New York, London: The Guilford Press; 1997. 261 pp. with index

ISBN 1-57230-237-2

Anxiety is a profound human experience. Anxiety disorders are universal in human societies, although the diagnostic patterns vary over time and from one place to another. This volume describes some culturally bound anxiety syndromes, but dwells on the diagnostic categories of the Diagnostic and Statistical Manual of Mental Disorders, third (DSM-III), third revised (DSM-III-R) and fourth (DSM-IV) editions. This manual provides diagnostic criteria for panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder and the generalized anxiety disorder. Twenty-seven prominent psychiatrists, psychologists and experts from related fields contributed to this volume, offering guidelines for diagnosis and culturally informed treatment.

The first part of the book deals with general issues in the cross-cultural treatment of anxiety disorders. The second part of the volume deals with the treatment of specific ethnic groups in the US, including Hispanic-, Caribbean-, Asian- and African-Americans, as well as Orthodox Jews, and Asian-Indian-Americans. The third part of the book examines the relations between psychopharmacology and ethnicity, and modern aspects of the clinical and research agenda in culture and anxiety.

P.J. Guarnaccia addresses risk factors, symptoms of distress, and the diagnosis of post-traumatic stress disorder (PTSD) among refugee groups from Southeast Asia and Central America. PTSD occurs with depressive disorders, and its prevalence rates vary in populations of trauma victims. E. Horwath and M.M. Weissman analyze epidemiological data on anxiety based on DSM-III and DSM-III-R criteria, comparing prevalence rates from the United States with data from other countries. The lifetime prevalence rates of panic disorder are remarkably consistent across community studies and ethnic boundaries. Data on agoraphobia show more variation across studies and cross-culturally.

The chapters in the second part of the book are organized around common themes. These include a description of the culture of the group, its view of mental illness and anxiety, treatment expectations, the possibilities of a therapeutic alliance and family involvement. E. Salman and colleagues examine anxiety disorders of Hispanic-Americans. The authors analyze the culturally bound syndrome of “ataque de nervios,” which is a folk label for loss of control, often with anxiety. The authors stress the need to reconcile the folk diagnoses with the DSM-IV framework.

S.-A. Gopaul-McNicol and J. Brice-Baker compare indigenous and western treatments of anxiety disorders in the Caribbean. G.Y. Iwamasa analyzes demographic and clinical variables in Asian-Americans, who tend to underuse both outpatient and inpatient mental health services. The author points out that, in many Asian ethnic groups, the needs of the family take precedence over those of the individual, that and religion and spirituality are important in everyday family life. CM. Paradis and her colleagues focus on the cognitive-behavioural treatment of anxiety disorders and emotional problems of Orthodox Jews, a minority in their own community. Confidentiality is important in this culture, and mental illness often has to be concealed. The assessment and treatment of patients with strong religious beliefs remain a mental health challenge.

There is still limited information on anxiety disorders in African-Americans. A.M. Neal-Barnett and J. Smith argue that the African-Americans have been targets of misdiagnosis. The authors discuss the clinical importance of spirituality, of the extended family and the therapeutic alliance in the treatment. R. Viswanathan and colleagues stress the fact that some attitudes of patients from the Indian subcontinent tend to be sociocentric rather than egocentric. Family and neighbours are valued, gender and hierarchical roles are rule-bound, and behaviour is influenced by the concept of shame.

In the third part of the volume, I.M. Lesser and colleagues provide a valuable overview of the clinical research on psychopharmacology and ethnicity, mechanism of drug effects and response to treatment. The authors highlight the interplay of ethnic background and genetics, but many of the important variables and relations need more research. In his closing chapter, L.J. Kirmayer reflects on the role of culture in emotional experience, considering the variations of anxiety symptoms in an increasingly ethnically diverse society.

The authors offer an updated and deep insight into factors inherent in the development, manifestation and treatment of anxiety in subjects from different cultures and ethnic groups. The book is well structured and clearly written, though the anxietynculture relations are complex and the evidence is still fragmented. This useful book will interest students and scholars in transcultural psychiatry/psychology and mental health professionals working with patients from ethnic groups.

