Bipolar Disorders: Clinical Course and Outcome (Clinical Practice) - Softcover

Softcover

ISBN 10: 0880487682 ISBN 13: 9780880487689

Publisher: Amer Psychiatric Pub Inc, 1999

Synopsis

Biopolar disorder has served as a principal point of focus for modern psychiatric research since the advent of the psychopharmacological revolution. Yet, the disparity between optimal and typical care for biopolar disorder is perhaps nowhere larger, and its human and economic impact nowhere greater.

An important and much-needed resource, Bipolar Disorders: Clinical Course and Outcome relates empirical data on outcome with practical information on the prognosis, course, and potential complications of bipolar disorders in the modern era.

Pulling together current knowledge on bipolar disorders from leading investigators in the field, Bipolar Disorders provides a concise, up-to-date summary of affective relapse, comorbid psychopathology, functional disability, and psychosocial outcome in contemporary bipolar disorders. Important issues regarding pharmacoeconomics and the burden of disease are presented in conjunction with a discussion of mania through the life cycle and a summary of clinical and treatment implications.

In addition, this timely resource covers the effect of lithium and anticonvulsants on outcome during controlled and naturalistic treatment; manic outcome in relation to specific comorbidities or subtypes of illness for mixed mania, alcoholism or other substance abuse, rapid-cycling bipolar disorders, hypomania, and comorbid anxiety disorders; individual psychotherapy and family psychoeducation; and the role of public sector psychiatry and community-based treatment programs for chronic bipolar illness.

As part of the Clinical Practice Series of the American Psychiatric Press, this book integrates current clinical research findings with practical clinical applications, providing a broad overview of course and outcome for bipolar patients treated under typical treatment conditions. Aimed at both clinicians and investigators, this book consciously relates naturalistic follow-up studies in mania to the routine clinical management of bipolar disorders over time.

About this title

About the Author

Joseph F. Goldberg, M.D., is Assistant Professor of Psychiatry at The Joan and Sanford I. Weill Medical College of Cornell University and the Director of the Bipolar Disorders Research Clinic at the Payne Whitney Clinic, and Presbyterian Hospital in New York, New York.

Martin Harrow, Ph.D., is Professor and Director of Psychology in the Department of Psychiatry at the University of Illinois–College of Medicine in Chicago.

From the Inside Flap

Biopolar disorder has served as a principal point of focus for modern psychiatric research since the advent of the psychopharmacological revolution. Yet, the disparity between optimal and typical care for biopolar disorder is perhaps nowhere larger, and its human and economic impact nowhere greater.

An important and much-needed resource, Bipolar Disorders: Clinical Course and Outcome relates empirical data on outcome with practical information on the prognosis, course, and potential complications of bipolar disorders in the modern era.

Pulling together current knowledge on bipolar disorders from leading investigators in the field, Bipolar Disorders provides a concise, up-to-date summary of affective relapse, comorbid psychopathology, functional disability, and psychosocial outcome in contemporary bipolar disorders. Important issues regarding pharmacoeconomics and the burden of disease are presented in conjunction with a discussion of mania through the life cycle and a summary of clinical and treatment implications.

In addition, this timely resource covers the effect of lithium and anticonvulsants on outcome during controlled and naturalistic treatment; manic outcome in relation to specific comorbidities or subtypes of illness for mixed mania, alcoholism or other substance abuse, rapid-cycling bipolar disorders, hypomania, and comorbid anxiety disorders; individual psychotherapy and family psychoeducation; and the role of public sector psychiatry and community-based treatment programs for chronic bipolar illness.

As part of the Clinical Practice Series of the American Psychiatric Press, this book integrates current clinical research findings with practical clinical applications, providing a broad overview of course and outcome for bipolar patients treated under typical treatment conditions. Aimed at both clinicians and investigators, this book consciously relates naturalistic follow-up studies in mania to the routine clinical management of bipolar disorders over time.

Reviews

This book opens with a chapter, written by the editors, on "poor-outcome bipolar disorders." It is as though they are challenging readers with the idea that this disorder, once thought to have a good prognosis, does not have a favorable outcome. The rest of Bipolar Disorders, written by some of the authorities on the course of bipolar disorders, seems to echo this sentiment. But this book is by no means pessimistic, because it has several chapters on innovative psychopharmacotherapy, psychoeducation, and emerging psychotherapies specific for bipolar disorder. Nonetheless, the thrust of the book documents the severe course that many patients with bipolar disorder endure. This adverse result is not limited to the rapid-cycling and continuous forms of illness but pertains to the overall decline in social functioning that many patients with the illness experience.

