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Book Review - The Difficult-to-Treat Psychiatric Patient
The Difficult-to-Treat Psychiatric Patient
by Mantosh J. Dewan and Ronald W. Pies (editors)
American Psychiatric Press, 2001
Review by Michael Brodsky, M.D.
Oct 22nd 2002

In The Difficult-to-Treat Psychiatric Patient, academic psychiatrists Mantosh Dewan and Ronald Pies have assembled a compendium of articles about the psychiatric treatment of mentally ill patients who do not improve with first-line treatments. The editors summarize the rationale for the volume in their epilogue:

There is an impressive… corpus of knowledge pertinent to the initial treatment of [the] mentally ill…However, after the first one or two steps, we are very quickly across the boundaries of scientific, evidence-based data and firmly into the realm of the art and poetry of psychiatry. (393)

The book is intended to shed light on the “art and poetry” of psychiatry, and fortunately the effort is by and large a success. In the space of approximately 400 pages, the editors compile a dozen chapters that address many of the major categories of psychiatric illness as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Included in this text are extensive discussions of unipolar and bipolar mood disorders, psychotic disorders, anxiety disorders, borderline personality disorder, dissociative and post-traumatic disorders, substance abuse, and dementia. Additional chapters address psychiatric treatment of medically ill patients and non-pharmacologic “somatic” therapies, including electroconvulsive therapy (ECT) and vagal nerve stimulation. Many of the contributors are renowned experts in their subject matter.

Each chapter includes a review of initial treatment options, an inventory of factors that may confound or limit response to treatment, a description of alternative strategies, an evaluation of the evidence for and against the novel approaches, and a case vignette. Within this basic framework, however, there are marked differences among the approaches to the topics. Some chapters provide highly specific and concrete recommendations for the systematic evaluation of less well-established treatments, whereas others discuss more broadly the potential barriers to successful treatment of specific disorders. The book is clearly aimed at an audience of psychiatrists and others with extensive knowledge of psychopharmacology; although the writing style is accessible, the content is quite technical, and medical terminology is sprinkled liberally throughout. The book would appear to be aimed at psychiatrists in residency training or those who have recently completed training and entered private practice. Experienced clinical psychiatrists might find this volume helpful as a review of less familiar topics, but not as an update on cutting-edge developments.

Most chapters, such as those covering bipolar disorder and dementia, espouse pharmacological treatment approaches, with less attention to psychotherapy options. Other chapters, such as those on eating disorders and post-traumatic stress disorder, emphasize the role of various psychotherapies and downplay the potential of medication treatment. A few chapters, such as those on anxiety disorders and borderline personality, smoothly and gracefully integrate the biological and psychological perspectives. These chapters are particularly valuable and reveal some findings that may surprise biologically-oriented psychiatrists. For example, readers may be startled to learn that research demonstrates that the second-most efficacious intervention for schizophrenia, a disease usually conceptualized as purely biological, is family therapy.

Generally, the chapters on the major mental illnesses—schizophrenia, bipolar disorder, and depression-- are the most elegantly written and cogently argued. This is in part a reflection to the greater availability of high-quality research on these disorders and in part a reflection of the care with which the chapters were written. Treatment strategies for each of the major mental illnesses are illustrated with algorithms and flow charts. Some of the assertions within these chapters may raise eyebrows, such as the contention that depressed patients with a family history of bipolar disorder (manic depression) should be considered “bipolar spectrum” patients, even without a personal history of mood swings. Overall, though, the chapters on the major mental illness provide an outstanding resource for clinicians struggling to decide among treatment options with questionable or unproven efficacy for severely ill patients.

Some chapters are less effective and appear to have been written with a different audience in mind. For example, the chapter on medically ill patients devotes considerable space to a review of research showing that the newer SSRI medications are generally safer than the older tricyclic antidepressants, a fact already well known to most medical professionals and much of the general public. Similarly, the chapter on dementia and traumatic brain injury focuses on the latter category of disease, which is relatively uncommon and usually treated by neurologists, rather than the former category, which is extremely common and is usually treated by psychiatrists. However, these are minor flaws that do not detract significantly from the overarching quality of the volume.

Every few years, the American Psychiatric Association publishes official “treatment guidelines” about optimizing psychiatric treatment of specific mental illnesses. These guidelines are intended to provide some sort of standardization of psychiatric care across the United States. Unfortunately, all too often these guidelines, written by committee and designed to minimize offending the pharmaceutical industry, amount to little more than tedious and poorly differentiated lists of medication options and dose guidelines. By contrast, The Difficult-to-Treat Psychiatric Patient is an incisive, well-written and nearly comprehensive guide to patients for whom treatment failure appears a likely outcome. Perhaps the most valuable element of The Difficult-to-Treat Psychiatric Patient is the overall tone of the volume. The editors manage to convey both sympathy and reassurance for psychiatrists who are faced with especially challenging patients. The editors’ epilogue, entitled “Clinical Wisdom,” provides a sort of summation of the volume as well as an extended meditation on the difficult nature of psychiatric work. In short, The Difficult-to-Treat Psychiatric Patient is an extremely valuable reference work to which psychiatrists should refer early and often during periods of therapeutic frustration.


© 2002 Michael Brodsky


Michael Brodsky is a psychiatrist in training in Los Angeles, California, and an avid reader.