Clinical Manual of Psychopharmacology in the Medically Ill

Over the past 20 to 30 years, there has been a massive proliferation in the pharmacologic armamentarium for virtually all medical and surgical illnesses. Although medical schools have stepped up training in pharmacology, most physicians are increasingly overwhelmed by the knowledge base necessary to keep track of all the medications available. Psychiatrists manage to develop expertise in the appropriate use of psychotropic medications to treat psychiatric illnesses but struggle to keep current with the pharmacotherapy of most medical and surgical conditions. Likewise, internists and surgeons are proficient in the use of pharmacotherapies in their own specialties but often lack essential knowledge about the use of psychotropic medications. And for all providers, understanding of the potential for interactions between the several classes of drugs is often beyond reach.

Entering the fray is the Clinical Manual of Psychopharmacology in the Medically Ill, a text that aims to provide a single reference for both general physicians and psychiatrists. To the credit of the editors, the book comes quite close to hitting its mark.

The text is divided into two main sections. The first is focused on general principles of psychopharmacology, which provide a context for understanding psychotropic medication issues in medical populations. The first two chapters on drug-versus-drug interactions and severe drug reactions are well organized but can be found in many other general psychiatry texts. For hospital-based physicians, the chapter on alternate routes of drug administration is useful and informative, providing some options for the complicated issue of patients unable to take oral medications because of medical circumstances.

The second section is organized around organ systems. These chapters discuss common medical illnesses of each particular organ that may have neuropsychiatric sequelae or in which psychotropic treatments may play some role, adverse psychiatric effects of the typical medications used to treat those illnesses, the impact of psychotropic medications on the organ system under discussion, and finally a detailed review of medical-psychotropic drug interactions particular to that organ. Each chapter provides a series of easily referenced, organized tables of the relevant medications used for the organ system and drug-drug interactions. All chapters end with a summary of key clinical points, most of which are somewhat too general to be of significant value.

Several of the chapters are especially beneficial to providers considering the complex interactions of a specific illness and its impact on the psychotropic treatment of patients. The chapter on gastrointestinal (GI) disorders, for example, discusses common disorders such as esophageal reflux and the potential indications for psychotropics, GI disorders on the interface of psychiatry (such as irritable bowel syndrome), GI side effects of psychotropic medications, and several important interactions. Special attention is given to patients with hepatic insufficiency, the pharmacologic impact of gastric bypass surgery, and antidepressant treatment issues with interferon-alpha hepatitis C treatment. The chapters on neurologic and endocrine disorders are equally superb. There is also an excellent discussion in the cardiology chapter on sudden death and QT prolongation due to psychotropic medications. Conversely, some of the chapters are a bit limited in the discussion of organ-specific illnesses, particularly the chapter on rheumatologic disorders.

General psychiatrists who frequently treat patients with comorbid medical disorders will find this book to be a terrific reference and useful review. Primary care providers will also find this to be a helpful volume to keep at hand, especially for patients with chronic psychiatric disorders and new-onset general medical illnesses. Last, for those of us who are consultation-liaison and psychosomatic medicine psychiatrists, the editors have created an indispensable textbook.