In The
Difficult-to-Treat Psychiatric Patient, academic psychiatrists Mantosh
Dewan and Ronald Pies have assembled a compendium of articles about the
psychiatric treatment of mentally ill patients who do not improve with
first-line treatments. The editors
summarize the rationale for the volume in their epilogue:

There is an impressive… corpus of knowledge
pertinent to the initial treatment of [the] mentally ill…However, after the
first one or two steps, we are very quickly across the boundaries of
scientific, evidence-based data and firmly into the realm of the art and poetry
of psychiatry. (393)

The book is intended to shed light on the “art and
poetry” of psychiatry, and fortunately the effort is by and large a
success. In the space of approximately
400 pages, the editors compile a dozen chapters that address many of the major
categories of psychiatric illness as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Included in this text are extensive
discussions of unipolar and bipolar mood disorders, psychotic disorders,
anxiety disorders, borderline personality disorder, dissociative and
post-traumatic disorders, substance abuse, and dementia. Additional chapters address psychiatric
treatment of medically ill patients and non-pharmacologic “somatic” therapies,
including electroconvulsive therapy (ECT) and vagal nerve stimulation. Many of the contributors are renowned
experts in their subject matter.

Each chapter includes a review of initial treatment
options, an inventory of factors that may confound or limit response to
treatment, a description of alternative strategies, an evaluation of the
evidence for and against the novel approaches, and a case vignette. Within this basic framework, however, there
are marked differences among the approaches to the topics. Some chapters provide highly specific and
concrete recommendations for the systematic evaluation of less well-established
treatments, whereas others discuss more broadly the potential barriers to
successful treatment of specific disorders.
The book is clearly aimed at an audience of psychiatrists and others
with extensive knowledge of psychopharmacology; although the writing style is
accessible, the content is quite technical, and medical terminology is
sprinkled liberally throughout. The book
would appear to be aimed at psychiatrists in residency training or those who
have recently completed training and entered private practice. Experienced
clinical psychiatrists might find this volume helpful as a review of less
familiar topics, but not as an update on cutting-edge developments.

Most
chapters, such as those covering bipolar disorder and dementia, espouse
pharmacological treatment approaches, with less attention to psychotherapy
options. Other chapters, such as those
on eating disorders and post-traumatic stress disorder, emphasize the role of
various psychotherapies and downplay the potential of medication treatment. A
few chapters, such as those on anxiety disorders and borderline personality,
smoothly and gracefully integrate the biological and psychological
perspectives. These chapters are
particularly valuable and reveal some findings that may surprise
biologically-oriented psychiatrists.
For example, readers may be startled to learn that research demonstrates
that the second-most efficacious intervention for schizophrenia, a disease
usually conceptualized as purely biological, is family therapy.

Generally, the chapters on the major
mental illnesses—schizophrenia, bipolar disorder, and depression– are the most
elegantly written and cogently argued.
This is in part a reflection to the greater availability of high-quality
research on these disorders and in part a reflection of the care with which the
chapters were written. Treatment
strategies for each of the major mental illnesses are illustrated with
algorithms and flow charts. Some of the
assertions within these chapters may raise eyebrows, such as the contention
that depressed patients with a family history of bipolar disorder (manic
depression) should be considered “bipolar spectrum” patients, even without a
personal history of mood swings.
Overall, though, the chapters on the major mental illness provide an
outstanding resource for clinicians struggling to decide among treatment
options with questionable or unproven efficacy for severely ill patients.

Some chapters are less effective and
appear to have been written with a different audience in mind. For example, the chapter on medically ill
patients devotes considerable space to a review of research showing that the
newer SSRI medications are generally safer than the older tricyclic
antidepressants, a fact already well known to most medical professionals and
much of the general public. Similarly,
the chapter on dementia and traumatic brain injury focuses on the latter category
of disease, which is relatively uncommon and usually treated by neurologists,
rather than the former category, which is extremely common and is usually
treated by psychiatrists. However,
these are minor flaws that do not detract significantly from the overarching
quality of the volume.

Every few years, the American
Psychiatric Association publishes official “treatment guidelines” about
optimizing psychiatric treatment of specific mental illnesses. These guidelines are intended to provide
some sort of standardization of psychiatric care across the United States. Unfortunately, all too often these
guidelines, written by committee and designed to minimize offending the
pharmaceutical industry, amount to little more than tedious and poorly
differentiated lists of medication options and dose guidelines. By contrast, The Difficult-to-Treat Psychiatric Patient is an incisive,
well-written and nearly comprehensive guide to patients for whom treatment
failure appears a likely outcome.
Perhaps the most valuable element of The
Difficult-to-Treat Psychiatric Patient is the overall tone of the
volume. The editors manage to convey
both sympathy and reassurance for psychiatrists who are faced with especially
challenging patients. The editors’ epilogue, entitled “Clinical Wisdom,”
provides a sort of summation of the volume as well as an extended meditation on
the difficult nature of psychiatric work.
In short, The Difficult-to-Treat
Psychiatric Patient is an extremely valuable reference work to which
psychiatrists should refer early and often during periods of therapeutic
frustration.

©
2002 Michael Brodsky

Michael Brodsky is a psychiatrist in training in Los
Angeles, California, and an avid reader.

Categories: Ethics, MentalHealth