Premenstrual dysphoric disorder is a fairly recent discovery in women’s health; yet, it currently costs the nation millions of dollars a year in direct and indirect costs.Most costs associated with PMDD patients are related to days missed from work or reduced work performance due to symptoms. Premenstrual dysphoric disorder symptoms result in a huge economic and health burden for our nation. To reduce the incidence of PMDD, it is crucial to understand the criteria and many different treatment options available.

When counseling a patient who may be suffering from PMDD, it is important to seek information. Table 6 provides a list of useful questions for the pharmacist to ask. The patient’s complete medical and personal history should be carefully reviewed and assessed. It is important for the pharmacist to then make a decision to triage the patient to a physician or begin to work with the patient to institute an effective self-care program.

If the self-care path is selected, nonpharmacological treatment should be considered first before medication. Pharmacists play a key role in counseling patients on the nonpharmacological and pharmacological treatments available. Understanding the patient helps the pharmacist to individualize patient therapy. A pharmacist should be well educated on the symptoms, treatment approaches, and strategies. Therefore, the patient should be encouraged to chart and identify target symptoms for at least two consecutive menstrual cycles. A healthy, well-balanced diet including sufficient vitamins, calcium, and minerals should be recommended. The patient should be informed of the negative association between increased caffeine, alcohol, nicotine, and drugs of abuse as triggers for specific premenstrual dysphoric disorder symptoms. Supportive therapy should also be discussed. In addition to nonpharmacological therapies, pharmacists should always discuss indications, side effects, and common concerns regarding medications to reduce symptoms of PMDD. The pharmacist should remember that premenstrual dysphoric disorder is an emotionally, socially, mentally, and physically debilitating condition. Respecting the concerns and confidentiality of the patient is significant for optimizing patient care. Patients need to aware of the wide spectrum of symptoms experienced in PMDD. Furthermore, because premenstrual dysphoric disorder affects the patient both emotionally and physically, it often interferes with family and relationships. The pharmacist should be sympathetic to all individuals involved in the care of the PMDD patient.

SUMMARY AND CONCLUSION

The most important point to remember when selecting the appropriate course of treatment for premenstrual dysphoric disorder is that therapy must be tailored to the individual patient’s needs and responses. Studies recommend nonpharmacological adjustments prior to initiating drug therapy. First-line pharmacological therapy includes SSRIs; second-line agents are anxiolytic agents. Finally, ovulation suppressors, oral contraceptives, or oophorectomy could all be considered after nonpharmacological and pharmacological agents (i.e., first- and second-line agents) fail. However, before changing classes of drugs or considering alternatives such as ovulation suppressors, it is important to note that the timeline to alleviation of symptoms may differ among patients. While many patients may notice relief of symptoms within three to five days of starting therapy during the luteal phase, many other patients may need to continue therapy for several cycles before noticing improvement. Although no data are currently available as to how long therapy should be continued, at least nine to 12 months of treatment is recommended. Once again, the pharmacist plays a crucial role in the care of the PMDD patient with regard to symptoms and treatment options.

The disadvantages of using GnRH agonists include cost and negative side-effect profiles, being associated with menopausal symptoms, e.g., hot flashes, vaginal dryness, depression, headaches, and muscle aches. Also, long-term effects of these drugs may include osteoporosis or heart disease. GnRH agonists have yet to be further researched to understand the risks and benefits associated with this class of drugs. In addition to GnRH agonists, the synthetic androgen, danazol, has been studied in the treatment of PMDD. Doses of 200 mg a day of danazol were found to reduce many symptoms related to ovulation such as mastalgia (muscle pain) and migraines. Adverse effects to be aware of when prescribing danazol include estrogen deficiency side effects (e.g., menstrual irregularities and hot flashes), androgenic side effects (hirsutism, acne, and deepening voice), and lipid changes (decreased high-density lipoprotein cholesterol and increased low-density lipoprotein cholesterol).

