Test-retest interviews examining recent sexual activity were administered to 27 severely ill psychiatric patients after stabilization. Three reports were judged to be questionable. For the I6 sexually active patients among the remaining 24, high test-retest reliability was found for number of sexual partners, frequency of episodes, and proportions of episodes involving vaginal intercourse and use of condoms. The interviews did not exacerbate psychiatric symptoms

Caraballo, Louis R.

Cournos, Francine

Exner, Theresa M.

Gruen, Rhoda

Guido, Jeannine R.

Herman, Richard

Margoshes, Elizabeth S.

McKinnon, Karen M.

Meyer-Bahlburg, Heino F. L.

English

Columbia University Academic Commons

BRIEF REPORTS972 Am J Psychiatry 1 50:6, June 1993Reliability of Sexual Risk Behavior InterviewsWith Psychiatric PatientsKaren McKinnon, M.A., Francine Cournos, M.D., Heino F.L. Meyer.-Bahlburg, Dr.rer.nat.,Jeannine R. Guido, M.A., Louis R. Caraballo, B.A., Elizabeth S. Margoshes, Ph.D.,Richard Herman, M.A., Rhoda S. Gruen, M.A., and Theresa M. Exner, Ph.D.Test-retest interviews examining recent sexual activity were administered to 27 severely illpsychiatric patients after stabilization. Three reports were judged to be questionable. For theI 6 sexually active patients among the remaining 24, high test-retest reliability was found fornumber ofsexual partners, frequency ofepisodes, and proportions ofepisodes involving vagi-nal intercourse and use ofcondoms. The interviews did not exacerbate psychiatric symptoms.(Am J Psychiatry I 993; 150:972-974)I n a recent study ( 1 ), one (5.6%) of 1 8 patients ad-mitted to two public psychiatric hospitals in NewYork City was HIV positive. Among these patients,past use of injection drugs was associated with HIV in-fection (1 ), but unsafe sexual activity appears to be themost prevalent current risk factor for acquiring ortransmitting HIV (2).Identification of high-risk activities is essential to per-forming appropriate HIV counseling and to designingtargeted prevention strategies ( 1 ). Whether people withsevere mental illness can be interviewed about their sex-ual behavior reliably and without substantial exacerba-tion of psychiatric symptoms has been largely unad-dressed in the psychiatric literature.Data on the frequency and nature of sexual activityamong the severely mentally ill are limited (3-8), andthe association between psychiatric disorders and sex-ual activity remains unclear.As part of a larger interview study investigating howpsychiatric symptoms and HIV risk-taking behaviorsare related, we conducted a pilot study 1 ) to learnwhether psychiatric patients could tolerate a detailedsexual behavior interview and 2) to establish the reli-ability of sexual risk histories with severely mentally illinpatient and outpatient groups.Received Jan. 28, 1992; revision received Sept. 21, 1992; acceptedOct. 29, 1992. From the Washington Heights Community ServiceResearch Office, the Research Foundation for Mental Hygiene, andthe HIV Center for Behavioral and Clinical Studies, New York StatePsychiatric Institute, and the Department of Psychiatry, College ofPhysicians and Surgeons, Columbia University, New York. Addressreprint requests to Dr. Cournos, New York State Psychiatric Institute,Unit I 12, 722 West 168th St., New York, NY 10032.Funded by NIMH grant MH-46251 and the New York State Officeof Mental Health.The authors thank Ewald Horwath, M.D., and the staffand patientsof the Washington Heights Community Service.Copyright © 1993 American Psychiatric Association.METHODEligible patients were between the ages of I 8 and 59 years, spokeEnglish, and could give informed consent. Paid volunteers were re-cruited from a 22-bed acute care inpatient unit and a day treatmentprogram serving 80 primarily chronically ill patients at a public psy-chiatric hospital in New York City. Eligible inpatients were referredby their treating psychiatrists. Day treatment patients responded toan announcement of the study at a community meeting or to noticesposted in the lunch room. Thirty patients volunteered to participatein a test-retest interview study of sexual behaviors occurring in thepast 6 months. Of these, three were excluded because they could notbe reinterviewed within 60 days because of scheduling difficulties ortransfer to another facility. The remaining 27 patients completedboth interviews. Nonvolunteers were not evaluated.The Sexual Risk Behavior Assessment Schedule (9) was adminis-tered. This interview, developed for injection drug users and adaptedfor a psychiatric population, elicits detailed oral reports of sexual be-haviors in the past 6 months. The item order, exploration of patients’sexual vocabulary, and interviewers’ explicit definitions of sexualpractices are designed to put patients at ease when talking about sex.The 45-minute interview can be completed in multiple sessions.The Sexual Risk Behavior Assessment Schedule contains an inter-viewer rating of the quality of the patient’s reports that takes intoaccount impairments in the patient’s concentration and memory, in-terferenee of psychiatric symptoms in understanding and respondingto questions, and degree of comfort