Psychopharmacology

The Psychopharmacology of Lithium

The Psychopharmacology of Lithium

F. Neil Johnson

New York, Oxford University Press, 1984. 327 pp.

Lithium is, at the same time, one of the most effective and one of the most poorly understood psychiatric medications. In this text, Johnson reviews a broad range of basic research and clinical data in an attempt to derive a cohesive model which explains the behavioral effects of the drug. Johnson is an experimental psychologist, and his work underlies many of the chapters which suggest that lithium decreases the behavioral response to novel external stimuli. He then utilizes this foundation to propose a cognitive model for lithium’s anti-manic action, its inhibition of violent impulsivity, and its prophylactic effects in recurrent depression.

Previous formulations which were clinically based, such as that of Mabel Blake Cohen and her associates, stressed the primacy of depression and noted the “manic defense” as an attempt to ward off intolerable depression. In direct contrast, Johnson views mania as the primary disturbance in bipolar disorder. He considers depression in bipolar disease as an over-zealous homeostatic inhibitory response to a mania-associated cognitive overload. Consistent with this, he believes, littium exerts its anti-manic effect by decreasing cognitive processing in a manner analogous to his animal studies. Johnson also suggests that lithium exerts its prophylactic effect in recurrent depressions by treating subclinical mania. These concepts are supported by the work of Johnson’s associate, Kukopulos, to whom the book is dedicated. The bulk of the research which describes the cognitive disturbance in mania is complex, however, and uncomfortably open to multiple interpretations. Recognized as a preliminary effort, Johnson’s formulation may help to guide further research.

Although Johnson clearly traces lithium actions through a broad range of subjects, his discussion of the neurophysiological aspects of this drug is notably spotty. In particular, Johnson ignores the work of Svensson, DeMontigny, Aghajanian, and others who suggest that serotonergic systems may play an important role in the antidepressant actions of lithium. As a result, he fails to discuss one of the most important current uses of lithium: as an agent used in conjunction with antidepressant medications to increase treatment response in medication-resistant forms of depression. Lithium augmentation of antidepressant medication also challenges the formulation presented by Johnson. This formulation suggests that lithium should have no therapeutic value in patients, such as those with endogenous depression, who already “under-process” cognitive information. The omission of lithium augmentation in depression is clearly unfortunate in this text.

Overall, this volume demonstrates the benefits of a single-authored text. It it clearly organized and readable. The bibliography is also broad and useful. In this book, Johnson primarily addresses a research audience, and his model seems designed to stimulate thought rather than to improve clinical technique. In this capacity, his book will be of most interest to behavioral psychologists. Other books, focusing purely on clinical data, may be more useful to clinicians. Nevertheless, the clear organization, the large bibliography, and the thoughtful presentation may make this text a useful addition to a clinical library as well.

Psychopharmacology

Psychopharmacology: The Third Generation of Progress

Edited by Herbert Y. Meltzer

New York, Raven Press, 1987. 1,824 pp.

The utility and desirability of Psychopharmacology: The Third Generation of Progress is attested to by the fact that it was the first book to be stolen from our newly established psychiatry library. This book is the third in a series, updated every decade since 1967, from the preeminent biological psychiatry organization in the United States, the American College of Neuropsychopharmacology (ACNP). This comprehensive review of clinical neuroscience was “trimmed” to 184 chapters by 350 authors and amounts to more than 1,800 pages.

For a book that is so large and cumbersome, relevant information on most topics in neuroscience is surprisingly accessible. Topics are presented as clusters of individual reviews covering specific interest areas rather than as a single comprehensive review chapter. Thus, an experienced clinician or researcher seeking an update on a specific topic, such as maintenance pharmacotherapy for schizophrenia, is likely to find a brief, focused review. In contrast, readers with limited psychiatry or neuroscience backgrounds may find that the magnitude of the text and its somewhat fragmented presentation style make information more difficult to integrate. For example, in order to learn about schizophrenia, the novice neuropsychiatrist must read two introductory chapters, at least four preclinical chapters, and 24 clinical chapters from over thirty authors. Although this mountain of information would appear to be daunting, I have found that the chapters are quite popular as review materials among second-year psychiatry residents.

