A Spectrum Approach to Mood Disorders

October 3, 2016

Bravely enter territory that academia has largely neglected-the nebulous region between full bipolar disorder and major depression.

[[{"type":"media","view_mode":"media_crop","fid":"51508","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4009321913005","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6668","media_crop_rotate":"0","media_crop_scale_h":"303","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]A Spectrum Approach to Mood Disorders: Not Fully Bipolar But Not Unipolar-Practical Management

by James Phelps, MD; New York:
WW Norton and Company; 2016
255 pages • $32.00 (hardcover)

In A Spectrum Approach to Mood Disorders, Dr. James Phelps bravely enters territory that academia has largely neglected-the nebulous region between full bipolar disorder and major depression. This is where so many of our patients live. The book is a must-read for any health professional involved in the treatment of affective illnesses, including psychiatrists, psychiatric nurse practitioners, psychologists, and therapists.

His previous book, Why Am I Still Depressed?, is a great source of information about bipolar II for professionals who wish to learn more and for patients who have bipolar II and soft bipolar.1 In A Spectrum Approach, he once again leads us to a greater understanding of the complexity of the bipolar disorders. The author’s website, Psycheducation.org, averages around 40,000 unique visitors each month. It is safe to assume that at one time or another, the majority of our patients with bipolar disorder have read Dr. Phelps’s work. He is perhaps one of the most widely read experts on bipolar disorder of our time.

The book is framed by a quote by Vieta and Suppes2 regarding bipolar disorders: “Dichotomies are useful for education, communication, and simplification. Unfortunately, simplicity is useful, but untrue; whereas complexity is true but useless.” Dr. Phelps renders the complexity of bipolar spectrum useful while making it simple enough to be true and understandable.

The author delves into the little-understood region between what is not fully bipolar and what is more than simple major depression. He gives us tools to understand and diagnose “mid-spectrum bipolar disorder.” He re-brands and puts under one “roof” what we have previously called soft bipolar-Akiskal’s bipolar II; IIa; bipolar III; bipolar IIIa; bipolar IV; or Fred Goodwin’s “highly recurrent depression.” By placing these disparate diagnostic schemata under one “roof” of bipolar spectrum illness, he simplifies the concept, rendering it far easier to understand and more useful. By doing so, Dr. Phelps also gives us new insights into bipolar spectrum.

To think of bipolar as a spectrum disorder is a satisfying fit into what we see in everyday practice and within Kraepelin’s original definition of manic depression.3 It allows both our patients and professionals involved in the treatment of these disorders a relatively easy way to understand the wide variety of symptoms that are disparate in nature yet are features of bipolar illnesses.

Perhaps one of the reasons so many clinicians are reluctant to diagnose bipolar II or mid-spectrum bipolar is the demoralizing effect of making a such a diagnosis.

The book provides useful tools to help diagnose and treat mid-spectrum bipolar disorders, with thoughtful discussions of how patients present in clinical settings. The author deftly explores the overlapping symptoms of mixed bipolar symptoms, anxiety disorders, borderline personality disorders, ADHD, and major depression.

In my opinion, there are some topics that Dr. Phelps is too polite about. His handling of the “bipolar-disorder-is-over-diagnosed crowd” is apt but somewhat weak. Unfortunately, many therapists, psychologists, and members of the public have latched onto a small body of poorly executed research that used the Structured Clinical Interview for DSM-IV (SCID) interview; purportedly, this research demonstrated that bipolar disorders are being overdiagnosed. As Dr. Jules Angst so appropriately stated at the 2011 International Bipolar Conference: “The SCID is not powered to differentiate between bipolar II depression and major depression.” [paraphrased] Indeed, using only the Structured Clinical Interview to try to diagnose mid-spectrum bipolar disorders or even bipolar II has previously been discredited in multiple studies.

There were also some missed opportunities in the book. Kraepelin’s original definition of manic depression lends much support to what A Spectrum Approach presents. Here is Kraepelin’s original definition:

Manic-depressive insanity . . . includes on the one hand the whole domain of so-called periodic and circular insanity, and the other hand simple mania, the greater part of the morbid state termed melancholy and also a not incomprehensible number of cases of amentia (confusion or delirious insanity) [definition added by this reviewer]. Lastly, we include here certain slight and slightest colorings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders, on the other hand pass over without sharp boundary into the domain of personal predisposition.3

Perhaps one of the reasons so many clinicians are reluctant to diagnose bipolar II or mid-spectrum bipolar is the demoralizing effect of making such a diagnosis-not having an effective treatment. Here, I believe Dr. Phelps makes the single most important point of the book. Treating mid-spectrum bipolar is not the same as treating bipolar I; the former often requires smaller doses of medication (eg, lithium at 450 mg).

Luckily, the book offers much more than pharmacological treatment options. There are descriptions on a wide range of treatments beyond medications, including various psychotherapies; the role of exercise and diet; social rhythms; light therapy; and dark/amber lens therapies (don’t laugh-it works).

A Spectrum Approach is not without criticism. It would have been helpful if the author had discussed the critical work of Dr. Hagop Akiskal in our understanding of mid-spectrum disorders. Also missing is an overview of the effectiveness of n-acetylcysteine and high-dose thyroid treatment, both of which are included in the Canadian treatment guidelines for bipolar II disorder.4

In the case of high-dose thyroid treatment, Dr. Phelps does not fully detail the research showing its safety or compare the significant risks of alternative psychiatric medications routinely used to treat bipolar disorders.5-7 In the near vacuum of research of treatments for mid-spectrum bipolar, he does sometimes substitute recommendations based on bipolar I research that do not always translate to mid-spectrum bipolar disorder. For example, lurasidone works quite well for bipolar I depressions, yet I do not get anywhere near as robust an effect for patients with bipolar II or mid-spectrum bipolar disorder.

Despite these weaknesses, the book will help clinicians gain a better understanding of the bipolar disorders and offers helpful ideas on how to treat mid-spectrum bipolar disorder.

This article was originally posted on 9/6/2016 and has since been updated.

Disclosures:

Dr. Kelly is Associate Clinical Professor in the Department of Psychiatry and Behavioral Sciences at George Washington University, Washington, DC, and Director of the Depression and Bipolar Clinic in Fort Collins, Colorado.

References:

1. Phelps J. Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder. New York: McGraw Hill; 2006.
2. Vieta E, Suppes T. Bipolar II disorder: arguments for and against a distinct diagnostic entity. Bipolar Disord. 2008;10:163-178.
3. Kraepelin E. Manic Depressive Insanity and Paranoia. Edinburgh, Scotland: E. & S. Livingstone; 1921.
4. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord. 2013;15:1-44.
5. Kelly T, Denmark L, Lieberman DZ. Elevated levels of circulating thyroid hormone do not cause the medical sequelae of hyperthyroidism. Prog Neuropsychopharmacol Biol Psychiatry. 2016;71:1-6.
6. Kelly T, A favorable risk-benefit analysis of High dose thyroid for treatment of bipolar Disorders with regard to osteoporosis. J Affect Disord. 2014;166:353-358.
7. Kelly T. An examination of myth: A favorable cardiovascular risk-benefit analysis of high-dose thyroid for affective disorders. J Affect Disord. 2015;177:49-58.