HIV prevention with severely mentally ill men: A randomised controlled trial

We conducted a randomised clinical trial to test the efficacy of an enhanced version of an intervention previously shown to reduce HIV sexual risk behaviours among men with severe mental illness. One-hundred-and-forty-nine subjects aged 18-59 years were randomly assigned to the experimental or control conditions. Sexual risk behaviours were assessed every three months for 12-months. The primary analysis compared experimental and control groups with respect to sexual risk behaviours with casual partners as measured by the Vaginal Episodes Equivalent (VEE) score. Additional analyses included comparison of VEE scores of those men sexually active in the three months prior to baseline and the proportion of condom-protected sexual acts with casual partners. There were no significant differences in sexual risk behaviours with casual partners between experimental and control subjects. Additional analyses demonstrated a trend toward sexual risk reduction at six months post-intervention (p=0.06) but not at 12 months. These results may reflect a lack of efficacy or a true reduction in risk that the trial was underpowered to detect at the 0.05-level. If there was a true reduction in risk, it was not maintained after the initial six months.

HIV/AIDS preparedness in mental health care agencies with high and low substance use disorder caseloads

PURPOSE

The Columbia University HIV Mental Health Training Project, created to improve the mental health workforce's AIDS preparedness in New York and neighboring states, sought to compare the perceived HIV-related needs and capacities of mental health care providers in settings where clients with substance use disorders predominated versus those where clients with substance use disorders were the minority of the agencies' caseload.

METHODS

The first consecutive 67 mental health care agencies that requested HIV/AIDS training between March 2000 and January 2001 completed a written needs assessment describing their HIV-related services and training needs.

RESULTS

Agencies with higher substance abuse caseloads were significantly more likely than others to have large HIV/AIDS caseloads, to be currently providing condoms to clients, and to rate staff comfort with sexual identity issues as well as drug-related issues as good. Overall, agencies that had received previous training in specific topic areas (e.g., HIV risk assessment) were significantly more likely than others to provide those services. Even so, in all settings, significant gaps in service provision were found.

IMPLICATIONS

Two decades into the AIDS epidemic, mental health care agencies, especially those treating smaller caseloads of patients with substance use disorders, may not be providing sufficient services to meet their clients' HIV-related needs.

Adherence to treatment

Since the advent of highly active antiretroviral therapy, the issue of strict adherence has become increasingly important. This chapter examines how the mental health provider can employ a multimodal approach to promoting patient adherence, which increases the chances of success.

Essential medical facts for mental health practitioners

New information about the life cycle of HIV, new HIV-specific laboratory tests, and newer antiretroviral medications have transformed the management of HIV illness. Knowledge about these changes will help mental health providers better understand the latest medical issues affecting their HIV-infected patients, which will assist them in providing better care.

Assessing the risk of recidivism in physicians with histories of sexual misconduct

Physicians who engage in sexual conduct with patients usually cause serious harm and have a high rate of recidivism. Although offending physicians may lose their privilege to practice, they have the right to appeal for restoration of the license. Yet medical licensing board members do not currently have any clear standards by which to predict whether a given physician is likely to abuse again. Using New York as a paradigm, this paper offers practical, clinically based guidelines for assessing the risk of restoring an offending physician's license. These guidelines are derived from psychoanalytic theories of character, the insights of therapists who have worked with abusive physicians, and the psychiatric model of assessing dangerousness. Recognizing character patterns and psychological vulnerabilities of physicians with histories of sexual misconduct will help board members identify those who are at high risk of abusing again if their licenses are restored.

AIDS-related services and training in outpatient mental health care agencies in New York

Directors of 471 outpatient mental health settings in New York State (82.1 percent of 574 settings located in counties with intermediate to high AIDS case rates) completed a survey about HIV and AIDS services, training needs, and barriers to care. Most of the sites served one to ten persons with HIV infection annually and had staff members who were trained in providing at least one HIV-related service. Nonetheless, 84 percent of the respondents reported unmet needs for training. The likelihood of providing certain services was significantly increased in sites that were in urban locations, primarily served clients with comorbid alcohol or other drug use disorders, lacked funds for providing condoms, had staff members who were trained in HIV and AIDS services, identified particular HIV training needs, believed clients needed condoms, and viewed HIV-related services as very important.

HIV and people with serious mental illness: the public sector's role in reducing HIV risk and improving care

OBJECTIVE

The paper discusses issues related to the detection, prevention of transmission, and treatment of human immunodeficiency virus (HIV) infection among persons with serious mental illness and suggests ways public mental health systems can address these issues.

