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Biologically informed psychotherapy for depression
Book Reviews
Biologically Informed Psychotherapy for Depression.By Stephen R. Shuchter, Nancy Downs, Sidney Zisook, New York, Guilford Press, 1996 ($30) 235 pp. Do clinicians need another psychotherapy for depression? Some of us do, others do not. This book offers a step forward for psychotherapists who have not yet learned to recognize depression as a psychiatric disorder. Biologically informed psychotherapy for depression (BIPD) may be a step backwards, however, for clinicians who know interpersonal psychotherapy (IPT) or cognitive behavioral therapy (CBT). The cover hints at the contents: the detail of Durer’s “Melanocholia I” on a largely blank white cover might symbolize the authors’ attempt to preserve a fragment of the art of the historical psychotherapeutic past within the framework of a larger, more “sterile” scientific present field. Their approach is based on a reasonable premise: to integrate current biological knowledge about depression with the psychodynamic lore that long predated and to some degree contradicts it. Much of what the authors state is common sense and probably useful-if untested, and thus inherently not up to date. The book’s major virtue is to underscore important treatment principles about depression, emphasizing the primacy of treating mood disorder rather than focusing on character. Its therapeutic rallying cry, a good one, is to tell the depressed patient “That’s the depression talking.” Brief early chapters charge through background information. The first tries to cover the neurobiology of mood disorders in 16 pages, 2 of which are figures. The resulting inevitable blur of generalizations is unlikely to educate those familiar with the material, and too sketchy to initiate the unfamiliar. A table on medications looks dated in its inclusion of isocarboxazid and in its low minimum therapeutic doses (75 mg) of tricyclic antidepressants. The subsequent chapter on psychodynamic psychotherapy, which displays the authors’ ambivalence toward that approach, is equally curt and cursory. It does demonstrate the fading of psychodynamic explanations in the face of biological data. These chapters are schematically clear, but clearly schematic. In the nicest but also vaguest section, the authors describe the “language of depression.” With this soft metaphor they observe that depressive episodes can “capture” normally insightful individuals, distorting their judgment and actions (p. 47 et passim). Convincing vignettes and patient self-
154
descriptions depict this phenomenon, including the “pseudostupidity” of cognitive depressive symptoms (p. 52). Beyond this, however, the metaphor of a depressive “language” lacks definition and utility. The authors could have made even more strongly than they do the point that dysthymic disorder [which they unhelpfully characterize as “milder” (pp. 43,80) than major depression] can masquerade as personality disorder but should be treated as a chronic mood syndrome. They appear to waffle at points on how much chronic depression is a developmental defect, and how much an illness. And they surprisingly omit diurnal variation as a prominent depressive symptom. There follows a description of BIPD, which seems more an adjunct to pharmacology than a psychotherapy proper. Although the authors call it an amalgam of psychodynamic plus cognitive behavioral (CBT) plus interpersonal therapy (IPT), BIPD appears to be much less than the sum of its parts. Despite authorial claims of a “biological” focus, the biology at which the initial chapter hints plays no direct part in BIPD treatment. It is, rather, an illnessfocused treatment focusing on education about depression as an illness, and as such, neither new nor innovative. BIPD is how any competent pharmacologist might reassure a depressed patient (“that’s the depression talking”) while awaiting a pharmacological response. I fantasized in reading this book that BIPD was the personal psychotherapeutic variant the authors developed in their private practice: a biological quasijustification of an idiosyncratic approach, an eclectic alloy of largely common sense elements. BIPD borrows an IPT medical-model stance, but