REBOOT #415 Bipolar Disorder With Dr. Kevin Johns

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So without further ado, let's get on to the episode. Matt, a patient walks into a psychoanalyst's office and asks, so how does this work? Do I just lie on the couch? And the psychoanalyst says, actually, it works much better if you tell the truth. Okay. All right. Paul, what do you call a depressed man with a robotic arm? Oh, no. I don't like this going. Go ahead and tell me. A cyborg. Like, sigh.

I got it. No. They're always the funny ones when you have to explain them afterwards. All right. What else do you got, Paul? All right. My last one. Just see if we can make Dad laugh. Why does Pavlov have such nice hair? I have no idea. Because he conditioned it. I think that's the winner.

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Pretty much, we are responsible if you screw up. You should always do your own homework and let us know when we're working. Welcome back to the Curbsiders. I'm Dr. Matthew Frank Wado, here with... my great friend and America's primary care physician, Dr. Paul Nelson-Williams. Paul, how are you doing tonight? I'm great, Matt. Thanks. How are you?

I'm good. You just told some hilarious puns. I'm sure the audience agrees. And tonight we'll be talking about bipolar disorder. We have a great guest, Dr. Kevin Johns. And before we get to our guest and our guest co-host, Paul, can you tell the audience, what is it that we do on The Curbsiders?

Sure, Matt. Thanks for the chance to do so. We are the Internal Medicine Podcast. We use expert interviews during your clinical pearls and practice changing knowledge. As you mentioned, we have a super producer and special co-host with us, Dr. Deb Gorth. Deb, how are you? I'm doing great. I'm excited to learn about bipolar. You can tell she's in the throes of residency right now, Paul. That's the energy that only a resident can muster.

Just too tired of even feign enthusiasm at this point. We just recorded an hour and plus change episode. So, all right. So, Deb, why don't you tell us a little bit about who we talked to and what we talked about? Yeah, so we just had a fantastic conversation with our guest, Dr. Johns. So Kevin Johns is a psychiatrist. He does...

Consultation Liaison Psychiatry at Ohio State University in the Wechsler Medical Center in Columbus, Ohio. He also sees inpatient consults in the General Medicine Hospital and provides collaborative services in ambulatory settings. He did a really great job teaching us about how we can recognize bipolar disorder and kind of the ins and outs of its treatment. So without further ado, let's get into it.

Kevin, we've been talking for a while. We got our, hopefully our technical difficulties out of the way. And now the audience just, they need to hear a hobby or interest that you have outside of medicine. Yeah. So I, actually have been playing competitive Pokemon cards for about the past year with my seven-year-old son. And so we've been traveling around, actually around the country sometimes on weekends in order to compete in huge tournaments. And so that's been a really great way to bond.

with my son. Wow, that is an answer I was not expecting. Have you guys won anything? Yeah, I've won some Pokemon card packs. Yeah, we're still early in terms of our journey to becoming Pokemon Masters, but we're working our way up. And there's like 10 million cards, right? You'll never collect them all. Is that a fair thing to say?

Yeah, yeah, yeah. There's so many cards to collect. And so I'm more interested in just playing the game and, you know, competing. But there's definitely lots of people out there that love collecting. Yeah, my kids are definitely, I don't know that they have a lot of cards.

I don't know that they know how to play the game. They just want to collect, to collect them. Yeah. I'm not sure I knew there was a game involved. I gotta be honest with y'all. I knew that there was card collection, but I didn't do anything. Yes, you did. Come on. It's like a Magic the Gathering type thing, Paul. You didn't know?

No, I think Paul is a secret Pokemon card player. Yeah, I can see that rumor going. All right, Kevin, I.

Let's pivot a little bit since I have nothing to contribute to the Pokemon discourse, but we do like to ask about, you can tell us about a Pokemon-related failure or really kind of any favorite failure that you have that you learned something from. Yeah, so my favorite... the failure that i've kind of learned learned something from was when i went on a trip to france southern france with my uh my father-in-law and uh my wife and we were very you know

grand plans to sail a boat down a canal through southern france for several days and but we landed there in the middle of a huge heat wave and our refrigeration on the boat broke and so we were all just like sweltering heat hot and it was humid and we were surrounded by mosquitoes and it was definitely like we were very cranky on the boat because we were all stuck on a small boat together.

We made a lot of really cool memories, though. It's one of those things that I wouldn't want to do again, but I'm so glad I did it. And so I think I learned things don't have to be perfect. Even misadventures can... bring people together and, you know, create lots of lasting memories. And I had some of the best seafood I ever had in my life. So that sounds kind of dangerous though.

Did you have to call the Coast Guard equivalent, the French Coast Guard equivalent, to help you out, get you some water that wasn't boiling hot? No. Luckily, there were lots of small towns that we could stop at along the way to get water. things like that. Okay. That's, that's making me feel better about this situation. It sounded scary. Yeah. If I was involved to be like a Lord of the fly situation, almost immediately, like two hours in, I would. That's what it felt like.

So I'm still in training. So I'd really appreciate if you could tell us some meaningful advice or feedback that you've received during your career or training that maybe I could apply to my career or training. Sure. I think early on as a medical student, one of my mentors gave me the feedback that when I was working with him, he was my gold standard and I should try to emulate his...

practices and his thinking as much as possible. And once I'm in independent practice, I can pick what techniques or what... philosophies you know i want to apply to my own practice but when you're working with like an attending for the you know especially for the first time you know really try to try to emulate that attending and have that

you know tending be you know like your gold standard and um you know you'll learn some things that some styles that you like and some things that you don't but you know once you're out of training you'll be able to pick from all the different

different styles that you've experienced and make your own style of how you want to practice medicine. And Deb, since you work at the same institution as Paul Williams, if he's ever, or you did, if he was ever your attending, you would definitely want to emulate everything he did. Yeah, he is my gold standard, especially when it comes to cats. Hey, yeah. Well, we have a lot to get to, Deb. So let's go to a case from Cashlack and start talking about bipolar.

So this is a 20-year-old college student who's coming into your office for a checkup during winter break from his freshman year at Cashlack University. His mother has become increasingly concerned because during the holidays, she noticed that her son stays in bed. until 1 p.m. He's not engaged with the family like he was during the summer. She's really worried that he might be depressed. For the past two weeks, he lost interest in food. He can't concentrate on anything.

in the middle of the exam, interrupts his mother, and he insists that he doesn't see what the problem is. He just doesn't want to do anything. He goes on to tell you that he's a successful engineering student. He has a good group of friends at school, but he concedes that... He and his girlfriend broke up a few months ago and he's been feeling a little bit down.

He meets all the criteria for depression. For greater than two weeks, he experienced five or more depressive symptoms. It seems like he has depressed mood, diminished interest, appetite disturbance, sleep disturbance. So he's depressed, right? And we should just prescribe him. an SSRI and move on with the episode. Yep. And we can all go to bed and yeah, no, actually. So, so yeah, this is actually a great case because, you know, it shows the complexity of what.

might appear to be a very straightforward presentation. So yes, you're right. He meets all the criteria for a major depressive episode, but there's multiple conditions that can cause a major depressive episode. So at this point, all we know is that he has met criteria for a major depressive episode. And the next step would be to drill down and see what is causing the major depressive episode.

