Community Mental Health Journal

, Volume 43, Issue 2, pp 153–169 | Cite as

Psychiatric and Psychosocial Correlates of Sexual Risk Behavior among Adults with Severe Mental Illness



Persons with severe mental illness (SMI) are disproportionately affected by HIV/AIDS. This study examined multivariate correlates of sexual risk among 152 adults with SMI receiving outpatient psychiatric treatment. Structured interviews assessed psychiatric, psychosocial, and behavioral risk factors. The majority was sexually active (65%), and many reported unprotected intercourse (73%), multiple partners (45%), and sex trading (21%) in the past year. Logistic regression models found that sexual behaviors were differentially associated with non-psychotic disorder, psychiatric symptoms, substance abuse, childhood sexual abuse, romantic partnership, and social support (all ps < .05). Findings underscore the need for targeted HIV prevention interventions that address psychiatric and psychosocial risk factors.


HIV/AIDS sexual risk behavior severe mental illness 


  1. Berkman A., Pilowsky D. J., Zybert P. A., Leu C.-S., Sohler N., Susser E. (2005) The impact of substance dependence on HIV sexual risk-reduction among men with severe mental illness. AIDS Care 17:635–639PubMedGoogle Scholar
  2. Brunette M. F., Rosenberg S. D., Goodman L. A., Mueser K. T., Osher F. C., Vidaver R., Auciello P., Wolford G. L., Drake R. E. (1999) HIV risk factors among people with severe mental illness in urban and rural areas. Psychiatric Services 50:556–558PubMedGoogle Scholar
  3. Buckley P., Thompson P., Way L., Meltzer H. (1994) Substance abuse among patients with treatment-resistent schizophrenia: Characteristics and implications for clozapine therapy. American Journal of Psychiatry 151:385–189PubMedGoogle Scholar
  4. Butterfield M. I., Bosworth H. B., Meador K. G., Stechuchak K. M., Essock S. M., Osher F. C., Goodman L. A., Swanson J. W., Bastian L. A., Horner R. D. (2003) Gender differences in hepatitis C infection and risks among persons with severe mental illness. Psychiatric Services 54:848–853PubMedCrossRefGoogle Scholar
  5. Carey M. P., Carey K. B., Gleason J. R., Gordon C. M., Brewer K. K. (1999) HIV-risk behavior among outpatients at a state psychiatric hospital: Prevalence and risk modeling. Behavior Therapy 30:389–406CrossRefGoogle Scholar
  6. Carey M. P., Carey K. B., Maisto S. A., Gordon C. M., Vanable P. A. (2001) Prevalence and correlates of sexual activity and HIV-related risk behavior among psychiatric outpatients. Journal of Consulting and Clinical Psychology 69:846–850PubMedCrossRefGoogle Scholar
  7. Carey M. P., Carey K. B., Maisto S. A., Gordon C. M., Schroder K. E. E., Vanable P. A. (2004) Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment: Results from a randomized controlled trial. Journal of Consulting and Clinical Psychology 72:252–268PubMedCrossRefGoogle Scholar
  8. Carey M. P., Carey K. B., Maisto S. A., Schroder K. E. E., Vanable P. A., Gordon C. M. (2004) HIV risk behavior among psychiatric outpatients: Association with psychiatric disorder, substance use disorder, and gender. Journal of Nervous and Mental Disease 192:289–296PubMedCrossRefGoogle Scholar
  9. Catz S. L., Kelly J. A., Bogart L. M., Benotsch E. G., McAuliffe T. L. (2000) Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychology 19:124–133PubMedCrossRefGoogle Scholar
  10. Chandra P. S., Carey M. P., Carey K. B., Prasada Rao P. S. D. V., Jairam K. R., Thomas T. (2003) HIV risk behavior among psychiatric inpatients: Results from a hospital-wide screening study in southern India. International Journal of STD & AIDS 14:532–538CrossRefGoogle Scholar
