Book Review

Comprehensive Textbook of AIDS Psychiatry

N Engl J Med 2008; 358:1412-1413March 27, 2008

Article

Comprehensive Textbook of AIDS Psychiatry
Edited by Mary Ann Cohen and Jack M. Gorman. 619 pp. New York, Oxford University Press, 2008. $98.50. ISBN: 978-0-19-530435-0

The publication of Comprehensive Textbook of AIDS Psychiatry marks the coming of age of this newly recognized specialty section of the Academy of Psychosomatic Medicine and documents the evolution over the past three decades of psychiatric care for people living with human immunodeficiency virus (HIV) infection. The book also arrives at an important time in the epidemic. Despite estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS) that the global pandemic has peaked, rates of new infections in the United States remain steady and may be increasing in certain risk groups, such as men who have sex with men. As a response to the persistence of new infections, in late 2007 the Centers for Disease Control and Prevention revised its recommendations to include “opt-out” testing of all persons presenting for routine medical care.

This change in policy, the goal of which is to bring into treatment the estimated 25% of all infected persons who are unaware of their HIV infection, has important implications for all physicians. They must understand the psychosocial factors that prevent people from seeking early HIV testing and medical care and that hinder safer sex and needle-sharing practices. The message of this highly readable and comprehensive book is that unlike many other illnesses that are relevant to psychosomatic medicine, HIV and AIDS are entirely preventable and eminently treatable. The main weakness of the book is that it is not clearly oriented toward either mental health or medical providers. This shortcoming probably reflects the indistinct boundary that exists between medicine and psychiatry in the area of HIV. Although the book loses focus in its attempt to reach a broad audience, it is an important contribution to a relatively uncharted area.

Mary Ann Cohen, one of the editors of the book, introduces it with a sensitive, first-person account of her early clinical work in HIV consultation and liaison psychiatry at a large academic medical center in New York City. An exploration of the links between mental health and immunology and the social conditions under which HIV thrives further establishes the relevance of psychiatry to HIV. The choice of topics that form the body of the book reflects the editors' belief that HIV is the quintessential “biopsychosocial” disorder. Although the social component receives relatively less attention than the biologic and psychological components, one of the book's more intriguing assertions is that high rates of incarceration in communities of color may explain the disproportionately high seroprevalence of HIV in those communities.

The section on psychosocial and neuropsychological assessment offers a thorough and practical model that is applicable to both medical and mental health settings. The authors include HIV-specific tools for neurocognitive evaluation, as well as detailed guides to taking patients' sexual and substance-use histories, a task that is often performed inadequately because providers and patients are uncomfortable discussing such topics. Also of practical use to medical providers is the discussion of substance-use disorders and problematic personality traits; the authors address the most common problems that are encountered by patients who routinely engage in high-risk behaviors and have difficulty forming therapeutic relationships with their providers.

The central concern of the book is the effect of mental health on the transmission of HIV, the prevention of HIV, and adherence to treatment. The section devoted specifically to this issue is particularly well written and offers useful advice about assessment and evidence-based interventions that improve adherence to antiretroviral medications. Recognizing and addressing the need to fill gaps in psychiatric knowledge for medical providers, the editors wisely have chosen the most relevant topics. Clinicians who are unfamiliar with psychiatric or HIV-related medications will find the section on psychiatric treatments extremely valuable. The chapter on psychopharmacology includes several tables that provide easily accessible information about potential interactions between antiretroviral and psychiatric medications, as well as a practical summary of HIV medications and their side effects on the central nervous system. The discussion of coexisting conditions that are associated with HIV is relevant to psychiatrists, who are often asked to manage depression that is induced by interferon for the treatment of hepatitis C, as well as the metabolic syndrome, that can be caused by both antiretroviral and psychotropic medications. Similarly, the book presents a diagnostic framework and approach to the management of insomnia, fatigue, and distress — ubiquitous symptoms with multiple psychiatric and medical determinants in patients with HIV.

An in-depth review of the pathophysiology that underlies the involvement of HIV in the central nervous system is the most biomedical and technical section. It presumes basic knowledge of immunology and neurophysiology. An excellent related chapter on clinical neurocognitive disorders appears elsewhere in the book. The psychosexual developmental stage is often overlooked by clinicians, yet it is hugely important in determining the patient's perception of risk, the nature of the patient's relationships, and the adaptation of the patient to illness. These issues are discussed in depth. The book closes with a discussion of some of the legal and public health issues that can affect the relationship between the patient and the provider, such as mandated public health reporting of AIDS and HIV infection, notification of contacts, and the duty to warn sexual and needle-sharing partners.

The deep and extensive clinical experience of the book's authors and the exhaustive, user-friendly presentation of current empirical knowledge are among the book's strengths, and they establish its stature as an authoritative source against which future texts will be measured. Equally notable is the fact that this book is accessible to providers from all disciplines and should be read by anyone who is involved in the care of people living with HIV infection. Judith Aberg, in one of the book's three forewords, remarks with surprise that she cannot recall ever reading a textbook from cover to cover and actually finding herself engaged throughout. Although I was at first skeptical of this statement, after reading the book from cover to cover myself, I believe that Aberg's impression will resonate with anyone who is interested in caring for patients with HIV infection.

John A.R. Grimaldi, Jr., M.D.
University of Tennessee College of Medicine, Memphis, TN 38105
jgrimald@utmem.edu