Archive for September, 2009

Advances in Neurology: Epilepsy and the Functional Anatomy of the Frontal Lobe

Advances in Neurology: Epilepsy and the Functional Anatomy of the Frontal Lobe. Volume 66

HH Jasper, S Riggio, PS Goldman-Rakic, editors

New York NY: Raven Press; 1995. 400 p

Frontal lobe epilepsy has proven to be much more difficult to diagnose and treat, both pharmacologically and surgically, than the more common temporal lobe epilepsy. This volume represents the proceedings of a multidisciplinary symposium designed to bring together clinicians and basic scientists to elaborate current concepts in frontal lobe function and pathology, especially as they pertain to frontal lobe epilepsy. The book complements a previous work by the same publisher, entitled Frontal Lobe Seizures and Epilepsies. The editors state that the present volume is intended to emphasize “recent experimental work on the developing functional neuroanatomy of the prefrontal cortex in relation to working memory, cognitive behavior, and the physiopathology of frontal lobe seizures and their neurosurgical treatment.”

The first 7 chapters provide a comprehensive overview of animal and human studies which have contributed to our insight into developmental, anatomical, functional, cognitive, and neuropsychological aspects of the frontal lobes. A chapter on “Frontal Degenerative Dementia and Neuroimaging” is somewhat removed from the main emphasis of this collection but nevertheless offers an up-to-date synthesis of the clinical and radiological features of this form of increasingly recognized dementia. One of the highlights of this section is the chapter by Brenda Milner summarizing the ground-breaking work, largely under her direction, on the neuropsychology of the frontal lobes, carried out at the Montreal Neurological Institute over half a century. Herbert Jasper, who also worked in Montreal, provides a historical survey of prefrontal lobotomy, a chapter which should be of interest to psychiatrists.

Frontal lobe complex partial seizures have been notoriously difficult to diagnose and treat. Because they often manifest bizarre motor and vocal features, their seizures are relatively short-lived, and they have minimal surface EEG manifestations both ictally and interictally, patients who present with these types of seizures are often incorrectly labelled as having psychogenic pseudoseizures. The rest of this book is devoted to clinical phenomenology, EEG features, neuroimaging studies, and surgical therapy of frontal lobe seizures. A variety of techniques for localization of foci or investigation of function such as computerized-evoked potential analysis, PET scanning, MRI, depth electrode recordings, and electrical stimulation is covered. Several centres from the US, Canada, and Europe have contributed their experience and expertise to this volume. One of the most useful features of this book is the inclusion of the often revealing and less formal discussions that followed each presentation.

This is a well-organized, up-to-date account of all aspects of frontal lobe function and their relevance to frontal lobe epilepsy. Because of the importance of the frontal lobe in human behavior, cognitive ftinction and memory, and also because of the overlap between epilepsy and psychiatric illness, psychiatrists should find this work useful. It will also serve as a reference for neurologists and neurosurgeons, especially those working in the field of epilepsy.

The Treatment of Anxiety Disorders: Clinician’s Guide and Patient Manuals

The Treatment of Anxiety Disorders: Clinician’s Guide and Patient Manuals

G Andrews, R Crino, C Hunt, L Lampe, and A Page

New York: Cambridge University Press; 1995.423 p

The Treatment of Anxiety Disorders: Clinician’s Guide and Patient Manuals begins with a section entitled “How To Use This Unusual Book”. The warning is useful because this book is presented differently from most. It consists of 3 sections that are repeated for each anxiety disorder: first, a collection of relatively brief reviews of the presentation, aetiology and treatment of anxiety disorders; second, a series of brief therapists’ manuals; and third, a set of more extensive patient manuals. The authors and publishers generously give the reader permission to photocopy the patient manuals for repeated use. The authors are well-known clinician researchers working in Australia. The senior author, Gavin Andrews, has contributed widely to the anxiety disorder field for many years, particularly in issues of neurotic defense styles and the use of behavioral treatments for anxiety.

The brief reviews are adequate and represent a fairly succinct way of obtaining current information on anxiety disorders, largely from a cognitive-behavioral perspective. Despite this general perspective, issues relating to biological and aetiological theories, genetics, and drug treatments are expertly handled. The clinician guide to general treatment issues focusses on cognitive and behavioral approaches which may disappoint those with other therapeutic orientations, but help those looking for advice on how to deliver behavioral treatments in their own practices.

