Surviving Manic Depression: A Manual on Bipolar Disorder for Patients, Families, and Providers

For two decades, Dr. Torrey's Surviving Schizophrenia (1), written for patients and their families, has helped benefit so many who suffer from the illness or provide support and care for them. The book is now considered a classic on schizophrenia.

Now Dr. Torrey and his colleague, Dr. Knable, have produced what will very likely be an equally useful book for those who suffer from manic-depressive illness or bipolar disorder.

Surviving Manic Depression is written in an easy-to-read style, largely in a question-and-answer format. It is addressed to those who suffer from manic-depressive illness and to those who provide support for them. Detailed explanations of the epidemiology of the illness, patients' perceptions, official diagnostic categories, differential diagnosis, risk factors, and course and outcome are presented in clear language. Pharmacological and nonpharmacological treatments are covered in a straightforward way and fairly comprehensively, including mention of some of the newer, unproven treatments for bipolar illness. The authors have done a remarkably good job of digesting the body of available literature and making it easy to read. This aspect of the book should be particularly appealing to readers.

Among the book's many strengths are the authors' discussions of some of the important clinical and other issues that accompany this lifelong disorder—for instance, how to find a good doctor, assisted treatment, arrests and jailing, creativity, substance and alcohol abuse, children and adolescents with manic depressive illness, suicide, and advocacy. Such issues, described in chapters with titles such as "Ten Special Problems" and "Commonly Asked Questions," are encountered routinely in the treatment of the illness but are seldom addressed appropriately in the training of psychiatrists or allied health care providers. Consequently, patients and their families are often dissatisfied with the answers they receive to their questions. This book can certainly help literate patients and their families and providers bridge this important gap.

The word "literate" should be emphasized, for the book is clearly addressed to educated persons who suffer from this illness, or to their family members. Similarly, providers will find the book to be an important resource to keep handy in their offices or hospitals.

Although one may quarrel with some of Dr. Torrey's views, both authors have a clear understanding of patient issues from the trenches, and this aspect comes through time and again in the text. Clearly their intent is to help sufferers and those who provide support and care, and their efforts to that end are abundant. I recommend this book highly, for patients, families, and clinicians.

In 1949, Dr. John Cade, an Australian psychiatrist, thought that mania might be caused by imbalances in protein metabolism. Cade knew that such a process could be evaluated by studying uric acid and urea (breakdown products of proteins) obtained from the urine of patients with mania. Cade's experimental method was to inject these compounds into guinea pigs, but he had a problem: "Since the compounds are not soluble in water, they had to be conjugated to an element such as lithium prior to injection." Incredibly, he found that "lithium urate—and later, lithium carbonate—produced a calming effect in the guinea pigs." Cade then began testing lithium's efficacy among humans. Ten patients with mania were injected, and most experienced a dramatic recovery.

Twenty years passed, however, and nothing happened. The authors of Surviving Manic Depression, E. Fuller Torrey and Michael B. Knable, attribute the slow clinical adoption of lithium to two factors. As a naturally occurring and plentiful salt, lithium "could not be easily marketed for commercial gain," but also, Cade's findings went almost unnoticed after publication in "a journal of limited circulation in a remote country."

"Lithium comes into its own," exclaimed the American Journal of Psychiatry in 1968. Nathan Kline, the article's author, noted that "lithium, the 20-year-old Cinderella of psychopharmacology, is at last receiving its due." Given the story of lithium, Torrey and Knable ask "How many other substances may exist that hold promise for the treatment of psychiatric illness but are not investigated because they have limited profit potential?"

Such socioeconomic perspective rings refreshingly throughout the book. For example, the authors cite the plethora of pharmaceutical company advertisements in medical journals that imply that mood stabilizer medications "are useful for individuals with minor mood changes." Indeed, Torrey and Knable remark that the notion of a pill for a bad day or occupational overexertion would almost be comical if such a dynamic were not inching toward fact. Or, as Patty Duke observed in her book A Brilliant Madness, which the authors quote, "Many people are compulsively driven, can get along on just a few hours' sleep, and can function at a very high energy level, but are not mood-disordered and do not come from a family that is."

The phenomenon of clever marketing by the pharmaceutical industry is one of the notable points the authors make; it must be recognized when trying to make sense of mood disorders. This is not to negate the profound positive effect on emotional health of pharmaceuticals, but it is a side of the industry that must be recognized.

Much of Surviving Manic Depression is hard science made understandable and discussed objectively, backed up by 571 scientific footnotes. For example, in their discussion of lithium and kidney damage, Torrey and Knable meticulously document scientific conclusions with elucidation from medical journals. They cite an article from Acta Psychiatrica Scandinavica comparing kidney function among patients with affective disorders who were taking or not taking lithium. Its authors concluded that the risk of kidney damage is "probably not greater than the naturally occurring rate of kidney failure due to other diseases such as diabetes and hypertension."

The book is not without wry humor. The word "bipolar," the authors note, "connotes a geographic entity and poles"; it also "refers to the two ends of a battery, suggesting electrical overtones." Much discussion is also given to genetic predisposition to manic-depression. For example, the authors note, knowing why there is an incidence of manic-depression in the so-called culturally inbred societies such as the Amish "would bring us much closer to understanding the disease."

The book bills itself as "A Manual on Bipolar Disorder for Patients, Families, and Providers," and much of the text is practical, "tool-belt" information. For example, the authors report that, in one small study, 60 percent of patients who received St. John's wort responded well, compared with 24 percent of those who received placebo. But the authors caution, a "recent huge study … showed no benefit in cases of major depression." Importantly, they note that no studies have been published on the use of St. John's wort in manic-depressive illness.

Jack Miles of the Los Angeles Times declared Torrey "a brilliant writer. … He combines zeal for the hard science of his field with an angry clarity about its bureaucracy and a healer's quiet determination to stay where the pain is worst." Indeed, in Surviving Manic Depression Torrey and Knable focus on what counts. It is a good read, and I highly recommend it.

Dr. Chengappa is associate professor of psychiatry at the Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center in Pittsburgh. Mr. Hartmann, a longtime sufferer of bipolar disorder, is an attorney and a freelance writer living in western Massachusetts.