Posts Tagged ‘medications’

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.

Novel Antipsychotic Drugs

Novel Antipsychotic Drugs

Edited by Herbert Y. Meltzer

New York, Raven Press, 1992. 267 pp.

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

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

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

Psychopharmacology of Cognitive and Psychiatric Disorders in the Elderly

Psychopharmacology of Cognitive and Psychiatric Disorders in the Elderly

Wheatley D, Smith D, editors

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

ISBN 0-412-82470-1 (hardcover)

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

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

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

Atlas of Psychiatric Pharmacotherapy

Atlas of Psychiatric Pharmacotherapy

Shiloh R, Nutt D, Weizman A

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

ISBN 1-85317-630-3

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

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

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

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

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

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

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

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

Biology of Personality Disorders

Biology of Personality Disorders

Annual Review of Psychiatry series

Silk KR. Washington: American Psychiatric Press; 1998. 156 pp

ISBN 0-8804-883-52

This book, part of the Annual Review of Psychiatry series, is a multi-authored text comprising 5 chapters by recognized authorities in the field. The topic is of interest because of the increased activity in the area of personality disorders over the past decade and a half with respect to typology, research and new treatment approaches. This book focuses on research into the biological aspects of personality disorders over the last 10 years or so. As Silk points out in the Foreword, earlier studies of biological correlates of personality disorders did not lead to clear conclusions because of lack of appropriate separation between personality disorders and Axis I disorders. The “second-generation” studies have focused on the core negative traits of personality disorders (e.g., impulsivity, aggression, cognitive disturbances and affective lability, which cut across most personality disorders) and sought to understand their biological underpinnings.

The first 2 chapters of the book review and discuss the biological research in the field, including research strategies employed, the results of some of the most important studies and the implications for further development.

The first chapter, by Coccaro, reviews studies of neurotransmitters that are significant for personality functioning. The most important of these are serotonin and the cate-cholamines, including dopamine and norepinephrine. The studies are reviewed under categorical headings including cerebrospinal fluid (CSF) metabolite studies, pharmacological challenge studies, platelet receptors and DNA in polymorphism studies, etc. The studies consistently find an inverse relation between CSF 5-HIAA levels and impulsive-aggressive behaviour.

There is a smaller body of research into the role of acetylcholine and vasopressin, which shows that acetycholine does contribute to affective lability.

The second chapter, entitled “New Biological Research Strategies for Personality Disorders” by Siever and colleagues, complements the first. It reviews studies using a variety of recently developed strategies to study core traits of impulsivity, affective instability and cognitive dysfunction. The strategies vary from neuroendo-crine and cognitive studies that look at the antecedents of neuroendocrine and cognitive abnormalities found in personality disorders, to the use of imaging (positron-emission tomography, single-photon emission computed tomography, magnetic resonance imaging [MRI] and functional MRI) to study neuroanatomical correlates of personality dysfunctional traits such as impulsivity and aggression. There are fewer studies using candidate gene strategies. The author comments on the implications of the findings to date from these areas of investigation.

A particularly creative strategy was the linking of the study of trauma to personality disorders. Trauma has its biological impact on the hypothalamic-pituitary-adrenal (HPA) axis, but trauma is also a major etiologic factor in many personality disorders, including borderline personality disorder (BPD). Studies of the HPA axis changes, such as dexamethasone suppression test (DST) in patients with post-traumatic stress disorder, have been extended to personality disorders as BPD, with the DST pattern more closely resembling that in PTSD than that in mood disorders.

The third chapter focuses on Cloninger’s proposed 7-f actor model of personality, comprising temperamental factors such as harm avoidance, novelty seeking, reward dependence and persistence, and 3 character elements: self-directedness, cooperativeness and self-transcendence. Cloninger makes the case for the neurobiological basis of learning abilities that underlie temperamental traits by summarizing studies of the psychobiological correlates of these traits. He then puts forward a psychobiological learning model based on his review of the neuropharmacological, neuroanatomical and biochemical studies, and on studies of the phylogeny of learning abilities. He concludes by making a strong argument in support of the 7-factor model as a basis for understanding the various dimensions of personality disorder and even the diagnostic clusters. Although much of the material is quite technical, the use of tables and other visual aids is helpful in summarizing and reinforcing the material presented in the text.

