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AIDS CARE (1996), VOL. 8, NO. 2, pp. 233?239 Research in psychopathology in patients with HIV/AIDS and psychiatric services in Spain J. L. AYUSO MATEOS,1 I. LASTRA 2 & F. MONTAN?E?S 3 1 Social Psychiatry Research Unit of Cantabria, University of Cantabria & Department of Psychiatry, University Hospital ?Marque?s de Valdecilla?, Santander, 2 Sanatorio Psiquia?trico Nuestra Sen?ora del Rosario & Social Psychiatry Research Unit of Cantabria & 3 Department of Psychiatry, University Hospital ?San Carlos?, Madrid, Spain Abstract In this article, we review the research carried out in Spain concerning psychiatric aspects of HIV/AIDS in general, and of suicide and suicidal ideation in particular. The paper presents available information concerning this psychopathology in patients with HIV infection, along with a review of the epidemic' s dimensions and friends in Spain. Available studies are based on retrospective eval‎uation of patients referred for psychiatric eval‎uations. No longitudinal studies have been carried out, nor studies on the preval‎ence of psychiatric disorders in unreferred samples of HIV-infected patients. This neglected area of research is also a neglected area of care within Spain' s mental health system. Introduction Suicidal ideation and acts have become more frequent in AIDS and HIV-positive patients than in the general population, according to data which have appeared in the literature recently, particularly in studies carried out in the United States. However, the extrapolation of data obtained in the USA is highly questionable until we obtain more information regarding the presence of psychopathology in unselected samples of patients in Spain. This is because the characteristics of Spain' s HIV epidemic have some peculiarities regarding the distribution of risk factors attributed to infected individuals, as well as differences in the social impact of the illness and the organization of health services and the availability of medical and psychiatric care. In this paper we will ?rst review the dimensions of the HIV epidemic in Spain, and then present available information on suicide and psychopathology in HIV/AIDS patients in Spain, as well as the mental health services provided to meet their needs for care and treatment. HIV epidemic in Spain In Europe, AIDS cases are concentrated in a few countries, with high incidences in the west, and low rates in countries of central and eastern Europe. By June 1994, the highest rates were recorded, in decreasing order, in Spain, Switzerland, France and Italy (Fig. 1). Hallauer has Address for correspondence: Dr J. L. Ayuso Mateos, Unidad de Investigacio?n en Psiquiatr悤 a Social de Cantabria, Hospital Universitario Marque?s de Valdecilla, Avda. Valdecilla s/n, Santander 39008, Spain. 0954-012 1/96/020233-0 7 $8.00 Journals Oxford Ltd 0 20 1992 1982 40 60 80 100 120 Number of AIDS incidence rates per million population 1983 1984 1985 1986 1987 1988 1989 1990 1991 Year Spain Switzerland France Italy Denmark Portugal x* * * * * * * * * * x x x x x x x x x 234 J. L. AYUSO MATEOS ET AL. FIG. 1. WHO European Region. AIDS incidenc e rates per million population , by country and year of diagnosis reported by 30 June 1994 (unadjusted for reportin g delays). recently pointed out (1995) that although these four countries represent only 19% of Europe' s population, they accounted for 72% of all AIDS cases diagnosed in 1993. Within Europe, Spain now has the second highest number of reported cases of AIDS: 27,584 at the end of 1994. Of this number, 64% contracted the virus through use of intravenous drugs, 15% through homosexual contact between males, 7.4% through heterosexual contact and 2% are children of infected mothers. The number of HIV-positive subjects is unknown. Of?cial Ministry of Health estimates are of 120,000 HIV carriers. The Anti- AIDS Foundation of Spain estimated a higher number of 150,000. Although the onset of the AIDS epidemic occurred later in Spain than in other west European countries, the increase in incidence has been comparatively greater in recent years. One out of every ?ve cases reported in Europe can be traced to Spain, which has the highest number of AIDS-affected injection drug users (IDU) and cases of mother-to-child transmission in Europe. Castilla et al. (1994) have analysed trends in the incidence of AIDS in Spain. All groups studied showed an upward trend, although variations were found between the different population groups classi?ed by sex and transmission category. The overall trend resembled