There is no doubt that this is
intended to be a major teaching aid for under and post-graduate mental health
professionals, and moves easily from basic to more complex text.  Largely
drawing on American expertise, the stand out man here is Prof Dan Stein, a well
known South African expert who holds the chair in Cape Town.

The book is well organized into 8
parts, with a fascinating start edited by Dan Stein on symptoms and
epidemiology, beginning with historical aspects of mood disorders written by
Michael Stone: and I do mean historical, beginning with medieval times, and
moving on to the reformation, renaissance, enlightenment and so on. 

This is not trivia: a counseling
colleague of mine paged through the book asking to see the part of the book on
anxiety, most perplexed that there is no section on these disorders anywhere in
the book, despite the co-morbidity of these conditions.  As with many others
who are not that au fait with the DSM and its peculiarities or of the
emergence of disorders such as the adjustment disorders into psychiatric
nomenclature, or the vanishing of ego-dystonic homosexuality, neurasthenia and
other conditions (the Russians might disagree), the placing of mood disorders
in their historical context is vital in understanding where diagnosis
(literally "through knowledge") is placed in western culture.

Continuing in Part 1 is the
didactic chapter on classification by Dan Klein and others, and the chapter on
Epidemiology is one of the longer ones predictably, given the difficulty with
changes in nomenclature, gathering of data and others across the years. These
issues are dealt with crisply and without entering into the more contentious
issues possible here, and which might confuse the student. Following on it
would be reasonable to include a chapter on the global economic and morbidity
burden of these seemingly common and perhaps increasingly common disorders, and
Wang and Kessler provide one here.  One of the most frightening aspects
presented here is the evidence for the inadequacy of treatments for mood
disorders, even when only the minimal standards are applied. Perhaps a quarter
to a third are adequately treated.  Given the low numbers of trainees entering
psychiatry and mental health nursing programs, and the same is certainly true
of Australia, the burden will fall to GP’s.  Many countries such as Australia
are failing to recognize the value of psychologists in the treatment of
patients alone and in partnership with GP’s, vainly trying to recruit more
nurses from overseas, and psychiatrists, with similar, poor results. While
patient numbers appear to increase, with treatment options dwindling, the
burden is likely to increase.  The section closes off with a chapter on rating
scales, a very thorough discussion of necessity dealing with the marked
differences among the scales in rating the thoroughness and strength of the reliability
and validity evaluations. Only the Ham-D and the MADRS show strength in the
clinician scales; the major strength of this chapter is the pages of comparison
showing the characteristics of each measure against each other.

Section 2 looks at the pathogenesis
of mood disorders under the steerage of Pedro Delgado. He kicks off with
Francisco Moreno on the neurochemistry, covering obviously the biogenic monoamines
involved, tightly again, in 16 pages.  A brief description of the putative role
of the neuropeptides follows, with an equally terse delivery on the role of
neuroplasticity.  One feels that the lag effect on publishing edited works
means that perhaps the last year or two of discovery is neglected and this may
be the case here.  Perhaps the inclusion of Kandel’s or Kolb’s work might
enhance such chapters and extend more current ideas into the argument. 
Nevertheless as a textbook, this is tight and informative and easy to examine.

A chapter on
psychoneuroendocrinology follows with Stu Seidman as the writer, starting with
HPA and HPT axes, moving on to the HP-gonadal axis with a long and welcome
discussion of male, and then female interactions, so often neglected elsewhere,
and firming my preference for chapters written by single authors.  Bruce
Christensen leads his colleagues in a chapter on cognitive processing models of
depression, again a tight 14 pages, considering that one can waffle on about
such things.  They focus on information processing, attention, bias of
attention, memory, and then literally a paragraph on each of the major
theoretical models, with a tiny bit on the clinical application of the above:
too little, but just enough for the student.

