Abstract
Keywords
Within Australia, the transmission of blood-borne viruses (BBVs) and sexually transmissible infections (STIs) among at-risk populations remains unacceptably high despite a number of successful prevention strategies, such as needle and syringe programs [1]. Although recent research suggests that psychiatric populations are at significant risk of contracting these infections [2–4], and the highest rate of new BBV/STIs occur among young people (i.e. those aged 15–29 years) [5], there is little information on the epidemiology of BBV/STIs among young people with mental health problems. In this paper, we outline available epidemiological data, specifically discussing findings related to psychiatric populations, aswell as interventions designed to target BBV/STI risk among those with serious mental illness (SMI) (i.e. those with a chronic psychiatric disorder). In particular, we will discuss the implications of such findings for young people with mental health issues, and suggest relevant directions for service development within Australia.
Blood-borne viral and sexually transmissible infection epidemiology in Australia
Viral hepatitis
Within Australia, the transmission of hepatitisB(HBV) and hepatitis C (HCV) is of concern for both health providers and policy-makers. Although recognizing that disease notifications (the principle method of collecting prevalence and incidence data) can underestimate true rates, it has been estimated that there are up to 16 000 newly acquired HCV infections in Australia per year [6], with over 240 000 Australians exposed to HCV, and over 180 000 with ongoing infection [6]. In comparison with HCV, there is a relative lack of information regarding HBV prevalence in Australia [7], [8], although recent data suggest that between 88 000 and 163 500 are currently living with HBV [7].
The highest rates of hepatitis infection occur among individuals reporting a history of injecting drug use (IDU), with 90% of newly acquired HCV infections [6] and 43% of new HBV infections attributed to IDU in 2003 [5]. However, the greatest risk appears to be among those who have recently commenced injecting. Estimates vary, but on average 50% of IDUs are infected by HCV within 2 years of commencing injecting [9]. HBV also appears to be rapidly acquired following initiation of injection practices [10].
Other risk factors for hepatitis include a history of migration from countries where hepatitis is endemic, needle stick injuries, unsterile tattooing and unprotected sexual activity. In fact, in 2003, 38% of newly acquired HBV notifications were attributed to sexual contact, the majority (76%) being heterosexual [5].
Young people in particular, are at significant risk of contracting HCV and/or HBV because they are more likely to undertake behaviours that place them at risk of these infections (e.g. unprotected sexual activity or unsafe IDU) [5]. For example, in 2003, approximately 45% of all newly acquired HBV in Australia and 65% of newly acquired HCV infections occurred in the 15- to 29- year-old age group [5]. Similarly, in a study conducted at a primary health care service for IDUs in Sydney, HCV incidence among those under 20 years (74.1 per 100 person years) was substantially higher than figures for the whole service (21 per 100 person years) [5].
HIV/AIDS
Transmission of HIV inAustralia occurs predominantly among men who have sex with men, accounting for 82% of notifications of newly acquired HIV infections between 1999 and 2003 [5]. During this period, the annual number of HIV cases and the rate of newly acquired HIV infection have both increased in Australia [5]. This, taken together with recent increases in the reporting of other STIs and unsafe sexual behaviour suggests a recent true increase in HIV infections [11]. This increase threatens recent gains made in reducing rates of transmission and raise questions regarding the effectiveness of current prevention strategies [12].
Other sexually transmissible infections
The number of cases of chlamydia notified nationally, dramatically increased from 14 082 cases in 1999 to 30 193 cases in 2003 [5]. Diagnoses of chlamydia occur predominantly within the 15–29 years age group, accounting for 78% of such diagnoses in 2003 [5]. Of major concern is that chlamydia infection in women can lead to pelvic inflammatory disease (PID). An estimated 8% of untreated chlamydia infections produce PID in women, which can lead to tubal infertility [13].
In the 5 years 1999–2003, gonorrhoeae notifications have also risen from 5587 to 6611 [5]. Again nationally, diagnoses among the 15- to 29-year-old age group were most frequently reported, and accounted for 3842 (58%) of diagnoses reported in 2003 [5]. Syphilis outbreaks have been reported in recent years, but the increase in numbers is predominately in men who have sex with men. In Victoria, infectious syphilis notifications, reported by the Department of Human Services, have increased more than fivefold in the past decade with 74% occurring in men who have sex with men; a similar increase in notifications has been observed in New South Wales [14].
Sequelae and costs of infection
Both blood-borne viruses and sexually transmissible infections are associated with significant morbidity, mortality and substantial financial costs. For example, the health care costs needed to treat an estimated 10 000 HCV infections annually over the next 60 years is predicted to exceed $A4 billion [15], while Australia's annual HIV treatment costs are estimated to reach $A269 million in 2008 [1]. Treatment and management of common STIs are also expensive, with direct costs of chlamydia infection estimated to range from $A90 million to $A160 million annually in Australia [16].
