Sexually ansmi ed in ec ions, sexual
li e and isk beha iou s o people li ing
wi h schizoph enia: sys ema ic e iew
and me a-analysis
Claudia Ayme ich, Bo ja Ped uzo, Gonzalo Salaza de Pablo, Lande Mada ia, Ja ie Goena,
Vanessa Sanchez-Gis au, Paolo Fusa -Poli, Philip McGui e, Miguel Ángel González-To es†and
Ana Ca alan†
Backg ound
Sexually ansmi ed in ec ions (STIs), along wi h sexual heal h
and beha iou , ha e ecei ed li le a en ion in schizoph enia
pa ien s.
Aims
To sys ema ically e iew and me a-analy ically cha ac e ise he
p e alence o STIs and sexual isk beha iou s among schizo-
ph enia pa ien s.
Me hod
Web o Science, PubMed, BIOSIS, KCI-Ko ean Jou nal Da abase,
MEDLINE, Russian Science Ci a ion Index, SciELO and Coch ane
Cen al Regis e we e sys ema ically sea ched om incep ion o
6 July 2023. S udies epo ing on he p e alence o odds a io o
any STI o any ou come ela ed o sexual isk beha iou s among
schizoph enia samples we e included. PRISMA/MOOSE-compli-
an (CRD42023443602) andom-e ec s me a-analyses we e used
o he selec ed ou comes. Q-s a is ics, I
2
index, sensi i i y ana-
lyses and me a- eg essions we e used. S udy quali y and publi-
ca ion bias we e assessed.
Resul s
Fo y-eigh s udies (N= 2 459 456) epo ing on STI p e alence
(including 15 allowing o calcula ion o an odds a io) and 33
s udies (N= 4255) epo ing on sexual isk beha iou s we e
included. Schizoph enia samples showed a high p e alence o
STIs and highe isks o HIV (odds a io = 2.11; 95% CI 1.23–3.63),
hepa i is C i us (HCV, odds a io = 4.54; 95% CI 2.15–961) and
hepa i is B i us (HBV; odds a io = 2.42; 95% CI 1.95–3.01)
in ec ions han heal hy con ols. HIV p e alence was highe in
A ica compa ed wi h o he con inen s and in in-pa ien ( a he
han ou -pa ien ) se ings. Finally, 37.7% (95% CI 31.5–44.4%) o
pa ien s we e sexually ac i e; 35.0% (95% CI 6.6–59.3%) epo ed
consis en condom use, and 55.3% (95% CI 25.0–82.4%) main-
ained unp o ec ed sexual ela ionships.
Conclusions
Schizoph enia pa ien s ha e high p e alence o STIs, wi h se -
e al- old inc eased isks o HIV, HBV and HCV in ec ion compa ed
wi h he gene al popula ion. Sexual heal h mus be conside ed
as an in eg al componen o ca e.
Keywo ds
Psycho ic diso de s/schizoph enia; STI; sexual li e; con acep-
ion; HIV.
Copy igh and usage
© The Au ho (s), 2024. Published by Camb idge Uni e si y P ess
on behal o Royal College o Psychia is s. This is an Open
Access a icle, dis ibu ed unde he e ms o he C ea i e
Commons A ibu ion licence (h p://c ea i ecommons.o g/
licenses/by/4.0/), which pe mi s un es ic ed e-use, dis ibu ion
and ep oduc ion, p o ided he o iginal a icle is p ope ly ci ed.
The Wo ld Heal h O ganiza ion de ines sexual heal h as ‘a s a e o
physical, emo ional, men al, and social well-being in sexuali y’.
1
Sexuali y is a na u al aspec o human beha iou and a signi ican
ac o in quali y o li e and main aining heal hy ela ionships.
2
Howe e , o indi iduals li ing wi h schizoph enia, sexual heal h
has ecei ed li le a en ion o ecogni ion as a undamen al
aspec o hei subjec i e quali y o li e and associa ed ca e.
3
Da a
sugges ha people wi h schizoph enia ha e bo h quan i a i e and
quali a i e di e ences in hei sexual li es compa ed wi h he
gene al popula ion,
4
iden i ying his a ea o heal h as one wi h
unme needs,
5
al hough sexual in e es and ac i i y do no disappea
a e diagnosis.
6,7
Indeed, indi iduals wi h schizoph enia a e a a highe isk o
engaging in isky sexual beha io s,
7
wi h po en ially ha m ul phys-
ical and men al heal h consequences such as unwan ed p egnan-
cies,
8
exposu e o in e pe sonal iolence in ela ionships
9
and
inc eased p e alence o sexually ansmi ed in ec ions (STIs).
10
The ela ionship be ween STIs and schizoph enia is complex
and mul i ac o ial, wi h an inc ease o isk o STIs due o
psychia ic symp oms (e.g. diso ganised beha iou leading o
hype sexuali y
11
o nega i e symp oms leading o a lack o skills
o asse i ely nego ia e sa e ela ionships
12
). Se e e s igma isa-
ion, pa icula ly in oman ic ela ionships,
13
and high a es o
como bidi y wi h o he men al diso de s and subs ance use,
14,15
among many o he ac o s, also con ibu e o his p oblem. On
he o he hand, ea ly exposu e o ce ain mic oo ganisms such
as hepa i is C i us (HCV)
16
o chlamydia
17
is associa ed wi h a
highe isk o de eloping schizoph enia.
18,19
Como bidi y
be ween schizoph enia and i al diseases leads o a poo e p ogno-
sis o bo h condi ions.
20
Despi e all he abo e indings, he sexual li es and isky beha-
iou s o indi iduals li ing wi h se e e men al heal h diso de s in
gene al, and schizoph enia in pa icula , con inue o be neglec ed
bo h in clinical p ac ice and esea ch. The e is a signi ican knowl-
edge gap in he a ailable li e a u e, in con as o o he impo an
aspec s o quali y o li e.
4
Conside ing hese complexi ies, his sys ema ic e iew and
me a-analysis aimed o ill his gap and examine he p e alence o
STIs in his popula ion, hei inc eased isk compa ed wi h he
gene al popula ion, and he demog aphic, clinical and me hodo-
logical ac o s in luencing his isk. Second, we aimed o cha ac e ise
he sexual isk beha iou s associa ed wi h schizoph enia.
†
These wo au ho s ha e con ibu ed equally and sha e he senio
au ho ship posi ion.
BJPsych Open (2024)
10, e110, 1–11. doi: 10.1192/bjo.2024.49
1
h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
Me hod
This s udy p o ocol was egis e ed on PROSPERO ( egis a ion
numbe : CRD42023443602). The s udy was conduc ed in acco d-
ance wi h he PRISMA (P e e ed Repo ing I ems o Sys ema ic
Re iews and Me a-Analyses)
21
(Supplemen a y Table 1 a ailable
a h ps://doi.o g/10.1192/bjo.2024.49) and MOOSE (Me a-
Analyses o Obse a ional S udies in Epidemiology
22
(Supplemen a y Table 2) checklis s, ollowing he EQUATOR
epo ing guidelines.