The next chapter is again well
written and with strong references to more global concepts such as social
capital, another neglected entity, but well to the fore in this section, which
is laudable.  David Williams and Harold Neighbors follow on here with a chapter
on social perspectives of mood disorders, covering well the various aspects of
our interconnectedness with society and how this covaries with mood.  Ralph
Nesse ends off with evolutionary explanations, a new field drawing on
evolutionary psychology, which now has a strong showing of adherents if the
Yahoo discussion group numbers indicate anything. Simply put, if such disorders
were totally counterproductive, they would have been bred out.  We know this is
not true, for instance in schizophrenia, where worldwide the prevalence remains
at about 1%, while this is not a high breeding group, and the multiple genes
with small effect are thus not dominantly expressed, but nevertheless,
Gazzaniga and others included, there is a purpose perhaps to nature in keeping
the disorders prevalent, or even increasing: the price we pay?  It must be
useful to the species, but perhaps not to the sufferer at the time, and
certainly extremes of mood must still be seen as an illness or aberrant brain
condition of sorts.

Part Three focuses on the
investigation of mood disorders, with Rajkowska looking first at anatomical
pathology with a very interesting focus on monaminergic, glial and glutamate
involvement.  The lag here is about 2-3 years, looking at the references,  but
not that critical here, given that the findings are unlikely to be strongly
revised, and Rajkowska is drawing on more recent research into morphological
cell abnormalities. There are still problems with regard to limitations of such
studies, but the field is in its infancy, and more to come in future.

Singh and colleagues look further
into molecular and cellular neurobiology of severe mood disorders.  Again, much
of the work is recent, with regard to neuroplasticity and resilience in mood
disorders.  The table on page 200 describing signaling cascades is stupefying, in
the manner of David Nutt and colleagues, with a page of explanation, in itself
enough to justify the chapter. A similar table on page 204 describes brain
derived neurotrophic factor interactions with various pathways, filling in the
gaps mentioned above.

Mayberg’s chapter on brain imaging
includes an interesting discussion on the differences between psychotherapeutic
and psychopharmacological approaches.  The latter pretty much demonstrate
common areas of change, but the former vary somewhat from these locales in the
brain, supporting an alternative hypotheses for firstly, how they work, and
secondly, for how they complement each other in a cumulative way.  Berrettini
follows with a chapter on the genetics of bipolar and unipolar disorders,
touching on the genetic concepts of linkage and linkage disequilibrium.  Sadly,
with multiple genes of small effect involved, unlike, lets say Huntington’s,
described through the application of linkage disequilibrium methods, much will
still need to be done before any treatment applications emerge.

Part four, under Mark George,
focuses on somatic interventions for mood disorders. Following the historical
format seen elsewhere, Potter and colleagues begin with the accidentally dirty
drugs, the tri- and tetracyclics and the MAOIs of yore.  Still regarded as
probably the best of the antidepressants available, this first generation were
discovered by default, and fell into disfavor because of their side effect
potential (sometimes lethal), and problems with giving efficacious doses that
would be tolerated and the risk of overdose given the therapeutic ranges.  Potter
reprints tables on the receptor affinities of the antidepressants in these
groups, looking in the text at adverse events, drug interactions, and the role
of their complex pharmacokinetics, a short and concise chapter.  In terms of
the deliberately clean (and sometimes deliberately ‘dirty’), second generation
treatments, discovered by design rather than default, Shelton and Lester take
on the SSRIs,  and include ideas about Norepinephrine reuptake blockade as
well.  They discuss each of the commonest ones in short paragraphs, contrasting
good response with less impressive remission rates in the ‘pure’ serotonin
agents versus the older agents or the SNRIs.  This latter group is then discussed,
looking at venlafaxine, duloxetine, and then the other more unusual agents such
as buproprion, nefazodone, mirtazapine, reboxetine and so on. No chapter is
complete without a table on the cytochromes, and so this follows.

Predictably again, the next chapter
focuses on lithium and the other mood stabilizers. Unpredictably this is a tiny
chapter!  I not sure why there is not more, but the authors, Keck and McElroy summaries
the current state of knowledge succinctly and leave it there, looking at valproate
and carbamazepine, exiting via oxycarbazepine and dismissing gabapentin,
topiramate and lamotrigine, with no reference to the last in major depression
in bipolar: a little unsatisfying, but they did their job.

