William R. Breakey

The Epidemiology of Alcohol, Drug, and Mental Disorders among Homeless Persons.

This article describes recent research on the prevalence of alcohol, drug, and mental (ADM) disorders and the characteristics of homeless substance abusers and persons with mental illness. Methodological problems in homelessness research are reviewed, particularly in relation to definitions of homelessness and sampling- and case-ascertainment methods. Prevalence rates of ADM disorders are much higher in homeless groups than in the general population. As is true of homeless people in general, homeless substance abusers and mentally ill persons are characterized by extreme poverty; underutilization of public entitlements; isolation from family, friends, and other support networks; frequent contact with correctional agencies; and poor general health. Knowledge of these disadvantages should be used to advocate for better services to prevent homelessness and support homeless people.

Mental health and social characteristics of the homeless: a survey of mission users.

Selected mental health and social characteristics of 51 homeless persons drawn as a probability sample from missions are compared to those of 1,338 men aged 18-64 years living in households from the NIMH Epidemiologic Catchment Area survey conducted in Eastern Baltimore. Differences between the two groups were small with respect to age, race, education, and military service but the differences in mental health status, utilization patterns, and social dysfunction were large. About one-third of the homeless scored high on the General Health Questionnaire which measures distress. A similar proportion had a current psychiatric disorder as ascertained by the Diagnostic Interview Schedule (DIS), with the homeless exhibiting higher prevalence rates in every DIS/DSM III diagnostic category compared to domiciled men. Homeless persons reported higher rates of hospitalization than household men for both mental (33 per cent vs 5 per cent) and physical (20 per cent vs 10 per cent) problems but a lower proportion received ambulatory care (41 per cent vs 50 per cent). Social dysfunction among the homeless was indicated by fewer social contacts and higher rates of arrests as adults than domiciled men (58 per cent vs 24 per cent), including multiple arrests (38 per cent vs 9 per cent) and felony convictions (16 per cent vs 5 per cent). Implications of these findings are discussed in terms of research and health policy.

Schizophrenia, aids and the decision to prescribe haart: Results of a national survey of hiv clinicians

SUMMARY Individuals with schizophrenia are at risk of developing HIV and are known to experience barriers to optimal medical care. Our goal was to determine, among a cohort of HIV clinicians, whether or not the diagnosis of schizophrenia affected the clinical decision to offer highly active antiretroviral therapy (HAART) to AIDS patients. This is a cross-sectional study of a random, national sample of HIV experts drawn from the membership of the American Academy of HIV Medicine. Participants were mailed a self-administered questionnaire with a case vignette of a new onset AIDS patient and were specifically asked whether or not they would recommend HAART treatment. Vignettes were randomly assigned to include a diagnosis of schizophrenia or not. We located 649 clinicians (93%); 347 responded (53.4%). Responders and non-responders did not differ in demographics or work characteristics. Recommendation of antiretroviral treatment did not differ between those who received a case vignette with schizophrenia versus those who did not (95.8% vs. 96.6%, p = 0.69). Compared to those who received a case vignette without schizophrenia, those who received vignettes with schizophrenia were more likely to avoid prescribing efavirenz, a medication with known neuropsychiatric side effects (17.7% vs. 45.5%, p < 0.01), more likely to agree to be helped by a specialist (34.5% vs. 12.9%, p < 0.01), and more likely to recommend directly observed therapy (20% vs.10%, p = 0.01). HIV clinicians recognize the importance of recommending HAART treatment to individuals with schizophrenia and AIDS and avoid using antiretroviral medication with known neuropsychiatric side effects.

Psychiatry, spirituality and religion

Training programs in psychiatry are increasingly offering structured curricula on the interface of religion and psychiatry (Puchalski et al., this issue). After decades of neglecting spirituality and religion in psychiatric discourse, research programs are delineating the relationships between spirituality and health and casting light upon the processes by which spirituality may have positive effects. This issue of the International Review of Psychiatry presents an overview of what is known about the interface between religion and psychiatry with the aim of encouraging further exploration of the issues in scholarship and practice. Most medical specialties are distinguished by their narrow focus on a particular organ system: the heart, the lungs, the skin, the gut, and so forth. In contrast, Psychiatrists broaden the focus. Their area of interest not only includes all organ systems, but also extends to many areas of human experience whose relationship even to the brain, as an organ, is partially understood at best. On a daily basis we help our patients with aspects of their lives that include selfworth, enjoyment, motivation, life goals, achievement, personal fulfillment, and family relationships. Our field of expertise is the disorders of mental life, and psychiatrists use a variety of perspectives to conceptualize these disorders (McHugh & Slavney, 1998). It is surprising, then, that in psychiatric discourse we tend to skirt around spirituality and religion (Neeleman & Persaud, 1995), all the more so in light of evidence that, for most of our patients, religion and spirituality are important motivating and supportive factors (Koenig & Larson, this issue). We consider personal identity, family relationships, guilt, sexuality, work and ambition to be legitimate areas of interest for psychiatry, and appropriate issues for psychotherapy, but spirituality is avoided. For the majority of people in every culture, belief in divine or transcendent reality is an important fact of daily life. This belief determines values and motivations, gives meaning to life and molds behavior. Psychiatrists understand that people do not live in a vacuum—patients and their psychopathology must be understood in terms of the culture in which they live. Social and community psychiatrists, in particular, understand the need for cultural competence if they are to appreciate fully and communicate adequately with patients whose culture differs from their own (Gaw, 1993). But we perhaps do not reflect sufficiently on the extent to which the culture of a group is shaped by the spiritual beliefs and values of its members. We should make efforts to be knowledgeable about the origins of our patients’ culture if we hope to understand their heritage in any depth. Frank & Frank (1991) stress the importance of understanding the assumptive world of a patient in psychotherapy: that set of ideas, beliefs and principles used consciously or unconsciously by the person to provide meaning to the events of his or her life. Religious ideas are important in the formation of many people’s assumptive world.