Dr. Margaret Wehrenberg’s “Anxiety + Depression” bills itself as a treatment guide for therapists managing comorbid anxiety and depression in an outpatient setting. That said, the book proves useful to the psychiatrist/therapist as well. The patient population on which the author focuses is one with less severe symptoms, and it is clear that issues such as suicidality and the more severe mood disorders are beyond the scope of the book. However, it demonstrates usefulness to clinicians by outlining treatment strategies for managing various presentations of less complicated depression and anxiety. Given that depression and anxiety are both so common in an outpatient clinical practice and that the two commonly co-occur, a practitioner can easily fall into a pattern of using the same treatment approach for every patient. However, by providing a taxonomy of various presentations, this book serves to encourage the treatment provider to look a little closer and develop a more individualized treatment plan geared to the specific variables of anxiety and depression that are most pressing in a particular patient.
The bulk of the book focuses on breaking down and defining seven different combinations of anxiety and depression encountered in the clinical setting, based on the most impairing symptoms for the patient. The author uses names such as “The Low-Energy Client” and “The High-Energy Anxious and Depressed Client” that make it abundantly clear that these different types of patients will have different strengths to draw from as well as different obstacles to overcome. Subsequently, the book easily serves to prompt the provider to move away from a one-size-fits-all approach to managing these disorders.
Most chapters focus on one of the seven presentations of anxiety and depression, such as “The Worried & Exhausted Client.” A synopsis of the more pertinent symptoms of each disorder in the particular presentation is outlined. Generally, two cases are used to better illustrate clinical issues and obstacles. The selection of case reports is fairly diverse in patient age, sex, and psychosocial stressors. The provider is then prompted to consider factors relative to the assessment of each case—physical health, readiness to change, and mental energy. To the provider with a medical background, the physical health assessment may seem a little cursory, but it is good to see a comprehensive assessment encouraged, nonetheless. Readiness to change provides thoughts on the strengths and weaknesses that each anxious/depressed combination brings with it, as well as ideas a therapist may use to help the patient toward recovery. Mental energy ties into this process as well but focuses a little more closely on how factors such as fatigue, poor concentration, and rumination may change the treatment approach.
Chapters then examine the therapeutic relationship for various patient populations. For example, when dealing with an individual who fits the archetype of a “Hopeless Ruminator,” the practitioner is cautioned to be aware of the patient’s sensitivity to disapproval. Case vignettes are brought back to help clarify these issues further. As an aside, the book does a good job of taking developmental issues and attachment into account and showing how they can contribute to the presentation as well as the working relationship with the therapist. Next chapters move into addressing the specific symptoms. Generally, all chapters have suggestions for lifestyle changes and general health considerations. However, therapeutic approaches vary greatly depending on the primary presenting issues. Overall, the specific therapeutic tools are sensible and well grounded in cognitive behavioral strategies. At times, the book briefly touches on a therapeutic approach, such as eye-movement desensitization and reprocessing, that it does not plan to fully explore. In these instances, there are references included, should a provider wish to learn more. Finally, chapters end with a treatment summary, making it easy to go back and search the highlights of each approach.
Several archetypal patient presentations are mentioned previously. In addition to those, the book also focuses on “The Panicky and Depressed Client,” “The Quiet Avoider,” and “The High Anxiety Client.” Focusing on seven manifestations of the combination of depression and anxiety will likely cause some sparks of recognition in your own clinical practice. However, it is just as likely to provoke some thought about symptoms that might have been missed as treatment steered toward one of the poles of anxiety and depression. In the instance of “The High Anxiety Client,” the anxiety is so clear and predominant that one could almost be excused for focusing on the anxiety and neglecting the depression welling up from years of living in such an anxious state. There are certainly clinical pearls to be found in the book, but a great deal of its usefulness is also to serve as a reminder to be vigilant of secondary symptoms complicating treatment.
Again, the main thrust of the book is identification and categorically individualized treatment of a variety of presentations of depression and anxiety. Other sections deal with outlining the neurobiology and neurochemistry of depression and anxiety. The science is sound in these sections but probably of more use to nonphysician providers. In addition, there is an appendix providing thoughts on medication, primarily so that a nonphysician provider can better assist a patient who is communicating with his/her prescribing physician. Again, this section is likely to be of limited benefit to a physician, but the overall tenets included are sound.
Overall, Dr. Wehrenberg’s latest contribution to the field of treatment of depression and anxiety is a useful tool for any practitioner working with such a patient population. It encourages in-depth thinking of the implications of the diagnoses and provides a number of useful strategies tailored to specific issues that a variety of patients might encounter.
Dale Peeples, MD
Sandra Sexson, MD
Division of Child
Adolescent and Family Psychiatry
Department of Psychiatry and Behavioral Health
Medical College of Georgia at
Georgia Regents University, Augusta
The authors declare no conflict of interest.