Stephen Strakowski and Richard
Shelton take us into the antipsychotics, again with some superficial treatment
of the subject matter that suggests this book is not likely to do much for
trainee psychiatrists: for instance, the cardiovascular paragraphs make no
mention of the early danger in administering clozapine.   Another shortcoming
is the absence here of a table comparing the affinities of the atypicals with
each other, as these are really fairly disparate compound sharing only a
variable potential for binding with dopamine and 5ht2a receptors: the
depression medication table noted above was excellent, and this chapter stands
in contrast as a little lightweight by comparison.

Stu Seidman comes in again at
Chapter 19 with an investigation of the effects of targeting peptide and
hormonal systems, mentioned briefly before.  Again, given the long history of
hormone-behavior interactions, it is a good place to start with such history,
as many chapters do, a strength of the book.  Targets include the HPA axis, CRH
receptor antagonists, HPT axis and antidepressants and mood stabilizers, exogenous
testosterone administration, and gonadal hormone treatments for female mood
disorders. This is a nice complementary chapter for his earlier piece in this
book, and a good idea to break his work up into the disparate sections of the
book.

ECT and TMS are contentious issues
for various reasons, the former fairly old and chaotic, and the latter much
more modern, and dubious. Nobler and Sackeim take this on in Chapter 20, again
with a very thorough history section, charting the waxing and waning of the favors
of the former treatment.  Careful justification is given to how it might work,
and the indications, a critical decision for its use. Equally long is a
discussion of its adverse effects, its use with concurrent medication, and
treatment considerations such as the placement of the electrode, and the
estimation of the necessary dose.  TMS is a much easier consideration, and
takes up just over a page at the end of this chapter.  rTMS may induce
seizures, and with dubious efficacy, the two treatments go well together in a
single chapter, a kind of dog and pony show for the curious.

George and colleagues entertain
another novel and contentious treatment, namely 10^th cranial nerve
stimulation and deep brain stimulation.  As with the previous chapter, the
editors have allowed the authors to move a little tangentially into
schizophrenia, Parkinson’s, OCD and so on.  Their focus on depression in this
chapter comes to show us that use of certain frequencies applied to neuronal
tissue results in functional ablation of activity, applied now to mood
disorders after some applications in other neuropsychiatric conditions.  As
knowledge about regional brain activity grows, we may see more from the
research to support efficacy, especially given the paucity of really good
outcomes in many conditions where mood becomes a factor. Not much evidence is
here though.

Part 5 brings us to a consideration
of the role of psychotherapy.  Ellen Frank overseas this section, and Friedman and
Thase begin, predictably in this evidence based age, with CBT for depression
and dysthymia, given the ascendance of CBT as the flavor of the era for
psychology in its quest for mainstream acceptance.  This is not a sine qua
non, not in any field, as a recent article in Medscape made the comment
that there was no evidence that psychotherapy had any application in mood
disorders, startling as such a clearly wrong statement must be.  This article
begins with the basics of Beck’s cognitive model, and then the basic strategies
of cognitive intervention and cognitive behavioral analysis system
interventions.  The caveat supplied at the end demonstrates that when CBT is
combined with optimal pharmacological interventions, then the outcome "may
be" effective in addressing the illnesses we are concerned with here (page
368). Again, there is stronger, more recent evidence produced then seen here,
but it is a basic chapter after all.  Markowitz then presents the case or IPT
for both disorders, and again there is the conclusion that integrating
pharmacotherapy with psychotherapy is most easily orchestrated with IPT which
has no real historical "tension" to overcome, with the caveat that
despite this, the combined outcome is not always better than either technique,
well, anyway, never worse.  One is however warmed by the approach of other
authors in other fields, let’s mention here, Jose Leon Carrion, in working a
combined approach to traumatic brain injury, with stronger sentiments about
outcome. Again, this is entry level writing, and gives a good account for
beginners in the therapy field.

