Mood Disorders: Systematic Medication Management: Modern Problems in Pharmacopsychiatry, vol. 25

The last decade of the second millennium from a psychiatric research standpoint has been designated as the Decade of the Brain. We have crossed that threshold, and judging from the number and variety of psychotherapeutic agents produced during this decade, we might as well call it the Decade of Psychopharmacology. This is actually the second peak in the psychopharmacological revolution, with the production of agents that have fewer side effects and target a greater variety of substrates in the brain. They offer physicians and patients greater flexibility, broader indications, and much better compliance. In terms of Food and Drug Administration approvals, the field of antidepressants certainly leads this revolution. There has never been a better time to get depressed!

This volume brings together some of the most eminent clinical researchers in this field. It is a transatlantic monograph that covers most areas in the treatment of depression, including the depressive phase of bipolar disorder, as well as phototherapy and ECT. The information covered in this monograph, although abundantly available as supplements to several psychiatric journals, is of better quality here, with superb scholarship and incisive logic. There is also a thoughtful chapter on “The Role of the Patient in Treatment Decisions,” a topic rarely discussed in the psychiatric literature. Beyond these substantive content areas, a distinctive feature of this monograph is its emphasis on how to think about treatment strategies in mood disorders. For this reason, I found the title of the book to be somewhat misleading, because it suggests a clinical focus—when it is largely epistemological.

One of the most palpable results of the user-friendly nature of the new antidepressants is that the pharmacological treatment of chronic depression has become more acceptable in the long-term. Therefore, I was somewhat surprised that dysthymia and chronic depression were not covered in a separate chapter. Instead, they are buried in a chapter on “The Psychopharmacological Treatment of Nonmajor Mood Disorders.” This chapter subsumes dysthymia, minor depressive disorder, recurrent brief depressive disorder, and premenstrual dysphoric disorder. I question the wisdom of placing the “minor” and dysthymic subtypes under the same chapter heading—it sends the wrong message.

Since a chapter covers the elderly, it would have been appropriate to cover the less well-developed field of mood disorders in childhood and adolescence as well. Although there is a chapter specifically devoted to medical comorbidity, psychiatric comorbidity is not adequately addressed in this monograph; patients with comorbid psychiatric disorders are precisely the type of patients excluded from most research protocols, and clinical readers would like to learn more about them. I was also surprised, given the dual research competence of the editor, that a chapter on combined pharmacotherapy and psychotherapy was not included. Finally, a chapter on how gender, ethnic, and cultural factors affect response to antidepressants and mood stabilizers would have enlightened clinical readers.

Although treatments of the manic and depressive phases of bipolar disorder are competently covered, I would have preferred a separate chapter that integrated what we know about the long-term treatment of patients with bipolar disorder. Because it endeavors to cover largely what is evidence-based, the volume tends to shy away from the art of clinical management. There was a time in the 1970s and 1980s when we had lithium clinics and mood clinics. Today, they are largely replaced by research programs. Some psychiatrists have actually proclaimed that “lithium has stopped working.” What specialty clinics provided was an ambiance of optimism about and commitment to long-term care, and a strong therapeutic bond was forged between patients and clinical staff. With the erosion of the family in large cities today in the United States and elsewhere, patients with lifelong illnesses like affective disorder need more of the type of care that mood and lithium clinics used to provide in the past.

The scientific advances in the pharmacology of affective disorders can best be described as spectacular. If they are not matched by humane clinical care, however, their impact on the course of the patients’ illness and quality of life cannot be optimized. Perhaps it is too much to ask that the editor and his distinguished authors address this issue with the requisite depth. As physicians, however, we cannot simply blame economic pressures coming from outside medicine.

Psychiatry must recreate itself by reaffirming the first revolution in our field: the humane treatment of the mentally ill. This is not merely a rhetorical matter. It is a pragmatic one that, in principle, can and should be solved. Talented bedside physicians who teach how to care for patients should be revered by medical school deans at least as much as rigorous scientists working in laboratories.

It is a curious fact that the care of the most treatment-refractory patients in psychiatry—including those with recurrent and chronic affective disorders—are entrusted to relatively inexperienced psychiatry residents, often without benefit of faculty with extensive hands-on clinical experience. Trainees at least have the advantage of not being jaundiced by negative professional experiences.

Affective illness, whether narrowly or broadly defined, involves more people from among the mentally ill and from the general population than any other type of psychiatric problem. I cannot foresee any improvement in our ability to improve the prognosis of affective disorders without the training of competent “affectiveologists” who will shoulder the clinical responsibility of taking care of these patients. Mere advice—on systematic medication use for mood disorders—will not do. Nor would publishing an algorithm—or consensus guidelines—every other month improve the day-to-day care of the affectively ill. Clinical situations are complex, and general principles of psychopharmacotherapy are preferable to elaborate diagrams or endless narration of the results of drug trials. They are no substitute for clinical acumen.

I very much hope that Dr. Rush and the distinguished clinical scientists he has assembled can one day rewrite this book with a different focus: the systematic application of the science of psychopharmacology to the care of the affectively ill. Such a book will greatly benefit from the synthetic wisdom of the editor. I say this because he has authored no chapter in the volume under review.

A decade earlier, Dr. Rush orchestrated a large number of scholars, psychiatrists, and other medical practitioners in the writing of two encyclopedic—yet concise—volumes in the diagnosis and treatment of depression in primary care (1, 2). This was the challenge that our field had been given by the Agency for Health Care Policy and Research. Those two volumes together represent a landmark in the war against depression. Patients and the medical profession would owe Dr. Rush a great debt of gratitude if these two volumes (geared to general medical practice) were updated, along with the volume under review here (more specifically geared to psychiatrists).