BOOK REVIEWS Jeffrey L. Geller, M.D., M.P.H.

, Editor

Clinical Governance in Mental Health and cerned with human dignity and pro-
Learning Disability Services: A Practical Guide vider integrity.
edited by Adrian James, M.D., Adrian Corral, and Tim This book does not present as an
Kendall; London, Gaskell Press, 2004, 360 pages, $60 easy read despite flourishes of English
wit. It took this reviewer some time to
Richard E. Kellogg, M.Ed. understand the context of the clinical
vice Framework for Mental Health. governance philosophy and how it is

T he goal of a comprehensive sys-

tem of quality assurance and im-
provement has been elusive in the ex-
The chapter concerning the role of
trust boards in clinical governance is of
particular interest to citizens, con-
embedded in the NHS. American
readers might find the book more ac-
cessible if the introduction included
ercise of public policy. Stops and starts sumers, and professionals involved information concerning the structure
in the field of publicly paid mental with the nonprofit community mental of the NHS, the purpose and role of
health and learning disability services health provider model. trusts, and the operational meaning of
appear to reflect changes of executive The section about building blocks some terms. A trip to the Web sites of
administrations at the state and feder- and key elements explores several cur- the NHS and Royal College of Psychi-
al levels rather than a reliance on con- rent and vital topics relevant in this atrists is recommended. Federal and
sistency, investment, and common country. The chapter concerning the state policy makers interested in com-
sense. In Clinical Governance in Men- role and involvement of service users parative systems of clinical practice
tal Health and Learning Disability and their relatives includes a cogent improvement, evidence-based prac-
Services the Royal College of Psychia- discussion about user and family in- tice, consumer involvement, and cul-
trists effectively acquits the search for volvement with organizational change ture change within organizations pro-
a comprehensive system of quality as- and service delivery. The authors sug- viding mental health services would
surance and improvement in a single- gest that what counts the most is a be- find merit with this work. Academic
pay public model. lief in the value of such involvement, programs in psychiatry could derive
The book describes the efforts of the not the model. The two chapters con- benefit from reviewing this book from
Royal College of Psychiatrists to im- cerning evidence-based practice are the perspective of physician-related
plement the processes of a compre- especially noteworthy. John Geddes quality standards and improvement
hensive quality assurance and im- discusses a pointed taxonomy for the based on external review.
provement system—clinical gover- selection and review of articles about
nance, within the relevant trusts of the evidence-based practice in the journal
National Health Services (NHS). Evidence-Based Mental Health that
The values and structure of the federal and state policy makers would
NHS model of clinical governance are benefit from reading. Mary Lindsay The Evidence-Based
explained and illustrated through the provides an excellent exploration of Practice: Methods,
prism of an operational guide. Atten- good and bad organizational practice Models, and Tools for
tion is given to the concerns of imple- relative to policies and procedures. Mental Health Professionals
menting administrative and opera- Her discussion of the need for policies edited by Chris E. Stout and
tional culture change. The book is and procedures as a foundation for Randy A. Hayes; Somerset, New
structured into four main categories: clinical governance and a well-func- Jersey, John Wiley and Sons,
background, history, and philosophy of tioning system is fertile ground for ad- Inc., 2005, 384 pages, $60
clinical governance; foundations and ministrators and staff who often feel
organizational structure; the building overburdened by internal and external Lloyd I. Sederer, M.D.
blocks and key elements of clinical policy and procedural requirements.
governance; and translating clinical
governance into the clinical context.
The sections on foundations and orga-
The final section covers a broad ar-
ray of topics that support the integra-
tion of clinical governance into the
T he trouble with evidence-based
practices—stated in this text as
“the use of treatment methodologies
nizational structure section discusses clinical context. Information systems, for which there is scientifically col-
the NHS model, the role of trust monitoring and improvement, and the lected evidence that treatment
boards, a labyrinth of inspectorates importance of leadership by clinicians works”—is that they don’t cover
and cross-audits, program guidance by and nurses in the management of enough ground, have typically exclud-
the National Institute for Clinical Ex- change of mental health services deliv- ed consumer and family preferences
cellence, support for the clinical gov- ery are discussed from the perspective and input, and can crowd out promis-
ernance model, and the National Ser- of quality improvement through the
system of clinical governance. The
Dr. Sederer is executive deputy commis-
Mr. Kellogg is the director of Mental chapter concerning vulnerable people sioner, Mental Hygiene Services, New
Health Services, Department of Social in care and person-centered values is York City Department of Health and
and Health Services, State of Washington. recommended to all readers con- Mental Hygiene.

