Archive for December, 2009

Assessment Scales in Old Age Psychiatry

Assessment Scales in Old Age Psychiatry

Burns A, Lawlor B, Craig S, editors

Martin Dunitz Ltd.; 1999. 302 pp. (paper)

ISBN 1-85317-562-5

Being asked to review Assessment Scales in Old Age Psychiatry was like being let loose in a candy store: fun, filled with many new experiences and ultimately vaguely disappointing, although definitely worth the visit.

About 150 diverse instruments are described, including neuropsychological assessments, tests for activities of daily living and quality of life, and tools for assessing depression and delirium. But to keep with the candy analogy, not all of the goodies are what they seem. Sometimes there is only a list of test contents, at other times only a description, and often there is nothing to help digest a complex mouthful.

The layout of this book is appealing. Each scale is described on one page, and the facing page lays out test elements. There is space on every page for notes and annotations; to use this book effectively, cross-referencing and additional notes from one’s own experience are necessary. Each chapter has an introduction that outlines the purpose of that domain of test and reviews the history of old or modified tests. Some analysis is given about which tests might be more useful for certain circumstances and why. The book usually indicates how long a test should take to administer and who is best suited to give it, along with information on how to score tests and what different total scores mean.

Disappointments include the following. Some of the “additional references” are oriented principally towards researchers or those interested in developing new tools, rather than clinicians. There are too few up-to-date references. For example, references are to articles re-evaluating older tools versus newer techniques, information that is essential where tests are unknown or where a choice has to be made between a tried-and-true older tool and a more recent tool. A few of the tools referred to “updated guidelines,” which may score an old test on a new scale, but unfortunately, in at least one instance, the new guidelines are not referenced and there is no example of the newer scale (for example, see Bartel on pages 132-3). One test is described as a “visual analogue” scale, but lacks a visual presentation. Primary sources are missed in a few cases.

Some information is given on the reliability, validity and accuracy of different tools, but the editors have not done a consistent enough job here. As a result, it is difficult for anyone unfamiliar with a test to choose between tools.

The editors excuse some of their lapses in editing in the introduction. However, I cannot accept their excuses. The job of a technical editor should be an arduous one. The editors of this book have not met the many technical requirements of their task and therefore fail their readers.

Despite my many reservations about this book, if you have the time to do your own homework, and the $77.50, it might be a fun addition to your library.

Psychosocial Factors in Pain

Psychosocial Factors in Pain: Critical Perspectives

Gatchel RJ, Turk DC, editors

New York: The Guilford Press; 1999. 510 pp. with index

ISGN 1-57230-285-2

The preface to this book stakes out its claim. We are told that 4 main developments, each involving psychologists, served as the impetus for a revolution in thinking about pain. This revolution consists in the rejection of a “medical model” in favour of a “bio-psychosocial approach.”

The volume comprises 30 chapters. Of these, the first 9 make up Part I, on biopsychosocial context. In Part II 11 chapters deal with special topics and populations, and Part III provides 10 more on issues in prevention and management. The book finishes with an overview on resolution and evolution. Three out of the 43 authors of the 30 chapters are physicians dealing with pain and AIDS (a magnificent review), the epidemiology of low-back pain, and work style and work-related upper extremity disorders. There is an epidemiologist or two, a dentist with qualifications in psychology, and almost all the rest are psychologists dealing with pain. These include 3 Canadians (Gagliese, Katz and Melzack), Flor from Germany, and Main (from Glasgow and now Manchester).

The great bulk of the material reflects the work and views of US psychologists and their special psychosocial context.

This is a long volume, well produced and full of information, often very well worked out. The text itself is easy to read and very solidly written for the most part. Some chapters are excellent in whole or in part, while others seem to exist only to disappoint.

It is an irritating pity that what could have been a superb volume is marred by 2 faults of emphasis. One is needless special pleading and the other is an ill-founded, albeit highly sophisticated, tendency to revise the understanding of what it means to favour a back-pain disability model.

The special pleading begins with the listing of 10 contributors to the psychological approach. Three of these were actually physicians but not identified as such. More important, and tellingly, there is a lack of understanding or recognition that psychosocial factors have always been strong in medicine. Psychologists now dwell in a field long inhabited and not relinquished by internists, family doctors, neurologists, psychiatrists and a host of others.

