Gavin Andrews, Rocco Crino, Caroline Hunt, Lisa Lampe, Andrew Page, 423 pp, ISBN 0-521-46927-9, Cambridge University Press 1996

Writing for psychiatrists and clinical psychologists, Gavin Andrews and his co-authors claim that their book ‘provides most of the information needed for the successful treatment of patients with anxiety disorders‘. About three-quarters of the book is said to be unique in terms of format, consisting of ‘patient treatment manuals’ (PTMs) and accompanying ‘clinician’s guides’ (CGs) dealing with each of the five common primary anxiety disorders (panic disorder and agoraphobia; social phobia; specific phobias; obsessive-compulsive disorder; generalised anxiety disorder). Secondary anxiety disorders (for example, post-traumatic stress disorder) are not included.

The PTMs are self-help manuals and the purchaser of the book is at liberty to copy them for individual patients, who will use them as self-help manuals. They are ‘both the guidebook and the journey’; whereas the CGs, ‘for clinicians’ eyes only’, are about the art of therapy, containing advice about devising treatment programmes and critical issues in therapy. The rest of the book consists of an introductory section dealing with general issues in anxiety disorders and their treatment, and detailed contemporary (references up to and including 1993) reviews of the epidemiology, aetiology and evaluation of each disorder. The contents are grouped by disorder with four chapters on each — syndrome, treatment, PTM and CG. The PTMs are printed in single-column format, whereas the rest of the book, for clinician use, is printed in double columns. An initial chapter helpfully entitled ‘Read Me’ describes the layout and authors’ intentions.

The book’s claim to fame rests with the PTMs and CGs, which are designed to bridge the gap between knowing about something and knowing how to do it. ‘It’ is cognitive behaviour therapy, the treatment of choice in the anxiety disorders. Alas, there are no quick and easy solutions that can be applied in busy out-patient clinics or doctors’ surgeries. There is no avoiding up to 20 h of therapist-patient contact, preferably over a smaller number of weeks. The PTMs seem straightforward to use. The contents typically cover an introductory explanation, physical relaxation techniques, cognitive aspects, dealing with avoidance behaviours, problem solving, maintaining progress and recommended reading. There are a lot of words, which I suspect would deter many of my patients.

Is the book genuinely new, as claimed? The contents seem to me, a general adult psychiatrist, uncontroversial. The writing is clear and the information is easily accessible. The book is a useful source of information for teaching both clinical medical students and psychiatrists in training. Colleagues with an interest in the psychopharmacology of anxiety disorders have pronounced in its favour, although ‘one commented on the verbosity of the PTMs. What is new is the combination of theory and practice, so that a single volume can serve as introduction, reference, treatment manual and problem-solving guide for clinicians ‘at all levels of expertise’. However, in the UK, the various components will probably be accessed by different disciplines. NHS psychiatrists generally will not have the time to use the book as a treatment manual. Junior doctors would probably be able to use the PTMs and CGs as a (desirable) training experience, but the issue of supervision arises. The likeliest users in therapy would be clinical psychologists and nurse behaviour therapists: how this book compares with previous offerings I cannot say. It goes beyond the available self-help literature.

In my opinion this book deserves a place in any medical library for its clear and comprehensive theoretical overview, and its synthesis of theory and practice for all doctors whose work brings them into contact with anxious patients. Because of the constraints of working practices, few doctors will be able to use it to its full potential.

Drug Use In Assisted Suicide And Euthanasia

Editors: Margaret P. Battin, Arthur G. Lipman
Pharmaceutical Products Press, 10 Alice St, Binghamton, NY 13904-1580 USA
1996/360 pp

Balanced discussion of a controversial topic

Overall Rating

Very good

Strengths

Balanced discussion of ethical, personal, legal, and pharmaceutical aspects of assisted suicide and euthanasia

Audience

All those (potentially) involved in decision making regarding assisted suicide and euthanasia

It is generally assumed that death by assisted suicide or euthanasia is to be caused by lethal doses of drugs, not guns or other violent means. This book addresses issues about the use of drugs in actively bringing about death. However, it offers much more than the title and the purpose suggest.

