Posts Tagged ‘pharmacotherapy’

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.

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.

Bipolar Disorders

Bipolar Disorders: Clinical Course and Outcome

Goldberg JF, Harrow M, editors

Washington (DC): American Psychiatric Press; 1999. 315 pp. with index

ISBN 0-88048-768-2 (cloth)

This volume is based on a symposium held at the annual meeting of the American Psychiatric Association in 1995. Various authors have contributed data on the course and outcome of bipolar disorder. Almost without exception, these data are from their own research programs, supplemented with a limited literature review. The topics covered are broad, including naturalistic outcome studies, the impact of a broad range of treatments — both pharmacotherapies and psychotherapies — on outcome, as well as the impact of comorbidity on the long-term prognosis of bipolar disorder. Other topics include clinical subtypes, such as rapid cycling and bipolar II disorder, and hypomania.

The book is comprehensive in its broad range of topics covered. Unfortunately, however, this comprehensiveness is achieved at the expense of a more in-depth and critical analysis of each topic. With a few notable exceptions, each chapter is quite cursory in its approach to the topic under consideration. Furthermore, as with many multi-authored books derived from symposia, the individual contributions are neither direct reports of particular studies nor a comprehensive and up-to-date literature review of the topic. Rather, one gets something in between, with the author’s individual studies supplemented by a relevant, but unnecessary, comprehensive literature review.

There are some very good chapters. For example, the chapter on psychotherapies by Miklowitz and Frank manages to achieve a succinct literature review and present some very tantalizing data on new psychotherapeutic approaches. Maj presents some very interesting findings on lithium prophylaxis of bipolar disorder, although frankly it is much more satisfying to read his original research reports. A chapter by Bowden compares and contrasts findings from open clinical studies and randomized controlled trials. This is particularly relevant to the literature on bipolar disorder, in which a vast amount of findings are from open clinical observation. This is an interesting attempt by Bowden but, because of the presumed constraints of a relatively brief chapter, the topic is not thoroughly dealt with in a way that the importance of the topic and the expertise of the author would justify. I thought that the chapters on comorbidity with alcoholism, substance abuse and anxiety disorders were an important addition to the book as these are very rarely broached in books on bipolar illness.

This book would have some interest for community psychiatrists and residents looking for a relatively brief review of the course and outcome of bipolar disorder. One cannot term this book an “update,” as much of the data has been superseded by the recent explosion of information on bipolar disorder. Furthermore, it adds very little to such important, seminal texts as Manic-Depressive Illness by Goodwin and Jamieson.

Obsessive-Compulsive Disorder: The Facts

Obsessive-Compulsive Disorder: The Facts, 2nd edition

de Silva P, Rachman S

New York: Oxford University Press; 1998.141 pp with index

ISBN 0-19-262860-7 (paper)

This is a small book — only 141 pages in its second edition — and part of a series on a number of medical topics entitled “The Facts.” Other topics in this series include alcoholism, asthma, cancer, eating disorders, and kidney failure.

The authors are both psychologists who are well known to psychiatry and have extensive experience in the area of anxiety disorders, including obsessive-compulsive disorder.

The book is intended as an information source for patients who have obsessive-compulsive disorder and their families and friends, but it would also be very useful for workers in health care who need to have an overview of this disorder but are not directly involved in assessment and treatment. It would also be useful for family practitioners as a quick read.

The first chapter describes the classification of anxiety disorders and the diagnostic criteria used for obsessive-compulsive disorder. Unfortunately, the authors use the terms “neurotic disorder” and “neuroses,” which have many negative connotations and have not been used in the Diagnostic and Statistical Manual of Mental Disorders for many years. Beyond this initial bad start, the chapter goes on to include an excellent description of obsessions and compulsions with great attention to detail — explaining covert compulsions, resistance, distress and interference. Obsessions and compulsions of everyday life are also discussed. The detail reflects the authors’ behaviouristic background and would be extremely helpful for a patient and family when first engaging in cognitive behavioural therapy.

Subsequent chapters continue with a good description of clinical phenomena, including the relation of obsessive-compulsive disorder to other psychiatric disorders and the various ways obsessive-compulsive disorder can present, illustrated with several clinical vignettes. The impact on family, prevalence rates and cultural factors are also included.

Even considering the main purpose of the book, the section on etiology is very brief and superficial. The description of the psychoanalytic view of obsessive-compulsive disorder could have been deleted, as this is only of historical interest and could be confusing to a lay reader. More detail regarding the biological aspects of obsessive-compulsive disorder should have been included, as well as some information on how obsessive-compulsive disorder can be seen from an evolutionary perspective. This would have been helpful in easing the guilt that patients and family often have about the role they feel they may have played in the development of the illness.

