Only in case of improper diagnosis!!! No, seriously. There are just few cases, mainly in course of pregnancy (first three months) or severe organic syndromes, poor compliance towards medication. Most SGAs (especially quetiapine) are "de facto" mood stabilizes too, so I would consider them in the "mood-stabilizes" you were ruling out. CBT and other strategies could help, but mood stabilizers are the cornerstone of BD treatment, especially from a long-term outcome perspective, so keep in mind that typical/atypical antipsychotics or antidepressants should not be intended as monotherapy, especially beyond the acute phase.

Regards, MF.

By the way, ECT or CBT alone are not the first line choice for BD, except for refractory/catatonic or mild/special population cases respectively. Ethics should simply counterbalance between efficacy and safety. As BD often presents with mixed or "midways" features, treatment as well should not follow a rigid "black or white" approach: compliance and information are core issues in the process.

It is difficult to say that antidepressants should never be used in bipolar disorder, because some guidelines recommend it in first line in association with a mood stabilizer, and some in third line. It is also difficult for the prescriber to refuse to the patient, or to refrain himself, to prescribe an antidepressant, when a patient is severely or chronically depressed. Nevertheless, in general, antidepressants are ineffective or harmful in bipolar disorder.

CBT or IPT, or may be more specifically Interpersonal and social rhythm therapy, may be interesting as add-on therapy.

Nevertheless, it is ECT that is very efficient in the treatment of resistant bipolar disorder (mania as well as depression), not only in the treatment of acute episodes but also as a maintenance therapy. This procedure is unfortunately underused and should be promoted

Darryl Bassett

My broad response is that mood stabilizers (broadly defined to include lithium, certain anticonvulsants and atypical antipsychotic medications) are essential to stability for bipolar disorders. However there are individuals who appear to have very few relapses and for them CBT alone may appear sufficient. The current research suggests that relapse is almost universal, but there are rare exceptions. My long experience of antidepressants is that when combined with mood stabilizers they can be very useful in some patients and are not usually damaging. Used alone antidepressants carry a significant risk, particularly in bipolar I. Management during pregnancy is challenging but quetiapine is my usual choice for the first trimester in many instances. ECT is particularly useful in pregnancy is major relapse occurs. First generation antipsychotics can be very helpful as mood stabilizers and interpersonal and social rhythms therapy is highly effective as a component of mood stabilization. I still think the combination of a mood stabilizer with IPSRT, and appropriate CBT, is the base of good management for bipolar disorders.

Under no circumstances should dispense with the use of mood stabilizers in patients with bipolar disorder. But it is important to be clear what we mean by "mood stabilizers", because there are combinations of antidepressants plus antipsychotics promoted as mood stabilizers and are far from it. A good option is lithium carbonate without doubt the best choice and the best known, unfortunately lithium is underutilized in clinical practice. The use of ECT is not a first-line option. Regarding psychotherapy, reports are controversial and generally there are few studies. The form of therapy whose effectiveness is indputable and has been widely documented is psychoeducation. The use of antidepressants as monotherapy in bipolar increases the risk of manic switch, favors the appearance of mixed episodes and negatively modifies the clinical course of the disease. Antipsychotics have an impact on neurocognitive functions (attention, executive functions, etc ...) that has not been adequately studied and, although avoiding manias, this happens at the expense of a greater number of depressions.

It is very interesting that most of the suggestions are based on the idea that bipolar disorder is a brain disease and has nothing to do with psychological factors.

From my perspective we should offer psychotherapy in any case. The depth and intensity will be different. Anyway we need time to establish therapeutic relationship. In severe cases medication is needed but as an additional part. The main principal here is moderation.

The objective is not a mood but the client, a person. The mood change is the symptom and a reaction to some life difficulties. Within psychotherapy process we try to find what is behind the symptoms.

I do psychotherapy with affective disorders and see the results. Psychotherapy along or with use of medication depends on disorder severity and client's resources.

Just medication puts client in a very passive position and does not encourage him to actively deal with everyday life. It is not very humane and not ethical. Psychotherapy is essential to bring person to a normal life.

Psychotherapy as a therapeutic tool is still a viable option in the clinical setting.

However, -and I make this approach without any encouragement from me to argue-, when we refer to bipolar spectrum disorders, we are referring to a group of genetic diseases (evidence of this is overwhelming) that are expressed by through brain alterations that modify the emotional control. That is, the basic problem is the brain disorder, emotional expression is the result of such alteration. The real problem of bipolar illness are NOT the emotional crises, but affective instability that prevails throughout the patient's life, and to be successful in the treatment, this instability should be corrected.

Regardless of the impact of psychotherapy in the life of the person, the bipolar needs to understand your condition, limitations, risks of using alcohol or drugs and the importance of adherence to treatment (not necessarily in that order). And, in this vein, the best form of psychotherapy that has documented its positive impact on the course of bipolar illness is psychoeducation (programs such as Colom and Vieta, in Barcelona, have proven useful in this regard in various studies throughout the world). It would be a mistake to assume that the other forms of therapy do not work, but it is also a mistake to blindly accept their effectiveness. Studies done with CBT give conflicting results, as with other forms of psychotherapy, have been little studied and in many cases the results are conflicting.

Perhaps I should add to my original, rather spontaneous comments, that I agree strongly that psychoeduction is fundamental to managing bipolar disorders and that these disorders have a clear biological substrate (regrettably still only poorly understood). I suppose I see the education of patients about their illness and treatment to be a fundamental component of comprehensive management, and this becomes inseparable from competant biological and psychological care.

I strongly agree with Darryl and Alvaro. The great question is about targets. Is our aim to have a person with an almost normal life, that has to deal with prevention and understanding of the disease, or is our goal to deal with emotional inestability that is almost fully tratable? REAL Bipolar Disease (and I emphasize that term because of the misuse of it that's been so extended last decades) is something that escapes the patient's ability to manage, so psychotherapy alone would have to focus in acceptance better than in health. There's no doubt psychological factors are so important, but they're not the basics of the problem. If we understimate them, we will have a patient not adherent and with a higher risk of relapse. But, if we overstimate them, maybe we will have no patient at all.

When mood stabilizers alone are not able to help the individual recover from episodes of Mania and depression, after administering them at adequate dose for adequate duration

I guess the question posed by Jagadeesan is what to do when the mood stabilizers are not enough to stabilize the patient during a crisis. Actually there are several options that may be helpful:

1. Combine two or more stabilizers. I prefer to combine stabilizers plus a benzodiazepine for mania and avoid the use of antipsychotics. If we are objective we realize that, in practice, the use of antipsychotics is decided according to its sedative effect. This effect can be achieved easily with a benzodiazepine. Something that we often overlook is that lithium is effective for psychotic symptoms (in fact the first studies were published using lithium in major psychotic patients). Another excellent choice is valproate administered intravenously.

2. If the crisis is depressive, the use of quetiapine (extended release to avoid concentration peaks that cause instability in the patient) associated with a mood stabilizer (lithium or valproate), can be helpful.

3. During mixed episodes I've found very useful combining valproate plus carbamazepine.

Eventually there will be some patients where it is necessary to consider other options (electroconvulsive therapy, etc..), But at the end we realize that, with very few exceptions, despite the efforts of the pharmaceutical industry to convince us otherwise, antipsychotics and antidepressants are not essential in the management of any phase of bipolar disorder. With regard to quetiapine there are a number of considerations that can be done to understand and properly classify this unique molecule.

I believe the key to don't overdiagnose Bipolar Disorder is the phasic component of the disease. The "rapid cycling" aspect is a late complication, not usually a debut feature. So it's a very useful trait to diferentiate Bipolar Disease and Personality Disorders.

I should also like to suggest a grossly understimated disease: Temporal Lobe Epilepsy. With its frequent changes of mood, it can be easily misdiagnosed if you don't look for other symptoms, and, contrary to usual beliefs, sensibility of EEG recordings is very poor.

The problem of the diagnosis of bipolar disorder is another topic on which we can generate a broad discussion. The fact is that despite all the progress we still misdiagnosing this disease. There are many patients diagnosed with bipolar disorder, who are not, and many schizophrenics and unipolar depressions, which are bipolar. In my humble opinion, the problem lies in the diagnostic tool we use today (e.g., DSM) that is not prepared according to the patient's best interests, but according to the interests of the insurance companies and the pharmaceutical industry.

Several reasons hinder the diagnostic process, but I will limit myself to two:

(1) We are faced with a genetic disease where, in the process of diagnosis, family history are not considered in the relevance they deserve.

(2) It is unacceptable that a disease with predominance of depression, such as bipolar disorder, diagnosis is based on episodes of mania or hypomania (60% of the bipolar patient's life passes with depressive symptoms; depressive symptoms predominate on hypo/manic in a 3:1 ratio. - see the works of Judd et al, Benazzi and others; in the majority of patients the first episode is depressive type and may take several years until the appearance of symptoms of mania/hypomania).

The problem of diagnosis is most often located in the extreme forms of the spectrum, severe forms (particularly in bipolar disorder type I) are confused with schizophrenia, and mild forms, which overlap with normality are diagnosed as personality disorders.

The vast majority of psychiatrists diagnosed crisis, but we overlook the fact that the problem of bipolar disorder aren't mood episodes, but the instability that prevails throughout life.

One of the most serious problems faced is the differential diagnosis to distinguish bipolar disorder from schizophrenia, depression and organic disorders (as rightly pointed out Bennett and Bahamondes) this is a daily exercise that we are not adequately resolved, as psychiatrists we have been adding categorical conceptions symptoms of the disease and forget psychopathology of the disease (Kraepelin was clear this concept) ignore the dimensional aspect of the disease (the existence of overlap between the disorders that paint pictures of all colors) where we find both in pictures atypical symptomatology and response to treatment.

Well, I wonder if my dear colleagues agree that we may not use mood stabilizers in cases of bipolar depression. FDA approved medications here are either quetiapine as monotherapy, or the combined olanzapine + fluoxetine.

If that failed to improve the case, then we may augment with mood stabilizers. As for ECT, it is one of the best therapeutic tools that can be of great help in cases of severe resistant episodes of mania or depression.

I believe that it is precisely the mood stabilizers first line drugs for the different clinical manifestations of bipolar disorder, both manic, hypomanic, mixed or depressive. Of course, in some cases it will be necessary to combine other molecules. The use of antipsychotics as first choice, either as monotherapy or in combination with antidepressants, leads us to generate a large number of patients with negative symptoms secondary to the use of antipsychotics (typical or atypical), metabolic problems and other "beauties". It is precisely the historical abuse in prescribing antipsychotics which has generated a huge amount of totally dependent patients and chronically hospitalized, while they may be functional and productive. Regardless of the postulates of the FDA and although this is a booming business for the pharmaceutical industry; for the patient and family is an unattractive business, especially for our patients in the third and fourth worlds.

I feel I must comment again having read many comments and particularly those by Alvaro. Firstly I agree strongly that lithium is the gold standard for mood stabilizers (if not the only true mood stabilizer) and several anticonvulsants (valproate and carbamazepine) are extremely valuable. I would add lamotrigine to that list.

