A small, yet significant, percentage of HIV-positive patients have a concomitant psychiatric or neurological disorder associated with impaired judgment. Clinical problems such as psychoses, certain personality disorders, and dementias are associated with disinhibition of impulses and diminished capacity for self-monitoring. These deficits in reasoning and judgment may prevent the patient from comprehending the significance of their HIV status and the consequences of sexual behavior or needle sharing. There are indications that the Tarasoff duty-to-protect may apply to this situation.
Method:
Available data about the prevalence of HIV risk behavior and HIV infection among psychiatric patients are reviewed. The applicability to these situations is described.
Results:
When an HIV patient engages in high risk sexual behavior with identifiable partners and refuses to notify them of their HIV status, physicians and mental health professionals may have a legal and ethical duty to warn.
Conclusion:
A decision model for this clinical dilemma is presented. Clinical strategies for these patients may include ongoing supervision and monitoring as well as possible quarantine.
CulverC. M., Health Care Ethics and Mental Health Law in Law & Mental Health: Major Developments and Research Needs, ShahS. and SalesB. (eds.), DHHS, Washington, D.C., 1991.
2.
SchechterM. T.CaribK. J.WilloughbyB.DouglasB.McLeodW. A.MaynardM.ConstanceP., and O'ShanghnesseyM.Patterns of Sexual Behavior and Condom Use in a Cohort of Homosexual Men, American Journal of Public Health, 78: 1535–1538, 1988.
3.
CoatesJ. J.Strategies for Modifying Sexual Behavior for Primary and Secondary Prevention of HIV Disease, Journal of Consulting and Clinical Psychology, 58: 57–69, 1990.
4.
PerkinsD. O.DavidsonE. J.LeseremanJ.LiaoD., and EvansD. L.Personality Disorder in Patients Infected with HIV: A Controlled Study with Implications for Clinical Care, American Journal of Psychiatry, 150: 309–315, 1993.
5.
ThompsonC.IsaacsG.SuppleD., and BercaS.AIDS: Dilemmas for the Psychiatrist, The Lancet, 1: 269–270, 1986.
6.
MorganJ. L.AmarsingheA. A.MorganG. V.ReddyN. T.Problems in Managing a Schizophrenic Patient with AIDS, American Journal of Psychiatry, 145: 380–381, 1988.
CournosF.EmpfieldM.HorwatheM.MacKinnonK.MeyerI.SchrageH.CurrieC., and AgusinM.HIV Seroprevalence among Patients Admitted to Two Psychiatric Hospitals, American Journal of Psychiatry, 148: 1225–1230, 1991.
9.
SacksM.PerryS.GraverR.ShindledeckerR., and HallS.Self-reported HIV-related Risk Behaviors in Acute Psychiatric Patients: A Pilot Study, Hospital and Community Psychiatry, 41: 1253–1255, 1990.
10.
VolvakaJ.ConvitA.O'DonnellJ.DouyonR.EvangelistaC., and CzoborP.Assessment of Risk Behaviors for HIV Infection among Psychiatric Patients, Hospital and Community Psychiatry, 43: 482–485, 1992.
11.
ClarkM. E.AIDS Prevention: Legislative Options, American Journal of Law and Medicine, 16: 107–153, 1990.
12.
MarzakR. M.TierneyH., and HardiffK.Increased Risk of Suicide in Persons with AIDS, Journal of the American Medical Association, 259: 1333–1337, 1988.
13.
HaysR. B.CantaniaJ.McCusickL., and CoatesT. J.Help-seeking for AIDS-related Concerns: A Comparison of Gay Men of Various HIV Diagnoses, American Journal of Community Psychology, 18: 743–755, 1990.
14.
GlasnerP. D. and KaslowR. A.The Epidemiology of Human Immunodeficiency Virus Infection, Journal of Consulting and Clinical Psychology, 58: 13–21, 1990.
15.
MonahanJ., Predicting Violent Behavior: An Assessment of Clinical Techniques, Sage, Beverly Hills, California, 1981.