23
Sea ch s a egy and selec ion c i e ia
A sys ema ic li e a u e sea ch was ca ied ou dually and inde-
penden ly by wo in es iga o s (C.A. and B.P.). The sea ch
encompassed he Web o Science da abase (Cla i a e Analy ics),
including he Web o Science Co e Collec ion, PubMed, he
BIOSIS Ci a ion Index, he KCI-Ko ean Jou nal Da abase,
MEDLINE, he Russian Science Ci a ion Index, and he SciELO
Ci a ion Index, as well as he Coch ane Cen al Regis e o
Re iews and O id/PsycINFO da abases, om incep ion un il
6 July 2023. Two sepa a ed sea ches we e conduc ed: one o
iden i y a icles con aining in o ma ion on he p e alence and
ela i e isk o sexually ansmi ed diseases among people wi h a
diagnosis o schizoph enia spec um diso de , and he o he o
iden i y a icles epo ing on ou comes ela ed o sexual beha iou
among he same popula ion. The comple e sea ch e ms a e
a ailable in Supplemen a y Table 3.
A icles iden i ied unde wen an ini ial sc eening o hei
abs ac s by he wo e iewe s. Subsequen ly, a e exclusion o
hose ha did no mee he inclusion c i e ia, he ull ex s o he
emaining a icles we e dually assessed o eligibili y and inclusion.
Inclusion c i e ia o he sys ema ic e iew and me a-analysis we e:
(a) indi idual s udies wi h o iginal da a; (b) epo ing on pa ien s
mee ing c i e ia o any schizoph enia spec um diso de (including
schizoph enia, schizoph enipho m diso de , schizoa ec i e dis-
o de , delusional diso de , and b ie psycho ic diso de , acco ding
o DSM-5-TR
24
o ICD-11
25
c i e ia); (c) epo ing ei he quan i a-
i e da a on he p e alence o an STI (including HIV, human papil-
loma i us, hepa i is B i us (HBV), HCV, T eponema pallidum,
Neisse ia gono hoeae,Mycoplasma geni alium and Chlamydia
achoma is) using a se ological, mic obiological o clinical diagno-
sis p o ided by a heal hca e specialis , o ei he any ou come ela ed
o sexual beha iou (a comple e lis o he sough -ou , s anda dised
ou comes is a ailable in Supplemen a y Table 4); (d) non-
o e lapping samples (o e lap was asce ained by examining he
inclusion da es, he demog aphics o he popula ion and he coun y
whe e he s udy was conduc ed; he s udy wi h he la ges sample
was selec ed); and (e) w i en in he English language. Exclusion
c i e ia we e (a) e iews, clinical cases, s udy p o ocols o quali a i e
s udies, con e en ial p oceedings, le e s and commen a ies; (b)
epo ing on pa ien s wi h an a ec i e psycho ic diso de acco ding
o DSM/ICD c i e ia;
24,25
(c) epo ing on a subsample o schizo-
ph enia pa ien s speci ically selec ed o hei cha ac e is ics o
isk o an STI; and (d) w i en in languages o he han English.
Da a ex ac ion
Th ee e iewe s (B.P., L.M. and J.G.) independen ly conduc ed da a
ex ac ion om all he s udies included, s a ing on 20 July 2023.
Subsequen ly, he h ee da abases we e c oss-checked, and any
inconsis encies we e esol ed h ough consensus unde he supe i-
sion o a senio esea che (A.C.).
Fo he included a icles, a summa y o he selec ed a iables
included: i s au ho and yea o publica ion, coun y and ci y,
sample size, age in yea s (mean ± s.d.), sex (pe cen age emale),
STI diagnos ic me hod, ela ionship s a us (pe cen age in s able
ela ionship), subs ance use diso de acco ding o any DSM o
ICD c i e ia (excluding nico ine) (%), quali y assessmen (see
below) and key indings. When s a i ied da a we e a ailable, da a
we e ex ac ed sepa a ely o male and emale popula ions.
Risk o bias (quali y) assessmen
Risk o bias was independen ly assessed by B.P. and C.A. using a
modi ied e sion o he Newcas le–O awa Scale (NOS) o asses-
sing he quali y o non- andomised s udies. This choice was made
aking in o accoun he he e ogenei y expec ed in he included
s udies
26
(Supplemen a y Table 5). Any disc epancy be ween he
wo assessmen s was esol ed h ough consensus.
S a egy o da a syn hesis
Fi s , we p o ided a sys ema ic syn hesis o he indings om he
included s udies s uc u ed a ound wo main opics: he p e alence
and ela i e isk o he examined STIs, and he included sex beha -
iou ou comes (Table 1 and Supplemen a y Table 6, espec i ely).
Second, whe e da a allowed, we pe o med me a-analyses using
as p ima y e ec size he p e alence (pe cen age and s anda d
e o , when a ailable) o he STIs. Each STI was sepa a ely analysed.
Then, o hose a icles whe e he p e alence o STIs in a compa i-
son g oup o heal hy con ols (de ined as people wi hou any men al
heal h diso de ) was also a ailable, he odds a io wi h a 95% con-
idence in e al was calcula ed using he numbe o indi iduals
wi h any pa icula STI and samples sizes o each sample,
wi hou adjus ing by any a iable, and hen sepa a ely me a-
analysed o each STI. An odds a io g ea e han 1 indica ed ha
he schizoph enia g oup had a highe isk o p esen ing wi h any
pa icula STI han he heal hy con ol g oup. Sepa a e p opo ion
me a-analyses we e also conduc ed o s udy he pooled p e alence
o each sexual beha iou o isk beha iou when h ee o mo e
samples we e a ailable.
The he e ogenei y be ween s udies was measu ed using he
Q-s a is ic, and pe cen ages o o e all a iabili y in he es ima es o
ORs we e de e mined using he I
2
index, classi ying he he e ogen-
ei y in o low (I
2
= 25%), medium (I
2
= 50%) and high (I
2
= 75%).
27
Me a- eg essions we e pe o med o s udy he e ec s o (a) age,
(b) publica ion yea , (c) pe cen age o emales, (d) pe cen age o
pa ien s wi h subs ance use diso de , (e) pe cen age o pa ien s in
a s able ela ionship, and ( ) isk o bias (NOS sco e) on ou comes
whe e se en o mo e a icles p o ided he da a. Sensi i i y analyses
we e pe o med o de e mine di e ences depending on (a) sample
con inen , (b) sample ype ( i s -episode psychosis, de ined as
pa ien s p esen ing wi h psychosis o ewe han 5 yea s om he
ini ial onse ,
24
e sus ch onic schizoph enia), and (c) se ing
(in-pa ien e sus ou -pa ien ) wi h espec o he s udy ou comes
when mo e han en a icles we e a ailable. A andom-e ec s
model was used, owing o he expec ed high he e ogenei y.
Publica ion bias was assessed by isual inspec ion o he unnel
plo s; when mo e han en a icles we e a ailable, Egge ’s es was
also pe o med.
All analyses we e conduc ed wi hin R 4.2.2
28
using he me a o
package.
29
The signi icance le el was se a P< 0.05, wo-sided.
