Book Review
Mood Disorders
Evidence and Experience in Psychiatry. Volume 5. Bipolar Disorder. Mario Maj, Hagop S Akiskal, Juan José Lopez-Ibor, Norman Sartorius, editors. New York: John Wiley and Sons; 2002. 523 p. US$105.00.
Reviewer
rating*: Good
Review by: Verinder Sharma, MB, BS, FRCPC
London, Ontario
This is the fifth volume in a series published by the World Psychiatric Association (WPA) on the most prevalent mental disorders. The series aims to narrow the gap between research developments and clinical practice. Previous titles have focused on depressive disorders, schizophrenia, dementia, and obsessive–
compulsive disorder.
The book is organized into 6 chapters, with several commentaries accompanying each. The first chapter, by Dr Hagop Akiskal, provides a scholarly and comprehensive review of the classification, diagnosis, and boundaries of bipolar disorders (BDs). Beginning with the ancient Greeks’ early descriptions of mania and melancholia, he traces the evolution of the concept of BD to the contemporary classification systems. Akiskal makes a persuasive case for broadening the concept of BD beyond the usual categories of BD I and BD II to include cases of antidepressant-induced hypomania, recurrent depression with hypomania of less than 4 days’ duration, depression superimposed on cyclothymic or hyperthymic temperaments, and finally, cyclic depressions responsive to lithium or with bipolar family history. He argues that this dilution of diagnostic boundaries is necessary both to facilitate early detection and diagnosis of the illness and to help future genetic studies uncover the etiology. This expansion of the diagnostic boundaries is reminiscent of Kraepelin’s description of manic-depressive insanity. Under its rubric, he included not only periodic and circular insanity, simple mania, melancholia, and amentia (that is, confusional or delirious insanity) but also “certain slight and slightest colourings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders, on the other hand pass over without sharp boundaries into the domain of personal disposition” (1). At the conclusion of his chapter, Akiskal proposes a broad definition of BD, with schizoaffective disorder at one end of the spectrum and depression superimposed on hyperthymia at the other. In an elegant commentary, Jules Angst agrees that the concept of BD should be broadened but raises important questions about implementing the definition of the term. He sums up the debate on the diagnostic status of the bipolar spectrum by commenting that “all things are indeed in a state of flux.”
Chapter 2 begins a discussion on the prognosis of the illness by clarifying confusion regarding use of the terms prognosis, course, and outcome. After reviewing the follow-up studies, the authors conclude that variables including sex, age, age at onset, and most socioeconomic features are poor predictors of course and outcome. Conversely, one of the best predictors of illness course is the number of previous episodes: the more prior episodes, the poorer is the outcome. On the other side of the coin, a high level of premorbid functioning predicts a favourable outcome.
The next 2 chapters deal with pharmacologic and psychosocial interventions, respectively. A comprehensive review of the currently available drugs should particularly help practising clinicians to make rational treatment decisions. The author touches on the controversy surrounding the use of antidepressants in the treatment of bipolar depression and recommends that the antidepressant be tapered off within several weeks of amelioration of depression. Chapter 4 reviews the data on psychosocial interventions. It begins by outlining the need to study the role of psychotherapeutic modalities in the overall management of BD. Most studies have shown positive results, both in regard to clinical outcome and in improved functioning. He proposes that uniform response to different types of psychotherapy may be owing to the similarity in their active components. Chapter 5 describes in detail the effect of sex and age on the phenomenology and pharmacologic management of BD. It highlights similarities and differences in the clinical presentation and response to pharmacotherapy among individuals of different age groups. The authors also describe the effect of reproductive events on the course of BD and discuss its management during pregnancy and after delivery. They emphasize the need for youth studies, particularly regarding pharmacologic treatment of bipolar depression.
In the final chapter, the authors review BD’s economic and social burden and note the significance of often-neglected indirect costs related to misdiagnosis and undertreatment. Occupational consequences of poorly treated illness are also discussed. A factor that contributes to illness burden is an unstable illness course associated with the overzealous use of antidepressants. To delineate better predictors of psychosocial burden, the authors recommend studies using effectiveness-based rather than efficacy- based models.
This well-written book includes recent developments and controversies regarding the diagnosis and management of BD and, overall, updates the state of our knowledge. It offers a great deal of clinically relevant and practical information. Not only does this book update what we know, it also addresses the gaps in our understanding of this complex disorder and recommends areas for further research. The authors largely succeed in meeting their stated objective of providing psychiatrists with a balanced, state-of-the-art account of emerging scientific evidence and accumulated clinical wisdom. However, I would be remiss if I did not mention the topics I would have liked to have seen addressed. These include neuroimaging, genetics, cognitive dysfunction, and finally, a more detailed discussion of suicide and its prevention. Another source of dissatisfaction with the book relates to the use of commentaries. While some of the commentaries are critical, others do little to advance the discussion. This book should interest both clinicians and researchers in the field of bipolar illness.
Reference
1. Kraepelin E. Manic-depressive insanity and paranoia. Edinburgh:Livingstone; 1921.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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