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

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

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

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

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

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

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

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

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

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

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

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