PHARMACOLOGICAL TREATMENT OF MOOD DISORDERS by David M. Goldstein, M.D., Director, Mood Disorders Program, Georgetown University Medical Center

Effective medical treatments now exist for the full range of mood disorders, from mild depression to severe manic depression. Treatment decisions are based on the severity of the symptoms as well as the type of symptomatology. There are a wide variety of treatments that are now available, but research studies consistently demonstrate that combined psychotherapy and medication treatments produce the best results. The psychotherapy treatments work by helping with the psychosocial and interpersonal adjustment of the individual, whereas the drugs help with the physical and physiologically based symptoms. Psychotherapy seems to help by improving the patient's willingness to continue with the medication treatment, also.

This review will focus on psychopharmacological treatments for depression and manic depression. Although the mode of action of the various psychotropic medications is not precisely known, it is thought that these drugs work by correcting imbalances in the brain's chemical messenger or neurotransmitter system. The brain is a highly complex organ, and it may be that the medications work to restore normal regulatory processes in the brain. These drugs are quite effective if taken for sufficient lengths of time and at proper dosages. It is common for there to be a several week delay in the onset of effectiveness of the medication, so patience and cooperation with the prescribing physician are crucial elements in treatment. A primary cause of patients' noncompliance with medication treatment is the emergence of side effects. The side effects associated with the use of these medications generally are dependent upon dosage and duration of treatment. A close cooperative and trusting relationship with the physician is important in helping the individual to navigate through the side effects, should they occur.

These medications have been carefully studied and have to pass rigorous standards by the Food and Drug Administration in order to be released into the marketplace. All available antidepressant prescription medications have been found to be safe and effective and they are not known to be addictive.

Medication choice is guided by diagnosis, so prior to the initiation of treatment, care must be taken to accurately diagnose the medical condition that best explains the presenting symptoms. Treatments for depression and manic depression often differ and this is an important distinction. Manic depressive patients treated with antidepressants alone may be at an increased risk for the development of a manic episode.

MEDICATION TREATMENTS FOR DEPRESSION

There are over thirty antidepressant medications now available in the United States to treat depression. There are three principal neurotransmitters that are involved in the development of depression, and they are serotonin, norepinephrine, and dopamine. The available anti-depressant medications differ in which of these neurotransmitters are affected. The medications also differ in which side-effects they are likely to induce. Other differences among the medications involve how they interact with other medications that an individual might be taking. The available medications for depression can be categorized in the following way:

Heterocyclic antidepressants

monoamine oxidase inhibitors

selective serotonin reuptake inhibitors (SSRI's).

Heterocylic antidepressants: The Heterocyclic antidepressants were the mainstay of antidepressant treatment from their inception in the United States in the late 1950's until the mid 1980's. These drugs include the tricyclic antidepressants, such as Elavil, Tofranil, Pamelor, Norpramin, and Vivactil. These medications have been quite effective in improving the symptoms of depression, but their usefulness is limited by the associated side-effects. These side-effects include dry mouth, constipation, weight gain, urinary hesitancy, rapid heartbeat, and dizziness upon arising. These side-effects, although they are rarely dangerous, may be of significant magnitude to warrant stopping that medication and switching to another. A more recent member of the Heterocyclic family is a new medication named Remeron. This is a recently released antidepressant that is chemically similar to the older compounds, although it has a more favorable side-effect profile.

The monoamine oxidase inhibitor antidepressants (MAO inhibitors): The monoamine oxidase inhibitor antidepressants, or MAOI's, are a group of antidepressants that were developed in the 1950's also. Initially they were used as treatments for tuberculosis, but were discovered to have antidepressant properties among that population. These medications can be highly effective for some individuals who have what is referred to as "atypical depression". These are patients who have a dominance of fatigue, excessive need for sleep, weight gain, and rejection sensitivity. Some investigators feel that this group of patients respond preferentially to MAOI drugs. This category of medications includes drugs such as Nardil and Parnate. There is another medication called Mannerix that is a useful drug in this category but is not commercially available in the United States. Monoamine oxidase inhibitor drugs are limited by the possibility of the infrequent but at times life threatening side effect of hypertensive crisis. This is a phenomenon where, while taking the medication, the individual eats certain foodstuffs or takes certain medications that contain an amino acid known as tyramine. This results in a sudden and severe rise in blood pressure associated with a severe headache. In some instances the use of this medication can be extremely helpful, but the dietary restrictions have to be followed faithfully.

