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Psychiatry, Education, Insight. Docs Tracey and Paul Discuss it All! Two psychiatrists — Dr. Paul E. Keck Jr., MD and Dr. Tracey Goodman Skale, MD of TMBO (Two Minds, Better than One) — illuminate mental illness, teach signs and symptoms, dispel myths, and advocate timely care and dignity. Nearly 70 years of combined expertise. DISCLAIMER: educational/general discussion only, not personalized medical advice; in crisis call the 988 Suicide & Crisis Lifeline.
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Welcome to the Two Minds
Better Than One podcast.
Docs Tracy and Paul discuss it all.
Hello and welcome to Docs
Tracy and Paul.
Our podcast today is about
bipolar disorder, one of our favorite
topics and something that we
both have had an enormous amount
of experience and in helping
people with bipolar disorder.
Welcome, Traci.
Thank you, honey.
I'm Traci.
This is Paul, my husband.
As you know, we're a married
psychiatric team and we love talking
to our friends and colleagues
about all aspects of mental illness.
And like you said, Paul, today
we're talking about one of our all
time favorite topics, bipolar disorder.
And I know you won't say this,
but I'll brag about you a little
bit.
Paul, you are one of the most
influential experts on bipolar disorder,
actually internationally.
I know you've written lots of
articles and book chapters and things
about bipolar disorder and
have treated thousands of people
with bipolar disorder over
your almost 40 years as a psychiatrist.
Well, and all due credit to
you, you've treated many thousands
of people with bipolar
disorder too, and are nationally
renowned speaker about bipolar
disorder and schizophrenia and other
things.
So that's why I think we're
both so excited about this topic.
We are.
We're so excited that we
actually aren't wearing our usual
blue today.
We're wearing these bright,
perky colors.
And it might maybe have
something to do with mania as opposed
to depression, but we'll be
talking about depression because
depression is a huge part of
bipolar disorder.
We'll be talking about bipolar
I disorder, bipolar 2 disorder.
How do we distinguish between
the two?
So, Paul, you want to kick it
off for us?
Sure.
Bipolar disorder used to be
called manic depressive illness for
a long, long time.
That nomenclature diagnostic
title got changed in 1980.
I'm not sure why.
Oh, I think so.
I think I know why.
I think it's an effort to destigmatize.
There's always talk about reinventing.
There's talk for years about
changing the name of schizophrenia
because I think there's a
stigma attached and if you change
it, people maybe will think differently.
So that was part of it was
kind of reinventing manic depressive
disorder.
The tricky thing about the
diagnostic name bipolar disorder
is it implies that you're
either in one pole, one state mania,
or in another state depression.
In fact, a lot of people with
bipolar disorder have what's called
a mixed state.
And that's a particularly
ugly, not that mania and depression
aren't, but a particularly
ugly way to feel because it combines
the symptoms of mania and
depression together.
So I think we need to talk
about the symptoms of mania and depression
then.
Well, let's review depression.
So depression is at least a
two week period of time where you're
either depressed or you're
numb or you have an anhedonia, lack
of interest in usual
pleasurable activities.
And why don't you go over some
of the pieces of depression, how
people can tell if they're depressed?
Well, depression is also
marked by what are called vegetative
symptoms.
Those symptoms are the
manifestation of the part of the
brain that controls basic
biologic functions like appetite,
sleep, sex drive,
concentration, energy, energy.
Overall level of arousal.
I don't mean sexual arousal.
I mean like how within you.
Yeah.
Also includes, unfortunately,
suicidal thoughts and sometimes attempts
to act on those thoughts.
Excessive.
Also excessive guilt,
rumination, helplessness.
Helplessness and hopelessness.
Yes.
So a person can present,
especially as a clinician, someone
can come into our office and
they present depressed, which is
very common.
So we start an algorithm in
our heads.
Could this be major depression?
Could this, could substances
be involved?
Could.
Because some substances are depressogenic.
Correct.
Cause depression?
Could there be some underlying
medical illnesses going on?
Could this be bipolar one depression?
Could this be bipolar two depression?
So there's a lot of things to
think about.
We don't want just someone
doing a knee jerk, oh, this person's
depressed.
We're going to write a
prescription for Prozac.
You don't want to do that.
We want to really do a
comprehensive exam of that person.
And even with that, sometimes
you just don't know.
There are clues that someone
who presents with depression.
And by the way, about 50% of
people with bipolar I or II disorder
present for help for the first
time with depression.
I thought it would be even
more than 50%.
And we'll get into all of this.
I don't want to jump the gun
on this, but there's a lot to talk
about because hypomania,
sometimes people just feel good or
just more productive.
So they wouldn't be presenting
in that state.
So a person can present
depressed, depressed, depressed,
depressed, depressed.
And it could be recurrent depression.
Recurrent major depression.
But there's some clues, as you
said, Paul, that we can look at.
But once that person presents
with a manic episode or we know of
a manic episode in their
history, that's it.
You have bipolar disorder.
Correct.
And that differentiation is
extremely important because the treatments
are vastly different.
Very different.
Correct.
So you mentioned some clues.
So one of the clues, the
earlier the depression is in childhood
and the more severe the
depression is, the More likely, that
person is to have a bipolar disorder.
Is that correct?
That is the biggest predictor.
So for our parents out there,
teachers be watching for depression
in children.
If you have a psychotic depression.
So a depression with psychotic
features, meaning maybe hallucinations,
maybe delusions, that kind of thing.
And we'll be talking about
that in depth in later episodes.
