Abstract
Still Down: What to Do When Antidepressants Fail tells the story of 9 patients who have travelled the path of antidepressant treatment and conveys the forks and curves in the road. Using the series of fictional case composites, Dr. MacKinnon has written this book to share his abundant clinical experience with practitioners who may be uncertain as to the causes of inadequate response to antidepressant pharmacotherapy and what clinical options are available to them. The book begins with an introduction to the structure of the book, with the case histories divided into 3 general categories. Section 1 explores challenges related to dosing, adherence, and sensitivity to side effects. Section 2 examines diagnostic issues, with patient stories of demoralization, bipolar depression, and oversedation or drug-induced delirium. Section 3 then discusses “truly” treatment-resistant patients, with examples given of “double depression” in the context of persistent depressive disorder, comorbidity with personality and substance use factors as well as complex family dynamics, and ending with the use of electroconvulsive therapy for an inpatient with severe nonpsychotic depression. Each chapter is similarly structured, beginning with a short synopsis of the case history and principal topic for exploration, a detailed case history, a summary of clinical issues relevant to the case, and case notes that provide brief clinical pearls. A small number of tables are used for topics that require more thorough information, such as a listing of available augmentation treatments.
Throughout the book, Dr. MacKinnon emphasizes the art of clinical psychiatry, imploring the reader to not jump to conclusions about the biological centrality of nonresponse to antidepressants. He deemphasizes lack of efficacy or intolerability to antidepressants as central contributors to an absence of full response, instead focusing on important clues provided by obtaining a careful and comprehensive clinical assessment that ultimately provides the roadmap for next steps in management. Herein lies the strength but also limitations of the book. For practitioners who are exploring these foundational aspects of clinical care for patients with depression, this book can provide a very useful resource, almost like a “clinical care 101” course. It is written in a way that makes the reader aware of potential clinical pitfalls they may fall into and then provides what feels like the gift of an open dialog and opportunity to learn many clinical pearls from a skilled, experienced, empathic psychiatrist. For practitioners who already have confidence in completing a full psychiatric history, diagnostic formulation, and comprehensive management plan, it is more challenging to identify the value of the book. The clinical challenges are too straightforward and sometimes are resolved too easily to provide anything other than good reminders of the basics. For this group, the book could serve as a capable teaching tool for trainees of various disciplines—medical students, psychology interns, social work students, and so forth. So although Dr. MacKinnon lists the intended audience as patients, family members, primary care providers, psychotherapists, and psychiatrists, the book is most successful for a more targeted audience of newer clinicians or those with fairly limited experience in treating patients with depression. The topics are too clinically framed to be of much value to most patients or families but could enhance understanding for highly knowledgeable lay readers who are interested in understanding approaches to individualizing care for depression. Lay readers may also derive some hope from learning about positive outcomes for patients they can relate to.
The quality of writing is quite high. The case histories are realistic, focused, and provide enough detail to allow for reflection on one’s own patients and similar challenges faced. The book is very well organized with an excellent flow and pace that allow for efficient reading and exploration of topics. The publication quality is high, and the price is reasonable. The title seems a little misleading, as the focus is more on overall management strategies for depression treatment rather than a concentrated focus on true treatment resistance.
Overall, for the right audience, this book provides good insights into commonly experienced challenges in the management of depression. It will disappoint as a handbook for management of depression but instead provides a very well-written exploration of an approach to ensure appropriate diagnosis and management for depression among readers hoping to enhance their clinical comfort in this area.