This book upset me. The title makes you interested. The cover illustration somehow makes you want to read it. The book contains 14 chapters — all reasonably well written — on the various authors' ideas about ‘difficult’ patients with bipolar disorder, schizophrenia, depressive disorders, anxiety disorders (social phobia, obsessive—compulsive disorder, generalised anxiety disorder and panic disorder), post-traumatic stress disorder, borderline personality disorder, dissociative disorder, eating disorders, dementia, post-traumatic brain injury, substance misuse, comorbidity and somatic conditions. The basic science is described well, but as difficult-to-treat patients are rarely included in research studies the science only takes us so far. The editors have clearly understood this and have allowed the contributors to become anecdotal. Most of the anecdote feels right and there are very few controversial moments.

So what upset me? Well, I have been a general psychiatrist for more than 20 years and have had many ‘difficult’ patients in all of these categories. Very few of them are in this book. The vignettes at the end of each chapter are like the people I see in most of my out-patient clinics — not particularly difficult or out of the ordinary. I want to know what to do with really difficult-to-treat patients, not this lot. There was very little in this book that could not have been written 10 years ago. There was hardly anything I did not know already and although the chapters were a handy summary of what I already knew, it is worrying that all these clever people in America do not know any more than I do.

For those post-membership trainees or recently appointed consultants grappling with the real world, the book provides clear guidance on the accepted management of treatment-resistant patients in most areas of psychiatry. For those of us with a bit more experience, what we need is a book that will get us out of a hole when necessary. This is not it.