Bipolar disorder

Abstract

Bipolar disorder's unique combination of three characteristics - clear genetic diathesis, distinctive clinical features, early availability of an effective treatment (lithium) - explains its special place in the history of psychiatry and its contribution to the current explosive growth of neuroscience. This article looks at the state of the art in bipolar disorder from the vantage point of: (i) genetics (possible linkages on chromosomes 18 and 21q, polygenic hypothesis, research into genetic markers); (ii) diagnosis (new focus on the subjective aspects of bipolar disorder to offset the current trend of underdiagnosis due to overreliance on standardized interviews and rating scales); (iii) outcome (increase in treatment-resistant forms signaling a change in the natural history of bipolar disorder); (iv) pathophysiology (research into circadian biological rhythms and the kindling hypothesis to explain recurrence); (v) treatment (emergence of the anticonvulsants, suggested role of chronic antidepressant treatment in the development of treatment resistance); (vi) neurobiology (evaluation of regulatory function in relation to affective disturbances, role of postsynaptic second-messenger mechanisms, advances in functional neuroimaging); and (vii) psychosocial research (shedding overly dualistic theories of the past to understand the mind and brain as an entity, thus emphasizing the importance of balancing the psychopharmacological and psychotherapeutic approaches). Future progress in the understanding and treatment of bipolar disorder will rely on successful integration of the biological and psychosocial lines of investigation.

Full text

State of the art
o approach the state of the art in diagnosis and
treatment of bipolar disorder requires a review of the cur-
rent state of both research and practice. There is no doubt
that bipolar disorder has been an especially important
and illustrative field of research in the evolution of psy-
chiatry. Consider the history of the discovery of lithium.
It is a classic example of an alert investigator with both
basic science and clinical interests seeing the potential of
an unexpected laboratory observation. Recent diagnostic
research, in which controversy abounds regarding under-
diagnosis and misdiagnosis of bipolar disorder, illus-
trates the richness of the clinical relevance of contempo-
rary diagnostic and nosological research. Other aspects
of current research that are relevant to diagnostic validity
include genetic and outcome research. With respect to
treatment, there are controversies regarding the use of
mood-stabilizing agents, and dilemmas in the use of anti-
depressant agents in bipolar disorder. In terms of theories
of the pathogenesis of bipolar illness, neurobiological
research and theories have advanced, with the kindling
hypothesis in particular seeming useful as a general the-
ory of the pathophysiology of bipolar disorder. In addi-
tion, integrative research that includes attention to the
psychosocial aspects of bipolar disorder appears on the
verge of full development.
Keywords: bipolar disorder; manic-depressive illness; mood disorder; depression;
research; diagnosis; treatment; genetics; neurobiology; outcome
Bipolar disorder's unique combination of three characteristics—clear genetic diathesis, distinctive clinical
features, early availability of an effective treatment (lithium)—explains its special place in the history of
psychiatry and its contribution to the current explosive growth of neuroscience. This article looks at the
state of the art in bipolar disorder from the vantage point of: (i) genetics (possible linkages on chromo-
somes 18 and 21q, polygenic hypothesis, research into genetic markers); (ii) diagnosis (new focus on the
subjective aspects of bipolar disorder to offset the current trend of underdiagnosis due to overreliance on
standardized interviews and rating scales); (iii) outcome (increase in treatment-resistant forms signaling a
change in the natural history of bipolar disorder); (iv) pathophysiology (research into circadian biological
rhythms and the kindling hypothesis to explain recurrence); (v) treatment (emergence of the anticonvul-
sants, suggested role of chronic antidepressant treatment in the development of treatment resistance); (vi)
neurobiology (evaluation of regulatory function in relation to affective disturbances, role of postsynap-
tic second-messenger mechanisms, advances in functional neuroimaging); and (vii) psychosocial research
(shedding overly dualistic theories of the past to understand the mind and brain as an entity, thus empha-
sizing the importance of balancing the psychopharmacological and psychotherapeutic approaches). Future
progress in the understanding and treatment of bipolar disorder will rely on successful integration of the
biological and psychosocial lines of investigation.
Address for correspondence: Dr Goodwin, Department of Psychiatry, George
Washington University, 2150 Pennsylvania Ave, NW, 8th Floor, Washington,
DC 20037, USA (e-mail: psyfkg@gwumc.edu)
Bipolar disorder
Frederick K. Goodwin, MD; S. Nassir Ghaemi, MD
T
From: the Center on Neuroscience, Medical Progress, and Society
Department of Psychiatry, George Washington University, Washington DC,
USA (Dr Goodwin); and the Department of Psychiatry, Harvard Bipolar
Research Program, Massachusetts General Hospital, Harvard Medical
School, Cambridge, Mass, USA (Dr Ghaemi)
41
Frederick K. GOODWIN

State of the art
Progress in scientific psychiatry:
the central role of bipolar disorders
Bipolar illness, among psychiatric conditions, has served a
central role in advancing clinical psychiatry, especially the
interaction of biological predisposition with environmental
stress. For one thing, there is a clear genetic diathesis for
bipolar illness. Also, there are six different clinical state
changes that can be studied: two states (depression and
mania), and four phase changes (from depression to mania,
from mania to depression, from depression to mixed states,
and from mixed states to depression). These multiple clinical
features of bipolar illness have served as a powerful research
tool. And, as noted, there is substantial new bearing on the
role of psychosocial factors in the emergence of episodes of
affective illness (eg, the kindling paradigm) and in its treat-
ment as well.
