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THE THERAPIST’S GUIDE
TO PSYCHOPHARMACOLOGY
The Therapist’s Guide
to Psychopharmacology
WORKING WITH PATIENTS, FAMILIES,
AND PHYSICIANS TO OPTIMIZE CARE
REVISED EDITION
JoEllen Patterson
A. Ari Albala
Margaret E. McCahill
Todd M. Edwards
THE GUILFORD PRESS

New York London
© 2006; revisions © 2010 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in a retrieval system, or

transmitted, in any form or by any means, electronic, mechanical, photocopying,
microfilming, recording, or otherwise, without written permission from the Pub-
lisher.
Printed in the United States of America
This book is printed on acid-free paper.
As with every work dealing with science, the contents of this book are subject
to evolving standards and advancements. Being apprised of such changes and
advancements is an important part of the informed consent to which patients
are entitled. In addition, any summary treatment of a subject so complicated
can omit details such as rare or newly discovered but unconfirmed contraindi-
cations. Because medications should only be administered according to the
most current guidelines available, practitioners are strongly reminded to con-
sult and review carefully the product information sheets that accompany each
drug administered, in light of the patient’s history.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the stan-
dards of practice that are accepted at the time of publication. However, in view
of the possibility of human error or changes in medical sciences, neither the
authors, nor the editor and publisher, nor any other party who has been
involved in the preparation or publication of this work warrants that the infor-
mation contained herein is in every respect accurate or complete, and they are
not responsible for any errors or omissions or the results obtained from the use
of such information. Readers are encouraged to confirm the information con-
tained in this book with other sources.
Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data is available from the Publisher.
ISBN 978-1-60623-700-7 (paperback)

ISBN 978-1-60623-713-7 (hardcover)
For David.
For all that has been,
Thanks.
For all that shall be,
Yes.
(Dag Hammarskjold)
— J. E. P.
I dedicate this book to the memory of my parents,

Américo and Juanita, who showed me the love of learning;
to my wife, Barbara, who showed me the love of caring;
and to my children, Johanna, Keren, and David,
who every day show me what’s meaningful.
— A. A. A.
I dedicate this work to my wonderful children and their spouses;

my grandchildren, sister, brother, mother, and most especially
my dear husband. We are fortunate to have been blessed
with a deeply devoted and loving family, and I thank you all
for your work and commitment to keeping it that way.
—M. E. M.
I lovingly dedicate this book to my family, close and extended,

and especially to my wife, Kyle, and our children,
Grayson, Cole, and Quinn Edwards.
—T. M. E.
About the Authors
JoEllen Patterson, PhD, is a Professor in the Marital and Family Ther-

apy Program at the University of San Diego. She is also an Associate
Clinical Professor of Family Medicine and Psychiatry at the Univer-
sity of California, San Diego School of Medicine. Besides receiving a
Rotary International Scholarship to work at Cambridge University, Dr.
Patterson has had two Fulbright Scholarships to work in Norway and
New Zealand. She serves on the editorial board for Family Systems and
Health and the Journal of Marital and Family Therapy. This is her third
book.
A. Ari Albala, MD, received his medical education at the University of

Chile and the University of Tel-Aviv, Israel, and completed a psychiatry
residency and a research fellowship at the University of Michigan. He is
currently Clinical Professor of Psychiatry at the University of California,
San Diego School of Medicine, Executive Medical Director at Paradise
Valley Hospital Behavioral Health Services, and Medical Director at Psy-
chiatric Centers at San Diego. Dr. Albala has received numerous distinc-
tions in his career as both an educator and practitioner, including a
Teaching Excellence Award from the University of California, San
Diego; an Education Award from the San Diego Psychiatric Society; and
the status of Distinguished Fellow of the American Psychiatric Associa-
tion.
vii
viii About the Authors
Margaret E. McCahill, MD, is a Health Sciences Clinical Professor of

Family Medicine and Psychiatry at the University of California, San
Diego (UCSD) School of Medicine. Dr. McCahill has practiced both
family medicine and psychiatry in the U.S. Public Health Service/Indian
Health Service, at a U.S. Naval Hospital, as a university faculty member,
and in a free clinic that serves the homeless. She is the Founding Director
of the UCSD Combined Family Medicine–Psychiatry Residency Training
Program and the Medical Director of St. Vincent de Paul Village in San
Diego, California. Dr. McCahill has received many teaching awards as a
teacher of resident physicians for more than 20 years, and she also pro-
vides classroom instruction and practicum supervision for mental health
care trainees in clinical social work, marital and family therapy, and clin-
ical psychology.
Todd M. Edwards, PhD, is an Associate Professor and Director of the

Marital and Family Therapy Program at the University of San Diego. He
is also a Voluntary Assistant Clinical Professor in the Department of
Family and Preventive Medicine at the University of California, San
Diego School of Medicine. Dr. Edwards received his doctorate in mar-
riage and family therapy from Virginia Tech and completed a medical
family therapy internship in the Department of Family Medicine at the
University of Rochester.
Contents
Introduction 1
PART I. The Mind–Body Connection 11
CHAPTER 1. How the Brain Works 13

CHAPTER 2. How Psychotropic Drugs Work 23
PART II. Psychiatric Disorders and Their Treatment 29
CHAPTER 3. Mood Disorders 31

CHAPTER 4. Anxiety Disorders 79
CHAPTER 5. Schizophrenia and Other Psychoses 105
CHAPTER 6. Cognitive Disorders 128
CHAPTER 7. Alcoholism and Substance Abuse 144
CHAPTER 8. Special Populations and Situations 163
ix
x Contents
PART III. Creative Collaboration 207
CHAPTER 9. Focusing the Lens: The Referral Process 209

and Medication Evaluation
CHAPTER 10. Sharing Care: Building Successful 235
Collaborative Relationships
CHAPTER 11. Strengthening Bonds: Collaborating with the Family 248
APPENDIX A. How Drugs Are Developed 261
APPENDIX B. Future Trends 266
APPENDIX C. Professional Outreach 280
Glossary 283
References 291
Index 302
Introduction
Several years ago, we were supervising student therapists working in

community clinics. During the students’ case presentations, they would
frequently mention, almost as an afterthought, that their patients were
taking medication X. Being therapists, we knew little about psychotropic
medication.1 It was not our domain, after all. Instead, we refocused the
discussion onto the “important” material—the topics we understood.
At that time, “important” material could include the patient’s diag-
nosis, family problems, stressors, previous mental health history, or ther-
apeutic relationships. As clinicians, however, we prided ourselves on not
being wedded to one particular model, theory, or treatment protocol. We
were open to almost all material, as long as it pertained to the patient’s
psychological or social experiences.
At the same time that we were ignoring information about psycho-
tropic medication usage or biological history, there were increasing ref-
erences to medications in daily life. Reading book reviews (notably
Listening to Prozac [Kramer, 1993]), having friends and family members
who began taking antidepressants, and having our own patients asking
about medication as a treatment option, we soon realized that psycho-
tropic medication was a burgeoning approach to treatment. And to stay
1
Terms in boldface type are included in the glossary at the end of the book.
1
2 Introduction
current, we had to gain a rudimentary knowledge about these medica-

tions and how they were used, as did our students (Patterson &
Magulac, 1994).
EMBRACING THE “BIO” IN BIOPSYCHOSOCIAL
While espousing the biopsychosocial model in our work as therapists in

medical settings, we did not have enough knowledge of human biology,
genetics, and neuroscience to consider our patients’ biological influences
and needs. Regardless of our knowledge or interest, neurobiological
research was creating a revolution by offering treatments for psychologi-
cal disorders that sometimes involved simply taking a pill every morn-
ing. These new treatments were less intrusive than traditional, weekly
psychotherapy, and they were frequently being delivered by primary care
physicians, not psychiatrists. In addition, new research suggested that
psychotherapy could affect biological systems such as the brain (Kandel,
1995, 1998, 2006). These combined research initiatives demonstrated
that cause and effect within the biopsychosocial model is a multidirec-
tional process.
The biopsychosocial model was originally created for physicians, to
help them have a more balanced view of patients’ needs. Engel (1980)
suggested that the biomedical model was flawed because it ignored the
patient’s context and even the patient him- or herself. Instead, Engel sug-
gested that the organized whole (the patient), as well as the component
parts (the patient’s brain, immune system, family, etc.), should be consid-
ered. According to systems theory, every unit is at the same time both a
whole and a part. Nothing exists in isolation. Thus, physicians must
take into account not only the patient’s physical body and the disease
but also the patient’s reported inner experiences (feelings, sensations,
memories) as well as his or her reported and observable behavior.
Similar to the physician’s myopic view, we as therapists were
equally short-sighted. We focused on our patients’ experiences and feel-
ings to the extent that we ignored their biological systems. Not acknowl-
edging or understanding the importance of these systems meant that we
ignored possible treatment options that targeted them—that is, we
failed to consider psychotropic medications. And by failing to consider
psychotropic medications in treatment, we were possibly failing our own
patients.
Realizing that our therapeutic knowledge had to expand if we were
going to truly follow a biopsychosocial model, we learned everything we
could about medications and started encouraging our students to do the
Introduction 3
same. Textbooks for nonphysicians about psychotropic medications

were published (Beitman, Safer, Thase, Blinder, & Riba, 2003; Gitlin,
1996; Riba & Balon, 1999; Sammons & Schmidt, 2001). Courses about
neurobiology, medications, and genetics were added to mental health
training programs. A paradigm shift was occurring: the dissolving of
mind–body dualism.
However, this revolution in the academic mental health community
did not necessarily lead to better patient care. Although we could
explain the basic neurobiological mechanisms of medications, we could
not get our patients to keep taking them if their spouses did not like the
way the patients’ sex drive was affected, if the medications made the
patients gain weight, or if the medications were taken off an insurance
company’s reimbursed medications list. The books we collectively read
on combining psychotherapy and medications or simply educating
nonphysicians and patients about medications led us to believe that pro-
viding knowledge to mental health professionals would be enough to
create change. This assumption was not true. In addition, there was vir-
tually no communication between the prescribing physician—regardless
of his or her medical discipline—and the therapist. And family members,
who may be most affected by patients’ responses to medication, were
completely ignored. The impact of payors, employers, health care system
providers, and others was never mentioned along with the discussion of
the neuromechanisms of the medications. But these impediments were
the everyday challenges that we faced with our patients. Even if our
patients were open to the idea of medication, structural impediments,
especially the lack of communication between the prescribing physician
and the therapist, limited the medications’ effectiveness.
Engel (1980) had originally focused on the biological, psychologi-
cal, and social systems of his patients. But we were discovering that
other systems were also affecting the care we could offer. The organiza-
tional and financial structures of the health care systems, as well as the
divisions among the different mental health disciplines, meant that
patient care was often fragmented and uncoordinated.
THE COLLABORATIVE CARE MOVEMENT
At the same time that we were struggling with these issues, there was a
growing movement in health care that had as its goal the collaboration
of physicians and therapists in assessing, planning, and providing patient
care. A growing group of health professionals had been attempting to
repair both the fragmentation in health care services and the conceptual
4 Introduction
split between mind and body. In fact, there were already several organi-
zations and groups devoted to this model of care, especially in the
United States, Canada, the United Kingdom, and Australia.
Defining Collaborative Care

Collaborative care has many definitions. It does not refer to split care,
which usually implies that the physician treats the biological part of the
patient by prescribing medication, and the therapist does the rest.
Although split care may be attractive in terms of cost and ease for the
provider, it is inadequate care. Patients need their therapist and physi-
cian to communicate, particularly in the creation and maintenance of a
treatment plan.
Collaboration also differs from consultation. Consultation implies
an event rather than a process. It is possible that a psychiatrist, for
example, could conduct an evaluation and offer suggestions without
prescribing medication, which may negate the need for ongoing contact.
However, in most cases, the physician ideally becomes a treatment team
member, not simply a consultant who offers expert advice and disap-
pears.
One definition of collaboration is “the concurrent use of medical
and mental health services” (Roesler, Gavin, & Brenner, 1995). Al-
though this definition is absolutely correct, it obscures the diversity in
how collaborative treatment is delivered. Collaboration can include
phone calls, hallway discussions, exchanges of letters, participation by a
physician—primary care or otherwise—in part or all of a therapy ses-
sion, and meetings that involve all professionals, the patient, and his or
her family. Nor does this definition suggest the difficulty in practicing
collaboratively. Even with good intentions to “work together” and
“share care,” good collaboration is hard work.
Several excellent works on collaboration have been published
(Blount, 1998; Doherty & Baird, 1983; Seaburn, Lorenz, Gunn, Ga-
winski, & Mauksch, 1996). Doherty (1995) developed a model that
defines five levels of collaboration. The levels range from minimal col-
laboration, in which professionals work in different sites and rarely
communicate about a case, to close collaboration in a fully integrated
system, in which professionals from different disciplines practice in the
same site and hold team meetings regularly to discuss collaboration
issues. For most physicians and therapists, level 5 is more of a dream
than a reality. Because of the structure of health care today, most profes-
sionals probably practice at levels 1 or 2.
Introduction 5
If levels 3 or 4 are not possible for therapists because of the location

of their practice, we advocate a model that is a modified version of level
2, which we call “close collaboration at a distance.” Such a model pro-
vides health care services that focus on coordinated assessment and
treatment by providers from different disciplines, so that all aspects
of the patient’s health—whether biological, psychological, spiritual, or
social—can be addressed. Successful collaborative care presumes shared
treatment planning and decision making by interdisciplinary teams.
Shared care over time and across disciplines results in comprehensive
care. Although the primary focus is on the integration of biomedical
problems and mental health problems, all variables related to the
patient’s quality of life are considered, most notably the patient’s family.
The importance of family in both treatment and the collaborative effort
is highlighted later in the text. Under the collaborative model, there are
regular interactions to discuss patients and an appreciation for each
other’s professional culture (Doherty, 1995).
Although lofty in its expectations, in practice this model provides
the best possible care for patients and their families. Sharing care also
decreases the isolation that therapists and physicians commonly experi-
ence, which can further complicate the work with complex patients.
Sharing responsibility for managing mental health crises, generating
fresh ideas, expressing frustration, and carrying the emotional burden of
serving these patients are only a few of the benefits that such care pro-
vides to the professional.
Collaborative Care: An Integrated Conceptualization

As clinicians, we were beginning to understand that a collaborative care
model addresses gaps and fragmentation in the health care delivery sys-
tem. It means that we do not have to know every fact about every system
that might affect the patient’s care. Instead of viewing ourselves as the
sole deliverers of treatment, we have become the purveyors of possibili-
ties in a system that extends beyond our own personal limitations, in
addition to offering the patient our clinical expertise.
All treatment options are equally plausible, regardless of whether
we can deliver the treatment ourselves. We might provide the treatment,
or we might serve as a conduit of information and resources so that our
patient can receive the best possible care. When psychotropic medica-
tions are used, we consider their impact beyond the patient’s biological
system. In a collaborative care model, it has become our job to under-
stand the impact that psychotropic medications could have on the
6 Introduction
patients and their families, at home or in their work environment, even

though as therapists we do not deliver the medication ourselves.
TRENDS IN MENTAL HEALTH CARE
We have also been reading about important trends in patient care such
as the following:
• The U.S. Surgeon General declared that ensuring that treatments

were available (minus problems of access) for patients with
depression was a more significant problem than developing more
efficacious treatment.
• There was a marked increase in the proportion of the population
who received outpatient treatment for mental health problems,
but this care was often provided by primary care physicians.
• There was greater involvement of physicians in patient mental
health care and greater use of psychotropic medications.
• Over one-half of all patients who were prescribed psychotropic
medications failed to complete the treatment course.
• With the exponential growth of the Internet, there was a dra-
matic increase in the use of self-help groups.
• Also, many patients used multiple venues to treat their mental
health problems—self-help groups, human services (school coun-
selors and ministers), primary care, and specialty mental health
services.
• In general, this care was uncoordinated (Kessler, Zhao, & Katz,
1999; Olfson et al., 2002).
It has become clear that training in collaborative care and the develop-
ment of supportive systems are essential initiatives if future patients are
going to receive optimal care. We have realized that we have to train our
students not only in traditional practice and technique but also in the
principles of collaborative care. We also have to play a part in building
support for collaborative care models within health care systems.
PREPARING THE NEXT GENERATION OF THERAPISTS
Despite our immersion in the collaborative care movement, we were

doing training as usual in our family therapy master’s program. That is,
we were training future therapists to work independently, using the tools
Introduction 7
that we gave them, including theory and popular treatment techniques.

