James Phelps, MD

(This is the second of a 2-part series. The first article discussed how categorization bias favors the DSM, and how to avoid the consequent narrowing of treatment options.—Ed.)

In part 1 of this series, I discussed cognitive biases related to inaccuracies in the DSM and some solutions for improving the process of shared treatment decision-making with patients. I noted that categorical DSM diagnosis and dimensional spectrum-based diagnosis can be used simultaneously, depending on which is most useful. 

Why Use the DSM When It Is Inaccurate? Cognitive Biases and Solutions

Sometimes categorical diagnosis is better—eg, for legal purposes or for communication with other medical colleagues. Dimensional assessment more closely matches mood phenomena (see 

). But is dimensional assessment difficult for clinicians to use? Are binary diagnoses necessary for binary treatment decisions?

No. Treatment decisions are often not binary, but instead lie on a continuum themselves. Here are 3 treatment-decision spectra:

1. Degree of certainty regarding a patient’s position on the mood spectrum

2. Number of previous treatments, and response thereto

3. Acuity versus chronicity and impact on long-term risk preference

Take Ms Smith, who presented in Part 1 with depression, anxiety, and a history of trauma. After consideration of thyroid, other medical issues, and substance use, the categorical differential for a mixture of depression and anxiety symptoms includes posttraumatic stress disorder (PTSD); major depression with mixed features (or comorbid generalized anxiety disorder); bipolar II; and borderline personality disorder. These diagnoses can be extremely difficult to differentiate, as suggested by the overlapping symptoms shown in the 

 Overlapping Symptoms in the Differential Diagnosis of Anxious Depression

What is a clinician to do? Likely what many readers have been doing for years: Choose treatment options by 

. Let’s examine this process using the hypothetical Ms Smith as an example.

If Ms Smith describes intrusive reexperience and avoidance, and if a PTSD-specific psychotherapy (eg, cognitive processing therapy or eye movement desensitization and reprocessing) is available to her, then your PAR (procedures, alternatives, and risks) discussion would emphasize these specialized therapies. But if PTSD is not clearly the basis of her depression and anxiety (her trauma might be predisposing, but not causative), then antidepressants and more widely available therapies would become more prominent in your PAR. As your certainty about the role of trauma in her presentation shifts, so do your treatment recommendations: not from black to white, but gradually from a strong preference for one treatment option toward another.

If Ms Smith’s history includes cutting behavior, suicidal ideation, and dramatic interpersonal chaos, dialectic behavior therapy is an obvious treatment option. If Ms Smith meets full DSM criteria for borderline personality disorder, then antidepressants are unlikely to be of significant benefit.

 But to the extent that borderlinity is not certain, an antidepressant becomes a more prominent option and psychotherapy options broaden; perhaps cognitive behavioral therapy (CBT) would have more value than dialectical behavior therapy (DBT). Your shared decision-making would be strongly influenced by how Ms Smith reacts to your description of antidepressants’ risk/benefit ratios, and the 2 psychotherapies’ relative strengths—a reaction that itself lies on a continuum from strongly favoring one treatment to strongly favoring another.

If borderlinity is not prominent, then the decision-making focus shifts to Ms Smith’s depression and anxiety symptoms. Your PAR discussion would include a comparison of psychotherapies:

CBT for depression, or a transdiagnostic CBT

 that can address her anxiety as well. The strength of her anxiety symptoms relative to her depression symptoms, which also lies on a continuum, would determine your emphasis.

Finally, if a history of hypomania/mania is obvious, then one would target Ms Smith’s depression using a mood stabilizer with antidepressant effects (MSAE): interpersonal and social rhythm therapy (IP/SRT)

; and/or lamotrigine, lithium, quetiapine, olanzapine, or lurasidone. But if her bipolarity is uncertain, then antidepressants and a more standard psychotherapy—CBT or interpersonal therapy—become options. The choice would depend on the question, “how bipolar is she?”—just the question advocated years ago by the STEP-BD research program’s principal investigator.

Is this process really any different from just making a DSM diagnosis and recommending the appropriate treatments? Yes. At minimum, one approaches one’s patients differently—not saying, “this is what you have, and this is the treatment for it,” Rather, one is in a humbler position vis-à-vis the patient, and vis-à-vis what we really know about psychiatric diagnoses. To Ms Smith, for example, you might say: “We cannot know for sure where on the mood spectrum you are, or how much your awful experiences account for the symptoms you have. But the treatment options are much the same: psychotherapy (not Freud, not about your parents, no couch), and/or a medication for the mood part. We can start with either or both. May I tell you more?”