As ovulation suppression has been shown to decrease symptoms associated with premenstrual dysphoric disorder, it is logical to consider the use of oral contraceptives. However, few studies have been conducted with conclusive evidence that specific contraceptives are advantageous in PMDD treatment. The most common concern is that the symptoms linked to birth control medications are often observed with those of the menstrual cycle (e.g., breast tenderness, headache, bloating, and depression). The challenge is to find the “right” birth control medication that provides relief from menstrual symptoms with minimal side effects. The new formulations of oral contraceptives attempt to achieve the right balance of estrogen and progestin to help decrease side effects. However, using oral contraceptives for premenstrual dysphoric disorder symptoms remains controversial, and no single oral contraceptive has been indicated as beneficial when side effects are considered.

Although emotional and psychological symptoms are often the focus of treatment in PMDD patients, it is important to remember that physical symptoms of premenstrual dysphoric disorder are similar to PMS. As a result, clinicians and health care providers have to be familiar with treatment options available for particular symptoms. The “symptom-based approach” is often the most successful when treating PMDD patients. Physical symptoms to be aware of include dysmenorrhea or cramps, headaches, weight gain and bloating, and mastodynia (breast tenderness).

Dysmenorrhea and Cramps and Headaches: Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended to reduce menstrual pain. These include ibuprofen, ketoprofen, naproxen, or cyclooxygenase-2 inhibitors, such as celecoxib.

Weight Gain and Bloating: Sufficient clinical data supports the use of spironolactone, an aldosterone antagonist with potassium-sparing properties, to treat weight gain or bloating. The recommended dose of spironolactone is 25 mg two to four times a day during the luteal phase. Triamterene and hydrochlorothiazide have also been used, but little clinical data exist on their therapeutic effectiveness for these symptoms.

Mastodynia: Although NSAIDs are often used for the relief of breast tenderness related to premenstrual dysphoric disorder, vitamin E or primrose oil has also been used as a nutritional modality for this condition. Bromocriptine, at 1.25 to 7.5 mg per day, during the luteal phase has been clinically studied and supported.Danazol has also been studied for its antiestrogenic properties in the treatment of mastodynia, and studies have found positive results in its use. Additionally, using tamoxifen citrate in the luteal phase has also been studied, but conclusions regarding its use in PMDD are controversial.

Surgical Intervention and Management

Pharmacological and nonpharmacological treatments sometimes fail. In these instances, the option of bilateral oophorectomy (“removal of ovaries”) should be considered. However, this should only be a last resort because of its irreversible nature and because patients may experience menopausal symptoms or develop osteoporosis. The patient’s demographic information and medical history should be assessed carefully before considering surgery.

Often, nonpharmacological interventions are insufficient for adequate menstrual relief for patients suffering from premenstrual dysphoric disorder. Dietary modifications that may then be recommended include daily calcium, magnesium, and L-tryptophan supplementation. These modifications have been clinically studied in premenstrual syndrome patients and are therefore assumed to be beneficial to the PMDD patient. Recommendations supported by controlled studies include 1,200 mg of calcium carbonate per day in divided doses, 50 to 100 mg of magnesium twice a day (up to 60 mg/day), 400 U of vitamin E per day, or 50 to 100 mg of vitamin B₆ per day. Supplementation of L-tryptophan to reduce symptoms of PMDD has been indicated with limited data. The daily recommended amount of L-tryptophan is 6 g from the time of ovulation until day 3 of menses.

