Promoting safer sex in people with severe mental illness


Recently there has been a splurge of research interest looking at the physical health of people with mental health diagnoses. This is largely due to the movement towards a ‘parity of esteem’, which simply means valuing both mental and physical health as equals.

Historically, mental health services, research…etc has been physical health’s unpopular and resource poor sibling. The benefits of recognising and addressing the physical health issues of those with mental ill-health are great, and this blog reports on a recent systematic review looking at behavioural interventions to promote safe sexual behaviour amongst people with severe mental illness (SMI).

The link between SMI and high-risk sexual behaviour is complicated by a number of factors. However, what we do know is that people with SMIs are sexually active, are more likely to engage in risky sexual behaviour and are disproportionately affected by sexually transmitted infections (including HIV) compared to the general population.

In March, fellow Elf Knowles reviewed a systematic review which asked how effective are sexual health promotion interventions for people with SMI? She concluded that based on the evidence sought out in the review (which was largely American studies with self-reported outcomes), we are still none the wiser regarding how best to promote safe sex to this group. Sigh.

However Walsh et al published a related systematic review this year which specifically asked how effective are behavioural interventions at promoting safe sex behaviour for people with SMI? What did they find out, I hear you ask with anticipation… read on.


Severe mental illness and safe sex do not always make for good bedfellows.


  • Population: the term SMI included secondary care in-patients with chronic, relapsing psychiatric conditions (such as schizophrenia, schizoaffective disorder, bipolar disorder, and major depression) who were aged over 18.
  • Intervention: the authors accepted any “non-pharmacological intervention” which promoted safe sex behaviour. For example written information/leaflets, CBT, skills training, peer advocacy and risk-reduction counselling. All randomised controlled trials were included which were administered in secondary care in-patient settings.
  • Comparator: studies either included treatment or care as usual (control group), or another specified comparison group.
  • Outcome: any sexual behaviour outcome was considered, both objective and subjective.

A systematic search was conducted using relevant databases (Cochrane, MEDLINE, EMBASE, PsychINFO, CINAHL and BNI) and the search terms used were reported in the paper (to the delight of this Elf who loves nothing better than transparent methods!). 515 references were assessed and whittled down to 11 from where data was extracted and findings were considered.

Most studies reported on group psychosocial interventions to promote safer sexual behaviour

Most studies reported on group psychosocial interventions to promote safer sexual behaviour


All 11 studies were randomised controlled trials from the USA. Risk of bias was assessed and was acknowledged by the authors to be unsurprisingly prevalent given the outcome being researched. However, many studies provided insufficient methodological details (e.g. regarding allocation concealment and blinding) which made it difficult to ascertain the exact risk of bias.

All studies used subjective self-report methods to assess outcomes. For example, increased use of condoms, fewer sexual partners, and fewer unprotected sexual encounters. However the types of outcomes varied across all studies (making comparisons difficult).

  • The majority of the studies used some form of psychosocial group intervention
  • Although seven of the studies reported statistically significant improvements in sexual risk behaviours, only four studies reported these improvements at four weeks post-intervention
  • However no studies reported behaviour maintenance at six months
  • The studies were very heterogenous, therefore a meta-analysis was not conducted
Barry remembered what he learnt at the group sessions: "don't be a fool, cover your tool"

Barry remembered what he learnt at the group sessions: “don’t be a fool, cover your tool”


The authors concluded:

There is emerging evidence to suggest that a behavioural intervention has the potential to reduce sexual risks in people diagnosed with SMI. However, further high-quality research is needed in this area.

I feel this concluding statement doesn’t fully reflect the results or discussion in the paper. It would be fairer to say that the studies identified support some short-term reduction in sexual risk behaviours, however no significant differences were evident six months post-intervention. Furthermore, it is possible that the potential of behavioural interventions has been not fully realised due to poor quality methods employed by studies to date.


This elf was impressed with the quality of the systematic review and author’s discussion of their findings (thumbs up). However, I was disappointed to find that all the studies had been conducted in the USA (from three research centres) which limits the applicability of any findings to UK settings, as our healthcare systems are very different.

Furthermore, the term ‘non-pharmacological interventions’ is pretty broad and arguably meaningless. This elf thinks it is ill-advisable to compare and group all forms of non-pharmacological interventions together (apples and pears, as Grandmaster Elf used to say to me). Although, as it turns out, most of the published studies to date have been group interventions of some sort. Which brings me to my final point.

There is so much scope for further research to promote safer sex behaviours! So listen up academics, get your research hats on, and I look forward to reviewing a future systematic review and meta-analysis which finds good quality methods and appropriately grouped interventions. Game on!

Researchers! Get your thinking caps on. There's a real opportunity to make a difference in this field.

Researchers! Get your thinking caps on. There’s a real opportunity to make a difference in this field.


Walsh, C., McCann, E., Gilbody, S. and Hughes, E. (2014), Promoting HIV and sexual safety behaviour in people with severe mental illness: A systematic review of behavioural interventions. International Journal of Mental Health Nursing, 23: 344–354. doi: 10.1111/inm.12065 (not open access)

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