Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis
Open accessAbstract
BACKGROUND: Although people with serious mental illnesses have a high risk of contracting blood-borne viral infections, sexual health has largely been neglected by researchers and policy makers involved in mental health. Failure to address this shortcoming could increase morbidity and mortality as a result of undetected and untreated infection. We did a systematic review and meta-analysis to estimate the prevalence of blood-borne viral infection in people with serious mental illness. METHOD: We searched the Cochrane Library, Medline, Embase, PsycInfo, CINAHL, and DARE for studies of the prevalence of HIV, hepatitis B virus, and hepatitis C virus in people with serious mental illness, published between Jan 1, 1980, and Jan 1, 2015. We group prevalence data by region and by virus and estimated pooled prevalence. We did a sensitivity analysis of the effect of study quality on prevalence. FINDINGS: After removal of duplicates, we found 373 abstracts, 91 of which met our eligibility criteria. The prevalences of blood-borne viral infections in people with serious mental illness were higher than in the general population in places with low prevalence of blood-borne viruses, such as the USA and Europe, and on par with the general population in regions with high prevalence of blood-borne viruses (Africa for HIV and southeast Asia for hepatitis B virus and hepatitis C virus). Pooled prevalence of HIV in people with serious mental illness in the USA was 6·0% (95% CI 4·3-8·3). Sensitivity analysis showed that quality scores did not significantly affect prevalence. INTERPRETATION: People with serious mental illness are at risk of blood-borne viral infections. However, because of methodological limitations of the studies the prevalence might be overestimated. Serious mental illness is unlikely to be a sole risk factor and risk of blood-borne viral infection is probably multifactorial and associated with low socioeconomic status, drug and alcohol misuse, ethnic origin, and sex. Health providers should routinely discuss sexual health and risks for blood-borne viruses (including risks related to drug misuse) with people who have serious mental illness, as well as offering testing and treatment for those at risk. FUNDING: Wellcome Trust.
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There is evidence of decreased access to appropriate oral health care in a range of psychiatric diagnoses including depression, anxiety, substance use disorder and severe mental illness.
“In the area of oral health, there is also evidence of decreased access to appropriate care in a range of psychiatric diagnoses including depression, anxiety, substance use disorder and severe mental illness.113,114”
From The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness (2019) · cites this paper as [113]
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Inflammatory Biomarkers and Risk of Schizophrenia
Hartwig, F. P., Borges, M. C., Horta, B. L., Bowden, J., & Smith, G. D. (2017) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2017.3191 · Cited by 299 · see citing works
Noncommunicable diseases among HIV-infected persons in low-income and middle-income countries
Patel, P., Rose, C. E., Collins, P. Y., Nuche‐Berenguer, B., Sahasrabuddhe, V. V., Peprah, E. K., Vorkoper, S., Pastakia, S. D., Rausch, D. M., & Levitt, N. S. (2018) · AIDS · doi:10.1097/qad.0000000000001888 · Cited by 270 · see citing works
