Sexual Risk Behaviors Among People With Schizophrenia and Their Association With Psychiatric and Situational Factors
Most studies of sexual risk behavior among people with psychiatric disorders have not linked behaviors to biological outcomes, but risk for HIV transmission is potentially very high; the role of sexual transmission in HCV infection is weak and poorly understood even in the general population.
Sexual risk behaviors among people in psychiatric treatment are common, with interview studies in Brazil, Canada, Spain, and the United States revealing that a majority of patients were sexually active with a partner in the past year (Acuda and Sebit 1996; Carey et al. 1997; Chuang and Atkinson 1996; Oliveira 1997). Moreover, reports of multiple sex partners are common among sexually active psychiatric patients (Chuang and Atkinson 1996). The sexual activity of people with serious mental illness also is characterized by a lack of condom use in a majority of sexual occasions, a finding true for both men and women (Carey et al. 1997; Cournos et al. 1993; Hanson et al. 1992).
Few studies have differentiated risks by psychiatric diagnosis, so critical information is lacking about patients with schizophrenia-spectrum illnesses; however, data on diagnostic and symptom contributions to sexual risk behavior are beginning to appear. Being sexually active has been found to be associated with a diagnosis of schizophrenia but not with bipolar disorder. Trading sex for money or drugs was more than three times as likely among patients with schizophrenia than among those with other diagnoses, and more than five times as likely among those with certain positive symptoms such as delusions (McKinnon et al. 1996).
Situational factors also appear to contribute to sexual risk taking. Extended periods of institutionalization in same-sex units in hospitals, shelters, or prisons may foster high-risk same-sex activity, often among those who do not identify themselves as gay or lesbian. This behavior is particularly risky for men. One study that directly compared psychiatric patients with nonpsychiatric groups found that psychiatric patients are more likely to engage in same-sex activity (McDermott et al. 1994).
The best predictor of condom use is having a condom. Institutional obstacles to condom acquisition are another factor likely to impede patients’ initiative and ability to practice safer sex. Making condoms anonymously available to all patients, including inpatients with off-ward privileges or who engage in consensual sex on the ward, has been shown to be a costeffective primary prevention intervention (Carmen and Brady 1990). Sexual victimization, in which there is increased likelihood of unprotected intercourse (Herbert 1995), also has been widely reported by psychiatric inpatients (Goodman and Fallot 1998). Among outpatients, one in eight reported having been pressured, coerced, or forced into unwanted sex in the past year (Carey et al. 1997). Identification of patients in abusive relationships will facilitate their engagement in individual and group interventions to help them practice assertive behaviors and negotiating skills to increase self-protective behaviors, including condom use.
HIV and Hepatitis C in Patients With Schizophrenia
Recurrent institutionalization, homelessness, transient living circumstances, alienation from supportive social relationships, and lack of privacy can all interrupt long-term relationships, reinforcing the tendency to have unfamiliar partners. Studies report that 10% to 16% of psychiatric patients had sex in the past year with someone they had known less than 24 hours (Chuang and Atkinson 1996; Kalichman et al. 1994; Kelly et al. 1992). These conditions also may make changing risk behaviors difficult for people with serious mental illness or may limit sexual opportunities to those that confer greater risk. Unemployment also may contribute to greater sexual risk taking (Acuda and Sebit 1996), possibly through pressures toward engaging in survival sex or commercial sex work. Having a sexually transmitted disease (STD) also renders a person biologically more vulnerable to acquiring subsequent infections when exposed.
Between 9% and 36% of psychiatric inpatients and outpatients are diagnosed with one or more STDs at some time in their lives (Carey et al. 1997; Rosenberg et al. 2001). Moreover, a patient may have an STD without being aware of it, and will likely remain untreated unless screening for STDs is included with other prevention efforts aimed at risk behaviors for sexually transmitted infections.
Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.
