Posts Tagged ‘antidepressants’

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.

Pharmacology of Anxiolytic Drugs

Pharmacology of Anxiolytic Drugs. WHO Expert Series on Neuroscience, vol. 3

Racagni G, Masotto C, Steardo L

Seattle (WA): Hogrefe and Huber; 1997. 132 pp. with index

ISBN 0-88937-088-5 (cloth)

This monograph forms part of the World Health Organization’s expert series in neuroscience, which is intended to help prevent or control mental neurological disorders and psychosocial problems, as well as to ensure broad use of mental health knowledge in general health care within WHO member states. It is indeed a textbook of pharmacology and should be viewed as such.

The authors must be world renowned in the field of pharmacology and its clinical application, although I could find only one citation by one of the authors (a publication in Nature in 1979) through MEDLINE. As well, the authors do not cite themselves in the book, indicating either that they are modest or that their publications are now aged. The University of Milan, however, has a reputation for expertise in pharmacology.

The book begins with a succinct history of the search for anxiolytics. The comprehensive contents of the book are then divided into 4 groups. Group 1, on benzodiazepines, is the most comprehensive of the chapters and includes a detailed description of each of the benzodiazepines, including their 2-dimensional chemical formulae. There is an extensive discussion of action, side effects, dependance and interactions. Group 2 discusses compounds with benzodiazepine-like activity, and details agonists, partial-agonists and antagonists. Group 3 reviews compounds that act on nonbenzodiazepine receptors and includes a large discussion of the role of serotonin in anxiety. Group 4 considers the role of antidepressants as anxiolytics and includes tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, α2-adrenergic blockers and β-blockers.

Only generic drug names are used throughout the book.

This book is a very comprehensive, well-organized and crisp discussion of anxiolytic drugs, and includes scientifically backed clinical use. Remember, the title is Pharmacology of Anxiolytic Drugs, and so the rather dry chemical formulae, pharmacokinetics and pharmacodynamics seem clinically sterile. The authors include substances that we prescribe routinely as well as medications that are not very commonly used in this country but may be in other parts of the world.

There are other texts, such as those by Goodman and Gilman or by Schatzberg and Nemeroff, that are more enjoyable to read, but they are not as complete as this book, and they cannot be held in one hand. This book is not a light read, but is a good, comprehensive reference.

My main criticism is that there is a lack of reference to the clinical situation, but then, this is a textbook of pharmacology.

The readership is meant to include nurse practitioners, social workers, family physicians, and others, but I believe they would use this book only as a reference text. Psychiatrists, residents in psychiatry and anesthetists would find this book quite valuable.

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.

Electroconvulsive Therapy

Electroconvulsive Therapy, 3rd Edition

Richard Abrams

New York: Oxford University Press; 1997. 382 pp

ISBN 0-19-510944-9

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

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

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

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

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

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

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

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

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

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.

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.

Neurobiology of Violence

Neurobiology of Violence

Volavka J

Washington (DC): American Psychiatric Press; 1995. 397 pp with index

ISBN 0-88048-343-4 (cloth)

Human behaviours are extremely complex; human aggression and violence toward other human beings are the most complex of them all. Neurobiology of Violence by Jan Volavka is an important contribution to the understanding of this most complex of human behaviours. If you are a practising clinician (psychiatrist, physician, psychologist or other mental health professional), I recommend that you order this book immediately. If you are a psychiatric resident preparing for the specialist examination, I recommend that you beg, borrow, steal or preferably buy a copy of this book, as it should be an essential part of your reading list.

In the preface the author talks about her imprisonment in a Nazi prison at the age of 10, an experience that inspired her to study and understand the roots of violence. In the introductory chapter she discusses the concepts of biological and environmental reductionism and the 3 models of the nature-versus-nurture debate: the either/or model, the combined model and the transactional model.