Despite the excitement and interest that a book such as this generates, it suffers from some flaws that are characteristic of multi-authored texts. Some parts of the book, such as the section on neuroanatomic and neurochemical mechanisms, contain several excellent chapters but lack a central focus or clearly apparent organization. The scope of reviewed materials also varies widely between chapters. As an illustration of this problem, “animal models in psychiatry” is included in the section on “Biology of Depression,” a review of animal models is absent from the section on “Biology of Schizophrenia,” and two of the four chapters in the “Biology of Anxiety” section review animal models. Also, the quality of the chapters varies noticeably in this book. In contrast to many chapters written with depth and clarity, others appear sketchy or even poorly written.

Although generally skeptical about the utility of purchasing expensive scientific books that rapidly become outdated, I wanted to own this text in order to insure continued access to the many useful reviews that it contains. In addition, it is one of very few books that I recommend to psychiatry residents interested in clinical neuroscience. Despite its flaws, Psychopharmacology: The Third Generation of Progress is clearly an important contribution to neuroscience and psychiatry.

Neurochemical Pharmacology

Neurochemical Pharmacology — A Tribute to B.B. Brodie. Fidia Research Foundation Symposium Series. Volume 2

Edited by E. Costa

New York, Raven Press, 1989. 369 pp.

This book represents the proceedings of a Symposium held in April 1988 to honor Dr. Bernard Brodie, who died in February 1989 while the book was in press. The book consists of a series of articles in neuropharmacology by many of the world’s leading experts in the field and is a fitting tribute to Dr. Brodie and his remarkable career.

Dr. Brodie was for many years director of the Laboratory of Chemical Pharmacology at the National Heart Institute. Under his direction, the laboratory played an important role in establishing a new approach to pharmacology, termed by the editor of this book “Neurochemical Pharmacology.” This approach, elaborated in the 1950—60s, was based on the view that it would ultimately be possible to understand all of the brain’s functions, including mental functions, on the basis of the underlying biochemistry of the brain. The approach had an enormous influence on the biomedical sciences and provided the basis for a generation or two of research in biological psychiatry. An impressive number of investigators trained in the Brodie laboratory during this time, among whom were Julius Axelfrod, Jack Cooper, Erminio Costa, and Solomon Snyder. In fact, the extraordinary productivity of Dr. Brodie’s laboratory and its disciples was the subject of a recent book, Apprentice to Genius by Robert Kanigel.

The current volume is divided into four sections entitled: “Transmitters,” “Transmitter Function,” “Receptor Modulation,” and “Signal Transduction.” The following articles are particularly noteworthy: Arvid Carlsson presents a challenging overview of the role played by brain dopamine systems in motor and mental functions. Tomas Hokfelt and others offer a comprehensive and helpful review of the localization of peptide neurotransmitters in monoaminergic and cholinergic neurons. Of note in the second section are reviews of the role of monoaminergic systems in satiety (by S. Garattini and others) and stress (by Roger Maickel). An article by S. Roy and others in the third section describes attempts partially to purify opiate receptors and prepare monoclonal antibodies to the receptor. K. Fuxe and colleagues describe “receptor/ receptor interactions,” the critical idea that neurotransmitter systems interact with one another, making it likely that psychotropic drugs influence brain function through effects on multiple types of neurotransmitter and receptor systems. Goran Sedvall and others describe their experience in the use of positron emission tomography to image neurotransmitter receptors in living human subjects. In the fourth section. Fridolin Sulser and Elaine Sanders-Bush offer a very thoughtful and up-to-date analysis of the probable mechanisms involved in the clinical actions of antidepressant treatments and experimental approaches. Erminio Costa presents some of the data obtained over the years, much from his own laboratory, underscoring the importance of the role played by the regulation of gene expression in adaptive changes in brain function.