Prevalence of BBV/STIs among psychiatric populations
Although certain populations within the general community (e.g. IDUs and sex workers) are considered to be at high risk of contracting BBV/STIs, recent research has highlighted that individuals with mental health problems are also at significant risk [2], [17]. Within the US, HIV rates have been reported to be between 13 and 76 times higher among mental health patients than the wider population [18]. Similarly, HBV and HCV rates have been reported to be up to 5 and 11 times higher, respectively [2]. In addition, in a recent large multi-site study in the US [19], 30% of 969 participants with a mental illness tested positive for at least one infectious disease (i.e. HIV/AIDS, HBV or HCV).
Although Australian data are limited, BBV/STI rates appear to be higher among psychiatric patients, impacting populations with SMI more than the general population. Ellen et al. found that 19.4% of 68 adult psychiatric inpatients were HCV positive [4] compared with a general population prevalence of 1.1% [6]. Unfortunately, no other data are available within the Australian context, although this preliminary study suggests that prevalence rates among Australian individuals with mental illness may be similar to international figures.
With reference to the impact of BBV/STIs on SMI populations, Western Australian data revealed that for all infectious diseases among mental health service (MHS) recipients, viral hepatitis was the second most common cause of hospitalization (after intestinal diseases) [20]. In fact, MHS patients were hospitalized for HCV five times more frequently than expected, andHBV hospitalizations occurred three times more frequently among male MHS patients than the general population [20]. Similarly, with regard to HIV and other STIs (syphilis, gonorrhoea, genital herpes and genital warts), MHS patients were hospitalized more frequently than the general population [20].
Despite surveillance data reporting high rates of BBV/STIs in younger people (15–29 years) [5], research on the prevalence of infectious diseases among psychiatric populations (both in the US and Australia) has been exclusively in older individuals (typically with a mean age of around 40 years) [2], [3], [17], [19], [21]. It is highly concerning that the epidemiology of BBV/STIs among younger people with mental health problems remains largely undetermined, especially given the potential costs for the individual, as well as the wider community.
Reasons for increased rates of infectious disease among psychiatric populations
Disorder-related issues
A number of specific reasons have been suggested for the increased risk of BBV/STIs among individuals with SMI, including increased levels of risk-taking behaviour and substance use [2], [17], [22], [23]. Mental health disorders are also frequently associated with a number of cognitive and behavioural impairments, and symptom relapse can seriously affect an individual's judgement, especially around the perception of risk [17], [24]. During these episodes, affected individuals may act impulsively and be less concerned with issues of self-care or the adoption of safe practices [2], [17], [23]. Difficulties managing interpersonal problems may also interfere with the development of stable social and sexual relationships [24]. In addition, individuals with mental illness are often concentrated within inner urban areas where homelessness and marginalization are common [22], [25], and such factors further increase the risk of infection.
The increased risk of BBV/STIs among individuals with SMI is in keeping with other common medical disorders disproportionately experienced by this population, including obesity, ischaemic heart disease and respiratory illness associated with smoking [20], and appears to be related to barriers in diagnosis and access to treatment (for a fuller review, see [26], [20]).
Diagnosis-specific factors also appear to be important, with risky sexual behaviour more likely among patients with a mood disorder (especially bipolar disorder) than those with schizophrenia [27]. The increased risk for BBV/STIs among patientswith affective disorders is suggested to be related to a combination of psychiatric vulnerabilities (low awareness and apathy regarding risks) and symptom resolution (involving improved energy levels, mood and sexual desire) that leads to increased risktaking behaviours [27]. In particular, manic episodes are frequently associated with significant hypersexuality and behaviours that increase the risk of BBV/STIs [27], [28].
A further contributing factor to increased BBV/STI risk among psychiatric populations is inaccurate knowledge regarding infectious disease and routes of transmission [29]. A study assessing knowledge of BBV/STI risks among a psychiatric cohort found that 43% of participants held the view that heterosexual women could not catch AIDS, 38% indicated that heterosexual men were not at risk of infection, while 45% asserted that a person's appearance indicates whether they are infected with HIV [28]. This level of ignorance is consistent with findings for high-risk youth populations. Research on adolescent males (14–17 years) in a juvenile justice setting, of whom 66% were at high risk of HBV infection due to reported histories of IDU or unsafe sexual behaviour, revealed that almost 90% of the cohort considered their risk of HBV to be ‘unlikely’, ‘very unlikely’ or ‘did not know’ [30]. In fact, there is an ongoing lack of knowledge and understanding regarding the risk behaviours leading to BBV and STI transmission among adolescents in general [31], suggesting that there is a need for ongoing education among this age group as well as psychiatric populations.
