The Curbsiders (00:00.274) 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, you know? 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 Deb laugh. Why does Pavlov have such nice hair?

The Curbsiders (00:39.298) I have no idea. Because he conditioned it. I think that's the winner. Yeah.

Curbsiders podcast is for entertainment, education, and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure, or prevent any diseases or conditions. For the more of the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash-like moral hospital and affiliate outreach programs. If indeed there are any, in fact there are none. Pretty much we are responsible if you screw up. You should always do your own homework and let us know when we're... Welcome back to the Curbsiders. I'm Dr. Matthew Francois, 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. Excited to learn about bipolar. You can tell she's in the throes of residency right now, Paul. You know, like. The enthusiasm. That's the energy that only a resident could muster. Just sneaks from my pores.

Just too tired even feign enthusiasm at this point. But let's be careful with, we just recorded our 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 Wexler Medical Center in Columbus, Ohio.

The Curbsiders (02:35.894) 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 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. And yeah, you know, we're still early in terms of our journey to becoming Pokemon masters. But, you know, we're...

We're working our way up though. And there's like 10 million cards, right? There's, 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 competing, but there's definitely lots of people out there that love collecting and that's a huge. My kids were 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 them.

Yeah, I'm not sure I knew there was a game involved. I got to be honest with you all. I didn't think there was card collection, but I didn't know there was any. Yes, you did. Come on. It's like a Magic the Gathering type thing, Paul. You didn't know? No. I think Paul's a secret Pokemon card player. Yeah, I can see that. See if you can get that rumor going. All right, Kevin, 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.

The Curbsiders (04:44.394) Yeah, so my favorite, the failure that I've kind of learned something from was when I went on a trip to France, southern France with my father-in-law and my wife and we were is very 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. But 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 this adventure can bring people together and create lots of lasting memories. 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 like lots of small towns that we could stop at along the way to get like water and things like that. Okay. That's, that's making me feel better about the situation. Sounded scary.

If I was involved, it would be like a Lord of the Flies situation almost immediately, like two hours in, I would be conkshield involved in that. That's what it felt like when we were in the middle of it. 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 like

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 I want to apply to my own practice. But when you're working with an attending, especially for the first time, really try to emulate that attending and have that.

The Curbsiders (07:06.438) attending be like your gold standard. And you'll learn some styles that you like and some things that you don't. But once you're out of training, you'll be able to pick from all the 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 Kashlak 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 Kashlak University. His mother has become increasingly concerned because during the holidays, she noticed that her son stays in bed until 1 PM. He's not engaging 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. Your patient 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 wanna 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 an SRSRI 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. And so at this point, all we know is that he has my criteria for major depressive episode. And the next step would be to drill down and see what is causing the major depressive episode. Yeah, this, cause this seems like in primary care,

The Curbsiders (09:30.37) 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. And 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, but 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 like substances or another medical condition. So, you know, assuming that this person doesn't have like hypothyroidism or other, you know, kind of medical issues that...

could create like depressive symptoms. You know, 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, you know, I'll ask them, assuming that they've never been diagnosed with bipolar disorder, you know, I'll ask them, you know, have there been times where your mood has been different from depressed, 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 people thought you were behaving strangely. And I'll lead 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, did you notice, did you talk to him 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 list? Because it looks like, if I remember correctly, the DSM-V criteria, you have to have the behavior be noticed by someone or it has to be significant enough to actually cause impairment, depending on 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 others? Do you just ask? Is it that straightforward?

The Curbsiders (11:53.518) 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 patients with history of manic episodes, if you ask them, they might not be able to really identify with it. So it is really hard. It's really challenging.

The Curbsiders (12:22.782) the functional impairment or the symptoms being noticed by others. Yeah, I asked them, did other people notice that you were acting differently? And if they say yes, I'll say, well, what did they say about you? Did they say that you were doing really well or were 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 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, you know, that does take additional time, which can be challenging in an office setting. And yeah, I was surprised to read that depression is the, like, main presenting symptom of bipolar disorder. I always thought that you had to have hypomania or mania to...