At best, working with other colleagues meant providing a referral for
some special treatment, such as psychological testing.
Eventually my colleagues and I realized that our training models
would no longer work. Using the ideals of the collaborative care move-
ment, we began creating new treatment goals. Believing that psycho-
tropic medication could be an essential treatment and that many of our
patients would be obtaining medication from their physicians, we con-
sidered what new knowledge future therapists (our students) would
need.
We began experimenting with collaborative care models of patient
care and thinking about how to train students in their use. The four of
us—two psychiatrists and two family therapists—began to share patient
care. That is, we began to provide joint clinical supervision to family
medicine residents and family therapy interns, and we began to teach
each other’s students.2
This book is the result of our collective search for better ways to
care for patients with mental health problems. Its purpose is to provide
the information a non-MD therapist needs to know about psychotropic
medication and collaborative care. It is intended for nonprescribing cli-
nicians who work in mental health. We wrote it with two objectives in
mind: to give readers a basic sense of pharmacotherapy for various men-
tal health disorders, and, more important, to provide a conceptual
framework, a mind-set, and specific approaches for working in a collab-
orative care environment with medical professionals who do prescribe
psychotropics.
Many books about psychotropic medications have been written for
psychotherapists, and some recent books discuss split treatment models.
As clinicians we found that these books, although helpful, did not meet
our needs. We recognized that there are many effective treatments,
including combined therapy and medications. However, many of these
treatments never reach the people who need them most. We became
increasingly interested in the efficacy of the delivery of mental health ser-
2
For example, in a specific week, Dr. Albala and Dr. Patterson might exchange e-mails
about a shared patient, jointly conduct live supervision for family medicine residents who
are interviewing challenging patients; Dr. Albala might lecture to Dr. Patterson’s students
about basic antidepressant medication.
Dr. Edwards and Dr. McCahill might meet to talk about further developing treatment
protocols at the collaborative clinic they are developing and might engage in a problem-
solving session to figure out ways to help their homeless, indigent patients get access to
appropriate care, including medication.
8 Introduction
vices. What obstacles exist for the typical clinician and patient who seek
optimal treatment?
Our goal in this book is to provide basic scientific information
about psychotropic medications and, even more important, to offer
pragmatic advice on helping patients benefit from these medications.
Although there are many potential concerns, such as a family’s response
and insurance issues, we believe collaboration is the cornerstone of effi-
cacy.
There are many models of care in addition to the psychotherapist–
physician collaboration. For example, there is a movement to provide
psychologists with prescription-writing privileges. As reported by the
American Psychological Association (2002), New Mexico was the first
state to give psychologists prescription-writing privileges, followed by
Louisiana. Some psychiatrists suggest that it is cost-effective for the psy-
chiatrist to provide both medication and psychotherapy, thus eliminating
the need for a nonphysician provider. In addition, some patients do not
want therapy and simply seek medication from their primary care pro-
viders. Other patients would never consider medication and seek therapy
only. Finally, some people seek informal help only through Internet
searches or talking to a friend, member of the clergy, or human resources
employee.
This book does not focus on these other treatment modalities. It
simply focuses on a non-MD therapist and a physician working together
to care for their common patient. However, the non-MD therapist could
be a psychologist, a social worker, a marriage and family therapist, a
psychiatric nurse, or a counselor. When we refer to physicians, we could
mean a family physician, a psychiatrist, an internist, a pediatrician, or an
obstetrician–gynecologist. To simplify matters, we refer to “the thera-
pist” and “the physician” throughout this book. This book is primarily
intended for therapists who want to build collaborative relationships
and learn the biological information they need to communicate with
physicians.
In writing this book, we made a few assumptions:
1. We want this book to be theory-neutral. Each model and every

therapist makes unique contributions to the therapeutic process. You
might be an expert in cognitive-behavioral therapy, family systems the-
ory, interpersonal therapy, or another model; your expertise is a critical
component of healing. However, because we assume that you already
have expertise in some type of psychotherapy, that is not the focus of
this book.
Introduction 9
2. Rather, we assume that you want to improve your collaborative

relationships with physicians. We suggest you can do this by knowing
more about psychotropic medications and how they work in the brain.
3. In addition to promoting more collaboration with physicians, we
also advocate for more family involvement in health care. We urge you
to think about not only your individual patient but also his or her fam-
ily. This need became strikingly clear to us when a seriously depressed
mother went to her primary care doctor because she “didn’t know what
else to do.” She had seen several mental health professionals during the
last year, yet none of their treatments had helped her. The physician
enlisted the aid of an on-site therapist, and they interviewed the patient
together. Fifteen minutes into the interview, it became clear that the
patient was a single mother of a 6-year-old and an 8-year-old. She tear-
fully reported that the 8-year-old had taken on all household responsibil-
ities: walking her younger brother to and from school, preparing all
meals, and doing all the shopping and other “parenting” responsibilities
that the mother could not do—given that she could not get out of bed
most days. The patient reported that she had never given this informa-
tion to any other health care professionals simply because none had
asked. Often, health care professionals are focused only on the individ-
ual patient who is present during the interview. As a result, they can miss
important information about other family members and the repercus-
sions of the problem throughout the entire family.
4. Some readers, particularly those already trained in neuroscience
and biological treatments, may find specific parts of this book too sim-
plistic. We have tried to write the book so that you can skip the parts
that are not helpful and turn instead to the sections that offer new infor-
mation. You may find the chapters on collaboration or the appendices
especially useful.
5. We assume that you are pressed for time, that the physicians you
work with are pressed for time, and that the payors (including employers
and insurance companies) want the patient to get better as quickly as
possible. The physicians you work with might have little knowledge or
interest in your contribution to the shared treatment—namely, the ther-
apy. They may even have little time or interest in working or communi-
cating with you. Although it is helpful if both professionals share a com-
mitment to collaborative care, it is not essential.
6. Biological treatments are changing at a rapid pace, and this book
can quickly become dated. Thus, we have tried to write in terms of gen-
eral ideas or principles. In general, we talk about classes of medications,
not specific drugs. In addition, we talk about the process of how drugs
10 Introduction
are created and tested. We know that you need to find your own meth-
ods of staying abreast of trends in psychopharmacology and collabora-
tive care. We hope this book serves as one foundation for the ongoing
process of learning about biology, neuroscience, psychotropic medica-
tions, and collaborative care.
We now narrow our focus to the information you need to effectively

collaborate with your medical colleagues. That information includes the
following:
• Basic neuroscience information on how the brain works and how

drugs affect the brain.
• The biomedical information that you need to understand about
psychotropic medications, one of the key treatments the physi-
cian might utilize. This is organized by specific disorders.
• An action plan for building collaboration: For example, we dis-
cuss what a therapist might consider when deciding to refer a
patient to a generalist physician or a psychiatrist. The basics ten-
ets of collaborative care are discussed (beyond collaborating
about the patient’s psychotropic medication). Whether you are
currently in a private practice or in a hospital-based interdisci-
plinary team, this section provides tools to enhance collabora-
tion.
We recognize that your professional experiences may be signifi-

cantly different from ours. But we surmise that you share some of our
frustrations as we try to provide excellent care in a rapidly changing
health care world. Your training may not have provided all of the tools
you need for optimal care, and you may be frustrated with the limits of
your work setting. We hope this book supplies some knowledge and
ways to help you overcome the limits you have faced in caring for your
patients.
PART I
The Mind–Body Connection
In this section, we discuss some basic concepts about how the

brain works and how psychotropic medications affect it. We
believe you should have some understanding of these issues for
four reasons:
1. To further develop your understanding of the biological

component in the biopsychosocial model. You will more readily
include biological issues in your thinking about your patients if
you know some specifics about the brain’s biology. And with that
knowledge, you will probably better understand the later chapters
on specific disorders and medications.
2. To help you communicate with physicians. The physicians
you collaborate with, by training, have a detailed and sophisticated
understanding of these issues. You will be better able to under-
stand and talk with them if you are familiar with terms like “neu-
rotransmitter,” “serotonin,” and “anticholinergic.”
3. To help you explain medications to patients and family
members. Some patients may feel more comfortable taking their
medications if they understand a little bit about what the drugs do.
Although the prescribing physician is the ideal person to provide
11
12 THE MIND–BODY CONNECTION
this information, not all physicians have the time or inclination to

discuss basic biology with their patients. It will often strengthen
your relationship with your patients and their confidence in your
collaboration with their physicians if you can answer some of their
questions and help them understand the information their physi-
cians give them (within the limits of your professional scope of
practice and personal knowledge). You may also find that educat-
ing your patients about their brain biology can provide them with
more productive ways to think about their medications—for exam-
ple, by replacing “I must be crazy if I need to take drugs” with
“My brain doesn’t make or use enough serotonin for it to function
at its best, but my medication can correct that problem.”
4. To improve your assessments. In contrast to the physician’s
view, you may have a differing opinion about the importance of
using the Diagnostic and Statistical Manual of Mental Disorders
(DSM) criteria as the primary means to assess and treat the patient.
Most physicians rely on the DSM criteria to make a diagnosis.
Their specific diagnoses often lead, naturally, to specific psycho-
tropic medication recommendations. In this way, assessment by a
physician may be more specific and, at times, more reductionistic
than an assessment by a therapist, who, for example, might prefer
a narrative of the patient’s complaints.
These viewpoints are not mutually exclusive, and in fact they

can be complementary. Physicians often need the therapist to pro-
vide a set of symptoms and also offer a holistic perspective on the
patient’s situation. Problems can occur when either professional is
wedded to a singular perspective, especially if the patient is con-
fused by two differing providers. We hope that basic information
on a biological perspective will help you understand the physician’s
unique contributions to your patient’s care.
Depending on your training and clinical background, the
information in this section may be familiar, or it may seem like a
foreign language. We have written it for the latter, the person
whose last foray into biology may have been a dimly remembered
high school class. On the other hand, if you already know this
information and have developed effective ways of communicating
it to patients, feel free to skip this section. We leave it up to you to
decide how this book can be most helpful.
CHAPTER 1
How the Brain Works
THE HUMAN BODY

. . . for I am fearfully and wonderfully made.
—PSALMS (139:14)
As we see ourselves and each other, alive and vivacious, we witness an

incredible principle in action: that of the preservation of homeostasis,
the tendency of a living organism to maintain balanced, constant condi-
tions in its internal environment. For example, if we drink too much
water, our kidneys will help preserve the balance in our internal environ-
ment by having us pass that extra water out as urine. Millions of checks
and balances are going on at every moment in a human body, and all of
the body’s components must be healthy for it to go exactly right. When a
body is ill, some of the compensatory mechanisms are not working well,
and, for example, there may be a fever, diarrhea, diabetes, high blood
pressure, or mental illness. If the attack on the body (or its deterioration)
is severe enough to overwhelm its compensatory mechanisms, homeosta-
sis cannot be preserved and the body dies. The preservation of homeo-
stasis is essential to the continuation of life. Medications used to treat
various maladies often affect the homeostatic compensating mechanisms
in the body, and we always hope that the medications’ influence is for
13
the better. When we treat mental illness, whether through therapy and/or
medication, we are attempting to assist in the brain’s and the body’s ten-
dency to restore homeostasis and healthy functioning.
CELLS, ORGANELLES, NEUROTRANSMITTERS, AND RECEPTORS
The basic building block of the human body is the cell, and a typical
adult has approximately 100 trillion cells. Each cell has an outer enve-
lope, or cell membrane, and a nucleus (see Figure 1.1).
That cell membrane is very complicated, governing what gets into
and leaves the cell, among many other tasks. The nucleus contains all of
the genetic information (DNA or genes) to tell the cell what to do and
how to make its contribution to the homeostasis of the total body. Cells
(e.g., neurons) are organized into organs (e.g., the brain), which are
organized into systems (e.g., the central nervous system, or CNS). At
every level of organization in the body, each cell, organ, and system has
one priority: maintain homeostasis; keep the balance that is essential to
survival.
FIGURE 1.1. The anatomy of a cell. Illustration copyright 2004 by James P.

McCahill. Used with permission.
How the Brain Works 15
Many tiny structures reside in the cytoplasm (the liquid interior) of

the cell; these organelles are responsible for making proteins and other
substances that enable the cell to do its job. Other organelles (mitochon-
dria) provide energy to other cell parts. Without healthy mitochondria,
cells cannot function. For example, in a nerve cell (a neuron; see Figure
1.2) there are components that make chemicals called neurotransmitters,
which allow one neuron to transmit an impulse to another.
FIGURE 1.2. The neuron, or nerve cell. Illustration copyright 2004 by James P.
McCahill. Used with permission.
The presynaptic neuron makes the neurotransmitters, puts them

into little sacs called vesicles, and moves the filled vesicles to the cell
membrane in order to secrete or dump the neurotransmitters out of the
neuron into the right place at the right time. The right place is a tiny
space between one neuron and another, called a synapse (Figure 1.3),
and the right time is when the neuron wishes to activate or inhibit its
neighbor neuron.
The postsynaptic neuron receives the neurotransmitter when the
neurotransmitter engages a receptor site on the neuron’s cell membrane.
Each type of neurotransmitter will react with one specific type of recep-
tor site and no other, similar to a lock and key. But it would not do to
just let neurotransmitters sit there in the synapse causing unending activ-
ity, so there are other components in presynaptic neurons that take the
extra neurotransmitters in a particular area back into the cell (this is
called reuptake). Sometimes the neurotransmitters that have been taken
back are broken down in the presynaptic neuron (by enzymes, such as
monoamine oxidase, or MAO), and then are recycled in the vesicles for
later use. There are at least 40 different chemicals that have been shown
to act as neurotransmitters; some of the most common are listed in
Table 1.1.
FIGURE 1.3. The nerve synapse. Illustration copyright 2004 by James P. McCahill.
Used with permission.
TABLE 1.1. Some of the Most Common Neurotransmitters
Medications used to influence this
Neurotransmitter Function/biology Disorder if malfunction neurotransmitter
Acetylcholine Usually excitatory, except for some A complex, diffuse symptoms Very diffusely affected by many medications.
parasympathetic nerve endings affecting all bodily systems. This is In particular, antihistamines, anti-Parkinsonian
where it is inhibitory (such as the a complex, widespread drugs, and medications for dementia affect
effect on the heart by the vagus neurotransmitter, the receptor sites this system, as do numerous medications for
nerve). Secreted by many neurons, of which are affected (usually general medical conditions. Many psychiatric
including those in the motor area adversely) by some psychotropic medications have side effects that occur
of the brain, basal ganglia, skeletal medications (anticholinergic side because of their influence on the acetylcholine
muscle motor neurons, all effects). receptors.
preganglionic autonomic nervous
system neurons, all postganglionic
parasympathetic neurons, and
17
some postganglionic sympathetic
neurons.
Dopamine Usually inhibitory. Secreted by Disorder in the dopamine system Diffusely affected by many medications.
neurons in substantia nigra onto has been hypothesized to be Antipsychotic medications and some
neurons of the basal ganglia, both important in psychotic disorders, antidepressants have some dopaminergic
subcortical areas of the brain. and many antipsychotic effects; certain medications, used for general
medications work on dopamine medical conditions also affect dopamine
receptors, of which there are receptors.
several subtypes. affects
cardiovascular system and has
other widespread effects.
(continued)
TABLE 1.1. (continued)
Medications used to influence this