Psychologists are much more numerous than psychiatrists in the field of pain and have made great contributions, starting with Hebb and Melzack. But some of their contributions (e.g., behavioural therapy of pain) remain controversial, and the field in which they have gained most recognition and added most to the subject appears to be cognitive treatment, which, incidentally, was applied to pain by a psychiatrist, A.T. Beck. Thus, what should have been a friendly and sociable claim to have made a large contribution has been spoiled by exaggeration.

More important, the way in which the biopsychosocial construct is now treated serves to reduce the biological element and to suggest that pain is largely due to psychological causes. I partly made that mistake myself and can sympathize, but the fact is that we have very few genuine indications that pain for which physical explanations are lacking is due to psychological causes except when it occurs with or after the onset of an obvious affective disorder. In other cases, and especially with musculoskeletal pain that arises with questionable indications of psychological difficulty, there is insufficient evidence to support the view that pain is due to vaguely alleged “behavioural factors,” but there is growing evidence from systematic controlled investigations that the determining factor is the state of the facet joints or degeneration (not prolapse) of intervertebral disks.

One of the most insidious practices connected with rejecting the patient’s pain consists in describing correlated information as “predictive.” Every psychologist knows that correlations do not demonstrate a causal link, except when there is a serial position, and should not be thought of as a causal consequence. Yet the insinuating word “prediction” is used repeatedly to corroborate some argument for psychological causation.

I do not want to leave the impression that Gatchel and Turk, as editors, make no attempt to acknowledge evidence that complicates their message. They recognize much of it. However, overall the book states the problems softly when they relate to weaknesses in psychological achievement, and overstates the failures of the organic approach. This is the more distressing because the authors and editors have all made significant contributions in the past, and continue to do so. Unfortunately, as one of my colleagues puts it, those who state their adherence to the biopsychosocial approach most loudly do not appear to be as serious about the “bio-” element.

Biology of Personality Disorders

Biology of Personality Disorders

Annual Review of Psychiatry series

Silk KR. Washington: American Psychiatric Press; 1998. 156 pp

ISBN 0-8804-883-52

This book, part of the Annual Review of Psychiatry series, is a multi-authored text comprising 5 chapters by recognized authorities in the field. The topic is of interest because of the increased activity in the area of personality disorders over the past decade and a half with respect to typology, research and new treatment approaches. This book focuses on research into the biological aspects of personality disorders over the last 10 years or so. As Silk points out in the Foreword, earlier studies of biological correlates of personality disorders did not lead to clear conclusions because of lack of appropriate separation between personality disorders and Axis I disorders. The “second-generation” studies have focused on the core negative traits of personality disorders (e.g., impulsivity, aggression, cognitive disturbances and affective lability, which cut across most personality disorders) and sought to understand their biological underpinnings.

The first 2 chapters of the book review and discuss the biological research in the field, including research strategies employed, the results of some of the most important studies and the implications for further development.

The first chapter, by Coccaro, reviews studies of neurotransmitters that are significant for personality functioning. The most important of these are serotonin and the cate-cholamines, including dopamine and norepinephrine. The studies are reviewed under categorical headings including cerebrospinal fluid (CSF) metabolite studies, pharmacological challenge studies, platelet receptors and DNA in polymorphism studies, etc. The studies consistently find an inverse relation between CSF 5-HIAA levels and impulsive-aggressive behaviour.

There is a smaller body of research into the role of acetylcholine and vasopressin, which shows that acetycholine does contribute to affective lability.

The second chapter, entitled “New Biological Research Strategies for Personality Disorders” by Siever and colleagues, complements the first. It reviews studies using a variety of recently developed strategies to study core traits of impulsivity, affective instability and cognitive dysfunction. The strategies vary from neuroendo-crine and cognitive studies that look at the antecedents of neuroendocrine and cognitive abnormalities found in personality disorders, to the use of imaging (positron-emission tomography, single-photon emission computed tomography, magnetic resonance imaging [MRI] and functional MRI) to study neuroanatomical correlates of personality dysfunctional traits such as impulsivity and aggression. There are fewer studies using candidate gene strategies. The author comments on the implications of the findings to date from these areas of investigation.

