Handbook of AIDS Psychiatry by Mary Ann Cohen, Harold W. Goforth, Joseph Z. Lux, Sharon M. Batista, Sami Khalife, Kelly L. Cozza and Jocelyn Soffer, Oxford University Press, New York, 2010, 384pp, $49.95

Book Review originally written for and published in  the Journal of the American Academy of  Psychoanalysis and Dynamic Psychiatry

It is unusual for the Book Review Editor of this journal to request a review about a book that does not have psychoanalytic theory, dynamic psychiatry or the application of these ideas, as it’s main thesis. This book, which is about all aspects of AIDS, is such an exception. It is fitting that it be presented to the readers of this journal since this disease, more than any other modern day medical condition has impacted all aspects of psychiatry and mental health. Those of us who were practicing in the early 1980s, especially if you were doing hospital consultations, first saw this become known as a mysterious disease with dark spots on skin that was universally fatal. It then became associated with homosexuals and drug addicts The disease was believed to be highly contagious and caused by blood and sexual transmission. Medical personal became fearful of contracting the disease from patients. An accidental  needle stick while drawing blood or being nicked with a scalpel during surgery, which once was an inconvenience, now became a potentially fatal event. The disease weakened the immune system  and could lead to  deadly opportunistic infections. It ultimately was identified as being caused by the Human Immunodeficiency Virus (HIV). From it’s discovery in 1981 to 2006 AIDS killed more than 25 million people and is still counting.

Not only did psychiatrists and mental health professional see the impact of this disease in our hospital work but those of us doing outpatient psychotherapy could not help but appreciate the effect of this pandemic on many of our patients. Homophobias, which could be multidetermined at any point in time, became greatly exaggerated because of fears of contamination from AIDS. There was a reexamination of all sexual behavior as people began to realize that heterosexual transmission of this disease was also a reality. Questions were being raised whether couples should exchange HIV testing results before engaging in sexual relations? Then there was the realization that AIDS was devastating the gay and bisexual community. We saw a grieving response that extended beyond immediate close friend and families. People throughout the country visited exhibits of  traveling AIDS quilts with patches made as a memorial to individual patients. There were forensic issues encountered by some of our colleagues where people were acting out their anger about being HIV positive by having unprotected sex . There were discussions among therapists of how to deal with a patient whom they  knew was HIV positive but was not telling his or her partners.

The NIH and the NIMH awarded huge amounts of grant money directed towards AIDS and HIV research in the past 25-30 years. As a result many of the psychiatrists practicing today were supported by these grants at some time in their career or were trained by people who had such support and were well oriented about the psychiatric and psychological aspects of AIDS.

All of this is what makes this 2010 first edition of the Handbook of AIDS Psychiatry such a valuable book. Psychiatrist Mary Ann Cohen, a pioneer in the AIDS field and her six outstanding colleagues have written a book, which includes just about everything we should or might want to know about HIV and AIDS. It is billed as a practical book, which it is, but it is also a definitive work on this subject with over 1500 references. Some of the chapters are adapted from an earlier book titled Comprehensive Textbook of AIDS Psychiatry edited by Drs. Mary Ann Cohen and Jack Gorman, published in 2008 also by Oxford. Seven of the contributors to the earlier work took on the task of developing this current book.

This is not an edited book. All the 14 chapters are written by some combination of the seven authors. Dr. Cohen was involved in all but two of the chapters. Drs. Battista and Soffer were listed as residents at the time the book was published. The first 13 chapters were each followed by multiple pages of references and the final chapter on resources had addresses, phone numbers and web sites.

The widespread imprint of this disease and the comprehensive approach of this book is illustrated in the first chapter where the authors lay out the setting and models of AIDS psychiatric care. They start with effective parenting and prevention of early childhood trauma and conclude with the sections on education, HIV testing, condom distribution, rehabilitation centers, chronic care facilities and nursing homes. They touch upon the prejudice and discrimination labeled as AIDSism which unfortunately is ubiquitous and is also discussed in other chapters in the book.

Chapters titled Biopsychosocial Approach and HIV Through The Life Cycle cover material with which a psychiatrist trained in the past twenty-five years should be quite familiar. However the authors are not content with just reminding the reader to take a comprehensive history in areas relevant to this disease, but they offer over 100 suggested questions in doing a sexual history, suicide evaluation, substance abuse history or a violence evaluation. The following are examples of a few questions, which you may not have thought to use:

1. (Taking a sexual history) How do your cultural beliefs affect your sexuality?

