Depression: The Mood Disease

Mondimore, Francis Mark, M.D. Baltimore: The Johns Hopkins University Press, 1990; revised 1993. Hardback, 256 pages; also in paperback.

Although Dr. Mondimore, who received his psychiatric training at Johns Hopkins and is now on the faculty of the University of North Carolina School of Medicine, focuses his book on the scientific knowledge about mood disorders, he makes the technical information easily understood by the reader. For example, to illustrate the action and malfunctions of the brain’s neurotransmitter system, Dr. Mondimore draws analogies to automatic teller machines (ATMs) and ATM cards. He uses the analogy of malfunctioning thermostats to illustrate the mechanics of mood disorders.

Because Dr. Mondimore keeps away from “typical” cases, the case-study vignettes he uses are more interesting than most. In many of these composite case studies, he portrays himself as making errors in the initial diagnosis and treatments. With this device he not only illustrates the difficulty and importance of accurate diagnosis and treatment, but also provides a refreshing bit of realism.

This comprehensive book covers not just depression, as its name may imply, but also manic-depressive disorder and other variations of mood disorders. In the discussion of each, Dr. Mondimore summarizes the current state of knowledge for the lay reader who does not want to pursue the details of individual studies. For example, in discussing the use of light to treat seasonal affective disorder, he reports that every pertinent research study has affirmed the effectiveness of this treatment. In contrast, he reports that studies have not substantiated some popular theories about the relationship between alcoholism and depression.

Dr. Mondimore’s advice to patients is candid. When asked, “How many drinks can I have?” he answers, “How many chocolate cupcakes should a diabetic eat?—the fewer, the better!” Although his advice to families is sympathetic, DRADA readers found it to be less substantive than other sections of the book; his description of involuntary commitment, for example, is more a textbook recital of procedures than the realistic discussion that characterizes his treatment of medical issues.

New in this revised (1993) edition is a section on new medications. Defending the value and safety of the antidepressant Prozac, Dr. Mondimore laments that many patients have stopped taking much-needed medication because of unfounded attacks on Prozac and other psychiatric drugs as well as irresponsible talk-how hosts who are uninterested in providing accurate information. Dr. Mondimore also comes on strong against stigma. He says it is time to toss the stigmatizing phrase “mental illness” into the trash bin, along with the terms “madness” and “insanity.”

The book ends on an upbeat note. Dr. Mondimore describes research as proceeding at a “dizzying pace.” Thus, he says, the answer to the question “Will I have to take this medication for the rest of my life?” is “Probably not.”

By Delphine Peck

There are two ways to support DRADA: Individuals, organizations, and corporations can become members or they can become donors or both.

Click here to learn about the benefits of membership.

Click here to learn about the benefits of a donation.

Click here to go to membership and donation form. (Requires Adobe® Acrobat® Reader®)

Book Reviews

The Noonday Demon: An Atlas of Depression, Solomon, Andrew. New York: Scribner, 2001. (Hardback, 576 pages, $28.00)

As its title implies, this book approaches depression from all directions, from historical and medical terms to social, political, and economic impact. The reader learns about the growing importance of depression, an ancient malady that is steadily increasing throughout the world. Mr. Solomon travels to Greenland, Senegal, and Cambodia to report how depression is viewed and treated in various cultures, as well as in Western society. Numerous treatment modalities are surveyed: from our standard drugs, psychotherapy, and ECT (electroconvulsive therapy) to the many experimental and alternative therapies, including sleep deprivation, psychosurgery, and homeopathy. In fact, in the chapter entitled “Alternatives to Treatment,” Mr. Solomon discusses support groups, citing DRADA as one of the organizations facilitating such groups (though DRADA considers support groups as supplemental to professional treatment). Mr. Solomon notes that DRADA “publishes a particularly good newsletter called Smooth Sailing.”

Noonday Demon, like William Styron’s Darkness Visible and Dr. Kay Redfield Jamison’s An Unquiet Mind, is a memoir of the author’s illness, the details of daily strains and anguish that turn everyday living into unrelenting challenge, distress, and despair. The book is lengthy, reflecting the monumental amount of research done in preparation. Yet the author’s articulate style and wit continue to intrigue the reader through the myriad of issues addressed, including suicide, addiction, and treatment.

