Archive for November, 2009

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Swinson RP, Antony MM, Rachman S, Richter MA, editors

New York: The Guilford Press; 1998. 478 pp with index

ISBN 1-57230-335-2 (cloth)

This book, as its subtitle indicates, sets out to review all aspects of obsessive-compulsive disorder. It is comprehensive, consisting of 18 chapters by 41 contributors, and is divided into 3 major sections. The first is on psycho-pathology and theoretical perspectives, the second on assessment and treatment, and the third on obsessive-compulsive spectrum disorders.

There is also a 6-page appendix of information on national organizations concerned with obsessive-compulsive disorder, anxiety disorders, and obsessive-compulsive spectrum disorders, both in and outside North America, as well as supplementary material intended for both the public and professionals.

The writing is consistent and clear, a tribute to the authors and the 4 editors — 2 of whom are psychiatrists and 2 psychologists. Each chapter is followed by a list of references that includes both those of historical interest and those that are refreshingly current, published as recently as 1998.

The first part, on psychopathology and theoretical perspectives, both psychological and biological, constitutes about half the book.

The presentations in this section are balanced and critical. The evidence in support of prevailing hypotheses is mainly from controlled studies, with suggestive evidence from case reports and clinical experience. Areas of uncertainty in theorizing about obsessive-compulsive disorder are clearly indicated, and arguments favouring or opposing prevailing theoretical positions are clearly set out.

Chapter 4 contains an intriguing discussion of the comorbidity of obsessive-compulsive disorder with various personality disorders and a preliminary consideration of possible subtypes of obsessive-compulsive disorder. The effect on the patient’s family is dealt with as well.

Chapter 9 mentions that resistance to obsessive thoughts and compulsive acts is not always found. To my knowledge, a paper by British psychiatrist Valerie Walker1 was the first to report this in the literature, but she is not given credit.

Discussion of the relation between obsessive-compulsive disorder and generalized anxiety disorder includes a description of worry, but does not include worries about possible but highly improbably occurrences (as one patient termed it, “the what ifs”).

Chapters 10 to 15 include a critical review of the instruments useful in establishing the diagnosis and a helpful section, in chapter 10, on clinical considerations. Both psychosocial and biological treatments are discussed thoroughly. The sections on clinical applications of treatment will be especially helpful to practitioners.

Chapter 16 covers comprehensively the subject of obsessive-compulsive disorder in children and adolescents, and chapters 17 and 18 deal with the subject of obsessive-compulsive spectrum disorders, including screening questions for patients and useful assessment instruments.

This is an excellent book. It contains a critical discussion of controversial issues, a challenge to our current classification of obsessive-compulsive disorder as an anxiety disorder, and evidence that obsessive-compulsive disorder is not a homogeneous disease entity — which should lead to more effective treatments.

I recommend it highly to all personnel who care for patients with mental disorders.

Obsessive-Compulsive Disorder: The Facts

Obsessive-Compulsive Disorder: The Facts, 2nd edition

de Silva P, Rachman S

New York: Oxford University Press; 1998.141 pp with index

ISBN 0-19-262860-7 (paper)

This is a small book — only 141 pages in its second edition — and part of a series on a number of medical topics entitled “The Facts.” Other topics in this series include alcoholism, asthma, cancer, eating disorders, and kidney failure.

The authors are both psychologists who are well known to psychiatry and have extensive experience in the area of anxiety disorders, including obsessive-compulsive disorder.

The book is intended as an information source for patients who have obsessive-compulsive disorder and their families and friends, but it would also be very useful for workers in health care who need to have an overview of this disorder but are not directly involved in assessment and treatment. It would also be useful for family practitioners as a quick read.

The first chapter describes the classification of anxiety disorders and the diagnostic criteria used for obsessive-compulsive disorder. Unfortunately, the authors use the terms “neurotic disorder” and “neuroses,” which have many negative connotations and have not been used in the Diagnostic and Statistical Manual of Mental Disorders for many years. Beyond this initial bad start, the chapter goes on to include an excellent description of obsessions and compulsions with great attention to detail — explaining covert compulsions, resistance, distress and interference. Obsessions and compulsions of everyday life are also discussed. The detail reflects the authors’ behaviouristic background and would be extremely helpful for a patient and family when first engaging in cognitive behavioural therapy.

