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c-0.4,1.7,0.9,3.1,2.5,3.1c3,0,5.1-3.9,5.1-8.5c0-3.5-2.4-6.1-6.7-6.1c-4.9,0-7.9,3.6-7.9,7.7c0,1.4,0.4,2.4,1.1,3.1 c0.3,0.3,0.3,0.5,0.2,0.9c-0.1,0.3-0.3,1-0.3,1.3c-0.1,0.4-0.4,0.6-0.8,0.4c-2.2-0.9-3.3-3.4-3.3-6.1c0-4.5,3.8-10,11.4-10 c6.1,0,10.1,4.4,10.1,9.2c0,6.3-3.5,11-8.6,11c-1.7,0-3.4-0.9-3.9-2c0,0-0.9,3.7-1.1,4.4c-0.3,1.2-1,2.5-1.6,3.4 c1.4,0.4,3,0.7,4.5,0.7c8.8,0,16-7.2,16-16C48,23.2,40.8,16,32,16z" fill="white"></path></svg></button><button aria-label="email" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#7f7f7f"></circle><path d="M17,22v20h30V22H17z M41.1,25L32,32.1L22.9,25H41.1z M20,39V26.6l12,9.3l12-9.3V39H20z" fill="white"></path></svg></button><a class="print-wrap flex justify-center items-center cursor-pointer"><svg id="print" xmlns="http://www.w3.org/2000/svg" width="24" height="24" fill="currentColor" class="print bi bi-printer" viewBox="0 0 16 16"> <path d="M2.5 8a.5.5 0 1 0 0-1 .5.5 0 0 0 0 1z"></path> <path d="M5 1a2 2 0 0 0-2 2v2H2a2 2 0 0 0-2 2v3a2 2 0 0 0 2 2h1v1a2 2 0 0 0 2 2h6a2 2 0 0 0 2-2v-1h1a2 2 0 0 0 2-2V7a2 2 0 0 0-2-2h-1V3a2 2 0 0 0-2-2H5zM4 3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1v2H4V3zm1 5a2 2 0 0 0-2 2v1H2a1 1 0 0 1-1-1V7a1 1 0 0 1 1-1h12a1 1 0 0 1 1 1v3a1 1 0 0 1-1 1h-1v-1a2 2 0 0 0-2-2H5zm7 2v3a1 1 0 0 1-1 1H5a1 1 0 0 1-1-1v-3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1z"></path></svg></a></div><style> .print-wrap { width: 32px; height: 32px; background: #7F7F7F; border-radius: 100%; } .print { background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><p class="py-2 mb-2 text-sm italic text-gray-600">A podcast on the role of randomized controlled trials in mobile mental health research. </p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class="audio d-block text-center mb-3"><audio controls="" controlsList="nodownload" class="audio w-full"><source src="https://cdn.sanity.io/files/0vv8moc6/psychtimes/3f8f3dbd40a3f23a8489c662dcdf4f4080316999.mp3" type="audio/ogg"/><source src="https://cdn.sanity.io/files/0vv8moc6/psychtimes/3f8f3dbd40a3f23a8489c662dcdf4f4080316999.mp3" type="audio/mpeg"/>Your browser does not support the audio element.</audio></div><p class="pb-2"> </p><p class="pb-2">Traditionally a benchmark of scientific evidence, randomized controlled trials (RCTs) are often unsuited for the fast-paced, open environment of smartphone apps and other mobile technology research.</p><p class="pb-2">So how can mobile health (mHealth) adapt to ensure it is evidence based and rigorously validated? Dr John Torous discusses these issues with researcher and PhD student, Jennifer Nicholas, BSc(Hons) BA.</p><p class="pb-2">Summarizing the main points of the interview, Ms Nicholas explains:</p><ul class="my-2"><li class="list-disc ml-8">The vast majority of apps for mental health are of poor scientific quality</li><li class="list-disc ml-8">Current research methodologies may be contributing to the shortage of high-quality apps</li><li class="list-disc ml-8">mHealth research needs to explore different ways of creating, testing, and disseminating apps</li></ul><p class="pb-2"><strong>About the speakers:</strong></p><p class="pb-2">Ms Nicholas studies mobile mental health, with a focus on bipolar disorders, at the <a rel="nofollow noreferrer noopener" target="_blank" href="http://www.blackdoginstitute.org.au">Black Dog Institute in Australia</a>. Dr Torous is a Clinical Fellow in Psychiatry at Harvard Medical School and Senior Resident at the Harvard Longwood Psychiatry Residency Training Program in Boston. He is the Digital Psychiatry Editor for <em>Psychiatric Times.</em> Twitter: <a rel="nofollow noreferrer noopener" target="_blank" href="https://twitter.com/JohnTorousMD">@JohnTorousMD</a>. The speakers report no conflicts of interest concerning the subject matter of this podcast.</p><p class="pb-2"><strong>Further reading:</strong></p><ul class="my-2"><li class="list-disc ml-8">An important article by Ms Nicholas on this topic: <a rel="nofollow noreferrer noopener" target="_blank" href="http://ebmh.bmj.com/content/19/2/33.full">mHealth in Psychiatry: Time for Methodological Change</a></li><li class="list-disc ml-8">Papers discussed in this podcast include <a rel="nofollow noreferrer noopener" target="_blank" href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0152285">A Systematic Assessment of Smartphone Tools for Suicide Prevention</a> and <a rel="nofollow noreferrer noopener" target="_blank" href="http://www.jmir.org/2015/8/e198/">Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality</a></li></ul></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"></div><div class="jsx-19ede9f0a5a45918 py-4 relative 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Bender, PharmD, MA</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/saint-itbs-protocol-shows-promise-for-bipolar-i-depression?