Characteristics of HIV-positive chronically mentally ill inpatients.

The growing population of chronically mentally ill persons who are HIV-positive or who have AIDS has not yet been adequately studied. We describe the entire population of known HIV-positive inpatients in a state psychiatric center in New York City. In this sample, the typical patient with known HIV infection is as likely to be a man as a woman and is a member of an ethnic minority group. HIV-positive patients had multiple risks for HIV infection including injecting drug use (IDU), sex with IDU partners, prostitution and male homosexual activity. Most patients were at a late stage of HIV-infection, typically with CD4+ cell counts of 400. Discharge plans were complicated by HIV illness and most HIV-positive patients had a longer length of hospital stay than non HIV-positive patients. We discuss the need to plan for the management of increasing numbers of HIV-positive patients in inpatient, outpatient, and residential facilities.

HIV seroprevalence among homeless patients admitted to a psychiatric inpatient unit.

OBJECTIVE: This study was conducted to determine the seroprevalence of HIV-1 antibodies among hospitalized homeless mentally ill patients. METHOD: From December 1989 through May 1991 the authors collected discard blood samples from patients consecutively admitted to a psychiatric unit designated for the care of severely mentally ill persons removed from the streets of New York City. The blood samples were tested for HIV-1 antibodies, and the results were analyzed for associations with age, gender, ethnicity, male homosexual activity, and use of injected drugs. RESULTS: The HIV seroprevalence was 6.4% (13 of 203 samples). Patients between ages 18 and 39 accounted for 51.2% of the admissions and 84.6% of the 13 positive results, a seroprevalence of 10.6% for this subsample. Patients under age 40 were more than six times as likely to test positive for HIV antibodies as those 40 or over. Ethnicity did not predict seropositivity. Women were as likely as men to be infected. Although clinicians had noted high-risk behavior on the charts for only three (23.1%) of the 13 positive cases, a recorded history of use of injected drugs was associated with a 6.5-fold greater risk of HIV seropositivity. CONCLUSIONS: One in every 16 patients admitted to the special unit was HIV positive. Age under 40 and use of injected drugs were strongly associated with seropositivity. Because information on high-risk behavior was infrequent, the reasons for younger patients' greater risk are unclear. The homeless mentally ill require outreach efforts to reduce the risk of acquiring or transmitting HIV.

HIV prevention among psychiatric inpatients: a pilot risk reduction study.

An HIV prevention program was piloted on an acute inpatient admission ward. Patients who volunteered to participate had significantly higher rates of histories of substance use than non-participants, suggesting that patients participated based on rational concerns about past HIV risk behavior. The program consisted of 75 minute sessions once a week for seven weeks and was co-led by an HIV counselor and the ward's social worker. Each session focused on a specific topic and included a short presentation of informational material, viewing of an educational videotape, a discussion, and role play and other educational games. In spite of a wide range in functioning among the participants, discussion was lively and participation was good. The pilot program demonstrates that chronic mentally ill patients can engage in, and benefit from, risk reduction programs and that frank and explicit discussion of sexual issues is well tolerated. Recommendations for improvement in the program are discussed.

HIV seroprevalence among patients admitted to two psychiatric hospitals.

OBJECTIVE: The authors determined the seroprevalence of HIV-1 among patients admitted to two psychiatric hospitals in New York City. METHOD: Patients consecutively admitted to an acute psychiatric unit in Manhattan and a large state hospital in Queens were anonymously tested for HIV-1 antibodies from December 1989 through July 1990. Test results were linked to age, gender, ethnicity, and two risk behaviors: male homosexual activity and injection drug use. RESULTS: Blood was obtained from 83.0% of the eligible patients. The prevalence of HIV was 5.5% (25 of 451). Black patients accounted for 38.0% of the patients tested and 76.0% of positive results (N = 19), a rate of 11.1% for this group. The rate of seropositivity was comparable in women and men. Clinicians had charted risk behavior for nine (36.0%) of the 25 HIV-positive patients. Infection control records suggested that clinicians were aware of seven (28.0%) of the positive cases. CONCLUSIONS: One in every 18 patients admitted to two public psychiatric hospitals in New York City was HIV positive. Clinical staff largely failed to identify HIV-positive patients. Ethnicity and a history of homosexual activity among men or use of injected drugs were strongly associated with seropositivity. This pattern of infection may be linked to needle sharing and/or sexual activity with partners who have shared needles. Future research should clarify how psychiatric illness affects risk-taking behavior, focus on improving detection by clinicians, and identify effective prevention strategies in this population.

HIV infection in state hospitals: case reports and long-term management strategies.

Issues facing state psychiatric hospitals as a result of the epidemic of human immunodeficiency virus (HIV) are illustrated by five cases. These issues include use of universal precautions to prevent transmission of HIV, medical diagnosis and management of HIV-infected patients, management of threatening behavior by infected patients, management of patients' sexual behavior, and discharge planning. The authors suggest that institutions will be required to ensure that sexual behavior between patients does not occur or to offer patients condoms or other means to protect themselves from infection. They recommend upgrading the medical capabilities of state hospitals so that they can competently provide long-term combined medical and psychiatric care to HIV-infected patients.

Clinical presentations of AIDS and HIV infection in state psychiatric facilities.

The epidemiologic, neuropsychiatric, and medical data on AIDS and HIV infection that are relevant to state psychiatric facilities are reviewed. The epidemiologic data suggest that a larger than expected number of AIDS patients may be seen in these facilities. Patients who are severely disturbed and psychotic may present to state hospitals with HIV encephalopathy. In patients who are chronically and severely ill, physical symptoms, including oral and cutaneous conditions, the HIV wasting syndrome, and lymphadenopathy, may provide early clues to HIV infection. The early neuropsychiatric and medical findings in HIV infection are discussed, and a clinical case is presented.

The management of HIV infection in state psychiatric hospitals.

Patients with AIDS and related illnesses are entering state mental hospitals in increasing numbers. State hospitals in New York City generally did not plan for patients infected with human immunodeficiency virus (HIV) until the first patient appeared; however, over the past five years, approaches to managing these patients have evolved in the areas of admission policies, in-hospital care, and discharge planning. Strengthening infection control procedures through the adoption of universal precautions was the most straightforward aspect of in-hospital care. Testing for HIV and confidentiality of the test results proved most controversial. Clinical leaders urged that testing be done only with pre- and posttest counseling and only if the patient has symptoms of HIV infection, has requested the test, or has exposed others to infection. The authors describe these and other policies addressing medical care, restraint and seclusion, sexual behavior, and education and training.

Multiple contributions to clinical presentation of flat affect in schizophrenia.

Flat affect has long been recognized as a central manifestation of schizophrenia, and has more recently been appreciated as a stable and prognostically important attribute of this disorder. Yet, because it is thought to be difficult to evaluate, flat affect has been deemphasized in criterion-based diagnostic systems. Results of this study suggest that the clinical evaluation of flat affect may be contaminated by a number of behaviorally similar processes. The components we identified included right hemisphere dysfunction, retardation and extrapyramidal effects, as well as the sequelae of hospitalization. Thus, in the clinical evaluation of flat affect, a multivariate approach in which these different components are considered separately might improve the reliability of evaluation and make this important sign more useful.

Early parental absence as an indicator of course and outcome in chronic schizophrenia.

In two studies of chronic schizophrenic patients, long-term inpatients were found to have a significantly higher rate of histories of early parental absence than outpatients. Early parental absence may be an indicator of course and outcome in chronic schizophrenia.