Tokyo psychiatrist, Dr. Douglas Berger, comments on “Expert Q&A: Bipolar Disorder” by Terence A. Ketter, MD, June 3, 2016 issue of the Psychiatric Times.

In Q2 you state that mixed features can be seen in both unipolar or bipolar depression. It seems strange to word unipolar people as having “mixed features”. “Mixed” must mean they have hypomanic symptoms. If they have hypomanic symptoms, then they should be designated as bipolar spectrum, i.e., bipolar depressives. If they are unipolar then the “mixed feature” designation should be discarded and they should be stated to have depression with agitated features (sleeplessness or obsessions etc. whatever seems to be over-active).

Then on Q4 you state that non-DSM markers of bipolarity can indicate bipolar spectrum disorder. How can DSM symptoms of bipolarity indicate unipolar depression while non-DSM markers indicate bipolarity? There seems to be a problem in definitions and/or the ability to confirm the validity of what diagnostic category these people really belong to and we should have the modesty to say so.

On Q5, it is hard for me to understand why patients with bipolar II need to go to a bipolar clinic instead of a depression clinic. Shouldn’t any psychiatrist who knows who to treat depression know how to treat bipolar disorder? Unless there are serious medical or treatment resistant complications then this is over-fractionating the roles of what psychiatrists can treat.

On Q6, you propose CBT for Bipolar. Note that there has never been a single- (=patient blind) or double blind study of CBT or DBT ever, significantly eroding the credibility of saying these modalities have robust studies behind them. For example, when controlling for blinding, this study found CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder:

Lynch D, Laws KR, McKenna PJ: Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychol Med. 2010; 40(1): 9–24

Doug Berger, M.D., Ph.D.
US Board Certified Psychiatrist
Tokyo, Japan

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