Subsequent chapters continue with a good description of clinical phenomena, including the relation of obsessive-compulsive disorder to other psychiatric disorders and the various ways obsessive-compulsive disorder can present, illustrated with several clinical vignettes. The impact on family, prevalence rates and cultural factors are also included.

Even considering the main purpose of the book, the section on etiology is very brief and superficial. The description of the psychoanalytic view of obsessive-compulsive disorder could have been deleted, as this is only of historical interest and could be confusing to a lay reader. More detail regarding the biological aspects of obsessive-compulsive disorder should have been included, as well as some information on how obsessive-compulsive disorder can be seen from an evolutionary perspective. This would have been helpful in easing the guilt that patients and family often have about the role they feel they may have played in the development of the illness.

The chapter on treatment heavily emphasizes behavioural therapy, reflecting the clinical background of the authors. Although this provides patients and families with information on an aspect of treatment that will require their active involvement, the brief discussion of drug treatments does not provide enough information and also implies that pharmacotherapy is a secondary aspect of treatment.

The penultimate chapter on assessment only briefly mentions the Yale Brown Obsessive Compulsive Scale, which is the one most commonly used in Canada, whereas it includes the complete Maudsley Obsessional Compulsive Inventory, which is useful but is not widely used. The Leyton Obsessional Inventory, also mentioned, is never used. All of this may serve to confuse patients who may see the book as authoritative and then wonder why these scales are absent from their assessment and treatment.

The final chapter on practical advice is good. However, the list of helpful organizations at the back of the book is very incomplete with respect to Canada; only 3 addresses from 3 provinces in eastern Canada are listed!

In conclusion, the book has some of the facts on obsessive-compulsive disorder, but not all. The description of clinical phenomena is excellent. The inclusion of a discussion of obsessive-compulsive disorder and pregnancy would have been useful, as would a treatment flow chart with more emphasis on biological treatment. Also, since the majority of cases of obsessive-compulsive disorder begin in childhood or early adolescence, a separate section on this area would have been useful. Such a section should include some comments on the known association between group A P-hemolytic streptococcal throat infections and the acute onset of obsessive-compulsive disorder in some cases.

This book is not the best self-help book for patients in Canada. There are others available that have more complete lists of helpful addresses and are more compatible with the clinical approach a Canadian psychiatrist would most likely take with respect to treatment. The suggested price of $28.50 also makes the book quite expensive, considering the small size and soft-cover format.

The strengths of the book are that it is well written, well organized and easy to read.

Emergencies in Mental Health Practice: Evaluation and Management

Emergencies in Mental Health Practice: Evaluation and Management

Kleespies PM, editor

New York, The Guilford Press; 1998. 450 pp

ISBN 1-57230-255-0 (cloth)

In the introduction to this book, the editor points out that most training sites for psychology interns provide limited or no training at all in emergency psychological services, reflecting a general inattention to such services in the field of professional psychology. However, the editor suggests, if clinicians are to regard themselves as independent practitioners, they must be prepared to assist patients in the event of a life-threatening behaviour or a psychological emergency, whether in the office, the emergency department or elsewhere. Referring to psychiatry as a paradigm, he recommends that mental health disciplines incorporate training in the management of emergencies as a professional requirement. For the purpose of such training, the editor offers the structure of this book as “a proposed curriculum for a knowledge base in emergency psychological services/’ The book is structured into 6 parts consisting of 19 chapters. Most of the chapters have been written from the perspective of the mental health professional who must evaluate and manage a behavioural emergency in the emergency department or, occasionally, in another setting. Some of these chapters are excellent, offering useful and practical advice. This is especially true of the chapters on emergency interviews, evaluation and management of suicidal patients and potentially violent patients, and emergency telephone calls. The 2 chapters on risk management offer helpful reminders of the importance of consultation and proper documentation in dealing with suicidal or violent patients. A laudable feature, not found in other comparable books, is the devotion of 3 chapters to the stressful impact on the clinician of patient suicidal behaviour, violent behaviour and disaster. The weaknesses of the book are likely the result of the large number of contributors — 33 in all — with 2 to 5 authors in 15 of the 19 chapters. There is duplication between chapters, the writing style is variable, and even the perspective from which the chapters are written differs. For instance, the last chapter is written from the point of view of the psychologist. The entire Part 5, consisting of nearly 100 pages, is not about emergencies but about syndrome psychiatry and pharmacotherapy, which are best covered in a traditional text-book. Inconsistencies also occur. A notable example is that considerable effort is expended in the first 2 chapters to distinguish “crisis” and “crisis intervention” from “psychological emergency” and “emergency intervention,” and to dissuade the reader from using these terms interchangeably. However, in chapters 3, 4 and 6, either these terms are used interchangeably or new definitions are given. Some chapters would benefit from increased succinctness and decreased preoccupation with referencing every statement.