In addition to nutritional supplements, herbal products have also been studied to treat premenstrual dysphoric disorder. Dong quai is a coumarin derivative widely used in China for menstrual cramps and irregular menses. Black cohosh is often recommended to patients who suffer from dysmenorrhea and hot flashes associated with menopause. Similarly, blue cohosh can be used for menstrual cramps and stimulation of menstrual flow. Valerian is indicated for patients with insomnia related to PMDD. Although these herbal products may relieve some symptoms of premenstrual dysphoric disorder, they cannot be recommended because little is known regarding their dosing, efficacy, and safety. If a patient insists on the use of herbal products, it is essential to evaluate her current drug therapy (both prescription and nonprescription) to prevent significant drug­herb interactions. Some herbal products most commonly used by patients for PMDD include evening primrose oil (contains prostaglandin to reduce breast pain), kava kava (anxiety, stress, restlessness, and premenstrual cramps), melatonin (sleep-wake cycle disorder or insomnia), passion flower (anxiety and restlessness), St. John’s wort (depression), and valerian (insomnia and restlessness). With patients using herbals, it is important to discuss the specific drug­herb interactions that may decrease or increase drug levels in the body, resulting in toxicity or subtherapeutic levels of drug.

Pharmacological therapies in patients with premenstrual dysphoric disorder in whom lifestyle modifications fail include prescribed SSRIs, antidepressants, anxiolytics, and ovulation suppressors. According to ACOG, an SSRI is considered a first-line agent in treating PMDD.Its effectiveness is strongly supported by the association between reduced serotonin neurotransmission and PMDD symptoms such as depression, sleep impulse, anxiety, and carbohydrate cravings.As can be expected, many hypotheses suggest that serotonergic dysregulation may be partly responsible for symptoms of premenstrual dysphoric disorder. Most studies performed during the last 10 years have shown SSRIs to be efficacious for its treatment. Fluoxetine was the first SSRI that was approved by the FDA for this disorder. Placebo-controlled studies have concluded that serotonergic antidepressants, particularly fluoxetine and sertraline, are more effective than placebo. Both have been shown to improve emotional and physical symptoms associated with PMDD and also to enhance psychosocial functioning, work performance, and quality of life. Results of randomized clinical trials of fluoxetine and sertraline conclude that their effectiveness in PMDD treatment is clinically significant.Fluoxetine, at doses of 20 to 60 mg per day, and sertraline, at doses of 50 to 150 mg per day, have been studied and recommended for premenstrual dysphoric disorder. Results of the fluoxetine studies concluded that when larger doses were used in some patients, no clinically significant advantage in efficacy was observed. Instead, patients given 60 mg of fluoxetine per day experienced more side effects than those given the smaller doses. However, no similar clinical findings were reported in those studies using higher doses of sertraline.

Although fluoxetine and sertraline are the two antidepressants most widely studied for PMDD, other antidepressants have also been used. For example, venlafaxine is a newer antidepressant that works slightly differently than SSRIs by inhibiting both serotonin and norepinephrine reuptake. Treatment with 50 to 200 mg per day of venlafaxine in a small number of female patients has been shown to be more effective than placebo.Finally, paroxetine and citalopram have also been studied as antidepressants to treat premenstrual dysphoric disorder.

Using anxiolytic agents, particularly alprazolam, for PMDD has been controversial. Some studies have shown it to be more beneficial than placebo, whereas others have indicated alprazolam to be as effective as placebo. However, these studies focused more on the premenstrual symptoms associated with premenstrual syndrome. Thus far, no large study has been performed to examine anxiolytic agents as premenstrual dysphoric disorder treatment. Because alprazolam is a triazolobenzodiazepine anxiolytic, the obvious caution is the risk of dependence and tolerance. Buspirone is another anxiolytic considered as treatment. Few studies have shown that buspirone, at a dose of 20 mg per day, is more effective than placebo. Significantly, although anxiolytic agents are being studied for PMDD, serotonin agents remain the drugs of choice and should be first-line therapy before initiating anxiolytic therapy. To date, fluoxetine and sertraline are the only FDA-approved SSRIs for the treatment of premenstrual dysphoric disorder. Anxiolytic agents should only be considered if a patient does not tolerate the SSRIs or as adjunctive therapy.

