Behavioural emergencies among HIV-positive men who have sex with men

OHTNEmployment, Men who Have Sex with Men, Mental Health, Rapid Responses, Stigma, Substance Use

Rapid Response Service

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  1. What is the scope and nature of behavioural emergencies or crises among HIV-positive adult men who have sex with men (MSM) in Canada?

Key Take-Home Messages

  • Behavioural emergencies are crises in which a person’s behaviour can become so out of control that he or she becomes a danger to others in their surroundings.
  • Few studies have characterized behavioural emergencies among HIV-positive men who have sex with men; most explored mental illness, psychological distress or suicidal ideation in this population.
  • In terms of mental health, sexual minorities — specifically men who have sex with men — are at increased risk for suicidal ideation and attempts (2-4).
  • Studies among HIV-positive men found that psychological distress, specifically suicidal ideation, was commonly associated with substance use, being black, being heterosexual and living in a precarious financial situation (i.e. homelessness and unemployment) (5-7).
  • Among HIV positive men who have sex with men, the relationship between psychological distress and HIV-status is unclear; however psychological distress is associated with substance use and unemployment (1;2;8).

The Issue and Why It’s Important

Behavioural emergencies are crises in which a person’s behaviour can become so out of control that he or she becomes a danger to others in their surroundings.  Signs of behavioural emergencies may include extreme agitation, threatening to harm oneself and others, yelling, screaming, lashing out and having irrational thoughts.

With medical advances treatment, HIV is now considered a manageable chronic (as opposed to acute) illness (1), and mental health and emotional well-being are now important aspects of overall care (1). The gay community also perceives mental health issues as a priority. For example, a cross-sectional study (9)

among 335 lesbian, gay, bisexual, transgender and intersex (LGBTI) individuals from Perth, Australia identified depression, anxiety, panic attacks and family relationship problems as important individual-level health issues, and depression and suicide as important health issues affecting the LGBTI community (9).

Suicidal ideation, a distressing psychological phenomenon identified by low mood and poor quality of life and characterized by hopelessness, depression and anxiety (7), is one of the more common types of behavioural emergencies and usually precedes suicide attempts and suicide completion (7). Sexual minorities are at increased risk for suicide (2-4). Men who have sex with men are at higher risk for suicide attempts, with some risk factors associated with being gay or bisexual in a hostile environment (10).

Suicide and other forms of self-harm have been associated with HIV infections, however it is unclear whether the factors leading to self-harm and suicide are associated with a group’s vulnerability to HIV infection. The extent to which HIV diagnoses contribute to psychological trauma (7) is also unclear.

Given these findings, it is important to explore the scope and nature of behavioural emergencies among HIV-positive adult men who have sex with men in Canada in order to understand the need for treatment and support

What We Found

Evidence to support the use of peers

Few studies characterized behavioural emergencies among HIV-positive men who have sex with men; most explored sub-categories of behavioural emergencies that include mental illness, psychological distress or more commonly suicidal ideation.

Among studies of HIV-positive individuals, psychological distress — specifically suicidal ideation — was commonly associated with substance use, black race, being heterosexual and living in a precarious financial situation (i.e., homelessness and unemployment).

  • A US study (5) estimated the prevalence and clinical correlates of HIV infection among patients using psychiatric emergency services. Authors analyzed 28,817 unique patients. HIV-positive individuals accounted for 2% of total psychiatric emergency visits. These patients were more likely to be male, homeless and African American. HIV-positive patients treated in psychiatric emergency departments were more likely to use drugs or alcohol, have borderline personality disorder and present with suicidality (5).
  • A study (7) among 778 HIV-positive people attending a clinic in the UK explored factors associated with suicidal ideation. It found that, over a seven-day period, 31% reported suicidal ideation. Similar to the findings of the previous study, the factors associated with suicidal ideation included being a black heterosexual man, being unemployed, not disclosing one’s HIV status, and interrupting HIV treatment. Suicidal ideation rates were lowest among the employed and highest among the long-term ill. Stable relationships were protective for suicidal ideation (7).
  • Another study (6) among 317 primarily male African American individuals (265 substance-using; 52 non-substance using controls) examined the impact of substance use and HIV-status on mental distress. Levels of distress were similar in HIV-positive and HIV-negative, non-drug using controls. However, asymptomatic HIV-positive African Americans who used substances reported more distress than HIV-negative substance users. Overall this suggests that substance use can exacerbate mental health distress in HIV-positive males – although the study found that drug choice had no influence on mental health distress. (6).

Some studies of HIV positive men who have sex with men pointed to a link between psychological distress or suicidal ideation and HIV-positive status, however one study that did not support this association found that psychological distress was associated with substance use and unemployment.

