The phenomenon of bipolar affective disorder has been a mystery since the 16th century.
History has shown that this affliction can appear in almost anyone. Even the great
painter Vincent Van Gogh is believed to have had bipolar disorder. It is clear that in
our society many people live with bipolar disorder; however, despite the abundance of
people suffering from the it, we are still waiting for definate explanations for the
causes and cure. The one fact of which we are pianfully aware4 is that bipolar disorder
severely undermines its' victoms ability to obtain and maintain social and occupational
success. Because bipolar disorder has such debilitating symptoms, it is imperitive that
we remain vigilent in the quest for explanations of its causes and treatment.
Affective disorders are characterized by a smorgasbord of symptoms that can be
broken into manic and depressive episodes. The depressive episodes are characterized by
intense feelings of sadness and despair that can become feelings of hopelessness and
helplessness. Some of the symptoms of a depressive episode include anhedonia,
disturbances in sleep and appetite, psycomoter retardation, loss of energy, feelings of
guilt and worthlessness, guilt, difficulty thinking, indecision, and recurrent thoughts
of death and suicide. The manic episodes are characterized by elevated or irritable mood,
increased energy, decreased need for sleep, poor judgment and insight, and often reckless
or irresponsible behavior (Hollandsworth, Jr. 1990 ).
Bipolar affective disorder affects approximately one percent of the population
(approximatly three million people) in the United States. It is presented by both males
and females. Bipolar disorder involves episodes of mania and depression. These episodes
may alternate with profound depressions characterized by a pervasive sadness, almost
inability to move, hopelessness, and disturbances in appetite, sleep, in concentrations
and driving.
Bipolar disorder is diagnosed if an episode of mania occurs whether depression has
been diagnosed or not (Goodwin, Guze, 1989, p 11). Most commonly, individuals with manic
episodes experience a period of depression. Mood is either elated, expansive, or
irritable, hyperactivity, pressure of speech, flight of ideas, inflated self esteem,
decreased need for sleep, distractibility, and excessive involvement in activities with
high potential for painful consequences. Rarest symptoms were periods of loss of all
interest and retardation or agitation (Weisman, 1991).
Effects
As the National Depressive and Manic Depressive Association (MDMDA) has demonstrated,
bipolar disorder can create substantial developmental delays, marital and family
disruptions, occupational setbacks, and financial disasters. This devastating disease
causes disruptions of families, loss of jobs and millions of dollars in cost to society.
Many times bipolar patients report that the depressions are longer and increase in
frequency as the individual ages. Many times bipolar states and psychotic states are
misdiagnosed as schizophrenic. Speech patterns help distinguish between the two
disorders (Lish, 1994).
Prevalence and Age of Onset
The onset of Bipolar disorder usually occurs between the ages of 20 and 30 years
of age, with a second peak in the mid-forties for women. A typical bipolar patient may
experience eight to ten episodes in their lifetime. However, those who have rapid
cycling may experience more episodes of mania and depression that succeed each other
without a period of remission (DSM III-R).
The three stages of mania begin with hypomania, in which patients report that they
are energetic, extroverted and assertive. The hypomania state has led observers to feel
that bipolar patients are "addicted" to their mania. Hypomania progresses into mania and
the transition is marked by loss of judgment. Often, euphoric grandiose characters are
recognized as well as a paranoid or irritable character begins to manifest. The third
stage of mania is evident when the patient experiences delusions with often paranoid
themes. Speech is generally rapid and behavior manifests with hyperactivity and
sometimes assaultiveness.
When both manic and depressive symptoms occur at the same time it is called a mixed
episode. These people are a special risk because of the combination of hopelessness,
agitation and anxiety make them feel like they "could jump out of their skin"(Hirschfeld,
1995). Up to 50% of all patients with mania have a mixture of depressed moods. Patients
report feeling very dysphoric, depressed and unhappy yet exhibit the energy associated
with mania. Rapid cycling mania is yet another presentation of bipolar disorder. Mania
may be present with four or more distinct episodes within a 12 month period. There is
now evidence to suggest that sometimes rapid cycling may be a transient manifestation of
the bipolar disorder. This form of the disease experiences more episodes of mania and
depression than bipolar.