Roncero, C., Buch-Vicente, B., Martín-Sánchez, Á. M., Álvarez-Navares, A. I., Andrés-Olivera, P., Gamonal-Limcaoco, S., Lozano-López, M. T., Aguilar, L., Sánchez-Casado, F., & García-Ullán, L. (2022) · Gastroenterología y Hepatología · doi:10.1016/j.gastrohep.2022.06.005 · Cited by 230 · see citing works
Public mental health: required actions to address implementation failure in the context of COVID-19
Campion, J., Javed, A., Lund, C., Sartorius, N., Saxena, S., Marmot, M., Allan, J., & Udomratn, P. (2022) · The Lancet Psychiatry · doi:10.1016/s2215-0366(21)00199-1 · Cited by 177 · see citing works
Interventions and approaches to integrating HIV and mental health services: a systematic review
Chuah, F. L. H., Haldane, V. E., Cervero‐Liceras, F., Ong, S. E., Sigfrid, L., Murphy, G. A. V., Watt, N. F., Balabanova, D., Hogarth, S., Maimaris, W., et al. (2017) · Health Policy and Planning · doi:10.1093/heapol/czw169 · Cited by 160 · see citing works
Hepatitis C virus infection, and neurological and psychiatric disorders – A review
Yarlott, L., Heald, E., & Forton, D. M. (2016) · Journal of Advanced Research · doi:10.1016/j.jare.2016.09.005 · Cited by 134 · see citing works
Evaluation of Brain-Body Health in Individuals With Common Neuropsychiatric Disorders
Tian, Y., Biase, M. A. D., Mosley, P. E., Lupton, M. K., Xia, Y., Fripp, J., Breakspear, M. J., Cropley, V., & Zalesky, A. (2023) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2023.0791 · Cited by 96 · see citing works
Hassan, L., Peek, N. B., Lovell, K., Carvalho, A. F., Solmi, M., Stubbs, B., & Firth, J. (2021) · Molecular Psychiatry · doi:10.1038/s41380-021-01344-2 · Cited by 75 · see citing works
Intervening for HIV prevention and mental health: a review of global literature
Collins, P. Y., Velloza, J., Concepcion, T. L., Oseso, L. N., Chwastiak, L., Kemp, C. G., Simoni, J. M., & Wagenaar, B. H. (2021) · Journal of the International AIDS Society · doi:10.1002/jia2.25710 · Cited by 68 · see citing works
Bauer‐Staeb, C., Jörgensen, L., Lewis, G., Dalman, C., Osborn, D., & Hayes, J. (2017) · The Lancet Psychiatry · doi:10.1016/s2215-0366(17)30253-5 · Cited by 65 · see citing works
Beiser, M. E., Smith, K. F., INGEMI, M., Mulligan, E., & Baggett, T. P. (2019) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2019.03.017 · Cited by 65 · see citing works
Jeon, H., Kwon, J. S., Park, S., & Shin, J. (2021) · The British Journal of Psychiatry · doi:10.1192/bjp.2020.251 · Cited by 61 · see citing works
Hughes, E. A., Edmondson, A., Onyekwe, I., Quinn, C., & Nolan, F. (2017) · International Journal of Mental Health Nursing · doi:10.1111/inm.12402 · Cited by 58 · see citing works
Self-citationJain, M. K., Thamer, M., Therapondos, G., Shiffman, M. L., Kshirsagar, O. S., Clark, C., & Wong, R. J. (2018) · Hepatology · doi:10.1002/hep.30171 · Cited by 48 · see citing works
Gray, R. J., & Brown, E. (2016) · International Journal of Mental Health Nursing · doi:10.1111/inm.12296 · Cited by 47 · see citing works
Clinically Relevant Interactions between Atypical Antipsychotics and Anti-Infective Agents
Spina, E., Barbieri, M. A., Cicala, G., & de Leon, J. (2020) · Pharmaceuticals · doi:10.3390/ph13120439 · Cited by 41 · see citing works
Samji, H., Yu, A., Kuo, M. E., Alavi, M., Woods, R. R., Alvarez, M., Dore, G. J., TYNDALL, M. W., Krajden, M., & Janjua, N. Z. (2017) · Journal of Hepatology · doi:10.1016/j.jhep.2017.06.025 · Cited by 44 · see citing works
A Global Systematic Review of Hepatitis C Elimination Efforts through Micro-Elimination