The chapter on treatment heavily emphasizes behavioural therapy, reflecting the clinical background of the authors. Although this provides patients and families with information on an aspect of treatment that will require their active involvement, the brief discussion of drug treatments does not provide enough information and also implies that pharmacotherapy is a secondary aspect of treatment.

The penultimate chapter on assessment only briefly mentions the Yale Brown Obsessive Compulsive Scale, which is the one most commonly used in Canada, whereas it includes the complete Maudsley Obsessional Compulsive Inventory, which is useful but is not widely used. The Leyton Obsessional Inventory, also mentioned, is never used. All of this may serve to confuse patients who may see the book as authoritative and then wonder why these scales are absent from their assessment and treatment.

The final chapter on practical advice is good. However, the list of helpful organizations at the back of the book is very incomplete with respect to Canada; only 3 addresses from 3 provinces in eastern Canada are listed!

In conclusion, the book has some of the facts on obsessive-compulsive disorder, but not all. The description of clinical phenomena is excellent. The inclusion of a discussion of obsessive-compulsive disorder and pregnancy would have been useful, as would a treatment flow chart with more emphasis on biological treatment. Also, since the majority of cases of obsessive-compulsive disorder begin in childhood or early adolescence, a separate section on this area would have been useful. Such a section should include some comments on the known association between group A P-hemolytic streptococcal throat infections and the acute onset of obsessive-compulsive disorder in some cases.

This book is not the best self-help book for patients in Canada. There are others available that have more complete lists of helpful addresses and are more compatible with the clinical approach a Canadian psychiatrist would most likely take with respect to treatment. The suggested price of $28.50 also makes the book quite expensive, considering the small size and soft-cover format.

The strengths of the book are that it is well written, well organized and easy to read.

Emergencies in Mental Health Practice: Evaluation and Management

Emergencies in Mental Health Practice: Evaluation and Management

Kleespies PM, editor

New York, The Guilford Press; 1998. 450 pp

ISBN 1-57230-255-0 (cloth)

In the introduction to this book, the editor points out that most training sites for psychology interns provide limited or no training at all in emergency psychological services, reflecting a general inattention to such services in the field of professional psychology. However, the editor suggests, if clinicians are to regard themselves as independent practitioners, they must be prepared to assist patients in the event of a life-threatening behaviour or a psychological emergency, whether in the office, the emergency department or elsewhere. Referring to psychiatry as a paradigm, he recommends that mental health disciplines incorporate training in the management of emergencies as a professional requirement. For the purpose of such training, the editor offers the structure of this book as “a proposed curriculum for a knowledge base in emergency psychological services/’ The book is structured into 6 parts consisting of 19 chapters. Most of the chapters have been written from the perspective of the mental health professional who must evaluate and manage a behavioural emergency in the emergency department or, occasionally, in another setting. Some of these chapters are excellent, offering useful and practical advice. This is especially true of the chapters on emergency interviews, evaluation and management of suicidal patients and potentially violent patients, and emergency telephone calls. The 2 chapters on risk management offer helpful reminders of the importance of consultation and proper documentation in dealing with suicidal or violent patients. A laudable feature, not found in other comparable books, is the devotion of 3 chapters to the stressful impact on the clinician of patient suicidal behaviour, violent behaviour and disaster. The weaknesses of the book are likely the result of the large number of contributors — 33 in all — with 2 to 5 authors in 15 of the 19 chapters. There is duplication between chapters, the writing style is variable, and even the perspective from which the chapters are written differs. For instance, the last chapter is written from the point of view of the psychologist. The entire Part 5, consisting of nearly 100 pages, is not about emergencies but about syndrome psychiatry and pharmacotherapy, which are best covered in a traditional text-book. Inconsistencies also occur. A notable example is that considerable effort is expended in the first 2 chapters to distinguish “crisis” and “crisis intervention” from “psychological emergency” and “emergency intervention,” and to dissuade the reader from using these terms interchangeably. However, in chapters 3, 4 and 6, either these terms are used interchangeably or new definitions are given. Some chapters would benefit from increased succinctness and decreased preoccupation with referencing every statement.

The inspiration for this book came from the editor’s considerable clinical and supervisory work with psychology interns in emergencies at the Boston Veteran Affairs Medical Center. The editor and the chapters’ authors, most of whom are psychologists, have created a book that will serve well psychology interns, their supervisors, and students and staff of other mental health professions in the evaluation and management of emergencies in mental health practice. I hope that this book will be a catalyst for increased training in this important but rather neglected field of mental health practice.

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.