Gabbard and Bennett speak for
psychoanalytic and psychodynamic views, and we must page through for some way
to find that the evidence base for these long-practiced and much theorized
approaches is somewhat thinner than for the new techniques. 10 columns are
devoted to finding whatever outcomes they can, and Karl Popper aside, we can
see that the outcome of just about any therapy is pretty much as good as any
other in meta-analytical studies, even nonsense therapy groups may produce good
outcomes (see Scott Lilienfeld’s work for such discussions elsewhere).  Based
on an untestable premise, namely that there is a thing called the unconscious,
the evidence here simply shows that we don’t really know what we are treating,
but there is efficiency and efficacy to a certain extent, at least as much as
other therapies for the most part. Others will disagree with this, and CBT is
probably more powerful if manuals are used and sessions are limited, and not
when Axis II is a problem confounding the treatment, where the psychodynamic
approach may provide some rebuilding techniques. The reference list is shorter
than any other chapter, however.

Bipolar disorder comes under the
treatment spotlight in Swartz and colleagues’ analysis of the psychotherapeutic
approach for this most disastrous of conditions, with so difficult a task as
establishing an evidence base providing headaches for researchers occasioned by
logistical issues, methodological and conceptual challenges. The authors take a
‘levels of intensity’ approach and present psychoeducation, CBT, Family
therapy, IPT and Rhythm therapy, and a good differential table on page 416
compares the differential effects of therapies in terms of the need for
experienced therapists, the effect on mania and depression with regard to
relapse or symptoms overall. The implication is that clearly, experience is
necessary, and the outcomes are good for CT to a certain extent, but more
likely in FT, IPT and intensive clinical management.   Ten key elements here
for enhancing clinical interventions are education about various aspects of the
disorder, careful review of symptoms and side effects, medical and behavioral
management of side effects, 24 hour on call service (hah!), early warning
signs, and non-specific support. Much sounds like the approaches to brain
injury rehab here, and that is just what one expects of such a patently organic
condition.  This is an example of how the tight, managed style of the book best
operates, with good use of tables and tight descriptions, without being
neglectful of the richness of the field.  However, why it takes about 5 years
to diagnose these disorders on the whole is not addressed, so before one
treats, the failure of treatment is built in to failed diagnosis, and local
experts here in Australia, such as Prof Mike Berk in Melbourne are trying to
find out why, so that the above work becomes more likely to have an impact. It’s
a good holistic approach though.

Children and adolescents come under
the spotlight now in the work of Weersing and Brent, and again CBT and IPT are
on the spot, which makes sense given the subjects, and long tables attest to
the favorable outcomes here albeit with only three investigations of the latter
technique, two by the founders.  Family therapy continues its resurgence, as it
does with BP and with addiction to alcohol, and social skills training likewise
gets a very brief paragraph.  Again, improvement is not recovery, and the
treatment kudos are limited by the sobering fact that most of the subjects stay
depressed, or get depressed again, or those that need it the most are less
recovered, with CBT and fluoxetine (Prozac and generics) about the best way to
go, 71% doing much better.  Again, it’s a sad indictment of 21^st
century medicine that this is the best we can do.

Less depressing is the next
section, namely number six, under A John Rush, show kicks off with guidelines
for the treatment of major depression.  He takes a careful look, actually more
of a scrutiny, of the rationale for developing and using guidelines and
developing algorithms, taking 7.5 pages to get to the treatment algorithms for
MDD.  Stage one is antidepressants excluding MAOIs and TCAs, step 1a is to
augment with Lithium (although the literature is based on the first use of the
drugs excluded in step 1), and stage 2 is just 1 and 1a with TCAs added in,
stage 3 includes MAOIs.  4 mandates Li augmentation with a TCA. 5 may include
more than one antidepressant with perhaps an antipsychotic, stage 6 is ECT, and
stage 7 is anything that may be an educated guess.  Treatment algorithms follow
for psychotic depression, and by page 14 of this chapter, we consider
psychotherapy. Crismon et al did now allow for this modality of treatment in
their algorithms, but Hollon et al in 2005 did.  CT, BT, IPT, CBT-analysis are
all mooted as being the most documented in terms of outcome, time limited
therapies are proposed as necessarily in the hands of trained and experienced
therapists, with Keller’s view of CBT-analysis being most strongly supported,
even when medication has NOT been successful, with no due deference to Medscape’s
editorial board and much praise to Schatzberg et al 2005 who found such
evidence in chronic depression.  In those with response but no remission,
psychotherapy is indicated.  Its one of the most useful chapters in the book,
in terms of teaching anyway.

