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by Stephen M. Stahl Cambridge University Press, 2000 Review by Caroline Mondoux, R.N., BGB on Aug 6th 2001
Comprehensive, succinct and beautifully illustrated, Essential
Psychopharmacology of Depression and Bipolar Disorder provides
a very technical biological explanation of depression and bipolar
disorder and, through the use of excellent diagrams manages to
explain the pharmacological actions of psychotropic medications
for these disorders in a manner even a layman can understand.
The book is divided into three chapters. The first addresses the
biology of depression and bipolar disorder, the second reviews
the classical antidepressants and finally the third covers the
newer antidepressants and mood stabilizers.
In the first chapter Stahl lays the groundwork for understanding
how the various antidepressants and mood stabilizers affect the
brain and ultimately cause both the desired effect and their side
effects. A short description of affective disorders - also known
as mood disorders - is given as is the current Diagnostic and
Statistical Manual of Mental Disorders - DSM IV - standard
for a Major Depressive Episode and a Manic Episode. The bulk of
the material presented relates to how monamines and neurotransmitters
work in the "normal" brain as compared to the "depressed"
brain and introduces us to the major players: monoamine oxidase,
serotonin, norepinephrine and dopamine. The three current theories
on the biology of depression are also presented.
The rest of the chapter offers some very interesting facts and
statistics regarding depression, bipolar disorder, suicide and
the stigma that still surrounds mental illness. In fact, according
to some studies, 71% of the population still believes that mental
illness is a sign of emotional weakness. One of the points Stahl
underscores is that in the U.S. the prevalence of depression is
5%, which represents approximately 15 million people and 1% are
afflicted with bipolar disorder, 2 to 3 million people.
"Unfortunately, only about one-third of individuals with
depression are in treatment, not only because of underrecognition
by health care providers but also because individuals often conceive
of their depression as a type of moral deficiency, which is shameful
and should be hidden. Individuals often feel as if they could
get better if they 'just pulled themselves up by the bootstraps'
and tried harder. The reality is that depression is an illness,
not a choice, and is just as socially debilitating as coronary
heart disease and more debilitating than diabetes mellitus and
arthritis. Furthermore, up to 15% of severely depressed patients
will ultimately commit suicide." (p.4-5)
The second chapter examines closely the mechanism of action and
the role played by the classical antidepressants such as the MAOI's
(Monoamine Oxidase Inhibitors), tricyclic antidepressants (TCA's),
SSRI's (Selective Serotonin Reuptake Inhibitors) and the NRI's
(Norepinephrine Reuptake Inhibitors). These are all related, with
clever diagrams to the roles that the neurotransmitters play in
the brain in terms of their effect on moods, emotions and thought
as well as on other systems on the body such as the gastrointestinal
system thus explaining why these drugs produce not only the desired
effects but also the side effects that come part and parcel with
Finally, in the third chapter Stahl examines the newer antidepressants:
the SNRI's - Dual Serotonin and Norepinephrine Reuptake Inhibitors,
the SARI's - Dual Serotonin 2 Antagonists/Serotonin Reuptake Inhibitors
- and their mechanism of action on the brain and explores the
concept of synergy where the mechanism of two drugs together is
greater than the sum of its parts. The mechanism of action of
common bipolar disorder drugs is also reviewed: mood stabilizers
such as lithium and valproic acid (Depakote), atypical antipsychotics
(Zyprexa), anticonvulsants (valproic acid, lamotrigine, gabapentin),
benzodiazepines (alprazolam, clonazepam) and talks of judicious
use of the careful mixing in of antidepressants which in susceptible
bipolar patients can induce mania.
Overall, this is a fantastic comprehensive compendium that is
only surpassed by the clever illustrations that clearly demonstrate
the difficult concepts and makes light of them. I would recommend
this book to anyone who truly wants to understand the nature of
depression and bipolar disorder and how the various psychotropic
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