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 1219

BOOK REVIEWS

ing but as yet unproven practices. self has not merely talked the talk, he bad clinicians; it is typically because
Also, knowing what works does not has walked it. His community-based our systems of information technology
equate to doing what works. organization has won the distinguished have yet to encode guidelines and best
I recall reading an opinion piece in Codman Award from the Joint Com- practices into electronic clinical
the British Medical Journal on evi- mission on Accreditation of Healthcare records and make them standard oper-
dence-based practices (EBPs) that Organizations and the American Psy- ating practices. When that happens,
examined MEDLINE and other chiatric Association’s Bronze Psychi- consumers, families, and clinicians
databases to see whether any ran- atric Services Award. His coeditor, Dr. alike will realize the aims of what the
domized controlled trials had been Stout, has notable experience in aca- editors offer as their standard, the Hip-
performed to determine whether demic, management, and government pocratic Oath: to help or at least to do
parachutes were effective in prevent- work. Together they have produced a no harm.
ing death and major trauma (1). text not only worth buying but worth
Clearly, no such trials exist, although reading. Reference
the effectiveness of parachutes is Still, even if we learn, we also must 1. Smith GC, Pell JP: Parachute use to prevent
death and major trauma related to gravita-
commonly known. The authors of the do. The world of clinical practice often
tional challenge: systematic review of ran-
opinion piece went on to say that falls short of using the evidence we domised controlled trials. British Medical
strict adherents of EBPs should or- have. This shortfall is not because of Journal 327:1459–1461, 2003
ganize and participate in a random-
ized, placebo-controlled, cross-over
trial of the parachute. They might then
come to reconsider their previously
held conviction that EBPs should be
Juvenile-Onset Schizophrenia:
the sole standard for clinical practice. Assessment, Neurobiology, and Treatment
But when EBPs exist, and when we edited by Robert L. Findling and S. Charles Schultz; Baltimore,
employ them, what good they can do. Maryland, Johns Hopkins University Press, 2005, 311 pages, $49.95
It is not sufficient, the editors of this
Calvin R. Sumner, M.D.
book assert, to intend to do well and yet
fail to do what has been proven to
work. They demonstrate that good
clinical practice is the fortunate mar-
U nderstanding complex mental
disorders is seldom a destination
of revelation and more often a jour-
tives of reviewing the current scientif-
ic and clinical understanding of schiz-
ophrenia among children and adoles-
riage of ethical intent and fidelity to ney of evolving discovery. In any jour- cents, which was once considered rare,
proven practices. And this text serves ney, it is wise to periodically pause and integrating this knowledge with
the cause of good clinical practice with and take stock of where you’ve been, the growing understanding of schizo-
a consistent and clear voice through where you are now, and where you’re phrenia in general. Full syndromal
standardized chapter design and capa- going. manifestation of schizophrenia re-
ble editors’ hands. Robert Findling and S. Charles mains uncommon among youths and
The book begins with nine chapters Schultz, editors of Juvenile-Onset is associated with unique treatment
on specific EBPs, including assertive Schizophrenia, have done a masterful challenges, different responses to
community treatment, supported em- job in charging their outstanding treatments compared with adults, and
ployment, child and adolescent treat- group of contributing authors to often poorer outcomes compared with
ments, treatments for clients with chronicle the evolution of our current those who develop the disorder in
mental illness and chemical abuse, and understanding of this severe and po- adulthood. Nevertheless, the authors
psychosocial rehabilitation. Six of these tentially devastating disorder and to present lines of evidence demonstrat-
nine chapters constitute the Substance anticipate future directions in the sci- ing the continuity of the juvenile and
Abuse and Mental Health Services Ad- entific and clinical journey. The au- adult disorders and consider the fac-
ministration’s “tool-kit” for EBPs. An thors also underscore the importance tors that may contribute differentially
exceptional chapter on recovery from of findings over the past decade in the to the emergence of the disorder at
severe mental illness offers the reader emergence of schizophrenia among different points during development.
decades of research and wisdom from young patients as a window into a bet- The validity and stability of the di-
William Anthony and the Center for ter understanding of the genetic and agnosis of early-onset schizophrenia
Psychiatric Rehabilitation. The text neurodevelopmental underpinnings is crucial to the foundation of re-
concludes with several chapters by one of the disorder across the lifespan. search on the disorder, and Dr.
of the editors, Dr. Hayes, that provide This book pursues the dual objec- Gabrielle Carlson and her colleagues
practical information on how to assess set the stage with a logical and evi-
programmatic readiness for EBPs and dence-based presentation on the phe-
Dr. Sumner is a medical advisor for Lilly
how to implement them in a practice, Research Laboratories, United States nomenology and assessment of the
agency, or facility. Medical Division, Neuroscience, Eli Lilly disorder. In a later chapter, Drs. Nitin
Dr. Hayes, one of the editors, him- and Company, Indianapolis, Indiana. Gogtay and Judith Rappoport lend a
1220 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8
 BOOK REVIEWS

