Smooth Sailing reports about professional presentations at symposiums co-sponsored by DRADA, and articles from Smooth Sailing and other publications.

Depression and the Brain by J. Raymond DePaulo Jr., M.D., Professor of Psychiatry, Johns Hopkins University School of Medicine

The need for more brain research to unlock the mysteries of depression was addressed in a talk by J. Raymond DePaulo Jr., M.D. at a conference sponsored by the Dana Alliance for Brain Initiatives. Dr. DePaulo discussed the relationship of genetic research, brain imaging and medication for depression. Dr. DePaulo is a professor of psychiatry at the Johns Hopkins University School and Medicine and on the board of directors of the Depression and Related Affective Disorders Association (DRADA).

The Manic Panic Connection
Dean F. MacKinnon, M.D., Assistant Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine

Dr MacKinnon provides details about research on the relationship of bipolar disorder and panic attacks.

Bipolar Illness: What Is Different about Young People
Gabrielle A. Carlson, M.D., Professor of Psychiatry and Pediatrics, Director of Child and Adolescent Psychiatry, State University of New York at Stonybrook

Dr. Carlson discusses the many ways in which bipolar illness in young people differs from that in adults.

How to Evaluate Your Psychiatrist or Other Therapist If You Have (Or Possibly Have) a Depressive Disorder by John R. Lipsey, M.D., Assistant Professor of Psychiatry at the Johns Hopkins University School of Medicine.

This article, originally appearing in Smooth Sailing, has been reprinted several times in response to popular demand and now is available here on the home page.

Am I Depressed? by David W. Goodman, M.D., Clinical Instructor in Psychiatry, Johns Hopkins University School of Medicine

A practicing clinician provides his perspective on how individuals can identify the symptoms of depression in themselves. It particularly addresses situations where depression has been previously diagnosed and treated and the individual is concerned about whether the depression is returning.

Pharmacological Treatment of Mood Disorders
David M. Goldstein, M.D., Director of the Mood Disorders Program, Georgetown University Medical Center.

A comprehensive review of the medications for both depression and manic depression written for our home page.

Treating the Illness
Andrew Feinberg, M.D., Assistant Professor of Psychiatry and Behavior, Johns Hopkins University School of Medicine

A clinician's perspective on out-patient treatment

Schizoaffective Disorder
Melvin McGinnis, M.D., Assistant Professor of Psychiatry and Behavior, Johns Hopkins University School of Medicine.

A review of the symptoms and diagnosis of Schizoaffective Disorder.

Neurobiology of Cyclic Affective Illness: Implications for Treatment.
Robert M. Post, M.D., Chief, Biological Psychiatry Branch, National Institute of Mental Health (NIMH).

Discussion of research showing neurobiological changes following traumatic life events and implications of research findings for cycles of depressive episodes.

Seasonal Affective Disorder
Norman E. Rosenthal. M.D., Chief, Section of Environmental Psychiatry, Clinical Psychobiology Branch, National Institute of Mental Health (NIMH).

A discussion of the pioneering research that established the existence of seasonal affective disorder and the effectiveness of light treatment.

Treatment Options in Bipolar Disorder
Charles L. Bowden M.D., Deputy Chairman and Chief, Division of Biological Psychiatry, University of Texas Health Science Center. (1996)

Effectiveness of medications relating to subtypes of bipolar disorder.

Affective Disorders and Pregnancy
Sylvia Simpson, M.D., Associate Professor Psychiatry, Johns Hopkins University School of Medicine (1995)

Risk factors and treatments of bipolar disorder and depression during pregnancy and postpartum period.

Schizophrenia Vs Mood Disorder: A Puzzle Solved?
Godfrey Pearlson, M.D. Department of Psychiatry, Johns Hopkins University School of Medicine. (1996)

Findings showing distinctly different brain structures in bipolar patients and in schizophrenia patients.

Recent Findings in the Genetics of Bipolar Disorder
J. Raymond DePaulo, M.D., Professor of Psychiatry, Johns Hopkins University School of Medicine (1996)

Findings relating to Chromosome 18 and a difference in paternal and maternal transmission.

Genetic Advances: Addition by Division,
Francis J. McMahon, M.D., Assistant Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine (1997)

Findings indicating subtypes of bipolar illness ties to different genes.

Book Reviews

Depression and Anxiety, The Johns Hopkins White Papers 2002, Margolis, Simeon, M.D., PhD, and Swartz, Karen L., M.D. New York: Medletter Associates, 2002. (Paperback, 72 pages, $19.99)

The Depression and Anxiety 2002 White Paper, like others in the Johns Hopkins White Paper series, is geared to audiences who want authoritative current information about a particular illness. The publication of a new edition each year allows for the inclusion of a significant amount of new material. The new material supplements the comprehensive text about the illnesses, which remains basically the same from year to year. The result is a publication that provides both comprehensive and up-to-date information about depression and anxiety.

