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BOOK REVIEWS |
Handbook of Psychiatry in Palliative Medicine
edited by Harvey M. Chochinov and William Breitbart
reviewed by John L. Shuster, Jr.
Crossing Over: Narratives of Palliative Care
edited by David Barnard, Anna M. Towers, Patricia Boston, and Yanna Lambrinidou
reviewed by John L. Shuster, Jr.
The Biological Basis of Mind-Body Interactions
edited by Emeran A. Mayer and Clifford B. Saper
reviewed by Robert Murison
Cytokines, Stress, and Depression: Advances in Experimental Medicine and Biology
edited by R. Danzer, E. E. Wollman, and R. Yirmiya
reviewed by Monika Fleshner
Director, Palliative Medicine Program, University of Alabama at Birmingham, 1700 7th Avenue South, Birmingham, AL 35294, Email: shuster@uab.edu
Harvey M. Chochinov and William Breitbart
Oxford University Press, New York, 2000, 435 pages, $79.50
Strengths: comprehensive review of field, should become a standard reference text for psychiatric palliative care
Weaknesses: none
Target reader: all students and practitioners in the area of mental health and palliative care
The body of palliative medicine knowledge, including psychiatric aspects of end-of-life care, has experienced rapid growth in the past few years. Although there has been an impressive amount of work done on the psychiatric care of the terminally ill, a useful summary of the field had been lacking until the publication of the Handbook of Psychiatry in Palliative Medicine. This text is a very thorough and accessible resource for students, physicians, psychologists, and other practitioners in mental health and palliative care. The editors have assembled a stellar group of contributors, and the material covered in the chapters represents a broad array of topics relevant to the field.
The first section provides a detailed, readable, and practical summary of knowledge concerning the psychiatric complications of terminal illness. Depression, anxiety, delirium, suicide, and chronic mental illness are covered. Psychotherapeutic interventions applicable to the palliative care and hospice setting are discussed in a subsequent section. Other sections summarize research issues in psychiatric end-of-life care, family and staff issues, and psychiatric care of dying children.
Of particular value to mental health professionals new to the field of palliative care are chapters dealing with symptom management. It is impossible to provide effective psychiatric care to terminally ill patients without understanding the complex interactions of physical symptoms, the resultant suffering, and associated mental disorders, symptoms, and distress. Thoughtful overviews of assessment and management of pain, fatigue, and disordered eating are provided. A philosophy and a practical overview of symptom control in palliative medicine are included in the introductory chapter to this section. This section is one of the chief strengths of the Handbook, and it provides substantial utility to mental health professionals.
Ethical and spiritual issues are similarly covered in a thorough and thoughtful manner. An entire chapter is devoted to the topic of suffering in the palliative care setting, giving this often-neglected topic the attention it deserves. Assisted suicide and euthanasia, from both clinical and ethical perspectives, are thoroughly covered.
The Handbook of Psychiatry in Palliative Medicine is a comprehensive, readable, and needed resource. It will occupy a prominent space on my bookshelf, and I expect to refer to the Handbook frequently in my practice, teaching, and research. It should serve as a valuable reference for years to come. Psychiatric palliative care now has a standard textbook.
Director, Palliative Medicine Program, University of Alabama at Birmingham, 1700 7th Avenue South, Birmingham, AL 35294, Email: shuster@uab.edu
David Barnard, Anna M. Towers, Patricia Boston, and Yanna Lambrinidou
Oxford University Press, New York, 2000, 451 pages, $39.95
Strengths: compelling narrative accounts of end-of-life experiences
Weaknesses: documentary and detailed writing style that requires a motivated reader
Target reader: physicians, mental health professionals, and trainees
One of the great rewards of caring for dying patients is hearing their stories. Attention to the narrative is important in all of clinical medicine, but it has special relevance and value in end-of-life care. The stories of patients approaching death allow the treating team to provide more effective care, provide healing for patients sharing their narratives, and enrich the experience of patient care. Success in achieving palliative care treatment goals often depends on an understanding of the patient’s story so that interventions can be matched to the preferences and wishes of the patient and family. Teaching the skills of eliciting and listening to the patient’s story to members of the treatment team can be a challenge. Barnard and colleagues present a thorough, satisfying, and useful collection of narratives that go beyond the superficial to provide rich, nuanced portraits of several patients facing the end of their lives. As such, Crossing Over is a fascinating and valuable contribution.