As would be expected, the quality and focus of the articles in this book are variable. Despite the considerable delay in publication of this volume, most of the articles remain up to date. The book would be useful to individuals in the field for its reviews and to individuals only peripherally associated with the field as a more general overview of current research in neuropharmacology.

Novel Antipsychotic Drugs

Novel Antipsychotic Drugs

Edited by Herbert Y. Meltzer

New York, Raven Press, 1992. 267 pp.

The field of schizophrenia research is rapidly changing. The advent of clozapine has led to the exploration of new pharmacotherapeutic strategies based on mechanisms other than dopamine-2 receptor blockade, the hallmark of typical neuroleptic treatment. As a result, investigators have explored many new approaches to antipsychotic treatment based on dopamine-1 receptor blockade, serotonin-2 receptor antagonism, serotonin-3 receptor blockade, enhancement of excitatory amino acid neurotransmission, and other novel approaches. As a result, people working within the field of schizophrenia and family members of individuals afflicted with schizophrenia frequently seek reference material that provides a snapshot progress report of novel pharmacotherapeutic approaches to schizophrenia. Novel Antipsychotic Drugs, edited by Herbert Meltzer, a leader in the psychopharmacology of schizophrenia, fulfills at least a part of this need by providing very brief introductions to treatment strategies based on a spectrum of neurobiological mechanisms.

Some of the 23 chapters in this book represent work in progress, bearing the strengths and weaknesses of this type of communication. Clinical investigators are hungry for information about drugs such as risperidone, amperozide, odansetron, remoxipride, and raclopride. This volume provides brief informative updates, but no definitive findings, regarding the use of these agents in treating schizophrenic patients. Chapters by investigators such as John Waddington, Philip Seeman, Carol Tamminga, and their colleagues manage to bridge approaches to the pathophysiol-ogy of schizophrenia and novel pharmacotherapeutic findings in short but informative chapters. Some of this material is unavailable in any other published source. An otherwise interesting chapter by John Olney, a leader in the field of excitatory amino acid neurotoxicity, draws parallels between neurotoxic and psychotomimetic effects of NMDA antagonists too closely. Olney suggests that anticholinergic agents would be antipsychotic, based on his data indicating that they protect against PCP-induced toxicity in the cingulate cortex. He ignores pre-clinical behavioral data and clinical studies suggesting that anticholinergic agents exacerbate and cholinergic agents alleviate the behavioral effects of PCP.

The key to this book is its timeliness. Priced at $90.00, this slim volume is unlikely to find its way into the personal library of many clinicians. At this price, this book would need to contain classic papers to be useful in the long run. Its snapshot reviews and introductions are likely to be out of date in a few years. Important contributions to the field of schizophrenia that emerge from its preliminary research presentations will eventually appear in the peer-reviewed literature. Advances that are blind alleys ultimately will be forgotten. In the long run, volumes such as these often gather dust on the back shelves of medical school libraries. During a critical period of time, however, there is an urgent need for the information contained in this book. I, and others interested in getting the latest update of a rapidly changing field, might do well to push our local libraries to obtain this handy and informative volume.

Psychopharmacology of Cognitive and Psychiatric Disorders in the Elderly

Psychopharmacology of Cognitive and Psychiatric Disorders in the Elderly

Wheatley D, Smith D, editors

London: Chapman & Hall Medical; 1998. 228 pp. with index

ISBN 0-412-82470-1 (hardcover)

