- Email: [email protected]
Treating resistant depression
289
Book reviewer
relatively limited research on the lateralisation of affect. One practical lesson which might tentatively be drawn from this chapter is that crying, moaning and shrieking may be marginally more effective if delivered to the recipient’s left ear. A chapter by the editor discusses various forms of dichotic conditioning technique. The chapters vary from the stylish to the stodgy, though the majority are well written. In a book of this length devoted to a single topic some overlap between the contents of each chapter seems inevitable. The coverage seems unduly repetitive, however, in respect of certain general issues such as reliability and measurement, which could have been dealt with once within a single chapter. Absence of British contributors aside, there are no serious omissions though, after 646 pages, one would have welcomed some form of final editorial reflection. More serious is the poor standard of the subject index and the total lack of any author index. The “camera ready” print style is acceptable as far as the ordinary text is concerned but tables of data can be rather difficult to interpret in this format. The book is undoubtedly of great value as a state of the art report. At the end, however, one feels that rather more has been learned about dichotic listening than about what has been learned from using it. The main cause of this dissatisfaction, however, is the inability of current models of dichotic performance to cope adequately with the complexity of the data rather than, for all its faults, the technique itself. It is to be hoped that the central character of future editions will be made of sterner stuff.
The Polytechnic
Andrew Burton of Eust London
Reference Fodor,
J. (1983). The modularity of mind. New York:
J. ZOHAR and (PMA Publishing
MIT Press
R.H. BELMAKER (Eds.), Treating Resistant Corp., New York, 1987) pp. 427, $50.00.
Depression
I was initially reluctant to review this book, as I expected it to consist of a mix of opinionated special pleading and unconvincing case reports. I could not have have been more wrong. The contributors to this volume have made a concerted effort to review critically the efficacy and place of numerous modes of dealing with depressions that resist treatment with antidepressant drugs. Many of the authors are enthusiasts for a particular therapy, but, almost
290
Book review
without exception, they are clear about the type of patients for whom it would be suitable. More important, they are commendably open about weaknesses in the evidence; I could find no instance of an author trying to conceal or downplay negative findings. The book is in three parts: introduction, “major steps”, and “adjunctive measures”. The introduction consists of three well chosen chapters, dealing with the classification of chronic depressions (Akiskal & Links), the characteristics of resistant depression (a particularly informative chapter by Thase & Kupfer), and the psychological management of resistant depression (Greenberg & Spiro). The second section, “major steps”, consists of seven authoritative reviews, including, inter alia, a discussion of the importance of blood monitoring in determining whether an apparently resistant patient has actually received an adequate antidepressant trial, and chapters on the role of ECT, MAOIs and antidepressant-neuroleptic combinations. The third section, “adjunctive measures”, contains 13 shorter pieces, dealing with a wide range of potential alternatives, including little-used drugs such as opiates and beta-receptor agonists, and non-pharmacological measures like sleep deprivation and light therapy. These chapters are a little uneven in scope and quality, but, if anything, this adds to the air of honest enquiry. The only serious omission is a chapter on selective 5-HT uptake inhibitors, which are discussed in passing by several authors, but surely are of sufficient importance to merit a chapter in their own right. The editors have made some curious choices in their designation of particular treatment approaches as “major steps” or “adjunctive measures”. The addition of lithium to antidepressant drug therapy, for example (“a major step”), is certainly an exciting new development, but it has been tried on only 100 or so patients, the majority of them in open trials. At present, the evidence in favour of combining triiodothyronine (T3) with a tricyclic (an “adjunctive measure”) is somewhat stronger. Similarly, it seems odd to designate carbamazepine, a treatment which the authors acknowledge is “not likely to be approved for use in affective disorders in the near future”, a “major step”, while relegating a review of second generation antidepressants to the section on “adjunctive measures”: There is very little evidence that these drugs are effective in patients who are genuinely resistant to tricyclics, but they do represent a major step forward in patients who are intolerant of tricychc side effects. The chapter on carbamazepine, incidentally, is far too long. But these criticisms are trivial. My only serious reservation about the book is that it would have benefitted from a final section, containing two further chapters. One is a short account of current developments in preclinical pharmacology, dealing particularly with potential new antidepressants that are now entering human trials, such as dopamine uptake inhibitors, 5HTl agonists and 5HT2 antagonists, While respecting the editors’ decision to confine their coverage to treatments actually in use, I cannot help feeling that the clinicians