Yeah, because this seems like in primary care, you get tons of patients coming in saying they're depressed. Sometimes you get a family member with them saying, I think they're depressed and asking you to prescribe medication or connect them to therapy. I have to admit, it's not always like first thing on my mind. If it's a younger person, I usually tend to think more about bipolar.

When patients are a little older, it doesn't always cross my mind and you might fall into the trap of prescribing like just a conventional antidepressant without doing anything further. So what questions do you ask to make sure we don't make that mistake? Yeah. So, you know, when someone comes in with a major depressive episode, you want to make sure that it's not due to like a bipolar disorder or not due to schizoaffective disorder, for example.

or not due to substances or another medical condition. So assuming that this person doesn't have hypothyroidism or other kind of medical issues that could create depressive symptoms, we really want to figure out Like you said, is this bipolar disorder or is this major depressive disorder? And so some of the questions I will ask is, I'll ask them, assuming that they've never been diagnosed with bipolar disorder.

I'll ask them, have there been times where your mood has been different from depressed or even the opposite of depressed and where you've been supercharged? had so much energy that you didn't know what to do with yourself and for days and days on end. And, you know, people thought you were behaving strangely. And I'll leave with something like that and kind of see what they say.

And if they say like, yes, I've had some times like that, then I'll explore further. Like, okay, tell me more about that time. What else was different about you during that time? Or if his mom was there, I'll ask like, did you notice? Did you talk to them on the phone during that time? Did you notice any changes? But if they say no, then I think that's usually pretty helpful. But if they say yes, definitely you have to explore further and ask them for more details.

How do you, because it looks like, if I remember correctly, the DSM-5 criteria... You have to have the behavior be noticed by someone or has to be significant enough to actually cause impairment, depending on sort of what type of bipolar we're talking about. But if you don't have an additional collateral information at the visit, how do you ask about that or how do you assess?

if a patient has appeared different to other. Do you just ask, is it that straightforward? It's hard because a lot of times when patients are manic, they might not find it. distressing and they may even like the feeling of being manic. Or other times they just don't realize that that's what's happening. So a lot of times even...

you know, patients with history of manic episode, if you ask them, you know, they might not be able to really identify with it. So it is really hard. It's really challenging. As far as, you know, kind of how would I ask about like the...

you know, the functional impairment or the symptoms being noticed by others. Yeah. I, I asked them, you know, you know, did other people notice that you were acting differently? And if they say yes, they'll say, well, what did they say about you? Did they say that you were doing really well or were they?

where they actually worried about you. And then as far as functional impairment, yeah, I'll ask them, did that cause any problems for you? Did you end up regretting that? Or what kind of troubles did that cause you? Did you have to go to the hospital or go to the emergency?

emergency department because of this. The other thing is just, if the patient will let you, you know, Being able to talk to their family member or partner or someone who's seen one of these episodes firsthand can be really helpful, although that does take additional time, which can be challenging in an office setting.

And yeah, I was surprised to read that depression is the main presenting symptom of bipolar disorder. I always thought that you had to have hypomania or mania to kick it off. I didn't realize that it could be... depression as a presenting symptom or that I guess maybe it could be a mixed episode. Can you speak to that a little bit?

Yeah. So patients with bipolar disorder, they will have both manic episodes and depressive episodes. And actually, the depressive episodes for most patients are actually the most... common episodes and also the most impairing. So about two-thirds of

patient's symptomatic times with bipolar disorder on average is going to be in the depressive phase. And so I've met plenty of patients where they've had maybe one or two manic episodes their entire lives and then just numerous depressive episodes after that.

One of the challenges of bipolar disorder is that if we're thinking of it as having bipolar disorder as like a trait and then being manic or depressed as a state, you know, until someone has had, you know, kind of that perfect storm of, you know, genetics and environments that trigger a manic episode, it's, you really can't identify.

um identify them as bipolar disorder even though they may have you know the underlying genetic vulnerabilities and everything so that's um that is a really challenging aspect of our field and especially a big limitation of using, you know, the DSM-5 as like a phenotypical diagnostic strategy.

I like psychiatry because there's no blood tests to tell me like what a condition a patient has. And, you know, I'm, I'm my own diagnostic instrument, but like, honestly, if there was a blood test to tell me. or help me diagnose the condition, it would be bipolar disorder because it is so challenging. I tell people, unless you see the patient manic, it is really hard to know for sure if they truly have bipolar disorder or not. Paul, another thing.

Paul and I are always just looking for the, just give me that test that tells me yes or no. That's what I want. Like I want a clear answer, but a lot of the times, a lot of the times we don't get that, Paul. We've never, not once. Yeah, especially in psychiatry. And it's tough, you know, like a person with bipolar disorder, if they become manic, you know, the day before they had their first manic episode, they would meet criteria for major depressive disorder.

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And listeners of Curbsiders can use the code CURB50 for $50 off their first month. So you gave us the questions, you know, you ask about their mood, their energy. any strange behaviors that they've had or that others have noticed and then like functional impairment and if you know if we're if we start to suspect based on those answers that maybe there's something going on like which tool do you like to go to to

to then sort out like, is this a formal diagnosis or not? Yeah, I think, I think, especially in primary care, where you guys aren't used to like asking for all the diagnostic criteria all day, you know, I think having a screening tool. can be really helpful. And you just have to know the psychometric properties of the screening tools though. So the most common one that I see in practice is called the mood disorder questionnaire or MDQ. Have you guys...

heard of that before or seen it before? I have not used it, no. Okay. It's a terrible test. I'll rant about it for a minute. It's widely distributed and it's easy to use because it's a patient report form. So patients can fill it out even while they're sitting in your lobby, for example. but it has really terrible positive predictive value. Its negative predictive value is pretty useful.

is pretty good. So I kind of consider it like the D-dimer of psychiatry. Like a negative test is helpful, but if they screen positive, they're actually more likely to have like, you know, borderline personality disorder or ADHD or something other than bipolar disorder, even though it's... presented as a bipolar screening tool. I see. But that's a common one that you'll see out there. I still use MDQ, especially in primary...

care settings because like I said, if it's negative, you can be fairly certain that the patient doesn't have bipolar disorder. It's just that when you have a positive test... You're still left with a lot of work to do because it's not clear that they truly have bipolar disorder. There's probably some kind of comorbidity, but it's not necessarily bipolar disorder. Another screening tool that I...

do like to use better is called the CIDI 3.0 or the CIDI bipolar screening tool. It's a little bit harder to use because it's a guided interview. So it's essentially a script and you read the script and to the patient. and ask them about the bipolar symptoms. And it kind of emulates like how we would ask because it really tries to capture and emphasize to the patient that all these symptoms should be happening at once. It's not just, you know, one night of like...

you know, not needing sleep or one day of, you know, talking more, being really excited, but, you know, really it's like an extended period of all these things happening at once. And so... So it gives you kind of a nice script to follow. And then you can kind of see how many of the symptoms, you know, the patient endorses during that time. And then that has much better sensitivity and specificity for bipolar disorder.