That person most likely has a
bipolar disorder.
Postpartum psychosis.
I know you've talked about
postpartum depression, too.
Postpartum depression.
We need to be watching for
potential of bipolar disorder.
Postpartum psychosis, for sure.
Bipolar disorder, yeah.
50% of people with a
postpartum depression, especially
with psychosis, will
ultimately go on to have a manic
episode.
Correct.
There's a hormonal component.
To some people, sometimes
around the menstrual cycle or right
after pregnancy is a time to
be very cautious.
Mood changes.
Menopause is a time can
exacerbate symptoms as well.
Seasonality.
Seasonality for sure.
So we hear people talk about
seasonal affective disorder.
But can you explain more why
there's a seasonality for some people?
Or is it to do with circadian
rhythms or the darkness?
What is that about?
Well, I think one of.
So just take a step back.
Bipolar disorder.
Bipolar I disorder has been.
Well, manic depressive illness
was first described by the Greeks
2,000 years ago.
So this is not a new syndrome
or diagnosis.
And it's probably also not
entirely a manifestation of Western
society.
For example, studies in all
kinds of countries around the world
found that the incidence is 1%.
So 1 out of 100 people have this.
And then the question is,
well, why is this so common?
May I go back?
How did you know this was in
the time of the Greek?
What were you saying?
Because Aristotle described.
How did he describe it?
He described classic manic
symptoms and classic depressive symptoms
in some people.
Okay.
Much as we describe them today.
So there's a genetic risk, big
genetic risk.
So I was taught that bipolar
disorder is the number one most genetically
transmissible of all the
psychiatric illnesses.
That is a true statement.
So why is something that's
inherited or heritable occurring
in 1 out of 100 people?
Happening.
And the analogy I always make
is sickle cell trait occurs in one
out of a thousand people from
southern Mediterranean, North Africa.
Why is that gene in the population?
If you have two of those
traits, you have a horrible illness.
Sickle cell disease.
If you have one of those
traits, it protects you against malaria.
So there must be something
advantageous about.
And the books have been
written about this Especially by
Kay Jamison about having
traits about bipolar disorder but
not having the full blown illness.
It's associated with
associative thinking, which is why
a lot of creativity artists.
Yes, creativity, exuberance, a
lot of positive things if you have
the traits, but not the full
blown illness.
There's been an enormous
amount of research on the genetics
of bipolar disorder.
And unfortunately it's not a
simple autosomal dominant recessive
illness, at least for most people.
It's what's called a complex
genetic illness.
And we're still trying to
figure out what those risk factors,
risk factor genes are.
Because if we could, and we
will someday, we could have much
more targeted treatments than earlier.
Earlier treatments.
Right, but you could be
genetically predisposed.
But that doesn't mean you're
going to get, have an episode of
bipolar disorder.
So there's just like other
disease states you can have.
You talk about cardiovascular
disease, right?
So environmental stress can
certainly bring out manic symptoms
or depressive symptoms.
And you mentioned circadian changes.
There's one very vulnerable
circadian function that people with
bipolar disorder have and
that's sleep.
Sleep.
If you disrupt sleep, that's a
very dangerous thing because that
often causes the mood
instability of either mania or depression.
Well, sleep is important to
almost all disease states.
But we always say for bipolar
disorder, for sure, we would often
tell our patients, try not to
do shift work, night nurse work,
or that kind of thing.
It's not good for you.
Let's go back to clues.
There's other clues too.
So we talked about the family history.
And another thing is light
switch phenomenon.
Everybody's so uniquely different.
But with depression, major
depression, there tends to be more
of an insidious slinking into
a deepening depression.
Again, that could, doesn't
have to be the case, but tends to
be.
Right.
Gradual onset.
Gradual onset.
With bipolar depression,
people will describe a light switch.
They'll say, I don't understand.
I was completely fine and it
was 3:42 on Tuesday afternoon and
suddenly I felt horribly depressed.
Families find that to be contrived.
Come on, like, give me a break.
We were fine five minutes ago.
But it is frustrating to
everybody involved, particularly
the person experiencing it.
So that is one thing.
Also the person presents
depressed to the psychiatrist, the
primary care office,
something, and somebody prescribes
an antidepressant and two days
later they say, you are the greatest
provider ever.
I feel fantastic.
That doesn't work.
None of them work that way.
I don't sleep as much.
No antidepressants as of this
date work that Quickly.
Some work more quickly than
others, but nothing works in two,
three days.
It doesn't work like that.
Conversely, you've prescribed
all different kinds of every kind
of antidepressant from all
different kinds of classes, and nothing
ever works.
Could be because they don't
have major depression, they have
bipolar depression.
And that's a different thing.
So those are some clues to
look for.
So doing the history is hugely important.
That's why we can't spend five minutes.
We need to do a thorough
diagnostic mental status exam, getting
history, and if we have
collaborative information from family,
friends, that's really important.
It's ideal.
Yes, because a lot of people
minimize socially hypomanic symptoms.
So we went through depressive symptoms.
Is it okay if I talk about
manic symptoms?
Because that's my favorite.
We better define that.
Right.
So we keep talking about mania.
So let's talk about this.
So I love mnemonics and I use
them all the time in medical school.
So I use mnemonic dig fast for this.
And we said depression is at
least two week period of time.
Mania, one week period of
time, unless it's so severe that
you end up hospitalized or
you're so ill you can't take care
of yourself.
Right.
It's harder to get
hospitalized these days than it used
to be.