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 gap-x-4"><a class="jsx-ad50481d5ee26850" href="/view/dont-fear-older-medications-and-treatments-for-our-senior-patients?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/d41a0f9b8e8701c71a0f100ad08e469352e7ee0a-4146x1969.jpg?fit=crop&auto=format" alt="older woman" width="288" class="jsx-ad50481d5ee26850 lg:w-[110px] lg:h-[100px] xl:w-[135px] xl:h-[125px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full xl:w-[70%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">October 22nd 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/dont-fear-older-medications-and-treatments-for-our-senior-patients?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent">Don't Fear Older Medications and Treatments for Our Senior Patients</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/elizabeth-varas-md">Elizabeth A. Varas, MD</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/dont-fear-older-medications-and-treatments-for-our-senior-patients?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div></div></div></div><div class="pb-24"></div></div><script type="application/ld+json">{"@context":"https://schema.org","@type":"NewsArticle","headline":"Apps for Mental Health Care: Benchmarks of Effectiveness","datePublished":"2016-08-09T19:58:58Z","dateModified":"2020-11-16T03:10:57Z","inLanguage":"en-US","image":"https://cdn.sanity.io/images/0vv8moc6/psychtimes/43dacc1f4e3b767d07a561c69315c57fd686b678-351x206.jpg?fit=crop&auto=format","mainEntityOfPage":{"@type":"WebPage","@id":"https://www.psychiatrictimes.com/view/apps-mental-health-care-benchmarks-effectiveness"},"publisher":{"@type":"Organization","name":"Psychiatric Times","logo":{"@type":"ImageObject","url":"https://www.psychiatrictimes.com/PsychiatricTimesLogo.png"}},"keywords":"Telepsychiatry,Bipolar Disorder","articleBody":"\n\n \n\nTraditionally a benchmark of scientific evidence, randomized controlled trials (RCTs) are often unsuited for the fast-paced, open environment of smartphone apps and other mobile technology research.\n\nSo how can mobile health (mHealth) adapt to ensure it is evidence based and rigorously validated? Dr John Torous discusses these issues with researcher and PhD student, Jennifer Nicholas, BSc(Hons) BA.\n\nSummarizing the main points of the interview, Ms Nicholas explains:\n\nThe vast majority of apps for mental health are of poor scientific quality\n\nCurrent research methodologies may be contributing to the shortage of high-quality apps\n\nmHealth research needs to explore different ways of creating, testing, and disseminating apps\n\nAbout the speakers:\n\nMs Nicholas studies mobile mental health, with a focus on bipolar disorders, at the Black Dog Institute in Australia. Dr Torous is a Clinical Fellow in Psychiatry at Harvard Medical School and Senior Resident at the Harvard Longwood Psychiatry Residency Training Program in Boston. He is the Digital Psychiatry Editor for Psychiatric Times. Twitter: @JohnTorousMD. The speakers report no conflicts of interest concerning the subject matter of this podcast.\n\nFurther reading:\n\nAn important article by Ms Nicholas on this topic: mHealth in Psychiatry: Time for Methodological Change\n\nPapers discussed in this podcast include A Systematic Assessment of Smartphone Tools for Suicide Prevention and Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality","description":"A podcast on the role of randomized controlled trials in mobile mental health research. 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"}],"_type":"block","style":"normal","_key":"0DkUFYLL"},{"markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"marks":[],"text":"Traditionally a benchmark of scientific evidence, randomized controlled trials (RCTs) are often unsuited for the fast-paced, open environment of smartphone apps and other mobile technology research.","_key":"FWKGDR4s","_type":"span"}],"_type":"block","style":"normal","_key":"TdVjvXm7"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"So how can mobile health (mHealth) adapt to ensure it is evidence based and rigorously validated? Dr John Torous discusses these issues with researcher and PhD student, Jennifer Nicholas, BSc(Hons) BA.","_key":"5PttsnXl"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"CPWZVqJK"},{"style":"normal","_key":"1mov1Sbh","markDefs":[],"children":[{"marks":[],"text":"Summarizing