Karen McKinnon

HIV seroprevalence among people with severe mental illness in the United States: a critical review.

The authors reviewed all studies in the peer-reviewed literature reporting HIV seroprevalence among people with severe mental illness in the United States, which varied from 4.0% to 22.9%. Findings across samples suggest that seroprevalence varies with geographic concentration of HIV and presence of comorbid psychoactive substance use disorders, but is consistently high. Unsafe sex, drug injection, and noninjected drug use were associated with infection, and in most studies women were as likely to be infected as men. Seroprevalence also varied with age and ethnicity, but not psychiatric diagnosis. The authors review questions and methodological issues important to future studies.

Schizophrenia and comorbid human Immunodeficiency Virus or Hepatitis C Virus

Patients with schizophrenia are at significantly increased risk for infection with human immunodeficiency virus (HIV), hepatitis C virus, or both. Several factors underlie this increased risk, including substance abuse and high-risk sexual behavior. Although being sexually active tends to be less common among patients with schizophrenia than among nonpsychotic individuals, patients with schizophrenia who are sexually active are more likely than nonpsychotic individuals to engage in high-risk behavior. Many patients with schizophrenia have inadequate knowledge about the risks of HIV, but delivering factual information is not likely, by itself, to bring about behavioral changes that reduce the risk of exposure and transmission. Comorbidity of schizophrenia and life-threatening viral illnesses incurs a worse prognosis for both conditions. Nevertheless, effective pharmacotherapy exists, and antipsychotics and highly active antiretroviral treatments for HIV can be used together successfully. The clinical challenge is to encourage adherence to treatment and to coordinate the clinical services needed to address the diverse psychiatric and medical problems that coexist in this population.

HIV, syphilis, and hepatitis B and C prevalence among patients with mental illness: a review of the literature

A limited number of studies worldwide have investigated the prevalence of HIV, syphilis, and hepatitis B and C infection among psychiatric patients. However, prevalence of these infections in the population with chronic mental illness has not been clearly established. Most of the published papers are from developed countries and have derived from relatively small and non-representative samples. We performed a systematic review of the published literature to identify studies on these infectious diseases within psychiatric populations in Brazil and other developing countries. Overall, prevalence rates varied from 0% to 29% for HIV; 1.6% to 66% for HBV; 0.4% to 38% for HCV; and 1.1% to 7.6% for syphilis. Several risk factors were identified and discussed, although sampling limitations restrict the generalization of study findings. This review highlights the lack of information on the prevalence of sexually transmitted diseases and their associated factors among persons with chronic mental illness and identifies gaps in the knowledge base in both developing and developed countries.

A Model for Adapting Evidence-based Behavioral Interventions to a New Culture: HIV Prevention for Psychiatric Patients in Rio de Janeiro, Brazil

As in other countries worldwide, adults with severe mental illness in Brazil have elevated rates of HIV infection relative to the general population. However, no HIV prevention interventions have been tested for efficacy with psychiatric patients in Brazil. We conducted participatory research with local providers, community leaders, patient advocates, and patients using an intervention adaptation process designed to balance fidelity to efficacious interventions developed elsewhere with fit to a new context and culture. Our process for adapting these interventions comprised four steps: (1) optimizing fidelity; (2) optimizing fit; (3) balancing fidelity and fit; and (4) pilot testing and refining the intervention. This paper describes how these steps were carried out to produce a Brazilian HIV prevention intervention for people with severe mental illness. Our process may serve as a model for adapting existing efficacious interventions to new groups and cultures, whether at a local, national, or international level.

HIV-1 infection at two public psychiatric hospitals in New York City.

Seroprevalence for HIV-1 was anonymously evaluated between November 1989 and July 1991 among severely mentally ill patients at two public psychiatric hospitals in New York City. The study population consisted of new admissions and long-stay patients aged 18-59. Of 1116 eligible patients, usable samples were obtained from routine blood drawings on 971 (87%). Seroprevalence was comparable among men (5.2%) and women (5.3%). Age did not predict seropositivity. Men with a recorded history of homosexual behaviour or injection drug use were, respectively, 1.8 and 2.0 times more likely to be seropositive than men without these histories. Women with a recorded history of injection drug use were 4.0 times more likely to be seropositive than women without such a history. Ethnicity was not predictive for men, but Black women were 2.4 times more likely to be HIV-1 positive than non-Black women. Severely mentally ill inpatients had a substantial rate of HIV-1 seropositivity, indicating a need for additional testing, education and counselling efforts for this population.