Neurotransmitter Function/biology Disorder if malfunction neurotransmitter
GABA (gamma- Inhibitory. Secreted by neurons in Anxiety states, also involved in Diffusely affected by many medications. Many
aminobutyric the cerebral cortex, subcortical chemical dependency. antianxiety medications work on GABA
acid) area, and spinal cord. receptor sites, especially in the frontal lobe of
the brain. Alcohol, benzodiazepines, and
barbiturates all affect GABA receptors, as do
other drugs.
Norepinephrine Mostly excitatory, but inhibitory in Diffuse and widespread symptoms, Diffusely affected by many medications.
some areas. Secreted by neurons in including depression, changes in Several antidepressants work specifically on
the locus ceruleus (subcortical blood pressure, heart rate, and this neurotransmitter and its receptor sites.
18
area) to widespread areas of the diffuse physiological responses, Many medications for general medical
brain, controlling wakefulness, among many others. An important conditions affect this neurotransmitter as well.
overall activity, and mood. Also transmitter in the sympathetic
diffusely secreted in the branch of the autonomic nervous
sympathetic nervous system. system.
Serotonin Usually inhibitory; helps control Diffuse and widespread symptoms: The selective serotonin reuptake inhibitors
mood, influences sleep, and depression, headache, diarrhea, (SSRIs), the most commonly used
inhibits pain pathways in the constipation, sexual dysfunction, antidepressants, work specifically on this
spinal cord. Secreted by subcortical and other medical symptoms. neurotransmitter system.
structures into hypothalamus,
brain, and spinal cord. There are
many subtypes of serotonin
receptors.
Also important in understanding the function of the nervous system

are the one-way flow of information across synapses and stimulatory
versus inhibitory impulses Most synapses in the CNS will conduct an
impulse (usually via a neurotransmitter) in one direction only; that is,
from the axon of the presynaptic neuron to the dendrite or cell body
(soma) of the postsynaptic neuron (see Figures 1.2 and 1.3). This
unidirectionality is critical in preserving the integrity of the information
flow in the CNS. A particular postsynaptic neuron will have anywhere
from 10,000 to 200,000 terminals, or receptor sites, that interact with
presynaptic neurons. These terminals are activated by neurotransmitters.
Activating some terminals will cause the postsynaptic neuron to fire an
impulse to its neighbor neurons. When other terminals are activated, the
same postsynaptic neuron will be especially quiet and will not fire off
any impulses. This concept of stimulation versus inhibition and inhibi-
tory impulses from one neuron to another is key in our discussion of
mental illness and its treatment.
In sum, most of the words in boldface type above represent areas of
active research and knowledge about how medications are used to treat
mental illness. How synapses function, the types of receptor sites, the
secretion of neurotransmitters from vesicles, the reuptake process, the
MAO inhibitors, and the process of neuron inhibition are all referred to
often in the chapters on mental illness and psychopharmacology.
ORGANIZATION OF THE HUMAN NERVOUS SYSTEM
There are approximately 100 billion nerve cells, or neurons, in the

human body. They are organized into peripheral nerves; the ANS; and
the CNS, which includes the spinal cord, subcortical brain, and cerebral
cortex.
The peripheral nerves in the various regions of the body, such as
hands, arms, legs, the torso, and so forth, come in two types: those that
send information to the spinal cord about what is going on (sensory neu-
rons) and those that carry orders from the spinal cord and brain telling
the body part to move or do something else (motor neurons). Depending
on how important the sensory information is, it may or may not be sent
up from the spinal cord to the brain. The sense of pressure of your shirt
on your skin is not considered important, and the brain is typically not
bothered with that information. If you are in a conversation, your brain
is generally focused on that and does not pay attention to the ventilation
fan that may be running in the background. In fact, more than 99% of
incoming sensory information is screened out by the CNS (spinal cord

and brain) as not being significant enough for the higher parts of the
brain (the cerebral cortex) to focus on. This important skill is called sen-
sory gating, and it is severely impaired in some patients who suffer from
a psychosis. Touching a hot flame is very important, much too impor-
tant to waste time sending it to the brain to think about before acting. So
the spinal cord sends a reflex message via the motor nerves to get the
hand out of the flame, then tells the brain later. The brain then tells the
mouth to say “ouch!” and maybe other things.
The ANS governs life-sustaining functions that are critical and too
complicated for the CNS to spend time on. If we had to think about how
fast our heart should beat minute to minute, how high our blood pres-
sure should be, or when the sandwich we ate for lunch is ready to move
from the stomach to the small intestine, we would be too busy to do
anything else. So the ANS controls all of these activities. It is divided into
two parts: the sympathetic nervous system and the parasympathetic ner-
vous system. Some effects of the sympathetic versus parasympathetic
stimulation on various organs are listed in Table 1.2.
In general, sympathetic system activity usually has a multiorgan
impact, such as the fight-or-flight response. On the other hand, the para-
sympathetic system usually causes a focused response of a particular
organ—for example, emptying the bladder (a very complex affair)—
without causing other organs or systems to be affected. Each of these
systems uses different neurotransmitters. The sympathetic nervous sys-
tem secretes norepinephrine primarily, and the parasympathetic nervous
system secretes acetylcholine. When we talk about medications used to
treat mental illness, we will refer to anticholinergic side effects of some
TABLE 1.2. Some Effects of Sympathetic and Parasympathetic Stimulation on Various

Bodily Organs
Organ Sympathetic stimulation Parasympathetic stimulation
Eyes—pupil Dilated Constricted
Eyes—focus Relaxed (distance vision) Constricted (near vision)
Heart Increased heart rate Decreased heart rate
Increased contraction force Decreased contraction force
Gut Decreased food movement Increased food movement
Increased tone of muscles Mostly relaxed muscle tone
Bladder Hold urine Void urine
Penis Ejaculation Erection
drugs, which are those side effects that interfere somehow with the nor-
mal function of the parasympathetic nervous system. A medication that
causes anticholinergic side effects would be expected to cause blurry
vision, dry mouth, heart rate disturbance, constipation, and difficulty in
voiding urine, among other symptoms.
The CNS includes the spinal cord (which deals with basic reflexes,
walking movements, and control of information to and from the brain),
the subcortical brain (which deals with such matters as coordination;
balance and equilibrium; wakefulness; respiration and heart rate; and
basic emotions such as anger, excitement, sexual response, and response
to pain and pleasure), and the cerebral cortex (which receives sensory
input; controls motor functions; and deals with higher functions of
thinking, memory, integration of information, learning, and executive
function (see Figure 1.4).
The cerebral cortex is a large memory storehouse, and it is essential
for thought processing. However, it relies on the subcortical brain cen-
ters to keep it awake, focused, and free of distracting stimuli and tasks.
The medications that we use to treat mental illness work in the synapses
FIGURE 1.4. The brain, brainstem, and upper spinal cord. Illustration copyright
2004 by James P. McCahill. Used with permission.
of both the cerebral cortex and subcortical levels. They also go every-
where else in the body, however, and they have effects, usually referred
to as side effects, in many other organ systems.
Modern psychopharmacology works by delivering chemical com-
pounds to the neurons of the brain and the synapses that will alter the
activity in those synapses. Research suggests that some drugs work by
one or more of the following mechanisms:
• Increasing the amount of neurotransmitter produced by pre-

synaptic neurons and released into a synapse.
• Blocking the reuptake of a neurotransmitter from the synapse.
• Binding to the receptor site on the postsynaptic neuron, disabling
the activity of the neurotransmitter present in the synapse.
• Inhibiting the enzymes that break down neurotransmitters.
• Changing the sensitivity of postsynaptic neurons to neurotrans-
mitters.
CHAPTER 2
How Psychotropic
Drugs Work
Why can suddenly stopping some antidepressants result in withdrawal

symptoms, yet stopping others does not? Why should some medications
be taken on an empty stomach? Why is the status of the liver important
for some medications, whereas kidney function is relevant for others?
Why do some psychotropic medications have noticeable effects minutes
to hours after ingestion (e.g., the antianxiety benzodiazepines), whereas
others (e.g., antidepressants) take days or weeks for their effects to
become apparent? The answers to these questions lie in several pharma-
cology factors, especially (but not restricted to) pharmacokinetics and
pharmacodynamics. Medications differ in the way they are processed
once inside our bodies. They also differ in the way they affect our bod-
ies. These differences confer unique pharmacological “profiles” that
make medications produce a unique set of clinical characteristics. When
physicians—who more often than not have several medications to
choose from for a particular disorder—select a drug, they consider all
these characteristics and attempt to match them to the specific needs,
sensitivities, and preferences of each individual patient. The purpose of
this deliberate decision-making process is to offer the patient an optimal
risk–benefit ratio. That is, the goal is to select a medication that will pro-
duce the strongest possible therapeutic effect with the fewest possible
negative side effects.
23
HOW THE BODY HANDLES DRUGS: PHARMACOKINETICS
The ultimate target for psychotropic drugs is the brain—in fact, specific
areas in the brain. Ideally, clinicians would be able to deliver a drug to
the desired target and only to that target. This, of course, is not possible,
at least not at the current level of clinical biotechnological development.
Drugs must use a rather nonspecific method of “public transportation”
to reach the brain: the bloodstream. Drugs transported by our blood-
stream do make it to the intended targets. Unfortunately, they also reach
many unintended areas in the brain, as well as elsewhere. This process,
known as distribution, will be affected by various factors, including
characteristics of the drug. Side effects usually result from this lack of
specificity in the delivery system. But first, drugs must reach the blood-
stream, and they do so through a process called absorption. Different
routes can be used: swallowing a pill is the most common. The pill is dis-
solved in the stomach or in the intestines, a phenomenon mediated by
specific “juices” that prepare the drug to cross the microscopic pores
that allow entry into the bloodstream. Certain properties of a particular
drug will result in faster or slower absorption and, as a result, increase
or decrease the time required to reach an appropriate concentration of
the medication in the bloodstream. The presence of food in the stomach
may, in some cases, interfere with the speed of absorption. Conversely,
certain drugs have an irritating effect on the lining of the stomach that
may lead to adverse consequences, namely, inflammation and pain.
Thus, some drugs have instructions to “take with food” and others have
instructions to “take on an empty stomach.”
In certain clinical situations, we want the beneficial effect of the
drug to occur as quickly as possible. For example, an acutely agitated or
anxious patient must be given relief very quickly, so getting the drug into
the bloodstream as quickly as possible would be of great benefit. For
these situations, certain drugs may be given parenterally—that is, via
routes other than the digestive system—such as intramuscular injections
of antianxiety or antipsychotic drugs. Intravenous injection of a drug
delivers it directly into the bloodstream, causing an immediate effect.
Another way to get a drug into the bloodstream quickly is inhala-
tion. In fact, the short time between the inhalation and the desired effect
can sometimes be exploited, with hazardous consequences, as with rec-
reational drugs. For example, nicotine and cocaine, which are very
quickly absorbed through the nasal mucosa and the lung tissue, reach
the brain in a matter of seconds. Other routes and techniques may be
used to deliver drugs to the brain in a controlled fashion. Injections
directly into the spinal fluid may be used for certain neurological condi-
How Psychotropic Drugs Work 25
tions. Other drugs, after being administered, are released very slowly
over a period of days or weeks. Certain antipsychotic preparations (i.e.
haloperidol [trade name Haldol], fluphenazine [trade name Prolixin],
and risperidone [trade name Risperdal Consta]) can be injected intra-
muscularly, and they are formulated to release the drugs over a period of
several weeks. This “depot” method of administration can provide an
essential, consistent baseline concentration of medication for patients
who otherwise would not take their medications reliably on a daily
basis. Slow-release patches applied to the skin also enable the gradual
absorption of certain medications. Nicotine patches, for example, have
become useful aids for smoking cessation programs. Selegiline (trade
name Emsam), a patch-based antidepressant, has recently been released
for clinical use.
Once a drug is in the bloodstream, it is subjected to various factors
that can influence how much of it will get into the brain. Some drugs
have great affinity for fatty tissue and will be retained in areas of the
body where such tissue is in abundance. Such medications need to be
taken in higher doses in order to achieve therapeutic concentrations in
the blood. Some drugs become tightly bound to proteins found in the
bloodstream. For these drugs, part of the administered dose is just bal-
last (we also call it a “loading dose” in medical terms) since the protein-
bound fraction of the ingested medication will not reach the brain.
If a second medication is added—whether for psychiatric purposes
or for a concurrent medical problem—there is always the possibility of
drug interactions. If the new medication is highly protein-bound, it can
compete for the proteins occupied by the first medication and in fact dis-
place some of it, which then becomes free in the bloodstream. Effec-
tively, the concentration of the first medication is now larger, so more of
it reaches the brain, with potentially toxic results.
If, following absorption, medications were undisturbed by the body,
we would need to take only one dose for an eternal effect. Of course,
this is not the case. As soon as drugs enter the bloodstream, the process
of metabolism ensues. The body recognizes the drug as a foreign sub-
stance and eliminates it outright (say, via the kidneys, as in the case of
lithium) or transforms it chemically, using a complex enzyme mechanism
located in the liver. This chemical transformation enables the medication
to be eliminated from the body. In some cases, the chemical transforma-
tion produces a new compound that may also have therapeutic effects
(or, in some rare instances, a toxic effect). For example, fluoxetine (trade
name Prozac) is transformed into norfluoxetine, which is also an antide-
pressant. A similar situation occurs with the old tricyclic antidepressants
(amitriptyline—trade name Elavil—to nortriptyline; the latter, in fact, is
“transformed” in the laboratory and marketed as a separate antidepres-

sant, with the trade name Pamelor).
All these different factors—absorption, distribution, metabolism,
and excretion—interact with each other and together determine various
pharmacological parameters that have clinical significance:
• Peak concentration: the time required for the drug, once it is

