Bipolar Disorders: Clinical Course and Outcome

Abstract

As part of the Clinical Practice Series of the American Psychiatric Press, this book on bipolar disorders integrates current clinical research findings with clinical applications and provides a broad overview of course and outcome for bipolar disorders. The book provides a concise, up-to-date summary of current knowledge about affective relapse, comorbid psychopathology, functional disability, and psychosocial outcome in bipolar disorders. It has been generally acknowledged that bipolar affective disorders are one of the leading causes of chronic disability worldwide. From the perspective of illness-related cost, the total economic impact of bipolar disorder is estimated at several billion dollars. In recent decades, the diagnostic trends in the United States have favored a broadened definition of bipolar illness. Another change in diagnostic approaches may involve new phenotypes of the disorder. These phenotypes may be reflected in cohort effects among contemporary bipolar patients involving factors such as drug and alcohol abuse, past treatment with tricyclic or other antidepressant agents, and cross-generational shifts due to transmission of unstable DNA sequences. As Dr. Frederick Goodwin notes in his foreword, “One fascinating hypothesis suggests that a cross-generational shift to more malignant forms of the illness may reflect a genetic mechanism involving unstable DNA. Trinucleotide repeats would increase the severity of the illness in succeeding generations, perhaps contributing to greater treatment resistance.” Indeed, this hypothesis may explain what clinicians have known for the past several years—that bipolar patients do not appear to be responding to lithium carbonate as before. There is clearly a disparity between what is observed in clinical practice and in controlled clinical trials with lithium carbonate. Clinicians have long known that bipolar disorder is a recurrent disorder. The episodes recur, and recurrences tend to come closer together as the disorder progresses. Furthermore, the degree of environmental stress associated with recurrent episodes becomes progressively less intense over time. These phenomena have generated the “kindling hypothesis.” Another hypothesis posits that the episodic nature of the illness reflects a disturbance in the regulation of biological rhythms. These hypotheses have clinical implications. Antiseizure medications have gradually replaced lithium carbonate as the treatment of first choice for most bipolar patients. It is believed that many of these drugs, such as valproic acid, may act through biological mechanisms that attenuate the kindling phenomenon. Psychosocial factors, at least initially, play an important role in precipitating episodes of either depression or mania. In what is perhaps the best chapter, Miklowitz and Frank explore psychotherapeutic strategies for bipolar disorder. They modify a model proposed by Goodwin and Jamison that posits a role for stressful life events. The authors suggest various stages in family-focused treatment of bipolar disorder that include, after the initial assessment phase, education about bipolar disorder, communication enhancement, and problem-solving training. And based on the observation that the episodic nature of the illness reflects a disturbance in the regulation of biological rhythms, they propose strategies for interpersonal and “social rhythm therapy” of bipolar disorder. In this model, the patients are taught to regulate social rhythm and sleep/wake cycles and to understand and renegotiate the interpersonal context associated with the onset of mood disorder symptoms. Lastly, the patients learn to master conflicts associated with interpersonal loss, deficits, and role transitions. In short, this book will serve as an excellent handbook for clinicians who work with bipolar patients. The book is of value not just to psychiatrists but also to primary care physicians who very often are the first to diagnose bipolar disorder and treat the condition through various stages of the disease. I highly recommend this book.