The book addresses each of the major anxiety disorder syndromes in turn, and provides the clinician with 5 structured manuals for the treatment of panic disorder and agoraphobia, social phobia, specific phobias, obsessive-compulsive disorder, and generalized anxiety disorder. Adjustment disorder and secondary anxiety are dealt with briefly without the manuals. The clinician manuals are useful guides to the step-wise treatments used in cognitive-behavioral therapy. The manual for panic and agoraphobia gives details of therapeutic tasks to be undertaken in each of 19 treatment sessions, and relates these steps to the patient manual consisting of 50 pages of information and exercises. Each of the other disorders is dealt with in similar fashion.

The patient manuals are rather repetitive and focus considerable attention on hyperventilation control and the use of relaxation. Appropriate attention is paid to the use of exposure methods and cognitive techniques. The patient manual for the treatment of obsessive-compulsive disorder is surprisingly short given the usual complexity of clinical cases of this disorder. One potential difficulty with the patient manuals is the level of reading skills necessary to understand them. With therapist help this will probably not be a problem, but the writing style of the 3 different sections varies less than expected.

This 423-page book sets out to tackle 3 large areas and it does so reasonably well. It cannot be all things to all anxiety sufferers, and there are other self-help manuals available that are more reader friendly. There are few sources for the clinician that combine, quite so conveniently, current information about the various anxiety disorders and their treatment. Andrews’ book can be recommended to clinicians looking for guidance on how to conduct cognitive-behavioral treatment. It is also a useful book for training junior colleagues, and I will use it in that setting. I expect that most clinicians who use this particular book and set of manuals will be reasonably satisfied, but they will probably want to add to their information base by turning to more comprehensive texts about the individual disorders.

The Clinical Interview Using DSM-IV

The Clinical Interview Using DSM-IV. Volume 2: The Difficult Patient

E Othmer and SC Othmer

Washington DC: American Psychiatric Press; 1994. 513 p

This book is a sequel to The Clinical Interview Using DSM-IV. Volume 1: Fundamentals. The authors recognized the need for an integrated approach to interviewing. Volume 1 came out of that recognition. It is now followed by Volume 2 The Difficult Patient.

“Clinical interviewing is a transitional process between diagnosis and treatment” according to Mel Sabshin, author of the foreword. In introducing the book, the authors identify the descriptive approach to DSM-IV, and address the special issue of difficult patients who express their distress in ways other than straightforward symptoms. They draw our attention to the differences between a diagnostic and a therapeutic interview (p. 55). The authors acknowledge the different approaches in interviewing: 1. the psychodynamic standpoint that engages open-ended, free-association interviewing aimed at uncovering conflicts; 2. the behavioral standpoint that explores the noxious stimuli leading to the maladaptive response; and 3. the descriptive standpoint that explores signs and symptoms and the diagnostic criteria. One has to agree with the authors that no one approach fits all groups of disorders. Their “New Think” approach claims to provide a different interview method. It is intended to help prepare the patient for “optimal therapeutic intervention”. I can’t help wondering if this also means cutting down the number of therapy sessions which will, in turn, result in cost cutting. If this, in fact, helps produce better-equipped physicians and specialists, so much the better.

The authors stress the significance of rapport with the patient as key to information gathering, which in turn is crucial in making a diagnosis. The authors have drawn from various schools such as the dynamic, cognitive, neuropsychiatric, and legal, hoping to provide a differential approach to interviewing.

The authors emphasize 5 steps in the therapeutic interview: listen, tag, confront, solve, and approve. With examples, they define and explain each of these steps in relation to special patient populations identified as difficult. These populations include patients with dissociation, conversion, psychosis, somatisation, cognitive impairment, delirium, dementia, and mental retardation. The authors further identify patient populations with different behavior patterns such as “self-protective and deceptive behavior”. Within the last group, they identify behaviors such as “concealing”, “falsifying and lying”, “factitious behavior”, and “self-deceptive behavior”.

What I found most useful in this book is the authors’ attempt to offer practical interventions for the interviewer in dealing with a patient who, for example, is seductive, dissociating, a victim of incest, leaves the office door partially open and asks the receptionist to check in every 10 minutes, and so on. The authors also provide step-by-step verbal and behavioral responses for both patient and therapist. They further explain the rationale behind the suggested interventions: “he (the therapist) gave her (the patient) space rather than pushing for answers”; “he combined empathy with limit setting”.

The book is refreshingly free of unnecessary jargon. A great deal of thought and experience with patients has been invested. The authors have given meaning to the defensive functioning aspect of the DSM-IV.

