Darkness Visible

Styron, William. New York: Random House, 1990. Hardback, 84 pages; also in paperback.

At DRADA’s 1989 mood disorders symposium acclaimed author William Styron spoke movingly about his experience with depression. That talk evolved into an article in Vanity Fair, which in turn, evolved into this short book. Darkness Visible is subtitled, rather dramatically, “A Memoir of Madness.” In it Styron recounts a severe depressive episode so vividly that even an incurably happy person will likely begin to comprehend his despair.

The story begins in Paris, where Styron—already clinically depressed and knowing it, but not yet in treatment—is receiving a prize for his writing. During the festivities, which “should have sparklingly restored my ego,” writes Styron, “my brain had begun to endure its familiar siege: panic and dislocation, and a sense that my thought processes were being engulfed by a toxic and unnameable tide that obliterated any enjoyable response to the living world.” He lists the problems he experiences during a dinner with friends that night as “failure to have an appetite . . . , failure of even forced laughter and, at last, virtually total failure of speech.” As his depression continues unrelieved, he contemplates suicide: “Hideous fantasies [of suicide], which cause well people to shudder, are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality.”

Styron rails against the general public’s failure to understand the seriousness of depression: “For in virtually any other serious sickness, a patient who felt similar devastation would be . . . in bed . . . His invalidism would be . . . unquestioned . . . .” But the depressed person “is thrust into the most intolerable social . . . situations [where] he must try to utter small talk . . . and, God help him, even smile.”

The word “depression,” Styron says, is “a true wimp of a word for such a major illness . . . Nonetheless, for over seventy-five years the word has slithered innocuously through the language like s slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control.” And because getting it under control is not accomplished overnight, “failure of [rapid] alleviation is one of the most distressing factors of the disorder to the victim . . . .”

In addition to the narrative of his descent into depression, survival of urges to suicide, and eventual recovery, the book includes Styron’s views on the morality of suicide; the high prevalence of depression and suicide among “artistic types”; the variety of causes of depression and ways of experiencing it; and the merits of psychotherapy, psychopharmacology, and psychiatric hospitalization.

Most DRADA readers will realize that Styron’s discussion of causes and treatments reflects his own views and does not provide a balanced or comprehensive presentation of current medical knowledge. With this caveat understood, this book is highly recommended for relatives, friends, and coworkers of persons with a depressive disorder.

By Anne Maclean Heasty

The Peace of Mind Prescription: An Authoritative Guide to Finding the Most Effective Treatment for Anxiety and Depression

Charney, Dennis S., M.D., and Nemeroff, Charles B., M.D., Ph.D. New York: Houghton Mifflin, 2004. Hardback, 259 pages.

The Peace of Mind Prescription, written by two preeminent psychiatrists specializing in mood and anxiety disorders, is subtitled “An Authoritative Guide to Finding the Most Effective Treatment for Anxiety and Depression.”

Despite the book’s bold subtitle, apparently written by salespeople rather than psychiatrists, the authors do attempt to empower patients to seek proper diagnoses and treatments for their anxiety and mood disorders. In general, the authors give thorough descriptions of all the major anxiety and mood disorders (except obsessive-compulsive disorder): their symptoms, causes, and treatments. The personal accounts of patients not only add color, but also help bring the various disorders to life. Some readers (especially those who are currently anxious or depressed) may find the science difficult to understand. The authors are to be commended, however, for emphasizing that these disorders are true diseases, with real brain pathology and physiological responses, caused by various genetic and environmental (including developmental) factors.

The lists and descriptions of medications for each disorder are comprehensive and informative, with the exception that Serzone has now been taken off the market (although the drug remains available as the generic preparation, nefazodone). However, it would have been helpful if the medications for bipolar disorder had been divided into classes (mood stabilizers vs. antipsychotics) and if the mood stabilizers had been addressed as a class as well as individually.

Finally, only two paragraphs are devoted exclusively to bipolar depression, the treatment of which can be a slow, difficult, and frustrating process for the patient and the psychiatrist alike.Of note, the separation between anxiety disorders and mood disorders in this book is necessary to keep things as simple and clear as possible. However, this separation obscures the coexistence in many people of an anxiety disorder and a mood disorder (the authors do allude to this dual condition). Patients should realize, for instance, that although the symptoms of their anxiety disorder are more prominent, they might also have an underlying mood disorder that may require different and perhaps even more aggressive treatment.Four additional chapters address the special features of and treatment considerations for anxiety and depression in women, men, children, teens, and older adults. It is certainly worthwhile to look at the particular concerns of each of these populations.

A chapter titled “Reducing the Risk of Suicide,” although well intentioned, gives a clinical vignette describing a particular therapeutic relationship (the relationship between the patient and the psychiatrist) that is seldom applicable or even advisable.