Resul s
Sexually ansmi ed diseases
The li e a u e sea ch o elec onic da abases yielded 1734 ci a ions,
which we e sc eened o eligibili y; 95 a icles unde wen ull-
ex assessmen , and 47 we e excluded. The inal sample o he
Ayme ich e al
2
h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
Table 1 Cha ac e is ics o he s udies included in he sexually ansmi ed in ec ions sys ema ic e iew
S udy Coun y STI
N, schizoph enia
pa ien s (STI)
N, heal hy
con ols (STI)
Age in yea s,
mean (s.d.)
Pe cen age
women Se ing
Pe cen age
wi h SUD
Pe cen age in
s able ela ionship NOS
Opondo e al, 2017 Bo swana HIV 545 (152) –30.3 (3.8) 22% In-pa ien n.a. 5% 7
Said e al, 2001 Jo dan HBV 192 (14) 192 (5) 39.9 (n.a.) 45% In-pa ien n.a. n.a. 6
Dou ik e al, 2022 Mo occo HIV 444 (0) –33.5 (9.2) 10% O he n.a. 24% 5
HBV 444 (7) –
HCV 444 (4) –
T. pallidum 444 (16) –
Mona e al, 2022 Sou h A ica HIV 370 (45) –n.a. 30% In-pa ien n.a. 6% 7
Mwelase e al, 2023 Sou h A ica HIV 294 (62) –n.a. 31% In-pa ien 53% 58% 8
Lundbe g e al, 2013 Uganda HIV 224 (26) 15 108 (1330) n.a. 51% O he n.a. 14% 8
Maling e al, 2011 Uganda HIV 87 (13) –n.a. n.a. In-pa ien n.a. n.a. 8
Mbewe e al, 2006 Zambia HIV 160 (5) –37.5 (21.4) 28% In-pa ien 56% n.a. 6
Wang e al, 2016 China HBV 415 (28) 3038 (101) 18.5 (1.6) 48% O he n.a. n.a. 6
Zhan e al, 2018 China T. pallidum 1586 (53) –n.a. n.a. O he n.a. n.a. 8
Zhu e al, 2015 China HBV 1649 (181) –34.0 (n.a.) 54% O he n.a. n.a. 7
Chaudu y e al, 1994 India HBV 100 (11) 100 (2) 54.6 (8.4) 0% In-pa ien n.a. n.a. 4
Imani e al, 2022 I an HBV 92 (1) –n.a. n.a. O he n.a. n.a. 7
Nakamu a e al, 2004 Japan HCV 455 (28) 197 827 (2374) n.a. n.a. In-pa ien n.a. n.a. 8
Chang e al, 2021 Taiwan HBV 15 914 (465) –40.1 (9.7) n.a. O he n.a. n.a. 9
HCV 15 914 (181) –
Chiu e al, 2017 Taiwan HCV 6097 (127) 6097 (85) 43.3 (13.7) 48% O he 2% n.a. 7
Hung e al, 2012 Taiwan HBV 511 (53) –42.5 (10.7) 42% In-pa ien n.a. n.a. 8
HCV 577 (11) –
Ha i i e al, 2011 Tu key HIV 88 (0) –34.9 (8.8) 64% Ou -pa ien n.a. n.a. 8
HBV 88 (0) –
HCV 88 (0) –
De He e al, 2009 Belgium HIV 595 (3) –36.7 (11.2) 35% O he n.a. 13% 7
HCV 595 (4) –
Felle ho e al, 2011 Ge many C. achoma is 72 (2) −n.a. n.a. O he n.a. n.a. 7
K ause e al, 2010 Ge many C. achoma is 31 (8) −n.a. n.a. O he n.a. n.a. 7
G assi e al, 1999 I aly HIV 33 (1) −35.3 (8.1) 35% O he 43% 15% 6
Cuad ado e al, 2020 Spain HCV 425 (8) −36.5 (n.a.) 47% O he n.a. n.a. 7
González-To es e al, 2015 Spain HIV 235 (5) −n.a. n.a. In-pa ien n.a. n.a. 7
Baue -S aeb, 2017 Sweden HIV 21 232 (44) 6 815 931 (5909) 46.0 (8.1) 50% O he 4% n.a. 8
HBV 21 232 (112) 6 815 931 (112)
HCV 21 232 (1194) 6 815 931 (41 600)
Jallow e al, 2016 Sweden HIV 10 347 (65) −n.a. 46% Ou -pa ien n.a. n.a. 8
Ka abulu e al, 2016 Tu key HIV 489 (0) −42.5 (11.3) 16% O he n.a. n.a. 7
HBV 489 (32) −
HCV 489 (1) −
Heslin e al, 2022 Uni ed Kingdom HIV 8562 (174) −n.a. n.a. Ou -pa ien n.a. n.a. 9
Closson e al, 2019 Canada HIV 6454 (835) 507 670 (12 499) n.a. 41% O he 49% n.a. 8
Sockalingam e al, 2010 Canada HCV 110 (3) −44.7 (10.8) 32% O he 7% n.a. 7
Rodge s-Johnson e al, 1996 Jamaica HIV 201 (5) −n.a. 38% In-pa ien n.a. 17% 7
Al a ado-Esqui el e al, 2005 Mexico HBV 33 (4) –n.a. n.a. In-pa ien n.a. n.a. 7
Bailla geon e al, 2008 USA HIV 4736 (173) –n.a. n.a. O he n.a. n.a. 5
Blank e al, 2002 USA HIV 8208 (98) 374 253 (2062) 40.3 (17.6) 47% O he n.a. n.a. 6
Ca ney e al, 2006 USA HCV 1074 (7) 726 262 (492) 40.2 (11.9) 53% O he 9% n.a. 7
Dinwiddie e al, 2003 USA HCV 153 (14) –n.a. n.a. In-pa ien n.a. n.a. 7
(Con inued)
Sexual heal h o people li ing wi h schizoph enia
3
h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
sys ema ic e iew and STI me a-analyses included 48 s udies
(Supplemen a y Fig. 1(a)).
Twen y-eigh s udies (58.3%) included da a on HIV,
30,57
20 (41.7%) on HCV,
36,40,45,48,50,51,54,55,57,67
14 (29.2%) on
HBV,
36,48,50,51,54,57,60,64,68,72
h ee (8.3%) on C. achoma is
17,49,73
and h ee (6.3%) on T. pallidum.
36,48,74
No s udies ul illing ou
inclusion c i e ia we e ound ega ding o he STIs included in ou
sea ch. The ull sample included 2 459 456 pa ien s wi h schizoph e-
nia. The mean age o he sample was 50.3 yea s, anging om 16 o
73 yea s (s.d. = 11.9); 21.1% we e emale, 24.8% we e in a s able ela-
ionship, and 23.7% p esen ed wi h a como bid subs ance use dis-
o de o he han nico ine- ela ed. Among he s udies epo ing
he p e alence o a como bid subs ance use diso de , wo epo ed
on alcohol and cannabinoids,
30,32
ou epo ed on he use o injec -
able d ugs,
41,51,53,58
ou epo ed on bo h o hese ca ego -
ies,
40,45,49,63
and six did no speci y he subs ance o subs ances
used.