The heart of the book is the narratives themselves. Sometimes inspiring, sometimes disturbing, but always engaging, these stories illustrate multiple aspects of the experience of facing death. By use of various qualitative research methodologies, including participant observation, interviews, and journaling, the authors assemble a series of compelling portraits of patients, their families, and their professional caregivers. The reader sees patients struggle with advanced illness and symptoms. Patients and families work to assemble and preserve meaning while they grapple with essential questions. Grief during and after the patient’s death is explored.
In addition to being the book’s chief strength, the narratives are also the source of its primary shortcoming. Such thorough and unflinching descriptions of the experience of living with a terminal illness do not make for light reading. Although the advanced student or practitioner of palliative care will find the book stimulating and enjoyable, the narrative format might lull the casual reader into expecting the flow and pace of fiction. Such an expectation would be frequently frustrated by the documentary style of the narratives; these are research reports as much as they are stories. Once the reader comes to terms with what they are, the narratives provide rewarding reading.
As much as I enjoyed reading Crossing Over for myself, I anticipate using the book primarily with my students. The authors have included a very helpful chapter on qualitative research methods used in assembling these narratives. The palliative care clinician may never replicate the depth of these narratives in clinical practice, but a glimpse into the methods used gives practical hints to help elicit narrative at the bedside. The final chapter is a collection of the authors’ comments and a set of discussion questions for each patient narrative, which should serve as helpful launch points for case-based teaching.
Clinical use of the narrative in end-of-life care is an invaluable teaching tool and therapeutic intervention. Crossing Over provides a marvelous resource for better understanding of this vital element of end-of-life care. I recommend this book highly to palliative care students and practitioners and those who practice at the interface of mental health care and palliative care.
Professor, Department of Biological and Medical Psychology, University of Bergen, Årstadveien 21, N-5009 Bergen, Norway, Email: murison@psych.uib.no
Emeran A. Mayer and Clifford B. Saper
Elsevier Science, Amsterdam, 2000, 528 pages, $223.50
Strengths: comprehensive and current reviews of specialty areas by authorities in the field
Weaknesses: most chapters require some background knowledge, lack of integrating final chapter
Target reader: scholars and researchers in psychiatry, psychology, and behavioral medicine; some chapters relevant for science and health policy makers
The Biological Basis of Mind-Body Interactions is published as volume 122 in the Progress in Brain Research series. It is an impressive and weighty collection of important review papers that otherwise might be spread across several, more discipline-specific journals. The editors, Emeran Mayer and Clifford Saper, are to be congratulated on putting together such a collection, based on a meeting in March 1998. As always with such conference-based books, there is the problem that many of the contributions are outdated to a greater or lesser extent. However, for both specialists and nonspecialists alike, the chapters provide a relatively up-to-date account of their various specialty fields. The reader should be aware that the content is not light reading. The level of scholarship is high, and the contributors are all outstanding experts in their fields. Readers may be put off by the technical level of some chapters, which inevitably means that the book will be used as a journal rather than as a whole. This is unfortunate because of the many interesting and illuminating chapters concerned with issues not usually addressed by volumes of this kind. In addition to essential review papers for scholars and researchers concerned with mind-body interactions and psychosomatic medicine, the volume contains material that should be read by those concerned with research policy and health care utilization. For example, why do so many sufferers forego conventional medical approaches and make use of alternative treatments, and what are the problems associated with this illness behavior?
It is impossible in this review to do justice to all the fine contributions. Rather, I will focus on just a few aspects. That a specific chapter is not mentioned is by no means a criticism; it is merely an indication that the volume is so substantial that it is impossible to cover all contributions.
The introductory chapter by the editors is very much an overview of the whole volume and perhaps could have been shorter. The subsequent chapters are presented in sections, some more diverse than others. The major section on the neurobiology of the stress response comprises contributions from an impressive list of scholars, including Bruce McEwen, Esther Sternberg, and Paul Sawchenko. These contributions provide a far more sophisticated coverage of the topic of stress than one often finds in such volumes. In the section on developmental issues, Ladd et al. review their important work on the significance of early life events for neuroendocrine responses in animal models and how these models might be relevant for humans. This same section concludes with a contribution concerned with the issue of early life abuse and gastrointestinal and pelvic floor dysfunction by Devroede. A number of case histories are presented in which it remains unclear whether the abuse has been verified, an issue of which the author is clearly aware and addresses at some length. If our task is to understand and intervene in the etiology of suffering, it is essential that we are able to differentiate between real life events and "false memories." The issues of false recall and attribution in somatization patients (whose real suffering is unquestionable) and others have not been sufficiently considered within the biomedical literature.
