by Mario Maj, Hagop S. Akiskal, Juan José López-Ibor and Norman Sartorius
John Wiley & Sons, 2002
Review by Duncan Double on Mar 17th 2004
This book is
volume 5 in a World Psychiatric Association (WPA) series "Evidence and
Experience in Psychiatry". The acknowledgements note that the publication
has been supported by an unrestricted educational grant from Sanofi-Synthelabo,
the global pharmaceutical company. Although the aim is to provide a balanced
state‑of‑the-art update of the scientific and clinical basis of
bipolar disorder, the WPA allows the production of such series to be contracted
with commercial publishers. The initiative and development of agreements about
donations for publications is the responsibility of the WPA Secretary for
Publications, who happens at the moment to be the first editor of this book. He
was also the first editor of previous volumes in the series.
and vested interest is relevant as Sanofi-Synthelabo manufactures valproate,
widely used in the pharmacological treatment of bipolar disorder. One form of valproate
- valproic acid (as the semisodium salt) - is indicated for the treatment of
manic episodes associated with bipolar disorder. Valproate more generally, like
other so-called mood stabilising drugs, is widely used outside licensed indications
in bipolar disorder. The pharmaceutical companies probably cannot be blamed for
this state of affairs, as they are not permitted to endorse the use of their
products for unlicensed indications. Sponsoring educational activities may be a
way round this regulation if clinical expertise encourages unlicensed
prescription. Companies need to provide evidence of efficacy to obtain a
licence and the economic return has to be balanced against the high cost of
is the modern term for manic-depressive illness. Emil Kraepelin introduced the
term manic-depressive illness in 1899 in the sixth edition of his psychiatric
textbook. For Kraepelin, manic-depressive illness was a single morbid process.
It included manic, mixed and depressed states.
The terms "unipolar"
and "bipolar" were coined by Karl Kleist in 1953. Unipolar disorders
were unipolar mania and unipolar depression. Bipolar disorders were circular
disorders of episodes of both mania and depression and cycloid psychoses, a
term used for psychoses separate from both schizophrenia and affective
psychoses. Like Kraepelin, Kleist still regarded unipolar and bipolar states as
a unitary disorder. Bipolar disorders were merely a combination of the monopolar
forms with a special affinity. It was Kleist's pupil, Karl Leonhard who
accepted the separate existence of unipolar and bipolar disorders.
The modern concept
of bipolar disorder is said to have originated independently in the 1960s in
three monographs by Carl Perris, Jules Angst and George Winokur et al. The
concept has moved on from that of Kleist and Leonhard. For example, it does not
include cycloid psychosis, which is a concept not well represented in modern
classificatory systems, such as ICD-10 and DSM-IV. Bipolar disorder now
includes mania without depression (unipolar mania in Leonhard's terms).
difference between bipolar and unipolar disorders arises out of evidence for
different morbidity risks among first degree relatives. Kleist and Leonhard had
assumed that the genetic loading in bipolar disorders was greater than in monopolar
disorders. The modern studies showed a significant bipolar morbid risk was
present in the families of bipolar probands and not in the families of their unipolar
depressive counterparts. However, the three monographs vary widely in their
conclusions as to the overall morbidity in first degree relatives.
polarity-based distinction between bipolar disorders and unipolar depression is
said to have been of benefit in research and clinically. So-called mood
stabilizers are now widely prescribed. However, there is dispute about the
definition of mood stabilizer. Although valproate, for example, has a license
for the treatment of mania, evidence of its efficacy as a prophylactic mood
stabiliser is questionable.
Over recent years,
the bipolar concept has expanded to include subtypes, which have lesser
episodes of mania, called hypomania. In particular, bipolar II disorder
(although this category is still not formally recognised in ICD-10) was
originally identified by David Dunner as those patients who had been
hospitalized for depression, but their hypomanic episodes had not been severe
enough to require hospitalization. However, hospitalization was not seen as an
adequate criterion for defining the diagnostic threshold for mania from
hypomania. DSM-IV now defines hypomania as a short‑lasting (4 days
minimum) elevation of mood identified by the usual criteria for
mania, but without marked social or occupational dysfunction and without severe
symptoms such as delusions and hallucinations. Bipolar II patients
have never had a manic episode, but have had one or more episodes of major
depression and at least one episode of hypomania, thus defined.
bipolar concept further, Hagop Akiskal, who is the first chapter contributor to
this book on classification, diagnosis and boundaries of bipolar disorder,
proposed a "soft bipolar spectrum" in 1987. What he meant by this was
a more inclusive term for bipolar conditions beyond classical mania. The
spectrum includes bipolar I, bipolar II, cyclothymic and hyperthymic traits, as
well as those with familial bipolarity; it also includes hypomania apparently
induced during antidepressant or other treatment (bipolar III). The term
"spectrum" is, therefore, used to refer to the broad range of
manifestations of bipolar disorder from core symptoms to temperamental traits.
In clinical practice, it may include those patients with emotional lability, who
may, for example, have otherwise been categorised as borderline personality
disorder. The core of the so-called disease could be seen generally as “mood
swings” or instability.
concept of bipolar disorder in this way has been controversial. It has been a
particularly american phenomenon, although the practices have been followed in
other countries. It may be reminiscent of the overinclusive use of the term
schizophrenia in USA in the
1960s. The US-UK Diagnostic Comparison Study demonstrated that American
psychiatrists were using the term schizophrenia up to four times as commonly as
their British counterparts. This finding contributed to a tightening of
diagnostic criteria in DSM-III, particularly a narrowing of the definition of
schizophrenia. Maybe we should now also have concern about the validity of the
broadening of the concept of bipolar disorder. Estimates of the proportion of
the population with bipolar spectrum are as high as at least 4-5%. The use of
the diagnosis bipolar disorder has become variable and unreliable.
Other chapters in
the book are on prognosis, pharmacological treatment, psychosocial
interventions, effects of gender and age on phenomenology and management, and
the economic and social burden of bipolar disorder. Each of the chapters has
several brief commentaries from experts in the field.
The aim of
treatment of bipolar disorder is euthymia. Democritus regarded this state of
being as one in which the soul is freed from all desire and unified with all
its parts. He believed it should be the final goal of everything we do in life.
Bipolar disorder could be said to have taken over from schizophrenia as the
paradigmatic mental disorder in modern psychiatry. It may say something about
present-day psychiatry that its objective is now "tranquility of the
soul" rather than unifying the mind-body split of schizophrenia. The
question is whether we have progressed from controlling the brutish nature of
mental illness, which was one of the reasons for the establishment of the
asylums. The book is a learned, scholarly exposition of the consensus about
bipolar disorder, but I am not sure how much it really helps us get in touch
with people given this diagnosis.
© 2004 Duncan
Double, Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk Mental
Health Care Trust and University of East Anglia, UK; Website Editor, Critical Psychiatry Network.