Psychiatry Research, 39: 109-I 14
109
Elsevier
HIV Seroprevalence Inpatients Jan Volavka, Antonio and Fidel Ventura
Convit,
and
Risk
Behaviors
in Psychiatric
Pal Czobor, Richard Douyon, Jane O’Donnell,
Received August 2, 1991; revised version received October IS, 199l;accepted
October20,1991.
Abstract. The seroprevalence of the human immunodeficiency virus (HIV) in 5 15 patients consecutively admitted to a state psychiatric hospital in New York City was 8.9%. There were 365 patients whose results were individually traceable; the remaining 150 patients were tested anonymously. Risk factors including parenteral drug abuse, male homosexual behaviors, and other sexual behaviors were studied in the traceable patients. Logistic regressions indicated that parenteral drug abuse was the main risk factor in both males and females. In females, two additional factors were significant: sex with parenteral drug users or with partners who have the acquired immunodeficiency syndrome (AIDS), and sex with bisexual men. Females with bipolar disorders were particularly likely to report sex with parenteral drug users or with partners who have AIDS. Key Words. Human immunodeficiency sexuality, acquired immunodeficiency
virus, seroprevalence, syndrome.
drug abuse, homo-
Risk behaviors related to the human immunodeficiency virus (HIV) are frequent among psychiatric patients (Sacks et al., 1990a, 1990b; Zafrani and McLaughlin, 1990). HIV seroprevalence in psychiatric inpatients in New York City was reported to
be 5.5% (Cournos et al., 199 1) or 7.9% (Sacks et al., quoted in Cournos et al., 1991). In Milan, the rate was 6.5% (Zamperetti et al., 1990). However, the risk behaviors established by questionnaires (Sacks et al., 1990a, 1990b; Zafrani and McLaughlin, 1990) have not been linked to HIV test results in the same patients, and the risk behaviors reported in the study of Cournos et al. (1991) were extracted by retrospective chart review instead of by structured risk assessment interviews. Our study was designed to determine HIV seroprevalence, assess risk behaviors by a specific questionnaire, and relate these behaviors to HIV infection. Furthermore, we were interested in a possible relationship between psychiatric diagnosis and risk behavior.
Jan Volavka, M.D., Ph.D., is Professor of Psychiatry, New York University Medical Center, and Chief, Clinical Research Division, Nathan S. Kline Institute for Psychiatric Research. Antonio Convit, M.D., is Assistant Professor, Department of Psychiatry, New York University Medical Center, and Nathan S. Kline Institute for Psychiatric Research. Pal Czobor, Ph.D., is Visiting Professor, Department of Psychiatry, New York Universitv Medical Center, and Nathan S. Kline Institute for Psvchiatric Research. Richard Douyon, M.D., is instructor, Department of Psychiatry, New York University Medical Center. Jane O’Donnell, M.A., and Fidel Ventura, M.D., are Research Scientists, Nathan S. Kline Institute for Psychiatric Research. Drs. Volavka, Douyon, Ventura, and Ms. O’Donnell work at the Manhattan Psychiatric Center in New York City, where all the patients were seen. (Reprint requests to Dr. J. Volavka, Nathan Kline Institute, Orangeburg, NY 10962, USA.) 0165-1781191
jSO3.50 @ 1991 Elsevier Scientific
Publishers
Ireland
Ltd.