note of caution on diagnostic speci- Mind, Brain, and Schizophrenia

ficity, reporting on the differential di- by Peter Williamson; New York, Oxford University Press, 2005, 304 pages, $65
agnostic possibilities of adolescent
mental disorders. Dr. Matcheri Ke- Miriam C. Tepper, M.D.
shavan makes a provocative observa-
tion in the chapter on progress to-
ward a developmental hypothesis of
schizophrenia. The quest for a unify-
I n this highly technicalized era in
which the work of a neurobiologist
is all too rarely directly relevant to
of a series of circuits needed for nor-
mal functioning.
Williamson goes on to describe two
ing theory of schizophrenia might be the clinician, Mind, Brain, and general sets of models, the first in-
well served by consideration of the Schizophrenia provides a welcome volving disconnection and coordina-
neurodevelopmental environment of synthesis of neurobiological explana- tion of information processing, in-
the adolescent brain and the extent to tory models and clinical manifesta- cluding observations about aberrant
which this evolving environment may tions of schizophrenia. Peter lateralization, corticocortical and cor-
provide insight into factors contribut- Williamson frames the thesis of this ticosubcortical disconnections, ab-
ing to the emergence of schizophre- book with an analogy to when the normal arousal of emotional centers,
nia. Subsequent chapters elaborate circulatory system was proposed 400 and cognitive dysmetria. The second
the general neurodevelopmental en- years ago to explain heart failure. model involves abnormalities of the
vironment of adolescence and the Whatever the specific cause of heart basal ganglia-thalamacortical circuits,
particular factors that may be relevant failure—genetics or renal failure, for including evidence for the failure of
to the emergence of schizophrenia instance—the circulatory system self-monitoring, subcortical neuro-
within that context, including an in- mediates the final clinical syndrome. transmitter imbalances, the impor-
teresting discussion of genetics fac- Williamson argues that the symp- tance of the nucleus accumbens, and
tors and endophenotypes. toms of schizophrenia can be dopamine sensitization. Williamson
The book transitions nicely from thought of in an analogous manner transitions easily from basic science
the scientific and research review to and that the search for the single ul- to clinical relevance, and this per-
the practicalities of clinical diagnosis timate cause of schizophrenia should spective is extremely helpful in con-
and treatment. Juvenile-onset schiz- be deemphasized in favor of focusing ceptualizing the pathophysiology of
ophrenia is a disorder of pervasive on the “final common pathway” of schizophrenia.
developmental disruption, and clini- the disorder. However, although Williamson’s
cal care requires careful assessment The bulk of the book considers var- bird’s eye view is so helpful in trying to
of multiple parameters of develop- ious perspectives on the neurobiology make sense of the tremendous quanti-
mental function. Pharmacologic of schizophrenia, with chapters dedi- ty of emerging data, his circulatory sys-
treatment of juvenile-onset schizo- cated to neuronal circuits, neurode- tem analogy seems to break down in
phrenia is not well studied, and velopmental models, neurotransmit- the realm of treatment. That is, though
many unknowns remain, including ters, psychophysiology, neuropsychol- the clinical manifestations of heart fail-
age-specific issues of efficacy and ogy, neuroimaging, and neuronal de- ure constitute a typical syndrome,
safety in the treatment of patients generation. The text summarizes treatment interventions rely critically
who are not yet physically mature. large bodies of information in rela- on the precise etiology of the failure.
Furthermore, the interacting com- tively accessible language, although at Similarly, the development of new
bination of biopsychosocial factors times it reads somewhat like a text- pharmacologic and psychosocial inter-
in the youthful emergence of schiz- book with an unclear target audience. ventions for schizophrenia seems to
ophrenia and the implications for At other points it loses the focus of depend to some degree on an individ-
treatment remain to be untangled. developing its thesis and instead me- ualized understanding of what re-
The concluding chapters offer a thodically catalogues research devel- quires attention most acutely.
compact review of the psychosocial opments over time. One absence from the text of rele-
factors in diagnosis and treatment of The greatest strength of the book vance to readers of this journal is that
juvenile-onset schizophrenia that is is in the final few chapters, which be- its content is focused on explaining
a welcome complement to the bio- gin to synthesize information about symptoms and does not venture to
logical perspective. regions and circuits that are impli- consider how the various models fit
Overall, the editors have stitched cated in the pathophysiology of with changes that accompany rehabil-
the varying perspectives of the con- schizophrenia. Williamson observes itation efforts. For instance, it would
tributing authors into a very satisfying that the heterogeneity in the location be interesting to consider how the
complete text, which is always a chal- and type of observed abnormalities discussion of neuronal degeneration
lenge in a multiauthor book. A sub- could result from damage to any part fits with the evolving understanding
stantial breadth of material is well of neurobiological changes accompa-
presented on state-of-the-art clinical Dr. Tepper is a clinical fellow in psychia- nying improvements in cognitive
care and cutting-edge science related try at Harvard Medical School and Mass- function or areas of compensatory
to juvenile-onset schizophrenia. achusetts General Hospital, Boston. function.
PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 1221
BOOK REVIEWS