administered, to reach maximum concentration in the blood stream. For
those medications that have an “immediate” effect and in which the
magnitude of the effect is proportional to the dose (curiously, this is not
the case with all medications), knowing the peak concentration will
enable us to predict, approximately, the time required for maximum
intensity of the desired effect (i.e., how long it will take to feel better).
• Trough levels: the point at which the concentration of the medi-
cation in the bloodstream is at its lowest. Trough levels that are very
low, say, because of lengthy intervals between doses, may actually result
in a loss of benefit or may even result in withdrawal symptoms.
• Half-life: the time required for the concentration of a medication
to decrease by 50% in relation to its peak level. This is the result of
metabolism and excretion.
• Steady state: the amount of time required for a drug to reach a
stable concentration level in the bloodstream. This means that the
amount entering the body (repeated doses) matches the amount being
eliminated (metabolism and excretion). Typically, for most drugs this
time is estimated to be about five half-lives for the medication in ques-
tion (assuming, of course, no interactions with other medications and
other phenomena). So a medication with a half-life of 24 hours will take
5 days to reach steady state. The range of half-lives for psychotropic
medications is quite wide, measured from hours (e.g., some ben-
zodiazepines) to many days (norfluoxetine, the active metabolite of
fluoxetine). The concepts of steady state and half-life are critical when
evaluating clinical results (including the assessment of need for dose
adjustments), adverse events, and medication discontinuation phenom-
ena.
• Plasma levels: for some psychotropic medications, certain correla-
tions have been established between plasma levels (the concentration of
a drug in the liquid portion of the blood) and therapeutic benefit. Using
this method, the prescribing physician can make adjustments to the
doses with the goal of reaching drug concentrations in the blood that are
associated with optimal response. In a few instances—for example the
antiobsessional clomipramine (trade name Anafranil) and the antide-
How Psychotropic Drugs Work 27
pressant nortriptyline (trade name Pamelor)—clinical research and expe-

rience have established a therapeutic window, that is, the boundaries of
a minimum concentration that must be reached and a maximum concen-
tration that must not be exceeded for the drug to work well. If a
patient’s blood level is outside the window, in either direction, the bene-
fit is diminished.
HOW DRUGS AFFECT THE BODY: PHARMACODYNAMICS
What are the effects of the medication on our systems, in particular, on

the intended targets? Given our current understanding, the intended tar-
gets are usually the receptors found in the surfaces of the neurons in the
brain. For example, some antidepressants interact with norepinephrine
and/or serotonin receptors; some antipsychotics exert their effect on
dopamine receptors. These effects may enhance the function normally
carried out by the receptor or inhibit it. Other, more complex interac-
tions can also occur in the neuron. Pharmacodynamics describe the ther-
apeutic and adverse effects of medication. An effect on the desired target
will result in symptom relief, but it may produce side effects on unin-
tended targets. Ideally, one would want a medication with high selectiv-
ity, that is, affecting the desired target with no or minimal effects on
other systems. Second best, a desirable drug will produce a therapeutic
benefit at a dose substantially less than that required to produce serious
side effects. This is often referred to as the drug’s therapeutic index. Lith-
ium is an example of a psychotropic drug with a low therapeutic index;
small amounts in excess of the doses needed to control manic symptoms
may produce serious or even life-threatening side effects. Through-
out these medication processes of pharmacokinetics and pharmacody-
namics, the body’s organ systems are reacting by working to maintain
homeostasis. For example, the kidneys detect the lithium as an excess
salt in the blood, and they strive to eliminate it. There is a tremendous
orchestration of activity going on everywhere in the body (not just the
brain) in response to any psychotropic medication, as this is added to the
daily physiology of health or disease in that person. Every time a medi-
cation is taken, those mechanisms of homeostasis come immediately into
play: Every time one neurotransmitter is altered, it sets off a string of
counterreactions throughout the body. All of the neurotransmitters
affect functions throughout the body and, at the current level of biotech-
nological development, it is simply impossible to give a medication that
does only one thing in one area of the body.
DIVERSE POPULATIONS
To make things a little more complex, different population subgroups

with unique pharmacokinetic and pharmacodynamic profiles may re-
quire adjustments in dosing and scheduling in order to achieve optimal
risk–benefit ratios with certain medications. Children and the elderly are
common examples. During their training, many physicians have been
admonished to “start low and go slow” when prescribing for geriatric
patients. The elderly have absorption, distribution, metabolic, and
excretion rates that in many cases differ significantly from those of
younger adults. In addition, the elderly often suffer from a number of
other medical problems, which in some cases may affect the way they
respond to and tolerate medications. Moreover, treatments that they
may be receiving for these other medical conditions may interact with
the psychotropic medications being prescribed.
An emerging area in clinical pharmacology that promises to pro-
duce some clinically meaningful guidelines is ethnopharmacology. It has
been suspected for a long time that different ethnic groups metabolize
and respond to medications differently. These differences appear to be,
by and large, genetically determined. However, other factors, such as
dietary predilections, may be at play as well. This means that “standard”
doses for specific medication might require adjustments when prescribed
for members of specific ethnic groups. For example, some data suggest
that tricyclic antidepressants are metabolized differently among African
Americans (higher blood levels, more side effects, and faster response),
Asians (longer elimination times), and native Puerto Ricans (simi-
lar response with lower doses and increased side effects) (Preskorn,
Feighner, Stanga, & Ross, 2004). Differential responses among some
ethnic groups have been reported also for SSRIs, lithium, clozapine
(trade name Clozaril), risperidone (trade name Risperdal), and olan-
zapine (trade name Zyprexa), to name a few. The next few years of
research should result in recommendations for specific dose adjustments
or, better yet, specific tests that will serve as guidelines for dosing and
monitoring the use of psychotropic medications in different populations.
The management of all of these factors in psychotropic medication man-
agement often constitutes some of the most complex challenges in the
practice of medicine.
PART II
Psychiatric Disorders
and Their Treatment
In this section, we discuss the various psychiatric disorders and the

medications that have been proven effective in treating them. Each
chapter focuses on a specific category of disorder and includes the
following:
• A definition of the disorder and a summary of the symp-

toms it gives rise to.
• The biology of the disorder.
• The medications that are commonly used to treat the dis-
order.
• Issues related to the disorder that may be important in
therapy with the patient and/or collaboration with the phy-
sician.
To establish a relationship and join with a physician–collaborator,

it is necessary to understand his or her way of thinking and talking
about patients. Depending on your theoretical orientation, making
a diagnosis according to DSM criteria may play a greater or lesser
role in how you ordinarily conceptualize your patients’ difficulties.
For the physician, accurate diagnosis based on criteria in the DSM
29
30 PSYCHIATRIC DISORDERS AND THEIR TREATMENT
is the linchpin of treatment, and for good reason. In general,

psychotropic medications are developed and approved by the U.S.
Food and Drug Administration (FDA) to target the symptoms or
symptom clusters of a specific DSM diagnosis. What works for one
diagnosis may not work for another; for example, medications that
are helpful for social phobia in general are not very effective for
specific phobias. So the physician needs to make a diagnosis before
he or she can begin to think about what medications are appropri-
ate for the patient. The physician will usually be appreciative if you
can assist him or her by communicating your working diagnosis
and the symptoms that led you to it in terms of DSM criteria.
Often the target symptoms are just as important as the diag-
nosis in deciding which medication would be most helpful. The
target symptoms are those symptoms that are interfering with the
patient’s life and function. They are often (but not always) part of
the diagnostic criteria, such as insomnia, poor concentration, and
fatigue. Although the diagnosis is very important, the target symp-
toms will assist the physician in deciding which medication within
a class would be the best choice.
These chapters will also help you understand any therapeutic
effects and unwanted side effects your patients have when they are
taking psychotropic medications. Because you will usually see the
patient more often than the physician does, you may be the first
professional to whom the patient brings these issues. Although
these concerns should be communicated to the physician—and any
medication changes must be made by the physician—your knowl-
edge can often reassure the patient, for example, that it is normal
for many antidepressant medications to take a few weeks to begin
alleviating symptoms. We have designed these chapters to provide
you with the basic information you will need to discuss your
patients in terms physicians will be familiar with and to alert you
to therapeutic issues that may arise in the process of diagnosis and
medication.
CHAPTER 3
Mood Disorders
Of all psychiatric disorders, mood disorders (depression, in particular)

are probably the most familiar to the general population. The universal-
ity of sadness, loneliness, and dejection, all found in different forms and
intensities as clinical manifestations of depressive syndromes, enables us
to understand and empathize with what a depressed person must feel.
Also, the pervasive nature of the syndrome, coupled with educational
and marketing efforts made in the past decade by mental health organi-
zations and by the pharmaceutical industry, have resulted in some
destigmatization. Stigmas of mental illness and of the mentally ill have
long been recognized as serious obstacles to access to proper psychiatric
care. Progress in CNS research has provided some explanation of the
mechanisms underlying psychiatric symptomatology and has strongly
emphasized the biopsychosocial interplay in mood disorders. The rela-
tive widespread availability of effective treatments, essentially nonexis-
tent about 50 years ago, certainly contributes to this improved under-
standing. A similar shift has occurred in how bipolar disorder and
certain anxiety disorders are perceived and understood.
Happily, this evolution in the public’s perception of mood disorders
has contributed to some improved recognition and treatment, especially
of depressive disorders. A large number of patients obtain relief from the
unbearable misery of depression in the offices of therapists, primary care
31
physicians, and psychiatrists. And yet we still reach only the minority of
those with mood disorders. As epidemiological studies have shown
(Kessler et al., 1994), more than half of those suffering from depression
in the United States suffer in silence, their condition undiagnosed and
untreated. We still have much to learn about how we provide treatment
to those with mood disorders. Even diagnosed patients often receive
inadequate and/or insufficient treatment. The most common causes of
unsuccessful antidepressant medication treatment are suboptimal dosing
and insufficient duration of treatment. Guidelines on how to prevent the
underdiagnosis and undertreatment of depression are well established
but not widely disseminated. And much additional research is needed in
order to establish the optimal use of agents that are currently available.
DEPRESSIVE DISORDERS
Epidemiology and Costs
How common is depression? What is its impact on our daily lives and
on society? The World Health Organization (WHO) forecasted not long
ago that depression would be the main cause of disability in the world
within the next several decades. It is estimated that in the United States
the lifetime prevalence for major depressive disorder (MDD) is about
17% (Kessler et al., 1994, 2003). The 12-month prevalence is about
6.5%. For dysthymia, the lifetime prevalence is about 6.4%. This means
that about one in every five Americans will suffer, at some point in their
lives, from a depressive condition that will temporarily render them fully
or partially disabled and that will have a serious impact on the lives of
their loved ones. About 20 million Americans suffer from clinical
depression—not just feeling “down”—on any given day.
By virtue of its severity and clinical impact, major depression is the
primary focus of this chapter. However, given its prevalence in outpa-
tient settings, dysthymic disorder—a mild but long-lasting depression—
merits additional comments as well. Dysthymic disorder receives less
attention from clinicians and less intellectual investment by researchers
than major depression, although recently this trend has been somewhat
reversed. Dysthymia is not as severe and disabling as MDD, yet it inflicts
considerable psychological pain and personal and social burdens.
The principal features of dysthymia are chronicity (duration of at
least 2 consecutive years) coupled with some of the symptoms of MDD,
although usually of lesser intensity. It often has an early (childhood and
adolescence) onset and an ill-defined beginning, slowly evolving into its
Mood Disorders 33
mature clinical form. Boys and girls are equally affected, but as they
enter adult life, dysthymia appears to occur twice as often among
women. Frequently, a dysthymic disorder will progress to MDD (for spe-
cific diagnostic criteria for each diagnosis, see the DSM). Diagnostic dif-
ferentiation between the two disorders is not easy. In some cases the
same patient will meet criteria for dysthymia at one time and for
major depression at another time, a condition sometimes called “dou-
ble depression.” From a pathophysiological perspective, it is unclear
whether these are two different mood disorders or some variant therein.
Treatment for dysthymic disorder is similar to that for major
depression. When a specific precipitating or sustaining stressor is present
(medical, marital, interpersonal, occupational, etc.), as is often the case
with these patients, this stressor must be addressed. Treatment includes
specific forms of therapy—cognitive-behavioral and interpersonal, in
particular—and medication. The clinicopharmacological concepts and
techniques discussed in the treatment of major depression later in this
chapter are generally valid as well for dysthymia.
Depression is an illness that “maims” and kills. It kills by suicide
and it kills by making medical conditions worse or less responsive to
treatment. It maims in the sense that it disables individuals socially and
occupationally, causes somatic symptoms itself, and contributes to the
development of medical conditions that are disabling. Suicide is a major
complication of depression and by no means rare. Approximately one
out of seven individuals with recurrent major depression will commit
suicide. The large majority—about 70%—are suffering from major
depression at the time of the act (Ezzell, 2003).
We are gaining considerable understanding about the close relation-
ship between mind and body and their impact on each other. Given that
the brain is the organ in which the mind lives—as Hippocrates taught us
more than two millennia ago—it is surprising that we ever considered
the notion that these two essential realms were separate from and oblivi-
ous to each other. Although there is plenty of evidence to support a uni-
tarian construct, we mention here only some examples relevant to
depression and its medical significance. Consider, for example, cardio-
vascular disease. Mental stress is associated with an almost threefold
increase in mortality rates in certain patients with coronary artery dis-
ease. Studies have shown that, following heart attacks, patients who also
suffer from depression fare much worse than nondepressed patients. In
particular, they die at higher rates (three times higher, during a 6-month
follow-up period; Frasure-Smith, Lesperance, & Talajic, 1993). Depres-
sion turns out to be the number-one risk factor for people who have suf-
fered a heart attack (even more influential than the ejection fraction, a
measure of the heart’s pumping function, or hypertension) for having a
future heart attack. Patients who undergo coronary bypass graft surgery,
if depressed at the time of discharge, experience in the subsequent 12
months three times more chest pains, heart failure requiring hospitaliza-
tion, repeat heart attacks, and need for repeat heart surgery, than indi-
viduals who are not depressed after bypass surgery.
This influence is also seen in many other medical conditions, and it
is very likely that research will show that the phenomenon probably
affects most diseases. We know that depression adversely affects the
functional status of patients with chronic obstructive pulmonary disease
(COPD); it negatively affects treatment and diet adherence, functional
status, and medical-related costs in patients with diabetes; it negatively
affects treatment adherence in a host of medical and psychiatric disorder
patients; it has even been shown that psychological factors are independ-
ent predictors of responses in patients receiving chemotherapy for
advanced local breast cancer. Finally, from an administrative and cost-
containment perspective, undiagnosed and/or untreated depression is
associated with longer stays for patients hospitalized for medical prob-
lems and a higher rate of complications, including a higher rate of mor-
tality.
The cost in suffering is clearly significant. There is, of course, a
financial impact as well. For depression alone, this is a staggering figure.
It costs our society approximately $12 billion to treat this disease (this
includes, among others, costs for hospitalization, psychiatric care, and
medications). When indirect costs (i.e., absenteeism, decreased produc-
tivity, and increased utilization of medical resources for nonpsychiatric
medical problems) are factored in, the total reaches $40 billion or more.
It is clear, therefore, that recognition and proper treatment of depression
can have a massive impact on individuals and public health efforts.
Although the following case is a singular example, considering it against
the backdrop of potentially millions throughout society demonstrates
the massive impact depression can have on the health care system.
CASE: MAJOR DEPRESSIVE DISORDER, ANXIETY, AND GRIEF