  11. Chuang H. T., Atkinson M. (1996) AIDS knowledge and high-risk behavior in the chronic mentally ill. Canadian Journal of Psychiatry 41:269–272Google Scholar
  12. Cohen S. (1988) Review: Psychosocial models of the role of social support in the etiology of physical disease. Health Psychology 7:269–297PubMedCrossRefGoogle Scholar
  13. Cournos F., McKinnon K. (1997) HIV seroprevalence among people with severe mental illness in the United States: A critical review. Clinical Psychology Review 17:259–269PubMedCrossRefGoogle Scholar
  14. Cunningham R. M., Stiffman A. R., Dore P. (1994) The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: Implications for public health. Child Abuse & Neglect 18:233–245CrossRefGoogle Scholar
  15. Davidson S., Judd F., Jolley D., Hocking B., Thompson S., Hyland B. (2001) Risk factors for HIV/AIDS and hepatitis C among the chronically mentally ill. Australian and New Zealand Journal of Psychiatry 35:203–209PubMedCrossRefGoogle Scholar
  16. Derogatis, L. R. (1983). SCL-90-R: Administration, scoring, & procedures manual-II. Clinical Psychometric Research, Baltimore, MDGoogle Scholar
  17. Fromme K., D’Amico E. J., Katz E. C. (1999) Intoxicated sexual risk taking: An expectancy or cognitive impairment explanation? Journal of Studies on Alcohol 24:313–319Google Scholar
  18. Goodman L. A., Fallot R. D. (1998) HIV risk-behavior in poor urban women with serious mental illness: Association with childhood physical and sexual abuse. American Journal of Orthopsychiatry 68:73–83PubMedCrossRefGoogle Scholar
  19. Goodman L. A., Rosenberg S. D., Mueser K. T., Drake R. E. (1997) Physical and sexual assault history in women with severe mental illness: Prevalence, correlates, treatment, and future research directions. Schizophrenia Bulletin 23:685–696PubMedGoogle Scholar
  20. Green B. L. (1996) Trauma history questionnaire. In: Stamm B. H. (Ed.), Measurement of stress, trauma, and adaptation. Sidran, Lutherville, MD, pp. 366–368Google Scholar
  21. Hosmer D. W., Lemeshow S. (2000) Applied logistic regression Wiley-Interscience, New YorkCrossRefGoogle Scholar
  22. Jacard J. (2001) Interaction effects in logistic regression Sage Publications, Thousand Oaks, CAGoogle Scholar
  23. Johnson-Masotti A. P., Weinhardt L. S., Pinkerton S. D., Otto-Salaj L. L. (2003) Efficacy and cost-effectiveness of the first generation of HIV prevention interventions for people with severe and persistent mental illness. Journal of Mental Health Policy and Economics 6:23–35PubMedGoogle Scholar
  24. Kalichman S. C., Heckman T. G., Kelly J. A. (1996) Sensation seeking as an explanation for the association between substance use and HIV-related risky sexual behavior. Archives of Sexual Behavior 25:141–154PubMedCrossRefGoogle Scholar
  25. Kalichman S. C., Kelly J. A., Johnson J. R., Bulto M. (1994) Factors associated with risk for HIV infection among chronic mentally ill adults. American Journal of Psychiatry 151:221–227PubMedGoogle Scholar
  26. Kalichman S. C., Sikkema K. J., Kelly J. A., Bulto M. (1995) Use of a brief behavioral skills intervention to prevent HIV infection among chronic mentally ill adults. Psychiatric Services 46:275–280PubMedGoogle Scholar
  27. Kelly J. A. (1999) Community-level interventions are needed to prevent new HIV infections American Journal of Public Health 89:299–301PubMedGoogle Scholar
  28. Kelly J. A., McAuliffe T. L., Sikkema K. J., Murphy D. A., Somlai A. M., Mulry G., Miller J. G., Stevenson L. Y., Fernandez M. I. (1997) Reduction in risk behavior among adults with severe mental illness who learned to advocate for HIV prevention. Psychiatric Services 48:1283–1288PubMedGoogle Scholar
