Book Forum
PSYCHOTHERAPY legitimately and inevitably coexist. Some softness lasts longer
Wisdom in the Practice of Psychotherapy, by T. Byram
Karasu, M.D. Northvale, N.J., Jason Aronson, 2001, 286 pp.,
$50.00.
This book is brief, clear, and wise. Karasu is a masterful
clinician and teacher, and in this era of heavily biological
academic psychiatry, to the astonishment of many admiring
colleagues, he has for many years been chairman of a fine de-
partment of psychiatry, where he is a deeply thoughtful
champion of whole human beings and of dynamic psycho-
therapy.
In Wisdom in the Practice of Psychotherapy, Karasu distills
decades of clinical experience and subtle and educated think-
ing, giving us stimulating maxims and providing both clear
generalizations and clear clinical examples, often accompa-
nied by interlinear notes of an excellent dynamic psychother-
apists concurrent thinking, feeling, understanding, and
choosing. His psychotherapeutic roots and styles, though var-
ied, are firmly grounded in major 20th-century psychoana-
lytic theory, including much of Freud, drive theory, ego psy-
chology, object relations theory, and self psychology. He
builds on some major psychoanalytic and psychotherapeutic
integrators and synthesizers such as Jerome Frank, Judd Mar-
mor, Ralph Greenson, Erik Erikson, Elvin Semrad, Carl Rog-
ers, Abraham Maslow, James Masterson, Heinz Kohut, Otto
Kernberg, Leston Havens, Robert Michels, and Glen Gabbard.
Most of us who have been doing, studying, and teaching
psychotherapy for several decades will find many of Karasus
chapter-heading maxims a pleasure. They are concise, strong,
deep-enough, well-chosen summaries that organize (and add
to) some of our own and others best thinking about simple
and complex clinical and theoretical tasks, challenges, and
habits of understanding patients and ourselves.
Luckily, though psychoanalytically well informed, Karasus
book is far more accessible to analysts and nonanalysts than
is much analytic writing. Psychotherapy is not just psycho-
analysis, as Karasu points out, but good psychotherapy often
involves good psychoanalytic understanding. This book, with
its bold maxims, should interest, intrigue, and help most psy-
chiatrists; most psychoanalysts; experienced psychothera-
pists; less experienced psychotherapists; less talented, edu-
cated, or disciplined psychotherapists; biological and even
behaviorist psychiatrists; all psychiatric training directors; all
psychiatric residents and fellows; early career psychiatrists;
most clinical psychologists and clinical social workers; and
many others.
Wisdom and psychotherapy may strike some readers of
this journal as soft words, not usually evidence-based or
quantifiably testable. Certainly both words have often been
denigrated in the past decade or two relative to the crisper as-
pects of physiological psychiatry. But psychiatry is not either/
or, not black and white, not psychosis versus neurosis, not bi-
ological versus psychosocial, not research versus clinical.
Some levels of reality, of understanding, of describing, and of
helping or changing human beings and psychiatric disorders
Am J Psychiatry 160:8, August 2003
and more solidly than some hardness, and good psychiatry
must be able to integrate biopsychosocial complexityin-
cluding psychotherapeutic complexity. As to wisdom,
Karasu defines it as a combination of knowledge, insight, and
judgment. As to wisdoms use in the title of this book, Karasu
displays some self-observation and some self-deprecating
humor right from the start, quoting Samuel Johnson:
I am accused of being a wise man. All I can tell you is
that I have good judgment. How does one have good
judgment? By having lots of experience. And how does
one have lots of experience? By having bad judgment.
Among the 48 chapter-heading maxims, each elaborated,
often with clinical examples, within its chapter, here are a few
that seem to me typical and useful:
Theories of psychotherapy should anchor, not drown,
the therapist.
The therapist establishes the optimum therapeutic en-
vironment through a balance of neutrality and empathy.
The therapist who completely understands the pa-
tient has stopped listening.
Therapists tend to underestimate the power of listen-
ing and overestimate the power of speaking.
Silence is not always golden.
The careful interpretation meets four criteria: opti-
mum timing, minimum dosage, concrete detail, and in-
dividual focus.
Every interpretation is incorrect on some level.
Only when the patient becomes more vulnerable
within treatment will he or she become less vulnerable
outside treatment.
Every therapist must be prepared for the element of
surprise.
Can one quarrel with some of Karasus maxims? Certainly,
and usefully. Does Karasu leave important things out? Cer-
tainly, and often usefully. I particularly missed some reference
to the fact that, as usual in books and articles on psychiatry
and psychotherapy, children and adolescentsa rather large
part of our worldare left out. Child and adolescent psycho-
therapy cannot simply be extrapolated from adult psycho-
therapy, and some of Karasus good maxims are not quite right
for dealing with children and adolescents. I would also have
liked some additional words about integrating psychotherapy
with pharmacotherapy, about dealing with money, and about
Karasus leaning toward the whole patient (with much mid-
20th-century psychiatry but against much recent psychiatry)
instead of defining ones work heavily by discrete-looking
diagnoses.
These are, however, very small quibbles. On the whole,
Karasus book is full of wisdom, and tidily expressed. I admire
it greatly and look forward to recommending it to colleagues
and students for many years to come.
LAWRENCE HARTMANN, M.D.
Cambridge, Mass.
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Treating Attachment Disorders: From Theory to Ther-
apy, by Karl Heinz Brisch; translated from the German by
Kenneth Kronenberg. New York, Guilford Publications, 2002,
270 pp., $36.00.
This very readable translation focuses on the attachment
work and legacy of John Bowlby and its clinical application by
Karl Heinz Brisch. This could be of interest to at least three
groups of American psychiatrists. The first would include psy-
chiatrists trained just after World War II, the heyday of psy-
choanalytic theory and therapy, who want to take a leisurely
trip back to when intrapsychic conflicts were considered etio-
logical and external conflicts between psychoanalyst gurus
and their adherents were on an international scale. They may
remember how Bowlbys biologically based attachment the-
ory moved considerably from the psychoanalytic theory of his
mentors such as Anna Freud and Melanie Klein. Bowlby
maintained an independent view in their midst while working
as a child psychiatrist and adult analyst at the Tavistock Clinic
and British Psychoanalytic Society.