A particularly creative strategy was the linking of the study of trauma to personality disorders. Trauma has its biological impact on the hypothalamic-pituitary-adrenal (HPA) axis, but trauma is also a major etiologic factor in many personality disorders, including borderline personality disorder (BPD). Studies of the HPA axis changes, such as dexamethasone suppression test (DST) in patients with post-traumatic stress disorder, have been extended to personality disorders as BPD, with the DST pattern more closely resembling that in PTSD than that in mood disorders.

The third chapter focuses on Cloninger’s proposed 7-f actor model of personality, comprising temperamental factors such as harm avoidance, novelty seeking, reward dependence and persistence, and 3 character elements: self-directedness, cooperativeness and self-transcendence. Cloninger makes the case for the neurobiological basis of learning abilities that underlie temperamental traits by summarizing studies of the psychobiological correlates of these traits. He then puts forward a psychobiological learning model based on his review of the neuropharmacological, neuroanatomical and biochemical studies, and on studies of the phylogeny of learning abilities. He concludes by making a strong argument in support of the 7-factor model as a basis for understanding the various dimensions of personality disorder and even the diagnostic clusters. Although much of the material is quite technical, the use of tables and other visual aids is helpful in summarizing and reinforcing the material presented in the text.

The last 2 chapters are more application-oriented. The fourth chapter, by Links, is interesting because of the proposal of an outcome-based approach to the pharmacotherapy of personality disorders. Outcome indicators would be reduction in certain characteristic behaviour patterns, such as repetitive self-injury, that have been shown to have a biological basis. Other outcome indicators include quality of life. The author notes the shortcomings of the current conceptual models of personality disorder as a basis for developing a treatment rationale. The outcome-based model proposes specifically desirable functional outcomes of treatment and more systematic approaches to assessment of the efficacy of medication. This proposal is very much in keeping with the current evidence-based approach to medical practice.

In the final chapter, Paris assesses the significance of research for a biopsychosocial model of personality disorders. The author points out inconsistencies between theoretical assumptions underlying some research strategies and real-world observations, as well as the many confounding factors that complicate the search for one-to-one correlations between biological variables and particular personality traits. Taking a dimensional view of personality disorders as the pathological amplification of normal traits, the author discusses the complicated interaction of biological and environmental factors in producing personality disorders via the diathesis-stress model. He proposes 3 potential research directions: new drugs targeting personality traits, gene therapy, and new forms of psychotherapy based on better understanding of temperament.

Since much of the research on impulsivity and aggressiveness reviewed is common to conduct disorder and attention deficit hyper-activity disorder as well as anxiety disorders in children, one would have expected a discussion of the relation of these conditions to personality disorders in adults. Despite this lack, I found this book to contain more than anticipated. The material in the first 3 chapters was detailed and informative, and the last 2 chapters helped to make it practically relevant. One is left with a feeling that personality disorders are now more real, and that there is hope for more targeted treatment in the future. I certainly recommend it.

John Hughlings Jackson: Father of English Neurology

John Hughlings Jackson: Father of English Neurology

Critchley M, Critchley EA

New York: Oxford University Press; 1998. 228 pp

ISBN 0-19512-339-5 (hard cover)

John Hughlings Jackson was an independent-minded, creative thinker who has enjoyed legendary status. The Critchleys’ new biography tells us that it was said that Jackson’s guess was worth the facts of 10 men. The authors of this biography have provided an exhaustive, although excruciatingly detailed, description of Jackson’s life (there are 2 pages on his use or non-use of a hyphen between Hughlings and Jackson), professional work and legacy. Embodied within the volume is much information relevant to the golden age of neurology — the latter half of the 19th century — and the key individuals who developed neurology, especially in the United Kingdom, including the establishment of the National Hospital and the journal Brain. The Critchleys profess to decry hagiolatry, but begin the book with the following statement “He possessed the rare combination of characteristics that ’sets the man among the little band of whom are Aristotle and Newton and Darwin.’” The book is uneven, with obsessive detailing of the Jackson family tree and repetition of Jackson’s personal characteristics.