However I do not accept that atypical antipsychotics are part of the "evil empire" (the pharmaceutical industry) and need to be relegated to rare application. I find them highly valuable, particularly in bipolar depression and mixed states. They have side effects like all forms of treatment and they need intelligent use and monitoring. However they have also driven far better management of varieties of bipolar depression and treatment resistant mania, than we had previously. ECT remains invaluable and in my practice, biased toward treatment resistant patients, it has a special place (including as maintenance treatment). I agree that psychoeducation is of great importance but once it moves into an understanding of the psychosocial processes which drive relapse, it has become exploatory psychotherapy and no longer purely education. I still see a role for antidepressants but they carry risks and are often not effective. They add an extra arm to the therapeutic armamentarium but are not central to routine management.

Let us think broadly, as bipolar disorders are often not easily managed and we still are far short of trully satisfactory treatment.

Of course, Darryl, and I fully agree with you, maybe I missed clarify a point, not that I'm against antipsychotics, which I do not share is that recourse to them too easily and to be put as a first-line option, when there are other options (like the ones you mention) with proven effectiveness and a better side effect profile, and a more reasonable cost to the patient. In bipolar depression, quetiapine, is the best available tool associated with a mood stabilizer.

I was diagnosed as bi-polar and given anti-psychotic medication despite not suffering from depression and both times I went manic it was after excessive and unsafe amalgam dental work. This was ignored by doctors and I was stuck on medication for 4 years with anxiety and a feeling of aggression as side effects. I have successfully come off medication with high nutrients, safe amalgam removal and heavy metal detoxing. The 'side effects' have gone and I feel great relief from leaving the horrible world of medication, stigma and dangerous long term outcomes. I wonder how many other people have also been treated like this?

To call mercury poisoning genetic or a disease is a best questionable and at worst just crazy.... here is a list I have compiled of causes for mental health distress:

Known indirect risks:

Childhood trauma, grief and loss, accident, abuse; both physical and sexual, hormonal turmoil of adolescence, relationship distress, overwhelm, depression, loss of meaning, substance abuse, addictions, gambling, dramatic change, seasonal (low Vit D), childbirth, financial worries, over work or shift work, jet lag, loss of child/job/home/parents/family/friend, illness, cancer, chronic pain, tooth infection, natural disaster, war, hormone imbalance, menopause, loneliness, self-neglect and dementia. Dramatic life changes, infatuation, sudden large financial gain, spiritual crisis, sudden fame, near death experiences and even too much sunshine.

Known direct causes:

Rabies, Toxoplasmosis (very common and caught from cat excrement, a leading cause of sz), Lymes disease, Pyroluria, Porphyria, parasites, heavy metal exposure (mercury, lead and others). Head injury, fetal alcohol syndrome, autisms, epilepsy and vaccine damage, high fever, dehydration, sleep deprivation, nutritional deficiency (B3, B12, Folic acid and Vit C all lead to psychosis in extreme deficiency), mineral deficiency (zinc, magnesium and manganese especially), abreaction to recreational and prescription drugs and stimulants. Side/direct effects from mental health drugs, other medical drugs. Incorrect use of nicotine patches, post-operative psychosis and post traumatic shock. Blood sugar imbalance, over or underactive thyroid, faulty methylation, essential fats deficiencies, histamine excess, serotonin deficiency, adrenal imbalance, acetylcholine imbalance, toxic poisoning overload and gut inflammation, bladder infection, metallothionein deficiency, direct food allergies, extreme physical and emotion exhaustion and extreme hypothermia.

Please treat cause and not symptoms and it will take some weeks to see positive effects of say high nutrition, parasite elimination and a heavy metal detox so leave the drugging to those who can not be helped from these basic interventions. Stop working for drug companies and honor the oath to first do no harm. Thank you to those who are already speaking up and questioning the current model.

I find the evidence that bipolar disorder is a group of genetic diseases far less overwhelming, but usually rather ambiguous. It is also inconsistent with the several real people with the diagnoses who I know to have recovered after discontinuing medications and addressing the many factors listed by Heather Howes above. The notion that mental health problems originate in a diseased brain that requires medical intervention is a political one, not a purely empirical one. The brain being an information processor, inside a person, who is inside an environment, sensing their world and then responding to it. The brain is not an isolated entity. Nor are our genetics. We are all feedback loops. This political idea that our mental health lies in our brains fuels stigma and promotes the idea that mental health problems are life-long conditions from which recovery is not a realistic expectation. When is it appropriate to consider not using mood stabilisers? When the individual in question wants to use something else. It would be ideal if everything else were tried first, in my opinion, but we seem to do things backwards, medication first, then maybe some therapy, maybe a bit of community support. That is not a truly recovery oriented model, nor is it one in which the individual has autonomy and choice.

Thank you Miriam. Great reply. I agree with you. Human being are little bit more complicated than sum of chemical processes.

In my practice, lithium is the first line of choice for the treatment. Valproic acid and other anticonvulsants, plus atypical antipsychotics, the second line, in the cases of intolerance of lithium, or liver toxicity. In all cases, the cognitive-behavioral therapy is considered, in psychoeducational format, or in a psychotherapeutic approach. I dont't have controlled data, but the satisfaction of patients about this care is good. An adaptation of program of Basco & Rush is my favourite approach to the therapeutic work with this patients.

Is a great truth, the great problem of differential diagnosis with psychosis or personality disorder that appoint my colleagues. The only clinical resource is a good clinical history with the eyes in the course and temporal variations in psychopatholoy. The clinical picture is the key here, with all yours weakness. Historically, this variables have been the key for to isolate the manic-depressioan as a nosological entity (e.g., Baillarger, Falret, Kraepelin). The genetical and neurobiological data be far of clarity (I have many patients without familiar history of bipolar disorder).

Is very important for the psychotherapy a good rapport, a very strong relationship between therapist and his patient. Likewise, for the prescription of drugs, is very important this good therapeutic relationship. I think that the "good therapeutic relationship" signify a great mount of acceptance of suffering, and a genuine approach to a collaborative quest for the sense of the experiences of patient in his life. Many of my patients diagnosed of bipolar disorder consider very important what is the sense of his experiences. A thing very difficult for the standard clinician, is inquire for the personal values of patient, and take into account his preferences. E.g., I follow about fifteen years one patient with bipolar disorder; in this case, his psychiatrist, the patient and I, we consider very seriously, discontinue lithium and all medication, and to center the therapeutic work in cognitive-behavioral psychotherapy with the patient and his wife (psychoeducation, a system of first relapse signs, couple therapy, and individual cognitive-behavioral therapy). The results was very good: in fifteen years, two brief relapses with hipomanic and psychotic symptoms, aborted with low doses (3 mg) of Risperidone per day in a week.

This clinical example, is a exception. We should much more hard research work in variables that allow to detect this cases, and that consider another therapeutic strategies ("holidays" of drugs, protocols of very sign relapse detection), choose with the patient. Is difficult nowaday, with scarce money for psychosocial research, and the great influence of big pharma in the clinical science. But is not hopeless. The associative movement is a powerful force for to consider in the future. A example that always I cite as an example, is INTERVOICE (http://www.intervoiceonlione.org).

Goodnight to all. With best wishes.

Congratulations to all for contributing to a very interesting discussion.

I cannot coment on the controversy about the proper pharmacological approach to these disorders as it's not my specialty, but some of my coments do address the relation of biomedical approach to other therapeutic offers such as psychotherapy, psychoeducation or community based approach.

First of all I agree with the concerns about the accuracy of diagnose. I've treated several patients that had been misdiagnoses with bipolar disorder. My experience tells me there is a trend in the last 15-20 years to overuse some diagnostic categories (ad, adhd, asd, bpd and bipolar disorder). Misdiagnose can account for psychotherapy success (I have helped people that came with the diagnose but did not really have bipolar disorder) but I can also attest success helping some people with "true" bipolar disorders.

I also agree with criticism about relying in genetic explanations to justify an exclusive or preferent biomedical approach to several mental health disorders: evidence shows that psychotherapy and other kind of psychosocial interventions have an impact at a neurophysiological level (obviously depending on the success of the intervention). In other words, the strict separation between a genetic/neurophysiological level and a psychological level and the supposition of a unidirectional hierarchy between these domains (genetics over neurophysiology over psyche) responds to disciplinary bias more than to any demostrable intrinsic quality of human nature.

Having said so, there are many good reasons that explain why a biomedical approach prevails in the treatment of bipolar disorder and other severe mental health disorders. Many patients presenting severe mood disorders cannot engage constructively in a meaninful human exchange given the severity of their condition, they are hindered from learning from experience. Some others plainly reject discussing issues about their lives that would allow them to understand and take control over their mood disorders, and even if they do, many demand immediate results that psychotherapy cannot afford. Medicine does provide help to many patients that cannot be helped or don't want to be helped by psychosocial interventions. In regard to respecting the client's autonomy, despite our best intentions, many clients choose not to exert autonomy and embrace any explanation available (including genetics) that bonds them for life to a condition becoming the justification for not taking full responsability for their lives and behaviour.

Human responses to suffering and to the help that might be offered are so vast and complex, specially in the most severe mental disorders, that no single formula has "the" answer and a collaborative approach seems recommendable, in which different resources are put to the service of providing the best possible state of wellbeing achievable in each particular case.

I fully agree with Jaime in the interesting contributions made by each of those who have been participating in this academic exercise that definitely favors our knowledge. A truly delightful and enlightening exercise.

In order to continue with this interesting exchange of opinions, I would like to point out an issue that has come up in the speeches of several colleagues: The problem of diagnosis.

I am convinced that the real problem of bipolar spectrum illness, more than treatment, is a diagnosis accurate and timely, and I think that is the real cause of the dispute (which occurs throughout the scientific field) around bipolarity.

I think nobody questions the effectiveness of psychotherapy, but unfortunately the evidence supporting this effectiveness is quite limited, especially when compared with the number of studies (some of these biased) that arise daily for pharmacotherapy.

When, as mental health professionals, we treat bipolar patients, we must face the biggest challenge of this disease:

The diagnosis, timely and accurate.The prognosis of bipolarity depends of early and accurate diagnosis and appropriate treatment:. The problem is that if we make a mistake in diagnosis, our treatment will be erratic. There are two basic mistakes that people make with these patients when the first crisis of the disease:

a) Depression, more than 60% of bipolar patients is their first depressive episode, and as it may take years to bring a crisis of mania / hypomania, the patient is usually treated as unipolar depression with antidepressants, this is a serious mistake made too often as antidepressants, when used alone, change the clinical course of the disease.

b) Psychosis, most patients in their first episode presenting with psychosis and are diagnosed with schizophrenia, and are treated as such, with antipsychotics, which have a deleterious neurocognitive impact in these patients, and this regardless of the stigma of diagnosis, or the expectations that the diagnosis generates in us as therapists.

I would like to make a number of specific questions to those who are involved in the treatment of bipolar patients,

- How many years pass between the first episode of the disease and the appropriate diagnosis? In general, various studies, diagnostic latency between 8 and 12 years.

- How many of our patients have been diagnosed and treated as unipolar depression before being diagnosed as bipolar?

- How many of our patients had been diagnosed as schizophrenic before receiving the proper diagnosis late?

- Why is this?

When we examine carefully the causes of these errors are going to realize something:

We are not getting an adequate medical history.

We are ignoring crucial information regarding the patient's family history.

We are ignoring crucial information concerning the patient's life (mood changes, irritability, etc ...).

We are limiting to add symptoms, without paying much attention to what the patient and family tell us.

2. Treatment. If our diagnosis is wrong, the treatment will also, unfortunately the consequences are going to take the patient and family.