  29. Kessler R. C., Berglund P. A., Zhao S., Leaf P. J., Kouzis A. C., Bruce M. L., Friedman R. M., Grossier R. C., Kennedy C., Narrow W. E., Kuehnel T. G., Laska E. M., Manderscheid R. W., Rosenheck R. A., Santoni T. W., Schneier M. (1996) The 12-month prevalence and correlates of serious mental illness In: Manderscheid R. W., Sonnenschein M. A. (eds) Mental health, United States, 1996. US Government Printing Office, Washington, DC, pp. 59–70Google Scholar
  30. Kim A., Galanter M., Castaneda R., Lifshutz H., Franco H. (1992) Crack cocaine use and sexual behavior among psychiatric inpatients. American Journal of Drug & Alcohol Abuse 18:235–246Google Scholar
  31. Kimberly J. A., Serovich J. M. (1999) The role of family and friend social support in reducing risk behaviors among HIV-positive gay men. AIDS Education & Prevention 11:465–475Google Scholar
  32. McKinnon K., Cournos F., Herman R. (2001) A lifetime alcohol or other drug use disorder and specific psychiatric symptoms predict sexual risk and HIV infection among people with severe mental illness. AIDS and Behavior 5:233–240CrossRefGoogle Scholar
  33. McKinnon K., Cournos F., Meyer-Bahlburg H. F., Guido J. R., Caraballo L. R., Margoshes E. S., Herman R., Gruen R. S., Exner T. M. (1993) Reliability of sexual risk behavior interviews with psychiatric patients. American Journal of Psychiatry 150:972–974PubMedGoogle Scholar
  34. McKinnon K., Cournos F., Sugden R., Guido J. R., Herman R. (1996) The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness Journal of Clinical Psychiatry 57:506–513PubMedGoogle Scholar
  35. Meade C. S., Sikkema K. J. (2005) HIV/AIDS risk among adults with severe mental illness: A systematic review. Clinical Psychology Review 25:433–457PubMedCrossRefGoogle Scholar
  36. Meyer-Bahlburg, H., Erhardt, A., Exner, T. M., & Gruen, R. S. (1991). Sexual risk behavior assessment schedule-adult armory inventroy (SERBAS-A-ARMM 1). New York, NY: New York State Psychiatric Institute and Columbia UniversityGoogle Scholar
  37. Mueser K. T., Bellack A. S., Morrison R. L., Wixted J. T. (1990) Social competence in schizophrenia: Premorbid adjustment, social skill, and domains of functioning Journal of Psychiatric Research 24:51–63PubMedCrossRefGoogle Scholar
  38. Mueser K. T., Salyers M. P., Rosenberg S. D., Ford J. D., Fox L., Carty P. (2001) Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. Psychological Assessments 13:110–117CrossRefGoogle Scholar
  39. Otto-Salaj L. L., Heckman T. G., Stevenson L. Y., Kelly J. A. (1998) Patterns, predictors, and gender differences in HIV risk among severely mentally ill men and women. Community Mental Health Journal 34:175–190PubMedCrossRefGoogle Scholar
  40. Otto-Salaj L. L., Kelly J. A., Stevenson L. Y., Hoffman R., Kalichman S. C. (2000) Outcomes of a randomized small-group HIV prevention intervention trial for people with severe mental illness. Community Mental Health Journal 37:123–144CrossRefGoogle Scholar
  41. Regier D. A., Farmer M. E., Rae D. S., Locke B. Z., Keith S. J., Judd L. L., Goodwin F. K. (1990) Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiological Catchment Area (ECA) Study. JAMA 264:2511–2518PubMedCrossRefGoogle Scholar
  42. Rosenberg S. D., Drake R. E., Wolford G. L., Mueser K. T., Oxman T. E., Vidaver R. M., Carrieri K. L., Luckoor R. (1998) Dartmouth Assessment of Lifestyle Instrument (DALI): A substance use disorder screen for people with severe mental illness. American Journal of Psychiatry 155:232–238PubMedGoogle Scholar
  43. Rosenberg S. D., Goodman L. A., Osher F. C., Swartz M. S., Essock S. M., Butterfield M. I., Constantine N. T., Wolford G. L., Salyers M. P. (2001a) Prevalence of HIV, Hepatitis B, and Hepatitis C in people with severe mental illness. American Journal of Public Health 91:31–37Google Scholar