with the topic. The interview wasscored on a 4-point scale in which I indicates “high quality,” 2 a“generally reliable” report, 3 a “questionable” report, and 4 an “un-satisfactory” report. The reasons for questionable or unsatisfactoryreports are recorded.One male and one female interviewer who were mental health pro-fessionals not involved in the direct care of the patients each receiveda minimum of 20 hours of seminar-style training and approximatelyI S hours of interviewing practice. The training included desensitiza-tion to sexual terminology, an overview of human sexual responseand dysfunction and potential adverse patient reactions, and instruc-tion in the interview method. Audiotape recordings of practice inter-views were reviewed by the interview supervisor. The study beganonly after the supervisor was confident of the interviewers’ ability touse the instrument.The interviewers and subjects were not matched on gender, race,or sexual orientation. To counter potential response sets by individ-ual patients and to provide a component of interrater reliability, theinterviewers were alternated so that one did not conduct both theTABLE 1. Characteristics of 24 Psychiatric Patient Volunteers Re-porting on Sexual Activity in the Past 6 MonthsPatient Characteristic N %TABLE 2. Test-Retest Reliability Coefficients for Psychiatric PatientVolunteers Reporting on Sexual Activity in the Past 6 Months16 66.78 33.34 16.720 83.32 8.312 50.010 41.716 66.78 33.33 12.512 50.04 16.7S 20.812 50.011 45.8I 4.2a kappa value of 0.75 or higher signifies excellent agreement beyondchance (11).bpe000l.Cp<005initial and retest interviews with the same patient. The mean intervalbetween the two interviews was 33.71 days (SD=28.00).The interview supervisor reviewed the interviewer ratings of thepatient reports and audiotape recordings of all interviews. Ratingsjudged by both interviewer and supervisor as questionable or unsat-isfactory were excluded from analysis.For common HIV risk-related behaviors we calculated correlationcoefficients for the relationship between interview and reinterview;kappas were determined for categorical variables, and Pearson r andintraclass correlations were used for rank-transformed variables (10).The patients appeared to respond well to the inter-views. In fact, many patients reported being pleased tobe asked about a normal aspect of life. There were nopatient reports of distress or staff complaints aboutdeleterious effects, and no interview needed to be pre-maturely terminated. Of the 27 patient volunteers whocompleted the test and retest interviews, three (1 1%)were judged to have provided questionable reports be-BRIEF REPORTSAm J Psychiatry 1 50:6, June 1993 973Sexually activeYesNoLocation at interviewAcute admissions unitDay programEthnicityWhiteHispanicBlackGenderMaleFemaleAge (years)18-2930-3940-4950-59Highest level of education completed8th grade or lessHigh school or GEDCollegeMarital statusNever marriedMarriedSeparated or divorcedDomicile before hospitalizationOwn house or apartmentGroup homeShelter or streetNumber of previous psychiatric hospitalizations2-10Substance abuse history (chart)YesNoMost recent axis I diagnosis (chart)SchizophreniaBipolar disorderSchizoaffective disorderOrganic brain syndromeRESULTSIntraclassCorrelationVariable N r Coefficient KappaaSexually active (yes/no)Number of sexual partnersNumber of sexual episodes241616074b088b0.760.880.82Proportion of episodes inwhich vaginal intercourseoccurred 16 0.60c 0.60Proportion of vaginal inter-course episodes in whichcondoms were used 16 088b 0.89cause of cognitive deficits (memory impairment associ-ated with polydrug abuse, inability to concentrate). Ofthe remaining 24 patients, 16 reported sexual activityduring the previous 6 months. Eight patients reported14 58 4 no sexual activity during the previous 6 months at both2 8:3 the interview and reinterview. Reliability coefficients8 33.3 were calculated for HIV-related heterosexual variables:sexually active (dichotomized yes/no), number of sex-21 87.5 ual partners and number of episodes, proportion of2 8:3 episodes in which vaginal intercourse occurred, andproportion of vaginal intercourse episodes in which con-6 25.0 doms were used. No patient reported homosexual ac-18 75.0 tivity or anal intercourse.17 70 8 Characteristics of the 24 patients reporting on hetero-7 29:2 sexual activity in the past 6 months are shown in table1. The subjects were demographically and clinically17 70.8 representative of the patient populations at both the in-  patient and day treatment units. Most were diagnosed1 4:2 with schizophrenia and had had two or more prior psy-chiatnic hospitalizations.The test-retest reliability coefficients for risk-relatedbehaviors occurring in the past 6 months are shown intable 2 and ranged between 0.61 and 0.89.DISCUSSIONNo exacerbation of psychiatric symptoms was ob-served in response to explicit sexual interviews. Cogni-tive deficits interfered with patient reports for onlythree ( 1 1 %) of the 27 patients. Most of these patientvolunteers at a public psychiatric hospital were able toreliably report specific sexual behaviors for the pre-vious 6 