The last 2 chapters are more application-oriented. The fourth chapter, by Links, is interesting because of the proposal of an outcome-based approach to the pharmacotherapy of personality disorders. Outcome indicators would be reduction in certain characteristic behaviour patterns, such as repetitive self-injury, that have been shown to have a biological basis. Other outcome indicators include quality of life. The author notes the shortcomings of the current conceptual models of personality disorder as a basis for developing a treatment rationale. The outcome-based model proposes specifically desirable functional outcomes of treatment and more systematic approaches to assessment of the efficacy of medication. This proposal is very much in keeping with the current evidence-based approach to medical practice.

In the final chapter, Paris assesses the significance of research for a biopsychosocial model of personality disorders. The author points out inconsistencies between theoretical assumptions underlying some research strategies and real-world observations, as well as the many confounding factors that complicate the search for one-to-one correlations between biological variables and particular personality traits. Taking a dimensional view of personality disorders as the pathological amplification of normal traits, the author discusses the complicated interaction of biological and environmental factors in producing personality disorders via the diathesis-stress model. He proposes 3 potential research directions: new drugs targeting personality traits, gene therapy, and new forms of psychotherapy based on better understanding of temperament.

Since much of the research on impulsivity and aggressiveness reviewed is common to conduct disorder and attention deficit hyper-activity disorder as well as anxiety disorders in children, one would have expected a discussion of the relation of these conditions to personality disorders in adults. Despite this lack, I found this book to contain more than anticipated. The material in the first 3 chapters was detailed and informative, and the last 2 chapters helped to make it practically relevant. One is left with a feeling that personality disorders are now more real, and that there is hope for more targeted treatment in the future. I certainly recommend it.

Managing Side Effects of Psychotropic Drugs

Managing Side Effects of Psychotropic Drugs: A Clinical Handbook for Health Care Professionals

Oyewumi LK, de Wit R

London (ON): Zxmaxx Communications; 1998. 263 pp. with index

ISBN 0-9684372-0-6 (paper)

As the authors note in their Introduction, the plethora of new psychopharmacological agents introduced in the last decade has led to an extensive literature on the use and proposed mechanisms of action of these drugs. However, the literature on the side effects of these medications is limited at best. Rare is the patient who does not have at least some side effects from our treatments, yet far too often the patient’s only source of information on the drug and its side effects is the Compendium of Pharmaceutical and Specialties (CPS).1 Unfortunately, more often than it should be, the CPS is also the physician’s side effect “handbook”!

The authors have attempted to bridge this gap in our psychopharmacological knowledge base with a user-friendly, spiral-bound “handbook” on managing side effects of psychotropic drugs. They have done a good job.

The 8 chapters begin with an overview of the different classes of psychoactive agents, which includes an excellent table listing all antipsychotic and antidepressant agents (generic and trade names) and the average daily dose ranges. Unfortunately, hypnotics, anxiolytics, mood stabilizers and stimulants are omitted from the tables without explanation.

Chapter 2 reviews predisposing risk factors, epidemiology and classification (e.g., predictable v. idiosyncratic, initial v. tardive) of side effects, while the bulk of the handbook — Chapter 3 — is a detailed overview of these side effects. The format of Chapter 3 is unique, with “generic” headings such “dermatological” followed by subheadings (e.g., acne, allergic rash, alopecia, etc.). Under the subheadings, prevalence, occurrence, presentation, mechanism of action, and commonly associated drugs with this specific side effect are outlined. This is a very useful presentation for mental health professionals (physicians, nurses and students), but I suspect that drug “consumers” would have difficulty navigating this section. (Would they know to look under dermatological and alopecia for “hair loss”?)

Chapter 4 is a more academic chapter on evaluating side effects, and provides a listing of the various rating scales available to measure and monitor side effects.

Chapter 5, “Management of Psycho-tropic Drug Side Effects/’ offers very practical, clinically relevant treatment guidelines. These “bedside tips” in the management of dry mouth, pruritis, incontinence, etc., is clearly lacking in most pharmacology and clinical psychiatry textbooks.

