Book Review: Psychofarm's Guide to Treating Depression
Am I allowed to review my own book?
At the expense as sacrificing my not highly protected anonymity, I recently helped co-author a book. Co-author may be generous. Dr. Malzberg reached out as with a partially completed book and permission to ‘go wild’ with edits - which I took to heart.
Fortunately, we are similar minded. From the start I felt like I was reading my own writing and my free rein edits were well received. The end product is something we both felt was lacking among all the textbooks and resources for psychiatric training - an easy to digest, down to earth manual for treating psychiatry’s most common presenting problem — ‘depression’.
It has four sections.
Depression as a concept
Neuroscience and Psychopharmacology Principles
Medications
Putting it all together.
What makes this book unique is its informal, mentor-mentee language. Text books will tell you the definition of depression, but they won't narrate the topic in a relatable, easy to understand way. The opening paragraphs of the book are a good demonstration of this:
Before we can understand how to treat depression, we need to know how psychiatrists define depression.
Note that I’m choosing my words carefully here. How psychiatrists define depression. Not what is depression.
In psychiatry, the word depression doesn’t actually mean much of anything. It doesn’t have a formal definition. This is the big issue with the word depression: it refers to a ton of different stuff. It can refer to a multitude of different disorders, different self-states, and different other things.
I’ve seen people use the word depressed to refer to the emotional experience that results from the pumpkin spice latte going out of season. And I’ve also seen the word depressed be used to refer to a catatonic woman who needs a feeding tube to stay alive.
Let’s get something clear. I’m not minimizing the agony of drinking a regular old latte when you were expecting pumpkin spice flavoring. But I am saying that this emotional experience is a categorically different one from being catatonic
This writing hits different. I've read many textbooks, but when I'm teaching mentees, I guarantee you that I've never verbatim quoted one of them. I can say the opposite is true for the language of our new book. Take what is ‘good’ about this opening quote and expand it into a 200+ page book about treating depression - that's what we've created.
Most of the statements in the quote above are self evident, you can find a sterile versions scattered across various textbooks, etc. But that isn't how people learn. And if we're preparing someone to care for something as precious as someone's mental health, we better make sure we teach it well. Teachings should be memorable and informative.
How do you make that happen? Humor is a useful tool, and the book does not shy from it.
This isn’t new news. Inter-individual variability is the rule of thumb in psychiatry. But it is not a scapegoat for poor reasoning and loosey-goosey prescribing.
The opening line on the chapter on Mild Depression Treatment Modalities: This isn’t about choosing an antidepressant - that’s a future chapter. This is about choosing the initial treatment. Shame on you for reaching for the prescription pad so quickly!
I snorted when reading the quips and commentaries scattered throughout the book, but even if it doesn't land for you, at the very least humor makes the content memorable.
This ‘informal’ approach also opened the door for us to say some of the quiet parts out loud. We could make more evident the simple truths that have to be seen by reading between the lines and peeking behind the false brevado of fancy scientific words.
Considering all this information, you might be wondering why high dosages are ever used. Some of these people are simply prescribed too high of a dose because of the prescriber’s bias to think ‘more is better’.
Don’t be this prescriber. More is not better.
The pipeline is so dry that the FDA just approved an app, Rejoyn, this year for the treatment of depression (when used alongside antidepressant medications).
Completely unrelated to the recently approved FDA app, I want to briefly make a few comments about the FDA that are all true:
A world without the FDA would result in a lot of snake oil being sold.
It is important to know what medications are FDA-approved for a given disorder.
FDA approval does not mean that it is the best treatment for any given disorder
Lack of FDA approval does not mean it is ineffective for a given disorder. It may be more effective than FDA-approved ones
FDA indications often intertwine with factors like politics and pharmaceutical marketing.
What does FDA approval tell us? It tells us it works and it is (relatively) safe. That makes it a useful starting point to understand a medication’s utility, but not much else
A colleague once said to me, “There’s no withdrawal with SSRIs; it’s a discontinuation syndrome.” I’m sorry, but this is drinking the pharmacological Kool-Aid. It’s withdrawal from medication, and using linguistic tricks isn’t going to change that.
So far, I've only been highlighting the informal nature of this book in all the quotes above. From this small sample, it could be a tempting mistake to dismiss the entire endeavor as frivolous and superficial.
It's not.
The language is informal, but the content is important
Psychiatry has a serious education problem. And with the threshold for being able to a prescribe medication1 becoming lower and lower, we have to do better at ensuring patients have access to competent care (conceptually, pharmacologically, and otherwise). Our current textbooks and educational material are failing at this, and patients pay the cost in so many ways it's painful to watch.
So, to repeat - the language is informal, but the content is important.
For example, topics of the Neuroscience and Psychopharmacology Principles section include concepts like sequential binding, pharmacologic nomenclature, and hyperbolic dose-response curves. Topics of the Putting it All Together section include the underappreciated reality of sexual side effects from SSRIs, SSRI taper protocols, and a framework on how to choose an antidepressant2
I can't find anywhere else that synthesizes these topics into one place. Let alone does so in a readable, enjoyable manner. To build this book, we had to draw from textbooks, academic journals, podcasts, blogs, mentorship, and more. Ultimately, this is the book I wish I had available when I started training. It didn't exist, and now it does. I'm glad have been part of it.
Of course, while trying to piece together a book of this complexity, it became apparent that balancing nuance and simplicity is impossible. How much nuance is enough? When does simplification become simply incorrect?
The voice in my head says it's context dependant… blah blah blah. The problem still remains - the nature of publishing a book is that you relinquish the ability to rephrase, clarify, add caveats, and change language based on the audience. Hitting publish releases a one way conversation into the wild. This is a hard thing to do for someone who loves nuance. I'm that someone. Still, we managed to do it, and I think the world is a slightly better place now.
The epilogue of the book includes the following:
At some point in your training, one of your teachers or seniors probably quipped something along the lines of “Half of what you learn in medicine is wrong. The problem is we don’t know which half.”
If I had to make a similar line for psychiatry, I’d make it: “Half of what you learn in psychiatry is wrong. The problem is the other half isn’t right.”
This book is not exempt from errors. We hedged our language where we thought it was most appropriate but intentionally avoided doing so when we felt it detracted from important points and concepts. In the end, we likely misstepped sometimes along the way. That’s life, I guess.
I don't know many educational resources willing to embrace humility. Because of this, I fear that bad ideas and poor understanding get swept under the vaneer of ‘science’. At risk of misstepping at times, this book sticks it's head out against that grain.
It attempts to demonstrate that psychiatry is infinitely more complex than our symptom checkboxes but also infinitely more simple than the dense pharmacologic textbooks make it seem.
Sometimes, I feel like the inverse - that people are simple, and the psychopharmacology is complex - is emphasized in psychiatric training.
And that's a shame.
.
.
.
If any of this resonates with you, I encourage you to buy the book or tell someone who is into psychiatry about it. We don't get kick backs from pharmaceutical companies like all the other textbook writers, just support from people like you. So seriously, if any of the above caught your eye, buy the book or spread the word.
In the United States. Referring to NPs and PAs. That topic is a something I have no interest in poking with a stick. But, I think (do I really need to hedge this statement?) it's undeniable that the minimum training standards are vastly different with these new prescribes compared to traditional MD/DO training
Contrast this with guides that focus on what to chose.