Nevertheless, the topic is one of fascination, the material scrupulously researched, and the book an explanation to a modern audience of what it was about Jackson that enraptured both contemporary and subsequent generations of those thinking about the nervous system.

Jacksonian concepts of the central nervous system need both an explanation and a guidebook. A critic once described Jackson’s writing as resembling the “love of God in that it surpasseth all understanding.” Those who wish to read Jackson in the original might be daunted by the following assessment by Sir George Savage, “His whole frame of mind was so carefully exacting that he scarcely ever dares to make a definite statement without qualifying it in some way; so that in studying his writings one meets endless footnotes and parentheses which are somewhat confusing.” The Critchleys make a reasonable effort in this volume, but picking Jackson’s key observations is not easy. We are told many times more often the importance of the observations than what they actually were. Certainly Jackson’s view of the brain comprised both holistic and compartmentalized notions. His successive levels of integration of motor functions coexisted with views contrary-minded to the passion for discrete localization that characterized his time. As the Critchleys state, the second half of the 19th century was a period of neurological fervour, when clinical-pathologic correlation was winning easy prizes. This work was descriptive in character, not reflective. They further point out that Jackson’s ideas, especially on aphasia, were temporarily overshadowed by those who conducted brief clinical studies highlighting the obvious. It is true that Jackson owed his principal contributions to germs of ideas derived from Herbert Spencer’s concept of “dissolution.” Nevertheless, one can’t help but feel affection for the man the Critchleys describe — his single-mindedness and recognition of the complexities of central nervous organization in the human brain. One feels a similar affection for his biographers, who have toiled tirelessly — in Mac-donald Critchley’s case, well into his 10th decade — to produce this work.

I have always thought that Critchley has been underrated by his countrymen. He did not appear to have been humble, and his writings redefine pedantry, but he was the longest surviving member of the era that overlapped Jackson’s final years and was also an exhaustive scholar. In the book, Critchley describes Jackson’s interaction with a colleague who had reviewed a piece of work so severely that the author was threatening violence. The reviewer protested to Jackson that the author’s anger was not justified, for he had only reviewed the book, not the man. “That is very true,” said Jackson. “You did not shoot at the man; you shot only at his coat but you must remember that it was on his back.” I am disinclined to shoot at the coat. There are shortcomings in this book to be sure, but there is also much fine biography.

Managing Side Effects of Psychotropic Drugs

Managing Side Effects of Psychotropic Drugs: A Clinical Handbook for Health Care Professionals

Oyewumi LK, de Wit R

London (ON): Zxmaxx Communications; 1998. 263 pp. with index

ISBN 0-9684372-0-6 (paper)

As the authors note in their Introduction, the plethora of new psychopharmacological agents introduced in the last decade has led to an extensive literature on the use and proposed mechanisms of action of these drugs. However, the literature on the side effects of these medications is limited at best. Rare is the patient who does not have at least some side effects from our treatments, yet far too often the patient’s only source of information on the drug and its side effects is the Compendium of Pharmaceutical and Specialties (CPS).1 Unfortunately, more often than it should be, the CPS is also the physician’s side effect “handbook”!

The authors have attempted to bridge this gap in our psychopharmacological knowledge base with a user-friendly, spiral-bound “handbook” on managing side effects of psychotropic drugs. They have done a good job.

The 8 chapters begin with an overview of the different classes of psychoactive agents, which includes an excellent table listing all antipsychotic and antidepressant agents (generic and trade names) and the average daily dose ranges. Unfortunately, hypnotics, anxiolytics, mood stabilizers and stimulants are omitted from the tables without explanation.

Chapter 2 reviews predisposing risk factors, epidemiology and classification (e.g., predictable v. idiosyncratic, initial v. tardive) of side effects, while the bulk of the handbook — Chapter 3 — is a detailed overview of these side effects. The format of Chapter 3 is unique, with “generic” headings such “dermatological” followed by subheadings (e.g., acne, allergic rash, alopecia, etc.). Under the subheadings, prevalence, occurrence, presentation, mechanism of action, and commonly associated drugs with this specific side effect are outlined. This is a very useful presentation for mental health professionals (physicians, nurses and students), but I suspect that drug “consumers” would have difficulty navigating this section. (Would they know to look under dermatological and alopecia for “hair loss”?)

