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Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
- By N.I. D.A.
- Published 01/15/2007
- Dual Diagnosis
- Unrated
Substance Use and HIV Risk Among People With Severe Mental Illness
Francine Cournos and Karen McKinnon
People with severe mental illness are often overlooked in the acquired immunodeficiency syndrome (AIDS) epidemic.
For a long time it was assumed that those with schizophrenia, the most common diagnosis in public treatment settings, were too disorganized or withdrawn to engage in the drug use and sexual behaviors related to human immunodeficiency virus (HIV) exposure (Carmen and Brady 1990).
The extent of these risk behaviors was unknown and uninvestigated. Unfortunately, this inattention may have facilitated the spread of HIV infection among people with the most severe psychiatric disorders. This chapter reviews the literature on the role of substance use in HIV risk among people treated in public mental health settings who have recurrent or persistent psychotic illness and significant functional impairments.
Most of these people have had multiple psychiatric admissions and courses of psychotropic medications. The majority are unemployed and rely on social welfare benefits. Some are homeless. They typically fit poorly into existing health care and substance abuse treatment programs—they receive inferior medical care, have higher morbidity and mortality, and are unwelcome in traditional treatment programs (Gelberg and Linn 1984; Kroll et al. 1986).
THE EMERGENCE OF THE AIDS EPIDEMIC IN THE PSYCHIATRIC POPULATION
In 1983, a 25-year-old woman hospitalized at a state psychiatric center in Brooklyn, New York developed a low white blood cell count. It was assumed to be caused by the antipsychotic medication she was taking, which was immediately stopped.
However, her blood count did not improve. Ten months later she developed pneumonia and was transferred to a general hospital. There was no HIV antibody test at the time, but the organism causing her pneumonia was pneumocystis carinii, and a diagnosis of AIDS was made. This woman was one of the first of a series of patients who would make it clear that AIDS could have a significant impact on the psychiatric population.
This was a shock to psychiatric institutions. Clinicians and hospital administrators of the time thought of AIDS as a disease of men who either had sex with other men or injected drugs. In 1983, there were only 143 newly diagnosed cases of AIDS among women in the entire country, and one of them was at a public psychiatric hospital in New York City. In fact, the majority of early cases reported in the psychiatric literature were women (Cournos et al. 1990; Gewirtz et al. 1988; Horwath et al. 1989).
Well into the second decade of the AIDS epidemic, such case reports were the only information in the peerreviewed literature about HIV infection among psychiatric patients. To what extent these cases were typical or represented an accurate picture of the epidemic in this population was unknown.
THE PREVALENCE OF HIV INFECTION AMONG ADULTS WITH SEVERE MENTAL ILLNESS
The first published study of the prevalence of HIV infection among a psychiatric population appeared in 1991 (Cournos et al. 1991a). There are now 11 studies in the peer-reviewed psychiatric literature on the rates of HIV infection among psychiatric patients in treatment in the United States, 10 conducted in New York City and 1 in Baltimore. Rates of infection range from 4.0 to 22.9 percent (Cournos et al. 1991a; Empfield et al. 1993; Lee et al. 1992; Meyer et al. 1993; Sacks et al. 1992a; Silberstein et al. 1994; Volavka et al. 1991).
One small study conducted outside a hospital setting found that 19.4 percent of mentally ill men attending a day program in a large homeless shelter had a positive antibody test noted in their records (Susser et al. 1993). Unfortunately, little peer-reviewed research examines seroprevalence among a defined psychiatric population in the United States outside New York City.
Anecdotal reports suggest elevated rates of infection in comparison to the general population in other geographic areas (personal communications). Although some psychiatric hospitals have conducted seroprevalence studies without external funding, results have not appeared in scientific journals, possibly because of flawed methods of data collection.
Methodological Issues in Estimating Prevalence
Estimating how many people with severe mental illness are infected with HIV requires identifying a group to study, learning their demographic and risk characteristics, and obtaining blood samples to test. Differences in the HIV infection rates obtained in seroprevalence studies may be due to differences in sampling and methodology.
Sampling. To map the distribution of HIV and the factors that influence it in the psychiatric population, a representative sample is required. The published seroprevalence studies are all limited by the selection of populations in treatment in hospital settings, who represent only some of those with severe psychiatric disorders.
In addition, all were conducted in New York City, where AIDS case rates are higher than in other parts of the United States. In these studies, sampling was carried out over varying timeframes, ranging from 3 (Meyer et al. 1993) to 18 months (Empfield et al. 1993). Changes in rates among subgroups of patients have not been reported and information on the number of new cases (incidence) of HIV infection occurring in the population has not appeared.
Method. Anonymous serosurveys have been described in detail elsewhere (Cournos et al. 1991a). Such surveys have several advantages over studies in which patients consent to testing. They capture a larger and more representative proportion of the population under investigation because they sample all patients, not specifically those selected either because they request testing, are urged to have it because of a history of HIV-related risk behaviors, or are capable of giving informed consent.
Larger sample sizes increase the statistical power to assess relationships between independent and dependent variables. In addition, infected patients are not individually identified, so there is little direct impact on staff and patients. Anonymous testing does not interfere with clinical judgments about the risks and benefits of testing, and pre- and posttest counseling can be tailored to individual patients. This method is best suited to hospital settings in which large patient pools permit anonymous blood collection.
By comparison, the major advantage of the open testing method, which is contingent on patient capacity to give informed consent, is the possibility of conducting structured diagnostic and risk assessment interviews to obtain detailed and reliable information that can be linked to HIV status. Open testing can be carried out in any setting.
In summary, the number of studies attempting to estimate HIV infection among people with severe mental illness is small. All were conducted in New York City and limited in the type and reliability of information obtained and by the selection of hospitalized people.
