The American Psychiatric Publishing Textbook of Psychopharmacology, 3rd ed.

This is the third edition of the textbook that has set the standard for knowledge and wisdom regarding psychopharmacology as practiced in the United States. Extensively revised from the 1998 edition, it includes 17 new chapters, 180 additional pages, and 138 distinguished contributors, many new to this volume. As in the previous edition, subject matter is logically organized, with 65 chapters divided among four major sections.

The first of these sections, Principles of Psychopharmacology, brings readers up-to-date on the basic (e.g., molecular biology and genomics) and clinical (e.g., statistics, brain imaging) sciences forming the foundations of psychopharmacology. These chapters vary in breadth, depth, and complexity, but all are suitable and understandable for psychiatric clinicians, residents, and medical students.

The second section, constituting about half the book, covers virtually all psychotropic medications used in U.S. psychiatry (and a few not yet introduced), giving most agents their own separate chapters. A basic structure is imposed on these chapters: each covers the same areas (pharmacokinetics, mechanism of action, indications, etc.) in the same order, easing the reading of and comparisons among chapters. However, this format also leads to some unnecessary repetition of content (for example, each individual selective serotonin reuptake inhibitor [SSRI] chapter discusses mechanism of action).

The third section delves into current knowledge of the neurobiology of seven broadly defined psychiatric disorders (e.g., schizophrenia, mood disorders, and personality disorders). More uneven in approach and substance than the other sections (e.g., schizophrenia receives nine pages and mood disorders 46 pages), the writing of the individual chapters is clear and the information current.

The fourth section is targeted at practicing clinicians with chapters devoted to treatment of the major categories of psychiatric disorders (schizophrenia, bipolar disorder, etc.), a few specific symptoms (agitation, insomnia), and special populations (children, the elderly, and pregnant women). Although these chapters have some overlap with the second section regarding discussions of specific drugs, the approaches are sufficiently different for both to be useful.

Given the comprehensive nature of the book, I would have liked other areas covered that are relevant to current practice, such as management of pain and the importance of the placebo effect in psychopharmacological treatment. Obviously, choices had to be made, and no book can contain every relevant subject. However, there are several overlapping chapters such as the four on geriatrics-related topics that could have been combined, leaving room for alternatives.

The book has many strengths and a few areas that might deserve attention in future editions. Physically, although hefty, it is put together well with a strong binding, clear readable type, and freedom from annoying grammatical and spelling errors. It is exceptionally well referenced through 2002 with several references extending into 2003. The 85-page index is serviceable and useful. The writing is of high quality with a few exceptions. Many of the chapters on specific drugs and treatments are rigorous in their approach, considering only or mainly double-blind controlled studies as guidelines for recommendations; others freely include case reports and open-label studies in their guidance. A consistent standard set by the editors as to what would constitute suitable data across all chapters may have been preferable. Tables and graphs are placed generously and usefully in a number of the chapters, add little or even confuse in other chapters, and are very sparse or absent in most. Perhaps more defined instructions to contributors regarding the use of such material would enhance future editions.

A few of the authors had notations at the beginning of their chapters on specific drugs indicating that a pharmaceutical company had “provided data and support for editorial assistance in the development of this chapter.” The companies mentioned are the manufacturers of the specific drug. The meaning of “support for editorial assistance” is not clear but may represent a worrisome trend. In a similar vein, there is little discussion of the influence of the pharmaceutical industry on research, education, and clinical practice, although the listing of 57 contributors’ relationships to commercial supporters, including pharmaceutical companies, is welcome. Only an occasional comment relates to this influence, e.g., “Later randomized, controlled trials that compared tricyclics with SSRIs were invariably supported by the pharmaceutical industry, which had no desire to compare their new compound against optimal tricyclic treatment” (p. 1087).

Occasional factual oversights occur, but not many; for example, lithium’s benefit in preventing suicide is not mentioned, fenfluramine is discussed as a therapeutic option without noting that it has been withdrawn from the U.S. market, and methamphetamine is not mentioned in the chapter on substance-related disorders, which also gives only two sentences each to Ecstasy and PCP.

In summary, this book competently and accurately reflects the current and best of psychopharmacological practice in the United States with its realistic optimism based on rapid advances in the neurosciences. However, many issues that cast a shadow on the future promise of this practice are given less or no attention. For example, genuine progress in applied psychotherapeutics is mixed at best. Of the multiple new drugs introduced in the past 15 years, none (with the possible exception of clozapine) offers a major efficacy advance over the medications serendipitously discovered 40 years ago (although offering advances in relief from adverse effects). Given this track record, both the reasons for this deficiency and the place of new and expensive medications in the allocation of scarce resources to psychiatric patients are issues in a debate yet to be fully engaged. In a similar vein, the clinical and economic consequences of the manner in which drugs are developed, marketed, and used are widely recognized but hesitantly confronted. More broadly, the need to reassess current methods of classifying disorders and symptoms as the basis for therapeutics is only beginning to be explored. It is perhaps unfair to expect this or any textbook of psychopharmacology to address these issues. However, the future of the field of psychotherapeutics may rest on an open and vigorous debate of these and similar issues. Until such time as decisions are made regarding the place of such issues in the education of psychiatrists, this book will deservedly continue to set the standard for comprehensive knowledge in psychopharmacology.