Despite the advances that have been made in research into
affective illness, such progress is not necessarily smooth and
rational. Unfortunately, there is also a tendency toward sci-
entific fads, or “make-believes” according to van Praag.
1
It is
unfathomable why certain areas of literature simply drop out
as others capture our attention and take over. For example,
the relatively robust literature on electrolyte disturbances
died out rather abruptly in the late 1960s for no apparent
reason. Certainly, there was no rash of nonreplications to
explain the curious disappearance of this trail. Yet, research
into bipolar disorder has nonetheless played an important
role in hastening growth of psychiatric knowledge. The best
example may be lithium and its presence at the creation of
the psychopharmacological revolution.
The psychopharmacological
revolution: lithium as a
case example
John Cade, an Australian physician, tested a hypothesis he
developed while interned in a Japanese POW camp during
the Second World War: he hypothesized that mania and
depression represented abnormalities of nitrogen metabo-
lism. To test the behavioral effects of urea, a nitrogenous
product in urine, in animals, he needed a soluble form of it;
he found that the lithium salt of urea was appropriately sol-
uble and when he gave it to guinea pigs, he found that it
calmed them without sedation. While he assumed this was
due to the urea, he was careful enough to try a different form
of lithium just to be sure the calming effect was not due to
lithium. Of course, he discovered that the effect was due to
lithium. Realizing that the existing treatments for mania
essentially put patients to sleep, he reasoned that lithium
might calm mania without knocking them out and so he tried
it in manic patients. While his early patients struggled with
lithium toxicity, Cade had made a major discovery. Later,
Cade’s preliminary observations were replicated and con-
siderably extended in controlled studies by Schou and his
colleagues, and the rest is history.
2
The story of lithium and mania provides a paradigm for a
process that was repeated with the introduction of neu-
roleptics for schizophrenia and tricyclic agents for depres-
sion in the 1950s and the 1960s. The psychopharmacolog-
ical revolution, which took shape with the development
of those drugs, spawned three subrevolutions. First, there
was a conceptual revolution; the effectiveness of medica-
tions implied that biological factors were involved in these
illnesses and were indeed relevant to understanding them.
Second, a methodological revolution ensued; psychophar-
macological research required reliable diagnoses, and the
work that led to DSM-III and DSM-IV (Diagnostic and
Statistical Manual of Mental Disorders IIIrd and IVth edi-
tions) stemmed from this need. Initially, new diagnostic
criteria were developed among the neo-Kraepelinian
school at the Washington University in St Louis (Eli
Robins, Samuel Guze, George Winokur), which laid the
basis for the Research Diagnostic Criteria (RDC). After
nearly a decade of research on the basis of these criteria,
sufficient data had been obtained to support the wholesale
reform of psychiatric diagnosis, which DSM-III repre-
sented. The publication of DSM-III in 1980 marked the
arrival of a new scientific psychiatry; all this had origi-
nated in the psychopharmacological revolution. Finally,
psychopharmacology played a substantial role in fueling
the explosive growth of neuroscience, since the introduc-
tion of new medications led to research into their mecha-
nisms of action. Thus, the understanding of central ner-
vous system synaptic function grew largely from efforts to
understand the mechanism of action of tricyclic antide-
pressants, neuroleptics, and lithium.
The state of the art:
diagnostic validity
The aim of sharper diagnosis remains an important goal
for research in bipolar disorder today. Forty years ago,
Robins and Guze
3
proposed that the diagnostic validity of
psychiatric disorders rested on the proposition that clinical
phenomenology should have a predictable relationship to
42

Bipolar disorder - Goodwin & Ghaemi Dialogues in Clinical Neuroscience - Vol 1- No. 1
genetics, course, and treatment response. With respect to
bipolar disorder, what is the state of the art in each of these
areas? While our accumulated knowledge about manic-
depressive illness in these four fields of research is indeed
impressive, we face a paradox. Despite all we know, bipo-
lar illness too often remains unrecognized or misdiagnosed,
and inappropriately or ineffectively treated. Robins and
Guze’s criteria can serve as springboards to comment on
the contemporary understanding of this fascinating and
challenging illness.
Clinical phenomenology
Clinical phenomenology is the framework that supports most
other research. Is manic depressive illness a valid syndrome?
Some
4,5
doubt that we can distinguish it from schizophrenia.
However, in our opinion, the Kraepelinian model appears
well supported by methodologically sound research.
6-8
To
further solidify the current model, future work should focus
on schizoaffective disorder and the validity of presumed
subtypes of bipolar disorder, such as pure vs mixed mania.