But still it's something.
It's typically, it's an
extended period of time.
What we're saying is it's not
just I have really high energy today
or this weekend.
And it's not because of you
use some kind of stimulant or something
like that.
Like everything with
psychiatric illness, it's based on
your baseline.
So it's a change in your
baseline behavior.
So one of the major.
With depression, we talked
about depressed mood or numbness
or anhedonia.
With mania, it's euphoria,
elevated happy.
Happy state or irritability.
And unfortunately, we're
seeing so much more irritability
than we see euphoria.
I don't know why.
Do you have a theory on that?
There are theories, one of
which is it has to do with substance
abuse.
The other is common
prescription of antidepressants.
Agitating people.
Agitating people?
Yeah.
Okay, so you have one of those
two things and then dig fast here.
Okay.
D Distractability.
Not in any particular order here.
Okay.
But distractibility is tricky.
So it's involved in
concentration that can be across
many disease states.
But be looking for a person
being much more distractible than
they usually are.
The next one, insomnia to me
is probably the most Important one,
it's not the person that comes
to us and they're yawning and they're
like, doc, help me.
I'm so tired.
Help me.
Help me.
It's not that person.
It's the person that I used to
need eight hours of sleep.
This is great.
I only need two.
This is not fantastic or I
don't need any sleep.
That's a huge red flag, G. Grandiosity.
So to the average person,
maybe you're just a shy, timid person
and suddenly you're arrogant
and you're challenging at work.
For you, that might be grandiosity.
To a certain percentage of
people, and I know you'll throw that
percentage in in a minute here.
It could be to psychotic proportions.
Some people have bipolar
disorder, mania, or depression with
psychotic features.
And so some people, it could
be, I'm, you know, king of the world.
I'm a famous superstar.
I, you know, whatever.
I had a person once in my
office who was getting really loud
and animated, and we would do
a show of force, basically, if someone
was getting screaming in the
office, other providers would come
and check on us.
And someone said, is
everything okay in here?
And he said, everything is
fine and you're fired.
Because he thought he was the
CEO of the organization.
So he was grandiose to
psychotic proportions.
So what is the percentage of
people that have psychotic features
with bipolar disorder?
Well, in their classic
textbook manic depressive illness,
Goodwin and Jameson actually
compiled data on that.
The average was 70%.
You told me that over dinner
one night.
And I was surprised because I
was taught somewhere along like 37%,
and I stuck with that forever.
Who knows?
But that's another thing.
The reason you like statistics
better than I do, because I think,
like, somebody reads 37% and
somebody reads 70%, and it's probably
something in between.
Different studies.
Different studies, right.
The most important thing is
when it's happening to you, it's
100% of you, you know, it's a.
So that's.
It's very serious.
That's often why mania is a
medical emergency.
People who are in the throes
of a manic episode are not thinking
clearly.
We're going to get to that
when we get through the rest of.
I can't help.
I'm so excited.
You go so f. Flight of ideas.
If we're observing that person
or we're talking to a friend who
is in mania, it looks like
their conversation.
It feels like their
conversation is all over the place.
That song Freight Train
Running through the middle of my
Head.
I always think of that like
things are going really fast for
that person.
So for that person, their
perception is things are going really
fast in my head.
So that's when they describe
racing thoughts.
So sometimes people have use
that term.
Yes.
I had a person that she would.
Her thoughts would go so
quickly that she would start to.
Everything was going so fast
and she was stuttering and you know,
it was all happening so fast.
A increased in goal directed activities.
Sounds good.
I'm gonna paint the house.
I'm gonna write a book.
I'm gonna do this, this, this
and that.
They can't sustain it.
It's too much.
It's 10, 10 things at once.
None of which ever get completed.
Right, Right.
But they feel excited at the time.
S speech disclaimer.
I'm from Massachusetts.
I'm a fast talker from New England.
I drink lots of caffeine, as
Paul will, you know.
Yes.
I'm excited.
I'm a fast talker at baseline.
So remember we said
everything's based on your baseline.
This is my baseline speech.
So nobody goes say, hey, that
Doc Tracy has mania right now.
It's not true.
Right.
Live with a bipolar expert.
I really don't.
This is my baseline speech,
but it's the person talking much
faster than they normally talk.
We call it pressured speech or
they can't stop talking.
My pharmacist friend will say,
you know, your, your guy just came
back to the window 12 times
saying, what about this, what about
that?
And they can't.
Or they leave.
You can't interrupt them, you
can't interrupt them.
And hey, is that what are you saying?
Or.
Or they leave 15 messages on your.
When we used to have answering
machines or your voicemail, they
just.
These days it's texting.
Text.
Oh, especially if you do
texting talk to text.
Oh, paragraph and paragraph.
Yes, that's pressured speech.
And the last.
This is where the medical
emergency, I think, comes in.
Thoughtlessness, risk taking
behavior so people drive recklessly,
excessive substance use,
sexual indiscretions, all these things.
They get themselves in all
kinds of trouble.
Yeah.
Judgment goes out the window
and that's what's dangerous.
Right, Right.
Thank you for letting me do
that because I love talking about
the science of mania.
So those are the things to
look for.
So if we hear that and we get
some history of that and we know
there's mania, that person has
bipolar one disorder.
If there ever is a history of
psychosis with the mood component,
then it has to be bipolar I
disorder, bipolar 2 disorder, which
we'll get into.
You never have psychosis with that.
That's because you have
hypomania, but you don't have psychosis
with it.
