in these urban centers. Outreach., testing, and prevention, ajvd treatment interventions are paramount to address this public health issue among our poorest citizens.
The vectors for infection for individuals with SMI appear to be the same as those for non-SMI populations. Contextual factors explain the apparent high risk rather than a specific risk associated with psychiatric illness, such as poor judgment or cognitive impairment.16 When compared to a contemporaneous sample of impoverished individuals without mental illnesses living in the same geographic area and with similar socioeconomic backgrounds, individuals with SMI actually had lower rates of HCV infection - albeit high compared to the general population.
The study has several limitations. One must be concerned about the comparability of two samples that are not equivalent on several key dimensions. For example, the younger soup kitchen sample had fewer years of exposure to the high base rates of infectious disease within Baltimore and, if matched in age to the SMI sample, may have had even higher rates of infection. In addition to démographie differences, critical variables such as rates of homelessness, experiences with jail and prison settings, or exposure to trauma must be considered in comparing rates of infection between the two groups. These factors have been associated with rates of HCV infection in previous studies6 and may be independent of whether a person has a mental illness or not. Subsequent modeling using logistic regression analyses needs to be conducted to assure the interpretation of these preliminary findings.
Prevalence of Risky Behavior Between Soup Kitchen Patrons and People With Serious Mental Illness (SMI)
The overall effect that having a SMl has on the risk of HCV infection may be masked by our selection of a SMI sample that is actively engaged in treatment. We know from the Surgeon General's 1999 report on mental illness that two thirds of individuals with diagnosable mental illnesses do not seek treatment.22 Untreated people with SMI may have clinical features that do influence HCV risk. Lastly, because the data were collected in a crosssectional survey, causality should not be inferred from our results.
These limitations notwithstanding, the increased use of drugs and alcohol among people with SMI remains a challenging clinical issue. In addition to the multiple health risks, including HCV, individuals with co-occurring disorders have also been found to be noncompliant with treatment and rehabilitation plans.23 The resulting morbidity and mortality has required modification of traditional approaches to care for the individual with co-occurring mental and substance use disorders.
Recent studies documenting the elevated rates of HCV infection among the SMI only serve to highlight the need for effective substance abuse interventions as a way of preventing future infection and the spread of infection. Integrated treatment approaches to curb the use of alcohol and drugs for this population have been endorsed broadly and are recognized as an evidenced-based practice. Integrated interventions are characterized as a coherent package of appropriate mental health and substance abuse services provided by the same clinician, or team of clinicians, working at the same locale.24 These approaches include specific attention to risk behavior associated with contracting and spreading infectious diseases. Psychoeducational material must be tailored to accommodate the cognitive and behavioral impairments associated with serious mental disorders. Unfortunately, too few people have access to integrated mental health and substance abuse treatment.22
So too, modifications to thè treatment of physical illnesses within the SMl population must be considered. Because the majority of people with SMI receive their mental health care within the specialty mental health service sector,22 they often have separate and, at times, inadequate contact with either the general health service or emergency service sectors. Swartz et al. found that individuals with SMI who were HCV-positive were far less likely to have regular somatic care than those without HCV infection.25 This makes coordination of medical care an important consideration. There needs to be both better identification of the somatic issues within the mental health sector and better linkage to medical care providers. Procedures for screening and assessment of blood-borne pathogens must be incorporated into psychiatric and medical care treatment plans with this vulnerable population.
Current research is investigating the implementation of screening and testing methods within outpatient mental health settings along with targeted case management to achieve higher rates of compliance with HCV follow-up and treatment.26 To improve access and compliance, once the person with SMI is identified as having HCV, the ongoing followup evaluation and treatment is assigned to specially trained case managers. Without identification and effective treatment interventions, individuals with SMI are likely to swell the numbers of people with chronic and fatal illnesses.
Loftis and Hauser (page 385) demonstrated that the psychiatric side effects of HCV therapies can be addressed through targeted psychopharmacologic interventions. These interventions should be available to people with pre-existing SMI as well. Just as Goldsmith (page 369) suggests the need for careful monitoring of any patient with HCV, this is extremely important for individuals with SMI. With the preponderance of negative symptoms among the SMI patient population, comprehensive baseline evaluations should guide subsequent psychopharmacologic interventions.
Once more, attention to compliance, psychiatric monitoring, and the provision of community supports, including child care and transportation, may be necessary to achieve the positive outcomes found in tiie HCV treatment of individuals without a SMI. Integrated and coordinated approaches require significant resources, yet effective interventions could have significant cost offsets if somatic and psychiatric morbidity are reduced.
High rates of HCV are well documented among the SMI. The factors associated with these rates have more to do with high-risk behaviors than issues specific to psychiatric impairment. Nonetheless, specialized responses are required to prevent and treat HCV among people with SMI because of their cognitive, behavioral, and socioeconomic limitations.
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Demographic Characteristics of the Serious Mental Illness (SMI) and Soup Kitchen Samples
Infectious Disease Rates of Samples
Prevalence of Risky Behavior Between Soup Kitchen Patrons and People With Serious Mental Illness (SMI)