The last 3 chapters review the consequences of drug side effects (compliance, economic effects); administrative aspects (the lack of postmarketing data on side effects); and psychodynamic/psychological aspects of side effects, such as placebo effect, “catching” side effects, drug side effects, and the transference/counter-transference in the doctor-patient relationship. All good stuff! The bibliography and references are detailed and up to date.

This is a very good start as a handbook that will be of value to psychiatrists, residents, nurses and consumers. It should find its way to psychiatric inpatient units, mental health centres and mental health support organizations as an excellent reference book. I do hope the authors are working on their second edition, as new drugs such as citalopram, reboxitine, and mirtazapine are already here, and additional new drugs could soon make this useful book outdated.

Some minor editing (e.g., in one section, it should have read “pharmacodynamic” not “psychodynamic” parameters) and combining the chapters on identifying and managing side effects would be helpful in the next edition. Further, more detail on the specifics of managing side effects (the book is entitled Managing Side Effects), such as specific dosages of drugs used to treat specific side effects, would enhance this work.

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications

Essential Psychopharmacology, Neuroscientific Basis and Clinical Applications. CD-ROM

Stahl SM. New York: Cambridge University Press; 1998

ISBN 0-521-62892-X

This CD-ROM is an introductory textbook to the extraordinary complexities of basic and clinical neurochemistry pertaining to psychopharmacology. To make this information lucid, engaging and accessible requires a gifted communicator; Stephen Stahl is such a teacher, whose credentials as a researcher give authority to the concepts, facts and speculations he conveys so clearly.

Since this “book” is in CD-ROM format, any review must consider both the content and the format. The text is structured into 12 chapters and relies heavily on figures and diagrams to illustrate key concepts. The first 4 chapters focus on basic science and provide the foundation for the remaining 8 chapters. Stahl begins with the principles of chemical neurotransmission, including signaling, receptor occupancy, second messengers and co-transmission. He then explains receptors and enzymes as targets of drug action and further explores special properties of receptors in terms of subtypes, agonists and antagonists. He concludes the basic science section with a chapter on the interaction between disease and chemical neurotransmission.

The second section is clinically focused and briefly summarizes the biological bases of mood disorders, anxiety disorders and psychoses as a prelude to explaining and rationalizing the actions and benefits of psychiatric medications — as well as speculating on interventions in the future. Stahl concludes by considering cognitive enhancers, neuroprotective agents and drugs of abuse.

Any one of these basic science concepts, clinical disorders and psycho-pharmacological treatments could easily be the subject of a separate book — one that Stahl himself could probably write. It is a remarkable talent to synthesize, integrate and communicate clearly this wealth of information as effectively as he does. The text is unencumbered by references or wordy explanations. Advanced experts in various areas may sneer at oversimplification (a similar phenomenon occurs when someone makes psychotherapy fundamentals obvious and accessible), but this text is clearly not intended for them.

The ideal readership for this CD-ROM includes medical students, residents in psychiatry and allied health professions, and psychiatrists whose training concluded more than 5 years ago.

This text existed as conventional “hard copy” (what we nostalgically refer to as a “book”) before its current incarnation as a CD-ROM. What is the advantage of the CD-ROM format? It could be an expensive proposition unless you already own an IBM-compatible computer with a 486 or faster processor, or a Macintosh computer with System 7 or 8, at least 16 mB of RAM, Quicktime software, a sound card and speakers or headphones, and a 2 x or faster CD-ROM drive. It is really designed for Macintosh computers, and the author acknowledges that there may be some limitations in using the CD-ROM in an IBM-PC environment. Reading the CD-ROM involves pressing keys and jumping backward and forward between text and figures. The advantages lie in the use of animated diagrams to illustrate neurotransmission concepts, often accompanied by audio narration featuring Stahl himself.

While the animation reflects the elegant synthesis characteristic of the author, it seems rather primitive compared with the sophisticated computer graphics on children’s games. The narration is the weakest of Stahl’s skills: it adds nothing and requires a separate keystroke to activate, when simply reading a caption would be preferable.

Other textbooks on CD-ROM provide more opportunity to print excerpts and take notes on the computer screen. This CD-ROM lacks flexibility. With a book version, I could have scribbled in the margin or photocopied a diagram. In summary, this textbook is superb in terms of content, but the technology of presentation does not facilitate access or understanding. Reading the CD-ROM made me want to buy the book.

