Posts Tagged ‘mental disorders’

Psychopharmacology

Psychopharmacology: The Third Generation of Progress

Edited by Herbert Y. Meltzer

New York, Raven Press, 1987. 1,824 pp.

The utility and desirability of Psychopharmacology: The Third Generation of Progress is attested to by the fact that it was the first book to be stolen from our newly established psychiatry library. This book is the third in a series, updated every decade since 1967, from the preeminent biological psychiatry organization in the United States, the American College of Neuropsychopharmacology (ACNP). This comprehensive review of clinical neuroscience was “trimmed” to 184 chapters by 350 authors and amounts to more than 1,800 pages.

For a book that is so large and cumbersome, relevant information on most topics in neuroscience is surprisingly accessible. Topics are presented as clusters of individual reviews covering specific interest areas rather than as a single comprehensive review chapter. Thus, an experienced clinician or researcher seeking an update on a specific topic, such as maintenance pharmacotherapy for schizophrenia, is likely to find a brief, focused review. In contrast, readers with limited psychiatry or neuroscience backgrounds may find that the magnitude of the text and its somewhat fragmented presentation style make information more difficult to integrate. For example, in order to learn about schizophrenia, the novice neuropsychiatrist must read two introductory chapters, at least four preclinical chapters, and 24 clinical chapters from over thirty authors. Although this mountain of information would appear to be daunting, I have found that the chapters are quite popular as review materials among second-year psychiatry residents.

Despite the excitement and interest that a book such as this generates, it suffers from some flaws that are characteristic of multi-authored texts. Some parts of the book, such as the section on neuroanatomic and neurochemical mechanisms, contain several excellent chapters but lack a central focus or clearly apparent organization. The scope of reviewed materials also varies widely between chapters. As an illustration of this problem, “animal models in psychiatry” is included in the section on “Biology of Depression,” a review of animal models is absent from the section on “Biology of Schizophrenia,” and two of the four chapters in the “Biology of Anxiety” section review animal models. Also, the quality of the chapters varies noticeably in this book. In contrast to many chapters written with depth and clarity, others appear sketchy or even poorly written.

Although generally skeptical about the utility of purchasing expensive scientific books that rapidly become outdated, I wanted to own this text in order to insure continued access to the many useful reviews that it contains. In addition, it is one of very few books that I recommend to psychiatry residents interested in clinical neuroscience. Despite its flaws, Psychopharmacology: The Third Generation of Progress is clearly an important contribution to neuroscience and psychiatry.

Disorders of the Developing Nervous System

Disorders of the Developing Nervous System: Changing Views on Their Origins, Diagnoses, and Treatments

Edited by John W. Swann and Anne Messer

New York. Alan R. Liss, 1988. 269 pp.

Disorders of the Developing Nervous System: Changing Views on Their Origins, Diagnoses, and Treatments is a volume based on the proceedings of the Birth Defects Symposium XVIII, held in Albany, New York, in September 1987. The book contains thirteen chapters written by 32 individuals, and is edited by John Swann and Anne Messer of the Birth Defects Institute, New York Department of Health. A possible criticism of this book is that many of the experimental findings are published by these authors elsewhere (e.g., The New England Journal of Medicine, Neurology, and Annals of Neurology). This circumstance is often a characteristic of books derived from symposia, however, and the strength of this work lies not in the novelty of its experimental results, but rather in its broad and masterful coverage of numerous “hot” areas in neurobiology. Thus, the reader is introduced to neuroimaging techniques being employed for the diagnosis and study of neurological disorders (e.g., PET scan in the diagnosis of epilepsy, MRI changes specific to the cerebellum of autistic individuals), the role of NMD A receptors in mechanisms of hypoxic-ischemic brain injury, and gene mapping and cloning in Duchenne muscular dystrophy. Other disorders dealt with in this book are cerebral palsy, dyslexia, Down’s syndrome, PKU, and storage diseases.