110 Disinhibition associated with mania frequently involves hypersexual or promiscuous behavior (Lehmann, 1985). Gewirtz et al. (1988) reported on two female patients whose promiscuous behaviors during manic or psychotic states had apparently resulted in HIV infection. Sex with intravenous drug users is a more important risk factor for the acquired immunodeficiency syndrome (AIDS) in females than in males (Centers for Disease Control, 1991). On the basis of these facts, we developed the following hypothesis: bipolar disorder is related to high-risk sexual activity, and females are more likely to demonstrate this relationship. Methods Between February 15, 1990, and February 15, 199 1, patients were consecutively admitted to a state psychiatric center in New York City. The patients were black (58%), hispanic (22%), or white (20%). The psychiatric center serves the indigent population of Manhattan. In general, this facility admits severely and persistently mentally ill patients. The patients were diagnosed by their ward psychiatrists, who were expected to use DSM-III-R criteria (American Psychiatric Association, 1987) and these diagnoses were available in 538 cases (diagnosis was listed as “deferred” in 3 1 cases, and in 6 cases it was missing altogether). The Axis I primary diagnoses of the 538 cases were as follows: schizophrenia (58.9%) bipolar disorder (I 1.3%). schizoaffective disorder (lO.O%), psychotic disorder not otherwise specified (6%) substance abuse or dependence (4. I%), major depression (2.2%), organic disorders (2.2%), and various other diagnoses (5.3%). Although the primary diagnosis of substance abuse or dependence was rare in this patient sample, reports of use and abuse were not. Standard HIV antibody tests (ELISA and confirmatory Western blot) were performed in 506 subjects whose HIV status was undocumented on arrival to the psychiatric center; documented HIV positive (HIV+) subjects (n = 11) were not retested. Two of the 506 HIV tests performed were inconclusive, and the patients were not available for retesting. Thus, we obtained 504 valid HIV tests, and were aware of an additional 11 (positive) results. Ourcomplete sample therefore consisted of 515 HIV-tested cases. We could not test 58 cases (mainly because they refused any blood extraction). Wecompared these 58 patients (plus the 2 patients with inconclusive HIV test results) with the 515 HIV-tested patients, and found no significant differences between these two sets on age, gender, or race. The patients were asked for consent to participate in the HIV seroprevalence study. If the patient gave written consent for an HIV test, the test result was traceable to that individual. Blood samples of patients unable or unwilling to give consent were analyzed anonymously (i.e., the samples were labeled in a way that made it impossible to trace the test results to any individual). This arrangement was approved by the appropriate Institutional Review Boards. Subjects were interviewed about their HIV-related risk behaviors using a Risk Behavior Questionnaire (RBQ) constructed for this purpose. The RBQ consists of 13 items covering the following risk factors: (a) parenteral drug use, (b) sex with parenteral drug users or with partners who have AIDS, (c) homosexual risk behaviors, (d) sex with prostitutes, (e) sex with bisexual males, and (f) blood transfusions. Factors (c) and (d) were established only for male patients; factor (e) only for female patients.
Results HIV Seroprevalence. Our sample was divided into two subsets. The traceable subset (n = 365) consisted of 354 consenters and 11 patients whose HIV positivity had been documented by previous tests. The anonymous subset (n = 150) consisted of patients who did not consent to the HIV test. Complete sample (traceable plus anonymous patients). A total of 46 out of 515 (8.9%) patients were HIV. There were no statistically significant differences
111 between traceable and anonymous subsets in HIV seroprevalence rate, gender, age, and race. The traceable patients were slightly younger (average age = 37.1, SD = 11.1) than the anonymous ones (average age = 39.1, SD = 11.2); this difference approached the level of statistical significance (F = 3.62; df = 1, 513; p = 0.06). The HIV seroprevalence among the traceable patients was 10.1% (37/365), in the nontraceable patients, it was 6% (9/ 150; x2 = 1.76, df = 1, NS). It should be noted, however, that the traceable subset included 11 patients whose HIV positivity had been documented before they entered the study; accordingly, we did not request their consent to an HIV test. To answer the question whether consent (rather than traceability) was related to seropositivity, we repeated the test after the exclusion of these 11 patients. Again, no significant relationship emerged (x2 = 0.12). Traceable subset. There were 14198 HIV females (14.3%) and 23/ 267 HIV males (8.6%); this difference in rates was not statistically significant (~2 = 2.53, df 1, p = 0.11). The traceable patients were black (56%), hispanic (24%), and white (20%); race was unrelated to seropositivity (x2 = 1.36, df 2, p = 0.51). The primary Axis I DSM-III-R (American Psychiatric Association, 1987) diagnoses were available in 34 of the 37 HIV+ patients (three were listed as “deferred”). The breakdown was as follows: schizophrenia 38.2% (n = 13); major depression, bipolar disorder, substance abuse or dependence, and psychotic disorder not otherwise specified 11.8% (n = 4 each); schizoaffective disorder 8.8% (n = 3) and other diagnoses 5.8% (n = 2). The diagnoses for the HIV- patients were: schizophrenia 56.7%, bipolar disorder 11.8% schizoaffective disorder 11.1% psychotic disorder not otherwise specified 5.9%, substance abuse or dependence 4.3%, major depression 2.3%, organic disorders 2%, and other diagnoses 5.9%. q
