Posts Tagged ‘bipolar disorder’

The Psychopharmacology of Lithium

The Psychopharmacology of Lithium

F. Neil Johnson

New York, Oxford University Press, 1984. 327 pp.

Lithium is, at the same time, one of the most effective and one of the most poorly understood psychiatric medications. In this text, Johnson reviews a broad range of basic research and clinical data in an attempt to derive a cohesive model which explains the behavioral effects of the drug. Johnson is an experimental psychologist, and his work underlies many of the chapters which suggest that lithium decreases the behavioral response to novel external stimuli. He then utilizes this foundation to propose a cognitive model for lithium’s anti-manic action, its inhibition of violent impulsivity, and its prophylactic effects in recurrent depression.

Previous formulations which were clinically based, such as that of Mabel Blake Cohen and her associates, stressed the primacy of depression and noted the “manic defense” as an attempt to ward off intolerable depression. In direct contrast, Johnson views mania as the primary disturbance in bipolar disorder. He considers depression in bipolar disease as an over-zealous homeostatic inhibitory response to a mania-associated cognitive overload. Consistent with this, he believes, littium exerts its anti-manic effect by decreasing cognitive processing in a manner analogous to his animal studies. Johnson also suggests that lithium exerts its prophylactic effect in recurrent depressions by treating subclinical mania. These concepts are supported by the work of Johnson’s associate, Kukopulos, to whom the book is dedicated. The bulk of the research which describes the cognitive disturbance in mania is complex, however, and uncomfortably open to multiple interpretations. Recognized as a preliminary effort, Johnson’s formulation may help to guide further research.

Although Johnson clearly traces lithium actions through a broad range of subjects, his discussion of the neurophysiological aspects of this drug is notably spotty. In particular, Johnson ignores the work of Svensson, DeMontigny, Aghajanian, and others who suggest that serotonergic systems may play an important role in the antidepressant actions of lithium. As a result, he fails to discuss one of the most important current uses of lithium: as an agent used in conjunction with antidepressant medications to increase treatment response in medication-resistant forms of depression. Lithium augmentation of antidepressant medication also challenges the formulation presented by Johnson. This formulation suggests that lithium should have no therapeutic value in patients, such as those with endogenous depression, who already “under-process” cognitive information. The omission of lithium augmentation in depression is clearly unfortunate in this text.

Overall, this volume demonstrates the benefits of a single-authored text. It it clearly organized and readable. The bibliography is also broad and useful. In this book, Johnson primarily addresses a research audience, and his model seems designed to stimulate thought rather than to improve clinical technique. In this capacity, his book will be of most interest to behavioral psychologists. Other books, focusing purely on clinical data, may be more useful to clinicians. Nevertheless, the clear organization, the large bibliography, and the thoughtful presentation may make this text a useful addition to a clinical library as well.

Bipolar Disorders

Bipolar Disorders: Clinical Course and Outcome

Goldberg JF, Harrow M, editors

Washington (DC): American Psychiatric Press; 1999. 315 pp. with index

ISBN 0-88048-768-2 (cloth)

This volume is based on a symposium held at the annual meeting of the American Psychiatric Association in 1995. Various authors have contributed data on the course and outcome of bipolar disorder. Almost without exception, these data are from their own research programs, supplemented with a limited literature review. The topics covered are broad, including naturalistic outcome studies, the impact of a broad range of treatments — both pharmacotherapies and psychotherapies — on outcome, as well as the impact of comorbidity on the long-term prognosis of bipolar disorder. Other topics include clinical subtypes, such as rapid cycling and bipolar II disorder, and hypomania.

The book is comprehensive in its broad range of topics covered. Unfortunately, however, this comprehensiveness is achieved at the expense of a more in-depth and critical analysis of each topic. With a few notable exceptions, each chapter is quite cursory in its approach to the topic under consideration. Furthermore, as with many multi-authored books derived from symposia, the individual contributions are neither direct reports of particular studies nor a comprehensive and up-to-date literature review of the topic. Rather, one gets something in between, with the author’s individual studies supplemented by a relevant, but unnecessary, comprehensive literature review.

There are some very good chapters. For example, the chapter on psychotherapies by Miklowitz and Frank manages to achieve a succinct literature review and present some very tantalizing data on new psychotherapeutic approaches. Maj presents some very interesting findings on lithium prophylaxis of bipolar disorder, although frankly it is much more satisfying to read his original research reports. A chapter by Bowden compares and contrasts findings from open clinical studies and randomized controlled trials. This is particularly relevant to the literature on bipolar disorder, in which a vast amount of findings are from open clinical observation. This is an interesting attempt by Bowden but, because of the presumed constraints of a relatively brief chapter, the topic is not thoroughly dealt with in a way that the importance of the topic and the expertise of the author would justify. I thought that the chapters on comorbidity with alcoholism, substance abuse and anxiety disorders were an important addition to the book as these are very rarely broached in books on bipolar illness.