Lazarus, J. V., Picchio, C. A., Byrne, C. J., Crespo, J., Colombo, M. G., Cooke, G., Dore, G. J., Grebely, J., Ward, J. W., & Dillon, J. F. (2022) · Seminars in Liver Disease · doi:10.1055/a-1777-6112 · Cited by 43 · see citing works
Gastrointestinal and liver disease in patients with schizophrenia: A narrative review
Grant, R. K., Brindle, W. M., Donnelly, M. C., McConville, P. M., Stroud, T. G., Bandieri, L., & Plevris, J. N. (2022) · World Journal of Gastroenterology · doi:10.3748/wjg.v28.i38.5515 · Cited by 39 · see citing works
Goodlet, K. J., Zmarlicka, M. T., & Peckham, A. M. (2018) · CNS Spectrums · doi:10.1017/s109285291800113x · Cited by 40 · see citing works
Rates of hepatitis B and C in patients with schizophrenia: A meta-analysis
Lluch, E., & Miller, B. J. (2019) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2019.10.007 · Cited by 37 · see citing works
Holden, J., Shamseddeen, H., Johnson, A. W., Byriel, B., Subramoney, K., Cheng, Y., Saito, A., Ghabril, M., Chalasani, N., Sachs, G. A., et al. (2020) · Journal of Palliative Medicine · doi:10.1089/jpm.2019.0501 · Cited by 37 · see citing works
McGinty, E. E., Presskreischer, R., Breslau, J. A., Brown, J. D., Domino, M. E., Druss, B. G., Horvitz-Lennon, M. V., Murphy, K. A., Pincus, H. A., & Daumit, G. L. (2021) · Psychiatric Services · doi:10.1176/appi.ps.202000768 · Cited by 36 · see citing works
Hasan, A., Falkai, P., Lehmann, I., & Gäebel, W. (2020) · Deutsches Ärzteblatt international · doi:10.3238/arztebl.2020.0412 · Cited by 37 · see citing works
Quinn, C., Platania‐Phung, C., Bale, C., Happell, B., & Hughes, E. A. (2018) · International Journal of Mental Health Nursing · doi:10.1111/inm.12452 · Cited by 33 · see citing works
Self-citationHepatitis C models of care: approaches to elimination
Biondi, M. J., & Feld, J. J. (2019) · Canadian Liver Journal · doi:10.3138/canlivj-2019-0002 · Cited by 31 · see citing works
Lorenzini, K. I., & Girardin, F. R. (2019) · Liver International · doi:10.1111/liv.14283 · Cited by 31 · see citing works
Harney, B. L., Brereton, R., Whitton, B., Pietrzak, D., Paige, E. K., Roberts, S. K., Birks, S., Saraf, S., Hellard, M. E., & Doyle, J. (2021) · Journal of Viral Hepatitis · doi:10.1111/jvh.13487 · Cited by 29 · see citing works
Management of schizophrenia and comorbid substance use disorders: expert review and guidance
Neyra, A., Parro-Torres, C., Ros‐Cucurull, E., Machado, I. C., Echarri, E., & Torrens, M. (2024) · Annals of General Psychiatry · doi:10.1186/s12991-024-00529-7 · Cited by 28 · see citing works
Page, K., Yu, M. A., Cohen, J., Evans, J. L., Shumway, M., & Riley, E. D. (2017) · BMC Public Health · doi:10.1186/s12889-017-4102-5 · Cited by 26 · see citing works
Place Still Matters: Racial/Ethnic and Geographic Disparities in HIV Transmission and Disease Burden
Brawner, B. M., Guthrie, B. J., Stevens, R. C., Taylor, L., Eberhart, M. G., & Schensul, J. J. (2017) · Journal of Urban Health · doi:10.1007/s11524-017-0198-2 · Cited by 27 · see citing works
Impacts of hepatitis B and hepatitis C co-infection with tuberculosis, a prospective cohort study
Feleke, B. E., Feleke, T. E., Adane, W. G., & Girma, A. (2020) · Virology Journal · doi:10.1186/s12985-020-01385-z · Cited by 26 · see citing works
Roble, A. K., Roba, K. T., Mengistie, B., & Kure, M. A. (2021) · International Journal of Women s Health · doi:10.2147/ijwh.s276526 · Cited by 26 · see citing works
Starace, F., Mungai, F., Baccari, F., & Galeazzi, G. M. (2017) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-017-1468-8 · Cited by 26 · see citing works