The main text provides extensive information about 10 types of depression and anxiety and a wide range of pharmacological and psychotherapeutic treatments. This material is well organized and detailed. One significant gap, however, is the failure to emphasize the absolute importance of obtaining a correct diagnosis before initiating treatment. In the section about mental health professionals, the word “diagnosis” appears only in a brief paragraph about the role of the primary care physician.

Information that is new for this edition appears in easily identified columns and boxes throughout the publication. This 2002 White Paper includes 14 columns headed “New Research,”each summarizing a journal article published in 2000 or 2001. This feature serves readers who want to keep up on the latest research, even when a single study is not conclusive in itself. This year’s research columns include studies showing that sertraline (Zoloft) is effective for panic disorder and posttraumatic stress disorder (PTSD); St. John’s wort is ineffective for major depression; depression and anxiety increase the risk of heart disease; and antidepressants can cause psychosis or mania.

Additional new material about specific subjects (which change each year) is presented in short, boxed articles. In contrast to the more formal style of the main text, some of these articles are written in a more pro-active, magazine style, addressing the reader as “you” and including lists of do’s and don’ts. Articles this year include “Exercise: A Treatment for Depression and Anxiety”; Evaluating Mental Health Information on the Internet”; “Serotonin Syndrome”; and “When Does Grief Become Depression?” This year’s edition includes a helpful glossary.

The great strength of the Depression and Anxiety White Paper 2002 is that within a very limited space, it presents a wealth of up-to-date information about depression and anxiety in a straightforward and factual manner.

By Delphine Peck

This and other Johns Hopkins White Paper titles may be ordered by writing to:
The Johns Hopkins White Papers
P.O. BOX 420083
Palm Coast, FL 32142-9264
Further information is available from www.HopkinsAfter50.com.

Bipolar Disorder: A Guide for Patients and Families, Francis Mark Mondimore. Baltimore: Johns Hopkins Press, 1999. (Paperback, 277 pages, $16.95)

In 1990, psychiatrist Francis Mark Mondimore, M.D., a member of the clinical faculty of the University of North Carolina at Chapel Hill, wrote the excellent book Depression: The Mood Disease (Johns Hopkins University Press; revised in 1993). His new book, Bipolar Disorder: A Guide for Patients and Families, is the first of its kind: a book written for the lay reader that provides basic information about bipolar disorder. Like the earlier book, it is comprehensive, authoritative, easy to read, useful, and practical. Dr. Mondimore writes elegantly, informally, very clearly (with no hint of "talking down"), and with unmistakable empathy for patients.

Bipolar Disorder has four parts: "Symptoms, Syndromes, and Diagnosis," "Treatment," "Variations, Causes, and Connections" (the illness in children, adolescents, and women; interrelated medical conditions; brain imaging; and creativity), and "Getting Better and Staying Well." It provides both broad and in-depth coverage, and its main points are illustrated with case studies drawn from the author's personal experience.

Although Dr. Mondimore's view of bipolar disorder is, as one reader commented, "100% mainstream biopsychiatry," he considers psychotherapy to be an important component of treatment, saying that even with the effectiveness of medication treatment, "every bipolar patient needs psychotherapy at one point or another."

Dr. Mondimore explains the principles of "mood hygiene," giving excellent advice about behavior that the patient can adopt to reduce the risk of relapse. [Ed. note: Although Dr. Mondimore uses the term "relapse prevention" in this part of the book, he clearly means that it is a goal of mood hygiene, not a sure consequence.] The first task for patients is to accept the reality of their illness. Then they must learn to take as much responsibility for controlling their illness as they can, but they also need to prepare for potential crises.

In Bipolar Disorder Dr. Mondimore focuses on information that patients and families actually want and need. His coverage of less central subjects, such as the use of the DSM IV (The Diagnostic and Statistical Manual of Mental Disorders, 4th edition) and the history of pertinent research findings, can be omitted by casual readers without their losing any critical information. Of special note is the "Resources" section, which includes "Recommended Reading," "Support and Advocacy Organizations" (including DRADA), and "Internet Resources."

Bipolar Disorder is a readable and comprehensive source of information, and Dr. Mondimore's guidelines for maintaining mood stability provide renewed hope that patients can lead healthier, more fulfilling and productive lives. The book can be helpful to social workers and other nonmedical caregivers and is suitable for anyone interested in the subject. Most of all, it will help patients and their family members and friends to deal with the bipolar illness that has burdened their lives.

