Mood Disorders Introduction

This effort was supported by the Sarah M. and Charles E. Seay Center for Basic and Applied Research in Psychiatry to the Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas. The administrative support of Kenneth Z. Altshuler, M.D., Stanton Sharp Distinguished Chair and Chairman, is deeply appreciated.

The nine chapters in this section are organized according to treatment modalities. We had the choice of organizing the section according to mood disorders or according to major treatment modalities. Because each treatment modality (e.g., psychotherapy, antidepressant medications, electroconvulsive therapy) is applicable to more than one mood disorder group, we chose to present the modalities, specifying the disorder groupings for which each modality would be appropriate.

Each chapter distills the essence of the available group-based data that are often developed for the purposes of establishing the efficacy and safety of a treatment and combines these data with the clinical experiences and case reports of individual patients being treated by individual clinicians. The natural tension between available group-based data and the need to adapt and apply these data to one patient at a time is illustrated in case vignettes. We hope that clinicians reading these chapters will find both an up-to-date fund of scientific knowledge and a sense of how to use this knowledge optimally in treating individual patients.

The authors of the chapters review efficacy and safety data and then provide an empirical basis for selecting each modality. They then provide specific information on how to apply each modality, often with clinical vignettes to illustrate the general principles and particular tactics involved in employing each treatment.

We are very fortunate to have engaged extraordinarily gifted authors for each section. The section begins with chapters on antidepressant and antimanic medications (Pedro Delgado and Alan Gelenberg), depression-focused psychotherapies (Michael Thase), psychodynamic psychotherapies (Glen Gabbard), combined medication and psychotherapy (Steven Hollon and Jan Fawcett), electroconvulsive therapy (Richard Weiner and Andrew Krystal), and light therapy (Dan Oren and Norman Rosenthal).

After these individual treatments are reviewed, two additional chapters are provided in which the authors specifically address commonly encountered clinical circumstances that require adaptation of these treatments. An excellent chapter on the management of treatment-resistant mood disorders, by Jerrold Rosenbaum, Maurizio Fava, Andrew Nierenberg, and Gary Sachs, guides clinicians through recommended steps should the first treatment fail. This chapter combines both established clinical research information and substantial clinical experience to provide a course roadmap to refer to in selecting the most effective modality for subsequent treatments.

In the next chapter, Greg Clary and Ranga Krishnan discuss the treatment of mood disorders occurring in the context of general medical conditions, as they 1) are known to constitute major risk factors for the development of mood disorders and 2) are associated with greater morbidity and mortality. Finally, the presence of general medical conditions makes the diagnosis, treatment, and ongoing clinical management of the mood disorders quite complex. Knowledge of optimal treatments for mood disorders, as well as knowledge of drug interactions, pharmacokinetics, and the effect of general medical conditions on drug metabolism, drug side effects, patient compliance, and so forth, is required for optimal outcome in these complex circumstances.

The final chapter, by John Rush and David Kupfer, provides an overview of the treatment of mood disorders by dividing these decisions into strategic and tactical issues. Strategic steps are the initial major decision points faced by clinicians. For example, should the initial treatment be medication, psychotherapy, the combination, electroconvulsive therapy, or light therapy? Tactics refer to the specific maneuvers used to implement the chosen strategic treatment option optimally, safely, and most efficiently. A careful reading of the literature suggests that optimal outcomes are associated not only with critical strategic decisions but with the diligent delivery of the strategy chosen for a sufficient period of time with careful outcome assessment so that timely revisions in the strategy (augmentation, switching treatments, etc.) can be made if appropriate (e.g., if the treatment is ineffective or is not tolerated by the patient).

A basic principle underlying this literature summary is that logic argues for the use of established treatments before those that are not as well established or whose safety has not been as well investigated. If this section had been written 30 years ago, the number of treatments available for mood disorders would have been surprisingly small. Furthermore, the differential diagnosis of mood disorders would have played only a minor role in treatment selection. It is to the substantial benefit of practitioners, patients, and their families that medical research, as well as an erudite compilation of clinical experience, is now available by which we can make more scientifically based recommendations and expect better overall results than ever before. This accumulation of information has resulted in the development of clinical practice guidelines for both psychiatrists (American Psychiatric Association 1993) and primary care practitioners (Depression Guideline Panel 1993a, 1993b).

When one considers all of these chapters together, perhaps most striking is that there is a monumental amount of solid scientific information indicating that we have safe and effective treatments for mood disorders. It is also clear that mood disorders are heterogeneous with regard to biology, familiarity, course, prognosis, and-most important-the likelihood of responding to a particular treatment. Patient history, age, chronicity, concomitant general medical conditions, and other factors appear to affect both the choice of treatment and the amount of time necessary to attain a full response to any one treatment. Thus, clinicians must weigh nomothetic data, basic pharmacology, and basic psychology and take into account a variety of situational and individual variables not only to select the best first treatment but to deliver it optimally.

We hope that this section has brought together, in a user-friendly and clinically informative manner, the vast clinical research data and substantial clinical experience and wisdom of the authors to provide a clinically relevant synthesis by which we can all better treat our patients.

References

_{American Psychiatric Association: Practice guideline for major depressive disorder in adults. Am J Psychiatry 150 (4, suppl):1-26, 1993}

Depression Guideline Panel: Depression in Primary Care, Vol 1: Detection and Diagnosis (Clinical Practice Guideline No 5; AHCPR Publ No 93-0550). Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993a

Depression Guideline Panel: Depression in Primary Care, Vol 2: Treatment of Major Depression (Clinical Practice Guideline No 5; AHCPR Publ No 93-0551). Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993b