Book Review
Mood Disorders
Handbook of Depression. Ian H Gotlib, Constance L Hammen, editors. New York: Guilford Press; 2002. 624 p. US$65.00.
Reviewer
rating*: Excellent
Review by: Mostafa Showraki, MD, FRCPC
Toronto, Ontario
Psychology was introduced into medicine and psychiatry in the 19th century, primarily by Sigmund Freud. Thereafter, most advances in theoretical and clinical psychology—for example, psychoanalysis, Jungian psychology, object relation theory, and self-psychology—were achieved by psychiatrists. However, psychology, influenced by behavioural, cognitive, and neuropsychology— especially since second half of the last century—gradually became an independent and powerful field. In the last 2 decades, some fields in psychiatry (for example, mood disorders) have been nourished abundantly by the scientific efforts of psychologists, among other nonpsychiatrist scientists. This book represents an extensive effort by our colleagues in psychology—an example that needs to be commended. The editors are eminent psychologists who have contributed immensely to our current understanding of mood disorders. Only 4 chapters out of 26 were written by hand-picked psychiatrists: Robert Boland and Martin Keller, Michael Thase, Michael Gitlin, and John Wallace. As a psychiatrist, this fact attracted my attention, not as a deterrent but, rather, as enlightening. It was an eye-opener to reexamine the psychiatrist’s position in the clinical and research fields. We must not limit ourselves to prescribing and researching drugs; otherwise, we may lose the lead in our own backyard. For these reasons, and because it is a good reference source for most scientific work done on depression, I strongly recommend this great book to all psychiatrists in both the clinical and research fields.
The book’s division into 4 parts guides readers and illustrates the editors’ scientific approach to depression. Following a concise introduction, Part One, “Descriptive Aspects of Depression,” begins with the epidemiology of depression. Here and throughout the book, readers are not bored by the repetition of information to be found in any psychiatric textbook. Rather, they are informed of the latest developments and data on depression, taken mostly from the past decade. For example, readers are reminded that depression has been on the rise over the past decade and that young people are experiencing higher rates of this debilitating and costly illness. The chapter on epidemiology reviews not only different prevalence rates of depression but also the epidemiology of its consequences, help-seeking behaviour, and service use. In addition, this chapter discusses the future directions of the epidemiology of depression: developmental, genetic, and experimental epidemiology.
The chapter on the course and outcome of depression is largely based on the longitudinal studies, such as the Collaborative Depression Study (CDS) initiated in 1979 and the Zurich cohort study by Angst and others. Here, we are reminded that a large number of depression patients (about 12% in the first year after their first episode, 20% in the second year, 12% after 5 years, 7% after 10 years, and 6% after 15 years) are still symptomatic and suffering from depression. We also learn that 22% of patients in the CDS relapsed within 1 year of follow-up, and the recurrence rate after 2 years is 25% to 40%. This increases to 60% after 5 years, to 75% after 10 years, and to 87% in 15 years. The risk factors for relapse, recurrence, and chronicity of depression are reported to be “history of multiple episodes, other comorbid illnesses, old age, double depression, long duration of each episode, family history of affective disorders, and the role of environment and adverse life events”(p 48–56). However, this chapter (written by 2 of the few psychiatrist authors) has not sufficiently emphasized that the undertreatment of depression—that is, not aiming for the full remission but, rather, achieving “wellness” with long-term continuation and maintenance therapies—is one of the most recognized risk factors in the recent literature on depression (1).
The chapter on the “Assessment of Depression” warns both clinicians and researchers not to approach and treat depression as an “all-or-nothing” and isolated entity but to see it as a heterogenous illness. It cautions against “overrelying on diagnostic benchmarks” that can “detract from appreciation of the importance of subsyndromal symptoms.” This chapter reviews common screening, diagnostic, and symptom-severity measures and provides related data. In the interesting chapter “Contemporary Methodological Issues in the Study of Depression: Not Your Father’s Oldsmobile,” the authors emphasize and support with empirical data the fact that research in depression has already been redirected toward identifying and assessing the roots of adult depression in “childhood origins of depressive vulnerability.” This signals the most important part of the book, “Vulnerability, Risk and Models of Depression.”