q
HIV Risk Behaviors. Diagnosis and risk behavior in the complete sample (traceable and anonymous patients). In 484 patients (a subset of the 5 15 patients in the complete sample), a primary Axis I diagnosis was recorded by their ward psychiatrists. (Diagnosis was listed as “deferred” in 26 cases, and was missing in 5 additional cases.) RBQ data were available in 440 of the diagnosed cases (318 males and 122 females). The diagnostic distribution within this subset of 440 patients was as follows: schizophrenia (58.0%) bipolar disorder (11.4%) schizoaffective disorder (9.8%), psychotic disorder not otherwise specified (5.7%), substance abuse or dependence (4.6%) major depression (2.5%), organic disorders (2.0%) and other diagnoses (6.0%). To test the hypothesis linking bipolar disorder, high-risk sexual behavior, and female gender, we implemented a maximum likelihood analysis of variance (categorical model) using the RBQ risk factor b (sex with parenteral drug users or with partners who have AIDS) as the dependent variable. The independent variables were gender and diagnostic category (bipolar or other). The interaction between gender and diagnostic category was also tested. The effect of gender was significant (x2 = 7.05, df = 1,p = 0.01) and so was the interaction (x2 = 4.34, df = 1, p = 0.04). Fig. 1 demonstrates that the females had a higher relative frequency of this risk factor (gender effect), and that bipolar disorder was more likely to be associated with this risk factor in females than in males (interaction). The interaction thus supported the hypothesis. Risk behaviors in the traceable subset. RBQ data were available for 363 of the
112 Fig. 1. Interaction between 3 variables: Sex with parenteral drug users or with partners who have AIDS (Sexrisk), gender, and diagnosis (bipolar or other) 50
40
z
30
x ." ; ::
20
m
Bipolar Other
10
0
MALES
FEMALES
Vertical axis indexes the percentage of subjects who answered positively the Sexrisk question. There were 21 female and 26 male bipolar patients; and 101 females and 292 males with other diagnoses. The effects of gender and gender X diagnosis interaction were statistically significant (see text). AIDS = acquired tmmunodeficiency syndrome.
365 traceable patients, but subsequent analyses are based on 353 patients for whom data on each of the risk factors were available. Logistic regressions using HIV status as the dependent variable and risk factors as independent variables were run separately for males (n = 262) and for females (n = 91). The risk factors used in the analyses were those described in Methods except for blood transfusions; we detected only one HIV+ patient with a history of blood transfusion who denied all other risk factors. Males. The following risk factors were used: (a) parenteral drug use, (b) sex with a parenteral drug user or with a partner who has AIDS, (c) homosexual risk behaviors, and (d) sex with a prostitute. The only factor reaching statistical significance was parenteral drug use (~2 = 21.9, df = 1, p < 0.0001, odds ratio 13.6,95% confidence limits 6.1-30.3). We noted that factors (a) and (c)co-occurred in 17 of 262 cases, which was more than expected by chance (contingency table analysis; x2 = 14.8, p < 0.0001). However, the principal risk factor for the males was parenteral drug abuse; homosexual risk behavior played a secondary role. q
Females. Factors (a) and (b) were the same as used in the analyses of the males. Additionally, factor (e) (sex with bisexual male) was used as another independent variable. All three factors reached the level of statistical significance (see Table 1). Discussion We found that approximately 9% of psychiatric patients newly admitted to an urban state hospital were HIV+, mostly without knowing it. The HIV seroprevalence we observed should be compared with the 5.5%-7.9% reported by others in psychiatric
113 Table 1. Logistic regression of risk factors for HIV infection in female patients 95% Confidence limits of odds ratio Risk factors
P’
Odds ratio
Low
High
Parenteral drug use
4.8
0.030
6.5
1.9
21.6
Sex factor b
4.0
0.050
6.2
1.8
20.1
Sex factor e
4.2
0.041
6.6
1.8
23.9
Note. HIV = human immunodeficiency virus. Sex factor b = sex with parenteral drug users or with partners who have acquired immunodeficiency syndrome. Sex factor e = sex with bisexual males.
