Controversies in bipolar disorder: Trust evidence or experience?

Gary E. Miller, MD
Clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Richard L. Noel, MD
Assistant clinical professor of psychiatry, University of Texas Health Science Center, Houston, TX

Today’s buzzword in health care is evidence-based medicine. Most clinicians would agree that evidence from clinical research should guide decisions about treating bipolar disorder. In theory, randomized controlled trials should tell us how to manage bipolar patients and achieve therapeutic success. But good theory does not always translate to good practice; many patients with bipolar disorder have poor outcomes, even when clinicians adhere to research-derived evidence.

The problem is that one well-designed study’s conclusions may contradict those of another equally well-designed study because of differences in subject selection, comorbidities, dosages, outcome criteria, and other variables. As a result, bipolar experts often disagree about issues as basic as antidepressants’ role in often disagree about issues as basic as antidepressants’ role in managing bipolar disorder and whether recurrent major depression should be considered a form of bipolar disorder. This leaves the clinician with the task of interpreting not only conflicting research findings but also conflicting expert opinion.

This article conveys clinical impressions gained from treating approximately 10,000 patients with bipolar disorder over 16 years. We do not claim to have resolved the issues in dispute, but we hope our experience will help practicing clinicians. We examine the evidence and address controversies in bipolar disorder—such as subthreshold hypomania, manic switches, use order—such as subthreshold hypomania, manic switches, use of antidepressants, juvenile depression/bipolar disorder, and atypical depression—together with our opinions on each.

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Postpartum psychosis: Strategies to protect infant and mother from harm

Susan Hatters Friedman, MD
Senior instructor, Departments of psychiatry and pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH

Phillip J. Resnick, MD
Professor, Department of psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Miriam B. Rosenthal, MD
Associate professor emeriti, Departments of psychiatry and obstetrics and gynecology, Case Western Reserve University School of Medicine, Cleveland, OH

Postpartum psychosis (PPP) presents dramatically days to weeks after delivery, with wide-ranging symptoms that can include dysphoric mania and delirium. Because untreated PPP has an estimated 4% risk of infanticide (murder of the infant in the first year of life), and a 5% risk of suicide, psychiatric hospitalization usually is required to protect the mother and her baby.

The diagnosis may be missed, however, because postpartum psychotic symptoms wax and wane and suspiciousness or poor insight cause some women—such as Andrea Yates—to hide their delusional thinking from their families. This article discusses the risk factors, prevention, and treatment of PPP, including a review of:

• infanticide and suicide risks in the postpartum period

• increased susceptibility to PPP in women with bipolar disorder and other psychiatric disorders

• hospitalization for support and safety of the mother and her infant.

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Psychiatry's future is here

Henry A. Nasrallah, MD, Editor-in-Chief

Do you sometimes wonder what psychiatry’s future holds? Wonder no more: abundant clues point to exciting innovations in our field. Let me highlight 6 trends that will shape how we practice psychiatry.

1. Earlier diagnosis and early intervention.
2. A tsunami of genetic discoveries.
3. Neuroplasticity as treatment target.
4. Neurostimulation for brain repair.
5. Pharmacogenomics in clinical practice.
6. Intertwining of physical and mental disorders.

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