Future diagnostic validity studies should also seek to sharpen
the reliability of diagnostic criteria and clarify discrepancies
in prevalence estimates. There appears to be a “coarsening of
diagnosis”
1
in clinical practice and research that may con-
fuse these issues. Particularly with respect to bipolar disorder,
the subtleties of the diagnostic process are often ignored in
the effort to avoid incorrectly labeling someone with the diag-
nosis. Thus, bipolar disorder tends to be underdiagnosed,
with even episodes of pure mania being completely missed
by clinicians (not to mention mixed mania, hypomania, or
bipolar depression). In a recent review of diagnostic patterns
in the community,
9
we and our colleagues found that about
60% of the hospitalized patients we diagnosed with bipolar
disorder had received that diagnosis from previous psychia-
trists. While this may not simply be an issue of diagnostic
reliability, part of this diagnostic disagreement represents
clinician disagreement. Similar diagnostic difficulties exist in
the clinical interview of paranoid patients (thus making it
difficult to diagnose some types of schizophrenia, schizoaf-
fective disorder, psychotic depression, and borderline per-
sonality disorder). As Leston Havens has remarked,
10
per-
haps diagnosis in psychiatry is in a stage similar to medicine
before the advent of auscultation. Sophisticated clinical inter-
views, such as those developed by Harry Stack Sullivan,
11
Havens, and others, may be similar to auscultation, allowing
us to see and hear what we otherwise would miss. This level
of subtlety in the clinical interview is often difficult to
achieve, much less standardize and teach for research pur-
poses. As van Praag again notes, “one can witness a stan-
dardized interview degenerating into a question-and-answer
game: answers being taken on face value, not caring for the
meaning behind the words, disregarding the as-yet-unspo-
ken and oblivious to the emotional content of the communi-
cation….There is the danger of the desk researcher studying
rating scale and standardized interview results rather than
actual patients. These may be data collected not by himself,
but by a research assistant with little psychiatric experience
and training.”
1
These observations could explain some of the contradictory
results found with our current research tools. In nosology,
these contradictory results are most relevant to the Epi-
demiological Catchment Area (ECA) and National Comor-
bidity survey, which sought to assess psychiatric illness in
the general population of the US. The ECA study used the
Diagnostic Interview Schedule (DIS) based on DSM-III,
administered by trained lay people. Despite reliability stud-
ies with clinicians before the study, clinician-administered
research interviews on the actual study population corre-
lated poorly with DIS-based diagnoses in one of the ECA
sites.
12
As shown in Figure 1(next page), the best diagnostic
agreement, with alcoholism, was only mild (κ=0.35), and it
was worse with more diagnostically complex conditions like
schizophrenia, depression, and (especially) mania. More
recently, ECA-like diagnostic methods were used in the
National Comorbidity survey; even with similar methods,
the prevalence of mania was twice as high as in the ECA
study (1.6% vs 0.8%) and the prevalence of unipolar depres-
sion was much higher (17% vs 8%).
13,14
On the other hand,
rediagnosis of a subsample in that study by clinician
researchers reported lower rates of nonaffective psychosis
diagnosis than those made by lay interviewers.
15
These stud-
ies support the notion that such research techniques lead to a
“coarsening of diagnosis,” which makes for less reliable and
possibly less valid results.
We would also suggest that attention to subjective aspects of
psychiatric syndromes is important if diagnostic skills are to
improve. One of the reasons that subjective phenomena are
little studied is that they are deemed unmeasurable in a stan-
dardized way. But this is not the case. An excellent example
is insight, the phenomenon of awareness of illness, patho-
logical symptoms, or psychosocial sequelae of illness. This
subjective phenomenon has recently been the subject of
sophisticated research, with the creation of multiple stan-
dardized rating instruments
16-19
and a number of studies have
quantified the impairment of insight in psychotic and mood
43

disorders.
20-25
Since patients with diminished insight deny the
presence of certain symptoms they actually possess, lack of
insight is obviously one of those subjective factors which
could affect accurate diagnostic assessment of mood and
psychotic disorders.
Directions for genetic research
Turning to genetics, the ideal neurobiological hypothesis
must explain two fundamental features of mood disorders:
genetic vulnerability and episodic recurrence. In recent
reviews of the genetic literature,
26-28
there is a consensus that
findings regarding chromosomes 5, 11, and X are inconclu-
sive; however, there are possible linkages on chromosome
18
29,30
and chromosome 21q.
31,32
In spite of these intriguing
findings regarding possible single loci, most of the genetic
epidemiology studies suggest a polygenic disorder.
Of relevance to genetic research is the kindling paradigm,
which posits an analogy between the episodic nature of mood
disorders and the phenomena of kindling and sensitization.
33
While a direct link between the physiological process of kin-
dling and clinical recurrence has not been definitively estab-
lished, the hypothesis possesses the advantage of encom-
passing key aspects of bipolar illness: the onset of early
episodes are preceded by major stress whereas later episodes
are not; the severity of untreated mood episodes worsens
over time; and the interval between episodes decreases over
time.
34
Now how might this have a bearing on genetic
research? Compared to older animals, younger ones require
a lower level of electrical or chemical stimulation to initiate
and sustain limbic kindled seizures.