The section on vulnerability to depression is central to the whole book, as it is to the phenomenon of depression at present. Through the chapters on the genetics and biological aspects of depression, readers learn that “unipolar depression is unlikely to be a good candidate in searching for a single (or a few) major genetic locus,” despite having a “significant genetic aspect, estimated to be in the range of 20% to 45%.” Readers also discover that “individuals do not inherit a disease of depression, instead they appear to inherit a susceptibility, or a vulnerability to develop depression.” Therefore, an interaction between the environment (stress), the cognitive perception (meaning) of the stress to the individual, temperament (which is also inheritable), and the genetics of depression cause the illness to develop. In the biology of depression, we see how structural abnormalities of the brain, such as hemispheric asymmetry or small size of the caudate nucleus, prefrontal cortex, and hippocampus, could cause emotional dysregulation characteristic of depression patients.
The chapters on psychological, social, and environmental vulnerability and risk factors in depression draw from all the recent empirical data and information from the literature and artfully intertwine these factors. The book’s integrative and comprehensive model clearly evident here, as empirical data are well presented to illustrate how cognitive and inter- personal vulnerabilities interact with early adversity and environmental stress to cause depression early in childhood and adolescence. Again focusing on the most recent proceedings in the cognitive studies of depression over the past decade, the book discusses information-processing abnormality in depression. Human studies of adults, pregnant women, and children are presented, as are animal studies, to show how major depressive episode is only the most visible aspect: much is to be seen as early in life the fetal stage.
The third part of the book starts with the chapter, “Preventing the Onset of Major Depression,” calling for prevention of the first episode of depression. Next, the authors discuss 3 models and strategies of prevention (that is, universal, selective, and indicated), with live examples from around the world. The relevant data across different prevention studies in adults, adolescents, and children (as early as the prenatal period) are cited. The emphasis throughout is on applying combination strategies to treat and prevent depression (for example, cognitive- behavioural therapy and pharma- cotherapy or interpersonal therapy and medication) and on continuation or maintenance treatments. Because the environment—particularly the family—is crucial in the development of depression, a chapter is dedicated to the “Marital and Family Therapy for Depression.” Some data on the negative impact of depression on marital and family relationships and parenting are comprehensively discussed, as is the bidirectional pattern of causation between family relationships and depression according to Hammen’s “stress-generation theory” (2).
The last part of the book deals with depression in specific populations. It begins with the chapter, “Understanding Depression Across Cultures,” introduced with the following quotation:
Depression is of such interest to anthropologists and psychiatrists alike because it provides a prime opportunity for exploration of the interaction of culture and biology (3).
Research on the prevalance rates and clinical manifestations of depression across cultures illustrates different rates and presentations that are probably attributable to the impact of culture on biology. The chapter, “Gender Differences in Depression,” discusses the relevant data and information on differential aspects of depression in men and women; at the end, an integrative model is well presented. The chapter, “Depression in Children,” asserts that depression may exist not only in children but also in infants and that it needs treatment as early as is possible. Data on the epidemiology, phenomenology, course and outcome, and comorbidity are well presented, as are the genetic, neuro- biology, cognitive, and interpersonal studies. The book’s last chapters discuss depression in adolescents and in later life, as well as suicide. The closing chapter reviews and summarizes the whole book, rather like the introduction but with promising directions for the next decade (when we can probably expect the next edition).
I strongly recommend this book for every one who is looking for more than a textbook and for the most recent information on depression. More important, this well-oriented handbook not only gives readers recent information on depression studies but also offers direction now and for the future.
References
1. Fava GA. Subclinical symptoms in mood disorders: pathophysiological and therapeutic implications. Psychol Med 1999;29:47–61.
2. Hammen C. Depression in families: the social context of risk and resilience in children of depressed mothers. New York: Springer-Verlag; 1991.
3. Kleinman A, Good B, editors. Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and disorder. Berkeley and Los Angeles (CA): University of California Press; 1985.
*Reviewer
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Not recommended / Pas recommandé
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