the main points of the interview, Ms Nicholas explains:","_key":"Wnx62zQo","_type":"span"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null},{"markDefs":[],"children":[{"text":"The vast majority of apps for mental health are of poor scientific quality","_key":"FFVuba4F","_type":"span","marks":[]}],"level":1,"_type":"block","upload_doc":null,"style":"normal","_key":"6fkqpcID","listItem":"bullet","uploadAudio":null,"medias":null},{"style":"normal","listItem":"bullet","children":[{"_type":"span","marks":[],"text":"Current research methodologies may be contributing to the shortage of high-quality apps","_key":"g05vzU3d"}],"level":1,"upload_doc":null,"_type":"block","_key":"Sa0XVJW2","markDefs":[],"uploadAudio":null,"medias":null},{"children":[{"marks":[],"text":"mHealth research needs to explore different ways of creating, testing, and disseminating apps","_key":"FMKmQB5s","_type":"span"}],"style":"normal","uploadAudio":null,"medias":null,"upload_doc":null,"_key":"E7Vapqfj","listItem":"bullet","markDefs":[],"level":1,"_type":"block"},{"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"About the speakers:","_key":"rKms8Xp4"}],"_type":"block","style":"normal","_key":"ZWTWissN","upload_doc":null},{"upload_doc":null,"uploadAudio":null,"medias":null,"_key":"QSHg3QWn","markDefs":[{"href":"http://www.blackdoginstitute.org.au","_key":"href_1582641648952789064","blank":true,"_type":"link"},{"href":"https://twitter.com/JohnTorousMD","_key":"href_1582641648609885415","blank":true,"_type":"link"}],"children":[{"marks":[],"text":"Ms Nicholas studies mobile mental health, with a focus on bipolar disorders, at the ","_key":"TE9PtXqj","_type":"span"},{"_type":"span","marks":["href_1582641648952789064"],"text":"Black Dog Institute in Australia","_key":"Tu5Ajsdp"},{"marks":[],"text":". Dr Torous is a Clinical Fellow in Psychiatry at Harvard Medical School and Senior Resident at the Harvard Longwood Psychiatry Residency Training Program in Boston. He is the Digital Psychiatry Editor for ","_key":"7TbXJkiq","_type":"span"},{"_type":"span","marks":["em"],"text":"Psychiatric Times.","_key":"V5pzNake"},{"_type":"span","marks":[],"text":" Twitter: ","_key":"Ip2sdhSB"},{"_type":"span","marks":["href_1582641648609885415"],"text":"@JohnTorousMD","_key":"4H7DGWiF"},{"_type":"span","marks":[],"text":". The speakers report no conflicts of interest concerning the subject matter of this podcast.","_key":"CDQPSxRR"}],"_type":"block","style":"normal"},{"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":["strong"],"text":"Further reading:","_key":"SXZobu6P"}],"_type":"block","style":"normal","_key":"KEKKONTE","markDefs":[]},{"upload_doc":null,"uploadAudio":null,"_type":"block","style":"normal","markDefs":[{"blank":true,"_type":"link","href":"http://ebmh.bmj.com/content/19/2/33.full","_key":"href_1582641648989107172"}],"children":[{"_type":"span","marks":[],"text":"An important article by Ms Nicholas on this topic: ","_key":"qoDVmRgV"},{"_key":"8SgerlKb","_type":"span","marks":["href_1582641648989107172"],"text":"mHealth in Psychiatry: Time for Methodological Change"}],"level":1,"medias":null,"_key":"OCCasaAM","listItem":"bullet"},{"_key":"LK9gxxtB","upload_doc":null,"uploadAudio":null,"medias":null,"level":1,"_type":"block","style":"normal","listItem":"bullet","markDefs":[{"blank":true,"_type":"link","href":"http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0152285","_key":"href_1582641648627054184"},{"_key":"href_1582641648641846237","blank":true,"_type":"link","href":"http://www.jmir.org/2015/8/e198/"}],"children":[{"_type":"span","marks":[],"text":"Papers discussed in this podcast include ","_key":"cEsuLaVY"},{"_type":"span","marks":["href_1582641648627054184"],"text":"A Systematic Assessment of Smartphone Tools for Suicide Prevention","_key":"PRu7Eb7S"},{"text":" and ","_key":"t6E9Ci9r","_type":"span","marks":[]},{"_type":"span","marks":["href_1582641648641846237"],"text":"Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality","_key":"nD4ZwaCD"}]}],"authorMapping":[{"displayName":"John Torous, MD, MBI","_createdAt":"2020-02-21T11:23:21Z","_rev":"pI9SawGKsTP14Lioy52fLS","_type":"author","company":"krugman associates","_id":"pst_author_324880","_updatedAt":"2020-08-21T07:23:47Z","url":{"current":"john-torous-md-mbi","_type":"slug"}}],"summary":"A podcast on the role of randomized controlled trials in mobile mental health research. 