Most of the educators in the field follow what Mel Sabshin advocates: “integration rather than ideological segmentation of our field”. I agree with Sabshin’s conclusion that this book will add to “education and continuing learning”. It delivers what it claims to deliver. The authors do not maintain that this book is everything to everybody.

The book ends on a high note by focussing on the patients’ assets, their highest reachable GAF score, and our responsibility as caregivers to help them get there. It also provides an appendix for Qualitative Evaluation of Dementia (QED) and The Executive Interview (EXIT) for dementia, which outlines these methods.

Synopsis of Neuropsychiatry

Synopsis of Neuropsychiatry

SC Yudofsky and RE Hales, editors

Washington DC: American Psychiatric Press; 1994. 641 p

This paperback is a synopsis of the American Psychiatric Press Textbook of Neuropsychiatry, which was first published in 1987 (a second edition has subsequently been published). The Synopsis of Neuropsychiatry is designed to condense most chapters from the second edition, and its content is aimed at medical students and residents in psychiatry and neurology.

The book is divided into 5 sections: the basic principles of neuroscience, neuropsychiatric assessment, neuropsychiatric symptomatologies, neuropsychiatric disorders, and neuropsychiatric treatments.

The section on basic principles of neuroscience includes chapters on cellular and molecular biology of the neuron, and on human electrophysiology. The chapter by Daniel Tranel on functional neuroanatomy from a neuropsychological perspective is particularly well done. These chapters are all well organized and plentiful diagrams add interest and clarity.

The neuropsychiatric assessment section includes chapters on bedside neuropsychiatry, neuropsychological evaluation, electrodiagnostic techniques, brain imaging, and epidemiology and genetics. The chapter on bedside neuropsychiatry by Fred Ovsiew is an excellent summary of the major symptoms and signs of neuropsychiatric disorders. The chapters on electrodiagnostic techniques and brain imaging are also good overviews. I found the chapter on epidemiology and genetics too technical when describing linkage analysis and molecular approaches to the investigation of various neuropsychiatric diseases such as Huntington’s Disease and schizophrenia.

The third section on neuropsychiatric symptomatologies includes chapters on differential diagnosis in neuropsychiatry, neuropsychiatric aspects of pain management, and delirium. Chapters on neuropsychiatric aspects of aphasia and related language impairments, and neuropsychiatric aspects of memory and amnesia are also part of this section. The chapter on differential diagnosis by Richard Strub and Michael Wise has an excellent algorithm on the approach to the patient with memory loss, as well as an informative and concise table on common focal behavioral syndromes and their localization. The chapter on pain management by William Brouse and David Spiegel focusses on neurological mechanisms of pain and neuropharmacology but could be more clinically oriented. Delirium is well covered by Michael Wise and George Brandt. Frank Benson provides a superb chapter on aphasia, which presents a complicated topic clearly and succinctly. The chapter on neuropsychiatric aspects of memory and amnesia by Arthur Shimamura and Felicia Gershberg describes the neural and biochemical mechanisms of memory very well, and outlines some clinical syndromes. However, it would benefit by a section on the differential diagnosis and investigation of the patient with memory disturbance.

The next section has 12 chapters on specific neuropsychiatric disorders: traumatic brain injury, epilepsy, sleep, cerebral vascular disorders, brain tumors, human immunodeficiency virus, endocrine disorders, poisonous and toxic disorders, alcohol-induced organic mental disorders, degenerative dementias associated with motor dysfunction, Alzheimer’s Disease and other dementias, and the neuropsychiatry of schizophrenia. There are particularly comprehensive and clinically focussed chapters on sleep (by Thomas Neylan, Charles Reynolds and David Kupfer), cerebral vascular disorders (by Sergio Starkstein and Robert Robinson), Alzheimer’s Disease (by Jeffrey Cummings), and the neuropsychiatry of schizophrenia by Henry Nasrallah. There is little, in any chapter, written on the neuropsychiatric aspects of multiple sclerosis despite its prevalence. Other missing topics include autistic disorders and mental retardation, neuropsychiatric aspects of street drug abuse, and chronic fatigue syndrome.