16.
GrantI. and HeatonR. K.Human Immunodeficiency Virus—Type 1 (HIV-I) and the Brain, Journal of Consulting and Clinical Psychology, 58: 22–30, 1990.
17.
FernandezF.HolmesV. F.LevyJ. K., and RvizP.Consultation Liaison Psychiatry and HIV-related Disorders, Hospital and Community Psychiatry, 40: 146–153, 1989.
18.
SimonR. I.AIDS Dementia Complex in Health Care Providers, Courts, Health Science & The Law, 2: 69–76, 1991.
19.
GostinL.A Decade of a Maturing Epidemic: An Assessment and Directions for Future Public Policy, American Journal of Law and Medicine, 16: 1–32, 1990.
20.
Tarasoff vs. Regents of the University of California, 551 p2d 340, 1976.
21.
LambD. H.ClarkC.DrumhellerP.FrizzellK., and SurryeL.Applying Tarasoff to AIDS-related Psychotherapy Issues, Professional Psychology: Research and Practice, 20: 37–43, 1989.
22.
SimonR. I., Clinical Psychiatry and the Law, (2nd Edition), American Psychiatric Press, Washington, D.C., 1992.
23.
AppelbaumR. S.The New Preventive Detention: Psychiatry's Problematic Responsibility for the Control of Violence, American Journal of Psychiatry, 145: 779–785, 1988.
24.
Naidu vs. Laird 539 A2d 1064 (Del Super Ct. 1988).
25.
AnnasG.Medical Legal Dilemma: The HIV Positive Patient Who Won't Tell the Spouse, Medical Aspects of Human Sexuality, 21: 16, 1987.
26.
KnappS. and Van de CreekL.Application of the Duty to Protect to HIV Positive Patients, Professional Psychology: Research and Practice, 21: 161–166, 1990.
27.
FalkT. C.AIDS Public Health Law, The Journal of Legal Medicine, 9: 529–546, 1988.
28.
EthS.The Sexually Active, HIV Infected Patient: Confidentiality versus the Duty to Protect, Psychiatric Annals, 18: 571–576, 1988.
29.
MeltonG. B.PetrilaJ.PoythressN. G., and SloboginC., Psychological Evaluations for the Courts, Guilford, New York, 1987.
30.
MonahanJ.The Prediction of Violent Behavior: Toward a Second Generation of Theory and Policy, American Journal of Psychiatry, 141: 10–15, 1984.
31.
HearstN. and HulleyS. B.Preventing the Heterosexual Spread of AIDS: Are We Giving our Patients the Best Advice, Journal of the American Medical Association, 259: 2428–2432, 1988.
32.
Ad Hoc Committee on AIDS Policy, Official Actions: AIDS Policy: Confidentiality and Disclosure, American Journal of Psychiatry, 145: 541, 1988.
33.
Ad Hoc Committee on AIDS PolicyOfficial Actions: AIDS Policy: Guidelines for Inpatient Psychiatric Units, American Journal of Psychiatry, 145: 542, 1988.
34.
Acquired Immunodeficiency Syndrome Legislation, 1987 Session of the 85th General Assembly, Illinois Department of Public Health, 1988.
35.
Chapter 543, California Health and Safety Code SEc. 199. 25 (A.B. 250).
36.
AnnasG. J.Control of Tuberculosis—The Law and the Public's Health, The New England Journal of Medicine, 328: 585–588, 1993.
37.
DurhamM. L.LaFondJ. Q.The Empirical Consequences and Policy Implications of Broadening the Statutory Criteria for Civil Commitment, Yale Law and Policy Review, 3: 395–446, 1985.
38.
AppelbaumP. S.AIDS, Psychiatry, and the Law, Hospital and Community Psychiatry, 39: 13–14, 1988.
39.
SearightH. R.Assessing Patient Competence for Medical Decision-making, American Family Physician, 45: 751–759, 1992.