not its framework or focus. It loosely employs cognitive and behavioral elements, and ambivalently retains some psychodynamic thinking, while firmly rejecting the dynamic model of depressive psychopathology. [Indeed, if the authors worked strictly from a biological model, there would be no necessary place in their system for psychodynamics. The psychodynamic ideas they include in their discussions (c. pp. 97f) appear unsupported.] The resulting gemischmay satisfy no one: certainly not IPT or CBT therapists who already have proven and coherent approaches to depression. Psychodynamic psychotherapists who have ignored depression as a syndrome stand to benefit, but they are likely to be unhappy with the handling psychodynamics receive here. The authors present case histories that seem more generic than useful. Surprisingly for a “biological”
approach, some of them omit mention of family history of depression. Of greater concern is the absence of any suggestion of differential therapeutics, i.e., how to choose among available therapies for a given patient. BIPD is apparently treatment for everyone. But if one chose among proven antidepressant treatment, BIPD would never enter the differential at all. The rationale for using such a therapy is unclear. The authors make no real case for its use, except to argue that it is better than a misguided psychodynamic approach. I agree with this point: psychodynamic therapy may have many other uses, but it is unclear that it is a preferred treatment for depressed patients. Yes, depression should be recognized as an illness; but the same scientific spirit demands its treatment with a proven therapy. The authors mention two successfully researched antidepressant psychotherapies, CBT and IPT, but give each short shrift. They never explain why BIPD, untested in research, might be preferable to either. They dismiss CBT because of its early theoretical focus on irrational thoughts as the etiology of depression, a stance most cognitive therapists have long abandoned. And they misstate that IPT focuses on life events as “causal,” which is simply wrong. The state of the art of psychotherapy now includes a manualized intervention for a defined diagnostic population, and research of its efficacy. This book might loosely be called a manual, and it does address a particular disorder (although the final chapter suggests its applicability to a variety of Axis I disorders). But there is no research to support the use of BIPD. Rather, the unstated assumption is that we should use BIPD because the authors believe it works. Such an argument no longer convinces, and in no way improves on the psychodynamic dogma the authors attack. (In the same vein the authors offer, without rationale, their idiosyncratic San Diego assessment scales in place of established instruments like the Hamilton Depression Rating Scale.) BIPD suffers not only from lack of research, but lack of a psychotherapeutic focus. Because it combines disparate psychotherapeutic techniques without a coherent psychotherapeutic framework (treating “depression” as a syndrome may not provide a clear rationale for using unconnected approaches), BIPD may well have less impact on depression than relatively pure and clear approaches such as CBT and IFT. Also, there is little here that is new: BIPD is mostly old, borrowed, and for the blue. ‘4s there is no compelling reason to use it, BIPD
will likely become marginalia in the great tome of psychotherapies, especially if it remains untested in research trials. In summary, BIPD represents an advance for therapists who might blame the patient’s character rather than identifying depressive disorders, offering support, and prescribing medication. It makes the point that the biological model has superseded the focus on psychodynamic conthcts and personality (although the DSM manuals get surprisingly little credit for this}. For general practitioners, BIPD provides a simple and clear model for conceptualizing antidepressant treatment. For residents in programs that teach no other psychotherapy (alas!), BIPD might provide a functional approach. But one hopes that the next generation of psychotherapists would learn proven treatments like CBT or IPT instead. JOHN
C. MAIIXOWITZ,
‘NW
M.D. York,
N.Y.