The inspiration for this book came from the editor’s considerable clinical and supervisory work with psychology interns in emergencies at the Boston Veteran Affairs Medical Center. The editor and the chapters’ authors, most of whom are psychologists, have created a book that will serve well psychology interns, their supervisors, and students and staff of other mental health professions in the evaluation and management of emergencies in mental health practice. I hope that this book will be a catalyst for increased training in this important but rather neglected field of mental health practice.

The Neuron: Cell and Molecular Biology

The Neuron: Cell and Molecular Biology, 2nd edition

Levitan IB, Kaczmarek LK

New York: Oxford University Press; 1997. 543 pp with index

ISBN 0-19-510021-2 (paper)

ISBN 0-19-510020-4 (cloth)

This book was first published in 1990, when it was received with a great deal of enthusiasm. The preface to the current edition is dated the summer of 1996 and the copyright date is 1997. In the field of neuroscience, where knowledge is growing exponentially over time, it is important to keep this perspective when reviewing a book.

The book covers all the major fields of learning within the neurosciences, and in a short text that can only afford space for the essentials, it succeeds beautifully, providing knowledge that both experts and novices can benefit from. The sequence by which the information is presented to the reader is logical and incremental. Thus, the reader learns first the electrical properties of neurons. This section allows the authors to present current knowledge regarding ion channels, membrane currents and action potentials. The book then moves onto the basics of cell-to-cell communication, describing synaptic function and how neurotransmitters interact with receptors, leading to both direct and indirect transfer of cellular information. The important concept of neuromodulation is well described in Chapter 12. With this knowledge base, the reader is then invited to tackle the rivetting section on Behaviour and Plasticity, where the building blocks reviewed earlier are used to describe how neurons grow and differentiate, how axons find their targets, and how learning occurs and memories form.

The format of each chapter is ideally suited for easy, enjoyable and almost effortless learning. A section starts with an introductory statement that positions the chapters in that section within the context of what has preceded and what will follow. Each chapter is then introduced, sometimes with a specific example, and other times with a general contextual description. Each chapter is nicely laid out, with many figures that not only illustrate concepts presented in the text, but rapidly become a strong distinguishing feature of this textbook’s high quality. The text emphasizes the important core messages of the chapter, and these are finally driven home by a summary section. At the end of the book, a bibliography section gives a list of recommended readings for each chapter, allowing the reader to return to source materials or to push knowledge of a particular area more deeply.

This is a wonderful book. It is alternately a textbook to be read cover-to-cover by graduate and undergraduate students of neuroscience; a reference text for those who are more advanced but need to refresh their memories about certain aspects of neuroscience; and a source of easily digestible new knowledge for those who need to learn about the advances in this field. Perhaps a reflection of how fast the field is moving, the book already appears ready for another edition! Programmed cell death, for instance, now a very competitive field of research work and new knowledge in the neurosciences, occupies slightly more than 1 page of text. Thus, an opportunity is sadly missed to inform the reader about not only the enormous influence this new field of understanding is having on current neuroscientific thinking, but also its relevance to neurodegenerative disease. There is, however, an excellent section on the neurotrophins, their actions, and the receptors they work through.

The book has some interesting peculiarities. I could not find anything at all about the authors from the book itself. They are, of course, known to us through their own extensive publications and eminent work, particularly on calcium and potassium channels. It would have been helpful to have an “About the Authors” section. This is especially true since the authors are experts in neurophysiology, and the general neurophysiological bias of the book is explained in the preface to the first edition, where the authors state that the text reflects their own training, research interests and biases. Perhaps for the next edition, which I would hope is imminent, the authors could invite the collaboration of a molecular neuroscientist who can round out the book with her or his own biases and interests.