The selective serotonin reuptake inhibitors (SSRIs): The final category of antidepressant medication is known as the selective serotonin reuptake inhibitors, or SSRI drugs. The first of these agents was Prozac, which came on the market in 1987, and was followed in short order by Zoloft, Paxil, Luvox, and more recently by Effexor and Serzone. Another medication related to this group is Wellbutrin. This group of medications has been shown to be equally effective in treating depression as compared to the older Heterocyclic and MAOI medications. The advantage of these drugs is that they have fewer and more benign side effects. Generally speaking, they have fewer cardiovascular side effects and present fewer problem to the patients or the physician. They are not without side effects, however, and some patients report symptoms such as nausea, sexual inhibition, insomnia, weight gain, and daytime sedation.

Results of treatment: Approximately 60-70% of patients who present with symptoms of depression will be successfully treated by the first antidepressant that they take. The remaining 30% of individuals may be helped by trying a second, third, or even fourth medication. In certain instances, the physician may enhance the effectiveness of a particular drug by adding on other agents, such as lithium, thyroid supplementation, or a second antidepressant concurrent with the initial medication. There are difficulties that may develop with loss of efficacy of antidepressants, also. In approximately 20% of cases, individual antidepressants seem to lose their efficacy. When this happens, the physician may change medication or try one of the enhancement strategies suggested above.

MEDICATION TREATMENT FOR MANIC DEPRESSIVE ILLNESS

Lithium: The first treatment developed for manic depressive illness was lithium carbonate. Lithium is a naturally occurring mineral that was known in the 19th century to have positive effects on mood. In the late 1940's it was evaluated by a psychiatrist in Australia and found to have beneficial effects in manic depressive illness. This research was followed up in the 1950's by Dr. Morgens Schou in Scandinavia. Since that time, lithium has been the mainstay of treatment for manic depressive illness, being effective for both the manic as well as the depressed phases of that illness. Lithium may be taken alone or in conjunction with other medications, depending on the circumstances. Side effects of lithium treatment include weight gain, memory impairment, tremor, acne, and occasionally thyroid disfunction. During treatment with lithium, which is usually over an extended period of time, that patient should be monitored for thyroid function as well as kidney function.

Valproic acid (Depakote): In addition to lithium, there are a number of other agents available for treatment of manic depressive illness. Valproic acid is available in the United States and was approved for treatment of manic depression this past year. Valproic acid is commonly prescribed as Depakote, and is an effective agent for mood stabilization. Current research studies are underway to compare the efficacy of Depakote as compared to lithium. Side effects associated with Depakote include nausea, weight gain, hair loss, and increased bruising.

Carbamazepine (Tegretol): A third commonly used mood stabilizer is Tegretol. This is a medication that was initially developed for facial pain and subsequently found to be useful for certain types of epilepsy. In the past twenty years it has been developed as a mood stabilizer, and it has been found to have anti-manic, antidepressant, and prophylactic efficacy. Tegretol is associated with a relatively low incidence of weight gain, memory loss, and nausea. Skin rash is sometimes found with Tegretol, and there is the possibility of bone marrow suppression, which requires monitoring by blood tests.

New medications: There have been several new medications that are under development for the treatment of manic depressive illness and show some promise. Neurontin, or Gabapentin is an anticonvulsant compound which is being developed as a mood stabilizer. It shows promise and has the benefit of very few interactions with other medications. Another medication under development is Lamictal. This medication is an anticonvulsant, approved in the United States as an anticonvulsant several years ago. It has been found to have antidepressant properties, and may turn out to have mood stabilizing effects as well, although this is currently under investigation. Lamictal carries the risk of rash with it, which at times may be severe.

ANTIPSYCHOTIC MEDICATIONS

The final class of medications is the antipsychotic category. This group of medications has usefulness in more severe states of depression and manic depression. This group of medications is very effective in controlling severe agitation, disorganization, as well as psychotic symptoms which sometimes accompany the more severe instances of mood disorders.

Typical antipsychotic medications: The Typical antipsychotic medications include drugs such as Haldol, Trilafon, Stelazine, and Mellaril. They are quite effective in controlling agitation as well as hallucinations and unrealistic thoughts. They are less effective in controlling or treating the apathy, withdrawal, and indifference that sometimes occurs in these conditions. ( Individuals with mood disorders may have an increased potential for developing neurological side effects associated with the use of these medications, specifically a condition referred to as Tardive Dyskinesia. This is a persistent twitching of the fingers or lips. )

Atypical antipsychotic medications: In recent years, a new class of antipsychotics has become available referred to as the "Atypical antipsychotic medications". This includes Clozaril, Zyprexa, and Risperdal. This group of medications represents an advance over the older medications in that they continue to be effective against psychotic symptoms such as agitation and hallucinations, but they are also helpful in treating apathy and indifference which may also occur. These medications seem to have a significantly reduced likelihood of development of neurological side effects as well.