Are we under-diagnosed or over-diagnosed bipolar disorder? both definitely happen, but the problem is not over- or under-diagnosis, the problem is that we are not doing our differential diagnosis, the problem is that we keep mistaking when making a diagnosis.

My question is did bi-polar issues exist in such large number as they do now or is it increasing due to the very drugs given to 'treat' it? As you say Alvaro antidepressants are a mistake as they have mania as a 'side effect'. As a mental health survivor I believe all drugs are a mistake and the very notion of disease or illness is a mistake. There are so many causes to address one by one till found and yes when in active distress some assisted sleep is often needed. Here are a few suggestions as to where to look:

Childhood trauma, grief and loss, accident, abuse; both physical and sexual, hormonal turmoil of adolescence, relationship distress, overwhelm, depression, loss of meaning, substance abuse, addictions, gambling, dramatic change, seasonal, childbirth, financial worries, over work or shift work, jet lag, loss of child/job/home/parents/family/friend, illness, cancer, chronic pain, tooth infection, natural disaster, war, hormone imbalance, menopause, loneliness, self-neglect and dementia. Dramatic life changes, infatuation, sudden large financial gain, spiritual crisis, sudden fame, near death experiences and even too much sunshine.

Rabies, Toxoplasmosis (very common and caught from cat excrement), Lymes disease, Pyroluria, Porphyria, parasites, heavy metal exposure (mercury, lead and others). Head injury, fetal alcohol syndrome, autisms, epilepsy and vaccine damage, high fever, dehydration, sleep deprivation, nutritional deficiency, mineral deficiency, abreaction to recreational and prescription drugs and stimulants. Side/direct effects from mental health drugs, other medical drugs. Incorrect use of nicotine patches, post-operative psychosis and post traumatic shock. Blood sugar imbalance, over or underactive thyroid, faulty methylation and B vitamin deficiency, essential fats deficiencies, histamine excess, serotonin deficiency, adrenal imbalance, acetylcholine imbalance, toxic poisoning overload and gut inflammation, bladder infection, metallothionein deficiency, direct food allergies, extreme physical and emotion exhaustion and extreme hyperthermia.

Plenty of work for a good psychiatrist who chooses to remember their medical training....

Dear Heather, precisely because of all the factors listed in your comment is that there are so many misdiagnoses around bipolarity, is that's what I meant in my previous comment, we are not making a differential diagnosis, we opted for symptomatic interpretations hasty and not listen to the patient.

In addressing psychopathology we will find many causes of depression and many causes of mania or even psychosis. But when we speak of bipolarity we are referring to a nosological entity whose boundaries are not well defined.

I think that trying to reduce all psychopathology to traumatic events in childhood or adolescence is to deny everything that happened in neuroscience over the past 15 years, the same error occurs in the opposite direction (ie, reduce all psychopathology to molecular motions). The fact is that we are all the sum of everything that happens inside us and in our exterior.

In that sense, deny the existence of people who are favored with proper treatment, it would be as wrong as denying the existence of people who benefit from psychotherapy. The problem is that, often, we do not do neither one nor the other, which creates dissatisfaction in people (if not, iatrogenic consequences).

A problem with the diagnostic criteria like DSM or CIE, is the low diagnostic threshold in all categories. In this mode, almost any person is a patient!! Maybe nowadays, the intolerance about emotions is huge. E.g., some anthropological data point that pain tolerance has decreased since the XVIII century (the introduction of anesthesia and other drugs with therapeutic use is a factor that probably shaped this event). Likewise, the psychopathology of affectivity in the XIX century identify as affective disorder only melancholy and manic-depressive psychosis; dysthimia was a descriptive term, as in "anguish dysthimia". Dysthimia as a diagnostic category is a creation of DSM and CIE, as well as the myriad of diagnostic categories in the mood disorders area: bipolar II, cyclothimia, etc. I think that the careful reflection about historical, anthropological and sociological data, bring into question the VALIDITY of our diagnostic concepts, otherwise constructed around the fiability obsession. The book of Christopher Lane (2007) is very pertinent here.

In my point of view, the explosion of incidence numbers of bipolar and other mood disorder (including very little children, as it were a adult miniature!), is partially an artifact of our diagnostic criteria. I think that the point of view of persons as Heather is a data that worthwhile a careful reflection. In this sense, I am in full accord with the last response of Alvaro. Perhaps, in psychopathology, signal his boundaries is a function of human sciences (anthropology, sociology, history), whatever to acknowledge is normative dimension. A mental symptom is a symptom in a normative context; a mental symptom is not a symptom per se.

Goodnight to all, and excused my poor and awful english.

Reading Richard Bentall's book Doctoring the Mind, Why psychiatric treatments fail, 2009 (shortlisted for mind book of the year). He states on page 110 that his personal opinion is that psychiatric diagnoses are about as scientifically meaningful as star signs, both have a wide following despite compelling evidence that it is useless.

Of course it serves medical insurance, medical services, political agendas (gun disarming from general populations) but not people in distress. Why would you treat two people differently if they are in the same state of distress depending on how 'reasonable' their distress appears? For example if their car had gone over a cliff and when they were found 4 days later they are delirious or they had a year of personal loss leading to self neglect which also resulted in dehydration, sleep deprivation and nutritional starvation.

Treating any child under the age of 18 with drugs should come with criminal charges if all logical steps to identify and address cause have not been tried. After all it is no different from doctors in the 1950' and 60's suggesting taking up smoking or a Valium addiction.to address stress. Lung cancer as a consequence of not addressing lifestyle cause is a small price to pay compared to diabetes, heart failure, worsening mental health issues, increased homicide and suicide. When will medicine learn from its mistakes and stop practicing profitable eugenics?

I think Alvaro and Francisco pointed out before some elements crucial for the understanding of the problem of psychiatric diagnoses. There's no use in denying psychiatric diseases, it would be like saying there are no dermatologic or endocrinologic diseases: they are palpable, they produce suffering and they appear in a life previously normal. So, they are real and they must be adressed.

The point is about categorization, and about psychopathology. When you try to differentiate an alergic reaction from an initial Stevens-Johnson syndrome, you may ask the patient if the red dot in his hand does hurt, or else, if it does itch. That can seem a very little thing, but that apparently meaningless detail can be a great difference. So, why should we ask a patient just if he/she feels "depressed" or "down"?

The patient says "yes, I feel", and then we start making checklists and asking if that's been happening one day, two days, etc, if he doesn't sleep, and at last me make a sum, and we say "oh, my goodness, you are depressed".

The usual diagnostic criteria forgot simply two meaningful things: we are medical doctors, and we are persons.

Why do they forget we are medical doctors? Because once we find a psychiatric problem, we assume immediately that the ORIGIN of the problem is psychiatric. And it's not always so. More, there are a lot of incredible times that is not. A lot of medical problems may start with psychiatric symptomatology, and if we only adress the mental symptoms, we will be treating symptoms, and not diseases, which is our very goal. It would be like trying to heal pneumonia with ibuprofen. That has been said by Heather and others, and can only be emphasized.

Second, but more important, diagnostic criteria forget we are persons. Not every person has the same "depression", or reacts the same way to similar dificulties in life. And, here is where I strongly disagree from Heather: not every person that's been through the same difficulties should be treated the same way. If a person has a grief, is normal he reacts to it. But what we try is NOT the grief. We only act if a disease starts. And, as an old teacher used to say: "Everyone can become ill if a stressor strong enough comes in action. But everybody will get ill only as he can". And here is where biological and previously formed vulnerabilities appear. That's why a bipolar person will always be a bipolar, independent of the gatillant of the first episode.

And here, let me introduce the old notion of organic / endogenous / reactive psychopathology. Jaspers did have a very vague notion about it, meaning endogenous only organic diseases of which we do not know still the cause, and reactions every illness that appears after a "personal disaster" (only the person himself knows what is the threshold for "disaster").

But, if we give it a turn of the screw, and we assume organic diseases share a common pool of symptoms independent of the origin (true hallucinations ("vera", as we say in spanish), predominantly visual, adhesivity, abstraction failure, confusion, etc), if we define "endogenous" not by our unknowing its origin, but by the concept of "endon" (introduced by Tellenbach), and we assume the "proportionality" for the concept of reactive (in which case we MUST remember we have a person in front and we must apply his/her proportionality and NOT OURS), some of the difficulties seem to vanish in the moment.

I know these are not concepts globally accepted, but I would invite you to try them in the clinical practice after a detailed study (without which they are not very useful, and can be very confusing to someone not used to them).

...but, I know, there would be still the same old problems...

how to diagnose bipolar disease in the first depressive episode?

how to differentiate when my borderline/bipolar patient is really ill vs. when the suffering comes from his/her personality disorder?

etc, etc,

well, it seems a long, long way to go, still...

I fully agree with Francis and Rodrigo. The problem of the diagnosis of bipolar disorder is something that has not been set due attention, I usually discuss it with my students in this way: "We have been seduced by the rapid advances in molecular genetics, neuropsychopharmacology, neuropsychoinmunoendocrinology, etc ... that we have forgotten the basic sciences, specifically, semiology and psychopathology. The classification manuals (DSM, ICD) -though they have contributed to a better understanding of pathologies- have been been sinking more in this confusing picture ... we are being overtaken by technological advances, and this is dehumanizing us "

Separating classic bipolar cases (those that seem taken from textbooks, with well-defined episodes), the diagnostic problem occurs in cases that are at the ends of the spectrum, especially those where the boundaries overlaping with the normality or in cases with severe symptoms that are mistaken with schizophrenia.

In my clinical practice, most patients are atypical bipolar, not classical paintings that identifies any neophyte. Many of these patients are referred from colleagues with misdiagnoses (most are treated as unipolar depressive patients).

What's going on? Why we are wrong?

Basically I have observed that (as Rodrigo points out quite rightly) we are starting from a false premise and assume that depressive symptoms are due to depression.

But I want to go a little further, and I apologize in advance for abusing of this space.

What do we mean by depression? ... Here begins the problem. Depression is understood as an episode (there is only one type of depression: major depressive episode). When the depressed is a patient with bipolar depressive episode debuting at 22 years old ... How do we differentiate bipolar depression from unipolar?. According to most experts there is no way to differentiate between the two types of depression ... So what we do?. If at this time we miss the diagnosis the consequences for the patient will not be very nice ... If are a bipolar and we prescribe antidepressants (which is logical behavior) we will modify adversely the clinical course of the disease, can trigger a mood shift or favor the emergence of a mixed episode ... What do we do? ...Would you ask to come back in 15 years when a manic or hypomanic episode appears, to avoid iatrogenic?...

This is where we have to resort to elements that classification manuals leave out: genetic elements (What is the genetic background of this patient?), Clinical data and evolutionary elements ... Why do not we do this? Because ... the tools we're using to make the diagnosis tie our hands and prevent us from doing our differential diagnosis successfully.

Why study therefore, if anyway, when we are in the clinic, with the patient, we do what any averagely trained secretary could do (a cardinal symptom plus five secondary symptoms, equal to depression)?. And no matter how much the clinic as the patient say us otherwise.

It is absurd that the diagnosis of bipolar disorder depends on the appearance of mania or hypomania, when most often (this has been proven for Judd, Angst, Perugi, Vieta, Hantouche, Strejilevich, and many others) is depression.

My point is, we need to develop tools that allow us to make an early and accurate diagnosis to offer our patients a better prognosis and, consequently, a better quality of life.

