BOOK REVIEWS. Mood Disorders, Gender, Sex

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1 BOOK REVIEWS Mood Disorders, Gender, Sex Mood Disorders in Women. Meir Steiner, Kim berly A Yonk - ers, Elias Eriks son, editors. Lon - don: Mar tin Duntiz Pub lish ers; p. USD Gail Er lick Rob in son, MD, FRCPC This is a great book. The editors have as - sem bled a com pre hen sive over view of the bi op sy cho so cial ba sis of de pres sion in women. Dr Stei ner is a pro fes sor of psy chia try, be hav ioural neu ro sci ences, and ob stet rics and gy ne col ogy at McMas ter Uni ver sity, Ham il ton, On - tario, and the Di rec tor of Re search for the De part ment of Psy chia try at St Jose - ph s Hos pi tal. He has ex ten sively re - searched women s mental health and has pub lished widely on such top ics as post - par tum de pres sion (PPD), pre men strual dys pho ric dis orde (PMDD), and meno - pause. Kim berly Yonk ers, an as so ci ate pro fes sor of psy chia try at Yale Uni ver - sity, has al ready made sub stan tial con tri - bu tions to the lit era ture, es pe cially in the area of psy cho phar ma col ogy treat ment in women. I am less fa mil iar with Dr Eriks son, an as so ci ate pro fes sor from the De part ment of Phar ma col ogy at Gote borg Uni ver sity. The edi tors have as sem bled an in ter na tional cast of authors (with heavy weighting toward the US). Well- known ex perts in the area of women s mental health and depres - sion in clude Dr Charles Ne mer off, Dr Kath er ine Halmi, Dr El len Lei ben luft, Dr Mi chael O Hara, Dr Donna Stewart, and Dr Zach ary Stowe. The book is di vided into 31 chap ters that can roughly be cate go rized as covering ba sic sci ences, spe cific types of de pres sion, ob stet ri cal- and gynecological- related is sues, and a mis - cel la ne ous group that ad dresses sev eral dis or ders that are more com mon in women, such as eat ing dis or ders and auto im mune dis ease, or that af fect women dif fer ently, such as alcoholism and pain dis or ders. All the chap ters end with clear sum ma ries. This can be very use ful for those chap ters that con tain im - por tant ma te rial but may pro vide far too much detail for many cli ni cians practi - cal use. The book be gins with sev eral chap ters dis cuss ing the epi de mi ol ogy of mood dis or ders in women, sex dif fer ences, the preva lence and cor re la tion of mood dis - or ders in the gen eral popu la tion, and evo lu tion ary con cepts of sex dif fer ences in de pres sive dis or ders. All these chap - ters are in ter est ing and well writ ten in their own right. There does, however, tend to be some over lap and repetition, es pe cially be tween the first 2 chapters. Chap ter 3 pres ents in ter est ing hy pothe - ses about the ex pla na tions for male fe - male dif fer ences in the preva lence of de pres sion from a bio medi cal, psy cho - so cial, and evo lu tion ary view point. The chap ters on neu roa na tomi cal sex differ - ences and the func tional neu ro chem is try of mood dis or ders in women are quite densely written. Al though the neu roa - nat omy chap ter fo cuses a bit too much on ro dents for my lik ing, both chap ters give a very com pre hen sive and de tailed over view of their sub jects. The chap ter on neu ro chem is try, by Dunn and Stei - ner, suf fers a little from the authors46pe - ri odi cally making de fini tive state ments with out dis cuss ing con flict ing evi dence. For ex am ple, it notes that the risk and se ver ity of de men tia are de creased in women re ceiv ing es tro gen ther apy, al - though this is still a hotly de bated sub ject. There are sev eral chap ters dealing with par ticu lar kinds of de pres sion, in clud ing grief and be reave ment, dysthymia, uni po lar de pres sion, bi po lar ill ness, sea - sonal af fec tive dis or der, and de pres sion in the eld erly. The authors give thor ough over views of their sub jects in clud ing symp toms, di ag no ses, sex differences, and treat ment. They re view the re search, dis cuss etio logi cal hy pothe ses, and pro - vide use ful clini cal in for ma tion about deal ing with women suf fer ing from these dis or ders. All the chap ters at tempt to bal ance the bi op sy cho so cial model, al though some tend to lean more in one di rec tion than the other. The chap ter on Grief and Be reave ment in Women, by Zi sook and oth ers, dis cusses in depth their mul ti di men sional way of evalu at - ing spousal be reave ment. They examine emo tional and cog ni tive ex pe ri ences, cop ing, the con tinu ing re la tion ship with the de ceased, func tion ing, and relation - ships and iden