Research on HIV, AIDS, and severe mental illness: recommendations from the NIMH National Conference.

We summarize the recommendations for research that emerged from a NIMH-sponsored Conference on HIV, AIDS, and Severe Mental Illness. Recommendations are made in four areas, namely, epidemiology of HIV infection, epidemiology of sexual and drug-use risk behaviors, risk reduction and transmission prevention, and treatment of infected persons. This research is urgently needed to adequately respond to the AIDS epidemic among people with severe mental illness.

Perceived Mental Illness Stigma Among Youth in Psychiatric Outpatient Treatment

This research explores the experiences of mental illness stigma in 24 youth (58.3% male, 13-24 years, 75% Latino) in psychiatric outpatient treatment. Using Link and Phelan’s (2001) model of stigmatization, we conducted thematic analysis of the interview texts, examining experiences of stigma at individual and structural levels, in addition to the youths’ social-psychological processes. Youth in psychiatric treatment acknowledged that their larger cultural context holds pejorative viewpoints toward those with mental illness and reported experiences of stigma within their families and social networks. Our results also offer insight into the social-psychological processes of stigma, highlighting how labeling may influence their self-concept and the strategies in which youth engage to manage a stigmatized identity. We discuss differences in stigma experiences by gender, age, and diagnosis. Findings provide new information on the stigma experiences of youth in psychiatric treatment and suggest that a multilevel approach to reduce stigma is warranted.

A Lifetime Alcohol or Other Drug Use Disorder and Specific Psychiatric Symptoms Predict Sexual Risk for HIV Infection Among People With Severe Mental Illness

To clarify the relative contributions of psychiatric and alcohol or other drug (AOD) use disorders on sexual risk for HIV infection among people with severe mental illness, we interviewed 195 psychiatric patients. In the prior 6 months the 100 (51%) sexually active patients had a mean of 3.9 sex partners and 27.5 sex episodes; 49% had known high-risk sex partners; 34% used AOD during sex; 28% traded sex; and 59% never used condoms. The likelihood of being sexually active decreased with age and cognitive symptoms, increased with excited symptoms, and was more than twice as high for African-American patients as others. The likelihood of trading sex increased with cognitive symptoms. The likelihood of having a sexually transmitted disease history (reported by 32% of all patients) increased with depressed/anxious symptoms, a lifetime AOD use diagnosis (obtained for 57% of patients), and was more than twice as high for African-American patients as others. HIV prevention interventions that address specific psychiatric conditions and developmental and cultural issues of psychiatric patients should be developed and tested.

HIV risk behaviors among outpatients with severe mental illness in Rio de Janeiro, Brazil

We conducted the first study to examine rates of sexual activity, sexual risk behaviors, sexual protective behaviors, injection drug use (IDU), needle sharing, and knowledge about HIV/AIDS among outpatients with severe mental illness (SMI) in Rio de Janeiro, Brazil. Using a measure with demonstrated reliability, we found that 42% of 98 patients engaged in vaginal or anal sex within the past three months. Comorbid substance use disorder was significantly associated with sexual activity. Only 22% of sexually active patients used condoms consistently, despite having better HIV knowledge than those who were sexually abstinent. Overall, 45% of patients reported not engaging in any HIV protective behaviors. There were no reports of drug injection. Adults with SMI in Brazil are in need of efficacious HIV prevention programs and policies that can sustain these programs within mental health treatment settings.

HIV Service Provision for People with Severe Mental Illness in Outpatient Mental Health Care Settings in New York

SUMMARY People with severe mental illness evidence significantly higher rates of HIV infection than the general population in the United States. Frequently, the only access to health care for this population is through their outpatient mental health care providers. In order to determine how these providers were dealing with the increased risk of HIV infection among this group, a survey of all licensed and certified outpatient mental health care centers in New York State was conducted. The data were compared to a similar previous survey conducted in 1997.