Lithium has been the primary treatment of bipolar disorder since its introduction in
the 1960's. It is main function is to stabilize the cycling characteristic of bipolar
disorder. In four controlled studies by F. K. Goodwin and K. R. Jamison, the overall
response rate for bipolar subjects treated with Lithium was 78% (1990). Lithium is also
the primary drug used for long- term maintenance of bipolar disorder. In a majority of
bipolar patients, it lessens the duration, frequency, and severity of the episodes of
both mania and depression.
Unfortunately, there are up to 40% of bipolar patients who are either
unresponsive to lithium or who cannot tolerate the side effects. Some of the side
effects include thirst, weight gain, nausea, diarrhea, and edema. Patients who are
unresponsive to lithium treatment are often those who experience dysphoric mania, mixed
states, or rapid cycling bipolar disorder (those patients who experience at least four
distinct episodes within one month period).
Among the problems associated with lithium includes the fact the long-term
lithium treatment has been associated with decreased thyroid functioning in patients with
bipolar disorder. Preliminary evidence also suggest that hypothyroidism may actually
lead to rapid-cycling (Bauer et al., 1990). Another problem associated with the use of
lithium is its use by pregnant women. Its use during pregnancy has been associated with
birth defects, particularly Ebstein's anomaly. Based on current data, the risk of a
child with Ebstein's anomaly being born to a mother who took lithium during her first
trimester of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general
population (Jacobson et al., 1992).
Anti-convulsants
There are other effective treatments for bipolar disorder that are used in cases where
the patients cannot tolerate lithium or can become unresponsive to it in the past. The
American Psychiatric Association's guidelines suggest the next line of to be
anticonvulsant such as valproate and carbamazepine. These drugs are useful as antimanic
agents, especially in those patients with mixed states. Both of these medications can be
used in combination with lithium or in combination with each other. Valproate is
especially helpful for patients who are lithium noncompliant, experience rapid-cycling,
or have comorbid alcohol or drug abuse.
Neuropletics
Neuroleptics such as haloperidol or chlorpromazine have also been used to help
stabilize manic patients who are highly agitated or psychotic. Use of these drugs is
often necessary because the response to them are rapid, but there are risks involved in
their use. Because of the often severe side effects, benzodiazepines are often used in
their place. Benzodiazepines can achieve the same results as Neuroleptics for most
patients in terms of rapid control of agitation and excitement, without the severe side
effects.
Anti-depressants
Antidepressants such as the selective serotonin reuptake inhibitors (SSRIs) fluovamine
and amitriptyline have also been used by some doctors as treatment for bipolar disorder.
A double-blind study by M. Gasperini, F. Gatti, L. Bellini, R.Anniverno, and E. Smeraldi
showed that fluvoxamine and amitriptyline are highly effective treatments for bipolar
patients experiencing depressive episodes. This study is controversial, however, because
conflicting research shows that SSRIs and other antidepressants can actually precipitate
manic episodes. Most doctors can see the usefulness of antidepressants when used in
conjunction with mood stabilizing medications such as lithium.
In addition to the mentioned medical treatments of bipolar disorder, there are
several other options available to bipolar patients, most of which are used in
conjunction with medicine. One such treatment is light therapy. One study compared the
response to light therapy of bipolar patients with that of unipolar depresses patients.
Patients are free of psychotropic and hypnotic medications for at least one month before
treatment.
Bipolar patients in this study showed an average of 90.3% improvement in their
depressive symptoms, with no incidence of mania or hypomania. They all continued to use
light therapy, and all showed a sustained positive response at a three month follow-up
(Hopkins and Gelenberg, 1994). Another study involved a four week treatment of morning
bright light treatment of patients with seasonal affective disorder, including bipolar
patients. This study found a statistically significant decrement in depressive symptoms,
with the maximum antidepressant effect of light not being reached until week four.
Hypomanic symptoms were experienced by 36% of bipolar patients in this study.
Predominant hypomanic symptoms included racing thoughts, deceased sleep and irritability.
Surprisingly, one-third of controls also developed symptoms such as those mentioned
above. Regardless of the explanation of the emergence of hypomanic symptoms in
undiagnosed controls, it is evident from this study that light treatment may be
associated with the observed symptoms. Based on the results, careful professional
monitoring during light treatment is necessary, even for those without a history of major
mood disorders.
Another popular treatment for bipolar disorder is electro-convulsive shock therapy.