The section on the influence of the internal environment on the brain provides a useful review of, among other things, the role of nutrients on brain function and of the role of visceral afferents in feelings. The section on the influences of body on brain focuses mostly on pain, whereas that on influences of the internal environment of the brain is primarily concerned with the digestive system. The section on influences of brain and mind on body is diverse, covering among other topics psychoimmunology (Felten, Kemeny), memory (Fuster), emotional coping, and the heart and emotions.
The final section is concerned with practical use of the body of knowledge. A thoughtful chapter by Sobel discusses socioeconomic issues. Why do so many people spend so much money on alternative medicine? It really might not matter what patients learn in therapy as long as they are successful (ie, the beneficial effects of coping). The flip side is, of course, that nonachievement of goals ("noncoping") because of unrealistic demands on the patient will have detrimental effects. I would have appreciated this as the first or second chapter of the book, thereby setting the scene for the problem. Diehl’s chapter emphasizes that whether the medical profession likes it or not, "complementary and alternative medicine" is popular and the issues of research and standardization must be addressed.
I appreciated the chapter by Read, who attempts to integrate psychoanalytical and neuroscientific views of visceral disease, a stimulating contribution and one that combines historical and contemporary approaches. This author, in particular, implicitly acknowledges the contributions of researchers "pre" neuroscience (eg, Spitz and Wolf; Harlow; and Hofer). We disregard these earlier works all too often. Scholarship should be done in a historical perspective, and the hard-earned knowledge gained by our predecessors should be integrated with our own.
I fear that the volume might not satisfy the expectancies of the lay reader attracted by the title (but at this price, lay readers are unlikely to invest). For researchers, there are many useful and important chapters. For health politicians there are warnings that we need to move toward a holistic (in the true sense of the word) approach to the biology of health and disease. There are some topics that could have been covered, even if only in a historical context. What of the role of psychological factors in defense against bacteria, a fascinating topic with wide-reaching implications and a burgeoning field of research? Why are gastrointestinal conditions now limited to the bowel? Given the history of the field, a discussion of the various concepts (functional disorder, psychosomatic, etc) and their overlap and differences would not have been out of place. The term functional disorder should be used with care and a little humility. Unknown etiology does not mean unknowable etiology. Lack of an observable organic basis or lesion underlying symptoms might instead reflect our own limited knowledge and skills.
I do believe that the volume lacks a final chapter. Although integration of the mass of contributions is certainly almost impossible, a final chapter on future directions and challenges would have been stimulating and useful.
Department of Kinesiology and Applied Physiology, Campus Box 354, University of Colorado–Boulder, Boulder, CO 80309-3054, Email: fleshner@colorado.edu
Edited by R. Danzer, E. E. Wollman, and R. Yirmiya
Kluwer Academic/Plenum Publishers, New York, 1999, 461 pages, $119.50
Strengths: autonomous chapters by authorities in field, well integrated with common theme
Weaknesses: typographical errors, some confusing figures
Target reader: scientists and clinicians working in areas of psychoneuroimmunology, neuroimmunology, and depression
The study of neural-immune interactions continues to stimulate important and interesting avenues of inquiry. Work in this field has involved the study of peripheral immune-to-brain communication, brain-to-peripheral immune communication, and most recently the immune response of the brain. This volume is an excellent collection of papers submitted by leaders in the field.
Research presented in Cytokines, Stress, and Depression supports the hypothesis that brain cytokines play a role in both normal physiology and pathophysiology. In fact, it is possible that cytokines in the brain will soon join the ranks of other known neuromodulators, such as hormones and neuropeptides. Although the cellular source of cytokines in the brain (ie, neural and/or glial) remains controversial, there is growing experimental evidence that cytokines, such as interleukin 1ß (IL-1ß), are endogenously produced in response to a variety of stimuli. For example, peripheral antigenic (ie, lipopolysaccharide) or pathogenic (ie, viral) challenge, as well as psychological stress, has been reported to increase the IL-1ß in the brain.