In shared decision-making, one would then contrast the forms of psychotherapy to be considered and the medication options. As you know from experience, this choice becomes particularly complex around 1 variable: bipolarity. Will you suggest an antidepressant or an MSAE? This thorny decision is strongly influenced by a second continuum: your patient’s previous treatments and responses.

Many patients who come to see you with depression and anxiety will have already seen their primary care provider and been given a prescription for an antidepressant, or several, and sometimes even an atypical antipsychotic. Or you may have tried these medications and now must follow the old dictum: “When your treatment’s not working, reconsider your diagnosis.” Your next recommendation depends on the number of previous treatments and response thereto.

Consider Ms Smith again. If she is “treatment naïve,” many symptoms or markers of bipolarity would be needed to justify using an MSAE instead of an antidepressant. One might even require that she meet DSM criteria for bipolar II. But if she has had 2 antidepressants without sustained benefit, an MSAE is more worthy of consideration. And if she has had 3 or more antidepressants, and perhaps a reliable course of CBT, and is still coming to you for help, then you might consider an MSAE as one of her best options even if she has very few bipolar markers. This continuum is shown schematically in 

 Major Depression, Mixed State, or Bipolar II? Pragmatic Decision-Making

(Lamotrigine is a first-line option for bipolar depression in 2 guidelines, from the Royal Australian and New Zealand College of Psychiatrists,

 and from the Canadian Network for Mood and Anxiety Treatments and the International Society for Bipolar Disorders (CANMAT-ISBD).

 Lithium is also first-line in these guidelines. The logic behind the positioning of these 2 medications is summarized on page 18 of the latter guidelines.)

A third continuum: If Ms Smith has been experiencing depression (perhaps in episodes) for years, she is more likely to accept that her treatment may also need to go on for a long time, for the prevention of recurrence. For many patients, this long-view perspective increases their preference for treatments with very low risk and very few side effects.

Conversely, a very acute or very severe episode may prompt a wish for a treatment with the strongest evidence for benefit, even if side effects or risks or costs are high. This continuum is shown schematically in 

 Treatment Options Vary Along a Continuum of Illness Acuity and Severity

inherently difficult for clinicians, because clinicians are not making binary treatment decisions. Rather, their treatment recommendations lie on at least 3 continua. Categorical diagnosis is not required to guide treatment.

In this series, I have used the example of a patient with depression, anxiety, and trauma to examine 1) the cognitive biases that sustain the DSM and 2) the dimensional nature of treatment decision-making. I chose a mood disorder case to illustrate these ideas because that is the field I know best. But I believe the logic presented here applies across almost all psychiatric illnesses. Most are better discerned using a dimensional perspective as well as categorical one, and treatment decisions are better understood as continua than as binary choices.

We need not abandon the DSM to move forward—we simply need to add a dimensional view of psychiatric illness alongside our categorical system. Use the one that most helps you help your patient.

is research editor at the Psychopharmacology Institute, emeritus faculty at Samaritan Mental Health in Corvallis, Oregon, and founder of 

. He is the bipolar disorder section editor for 

Mixed features in patients with a major depressive episode: the BRIDGE-II-MIX study

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

3. Barlow DH, Farchione TJ, Bullis JR, et al. 

The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial

4. Interpersonal and social rhythm therapy. 

Depression and Bipolar Workbook: 30 Ways to Lift Your Mood & Strengthen the Brain

The Bipolarity Index as a tool for assessment and creating rapport: an expert interview with Gary Sachs, MD

The 2020 Royal Australian and New Zealand College of psychiatrists clinical practice guidelines for mood disorders: Bipolar disorder summary. 

8. Yatham LN, Kennedy SH, Parikh SV, et al. 

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Articles

Treatment decisions lie on a continuum—befitting a dimensional approach to diagnosis.

Depression/Anxiety: Dimensional Treatment Decisions

(This is the first of a 2-part series. The next article will discuss the spectrum nature of treatment decisions and how this can improve the process of shared decision-making with patients—Ed.)