The final section on neuropsychiatric treatments includes chapters on psychopharmacological treatment in neuropsychiatry, psychotherapy for neuropsychiatric disorders, cognitive rehabilitation and behavior therapy, stress and coping in family caregivers, and ethical and legal issues in neuropsychiatry. The chapter on psychopharmacology by Steven Dubovsky is comprehensive and well organized. I found the chapter on psychotherapy too long and wordy, although the tables nicely summarize the lengthy discussion in the text. The chapter on cognitive rehabilitation and behavior therapy by Mark Lovell and Christopher Starratt is a well-written overview, and serves as a good introduction to this topic. Stress and coping in family caregivers is covered mostly by discussing theorical models with little attention to clinical issues. Ethical and legal issues in neuropsychiatry are well covered in the chapter by Robert Simon.

Overall, this is a strong textbook which provides a solid overview of neuropsychiatry. The authors are all recognized neuropsychiatry experts. Every chapter is well referenced, which enables the reader to investigate any topic in more depth, if necessary. A strength of almost every chapter is the liberal use of tables, diagrams and figures. Unfortunately, several chapters contain diagrams and figures that require colour to be useful, such as figures of PET and SPECT scans. The reader is referred to The American Psychiatric Press Textbook of Neuropsychiatry, second edition, for full-color figures. This is extremely irritating, and it is unlikely that many readers will have ready access to the larger textbook when reading this chapter, thus losing the benefit of illustrations. I suggest that the publisher consider adding full-color figures even if it increases the cost of the Synopsis of Neuropsychiatry.

This book will be very useful for residents in psychiatry, particularly during a rotation in consultation-liaison psychiatry, and also for neurology residents and neuropsychology interns. Medical students will benefit from this book during their rotations in psychiatry and neurology. It will also be useful to clinical psychiatrists involved in inpatient and consultation-liaison psychiatry, although other textbooks will be necessary if an indepth look into a particular area is desired.

Epilepsy and Quality of Life

Epilepsy and Quality of Life

MR Trimble and WE Dodson, editors

New York: Raven Press; 1994.306 p

This volume affords the opportunity to assess the current state of quality of life (QOL) research in epilepsy. As is the case with most concepts in science, one can trace the evolution of an area of interest from its infancy (early attempts to define the subject domain, followed later by single-variable studies) to maturity (multifactorial experimental designs, links to theory, consensus regarding definition, and randomized controlled trials).

Trimble and Dodson’s book is worthwhile in that it indicates quality of life research in epilepsy has moved past its infancy, but has yet to reach its mature state. The book is the product of a 1993 workshop during which definition and measurement issues regarding QOL in epilepsy were addressed. It contains chapters written by international researchers who are prominent in the field. Researchers and clinicians who deal primarily with epilepsy will find this book useful. Considerable space is devoted to contemplating the dimensions of quality of life in epilepsy, and how QOL is experienced by patients, families, and their associated social systems. Key assessment instruments are reviewed in significant detail, and 4 of the leading measures are actually reproduced in appendices. The book’s effort to provide practical information is helpful. Specific implications of quality of life are also given attention. Examples include Cramer’s chapter on compliance issues, and Hermann’s particularly well-written chapter on cognitive and psychosocial outcomes following epilepsy surgery. It was enlightening to read the 2 chapters written by representatives of the pharmaceutical industry who provide a novel view of advances and problems in the research. Their suggestions cause us to reflect on the directions our work is taking.

The editors are to be commended for trying to balance applied and statistical/experimental issues. They acknowledge the diverse perspectives that QOL research has adopted. The North American approach to QOL seems to be overshadowed by the ESI-55 and Quality of Life in Epilepsy questionnaire (QOLIE) (both described in this book), but it is abundantly clear from other chapters that the European approach is somewhat different (for example, Trimble’s use of repertory grid techniques in the UK). In contrast to these approaches are the epidemiological concepts of risk and standard gamble; several contributing authors appropriately cite the seminal influence of Guyatt and others in this area. This wide diversity reminds us that as much as a consensus regarding definition and measurement of QOL would be desirable, it has not yet been achieved.

This volume is comprehensive and most chapters are clear, well organized, and well written. Two of the strongest are by Johnson and Fallowfield, who discuss theoretical and practical issues pertaining to test construction and human measurement. All who conduct research into QOL must have a grasp of these concepts, and the field will likely not advance further until such is the case. Although progress is apparent in the work contained in these pages, a consensus definition of QOL remains elusive. Coordinated, programmatic research efforts are still the exception. This volume has usefully taken the pulse of QOL research in epilepsy, and should stand as an impetus to advance its level of sophistication and scientific rigor.