The first chapter deals with semantics: definitions of aggression, violence and destructive behaviour, and the difficulties with these definitions. The author goes on to define crime and criminality and points out the flaws in the studies of crime rates, incidence and prevalence; she also discusses instruments for assessing aggression and hostility. Thus, in chapter 1 the author primes the reader for a critical review of various research studies on violence. Chapters 2 and 3 review studies of aggression in animals and human beings, especially the role of neurotransmitters and hormones. Chapter 4 deals with neurological, neuropsychological and electro-physiological correlates of violence. Chapter 5 covers congenital and demographic factors in the causation of violence. Chapter 6 deals with developmental antecedents of violent behaviour, including early childhood factors such as inappropriate parenting, attention deficit with hyperactivity disorder and physiological traits that interfere with the child’s ability to learn the inhibition of antisocial and aggressive behaviour. Chapter 7 moves on to the clinical area of personality disorders and impulse control. Specific types of impulse control disorders, such as intermittent explosive disorder and pyromania, are explained. Relevant research on the serotonergic system, glucose metabolism and electrical brain activity are reviewed. Chapter 8 deals with the important area of violence and psychoactive substance abuse. The effects of both acute and chronic use of alcohol and cocaine and other drugs — alone and in combination with alcohol — are discussed. The review of research on the effects of cannabis is topical, as there is renewed discussion of the decriminalization of the use of marijuana, especially for medical purposes.

Chapter 9 is probably the most clinically relevant chapter in this book. It deals with the violent behaviour of persons with mental disorders outside the hospital setting. The relation between major mental disorders, arrest rates (criminal behaviour) and violence is discussed. The author reviews various studies and evaluates the strengths and weaknesses of their methodologies and, consequently, of their findings. The author also discusses the concepts of criminalization of mental illness and “psychiatricization” of criminal behaviour. Prediction of violence and risk assessment are examined with findings from relevant studies. The author compares and contrasts the concepts of prediction of violence using clinical methods and actuarial methods. (There is an appendix on “Statistical explanation of the actuarial method: Bayes decision.”) The author goes on to analyze critically the limited number of studies and points out the “failure of psychiatric prediction of dangerousness.” Clinicians face the task of predicting violence in individual patients daily, in hospitals, emergency department and other clinical settings. This chapter describes the strengths and weaknesses in this task. The author’s willingness to state her opinion on controversial and complex issues is very evident in her review and analysis of findings from various studies of the prediction of violence.

Chapter 10 deals with the violent behaviour of psychiatric patients in the hospital setting. Chapter 11 discusses the pharmacological treatment of violence and problems in conducting research in this area. The use of drugs — including antipsychotics, benzodiazepines, 6-adrenergic blockers, lithium, antidepressants and anxiolytics — is adequately covered. Chapter 12 is a summary of the subjects dealt with in the previous 11 chapters. There are also 60 pages of references of all the studies referred to in the main text. This is followed by an 28-page index that helps the reader to locate information readily.

The author’s writing style is very enjoyable, and her ability to synthesize information from a large number of studies and arrange them in a clinically relevant sequence is very evident. The author has made an excellent contribution through this important book on the study and understanding of violence.

This book deals only with the biological aspects of violence. Any reader who wishes to understand the other facets of violence must rely on books dealing with nonbiological factors.

I hope that every clinician will get a copy of this book, since dealing with and predicting violence in psychiatric patients is an unavoidable task and this book helps immensely in fulfilling that task as an informed and erudite practitioner.

Assessment and Diagnosis of Personality Disorders

Assessment and Diagnosis of Personality Disorders: The ICD-10 International Personality Disorder Examination (IPDE)

Loranger AW, Janca A, Sartorius N (editors)

New York: Cambridge University Press; 1997. 226 pp with index

ISBN 0-521-58043-9 (cloth)

Personality disorders are a controversial construct in psychiatry. There is no clear separation between normal traits and disorders. In spite of the diagnostic requirement that personality disorders continue over time, they are not always stable. Patients with other disorders, particularly depression, undergo distortions of their normal personality. As well, the categories of disorders described in the present classification system suffer from validity problems.

Nonetheless, there are several reasons why the construct of personality disorder is essential to psychiatry. Clinicians — particularly those interested in psychotherapy — find these diagnoses useful in describing patients who are unusually resistant to treatment. Failure to consider an Axis II diagnosis can lead to many clinical errors, since patients with these diagnoses respond relatively poorly to antidepressants and since their condition cannot be accounted for by an Axis I diagnosis alone.

