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Martin B. Keller, editor-in-chief.  Clinical Guide to Depression and Bipolar Disorder. Findings from the Collaborative Depression Study. Arlington (VA): American Psychiatric Publishing Inc; 2013. (218 pages)

INFORMATION ON CONTENTS:  Conceived in the early 1970s to study the phenomenology, diagnosis, genetics, and clinical course of depression, the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) has influenced research and practice since its inception. Prior to the CDS, there had been no longitudinal study of this scope and clinical focus. This book summarizes key findings from the study and the related literature to provide comprehensive and up-to-date knowledge on the course and outcome of illness in mood disorders. The first chapter of the book, the Introduction, outlines the epidemiological findings underscoring the importance of the CDS, the inception of the collaborative program on the psychobiology of depression, the transformation of the CDS into an extended longitudinal study, and topics covered in the book, as well as a summary of the effect of the CDS. The second chapter, “Collaborative Depression Study Procedures and Study Design”, reviews the assessments, procedures, and study designs of the CDS. Chapters 3 and 4, titled “Dimensional Symptomatic Structure of the Long-Term Course of Unipolar Major Depressive Disorder” and “Dimensional Symptomatic Structure of the Long-Term Course of Bipolar I and Bipolar II Disorders”, put forth a dimensional method of studying the severity of symptoms in unipolar Major Depressive Disorder and bipolar disorders. Chapter 5, “Risk Factors for Suicide Attempts and Completions”, covers risk factors, with attention to the symptoms and temperament measures that were consistent for short and long term attempts and completions. Chapter 6, “Psychotic Features in Major Depressive and Manic Episodes”, describes the boundaries between psychotic mood disorders and schizophrenia, and summarizes the effects of psychotic features on manic and depressive episode prognoses. Chapter 7, “Development of Mania or Hypomania in the Course of Unipolar Major Depression”, speaks to the incidence and determinants of progression to bipolar disorder. Chapter 8, “Comorbidity of Affective and Substance Use Disorders”, analyzes the importance of the CDS to research regarding the comorbidity of affective and substance use disorders. Chapter 9, “Treatment Effectiveness and Safety in the Longitudinal Course of Mood Disorders”, highlights the CDS studies which looked into somatic treatments’ effectiveness and safety for mood disorders. Chapter 10, “Personality and Mood Disorders”, describes CDS contributions to existing knowledge regarding the relationship between depression and personality. Chapter 11, “Family History and Genetic Studies in Mood Disorders”, assesses findings when diagnoses in relatives were analyzed, including the results of a second blind reassessment six years after the first assessment. Chapter 12, “Clinical Course and Outcome of Unipolar Major Depression”, describes information on time to recovery, time to recurrence, and various predictors. Chapter 13, “Predictors of Course and Outcome of Bipolar Disorder”, shows typical phase lengths and risk factors for change, as well as symptom morbidity. Chapter 14, “Under-treatment of Major Depression”, notes the finding that about two-thirds of patients who entered the study with Major Depressive Disorder (MDD) did not receive antidepressants for an adequate time (with even fewer at an adequate dose). Chapter 15, “Impact of Anxiety Severity on Mood Disorders”, demonstrate how ratings enabled the measurement of anxiety symptoms with major affective disorders. Chapter 16, “Contributions of the NIMH Collaborative Depression Study to DSM-5”, discuss key contributions, such as a spectrum view of mood disorders and the comorbidity of anxiety. An Index rounds out the volume.

EDITOR’S STATEMENT: The Clinical Guide to Depression and Bipolar Disorder is the culmination of over 30 years of semi-annual and annual interviews with almost 1000 patients and a series of interviews with more than 4000 first degree relatives, spouses, and mates. To date, there have been more than280 peer reviewed original articles published in leading psychiatric and general medical journals. The findings of the CDS, have led to the most meaningful changes in the field’s understanding of the clinical course and outcome of mood disorders and co-morbid conditions since the writings of Kraepelin at the end of the nineteenth century.

During the 1950s and 1960s, descriptive and biological psychiatry were challenging the prevailing approach of psychodynamic psychiatry.  The swirling controversy was fueled by limited clinical assessments and the lack of reliable and valid diagnostic criteria sets.  The NIMH’s recommendation for intensive research focusing on nosology, genetics, and pathophysiology resulted in establishment of the biological studies and clinical studies components of the CDS.  Initiated in 1977, the findings from the early data of the clinical studies component were stunning; showing the clinical course of depression was worse than what was previously known.  Findings of longer durations of episodes, higher relapse and recurrence rates, and higher rates of chronicity led to the transformation of the CDS from a two year follow up into a longitudinal study with the largest sample, shortest interval interview prospective study of mood disorder in the history of psychiatry.  The findings of the CDS conceptualized unipolar depression as a lifelong illness.  Results showed subsyndromal symptoms as the second most common symptomatic state during follow up of unipolar and bipolar depression and are associated with significant dysfunction in 7 out of 9 domains of psychosocial functioning.  The presence of residual symptoms is associated with early relapse and a worsening of future course of these disorders.  The findings were essential in the development of treatment goals for both bipolar disorder and unipolar major depression.  The findings of the CDS led to identification of risk factors, such as comorbid anxiety or substance use, double depression, and long duration of episodes,  and improved treatments for those long suffering from mood disorders.

The specific data on the timing and predictors of long term outcomes and comorbidities from the CDS inspired the motivation and design of numerous continuation and maintenance studies of depression and bipolar disorder, which led to improved treatments for those long suffering from mood disorders. The CDS data also inspired massive advocacy efforts to significantly increase funding for research on mood disorders by the NIMH, National Alliance of Mental Illness (NAMI), National Alliance for Research in Schizophrenia and Depression (NARSAD) and other foundations, and served as the impetus for numerous advocacy campaigns by non-profit (The National Depressive and Manic Depression Association, The Depression and Bipolar Support Alliance, NAMI  and others) and government organizations to reduce the stigma of depression, bipolar disorder and mental illnesses which have had major success, although there is still much work to be done. The CDS data on suicide also contributed to the creation of organizations, such as the American Foundation for Suicide Prevention and the JED foundation, and efforts by the NIMH and Substance Abuse and Mental Health Services (SAMSA) to raise awareness about suicide risk and efforts to reduce this risk through public education and new research.

Each chapter in the Clinical Guide to Depression and Bipolar Disorder provides a summary of the findings, focusing on various aspects of the research, including the dynamic and fluctuating severity levels of symptoms of unipolar and bipolar depression, the course and outcome of the disorders, and treatment implications in relation to effectiveness, safety, and the ongoing gaps between research and practice.  Genetics, psychotic symptoms, substance use, and anxiety severity were explored through the decades of research.With each chapter summarized with clinical implications, the authors provide practical and evidence-based guidelines for clinicians. 

Martin B. Keller

January 16, 2014