The use of mortality as a major public health indicator, perhaps a legacy from the era of communicable diseases, has resulted in inadequate attention being paid to highly prevalent, seriously disabling but nonfatal disorders, including mental disorders. 1 Mental health problems (mental disorders) are psychological and behavioral patterns that are associated with emotional suffering or disability (i.e., impaired functioning), loss of freedom and increased mortality. These conditions are assumed to arise from a biologic, behavioral or psychological dysfunction within the individual. 2 Thus, the definition of mental disorders excludes normal and culturally sanctioned responses to adverse events. The National Co-morbidity Survey, 1990-1992 an epidemiologic study of a national probability sample of over 8,000 noninstitutionalized United States adults aged 15 to 54 years, provides estimates of the magnitude of these problems in the general population. 3 In the National Co-Morbidity Survey, 17% of the sample had experienced one or more episodes of major depressive disorder at some time in their lives; 10% had had one or more episodes in the 12 months preceding the interview. In this sample, the lifetime prevalence of one or more types of anxiety disorder was 25% and the 12-month prevalence was 17%. Anxiety disorders include a range of diverse syndromes such as post traumatic stress disorder, panic disorder, obsessive compulsive disorder, and social phobia. Approximately 1% of the respondents had experienced one or more episodes of nonaffective psychosis, including schizophrenia, delusional disorder, or a typical psychosis in their lifetime; 0.5% of the respondents reported an episode within the past year. The high prevalence and incidence of mental health problems in the United States have attracted recent attention and this health area has been defined as a high priority for public health. 4 The population distribution of mental health problems reflects considerable racial and ethnic disparities. 5 A recent surgeon general’s report and various studies also document racial and ethnic disparities in mental health care, including gaps in access, questionable diagnostic practices, and limited provision of optimum treatments. 6
Mental disorders are strongly linked to other health problems including suicide, cirrhosis of the liver, lung cancer, and heart disease. 1 Both depression and anxiety have been implicated in the risk for onset of coronary heart disease. 1 Depression has also been linked to survival among patients with established coronary heart disease. 7,8 Both depression and anxiety disorders have been linked to drug use and physical and sexual abuse. 9-11
Co-occurrence of multiple health problems in the same subpopulations has been observed repeatedly by public health workers. 12 Recent work stimulated by the HIV/AIDS epidemic has revealed the relatively higher prevalence of substance abuse, partner violence, depression and childhood sexual abuse among men who have sex with men (MSM) and identified the overlap among these conditions as “syndemics.”13-15 Work on childhood sexual abuse in heterosexual populations also highlighted the co-occurrence of multiple health problems. 16,17
A recent analysis of data from a large-scale household based sample of urban MSM in the United States showed that polydrug use, depression, childhood sexual abuse, and partner violence are all positively associated with each other and have an additive effect on the increased vulnerability of the MSM population to HIV/AIDS. 15 Another study of a probability sample of Latino gay men recruited from venues and public social spaces identified as Latino and gay in the cities of Miami, Los Angeles, and New York documented the co-occurrence of anxiety, depression, and suicide ideation with homophobia, racism, and financial hardship. 18 Among young MSM recruited in 7 United States urban areas poly-drug use was associated with sexual abuse. 19 Among 515 transgender persons recruited through targeted and respondent-driven sampling, 62% of the male-to-female and 55% of the female-to-male transgender persons were depressed; 32% of each population had attempted suicide. HIV prevalence in this population was 35% among male-to-female transgender persons and 2% among female-to-male transgender persons. 20
In this issue of Sexually Transmitted Diseases, Erbelding and colleagues 21 report on yet another link between mental health disorders and other health problems, in this case sexually transmitted diseases. The authors found that, overall, 45% of STD clinic patients interviewed had a current AXIS I disorder and 29% had an AXIS II personality disorder. Prevalence of antisocial personality disorder (ASPD) was 29.4% in men and ASPD was significantly associated with a diagnosis of STD. These are interesting findings with important implications for future research and prevention program efforts. The prevalence of psychiatric disorders reported in this paper is higher than the revised prevalence estimates for psychiatric disorders 22 in the community; however, they do not appear to be higher than the prevalence reported above, based on the National Comorbidity Survey. More importantly, based on the reported analysis, it is difficult to know the extent to which the relatively high prevalence of psychiatric disorders in this population was due to the highly skewed racial/ethnic composition of the clinic population. Because over 90% of the respondents were black, the appropriate community comparisons would be the prevalences of the various psychiatric disorders in the black population. Moreover, mental disorders tend to be more prevalent among lower socio-economic status subpopulations. Erbelding and colleagues do not present data on the socioeconomic status of their respondents; earlier studies among the clientele of this particular STD clinic would suggest that the study population was predominantly composed of lower socio-economic status individuals. It would be important to standardize the psychiatric disorder prevalence rates by socio-economic status before comparing them to prevalence rates in the community. Assuming the association between STD clinic attendance and psychiatric disorders remains constant after the effects of population composition mentioned above are corrected for; future research would need to address many interesting questions. Some of these may include: 1) which demographic categories are responsible for the association between psychiatric disorders and STDs?; 2) what are the racial/ethnic, age, gender differentials in the association between psychiatric disorders and STDs?; 3) are psychiatric disorders causally related to STDs?; 4) what are the mechanisms of action that explain the association between psychiatric disorders and STDs?; and 5) what are the implications of the association between psychiatric disorders and STDs for the implementation of STD prevention interventions?
