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Book Review   |    
Neuropsychiatry and Mental Health Services
Joseph M. Tonkonogy, M.D.
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.7.939
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edited by Fred Ovsiew, M.D.; Washington, D.C., American Psychiatric Press, 1999, 406 pages, $61.95

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This book constitutes an important attempt to review the role of the rapidly growing body of knowledge in neuropsychiatry in the care of patients by mental health services. Based on the experiences of physicians and psychologists directly involved in neuropsychiatric consultation, the book aims to highlight data that help in the understanding of mental illnesses as brain diseases and to discuss epidemiological and clinical data reflecting neuropsychiatric approaches to the diagnosis and treatment of psychiatric patients.

The book is edited by Fred Ovsiew, a prominent neuropsychiatrist with special experience in neuropsychiatric consultation. The contributors to the book's 13 chapters include Sheldon Benjamin, Jeffrey Cummings, Barry Fogel, Jonathan Silver, and other leading neuropsychiatrists known for their expertise in the development of neuropsychiatric services in mental health settings.

The book begins by taking the reader through a history of the place of neuropsychiatry in public mental health services. In this fascinating chapter, Fred Ovsiew and Thomas Jobe review 19th-century psychiatry in the United States and the United Kingdom and show that the development of psychiatry as a profession largely resulted from the efforts of asylum doctors to treat poor and disadvantaged patients with severe mental illnesses. The psychiatrists and the neurologists of the time agreed that insanity was a brain disease. However, the neurologists emphasized the role of psychological factors in the development of "neurosis" in their more wealthy private patients who had business, financial, or family problems.

More than a quarter of psychiatric patients in asylums— whom neurologists had little role in treating— suffered from overt brain diseases such as general paresis of the insane, epilepsy, and senile dementia as well as from substance abuse and mental retardation. The asylum doctors often used moral therapy— which we might now call psychological therapy— to try to help these patients, bringing a humanistic attitude to treatment.

The ensuing chapters describe the epidemiology, clinical manifestations, diagnostic evaluation, and treatment of neuropsychiatric patients in mental health settings. Epidemiological data show a high prevalence of medical diseases among mentally ill patients in various settings, including state hospitals, outpatient clinics, nursing homes, prisons, and homeless populations. Special attention is given to the psychiatric symptoms directly related to vascular, degenerative, infectious, toxic, and neoplastic processes as well as to mental disorders caused by physical disturbances in less direct ways, including side effects of psychiatric medications.

Several chapters in the book discuss neuropsychiatric approaches to the evaluation and treatment of mentally ill patients. These approaches include screening to detect general medical problems, neurological and neuropsychological examinations, use of neurodiagnostic technology such as electroencephalography, brain imaging— especially computed tomography and magnetic resonance imaging— analysis of psychiatric history, and mental state evaluation in relation to psychiatric manifestations of overt brain diseases.

Readers will find useful the chapters describing important neuropsychiatric manifestations of mental illnesses, including tardive dyskinesia, dementia, and aggressive behavior. The discussion of neuropsychiatric approaches to aggressive behavior highlights the role of several important conditions associated with aggression in psychiatric patients, including epilepsy, frontal lobe syndromes, intermittent explosive disorders, attention-deficit hyperactivity disorder, and neurotransmitter abnormalities. The increasing use of anticonvulsants as antiaggresive medication in psychiatric settings and the positive and negative effects of such treatment are also described.

The book also discusses neuropsychiatric aspects of substance abuse, HIV infection, developmental disabilities, late-onset depression, and psychosis. One chapter analyzes the controversial topic of sexual deviations. Special attention is given to the results of neurodiagnostic and neuroendocrinological investigations of sexual offenders and to the treatment and management of sexual deviations. These topics are extremely important, as modern mental health services are increasingly involved in the diagnosis, forensic evaluation, and long-term care of sexual offenders.

Later editions of the book might benefit from the inclusion of chapters discussing the major diagnostic tasks that neuropsychiatrists face in their consultation in mental health settings— for example, the diagnostic evaluation of confusional states or delirium as the major psychiatric manifestation of infection, intoxication, head injury, or stroke. Neuropsychiatric consultations often include differentiating acute and subacute confusional states and progressive dementia as well as identifying the causes of confusional states, which can vary from side effects of psychiatric medications to manifestations of afebrile pneumonia. Other difficult diagnostic tasks may include differentiating between severe cognitive impairment in residual schizophrenia and primary degenerative dementia, between parkinsonian signs caused by neuroleptics and development of Parkinson's disease in psychiatric patients, and between abbreviated types of seizure and pseudoseizure in psychiatric patients treated with anticonvulsants.

Neuropsychiatry and Mental Health Services is one of the first attempts to describe the role of neuropsychiatry in mental health settings— and it is a successful one. It may help readers navigate through the maze of complex research and clinical findings that are important in the use of neuropsychiatric approaches by mental health services. The book can be an invaluable reference for mental health professionals involved in the care of patients with neuropsychiatric problems.

Dr. Tonkonogy is professor of psychiatry and neurology at the University of Massachusetts Medical School in Worcester.




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