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Depression: Major Depression & Unipolar Varieties
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by Mitzi Waltz
O'Reilly & Associates, 2002
Review by Jack Anderson, M.D. on May 25th 2003

Adult Bipolar Disorders

In the fourth paragraph of the preface, Mitzi Waltz explains why she wrote this book. "This book is intended to bring together all the basic information needed by people diagnosed with a bipolar disorder."

This was a formidable task to set for herself, but in my opinion she is eminently successful. I recommend the book, without reservation, not only to bipolar patients, but also to their families, their friends, their caretakers, and to the clinicians who prescribe medicine and other treatment modalities for them.

The preface, chapters and appendices are all clearly written, without unnecessary medical or psychiatric jargon. Each of the eight chapters is divided into short, comprehensible sections with appropriate headings. There are over one hundred of these sections, any one of which can be meaningfully read by itself. Generally speaking, chapter subjects fall into four categories: diagnosis; treatment; insurance and healthcare systems; and strategies for survival with bipolar disorder.

One of the most useful and interesting parts of the book is Chapter 7, "Healthcare and Insurance." In a sub-section entitled "Making insurance choices," seventeen practical nuts-and-bolts questions are listed, for use in choosing an insurance plan. For example: How are the insurance plan's doctors paid--are they penalized or rewarded for referrals to specialists, number of office visits, hospitalizations or any similar actions? Does the plan pay for a second opinion if you request one? Does the plan have a "gag order" which prevents doctors from informing you of all treatment options?

In the section entitled "Managing managed care," the author acknowledges that HMO's and their physicians are apt to consider patients with long-term conditions as obstacles in the way of their profits. However, instead of complaining about the injustices of these systems, she offers sound and detailed advice as to how patients can profitably use them.. Some of the topics covered are: fighting limits on psychiatric care; fighting denial of care; resolving grievances; and filing appeals. In a sub-section titled "Semi-sneaky tips" she suggests a method for penetrating the interminable cycle of recorded messages in automated phone systems, in order to establish contact with a real person.

Chapter 7 also contains descriptions of military healthcare coverage, Medicare, Medicaid--including the possibility of waivers of certain income limitations under specific circumstances--SSI, and state and local public health plans. This chapter also describes healthcare systems in Canada, England and Scotland, the Republic of Ireland, Australia and New Zealand.

Chapter 8, "Living with Bipolar Disorders," is also a treasure trove of suggestions and recommendations about how to deal with the negative effects bipolar disorders can have on people's lives. Waltz refers to this body of recommendations as "a guideline for self-care." The chapter contains quotations from bipolar patients describing their personal experiences with social, financial, professional and occupational losses caused by bipolar episodes, and the strategies patients have developed for dealing with and living with these losses.

One of the strategies recommended is the journal method, "The mood and behavior diary." This method I have personally found to be effective for bipolar patients I have treated in private and public psychiatric facilities. As the author describes, patients who make daily notes about their mood and behavior learn to recognize early warning signs of manic, depressive, or psychotic episodes and to take appropriate methods to abort them. In this section is included a daily mood and behavior worksheet containing thirty-one Yes/No questions.

The following list of additional section headings will give some idea of the breadth and scope of this chapter: "Bipolar disorders at college," "Bipolar disorders at work," "Housing," "Legal and financial planning," "Family relationships," "Suicide prevention," "Criminal justice and mental illness," "Maintaining your sanity," and "Hold on to hope."

Appendix A, "Resources," provides addresses, telephone numbers, fax numbers and email addresses of advocacy and support groups in the United States, Canada, UK, Ireland, Australia and New Zealand. Public mental health agencies, state and federal, are also listed for the same countries, as well as books and publications, videos, and online resources. Contact information for some of the world's best-known diagnostic and treatment centers is also included in this appendix.

The first three chapters are concerned with the problem of diagnosing bipolar disorders. Chapter 1 proposes a definition, discusses the various types, and explains some of the causes of bipolar disorders. Chapter 2 explains how mental health specialists use diagnostic interviews and tests to establish a definite and specific diagnosis. Chapter 3 discusses the difficulty of differentiating bipolar disorders from other diseases that contribute to the symptoms and tend to confuse the diagnostician. Some of the conditions discussed are: ADHD; Anxiety; Conduct disorder; Cushing's disease; Depression; Diabetes mellitus; Fibromyalgia; Hormonal disorders; Hypoglycemia; Lupus; Medication side effects; Multiple sclerosis; Personality disorders; Psychosis; Rheumatoid Arthritis; Substance abuse; Schizophrenia; Schizoaffective disorder; Thyroid disorders; Aids; Chronic fatigue syndrome; Hepatitis; Infectious mononucleosis and Siezure disorders.

I am afraid that these detailed discussions of diagnosis are more apt to confuse than enlighten the bipolar patient. In my experience, even the most highly educated and broadly experienced of us mental health specialists have difficulty applying the convoluted diagnostic criteria of DSM-IV to individual patients. When I reviewed medical records of patients admitted to a local crisis center, I frequently found as many as ten different DSM-IV diagnoses for the same patient by different specialists within a period of two or three years. In 1968, when DSM-II was published, there were only four variations of manic-depressive illness--the diagnostic forerunner of bipolar disorder. Now, in DSM-IV, there are eight variations of bipolar disorder, which tends to increase the difficulty of accurate differential diagnosis.

I also doubt the wisdom of the long, involved discussion of the causes of bipolar disorder. That there is some genetic predisposition is beyond doubt, given the increased incidence in children of bipolar patients. However, our knowledge of brain structure and function, neural circuits, neurotransmitters, chemoarchitecture, and the roles of various enzymes and other "brain messengers" is till scanty and incomplete.

Many philosophers have warned us against the fallacy of believing that a mind can ever understand itself completely. Shakespeare has Hamlet say "There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy." I think we should take these caveats seriously and not pretend to ourselves and to bipolar patients that we understand more about their condition than we actually do.

Bipolar patients will find invaluable suggestions in this book about how to cope with their condition, how to obtain treatment and how to pay for it. Family members, caretakers, and clinicians in the US and other English-speaking countries can also learn a lot. Waltz deserves a vote of thanks from all of us for the tremendous effort and dedication she demonstrated by assembling all of this information into one volume.

© 2003 Jack R. Anderson

Jack R. Anderson, M.D. is a retired psychiatrist living in Lincoln, Nebraska.