ECT is the preferred treatment for severely manic pregnant patients and patients who are
homicidal, psychotic, catatonic, medically compromised, or severely suicidal. In one
study, researchers found marked improvement in 78% of patients treated with ECT, compared
to 62% of patients treated only with lithium and 37% of patients who received neither,
ECT or lithium (Black et al., 1987).
A final type of therapy that I found is outpatient group psychotherapy. According
to Dr. John Graves, spokesperson for The National Depressive and Manic Depressive
Association have called attention to the value of support groups, challenging mental
health professionals to take a more serious look at group therapy for the bipolar
population.
Research shows that group participation may help increase lithium compliance,
decrease denial regarding the illness, and increase awareness of both external and
internal stress factors leading to manic and depressive episodes. Group therapy for
patients with bipolar disorders responds to the need for support and reinforcement of
medicationmanagement, the need for education and support for the interpersonal
difficulties that arise during the course of the disorder.
References
Bauer, M.S., Kurtz, J.W., Rubin, L.B., and Marcus, J.G. (1994). Mood and
Behavioral effects of four-week light treatment in winter depressives and controls.
Journal of Psychiatric Research. 28, 2: 135-145.
Bauer, M.S., Whybrow, P.C. and Winokur, A. (1990). Rapid Cycling Bipolar
Affective Disorder: I. Association with grade I hypothyroidism. Archives of General
Psychiatry. 47: 427-432.
Black, D.W., Winokur, G., and Nasrallah, A. (1987). Treatment of Mania: A
naturalistic study of electroconvulsive therapy versus lithium in 438 patients. Journal
of Clinical Psychiatry. 48: 132-139.
Deltito, J.A., Moline, M., Pollak, C., Martin, L.Y. and Maremani, I. (1991).
Effects of Phototherapy on nonseasonal unipolar and bipolar depressive spectrum
disorders. Journal of Affective Disorders. 23: 231-237.
Fawcett, Jan. (1994). Bipolar depression highlights of the first international
conference on bipolar disorder. University of Pittsburgh, Pennsylvania.
Forster, P.L. Videoconference program synopsis. Annenburg Center for Health
Services at Eisenhower Rancho Mirage, C.A. (http://www.wpic.pitt.edu/research/
stanley/othnws/vidtel12.htm).
Gasperini, M., Gatti, F., Bellini, L., Anniverno, R., Smeralsi, E., (1992).
Perspectives in clinical psychopharmacology of amitriptyline and fluvoxamine.
Pharmacopsychiatry. 26:186-192.
Goodwin, F.K., and Jamison, K.R. (1990). Manic Depressive Illness. New York:
Oxford University Press.
Goodwin, Donald W. and Guze, Samuel B. (1989). Psychiatric Diagnosis. Fourth
Ed. Oxford University. p.7.
Hirschfeld, R.M. (1995). Recent Developments in Clinical Aspects of Bipolar
Disorder. The Decade of the Brain. National Alliance for the Mentally Ill. Winter.
Vol. VI. Issue II.
Hollandsworth, James G. (1990). The Physiology of Psychological Disorders.
Plenem Press. New York and London. P.111.
Hopkins, H.S. and Gelenberg, A.J. (1994). Treatment of Bipolar Disorder:
How Far Have We Come? Psychopharmacology Bulletin. 30 (1): 27-38.
Jacobson, S.J., Jones, K., Ceolin, L., Kaur, P., Sahn, D., Donnerfeld, A.E.,
Rieder, M., Santelli, R., Smythe, J., Patuszuk, A., Einarson, T., and Koren, G.,
(1992). Prospective multicenter study of pregnancy outcome after lithium exposure during
the first trimester. Laricet. 339: 530-533.
Lish, J.D., Dime-Meenan, S., Whybrow, P.C., Price, R.A. and Hirschfeld, R.M.
(1994). The National Depressive and Manic Depressive Association (DMDA) Survey of Bipolar
Members. Affective Disorders. 31: pp.281-294.
Weisman, M.M., Livingston, B.M., Leaf, P.J., Florio, L.P., Holzer, C. (1991).
Psychiatric Disorders in America. Affective Disorders. Free Press.
University of Pittsburgh, Pennsylvania. (1994). Bipolar depression highlights
of the first international conference on bipolar disorder.
(http://www.wpic.pitt.edu/research/ bipolar2.htm).