In full accord with Heather, Rodrigo and Alvaro. I carry on in the idea that the mental symptom is a symptom in a context, in this case, personal history, personal narratives derived of first, and cultural variables. So, sadness is not a depressive symptom per se. Paradoxically, our measure instruments (BDI, BPRS, etc.) insert a great amount of circularity, just one of the origins to our diagnostic mistakes. Curiously, the circularity is a feature of human behavior (e.g., the operant behavior as unit of analysis): context-behavior-consequences in a eternal and golden brain. Our instrument erase this feature of behavior, but reinsert this in our reasoning...a vicious consequence. Curious...

Thank you for the discussion however the disease model is still persisting... where are the pathology markers? Why is cortisol not measured? Where is the line between normal depression as a reaction to life's stress and abnormal? Why are questionnaires such as the PQ-9 written by pharmaceutical companies and produce such staggering numbers of 'false positives'?

Francisco by circularity do you mean statements like 'Why is she crying? Because she is depressed. Why is she depressed? Because she is crying..... This reasoning is appearing more readily these days as compartmentalization increases in medicine. Its like saying an upset stomach is caused by upset stomach disease and lets ignore the food poisoning or intolerance's. I do understand that you are all making positive contributions to this discussion re the lack of context and individuality in many psychiatric practices and I applaud you for that.

My own lived experience causes me to disagree with you Rodigo when you state that bi-polar is something you are for life. I was given the diagnosis of bi-polar in a 10 minute interview that has affected my life negatively. What was not taken into account was the first episode of psychosis was when I was aged 32, 2 weeks after a traumatic c-section birth complicated by child hood trauma (my tonsils were removed while I was awake), missed giardia infestation, teeth grinding, amalgam poisoning, uncomfortable hospital stay, back pain, sleep deprivation and a crying baby with colic. It was also winter so low levels of light and Vit D, plus relationship issues.

The diagnosis came 16 years later... I had been drug free after 1 year, had a second child without problems, been through marriage break up then after unsafe amalgam removal and early menopause I experienced a second episode of hyper mania. A four year battle of forced medication and withdrawal induced psychosis followed based on the bi-polar diagnosis. By my own stubborn actions, full nutrition, safe mercury removal, removal of failed root canal teeth, mercury detox and exercise I am now med free, symptom free and have completed a university degree. And yes I was down at times about my loss of relationship choices, employment options, social standing, mental health stigma, finances, lack of vitality due to medical drugging and positive future perceived by others including family... Any one not feeling down with all that going on has something wrong with them!

If being bi-polar were genetic and for life I would have experienced distress as a child, teen, young person, For the greater part of my life (I am 51) I have been symptom free and I do not feel like a ticking time bomb. Yes my default may be to psychosis if under enough stress, so what, other people default to addiction, heart disorders, obesity, diabetes or cancer, I would rather have a psychotic few days, actually they are quite fun and creative, than any of those. But can any chronic distress really be called 'disease' or simply dis-ease? Typhoid is a disease, bi-polar is a temporary emotional/physical/spiritual/stress/distress default pathway. Unless it is locked in via diagnosis and medication as many people are now learning when they look at the exploding numbers. As Richard Bentall demonstrates outcomes are now worse than they were in the 1980's!

No exactly Heather. By circularity I mean mutual relation behavior-consequences, consequences-bahvior. The behavior make present the consequences, but the apparition of consequences, requires behavior. Include context in this relation, and you have a web of relations. This is the circularity of human behavior in my point of view, obviously informed by the radical behaviorism of B.F. Skinner.

Thank you for your contributions to this debate Heather.

Having bipolar disorder, or having a bipolar diagnosis, are clearly very distressing. The cause of bipolarity is basically unknown, so for the time being we need to keep open minds. It is surely better to start with that which we do know from 150 years of research by millions of well-intended and dedicated people as summarized in Wikipedia, than to rely on one's own lived experience. No one likes drug companies, but they are a necessary evil, as drug treatment was surely the major advance in psychiatric treatment in the last century (ie compared to what went before).

It seems the problem, Heather, is diagnosing a Bipolar Disorder because you have "bipolar behavior", and here I fully agree with you. The apparition of a manic episode does not guarantee a right diagnosis of Bipolar Disorder, nor does a depressive episode guarantee Recurrent Monopolar Depression. And one of the very facts is what you pointed out. In your case, the right etiology should have been "Metal poisoning", and not Bipolar Disorder. It should have made a lot of difference if that was detected from the beginning.

When I said "a bipolar person is always a bipolar person", I didn't mean the diagnosis don't have to be reviewed when time passes. I only did mean that once a TRUE Bipolar Disorder is switched, the person has a vulnerability that will be present. It's like having a condensator that modulates the energy power in your house, and turning it off permanently. From then on, you'll have to be very careful...

Don't forget that "manic-depressive psychosis" has been associated with long-term complications, and that is the very reason why we treat it. Mood phases tend to relapse spontaneously without treatment, so, why should we treat something that resolves itself naturally? Because we don't want the complications, and they're very known to us. They are called hight rates of suicide, rapid cycling, cognitive decline, bad QOL and so on...

But, as others had pointed before, there are always some patients that do well without pharmacotherapy. They are, sadly, very few. And we don't have any way to know it beforehand.

There are reasons to treat Bipolar Disease. But I can understand also a patient that decides to go on without medication. I have one now, that I have been following for almost a year, and he is really well. But I explained him every risk of this, because it had to be his decission. It can't be mine. It can't be ours.

Our goal is not only to diagnose. It is also to not diagnose what is not illness. And here, I agree with you, Heather.

I should also add a personal impression. We'll never find any marker of the disease if we continue researching the way we have been doing. Because we are not talking about an organic, but and endogenous disease. So, before we can define it in full, we have to understand better what an "endogenous" disease is.

But it's just a personal impression...

First, I have to explain that "endogenous" is not only a controversial concept, but it is also one which has been developing over the years, and has changed since the beginning from a "taxonomic" one to an anthropologic one, and is this last meaning which is really useful in clinic.

I should also state that what I will explain it from my own knowledge, which is, of course, limited.

One of the first authors that used the term was Jasper, in his "General Psychophatology". Here, he introduced some terms to categorize psychiatric diseases. They were, grossly "reactions" (something that appears in response to a vital event, like, for example our modern "Adaptative Disorders"), developments (a classical view to some of our modern "Personality Disorders", meaning something that is consequence of the evolution of the individual) and processes (something that appears in the life of the person, and is not understandable by the biography, or by some vital event).

In the "Processes" he identified two different kind of diseases: "Organic Processes" (something which is explained by known biological factors, like delirium secondary to an infectious disease), and "Endogenous Diseases" (basically, diseases of biological, but unknown origin).

The problem with this definition of "Endogenous" is that it puts the emphasis of what we DON'T KNOW. So, it's not useful clinically, and that's how diseases like epilepsy, which were classified as "endogenous" in Jasper's time, are now clearly understood as organic processes.

Now, clearly endogenous diseases are distinct and different, but, what is the core of them? Is there any concept which could be useful to identify them?

It was not until 1974 that the problem was, at least partially, resolved, by the introduction of the concept of "endon". In his book "Melancholie", he introduced the concept of "Typus melancholicus" as a psychological form-of being, precursor of melancholia (one should say, "Recurrent Depression", today, but, due to DSM-IV, that is not entirely right).

Here, Tellenbach presents the "ENDON" as a third "field of causality", aside of soma and psyche. A fundamental postulate of the endon is its absolute "human" characteristics. So, neither soma nor psyche would be enough to explain its meaning.

That's why endogenous diseases will be notorious in everything that is specifically "human". For example, schizophrenia will be evident in communication as human language and social interaction. And affective disorders will be endogenous in that they not only affect the mood, but also cycles, interaction, activities and so on.

Tellenbach identified "rythmicity" as the main characteristic of endogenicity, and he postulated seven aspects which we can observe as the base of his theorization:

1. RHYTHMICITY AS THE BASIC WAY OF LIVING: this is basically the "endocosmogenic" periodicity, being its main representative circadian rhythms (wake/sleep cycles). This is not exclusively human (for example, bird migrations follow this pattern), but almost every human activity is based on this.

2. RHYTHMS OF LIFE AS TRANSFORMATION: there is always a transformation in the rhythms of life, as there is transformation in nature with, for example, seasons of the years. Only, in endogenous diseases it is grossly marked. The classic example is the symptom daily variation in endogenous depression: with morning worsening and a relatively better mood in the evening. If it follows the inverse pattern (evening worsening), it is more sugerent of bipolar depression. Pure reactive depressions rarely follow this pattern at all (it is fundamental to differentiate mood worsening vs. ANXIETY worsening, which is highly inespecific). Other examples are periodic catatonias (rarely seen these days). Interesting to note is that, even rapid-cycling bipolar disorder tends to follow a pattern, even if the cycling occurs within a day (if it does not, is more probable you have a borderline patient in front of you).

3.TRANSFORMATION OF "CYNESIS" OF LIFE: life is a constant movement forward. In melancholic disease, inhibition is the most clear marker of this aspect. And that's how, for example, insomnia appears: a disturbing of circadian rhythms, but a stopping of sleep also. Literally, for a melancholic depressed, there is no future, because time is not moving. That's why desperation is not so grave as inhibition (psychopathologically speaking), because for a person to be desperate there has to be movement still. There's a paradox here: if someone is fully depressed, there is less chance for him to commit suicide than if he's just recovering (That's why, personally, I think ECT should be the election treatment for inhibited depression).

By the contrary, in a manic person, the future is always happening. So, if you have to work five years to have a million dolars, there's no difference, you just have them now.

4. GLOBALITY OF TRANSFORMATION: when the endogenous is affected, every aspect of the person is altered. For example, if you have an inhibited depression, he/she will not recover if something happens. Here, is a remarkable a phenomena largely misunderstood that happens in Atypical Depression. If you have an inhibited depressed person, and is his/her birthday, he may not even smile. If you have an atypical depressed one, he/she will smile, maybe will even enjoy it a little. BUT HE/SHE WILL NOT ENJOY AS SHOULD HAVE WHEN HE WAS EUTIMIC. So, atypical depression keeps some degree of movility, but it doesn't disappear. That's a key to differentiate real atypical depression (sugestive of bipolar depression) from a reactive depression in personality disorders (or even without a PD). Why does it happen? I don't know. Maybe because Bipolar Depression always have a little "mixing" itself. But just maybe.

5. ENDOGENOUS IS VINCULATED TO MATURITY STAGES: the classic example is schizophrenia, being largely vinculated to puberty. But there is growing evidency for an age of appearance early than we thought for Bipolar Disorder, for example. Maybe puberty is more complicated now than it ever was, because in affective disorders it is vinculated more to life changes than age itself. For example, changes like getting married, getting a new house, a better job, etc, can be very exciting, but... do you guess what? you bet! They can be enough to trigger a mood phase. And what they have in common is that they affect the globality of person's life.

6. REVERSIBILITY: maybe the more controversial element, but one which is very important if we want to keep faith in our work. Jaspers stated just the opposite: processes (including the endogenous) are something which changes the person irrevocably, and since then the term "deffect" has been used to describe this "something" that does not cure even with the better of treatments. That's why "Manic Depressive Psychoses" was not clearly seen as process, because the general view was that it cured without deffect.