inpatients (Zamperetti et al., 1990; Cournos et al., 1991), and with the 3.7% reported among unselected admissions to a general hospital in Washington (Gordin et al., 1990). The subset of traceable patients did not differ from the anonymous subset in HIV seroprevalence or in demographic composition. The traceable subset, the focus of our inquiry, can therefore be taken to represent the population of our hospital, and perhaps of other psychiatric hospitals serving indigent inner city populations. Our data suggest that HIV testing of consenting, newly admitted psychiatric patients should become a routine procedure, particularly in those patients who abuse drugs. Mentally ill drug abusers should also be primary candidates for HIV prevention programs (including HIV counseling). The HIV seroprevalence rate among New York City drug abusers enrolled in methadone maintenance programs is 30% (Novick, 199 1). In spite of the fact that drug abuse was not the primary diagnosis in most of the patients we studied, our results reflect, in part, the seroprevalence rates among drug abusers in the hospital’s catchment area. Sexual transmission of HIV infection is an important factor among mentally ill females; this applies particularly to inner city females with bipolar disorder. It appears that such females may, perhaps during manic episodes, be particularly prone to engage in sex with known intravenous drug users or even with AIDS patients. The possibility of such very dangerous sexual behavior during mania should be kept in mind by patients’ caregivers. Manic patients may require particularly careful management and supervision; early hospitalization may be needed as soon as the first symptoms of mania appear. The hospitalization should accomplish prevention of sexual activity as well as aggressive treatment of the manic episode (Gewirtz et al., 1988). The diagnoses we used were provided by ward psychiatrists instead of by trained researchers using standard diagnostic interviews. This limits the reliability (and validity) of our results. However, a previous review of diagnostic practices in the hospital where our study was carried out (Lipton and Simon, 1985) had revealed a tendency to underdiagnose affective disorders (including mania). One can thus argue that the diagnosis of bipolar disorder in our sample may sometimes have been missed, but that those patients who received it were diagnosed correctly. Psychiatric patients in other geographic locations probably have lower seroprevalence rates than we observed since the prevalence of HIV infection among intravenous
114 drug users in the catchment area of our hospital is generally much higher than elsewhere (Hahn et al., 1989). Furthermore, the interaction between bipolar disorder, female gender, and sex with parenteral drug users (or AIDS patients) may not be occurring in geographic locations which lack sufficient numbers of such users or patients, or which are characterized by different cultural patterns shaping the behavior of female manic patients. These issues should be addressed in future research. Acknowledgments. HIV antibody tests were performed by the Division of Retrovirology
Immunology
(Department
ble without the support Clinical Director. We assistance of Mr. Jack ric Center. L. Camus, Vitrai, Ph.D., assisted
and of Health, City of New York). The study would have been impossi-
of Michael Ford, M.D., Executive Director, and Yves Chenier, M.D., acknowledge the effort of the staff of the Admissions Unit and the Mannheim and other staff of the laboratory of the Manhattan PsychiatM.D., and Joy Caparas, M.D., participated in data collection. Jozsef with statistical analyses.
References American Psychiatric Association. D&W-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: Author, 1987. Centers for Disease Control. HIV/AIDS Surveillance Report, September:8, 1991. Cournos, F.; Empfield, M.; Horwath, E.; McKinnon, K.; Meyer, I.; Schrage, H.; Currie, C.; and Agosin, B. HIV seroprevalence among admissions at two psychiatric hospitals. American Journal of Psychiatry, 148: 12251230, 199 1. Gewirtz, G.; Horwath, E.; Cournos, F.; and Empfield, M. Patients at risk for HIV. Hospital & Community Psychiatry, 39:131 I-1312, 1988. Gordin, F.M.; Gibert, C.; Hawley, H.P.; and Willoughby, A. Prevalence of human immunodeficiency virus and hepatitis B virus in unselected hospital admissions: Impiications for mandatory testing and universal precautions. Journal of Infectious Diseases, 161:14-17, 1990. Hahn, R.A.; Onorato, I.M.; Jones, T.S.; and Dougherty, J. Prevalence of HIV infection among intravenous drug users in the United States. Journal of the American Medical Association, 261:2677-2684, 1989. Lehmann, H.E. Affectivedisorders: Clinical features. In: Kaplan, H.I., and Sadock, B.J., eds. Comprehensive Textbook of Psychiatry. Baltimore: Williams & Wilkins, 1985. p. 798. Lipton, A.A., and Simon, F.S. Psychiatric diagnosis in a state hospital: Manhattan State revisited. Hospital & Community Psychiatry, 36:368-373, 1985. Novick, L.I. New York State HIV seroprevalence project: Goals, windows, and policy considerations. American Journal of Public Health, 8 I(Supp1.): I I-14, 1991. Sacks, M.H.; Perry, S.; Shindledecker, R.; and Hall, S. Self-reported HIV-related risk behaviors in psychiatric patients: A pilot study. Hospital & Community Psychiatry, 41: 12531255, 1990a. Sacks, M.H.; Silberstein, C.; Weiler, P.; and Perry, S. HIV-related risk factors in acute psychiatric inpatients, Hospital & Community Psychiatry, 41~449-45 1, 1990b. Zafrani, M,, and McLaughlin, D.G. Knowledge about AIDS. Hospital & Community Psychiatry, 41: 1261, 1990. Zamperetti, M.; Goldwurm, G.F.; Abbate, E.; Gris, T.; Muratori, S.; and Vigo, B. Abstracts, VI International Conference on AIDS, 1990. p. 182.