Psychopharmacology is a rapidly growing field. The elderly population is also expanding, especially the oldest of the population, who are major consumers of pharmaceutical drugs. However, elderly patients are under-represented in clinical studies because of difficulties in recruitment, greater interindividual variability and the lack of consistent changes in pharmacokinetics associated with the aging process. They also have increased susceptibility to adverse effects for various reasons, including multiple chronic or degenerative physical illnesses, multiple pharmacotherapies, difficulties with compliance, lack of reporting of side effects and lack of recognition of adverse drugs effects that may be attributed to other causes. For all of these reasons, the astute clinician working with the elderly must have a good understanding of the aging process, of the pharmacokinetic and pharmacodynamic changes of psychotropic drugs and potential adverse drug reactions. This international contribution attempts to critically review the vast field of psychopharmacotherapy in a concise, clinically useful and well-written monograph. The book is divided into 3 parts: basic concepts, cognitive disorders and psychiatric disorders. Like most textbooks, it has the drawback of not being up-to-date with the most recent advances in pharmaceutical drugs available to the clinician, especially as there is a dearth of information concerning elderly patients. Its major contribution is in providing guiding principles that will help the clinician choose a proper drug and monitor its effects on patients. Most authors are recognized experts in their respective fields of pharmacology or clinical pharmacology, but, as is the case of multi-authored books, there is an unevenness in the chapters. The editors succeeded in avoiding duplication within the book, however. The chapters on neurochemical substrates, neuropathology and drug therapy for Alzheimer’s disease were well integrated. Only one chapter, on measuring memory, lost my interest. Although the discussion on the different types of memories was insightful, examples or diagrams would have been helpful. It listed several assessment and screening tests of cognitive functions which are, for the most part, more suited for research purposes and have little use in the clinical setting.

The major psychiatric syndromes are covered in part 3 of the book; however, a discussion on bipolar illness, which often presents as a major clinical challenge in the elderly, is lacking. Newer anticonvulsants used in psychiatry, such as lamotrigine and gabapentin, are not discussed. There is no mention of the use of bupropion (antidepressant) or quetiapine (atypical antipsychotic) in the elderly. Other newer treatments, such as risperidone, olanzapine and venlafaxine are only briefly discussed, yet they are used commonly in clinical practice and are rapidly becoming a first treatment choice because of their favourable adverse effects profile.

Of the many textbooks of psychopharmacology, few are dedicated specifically to the elderly. Overall, this is a comprehensive, yet concise, well-written and clinically applicable monograph which does what it proposed to do — review the nature of the aging process, the pharmacokinetics and pharmacodynamics, and the side effects of the various drugs used to treat elderly patients. It would be of interest to all clinicians seeing elderly patients and to residents in psychiatry, geriatric medicine and family medicine.

Atlas of Psychiatric Pharmacotherapy

Atlas of Psychiatric Pharmacotherapy

Shiloh R, Nutt D, Weizman A

London (UK): Martin Dunitz; 1000. 235 pp. with bibliography

ISBN 1-85317-630-3

For the psychiatric clinician for whom chemotherapy is the mainstay of his or her practice, this is a really, really good book! The text is easy to read (the entire book can be read in a few hours), and the unique format actually makes it fun.

The Atlas of Psychiatric Pharmacotherapy is, indeed, an atlas — a book of tables, charts and illustrations. There are approximately 100 of these figures on the left-hand pages, with corresponding text on the right-hand pages. And what charts and tables they are: glossy, coloured, well codified, elegant and easy to follow.

The text and corresponding tables start with basic principles of psychopharmacology. Tables and text include not only clinically well-known information on control and modulation of neurotransmitter release, specific biogenic amines, the P450 system, etc., but also relatively up-to-date (references through 1997) information and tables on signal transduction (3 different tables), vesicular mono-amine transporter (VMAT2), etc. The first section also includes tables on mood stabilizers, antidepressants, antipsychotics and their supposed mechanism of action, focusing on their specific action(s) at different receptor sites. There is a specific section on abused substances, their acute effects, withdrawal symptoms and specific profiles, with colour tables on each drug of abuse (opioids, cocaine, amphetamines, alcohol, cannabis, etc.), their supposed mechanism of dependence, adverse effects and treatment options. My only criticism of this section is that there could have been more detail on treatment options for alcohol abuse, by far the most common drug of abuse.