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. It's – 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 patients' symptomatic times with bipolar disorder on average is going to be.

in the depressive phase. And so there's, 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. And one of the challenges of bipolar disorder is that, you know, for 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 to trigger a manic episode, you really can't identify them as bipolar disorder, even though they may have the underlying genetic vulnerabilities and everything. So that is a really challenging aspect of our field and especially a big limitation of using the DSM-5 as a phenotypical diagnostic strategy. I like psychiatry because there's no blood tests that tell me what...

The Curbsiders (14:42.966) a condition a patient has and I'm my own diagnostic instrument. But 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. I want a clear answer, but a lot of the times...

A lot of times we don't get that, Paul. We've never not once. Yeah, medicine is awesome. Yeah, especially in psychiatry. And it's tough. A person with bipolar disorder, if they become manic, the day before they had their first manic episode, they would meet criteria for major depressive disorder. So you gave us the questions. You ask about their mood, their energy, any strange behaviors that they've had or that others have noticed, and then functional impairment.

And if we start to suspect based on those answers that maybe there's something going on, which tool do you like to go to then sort out, is this a formal diagnosis or not? Yeah, I think especially in primary care where you guys aren't used to asking for all the diagnostic criteria all day, I think having a screening tool could 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 now. 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. It's 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, 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.

The Curbsiders (17:04.918) I still use the 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 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 the patient that all of these symptoms should be happening at once. It's not just one night of like not needing sleep or one day of...

talking more, being really excited, but really it's like an extended period of all these things happening at once. And so it gives you kind of a nice script to follow and then you can kind of see how many of the symptoms 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 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 20 or 30 minutes to administer, it's just not going to get done in primary care because that's your whole visit time. But 10 minutes, you still have some time in the visit to talk about the results. And

So it might, 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 concerned about bipolar disorder and 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.

The Curbsiders (19:24.418) 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 and 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 kind of 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 bipolar or manic symptoms in retrospect like the CIDI are more practical. Okay. Yeah. Debra Paul, any other questions about this part of it that you had? Well, I did, it was 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, dad are also bipolar or have a diagnosis, like how substantive is that or how meaningful is that when you're actually, and 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 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 Julie 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?

The Curbsiders (21:47.046) or what kind of symptoms they had because yeah, you know, the kind of colloquial use of bipolar disorder is very different from how mental health clinicians use it. Yeah, I think about like Katy Perry's song Hot and Cold, like you're hot and you're cold, you're yes and you're no, something, something love bipolar. I think most non-mental health people think of bipolar as like people who...

rapidly go from one mood to another, 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. And 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, you know, rapid moods mood shifts like within a single day You know things such as like a borderline personality disorder for example But yeah, the way that we think about bipolar disorder is very different from how like, you know 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 like the first paragraph is like it's normal to be

happy when something good happens instead was something bad. Like they sort of normalized moods, which I really enjoyed as an opening paragraph to the New England Journal of Medicine article. 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, other psychiatric illness or other things that would kind of be in the DSM. So like substance use, anxiety, PTSD, ADHD are all 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 it 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? Like how many disorders somebody can have? Uh yeah they can have uh

The Curbsiders (23:54.322) Yeah, many comorbid disorders and comorbidities are 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 with bipolar disorder. And they also can be present in a patient with bipolar disorder. You know, substance use is a tricky one because, you know, some people may...

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

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 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. I might say these are things that make me concerned, but I also could be wrong, and I tell patients that all the time that just off of one first meeting, I can't 100% diagnose them with bipolar disorder.

makes this point a lot in that patients, we'll 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 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 people that also genetically respond to substances differently. So...

The Curbsiders (26:17.042) For example, there's some people with opioid use disorder where they say opioids energize them and whereas most other people would consider it a downer. So people have different biological responses to these substances that can change the risk of 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 in 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, but 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, you know, appeared 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, things like hypersexuality, grandiosity, flight of ideas, things like that. So I really think of bipolar disorder as a syndrome, because all these symptoms individually, they're all...

you know, aspects of normal human experience. You know, everyone's had times where they have not needed as much sleep as normal because they were excited or they were nervous about like a board exam coming up or something. You know, everyone's had times where they talked more than other people. And so really like, really trying to obtain this history of a period of, a discrete period of time where all these symptoms are happening at the same time, you know, I think that that's really important for the.