tity. It beau ti fully de tails risk fac tors, course, and out come and treat ment fac tors. O Keane6s chap ter on uni po lar de pres sion in women also does an ex cel lent job of looking at ge netic, per son al ity, so cio poli ti cal and de vel op - men tal, and bio logi cal etio logi cal fac - tors. Each sec tion has a con clu sion that as sists in syn the siz ing the de tailed in for - ma tion given. The sec tion on ob stet ri cal and gy ne co - logi cal is sues in cludes chap ters on fe - male sex ster oids; the brain and be hav iour; es tro gens, pro ges ter ones, and mood; ef fects of an dro gens; PDD; treat ment of mood and anxi ety dur ing preg nancy; post par tum psy chi at ric dis - or ders; preg nancy loss; meno pause; and in fer til ity. The ma te rial is gen er ally well pre sented and very clearly written. The charts that are in cluded are ex cel lent, and the ref er ences are all very cur rent. I have mi nor quib bles with some of the chap ters. For ex am ple, the chap ter on pre men strual dys pho ria dis misses in a sin gle sen tence the so cio logi cal and cul - tural fac tors that many be lieve are in - volved in di ag nos ing PMDD. Al though I, too, be lieve in the more bio logi cal ex - pla na tion, I think the sub ject would have Can J Psychiatry, Vol 46, October

2 756 The Canadian Journal of Psychiatry Vol 46, No 8 been bet ter served by a more de tailed refu ta tion of these ar gu ments. The chap - ter on the meno pause could have of fered a fuller dis cus sion of the psy cho so cial fac tors af fect ing mood and at ti tudes at meno pause. The last sec tion dis cusses an as sort ment of dis or ders, in clud ing eating disorders, obe sity, al co hol and drug abuse, pain and psy choneu ro im mu nol ogy. As well, this section in cludes chap ters looking spe cifi cally at psy cho phar ma col ogy, psy cho so cial treat ments, and a broad base of so cio geo po liti cal is sues. The last chap ter, writ ten by Kel ley Phil lips, pro - vides a con tex tual frame work for the men tal health care of women. It dis - cusses the es tab lish ment of a womencentred health model and looks at crosscultural per spec tives on women s men - tal health and vio lence. It also de tails strate gies to promote women s mental health, fo cus ing on the un der treat ment of de pres sion. The cross- cultural per - spec tive is some what lim ited, and again, the em pha sis is largely on these is sues from a US point of view; over all, how - ever, it is an ex cel lent and well- written chap ter. With an es ti mated 7 million US women suf fer ing from ma jor de pres sive disor - der (MDD) at any given time and the pros pect that, by the year 2020, depres - sion will be the lead ing cause of ill ness in the world, this book ob vi ously touches on a very im por tant sub ject. Dif - fer ent read ers will ob tain dif fer ent bene - fits. As a whole, it pres ents a very thor ough over view of the total sub ject, and it can be used as a ref er ence text for neu roa nat omy and neu ro chem is try. Other health care pro fes sion als will use it to ob tain an ex cel lent over view of spe - cific dis or ders. It is not spe cifi cally a treat ment guide: it does not, for exam - ple, give de tails of ex act dos ages of anti - de pres sant medi ca tion but, rather, gives an over view of the im pact of dif fer ent types of thera pies and their in ter re la tion - ship. Over all I am very pleased that this book was brought to my at ten tion. It is cer - tainly one that I would want to have on my bookshelf. Even at its rather high cost, it is a use ful ad di tion to the li brary of any one treat ing women with any type of depression. Geriatrics Psychiatric Medications for Older Adults: The Con cise Guide. Carl Salz man. New York: The Guil ford Press; p. USD Matt Ro bil lard, MD, FRCPC This book pro vides quick an swers about psy chi at ric medi ca tions to pre scrib ing phy si cians. It also makes the prin ci ples and prac tices of geri at ric psy cho phar - ma col ogy un der stand able to cli ni cians, health care work ers, and oth ers con - cerned with their well- being. It is a use - ful ref er ence guide that pres ents im por tant in for ma tion and con cepts needed to de velop and moni tor safe, ef - fec tive regi mens for older adults. The book first pro vides criti cal prin ci - ples for un der stand ing pa tients con - cerns about medi ca tion and for maxi miz ing treat ment com pli ance. It then moves chapter by chap ter through fre quently en coun tered clini cal prob - lems: de pres sion, mania, anxiety, sleep dis or ders, fail ing mem ory, and agi ta - tion. Di ag nos