And you say this script, this is the one that has like the two STEM questions to start. And then if one of those is positive, you go to the next part.

But it's not super long, right? This looks like it might take five, 10 minutes to do. How long do you estimate it takes to finish? Yeah, I would say, yeah, five to 10 minutes. I think is a fair estimate. Yeah. If it's a test that takes like 20 or 30 minutes to administer, it's just not going to get done in primary care because that's like your whole visit time. But 10 minutes, you still have some time in the visit to talk about the results.

So this one seemed a little more practical to me when I was looking through it. It was mentioned in a couple of the papers. Yeah, yeah. That's the one that I recommend when I'm... when I'm concerned about bipolar disorder, I'm really looking for like a diagnosis of bipolar disorder. If I'm just trying to like, try to screen it out in a patient where like, I don't think they really have bipolar disorder anyway, like the MDQ is a fine self-report tool that can.

rule it out essentially. But if I have a patient where I'm really concerned that they might truly have bipolar disorder, the CIDI is what I tell my primary care colleagues to use. Okay. And that one's pretty easy to find for the audience. We can, of course, link to the paper and some resources in the show notes for that. But that's a good one. Any other ones that you wanted to highlight?

There's other rating scales out there. There's the Young Mania rating scale that you'll see, but those are more for acute... manic presentations. And I think especially in primary care, like you're going to see these patients for the most part in their depressive phase of the illness. So I think tools that ask about, you know, bipolar or manic symptoms in retrospect, like the CIDI are more practical. Okay. Yeah. Deborah, Paul, any other questions about this part of it that you had?

Well, I did it was since while we're taking a history and we're trying to kind of dig down to whether or not this is bipolar or not, I was going to ask how important is, say, the family history in this? Does that move the needle?

Either way, if there's no family history of any kind of mental health issues or if they say, oh, yes, my mom and dad are also bipolar or have a diagnosis, like how how substantive is that or how meaningful is that when you're actually in compared to the rest of the history that you're taking? Yeah, that's a great point. Yeah, family history, certainly bipolar disorder can run in families. And so if someone has a family history of bipolar disorder, it increases my index of suspicion.

The other thing to keep in mind, though, is just that major depressive disorder is also just a much more common condition. So even in someone who has a family history of... bipolar disorder, they still may have major depressive disorder as well. It's not necessarily bipolar disorder.

But certainly if they do have a positive family history, especially like first degree relatives or multiple first degree relatives, that increases my index of suspicion a lot. I think something I struggle with, this feels kind of like... the family history of rheumatoid arthritis, where it's the patient may just not understand what that diagnosis is or how it's differentiated from other more common diagnoses. So like if a patient endorses it, I still...

fairly or not, sort of second guess whether or not the family member truly has the diagnosis, because I think there's such a baseline misunderstanding of what bipolar actually represents. Yeah, I think I agree with that. A lot of times when patients tell me that

they had a family member who had bipolar disorder. I'll ask like, you know, was it formally diagnosed by a mental health professional or what kind of symptoms they had? Because yeah, you know, the the kind of colloquial use of like bipolar disorder is very different from how you know like mental health clinicians use it yeah you know i think about like the like

Katy Perry song, hot and cold, like you're hot and you're cold, yes and you're no, something, something love bipolar. Like I think like most, you know, non mental health. People, you know, think of bipolar as like people who, you know, rapidly go from one mood to another and, you know, or they'll say, I love you, then I hate you or things like that. When we think about bipolar disorder in the psychiatric sense, we're talking about sustained mood episodes that last a week or longer.

it's not just flipping from one mood to another in a single day. Having more than one mood in a single day doesn't mean you have bipolar disorder. It just means you're a normal human being. Or there are other conditions that can cause rapid mood shifts within a single day, things such as borderline personality disorder, for example. But yeah, the way that we think about bipolar disorder is very, very different from how...

lay people use the term bipolar disorder. There's a recent New England Journal of Medicine review article on bipolar disorder, and it's wonderful. This is not me making fun of it, but the first paragraph is like, it's normal to be... happy when something good happens instead was something bad. Like they just sort of normalized moods, which I really enjoyed as an opening paragraph to the, I know the general medicine article. Yeah. Yeah.

Another thing I noticed just while we're talking about things that would raise our suspicion, it just seemed like... the list of the comorbid, like other psychiatric illness or other things that would kind of be in the DSM. So like substance use, anxiety, PTSD, ADHD are all like more likely to be present.

in addition to bipolar. Is that fair to say? I mean, it sounds like substance use might make the diagnosis a little bit like, is this a substance use problem or substance use or withdrawal or is this bipolar? But can you speak to how you sort that out? how many disorders somebody can have? Yeah, they can have...

Yeah, many comorbid disorders and comorbid is very common, you know, substance use disorders, borderline personality disorders, ADHD, trauma, PTSD. All those things can cause like, you know, mood lability and create similar symptoms as bipolar disorder. And they also can be present in a patient with bipolar disorder. Substance use is a tricky one because some people may...

develop manic-like symptoms if they're using like methamphetamines, for example. But on the other hand, you know, there's also patients who would never use methamphetamines, but then they get manic and they start taking, you know, much more risky, you know, engaging in risky behaviors and they might start using drugs. And so it's, you know, it's hard to tell like what came first, you know, the drug or the mania.

And so a lot of times in these situations with patients where there are a lot of these comorbidities, it's hard to know for sure from one. diagnostic interview and you just have to follow them over time, sometimes for years before you get a clear understanding of what's actually going on.

I tell patients all the time that, you know, this is the first time I'm meeting you and it's really hard for me to know for sure if you truly had bipolar disorder or not. You know, I might say like, these are the things that make me concerned, but I also could be wrong. And I tell patients that all the time that, you know, just off of one first meeting, I can't.

you know, 100% diagnosed with bipolar disorder. So one of my colleagues makes this point a lot in that, you know, patients will often talk about patients with substance use disorder as sort of self-managing their symptoms. Like, oh, this patient's anxious, so that's why they have heroin use.

And her point is like that's heroin use is not the behavior of an anxious person as someone who's filled with anxiety like that would make me even more anxious to consider it. So like that, it's much more characteristic of someone who might be having a manic episode. And she's she's of the opinion that's probably even underdiagnosed.

that being bipolar and patients with substance use disorder, which the more I learn, the more I kind of agree with. Yeah, and I think there's also just so many patients with substance use disorder also have trauma too, which I think... changes how they cope with emotions and difficult emotions and make it more easy for them to seek out coping skills.

like using substances, whereas people without trauma may not. And then there's also, you know, people that also genetically respond to, you know, substances differently, you know. So, you know, for example, there's some people with like opioid use disorder where they say like opioids.

energize them. And whereas, you know, most other people would consider it a downer. And so, you know, people have like different biological responses to these substances that can kind of change their risk of, you know, developing a use disorder. Deb, let's go on to the next part of the case and then we can keep going on the diagnosis portion here.