The Curbsiders (28:37.474) bipolar disorder diagnosis on top of the change in level of functioning. So whereas, you know, where in this patient, you know, those things are pretty clear, you know, 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, because I've had some patients like, yeah, there was one time where I spent too much money and I've had depression in the past, but 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 manias. 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, you know, 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 if they become so manic that they have to, you know, 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, 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 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.

The Curbsiders (30:58.166) diagnosis to make. But I think in this case, this patient is telling a very consistent history that's consistent with a bipolar manic episode. Especially if they elicited or if they volunteered this on their own with minimal prompting from you, I think that would 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. You know, I try not to list off the rest of the DSM-5 criteria because I don't want them to, you know, just say, oh yeah, I had that and I had that, I had that. You know, I want them to come to me and actually tell me what their last episode 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 1, that's if they've had one episode that qualified as mania, even if they've never been depressed, they get that diagnosis bipolar 1, 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 how bipolar 2 and then cyclothymic?

disorder, how are those different? Yeah. So with bipolar II, 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 symptoms, so episodes that don't meet full criteria for hypomania and they also have had numerous periods of sub-threshold like depressive episodes as well that don't fully meet criteria for major depressive episode. That seems like one where you'd, it'd be kind of hard to make the diagnosis in one visit. You'd have to follow the person for a long time.

The Curbsiders (33:13.518) And it just seems kind of vague. That's not a diagnosis that I see often on charts. Maybe in a psychiatrist 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 make the case that they meet that pattern of never having been too manic to be fully manic or meet criteria for bipolar disorder, never having been so depressed that they meet criteria for a major depressive disorder. It takes time to establish this diagnosis like that. Okay. So you mentioned earlier some of the things that we want to make sure we're not missing like schizoaffective disorder or substance use. You said endocrine disorders like

a 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 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. So 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 like when their youth thymic or when their mood is normal, like 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 you know follow someone for a long time. Okay that's good. So Deb, what else what else do we want to ask about here? Are we are we ready to get to treatment or do we have other things we need to know about?

The Curbsiders (35:37.498) our patient here. I don't think we gave him a name. We're just 20 year old college students. So 20 year old college, yeah, we're HEPA compliant. Thanks Deb, it's so responsible of you. I think like looking at other mimickers, what are some like 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, depressants cause depressive symptoms, 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 is receiving steroid treatment that can present with manic symptoms, I think more people have neuropsychiatric side effects of steroids than we really fully appreciate. I've seen patients develop mania and psychosis while they're being treated with prednisone or even while the prednisone is being tapered, I've seen patients develop psychotic or manic symptoms.

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. That's... Yeah. So this is somebody that was on it for giant cell arteritis or some high dose and they're on a long slow taper? Yeah. Okay. Yeah. So just because it's being tapered, I wouldn't rule out steroids as being the cause.

You know, more rare things like, you know, perineoplastic encephalitis, you know, or limbic encephalitis could present with like manic symptoms. You know, I think if someone is like post-ictal, they can present with like psychosis. Sometimes it can look like mania and cross-section. One of the more challenging things though is just kind of differentiating between bipolar disorder and the...

The Curbsiders (37:55.394) the other psychiatric comorbidities that it could present as, such as for example, borderline personality disorder, where they have very rapid mood shifts, but those tend to be very rapid, 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 unstable self-image, things like that. Or ADHD, which can cause a lot of

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, lifelong. And so, so getting that chronological history is really important for, you know, differentiating between, you know, something like bipolar disorder and ADHD. The irritability part of bipolar isn't one that I had thought about as much, like, 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 the just the typical like 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.

Classically, we think of the euphoric manic patient who is gambling, having sex with everyone, thinks that they're the mayor, the president, and they're just on top of the world. But in reality, 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 also saying, at the same time, I feel so depressed and I want to die. And so there's...

The Curbsiders (40:06.314) I think mixed symptoms are very common in these patients. And so very often you're going to see depressive symptoms and irritability mixed in instead of just pure euphoria. So I do think we should start to delve into treatment. It seems like with our 20-year-old name withheld that he definitely has what's concerning for bipolar. So it's...

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 and 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.

