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20/12/10

59% for me: Biggest drawback is too much debt and too little savings. Savings is currently being eaten up by family members who are having problems. Debt is going down but not fast enough. (more...)

 

A PATIENT'S PERSPECTIVE — ART BUCHWALD, a report on an interview 1 of Art Buchwald, Smooth Sailing, Spring 1997

For this year's "Patient's Perspective," Dr. Ray DePaulo interviewed renowned humor columnist Art Buchwald (who was kind enough to substitute for an ailing Margot Kidder). As they spoke, Mr. Buchwald frequently filled the auditorium with laughter.

In his introduction, Dr. DePaulo noted that several previous symposium interviewees had mentioned Mr. Buchwald's depressive illness, although he himself had been very reluctant to go public. That reluctance may have been related to a severe loss in early childhood: when he was four years old, Mr. Buchwald said, his mother was institutionalized after a mental breakdown, and she remained hospitalized for 35 years. Mr. Buchwald was hospitalized in 1963 for his first depressive episode, and he was in the same hospital where some of his relatives had been. He recalled his horror and despair; he was concerned that he would never be able to write again, and he was suicidal. He remembered being racked with guilt and sleeping very poorly, but he also recalled the kindness of the hospital staff who stayed beside him throughout a despondent night. Some "tricks" helped keep him alive; his wife left a picture of their children at his bedside as a reminder of hope. Jokingly, Mr. Buchwald stated that he really did not want to kill himself, because he was afraid his obituary wouldn't make the New York Times.

Summertime neighbors William Styron (author of Sophie's Choice), Mike Wallace (of 60 Minutes), and Mr. Buchwald became friends through their mutual experiences with mood disorders. Mr. Buchwald wryly reported his disappointment that Mr. Styron made money off his depressive episode by publishing a book about it, Darkness Visible: A Memoir of Madness, whereas he himself hasn't made a cent off his depression. Recalling his discussions with Mr. Styron, he said, "Bill and I used to spend time on his front porch arguing. He maintained that his depression was a 9.5 on the Richter scale and all I had was a rainy day at Disney World."

Mr. Buchwald strongly urged the audience to use the media to educate the public about mood disorders. He has been stopped in airports and on the street by people thanking him for his message of hope. He reminded the audience of the immensely popular mood-disorders segment of the talk show Larry King Live (CNN) that aired in February 1997. Mr. Buchwald, Mike Wallace, Dr. Kay Jamison (author of An Unquiet Mind), and Wynonna Judd (formerly of the country singing duo The Judds) spoke of their personal and professional experiences with mood disorders. This segment of Larry King Live remains the most requested video in the program's history.

Recalling another public appearance, Mr. Buchwald spoke of the time he talked about depression as a guest on Prime Time Live. He urged depressed viewers not to commit suicide, because their loved ones would have to live with the memory of it for the rest of their lives. Later, he received a letter from a woman saying that he had saved her life. She said that just after taking an overdose of pills, she had rolled over onto the remote control. Art Buchwald's face appeared on the TV screen, imploring her not to commit suicide. This sequence of events struck her as being a sign from God. She promptly forced herself to vomit up the pills.

Mr. Buchwald mentioned a helpful "trick" he had used to persuade a friend to take medication for a depressive episode: he likened the illness to a car that cannot move and likened the treatment to the pressure on the accelerator that will get the car (the person) moving again.

In response to a question from the audience about medication and creativity, Mr. Buchwald said that some people involved in the arts do not understand their talent or where it comes from. Some believe that their talent is derived from their illness and will disappear if they are treated, but Mr. Buchwald urges people with doubts to give medication a try. He believes that you can become a better person from the experience of recovering from a mood disorder.

1 An interview at a DRADA/Johns Hopkins symposium, Baltimore, Maryland, April 1997

by Frieda Vandegaer, R.N., M.S., C.S.
Smooth Sailing: Spring 1997

 

Book Reviews

New Hope for People with Bipolar Disorder, Fawcett, Jan, M.D., Golden, Bernard, Ph.D., and Rosenfeld, Nancy. Roseville, Calif.: Prima Publishing, 2000. Paperback, 333 pages.