Guidelines for BD follow in the
chapter by Muzina and Calabrese. They introduce the concept of stabilizing mood
from above and below the baseline, based on Ketter and the second author in
2002.  This is a chapter that now introduces lamotrigine and other drugs, where
the earlier chapter did not, and filling out the book a little better than the
earlier chapters, and seeming to be more neuropsychiatric in its approach
rather than more depressed-give-antidepressants approach.  Pregnancy is
addressed here, and lactating mothers as well, and all available drugs then
otherwise carefully examined against a more general application context. This
is another very good chapter for doctors.

A wonderful addition now is one by
Mann and Currier, in understanding and preventing suicide, again following the
short but totally adequate model of other chapters. It covers the usual, but
then also genetic and family aspects, the neurobiology of suicidal behavior and
the management of suicidal patients examining long term traits as well as
transient risks.  Even more impressive is an inclusion of a chapter now (we are
now at Ch 30) on suicide in children and adolescents, by Cynthia Pfeffer
alone.  She follows the same format as others have done before her, such as
Gould, Brent, and Joe in Daniel Romer’s 2003 adolescent risk anthology, a work
worth reading in its entirety on various subjects in adolescent risk (see http://mentalhelp.net/books/books.php?type=de&id=2384).

Not content with the above
chapters, Rush now includes on polypharmacy, namely combing and augmenting
agents, by Pierre Blier.  There are now so many agents, that this is indeed a
necessary addition to the book, and most welcome.  NE uptake inhibitors, Li,
buspirone (5ht-1a agonist), triiodothyronine (no evidence with SSRIs),
buproprion (popular, no evidence, but safe with SSRIs, dual reuptake
inhibitors, mirtazapine, or on its own at 150mg starting dose) are all
examined, as are the alpha-2 adrenergic antagonists, drawing on the old drug,
mianserin, and the newer mirtazapine as well as the plant extract yohimbine in
combination with SSRIs. This alone is a fascinating column, followed by
nefazodone, not as sustained in its action as mirtazapine again. It’s a
wonderful walk down the neuropsychiatric lane, and a most welcome chapter as
this book really warms up.

We bid farewell to all that in this
marathon book, to Part 7 which is Alan Schatzberg’s baby, looking at subtypes,
the first being Seasonal Affective Disorder, with Josh and Norm Rosenthal in
the driver’s seat. They begin, as always, with the history of this disorder,
looking at clinical and demographic features, comorbidity, especially Axis II
and Anxiety disorders, and the common finding in adolescents again. 
Predictably, light therapy is carefully examined, a novel chapter and worth
reading for sheer interest value.  Atypical mood disorders are looked at by
Stewart and colleagues, a modifier for both depression and dysthymia. 
Dysthymic and Cyclothymic disorders are discussed, and that is it for this
chapter.  Psychotic depression is given the same treatment by Flores and the
section editor, a short chapter again, with Pediatric (sic USA) mood disorders
under Emslie (Texas) and colleagues.  A very good inclusion is a table on long
term psychosocial difficulties, enough to scare any parent, but with good recovery
(90%) in the first years after diagnosis being more promising, MDD doing better
than depressive disorder. High correlation with neurochemical reward seeking in
later life is noted (see Romer again), and a long and tabled review is then
given on the treatment options and the guidelines for choice, with again
preference for the evidence behind CBT and IPT, and now DBT (as per borderline
PD, Marsha Linehan approaches) getting some look in, with mindfulness and
stress tolerance techniques particularly admired, which makes sense.  Bipolar
disorders are examined here as well, with another very useful table on page 588
comparing features of mania in children and adolescents.  Most authors refer to
the same research when presenting evidence, e.g. Miklowitz et al, so there may
be little variety of evidence with regard to treatment options. This chapter is
very extensively researched.