A substantial group of researchers who have become interested in this subject have formed an international society that publishes its own journal. Granting agencies have often supported personality research and, in light of the possibility that personality pathology could eventually be treated pharmacologically, even drug companies have financed some research endeavours in this area.

Establishing the cross-cultural reliability and validity of these disorders would therefore be an important step in increasing the use of personality diagnosis by clinicians and researchers. This book offers a coherent method of addressing these problems, through a diagnostic instrument, the International Personality Disorder Examination (IPDE), that has been pilot-tested in many countries: Canada, the United States, Great Britain, Austria, Germany, Italy, Luxembourg, the Netherlands, Norway, Switzerland, Kenya, India and Japan.

Armand Loranger was the driving force behind this project. The interview described in this book is adapted from an earlier one that he developed for use in North America. The first part of the book contains several well-written and useful chapters by personality disorder researchers: Dahl from Norway, Andreoli from Switzerland and Reich from the United States. Most of the text consists of a detailed description of the IPDE, which is part of the International Classification of Diseases, 10th revision (ICD-10). The instrument can also be used to generate diagnoses from the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM-III-R), but describing this procedure would have required a longer book.

The research findings in this volume are of some general interest. Patients who met the criteria for the ICD-10 personality disorder categories (as well as those for the DSM-III-R categories) were found at all sites where the instrument was tested. The 2 disorders that were common in most countries were emotionally unstable (or “borderline” in the DSM-III-R system) personality disorder and anxious (or “avoidant” in DSM-III-R) personality disorder.

Since the IDPE is designed for research use, this book will be of interest primarily to investigators. The interview described here is extensive, in fact too extensive for wide application in practice. The authors caution that is not intended as a substitute for clinical diagnoses. Ultimately, the most important use for the IDPE is in community surveys to measure the cross-cultural prevalence of personality disorders. Such surveys could provide support for the cross-cultural validity of these disorders and examine the important question of whether there are cross-cultural differences in their prevalence. If we can identify such differences, social factors may play an important role in etiology of these puzzling conditions.

Biology of Schizophrenia and Affective Disease

Biology of Schizophrenia and Affective Disease

SJ Watson, editor

Washington (DC): American Psychiatric Press; 1996. 540 p

Over the past 30 y and particularly over this last decade — the decade of the brain — there has been marked acceleration of research efforts in the fields of neuroscience, molecular genetics, and biochemistry of mental disorders. Coupled with increasing sophistication in clinical observations, there has been an explosion of information about mechanisms of normal and pathological brain function. Although we are still far away from a clear understanding of the psychopathology behind 2 of the major psychiatric disorders, schizophrenia and affective disorders, substantial information already exists linking subcellular biological activities and the functioning of the neurons. The integration of information from molecular genetics, biochemistry, pharmacology, brain anatomy, and neuroimaging has advanced our knowledge about the impact of mental illness on specific brain neural circuits and their response to treatment. The recent and evolving knowledge about such specific brain circuits has inspired a new strategy of pharmacological targeting in the treatment of mental disorders. In this context, this book has its major strength focusing on the interface between several mental disorders and the genetics, pharmacology, neurochemistry, brain imaging, and postmortem studies reported by the researchers themselves, who are active in these fields.

The book emanates from contributions by a number of well-known and accomplished researchers in neuroscience to the 73rd meeting of the Association for Research in Nervous and Mental Disease, which took place in New York in 1993. One major feature of that meeting was that speakers were asked not only to present an overview of their field and their own work but also to provide their views on future developments. The book includes 17 chapters that deal with topics related to schizophrenia, affective disorders, infantile autism, an introductory chapter by the editor himself, and an overview chapter with discussions at the end. The introductory chapter by Watson presents an overview of mood disorders, autism, and schizophrenia from a clinical perspective and sets the stage for the basic science chapters that follow. The chapter written by Akil, “Biology of Stress from Periphery to the Brain,” explores the concept of “stress” as a trigger for psychiatric illnesses. The contributor documents her extensive work on the regulation of the limbic-hypothalamic pituitary-adrenal access and makes clear the well-known point that “the stressful nature of any given stimulus resides less in its objective characteristics and more in the organism’s ability to cope with it” (p 15).

