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by Dan J Stein, David J Kupfer and Alan F Schatzberg (Editors)
American Psychiatric Publishing, 2005
Review by Roy Sugarman, Ph.D. on Dec 8th 2005

The American Psychiatric Publishing Textbook of Mood Disorders

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 10th 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 21st 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 5-6th 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