There is a chapter early in the book, titled “Building Emotional Resilience,” which may be too complicated or premature for many patients, especially those who are still anxious or depressed.

Finally, a useful appendix includes contacts for various resources, help in making sense of health information, and a comprehensive list of prescription medications that can worsen anxiety and depression.In the end, this book does give patients information that can empower them to seek the most effective treatments for their mood and anxiety disorders. Although it is important for patients to remember that this information is not meant to be interpreted as any sort of treatment suggestions or guidelines, it should, if used correctly, help them ask the right questions and become more active participants in their own care.

By Phillip Kronstein, M.D.

Recommended Books on Depression and Bipolar Disorder

The books listed here have been chosen and reviewed by a DRADA Information Committee composed of professionals and volunteers. The book reviews have been printed in DRADA's publication, Smooth Sailing.

Recommended Books Listed in Chronological Order Based on Date of Publication

Depression and Anxiety, The Johns Hopkins White Papers 2005, Karen Swartz, M.D. (ed.). New York: Medletter Associates, 2005. (Paperback, 64 pages, $24.95.) Can be ordered online at www.HopkinsWhitePapers.com or www.HopkinsAfter50.com.

Summary: The 2005 edition of Depression and Anxiety provides updated versions of much of the excellent material of earlier editions, supplemented with reports on recent research findings and discussions of newly addressed topics. This publication is particularly appropriate for the layperson who wants an authoritative summary of the most up-to-date scientific information available.
Read Review

The Peace of Mind Prescription: An Authoritative Guide to Finding the Most Effective Treatment for Anxiety and Depression, Charney, Dennis S., M.D., and Nemeroff, Charles B., M.D., Ph.D. New York: Houghton Mifflin, 2004. Hardback, 259 pages.

Summary: Thorough description of most major anxiety and mood disorders, their symptoms, causes and treatments. Helps patients ask the right questions and become more active participants in their own care.
Read Review

Raising a Moody Child: How to Cope with Depression and Bipolar Disorder, Fristad, Mary A., Ph.D., and Arnold, Jill S., Ph.D. New York: Guilford Press, 2004. Hardback, 260 pages.

Summary: A helpful book for parents who have a teen or younger child with emotional or behavioral problems, which provides information on depression or bipolar disorder as it manifests itself in those ages.
Read Review

Exuberance: The Passion for Life, Jamison, Kay Redfield, Ph.D. New York: Alfred A. Knopf, 2004. Hardback, 405 pages.

Summary: Kay Jamison’s exploration into the long neglected emotion of human condition. Exuberance is defined by the author as a “mood or temperament of joyfulness, ebullience and high spirits, a state of overflowing energy and delight.” Other books by Kay Jamison reviewed on this site include: An Unquiet Mind, Night Falls Fast: Understanding Suicide, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament.
Read Review

Understanding Depression: What We Know and What You Can Do About It, DePaulo, J. Raymond, Jr., M.D., and Horvitz, Leslie Alan. New York: John Wiley & Sons, 2002. Hardback, 304 pages; also in paperback.

Summary: A comprehensive primer for patients, family members, and others seeking clear and up-to-date information about the illnesses of clinical depression (unipolar depression), and bipolar disorder (manic-depressive illness), and related disorders by the Director of the Department of Psychiatry at Johns Hopkins. In his interview he attributes the inspiration for the book to a visit to a DRADA support group. He stresses the need to recognize and communicate what is still not known about the illness as well as what is known. The book includes discussion of genetic and hormonal research.
Read Interview

The Years of Silence Are Past: My Father’s Life with Bipolar Disorder, Hinshaw, Stephen P. New York: Cambridge University Press, 2002. Hardback, 227 pages.

Summary: An accomplished psychologist writes about his memories of his father, a prominent philosopher who suffered from bipolar disorder. Written in an insightful and sympathetic way, this book has been recommended by the reviewer for patients and family members.

Adult Bipolar Disorders: Understanding Your Diagnosis & Getting Help, Waltz, Mitzi. Sebastopol, Calif.: O’Reilly & Associates, 2002. Paperback, 371 pages.

Summary: This book addresses information on bipolar disorders: definitions, diagnosis, medication, and talk therapies, included are sections on going to college, working, and whether to “come out” at work, the Americans with Disabilities Act, medical leave (including the Family and Medical Leave Act), and legal and financial planning. Of particular note to readers are chapters on complementary therapies and health care insurance.
The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, Miklowitz, David J. Ph.D. New York: Guilford Press, 2002. Paperback, 322 pages.