--------------------------------------------------------------
The phenomenon of bipolar affective disorder has been a mystery since the 16th century.
History has shown that this affliction can appear in almost anyone. Even the great
painter Vincent Van Gogh is believed to have had bipolar disorder. It is clear that in
our society many people live with bipolar disorder; however, despite the abundance of
people suffering from the it, we are still waiting for definate explanations for the
causes and cure. The one fact of which we are pianfully aware4 is that bipolar disorder
severely undermines its' victoms ability to obtain and maintain social and occupational
success. Because bipolar disorder has such debilitating symptoms, it is imperitive that
we remain vigilent in the quest for explanations of its causes and treatment.
Affective disorders are characterized by a smorgasbord of symptoms that can be
broken into manic and depressive episodes. The depressive episodes are characterized by
intense feelings of sadness and despair that can become feelings of hopelessness and
helplessness. Some of the symptoms of a depressive episode include anhedonia,
disturbances in sleep and appetite, psycomoter retardation, loss of energy, feelings of
guilt and worthlessness, guilt, difficulty thinking, indecision, and recurrent thoughts
of death and suicide. The manic episodes are characterized by elevated or irritable mood,
increased energy, decreased need for sleep, poor judgment and insight, and often reckless
or irresponsible behavior (Hollandsworth, Jr. 1990 ).
Bipolar affective disorder affects approximately one percent of the population
(approximatly three million people) in the United States. It is presented by both males
and females. Bipolar disorder involves episodes of mania and depression. These episodes
may alternate with profound depressions characterized by a pervasive sadness, almost
inability to move, hopelessness, and disturbances in appetite, sleep, in concentrations
and driving.
Bipolar disorder is diagnosed if an episode of mania occurs whether depression has
been diagnosed or not (Goodwin, Guze, 1989, p 11). Most commonly, individuals with manic
episodes experience a period of depression. Mood is either elated, expansive, or
irritable, hyperactivity, pressure of speech, flight of ideas, inflated self esteem,
decreased need for sleep, distractibility, and excessive involvement in activities with
high potential for painful consequences. Rarest symptoms were periods of loss of all
interest and retardation or agitation (Weisman, 1991).
Effects
As the National Depressive and Manic Depressive Association (MDMDA) has demonstrated,
bipolar disorder can create substantial developmental delays, marital and family
disruptions, occupational setbacks, and financial disasters. This devastating disease
causes disruptions of families, loss of jobs and millions of dollars in cost to society.
Many times bipolar patients report that the depressions are longer and increase in
frequency as the individual ages. Many times bipolar states and psychotic states are
misdiagnosed as schizophrenic. Speech patterns help distinguish between the two
disorders (Lish, 1994).
Prevalence and Age of Onset
The onset of Bipolar disorder usually occurs between the ages of 20 and 30 years
of age, with a second peak in the mid-forties for women. A typical bipolar patient may
experience eight to ten episodes in their lifetime. However, those who have rapid
cycling may experience more episodes of mania and depression that succeed each other
without a period of remission (DSM III-R).
The three stages of mania begin with hypomania, in which patients report that they
are energetic, extroverted and assertive. The hypomania state has led observers to feel
that bipolar patients are "addicted" to their mania. Hypomania progresses into mania and
the transition is marked by loss of judgment. Often, euphoric grandiose characters are
recognized as well as a paranoid or irritable character begins to manifest. The third
stage of mania is evident when the patient experiences delusions with often paranoid
themes. Speech is generally rapid and behavior manifests with hyperactivity and
sometimes assaultiveness.
When both manic and depressive symptoms occur at the same time it is called a mixed
episode. These people are a special risk because of the combination of hopelessness,
agitation and anxiety make them feel like they "could jump out of their skin"(Hirschfeld,
1995). Up to 50% of all patients with mania have a mixture of depressed moods. Patients
report feeling very dysphoric, depressed and unhappy yet exhibit the energy associated
with mania. Rapid cycling mania is yet another presentation of bipolar disorder. Mania
may be present with four or more distinct episodes within a 12 month period. There is
now evidence to suggest that sometimes rapid cycling may be a transient manifestation of
the bipolar disorder. This form of the disease experiences more episodes of mania and
depression than bipolar.
