Psychiatry: Past, Present and Prospect

Psychiatry: Past, Present and Prospect Edited by Sidney Bloch, Stephen Green & Jeremy Holmes Oxford University Press, 2014, £34.99, pb, 432 pp ISBN: 9780199638963 

The editors of this prodigiously ambitious collection of personal essays hint that they strived with some difficulty to extract from

Tim Swanwick (ed.) Wiley-Blackwell, 2013, £46.99, pb, 520 pp. ISBN: 9781118472408 Why should a jobbing psychiatrist be interested in a medical education textbook? Simply put, it is that we have shifted from an era of 'See one, do one, teach one' to one where an evidence base is available for education, not just for treatments. This is particularly the case for medical education, where the need to evidence pedagogic practice for regulators has been a priority for many years and has driven research to support and drive practice. This is an increasingly important issue. The General Medical Council, in Recognition and Approval of Trainers, has set out the standards it requires for clinicians to be trainers, with an implementation date of 31 July 2016, and a similar standardised approval process is well underway for undergraduate teaching.
Understanding Medical Education is a good place to start for those wishing to build their knowledge of the evidence base to inform their teaching. With a strong cast of the 'usual suspects' in the field, it delivers a broad range of chapters covering the breadth of educational topics. The book is set out in themed sections allowing selection of topics of interest. For the determined reader, read sequentially they build from basic foundations through strategy and assessment to research and finally, a 'Staff and Students' section that covers issues related to learners and teachers. This all finishes with an excellent chapter on educational leadership.
This should not be seen as a book targeted at the academic community. Even though one or two chapters may not affect most doctors' teaching practice (e.g. the chapter on curriculum design), they will nonetheless enhance understanding of the choices that went into learning and teaching strategies.
So at the end of this, a reasonable question might be, 'Is it worth my time buying/borrowing this book?' If you already have a strong background in pedagogic theory, then it gives up-to-date monographs collected together in one place but perhaps nothing new, so it may be one you borrow rather than buy (and this is not a criticism). If you are developing your knowledge or wish a reference to support your teaching, whether undergraduate or postgraduate, then the answer is indubitably 'Yes.' This text is part of the Oxford Psychiatry Library series and at about 80 pages there is nothing anxiety-provoking about its length. The authors make clear from the outset that this is a book designed to be user friendly in its approach and, with four independently referenced chapters, the reader instantly feels it will live up to this claim.

Panic Disorder and Agoraphobia
Published in the USA, the opening chapter on diagnosis refers to the (at the time of print) current DSM-IV and new DSM-5 diagnostic criteria. The main focus of diagnosis is, however, referencing the complex interplay between patients with panic disorder who frequently present with multiple and varied somatic complaints to a wide range of medical, surgical and psychiatric specialties. Of particular interest to this reader was the comprehensive table of medical conditions that can mimic panic attacks. Concise text is interspersed with useful boxes and tables, drawing the reader's eye to the key points and considerations. Three further chapters on aetiology, pharmacological treatment and non-pharmacological treatment follow a similarly structured pattern.
For those who are looking for a summary of the current research into these disorders the 'aetiology' section on neurochemistry will not disappoint. For those, perhaps from non-psychiatry-based disciplines, looking to jump to more practical management advice, the section on 'pharmacological treatment' contains a handy FAQ list.
This book is by no means exhaustive, but what it quite cleverly manages to do is educate and interest the reader while guiding them through the practicalities of treating patients with panic disorder and agoraphobia in clinical practice. The section on pharmacological treatments is not as detailed as, say, the NICE or Maudsley guidelines, but its handy 'pocket' size means it is a worthy supplement and far more likely to be carried around. I have already found it useful, not only in my out-patient clinics but also in the acute care setting while on call -where it is important to bear in mind the reminder that appropriately placed psychoeducation can go a long way. The editors of this prodigiously ambitious collection of personal essays hint that they strived with some difficulty to extract from their distinguished authors personal views of how psychiatry has developed during the course of the past 50 years. The editors did not want a series of academic reviews but more the experience and wisdom gleaned during successful careers. This is history but as reminiscence, memoir as well as critical scientific review. The editors have achieved magnificently what they set out to do and nearly all the individual essays are worth spending time absorbing. The book is quite simply the best account, a searingly honest one, of the progress we have made over the working lifetime of the internationally renowned authors of the essays, nearly all like your reviewer at the tail end of their careers.
Every practising psychiatrist and trainee should read this book. I did not just read it, I devoured it, but readers beware, I put down the finished book with a disturbing sense of disappointment. Have we really changed the prospects for our patients' lives so little in 50 years? Has so much neuroscientific research, psychopharmacology, sociology and changing political environments produced so little? I fear so. 'What's past is prologue', as pronounced by Shakespeare in The Tempest. The real story is yet to be revealed.
The perennial indecisiveness about the boundaries of psychiatry's responsibilities, the repeated creation of social movements that ultimately fail to shift patients' life chances, the deficiency in translating what we know from social psychiatric studies into practical treatment modalities, the ever-shifting ethical sands of risk and restraint and the almost total lack of significant improvement in medications after imipramine in 1940 and clozapine in the 1960s, all this makes disturbing reading. Yet many essays contain scholarly reviews of fruitful paths of research that have not quite yielded success yet, such as Peter McGuffin on genetics, Steven Hyman on neuroscience, Edwin Harari on personality disorders. We are always on the brink, looking upwards but not quite over the brow of the hill just yet. Inevitably, the reader is drawn to areas of one's own personal interest. This reviewer turned straight away to George Szmukler's entertaining review of the vicissitudes of legal controls versus professional judgement, Paul Mullen and Danny Sullivan's pithy and sceptical account of the development of forensic psychiatry and Julian Leff's cri de coeur bemoaning the loss of social psychiatry developments from its exciting origins. Why have we not implemented what we know from social skills training and education for patients with schizophrenia, for example? I fear the answer is that mental health services have plenty of doctors and nurses but insufficient numbers of educationalists, social work interventionists and behavioural trainers. The administrative context in which psychiatry is practised has remained almost unchanged in the past 50 years, asylums are gone but the care and treatment has barely changed. Scientific endeavour plods on, our understanding of aetiology makes modest progress, but clinical practitioners must do the best they can with inadequate tools, today just as our colleagues did 50 years ago.
I have one criticism and this is not of the authors or editors. Oxford University Press should surely have produced this book in a better-quality format. It is printed in a small font (although not as small as this journal!) and the cover is somewhere between dull and unfathomable; it looks cheap. A tome so rich in content deserves a more sumptuous coat.