The second group of potential readers includes todays
neuroscientifically trained residents, especially those with a
child orientation, who may disavow psychoanalysis and
might have missed attachment theory in the course of train-
ing. For them the operational definitions of terms underlying
attachment theory through Mary Answorths systematic
Strange Situation Protocol for children and Carol Georges
Adult Attachment Interview may serve as a stimulating eye-
opener for further inquiry. The third group of readers would
be adult or child psychiatrists versed in the concept of devel-
opment of the self who want an intense revisiting of attach-
ment theory and application as defined by John Bowlby and
influenced by the likes of Michael Balint, Daniel Stern, and
the author.
Brisch, a psychoanalytically trained child and adult psychi-
atrist as well as researcher of child development, notes
Bowlbys upper-middle-class childhood, a father absorbed
with his surgical profession, a mother whose role was dele-
gated to governesses with loss of Bowlbys favorite at age 3,
and a medical career interrupted to teach at both a boarding
school and a day school for maladjusted children. After med-
ical school, when exposed to the ideological conflicts of the
pioneering child analysts at the London Child Guidance
Clinic, Bowlby veered toward empirical observations, espe-
cially of loss and of separation of children from the mother.
He concluded that such events were as crucial in the childs
development as were resolution of the Oedipus complex or
other aspects of psychosexual development. An early high-
light of this observational zeal was seen in the documentary
film made in 1952 by Bowlby and Robertson of behavioral
changes (protest, despair, detachment) in a 2-year-old girl ad-
mitted to the hospital without her mother.
Brisch lays out the basic assumptions of attachment the-
ory: a genetically anchored motivational and behavioral sys-
temthat serves a survival function for the childto find
safety, protection and security in proximity to the mother by
visual or close bodily contact with her. The sensitive behav-
ior of the attachment figure, the childs need to explore, and
the reciprocal relationship between attachment and explora-
tion throughout the life cycle are emphasized.
1530 http://ajp.psychiatryonline.org
Attempts to relate infant attachment types derived from
the Strange Situation Protocol to parental types derived from
the Adult Attachment Interview are described. Brisch liberally
documents the interdigitation of Bowlbys thinking with
quotes or concepts from an array of early therapists and ob-
servers of child development, including Klein, Mahler, Spitz,
Winnicott, Burlingham, Anna Freud, Balint, Kohut, Stern, and
Jacobson.
Although connections have been reported between inse-
cure attachment patterns and childhood phobia or conduct
disorder, Brisch complains that none of the ICD or DSM diag-
nostic systems contain a clear category for attachment dis-
order. He presents his own classifications: no signs of at-
tachment behavior, undifferentiated attachment behavior,
exaggerated attachment behavior, inhibiting attachment be-
havior, aggressive attachment behavior, attachment behavior
with role reversal, and psychosomatic symptoms.
Brisch lists nine guidelines for the therapist in becoming a
secure base for adult patients and six guidelines for psycho-
therapy with children and their parents. The balance of the
book is filled with case examples of attachment disorders,
ranging from the mother with a fear of attachment to an un-
conceived child through attachment disorder in adolescence,
adulthood, and old age. These clinically interesting vignettes
from Brischs practice vary in length from two to nine pages,
and each includes a formulation of attachment dynamics, of-
ten with an alternative psychodynamic viewpoint as well.
Brisch regularly comments on countertransference but uses
the term to refer to the therapists general reaction to the pa-
tient rather than the classical reference to unconscious drives
or defenses. Although the patients use of psychiatric drugs is
occasionally mentioned, there is no attempt to address the in-
dications for these drugs or the interaction of drugs and psy-
chotherapy. Likewise, there is no attempt to tie in positive at-
tachment effects, or failure thereof, with possible changes in
brain structure or function as revealed in modern neuroimag-
ing techniques. Nevertheless, there may be lessons from at-
tachment theory and treatment for todays psychopharma-
cologist-therapist who is struggling with the patient suffering
from some degree of attachment disorder reflected in reluc-
tance to accept medication, treatment-resistant depres-
sion, or childhood oppositional disorder and the like.
STEPHEN L. WASHBURN, M.D.
Belmont, Mass.
CLINICAL PRACTICE
Behavioral Healthcare Informatics, edited by Naakesh A.
Dewan, Nancy M. Lorenzi, Robert T. Riley, and Sarbori R. Bhat-
tacharya. New York, Springer-Verlag, 2001, 186 pp., $59.95.
A colleague of mine recently remarked, No matter what, it
always comes back to people. Although we were discussing
politics, his perspective provided a nice starting point for this
review.
The importance of the books subject is indisputable. While
I was writing this review, Congress substantially restricted the
scope of the fledgling Defense Advanced Research Projects
Am J Psychiatry 160:8, August 2003

Agency Information Awareness Office (which dropped its Or-
wellian eye-in-the-pyramid logo and its Janusian motto,
Knowledge is power). Contemporaneously, more than 400
physicians petitioned Cedars-Sinai Medical Center to sus-
pend the use of its computerized order entry system, stating
that it required excessive work and endangered patient safety
(1). The impact of computer technology on our personal and
professional lives is pervasive and deserves our informed,
proactive attention.
Behavioral informatics has a very small literature and an
even smaller useful literature. This book augments the latter
category. It is the 11th book in the Health Informatics Series,
formerly titled Computers in Health Care. The change in
name reflects the recognition that computers are only half of
a computers-people dyad. Informatics increasingly addresses
both partners in that relationship, as does this book.
