Sexual health risk reduction interventions for people with severe mental illness: a systematic review

Abstract

BackgroundDespite variability in sexual activity among people with severe mental illness, high-risk sexual behavior (e.g. unprotected intercourse, multiple partners, sex trade and illicit drug use) is common. Sexual health risk reduction interventions (such as educational and behavioral interventions, motivational exercises, counselling and service delivery), developed and implemented for people with severe mental illness, may improve participants’ knowledge, attitudes, beliefs behaviors or practices (including assertiveness skills) and could lead to a reduction in risky sexual behavior. This systematic review evaluates the effectiveness of sexual health risk reduction interventions for people with severe mental illness.MethodsThirteen electronic databases (including MEDLINE, EMBASE and PsycINFO) were searched to August 2014, and supplemented by hand-searching relevant articles and contacting experts. All controlled trials (randomized or non-randomized) comparing the effectiveness of sexual health risk reduction interventions with usual care for individuals living in the community with severe mental illness were included. Outcomes included a range of biological, behavioral and proxy endpoints. Narrative synthesis was used to combine the evidence.ResultsThirteen controlled trials (all from the USA) were included. Although there was no clear and consistent evidence that interventions reduce the total number of sex partners or improved behavioral intentions in sexual risk behavior, positive effects were generally observed in condom use, condom protected intercourse and on measures of HIV knowledge, attitudes to condom use and sexual behaviors and practices. However, the robustness of these findings is low due to the large between study variability, small sample sizes and low-to-moderate quality of included studies.ConclusionsThere is insufficient evidence at present to fully support or reject the identified sexual health risk reduction interventions for people with severe mental illness. Given the serious consequences of high-risk sexual behaviors, there is an urgent need for well-designed UK based trials, as well as training and support for staff implementing sexual health risk reduction interventions.Trial registrationPROSPERO CRD42013003674.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1448-4) contains supplementary material, which is available to authorized users.

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“…Also, patients with severe mental disorders frequently have risky sexual behaviors, which are often due to the presence of cognitive deficits and manic symptoms, and represent the cause of many sexual transmitted diseases. Moreover, the sexual health of patients with severe mental disorders is often neglected by clinicians who do not routinely ask to patients about their sexual life ( 75 , 76 ). The circadian rhythms are frequently altered due to polarity switch of mood in affective disorders or to the non-adherence to psychotropic medications.…”

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“…Research has shown that psychiatric symptoms are often not the direct cause of sex risk behavior; instead, indirect socioeconomic factors like financial instability and partner violence [11] and individual characteristics such as substance use and attitudes toward sex [8, 10] may drive sex risk behavior. There are a number of effective interventions to reduce sex risk among this population in the short term, but research assessing sustained effects is needed [19, 20]. Future studies could better assess the effectiveness of these interventions by implementing more rigorous randomized clinical trials.…”

“…Two reviews evaluated the effectiveness of these interventions for improving sex risk behavior, knowledge, and attitudes [19, 20]. The number of intervention sessions was quite variable, ranging from 3 to 15.…”

“…In addition to highlighting the efficacy of these interventions, Pandor and colleagues also describe the methodological limitations, including selection bias, no randomization to interventions, lack of data on confounds between study groups, not blinding assessors to condition, no assessment of treatment fidelity, and small sample sizes [20]. Both review papers identified several potential moderators of treatment success, such as gender and psychiatric diagnosis.…”

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“…The EPHPP was developed to be suitable for evaluating a range of study designs including randomized clinical trials (RCTs) and observational studies. The instrument has been used in multiple systematic reviews see 34–37 relevant to mental health treatment and has demonstrated content and construct validity. 38, 39 This is the first systematic review to adapt the EPHPP to evaluate studies of DTCA.…”