Dementia and Normal Aging

Dementia and Normal Aging

FA Huppert, C Brayne and DW O’Connor, editors

New York: Cambridge University Press; 1994, 559 pages

This book opens with a statement, presumably by the publisher, as follows: “Age has been identified as the strongest risk factor for Alzheimer’s Disease, and is also strongly associated with the cerebrovascular risk factors for vascular dementia. When a disorder is so strikingly age dependent, it is appropriate to examine its relationship to normal aging, and this book is based upon the premise that the challenge of dementia lies in establishing its true relationship with normal aging.”

In the introduction, the authors summarize the chapters and conclude that the issue in question cannot be decided with certainty until cognitive, behavioral and neurobiological data are available from representative population samples. Furthermore, the authors note that the bulk of the evidence presented in the book is consistent with a continuum model of age-associated decline, where chronological age, intrinsic variables, and environmental factors combine to determine when disability becomes manifest. It is then convenient to make a diagnosis when a threshold of disability has been reached. When the authors refer to dementia with respect to aging, they seem to think, most of the time, about senile dementia of the Alzheimer type (SDAT). Vascular dementia is also mentioned as part of a possible process of Alzheimer’s Diseast, but the editors tend to use dementia as a synonym for SDAT. Following the introduction, the book is divided into sections dealing with the development of contemporary views of dementia, the diagnosis of dementia today, research methodology and population studies, behavior and cognition in dementia and normal aging, neurobiology of dementia and normal aging, and health care and social policy issues.

The book can be enjoyed (for it is an excellent monograph) in two ways. It comprises a comprehensive series of chapters on diagnosis, clinical features and epidemiology with useful items on service and psychology and an attractive section on biological aspects. It can be read for these items individually. It can also be appreciated for the development of the continuum hypothesis.

In the first respect, the volume is of uniformly high standard and indeed exceptional. Chapter after chapter deals with the topics clearly and well, so that, whether or not one of them is dedicated to the particular theme of the book, the interested reader is likely to learn something from it, see something in a fresh light, or discover a rounded judgment. The range of the volume is such that no single reader is likely competent to evaluate every chapter and, no doubt, some issues are dealt with less comprehensively than others. I noticed that the chapter on imaging had no reference later than 1991, which is unfortunate because that field is changing particularly rapidly. I speculated that the editors had accepted a complete version of this chapter early on, and had not sought updating or had not received it, while continuing with their own revisions up to the last minute. Even so, that chapter was instructive and a model of clarity.

The main thesis that normal aging lies on a continuum with the disorders or diseases ofdementia is politically incorrect but deserves attention for better reasons. Among them is the argument that, notwithstanding Krai’s description of Benign Senescent Forgetfulness, minor lapses in cognition may be far from innocuous. The zone of transition from normality to dementia is frequently fuzzy, education and previous social history influence the cutoff points which may be used to mark the threshold ofdementia, and the boundaries of minimal or questionable dementia appear to be fluid. In addition, cholinergic changes in SDAT, particularly with onset in the seventies, tend to be less marked. Other changes in biogenic amines (which are quite prominent in younger cases) do not differ notably among the older cases compared with normal controls; and senile plaques overlap awkwardly, occurring in nearly all older controls. However, some biological changes can be read as strongly supporting the discontinuity hypothesis in Alzheimer disease. One of the strongest arguments for this, the increased loss of cells in Alzheimer disease compared with normal aging, is neglected, yet other biological discontinuities are observed, particularly as Wischik et al point out (Chapter 20) in the case of the great excess of tangles in Alzheimer disease compared with normal aging, and in the presence of an excess of perihelical filaments in Alzheimer disease at all ages. Further, patients with familial Alzheimer disease are evidently different genetically and cognitively from controls.

In addition, for all other types of dementia, e.g., those associated with head injury, tumor, Lewy Body Disease and Huntington’s Chorea, there are clear qualitative differences. So, normal aging is only an issue when compared with Alzheimer’s Disease, although Alzheimer disease remains the commonest cause ofdementia in the Western World, accounting for about 60% of all cases at a conservative estimate.

Altogether, this is an interesting argument. However, the weight of the evidence still suggests major biological differences, while the problems of discrimination, not unnaturally, seem to reflect a mixture of assessment difficulties with independent complicating influences, whether from premorbid intelligence, education, or temporary confusion.