The book is divided into five sections: Overview, Clinicians
Issues, Consumers Issues, Informatics and Quality Improve-
ment, and Organizational Issues. While each section is pre-
ceded by a brief introduction, the book might have benefited
from greater overall editorial integration. It remains more of a
collection of discrete chapters, albeit informative ones, than a
unified statement. I found some essays (e.g., those in the
Overview section) mildly dissatisfying, perhaps because their
breadth of scope allowed only a surface view. Others, particu-
larly those in the last section, are more immediately useful.
Infrequently, this book falls prey to prepublication obsoles-
cence, the great curse of computer writing; for example, the
information on the Health Insurance Portability and Ac-
countability Act is somewhat outdated. The book commits
rare errors of commission (e.g., SETI is not the acronym for
Signs of Extraterrestrial Intelligence) and omission (e.g.,
such topics as PDAs, wireless technologies, and computer-
assisted therapy receive less coverage than they deserve).
Readers interested in pursuing topics in greater depth will
find the adequacy of references variable. Overall, however, the
book rewards the interested reader.
Perhaps not surprising in a book on behavioral informatics,
the best parts of the book are those addressing the human,
rather than the technological side of the dyad. For example,
the book includes discussions of the importance of user-
friendliness concerns in designing computerized decision
support systems (p. 58); how psychological ownership of be-
havioral healthcare systems is crucial to their success (p. 139);
why physicians sometimes resist implementation or changes
of computer systems, and what to do about that (pp. 140
148); and the dynamics of organizational change manage-
ment (p. 156).
Both explicitly and implicitly, the book illustrates how we
can use computers to enable or to regiment; to individualize
or to centralize; to help or to hinder; and to liberate or to con-
trol. Computers dont have that power, nor do they face those
choices, but people using computers do. This book helps in-
form those choices.
Reference
1. Ornstein C: Hospital heeds doctors, suspends use of software.
Los Angeles Times, Jan 22, 2003, p 2
ROBERT BAILEY, M.D.
Albuquerque, N.Mex.
Am J Psychiatry 160:8, August 2003
BOOK FORUM
American Psychiatric Association Practice Guidelines
for the Treatment of Psychiatric Disorders Compen-
dium 2002, edited by the APA Steering Committee on Prac-
tice Guidelines. Washington, D.C., American Psychiatric Pub-
lishing, 2002, 928 pp., $77.95; $59.95 (paper).
This volume presents a collection of 11 practice guidelines
developed by APA. The guidelines cover many important top-
ics in psychiatry, namely, psychiatric evaluation, dementia,
delirium, HIV/AIDS, substance abuse, schizophrenia, depres-
sion, bipolar disorder, panic disorder, eating disorders, and
borderline personality disorder. It is an invaluable resource
for practitioners in any type of psychiatric setting, and it will
be a very useful resource for psychiatric nurses, clinical psy-
chologists, and social workers as well as primary care physi-
cians. The guidelines have been published in the American
Journal of Psychiatry and also as individual monographs. It is
very convenient to have all of them in one volume.
The book starts with a statement of intent, which serves as
a short disclosure. It is followed by an introduction authored
by John McIntyre and Sara Charles. The introduction de-
scribes the history of APAs practice guidelines, the develop-
ment process, and the potential benefits and risks of this
project. It also outlines the progress in guideline development
and gives instructions on how to obtain Category I continuing
medical education (CME) credit through related Internet-
based programs on APAs web site. I looked it up and found
that nine of 11 guidelines are covered by 3 hours of CME
credit each with a $15 fee ($30 for nonmembers) for process-
ing the self-test and provision of a CME certificate.
New for this publication are guidelines for HIV/AIDS and
borderline personality disorder. The guideline for bipolar dis-
order is a revision of the previously published guideline. Each
practice guideline has its own section, which starts with the
list of work group participants, date of original publication,
and date of revision. The detailed table of contents makes it
very easy to navigate each section.
Most of the guidelines are preceded by a summary, an in-
troduction, and/or a description of the guideline develop-
ment process. Each guideline is followed by an extensive list
of hundreds of references for supporting evidence and pro-
vides acknowledgment to individuals and organizations that
submitted comments. A notable feature of these guidelines is
a section on future research needs and questions, which pro-
vides an understanding of the unresolved problems not only
for a researcher but also for anybody involved in the mental
health field.
The structure of each guideline is different. The Practice
Guideline for the Evaluation of Adults describes purpose of
evaluation, possible settings, and the evaluation process with
special attention devoted to all domains of the clinical evalu-
ation. The disease-specific guidelines generally include sec-
tions on definitions, epidemiology, and treatment principles
and alternatives, including both pharmacological and psy-
chosocial treatments. I found quite interesting the sections
on clinical features influencing treatment. They point out the
variability of clinical situations and different management
approaches. I highly recommend that the multiple tables of
contents be moved to one place for future editions. Currently,
a table of contents precedes each guideline and slows down
navigation through this volume. Overall, this is an important
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BOOK FORUM
summary of psychiatric research and practice that has an im-
portant place among other reference resources.
ANDREI PIKALOV, M.D., PH.D.
Kansas City, Kan.
Clinical Behavior Therapy: Adults and Children, edited
by Michel Hersen. New York, John Wiley & Sons, 2002, 513 pp.,
$65.00.
One of the more recent trends in mental health care is the
development of practice guidelines and a greater emphasis
on evidence-based treatment. Behavioral therapy has been
shown to be empirically effective for many axis I disorders
(e.g., depression, panic disorder, bulimia nervosa), and be-
havioral approaches have been used in recent years to treat
different axis II disorders; most attention has been directed at
borderline personality disorder. However, mental health care
for adults and children is very broad, complicated, and ever
changing, especially in the area of treatment. As a result, prac-
titioners can be hard-pressed to keep up with the latest treat-
ment protocols or evidence-based therapy. The large amount
of information on the psychological treatment of adults and
children is not easily synthesized into one reliable book. The
present work, edited by Dr. Hersen, represents an excellent
job of assembling, analyzing, and synthesizing this material
and discusses treatment from one consistent viewpoint.