Summary: This 322 page guide is designed to help patients with bipolar disorder cope with their illness.
Living Longer DEPRESSION FREE: A Family Guide to Recognizing, Treating, and Preventing Depression in Later Life, Miller, Mark D., M.D., and Reynolds III, Charles F., M.D. Baltimore: The Johns Hopkins University Press, 2002. Paperback, 184 pages.

Summary: Focuses on depression and bipolar disorders in the older generation. Valuable resource for any older person struggling with a depressive illness, as well as their family, friends, and caregivers.
Read Review

Adolescent Depression: A Guide for Parents, Mondimore, Francis Mark, M.D. Baltimore: Johns Hopkins University Press, 2002. Paperback, 287 pages; also in hardback.

Summary: A comprehensive, clearly written guide for parents and those working with teenagers about the signs and symptoms of clinical depression, how medications work, benefits of talk therapy, and other interventions. Differentiates bewildering moods and behaviors of depressed teenagers from problems incurred as “part of growing up.”

More Than Moody: Recognizing and Treating Adolescent Depression, Koplewicz, Harold S., M.D. New York: G. P. Putnam’s Sons, 2002. Hardback, 303 pages.

Summary: Using case studies, Dr. Koplewicz walks the reader through the various manifestations of adolescent depression detailing symptoms that are not normal and need to be investigated by parents, diagnosis, treatment and response to treatment.

Overcoming Teen Depression: A Guide for Parents, Kaufman, Miriam, B.S.C.N., M.D., FRCP. Buffalo, N.Y.: Firefly Books, 2001. Paperback, 262 pages.

Summary: Gives a comprehensive overview of the depressive illness, emphasizing the medical components. The tone of the book is hopeful, emphasizing the parents can help their teens get better by seeking a diagnosis, finding appropriate treatment and providing support in many ways.
Read Review

I Am Not Sick, I Don’t Need Help!, Amador, Xavier with Johansen, Anna-Lisa. Peconic, NY: Vida Press, 2000. Paperback, 197 pages.

Summary: Advises a lay person how to communicate and cope with a family member so as to aid and support continuation of treatment. Explains the process of calling the doctor, a mobile crisis team, the police and filing civil commitments.

Night Falls Fast: Understanding Suicide, Jamison, Kay Redfield, Ph.D. New York: Knopf, 1999. Hardback, 432 pages; also in paperback.

Summary: Covers general information about suicide, its history, the psychological patterns that underlie suicide attempts, suicide’s biological component, and suicide prevention. Also includes stories about persons who have attempted or committed suicide.
Electroshock: Restoring the Mind, Fink, Max, M.D. New York: Oxford University Press, 1999. Hardback, 157 pages.

Summary: Thoroughly covers modern electroconvulsive therapy (ECT), dispelling common misconceptions and fears and detailing its benefits.
How You Can Survive when They’re Depressed: Living and Coping with Depression Fallout. Sheffield, Anne. New York: Random House, 1999. (Paperback, 306 pages)

Summary: Offers good sensible advice on self-help for those living with a person who has depressive illness.
Bipolar Disorder: A Guide for Patients and Families, Mondimore, Francis Mark, M.D. Baltimore: Johns Hopkins Press, 1999. Paperback, 277 pages.

Summary: 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.

Personal History, Graham, Katharine. New York: Vintage Books. 1998, Paperback, 642 pages.

Summary: 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.

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.

Summary: Dr. McHugh, former chairman of the Department of Psychiatry at the Johns Hopkins School of Medicine, and Dr. Slavney provide four conceptual approaches to psychiatry illnesses, as described in the review.

An Unquiet Mind, Jamison, Kay Redfield, Ph.D. New York: Alfred A. Knopf, 1995. Hardback, 224 pages; also in paperback.

Summary: Dr. Jamison, an acclaimed author and educator of scholarly books about depression and bipolar disorder, describes for the first time, her own struggles with bipolar illness. She 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.

Undercurrents: A Therapist’s Reckoning with Her Own Depression, Manning, Martha. San Francisc HarperCollins, 1994. Hardback, 197 pages; also in paperback: Undercurrents: A Life Beneath the Surface.

Summary: 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).

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

Summary: Focuses on scientific knowledge about mood disorders in easy-to-understand style. Illustrates the difficulty and importance of accurate diagnosis and treatment.

Winter Blues: Seasonal Affective Disorder: What It Is and How to Overcome It, Rosenthal, Norman E. M.D. New York: Guilford Publications, Inc., 1993. Paperback, 325 pages.

Summary: This expert’s book is an invaluable resource for seasonal affective disorder (SAD) patients. Covers light treatment, medication, psychotherapy, diet, and exercise.

