The Maudsley Handbook of Practical Psychiatry

The Maudsley Handbook of Practical Psychiatry, 3rd edition

D. Goldberg, editor

New York: Oxford University Press; 1997

ISBN 0192628534 (hard cover)

Often when residents begin training in psychiatry there is a great deal of anxiety, particularly related to the first on-call experience. Most training in medical school focuses on the skills used to take patient histories and conduct medical examinations; these need to be modified when dealing with psychiatric patients.

Residents who have been comfortable with the medical model are frequently unsure about how to elicit information from patients with psychiatric difficulties. And most introductory psychiatry textbooks contain a great deal of factual information but do not provide practical advice. The widely used Synopsis of the Comprehensive Textbook of Psychiatry by Kaplan and Saddock is an example of a work that began as a condensed version of a larger textbook but has grown to such a size that there will soon be a need for a synopsis of the Synopsis of the Comprehensive Textbook.

In the Maudsley Handbook of Practical Psychiatry, David Goldberg, director of medical education at the Bethlehem Maudsley NHS Trust in London, has attempted to provide a comprehensive yet accessible introductory textbook for residents as they begin training. The book was developed in consultation with staff psychiatrists and house officers from the Maudsley to ensure that the book meets the needs of house officers and residents. It attempts to provide a comprehensive guide to psychiatric and neuropsychiatric examinations and guidelines for the clinical management of common psychiatric presentations in the emergency setting and in the early phases of treatment. It is meant to be a guide for doctors beginning their training in psychiatry and for those preparing for professional examinations, and although written in the United Kingdom, is intended to be used elsewhere.

The structure of the book reflects these objectives. There is a section on the psychiatric interview and assessment, which includes the mental status examination as well as some aspects of neuropsychiatric assessment. The section on early treatment is less extensive and focuses primarily on the initial stages of management. There are also sections on referring patients to specialists and on the medicolegal issues related to psychiatry in the UK.

The most valuable section of the book is on interview and assessment; it provides practical guidelines for the assessment of children, adults and geriatric patients. Although written for the beginning trainee, a review of this section would be valuable for residents preparing for their oral examinations. There are well-written discussions of difficult situations in the interview setting, and of issues such as gifts, disinhibited patients, violence and sexual involvement with patients.

The issue of false memory and repressed memory is certainly a controversial one in the field of psychiatry. This handbook provides one of the better overviews of this area, discussing the evidence for repressed memory and for concerns about false memory. Practical discussions about the impact of these issues on the psychiatric interview are clear, as are discussions of cross-cultural issues and their impact on the psychiatric assessment.

Unfortunately, other sections of the book are not as helpful. The sections on medico-legal issues are relevant largely to the UK. Although there is some interesting discussion of such things as consent and hospitalization, these are presented within the context of UK laws rather than in terms of general principles. The section on referral is largely unhelpful in the Canadian context; many of the suggested indications for specialist referral are in fact issues that residents are directly involved with.

Because drug therapy evolves so rapidly, by the time a book is in print, aspects of it are already out of date. This fact has limited the usefulness of the section on early treatment. For example, haloperidol is recommended for patients who present with acute psychosis, and for patients who are unresponsive, treatment with chlorpromazine and clozapine is recommended. Obviously, this does not take into account the impact of newer atypical antipsychotic agents on the management of patients in the acute treatment setting or in first-episode psychoses. There is even less discussion of medication use, probably because the goal of the book is to focus on early management, the assumption being that residents will discuss the initiation of such treatments as antidepressant medication with a staff psychiatrist. In many cases the treatment plans outlined are general, probably insufficient to allay the anxiety of a beginning resident, and lack sufficient complexity to be of use to a senior resident.

The final difficulty I had with this book is related to one of its strengths. As noted above, there is an unfortunate tendency in the medical field for handbooks and synopses to rapidly balloon into tomes large enough that no hand could easily encircle their girth. The Maudsley Handbook is in fact a book that could slip quite comfortably into the pocket of a lab coat. Because of that, however, the layout is very tight and the margins are small. This makes it difficult to find things quickly when leafing through it. Breaks are not obvious and sections blend together.

The Maudsley Handbook is, I believe, a valuable introductory handbook in terms of its discussion of the psychiatric interview and assessment. For this reason alone I would recommend it for beginning residents and those preparing for their oral examinations. It does not, however, live up to its billing as a provider of extensive and practical management guidelines for a variety of psychiatric conditions, and is limited by the fact that it is written primarily for the UK audience, despite its claim to do otherwise.