The third section is on drug interactions, arranged by class of medication. We have seen this information before, but not displayed in this manner — where the graph indicates where and why the specific side effect/drug interaction occurs (e.g., direct neurotransmitter effect, gastrointestinal absorption, first-pass effect, etc.).

The final section, on treatment strategies — is a gem. Thirty-five colour algorithms on the left-hand pages and text explanations on the right-hand pages explain the treatment for each syndrome — from major depression (non-resistant or treatment-resistant), acute exacerbation of schizophrenia, bulimia, anorexia, etc., including the 7 personality disorders. (Pharmacotherapy is not the treatment of choice for personality disorders, according to this atlas.) While the algorithms may not fit perfectly with some of the recent Canadian guidelines, they are pretty close to Canadian standards. Furthermore, the 35 algorithms for 35 specific DSM-IV diagnostic syndromes, with a corresponding text explanation is, in my opinion, a unique resource for the busy practising clinician.

My criticisms of this book are minor. The detailed references at the end of the manuscript are not footnoted in the text, so one cannot easily find a specific reference for a statement. I would have liked to review specific references in cases where a few text comments puzzled me (e.g., akathisia occurs in 90% of patients on antipsychotics in the first 10 weeks; the purported efficacy of amoxapine in psychotic depression). A second edition should include footnoted references and a cross-referenced index.

There is a little too much on sexual functioning, and, in particular, the mechanism of retrograde ejaculation with thioridazine. This topic is covered in 14 pages (7 tables/ graphs; 7 pages of text), whereas topics such as electroconvulsive therapy, Alzheimer’s disease and alcohol each get one table and one page of text.

The price is steep, but worth it. Where else can a clinician find “everything you really wanted to know but were too overwhelmed to ask” in a few pages? There is enough basic science detail for the clinician, but in a format that is easy to comprehend. The treatment and side-effects tables and text are excellent. (I found the tables on which specific drugs to use for specific extrapyramidal symptoms and the illustrated graph on side effects of antipsychotics particularly helpful.) As stated, the outstanding treatment algorithms are clear, organized, and would be an asset for any psychiatric clinician.

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.

Handbook of Essential Psychopharmacology

Handbook of Essential Psychopharmacology

Pies RW

Washington: American Psychiatric Press; 1998. 416 pp. with index

ISBN 0-88048-765-8

This concise, slim, well-edited paperback review of essential psychopharmacology is divided into 4 chapters, on antidepressants, anti-psychotics, anxiolytics and sedative-hypnotics, and mood stabilizers, including novel anticonvulsants. Each chapter begins with an overview that includes drug class indications, mechanism of action, pharmacokinetics, common side effects, drug interactions, augmentation strategies, and use in special populations, such as pregnant women, the elderly, and develop-mentally disabled patients. Each chapter ends with a series of well-selected, clinically relevant questions, along with answers and a case discussion that illustrate and clarify various teaching points.

The chapter on antidepressants is a general review of the literature in that area. I often hear residents expressing their concern about the inability to keep up with the number of new antidepressants being introduced into our pharmacopoeia. It is also not uncommon to meet residents who, in their final years of training, have yet to prescribe or be familiar with the frequent clinical challenges in using tricyclic antidepressants or monoamine oxidase inhibitors. This chapter provides a user-friendly review of the newer agents and also the “older” classes of antidepressants. The author succeeds in assembling the information in a way that is not information overload and yet is academically and clinically useful, particularly for residents. This is made possible in part by the author’s careful use of various tables, which compare clinical issues such as off-label indication, neurotransmitter effects, side effects and their basic management, drug-drug interactions, and therapeutic drug monitoring.

The chapter on antipsychotics provides the reader with a concise, comparative review of conventional and atypical antipsychotics. Tables illustrate comparative mechanisms of action and side effects, along with strategies for antipsychotic potentiation. This latter issue is something clinicians are often faced with, particularly in patients who cannot tolerate or respond poorly to antipsychotics, including the newer atypicals. The question section deals with disparate clinical areas, and has a very good review of neuroleptic malignant syndrome.

