Posts Tagged ‘depression’

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.

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.

Treatment Compliance and the Therapeutic Alliance

Treatment Compliance and the Therapeutic Alliance

Barry Blackwell, editor

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

ISBN 90-5702-546-9 (cloth)

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

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

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

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

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

Handbook of Behavioral State Control

Handbook of Behavioral State Control: Cellular and Molecular Mechanisms

Lydic R, Baghdoyan HA, editors

Boca Raton (FL): CRC Press LLC; 1999. 700 pp. with index

ISBN 0-8493-3151-X (hard cover)

Although one may argue that any change in neuronal activity may ultimately lead to behavioural alterations, a closer relation between single cell function and behavioural consequences is needed. This relation is complex, and there are numerous and inter-related regulatory levels between cellular/molecular processes and behavioural outcome. It is therefore not surprising that there is a remarkable lack of exhaustive textbooks that explain cellular mechanisms underlying behavioural activity more globally. This book, edited by Lydic and Boghdoyan, both from Pennsylvania State University, partially fills this gap. It is a carefully planned handbook divided into 38 chapters organized in 8 sections, and written by 95 authors. The book’s major goal is to provide updated material on the cellular and molecular mechanisms generating diverse behavioural states. The authors do not explain cellular mechanisms of particular behaviours but rather provide information about the neural processes that regulate behavioural states, such as sleep, wakefulness, consciousness, arousal, etc. Different behavioural states, in turn, determine a subset of possible behavioural outcomes. The dominating theme of the book is sleep, wakefulness, arousal, and vigilance; this theme is compatible with the research interest and experience of the editors in the neurobiology of sleep mechanisms.

The handbook represents a working reference for numerous topics relating to physiological, psychological and pathophysiological states, including information on epidemiology, diagnosis, and treatment of common state disorders. The chapters in the first section discuss mammalian circadian rhythms, structure and function of the suprachiasmatic nuclei, melatonin rhythm-generation systems, and genetic circadian clock mechanisms. The subsequent chapters of the second section describe daily alterations in the arousal state, REM sleep dreaming, NREM sleep mentation, and neurological disorders of sleep. Section 3 deals with the anatomical substrate, neurochemical coding, and functional organization of components of the ascending reticular activating system, which includes ascending cholinergic, monoaminergic, and glutamatergic pathways. Particular attention is paid to the mesopontine cholinergic system and its role in REM sleep, wakefulness and cortical activation, and the noradrenergic and serotonergic pathways and their role in sleep, wakefulness, regulation of motor output and sensory information processing. The same systems are further discussed in more detail in the next section. Successive chapters deal with intrinsic membrane properties, synaptic activity, membrane current characteristics and excitability of cholinergic, noradrenergic, and serotonergic neurons. Particular attention is focused on the state-dependent cellular oscillations in the corticothalamic system and on the rhythmic oscillations in the hippocampal formation.

Mechanisms of behavioural state control may be altered by centrally active drugs. Several chapters in the section entitled “Molecules modulating mental state” discuss this issue. Neuronal and neurochemical mediation of addictive behaviour, and alterations in behavioural state caused by benzodiazepines, barbiturates, ethanol, caffeine, nicotine, marijuana, and serotonin antagonists are discussed.

The following 2 sections of the handbook review the current knowledge regarding state-dependent processing in somatosensory pathways and the role of the rostral ventromedial medulla in regulating ascending sensory transmission. Several chapters of the last 2 sections of the handbook deal with pathophysiological states. There is a particular emphasis on pain sensation, anesthesia, pharmacological and surgical treatment of pain, and immunological alterations in the arousal state. The topics cover cytokines in sleep regulation, immune effects on neurotransmission, and finally, body temperature, fever and microbial modulations of arousal.

Although the textbook covers vast areas of behavioural neuroscience, there are several important areas that are not represented. Results of the vast research concerning emotional states, such as anxiety or fear, and relevant regulatory functions of the limbic structures are not included. Also, psychopathological states of panic, depression, or euphoria are not described, except in parts of one chapter about addictive behaviour and neural mechanisms of reward. This topical selection was probably necessary to keep the textbook at the manageable size.

