In This Issue

Sub-Saharan Africa is home to the majority of people with HIV infection, but the rate and characteristics of HIV-associated mania there are largely unknown. Nakimuli-Mpungu et al. (p. 1349 ) report that about half of the 125 cases of acute mania at two Ugandan hospitals over 6 months were secondary to HIV. Compared to HIV-negative patients with primary mania, those with secondary mania had more severe manic symptoms, cognitive impairment, and immunologic suppression. This severity might be due to limited access to health services, as these patients were poorer and less educated. They were also older and more likely to be female. Widows were found exclusively among the patients with secondary mania; 48% had lost their spouse or partner to AIDS. Dr. Robert Robinson offers an accompanying editorial on p. 1309 .

The mentally ill are frequently perceived to be dangerous. To determine how much the mentally ill actually contribute to violent crime, Fazel and Grann (p. 1397 ) calculated the proportion of crimes committed by the mentally ill in Sweden. They obtained population-wide data from Swedish registers of crimes and hospitalizations during 1988–2000. The proportion of all violent crimes attributable to people with schizophrenia or other psychosis was 5%. Youth and male gender are also risk factors for violent crime, and so the effect of severe mental illness on the crime rate increased with increasing age and the contribution of female patients was almost negligible. Norris et al. (p. 1392 ) also cite the perception that the mentally ill are violent in their discussion of firearms laws pertaining to the mentally ill. Familiarity with their jurisdictions’ laws may help prepare psychiatrists to certify that a patient meets the mental health requirements for a firearms application, perform a firearms-related assessment, or identify the consequences of gun ownership to patients. Because the laws vary considerably, Norris et al. list firearms statutes in the 50 U.S. states, the District of Columbia, and Puerto Rico as they relate to people with mental illness or substance use disorders. Dr. Paul Appelbaum comments on these issues in an editorial on p. 1319 .

To encourage adherence to outpatient treatment by patients with severe mental illness, the courts and other government agencies sometimes offer legal or financial incentives . Swanson et al. (p. 1404 ) found that a history of violence does not preclude community treatment with such incentives, or leverage. Of 1,011 patients in public mental health service systems in five U.S. cities, about three-quarters reported receiving some form of leveraged community treatment, compared to about one-half of nonviolent patients. Violence increased the likelihood of legal leverage, e.g., probation, but not incentives involving social welfare, e.g., subsidized housing. Younger age, male gender, poorer functioning, and more frequent hospitalizations also independently increased the likelihood of receiving any type of leverage.

Treatment with antipsychotic drugs, especially first-generation antipsychotics, can lead to acute movement and muscle changes involving the brain’s extrapyramidal motor system. It has been unclear how many of the patients with these changes later develop tardive dyskinesia, a persistent syndrome of hyperkinetic, repetitive involuntary movements. Tenback et al. (p. 1438 ) report that patients with any of three acute extrapyramidal symptoms-parkinsonism, muscle rigidity, or restlessness-are twice as likely as other patients to develop tardive dyskinesia. As part of the Schizophrenia Outpatient Health Outcomes (SOHO) study, extrapyramidal symptoms were evaluated four times over 1 year in more than 9,000 antipsychotic-treated patients. The size of this study reinforces earlier suggestions that extrapyramidal symptoms are a risk factor for tardive dyskinesia. Dr. John Kane discusses this finding in an editorial on p. 1316 .