Sexual activity
Sexual risk behaviours for BBV/STIs include unprotected sex, unprotected sex with multiple partners and trading sex for basic survival needs. People with serious mental illness report higher rates of unprotected sexual activity with multiple casual partners than the general population [17], [23], with up to 28% also reporting that they trade sex for material gain [18]. Worryingly, condom use is also infrequent among this population. Studies suggest that approximately 25–50% of psychiatric patients never use condoms during intercourse, with only 10–30% reporting regular condom use [18]. Although the percentage of younger patients who regularly use condoms is less clear, general population studies suggest that only 60% of adolescent males and 46% of adolescent females repeatedly use condoms [31].
Substance use
Large-scale epidemiological surveys, both within Australia and internationally, have consistently shown high levels of co-occurring substance abuse among people with mental health disorders [19], [32], with studies in youth also reporting significant rates of use [33], [34]. In addition, the rate of IDU among SMI populations is also substantial, with Davidson et al. reporting that psychiatric patients are eight times more likely to have injected drugs than the general population [17]. The highest BBV risk associated with IDU relates to sharing equipment, and studies of IDU among mental health samples suggest that between 47% and 67% report unsafe injecting behaviours [4], [35].
To date, studies that have examined the relationship between mental health, substance abuse and infectious disease among adult populations have produced disturbing findings. For example, Rosenberg et al. revealed that 50% of adult patients with co-occurring mental health and substance use disorders tested positively for BBVs, with the prevalence increasing to 66% in those who had previously injected drugs [19]. Locally, SMI patients also experience higher rates of infectious diseases [20]. These findings are alarming, especially as there is an inconsistent approach to education, screening and immunization for BBV/STIs among individuals with comorbid substance use and mental health problems. This is particularly concerning, as people with mental health issues often experience barriers in accessing medical care [20], [26], and are less likely to seek treatment or review for physical health issues, even if they suffer with a significant medical condition [36]. This is especially true for young people, who are reluctant to access health care settings for either mental or physical health problems.
Current treatment approaches
Despite reports of significant risky behaviours and increased BBV/STI prevalence among psychiatric patients, relevant services or educational materials are not routinely targeted at this population [35], [37]. However, internationally a number of researchers have begun implementing risk reduction and health promotion strategies to produce behavioural change in adults with SMI [38–41]. Intensive programs, involving up to 15 hours of contact time, appear to be most effective, with interventions that explore BBV/STI knowledge, attitudes, intentions, behavioural self-management and personal problem-solving components more likely to produce behavioural change than those involving education alone [24]. These interventions tend to produce reduction rather than cessation of risky behaviours, although there is limited data available regarding their long-term effectiveness. Nevertheless, it seems appropriate that such interventions are integrated within standard treatment to increase the potential for ongoing behavioural change.
A primary, public health approach has been used by Rosenberg et al., who have developed the screen, test, immunize, reduce risk and refer (STIRR) intervention [41]. By screening and testing patients at high risk, this group have attempted to reduce infections among a US population of adults with psychiatric diagnoses through immunization (HBV and hepatitis A) and harm reduction strategies [41]. The STIRR intervention directly provides basic services to mental health treatment agencies, with on-site infectious disease referral and support. Within this program, almost 79% of patients underwent testing, immunization and risk reduction counselling [41]. At a local level, Ellen et al. have piloted a proactive BBV testing program among adult psychiatric inpatients [4]. Preliminary results indicate that the proactive program has led to a twofold increase in testing rates, as well as the identification of increased rates of HCV [4].
Such studies provide encouraging evidence of the feasibility and efficacy of risk reduction interventions for adults with mental illness. However, methodological limitations such as small sample sizes, limited control groups, brief follow-up periods, inadequate data analysis and the use of arbitrary measures of risk behaviour (e.g. rates of condom use) rather than quantification of actual risky behaviour weaken the overall findings [40]. There is a clear need to refine these programs and rigorously evaluate behavioural change among individuals with mental health issues. This is particularly important for young people, especially given epidemiological data that highlights they are at high risk of infection.