Lithium has been the primary treatment of bipolar disorder since its introduction in
the 1960's. It is main function is to stabilize the cycling characteristic of bipolar
disorder. In four controlled studies by F. K. Goodwin and K. R. Jamison, the overall
response rate for bipolar subjects treated with Lithium was 78% (1990). Lithium is also
the primary drug used for long- term maintenance of bipolar disorder. In a majority of
bipolar patients, it lessens the duration, frequency, and severity of the episodes of
both mania and depression.
Unfortunately, there are up to 40% of bipolar patients who are either
unresponsive to lithium or who cannot tolerate the side effects. Some of the side
effects include thirst, weight gain, nausea, diarrhea, and edema. Patients who are
unresponsive to lithium treatment are often those who experience dysphoric mania, mixed
states, or rapid cycling bipolar disorder (those patients who experience at least four
distinct episodes within one month period).
Among the problems associated with lithium includes the fact the long-term
lithium treatment has been associated with decreased thyroid functioning in patients with
bipolar disorder. Preliminary evidence also suggest that hypothyroidism may actually
lead to rapid-cycling (Bauer et al., 1990). Another problem associated with the use of
lithium is its use by pregnant women. Its use during pregnancy has been associated with
birth defects, particularly Ebstein's anomaly. Based on current data, the risk of a
child with Ebstein's anomaly being born to a mother who took lithium during her first
trimester of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general
population (Jacobson et al., 1992).
Anti-convulsants
There are other effective treatments for bipolar disorder that are used in cases where
the patients cannot tolerate lithium or can become unresponsive to it in the past. The
American Psychiatric Association's guidelines suggest the next line of to be
anticonvulsant such as valproate and carbamazepine. These drugs are useful as antimanic
agents, especially in those patients with mixed states. Both of these medications can be
used in combination with lithium or in combination with each other. Valproate is
especially helpful for patients who are lithium noncompliant, experience rapid-cycling,
or have comorbid alcohol or drug abuse.
Neuropletics
Neuroleptics such as haloperidol or chlorpromazine have also been used to help
stabilize manic patients who are highly agitated or psychotic. Use of these drugs is
often necessary because the response to them are rapid, but there are risks involved in
their use. Because of the often severe side effects, benzodiazepines are often used in
their place. Benzodiazepines can achieve the same results as Neuroleptics for most
patients in terms of rapid control of agitation and excitement, without the severe side
effects.
Anti-depressants
Antidepressants such as the selective serotonin reuptake inhibitors (SSRIs) fluovamine
and amitriptyline have also been used by some doctors as treatment for bipolar disorder.
A double-blind study by M. Gasperini, F. Gatti, L. Bellini, R.Anniverno, and E. Smeraldi
showed that fluvoxamine and amitriptyline are highly effective treatments for bipolar
patients experiencing depressive episodes. This study is controversial, however, because
conflicting research shows that SSRIs and other antidepressants can actually precipitate
manic episodes. Most doctors can see the usefulness of antidepressants when used in
conjunction with mood stabilizing medications such as lithium.
In addition to the mentioned medical treatments of bipolar disorder, there are
several other options available to bipolar patients, most of which are used in
conjunction with medicine. One such treatment is light therapy. One study compared the
response to light therapy of bipolar patients with that of unipolar depresses patients.
Patients are free of psychotropic and hypnotic medications for at least one month before
treatment.
Bipolar patients in this study showed an average of 90.3% improvement in their
depressive symptoms, with no incidence of mania or hypomania. They all continued to use
light therapy, and all showed a sustained positive response at a three month follow-up
(Hopkins and Gelenberg, 1994). Another study involved a four week treatment of morning
bright light treatment of patients with seasonal affective disorder, including bipolar
patients. This study found a statistically significant decrement in depressive symptoms,
with the maximum antidepressant effect of light not being reached until week four.
Hypomanic symptoms were experienced by 36% of bipolar patients in this study.
Predominant hypomanic symptoms included racing thoughts, deceased sleep and irritability.
Surprisingly, one-third of controls also developed symptoms such as those mentioned
above. Regardless of the explanation of the emergence of hypomanic symptoms in
undiagnosed controls, it is evident from this study that light treatment may be
associated with the observed symptoms. Based on the results, careful professional
monitoring during light treatment is necessary, even for those without a history of major
mood disorders.
Another popular treatment for bipolar disorder is electro-convulsive shock therapy.
