AIDS/HIV risk behavior among the chronic mentally ill.

OBJECTIVE: There is growing concern that chronic mentally ill adults living in the community have a high risk for HIV infection. The purpose of this study was to identify risk knowledge, high-risk behaviors, and risk-related encounters of chronic psychiatric outpatients. METHOD: Detailed information on high-risk behaviors and risk-related situations during the past 12 months was collected from 60 outpatients appearing for regular visits at inner-city community mental health clinics. RESULTS: Of the 60 outpatients, 37 (62%) had been sexually active during the past year, and 42% of the men and 19% of the women reported multiple sexual contacts and infrequent use of condoms during intercourse. Assessments of the patients' knowledge of AIDS risks revealed substantial deficits in their practical understanding of AIDS and risk reduction measures. Although use of intravenous drugs was uncommon in this group, many subjects reported histories of 1) trading sex for money, drugs, or a place to stay, 2) coercion to engage in unwanted sex, 3) causal sexual encounters, and 4) sexual activity after use of drugs or intoxicants. Twenty percent of the subjects had met their sexual partners on the streets, in parks, or in other public places. One-third had been treated for sexually transmitted diseases other than AIDS. CONCLUSIONS: These findings underscore the need for AIDS risk assessment, counseling, and prevention programs for the chronic mentally ill.     

AIDS risk and prevention for the chronic mentally ill

Some chronic mentally ill populations are at high risk for infection with human immunodeficiency virus. The authors argue that stereotypes of the mentally ill as asexual or neutered have had dangerous consequences, namely the absence of sex education and AIDS prevention as an integral part of treatment. To counter this neglect, the authors developed an AIDS prevention program in a large inner-city mental health center that serves primarily black and Latino patients. Prevention efforts include individual risk assessments and an innovative drop-in group. Central to effective patient education are the distribution of condoms and concrete instruction in their use.     

Substance abuse among the chronic mentally ill

Substance abuse was examined in a group of 187 chronic mentally ill patients living in the community. According to ratings by aftercare clinicians, approximately onethird of the sample abused alcohol, street drugs, or both during the six months before evaluation. Patients who were dually diagnosed with substance abuse and mental illness differed from those with mental illness alone in several respects: they were younger and more often male; were less able to manage their lives in the community in terms of maintaining regular meals, adequate finances, stable housing, and regular activities; showed greater hostility, suicidality, and speech disorganization; and had poorer medication compliance. In addition, they were nearly twice as likely to be rehospitalized during one-year follow-up. Substance abuse, appeared to add the problems of disruptive, disinhibited, noncompliant behaviors to chronic mental illness.     

Risk factors for HIV,hepatitis B,and hepatitis C among persons with severe mental illness

OBJECTIVE: Previous reports have indicated that persons with severe mental illness have an elevated risk of contracting HIV, hepatitis B, and hepatitis C compared with the general population. This study extends earlier findings by examining the factors that are most predictive of serologic status among persons with severe mental illness. METHOD:S: A total of 969 persons with severe mental illness from five sites in four states were approached to take part in an assessment involving testing for blood-borne infections and a one-time standardized interview containing questions about sociodemographic characteristics, substance use, risk behaviors for sexually transmitted diseases, history of sexually transmitted diseases, and health care. RESULTS: The greater the number of risk behaviors, the greater was the likelihood of infection, both for persons in more rural locations (New Hampshire and North Carolina), where the prevalence of infection was lower, and those in urban locations (Hartford, Connecticut; Bridgeport, Connecticut; and Baltimore, Maryland), where the prevalence was higher. Although no evidence was found that certain behaviors increase a person's risk of one blood-borne infection while other behaviors increase the risk of a different infection, it is conceivable that more powerful research designs would reveal some significant differences among the risks. CONCLUSION:S: Clinicians should be attentive to these risk factors so as to encourage appropriate testing, counseling, and treatment.     

AIDS knowledge and high risk behaviors in the chronic mentally ill

Chronic mentally ill adults are a high risk group for AIDS. In the present study, we used a questionnaire to assess AIDS knowledge, attitudes, and risk behaviors in 54 men and women who were clients at a drop in center for mentally ill adults. Most of the subjects were suffering from schizophrenia and about one-third of them had co-existing drug problems. Results showed widespread misunderstandings about AIDS transmission, high risk groups, and practices. Many of the subjects had been treated for STDs such as syphilis and gonorrhea and were engaging in behaviors that increased their vulnerability to AIDS. These include casual sex, anal sex, sex with an IV drug user, or sex in exchange for money, drugs, or a place to sleep. Subjects expressed a moderately high level of concern about acquiring AIDS/HIV, and 15% of those tested (5/33) said they already had the illness. We observed a significant correlation between misinformation about AIDS and the frequency of high risk behaviors. We also detected ambivalence about using condoms and IV drugs. Although males and females did not differ in AIDS knowledge or risk behaviors, the AIDS knowledge of both groups was significantly lower than a comparison sample of public high school students. Taken together, the results underscore the immediate need for comprehensive AIDS assessment, education, and prevention in this segment of the population.     

An HIV/AIDS risk-reduction program for mentally ill hospital patients: assessing readiness for change

This study evaluated the effectiveness of an HIV/AIDS cognitive-behavioral skills-training program in promoting readiness for behavior change among a sample of psychiatric inpatients. Significant differences were found in the domain of precontemplation for women patients, in domain of contemplation for patients diagnosed with a psychotic disorder, and in the domain of action for men and for patients with a mood disorder. In all areas, difference scores reflected an improvement between pre- and posttest levels.     

