Treatment of Bipolar Illness: A Casebook for Clinicians and Patients

This book originated at the National Institute of Mental Health (NIMH), where both authors worked for many years, the main author for almost four decades. The cases included in the book are all patients who were admitted to the inpatient Clinical Research Unit in the Biological Branch of NIMH and were deemed “treatment failures” or “treatment refractory,” particularly to treatment with lithium carbonate, and who voluntarily entered the institute to participate in clinical studies. Patients first participated in double-blind clinical studies and next were offered a period of treatment optimization. The cases included in this book span more than three decades. The authors gracefully credit and list the names of about 30 ward chiefs and clinical research associates who spent time at NIMH in the 1970s and 1980s and whose names are readily recognized. Indeed, a majority of these distinguished colleagues would become deans or chairpersons of academic departments of psychiatry or leading figures in education and research. Also, the authors properly express their heartfelt gratitude to the patients who “donated their time and their bodies” and allowed the use of the life chart approach, which, in my opinion, is the key element of the book.

The descriptions of the individual patients include rich and detailed clinical information on history, mood shifts, and treatment response (or lack thereof) that are carefully charted in a “classic” lifetime format following the example of Emil Kraepelin’s mood charts (a historical description of these charts represents the core of Part I of the book). Thus, from the outset, the book has a personalized approach, highlighting unique individual differences in course and response and advocating individualized treatments. This contrasts with the age of large randomized trials in which individual patients are lost among “averages” of weighted and manipulated numerical equations in search of significance above the elusive p<0.01 level.

The book is made up of 17 parts and 69 chapters. Most of the chapters focus on individual cases illustrating specific clinical or therapeutic issues. A majority include detailed mood charts, in addition to case descriptions, background literature, principles of the case, and a take-home message, which I found to be a valuable and refreshingly practical bottom line.

Part II, “Phenomenology of Untreated Course of Illness,” includes excellent case descriptions and mood charts that illustrate acceleration of cycle frequency, increased depressive episode frequency, shorter “well” intervals, psychosocial stressors, traumatic stress-induced episodes, anniversary reactions, and other important aspects of the clinical phenomenology.

Part III, “Pharmacology and Neurobiology of Bipolar Illness,” is a review of fundamental issues on psychopharmacology and the causes and mechanisms of the onset of bipolar illness. This information is the type one would find in other textbooks and is entirely theoretical, not including mood charts or case reports, but it sets the stage for the treatment response sections that follow.

Starting with Part IV, “Response to Mood Stabilizers,” we start seeing again several chapters based on clinical cases that also include mood charts. Here, the reader finds six chapters devoted to carbamazepine, four to valproate, three to lithium, and one each to topiramate, lamotrigine, and gabapentin, as well as oxcarbazepine and zonisamide. However, no case histories or mood charts were provided for these last two drugs. Next follow sections on antidepressants, ECT, dietary supplements, and atypical antipsychotics. Again, I was disappointed that possibly due to the novelty of this research, the information for quetiapine, risperidone, ziprasidone, and aripiprazole in bipolar patients included no formal case reports or mood charts. One gets the impression that with each “newer” treatment, the quality of the clinical data and mood charts seems to decline a bit—the clinical information becoming less rich and the charts more sketchy—which I sadly suspect is a sign of the times.

Finally, the book ends with an excellent brief section targeted to patients entitled, “Getting Well and Staying Well.” Appendices include medication names/classes and additional details that may be useful to patients and a section on retrospective and prospective mood charting that should be very valuable to researchers.

The topic of bipolar illness has generated a large number of books in the last two to three decades. Most have been “snapshots,” focusing on fashionable new theories, drugs, instruments, potential tools, or elusive biological markers that quickly fade out of memory, go out of print, and accumulate dust, forgotten in bookshelves. Among those that have survived the passage of time, I can think of a few—on the scientific and scholarly side, the authoritative textbook (also originating at NIMH) by Goodwin and Jamison, which has been recently updated, and on the personal, experiential side, Kay Jamison’s masterful autobiographical account of her own illness. The current book seems to fall between these two, insofar as it provides us with a wealth of clinical experience originating at NIMH, presented in a highly personalized fashion. I believe that this book will also have permanency, since it is quite different from most of the others and represents a new approach to individualized, personalized medicine that is much needed in these times of massive randomized clinical trials in which individuals do not even make it anymore as tiny dots in regression graphs.

This book represents an excellent resource for practicing clinicians, who will identify many of their patients in the richly described cases and whose patients may therefore find benefit in their treatment. It is less clear how patients will benefit directly from this book (perhaps with the exception of a couple of chapters), due to the complexity of clinical issues, terms, and treatments. As we move toward DSM-V, one hopes that this book will stimulate a return of the traditional (e.g., Kraepelinian psychopathology), with its detailed observations, diaries, and systematic charting of events. This may contribute to a more precise dissection of broad syndromes such as bipolar illness and lead to further refinement of our diagnostic systems.