The discussion about continuity is interesting but the book could stand on its own as a splendid collection of essays and reviews. It is well produced, consistently well-written, clear, informative, and stimulating. It has a firm, hard back, is a good size, and is clearly printed on white paper (in contrast with some current publications). One-third of the chapters originate from the Cambridge School of Medicine, where three of the editors work, but there are other contributions from Britain, the US and Australia. Nearly all the chapters would seem outstanding in any other volume, but they merge here into the overall high level of information and ideas. This book contains relevant information for clinicians or scientists with an interest in Alzheimer disease, and is essential reading for all disciplines working with Alzheimer’s Disease.

Screening for Brain Impairment: A Manual for Mental Health Practice

Screening for Brain Impairment: A Manual for Mental Health Practice. 2nd ed

RA Berg, M Franzen and D Wedding

New York: Springer Publishing Co; 1994, 201 pages

Screening for Brain Impairment is an introduction to neuropsychology intended for, in the words of the authors, “general clinicians”. It is a well-written summary of existing material on the subject and is presented in a very accessible way. The authors are experienced neuropsychologists who have published a number of papers and books on this topic.

The first half of the book presents an introduction to neuroanatomy, neuropathology and neurological examinations. This part is apparently intended for a readership with no previous exposure to neurology (i.e., neuroanatomy, neuropathology or clinical examination). It would be appropriate and useful for the social worker who has no experience with brain-impaired patients. However, it is introductory and over-simplistic for other healthcare professionals such as nurses, speech therapists, physicians, occupational- and physiotherapists.

The second half of the book is of much broader interest to the general clinician, and focusses specifically on neuropsychology, its assessment and approaches. These chapters contain a wealth of information related to neuropsychological assessment, its appropriate application and implications. This information is likely to facilitate more effective interaction between the healthcare team and the neuropsychologist. It will also guide the general clinician in conducting a preliminary neuropsychological assessment of the patient.

However, a word of caution is in order. At various points in this book, the authors suggest referring a patient for Anther examination to a neuropsychologist or a neurologist if an undiagnosed neurological disorder is suspected. In my opinion, equating a neuropsychologist with a neurologist is potentially dangerous. Typically, the neuropsychologist has no access to inpatient beds; to neuroimaging diagnostics; to invasive diagnostic procedures (e.g., spinal tap); and to emergency neurosurgical consultation. Valuable time may be lost in a neuropsychological assessment, thereby missing a window of opportunity to diagnose and treat a potentially treatable neurological condition such as subdural hematoma or meningitis.

In summary, this book is a well-written introduction to neuropsychology. Parts of it are oversimplistic for most general clinicians; other parts provide valuable information for people wishing to learn more about assessment devices and concepts of neuropsychology.

Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines

Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines

RF Prien and DS Robinson, editors

New York: Raven Press; 1994, 669 pages

This book reflects several decades of active development in psychotropic drug evaluation. The first modern, randomized, double-blind controlled trial of a psychotropic drug was conducted in the early 1950s (Schou’s evaluation of anti-manic lithium). Since the first methodological book on evaluation, edited by Cole and Gerrard (1959), several international statements of expectations have been published describing how psychotropic drug evaluations should take place. The present volume represents a culmination of the US national effort to establish guidelines for clinical evaluation of psychotropic drugs. Academic, clinical, pharmaceutical, regulatory and public health sectors, as well as several other disciplines contributed to this unfolding over the years.

This book was initiated in 1990 by the establishment of a task force on guidelines for clinical evaluation of psychotropic drugs; the American College of Neuropsychopharmacology (ACNP) and the National Institute of Mental Health (NIMH) collaborated. While the recent international volume (Grof et al 1993) focuses on education, the Prien and Robinson book appears more appropriate for experienced investigators. It often deals with issues and problems that would confound the novice looking for guidance in a maze of clinical trials.

Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines is a resource that reflects the knowledge and experience of a wide group of US experts. The contributing authors number exactly 100, and the list reads almost like a “Who is Who” in US psychopharmacology. The book is as multi-authored as one could possibly imagine. An editorial group provided overall leadership. The ACNP taskforce advised on content and authorship of the book, and reviewed initial chapter drafts. Subsequent drafts were circulated to outside reviewers specializing in particular fields. Those of us foolish enough to engage in multi-authored writings will appreciate the challenges and the extensive nature of this process.

