Treatment of Depression:Old Controversies andNew ApproachesEdited by Paula J. Clayton and James E.Barrell. New York. Raven Press. 1983. 338pages. $49.

• "This volume is a review of thecurrent state of biological and psy­chological research in the treat­ment of depression," the editorsstate in the preface. This is an am­bitious goal, but in the 22 chaptersthat follow, they and 71 other con­tributors are remarkably successfulin surveying the state of this art.The 1981 annual meeting of theAmerican Psychopathological As­sociation is the source of these col­lected papers, representing theviews, reviews, and research ofmany reputable groups working inthe area of affective disorders.Their conclusions are both stimu­lating and cautionary.

Beginning aptly with a review ofthe dexamethasone suppressiontest by one of its earliest exponents(Carroll), the section on biologicpredictors of treatment responsehighlights the advances and limita­tions in contemporary biologic psy­chiatry. The reports of disinhibitedhypothalamic-pituitary-adrenalaxis function, shortened REM la­tency, and heightened responsive­ness to physostigmine injection indepressed patients are tantalizing.So is the possibility of identifyinghomogeneous biochemical sub­groups of depressives, perhaps withmore consistent and predictable re­sponse to specific therapeutic mo­dalities. The utility of thesemarkers in general psychiatrypractice remains to be fully de­fined, however, and one may antic-

DECEMBER 1983 • VOL 24 • NO 12

ipate many "new controversies" forfuture editions.

Interpretation of tricyclic antide­pressant plasma concentrations,maintenance of long-term lithiumtherapy in unipolar depressives,and selection of unilateral vs bilat­eral ECT are examined in the sec~

tion on somatic and drug therapies.These discussions are cogent andevenhanded. A chapter on the pos­sible role of cerebral hypoxia in thedevelopment of depression asso­ciated with certain physical ill­nesses, and another on altered re­ceptor sensitivity and antidepres­sant actions, both present morebasic research into the mechanismsof depression. The "old" mono­amine deficiency hypothesis isclearly challenged.

The nosology of depression andtreatment response of clinical sub­types are considered in the wide­ranging third section. Secondary,mild, and atypical depressionscome under particular scrutiny,with conflicting evidence and opin­ions on each of these constructs.Despite the disagreement, Winokurconcludes in a lucid and reassuringchapter that clinicians probably"know something after all."

Finally, selected topics in psy­chotherapy research are reviewed.Citing some of his current work,Beck offers an expanded view ofcognitive therapy that considerspersonality variables and depres­sive subtypes; and Klerman suc­cinctly describes several problemsinherent in evaluating the efficacyof psychotherapy. The sectionoverall is both readable and pro­vocative.

There are inescapably a fewproblems with this type of book.

Writing styles, terminology, andorganization vary considerablyfrom chapter to chapter; and thiscan be jarring if the volume is readcover to cover. The brief discus­sions between authors and auditorsthat follow most of the papers alsocan be more confusing than en­lightening, and many readers mayelect to bypass these interludes.References are numerous and cur­rent to 1981. There are a few typo­graphic errors, but the physicalconstruction of the book is good.

I recommend this volume, not asa textbook of depression therapeu­tics, but as a topical and substantialreview of recent work and impor­tant issues in this field. It should beof interest to practicing psychia­trists, clinical researchers, ad­vanced students, and anyone withspecial interest in the moderntreatment of depressive disorders.

Mark R. Hansen, M.D.Mayo Clinic

Anxiety: A Guide toBiobehavioral Diagnosis andTherapy for Physicians andMental Health CliniciansBy Richard J. Goldberg. New York. Medi­cal Examination Publishing. 1982. 142 pp.$22.50.

• Anxiety is one of the most com­monly encountered clinical prob­lems and may represent the reasonfor as many as 30% of patient visitsto primary care physicians. Thisbook provides a concise overviewof the diagnosis, etiology, andtreatment of anxiety disorders.Oriented primarily toward nonpsy­chiatric physicians and mentalhealth clinicians, it would also be ofvalue of medical students and psy-

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BOOK REVIEWS

chiatry residents. The author pre­sents a "biobehavioral" approachto anxiety and offers a good inte­gration of biologic and psychoso­cial factors.