The copy editing is no better or worse in this book than in any text that depends on the inadequate skills of computerized text management. For example, in the preface to the first edition, “form” is found where “from” was needed, and since that text dates from October 1990, it is a surprise that the mistake was not caught in this edition (or was it left there intentionally for authenticity purposes?). Another minor error is found on page 343, line 7, where the word “to” is missing. Finally, despite my admiration for the judicious and appropriate use of figures in this text, not all of the figures are helpful. For example, Figure 16-3 is spread over 2 pages, yet does not add much to the text. In addition, the word TOP is introduced in the legend to that figure, but does not show up in the figure itself and is defined in the text only 2 pages later.

In summary, this is a superbly written and well-illustrated text covering all the major aspects of neuroscientific knowledge, albeit with an understandable emphasis on neurophysiology. Regardless of the state of knowledge or the specific expertise of the reader, every neuroscientist should keep a copy handy.

Acute Stroke Treatment

Acute Stroke Treatment

Bogovsslavsky J, editor

London (UK): Martin Dunitz; 1997. 304 pp with index

ISBN 1-85317-413-0 (cloth)

Few fields in medicine are undergoing a greater shift from despair to hope than stroke therapy. As the editor points out, the title of the book itself — Acute Stroke Treatment — would have been taken as a bad joke even just a few years ago. So what has changed? First, there is converging evidence of a therapeutic window between the onset of the neurological deficit and intervention. Second, stroke units have been demonstrated to be effective in reducing mortality, morbidity and length of hospital stay. Third, a US National Institutes of Health study has demonstrated that, if tissue plasminogen activator is given within 3 hours of a stroke in selected patients, 12% of them will have minimal or no neurological deficits compared with control patients.

This book addresses all the relevant areas of acute stroke treatment. It begins with a thoughtful overview of acute stroke management from around the world by Stephen M. Davis and colleagues, and continues with practical chapters on clinical, imaging, ultrasonography and cardiac evaluations. Chapters by Kogure and associates, and by Dolkara and Moskowitz, identify the experimental evidence for therapeutic targets for clinical stroke. Separate chapters address intensive care treatment of ischemic stroke, thrombolysis neuroprotection, gene therapy and surgery. Lawrence M. Brass contributes a conceptually valuable chapter on “Ideal Trials for Acute Stroke/’ and the book concludes with chapters on the treatment of intracerebral hemorrhage, subarachnoid hemorrhage, prophylactic neuroprotection for pretreatment of brain infarction and prevention of early recurrent stroke.

All the senior contributors to the chapters are recognized experts in their fields, and the emphasis is on clarity and pragmatism, a compliment to the editor. An obvious objection to a book such as this is that the field is moving so rapidly that many items in this book are already obsolete. However, concepts, approaches and basic knowledge do not change as quickly. Moreover, if there is a major advance, you will be sure to read it, hear it, or see it on the news. Even if you miss it, your patients will tell you about it. As a practical, comprehensive, yet succinct book, it can be highly recommended to all those dealing with acute stroke.

Schizotypy: Implications for Illness and Health

Schizotypy: Implications for Illness and Health

Claridge G, editor

New York: Oxford University Press; 1997. 340 pp with index

ISBN 0-19-852353-X (cloth)

Psychiatrists and psychologists start from a different place. Given their medical background, psychiatrists tend to emphasize the dichotomy between health and illness. Moreover, classifications of mental disorders, such as the various editions of the Diagnostic and Statistical Manual of Mental Disorders, are taken to imply that psychiatric illnesses, like medical conditions, are distinct entities with unique etiologies.

Yet a great deal of evidence indicates that psychiatric diagnoses are very fuzzy indeed. In fact, the phenomenon of “comorbidity,” which is the focus of many research studies, may be nothing but a reflection of the failure of the categorical system to describe psychopathology adequately.

Psychologists, who study normality and variation from it, are much more inclined to see health and illness as continuous. Since the editor (a professor at Oxford University) and most of the contributing authors of this book are psychologists, it is not surprising that this volume takes a strongly dimensional view of psychopathology. “Schizotypy” — the focus of this book — can be conceptualized as a set of traits that form the basis of a variety of illnesses, ranging from schizophrenia to personality disorders, as well as of normal variations in personality that can produce eccentricity or creativity.