So after taking a more detailed history, you learn that during finals, he barely slept for five days without feeling tired while he completed his engineering final project, which at the time he thought he should sell to NASA. His girlfriend broke up with him because he cheated on her after turning into the project, something he still regrets. Later on, his mom chimes in and says that her brother suffered from bipolar disorder.

Lastly, after you appropriately scream for self-harm, he insists that he has never thought about hurting himself or suicide. So, you know, just that we've kind of gone over some of the screening tools for bipolar. Can we just nail down exactly how you define bipolar? Yeah, so the DSM-5 would define bipolar as having had at least...

one manic episode in their lifetime. And with a manic episode being a period of lasting at least one week of... elevated, expansive or irritated mood along with increased goal-directed activity. And they have to be accompanied by the other manic symptoms as well, you know, things like hypersexuality, grandiosity, flight of ideas, you know, things like that. So, you know, I really think of...

bipolar disorder as a syndrome. Because all these symptoms individually, they're all aspects of normal human experience. Everyone's had times where they have not needed as much sleep as normal because they were excited. were nervous about a board exam coming up or something. Everyone's had times where they talked more than other people. Really trying to obtain this history of a discrete period of time where all these symptoms are happening at the same time. I think that that's really important.

bipolar disorder diagnosis, you know, on top of the change in level of functioning. So whereas, you know, we're in this patient, you know, those things are pretty clear, you know, he, he wasn't sleeping, he was having like grandiose ideas, and is clearly causing like,

you know, relationship, you know, functional impairments in his relationships, I would say that this patient, you know, the narrative that you're presenting, you know, it's a pretty convincing narrative for a manic episode. Yeah, because I've had... like you're saying, a discrete period of time. Cause I've had some patients like, yeah, there was one time where I was spent too much money and I've had depression in the past, but you know, they're not, they're not really hitting. Maybe they've had.

a brief time where they had one of these symptoms, but you're saying this is like at least a week. For mania, the bipolar one, it has to be at least a week. It has to be really severe, right? That's the difference between hypomania and mania is hypomania is a little less severe. The functional impairment is not as severe. Right. Any other differentiators between the two?

Hypomania doesn't have to last as long. I think hypomania just has to last four days or more. With mania, it has to be at least a week, or it could be less than a week if a person is hospitalized. So they become so manic that they have to get... brought to the emergency department to get hospitalized, to get treated with medications. And, you know, the episode is treated in less than a week. We would still consider that a manic episode though. And yeah, the functional impairment.

And psychosis is, I've seen that happen as well, I guess. So it's usually not, it's less subtle. It seems like hypomania could be a little bit more subtle. If you're not around the person in close contact all the time. Yeah, hypomania is definitely more subtle. And some people may even function better when they're hypomanic. And so they may get more work done and be more, you know.

be more creative. I'm glad you mentioned psychosis because psychosis is something else that would push them over from hypomania to mania. So if they have psychotic symptoms, that would automatically...

categorize them as having full mania as well. Yeah. It's a really challenging diagnosis to make. But I think in this case, this patient is telling a very... a very consistent history that, you know, that's consistent with, with the bipolar manic episode. And, you know, especially if they like elicited or if they volunteered this on their own with like minimal prompting from you. I think that that would, you know, really.

increase the diagnostic probability. With mania, I like to just kind of... give them like a question stem, like ask them, like, have there been times where you've been the opposite of depressed or supercharged for a week at a time and kind of leave it at that and ask them to.

come to me with the rest of the symptoms. I try not to list off the rest of the DSM-5 criteria because I don't want them to just say, oh yeah, I had that, I had that, I had that. I want them to come to me and actually tell me what their last episode was. was like and see if their description of their most recent, you know, so-called manic episode would meet criteria for a DSM-5, you know, manic episode. So with bipolar one, that's if they've had one episode that qualified as mania.

even if they've never been depressed, they get that diagnosis bipolar one, right? That's correct. Yeah. Many times they, their initial mood episode will be a depressive episode, but sometimes, yeah, they will present initially with the manic episode that happens as well. And how about for the audience, just the bipolar 2 and then cyclothymic disorder, how are those different?

Yeah, so with bipolar 2, these patients have never had a manic episode, but they have had hypomanic episodes. And then also, almost always, they've also had numerous. major depressive episodes as well. With cyclothymic disorder, they have had numerous episodes of sub-threshold hypomanic symptoms, so episodes that don't meet full criteria for hypomania. And they also have had numerous periods of sub-threshold depressive episodes as well that don't fully meet criteria for major depressive episode.

That seems like one where it'd be kind of hard to make the diagnosis in one visit. You'd have to follow the person for a long time. And it just seems kind of vague. That's not a diagnosis that I see often on charts. Maybe in a psychiatrist's office it is, but in primary care, Paul, have you seen that diagnosis? I can't imagine a world where I had the courage to make that diagnosis. And no, I haven't seen it very often either.

Yeah, no, I think even in psychiatry practice, it's a diagnosis that's made very rarely. Because like you said, you do have to follow a patient for a very long time to really, you know. make the case that they meet that pattern of never having been too manic to be fully manic or meet criteria for a bipolar disorder, never having been so depressed that they meet criteria for a major depressive disorder. It takes time to establish a lot of this.

diagnosis like that. Okay. So you mentioned earlier some of the things that we want to make sure, you know, we're not missing like schizoaffective disorder or substance use. You said endocrine disorders like... thyroid disorder as a potentially causing someone to be depressed or I guess some of these could cause mania as well, substances and things. How is schizoaffective?

disorder different than bipolar because those those seem pretty close and you can have psychosis with bipolar. So it seems like it might be hard to figure that out. It is hard to figure that out. And it's also one of those things that can be hard to figure out until you've followed a patient for a long time. So with schizoaffective disorder, the psychotic disorder is the primary disorder.

they will have symptoms of psychosis such as hallucinations or delusions, even in the absence of a mood episode. Whereas in bipolar disorder, the mood disorder is primary. So they will only have... hallucinations, delusions, when they're having a manic episode or when they're having a depressive episode. So it's really important to see when they're euthymic or when their mood is normal, do they have any psychotic symptoms.

And you can try to ask them that on interview. But really, yeah, you know, the best way to know for sure really is to follow someone for a long time. Okay, that's good. So, Deb. What else do we want to ask about here? Are we ready to get to treatment or do we have other things we need to know about our patient here? I don't think we gave him a name. We're just 20-year-old college students. Yeah, we're HIPAA compliant.

Thanks, Deb. It's so responsible of you. I think looking at other mimickers, what are some... potential physiological causes or drugs that could mimic bipolar disorder? Yeah. So, you know, I think... with substances, things that could cause mania include stimulants like methamphetamines, cocaine. dissociative substances, you know, depressants cause depressive symptoms, you know, things like alcohol or opioids, physiological things. So for example, things like...

Hypothyroidism could present with some symptoms of depression. Hyperthyroidism can sometimes present with manic symptoms. If someone's receiving steroid treatment, that can present with manic symptoms. more people have like neuropsychiatric side effects of steroids than we really fully appreciate. And so, you know, I've seen patients develop, you know, mania and psychosis, you know, while they're being treated with prednisone or even...

