Mental illness

Mental illness

CORRESPONDENCE 4 5 ultrasonsography in utero and subsequent handedness and neurological development. BMJ 1993; 307: 159–64. Salvesen KÅ, Jacobsen G...

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CORRESPONDENCE

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ultrasonsography in utero and subsequent handedness and neurological development. BMJ 1993; 307: 159–64. Salvesen KÅ, Jacobsen G, Vatten LJ, Eik-Nes SH, Bakketeig LS. Routine ultrasonography in utero and subsequent growth during childhood. Ultrasound Obstet Gynecol 1993; 3: 6–10. Bakketeig LS, Eik-Nes SH, Jacobsen G, et al. Randomised controlled trial of ultrasonographic screening in pregnancy. Lancet 1984; 2: 207–11.

Mental illness Sir—Angela Pirisi, in her Dec 2, news item1 asks what had kept mental illness from getting its due recognition as a costly, disabling form of disease. In endeavouring to answer this question, she mentions ignorance, isolation, and social stigma as leading contenders. This summation is followed by stating that one of the biggest challenges “remains the public’s lack of awareness regarding mental disorders and available treatments.” I agree that the inhibiting factors which Pirisi lists are important, but they are not, in my view, those which actually deter people from seeking psychiatric help. The greatest barrier lies in the gap between the patient’s expectations of what help he or she actually experiences at their hands. The dogged adherence of psychiatry to the medical model is largely to blame, and this is an issue all over the moredeveloped world. What patients are asking for is that inner conflicts and difficulties be listened to, heard, and understood. Medication might help in some cases, but frequently it is seen by the patients as a substitute for the doctor’s time, undivided attention, and understanding. Most of this misinterpretation stems from the extraordinary fact that psychodynamics and psychotherapy still form a minimum part of the training of psychiatrists in many places. Trainees themselves would welcome more training in individual and group psychotherapy. If some of the present efforts being expended on changing attitudes towards mental illness by our Royal College were put into rescuing psychotherapy from its position as the Cinderella of the treatment options available to patients we might begin to see a change. The quotation from the Australian study which showed that people viewed many standard psychiatric treatments as more harmful than helpful,2 seems to support my view. Also, while I agree with P S Wang3 that efforts to overcome mental health barriers should generally begin in the doctor’s office, Pirisi does not make it

THE LANCET • Vol 357 • April 28, 2001

clear as to what changes are necessary. Doctors cling to the notion that their job is to diagnose and to treat rather than to heal. There are, of course, other changes in the whole structure of mental health care that have taken place in the past 50 years, many of which have been of dubious benefit to patients. However, I make a plea for the integration of medical and psychodynamic psychiatry.4 Ronald Sandison Park View, 28 The Southend, Ledbury, Herefordshire HR8 2EY, UK 1 2

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Pirisi A. Mental illness cries for attention. Lancet 2000; 356: 1908. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. Mental health literacy: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166: 182–86. Wang PS, Gilman SE, Guardino M, et al. Initiation of and adherence to treatment for mental disorders: examination of patient advocate group members in 11 countries. Med Care 2000; 38: 926–36. Sandison R. A century of psychiatry, psychotherapy and group analysis. Jessica Kingsley, 2001.

HIV-1 progression in hepatitis-C-infected drug users Sir—G Greub and Colleagues (Nov 25, p 1800)1 describe an association between clinical progression of HIV-1 disease and death and hepatitis C virus (HCV) infection in patients on highly active antiretroviral therapy. Camilla Graham and Margaret Koziel, in their Dec 2 commentary,2 speculate about possible immunological mechanisms underlying the reduction in increase of CD4 cell count observed in the same patients. We think many factors must be assessed before confident conclusions are reached. First, the role of infections with other viruses must be ruled out. In particular, current or past infection with hepatitis G virus, which is frequently detected in intravenous drug users, is associated with higher CD4 lymphocyte counts and slower progression of HIV-1 disease in coinfected people.3 By contrast, TT virus co-infection, also frequently seen in HIV-1-infected patients, has a negative, independent effect on HIV-1 disease progression, since high TT viraemia is associated with shortened survival and lowered CD4 T-cell counts. Second, some subpopulations of CD8 lymphocytes seem to have a powerful role in predicting progression

to AIDS in intravenous drug users; in particular, the CD8 CD38 cell percentage has much added value over the CD4 count alone in predicting HIV-1 clinical progression. Measurement of this CD8 T-lymphocyte subpopulation seems, therefore, important in studies of HIV-1 disease progression. Third, perhaps the clearest significant association is between HIV-1 disease progression, death, and CD4-cell loss, and HLA phenotypes. The HLA AI,B8,DR3 phenotype has a negative prognostic influence, whereas HLA B27 has a positive one.4 Finally, CD4-cell decline and progression to AIDS are lower in intravenous drug users who frequently borrow injecting equipment.5 This finding is apparently in contrast to those of Greub and colleagues (although seen in the era before highly active antiretroviral therapy), since borrowing injecting equipment should be associated with a high rate of HCV infection. Hepatitis G virus coinfection might be an explanation. In conclusion, we think all the above factors must be investigated and taken into account for studies including the time before and after the introduction of highly active antiretroviral therapy, since they all contribute to the complex interaction between the immune system and HIV. Any one viral coinfection will not have an effect. *Francesca Cainelli, Maria Serena Longhi, Ercole Concia, Sandro Vento Department of Infectious Diseases, University of Verona, via Vasco de Gama 7, 37138 Verona, Italy 1

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Greub G, Ledergerber B, Battegay M, et al. Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfections. Lancet 2000; 356: 1800–05. Graham CS, Koziel JM. Why should hepatitis C affect immune reconstitution in HIV-1-infected patients? Lancet 2000; 356: 1865–66. Yeo AE, Matsumoto A, Hisada M, Shih JW, Alter HJ, Goedert JJ. Effect of hepatitis G virus infection on progression of HIV infection in patients with hemophilia: Multicenter Hemophilia Cohort Study. Ann Intern Med 2000; 132: 959–63. Brettle RP, McNeil AJ, Bums S, et al. Progression of HIV: follow-up of Edinburgh injecting drug users with narrow seroconversion intervals in 1983–85. AIDS 1996; 10: 419–30. Mientjes GH, van Ameijden EJ, van den Hoek AJ, Gouldsmit J, Miedema F, Coutinho RA. Progression of HIV infection among injecting drug users: indications for a lower rate of progression among those who have frequently borrowed injecting equipment. AIDS 1993; 7: 1363–70.

Sir—G Greub and colleagues’ data1 add new evidence for treating chronic hepatitis C as soon as possible in HIV-

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