39,43,54,59,62,66
S udies included samples om 24 coun ies in
six con inen s: 17 (35.4%) om No h Ame ica, en (20.8%) om
Eu ope, en (20.8%) om Asia, eigh (16.7%) om A ica, wo
(4.2%) om Oceania and one (2.1%) om Sou h Ame ica. The
mean NOS sco e o he included s udies was 6.9 ± 1.2 (Table 2A
and Supplemen a y Table 6).
Fi een o he included s udies p o ided da a o a heal hy
con ol compa ison g oup, he eby enabling he calcula ion o an
odds a io. O hese s udies, se en included da a on
HIV,
33,38,39,41,44,45,54
se en on HCV
45,54,61,63,66,67
and ou on
HBV
54,69,72,75
(Table 2B).
HIV
The p e alence o HIV among people wi h schizoph enia was
epo ed in 28 s udies, comp ising a o al sample o 2 421 702
pa ien s. All HIV diagnosis we e se ological. The pooled p e alence
o HIV was 1.67% (95% CI 0.82–3.37%) (Fig. 1). Me a- eg essions
ound a s a is ically signi ican highe p e alence o HIV among
samples wi h highe p e alence o subs ance use diso de (β=
8.079; 95% CI 0.003–4.020) bu no s a is ically signi ican e ec
o age, sex, ela ionship s a us, isk o bias o publica ion yea
(Supplemen a y Table 7). P e alence o HIV was signi ican ly
highe in samples om A ica (7.32%; 95% CI 1.51–28.94%) and
in in-pa ien se ings (5.94%; 95% CI 1.78–18.04%) when compa ed
wi h o he con inen s o wi h ou -pa ien se ings (Supplemen a y
Table 9). No publica ion bias was iden i ied by isual inspec ion
o he unnel plo (Supplemen a y Fig. 3(a)) o by Egge ’s es
(P= 0.48).
Se en o hese s udies also included he p e alence o HIV in a
heal hy con ol compa ison sample ( o al sample: 346 362 pa ien s
wi h schizoph enia and 11 870 350 heal hy con ols), allowing o
an odds a io calcula ion. The odds a io o HIV in ec ion was
2.11 (95% CI 1.23–3.63, P< 0.01), implying a s a is ically signi ican
highe isk o HIV in ec ion in he schizoph enia sample (Fig. 2).
Me a- eg essions e ealed no s a is ically signi ican e ec o isk
o bias o publica ion yea . The unnel plo did no sugges he p es-
ence o publica ion bias (Supplemen a y Fig. 3(b)).
Hepa i is C i us
The p e alence o HCV among he schizoph enia sample was
epo ed in 20 s udies ( o al sample: 146 326 pa ien s). All diagnosis
we e se ological. The pooled p e alence o HCV was 2.82% (95% CI
1.51–5.20%) (Supplemen a y Fig. 2(a)). Me a- eg essions ound a
s a is ically signi ican highe p e alence o HCV p e alence in
olde samples (β= 0.143; 95% CI 0.090–0.196) and samples wi h
highe p e alence o subs ance use diso de (β= 4.201; 95% CI
0.692–7.710) and in olde a icles (publica ion yea β=−0.097;
95% CI −0.187 o −0.007) (Supplemen a y Table 8). No e ec o
Table 1 (Con inued)
S udy Coun y STI
N, schizoph enia
pa ien s (STI)
N, heal hy
con ols (STI)
Age in yea s,
mean (s.d.)
Pe cen age
women Se ing
Pe cen age
wi h SUD
Pe cen age in
s able ela ionship NOS
Doyle e al, 1997 USA HIV 138 (0) –32.0 (13.7) n.a. In-pa ien 27% n.a. 5
F euden eich e al, 2007 USA HCV 98 (8) –44.7 (n.a.) 25% Ou -pa ien n.a. n.a. 6
Fulle e al, 2011 USA HCV 6521 (1076) 6521 (124) 57.2 (n.a.) 6% O he 65% n.a. 8
Ha e al, 1999 USA HIV 38 (2) 16 (0) n.a. n.a. O he n.a. n.a. 4
Himelhoch e al, 2007 USA HIV 89 189 (858) 67 965 (346) 55.5 (11.9) 5% O he 25% 25% 7
HCV 89 189 (6287) 67 965 (1708)
Huckans e al, 2006 USA HCV 2207 (219) 73 687 (3888) n.a. n.a. O he n.a. n.a. 6
P ince e al, 2012 USA HIV 221 017 (1413) 4 089 407 (24 607) n.a. n.a. O he n.a. n.a. 8
Rosenge g e al, 2005 USA HIV 495 (18) –n.a. 32% O he 29% n.a. 7
HCV 495 (96) –
Walkup e al, 2010 USA HIV 2 047 199 (37 054) –n.a. n.a. O he n.a. n.a. 6
B own e al, 2021 Aus alia HIV 69 (1) –19.6 (10.8) 42% O he n.a. 10% 9
C. achoma is 69 (5) –
Williams e al, 2020 Aus alia HIV 97 (0) –46.0 (n.a.) 40% Ou -pa ien n.a. n.a. 6
HBV 97 (0) –
HCV 97 (7) –
San os da Sil a e al, 2019 B azil HIV 66 (0) –n.a. n.a. Ou -pa ien n.a. n.a. 8
HBV 66 (1) –
HCV 66 (0) –
T. pallidum 66 (0) –
STI, sexually ansmi ed disease; SUD, subs ance use diso de ; NOS, Newcas le–O awa Scale; HBV, hepa i is B i us; HCV, hepa i is C i us.
Ayme ich e al
4
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se ing was de ec ed in he sensi i i y analyses (Supplemen a y
Table 10), and no publica ion bias was iden i ied (Supplemen a y
Fig. 3(c)).
Se en o hese s udies also included he p e alence o HCV o a
heal hy con ol compa ison g oup ( o al sample: 126 775 pa ien s
wi h schizoph enia and 7 894 290 heal hy con ols), allowing o
Table 2A P e alence o sexually ansmi ed in ec ions
STI Numbe o s udies Sample size P e alence 95% CI
He e ogenei y
I
2
(%) P
HIV 28 2 421 702 0.0167 0.0082–0.0337 99.6 <0.01
HCV 20 146 326 0.0282 0.0151–0.0520 99.0 <0.01
HBV 14 41 322 0.0326 0.0157–0.0664 98.4 <0.01
C. achoma is 3 172 0.0850 0.0069–0.5540 82.4 <0.01
T. pallidum 3 2096 0.0329 0.0197–0.0545 0.00 0.96
STI, sexually ansmi ed in ec ion; HCV, hepa i is C i us; HBV, hepa i is B i us.