Even while the prednisone is being tapered, I've seen patients develop psychotic or manic symptoms, which... Seems really odd, and I don't really have a great explanation for why that is, but it's something that I've seen multiple times in my career. Yikes. So this is somebody that was on it for... giant cell arteritis or some high dose on a long, slow taper. Yeah. Yeah. And so, um, yeah, so, so, um, you know, just because it's being tapered, I wouldn't rule out steroids as, as being the cause.

More rare things like perineoplastic encephalitis or limbic encephalitis could present with manic-like symptoms. I think if someone is postictal, they can present with psychosis. Sometimes it can look like mania in cross-section.

One of the more challenging things, though, is just kind of differentiating between bipolar disorder and the other psychiatric comorbidities that it could present as, you know, such as, for example, like borderline personality disorder where they have, you know, very rapid mood shifts. But those tend to be like very...

rapid, you know, kind of multiple moods within a day. And it's a lot of the core is a lot of interpersonal instability. So fears of abandonment and, you know, unstable self-image, you know, things like that. or, like, ADHD, which can cause a lot of impulsivity that can look like mania. But ADHD is also something that, like, doesn't just last for a week. You know, ADHD is something that, you know, goes, you know.

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Out of the ordinary. The irritability part of bipolar isn't one that I had thought about as much. Because that second question on the CID. CIDI 3 that you talked about is talking about, have you been irritable for like a prolonged period of time and you were getting in fights or yelling at people? Is that one harder to diagnose than just the typical person's really happy and having sex with everyone and gambling and starting businesses and all those kind of things? Yeah, it is more challenging.

And I classically, you know, we think of like the euphoric manic patient who is, you know, gambling, having sex with everyone, thinks that they're the mayor, the president, and they're, you know, just on top of the world. But in reality, like patients with mania are actually. usually quite miserable.

because they have a lot of that irritability or there's a lot of mixed depressive symptoms mixed in there. And so classically, we think about patients being very euphoric, but in reality, many of these patients are very... angry. They can be feeling very hopeless. I remember patients screaming about how happy they are, but then at the

Also saying like, but at the same time, I feel so depressed and I want to die. And so there's, I think mixed symptoms are very common in these patients. And so very often you're going to see. depressive symptoms and like irritability mixed in instead of just like pure euphoria. So. I do think we should start to delve into treatment. And it seems like with our 20-year-old name withheld that he definitely has what's concerning for bipolar.

So he's had depression and it also sounds like he's had mania or manic symptoms. So how would you approach the treatment? Because there's just so many medications. It can seem overwhelming. So if you could give us a framework, that would be great. Sure. Yeah, I think with treatment of bipolar disorder, it's really important to consider what phase of the illness that you're treating.

because there's different treatments for mania compared to bipolar depression. So in this case, you know, the patient is presenting with a major depressive episode. It doesn't seem from the... case presentation, it doesn't seem like there's any mixed manic features in there. Like, you know, he, you know, maybe was like talking back to his mom a little bit, but I wouldn't call that like abnormal irritability for like a 20 year old who's dragged into the office by, by their mom.

I'm not hearing about any other currently active manic symptoms. So we're looking at the acute depressive phase of the illness. And unfortunately... With bipolar disorder, the depressive phases of the illness are the most common phases. Also the phase of the illness that has more limited treatment options. And so with the... More commonly used FDA-approved treatments would include lorazodone and quetiapine. You know, those are two FDA-approved treatments for bipolar depression.

Lamotrigine is another option, but the titration is quite slow. And so it's usually more helpful for the maintenance phase than the kind of acute depressive phase. So, Kevin, can you... What's confusing to me is that because sometimes patients are only having depression, but they have bipolar. and we're worried they will develop mania, do we always have to give them an agent that covers both? Because I think a lot of the agents cover both, but not all of them do. So how do you sort that out?

Yeah, that's a great question. So the treatment for different phases is different, but there are a lot of medications that we'll cover for both. So for example, like a lot of the atypical antipsychotics. They're all useful for treating the manic symptoms. It's actually the depressive phase of the illness that's more challenging because there's fewer medications that have been shown to be effective for the depressive phase of the illness.

So, you know, really it's making sure that you're covering for the depressive side of the illness. That's actually the most challenging side in terms of things that are approved for treating the depressive phase of the illness. That would include cotiapine, lorazodone. Those are two very commonly used atypical antipsychotic options.

Another option is lamotrigine, but lamotrigine, because of the risk of Stevens-Johnson syndrome, you have to titrate that very slowly. So that's less useful in the acute phase of the illness and more useful in... in the maintenance setting. There are other medications that are helpful for the manic symptoms, for example, like valproic acid, but that...

doesn't help as much for depression. Lithium can be helpful for both phases of the illness, but lithium could also be more challenging to use in the primary care setting because of the lab monitoring. Yeah, so is that one that you generally recommend we stay away from? Yeah, unless you have a really close friend who is a psychiatrist that you can... check in with for help. It has a narrow therapeutic index.

therapeutic window. So, you know, patients can get in trouble with toxicity. They also, there's a lot of drug-drug interactions, like for example, NSAIDs or a lot of the diuretics can increase lithium levels and trigger toxicity. So it's...

a great medicine. It's a lifesaving medicine. But you just have to be really careful and, you know, do a lot of patient education. And so, you know, I think it can be done in primary care setting, especially, you know, in like collaboration with the psychiatrist, I think. Using an atypical antipsychotic in the primary care setting is a lot more practical because the laboratory monitoring is a lot less frequent. There's less acute toxicity that you have to watch out for.

Yeah, that kind of addresses the question that I had. This feels sort of like a prototypic situation where in primary care, you have someone who presents depressive symptoms. You're like, I'm concerned for bipolar disorder. How much harm can I do?

I just might not be a question that you can answer as a primary care doctor, sort of starting with, say, quetiapine, just to be on the safe side to do something just because access, as I'm sure you're aware, to behavioral health can be really, really challenging. And, you know, it just feels so unsatisfying.

potentially even harmful be like, you know, you just have to wait until you see a psychiatrist months from now, like, you know, you kind of want to do something in the moment is can you get into trouble? Assuming that you have the correct diagnosis, at least starting with the quetiapine, or Or Latuda. Remind me that. Lorazidone. Lorazidone. Yeah. Like, is there, what's the downside, I guess, or what kind of harms can we have if we have less of a nuanced approach than you might have?

Sure. Yeah, I think the main downside for things like lorazidone or quetiapine would be short-term, they can have more metabolic side effects, especially with quetiapine. Lorazodone, there is a risk of weight gain, increased blood sugar, cholesterol, things like that, but it seems fairly minimal, especially compared to the other atypical antipsychotics. Things like NMS would be like...

very rare, especially at like low doses that we're using, especially low doses that we're starting in primary care. There's also risk of like extrapyramidal side effects. you know, tremors, rigidity. With long-term use, typically after years, you could develop like tardive dyskinesia, which presents typically with like involuntary movements of the mouth or tongue, but it can involve other parts of the body. But that's something that typically does.

doesn't manifest until an extended period of treatment, usually years. Yeah, these are some scary side effects. I think that's why... you know, bipolar has always been something that I try to get people to go see psychiatry for because, I mean, all my patients already have metabolic syndrome. So I'm just like starting to get out of medication that... is going to worsen it is a is always is never like a prospect that i look forward to and then you talk about uh lithium sounds like that's

not super easy to use unless you're familiar with it, more familiar with it than the average primary care or have have you as like a best friend that you can just like have on speed dial. And then you have, I think. Deval Pro X or Val Pro 8, you know, that one, that seems a little less scary to me, but I'm also not that familiar how to use it.