- Acuda SW, Sebit MB: Serostatus surveillance testing of HIV-I infection among Zimbabwean psychiatric inpatients in Zimbabwe. Cent Afr J Med 42:254-257, 1996
- American Psychiatric Association: Practice Guideline for the Treatment of Patients with HIV/AIDS. Am J Psychiatry 157 (suppl):1-62, 2000
- Ayuso-Mateos JL, Montanes F, Lastra I, et al: HIV infection in psychiatric patients: an unlinked anonymous study. Br J Psychiatry 170:181-185, 1997
- Barnes R, Felker B, Sloan K, et al: Safety of valproic acid treatment in patients with hepatitis C. Poster presented at the 40th annual meeting of the American College of Neuropsychopharmacology, Waikoloa, HI, December 9, 2001
- Barre-Sinoussi F, Chermann JC, Rey F, et al: Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immunodeficiency syndrome. Science 220:868-871, 1983
- Broder S, Merigan TC, Bolognesi D (eds): Textbook of AIDS Medicine. Baltimore, MD, Williams & Wilkins, 1994
- Brunette MF, Mercer CC, Carlson CL, et al: HIV-related services for persons with severe mental illness: policy and practice in New Hampshire community mental health. J Behav Health Serv Res 27:347-353, 2000
- Carey MP, Carey KB, Kalichman SC: Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illnesses. Clin Psychol Rev 17:271-291, 1997
- Carmen E, Brady SM: AIDS risk and prevention for the chronic mentally ill. Hosp Community Psychiatry 41:652-657, 1990
- Chuang HT, Atkinson M: AIDS knowledge and high-risk behaviour in the chronic mentally ill. Can J Psychiatry 41:269-272, 1996
- Cividini A, Pistorio A, Regazzetti A, et al: Hepatitis C virus infection among institutionalized psychiatric patients: a regression analysis of indicators of risk. J Hepatol 27:455-463, 1997
- Community Research Initiative on AIDS: HIV/hepatitis C co-infection: confronting twin epidemics. http://www.CRIANY.org, accessed January 2000
- Corbitt G, Crosdale E, Bailey A: Protracted sero-conversion in haemophiliacs in whom infection is confirmed by p24 antigen detection and/or positive HIV PCR, in Abstracts, 7th International Conference on AIDS, Florence, Italy, 1991, p 387
- Cournos F, McKinnon K: HIV seroprevalence among people with severe mental illness in the United States: a critical review. Clin Psychol Rev 17:259-269, 1997
- Cournos F, Guido JR, Coomaraswamy S, et al: Sexual activity and risk of HIV infection among patients with schizophrenia. Am J Psychiatry 151:228-232, 1993
- Fernandez F, Levy JK: The use of molindone in the treatment of psychotic and delirious patients infected with the human immunodeficiency virus: case reports. Gen Hosp Psychiatry 15:31-35, 1993
- Gallo RC, Salahuddin SZ, Popovic M, et al: Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 224:500-503, 1984
- Goodman LA, Fallot RD: HIV risk-behavior in poor urban women with serious mental disorders: association with childhood physical and sexual abuse. Am J Orthopsychiatry 68:73-83, 1998
- Hanson M, Kramer TH, Gross W, et al: AIDS awareness and risk behaviors among dually disordered adults. AIDS Educ Prev 4:41-51, 1992
- Hardy AM: National health interview survey data on adult knowledge about AIDS in the United States. Public Health Rep 105:629-634, 1990
- Herbert B: Woman battering and HIV infection, in Abstracts (TP500), HIV Infection in Women: Setting a New Agenda. Washington, DC, Philadelphia Sciences Group, 1995
- Horwath E: Psychiatric and neuropsychiatric manifestations, in AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals. Edited by Cournos F, Bakalar N. New Haven, CT, Yale University Press, 1996, pp 57-73
- Horwath E, Cournos F, McKinnon K, et al: Illicit-drug injection among psychiatric patients without a primary substance use disorder. Psychiatr Serv 47:181-185, 1996
- Kalichman SC, Kelly JA, Johnson JR, et al: Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry 151:221-227, 1994
- Katz RC, Watts C, Santman J: AIDS knowledge and high risk behaviors in the chronic mentally ill. Community Ment Health J 30:395-402, 1994
- Keet IP, Krol A, Koot M, et al: Predictors of rapid progression to AIDS in HIV-1 seroconverters. AIDS 7:51-57, 1993
- Kelly JA: HIV risk reduction interventions for persons with severe mental illness. Clin Psychol Rev 17:293-309, 1997
- Kelly JA, Murphy DA, Bahr GR, et al: AIDS/HIV risk behavior among the chronic mentally ill. Am J Psychiatry 149:886-889, 1992
- Levy J: Pathogenesis of human immunodeficiency virus infection. Microbiol Rev 57:183-189, 1993
- Liberman RP, Mueser KT, Wallace CJ, et al: Training skills in the psychiatrically disabled: learning coping and competence. Schizophr Bull 12:631-647, 1986