2- Are you aware that petroleum-based lubricants (Vaseline and others) can cause leakage of condoms?

3- (To an LGBT person) What words do you prefer to describe your sexual identity?

4- (Evaluating suicidality) Do you plan to rejoin someone you lost?

5- (Taking a substance abuse history) What led to your first trying (the specific substance or substances)?

6- What effect did it have on the problem, crisis, or trauma in your life?

While it is stated that little is known about the relationship between aging and manifestations of psychiatric disorders in HIV positive persons, the discussion and questions raised about this topic in these chapters seem particularly important as treatment is now allowing people with AIDS to become senior citizens.

In the chapter titled Psychotherapeutic Treatment of Psychiatric Disorders it was noted that the enhanced understanding of the conflicts and struggles of the HIV positive  patient afforded by psychodynamic psychotherapy  has been described by multiple authors. This modality of treatment may be especially suited for patients with a trauma history as physical changes in the body and relationship stresses can awaken conflicts triggered by early trauma and neglect. This history of childhood emotional, physical and sexual trauma as well as neglect is also reported to be associated with risk behaviors and is prevalent in persons with HIV.  Other major themes, which were identified, that could surface in psychodynamic work include fears about mortality with the erosion of defensive denial as the illness progresses and conflicts surrounding sexuality. There also was a review of interpersonal psychotherapy, CBT, spiritual focused care, and various group therapy formats.

The chapters on psychiatric aspects of  stigma of HIV/ AIDS  will also be of  particular interest to the readers of this journal who are usually quite involved in dealing with subtle nuances in psychotherapy. Victim blaming, addict phobia and homophobia also called heterosexism are discussed in this context. While clinicians usually don’t have any trouble identifying stigma when they see it, there are scales which can be administered in both research protocols and clinical settings.

Dr. Cozza is the lead author in the chapter concerned with psychopharmacologic treatment issues. It is the longest chapter in the book and can best be summarized by their conclusion that the prescribing of psychotropic or any other class of medications to HIV positive patients taking ART is a complicated undertaking. The chapter provides an explanation of this statement in a narrative style as well as with some detailed tables showing the propensities of various medications to cause inhibition and induction.

Although psychiatrists are usually not involved with the treatment of physical symptoms or the actual administration of therapeutic drugs for  medical conditions, if they work with patients with AIDS they will be discussing various symptoms and complications. Dr. Goforth and Cohen put together two chapters which clearly explain symptoms of AIDS, as well as the medical illnesses associated with them. They review fatigue, sleep disorders, appetite problems, nausea and vomiting with a complete differential diagnosis and intervention options. The full range of endocrine problems, dermatological disorders , HIV associated opthamalogical diseases, malignancies, liver and kidney disease as well as the potential symptoms of these conditions are covered.

The one chapter, which was written by four authors, was titled Palliative and Spiritual Care of Persons with HIV and AIDS. This not only covered a discussion of the management of pain, other physical symptoms, behavioral symptoms including violent behavior and suicidality but it offered a review of models for spiritual care. The work of Breitbart and colleagues with cancer patients using meaning  centered interventions based on Victor Frankels ideas was introduced as was Kissane and colleagues description of a syndrome of  “demoralization” in the terminally ill which is distinct from depression. It consists of a triad of hopelessness, loss of meaning and existential distress expressed as a desire for death. A treatment approach for this state is outlined. This chapter concludes with a review of the role of psychiatrists and other clinicians at the time of death and afterwards. This includes a discussion of anticipatory, acute and complicated grief.

Although HIV disease and AIDS is no longer the mysterious disease which people are afraid to talk about and healthcare workers dread seeing patients with, nevertheless it is a very serious illness which cuts across all specialties and has great relevance for psychiatrists and other mental health professionals. It is estimated that more than one million people are living with HIV in the USA. Even now with retroviral treatment available, this disease is expected to infect 90 million people in Africa resulting in a minimum of 18 million orphans. Needless to say, this book should be translated into many languages and should be available internationally. This book gives us a full background about AIDS and allows psychiatrists and other mental health professionals to have this fund of knowledge at our fingertips. Also, if and when there is another deadly virus that appears on the scene, our profession will have a model and a valuable compendium of how to approach it, which is something we did not have thirty years ago.

