Insufficient evidence for sexual health promotion interventions in people with severe mental illness

People with serious mental illness (SMI) such as schizophrenia and bipolar disorder have higher morbidity and mortality rates due to physical illness. It’s estimated that people with SMI die 10-15 years earlier than the general population (DeHert et al, 2011).

Increasingly attention is being paid to ways to improve the physical health of people with SMI, for example looking at reducing smoking or increasing exercise. This new review (Kaltenthaler et al, 2014) was commissioned to examine a particularly sensitive and neglected physical health issue, namely sexual health.

People with SMI are more likely to engage in sexually risky behaviours and there is a higher HIV infection rate amongst people with SMI compared to the general population. However, the sexual health needs of people with SMI have tended to be ignored.

The team from Sheffield health research group ScHARR aimed to review the available evidence on the effectiveness of sexual health promotion in this population, to identify where further research is needed.

People with severe mental illness are more likely to engage in sexually risky behaviours

Methods

The authors systematically searched for any controlled trials (both randomised and non-randomised) of sexual health promotion interventions. They included all types of interventions – educational, behavioural, psychological and so on, delivered at any level (group, individual or community.)
They included studies looking at adults (over 18) with a diagnosis of schizophrenia or bipolar disorder. They excluded populations with dementia, personality or intellectual disability.
They conducted a narrative review as the differences in study design and type of outcomes measured meant they couldn’t pool the statistical outcomes to perform a meta-analysis.

Results

13 randomised controlled trials were found to meet the inclusion criteria
The trials varied widely in terms of duration of the intervention, length of follow up and what type of comparator groups were used (for example whether the sexual health promotion intervention was compared to a waiting list or to educational sessions)
The participants included also varied widely, in terms of demographics (for example ethnicity, whether only males or females were included) and where they were recruited from, ranging across a substance abuse treatment programme, drop-in centres, outpatient clinics and homeless shelters.

There was similarly a mixed bag in terms of effectiveness:

4 of the studies reported improvements across all outcomes
4 reported improvements on some outcomes
2 reported improvements for certain subgroups only (based on gender and ethnicity)
2 reported no differences between the intervention and comparison groups
Only 2 of the studies were considered to have ‘very few’ methodological limitations

Notably, all of the trials were from the USA, so the authors note that it’s uncertain whether the findings generalise to the UK and beyond.

Little detail was provided in the studies regarding the content of interventions, how they
were delivered and by whom, making replication or generalisability difﬁcult

Conclusions

The authors state:

There is insufficient evidence to fully support or reject the identified sexual health interventions for people with SMI.

The authors reported that there was a lack of detail about what happened in the interventions, which makes it hard to judge whether the intervention would be applicable in different settings. This has implications for assessing how feasible it would be to provide such interventions, for example whether they can be provided in routine care. The authors comment that:

There needs to be an assessment of whether or not sexual health interventions could be integrated into the current care provision provided for people with SMI on the NHS.

The authors recommend that robust and well-designed trials are now run here in the UK. The cost of delivering sexual promotion interventions and the acceptability of the intervention to patients also need to be researched. Acceptability and feasibility are crucial questions for any complex intervention, and likely to be particularly important in this context given the sensitivity of the issue and the uncertainties around how best to improve physical health care for this group.

Limitations

The broad inclusion criteria, for example not differentiating based on type of intervention, make it difficult to compare across the studies.
Most of the studies included participants with a range of disorders. For example, several of the included studies included people with major depressive disorder, and the authors’ state it wasn’t possible to pull out the findings only for people with SMI.
- The included studies tended to report self-reported outcomes which may be open to bias. None of the studies provided data on objective behavioural outcomes such as unintended pregnancy or uptake of screening.
- The fact that people with SMI have higher risk of poor sexual health may be related to other vulnerabilities such as substance abuse, homelessness and childhood abuse which we know are also more prevalent amongst people with SMI and are linked to sexually risky behaviours. Addressing these complex combinations of risk is likely to be especially challenging, so future studies may need to specifically explore whether interventions are effective for these particularly vulnerable subgroups.