Book Review: Psychopharmacology: Polypharmacy in Psychiatry

Abstract

Psychopharmacology Polypharmacy in Psychiatry. S Nassir Ghaemi, editor. New York: Marcel Dekker Inc; 2002. 347 p. US$135.00. Reviewer rating: Very Good Only recently was a pejorative term implying nonscientific and, perhaps, even sloppy care. This was all the more so as diagnoses became more refined, information regarding the neurobiology of psychiatric disorders increased, and the mechanisms of action of psycho tropic medications became progressively more clear-developments that held out the promise of a neurophysiology of psychiatric disorders with drugs designed appropriately to match. In this book's opening chapter, Dr Nassir Ghaemi carefully discusses the history of polypharmacy, including the fluctuations in attitude toward this practice over time that directly reflect the level of understanding of medical illnesses. He feels that, today, polypharmacy persists in part because psychiatric disorders continue to be difficult to understand, despite vast progress in the neuroscience of psychiatric disorders over the past decade and a half. There are several other factors, which he details. For example, it is an important fact that drugs are marketed for specific diagnoses on the basis of research that employs drug-disease paradigms-even though in the real world patients present with clinically complex symptoms rather than with discrete syndromes matching the actions of a particular drug or class of drugs. The book is part of the Medical Psychiatry series edited by William A Frosch. It has 14 chapters by 14 authors and coauthors. The opening chapter, by Ghaemi, defines the conceptual and historical background of polypharmacy in psychiatry from the time of Oliver Wendell Holmes. It discusses William Osier and the early struggles between psychotherapy, psychoanalysis, and pharmacologie treatment (with barbiturates and sedatives) and includes the introduction of the phenothiazenes and the tricyclics. Ghaemi also mentions the efforts of several people familiar to the reader, including Gerald Klerman of Yale and Harvard and Gerald Sarwer-Foner of the University of Ottawa, Ottawa, Canada. Sarwer-Foner is mentioned as someone who began in the 1960s to specialize in the relation between psychopharmacology and psychotherapy. Ghaemi also presents the US Food and Drug Administration as a powerful influence in the evolution of polypharmacy and attitudes toward its practice. The way drugs have been approved by the US Food and Drug Administration and marketed by drug companies, and also the US cultural and historical appetite for pharmacologie treatment, are seen as significant contributors. Other important factors, such as research findings on biogenic amines in depression and schizophrenia, elucidate the mechanisms of action of drugs and the development of the DSM. Ghaemi concludes by emphasizing that polypharmacy is part of psychiatry today. Ghaemi also devotes much attention to defining polypharmacy, distinguishing betweeri rational and irrational polypharmacy. Some disorders (for example, bipolar disorder [BD]) historically require 2 or more drugs for adequate treatment of the disorder and its associated symptoms. In such cases, polypharmacy is not only rational but may be standard treatment. ; Eight chapters discuss polypharmacy for different disorders according to the following diagnoses or clinical groupings: BD, unipolar depression, schizophrenia, anxiety disorders, and posttraumatic stress disorder, Polypharmacy for medically ill psychiatric patients, the elderly, and children and adolescents is also discussed. The question of defining polypharmacy is taken up in each chapter. In the chapter on BDs, for example, it is argued that standard treatment requires at least 2 drugs. Therefore, polypharmacy would be 3 or more drugs in the case of this disorder. Various aspects of the diagnosis and treatment of BD are discussed as they relate to polypharmacy. …