Schizophrenic Speech: Making Sense of the authors write, “There seems to be

Bathroots and Ponds That Fall in Doorways no way of avoiding the unwelcome
by Peter McKenna and Tomasina Oh; New York, conclusion that thought disorder
Cambridge University Press, 2005, 210 pages, $95 comprises a number of quite differ-
ent abnormalities which combine
Mark R. Munetz, M.D. and recombine erratically, often in
the same patient.” By raising the

T he preface of this compact vol-

ume begins with the question,
why do we need another book on
reading, are interspersed throughout
the book. We are reminded that
thought disorder occurs in mania and
question of whether thought disorder
is really a disorder of thought, lan-
guage, or both, the inevitable conclu-
schizophrenia? The authors answer schizophrenia. Comparison samples sion appears to be both.
honestly that it is the only way they of speech from aphasic, head-in- The authors’ argument as to why
could get a paper published based on jured, postlobotomy, and autistic pa- there has been reluctance to consid-
a Ph.D. dissertation and because tients are included, as are samples er language disorder as part of schiz-
there has yet to be a book that re- from so-called normal and eccentric ophrenia is intriguing. If I under-
flects two major developments in the persons. The inclusion of the open- stand their argument, if schizophre-
field: studies following Andreasen’s ing paragraphs of James Joyce’s nia were seen as involving dysphasia
rating scale for thought, language, Finnegans Wake, with the author’s or language disorder, it would be
and communication disorders and key to some of its meaning, adds to seen as fundamentally a neurologic
the rise of a neuropsychological ap- richness of the discussion. disorder, which is presumably unac-
proach to schizophrenia. The conclusions may not satisfy the ceptable to psychiatry. The fact that
Although fascinating in places, this casual reader because final answers schizophrenia is both a disorder of
scholarly work is not light reading. are not in yet, but I found the final the brain and the mind seems clear
The authors are a British psychiatrist chapter made for the most interest- from this critical, scholarly review of
with a special interest in neuropsy- ing reading. In a section titled “Why the not so simple concept of thought
chology and a linguist. Essentially is thought disorder so complicated?” disorder.
this book is everything you wanted to
know about the concepts of the for-
mal thought, speech, and language
disorders in schizophrenia. The na- Relapse Prevention: Maintenance Strategies in
ture of these disorders is examined in
the Treatment of Addictive Behaviors, 2nd edition
detail in seven chapters. A final chap-
edited by G. Alan Marlatt and Dennis M. Donovan;
ter offers some conclusions and a few
New York, Guilford Press, 2005, 406 pages, $45
speculations. The authors start with
what may be a surprising premise, Janice F. Kauffman, R.N., M.P.H.
that we really don’t have a good un-
derstanding of the nature of formal
thought disorder in schizophrenia—
for those of us trained in the era of
C linicians working with addictions
are challenged by the prevalence
of relapse. When seeking guidance,
treatment of relapse. Marlatt and
Witkiewitz reconceptualize relapse as
a dynamic process, expanding on Mar-
Bleuler’s 4-As, loose associations. they look to Alan Marlatt and Dennis latt and Gordon’s cognitive-behavioral
The book then supports this premise Donovan for their wisdom. Relapse model. This new model incorporates
in great detail and critically reviews Prevention offers clinicians a compre- distal risk factors, such as years of de-
the many concepts about what un- hensive update of the science and pendence, family history, supports,
derlines thought and language disor- how it has been applied to major ar- and comorbid psychopathology, with
der in schizophrenia. eas of addictive disorders. cognitive processes—self-efficacy,
The clinical material contained in The opening chapter, by Marlatt outcome expectancies, craving AVE,
the book may be of the greatest in- and Katie Witkiewitz, provides a and motivation—and cognitive and
terest to clinicians. Samples of broad overview of relapse prevention behavioral coping skills. They propose
speech from individuals with schizo- for drugs and alcohol and special a reciprocal causation or feedback
phrenia, which make for fascinating treatment considerations. It summa- loop that allows for the interaction be-
rizes the models of relapse, the effec- tween coping skills, cognitions, affect,
tiveness and efficacy of relapse pre- and substance use behavior. This
Dr. Munetz is chief clinical officer of the vention, the Relapse Replication and
Summit County Alcohol, Drug Addiction, Extension Project, and the intraper-
and Mental Health Services Board, sonal and interpersonal determinants Ms. Kauffman is the director of the Addic-
Akron, Ohio. He is also affiliated with the tion Psychiatry Service, Brigham and
Department of Psychiatry, Northeastern of relapse. The newest and most excit- Women’s Hospital, and assistant professor
Ohio Universities College of Medicine, ing section explores future directions of psychiatry, Harvard Medical School,
Rootstown, Ohio. in the definition, measurement, and Boston.