Many chapters, some written by opponents of assisted suicide and euthanasia and others by advocates of these practices, offer excellent discussions of multiple aspects of assisted suicide and euthanasia, creating deep awareness of the complex issues involved. The perspective of pharmacists, which has often been overlooked, provides insightful information about pharmacists’ attitudes about the use of drugs intended to end the lives of terminally ill patients. Concrete and specific information about the actual practice of drug use in assisted suicide and euthanasia is included.

An important message that is conveyed throughout the book is that, whether we favour or oppose these practices, we cannot deny that they happen. One of the papers demonstrates that self-enacted and assisted death is more common than previously suspected and provides a moving account of what happens when drugs fail.

Palliative care and pain control, which are often suggested as alternatives to assisted suicide and euthanasia, receive ample attention. However, as some papers suggest, it is not always the experience of pain but unbearable suffering that leads terminally ill patients to ask for termination of their lives.

A particularly important issue for physicians is the attention paid to patient-physician communication and the need for long-range planning with patients and families regarding pain control and symptom management.

The final section of the book contains many position statements of various organizations in the United States, followed by a series of brief clinical vignettes and commentaries. These provide a basis for readers to analyze their personal positions on active life-ending acts.

Everyone interested in end-of-life decision making is likely to find something valuable in this book.

Colchester: Portland Press, 1991, 516 pp

ISBN 1-869868-74-9

The Royal College of Psychiatrists and the Royal College of General Practitioners launched a 5-year Defeat Depression Campaign on 30 January 1992. The first year of the campaign is intended to educate health professionals in the recognition and treatment of depression.

This book, which is the proceedings of the Conference of the British Society for Psycho-Pharmacology held in Ireland in September 1988, provides an overview of the current pharmacological options in the treatment of depression. Thirty years have elapsed since the almost simultaneous discovery of the therapeutic effect of MOA inhibitors and Imipramine in a substantial percentage of patients with severe depression. Antidepressants are the leading category of CNS drugs in research and development, occupying 11th place of all therapeutic categories, with more than 100 new chemical entities at various stages of development at the time of the Conference. One hundred and nineteen contributors helped to place the current use of antidepressants in context and the nine sections of the book cover a wide range: biochemical mechanisms thought to underlie drug action; animal models of depression and laboratory methods of discovering new drugs; biochemical markers of depression and the discussion of toxicity and side effects of both older and new antidepressants. The section with clinical emphasis covers treatment issues, in particular the problem of resistant depression, with advice on management and indications for psycho-surgery. There is also advice on drug treatment for the depressed elderly, depression as seen in general practice with particular reference to the side effects of treatment and the corresponding problems with patient compliance.

This book will be of wide interest both to researchers concerned with the development of future antidepressants and to clinicians wishing to have a fuller understanding of the mechanism of action of these frequently prescribed drugs.

Managing Mental Health Problems. A Practical Guide for Primary Care

Managing Mental Health Problems.

A Practical Guide for Primary Care

Nick Kates, Marilyn Craven
Hogrefe & Huber Publishers, 12 Bruce Park Ave, Toronto, ON M4P 2S3
1998/390 pp

Strengths

Practical, useful instruction

Weaknesses

Not comprehensive

For a long time, managing mental health problems in primary care has been poorly understood and criticized by physicians not principally involved in primary care. I believe this misunderstanding stems in part from not having defined the skill set unique to family practice. Therefore, the authors have done much to fill that gap in the primary care literature by publishing this book.

The authors are well-known to many family physicians through their links to the psychiatry and family practice departments at McMaster University in Hamilton, Ont. Their involvement in fostering shared mental health care anticipates the growing reality that family physicians are being asked to provide more mental health care. This book offers a solid, practical working definition of the skill set necessary to meet that challenge.

Particularly useful are the many lists, tables, medication summaries, and information sheets that can be useful as patient handouts. Each chapter concludes with a list of “reasonable expecations of the primary care provider.” These are behavioural objectives that, taken collectively, should be a “core curriculum” for any practising family physician.

There are some omissions. The norepinephrine-dopamine modulator class of antidepressents is not covered. The chapter “Mental Health Problems in the Older Patient” deals only with dementia and depression. Some of the management recommendations cannot be followed because the services recommended are not available. For example, mood disorder clinics and basic psychologist and social work support are not available in many parts of rural Canada.

Aside from that, I know I will refer to this practical, useful textbook often.