The textbook is well illustrated and contains overall 3500 references, more than 90 references per chapter. The book may serve as an excellent resource for advanced undergraduate and graduate students, postdoctoral fellows and biomedical researchers working with animal models of neurological and neuropsychiatric disorders. It will also be highly useful for medical residents, lecturers in neuroscience courses, and other professionals interested in problems of behavioural neuroscience and general neural principles governing animal and human behaviour.

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.

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.

Concise Guide to Geriatric Psychiatry

Concise Guide to Geriatric Psychiatry, 2nd edition

Spar JE, La Rue A

Washington (DC): American Psychiatric Press; 1997. 326 pp with index

ISBN 0-88048-796-8 (paper)

Geriatric psychiatry is becoming an important psychiatric sub-specialty. The authors, James Spar, MD, and Asenath LaRue, PhD, from the University of California, Los Angeles and the University of Mexico, respectively, are experts in this burgeoning field. The first edition of their book, based on the DSM-III-R and published in 1990, provided a delightful, well-written, pocket-book-sized summary of practical information for psychiatrists, psychiatry residents and medical students working in a variety of treatment settings. It included information on mental health issues in old age, on normal aging and on the diagnosis and management of geropsychiatric disorders.

The second edition (based on the DSM-IV) is even better. It is 50% longer than the original and includes necessarily expanded sections on the differential diagnosis and psychopharmacology of mood disorders, an additional section on Alzheimer’s disease, and a thoughtful 30-page appendix of instruments (e.g., Mini Mental State Examination, Geriatric Depression Scale) commonly used for clinical assessment. Particularly useful are the numerous clinical vignettes throughout the text and the many tables and figures that summarize information.

Despite the strengths of this little book, it does have limitations. It is not evidence-based. It does not define the frontiers of knowledge or encourage critical thinking. Some statements or recommendations appear to be just opinions; for example, some readers might not agree that selective serotonin reuptake inhibitors (SSRIs) are first-line drugs for the treatment of depression. Finally, the lists of references and additional readings include articles published almost exclusively in US journals.

Limitations notwithstanding, this pithy paperback is the book of choice for psychiatry residents completing a mandatory rotation in geriatric psychiatry. It may also be of interest to general psychiatrists, geriatricians or family physicians who want a clear summary of the psychiatry of old age.

Multi-axial Classification of Child and Adolescent Psychiatric Disorders

Multi-axial Classification of Child and Adolescent Psychiatric Disorders: The ICD-10 Classification of Mental and Behavioral Disorders in Children and Adolescents

World Health Organization

New York: Cambridge University Press; 1996. 302 pp with index

ISBN 0-521-58133-8 (cloth)

For many decades, psychiatric epidemiology involving comparisons among countries has been handicapped by different classification systems. North Americans tend to use the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) criteria, developed primarily by committees of the American Psychiatric Association, whereas western European countries use the International Classification of Diseases system, now in its 10th revision (ICD-10). This book is the ICD-10 equivalent of the big green DSM-IV manual that lists the multi-axial classification of psychiatric disorders, together with the brief description of signs and symptoms that make up the essence of the diagnoses.

The introduction, by the eminent child psychiatrist Michael Rutter, is first-rate. It indicates that there has been serious corroboration with DSM-IV. The similarities, including the use of a multi-axial description of each diagnosis and brief descriptions of signs and symptoms, are much more evident than any differences. As with DSM-IV, the diagnoses are based on clinical description and not on etiology, since precise causation in psychiatric disorders cannot be determined in most diagnostic categories.

As is often the case with British medical textbooks, the language is more succinct and the book is shorter than its North American counterpart.

A compare-and-contrast exercise does reveal some interesting, although relative minor, differences. Autism or pervasive development disorder and mental retardation are placed on axis II, instead of on axis I, in the ICD-10 system.

Under conduct disorders, always a problematic diagnostic category, there is an intriguing and possibly useful category called “conduct disorder confined to the family context.” In the section on affective disorders, the ICD-10 system does not include rapid cycling bipolar disorder.

The ICD-10 system has maintained a category of neurotic disorders, which are virtually identical to the personality disorders in DSM-IV. Among the neurotic disorders described by ICD-10 is “neurasthenia.” This concept, which feels outdated from a North American perspective, is related in a fairly modern way to postviral fatigue states and depression. “Neurasthenia” appears to have resurfaced in North America as chronic fatigue syndrome.