A collaboration between a psychiatrist, a psychologist, and a writer-patient, New Hope for People with Bipolar Disorder is written for the layperson and has basic, reader-friendly information about bipolar disorder. Like most books of this type, it provides a general overview of the illness, medications and therapies, and tips for living with the illness. Also included is a brief section on children and adolescents, a subject that was often ignored. Unlike Adult Bipolar Disorders, reviewed above, it mentions only two alternative medicines (supplements): St. John’s wort and the omega-3 fatty acids.

This book claims to be an authoritative guide to bipolar disorder. However, the authors fall short of this goal, contradict accepted theories, and present complementary therapies not mentioned in other books on the subject. The dubious thinking of the authors is shown when they expound on “authorities” who failed to handle the illness appropriately. Among these are Danielle Steel (ignorant of the danger in her son’s illness) and Judge Sol Wachtler (the Chief Judge of the New York Court of Appeals who was ultimately convicted and jailed for his behavior). Chapter 8, entitled “Optimism, Hope and Transcendence,” discusses the works of Czikszentmihalyi, Seligman, and Coleman (names this reviewer has not come across before in her reading), with their ideas on observing our emotions and thinking as strategies “to directly observe and alter our emotional life in a positive way.” Most of the section on psychotherapy is devoted to cognitive therapy, although coping skills and problem-solving therapy are also mentioned. A final example of the book’s shortcomings is in the chapter on medication, in a brief overview of ECT (electroconvulsive therapy). The authors state, “Although it is vastly safer and more humane today than it was in the past, it is still a controversial and seldom employed therapy.”

Although the book is easy for the layperson to read, New Hope for People with Bipolar Disorder falls short of the authors’ claims of “proven methods of managing your life & your work.” In fact, the promised “cutting-edge treatment models” ignore many proven methods in use by practitioners.

By Marion Ehrlich

 

Book Reviews

The Complete Guide to Psychiatric Drugs: Straight Talk for Best Results, Drummond, Edward, M.D. New York: John Wiley & Sons, Inc., 2000. (Paperback, 314 pages, $17.95)

The Complete Guide to Psychiatric Drugs: Straight Talk for Best Results, by Edward Drummond, is a useful handbook for the layperson attempting to sort through the myriad of psychiatric drugs on the market. One section provides, in alphabetical order, a general description of each drug, its generic and brand names, and the condition it is used to treat. Included are precautions necessary when taking the drug, possible side effects, doses, interactions, how to monitor your use, and what to expect when you stop taking the drug. Other helpful information includes how to proceed when you have missed a dose and the effects of drinking alcohol while taking the drug. In a clear style, the author skillfully integrates this information without raising undue fear in the reader. The author addresses many questions that patients and family members may have about medication treatment.

The Complete Guide to Psychiatric Drugs deals with all psychiatric syndromes, not just affective disorders. It discusses disorders of anxiety, attention deficit, development (such as autism), drug dependence, Alzheimer’s, eating, and sleep.

The chapter that should be the most important in the book, “What to Discuss with Your Doctor before You Start Medication,” unfortunately does not live up to its title. The reader is left with the impression that it is up to the patient?not the expert, the doctor?to consider treatment plans and choose the best.

The Complete Guide to Psychiatric Drugs can probably be found in the self-help section of your library—a placement with which this reviewer finds fault. Despite the hype on the front and back covers, i.e., “How to decide if drugs can help you,” “How to start and stop drugs safely,” and “Your complete guide to choosing and using medication,” medication treatment for psychiatric disorders is not a self-help issue. The book is a good guide for educational purposes or for an intelligent discussion with the doctor. It is not, however, the definitive answer to medication treatment.

By Marion Ehrlich
Ed. note: Bruce Hershfield, M.D., and Sallie Mink contributed to this review.

 

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    The information contained in www.drada.org is presented in summary form only and intended to provide broad consumer understanding and knowledge of mood disorders and the resources offered by DRADA.

    All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for depressive disorder. This Web site should not be used in place of a visit, call, consultation or advice of your physician or other health care provider. You should seek prompt medical care for any specific health issue you may have. You should never disregard medical advice or delay in seeking it because of something you have read here.