The introductory chapter in­cludes useful information about theprevalence and diagnosis ofanxietydisorders. It relates previously useddiagnostic terms to DSM-III termi­nology. A chapter on brain mecha­nisms of anxiety provides basic re­search findings on pathogenesis. Adiscussion ofmedical disorders thatcan produce anxiety emphasizesthe importance of ruling out organ­ic disease in the anxious patient.The various organic causes of anxi­ety states are listed in a table; someofthe more significant disorders aredescribed in detail in the text.

A chapter on pharmacologictreatment reviews the use ofbenzo­diazepines, antidepressants, and p­blockers in the treatment of anxi­ety. The section on benzodiaze­pines offers many practical guide­lines.

There is discussion of the basicprinciples and application of be­havioral techniques to the treat­ment of anxiety, and self-regula­tion strategies of anxiety reductionsuch as biofeedback, relaxationtechniques, and meditation are de­scribed. The specific methodology,value, and limitations of these ap­proaches are touched on, as are theproblems of resistance and mainte­nance of motivation.

A chapter on psychologicalissues in the anxious medical pa­tient illustrates how psychologicalfactors relate to anxiety disorders.The presence of anxiety in thecancer patient is somewhatoveremphasized in this section.

A final section on the "multimo-

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dal treatment approach" includes anumber of case histories focusingon the interaction of multiple etiol­ogies leading to the production ofanxiety. A "special review" of hy­perventilation and postconcussionsyndromes seems out of place inthis chapter.

The text is written in a terse,factual style and offers extensivedocumentation. In fact, about onefourth of the book consists of refer­ences. This points to its major fail­ing-it attempts to cover too muchmaterial in too small a space. Yet,for the busy clinician, A nxiety is anadequate guide to the current stateof knowledge in the field.

James Dietch; M.D.University ofCalifornia, Irvine

Social and HistoricalFoundations of ModemMedicineBy Iago Galdston, New York, Brunner/Mazel, 1981, 147 pp, $20.

Medical Thinking,A Historical PrefaceBy Lester S. King, Princeton, NJ, PrincetonUniversity Press, 1982,328 pp, $19.50.

• We are aU aware of the continu­ing exponential increase in medicalpublications. Experts write andwrite and write, and the rest of usread and read and read, sifting in­formation in an attempt to deter­mine what might be helpful, andtrying to discard discredited infor­mation while still maintaining theparadigms and models on which wehang our clinical hats. It is discon­certing-though not surprising­that all this writing contains littlethat could be described as medicalwisdom.

These two books by senior physi­cians who have made significantcontributions to the details of ourdata base are wise in the true senseof that word.

Galdston's book is a slim, epi­grammatic volume that is a plea­sure to read. It consists ofa series ofshort essays many of which are re­lated to social aspects of medicine,and some ofwhich are an extensionof the work and ideas of HenrySigerist. The essays feature topicssuch as medicine and culture, diag­nosis in historical perspective, thebirth and death of specialties, andthe role of the amateur in medicalhistory. Several of the essays show aprofound appreciation of the sig­nificance, rather than the historicalepiphenomena, of Greek Hippo­cratic medicine-the understand­ing, at many levels, that humanbeings are in a delicate relationshipwith their own bodies and the restof nature. Other essays are provoc­ative and interesting, such as thedemonstration that much of the re­vered corpus of "medical ethics,".thought by many to be ancient andinviolable, was developed by nine­teenth-century physicians. Stillother essays are more opinionated.Galdston's view of the amateur inmedical history is a good example,and it is a delight,since I happen toagree with him that many of theprofessionals in this discipline missthe forest for the trees.

All in all, this is a fine book. Noneof the essays is developed to its fullextent-most of the topics couldmake fine books-but each is intel­lectually stimulating.

Lester King's book is longer andfar more detailed. His argumentsare intricate and well documented.Medical Thinking is not a book to

PSYCHOSOMATICS