This message may surprise those who have not closely followed recent developments in the field of bipolar disorders. Even Emil Kraepelin -- who exactly 100 years ago separated manic-depressive illness, in which the patient has a good prognosis, from schizophrenia, in which the patient deteriorates -- had described chronic evolution (manic "dementia") in a small proportion of cases. The mystery today is that despite the cyclic or periodic course of the illness, which includes intervals in which patients are free of episodes, many patients undergo a substantial decline in social functioning. The orientation toward achievement and the creativity that are touted as characterizing bipolar disorder in reality occur more often in the relatively well kin of the patients. This suggests that we are dealing with a polygenic disorder, whereby the patients are paying the price of the benefits that accrue to family members with more "dilute" genotypes. Patients with the severest forms of the illness are obviously more likely to be studied in tertiary care university centers. Because physicians study the mildest phenotypes of an illness only rarely, one might argue that the findings reported in this book do not apply to all patients with bipolar disorder. We lack data on the outcome of bipolar disorder in patients who are treated in private-practice settings.

But a review of the literature does suggest that lithium -- as currently used -- is no longer as effective as it was when it was first introduced in the 1960s. This finding invites several interpretations. Some environmental factor, such as a rise in the abuse of stimulants, may have complicated the underlying biologic substrates of mood, drive, and cognition, so that anticonvulsants are needed to control the complicated forms of the illness. What is not clear is whether the new course of the illness is substantially better with the use of anticonvulsants and rational polypharmacy, both of which are covered extensively in this book. Another possible contribution to the failure of lithium treatment is the extension of the boundaries of bipolarity to more complex forms, which are less likely to respond to lithium.

Lithium worked well for the first two to three decades after its discovery in 1949: not only did it prevent disruptive episodes, but it also appeared to attenuate mood flare-ups between episodes. Lower suicide rates and reduced mortality in patients with bipolar disorder are perhaps the most persuasive evidence for the long-term effectiveness of lithium therapy. A book on the prognosis of bipolar disorder should have devoted an entire chapter -- not a meager seven lines -- to this important preventable complication of bipolar disorder.

I submit that the success of lithium when it was first introduced has much to do with the fact that it was dispensed in clinics for mood disorders. There was an enthusiasm among clinicians -- physicians, nurses, psychologists, and social workers -- that was in part based on a belief in the "magical" powers of lithium. This translated into more personal and systematic long-term care of patients with bipolar disorder and their families. Unfortunately, today's health care climate is not geared to the care of patients with long-term illness who require close follow-up. Lithium, which necessitated medical vigilance, had created an ambience of personalized care. Today, lithium and the new mood stabilizers are, unfortunately, not being administered in such an environment.

Before 1990, antidepressants -- believed by some to destabilize the neuropharmacologic substrates of bipolarity -- were used more sparingly in the treatment of bipolar disorders. When patients are not followed in a specialized clinic, their treatment is often fragmented. As a result of only some of their symptoms being observed, they can be exposed to indiscriminate antidepressant treatment and not treated with mood stabilizers. The lack of a chapter devoted to the proper setting in which to study and care for patients with bipolar disorder -- a reflection of the inadequacy of current mental health care -- is one of the shortcomings of this book.

Edward Hare, in a provocative paper on the "two manias" (British Journal of Psychiatry. 1981;138:89-99), contends that before the introduction of humane methods for the treatment of the mentally ill at the turn of the 18th century, mania often pursued a chronic course. Only after the mentally ill were unchained and provided with good general physical care, good nutrition, and proper social rehabilitation did patients with mania have periods of remission long enough for them to leave the hospital. I contend that the current closing of mental hospitals has created a homeless population of patients with bipolar disorder who have no one to care for them. It is ironic that an action intended to liberate the mentally ill from the milieu of the state hospital is now exposing them to greater perils. The prognosis of bipolar illness will not improve through better science unless it is coupled to social policy that provides humane care for the severely mentally ill.

One must not, however, be lulled into complacency, thinking that we will conquer this disorder with humane legislation. Bipolar disorder continues to be an important challenge to psychiatry, and this book documents our failure to meet this challenge. As such, it deserves to be studied by all serious students of bipolarity. They will be rewarded by the considerable scholarship reflected in the individual chapters.

Reviewed by Hagop S. Akiskal, M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Edition details

• Publisher: Amer Psychiatric Pub Inc
• Publication date: 1999
• Language: English
• ISBN 10: 0880487682
• ISBN 13: 9780880487689
• Binding: Paperback
• Edition number: 1
• Number of pages: 315
• Editor: Goldberg Joseph F., Harrow Martin