Handbook of Diagnosis and Treatment of Bipolar Disorders
The title of this edited volume is something of a misnomer. In fact, this "handbook" is a magnificent compendium of everything that a clinician would ever want to know about bipolar disorder, but was afraid to ask. Most of the book was written by Terry Ketter, with very able assistance from a number of colleagues, mostly from Stanford University.
The book begins with a straightforward presentation of diagnostic criteria for bipolar disorders, according to DSM-IV. It quickly segues into a discussion of the evolution and the clinical course of bipolar disorder in a way that is very useful to clinicians dealing with bipolar patients.
Of a special utility to clinicians and to students is the section on distinguishing bipolar disorders diagnostically from other psychiatric conditions. For example, how do you distinguish bipolar disorder from depressive disorder? Dr Ketter recommends use of screening instruments and life charting and paying particular attention to distinguishing mixed episodes from major depressive episodes with prominent irritability or agitation. There are also sections on distinguishing bipolar disorder from schizophrenia, from schizoaffective disorder, from borderline personality disorder, and from attention-deficit/hyperactivity disorder.
The bulk of the book is devoted to a straightforward and well-referenced overview and description of the treatment of bipolar disorder in all of its forms. This is preceded by a concise and user-friendly presentation of the concepts of number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients a clinician would have to treat before having a successful outcome. Obviously, the lower the number for NNT, the better for the patient. These clinical concepts help to put into context findings from a variety of clinical trials and help to compare results across clinical trials. The section on the management of mania and mixed episodes uses the concepts of NNT and NNH to present and compare various pharmacologic options. These options are presented in 4 tiers, with Tier I containing medications having clear evidence of efficacy and US Food and Drug Administration (FDA) approval. Tiers II, III, and IV include medications ranging from those with less research support to those with anecdotal support and to novel treatments.
Similarly, the section on depression includes a 4-tier approach to the acute pharmacotherapy of bipolar depression. Tier I includes the olanzapine/fluoxetine combination and quetiapine, both approved by the FDA for the acute treatment of bipolar depression. Tier II includes lithium and lamotrigine. Tiers III and IV include a variety of other agents with some empirical research-based evidence of efficacy or anecdotal reports or truly novel approaches. Included among novel approaches are sleep deprivation, light therapy, vagus nerve stimulation, transcranial magnetic stimulation, and adjunctive psychotherapies. Unfortunately, the book was written before the studies of ketamine were presented.
The section on nutraceuticals is particularly enlightening because many patients will try these on their own, often without informing the clinician. Nutraceuticals include dietary supplements such as omega-3 polyunsaturated fatty acids, inositol, and other products. It is important to inform patients that some of these agents may have side effects on their own and may interact unfavorably with prescribed medications.
The section on bipolar II disorder is unfortunately very short, reflecting the paucity of research in the area. This is unfortunate because many of our patients suffer from bipolar II disorder.
Long-term management of bipolar disorder, including continuation treatment and maintenance treatment, is perhaps the most difficult for clinicians. The book contains many useful strategies and suggestions. It begins with a lucid discussion on how to interpret the literature on continuation and maintenance trials. Such variables as the polarity of the most recent episode, medication used to stabilize mood, the minimum duration of the stability, and the rate of tapering and/or discontinuation of medications used to transition to the randomized controlled stage may substantially influence outcome. Of particular importance is the concept of "enriched samples"—enriched in that the patients studied for maintenance are enriched by virtue of being responders to the medication to be studied. Of interest and importance is that only lithium has demonstrated maintenance efficacy in non-enriched samples. All other agents’ efficacy has been demonstrated in enriched samples.
Again, a 4-tier approach is used to help the clinician establish a strategy for maintenance treatment. Tier I includes 5 medications with well-demonstrated efficacy and FDA approval. In Tier II is divalproex. Tiers III and IV include other medications with more limited data and efficacy.
The book has detailed sections on management of bipolar disorder in special populations, including in children and adolescents by Kiki Chang and colleagues, in women by Laurel Zappert and Natalie Rasgon, and in older adults by John Brooks III and colleagues.
After this are detailed descriptions of the pharmacokinetics, drug interactions, adverse effects, and details for clinical administration and monitoring for all medications used in the treatment of bipolar disorder.
The final section is on adjunctive psychosocial interventions and the management of bipolar disorders, written by Jennifer Culver and Laura Pratchett. This is well-done. My concern is that the brevity of the chapter and its placement at the end of the book may inadvertently convey a devaluing of the extraordinary psychosocial interventions in the management of patients with bipolar disorder. These interventions, such as education, family-focused therapy, and cognitive-behavioral therapy, have been demonstrated to be extraordinarily helpful in preventing relapses and recurrences. Furthermore, effective assistance with management of the many crises that occur with bipolar patients and their families can be invaluable.
In conclusion, this "handbook" is a true tour de force for clinicians who want to acquire and/or improve their skills in the diagnosis and management of patients with bipolar disorder. I would recommend to Dr Ketter and colleagues that a much shortened, condensed handbook be prepared from this book that house staff could carry in their pockets. Such a volume unquestionably would substantially improve treatment of this disorder.
Author affiliation: University of Texas School of Medicine, Galveston. Potential conflicts of interest: Dr Hirschfeld has been a consultant for Equinox Group; has received royalties from Taylor and Francis Group and Jones and Bartlett; has provided Continuing Medical Education (CME) content for American College of Psychiatrists, Brown University, CME Alliance, CME Outfitters, and Letters & Sciences; and has received an honorarium from the Merck Manual Editorial Board.
doi:10.4088/JCP.11bk06893
© Copyright 2011 Physicians Postgraduate Press, Inc.