Book i-CUICWS
291
at whom this book is aimed might have appreciated the opportunity to gaze a little way into the future. The other, and more serious omission, is an overview from the editors that uses the wealth of material in this book to lay out a rational treatment strategy. In the absence of recommendations from the editors, I found myself constructing the following scheme, which, as a non-clinician, I offer somewhat diffidently (references are to chapters in the book): (i)
Ensure that non-affective disorders, particularly hypothyroidism and anxiety, are absent, or, if present, are adequately treated. (ii) Commence treatment with a tricyclic, and ensure compliance and adequate dosing by monitoring plasma drug level. (Gold et al. make a strong case that this procedure, while currently expensive, is actually cost-effective.) As there is little to choose between tricyclics, use imipramine or nortriptyline, for which the best evidence is available relating clinical response to plasma level. (iii) If plasma monitoring is not available, raise the dose. As noted in several chapters, while the efficacy of tricyclics appears to be in the region of 60-70%, the true figure may be closer to 90% if adequate doses are delivered. (iv) If the tricyclic still does not work, try an atypical antidepressant, chosen on the basis of its side effect profile (Pohl & Gershon); there is no rational basis for switching to another tricyclic (Montgomery). (v) If this doesn’t work either, try adding lithium (de Montigny & Cournoyer) or T3 (Prange). If my reading of this book is correct, precious few depressions will remain intractable to a treatment regime of this kind, and those that do fall into a small number of more-or-less treatable categories. Indeed, for these patients it probably makes better sense to omit steps (iv) and (v). They are: (i)
Severely agitated, delusional depressions: Use ECT (Fink) or a tricyclic/ neuroleptic combination (Nelson). (ii) Mild depressions with “atypical” symptoms: Use an MAO1 (Shawcross & Tyrer) or tricyclic plus T3 (Thase & Kupfer). (iii) Rapidly cycling bipolar patients: Use lithium or carbamazepine (Post & Uhde). (iv) Chronic mild depressions: Use cognitive therapy or social skills training (Goldberg & Spiro) or try a psychostimulant (Ayd & Zohar). How well would this scheme work (and more important, is it correct)? The editors could have answered these questions, and I wish they had. In general, however, the editors are to be congratulated on compiling an exciting and objective collection. The book is aimed at “the up-to-date clinician who is willing to expand his armamentarium while treating the
resistant depressive”. I would recommend this book strongly, not only to the adventurous clinician, but also basic researchers who need to know the state of the art in the clinic: This book will tell them. Paul Willner City of London Polytechnic
F.E. BLOOM and A. LAZERSON, Bruin, Mind und Behauiour, 2nd Edition (W.H. Freeman and Co., New York, 1988) pp. xiii + 394, Paperback U7.95. The production of textbooks on psychobiology is flourishing. Over the last 4 to 5 years I have come across. in a fairly unsystematic search. 15 or so. The majority are American, and conform to a pattern of large size, extensive illustrations, and glossy presentation. Major variation comes in choice of topics covered, and style of text - insets covering case studies or brief biographies of legendary psychobiologists, coordinating materials for companion study guides, and so forth. The particular and unique feature of Brain, Mind, und Behavior is that it sets out a quasi-philosophical position right from the preface, and then uses this to provide a framework for the latter detailed material on brain function. This is a commendable course. However hard one tries, texts in this area always end up as separate topic-based chapters which can be read in any order. giving the reader little or no sense of a co-ordinated research area. A consistent conceptual approach at least tries to provide some coherence to a very bitty subject. The approach taken is strictly biological. Mind and behaviour will ultimately be explainuhle in terms of the brain’s cellular structure, chemical signals, and operations. Now my own position, for what it is worth. is that this approach is severely misleading. Certainly I would agree that the brain’s material structure produces both normal and abnormal behaviour, but also acts as a final common pathway mediating the effects of non-biological variables (immediate social environment, cultural influences, etc.) on behaviour. All behaviour will have biological correlates, but describing these does not necessarily provide an explanation of the behaviour. The danger is that the drive to identify the neurophysiological correlates of a behaviour leads to a neglect of other non-biological factors. The presentation of material in the book is excellent. The anatomical illustrations are true illustrations rather than figures, with fine use of colour, bringing out the three-dimensional nature of brain structure with dramatic impact. Where figures are used they are clear and comprehensible, and there is a sensible use of photographs. It is the best presented text I have seen.
