Review articleRates, types and associations of sexual risk behaviours and sexually transmitted infections in those with severe mental illness: a scoping review
Introduction
Serious mental illness (SMI) causes persistent and significant emotional and cognitive disability (American Psychiatric Association., 2013; Morgan et al., 2014). In 2010, nearly 408,000 or 1.5% of those living in Australia and New Zealand had a diagnosis of SMI (Royal Australian and New Zealand College of Psychiatrists, 2016). SMI encompasses psychotic disorders such as schizophrenia and schizoaffective disorder, and mood disorders including bipolar affective disorder (BPAD) and major depressive disorder (MDD). Individuals with SMI incur impairments in social, occupational and physical functioning (Hayes et al., 2012; Moreno et al., 2013; Morgan et al., 2014).
The burden of physical illness is disproportionately borne by individuals with psychotic disorders (Moreno et al., 2013; Scott and Happell, 2011). Those with psychotic disorders have a reduced life expectancy compared to the general population by up to 20 years (Chesney et al., 2014). Of this disparity in mortality, 60% is due to physical illnesses, such as the metabolic syndrome, cardiovascular disease, diabetes mellitus, and human immunodeficiency virus (HIV; De Hert et al., 2011). Sexual health is an aspect of physical health that might perpetuate the differences in physical health outcomes between those with SMI and the general population (Brown et al., 2010; Coverdale and Turbott, 2000; Heaphy et al., 2010; King et al., 2008; Meade and Sikkema, 2005); however, it is an area that has largely been overlooked and under-researched.
Sexual risk behaviours are commonly demonstrated among those with SMI (Brown et al., 2010; Coverdale and Turbott, 2000; Heaphy et al., 2010; King et al., 2008; Ramrakha et al., 2000). Those who engage in sexual risk behaviours are more likely to have more severe psychiatric symptoms (Heaphy et al., 2010) and more than one psychiatric diagnosis (Heaphy et al., 2010; Ramrakha et al., 2000).
Individuals who engage in sexual risk behaviours such as infrequent condom or barrier use, multiple sexual partners, substance use and transactional sexual acts (for money, food, shelter or other goods), are at higher risk of contracting sexually transmitted infections (STIs), including HIV (Meade and Sikkema, 2005). STIs can lead to long-term serious health consequences. Infections, such as gonorrhoea, chlamydia, human papillomavirus (HPV), syphilis, trichomoniasis, and herpes simplex virus type 2 (HSV-2), are associated with infertility, foetal and neonatal mortality, genital and cervical cancer, epididymitis and urethral damage (Smith and Anagarone, 2015). Further, STIs statistically heighten an individual's risk of HIV infection, due to the association of SRBs with both STIs and HIV (Meade and Sikkema, 2005); STIs causing ulcers and sores can also make HIV infection more likely due to disruption of skin integrity and inflammation (Ward and Rönn, 2010). Sexual risk behaviours can also result in other undesirable outcomes including unwanted pregnancy (Miller, 1997). Thus, engaging in sexual risk taking behaviours is likely to have long-term health impacts and may compound the psychiatric problems experienced by those with SMI (Ramrakha et al., 2000).
The rates and types of sexual risk behaviours and STIs in the SMI population remain poorly characterised. Most of the existing literature focuses on HIV-risk behaviours in SMI, particularly intravenous drug use (IVDU) and sharing needles (Carey et al., 2004; Chandra et al., 2003; Heaphy et al., 2010; Maling et al., 2011; Meade and Sikkema, 2005; Tucker et al., 2003). Rates of IVDU are less relevant for examining sexual health outcomes more generally, as IVDU is not an independent risk factor for STI contraction, other than HIV (Islam et al., 2013). Additionally, most studies have not compared sexual health outcomes of participants with SMI to healthy controls, making meaningful conclusions difficult to draw.
In order to gain a better understanding of sexual health outcomes over the natural course of SMI, it is useful to consider risk behaviours from the first episode of illness. Longitudinal data on sexual health outcomes after a first episode is non-existent. Therefore, it cannot be determined at what stage the suggested disparities in sexual health outcomes in SMI populations compared to the general population emerge across the course of mental illness. Prevention is extremely difficult to implement without this knowledge.
The overall purpose of this scoping review is to summarise the emerging literature on sexual health outcomes in SMI. We focus specifically on elucidating rates and types of sexual risk behaviours and STIs in SMI. We also identify factors associated with sexual risk behaviours and STIs. A critical analysis of the literature is provided particularly focusing on methodological rigour of existing studies. Finally, this information is placed in the context of recommendations for the provision of healthcare in those suffering SMI.
Section snippets
Inclusion and exclusion criteria
Articles were considered relevant based on their population, concept and context. The population was limited to participants aged over 18 years with a Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of any psychotic disorder. The age cut-off of 18 years was largely driven by the research literature; there were no studies with participants under 18 years of age. The focus of studies
Study selection
After applying the inclusion and exclusion criteria outlined above to the 184 articles returned by the search, 14 articles (of 13 studies) were included for critical appraisal in this review (see Figure 1). Of the 10 excluded articles on full text review, 4 were review articles, 5 studied patients without a psychotic disorder diagnosis or any formal mental illness diagnosis, (additionally 1 of these included primarily participants under 18 years of age) and 1 was designed to assess participant
Sexual health outcomes in SMI
Individuals with SMI have poorer physical health outcomes than the general population (De Hert et al., 2011; Moreno et al., 2013; Scott and Happell, 2011), yet very little is known about sexual health outcomes in this population. Sexual health may be an important contributor to poor physical health outcomes in SMI. This is the first scoping review to examine sexual risk behaviours and STIs in SMI populations.
Although the evidence is extremely heterogeneous and of a poor quality (i.e., average
Declaration of Conflicting Interest
The Author(s) declare that there are no conflicts of interest.
Funding
Aswin Ratheesh is supported by a National Health and Medical Research Council Early Career Fellowship (APP1160108). Brian O'Donoghue is also supported by a NHMRC Early Career Fellowship (APP1142045). Sue Cotton is supported by a NHMRC Senior Research Fellowship (APP1136344).
Acknowledgements
Nil.
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