Posts Tagged ‘Psychopharmacology’

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.

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.

Neurochemical Pharmacology

Neurochemical Pharmacology — A Tribute to B.B. Brodie. Fidia Research Foundation Symposium Series. Volume 2

Edited by E. Costa

New York, Raven Press, 1989. 369 pp.

This book represents the proceedings of a Symposium held in April 1988 to honor Dr. Bernard Brodie, who died in February 1989 while the book was in press. The book consists of a series of articles in neuropharmacology by many of the world’s leading experts in the field and is a fitting tribute to Dr. Brodie and his remarkable career.

Dr. Brodie was for many years director of the Laboratory of Chemical Pharmacology at the National Heart Institute. Under his direction, the laboratory played an important role in establishing a new approach to pharmacology, termed by the editor of this book “Neurochemical Pharmacology.” This approach, elaborated in the 1950—60s, was based on the view that it would ultimately be possible to understand all of the brain’s functions, including mental functions, on the basis of the underlying biochemistry of the brain. The approach had an enormous influence on the biomedical sciences and provided the basis for a generation or two of research in biological psychiatry. An impressive number of investigators trained in the Brodie laboratory during this time, among whom were Julius Axelfrod, Jack Cooper, Erminio Costa, and Solomon Snyder. In fact, the extraordinary productivity of Dr. Brodie’s laboratory and its disciples was the subject of a recent book, Apprentice to Genius by Robert Kanigel.

The current volume is divided into four sections entitled: “Transmitters,” “Transmitter Function,” “Receptor Modulation,” and “Signal Transduction.” The following articles are particularly noteworthy: Arvid Carlsson presents a challenging overview of the role played by brain dopamine systems in motor and mental functions. Tomas Hokfelt and others offer a comprehensive and helpful review of the localization of peptide neurotransmitters in monoaminergic and cholinergic neurons. Of note in the second section are reviews of the role of monoaminergic systems in satiety (by S. Garattini and others) and stress (by Roger Maickel). An article by S. Roy and others in the third section describes attempts partially to purify opiate receptors and prepare monoclonal antibodies to the receptor. K. Fuxe and colleagues describe “receptor/ receptor interactions,” the critical idea that neurotransmitter systems interact with one another, making it likely that psychotropic drugs influence brain function through effects on multiple types of neurotransmitter and receptor systems. Goran Sedvall and others describe their experience in the use of positron emission tomography to image neurotransmitter receptors in living human subjects. In the fourth section. Fridolin Sulser and Elaine Sanders-Bush offer a very thoughtful and up-to-date analysis of the probable mechanisms involved in the clinical actions of antidepressant treatments and experimental approaches. Erminio Costa presents some of the data obtained over the years, much from his own laboratory, underscoring the importance of the role played by the regulation of gene expression in adaptive changes in brain function.

As would be expected, the quality and focus of the articles in this book are variable. Despite the considerable delay in publication of this volume, most of the articles remain up to date. The book would be useful to individuals in the field for its reviews and to individuals only peripherally associated with the field as a more general overview of current research in neuropharmacology.

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.

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.

Handbook of Essential Psychopharmacology

Handbook of Essential Psychopharmacology

Pies RW

Washington: American Psychiatric Press; 1998. 416 pp. with index

ISBN 0-88048-765-8

This concise, slim, well-edited paperback review of essential psychopharmacology is divided into 4 chapters, on antidepressants, anti-psychotics, anxiolytics and sedative-hypnotics, and mood stabilizers, including novel anticonvulsants. Each chapter begins with an overview that includes drug class indications, mechanism of action, pharmacokinetics, common side effects, drug interactions, augmentation strategies, and use in special populations, such as pregnant women, the elderly, and develop-mentally disabled patients. Each chapter ends with a series of well-selected, clinically relevant questions, along with answers and a case discussion that illustrate and clarify various teaching points.

The chapter on antidepressants is a general review of the literature in that area. I often hear residents expressing their concern about the inability to keep up with the number of new antidepressants being introduced into our pharmacopoeia. It is also not uncommon to meet residents who, in their final years of training, have yet to prescribe or be familiar with the frequent clinical challenges in using tricyclic antidepressants or monoamine oxidase inhibitors. This chapter provides a user-friendly review of the newer agents and also the “older” classes of antidepressants. The author succeeds in assembling the information in a way that is not information overload and yet is academically and clinically useful, particularly for residents. This is made possible in part by the author’s careful use of various tables, which compare clinical issues such as off-label indication, neurotransmitter effects, side effects and their basic management, drug-drug interactions, and therapeutic drug monitoring.

The chapter on antipsychotics provides the reader with a concise, comparative review of conventional and atypical antipsychotics. Tables illustrate comparative mechanisms of action and side effects, along with strategies for antipsychotic potentiation. This latter issue is something clinicians are often faced with, particularly in patients who cannot tolerate or respond poorly to antipsychotics, including the newer atypicals. The question section deals with disparate clinical areas, and has a very good review of neuroleptic malignant syndrome.

The chapter on sedative-hypnotics and anxiolytics has several useful charts, such as a diazepam equivalency chart, a chart of clinical indications, and a table on the off-label uses for clonidine and β-blockers.

The final chapter, on mood stabilizers, has a clinically relevant review of lithium, valproate and carbamazepine. The author has included an up-to-date review of gabapentin and lamotrigine and their potential interactions with other commonly used psychiatric medicines.

As a psychiatric educator, I was very pleased with the question-and-answer section in this book. In fact, I have yet to come across a similar psychiatric textbook that effectively asks well-selected clinically relevant questions and provides the reader with practical answers. I do like how the author began by providing the basic informational background to these various compounds, followed by questions forcing the reader to “work” the information, and rounding up with a practical case to apply this new-found knowledge.

I found the graphs, diagrams and tables very useful, and very good complements to the written material, often clarifying the concepts presented. The large print of the text is very easy to read. The information is presented in a systematic way and includes extensive references to the literature for those interested in pursuing more knowledge on the topics.

Dr. Pies’ book is intended to be a “micropedia” for residents and busy clinicians. I see it as a very useful, helpful teaching textbook and resource for its intended audience. Psychiatric psychopharmacology has had a history of being somewhat limited by the absence of clearly established evidence-based algorhythmic approaches to treatment. That being said, there have recently been useful treatment guidelines for the diagnosis and treatment of major depressive disorder, bipolar disorder, and schizophrenia, among others. The author may wish to incorporate some of these reviews in future work. Overall, I congratulate the author and recommend this text.

Concise Guide to Geriatric Psychiatry

Concise Guide to Geriatric Psychiatry, 2nd edition

Spar JE, La Rue A

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

ISBN 0-88048-796-8 (paper)

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

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

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

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