Chapter 4 is a more academic chapter on evaluating side effects, and provides a listing of the various rating scales available to measure and monitor side effects.

Chapter 5, “Management of Psycho-tropic Drug Side Effects/’ offers very practical, clinically relevant treatment guidelines. These “bedside tips” in the management of dry mouth, pruritis, incontinence, etc., is clearly lacking in most pharmacology and clinical psychiatry textbooks.

The last 3 chapters review the consequences of drug side effects (compliance, economic effects); administrative aspects (the lack of postmarketing data on side effects); and psychodynamic/psychological aspects of side effects, such as placebo effect, “catching” side effects, drug side effects, and the transference/counter-transference in the doctor-patient relationship. All good stuff! The bibliography and references are detailed and up to date.

This is a very good start as a handbook that will be of value to psychiatrists, residents, nurses and consumers. It should find its way to psychiatric inpatient units, mental health centres and mental health support organizations as an excellent reference book. I do hope the authors are working on their second edition, as new drugs such as citalopram, reboxitine, and mirtazapine are already here, and additional new drugs could soon make this useful book outdated.

Some minor editing (e.g., in one section, it should have read “pharmacodynamic” not “psychodynamic” parameters) and combining the chapters on identifying and managing side effects would be helpful in the next edition. Further, more detail on the specifics of managing side effects (the book is entitled Managing Side Effects), such as specific dosages of drugs used to treat specific side effects, would enhance this work.

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications. CD-ROM

Stahl SM. New York: Cambridge University Press; 1998

ISBN 0-521-62892-X

This CD-ROM is an introductory textbook to the extraordinary complexities of basic and clinical neurochemistry pertaining to psychopharmacology. To make this information lucid, engaging and accessible requires a gifted communicator; Stephen Stahl is such a teacher, whose credentials as a researcher give authority to the concepts, facts and speculations he conveys so clearly.

Since this “book” is in CD-ROM format, any review must consider both the content and the format. The text is structured into 12 chapters and relies heavily on figures and diagrams to illustrate key concepts. The first 4 chapters focus on basic science and provide the foundation for the remaining 8 chapters. Stahl begins with the principles of chemical neurotransmission, including signaling, receptor occupancy, second messengers and co-transmission. He then explains receptors and enzymes as targets of drug action and further explores special properties of receptors in terms of subtypes, agonists and antagonists. He concludes the basic science section with a chapter on the interaction between disease and chemical neurotransmission.

The second section is clinically focused and briefly summarizes the biological bases of mood disorders, anxiety disorders and psychoses as a prelude to explaining and rationalizing the actions and benefits of psychiatric medications — as well as speculating on interventions in the future. Stahl concludes by considering cognitive enhancers, neuroprotective agents and drugs of abuse.

Any one of these basic science concepts, clinical disorders and psycho-pharmacological treatments could easily be the subject of a separate book — one that Stahl himself could probably write. It is a remarkable talent to synthesize, integrate and communicate clearly this wealth of information as effectively as he does. The text is unencumbered by references or wordy explanations. Advanced experts in various areas may sneer at oversimplification (a similar phenomenon occurs when someone makes psychotherapy fundamentals obvious and accessible), but this text is clearly not intended for them.

The ideal readership for this CD-ROM includes medical students, residents in psychiatry and allied health professions, and psychiatrists whose training concluded more than 5 years ago.

This text existed as conventional “hard copy” (what we nostalgically refer to as a “book”) before its current incarnation as a CD-ROM. What is the advantage of the CD-ROM format? It could be an expensive proposition unless you already own an IBM-compatible computer with a 486 or faster processor, or a Macintosh computer with System 7 or 8, at least 16 mB of RAM, Quicktime software, a sound card and speakers or headphones, and a 2 x or faster CD-ROM drive. It is really designed for Macintosh computers, and the author acknowledges that there may be some limitations in using the CD-ROM in an IBM-PC environment. Reading the CD-ROM involves pressing keys and jumping backward and forward between text and figures. The advantages lie in the use of animated diagrams to illustrate neurotransmission concepts, often accompanied by audio narration featuring Stahl himself.

