The Harvard Guide to Psychiatry, 3rd ed.

This new edition of the Harvard Guide to Psychiatry continues the tradition of distinction established by its two predecessors. It is not a comprehensive textbook of psychiatry; instead, it is a skillfully selected, well-organized collection of 38 chapters that address the core topics of our profession. Almost all of the chapters are written by one or two members of the Harvard faculty selected by the editor and senior faculty advisory group, who also limited both the number of contributors and the space allotted for each topic.

For me, the noteworthy feature of this superb volume is its dedication to the doctor-patient relationship, which, in Graham Greene’s words, is “the heart of the matter.” Accordingly, there is a focus on style and on the art of medicine being as important as the science for the care of the patient.

The arrangement of the six sections contributes to the volume’s attaining its objectives. In section 1, Examination and Evaluation, the first chapter, “The Therapist-Patient Relationship,” emphasizes the necessity to view this relationship as “crucial in the practice of psychiatry” for successful therapeutic outcomes. The chapter contains discussions of resistance, transference-countertransference, and ethics, including those regarding sexuality.

Section 2, Brain and Behavior, presents a lucid discussion titled “Neural Substrates of Behavior: The Effects of Focal Brain Lesions Upon Mental State.” Steven Hyman’s 16 pages on “The Neurobiology of Mental Disorders” is the best short discussion of this complex, important topic that I have read.

Section 3, Psychopathology, is well worth the price of the book by itself. The chapters are written by the experts, including W.W. Meissner, George Vaillant, and John Nemiah. Discussions of the clinical disorders summarize the results of recent research that is advancing our understanding, even though we still do not have a “breakthrough.” In these chapters, the continuing emphasis on the importance of the therapeutic alliance for patient care is especially meaningful.

John Gunderson’s chapter, “Personality Disorders,” is truly comprehensive. He presents a short but important historical discussion and describes what is known about the etiology of personality disorder. He also presents the models of Millon and Cloninger along with his own ambitious integrative model of the personality disorders, which groups them according to severity and is built on the psychobiological dispositions conceptualized by Jieves and Davis in 1994.

“Psychosomatic Medicine and Consultation-Liaison Psychiatry” is a sketchy chapter, especially in a volume that emphasizes patient care and at a time when somatization is considered ubiquitous. Multiple studies show that from 25% to 50% of patients in primary care practices have somatizing symptoms and/or disorders. Also, we need to acknowledge that the role of consultation-liaison psychiatry in our current era is increasing, greatly as a result of at least two major factors—the dictates of managed care and the advent of “new” diseases such as AIDS.

Section four, Principles of Treatment and Management, begins with Meissner’s excellent presentation of the individual, group, and family psychotherapies. Although the descriptions of each are brief, they are valuable introductions. I wish that the chapter had listed some additional references, especially those describing “how to” approaches, such as the work of McDaniel and her associates in medical family therapy. Ross Baldessarini’s chapter, “Psychopharmacology,” is comprehensive and contains helpful short summaries. Lee Birk’s chapter, “Cognitive Behavior Therapy and Systemic Behavioral Psychotherapy,” is an excellent introduction to these important treatment modalities. In addition, he presents a valuable chapter on “Sex Therapy,” parts of which need to be given to patients to read and discuss in therapy, as they wish. After short chapters titled “Electroconvulsive Therapy” and “Clinical Hypnosis,” the outstanding chapter “Patient Management” by Paul Summergrad et al. contains discussions of emergency and crisis care, inpatient management, and initiation of treatment in a supervised or medically safe setting. I will recommend this chapter to students and residents.

Part 5 deals with Special Populations. The first three chapters are “The Child,” “The Adolescent,” and “The Elderly Person.” In each, the relevant disorders are presented and the discussions focus on pertinent problems for management. Other chapters are “The Person With Mental Retardation,” “The Person With Chronic Mental Illness,” and the important, but often neglected, “The Person Confronting Death,” which needs to be included on students’ and residents’ mandatory reading lists. Its author, Edwin Cassem, is direct; for example, he presents paragraphs on “breaking bad news” and on “telling the truth,” along with short, penetrating discussions of suicide, the dying patient, grief, and mourning.

The last section, Psychiatry and Society, can be seen, in some ways, as the most distinctive in this highly recommended book. The array of authorities assembled for this section begins with a chapter by Chester Pierce, Felton Earls, and Arthur Kleinman, titled “Race and Culture in Psychiatry.” Edward Hundert presents a chapter titled “Ethical Issues,” and Jane Murphy et al. contribute an excellent, timely discussion of “Psychiatric Epidemiology” that even has J.N. Morris’s 1957 gem “The Uses of Epidemiology” in the reference list.

The last two chapters in the book tackle the really “tough” issues in American psychiatry at this time. Ken Duckworth and Jonathan Borus discuss “Population-Based Psychiatry in the Public Sector and Managed Care.” They begin with a review of the complicated history of public and community mental health care and then outline the principles of community psychiatry and look at the emergence of managed care. Their discussion considers such problems with managed care as the nefarious (my word) “carve out” strategies that produce an even greater separation between mental and physical health care than has existed many times in the past. I think that Duckworth and Borus underestimate the negative effects and the long-term as well as short-term adverse consequences of for-profit managed care for our society.

In the final, masterful chapter, Alan Stone presents “Psychiatry and the Law.” He insightfully points out that the lack of a coherent, generally accepted theory about responsibility and competency is an indication of the inability of Western thought to “reconcile its scientific and deterministic conceptions of human nature with its moral conceptions of the human condition.” After a brief historical survey, Stone outlines “the building blocks of law,” including the insanity defense and the test of competency to stand trial, along with other issues in the criminal courts that are pertinent today. These include capital punishment, hypnosis and recovered memory, the right to treatment, physician-assisted suicide, and standard issues such as informed consent and confidentiality.

Stone concludes his valuable chapter with a discussion of managed care and the “transformation of American psychiatry.” His grim but sensitive description of the growing crisis both in mental health care and in our profession unfortunately documents that for-profit managed care organizations are living up to their names as “managers.” As such, they are diminishing the roles of psychiatrists and other physicians who adhere to the convictions emphasized throughout this book, namely, that the doctor-patient relationship and the patient’s and family’s well-being are of foremost importance.

This third edition of the Harvard Guide ranks as the best of the three, all of which are very good indeed. It is my “desert isle” psychiatry guidebook.