The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. Glenn J. Treisman, MD, PhD, and Andrew F. Angelino, MD. The Johns Hopkins University Press, Baltimore, MD, 2004. ISBN: 0801880068, pages: 217.
The authors describe this as a "book of hope," based on their extensive experience in treating mentally ill HIV patients. Admittedly, these are challenging patients, but at the same time, the authors stress the importance of not giving up. They quote the Talmudic phrase, "He who saves one life, it is as if he saves the whole world," to summarize the motivation that inspired this book and the therapeutic optimism associated with their ongoing clinical work. Clinicians who treat mentally ill HIV patients know that this is a challenging patient population to work with, and the reader of this book will sense this challenge and also come away with practical insights for assessing and treating mental illness in the context of HIV.
The book starts with "Quotes From the Clinic," which highlights the clinical and personal challenges associated with caring for this population. These quotes illustrate the clinical wisdom that is won by working in the trenches and believing that patients can make the changes that will result in improved quality of life, improved engagement in medical treatment, and decreased risk of transmitting HIV. The remainder of the book is organized into 9 chapters that address the following topics: why AIDS psychiatry is needed, depression, other psychiatric diseases (delirium, dementia, bipolar disorder, and schizophrenia), personality disorders, substance abuse, sexual problems, life story problems, hepatitis C, adherence, and how to fight AIDS. There are also 6 case presentations to further illustrate the points made in the chapters. Some of these case presentations also include the patient's perspective.
A major theme of the book is that mental health disorders increase vulnerability to contracting HIV and then further impair access and adherence to treatment. The goals of mental health treatment of HIV patients are summarized as improving function, quality of life, longevity, engagement, and adherence to treatment and decreasing further HIV transmission. The vulnerability theme and goals of mental health treatment are presented in chapter 1 and reinforced in subsequent chapters.
There is a useful discussion of how to diagnostically distinguish between depression and demoralization in chapter 2. A treatment algorithm is presented along with a useful table of the advantages and disadvantages of various antidepressants in the context of HIV and a table of drug-drug interactions between antidepressants and HIV medications. In chapter 7, a useful treatment approach to demoralization is also presented.
Patients with personality disorders are always a challenge, and consistent with other chapters in this book, a pragmatic approach to assessment and treatment is presented. Instead of using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for personality disorders, they recommend an assessment method that involves understanding the patient along 2 intersecting continuums: introversion/extroversion and stability/instability. They estimate that the majority of patients in their clinic are in the extroversion/instability quadrant of this model. The implications of this personality type are increased risk for nonadherence, focus on reward seeking, insensitivity to punishment, and increased need for attention. Clinical approaches presented to optimize the goals of mental health treatment include focusing on thoughts and not feelings, setting up a verbal behavioral contract with ordered priorities or a written contract if needed, and emphasizing rewards associated with adherence (e.g., decreased viral load, increased CD4 count, increased disposable income associated with decreased substance use) and not bad outcomes associated with nonadherence. Approaches to patients in the other quadrants are also discussed.
There are also useful discussions about treatment approaches to substance abuse and paraphilias (defined as a sexual behavior that causes problems or interferes with other activities). Assuming that high-quality mental health care is being provided, they discuss how to get the patient to do more if the treatment is failing, not the clinician. There are also cautions presented, such as trying to understand the cause of a paraphilia or other addiction without the patient giving up the behavior. There is also a useful outline in chapter 9 for what to think about when completing an assessment and treatment plan for HIV patients with mental illness.
The strength of this book comes from the lessons learned in the trenches during many years of caring for HIV patients with mental illness. There are also many clinical pearls that are shared in terms of what to do and not do. The text is well referenced, and the writing style is straightforward and easy to read. When the authors are including their opinions on such topics as managed care and legalization of marijuana, these sections are easy to distinguish from the more data-driven content. The inclusion of the case presentations is also very helpful for illustrating how the recommended approaches to these challenging patients play out in real patients.
The weaknesses of this book include the unique clinical environment from which the authors based their experience. Their psychiatric and substance abuse services are integrated into their HIV clinic. The majority of HIV clinics do not enjoy this level of integration. More discussion about how to maximize access to mental health care in HIV clinics that are organized differently would be helpful. There is also not much discussed about how to optimize the interaction between mental health and HIV providers.
This book will be of interest to providers who want to learn from the authors' years of experience caring for mentally ill HIV patients rather than learning these lessons the hard way through trial and error. This book will be of particular interest to mental health providers, given that, in parts, the text assumes a familiarity with the diagnostic criteria for mental health disorders and assumes that the time is available to implement the recommended assessment and treatment approaches. However, both HIV and mental health providers will benefit from the authors' lessons learned in treating HIV patients with mental illness, and ultimately, our patients will also benefit.
Jeffrey M. Pyne, MD
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