Case Description
Mr. A called Dr. P on the recommendation of another man in his men’s
Bible study group who had seen Dr. P himself. Mr. A made an initial
Mood Disorders 35
appointment for himself and gave little explanation of why he wanted it

except to say he was “stressed.”
During the initial session, Mr. A recounted a painful story, describ-
ing the death of his 3-year-old daughter. Mr. A had reluctantly gone on a
business trip, leaving his wife with his child, who had flu-like symptoms.
His daughter quickly became worse, and Mr. A realized there was an
emergency and returned home. Within 24 hours after returning home,
Mr. A’s beloved daughter died.
Her death had occurred approximately a year earlier. Mr. A
recounted the grief and loss he and his wife felt. But he also shared the
strength his Christian faith had provided and the tremendous support
they had obtained from their friends at church. Mr. A said that he and
his wife didn’t know how they would have coped without the caring of
their friends and their strong faith.
Nevertheless, Mr. A felt it was becoming increasingly difficult to
get up every morning and go through the day. He was having trouble
concentrating, and it was affecting his business. He was very reluctant
to travel, and yet his job required frequent travel. Mr. A became
increasingly somber, sad, and discouraged as he described his current
situation. When Mr. A had shared these same thoughts with his men’s
Bible study group, a dear friend had recommended that he come see
Dr. P.
It was easy for Dr. P to ascertain that Mr. A’s grief had become a
major depressive disorder. Both the amount of time and the loss of daily
functioning suggested that Mr. A could benefit from treatment. Never-
theless, Dr. P could tell that Mr. A was uncomfortable with the idea of
“therapy” and much preferred the support of his church friends. In fact,
Dr. P doubted that Mr. A would have ever even considered therapy if his
trusted, Christian friend hadn’t personally recommended it. Although
Dr. P knew that medication might help, she initially decided not to rec-
ommend a medication referral because she hoped Mr. A could first
become comfortable with therapy. Instead, she spent time listening to
Mr. A, building rapport and encouraging the positive coping skills that
he already had in place. She also invited him to bring his wife with him
to therapy.
Mrs. A accompanied Mr. A to the next few therapy sessions, and
she appeared equally depressed. In fact, Dr. P noticed that she felt sad
and exhausted herself after each session with the A’s. Dr. P felt that her
own responses to the A’s indicated that the depression was not improv-
ing. After careful assessment and attentive empathy to the A’s pain, Dr. P
felt that they needed additional resources. She brought up the idea of a
medication evaluation. Initially, the A’s were reluctant. But after discuss-
ing the idea of medication for an entire therapy session, they consented
to be seen by Dr. P’s colleague, Dr. R.
Beginning Collaboration
Dr. R set aside two consecutive hours to evaluate both Mr. and Mrs. A.
She let them decide how the sessions would be run—individually or con-
jointly. Similar to Dr. P, she allowed the A’s the opportunity to tell the
story of the loss of their daughter before she focused the session on clini-
cal symptoms. Both Mr. and Mrs. A agreed to begin taking medication.
Mr. and Mrs. A continued working with Dr. P, and within a few
weeks, Dr. P noted improvement. The A’s were able to participate more
fully in the therapy, and they were able to complete the homework
assignments between the sessions. Within a few weeks, the A’s were feel-
ing better and able to complete the tasks of daily living with renewed
energy. Dr. P found it easier to conduct the therapy sessions. She called
Dr. R to thank her for her critical help with a very difficult family situa-
tion.
Questions for Consideration

• What symptoms did Mr. A present that led to recommendations
for both therapy and medication? It is important to note that environ-
mental events—such as the death of a loved one—while stressful and
painful, may not require therapy and/or medication. Dr. P noted the
length of time that the A’s had been dealing with their grief and the fact
that they seemed to be getting worse, not better. In addition, their pro-
ductivity and ability to complete the tasks of daily life had deteriorated.
These were all signs to her that the A’s needed therapeutic interventions.
In addition, Dr. P noted her own responses to the A’s—a sense of sadness
and loss that she felt as the end of each of their sessions. Her own sad-
ness helped her understand and empathize with the overwhelming grief.
• How did the therapist utilize the patient’s natural coping skills
and the supportive resources he already had in place when he came to
therapy? Dr. P noted how helpful the social support that the A’s had
received from their church had been to them. She wanted to reinforce
the coping strategies and resources that the A’s already had. She tried to
demonstrate respect for all that the A’s had already addressed and tried
to keep the therapy in synchrony with the work the A’s were doing
through their church.
• What circumstances prompted Dr. P to refer to a physician? Why
did she wait a while before she made the referral? The timing of the
medication referral was critical. Since the A’s were reluctant to come to
therapy in the first place, Dr. P was hesitant to send them to one more
doctor. She wanted to establish rapport. In addition, she wanted to
explore the possibility of addressing the grief and depression through
therapy alone. However, it became clear that the A’s were not improving
during therapy. Furthermore, the therapy was hard to conduct because
Mood Disorders 37
the A’s had so little energy, motivation, and concentration during the ses-
sions. A medication referral was necessary.
• How did Mr. A’s therapy facilitate the therapeutic experience of
his wife and vice versa? As a therapist, Dr. P was trained to consider
other family members even when they did not appear at the initial ses-
sion. Dr. P knew that Mrs. A must be equally affected by the loss of their
daughter and wondered aloud how Mrs. A was doing. Mr. A was enthu-
siastic about including his wife in the therapy. Dr. R created one long
conjoint medication evaluation—in essence a “family medication evalua-
tion.” Dr. R and Dr. P were convinced that the A’s would improve faster
if they improved together instead of in isolation. Thus, the entire treat-
ment was couple-based.
Risk Factors
Although the ultimate causes of depression are unknown, research has
contributed substantially to our knowledge about the interaction among
biological, psychological, and social spheres of influence. A number of
factors, when present, are thought to increase the risk that a specific
individual would experience depression (see Table 3.1).
It is well known that individuals with prior episodes of depression are
at a much higher risk for relapse (see Table 3.2). In fact, the more prior epi-
sodes, the higher the risk. If the 45-year-old patient sitting in your office is
presenting with her first episode of depression, in general, the risk of a
future episode sometime during her lifetime will be about 50%. As you
take further history, it becomes apparent that when she went to college this
patient had an unequivocal (albeit untreated) episode of major depression.
TABLE 3.1. Some Risk Factors for Depression
• Prior episodes of depression

• Family history of depressive disorder
• Prior suicide attempts
• Female gender
• Early age of onset (< 40)
• Postpartum period
• Menopause
• Current/past marital status
• Medical comorbidity
• Lack of social support
• Stressful life events
• Current alcohol or substance abuse
TABLE 3.2. Risk Factors for Recurrence of Depressive Episodes
• Insufficient treatment duration

• Insufficient maintenance dose
• Poor treatment compliance
• Postpartum period
• Menopause
• Early (< 20 years) or late (> 60 years) age of onset
• History of multiple previous episodes
• History of dysthymia
• Psychosocial stressors (job loss, bereavement, financial
distress, etc.)
• Long duration of recent episode
• High severity of recent episode
• History of seasonality of depressive episodes
• Alcohol and/or substance abuse
• Medical comorbidity
Now you are in the presence of a patient on her second episode of depres-
sion. The estimated risk for a subsequent episode in her case has now
increased to about 80%. Now your clinical curiosity is really stimulated.
You probe further (in reality, it takes several sessions and questioning to
assemble a solid history, as patients simply do not readily remember all
details), and it becomes apparent that this patient had an episode of
postpartum depression after the birth of her second child 9 years ago. And
now, statistically, the risk for a fourth episode sometime in the future is
increased to almost a certainty—90% or more.
Other factors include gender (women are nearly twice as likely
[1.7:1.0 ratio] to suffer from major depression), marital status (higher
risk for separated or divorced individuals living alone), the presence of
medical conditions (especially seriously disabling conditions), and a his-
tory or current diagnosis of alcohol and/or substance abuse (Kessler et
al., 1994). Stressful life events (bereavement, financial loss, and employ-
ment changes affecting self-esteem) are notoriously noxious in individu-
als predisposed to depressive illness (Caspi et al., 2003). This finding,
replicated by Kendler, Kuhn, Vittum, Prescott, and Riley (2005), but not
confirmed in a recent study (Risch et al., 2009), will continue to fuel the
debate on whether genes and the environment interact in such a way
that the effect of the environmental stress will be dependent, to some
extent, on the individual’s genetic predisposition. If confirmed,
conversely, one could speculate that environmental manipulation—early
or even “preventive” psychotherapy, for example—may attenuate the
Mood Disorders 39
effect of a genetic makeup that would make an individual particularly

