BOOK REVIEWS
General Psychiatry
Integrated Mental Health Care: A Comprehensive Community-Based Approach. IRH Falloon, G Fadden. New York: Cambridge University Press; 1995. 338 p. Can$34.96.
Review by
Nick Kates, MB, BS
Hamilton, Ontario
One of the shortcomings of the community mental health movement has been the difficulty experienced in trying to bring together providers from different backgrounds or sectors to create an integrated mental health service within a community, with practitioners working together to ensure individuals with psychiatric disorders receive the care they require when they need it.
Nowhere is this more striking than in the lack of collaboration between mental health services and primary care practitioners. Family physicians see and treat significant numbers of individuals with psychiatric disorders, often with limited input from mental health services. Rather than working out collaborative care plans in which the expertise of the 2 disciplines could be complementary, however, the relationship between mental health services and family physicians is all too often characterized by poor communication and mutual disrespect. Mental health services are often seen as inaccessible, in contrast to most other specialties with which family physicians interact.
At a time of decreasing resources, this waste or duplication of resources is illogical. Very gradually, this is being recognized in different parts of the country. Models that enable the family physician and mental health worker to “share” care are being developed. While based on common goals and principles, there are many ways such models can be implemented. At one end of the spectrum are approaches that have the important but limited goal of reinforcing continuity of care and improving communication between providers. At the other end are models that integrate mental health providers within primary care settings, creating primary care mental health teams. While such programs are in their infancy in Canada, the United Kingdom has a much more successful track record in this area.
One of the most innovative English programs was set up 10 years ago in Buckinghamshire. An opportunity arose to reallocate all existing mental health resources for a community of 35 000 inhabitants, integrating them with local primary care physicians and community nurses to form a single community mental health service based within the offices of local family physicians.
Falloon and Fadden detail the evolution of this service and the lessons they learned in shifting mental health services into this setting. Using a needs-based approach for setting goals and allocating resources, the integrated program was able to enhance the mental health care delivered by family physicians and bring about earlier interventions in episodes of illness. Unlike many similar programs, however, the Buckinghamshire project was not content with just improving the quality of care delivered in the family physician’s office. Instead, primary care provided a stepping stone into other community settings, especially the patient’s homes. The mobility of the team enabled them to work with individuals in their own environment, developing management plans that prevented hospitalizations, supported individuals in crisis and their families, enhanced rehabilitation activities, and linked individuals with necessary services they might otherwise not have used.
So effective was this approach that 6 years into the project a newly built 15-bed inpatient psychiatry unit proposed for the region was deemed unnecessary and was converted to a general medical unit which could accommodate the few individuals who still required a psychiatric admission.
Drs Falloon and Fadden have produced a stimulating description of their program, packed with practical advice and tips that are transposable to other settings, such as the 10-question screening interview family physicians employed to detect mental health problems. The chapters in which they discuss their approach to early intervention, crisis management, problem-based assessment of functioning, and ways of enhancing compliance and supporting other caregivers are particularly helpful, although the authors fail to make a completely convincing case as to the cost benefits of their approach.
Less time is spent, however, on the important question of how to increase the skills and comfort of the family physician when handling mental health problems. If mental health workers fail to work closely with participating family physicians, they run the risk of working in parallel—as opposed to being truly integrated—with the activities of the family physicians who may then begin to refer cases they might otherwise treat themselves.
One criticism of the book is the excessive time and space dedicated to reviewing core concepts in the community management and treatment of psychiatric problems. While the goal was to put the new program into a community mental health context, these chapters say little that is new and detract from the book’s innovative ideas, which do not need this kind of theoretical framework. The authors have tried to cover too much ground. A more focused book that concentrated on the achievements of the Buckinghamshire team could have devoted more space to the practical sections where the book excels.
Nevertheless, Falloon and Fadden are to be congratulated on a timely and thought-provoking volume. The integration of mental health services and primary care is slowly becoming a more relevant and essential part of psychiatric practice in Canada as well as the United Kingdom. This book adds some thought-provoking ideas as to how this kind of collaboration can be achieved.
