Bipolar Disorders: Clinical Course and Outcome

Since the advent of the psychopharmacological revolution, manic-depressive illness (bipolar disorder) has served as a principal point of focus for modern psychiatric research. Today, although the accumulation of knowledge about this illness and its treatment constitutes one of the extraordinary success stories of modern biomedical science, it remains in many ways a paradox—a paradox because, despite all we know, the illness too often is unrecognized or misdiagnosed, and inappropriately or ineffectively treated. The disparity between optimal care, on the one hand, and what is routinely provided, on the other, is perhaps nowhere larger than in manic-depressive illness. Its human and economic impact remains excessive.

Throughout medicine, course and outcome are basic to the very concept of a disease entity. Further, an understanding of the pathophysiology—and ultimately the etiology—of an illness requires understanding its natural course. Indeed, the contemporary development of pathophysiological models for bipolar disorder is increasingly focusing on the biology of recurrence.

In Bipolar Disorders: Clinical Course and Outcome, Drs. Goldberg and Harrow have pulled together many of the leading authorities in this area, covering everything from the kindling-sensitization model for understanding recurrence to psychosocial treatment in the public sector. This book is both timely and needed. The advantage of edited books—a wide range of self-contained reviews by a large number of leading experts—is generally offset by their principal disadvantages, which are lots of overlap and little or no integration. This book certainly delivers the leading experts and even manages to achieve a level of integration by virtue of a good summary chapter by Goldberg and Keck. Another feature that ties the individual contributions together is that each is both conceptual and practical. Also, a welcome focus on methodology characterizes many of the contributions.

One of the intriguing issues addressed in this book is the apparent decline over the years in the prophylactic effectiveness of lithium. During the 1970s, most controlled studies of lithium were conducted in research centers. Investigators reported complete response as defined by the elimination of the need for hospitalization for 75 to 80 percent of patients.

The contemporary follow-up studies reviewed in this volume show apparent response rates to lithium that are substantially lower than those in the "classic" studies, both open and controlled. The book reviews several reasons that may account for this difference. First, follow-up studies today reflect the results of treatment in the community, as opposed to carefully controlled medication trials in a research setting. This bias suggests that the "true" effectiveness of lithium in the "real world" is lower than what was achievable in the controlled trials. However, it can be argued that patients who respond well to outpatient treatment seldom volunteer for research studies; thus many of the lithium-responsive patients are already filtered out of the research population.

It is both remarkable and wholly appropriate that one-quarter of the chapters in Bipolar Disorders focus on psychosocial and psychotherapeutic aspects of the disorder. The data reviewed in those chapters, while still somewhat preliminary, show a substantial advantage of combined psychosocial-pharmacological strategies over medication alone. Interestingly, the size of the reported effects of adjunctive psychosocial interventions is larger than that observed in studies in which psychotherapy alone was administered to "good" psychotherapeutic candidates, that is, patients whose overall functioning is reasonably intact. Clearly, the evolution of effective medications for this severe psychiatric disorder has opened up major new vistas for psychotherapy broadly defined. It will behoove the health insurance and managed care industries to consider these data carefully rather than to continue to rely on antiquated "Woody Allen" images of psychotherapy.

Dr. Goodwin is professor of psychiatry and director of the Center on Neuroscience, Medical Progress, and Society of the George Washington University Medical Center in Washington, D.C.