tic point ers for as sess ing preva lent symp toms and dis or ders are listed. Em pha siz ing a start low, go slow ap - proach, the book of fers prac ti cal ad vice on se lect ing the right medi ca tion, deter - min ing start ing and main te nance dos - ages, and an tici pat ing side ef fects that may be of par ticu lar con cern to frail pa - tients or those with chronic health con di tions. Through out the vol ume, case il lus tra - tions, ta bles, and bul leted lists pres ent in for ma tion in a con cise, ac ces si ble for mat. The ap pen dix fea tures ta bles that sum ma rize rec om mended dos age ranges for all medi ca tions. Dr Salz man is Di rec tor of Psy cho phar - ma colgy and Di rec tor of Edu ca tion at the Mas sa chu setts Men tal Health Centre and Professor of Psy chia try at Har vard Medi cal School. He is a well- respected cli ni cian, edu ca tor, and re searcher, with a wealth of clini cal ex pe ri ence. In this concise guide, he de lib er ately keeps the number of ref er ences to a mini mum. For spe cial ized geri at ric psy - chia trists, com pre hen sive clini cal and re search bib li og ra phies can be found in the third edi tion of Clini cal Geri at ric Psy cho phar ma col ogy. This co he sive, well- written guide pro vides a co her ent over view of the fun da men tals, prin ci - ples, and is sues. Through out the chap - ters, the author in ter poses case vi gnettes to il lus trate im por tant prin ci ples of treat - ment with drugs. These are very in ter est - ing and thought pro vok ing. These vi gnettes in te grate the clini cal the ory and knowl edge re quired to deal with the elderly. I en joyed the sec tions on depression, ma nia, de men tia, agi ta tion, and psy cho - sis. The case his to ries are fascinating. The author does give some in for ma tion on the rela tively new medi ca tion treat - ments for mood dis or ders, such as the use of the an ti con vul sants la mo trig ine, ga bap en tin, and topiri mate. He points out that a lot more re search and clini cal ex pe ri ence with these agents is needed. It would have been in ter est ing and help - ful if the sec tion on mood dis or ders had dis cussed such things as what to do if the pa tient does not get bet ter on the first an - ti de pres sant medi ca tion, what is the up - per dosage limit that the author is willing to give his pa tients, and what is his expe - ri ence with aug men ta tion strate gies as well as sub sti tu tion strate gies for an ti de - pres sant medi ca tion. These are com mon clini cal situa tions that ei ther psychia - trists or pri mary care phy si cians con - front daily. An al go rithm or flow chart would have been one way to deal with these mat ters. I wish also that the author had given some in for ma tion on de pot

3 October 2001 Book Reviews 757 neu ro lep tics and other sub stances such as St John s wort, SaMe, and kava- kava. I found that my own clini cal ex pe ri ence does not ex actly mir ror his clini cal expe - ri ence in that he ad vo cates tra zo done as a good and con sis tent an ti agi ta tion agent. I un der stand that there are a few case re ports that might sup port this ex - pe ri ence but that good clini cal re search on this topic has yet to be done. There is a 2- page de scrip tion of electro - con vul sive ther apy (ECT), which I felt could have con tained more in for ma tion: it is im por tant to in clude clini cal mat ters for ECT in any book on geri at ric psy cho - phar ma col ogy. Per haps there could have been some mention of some of the newer ex peri men tal physi cal thera pies such as vagus nerve stimu la tion (VNS) and tran - scra nial mag netic stimu la tion (TMS) ther apy. The layout is at trac tive. There are many ta bles and lists, but there are no clini cal al go rithms, pic tures, or pho to graphs. The book ap pears free from production er rors, and the price seems rea son able. Over all, this is a good, con cise guide to many im por tant as pects of psy chi at ric medi ca tions for older adults. Psychotherapy: Fam ily The Relational Trauma of In - cest: A Family-Based Ap - proach to Treatment. M Sheinberg, P Fraenkel. New York: Guilford Press; p. USD Janet Cleghorn, MSS Mar cia Shein berg and Pe ter Fraen kel, the authors of this ground break ing book on in cest, hold in ter na tional stat ure in the fam ily studies field. In a wel come con trast to the sense of hor ror, tur moil, and con fu sion that fol lows the trauma, they bring sea soned judgement to their work with sexu ally abused chil dren and their fami lies This brief and lu cid vol - ume is ex cep tion ally well or gan ized. Its lay out is at trac