Two issues arising from this theory are of particular interest to psychiatrists. First, some evidence suggests that both forms of psychosis originally described by Kraepelin (i.e., schizophrenia and bipolar disorder) could lie on a single dimension, and may not be as separate as we often assume. Second, disorders not usually considered to reflect schizotypal traits, such as obsessive-compulsive disorder and dyslexia, may reflect the same psychopathologic dimension — at least in part.

Several chapters in the book raise questions of broader theoretical significance. There are excellent reviews of research on cognitive processes and cerebral lateralization in schizotypy. Other chapters concern the measurement of schizotypal traits. Finally, there is a whole section entitled “schizotypy in health subjects.”

This book has strengths and weaknesses. Since all chapters are written by Claridge and his collaborating colleagues, the text is much more coherent than many multi-author books. On the other hand, research conducted outside of Great Britain is not given enough weight. Although Claridge suggests that readers also consult a recent companion volume based on a conference on schizotypal personality, the contributions of investigators such as Holzman and Siever and Davis could have been given much more space.

Claridge’s strong editing leads to a relatively high standard of scientific writing throughout. Inevitably, however, some of the chapters are hard-going, while those written by the editor himself are the best. Claridge is a natural writer and communicates in an incisive and witty way that quickly engages the reader.

I was particularly stimulated by Claridge’s ideas about how to conceptualize psychopathology in a dimensional system. The point of view is refreshingly different from the perceived wisdom in North America. These principles are also developed in several of the chapters written by neuropsychologists.

Although I agree strongly with the general approach of this book, it lacks breadth. It fails to address some of the most crucial areas for theory, most particularly genetics and neurobiology. I also found myself less than sympathetic toward the chapters on normal schizotypy, some of which come dangerously close to reviving the Laingian romanticism of the 1960s.

A related objection concerns the emphasis in many chapters on the role of psychosocial factors in the etiology of schizophrenia and related disorders. I agree with Claridge that psychiatrists are often too busy prescribing medication to consider individual differences in the psychology of their patients, and that cognitive therapy may well have a role in the treatment of psychosis. However, his views on the role of the environment can be somewhat quirky, most particularly his somewhat dogmatic idea that trauma and bad parenting are the major factors that determine whether traits develop into disorders.

With these caveats, I found this book highly original and extremely thought-provoking. Researchers studying disorders related to schizotypy will find it a useful reference, and clinicians and clinician-teachers will benefit from reading the theoretical chapters. The main impediment to the wide use of this volume is the price, which, whatever the state of the Canadian dollar, is much higher than for books imported from our southern neighbour.

Psychiatric Comorbidity in Epilepsy

Psychiatric Comorbidity in Epilepsy: Basic Mechanisms, Diagnosis, and Treatment

H. Mc-Connell, Peter J. Snyder, editors

Washington (DC): American Psychiatric Press; 1998

ISBN 0-88048-853-0 (hardcover)

There is a fascinating and complex interrelation between psychiatric pathology and epilepsy. Historically, epilepsy was known as the “sacred” disease because of its alleged association with astrology, with the divine, and with demoniacal possession. Despite Hippocrates’ assertion that epilepsy “is no more divine nor more sacred than other diseases, but has a natural cause like other diseases,” these misconceptions continued until well into the 19th century, when the neuropathologic origins of epilepsy were identified.

However, the association between epilepsy and psychiatric illness did not cease when it was identified as a neurologic condition. People with epilepsy have an increased prevalence of both affective and schizophreniform disorders. Personality and adjustment disorders are common and seizures may be simulated by conversion states. Epilepsy also has profound socioeconomic implications for the sufferer. It is perhaps therefore the “psychosomatic” illness par excellence.

This book is a compendium of the psychiatric conditions associated with epilepsy. Its 12 chapters cover the historic, physiologic, pathologic, clinical and social aspects of epilepsy. There is an excellent chapter on the changing systems of classification of the epilepsies; the current international classification bears little resemblance to the systems used even 50 years ago. The advent of sophisticated investigative techniques for studying neuronal activity, such as EEG recordings and neuroimaging, has given this system a firm neuroanatomical basis, and has helped to integrate the neuroanatomical changes with the clinical seizure pattern.

There are excellent chapters on the neuropsychological assessment of patients with seizures, and on the mood disorders and psychoses associated with epilepsy. The latter chapter is of particular interest because recent developments have shown that there are lesions in the medial temporal structures of the brain in both epilepsy and schizophrenia. This etiologic overlap may explain not only the increased prevalence of schizophreniform psychoses in patients with epilepsy, but also suggests that there may be a neurophysiologic overlap at the neurotransmitter level between these seemingly disparate conditions.