Without exception, the contributors to this review consider Dr. Mondimore's Bipolar Disorder a welcome and much-needed contribution to the understanding of bipolar illness and how to live with it.

by Anne Heasty, M.S. and Louise Riemer
DRADA Book Committee.
Smooth Sailing: Summer 1999

How to Evaluate Your Psychiatrist or Other Therapist If You Have (Or Possibly Have) a Depressive Disorder by John R. Lipsey, M.D., Assistant Professor of Psychiatry at the Johns Hopkins University School of Medicine.

1) It is impossible to get good treatment for depression if your therapist does not fully understand the differential diagnosis of depression. That is, some patients have symptoms of depression as a reaction to life circumstances; others, as a manifestation of an underlying major depressive disorder. The latter disorder is a medical illness strongly influenced by genetic factors, and it appears as a more or less stereotyped syndrome. In major depression, the patient has a profound and sustained lowering of mood and of mental and physical energy, often accompanied by self-doubt, self-criticism, and self-blame. Patients usually have changes in their sleep and appetite (in either direction). They may be irritable, their pleasure in usual activities is greatly diminished, and their hope for the future darkens. Suicidal ideas are not uncommon. Clearly, patients with this illness may find that their symptoms are worsened by environmental stressors, and at times these stressors may even provoke an episode of the illness in a predisposed person. However, environmental factors are not the major cause, and for these patients the most effective intervention is pharmacological treatment with antidepressants.

On the other hand, some patients have symptoms of depression that are fully understandable as an emotional reaction to difficult life circumstances. These depressive reactions are usually transient; respond well to positive changes in the environment; and occur most frequently in vulnerable individuals who find themselves in situations where their intentions, wishes, and desires for the future are thwarted in some way, or who have been severely disappointed or grief-stricken by some sort of loss. In general, these patients do not need pharmacological treatment, do not have strong family histories of mood disorder, and are best approached with appropriate psychotherapy.

The important issue, however, is that patients in the second category, who are demoralized, are not necessarily less depressed than patients with major depressive disorders. You simply cannot tell from the degree of a person's sadness or depression whether the person is demoralized or whether he or she has a major depression. If your therapist doesn't know this, and treats all depression as an illness, with antidepressants, or treats all depression as a response of life difficulties, with psychotherapy, you don't have a good therapist. Put another way, if your therapist only knows about one type of depression, you'd better be sure it's the one you have, or you may be hit with a hammer when you aren't a nail.

2) A good therapist will always take a detailed story of both the patient's various symptoms of mood disorder (especially, suicidal ideas) and the patient's current life circumstances. If a therapist does only one or the other, it is difficult to see how he or she will be able to reach an appropriate diagnosis and treatment.

3) A good therapist should always take a detailed family history of psychiatric disorders, because the evidence is overwhelming that major depressive disorders are strongly genetically influenced.

4) A good therapist should take a thorough medical history, looking for potential medical causes of depression. For example, several neurological disorders, endocrine disorders, and a variety of medications can cause depression, so the medical history is extremely important in planning appropriate treatment.

5) Any good therapist should be willing to speak to family members in order to get another view of the patient's symptoms and history.

6) If antidepressants are used to treat major depression, the prescribing physician should initiate thorough trials of such medication and try different antidepressants if the first ones are not successful. Approximately 80 percent of patients with major depression should respond to one of the first three antidepressants prescribed, if these medications are given in adequate doses for about eight weeks each. Blood tests to measure levels of antidepressants are useful to assess the adequacy of the dosage.

7) Depression, from whatever cause, is usually a treatable condition. A good therapist is one who does not give up early.

There is little sense in seeing a therapist who doesn't basically believe what you say. Similarly, it makes little sense for the patient not to tell the truth. If the truth is not being regularly told and believed, there is obviously a mismatch between the therapist and the patient.

9) Any good therapist should be flexible in approach to diagnosis and treatment. That is, he or she should always be willing to at least consider different diagnoses and treatment approaches, and he or she should always be willing to discuss the reasons for making a particular diagnosis and proposing a particular treatment. A good therapist also is always willing to consider having the patient obtain a second opinion, especially if diagnosis is in doubt or if treatment is not progressing successfully.

You need to find a doctor
you trust and with whom you feel comfortable,
who is knowledgeable about various
treatments, and is open-minded to
new approaches. Note: This topic is frequently brought up by patients and prospective patients. In this article, I have outlined briefly some general rules that I believe patients might use when evaluating their own treatment. Of course, these rules are really my personal opinions, and different mental health professionals might have different views; but the above thoughts may be helpful to patients as they seek and enter treatment.

John R. Lipsey, M.D.