And hypomania really means
milder manic symptoms.
Okay, milder manic symptoms, yes.
Hypolescent.
But it doesn't mean a milder
disease state.
So let's elaborate on that.
Well, people with bipolar 2
disorder are sometimes very difficult
to diagnose because that
hypomanic or mild manic state usually
is actually not very long.
Right.
A couple days, not even.
Yeah, yes, I agree with that.
That's controversial, though.
Well, you'll have to tell me
more later then, because again, that's
what I go by.
A couple days, a little bit
short periods of time, snippets of
time.
And I thought.
And it's the hallmark of
making the decision about bipolar
2 disorder is hypomania.
Yeah.
But it's often a difficult
piece of history to pick up because
people don't remember it as
anything bad.
That's why having, as you said
earlier, significant other is so
very helpful.
Well, they feel more
productive during that time.
They just feel like they have
a little bit more energy.
Right.
But compared with people with
bipolar 1 disorder, where they still
struggle more with depression
than mania, about three times as
much depression compared with mania.
People with bipolar 2
disorder, again, this was without
treatment.
People with bipolar 2 disorder
have 30 times more time spent in
the depressed, in depression
compared with the hypomanic period.
And I've told you this story,
but I treated a woman who supposedly
had treatment, refractory
depression, meaning she had not done
well over 10 years with
different antidepressant medicines.
And she was unemployed and
really not functioning.
And she came to see me in consultation.
And there were some other clues.
People with bipolar 2 disorder
have three times the rate of migraine
headaches.
Migraine headaches, Other
comorbid medical issues too, and
psychiatric.
Right.
So we'll get to comorbidity in
a second.
So there were some red flags, though.
One was, hadn't responded well
to any antidepressants.
In fact, in some cases got
more agitated.
Secondly, she had migraines,
so there were all kinds of soft red
flags.
So I used to have a stack of a
book called the Bipolar Survival
Guide by David Miklowitz.
It's a great book.
It's a great book for people
with the illness and their families.
And I just gave her a copy and
I said, I'm not 100% sure, but I
think you might have bipolar 2 disorder.
But I'd like you to go home
and read the chapter, see what you
think, and come back and see me.
And we'll go from there.
She came back and she had
highlighted practically every line.
I bet she was relieved in a
way, Paul.
She was.
So I said, well, there's a
reason you haven't done well on all
these medicines.
And I think that's it.
Fast forward.
She don't want to give too
much identifying information.
She's in the medical
profession now after being.
And put herself through school.
I mean, you talk about a
success story, but it was only because
we figured out the diagnosis.
Oh, we've.
You and I have seen that time
and time again.
It's getting.
That's why getting the correct
diagnosis is important.
Right.
And spending that time.
What else?
Wait, I think we were talking
about something else too, about hypomania.
Oh, so it's the ill.
It's not like Coca Cola and
Coke light, you know, or Diet Coke
or.
So it's not like that.
It's.
It's its own unique state as
well, because people still have.
Can't keep relationships, they
can't keep jobs.
All these things can be very
disruptive to them.
So we were talking about
comorbid illnesses associated with
bipolar 2 disorder.
So tell us more about that.
Well, comorbidity for both
bipolar 1 and 2 disorder are very
similar.
And just to go back to bipolar
I disorder for a second, there was
a study funded by the National
Institute of Mental Health.
Gosh.
Now, about 20 years ago,
called the National Comorbidity Survey,
this was a study that
researchers went to five communities
around the US Identified to
represent the demographics of our
population.
And the importance of that is
this was not a referral bias.
So in other words, you might
see a high rate of comorbidity in
people seeking treatment, but
they may be suffering more than people
not seeking treatment.
What they found was that for
people with bipolar I disorder, there
was no one, not a single
person that only had bipolar I disorder.
What else did they have?
Adhd.
The most common is actually
social anxiety or pathologic shyness,
which is sort of
counterintuitive because people who
are manic are not shy.
Well, they're disinhibited.
They're disinhibited.
Yeah.
They have no filter.
So every anxiety disorder was
more common.
Panic disorder, generalized
anxiety disorder, substance use,
70% of people.
So for sure.
So people self medicate too.
So sometimes people are high,
they're bringing themselves down,
they're low, they're bringing
themselves up.
But then the Substance misuse
issue becomes its own problem.
Right?
Yeah.
And the most common substance
of misuse was actually cannabis.
And I've treated a lot of
people who were using, misusing cannabis,
or getting medical marijuana
more recently, and it never goes
well.
It's like poison on the brain
of somebody with bipolar disorder.
It makes the illness worse,
and there's good data on that, too,
so.
Well, definitely the apathy
component, it adds to that.
Well, it sometimes exacerbates
psychosis too, paranoia from people.
Right.
Yeah.
Let's talk about the anxiety
piece, though, because when I was
wrapping up things at my
practice, I was cleaning up charts
and I was looking at a lot of
people who over the years had a bipolar
diagnosis and an anxiety
diagnosis separate, like a generalized
anxiety, because they
presented anxious so much at the
time.
But I started thinking about
it more, especially since we know
more now.
You had mentioned earlier on
bipolar, mixed states.
We've talked about mania,
we've talked about depression.
So a mixed state used to be in
the old DSM Diagnostic and Statistical
Manual.
Used to be you had to meet
full criteria for mania and full
criteria for depression.
And that's hard to do.
So we missed a whole bunch of
people doing that, but the people
were nevertheless suffering.
DSM 5 text revised Dow says
you could have bipolar disorder with
mixed features.