Perhaps the 2 most useful chapters in the book are those on pharmacology. One reviews the behavioural effects of antiepileptic drugs, the other discusses the treatment of psychiatric disorders in patients with epilepsy. They provide an excellent state-of-the-art summary of the pharmacology of epilepsy and give many practical suggestions about the use of psychotropic agents and their effects on seizure threshold.

The book ends with 2 chapters on the “social” part of biopsychosocial aspect of epilepsy: one on family systems theory and the other, written by a man with epilepsy, entitled “Living with Epilepsy.” The latter is of special interest because the experiences he describes and the problems he raises are not dealt with elsewhere in the book. For example, he describes memory dysfunction, post ictal pain, social rejection and communication difficulties with his neurologists — experiences that are surely not unique to people with epilepsy. It would have rounded out the book if these consumer-driven issues had been dealt with in the clinical sections.

There are weaknesses in the book. The history of epilepsy is long and colourful and it is unfortunate that it is described here in a trite and cliche-ridden way. The chapter on diagnosis and treatment of nonepileptic seizures was superficial and unhelpful. It is puzzling why such seizures should be described in negative language when acceptable terms such as “conversion” or even “hysterical” seizures are available.

On the whole, however, this is a comprehensive, well structured and well referenced book. Each chapter ends with a conclusion that summarizes the main points in that chapter. I was very glad also to see

a uniform and consistent use of the term “people with epilepsy” rather than “epileptic” throughout the book. The word “epileptic” brands the sufferer in a pejorative manner and reinforces the very stigma we try to avoid. If only psychiatrists would similarly use the term “people with schizophrenia” rather than “schizophrenics”!

This book is highly recommended to psychiatrists, neurologists, neuropsychologists and others who see people with epilepsy in their practice.

Women’s Health: Hormones, Emotions and Behavior

Women’s Health: Hormones, Emotions and Behavior

Regina C. Casper, editor

Cambridge (UK): Cambridge University Press; 1998. 328 pp

ISBN: 0-52156-341-0 (hardcover)

Cambridge University Press has initiated a very useful series of clinical texts in the area of psychiatry and medicine. The editorial board of this series is to be congratulated for its selection of books and for its uniformly high standard of publication. This book is no exception. It is a “must read” for all mental health professionals, both women and men.

Women’s Health: Hormones, Emotions and Behavior is well written and informative, but not overly detailed. It covers the important areas and keeps the reader’s attention throughout. Women’s health has become a popular topic and there has been a recent spate of books in this area. This is the best one. Although it is multi-authored, the editor has kept a strict rein on the contributors, has participated actively in each of the chapters and has ensured a high level of readability, comprehensiveness and up-to-date thinking on a common theme.

She has done what is very difficult to do — she has interwoven highly sophisticated neuroendocrine and neuropharmacological information and recent thinking about the impact of roles, functions, supports and losses in women’s lives so seamlessly that perspectives from many different fields are integrated into a complex framework. The readership will emerge not only with knowledge but also with wisdom.

The field of women’s health is evolving so quickly that the book is already a little out of date. The discovery of a second estrogen receptor and of several ways in which selective estrogen receptor antagonists affect and protect different body tissues all promise new insights and new therapies. The role of estrogens in Alzheimer’s disease is attracting new attention. Our increasing awareness of autosomal differences between the sexes, and of immune differences, will incrementally contribute to this field. As all this happens, women’s (and men’s) roles will change and diversify, and will no doubt induce hormonal and neurotransmitter changes, which perhaps will stand all the old findings on their heads. As we have recently learned, the expansion of the universe we inhabit is accelerating. So is knowledge in this field of study. This is a book we should all read to try to keep up.

Electroconvulsive Therapy

Electroconvulsive Therapy, 3rd Edition

Richard Abrams

New York: Oxford University Press; 1997. 382 pp

ISBN 0-19-510944-9

The dust jacket describes this textbook on electroconvulsive therapy (ECT) as “indispensable.” I agree. Now in its third edition, this book is unique in the field. It is written entirely by the author — a practising clinician with expertise in ECT, a scholar (this book has 73 pages of references; about 125 references have been added since the second edition in 1992) and a researcher whose contribution to the scientific literature goes back more than 30 years. Written in an engaging style, this book reflects the author’s intimate knowledge of an indispensable psychiatric treatment.