The section in ICD-10 on personality disorders suggests that these disorders can be diagnosed as early as 16 years of age, in contrast to the North American view that personality disorders begin only at age 18. The North American approach takes into account the flexibility of adolescent minds, which we hope will not settle into permanent personality structures prematurely. The use of the term “anankastic” for obsessive-compulsive disorders is another example of the way that traditional psychiatric phenomenology is maintained in the ICD-10.

Another example of a difference in terminology, which is illustrative of British brevity, is “clumsy child syndrome,” which is the same as “developmental coordination disorder,” described in DSM-IV.

In contrast with DSM-IV, ICD-10 does not set up lists of symptoms with the instruction that 3 or more must be present. There is usually a description of the general presentation of the problem. Instead of counting up symptoms, the clinician then forms personal impressions and makes his or her own judgements.

Axis V in ICD-10 refers to associated abnormal psychosocial situations. This is virtually the same as axis IV in DSM-IV, which refers to psychosocial and environmental problems. I found, however, that the ICD-10 axis V was more specific and clearer in describing the precise problems that children and families have. For instance, there is a specific category for lack of warmth in parent-child relationships, for scapegoating of a child, for disability in a sibling, for experiential privation and even for parental overprotection. Such clear categories allow family dysfunction to be introduced diagnostically in a clearer way.

The ICD-10 text on multi-axial classification of child and adolescent psychiatric disorders is a parallel but not identical effort to the DSM-IV currently in use in North America. Each system has something to teach the other. The continuing collaboration between the two evolving systems can only be of benefit. This book is not exactly a thriller to read, but for those interested in international collaboration in clarity of diagnostic categories, it is a very important sourcebook.

The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

This book describes the role of primary care physicians in the prevention of mental disorders. The literature consistently reports that 25% to 30% of patients presenting in primary care have significant psychological problems. The book is divided into 3 sections dealing with the major types of illness prevention: primary (risk factors), secondary (early identification and intervention), and tertiary (decreasing complications and recurrence). These distinctions are not consistently followed, but overlap between sections is avoided. Each chapter is well referenced, and most chapters cover the subject adequately. A preventive model of conceptualizing problems is employed, but the flaw in this approach to primary prevention is acknowledged. Many known risk factors, such as social, economic, and societal conditions and attitudes, cannot be modified by primary care professionals. Effort must be directed primarily at high-risk patients. The authors recognize that some physicians lack sufficient interest and ability to diagnose and manage psychiatric illness and throughout the book suggest ways to address this problem.

Chapters 1, 9, and 15 deal with primary, secondary, and tertiary prevention of childhood psychiatric disorders. Risk factors in the child, parenting, and environment, as well as protective factors, are very well described. Most children are seen regularly in primary care, which gives these practitioners a unique opportunity to employ all 3 types of prevention. When disorders are detected, care must be taken to avoid inappropriate reassurance and unnecessary pharmacotherapy. The role of the family in the management of chronically ill and disabled children is emphasized, along with the need to provide support to the parents. Chapter 3, on the relevance of life events in mental illness, relies mainly on the work of George Brown and his colleagues. A practical guide for intervention strategies is also included. Prevention of postnatal depression, a distinct diagnosis in British psychiatry, is discussed in Chapter 4. The unique opportunity for primary care physicians to detect this disabling condition is emphasized, but the suggested role for health care visitors is generally unavailable in this country. Chapter 5, on bereavement, has a good description of normal grief and an excellent discussion of risk factors for abnormal grief reactions. Practical suggestions for the appropriate use of counseling and medication are included.

Chapter 6, on prevention in ethnic minorities, is quite specific to British society, although the principles of how physicians perceive, interpret, and treat psychiatric problems in ethnic patients are universally applicable. The chapter on “learning disability” is initially confusing because in Britain, unlike North America, the term refers to developmental delay. The references suggest that 33% to 66% of children with “learning disability” have significant psychopathology. The important role of primary care practitioners in secondary prevention is discussed, but the use of a team for management is seldom feasible for Canadian family doctors. Chapter 8 contains a general discussion of the importance of good counseling skills but again assumes the existence of a primary care “team” of professionals.