Nevertheless, they represent the state of the art, and must be used as a basis for further research.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
Francine Cournos and Karen McKinnon
People with severe mental illness are often overlooked in the acquired immunodeficiency syndrome (AIDS) epidemic.
For a long time it was assumed that those with schizophrenia, the most common diagnosis in public treatment settings, were too disorganized or withdrawn to engage in the drug use and sexual behaviors related to human immunodeficiency virus (HIV) exposure (Carmen and Brady 1990).
The extent of these risk behaviors was unknown and uninvestigated. Unfortunately, this inattention may have facilitated the spread of HIV infection among people with the most severe psychiatric disorders. This chapter reviews the literature on the role of substance use in HIV risk among people treated in public mental health settings who have recurrent or persistent psychotic illness and significant functional impairments.
Most of these people have had multiple psychiatric admissions and courses of psychotropic medications. The majority are unemployed and rely on social welfare benefits. Some are homeless. They typically fit poorly into existing health care and substance abuse treatment programs—they receive inferior medical care, have higher morbidity and mortality, and are unwelcome in traditional treatment programs (Gelberg and Linn 1984; Kroll et al. 1986).
THE EMERGENCE OF THE AIDS EPIDEMIC IN THE PSYCHIATRIC POPULATION
In 1983, a 25-year-old woman hospitalized at a state psychiatric center in Brooklyn, New York developed a low white blood cell count. It was assumed to be caused by the antipsychotic medication she was taking, which was immediately stopped.
However, her blood count did not improve. Ten months later she developed pneumonia and was transferred to a general hospital. There was no HIV antibody test at the time, but the organism causing her pneumonia was pneumocystis carinii, and a diagnosis of AIDS was made. This woman was one of the first of a series of patients who would make it clear that AIDS could have a significant impact on the psychiatric population.
This was a shock to psychiatric institutions. Clinicians and hospital administrators of the time thought of AIDS as a disease of men who either had sex with other men or injected drugs. In 1983, there were only 143 newly diagnosed cases of AIDS among women in the entire country, and one of them was at a public psychiatric hospital in New York City. In fact, the majority of early cases reported in the psychiatric literature were women (Cournos et al. 1990; Gewirtz et al. 1988; Horwath et al. 1989).
Well into the second decade of the AIDS epidemic, such case reports were the only information in the peerreviewed literature about HIV infection among psychiatric patients. To what extent these cases were typical or represented an accurate picture of the epidemic in this population was unknown.
THE PREVALENCE OF HIV INFECTION AMONG ADULTS WITH SEVERE MENTAL ILLNESS
The first published study of the prevalence of HIV infection among a psychiatric population appeared in 1991 (Cournos et al. 1991a). There are now 11 studies in the peer-reviewed psychiatric literature on the rates of HIV infection among psychiatric patients in treatment in the United States, 10 conducted in New York City and 1 in Baltimore. Rates of infection range from 4.0 to 22.9 percent (Cournos et al. 1991a; Empfield et al. 1993; Lee et al. 1992; Meyer et al. 1993; Sacks et al. 1992a; Silberstein et al. 1994; Volavka et al. 1991).
One small study conducted outside a hospital setting found that 19.4 percent of mentally ill men attending a day program in a large homeless shelter had a positive antibody test noted in their records (Susser et al. 1993). Unfortunately, little peer-reviewed research examines seroprevalence among a defined psychiatric population in the United States outside New York City.
Anecdotal reports suggest elevated rates of infection in comparison to the general population in other geographic areas (personal communications). Although some psychiatric hospitals have conducted seroprevalence studies without external funding, results have not appeared in scientific journals, possibly because of flawed methods of data collection.
Methodological Issues in Estimating Prevalence
Estimating how many people with severe mental illness are infected with HIV requires identifying a group to study, learning their demographic and risk characteristics, and obtaining blood samples to test. Differences in the HIV infection rates obtained in seroprevalence studies may be due to differences in sampling and methodology.
Sampling. To map the distribution of HIV and the factors that influence it in the psychiatric population, a representative sample is required. The published seroprevalence studies are all limited by the selection of populations in treatment in hospital settings, who represent only some of those with severe psychiatric disorders.
In addition, all were conducted in New York City, where AIDS case rates are higher than in other parts of the United States. In these studies, sampling was carried out over varying timeframes, ranging from 3 (Meyer et al. 1993) to 18 months (Empfield et al. 1993). Changes in rates among subgroups of patients have not been reported and information on the number of new cases (incidence) of HIV infection occurring in the population has not appeared.
Method. Anonymous serosurveys have been described in detail elsewhere (Cournos et al. 1991a). Such surveys have several advantages over studies in which patients consent to testing. They capture a larger and more representative proportion of the population under investigation because they sample all patients, not specifically those selected either because they request testing, are urged to have it because of a history of HIV-related risk behaviors, or are capable of giving informed consent.
Larger sample sizes increase the statistical power to assess relationships between independent and dependent variables. In addition, infected patients are not individually identified, so there is little direct impact on staff and patients. Anonymous testing does not interfere with clinical judgments about the risks and benefits of testing, and pre- and posttest counseling can be tailored to individual patients. This method is best suited to hospital settings in which large patient pools permit anonymous blood collection.
By comparison, the major advantage of the open testing method, which is contingent on patient capacity to give informed consent, is the possibility of conducting structured diagnostic and risk assessment interviews to obtain detailed and reliable information that can be linked to HIV status. Open testing can be carried out in any setting.
In summary, the number of studies attempting to estimate HIV infection among people with severe mental illness is small. All were conducted in New York City and limited in the type and reliability of information obtained and by the selection of hospitalized people.
Nevertheless, they represent the state of the art, and must be used as a basis for further research.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