CONTINUATION OR DISCONTINUATION OF MEDICATIONS

Depression and manic depression tend to be recurrent problems, and often maintenance medication is recommended. This recommendation should be discussed carefully between the patient and his or her physician.

A final issue in the use of the psychotropic medications is the issue of discontinuation. The timing of discontinuation of psychotropic medications is an important and highly individual decision, which should always be made in conjunction with one's physician. As a general rule, stopping medications in a gradual way is preferable to abrupt discontinuation. Abrupt discontinuation may result in return of original symptoms, or may result in what is referred to as "discontinuation syndrome". Discontinuation syndrome has a variable presentation. Patients often will feel as if they have a severe case of the flu. Abrupt discontinuation of lithium in the context of manic depressive illness carries the risk of a sudden return of manic or depressive symptomatology. In addition, there is a small group of manic depressive patients who, once they discontinue lithium, become refractory to its effectiveness at a later time.

These medications can be highly effective and may significantly alter the course of an individual's life. One must always keep in mind that the choice to take the medication is based on an assessment of the risks and benefits associated with taking medication as well as not taking the medication. Those choices should always be undertaken in the context of an ongoing relationship with the prescribing physician.

WHAT IS BIPOLAR DISORDER?
Bipolar disorder—which is also known as manic-depressive illness and will be called by both names throughout this publication—is a mental illness involving episodes of serious mania and depression. The person's mood usually swings from overly "high" and irritable to sad and hopeless, and then back again, with periods of normal mood in between.

Bipolar disorder typically begins in adolescence or early adulthood and continues throughout life. It is often not recognized as an illness, and people who have it may suffer needlessly for years or even decades.

Effective treatments are available that greatly alleviate the suffering caused by bipolar disorder and can usually prevent its devastating complications. These include marital break-ups, job loss, alcohol and drug abuse, and suicide.

Here are some facts about bipolar disorder.

AWARENESS

Manic-depressive illness has a devastating impact on many people.

At least 2 million Americans suffer from manic-depressive illness. For those afflicted with the illness, it is extremely distressing and disruptive.

Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.

Family members of people with bipolar disorder often have to cope with serious behavioral problems (such as wild spending sprees) and the lasting consequences of these behaviors.

Bipolar disorder tends to run in families and is believed to be inherited in many cases. Despite vigorous research efforts, a specific genetic defect associated with the disease has not yet been detected.

Bipolar illness has been diagnosed in children under age 12, although it is not common in this age bracket. It can be confused with attention deficit/hyperactivity disorder, so careful diagnosis is necessary.

RECOGNITION

Bipolar disorder involves cycles of mania and depression.

Signs and symptoms of mania include discrete periods of:

Increased energy, activity, restlessness, racing thoughts, and rapid talking

Excessive "high" or euphoric feelings

Extreme irritability and distractibility

Decreased need for sleep

Unrealistic beliefs in one's abilities and powers

Uncharacteristically poor judgment

A sustained period of behavior that is different from usual

Increased sexual drive

Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

Provocative, intrusive, or aggressive behavior

Denial that anything is wrong

Signs and symptoms of depression include discrete periods of:

Persistent sad, anxious, or empty mood

Feelings of hopelessness or pessimism

Feelings of guilt, worthlessness, or helplessness

Loss of interest or pleasure in ordinary activities, including sex

Decreased energy, a feeling of fatigue or of being "slowed down"

Difficulty concentrating, remembering, making decisions

Restlessness or irritability

Sleep disturbances

Loss of appetite and weight, or weight gain

Chronic pain or other persistent bodily symptoms that are not caused by physical disease

Thoughts of death or suicide; suicide attempts

It may be helpful to think of the various mood states in manic-depressive illness as a spectrum or continuous range. At one end is severe depression, which shades into moderate depression; then come mild and brief mood disturbances that many people call "the blues," then normal mood, then hypomania (a mild form of mania), and then mania.

Some people with untreated bipolar disorder have repeated depressions and only an occasional episode of hypomania (bipolar II). In the other extreme, mania may be the main problem and depression may occur only infrequently. In fact, symptoms of mania and depression may be mixed together in a single "mixed" bipolar state.