the pattern for IDU, the largest group. The heterosexual group displayed an initial lag compared with the other groups, but the growth in HIV cases in this group has increased steadily, displaying the greatest percentage increases since 1989. AIDS incidence among blood transfusion recipients has risen slowly since 1988, while that for blood factor recipients reached its highest level in 1989 and has declined progressively thereafter. Since 1992, a levelling-off in the annual incidence of HIV in homosexual/bisexual men has been observed; this phenomenon could be attributed to an effective reduction in risky sexual behavior in this community. The male-female ratio for heterosexual transmission cases is approximately 1 1, despite the higher proportion of male IDU and the greater likelihood of male-to-female than female-to-male heterosexual transmission. This might be due to heterosexual infection of multiple males by HIV-positive prostitutes, most of whom are IDU (Casabona et al., 1990). In conclusion, while advances in controlling the epidemic have been made in certain groups (homosexual/bisexual men, perinatal cases, blood factor recipients), the trend of the AIDS epidemic in Spain, as a whole is increasing. PSYCHOPATHOLOGY OF HIV/AIDS 235 Suicide and psychopathology in HIV Carriers Little research has been carried out in this ?eld of suicide in HIV-infected individuals in Spain. It is particularly striking that despite the epidemic' s impact on subjects with obvious psychiatric disorders, such as the drug-using population, the interest shown in planning research studies concerning psychiatric aspects of HIV/AIDS by the psychiatric community in Spain is minimal. Not surprisingly, there are few studies that directly address the issue of suicide in HIV/AIDS patients. Register-based studies The ?rst evidence showing an increased risk of suicide in AIDS patients was data obtained from all cases of suicide among residents of New York (Marzuk et al., 1988). Similar studies were conducted in California and Texas (Plott et al., 1989, Kizer et al., 1991). No such studies have ever been carried out in Spain, and if they were attempted, there would be a number of dif?culties. Firstly, the preval‎ence of AIDS and HIV infection in the general population as a whole is low. Secondly, deaths related to drug overdose in known drug users are often reported as accidental or involuntary, although in many cases they are the result of a well-planned suicidal act. Thirdly, the National Institute of Statistic' s annual reports on nationwide suicide cases, based on information provided by the judicial system and the Civil Register of deaths are unreliable and the Health Ministry has no registry of suicide cases in Spain. Postmortem studies Other studies on suicide in AIDS patients have used postmortem serological HIV investigations carried out on fatalities with an unknown or unnatural cause of death. Recently, Pu?schel (1995) presented data of a multicentre study concerning HIV-1 preval‎ence among drugrelated deaths in several European cities. The study included two Spanish cities, Bilbao and Madrid, with an HIV preval‎ence of 21% and 55% respectively among drug-related fatalities, re?ecting the regional preval‎ence among IDU. No studies have been carried out in Spain concerning HIV preval‎ence among suicide fatalities, and the same methodological problems noted above for register-based studies would be present if such a study were planned. Psychopathology in HIV/AIDS patients This is the only ?eld where information is available, mainly through the study of HIVinfected patients who contact drug abuse treatment centres, samples of AIDS patients in contact with health care services, patients referred for psychiatric eval‎uation and HIV patients admitted to psychiatric units HIV/AIDS in drug abuse treatment centres. In a recent study carried out in an inpatient detoxi?cation unit in Valencia (Cervera et al., 1995) for opiate-dependent patients, 57 HIV-positive subjects and 43 HIV-negative subjects were eval‎uated with a complete battery of psychological tests. There were no signi?cant differences in the presence of depressive symptoms between the two groups. 