  • In a study (2) among urban Australian men who varied in sexual orientation and HIV-status that explored factors associated with feeling suicidal, men who identified as gay or bisexual were more likely to report feeling suicidal than men who identified as heterosexual. In addition, men who were HIV-positive as well as men who were close to the HIV epidemic were more suicidal than other men who have sex with men (2).
  • A US mixed methods study (8) among HIV-positive men who have sex with men found associations between stigma and increased levels of anxiety, loneliness, depressive symptoms, avoidant coping strategies and suicidal ideation. It reinforced that HIV stigma within the gay community has a negative effect on the mental health of men who are living with HIV (8).
  • One study (1) — a cross-sectional convenience sample of 250 Australian men who have sex with men — did not find an association between psychological distress and HIV-status; however, it did find an association between psychological distress and substance use and unemployment.  In the authors’ view, the relationship may indicate either that those with serious mental health symptoms are unable to work and use drugs to cope with their life stress or that unemployment or substance use leads to higher psychological distress (1).

Resources for Clinicians

In terms of treatment for people experiencing behavioural emergencies, we found two general guidelines for clinicians: one specifically on behavioural emergencies and one on the psychiatric aspects of HIV/AIDS:

  • The Expert Consensus Guideline Series – Treatment of Behavioural Emergencies (2003) gathered expert opinions to create useful, comprehensive evidence-based guidelines in managing behavioural emergencies. A panel of 50 experts reached consensus on: the threshold for emergency interventions; the scope of assessment for varying levels of urgency; and guiding principles in selecting appropriate physical and medical interventions (11).
  • Psychiatric Aspects of HIV/AIDS (12) – Although it is not focused specifically on behavioural emergencies, this comprehensive book discusses psychiatric issues associated with HIV/AIDS and provides basic information on the bio-social, psychiatric and psychological aspects of care. It emphasizes early response to psychiatric and psychological disorders as key to successful care (12).

Factors That May Impact Local Applicability

At the time of this rapid response, the body of literature on HIV-positive men who have sex with men and behavioural emergencies was severely limited, and none of the studies included in this summary were conducted in Canada. Because literature on this topic was limited, we included literature on all HIV-positive individuals and men who have sex with men, as well as information other mental health conditions, such as psychological distress and suicidal ideation.

What We Did

We searched Medline and PsycINFO for articles using a combination of text terms [(HIV) or (AIDS)] AND text terms [(emergency mental health) or (mental health emergenc*) or (behavio*ral crisis) or (behavio*ral crises) or (psychiatric emergenc*) or (violence*) or (suicid*) or (victimization)] AND text terms [(gay) or (men who have sex) or (MSM)]. The search was limited to articles published since 2002 onwards in English.

Reference list

  1. Gibbie TM, Mijch A, Hay M. High levels of psychological distress in MSM are independent of HIV sta-tus. Journal of Health Psychology 2012;17(5):653-63.
  2. Abelson J, Lambevski S, Crawford J, Bartos M, Kippax S. Factors associ-ated with ‘feeling suicidal’: The role of sexual identity. Journal of Homo-sexuality 2006;51(1):59-80.
  3. Kulkin HS, Chauvin EA, Percle GA. Suicide among gay and lesbian adolescents and young adults: A review of the literature. Journal of Homosexuality 2000;40(1):1-29.
  4. Ploderl M, Wagenmakers EJ, Trem-blay P, Ramsay R, Kralovec K, Fartacek C et al. Suicide risk and sexual orientation: A critical review. Archives of Sexual Behavior 2013;42(5):715-27.
  5. Bennett WR, Joesch JM, Mazur M, Roy-Byrne P. Characteristics of HIV-positive patients treated in a psy-chiatric emergency department. Psychiatric Services 2009;60(3):398-401.
  6. Nnadi CU, Better W, Tate K, Hern-ing RI, Cadet JL. Contribution of substance abuse and HIV infection to psychiatric distress in an inner-city African-American population. Journal of the National Medical Association 2002;94(5):336-43.
  7. Sherr L, Lampe F, Fisher M, Arthur G, Anderson J, Zetler S et al. Suicid-al ideation in UK HIV clinic attend-ers. AIDS 2008;22(13):1651-8.
  8. Courtenay-Quirk C, Wolitski RJ, Parsons JT, Gomez CA. Is HIV/AIDS stigma dividing the gay communi-ty? Perceptions of HIV-positive men who have sex with men. AIDS Edu-cation and Prevention 2006;18(1):56-67.
  9. Comfort J, McCausland K. Health priorities and perceived health determinants among Western Australians attending the 2011 LGBTI Perth Pride Fairday Festival. Health Promotion Journal of Aus-tralia 2013;24(1):20-5.
  10. Paul JP, Catania J, Pollack L, Mos-kowitz J, Canchola J, Mills T et al. Suicide attempts among gay and bisexual men: Lifetime prevalence and antecedents. American Journal of Public Health 2002;92(8):1338-45.
  11. Allen MH, Currier GW, Hughes DH, Docherty JP, Carpenter D, Ross R. Treatment of behavioral emergen-cies: a summary of the expert con-sensus guidelines. Journal of Psy-chiatric Practice 2003;9(1):16-38.
  12. Fernandez F, Ruiz P. Psychiatric aspects of HIV/AIDS. 2006.

Suggested citation

Rapid Response Service. Rapid Response: Behavioural Emergencies among HIV-positive Men who have Sex with Men. Toronto, ON: Ontario HIV Treatment Network; June 2014.

Prepared by

Sanjana Mitra and Jason Globerman