Psychosomatics 49:365-366, July-August 2008
doi: 10.1176/appi.psy.49.4.365
© 2008 Academy of Psychosomatic Medicine
Comprehensive Textbook of AIDS Psychiatry
Edited by Mary Ann Cohen, M.D., and Jack M. Gorman, M.D., New York, Oxford University Press, 2008, 619 pages, ISBN-13: 978-0-19-530435-0, $98.50
Donna M. Sudak, M.D.
Key Words: AIDS Psychiatry
This book is a thorough and practical summary of the current knowledge about the medical and psychiatric management of patients with HIV/AIDS. It is ambitious in its scope, and it provides a historical overview of the experience of treating HIV/AIDS patients. The chapters generally provide sufficient information to "stand alone" in detailing the complex neurobiology of HIV/AIDS infection; the editors have managed to provide the reader with substantial detail with a minimum of redundancy. The book is divided into 10 sections, with 41 chapters. The organization of the text is designed to highlight the psychiatric manifestations of HIV/AIDS infection in the context of the sociocultural and life-cycle issues common to patients with the disorder. There are 72 contributors, but the careful editorial work has produced a consistent and readable volume.
In the first section, "Psychiatric Relevance and Implications of AIDS Psychiatry," the authors provide five chapters that set the historical context for our understanding of HIV/AIDS psychiatry. Case vignettes provided remind the reader of how much has changed in our understanding of the pandemic and the stigma associated with the disorder. This section includes an overview of the prevalence of psychiatric disorders in persons with HIV and AIDS; it details the changes in the epidemiology of the disorder over the past 25 years and the rise in infection rates in severely and persistently mentally ill persons. It makes the case for psychiatric care of persons with HIV/AIDS as a paradigm for psychosomatic medicine.
The second section, "Comprehensive AIDS Psychiatric Assessment," contains two chapters that could help anyone learn a comprehensive approach to a psychiatric consultation. The format, consisting of a detailed sexual history, inpatient consultation, and suicide assessment, would be useful in multiple contexts. Many helpful questionnaires are provided. An additional chapter reviews the neuropsychological evaluation tools available to evaluate functional capacity and details changes seen both in HIV/AIDS and in hepatitis C infection.
The six chapters in the third section, "Psychiatric Disorders and HIV Infection," review the most common mental health issues in HIV/AIDS and provide concise summaries of diagnosis and treatment issues. The authors make a compelling argument for the need to aggressively and diligently advocate for treatment in individuals marginalized in the United States, and they provide a blueprint for comprehensive service delivery in this complicated group of patients. An excellent review of HIV-associated neurocognitive disorders is also included in this section.
"Unique Psychiatric Manifestation of HIV Infection" is the fourth section, providing five chapters about symptoms common to HIV-infected patients; these include distress, insomnia, fatigue, unique manifestations of dementia, and suicide. Each of these chapters details differential diagnoses to consider in the evaluation of these complaints and potential treatment approaches. Despite the HAART (highly active antiretroviral therapy) regimens available to treat HIV, suicide remains a significant risk in these patients. The chapter devoted to suicide considers protective, dynamic, and preventive strategies to consider in working with patients with HIV, but could also inform the treatment of other patients with chronic medical illness.
The fifth section, "Neuropathologic Manifestations of HIV Infection," contains two chapters explaining the molecular and cellular pathophysiology of HIV nervous system infection in adults and children. It was a wonderful section for me to read to review recent developments in basic neuroscience. HIV has been a catalyst for learning about inflammatory mediators in the CNS, and these chapters bear a powerful witness to the concept that the sicker and more inflamed our brains are, the sicker we become. The significant (and often under-appreciated) complications of HIV infection in the peripheral nervous system are well covered by the text.
"Psychiatric Aspects of Risk Behaviors, HIV Transmission, and Adherence to Medical Care" is the sixth section, and it includes three chapters about the domains of psychiatric disorders that directly and indirectly affect HIV transmission and treatment. The statistics presented indicate the scope of the problem: for example, 2%–5% of individuals with severe and persistent mental illness, especially those who are homeless or who have comorbid substance use, have HIV, versus 0.6% of the United States population. Also, this section reviews the importance of good mental health in managing the physical challenges posed by HIV disease and treatment. Finally, the chapter on homelessness provides a cogent and authoritative review of our failure to provide decent and affordable housing for many, and the significant consequences this has in relation to developing or managing HIV/AIDS.
My favorite section of the book is "AIDS Psychiatry Through the Life Cycle," three chapters that present challenges unique in managing the illness in childhood and adolescence, in young adulthood and serodiscordant couples, and in older age. Having lived through the early years of the epidemic with loved ones and patients, I can attest to the authenticity of the issues facing elderly survivors with HIV that are discussed in these chapters. New risks for contracting HIV in later life are discussed, as well. The two chapters on childhood and young adulthood represent some of the finest writing I have encountered in any text about living and dying with HIV and how to engage with families and couples struggling to manage this task. The existential issues detailed in this section would help any practitioner contending with end-of-life issues.
The eighth section, "AIDS Psychiatric Treatment and Psychotherapeutic Modalities," is divided into six chapters, reviewing biological, psychological, social, and spiritual interventions that are available to help patients with psychiatric conditions and HIV. It includes reviews of multidisciplinary interventions such as nursing, social service, spiritual practitioners, and complementary and alternative medicine. It describes challenges to providing adequate care in settings where HIV/AIDS patients are frequently encountered—psychiatric facilities, nursing homes, and correctional facilities.
"AIDS Psychiatry and Comorbid Medical Conditions" is the next section: five chapters that detail the common medical disorders encountered in treating HIV-infected patients, including hepatitis C, renal disease, and endocrinopathies. The medical consequences of HAART, including lipodystrophy and metabolic abnormalities and the impact of these consequences on psychological well-being are described. This section is particularly useful in providing differential diagnoses for medical conditions that could mimic psychiatric disorders.
The final section is four chapters long and concerns ethical and health-policy aspects of AIDS psychiatry. These sections care for the caregiver, addressing both burnout and end-of-life issues in a sensitive and multidimensional context. Bereavement overload is still a factor in working with the disorder. Ethical issues, including confidentiality, capacity, advance directives, and medico-legal concerns are well covered. Finally, a chapter about the intersection between HIV/AIDS and health policy ends the book.
This is a highly readable, well-written textbook. My only quibble is the frequent use of acronyms—in this field, there are many, but the book would be improved by less frequent use of the more obscure varieties. The illustrations, tables, and diagrams are extremely helpful, as are the many questionnaires provided in the text.
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FOOTNOTES
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Dr. Sudak is Professor of Psychiatry at the Drexel University College of Medicine, in Philadelphia.
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