So you don't have to meet full criteria.
You just have some criteria of
mania, some criteria of depression.
That is the worst of both worlds.
So my patient, I always, you
know, you have different people in
your head that all my patients
have taught me so much.
But I remember this one in a
mixed state.
And she was.
She couldn't sleep at all.
She was rocking in her chair,
her, her hands, she was wringing
her hands, big tears falling
out of her face, talking really fast,
completely dysphoric.
And she said, this is the
worst of both worlds.
I mean, she just really wanted
to die.
She had no comfort.
She was so, so upset.
So I ended up looking at that.
I thought, you know what?
I think a lot of these people,
their anxiety falls under the umbrella
of their bipolar illness.
And it was bipolar disorder
depressed or bipolar disorder depressed
with mixed features.
And I was able to take away
the, the separate anxiety disorder
piece.
Yeah, anxiety is just a feeling.
I mean, severe anxiety,
sometimes called anxious distress,
is common in depression and
bipolar disorder.
The tricky thing about the
mixed features part is if you, if
you can't pick that up, that
it's a mixed state.
A lot of clinicians will
prescribe an antidepressant, which
is like pouring gasoline on A fire.
So it just agitates things.
So we see that time and time
again and again.
Another reason you don't want
to have somebody just automatically
knee jerk, prescribe an
antidepressant, because if it's bipolar,
they can get much more
agitated and irritable and anxious.
So that people describe the
sense of impending doom, something
bad's gonna happen with their anxious.
So that's the anxious distress piece.
And for a while, we really
didn't have anything particularly
to treat anxious distress.
Part of it.
Now there's other meds that
they talk about, target that.
So talk about medications,
though, because, you know, when did
lithium come out and talk
about lithium?
A little bit?
Yeah.
I've always taught residents
and medical students that if you
can treat bipolar disorder,
you can treat just about anything.
Why do I say that?
Because if you prescribe an
antidepressant for somebody with
bipolar disorder, and you know
they have bipolar disorder, that
antidepressant can still
trigger a manic episode.
So you can go from depression
to mania just from the antidepressant.
Conversely, some of the old
medicines used for mania could push
somebody down into depression.
So that's sort of a balancing act.
We have much better medicines now.
But, yes, lithium was the
first medicine discovered for people
with bipolar manic depressive
illness back then.
Back when, 1949, by a bench
lab physiologist named John Cade.
And he was using lithium to.
As a.
To calm.
I forget whether it's guinea
pigs or hamsters, but at any rate,
it was incredibly effective.
And so you couldn't do this now.
But back then he talked to a
psychiatrist and said, hey, I just
discovered this or observed
this in the lab.
Do you think it would be
helpful to some of your patients?
And when I say you can't do
this now, you have to have IRB approval
and informed consent, which is good.
Yes.
Regulations are much, much tighter.
So I think it was seven out of
10 people in the hospital who were
given lithium were dramatic,
who were manic, were dramatically
better.
Now, those observations got
follow up in research studies done
primarily in scandinavia in
the 50s and 60s, where ultimately
got approved in the U.S.
lithium wasn't approved till 1970.
So it's an old drug.
It's still a very effective drug.
In fact, one of the nice
things about lithium is people either
respond well or they have no response.
So you don't have to wait forever.
People don't sort of get
better, but not well.
But for 24 years, there was no
other medicine FDA approved for people
with bipolar disorder.
Other than lithium.
Since then, since 1994, we've
had over a dozen new medicines that
fortunately work differently.
And I say fortunately because
the more different a medicine, when
you haven't responded to a
medicine that works in a certain
way, then you've got a chance
to respond to something that works
in a different way.
Right.
And it gives hope when people
have lost hope.
And we're all about that.
And you know, lithium is not
without its challenges.
My patient population
different than your patient population.
But we had an episode many
years ago that there was a shortage
of escalith, let's say, which
is a type of lithium or lithobid,
one or the other.
And we had several people in
group home settings and group home
operators.
They're not medical people.
And multiple people, I
remember this happening, got lithium
toxic because they ran out of lithabid.
The pharmacy gave something
like that.
Anyway, they didn't know it
was the same thing and they were
double dosed on it and they
had lithium toxicity.
So that's a potentially
dangerous thing.
But again then, some people
are more aware of what they're taking
and how they're taking it than others.
Issues with drinking on it,
issues with being pregnant on it.
What happens if you're in the
early stages of pregnancy on lithium?
There's a risk of endocardial
cushion defects, which is part of,
part of the heart chambers.
So yeah, it's not a very safe drug.
And then that and then.
And again, lots of people
still consider it the gold standard
and.
But this is where you, this is.
Where you and I, I know, and I
know, dear friend Jonathan Meyer.
I know also, just.
But I get, I.
You're selling me on lithium
more and more as I get older, but
I, I guess I've seen a lot of
things too.
I had, you know, you can
downregulate your thyroid.
Yes, we can take care of that.
But I, I mean, everybody
shapes you, right?
All your different patients
shape you.
And I, I'll never forget, I
had someone come in who was an octogenarian
and she had been stable for
years and years and years on her
lithium.
Nothing changed for years.
But then she later in life,
she also had kidney disease and the
nephrologist said we need to
take her off lithium because.
And actually, for goodness
sake, she's been stable for 50 years.
Like, for God's sake, she
doesn't need lithium anymore.
And take her off her lithium.
And because her renal
functions were rising, that's dangerous
too, right?
So they took her off her
lithium cold turkey.