1222 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8

 BOOK REVIEWS

reconceptualization of relapse ad- the experts attempt to address and anxiety, and posttraumatic stress disor-
dresses the complexity and unpre- apply the conventional wisdom of der (PTSD) follow. I found the chap-
dictability of substance use behavior. models of relapse prevention and ar- ters on the anxiety disorders to be the
Eleven chapters written by experts eas for future study. most interesting in the volume be-
who address cutting-edge relapse This is not a book that lends itself cause they were the richest in theory.
prevention science and practice in readily to reading cover-to-cover, but Some of the topics covered include el-
their respective fields follow the first it is a must-have resource for both evated responsibility and thought-ac-
chapter. Topics include diverse popu- seasoned clinicians and researchers. tion fusion in OCD; attention, memo-
lations, alcohol, smoking, stimulants, The numerous citations can distract ry, judgment, and interpretation biases
opioids, cannabis, club drugs, hallu- the reader from the salient points, but in social anxiety; as well as rigid world
cinogens, inhalants, and steroids. the reader will find it a worthwhile and self schemas, and maladaptive
Other chapters cover eating disorders endeavor. The book represents the coping styles in PTSD.
and obesity, gambling, sexual offend- next step in the evolution of under- In Part III, the chapter on bulimia
ers, and high-risk sexual behaviors. standing the complexity of relapse gives great attention to resolving the
Each chapter offers a comprehensive which is common for patients strug- perfection paradox, that is if the indi-
review of the literature and empirical gling to manage chemical and non- vidual’s goal is body perfection, why
data where applicable. In addition, chemical addictive behaviors. does he or she binge and undermine
the goal? The authors offer a three-
factor model combining high perfec-
tionism, body dissatisfaction, and low
self-efficacy. They also discuss binging
Cognitive Vulnerability to Emotional Disorders
as an attempt to regulate aversive
edited by Lauren B. Alloy and John H. Riskind; Mahwah, New
emotion and self-awareness. The
Jersey, Lawrence Erlbaum Associates, 2005, 451 pages, $39.95
anorexia and integrative chapters
Stephanie Bagby-Stone, M.D. make it clear that there is a relative
shortage of cognitive vulnerability re-

C ognitive vulnerability refers to

cognitive antecedents, beliefs,
and patterns that make way for devel-
ing thoughts preceding and promoting
psychological disorders.
Alloy and Riskind begin the book
search on anorexia.
Overall, I found Cognitive Vulnera-
bility to Emotional Disorders to be a
opment and maintenance of psycho- excellently by introducing the con- fascinating and thought-provoking ex-
logical problems. Better insight into cept of cognitive vulnerability includ- perience that left me with many new
cognitive vulnerability could lead to ing a discussion of distal and proximal ideas, insights, and questions.
better prevention, understanding, and cognitive antecedents, the cognitive
treatment of mental illness. Cognitive vulnerability-stress paradigm, and a
Vulnerability to Emotional Disorders theoretical framework of cognitive
attempts to synthesize the most recent vulnerability. The remainder of the
information in this promising field. chapter deals with issues in research Assessment of Addictive
Editors Lauren Alloy and John theory and design. Behaviors, 2nd edition
Riskind take on the task of compiling Part I begins with a chapter on the edited by Dennis M. Donovan and
essays in the burgeoning area of cogni- Cognitive Vulnerability to Depression G. Alan Marlatt; New York, Guilford
tive vulnerability in emotional disor- Project providing a model of how re- Press, 2005, 480 pages, $55
ders. The introduction provides infor- search is being done in this area. Chap-
mation on theory and research design. ters on depression, bipolar, and suicide Mark J. Albanese, M.D.
The remainder of the book is organ- follow. Much discussion is given to the
ized into three parts: mood, anxiety,
and eating disorders. Each part con-
tains chapters on specific disorders as
hopelessness theory and Beck’s theory
of depression and stress-diathesis para-
digm. Read as a whole, Part I can at
D ennis Donovan and Alan Mar-
latt are two of the preeminent
leaders in addictions. They have as-
well as an integrative chapter written times be redundant, because the chap- sembled others with similar creden-
by a leading expert in the field. The ters are written to stand alone. tials to contribute chapters to this
book is structured so that readers can Part II begins with a chapter de- book, which reflects the collective
enjoy the work as a whole or focus on scribing the “looming maladaptive scholarship and clinical wisdom of
their area of interest. This book will style,” which focuses on dynamic dan- the contributors. The book exam-
appeal to readers who wish to have a ger content and how this style may re- ines the biopsychosocial aspects of
greater understanding of the underly- late to specific anxiety disorders. This
chapter also presents information from
Dr. Albanese is medical director of addic-
Dr. Bagby-Stone is assistant professor of the Cognitive Vulnerability to Anxiety tions at Cambridge Health Alliance and
clinical psychiatry at the University of Project. Chapters on panic, obsessive- assistant clinical professor of psychiatry
Missouri–Columbia, Missouri compulsive disorder (OCD), social at Harvard Medical School, Boston.

