C H R I S T O P H M U N D T , M I C H A E L J. G O L D S T E I N , K U R T H A H L W E G a n d P E T E R F I E D L E R , w i t h the a s s i s t a n c e o f H U G H F R E E M A N : Interpersonal
Factors in the Origin and Course of Affective Disorders R o y a l C o l l e g e o f P s y c h i a t r i s t s 11996)
This book contains a series of papers that were presented at an international forum held at Heidelberg in September 1993. It is essentially in five parts. The first deals with temperament and personality factors, a somewhat neglected area particularly in U.S. psychiatry, with the notable exception of Akiskal, who starts the book with a chapter on "The Temperamental Foundation of Affective Disorders." It is packed with information which makes it a little bit difficult to read, but it is well worth persevering. His is a more general approach to some of the more specific personality structures written about by Sato and yon Zerssen. While their melancholic pre-morbid personality traits overlap to a large degree, they are not in any way identical. In Part 2, a paper from Zurich highlights the difficulty in assessing pre-morbid personality, i.e.~ it is often done post episode or by retrospective review. They do review von Zerssen s prospective study but also conclude that a later vulnerability to mania is associated with a non-neurotic type of pre-morbid personality. Other chapters deal with stress, including family transmission. There are further chapters on marital and family interactions in these disorders, including some outcome studies and discussions of high expressed emotions interspersed with an excellent chapter by Brown on the onset and course of depressive disorders. The book concludes with chapters on intervention, written by many famous names, but they will not please everyone. This might be the strength of these chapters since it is all too easy to adopt a biological or psychosocial party line when clearly the work of Brown and others has shown that stress or life events are important provokers of depression and various psychological interventions have an impact on outcome. From a treatment point of view, I am not sure you would be any wiser as to who should get what from whom or for how long. There are some apparent contradictions between the excellent papers by Kupfer and Frank on the prevention of recurrence and the effects of interpersonal psychotherapy in major depression, which show a highly positive effect for antidepressant treatment in bringing about the remission of symptoms, with interpersonal psychotherapy being valuable not in the acute, but in the maintenance phase. This is contrasted with the study by Hautzinger and deJong-Meyer where cognitive therapy appeared to be superior to tricyclics, at least in outpatient therapy of depression. It is probably too early to try and assign specific treatment for all patients and, until there are more data than we have, severe depressions will be treated by antidepressants and electroconvulsive therapy, moderate by what appears most appropriate to the treating person and mild by whoever is available. A critique about comparative trials using antidepressants is that they all use tertiary amines, though I know of no psychopharmacologist who has used these drugs in decades, preferring to use secondary amines such as desipramine or nortriptyline which have fewer side effects and fewer drop-outs and are also easier to monitor. This would
Requests for reprints should be addressed to George M, Simpson, M.D., University of Southern California, Department of Psychiatry & the Behavioral Sciences, 90033, U.S.A. LAC/USC Medical Center~ 1934 Hospital Place, Los Angeles, C.A.
apply to the comparative studies reported here, but on the other hand pharmaceutical companies to this day persist in doing the same thing - - no doubt so that their new drug treatment will have an edge in side effects over imipramine or amitriptyline. It is difficult to know to whom this book is addressed, certainly not for trainees unless at an advanced level. The chapters on temperament would be recommended for anyone who treats depression. The book has an interesting cover, but unfortunately some pages were falling out before I had finished reading it. GEORGE M. SIMPSON
Professor of Research Psychiatry University of Southern California School of Medicine U.S.A.