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    The Depression and Related Affective Disorders Association (DRADA) is a nonprofit organization whose mission includes providing information about depressive disorders. Prior to publication, all medically related material on the DRADA web site is reviewed for medical accuracy by a psychiatrist on the faculty of the Johns Hopkins School of Medicine. From time to time, material published on the DRADA web site is reviewed to ensure that it remains accurate, relevant, and generally appropriate. The information provided on the DRADA web site is designed to support, not substitute for, the relationship between a patient/site visitor and his or her physician.

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    TREATING THE ILLNESS, excerpts from an article by Andrew Feinberg, M.D.,1 Smooth Sailing, Fall 1995, pp. 1, 2.

    I've been directing my professional energy toward the diagnosis and treatment of mood disorders in teenagers, adults, and seniors for the past 10 years. . . . I think the single most important function of any psychiatrist who is treating a clinically depressed patient is to offer hope in a confident manner. I tell my patients that they are indeed fortunate to have available such a wide variety of effective antidepressants. I remind them that . . . not that long ago . . . we had only two groups of antidepressants from which to choose. Unfortunately, all available antidepressants have side effects, and a significant amount of my time is spent either reassuring patients that side effects are frequently only transient, or helping them try to cope with the longer-lasting side effects.

    Often when I'm discussing treatment options with a depressed patient, I use a graphic mythological metaphor which may represent my five-year-old son's influence; he loves playing with plastic gargoyles, castles, and aliens. It seems to leave an impression on the patient when I describe the medical illness we call depression as a dragon—which we are fighting with a growing arsenal of effective weapons much like the swords, lances, and crossbows that my son's toy heroes wield in their battles with hostile zoological predators.

    Now I'm sure that some will find this image overly dramatic or ripe with Freudian significance. It is, however, a useful metaphor. I think it encourages the patient to see his or her illness as a challenging foe, which together we can defeat with our hope and pharmacologic weapons.

    My main regret in my clinical practice is the limited opportunity to conduct psychotherapy beyond the confines of a 15- to 30-minute appointment. Unfortunately, such time constraints are a frequent reality in our environment of increasingly managed care. I'm amazed, however, at the effective supportive psychotherapy that can be accomplished in a very brief contact with a patient. I've learned, and I continue to learn, which non-M.D. psychotherapists are most skilled at helping my mood-disorder patients who require more intensive psychotherapy. In fact, I encourage most of my new patients with depression and related conditions to consider the combination of medication, my brief supportive treatments, and fuller psychotherapy at the hands of an expert in that form of treatment.

    I can't even guess at the vast number of patients I've referred to DRADA. . . . I'm impressed by the number of folks I see who already know about [it, and] I think DRADA does a wonderful job of encouraging the involvement of family and friends, who then assist in the patient's care.

    . . . What are some other components of my work with patients? I'm an enthusiastic advocate of various forms of aerobic exercise. After approval from the patient's internist or family practitioner, I encourage exercise as a healthy, constructive, structured activity which can at least somewhat improve sleep and mood while the patient is waiting for medication to begin working.

    Diet is another important consideration for some patients with mood disorders. When people come in with concerns about diet or weight, I frequently refer them to hospital based nutritionists for consultation. Of course, patients with both a mood disorder and an eating disorder may need more specialized treatment than can be provided by a general nutritionist.

    . . . I've been reflecting on the potential benefit that organized religion can have for the mood disorder patient. I think the social support, moral direction, structure, sense of hope, and proscription against suicide common to most major religions can be immensely therapeutic.

    [These are some of my] thoughts about the outpatient treatment of people with mood disorders. Hopefully, we will all continue to accumulate and share ideas as we progress in our ability to understand and control depressive illnesses.

    _________________________

    1 Assistant Professor of Psychiatry and Behavior, Johns Hopkins University School of Medicine.

     

    VIRGINIA WOOLF a report on a presentation 1 by Kay Redfield Jamison, Ph.D., 2 Smooth Sailing, Spring 1997

    Celebrated writer Virginia Woolf was born Adeline Virginia Stephen on January 25, 1882. She had manic depression, and the disease could be traced through three generations in her family. Her father, Sir Leslie Stephen, inherited manic depression from his father and had been hospitalized three times for it. Virginia Woolf wrote that being with her father was like "being shut up in a cage with a wild beast." Her two brothers and her sister had recurrent bouts of depression, and other members of her family had affective disorder. A cousin died of manic exhaustion and a refusal to eat.