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As the author admits, he has no academic credentials in this area, but his years of work, meticulous pursuit of credible knowledge, his level of integration, and his personal and determined experiences deserve some academic institution granting him an honorary degree.","_key":"ce0675d2a2671"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"7165516e562a","markDefs":[],"children":[{"text":"","_key":"85ed147dff030","_type":"span","marks":[]}]},{"style":"normal","_key":"96295e7154b0","markDefs":[],"children":[{"_type":"span","marks":[],"text":"While Blackwell recognizes the necessity of psychiatric medications for many individuals with a bipolar diagnosis, he suggests that a significant number of them may be able to resolve their disorder using specific somatic practices which focus on “healing” (a word we almost never hear in psychiatric circles) life trauma, which he believes is the root cause of many disorders. With this claim, the challenge would be for him to work with an experienced psychiatrist to assess whether they think the disorder in specific patients is biological or psychological, which was not the case for Blackwell’s work. However, my addiction psychiatry practice affirms that about half of all clients that come to me with a bipolar disorder diagnosis are incorrectly diagnosed. His alternative explanation that many are trauma related and possibly spiritually related is fully consistent with my clinical experience and judgment. 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In some ways, his work affirms Loren Mosher, MD’s Soteria House","_key":"3cf892ab1fb2","_type":"span"},{"_key":"7d09619b9438","_type":"span","marks":["superscript"],"text":"2"},{"_type":"span","marks":[],"text":" model of “being with” the individual with bipolar-related experiences and recognizing that there is an internal healing process that can be facilitated. He draws on work neglected by mainstream psychiatry of Stanislav Grof, MD,","_key":"165c1d012c97"},{"_type":"span","marks":["superscript"],"text":"3","_key":"08d4448596c2"},{"_type":"span","marks":[],"text":" highlighting the relationship of psychosis symptoms with spiritual experiences that may intensify to spiritual emergency if poorly understood or poorly handled. Though Blackwell connects with current knowledge of the abuses of the mental health system with incorrect diagnoses, as recently exposed by such authors as Robert Wipond,","_key":"c54ffe746d79"},{"_type":"span","marks":["superscript"],"text":"4","_key":"542a5a55ca96"},{"_type":"span","marks":[],"text":" he is not antipsychiatry. His critical message is that it is time for psychiatry and mental health to support the awareness of spiritual experience that was opened up with the exploration of the unconscious but missed by Sigmund Freud.","_key":"955397fd3ec8"},{"_type":"span","marks":["superscript"],"text":"1","_key":"8dd12faa5f3a"},{"_type":"span","marks":[],"text":" Assessment and understanding are presented within the psycho-spiritual developmental framework of Ken Wilber,","_key":"c8847f6bc6a2"},{"marks":["superscript"],"text":"5","_key":"7b72edddb4cd","_type":"span"},{"_key":"d637a1274a02","_type":"span","marks":[],"text":" that suffices but complicates some matters and requires further exploration. More simply stated, lower cognitive-psychological function and more severe trauma are related to schizophrenia spectrum problems, and higher cognitive-psychological development and less trauma are related to more spiritual emergency type problems. Bipolar disorder is often in between these extremes ("},{"_type":"span","marks":["strong"],"text":"Figure 1","_key":"3c4c13ea18711"},{"_type":"span","marks":[],"text":").","_key":"3c4c13ea18712"}]},{"disableTextWrap":false,"widthP":49,"disableLightBox":true,"_type":"figure","_key":"4894f4987b45","imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure 1.","_key":"77df132a751d"},{"_type":"span","marks":[],"text":" The Spectrum of “Psychosis/Spiritual Emergency” Experiences","_key":"abe0d3df2006"}],"_type":"block","style":"normal","_key":"59666de02074"}],"alignment":"right","asset":{"_ref":"image-93ba6c055a7bde7601ccec5d18fe5544ec334464-788x479-jpg","_type":"reference"},"blank":true,"alt":"igure 1. 