[Norton, 2016] His website– www.psycheducation.org– is a good resource for patients to understand their condition and treatment options.   More comments on this book below.  Quite a few of my patients were happily relieved after reading this book: they finally understood their illness, and they finally came to terms with the word bipolar and realized it had very little to do with Manic Depression/Bipolar I Disorder

#2: Treatment of Bipolar Illness, A Casebook for Clinicians and Patients, by Robert M. Post, MD and Gabriele S. Leverich, LCSW, BCD.  Norton, 2008. I think this is an invaluable classic that will not be surpassed for decades, if ever.   It is t0o costly to treat inpatients for long periods as he did.   Each chapter is centered around one case (usually decades long) and one [or two] medications.  It is organized with sections on lithium, carbamazepine, CCB’s etc.   This should be on the desk of every psychiatrist who treats Bipolar I Disorder.   Robert Post was a little disappointed though. It did not sell well, which is a shame.    I keep a volume in each office.   The graphs of the course of illness in various patients has been helpful in securing compliance from some of my patients.    #1:  Seeing examples of the big picture, the patient can grasp his/her own episodes and treatment over years and decades, rather than just focusing on one recent episode.  One graph of a Bipolar I man: there were ups and downs with episodes and treatment earlier in his life.    Finally, he was completely normal for 10 years on lithium.  He insisted on tapering off it.   Untreatable rapidly cycling ensued.  After a year of that torture, he committed suicide.     #2:  When I want to use something unusual I can show the patient the chapter on nimodipine or Tegretol/ carbamazepine, or whatever.

A Spectrum Approach to Mood Disorders, by James Phelps: an interesting and informed summary of most of the possible treatments of bipolar spectrum patients [which includes Atypical Depression and Bipolar II Disorder], with excellent references.  His main points are:

#1: it has been a mistake to treat bipolar spectrum patients with SSRI’s, which either don’t work at all, or poop out—and are making the illness worse.   [compare Jay Amsterdam]

#2: the ideal treatment for bipolar spectrum patients is a combination of Lamictal/ lamotrigine and low dose lithium.   If they are very sick right now, then this combination may have to be an eventual goal.  But one could start the patient on both now or at minimum start lithium 150mg/day.   

These are some other arbitrary examples from the book:

• The upper limit of normal for TSH is 2.5 (American Thyroid Society). If the patient is depressed and TSH is >2.5, you treat the thyroid, and it is better if the psychiatrist does it.
• Too frequently we do not realize when antipsychotics are causing cycling.
• “5 controversies about antidepressants—and 9 solutions.”
• El-Mallakh, et al (2008) pointed out that long-term antidepressant treatment often causes “ACID syndrome” (antidepressant-induced chronic irritable dysphoria). Later he called it “tardive dysphoria”.
• Gary Sachs: bipolar spectrum patients (~half of all patients with chronic depression) should be tapered off antidepressants very slowly—~25% per month.
• When a patient is in despair over years of poor antidepressant benefit, tell him/her that they are at the BEGINNING of treatment. The antidepressants [SSRI’s et al] were making things worse.  Some of what was used with them in the past might well help now–when no longer on a classic antidepressant.
• The author discusses Jonathan Haidt (ground-breaking social psychologist–The Happiness Hypothesis, The Righteous Mind, the first book is more interesting–) who, in the latter book, described five principles of moral decision making. Liberals emphasize the first two almost exclusively.    Conservatives endorse all five.  He uses such differences to explain why people (including psychiatrists) so intensely hold to their opinions.   The 5 principles:  #1: Do no harm.  #2: Be fair.  #3: Stick with your group. [2018: white males] #4: Respect authority. [president Trump] #5: Some things are sacred, don’t violate them.  [the flag; religion; fetus; don’t kneel when the national anthem is sung].

I have only a few quibbles with the book. E.g.,

• Depakote/ divalproate has much more antidepressant effect than he believes. I have had patients who remained euthymic on it alone for decades, and relapse if it is decreased.
• TMS: He is not exceptionally positive about TMS, though it now almost equals ECT and it is more durable than ECT.  The benefit lasts longer and when they relapse, they only need 5-6 treatments not a full course of 30.   For psychotic depression and severe TRD (treatment resistant depression) wherein the patient has hardly responded to anything in years, ECT is superior. But in people who are treatment resistant and have atypical symptoms, who fluctuate a lot, who sometimes cycle up close to normal, or have an infrequent hypomania:  these people respond extremely well to TMS in my experience.    The benefit can last for years and when they relapse they only need 5 to 6 TMS, not another full course.
• NAC must be ≥ 4 grams. It is likely that his relatively meager results with NAC (N-acetyl cysteine) is because of insufficient dose—though he does not mention dose.   Michael Berk’s people have shown that 4 grams is much better than 2 grams.   Initially they used 2 grams, but it took 4.5 months to reach significance for depression.  [Berk told me I had to be right about the 4g dose because none of his patients did remotely as well as the examples I wrote up for him.]   I have one young woman with severe lifelong depression who responds well to 5 grams b.i.d. of NAC.    5 grams t.i.d. is even better–15 grams per day!  Many of these supplements are foods—how high can we safely go?
• Osteopenia and high dose T4 and carbamazepine. He discusses the controversies over two agents that may decrease bone density:   very high dose T4 (to stop rapid cycling) and carbamazepine.   Since virtually everyone has an inadequate vitamin D level, replenishing vitamin D to levels ≥ 32 ng/ml in many people should balance the risk of osteopenia.