In fact, both views are right. There is more and more evidence that Affective Diseases don't cure fully. There is always something that changes. Proof of that is the simple fact of the recurrence: if we don't use the right treatment, phases come and go, come and go. Why, if previously it didn't happen? Easy, my friend, because you are not exactly what you were before. And because there are very subtle changes in your functionality that are enough to put you in risk of new episodes. And, more, if you have enough episodes without the appropiate treatment, there will be a cognitive deffect, that, sadly, will not recover. So, Affective disorders (at least the endogenous ones) ARE processes, because they HAVE a deffect, which is, of course, different in nature to the schizophrenic deffect.

And do they heve reversibility? Yes, of course. The vast majority of affective episodes have spontaneous remisions, that's not why we treat them. We treat them (or at least, I treat them), because they have long-term complications. But phases are reversible.

The same is aplicable to psychotic episodes. Sometimes we see patients that have been 12 years psychotic, and, one day they come to you, and, voila!, they tell you: "doctor, I have understand that nothing that I told you last week was real, I don't know how I could have think it". The episode has reversed. But they never get to live a normal life, they don't even laugh as much as their friends (if they have some), and they laugh sometimes you don't know why. So, they have a deffect.

7. THE ASPECT OF HEREDABILITY AS A POSSIBILITY, GENETICALLY INSTALED, OF AN SPECIFIC PHENOTYPE. Here, Tellenbach spoke not only of genetic heredability, but of a disposition that is modelled by environmental factors. A concept very similar to the modern "endophenotypes", but without all the molecular research we have today.

I have extended too much, and I fear there is not much about biological markers in this, but I hope it serves to give a light about a complex concept such as "endogeneity".

I strongly recommend you to read "Melancholie" of Tellenbach. It's always better to read from the origins...

Rodrigo,

Thank you for your review of Tellenbach's concept of "endogenous" (and your clinical insights as well). This definition is much more detailed than the former unsatisfactory "an etiology that resides within, ie, organic or functional sources." It seems to me that Tellenbach's seven aspects of endogeneity could be very helpful clinically, and might even suggest some lines of research that would help clarify the biological and environmental components of Bipolar Disorder.

As a lay person working in emergency mental health services, primarily for youth, I hesitate to jump in to such a wide-ranging discussion, but some of the answers are out here:

1. There are subtypes of depression in DSM-IV TR, including dysthymia, etc. also many medical rule-outs and a lot of evidence base for non-medication as there wasn't any until the 1950s.

2. There is evidence for non-medical success with depression and bipolar from the 19th century, before any psychoactive medication, in the studies done of asylum clients re-enterring the general populaton and followed with census data. People resumed functional lives for decades, some of them.

3. ECT is, in my area, coming back into use for refractory bipolar depression in my area.

4. Differential diagnosis of Bipolar 2 (no mania) is happening around Boston based on non-response to several anti-depressants. Medicine defined by response to medication, but there you are.

5. I think that while there is some difficulty distinguishing major depression from various kinds of culturally appropriate sadness, and almost none of the DSM diagnoses are yet based on understanding biochemical events in the body (which tends to become a medical rule-out), the really difficult issue in this discussion is mania. While many of us have experienced endogenous hypomania *for short periods,* psychotic mania is fairly distinctive.

6. In a family I know well that was part of a multi-generational study of bipolar, there were some individuals with "classic" bipolar or completed suicides, several with Bipolar primarily of a depressive type, and several who seemed to others (or to themselves) to have a baseline of mild-moderate hypomania -- and therefore were high achievers and never felt enough distress to consider themselves as having a mental health disorder, unless thinking about other family members later in life or as a result of the study. Prior to the study, some of the people who might hypomanic mostly rather looked down on the depressive relatives as being weak, lazy, etc.

7. So if one can sustain hypomania without either full mania depression, it's not an illness requiring treatment (rather like the people who can ignore audio or visual hallucinations, estimated to be .2 per cent of the population anecdotally by Leroy Spagniol). There are probably people at the edges of this cohort who can control symptoms easily without medication, as many people with more serious bipolar do with varying success.

8. And then of course there is self-medication, often part of a regime for mood illness with some success over time. Do we see someone as a "functional alcoholic" or as a "person successfully self-medicating depression?" We lean toward the former because of the side effects of ETOH, but we may lean the other way in contemplating the side effects of Lithium or Olanzapine.

--Mark Zanger

S

I think Mark has taken notice of some points that are fundamental in our daily practice. With some I disagree, but, in the most part, I fully agree with him, but considering important to make some distinctions:

1. There are many subtypes of depression (at least in the clinical presentation), but, unfortunately, I don't agree that DSM categories are correct. This is mainly because DSM relies predominantly in symptoms, and not in the phenomena subsiding them. We should always remember that DSM was originally made to make diagnosis of consensus that allowed to make investigation, at least pharmacoterapeutical, but NOT to be used in clinic. So, it's useful to homogeinize pharmaceutical trials, but not to make differential diagnosis. That's something we always forget.

2. We should not forget that the success achieved by therapeutics pre-pharmacological was mainly recovering from phases, which as I say before, are usually self-limited. And, in 18th and 19th century, life expectation was also less than today. So, there was no difference in cognitive decline for a person that should be dying around 50 years. But there's a great difference for someone who will die (if he is lucky enough) at 70 or 80 years. It can signify 20 or 30 years of unnecesary cognitive deffects.

3. I absolutely agree with the utility of ECT for refractory Bipolar Depression.

4. I think the great challenge is, really, in Bipolar 2 disorder. There are many reasons for this: it's the most difficult to diagnose affective disorder, it's far more prevalent than we previously thought, and, of course, we have to try everyday to not fall in the "spectrum" fashion, and diagnose only those who are really BD 2. I have seen too many borderline patients diagnosed as being "part of the spectrum", but I have seen also Bipolar 2 misdiagnosed as Personality Disorders, that once are rightly treated, lead an absolutely normal life. Also, it's important to keep in mind that the 11 or 12 years between first depression and diagnose are not only for the underdiagnose, but also because the only right diagnose of bipolar disorder is longitudinal. Probably we should try to keep (for now) our score around 2 or 3 years, since there are not absolute guidelines for diagnosis BD2 before hypomania.

6. In that family you describe, there is a clear example of what Kraepelin called the "Hyperthimic Temperament". He saw Depressive-Manic Psychosis as a continuum between normality and disease. In one end of the line, there was the full syndrome, but in the other were "Hyperthimic" and "Cyclothimic" temperaments, variations of the normal being that were like "aborted" forms of the disease.

This poses a great problem, for the question of "normality" will be always a problem in psychiatry. The way I have resolved it until now, is using two simple criteria:

==>First, if he/she doesn't enter my box, I don't have a patient. So, there is nothing to treat. From the moment he crosses the door, there's something to treat, and then I have to dilucidate if it is a disease or not (don't forget people get to the consultation office for diseases, but ALSO for problems that are not diseases).

==>Second, I here apply (combined) the concepts of vulnerability and phases. Temperaments are markers of vulnerability, but only phases are markers of disease. So, if an hyperthimic patient gets depressed, I treat him with antidepressants. If the first trial is unsuccesful, I apply the concept of vulnerability to choose my second strategy, and then use mood stabilizers to augment the therapy. But I explain to him that, from my point of view, he is not Bipolar, but has a chance to have a mania/hypomania in the future, so we will keep a close observation.

7. I agree with you about not treating hypomania, although I have my doubts. We don't know still if it's neurotoxic per se, so, there's no reason to treat it now, but I don't know what the future investigations will tell us, BD2 is, almost, a new disease we know almost nothing about.

...but I doubt a patient that only has hypomanias will ever consult, so he'll never be a patient... :)

Is anyone here able to outline why they so fully endorse ECT for bipolar? I am aware ECT is still technically considered a 'best practice' but I am also very aware of its punitive or coercive use and am not aware of the evidence-base for such a practice. I do know many service-user groups argue ECT should not be used and am familiar with stories of people who have forgotten portions of their childhoods as a result. To be honest, it appears rather barbaric as a treatment option to me and I am surprised to find people here so wholeheartedly endorsing its use. I admit I am ill-informed on the topic though.

Because it is a very effective treatment for depression, and therefore unethical not to offer it or even insist on it in the long term interests of the patient. If unpleasant or coercive medical treatments were banned, we would not have heart transplants, child dentistry, chemotherapy, removal of large chunks of the brain for epilepsy, resetting of dislocated joints, etc. The public gets its views from films like One flew over the cuckoo's nest.

Bravo to Angela and Antony for their advocacy of ECT.

We have also to take into account that it can be successfully used as a maintenance as well as an acute treatment, and in bipolar disorder as well as in recurrent major depression.

It should be emphasized also the great difference in the time of response. Antidepressants and/or stabilizers have a two to three weeks latency. But, for ECT usually between 3 or 5 sesions are enough to achieve remision, which means (considering three sessions per week), one or two weeks for a significant recovery,

I agree with Angela, Antony, Jean and Rodrigo. ECT remains the best treatment we have for severe, biologically driven depression and mania. It is usually very well tolerated and adverse memory effects are temporary, except when severe anxiety over memory loss and personality disorder intervene. I have use this treatment since 1974 and for three years was Director of an ECT service giving around 1,500 - 2,000 treatments per year (covering three hospitals). I continue to use this treatment and have told my wife that should I ever develop psychotic depression, I want ECT!

I have not seen much actual discussion of cognitive-behavioral therapy or mind/body techniques in this discussion so I am going to add my two-cents on that topic. I preface this, however, by agreeing with Alvaro Jerez – medication should be maintained. Complementary/Integrative medicine is just that – complementary to and integrated with more traditional methods of treatment.

Many bipolar clients find CBT and techniques such as mindfulness, conscious breathing, meditation, visualization, EMDR, and biofeedback much more empowering than talk therapy alone because it gives them a set of tools with which to proactively address the condition. Talk therapy tends to be reactive - a discussion of how one is swept up in the mood swings, how one is cycling between phases, what impact the mood swings are having, etc. These other techniques I mention teach clients to recognize the signs of transitions, well in advance in many cases, and how to prepare for it or redirect it. Being able to step aside and say “hey look, I am really depressed/hypermanic/mixed/etc” without being dragged into the emotional whirlwind is essential in being able to gain control over the condition. All of this is from my personal observations, though there is a significant body of research out there supporting the use of these techniques for the treatment of bipolar. Additional holistic approaches such as proper nutrition, regular exercise, and relaxation and stress reducing techniques are also very helpful to the bipolar client.

A side note about ‘mood stabilizers.’ The answer to that question really depends greatly on what you are calling mood stabilizers. The three general categories are mineral, antipsychotics, and anticonvulsants. I am not a fan of lithium (mineral) due to the nasty potential side effects. Antipsychotics are also less favorable due to the neurocognitive impact. I have repeatedly had clients on Olanzapine (Zyprexa) say “I would rather be crazy than comatose.” Anticonvulsants are really mixed on how they impact the bipolar client and what kind of risk they carry. I think Lamotrigine (Lamtical) and Oxcarbazepine (Trielptal) are some of the best treatments. Risk of side effects is very low, though in the case of Lamotrigine potentially very serious. ** Please note that I am not an MD (I only play one on the Internet). I am a holistic practitioner who has worked with clients on these medications and coordinated treatments with their MD/PsyD. I also have a knee-jerk reaction to the idea of ECT and feel that, while it has shown effective, it should be reserved for very severe cases and acute psychosis.