vulnerable to depression. Clinicians should always take a detailed clini-
cal history in order to identify the possible presence of these risk factors.
Some risk factors are not controllable at the present time (e.g., genetic
predisposition), whereas others are subject to intervention (e.g., stress,
social support, and substance abuse).
Although the risk factors that are subject to intervention are charac-
teristically universal and cross-demographic, symptomatic depression
among the elderly is particularly notable, given that it is the one popula-
tion in which collaborative care models of treatment have demonstrated
the most initial success (Bruce, Ten Have, & Reynolds, 2004; Unützer,
Katon, & Callahan, 2002). Several studies, including the PRISMe study,
the PROSPECT study, and the IMPACT study (Caton et al., 2005), have
demonstrated that collaborative care has better results than the usual
care. In particular, collaborative care improves access to mental health
services and improves detection rates of commonly missed mental health
problems. Usual care, in this case, refers to traditional health care pro-
vided by a primary care physician or traditional mental health care. The
results of these studies are motivating policymakers to push for more
collaborative care on a national level (Boschert, 2004). The goal of
policymakers is to promote interdisciplinary team care and ensure conti-
nuity of care. An equally important goal is to find ways to include the
fundamentals of collaborative care in the training of health care profes-
sionals and to ensure ongoing research that examines the best models
and applications of collaborative care.
Suicide
Suicide is the ultimate price of severe undetected or untreated depres-
sion. The fact that suicide appears to be a fully willful act (which it is
not, when committed by an individual whose judgment is affected by a
severe depression) contributes to the mistaken perception that the mor-
tality factor in depression is low. What makes the act of suicide particu-
larly painful is that in the great majority of cases, it is fully preventable
with appropriate treatment and monitoring. Many patients, reflecting
on their now resolved depressive episode, regard with horror their strug-
gle with suicidal thoughts and the notion that, without treatment, they
would have carried out the act. Important suicide facts are summarized
in Table 3.3.
Assessment of suicidal risk is an inherent component of every psy-
chiatric evaluation and should be conducted during the initial visit or
Another random document with
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down one of the colours of a renowned regiment, and made off to
the rear, without thinking more of it, from having been hit rather
sharply by a spent ball. These are likely, I fear, to be thought too
trifling matters for a work of this kind; but I hope the reader will
excuse me for having introduced them; and also for adding, that in
order to keep pace with improvements made by other nations in
modern warfare, ought it not to be well considered whether our
slowest movements, in what is termed ordinary time, would not be
improved, if the soldier was required to take a greater number of
steps, say 87, of only 30 inches in length in the minute; and if what
is called quick time was made 126 paces of only 30 inches each per
minute, which would make him pass over the same extent of ground
in the same space of time as he does by the present plan. At least, I
have no doubt, and I speak, as an old adjutant, and as an officer
long practised in the movements of both small and large bodies of
troops, that all manœuvres would be performed at these paces with
much less chance of confusion, and with more ease to the soldier,
especially in action, than according to the present mode.
It would lead me far beyond my present intentions if I were to enter
extensively upon the subject of military evolutions; but I beg leave
to say, that to simplify and render their execution easy, ought to
become the primary object of all modern tacticians.
In manœuvring, especially large bodies of troops, rapid movements
in columns at quarter distances ought to be much more attended to
than they are.—Masses of such columns, or close columns, as
practised by the Duke of Wellington at Paris or elsewhere, can be
quickly and scientifically placed or prepared for advancing or retiring
in any direction, or for deployment, by simply, when put in motion,
marking time and bringing up the shoulder; and by this means
gradually producing a change of position or of formation of the
whole mass. Deployments can be made from such columns in quick
or double-quick time, and with the greatest accuracy, by merely
moving in threes or fours to the right or left. What an advantage an
army thus instructed would have over one proceeding in the old
heavy manner, in seizing hold of a position, or of a point, presenting
evident advantages, and that too with perfect safety; for, in case of
a sodden attack of cavalry, a quarter-distance column is in security in
square in an instant. This column also possesses many advantages
over the close column, not only in the superiority and rapidity of its
movements, but likewise in its being much less liable to get into
disorder in broken ground, or to suffer from cannon, which very
soon, if well served, destroy a perfectly solid mass, especially if
steady battalions of infantry are also firing into it, as was the case at
Talavera, when our Guards in the afternoon made a gallant but
injudiciously-directed charge; and when the 48th regiment, on the
one hand, and the 45th on the other, taught the French, that
breaking through an enemy's line in dense columns would not
answer with a British army.—Echelons of these quarter-distance
columns would, in many instances, be very superior to lines of
battalions or brigades, as they could be moved with rapidity to the
points of formation in a new line or position, and without any risk of
getting into confusion; commanding officers of corps, their majors
and adjutants having only carefully to attend to, judge, and preserve
their respective distances; and even in common drill or manœuvres
of a single battalion, this ought always to form an important part of
the practice and instruction of these officers, who in regimental
tactics are, in general, not sufficiently occupied, and consequently
are too often found ignorant of their business when obliged to act in
brigade, and with this object in view every movement should be
performed as if in reference to a corps supposed to be upon either
or both flanks, with which they ought to work in unison. Now I must
beg the unmilitary reader to imagine a large body of troops thus
manœuvring in columns at quarter-distances, or in open columns, or
lines formed from them, covered by clouds of sharpshooters,
supported by these columns or lines, cannon and cavalry, and he will
have at once before him a chief feature in modern warfare, in which
science and experience on the part of generals and staff officers
must be so essential and indispensable.
In thus endeavouring to bring certain matters under consideration,
and in doing so I fear I may exhaust the patience of the reader, I
hope I may not give offence to some of those interested in their
remaining as they are at present; but I must proceed in the task I
have assigned myself, and observe, that I look upon it to be a point
of importance that the present mode of furnishing clothing and
accoutrements for regiments should be altered, and that upon a
general being appointed colonel of a regiment, he should receive a
fixed income as such; but all clothing and accoutrements of every
description, ought, under proper regulations, to be supplied through
the regimental agents, upon the responsibility of the colonels, but it
should be so arranged that neither could have any interest in the
articles being procured at a cheap rate. The granting, however, a
fixed income to colonels need be no additional expense to the
country; for what are the off-reckonings which go to colonels of
regiments but an over-payment on the part of Government for
clothing, &c. &c. Some colonels are very liberal to their corps, but
many more cannot afford to be so; an alteration, whatever it may
be, ought therefore to come under the notice of some board or
other, so as to be kept, if possible, out of the hands of Mr. Joseph
Hume and his liberal associates.
To all who saw much service during the late wars, it must have been
obvious under what disadvantages, owing to the colours of their
dress, our soldiers had often to contend with the French, but
especially with the United States troops in skirmishing. The latter
were certainly, from having much practice, good marksmen; and
thickly wooded America was very favourable to their irregulars; for
our brilliant scarlet coats, white belts, and bright belt and cap-plates,
enabled the enemy to discover, whether in a wood, at the back of a
hedge, or wherever they were posted, our unlucky soldiers, who
were too apt to expose themselves, and many of them were in
consequence laid low; whereas the French, or wary Yankees, almost
entirely escaped; and that much owing to their being dressed in dark
colours, which enabled them easily to conceal themselves. But
officers who served in our Rifle brigade, and in that also experienced
corps, of which I saw so much on many occasions, the 5th battalion
of the 60th, could give the best information, and a correct opinion
upon this head; and I feel certain that they would join with me in
recommending that a change should be made in the dress of our
army, so as to make it more suitable for modern warfare, in which
light troops are so much employed. I must beg, at the same time, to
say, that I often regretted that these fine regiments were not armed
with superior muskets in place of rifles, for they are seldom to be
preferred to muskets, and never but when loaded with great care,
and this, in action, takes up too much time.
We every day hear of experiments and improvements in the
construction of fire-arms; and the country can surely afford to supply
our army with a superior musket, with a proper elevation, and a
percussion lock. The present old fashioned firelock, with which
nearly all our troops are still supplied, is very imperfect, and heavier
than it ought to be. But would it not be well to consider, whether the
new musket should not be considerably longer in the barrel and
smaller in the bore; and that the bayonet should be much reduced in
size; and I would also arm the soldiers, I have in view, with a sword,
of the shape and size used by the ancient Romans; for we may
depend upon it, that our brave, powerful men, would follow their
officers, sword in hand, into the midst of their enemies. The musket
could be then carried either in the left hand or slung upon the
soldier's shoulder, and the bayonet could be fixed to it if preferred. It
might be necessary to weigh well the consequences before we so
armed our impetuous soldiers, for it would be certain to lead to a
new era in war; and would expose troops so fighting, which must be
in a degree of loose order, to be charged by cavalry; yet the Romans
fought in that manner, and with great success, though equally liable
to be so attacked. Every thing would, however, depend upon so high
a state of discipline being established amongst the troops, as would
enable officers to keep them in hand, and at all times obedient when
commanded to resume their places; and our dragoons ought always
to be at hand, ready to support infantry so acting. Such views as
these are, I suppose, entertained by those officers who seem to be
so anxious to have broad sword and bayonet exercises, introduced. I
do not wish to enter farther into this discussion; yet I beg leave to
say, that, though I am certain our soldiers would have closed with
their enemies, yet, in all my practice, which was tolerably extensive,
I never saw two bodies of troops fairly charge each other with the
bayonet; for one side or other (and generally it was that attacked)
gave way. I have certainly seen a few instances of individuals,
French and British soldiers, actually attacking each other with the
bayonet; and at the battle of Roliça, I remember seeing a soldier of
the 29th regiment, and a fine-looking Frenchman, lying on the
ground close together, who had, judging from the positions in which
they lay, evidently killed each other with their bayonets; but such
occurrences were, I believe, very rare.
The introduction of the percussion lock into the army will necessarily
cause a change to be made in part of the musket exercise; but it will
simplify the motions and expedite the firing. I, however, hope, that
before any thing of this kind is decided upon, the following remarks
may be allowed to have due consideration.
The pouch might be differently constructed, and advantageously
converted into a magazine, to carry securely a certain quantity of
powder in bulk, in an air tight tin canister, with a screw stopper, to
insure its being, at all times, and in all situations, kept perfectly dry;
and this is a very essential point, as many cartridges are destroyed
or rendered unserviceable in the men's present pouches by rain, a
damp atmosphere, and even continued friction; and this is too often
only found out at the moment when they are required for service,
and when there is, perhaps, no opportunity of exchanging them; and
as this magazine ought at all times on service to be kept full of
powder, the officer when inspecting his company or detachment,
could easily ascertain if any of it had been made away with: indeed,
the stopper might be safely sealed over, or otherwise secured; and
thus the soldier could be made, without inconvenience, to carry such
a supply of ammunition as to render it unnecessary that recourse
should be so constantly had to that carried in reserve for the army.
The pouch should also be made to contain, besides the powder, a
sufficient supply of percussion caps, and a proportionate number of
balls, to the quantity of powder in the canister; and every ball should
be separately, thinly, yet sufficiently covered with a kind of stuff
similar to soft leather, so as to make it fit tightly when rammed down
into the barrel of the musket, and it would thus become a good
wadding over the powder. For what is called blank cartridge firing,
waddings of the common kind, and of the proper size, could be
used.
The pouch thus contracted, would hold the soldier's reserve
ammunition, which would amount to a much greater number of
rounds than it contains according to the present plan. But to effect
what I have in view, every soldier should be supplied with a good
powder flask, with a proper measure to suit the musket, according
to the most improved method, and similar to that which Mr. John
Manton usually supplied along with his guns; having the measure
forming an angle to one side, so as, in case of explosion, if such a
thing could happen in loading, the right hand would not be much, if
at all, hurt. This flask could be made to contain a sufficient quantity
of powder, say for twenty rounds, at all times on service ready for
use, and which, for the reason I have already assigned, ought, when
the soldier is required to have ammunition in his possession, to be
likewise kept full; and should it at any time be suspected that the
powder in it had become damp, it could be easily aired by simply
dipping the flask in boiling water.
I regret that I am obliged to be particular in my descriptions of such
trifles; but this flask should, I conclude, be carried for convenience
on the left side or breast, and secured from falling when the soldier
is in movement, by a slight chain attached to the belt, to which the
flask might also be steadily fixed by some simple contrivance; and to
render this the more easily done, it ought to be rather flat in shape,
and not larger than to contain the quantity of powder I have
mentioned; and twenty rounds are quite as many as can be wanted
at reviews or field days. In action, if these twenty rounds are
expended, I need scarcely observe, that if no other reserve powder
be at hand, the flask could be replenished instantly from the
magazine; but under an apprehension that ammunition might be
made away with, the quantity in bulk should be touched as seldom
as possible, and if any of it be used, it ought to be immediately
replaced. A small pocket might be made in the right side of the
soldier's coat, which should be only sufficiently large to contain a
number of covered balls in proportion to the quantity of powder in
the flask; and a flap should button over this pocket to prevent the
balls from falling out. Each soldier would likewise require to be
equipped with one of those brass cases for holding percussion caps,
which, by a spring inside, forces each cap out in succession as it is
wanted. Those I use contain thirty caps. This case should also be
attached to the belt, but upon the right side.
The buck shot, I before mentioned, can easily be made up so as to
serve for wadding, in place of the covered ball; and a sentry upon
his post, especially at night, in many situations, would have more
confidence with his piece so loaded, than if he had only a single ball
in it. A better method than that which I have ventured to propose,
may very likely be pointed out; but whatever it may be, the
admitting of the knapsack being carried somewhat lower and easier
to the soldier, ought to be kept in view; and he should not be
obliged, as at present, to take cartridges with so much
inconvenience out of his pouch every time he loads his musket; and
the new exercise introduced on account of the percussion lock, must
of course be made to suit the alterations.
Should the soldier be supplied with a well-constructed musket with a
percussion lock—and if he be required to use a muzzle stopper, a
charge though a day or two in the barrel, will go off almost as well
as if just loaded, and this too in any kind of weather. Our
commanding officers when going into action, or rather on supposing
that they were about to do so, in general made the soldiers prime
and load too soon, for this, I may say, is the business of a moment;
and how often after the regiments had loaded, have they never had
an opportunity of firing a shot the whole day. At night probably the
soldiers bivouacked, and it rained heavily, so that in the morning not
a firelock, if it had been attempted, would have gone off. Darkness
had prevented it from being done the night before, and when the
charge had next morning to be drawn, it was found to be a very
difficult job, when the ball was held tight by wet paper. And then the
barrel required to be well washed out, which took more time than
could be allowed for the purpose, and consequently it was badly
done. I need, therefore, now scarcely observe, that the percussion
lock, in a great measure, obviates, by a very little attention, such
serious inconveniences and defects.
It may very likely be deemed great presumption for me to propose
so many changes; yet, having spoken of an alteration in the uniform
of the regiments, I shall now venture to mention what has been
suggested to me as likely to be a great improvement; but I do not
by any means pretend to say that nothing superior could be thought
of or invented. But if people take the liberty of finding fault with
fashions or systems, whether old or new, it is but fair that they
should be required to point out remedies or improvements.
Suppose that the uniform of the regular infantry was nearly
assimilated to that of our Rifle Brigade (with Her Majesty's Guards I
don't venture to interfere). It is generally allowed, that the dress of
both officers and men of these corps is soldier-like, handsome, and
far better adapted for service than that now worn by the rest of our
army. But I am most anxious that the soldier's coat should be made
for comfort as well as for appearance; and I should, therefore,
greatly prefer that it was made in the shape of what is usually
termed a frock, but to have a stand up collar, and to come down
nearly to the knee. Both coat and trousers could, at a very trifling
additional expense, be made water-proof. But soldiers ought never
again to be overloaded on service with blankets, and let the reader
only imagine their being obliged, as was often the case, to carry
them when wet. But to make up for the blanket, they should be
furnished with a large sized water-proof cloth great coat; in these
they could sleep sufficiently warm and secure from any damp that
might rise from the ground, and which in campaigning is of such
importance towards preservation of health. The country would also
be saved expense if this plan were adopted, by not being obliged to
provide and convey bulky blankets to the points where they were to
be delivered out to the troops; and these water-proof great coats
being of a very durable material, would last much longer than the
old fashioned ones.
Many of the absurdities which once existed in the dress of our
infantry officers and soldiers; such as the powdered heads and long
pigtails, and white pipe-clayed tight buckskin breeches, and large
jack-boots of the former; and the soaped hair with finely feathered
sidelocks, as they were termed, and long highly polished leather
queues, tight white cloth breeches, and long tight gaiters of the
latter, have long been done away with; and why not go a step
farther, and in the way hinted at, in order to secure to our infantry
great and decided advantages. Many may remember the strange
figures, which most of our soldiers cut in Paris after the battle of
Waterloo, in their dirty red coats, and ugly shaped caps; the former
much stained, and the latter become brown and disfigured by
exposure to rain and weather; the consequence was, that our army
made, I do not hesitate to say, the worst appearance of all those
assembled in and around that capital.
I do not intend in this work to make many remarks upon our cavalry,
but I must say, that I hope yet to see some of our lights made
heavier, and mounted on powerful yet sufficiently active horses. I
confess I am not one of those who admire what are called hussars,
&c., because I know how to value our heavy cavalry, and am
therefore induced to draw a comparison between the two; and I
boldly assert, that no cavalry in the world can stand before our
splendid heavy dragoons and their noble steeds. One regiment—and
I am enabled to judge from what I saw of them upon several
occasions—would with ease cut their way through all the Cossacks
of the Don, or any such Lights, which are seldom of any other use
but to follow up a beaten enemy; and, I must say, that it has often
surprised me, how we could think of copying the inefficient cavalry
of any nation. Sir Thomas Picton, but he was an infantry officer, was
also no great admirer of our light cavalry, and some of them may,
perhaps, remember an opinion he publicly expressed of their
efficiency at Roncesvalles, when he, in his emphatic way, and, I
must admit, not very politely, drew a comparison between them and
the dragoons of the German Legion, who were not only excellent
and experienced, but always effective. We were all greatly attached
to the German dragoons, and for nothing more, than for their
literally making companions, or playfellows, of their fine English
horses, which they always thought of, with respect to care and food,
before they did of themselves.
At the opening of one of the campaigns, a body of these German
dragoons, so much and deservedly admired by Picton, which had
been attached to the third division during most of the previous one,
returned to us from their cantonments, when we were again close
up to the enemy, and hourly expecting to be engaged; officers, non-
commissioned officers, and soldiers, turned out in a body to
welcome their old friends, who passed through the camp to where
they were to be stationed for the night, amidst the cheering and
congratulations of the fighting division—and Picton's division knew
well who were good soldiers. In making these remarks, I by no
means presume to say any thing against our light cavalry, but I must
protest against a system of mounting brave men upon horses unable
to carry them through their work on the day of trial, and in this
respect foolishly aping foreigners, who would give the world for such
horses as we possess; and who are doing all they can to improve
their breeds in order to be able to meet us at a future period. The
plan, however, which I have suggested for promotion in the army,
would wonderfully change matters in our cavalry regiments, into
which many officers would no longer go merely for the day, and for
amusement, but into a profession to which they were to belong for
life. But mentioning these German dragoons, reminds me of a
welcome Sir Thomas Picton himself met with on his return to the 3d
division in the South of France, after an absence occasioned by
severe illness, and to which the following letters allude.
"Valley of Bastau, August 27, 1813.
"Dear Sir,
"It has long been the wish of the officers of the three brigades,
which we have had the honour to command under you in the 3d
division, as also of the divisional staff, to have an opportunity of
offering you an ostensible mark of their high respect, gratitude, and
esteem, which we so sincerely feel in our hearts.
"Every objection seems now removed, in point of time and
otherwise, when on the recurrence of severe illness, which has in
four successive seasons assailed you; you at present only await a
sufficient degree of convalescence, to admit of your trying change of
climate, with but too little prospect, we lament to think, of your
returning to your command in this country.
"Services such as yours, cannot but have been acknowledged before
this, by the offering of one or more swords from your attached
military brethren, or a grateful country. We therefore, for ourselves,
and those who have desired us to represent them, request you will
do us the honour to accept of a piece of plate with a short
inscription, commemorative of the circumstance, and of the corps
which composed the 3d division under your command in the
Peninsula.
"With most sincere wishes for your early convalescence, followed by
your confirmed good heath, on leaving a climate that has proved so
unfriendly to you, we have the honour to subscribe ourselves,
"Dear Sir,
"Your ever faithful Servants,
(Signed,) "C. Colville,
Thomas Brisbane,
M. Power.
"For the Staff of }
the Division, } F. Stovin, A.A. Gr.
"Lt.-Gen. Sir Tho. Picton, K.B.
&c. &c. &c."
"London, 18th Sept. 1813.
"My Dear General,

"In the extreme weak state to which I was reduced previous to my
leaving the Peninsula, my feelings were too powerful for my spirits,
and it was not possible for me adequately to answer the kind letter
of the general officers commanding brigades in the 3d division,
which you did me the honour of forwarding to me from the Valley of
Bastau, on the 29th of August last.
"I cannot but highly value the testimony of gentlemen, to whose
talents, zealous co-operation, and gallantry on every occasion, I feel
myself indebted for the honours that have been conferred upon me,
and for the degree of reputation to which I have risen in the service;
and I shall receive any memento of their esteem and regard with
corresponding sentiments and feelings of the heart.
"The period of my life to which I shall always recur with the greatest
satisfaction, is that which was passed at the head of the 3d division,
when I always experienced such a spirit of unanimity and heroism,
as never once failed of success in any of the difficult enterprises we
were employed upon. Though I may never again have the honour of
commanding so distinguished a corps, I shall ever feel myself
identified with the 3d division in all its operations, and shall take as
strong an interest in its success as I ever did, whilst I had the
honour of presiding at its head.
"Accept my many acknowledgments for your kind attention, and of
my sincere and constant wishes for your success and prosperity on
all occasions.
"Your devoted and faithful,
"Humble Servant,
(Signed,) "Thomas Picton, Lt.-Gen.