109
Elsevier
HIV Seroprevalence Inpatients Jan Volavka, Antonio and Fidel Ventura
Convit,
and
Risk
Behaviors
in Psychiatric
Pal Czobor, Richard Douyon, Jane O’Donnell,
Received August 2, 1991; revised version received October IS, 199l;accepted
October20,1991.
Abstract. The seroprevalence of the human immunodeficiency virus (HIV) in 5 15 patients consecutively admitted to a state psychiatric hospital in New York City was 8.9%. There were 365 patients whose results were individually traceable; the remaining 150 patients were tested anonymously. Risk factors including parenteral drug abuse, male homosexual behaviors, and other sexual behaviors were studied in the traceable patients. Logistic regressions indicated that parenteral drug abuse was the main risk factor in both males and females. In females, two additional factors were significant: sex with parenteral drug users or with partners who have the acquired immunodeficiency syndrome (AIDS), and sex with bisexual men. Females with bipolar disorders were particularly likely to report sex with parenteral drug users or with partners who have AIDS. Key Words. Human immunodeficiency sexuality, acquired immunodeficiency
virus, seroprevalence, syndrome.
drug abuse, homo-
Risk behaviors related to the human immunodeficiency virus (HIV) are frequent among psychiatric patients (Sacks et al., 1990a, 1990b; Zafrani and McLaughlin, 1990). HIV seroprevalence in psychiatric inpatients in New York City was reported to
be 5.5% (Cournos et al., 199 1) or 7.9% (Sacks et al., quoted in Cournos et al., 1991). In Milan, the rate was 6.5% (Zamperetti et al., 1990). However, the risk behaviors established by questionnaires (Sacks et al., 1990a, 1990b; Zafrani and McLaughlin, 1990) have not been linked to HIV test results in the same patients, and the risk behaviors reported in the study of Cournos et al. (1991) were extracted by retrospective chart review instead of by structured risk assessment interviews. Our study was designed to determine HIV seroprevalence, assess risk behaviors by a specific questionnaire, and relate these behaviors to HIV infection. Furthermore, we were interested in a possible relationship between psychiatric diagnosis and risk behavior.
Jan Volavka, M.D., Ph.D., is Professor of Psychiatry, New York University Medical Center, and Chief, Clinical Research Division, Nathan S. Kline Institute for Psychiatric Research. Antonio Convit, M.D., is Assistant Professor, Department of Psychiatry, New York University Medical Center, and Nathan S. Kline Institute for Psychiatric Research. Pal Czobor, Ph.D., is Visiting Professor, Department of Psychiatry, New York Universitv Medical Center, and Nathan S. Kline Institute for Psvchiatric Research. Richard Douyon, M.D., is instructor, Department of Psychiatry, New York University Medical Center. Jane O’Donnell, M.A., and Fidel Ventura, M.D., are Research Scientists, Nathan S. Kline Institute for Psychiatric Research. Drs. Volavka, Douyon, Ventura, and Ms. O’Donnell work at the Manhattan Psychiatric Center in New York City, where all the patients were seen. (Reprint requests to Dr. J. Volavka, Nathan Kline Institute, Orangeburg, NY 10962, USA.) 0165-1781191
jSO3.50 @ 1991 Elsevier Scientific
Publishers
Ireland
Ltd.