Bottom line: Ethically, you want the client to receive the treatment which offers the best results with the lowest risk. This can be a single treatment or combination as long as it is effective, not cost-prohibitive, and promotes consistent client adherence. CBT and mind/body techniques strongly speak to all three of these requirements.

And then there are studies that show if a person thinks they are having ECT, are sedated and not zapped their outcomes are better than those who were. The placebo effect is factored at 40% in medicine, it makes sense that it is this or greater with ECT.

UK ECT Review Group (2003) Efficacy and safety of ECT in depressive disorders: A systematic review and meta-analysis, Lancet, 361: 799-808

I agree with Angela. Actually, the review supports two views we have been talking about: ECT is effective, and it is better than pharmacotherapy. It also supports bilateral over unilateral ECT, but it is just a technical aspect.

Sorry I had misread however what was said is still interesting so I will quote directly out of Richard Benatall's book 'Doctoring the mind, Why psychiatric treatments don't work'.... Page 193.

'The placebo effect appears to be a factor in many kinds of therapies so, for example, there is evidence that a sham ECT (in which patients are anesthetized, have electrodes placed on their heads, but do not receive a shock) is considerably more effective than not being exposed to any kind of ECT procedure at all.'

I am delighted to see that ECT is being put in it's rightful place. It is an excellent treatment for very severe mood disorders and for some other very select problems. It is the best treatment we have for very severe biologically driven depression (recognising that psychological therapies, of which CBT is one, are always essential once a person is capable of using these treatments). The placebo ECT studies are of great interest, but are limited by the substantial problems in subject selection, because of ethical issues. As in so many efficacy trials of all treatments of mental illness, the populations being studies are rarely representative of those being treated in practice. There is no age restrictions for the indications for ECT but I agree that the elderly respond particularly well because their depressive disorders usually have such prominent biological elements. The technical details of ECT administration are complex and I would not like to one electrode placement be used exclusively. This harks back to my early days in psychiatric practice and I do not want to see us lose sight of the very real advances in this treatment. Finally, let us remember that biological treatments for mood disorders are also moving on to new territory such as TMS, MST and DBS. While ECT remains fundamentally important, advances are being made all of the time.

I'm always troubled to see speculations passed off as facts and science. I read some comments referring to "biologically driven depression," yet we have no proof that there is any biological, causal component to depression - or any mental illness for that matter.

As a means to justify the continued use of medications and controversial treatments like ECT, we pretend to know things about biological or chemical origins of mental illness, but we do not know this. In fact, we have been researching such things for decades and know virtually nothing more about the role, if there any, of biology in the onset of mental illness. We have just as much, if not more, evidence suggestive that biology is changed BY, not as a result of, mental illness.

ECT is no different. It has been around for decades and we know almost nothing about how it "works" or what it does. Again, I am troubled to see so many comments praising such a barbaric practice, heralded as something wonderful because it - at times - takes away some symptoms (while producing others in their place).

I agree that we know very little about the physiological basis of depression or indeed most mental illnesses, or why ECT works, and I think the brain changes in schizophrenia are a result not a cause of the symptoms. Therapy for cancer is a barbaric treatment, and a mother in the UK recently refused to allow her young son to have it, but lost the court case as it was on balance clearly in the long term interests of her son. There is a genetic component to all mental illnesses, and what is more biological than a gene?

Rod,

No proof of biological components to any mental illness? Wow, I don't know what your standards are for proof.

Saying there are no "biological components" is a different than saying there is no proof of biological causation. We do not know, in any capacity, that any biological component causes mental illness.

We have not identified any gene or chemical that, when broken or malfunctioning, causes someone to be mentally ill. We speculate about chemical imbalances, which we then defend by using the "proof" of behavioral change when psychiatric medications are used. However, this is shoddy proof and inapplicable in any other scientific field. We would not argue that a heroin addict had an opiate imbalance and thus the heroin they used corrected it, yet this is precisely the "evidence" we use with mental illness.

Of course there are biological components to mental illness, because there are biological components to every aspect of the human condition: breathing, sneezing, talking, etc. However to argue that biology causes these things is a whole different matter, yet this is precisely the argument we make with mental illness. We say chemical imbalances or genetic malfunctions cause mental illnesses like Bipolar Disorder or Schizophrenia, and while these are reasonable hypotheses, we do not know this.

Rod,

I think I understand your point. But we have lots of evidence of involvement of the HPA and various neurotransmitter imbalances that are in the mix. I would certainly agree that there is an interaction between biology and environment in the expression of mental disorders, with some individuals having a much stronger biological vulnerability to the development of mental and behavioral disorders than others.

I've been following this interesting debate and I would point out a couple of observations to contribute to this interesting academic exercise:

I really think that by now no one doubts the efficacy of ECT, however remember that its effect is similar, in molecular terms, to a seizure, in that sense, when analyzing MRIs of patients with chronic seizures brain atrophy becomes evident that determines a series of behavioral changes of chronic epileptics. The families of our patients refuse ECT by "Hollywood" effect; but, as professionals, we are forced to weigh the risks and benefits of our interventions always thinking about the welfare of the patient.

Recall also that ECT is not exempt from possible complications during the procedure, that is, although its high level of efficiency in terms of security is not a 100% safe procedure. In some environments the use interventions such as ECT is a decision made too easily, without having exhausted the rational use of drugs, which either are not without edges that could complicate the picture, and that is where much of the problem arises.

For many years I led a reference center of bipolar patients. Most of these patients had been classified as "treatment resistant" or difficult to manage patients. In evaluating each clinical case from a different perspective arises a series of circumstances that determine a greater or lesser extent the alleged "treatment resistance": Diagnostic errors, bad drug combinations, poor adherence to treatment, use of alcohol or drugs, and a very long etcetera...

The term "treatment resistant" involves on the one hand to the drug selected, and on the other, to the patient.

Many of the current drugs generate a series of adverse events that make it difficult to adhere to treatment (weight gain, sedation, etc ...). These events are enhanced when combined psychotropic drugs, and multiply when we combine them wrong.

Another problem arises when we misuse drugs: for example, I have seen many manic patients treated with antipsychotic prescribing by psychiatrists to sedate the patient, it is common to see bipolar patients concurrently treated with an antipsychotic plus an antidepressant; chronically depressed patients treated with benzodiazepines; Use low-dose antipsychotic as hypnotics, in short a long series of iatrogenic interventions.

Under this line of thinking, it is not hard to understand why many patients and family members they oppose drug treatment, and because many practitioners avoid complicated life taking other paths. And it should not be difficult to understand that many depressions "resistant" really are not.

Again: I completely agree with the effectiveness of ECT, but insist that this is NOT a first line option, much less should be used as maintenance therapy.

Ok. Mauree, Let's set as a starting point an initial premise was that which gave rise to this debate: Under no circumstances should dispense with the use of mood stabilizers in patients with bipolar disorder.

The mainstay of treatment is to treat the bipolar mood instability base that predisposes the patient to experience the crisis. Seeing a patient longitudinally becomes apparent mood instability that prevails throughout his life and is, as it were, his temperamental basis. This instability is periodically overlapping by crises that occur in the presence of various stressors (emotional losses, drugs, alcohol, successes, pregnancy, etc.) that act as triggers of the crisis. One of the most frequent errors lies in dealing with crises (mania, depression, hypomania, mixed) and forget to correct the instability. Many drugs are able to get the patient out of the crisis, but only the mood stabilizers correct in the long term the instability.

To answer the question of Mauree: mood stabilizers such as valproate and lithium are effective in mania, remember that Cade began his studies in severe psychotic patients, where lithium showed its effectiveness. Many patients leave their manic crisis with lithium or valproate and others with a combination of both, without resorting to antipsychotics, while mania is solved you can use a long half-life benzodiazepine (clonazepam is a good option) for a good sedative effect; and in agitated patients using benzodiazepines of short half-life (as midazolam, triazolam, etc. ..) is also effective to induce sedation. Unfortunately many professionals lean too easily by the use of antipsychotics (such as olanzapine, risperidone, or other), not for its antipsychotic effect but for the sedative effect. There will definitely be a number (very small, by the way) of patients who will have to use an antipsychotic, as have patients with bipolar depression who require an antidepressant, but in such cases the shortest time possible and limited to the crisis, in general few days (no more). I have had severe hospitalized manic patients treated only with valproate plus a benzodiazepine, without resorting to the use of antipsychotics, not to be afraid to use them but because I often can not find a valid justification for use rationally.

The answer then is to direct our therapeutic efforts to correct the basic instability and not just to get the patient out of the crisis. Resolving sub-syndromatic symptoms and return the patient to the stability and euthymia.

One of the mistakes people make most often is to make a diagnosis of schizophrenia in the presence of psychotic symptoms, this error -which originates in classification manuals (DSM and ICD)- is because the clinician, in the presence of psychotic symptoms, is forced to think first about the diagnosis of schizophrenia, leading to make an equivalence between psychosis and schizophrenia.

It is also important to note that between 50-75% of bipolar patients may experience psychotic symptoms throughout their lives, which can mask affective symptoms and generate diagnostic confusion.

Psychotic symptoms are so common in mania is not bold to say that mania is a psychotic experience. There are different models to explain mania, not only the categorical model (used in classification manuals): see for example the Court model or the model of Whybrow and Mendels, and more recently factorial analysis studies have helped us to better understand these syndromes by showing the existence of various subtypes of mania.

Between schizophrenia and bipolar disorders are schizoaffective disorders, in these clinical pictures the prevalence of psychotic symptoms has been controversial (are the one, are the other, or both?) However the longitudinal assess them often evident the cyclical aspect characteristic of bipolarity, there arose the concept of schizo-bipolar (of course this diagnosis involves other aspects beyond the clinical course). I believe that an unconventional but very practical way to differentiate is treated with mood stabilizers, a schizophrenic not respond to this controversial strategy, but a bipolar not be unnecessarily exposed to an antipsychotic. Something that often omitted as professionals is to see our patients as our family, in that sense we should consider with what intervention will do less damage to my patient?

There is an interesting paradox behind all this: despite all the advances in science and technology remain bipolar patients misdiagnosed as schizophrenic, and when these patients were removed antipsychotics and were initiates a mood stabilizer, a new world is opening up before them.

And, please, do not misunderstand me, I do not deny the existence of schizophrenia, but this definitely is much less prevalent than bipolarity, unfortunately in clinical practice it seems that we are happier dealing with schizophrenics than bipolar subjects, and find it easier too put a label of schizophrenic patient to work a bit and discard before a disease much more prevalent.

When considering the CNS, the question for me has been a "chicken or an egg" scenario. Nervous tic may just be the result of faulty wiring, yet cause anxiety and so on as it reeks havoc on the mentality. To the contrary, chemical imbalance may be the culprit. Can you see how treatment for each might be different? Not combined, and NEVER lithium or oxycontin! EVER YOU HAVE CREATED AN EPIDEMIC without precedent, thanks.

This is a really interesting thread, and if I was to add my voice to this conversation I would suggest that the literature around so-called bipolar disorders is about 20 years behind that for psychosis.

A good starting point to answering this question may begin with acknowledging the uncertainties in our current state of knowledge around key issues such as classification, causation, treatments as well as wider questions about psychological and social aspects of mood regulation difficulties. Given our current gaps in knowledge, I would suggest that clinicians base difficult decisions (inaction is rarely an option) on basic principles such as primum non nocere (first, do no harm), parsimony/Occam's razor, and crucially, listening to our clients.

