Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression

Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression-The Essential Guide to Recognize and Treat the Mood Swings of This Increasingly Common Disorder

by Ronald R. Fieve
New York: Rodale Press, 2006
275 pages o $22.95 (hardcover)

Ronald Fieve and his colleagues were among the first to document milder versions of manic symptoms-hypomania-in the 1970s, observations that did not make it into DSM until 1994. Perhaps the reason for this delay is that hypomania is possibly the only DSM axis I condition that does not involve marked functional impairment and, in fact, requires the absence of such impairment. It is a condition in which persons are happy and functional. How are they not normal? One difference that can be noted in this condition, as Hagop Akiskal once quipped, is that it is episodic: hypomania is recurrent, whereas happiness is not.¹

Besides the absence of impaired function, the distinction between hypomania and mania is also complex. If a patient is manic, clinicians tend to call him or her hypomanic. However, the difference between the two is important because when determining the best treatment for patients with type I bipolar disorder (BDI), a great deal of evidence for this type exists that should constrain our decisions (eg, the proven benefits of the use of mood stabilizers, the need for caution when prescribing antidepressants).

In determining the best treatment for type II bipolar disorder (BDII), there are so few data that the clinician is left to do what he sees fit. For instance, there are no randomized prophylaxis data and no placebo-controlled antidepressant data for BDII.

The reticence of the pharmaceutical industry and the FDA to study or provide indications for BDII is based on the vagaries of clinical practice: some clinicians cannot distinguish it from normality, others from mania. In addition, BDII frequently overlaps with unipolar depression. Recent data suggest that up to half of persons who have refractory depression in fact have BDII.²

Into this void steps Ronald Fieve with a follow-up to his 30-year-old book, Moodswing, which introduced America to BD and lithium. Fieve joins Jim Phelps,³ another psychiatrist with bipolar expertise, in writing the first books to introduce the bipolar spectrum concept to the public. He provides a rational, objective review of this subject with a great deal of common sense that is based on decades of clinical experience and many illustrative cases.

This book appears mainly to be intended for families and patients; clinicians might find some parts simplistic and other parts informative. The book is divided into 2 sections-"Bipolar II Defined" and "Diagnosis and Treatment of Bipolar II." Over half of the book is devoted to "Bipolar II Defined," with much less space given to treatments. In Chapter 9, "Special Situations That Complicate a Bipolar Diagnosis," Dr Fieve touches on the third rail of psychiatry-the concept of attention-deficit/hyperactivity disorder (ADHD)-and makes the observation that many children and adults have either BD with or instead of ADHD. His discussions of mixed states, pregnancy, and the elderly are also full of clinical wisdom.

Perhaps the most controversial section is Chapter 6, "The Hypomanic Advantage of Bipolar II Beneficial." Here, Fieve tries to do a lot in limited space, with short paragraphs on historical figures like Lincoln, Churchill, and Theodore Roosevelt, as well as comments on contemporary celebrities like Ted Turner. These historical facts are too complex for such a book; Lincoln, for instance, was clearly severely depressed but not as clearly hypomanic or energetic as is implied here.⁴ Even if we admit that some of these figures benefited from bipolar illness, it is arguable whether they had BDII. Turner and Churchill appear to have had full manic episodes, making the diagnosis of BDI more probable.

The larger issue is whether and how hypomanic, as opposed to manic, symptoms are useful or helpful. Fieve repeatedly and appropriately cautions readers that such symptoms can be followed by severe depression or can segue into severe mania and, thus, should not be viewed simplistically. And, as some advocates and patients have noted, Fieve's emphasis on the positive aspects of hypomania is affirming and fights stigma. I agree with these perspectives, but I also have some concern that some persons with BD (usually type I) may misinterpret some of Dr Fieve's comments when they are manic as further justification for denying their illness. Consider the following: "If you do have [BDII], celebrate the highly adaptive, high- energy, hypomanic mood state . . . that enables you to accomplish greatness. Take advantage of the productivity and nonstop ideas to rise to the top of your field."

Dr Fieve notes that many of his patients are highly successful New Yorkers; I wonder how much of his experience is limited to patients typical in New York City or other major cities where other psychiatrists also note a high prevalence of bipolar spectrum conditions. In contrast, in China, it is reported that hypomania, far from being highly adaptive, seems to lead to notable consternation socially, while psychological symptoms of depression are not viewed as pathologically as they are in the West.⁵

Be that as it may, Fieve raises an important point and tries to be objective. While emphasizing the need for treatment of the depressive component, he also warns clinicians against overtreating patients who exhibit the beneficial symptoms of hypomania. One cannot help but agree with Dr Fieve, although it is my experience that clinicians are more likely to undertreat mania than they are to overtreat hypomania. Clinicians do not treat BDII out of the need to relieve the symptoms of hypomania-which is by definition unnecessary since hypomania is not dysfunctional-but instead, do so out of the realization that this variety of bipolar depression may need a different treatment approach from non- bipolar depression (eg, mood stabilizers versus antidepressants).

In sum, Fieve has now provided patients and families, as well as clinicians, with a wise summary of the state of the art as it relates to BDII. Although more needs to be said, and some aspects of this book may be misinterpreted, it is time that BDII received more attention; books like this one are a good start.

References:

References:1. Akiskal HS, Mallya G. Criteria for the "soft" bipolar spectrum: treatment implications. Psychopharmacol Bull. 1987;23:68-73.
2. Sharma V, Khan M, Smith A. A closer look at treatment resistant depression: is it due to a bipolar diathesis? J Affect Disord. 2005;84:251-257.
3. Phelps J. Why am I still depressed? New York: McGraw-Hill; 2006.
4. Shenk JW. Lincoln's Melancholy: How Depression Challenged a President and Fueled His Greatness. New York: Mariner Books; 2006.
5. Kleinman A, Mechanic D. Some observations of mental illness and its treatment in the People's Republic of China. J Nerv Ment Dis. 1979;167:267-274.