"To the Hon. Major-General Colville,
Major-General Brisbane,
Major-General Power,
Lt.-Colonel Stovin, &c."
The day upon which Sir Thomas Picton unexpectedly rejoined his
division, the 45th regiment was lying down at the head of Sir
Thomas Brisbane's brigade, which was concealed behind a height,
ready for an intended attack. The enemy were posted at a bridge on
the right bank of a brook, and occupying, advantageously, a few
houses close to it. Our sentinels and theirs were within ten yards of
each other, when to this corps delight, which had so long served
under him, up rode their favourite chief: in an instant, and under
strong and general impulse of feeling, which could not be
suppressed, they to a man stood up, and gave him three hearty
cheers, which were immediately responded to by the 74th and 88th
regiments; thus discovering where they were to the French. "Well
45th, you have let the enemy hear you, you may now, if you please,
let them feel you," was Picton's smiling reply; and at the same
instant he ordered the attack, which I need scarcely say was
completely successful.
I hope I may be excused for giving here another trifling anecdote. I
remember well Colonel Guard, whose adjutant I was at the time,
being most anxious that the 45th regiment, which he for some years
commanded, should be made Light Infantry, and also to have had
them styled, "The Sherwood Foresters." He, however, for what
reason I know not, failed in the objects he had in view. Not long
after, the 45th was brigaded in England for exercise with the 87th
and 88th regiments. Colonel Guard had constantly, and much to his
annoyance, and more particularly on account of his recent failure,
heard these corps called to attention by their appropriate local
designations, in place of their numbers; but one day he could stand
it no longer, and when Colonels Butler and Duff loudly and proudly
exclaimed, "Prince's Irish," and "Connaught Rangers,"—he in a very
shrill voice, called out at the same instant, "Nottingham Hosiers,"
attention. His brother chiefs, who seemingly had not heard, or
understood what he had said, looked all astonishment, when the
whole brigade burst into an irrepressible, and unmilitary fit of
laughter. I fear that in this instance, like old soldiers in general, I
have been led away by the love of telling my story, and must
therefore apologize for the liberty I have taken with the reader; yet,
if I am not mistaken, I think I have shown, that a particular
designation, however acquired, is considered by many, as of more
importance to a corps, than a mere number; I therefore look forward
to the day, if my views are adopted, when a district will have just
cause to be proud of its regiment; and to a regiment never hearing
it named but with a feeling of revived affection, and a determination,
that their home shall never be disgraced by any act of theirs.
CHAP. IV.
Other causes besides those arising from the description of men
generally enlisted into our army, tended greatly to keep soldiers
what they were—that is to say, difficult to manage, and always ready
to avail themselves of any opportunity of getting away from under
the eyes of their officers, with the view of indulging in irregularities
whenever it was possible to do so; as, I trust, I shall be able
hereafter to point out. I cannot, however, undertake to say, what
may be the custom in the present day; but a soldier, in former times,
could not commit a greater offence than to presume to think or act
for himself; and I remain still in doubt, when, or at what rank, an
officer was supposed to be capable or had a right to think. And as
for education, too many entertained the strange notion, that beyond
reading and writing, which were allowed to be useful to non-
commissioned officers, the less soldiers knew of such matters the
better. After this need it have surprised any one, that intelligence of
any kind was but rarely to be met with in the ranks of a British army;
and that it was constantly found in those of the French, into which
the conscription necessarily introduced it; and when evinced, it was
sure to meet a due reward.
I remember, years ago, being visited by a brother-adjutant. As he
entered my barrack-room, a young soldier placed a book upon the
table and retired; which my visitor, a few minutes after, took up, and
being surprised at what it indicated as its contents, he asked me, in
seeming astonishment, what a private soldier could have to say to
such a work? I replied carelessly, that the soldier who had just left
the room, was a young man of considerable ability and great
promise; and that I wished him to read useful books; so as to be fit,
at a future period, for any station he might attain. He looked at me
again, and seemed by no means satisfied by what I had said, nor
with the book, and thus in a very friendly way addressed me:—"You
are a very young man, the youngest I ever saw made an adjutant—I
have myself risen from the ranks, and have consequently had much
experience amongst soldiers; and know them well. You may
therefore take my word for it, that books containing such
information, only tend to make soldiers question the wisdom of their
officers; and to fit them for being ringleaders in any discontent, or
even mutinous conduct in their companies: and it also causes them
to be disliked by the non-commissioned officers who have to teach
them their duties, and especially the drill-serjeants, who are always
jealous of those who are likely to become rivals." This certainly
surprised me as coming from my visitor, but he had been for many
years an adjutant, and it has often been remarked, that no officers
are so severe, or have so little consideration for the feelings of
soldiers as those who have risen from the ranks. With this as a kind
of text, and also requesting that the reader will bear in mind what
was shown at the commencement of this work, by excellent
authorities, to be the character of our soldiers in general, I shall now
proceed with my remarks, some of which may probably be thought
trifling.
The French plan of carrying the knapsack, though not so smart
looking, is in the opinion of many, superior to that adopted in our
army; as it has much more the ease and comfort of the soldier upon
a march in view. Our present mode, which binds the soldier so
tightly within the slings and straps of the knapsack, as almost to
prevent the free circulation of the blood, is certainly far from
judicious, but we have been long accustomed to it, and like it on
account of appearance. But in olden times, we had many ways of
trying the tempers and dispositions of our soldiers; such as making
them, though kept at drill, or at exercise in the field the greater part
of the day, to burnish the barrels of their firelocks, to their serious
injury, till they were made to shine like silver, and to polish their
pouches, and oddly shaped caps, so as to render looking-glasses
quite unnecessary. How often have I, when a zealous and
enthusiastic adjutant, cracked a pouch with the head of my cane,
when it was not bright enough to please my practised eye, with the
kind intention of affording the owner a pleasant week's occupation
to get it again into order. And how often have I, on my well-
practised horse, placed camp colours as points of movement, till the
whole "Eighteen Manœuvres" were gone through; many of them, if
the commanding officer was dissatisfied, with the regiment's day's
performance, two or three times over; having previously had the
delight of marching past repeatedly, in quick and slow time, to
please the spectators, or because the soldiers did not make the
ground sufficiently resound by the firmness of their steps; thus
altogether agreeably occupying from five to six hours of the officers
and soldiers time, with the prospect before them of a long evening
parade, or inspection, because they had not been so steady under
arms as they ought to have been during the morning's occupations.
I sincerely hope we shall never again hear of such things being
practised in a British army; and no commanding officer should be
allowed to keep his regiment longer than an hour and a half, or two
hours at a time under arms, which will be found quite sufficient, if
well occupied, for every useful purpose of instruction; especially as
at almost every parade, a battalion ought to be made to perform a
movement or two before it is dismissed. I however look upon it to be
of the first importance, that a soldier should be accustomed to
consider his knapsack and accoutrements, I may say, as parts of
himself, and that he should be so habituated to them, that whether
marching or not, he could perceive little or no difference; and to
effect this, he should never appear under arms without his
knapsack; but I hope, if this plan be enforced, as it ought to be, to
hear of an improvement being made in the mode of carrying them.
Our soldiers were greatly overloaded, especially on service, when
they had to carry, besides their arms, accoutrements and
ammunition, their canteens, haversacks, and well-filled knapsacks,
their great coats, and often wet and consequently very heavy
blankets, and sometimes in addition two or three days bread, and
generally ten extra rounds of ball cartridges. Overloading soldiers in
this manner was down right madness, especially if we had
considered the description of men we too often had to deal with;
and this will never answer in the more rapid modes of carrying on
war, to which we must hereafter look forward.
I saw it not along ago announced in a daily paper, that the recruiting
of the army had been very successful, 13,000 men having been
raised for the line, and had joined their corps in the course of 1838.
Of that number, more than 4000 were passed in the London district,
and this was exclusive of men raised for the East India Company's
service. By this it would appear, that London alone furnishes about a
third of the men raised to fill up casualties in Her Majesty's
regiments.
It is very likely that the editor of the paper, who seemed so pleased
at being able to afford us this intelligence, is a zealous advocate for
doing away with flogging in the army; but if such be the description
of men of which it is chiefly composed, any person of common sense
must see that it is impossible to do so, for what are these men in
general but the vitiated and debilitated part of our population.
I have no doubt but it is very desirable that the country should get
rid of such subjects, who are mostly unfit for any military purpose
whatever; but why, at a great expense, burden the army with them?
Would it not be much better to allow the worthy Yankees to have
many of them at once, as emigrants or soldiers; and if sufficient
authority were given to our Police Magistrates, they could very soon,
by only threatening such fellows, with what a certain Colonel once
upon a time practised in Ireland with so much success, make
volunteers in plenty, and thus save our sympathizing friends the
trouble and expence of enticing them to desert from their corps in
the Canadas. I am well acquainted with their proceedings in this
way, and can therefore speak from experience, having been for
some time employed upon the staff of the army stationed in that
part of the world. I certainly had at that time no trifling task
assigned me to make arrangements, so as to have a good look-out
kept all along the extensive frontier of the lower Province, to prevent
desertions, to which our soldiers were much addicted, and
encouraged by promises of both money and land, but which were
seldom intended to be fulfilled; indeed, most of those who got off
had nothing else left for it, in order to keep themselves from
starving, but to become once more soldiers, and to fight against
their old comrades.
It was supposed by some officers, that shooting a number of them
(I saw six shot in one day at Chambly), who were caught in
attempting to cross the boundary line, would have put a stop to this
disgrace to our army, but it had no effect whatever; indeed nothing
we could devise produced any change in this respect, until it was
made the duty of commanding officers to give me immediate
information whenever a man was missed from his corps. Small
detachments of dragoons were posted at certain points to convey to
me at St. Johns the necessary intelligence. Upon receiving it, the
out-posts were instantly informed of the circumstance. At the same
time parties of Indian warriors were sent out in all directions in
search of him, and a reward was held out to them for bringing him
in. These arrangements being made known to the several corps, and
the deceptions of our kind neighbours being pointed out to them, a
complete stop was thus put for the time to desertions. But are men
who would so readily desert, those Great Britain should have in her
armies? I ought here however to mention, to the honour of my old
friends, the 88th, or Connaught Rangers, that they were exempted,
by Sir Thomas Brisbane, from witnessing executions for this crime,
as not a man of that corps had deserted to the United States.
In order to show what little effect executing men for desertion had
upon others, I shall take the liberty of mentioning what took place
upon one occasion at St. Johns. My General being absent at
Montreal, as Brigade-Major attached to the troops, most of the
melancholy duty of superintending such executions fell to my share.
A private of De Meuron's regiment was at this time to be shot. The
troops were formed in three sides of a square, at the other side
towards the forest the grave was dug, and the coffin for the criminal
to kneel upon, was placed, as usual upon such occasions, beside it.
The Provost, with the firing party escorting the prisoner, and with
the band of the regiment at their head playing the Dead march,
entered the square—when, to my surprise, there proudly marched
the prisoner—coolly smoking a cigar. Seeing at once the bad effects
likely to result from such evident contempt of death, painful as it
was to me, I called the Provost, and ordered him to take away the
cigar from him. On approaching the grave, the prisoner walked
quietly, but steadily forward, looked into it, and turning round to me,
said, in French, "it will do." But still more to my surprise, yet with
equal calmness, he walked up to his coffin, and before I was aware
of what he was about, with his middle finger and thumb he
measured its length, and turning round again to me, he said, in
French, which his corps generally spoke, "it will do also." This was so
far beyond any thing I had ever before witnessed, that I found it
necessary to direct the Provost to proceed with the execution as
quickly as possible; he therefore went up to the prisoner with a
handkerchief, and, as is customary, offered to bind up his eyes. He
however, pushed the Provost aside, exclaiming, in French, "I am a
brave soldier, and have often looked death in the face, and shall not
shrink from it now." The Provost then desired him, or rather made
signs to him, to kneel upon his coffin, but he replied, "I prefer
standing, and shall do so firmly." "Vive L'Empereur, vive Napoleon,"
were his last words. The party fired, and in an instant he ceased to
exist.
He was a Frenchman, and had been a prisoner of war for a
considerable time in England, but had been very improperly allowed
to enlist into De Meuron's regiment; which he had, no doubt,
entered with the intention of deserting the first opportunity which
should present itself.
I have yet to mention our North American possessions; but it would
appear, that it is now in contemplation, to employ corps of veterans
upon the Canadian and our other North American frontiers. It is,
however, evident that whoever can have suggested such a scheme,
must have altogether overlooked, or be ignorant of the rigorous
nature of a Canadian winter, and must likewise have forgotten, that
almost all our veterans have spent a great portion of their lives in
tropical climates, which cannot be supposed to have prepared their
constitutions to bear up against such cold as is quite unknown in any
part of Great Britain, as indicated by registers of the thermometer
kept during a residence there; where it ranges from zero to 10, 20
and even 35 degrees below it; and should a strong wind prevail
along with such cold, any one exposed to it is very likely to be frost-
bitten. It may also be supposed, that the proposers of such a plan,
are not aware of its being often necessary during winter in Canada,
to have sentries relieved, or at least visited every half hour; for if
they be unfortunately overcome by the severity of the cold, and in
consequence fall asleep, it is certain death. Are worn-out men, many
of them already martyrs to rheumatism, or must soon become so, fit
for service in such a country, and to which they may be sent from
their homes, probably reckoned upon as permanent, contrary
perhaps to their wishes, and very likely only to suit the economical
notions of penny-wise theorist and grumblers, who grudge old
soldiers and sailors, even the pittance their services entitle them to,
whilst they would handsomely reward the author of a mischievous
pamphlet? But are these poor veterans, I again ask, fit to guard
such an extensive frontier, constantly menaced by hardy and restless
men, inured to a North American climate?
I have no doubt but that prejudiced men, and such as are always
ready to cavil at any change proposed, be it good or bad, will at first
be inclined to look upon what I have suggested for keeping up our
army, as not only a wild and visionary, but also as an impracticable
scheme; yet all I request is a full and fair consideration of what I
have said and brought forward; and it ought now, I think, to be
obvious, that our regiments must be composed of a superior
description of men, if the country is to be served as it ought to be in
our future wars, as will, I trust, more fully appear as I proceed.
I shall now beg to remind officers, in general, of the numbers of
soldiers who arrived in Portugal and Spain, who went into hospitals
before we had many weeks carried on military operations in those
countries, many of whom, as might have been expected from their
early debilitating habits, never rejoined their regiments; and
throughout the war when fresh battalions arrived from England,
nearly the same thing invariably occurred, and with detachments of
recruits for corps already in the field, it was still worse, so much so,
that we could never calculate upon one-third of the new comers
remaining fit for duty with their regiments, even for a short time
after their first arrival; some of them, however, as they became more
habituated to campaigning, turned out to be good soldiers. Now
many of these were men who had been probably raised, according
to our present system of recruiting, in London, or in our
manufacturing districts, and thus the country was put to an
enormous but useless expense.
The soldiers we could chiefly depend upon, were those who
originally belonged to the corps, or had come to us from many of
the militia regiments, and particularly those who had been brought
up to early habits of labour in our agricultural districts. I am aware
that many of the men we got as volunteers from the militia, had
been called out from our manufacturing population, but their habits
and health had been much improved by being obliged to relinquish
debilitating practices, by good feeding, and regular military exercises
for a length of time before we got them. A long peace has probably
brought into our corps a more robust description of men, than we
had often to make the best we could of during the late wars, and
many of whom were frequently most wretched creatures, so much
so, that it was unfair to expect that British officers, however zealous
they might be, could always be successful in battle against the finest
men of France, which the conscription brought into the French
ranks; but if an immediate increase of the army, to any considerable
extent, should become requisite, and if the present system of
recruiting is to be still pursued, the same generally unprofitable and
expensive materials must be resorted to, for augmenting or
completing the respective establishments of our old, and also of any
new corps which it might be necessary to form, and many of whom
must be again found to sink under the fatigues and hardships of war,
and the weight of their knapsacks. I must, however, declare that
none of the inhabitants of Great Britain and Ireland are deficient in
courage. But let us reflect upon the state into which Sir John Moore's
army (which almost set him distracted) had got in the retreat to
Corunna. Almost all the corps had become completely disorganized
in every respect, and had nearly lost the appearance of regular
troops. An opportunity of fighting presented itself, and in a moment
steady and well disciplined British battalions appeared in the field.
Such were the strange beings British officers had to manage as well
as they could.
It would appear that a new plan is about to be adopted for re-
organizing and training the militia, and that the men are in future to
be raised at a small bounty to serve for a period of five years; and
that the whole are to be formed into battalions, of one thousand
strong each. The training to take place annually, in portions of two
companies at a time, for 28 days, under the adjutant, or permanent
staff; which in future is to consist of an adjutant, a serjeant-major,
eleven serjeants, one drum-major, and five drummers: one Serjeant
to do the duty of quarter-master-serjeant; and it is intended to allow
a part of the men to volunteer annually for the line.
This appears to me an exceedingly bad plan. In the first place, the
corps of militia must hereafter be composed of a very inferior
description of men to what they were of old; and flogging must, as a
matter of course, be persevered in; but why in these times are the
militia to be embodied and badly trained at a considerable and
unnecessary expense to the country; for it is quite time enough to
think of calling out this force when the country may be threatened
by an enemy with invasion; for with the fine regular army I have in
view, the tranquillity of the United Kingdom can be completely
secured; and such militia corps, as those that seem to be in
contemplation, must be the very worst description of troops which
could possibly be employed in case of commotions. I must sincerely
hope that the old and constitutional mode of calling out the good
and true men of the nation to serve in the militia regiments will
never be abandoned, and I yet trust to seeing it extended, as I have
proposed, to the Guards and regular army. Surely I have shewn
plainly enough the evils of our present recruiting system to dissipate
the notion of extending it to the militia. I have long entertained a
dislike to the plan of enlistment, unless every possible inquiry were
made into the characters of the men who offered themselves as
recruits; and I endeavoured to act in this manner some years ago,
when commanding a depot at Glasgow. I had an old friend in that
city, who had been one of its magistrates, and could look back to the
period when only herring boats could come up to the Broomilaw,
and who knew every body. I never took a recruit without the
approbation of my friend the Bailie; but he rejected so many, who
were instantly taken by other depots, of which there were several at
the time in Scotland, that I was at last called upon to say why I did
not get on quicker with the enlistment of men for the regiment. I
gave as my reason, that I was anxious to take only men who could
prove that they were respectable in character; but this was not
deemed satisfactory, and I had no longer any thing for it but to take
such as presented themselves; and then I certainly got on fast
enough with recruiting.
Not very long after this, the Bailie came to see me, and I happened
at the time to be superintending the drill of several strong squads of
my newly enlisted recruits. The Bailie looked closely at them all, and
I could not help fancying that I read alarm in the countenances of
many of my prizes. "Well, Colonel," said the Bailie, "the city of
Glasgow is infinitely indebted to you, for you have freed it of many
deserving characters;" but observing that I became rather chop-
fallen, he added, "Never mind, man—they'll fight—they'll fight like
devils. Was there ever a better fighting regiment in the world than
the ——, and they were nearly all raised in Glasgow, which was, to
my certain knowledge, very peaceable for many a day after they
were gone from it."
I am at this moment reminded, by what occurred upon the retreat to
Corunna, of the state into which many of our men were brought
upon that and other occasions from want of shoes. I may venture to
say, that we had seldom taken the field a fortnight—and our armies
had even more than once to halt on this account—when the greater
part of the soldier's shoes had gone to pieces, and others could not
always be got to replace them. This destruction of shoes was in a
great measure occasioned by the previous injudicious practice of
highly polishing them with injurious kinds of blacking, which I
suppose must continue to be the fashion in these quiet times; and I
hope I may be allowed to say, that whenever a corps of infantry is
ordered upon service, this practice should be positively forbidden.
Two good pairs of boots—not such clumsy concerns as some of the
Russian soldiers wore in France—should be properly prepared for
every man—that is, well saturated with the water-proof stuff, now so
much used by sports-men, and they should never after have
anything else put upon them but some of this composition, which
not only softens, but also tends to preserve them for a considerable
time. Such boots will certainly not look so well as those now in
general use; yet for grand occasions, the soldier might be made to
carry another finer polished pair; but with the boots I want, and
good stockings, every soldier should be furnished, or he cannot
march as he ought to do, and is, therefore, so far unfit for service.
Some people may consider this trifling, but experienced soldiers will
think otherwise.
The plan I have suggested of calling out the regular army, of course,
overturns the present defective depot system, which seems to me to
be only calculated to give officers habits of idleness and
restlessness; and their frequent removals from the companies
abroad to those forming the depots, requiring others to be sent out
to replace them, afford opportunities of indulging in such pernicious
habits. Depots are but very inferior schools for the instruction of
officers, non-commissioned officers, or privates. The ten companies
assembled form a fine battalion, well adapted for all kinds of military
movement and instruction: a depot is quite the reverse of this.
There are now before me notes upon certain points, which I wish to
bring under consideration; but if they should appear to some readers
tiresome, or uncalled for, I can only regret that they should seem so,
and I must request that they will arm themselves with patience
sufficient to enable them to accompany me to the end of the
chapter.
Regimental bands are looked upon as very pretty and necessary
appendages to corps; but as it is most essential that as few soldiers
as possible should be taken out of the ranks, it might be advisable to
consider whether it would not be wise to place them upon a
different footing. The present plan takes away from their companies
perhaps twenty soldiers to make second-rate musicians; as more
men are almost always occupied in this way, (at least it was so
formerly) than regulations would admit of; and supposing that all
our regiments were made light infantry, there would, I conclude, be
neither drummers nor fifers; but, in place of them, one sergeant as
bugle-major, and two buglers per company, and two extra buglers to
accompany (when necessary) detachments, the whole to be clothed
almost the same as the other soldiers; and I would also arm them
with light muskets—indeed, those which belonged to light companies
generally contrived, when in the field, to arm themselves. These
muskets might be slung over their shoulders when they were
required to cheer the regiment on a march, or to attract the fair to
the windows as corps passed through towns; and most delightful
strains, at least, to a military ear, can be produced by key bugles,
French horns, trumpets, &c. There should, however, be one good
sized drum, on the new principle, allowed to mark the time; and
surely twenty-three men per regiment are quite sufficient for such
purposes, especially if some of them were also taught to perform
upon a few other instruments.
The corporal and ten pioneers per regiment, who are generally
nothing else but so many attendants upon the quarter-master and
his sergeant, should be done away with; that is, I would keep the
men hitherto employed in this way where they ought to be—in the
ranks. If men are wanted for fatigue, as it is termed, the soldiers
should be employed on it as a duty, and their time can never be
better occupied than in all kinds of labour or works, especially those
which may tend to instruct them in what is likely to be required of
them at sieges, or during campaigns; and above all, they should
have a knowledge of the best and quickest methods of making
roads, temporary bridges, &c., and even of preparing food, and
lighting fires; if they were also taught to be boatmen and good
swimmers so much the better. It certainly would be very desirable
that soldiers had more practice in this way than is the fashion in our
army. But having mentioned preparing food, I think it important to
say a few words upon the subject.
The comfort in which the men of the 5th battalion 60th regiment
(who were chiefly Germans,) lived upon service was very striking,
when compared with the wretched diet of the generality of British
soldiers. I must, however, preface my remarks upon this subject by
the following division order which was issued by Major-general
Colville, at Moimenta de Beira, in Portugal, on the 29th March, 1813,
respecting this corps:
"No. 9. A detachment of the 5th battalion 60th, has arrived at head-
quarters under the command of Captain Kelly, and which having left
Lisbon consisting of fifty men, has brought up all but one man who
was left sick at Coimbra, and no prisoners.
"This is so unlike the report of any detachment of the British part of
the division that has arrived at quarters since the Major-General's
taking the command of it, that he cannot help mentioning the
mortifying distinction, in the hopes that there may be yet left among
the good men of the division regard enough for their own honours to
keep a check upon the conduct of those of an opposite character."
It seemed to be settled amongst themselves, that every man of the
mess of the 5th battalion 60th, had to carry something, that is say—
highly-spiced meats, such as sausages, cheese, onions, garlic, lard,
pepper, salt, vinegar, mustard, sugar, coffee, &c.; in short, whatever
could add to or make their meals more palatable, nourishing, or
conducive to health. As soon as the daily allowance of beef was
issued, they set to work and soon produced a first-rate dinner or
supper, which were often improved by certain wild herbs which they
knew where to look for, whereas, in attempting this, I have known
instances of our men poisoning themselves; and what a contrast to
this were the ways of our too often thoughtless beings who rarely
had any of the above articles—day after day they boiled their beef,
just killed, in the lump, in water, which they seldom contrived to
make deserving the name of soup or broth. This and their bread or
biscuit was what they usually lived upon. But I lament to be obliged
to add, that their thoughts, of course unconnected with military
matters, were too often directed to ardent spirits and to the means
of procuring enough of it; for though a certain allowance, usually of
rum, was issued daily, this was not sufficient to satisfy their longings
for more. And it was always known when the rum was about to be
given out when we heard a shout in the camp, and from many
voices a cry of "turn out for rum!"
Our mode of messing in barracks is extremely regular, and much in
the style so carefully exhibited in Russia to visitors of importance,
and is well calculated to produce effect. In general (at least in
former times,) cooks were hired, and the soldiers' wives were
sometimes engaged for this purpose, so that most of the men were
kept almost in ignorance of learning the simple art of boiling beef
and potatoes: they only knew, that at fixed hours daily, they were
sure of a breakfast and dinner; and although this was to be admired
in quiet times, it sadly unfitted soldiers for what they were
afterwards to turn their minds and hands to in the field; and it also
sometimes left them more money than they could spend with
propriety. But if their thoughts could now be more directed to the
German and French style of living it would be attended with the best
results, and we should hear less of drunkenness and the crimes
arising from out of it in our regiments. These hints might, perhaps,
be thought useful to those interested in the welfare of our
population in general, whose early habits are too often very
pernicious and demoralizing.
The observations of his Grace the Duke of Wellington, on the 1st and
3rd of October, 1812, at the siege of Burgos, will shew the necessity
of our soldiers' being accustomed to labour and the consequences of
their not being habituated to it:—"The Commander of the Forces is
concerned to state, that the working parties in the trenches do not
perform their duty, notwithstanding the pains which have been taken
to relieve them every six hours, &c.;" and his Grace adds—"The
officers and soldiers of the army should know that to work during a
siege is as much a part of their duty as it is to engage the enemy in
the field; and they may depend upon it, that unless they perform the
work allotted to them, with due diligence, they cannot acquire the
honour which their comrades have acquired in former sieges." The
Guards were exempted from the censure contained in this order;
indeed their conduct was most exemplary on all occasions. And we
can again read in a general order, dated Cartaxo, 4th March, 1811:—
"No. 2. As during the two years which the brigade of Guards have
been under the command of the Commander of the Forces, not only
no soldier has been brought to trial before a general court-martial,
but none has been confined in a public guard; the Commander of
the Forces desires that the attendance of the brigade, at the
execution to-morrow, may be dispensed with."
This ought surely to convince the country, that though the changes I
have proposed, as to the officers of the Guards, may be necessary
for the general good of the army; yet the idea of disbanding such
troops can only be entertained by an ignorant and absurdly
prejudiced mind.
I have often wondered it has never been deemed indispensable, that
an uniform system of regimental economy was adopted for the
whole army. This most desirable object is by no means attained by
the book of general regulations and orders; for although there is to
be found in it much that is useful, still a vast deal more is required to
come up to what is necessary for the guidance of a regiment in the
various situations in which it may be placed; and the want of such a
well digested plan is the reason we see such a difference in the state
of corps; some being in every respect in the highest possible order,
whilst others are the very reverse. The former is entirely owing to
their being commanded by talented and judicious officers; the latter
is evidently occasioned by their being under men who are
themselves ignorant, inexperienced, and yet very likely self-
sufficient. Many regiments have good standing orders if they were
steadily acted up to; but much depending upon the will of the
commanding officer, he most probably adopts something of his own,
which is often injudicious, or even injurious; or as much only of the
old standing orders as he thinks fit; or perhaps he allows the whole
to become a dead letter. A matter of such importance as this should
not be left to whim or caprice; but a simple, uniform, and sufficiently
comprehensive system should be established for the whole army, for
the guidance of regiments in barracks and quarters at home and
abroad; upon a march, or when on board ship, or in any situation,
but especially when employed in the field. If this were done, and
positive orders given, that there should not be the slightest deviation
from the system laid down, on the part of commanding officers, we
should hear less of corps being more annoyed and teazed by one
commander than another; and we should not be able to observe
that remarkable difference to be met with amongst them, both in
appearance and discipline.
There could not be much difficulty in effecting this most important
object. The standing orders of some corps, though in general too
diffuse and complicated, and requiring too many returns or reports
from companies, &c., would afford ample ground-work for all useful
purposes, except in what is essential for the field; in which respect,
all those I have seen were totally defective; but uniformity in every
point is as necessary in this as it is in military movements; and if
judiciously adopted, would be found as strikingly beneficial, as the
changes were from the fancies of every commanding officer to the
well known "eighteen manœuvres."
Having proposed to do away with regimental pioneers, to make up
efficiently for them, two men of good character should be enlisted—
but that only for service in the field, to take charge of and lead a
bat-horse each, to carry on well fitted pack-saddles a few of such
useful tools as might be required for ordinary military purposes. The
surgeon, at such times, also requires a man and a horse of this kind
for his instruments and medicines; and so do the pay-master and
adjutant, for the conveyance of money, books, and various
indispensable papers and returns. These ought always to march in
the rear of the corps to which they belong. Thus, by doing away

