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Book Review   |    
Symptom-Focused Psychiatric Drug Therapy for Managed Care
Neil S. Kaye,, M.D.
Psychiatric Services 1998; doi:
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by S. Joseph, M.D., Ph.D., M.P.H.; Binghamton, New York, Haworth Medical Press, 1997, 510 pages, $89.95 hardcover, $24.95 softcover

I must admit my bias: I was turned off by the title of this book. The notion that we should treat "symptoms" in order to further the cause of managed care is offensive. Although I run a busy, managed-care-friendly multidisciplinary mental health practice with six offices, I teach my residents that the bane of our profession is the "one symptom—one drug" thinking foisted on us by the pharmaceutical industry. Nonetheless, as I read the author's book, I tried to forgive him for trying to be timely and to appeal to the marketing forces where anything with "managed care" in the title is expected to sell; he has also writtenPersonality Disorders: New Symptom-Focused Drug Therapy1.

The current book,Symptom-Focused Psychiatric Drug Therapy, has little new to offer the reader. It contains the largely anecdotal experience of one clinician and is sadly devoid of research findings to back up many of his assertions. The book is divided into two parts. In the first the author presents what is essentially a restatement of DSM-IVcriteria for each diagnosis and then a brief review of almost every medication known to have been tried for the disorder. He includes a list of the advantages and disadvantages of each compound. Unfortunately, they read like the slick marketing pamphlets of the pharmaceutical industry and again lack the substance that the reader would appreciate.

Joseph also has an admitted tendency to lump together related but distinctly different classes of medications in way that any psychopharmacologist should eschew. An example is his inclusion of the tetracyclic compound maprotiline with the tricyclic antidepressants or his inclusion of venlafaxine as a selective serotonin reuptake inhibitor.

The second part of the book contains 100 clinical cases, allegedly organized by degree of severity. Although earlier in the book Joseph argues for "rational polypharmacy," the cases presented reflect my initial fears. For most of these patients, at least one medication has been prescribed for each of their symptoms rather than an attempt being made to medicate the underlying disorder and then allow the symptoms to respond. This failure to see the patient as a whole is perhaps one of the greatest chimeras introduced to the medical world by managed care.

In short, the book is best suited for a resident who might want to see what someone has tried. It is hoped that the resident would then ask himself or herself about the full conceptualization of the case and what else might be done to better assist the patient. Mixing numerous medications where another psychiatrist might hesitate to do so does not make one a psychopharmacologist. Reading the actual research journal articles and understanding the science should not be replaced by war stories, even when written by a well-known, published, and highly credentialed author. Other writings with treatment algorithms are far more useful and readily available to assist all of us as we attempt to treat patients most effectively and efficiently under the increasing pressures of managed care.

Dr. Kaye is clinical assistant professor in the departments of psychiatry and family practice at Jefferson Medical College in Philadelphia and president of Allied Mental Health in Wilmington, Delaware.

Joseph S: Personality Disorders: New Symptom-Focused Drug Therapy. Binghamton, NY, Haworth, 1997


Joseph S: Personality Disorders: New Symptom-Focused Drug Therapy. Binghamton, NY, Haworth, 1997

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