Touched With Fire: Manic-Depressive Illness and the Artistic Temperament, Jamison, Key Redfied, Ph.D. New York: The Free Press, 1993. Hardback, 370 pages; also in paperback.

Summary: Presents evidence for a link between the illness and artistic creativity, featuring quotations from the artists' writings. Also covers biochemical and genetic information. Beautifully written.

Darkness Visible, Styron, William. New York: Random House, 1990. Hardback, 84 pages; also in paperback.

Summary: When this Pulitzer-Prize winning author wrote about his personal experience with depression, this small, powerful book became a national best seller. Speaker at the DRADA/Johns Hopkins Mood Disorders Symposium in 1989 and again in 2002, Styron’s words are chilling, yet hopeful.

DRADA PUBLICATION

The Manual for Mood Disorder Support Groups, Resnick, Wendy Miller, R.N., M.S., C.S. Baltimore: DRADA, 2004. Spiralbound, paperback, 88 pages.

Summary: Comprehensive guide which provides a time-tested framework for developing, facilitation, and maintaining a mutual-help support group. Answers frequently asked questions about starting a group. Deals with problems and offers solutions to difficulties that may arise in many types of group settings.
Read Review

Overcoming Teen Depression: A Guide for Parents

Kaufman, Miriam, B.S.C.N., M.D., FRCP. Buffalo, N.Y.: Firefly Books, 2001. Paperback, 262 pages.

In Overcoming Teen Depression: A Guide for Parents, Miriam Kaufman, M.D., gives a comprehensive overview of depressive illness, emphasizing the medical components. In addition, the book is full of case histories that demonstrate the various manifestations of clinical depression. Dr. Kaufman covers treatment options, including a good explanation of alternative treatments.

All adolescents experience a wide range of emotions and behaviors. Often moodiness and experimentation are viewed as merely typical teen angst. Some teens, however, exceed ordinary erratic temperament and conduct. Having a “bad day” may lengthen to months of irritability or sadness. Sleep and appetite may increase or decrease. Concentration is limited, and grades drop. Hobbies, interests, or pleasurable activities may become boring. If these signs persist into several weeks, the teen may be suffering from clinical depression.

The book contains information and support for parents who experience trying times when their child is going through a course of clinical depression or bipolar illness. It is a good source not only for parents, but also for family members, friends, teachers, and counselors. It could be quite helpful to a teen who is trying to understand his or her diagnosis—preferably after recuperation, when the teen has more energy and is able to concentrate.
The tone of the book is hopeful, emphasizing that the parents can help their teens get better by seeking a diagnosis, finding appropriate treatment, and providing support in many ways.

Overcoming Teen Depression was published in 2001 and thus newer medications now commonly used in treating depression are, of course, not mentioned.. But it has a lot of useful information that could have been helpful. I do wish that Dr. Kaufman had more strongly emphasized the genetics of mood disorders. I think that when they have this information, patients, family members, and friends are better able to embrace the disorders as scientific phenomena—causing less blame and stigma in families.

By Sallie Mink

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

Touched With Fire: Manic-Depressive Illness and the Artistic Temperament

Jamison, Key Redfied, Ph.D. New York: The Free Press, 1993. Hardback, 370 pages; also in paperback.

I think continually of those who were truly great.
Who, from the womb, remembered the soul’s history
. . . . . . . . . Whose lovely ambition
Was that their lips, still touched with fire,
Should tell the spirit . . . . . . . .
Who wore at their hearts the fire’s centre.
--STEPHEN SPENDER

Kay Redfield Jamison, associate professor of psychiatry at The Johns Hopkins University School of Medicine and a featured speaker at the 1993 DRADA symposium, has penned another groundbreaking book. (Previously, she coauthored the definitive medical reference Manic-Depressive Illness [1990, Oxford University Press].

Her newest effort, Touched With Fire, is about manic depression—the “disease of perturbed gaieties, melancholy, and tumultuous temperaments, and its relationship to the artistic temperament and imagination.” Dr. Jamison offers literary, scientific, and biographical evidence for a symbiotic relationship between the creative process and the “fires” of manic depression (or related mood disorders) that touch many writers, poets, composers, and artists.

Dr. Jamison defines the symptoms of manic-depressive illness and details the history of the view that artists possess a “divine madness,” citing the lives of famous artists such as Robert Lowell, Robert Burns, Hector Berlioz, Hugh Wolf, Theodore Roethke, Edgar Allen Poe, Samuel Taylor Coleridge, John Berryman, William Styron, Leo Tolstoy, and Percy Bysshe Shelly, among others. She clarifies the relationship between “moods and the creative process,” illustrating that for these creative individuals, “elation in mood often preceded the creative periods rather that being entirely a result of them.” She further documents seasonal fluctuations in productivity cycles for many of these artists.