    The many pictures of Virginia Woolf shown during the presentation indicated that she had a very expressive face. She was described as "having laughter like a child's" and having a "great capacity for joy," although "an undertow of sadness" was also noticeable in her presence. Her father's death in 1904 triggered the first of several nervous breakdowns that darkened her adult life.

    In 1912, she married Leonard Woolf, also a writer. This devoted man would take her temperature and weigh her in the attempt to predict her moods. During their marriage she would "pass from sanity to insanity" many times. While in her manic episodes, she became violent and had delusions (persistent false beliefs) and auditory hallucinations (she heard voices). Dr. Jamison mentioned that during one manic episode, Virginia Woolf talked for three days without stopping, and during another she believed she heard birds talking in Greek in the garden. When she was in a depressive state, she barely spoke or ate, and during several of these episodes, she tried to commit suicide. She felt she was a failure and ex-perienced overwhelming, irrational pain. She described her moods as "wild waves of emotions."

    Virginia Woolf believed that her "madness" inspired her and made her a better writer. Her disease probably gave rise to the nontraditional narrative techniques and definitions of reality in her stream-of-consciousness style of writing. A friend said, "A dull moment in her company was not likely . . . her mind was a rich kingdom to itself and her going was the end of an age."

    Virginia Woolf wrote two suicide notes telling of her certainty that she would become manic and that she "cannot fight it." In both notes she expressed gratitude to her husband. She believed she owed the happiness in her life to her husband and she did not want to spoil his life. She wrote that they "were happy until this disease came on." On March 28, 1941, sensing the beginning of another manic episode and a flight into madness, she drowned herself.

    In 1949, only eight years after Virginia Woolf's suicide, lithium was found to be useful in treating manic depression.

    1 Presented at the DRADA/Johns Hopkins symposium, Baltimore, Maryland, April 1997

     

    WHAT'S NEW
    Updated November 25, 2002

    Health Insurance Coverage and Mental Illness

    A DRADA Program Cosponsored with the Pastoral Counseling Services
    Thursday, January 16, 2003, 7:00 — 9:00 P.M.
    Severna Park United Methodist Church
    731 Benfield Road, Severna Park, MD

    You are invited to attend an educational program which will address issues regarding mental illness and insurance coverage on Thursday, January 16,
    2003, from 7:00 to 9:00 P.M. Our meeting place is a short drive from Baltimore, the Washington area, or Annapolis and the Eastern Shore — just seconds off Interstate I-97. There is ample free parking.

    Our program features James P. Koch, Attorney-At-Law, who presented information on this topic for us several years ago. Mr. Koch received his B.A. from Johns Hopkins University and J.D. from the University of Maryland School of Law. For more than 20 years he has represented clients in Maryland's state and federal courts. Issues that may be addressed at our
    meeting include parity legislation, ERISA, coverage denials and terminations, pre-existing conditions, and Medicare/Medicaid coverage.

    Everyone is welcome and there is no charge to attend. For more information, please call 410-955-4647; 202-955-5800; or visit www.drada.org.

    DIRECTIONS
    From Baltimore:
    Take 695 East to Route 97 South toward Annapolis. After passing the Route 100 intersection move toward the right lanes and take exit 10 A (Benfield Boulevard/Severna Park). Go one mile on Benfield through two lighted intersections to Severna Park United Methodist Church on the right.

    From the DC area:
    Take either 95 North or the Baltimore/Washington Parkway (295 North) to Route 32 East. From 32 East, exit at Route 97 North/Baltimore. Move left to get on Route 97 North toward Baltimore. Take exit 10 Benfield Boulevard/Severna Park. Go left at signal at end of ramp (Veteran's Highway). Take first right (Benfield Boulevard) and proceed approximately one mile. Severna Park United Methodist Church will be on
    your right.

    From Annapolis/Eastern Shore:
    From Route 50 take I-97 North toward Baltimore. Take exit 10 Benfield Boulevard/Severna Park. Go left at signal at end of ramp (Veteran's Highway). Take first right (Benfield Boulevard) and proceed approximately one mile. Severna Park United Methodist Church
    will be on your right.