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His journey provides great teaching material for trainees in psychiatry, psychology, and mental health settings.","_key":"7d3d1c3d74a20"}],"_type":"block"},{"_key":"8482bda34b1d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"183561a988a30"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"029e76178a64","markDefs":[],"children":[{"text":"Blackwell’s greatest contributions to psychiatry and the mental health field are 3 revolutionary ideas and 3 revolutionary methods that must be taken seriously and merit psychiatry’s attention. Remember that these ideas and methods are for persons with these problems that are not the biogenetic/medical cases with proper diagnoses.","_key":"a81f4fd1e3a00","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"92a030c06315","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4004c617f9e60"}]},{"_key":"f16856ba5eab","markDefs":[],"children":[{"text":"Revolutionary Idea #1","_key":"34b8d10d108e0","_type":"span","marks":["strong"]}],"_type":"block","style":"normal"},{"style":"normal","_key":"4c58fb348c27","markDefs":[],"children":[{"text":"Spiritual experience and spiritual emergency must be included in mainstream psychiatry. Spiritual experience is real, common, important, and is often connected with mental disorder symptoms. Recent work with psychedelics has made this even more evident.","_key":"f70f67863c2d0","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"6","_key":"63a69e6694d4"},{"_key":"2382f8a08b1f","_type":"span","marks":[],"text":" Spiritual experiences can be intense, and when misunderstood or mishandled, progress to spiritual emergency which may have psychosis symptoms—but not be a mental disorder."}],"_type":"block"},{"_type":"block","style":"normal","_key":"0f139e7a294f","markDefs":[],"children":[{"text":"","_key":"88bd1155df260","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"“Whether experienced as a blissful dream, a paranoid nightmare, or a mix of both, the source of what psychiatry labels an “acute psychosis” is (","_key":"ffe2bc6f72b90"},{"_type":"span","marks":["em"],"text":"may be","_key":"ffe2bc6f72b91"},{"_type":"span","marks":[],"text":") our natural spiritual dimension. This dimension is possessed by every living being, regardless of their belief system.”(Italics added by reviewer)","_key":"ffe2bc6f72b92"}],"_type":"block","style":"normal","_key":"cb99fcd069fe"},{"markDefs":[],"children":[{"text":"","_key":"e0a495540e180","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"91b14a9fe940"},{"_type":"block","style":"normal","_key":"7ec6a20e54e1","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Revolutionary Idea #2","_key":"ce248b6cf7730"}]},{"children":[{"_type":"span","marks":[],"text":"Schizophrenia, bipolar disorder, and spiritual emergency are part of a spectrum of human experience (in many, but not all cases) that is directly related to severity of life traumas (","_key":"8c6573c0a7610"},{"_type":"span","marks":["strong"],"text":"Figure 2","_key":"8c6573c0a7611"},{"_type":"span","marks":[],"text":"). His explanation and examples of this are detailed and credible, providing further support for revolutionary idea #1.","_key":"8c6573c0a7612"}],"_type":"block","style":"normal","_key":"df6158dfb94f","markDefs":[]},{"asset":{"_ref":"image-c5bca3b0a67ce0cb2dd3c5c7530f72258699b304-390x298-jpg","_type":"reference"},"widthP":50,"alignment":"right","disableTextWrap":false,"_type":"figure","alt":"Figure 2. The Relationship Between Diagnosis, Consciousness, and Trauma","blank":true,"disableLightBox":true,"imgcaption":[{"_type":"block","style":"normal","_key":"df97be560489","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure 2.","_key":"169e516f42730"},{"_type":"span","marks":[],"text":" The Relationship Between Diagnosis, Consciousness, and Trauma","_key":"169e516f42731"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The axis of consciousness comes from Wilber’s theory as a model of cognitive-psycho-spiritual development.","_key":"7b3831cdaac3"}],"_type":"block","style":"normal","_key":"29a55951c01d"}],"_key":"b802ef5df5ef"},{"_key":"937bb190fd9d","markDefs":[],"children":[{"_key":"6da79b8b78b40","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"_key":"df582f1a455d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Revolutionary Idea #3","_key":"cd609a6182e10"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"An ever-present spiritual core is holotropic (drives to wholeness) and has natural healing abilities. Blackwell (as attributed originally to Stanislav Grof) calls it an “Inner Healer” that with processes described facilitate its coming forward from within the patient and provides emotional and sometimes physical symptom healing. My work has fully confirmed this idea","_key":"cd6b8ddbac010"},{"_type":"span","marks":["superscript"],"text":"1,7","_key":"29c46d4055fb"},{"_key":"ff22896a167d","_type":"span","marks":[],"text":" and is successfully being applied in a residential treatment setting."