Dealing with Depression: A commonsense guide to mood disorders

The World Health Organisation tells us that depression is the greatest cause of disability in our world. But how many depressions are out there, and what can be done about them? Read Gordon Parker’s book and find out.

Gordon Parker is a Professor of Psychiatry at the University of New South Wales and was instrumental in setting up the Black Dog Institute which leads research into depression in Australia. His book is filled with careful clinical observations, wise recommendations on treatment and much more. His views on the increasing incidence of bipolar disorder are interesting and important. Anyone experiencing depression or managing it should read this book carefully.

John Ellard AM, Former editor Modern Medicine Australia

. . . compelling and compassionate . . . honest concerning available facts . . .

Anthony W. Clare, MD. St Patrick’s Hospital, Dublin

. . . an excellent overview of the depressive illnesses, written by one of the leading authorities on the subject.

Kay Redfield Jamison, PhD, Professor of Psychiatry, The Johns Hopkins School of Medicine

Gordon Parker has style. The second edition of Dealing with Depression provides an outstandingly accessible account of how he sees the theory and practice of treating depression. While it is clearly written originally for the non-professional, the story is told from the cutting edge of research and treatment. It exemplifies the modern unifying approach to psychiatry–a synthesis of reliable knowledge and clinical judgment. It is a book both to read and to recommend to one’s patients and their families.

Guy Goodwin, Professor of Psychiatry, Oxford University

Gordon Parker is a leading international expert on depression

and mood disorders. He is Scientia Professor of Psychiatry at the

University of New South Wales, and Executive Director of the

Black Dog Institute (incorporating the former Mood Disorders

Unit) at the Prince of Wales Hospital in Sydney.

DEALING WITH

DEPRESSION

A common sense guide to mood

disorders

2nd edition

GORDON PARKER

with the assistance of David Straton, Kay Wilhelm,

Philip Mitchell, Marie-Paule Austin, Kerrie Eyers,

Dusan Hadzi-Pavlovic, Gin Malhi and Sue Grdovic

This edition first published in 2004

First Published in 2002

Copyright © Gordon Parker 2004

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage or retrieval system, without prior permission in writing from the publisher. The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or ten per cent of this book, whichever is the greater, to be photocopied by any educational institution for its educational purposes provided that the educational institution (or body that administers it) has given remuneration notice to Copyright Agency Limited (CAL) under the Act.

Allen & Unwin

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National Library of Australia

Cataloguing-in-publication entry:

Parker, Gordon, 1942-.

Dealing with depression : a commonsense guide to mood

disorders.

2nd ed.

Includes index.

ISBN 1 74114 214 8.

1. Depression, Mental - Popular works. I. Title.

616.8527

Typeset in 11/14 pt Adobe Garamond by Midland Typesetters

Printed by McPherson’s Printing Group

10 9 8 7 6 5 4 3 2

People seem to be able to bear or tolerate depression as

long as there is the belief that things will improve.

Kay Jamison, Night Falls Fast

CONTENTS

Preface to the second edition

List of tables and figures

Acronyms

Introduction

1 What is depression?

2 Depresssion, a common experience

3 Classification of depression

4 Clinical depression

5 Unipolar and bipolar disorders

6 General features of depressive and bipolar disorders: the experience

7 Postnatal mood disorders

8 Grief: the experience

9 Stress and depressive subtypes

10 Personality styles and non-melancholic depression

11 Four vignettes

12 The biology of depression

13 Professional assessment

14 Drug treatments

15 Electroconvulsive therapy and transcranial magnetic stimulation

16 Cognitive therapies

17 Interpersonal therapy

18 Psychotherapies and counselling

19 Anger management

20 Matching the treatment to the depression

21 Living with someone with depression

Appendix Mood disorders, the artistic temperament and wordly success

Glossary

Resources

References

Index

PREFACE TO THE

SECOND EDITION

Dealing with Depression was first published in early 2002. While the book was written for those with mood disorders and their families, it also proved to be of considerable interest to health professionals. In preparing this edition, the objective has been to maintain the strengths of the original publication but to give greater emphasis to topics that have generated questions from interested readers. In particular, the book now covers in much greater detail the bipolar disorders and the ways in which differing personality styles can contribute to the non-melancholic depressive disorders.

The non-melancholic disorders represent the most common depressive conditions in the community but they have proved difficult to define and differentiate from each other. It has therefore been difficult to determine the most appropriate treatments. Most systems classify them on a dimensional basis (i.e. severity, duration and persistence). We argue for an alternative model—that certain personality styles predispose individuals to develop these depressive conditions following germane stressful events. We also suggest that personality style shapes the clinical depressive pattern and, perhaps more importantly, influences the chance of responding to differing treatments. This is a central component of our approach, but it remains a field where much more research is required to determine its capacity to indicate the most appropriate treatments for different disorders.

Our Mood Disorders Unit team (incorporated within the Black Dog Institute) is working hard at developing the model and those with non-melancholic conditions may be able to help us with parts of that research. Thus, this book has a unique feature. Those who have experienced a depressive disorder may wish to complete the Personality and Treatment Response Survey on our website (www.blackdoginstitute. org.au), a confidential approach where your anonymity is totally respected. As part of that survey, you will complete a personality measure, with scores on key dimensions being given to you at the end of the questionnaire. As noted, personality influences the chance of onset of non-melancholic disorders (in particular), as well as influencing how long they last and (possibly) response to differing treatments. Your personality profile will give you a ‘snapshot’ of how you may be at increased (or decreased) risk to a non-melancholic depressive disorder, and thus allow you to consider the material in Chapter 10 (Personality Styles and Non-melancholic Depression) more closely. It may assist your thinking about what might be the most appropriate treatment for you.