35
Clinical genetic data
suggest 15% to 20% of children of a parent with bipolar dis-
order may develop the disorder. It is possible that, in the
future, genetic markers with predictive validities near 80%
would allow testing of the efficacy of antikindling agents in
genetically vulnerable children before their first bipolar
episode. Once beyond the high-risk period, one might be
able to evaluate whether treatment could be withdrawn with-
out the illness having ever expressed itself.
Outcome
Traditionally, the outcome of patients with bipolar disorder
has been reported to be intermediate between schizophrenia
and nonpsychotic unipolar major depressive disorder. Recent
naturalistic outcome data from several research centers sug-
gest rather poor outcome in bipolar disorder, even when
treated.
36-38
However, in evaluating the meaning of this, we
must recall that tertiary care research centers include a selec-
tion bias because they treat more severely ill patients. The old
adage in medicine that the longer a successful treatment is
available, the more difficult it becomes to show it still works,
certainly applies to lithium, where research in practice set-
tings continues to support its effectiveness.
39
Even though
early intervention may improve long-term outcome, many
patients receive ineffective treatment for initial episodes,
allowing the psychological and perhaps biological “scars” of
episodes to linger, resulting in a more virulent illness.
33
This
often involves early overuse of antidepressant agents, which
may function as “mood-destabilizing” agents in bipolar dis-
order, an important point to which we will return later.
40
The fact remains that there are more treatment-resistant bipo-
lar patients today than there were two or three decades ago.
Clearly, for many, the illness has changed. But why? Some of
the relevant factors include the potentially destabilizing effect
of chronic antidepressant treatment, cultural factors like the
cocaine epidemic, and environmental factors like the increas-
ing impact of environmental stimuli associated with modern
44
0
OCD Mania SZ PD MDD EtOH
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.35
0.25
0.24
0.19
0.09
0.05
Diagnosis
Kappa value
Figure 1. Agreement (kappa) of lay-administered Diagnostic Interview
Schedule (DIS) diagnoses with clinician-researcher diagnoses (from the
Epidemiological Catchment Area [ECA] study Baltimore site. EtOH,
alcohol use disorders; MDD, unipolar major depressive disorder; OCD,
obsessive-compulsive disorder; PD, phobic disorders; SZ, schizophrenia.
Based on data from ref 12.
State of the art

Bipolar disorder - Goodwin & Ghaemi Dialogues in Clinical Neuroscience - Vol 1- No. 1
45
society. Wehr and colleagues found that when rapid-cycling
bipolar patients were in a simulated environment without
artificial light (10-14 hours of darkness daily), cycling
improved; thus, civilization’s long “unnatural” photoperiod
(about 16 hours) may promote mood cycling.
41
Changes in
dietary habits may also play a role. A striking negative cor-
relation between population rates of depression and fish con-
sumption in different countries has led to a trial of omega-3
fatty acids (rich in fish oil) in treatment-resistant bipolar
patients, with striking results.
42,43
There are indications that in
Western countries, especially the US, fish consumption as a
proportion of our diets has declined over the past few
decades, and that low omega-3 fatty acid levels are present in
patients with unipolar depression.
44
The declining age of onset and worsening course of bipolar
disorder may also have, in part, a genetic explanation. Such
an epidemiologic pattern (“anticipation”) is known to occur
in a number of neurological disorders in which triplet repeat
sequences have been found to contribute to DNA instability.
45
Circadian rhythms and kindling
Two lines of investigation that relate directly to the unique
clinical feature of recurrence in mood disorders also char-
acterize current research. The first holds that clinical recur-
rence involves abnormalities in biological rhythms, espe-
cially circadian cycles, an area pioneered by Wehr and his
colleagues.
46
The second posits an analogy between the
episodic nature of mood disorders and electrical kindling,
with behavioral sensitization to mood episodes, a hypoth-
esis developed most extensively by Post and associates.
47
Research on circadian rhythms suggests that abnormalities
involving the suprachiasmatic nuclei (SCN) of the hypo-
thalamus may explain many of the clinical features of
recurrent mood disorders (including seasonality of episode
type), perhaps through secondary effects on neurotrans-
mitter systems. “Free-running” rhythms, cycles that are
not entrained to the 24-hour day/night cycle, may desyn-
chronize other circadian rhythms, adversely affecting
mood.
46
This hypothesis has recently been supported by an
animal model of a genetically fast biological clock in rats
missing the tau gene, with behavioral characteristics
roughly analogous to manic-depressive symptoms.
48
Even-
tually, genetic approaches will sharpen the research for
abnormal clocks by leading to an understanding of the pro-
teins synthesized under the direction of those genes.
The second hypothesis relevant to recurrence, as discussed
previously, is the kindling paradigm. As advanced by Robert
Post,
49
this theory builds on the physiological finding that in
the limbic system, intermittent subthreshold electrical or
chemical stimuli produce increasingly strong neuronal depo-
larization; such depolarization can lead to an independent
permanent seizure focus, with possible behavioral effects
roughly analogous to mood disorders. Thus, kindling is a
process in which a highly regulated system, with multiple
feedback loops, shows an escalating response to a repetitive
stimulus, reaching a point where the stimulus is no longer
needed for the disturbance to continue. Post drew an anal-
ogy between this phenomenon of kindling in the nervous
system and the clinical observation (originally made by
Kraepelin and confirmed in later more quantitative studies
by Post and others) that external stress appears to activate
early episodes of illness, but eventually the illness seems to
take on a life of its own, with later episodes often occurring
without precipitating stressors. In other words, both kin-
dling and bipolar illness seemed to be processes of initial
activation giving way, over time, to a self-driven process.
