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Bipolar II Disorder: Modelling, Measuring and Managing

Nagy Youssef, MD

Duke University, Durham, NC, USA

Edited by Gordon Parker; Cambridge, UK; Cambridge University Press; 2008; ISBN 978-0-521-87314-7; pp 304; $59.00 (paperback); $120.00 (hardcover).

When we talk about bipolar disorder, most think of bipolar I. As clinicians, we are guilty of overlooking bipolar II and other forms described by Emil Kraepelin—which today would be classified as bipolar disorder not otherwise specified or spectrum disorder—that can cause significant morbidity, similar to how some patients deny hypomania. This book presents the current state-of-the-art science on the subject in the first 14 chapters and then the art of diagnosis and treatment in the rest of the book (chapters 15 to 27).

The denial or misdiagnosis of bipolar II disorder adds to the patients’ suffering and our frustration when patients do not respond to treatment. It is gratifying to treat patients who have not been treated before or to help patients overcome recurrent hospitalizations due to depression that does not completely respond to multiple antidepressants. For those patients who need to decode their mystical beliefs and learn about mood disorders beyond major depression, I recommend Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder.1

The lack of recognition of the seriousness of this disorder is not only reflected by the scarcity of controlled trials on bipolar II and bipolar spectrum compared with bipolar I, but also by the fact that Bipolar II Disorder: Modelling, Measuring and Managing is the only book that I—as well as amazon.com—know of about bipolar II that is addressed to clinicians, compared with more than 10 books targeted to patients, including the one mentioned above. This is surprising, given the substantial number of patients suffering from bipolar II and the reality that bipolar disorder is the seventh leading cause of life lost to disability or death among all medical disorders, according to the World Health Organization.2

One reason for denial or misdiagnosis might be that bipolar II is harder to diagnose, especially with time constraints imposed by managed care, making a comprehensive history and collaterals things of the past, although they are crucial to improve diagnostic accuracy. In addition, a high index of suspicion, longitudinal follow-up, life charts, collaterals, old records, genetic loading, etc are all necessary for proper assessment and for uncovering histories of hypomania or rapid cycling. The great physician William Osler emphasizes this point by saying, “If you listen carefully to the patient[s], they will tell you the diagnosis.”3 Also, adequate time to use both pharmacologic and psychotherapeutic interventions is hard to come by in the 15-minute “med check.” Historian Edward Shorter, PhD, reminds us that “the most effective of all approaches in dealing with diseases of the brain and the mind…converge on the finding that ‘neurochem’ and ‘neurochat’ augment each other as the optimum form of care.”4 I believe that knowing signs that can predict bipolar II helps improve clinical detection of the disorder. This book serves that purpose, among others. This book tells us why bipolar depression is not the same as major depression and that differentiating between the two has important treatment and prognostic implications—a story Kraepelin told but is often forgotten.

Most chapters are informative and nicely presented and summarize the scarce literature on bipolar II. The book specifies the boundaries of our knowledge and identifies the information that has been extrapolated from the more abundant literature on bipolar I. Given the paucity of the literature on bipolar II, the editor dedicated the second half of the book (chapters 15 to 27) to the “episteme” of experts in the field based in part on their interpretation of the literature and their philosophical approaches to management, which creates a nice “epistemic rhetoric,” so to speak. These authors included European experts, such as the late Franco Benazzi, Eduard Vieta, and Guy M. Goodwin, and American experts, such as Terence A. Ketter, Robert M. Post, and Michael Thase, in addition to the Australian input by Gordon Parker et al at the beginning of this section and a thoughtful “Rounding up” chapter to “identify many commonalities, reconcile some controversies.”

S. Nassir Ghaemi, in chapter 26, presents a nice philosophical discussion of our deviation from the Hippocratic view and pharmacopeia—as he call it in one of his papers5—of patient care. I believe that although we do not have the epistemic resources or the full corpus of knowledge because of limited literature on this area, we can count it as the alchemy from which modern chemistry will arise.

This book not only helps clinicians navigate an uncharted area but also paves the road for further scholarly research of a disease with such a high burden of suffering. This might be a primer for conducting further research and perhaps the “experimenta fructifera” in the Baconian sense as described in the Novum Organum.6

This stimulating and insightful book should be on the reading list of every clinician who cares for patients with mood disorders.


  1. Phelps J. Why am I still depressed? Recognizing and managing the ups and downs of bipolar II and soft bipolar disorder. New York, NY: McGraw-Hill; 2006.
  2. Chisholm D, van Ommeren M, Ayuso-Mateos JL, et al. Cost-effectiveness of clinical interventions for reducing the global burden of bipolar disorder. Br J Psychiatry. 2005;187:559–567.
  3. Silverman M, Murray JT, Bryan CS. The quotable Osler. Philadelphia, PA: American College of Physicians; 2007.
  4. Shorter E. A history of psychiatry: from the era of the asylum to the age of Prozac. New York, NY: John Wiley & Sons, Inc; 1997.
  5. Ghaemi SN. Toward a hippocratic psychopharmacology. Can J Psychiatry. 2008;53:189–196.
  6. Zagorin P. Francis Bacon. Princeton, NJ: Princeton University Press; 1999.