Depression

Depression is among the latest contributions to Oxford University Press’s A Very Short Introduction series. It is written by practicing psychiatrist Mary Jane Tacchi and Professor of Psychiatry Jan Scott (Institute of Psychiatry at Kings College London). Like all entries in the series, the book provides a brief overview of the topic (typically around 120 pages of text), offers recommendations for further reading, and is written for a general audience (i.e. no background knowledge is presumed). In this review, I will describe each section of the book, provide critical commentary, and give an overall impression of the book’s value.

          Depression is divided into 7 chapters. Chapter 1 gives a historical introduction to the concept of depression going back to the Ancient Greeks, through the Middle Ages, and leading up to 19^th & 20^th Century conceptions by Western society. Chapter 2 picks up where the previous chapter left off, examining more modern conceptualizations and designations of depression. Tacchi and Scott detail various attempts to classify and diagnose depression, such as Freudian, Kraepelian, and DSM-based classificatory schemes. Chapter 3 explores various sociodemographic factors associated with depression. These include differences across age, race, class, marital status, and culture, among other factors. The authors conclude the chapter with a nuanced and thoughtful discussion around the issue of suicide and problems related to researching/understanding the phenomenon. Chapter 4 expounds upon classical biological, psychological, and social models of depression. The major etiological hypotheses are discussed, including the moanamine imbalance hypothesis and Beck’s cognitive model). This discussion is complemented in Chapter 5, which examines various attempts throughout history to treat depression, from early sedatives (e.g. opium/morphine) to shock therapy (i.e. electroconvulsive therapy) to the various classes of antidepressants and psychosocial interventions (e.g. Cognitive Behavioral Therapy). Chapter 6 discusses current controversies around overdiagnosis, antidepressant efficacy, alternative medicines/therapies, and newly proposed etiological models. The book concludes with Chapter 7, which vacillates between a discussion about the global burden of depression, the stigma of depression, and the relationship between depression and creativity. This chapter, due to its brevity and seeming lack of coherence, is in my opinion, the weakest. The book concludes with some helpful recommendations for further reading. Having provided a brief overview of the book’s content, I now turn to a few (hopefully constructive) criticisms of the information presented.

While the book serves primarily as an introduction to the topic, time is well-spent throughout going into detail on specific topics (e.g. the monamine and neuro-endocrine hypotheses of depression discussed in Chapter 5 and current investigations into the role of inflammation in causing or contributing to depression in Chapter 6). As such, it is puzzling that the authors do not go into greater detail (or in some cases leave out details all together) regarding diagnostic reliability/validity and antidepressant treatment effects.

As described earlier, Chapter 2 discusses the evolution of various classifications for depression. This includes a discussion about the DSM diagnosis of Major Depressive Disorder (MDD). Instead of going into detail regarding the reliability of the diagnosis, the authors acknowledge the malleable nature of psychiatric classification systems and compare the fuzzy boundaries of psychiatric diagnosis to that of general medicine (e.g. the continuum of blood pressure scores, p. 26). In doing so, the authors minimize the epistemological/ontological questions surrounding psychiatric diagnosis and neglect pragmatic problems, such as clinical reliability of MDD. A deeper discussion would acknowledge the “questionable” reliability of adult and child MDD in the DSM-5 field trials (see Regier et al., 2013 for reported Kappa values) and criticisms that MDD is not a consistent syndrome (see Fried & Nesse, 2015); to speak nothing of disparate attempts to measure the phenomenon (Fried, 2017). Such issues are important to acknowledge when discussing depression, its diagnosis, and how it manifests in society (problems left unexamined in Chapters 3 and 6, which treat depression as a reliable and uniform phenomenon).

Another issue unsatisfactorily covered by Tacchi and Scott regards antidepressant medication effects. While the limitations of antidepressant efficacy are acknowledged (e.g. p. 89), the impact of adverse effects, especially among the SSRI class of antidepressants, is only discussed in passing. Little or no mention is given to the issues of antidepressant-induced dependence (and associated abstinence syndromes; Fava et al., 2015), sexual dysfunctions (Montejo, Montejo, & Navarro-Cremades, 2015), or agitation/suicidality (Bielefeldt, Danborg, & Gøtzsche, 2016; Healy & Whitaker, 2003; Sharma, Guski, Freund, & Gøtzsche, 2017). These adverse effects, in part, explain why users are, “not always good at sticking with a medication regime[n]” and the returning or intensification of symptoms upon withdrawal, a problem the authors incorrectly dismiss as merely signifying “relapse” (p. 84).

With these issues in mind, I can recommend Depression as a short, but helpful introduction to the concept of depression, it’s various interpretations, and treatment efforts. It is recommended to the interested lay-reader, high school or bachelor’s level college students interested in mental health, and practitioners/consumers in the mental health field. Its biggest strengths are its clear writing-style, succinct delivery, and scope. The authors have endeavored to capture the broad range of issues surrounding depression within a little over 100 pages, and have arguably succeeded, without much loss of depth or accuracy. Its biggest weaknesses are in its presentation of particular issues (e.g. reliability/validity of diagnosis; antidepressant effects). New readers to the subject will want to complement their reading with accounts featuring a bit more depth. Tacchi and Scott make two good recommendations in their Further Reading section; historian Roy Porter’s 1987 Mind-Forg’d Manacles and Edward Shorter’s 1997 A History of Psychiatry. To provide a more well-rounded account, I’d suggest Shorter’s 2013 How Everyone Became Depressed and psychiatrist David Healy’s 1999 The Antidepressant Era as well; in addition to any given introductory psychiatric textbook.

References

Bielefeldt, A. Ø., Danborg, P. B., & Gøtzsche, P. C. (2016). Precursors to suicidality and violence on antidepressants: Systematic review of trials in adult healthy volunteers. Journal of the Royal Society of Medicine, 109(10), 381-392.

Fava, G. A., Gatti, A., Belaise, C., Guidi, J., & Offidani, E. (2015). Withdrawal symptomsafter Selective Serotonin Reuptake Inhibitor discontinuation: A systematic review. Psychotherapy and Psychosomatics, 84, 72-81.

Fried, E. I. (2017). The 52 symptoms of major depression: Lack of content overlap among seven common depression scales. Journal of Affective Disorders, 208, 191-197.

Fried, E. I. & Nesse, R. M. (2015). Depression is not a consistent syndrome: Aninvestigation of unique symptom patterns in the STAR*D study. Journal of Affective Disorders, 172, 96-102.Healy, D. & Whitaker, C. J. (2003). Antidepressants and suicide: Risk-benefit conundrums. Journal of Psychiatry and Neuroscience, 28(5), 331-337.

Montejo, A. L., Montejo, L., & Navarro-Cremades, F. N. (2015). Sexual side-effects of antidepressant and antipsychotic drugs. Current Opinion in Psychiatry, 28(6), 418-423.

Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., &Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, part II: Test-Retrest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170(1), 59-70.

Sharma, T., Guski, L. S., Freund, N., & Gøtzsche, P. C. (2016). Suicidality and aggression during antidepressant treatment. Systematic review and meta-analyses based on clinical study reports. BMJ, 352: i65.

© 2018 Daniel J. Dunleavy

Daniel J. Dunleavy, M.S.W., Doctoral Candidate; Florida State University, College of Social Work