The individual chapters are written with exceptional clarity, and are easy to follow; each contains appropriate amounts of background information to orient the reader, which is probably due to the fact that each chapter is based on a talk at the Birth Defects Symposium. Although the central themes of this volume are the developing nervous system and childhood disorders of the nervous system, several papers contain information relevant to disorders of the adult nervous system (e.g., hypoxia-ischemia, epilepsy, and Alzheimer’s disease). This feature will undoubtedly provide the book with a larger audience. In addition, its emphasis on histopathology (especially those chapters dealing with neuroanatomic changes observed in autism), will be of interest to neuropathologists. The majority of the chapters are extremely readable and provide enough interesting information to maintain the reader’s attention, without becoming overly detailed and dry. Certain chapters tend toward the obscure, however, and their subject matter is more difficult to follow. This criticism is particularly true of the chapter entitled “Timing of cell interactions in cerebellar development.” The chapter contains a veritable maelstrom of information on cerebellar mutations in several mice strains (e.g., sg/sg, Lc). In addition, the chapter entitled “Synaptic mechanisms of focal epileptogenesis in the immature nervous system” would be more readily understood if it contained a more extensive introduction to elementary neurophysiology.

On the whole, I would recommend this book. I think it will be of interest to adult and pediatric neurologists, neuropathologists, and neurobiologists. Its strength lies in its clear presentation of the research being conducted in neurobiology today.

The Biological Aspects of Mental Disorder

Solomon H. Snyder

New York, Oxford, Oxford University Press, 1980.

Readers interested in psychiatry and the behavioral sciences will be pleasantly surprised by this compact book. Lasker award winner Solomon Snyder, known for his neuroscience achievements at Johns Hopkins, and specifically for his contributions to the understanding of the dopaminergic receptor sites and other neurotransmitters in the brain and their relationship to psychosis, has produced a succint and pluralistic handbook touching upon the major afflictions of the mind. In 23 chapters the focus ranges from schizophrenia to organic brain disorders, from alcoholism to sexual dysfunctions. (The chapter on psychosomatic disorders was contributed by Robert L. Sack.) Apart from neurochemical and genetic references one finds substantive phenomenological and clinical description. Because of the briefness of the presentation, those who long for more may feel that the book may fall within the ranges of a diagnostic manual. In fact, the recently published DSM III by the American Psychiatric Association may have more bulk. The two chapters covering the phenomenology, etiology, and treatment of schizophrenia are attractive, lucid, and informative. When discussing its etiology, one may more prudently refer to pathogenesis because the decoding of this riddle remains unknown. Chapter 6, with the title Chemical messengers in the Brain, covers in 15 pages the neurochemical findings which, although they clarify only a miniscule fraction of the functions of the human mind, have restored psychiatry to science. The references to published literature reflect the author’s preference for the American scene of the past 20 years rather than worldwide contributions. The book, written by a researcher, identifies him as a skilled clinician and it can be effectively used either as an introduction to or an overview of psychiatry.

The Cytokine Network and Immune Functions

The Cytokine Network and Immune Functions

J. Thèze, editor

New York (NY): Oxford University Press; 1999. 373 pp with index

ISBN 0-19-850136-6 (cloth)

Like the brain, which orchestrates behaviour principally through the secretion by neurons of various neurotransmitters that act on other neurons, the immune system displays similar finesse by synthesizing and secreting a large variety of chemical messengers, generically referred to as “cytokines.” As readers of The Cytokine Network and Immune Functions will appreciate, this function of the immune system is no less complex and exquisitely sophisticated than the exchange of information between neurons in the brain or the response of endocrine tissues to hormones. Indeed, from a behavioural perspective, the immune system — like the brain — evolved to mediate defensive functions that would optimize successful adaptation and survival. Whereas the brain scans and processes information in response to stimuli with circumscribed physical and sensory dimensions, the immune system performs similar functions at a molecular level, responding to viruses and bacteria that our more traditional senses are unable to perceive. Ultimately, the “foreigness” of viruses and bacteria elicits a coordinated set of defensive actions (what immunologists call an effector function) by a variety of immunological cells that ultimately rids our bodies of the would-be colonizers.