}],"_type":"block","style":"normal","_key":"e68f419ca52c"},{"_key":"9b5ac5015d0a","markDefs":[],"children":[{"_key":"8467e0e7596d0","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"Revolutionary Method #1","_key":"9d18203a38d10"}],"_type":"block","style":"normal","_key":"8e71a14174b8","markDefs":[]},{"markDefs":[{"href":"https://www.psychiatrictimes.com/topics/schizophrenia","_key":"a80d24ef38bc","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"Holotropic Breathwork","_key":"9714837d6aa30"},{"marks":["superscript"],"text":"TM","_key":"2b2cdffe8696","_type":"span"},{"_type":"span","marks":[],"text":" (developed by Stanislav Grof) for psychosis and bipolar disorder is possible and can be very effective. Holotropic Breathwork is a way of being with a client, and through voluntary over-breathing in a safe setting, opens a trance-like state that facilitates awareness of life events, especially those that are trauma-related, that can then be processed therapeutically. Until now, Holotropic Breathwork has had bipolar disorder and ","_key":"a31f1db0dfce"},{"_type":"span","marks":["a80d24ef38bc"],"text":"psychosis","_key":"6ab4548c40a4"},{"_type":"span","marks":[],"text":" as contraindications for its application. However, with a few security-related enhancements to the standard Holotropic Breathwork practice, Blackwell has described encouraging results when working with carefully screened clients in a private retreat setting. Psychotropic medication use can be included but must be assessed on each individual case related to severity of symptoms, timing of recent episodes, impact on cognition and emotional awareness, and current adverse effects.","_key":"ab0db11bb890"}],"_type":"block","style":"normal","_key":"7010b9d0e69a"},{"children":[{"_type":"span","marks":[],"text":"","_key":"b74d6515598b0"}],"_type":"block","style":"normal","_key":"36999f01c760","markDefs":[]},{"style":"normal","_key":"a70a2c9b0aa6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I will alert the reader that there are elements of Holotropic Breathworkthat will be easy to dismiss, especially when it comes to a focus on birth-trauma. Grof’s birth-trauma theories are not accepted by mainstream psychiatry or psychology, but are widely acknowledged within transpersonal circles as one of his great discoveries. I would just urge readers to know that Holotropic Breathworkis a very effective treatment, so do not throw out the baby-trauma with the bathwater. I am presenting these ideas now as I think psychiatry and the American Psychiatric Association (APA) are at a turning point in accepting the power of spirituality.","_key":"b16d436b5bde0"}],"_type":"block"},{"_key":"e97e64d15614","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"d0d5118a13e80"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"65ea78c2308b0","_type":"span","marks":["strong"],"text":"Revolutionary Method #2"}],"_type":"block","style":"normal","_key":"d708b54cff84"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Surrogate breathwork (being done by a trained person such as a facilitator either with or separate from the patient) can be similarly effective.","_key":"0229e017e3780"}],"_type":"block","style":"normal","_key":"f0a148a21eb7"},{"children":[{"text":"","_key":"b05158ec2eef0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"d98ca35234c4","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"Since this amounts to psychiatric heresy, I realize I am placing my reputation as an APA Distinguished Life Fellow in jeopardy with fear of ex-communication! Blackwell postulates a “Healing Field” that is beyond the Inner Healer of our spiritual core that can operate from a distance. To have you think that this is not so far into heresy, respected anthropologist Michael Harner, PhD’s","_key":"a7681724e1500","_type":"span"},{"_type":"span","marks":["superscript"],"text":"8","_key":"5fa0c58688e3"},{"_type":"span","marks":[],"text":" contemporary core shamanism instructs students in ways of connecting with this nonordinary spirit experience for promoting healing in a partner.","_key":"cec0aad12381"}],"_type":"block","style":"normal","_key":"ba0d74d36d6d"},{"_type":"block","style":"normal","_key":"a743595cb613","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"e161729e4e400"}]},{"_type":"block","style":"normal","_key":"0b975d13ad7b","markDefs":[],"children":[{"_key":"2fe51141850e0","_type":"span","marks":[],"text":"Nevertheless, this is a hard one for me to get my mind around. Even with, as I have publicly presented, my own personal experiences of dealing with family members with medication-responsive bipolar disorder; my own medication responsive major depressive disorder; an episode of psychosis resolved in 1 session with a good psychoanalyst; and my multiple ecstatic reality challenging, non-drug related personal spiritual experiences, the presence of a “Healing Field” has escaped my experience. In defense of identifying this as a revolutionary method, after many hours of meeting and talking with Blackwell—who is one of the most science-grounded, rational, open-minded, and nondogmatic therapists I have met—his description of these experiences appears compelling enough for me to make this statement. You must read this book and judge for yourself."