Table 2B Odds a io o he isk o each sexually ansmi ed in ec ion among schizoph enia samples compa ed wi h heal hy con ol samples
STI Numbe o s udies Schizoph enia pa ien sample Heal hy con ol sample Odds a io 95% CI P- alue
He e ogenei y
I
2
(%) P
HIV 7 346 362 11 870 350 2.11 1.23–3.63 0.01 99.5 0.00
HCV 20 126 775 7 894 290 4.54 2.15–9.61 0.00 99.5 0.00
HBV 4 21 939 6 819 261 2.42 1.95–3.01 0.00 0.00 0.59
STI, sexually ansmi ed in ec ion; HCV, hepa i is C i us; HBV, hepa i is B i us.
S udy E en s
Random-e ec s model 2 421 702 0.0167 0.0082–0.0337
To al P opo ion 95% CI
Ka abulu , 2016 0 489 0.0000 0.0000–0.0075
0.0000
0.0021
0.0000–0.0083
0.0015–0.0028
0.0000 0.0000–0.0264
0.0050 0.0010–0.0147
0.0000 0.0000–0.0373
0.0000 0.0000–0.0411
0.0062 0.0048–0.0079
0.0064 0.0061–0.0067
0.0000 0.0000–0.0544
0.0096 0.0090–0.0103
0.0119 0.0097–0.0145
0.0145 0.0004–0.0781
0.0181 0.0179–0.0183
0.0203 0.0174–0.0235
0.0213 0.0069–0.0490
0.0249 0.0081–0.0571
0.0303 0.0008–0.1576
0.0312 0.0102–0.0714
0.0364 0.0217–0.0569
0.0365 0.0314–0.0423
0.0526 0.0064–0.1775
0.1161 0.0772–0.1654
0.1216 0.0901–0.1593
0.1294 0.1213–0.1378
0.1494 0.0820–0.2420
0.2109 0.1657–0.2620
0.2789 0.2416–0.3186
444
21 232
138
595
97
88
10 437
221 017
66
89 189
8208
69
2 047 199
8562
235
201
33
160
495
4736
38
224
370
6454
87
294
545
0
44
0
3
0
0
65
1413
0
858
98
1
37 054
174
5
5
1
5
18
173
2
26
45
835
13
62
152
0 0.05 0.1 0.15 0.2 0.25 0.3
Dou ik, 2022
Baue -S aeb, 2017
Doyle, 1997
DeHe , 2009
Williams, 2020
Ha i i, 2011
Jallow, 2016
P ince, 2012
San osDaSil a, 2021
Himelhoch, 2007
Blank, 2002
B own, 2021
Walkup, 2010
Heslin, 2022
Gonzalez-To es, 2015
Rodge s-Johnson, 1996
G assi, 1999
Mbewe, 2006
Rosenge g, 2005
Bailla geon, 2008
Ha , 1999
Lundbe g, 2013
Mona, 2022
Closson, 2019
Maling, 2011
Mwelase, 2023
Opondo, 2017
He e ogenei y: I2 = 100%, τ2 = 2.8446, P = 0
Fig. 1 Fo es plo o HIV p e alence.
Sexual heal h o people li ing wi h schizoph enia
5
h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
an odds a io calcula ion. The odds a io o HCV in ec ion was 4.54
(95% CI 2.15–9.61, P< 0.01), implying a s a is ically signi ican
highe isk o HCV in ec ion in he schizoph enia sample
(Supplemen a y Fig. 2(b)). Me a- eg essions e ealed no s a is ically
signi ican e ec o isk o bias o publica ion yea , and he unnel
plo did no sugges he p esence o publica ion bias
(Supplemen a y Fig. 3(d)).
Hepa i is B i us
The p e alence o HBV among people wi h schizoph enia was
epo ed in 14 s udies, comp ising a o al sample o 41 322 pa ien s.
All diagnosis we e se ological. The pooled p e alence o HBV was
3.26% (95% CI 1.57–6.64%) ( o es plo a ailable in
Supplemen a y Fig. 2(c)). Me a- eg essions ound a s a is ically sig-
ni ican highe p e alence o HBV p e alence in olde a icles (pub-
lica ion yea β=−0.082; 95% CI −0.157 o −0.007) (Supplemen a y
Table 8), and sensi i i y analyses ound a g ea e p e alence o HBV
among in-pa ien samples (9.81%; 95% CI 6.99–13.60%) compa ed
wi h ou -pa ien o mixed samples (Supplemen a y Table 10). No
publica ion bias was iden i ied (Supplemen a y Fig. 3(e)).
Fou o hese s udies also included he p e alence o HBV o a
heal hy con ol compa ison sample ( o al sample: 21 939 pa ien s
wi h schizoph enia and 6 819 261 heal hy con ols), allowing o an
odds a io calcula ion. The odds a io o HBV in ec ion was 2.42
(95% CI 1.95–3.01, P< 0.01), implying a s a is ically signi ican
highe isk o HBV in ec ion in he schizoph enia sample
(Supplemen a y Fig. 2(d)). The unnel plo did no sugges he p es-
ence o publica ion bias (Supplemen a y Fig. 3( )). No enough da a
we e a ailable o pe o m any me a- eg ession o sensi i i y analysis.
C. achoma is
The p e alence o C. achoma is in he schizoph enia sample was
epo ed in h ee s udies ( o al sample: 172 pa ien s). One a icle
p o ided clinical diagnosis by he pa ien s’gene al p ac i ione s,
49
ano he epo ed se ological diagnosis
73
and he hi d used molecu-
la diagnosis h ough DNA polyme ase chain eac ion.
17
The
pooled p e alence o chlamydia was 8.50% (95% CI 0.69–55.40%)
(Supplemen a y Fig. 2(e)). No enough da a we e a ailable o
pe o m any me a- eg ession o sensi i i y analysis, o o calcula e
an odds a io o C. achoma is compa ing a schizoph enia
sample wi h a heal hy con ol compa ison sample.
T. pallidum
The p e alence o T. pallidum in he schizoph enia sample was
epo ed in h ee s udies ( o al sample: 2096 pa ien s). All diagnoses
we e se ological. The pooled p e alence o T. pallidum was 3.29%
(95% CI 1.97–5.45%) (Supplemen a y Fig. 2( )). No enough da a
we e a ailable o pe o m any me a- eg ession o sensi i i y ana-
lysis, o o calcula e an OR o T. pallidum compa ing a schizoph e-
nia sample wi h a heal hy con ol compa ison sample.
Sexual beha iou
The li e a u e sea ch o elec onic da abases yielded 789 ci a ions,
which we e sc eened o eligibili y; ull ex s o 344 a icles we e
assessed, and 311 a icles we e excluded. The inal sample o he
sys ema ic e iew and me a-analyses included 33 s udies
(Supplemen a y Fig. 1(b)).
The ull sample comp ised 4255 pa ien s wi h schizoph enia.
The mean age o he sample was 38.0 yea s, anging om 16 o
65 yea s (s.d. = 8.02); 51.2% we e emale, 33.72% decla ed hem-
sel es o be in a s able ela ionship, and he mean du a ion o
illness was 11.9 yea s (s.d. = 7.4). S udies included samples om
14 coun ies in i e con inen s. The mean age a i s sexual ela ion-
ship was 18.15 yea s. The mean NOS sco e o he included s udies
was 6.7 ± 1.2 (Table 2).