The chapter headings are the same as those in the second edition, but new material has been incorporated throughout (sometimes with new subheadings). The result is a refined and up-to-date disquisition on a complex and multifaceted subject. I recommend it for psychiatrists — particularly those who prescribe or administer ECT, for residents, for clinical psychologists and for anyone else with clinical or research interests in ECT. Supplemented by some recent research papers, this book would provide an ideal structure on which to base a course on ECT for residents. With such a knowledge base complementing supervised experience in the administration of ECT, a trainee would quickly acquire the expertise needed to deliver ECT.

Despite the favourable overall impression the book makes, there are some minor points with which one might reasonably take issue. For example, the advice to use ECT before drugs to treat pregnant women (page 29) seems unbalanced, especially in view of recent studies showing the safety of a number of medications, even during the first trimester. Although there is certainly a place for the use of ECT during pregnancy, there is also a place for the judicious use of psychoactive medication. Another point of contention is the statement that “despite manufacturers’ claims, no significant progress in the pharmacological treatment of major depression has occurred since the introduction of imipramine in 1958″ (page 9), which is made to support the continued use of ECT. In fact, there has been considerable progress in this area, and indeed the author does go on to mention lithium augmentation of tricyclic antidepressants (page 16). This style of making strong, unequivocal statements at least lets the reader know where the author stands and should, in fact, make it easier for critical readers to draw their own conclusions.

The book begins with the history of ECT and then reviews studies on efficacy, including those employing a sham ECT control group. The third chapter deals with predictors of successful outcome, and the fourth reviews the physiology of ECT. A later chapter on the high-risk patient will be very useful to practitioners considering ECT for severely depressed patients who have had a recent stroke, myocardial infarction or other serious medical problem, and who may also be on more than one medication. This chapter, supplemented by a MEDLINE search, will help the clinician make the best treatment decision in such cases.

There is a chapter devoted to the ECT stimulus, a critical variable affecting the response to treatment. Another chapter reviews the issue of unilateral treatment. The author concludes that high-dose (i.e., several times seizure threshold) right unilateral ECT should generally be the method of choice, at least initially. This recommendation may indeed improve the general standard of ECT, but the practitioner should also consider alternative electrode placements and levels of stimulation. Some patients may receive excessive doses with the high-dose unilateral approach. Of course this is an evolving area, and clinicians administering ECT must be aware of the issues regarding electrode placement and stimulus level when they make treatment decisions. They must also take into account side effects and clinical response as the series of ECT progresses.

Two chapters comprehensively cover the technique of ECT, and another covers the issue of memory and cognitive functioning after ECT (and contains descriptions of the important studies in the area). In the chapter on neurochemical correlates, Dr. Abrams concludes that “modern ECT researchers, regardless of their species of predilection, do not have any more of a clue about the relation between brain biological events and treatment response in ECT than they did when the first edition of this book was published — which is to say, none at all. Moreover, modern theories of the action of ECT — even as formulated by sophisticated investigators with impeccable credentials — have not surpassed in conceptual elegance the 18th century claim that things burned because they contained phlogiston; “ECT awaits its Lavoisier” (page 268). Thus there is plenty of scope for further research, but new researchers would be wise to understand the history of basic research in this field, particularly animal-based research, before embarking on their own.

The last chapter is on patients’ attitudes, legal-regulatory issues and informed consent. It is of interest that the history of ECT regulation in the US includes a 1982 ordinance, approved in a referendum by the citizens of Berkeley, California, that made the administration of ECT in city hospitals a crime punishable by a fine, 6 months in prison, or both! (The regulation was later reversed by a court decision on a technical point of law.) ECT continues to be a controversial treatment, despite its safety and proven efficacy. Perhaps because of its safety, ECT is surprisingly unlikely to result in malpractice claims. The best protection against the minimal risk of complaints or litigation is good clinical practice and fully informed consent. A sample consent form is presented in the appendix.