tive, and I did not come across any pro duc tion er rors. It is rea - sona bly priced. These prac ti cal ad van - tages make the book ac ces si ble to a wide read er ship, both lay and pro fes sional. The authors be gin by re view ing the epi - de mi ol ogi cal data, re port ing the alarm - ingly high and in creas ing rates of child sex ual abuse across 21 coun tries, with most chil dren abused by fam ily mem - bers. Their first ob jec tive is to ad dress the needs of cli ni cians who will be treat - ing these larger num bers. Their fo cus is on fam ily re la tion ships as the pri mary con text for the oc cur rence, mean ing, and heal ing of fa mil ial sexual abuse. Be - cause the authors uniquely in te grate as - sump tions from so cial con struc tion ist, femi nist, and sys tems the ory in un der - stand ing the psy chol ogy of in cest, their con cep tion of the in ter nal and ex ter nal worlds of its mem bers is fresh and re - sults in their new defi ni tion of re la - tional trauma : the lack of safety, ac ces si bil ity, and clar ity in fam ily re la - tion ships. Treatment be gins with multi - di men sional as sess ments and capi tal izes upon col labo ra tion among mul ti ple treat ment mo dali ties (for ex am ple, indi - vid ual, fam ily, and group) and the wider sys tem of such com mu nity in sti tu tions as the courts and child pro tec tion agen - cies. Their ex cel lent re view of re search stud ies (Ap pen dix A ) sup ports their sec - ond ob jec tive, to ad dress the need for a treat ment ap proach that fo cuses on the child s fam ily re la tion ships. There is no evi dence that dis tin guish ing fam ily or - gani za tion pat terns such as par ticu lar fam ily con stel la tions con trib ute to in - cest. With no sin gle incest story, and each fam ily sce nario there fore unique, the authors call for clini cal complexity. This con sti tutes their third ob jec tive, both in terms of re la tional sche mas fea - tur ing chal leng ing re la tional con tra dic - tions and in terms of the mul ti ple choice- points for treat ment in ter ven - tions. Here, gen er al ized familyexperience themes are bal anced with open ness to varia tions on those themes. The authors tackle head on the thera - pist s moral di lemma of sus tain ing a re - spect ful co la bo ra tive con nec tion with the fam ily in the face of an egre gious vio la tion of the safety of the child, whose pro tec tion by the thera pist is para mount. The authors make clear that fam ily ther apy has ma tured as it has aban doned func tional causal ex pla na - tions of symp to matol ogy that serve fam - ily or gani za tion (as though all mem bers in equal meas ure con trib ute) in favour of rec og niz ing feminist- derived in for ma - tion about gender- based power in eq uity, where male op pres sion, in timi da tion, abuse, and vio lence is domi nant. One out stand ing chap ter dis cusses treat ment of the of fend ing (usu ally male) per pe tra - tor, which may be co or di nated with that of other fam ily mem bers un der cer tain rig or ous con di tions. Re search into the fore most risk factors, ef fects, and me di at ing vari ables is in its rela tive in fancy. In general, the most con sis tent find ings re gard ing risk fac - tors point to the pro tec tive par ent s ab - sence, the child s pro longed sepa ra tion from the non of fend ing par ent, and emo - tional dis tance be tween child and par ent. The authors caution that these condi - tions not be viewed as fea tures of an in - ces tu ous fam ily but, rather, as prob lem atic if as so ci ated with an abu - sive fam ily mem ber s pres ence. A heavy fo cus on fam ily risk fac tors may lead to un de ri den ti fy ing sources of fam ily strength, and in deed, re search into sources of fam ily strength has been ne - glected. It is striking that a fair percent - age of abused chil dren ap pear to be as ymp to matic. At tach ment lit era ture con cerned with me di at ing fac tors in - creas ingly iden ti fies at tach ment dif fi - cul ties fol low ing mal treat ment. The criti cal, posi tive me di at ing in flu ence on abuse s im pact on the child cen tres on