Straight Talk About Psychiatric Medications for Kids

Straight Talk About Psychiatric Medications for Kids

Wilens TE. New York: The Guilford Press; 1999

ISBN 1-57230-204-6 (paper)

In general, psychiatry has come a long way — from a pure psychoanalytical focus to a strong medical-neurobiological approach to treating psychiatric disorders. It is now well known in our clinical practice and in psychiatric literature that biologically based treatment with psychotropic medications, combined with other traditional and non-medical treatments, has proven superior to either treatment modality used alone. Similarly, child psychiatry and psychopharmacology have gained significant positions, both within the fields of medicine and general psychiatry.

Psychiatric conditions are recognized earlier in children who present with behavioural/emotional and developmental problems. These special children are more at risk of academic difficulties and parental rejection. In the best interests of the child and family, the challenge facing child psychiatrists is to provide an integrated assessment from a bio-psychosocial perspective before proceeding with specific treatment modalities; treatment should be conducted within interdisciplinary teams in which parents and their children are encouraged to participate actively. Physicians can expect parents and youth to be more active in questioning and decision-making. Medication may be indicated if behaviour modification and other therapies achieve only partial success; however, parents may still be reluctant to accept medication trials as a first-line approach. This book fills a need as a comprehensive reference source on current psychiatric medications.

The author is a well-known child psychiatrist and associate professor of psychiatry at Harvard Medical School. He specializes in pediatric and adult psychopharmacology and addiction psychiatry, and does his clinical work at Massachusetts General Hospital. He has published widely on psychiatric medications and their uses.

This book is the result of Wilens’ extensive clinical experience; it focuses on questions typically raised by parents concerning the assessment and treatment of their children. I believe it can serve as a useful information package for parents, educators and trainees in the field of psychiatry.

The contents are divided into three main parts. Part I describes and explains in straightforward language the general clinical processes of psychiatric evaluation, diagnosis and treatment plan. A central theme is that, as parents become familiar with the treatment process, they learn the importance of working collaboratively with the psychiatrist treating their child.

Part II informs the reader about common childhood psychiatric disorders as well as neurobiological conditions such as temporal lobe epilepsy, tic disorders, Tourette’s syndrome and organic mental disorders. For each condition, the author succinctly summarizes basic factual information; this is followed by information about coexisting emotional/behavioural conditions. The range of dosages is given for different medications.

With this basic understanding, the reader is prepared for Part HI, in which each class of psychotropic medications used in children is described with respect to names, dosages, indications and contraindications. Whenever needed, specific baseline testing or monitoring is also included.

Definitions of medical terms and expressions are interspersed appropriately in the text and framed in double lines for easy reference. Questions are printed in bold. Medications in each class are presented in a table form with names, preparations and strengths.

The last 37 pages include an appendix, medication log, resources, bibliography and index. The appendix is a table listing both generic and brand names of medications, with strengths and preparations. I found the example of a completed medication log useful for keeping track of each medication with respect to start date, dosage, response, side effects and comments.

The section on resources supplies the names and addresses of community and organizational supports within the United States, broken down by general mental health and specific disorders. The bibliography lists journal articles and books by recognized clinicians in different disorders. The section on tics and Tourette’s syndrome mentions 4 excellent references, but could have included Tourette Syndrome & Human Behavior, by David E. Comings, which is widely used by parents and professionals.

The author does not mention the use of psychiatric medication in preschool children (ages 2 to 6 years). Parents of these children are even more reticent to accept medication, even when their child’s condition is severe. There is no information on treating children with the amino acid tryptan (L-tryptophan) for various conditions. Also, the text does not clearly convey the serious potential risk of dependence on benzodiazepines. For this reason, it is better to avoid the use of benzodiazepines in children and youth. It is known that they may mix these prescribed drugs with other substances once the body develops a tolerance.

Overall, this book may enable mental health professionals to feel confident about addressing parents’ concerns and questions regarding psychiatric medications. It may save time for health care providers by giving parents the understanding they need to collaborate with professionals in the treatment of their child with psychiatric and mental health problems. Despite some weaknesses, the book does provide an abundance of valuable information. In clinical practice, however, it should be used as an adjunct to current literature on each drug in question, providing the reader with a balanced perspective.

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.

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.