Bipolar disorder (BD) is a categorical diagnosis according to the DSM—

. But bipolarity is increasingly recognized to be a spectrum phenomenon that warrants dimensional diagnosis—eg, per the chairman of the DSM-5,

 the patient has bipolar disorder, the head of the STEP-BD research program suggested in 2005 that we should ask, “

 Why then are we still using the DSM as though it were the only way to think diagnostically? Here is 1 reason: categorization bias.

 presents an example of bipolarity as a spectrum phenomenon. It includes structured interview results from 641 primary care patients referred for psychiatric consultation,

 using the CIDI 3.0—a bipolar assessment tool

 from the World Health Organization that has been used in primary care research.

 Distribution of CIDI Scores Among 700 Primary Care Patients Referred for Psychiatric Consultation

The CIDI asks 2 questions about euphoria and irritability. If either is endorsed, another screening question asks whether this is episodic. If that too is endorsed, the full questionnaire

 is administered, containing additional questions about manic symptoms. The 

 shows the frequency of each score, from 0 to 9.

As you can see, among these patients—who were referred primarily for depression or anxiety problems—most scored 0 on the CIDI. But among the rest of the patients, scores created a bell-shaped curve. In this study, the same phenomenon was seen

 with additional questions about bipolar markers: family history, age of onset of depression, course of illness, and response to previous treatments. All these indicators of bipolarity lie on a spectrum from absent to fully present. There is no step-up—no obvious place to put a categorical diagnostic cut-off (including at 7 

 responses, which is the criterion used in previous research

Likewise, in clinical experience, hypomania/mania is also dimensional. Manic symptoms can present at any intensity. Some patients have the full experience, for which DSM criteria work well: That is bipolar I. Some patients have obvious hypomania that is observable to others: That is DSM-level bipolar II. But patients describe myriad variations of “up” symptoms.

If you have seen lots of patients with depression, you will have also observed the subtle forms of hypomania: a little more talkative than usual, a little more flamboyant, enthusiastic, confident. Needing less sleep, more motivated, energized. More willing to spend money. This state can accelerate into overt hypomania or mania, or just subside—or collapse into depression or become admixed with it. There are no cut-offs between such states in clinical experience—nor in patients’ experience. A brilliant example is presented in a newly published memoir, 

BrainStorm: From Broken to Blessed on the Bipolar Spectrum

 a bipolar II parallel to Kay Jamison, PhD’s, descriptions of the full manic-depressive experience.

If bipolarity is a dimensional phenomenon, why is the DSM still our primary diagnostic approach to mood disorders? Categorical and dimensional approaches can be used simultaneously,

 but multiple cognitive biases incline psychiatry toward the DSM (

Cognitive Biases that Inhibit Moving Beyond the DSM’s Categorical System

recently examined another that is relevant to psychiatric diagnosis: categorization bias.

 (This analysis is replete with examples of the serious costs associated with this bias in the financial world.)

According to 2 marketing professors, our natural tendency to draw lines and create categories has 4 downsides:

1. Compression: One can lose sight of the many variations that exist within the category.

2. Amplification: One can exaggerate differences across category boundaries.

3. Discrimination: One can favor certain categories over others, insufficiently attending to other categories.

4. Fossilization: To quote John Maynard Keynes, “The difficulty lies not in the new ideas, but in escaping from the old ones.”

To these we should add 1 more crucial downside of categorization bias: 

, or the tendency to make a thing out of a label. As Kenneth S. Kendler, MD, a scholar of psychiatric diagnosis, put it, “our field has undergone a ‘conceptual creep’ in which our criteria have mistakenly become our disorder.”

 In his article entitled “The Problem of Reification,” former National Institute of Mental Health (NIMH) Director Steven E. Hyman, MD, suggested that categorization creates “epistemic blinders” that impede progress toward valid diagnoses.

An article in the American Medical Association’s 

 asserts that, like all humans, health professionals are subject to cognitive biases, and we must recognize the costs of these cognitive biases and the potential benefits of combating them.

 The article cites a clinical decision-making specialist who has suggested using “cognitive forcing” to reduce errors.

 means conscious consideration of an alternative diagnosis—or, in this context, an alternative diagnostic perspective (eg, dimensional in addition to categorical).

For example, suppose your next patient, Ms Smith, presents with depression, anxiety, and a history of trauma. Posttraumatic stress disorder (PTSD) is an obvious potential diagnosis. Diagnostic forcing would entail consideration of alternative diagnoses, such as major depression with mixed features. Nosologic forcing would invite letting go of distinctions between trauma, mood, and anxiety disorders. 