Using George Gordon, Lord Byron as her vehicle, Dr. Jamison examines the genealogy of manic-depressive illness and its related temperaments. She develops a fully integrated picture of Byron’s “tumultuous passions,” weaving quotes from his physician, friends, biographers, and wife, as well as from his own journals, letters, and poetry. Byron becomes the picture of the manic-depressive artist, in his own words,
The apostle of affliction, . . . [who] knew
How to make this madness beautiful, and cast
O’er erring deeds and thoughts, a heavenly hue
Of words.
(“Child Harolde’s Pilgrimage”)
Dr. Jamison documents more briefly the genealogies of Tennyson, Schumann, James, Melville, Woolf, Hemingway, Johnson, Van Gogh, and others, showing evidence that “manic-depressive illness is a genetic disease, running strongly, not to say pervasively, in some families, while absent in most.”

Although Dr. Jamison also examines the treatments available for manic-depressive illness, this book is not a comprehensive introduction to the illness for the newly diagnosed or their family members. It is better suited to someone particularly interested in the artistic temperament and the problems, ethical issues, and misconceptions associated with tempering creative thinking.

Dr. Jamison should be recognized not only for the incredible scholarship of Touched With Fire (she cites over 800 pieces of scientific, literary, and biographical information), but also for her literary efforts. Dr. Jamison’s style is exquisite—although provoking, laced with lush images and poetry, and highly readable. In addition, her admiration and concern are obvious for these artists who create ‘in the wind’s eye,’ and [bring] back with them words or sounds or images to ‘counterbalance human woes.’

By Connie Pryor

Winter Blues: Seasonal Affective Disorder: What It Is and How to Overcome It

Rosenthal, Norman E. M.D. New York: Guilford Publications, Inc., 1993. Paperback, 325 pages.

Norman Rosenthal, M.D., is a pioneer in the study of seasonal affective disorder (SAD) and director of the light studies at the National Institute of Mental Health. His expertise and his own sensitivity to seasonal variations first resulted in his 1989 classic, Seasons of the Mind. The revised edition, renamed Winter Blues, is a “must read” book for anyone interested in SAD. Dr. Rosenthal invites the reader to see what SAD is, how it affects people, and what can be done about it. The reader feels as if he or she has the benefit of expert, cutting-edge medical information along with the common-sense help and caring of a support group.

Winter Blues is written at a level useful to both the novice and the informed SAD patient. It also has practical information for family members and friends; family physicians; and the clergy, school personnel, and other helping professionals. Further, this book is an excellent introduction to affective disorders for the layperson whose interest has been piqued by the recent media focus on SDA, Prozac, and depression in general.

The first section of the book gives a detailed clinical profile that addresses the central features of SAD along with individual variations. Dr. Rosenthal presents an appealing case for placing SAD along a continuum of seasonal responses experienced by many people, a model which aids understanding of the illness and may act to lessen stigma. Particularly well explored are the somatic (bodily) complaints of fatigue/low energy, difficult morning rising, carbohydrate craving, and weight loss/gain. Also discussed is the “just leave me alone” symptom which can be so distressing to family members and friends.

Part 2, “Treatments,” explores light therapy in detail, focusing on recent developments in implementation and refinements of light-box technology. Psychotherapy and medication are discussed in a manner helpful even to treatment veterans. Most interesting to me were the chapters “Beyond Light Therapy: Other Ways to Help Yourself” and “Combining Different Types of Treatment.” These issue frequently come up in support groups and informational meetings; addressing them encourages people to work with their mental-health professionals on a personalized treatment plan for attaining the highest possible degree of functioning.

There is also a comprehensive resource section providing information ranging from where to purchase a light box; to dietary advice, menus, and recipes; to support groups. Depression self-rating scales are also included, but be careful to make sure, if you’re buying, that a browser has not already filled them in.

Winter Blues is one the best books I’ve read about mood disorders and will be a well-thumbed volume on my bookshelf.

By Lissa Falk

Understanding Depression: What We Know and What You Can Do About It

DePaulo, J. Raymond, Jr., M.D., and Horvitz, Leslie Alan. New York: John Wiley & Sons, 2002. Hardback, 304 pages; also in paperback.

J. RAYMOND DEPAULO JR., M.D., TALKS ABOUT HIS LATEST BOOK, UNDERSTANDING DEPRESSION
Dr. DePaulo, Henry Phipps Professor and Director, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine was interviewed by Wendy Resnick,R.N., M.S., Director, DRADA Support Services Program. The entire interview was first published in Smooth Sailing, DRADA's newsletter and makes references to DRADA's beginnings. Excerpts are included below.