We have reviewed the clinical psychiatric literature rele-
vant to assessing some of the predictions of the kindling
hypothesis in detail elsewhere.
50
In that review, we noted
that the majority of the studies support the kindling hypoth-
esis, although with some caveats. Many were retrospective
and limited to assessing hospitalized episodes of bipolar
disorder. Thus, their results may not apply to milder forms
of bipolar illness. In the prospective studies, nonhospitalized
mood episodes were assessed, but evidence in support of
kindling was not consistently attained. Some of this research
suggests that kindling phenomena may characterize a sub-
group of patients with bipolar disorder, perhaps with more
severe illness. A recent, yet to be published, study from the
National Institute of Mental Health (NIMH) Depression
Collaborative research program
51
also found no evidence to
support kindling-like phenomena, and instead reported that
poor outcome was associated with polyphasic mood
episodes, rather than monophasic mood episodes. Thus,
patients whose mood episodes cycle directly between
depression and mania had a worse outcome than those who
experience a single episode followed by a period of
euthymia. The investigators in the latter study suggest that
amount of time ill is a better criterion for poor outcome
than number of episodes and shortening of episode cycles,
as suggested by the kindling hypothesis. There are method-
ological limitations to the NIMH study, as well, however;
for instance, most patients were not in their early episodes
of illness, which would be the period of time when the
shortening of illness-free intervals between episodes, as

predicted by the kindling model, might be most evident.
Thus, the clinical research on the kindling hypothesis may
be interpreted as supportive of the hypothesis, albeit in a
limited and not yet definitive manner.
Patterns of mood-stabilizing treatment
Research on outcome in bipolar disorder has led to an
interest in new treatments for the illness. In the last
decade, anticonvulsants have assumed a well-deserved
role in the treatment of bipolar disorder. Initial studies
focused on lithium-resistant patients, especially rapid
cycling, mixed states, and/or concurrent substance
abuse. Recently, some authors have advocated anticon-
vulsants as treatments of first choice. Caution is in order
here. The long track record of lithium provides a firm
knowledge of risks and benefits. For example, lithium’s
impact on preventing suicide is established. A recent
review of 28 studies involving over 150 suicides indi-
cates a sixfold reduction in suicide with lithium treatment
of bipolar disorder compared to no treatment.
52
The sero-
tonergic effects of lithium implicated in the neurobiology
of suicide may help explain these data.
53
A recent large
prospective 2
1
/
2
-year randomized study comparing lithium
with carbamazepine found 9 suicide events in the carba-
mazepine group (5 deaths, 4 severe attempts) versus none
for the lithium group (P<0.02).
54
Meanwhile, a 1-year
multisite study of divalproex prophylaxis could not estab-
lish a significant advantage over placebo.
55
While this
negative finding may stem from inadequate statistical
power since severely ill patients were excluded, nonethe-
less, the lack of a robust prophylactic effect in those
patients studied suggests caution. In an earlier multisite
study comparing the acute antimanic effects of divalproex,
lithium, and placebo, those patients with a history of prior
response to lithium had a robust antimanic response to its
readminstration, but the divalproex response in this group
was only 27%. On the other hand, those with a prior his-
tory of nonresponse to lithium showed a relatively high
rate of response to the anticonvulsant, suggesting that
there may be two substantially separable antimanic
response patterns. Since antimanic response may predict
prophylactic efficacy,
39,56-58
this highlights the danger
of discontinuing lithium treatment in responders to it.
Also, lithium discontinuation (especially when abrupt)
promotes rapid relapse.
59,60
The possibility of lithium with-
drawal–induced treatment refractoriness has also been
raised,
61
though not settled.
62
The antidepressant problem
Not surprisingly, patients with bipolar disorder often are
more aware of depression and its concomitant symptoms
than they are of mood elevation. Hence, even in the midst of
an episode of mood elevation, they may present requesting
antidepressant treatment and often refuse mood stabilizers.
Regardless of whether these patients are simply less con-
cerned about the consequences of mood elevation or are
relatively insensitive in perceiving it, the demand for anti-
depressant treatment presents a clinical dilemma. Consider-
able evidence suggests a relationship between chronic anti-
depressant treatment, especially without concurrent
mood-stabilizing treatment, and development of treatment
resistance. Goodwin and Jamison have reviewed this matter
and marshaled much of the relevant data.
34
Briefly, in three
double-blind outcome studies, the rate of manic episodes
in patients with bipolar disorder treated with antidepres-
sants and lithium is roughly twice the rate of those treated
with lithium alone.
56,63,64
In two studies of patients with rapid-
cycling, antidepressants were thought to be the likely causes
of rapid-cycling in 26% to 35% of cases (n=85).