Whilst I acknowledge that many people take medication (to varying degrees, with varying levels of choice, and with varying results) and may find this helpful in coping with mood regulation difficulties (even if it just results in people feeling less strongly about everything, not just the problematic issues in their lives), I'm optimistic that the role for psychological therapies will become more strongly established over the next few years (not just as an adjunctive treatment either) - the analogy for this can be found in the advances seen in psychological therapies for psychosis over the past couple of decades.

I strongly agree with Alvaro about how DSMs and other manuals have impoverished psychiatry, and lead to the ilusion that every psychosis is schizophrenia. Bipolar disorder, at least, doubles the frequency of schizophrenia, and one of the facts that help us differentiate Bipolar I and II is the presence of mania vs. hypomania. Considering that psychotic behavior is usually one of the aspects of mania, it's easy to understand how it can be misplaced as an schizophrenic episode. But it is also hard to understand how so many of our colleagues are tempted by that, when you know how differents are treatment and prognosis.

We must also admit how little we know about schizoaffective disorder. Is it a "grave" bipolar disorder? Is it schizophrenia with a better prognosis? Or is it just a third disease we know so little about yet? All I can say is that, when we are strict with criteria used (and don't fall on the temptation of misdiagnosing hebephrenia as "schizoaffective"), they usually have a good prognosis, and in the long run it is not rare they are well only on mood stabilizers, and sometimes with a little antidepressant added, but without antipsychotics.

Of more is to say that I completely agree with Rodrigo. Definitely in the land of mood disorders are some areas little explored, such as schizoaffective disorder, bipolarity in extreme ages and others, of which there will be much to say in the coming years.

However I would like to respond to the last comment of Maree: "So if a patient is diagnosed as bipolar and schizoaffective too - and improves with mood stabilizers, why use an additional medication such as olanzapine? What is supposed to do? When many drugs are administered to the patient how does the doctor what medication is doing?."

Dear Maree, from the practical and rational point of view, there would be no reason to. Moreover, when we review the available evidence (not the great flood of studies sponsored by the pharmaceutical industry, but from meta-analyzes and serious scientific studies sponsored by Universities or the NIH) found that logic would dictate not use them. However, when we review the prescription drug guides, these very hastily recommend the resort to this type of molecules.

I do not know what to expect other colleagues of adding a molecule as olanzapine in the conditions you said, all I can say is what I expect: A patient with an alarming over weight, abdominal obesity, abnormal lipid profile (especially increased triglycerides) with great risk of developing metabolic syndrome and that over the years could develop type II diabetes and die prematurely from any cardiovascular complication ...

Unfortunately, in countries like the U.S., the use of olanzapine is almost like a fad, and sadder still that in many sub-developed countries are copied these trends ... Why is this? It's a question that could be very interesting for another discussion.

From my humble perspective, I think (though I know many will not agree with me) that we are using many drugs irresponsibly and not necessarily for the benefit of our patients.

Thanks Maree: Francesc Colom & Eduard Vieta from Barcelona, Spain, have developed, several years ago, a method of psychoeducation in bipolar disorder that has been widely studied by several authors and has been used worldwide for many years. This method is very convenient and I really find very useful. There are about 21 sessions and at the end, the patient is more aware of his illness, the why of it, the importance of treatment, side effects, etc ...

I think that might work for utility, is available on Amazon: Francesc Colom, Eduard Vieta & Jan Scott: "Psychoeducation Manual for Bipolar Disorder".

The truly horrific and immediate 'side effect' of olanzapine is terrible constipation. Senna tea and magnesium both address this problem, a decent dose of magnesium of course helping to relax muscles, calm the mind and aid sleep.

One third of patients are non responders to atypical psychotropics yet this one solution persists.... When are people going to look at all the causes not discussed such as heavy metals, chemical exposure, food allergies, dental infections, failed root canals, fluoride, parasites, food additives and so many more? There has to be other practical treatments apart from psychological and bio-medical that slip past the industry controlled medical journals, lobby groups and one eyed government funding.

In many psychotic conditions, schizophrenia and major affective disorders ECT's have been used as a last resort. Psychopharmacologic agents may still be administered as an adjunct at an appropriate time. Psychotherapy can be used providing the client is up to it.

My point exactly.... all mind stuff and no addressing of holistic (whole person) physical cause. The mad cat lady is not even checked for toxoplasmosis, the scrap metal worker for lead poisoning, the sensitive child for food allergies, the street wanderer for rotten teeth, the traveler for unexpected parasites, the gardener for spray exposure, the junk food junky for nutrition starvation and blood sugar imbalance, the stressed worker for burnout, the person experiencing loss for overwhelm, the aware person who questions society and finds its all financial and power based smoke and mirrors for existential crisis.

We can all go mad given enough physical and emotional dis-stress such as sleep deprivation and pain. How would you like to be treated if this happened to you? Why treat the person who has been trapped in a car down a cliff for 3 days and is delirious differently to a person in society who was functioning well till something went seriously out of balance? Diagnosis, drugs and shock only compounds the crisis. Safety, rest, hydration, nutrition, cause identification and addressing that has to come before any long term disorder is slapped on a person.

Dear Heather. I think we all agree with you about the need to assess every other possible origin for a mental disease, meaning by it infections, poisoning, etc. But, you must keep in mind, that is exactly what a good psychiatrist would do. We can't take the blame for medical errors of other physicians, nor can medicine itself take it. We all know medical science has its flaws, but also has its strengths. Not taking notice of both is responsability of the physician who omitted it, not of psychiatry itself.

P.S. By "physician" I mean every speciality, including ourselves. Not to take the blame on general or family physicians, something that is so usually (and unfortunately) done.

I am by no means an expert on mental health problems, but I would like to add to the mix a question or two and perhaps an idea for an alternate therapy. My main question has to do with those who are unable to take standard anti-psychotic and anti-depressant medications because of severe allergic reactions and become unresponsive to the medications he or she can tolerate. What would you recommend for those individuals? Additionally, I have done a little research into using music therapy and the combination of guided imagery and music as a tool to calm the storms in the brain or as a stepping stone to medication adherence and better cooperation in talk/CBT therapy.. Would you recommend similar alternative therapies; especially for those who have difficulty with standard medication therapy?

Dear Christine:

The problem is that there are no studies that demonstrate the effectiveness of different forms of psychotherapy as a mood stabilizer in bipolar patients, at least I know no clinical studies in large populations, except for a few anecdotal experiences. In the field of psychotherapy, the best studied and the only one that has been well documented is psychoeducation, which has shown to improve treatment adherence and reduce relapse rate.

Moreover, in recent years being tested with omega 3, and there are some studies with N-Acetyl Cysteine​​, but the results are not conclusive, there are even some conflicting results.

Instead mood stabilizers (and this is a very small group of molecules with lithium as gold standard, valproate, carbamazepine, lamotrigine and quite possibly quetiapine) have shown efficacy in several trials.

Now that there is no evidence to support its use, does not mean they can not be used different forms of psychotherapy and other alternative therapies as adjuncts to treatment, that if, without losing sight that the goal of treatment should always be the recovery and maintenance of stability and euthymia. And, today, the only thing that has shown efficacy are mood stabilizers.

Regarding the possibility of allergy, something that we should always keep in mind is that bipolar patients rarely need treatment with antipsychotics or antidepressants. The problem with these, other than the possibility of allergies or intolerance, is its ability to produce severe adverse events (neurocognitive impairment, negative symptoms, depression, etc. -with antipsychotics-; and mixed episodes, manic switch, modification of cycling and others, with the use of antidepressants). In this context, the combined use of antipsychotics plus antidepressants, is completely irrational.

As I said, I am by no means an expert -however I have a niece who has proven allergic to about 4 or 5 of the medications she was given to control her bi-polar symptoms and has unresponsive to about 3 others. They have needed to find two or so that she can tolerate and cycle her on and off of them so they have effect. I do know that music has proven helpful under certain circumstances in lessening some psychotic symptoms in schizophrenia. Of course the paper I remember the details of was a small-n study. But there was another, more extensive study, I read that I used - along with the small-n study - for a paper comparing the effectiveness 3 forms of therapy psycho-pharmaceuticals, CBT, and an alternative therapy - individualized music therapy.

Sorry - I meant to add an attachment - this is one of the articles - the small-n case.

I will look up my paper and find the other article that included more test participants

Christine take a look at EMPowerPlus from Truehope Canada, they have a 10 history of helping people with an orthomolecular product. Their independent studies show at least a 50% reduction of symptoms and a 50% reduction of medication. Many people quit their meds all together. Their on-line and direct phone support is available in many countries and is included in the cost of the product. They work with the GP or psychiatrist and it is endorsed by a Dr C.W. Popper who is a very well known American psychiatrist.

Kaplan, B.J., Simpson, J.S., Ferre, R.C., Gorman, C.P., McMullen, D.M. & Crawford,

S.G. (2001). Effective mood stabilization with a chelated mineral supplement: An open-label trial in bipolar disorder. Journal of Clinical Psychiatry, 62, 936-944.

Kaplan, B.J., Fisher, J.E., Crawford, S.G., Field, C. J. & Kolb, B. (2004). Improved

mood and behaviour during treatment with a mineral-vitamin supplement:; an

open-label case series of children. Journal of Child and Adolescent

Psychopharmacology, 14, 115- 122.

Popper, C.W. (2001). Do vitamins or minerals (apart from lithium) have mood stabilizing effects? Journal of Clinical Psychiatry 62:933-935.

Alvaro,

Would you give mood stabilizers Li, in combination with Valproate to a patient who has suffered a sever Cerebral Trauma and has developed manic episodes from time to time? instead of other drugs.

Dear María, Personally I would like to know more about this patient (age, current diagnosis, if the patient was bipolar before the traumatic event, or if manic episodes are post-traumatic, etc ...).

Personally I do not believe that lithium is a good option in these kind of patients, who tend to respond better to anticonvulsants such as carbamazepine or valproate.

Dear Alvaro , patient is 26 years old with some evidences of mild depressions before the accident ( 1,5 years ago) but uncertain that this was a bipolar disorder. He was never treated before. By now he has been treated with Valcote ( 750 mg) in combination with Olanzapine. As you pointed out Olanzapine has not help at all with the recovery of executive functions, although it has been of great help in maniac episodes. (more or less every three weeks and not so severe). One suggestion of a college is to administrate Valcote R and Li together, but we have not arrive to this point because of the organic damage. I would appreciate your opinion!

I'm not sure that an internet forum such as this is the best place for discussions about individual patients - there's always the risk of breaking confidentiality, even if inadvertently. I would, however, make some general points. Firstly, it's vital to conduct a full assessment and formulation before making decisions about treatments/care planning. This should include assessing any post-traumatic psychological sequellae as well as (in this case) assessing the neuropsychological and social consequences of the trauma. Rather than trying to categorise this or that "sort" of patient, I reckon there is real value in developing a working understanding of the needs, capabilities, problems and wishes of this specific patient/person (as well as involving his family as allies in supporting his recovery). There aren't any shortcuts to doing this, even though there are some heuristics that may help with short-term coping whilst conducting a more comprehensive, individualised and recovery-focused care plan.