One physiological consequence to stimulation of brain IL-1ß is the "sickness response." Several research groups presented evidence that brain cytokines such as IL-1ß stimulate the sickness response (Danzer et al., Chapter 6; Anisman and Merali, Chapter 12; and Yirmiya et al., Chapter 16). The sickness response, an adaptive response to infection, causes fever, increases acute-phase proteins, decreases social behavior, and causes anhedonia, anorexia, increased sleep, and altered pain perception. In addition to evidence that antigenic challenge or infection elevates brain IL-1ß, exposure to nonimmunogenic stimuli can also produce this effect. For example, exposure to acute stress can increase circulating and brain levels of cytokines (Watkins et al., Chapter 10; and Maier et al., Chapter 13). In fact, many of the neurochemical (Linthorst and Reul, Chapter 9; Dunn et al., Chapter 8), behavioral (Danzer et al., Chapter 6; Anisman and Merali, Chapter 12; and Yirmiya et al., Chapter 16), hormonal (Tilders and Schmidt, Chapter 11; Yirmiya et al., Chapter 16), and immunological (Maier et al., Chapter 13) consequences of acute stressor exposure can be stimulated by administration of IL-1ß into the central nervous system.
Brain cytokines may also play a role in the pathophysiology of depression. Several groups report that persons with some types of depression have increased circulating proinflammatory cytokines (Maes, Chapter 2; Seidel et al., Chapter 3; and Sluzewska, Chapter 4). This increase in circulating cytokines could be indicative of a more generalized stimulation of the acute-phase response and/or innate immune function (Maes, Chapter 2). Interestingly, an increase in certain aspects of acute-phase response and/or innate immune function has been previously reported to suppress many measures of acquired immune function (1, 2). In fact, there is evidence that persons with depression also suffer a reduction in many measures of acquired immune function, leading to an increase in disease susceptibility and severity (Irwin, Chapter 1). It is possible, therefore, that depression results in an elevation of innate immunity and a suppression of acquired immunity. Specifically it has been suggested that depressed patients have increases in proinflammatory cytokines such as IL-1ß (a feature of innate immune function), and this increase is etiologically involved in some types of clinical depression.
One intriguing issue that remains unresolved is what triggers the elevation in proinflammatory cytokines (ie, IL-1ß) and why patients with depression experience the maladaptive consequences of increases in brain IL-1ß. One potential hypothesis is that exposure to immune stimulation or stress triggers increases in both brain and peripheral cytokines (Leonard and Song, Chapter 14) that result in an adaptive behavioral responses to these stimuli. In persons not susceptible to depression, these increases are normally short-lived because of the elimination of the stress or infectious agent and inhibition by glucocorticoid negative feedback. In fact, there is clear evidence that removal of glucocorticoids results in a potentiated brain IL-1ß response after either immune stimulation (Yirmiya et al., Chapter 16) or stress (Maier et al., Chapter 13). In persons with depression, however, the elevation is greater and remains elevated longer than necessary.
What causes the prolonged elevation in proinflammatory cytokines in depressed patients? One suggestion is that persons with depression (perhaps because of genetic predisposing factors) are insensitive to glucocorticoid negative feedback (Miller et al., Chapter 7) such that after exposure to immune stimulation or stress, their proinflammatory cytokine response is greater and remains elevated longer than normal. It is suggested, therefore, that the overshoot in the brain and peripheral cytokine response contributes to the pathology of depression. If this is true, then therapy that leads to a reduction in the proinflammatory cytokines excess should reduce symptoms of depression. Interestingly, there is evidence that antidepressant drugs increase glucocorticoid receptor function (ie, increase glucocorticoid receptor translocation into the nucleus; Miller et al., Chapter 7). Restoration of the normal glucocorticoid negative feedback might correct excessive IL-1ß in both the brain and periphery in persons with depression. If such a mechanism exists, then antidepressant medication in depressed organisms should reduce elevated proinflammatory cytokines. There is some evidence to support this idea (Leonard and Song, Chapter 14; Neveu and Castanon, Chapter 15).
In conclusion, Cytokines, Stress, and Depression offers a comprehensive and intriguing series of papers that support the hypothesis that the brain cytokine system is involved in both the normal physiology of "sickness" and acute stress, and the pathophysiology of depression. This book will stimulate investigation and inquiry into a new and exciting area of research.
REFERENCES
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