The Analysis of Hysteria: Understanding Conversion and Dissociation. 2nd ed. H Merskey. London (UK): Gaskell; 1995. 486 p. £30.00.
Review by
François M Mai, MD
Ottawa, Ontario
“Hysteria tends to outlive its obituarists,” said Aubrey Lewis, 25 years ago (1). For many reasons, as Lewis himself acknowledged, “hysteria” is an unsatisfactory word. This is partly because of its widespread pejorative use but also because of its inappropriate etymological origins. The most recent and perhaps most powerful effort to eliminate its use from clinical nomenclature was the absence of hysteria from the recent DSM classificatory systems. The term continues to be used in both informal and formal professional circles, however, and Merskey’s inclusion of the word in the title of this book will certainly help to perpetuate its usage.
Merskey, through his writings and presentations on the various manifestations of hysterical phenomena, must be regarded as one of the world’s leading authorities in this field. This second edition of his book has been expanded and updated to such an extent that it can almost be regarded as a new book. It discusses and reviews not only the core clinical conditions of conversion, somatizing, and dissociative phenomena but also the way in which hysteria impinges on related clinical conditions such as eating disorders, psychoses, pain, and depression. New chapters have been added on somatization disorder, chronic fatigue syndrome, “multiple personality disorder” and dissociation, repression, and falsememories.
In discussing terminological issues, Merskey concludes that if “hysteria” continues to be used, it should be used and defined precisely: he provides 5 separate meanings of the word. The most appropriate (and the sense in which Merskey himself uses hysteria in the title of the book) is as an umbrella term to cover the many clinical presentations of the condition. These presentations all have much in common; it would seem sensible, therefore, to place them in the same diagnostic rubric, rather than separate them as if they had nothing in common, as the recent DSM classification systems have done. This is also the sense in which I have used the concept of hysteria (2).
The book opens with an in-depth review of the endlessly fascinating topic of the history of hysteria. There was a centuries-old misreading of Hippocrates’ writings that hysteria was caused by the womb wandering through the body, a view which Merskey and Potter corrected in 1991. During the 19th century, there were stark controversies as to whether it was primarily a condition affecting the genitalia, the brain, or the psyche. Finally, in our 20th century, we have argued about the psychodynamics and the role of sex and of gender in the psychopathology, and we have attempted to develop a systematic classification of hysterical syndromes.
There are fascinating chapters on combat hysteria and on posttraumatic stress disorder. Combat hysteria was known as “shell shock” during World War I, and it was a major problem affecting the health and morale of troops on both sides of the battle line. Merskey compares and contrasts the way this problem was dealt with in the different national armies. On both sides of the line, the cause was initially thought to be physical trauma to the brain, for example, from the explosion of shells or from inhaled noxious gases. It was only toward the end of the war that the overwhelming effect of psychological trauma was recognized. Interestingly, this was appreciated by the German before the Anglo-French armies and psychiatrists. These developments also showed that sexual trauma as described by Freud before World War I was not an essential requirement in the pathogenesis of hysterical phenomena.
The author also discusses the important issue of motives in hysteria, including that of compensation and the relationship of hysteria to malingering. Merskey is well known in legal circles for his views regarding the pathophysiology of chronic pain syndromes, and he and I have discussed our different perspectives in public (3,4). In this book, his views come across as more dispassionate and holistic than previously expressed. The relationship between organic and psychological factors in pain is a complex one, and both aspects must be evaluated in managing these often very difficult cases.