Book reviewer
relatively limited research on the lateralisation of affect. One practical lesson which might tentatively be drawn from this chapter is that crying, moaning and shrieking may be marginally more effective if delivered to the recipient’s left ear. A chapter by the editor discusses various forms of dichotic conditioning technique. The chapters vary from the stylish to the stodgy, though the majority are well written. In a book of this length devoted to a single topic some overlap between the contents of each chapter seems inevitable. The coverage seems unduly repetitive, however, in respect of certain general issues such as reliability and measurement, which could have been dealt with once within a single chapter. Absence of British contributors aside, there are no serious omissions though, after 646 pages, one would have welcomed some form of final editorial reflection. More serious is the poor standard of the subject index and the total lack of any author index. The “camera ready” print style is acceptable as far as the ordinary text is concerned but tables of data can be rather difficult to interpret in this format. The book is undoubtedly of great value as a state of the art report. At the end, however, one feels that rather more has been learned about dichotic listening than about what has been learned from using it. The main cause of this dissatisfaction, however, is the inability of current models of dichotic performance to cope adequately with the complexity of the data rather than, for all its faults, the technique itself. It is to be hoped that the central character of future editions will be made of sterner stuff.
The Polytechnic
Andrew Burton of Eust London
Reference Fodor,
J. (1983). The modularity of mind. New York:
J. ZOHAR and (PMA Publishing
MIT Press
R.H. BELMAKER (Eds.), Treating Resistant Corp., New York, 1987) pp. 427, $50.00.
Depression
I was initially reluctant to review this book, as I expected it to consist of a mix of opinionated special pleading and unconvincing case reports. I could not have have been more wrong. The contributors to this volume have made a concerted effort to review critically the efficacy and place of numerous modes of dealing with depressions that resist treatment with antidepressant drugs. Many of the authors are enthusiasts for a particular therapy, but, almost
290
Book review
without exception, they are clear about the type of patients for whom it would be suitable. More important, they are commendably open about weaknesses in the evidence; I could find no instance of an author trying to conceal or downplay negative findings. The book is in three parts: introduction, “major steps”, and “adjunctive measures”. The introduction consists of three well chosen chapters, dealing with the classification of chronic depressions (Akiskal & Links), the characteristics of resistant depression (a particularly informative chapter by Thase & Kupfer), and the psychological management of resistant depression (Greenberg & Spiro). The second section, “major steps”, consists of seven authoritative reviews, including, inter alia, a discussion of the importance of blood monitoring in determining whether an apparently resistant patient has actually received an adequate antidepressant trial, and chapters on the role of ECT, MAOIs and antidepressant-neuroleptic combinations. The third section, “adjunctive measures”, contains 13 shorter pieces, dealing with a wide range of potential alternatives, including little-used drugs such as opiates and beta-receptor agonists, and non-pharmacological measures like sleep deprivation and light therapy. These chapters are a little uneven in scope and quality, but, if anything, this adds to the air of honest enquiry. The only serious omission is a chapter on selective 5-HT uptake inhibitors, which are discussed in passing by several authors, but surely are of sufficient importance to merit a chapter in their own right. The editors have made some curious choices in their designation of particular treatment approaches as “major steps” or “adjunctive measures”. The addition of lithium to antidepressant drug therapy, for example (“a major step”), is certainly an exciting new development, but it has been tried on only 100 or so patients, the majority of them in open trials. At present, the evidence in favour of combining triiodothyronine (T3) with a tricyclic (an “adjunctive measure”) is somewhat stronger. Similarly, it seems odd to designate carbamazepine, a treatment which the authors acknowledge is “not likely to be approved for use in affective disorders in the near future”, a “major step”, while relegating a review of second generation antidepressants to the section on “adjunctive measures”: There is very little evidence that these drugs are effective in patients who are genuinely resistant to tricyclics, but they do represent a major step forward in patients who are intolerant of tricychc side effects. The chapter on carbamazepine, incidentally, is far too long. But these criticisms are trivial. My only serious reservation about the book is that it would have benefitted from a final section, containing two further chapters. One is a short account of current developments in preclinical pharmacology, dealing particularly with potential new antidepressants that are now entering human trials, such as dopamine uptake inhibitors, 5HTl agonists and 5HT2 antagonists, While respecting the editors’ decision to confine their coverage to treatments actually in use, I cannot help feeling that the clinicians