Um, in this case, you know, the patient is presenting with a major depressive episode there. 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 it 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. He's dragged into the office by, by their mom. Um, you know, I'm not hearing about any other like 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 of the illness, also the phase of the illness that has more limited treatment options. And so, with the more commonly used FDA-approved treatments would include...

lorazidone and quetiapine, those are two FDA approved treatments for bipolar depression. Limonchegene is another option, but the titration is quite slow and so is usually more helpful for the maintenance phase than the kind of acute depressive phase. So Kevin, what's confusing to me is that because sometimes patients are only having depression, but they have bipolar.

The Curbsiders (42:23.286) 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 will 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. And 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 cotyapine, lorazadone. Those are two.

You know, very commonly used atypical antipsychotic options. Another option is limoche gene, but limoche gene, 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, you know, more useful 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 than primary care setting because of the lab monitoring. Yeah. 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 window, so patients can get in trouble with toxicity. 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. It's a great medicine. It's a life-saving medicine.

The Curbsiders (44:31.638) But you just have to be really careful and do a lot of patient education. And so I think it can be done in primary care setting, especially in collaboration with the psychiatrist. I think using an atypical and a psychotic 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.

That addresses the question that I have. This feels 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? Despite that, that'd be a question that you can answer. As a primary care doctor, starting with say a 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. It just feels so unsatisfying and-

potentially even harmful, be like, you know, you're just gonna 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, um, or a Lutuda, um, remind me of the general. Lurazadone. Yeah. Like is, is there, what's the downside, I guess, or sort of what kind of harms can we have if we have less of a nuanced approach than you might have? Sure. Yeah. I think the, the main downside for, you know, things like a lurazadone or

would be short-term, they can have more metabolic side effects, especially with like quetiapine. Lurazidone, 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 very rare, especially at low doses that we're using, especially low doses that we're starting in primary care. There's also...

risk of like extra pyramidal side effects. So, you know, tremors, uh, rigidity, um, with long-term use, uh, typically after years, um, you could develop like tardive dyskinesia, um, which, you know, presents typically with like involuntary movements of the mouth or tongue, but it can involve other parts of the body. Um, but that's something that typically doesn't, uh, doesn't manifest until, you know, an extended period of treatment, you know, usually years. Yeah. These are some scary side effects. I think that's why

The Curbsiders (46:51.182) 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 just like starting about a medication that is going to worsen it is always, is never like a prospect that I look forward to. And then you talk about 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. Um, and then you have, I think, uh, deval pro X or Valpro eight, you know, that one, uh, that seems a little less scary to me, but I'm also not that familiar how to use it. So maybe, maybe that's worth talking about a little bit more like how you might start that and, and some of the typical dosing. Yeah. You know, I think with the Val, Val pro X, 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 drug-level monitoring as well. So typically after 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 70 to 90, somewhere in that range. Many patients will develop asymptomatic hypereminemia 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 like...

twice the upper limit of normal or if they're having like clinical symptoms. But you'll see recommendations for checking that. The other thing is to kind of keep in mind with valproic acid would just be risk of like thrombocytopenia. 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.

The Curbsiders (49:09.79) And this one, I think this causes weight gain as well, right? Yeah. I mean, like pretty much all things too. Yeah, valpro, it can cause weight gain. It can cause a hair loss. Um, you know, in terms of like weight neutral options, like lorazadone is really probably one of the more metabolic and friendly, you know, there is some risk, but especially compared to other atypical antipsychotics like quetiapine or especially olanzapine, um, the lorazadone typically does not cause very much weight gain. Um, limotrigine is also something that is usually weight neutral for most patients. It just takes.

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

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

use it as an augmentation treatment. Okay. So, uh, yeah, could type in is, you know, something that I recommend a lot in, um, 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, 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. Um,

at bedtime and then I'll gradually increase it in like 50 milligram increments until I get to 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 for the PHQ-9? Like is there something 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.

The Curbsiders (51:29.894) 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 catiopine 50 milligrams and then we follow him every two, three weeks and kind of adjust the dose and we're following for signs of metabolic syndrome.

