Essentials of Clinical Psychiatry, 2nd ed.

When this 1,000-plus-page book arrived, I expected to sample it here and there to review it. I found myself reading virtually the entire book, which tells you how helpful and readable I found it. It has an unusual degree of coherence and consistency and a tolerable degree of repetitiousness, especially for a multiauthored book. The editors included what they consider the 20 most clinically relevant of the 40 chapters in the fourth edition of The American Psychiatric Publishing Textbook of Clinical Psychiatry (1). Much of the book is remarkably up-to-date—for example, it includes nearly a page on transcranial magnetic stimulation, half a page on aripiprazole, and a 2003 reference on lamotrigine. Given the current shortage of child psychiatrists, general psychiatrists will be grateful that one-fourth of the book is devoted to children and adolescents. A chapter on the psychiatric interview has many suggestions particularly useful for trainees, including the prudent recommendation that they seek a personal analysis.

The chapter on psychopharmacology is especially strong, with abundant and sound clinical advice that blends the chapter authors’ clinical experience with their knowledge of the literature. I was pleased that they advise readers not to prescribe amoxapine; they might have added that it can be up to 15 times more lethal in overdose than even other tricyclics (another chapter states that antidepressant overdose is the most common method of suicide in the United States). In discussing adjunctive use of triiodothyronine in treating depression, they fail to mention that its half-life of 2–4 hours requires divided doses (it is my impression that most psychiatrists are unaware of this, which could be one reason that some studies find it ineffective). The chapter claims that all neuroleptics are equally effective; the authors should have added that molindone works only for some patients (but it has the advantage of not causing weight gain). The list of cytochrome P450 inducers that lower drug plasma levels omits smoked foods. The authors remind us that cigarettes are inducers of these isoenzymes—yet another reason our patients should stop smoking! There is no mention of genetically determined slow and rapid metabolizers of psychotropics; the CYP2D6 gene, for example, has more than 70 known variants. Generics get short shrift, although the exorbitant cost of drugs is a substantial factor in noncompliance for many patients. Another complication of prescribing an expensive drug is the greater risk that the patient will end up with a counterfeit drug, since counterfeit drugs represent an estimated 10% of the prescription medicines sold globally each year and counterfeiters have more to gain from imitating expensive drugs.

The chapter on mood disorders states that “it is impossible to know” (p. 266) if widespread use of stimulants in children plays any role in the increased incidence of bipolar disorder in this age group. This question clearly needs to be studied, especially since stimulants are prescribed to children less often in Europe and childhood bipolar disorder is less common there.

Some chapters are written mostly from the perspective of what we know from controlled studies (for example, chapter 6). Such information has its place, but it suffers from numerous limitations. Researchers like to remind us that the plural of anecdote is not data. However, clinicians sometimes need to remind researchers that the research literature can never replace clinical judgment. We all tend to forget the role of the so-called beta error in failing to validate truthful clinical assertions through a given study. We increasingly hear about the suppression of negative results from published drug trials, and we learn from clinical experience that drugs may be less efficacious and have more side effects than published results claim.

When it comes to psychotherapy, this text vastly overrates the clinical efficacy of cognitive behavior therapy. True, it is easier to study than psychodynamic psychotherapy. However, meta-analysis of its purported results demonstrates its much more limited value in the real world, in contrast to the world of research studies that exclude a high percentage of patients with the disorder being studied because they are deemed unsuitable for the trial.

Each chapter is followed by extensive references—up to 25 pages for one chapter alone. However, most readers would benefit more from much briefer references that included annotated suggestions of good review articles and texts on each topic. The many pages saved could be put to better use by covering areas that this synopsis omits. For example, there is a stunning omission of geriatric psychiatry, despite the many special psychological, medical, and pharmacological needs of the elderly—a burgeoning population.

Differential diagnosis is addressed better in some chapters than in others. Possible “medical” etiologies of mood symptoms are covered only in a table. We are not told that obsessive-compulsive symptoms can occur in the prodromal phase of schizophrenia. There is no mention of dissociative identity disorder in the differential diagnoses of schizophrenia, depression, “ultradian” cycling in bipolar disorder, gender identity disorder, or in the table on causes of amnestic disorders. The chapter on eating disorders fails to mention the history of childhood trauma in many of these patients; in general, it suffers from the absence of a psychodynamic perspective. Such a perspective does enrich much of the book, especially the chapters on child development and psychodynamic psychotherapy.

If I have focused on this text’s few weaknesses, it is with the hope that such feedback will help improve the next edition of this excellent resource.