Having dealt with children, Roose
and Devanand are chosen to present on geriatric mood disorders, with a careful
look at subthreshold depressions, one of the few times that subsyndromal
disorders are considered here in this anthology.  Not much attention is given
to psychotherapy, a surprising approach to treatment one might think, this
exclusion here.

Part 8 under the steerage of David
Kupfer widens the focus, with depression in primary care to start with, by
Bentley and Katon, and then depression in medical illness by Robert Boland. 
Many dilemmas in these areas are rooted in history, and there are many
diagnostic issues, given earlier approaches to endogenous verses reactive
depression nomenclature in history.  Mood disorders and substance abuse
comprise Ch 39, by Nunes and colleagues, with mood regulation and rewards
systems compared with sustained abstinence being a problem for most studies of
treatment efficacy and outcome.  No real analysis of treatment modalities is
made, such as Motivational Enhancement Therapy, or Family Therapy, that have
shown promise.

Depression and personality is dealt
with by Yen and her colleagues, with excellent review of the relationship
between personality and depression in terms of the conceptualization and
empirical findings in the literature, and the influence of this
interrelationship on outcomes in treatment. The dearth of decent studies here
is saddening.  Depression and gender is another contentious and poorly
researched issue, dealt with in Ch 41 by Kornstein and Sloan, the latter
strangely for such a chapter is a pharmacologist.  Premenstrual Dysphoric
Disorder is a must for such a chapter given the subject’s controversy, having a
stirring effect on Feminists.  Pregnancy and menopausal transition are also
dealt with in a most medical fashion, avoiding any controversy.  Finally,
culture is dealt with, a confounding variable akin to gender, and equally as
political, Kirmayer and Jarvis providing the chapter.  Cultural variance in
prevalence, clinical presentation, mechanisms, and treatment are addressed as
some of the broader issues involved.  The word ‘construct’ comes up early as it
should, with vocabularies of distress so important here, leading to category
fallacy (page 701). Nice to see is the care the authors take to explain the
dominance of summarization seen in presenting symptoms, much the same as one
expects in traumatic brain injury, with unfortunate consequences for patients
confronting western paradigms, mostly British Colonial, as to how patients are
supposed to present when ill or in pain.  Of course the evil of Universalist
beliefs has been addressed elsewhere, and so importantly here as well.  The
idea of schemata is developed in tables and figures in this chapter, and of
course where there are cultures colliding, there are politics, and a short
column or two is devoted to this here, such as Kleinman on neurasthenia (see my
earlier comments).

No work on mood disorders would be
considered complete without a chapter on sleep, and Buysse and colleagues take
this on in the final chapter, which embarks on the neurobiology of the
disturbance during mood problems in some depth.

As with any marathon anthology, the
book cannot be all things to all mood disorders and approach, and specialize at
once and the same time, but it tries and does well.  There is nothing to
compare it to in this regard, culture, gender, age, psychosocial and neurobiological
treatment, all are dealt with.

Where it fits in is less clear. 
Probably 5-6^th year medical school, as well as some entry level work
for psychiatrists in residency/registrars, perhaps a little unsatisfying for
the neo-expert, but enough to justify its inclusion, certainly to clinical
psychologists engaged in more than the ludicrous Australian four year
undergraduate generic health worker-allied health approach, in the rest of the
world where doctorate and post-doc work in clinical mental health science is
the norm.  As a textbook it does its job beyond reproach, being thorough enough
without being over-lengthy, although it will scare most students: it’s not that
much of a burden.

 

© 2005 Roy Sugarman

 

Roy Sugarman,
Ph.D., Conjoint Senior Lecturer in Psychiatry, University
of New South Wales, Australia

Categories: Depression