Descriptions provided by patients themselves offer valuable insights into the various mood states associated with bipolar disorder:

Depression:
I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless....[I am] haunt[ed]...with the total, the desperate hopelessness of it all... Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?

Hypomania:
At first when I'm high, it's tremendous...ideas are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do anything...but, somewhere this changes.

Mania:
The fast ideas become too fast and there are far too many...overwhelming confusion replaces clarity...you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped.

Recognition of the various mood states is essential so that the person who has manic-depressive illness can obtain effective treatment and avoid the harmful consequences of the disease, which include destruction of personal relationships, loss of employment, and suicide.

Manic-depressive illness is often not recognized by the patient, relatives, friends, or even physicians.

An early sign of manic-depressive illness may be hypomania—a state in which the person shows a high level of energy, excessive moodiness or irritability, and impulsive or reckless behavior.

Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong.

In its early stages, bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work performance.

If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression.

TREATMENT

Most people with manic-depressive illness can be helped with treatment.

Almost all people with bipolar disorder—even those with the most severe forms—can obtain substantial stabilization of their mood swings.

One medication, lithium, is usually very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

Most recently, the mood stabilizing anticonvulsants carbamazepine and valproate have also been found useful, especially in more refractory bipolar episodes. Often these medications are combined with lithium for maximum effect.

Some scientists have theorized that the anticonvulsant medications work because they have an effect on kindling, a process in which the brain becomes increasingly sensitive to stress and eventually begins to show episodes of abnormal activity even in the absence of a stressor. It is thought that lithium acts to block the early stages of this kindling process and that carbamazepine and valproate act later.

Children and adolescents with bipolar disorder are generally treated with lithium, but carbamazepine and valproate are also used.

Valproate has recently been approved by the Food and Drug Administration for treatment of acute mania.

The high potency benzodiazepines clonazepam and lorazepam may be helpful adjuncts for insomnia.

Thyroid augmentation may also be of value.

For depression, several types of antidepressants can be useful when combined with lithium, carbamazepine, or valproate.

Electroconvulsive therapy (ECT) is often helpful in the treatment of severe depression and/or mixed mania that does not respond to medications.

As an adjunct to medications, psychotherapy is often helpful in providing support, education, and guidance to the patient and his or her family.

Constructing a life chart of mood symptoms, medications, and life events may help the health care professional to treat the illness optimally.

Because manic-depressive illness is recurrent, long-term preventive (prophylactic) treatment is highly recommended and almost always indicated.

GETTING HELP

Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease.

Other mental health professionals, such as psychologists and psychiatric social workers, can assist in providing the patient and his or her family with additional approaches to treatment.

Help can be found at:

University- or medical school-affiliated programs

Hospital departments of psychiatry

Private psychiatric offices and clinics

Health maintenance organizations

Offices of family physicians, internists, and pediatricians

People with manic-depressive illness often need help to get help.

Often people with bipolar disorder do not recognize how impaired they are or blame their problems on some cause other than mental illness.

People with bipolar disorder need strong encouragement from family and friends to seek treatment. Family physicians can play an important role for such referral.

If this does not work, loved ones must take the patient for proper mental health evaluation and treatment.

If the person is in the midst of a severe episode, he or she may have to be committed to a hospital for his or her own protection and for much needed treatment.

Anyone who is considering suicide needs immediate attention, preferably from a mental health professional or a physician; school counselors and members of the clergy can also assist in detecting suicidal tendencies and/or making a referral for more definitive assessment or treatment. With appropriate help and treatment, it is possible to overcome suicidal tendencies.

It is important for patients to understand that bipolar disorder will not go away, and that continued compliance with treatment is needed to keep the disease under control.

Ongoing encouragement and support are needed after the person obtains treatment, because it may take a while to discover what therapeutic regimen is best for that particular patient.

Many people receiving treatment also benefit from joining mutual support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association.

Families and friends of people with bipolar disorder can also benefit from mutual support groups such as those sponsored by NDMDA and NAMI.

ACKNOWLEDGMENTS

This publication was written by Mary Lynn Hendrix of the Office of Scientific Information, National Institute of Mental Health. Expert assistance was provided by Frederick K. Goodwin, M.D., Robert M. Post, M.D., Hagop S. Akiskal, M.D., and William Z. Potter, M.D.

All material in this pamphlet is free of copyright restrictions and may be copied, reproduced, or duplicated without permission from the Institute; citation of the source is appreciated.

