Understanding Depression

by Donald F. Klein and Paul H. Wender
Oxford University Press, 2005
Review by Roy Sugarman, Ph.D. on Aug 15th 2006

These two authors are professors of psychiatry, one at Columbia and the other at Utah (the latter is also a lecturer in psychiatry at Harvard). Whilst these are impressive qualifiers which grant them credibility psychiatrists will generally operate from one of two perspectives. This often depends on their age: the older tend to adopt a more biological-medical model in their approach while the younger, more recently qualified, lean towards a more egalitarian combination of a biological, sociological and psychological approach.

These two authors are rigid applicators of the biological approach, referring often to biological depression, and the need for biologically trained physicians to treat it. Right at the end of the book they note that there is no convincing role for psychotherapy based on their being no convincing evidence of the efficacy or efficiency of psychotherapy in 'biological depression'. They are certainly very clear-cut in their exposition of the flaws in the science and practice of psychiatry, but their absolute faith in the application of medicine to the 'disease' of depression is paramount and exhibited clearly. I also note that despite very clear descriptions of most things medical in depression, there is no reference anywhere to the withdrawal effects a patient may experience when antidepressants have been applied. Given their first edition came out in 1993, and was probably a few years in the making, some of the information and the structure in which it is presented may be more than 12 years old. The result is a thorough, biologically based and biased book, with much utility nevertheless for the depressed patient.

Despite their allegiance to biology, they often make reference to depression that emerges from psychological causes rather than from biological, a duality that is surely out of date, but still alive everywhere it seems. Even a fairly recent work on depression published on Medscape's pages made reference to the lack of evidence in the utility of psychotherapy. In all of these instances I refer the reader back to several reviews on Metapsychology Online, particularly with reference to science and pseudoscience in psychology (see Science and Pseudoscience in Clinical Psychology edited by Scott O. Lilienfeld, Steven Jay Lynn and Jeffrey M. Lohr, reviewed in Metapsychology 7: 39), and the need to be vigilant for side effects of withdrawal of popular antidepressant medication (see The Antidepressant Solution by Joseph Glenmullen, reviewed in Metapsychology 10:17).

Overall the approach of these two authors goes as follows: depression requiring treatment is a biological entity, the cause and disease processes are unknown. The only understanding of the illness is provided by lists of diagnostic criteria so that we can identify the particular disease entity afflicting the patient. Modern antidepressants are good, the older ones are probably better for more resistant depressions. ECT is great, effective and free of long term harmful effects, but some people who perhaps rely on intact memory may not be happy with it. One can refer the patient for more support and treatment by other professionals, but this is a waste of time when depression is biological rather than psychological in origin, whatever they mean by that. Nevertheless, they acknowledge a role for other professionals, even if they say this is only because professionals are seldom well enough trained in both biological and sociological interventions. They accuse the APA and others for becoming guilds for psychology, rather than anything else [there may be some truth to this argument]. In other places, they clear up the idea of endogenous and exogenous (reactive) depression as outdated concepts, but, as noted above, they seem to refer to psychological and biological mood states at the same level, which is clearly confusing. This same dilemma caused the creation of the heretofore unheard of illnesses for inclusion in the DSM in order to give a strong lobby group, from the psychologists of the APA, something to work on: Adjustment Disorders with some or other mood or anxiety state.

The authors' initial tactic in the book is to present a host of non-fictional case histories, gallingly disguised by using the same initial for both name and surname (for example Carl Carr and George Gelb), in order to clarify and expand on their hypotheses. However, I found it hard to follow who was who in this section in which each case was recalled to talk about some fetish or other. Next is a discussion of the various treatments employed.

One of latter discussions is around the chemistry of depression, using the term 'chemical imbalance' among others. Laymen, for whom the book is written, will likely not make sense of this term, nor will they come to know anything about the neurohumeral response of the body, during the stresses on the system, that seem putative in any discussion. Another issue which confounds the authors is the apparent lag in improvement in patients even though it is clear that the drugs begin to have an impact on brain within hours: no comments are delivered on the ideas of, for example, neurogenesis. Ideas and evidence of the dynamic homeostasis of the neurotransmitters of the brain are not recorded here either, although most patients we see are fascinated and intrigued by the possible effects their medications might have in restoring brain capacity, thereby enhancing their faith and compliance in medication. The reasons these authors do not address these issues is unclear but may reflect on the original publication date about 13 years ago.

Overall, the epilogue is the best part of the book, critical of everything and sharply written. Such tone, applied to the rest of this little book, would enhance it a lot.

However, the book really is useful, despite its perhaps biased and even outdated approach, as it attempts to be thorough yet accessible for the lay person. It certainly, however, provides a lot of information, and will persuade many to see their presentations as the result of a disease entity and thus only subject to revision by a medical professional. It will also convince many that psychologists are charlatans who have no place in the field of mood disorders, and should be largely ignored unless your doctor points you in the direction of an acceptable one. It may also calm your worries about the safety and efficacy of antidepressants, both old and new, even though so many complain that this is not the case. I can see that, for the most part, very little of this is their overt intention, but I see too that there will inevitably be those who will see between the lines and come to unwarranted conclusions.

Increasingly, world opinion among psychiatrists has leant towards fighting for their contingents of psychologists on their wards, and defending the value of these rather highly trained, often postdoctoral professionals. Most psychologists today now have a strong understanding of the biological mechanisms that are the target of treatments, both psychiatric and psychological. The chemistry of the brain, most would agree, is designed to process information, and psychology inputs are just that, information. The fact that much of CBT, and other more modern interventions, are informed by knowledge of the brain mechanisms underpinning learning and information management is ignored here and this does not enhance the book.

The authors know their stuff, that is clear, but their focus is still on the things which make our patients most angry, namely the medical side to their phenomenological experience of their depressions being forced upon them. The rosy outcomes put forward by these psychiatrists is not exactly the experience of most mental health professionals, and the idea that this is a disease entity is far from proven. While one must applaud such attempts by authors to remove the stigmatic experience through the application of science this book is not clear, nor does it argue for a more inclusive approach beyond the medical model. However, within the medical model, Dan Stein and others (see The American Psychiatric Publishing Textbook of Mood Disorders, edited by Dan J Stein, David J Kupfer and Alan F Schatzberg, reviewed in Metapsychology Online 9:49) have, in my opinion, done a better job; certainly with regard to engaging with the suffering of these clients within the evidence base of medical and other treatments (see Facing Human Suffering, by Ronald B. Miller, reviewed in Metapsychology 9:42).

I am glad that the demand for the previous book has led to its revision and expansion, and this book is better than most of its genre. I do wish however that it had been modernized and expanded to include a more inclusive model for treatment.

Roy Sugarman, PhD, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, A-Dir of Psychology, Royal Rehab Centre Sydney, Australia

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