To purchase this book on Amazon, please click here 

The following is a book review that I wrote which was published in the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. It is followed by a brief Q & A with the author.

UNHINGED  Daniel J. Carlat, M.D. Free Press 255 pages 2010

Dan Carlat, in addition to practicing psychiatry, writing his popular newsletter and blog, editing a series of psychiatry books for Lippincott/Klowers (one of which I co-authored) and writing monthly blogs for Psychiatric Times periodically (as do I)   has written expose pieces about psychiatry for the N.Y Times and other widely circulated publications. He has spoken out about the influence of the pharmaceutical industry on the practice of psychiatry and particularly the large amount of money earned by psychiatrists from the drug companies  often without disclosures. This latter point has been considered to have  ethical and legal ramifications. Knowing this background, I eagerly approached the opportunity to review his new book Unhinged  published by Free Press    (2010) and given a subtitle of  “The Trouble with Psychiatry-A Doctor’s Revelations about a Profession in Crisis.”

Early in the book, Dr. Carlat shared his own experience as a practicing psychiatrist where he specialized in prescribing medications and referred patients in need of talk therapy to a “psychotherapist.” He expressed his view “that most people are under the misconception that an appointment with a psychiatrist will involve counseling, probing questions and digging into the psychological meaning of one’s distress.” He goes on to site data which shows that 1 out of 10 psychiatrists offer therapy to all their patients. (I am not sure if this is a valid point since some patients clearly don’t need or want psychotherapy.) He then talks about the well known income differential which favors providing psychopharmacology treatment over psychotherapy. He provides a case history where he did not tell a patient that psychotherapy might work just as well as medication. He said that he decided upon medication because he received little training in  psychotherapy during his three years of psychiatry residency (Mass General) and that he “ doesn’t do psychotherapy  because “I can’t do psychotherapy.” One of the themes of this book is Carlat’s odyssey to ultimately deciding to learn more about psychotherapy and follow a mode of his father who is a psychiatrist and develop a practice which combines psychopharmacology and psychotherapy even if he doesn’t make quite as much income as he did in the past. He shares the interactions with colleagues, teachers and mentors as well as patient vignettes, which lead him to this decision.

This book also examines other controversial issues. For example, Dr. Carlat discusses DSM which he calls “ The Bible of Psychiatry.” He believes that the tradition of psychological curiosity has been dying a gradual death and that DSM is in part the cause and the consequence of this transformation of our profession. He argues that as a result psychiatrists are less interested in “why” and more interested in “what”. (I thought that psychiatrists could chew gum and do other things at the same time. If we continue to use and refine it, DSM allows us to communicate better, do research and get paid.) Carlat interviewed both Bob Spitzer and Alan Francis, the leaders of DSM III and IV respectively who are  both quite critical of the emerging DSMV.

Not surprising, knowing of the previous writings of the author, a good part of the book dealt with the relationship between psychiatry and the pharmaceutical industry starting off with a chapter on “How Medication Became the New Therapy.” There is a  description of the evolution of various drugs used  in psychiatric  practice including the story of Prozac as well as examples of how and why new drugs are introduced as patents on old ones expire. While most of these stories are fairly well known to psychiatrists, it may be surprising to see the behind the scenes descriptions of how side effects such as sexual dysfunction and suicidality were initially minimized and ultimately handled.

The chapter on “How Companies Sell Psychiatrists on their Drugs” reflects some of the writing that Carlat has made in the popular media. He personalizes this important topic by describing his own  previous  relationship with various pharmaceutical representatives. He also reveals the fact that drug representatives have access to each doctors’ prescribing pattern before they visit him or her. He discusses how friendliness and  bringing little gifts such as books or one’s favorite Starbucks coffee have played a subtle but distinct influence on doctors and their prescribing habits. (There have been recent restrictions on these practices.)

Dr. Carlat also outlines his own experience of being a “hired gun” where he gave paid talks to primary care doctors and psychiatrists earning as much as $30,000 in one year. He told how he and his wife were flown to NY and stayed at luxurious hotels and ate in fine restaurants paid for by the pharmaceutical firm for which he was a speaker. He eventually decided that this was morally wrong and stopped this practice. He did go on to write about other psychiatrists whom he reports have made millions of dollars and in some cases were also receiving research grants.  He told  how they were not reporting to their universities, the income that they were receiving which was required. He details Iowa Senator Grassley’s investigations into very well known psychiatrists. He raises ethical questions about doctors taking pharmaceutical money while promoting off label use of various medications for treatment of ADHD and bipolar disorders in children.