PI1 S0163-8,713(Yh)00149-7
Mood Disorders Across the Life Span. Edited by Kenneth I. Shulman, Mauricio Tohen, and Stanley I’. Kutcher. New York, Wiley Publishers, 19% ($59.96), 442 PP. Mood disorders have been recognized since the earliest times. However, there is still significant controversy on both the classification of mood disorders and its manifestation across the life-span. Is the disorder which starts in prepubertal years the same as the one that arises during senescence? Does the disorder change its presentation across the lifespan? Are genetic factors the same for disorders that develop during different stages of the life cycle? Is the treatment for mood disorders the same across the life-span? These and similar questions are critical to our understanding of mood disorders. This book makes an outstanding attempt to explicate these questions and develop an understanding of the current status both conceptual and experimental of mood disorders across the life-span. The chapters are organized in a logical sequence with sections beginning in childhood and ending in senescence. Within each section, there are chapters discussing clinical features, course, and treatment of both unipolar and bipolar disorders. The foreword by Dr. Akiskal and the introductory chapter by Drs. Suppes and Rush are thought provoking and bring a remarkable clarity and focus
155
Biologically Informed Psychotherapy for Depression.By Stephen R. Shuchter, Nancy Downs, Sidney Zisook, New York, Guilford Press, 1996 ($30) 235 pp. Do clinicians need another psychotherapy for depression? Some of us do, others do not. This book offers a step forward for psychotherapists who have not yet learned to recognize depression as a psychiatric disorder. Biologically informed psychotherapy for depression (BIPD) may be a step backwards, however, for clinicians who know interpersonal psychotherapy (IPT) or cognitive behavioral therapy (CBT). The cover hints at the contents: the detail of Durer’s “Melanocholia I” on a largely blank white cover might symbolize the authors’ attempt to preserve a fragment of the art of the historical psychotherapeutic past within the framework of a larger, more “sterile” scientific present field. Their approach is based on a reasonable premise: to integrate current biological knowledge about depression with the psychodynamic lore that long predated and to some degree contradicts it. Much of what the authors state is common sense and probably useful-if untested, and thus inherently not up to date. The book’s major virtue is to underscore important treatment principles about depression, emphasizing the primacy of treating mood disorder rather than focusing on character. Its therapeutic rallying cry, a good one, is to tell the depressed patient “That’s the depression talking.” Brief early chapters charge through background information. The first tries to cover the neurobiology of mood disorders in 16 pages, 2 of which are figures. The resulting inevitable blur of generalizations is unlikely to educate those familiar with the material, and too sketchy to initiate the unfamiliar. A table on medications looks dated in its inclusion of isocarboxazid and in its low minimum therapeutic doses (75 mg) of tricyclic antidepressants. The subsequent chapter on psychodynamic psychotherapy, which displays the authors’ ambivalence toward that approach, is equally curt and cursory. It does demonstrate the fading of psychodynamic explanations in the face of biological data. These chapters are schematically clear, but clearly schematic. In the nicest but also vaguest section, the authors describe the “language of depression.” With this soft metaphor they observe that depressive episodes can “capture” normally insightful individuals, distorting their judgment and actions (p. 47 et passim). Convincing vignettes and patient self-
154
descriptions depict this phenomenon, including the “pseudostupidity” of cognitive depressive symptoms (p. 52). Beyond this, however, the metaphor of a depressive “language” lacks definition and utility. The authors could have made even more strongly than they do the point that dysthymic disorder [which they unhelpfully characterize as “milder” (pp. 43,80) than major depression] can masquerade as personality disorder but should be treated as a chronic mood syndrome. They appear to waffle at points on how much chronic depression is a developmental defect, and how much an illness. And they surprisingly omit diurnal variation as a prominent depressive symptom. There follows a description of BIPD, which seems more an adjunct to pharmacology than a psychotherapy proper. Although the authors call it an amalgam of psychodynamic plus cognitive behavioral (CBT) plus interpersonal therapy (IPT), BIPD appears to be much less than the sum of its parts. Despite authorial claims of a “biological” focus, the biology at which the initial chapter hints plays no direct part in BIPD treatment. It is, rather, an illnessfocused treatment focusing on education about depression as an illness, and as such, neither new nor innovative. BIPD is how any competent pharmacologist might reassure a depressed patient (“that’s the depression talking”) while awaiting a pharmacological response. I fantasized in reading this book that BIPD was the personal psychotherapeutic variant the authors developed in their private practice: a biological quasijustification of an idiosyncratic approach, an eclectic alloy of largely common sense elements. BIPD borrows an IPT medical-model stance, but not its framework or focus. It loosely employs cognitive and behavioral elements, and ambivalently retains some psychodynamic thinking, while firmly rejecting the dynamic model of depressive psychopathology. [Indeed, if the authors worked strictly from a biological model, there would be no necessary place in their system for psychodynamics. The psychodynamic ideas they include in their discussions (c. pp. 97f) appear unsupported.] The resulting gemischmay satisfy no one: certainly not IPT or CBT therapists who already have proven and coherent approaches to depression. Psychodynamic psychotherapists who have ignored depression as a syndrome stand to benefit, but they are likely to be unhappy with the handling psychodynamics receive here. The authors present case histories that seem more generic than useful. Surprisingly for a “biological”
