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Styron, William. New York: Random House, 1990. Hardback, 84 pages; also in paperback.
At DRADAâ€™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, â€śA Memoir of Madness.â€ť 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 Styronâ€”already clinically depressed and knowing it, but not yet in treatmentâ€”is receiving a prize for his writing. During the festivities, which â€śshould have sparklingly restored my ego,â€ť writes Styron, â€śmy 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.â€ť He lists the problems he experiences during a dinner with friends that night as â€śfailure to have an appetite . . . , failure of even forced laughter and, at last, virtually total failure of speech.â€ť As his depression continues unrelieved, he contemplates suicide: â€śHideous fantasies [of suicide], which cause well people to shudder, are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality.â€ť
Styron rails against the general publicâ€™s failure to understand the seriousness of depression: â€śFor in virtually any other serious sickness, a patient who felt similar devastation would be . . . in bed . . . His invalidism would be . . . unquestioned . . . .â€ť But the depressed person â€śis thrust into the most intolerable social . . . situations [where] he must try to utter small talk . . . and, God help him, even smile.â€ť
The word â€śdepression,â€ť Styron says, is â€śa 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.â€ť And because getting it under control is not accomplished overnight, â€śfailure of [rapid] alleviation is one of the most distressing factors of the disorder to the victim . . . .â€ť
In addition to the narrative of his descent into depression, survival of urges to suicide, and eventual recovery, the book includes Styronâ€™s views on the morality of suicide; the high prevalence of depression and suicide among â€śartistic typesâ€ť; 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 Styronâ€™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
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
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.
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 â€śdiagnosisâ€ť 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 â€śNew Research,â€ťeach 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 yearâ€™s research columns include studies showing that sertraline (Zoloft) is effective for panic disorder and posttraumatic stress disorder (PTSD); St. Johnâ€™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 â€śyouâ€ť and including lists of doâ€™s and donâ€™ts. Articles this year include â€śExercise: A Treatment for Depression and Anxietyâ€ť; Evaluating Mental Health Information on the Internetâ€ť; â€śSerotonin Syndromeâ€ť; and â€śWhen Does Grief Become Depression?â€ť This yearâ€™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.
A FAMILY MEMBER'S PERSPECTIVE — WENDY F. BAYNARD, a report on a presentation 1 by Wendy F. Baynard, M.S.W., Smooth Sailing, Spring 1995
Although Wendy Baynard's talk (at the symposium) focused on her husband's bipolar disorder and its effect on their family, it also poignantly illustrated the apparent genetic basis of the disorder (highlighted by other speakers): she noted that two of their children have mood disorders (one depression, the other manic depression). Their 12-year old daughter started treatment at age eight and has taken lithium.
Ms. Baynard outlined her 50-year-old husband's 20-year history of mood changes, which for many years was "explained" as a drinking problem. Sixteen years ago, after the birth of their first child, he went to Alcoholics Anonymous and stayed sober for 13 years—but was never "really happy." Her husband's career—he was at times a Reagan administration appointee, a law partner in a prestigious firm, and an attorney in a solo practice that did not take off—seemed to be a reflection of the highs and lows of his personal life.
Early in her talk, Ms. Baynard described life with her husband as "never dull"; later she noted that "the hardest part of living with him was the unpredictability of his moods." Medication for depression enabled him to get out of bed to go to work, but it did not help him avoid having inappropriate reactions which ravaged his personal and professional life. Those reactions ranged from frustration at trying to understand the new phone system his company installed, to believing he could do anything (including choreograph his daughter's sixth-grade dance program), to having irrational outbursts of temper.
To be able to sustain financial stability, Ms. Baynard got a master's degree in social work, and for her own well-being, she promoted friendships for support. She described her anger and frustration at seeing her husband's potential "thrown away." For the children's sake, she maintained an atmosphere of calmness and never maligned her husband before their children. She also discovered DRADA in 1993, took the training program for support-group leaders and started a support group for family members.