110 Disinhibition associated with mania frequently involves hypersexual or promiscuous behavior (Lehmann, 1985). Gewirtz et al. (1988) reported on two female patients whose promiscuous behaviors during manic or psychotic states had apparently resulted in HIV infection. Sex with intravenous drug users is a more important risk factor for the acquired immunodeficiency syndrome (AIDS) in females than in males (Centers for Disease Control, 1991). On the basis of these facts, we developed the following hypothesis: bipolar disorder is related to high-risk sexual activity, and females are more likely to demonstrate this relationship. Methods Between February 15, 1990, and February 15, 199 1, patients were consecutively admitted to a state psychiatric center in New York City. The patients were black (58%), hispanic (22%), or white (20%). The psychiatric center serves the indigent population of Manhattan. In general, this facility admits severely and persistently mentally ill patients. The patients were diagnosed by their ward psychiatrists, who were expected to use DSM-III-R criteria (American Psychiatric Association, 1987) and these diagnoses were available in 538 cases (diagnosis was listed as “deferred” in 3 1 cases, and in 6 cases it was missing altogether). The Axis I primary diagnoses of the 538 cases were as follows: schizophrenia (58.9%) bipolar disorder (I 1.3%). schizoaffective disorder (lO.O%), psychotic disorder not otherwise specified (6%) substance abuse or dependence (4. I%), major depression (2.2%), organic disorders (2.2%), and various other diagnoses (5.3%). Although the primary diagnosis of substance abuse or dependence was rare in this patient sample, reports of use and abuse were not. Standard HIV antibody tests (ELISA and confirmatory Western blot) were performed in 506 subjects whose HIV status was undocumented on arrival to the psychiatric center; documented HIV positive (HIV+) subjects (n = 11) were not retested. Two of the 506 HIV tests performed were inconclusive, and the patients were not available for retesting. Thus, we obtained 504 valid HIV tests, and were aware of an additional 11 (positive) results. Ourcomplete sample therefore consisted of 515 HIV-tested cases. We could not test 58 cases (mainly because they refused any blood extraction). Wecompared these 58 patients (plus the 2 patients with inconclusive HIV test results) with the 515 HIV-tested patients, and found no significant differences between these two sets on age, gender, or race. The patients were asked for consent to participate in the HIV seroprevalence study. If the patient gave written consent for an HIV test, the test result was traceable to that individual. Blood samples of patients unable or unwilling to give consent were analyzed anonymously (i.e., the samples were labeled in a way that made it impossible to trace the test results to any individual). This arrangement was approved by the appropriate Institutional Review Boards. Subjects were interviewed about their HIV-related risk behaviors using a Risk Behavior Questionnaire (RBQ) constructed for this purpose. The RBQ consists of 13 items covering the following risk factors: (a) parenteral drug use, (b) sex with parenteral drug users or with partners who have AIDS, (c) homosexual risk behaviors, (d) sex with prostitutes, (e) sex with bisexual males, and (f) blood transfusions. Factors (c) and (d) were established only for male patients; factor (e) only for female patients.
Results HIV Seroprevalence. Our sample was divided into two subsets. The traceable subset (n = 365) consisted of 354 consenters and 11 patients whose HIV positivity had been documented by previous tests. The anonymous subset (n = 150) consisted of patients who did not consent to the HIV test. Complete sample (traceable plus anonymous patients). A total of 46 out of 515 (8.9%) patients were HIV. There were no statistically significant differences
111 between traceable and anonymous subsets in HIV seroprevalence rate, gender, age, and race. The traceable patients were slightly younger (average age = 37.1, SD = 11.1) than the anonymous ones (average age = 39.1, SD = 11.2); this difference approached the level of statistical significance (F = 3.62; df = 1, 513; p = 0.06). The HIV seroprevalence among the traceable patients was 10.1% (37/365), in the nontraceable patients, it was 6% (9/ 150; x2 = 1.76, df = 1, NS). It should be noted, however, that the traceable subset included 11 patients whose HIV positivity had been documented before they entered the study; accordingly, we did not request their consent to an HIV test. To answer the question whether consent (rather than traceability) was related to seropositivity, we repeated the test after the exclusion of these 11 patients. Again, no significant relationship emerged (x2 = 0.12). Traceable subset. There were 14198 HIV females (14.3%) and 23/ 267 HIV males (8.6%); this difference in rates was not statistically significant (~2 = 2.53, df 1, p = 0.11). The traceable patients were black (56%), hispanic (24%), and white (20%); race was unrelated to seropositivity (x2 = 1.36, df 2, p = 0.51). The primary Axis I DSM-III-R (American Psychiatric Association, 1987) diagnoses were available in 34 of the 37 HIV+ patients (three were listed as “deferred”). The breakdown was as follows: schizophrenia 38.2% (n = 13); major depression, bipolar disorder, substance abuse or dependence, and psychotic disorder not otherwise specified 11.8% (n = 4 each); schizoaffective disorder 8.8% (n = 3) and other diagnoses 5.8% (n = 2). The diagnoses for the HIV- patients were: schizophrenia 56.7%, bipolar disorder 11.8% schizoaffective disorder 11.1% psychotic disorder not otherwise specified 5.9%, substance abuse or dependence 4.3%, major depression 2.3%, organic disorders 2%, and other diagnoses 5.9%. q