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 1223

BOOK REVIEWS

addictive disorders as they relate to Taking Your Medicine: A Guide to Medication

relapse. Although this book focuses Regimens and Compliance for Patients and Caregivers
on assessment of patients, it is by Jack E. Fincham, Ph.D., R.Ph.; Binghamton, New York, Haworth Press,
meant to be used with the authors’ Inc., 2005, 179 pages, $22.95 softcover
companion volume, Relapse Preven-
tion: Maintenance Strategies in the Michael Angelini, M.A., Pharm.D.
Treatment of Addictive Behaviors.
Addiction is defined broadly, with a
chapter devoted to each addiction.
Thus there are chapters on alcohol,
J ack Fincham has created a guide-
book that attempts to enhance med-
ication compliance and patient and
cautions relate only to benzodiazepines
and not the multiple other medication
classes that are used to treat anxiety
smoking, cocaine, amphetamines, caregiver knowledge about prescrip- disorders. The chapter regarding drug
opioids, and cannabis and a chapter tion and over-the-counter medications. interactions is generally too superficial
on club drugs, hallucinogens, in- In his book, Dr. Fincham tackles such and runs the risk of causing inappropri-
halants, and steroids. The book also topics as medical abbreviations, meth- ate alarm in a patient. He makes a gen-
includes chapters on eating disor- ods of enhancing adherence, accept- eral statement that medications that
ders, gambling, sex offenses, and sex- able ethical behavior of pharmacists treat the same condition should not be
ually risky behaviors. Each chapter and doctors, legal rights regarding taken together and further cautions
details both a general overview of as- health information, useful health care that “pain medications should not be
sessment and specific biopsychoso- websites for patients, and other practi- combined together.” One section has
cial aspects of assessment. For exam- cal aspects of medication use. The been mislabeled angiotensin-convert-
ple, the chapter on alcohol problems book is written for the patient or the ing enzyme inhibitors but refers to and
describes screening methods for al- patient’s caregiver but also provides di- lists calcium channel blockers. Also,
cohol misuse, moves on to assess- rection to a health care provider as to descriptions of medical conditions and
ment for alcohol disorders, then what are real patient concerns. medication characteristics, both kinetic
takes up more specific assessment is- The book itself can be detailed at and dynamic, are provided, at times, in
sues, such as psychological factors times, but the author has added text terms that are too sophisticated for the
like readiness to change. Each chap- boxes, Key Points, which highlight the lay person. For example, he writes that
ter also contains sample assessment more important points. One of the cisapride and other drugs should not
instruments and a comprehensive, more valuable chapters discusses barri- be taken together because “they can
exhaustive list of references. ers to compliance and methods to re- lead to cardiac arrhythmias, including
The book starts with a terrific move them. Other useful sections dis- torsades de pointes.” He does com-
overview of relapse prevention by cuss professional, appropriate behavior ment after these sections that con-
Dennis Donovan. He pays particular and what to expect from a pharmacist. sumers should consult with their doc-
attention to describing the three do- These areas provide examples of be- tor or pharmacist about these issues.
mains of assessment of relapse risk: haviors that will help alert the patient Although the title of the book leads
distal personal characteristics, inter- to when a pharmacist may be acting in one to think that it is for consumers,
mediate background variables, and either unethical or illegal ways. Online the content of the book could also be
proximal precipitants. He under- pharmacies and other online services used as a teaching tool in pharmacy or
scores the notion that the occur- are discussed, and Dr. Fincham pro- allied health academic programs. It
rence of intermediate and back- vides signs of fraud and abuse for the refers to issues that all pharmacists
ground variables, and how they con- reader so they can address these issues should be aware of and should be pre-
tribute to stress, makes it important or avoid these pharmacies altogether. pared to deal with. By using the book
to assess patients for coping skills. Another beneficial chapter reviews as a required reading in a pharmacy
This chapter sets the stage for the herbal products. He cautions about le- course, the students would be guided
following chapters. Notably, the sec- gitimate risks associated with herbal to the public’s perspective and the in-
ond chapter is a valuable overview of products and also provides examples of formation they may be using for deci-
assessment of addictions in ethnic- harmful and deadly drug interactions sion making.
minority cultures. Most of the chap- between herbal products and prescrip- Dr. Fincham has created a text that
ters also discuss assessment of co- tion medications. compiles most of the critical topics re-
morbid psychiatric disorders and At times, however, the author seems lated to taking medications. He pro-
other co-occurring conditions—per- to provide information that may be in- vides insights into the medical profes-
tinent medical and neurological dis- terpreted in a misleading way. He fre- sion that patients may find useful when
orders, for example. quently refers to anxiolytics, but his trying to work with the health care sys-
This book is a treasure that will be tem. The book tries to empower the
useful to anybody who treats patients consumer and help maximize thera-
Mr. Angelini is assistant professor in the
with addictive disorders. It will like- Department of Pharmacy Practice, Mass- peutic outcomes, yet some concerns
ly be used less as a text read cover-to- achusetts College of Pharmacy and Health described in the book may need inter-
cover and more as a reference tool. Sciences, Boston. pretation by a pharmacist or physician.
1224 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8
 BOOK REVIEWS