What is the audience that you wrote the book for?
As we do say in the book, there are three kinds of audiences:
- One is patients with depression or bipolar disorder who may want to know more about their diagnosis and/or their treatment;
- Family members who also may want to know about the diagnosis and treatment of their family member, or how to get someone into treatment or whether it’s likely they have an illness; and
- People who are not in treatment and may want to know if they should be in treatment, or anyone else who is interested. This book, as my previous book, How to Cope with Depression has been, could be used as an adjunct to a classroom text for certain classes.

What would you like readers to take away with them?
The thing I wanted to emphasize in this book that is the same as in my first book, is that depression is a treatable medical disease. Though we do not know exactly what happens in the brain to cause it, we know that it is a brain disease of some sort. We don’t have a specific abnormality in the brain that we can point to, and we don’t know what genes and what in the environment interact to cause the disease; based on our real-life experience, we know that it is a treatable disease with both medications and psychotherapy.

I want people to know what we know and also what we do not know. I wanted to underscore our limitations in knowledge in this book to give a context for what we do know. The inspiration for what I actually wrote came from a DRADA support group for family members in Timonium. What I saw, to my great surprise, was a very high level of distress similar to what you and I first encountered when we started DRADA, in the 1980s. I saw that the anger and distress hadn’t changed as much as I imagined. Here we are in a DRADA group and these family members—struggling with the illness in their loved ones—were feeling a lot of frustration. I was stunned and wondered why this anger wasn’t yielding to all the good information and support now available. Members of the group were frustrated with doctors, administrators of the schools, and the mental health system. Then, towards the end of the meeting, two or three veterans of the group reminded the more frustrated and distressed members that “we all need to know our own limits so that we have something left to give to our family members.” They said, “You don’t know the limitations that the doctors and other professionals are working under, and if you did, you might understand a bit more.” Then I got it! The members did not under-stand the limits of what they and their doctors could do.

For us doctors, the most significant constraint is our knowledge of what to do. Administrators and schools, too, have limits to their knowledge and their resources. I remembered that when I would try to answer patients’ questions, so often the answer was, “We don’t know the answer to that question.” We don’t know why a treatment works, when it works, or how it works. We do it based on experience or based on empirical trials. We doctors would help the patient by letting him or her know that we do not know everything. We should make clear what we know and what we don’t.

Why is it important to get your message out—how we conceptualize these illnesses?
The Hopkins message is that this is a disease and certainly we are not alone in that message. Most psychiatrists agree with that idea. What we bring to it is an emphasis on reasoning—if it is a disease, what does that mean, is it certain, and what other alternative formulations are there? In fact, when you do see a patient, knowing that they have a disease is rarely a sufficient understanding of their problem. To understand the impact of the disease on a person, you need to know a lot about the person’s background, their normal temperament, their personal goals and their behavior patterns—in order to develop a comprehensive treatment plan. I want to reassure and orient patients and families so they can act more independently and effectively in their own best interest.

Where will the book fit into the bigger picture of the many books about mood disorders?
There are hundreds of other books. This one is my personal consultation. I tried to make this a discussion—though obviously a one-way discussion. I tried to anticipate questions and respond to concerns and issues that I’ve heard about in the consultation room over the years. Also, I wanted to put in the things that I’ve tried to teach young doctors, whether it is talking about St. John’s wort, or the public suspicion about this or that aspect of psychiatry. It is not intended to be “the facts and nothing but the facts.” It is intended to be a personal account from someone who has seen lots and lots of patients.

What I want to emphasize as someone who has seen 8,000 patients or so, is what we still don’t know. …How do we go get the information that we need? (because at least some of the things that we don’t know are knowable). There is a message here: however you do it, the word is research. We’ve got to find out the answers.

The number of people with mood disorders is very high relative to the number treated. What more can be done in terms of educating people about depression?
That’s a very good question. There have been efforts at this in the past, but we need to do more in educating the educators of our patients. Those include the school system. I am thrilled and proud that DRADA has been involved in developing a curriculum on depression to teach in health class. The other health teachers for patients are doctors, nurses, psychologists, and social workers who traditionally have been educators and therapists and we need to beef up their curriculum. Educate the educators!

Now that you chair the psychiatry department in one of the most prestigious universities of medicine, what would you say is the future of American psychiatry, and your role in its development?
I think that the present in psychiatry is exciting in that we see an emerging consensus about a number of disorders. Over the last 20 years or so, people have been more coherent in their teaching about the most severe mental disorders, i.e., depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder, autism in children, etc. There is an understanding of them mostly as diseases caused by genetic and nongenetic contributors. But also, we still are faced with the difficulties of psychiatry dating back to the ‘40s, ‘50s, ‘60s and ‘70s, and now they have the added 1990s—2000 twist of managed care. Psychiatric care, for patients and the doctors, is more economically disadvantaged now than it was in the 1950s and 1960s. Though two-thirds of people have some form of insurance, even the insurance doesn’t cover psychiatry in the way it used to.