65,66
Using
mood charting, Wehr and Goodwin
67
also documented
increased frequency of affective cycles in patients treated
with desipramine (and lithium) instead of lithium alone.
The risks of antidepressant use documented in these studies
are summarized in Table I.
The absence of systematic or objective measures for
cycling may account for the general underrecognition of
these phenomena. Simple reliance on the patient's sub-
jective self-report often is insufficient. The limitations of
self-report can be decreased by systematically collecting
information from other sources, such as mood charting
and family reports. In a recent examination of diagnosis
and treatment practices,
9
we found that one third of bipo-
lar patients admitted to the hospital were taking antide-
pressant agents, whereas all but 4% were able to be dis-
charged in 1 to 2 weeks without them (even 50% of
acutely depressed bipolar patients improved at least
mildly without antidepressant agents). It seems that the
clinical importance of minimizing acute antidepressant
State of the art
46
Table I. The antidepressant problem.
Risks with antidepressants
Acute mania
Rapid-cycling
Treatment resistance to mood stabilizers

Bipolar disorder - Goodwin & Ghaemi Dialogues in Clinical Neuroscience - Vol 1- No. 1
47
treatment and emphasizing aggressive mood-stabilizing
prophylaxis has yet to be fully appreciated in clinical
practice. If antidepressants are used, bupropion
68
or
paroxetine
69
may be the least risky since they are the only
two new antidepressants that have been shown, in double-
blind randomized studies of add-on therapy with lithium,
to have a lower risk of precipitating mania than tricyclic
antidepressants. Nonetheless, all antidepressants appear to
have longer-term risks of promoting rapid cycling.
Neurobiological research in bipolar
disorders: the state of the art
Clinical psychopharmacology is, of course, dependent on
advances in neurobiology. Here, an evolution has occurred.
Early studies from the 1960s and 1970s were influential in
developing neurobiological hypotheses based on function-
ing of central nervous system (CNS) monoamine systems,
as suggested by the efficacy of antidepressant and mood-sta-
bilizing agents and then testing those hypotheses through
innovative approaches to the direct assessment of amine
metabolism in patients. These studies emphasized possible
excess or deficiency states of monoamines such as norepi-
nephrine, dopamine, or serotonin.
70,71
Later work centered on
interactions among monoamine systems, indicating that even
“selective” new-generation psychotropic agents have multiple
effects within the brain based on extensive neuronal inter-
connectivity among monoaminergic tracts within limbic
regions. Starting in the 1970s, a number of investigators
began to emphasize the importance of moving beyond excess
or deficiency states to an understanding of regulatory sys-
tems.
72,73
More recently, the evaluation of regulatory function
in relation to affective disturbances has been accelerated by
rapid progress in the delineation of specific neuronal tracts
and their interconnections, especially as modeled by neural
network paradigms.
74,75
Another line of advance in the neurobiological investiga-
tion of bipolar disorder has been the evolution from synaptic
neurotransmitter–based hypotheses as discussed above to
postsynaptic second messenger-based hypotheses. Manji
76
has suggested a central role for G-proteins in the mecha-
nism of action of lithium, a role which may be more impor-
tant pathophysiologically than lithium’s synaptic effects. If
this is true, similar second messenger postsynaptic mecha-
nisms may remain to be discovered as possibly underlying
sources of action of other mood-stabilizing agents, such as
valproate and carbamazepine, as well as some antidepres-
sants. Particularly relevant to bipolar disorder, second mes-
senger mechanisms may explain the unique mood-stabilizing
effects of lithium and other agents that produce psychomotor
activation and mood elevation in the depressed state, reduce
them in the manic state, and have little effect on the
euthymic state. For instance, Berridge and colleagues
77
hypothesized that lithium selectively inhibits the second
messenger phosphatidylinositol in neuronal pathways that
are overactive; this would suppress an excessively excited
system, but exert no effect on a normally functioning path-
way. Such second messenger systems generally are linked
initially to G-proteins that translate synaptic neurotransmis-
sion into intracellular changes, such as with phosphatidyli-
nositol. Medications developed on the basis of these spe-
cific effects on different G-proteins are in process of early
clinical evaluation and may prove to be more pharmacolog-
ically specific in bipolar disorder than current treatments.
In this regard, the recent preliminary finding that high doses
of omega-3 fatty acids may have mood-stabilizing properties
in bipolar disorder is of considerable interest, given the role
of these essential fatty acids in postsynaptic signal trans-
duction.
78
Further work on postsynaptic mechanisms has
involved other aspects of cellular communication linked to
G-protein function, particularly the activity of the enzyme
protein kinase C. We have summarized much of this research
in Table II (see next page).
Eventually, understanding of such intracellular mechanisms
may lead to explication of alterations in gene expression that
may be involved in the pathogenesis or treatment of mood
disorder.
