Atypical Antipsychotics: From Bench to Bedside

“Who ordered this?” my grandfather would say good-naturedly when unexpected inclement weather ruined a planned outing. That phrase came back to mind when I hefted this medium-sized volume, promising to review the topic of “atypical antipsychotics” (when will we shift to a more appropriate term?). This is certainly germane to everyday practice, but for more than a decade we have been assaulted by an unremitting stream of information about these agents, sometimes accurate but often strongly colored by pharmaceutical marketing messages, invading us through sight and sound, journals, conferences, mailings, luncheons, APA conferences, advertising, etc. At this time, do we need a whole volume on this subject, I wondered?

This multiauthored monograph comprises five chapters covering relevant basic science followed by seven chapters mostly exploring the use of these medications in treating different disorders. Csernansky and Filippino begin with a chapter providing historical background and a review of the popular theories of what makes the newer drugs “atypical” that is informative, clear, and interesting. The chapter on rodent behavioral models usefully reminds us that the extant paradigms lack face validity for relevance to psychotic symptoms. My eyes glazed over, however, while slogging through the chapter on metabolic regulation: 35 pages of details of study results and references. The recited findings of these studies, almost exclusively poorly controlled retrospective analyses and numerous case reports, mostly about diabetes and glycemic control, do not add new conclusions to the current level of understanding of most clinicians. One chapter addressing the nosology of psychotic disorders might seem misplaced, but it provides a clear and engaging review of where our diagnostic categories have come from and their inherent limitations.

Further topics are neuroimaging studies, the acute and long-term efficacy of the newer antipsychotic medications (both covered in well-crafted chapters), their use in childhood disorders and “affective disorders” (mood disorders for most of us), and new targets for antipsychotic drugs (rather a more interesting piece, in which future directions are succinctly described). At best these provide current useful and intelligent reviews, but reading the book cover-to-cover exposes one to a moderate amount of repetition. On the other hand, the chapters are well referenced and most are well written, with only a modest number of small errors and typos. So perhaps this should be endorsed as a worthwhile addition to the literature.

Who, however, will be the audience for this book? It is more than most practicing clinicians will want to read on a familiar topic. Some motivated individuals might prefer to perform PubMed searches for the latest reviews when a question arises for them. As an alternative to a book, the authors might have published the chapters separately as review articles. This volume will principally be of value to researchers in the field, to those whose practices are focused on treating psychotic disorders, to trainees who wish a more thorough introduction to this class of medications with some historical background, and perhaps to those reviewing practice guidelines and administrative controls on prescribing. The latter group may be disappointed, though, to find only a single passing mention of one administrative scourge of current institutional psychiatry: the frequent and expensive practice of nonrational polypharmacy.