This book is divided into two parts that build very effec-
tively on each other. The first part focuses on the behavioral
treatment of adult disorders, and the second reviews behav-
ioral interventions for disorders of children and adolescents.
The book covers such topics as major depression (adult and
childhood), anxiety disorders, posttraumatic stress disorders,
eating disorders (adult and childhood), obsessive-compulsive
disorder in children, conduct disorder, and mental retarda-
tion. The initial chapters of each section begin with a behav-
ioral case conceptualization that sets the stage for the follow-
ing chapters. Each chapter is organized consistently to give
the reader a common blueprint to understand each disorder.
Individual chapters go by the following outline: 1) description
of the disorder, 2) case description, 3) chief complaint, 4) his-
tory, 5) behavioral assessment, 6) medical complications, 7)
case conceptualization, 8) rationale for treatment, 9) course
of treatment, 10) therapist-client factors, 11) course of termi-
nation, 12) follow-up, 13) managed care considerations, and
14) overall effectiveness.
All of the chapters in this edited work are extensively sup-
ported by empirical research and integrate research into
practical clinical applications. The volume helps the reader
understand the biological and psychological underpinnings
of specific disorders, and the excellent case vignettes put each
disorder into a clear and concise clinical framework. The
book will give the reader a foundation to understand the
treatment of a wide range of mental health problems and can
serve as a primer in advanced undergraduate and graduate
courses to detail behavioral interventions for adult and child-
hood psychiatric disorders. Also, this book would serve as a
valuable resource to mental health professionals and re-
searchers who are interested in learning more about the theo-
retical and empirical nature of treatment for adult and child-
hood mental health problems. I would heartily recommend
this book to any student, psychiatric resident, researcher, or
1532 http://ajp.psychiatryonline.org
mental health professional who is engaged in research or
treatment of adult and childhood psychiatric disorders.
WAYNE A. BOWERS, M.D.
Iowa City, Iowa
Dementia, 2nd ed., e d i t e d b y J o h n O B r i e n , D . M . ,
M . R .C .Psy c h ., D av i d Am e s, B .A . , M . D. , F.R . C. Ps yc h . ,
F.R.A.N.C.P., and Alistair Burns, M.D., F.R.C.P., F.R.C.Psych.
New York, Oxford University Press, and London, Arnold (Hod-
der Headline Group), 2000, 940 pp., $198.50.
If you are old enough to remember when Alzheimers dis-
ease was a relatively rare disorder and can recall memorizing
the difference between senile dementia and arteriosclerotic
dementia for board examinations, your age puts you at risk
for the subject of this excellent book. On the other hand, you
are also old enough to recall simpler nosological ages, when
all that was known about dementia could fit in a chapter. This
book is clearly the current magnum opus on the disorder
likely to reach epidemic proportions in the 21st century in the
West unless more effective treatments or preventions are
found.
The 1990s saw the publication of a number of books on de-
mentia, including the first edition of this book. Given the in-
formation explosion at the end of the 20th century, most of
these will need to go into second editions as this one has.
Published concurrently in London and New York, it is largely
written by experts from the United Kingdom, Australia, and
New Zealand, although there are contributions from the rest
of the world (including some from the United States), making
it an international endeavor. The use of whilst instead of
while in numerous places, the use of carers for what in the
United States are called caregivers, and the use of old age
psychiatry in professorial titles instead of geropsychiatry
or geriatric psychiatry signal its British English origins. It
seems as if Americans have become fonder of Greek word or-
igins and the United Kingdom goes with plain English.
The book is divided into seven parts: Dementia: General
Aspects, Alzheimers Disease, Vascular Dementia, Dementia
With Lewy Bodies, Focal Dementias, Dementia With Neuro-
psychiatric Disorders, and Other Dementias. The chapters are
all succinct yet thorough and very well referenced. The sec-
tion on the general aspects of dementia makes up more than
one-third of the book, covering diagnosis and assessment as
well as investigations that include all the imaging techniques.
Neuropsychiatric aspects of dementia are covered in chapter
6, a useful summary for the psychiatrist. This section also cov-
ers the management of dementia thoroughly, including an
emphasis on the importance of environment in managing
those with dementia (chapter 17). Chapters of particular in-
terest to psychiatrists in this section are those on services for
dementia in several parts of the world, including the United
States.
The section on Alzheimers disease is the next longest in the
book and is again very thorough. The entire biopsychosocial
spectrum is well covered. Chapter 32, The Epidemiology of
Alzheimers Disease, is of particular interest, comparing data
between developed and developing countries.
The following sections are briefer. Section 6, Dementia
With Neuropsychiatric Disorders, will be of particular interest
to general psychiatrists. Depression, alcoholism, and schizo-
Am J Psychiatry 160:8, August 2003

phrenia are covered in separate chapters. Discussion of the
concept of pseudodementia in the chapter on depression is
particularly useful.
This is a very comprehensive textbook of enormous value
to all who deal with dementias. I have no reservations about
the book whatsoever. However, the reader will find a plethora
of information that is, at least for now, of heuristic merit with-
out much in the way of active intervention. There is an epi-
logue by Elaine Murphy, M.D., Ph.D., F.R.C.Psych., which
could have served as an excellent book review on its own.
Having read this entire book in 1 week, she concludes that al-
though there has been an explosion of knowledge and some
reason for optimism, major advances still seem just over the
next mountain range. Chapter 4, Assessment and Differen-
tial Diagnosis of Dementia, which essentially presents the
workup a psychiatrist would do, does not differ substantially
from what I learned in residency 40 years ago. What has
changed is the therapeutic nihilism that used to be abroad.
This book provides the reasons for optimism that eventually
we will better understand the neurophysiology and patho-
physiology of dementia.
PHILIP E. VEENHUIS, M.D., M.P.H.
Detroit, Mich.