METHODS

MEDLINE was searched from 1980 through 1998, and all pertinent references were reviewed.

RESULTS

Persons with severe mental illness are at greatly increased risk of HIV infection due to increased likelihood of high-risk sexual behaviors and injection drug use. The formidable barriers to detection and effective treatment of HIV that exist in this population can be attributed to the unique characteristics of this population, lack of knowledge and expertise among mental and physical health care providers, and fragmented mental and physical health care systems.

CONCLUSIONS

In the last five years, treatments for HIV that are far more efficacious than earlier treatments have become available, making it more important for HIV infection be detected and treated among persons with serious mental illness. Public mental health systems need to implement active prevention policies and practices, educate both mental health and physical health care providers about key treatment issues, and develop effective linkages between mental and physical health care providers and systems.

Parenting and adjustment in schizophrenia

OBJECTIVE

Patients with schizophrenia who became parents and those who remained childless were compared on premorbid characteristics and current clinical and social adjustment.

METHODS

Subjects were 400 men and women with a DSM-III-R diagnosis of chronic schizophrenia based on the Structured Clinical Interview for DSM-III-R (SCID). Assessments measured concurrent substance abuse and antisocial behavior, positive and negative symptoms using the Positive and Negative Syndrome Scale, functional status using the Global Assessment of Functioning scale, family support, and treatment compliance. A total of 158 patients were parents (47 men and 111 women), and 242 were childless (153 men and 89 women).

RESULTS

Compared with childless subjects, parents were more likely to have had better premorbid social adjustment, to have ever been married or involved in a conjugal relationship, and to have become ill at a later age. More than two-thirds of parents entered parenthood before the onset of schizophrenia. More women than men were parents, and parents were more likely to be members of ethnic minority groups. No differences were found in current clinical and social adjustment of parents and childless subjects.

CONCLUSIONS

Parenthood was associated with better premorbid social adjustment, but it conferred no advantage in the long-term course of schizophrenia. Patients who experience a later onset of schizophrenia or have better premorbid social skills may be more likely to undertake marriage and parenthood, but they will then also be more likely to need special support for the parenting role once the illness begins and takes its typical course.

Childhood experiences and current adjustment of offspring of indigent patients with schizophrenia

OBJECTIVE

This study reports the childhood experiences, current life situation and level of adjustment, and prior mental health service use of offspring of indigent people with schizophrenia.

METHODS

Sixty-eight patient-parents were asked for consent for researchers to contact their adolescent and adult offspring. Thirty-nine consenting offspring were interviewed with an assessment battery that included measures of current occupational and social functioning, psychiatric status, and mental health service use.

RESULTS

Interviewed offspring were raised in an average of three different settings from birth to 18 years of age. Relatives, particularly grandparents and aunts, were more likely to provide surrogate parenting than were nonkin foster parents and were more significant nurturing figures than biological parents. The typical offspring had a high school diploma, was gainfully employed, and was involved with a spouse or household partner or had a close friend. Twenty-three of the 39 offspring had children, and most were raising their children alone. Ten offspring had a diagnosis of major depression, schizoaffective disorder, or drug or alcohol abuse, but none had a diagnosis of schizophrenia. Four of the ten offspring with a psychiatric diagnosis had never been treated.

CONCLUSIONS

Findings underscore the need for long-term studies of families with a parent who is a psychiatric patient. Rehabilitation efforts should include extended family who play a critical role in raising offspring during periods when patient-parents are unable to do so. Offspring should be included in efforts to educate families about schizophrenia.

HIV seroprevalence among people with severe mental illness in the United States: a critical review

The authors reviewed all studies in the peer-reviewed literature reporting HIV seroprevalence among people with severe mental illness in the United States, which varied from 4.0% to 22.9%. Findings across samples suggest that seroprevalence varies with geographic concentration of HIV and presence of comorbid psychoactive substance use disorders, but is consistently high. Unsafe sex, drug injection, and noninjected drug use were associated with infection, and in most studies women were as likely to be infected as men. Seroprevalence also varied with age and ethnicity, but not psychiatric diagnosis. The authors review questions and methodological issues important to future studies.