Saying that, it is absolutely worth drawing on best practice guidance, assuming that a patient/person does present with difficulties that are covered by such guidance. For instance, in the UK we have NICE (National Institute for Health and Clinical Excellence)guidance (the bipolar guidance is currently being updated, but here is the existing if somewhat aged version: http://publications.nice.org.uk/bipolar-disorder-cg38/guidance ). Within our National Health Service, this guidance is taken extremely seriously, even if there are sometimes challenges in implementing all of its' recommendations due to (for example) the availability of sufficient numbers of suitably trained psychological therapists to deliver the recommended interventions.

Also, I noted an earlier comment suggesting that there are no studies demonstrating the effectiveness of psychotherapy as a mood stabiliser. Whilst I would argue that psychological therapies such as Cognitive (and Cognitive-Behavioural) Therapies are not intended to control symptoms so much as to reduce distress, maximise recovery & wellbeing etc (in the words of Prof Max Birchwood, "CBT is not a quasi-neuroleptic"), there is a growing evidence base that CT/CBT based interventions can have a significant impact on affective "symptoms", relapse rates etc. The NICE guidance link I included above makes recommendations based on the extant literature at the time of publication, although there have been several trials since then, some of which are currently in progress. Clearly there is less funding available for trials of psychological therapies than there are for pharmaceuticals, so some studies are small scale pilot/feasibility RCTs rather than larger scale multisite RCTs. However my reading of the literature is that CBT/CT interventions appear reasonably effective (not for everyone, but I guess the same is true for other treatments such as medication), but that there is room for improvement in terms of effectiveness and developing a range of delivery methods in order to increase access to key components of such interventions (perhaps in a phase-specific manner). I've yet to see convincing evidence that psychological therapies are particularly effective in the short term during episodes of mania (though longer term therapy may reduce the likelihood of the occurrence of further episodes), but it's early days in terms of the development of evidence-based psychological therapies for this sort of difficulty, so time will tell...

Dear Maria:

I agree with Graeme that this is not the appropriate forum to discuss the treatment of a specific patient as we are omitting the most essential part of the treatment: the patient assessment.

However I think it is necessary to make some very general considerations: It is important to make a proper diagnosis, accurate and timely diagnosis is essential for the prognosis of the disease.

Lithium as a mood stabilizer is unparalleled, however, in patients with head trauma, neoplasm or other neurological comorbidities, there has been better effect with anticonvulsants.

Olanzapine is not a mood stabilizer, and though antimanic effect I don't believe it's a good choice (for its effect on the seizure threshold, the risk of metabolic complications, the risk of triggering depression, and the impact on the neurocognitive ability of the patient).

Both valproate and carbamazepine have an excellent antimanic effect, even the combination of both molecules may be more useful than other options considered.

As far as psychotherapies go, intensive short-term dynamic psychotherapy has proven very effective with all kinds of somatic problems including IBS and bipolar disease. I work with a patient who had recurring severe mood episodes, both psychotic mania and strong depression, before we began the ISTDP work. He has come in several times so manic that his speech was nearly incomprehensible, only to leave 2 hours later looking perfectly normal and then not escalating any other symptoms either. We have maintained this for 2 years. He has learned how to work through huge rage and disappointment at genetic figures in his past and this seems to have "defused" his bipolar episodes. I suggest looking at ISTDP.ca and TheISTDPInstitute.com for information on this modality of therapy. There are now practitioners all over the world. It is indeed much shorter term than other forms of therapy and Allan Abbass at Halifax, NS has shown that it is cheaper and the effects keep growing even 5 years out.

Good summary by AJ. As a non-professional, I would suggest from reading that almost all the medicines used for BPAD have cognitive effects, either anti-cholinergic (from diphenhedramine for sleep to anti-depressants used with mood stabilizers)or otherwise -- lithium notoriously as well as all the neuroleptics, and the benzodiazapenes sometimes given for anxiety or acute mania. And people with BPAD really like being supersmart and energetic during hypomania, thus their many complaints that medication makes them "not myself, another person." The self they often fix upon is the hypomanic self.

In response to earlier comments, people I know and meet with BPAD who will abide talk therapy regard it as vital, possibly because it contains psychoeducation, but often CBT or DBT because those are more transparent and problem-focused. (An untested theory of mine is that everyone with major mental illness develops some "borderline" traits over the course of the trauma of having major mental illness.)

I agree with the last statement about "borderline" traits, in general. That's why, sometimes, an easy diferential diagnosis between borderline personality disorder and bipolar disorder is not easy, specially when the disease begins in childhood (rare, but it's sometimes seen) or in adolescence (not so uncommon as we once thought). We must take into account how disruptive it is for a personality that is developing to have, almost out of nothing, something that changes completely your way of behaving in day-to-day life (be it maniac or depressive episodes), and then, after a few months, have to digest that not only that wasn't yourself, but that it can also happen again sometime. Once diagnosis is accurately made and mantenaince treatment is optimized, there's a long way for an adolescent to internalize it. In that time, drop of treatment is frequent, so recurrence use to be frequent too, and then for the patient is easy to acknowledge the inestable self as "the real me". So that's why psychotherapy is so important not only as a way of psychoeducation, but as a way of knowing again oneself also.

About medication, I'm not so sure about cognitive effects. Cognitive alterations are drug-specific, and we cannot generalize about it. In my experience, when the most used therapies produce cognitive effects, it's usually due to an excess of the administered dose, so it resolves very well after reducing it, or, if it's not possible because of lack of response, then the best option is just trying to use another treatment.

Lithium, in particular, does not produce cognitive effects unless there's intoxicating signs (it's important to note that intoxication is idiosyncratic, so there can be patients intoxicated with normal blood levels). In fact, there are studies showing a possible neuroprotective effect (although that is also on doubt today).

About benzodiazepines, it's true they produce cognitive alterations, but we must remember they are NOT treament of bipolar disorder, they are just ansyolithics, so there is no reason to keep then in the treatment phase.

The only mood stabilizer widely known to affect cognitive function is topiramate. But it's not a very good mood stabilizer, by the way...

About antidepressants... the anticholinergic effect is characteristic of tryciclics. But antidepressants (and particularly, tryciclics are not part of the maintenance treatment). In fact, in many many cases they can be detrimental

Let's remember that we have not bothered to develop ANY biological measures for any of the disease processes mentioned in this discussion. Even the discovery 40 years ago that people with low levels of platelet MAO were clinically bipolar hasn't been translated into clinical practice. There are also indications that an elevated platelet MAO may mimic a borderline personality disorder - and responds quite nicely to MAOIs. I would like to make a plea for all of us to included the results of a basic higher cortical function workup with an MRI, CT scan, computerized EEG, and neuropsych. testing, metabolic screening for heavy metals, endocrine screen, tox screen, genetic screen/family history, and a basic neuro workup. At least ONCE in every patient's career these must be done. Our job is to find the treatment that takes the least time at the lowest risk with the highest protection against relapse - not to use patients to justify a favored treatment that we just happen to bill for repeatedly. Rational supportive therapies have always been the treatment of choice for illnesses that had no physiological mechanism established. Atrial fibrillation will probably resolve---eventually...with soothing image production and meditation - that is unless the patient happens to flip an embolus while he's chanting. As long as a practitioner is willing to take full responsibility for the outcome of a recommended treatment and advises the patient about risks and merits we're all on the right page clinically.

I agree to some degree with Mr. Rohde. I would always argue to take the bigger picture and do every reasonable test that might provide useful data. I would argue that a SPECT or PET scan would be much more useful than most MRI or CT scans or QEEG, as they are much more detailed looks at levels of activity by brain locale. I do neuropsych testing and tons of interviewing and paper and pencil testing. I agree that we must be well networked with physicians and geneticists who can provide this kind of quality data for our patients. I do these things with my pateints as I believe in them. More directly, every patient's diet, sleep hygiene, and exercise routines are scrutinized and I explain that unless these three are in good working order and they are disciplined about them, we may never know what is going on. Too many variables and risk factors at work.

Thank you Dr. Ammons. We clearly lack an algorithm for treating alcohol and illegal drug of pleasure cravings. Here is the pattern that we need to address, regardless of our professional association or training: When a patient presents with a psycho-social-behavioral collapse associated with the use of an intoxicant, if the intoxicant isn't pleasurable, such as atropine-like substances found in OTC sleeping pills, or bromides, the patient goes to and stays in medical treatment until the underlying condition that provoked the craving has been identified and treated medically. However, you and I know that exactly the opposite happens when the collapse is due to toxic ingestion of a drug of pleasure: We do everything EXCEPT search for the underlying condition that provoked the craving for a chemical that the brain wasn't producing adequately. Regardless of how dedicated we are to the belief that you can talk anyone out of cravings for exogenous chemicals which made them feel better and alleviated their mental suffering - which billions of people seem to have instinctively reached for throughout human history - we have used rattling gourds and shaking feathers along with chants and hymns as the "legitimate" ways to separate sick people from the chemicals that helped them originally - but had become dangerous due to unwanted side effects. We don't "get it" that we have to find safer and more effective chemicals to offer people who only want to "feel better." Obviously, for many if not most sufferers, the brain will eventually repair itself given time and a safe environment. Endogenous depression episodes usually resolve in 2 - 3 years, which is about the same time frame as a course of talking treatment. As you point out, we have multiple effective interventions for transitory neurotransmitter deficiency states. I am not interested here in discussing the relative merits of CBT versus ECT, etc. This narrows the field of conditions that must be detected and treated acutely. Brain trauma, principally temporal lobe damage has to be at the top of the list to be ruled out immediately. TLE can manifest as mood swings refractory to the usual bipolar treatments, intractable depression, maladaptive social behavior, stereotypic or compulsive pattern repetition, and may be associated with panic attacks and agoraphobia. Next, always look at the back of your patient's head to appreciate scars, hair loss, patches of discolored hair -- indicating the presence of countercoup frontal lobe brain damage. You must treat those conditions - you can't correct a broken brain with soothing words and empathy alone. That is why a CT scan, a dynamic MRI, and a computerized EEG, in addition to thyroid screening and detection of a family history of panic disorder or agoraphobia are mandatory. Reparative and reconstructive cognitive treatment can and should be done after we have a working brain that can process information predictably.

I strongly disagree with something. The endogenous episodes doesn't resolve in 2-3 years, the natural history for inicial episodes is about 2 - 3 months. But melancholic (or endogenous) depression has recurrence of episodes, just as Bipolar Disorder, and in the long run they are less easy treatable, last more time, and leave cognitive deficits. That's why, even if neuropsychological assessment and neuroimaging are very useful tools, they are not near the solution for the problem. We FIRST must do a diagnosis, and then use complementary tests according to a finding. If it were the reverse, and you diagnose depression by SPECT, how would you difference it from initial frontal dementia? Are there studies about frontal metabolism in hypothiroidism? Because if they share neurological pathways, it's also probably they will share that too.

By the contrary, I strongly agree with the observation about TLE. I work in a public health facility, and many many patients diagnosed as refractory depression, bipolar disorder, schizophrenia, etc. are in fact epileptic patients. There's important to note that, when the epilepsy is frontal it use to have motor symptomatology that sometimes is missed, and EEG tends to be pathological in more cases. But TLE usually doesn't have motor manifestations (unless it has automatisms, which tend to be unnoticed), and the usefulness of the EEG is very less (about 30% in standard protocols).

So, it goes back to the same always: the only perfect way to make diagnoses is clinical. So we have to explore exhaustively the patient information, and look at every little hint that could guide us to an "unexpected" disease