THE PATIENT S PERSPECTIVE
Who Qualifies for Rights? Homelessness, Mental Ill-
ness, and Civil Commitment, by Judith Lynn Failer. Ith-
aca, N.Y., Cornell University Press, 2002, 200 pp., $29.95.
Why are people with severe mental illness homeless and
living on the streets? In my opinion, this book provides some
answers.
The author provides an exposition of the logic and lan-
guage of rights of people with severe mental illness, the the-
ory behind civil commitment, basic assumptions about who
does, and who should, qualify for constitutional rights, and
the arguments for and against civil commitment. The well-
known case of Joyce Brown and her attempted commitment
in 1987 while she was living on the streets of New York City is
used throughout the book to illustrate the issues and argu-
ments about rights.
If all the complexities of this analysis of rights were taken
into account with regard to every case in clinical settings,
would civil commitment of persons with severe mental illness
ever happen? Obviously it would, but the frequency would be
considerably decreased if those trying to decide were obsess-
ing about all the points raised in this book. As I followed all
the twists and turns of the discussion, I found myself wishing
that Alexander the Great were here to confront this huge knot
of arguments and slice it through as he did so long ago with
the Gordian Knot.
In practice, are the criteria of danger to others, danger to
self, and grave disability so difficult to apply appropriately in
a clinical setting? Not in my experience. And when there is a
disagreement, a decision can be taken to court, where a judge
weighs in with still another perspective.
Am J Psychiatry 160:8, August 2003
BOOK FORUM
Unfortunately, obsessively debating issues of rights, as is
done in this book, is more than just an intellectual exercise.
There are real-life consequences to decreasing the frequency
of involuntary treatment. The result is that people with severe
mental illness who need treatment do not receive it. For those
who are homeless, homelessness continues, and this is not a
benign thing. The quality of life on the streets is poor and can
be abysmalbeing outdoors in dangerously low tempera-
tures, eating out of garbage cans, and having little access to
treatment of medical disorders such as cardiac disease, dia-
betes, hypertension, tuberculosis, and infestations of scabies
and lice. Life on the streets is dangerous. Rape is common,
and one can be severely beaten or killed for ones meager pos-
sessions. Where is the morality in letting severely mentally ill
people be subjected to such a life because their illness pre-
vents them from knowing what they need while we are ob-
sessing about their rights?
Many homeless, severely mentally ill people find their way
into the criminal justice system for offenses that stem from
their illness. One has considerably fewer rights in a jail than in
a hospital. If the person is released from jail and placed in an
outpatient program under the jurisdiction of the criminal jus-
tice system, that person is in a system far more coercive than
anything proposed in outpatient civil commitment. After all,
the criminal justice system by its very nature must be con-
cerned with the public safety and the persons potential threat
of harm.
The homeless, severely mentally ill person whose access to
civil commitment is reduced and, as a consequence, remains
on the streets or is arrested may well suffer a significant loss of
rights. In my opinion, the right that should have received far
more emphasis in this book is the right to treatment of people
with severe mental illness.
H. RICHARD LAMB, M.D.
Los Angeles, Calif.
Beating Depression: The Journey to Hope, by Maga Jack-
son-Triche, M.D., M.S.H.S., Kenneth B. Wells, M.D., M.P.H., and
Katherine Minnium, M.P.H. New York, McGraw-Hill, 2002, 204
pp., $14.95 (paper).
This volume has one persistent message about depression:
Recovery is the rule, not the exception. This message is reiter-
ated in chapter after chapter and reinforced with easy-to-read
charts. The eight chapters cover the topic with surprising
thoroughness while maintaining an easy-to-read style. There
is a marked absence of clinical jargon, but the book retains an
authoritative examination of Americas number-one mental
health problem.
The direction of this volume is not merely to describe de-
pression and its root causes. Rather, the volume provides any-
one who reads it with very workable tools to evaluate their
own level of depression, review the standard options for treat-
ment, and gain an informed assessment regarding the course
of their recovery from depression. Laying out the biochemical
underpinnings of depression, the authors nevertheless stress
the importance of making behavioral changes in ones life-
style and cognitive changes in ones self-image as necessary
components to fully treating depression. In the chapter Ten
Things I Can Do to Help Myself, the recommendation to
Follow doctor and therapist recommendations is number
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9a no-doubt intentional placement that reinforces the
hope-filled take charge of your recovery message resonat-
ing throughout the book.
Two other chapters deserve special mention. Coping With
Special Issues is a chapter devoted to examining depression
in children, the elderly, during pregnancy, and as a reaction to
trauma. These areas are routine breeding grounds for depres-
sion, areas where we too easily assume someone just has the
blues or is going through a phase rather than recognizing
the presence of depression. This chapter also addresses the
topic of suicidal thoughts in a brief but realistic fashion. The
chapter titled Living With Depression focuses on matters of
privacy in the workplace for people as they seek treatment for
depression. This chapter also honestly discusses the topic of
how difficult it is for the family member of someone who has
chronic depression.
What would be the most useful way to use this book? I have
placed it in our agencys waiting room. It provides more de-
tailed information about depression than the Am I De-
pressed? pamphlets we often find in waiting rooms. More
importantly, it also provides concrete ways patients can alter
their personal habits to beat depression.
DONALD D. DENTON, JR., D.MIN.
Richmond, Va.
Reducing Suicide: A National Imperative, e d i t e d by
Sara K. Goldsmith, Ph.D., Terry C. Pellmar, Ph.D., Arthur M.
Kleinman, M.D., and William E. Bunney, Jr., M.D. Washington,
D.C., Joseph Henry Press (National Academies Press), 2002, 496
pp., $59.95.
About 30,000 deaths occur from suicide in the United States
annually; 650,000 receive emergency treatment after an at-
tempt. Worldwide, 1,000,000 people kill themselves each and
every year. No wars during the past 50 years match that death
rate, and yet they attract far more public attention and outcry.