Sexual health promotion in people with severe mental illness: the RESPECT feasibility RCT
Hughes, E. A., Mitchell, N., Gascoyne, S., Moe‐Byrne, T., Edmondson, A., Coleman, E., Millett, L., Ali, S., Dare, C. R. J., Hewitt, C. E., et al. (2019) · Health Technology Assessment · doi:10.3310/hta23650 · Cited by 25 · see citing works
Self-citationLiver Illness and Psychiatric Patients
Carrier, P., Debette‐Gratien, M., Girard, M. F., Jacques, J., Nubukpo, P., & Loustaud-Ratti, V. (2016) · Hepatitis Monthly · doi:10.5812/hepatmon.41564 · Cited by 25 · see citing works
Girardin, F. R., Painter, C., Hearmon, N., Eddowes, L. A., Kaiser, S., Negro, F., & Vernaz, N. (2021) · JHEP Reports · doi:10.1016/j.jhepr.2021.100279 · Cited by 23 · see citing works
Securing wider EU commitment to the elimination of hepatitis C virus
Wedemeyer, H. H., Tergast, T. L., Lazarus, J. V., Razavi, H. A., Bakoyannis, K., Baptista‐Leite, R., Bartoli, M., Bruggmann, P., Buşoi, C., Buti, M., et al. (2022) · Liver International · doi:10.1111/liv.15446 · Cited by 23 · see citing works
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Ramachandran, J., Budd, S., Slattery, H., Muller, K., Mohan, T. S., Cowain, T., Tilley, E., Baas, A., Wigg, L., Alexander, J., et al. (2018) · Journal of Viral Hepatitis · doi:10.1111/jvh.13056 · Cited by 21 · see citing works
The sexual health and relationship needs of people with severe mental illness
Gascoyne, S., Hughes, E. A., McCann, E., & Quinn, C. (2016) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12317 · Cited by 20 · see citing works
Self-citationManagement of psychiatric disorders in patients with hepatic and gastrointestinal diseases
Menon, V., Ransing, R., & Praharaj, S. K. (2022) · Indian Journal of Psychiatry · doi:10.4103/indianjpsychiatry.indianjpsychiatry_18_22 · Cited by 19 · see citing works
Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City
Cowan, E. A., Dinani, A. M., Brandspiegel, S., O'Brien‐Lambert, C., Zaheer, J., Eiting, E., Loo, G. T., & Calderon, Y. (2020) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2020.09.034 · Cited by 19 · see citing works
Sensitive, Single-Pot, Two-Stage Assay for Hepatitis Viruses
Seok, Y., Yin, Q., Bai, H., & Bau, H. H. (2022) · Analytical Chemistry · doi:10.1021/acs.analchem.1c04480 · Cited by 19 · see citing works
High‐risk sexual behaviours in young people experiencing a first episode of psychosis
Brown, E., Castagnini, E., Langstone, A., Mifsud, N. G., Gao, C. X., McGorry, P. D., Killackey, E. J., & O'Donoghue, B. N. (2022) · Early Intervention in Psychiatry · doi:10.1111/eip.13301 · Cited by 18 · see citing works
Gutiérrez-Rojas, L., Martín, J. J. D. L. G., Buey, L. G., Otano, J. I. U., Mena, Á., & Roncero, C. (2022) · Gastroenterología y Hepatología · doi:10.1016/j.gastrohep.2022.06.001 · Cited by 18 · see citing works
Hassan, L., Sawyer, C. S., Peek, N. B., Lovell, K., Carvalho, A. F., Solmi, M., Tilston, G., Sperrin, M., & Firth, J. (2022) · Schizophrenia Bulletin · doi:10.1093/schbul/sbac118 · Cited by 17 · see citing works
Expert Opinion on Managing Chronic HCV in Patients with Neuropsychiatric Manifestations
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Tennille, J. A., Bohrman, C., Barrenger, S. L., Compton, E., Meduna, E., & Klein, L. A. (2021) · Community Mental Health Journal · doi:10.1007/s10597-021-00838-1 · Cited by 15 · see citing works
Ending HIV, hepatitis B, and hepatitis C: what about people with severe mental illness?