While the animation reflects the elegant synthesis characteristic of the author, it seems rather primitive compared with the sophisticated computer graphics on children’s games. The narration is the weakest of Stahl’s skills: it adds nothing and requires a separate keystroke to activate, when simply reading a caption would be preferable.

Other textbooks on CD-ROM provide more opportunity to print excerpts and take notes on the computer screen. This CD-ROM lacks flexibility. With a book version, I could have scribbled in the margin or photocopied a diagram. In summary, this textbook is superb in terms of content, but the technology of presentation does not facilitate access or understanding. Reading the CD-ROM made me want to buy the book.

Straight Talk About Psychiatric Medications for Kids

Straight Talk About Psychiatric Medications for Kids

Wilens TE. New York: The Guilford Press; 1999

ISBN 1-57230-204-6 (paper)

In general, psychiatry has come a long way — from a pure psychoanalytical focus to a strong medical-neurobiological approach to treating psychiatric disorders. It is now well known in our clinical practice and in psychiatric literature that biologically based treatment with psychotropic medications, combined with other traditional and non-medical treatments, has proven superior to either treatment modality used alone. Similarly, child psychiatry and psychopharmacology have gained significant positions, both within the fields of medicine and general psychiatry.

Psychiatric conditions are recognized earlier in children who present with behavioural/emotional and developmental problems. These special children are more at risk of academic difficulties and parental rejection. In the best interests of the child and family, the challenge facing child psychiatrists is to provide an integrated assessment from a bio-psychosocial perspective before proceeding with specific treatment modalities; treatment should be conducted within interdisciplinary teams in which parents and their children are encouraged to participate actively. Physicians can expect parents and youth to be more active in questioning and decision-making. Medication may be indicated if behaviour modification and other therapies achieve only partial success; however, parents may still be reluctant to accept medication trials as a first-line approach. This book fills a need as a comprehensive reference source on current psychiatric medications.

The author is a well-known child psychiatrist and associate professor of psychiatry at Harvard Medical School. He specializes in pediatric and adult psychopharmacology and addiction psychiatry, and does his clinical work at Massachusetts General Hospital. He has published widely on psychiatric medications and their uses.

This book is the result of Wilens’ extensive clinical experience; it focuses on questions typically raised by parents concerning the assessment and treatment of their children. I believe it can serve as a useful information package for parents, educators and trainees in the field of psychiatry.

The contents are divided into three main parts. Part I describes and explains in straightforward language the general clinical processes of psychiatric evaluation, diagnosis and treatment plan. A central theme is that, as parents become familiar with the treatment process, they learn the importance of working collaboratively with the psychiatrist treating their child.

Part II informs the reader about common childhood psychiatric disorders as well as neurobiological conditions such as temporal lobe epilepsy, tic disorders, Tourette’s syndrome and organic mental disorders. For each condition, the author succinctly summarizes basic factual information; this is followed by information about coexisting emotional/behavioural conditions. The range of dosages is given for different medications.

With this basic understanding, the reader is prepared for Part HI, in which each class of psychotropic medications used in children is described with respect to names, dosages, indications and contraindications. Whenever needed, specific baseline testing or monitoring is also included.

Definitions of medical terms and expressions are interspersed appropriately in the text and framed in double lines for easy reference. Questions are printed in bold. Medications in each class are presented in a table form with names, preparations and strengths.

The last 37 pages include an appendix, medication log, resources, bibliography and index. The appendix is a table listing both generic and brand names of medications, with strengths and preparations. I found the example of a completed medication log useful for keeping track of each medication with respect to start date, dosage, response, side effects and comments.

The section on resources supplies the names and addresses of community and organizational supports within the United States, broken down by general mental health and specific disorders. The bibliography lists journal articles and books by recognized clinicians in different disorders. The section on tics and Tourette’s syndrome mentions 4 excellent references, but could have included Tourette Syndrome & Human Behavior, by David E. Comings, which is widely used by parents and professionals.