Mr. Solomon uses anecdotes from his own life and the lives of hundreds of people he interviewed while writing the book. He does not judge, yet he is not afraid to expound his theories. For instance, in the chapter on suicide, Mr. Solomon distinguishes between “wanting to be dead, wanting to die, and wanting to kill yourself. Most people from time to time wished to be dead, null, beyond sorrow. In depression, many want to die to undertake the active change from where they are, to be freed from the affliction on consciousness. To want to kill yourself, however, requires . . . a great deal of energy and a strong will in addition to a belief in the permanence of the present bad moment and at least a touch of impulsivity.” Mr. Solomon is able to verbalize what many other people suffering with the illness are not.
At times, Mr. Solomon seems to purposely shock and titillate the reader. Although perhaps cathartic for him, the details of his family’s euthanasia assistance for his mother, a cancer patient who killed herself at age 58, contributes nothing to a book on depression. Perhaps this section would be more appropriate in another New Yorker article—like the one that launched the writing of this book.

The Noonday Demon has a broad appeal not only to mental health professionals and others touched by the illness, but to the general population as well. In fact, the book won the 2001 nonfiction National Book Award. Mr. Solomon ends his book with a chapter on hope. He notes, “the opposite of depression is not happiness but vitality, and my life as I write this is vital, even when sad. I may wake up sometime next year without my mind again…Every day, I choose, sometimes gamely and sometimes against the moment’s reason, to be alive.”

By Marion Ehrlich

Ed. note: Sallie Mink and David Seaman contributed to this review.

THE MANIC PANIC CONNECTION - A report on a presentation1 by Dean F. MacKinnon, M.D.,2, Smooth Sailing, Spring 1998.

While studying the genetics of affective disorders, Dr. Dean F. MacKinnon has been working with families in which several members have bipolar disorder. Recent analysis of data from a large epidemiological study of the 1980s showed that 20 percent of families affected by bipolar disorder (but only 1 to 2 percent of families in the general population) are also affected by panic disorder. In other words, panic disorder clusters in families affected by bipolar disorder. Dr. MacKinnon is exploring the likely existence of a genetic subtype—perhaps a distinct form of bipolar disorder—that is responsible for the combined disorder (bipolar disorder plus panic disorder). The work may assist researchers in other studies of the genetic transmission of bipolar disorder.

As background, Dr. MacKinnon explained that panic disorder is characterized by panic attacks, with sudden, severe onsets of extreme anxiety. They are self-limited at twenty minutes to one-half hour, with physical symptoms that may include racing heart or palpitations, shortness of breath, dizziness, tingling, and nausea. Psychological symptoms include feelings of derealization [changed reality], depersonalization [unreality], and imminent death. Panic attacks can reoccur in the settings of previous panic attacks, leading to avoidance of those settings and sometimes to agoraphobia (fear of open spaces [or of leaving home]). Many people go the emergency room during a panic attack, believing that they are having a heart attack.

The study was limited to families in which at least three closely related members had bipolar disorder, and they were selected from the clinic population or from volunteers in the community. Blood was drawn from the family members for DNA testing. A psychiatrist conducted a structured diagnostic interview to confirm the diagnosis of a mood disorder and any other psychiatric disorders. Also, the research team examined the medical records and took a family history of the study participants to be sure of the diagnosis (some physical disorders cause symptoms similar to those of mood and panic disorders).

The researchers found that 18 percent of the participants with bipolar disorder also had a diagnosis of panic disorder—a much higher rate of panic disorder than is found in the general population. In participants with unipolar depression, however, the rate of panic disorder was very low. If one member of a family affected by bipolar disorder has panic disorder, the chance that other bipolar members will also have panic disorder is 30 percent. Finally, rates of substance abuse and eating disorders were higher in the families affected by bipolar disorder than in the general population.

Dr. MacKinnon reminded the audience of the recent statistical evidence that a gene related to bipolar disorder is located on chromosome 18. While testing DNA from the participant families affected by bipolar disorder, the researchers detected a bipolar-related gene on chromosome 18 in some families and not in others—adding to evidence of multiple genetic causes for bipolar disorder. In families affected by bipolar disorder and panic disorder, evidence for a bipolar-related gene on chromosome 18 was very strong

The researchers want to learn more about the timing, frequency, and treatment response of panic attacks in people with bipolar disorder. Antidepressants are the treatment of choice for panic disorder, but they may worsen mania. The researchers hope that recognition of the manic-panic connection will lead to early diagnosis and improved treatments.