What this book summarizes in some detail, is that from the point of initial pathogenic stimulus exposure to the ultimate effector response, the defensive functions of the immune system are orchestrated by several families of cytokines, acting in coordinated fashion — as a network — and mobilizing in cascade fashion, and according to specific needs, the fatal blow to foreign microorganisms.

However, all networks possess the potential for dysregulation. Hence, aberrant cytokine responses are believed to be responsible for allergies, asthma and numerous autoimmune disorders. Moreover, there is a growing recognition that cytokines can affect brain function. Unfortunately, this is exclusively addressed in only a single — and lamentably, brief — chapter (”Cytokines in the brain” by Laye et al). Additional indirect treatment of the relation between neuroendocrine function (e.g., the hypothalamic-pituitary-adrenal axis) and cytokines is rendered in a chapter on cytokines and inflammation (”Cytokines and the cellular mechanisms of inflammation” by Cavaillon and Duff). Therefore, for researchers and practitioners in the brain sciences, there is little in this volume that cannot be obtained in other publications that provide a more comprehensive discussion of the relation between the immune system, cytokines and neural and behavioural functions.

Alternatively, a considerable amount can still be learned about basic cytokine biology, receptors and signal transduction mechanisms. To echo the foreword by William Paul, which was perhaps directed to a more immunological audience, there is much in this book that can greatly inform and equip those of us involved in research in neuroimmunology and the behavioural consequences of immune responses and inflammation. Indeed, subsets of mood disorders, such as dysthymia, have been hypothesized to involve an autoimmune component that is mediated by cytokine dysregulation. Similarly, multiple sclerosis is an autoimmune disorder, but with severe depressive symptomatology and cognitive deficits. A greater knowledge of cytokines and their cellular actions at the molecular level would certainly enhance efforts toward understanding central nervous system diseases that involve the immune system. In fact, this book is probably indispensable to all whose work involves cytokines, no matter what biological system is being scrutinized.

As witnessed in recent years, the leaps-and-bounds advance in molecular biology has not so much rippled, as ripped its way through much of the biological sciences, and as readers of The Cytokine Network and Immune Functions will no doubt appreciate, has also served to propel the study of cytokines. For example, it was not that long ago that the number of known cytokines could be counted on a single hand. However, currently, and as well described in the book, cytokines are bunched into at least 6 families, based on the structure and characteristics of the receptors to which they bind (i.e., the hematopoietin, interferon, tumour necrosis factor, interleukin-1 and chemokine receptor families and the immunoglobulin superfamily). For the uninitiated, this may be somewhat perplexing and confusing, but an introductory overview chapter (”General aspects of cytokine properties and functions” by Dy et al), although not exactly smooth sailing because of a plethora of abbreviations and acronyms that do not fall immediately into coherent place, does prepare the reader for the tone and level of complexity in subsequent chapters. For those comfortable with molecular levels of analysis, these should not be turbulent waters. However, those wishing a more superficial description of cytokines and their functions may find the going tough. This book is not light reading, but it is a well-organized and broad overview for those who are serious about wanting to know more about cytokine biology. Indeed, seasoned researchers and teachers of immunology will easily find it a valuable resource in a field that is incredibly dense with information and complexity.

The organization of chapters revolves around 3 sections, beginning with basic, fundamental discussions and moving on to more immunobiological and clinical considerations. In the first and largely molecular section, chapters are devoted to classes of cytokines, such as the hematopoietin or class I receptor family of cytokines (e.g., interleukins 2,4, 7,9,13 and 15), as well as specific chapters on individual cytokines, including tumour necrosis factor, interleukin-1, interleukin-6, interleukin-10, inter-leukin-12 and transforming growth factor (3. There is also a chapter devoted to the Type I (wherein there are up to 21 different types) and Type II (viz., interferon y) interferons, as well as an update on more recently discovered cytokines (interleukins 16, 17 and 18). These chapters characterize the biochemical structure, genetics and cellular origins of these cytokines as well as describe the localization and structure of their receptors. Additional chapters also address signal transduction mechanisms, the role of accessory surface molecules (e.g., CD40) in cytokine regulation of function and cytokine gene regulation.

