by E. Fuller Torrey and Michael B. Knable
Basic Books, 2001
Review by Robert Tarzwell MD, BA on Jul 16th 2002
Manic-depressive illness, state the authors in
their opening paragraph, is now openly discussed as a brain disease. This places them squarely in the camp of
biological psychiatry, and indeed I suspect this is where they would choose to
identify themselves, at least with regards to Bipolar Disorder (BD), the topic
of this book. Rather than BD, the
terminology of DSM-IV, the authors intentionally choose the term
Manic-Depressive Illness, explaining in a preface that this term is more
accessible to the general public.
Topics discussed in the book are
broken down in a similar manner as they might be in a medical textbook focused
on a particular disease, but they are given much friendlier titles. For instance, the first chapter, Dimensions
of Manic-Depressive Illness, is actually a chapter on the epidemiology of
BD. However, the chapter subjects are
treated in sufficient depth for the book to easily suffice as a stand-alone
psychiatric text, or even a reference, suitable for a junior psychiatric
resident seeking a deeper understanding of the disease. This junior psychiatric resident, at least,
certainly found that to be the case.
Although Torrey and Knable discuss
an impressively broad array of technical topics, and all in considerable depth,
this sometimes occurs at the price of being tedious. I periodically found myself losing interest in the exhaustive
detail, even while admiring its thorough completeness, and I wondered about the
usefulness of such technical detail for general audiences. For instance, I can hardly imagine a non-technical
audience being able to easily slug through the above-mentioned opening chapter
on the epidemiology of BD. This detail
could easily have been relegated to an appendix. Fortunately, the authors wisely sprinkle the text with bulleted
side-bars to encapsulate their core points, and detail-o-phobes who are
nevertheless interested in knowing core points about BD will find these
side-bars a welcome relief.
The work becomes far more engaging,
both topically and stylistically, in its second chapter, The Inner World: Mania and Depression from the Inside. The reader is offered rich, detailed
descriptions of the symptoms and signs of BD, presented from a nicely eclectic
sampling of clinical literature of the past and present, quotations from books
written by famous manic-depressives, and passages from literary, poetic, and
dramatic works about the illness. The
authors achieve an impressive balance between full explication of the clinical
phenomena of the disease and a sympathetic portrayal of the illness experience
from the perspective of the sufferer.
From the point of view of pure human interest, the second chapter is the
most compelling, even heart-wrenching, particularly in its vivid descriptions
of the depressive side of BD. Torrey
and Knable make an impressive case that mania and depression are not simply
happiness and sadness to a greater degree but are qualitatively distinct,
personally destructive, phenomena.
The next several chapters delve
largely into the technical, considering such topics as the spectrum of
disorders that a psychiatrist must consider when confronted with a patient
exhibiting mood symptoms, other causes of mood symptoms, such as medications,
infectious disease, or trauma, the risk factors for developing BD, and the
typical course of the disease. As with
the chapter on epidemiology, the detail, while being complete, can run into the
Chapter 7, Causes, deserves
separate consideration in this review.
Here, the authors look at the cutting edge of research: high-resolution brain scanning, genetics,
immunology, neurochemistry, and even evolutionary psychology. For those interested in seeing where the
latest breakthroughs in basic and clinical neuroscience are coming from, and
how those techniques are applied to solving complex problems, this chapter is
very exciting reading. As one brief
example, from the evolutionary perspective, the authors discuss the intriguing
idea that mania, at key moments in human evolutionary history, may have
conferred an adaptive advantage. The
manics predisposition toward fearless certainty and risk-taking behavior
might, for instance, give a distinct advantage in battle or the hunt, promoting
the overall reproductive success of the tribe, even while conferring distinct
interpersonal disadvantages on the manic individual.
From the psychiatric standpoint,
the core of the book comes in chapters 8 through 10, a discussion of all the
medications involved in the treatment of BD.
These chapters are very nearly a miniature pharmacopeia of all psychiatric
medication classes, with drugs highly relevant to BD given detailed, specific
treatment. The key mood stabilizers,
for instance Lithium, Valproate, and Carbamazepine are discussed under the
headings of Efficacy, Prediction of Response, Administration, Laboratory
Monitoring, Side Effects, Toxicity, Risks of Discontinuation, and Interactions
with Prescription Drugs. While this
information should be known by any psychiatrist working with Bipolar patients,
the information is extremely useful to patients and their families, especially
as they interact with family physicians, non-psychiatric specialists, and any
other health-care providers, who will almost certainly not have this
information at their fingertips.
I expect that the wide
dissemination of this information to those who have or care for people with BD
will improve quality of care and will lead to fewer adverse drug events. Readers do need to realize, though, that
psychopharmacologic research is constant and ongoing. Therefore, unless the authors intend to publish frequent updates,
much of this information will be superseded in time. The Bipolar patients primary treating psychiatrist is always the
best source of information for the most current therapeutic practices. For instance, current thought is shifting
with respect to Lithium dosing. The
authors advocate dividing the dose into thrice daily, but some authorities
recommend the full daily dose be administered at bedtime, to hypothetically
allow a daily period of low blood levels for kidney detoxification and
regeneration (1). It was disappointing
to see the authors not acknowledge this controversy.
The final chapters of the book move away from traditional medical
arenas and look more at the social and political situation, focusing entirely
on the United States. Im from Canada,
so I cant speak directly to the claims the authors make regarding a dearth of
research funding for BD, and I also cant address their allegation that
patients with BD are not strongly advocated for in the political realm. I did find it odd that the authors bemoaned
the lack of strong individual advocates for the mentally ill and yet then went
on to give brief biographical sketches of a fair number of just such
advocates. I suppose the general
message here is that there ought to be more research money and more advocacy on
behalf of BD.
Appendices A through D are a
marvelous resource for patients and families.
Appendix A offers brief reviews of numerous current books in the
field. Appendix B is a listing and
appraisal of current websites. Appendix
C reviews psychoeducational videotapes from approximately the last decade. Appendix D is primarily a list of addresses
of groups of various kinds involved with BD.
It also lists a few medical journals, more aimed at the technical
reader. Appendix B is the most likely
to change with time, given the dynamic nature of the web, but the list of
links, and especially the appraisals, are probably one of the most useful parts
of the book, especially for families and patients new to BD who are likely
bewildered by the meaning and implications of the diagnosis.
All in all, Torrey and Knable have
offered the popular psychiatric literature an immense, complete, and useful
resource. My own knowledge of the
disorder, as a psychiatrist-in-training, was certainly enhanced. I can only expect that, with the exception
of the BD sub-specialist, this increase in knowledge, after reading the book,
will be the case for anyone with an interest in the field of Bipolar Disorder.
McIntyre R, et al.
Lithium Revisited. Can J Psychiatry 2001;46:322-327
© 2002 Robert Tarzwell
Robert Tarzwell is currently in his
second year of a five-year psychiatry residency at Dalhousie University in
Halifax, Nova Scotia, Canada. He
completed his MD at the University of Manitoba in May 2001. Prior to medical school, he spent 8 years in
the Canadian Forces as an Air Navigator, employed on the CP-140 Aurora maritime
patrol aircraft. He also completed a
staff tour, acting as Air Force Webmaster and speechwriter for the Commander of
the Air Force. He holds a BA in English
Literature from Simon Fraser University in Burnaby, British Columbia, Canada.