U.S. Department of Health and Human Services
National Institutes of Health
NIH Publication No. 95-3679
September 1995

For more detailed information on bipolar disorder (manic-depressive illness), be sure to visit our Reference Shelf. Supplemental information can be found in our First Person Experiences, Books, and Videos sections.

Return to Basic/General Information About Depression and Bipolar Disorder (Manic-Depressive Illness)

Our newsletter Smooth Sailing features reviews of books about depression and bipolar disorder (manic-depressive illness), prepared by DRADA's book review committee.

Night Falls Fast: Understanding Suicide by Jamison, Kay Redfield, Ph.D.
Covers general information about suicide, its history, the psychological patterns that underlie suicide attempts, suicide's biological component, and suicide prevention. It also includes stories about persons who have attempted or committed suicide.

Read review.

Bipolar Disorder: A Guide for Patients and Families, by Francis Mark Mondimore, M.D.
In Bipolar Disorder, Dr. Mondimore has focused on information that patients and families really want and need about the illness more commonly known as manic depression. The comprehensive and authoritative coverage in the 277 page book ranges from brain imaging to practical ways to reduce the risk of relapse.

Read review.

The Perspectives of Psychiatry, by McHugh, Paul R., M.D., and Slavney, Phillip R., M.D., 2nd ed.
Dr. McHugh, chairman of the psychiatry department at the Johns Hopkins University School of Medicine, and Dr. Slavney provide four conceptual approaches to psychiatric illnesses, described in the review.

Read review.

Personal History, by Katherine Graham.
This Pulitzer Prize-winning book is an introspective account of the life of an exceptional woman, former publisher of the Washington Post. The review describes her frank discussion of her husband's bipolar illness.

Read review.

Stronger than Death: When Suicide Touches Your Life by Sue Chance, M.D.

Read review.

Undercurrents: A Therapist's Reckoning with Her Own Depression. by Martha Manning.
The author uses episodes from her own personal and professional life to portray the course of her severe depression, including her successful treatment with electroconvulsive therapy (ECT).

Read review.

An Unquiet Mind by Kay Redfield Jamison, Ph.D.
Dr. Jamison describes with candor and wit how her bipolar illness shaped her personal and work life. The review includes quotes from the book, describing her feelings of depression.

Lonely, Sad and Angry: A Parent's Guide to Depression in Children and Adolescents, by Barbara D. Ingersoll, Ph.D. and Sam Goldstein, Ph.D.
The authors give a readable overview of symptoms, diagnosis, and treatment of depression in the young. The review describes the topics covered.

GENETIC ADVANCES: ADDITION BY DIVISION, a report on a presentation 1 given by Francis J. McMahon, M.D. 2 Smooth Sailing, Spring 1997

A requirement for appreciating the complex genetics of affective disorders—the focus of Dr. McMahon's presentation—is an awareness of the effects of gene mutation. Dr. McMahon explained that a gene mutation can have one of three outcomes: A one-to-one relationship: a person who has the gene mutation will have the illness. A partial effect: the illness is present in some people carrying the mutation, but not all. (Here risk factors become important as well as the strength of the gene effect, which is quantified statistically.) A silent relationship: the gene mutation does not produce any illness.

When people think of inherited illnesses, they often think of the one gene/one disease construct. It is becoming quite clear, however, that this basic model does not apply to affective disorders. Dr. McMahon suggested a conceptual model that may be valid for the inheritance of affective disorders, which are clearly a family of disorders. Perhaps their transmission is related to a family of genes instead of a single gene—a seemingly simple concept, but with complex implications. To illustrate, Dr. McMahon contrasted a schematic of the transmission of Huntington's disease (a one-to-one relationship) with a model of the transmission of affective disorders by several minor genes.

(Link to chart 1) He noted that the standard approaches to genetic linkage studies are not sophisticated enough to locate genes for affective disorders. Investigators at Johns Hopkins and their international colleagues are identifying specific places on certain chromosomes where affective disorder genes appear to be located. While chromosome 18 has received the most attention in the popular press, chromosomes 4 and 21, and perhaps the X chromosome, may also be involved. Replications of these studies are lending credence to the implication of at least four genes.