And that's Where I came in,
she ended up in a community mental
health agency after no
psychiatric issues, honestly, in
50 years and was in full blown mania.
And I remember they were very
religious couple, they went to mass
as often as they could and all
these things.
And she was saying the most
foul, raw sexual things with pressured
speech only.
And her poor husband was
mortified and it was hard for us
to get her back because we
couldn't do lithium again because
of her kidneys and we had to
do a lot of things to get her out
of track.
But no, I agree lithium can be
very, very helpful for people, but
there's so many other options.
And I always say to you, for
my purposes, if I, God forbid, develop
geriatric bipolar disorder, I
would like you to start me on something
different.
I would like to try something
else first.
Just, just saying.
So to get out of the weeds on
lithium for a second.
I know, how did we get there?
I think the point is that
drugs that are mood stabilizers,
and that's the phrase we use
in the field, so they treat either,
well, treat manic and ideally
depressive symptoms and ideally prevent
them from coming back.
They are the foundation of
treatment of bipolar disorder.
But one or two, and there's
just no way around it unless manic
symptoms or depressive
symptoms are caused by some medical
condition.
So that's why there's good
news in that we have, we have options
now.
Yeah, a lot of good options
with the availability of a bunch
of different mood stabilizing methods.
So when you say mood
stabilizers, are you putting under
that atypical antipsychotics
as a mood stabilizer?
So to explain to our, the
audience, if, if you are prescribed
something and it, you look it
up and it says antipsychotic and
you say, wait a minute, I
don't have schizophrenia or I don't
have psychosis.
What's this all about?
Many of the atypical
antipsychotics and we'll be having,
we'll be talking about that
atypical means.
It's not the traditional
Haldol and prolixins.
It's newer, newer classes of
antipsychotics are used, many of
them are used to treat people
with bipolar disorder successfully.
So that's what that's about.
So, yeah, this is a really
unfortunate label, antipsychotic.
Well, they'll probably change
that name too.
They should.
That would be a good thing to change.
So I like the idea of the mood
stabilizer piece.
That sounds better.
Yeah.
Hypo bipolar 2.
For years there was not a
particular treatment for bipolar
2.
So we really, we really
didn't, we didn't know what to do.
So yeah, maybe I think it
wasn't talked about as much because
first of all, as you said, it
was hard to diagnose, but really
there was nothing we could give.
There was no medication that
was indicated for bipolar 2.
So most people with bipolar 2,
as you said, spend most of their
time in a depressed state.
So what did we end up doing?
You have to do something and
you kind of, I would call it, they
were hanging in the depressed
state most of the time and they felt
terrible.
You ended up giving an
antidepressant, even though that's
not necessarily the best thing
to do.
But some people, they really,
really needed it.
Something, you know, and you
hoped for the best.
But now we have some things
that are actually have an indication
for bipolar too.
So that's good.
Yes.
Mood stabilizers.
Stabilizers that have been
studied in bipolar 2 and found to
be effective.
Right?
Yeah.
So can I piggyback or go back
to the thoughtlessness and how people
can get themselves in all
kinds of trouble?
I guess you can't say no.
I'm only going to say no.
You're not going to say, I'm
going to do it anyway.
But I want to.
I completely disagree.
So I was presenting at a
conference one time and it was a
bipolar conference.
And a friend, a colleague of
ours was presenting from his private
practice.
He had a very high end private practice.
All of his patients were
Doctors, lawyers, engineers, CEOs,
that kind of thing.
And I was presenting from my
practice and his person was on Skype
at the time is what it was.
Was zoomed in basically and
was able to tell his story.
And his story was he was a
multimillionaire, had a CEO of a
large corporation, he had
bipolar disorder and he was self
medicating and not medicating
and you know, and will remind us
to talk about that of not
taking medications.
So he was off his medications
at the time.
And anyway, he flew on a
private jet to Las Vegas.
And if any of you have been to
Las Vegas, you kind of got a picture
of what it's like, glitz and
glamour and there's a lot of.
Activity going on, a lot of stimulation,.
A lot of stimulation.
And he was an older man, went
to a casino and said loudly to anyone
who would listen, hey
everybody, all the drinks and everything's
on me.
And it was pretty clear that
he was kind of throwing money around
everywhere, that people were
glomming onto this man.
He got Himself in so much
trouble on a long weekend in Las
Vegas.
There were strippers involved,
there were police involved.
He ended up in jail.
He ended up in a psychiatric hospital.
Ultimately, it was a mess.
And yes, he had a lot of
money, but he lost a lot of money.
And he said on film that day,
he said, I am so fortunate that my
family stuck by me because a
lot of bad things could have happened,
and I am no longer the CEO of
my organization, but my family still
stood by me and are supporting me.
And yes, I'm taking my meds
now, but things could have gotten
really bad.
So that was that story.
You know, I. I have patients
that, you know, have.
Were presenting really
depressed, and then we were, you
know, they would get in this
manic state and all kinds of horrible
things ensued.
Children are taken away, you
know, just bad things happen.
So let's talk about why people stop.
Taking medication before we
get to that.
And.
And I want to get to that next.
But spending sprees, we've
alluded to that, but that's a very
common.
Oh, yes.
Presentation.
Spending way beyond your means
and getting themselves in all kinds
of debt.
And then, of course, that
leads to families being furious and
all of that.
Oh, well, you just reminded me
of another story then.
Thank you.
So one of my patients.
Do you remember the days they
used to give hospital passes?
