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by E. Fuller Torrey and Michael B. Knable
Basic Books, 2001
Review by Robert Tarzwell MD, BA on Jul 16th 2002

Surviving Manic Depression

“Manic-depressive illness,” state the authors in their opening paragraph, “is now openly discussed as a brain disease.”  This places them squarely in the camp of biological psychiatry, and indeed I suspect this is where they would choose to identify themselves, at least with regards to Bipolar Disorder (BD), the topic of this book.  Rather than BD, the terminology of DSM-IV, the authors intentionally choose the term “Manic-Depressive Illness,” explaining in a preface that this term is more accessible to the general public. 

Topics discussed in the book are broken down in a similar manner as they might be in a medical textbook focused on a particular disease, but they are given much friendlier titles.  For instance, the first chapter, “Dimensions of Manic-Depressive Illness,” is actually a chapter on the epidemiology of BD.  However, the chapter subjects are treated in sufficient depth for the book to easily suffice as a stand-alone psychiatric text, or even a reference, suitable for a junior psychiatric resident seeking a deeper understanding of the disease.  This junior psychiatric resident, at least, certainly found that to be the case. 

Although Torrey and Knable discuss an impressively broad array of technical topics, and all in considerable depth, this sometimes occurs at the price of being tedious.  I periodically found myself losing interest in the exhaustive detail, even while admiring its thorough completeness, and I wondered about the usefulness of such technical detail for general audiences.  For instance, I can hardly imagine a non-technical audience being able to easily slug through the above-mentioned opening chapter on the epidemiology of BD.  This detail could easily have been relegated to an appendix.  Fortunately, the authors wisely sprinkle the text with bulleted side-bars to encapsulate their core points, and detail-o-phobes who are nevertheless interested in knowing core points about BD will find these side-bars a welcome relief.

The work becomes far more engaging, both topically and stylistically, in its second chapter, “The Inner World:  Mania and Depression from the Inside.”  The reader is offered rich, detailed descriptions of the symptoms and signs of BD, presented from a nicely eclectic sampling of clinical literature of the past and present, quotations from books written by famous manic-depressives, and passages from literary, poetic, and dramatic works about the illness.  The authors achieve an impressive balance between full explication of the clinical phenomena of the disease and a sympathetic portrayal of the illness experience from the perspective of the sufferer.  From the point of view of pure human interest, the second chapter is the most compelling, even heart-wrenching, particularly in its vivid descriptions of the depressive side of BD.  Torrey and Knable make an impressive case that mania and depression are not simply happiness and sadness to a greater degree but are qualitatively distinct, personally destructive, phenomena.

The next several chapters delve largely into the technical, considering such topics as the spectrum of disorders that a psychiatrist must consider when confronted with a patient exhibiting mood symptoms, other causes of mood symptoms, such as medications, infectious disease, or trauma, the risk factors for developing BD, and the typical course of the disease.  As with the chapter on epidemiology, the detail, while being complete, can run into the tedious. 

Chapter 7, “Causes,” deserves separate consideration in this review.  Here, the authors look at the cutting edge of research:  high-resolution brain scanning, genetics, immunology, neurochemistry, and even evolutionary psychology.  For those interested in seeing where the latest breakthroughs in basic and clinical neuroscience are coming from, and how those techniques are applied to solving complex problems, this chapter is very exciting reading.  As one brief example, from the evolutionary perspective, the authors discuss the intriguing idea that mania, at key moments in human evolutionary history, may have conferred an adaptive advantage.  The manic’s predisposition toward fearless certainty and risk-taking behavior might, for instance, give a distinct advantage in battle or the hunt, promoting the overall reproductive success of the tribe, even while conferring distinct interpersonal disadvantages on the manic individual.

From the psychiatric standpoint, the core of the book comes in chapters 8 through 10, a discussion of all the medications involved in the treatment of BD.  These chapters are very nearly a miniature pharmacopeia of all psychiatric medication classes, with drugs highly relevant to BD given detailed, specific treatment.  The key mood stabilizers, for instance – Lithium, Valproate, and Carbamazepine – are discussed under the headings of Efficacy, Prediction of Response, Administration, Laboratory Monitoring, Side Effects, Toxicity, Risks of Discontinuation, and Interactions with Prescription Drugs.  While this information should be known by any psychiatrist working with Bipolar patients, the information is extremely useful to patients and their families, especially as they interact with family physicians, non-psychiatric specialists, and any other health-care providers, who will almost certainly not have this information at their fingertips. 

I expect that the wide dissemination of this information to those who have or care for people with BD will improve quality of care and will lead to fewer adverse drug events.  Readers do need to realize, though, that psychopharmacologic research is constant and ongoing.  Therefore, unless the authors intend to publish frequent updates, much of this information will be superseded in time.  The Bipolar patient’s primary treating psychiatrist is always the best source of information for the most current therapeutic practices.  For instance, current thought is shifting with respect to Lithium dosing.  The authors advocate dividing the dose into thrice daily, but some authorities recommend the full daily dose be administered at bedtime, to hypothetically allow a daily period of low blood levels for kidney detoxification and regeneration (1).  It was disappointing to see the authors not acknowledge this controversy.

 The final chapters of the book move away from traditional medical arenas and look more at the social and political situation, focusing entirely on the United States.  I’m from Canada, so I can’t speak directly to the claims the authors make regarding a dearth of research funding for BD, and I also can’t address their allegation that patients with BD are not strongly advocated for in the political realm.  I did find it odd that the authors bemoaned the lack of strong individual advocates for the mentally ill and yet then went on to give brief biographical sketches of a fair number of just such advocates.  I suppose the general message here is that there ought to be more research money and more advocacy on behalf of BD.

Appendices A through D are a marvelous resource for patients and families.  Appendix A offers brief reviews of numerous current books in the field.  Appendix B is a listing and appraisal of current websites.  Appendix C reviews psychoeducational videotapes from approximately the last decade.  Appendix D is primarily a list of addresses of groups of various kinds involved with BD.  It also lists a few medical journals, more aimed at the technical reader.  Appendix B is the most likely to change with time, given the dynamic nature of the web, but the list of links, and especially the appraisals, are probably one of the most useful parts of the book, especially for families and patients new to BD who are likely bewildered by the meaning and implications of the diagnosis.

All in all, Torrey and Knable have offered the popular psychiatric literature an immense, complete, and useful resource.  My own knowledge of the disorder, as a psychiatrist-in-training, was certainly enhanced.  I can only expect that, with the exception of the BD sub-specialist, this increase in knowledge, after reading the book, will be the case for anyone with an interest in the field of Bipolar Disorder.

 

1.      McIntyre R, et al.  Lithium Revisited.  Can J Psychiatry 2001;46:322-327

 

© 2002 Robert Tarzwell

 

Robert Tarzwell is currently in his second year of a five-year psychiatry residency at Dalhousie University in Halifax, Nova Scotia, Canada.  He completed his MD at the University of Manitoba in May 2001.  Prior to medical school, he spent 8 years in the Canadian Forces as an Air Navigator, employed on the CP-140 Aurora maritime patrol aircraft.  He also completed a staff tour, acting as Air Force Webmaster and speechwriter for the Commander of the Air Force.  He holds a BA in English Literature from Simon Fraser University in Burnaby, British Columbia, Canada.