The mental health community is concerned about suicide,
however. A cursory glance at the medical literature during the
past decade reveals more than 13,000 publications and ab-
stracts on the subject. Do we need yet another scientific
study?
The very fact that suicide remains a major health problem
worldwide shows that we are far from knowing all the answers.
Despite the appearance of the excellent Comprehensive Text-
book of Suicidology published in 2000 and reviewed in the
Journal (1), there is room for Reducing Suicide: A National
Imperative. This fine book is published by the Institute of
Medicine, which is greatly respected for the high quality of its
publications. Not surprisingly, the three editors of the Compre-
hensive Textbook of Suicidology are also contributors to this
work. It certainly is on a level with all the reports from the In-
stitute. The intention of this report is to identify the next steps
necessary to significantly reduce suicide, and within this task,
discuss the most relevant information (p. 21).
The report is composed of 13 sections consisting of an ex-
cellent executive summary, 11 chapters, and three appen-
dixes. The chapters are titled Introduction, Magnitude of
the Problem, Psychiatric and Psychological Factors, Bio-
logical Factors, Childhood Trauma, Society and Culture, Suicidology to be an indispensable addition to your profes-
Medical and Psychotherapeutic Interventions, Programs
for Suicide Prevention, Barriers to Effective Treatment and
1534 http://ajp.psychiatryonline.org
Intervention, Barriers to Research and Promising Ap-
proaches, and Findings and Recommendations. The ap-
pendixes provide statistical details, a list of the consultants,
and agendas of the workshops that contributed to the report.
The executive summary is extremely well prepared and
packed with concise, relevant findings that will immediately
appeal to the busy clinician when pressed to speak to profes-
sional and lay audiences about suicide. Magnitude of the
Problem provides very quotable and important facts on geo-
graphic trends, populations at risk, race and ethnicity, incar-
cerated populations, occupations at risk, sexual orientation,
limitations of data, and cost to society. Psychiatric and Psy-
chological Factors covers psychiatric and substance use dis-
orders and suicide risk as well as psychological dimensions of
suicide risk. Biological Factors looks at the physiological
stress system, neurochemistry, and genetic factors. Child-
hood Trauma examines childhood trauma as a risk factor,
childhood sexual abuse and the risk for suicide, modifying
factors, biopsychosocial effects of childhood trauma, child-
hood trauma as a risk factor for psychopathology, pathways to
suicidality, and prevention and intervention. Society and
Culture discusses a social safety net, society and culture in
suicide, and the challenges.
In Medical and Psychotherapeutic Interventions the areas
of assessment, psychoactive medications, ECT, psychothera-
pies, inpatient and follow-up care for suicidality, cultural con-
siderations, and faith-based interventions are well covered. I
found this chapter to be one of the most outstanding.
Programs for Suicide Prevention offers information about
a framework for prevention, universal prevention, selective
prevention, indicated prevention, and integrated approaches
to prevention and assessing the effectiveness of prevention
approaches. Again, this is a fine chapter. Barriers to Effective
Treatment and Intervention talks about general, clinician,
and patient barriers to treatment, barriers to treatment for
high-risk groups, and global barriers. Barriers to Research
and Promising Approaches examines methodology, surveil-
lance of suicide and suicide attempts, ethics and safety, and
research design and analysis issues. The report concludes
with a summary containing discussions on enhancing the in-
frastructure, a database on suicide, the identification of those
at risk for suicide, and prevention and interventions.
The strong points of this report are its surprising breadth of
scope; clarity of expression; memorable quotes at the start of
each section by famous clinicians, authors, philosophers and
poets; illustrative clinical examples; abundant and well-cho-
sen references; and superb editing. Each chapter follows a
uniform format with findings listed at the end of the chapter,
and each is concise and to the point. The books very minor
failings are that the executive summary steals the thunder
from some of the ensuing chapters, there is redundancy and
some crossover in several chapters that belabor well-known
findings and frequently quoted statistics about suicides, and,
obviously, readers will find some chapters to be less compre-
hensive or relevant than others depending on their interest in
the subject.
In conclusion, if you found the Comprehensive Textbook of
sional mental health library, then you should grab Reducing
Suicide: A National Imperative as the next logical step. This
Am J Psychiatry 160:8, August 2003

book should not be restricted to professional audiences; In-
ternet news junkies will also love this report.
Reference
1. Maris RW, Berman AL, Silverman MM: Comprehensive Text-
book of Suicidology. New York, Guilford, 2000
NORMUND WONG, M.D.
Silver Spring, Md.
MEDICAL PSYCHIATRY
Medical Complications of Psychiatric Illness, by Claire
Pomeroy, M.D., James E. Mitchell, M.D., James Roerig,
Pharm.D., B.C.P.P., and Scott Crow, M.D. Washington, D.C.,
American Psychiatric Publishing, 2002, 228 pp., $29.95
(paper).
Written by a multidisciplinary team representing internal
medicine, psychiatry, and pharmacology, this book has the
goal of informing practicing psychiatrists of the medical com-
plications of psychiatric disease and suggesting guidelines for
routine health maintenance. The authors report that psychia-
trists have increasing responsibility for medical care of pa-
tients. Our experience is that many psychiatric patients are
unable or unwilling to access services in primary care. The
book is divided into two sections: one on psychiatrys rela-
tionship to health maintenance and reproductive health and
the other on the evaluation and treatment of medical prob-
lems associated with specific psychiatric disorders. The book
is a useful contribution to the literature, and portions of it are
excellent models for future books to follow in addressing the
topic.