q
HIV Risk Behaviors. Diagnosis and risk behavior in the complete sample (traceable and anonymous patients). In 484 patients (a subset of the 5 15 patients in the complete sample), a primary Axis I diagnosis was recorded by their ward psychiatrists. (Diagnosis was listed as “deferred” in 26 cases, and was missing in 5 additional cases.) RBQ data were available in 440 of the diagnosed cases (318 males and 122 females). The diagnostic distribution within this subset of 440 patients was as follows: schizophrenia (58.0%) bipolar disorder (11.4%) schizoaffective disorder (9.8%), psychotic disorder not otherwise specified (5.7%), substance abuse or dependence (4.6%) major depression (2.5%), organic disorders (2.0%) and other diagnoses (6.0%). To test the hypothesis linking bipolar disorder, high-risk sexual behavior, and female gender, we implemented a maximum likelihood analysis of variance (categorical model) using the RBQ risk factor b (sex with parenteral drug users or with partners who have AIDS) as the dependent variable. The independent variables were gender and diagnostic category (bipolar or other). The interaction between gender and diagnostic category was also tested. The effect of gender was significant (x2 = 7.05, df = 1,p = 0.01) and so was the interaction (x2 = 4.34, df = 1, p = 0.04). Fig. 1 demonstrates that the females had a higher relative frequency of this risk factor (gender effect), and that bipolar disorder was more likely to be associated with this risk factor in females than in males (interaction). The interaction thus supported the hypothesis. Risk behaviors in the traceable subset. RBQ data were available for 363 of the
112 Fig. 1. Interaction between 3 variables: Sex with parenteral drug users or with partners who have AIDS (Sexrisk), gender, and diagnosis (bipolar or other) 50
40
z
30
x ." ; ::
20
m
Bipolar Other
10
0
MALES
FEMALES
Vertical axis indexes the percentage of subjects who answered positively the Sexrisk question. There were 21 female and 26 male bipolar patients; and 101 females and 292 males with other diagnoses. The effects of gender and gender X diagnosis interaction were statistically significant (see text). AIDS = acquired tmmunodeficiency syndrome.
365 traceable patients, but subsequent analyses are based on 353 patients for whom data on each of the risk factors were available. Logistic regressions using HIV status as the dependent variable and risk factors as independent variables were run separately for males (n = 262) and for females (n = 91). The risk factors used in the analyses were those described in Methods except for blood transfusions; we detected only one HIV+ patient with a history of blood transfusion who denied all other risk factors. Males. The following risk factors were used: (a) parenteral drug use, (b) sex with a parenteral drug user or with a partner who has AIDS, (c) homosexual risk behaviors, and (d) sex with a prostitute. The only factor reaching statistical significance was parenteral drug use (~2 = 21.9, df = 1, p < 0.0001, odds ratio 13.6,95% confidence limits 6.1-30.3). We noted that factors (a) and (c)co-occurred in 17 of 262 cases, which was more than expected by chance (contingency table analysis; x2 = 14.8, p < 0.0001). However, the principal risk factor for the males was parenteral drug abuse; homosexual risk behavior played a secondary role. q
Females. Factors (a) and (b) were the same as used in the analyses of the males. Additionally, factor (e) (sex with bisexual male) was used as another independent variable. All three factors reached the level of statistical significance (see Table 1). Discussion We found that approximately 9% of psychiatric patients newly admitted to an urban state hospital were HIV+, mostly without knowing it. The HIV seroprevalence we observed should be compared with the 5.5%-7.9% reported by others in psychiatric
113 Table 1. Logistic regression of risk factors for HIV infection in female patients 95% Confidence limits of odds ratio Risk factors
P’
Odds ratio
Low
High
Parenteral drug use
4.8
0.030
6.5
1.9
21.6
Sex factor b
4.0
0.050
6.2
1.8
20.1
Sex factor e
4.2
0.041
6.6
1.8
23.9
Note. HIV = human immunodeficiency virus. Sex factor b = sex with parenteral drug users or with partners who have acquired immunodeficiency syndrome. Sex factor e = sex with bisexual males.