    Summaries of the 16th annual Mood Disorders Symposium Presentations

    Were you unable to attend the DRADA symposium this year?

    If you were in attendance, would you like a summary of your favorite speaker presentation?

    Well, you're in luck! In the summer issue of Smooth Sailing, there will be summaries of all presentations made for the 16th annual symposium. Smooth Sailing is one of the benefits of a DRADA membership. To learn more about membership click here.

    J. Raymond DePaulo, Jr., M.D. Named Chairman, Johns Hopkins Medicine Department of Psychiatry - a letter from Edward Miller, M.D., CEO, Johns Hopkins Medicine and Dean, Johns Hopkins Medical Faculty

    February 14, 2002

    Dear Colleagues,

    I am delighted to report that J. Raymond DePaulo, Jr., M.D., is the Henry Phipps Professor and new chairman of the Department of Psychiatry and Behavioral Sciences, effective February 15. With "confidence, enthusiasm and unanimity" in recommending Dr. DePaulo’s appointment, the Search Committee headed by Jack Griffin and Sol Snyder commented on his "indispensable strengths in clinical psychiatry and teaching, and his exciting vision of the future of neuropsychiatric research."

    Ray DePaulo is one of the world’s foremost investigators into the genetic bases of affective disorders. His ongoing research includes genetic studies of bipolar disorder and unipolar disorder, combined brain imaging and genetic studies of bipolar families, and studies to improve the high school health curriculum on depression and other mood disorders.

    Dr. DePaulo received his B.S. (Magna Cum Laude) from Xavier University in Cincinnati and his M.D. from Hopkins. After completing his internship and residency at Hopkins, he began his full-time academic career with us in 1977 as assistant professor in the Department of Psychiatry and founding director of the Affective Disorders Clinic. He rose through the ranks to become associate professor in 1983 and professor in 1993.

    A member of many prestigious professional societies and editorial boards, Dr. DePaulo also has been on several advisory committees, including those of the National Depression and Manic Depression Illness Association and the National Association for Research in Schizophrenia and Depression. He is a founding member of the Depression and Related Affective Disorders Association (DRADA).

    In addition to his numerous awards for research in depression and bipolar disorder, Dr. DePaulo was invited to address the World Economics Forum in Davos, Switzerland, both in 2000 and 2001, about the burden of psychiatric disease on national and global economies. He is the author of two books, more than 90 scientific articles and six educational videos on depressive illness.

    During his tenure at Hopkins, Dr. DePaulo has made great contributions to the clinical management of neuropsychiatric disorders and enjoyed extensive grant support from the National Institutes of Health. Additionally, the search committee noted "his ability to inspire medical students and young investigators about the future of psychiatry."

    While we look forward to Dr. DePaulo’s leadership, I know you also join me in thanking Chester Schmidt for a superb job as Interim Director of the Department of Psychiatry and Behavioral Sciences – and, of course, Paul McHugh for his quarter century at the department’s helm.

    Sincerely,

    Edward D. Miller, M.D.

    SUMMIT ON WOMEN AND DEPRESSION: PROCEEDINGS AND RECOMMENDATIONS

    A new report was just released on March 15th focusing on depression in women by the American Psychological Association. The newly released report
    summarized the proceedings of a summit meeting cosponsored by the National Institute of Mental Health that focused on depression in women. Over 35
    experts from a variety of disciplines were in Attendance to provide reviews of research findings on women and depression, to provide recommendations on how these findings might inform health Policy and improve clinical practice, and to produce a targeted research agenda on women and depression. Findings
    in four major areas are reflected in the report: the etiology of sex and gender differences in depression; treatment and prevention of depression in
    women; treatment and prevention of depression in special populations of women; and services for women with depression. The entire report is
    available in pdf format at www.apa.org/pi/wpo/women&depression.pdf.
    (posted on March 28th by NIMH)

    Volunteers Needed for Outreach Project
    DRADA needs volunteers to give presentations at Baltimore-area hospitals and day treatment programs as part of our Hospital Networking Project. The goal is to introduce patients to support groups, peer support, referral services, and other resources that DRADA has to offer. If you are interested, please call DRADA at 410-955-4647 and leave a message, or call Jennifer Ecton at 410-614-4588.