ECT is the preferred treatment for severely manic pregnant patients and patients who are
homicidal, psychotic, catatonic, medically compromised, or severely suicidal. In one
study, researchers found marked improvement in 78% of patients treated with ECT, compared
to 62% of patients treated only with lithium and 37% of patients who received neither,
ECT or lithium (Black et al., 1987).
A final type of therapy that I found is outpatient group psychotherapy. According
to Dr. John Graves, spokesperson for The National Depressive and Manic Depressive
Association have called attention to the value of support groups, challenging mental
health professionals to take a more serious look at group therapy for the bipolar
population.
Research shows that group participation may help increase lithium compliance,
decrease denial regarding the illness, and increase awareness of both external and
internal stress factors leading to manic and depressive episodes. Group therapy for
patients with bipolar disorders responds to the need for support and reinforcement of
medicationmanagement, the need for education and support for the interpersonal
difficulties that arise during the course of the disorder.
References
Bauer, M.S., Kurtz, J.W., Rubin, L.B., and Marcus, J.G. (1994). Mood and
Behavioral effects of four-week light treatment in winter depressives and controls.
Journal of Psychiatric Research. 28, 2: 135-145.
Bauer, M.S., Whybrow, P.C. and Winokur, A. (1990). Rapid Cycling Bipolar
Affective Disorder: I. Association with grade I hypothyroidism. Archives of General
Psychiatry. 47: 427-432.
Black, D.W., Winokur, G., and Nasrallah, A. (1987). Treatment of Mania: A
naturalistic study of electroconvulsive therapy versus lithium in 438 patients. Journal
of Clinical Psychiatry. 48: 132-139.
Deltito, J.A., Moline, M., Pollak, C., Martin, L.Y. and Maremani, I. (1991).
Effects of Phototherapy on nonseasonal unipolar and bipolar depressive spectrum
disorders. Journal of Affective Disorders. 23: 231-237.
Fawcett, Jan. (1994). Bipolar depression highlights of the first international
conference on bipolar disorder. University of Pittsburgh, Pennsylvania.
Forster, P.L. Videoconference program synopsis. Annenburg Center for Health
Services at Eisenhower Rancho Mirage, C.A. (http://www.wpic.pitt.edu/research/
stanley/othnws/vidtel12.htm).
Gasperini, M., Gatti, F., Bellini, L., Anniverno, R., Smeralsi, E., (1992).
Perspectives in clinical psychopharmacology of amitriptyline and fluvoxamine.
Pharmacopsychiatry. 26:186-192.
Goodwin, F.K., and Jamison, K.R. (1990). Manic Depressive Illness. New York:
Oxford University Press.
Goodwin, Donald W. and Guze, Samuel B. (1989). Psychiatric Diagnosis. Fourth
Ed. Oxford University. p.7.
Hirschfeld, R.M. (1995). Recent Developments in Clinical Aspects of Bipolar
Disorder. The Decade of the Brain. National Alliance for the Mentally Ill. Winter.
Vol. VI. Issue II.
Hollandsworth, James G. (1990). The Physiology of Psychological Disorders.
Plenem Press. New York and London. P.111.
Hopkins, H.S. and Gelenberg, A.J. (1994). Treatment of Bipolar Disorder:
How Far Have We Come? Psychopharmacology Bulletin. 30 (1): 27-38.
Jacobson, S.J., Jones, K., Ceolin, L., Kaur, P., Sahn, D., Donnerfeld, A.E.,
Rieder, M., Santelli, R., Smythe, J., Patuszuk, A., Einarson, T., and Koren, G.,
(1992). Prospective multicenter study of pregnancy outcome after lithium exposure during
the first trimester. Laricet. 339: 530-533.
Lish, J.D., Dime-Meenan, S., Whybrow, P.C., Price, R.A. and Hirschfeld, R.M.
(1994). The National Depressive and Manic Depressive Association (DMDA) Survey of Bipolar
Members. Affective Disorders. 31: pp.281-294.
Weisman, M.M., Livingston, B.M., Leaf, P.J., Florio, L.P., Holzer, C. (1991).
Psychiatric Disorders in America. Affective Disorders. Free Press.
University of Pittsburgh, Pennsylvania. (1994). Bipolar depression highlights
of the first international conference on bipolar disorder.
(http://www.wpic.pitt.edu/research/ bipolar2.htm).
|