Psychiatric Primary Care

Linda Denise Oakley, Claudette Potter
Mosby-Year Book, Inc, 11830 Westline Industrial Dr, St Louis, MO 63146 USA
1997/448 pp

Strengths

Assessment and DSM-IV diagnosis

Weakness

Specific pharmacologie treatment

Audience

Family physicians and allied mental health professionals

The authors of this ambitious book state, “We have developed a book for primary care practitioners that presents everything from basic mental concepts and terms to clinical examples of psychiatric primary care.”

The book is divided into five parts that deal with basic concepts of assessment and diagnosis; common mental disorders; psychosocial problems; special populations and problems, such as children; and practice notes covering mental health laws, threatening patients, and clinical vignettes.

Illnesses are conceptualized in the biopsychosocial model, and diagnoses are based on DSM-IV definitions. This book is very strong in assessing mental disorders, presenting epidemiologic data, risk factors, psychiatric terminology, and DSM-IV criteria. It is also strong in addressing the psychosocial context in which mental illnesses occur.

This book is too general in the area of management. For example, in treating depression, information on using specific medications and dosages is not provided. As well, while cognitive-behavioural therapy is mentioned, advice on how to use it in specific disorders is not given. This wide-angle perspective on management, especially pharmacologie treatment, probably arises from the nursing background and praètice of the authors.

It is important to note, given the book’s emphasis on DSM-IV diagnoses, that the DSM itself is continually evolving and that its diagnoses are based strictly on empirical clinical presentation. We would be wise to acknowledge the ambiguities of human nature and not thoughtlessly use formulae to reduce the complexities and richness of human expression into 5-digit codes.

This book excels in teaching attitude and background knowledge of psychiatric primary care. However, specific knowledge and skills are still required for proficient practice. The book describes certain important aspects of continuing education in psychiatric primary care for Canadian physicians.

Helping Your Depressed Teenager. A Guide for Parents and Caregivers

Helping Your Depressed Teenager.

A Guide for Parents and Caregivers

Gerald D. Oster, Sarah S. Montgomery
John Wiley & Sons Canada, Ltd, 5353 Dundas St W, 4th Floor, Etobicoke, ON M9B 6H8
1995/184 pp

Strengths

Very informative, logical presentation, useful bibliography and resource list

Weaknesses

Support groups mostly in the United States

Adolescents are not just “big children” or “little adults.” They represent a separate stage in the transition from infancy to old age. The authors have written an informative guide on the teenage years to help parents and caregivers understand the normal and abnormal transitional stages and emotional experiences of adolescents. They identify the feelings and symptoms of clinical depression, as distinct from the “ups and downs” that we take for granted in this age group. Signs and symptoms of suicidal thoughts and actions are given and what treatment approaches to take. Overall, the emphasis in this handbook is for parents to listen to, understand, communicate with, and take their teenagers seriously.

Most material is presented logically, with case studies and tables describing danger signs of depression, as well as guidelines on how to talk to teenagers. Key points are highlighted at the end of each chapter. Information is given on the indications and use of antidepressant medication, available therapies and how to access them, and the need for and process of hospitalization. An appendix provides resources for parents with depressed and suicidal adolescents and a useful bibliography of books and pamphlets for parents and caregivers.

The preface states, “most parents have the opportunity to watch their teens successfully move through the adolescent years without extended emotional upheaval.” It also states that the book is directed toward parents of a distinct “subgroup of teens who do suffer from clinical depression.” Although the book is directed to this particular group, it provides some excellent general insights into teenage developmental tasks in general.

Support organizations and groups, however, are relevant largely in the United States. Nevertheless, a better understanding can be gained, especially by parents, about the very real existence of depression in teenagers, how to recognize it, and how to react to it.

The authors believe that psychiatry in general practice is a different specialty from psychiatry in hospitals. The authors suggest that a problem-oriented model is more appropriate to family practice. The authors also believe that psychoanalysis is a frame of reference that has outlived its usefulness and have introduced their textbooks with chapters on ethology, psychology, and social science, as well as an introduction to the excellent British literature on the epidemiology of psychiatric illness in general practice.

The bulk of the book focuses on practical management by the primary care team, the family life cycle and its turning points, mind and body relationships, and traditional psychiatric disorders.

This book is well written, comprehensive, and for the most part, the authors have met their objective of providing information about the problems in family practice. I do have several reservations about the book, which perhaps reflect my bias of being a psychiatrist trained in North America and not a British family physician.