Maybe that's worth talking about a little bit more like how you might start that and some of the typical dosing. Yeah, you know, I think with the Valproix, you know, especially in someone who's not like acutely manic, you know, I would... I would typically start low just to make sure that they're tolerating it well. So something like 250 milligrams twice a day and then titrating gradually. It is a medicine where we do therapeutic. uh drug level monitoring as well so typically after like uh

four or five half-lives, I'll ask the patient to get a trough level drawn in the lab if possible, just so we can see where it's at. In terms of the total level, we usually like to aim for something like kind of 70 to 70 to 90, somewhere in that range. Many, many patients will develop like asymptomatic hyperaminemia with it.

It's actually very common when they're taking valproic acid. I would say it's more uncommon for someone to be taking valproic acid and have a normal ammonia. And so I usually don't worry about it unless it's really... you know, like twice the, you know, upper limit of normal, or if they're having like clinical symptoms. But, you know, you'll see recommendations for checking that. The other thing that I kind of keep in mind with valproic acid would just be risk of like...

So, you know, checking a CBC, you know, I would check it, you know, I think once every six months is probably what I would do. And also keeping an eye on LFTs, you know, ideally like once every six months as well. And this one, I think this causes weight gain as well, right? Yeah. I mean, like pretty much all of these do. Yeah, Valproate can cause weight gain. It can cause hair loss. You know, in terms of like weight neutral options, like lorazodone is really probably one of the more metabolic.

friendly, you know, there is some risk, but especially compared to other atypical antipsychotics like quetiapine or especially olanzapine. The lorazodone typically does not cause very much weight gain. Lamotrigine is also something that is usually weight neutral for most patients. It just takes time to titrate it.

Okay. So for the acute phase, Lamotrigine, you told us you can't titrate too quickly because of Steven Johnson. So that's kind of off the table. It sounds like ketiapine is a good one because it's good for... depressive symptoms if they're having a depressive episode, but it can also treat more of the mixed symptoms if they have that. Yeah. Yeah. It can be helpful for mania. It's not a particularly potent antipsychotic, so if they're truly like...

manic and having a lot of psychotic symptoms, it might not be enough to really control their symptoms. But, you know, for the depressive phase of the illness or for maintenance, I think it's a good option. And, you know, a lot of patients already use it in primary care. It also can be useful for antidepressant augmentation. So if it turns out that it's more of a major depressive disorder, it could still be used for, they could still potentially add on an antidepressant to augment.

used as augmentation treatment. And so, yeah, cotaipine is, you know, something that I recommend a lot in the primary care setting. And the doses, like how high is the dose going? Is it... Yeah, typically like, yeah, like, you know, 300 milligrams, you know, it's kind of the target that I aim for, you know, but different patients will respond to different doses. I usually try to start with like 25 or 50 milligrams.

at bedtime, and then I'll gradually increase it in, like, 50 milligram increments until I get to, you know, about 300 milligrams or until their symptoms get better. Is there... A scale that you're tracking the symptoms with, like in the same way that you can use sort of the PHQ-9, like, is there something that you use? Do you just use the similar tools for these patients as well in terms of tracking? Yeah, so for bipolar, yeah, bipolar depression, I use the PHQ-9 as well.

All right. That's good. I'm comfortable with that. Yep. Yeah. So it's, yeah, that part's easy. At least that part's the same. Yeah. So for this guy that we, our 20-year-old name withheld, let's say he didn't have any kind of weight problem. So we start him on quetiapine 50 milligrams, and then we follow him every two, three weeks.

kind of adjust the dose and we're following for signs of metabolic syndrome. Because I read that this is a biopsychosocial so that it's not just the medication. You also want to do some things to set this guy up for success. So what, what else, what other counseling would you be giving to him and his mother at that visit? And then we'll, we'll go on and we'll have another case where we talk a little bit more about some of the maintenance medications. Sure. Yeah. So, you know, I would really.

Council Council the patient and mom on the importance of just leading an overall healthy lifestyle, especially sleep hygiene. So for patients with bipolar disorder, you know, having disrupted sleep can be really risky for triggering a manic episode. And so I would really...

emphasize the importance of, you know, going to bed at a regular time, you know, waking up at the same time, you know, working night shift is probably something that would be, you know, risky for, you know, a patient like this. And also just, you know,

healthy diet, exercise, those things have antidepressant effects and, you know, also useful, especially in the case of, you know, taking medications that can cause metabolic side effects. And, you know, I would also just tell, encourage mom to, you know,

bring her, bring her son in if there's, if she's noticing, you know, changes in mood again, either like too high or too low or increase the irritability because, you know, getting, you know, treating these mood episodes early or getting treatment started is really important. Awesome. Fantastic. Deb, anything else for this case? So we've put him on treatment. We've counseled him and his mother. And do we have a happy ending here? Do we have to go into...

Anything else, any other tweaks you want to make to the case or other scenarios? No, I think it's a happy ending. I mean, I remember being taught during medical school that... antidepressants are a complete non sequitur, a complete no with bipolar. But, you know, it does seem kind of cruel that we're not treating the depression as effectively as it could. potentially, is it still the case that antidepressants are like a hard no for patients with bipolar? That's a great question. I would say...

With antidepressants, I think there's two risks to think about in patients with bipolar disorder. There's the risk of inducing a manic episode, which can certainly happen. or making their mood episodes like more rapid cycling. The other kind of more insidious risk is just that the antidepressant isn't going to work for...

their bipolar depression. So bipolar depression just doesn't seem to respond to traditional antidepressant medications as well. So if you throw antidepressants at them, even if you don't make them manic, you might just not be helping them and like leaving them depressed for longer. And so those are kind of two risks to kind of think about.

There are some patients with bipolar disorder, especially like bipolar 2 disorder, who will respond to antidepressants, though. And so it's not something that I will never consider, but I would definitely want them to be on a therapeutic. dose of a mood stabilizing medication before I consider adding on an antidepressant carefully. So for example, like in this case, like I would want this

this young man to be on a decent dose of quetiapine or lorazodone or valproic acid or something, lithium, before I would consider adding on like a low dose of antidepressant carefully. Are there any...

are the traditionally used antidepressants that are particularly dangerous in terms of precipitating a manic episode? Like I would think, unlike the propion, I feel it can be a little bit activating. Like, is that one that sends people sort of straight into mania? Are there ones that we should be a little bit more mindful of or does it not seem to matter so much?