Does this mean “farewell to differential diagnosis,” as one expert lamented

 following a description of the complexity of mixed states?

 Not entirely. One can think both categorically 

dimensionally (perhaps not at the same moment):

a) What is the diagnosis? Does the patient meet DSM criteria for PTSD?

b) How mixed is this depression? How traumatic was the experience?

Perhaps the latter questions will not help a busy clinician. Aren’t categories better for guiding clinical decisions? As a clinician myself, I strongly disagree, but we can all easily agree that we want what is best for Ms Smith. If it helps her to say yes or no to a diagnosis of PTSD, fine. For example, a formal diagnosis might make it easier to strongly recommend psychotherapy as first-line treatment for PTSD, rather than an antidepressant. On the other hand, if Ms Smith struggles with the label; if her trauma was not profound and she does not have pronounced avoidance and intrusive recall; and if she has a first-degree relative with a clearly established diagnosis of bipolar I—then perhaps then perhaps inviting her to learn more about subthreshold bipolarity and its treatment options is the next step. I created a series of 6 5-minute videos for this purpose.

In the next segment of this 2-part series on psychiatric diagnosis, I will suggest that treatment decisions lie on a continuum just as psychiatric diagnoses do. Contriving diagnostic cut-offs does not facilitate these decisions—indeed, it can interfere with them. Instead, acknowledging the spectrum nature of treatment decisions can improve the process of shared decision-making with patients. I suspect this is what many of us are really doing even while operating under the DSM roof.

is research editor at the Psychopharmacology Institute; emeritus faculty at Samaritan Mental Health in Corvallis, Oregon; and founder of 

Bipolar disorder diagnosis: challenges and future directions

2. Angst J, Merikangas KR, Cui L, et al. 

Bipolar spectrum in major depressive disorders

Bipolar spectrum disorder masquerading as treatment resistant unipolar depression

5. Phelps J, Bale J, Squires III K, et al. 

Bipolarity in a collaborative care model variation: detection, prevalence, and outcomes

6. Kessler RC, Akiskal HS, Angst J, et al. 

Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0

7. Cerimele JM, Chan YF, Chwastiak LA, et al. 

Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder

ased Screening Scale for Bipolar Spectrum Disorders

. University of Washington Advancing Integrated Mental Health Solutions Center.

Brainstorm: From Broken to Blessed on the Bipolar Spectrum

12. The psychiatrist’s list of cognitive biases. Psych Scene. Accessed January 26, 2022. 

https://psychscene.com/psychiatrists-list-cognitive-biases/

13. de Langhe B, Fernbach P. The dangers of categorical thinking. 

https://hbr.org/2019/09/the-dangers-of-categorical-thinking

The phenomenology of major depression and the representativeness and nature of DSM criteria

The diagnosis of mental disorders: the problem of reification

The importance of cognitive errors in diagnosis and strategies to minimize them

Mixed depression: a farewell to differential diagnosis?

19. Perugi G, Angst J, Azorin JM, et al. 

https://www.youtube.com/playlist?list=PL1lTWq-FqdPIBYwhJb8j5NCMMTg0lxTVI

Exploring cognitive biases toward the DSM and their avoidable effects on treatment decisions.

Even before the COVID-19 pandemic hit, many patients were already waiting months to see a psychiatrist. In this edition of 

, we speak to James Phelps, MD, about the roots of the crisis and what psychiatrists can do to meet the nation’s mental health needs, especially through 

Phelps also looks back on a long career of treating bipolar and other mood disorders. He discusses some of the most exciting recent research on inflammation, circadian rhythm disturbance, and mood bias. He also reviews recent developments in digital therapeutics, which may offer powerful 

is research editor at the Psychopharmacology Institute, medical director at 

, and adjunct faculty at Samaritan Mental Health in Corvallis, Oregon. He is the bipolar disorder section editor for 

Podcasts

Despite recent advances in research on bipolar disorder, it remains a complex and even mysterious condition. 

How Can One Mental Illness Generate the Opposite Mood Experiences?

Do you sometimes have trouble continuing your daily work under the shadow of looming climate change? Wonder about chucking your practice and working exclusively on ending our reliance on fossil fuels? Is someone who devotes his life to arresting climate change a fanatic-or maybe even manic? Let’s take a brief tour through climate science to the story of such a man who acquired such a diagnosis.

 asserts that science is not simply the result of following “the scientific method” of rigorous hypothesis testing. Rather, she believes that science is a process of arriving at a consensus, a current working understanding.