(link to chart 2) The evidence supporting the involvement of several minor genes leads to questions such as whether affective disorders can be divided into genetically simpler sub-types. Since these heterogeneous disorders have such complex genetics, Dr. McMahon and colleagues are now focusing on a number of discrete characteristics that should help to identify specific modes of transmission in bipolar disorders. These characteristics include age of onset of the disorder, parent of origin (which parent passed the disorder on), comorbid conditions (other illnesses that are also present, such as alcoholism or panic disorder), diagnosis (such as bipolar I, with full-blown manias, versus bipolar II, with relatively mild manias), and response to treatment. Other critical characteristics may be found as the research progresses. We know that the age of onset differs in recurrent unipolar depression versus the bipolar disorders, and logic points to genetic differences among the disorders as being responsible. In studies of bipolar disorder, a clear parent-of-origin effect was observed. When the parent of origin was the mother, more offspring and more maternal relatives were affected. Another intriguing study involved comorbidity. In people who have panic disorder as well as bipolar disorder, the two disorders appear to be inherited together from a gene located in a specific region of chromosome 18 that is designated 18q. Dr. McMahon speculated that this gene may transmit one subtype of bipolar disorder.

Dr. McMahon noted that one of the most significant research findings relates to genetic differences between bipolar I and bipolar II disorders. Analysis of certain alleles (different versions of the same gene) on 18q in pairs of siblings having bipolar disorder indicated that pairs with bipolar II were surprisingly homogeneous, whereas pairs with bipolar I were not. Allele sharing was 100 percent for bipolar II, but only 50 percent (i.e., no more than chance) for bipolar I disorder. These findings suggest that the gene on 18q underlies bipolar II and not bipolar I disorder. A current study of differences in treatment response may reveal subtypes of bipolar disorder by finding genetic differences between patients who do and do not respond to lithium. In time, the treatment-response studies will also expand the information base on different genetic forms of affective disorders. Dr. McMahon stated that the future will bring studies on seasonal affective disorder and rapid cycling.

References provided by Dr. McMahon

Blackwood DHR, He L, Morris SW, et al: A locus for bipolar affective disorder on chromosome 4p. Nat Genet 12: 427-430, 1996.MacKinnon DF, McMahon FJ, Simpson SG, et al: Panic disorder with familial bipolar disorder. Biol Psychiatry (In Press).McInnis MG, McMahon FJ, Chase GA, et al: Anticipation in bipolar affective disorder. Am J Hum Genet 53: 385-390, 1993.McMahon FJ, Stine OC, Myers DM, et al: Patterns of material transmission in bipolar affective disorder. Am J Hum Genet 56:1277-1286, 1995.Stine OC, Xu J, Koskella R, McMahon FJ, et al: Evidence for linkage of bipolar disorder to chromosome 18 with a parent-of-origin effect. Am J Hum Genet 57:1384-1394, 1995.

_________________

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

2 Assistant Professor of Psychiatry and of Neuroscience, Johns Hopkins University School of Medicine .

by Anne M. Bain, Ed.D.
Smooth Sailing: Spring 1997

For information about the Johns Hopkins genetic study of manic depression: www.med.jhu.edu/bipolar/

Lonely, Sad, and Angry: A Parent's Guide to Depression in Children and Adolescents, Ingersoll, Barbara D., Ph.D., and Goldstein, Sam, Ph.D. New York: Doubleday Books, 1995. (Hardback, 225 pages, $21.95)

Lonely, Sad, and Angry is an excellent little book. The authors are psychologists with extensive experience in the treatment of childhood disorders. Dr. Ingersoll lives and practices in Bethesda, Maryland, and has a particular interest in attention deficit disorder; Dr. Goldstein, of the University of Utah School of Medicine, is knowledgeable about hyperactivity. Both authors are members of the professional advisory board for CH.A.D.D. [Children and Adults with Attention Deficit Disorder].

After defining childhood depression, the book describes various related emotional and behavioral problems; schizophrenia, however, is almost entirely ignored. Diagnosis and evaluation are treated next, and an overview of theories about depression's cause(s) follows. Psychotherapy is addressed, and equal time is given to medical treatments (medications, ECT [electro-convulsive therapy], and light therapy). The very important subject of potential suicide is covered, as is psychiatric hospitalization. The rest of the book sets forth some general advice on topics such as keeping communication open in a family with a depressed youngster, and ensuring that parents take care of themselves while under stress. Also included are suggestions for teachers, as well as several useful depression-history checklists, a directory of organizations that offer information and support, and even a behavior modification checklist to use for rewards, "Fun Things to Do."

Lonely, Sad and Angry has been welcomed by parents and psychiatrists as one of the best books on depression in the young. Clinicians might well recommend it to their clients and clients' families as background reading. It provides a readable overview of the field and demystifies a subject that is often feared and denied.