1Presented at a DRADA/Johns Hopkins symposium, Baltimore, MD, April 30, 1998.

2Assistant Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine

by Frieda Vandegaer, R.N., M.S., C.S.
Smooth Sailing: Spring 1998

The Perspectives of Psychiatry, McHugh, Paul R., M.D., and Slavney, Phillip R., M.D., 2nd ed. Baltimore: The Johns Hopkins University Press, 1998. (Paperback, 299 pages)

In The Perspectives of Psychiatry, Drs. McHugh and Slavney present a "conceptual structure" for the developing science of psychiatry. The first edition of the book (1986) won wide acclaim; the New England Journal of Medicine called it "the best single volume on psychiatry that anyone could read." This newly published second edition updates and expands on the authors' four conceptual perspectives ("disease," "dimensions," "behavior," and "life experience") in the context of psychiatry today.

Although the primary audiences for The Perspectives of Psychiatry are psychiatrists and other mental-health professionals, a persevering layman, working through or around hard-to-understand parts, can learn much from this book. It provides helpful examples and a summary at the end of each chapter.

Part I, a completely rewritten introductory section, provides an extensive discussion of key psychiatric issues. One chapter reviews past conceptual developments in psychiatry and the resulting factionalism between the "biological" and the "psychodynamic" (conflict-driven) orientations, which continues today. The authors' view is that neither orientation provides a complete understanding of psychiatric disorders. Part I also includes a new chapter on the classification system of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The authors commend the system as an advance that increases the "reliability" of diagnoses across the field of psychiatry, but they also point to the weaknesses of its symptom-based classification system, which does not address the sources of the disorders. They suggest that the sources can be approached through the conceptual framework of the four perspectives they propose. The remainder of the book is devoted to explanations of those four perspectives.

In the disease perspective (Part II), the authors outline the criteria used in medicine to determine which psychiatric disorders are "diseases" and which are not. They describe how manic depression (bipolar disorder) and schizophrenia meet the disease criteria, and devote a separate chapter to each. They discuss the symptoms relating to changes in mood, self-attitude, and energy that are present in manic depression and the growing body of research findings that provide clues to the etiology (causes) of the disease.

Under the dimensions perspective (Part III), the authors discuss findings showing that inborn traits of personality and general emotional stability, as well as cognitive abilities, are distributed in the standard bell-shaped curve. Such inborn traits result in varying emotional responses to life circumstances, causing more emotional distress in some individuals than in others. The authors discuss the need to differentiate between cases in which feelings such as anxiety or depression are related to an individual's inborn traits and cases in which similar symptoms may indicate the existence of a disease.

The authors' treatment of the behavior perspective (Part IV) is the longest and most detailed, reflecting Dr. McHugh's interest and research in these areas. It focuses on the varying contributions of the factors of drive and learning to behavioral disorders such as alcoholism and bulimia. There is also extensive discussion of the treatment of behavioral disorders.

The life experience perspective (Part V) is based on the everyday concept of looking at what has happened in an individual's life and what the effect has been. It encompasses a consideration of the other perspectives, such as whether a psychiatric disease is impacting the individual's life. In stressing the importance of the life experience in the diagnosis and treatment of an individual, the authors caution that psychiatrists must be careful how they interpret an individual's life history, and not superimpose a theory or interpretation that is not applicable.

Throughout, the authors discuss the interaction between perspectives. For example, the behavior of alcoholism may be influenced by the disease of manic depression. Advantages of the perspectives concept are summarized in the concluding section of the book.

The Perspectives of Psychiatry will interest those who want to learn more about psychiatry in general and, in particular, about the thinking of Dr. McHugh, chairman of the Department of Psychiatry at Johns Hopkins University Medical School and a nationally recognized leader in psychiatry.

by Delphine Peck
DRADA Book Committee.
Smooth Sailing: Winter 1999

The Perspectives of Psychiatry is available from DRADA: $17.00 for Maryland residents ($16.19 for nonresidents), plus $4 for shipping and handling. Call Paula at 410-987-7447 to order by credit card or for more information.