A DSM III-R Case Book of Treatment Selection

A DSM III-R Case Book of Treatment Selection

Samuel Perry, Alan Francis, John Clarkin

New York, NY: Brunner/ Mazel Publishers, 416 pp., 1990

In the introduction to this book John Talbot states “as the science of psychiatry progresses at such a rapid pace it is apparent that its art must advance just as quickly. With every development, the selection of the most perfect treatment becomes more complex but also more critical.”

Talbot goes on to state “too often patients receive the treatment known best to, or practised primarily by the first person they consult, rather then that from which they might best benefit.” These ideas resonate very much with the concerns of many academic psychiatrists in North America.

The authors of this book have attempted to offer some guidelines for appropriate and yet critical treatment selection. They have written a fine introductory chapter in which they describe how treatment needs to be planned, they also indicate their biases. Some of these biases are that treatment decisions are not based on disgnosis alone, but in order for patients to receive the best and most effective treatment their past history, life style, current situation and interaction with the therapist must be considered in order to provide properly individually tailored treatment.

They indicate that there are somewhere between 130-200 treatments available in psychiatry, and that perhaps psychiatrists can be categorized in three groups: specialists, eclectics and sceptics who believe that non-specific factors are most important. The authors examine the setting, format, time, approach, and the question of somatic treatments or no treatment as entering into all treatment decisions.

They state that the process of treatment selection is truly a matter that academic psychiatrists must examine more carefully. For instance people can decide on a medical model entirely. The authors state this is too simple. They state that diagnosis has been shown to have only slight correlation with treatment selection and outcome and give a reference in the Archives of General Psychiatry to back up this statement.

A preferable method of selecting treatments is to consider other aspects of the patient in addition to treatment. One must train our students and all mental health professionals to consider the presenting problem, character traits, premorbid personality, motivation, psychological-mindedness, socio-economic status, family situations and ego strength. The authors point out that patients have expectations of treatment and that this influences outcome. This finding has been shown in many trials particularly in the area of depression.

And finally as we might expect, the cases which are outlined in all DSM III-R categories are rich and exciting to read. Furthermore, cases under mood disorders, anxiety disorders and adjustment disorders provide the most provocative and interesting discussions as to why various forms of psychotherapy or pharmacotherapy or a combination of these modalities have been chosen. It has always been my view that these are the most exciting areas in psychiatry because they lead to bias in treatment selection and should, in sophisticated academic centers, lead to an opportunity to further our knowledge by enlightened and constructive intellectual debate.