The method of service delivery also requires consideration. There are a number of challenges associated with M. HERCUS, D.I. LUBMAN, M. HELLARD 853 the implementation of BBV/STI risk reduction interventions among mentally ill populations. Severe mental illness is often associated with cognitive and social impairments that necessitate the use of considerable therapeutic effort and resources in implementing behavioural change [40]. Optimal participation in risk reduction and primary care programs requires information to be provided in a clear and concise manner, delivered at the usual site of mental health care [41], [42]. This in itself raises questions about the capacity of services to support and implement BBV/STI behavioural change interventions. In a study exploring the role of mental health case management as a locus for BBV/STI prevention services, case managers expressed motivation to offer prevention interventions that were contextualized within existing case-management tasks [43]. However, mental health providers may be unwilling to deliver such interventions within psychiatric settings [41]. Exploration of service-specific issues relating to the delivery of risk reduction interventions is clearly required.
Future directions: research, service development and accepting the challenge
Research
A number of studies over recent years have shown that adults with serious mental illness are at significant risk of BBV/STIs. This has been accompanied by the call for appropriately targeted interventions, resulting in some innovative responses internationally. However, to date a coordinated local response has been lacking, although this is in part related to deficits in the current evidence base, and the segregation ofmental health, drug treatment and general medical services. Deficits in the literature impede service development, and future research should specifically target the full range of diagnosable mental health disorders, with special emphasis on younger people with diagnosed or emerging mental health problems. Such studies should also use biological measures of risky behaviour, such as screening for incident BBV/STIs, and include examination of psychological and social factors that may underlie increased risk.
In fact, despite high levels of substance use among younger people with mental health problems, there is a paucity of data available on the prevalence of infectious disease or risk factors among this population. This is problematic, as health providers remain ignorant of the needs of this population, young people do not typically access health services, and vaccination or treatment is not routinely offered. As such, research investigating the prevalence of BBV/STIs and risk behaviours (such as substance misuse and sexual practices) among young people with mental health disorders is urgently required, especially as studies have suggested the feasibility of targeted and integrated interventions [38–41]. Such an approach has major implications for young people, clinicians, health service managers and policy-makers. Given the sequelae and high treatment costs of contracting avoidable BBV/STIs, development of appropriate interventions to reduce risk, treat and manage infection among young people with mental health issues, is of the highest priority. In this regard, innovative strategies designed specifically for young people with mental illness (based on accurate prevalence and risk profile data) are required in an attempt to elicit long-term behavioural change. Such initiatives should aim to include health education, harm reduction and behavioural modification early enough for them to be effective in preventing entrenched risk-taking behaviours.
Service development
Current evidence regarding BBV/STIs among people with serious mental illness and the role of problematic substance use in increasing risk for disease transmission indicates that a broad multidisciplinary response is required. In addition to psychiatric services, currently stretched to clinical capacity across all sectors, a comprehensive approach requires inclusion of substance use and infectious disease specialists, with a public health paradigm as an overarching framework. The issue of infectious disease is clearly the responsibility of many. Ignoring the presence of BBV/STIs by failing to respond is pure folly, as burgeoning high costs associated with their sequelae will be borne by both individuals and the community. However, configuring an appropriate response to any complex issue necessitates attitudinal and policy shift, as well as additional funding support. Although relatively minor capital investments in the present, targeting risk behaviours, have enormous potential health benefits and cost-savings in the future, funding for such projects remains problematic, especially as each service system (mental health, drug treatment, public health) sees the issue as the other's domain.
Nevertheless, organizational development is a necessary component of a systemic response to the issue of comorbid mental illness, substance use and infectious disease. Research and health policy (both international and Australian) has identified the need for improved relationships between health care systems (mental health, substance use treatment and general health services) to develop ‘best-practice’ models for people with mental illness, comorbid substance use and infectious disease [2], [22],[44–47]. Although historical divisions between medical and specialist services can complicate interagency relationship-building, recognition of these divisions, and exploration of the means by which barriers to effective partnerships may be reduced are integral in responding to complex issues. In addition to collaborative program development, there is also a need to expand comorbidity services, such that mental health becomes meaningfully integrated with substance abuse treatment and general medical care.
Accepting the challenge
Mental health services are faced with the challenge of focusing on substance use and sexual risk behaviours specific to BBV/STIs, and establishing programs and procedures designed to reduce risk and minimize negative long-term outcomes for their patients. Delaying the process of instituting specifically designed interventions targeting substance use disorders and BBV/STI risk behaviours among individuals with serious mental illness, in particular young people aged 15–29, represents a missed opportunity to address a significant public health issue. With passing time, the health and financial costs to both individuals and the community continue to accrue. There is a need to accept the challenge to act, and to act immediately.
Footnotes
Acknowledgements
Matthew Hercus is on secondment to ORYGEN Youth Health, supported by an Alcohol Education and Rehabilitation Foundation (AERF) Workforce Development Grant. Dan Lubman is supported by the Nauma Licht Trust. The authors acknowledge the financial support of the Nurses Board of Victoria.