HIV and AIDS among the severely mentally ill: introduction to the special series

Men and women who have a severe and persistent mental illness are vulnerable to infection with HIV. Recognition of this vulnerability led the Office of AIDS at the National Institute of Mental Health (NIMH) to invite leading practitioners, researchers, consumer advocates, and policy makers to a National Conference on HIV and AIDS among the Severely Mentally Ill. This article describes the proceedings of the Conference, and provides an overview of the resulting summary reports that comprise this special issue.

Research on HIV, AIDS, and severe mental illness: recommendations from the NIMH National Conference

We summarize the recommendations for research that emerged from a NIMH-sponsored Conference on HIV, AIDS, and Severe Mental Illness. Recommendations are made in four areas, namely, epidemiology of HIV infection, epidemiology of sexual and drug-use risk behaviors, risk reduction and transmission prevention, and treatment of infected persons. This research is urgently needed to adequately respond to the AIDS epidemic among people with severe mental illness.

The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness

BACKGROUND

This study was designed to determine whether psychiatric symptoms and acquired immunodeficiency syndrome (AIDS) knowledge predict human immunodeficiency virus (HIV) risk behavior among people with severe mental illness.

METHOD

We interviewed 178 psychiatric patients to determine Axis I diagnosis, level of functioning, severity of psychiatric symptoms, knowledge about AIDS, sexual risk behaviors in the previous 6 months, and drug injection since 1978. Severity of psychiatric symptoms was rated on the Positive and Negative Syndrome Scale within the classification of positive, negative, cognitive, excited, and depressed/anxious symptoms.

RESULTS

Ninety-two patients (51.7%) reported being sexually active in the previous 6 months. Of sexually active patients for whom data were available, 44 (47.8%) of 92 had multiple sex partners; 32 (35.2%) of 91 used drugs during sex; 27 (29.7%) of 91 traded sex for drugs, money, or other goods; and 50 (58.1%) of 86 never used condoms. Thirty-one patients (17.5%) had drug-injection histories. The median AIDS knowledge score was 23 (82.1%) of 28. Although AIDS knowledge was negatively correlated with cognitive and negative symptoms and positively correlated with excitement, knowledge alone did not predict any risk behavior. However, when AIDS knowledge was taken together with age and excited symptoms, the odds of being sexually active versus abstinent were three times higher among patients with better AIDS knowledge and twice higher among patients with greater excited symptoms. Having multiple sex partners was nearly three times as likely among patients with greater positive symptoms. Trading sex 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 more excitement symptoms.

CONCLUSION

Patients, particularly those who were sexually active, were well informed about AIDS. Specific psychiatric conditions, including the presence of positive and excited symptoms and a diagnosis of schizophrenia, predicted certain sexual risk behaviors and must be the focus of innovative prevention efforts.

Illicit-drug injection among psychiatric patients without a primary substance use disorder

OBJECTIVE

To increase understanding of HIV infection risk among patients with severe mental illness, the study sought to identify predictors of injection drug use among patients who did not have a primary substance use disorder.

METHODS

A total of 192 patients recruited from inpatient and outpatient public psychiatric facilities were interviewed by trained mental health professionals using the Structured Clinical Interview for DSM-III-R (SCID), the Positive and Negative Syndrome Scale, and the Parenteral Drug Use High-Risk Questionnaire.

RESULTS

Sixty percent of the sample met SCID criteria for lifetime substance abuse or dependence. Although only two patients reported drug injection in the past six months, 38 (20 percent) had injected drugs since 1978, the year that HIV began to spread in the U.S. A lifetime diagnosis of opioid abuse or dependence was a strong predictor of drug injection, but only 11 of the 38 patients with a recent history of injection drug use had either of these diagnoses. The likelihood of injecting drugs was four times greater among patients with a history of intranasal substance use compared with those without such use, three and a half times greater among African-American patients than among non-African-Americans, and five times greater among patients aged 36 or older compared with younger patients.

CONCLUSIONS

In assessing HIV risk among patients with severe mental illness, it may be more important to identify the route of drug administration than the specific substances used because of the strong association between intranasal drug use and history of injection.

Risk factors for homelessness among women with schizophrenia

A study of risk factors for homelessness among the severely mentally ill was extended to include women, and a case-control study of 100 indigent women with schizophrenia meeting criteria for literal homelessness and 100 such women with no history of homelessness was conducted. Subjects were recruited from shelters, clinics, and inpatient psychiatric programs in New York City. Clinical interviewers used standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. Findings adjusted for ethnicity revealed that homeless women had higher rates of a concurrent diagnosis of alcohol abuse, drug abuse, and antisocial personality disorder. Homeless women also had less adequate family support.