 This is why a physicist may accept the idea that a vaccine increases one’s safety even without being able to deeply evaluate the epidemiologic data, or a geologist accepts speciation by natural selection without examining all the relevant data: they rely on the consensus of scientists who specialize in epidemiology or evolution. Says Orestes, we can think of scientific knowledge as the result of “a jury of geeks.”

Science’s current working understanding of climate indicates that the earth is warming rapidly, sufficient to cause social disasters beyond anything humans have ever seen, during most of our patients’ current lifetimes. If you have any difficulty with this assertion, please do listen to Orestes’ TED talk on science first, then the 

 predicting climate-driven migration of 140 million people by 2050.

Watching humans destroy the very basis of their existence (a stable climate), one man thought “this is insane.” He could not understand how we could persist in our current behaviors. He thought a global awakening to our collective insanity was emergently needed. So he dedicated his life to helping people recognize and respond to the problem of climate change. The result: he was diagnosed as bipolar and given lithium.

Was this man fanatic, or manic? What is the difference? The literature on this question is surprisingly small: there are no references on Pub Med for a search of fanatic manic, or fanatic bipolar, for example. A more substantial work has examined the boundary of religious and delusional beliefs (some of it 

). A lengthy user post and replies on the International Bipolar Foundation (IBPF) website includes many 

 of manic phases and intensified religious thinking.6 Indeed the term “fanatic” has a strong connection etymologically to religion (from fanum, a holy place, sanctuary or temple; and the verb fano, to devote).

But not all fanaticism is religious. Perhaps fanaticism itself is a disease, like alcoholism: a Psychology Today 

 suggests there should be a Fanatics Anonymous.

 Or perhaps fanaticism is like a brain infection, a la the 

 that can infect an ant’s brain and make it climb up a blade of grass where it is more likely to be eaten by the cow that is the parasite’s next life-cycle port of call.

 Perhaps fanaticism is a neurologic problem: combat injury to the frontal cortex is associated with fundamentalist beliefs, according to 

Whatever the etiology, some fanaticism comes very close to the behaviors of bipolar mania: energized devotion to an idea. Sex and money are frequent foci, but also political ideas: see, for example, the complex patterns of bipolar-like behaviors in world leaders, examined by Nassir Ghaemi in his book 

 In this territory of highly uncertain boundaries between passion and determination and mental illness lies the story of the man who had a diagnosis of bipolar mania based on his insistence that humankind itself is insane for continuing to mine and burn fossil fuels. It’s an interesting twist, no?

You must see the documentary of this man, 

. It is a fascinating tour through fanaticism and its consequences, including bipolar diagnosis (in this case, likely over-diagnosis). It’s a polished production, easy to watch, with a message of the utmost importance: that we ourselves are indeed acting insanely and must quickly recognize our own collective “mental illness” with radical behavior change.

Dr Phelps is the Bipolar Disorder Section Editor for 

 to share your views. We might include your letter at the end of this article, possibly with a response from the author. Please include your full name, title, and affiliation for consideration.

This article was originally published on 10/15/18 and has since been updated.

Dr Phelps stopped accepting honoraria from pharmaceutical companies in 2008 but receives honoraria from McGraw-Hill and W.W. Norton & Co. for his books, including 

, which he coauthored with Chris Aiken, MD.

 Department of the History of Science, Harvard University. 

https://histsci.fas.harvard.edu/people/naomi-oreskes

https://www.ted.com/talks/naomi_oreskes_why_we_should_believe_in_science

 World Bank. Climate Change Could Force Over 140 Million to Migrate Within Countries by 2050. 

https://www.worldbank.org/en/news/press-release/2018/03/19/climate-change-could-force-over-140-million-to-migrate-within-countries-by-2050-world-bank-report

https://www.thereluctantradicalmovie.com/

 Iyassu R, Jolley S, Bebbington P, et al. Psychological characteristics of religious delusions. 

 Jost B. Mania and “Hyper-Religiousity.” International Bipolar Foundation. 

http://ibpf.org/blog/mania-and-%E2%80%9Chyper-religiosity%E2%80%9D

 Sherman JE. Fanaticism Is a Disease Like Alcoholism. 

https://www.psychologytoday.com/us/blog/ambigamy/201411/fanaticism-is-disease-alcoholism

https://www.damninteresting.com/a-fluke-of-nature/

 Zhong W, Cristofori I, Bulbulia J, et al. Biological and cognitive underpinnings of religious fundamentalism. 

