Sagar V Parikh and Sidney H Kennedy

Bipolar disorder is often characterized by grandiosity as a cardinal symptom of mania, but grandiosity may also characterize the illness from another perspective: virtually no other psychiatric disorder is as grand in its plethora of clinical presentations (Goldberg & Harrow, 1999; Goodwin & Jamison, 1990). Depression, mania, and mixed states each require substantially different biological, psychological, and social interventions, and even the same episode can be approached very differently by two biological psychiatrists or two psychotherapists (Prien & Potter, 1990; Prien & Rush, 1996). How is a practitioner to choose among the many pathways to treatment? The science of medicine identifies the efficacy of each particular path, but only the art of medicine—the weighing of individual circumstances with clinical judgement and the capacity to integrate approaches—allows for truly effective treatment. This chapter explores several dominant approaches to treatment, each of which has been discussed in detail in this book—but it then attempts to provide a model for weaving a therapeutic tapestry.

The challenges of treatment are perhaps best shown by examining a common clinical scenario illustrating how different experts might approach the problem and then offering a sequence of recommendations based on the integration of approaches at the end of the chapter.

Vignette: Bipolar depression. Mr Y is a 22-year-old college student with a previous history of a psychotic manic episode requiring 3 weeks of inpatient treatment at age 19. He had discontinued lithium and antipsychotics after 6 months of treatment originally, because he "didn't need pills to be well". He was successful in his studies, was in a serious relationship, and had become an impassioned animal rights activist. He was particularly skeptical of medical research for its reliance on animals, and fond of movies that depicted

Mood Disorders: A Handbook of Science and Practice. Edited by M. Power. © 2004 John Wiley & Sons, Ltd. ISBN 0-470-84390-X.

psychiatric problems as a result of individuals struggling to assert individuality in the face of oppressive societal norms. Two months prior to the current assessment, he developed low energy and difficulty in concentrating; this had evolved to more explicit major depression with excessive sleepiness, overeating, severe depressive ruminations, social withdrawal, hopelessness, and suicidal ideation. Nevertheless, he felt that it was not right to kill—either animals or himself—and so he sought help to "get over the suicidal urges and get my energy back".

How should he be treated?

Most psychiatrists would agree that medication—most likely a mood stabilizer such as lithium—would be a critical first step. Major treatment guidelines on bipolar disorder stress the importance of this step, and cite the substantial evidence on the use of lithium mono-therapy for bipolar depression (Bauer et al., 1999; Kusumakar & Yatham, 1997). Common clinical practice, however, often includes starting both a mood stabilizer and an antidepres-sant concurrently, to treat fully the depression, despite limited research evidence for this. Further complicating the biological approach is the lack of agreement on which antidepressant should be used, although most, if not all, biological psychiatrists would probably agree on the mood stabilizer/antidepressant combination in conjunction with "medication visits".

Psychotherapists might take a more complex approach (Roth et al., 1996). Most would grudgingly accept the need for a mood stabilizer, but the target and technique for psychotherapy would differ markedly. Cognitive-behavioral therapy (CBT) practitioners would target the depressive ruminations, social withdrawal, hopelessness, and suicidality. Interpersonal psychotherapy (IPT) practitioners might attend to the sleep changes while searching for evidence of interpersonal deficits or conflicts underlying this particular episode. Still other therapists would also look to family/couple or even psychodynamic issues for intervention. Members of the public and self-help advocates might counsel the wisdom of avoiding the formal health-care system and looking to time, social support, and environmental change as key steps to be pursued. In particular, stigma as a barrier to recovery would be targeted by some (Perlick, 2001). Idealists would look at integrating a variety of interventions in the most "person-centered" way. For each intervention—biological, psychological, and social—advice would be available in the literature, and, indeed, in this volume—yet how to decide what is right for this person? Furthermore, how would one design a bipolar treatment service that would best suit situations such as this?

Bipolar Disorder Uncovered

Bipolar Disorder Uncovered

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