Yeah, I don't think they do
that anymore.
I don't think they do anymore.
But our state psychiatric
hospital would give these pass.
People would be in their long
time and to see if they were getting
ready for discharge, they
would let them go out on passes.
And first it'd be supervised passes.
And then they.
When you're really getting
ready to get out, you could go on
just to pass on your own.
And one of my patients who
still had mania in the state psychiatric
hospital, and I told them we.
I would go every Wednesday, I
would do rounds, even though I'm
outpatient, but I would just
check the status of my patients because
I knew their baseline.
I said, he is not at baseline.
This is not his baseline.
Well, they let him go on a pass.
And in a long weekend from
Cincinnati, this guy got a plane
ticket to.
He didn't have that much
money, but any money he had.
This is all went to Tokyo.
And however he ended up
getting to Tokyo as multiple planes
and all that stuff.
And he got to Tokyo and then
flew back to Cincinnati and got back
when checked back into the hospital.
So he spent all this money and
all that time.
And so it was, you know, very manic.
And again, throwing money
along the way.
Yeah, people have lost
fortunes or what fortune they had.
That's again, part of the
devastation of this illness.
Untreated, Untreated.
So that's key.
So people often stop taking
meds with all kinds of illnesses.
It's not just psychiatry.
People stop taking their blood
pressure medicine because they don't
feel it, or I feel fine.
You know, they took my blood
pressure, it's fine.
I don't need to take blood
pressure medicine anymore.
You.
My, my glucometer is saying my
blood glucose is great.
I don't need to take metformin anymore.
Whatever.
Right.
So people do that in all
disease states.
With bipolar disorder, we
really see it because bipolar disorder
is a cyclical illness.
So you can present with
depression or mania or whatever,
and it can last a couple
weeks, and then you could, you could
not be on meds and you might
not have an episode for a year.
Right.
So people tend to explain it away.
I had a fight with my girlfriend.
This stress, that stress, and
I'm going to be fine.
Now, again, if they had mania,
we know what's coming back.
You know, depression might be
a different story.
But the next time it comes back.
Now it's nine months, it comes
back and it's.
This time it lasts three and a
half weeks.
Besides that, you are accruing
losses psychosocially.
Your family, your friends, all these.
You're.
It's an insult to the brain.
So you referred to these as
brain attacks before people understood
heart attacks.
And you keep having heart attacks.
Your heart doesn't function as
well, your ejection fraction goes
down.
It's not good.
Brain attacks, a manic
episode, a psychotic episode, depressive
episodes, transiting ischemic
attacks, mini strokes, seizures,
all these are insults to the brain.
It's not good for your brain.
Right.
And it's possible that you're
actually causing some brain damage.
Right.
Well, there's been studies
done that, looking at serial MRIs
of people over time.
And some people have decreased
gray matter, increased ventricle
size.
Nobody wants that.
Well, the point I really want
to make about this is yes, there
are all kinds of dire things
that can happen if you have Bipolar
I or II disorder and don't get
help and stop your meds.
On the other hand, I've seen
the difference between people who
successfully manage their
illness and the people who end up
unhoused is often insight and
adherence to good medical treatment.
Right.
And we want the least
effective medical.
We don't want lots of medications.
If you don't need that.
We'd like to be on the least
effective medication that we can.
Least number.
Least number of effective medications.
Right, Right.
Thank you.
Thank you for the clarification.
So it's very easy to explain away.
And people don't want the stigma.
They don't want it whatever.
They don't want to take med if
they don't have to.
And especially when they feel
fine, it's confusing.
If you have a headache, I take
a medicine for that.
My headache goes away.
That makes sense.
But if they feel fine, they
don't understand the need to take
it.
But it's really important,
especially when they're what we call
euthymic.
Inter.
Episodically, they're neither
manic nor are they depressed.
They're euthymic.
That we emphasize the need to
stay on a maintenance medication
because this will come back.
It's cyclical in nature.
Yeah.
And the age of onset of
bipolar disorder, the usual age range
of onset is 18 to 25.
I was once involved in a
research study in which we were systematically
asking people, looking back on
your life, when did you first notice
that you had any symptom?
And these were people who had
insight and weren't denying it.
And one third of the people
said, from my earliest memories,
they didn't say, oh, I had
classic manic or depressive symptoms.
They just said, I knew
something was off with me and that
I was different from other kids.
And then retrospectively, they
can look back and say, so we're getting
more and more referrals from
Children's Hospital, from the child
psych and pediatricians are
recognizing it earlier, which is
good.
It's very good.
But I think that's one reason
a lot of younger people are just
stop their medicine.
Because you're not supposed to
be sick.
When you're 18 to 25 or
younger, you're not supposed to be
sick.
And it's a big insult and a
difficult insult emotionally.
And it's very difficult to
admit, oh, my gosh, I have a psychiatric
illness that I have to take
medicine for every day.
And you had toxic.
We both like to talk about
anosognosia, the lack of insight.
So we see that a lot with our
people with bipolar disorder or schizophrenia.
They do not think they have
mental illness.
So it's not even that they're
being difficult.
Some of them.
Some of them just choose not
to take it.
But some are like, I, there's
nothing wrong with me.
They could be hospitalized
many, many, many times and then say
somebody was paid off.
Or you Know, the system's
corrupt, different excuses, and sometimes
it takes a long time.
Or before that insight comes
along, we're.
Literally hitting rock bottom
and having, okay, this is my sixth
hospital admission.
Maybe there's something to this.