A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness

Whatever the etiology, some extreme views come very close to the behaviors of bipolar mania, as illustrated in a recent documentary.

Bipolar Disorder or Fanaticism?

 bipolar disorder is hard work. In the hopes of maintaining your enthusiasm and determination, let us look at two major trends in our evolving understanding of this complex mood disorder and its treatment, to wrap up 2018 and to consider the year ahead.

Imagine having or treating Type 1 diabetes before pancreatic insulin deficiency was understood, and the excitement that would accompany the discovery of that mechanism. While we are not on the verge of such a discovery in bipolar disorder, at least six seemingly independent mechanisms have been identified (

 reviews are linked below). Imagine what will happen when the way they interact is better understood.

Consider some treatment corollaries for each of these pathways:

Cognitive Behavioral Therapy for Insomnia: Bipolar-Specific (

 lowered rehospitalization rates. Patients with 

Anticipate worsening with prednisone; avoid testosterone; monitor when estrogen and progesterone are introduced, and watch closely for post-partum depression. Thyroid hormone has a 

Incorporate in bipolar-specific CBT: “Clients are educated in identifying increased self-esteem and “positively biased” cognitions as indicators of possible 

Mindfulness-Based Cognitive Therapy for bipolar disorder; initial data positive

End poverty and childhood maltreatment? (a larger project)

Multiple bipolar treatments are neuroprotective: lithium stands out; it may even decrease 

there is no single “cause” of bipolar disorder, just as there is no single gene. Tackling this illness is more complicated than managing diabetes, where the pathways of the disease are known and the corresponding treatments well defined. Ironically, diabetic education is paid for by insurance, but not “bipolar education.” Which brings us to an evolution in bipolar management…

There are now at least 6 bipolar-specific psychotherapies with randomized trial evidence for benefit greater than treatment as usual (or in some cases versus active control treatments). They share common ingredients, as shown in the 

Personal self-monitoring is a central element in most of these therapies, but patients do not easily maintain logs of their activity, sleep, and mood. The process is cumbersome at minimum, even using modern smartphone apps. Worse, it is a daily reminder of their illness. Patients avoid this aversive reminder, understandably wishing to not have bipolar disorder.

However, at least two major research teams have developed 

 monitoring systems. Using a patient’s phone, these programs gather data on number of calls and texts; typing speed and errors; and the time of use. The phone’s accelerometer yields additional data on sleep versus activity.

The BiAffect program is under study at the University of Michigan, where the team reports good correlation between the program’s data and Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS) scores.

The MONARCA program also has shown good correlation with HAM-D and YMRS scores.

 Interestingly, it did not improve outcomes when tested against treatment as usual: depression and mania scores did not differ between the two groups.

However, in my view the major value of these programs will not be manifest if the goal is to provide 

 with data to better manage their patients, as in the MONARCA study. Rather, their value will be in enabling 

 to better manage their own mood stability. The phone app is simply a tool to engage patients in a much larger endeavor: implementing key elements of the six bipolar-specific psychotherapies.

I hope that 2019 brings such a transition in the use of these devices. When they are available to the public (the free BiAffect app appears to be 

 for iPhones), pioneering clinicians and patients will figure out how to integrate them into a complete treatment package, paralleling some of the known mechanisms of bipolar disorder. For example:

creating and maintaing a pattern of regular sufficient sleep

avoiding mood-bias driven decisions, by having data on acceleration or deceleration of thought and activity

receiving automatic reminders to use a mindfulness-based relaxation technique

Solving poverty and child abuse may take a bit longer. Onward to 2019!

Dr. Phelps stopped accepting honoraria from pharmaceutical companies in 2008 but receives honoraria from McGraw-Hill and W.W. Norton & Co. for his books on bipolar disorders, including 

, a book he coauthored with Chris Aiken, MD.

1. Nusslock R, Abramson LY, Harmon-Jones E, et al. Psychosocial Interventions for Bipolar Disorder: Perspective from the Behavioral Approach System (BAS) Dysregulation Theory. Clin Psychol. 2009;16:449–469. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2790718/

2. Lovas DA, Schuman-Olivier Z. Mindfulness-based cognitive therapy for bipolar disorder: A systematic review. 

Let us look at two major trends in our evolving understanding of this complex mood disorder and its treatment, to wrap up 2018 and to consider the year ahead.