months. Reports of number of sexual partners,number of sexual episodes, and proportions of episodesin which vaginal intercourse occurred and condomswere used were consistent after an average interval of 4weeks.Our patients reported no homosexual activity or analintercourse during the preceding 6 months. This is un-likely to be a reporting artifact given that studies usingsimilar versions of the Sexual Risk Behavior AssessmentBRIEF REPORTS974 Am J Psychiatry I 50:6, June 1993Schedule and identical interviewer training have yieldedcomparable prevalence rates of both behaviors for pre-dominately black and Hispanic groups consisting ofrunaway youths (12) and severely mentally ill homelessmen (Susser, unpublished data). We assume that the ex-planation lies in the relatively modest size of our studygroup, which by chance did not include patients prac-ticrng either sexual activity during the reporting period.This study combines in its design an examination oftest-retest reliability and interrater reliability becausedifferent interviewers were used on the two occasions.Given the length of the retest interval, the practice ofalternating interviewers, and the exclusion of consis-tently sexually inactive patients, the reliability coeffi-cients obtained probably represent lower limits and,therefore, conservative estimates. This assumes that ob-viously poor reports are excluded.Limitations to the generalizability of our findings in-dude potential sampling bias since the study includedonly a small number of subjects, particularly inpatients,and all participants were paid volunteers, who mayconstitute a self-selected group of sexually less inhibitedor psychiatrically more stable patients than nonvolun-teens. Furthermore, the participants had been evaluatedby clinicians as capable of giving informed consent,thereby excluding patients who were considered acutelyill and not yet stabilized. However, the participants didnot appear to differ from the overall census of eitherunit, and in our larger interview study, in which all eli-gible patients on the same units were sampled, nearly83% consented to participate and only a small propor-tion of reports (6%) were judged to be of questionableor unsatisfactory quality (2).This pilot study demonstrates that structured, sensi-tive probing of sexual risk histories by well-trainedmental health professionals can be done with stabilizedinpatients and outpatients and can yield reliable infor-mation essential to HIV risk reduction efforts. Patientswith cognitive impairment (three in our group) mightbe successfully interviewed if their condition improvesor with multiple interview sessions over time.Although devised as a research instrument, the SexualRisk Behavior Assessment Schedule can serve in clinicalsettings as a model for taking sexual risk histories. Itprovides an approach to training appropriate clinicalstaff to elicit behaviorally specific information aboutsexual behaviors from patients. We urge clinicians toattempt decisive HIV risk detection efforts with se-vereby mentally ill patients as the basis for HP! testingand counseling.REFERENCES1. Cournos F, Empfield M, Horwath E, MeKinnon K, Meyer I,Schrage H, Curric C, Agosin B: HIV seroprevalence among pa-tients admitted to two psychiatric hospitals. AmJ Psychiatry 1991;148:1225-12302. Cournos F, Empfield M, MeKinnon K, Weinstock A, HorwathE, Meyer I, Currie C: HIV seroprevalence and risk behaviorsamong homeless and hospitalized mentally ill, in Abstracts, VIIInternational Conference on AIDS. Rome, Istituto Superiore diSanita, 19913. Holbrook T: Policing sexuality in a modern state hospital. HospCommunity Psychiatry 1989; 40:75-794. Binder RL: Sex between psychiatric inpatients. Psyehiatr Q I 985;57:121-126S. Akhtar 5, Croeker E, Docleu N, Helfrich J, Rhcubau Wi: Overtsexual behavior among psychiatric inpatients. Dis Ncrv Syst1977; 38:359-36 16. Verhulst J, Schneidman B: Schizophrenia and sexual functioning.Hosp Community Psychiatry 1981; 32:259-2627. Raboch J: Sexual development and life of psychiatric female pa-tients. Arch Sex Behav 1986; 15:341-3538. Kelly JA, Murphy DA, Bahr GR, Brasfield TL, Davis DR, HauthAC, Morgan MG, Stevenson LY, Eilers MK: AIDSIHIV risk be-havior among the chronic mentally ill. Am J Psychiatry 1992;149:886-8899. Meyer-Bahlburg HFL, Ehrhardt AA, Exner TM, Gruen RS: Sex-ual Risk Behavior Assessment Schedule-Adult-Psychiatric In-patient Interview. New York, New York State Psychiatric Insti-tute,June 6, 199010. Conover WJ, Iman RL: Rank transformations as a bridge be-tween parametric and nonparametric statistics. Am Statistician1981; 35(3):124-133I I . Fleiss JL: Statistical Methods for Rates and Proportions, 2nd ed.New York, John Wiley & Sons, 1 981, p 21812. Rotheram-Borus MJ, Meyer-Bahlburg HFL, Koopman C,Rosario M, Exncr TM, Henderson R, Matthieu M, Gruen RS:Lifetime sexual behaviors among runaway males and females. JSex Res 1992; 29:15-29

Reliability of sexual risk behavior interviews with psychiatric patients

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Reliability of sexual risk behavior interviews with psychiatric patients

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