inpatients (Zamperetti et al., 1990; Cournos et al., 1991), and with the 3.7% reported among unselected admissions to a general hospital in Washington (Gordin et al., 1990). The subset of traceable patients did not differ from the anonymous subset in HIV seroprevalence or in demographic composition. The traceable subset, the focus of our inquiry, can therefore be taken to represent the population of our hospital, and perhaps of other psychiatric hospitals serving indigent inner city populations. Our data suggest that HIV testing of consenting, newly admitted psychiatric patients should become a routine procedure, particularly in those patients who abuse drugs. Mentally ill drug abusers should also be primary candidates for HIV prevention programs (including HIV counseling). The HIV seroprevalence rate among New York City drug abusers enrolled in methadone maintenance programs is 30% (Novick, 199 1). In spite of the fact that drug abuse was not the primary diagnosis in most of the patients we studied, our results reflect, in part, the seroprevalence rates among drug abusers in the hospital’s catchment area. Sexual transmission of HIV infection is an important factor among mentally ill females; this applies particularly to inner city females with bipolar disorder. It appears that such females may, perhaps during manic episodes, be particularly prone to engage in sex with known intravenous drug users or even with AIDS patients. The possibility of such very dangerous sexual behavior during mania should be kept in mind by patients’ caregivers. Manic patients may require particularly careful management and supervision; early hospitalization may be needed as soon as the first symptoms of mania appear. The hospitalization should accomplish prevention of sexual activity as well as aggressive treatment of the manic episode (Gewirtz et al., 1988). The diagnoses we used were provided by ward psychiatrists instead of by trained researchers using standard diagnostic interviews. This limits the reliability (and validity) of our results. However, a previous review of diagnostic practices in the hospital where our study was carried out (Lipton and Simon, 1985) had revealed a tendency to underdiagnose affective disorders (including mania). One can thus argue that the diagnosis of bipolar disorder in our sample may sometimes have been missed, but that those patients who received it were diagnosed correctly. Psychiatric patients in other geographic locations probably have lower seroprevalence rates than we observed since the prevalence of HIV infection among intravenous
114 drug users in the catchment area of our hospital is generally much higher than elsewhere (Hahn et al., 1989). Furthermore, the interaction between bipolar disorder, female gender, and sex with parenteral drug users (or AIDS patients) may not be occurring in geographic locations which lack sufficient numbers of such users or patients, or which are characterized by different cultural patterns shaping the behavior of female manic patients. These issues should be addressed in future research. Acknowledgments. HIV antibody tests were performed by the Division of Retrovirology
Immunology
(Department
ble without the support Clinical Director. We assistance of Mr. Jack ric Center. L. Camus, Vitrai, Ph.D., assisted
and of Health, City of New York). The study would have been impossi-
of Michael Ford, M.D., Executive Director, and Yves Chenier, M.D., acknowledge the effort of the staff of the Admissions Unit and the Mannheim and other staff of the laboratory of the Manhattan PsychiatM.D., and Joy Caparas, M.D., participated in data collection. Jozsef with statistical analyses.
References American Psychiatric Association. D&W-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: Author, 1987. Centers for Disease Control. HIV/AIDS Surveillance Report, September:8, 1991. Cournos, F.; Empfield, M.; Horwath, E.; McKinnon, K.; Meyer, I.; Schrage, H.; Currie, C.; and Agosin, B. HIV seroprevalence among admissions at two psychiatric hospitals. American Journal of Psychiatry, 148: 12251230, 199 1. Gewirtz, G.; Horwath, E.; Cournos, F.; and Empfield, M. Patients at risk for HIV. Hospital & Community Psychiatry, 39:131 I-1312, 1988. Gordin, F.M.; Gibert, C.; Hawley, H.P.; and Willoughby, A. Prevalence of human immunodeficiency virus and hepatitis B virus in unselected hospital admissions: Impiications for mandatory testing and universal precautions. Journal of Infectious Diseases, 161:14-17, 1990. Hahn, R.A.; Onorato, I.M.; Jones, T.S.; and Dougherty, J. Prevalence of HIV infection among intravenous drug users in the United States. Journal of the American Medical Association, 261:2677-2684, 1989. Lehmann, H.E. Affectivedisorders: Clinical features. In: Kaplan, H.I., and Sadock, B.J., eds. Comprehensive Textbook of Psychiatry. Baltimore: Williams & Wilkins, 1985. p. 798. Lipton, A.A., and Simon, F.S. Psychiatric diagnosis in a state hospital: Manhattan State revisited. Hospital & Community Psychiatry, 36:368-373, 1985. Novick, L.I. New York State HIV seroprevalence project: Goals, windows, and policy considerations. American Journal of Public Health, 8 I(Supp1.): I I-14, 1991. Sacks, M.H.; Perry, S.; Shindledecker, R.; and Hall, S. Self-reported HIV-related risk behaviors in psychiatric patients: A pilot study. Hospital & Community Psychiatry, 41: 12531255, 1990a. Sacks, M.H.; Silberstein, C.; Weiler, P.; and Perry, S. HIV-related risk factors in acute psychiatric inpatients, Hospital & Community Psychiatry, 41~449-45 1, 1990b. Zafrani, M,, and McLaughlin, D.G. Knowledge about AIDS. Hospital & Community Psychiatry, 41: 1261, 1990. Zamperetti, M.; Goldwurm, G.F.; Abbate, E.; Gris, T.; Muratori, S.; and Vigo, B. Abstracts, VI International Conference on AIDS, 1990. p. 182.