This book would have some interest for community psychiatrists and residents looking for a relatively brief review of the course and outcome of bipolar disorder. One cannot term this book an “update,” as much of the data has been superseded by the recent explosion of information on bipolar disorder. Furthermore, it adds very little to such important, seminal texts as Manic-Depressive Illness by Goodwin and Jamieson.

Schizotypy: Implications for Illness and Health

Schizotypy: Implications for Illness and Health

Claridge G, editor

New York: Oxford University Press; 1997. 340 pp with index

ISBN 0-19-852353-X (cloth)

Psychiatrists and psychologists start from a different place. Given their medical background, psychiatrists tend to emphasize the dichotomy between health and illness. Moreover, classifications of mental disorders, such as the various editions of the Diagnostic and Statistical Manual of Mental Disorders, are taken to imply that psychiatric illnesses, like medical conditions, are distinct entities with unique etiologies.

Yet a great deal of evidence indicates that psychiatric diagnoses are very fuzzy indeed. In fact, the phenomenon of “comorbidity,” which is the focus of many research studies, may be nothing but a reflection of the failure of the categorical system to describe psychopathology adequately.

Psychologists, who study normality and variation from it, are much more inclined to see health and illness as continuous. Since the editor (a professor at Oxford University) and most of the contributing authors of this book are psychologists, it is not surprising that this volume takes a strongly dimensional view of psychopathology. “Schizotypy” — the focus of this book — can be conceptualized as a set of traits that form the basis of a variety of illnesses, ranging from schizophrenia to personality disorders, as well as of normal variations in personality that can produce eccentricity or creativity.

Two issues arising from this theory are of particular interest to psychiatrists. First, some evidence suggests that both forms of psychosis originally described by Kraepelin (i.e., schizophrenia and bipolar disorder) could lie on a single dimension, and may not be as separate as we often assume. Second, disorders not usually considered to reflect schizotypal traits, such as obsessive-compulsive disorder and dyslexia, may reflect the same psychopathologic dimension — at least in part.

Several chapters in the book raise questions of broader theoretical significance. There are excellent reviews of research on cognitive processes and cerebral lateralization in schizotypy. Other chapters concern the measurement of schizotypal traits. Finally, there is a whole section entitled “schizotypy in health subjects.”

This book has strengths and weaknesses. Since all chapters are written by Claridge and his collaborating colleagues, the text is much more coherent than many multi-author books. On the other hand, research conducted outside of Great Britain is not given enough weight. Although Claridge suggests that readers also consult a recent companion volume based on a conference on schizotypal personality, the contributions of investigators such as Holzman and Siever and Davis could have been given much more space.

Claridge’s strong editing leads to a relatively high standard of scientific writing throughout. Inevitably, however, some of the chapters are hard-going, while those written by the editor himself are the best. Claridge is a natural writer and communicates in an incisive and witty way that quickly engages the reader.

I was particularly stimulated by Claridge’s ideas about how to conceptualize psychopathology in a dimensional system. The point of view is refreshingly different from the perceived wisdom in North America. These principles are also developed in several of the chapters written by neuropsychologists.

Although I agree strongly with the general approach of this book, it lacks breadth. It fails to address some of the most crucial areas for theory, most particularly genetics and neurobiology. I also found myself less than sympathetic toward the chapters on normal schizotypy, some of which come dangerously close to reviving the Laingian romanticism of the 1960s.

A related objection concerns the emphasis in many chapters on the role of psychosocial factors in the etiology of schizophrenia and related disorders. I agree with Claridge that psychiatrists are often too busy prescribing medication to consider individual differences in the psychology of their patients, and that cognitive therapy may well have a role in the treatment of psychosis. However, his views on the role of the environment can be somewhat quirky, most particularly his somewhat dogmatic idea that trauma and bad parenting are the major factors that determine whether traits develop into disorders.

With these caveats, I found this book highly original and extremely thought-provoking. Researchers studying disorders related to schizotypy will find it a useful reference, and clinicians and clinician-teachers will benefit from reading the theoretical chapters. The main impediment to the wide use of this volume is the price, which, whatever the state of the Canadian dollar, is much higher than for books imported from our southern neighbour.

Child and Adolescent Psychopharmacology

Child and Adolescent Psychopharmacology

S.P. Kutcher

Philadelphia: WB Saunders; 1997. 509 pp. with index

ISBN 0-7216-5749-4

This book represents the state of the art in childhood psychopharmacology. Well written and capturing the highest level of existing evidence in the field, it serves as a reference text as well as an instructive how-to manual for those practising childhood psychopharmacology.

The text is organized into five sections. Section 1 is very brief and introduces the book by outlining the move toward empiricism in child and adolescent psychopharmacology, specifically, and childhood psychiatric disorders, generally. A broad clinical model is emphasized, to bring the science of the controlled experimental study into the realm of the clinical environment by combining medication with other empirical interventions.

Section 2 deals with baseline assessment before beginning psychopharmacological treatment. The section begins with general issues and then moves to more specific assessment, both in terms of rating scales for different disorders as well as more specialized ancillary assessments such as family, social and interpersonal, academic, speech and language and institutional assessments. The fourth chapter of the section covers baseline medical assessment for psychopharmacological treatment. Useful pointers in the medical history, exclusion of medical illness, baseline investigations and monitoring (including principles of therapeutic drug monitoring) are covered extensively.