}]},{"markDefs":[],"children":[{"text":"","_key":"2de50a2feb190","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"b5edd334d91b"},{"_key":"c66018c0bff8","markDefs":[],"children":[{"_key":"eea23b5be9a10","_type":"span","marks":[],"text":"Additionally, anyone that has not had their own personal nonordinary spiritual experience can easily dismiss this entire book as “quackery.” Similarly, anyone that has not had the experiences Blackwell describes about surrogate breathwork, distance healing, and shamanism will almost surely dismiss these ideas based on our materialist grounding. (I do wish he would change the term quantum shamanism to transcendent shamanism or something else. Quantum theory has nothing to do with these macro-level experiences.) Before dismissing these ideas, please read the final words of this review"}],"_type":"block","style":"normal"},{"style":"normal","_key":"fdd3a5f7371a","markDefs":[],"children":[{"_key":"d8a93ff5659b0","_type":"span","marks":[],"text":""}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Revolutionary Method #3","_key":"77fe8c8810c40"}],"_type":"block","style":"normal","_key":"31c365c28358"},{"style":"normal","_key":"0ce180fccfc9","markDefs":[],"children":[{"_key":"accca47718c50","_type":"span","marks":[],"text":"Conscious emotional clearing, the use of body sensations related to trauma-related emotions that when properly processed promote healing. Though this may not be as revolutionary as the other choices, and may be an extension of Bessel Van der Kolk, MD’s"},{"_type":"span","marks":["superscript"],"text":"9","_key":"a1736ce69585"},{"_type":"span","marks":[],"text":" work, I include it here as this would be considered revolutionary if adopted by the mainstream psychiatric community.","_key":"617dd9f34f44"}],"_type":"block"},{"markDefs":[],"children":[{"text":"","_key":"42c557266adc0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"a746a128e33c"},{"_type":"block","style":"normal","_key":"01ecc5ae619b","markDefs":[],"children":[{"_key":"4d5688a2b1630","_type":"span","marks":[],"text":"In support of my conclusions, I will add that we now have a clear understanding of this spiritual core and how it is psychologically organized within human experience."},{"_type":"span","marks":["superscript"],"text":"1","_key":"b231663dabc2"},{"_type":"span","marks":[],"text":" Clinically we have evidence of how being with the person can open this spiritual core to provide transformational growth with healing and often a new sense of meaning and purpose and faith in life.","_key":"ef87358461b4"}]},{"style":"normal","_key":"9ba930cbf2ae","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"e312fb6baef80"}],"_type":"block"},{"style":"normal","_key":"afcc4dac1d60","markDefs":[{"_key":"17b26c9a387f","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/ptsd"}],"children":[{"_type":"span","marks":[],"text":"Beyond these important psychiatric considerations, Blackwell’s journey is engagingly presented with authentic and self-exposing detail that will provide “grist for the mill” that hopefully will help the APA, psychiatry, and mental health be awakened to these truths. In a closing chapter, Blackwell presents a blueprint of how he imagines his somatic healing processes could possibly work in cooperation with mainstream psychiatry. He also opens a door for the fascinating exploration of his claims with potentially life-changing results. At the least, I hope that this book would lead to all future studies being done on bipolar disorder and schizophrenia including a full trauma assessment beyond excluding or assessing just for ","_key":"0b31a153a2770"},{"marks":["17b26c9a387f"],"text":"posttraumatic stress disorder","_key":"273d5866fa17","_type":"span"},{"text":".","_key":"3fd2a69365d5","_type":"span","marks":[]}],"_type":"block"},{"_key":"a8063fd718ad","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"48f477894ed30"}],"_type":"block","style":"normal"},{"_key":"c81c2a21e84a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"These final words are to anyone that has had personal spiritual experiences and explored the absolutely real, irrational, archetypal, dream-like experiences, and healing powers of our spiritual core who may help psychiatry enter