That's a good question. I'm not aware of data comparing the risk of mania between different antidepressants. It certainly might be out there, but I'm not aware of it. I think bupropanone is actually used... more commonly in treatment with bipolar disorder.

And I think one of the reasons is that it has a shorter half-life. So if someone does become manic, you know, you can stop it and it washes out pretty quickly. So, so I would say, you know, be propran, even though, even though it is, you know, more stimulating and, you know, it certainly can. can cause mania. It is something that you'll see used in patients with bipolar disorder if they're already on a mood-stabilizing medication to act as prophylaxis against mania.

Okay, so we talked about, just to recap the meds before we go, for the acute phase for depression, ketiapine and lorazodone seem like the ones that are, you know, best at treating the acute phase of... depression, lamotrigine more for like the maintenance phase of depression. And because you have to start it more slowly, we talked about the razedone having less of the, some of the less weight gain. It's a little more metabolically friendly than ketiapine.

And then for mania, lithium, some of the anticonvulsants like valproic acid is a possibility. There's a lot of monitoring we talked about with valproic acid. and then including trough levels. And then we talked about most of the atypical antipsychotics or second-generation antipsychotics have some effect as a mood stabilizer as well. And then...

talking about just healthy lifestyle, exercise, sleep schedule, and then early intervention, like family members and the patient themselves. Just if they start to notice things going south, they need to come in and... and adjust things to make sure it doesn't get out of control. As Deb asked, the conventional antidepressants, we worry about not being effective for the depression and also maybe rapid cycling or sending someone into mania.

So that's kind of it we've talked about for treatment. Deb, let's get to our last case and just the last few questions. Yeah, so this is a patient who's coming to you. It's a 34-year-old patient who presents to your... outpatient clinic to establish care. Their only past medical history is a bipolar diagnosis. They take lithium daily, and they've been taking that since they were diagnosed with bipolar disorder around seven years ago.

They have no health concerns today, and they just want you to fill out a pre-employment form. How would you manage a patient who's presenting with a... diagnosis of bipolar disorder. If you see it in the chart, does that mean it's true? And we just kind of move on and don't ask any more questions and write this script for lithium? Yeah. So, you know, like we...

talked about before the show, I think bipolar disorder, on the one hand, it's very underdiagnosed, but on the other hand, it's also at the same time overdiagnosed. And so just because someone has bipolar disorder in the chart, you can't really... Trust that they truly have bipolar disorder. Patients with bipolar disorder, oftentimes they'll go 10 years before they are diagnosed because they keep presenting with depressive episodes. But then there's also so many mimickers, things like...

you know, like borderline personality disorder, PTSD, ADHD, substance use that we talked about earlier, that oftentimes patients with those conditions may incorrectly get diagnosed with bipolar disorder. So it's always important to, you know, kind of do your own homework and, you know, ask the patient. you know, take a full history. And a patient like this, where they come with a diagnosis of bipolar disorder, I will ask them, you know, how are you diagnosed with bipolar disorder?

You know, who made the diagnosis? What was happening? And I'll often ask them, like, what symptoms made... this doctor concerned that you had bipolar disorder. Because a lot of times, you know, the patients will just say, oh, well, you know, I get angry really fast. And so they said I had bipolar disorder. And then I might explore further and say, well, you know, how long does those anger episodes last?

You know, does it ever last like a full week? You know, and they say, no, you know, I just get angry at the drop of a hat and then I cool off after 30 minutes. And, you know, that tells me that it's probably not bipolar disorder. It's probably, you know, like any number of other, you know, kind of like.

borderline personality disorder or PTSD or other things that are causing like kind of that moment to moment lability. But if they, if they tell me like, Oh, you know, I had a manic episode where I went a whole week without sleep. And then I, you know, got really angry. I told my boss. that they were the worst boss in the world. And I bought a Ferrari and I raced it downtown and crashed it. And then, okay, yeah, that's a different story. We're talking, you probably have bipolar disorder then.

When you said that for some reason, and Paul, you'll probably, you'll probably remember. I just remember the beginning of Happy Gilmore where he's like, I had a real bad temper and it shows him like, I don't know, throwing a hockey stick at somebody or something. And he goes, but I was quick to apologize. And then it shows him giving another kid like a back massage. Do you remember that, Paul? Yeah, of course. You're saying that's not bipolar. That's just the guy that got angry.

Yeah. He apologized. That's right. Yeah. Yeah. It certainly could be other things going on, but it's not bipolar. Yeah. Okay. Yeah. So I... I wanted to ask about the medication. I mean, this patient's taking lithium. So if we have someone on lithium and this does come up once in a while and they're like, can you refill this? I've been on it for years. What should we check?

just to make sure it's okay? And of course, we'll probably refer to a psychiatrist to help us with this, but what would you do? Absolutely. So for lithium, you know, we... really want to, it can cause a lot of different side effects. So renal impairment, hypothyroidism, it can cause hyperparathyroidism. So there's a lot of things that we want to look out for.

In a patient like this, I would check their chemistry panel to check their renal function, check their calcium level. I would also check their TSH. and make sure that their TSH is okay. So those would be kind of some of the basic labs that I would get in a situation like this if they're taking lithium. Okay. And if they were coming to us and they hadn't been on anything, and let's say they're not in any kind of episode right now, they're not in a depressive episode, they're not manic.

what would you recommend we use as an approach for medication here? Yeah, I would ask why they're not on any medication. And, you know, they may have had side effects or other... bad experiences or maybe they just lost touch with their psychiatrist uh you know that's something that does happen um

And, you know, I would just talk to them about how, you know, with their bipolar illness, it's lifelong. And, you know, being on a preventative medication is the safest thing in terms of, you know, keeping them from developing, you know, either manic or depressive episodes. and try to explore that. Yeah. And so if we wanted to start anything at this point, is it kind of like dealer's choice we could start?

Lamotrigine, we could start, you know, quetiapine, lorazodone, any of those ones we talked about. I think so. You know, I would ask like what has historically been most helpful for the patient. If the patient says like, you know, quetiapine or lamotrigine was most helpful, I would...

I would try to restart that. The other thing to consider is just historically what has been the most impairing phase of the illness. Are they someone who has a lot of depressive episodes or are they someone who has a lot of manic episodes? Try to figure out what... which phase of the illness is most impairing for them and try to tailor the treatment to that. Paul, I know you probably have encountered this before. Do you have any other questions about this?

specific scenario where it's just the patient comes to you and they're like, I have bipolar. And you're like, I don't see any medicines on here. You take buckwheat once a day and vitamin D. Sure, bios and supplement. No, I think the instruction to sort of specifically how the diagnosis was made, what was happening at the time, I did...

For patients like this who seem ostensibly stable, or even if you're fairly sure of a diagnosis of bipolar disorder, I wonder if you couldn't talk a little bit about suicidality, I think even with depression. A lot of times we ask and then you just kind of close your eyes and grit your teeth and just hope the patient says no. And then you're done with the question for the visit and you can sort of breathe a sigh of relief. But I guess what.

