Review of "Bipolar Disorder"

By Mario Maj, Hagop S. Akiskal, Juan José López-Ibor and Norman Sartorius
John Wiley & Sons, 2002
Review by Duncan Double on Mar 17th 2004
Bipolar Disorder

This book is volume 5 in a World Psychiatric Association (WPA) series "Evidence and Experience in Psychiatry". The acknowledgements note that the publication has been supported by an unrestricted educational grant from Sanofi-Synthelabo, the global pharmaceutical company. Although the aim is to provide a balanced state‑of‑the-art update of the scientific and clinical basis of bipolar disorder, the WPA allows the production of such series to be contracted with commercial publishers. The initiative and development of agreements about donations for publications is the responsibility of the WPA Secretary for Publications, who happens at the moment to be the first editor of this book. He was also the first editor of previous volumes in the series.

This sponsorship and vested interest is relevant as Sanofi-Synthelabo manufactures valproate, widely used in the pharmacological treatment of bipolar disorder. One form of valproate - valproic acid (as the semisodium salt) - is indicated for the treatment of manic episodes associated with bipolar disorder. Valproate more generally, like other so-called mood stabilising drugs, is widely used outside licensed indications in bipolar disorder. The pharmaceutical companies probably cannot be blamed for this state of affairs, as they are not permitted to endorse the use of their products for unlicensed indications. Sponsoring educational activities may be a way round this regulation if clinical expertise encourages unlicensed prescription. Companies need to provide evidence of efficacy to obtain a licence and the economic return has to be balanced against the high cost of clinical trials.

Bipolar disorder is the modern term for manic-depressive illness. Emil Kraepelin introduced the term manic-depressive illness in 1899 in the sixth edition of his psychiatric textbook. For Kraepelin, manic-depressive illness was a single morbid process. It included manic, mixed and depressed states.

The terms "unipolar" and "bipolar" were coined by Karl Kleist in 1953. Unipolar disorders were unipolar mania and unipolar depression. Bipolar disorders were circular disorders of episodes of both mania and depression and cycloid psychoses, a term used for psychoses separate from both schizophrenia and affective psychoses. Like Kraepelin, Kleist still regarded unipolar and bipolar states as a unitary disorder. Bipolar disorders were merely a combination of the monopolar forms with a special affinity. It was Kleist's pupil, Karl Leonhard who accepted the separate existence of unipolar and bipolar disorders.

The modern concept of bipolar disorder is said to have originated independently in the 1960s in three monographs by Carl Perris, Jules Angst and George Winokur et al. The concept has moved on from that of Kleist and Leonhard. For example, it does not include cycloid psychosis, which is a concept not well represented in modern classificatory systems, such as ICD-10 and DSM-IV. Bipolar disorder now includes mania without depression (unipolar mania in Leonhard's terms).

The qualitative difference between bipolar and unipolar disorders arises out of evidence for different morbidity risks among first degree relatives. Kleist and Leonhard had assumed that the genetic loading in bipolar disorders was greater than in monopolar disorders. The modern studies showed a significant bipolar morbid risk was present in the families of bipolar probands and not in the families of their unipolar depressive counterparts. However, the three monographs vary widely in their conclusions as to the overall morbidity in first degree relatives.

This polarity-based distinction between bipolar disorders and unipolar depression is said to have been of benefit in research and clinically. So-called mood stabilizers are now widely prescribed. However, there is dispute about the definition of mood stabilizer. Although valproate, for example, has a license for the treatment of mania, evidence of its efficacy as a prophylactic mood stabiliser is questionable.

Over recent years, the bipolar concept has expanded to include subtypes, which have lesser episodes of mania, called hypomania. In particular, bipolar II disorder (although this category is still not formally recognised in ICD-10) was originally identified by David Dunner as those patients who had been hospitalized for depression, but their hypomanic episodes had not been severe enough to require hospitalization. However, hospitalization was not seen as an adequate criterion for defining the diagnostic threshold for mania from hypomania. DSM-IV now defines hypomania as a short‑lasting (4 days minimum) elevation of mood identified by the usual criteria for mania, but without marked social or occupational dysfunction and without severe symptoms such as delusions and hallucinations. Bipolar II patients have never had a manic episode, but have had one or more episodes of major depression and at least one episode of hypomania, thus defined.

Expanding the bipolar concept further, Hagop Akiskal, who is the first chapter contributor to this book on classification, diagnosis and boundaries of bipolar disorder, proposed a "soft bipolar spectrum" in 1987. What he meant by this was a more inclusive term for bipolar conditions beyond classical mania. The spectrum includes bipolar I, bipolar II, cyclothymic and hyperthymic traits, as well as those with familial bipolarity; it also includes hypomania apparently induced during antidepressant or other treatment (bipolar III). The term "spectrum" is, therefore, used to refer to the broad range of manifestations of bipolar disorder from core symptoms to temperamental traits. In clinical practice, it may include those patients with emotional lability, who may, for example, have otherwise been categorised as borderline personality disorder. The core of the so-called disease could be seen generally as “mood swings” or instability.

Expanding the concept of bipolar disorder in this way has been controversial. It has been a particularly american phenomenon, although the practices have been followed in other countries. It may be reminiscent of the overinclusive use of the term schizophrenia in USA in the 1960s. The US-UK Diagnostic Comparison Study demonstrated that American psychiatrists were using the term schizophrenia up to four times as commonly as their British counterparts. This finding contributed to a tightening of diagnostic criteria in DSM-III, particularly a narrowing of the definition of schizophrenia. Maybe we should now also have concern about the validity of the broadening of the concept of bipolar disorder. Estimates of the proportion of the population with bipolar spectrum are as high as at least 4-5%. The use of the diagnosis bipolar disorder has become variable and unreliable.

Other chapters in the book are on prognosis, pharmacological treatment, psychosocial interventions, effects of gender and age on phenomenology and management, and the economic and social burden of bipolar disorder. Each of the chapters has several brief commentaries from experts in the field.

The aim of treatment of bipolar disorder is euthymia. Democritus regarded this state of being as one in which the soul is freed from all desire and unified with all its parts. He believed it should be the final goal of everything we do in life. Bipolar disorder could be said to have taken over from schizophrenia as the paradigmatic mental disorder in modern psychiatry. It may say something about present-day psychiatry that its objective is now "tranquility of the soul" rather than unifying the mind-body split of schizophrenia. The question is whether we have progressed from controlling the brutish nature of mental illness, which was one of the reasons for the establishment of the asylums. The book is a learned, scholarly exposition of the consensus about bipolar disorder, but I am not sure how much it really helps us get in touch with people given this diagnosis.



© 2004 Duncan Double


Duncan Double, Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk Mental Health Care Trust and University of East Anglia, UK; Website Editor, Critical Psychiatry Network.


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