Pharmacologically, when treating patients, it is crucial to understand the menstrual cycle and rise and fall of sex steroids. Many drugs have only been studied in the administration of certain phases of the menstrual cycle. Research has shown that taking these drugs “intermittently” or “semi-intermittently” has been more effective than continuous administration. Intermittent doses require administration only during the luteal phase, whereas semi-intermittent require lower doses during the follicular phase and higher doses during the luteal phase. Fluoxetine and sertraline are recommended during the luteal phase. Alprazolam has been found to be beneficial in both the luteal and follicular phases. Buspirone has also been shown as more effective during the luteal phase. Overall, a luteal phase administration of these agents mentioned previously has been found to not only reduce the side-effect profile but also to reduce the cost of treatment.

Some physicians prefer to use medications at higher doses during the luteal phase and then employ lower doses during the follicular phase. It is important to understand the patient’s cycle and review the menstrual calendar and symptoms experienced at particular phases to provide optimal relief. Patients should be very specific and thorough when recording symptoms associated with their menstrual cycle, as it is extremely helpful to pharmacists and physicians in tailoring their medication regimen. Tables 4 and 5 summarize the drugs currently available that are studied for premenstrual dysphoric disorder treatment.

ISBN 0-19509-334-8

Understanding the pharmacodynamics, or actions, of drugs is essential in central nervous system (CNS) research. Much of what we understand about the biological mind is the result of examining the effects of drugs on human functioning. This book by Dr. Paul M. Carvey, a well-respected professor of neuropsychopharmacology, is a very concise, easy-to-read textbook that reviews brain and receptor functioning and the effects of different drugs that act on the CNS. The book is well designed, starting with a general review of functioning and then focusing on different types of CNS clinical problems. It includes chapters on opioid analgesics, antidepressants, anxiolytics and antipsychotics, the treatment of headaches and movement disorders, and drugs of addiction and abuse. The style is clear and succinct, making good use of lists and diagrams. The diagrams, although in black and white, are effective in explaining many of the complex relations between drugs and the brain.

The first chapter is an introduction to pharmacology, explaining the basic principles that readers must understand to get the most out of the rest of the book. It reviews the different sites of action and the neurotransmitters. It also discusses the interactions between the various neural systems: motor, sensory, memory, emotional, cognitive and autonomic. The chapter is extremely well written and does not presume a lot of basic knowledge. This excellent review would be very useful for clinicians with no previous experience with CNS medications.

The next chapter explores the delivery of drugs to the CNS using the acronym LADME: liberation, absorption, distribution, metabolism and excretion. The difficulties presented by the blood-brain barrier are explained, as are the concepts of tolerance and drug half-life. Chapter 3 discusses the form and functions of neurotransmitter receptors, and the interactions of CNS drugs. Drugs that act on receptor systems do so through 4 mechanisms of action: direct- or indirect-acting agonists, and direct- or indirect-acting antagonists. The chapter also reviews the influence of neuronal location on receptor function and dose-response relations.

The next chapters each examine a unique topic. This excellent format allows clinicians to focus on the sections they are interested in, finding new information quickly and easily. The chapters on opioid analgesics and pain, the pharmacology of headaches, and anesthetics and muscle relaxants were all very clear to us, although we are not specialists in those fields. The topics of the remaining chapters were familiar to us. Although the information included was correct, there is no way a textbook can be up-to-date. But this is more a criticism of the publication process than of this textbook.

This minor criticism does not take away at all from the quality of Drug Action in the Central Nervous System. It is concise, has a logical structure, and provides a lot of information. The figures and tables are quite good and explain complex information well. One aspect of the book that is particularly useful is the series of chapter questions. These questions review all the major points of psychopharmacology. Sample questions include, “What is the role of brain perfusion in drug action and redistribution?” and

“How do the TCA and SSRI antidepressants alter neuron firing rates and what receptor changes are associated with the chronic use of each drug class?” This book seems to be best suited to medical students and to psychiatrists or neurologists who would like to review drug action in the CNS.

Future editions should consider the actions of the newer CNS medications. For example, as depression research is now focusing on faster-acting drugs, clinicians and medical students need to know how these medications work. Future work should also address the changing directions of psychopharmacology research and development.