Highlighted summaries allow quick rereading of a chapter. In addition, chapter 3, which deals with individual baseline psychiatric assessment for psychopharmacological treatment, has several useful tables with pointers to the psychiatric diagnosis. The reader is referred to relevant rating scales contained in the appendices. Of great use to the busy clinician is the visual analog scale, which allows for baseline rating and monitoring of specific target symptoms. Chapter 3 uses case examples and commentaries to illustrate points made in the text. These cases are relevant and reminiscent of my own day-to-day practice. Each raises important clinical examples and dilemmas. Rather than distracting from the text, in most cases they reinforce the text and make the book more readable. This excellent technique continues through the rest of the book.

Section 3 covers the planning, initiation and provision of psycho-pharmacological treatment. Although superficially this section seems to repeat some of the content of the previous section, it does in fact offer additional wisdom and deals with important practical issues in the treatment of children and adolescents generally and psychopharmacology more specifically. The principles of patient and family education are clearly articulated, as are the standards of informed consent. While legislation may vary in different jurisdictions, a useful set of guidelines is provided for obtaining informed consent from both the child and family, taking into account the developmental and cognitive status of the child. Throughout, the book adopts a respectful client-centred philosophy. This attitude is well reflected in the clinical case examples.

Section 4, appropriately the most dense segment of the book with 10 chapters, deals with the clinical practice of child and adolescent psychopharmacology. Each chapter outlines the treatment of a particular disorder, with 3 chapters devoted to the anxiety disorders; the first of these very briefly describes the general issues in the psychopharmacological treatment of the anxiety disorders, followed by a chapter devoted to the treatment of panic disorder and the third to other anxiety disorders. The author emphasizes the high morbidity of anxiety disorders beginning in childhood and suggests that evidence supporting the principle of least intrusive intervention first is lacking. Combined interventions (pharmacological and psychological) applied aggressively, especially when symptoms and functional impairment are significant, may lead to better outcomes. This principle is applied in the subsequent 2 chapters. In keeping with the format of the book, these 2 chapters guide the clinician — with the use of case material — through the management of these disorders, providing a framework for assessment and measurement of outcome, as well as the specifics of drug choice, augmentation techniques, dosage ranges and some principles for treatment duration.

Other chapters that are highly recommended are those on the treatment of depressive disorders and bipolar disorder. In chapter 11, the author takes the reader through the standard management of depressive disorders in childhood and adolescence using 2 case examples and commentaries, which highlight treatment issues. The text is written like an expanded step-wise treatment manual but remains interesting and readable. The chapter focus is on the use of selective serotonin reuptake inhibitors (SSRIs). While the author clearly outlines alternative and augmentative treatment strategies, he completely dismisses the use of tricyclic antidepressants (TCAs) as alternatives, although there may still be a role for these drugs — for example, the use of desipramine or nortriptyline to treat dysthymia in adolescents with comorbid attention deficit hyperactivity disorder. There is only a single line devoted to the newer-generation antidepressant venlafaxine, and this appears odd and out of context. Nefazodone is not mentioned at all, perhaps because of its novelty.

Chapter 12 is thorough in its review of the thymoleptics and ancillary treatments for bipolar disorder. A subsequent edition will likely review the use of the novel antipsychotics, especially risperidone and olanzapine in the treatment of bipolar disorder with psychosis. These drugs are not mentioned, perhaps as a result of the author’s use of the highest available level of evidence in outlining psychopharmacological treatment of children.

If this book has any drawbacks, it is a tendency to be long-winded and repetitive. For example, the last paragraphs of the 2 case commentaries in the chapter on acute schizophrenia (chapter 13) are almost identical. While each of these paragraphs (page 224 and page 225) “emphasize[s] the importance of using proper pharmacological treatment within the context of optimal and comprehensive care” “and keeping in mind the expected paradigm of chronic care with the goal of controlling acute symptoms, preventing relapse, and optimizing patient function,” a single statement would suffice. Occasionally, terminology is used loosely; for example, neuroleptic malignant syndrome is referred to as a “true psychiatric emergency” when it is better defined as a true medical emergency. The section describing “initiating and optimizing methylphenidate treatment” (on page 279 of chapter 15, “Psychopharmacologic Treatment of Attention-Deficit Hyper-activity Disorder”) is quite unclear: 2 potential strategies are outlined (1 and 2) and then strategy 3 (which appears to be strategy 1) is referred to in the case example. Furthermore, it is difficult to determine any real difference between strategies land 2.

There are 7 appendices, which provide an inclusive array of potential rating scales available for the use of psychopharmacologists treating children. The book is well indexed, and a useful reference list can be found at the conclusion of each chapter.

Overall, this book is a very useful addition to the growing library of texts on child and adolescent psychopharmacology. I strongly recommend it as a useful and practical guide for practitioners prescribing psychopharmacologic agents to children and adolescents. I look forward to an updated and perhaps more streamlined edition in a few years’ time.