A de ailed desc ip ion o he me a-analy ical esul s can be
ound in Table 2; 37.77% (95% CI 18.93–61.22%) conside ed hem-
sel es o be in a s able ela ionship.
49,50,53,76,91
59.66% (95% CI
43.57–73.91%) epo ed being in e es ed in sexual ela ionships
wi h o he s
4,76,77
and 53.71% (42.85–64.22%) we e sa is ied wi h
hei sex li e.
77,85,92
Whe eas 74.10% (95% CI 53.20–87.89%) had
had sexual ela ionships wi h ano he pe son a leas once in hei
li e ime,
37,49,53,77,79,81,93
only 37.72% (95% CI 31.52–44.35%) we e
sexually ac i e (de ined in mos cases as sexual in e cou se a leas
once o e he p e ious 12 mon hs).
50,53,77,79,84,85,92,94,98
Among
hose who we e sexually ac i e, 35.37% (95% CI 15.56–61.92%)
epo ed ha ing mul iple pa ne s,
50,53,83,84,87,96
30.95% (95% CI
11.88–59.84%) had paid o sexual ela ionships,
50,53,92
and
13.38% (95% CI 5.02–31.09%) epo ed ha ing had ela ionships
in exchange o goods o money.
50,83,87
Only 34.98% (95% CI
16.58–59.29%) epo ed consis en use o a condom in hei ela-
ionships,
37,49,53,80,83,96
whe eas 55.28% (95% CI 24.59–82.41%)
epo ed ha ing unp o ec ed sexual ela ionships,
49,50,80,87,98,99
and 28.72% (95% CI 8.38–63.99%) o pa ien s had expe ienced an
unplanned p egnancy on he pa o hemsel es o hei pa -
ne s
49,50,92,100,101
(Table 3A and Supplemen a y Fig. 2(g,i)). Me a-
eg essions and sensi i i y analyses e ealed no s a is ically signi i-
can di e ences ega ding age, sex, isk o bias, publica ion yea ,
con inen o se ing o any o he s udied ou comes
(Supplemen a y Tables 8 and 10, espec i ely). The unnel plo s
did no sugges he p esence o publica ion bias o any o he ou -
comes (Supplemen a y Fig. 3).
P ince, 2012 1.06 16.9%
15.0%
16.8%
16.4%
2.0%
15.9%
16.9%
1.01–1.12
0.90–2.06
1.67–2.15
1.78–2.67
0.10–49.75
1.78–3.22
5.46–6.34
1.36
1.90
2.18
2.26
2.39
5.89
0.1 0.5 12 10
Lundbe g, 2013
Himelhoch, 2007
Blank, 2002
Ha , 1999
Baue -S aeb, 2017
Closson, 2019
He e ogenei y: I2 = 100%, τ2 = 0.3414, P < 0.01
S udy
Random-e ec s model
Expe imen al
1413
26
858
98
2
44
835
221 017
224
89 189
8208
38
21 232
6454
E en s To al
346 362 11 870 350
24 607
1330
346
2062
0
5909
12 499
4 089 407
15 108
67 965
374 253
16
6 815 931
507 670
E en s To al Odds a io Odds a io
2.11 100.0%1.32–3.38
95% CI Weigh
Con ol
Fig. 2 Fo es plo o HIV in ec ion odds a ios. An odds a io g ea e han 1 implies ha heschizoph enia popula ion has g ea e isk o he in ec ion.
Ayme ich e al
6
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When compa ed wi h heal hy con ols, pa ien s wi h schizoph e-
nia we e signi ican ly less likely o be in a s able ela ionship (k=6,
odds a io = 0.18, 95% CI 0.07–0.45, P< 0.01)
49,50,78,79,84,89
o o be
sexually ac i e (k= 4, odds a io 0.19, 95% CI 0.13–0.29, P<
0.01)
50,79,84,92
(Tables 2B and 3B, and Supplemen a y Fig. 2(h, j)).
Discussion
To he bes o ou knowledge, his is he i s sys ema ic e iew and
me a-analysis o comp ehensi ely assess he p e alence and odds
a ios o STIs among people li ing wi h schizoph enia, along wi h
hei sexual isk beha iou s.
Se e al impo an indings ha e been made. Fi s , a high p e a-
lence o STIs was no ed. The pooled HIV p e alence was 1.67%
(wi h an odds a io o 2.11 compa ed wi h he gene al popula ion),
whe eas o HCV and HBV, posi i i y p e alence eached 2.82 and
3.26%, wi h ORs o 4.54 and 2.42, espec i ely. A high p e alence
was also been ound o less-s udied STIs such as T. pallidum
(3.3%) and C. achoma is (8.5%). I is impo an o highligh ha
he included s udies we e c oss-sec ional, so i can be an icipa ed
ha he p opo ion o indi iduals wi h schizoph enia who
de elop an STI o e he cou se o hei li e ime will be subs an ially
highe han epo ed he e. This is in line wi h p e ious indings in
li e a u e, om sys ema ic e iews
102
and la ge coho s udies.
10,103
Posi i e symp oms a e associa ed wi h diso ganised beha iou , sub-
s ance use (including injec ion d ug use, ano he majo sou ce o
con agion o he s udied i uses) and hype sexuali y in some
cases.
87,104
In ou me a-analysis, HIV p e alence was subs an ially
highe in samples wi h highe subs ance use diso de como bidi y
and in samples om A ica, a 7.32%. A p e ious me a-analysis
examining he p e alence o HIV se oposi i i y among pa ien s
wi h i s -episode psychosis pa ien s in he A ican con inen
ound an e en g ea e pooled p e alence o 26%, which hey hypo-
he ically linked o longe du a ion o un ea ed schizoph enia, low
access o heal h se ices and high p e alence o in ec ion in he con-
inen .
105
On he o he hand, and mo e encou agingly, he
p e alence o HBV and HCV appea s o be lowe acco ding o
mo e ecen ly published a icles (and in he case o HCV, o
samples wi h younge mean age). Global ends o hepa i is B
and C ha e shown a posi i e e olu ion o e he las decades,
106
espe-
cially wi h he appea ance o di ec -ac ing an i i al ea men s o
HCV.
107
This has been especially no o ious in some co ec ional
ins i u ions,
108
whe e pa ien s wi h se e e men al heal h diso de s
a e o e ep esen ed.
109
On he o he hand, ano he impo an inding o ou s udy was
ha indi iduals wi h schizoph enia we e signi ican ly less likely o
be in a s able ela ionship (odds a io = 0.18) o engage in sexual
ac i i y wi h o he people (odds a io = 0.19) compa ed wi h
heal hy con ols. This is consis en wi h p e ious indings in he li -
e a u e, wi h s udies epo ing bo h lowe a es o ma iage and
highe a es o di o ce among people wi h schizoph enia.
110
Fu he mo e, he o e all pooled p e alence o pa ien s in ou
s udy who decla ed hemsel es o be sexually ac i e was unde
40%. This could be a ibu ed o se e al ac o s. Posi i e symp oms
such as sex- ela ed delusions and hallucina ions can ha e a nega i e
impac on ela ionships and sexual li e,
111
whe eas nega i e symp-
oms a e associa ed wi h sexual dys unc ion and de ici s in sexual
in e es and ac i i y.
