imageSevere mental illness and certain chronic bloodborne infections are often linked,1 creating unique considerations for patient care. Behaviors commonly observed in mental illness, such as substance abuse or unprotected sex, are risk factors for HIV or chronic hepatitis B (CHB).2 Alternately, patients may experience anxiety or depression after receiving news that they are infected with a chronic disease.

Research has shown that among individuals with mental illness, the prevalence of CHB is almost 5 times higher than that of the general US adult population.1 Rosenberg and colleagues provided one explanation for the high prevalence of CHB among individuals with severe mental illness: substance use disorder, notably from injection drug use, increases the risk for certain chronic bloodborne infections from 2.2-fold to more than 31-fold.1

David Bernstein, MD

David Bernstein, MD, chief of hepatology and liver diseases, North Shore Long Island Jewish Health System, Manhasset, New York, sees a full range of patients with liver disease, including those with CHB infections.

Following a positive CHB diagnosis, patients are referred to Dr. Bernstein for care. “The younger patients tend to be in denial, and sometimes after the discussion they tend not to come back, or don’t come back at the prescribed intervals. It’s hard to come to terms with a chronic disease at a healthy young age,” he said.

Individuals with co-occurring chronic bloodborne infections and mental illness may face considerable barriers to care, such as inconsistent motivation toward treatment, lack of transportation or housing, and inadequate insurance coverage or poverty.3,4 Moreover, mental health providers may be reluctant or unable to provide care for these diseases, or they may assume patients already receive treatment elsewhere, a situation exacerbated by fragmented health care.3,4

Unfortunately, these patients often require multidisciplinary care. A study in Hong Kong conducted among patients with CHB at an infectious disease clinic found that 32% (48 of 149) had a psychiatric condition: 16% were diagnosed with depressive disorders and 14% had anxiety disorders.5 In this Hong Kong study, only 10% of patients with a psychiatric disorder were receiving treatment for their condition.5 Not having someone to confide feelings of distress to was a risk factor for depressive disorders (odds ratio [OR], 3.718, 95% confidence interval [CI], 1.166-11.851; P<0.03).5 Not knowing how one became infected with HBV was a risk factor for overall psychiatric disorders (OR, 3.828, 95% CI, 1.624-9.024; P<0.002).5

Because there is no cure for CHB and treatment is usually long-term, Dr. Bernstein encourages a strong support network for his patients. “The best thing that primary care physicians can do is tell people there’s nothing to be ashamed of. How they got [CHB] and how long they’ve had it are questions that [primary care physicians] may not be able to answer. However, once identified, the disease is treatable, not curable, and treatment can prevent or delay long-term complications,” he said.

Stigma also may impose a mental health toll. For example, some Asian countries include screening for CHB in the job-hiring process, particularly for government positions.6,7 In China, discrimination against individuals infected with CHB is not uncommon.7

“Culturally, Asian Americans may not talk about their disease state to other people, including their families,” said Dr. Bernstein. “When anyone hears ‘hepatitis,’ they’re thinking of sex and drugs, and a lot of people within the Asian population don’t understand that they could have acquired CHB from their mother at birth.”

Fortunately, China has taken great strides to end prejudice against HBV.7 And despite the mental anguish that these individuls may face, Dr. Bernstein offers messages of hope. “Ultimately, try to spin it as a positive. You find [the virus], you can do something about it. It’s when you don’t know about it that there can be problems, both for the patient and for others,” he said.


  1. Rosenberg SD, Goodman LA, Osher FC, et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health. 2001;91(1):31-37.
  2. Essock SM, Dowden S, Constantine NT, et al; Five-Site Health and Risk Study Research Committee. Risk factors for HIV, hepatitis B and hepatitis C among persons with severe mental illness. Psychiatr Serv. 2003;54(6):836-841.
  3. Willenbring ML. Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches. AIDS. 2005;19(suppl 3):S227-S237.
  4. Rosenberg SD, Brunette M, Oxman T, et al. The STIRR model of best practices for blood-borne diseases among clients with serious mental illness. Psychiatr Serv. 2004;55(6):660-664.
  5. Chan H, Yu CS, Li SY. Psychiatric morbidity in Chinese patients with chronic hepatitis B infection in a local infectious disease clinic. East Asian Arch Psychiatry. 2012;22(4):160-168.
  6. Asian Liver Center at Stanford University.​media/​publications/​Business/​English.pdf. Accessed December 12, 2013.
  7. Webster TJ. Ambivalence and activism: employment discrimination in China. VJTL. 2011;44(643):643-709.

Mental Health Resources: HBV Support Groups


This free online support group brings together patients living with HBV, as well as family members and friends who are involved in the therapeutic alliance. Registered users can participate in 4 different discussion boards, maintain a daily diary, and share informative or personal stories by writing an article.


The free online HBV community provided through DailyStrength allows registered users to keep a personal journal, join discussion forums, post video journals, share photos, and create and track goals.


On the American Liver Foundation website, users can search for support groups and other resources in their area by various liver-related topics (eg, hepatitis B) and state/region.

DISCLAIMER—These organizations are listed for reference only and are not intended to imply endorsement of or by Gilead.