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The Centre Cannot Hold (My Journey Through Madness)

The global problem of substance abuse has been well documented, yet training and resource allocation in this area is often unsatisfactory. The WHO's Global Burden of Disease Study (1996) found that alcohol use was the fourth leading cause of disease burden, preceded only by cardiovascular disease, major depression and ischaemic heart disease – all of which can be exacerbated by substance abuse. Research quoted here shows that 14% of Americans are alcohol dependent, and substance abuse is estimated to cost the American economy more than $200 billion per year. There is a high prevalence of substance dependence in patients with psychiatric disorders and this is typically associated with a poorer prognosis. 
 
This book by two leading psychiatrists in the USA is aimed primarily at non-specialists in primary care and psychiatric practice. It appears to be particularly aimed at those clinicians who have become disheartened and pessimistic about the ability of their patients to recover in the longer-term. The authors are clearly passionate about their work and have produced a very readable and understandable overview of the biopsychosocial model of addiction and how to effectively recognise and treat addiction problems. 
 
A feeling of optimism permeates every section of the book. It begins by highlighting the rapid progress made over the past 20 years in scientific understanding of addiction. This is based very much on the theory of addiction as a disease of the brain, focusing on the dopamine-rich reward pathway. The authors effectively summarise the available scientific evidence for those not well-acquainted with complex neuroanatomy and neurochemistry. The book also neatly describes pathological psychological defence mechanisms employed by addicts such as denial. An understanding of these defences can help explain why these patients continue to engage in activities that are clearly harmful to themselves and others and can be used by the clinician to advance treatment. 
 
There follows a comprehensive section on identification and diagnosis of the different substance abuse problems. Useful screening questions and tools are provided and clinical vignettes are used to illustrate and further explain concepts. This earlier part of the book neatly summarises a large body of work in a readable fashion. This style is carried into the section on treatment, but I was left disappointed that there was not more detail in this area. The authors describe how to decide the intensity of care required and the appropriate treatment setting and how to effectively use motivational interviewing. Unfortunately there is considerably less information on cognitive-behavioural approaches and facilitation of twelve-step programmes. Brief interventions are described but again, not in a lot of detail, somewhat surprisingly given their increasing use in primary care. 
 
The chapter on pharmacological treatment effectively summarizes the evidence for Acamprosate, Disulfiram and Naltrexone in alcoholism, including details on these medications' modes of action and side effects. The use of substitute prescribing in opiate dependence is outlined, and a useful section in the appendix describes medication regimens that could be used in the management of alcohol and drug withdrawal, although some specific drugs and doses would appear to differ from local practice. The book concludes with chapters on nicotine dependence and specific challenges in treating substance abuse problems in the elderly and adolescents. 
 
This enjoyable and readable book will be of particular use to general practitioners, general medical physicians and general adult psychiatrists. It provides a useful introduction for those wishing to specialise in the field of addictions, but its brevity ensures that these individuals will also need to invest in other more detailed texts.