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Book Review

Uneven Foray Into A "Spectrum"

bipolar spectrum
The Bipolar Spectrum
Fighting a disease with a thousand faces

By Marietta N. Almazan, MD
Radiant Press Inc. © 2008
ISBN 978-0-9814-500-0-1

The depth of Almazan's experience and compassion is evident in the numerous vignettes that she shares from actual patient files, using initials or omitting names altogether to protect confidentiality.

According to the National Alliance for the Mentally Ill (NAMI), more than 10 million people in the U.S. have bipolar disorder, also called manic depression. As one might guess from the term "bipolar," the disease is characterized by cycles of mania (highs) and depression (lows) that can vary in length from days to months, and in intensity from subtle to dramatic. These and other variations are more precisely encompassed in the term, "bipolar spectrum," which is the title of a new book by Dr. Marietta N. Almazan. Subtitled "Fighting a disease with a thousand faces," she generously shares her experience as a psychiatrist specializing in treating people with bipolar disorders, coming into contact with hundreds of those faces over 18 years. She knows only too well that the disease is chronic and lifelong, requiring consistent and vigilant treatment in the form of medication, psychotherapy, support and education to achieve balance in mood, energy and functioning. She writes, “I want to be as open as I can be: bipolar disease is a lifelong brain disorder. We can expect mood fluctuations or a period of destabilization often times triggered by life stressors.” But she also knows that the disease is treatable and manageable, and she is rejuvenated by patients who realize, "I can function, my mind is clear even on five medications," and “This is the best treatment combination makes me feel the most balanced" (sic). However, while she undoubtedly has experience and compassion, the book is a disappointing addition to the short bibliography of bipolar disease.

Dr. Almazan went to medical school at Far Eastern University in the Philippines. She completed residencies in adult, child and adolescent psychiatry at University of North Dakota in Fargo, ND and University of California-Davis in Sacramento, CA. She maintains a full-time, private, outpatient psychiatry practice and bipolar clinic as president and CEO of Specialty Center, Inc., Fair Oaks, California. The depth of Almazan's experience and compassion is evident in the numerous vignettes that she shares from actual patient files, using initials or omitting names altogether to protect confidentiality. These vignettes are the most informative and touching parts of the book, as they reveal the spectrum of sensations and symptoms, and the simultaneous manageability and intractability of the disease.

However, she does not write about her approach to patient care until Chapter 16 (of 24 chapters), entitled, "My Practice Style." Why this chapter comes so late is a mystery, and after reading it, what is unique to her practice, or what qualifies as her "style," is also a mystery. She uses passive voice so often that it is difficult to know when she is the practitioner, when other specialty practitioners take over, and whether those specialties are present on her team. For example, does she provide the complicated polypharmacological interventions as well as the psychotherapy? She details both in the chapter. It would be useful to know when and how the handoff (and hand-back) takes place. For the most part, she does not compare her practice to accepted medical standards of quality or support her choices with references to cutting edge research. Given the plethora of medications mentioned, I imagine she is writing this to other physicians, as there is no way for a lay person to evaluate the treatment regimens based on what she has written alone. Finally, unlike the other chapters, there is only one case presented, at the very end. Her medical choices would make much more sense in the context of specific cases presented throughout the chapter.

Clearly, she has much to share, and, laudably, not just as a physician concerned with medical care, but also as a fellow human being who understands the totality of her patients' lives.

For lay readers, the most useful chapter is "Clinical Opinions on Patient's FAQs" (Chapter 20). Her writing is more relaxed than in the rest of the book, though still quite clinical. She answers more than 100 questions in several categories including definition of terms, patient's role in treatment, job issues, pregnancy, custody, and stigma. Clearly, she has much to share, and, laudably, not just as a physician concerned with medical care, but also as a fellow human being who understands the totality of her patients' lives.

Almazan gives a nod to her ethnic and educational background with an appendix on "An Asian Perspective: Policy and Practice of Psychiatry in the Philippines." Use of mental health services among Asians and Asian Americans is low for a number of cultural and linguistic reasons and the Philippines is no exception unfortunately. She provides a basic overview of the scant resources available to Filipinos in the Philippines. However, given that her practice is in California, and she does not provide demographic information on her patient population, the relevance of this section is questionable. She does recognize that cultural diversity should impact the practice of psychiatry and shares several vignettes of Asian and Hispanic patients in the main section of the book.

As stated earlier, her inclusion of so many real patient stories is the most useful and touching part of the book. However, the lessons that could be drawn out of their individual and collective stories are lost in her overwhelming use of medical and pharmaceutical jargon, combined with a writing style that reads like stream-of-consciousness note-taking rather than fully developed prose. Sometimes prose is dispensed with altogether, with whole sections comprised of lists with little context for why such a listing is necessary. Moreover, the book needs another round of copy editing, as the reader is forced to stumble over sentence fragments, run-ons, subject-verb disagreements and other mistakes like in the quote at the end of this review's first paragraph. The result of these shortcomings is a book that could be useful for clinicians and allied professionals, but patients and family members would be much better served by NAMI's website.

Finally, I must raise a gentle objection to the title of Chapter Two: "The Agony of a Sick and Weak Mind." Given the stigma around mental illness, which Almazan knows and seeks to diminish, I would expect a qualification of some sort for describing the mind as weak. "Sick" I can accept in the context of educating the public that bipolar disorder and other mental illnesses are as much diseases as cancer or HIV/AIDS. But "weak" recalls outdated misconceptions and judgments about the mentally ill. Almazan offers no explanation for this word choice-a choice which I believe to be unintentional and would be willing to be persuaded as to its appropriateness. But in the absence of any explanation, and given her position and the public nature of this work, I must raise the issue. This does not belong in "A guide to the truth," the book's other subtitle.

© Gem P. Daus, MA

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