The Depression Sourcebook.

From the Physician… The pervasiveness of mood disorders is striking and well known to primary care practitioners. Treatment of these disorders is complicated by lack of public awareness about and prejudice against admitting to having such a condition. For example, the single mother who saw me last week to treat her child's attention deficit had attributed the last 5 years of intense mood swings to the stress of raising a hyperactive child. It is Dr. Quinn's admirable ambition to clear up some of this confusion for lay people. While writing from a strongly biological perspective, he commits to giving a balanced view of varied approaches including pharmacologic, psychotherapeutic, and natural. A prime goal of this education is to “give the reader hope” that his or her symptoms are treatable and can be greatly improved, if not cured. This is a worthy ambition, partly realized, but falls short of the ideal. The first chapters, which attempt to orient the reader to the variety of mood disorders, need better organization. The book is liable to be of limited use to patients seeking to get acquainted with mood disorders for the first time or to answer the question that these chapters seem to address, namely, “Could I have a medical problem, and if so, what type?” Even to one familiar with the broad categories of these illnesses, the outline is perplexing and lacking parallelism, blurring the distinctions between diagnoses. It would have been better first to define, say, bipolar disorder and cyclothymia clearly, before showing how the boundaries between them are not always clear. There is also a lack of conscious acknowledgment of the fuzzy border between normal and abnormal. This distinction is implicit in the biographical sketches of historical figures and modern celebrities, but the big question lingers. What separates illness, which should be treated medically, from character and life trials, which demand effort and force of will to overcome? This issue is not explicitly addressed. Van Gogh may not have died so early if he had taken lithium instead of absinthe, but would the world have seen The Starry Night? In treating individuals in distress, the ethical responsibility of the mental health provider is clear, but what are the cultural and societal consequences of taking a biological, largely deterministic approach to these types of problems? Such a discussion is beyond Dr. Quinn's scope. The book leaves me with a nagging feeling that we are at risk of losing the mystery and heroism of the human struggle. In looking at the array of different approaches to these problems, the book will be more helpful to sophisticated readers already diagnosed (or having a family member diagnosed) with a mood disorder. At times, Dr. Quinn is a little strident. The chapter “Medication for Depression” takes the point of view that each imagined question or doubt about the pharmacologic approach can be dismissed quickly. But on the whole, a variety of approaches are described in detail and with respect, without weakening the author's argument for the power and safety of biological methods. The self-help chapter is long and involved with largely helpful tips about coping with difficult circumstances. The Appendix is a good source for resources and support groups. The book is replete with case histories, which illustrate well the complexities of these illnesses. The case histories work to call attention to the nuances of these illnesses and the difficulty of arriving at a proper diagnosis, but may be difficult for the first-time reader to penetrate, as they do not always describe “classic” symptoms. The histories could also have been amplified to add strength to the argument for the biological approach—the case reports of the early chapters, dealing with diagnosis, should have been concluded in the chapters on medication. Were these patients helped once their illness was properly diagnosed and treated with right therapy? Finally, the Sourcebook has a flaw that may make it hard for primary care physicians and nurse practitioners to recommend it to their patients. Dr. Quinn does not recognize these types of providers as partners in the process of treating depressed patients. There is much to be done to upgrade training programs in this area, but the need to include primary caregivers as legitimate therapists is unavoidable. First, there are just too many patients. Dr. Quinn reflects his sense that even many mental health professionals miss the boat with mood disorder patients, and his case histories serve to prove this point. He openly advocates seeking help from psychiatrists with special interest and skills in treating mood disorders. One can't help but wonder how many hours a week they would need to work in order to see all these patients. Most patients will present to primary care long before they recognize the need for mental health help. The presence of overlap syndromes such as chronic fatigue and pain syndromes is not well acknowledged in this volume. These disorders, as well as problems with “nerves,” will continue to be frequently presenting complaints to medical caregivers. Many of these patients will continue to feel more comfortable getting care for these problems with their regular medical providers. Also, psychiatrists often need help in managing medications in the medically complex patient. There is clearly a great deal of work yet to do, not only in educating patients about depression and associated conditions, but also in educating a broad array of practitioners and in finding the best strategies for cooperation.