The book is divided into three main sections of increasing length. The first section, “Historical Perspectives”, describes the context of the book by providing a historical overview of clinical psychopharmacological research and guidelines. It also describes the decision-making process of establishing the efficacy and safety of psychotropics. The second section, “General Principles in the Evaluation of Psychotropic Drugs”, contains a broad outline of developments and issues of clinical methodology, and provides direction in research principles, study design and implementation, presentation of study findings, and ethical considerations involving drug evaluations. The third and most extensive section,”Specific Patient Groups: Application of General Methodologic Principles”, addresses methodologic developments and recommends clinical evaluation of specific diagnostic and age populations. This section builds on the ideas expounded in the preceding sections. A predecessor of this book, entitled Principles and Problems in Establishing the Efficacy of Psychotropic Agents and edited by Jerome, Levin, Burtrum, Schiele, Lorraine and Bouthelet, was published in 1971. The present book can be seen as an extensive revised and updated version of that first comprehensive volume, and it documents the advancement in the clinical trial methodology of psychopharmacology over the past 25 years.

This outstanding book will be essential for anyone actively involved in psychotropic drug trials. I found three parts particularly intriguing. First, the sections on ethical and legal considerations, which have become particularly heated during this time of political correctness, are of great interest. Second, the sections on maintenance (prophylactic) trials in general and in specific patient groups are also fascinating. If recent developments are indicators, there will be a major expansion in die area of testing, in particular because of the clinical need, and the widespread use of long-term treatments. Third, some of the innovative ideas that may improve and hasten the evaluation of new drugs are of interest. The desire for innovative approaches is driven by a new emphasis on cost containment as well as by the increasing importance awarded to treatment effectiveness, rather than relying solely on randomized, controlled trials for proof of efficacy.

It is clear that we are going through a stage of developing new methodology, and are questioning older ideas. It seems likely that in the future we will view the traditional, randomized, clinical trial as a necessary but insufficient technique in providing comprehensive evaluation. The Bayesian approach is becoming more common in clinical trials, with a de-emphasis on the frequentist approach. Increased attention is being paid to the problems of statistical analysis of longitudinal data, and the techniques of integrating information through meta-analysis. Researchers have become increasingly concerned about the limitations of generalized clinical trials in clinical practice. New strategies, envisaged in the World Health Organization (WHO) guidelines, are being proposed, ranging from the value of vigorously-collected observational data to the use of clinical databases and new strategies of cross design synthesis.

In a book of this size, with several contributing authors, it is to be expected that everything will not emerge perfectly, and that one will encounter allusions to the same issues a number of times (e.g., the complex placebo issue). It is also inevitable that, when a book is in preparation for several years, certain issues are dated by the time of publication. This is the case with the incorrect statement that the regulatory agencies in Europe do not require proof of prophylactic efficacy for new antidepressants. It is also of interest that the authors, although referring to the traditional phases of evaluation, have not structured the book following the four classical phases, as in previous books on clinical trials. Although this excellent book could not be useful to a psychopharmacological novice, it will be of much value to experienced investigators for years to come.

Neural Activity and Growth of the Brain

Neural Activity and Growth of the Brain

D Purves

New York: Cambridge University Press; 1994, 108 pages.

This booklet contains four lectures on the issue of the brain map, modular circuitry, trophic interactions and neural activity. This curriculum, as others, ranging from physics to economy and serving as stage-setting instructions, was delivered in Pisa, Italy, in 1992 for a broad audience of graduate students. Anyone who provides such lectures for a mixed audience will be painfully aware of the narrow and dangerous path one has to follow between pitiless pedantry and gross generalization. Each lecture is approximately 2 to 24 small-format printed pages of which 7 or 8 are taken up by illustrations. None of the four lectures contains any strikingly new information; each is intended as a brief review on the subject.

The fact that only a small fraction of the material can possibly be presented in a review provides the author with the privilege of selecting freely from a vast amount of available data. The collection of these choices amounts to a bouquet of information that will determine success or failure.

In a brief introduction, the author highlights the formative impact of the early experiences and memories of an individual upon the developing structure. He equates the resultant novel style of circuitry with the paradigm of personality. Although he refers to Donald Hebb’s work at McGill University in the 1940s on the neural effect of the enriched milieu, he regrets that this area has never been thoroughly examined. Unhappily, the author fails to quote from the much later work of Rosenzweig, Diamond and Bennett, the original researchers who created the term “enriched [stimulating] milieu”, and from their ingenious experiments that explored its effect upon neural growth, neural migration, dendritic arborization, and on the levels of different neurochemical substances. In contemporary research, the capacity of the brain tissue to respond to environmental-modifying influences with a structural alteration is dealt with under the heading of “plasticity”. A large number of substances including gonadal hormones, neurotransmitters, modulators, especially N-methyl-D-aspartate, calmodulin and other calcium-containing intracellular messengers, to mention but a few, were described in relation to plasticity. Regretfully, none was mentioned by the author.