For patients with true bipolar disorder, how concerned should we be about suicidality? How do we approach that? How often do we sort of screen for it, even in the absence of avert depressive symptoms? Yeah, that's a great question. You know, suicide is a...

certainly a risk for, you know, patients with bipolar disorder. And it's something that I would screen at every visit, you know, even if they're asymptomatic or in, you know, in the remission phase of the illness, I would still ask them at every visit because it is something that... But yeah, unfortunately, many patients with bipolar disorder will attempt suicide and some of them will even die by suicide, unfortunately.

Any last-minute questions, Deb, that you wanted to get to before we go to take-home points? In terms of other diagnoses that this patient may have, I was reading a little bit about there being a racial discrepancy between bipolar and schizophrenia diagnoses. Is there a way that as a primary care physician that we may be able to step in and get a little bit more history and try to help kind of steer them in the right direction? Because I know there would be different...

medication approaches to both of those conditions. Yeah, you know, unfortunately, there's, you know, racial bias in medicine, you know, unfortunately that... happens. It's something that we all have to work to address. I think patients...

minority patients, especially like African Americans, they have a higher rate of being diagnosed with, you know, serious mental illnesses, like, for example, like schizophrenia, compared to, you know, compared to white Americans. And so I think... when working with minority patients when they come with a diagnosis of schizophrenia or bipolar disorder, it's even more important to explore like how did you get that diagnosis and really try to make sure that they actually meet criteria.

for that condition and try to refer them to specialists who can help with clarifying the diagnosis. Those diagnoses in particular are... like the scarlet letters of the problem list. Like once they're on there, you cannot get them off of forever. They're just sort of self-perpetuated. So it's, yeah, if you can. Yeah. Removing problems off of problem lists is one of my few joys in life. So yeah, if you can.

Do that for a patient. Sprinkle in some sarcoidosis, Paul. Oh, my God. I find AFib tends to stick to problemless, too, like even if, you know, even if they've never had AFib.

sometimes. Yeah. There's so many patients that, you know, maybe they show up to the emergency department intoxicated on, you know, stimulants or something once, and then they get diagnosed with schizophrenia and it sticks with them in the chart forever. My final question, we were talking a little bit off here about this, but. What am I to do with cannabis for these patients? Like we talked a little bit about sort of the co-occurring substance use.

But I know it's become so prevalent in so many states and so many patients are really, really find it helpful for their anxiety and for sleeping and all that kind of stuff. But I know there is some evidence that... It may worsen outcomes in certain populations. How do I counsel patients and what should I talk to them about if they have, say, daily cannabis use too?

Yeah, it's a great question, especially with cannabis becoming much more culturally accepted these days. I think it creates a unique challenge for physicians, especially when we're taking care of patients with mental illness, where there's limited evidence for... for benefit, and also there is evidence for harm in some cases. So I typically start by just acknowledging that the patient is doing what they're doing.

for a reason. They're not trying to harm themselves. They're usually just trying to self-medicate or feel better. So I'll ask them, what does the cannabis help you with? And start the conversation that way. You know, they may say it helps me with sleep or helps me with appetite or something. And we can maybe open up, you know, opportunities to address it in other ways. And then also, you know, just talk to them about how, you know.

Yes, many of your friends may smoke cannabis and they might be fine and doesn't cause any problems. But because you have bipolar disorder or you have schizophrenia, for example, your brain is different. Your brain is... going to be more sensitive to the side effects of it. And so that's something that is really important to think about. Paul, are you...

Are you satisfied? When you first asked about, can you, what am I to do with cannabis? I was like, oh, are you asking for tips on how to, do you have some and you're asking? Do you have a guy? That's actually, that's very helpful. Yeah, I think that's a great point. Sort of what benefits are they getting out of it? And can we help them another way or at least sort of address those issues, I think is a great way to frame it. So that's terrific. Thank you.

So, Kevin, we've come such a long way. We talked extensively about the diagnosis. We've been through the treatment, the medications. And now... Just if there was a couple of things that you wanted the audience to definitely remember from this conversation, what would those be as your take home points? Yeah, I would say, you know, number one, like the classic kind of sticky caps symptoms.

diagnostic criteria for a major depressive episode, not major depressive disorder. So if someone has a major depressive episode, you still have to try to figure out, is it major depressive disorder or bipolar disorder or something else that's causing it? The other thing is that diagnosing bipolar disorder is really hard, even for psychiatrists. And it's something that is very difficult to do on an initial visit.

you know, experienced psychiatrists oftentimes will have to follow patients for an extended period of time before we can truly be certain of the diagnosis. And so, you know, don't feel like you have to have the diagnosis on the first visit. Just, you know, having it on your radar. radar and knowing how suspicious to be of it is probably the most important part because realistically, it's a very challenging diagnosis to make in a single visit.

Yeah. And I'm sorry to ask this now, but I think we had talked about this, but like, so with a patient where you're not sure in that first visit, but you have suspicion. They should use the medications that we talked about for as if this were bipolar. Is that just the safest way to go?

Yeah, I think it depends on kind of how suspicious you are. You know, sometimes I may start like a low dose of an antidepressant, just counsel them really clearly. Like, you know, if you develop, you know, changes in mood, like, you know, irritability increases in mood, decrease due for sleep.

definitely tell me immediately. On the other hand, if, you know, they have a strong family history and I'm, you know, leaning more towards, I think that this is a bipolar disorder, then yeah, I probably would treat them with, you know, bipolar medication. And yeah, the other, I think the other take home point would just be that, you know, bipolar depression does not respond to traditional antidepressants the way that major depressive disorder, depressive episodes do. And so.

Unfortunately, our treatment options are much more limited, but that's also why it's important to identify bipolar depression because the treatment is different. Okay. All right. Well... If there's anything you'd like to plug, feel free. Otherwise, we'll let you go. And this has been great. Thank you so much. Sure. The other thing I wanted to also just bring up is for bipolar depression. You really can't...

understate the importance of psychotherapy as well, cognitive behavioral therapy. I think you asked earlier about what would I counsel the patient on? And in addition to lifestyle factors, I would really encourage them to engage in cognitive behavioral therapy as well.

because, you know, like I don't have a pill that's going to fix, you know, this, you know, patient's relationship problems or change their, you know, school stressors and things like that. So, you know, cognitive behavioral therapy is going to be a really important tool to help. um, change like how they relate to those, those stressors and how they cope with that. Um, you know, it's, uh, you know, not, not as helpful for mania. Cause usually when patients are manic, they're.

They're not able to sit still long enough to do cognitive behavioral therapy, but certainly for the depressive phase of the illness, I really can't overstate how important the psychotherapy piece is for a patient's recovery. Paul, CBT, always a right answer, correct? Especially for boards. Yeah, absolutely. Yep. Yeah. All right. Thank you so much, Kevin. Really, really awesome stuff. Thank you.

This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy. Great. Slightly ominous, which is probably appropriate. Still hungry for more? Join our Patreon and get all of our episodes ad-free plus twice monthly bonus episodes at patreon.com slash curbsiders.

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So with all that, until next time, I've been Dr. Matthew Frank Waddle. And I've been Dr. Deborah Gorth. And as always, I remain Dr. Paul Nelson-Williams. Thank you and goodbye.