In Reply: We welcome Dr. Rifai's comments on our study of the prevalence of viral infections, including hepatitis C, in a psychiatric hospital in Greece. We favor the idea of screening for HCV infection among hospitalized psychiatric patients primarily because we found a high prevalence of this infection in our study hospital, as other studies have found worldwide, and for other reasons that we discuss below.
Proper consideration of underlying mental or psychiatric disease, including substance abuse, is warranted before treatment for chronic HCV infection is initiated. Current HCV therapies with pegylated interferon alpha and ribavirin can cause adverse neuropsychiatric events (depression, suicidal ideation, irritability, and mania) and other troubling symptoms (fatigue, sleep disorders, and appetite disorders).
The American Association for the Study of Liver Diseases has recommended screening for groups with a high prevalence of HCV infection and has stated that antiviral treatment for chronic hepatitis C, coupled with counseling and psychiatric pretreatment, is a valid option for psychiatric patients (1). Recent trials demonstrated sustained virologic response with pegylated interferon alpha and ribavirin for a substantial proportion (>50%) of "difficult-to-treat" psychiatric patients when a multidisciplinary team was employed (2,3).
Many factors, apart from psychiatric ones, determine the eligibility of an HCV-positive patient for antiviral treatment (2). Some of the HCV genotypes do not readily respond to treatment, and physicians await more potent therapies in the near future. For some patients, the decision to treat, which balances presumed effectiveness against potential adverse events, can be deferred until better therapies become clinically available (1).
Apart from antiviral treatment, several approaches can improve the course of chronic hepatitis C disease once it is diagnosed. Vaccination against hepatitis A and B is one approach, because superinfection with these viruses can accelerate liver disease or even lead to fulminant liver failure. Avoidance of alcohol and hepatotoxic drugs is also paramount. Use of benzodiazepines, for example, can exacerbate hepatic encephalopathy among patients with cirrhosis. The dosage of several medications must be adjusted for patients with hepatic insufficiency. Monitoring for the development of cirrhosis or its complications can also be of value.
The value of infection control for HCV in psychiatric hospitals arises from the fact that the mode of HCV transmission is cryptogenic in approximately 50% of cases. Sharing a common residence presents the risk of using the same objects for personal hygiene, including razors and toothbrushes, and HCV can be transmitted by such practices. Inflicted injuries can also be of concern in this regard.
Beyond issues of eligibility of psychiatric patients for antiviral treatment, potential effectiveness of such treatment, and prevention of virus transmission, we believe that identifying patients with HCV infection in a psychiatric hospital can help improve their overall medical and psychiatric management. We agree, however, with Dr. Rifai that the issue of screening for hepatitis C in this setting is multifaceted and merits further investigation.
1.Ghany MG, Strader DB, Thomas DL, et al: Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 49:1335–1374, 20092.Schaefer M, Hinzpeter A, Mohmand A, et al: Hepatitis C treatment in "difficult-to-treat" psychiatric patients with pegylated interferon-alpha and ribavirin: response and psychiatric side effects. Hepatology 46:991–998, 20073.Alvarez-Uria G, Day JN, Nasir AJ, et al: Factors associated with treatment failure of patients with psychiatric diseases and injecting drug users in the treatment of genotype 2 or 3 hepatitis C chronic infection. Liver International 29:1051–1055, 20094.Freedman K, Nathanson J: Interferon-based hepatitis C treatment in patients with pre-existing severe mental illness and substance use disorders. Expert Review of Anti-infective Therapy 7:363–376, 2009