    Reference Shelf: Living and Coping with Mood Disorders
    Our Reference Shelf now features three new books:

  • " Mood Genes: Hunting for Origins of Mania and Depression" by Samuel H. Barondes, M.D.
  • "How You Can Survive When They're Depressed: Living and Coping with Depression Fallout" by Anne Sheffield
  • Support Group Leader Training

    Interested in starting a mutual-help support group in your community? DRADA offers a one-day training program for prospective leaders at Johns Hopkins Hospital in Baltimore. Participants receive a training manual, materials and a deli lunch.

    DRADA's next one-day training program for prospective support group leaders will be Saturday, January 18, 2003 at The Johns Hopkins Hospital in Baltimore, Maryland. Advanced registration is required. To register or for more information, call Wendy Resnick at 410-987-1156. To learn more about the program and support groups, see Support Group Leader Training.

    New Washington D.C. Phone Number
    The D.C. phone number has changed from 202-884-3964. The new number is 202-955-5800.

     

    DEPRESSION AND THE BRAIN

    An edited transcript of a talk by Dr. J Raymond DePaulo Jr., M.D., professor of psychiatry at Johns Hopkins University School of Medicine at a conference on March 17, 1999, sponsored by the Dana Alliance for Brain Initiatives.

    As you know, I am a psychiatrist, or to put it more simply, I am a depression doctor. Because I work at Johns Hopkins, I have been able to focus on one illness, depression.

    I am here to talk to you about four topics: the impact of clinical depression on patients and families, the current state of clinical care of patients with depression and manic depression (bipolar disorder), the contributions that three brain sciences (genetics, brain imaging, and pharmacology) already have made to the field, and what is needed to assure a brighter future for those afflicted by this illness.

    First, I want to clarify what I mean by the term depression. When I talk about depression, I am not talking about discouragement. I remember a patient I evaluated several years ago. When I told him at the end of the evaluation he had clinical depression, he looked at me, shaking his head, as if I was from Mars, and he said 'Look, DePaulo, I know what depression is. That is when your dog dies and you feel sad. I don’t own a dog. I don't feel sad. Start over again." He had clinical depression, but the word depression was confusing to him as it confuses many others. By clinical depression I mean a set of signs and symptoms affecting not only mood, but mental and physical vitality, self esteem, self confidence, and several bodily functions.

    Depression's Impact on People and Dollars
    What is the impact or importance of clinical depression as compared to other diseases? The first important fact is that 15 million Americans have it. It comes in episodes, often beginning late in adolescence and reoccurring throughout the life span, if untreated. The number of people affected and the long-term course are only the beginning. In 1990, when a series of studies was done to calculate the costs of several diseases, the cost of depression in the U.S. economy was estimated at $44 billion per year.

    For comparison, the estimates of the cost of coronary artery disease and of cancer were estimated at the same time. Using the same methods for calculation, the estimated cost of all coronary artery disease was almost identical to depression: $43 billion. The estimated cost to our economy from all cancers taken together was $101 billion. So, depression is enormously disruptive to the lives of our patients and their families, but it is also of economic importance for us as a society.

    The World Health Organization has recently published a very extensive study on the causes of disability and the economic and social burden caused by various diseases on a worldwide basis. They found that the leading cause of disability in world today is unipolar depression (i.e., episodes of clinical depression without manic episodes). Bipolar disorder or manic depression is number six on the list. In fact, five psychiatric disorders are among the top ten causes of disability worldwide. Unipolar depression alone makes up 10 percent of all cases. In terms of their impact, these have been the most neglected diseases in medicine.

    What is the current state of clinical care? It is quite different than for diseases like Huntington's disease (HD), which Dr. Gusella described. Through the genetics studies he and his colleagues have carried out, we now know much about its cause (the gene, the protein it makes, and even some aspects of the protein's function), but we still don't have a treatment for it.

    In depression, just the opposite is true. We have some fairly effective antidepressant medications. Each one works in about 65 percent of patients with major depression. These breakthroughs came from pharmacology. However, we know almost nothing about the mechanism of the disease in the brain, so that when antidepressants are helpful, we don’t know why they work. Nor do we know why they fail when they fail.