The $800 Million Pill: The Truth should be measured against other
Behind the Cost of New Drugs therapies and also suggests patent
by Merrill Goozner; Berkeley, California, University law reform.
of California Press, 2004, 296 pages, $24.95 The $800 Million Pill is a cogent
and important addition to a number
Bruce Hurter, M.D. of books exploring the costs of our
current system. The author’s argu-
Merrill Goozner’s The $800 Million ments are well documented, and the
Pill reviews recent scientific and eco- ment to Prevent Heart Attack Trial issues are particularly significant giv-
nomic developments of the biotech- and the Clinical Antipsychotic Trials en the increased pressure to provide
nology and pharmaceutical indus- in Intervention Effectiveness, which affordable medical care. At the same
tries. Mr. Goozner extols the creativi- would compare existing drugs. He time, Mr. Goozner also presents a
ty of scientists and research groups, recommends an institution of clini- readable, informative, and even rev-
which has led to the discovery of cal practice in the NIH to generate erent history of the biotechnology
many clinically valuable medications. independent best practice guide- revolution and some of the remark-
However, in reviewing the important lines. He suggests that new drugs able advances in molecular biology.
development of medicines such as
Epogen, the AIDS cocktails, Cere-
dase, and Gleevec, the author argues
that though the large pharmaceutical
companies have profited significantly,
What Your Patients Need to Know
their roles in the creations of these
About Psychiatric Medications
drugs were limited. He makes several
by Robert E. Hales, Stuart Yudofsky, and Robert Chew; Washington D.C.,
strong arguments to refute the phar-
American Psychiatric Publishing, Inc., 2005, 356 pages, $59.95
maceutical industry’s claims that large David S. Heath, F.R.C.P.C.
profits are necessary to drive future
research. This book is essentially a collection of So, how is reading level measured?
Mr. Goozner, the former chief patient education handouts about psy- It’s easy; you use Simple Measure of
economic correspondent for the chotropic drugs written by two psychi- Gobbledygook (SMOG), Fog, or
Chicago Times, presents evidence to atrists, Robert Hales and Stuart Yudof- Flesch-Kincaid. These are all scales
challenge the often-quoted $800 sky, and a pharmacist, Robert Chew. It that measure reading level by using
million price tag for a new medica- comes with a CD that the clinician can such items as average sentence length
tion. In reviewing important medical use to generate individual printed and number of words with three or
advances, he suggests that years of handouts. These handouts are of two more syllables.
basic research and development by types: information about a class of Applying these scales to a random-
the National Institutes of Health medications—for example, selective ly picked section of the book resulted
(NIH) have usually preceded the de- serotonin reuptake inhibitor antide- in the following conclusions. SMOG
velopment of breakthrough drugs. pressants—and information about a assessed the readability at grade 14.
He also argues that pharmaceutical specific drug, such as sertraline. The Fog index score is 16; the ideal is
costs have shifted to the increased As soon as I started reading this 7or 8. Above 12 indicates it is too dif-
creation of “me too” drugs and that book, it was immediately apparent ficult. Finally, the Flesch-Kincaid
the industry has increased marketing that it founders on the rock of read- Grade Level Index, which can be au-
budgets to support the sale of these ability. For example: “anticonvul- tomatically calculated on your Mi-
drugs. He notes that the pace of de- sants…may be effective by control- crosoft Word documents, is grade 12.
velopment of recent new molecular ling ‘kindling’ in the areas of the brain Furthermore, in addition to not be-
entities has dropped at the same from which the psychiatric disorder ing easy to read, the book has no illus-
time that the cost of drugs as a per- emanates. Kindling is a phenomenon trations. It attempts to explain the bio-
centage of the health care dollar has that occurs when repeated subthresh- chemical theories of mental illness to
increased dramatically. old stimulation….” patients without any diagrams. Even
Mr. Goozner suggests a number of Patient handouts should be easy to texts for psychiatrists have pictures.
directions for drug innovations, in- read, which means that they should So, unless you work in a university
cluding government support of unbi- be written at about a grade 6 reading student health service—and even in
ased studies, such as the Antihyper- level. Patient information provided this setting the book should have il-
tensive and Lipid-Lowering Treat- by the American Medical Association, lustrations—I would not recommend
the American Academy of Family this book.
Dr. Hurter is assistant professor at Uni- Physicians, and the U.S. Pharma-
versity of Massachusetts Medical Center, copoeia is written at an average read- Dr. Heath is a psychiatrist in Waterloo,
Worcester. ing level of grade 5 or 6. Ontario, Canada.

