A decade ago, the director of the Harvard-associated mood disorders clinic suggested that rather than asking, “Does this patient have Bipolar Disorder or not?” we should be asking, “How bipolar is he?” In James Phelps’s comprehensively researched and engaging book, A Spectrum Approach to Mood Disorders: Not Fully Bipolar But Not Unipolar — Practical Management, he asks us to again ask this question and consider how we treat and manage Bipolar Disorder.
By broadening the lens through which we evaluate Bipolar Disorder, Phelps argues that we would not only diagnose bipolar with greater accuracy, but we could also treat it more effectively. Consider the work of the Spectrum Collaborative Project, where 14 researchers in three centers around the world found that hypomanic/manic symptoms in patients with mood disorders form a remarkably smooth continuum from absent to fully manifested.
And while some have expressed concern that a spectrum approach could lead to over-diagnosis of bipolar disorder, Phelps contends that just the opposite is true. He writes, “From a spectrum view, over-diagnosis and under-diagnosis are not possible. If there is no real dividing line between unipolar depression and bipolar disorder, then there is no line to be over and under.”
While Phelps offers the Bipolar Index along with several mood scales as practical and useful tools to detect bipolar symptoms, ultimately, he tells us, the answer is not a black and white decision, but rather a judgement call to be made with the patient. This may be especially important during mixed states where anxiety and depression can comingle, often confusing the diagnosis. An alternative approach, Phelps suggests, is the “waves” model, where individual symptoms such as mood, energy, and speed of thought/creativity can shift independent of each other. In this model, it is possible to feel a depressed mood, along with increased energy and creativity, or conversely, what is commonly referred to as agitated depression.
The idea of a mixed state has also been supported in the latest DSM edition, which suggests broadening the range of mixed states to include subthreshold manic symptoms, as well as allowing the mixed state specifier to be used in Major Depression. For Phelps, improving the way we detect and treat Bipolar has critical ramifications. He writes, “Once again the very medication to which the patient is led if bipolarity is missed can make things worse, in this case (treating depression symptoms and not bipolar symptoms) inducing the very symptoms it is used to treat.”
Treating bipolar more effectively, however, also relies on better patient-clinician communication. Here, Phelps offers several helpful tools to ensure that patient understanding precedes the rendering of treatment, especially medication. This communication can also yield improved differential diagnoses. For example, in differentiating Bipolar from Borderline Personality Disorder, it is in the interview process that the critical attachment disturbance which characterizes borderline can be detected. Similarly, the “emotionally invalidating environment” that often precedes borderline can also be viewed as trauma, which creates not just overlapping criteria, but three separate spectrums: mood, borderline, and trauma.
The important point in treating bipolar, Phelps tells us, is not to treat the mood at the moment, but rather the cycling of mood which represents bipolar. To do this, Phelps offers three general principles: maximize non-medication approaches, rely on mood stabilizer medications, and avoid antidepressants. He also points to the exponential growth of shared decision making, as evidence that collaborative processes — where the clinician and the patient together assess the best scientific evidence along with the patient’s values and preferences to make the best decision — are preferable to patients.
Phelps then covers several treatment options, including prodrome detection, psychoeducation, Cognitive Behavioral Therapy and Dialectical Behavioral Therapy, and Family-focused therapy. He introduces Social Rhythm Therapy which aims to restore the patient’s social rhythms, which is thought to lead to a more stable mood. Phelps also discusses the use of darkness as a mood stabilizer and points to the experience of a patient who was treated at the National Institute of Mental Health for severe rapid cycling bipolar disorder. After no improvement through medication, clinicians used a dark room, where the patient underwent enforced darkness from 6 p.m. to 8 a.m. the next morning, to return the patient to a stable mood.
Always a crucial component of any treatment regimen, Phelps addresses the issue of treatment efficacy versus tolerability. Of critical importance, he tells us, is to weigh not only the results of randomized clinical trials, but also observations of patient outcomes. He writes, “The strong weighting of tolerability over efficacy is even more pronounced among mid-spectrum patients where the risk of a recurrent manic episode does not loom in the past, a specter of potential threat that must be prevented even if the costs are relatively high.” Both Lamotrigine and low-dose Lithium offer promising treatment options and Phelps provides a comprehensive review of the safety and efficacy of these two medications as well as several other anti-psychotic medications. Phelps also covers the research on the interaction between thyroid levels and mood stability, along with a review on how to use thyroid medication to assist the treatment of bipolar disorder. Lastly, Phelps addresses the debate about anti-depressants, offering nine practical alternatives to anti-depressants, such as exercise, fish oil, dawn simulators, psychotherapy, and low-dose lithium.
Bipolar Disorder is a perplexing problem both for those who suffer it and those who treat it, yet in this superbly researched and clearly written guide, Phelps provides a promising alternative to the traditional categorical approach — one that not just improves the diagnosis, but also the treatment of bipolar.
A Spectrum Approach to Mood Disorders: Not Fully Bipolar But Not Unipolar- Practical Management
W.W. Norton, June 2016
Hardcover, 272 pages