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THE GUILFORD PRESS

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system, or

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data is available from the Publisher.

ISBN 978-1-60623-700-7 (paperback)

I dedicate this book to the memory of my parents,

I dedicate this work to my wonderful children and their spouses;

I lovingly dedicate this book to my family, close and extended,

JoEllen Patterson, PhD, is a Professor in the Marital and Family Ther-

A. Ari Albala, MD, received his medical education at the University of

Margaret E. McCahill, MD, is a Health Sciences Clinical Professor of

Todd M. Edwards, PhD, is an Associate Professor and Director of the

PART I. The Mind–Body Connection 11

CHAPTER 1. How the Brain Works 13

PART II. Psychiatric Disorders and Their Treatment 29

CHAPTER 3. Mood Disorders 31

PART III. Creative Collaboration 207

CHAPTER 9. Focusing the Lens: The Referral Process 209

APPENDIX A. How Drugs Are Developed 261

APPENDIX B. Future Trends 266

APPENDIX C. Professional Outreach 280

Several years ago, we were supervising student therapists working in

current, we had to gain a rudimentary knowledge about these medica-

EMBRACING THE “BIO” IN BIOPSYCHOSOCIAL

While espousing the biopsychosocial model in our work as therapists in

same. Textbooks for nonphysicians about psychotropic medications

THE COLLABORATIVE CARE MOVEMENT

Defining Collaborative Care

If levels 3 or 4 are not possible for therapists because of the location

Collaborative Care: An Integrated Conceptualization

patients and their families, at home or in their work environment, even

TRENDS IN MENTAL HEALTH CARE

• The U.S. Surgeon General declared that ensuring that treatments

PREPARING THE NEXT GENERATION OF THERAPISTS

Despite our immersion in the collaborative care movement, we were

that we gave them, including theory and popular treatment techniques.

1. We want this book to be theory-neutral. Each model and every

2. Rather, we assume that you want to improve your collaborative

We now narrow our focus to the information you need to effectively

• Basic neuroscience information on how the brain works and how

We recognize that your professional experiences may be signifi-

The Mind–Body Connection

In this section, we discuss some basic concepts about how the

1. To further develop your understanding of the biological

this information, not all physicians have the time or inclination to

These viewpoints are not mutually exclusive, and in fact they

How the Brain Works