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8 1225

BOOK REVIEWS

Opening Skinner’s Box: Great Psychological sion of Rosenhan’s study herself, in

Experiments of theTwentieth Century which she reports to various emer-
by Lauren Slater; New York, W. W. Norton gency rooms with the same single
and Company, 2004, 256 pages, $24.95 complaint. Slater claims that she was
prescribed numerous antipsychotic
Benjamin A. Spinner, M.D. and antidepressant medications dur-
ing her visits to the emergency de-

L auren Slater’s book Opening

Skinner’s Box provides a descrip-
tion of and reflection on ten psycho-
buckled linoleum.” On Milgram’s
death by myocardial infarction, Slater
describes the hospital scene: “[T]hey
partment. Psychiatry and psychia-
trists, by necessity, continue to refine
diagnosis and treatment. The fact that
logical experiments of the last centu- shocked him once, twice, who knows the system is flawed translates into
ry. Slater’s choice of experiments, how often his body rose into the air, continued effort to improve our tools,
which includes Stanley Milgram’s flailing like a fish’s, shock shock, the and the fact that the system can be
obedience experiment and Harry black cardiac cuffs beating down.” fooled seems to be only a superficial
Harlow’s experiments of primate at- Such passages are unfortunate and satisfaction for those who wish to crit-
tachment, points toward a concern peculiar distractions from what is a icize the field. Psychiatry will contin-
with the social aspects of psychology. very informative book. Slater’s unac- ue to evolve, along with its imperfec-
In this discussion of the limits and ceptable misspelling of names such as tions as a clinical field. Evolution, af-
limitlessness of human behavior and those of psychiatrists Thomas Szasz ter all, is a progress not to perfection
human relationships, Slater chooses and R. D. Laing, among others, fur- but to improvement.
the Holocaust, which may be the cen- ther detracts from the seriousness of Slater’s final chapter is a thoughtful
tral historical and psychological event the book. conclusion in which she raises the
of the 20th century, as one of her mo- One of the more engaging chapters hope that experimental psychology
tifs. By doing so, she sets a tone in in the book deals with the 1972 ex- might inform clinical psychiatry and
which psychology is intimately con- periment of David Rosenhan, who re- that the stamp of several remarkable
nected to social behavior and in cruited several participants to visit experiments might remain as a re-
which psychological inquiry gains im- psychiatric emergency rooms with a minder of the need to progress by
mediacy in the aspiration for practical single complaint: “I am hearing a provocation. She stretches her criti-
application. voice. It is saying, ‘Thud.’” They were cism too far when she complains that
Slater would have written a better to present no other remarkable symp- psychotherapy has failed to incorpo-
book had she not littered her text with toms or behavior. Rosenhan’s partici- rate the lessons and inquiries of psy-
purple prose and poorly written nov- pants were purportedly all admitted chology. “Psychotherapy,” writes
elistic passages. On Milgram’s youth, to inpatient units and diagnosed as Slater, “is all about feeling good, to its
Slater writes “[h]e had spent his mentally ill. Celebrants of Rosenhan’s detriment, I believe.” Such silly gen-
childhood years in the South Bronx, study have a certain sanctimonious eralizations tarnish Slater’s criticism
where wildflowers grew in gutters “gotcha” glee and criticize psychiatry and her hopes. Nonetheless, the
and cockroaches scuttled across as a discipline unable to differentiate moral context in which she frames
between illness and health, between psychiatry remains a crucial context
Dr. Spinner is a resident in psychiatry at insanity and sanity. Slater joins the in which to continue to study human
the Boston Medical Center. ranks of the gleeful and repeats a ver- behavior.

Additional Book Reviews Available Online

Reviews of two additional books are available as an online supplement to this
month’s book review section on the journal’s Web site at ps.psychiatryonline.org:

♦ Patricia Singer, M.D., reviews Lost and Found: My Life in a Group Marriage
Commune, by Margaret Hollenbach
♦ Margo Lauterbach, M.D., reviews Ambivalence, a Love Story: Portrait of a
Marriage, by John Donatich

1226 PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ August 2006 Vol. 57 No. 8