These initial 13 chapters are followed by 7 chapters that consider cytokines within their biological context, largely the immune system, but as mentioned above, also in the brain. The immunological profile of mice with deletions and/or overexpression of various cytokine genes and/or their receptors is discussed, as is the role of cytokines in immunological development. In addition, separate chapters address the way in which cytokines regulate specific (e.g., T cells) and nonspecific (e.g., macrophages) arms of the immune system. This segregation ultimately reveals a great deal of overlap, because it has become clear that many cytokines are pleiotropic and redundant.

The book concludes with a section on pathological conditions, wherein cytokine dysregulation is believed to either be at the root of various diseases (i.e., allergies, asthma, infectious disease, autoimmune disorders and cancer) or, conversely, where their immunotherapeutic use may promote recovery from disease.

The book accomplishes its goal of attempting to provide a more synthetic and “network-oriented” view of how cytokines serve their purpose. The treatment is broad, and of course, at some expense. There appears to have been a conscious effort to emphasize facts and predominant points of view, giving the book a textbook quality. In-text citations are not provided, although each chapter does conclude with a reference list. Therefore, one should look to this book, not as a literature review, but more an informed statement of the current state of knowledge in cytokine immunobiology.

Handbook of Neurodevelopmental and Genetic Disorders in Children

Handbook of Neurodevelopmental and Genetic Disorders in Children

Goldstein S, Reynolds CR, editors

New York: The Guilford Press; 1999. 602 pp. with index

ISBN 1-57230-448-0 (cloth)

I found this book very interesting to read and extremely informative. It consists of 3 sections, which are authored by individual professionals well known in their fields. The book’s presentation, as well as the specific information in each section, are very attractive to the reader and easy to follow.

The first section addresses the basic principles and applications relevant to neurodevelopmental and genetic disorders in children. The principal editors and contributing authors address rather difficult and, in some way, controversial areas of specific neurodevelopmental disorders, their origin and the basic interplay of “nature versus nurture.” The section also contains various ways of assessing these disorders and various interventions that are helpful for each subcategory.

In the second section the authors contribute a great deal of knowledge in the areas of specific disorders that primarily affect learning and behaviour. They shed new light in the exploration of such disorders such as learning disabilities, attention-deficit/hyperactivity disorder, Tourette’s disorder, anxiety disorders, and autism and other pervasive developmental disorders.

This section of the book is particularly interesting, as the various contributing authors offer general, updated information on the definition and genetics of each disorder, as well as the associated phenomenology, assessment methods and available interventions. The state-of-the-art knowledge presented is linked to relevant research and clinical data, offering a wealth of references as the literature has evolved during the past 3 decades. As a professional child psychiatrist, specialized in neurodevelopmental and genetic disorders of childhood and dealing daily with these issues, I found this section very useful, not only for its knowledge base, but also for its clinical implications and suggested services related to these disorders.

The third section of this volume deals with disorders with broader-spectrum effects. This is very relevant and important for professionals in this sphere, as well as for parents and other interested readers. I believe that each group can profit from the richness of the contributions offered in the areas of specific genetically transmitted disorders with associated neurodevelopmental deficits. The conditions explored in this section are Turner’s syndrome, fragile X syndrome, mucopolysaccaridoses, Noonan’s syndrome, neurofibromatosis, sickle cell disease, Down’s syndrome, Klinefelter’s syndrome, phenylketonuria, Rett’s syndrome, Lesch-Nyhan syndrome, seizure disorder, Prader-Willi syndrome and Williams’ syndrome.

This section has a presentation similar to the previous 2 sections. It is well written, with up-to-date information in the areas of genetics and neurodevelopment, classification assessment and clinical presentation, as well as interventions for these disorders. I found each chapter in this section to be very informative and well researched, with extensive references.

