Book Review

Principles and Practice of Psychopharmacotherapy

N Engl J Med 1994; 330:226-227January 20, 1994

Article

Principles and Practice of Psychopharmacotherapy
By Philip G. Janicak, John M. Davis, Sheldon H. Preskorn, and Frank J. Ayd, Jr. 592 pp. Baltimore, Williams and Wilkins, 1993. $80. ISBN: 0-683-04373-0

Textbooks of psychopharmacology age quickly -- a tribute to the vibrancy of the field. The best of them offer more than a summary of current knowledge; they demonstrate how to reduce a mass of data to usable generalizations without losing the details that separate the wheat from the chaff. Such good textbooks give the reader a method of adding new information. This leaves a narrow ridge between uncritical conciseness and verbose criticism. Principles and Practice of Psychopharmacotherapy does an excellent job of finding that ridge. The authors, recognized researchers and teachers in psychopharmacology, not only provide us with a comprehensive review of psychopharmacology, but also accurately and concisely present the data on which they base their conclusions.

There is much more here than a textbook on drug treatment. The first 80 pages review what the clinician needs to know to treat patients with more than a cookbook approach. They provide valuable principles, such as the need for a careful diagnosis, the inadequacy of using drugs as sole treatment, and the value of assessing the risk-to-benefit ratio. In these preliminary chapters, the authors discuss different methods of evaluating drugs and the degree to which these methods adequately test hypotheses. The theory of meta-analysis -- combining data from all available studies -- long a special interest of one of the coauthors (Davis), is discussed here to prepare the reader for the extensive use of this method later in the book. However quickly the reviews of particular drug studies may age, this initial section of the book will remain valuable and well worth readers' attention for many years.

Although it focuses on drug treatments, this book's scope is far broader. With regard to the major mental disorders, the authors discuss diagnosis, biologic correlates, and even psychotherapy. This shows not only that this is more of a general textbook of psychiatry than a book on psychopharmacology, but also that to appreciate drug treatment adequately, we should understand diagnosis, theories of causation, normal and abnormal brain function, pharmacology, and psychotherapy. We cannot treat or understand mental disorders without this broad view.

At the heart of the book is the evidence marshaled for the best treatments for each disorder. For every major question, the authors summarize the data in tabular form, enabling the reader who wants detailed information to obtain it, while sparing the casual reader long stretches of text. This approach treats the reader with respect and honesty. Rather than offer conclusions only, the authors let the reader see the depth of the evidence. For example, we learn that a comparison of lithium with placebo for the treatment of mania involved a total of only 28 subjects.

The authors deftly review the voluminous literature on antipsychotic drugs, combining practical advice with biochemical information. I generally agree with their recommendations, but I notice a lack of critical review of the literature concerning the dosage for an acute or exacerbated episode of psychosis. In this area, they refer to a wide variety of options, but offer little guidance to the clinician. The authors mention using a loading dose, such as 60 mg of haloperidol per day, for quick control of symptoms, although I know of no study testing this technique. Double-blind, controlled studies of “rapid-neuroleptization” have compared a standard dose of antipsychotic medication with a higher dose in newly admitted patients with schizophrenia. All studies showed no advantage to the higher dose. The reader would appreciate a critical review of these studies.

In a work so filled with facts and opinions, I can naturally find many points with which I disagree. The authors refer to decreased thyroid function in unipolar depression, citing the well-established fact that the response of thyrotropin to thyrotropin-releasing hormone is blunted in a substantial minority of patients, but they do not explain how a blunted response indicates decreased thyroid function; we would expect an increased response in hypothyroidism. Their list of food restrictions for patients taking monoamine oxidase inhibitors omits beer and red wine. They recommend an adjunctive benzodiazepine or trazodone to a tricyclic antidepressant or a serotonin-reuptake-inhibitor antidepressant in cases of insufficient response, whereas the best evidence favors lithium or triiodothyronine as a booster. They describe bitemporal electroconvulsive therapy as equally effective for major depression as right unilateral electroconvulsive therapy, which is contrary to the best data -- some of it, to be fair, published recently. In their discussion of disulfiram for alcohol dependence, they omit the chief evidence showing it to be ineffective. These and other disagreements about some details do not detract from my assessment: this is a wise and authoritative book, which I recommend highly.

Arthur Rifkin, M.D.
Hillside Hospital, Glen Oaks, NY 11004