Apparently, only after a drinking relapse, detoxifica-tion, and inpatient psychiatric treatment was her husband properly diagnosed with bipolar disorder. He had to learn to accept that diagnosis and the words that go with it, such as mentally ill and manic depression.
The attitude of acceptance appears to have been trans-mitted from father to son. Ms. Baynard concluded by recalling a conversation she had with her younger son, who had read a poem about Vincent van Gogh and was surprised to learn that van Gogh had committed suicide. Mother explained to son that had van Gogh lived today, he probably would not have died, given modern treatment and medica-tion. Her son's response: "I didn't know I was that lucky."
1 Presented at a DRADA/Johns Hopkins symposium, Baltimore, Maryland, April, 1995
by Marion Ehlrich
Smooth Sailing: Spring 1995
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Current Johns Hopkins Research Studies
1. CLINICAL TRIAL ON BIPOLAR DEPRESSION:
Dr. Jennifer Payne is conducting a research study to examine the effectiveness of Riluzole in treating the depression phase of bipolar disorder. This outpatient study of medication or placebo will last 9 to 12 weeks. Participants should be between the ages of 18 and 75, have a diagnosis of Bipolar I or Bipolar II, be depressed, and be in current treatment with an outpatient psychiatrist. The study includes medical and psychiatric evaluations as well as time-limited medication treatment at no cost. If you are interested in participating, please contact Annie Chewning at 410-502-2334.
2. CONNECTIONS OF MOOD AND ANXIETY DISORDERS:
Dr. Sean F. MacKinnon is conducting a research study to discover a possible cause of both anxiety and mood symptoms. Anyone who has been part of a Johns Hopkins Genetic study of bipolar disorder is eligible. The study involves a on-time visit to Johns Hopkins Hospital for a session lasting approximately two hours. Study participants will have their breathing and blood pressure measured while they breathe regular air and air mixed with a small amount of carbon dioxide over a period of 15 minutes each (carbon dioxide is a natural byproduct of breathing, and is the gas that makes up soda bubbles). The patterns of response to these tests will be used to look for genes for bipolar and anxiety disorders. If you are interested in participating, or have questions, please call Brandie Craighead at 410-955-3616.
3. EMPLOYMENT AND WORK DISABILITY IN BIPOLAR DISORDER:
Dr. David Schretlen is conducting a study of factors that are associated with work disability and employment in individuals with bipolar disorder. Study participants will be interviewed about their work history and current mood symptoms, and they will take some pencil-and-paper tests of attention, memory, and problem-solving. All reasonably healthy persons with bipolar disorder are welcome to participate, regardless of whether or not they are employed. The assessment will take about 2 and 1/2 hours, and participants will be paid for their time. If you are interested in this study, please call Patricia Gregory at 410-614-4476.
Sheppard Pratt Research Study:
Sheppard Pratt is seeking volunteers for a clinical research study to evaluate the safety and effectiveness of an approved medicine under investigation for the treatment of depression due to bipolar disorder. To qualify for participation you must:
Đ˛Đ‚ Be at least 18 years old
Đ˛Đ‚Ńž Have been diagnosed with Bipolar Disorder
Đ˛Đ‚Ńž Be experiencing symptoms of depression
As a qualified participant you will receive, at no cost:
Đ˛Đ‚Ńž Monitoring of depression and bipolar symptoms
Đ˛Đ‚Ńž Study-related examinations
Đ˛Đ‚Ńž Study-related medication
If you are experiencing depression due to bipolar disorder please call 410-938-3139 to learn more about becoming a participant in this research study.
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 â€śAn Authoritative Guide to Finding the Most Effective Treatment for Anxiety and Depression.â€ť
Despite the bookâ€™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 â€śReducing the Risk of Suicide,â€ť 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 â€śBuilding Emotional Resilience,â€ť 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.« Older Posts — Newer Posts »