Practitioner's Guide to the Neuropsychiatry of HIV/AIDS

This book is targeted for “mental health clinicians who do not necessarily have training in neuropsychology, neuropsychiatry, or neurology.” Overall, the editors and authors have met the goal of providing useful information to their target audience, though the strength of the different contributions varies somewhat.

There are 10 chapters in all, covering neuropsychological features of HIV; neurobiological basis of behavioral changes in HIV encephalopathy; differential diagnosis of neurological diseases; neuropsychiatric features; pharmacological interventions; psychosocial interventions; issues for caregivers; suicide and HIV; enhancing adaptive function in cognitively impaired patients; and legal and ethical issues in HIV care. The first five chapters make up two-thirds of the book, and the fourth chapter alone is 94 pages with a lengthy reference section.

The contributing authors are from diverse fields, including psychiatry, psychology, neurology, neuropsychology, nursing, social work, law, and occupational therapy.

The opening chapter, covering neuropsychological features of HIV infection, is comprehensive, current, and well written, and it includes a detailed case study that illustrates key points. The differing terminology and diagnostic criteria for HIV-associated cognitive impairment are well reviewed. The section “Neuropsychological Performance by Domain” helps readers who are not trained in this specialty gain an appreciation of this complex area.

The second chapter, “Neurobiological Basis of Behavioral Change in HIV Encephalopathy,” is both well written and well referenced; however, many points discussed are also mentioned elsewhere in the volume; in this regard, the book would have benefited from tighter editorial work. “Differential Diagnosis of HIV Neurological Disease” follows and is an outstanding review of this topic; numerous clinical vignettes serve well to complement the academic discussion. The fourth chapter, “Neuropsychiatric Features of HIV Disease,” is too long (94 pages), lacks a clear focus, and is over-referenced. The authors attempt to cover too much material, especially for a volume that is supposed to be a primer in this subject. Despite this chapter's meanderings, however, much of value can be found within.

Wetherby and colleagues' chapter on pharmacologic interventions includes thoughtful commentary on the literature that supports a role for the antiviral AZT (zidovudine) in improving cognitive deficits. The authors do not discuss the new, highly active antiretroviral therapies (usually combined regimens of protease inhibitors and reverse transcriptase inhibitors). Although mentioned briefly, the clinical uses and research findings of psychostimulant agents such as methylphenidate and dextroamphetamine should have been expanded upon further, since this class of medicines is used often to help palliate neurobehavioral sequelae in HIV infection.

The second part of the book concerns itself with psychosocial topics, and its contributions generally are quite different from those in the first part: much shorter in length, tighter in text, more “how-to” focused, and much less extensively referenced. I found the chapters on psychosocial interventions and issues for caregivers informative and helpful. The former chapter has a table that lists specific recommendations for cognitively impaired patients to help them cope with problems such as memory loss, visuospatial deficits, and inattentiveness.

“Issues for Caregivers, Families, and Significant Others” is a thoughtful contribution, providing a fresh discussion on a topic that is all too frequently neglected. It helps us not only understand the stresses and demands on caregivers, but also informs us on how best to educate and support caregivers and how to effectively enlist their help in caregiver support systems.

“Suicide and HIV Disease” follows, and it is an outstanding chapter. The text is supplemented with tables covering risk factors for suicide, commonly used terms in suicidology, selected research, and clinical practice guidelines. There is a section on how to effectively manage the suicidal HIV-infected patient. The chapter on enhancing adaptive function, from an occupational therapist working in AIDS care, provides a novel perspective. The chapter “Legal and Ethical Issues,” although it lacks clinical vignettes, includes useful and timely discussion of guardianship, advance directives, and discrimination.

Overall, this volume, though somewhat uneven, is an important addition to the literature for mental health professionals working in AIDS care. A chapter that updates the latest medical treatments of HIV infection would have been helpful, since the medical management of HIV has changed significantly with the advent of new technologies that allow a much more accurate monitoring of a patient's disease status (viral load monitoring) and the combination antiretroviral regimens that typically include at least three distinct antiviral agents. This book may be best suited for multidisciplinary treatment teams, where professionals of differing backgrounds and expertise could make the best use of its informative contents.

Jon A. Levenson, M.D., is Assistant Clinical Professor of Psychiatry at Columbia University College of Physicians and Surgeons and director of the HIV liaison psychiatry service at Presbyterian Hospital, New York, NY.