Evaluating prosthetic technology for the chronic mentally ill

As treatment and rehabilitative approaches evolve, mental health administrators face an increasing number of choices in developing supportive service delivery systems for chronic patients. This paper reintroduces and elaborates upon the concept of prosthetic technology to provide administrators with a tool to aid their program selection decisions. A method is described for evaluating the prosthetic efficacy of program interventions.     

Therapeutic stereotypes among the mentally ill

Using mathematical models described by Overall, the authors investigated in a sample of 301 psychiatric inpatients the therapeutic stereotypes in medicating psychotropic drugs and its dependence on symptom, syndrome and diagnostic level. The psychotropic drugs were described in a dimensional representation of psychopathology ('symptomatic space'). Besides dependencey from patient's characteristics as age and clinician's characteristics as special orientation, the therapeutic stereotype is mostly influenced by the symptom level. Only lithium therapy and electroconvulsive therapy are keyed to diagnosis. Getting more familiar with a psychotropic drug increases indications and contraindications on symptom level, the therapeutic stereotype gets more differentiated. The comparison between the therapeutic stereotypes of German and French psychiatrists shows a satisfactory congruence relating to dimensionality and relationships among the drugs.     

Strategies for improving services for the chronic mentally ill

A central goal of policies aimed at improving care of the chronic mentally ill is better service coordination and integration. The author examines four current policy strategies--continuous care teams, local mental health authorities, integrated entitlement programs, and capitation payment systems--and discusses their incorporation in four model programs of integrated services. The programs differ in the degree to which they attempt to direct service coordination at the patient level, but all four programs have created local mental health authorities to oversee services. The success of any of the policy strategies depends on a system's capacity not only to regulate services but to ensure that presumed incentives to deliver cost-effective services filter down to well-trained and motivated front-line staff.     

HIV risk behavior in the chronically mentally ill

Patients with chronic mental illnesses including schizophrenia and bipolar disorder constitute an important risk group for AIDS. Although limited by a lack of control groups, study findings indicate that an important minority of patients report having multiple sexual partners, use alcohol or drugs preceding sexual intercourse, report a history of intravenous drug use, are coerced into unwanted sexual activity, experience homosexual or heterosexual anal intercourse, and fail to use condoms consistently, if at all. Furthermore, chronically and variably impaired autonomy may add to patients’ vulnerability. In this context the author makes recommendations for limiting chronic mental patients’ risk for AIDS that include techniques for reliably assessing individual risk. Preventive clinical interventions include treating variable impairment of autonomy, communication and behavioral skills training targeted to skills deficits while augmented by educational strategies, and outreach to the partners of at-risk patients. Preventive services should also be integrated and coordinated with sexually transmitted disease clinics, substance abuse treatment programs, and family planning programs.     

Small group work therapy for the chronic mentally ill

In 1980 the authors reviewed the records of the first 130 patients to enter small group work therapy, a program begun in 1964 by Arkansas State Hospital and Arkansas Rehabilitation Services in which chronic schizophrenic patients live in group homes and work in Hot Springs. Forty-five of the original patients were still in the program in 1980. Although the patients had been hospitalized for an average of 11 years, they spent an average of seven years in the program, during which time their hospital utilization dropped significantly. Forty-two were discharged to settings offering greater independence. The authors focus on the role of a rehabilitative unit of Arkansas State Hospital known as the HIP unit, which, until it was closed in 1976, prepared patients to live and work with each other before entering small group work therapy.     

Pathways to homelessness among the mentally ill

  Background: Persons with mental illness are over-represented among the homeless relative to the general population, and mental illness is most likely one of many vulnerabilities that confer risk for homelessness. Method: This paper elucidates the pathways to homelessness for persons with mental illness by comparing and contrasting groups of mentally ill homeless persons, non-mentally ill homeless persons, and housed mentally ill persons drawn from RAND's Course of Homelessness (COH) study and the Epidemiological Catchment Area (ECA) survey. Results: Homeless persons share childhood histories of economic and social disadvantage. The mentally ill homeless appear to have a “double dose” of disadvantage: poverty with the addition of childhood family instability and violence. Among the mentally ill homeless, those who became homeless prior to becoming mentally ill have the highest levels of disadvantage and disruption; while those who become homeless after becoming ill have an especially high prevalence of alcohol dependence. Conclusions: Mental illness may play a role in initiating homelessness for some, but is unlikely in and of itself to be a sufficient risk factor for homelessness. In addition to outreach and treatment programs for adult mentally ill homeless persons, emphasis should be placed on interventions with children and on addressing more pervasive causes of homelessness. Accepted: 14 June 2000     

Routine HIV testing for the severely mentally ill: considerations and cautions

The last few decades have brought major changes in both mental health laws and AIDS public health laws. The author first examines the impact of the HIV epidemic on those with severe and persistent mental illness. He then discusses how changes in public health laws have affected those infected with HIV and how changes in mental health laws have affected those with mental illness. People suffering from severe mental illness are increasingly being held legally responsible for their personal actions. At the same time, AIDS public health laws have begun to change so that those infected with HIV enjoy less legal protection and have more personal responsibility for transmitting the virus to others than in the recent past. The author then considers what impact the convergence of these legal changes is likely to have on the growing population of people with mental illness who are infected with HIV. The article concludes with some practical recommendations concerning HIV assessment and treatment in individuals with severe and persistent mental illness.