The author does not mention the use of psychiatric medication in preschool children (ages 2 to 6 years). Parents of these children are even more reticent to accept medication, even when their child’s condition is severe. There is no information on treating children with the amino acid tryptan (L-tryptophan) for various conditions. Also, the text does not clearly convey the serious potential risk of dependence on benzodiazepines. For this reason, it is better to avoid the use of benzodiazepines in children and youth. It is known that they may mix these prescribed drugs with other substances once the body develops a tolerance.

Overall, this book may enable mental health professionals to feel confident about addressing parents’ concerns and questions regarding psychiatric medications. It may save time for health care providers by giving parents the understanding they need to collaborate with professionals in the treatment of their child with psychiatric and mental health problems. Despite some weaknesses, the book does provide an abundance of valuable information. In clinical practice, however, it should be used as an adjunct to current literature on each drug in question, providing the reader with a balanced perspective.

Thyroid Diseases of Infancy and Childhood

Thyroid Diseases of Infancy and Childhood: Effects on Behavior and Intellectual Development

Hauser P, Rovet J, editors

Washington: American Psychiatric Press; 1999. 312 pp. with index

ISBN 0-88048-767-4 (cloth)

This book, by a group of distinguished authors, presents the neurobehavioural science underlying and a clinical overview of thyroid deficiency and excess in the growing human organism.

The current knowledge of thyroid physiology and molecular genetics is reviewed in detail and is well referenced. Hence, this book is more than enough for the busy clinician.

A historical review of newborn screening programs over the past 25 years includes the complete history of thyroid screening in North America, from the Quebec experience starting in the mid-1970s to the present. The problem of false-positive results in term as well as premature infants is elucidated.

For the basic scientist, pediatrician or pediatric endocrinologist seeing newborns with positive thyroid screening tests, the later chapters on screening and long-term results of L-thyroxine therapy heighten awareness of the potential behaviour, intellectual and hearing problems faced by these children due to an otherwise treatable disorder. The association between thyroid hormone resistance syndrome and attentional disorders is intriguing. The neurobehavioural aspects of acquired thyroid disorders in children has been adequately highlighted for the clinician.

Finally, the chapters on neurodevelopmental change with thyroid-disrupting contaminants is thought-provoking for the environmentally conscious reader.

The book as a whole presents a balanced perspective on the neurobehavioural consequences of thyroid disease in infants and children and should be on the bookshelf of every pediatric library for current and future basic scientists and clinicians involved with children. It is a “must read” for every pediatric endocrinologist and child psychologist.

Treatment Compliance and the Therapeutic Alliance

Treatment Compliance and the Therapeutic Alliance

Barry Blackwell, editor

The Netherlands: Harwood Academic Publishers; 1997. 325 pp. with index

ISBN 90-5702-546-9 (cloth)

Many clinicians take the “compliance” of their patients for granted. They assume that medications are taken as ordered and rarely check pill boxes or take any action other than questioning the patient to ensure that instructions are being followed. Yet we know from well-designed studies that as many as 50% of patients do not take their medications as prescribed. Contrary to expectation, psychiatric patients are not notably less compliant than nonpsychiatric “medical” patients. Compliance also is impaired in older patients when medication requirements are complex, and in socially isolated people, and it is adversely affected by a poor doctor-patient relationship.

The philosophy of compliance is also changing, to keep up with changes taking place in the role of the physician in our society. The older paternalistic medical model of “the good doctor knows best” no longer holds. Patients are far better informed about their health problems and their treatment options and are encouraged, and rightly so, to take charge of their medical treatment. With some exceptions, the medical profession has come to terms with these changes, and most physicians have accepted their new role as health educators and advisers rather than treatment directors.

This book deals with many of these issues, in particular the doctor-patient relationship. Yet it is curiously uneven in content, philosophy and quality. It is divided into 3 sections: “Compliance research, theory and social context,” “Participants in the alliance” and “People with special needs.” The first section provides a useful and practical overview of the field. The chapters entitled “Models of the compliance process, “Medication noncompliance in schizophrenia,” “Insight and compliance” and “Compliance and decision making capacity” were of particular interest and value. The second section includes chapters on community mental health programs, the role of families, and the role of the physician in the therapeutic alliance. The final section has chapters on schizophrenia, manic depression, developmental disabilities, alcoholism and the elderly.