Since the first edition was published, three concerns about the current management of mood disorders have increasingly occupied our Institute’s attention. First, we believe that—as a consequence of the current model of depression—a significant number of individuals with a more ‘biological’ depressive disorder are being undertreated. Second, and more commonly, a high percentage of people with the less ‘biological’ disorders (i.e. non-melancholic ones) appear to be receiving treatment that is excessively physical. It is not unusual for us to see people with so-called ‘treatment-resistant’ non-melancholic disorders who have received up to 20 different drugs and/or ECT, the doctor’s view being that depression is a disease and that only a physical treatment approach is relevant.

Third, there is a distinct failure to detect bipolar disorder. We undertook three informal surveys in 2003 among people referred with depressive conditions and found that 30–50 per cent across the samples had a bipolar disorder; 80 per cent of the subjects had not received such a diagnosis before. The average time between the onset of their bipolar disorder and receiving such a diagnosis was 15 years. Such issues concern us. There is no doubt that the mood disorders have been destigmatised considerably in the last few years and this is of major importance, as it is for people to seek help. However, if the help lacks sophistication, there is a real risk that many people will not only receive inappropriate treatment but feel that they have received a ‘bouncing cheque’.

Our Black Dog Institute is clinically focused. We seek to ensure that people with mood disorders (and their relatives and friends) receive a rich and sophisticated message about multiple mood disorders and a rational model for their treatment. Many of the issues considered in this book can be pursued further by reference to our website (www.blackdoginstitute. org.au), where we try to keep you up to date with advances in dealing with mood disorders.

I remain indebted to my colleagues and to our many supporters who have assisted the preparation of this edition, and I remain indebted to Kerrie Eyers from our Institute and Rebecca Kaiser from Allen & Unwin for superb editing.

LIST OF TABLES

AND FIGURES

Table

Figures

ACRONYMS

INTRODUCTION

Depression is … a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a major illness.

William Styron, Darkness Visible

Others imply that they know what it is like to be depressed because they have gone through a divorce, lost a job or broken up with someone. But these experiences carry with them feelings. Depression, instead, is flat, hollow, and unendurable.

Kay Jamison, An Unquiet Mind

The depressive disorders comprise our most common, and most commonly misdiagnosed, psychological illnesses. While we cannot claim to cover every aspect of depression or offer any miracle cures, Dealing with Depression is written for those suffering depression themselves, the families and friends of those with depression and professionals who want to know more about these conditions and their treatments.

In attempting to make people aware of the high incidence of depression and its impact on the community, definitions of depression have been progressively redefined and oversimplified in communications to patients and the public. The current dominant model views depression as an ‘it’—that is, a single entity rather than a set of conditions, a ‘disease’ varying only in severity, and having nothing to do with an individual’s personality (and thus beyond the individual’s control). ‘It’ is commonly thought to be brought about by chemical changes in the brain, thus requiring antidepressant medication—with all antidepressant drugs being equally effective.

By contrast, numerous psychotherapies and a range of quite different approaches are also held to be relevant to all expressions of depression, and of comparable effectiveness to antidepressant medication. But, by lumping multiple potentially different depressive disorders under unifying terms such as ‘clinical depression’ or ‘major depression’, by not respecting multiple causes and by testing treatments as if they had universal rather than specific application, we have a non-specific model for depression and an ‘All roads lead to Rome’ therapeutic paradigm. Treatments tend to be dictated more by the therapist’s discipline, training or interest than by characteristics of the particular depressive condition.

Such a model is rather like viewing all cancers as the same and applying any one of multiple treatments to them, whereas we know that there are many types of cancer (some benign, some malignant), all triggered by different factors, some environmental, some genetic. We also know that there are many different treatments for cancers, each specific to the type of cancer diagnosed.

Research at the Mood Disorders Unit (MDU)—now based in the Black Dog Institute in Sydney—has challenged many of the current assumptions about depression. Those of us working at the Institute do not view depression as an ‘it’ but suggest that there are multiple expressions of depression that can represent diseases, disorders or reactions. For some depressive diseases, chemical changes in the brain may be a primary cause, with the depression occurring independently of personality and temperament; for other depressive disorders, the individual’s personality style may be all-important.

We also argue against the view that each of the available antidepressant drugs are equally effective. We also suggest that the most effective therapies are not the same for each principal depressive type, with some expressions of depression most likely to respond to antidepressant medication and others quite unlikely to respond. Similarly, we suggest that the usefulness of some of the psychotherapies (such as cognitive behavioural therapy) is not equivalent across the depressive types.

In journal papers as well as educational and training activities, our Institute staff seek to challenge the ‘dumbed down’ view of depression, and we also believe that it is important to communicate the challenge more widely. Such issues shape the content and objectives for this book.

A diagnosis of depression, therefore, is only half the answer. The first question should be ‘What type?’ Once the specific type of depression has been identified, patients (and their families) can