Cause 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, this guy up for success. So what, what else, what other counseling would you be giving to him and his mother at that visit? Um, and then we'll, we'll go on and we'll, 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 counsel, uh, the patient and mom on the importance of

just leading an overall healthy lifestyle, especially sleep hygiene. So for patients with bipolar disorder, having disrupted sleep can be really risky for triggering a manic episode. And so I would really emphasize the importance of going to bed at a regular time, waking up at the same time, working night shift is probably something that would be risky for a patient like this. And also just healthy diet, exercise, those things have antidepressant effects and also

useful, especially in the case of taking medications that can cause metabolic side effects. And I would also just encourage mom to bring her son in if she's noticing changes in mood again, either too high or too low or increased irritability because treating these mood episodes early or getting treatment started is really important.

Anything, Deb, anything else for this case? Like, so we've put him on treatment, we've counseled him and his mother. And, uh, do we have a happy ending here? Do we have to go into, uh, any, anything else, any other like tweaks you want to make to the case or other scenarios? No, I think it's, I think it's a happy ending. Um, I mean, I, I remember being taught, you know, during medical school that antidepressants are a complete non sequitur, a complete note with bipolar.

The Curbsiders (53:47.63) but it does seem kind of cruel that we're not treating depression as effectively as we 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 gonna 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 two disorder, who will respond to antidepressants though. 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. For example, in this case, I would want this young man to be on...

a decent dose of a quetiapine or lorazadone or valproic acid or something, lithium, before I would consider adding on a low dose of antidepressant carefully. Are there any nutritionally used antidepressants that are particularly dangerous in terms of precipitating a manic episode? I would think, like the Proprion, I feel like can be a little bit activating. 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 bupropionate is actually used more commonly in treatment with bipolar disorder. I think one of the reasons is that it has a shorter half-life, so if someone does become manic, you can stop it and it washes out pretty quickly. I would say bupropionate, even though it is more stimulating, it certainly can...

The Curbsiders (56:08.886) 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, catiopine and lorazadone seem like the ones that are best at treating the acute phase of depression. Lamotrigine more for the maintenance phase of depression.

and because you have to start it more slowly. We talked about the razzadone having less of the, some of the less weight gain. It's a little more metabolically friendly than cation. And then for, for mania, lithium, some of the anti-convulsants 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 anti-

atypical antipsychotics or second generation antipsychotics have some effect to 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 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...

The Curbsiders (58:29.75) 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, can't 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 the patients will just say, oh well, I get angry really fast and so they said I was bipolar disorder and then I might explore further and say, well, how long does those anger episodes last? Do they ever last like a full week? And they say, no, I just get angry at the drop of a hat and then I cool off after 30 minutes.

That tells me that it's probably not bipolar disorder. It's probably any number of other kind of borderline personality disorder, PTSD, or other things that are causing that moment-to-moment lability. But if they tell me, oh, I had a manic episode where I went a whole week without sleep and then I 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. Then, okay, yeah.

That's a different story. You know, we're talking, you probably have bipolar disorder then. So. 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. Just like that's so that's not, you're saying that's not bipolar. That's just the guy that got angry and.

The Curbsiders (01:00:51.594) Yeah. You know, he apologized. That's right. Yeah. Certainly could be other things going on, but it's not bipolar. Yeah. Okay. Yeah. So 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, you know, renal impairment, hypothyroidism, it can cause hyperparathyroidism. So there's a lot of things that we want to look out for. I would, in a patient like this, I would check their chemistry panel to, you know, 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 they may have had side effects or other bad experiences or maybe they just lost touch with their psychiatrist. That's something that does happen. I would just talk to them about how with their bipolar illness, it's lifelong and being on a preventative medication is the safest thing in terms of keeping them from developing either manic or depressive episodes and try to explore that. Yeah.

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, Cotyapine, Lurazadone, 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. As the patient says, like, you know, Cotyapine 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.

