Bipolar Disorders: Clinical Course and Outcome

Another opening, another show, another conference book from those in the know. Emerging out of a symposium titled Modern Day Bipolar Disorders: Course and Outcome presented at the Annual Meeting of APA in 1995, this volume is a compilation of reports from a number of academically based bipolar disorder clinics summarizing their experience of the naturalistic course, treatment, and outcome of patients in their care and possible individual factors that affect the process. The key word here is “naturalistic,” since a focus of many of the chapters is on the discrepancy between a relatively optimistic view of bipolar disorder and the efficacy of available treatments that arises out of randomized clinical trials and the more pessimistic findings that reflect clinical experience and case series.

One chapter critically examines possible explanations for reported differences between open and blinded studies, and others look at issues of comorbidity with substance abuse or anxiety disorders, the presence of rapid cycling, and the underdiagnosis of mixed-state disorders as possible contributory factors. Additional chapters address the comparative benefits of lithium and anticonvulsant treatments in long-term prevention of relapse and report on the development of specific methodologies for the psychotherapy of bipolar disorder and for assertive psychosocial treatment in the community over the life course of the individual.

Many questions are posed, but few answers are provided, and many of the observations that are made are rather unsurprising discoveries. Patients who have residual symptoms or more episodes, who don’t take their medications, or who abuse alcohol do less well than those who do not. Patients who are not stabilized on a single medication often require additional pharmacological intervention and do not do as well as those who do not require adjunctive treatment. Psychosocial support is good, as are education of the patient and family, and an attentive follow-up on the part of clinician is helpful.

The chapter articulating specific psychotherapeutic interventions for patients with bipolar disorder is particularly useful in terms of operational advice, but a reader seeking a current treatment manual on bipolar disorders is likely to be disappointed. The chapters summarizing pharmacotherapeutic approaches are essentially reviews of published literature, with little discussion of side effects, dosage strategies, or treatment algorithms. For a book that is part of a Clinical Practice Series and that intends to be of interest “to the clinician working outside of the hospital setting,” this is surprising.

The final chapter, a summary by the editors of the previous contributions, appears to recognize, on reflection, many of the issues that have not been addressed and devotes individual short paragraphs to such things as bipolar disorder in children and adolescents, treatment decisions during pregnancy and the postpartum state, mania in the elderly, and the effect of gender on course and treatment. A number of questions regarding how to translate observational findings into clinical decision making are raised and answered in a staccato two pages at the end of the volume.

One particular aspect of social history that goes unexamined is the degree to which pharmaceutical company marketing strategies and sponsored trials have shaped our knowledge base. This is particularly relevant in the bipolar area, given the orphan drug status of lithium and the historical withdrawal of the National Institute of Mental Health from sponsorship of large-scale drug trials. In the absence of editorial consideration of the issue, a page delineating the authors’ past and present support from commercial sources would be welcome and allow the reader some added perspective on the literature review and conclusions reached.

Bipolar Disorders achieves its goal of providing a concise and current summary of issues relating to relapse, disability, and outcome in current treatment; the picture remains fragmentary, and how to proceed is unclear, but this is a reflection of reality and not a fault of the book.