I think that anosognosia was
first described in people who had
right frontal lobe tumors or strokes.
And the right frontal lobe is
right above your right eye and was
described in neurology
patients because those folks, although
they'd had a stroke or a tumor
affecting their entire left side
and was often paralyzed, they
wouldn't admit it.
They thought they could still
use their arm.
Right.
Same thing with vision.
Sometimes people are blind in
one eye and they still think they
can see.
So that's anosognosia as well.
So not incidentally, people
with bipolar disorder and schizophrenia
have right frontal lobe.
I mean, the right frontal lobe
is involved in the neurobiology of
those illnesses.
How do we know?
PET scan.
How do people know that?
What's based on what?
Functional MRIs, mostly
neuroimaging, but also neuropsych
testing, things like that.
So that can be the biggest
impediment for helping somebody with
bipolar disorder because they,
you know, you are all crazy.
I'm fine.
And that leads to antagonism
between that person and their family
and friends.
Antagonism with a provider
who's trying to help them sets up
a really dicey situation.
And I think we're going to do
a podcast specifically on anosognosia.
Yeah.
So untreated bipolar disorder
can look a lot like character pathology
in a way.
I mean, borderline personality
disorder and bipolar disorder can
often look a lot alike when.
Especially if someone's in an
irritable mania and they're not.
Impulsivity, mood instability.
The argumentative piece of it.
Yeah.
Well, one of the world's
renowned researchers in borderline
personality disorder was one
of my supervisors, and there was
a huge debate at the time, and
there still is, about the validity
of borderline personality disorder.
I think it's legit.
I do, too.
But.
But when this expert.
Whole episode on that as well.
Yeah.
This expert published a paper
showing that 20% of people with borderline
personality disorder had
bipolar disorder and 80% had depression.
Equal, 100% had a mood disorder.
I can see that that'll be
interesting to explore.
I would talk to you more.
I mean, clearly, people with
borderline personality disorder are
not happy.
They're having.
They're not in a comfortable place.
Yeah, we'll pick that up.
Well, yeah, we could take a
note of that.
That'll be interesting.
To talk about?
Well, there's so many good
treatment options.
Now, what about, what's the,
what's the role of therapy with someone
with bipolar disorder?
Well, we focused on how mood
stabilizing medications are the foundation.
Right.
But again, stress can trigger
manic and depressive episodes.
Stress in families,
relationships, workplace issues.
Plus there's the aftermath that.
Oh, cleaning up afterwards.
Right.
That can happen when
somebody's had a severe episode,
been in the hospital.
So people with bipolar
disorder, there's no formal psychotherapy,
and in fact, it's almost
ridiculous to try to do psychotherapy
with somebody who's manic.
Well, you can't.
When someone's manic, you can,
but it's an important component of
treatment depending on what's
going on in that person's life.
My very, very shorthanded form
of psychotherapy was I tried to distill
down everything I learned
about this illness and tell people
what they could do to manage it.
One was take your medicines religiously.
Two, no drugs or alcohol.
Three, eight hours of sleep.
You can call that
psychotherapy, psychoeducation, psycho.
Education, or supportive psychotherapy.
Good.
You want to keep it simple anyway.
Right.
You don't want it to be overwhelming.
We'll be doing deeper dives
into all the disease states, and
we'll definitely be bringing
some people in to talk about their
lived experience with bipolar disorder.
And I think that will be
interesting for people.
We're so fortunate that more
and more people are coming out socially,
celebrities are coming out and
sports figures to talk about having
bipolar disorder.
They're being open about it,
which is helping destigmatize.
I know you talk about
discrimination versus stigma, but
again, they're combined.
The more people talk about it
openly and raise awareness, the better
it is for everyone.
And I think it's a
generational thing, too.
Younger people, I think, are
more enlightened about mental illness
and more willing to.
Although I'm contradicting
myself because I just said people
18 to 25 don't want to be
taking medicines and all that, which
is true.
But I think there's much less
stigma because of education.
I mean, that's the stigma buster.
The more hopefully people
learn, hopefully including from this
podcast, the more they'll be
mobilized to get help.
And the important point, I
think, is this is a manageable illness.
It is.
So there's also.
They start the conversation,
people are talking, just getting
kids and everybody to talk
more about their emotions, their
feelings.
Sometimes it's transient,
sometimes it is an illness that needs
further investigation and treatment.
But Just giving people
support, making sure people.
People aren't isolated, giving
them hope, which we just always.
That's how we always end up.
We always end up in this hope
piece because I think that that's
the.
The theme of everything that
we do right.
Difficult diseases, but so are
all kinds of diseases.
But there's options available.
A lot of good options.
Never quit.
We never quit.
And we.
That's the biggest thing we
need to do, is have family, friends,
loved ones, professionals.
There needs to be love,
support, understanding, compassion,
and being the keepers of hope
when people aren't seeing that they
have much hope.
100% agree.
Well, we could talk about
bipolar disorder all day, and we'll
be talking about it again and
again and again.
But this was good
conversation, Paul.
I enjoyed it.
So did I, truly.
Did we leave anything out?
I'm sure we did, but I think
we hit the highlights.
You know, I'm going to be
stewing over this tonight, I think,
oh, I meant to say this and
that, and then I didn't do it.
But do you think that we.
I think we covered.
We covered the highlights.
Covered the big highlights.
But more to come.
Thank you all for your very
kind attention to our discussion
about bipolar disorder.
More to come.
Never quit.
Keep hope alive.
Thank you,.
Sam.