In the first lecture, the author points out the usefulness of the concept of neural Darwinism, describing the fact that many more neurons and neural connections were originally created than what eventually remains after a selective atrophy weeds out the less viable ones. But in discussing brain maps, the author restricts his information to the ultimate, the cortical brain maps, and does not take notice of the fact that the neural connections also have subcortical topographic representations, subcortical maps, if you will. The lecture concentrates on rat studies that may have only a remote significance for the human brain. The author rightly points out that the important areas are over-represented in the map.

The second lecture deeds with the modularity of the brain, that is, with the vertical columnar pattern of the cortical histology. Although the reason for this modularity remains a puzzle, the author states that it contributes to the understanding of the complexity of the neural circuitry, partly because its number can be counted exactly. He alludes to the work of Hubel and Wiesel, along with the notable contribution of Montcastle, that both contributed significantly to the understanding of the cortical columnarity.

The third lecture is on trophic interactions, synaptogenesis and trophic signals. Since permanent synaptic alterations represent the essence of learning, one would have expected that the meaningful contributions of Eric Kandell or Garry Lynch would be at least briefly recognized. Unfortunately, this was not the case. While the subject of neural sprouting was clearly elaborated, the role of the nerve growth factor was discussed only briefly. No other substances, so important in the trophic interactions, were noted.

The subject of the last lecture was the role of electrical activity in the growth of the brain and in neural development. The author elaborates on the hippocampal long-term potentiation (LTP) and glutamate that are involved in short-term memory, and somewhat repeatedly discusses Hubel and Wiesel’s studies. I missed at least a reference to the hippocampal theta (learning) waves that would have fit well in this presentation. In none of the four lectures is any mention made of neurotransmitters, neuromodulators or receptors. The time limit on these lectures is the reason for this disappointing omission.

Effective Use of Group Therapy in Managed Care

Effective Use of Group Therapy in Managed Care

K. Roy MacKenzie

Washington DC: American Psychiatric Press, 182 pp., 1994.

Managed care is clearly an area of current and growing concern for psychiatrists. Even in jurisdictions where managed care itself is not currently part of the practice climate, the containment of cost and measurement of efficacy of treatments are central to health care planning. In some ways it is surprising that a book like this has not appeared earlier, as the face validity of group therapy as a cost containment measure seems obvious.

This book is one of the American Psychiatric Press’ Clinical Practice Series and, hence, is a relatively succinct outline of both the potential role of group therapy in managed care systems, and some of the possible forms that such treatment systems may take. Thus, the book includes chapters on the rationale for group psychotherapy in managed care and an overview of managed care and competition. It also includes several chapters on various forms of group therapy systems that have been devised for such varying clinical populations as the seriously mentally ill, personality disordered patients, depressed patients and individuals who have experienced loss. There is, however, nothing dealing specifically with patients at either end of the age spectrum — children and adolescents, or the elderly.

The book draws on contributions from an impressive group of authors, and is, therefore, able to reflect in many ways the state of the art in group therapy systems. The editor, Dr. Roy MacKenzie, is an experienced and well-known group therapist who has worked in both Canada and the United States, giving him a useful perspective on managed care. The other authors include such highly respected names as Dr. William Piper, Dr. Howard Kibel and Dr. Walter Stone.

The strength of the book and its greatest value lies in its ability to challenge the reader to think creatively about service delivery in psychiatry and psychotherapy. Anyone who is looking at the issue of providing effective and efficient psychotherapeutic interventions for a patient population would be well-advised to consult this book, both for its usefulness in presenting what has been done and, hence, stimulating one to think creatively about service delivery, and for the ways that several of the authors have attempted to measure the effectiveness of their work. If one is thinking of setting up a new treatment system or trying to assess the effectiveness of an ongoing psychotherapy service, the chapters in this book provide useful models.

Despite its claim on the cover to “provide a solid understanding of how group programs work,” this book is not a textbook of group therapy. It will not help someone learn how to provide effective group therapy. It will instead help an experienced therapist expand his or her horizons. It is not an extensive examination of the technique, but rather an excellent overview of the possibilities of group therapy.

Group psychotherapy is frequently treated as the poor cousin of individual psychotherapy. MacKenzie’s book goes some way to show that group therapy may, in fact, have an extremely important role to play in the future, as we are increasingly forced to examine the efficiency and effectiveness of our treatments in psychiatry.