4 758 The Canadian Journal of Psychiatry Vol 46, No 8 her re la tion ship to a safe, care tak ing mother. (Most such chil dren are fe male, hence the pro noun she. ) There fore, the re la tional ap proach fo cuses on mak - ing safe, re stor ing, and strength en ing the mother daugh ter bond. Re search has found that pa ren tal sup port is the best pre dic tor of free dom from clini cal symp toms and is as so ci ated with the child s main tain ing so cial com pe tence. Fol low ing this, Shein berg and Fraen kel note that the de vel op ment of per sonal agency and free dom from self- blame for abuse are goals for the child, while the non of fend ing par ent s goals are to be a mor ally sound and pro tec tive care - giver one who can tol er ate the child s ex pres sion of a range of feel ings about the of fender. When non of fend ing moth - ers of sexually- abused chil dren ac cess with out shame and guilt their oftenhidden yearn ings for lov ing connection with their vio lent abus ing part ner, they can put their child s safety first. The authors have found that the wellmeaning de sire of the ex tended family and the com mu nity to sim plify the story of good and evil often re sults in secon - dary re trau ma ti za tion, be cause family mem bers feel bound to hide their own ex pe ri ences. De scribed as the Both And path, mixed feel ings that are mani fest in ap par ently mu tu ally ex - clu sive per sonal at ti tudes and fam ily be - liefs are actively ex plored, as is their link to loy alty bonds and en dur ing attach - ments. There is a nod to con tem po rary attach - ment the ory, par ticu larly with re gard to fam ily sys tems af filia tion con cepts (that is, fam ily as a se cure base from which to ex plore), but it is some thing of a passing nod. The word bond is miss ing from the in dex, al though not in the main text, and (loosely held) hy pothe ses regarding the in ter nal world of work ing mod els are left out. As a mo ti va tional sys tem, at - tach ment is not ac counted for by femi - nist, sys tems, or so cial con struc tion ist ideas. It would make sense to me to rec og nize at tach ment the ory as a fourth plank of in te grated as sump tions, em bed - ded as it is in the re search lit era ture and in the ex cel lent, rich, de tailed, clini cal ex am ples, wherein thera pists in quire about the missing close ness pain fully felt by fam ily mem bers, not only with re - gard to the abused child but also with re - gard to their par ents of the same sex. I also look for ward to know ing more about the thera pists side of the experi - ence of co con struct ing fami lies sto ries of shame and pride. When Mar cia Shein berg in vites a child to ask her ques - tions about her self, and self- discloses shared pa ren tal ex pe ri ence, she arouses my cu ri ou sity about these match ing ex - pe ri ences and also about the in stances of misat tune ment, dis rup tion, re pair, and the hot mo ments of dis tress or joy in the in ter ac tions among thera pists, fami - lies, and col leagues. In the Both And chal lenge of balanc - ing safety and pro tec tion with equal ity and mu tu al ity, the authors have sev eral crea tive prac tices that are cen tral to their ef fec tive ness. One of these is an in gen - ious thera peu tic tool called the De ci - sion Dia logue. This is the pro cess of talk ing about the trauma and then trans - fer ring in for ma tion across treat ment mo dali ties, with each new tell ing bring - ing new per spec tives. In in di vid ual ses - sions, the child is en cour aged to decide what to tell her mother and oth ers, de - pend ing on how safe it feels. Then fears of ten of a par ent s an ger and of be ing pun ished can be ex plored, with the thera pist re ceiv ing the child s per - mis sion to codesign a dia logue of safe dis clo sure. This pro cess pro motes the child s self- agency, sense of efficacy, and re flec tive self- function. Fur ther, it cre ates a tem plate for fu ture conversa - tions be tween mother and child in ado - les cence and adult hood. It em bod ies the re la tional ap proach value that trauma - tized fam ily mem bers can self- right. It also suggests that a wider ap pli ca tion to other clini cal popu la tions (such as cou ple ther apy, where is sues of secrets, be tray als, and fear of aban don ment are ubiq ui tous) is pos si ble. We are for tu nate to bene fit from Shein berg and Fraen - kel s ex pe ri ence, wis dom, and good writ ing. This book de serves high praise and likely will be come a classic in the field. Suicide Comprehensive Textbook of Suicidology. Ronald W Maris, Alan L Berman, Mor ton M Sil - ver man, editors. New York: The Guilford Press; p. USD70.00 Isaac Sak inof sky, MD, FRCPC In the last year, at least 2 wide- ranging text books on suicide have be come avail - able from op po site sides of the At lan tic. TheCom pre hen sive Text book of Sui ci - dol ogy is a ma jor text among these works, pre sent ing us with the per spec - tive of sev eral mainly North Ameri can ex perts. The edi tors (and co authors of most of the chapters), Ron ald Maris, Alan Ber man, and Morton Sil ver man, are well- respected schol ars and suicide in ves ti ga tors who come from dif fer ent back grounds in so ci ol ogy, psychology, and psy chia try. In ad di tion to them - selves, they have com mis sioned other well- qualified ex perts from ap pro pri ate back grounds to deal with 10 of the 22 topic ar eas in this all- encompassing work, which cov ers the his tori cal, em - piri cal, and theo reti cal foun da tions of sui ci dol ogy; so cio de mo graphic and epi - de mi ol ogi cal is sues; medi cal and psy - chi at ric as pects; eth ics, phi loso phy, and the law; and treat ment and pre ven tion. Con cerned not to ex clude any as pect of