76
In ou me a-analysis, 59.6% o pa ien s
(pooled p e alence) epo ed being in e es ed in main aining
sexual in e cou se wi h o he people. Bianco e al epo ed a
bimodal dis ibu ion o sexual in e es among adul s wi h schizo-
ph enia, wi h mos pa ien s epo ing ei he no p oblem wi h
sexual in e es o se e e impai men in ha a ea.
76
E en when
sexual in e es is p esen , sexual dys unc ion is a equen side-
e ec associa ed wi h he use o an ipsycho ic medica ions, occu -
ing bo h di ec ly h ough ele a ed p olac in due o blockade o
dopamine D2 ecep o s
112
and indi ec ly h ough o he ad e se
e ec s such as me abolic synd ome and obesi y.
113
O he sou ces
o sexual dys unc ion may include concomi an use o an idep es-
san s and anxioly ics, como bidi y wi h o he men al heal h and
subs ance use diso de s
114
and, in mo e se e ely a ec ed popula-
ions, he closed managemen model o mos psychia ic in-
pa ien uni s, which leads o a lack o p i acy and limi s he
Table 3A P e alence o each o he s udied sexual and isk beha iou s
Numbe o s udies Sample size P e alence 95% CI
He e ogenei y
I
2
(%) P
S able ela ionship (%) 20 2127 0.3777 0.1893–0.6122 93.4 <0.01
Li e ime sexual ela ionship (%) 7 881 0.7410 0.5320–0.8780 91.9 <0.01
Sa is ac ion wi h sex li e (%) 3 391 0.5371 0.4285–0.6422 49.7 <0.01
In e es in sexual ela ionship (%) 3 576 0.5966 0.4357–0.7391 70.8 0.03
Sexually ac i e (%) 16 2292 0.3772 0.3152–0.4435 85.9 <0.01
Among sexually ac i e people wi h schizoph enia
P os i u ion use (%) 3 223 0.3095 0.1188–0.5984 80.8 0.01
P os i u ion wo k (%) 3 612 0.1338 0.0502–0.3109 77.3 0.01
Consis en use o condom (%) 6 577 0.3498 0.1658–0.5929 93.5 <0.01
Ho monal con acep ion (%) 3 154 0.1297 0.0017–0.9300 94.5 <0.01
Unp o ec ed sexual ela ionship (%) 6 937 0.5528 0.2459–0.8241 97.9 <0.01
Unplanned p egnancy (%) 5 286 0.2872 0.0838–0.6399 92.0 <0.01
Mul iple pa ne s (%) 6 861 0.3537 0.1556–0.6192 97.0 <0.01
Table 3B Odds a io o he isk o being in a s able ela ionship and being sexually ac i e among schizoph enia samples compa ed wi h heal hy con ols
Numbe o s udies
Schizoph enia
pa ien sample
Heal hy con ol
sample Odds a io 95% CI P- alue
He e ogenei y
I
2
(%) P
S able ela ionship (%) 6 489 518 0.18 0.07–0.45 0.00* 86.5 0.00
Sexually ac i e (%) 4 285 317 0.19 0.13–0.29 0.00* 27.2 0.00
Sexual heal h o people li ing wi h schizoph enia
7
h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
chance o ha ing sexual ac i i y.
5
I is impo an o add ess his, as a
sa is ac o y oman ic and sexual li e has p o en o be bene icial
o he eco e y o people wi h schizoph enia, inc easing sel -
con idence, ea men compliance and e en o e all su i al.
5,115
Among hose who we e sexually ac i e, a g ea p e alence o isk
beha iou s was ound. Only 34.9 and 12.9% o pa ien s wi h schizo-
ph enia epo ed consis en ly using condoms o ho monal con a-
cep ion in hei sexual ela ionships, whe eas 55.3% o he pooled
sample egula ly had unp o ec ed in e cou se. Mo eo e , 35.4% o
pa ien s epo ed ha ing mul iple concu en sexual pa ne s, and
28.7% had expe ienced an unwan ed p egnancy ei he hemsel es
o in hei pa ne s. This pa e n o conce ning sexual beha iou s
among people li ing wi h schizoph enia has been desc ibed in p e-
ious s udies, wi h a p e alence o isky p ac ices o up o 83%.
83,87
I is impo an o no e ha a simila beha iou al pa e n has been
iden i ied among people who ha e su e ed auma ic expe iences,
pa icula ly sexual auma, wi h a highe isk o engaging in isky
sexual beha iou s such as compulsi e sexual beha iou and unp o-
ec ed sexual in e cou se.
116,117
Conside ing ha sexual auma ic
his o y is g ea ly o e ep esen ed among schizoph enia
samples,
118
u u e esea ch should ocus on explo ing whe he he
p esence o auma ic his o y could be a majo media ing ac o
in his popula ion.
Ou indings pose signi ican implica ions o he unde s and-
ing and ca e o indi iduals li ing wi h schizoph enia. I is essen ial
o no e ha mos o he s udies included in ou analyses in ol ed
samples ha had unde gone STI sc eening o esea ch pu poses.
This ha dly e lec s he clinical eali y o many cen es, whe e
ou ine sc eening is no commonly pe o med in pa ien s wi h
se e e men al diso de s. Tailo ed sex educa ion and p e en i e
measu es (including egula sc eening o STIs) a e essen ial o
all membe s o socie y, and people wi h schizoph enia a e no
excep ion. In e en ions a ge ed a indi iduals wi h se e e
men al heal h diso de s mus be pu in place o educe he
bu den associa ed wi h STIs and o he ad e se consequences o
isky sexual beha iou s.
Limi a ions
The indings o his s udy should be in e p e ed conside ing ce ain
limi a ions, p ima ily he signi ican he e ogenei y de ec ed in mos
o he s udied ou comes. Al hough high he e ogenei y is expec ed in
p opo ional me a-analyses,
119
samples included in his wo k we e
he e ogeneous in e ms o hei geog aphic o igin, se e i y and cha -
ac e is ics, which on he o he hand allows o be e gene alisa ion
o ou esul s. Owing o a lack o da a, some po en ially mode a ing
ac o s such as eligion,
120
an ipsycho ic ea men
121
o access o
sexual heal h se ices
122
we e no analysed. Fu he mo e, i was
no possible o s a i y he s udied ou comes by sex, e en hough sig-
ni ican gende - ela ed di e ences may exis .
123
Ano he c ucial
de e minan o he ansmission o he in ec ions s udied is he
use o injec able d ugs. Al hough we add essed he e ec o a
como bid subs ance use diso de on he p e alence o STIs
h ough me a- eg essions, un o una ely he e we e insu icien
da a o s a i y he e ec o each subs ance, o he injec ion ou e.
In he case o sexual beha iou ou comes, mos o he da a in he o i-
ginal s udies we e ob ained h ough sel - epo , which can be po en-
ially subjec o social desi abili y bias; his has p o en o be
pa icula ly p oblema ic in s udies on his opic.