236 J. L. AYUSO MATEOS ET AL. HIV/AIDS patients referred for psychiatric consultation. In a study conducted during the early years of the epidemic in Barcelona, Lluch et al. (1989) eval‎uated psychopathology with the PSE in a total of 25 patients with AIDS admitted to the medical or surgical wards of a university general hospital. They found that 80% had a psychiatric diagnosis, of which 50% showed depressive symptoms. We studied the psychiatric diagnosis and symptoms of patients with AIDS treated at a psychiatric consultation service (Ayuso et al., 1989). Of the 100 patients studied, the following were principal diagnoses according to DSM-IIIR criteria: psychoactive substance abuse, 51%; adjustment disorder, 15%; and delirium, 12%. Past suicide attempts were present in 10% of the subjects and there was a statistically signi?cant relationship with an Axis II diagnosis. Of the total sample, (11) 11% had suicidal ideation; there was no association with any of the risk behaviours, and its presence was only noted by the consultee in two of the 11 cases. Crespo et al., (1992) published ?ndings of psychiatric eval‎uation in a sample of 107 subjects referred to a liason programme in another Madrid general hospital. They found very similar results, with psychoactive substance abuse present as the primary psychiatric diagnosis (44%), and adjustment disorder with depressed mood present in 12%. Six per cent of the sample had no psychiatric diagnosis. A depressive syndrome was noted in 14% of the subjects. Our study of patients referred for psychiatric consultation seems to indicate that the presence of suicidal ideation and behaviour is related to previous psychopathology in the individuals at risk, and is a symptom that tends to be under-recognized by the consultee. Patients admitted to psychiatric units. Patients suffering from serious mental illness are at higher risk for HIV infection due to a number of reasons. As psychiatric diagnosis is often linked to substance abuse, with a two-way cause-and-effect relationship: chronic substance abuse can exacerbate and even trigger psychotic episodes, while some authors support the hypothesis of self-medication in mentally ill drug-users. The use of intravenously-injected opiate derivatives is frequently seen in psychiatric patients. In this context, it is interesting to note that the Madrid region' s estimated rate for HIV infection among IDU is 60%. Seriously ill mental patients' sexual conduct also puts them at risk for contracting HIV (Kelly, 1992). Chronic mental patients who do not exhibit inappropriate sexual conduct may present personality de?cits which increase their vulnerability to being victims of sexual abuse or falling into casual or coercive relationships. In addition to these factors, chronic mental patients tend to live in neighbourhoods with a very low socioeconomic level, whose inhabitants have a high rate of substance abuse, alcoholism and sexually-transmitted diseases. Yet another factor for a negative prognosis in the management and evolution of a mental patient' s illness is the lack of awareness of these aspects on the part of medical personnel shown in several studies. The signi?cant increase in the number of HIV-positive patients who have been admitted to the psychiatric units of general hospitals over the last few years has led numerous task forces to carry out anonymous seropreval‎ence studies or chart reviews, in order to examine the true preval‎ence. Table 1 shows the HIV infection preval‎ence found in various studies of acute psychiatric units, with rates that range between 5% and 7%. Those studies carried out among homeless psychiatric patients, or in alcohol rehabilitation units reveal a higher rate of HIV. It should be noted that all of the anonymous seropreval‎ence studies conducted to date in acute psychiatric units show a low percentage of HIV-infected patients who are not detected during their hospitalization. Attention needs to be drawn to the consideration of severely ill psychiatric patients, and PSYCHOPATHOLOGY OF HIV/AIDS 237 Table 1. Seropreval‎ ence studies in psychiatric inpatient s Authors Patients Methods Seropreval‎ence (%) Ayuso et al., 1993 Acute psychiatric unit Chart review 23/652 (3.5) Ayuso et al., 1995 Acute psychiatric unit Anonymous 20/390 seropreval‎ence (5.1) Chart review 18/390 (4.6) Cournos et al., 1991 Acute and Anonymous 25/350 chronic psychiatric unit seropreval‎ence (5.5) Chart review 7/350 (2) Emp?eld et al., 1993 Homeless Anonymous 13/203 seropreval‎ence (6.4) Mahler et al., 1994 Alcohol rehabilitation unit Anonymous 31/300 seropreval‎ence (10.3) Chart review 7/300 (2.3) Saks et al., 1992 Acute psychiatric unit Anonymous 25/350 seropreval‎ence (7) Chart review 17/350 (4.8) Schleifer et al., 1990 Unit for alcohol treatment but not Anonymous 3/68 with simultaneous use of other drugs seropreval‎ence (4.5) Unit for alcohol treatment with Anonymous 13/27 intravenous drug use currently or in seropreval‎ence (48.1) the