A biopsychosocial approach to treating patients with affective disorders

Treatment-resistant bipolar depression

Patients with treatment-resistant bipolar depression require careful management, which takes into account the life-threatening potential of their depression and the risk of iatrogenic mania. Because there are few data specific to treatment of bipolar depression, much of the approach to bipolar depression is derived from experience with unipolar depression. There are, however, important differences between these two illnesses. Compared with patients with unipolar illness, patients with bipolar depression more likely experience antidepressant benefit from mood-stabilizing medication and, therefore, avoid the risks of antidepressant medication. Treatment of comorbid anxiety and substance abuse improves response. The risk of treating bipolar patients can be reduced but not avoided. Improved outcome may be achieved by careful assessment, prospective mood charting, and attempts to taper antidepressant medications after an appropriate continuation phase.

Bipolar mood disorder: practical strategies for acute and maintenance phase treatment

The chronic, complex, and episodic course of bipolar mood disorder presents a formidable challenge to the clinician making a treatment plan. Although numerous therapeutic agents are reported to be efficacious for one or more aspects of bipolar illness, treatment is seldom completely effective and is never curative. The goal of treatment is to modify the symptomatic expression of the illness with the result that fewer, briefer, and milder episodes occur. In pursuit of this goal, the use of multiple medications, polypharmacy, is the rule rather than the exception. This article offers recommendations for treatment strategies based on the phase and stage of the illness. The strategies are organized into algorithms that emphasize the use of mood-stabilizing medications as initial steps in a systematic, iterative approach to treatment. Practical issues related to the use of mood-stabilizing therapies are discussed.

Psychiatry Today : Biology vs. Psychology

This research addresses preferences and theoretical leanings of present-day psychiatrists along the continuum defined at one end by biology and at the other by psychology. A questionnaire was devised and sent to 5,702 randomly selected members of the American Psychiatric Association in 1990. The response rate was 307%. The results were analyzed for two groups: psychiatrists with fewer than 15 years of practice since residency and psychiatrists with more than 15 years of practice since graduation. Although the great majority of psychiatrists in both groups equally valued psychology and biology, the senior group attributed a greater importance to psychological methods, whereas the younger group stressed equally the importance of biology and psychology. This suggests that psychiatry has evolved over the years from a predominantly psychological practice to one with a more equal emphasis on psychology and biology. Recent advances in neuroscience may have shifted the pendulum toward a more balanced willingness of clinicians to consider the broad armamentarium of psychosocial and biological treatments. The results point to the need for further conceptualization into the relationship between biology and psychology and its incorporation into the psychiatric residency curriculum.

Treatment resistant depression in an Australian context. II: Outcome of a series of patients

The clinical characteristics and treatment outcome of a series of 107 patients referred to a mood disorders unit with an episode of "treatment resistant" Major Depression are reviewed. Subjects were categorised by diagnosis (into melancholic and non-melancholic subtypes) and by adequacy of previous treatment. At subsequent review (mean period of 37.5 months) these patients were re-assessed both in terms of outcome and which treatments had been considered to be most effective. Forty one percent of the patient group were fully recovered and a further 43% were partially improved. Different treatments were considered effective for melancholic and non-melancholic sub-types.

Bipolar disorder and the family: an integrative model

The relationship between major mental illness and the family is complex. This article describes a model that recognizes biological, individual, and familial aspects of illness, and the interaction and reciprocal effects of these different levels. This model is illustrated using the example of bipolar illness, with particular emphasis on the effects of the illness on the family. Many characteristics previously noted in bipolar families can be understood as consequences, rather than causes, of the illness. A framework for integrated treatment is also described.

Psychosomatics of beauty and ugliness: theoretical implications of the systems approach

In this presentation, physical appearance has been considered an inseparable part of daily human existence. Relevant aspects of research in social psychology on interpersonal attraction and personality theory stressing narcissistic vulnerability were reviewed. General systems theory was proposed as a theoretical framework from which to view the multifactorial aspects of the psychosomatics of beauty and ugliness. In support of this proposition, the contemporary use of systems thinking in medicine, psychiatry, psychoanalysis, family therapy, and the understanding of emotions was stressed. Emotional reactions to the evaluations of physical appearance by self and others were shown to be inevitable, involving appraisal and feedback processes affecting different systems in the person's life. The person's self-image and self-esteem were stressed as underlying determinants of outcome in health and in illness. Finally, we hope to have communicated our belief that in the present, as a way of integrating and summarizing the knowledge obtained in the specialized fields, systems thinking allows for more creative and successful treatment outcomes.

The International Classification of Impairments, Disabilities and Handicaps: its usefulness in classifying and understanding biopsychosocial phenomena

The International Classification of Impairments, Disabilities and Handicaps (ICIDH) was developed because of the growing awareness that ICD-9 failed to reflect many of the problems that people bring to health care systems. The ICIDH was designed to classify the consequences of disease such as the disruption of daily activity and the social disadvantage that accompany illness. However, since its introduction, the ICIDH has largely been ignored by psychiatry, despite its conceptual strength. In particular, it provides a framework for applying the biopsychosocial model and studying the phenomena of mental illness. The latter is an important issue because of clinical psychiatry's inherent weakness in distinguishing between symptoms of disease and the psychosocial consequences, a particular inadequacy of the DSM-III diagnostic criteria. The utility of the ICIDH is shown in the study of the phenomena of panic disorder and agoraphobia, where I conclude that agoraphobia should be classified as a disability/handicap and not a disorder.