We are in the age of evidence-based practice. By now we should all be thoroughly versed in the skills of critical appraisal. Our ideal response to any clinical conundrum should be to find time for the working up of a ‘critically appraised topic’, during which we perform an up-to-the-minute trawl of Medline and the internet (using an impeccable search strategy, of course) and then distil out the wisdom we require through razorsharp methodological dissection of the papers we find. The real world, of course, still lags a little behind this, and hard-pressed clinicians may have neither the time nor the aptitudes to engage in the process described. Enter Difficult Clinical Problems in Psychiatry. This is one of those handbooks that appear from time to time seeking to provide a reference point for advice on the management of some common intractable problems.

Many of the chapter headings cover predictable (if well loved) favourites such as refractory schizophrenia, treatment-resistant unipolar depression and unstable manic-depression. Others go into less frequently charted areas such as treatment of panic and behavioural disturbances in old age. One or two sub-speciality areas are discussed, for example anorexia nervosa and attention-deficit hyperactivity disorder (ADHD). Taken together, however, the topics span a broad range of clinical issues which daily challenge many a jobbing clinician. How helpful is the material provided? Well, none of the chapters purports to be a systematic review, but they are all written by recognised authorities in their field and some internationally known opinion leaders. For the most part the contributions are readable, although it is in the nature of the beast that the wish to be comprehensive in content in a finite space leads at times to heavy-going reading and sometimes a disappointingly cursory treatment of certain issues. In the chapter on improving compliance, for instance, the model of compliance therapy developed by Kemp, Hayward and David at the Institute of Psychiatry is cited once, but the treatment approach itself is not described at all. This seems a pity given the attractiveness and proven efficacy of this model.

In a handbook of this kind, there is always a balance for the authors to strike between presenting only that evidence which is clear and robust (but therefore leaving sometimes huge gaps in the story) and taking the risk of offering ‘pointers’ based on the authors' experience and opinion. On the whole a good balance is struck here, with comprehensive coverage of the topic areas and helpful treatment protocols suggested.

With the increasing development of clinical guidelines and systematic reviews, it might be argued that some of the functions of such a handbook will eventually be supplanted. In the meantime, many clinicians will find this a useful reference work. It should certainly be considered for library purchase and some practitioners may think a personal investment worthwhile. Be warned, however: with intellectual material of this calorie content small but regular helpings are indicated - and preferably a none-too-warm reading environment. The information available here merits concentrated attention.