past. chronic mental patients in particular, as a previously unrecognized high-risk group for HIV infection (Ayuso et al., 1993; Menon et al., 1990; Seeman, 1990). It has been suggested that the increased risk of suicide and suicidal ideation found in HIV-positive patients could be related to the higher preval‎ence of psychiatric syndromes in the population with risk behaviour for HIV infection. We have data that partially support this explanation. In a total sample of 492 psychiatric inpatients who reported that they were HIV-negative upon admission to hospital, there was a signi?cant relationship between past suicide attempts and the presence of at least one risk behaviour for HIV infection While 34.4% of the patients with no HIV risk behaviours had a history of past suicide attempts, 62.5% of the patients with at least 1 or more risk behavoiurs had attempted suicide. The difference was statistically signi?cant (c 2 5 8,8; p 5 0.003). Research on the preval‎ence of HIV infection among psychiatric inpatients and chronic mentally ill patients highlights the dif?culties of investigating neuropsychiatric aspects of HIV-1 infection, since the preval‎ence of certain psychiatric disorders appears higher in some groups than in the general population, confounding assumptions of causality between HIV infection and psychiatric syndromes. 238 J. L. AYUSO MATEOS ET AL. Mental health services for patients with HIV/AIDS in Spain Data regarding the preval‎ence and incidence of HIV-associated neuropsychiatric disorders in unreferred Spanish patients are lacking, and the available information in this ?eld comes from retrospective eval‎uation of selected samples referred to psychiatric services. Apart from the case of haemophilia, no psychological services have been newly created within the National Health System for the care or people with HIV infection in the Madrid region. This is also the case for many other parts of the country. Existing facilities have undertaken new responsibilities to deal with HIV infection, but no global programme integrates all these services. There are also different local agencies involved in the care of patients with HIV which are poorly integrated among themselves. Drug treatment programmes are currently not speci?cally addressing the wide range of psychological and neuropsychiatric problems related to HIV infection. Particularly striking is the reluctance of the drug abuse treatment directors in major cities like Madrid to implement methadone maintenance programmes for drug users in general, including the HIV-positive drug user. Conclusion It is clear that there are currently a number of unmet needs in this area of research and care in Spain. Despite the dimensions of the epidemic and the failure to control its expansion, particularly among the IDU population and their sexual partners, research on suicide, suicidal ideation and the psychopathology associated with HIV patients is lacking. Parallel to this neglected area of research, there are also aspects of care that are not being covered with the mental health services. Data obtained from studies in other countries are not easily applicable to this ?eld in Spain, nor are the models of care extrapolated from them. It is imperative that studies be carried out in order to throw into relief the complex mental health problems associated with the HIV epidemic. Until now, in our country, as in many others, the focus of research and care provision has been the prevention of the epidemic and implementation of counselling techniques related to HIV testing. Studies are now needed on the psychological and neuropsychiatric disorders comorbid with HIV infection in order to ?nd out the preval‎ence and incidence of HIV-1 neuropsychiatric disorders and the psychopathology of patients with HIV/AIDS. This will feed into the development of adequate care models in order to improve the quality of health services. Acknowledgments Research for this article was supported by grant 96/1123 from the Fondo de Investigacio?n Sanitaria (FIS), funded by the Spanish Ministry of Health. Dr Lastra and Dr Montan?e?s are FIS Research Fellows. References AYUSO MATEOS, J.L., BAYON PEREZ, C., SANTO-DOMINGO, J. et al. (1989). Psychiatric aspects of HIV infection in the general hospital. Psychotherapy and Psychosomatics, 52, 110?113. AYUSO MATEOS, J.L., LASTRA, I. & MONTAN?ES, F. (1993). Infeccio?n por VIH en el paciente psiquia?trico hospitalizado, XIX Congreso Nacional de la Sociedad Espan?ola de Psiquiatr??a Madrid: Editorial Libro del An?o. 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