Chapters 10, 16, and 17 describe secondary and tertiary prevention of depression. This common and treatable disorder is frequently unrecognized in general practice both because of the symptoms presented (often somatic) and the knowledge, skills, and attitudes of physicians. Ways to improve the detection rate are described, and an excellent section on long-term drug management is presented. The particularly important role of general practitioners in encouraging compliance is acknowledged. Discussion of psycho-therapeutic interventions in the management of depression is limited to a good description of cognitive therapy. Primary and secondary prevention of anxiety disorders is addressed in Chapter 11, which includes a discussion of the physical, behavioral, and environmental factors that maintain anxiety symptoms. The author recommends and briefly describes nonpharmacological management techniques, although the use of a team approach is again assumed. Chapter 12, on eating disorders, addresses the well-recognized problems in primary prevention that deeply ingrained societal attitudes are impossible to change and that prevention programs sometimes increase unwanted behaviors (for example, binging and purging). The physical consequences of these disorders are well outlined, but little reference is made to the psychological and social sequelae. Detection of eating disorders is a major responsibility of general practitioners but requires a high level of awareness of risk factors and signs and symptoms — these patients are often very secretive. Not discussed is the role of physicians in monitoring physical health or supportive counseling as an adjunct for their patients who attend specialized treatment programs. Chapter 13, on alcohol and drugs, describes the detection and management of alcohol abuse, as well as the primary prevention of medication abuse by judicious prescribing practices. Because drug seeking from multiple physicians is uncommon under the British system, the problem is not mentioned in this book. Psychosis, primarily schizophrenia, is discussed in Chapters 14, 18, 19, and 20. As in Canada, general practitioners are now expected to detect and treat 1st-episode psychosis, and the importance of early pharmacological treatment is emphasized. Increasingly, patients are managed for the long term in primary care, and physicians must be aware of the special physical, psychological, and social needs of this vulnerable group and be cognizant of the high suicide risk. Social management of patients with schizophrenia is well described, with emphasis on the role of families. In Canada, the functions proposed for primary caregivers are provided, if at all, by specialized mental health services. Finally, Chapter 21 briefly discusses suicide prevention in primary care. The major roles are to recognize patients at risk, provide treatment and/or referral, and offer support for staff and families when suicide occurs.

The authors of this book are academics from general practice and psychiatry backgrounds. The intended audience is primary care physicians and their teams, but the book should also be read by psychiatrists and mental health professionals who treat patients also seen by family doctors and who teach medical students and residents. In conclusion, this is a very readable volume which is well researched and which provides good recommendations, although some are not applicable to the Canadian system.

Psychiatry in Progress

Psychiatry in Progress, Volume 3: Neuropsychiatry in Old Age

C Stefanis, H Hippius, editors

Toronto: Hogrefe &Huber; 1996. 171 p

This slim volume contains the proceedings of a symposium sponsored by Ciba-Geigy and held on the island of Rhodes, Greece, in April 1994. Its aims are both to outline the current state of scientific knowledge on the biology of aging and to address major issues relating to neuropsychiatric disorders in the elderly. Unlike the published proceedings of many other symposia, this volume is well written, well edited, and flawlessly produced.

Internationally recognized experts, most from Europe, distill knowledge on selected topics that range from molecular biology to ethical issues near the end of life. For example, Wisniewski writes on the neuropathology of Alzheimer’s disease caused by fibrillation of A, p, and tau proteins; Copeland writes on the comparative epidemiology of dementia and depression in old age; Ritchie writes on psychological testing, and Gottfries writes on the pharmacotherapy of cognitive deficits. Each chapter begins with a useful summary and finishes with pertinent references and discussion from the floor.

The chapters are concise and informative but not comprehensive. Usually, each chapter presents a point of view or develops a theme that summarizes current knowledge and highlights a topic or issue requiring further research. For example, Bar and Gispen cite evidence that neuroplasticity exists throughout the life span and may be modifiable with calcium channel-blocking drugs; Muller-Spahn and Hock examine the spectrum of dementia and depression and propose biological approaches to the differential diagnosis of these disorders.

Obviously, this book is neither a text of neuropsychiatry in old age nor a reference work. Rather, it contains a series of interesting and authoritative reports on 13 selected topics. It is therefore a valuable book for the geriatric psychiatrist or psychologist who wants some challenging recreational reading or even for the general psychiatrist who wants to explore more recent developments in the neuropsychiatry of old age.