Preface

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

Copyright 2003 Lippincott Williams & Wilkins

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PREFACE

The first edition of the Manual of Psychiatric Therapeutics was written about 20 years after the advent of modern psychopharmacology. Diagnostic systems were in flux at that time, partly because responses to specific psychopharmacologic agents were provoking some psychiatrists to rethink certain traditional descriptive and etiologic concepts. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems, tenth revision, (ICD-10) are now in place, and, in many instances, treatment efficacy can be anticipated for patients who meet these descriptive and course criteria. The second edition of this manual was written in the early 1990s; it contained changes in treatment and management strategies reflecting the broad acceptance of the DSM-IV and the penetration of managed care into the lives of both treating clinicians and their patients. The new millennium has brought globalization of the pharmaceutical industry, an increasing use of practice guidelines and algorithms, an even greater impact from managed care, an increasing reliance on evidence-based medicine that is being countered by trends emphasizing effectiveness over efficacy and challenges to the use of placebo controls to support claims of efficacy, a growing use of assessments of the economic impact of disorders and of specific therapies, the greater use of quality of life assessments in the evaluation of both new and older agents, more informed patients and families who advocate for themselves, and an almost blind faith in so-called natural products (e.g., herbals and botanicals). In the face of these changes, the introduction of a third edition of this manual seemed appropriate. In addition, with the years that elapse between each edition, awareness of the benefits and limitations of electronic media is growing, especially regarding the Internet and other online resources.

Although the limitations to online publications are obvious, real time resources, such as textbooks and briefer manuals, by their very nature also have limitations. To be truly practical, manuals have to be small enough to be portable, with the pocket size being preferable. To accomplish this, they must be succinct. Manuals are temporally bound; therefore, they cannot be completely up-to-date. For more current information and new research findings, interested readers may wish to consult the Journal of Clinical Psychopharmacology (JCP) to which many of the authors of this manual regularly contribute. The tables of contents of the JCP can be found online at http://www.psychopharmacology.com/.

This edition features two new chapters (Chapter 21, Approaches to the Psychopharmacologic Treatment of Children and Youth, and Chapter 28, Understanding and Assessing Pain and Pain Syndromes ), and all of the chapters from the second edition have been updated, expanded, or reordered. Chapter 21 has been added because the Food and Drug Administration has added patent extension incentives to encourage the development of more information about the use of some agents in children and because more and more children are being treated with these medications, reflecting a trend that is not yet adequately supported by an understanding of the impact that some of these agents may have on their development. The chapter on attention deficit hyperactivity disorder (ADHD) (Chapter 22) has been enlarged to reflect not only the greater likelihood of treatment for this condition but also the growing number of adults who are seeking treatment for behaviors that they attribute to unrecognized and untreated residual ADHD from childhood. The chapters have been reordered to improve the flow in this edition, although the logic behind the new ordering may be questioned by some. For example, the chapter covering tic disorders (Chapter 7) is located after the chapter on obsessive-compulsive disorders (Chapter 6) because of the high incidence of overlapping comorbidity, even though some might have preferred to see the chapter on tic disorders aggregated with Chapters 21 and 22. The chapter on drug interactions (Chapter 29) has been totally revamped and expanded to reflect the fact that so many psychotherapeutic agents have a narrow therapeutic index or range. Inhibition of their metabolism can readily lead to toxicity, and induction can easily compromise efficacy. No chapter has been devoted exclusively to the elderly. Instead, appropriate material has been included where it is relevant. In this century, the aged are the modal patients for many clinicians. While special issues of dosing, receptor sensitivity, metabolism, and side effects are present, the inclusion of a separate chapter would have required more space than is appropriate for this format.

Another addition in this edition is Appendix VII. In it, Osser and Patterson provide a bibliography of treatment algorithms and guidelines that contains not only basic references and a conceptual framework but also websites that can be consulted for updated iterations (an example of how online materials can act as supplements to traditional texts). The fact that these algorithms are presented is not an endorsement of them. Rather, the purpose for their presence is to give readers of this manual a perspective on treatment alternatives that some clinicians or groups have found useful.

Some may still take issue with the chapters on seclusion and restraints, and new guidelines or regulations are now in place in many states, as well as at the federal level. However, whenever I am in hospitals or emergency departments that care for seriously disturbed psychiatric patients or for those suffering from toxic delirium, I find that, while seclusion, restraints, or both are in use, staff often have not thought through what they are about to do or have done, nor have they received adequate training and retraining in the proper uses and limitations of these strategies.

The indications and dosages of all drugs in this book have been recommended in the medical literature or conform to the practices of many in the general medical community. The medications described do not necessarily have specific approval from the Food and Drug Administration (FDA) for use in the diseases and dosages for which they are discussed or recommended. The package insert for each drug should be consulted for the use and dosage as approved by the FDA. Because standards for usage change, it is advisable to keep abreast of the revised recommendations, particularly those concerning new drugs. It is important to realize that, when a drug is withdrawn from the market for reasons other than safety (e.g., the manufacturer feels either that the need is no longer sufficient or that profitability has diminished significantly), the practicing community may not become aware of this. Notices of drug withdrawals eventually appear in the Federal Register, but they may not appear until some time (e.g., a year) after the drug has been withdrawn.

Particular attention should be paid to the so-called black box warnings whenever they appear for a given agent. These warnings are almost always added after a drug has been marketed for some time and postmarketing surveillance has revealed an adverse outcome that was not noted in premarketing trials. In most instances, this was because of the careful selection of the patients studied in the trials or the limited size of the exposed population.

Interested readers may also wish to review Appendix II for information about the FDA and herbal remedies and dietary supplements.

My hope is that the approaches and perspectives offered in this text will encourage readers to engage in the treatment of those suffering from psychiatric disorders and that they will continue to reduce the dual burdens of stigma and hopelessness that are so often felt by patients, their families, their physicians and other care providers. Some physicians may even be encouraged to do clinical and basic research in order to reduce ignorance. If reading this edition improves the care of patients or inspires or enables research, then the energy put into its creation and publication will surely have been worthwhile.

Richard I. Shader

Bourne, Massachusetts