Book i-CUICWS
291
at whom this book is aimed might have appreciated the opportunity to gaze a little way into the future. The other, and more serious omission, is an overview from the editors that uses the wealth of material in this book to lay out a rational treatment strategy. In the absence of recommendations from the editors, I found myself constructing the following scheme, which, as a non-clinician, I offer somewhat diffidently (references are to chapters in the book): (i)
Ensure that non-affective disorders, particularly hypothyroidism and anxiety, are absent, or, if present, are adequately treated. (ii) Commence treatment with a tricyclic, and ensure compliance and adequate dosing by monitoring plasma drug level. (Gold et al. make a strong case that this procedure, while currently expensive, is actually cost-effective.) As there is little to choose between tricyclics, use imipramine or nortriptyline, for which the best evidence is available relating clinical response to plasma level. (iii) If plasma monitoring is not available, raise the dose. As noted in several chapters, while the efficacy of tricyclics appears to be in the region of 60-70%, the true figure may be closer to 90% if adequate doses are delivered. (iv) If the tricyclic still does not work, try an atypical antidepressant, chosen on the basis of its side effect profile (Pohl & Gershon); there is no rational basis for switching to another tricyclic (Montgomery). (v) If this doesn’t work either, try adding lithium (de Montigny & Cournoyer) or T3 (Prange). If my reading of this book is correct, precious few depressions will remain intractable to a treatment regime of this kind, and those that do fall into a small number of more-or-less treatable categories. Indeed, for these patients it probably makes better sense to omit steps (iv) and (v). They are: (i)
Severely agitated, delusional depressions: Use ECT (Fink) or a tricyclic/ neuroleptic combination (Nelson). (ii) Mild depressions with “atypical” symptoms: Use an MAO1 (Shawcross & Tyrer) or tricyclic plus T3 (Thase & Kupfer). (iii) Rapidly cycling bipolar patients: Use lithium or carbamazepine (Post & Uhde). (iv) Chronic mild depressions: Use cognitive therapy or social skills training (Goldberg & Spiro) or try a psychostimulant (Ayd & Zohar). How well would this scheme work (and more important, is it correct)? The editors could have answered these questions, and I wish they had. In general, however, the editors are to be congratulated on compiling an exciting and objective collection. The book is aimed at “the up-to-date clinician who is willing to expand his armamentarium while treating the
resistant depressive”. I would recommend this book strongly, not only to the adventurous clinician, but also basic researchers who need to know the state of the art in the clinic: This book will tell them. Paul Willner City of London Polytechnic
F.E. BLOOM and A. LAZERSON, Bruin, Mind und Behauiour, 2nd Edition (W.H. Freeman and Co., New York, 1988) pp. xiii + 394, Paperback U7.95. The production of textbooks on psychobiology is flourishing. Over the last 4 to 5 years I have come across. in a fairly unsystematic search. 15 or so. The majority are American, and conform to a pattern of large size, extensive illustrations, and glossy presentation. Major variation comes in choice of topics covered, and style of text - insets covering case studies or brief biographies of legendary psychobiologists, coordinating materials for companion study guides, and so forth. The particular and unique feature of Brain, Mind, und Behavior is that it sets out a quasi-philosophical position right from the preface, and then uses this to provide a framework for the latter detailed material on brain function. This is a commendable course. However hard one tries, texts in this area always end up as separate topic-based chapters which can be read in any order. giving the reader little or no sense of a co-ordinated research area. A consistent conceptual approach at least tries to provide some coherence to a very bitty subject. The approach taken is strictly biological. Mind and behaviour will ultimately be explainuhle in terms of the brain’s cellular structure, chemical signals, and operations. Now my own position, for what it is worth. is that this approach is severely misleading. Certainly I would agree that the brain’s material structure produces both normal and abnormal behaviour, but also acts as a final common pathway mediating the effects of non-biological variables (immediate social environment, cultural influences, etc.) on behaviour. All behaviour will have biological correlates, but describing these does not necessarily provide an explanation of the behaviour. The danger is that the drive to identify the neurophysiological correlates of a behaviour leads to a neglect of other non-biological factors. The presentation of material in the book is excellent. The anatomical illustrations are true illustrations rather than figures, with fine use of colour, bringing out the three-dimensional nature of brain structure with dramatic impact. Where figures are used they are clear and comprehensible, and there is a sensible use of photographs. It is the best presented text I have seen.