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-1 infection at two public psychiatric hospitals in New York City

Seroprevalence for HIV-1 was anonymously evaluated between November 1989 and July 1991 among severely mentally ill patients at two public psychiatric hospitals in New York City. The study population consisted of new admissions and long-stay patients aged 18-59. Of 1116 eligible patients, usable samples were obtained from routine blood drawings on 971 (87%). Seroprevalence was comparable among men (5.2%) and women (5.3%). Age did not predict seropositivity. Men with a recorded history of homosexual behaviour or injection drug use were, respectively, 1.8 and 2.0 times more likely to be seropositive than men without these histories. Women with a recorded history of injection drug use were 4.0 times more likely to be seropositive than women without such a history. Ethnicity was not predictive for men, but Black women were 2.4 times more likely to be HIV-1 positive than non-Black women. Severely mentally ill inpatients had a substantial rate of HIV-1 seropositivity, indicating a need for additional testing, education and counselling efforts for this population.

Sexual activity and risk of HIV infection among patients with schizophrenia

OBJECTIVE

This study sought to determine the frequency and types of sexual behavior among patients with schizophrenia and to assess the behavior with respect to risk of HIV infection.

METHOD

Ninety-five inpatients and outpatients with a research diagnosis of schizophrenia underwent a series of face-to-face interviews to determine their sexual activity and correlate it with demographic characteristics, psychopathology, and medication side effects.

RESULTS

Forty-four percent of the patients had been sexually active in the preceding 6 months, and 62% of these had had multiple partners. Sexual activity was associated with greater general psychopathology. Having multiple sexual partners was associated with younger age, a lower level of functioning, the presence of delusions, and more positive symptoms. Of the sexually active patients, 12% reported at least one partner who was HIV positive or injected drugs, or both, and 50% had exchanged sex for money or goods. Ten percent of the patients had engaged in homosexual activity in the preceding 6 months and 22% during their lifetime; the frequency was similar among men and women. Consistent condom use was uncommon.

CONCLUSIONS

A substantial proportion of schizophrenic patients had recent histories of sexual abstinence, but an almost equal number were sexually active. Sexual activity was usually accompanied by behavior related to HIV risk. Sexual activity and having multiple partners were associated with certain measures of more severe illness. Younger patients were more likely to have multiple partners but were also more likely to use condoms. There is a need for aggressive prevention strategies with this population.

Reliability of sexual risk behavior interviews with psychiatric patients

Test-retest interviews examining recent sexual activity were administered to 27 severely ill psychiatric patients after stabilization. Three reports were judged to be questionable. For the 16 sexually active patients among the remaining 24, high test-retest reliability was found for number of sexual partners, frequency of episodes, and proportions of episodes involving vaginal intercourse and use of condoms. The interviews did not exacerbate psychiatric symptoms.

Do psychiatric patients need greater protection than medical patients when they consent to treatment?

It is commonly assumed that psychiatric patients require greater protection than medical patients when they make health care decisions. A review of the literature reveals that there is meager evidence for this belief and that both groups have significant capacity problems. Many factors other than psychiatric illness have been shown to impede understanding of informed consent information in health care settings. These include powerful emotional states, lack of a high school education, the presence of a severe medical illness, and increasing age. Clinicians can help patients become more adequate decision makers by taking such steps as providing adequate disclosure and inquiring about patient understanding. Even then, setting a realistically lenient standard of capacity seems the most practical approach. If screening for capacity is important for a specific health care decision, all vulnerable groups should be targeted.

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.

Outcome of involuntary medication in a state hospital system

OBJECTIVE

The purpose of the study was to examine the course of involuntarily administered medication in a state hospital population.

METHOD

The authors retrospectively examined the records of all 51 involuntarily medicated patients in six state hospitals in New York City in a single calendar year. Clinical course was recorded for the period of involuntary medication and for 12 months thereafter. These patients were compared to 51 patients on the same wards who accepted medication.

RESULTS

Clinicians assessed involuntarily medicated patients as more dangerous to themselves or others and less delusional after treatment than the comparison patients. Long-acting intramuscular antipsychotics were prescribed more frequently for involuntarily medicated patients. No differences were observed in rates of discharge, outpatient cooperation, or rehospitalization. Half of the patients in both groups remained continuously institutionalized, and of those who left the hospital, only 30% of the involuntarily medicated group and 40% of the comparison group took medication as outpatients.

