Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

There are a number of texts and books for clinicians and other books for the general public that focus on the diagnosis and treatment of classic bipolar mania and depression. However, clinicians are increasingly seeing patients in the office and hospital that have a mixed affective disorder, or rapid cycling state, or an atypical depression. This book is unique in its comprehensive, readable, and up-to-date account of these difficult to assess and treat subgroups of affectively ill adults and children. This is an excellent reference for residents as well as senior clinicians, and it belongs on the shelf of an office or hospital library. This book is not written for the lay reader, but some people with very ill relatives may find some material information, since it is hard to find one book that conveys this scope of information so concisely.

The two co-editors, Frederick Goodwin from the United States and Andreas Marneros from Germany, are both very well known and respected researchers and clinicians. They wrote the first chapter and invited 38 other colleagues—12 from the United States and 26 from Europe (primarily Germany, Italy, and Switzerland) and Canada—to write the remaining 16 chapters.

The co-editors of “Bipolar Disorders Beyond Major Depression and Euphoric Mania” emphasize that the three entities in the book title, mixed states, rapid cycling, and atypical forms, are not identical descriptors. “These terms correspond to three distinct organizational levels used in the DSM-IV mood disorder nosology and represent the concepts of course specifier, acute episode, and subtype of bipolar ” (p. 369 ). In order to generate good research data to help with treatment, the research design must be matched to the “sample selection, outcome measures and analysis plan” (p. 369). Sachs and Graves reemphasize this point in the concluding chapter on research and explain why these nonequivalent terms complicate the efforts to get research grants to test the effectiveness of certain drugs in these bipolar subtypes. Nonresearchers will find this information enlightening. The first chapter is an excellent detailed overview of these affective subgroups. The first 10 chapters describe various subtypes of affective disorders, and the authors emphasize the historical background, the known pathophysiology, phenomenology, epidemiology, and the current treatment approaches. Marneros shares Hippocrates’ original writings in Greek and then gives the English translation. He is showing that some of the early observations of “polymorphism of mania” are very similar to what clinicians are describing today. Hippocrates is credited with dividing mental disorders into melancholia, mania, and paranoia and pointing out the varied presentations of mania. Maneros discusses Kraeplin’s student Waygandt, who wrote about mixed states and the six different combinations of mood that were possible in mixed states. The authors note that with the advances in treatment using atypical antipsychotics and antiepileptic drugs, there is a renewed attention paid to the presence of various temperaments in individuals and their clinical responses. A few of the chapters include Benazzil, who reviews the literature on “Atypical Depression and Its Relation to the Bipolar Spectrum.” Akiskal and Perugi, in their chapter “Emerging Concepts of Mixed States,” use the term “hyperthymic depression” and view it as a subtype of bipolar IV. Koukopoulos is the author of “Agitated Depression: Spontaneous and Induced” and describes how this state may fit in with the expanding spectrum of bipolar disorder. Marneros’s chapter on “Schizoaffective Mixed States” is another detailed chapter. Calabrese and Elhaj, co-authors of “Rapid-Cycling Bipolar Disorder,” review the current literature and the use of mood stabilizers in adult patients. There are two other chapters on treatment: one chapter by Cookson and Ghalib devoted to “The Treatment of Bipolar Mixed States” and one by Baker, Schuh, and Tohen on “Using Atypical Antipsychotics in Subgroups of Bipolar Disorder: Mixed and Pure States, Psychotic and Non-Psychotic.” These chapters are particularly useful resources in an acute inpatient setting.

There is still considerable controversy over how broad or narrow the criteria should be for the diagnosis of less classic juvenile mania and bipolar depression. Birmaher and Axelson are co-authors of “Bipolar Disorder in Children and Adolescents.” They discuss the criteria in large studies, the comorbidities that are found, and the frequent presence of mixed states or rapid cycling. Treatment is discussed, but for those readers who want more background, the text by Geller and DelBello (1) is recommended. Shulman’s chapter “Atypical Features of Bipolarity in Old Age” is timely given the aging demographics. The chapter on “Genetics of Bipolar Disorder,” by Merikangas and Yu, and Brunze’s chapter on “Biological Aspects of Rapid Cycling and Mixed States” are more complex chapters to read. Brunze looks at the biological differences that may be present among mixed states and rapid cycling states and healthy controls.

In summary, this book has a great breadth of material with very little repetition, despite the many contributors.