Parker and Manicavasagar confront the most difficult clinical disorder in all of psychiatry, and emphasize the observation of their expatriate, Barney Carroll, “to understand depression is to understand psychiatry” (Carrol, 1989 Chapter 3). They know well, by dint of clinical experience and research, the topic about which they speak. The book represents a scholarly meld of scientific and clinical experience brought together by shear, concentrated reflection.
Their text is not staid. Indeed, it begins with an evangelistic and humorous verve. In chapter one, they frame their whole exercise with the light-hearted parody of “A declaration of independence”. Copying the US Congress 1776 address, they humorously offer that all depressive disorders are not created equal, that the current model of depression (read DSM and ICD model) should be scorned and considered sufferable nonsense (terms inspired by the American revolutionaries). Yet their polemic is not simply based on clinical frustration over a consensus description that never quite fits. They offer expert and systematic research of clinical data to show the multiple means by which the current model has failed. Depression is not a single “it” and “it” does not lead, like all roads of Rome, to the diencephalons. They note that descriptors of severity (mild, moderate and severe) are woefully thin and inadequate. The authors allow us to see the unfortunate consequences of our commonly used model, and their data is convincing. An imperfect understanding of depression engenders flawed research, non-specific findings and, perhaps more importantly, “watered-down outcomes” that can make our choice of treatments perilous.
The format of the text is provided in their introduction.
They revisit first the challenging topics of melancholic and psychotic depression dealt with in their previous work (Parker and Hadzi-Pavlovic, 1996). Here they seem to get it right. The reader is reminded that psychotic and melancholic depression are parts of the same entity, carry their own descriptors, are identified by the pathology of their own special neurotransmitters, and have more powerful data to predict their clinical course and best practices for good outcome. These early chapters are a refreshing review, and by themselves, make the book worthwhile.
Their main challenge, however, is the delineation, definition and classification of sub-types of non-melancholic depression. The reader is forewarned that this is the territory of multiplicity, where definitions lose their crispness, and where duty to get it right, leaves one in a meaningless graveyard of over-inclusiveness. The irony here is that where there is so much difference- when all is obsessively accounted for-everything begins to look the same.
The authors offer a comprehensive hierarchal model of depression but apologize that their model is inherently flawed as it moves from definition of clinical features (read melancholic depression) to etiology (read the residual categories that are unnamed and nebulous). Despite this, they seem willing to live with the variant sub-categories so defined and so understood. They push on, using their years of clinical experience with depressed patients and various personality models, and offer stress (not new) as the active agent of disease that brings differing types of depression to persons with differing types of personality styles. This is not just a theoretical treatise since they use (see Chapter 9) the North American Five-Factor Model of Personality Dimensions (Costa & McCrae, 1990), filtered through multivariate analyses to emerge with a series of associated variables that are peculiar to depression risk. To this model, they offer their own 89-item Temperament and Personality questionnaire to achieve “eight personality styles”. These styles are: the perfectionist, the irritable, the anxious, the avoidant, the self-focused, the self-critical, the rejection-sensitive and the personality type with personal reserve. Each of these styles is specifically vulnerable to its own type of non-melancholic “depression”.
If the categories are confounding, the authors seem to recognize the problem and offer what they term a “metaphorical” neurotransmitter model for illustration. But metaphor is meant to be a bridge between what is familiar and what is foreign. In this case, their model, although painstakingly rational and complete, is, in the end, as difficult as the abstract concepts it tries to describe. And worse, eight (8) times offered and eight (8) times explained, the “theoretical” metaphor carries, for the thoroughly obsessive reader, the risk of biological hoax. One must be reminded that it is, after all, a metaphor and not neurobiology.
Finally, compelled by their mission statement, Parker and Manicavasagar offer 8 unique strategies and modalities of treatment for each type of depression (be it Cognitive Behavioral Therapy, Supportive Therapy, Solution-based Therapy, pharmacological treatment etc.). If sincerity is their strength, then the tedium of sincerity is their chief flaw. After a brilliant start and, after an energetic and exciting declaration of independence, the authors are crushed under the weight of their own altruistic mission. They have proceeded with noble intentions, attempting both to define and to describe and then to prescribe. Perhaps it is too much ambition for an otherwise well-written book. Perhaps a simple, bold statement might have been easier: “There are fully 10 types of depression; eight (8) are peculiar to persons with particular personality styles; and here they are.”
Still, however, for the fortunate that give this book a thorough reading, it is - in the quiet of a reading room - akin to mentorship of the best sort. Here one can be impressed with every page. Despite its ponderous title, its myriad of sub-sections and, yes, the difficult metaphorical model, this reader offers a simple but strong endorsement, “Buy this book!”