by Ronald R. Fieve
New York: Rodale Press, 2006
275 pages • $22.95 (hardcover)
Ronald Fieve and his colleagues were among the first to document milder versions of manic symptoms—hypomania—in the 1970s, observations that did not make it into DSM until 1994. Perhaps the reason for this delay is that hypomania is possibly the only DSM axis I condition that does not involve marked functional impairment and, in fact, requires the absence of such impairment. It is a condition in which persons are happy and functional. How are they not normal? One difference that can be noted in this condition, as Hagop Akiskal once quipped, is that it is episodic: hypomania is recurrent, whereas happiness is not.1
Besides the absence of impaired function, the distinction between hypomania and mania is also complex. If a patient is manic, clinicians tend to call him or her hypomanic. However, the difference between the two is important because when determining the best treatment for patients with type I bipolar disorder (BDI), a great deal of evidence for this type exists that should constrain our decisions (eg, the proven benefits of the use of mood stabilizers, the need for caution when prescribing antidepressants).
In determining the best treatment for type II bipolar disorder (BDII), there are so few data that the clinician is left to do what he sees fit. For instance, there are no randomized prophylaxis data and no placebo-controlled antidepressant data for BDII.
The reticence of the pharmaceutical industry and the FDA to study or provide indications for BDII is based on the vagaries of clinical practice: some clinicians cannot distinguish it from normality, others from mania. In addition, BDII frequently overlaps with unipolar depression. Recent data suggest that up to half of persons who have refractory depression in fact have BDII.2
Into this void steps Ronald Fieve with a follow-up to his 30-year-old book, Moodswing, which introduced America to BD and lithium(Drug information on lithium). Fieve joins Jim Phelps,3 another psychiatrist with bipolar expertise, in writing the first books to introduce the bipolar spectrum concept to the public. He provides a rational, objective review of this subject with a great deal of common sense that is based on decades of clinical experience and many illustrative cases.
This book appears mainly to be intended for families and patients; clinicians might find some parts simplistic and other parts informative. The book is divided into 2 sections—"Bipolar II Defined" and "Diagnosis and Treatment of Bipolar II." Over half of the book is devoted to "Bipolar II Defined," with much less space given to treatments. In Chapter 9, "Special Situations That Complicate a Bipolar Diagnosis," Dr Fieve touches on the third rail of psychiatry—the concept of attention-deficit/hyperactivity disorder (ADHD)—and makes the observation that many children and adults have either BD with or instead of ADHD. His discussions of mixed states, pregnancy, and the elderly are also full of clinical wisdom.