The chapter on sedative-hypnotics and anxiolytics has several useful charts, such as a diazepam equivalency chart, a chart of clinical indications, and a table on the off-label uses for clonidine and β-blockers.

The final chapter, on mood stabilizers, has a clinically relevant review of lithium, valproate and carbamazepine. The author has included an up-to-date review of gabapentin and lamotrigine and their potential interactions with other commonly used psychiatric medicines.

As a psychiatric educator, I was very pleased with the question-and-answer section in this book. In fact, I have yet to come across a similar psychiatric textbook that effectively asks well-selected clinically relevant questions and provides the reader with practical answers. I do like how the author began by providing the basic informational background to these various compounds, followed by questions forcing the reader to “work” the information, and rounding up with a practical case to apply this new-found knowledge.

I found the graphs, diagrams and tables very useful, and very good complements to the written material, often clarifying the concepts presented. The large print of the text is very easy to read. The information is presented in a systematic way and includes extensive references to the literature for those interested in pursuing more knowledge on the topics.

Dr. Pies’ book is intended to be a “micropedia” for residents and busy clinicians. I see it as a very useful, helpful teaching textbook and resource for its intended audience. Psychiatric psychopharmacology has had a history of being somewhat limited by the absence of clearly established evidence-based algorhythmic approaches to treatment. That being said, there have recently been useful treatment guidelines for the diagnosis and treatment of major depressive disorder, bipolar disorder, and schizophrenia, among others. The author may wish to incorporate some of these reviews in future work. Overall, I congratulate the author and recommend this text.

Child and Adolescent Psychopharmacology

Child and Adolescent Psychopharmacology

S.P. Kutcher

Philadelphia: WB Saunders; 1997. 509 pp. with index

ISBN 0-7216-5749-4

This book represents the state of the art in childhood psychopharmacology. Well written and capturing the highest level of existing evidence in the field, it serves as a reference text as well as an instructive how-to manual for those practising childhood psychopharmacology.

The text is organized into five sections. Section 1 is very brief and introduces the book by outlining the move toward empiricism in child and adolescent psychopharmacology, specifically, and childhood psychiatric disorders, generally. A broad clinical model is emphasized, to bring the science of the controlled experimental study into the realm of the clinical environment by combining medication with other empirical interventions.

Section 2 deals with baseline assessment before beginning psychopharmacological treatment. The section begins with general issues and then moves to more specific assessment, both in terms of rating scales for different disorders as well as more specialized ancillary assessments such as family, social and interpersonal, academic, speech and language and institutional assessments. The fourth chapter of the section covers baseline medical assessment for psychopharmacological treatment. Useful pointers in the medical history, exclusion of medical illness, baseline investigations and monitoring (including principles of therapeutic drug monitoring) are covered extensively.

Highlighted summaries allow quick rereading of a chapter. In addition, chapter 3, which deals with individual baseline psychiatric assessment for psychopharmacological treatment, has several useful tables with pointers to the psychiatric diagnosis. The reader is referred to relevant rating scales contained in the appendices. Of great use to the busy clinician is the visual analog scale, which allows for baseline rating and monitoring of specific target symptoms. Chapter 3 uses case examples and commentaries to illustrate points made in the text. These cases are relevant and reminiscent of my own day-to-day practice. Each raises important clinical examples and dilemmas. Rather than distracting from the text, in most cases they reinforce the text and make the book more readable. This excellent technique continues through the rest of the book.

Section 3 covers the planning, initiation and provision of psycho-pharmacological treatment. Although superficially this section seems to repeat some of the content of the previous section, it does in fact offer additional wisdom and deals with important practical issues in the treatment of children and adolescents generally and psychopharmacology more specifically. The principles of patient and family education are clearly articulated, as are the standards of informed consent. While legislation may vary in different jurisdictions, a useful set of guidelines is provided for obtaining informed consent from both the child and family, taking into account the developmental and cognitive status of the child. Throughout, the book adopts a respectful client-centred philosophy. This attitude is well reflected in the clinical case examples.