Chapter 1, Routine Medical Evaluation and Health Main-
tenance, discusses higher rates of morbidity and mortality
(e.g., annual death rates 24 times those of healthy people) in
psychiatric patients, partly due to medical disorders. Unfor-
tunately, medical disorders are diagnosed as psychiatric dis-
orders in 6%20% of patients. The authors correctly point out
that medical training is compartmentalized, resulting in psy-
chiatrists not having the knowledge and/or skills for the pa-
tient population with whom they work. Our experience is that
not all psychiatrists maintain medical knowledge and skills
unless they are actively involved in consultation-liaison psy-
chiatry, sit on an institutional review board, or take continu-
ing medical education courses. The authors do an excellent
job of providing an overview of the biopsychosocial reasons
for misdiagnosis and provide guidelines for routine medical
examinations for psychiatric patients.
Reproductive Health, chapter 2, focuses on patients sex-
ual behaviors, lack of family planning, teratogenic effects of
psychotropic medication, patients exposure to danger (e.g.,
HIV, abuse), and prevention of illness. This is an absolutely
critical topicone that deserves a book of its own. The au-
thors do a splendid job of informing psychiatrists how to pro-
mote health and how to prevent, identify, and manage prob-
lems. As important, our experience is that primary care and
specialty physicians must collaborate on prevention and
management, which is still something to strive for in the inte-
grated care of psychiatric patients.
Am J Psychiatry 160:8, August 2003
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Chapters 38 focus on the medical illnesses that patients
with a given psychiatric disorder (e.g., schizophrenia) experi-
ence. Chapter 3, Affective, Anxiety, and Somatoform Disor-
ders and Dementia, is most helpful for consultation-liaison
psychiatrists or for psychiatrists working with primary care
physicians, since it talks mainly about rates of these disorders
in medical populations. In addition, it explores the potential
relationships between medical and psychiatric disorders:
does one cause the other or do they have a common etiology?
There are very practical tips for treating common problems
for patients with dementia (e.g., urinary incontinence). Chap-
ters 4 and 7 are outstanding in that they methodically outline
common medical problems in patients with schizophrenia
and those with eating disorders, respectively. For example,
patients with schizophrenia have higher rates of ingestion of
objects, self-mutilation, coronary artery disease, and cancer
than the general population. These chapters quickly bring the
practicing psychiatrist up to date. Chapter 5, Munchausens
Syndrome and Other Factitious Disorders, and chapter 6,
Self-Injurious Behavior, each includes a section on when to
get a medical consultationa section that would be good for
all of the chapters. Chapter 8, Alcohol and Drug Abuse, is
well written but less critical, since most psychiatrists have
exposure to this topic in practice and in continuing medical
education.
Overall, Medical Complications of Psychiatric Illness is a
useful contribution to the literature because it highlights the
importance of health maintenance as well as the identifica-
tion and the management of medical problems in psychiatric
patients. The book is well written, well referenced, and con-
cise. It is a practical resource for practicing psychiatrists, and
it would also be useful for psychiatry residents, medical stu-
dents, and other mental health staff. In addition, there is suf-
ficient value for primary care physicians and/or hospital phy-
sicians who care for psychiatric patients.
We have a few suggestions for future editions and/or simi-
lar books. First, an entire chapter on mood disorders would
be helpful, focusing on what medical disorders are commonly
comorbid and how to manage them (e.g., like chapters 4 and
7). Second, tiered guidelines would be helpful on what medi-
cal problems the psychiatrist could manage and when to refer
to routine, subacute, or emergency medical settings. Third,
we suggest a chapter on the management of disorders or
symptoms that plague so many of our psychiatric patients
(e.g., obesity, sexual dysfunction, and pain).
DONALD M. HILTY, M.D.
THOMAS S. NESBITT, M.D.
Sacramento, Calif.
Handbook of Clinical Health Psychology, vol. 1: Medi-
cal Disorders and Behavioral Applications, e d i t e d b y
Suzanne Bennett Johnson, Ph.D., Nathan W. Perry, Jr., Ph.D.,
and Ronald H. Rozensky, Ph.D. (Thomas J. Boll, Ph.D., editor-
in-chief ). Washington, D.C., American Psychological Associa-
tion, 2002, 654 pp., $69.95.
We eat, drink, worry and smoke too much, and we drive
too fast (Robert R. Whalen, quoted in reference 1). But there
is more to say about health psychology, much more, to the ex-
tent of three thick volumes, of which the book reviewed here
is the first. The American Psychological Association, the
http://ajp.psychiatryonline.org 1535
BOOK FORUM
books sponsor and publisher, has reason to be well pleased
with this encyclopedic treatise, for it signifies the maturity of
health psychology. As of 2003, in its 25th year, the Division of
Health Psychology of the American Psychological Association
has grown to 2,800 members. Health psychology, which might
be roughly defined as the sum of the activities of psycholo-
gists who work in the health care system, includes a remark-
able diversitybehavior change programs for smoking, obe-
sity, and stress; support groups for victims of chronic illness
and their families; nonpharmaceutical treatment to help
patients cope with chronic pain; cognitive and emotional
retraining following stroke; assessment of candidates for sex
reassignment surgery, back surgery, and sterilization; and
much more.
The 17 chapters of this handbook correspond to the 17
main categories of ICD-9 (2): a chapter each on neoplasms,
metabolic disorders, mental disorders, and so forth. This
medicine-centered approach has drawbacks, as the editors
acknowledge, but it has advantages as well. The book is com-
prehensive, covering every illness from infections (codes 100
139) to symptoms, signs, and ill-defined conditions (codes
780799). A user looking into any medical problem should
need no more than a minute to determine whether it is dis-
cussed, and, if so, where. The diagnosis-oriented arrange-
ment also meshes well with the specialties of the 35 authors.
A major limitation of the ICD-9 scheme stems from the fact
that most of the practice and most of the theory of health psy-
chology cuts across organ systems and diseases. It is no secret
that excessive stress contributes to susceptibility to most dis-
eases, exacerbates almost all diseases, and frequently is a
consequence of disease. Naturally, almost every chapter dis-
cusses research on stress and coping with stress. The result is
a good deal of repetition and, at the same time, less depth
than would be expected in a single, combined treatment of
the subject. We may expect such in-depth topical chapters in
the handbooks forthcoming volumes 2 and 3.
