Given the strong evidence of the high prevalence of treatment-resistant and/or chronic affective disorders in the population and the impact that these conditions have on our services (not least in psychiatric out-patient clinics) a book on this topic is welcome. Each chapter is written by an expert and contains a wealth of detail and a good review of the literature. It is slightly out of date and this is a particular problem in relation to the chapters on neurobiology: for example, the imaging chapter does not include Shah et al's (Reference Shah, Ebmeier and Glabus1998) influential study. The main problems, however, are that many of the chapters are written by people with strong views supporting their particular strategy and the chapters written by those taking an overview have an uneven use of evidence. These two problems amplify rather than counteract each other. For example, the chapter on electroconvulsive therapy (ECT) is written by Max Fink, who is over-whelmingly positive about the role of ECT in these cases (e.g. he writes, ‘When depression is still debilitating after two adequate medication trials, ECT is the proper treatment’), and the debate on whether ECT response is reduced in patients who fail on medication is not discussed despite much recent controversy and research in this field. The overview chapter rehearses some of the studies without analysing the quality of the evidence. A further example is the use of T3: this is enthusiastically supported by Joffe and lukewarmly supported in the overview chapter but nowhere is the fact that much of the evidence is based on open and/or poorly designed studies discussed. This part of the book therefore compares unfavourably with publications on the use of ECT that give recommendations and also indicate the strength of the evidence (e.g. Reference Anderson, Nutt and DeakinAnderson et al, 2000).
However, in the chapters away from evidence base and algorithms the book has considerable strengths and gives very good summaries and a distillation of clinical wisdom about these disorders in a variety of populations, including adolescents, the elderly and the current or recently pregnant. These discussions would help the clinician with the assessment and management of cases and provide a logical basis for therapeutic trials. The book is also strong on the psychological aspects and it is pleasing to note that dysthymia — a difficult concept in relation to these disorders — is sensibly handled, as this has often caused confusion in the US/UK literature.
One often looks in these American books for tricks that will help in one's clinical practice, and I thought that I had found one with the description of the concept of tachyphylaxis, which was described as the loss of initial response to treatment despite maintenance of the drug at the initially effective dosage — I could see my patients telling their friends that the doctor had said they had a bad case of tachyphylaxis. However, a dictionary definition of this term is the rapidly decreasing response to a drug after a few doses, and so this does not fit the common clinical scenario (sometimes called, usually on the internet, ‘poop-out’). Perhaps we need a new term? Bradyphylaxis? Or perhaps good old-fashioned tolerance would suffice.
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