Merskey explores his well-known views on “multiple personality disorder” (MPD) and on the false memory syndrome. His critique of MPD as a diagnosis is powerful, and it would seem imperative for the authors of the DSM-V to deal with these issues if the whol classification system is not to be brought into disrepute. The use of suggestion or hypnosis to elicit symptoms of “alters” attacks the foundations of psychiatric diagnosis, which is based on the presence of predominant symptoms as volunteered by the patient. If pressure has to be exercised to “elicit” a symptom, a psychiatric syndrome can then become, to paraphrase Alice in Wonderland, whatever a psychiatrist wants it to be. False memories are another controversial area that has profound clinical and legal implications. Merskey argues persuasively that although repression and “recovered memories” may at times exist, the alleged memories have frequently been implanted by unscrupulous or misguided therapists. Again, the use of suggestion to elicit a symptom invalidates the data and brings both the process and the concept into disrepute. The area of recovered memories is likely to become a fertile and productive field for future clinical research.
In the final chapter entitled “A Perspective—The Survival of Hysteria,” Merskey summarizes his views on the broad field of hysteria. The concluding paragraph may be quoted as epitomizing his view of this complex field:
. . . it becomes harder to advance any single theory of the origins of hysteria. We must accept that we are dealing with a disorder of infinite variety, determined always by human motives and circumstances. These motives derive from the fundamental experiences of childhood, from acute stress situations, especially conflict, and from the circumstances of physical illness. The numerous symptoms which may result give expression to the individual’s need for survival and for the resolution of emotional dilemmas,and the mechanism employed to attain these ends is primarily one of regression. The personality traits with which the disorder is associated probably result from the same mechanisms as the symptoms, leaving the individual more prone to these symptoms in later life. The simplest, ultimate paradigm is of the small child within the adult frame crying for his or her mother and protesting weakness and debility to secure love and affection (p 392–3).
The book has some weaknesses. At times the literature is reviewed in excessive detail, and it becomes difficult to discern what the author’s own views are. The more frequent use of subtitled summary sections would have helped the reader to understand the book’s objectives. Finally, there is not much in this book on the management of individuals with hysterical syndromes. This is consistent with the author’s own objectives, however, which are to “understand” rather than to treat conversion and dissociative symptomatology.
It is clear that an enormous amount of reading, thinking, and writing has gone into producing this work. Over 1300 references are listed as sources at the end of the book. It is not only a summary of the “state of the art” in this field, but it is likely to become a widely quoted classic.
This book can be highly recommended to students, residents, and physicians (not only psychiatrists) with a theoretical and practical interest in the mosaic of hysterical syndromes. The book is not inexpensive but is well bound and attractively laid out. Dr Merskey must be congratulated on his industry and resourcefulness in updating this major monograph.
References
1. Lewis AJ. The survival of hysteria. Psychol Med 1975;5:9–12.
2. Mai FM. “Hysteria” in clinical neurology. Can J Neurol Sci 1995;22:101–10.
3. Mai F. Psychiatry and chronic pain [letter]. Can J Psychiatry 1990;35:196–7.
4. Merskey H. Dr Merskey replies [letter]. Can J Psychiatry 1990;35:197–8.
Affective Disorders
Diagnosis and Treatment of Chronic Depression. JH Kocsis, DN Klein, editors. New York: Guilford; 1995. 180 p. US$27.50.
Review by
AV Ravindran, MB, PhD
Ottawa, Ontario
Until recently, dysthymia and overlapping chronic depressive disorders were conceptualized more as temperamental or character traits than affective illnesses. In the last decade, there has been a significant increase in research on many aspects of chronic depression, particularly with respect to its prevalence, morbidity, and treatment. Recent epidemiologic studies estimate that 3% to 5% of the population may be suffering from dysthymia and that a chronic course supervenes in at least 25% of subjects with major depression. It is also now recognized that these patients suffer significant morbidity, use health care resources excessively, and are often underdiagnosed and inadequately treated.