There is a discussion of what Carlat calls “the seduction of technology”, specifically referring to the promotion of Vagal Nerve Stimulation and Trans Magnetic Stimulation.    (I observed how the latter technique was actively being promoted at the recent APA Meeting in New Orleans).  Interestingly, Carlat concludes this chapter with a statement that “psychiatrists  need to reacquaint themselves with the missing skill of psychotherapy.”

Perhaps one of the most interesting and controversial thesis of this book is the author’s conclusion that “medical school is the wrong place to train psychiatrists.” He believes that there should be programs that integrate psychopharmacology and psychological technique from the beginning of the training of psychologists . He goes on to say that  psychologists should ultimately prescribe medication as well as do psychotherapy. He describes one experimental model that was briefly used in the 1970s  at  a teaching institution in California but failed to be accepted as a model for licensed care. .

Whether or not you  agree with the arguments, analysis or conclusions of Dr. Carlat, there is no doubt that he has written a very thought provoking book that is based on his own experience with a reasonable attempt at documenting many of his statements. (There are 16 pages of notes and references).  His discovery of psychotherapy as a valid form of treatment will not surprise many of the readers of the journal where this review is appearing. His idea that that psychiatry at this time is troubled and in crisis is probably best judged by a longer historical view. However I suspect that this book will be used by historians to reflect some of thinking of the time as will be  another book written by the psychiatrist Peter Kramer  which came out  17 years ago titled Listening to Prozac . In the meantime Dr. Carlat’s views are out there for discussion and debate.

Take Five With the Author

Following are the answers to five questions I recently asked Dr. Carlat for this blog:

Dr B: Can you describe the reaction of your colleagues to this book?

Dr. C: The reaction from colleagues has been mixed. Most have agreed with the central idea, which is that psychiatry has moved too far into psychopharmacology and has largely abandoned therapy. Many have disagreed with my fairly radical proposals, such as creating an entirely new training system that would be an alternative to medical school and residency. And of course, some have become positively apoplectic at the idea that psychologists can prescribe from a limited formulary safely. So I’ve had my share of fan mail and hate mail.

Dr. B: Do you believe that at present there is enough transparency about possible conflicts of interest in national presentations at meetings and in journal articles?

Dr. C: No, all we get is the name of the company. We don’t get the amount of money, nor the name of the product that the presenter has promoted. These pieces of information are critical for the audience to judge the likelihood that money is affecting the accuracy of a presentation.

Dr. B: Do you have any ideas how the new healthcare legislation (Obamacare) will impact on the practice of psychiatry ?

Dr. C:It will increase the demand for psychiatrists, simply because we will be adding about 30 million people to the health insurance rolls. Some have argued that the emphasis on gate-keepers and accountable care organizations will take business away from psychiatrists, but I can’t imagine PCPs have either the time, interest, or expertise to deal with our patients.

Dr.B: Do you see psychotherapy by psychiatrists being viable in over the next 5- 10 years.?

Dr.C: Not unless psychiatrists are willing to take a drastic pay cut. There’s way of prettying this one up. Insurance companies are never going to pay nearly as much for an hour of therapy as for 3 or 4 psychopharm visits. So the more therapy you choose to do, the less money you will make in direct proportion. That’s assuming, of course, that you are taking insurance. As many as a third of psychiatrists have opted out of insurance and charge their regular fees for therapy, much higher than what they get reimbursed by insurance. Personally, I don’t think that’s a viable option from the standpoint of ethics and health care policy. And it’s demeaning to us. We’re saying, essentially, “our skills are not valuable enough for your health insurance to pay what we think we’re worth, so we don’t take insurance.” I’m not one of those who villainizes insurance companies, partly because many of my trusted psychiatrist colleagues work for insurance companies, and I know what they are up against. They make a serious attempt to come up with a fair market price for therapy, and they have found no compelling empirical evidence to suggest that a psychiatrists’ therapy session is worth double a social workers’.

Dr. B: Can you tell us about any new books or projects with which you are involved?

Dr. C: I am just extremely busy managing my publishing business right now. I wish I had time to write another book, but I have nothing in the wings.