The 5 chapters that relate to affective disorders include a contribution by Blakely about norepinephrine and serotonin transporters that highlights the progress on the molecular targeting of antidepressant effects. Another chapter, by Owens and others, deals with peptides and affective disorders and concludes with an account of future directions in the area based on the development of such new approaches as the application of ribonuclease (RNASE) protection assay, the expanding knowledge of the peptidergic brain circuits, and the ability to image central nervous system tissue with magnetic resonance imaging and positron emission tomography technology. The chapter about the mechanism of action of antidepressants by Berman and others elegantly reviews information, both basic and clinical, about well-known monoamines that have been explored in terms of their mechanism of action: serotonin, norepinephrine, dopamine, and neuropeptides. The chapter delves beyond the monoamines theory, however, by exploring postreceptors signal transduc-tion and neuroanatomy of antidepressant action and their relevance for the development of novel treatment approaches to depressive disorders. The chapter by Raichle and Drevets maps brain circuits relative to brain function and explores its implication for psychiatric illnesses. Another excellent chapter, by Mann and others, presents an up-to-date review of available information spanning more than 2 decades about postmortem studies of suicide victims.

The book includes 8 chapters related to schizophrenia. The chapter by Benes entitled “Excitotoxicity in the Development of Cortico Limbic Alterations in Schizophrenia” examines both the proposition that schizophrenia is a neurodegenerative disorder and the evidence for glutamatergeric dysfunction in schizophrenia. Goldman-Rakic, in her chapter, “Dissolution of Cerebral Cortical Mechanisms in Schizophrenia,” advances the argument from a neurocognitive perspective about the importance of frontal cortex and the role of working memory in the disordered thinking of patients with schizophrenia. Using postmortem studies, Kleinman and Nawroz provide evidence for the involvement of dorsal lateral prefrontal cortex, the hippocampus, and the entrorhinal cortex in the pathology of schizophrenia. An up-to-date review of the “Epidemiology and Behavioral Genetics of Schizophrenia” is provided by Tsuang and Faraone. Khan and her colleagues, in their excellent chapter, “Revisiting the Dopamine Hypothesis in Schizophrenia,” advance the argument for schizophrenia as both a hyper- and hypodopamine state, thus linking such diverse elements of the broad spectrum of symptomatology as positive and negative symptoms as well as neurocognitive deficits. The contributions of neuroimaging to the understanding of the psychopathology of schizophrenia is well presented in a chapter by Van Horn and colleagues. “Abnormal Frontotemporal Interactions in Patients with Schizophrenia,” by Friston and others, provides results of their extensive work using neuroimaging in examining functional connectivity by studying corticocortical interactions in patients with schizophrenia. The last contribution related to schizophrenia is the excellent chapter by Meltzer and others, “Exploring the Mechanism of Atypical Anti-psychotic Medications,” which provides evidence for Meltzer’s recent argument for a major role for serotonergic mechanics in the improved therapeutic effects of atypical antipsychotics, particularly their tendency to produce significantly fewer extrapyramidal side effects.

The chapter devoted to “Linkage and Molecular Genetics of Infantile Autism” by Ciaranello reports the results of extensive linkage studies of 1 of the least understood disorders: infantile autism. This chapter, coming after the recent sudden and untimely death of its author, serves as a memorial to a distinguished scientist.

Overall, the book is a significant contribution, providing valuable information for understanding the mechanisms of normal and pathological brain function and its relevance to schizophrenia and affective disorders. The book makes a good attempt to integrate information at the level of functional neurocircuits. It should be of interest not only to neuroscientists but also to psychiatrists, neurologists, and psychologists. Although the book is about basic neuroscience, its relevance to clinicians is obvious because it explores the basic biological brain functions in relation to mental

illness. The book reads well, which reflects the skills of its editor, Stanley Watson. The only regret I have is that it took 3 y to publish the proceedings of that 73rd meeting of the Association for Research in Nervous and Mental Disease, which is rather a relatively long time in terms of the rapidly evolving neuroscience research. Nevertheless, the book is a valuable contribution and continues to be equally relevant today.