The thing I’m looking forward to is when we are able to validate or prove this disease idea for these disorders and say, “Here is the brain abnormality you will see every time someone has a clinical depression,” whether someone got this from a stroke or from a genetic predisposition. If we can show the pathway in the brain that leads to manic-depressive illness or depression then I think we will be ‘relicensed’ as doctors to offer care in the way that we think we should. That will give support to patients and to the profession in terms of reimbursing the care and then we will judge treatments as effective or ineffective like we do in any other field of medicine. There will be a more level playing field with other diseases. It is also important because we will have much better ways to diagnose these disorders and we will hopefully develop more powerful forms of treatment.

Also, I am delighted to lead our efforts as educators—both to train young people in psychiatry and to teach them their special role as educators with families and patients. I get very excited thinking about that because I think in the next 15 years we will be able to make key breakthroughs for several major illnesses in psychiatry though I can’t tell you where the breakthroughs will be.

What is the future of the management of mood disorders?
In terms of the overall management—I’m glad to hear you use the word “management,” because our job as doctors is to manage all of the impacts of a disorder on the person’s life—as a package. That does not limit it to specific treatments of the symptoms. It is everywhere that this condition affects the person, we should be cognizant of that and have a plan that incorporates, to the extent that it can, all of the impacts. If it is affecting the person’s education, intervene with the family, the school—this is just as important as the medications and psychotherapy that you are doing. It is a truly comprehensive thing. The future of this is that hopefully we will get broader about our discussion. For example, because it takes 10 or more years to get the diagnosis made, what can we do in the meantime? It seems to me we can educate the higher-risk families about what to be aware of. The typical age of onset is 17 or 18 years of age; ask the doctor, “What is the impact of that?” The age range of 17 to 27 (onset to diagnosis) is big—so many things happen during that time that contribute to successful adjustment as adults.

Where is the latest research involved in the genetics of mood disorders?
We are getting closer to the genes that cause depression and bipolar disorder. We are at the place where we have strong evidence that there are multiple genes related to these disorders, but we haven’t yet isolated the genes.

What is your prediction of milestones–for next year?– for 20 years?
I have been taught by experience not to give specifics on that . . . .In 1990 Dr. James Watson answered very clearly that in two to three years we’ll have one or two or more of the genes for bipolar disorder and schizophrenia—and here we are 10 or 12 years later without any of those in hand for sure. I certainly believe that it will happen and that it will happen over the next 15 years. Honestly though, with the substantial resources that we have devoted to it, there is no reason that it shouldn’t happen in two or three years if we can find at least some of the genes . . .If we can find two or three or four of the genes for this disorder, we will make a clear breakthrough in understanding the pathway to depression or bipolar disorder. In Alzheimer’s disease, the first gene was found in about 1987 (the amyloid precursor protein gene) and then a second and a third gene were found. Then we could look at these three genes and see that one gene was found in this set of families, another gene in another set of families, and another gene was found by looking across the rest of the chromosomes for a look-alike gene compared to the second one. So that these three genes, though found in very different families, in the metabolic pathway of the brain, they line up–1,2,3.

Any final thoughts that you would like to add?
The only thing we could add is that we now know, due to the World Health Organization (W.H.O.) global- burden-of-disease studies, that this disease is worldwide. It is even less well-addressed in other countries than it is here. I do think we have to have an eye to the whole world and to all the people that are suffering from this. The W.H.O. estimates that this will be the number-two disease in terms of causing social, economic and other burdens—to societies as of the year 2020, worldwide. Currently, our vision of how to manage depression is really only applicable to the relatively well-to-do countries. That’s something that needs to change also.

Interview conducted by Wendy Resnick,R.N., M.S., Director, DRADA Support Services Program

Adult Bipolar Disorders: Understanding Your Diagnosis & Getting Help

Waltz, Mitzi. Sebastopol, Calif.: O’Reilly & Associates, 2002. Paperback, 371 pages.

This easy-to-read “patient-centered guide” addresses the usual information on bipolar disorders—definitions, diagnosis, medication, and talk therapies. The chapter “Living with Bipolar Disorders” includes sections on going to college, working, whether to “come out” at work, the Americans with Disabilities Act, medical leave (including the Family and Medical Leave Act), and legal and financial planning.

