Neuropsychiatry and Mental Health Services
Neuropsychiatry and Mental Health Services highlights the importance of maintaining a neuropsychiatric approach in the assessment, evaluation, and treatment of psychiatric disorders. Ovsiew defines neuropsychiatry as “encompassing both the care of patients with overt brain diseases and an approach to the care of patients with major psychiatric disorders traditionally considered nonorganic or functional.” Even though “neuropsychiatric approach” is not specifically defined, it is obvious from reading the book what it means: complete evaluation, comprehensive workup, regular follow-up, and provision of total care to patients with mental illness.
There are 13 chapters and 25 contributors, many of whom are renowned psychiatrists. Every chapter is well written, addressing the care of patients in public health settings. Each chapter focuses on the same three specific issues: 1) the epidemiology and costs of the disorder under discussion, 2) providing clinical guidelines for the physicians working in a public health setting, and 3) recommendations for policymakers using neuropsychiatric data as a framework.
The first chapter takes us back to the nineteenth century and explores the development of public asylums, including the role of neurologists in “diagnosing and treating organic brain disorders” and that of psychiatrists in providing “custodial and psychological care.” Yates and Koran next discuss the overwhelming prevalence of undiagnosed medical illness in patients with psychiatric disorders; such illness is often underdiagnosed and untreated because they are “psychiatric patients.” The authors stress the importance of a careful evaluation, complete workup, and periodic follow-up by psychiatrists to eliminate misdiagnosis and improve quality of life for these patients.
Mental health workers will find Fogel's chapter, “Neuropsychiatry in Public Mental Health Settings,” interesting and educational. He discusses problems associated with prolonged hospitalization and recommends using a neuropsychiatric approach in the assessment and care of long-term inpatients. Successful community placement should be the goal for patients with continued hospitalization, and this can be achieved by “setting priorities for diagnosis and treatment, ensuring the safety of patients/others, addressing acute/unstable medical problems, and optimizing psychiatric treatment.”
Dementia, substance abuse, late-onset psychosis and depression, aggressive behavior, and HIV infection are discussed in separate chapters. The chapter on dementia details the evaluation, differential diagnosis, and management of patients with cognitive problems, concluding with a discussion of available community resources. The authors also emphasize the significant role of family/caregivers and the need for research to validate the quality of care in the existing services.
Aggression is well described by Benjamin, who emphasizes repeatedly that care providers in public health facilities should develop expertise in the evaluation and management of aggression because there is “no unitary concept for the etiology or treatment of aggressive behavior.” The pathophysiology and treatment of aggression are well depicted in simple figures.
Levy and colleagues review the neuropsychiatric sequelae of HIV infection, stressing the need to maintain a high index of suspicion in all HIV-positive patients. Management of HIV infection is multidisciplinary, and thus psychiatrists should work in collaboration with other health care providers to “limit morbidity and forestall mortality.”
The chapter on late-onset psychosis and depression presents a concise review of these disorders and clearly delineates the existing barriers to providing optimal care for the elderly, namely “ageism and feelings of hopelessness on the part of providers, lack of training of providers, lack of resources, and economic disincentives.” I agree with Lesser and Swartz that the age of patients should not stand in the way of providing comprehensive care; as they note, “the elderly are equally worthy of our attention and resources.”
Other chapters examine the use of the neuropsychiatric approach in other settings, such as prison, and in special populations, such as patients with developmental disabilities, the homeless, sexual deviants, and patients with tardive dyskinesia.
Ovsiew and Fenwick's review of psychiatric illness in penal institutions is a thoughtful contribution, providing fresh discussion on a topic that is frequently neglected. They consistently and correctly point out that neuropsychiatry is an “ideal discipline to clarify the relationship between cerebral dysfunction, social adversity, and psychiatric disturbances” but it cannot guarantee treatment “effective enough to substitute for incarceration.”
The chapter on developmental disabilities is comprehensive and well written, pointing to myths about mental retardation that often interfere with proper care. Silver elaborates on the complexities of treating the homeless, who often suffer from multiple problems that may include substance abuse, HIV infection, traumatic brain injury, tuberculosis, schizophrenia, and epilepsy. He also includes a case study that highlights the key point: that a neuropsychiatric approach to assessment and treatment of the homeless would help in achieving the much-needed integrated and comprehensive care.
The chapters on tardive dyskinesia and sexual disorders provide updated and clinically relevant information on these problems. Jeste and colleagues reemphasize the well-known rule: use neuroleptics only when necessary and in the lowest effective dose, because abnormal involuntary movements “directly and indirectly influence a patient's rehabilitation.” Cummings, in his chapter on sexual deviation, argues that there is an urgent need for more research on the treatment of aberrant sexual behavior that “preserves the right of the individual with brain disorders while protecting the society.”
In summary, Neuropsychiatry and Mental Health Services is an excellent book for mental health professionals, providing clear and comprehensive clinical guidelines for the assessment and management of patients with brain diseases. The only notable deficiency is the absence of a chapter on neuropsychiatry in a medical setting, as far too commonly patients visit their neurologist or internist before approaching a psychiatrist. Nonetheless, the book is interesting, informative, and a valuable addition to my library.
Dr. Rao is Assistant Professor of Psychiatry at Johns Hopkins School of Medicine, Baltimore, MD.
