The Alcohol and Drug Wildcard. Substance Use and Psychiatric Problems in People with HIV By Joan E. Zweben & Patt Denning. UCSF AIDS Health Project Monograph Series Number Two. 1998. 98 pp. $9.95 (pb) ISBN 1–879168–02–2

This monograph looks at ‘triple diagnosis’ concentrating on the complications the additional diagnosis of substance misuse brings to those people already diagnosed with HIV and mental health problems.

The book examines the ways in which the mercurial influence of substance use may be better managed if treated as a primary disorder rather than by way of handling the other two conditions. It centres its arguments around three neatly packaged case studies which offer all the variations of the triple diagnosis which life is likely to throw at a carer. From here, there are concise chapters addressing assessment, diagnosis and addiction treatment. The book tries to integrate the management of the three conditions simultaneously, accepting that few carers are adequately trained to do so. Unfortunately, this very dilemma is reflected in the book's own infrastructure. The authors seem comfortable with the concept of the dual diagnosis of alcohol misuse and mental illness, but need to keep reminding themselves, and us, of the inconvenient addition of an HIV diagnosis.

Treatment, they advise, should always be accompanied by group or individual psychotherapy as “evidence points to an improvement in socialisation and a reduction of relapse”. What this evidence is, we are not told.

The authors are over-inclusive in their attempt to improve our understanding of the three conditions and only manage to critically review the addiction problem.

For those with severe mental illness, they recommend a highly structured programme of low intensity — including an evaluation of support networks. Ways of funding these programmes are not discussed and money is not mentioned at all, the lack of which may trump all attempts to treat triple diagnosis, however wild the card.

Much is made of the conflict between total abstinence and harm minimisation. Various alternatives to classical therapies are discussed, even programmes in which a patient may ‘rebirth a new life’, reflecting, perhaps, the book's bias towards the USA market. None of the resources mentioned is based over here.

Overall, the book is well written and easy to follow. It offers a succinct overview of the complexities of comorbidity and is to be welcomed for this.