- Lifson AR, Buchbinder SP, Sheppard HW, et al: Long-term human immunodeficiency virus infection in asymptomatic homosexual and bisexual men with normal CD4+ lymphocyte counts: immunologic and virologic characteristics. J Infect Dis 163:959-965, 1991
- Masliah G, Achim CL, DeTeresa R, et al: The patterns of neurodegeneration in HIV encephalitis. Journal of NeuroAIDS 1:161-173, 1996
- McDaniel JS, Purcell DW, Farber EW: Severe mental illness and HIV-related medical and neuropsychiatric sequelae. Clin Psychol Rev 17:311-325, 1997
- McDermott BE, Sautter FJ, Winstead DK, et al: Diagnosis, health beliefs, and risk of HIV infection in psychiatric patients. Hosp Community Psychiatry 45:580-585, 1994
- McKinnon K, Cournos F: HIV infection linked to substance use among hospitalized patients with severe mental illness. Psychiatr Serv 49:1269, 1998
- McKinnon K, Cournos F, Sugden R, et al: The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. J Clin Psychiatry 57:506-513, 1996
- McKinnon K, Cournos F, Herman R, et al: AIDS-related services and training in outpatient mental health care agencies in New York. Psychiatr Serv 50:1225-1228, 1999
- McKinnon K, Wainberg ML, Cournos F: HIV/AIDS preparedness in mental health care agencies with high and low substance use disorder caseloads. J Subst Abuse 13:127-135, 2001
- Mellors JW, Rinaldo CR Jr, Gupta P, et al: Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science 272:1167-1170, 1996
- Menon AS, Pomerantz S: Substance use during sex and unsafe sexual behaviors among acute psychiatric inpatients. Psychiatr Serv 48:1070-1072, 1997
- Meyer JM: Prevalence of hepatitis A, hepatitis B and HIV among hepatitis C seropositive state hospital patients: results from Oregon State Hospital. J Clin Psychiatry (in press)
- Mulder RT, Ang M, Chapman B, et al: Interferon treatment is not associated with a worsening of psychiatric symptoms in patients with hepatitis C. J Gastroenterol Hepatol 15: 300-303, 2000
- National Digestive Diseases Information Clearinghouse: Chronic hepatitis C: current disease management. Available at: http://www.niddk.nih.gov/health/digest/pubs/chrnhepc. Accessed February 17, 2003
- National Institutes of Health Consensus Development Conference Panel: Management of hepatitis C. Hepatology 26:2S-10S, 1997
- O'Brien WA: Genetic and biologic basis of HIV-1 neurotropism, in HIV, AIDS and the Brain. Edited by Price RW, Perry SW. New York, Raven, 1994, pp 47-70
- O'Brien WA, Hartigan PM, Martin D, et al: Changes in plasma HIV-1 RNA and CD4 + lymphocyte counts and the risk of progression to AIDS. N Engl J Med 334:426-431, 1996
- Oliveira SB: Avalia'o do comportamento sexual, conhecimentos e atitudes sobre AIDS, dos pacientes internados no instituto de psiquiatria da UFRJ, in O Campo da Aten'o Psicossocial. Edited by Venncio AT, Leal EM, Delgado PG. Rio de Janeiro, Te Cor, 1997, pp 343-351
- Oquendo M, Tricarico P: Pre- and post-HIV test counseling, in AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals. Edited by Cournos F, Bakalar N. New Haven, CT, Yale University Press, 1996, pp 97-112
- Otto-Salaj LL, Heckman TG, Stevenson LY, et al: Patterns, predictors and gender differences in HIV risk among severely mentally ill men and women. Community Ment Health J 34:175-190, 1998
- Otto-Salaj LL, Kelly JA, Stevenson LY, et al: Outcomes of a randomized smallgroup HIV prevention intervention trial for people with serious mental illness. Community Ment Health J 37:123-144, 2001
- Resnick L, Berger JR, Shapshak P, et al: Early penetration of the blood brain barrier by HTLV-III/LAV. Neurology 38:9-15, 1988
- 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 91:31-37, 2001
- Sewell DD, Jeste DV, McAdams LA, et al: Neuroleptic treatment of HIV-associated psychosis. Neuropsychopharmacology 10:223-229, 1994
- Staprans SI, Feinberg MB: Natural history and immunopathogenesis of HIV-1 disease, in The Medical Management of AIDS, 5th Edition. Edited by Sande MA, Volberding PA. Philadelphia, PA, WB Saunders, 1997, pp 29-56
- Susser E, Miller M, Valencia E, et al: Injection drug use and risk of HIV transmission among homeless men with mental illness. Am J Psychiatry 153:794-798, 1996
- Varmus H: Retroviruses. Science 240:1427-1435, 1988
- Vento S, Garofano T, Renzini C, et al: Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 338:286-290, 1998
- Wainberg ML, Forstein M, Berkman A, et al: Essential medical facts for mental health practitioners, in What Mental Health Practitioners Need to Know about HIV and AIDS. Edited by Cournos F, Forstein M. San Francisco, CA, Jossey-Bass, 2000, pp 3-15
- Warner GC: Molecular insights into HIV-1 infection, in The Medical Management of AIDS, 5th Edition. Edited by Sande MA, Volberding PA. Philadelphia, PA, WB Saunders, 1997, pp 17-28
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