The quality of the book starts at a high level but rapidly deteriorates in the middle and later chapters. Many of the later chapters are written by “consumers” or health care professionals with antiestablishment axes to grind. Their tone tends to be adversarial, and they write as if nothing has changed since the days of the paternalistic medical model. There is much discussion of the individual’s right to refuse treatment but little or no discussion of a patient’s right to have effective treatment when such is available. The topical issue of community treatment orders is barely mentioned. Although the editor (who authored 2 of the chapters) commendably attempts to integrate compliance into the therapeutic alliance, the book nevertheless lacks philosophical coherence and consistency. One has the impression that no decision was reached on whom the book is addressed to, and too wide an audience has been targetted.

Despite the importance of the subject, this book is likely to be of value only to those with a special interest in compliance.

A Primer of Supportive Psychotherapy

A Primer of Supportive Psychotherapy

Pinsker H

Hillsdale (NJ): The Analytic Press; 1997. 278 pp. with index

ISBN 0-88163-274-0 (cloth)

Convincing evidence has accumulated that the supportive or nonspecific component, common to most forms of psychotherapy, is responsible for most of the change that results from psychotherapeutic interventions. This component appears to be both supportive — in that it is derived from the quality of the therapeutic relationship — and technical — in that it stems from the contract established with the patient and the use of nonspecific interventions. Specific interventions drawn from different schools of thought account for surprisingly little of the variance in outcome for most disorders, with the possible exceptions of panic and obsessive-compulsive disorders. The implications of these findings are clear. All mental health clinicians, regardless of their field, should be well versed in nonspecific interventions, and clinical training should emphasize integrated or so-called transtheoretical perspectives. Unfortunately, both practice and training tend to lag behind research. Many clinicians continue to rely on specific psychotherapeutic models, and training rarely gives nonspecific interventions the weight that they deserve, although there is some evidence that this is changing.

In this context, Dr. Pinsker’s very practical little volume is a useful addition to the growing number of texts on supportive therapy. Although one might disagree with some of the ideas and with the theoretical model that lies behind the volume, one must agree with the tone. This is the work of a sensitive and humane clinician who respects his patients. The approach emphasizes a conversational style and a responsive approach, rather than listening silently or interrogating the patient. The volume offers a model worth emulating. Anyone who adheres to the spirit of this work will not go far wrong, nor will his or her patients come to harm.

The value of this work lies in the large number of examples of the kinds of statements patients typically make and the clinician’s possible responses. The topics discussed include most of the key issues in therapy: increasing self-esteem, reducing and preventing anxiety, promoting adaptive skills, building a treatment alliance, and so on. These topics are explored through specific examples that include illustrations of helpful and less helpful responses that therapists may make. It is these examples that make this book especially helpful as an introductory text. Here is an experienced clinician talking in a common-sense way about the nuts and bolts of therapy. This makes for a style that is at times a little dull but replete with clinical wisdom. The simple practical examples will be helpful to a neophyte clinician who is learning how to conduct assessment and therapy interviews. They may also be worth a brief perusal by those who are much more experienced, who may be surprised to recognize bad habits unwittingly accumulated over the years.

The volume is not without limitations. Two issues are worthy of comment. First, some of the examples are a little sparse, and the discussion of alternative responses by the clinician is a little limited. Hence, the implications of the different possible therapist responses may not always be clear to the beginning therapist. More problematic is the theoretical perspective that runs through the volume. This is classically psychodynamic; hence, much is made of the distinction between supportive and expressive therapy. With increasing emphasis on integrated approaches, this distinction is less important. It may also be a little dated. The problem emerges on the first page when supportive therapy is differentiated from expressive therapy in terms of technical considerations. These are defined as using a conversational style, viewing the patient-therapist relationship as a real relationship that is not analysed, and supporting defences that are not maladaptive. Perhaps the important issue is not the distinction between supportive and exploratory therapy — which is important only to those who espouse the psychoanalytic tradition — but rather the degree of intrusiveness and the extent to which generic mechanisms are used to effect change. Dr. Pinsker describes these clearly, although in different terms. Consequently, it is easy to put theoretical issues to one side and concentrate on the practical component of the book. In this regard, the volume meets its goal of being a is a useful primer.