In summary, this book presents extremely interesting, important and relevant information for specialists in child psychiatry, neurology, psychology and allied sciences such as social work and speech or occupational therapy. It also offers good insights and general information for families with children with such disorders and suggests relevant interventions, which are so important for these families. I believe that this book is a “must-read” for all concerned with the specific topics that are covered.

Psychosocial Factors in Pain

Psychosocial Factors in Pain: Critical Perspectives

Gatchel RJ, Turk DC, editors

New York: The Guilford Press; 1999. 510 pp. with index

ISGN 1-57230-285-2

The preface to this book stakes out its claim. We are told that 4 main developments, each involving psychologists, served as the impetus for a revolution in thinking about pain. This revolution consists in the rejection of a “medical model” in favour of a “bio-psychosocial approach.”

The volume comprises 30 chapters. Of these, the first 9 make up Part I, on biopsychosocial context. In Part II 11 chapters deal with special topics and populations, and Part III provides 10 more on issues in prevention and management. The book finishes with an overview on resolution and evolution. Three out of the 43 authors of the 30 chapters are physicians dealing with pain and AIDS (a magnificent review), the epidemiology of low-back pain, and work style and work-related upper extremity disorders. There is an epidemiologist or two, a dentist with qualifications in psychology, and almost all the rest are psychologists dealing with pain. These include 3 Canadians (Gagliese, Katz and Melzack), Flor from Germany, and Main (from Glasgow and now Manchester).

The great bulk of the material reflects the work and views of US psychologists and their special psychosocial context.

This is a long volume, well produced and full of information, often very well worked out. The text itself is easy to read and very solidly written for the most part. Some chapters are excellent in whole or in part, while others seem to exist only to disappoint.

It is an irritating pity that what could have been a superb volume is marred by 2 faults of emphasis. One is needless special pleading and the other is an ill-founded, albeit highly sophisticated, tendency to revise the understanding of what it means to favour a back-pain disability model.

The special pleading begins with the listing of 10 contributors to the psychological approach. Three of these were actually physicians but not identified as such. More important, and tellingly, there is a lack of understanding or recognition that psychosocial factors have always been strong in medicine. Psychologists now dwell in a field long inhabited and not relinquished by internists, family doctors, neurologists, psychiatrists and a host of others.

Psychologists are much more numerous than psychiatrists in the field of pain and have made great contributions, starting with Hebb and Melzack. But some of their contributions (e.g., behavioural therapy of pain) remain controversial, and the field in which they have gained most recognition and added most to the subject appears to be cognitive treatment, which, incidentally, was applied to pain by a psychiatrist, A.T. Beck. Thus, what should have been a friendly and sociable claim to have made a large contribution has been spoiled by exaggeration.

More important, the way in which the biopsychosocial construct is now treated serves to reduce the biological element and to suggest that pain is largely due to psychological causes. I partly made that mistake myself and can sympathize, but the fact is that we have very few genuine indications that pain for which physical explanations are lacking is due to psychological causes except when it occurs with or after the onset of an obvious affective disorder. In other cases, and especially with musculoskeletal pain that arises with questionable indications of psychological difficulty, there is insufficient evidence to support the view that pain is due to vaguely alleged “behavioural factors,” but there is growing evidence from systematic controlled investigations that the determining factor is the state of the facet joints or degeneration (not prolapse) of intervertebral disks.

One of the most insidious practices connected with rejecting the patient’s pain consists in describing correlated information as “predictive.” Every psychologist knows that correlations do not demonstrate a causal link, except when there is a serial position, and should not be thought of as a causal consequence. Yet the insinuating word “prediction” is used repeatedly to corroborate some argument for psychological causation.

I do not want to leave the impression that Gatchel and Turk, as editors, make no attempt to acknowledge evidence that complicates their message. They recognize much of it. However, overall the book states the problems softly when they relate to weaknesses in psychological achievement, and overstates the failures of the organic approach. This is the more distressing because the authors and editors have all made significant contributions in the past, and continue to do so. Unfortunately, as one of my colleagues puts it, those who state their adherence to the biopsychosocial approach most loudly do not appear to be as serious about the “bio-” element.

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.

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.