This short volume is edited by 2 leading clinical researchers on the topic, who (together with Akiskal and Keller, among others) are influential in shaping the current understanding of chronic depression and its treatment. The book begins with a foreword by Allen J Frances, which serves as an excellent summary of the chapters to follow. The classification of dysthymia, because of the heterogenous nature of the illness and its overlap with character disorders, has always been a confusing and contentious topic. Daniel Klein’s first chapter on the topic provides a clear, concise summary of its current status. This is followed by the author’s account of dysthymic illness during adolescence and childhood and incorporates a landmark study on the topic. Klein provides a description of the longitudinal perspectives of early-onset dysthymic illness and an excellent account of the unusual and broad spectrum of symptoms seen in youngsters with dysthymia. It is frequently said that comorbidity is the rule rather than the exception with dysthymia, and the evidence for this is well presented in the next chapter. The risk for comorbidity significantly influences the course and natural history of chronic depressions, and this fact is well emphasized. Chronic depressions are often associated with significant impairment of social and interpersonal functioning and it is well known that people with dysthymia use health care resources excessively. Freedman reviews the scientific data on this topic. He notes the reported positive effects of antidepressant treatment on social functioning and the lack of studies examining the effectiveness of psychotherapy in this respect. The following chapter describes family and genetic data and provides a good summary of the few related studies in chronic depressions.
The latter part of the book covers the treatment aspect of dysthymia. The different forms of psychotherapy used in dysthymia are described, and the research literature is well reviewed. The book reiterates the fact that, in spite of the extensive use of psychotherapy in this population, the research into the efficacy of psychotherapy in dysthymia is very limited. It is now generally accepted that significant numbers of patients with dysthymia benefit from antidepressant treatment, and the chapter on pharmacotherapy provides a succinct review of the literature on clinical trials in dysthymia. Of particular interest is the section on long-term treatment as well as the treatment of pure dysthymia versus dysthymia with comorbid conditions. This chapter also provides answers to some common clinical questions regarding the use of antidepressants in dysthymia and gives some useful tips on treatment strategies.
Generally, the chapters are well written and succinct. For each topic, a comprehensive, balanced review of the literature is given, as well as a good list of current references. Each chapter is self-contained and can be read independently. For the most part, the research findings by the authors are integrated successfully into the review of the previous literature. The only possible exception is the chapter on the assessment of symptoms. Although the development of instruments represents good research, it does not appear to flow with the rest of the book. The book may also have benefitted from some terminology clarification. In particular, terms such as chronic depression and dysthymia are often used interchangeably, and early clarification of their relationship may be useful.
Overall, Diagnosis and Treatment of Chronic Depression is a very readable book. The chapters are written in a clear, concise, jargon-free language. Although its target population is not stated, it will likely appeal to a wide audience including physicians and allied mental health professionals. It may also serve as introductory reading to nonclinician researchers and as a source of up-to-date references on the topic. The hardcover copy is priced at US$27.50, and hopefully a paperback copy will be made available at a lower price.
Suicide in Canada: Update of the Report of the Task Force on Suicide in Canada. Ottawa: Health and Welfare Canada; 1994. 206 p.
Review by
Alain D Lesage, MD, MPhil
Montreal, Quebec
This report represents an important reference on suicide in Canada. Half the book contains tables and graphs on rates of completed suicide in Canada updated until 1992. Data are presented for all of Canada as well as for each province and territory individually and are broken down by sex and age groups; age-standardized data are also available. Some graphs cover the period 1950 to 1992, others even cover the period 1924 to 1992. Such data provide a perspective on the historical trends, on the Canadian regional variations, and on some classic demographic factors. Do you know that Canadian suicide rates peaked in 1978 and have slightly declined since then? That Alberta and Quebec have the highest provincial rates? That Ontario, following an increase in the 1960s and 1970s, is now back to the 1950 rates? That suicide accounted for only 1.9% of all deaths in Canada but is the third cause of potential years of life lost following malignancies and coronary heart disease? That suicide rates have tripled among adolescents and young male adults over the past 30 years? How does such an abundance of facts translate into understanding etiology and planning prevention?