    SSRIs Make a Difference
    The biggest watershed that pharmacology has crossed for us has been the development of the first rationally designed family of antidepressants, the selective serotonin reuptake inhibitors (SSRIs). About 20 years ago pharmacologic studies suggested that some depressions came from depletion of brain catecholamine neurotransmitters. Drugs like Serpasil deplete them and are associated with severe depressions, as Dr. Bloom noted. It was thought that other depressions were caused by a depletion of serotonin. Some pharmaceutical companies wisely set out to develop drugs which would specifically enhance the brain concentrations of those chemicals. In this country, Prozac is the drug that we know as the primary SSRI. Others were developed at the same time in Europe. We still don’t know why they work, but we have better ideas to test now.

    It is a strange twist, but that is our situation today. We need to understand the brain mechanism of the disease and the mechanism of action of these drugs to advance beyond this state. Despite the availability of many new antidepressants, only 15 to 30 percent of patients with major depression and bipolar disorder are getting diagnosed and treated for it. That is a scandal.

    Why does this happen? First, most depressed patients are not diagnosed. These patients often come to their doctor, but they don't know what they are coming for, and, unfortunately, many clinicians don't recognize the disorder in their patients. There are no laboratory tests to help the clinician resolve or confirm any suspicion.

    Once you have diagnosed it, you can at least apply these treatments. Where are these laboratory tests going to come from? Probably genetics, but genetics, imaging, pharmacology, as I said, all work together.

    The third thing is what have the contributions been from these research areas? From brain imaging studies, we have learned what brain regions are crucial for depression that comes following stroke.

    Searching for the Genes
    We know now that Huntington's disease involves the same brain regions, about 40 percent of patients with Huntington's disease have depression in the early stages of their illness, interestingly not so in the later stages. We now know that those brain regions that are important in post-stroke depression and in Huntington's disease are important in families with the familial forms of depression.

    Genetic studies have demonstrated in twin and adoption studies that genes are important causes of many forms of depression. Finding the genes has been difficult probably because it is so common. Since depression affects 15 million Americans at any one time, the disease can't be caused by a single gene, but is more likely to be the result of an interaction of several common genes with co-occur in some individuals in some families. We know that for most people a single gene will not be sufficient as it is in Huntington's disease, where having the gene almost guarantees that you will get the disease. Depression and bipolar disorder will occur in an individual when a number of specific genes react in the absence of protective genes. To put it simply, most people with any one of these genes will not have any illness at all.

    It is not a needle in a haystack, it's a haystack full of needles that we have got to sort out. We can do it and we must. An early report has recently been presented demonstrating that specific genes can predict which patient will have terrible side effects from one group of psychoactive medicines and which patients will not.

    What is needed from the three big brain sciences? We need laboratory tests to help all clinicians improve in diagnosing depression and bipolar disorder. From brain imaging we need more precise localization of the brain areas and brain cells which malfunction in depression. As Dr. Phelps noted, new and more powerful ways of using brain imaging methods can monitor brain function as well as structure. Further development of these methods that will link imaging and pharmacologic experiments in the same patients is crucial.

    We also need more rational drug development. That will come from not only basic pharmacology, but also from genetics where we will get blueprints of the molecules which contribute to depression.

    What do we need from genetics (and this is the area where I am trying to do my best to be of help)? Fundamentally, we need the genes that predispose people to this illness. We also would be very happy to know of the genes — and we think they are there — that protect people from this illness.

    The three major brain sciences, brain imaging, pharmacology, and genetics, can work together hand and glove, and when needed hand and glove and foot, to illuminate a mysterious disorder like depression.

    We have come a long way. We have got a much further way to go. How would I conclude? We need much more support for the brain sciences and the clinical sciences that relate to brain diseases such as depression. That support certainly is financial, but it is also in the form of more public education about these illnesses and more scientific careers devoted to studying them.

    Reprinted from "Advances in Brain Research 1999", The Charles A. Dana Foundation.

     

    Reports in Smooth Sailing of talks at symposiums co-sponsored by DRADA.

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