Advances in neuroimaging represent another exciting area
of progress in neurobiological research. Mood disorders still
lag behind schizophrenia in being a focus of such work, and
future neuroimaging research should focus more on the need
for such data in mood disorders. As Meltzer
79
has noted, much
of the available neuroimaging research on mood disorders
has not demonstrated clear differences from findings in schiz-
ophrenia, which some have taken to support the unitary psy-
chosis diagnostic model. However, the relative paucity of
work in mood disorders raises the likelihood of type II error
in the interpretation of available small data sets due to lack of
statistical power to find existent differences. Functional neu-
roimaging in particular may demonstrate more subtle patho-
physiological differences that may have eluded structural
brain imaging such as computed tomography or magnetic
resonance imaging. Again, the importance of state vs trait
differences needs to be reemphasized, since it is more rele-
vant to recurrent conditions such as mood disorders than to
chronic conditions such as schizophrenia.

Integrating biological and psychosocial
aspects of bipolar disorder
While research in neurobiology is central to understand-
ing bipolar disorder, psychosocial research is also vital. In
the future, we hope that theories regarding mood disorders
suffer less from the reductionistic effects of Cartesian dual-
ism than in the past. Given the emerging realization that
mind and brain are not different entities belonging to dif-
ferent realms of experience, the distinction between the
biological and the psychosocial aspects of illness begins
to break down. Advances in biological research itself sup-
port this approach. New developments in neuroscience are
beginning to show that even subtle changes in the environ-
ment (especially early in life) can result in long-lasting
changes in the brain. These advances are based on new
insights into the plasticity of the CNS, with elegant demon-
strations of often-specific environmental influences on spe-
cific neurobiological processes, including gene expression.
Thus, for example, in the study of stress effects, the field
has moved rapidly beyond immediate, often sort-term bio-
logical responses (eg, hypothalamic-pituitary-adrenal axis
activation) to demonstrations of environmental manipula-
tions producing long-lasting, even permanent changes.
These changes have been shown to operate through recep-
tor-coupled intracellular signal transduction pathways reg-
ulating gene expression that, in turn, alters the synthesis
of specific proteins and cell components. Kandel
80
has sug-
gested that a mechanism of action for psychotherapy may
involve these kinds of alterations in synaptic structure and
function. If this is true, then medication treatment and psy-
chotherapy may be acting through a similar final common
pathway—the brain. This view is supported by recent work
in obsessive-compulsive disorder, where behavior therapy
was shown to produce similar changes in positron emis-
sion tomography neuroimaging as did medication treat-
ment, leading Baer
81
to suggest that behavior therapy may
be a form of “endogenous serotonin therapy.” More work
will be needed in this fruitful field of translating psy-
chotherapeutic treatment into alterations in brain structure
and function.
Once the brain is understood to be a final common pathway
for both medication and psychotherapeutic treatments, then
the importance of balancing biological and psychosocial
approaches becomes more understandable. The brain medi-
ates both treatment approaches. It may be, then, that a mood
disorder may have a largely biological origin, and yet be
responsive to psychotherapy. Conversely, a mood disorder
may be largely psychosocial in origin, and yet respond to
medication treatment. It is an elementary error of logic to
reason from conclusion to premises; one must always work
the other way around. While the etiology of a certain con-
dition may be psychological, its pathogenesis may be bio-
logical and hence amenable to biological interventions (and,
at least theoretically, vice versa). Hence, while the efficacy
of pharmacological or psychotherapeutic treatments may
give us clues about where we need to look in the search for
the etiologies of mood disorders, in themselves the fact that
these treatments work does not establish any specific etiol-
ogy. Advances in neurobiology, in particular, should com-
plement, rather than curtail, psychosocial research and psy-
chotherapeutic practice.
State of the art
48
Table II. Findings regarding second messenger systems in bipolar
disorder.
G-proteins
●
Stimulatory G-protein levels may be elevated compared to
controls in patients with bipolar disorder; whether these differ-
ences are state- or trait-dependent is unclear
●
Lithium may decrease activity of certain pathways by
inhibiting certain stimulatory G-proteins (Gs)
●
Lithium may increase activity of certain pathways by
inhibiting certain inhibitory G-proteins (Gi)
Other second messengers
●
Phosphatidylinositol (PI): lithium or valproate reduces
PI activity and depletes intracellular inositol
●
Protein kinase C (PKC): chronic lithium or valproate
use impairs PKC activity and reduces PKC levels
●
Myristoylated alanine-rich C kinase substrate (MARCKS):
chronic lithium use impairs MARCKS activity
●
Intracellular calcium: increased intraneuronal levels in
patients with bipolar disorder. Reduction by calcium channel
blockers may produce antimanic efficacy. Augmentation by
lithium may produce antidepressant efficacy
Genetic expression
●
Lithium augments expression of certain parts of the c-fos
gene, mediated mainly by PI and PKC

Bipolar disorder - Goodwin & Ghaemi Dialogues in Clinical Neuroscience - Vol 1- No. 1
This perspective is supported by some recent psychosocial
research in bipolar disorder. Since many outcome studies
have found marked impairment in social and occupation-
al functioning in bipolar disorder despite some sympto-
matic improvement pharmacologically, one might con-
clude that psychotherapeutic interventions are able to
improve social and occupational functioning. Recent data
support this hypothesis, which experienced clinicians
already know: combined psychosocial/pharmacological
strategies are more effective than medication alone, espe-
cially in improving function, reducing relapse, and pre-
venting hospitalization.