The programmatic implications of Erbelding et al.’s findings may be more daunting. The effectiveness of available preventive interventions is limited. Methodologically sound evaluations of available interventions are few in number; most of them have been conducted among populations with no known mental disorders. These interventions may need to be modified in important ways to be effective among persons with psychiatric disorders. In addition, the co-occurrence of mental health problems with STDs points to the need for categorical, vertical public health programs to network with each other. Systems that refer individuals to appropriate mental health programs should be available and easily accessible through STD programs; conversely, mental health programs should have effective and user friendly referral systems for STD prevention and care.
The association between STDs and mental disorders reported by Erbelding and colleagues 21 may be causal, or it may be an artifact of the demographic composition of the study population. Regardless of the reasons for the association, the reported findings accurately describe the morbidity profile and health needs of this STD clinic population. The STD prevention community needs to develop and implement a plan to address both the mental health needs and the modified STD prevention needs of individuals with psychiatric disorders encountered in STD care venues.
1. Neugebauer R. Mind Matters: The Importance of Mental Disorders in Public Health’s 21st
Century Mission. Am J Public Health 1999; 89: 1309–1311.
2. Diagnostic, Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC. Am Psychiatric Association; 1994.
3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month Prevalence of DSM-III-R Psychiatric Disorders in the United States. Arch Gen Psychiatry 1994; 51: 8–19.
4. Mental Health. A Report of the Surgeon General. Rockville, MD: United States Department of Health and Human Services; 2001.
5. Mental Health. Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General, Rockville, MD: United States Department of Health and Human Services; 2001.
6. Snowden LR. Bias in Mental Health Assessment and Intervention: Theory and Evidence. Am J Public Health 2003; 93: 239–243.
7. Hemingway H, Marmot M. Evidence Based Cardiology. Psychosocial Factors in the Aetiology and Prognosis of Coronary Heart Disease: Systematic Review of Prospective Cohort Studies. BMJ 1999; 318: 1460–1467.
8. Musselman DL, Evans DL, Nemeroff CB. The Relationship of Depression to Cardiovascular Disease: Epidemiology, Biology and Treatment. Arch Gen Psychiatry 1998; 55: 580–592.
9. Newcomb MD. Psychosocial Predicators and Consequences of Drug Use: A Developmental Perspective within a Prospective Study. J Addict Dis 1997; 16: 51–89.
10. Ghindia DJ, Kola LA. Co-Factors Affecting Substance Abuse among Homosexual Men. An Investigation within a Midwestern Gay Community. Drug Alcohol Depend 1996; 41: 167–177.
11. Molnar BE, Buka SL, Kessler RC. Child Sexual Abuse and Subsequent Psychopathology: Results From The National Comorbidity Survey. Am J Public Health 2001; 91( 5): 753–760.
12. Link BG, Phelan JC. Mckeown and the Idea That Social Conditions Are Fundamental Causes of Disease. Am J Public Health 2002; 92: 730–732.
13. Singer M. AIDS and the Health Crisis of the US Urban Poor: The Perspective of Critical Medical Anthropology. Soc Sci Med 1994; 39: 931–948.
14. Singer M. A Dose of Drugs, a Touch of Violence, a Case of AIDS: Conceptualizing the SAVA Syndemics. Free Inq Creat Sociol 1996; 24: 99–110.
15. Stall R, Mills TC, Williamson J, et al. Association of Co-Occurring Psychosocial Health Problems and Increased Vulnerability of HIV/AIDS among Urban Men Who Have Sex With Men. Am J Public Health 2003; 93: 939–942.
16. Greenberg JB. Childhood Sexual Abuse and Sex Transm Dis in Adults: A Review Of and Implications for STD/HIV Programmes. International Journal of STD & AIDS 2001; 12: 777–783.
17. Beck-Sagué CM, Solomon F. Sex Transm Dis in Abused Children and Adolescent and Adult Victims of Rape: Review of Selected Literature. Clin Infect Dis 1999; 28( Suppl 1): S74–S83.
18. Diaz RM, Ayala G, Bein E, et al. The Impact of Homophobia, Poverty, and Racism on the Mental Health of Gay and Bisexual Latino Men: Findings from 3 US Cities. Am J Public Health 2001; 91: 927–939.
19. Thiede H, Valleroy LA, MacKellar DA, et al. Regional Patterns and Correlates of Substance Use among Young Men Who Have Sex With Men in 7 US Urban Areas. Am J Public Health 2003; 93: 1915–1921.
20. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV Prevalence, Risk Behaviors, Health Care Use, Mental Health Status of Transgender Persons. Implications for Public Health Intervention. Am J Public Health 2001; 91: 915–921.
21. Erbelding EJ, Hutton HE, Zenilman JM, et al. The Prevalence of Psychiatric Disorders in STD Clinic Patients and Their Association with STD Risk. Sex Transm Dis 2003; 31: 8–12.
22. Narrow WE, Rae DS, Robins LN, Regier DA. Revised Prevalence Estimates of Mental Disorders in the United States: Using a Clinical Significance Criterion to Reconcile 2 Surveys’ Estimates. Arch Gen Psychiatry 2002; 59: 115–123.