Book Review

Difficult Clinical Problems in Psychiatry

N Engl J Med 2000; 342:901March 23, 2000

Article

Difficult Clinical Problems in Psychiatry
Edited by Malcolm Lader and Dieter Naber. 246 pp. London, Martin Dunitz, 1999. £ 39.95. ISBN: 1-85317-550-1

In the introduction to this book, editors Malcolm Lader and Dieter Naber note that, intricate though our psychiatric nosology has become, it does not offer the kinds of sharp demarcations that would make decisions about treatment easy. Illnesses overlap one with another, and medications developed for one condition prove to be of use for seemingly disparate problems. In day-to-day work with patients, how is the practicing psychiatrist to sort this out? Difficult Clinical Problems in Psychiatry, directed at the general psychiatrist, is an offer of assistance from an international group of experts.

This book tackles 13 tough subjects, including refractory schizophrenia, the treatment of tardive dyskinesia, and ways to improve compliance. The authors are well-respected experts, and they have produced high-quality chapters that make complex problems accessible to the reader. The book has many useful tables, and the bibliographies are comprehensive. In general, it achieves a uniformly high standard of quality, which is always a challenge in edited books. The reading was both enjoyable and informative; I found it time well spent.

I was struck, however, by the editors' choice of issues, which represent core problems in psychiatry as defined by the Western tradition. The chapters are deeply influenced by the biomedical approach to psychiatry. They focus on a core set of diseases amenable to treatment with medication, to the near exclusion of a wide range of psychosocial, cultural, and environmental issues that are also of concern to the practicing psychiatrist.

As a psychiatrist who works in the fields of substance abuse and AIDS, I was surprised to read a chapter on compliance that made no mention of the remarkable experiences confronted by people with AIDS who are receiving highly active antiretroviral therapy. The success of such treatment depends on exceptionally high rates of compliance, much higher than those required with any other regimen. Furthermore, patients treated with these regimens often have to take many pills, many times a day. Compliance with highly active antiretroviral therapy is the most difficult problem in the literature on compliance and seemed a logical choice for discussion in this book. The fact that AIDS is not considered a core psychiatric condition may explain the editors' omission of this topic, but that is a choice I would challenge.

The chapter on the violent patient in the community notes that racial and economic inequality can lead to violence, but it offers no guidance on the management of deprivation that results from such inequality. Although it is true that poverty is created outside the doctor's office, it is equally true that the experience of deprivation must be addressed if treatment is to be lasting. This leads me to a more general comment on the lack of serious consideration of the role of social and cultural factors in the creation of illness. It seems out of step with the current movement toward globalization and cultural interchange to write about psychiatry as though it were free of these larger influences.

The problems of what to include and what to exclude in a book of this type reflect what we think psychiatry is or is not, and such frontiers are constantly expanding. Lader and Naber are talented editors, and they have produced an excellent book. It is my hope that they will see this book as a first attempt to address “difficult clinical problems.” I look forward to future editions, based on a broader definition of what psychiatry is and can be.

Mindy Thompson Fullilove, M.D.
Columbia University, New York, NY 10032