Wainberg, M. L., & Dixon, L. B. (2017) · The Lancet Psychiatry · doi:10.1016/s2215-0366(17)30282-1 · Cited by 15 · see citing works
Increased risk of concurrent hepatitis C among Male patients with schizophrenia
Chiu, Y., Lin, H., Kuo, N., Kao, S., & Lee, H. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.08.036 · Cited by 15 · see citing works
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Global mental health and the ambition to end AIDS by 2030
Abas, M., & O’Cleirigh, C. M. (2018) · The Lancet Psychiatry · doi:10.1016/s2215-0366(18)30385-7 · Cited by 14 · see citing works
“Why Me?” Understanding the HCV Care Continuum Among People With Serious Mental Illness
Arnold, R. M., Machover, H., Wall, M., Ahmadizadeh, I., Potts, W., & Himelhoch, S. S. (2018) · Psychiatric Services · doi:10.1176/appi.ps.201700542 · Cited by 13 · see citing works
Occupational justice and social inclusion in mental illness and HIV: a scoping review protocol
Nhunzvi, C., Langhaug, L. F., Mavindidze, E., Harding, R., & Galvaan, R. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-024049 · Cited by 13 · see citing works
Furness, T., Giandinoto, J., Wordie‐Thompson, E., Woolley, S., Dempster, V., & Foster, K. (2019) · International Journal of Mental Health Nursing · doi:10.1111/inm.12680 · Cited by 13 · see citing works
Compton, M. T., Manseau, M. W., Dacus, H., Wallace, B., & Seserman, M. (2020) · Community Mental Health Journal · doi:10.1007/s10597-019-00532-3 · Cited by 13 · see citing works
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Hépatite C en milieu psychiatrique : un réservoir oublié ?
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The case for prescribing PrEP in community mental health settings
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Self-citationPrevalence of hepatitis C in patients with non-affective psychotic disorders
Cuadrado, A., Cabezas, J., Llerena, S., Salceda, J. F. N., Fortea, J. I., Crespo‐Facorro, B., & Crespo, J. (2020) · Revista Española de Enfermedades Digestivas · doi:10.17235/reed.2020.7278/2020 · Cited by 11 · see citing works
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Self-citationRiano, N. S., Borowsky, H. M., Arnold, E. A., Olfson, M., Walkup, J. T., Vittinghoff, E., Cournos, F., Dawson, L., Bazazi, A. R., Crystal, S., et al. (2021) · Psychiatric Services · doi:10.1176/appi.ps.202000524 · Cited by 11 · see citing works
Catalão, R., Dorrington, S., Pritchard, M., Jewell, A., Broadbent, M. T. M., Ashworth, M. J., Hatch, S. L., & Howard, L. M. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-059257 · Cited by 11 · see citing works
Meacham, M. C., Bahorik, A. L., Shumway, M., Marquez, C., & Riley, E. D. (2018) · AIDS and Behavior · doi:10.1007/s10461-018-2280-5 · Cited by 10 · see citing works
Three Decades and Counting: HIV Service Provision in Outpatient Mental Health Settings
McKinnon, K. M., Satriano, J., Alves-Bradford, J.-M. E., Erby, W. J., Jaafar, F., Simonen, E. H., Gozzo, I. S., Huang, A. N. R., Sposito, J. S., Tao, Z., et al. (2020) · Psychiatric Services · doi:10.1176/appi.ps.201900415 · Cited by 10 · see citing works
Increasing HIV Testing in Inpatient Psychiatry
Shumway, M., Mangurian, C. V., Carraher, N., Momenzadeh, A., Leary, M. R., Lee, E. K., & Dilley, J. (2017) · Psychosomatics · doi:10.1016/j.psym.2017.10.007 · Cited by 9 · see citing works
Tumwakire, E., Hofmeister, A., & Gavamukulya, Y. (2022) · BMC Public Health · doi:10.1186/s12889-022-14128-2 · Cited by 9 · see citing works
Characteristics and Trends in HIV Testing Among Medicaid Enrollees Diagnosed as Having Schizophrenia
Walkup, J. T., Thomas, M. D., Vittinghoff, E., Hermida, R., Crystal, S., Arnold, E. A., Dahiya, P., Olfson, M., Cournos, F., Dawson, L., et al. (2023) · Psychiatric Services · doi:10.1176/appi.ps.20220311 · Cited by 9 · see citing works