The second half of the book first reviews the Canadian and international literature on the factors contributing to suicide and suicidal behaviour: socioeconomic and cultural factors, mental disorders, neurobiological findings, genetic and family background, life events, AIDS or other terminal illness, personality, and psychological influences are all considered. Then, the headings of prevention, intervention, and postvention are used to discuss the strategies and approaches for the reduction and prevention of suicide. A section on suicide and the law follows, and this discussion briefly reviews the current Canadian criminal code, involuntary admission and provincial mental health acts, the issue of confidentiality, and how legislation on this issue may help peer review and research onsuicide. Finally, this section ends with a fine discussion on the issue of euthanasia and assisted suicide. The next section contains recommendations for research and evaluation. The book is completed with over 250 references, a statement concerning the First Nations and Inuit communities, suggestions for determining suicide in order to improve Canadian data collection and standardizing certification and, finally, the recommendations of the original task force.
The update has been prepared by 3 members of the original 1987 Task Force on Suicide in Canada with the assistance of 8 other experts on this topic. Some sections of the original report have undergone a revision; some sections have been merged with other sections or omitted, while others have been expanded. The authors have attempted to maintain the integrity of the original report while at the same time providing information appropriate for the current time frame. The literature review does not purport to be a comprehensive, in-depth review of the field. Some sections have been updated less thoroughly; for example, the small section on murder-suicide failed to mention the study by Buteau and others (1). In general, however, important Canadian and international papers have been cited, and the reader can find them through the reference section. I read the French version of the report, and with the exception of certain graphs that did not translate some English labels, it is reasonably free of production errors. It reads well.
The present report still fulfills the original (1987) mandate. Its aims were to investigate and better define the dimensions of suicide and to consider effective strategies for responding to the problem. But as the task force found and the update maintains, there are many unanswered questions about suicide, as well as a multitude of conflicting theories. The role of environmental influences and mental disorder, the existence and nature of predisposing genetic or biochemical factors, and the parallel issues of proper and effective treatment and prevention are quite complex. Identifying the chain of causal and triggering factors and deriving from it an overall prevention strategy is one of the most vexing problems that faced the task force and, for that matter, the suicide research field itself. One strategy employed by the original task force and retained by the present one was to adopt a broad model of crisis intervention. The model supports the involvement of mental health professionals practising independently, multidisciplinary community mental health teams, suicide-prevention and crisis-intervention centres, self-help services, and peer-support programs. The emphasis remains on dealing with immediate issues rather than on the long-term care of persons at risk. Related to this issue is the role of mental disorders in suicide, which has divided the experts of the committee. Its final position states that it is “not the intention of the Task Force to resolve this controversy: its source and solution lie in ongoing research and in the broader philosophical debate between the so-called ‘hard’ and ‘soft’ sciences.” Will this compromise elp the integration of the various agencies involved in suicide intervention, in particular between public health or social services and crisis-intervention centres? Some Canadian experiences of integration are described but are not formally proposed as models in the recommendations.
On a lighter note, this report represents a goldmine for Canadian Board Examination questions and is a must-read for Canadian psychiatric residents. The updated report should continue to be an important resource for people across Canada involved in suicide prevention, intervention, postvention, and research.
Reference
1. Buteau J, Lesage AD, Kiely MC. Homicide followed by suicide: a Quebec case series 1988-1990. Can J Psychiatry 1993;38:552–6.
Substance Abuse
Psychiatric Services for Addicted Patients: A Task Force Report of the American Psychiatric Association. SB Blume, M Belfer, DJ Gill, W Ling, PS Stephens. Washington (DC): American Psychiatric Association; 1995. 150 p. US$39.25.
Review by
Robert Milin, MD, FRCPC
Ottawa, Ontario
The origin of this book arose with the establishment in 1990 by the American Psychiatric Association of the Council on Addiction Psychiatry, whose purpose was to identify the major role of addiction treatment within psychiatry. The Task Force on Psychiatric Services for Addicted Patients was appointed in March of 1991. The task force report on the current state of addiction treatment and recommendations for improving the services with a focus on both the psychiatrists’ role and on the funding of the system was completed in the summer of 1994. It is this report that is reproduced in the book.
