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Anxiety Disorders
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by Stephen M. Stahl
Cambridge University Press, 2000
Review by Caroline Mondoux, R.N., BGB on Aug 6th 2001

Essential Psychopharmacology of Depression and Bipolar DisorderComprehensive, 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 them.

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 drugs function.

© 2001 Caroline Mondoux-Gardiner

Caroline Mondoux-Gardiner, RN, BGB is a freelance author. She is currently
working on a book on bipolar disorder.