Much refined over the years, ECT will continue to be an important part of our therapeutic armamentarium in the foreseeable future. Apart from the mechanism of action of ECT, which remains an intriguing mystery, other promising areas for research include magneto-convulsive therapy (with induction of electrical currents by magnetic fields), new approaches to the control of ECT-induced increases in pulse and blood pressure, effects of bifrontal ECT on autobiographical memory, maintenance ECT (which appears to be increasingly prescribed) and stimulus variables.

This comprehensive review of a complex and sometimes controversial topic by one of the leading researchers in the field is highly recommended for both the clinician and researcher.

Thérapie brève et intervention de réseau

Thérapie brève et intervention de réseau: une approche intégrée

Jérôme Guay

Montréal : Les Presses de l’Université de Montréal; 1992. 189 pp

ISBN 2-7606-1556-1 (papier)

L’auteur de ce livre de base souligne l’importance de la multidisci-plinarité pour traiter les personnes souffrant de troubles psychiques en pointant les interventions psychosociales comme composante indispensable des soins aux malades.

Dans le premier chapitre, il affirme que la psychothérapie est seulement efficace pour régler des problèmes mineurs. Malheureusement, ses références sont limitées et datent de plus de 10 ans. Au cours de la dernière décennie, de nombreuses études de recherche ont prouvé l’efficacité de la psychothérapie brève (thérapie cogni-tive du comportement, psychothérapie interpersonnelle et dynamique) pour des troubles mentaux sérieux.1 La psychothérapie à long terme, la psychothérapie de groupe et l’hospitalisation à temps partiel sont essentielles pour les patients souffrant de troubles psychopathologiques plus sévères qui manquent de soutien social.

L’auteur identifie les compétences essentielles du thérapeute pour améliorer l’alliance thérapeutique, p.ex., se montrer sincèrement intéressé, écouter et avoir de l’empathie envers les patients. Les principes de base de la psychothérapie sont abordés. Cependant, l’auteur a omis de définir clairement des concepts principaux, comme la résistance, le transfert et le contre-transfert. L’importance de garder des «limites» à l’intérieur de la relation thérapeutique est décrite brièvement mais elle n’est pas expliquée. Cela est inquiétant, compte tenu que la violation des limites est plus souvent initiée par le thérapeute et qu’elle cause des dommages psychologiques aux patients.

Le deuxième chapitre renferme un guide d’évaluation avec des questions utiles pour évaluer le degré de motivation du patient, le type de crise, la stratégie d’adaptation, les aspirations et le réseau de soutien. L’auteur, qui mène un rôle actif dans la promotion des programmes communautaires, souligne l’utilité de rencontrer les membres de la famille et les amis qui constituent le réseau de soutien social du patient. Cinq types de thérapie sont résumés. Parmi les faiblesses dans ce chapitre, je remarque l’absence d’une évaluation de la force du Moi, qui est un outil utile pour déterminer les contre-indications pour des psychothérapies brèves. De plus, à l’intérieur du guide d’évaluation, on ne fait pas mention du besoin d’éliminer les troubles médicaux qui peuvent simuler et (ou) compliquer des symptômes psychologiques. L’auteur n’a également pas abordé l’importance d’un renvoi à un psychiatre pour les patients qui ont besoin de phar-macothérapie pour traiter des symptômes graves.

Les troisième et quatrième chapitres sont intéressants et ils atteignent vraiment les objectifs fixés par l’auteur. Il encourage les praticiens à développer une confiance dans la pratique d’interventions psychosociales. Il élabore sur les jumelages entraidants, les groupes d’entraide, les groupes communautaires et d’autres ressources précieuses. L’annexe comprend des tableaux détaillés, des diagrammes et des questions qui sont pratiques et bien organisés.

Ce livre facile à lire est une bonne introduction pour les professionnels de la santé qui sont intéressés à connaître les évaluations et les interventions psychosociales. Les lacunes principales de ce livre sont l’absence de concepts essentiels de psychothérapie et le manque d’explication sur le moment opportun pour envoyer un patient recevoir des consultations médicales et (ou) psychiatriques.

J’apprécie le commentaire de l’auteur affirmant que la pratique de la psychothérapie requiert une formation clinique. Toutefois, en tant que psychiatre spécialisé en psychothérapie psychodynamique, je crois que nous devons maintenir les normes sociales et morales, chercher à obtenir la supervision d’experts qualifiés et obtenir beaucoup plus que deux ans d’expérience clinique. La compétence clinique est essentielle et fondamentale à la pratique de la psychothérapie.