Section 4, appropriately the most dense segment of the book with 10 chapters, deals with the clinical practice of child and adolescent psychopharmacology. Each chapter outlines the treatment of a particular disorder, with 3 chapters devoted to the anxiety disorders; the first of these very briefly describes the general issues in the psychopharmacological treatment of the anxiety disorders, followed by a chapter devoted to the treatment of panic disorder and the third to other anxiety disorders. The author emphasizes the high morbidity of anxiety disorders beginning in childhood and suggests that evidence supporting the principle of least intrusive intervention first is lacking. Combined interventions (pharmacological and psychological) applied aggressively, especially when symptoms and functional impairment are significant, may lead to better outcomes. This principle is applied in the subsequent 2 chapters. In keeping with the format of the book, these 2 chapters guide the clinician — with the use of case material — through the management of these disorders, providing a framework for assessment and measurement of outcome, as well as the specifics of drug choice, augmentation techniques, dosage ranges and some principles for treatment duration.

Other chapters that are highly recommended are those on the treatment of depressive disorders and bipolar disorder. In chapter 11, the author takes the reader through the standard management of depressive disorders in childhood and adolescence using 2 case examples and commentaries, which highlight treatment issues. The text is written like an expanded step-wise treatment manual but remains interesting and readable. The chapter focus is on the use of selective serotonin reuptake inhibitors (SSRIs). While the author clearly outlines alternative and augmentative treatment strategies, he completely dismisses the use of tricyclic antidepressants (TCAs) as alternatives, although there may still be a role for these drugs — for example, the use of desipramine or nortriptyline to treat dysthymia in adolescents with comorbid attention deficit hyperactivity disorder. There is only a single line devoted to the newer-generation antidepressant venlafaxine, and this appears odd and out of context. Nefazodone is not mentioned at all, perhaps because of its novelty.

Chapter 12 is thorough in its review of the thymoleptics and ancillary treatments for bipolar disorder. A subsequent edition will likely review the use of the novel antipsychotics, especially risperidone and olanzapine in the treatment of bipolar disorder with psychosis. These drugs are not mentioned, perhaps as a result of the author’s use of the highest available level of evidence in outlining psychopharmacological treatment of children.

If this book has any drawbacks, it is a tendency to be long-winded and repetitive. For example, the last paragraphs of the 2 case commentaries in the chapter on acute schizophrenia (chapter 13) are almost identical. While each of these paragraphs (page 224 and page 225) “emphasize[s] the importance of using proper pharmacological treatment within the context of optimal and comprehensive care” “and keeping in mind the expected paradigm of chronic care with the goal of controlling acute symptoms, preventing relapse, and optimizing patient function,” a single statement would suffice. Occasionally, terminology is used loosely; for example, neuroleptic malignant syndrome is referred to as a “true psychiatric emergency” when it is better defined as a true medical emergency. The section describing “initiating and optimizing methylphenidate treatment” (on page 279 of chapter 15, “Psychopharmacologic Treatment of Attention-Deficit Hyper-activity Disorder”) is quite unclear: 2 potential strategies are outlined (1 and 2) and then strategy 3 (which appears to be strategy 1) is referred to in the case example. Furthermore, it is difficult to determine any real difference between strategies land 2.

There are 7 appendices, which provide an inclusive array of potential rating scales available for the use of psychopharmacologists treating children. The book is well indexed, and a useful reference list can be found at the conclusion of each chapter.

Overall, this book is a very useful addition to the growing library of texts on child and adolescent psychopharmacology. I strongly recommend it as a useful and practical guide for practitioners prescribing psychopharmacologic agents to children and adolescents. I look forward to an updated and perhaps more streamlined edition in a few years’ time.