Each of the handbooks chapters describes the most com-
mon medical problems within its ICD-9 category and, often,
the less common as well. One finds well-written summaries of
incidence, etiology, symptoms, physiology, prognosis, pre-
vention, and treatmentspharmaceutical, surgical, and psy-
chological. The summaries emphasize, as they should, the
topics of most interest to health psychology: prevention,
long-term management, interventions to increase compli-
ance with treatment, and the role of psychosocial factors in
causation and cure.
The book is at its best as a guide to the vast field of health
psychology research. It cites more than 4,000 authors, almost
half of them for work published within the past decade. But
the handbook reviewed here is not the only guide to the field,
and it is not necessarily the best. A rival one-volume Hand-
book of Health Psychology (3), published only 1 year earlier,
cites nearly 12,000 authors! Less than 7% of the author cita-
tions are common to both handbooks, so the user would be
well advised to consult both. Until the second and third vol-
umes of the Handbook of Clinical Health Psychology appear,
most practitioners will find the one-volume Handbook of
Health Psychology more useful because it covers the core of
health psychologypractical applications and theorywhile
those topics are left mostly to the future volumes of the three-
volume handbook reviewed here.
1536 http://ajp.psychiatryonline.org
The Handbook of Clinical Health Psychology has some sur-
prising omissions. Diagnosis of attention deficit hyperactivity
disorder has mushroomed during the past quarter century,
and with it an armamentarium of increasingly costly pharma-
ceutical treatments (4). One would expect health psycholo-
gists to be deeply involved in the controversies concerning
the diagnosis, prevalence, and treatment of this condition,
but volume 1 mentions none of this.
Depression is treated in detail, but schizophrenia, mania,
bipolar disorder, and posttraumatic stress disorder are not
mentioned. Stigma, a major psychosocial concern for many
patients, is barely mentioned. Death and dying are not even
indexed, although much of value has been published on these
subjects (5, 6). Some chapters cite the research literature ex-
tensively, but the chapter on neurology is little more than a
descriptive summary of neurological diseases and patholo-
gies. One of the best chapters surveys cardiovascular disease.
It marshals the impressive evidence that lifestyle treat-
mentspromotion of healthier diet, healthier habits, health-
ier emotions, and moderate exerciseproduce dramatic im-
provement in overall heath and life expectancy, effects much
greater than are foreseeable from drugs or surgery.
The ICD-9 approach omits some important topics. Clinical
health psychologists cannot help but be affected for better or
worse by newly coined diagnoses, many of them heavily pro-
moted by pharmaceutical manufacturers. Recovered mem-
ory syndrome soon may be swept into the dustbin of history,
but other new diagnoses are on the way. Social phobia, for-
merly known as shyness, is a promising source of income for
the pharmaceutical industry; so is sexual dysfunction, i.e.,
disappointment with ones sex life (79). Some health psy-
chologists will welcome medicalization, others will resist it,
but all will be affected by it. Controversies over commercial
influence on research, diagnosis, and treatment (10) inevita-
bly will be with us for many years, especially in health psy-
chology, where results are so often measured in subjective
feelings and subjectively assessed behavior. I hope that vol-
umes 2 and 3 of this handbook will give these controversial is-
sues the attention they deserve.
References
1. Stone GC, Cohen F, Adler NE (eds): Health Psychology: A Hand-
book. San Francisco, Jossey-Bass, 1979, p 488
2. Hart A, Schmidt K, Aaron W (eds): St Anthonys ICD-9 CM Code
Book. Reston, Va, St Anthony Publishing, 1998
3. Baum A, Revenson TA, Singer JE (eds): Handbook of Health Psy-
chology. Mahwah, NJ, Lawrence Erlbaum Associates, 2001
4. Zito JM, Safer DJ, dosReis S, Magder LS, Gardner JF, Zarin DA:
Psychotherapeutic medication patterns for youths with atten-
tion-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med
1999; 153:12571263
5. Hoefler JM: Managing Death. Boulder, Colo, Westview Press,
1997
6. Presidents Commission for the Study of Ethical Problems in
Medicine and Behavioral Research: Deciding to Forego Life-
Sustaining Treatment. Washington, DC, Government Printing
Office, 1983
7. Moynihan R: The making of a disease: female sexual dysfunc-
tion. Br Med J 2003; 326:4547
8. Tiefer L: The medicalization of sexuality: conceptual, norma-
tive, and professional issues. Annu Rev Sex Res 1996; 7:252
282
Am J Psychiatry 160:8, August 2003
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9. Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Four- 10. Bekelman JE, Le Y, Gross CP: Scope and impact of financial con-
croy J, Goldstein I, Graziottin A, Heiman J, Laan E, Leiblum S, flicts of interest in biomedical research. JAMA 2003; 289:454
Padma-Nathan H, Rosen R, Segraves K, Segraves RT, Shabsigh 465
R, Sipski M, Wagner G, Whipple B: Report of the international EDWARD M. OPTON, JR., PH.D., J.D.
consensus development conference on female sexual dysfunc- Berkeley, Calif.
tion: definition and classification. Urology 2000; 163:888893

Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org.

Corrections
A Letter to the Editor published in the March issue of the Journal contained an error. The authors of the letter
by Andrea Messori, M.D. (Comparative Effectiveness of Antipsychotic Drugs, Am J Psychiatry 2003; 160:591
592) should have been as follows: F. Vacca, B. Santariasci, S. Trippoli, A. Messori.

In the May 2003 Book Forum, the review by William M. Greenberg, M.D., of Descriptions and Prescriptions:
Values, Mental Disorders, and the DSMs, edited by John Z. Sadler, M.D., contains an error. On page 1021, in the
third paragraph of the review, line seven, Jerome Wakefield, not James Wakefield, should be cited.

Am J Psychiatry 160:8, August 2003 http://ajp.psychiatryonline.org 1537