The book is divided into 5 chapters with a preceding summary. The first chapter, “Introduction,” briefly reviews the history, development, organization, role of the psychiatrist, and significance of addiction-treatment services in the United States (US). This chapter is intended to provide the reader with background information for subsequent chapters. It highlights the marked prevalence of substance use disorders and comorbidity with other psychiatric disorders. The chapter also identifies the 2-tiered structure of the treatment system, namely, public programs serving mostly indigent patients and private programs treating those with insurance coverage. Many addicted patients seek assistance in general and mental health settings. Unfortunately, no central or connecting theme emerges from the introduction. Several of the components of the introductory chapter could have been better incorporated within subsequent chapters, leading to an improved cohesiveness of the book.
The second chapter, “Services for Addicted Patients,” provides a solid overview of the wide variety of treatment programs and settings servicing patients with addictions. In each of these programs, treatment goals, multimodal therapy, and the role of the psychiatrist are addressed. The last section of the chapter deals with the size, scope, and utilization of the current addiction treatment system in the US. A strength of this chapter lies in its advocacy for proper screening of alcohol- and drug-related problems in general medical settings and the important need for education and training of primary care personnel. There is a strong section on outpatient programs, including outpatient detoxification, partial hospitalization, and private practice considerations, with ambulatory treatment being the most common type of specialized addiction treatment provided in the US. The changing role of the psychiatrist from medical director to consultant in the different treatment programs and settings is well defined. A welcome complement to this chapter, however, would have been a section discussing treatment matching and outcome studies of the various programs.
The third chapter, “Support for Addiction Treatment,” can be divided into 2 parts: the economics and the financing of addiction treatment. This chapter is one of facts and figures that are specific to the US system of medical care and organization. It is a comprehensive chapter that takes the reader through the huge societal cost and myriad of financing sources available for addictive disorders. An excellent section on the effectiveness and cost–benefit profile of addiction treatment reviewing current empirical studies is found in this chapter. The section further examines cost–benefit analysis, cost-effectiveness, and cost-offset of addiction treatment, concluding that treatment is effective, cost-beneficial, and productive of cost-offset within the health care system. That investment in addiction treatment makes good economic sense, therefore, is an important message the book has to offer.
The fourth chapter, “Needs of the Addiction Treatment System,” addresses the various deficiencies in the addiction-treatment system. System modifications and resource needs are put forward to provide a cost-effective and high standard of care for addicted patients and their families. Several important areas are examined, including screening and intervention, system coordination, availability of treatment, rational utilization, matching of treatment modalities and patient needs, the establishment of treatment guidelines through research, and the application of current research and training. In addressing support for the addiction-treatment system, a strong case is made for funding equal to that provided for other diseases in the health care system. The fifth chapter is a one-page conclusion similar to an abstract.
In general, the book is clearly and succinctly written by a committee of psychiatrists with considerable expertise in the field of addiction. It is a book of significance for both the field of addiction and addiction psychiatry given the current atmosphere of health care reform. The book is formatted and reads as a committee “report/monograph,” however, lacking the cohesiveness or elaboration of a more formal book or textbook. The general message of the book is relevant to the Canadian experience, but there are many sections specific to the US funding and health care system. An appendix of abbreviations as well as flow diagrams illustrating various interconnected organizations and structures would have been helpful for easy reference. The book does identify that information is lacking on addiction treatment of special populations such as adolescents. The central message that both appropriate addiction treatment and the role of the psychiatrist are beneficial and important to the health care system is well presented.
The book makes for both interesting and at times dry reading. It is most suited for those interested in gaining further knowledge or specializing in the field of addiction, and it is recommended reading for administrators in the health care system. The price of US$39.25 is somewhat expensive for a general purpose purchase, but it is money well spent for special needs.
Achievement and Addiction: A Guide to the Treatment of Professionals. EP Nace. New York: Brunner/Mazel; 1995. 264 p. US$32.95.