Of particular note to readers, and often glossed over by other authors, are chapters on complementary therapies and health care insurance.
The author begins the section on complementary therapies by advising the reader not to rely on these therapies alone, but to use them only as adjuncts to traditional therapies (medication and psychotherapy) included in the treatment plan. A variety of complementary treatments are reviewed, including supplements (health and nutritional, such as essential fatty acids), herbal remedies, acupuncture, message, help with sleep problems, and sensory integration therapy (identification and reduction of disturbing sensory stimuli).

Forty pages are devoted to negotiating the U.S. health-care system, and some comparable information is given for other English-speaking countries. The book provides practical information, such as what questions to ask when choosing an insurance company, how to talk on the phone to managed-care staffers (even tricks to use), how to document any information received, and how to negotiate the appeals process. It also discusses carve-outs for mental health, COBRA (the Consolidated Omnibus Reconciliation Act), SSI (Supplemental Security Income), and finding help in getting medications when you cannot afford them.

The phone numbers and e-mail addresses found throughout the book and the appendix, which lists resources for information are very helpful. Peculiarly, DRADA is mentioned in the preface as providing “much-appreciated assistance,” but it is not listed on the resources.

By Marion Ehrlich

How You Can Survive when They’re Depressed: Living and Coping with Depression Fallout

Sheffield, Anne. New York: Random House, 1999. (Paperback, 306 pages)

In this realistic and helpful book, Anne Sheffield describes what she calls “depression fallout,” the painful, debilitating emotions experienced by those living with a person who has a depressive illness. The valuable insight, information, and advice she provides is designed to help the reader in a battle against depression fallout, a battle that she says “has to be fought simultaneously on two fronts: yours and the depressive’s.”

The author writes in a straightforward, no-nonsense style, with imaginative phrasing. She chooses everyday language, using the old, familiar term “manic depression” rather than “bipolar disorder.” Her stated assumption is that the readers are persons living with someone with depressive illness. Thus, she addresses the reader as “you,” creating the feeling that she is sitting down with you and a few others and giving frank, “tell-it-like-it-is” advice and information. In this context, she often uses the phrase “your depressive” or “your manic depressive” to refer to the person with the illness. Ms Sheffield describes five predictable stages of depression fallout: confusion, self-doubt, demoralization, anger, and the desire to escape. Beginning with her own personal experience, gaining further insight in a family support group, and continuing to learn from other sources, she found these reactions surprisingly common, despite many differences in individual situations. She provides examples involving spouses, lovers, parents, and children—rich, and poor. Donald Klein, M.D., in his preface praising the book, finds that these stories “ring true.”

Ms. Sheffield’s premise is that obtaining effective treatment and staying in it is the critical element for both the ill person and those living with him or her. But compared with similar passages in many mainstream books, her approach is more realistic and down-to-earth, acknowledging the frequency of misdiagnosis, inadequate treatment, failure of the depressed person to take prescribed medication, and problems that remain even with good treatment. Her advice is tailored to overcoming these difficulties.

Emphasizing that knowledge about the illness is an essential tool in the battle against depression fallout, Ms. Sheffield includes up-to-date, succinct information about the illness, written from the perspective of the family member. For example, she lists the “official” list of symptoms of depression and then lists what she calls “unofficial” symptoms, which most often affect those living with a person who has a depressive illness.

The book provides an overview of the often conflicting medical and psychological theories and treatments available, with useful suggestions for negotiating the maze. Ms. Sheffield emphasizes the primary need for those with a depressive illness to get an effective medication. She maintains that the treatment is most likely to succeed when the patient, the family member, the psychiatrist, and the psychotherapist (if there is one) work as a team. She notes that many times the family member is the person most aware of the signs of the patient’s illness. If the treating professional refuses to accept calls from the family member, Ms. Sheffield urges that the professional be left messages when the patient stops taking medication or talks of suicide, or when there is other important information to communicate.

In the chapter title “Setting Boundaries,” the author makes clear that accepting the patient’s illness as a biological one does not mean that the family member or other person involved should passively accept the ill person’s behavior. On the contrary, she argues that the illness necessitates setting boundaries is two-fold: to help the person with the illness and to help those living with him or her to avoid demoralization and depression fallout.
Ms. Sheffield describes demoralization as the most common element of depression fallout, “arriving early and staying late.” The examples she gives throughout the book make its eroding presence crystal clear. In some individuals, the demoralization slips into a serious depression that needs treatment.
Although the insights, perspectives, and advice outlined in How You Can Survive when They’re Depressed cannot be expected to apply to every situation, they can be very helpful for persons struggling to cope with a family member or friend who has a depressive illness. As one rader said, this book can be a “light in the darkness.”

By Delphine Peck and Connie Pryor

Note: David V. Seaman contributed to this review.