approach, some of them omit mention of family history of depression. Of greater concern is the absence of any suggestion of differential therapeutics, i.e., how to choose among available therapies for a given patient. BIPD is apparently treatment for everyone. But if one chose among proven antidepressant treatment, BIPD would never enter the differential at all. The rationale for using such a therapy is unclear. The authors make no real case for its use, except to argue that it is better than a misguided psychodynamic approach. I agree with this point: psychodynamic therapy may have many other uses, but it is unclear that it is a preferred treatment for depressed patients. Yes, depression should be recognized as an illness; but the same scientific spirit demands its treatment with a proven therapy. The authors mention two successfully researched antidepressant psychotherapies, CBT and IPT, but give each short shrift. They never explain why BIPD, untested in research, might be preferable to either. They dismiss CBT because of its early theoretical focus on irrational thoughts as the etiology of depression, a stance most cognitive therapists have long abandoned. And they misstate that IPT focuses on life events as “causal,” which is simply wrong. The state of the art of psychotherapy now includes a manualized intervention for a defined diagnostic population, and research of its efficacy. This book might loosely be called a manual, and it does address a particular disorder (although the final chapter suggests its applicability to a variety of Axis I disorders). But there is no research to support the use of BIPD. Rather, the unstated assumption is that we should use BIPD because the authors believe it works. Such an argument no longer convinces, and in no way improves on the psychodynamic dogma the authors attack. (In the same vein the authors offer, without rationale, their idiosyncratic San Diego assessment scales in place of established instruments like the Hamilton Depression Rating Scale.) BIPD suffers not only from lack of research, but lack of a psychotherapeutic focus. Because it combines disparate psychotherapeutic techniques without a coherent psychotherapeutic framework (treating “depression” as a syndrome may not provide a clear rationale for using unconnected approaches), BIPD may well have less impact on depression than relatively pure and clear approaches such as CBT and IFT. Also, there is little here that is new: BIPD is mostly old, borrowed, and for the blue. ‘4s there is no compelling reason to use it, BIPD
will likely become marginalia in the great tome of psychotherapies, especially if it remains untested in research trials. In summary, BIPD represents an advance for therapists who might blame the patient’s character rather than identifying depressive disorders, offering support, and prescribing medication. It makes the point that the biological model has superseded the focus on psychodynamic conthcts and personality (although the DSM manuals get surprisingly little credit for this}. For general practitioners, BIPD provides a simple and clear model for conceptualizing antidepressant treatment. For residents in programs that teach no other psychotherapy (alas!), BIPD might provide a functional approach. But one hopes that the next generation of psychotherapists would learn proven treatments like CBT or IPT instead. JOHN
C. MAIIXOWITZ,
‘NW
M.D. York,
N.Y.
PI1 S0163-8,713(Yh)00149-7
Mood Disorders Across the Life Span. Edited by Kenneth I. Shulman, Mauricio Tohen, and Stanley I’. Kutcher. New York, Wiley Publishers, 19% ($59.96), 442 PP. Mood disorders have been recognized since the earliest times. However, there is still significant controversy on both the classification of mood disorders and its manifestation across the life-span. Is the disorder which starts in prepubertal years the same as the one that arises during senescence? Does the disorder change its presentation across the lifespan? Are genetic factors the same for disorders that develop during different stages of the life cycle? Is the treatment for mood disorders the same across the life-span? These and similar questions are critical to our understanding of mood disorders. This book makes an outstanding attempt to explicate these questions and develop an understanding of the current status both conceptual and experimental of mood disorders across the life-span. The chapters are organized in a logical sequence with sections beginning in childhood and ending in senescence. Within each section, there are chapters discussing clinical features, course, and treatment of both unipolar and bipolar disorders. The foreword by Dr. Akiskal and the introductory chapter by Drs. Suppes and Rush are thought provoking and bring a remarkable clarity and focus
155