Prevalence of HIV in mental health service users: a retrospective cohort study
Heslin, M., Jewell, A., Croxford, S., Chau, C., Smith, S. M., Pittrof, R., Covshoff, E., Sullivan, A. K., Delpech, V., Brown, A. E., et al. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-067337 · Cited by 9 · see citing works
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Emergency department testing is feasible but ineffective to eliminate hepatitis C in Denmark
Wentworth, J. J., Øvrehus, A. L. H., Hansen, J. F., Biesenbach, P., & Christensen, P. B. (2021) · Scandinavian Journal of Infectious Diseases · doi:10.1080/23744235.2021.1962542 · Cited by 8 · see citing works
Wedemeyer, H. H., Marco, V. D., Garcı́a-Retortillo, M., Teti, E., Fraser, C., Morano, L. E., Rodríguez‐Tajes, S., Acosta-López, S., O’Loan, J., Milella, M. S., et al. (2022) · Viruses · doi:10.3390/v14112493 · Cited by 8 · see citing works
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Asif, A., Ayub, S., Komal, A., Noor, S., & Jalal, U. (2019) · Pakistan Journal of Medical Sciences · doi:10.12669/pjms.35.2.500 · Cited by 7 · see citing works
Stevens, E. R., Nucifora, K. A., Irvine, M. K., Penrose, K., Robertson, M. M., Kulkarni, S., Robbins, R. S., Abraham, B. K., Nash, D., & Braithwaite, R. S. (2019) · PLoS ONE · doi:10.1371/journal.pone.0215965 · Cited by 7 · see citing works
Hepatitis C Screening Among Medicaid Patients With Schizophrenia, 2002–2012
Thomas, M. D., Vittinghoff, E., Crystal, S., Walkup, J. T., Olfson, M., Khalili, M., Dahiya, P., Keenan, W., Cournos, F., & Mangurian, C. V. (2022) · Schizophrenia Bulletin Open · doi:10.1093/schizbullopen/sgab058 · Cited by 7 · see citing works
Şizofreni hastalarında fiziksel hastalık eş tanılarının değerlendirilmesi
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Hepatitis C virus and hepatitis B virus in patients with schizophrenia
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Hepatitis C Screening in an Underserved U.S. Cohort of Reproductive Age Women
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- Authors
- Hughes, E., Bassi, S., Gilbody, S., Bland, M., & Martin, F.
- Affiliations
- University of Huddersfield (GB)
- University of York (GB)
- Corresponding author
- Hughes, Elizabeth
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2016-01
- Volume
- 3
- Issue
- 1
- Pages
- 40-48
- ISSN
- 2215-0366 (ISSN-L)
- PMC
- PMC4703902
- OpenAlex
- W2178523807
- Cited by
- 272
- References
- 96
- Citations by year
- 2026: 13 · 2025: 25 · 2024: 25 · 2023: 28 · 2022: 37 · 2021: 44 · 2020: 28 · 2019: 29 · 2018: 16 · 2017: 16 · 2016: 11
- FWCI
- 2.18
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- The Lancet Psychiatry (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Huddersfield Repository (University of Huddersfield) (submittedVersion)
- Edinburgh Napier Research Repository (Edinburgh Napier University) (submittedVersion, cc-by)
- Huddersfield Research Portal (University of Huddersfield) (submittedVersion, cc-by)
- Funders
- Wellcome Trust (reference 097829)
- Topics
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
- Health Sciences › Medicine › Hepatology › Hepatitis C virus research
- Keywords
- HIV, hepatitis B virus, hepatitis C virus, blood-borne viral infections, severe mental illness, prevalence, sexual health, substance abuse, drug abuse, alcohol abuse, socioeconomic status, risk factors
- MeSH terms
- Mental Disorders, Hepatitis B, Hepatitis C, Humans, Severity of Illness Index, HIV Infections, Prevalence
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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