The Curbsiders (01:03:15.414) phase of the illness, you know, are they someone who has a lot of depressive episodes or they're someone who has a lot of manic episodes Try to figure out you know, what which phase of the illness is most impairing for them and try to tailor the treatment to that Paul do you 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, biotin supplement. No, I think the instruction to sort of specifically how the diagnosis was made and 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 a very depressive symptoms? Yeah, that's a great question. You know, suicide is 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 the remission phase of the illness, I would still ask them at every visit because it is something that

Yeah, unfortunately, you know, many patients with bipolar disorder will attempt suicide and you know, some of them will even die by suicide, unfortunately. So 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, get a little bit more history and try to help steer them in the right direction? Because I know there would be different medication approaches to both of those conditions. Yeah. Unfortunately, there's racial bias in medicine. Unfortunately, that

The Curbsiders (01:05:40.034) that happens, it's something that we all have to work to address. I think minority patients, especially African-Americans, they have a higher rate of being diagnosed with serious mental illnesses, for example, like schizophrenia, 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, the problem list, like once they're on there, you cannot get them off for forever. They're just sort of self-perpetuated. So it's, yeah, if you can, removing problems off of problem lists is one of my few joys in life. So yeah, if you can do that for patients that have SQA3. Yeah, sprinkle in some sarcoidosis, Paul. Oh my God. You talked about that. I find, I find, AFib tends to stick to problem lists 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 finding it helpful for their anxiety and for sleeping and all that kind of stuff. But I know there is some evidence that may worsen outcomes in certain populations. How do I counsel patients and what should I talk to them about if they have a state-of-the-art 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

The Curbsiders (01:07:49.762) 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. They may say it helps me with sleep or helps me with appetite or something. And we can maybe,

open up opportunities to address it in other ways. And then I'll also just talk to them about how, 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 and 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 satisfied? When you first asked about, what do I do with cannabis? I was like, Paul, 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 in 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 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 number one, like the classic kind of sticky caps symptoms, that's a 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. It's something that is very difficult to do on an initial visit and even experienced psychiatrists oftentimes will have to follow patients for an extended period of time before we can truly be certain of the diagnosis.

The Curbsiders (01:10:13.546) don't feel like you have to have the diagnosis on the first visit. Just, you know, having it on your 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 like, you know, 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 on 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 antidepressant, just counsel them really clearly, like, you know, if you develop, you know, changes in mood, like, you know, irritability increases in mood, decreased you for sleep, you know, definitely tell me immediately.

On the other hand, if they have a strong family history and I'm leaning more towards I think that this is a bipolar disorder, then yeah, I probably would treat them with bipolar medication. And yeah, I think the other take home point would just be that bipolar depression does not respond to traditional antidepressants the way that major 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, you know, cognitive behavioral therapy. You know, I think you asked earlier about, you know, what would I counsel a patient on?

in addition to lifestyle factors, I would really encourage them to engage in cognitive behavioral therapy as well because I don't have a pill that's going to fix this patient's relationship problems or change their school stressors and things like that. Cognitive behavioral therapy is going to be a really important tool to help change how they relate to those stressors and how they cope with that. Not as helpful for mania because usually when patients are manic, they're...

The Curbsiders (01:12:30.51) 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. Right. Paul, CBT, always the right answer, correct? Yes, especially for boards. Yeah, absolutely. Yep. Yeah. All right. Thank you so much, Kevin. Really awesome stuff.

The Curbsiders (01:12:58.422) This has been another episode of The Curbsiders, bringing you a little knowledge food for your brain. Oh, yummy. Great. Slightly ominous, which is probably appropriate. Still hungry for more? Join our Patreon and get all of our episodes at free plus twice monthly bonus episodes at patreon.com slash Curbsiders. You can find our show notes at thecurbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox, including our Curbsiders Digest, which recaps the latest practice changing articles, guidelines and news in internal medicine.

And we're committed to high value practice changing knowledge. And to do that, we want your feedback. So please send an email to ask curbsiders at gml.com. It also helps if you subscribe, rate and review the show. We're on YouTube, Spotify, Apple podcasts. So like, and follow us on there. A reminder that this and most episodes are available for CME through vcuhealth at curb I wanted to give a special thanks to our writer and producer for this episode, Dr. Deborah Gorth.

And to our whole Curbsiders team, our technical production is done by the team at PodPace, Elizabeth Proto runs our social media, Chris the Chew Man Chew runs our Discord, and Stuart Brigham composes our theme music. So with all that, until next time, I've been Dr. Matthew Frankuoto. And I've been Dr. Deborah Gorth. And as always, I'm Dr. Paul Nelson Williams. Thank you and goodbye.