124
Al hough i
emains unclea whe he his bias di e en ially a ec s popula ions
wi h se e e men al heal h diso de s, i should be conside ed in
u u e esea ch. Finally, mos o he s udies included in his analysis
we e c oss-sec ional in na u e. Longi udinal esea ch is needed o
be e unde s and he empo al dynamics o sexual beha iou and
STI isk in indi iduals wi h schizoph enia.
Fu u e implica ions
Pa ien s wi h schizoph enia exhibi a high p e alence o STIs, ha ing
se e al- old inc eased isks o HIV, HBV and HCV in ec ion com-
pa ed wi h he gene al popula ion. Al hough indi iduals in his popu-
la ion a e signi ican ly less likely o be in a s able ela ionship o
engage in sexual ac i i y, hey show ex emely high p e alence o
isky sexual beha iou s, engaging in unp o ec ed sexual ela ionships.
These indings highligh he need o inco po a e sexual heal h in o
he o e all ca e amewo k o pa ien s wi h schizoph enia, wi h
he aim o p e en ing and ea ing sexually ansmi ed diseases.
Claudia Ayme ich , MD, Psychia y Depa men , Basu o Uni e si y Hospi al,
Osakide za, Basque Heal h Se ice, Bilbao, Spain; Biobizkaia Heal h Resea ch Ins i u e,
OSI Bilbao-Basu o, Bilbao, Spain; Cen o de In es igación en Red de Salud Men al
(CIBERSAM), Mad id, Spain; and Neu oscience Depa men , Uni e si y o he Basque
Coun y, Leioa, Spain; Bo ja Ped uzo, MD, Psychia y Depa men , Basu o Uni e si y
Hospi al, Osakide za, Basque Heal h Se ice, Bilbao, Spain; Gonzalo Salaza de
Pablo , PhD, Child and Adolescen Men al Heal h Se ices, Sou h London and he
Maudsley NHS Founda ion T us , London, UK; Ins i u e o Psychia y and Men al Heal h.
Depa men o Child and Adolescen Psychia y, Hospi al Gene al Uni e si a io G ego io
Ma añón, School o Medicine, Uni e sidad Complu ense, Ins i u o de In es igación
Sani a ia G ego io Ma añón, CIBERSAM, Mad id, Spain; and Depa men o Child and
Adolescen Psychia y, Ins i u e o Psychia y, Psychology and Neu oscience, London,
UK; Lande Mada ia, MD, Psychia y Depa men , Basu o Uni e si y Hospi al,
Osakide za, Basque Heal h Se ice, Bilbao, Spain; and Biobizkaia Heal h Resea ch
Ins i u e, OSI Bilbao-Basu o, Bilbao, Spain; Ja ie Goena, MD, Psychia y Depa men ,
Basu o Uni e si y Hospi al, Osakide za, Basque Heal h Se ice, Bilbao, Spain;
Vanessa Sanchez-Gis au, PhD, Ea ly In e en ion in Psychosis Se ice, Hospi al
Uni e si a i Ins i u Pe e Ma a, IISPV-CERCA, CIBERSAM, ISCIII, Uni e si a Ro i a i Vi gili,
Reus, Spain; Paolo Fusa -Poli, PhD, Ea ly Psychosis: In e en ions and Clinical-
De ec ion Lab, Depa men o Psychosis S udies, Ins i u e o Psychia y, Psychology &
Neu oscience, King’s College London, London, UK; Depa men o B ain and Beha io al
Sciences, Uni e si y o Pa ia, Pa ia, I aly; OASIS Se ice, Sou h London and Maudsley
Na ional Heal h Se ice Founda ion T us , London, UK; and Na ional Ins i u e o Heal h
Resea ch, Maudsley Biomedical Resea ch Cen e, Sou h London and Maudsley NHS
Founda ion T us , London, UK; Philip McGui e , FMedSci, Depa men o Psychia y,
Uni e si y o Ox o d, Ox o d, UK; and NIHR Ox o d Heal h Biomedical Resea ch Cen e,
Ox o d, UK; Miguel Ángel González-To es, PhD, Psychia y Depa men , Basu o
Uni e si y Hospi al, Osakide za, Basque Heal h Se ice, Bilbao, Spain; Biobizkaia Heal h
Resea ch Ins i u e, OSI Bilbao-Basu o, Bilbao, Spain; CIBERSAM, Mad id, Spain; and
Neu oscience Depa men , Uni e si y o he Basque Coun y, Leioa, Spain; Ana Ca alan,
PhD, Psychia y Depa men , Basu o Uni e si y Hospi al, Osakide za, Basque Heal h
Se ice, Bilbao, Spain; Biobizkaia Heal h Resea ch Ins i u e, OSI Bilbao-Basu o, Bilbao,
Spain; CIBERSAM, Mad id, Spain; Neu oscience Depa men , Uni e si y o he Basque
Coun y, Leioa, Spain; Ea ly Psychosis: In e en ions and Clinical-De ec ion Lab,
Depa men o Psychosis S udies, Ins i u e o Psychia y, Psychology & Neu oscience,
King’s College London, London, UK; and Depa men o Psychia y, Uni e si y o Ox o d,
Ox o d, UK
Co espondence: Claudia Ayme ich. Email: [email p o ec ed]
Fi s ecei ed 10 No 2023, inal e ision 28 Feb 2024, accep ed 5 Ma 2024
Supplemen a y ma e ial
Supplemen a y ma e ial is a ailable online a h ps://doi.o g/10.1192/bjo.2024.49.
Da a a ailabili y
The da a ha suppo he indings o his s udy a e a ailable om he co esponding au ho ,
C.A., on easonable eques .
Au ho con ibu ions
C.A.: concep ualisa ion, me hodology, p ojec adminis a ion, w i ing –o iginal d a ; B.P.: con-
cep ualisa ion, da a cu a ion, w i ing –o iginal d a ; G.S.d.P.: w i ing – e iew and edi ing, o -
mal analysis; L.M.: da a cu a ion, w i ing – e iew and edi ing; J.G.: da a cu a ion, w i ing –
e iew and edi ing; V.S.-G.: concep ualisa ion, w i ing – e iew and edi ing; P.F.-P.: concep u-
alisa ion, w i ing – e iew and edi ing, supe ision; P.M.: concep ualisa ion, w i ing – e iew
and edi ing; M.A.G.-T.: concep ualisa ion, w i ing – e iew and edi ing; A.C.: supe ision, o mal
analysis, alida ion, w i ing – e iew and edi ing.
Funding
This esea ch ecei ed no speci ic g an om any unding agency in he public, comme cial o
no - o -p o i sec o s.
Decla a ion o in e es s
C.A. has ecei ed pe sonal ees o g an s om Janssen Cilag and Neu axpha m ou side he cu -
en wo k. G.S.d.P. has ecei ed pe sonal ees o g an s om Janssen Cilag and Mena ini. A.C.
has ecei ed pe sonal ees o g an s om Janssen Cilag, ROVI and Lundbeck ou side he cu -
en wo k.
Ayme ich e al
8
h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
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h ps://doi.o g/10.1192/bjo.2024.49 Published online by Camb idge Uni e si y P ess
