Mood Disorders

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1. John Rush: Mood Disorders, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard.

Copyright ©2009 American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.265168. Printed

5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part V. Mood Disorders >

Mood Disorders

INTRODUCTION

The six chapters in this section are organized according to treatment modalities. We had a choice of

organizing the section according to mood disorders or according to major treatment modalities.

Because the different treatment modalities (e.g., psychotherapy, antidepressant medications,

electroconvulsive therapy) are often 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 briefly summarizes the therapeutic approach, with the indications and the available

efficacy data for each treatment approach. The authors add their own clinical experiences to help

readers understand both research evidence and its limitations. 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.

We are very fortunate to have engaged extraordinarily gifted authors for each chapter. The section

begins with antidepressant and antimanic medications (Andrew Nierenberg, Michael Ostacher,

Pedro Delgado, Gary Sachs, Alan Gelenberg, Jerrold Rosenbaum, and Maurizio Fava), followed by

depression-focused psychotherapies (Edward Friedman and Michael Thase), psychodynamic

psychotherapies (Glen Gabbard and Tanya Bennett), combined medication and psychotherapy

(Steven Hollon and Jan Fawcett), convulsive and other somatic therapies (Arielle Stanford,

Alexandra Sporn, Andrew Krystal, Richard Weiner, and Sarah Lisanby), and light therapy (Norman

Rosenthal and Dan Oren).

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 response to a

particular treatment. Patient history, age, chronicity, concomitant general medical conditions,

comorbid psychiatric and general medical conditions, potential drug–drug interactions, and patient

preference affect both the choice of treatment and the amount of time necessary to obtain the full

benefit with any one treatment. Thus, clinicians must weigh the scientific evidence and understand

the basic pharmacology and psychology while taking into account a variety of situational and

individual variables to both select the best first treatment and ensure its optimal delivery.

Currently the field and clinical practice are confronted with the issue of how to best organize andPrint: Mood Disorders

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sequence the available treatments for specific patients. While treatment algorithms have

demonstrated better efficacy than treatment as usual, these algorithms provide a wide range of

treatment options at each step. Which options are better at each step for particular patients is yet

to be defined. In addition, the potential value of genetic or other biomarkers or psychological

markers in selecting (or avoiding) particular treatments for individual patients has yet to be

realized, though such efforts are likely to pay off in the future. Until then, and even after such

discoveries, it is essential for patients and clinicians to engage in a diligent assessment on a regular

basis of the symptomatic and functional effects as well as the side-effect burden entailed in each

treatment trial, since no one treatment combination will be uniformly effective for all patients with

mood disorders.

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.

This effort was supported by the Sarah M. and Charles E. Seay Center for Basic and Applied Research in Psychiatric

Illness to the Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas.

REFERENCES

American Psychiatric Association: Practice guideline for major depressive disorder in adults. Am J Psychiatry

150:1–26, 1993

Depression Guideline Panel: Clinical Practice Guideline No. 5: Depression in Primary Care, Vol 1: Detection and

Diagnosis. Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, Agency for

Health Care Policy and Research, 1993a

Depression Guideline Panel: Clinical Practice Guideline, No. 5: Depression in Primary Care, Vol 2: Treatment of

Major Depression. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service,

Agency for Health Care Policy and Research, 1993b

Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.