82,83
Conclusions
The state of the art in the diagnosis and treatment of bipolar
disorder is both heartening and challenging. We have come
a long way and appear to be headed in the right direction.
However, we face a number of challenges, which, with effort
and foresight, we should be able to meet. First, we need to
Trastorno bipolar
La singular combinación de tres características en los
trastornos bipolares - clara diátesis genética, caracterís-
ticas clínicas distintivas y la rápida disponibilidad de
un tratamiento eficaz (el litio) - explica el lugar especial
que ocupan en la historia de la psiquiatría y su con-
tribución al crecimiento explosivo de las neurociencias.
El presente artículo aborda las mejores perspectivas en
el trastorno bipolar desde diferentes ángulos: 1)
genético (enlaces posibles en los cromosomas 18 y 21q,
hipótesis poligénica, investigaciones sobre marcadores
biológicos); 2) diagnóstico (nuevo enfoque sobre los
aspectos subjetivos del trastorno bipolar para compen-
sar la tendencia actual a subdiagnosticarlo debido a un
exceso de confianza en las entrevistas estandardizadas
y las escalas de evaluación); 3) resultados (aumento de
las formas resistentes al tratamiento lo que indica un
cambio en la historia natural del trastorno bipolar); 4)
patofisiología (investigación del papel de los ciclos cir-
cadianos biológicos y de las hipótesis que explican las
recurrencias); 5) tratamiento (aparición de los anticon-
vulsivos, papel supuesto del tratamiento antidepresivo
de larga duración en el desarrollo de una resistencia al
tratamiento); 6) neurobiología (evaluación de la fun-
ción reguladora en los trastronos afectivos, papel del
mecanismo del segundo mensajero, avances en las neu-
roimágenes funcionales); por último, 7) investigación
psicosocial (revisión de las antiguas teorías dualistas
para comprender la mente y el cerebro como entidad
enfatizando, así, la importancia del enfoque equili-
brado: psicofarmacológico y psicoterapéutico). El
progreso futuro en la comprensión y el tratamiento del
trastorno bipolar se apoyará en la exitosa integración
de los ejes de investigación biológico y psicosocial.
Trouble bipolaire
L’association unique des trois caractéristiques du trou-
ble bipolaire - terrain génétique manifeste, signes cli-
niques typiques, découverte précoce d’un traitement
efficace (lithium) - explique la place particulière qu’il
tient au sein de l’histoire de la psychiatrie et sa contri-
bution à la croissance explosive actuelle des neuro-
sciences. Cet article donne un aperçu de l’état de nos
connaissances sur le trouble bipolaire à partir des
points de vue : 1) de la génétique (liaisons possibles sur
les chromosomes 18 et 21q, hypothèses polygéniques,
recherche de marqueurs génétiques); 2) du diagnostic
(éclairage nouveau sur les aspects subjectifs du trouble
bipolaire pour compenser la tendance actuelle à sous-
diagnostiquer due à une confiance excessive dans les
entretiens standardisés et les échelles d’évaluation; 3)
du devenir (augmentation des formes résistantes au
traitement témoignant d'un changement dans l’histoire
naturelle du trouble bipolaire); 4) de la physiopatholo-
gie (recherche sur les rythmes biologiques circadiens et
l’hypothèse d’embrasement pour expliquer les
rechutes); 5) du traitement (émergence des anticonvul-
sivants, suggestion d’un rôle joué par le traitement anti-
dépresseur chronique dans le développement des résis-
tances au traitement); 6) de la neurobiologie
(évaluation de la fonction de régulation en relation avec
des troubles affectifs, rôle des méca-nismes de seconds
messagers post-synaptiques, progrès en neuro-imagerie
fonctionnelle); et 7) de la recherche sociopsychologique
(s’éloigner des théories du passé trop dualistes pour
comprendre l’esprit et le cerveau en tant qu’une seule
entité, soulignant ainsi l’importance de l’équilibre entre
les approches psychopharmacologiques et psy-
chothérapeutiques). Les progrès ultérieurs dans la com-
préhension et le traitement du trouble bipolaire dépen-
dront de l’intégration réussie des voies d’investigation
biologiques et sociopsychologiques.
49

avoid an historical tendency in psychiatry towards reduc-
tionism, which led to a swing away from biological work for
much of this century. Yet, as much as nonbiological
approaches, biological psychiatry carries a risk of going too
far with untested assumptions. We must promote further
progress in the burgeoning field of neurobiological research
and inform it clinically with an understanding of important
features of psychiatric illnesses such as recurrence and genetic
susceptibility. We should recall the two-way interaction
between clinical research and laboratory investigation, with-
out ignoring either side of this important paradigm for
progress. And we need to integrate biological and psychoso-
cial lines of investigation much better than in the past. Ulti-
mately, these efforts all pay off at the clinic and at the bedside,
where we may assist individuals suffering from bipolar illness
to recover and return to their lives free of its ravages. ❏
State of the art
50
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