There is too much background information in the relatively lengthy book and not enough focus on the common clinical presentations of anxiety, depression, and substance abuse. The reference material is largely from the literature in England, and while I found that fascinating, I wondered whether some of the references and contents were relevant to North American practice.

Finally, the sections on counseling and individual psychotherapy, family and couple therapy, group therapy, etc, are well written, but they seem to expect more of a family physician than training and experience would suggest is reasonable. This book (no. 15 in the Oxford General Practice series) is a good example of newer models and practices for psychological problems in general practice and provides an introduction to literature not available in North American books. There are, however, shorter and more practical paperbacks available in the marketplace.

Chris Freeman and Peter tyrer (eds)

The Royal College of Psychiatrists, London

1989, 240 pages

Not every doctor will become a dedicated researcher but an understanding of research principles and methods is essential for effective critical enquiry or performance review and thus for improved patient care. Like their psychiatrist colleagues, general practitioner trainees increasingly accept the link between individual research and better clinical practice. Chris Freeman and Peter lyrer have drawn on their experience of running research methodology courses to assemble a beginner’s guide which succeeds admirably in its aims. Though primarily intended for trainee psychiatrists, there is much that is common to research work in any scientific discipline and much that is of interest to general practitioners.

Besides the standard topics covered in the introduction, the authors give advice on ‘getting supervision’ and ‘keeping a research diary’ and counsel on ‘coping with failure and how to prevent it’. They amuse by examining the motivation for carrying out research and give a range of predicted success probabilities, from ‘keeping a critical attitude’ (P=0.75) to ‘fame, prestige and glory’ (P=0.0001). There is a useful checklist of the functions of a statistical coordinator but some duplication of advice on preparing a protocol. For general practitioners the three chapters on rating scales may seem overlong but many will be intrigued by the chapter on research with single (or few) patients.

This pocket-sized book is concise and readable with clear and sometimes humorous diagrams and illustrations lightening the reading load. There are extensive references, an extended reading list, a short but helpful glossary and a workmanlike index. Throughout, there is the reassuring feel of authors with ‘hands on’ experience of their subject which will ensure a favoured place on my bookshelf for this book.

Routledge, Chapman and Hall, London

1989, 196 pages

This useful book is the first in a series on strategies for mental health. Forthcoming titles will include Assertiveness training, Bereavement and loss and Rehabilitation and community care. If these volumes are of the same high standard as this book then they may, as the series title implies, have a positive effect on mental health.

The contents of this book divide into four parts: the first part looks at the research underpinning theories of stress and anxiety, the second describes a wide range of assessment procedures, the third and by far the largest section looks at management strategies, and a final section uses clinical cases to demonstrate the application of the strategies which are described.

The stated aim of the authors is to demystify symptoms and to provide individuals with coping skills. There are skills here in abundance for the general practitioner and other members of the primary health care team. At a personal level there are useful sections on goal planning and time management, and the chapters on self-help techniques, changing client’s lifestyles and running anxiety management groups should further reduce the prescribing of sedatives and tranquillizers.

Oxford University Press

1990, 177 pages

Anxious patients can be treated in many ways and as general practitioners we have numerous opportunities for exercising our therapeutic skills. Tranquillizers have had a bad press lately so it is good to be reminded that psychological methods have been steadily simplified over the years, are at least as effective as drug treatment and are a good deal safer.

This deceptively slim volume is addressed to all members of the primary care team who wish to develop skills in anxiety management training. The physical symptoms, worrying thoughts and psychomotor behaviour associated with anxiety are carefully explained and illustrated in four typical but fictional cases. The problems are examined in a clear and ordered way and the formulation of conclusions are shared with the client who can then be offered a personal treatment programme, including carefully planned homework between the sessions. A range of therapeutic approaches is described and their practical application is explained with admirable clarity. The book includes sample diary sheets and scripts for making relaxation tapes. In addition, there are nine information sheets for clients to reinforce the recommended homework. It is all well presented with helpful summaries at the end of each short section. At the end of the volume are fuller references both to the technical literature and to books and organizations that clients might find useful.

This book shows exactly how to go about helping anxious and phobic patients. It is so well explained that even beginners might feel tempted to try out some of these ideas.