Treatment Strategies for Patients With Psychiatric Comorbidity
The editors of Treatment Strategies for Patients With Psychiatric Comorbidity assert that psychiatric “comorbid disorders necessitate modifications in standard psychotherapeutic and psychopharmacological treatments” and hope to illustrate the appropriate interventions in this book. Their thesis is that most psychiatric patients meet diagnostic criteria for more than one disorder and that neglecting to consider the impact of a second diagnosis, such as substance abuse, anxiety, or an axis II disorder, may render treatment for the primary disorder ineffective. Hence the importance of a careful initial evaluation with an eye toward commonly correlated conditions and a treatment strategy designed to ameliorate all major problems, not just the predominant diagnosis.
The book is divided into three sections: Introduction, Treatment Strategies, and Special Topics. The introduction covers the implications, prevalence, and assessment of psychiatric comorbidity. Treatment Strategies addresses the effects of comorbidity on the treatment of anxiety, mood disorders, schizophrenia, and substance abuse. For each class of comorbid disorders there is a chapter on psychological treatment or psychotherapy and a chapter on pharmacotherapy. The third section considers the impact of comorbidity on suicide, on assessment and treatment of children and adolescents, and on the elderly. Such a format lends itself to redundancy, and indeed there is a great deal of repetitiveness throughout.
The book is edited by two psychology professors in the department of psychiatry at Albert Einstein College of Medicine in New York City. The 31 authors are almost equally divided between psychologists and psychiatrists, and all but one are in academia. The monograph has a decided academic tone.
The chapter on prevalence of psychiatric comorbidity uses data from two epidemiological surveys of a general population to demonstrate that more than 54 percent of people with a DSM-III psychiatric diagnosis, 52 percent with an alcohol diagnosis, and 75 percent with a substance abuse diagnosis have a second diagnosis. Although lifetime comorbidity is common, the calculated odds for associations of specific disorders vary considerably. The odds are fairly high for a patient to have several mood disorders or mood disorders along with anxiety disorders, but are weaker for comorbidity of several anxiety disorders as well as for the occurrence of substance abuse with anxiety or mood disorders. These findings are limited by the experimental methodology and are only indirectly applicable to clinical situations. The chapter on assessment of comorbidity deals with methodological factors, such as base rates, issues of classification, boundaries, assessment methods, and specific instruments.
The therapy section has a cognitive-behavioral orientation throughout. For anxiety, the authors promote a cognitive-behavioral treatment that focuses on symptoms. They provide a detailed discussion of cognitive restructuring, exposure, and relaxation training for anxiety disorders and comorbid conditions. The treatment of depression is discussed in similar terms with the caveat that the disorder that is perceived by the patient to be the most distressing should be addressed first. Alternative psychotherapeutic interventions are not described. For dual-diagnosis schizophrenia, the authors propose a multicomponent behavioral treatment for substance abuse and schizophrenia along with pharmacotherapy for cosyndromal depressive disorders.
The book has a dearth of clinical illustrations, which makes for a somewhat dry presentation. The chapters on pharmacotherapy start with a description of the characteristic symptoms of each comorbid syndrome and assess its impact on the course of the primary disorder. The authors list classes of relevant drugs and recommend medications in order of preference. Several useful new medications, such as olanzapine, donepezil, and mirtazapine, are not mentioned in the monograph. Protocol-driven treatment interventions are fairly clearly described, but the psychopharmacological discussions are not detailed enough to use in clinical practice.
The chapter on comorbidity in the elderly population is the most interesting one in the Special Topics section. The authors point to the deleterious effects of polypharmacy, the interaction between physical disease and psychiatric disorders, the disabling effects of subsyndromal depression, and the value of comprehensive treatment. An unfortunate typographical error converts the monamine oxidase inhibitor tranylcypromine, an irreversible inhibitor, to a reversible one; if only it were true!
The problem of comorbidity that the authors address is important. The book might be of interest to psychologists and researchers, and the data could be useful in managed care settings to justify specific interventions. However, the clear preference throughout for cognitive-behavioral therapy and the sketchiness of the chapters on pharmacotherapy limit the book's usefulness for psychiatrists.
Dr. Backus is a psychiatrist with the Scripps Clinic Medical Group in La Jolla, California, and clinical associate professor of psychiatry at the University of California, San Diego.