Review by
Reid Finlayson, MD, FRCPC, DABPN, FAPA, ASAM
Guelph, Ontario
This 264-page hardcover volume consists of 14 chapters describing the process of assessment and treatment of addiction in professionals. Various professions are specifically described in this context: medical students and residents, physicians, nurses, pharmacists, attorneys, and executives.
In the foreword, Dr Richard Frances quotes Dr Nace as saying “It is as great a mistake to avoid the unique problems and needs inherent in treating addicted professionals as it is to make errors because of demands to give VIP patients special treatment.” Addiction has been called the American writer’s disease (the foreword notes that of the 8 Americans awarded the Nobel Prize for literature, 5 were alcoholics), but it is also very much a disease of lawyers, doctors, nurses, and business managers.
Dealing with professional patients, who are much like ourselves, enables us to appreciate in bas-relief how the tentacles of addiction choke and potentially destroy character, ambition,accomplishment, reputation, health, family, and future. Dr Nace outlines the attributes of professionals: they are well rewarded and compensated by esteem, status, privileges and better-than-average earnings; they tend to be self-efficacious and goal-directed; their endurance for intense academic preparation and years of apprentice-like training is high; they exhibit responsibility and accountability both in intellect and character; and they have a strong desire to help their fellow humans. He goes on to define the various concepts of chemical dependence, which include enhanced social interaction, relaxation of social tension, interest in and use of drugs, and polydrug use.
Next, Dr Nace outlines how drug use produces relief, escape, euphoria, relaxation, energy, sedation, and peace. Addictive phenomena are discussed and include psychological dependence (such as inadequacy, grief, or loss related to abstinence) and other phenomena like craving, repression, denial, and consequences. The third chapter is a short overview of various postulated etiologic mechanisms for addiction, but the 20-page bibliography should satisfy those with deeper interest.
Prior to the chapters that describe the peculiarities of each professional group in diagnosis, treatment, and outcome, there is a thorough yet concise discussion of “Initial Steps: Intervention and Diagnosis/Evaluation” (Chapter Four).
Six chapters describe the specific characteristics of assessment and treatment in each of the specified groups of professionals. These chapters are full of solid clinical material, research citations, and well-written case examples.
In the chapter on medical students and residents, Dr Nace argues that compulsiveness, loss, anxiety, and depression provide a backdrop for substance use. Cited references point to a rate of alcoholism among physicians equal to that in the general population (lifetime 13%, point prevalence 3%). Drug abuse and dependence figures are higher in physicians than in the general population.
Characteristics of chemically dependent nurses include academic success, family histories of dependence or depression, and other specific stressors. Among these are fatigue, responsibility/accountability, physician domination, access to drugs, exposure to death and illness, hospital cost containment, and the balance of career and child-raising responsibilities.
Each of the chapters on specific professionals describes the identification and recognition of unique impairment behaviour patterns, and these are well illustrated in the clinical examples. The chapter on the recovery process describes the issues of patients in earlier and later stages of recovery.
The text concludes with 3 chapters describing specific treatments, matching patients to levels of care and 12-step programs.
Four appendices give guidelines for taking a thorough substance abuse history, a recovery program schedule, the signs of, symptoms of, and techniques for withdrawal, and a treatment contract for an impaired health professional.
This book is an easy-to-read, brief, and clear summary of the problems and rewards of treating addiction in health care and other professionals. It also contains sufficient information to be described as a primer in addiction practice generally. Dr Nace has done a masterful job of summarizing the literature and his own experience in this area. The text and examples are concise, and more information is available in the bibliography. The illustrations and appendices are practical and comprehensible. The volume is attractive and free of production errors.
Priced at US$32.95, this laudable book will be a worthwhile addition to any physician’s library both as a source of interest about the psychology of professionals and as an up-to-date, concise reference on standard addiction practice. Reading this book should enhance the physician’s ability to recognize addiction more quickly and to intervene more accurately and helpfully with any patient or colleague.