  44. Rosenberg S. D., Trumbetta S. L., Muesser K. T., Goodman L. A., Osher F. C., Vidaver R. M., Metzger D. S. (2001b) Determinants of risk behavior for human immunodeficiency virus/acquired immunodeficiency syndrom in people with severe mental illness. Comprehensive Psychiatry 42:263–271CrossRefGoogle Scholar
  45. Rothbard A. B., Metraux S., Blank M. B. (2003) Cost of care for Medicaid recipients with serious mental illness and HIV infection or AIDS. Psychiatric Services 54:1240–1246PubMedCrossRefGoogle Scholar
  46. Schinnar A., Rothbard A., Kanter R., Jung Y. (1990) An empirical literature review of definitions of severe and persistent mental illness. American Journal of Psychiatry 147:1602–1608PubMedGoogle Scholar
  47. Schroder K. E. E., Carey M. P., Vanable P. A. (2003) Methodological challenges in research on sexual risk behavior: I. Item content, scaling, and data analytical options. Annals of Behavioral Medicine 26:76–103PubMedCrossRefGoogle Scholar
  48. Sherbourne C. D., Stewart A. L. (1991) The MOS social support survey. Social Science & Medicine 32:705–714CrossRefGoogle Scholar
  49. Sohler N., Colson P. W., Meyer-Bahlburg H. F., Susser E. (2000) Reliability of self-reports about sexual risk behavior for HIV among homeless men with severe mental illness. Psychiatric Services 51:814–816PubMedCrossRefGoogle Scholar
  50. Susser E., Valencia E., Berkman A., Sohler N., Conover S., Torres J., Betne P., Felix A., Miller S. (1998) Human immunodeficiency virus sexual risk reduction in homeless men with mental illness. Archives of General Psychiatry 55:266–272PubMedCrossRefGoogle Scholar
  51. Susser E., Valencia E., Miller M., Tsai W.-Y., Meyer-Bahlburg H., Conover S. (1995) Sexual behavior of homeless mentally ill men at risk for HIV. American Journal of Psychiatry 152:583–587PubMedGoogle Scholar
  52. Thompson N. J., Potter J. S., Sanderson C. A., Maibach E. W. (1997) The relationship of sexual abuse and HIV risk behaviors among heterosexual adult female STD patients. Child Abuse and Neglect 21:149–156PubMedCrossRefGoogle Scholar
  53. UNAIDS (2002). Report on the Global HIV/AIDS Epidemic. World Health Organization, GenevaGoogle Scholar
  54. Volavka J., Convit A., O’Donnell J., Douyon R., Evangelista C., Czobor P. (1992) Assessment of risk behaviors for HIV infection among psychiatric inpatients. Hospital and Community Psychiatry 43:482–485PubMedGoogle Scholar
  55. Weinhardt L. S., Carey M. P., Carey K. B., Maisto S. A., Gordon C. M. (2001) The relation of alcohol use to HIV-risk sexual behavior among adults with severe and persistent mental illness. Journal of Consulting and Clinical Psychology 69:77–84PubMedCrossRefGoogle Scholar
  56. Weinhardt L. S., Carey M. P., Carey K. B., Verdecias R. N. (1998) Increasing assertiveness skills to reduce HIV risk among women living with severe and persistent mental illness. Journal of Consulting and Clinical Psychology 66:680–684PubMedCrossRefGoogle Scholar
  57. Weiss R. D., Najavits L. M., Greenfield S. F., Soto J. A., Shaw S. R., Wyner D. (1998) Validity of substance use self-reports in dually diagnosed outpatients. American Journal of Psychiatry 155:127–128PubMedGoogle Scholar
  58. Zierler S., Feingold L., Laufer D., Velentgas P., Kantrowitz-Gordon I., Mayer K. (1991) Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. American Journal of Public Health 81:572–575PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2006

Authors and Affiliations

  1. 1.Harvard Medical School, McLean HospitalBelmontUSA
  2. 2.Department of Epidemiology and Public HealthYale UniversityNew HavenUSA

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