5 October 2001 Book Reviews 759 sui ci dol ogy even a fringe area they have in cluded an in ter est ing chap ter on risk- taking and in di rectly selfdestructive be hav iour by Nor man Far - berow (one of the origi nal Los An ge les pio neers who, with Shneid man and Lit - man, first put the sub ject of sui ci dol ogy on the North American map). This text sig nals sui ci dol ogy s coming of age as a unique field of knowl edge and sci en tific in quiry. In the early 1950s and 1960s, be fore Ed win Shneid man coined the term, and even through the early 1990s, psy chia trists did not regard the study of sui cide as a le giti mate dis ci - pline: they saw it only as a po ten tial sec - on dary out come of se ri ous men tal ill ness, to be ex plored in ci den tally to the men tal dis or der of in ter est. Al though psy cho logi cal autopsy in ves ti ga tions have ret ro spec tively con firmed that psy - chi at ric di ag no ses co ex ist in over 90% of sui cide cases, these di ag no ses cover the en tire gamut of psy chi at ric classifi - ca tion sys tems, with out speci fy ing causes. Even more im por tant, these di - ag nos tic find ings do not clar ify why par - ticu lar suf fer ers from men tal ill ness killed them selves while most did not con sider it. The field of sui cide studies qua sui ci dol ogy, at tempts to ad dress these ques tions spe cifi cally by examin - ing the phe nome non of sui ci dal ity as the pri mary ques tion of in ter est run ning hori zon tally across, and tran sect ing, the ver ti cal di ag nos tic axes. Sui ci dol ogy s strug gle for rec og ni tion has been long and hard; the dis ci pline is the re sult of a half- century of ex ten sive mul ti dis ci plin - ary re search. Not the least out come has been the relatively recent find ings in neu ro bi ol ogy by As berg, Mann, Stan - ley, and oth ers. The body of knowledge thus created has re cently en abled David Satcher, Surgeon- General of the US (a coun try with over sui cides a year), to prom ul gate a na tional strat egy for sui cide re duc tion. (Can ada, with 3500 sui cides a year and the re ports of 2 na tional task forces in 1987 and 1994, has yet to join other na tions and adopt a sui cide re duc tion strat egy simi lar to that of the US, the UK, or New Zea land.) This book is emi nently reader- friendly and at trac tive. The edi tors have set them selves to make it ac ces si ble and in - ter est ing to read ers from al most every back ground and to sat isfy both spe cial ist and gen er al ist in ter ests. Boxed texts in - cluded in the main body of each chap ter fo cus on cur rent con tro ver sies (such as whether se lec tive se ro tonin re up take in - hibi tors [SSRIs] cause sui cide and what treat ments work best for which cases). They are also used to set off dis cus sions of an ec do tal case ex am ples in a bio - graphi cal con text: the tragic suicide of White House coun sel and Clinton as so - ci ate, Vince Fos ter, is one of these. Of par ticu lar in ter est to psy chia trists will be the chap ters on psy chi at ric di ag no ses and per son al ity dis or ders, by Ca na dian Bryan Tan ney, on physi cal ill ness and sui cide, by Mark Gold blatt, and on alco - hol ism and other sub stance abuses, by David Lester. Well- covered by the pri - mary authors, the biology of sui cide is both com pre hen sive and com pre hen si - ble. It con tains use ful sec tions on the art and sci ence of pre scrib ing medi ca tion and on psy cho phar ma col ogy. Ap pro pri - ately, the fi nal chap ter deals with al le vi - at ing the pre dica ment and pain of those who sur vive the sui cide of a loved one. It may be the most im por tant chap ter in the book. This book is rele vant to the daily clini cal prac tice of medi cal prac ti tio - ners, psy chia trists, psy cholo gists, nurses, so cial work ers, and even cri sis vol un teers. It will also be a use ful refer - ence for policy- makers, the le gal pro fes - sion, and crimi nal jus tice work ers.