The thrust of this historical, phenomenological and therapeutic research savvy book is that bipolar disorder remains “a source of confusion for many psychiatrists” which often leads to inappropriate treatment. The mixed forms of bipolar disorder are poorly responsive to lithium and are induced or aggravated by the use of antidepressants. So the clinical nuggets here are to look for the diagnostic subtleties, avoid or minimize the use of antidepressants, and focus on atypicals and mood stabilizers. Another tip is to be aware that antidepressants and atypicals can induce dysphoria apart from the mood disorder one is trying to treat.

The cross-sectional definition of schizoaffective disorder (p. 30) is the simultaneous occurrence of a schizophrenic and a mood disorder, independent of the time course. “Longitudinal research demonstrates that the course of schizoaffective disorders can be very unstable because schizoaffective episodes, pure mood episodes, and pure schizophrenic episodes can each occur at different points in the patient’s longitudinal course.” (p. 31).

Another layer of meaning is the idea of affective temperaments (depressive, hyper-thymic, cyclothymic and irritable) formulated by Akiskal, which refers to “subaffective trait expressions that represent the earliest subclinical trait phenotypes of affective disorders, and which persist as the subthreshold interepisodic phase of these disorders” (p. 54). Such temperamental dysregulation might underlie the exquisite sensitivity of these patients to anti-depressants, alcohol and stimulants.

The proper identification of a mixed state resolves confusion vs. unipolar agitated depression, delusional depression, schizophrenia, borderline personality disorder and organic mental disorder. Rapid cycling bipolar disorder is a world unto itself. The depressive phase is far more common, onsets more frequently, receives more treatment and if that includes antidepressants may precipitate rapid cycling. Bipolar II is a severe pathology with higher episode frequency, comorbidity, suicidal behaviour and rapid cycling (p.89).

Benazzi’s question and answer format in Chapter 6 on the relation of atypical depression to the bipolar spectrum makes for fractured reading but compresses a great deal his of his research into a few pages. I was encouraged by his comment that, “Mood disorder patients in tertiary care centers may not be representative of patients who are usually treated in clinical practice.” Agitated depression and psychotic depression respond poorly to antidepressants and very well to Electro Convulsive Therapy, which questions their nosological status as depressive states. Acute and transient psychotic disorder may be a form of bipolar disorder. Fig. 8.10 of the affective continuum on page 202 is worth the price of the book.

The chapter on “Bipolar disorder in children and adolescents” is disappointing in terms of the meagerness of the research compared to that in adults. There is a discussion of this very point. However, many children have rapid cycling and mixed bipolar presentations which make the entire book particularly relevant to the teaching and practice of child psychiatry. The broad phenotype includes continuous mood lability, affective storms, irritability, anger, aggressiveness, periodic agitation, explosiveness, and Attention Deficit Hyperactivity Disorder (ADHD)-like symptoms. Only symptoms specific for Bipolar disorder, including grandiosity, elation, flight of ideas and hypersexuality, distinguish it from ADHD. Severe psychopathology is the norm with high rates of psychosis, suicide attempts and conduct disorder. Irritability is present equally in 90% of BP and MDD patients. Misdiagnosis as ADHD or depression, with antidepressant or stimulant treatment, without concomitant mood-stabilizer treatment, may worsen the course of illness.