CONCLUSIONS

For these chronically severely ill patients, involuntary medication did not appear to enhance insight or cooperation or result in rapid return to the community. Involuntary medication is often a necessary short-term, in-hospital management strategy, but it does not replace the need to develop comprehensive, long-term inpatient and community-based approaches to the management of treatment refusal.

Medication and psychotherapy in the treatment of chronic schizophrenia

Current theory in the treatment of schizophrenia emphasizes medication and expresses considerable doubt about the value of psychotherapy. Yet the data that lead to this conclusion have been gathered in studies of carefully selected groups of cooperative patients who consent to treatment and participate well in scientific studies. In public psychiatry, where many patients are uncooperative and even coerced into treatment, we have found that attention to the patient's individual psychology is essential to success. We examine the role of the psychiatrist who provides psychotherapy and medication in the context of a comprehensive program for patients with chronic schizophrenia.

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.

Rivers in practice: clinicians' assessments of patients' decision-making capacity

Since the Rivers v. Katz decision in 1986, clinicians in New York State have been required to assess patient decision-making capacity before judicial review of petitions to administer involuntary medication. The authors examined 42 capacity assessments made by psychiatrists at a large state hospital in New York City. Although the capacity assessments were often incomplete and rarely addressed the treatment decision, most clinicians judged patients as lacking capacity to make treatment decisions. The findings suggest that psychiatrists may view capacity assessments as irrelevant because of the manifestly grave nature of patients' illnesses or may not differentiate the capacity assessment from the mental status examination. The capacity assessment may nonetheless be a useful tool because it encourages clinicians to discuss the proposed treatment with patients and to present information more effectively in court.

Involuntary medication and the case of Joyce Brown

In October 1987, Joyce Brown became the first homeless person removed from New York City's streets and hospitalized under a city initiative that authorized evaluation of "gravely disabled" homeless persons for admission to inpatient psychiatric treatment. Miss Brown's highly publicized and ultimately successful court battle to prevent a course of forced medication is described. Her refusal of medication was upheld based on her capacity to understand the proposed treatment and to express a partially rational opinion about it. The author, who served as independent psychiatric consultant to the court on the decision about Miss Brown's involuntary medication, uses the case to illustrate some of the problems of involuntary psychiatric intervention, including the commitment of competent patients and the lack of a coherent approach to persistent treatment refusal.

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.

A comparison of clinical and judicial procedures for reviewing requests for involuntary medication in New York

The Rivers v. Katz decision substituted judicial review for administrative review of requests for involuntary medication of patients in New York State mental hospitals. This change, prompted by concern for the rights of involuntarily committed patients, did not delay or diminish the use of involuntary medication in a large state hospital. Advantages of judicial review include a better understanding by clinicians of the legal basis for involuntary medication and greater patient participation in the review procedure. Disadvantages include lack of an independent clinical review and increased costs.

The impact of environmental factors on outcome in residential programs

Although community residential placements are among the leading areas of program expansion for the chronic mentally ill, they have been designed without scientifically validated models. The author reviews the literature on the impact of residential environment on the course of serious mental illness. In most studies, environmental variables were better predictors of outcome than were patient variables. This overall finding suggests the value of further research on environment and the importance of applying the results to program development.

Hospitalization outcome studies. Implications for the treatment of the very ill patient

There are two basic findings from the hospitalization outcome literature: Active treatment is more effective than custodial care, and length-of-stay has little influence on later outcome. We have no current models that help us conceptualize the optimal hospital treatment for patients who are refractory, noncompliant, or without social supports. This article reviews the most important hospitalization outcome studies and emphasizes the need for further research in this area.

Orders not to resuscitate and the psychiatric hospital

In 1983, the President's Commission for the Study of Ethical Problems in Medicine recommended that all health care institutions be required to develop appropriate policies and procedures for withholding life-sustaining treatment from terminally ill patients. While such policies have been extensively debated, there has been little discussion of the problem in the psychiatric literature. Yet state mental hospitals handle many terminally ill patients, often without having clarified their medical responsibilities. This article focuses on Do Not Resuscitate (DNR) policies in psychiatric settings. It offers illustrative case examples and reviews the important principles and legal decisions that pertain to DNR policies. In hospitals that have no clearly defined medical standards, patients often receive inferior care. The need to develop DNR policies presents an opportunity to discover more thoughtful approaches to medical care in psychiatric hospitals.