AJP nov97 Book Forum • AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals

Two things I never expected to occur in my lifetime: the breakup of the U.S.S.R. and the resurgence of infectious diseases. The U.S.S.R. is history, and infectious diseases are back, led by the unparalleled viral disorder HIV, which effectively neutralizes the immune system. As medical director of a large state system, I get calls from local health departments seeking advice on how to deal with HIV-positive clients who are mentally retarded, mentally ill, or substance abusers and who are sexually active with multiple partners. In 1994 we found that the HIV prevalence rate for patients admitted into our four state hospitals was about 1.6%, about 1.5 times the level the Centers for Disease Control regards as high (unpublished data of K. Kirkland et al.). Now at last there is a book that deals with the issues of comorbidity of HIV and serious mental illness.

In 1987, the late Randy Shilts, chronicler (and ultimately victim) of the epidemic wrote, “By the time America paid attention to the disease, it was too late to do anything about it. The virus was already pandemic in the nation, having spread to every corner of the North American continent. The tide of death that would later sweep America could, perhaps, be slowed, but it could not be stopped” (1). Initial societal denial seemed vested in regarding AIDS as a disease of gay men. Current denial within the mental health professions is more subtle, tied to an acknowledgment of risks but denial of exposure of clients to these risk factors. For example, mental health workers do not routinely inquire about their clients' sexual habits, believing that seriously mentally ill persons are too confused and disorganized to be interested or competent enough to find partners or concerned about the impact of trying to inquire regarding sexual practices. There is a familiar ring to this concern—usually expressed about sexual education for children or adolescents—that it will encourage practices currently unconsidered. Mental health professionals and workers must become knowledgeable about HIV and skilled at imparting risk-reduction information. AIDS and People With Severe Mental Illness brings this information in a well-written handbook.

There are three main parts to the book. Part 1 deals with the epidemiology, risk behavior assessment, psychiatric manifestations, and medical manifestations of AIDS. Part 2 is the “how to” part of the book, covering interventions to reduce the risk of infection and telling how to work with the HIV-infected patient with serious mental illness. Part 3 covers policy and legal issues. There are nine very useful appendixes, including one on universal precautions that is required reading for anyone in the health care field. There is also a very useful glossary.

The chapters on intervention are written by professionals who have “been there and done that.” They offer very practical advice. Inevitably, there is some repetition. Many chapters tell how professionals make false assumptions about their patients' sexual behavior, that intervention starts with information about HIV prevention (safe sex, no sharing of intravenous drug paraphernalia), and that information is not enough. There needs to be training in assertive behavior and in repetition. However, since the chapters tend to deal with different subpopulations, and the book is likely to be used by readers who seek to become informed about these subpopulations, the repetition lends itself to finding information on a given group in one chapter.

All chapters are so well written that I hesitate to single out chapters for excellence; the editors and all contributors are to be congratulated. However, I found two chapters particularly striking. Chapter 10, “Working With HIV-Infected People” by Empfield blends anecdotes and practical advice unusually well. In chapter 12, “Working With Homeless Mentally Ill Men,” Valencia, Torres, and Susser describe a project that is a model of ingenuity.

The editors say in the preface that their intention is to provide in one volume all the information health care workers need to contain the spread of AIDS among the mentally ill. They have succeeded. This book should be read by every person who works with the severely mentally ill, the mentally retarded, and the substance abusing patient.