a new dimension of true healing of the psyche/soul. This book is an invitation to step forward and be heard. It is also an invitation to those who have not had spiritual experiences to not dismiss them, but to engage in processes of self-discovery for one of the greatest adventures of your personal and professional life. Open-mindedness, open-heartedness, and open-handedness are the source of our creative forces.","_key":"dd4c64ba6fc50"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"cb8b3cf77cf6","markDefs":[],"children":[{"marks":[],"text":"","_key":"21bb01b42f080","_type":"span"}]},{"markDefs":[],"children":[{"text":"Dr Chatlos ","_key":"d30bfbbcafd80","_type":"span","marks":["strong"]},{"marks":["em"],"text":"is medical director of the Avatar Residential Detox Center in NJ, and professor of psychiatry at the Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ. He is an addiction, child and adolescent, and adult psychiatrist working with spiritual principles in his practice for over 30 years. He is the originator of a “Framework of Spirituality” that describes how spiritual experience is psychologically organized in human experience and has developed successful intervention techniques to address the “spirit/soul” experience. He is an APA Distinguished Life Fellow.","_key":"d30bfbbcafd81","_type":"span"}],"_type":"block","style":"normal","_key":"ce8652efe99c"},{"style":"normal","_key":"50e7f46b211e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"100eca80a2500"}],"_type":"block"},{"children":[{"marks":["strong"],"text":"References","_key":"6b1561ff311f0","_type":"span"}],"_type":"block","style":"normal","_key":"d0c80b89d491","markDefs":[]},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.mdpi.com/2077-1444/14/2/282","_key":"31317f25b169"}],"children":[{"_type":"span","marks":[],"text":"1. Chatlos JC. ","_key":"1ed0d9d67b560"},{"marks":["31317f25b169"],"text":"Did Freud miss the discovery of our spiritual core?","_key":"1ed0d9d67b561","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"9b2dc124125c"},{"_type":"span","marks":["em"],"text":"Religions.","_key":"1ed0d9d67b562"},{"_type":"span","marks":[],"text":" 2023;14(2):282-306.","_key":"1ed0d9d67b563"}],"_type":"block","style":"normal","_key":"5224c3a34e7f"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Mosher L. Hendrix V. ","_key":"932acdcf91750"},{"_type":"span","marks":["em"],"text":"Soteria: Through Madness to Deliverance","_key":"932acdcf91751"},{"_type":"span","marks":[],"text":". Xlibris Corp; 2004.","_key":"932acdcf91752"}],"_type":"block","style":"normal","_key":"b6fed0cd0e6f"},{"children":[{"_type":"span","marks":[],"text":"3. Grof S. Psychology for the future: lessons from modern consciousness research. ","_key":"5299510d89360"},{"_type":"span","marks":["em"],"text":"Spirituality Studies. ","_key":"5299510d89361"},{"_key":"5299510d89362","_type":"span","marks":[],"text":"2016;2(1):3-36."}],"_type":"block","style":"normal","_key":"d6c52c3db0f3","markDefs":[]},{"_key":"142ed4fb2c5f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. Wipond R. ","_key":"9979fd4a081d0"},{"text":"Your Consent Is Not Required: The Rise in Psychiatric Detentions, Forced Treatment, and Abusive Guardianships","_key":"9979fd4a081d1","_type":"span","marks":["em"]},{"text":". BenBella Books; 2023.","_key":"9979fd4a081d2","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"style":"normal","_key":"e875c0728a16","markDefs":[],"children":[{"_type":"span","marks":[],"text":"5. Wilber K. ","_key":"6a6fff9b18440"},{"_type":"span","marks":["em"],"text":"Integral Spirituality: A Startling New Role for Religion in the Modern and Postmodern World","_key":"6a6fff9b18441"},{"text":". 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A lot, as you will see in this podcast, but it depends on what time of day it is shining.","_key":"42ef81dde900","_type":"span"}],"_type":"block","style":"normal","_key":"0ce7ac78ec27","markDefs":[]},{"_type":"block","style":"normal","_key":"c3b8c78f0b23","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Welcome to ","_key":"cf7c6d416e77"},{"_key":"421a89ac820f","_type":"span","marks":["em"],"text":"PsychPearls"},{"_type":"span","marks":[],"text":" podcast with ","_key":"658381dface0"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"0b34a41d150b"},{"marks":["superscript"],"text":"TM","_key":"f1c17b9b6f6d","_type":"span"},{"_key":"09b937be1cc2","_type":"span","marks":[],"text":", the Voice of Psychiatry. With thoughtful insights into the world of mental health, this podcast provides timely clinical commentary and practical cutting-edge pearls for you and your practice. We hope you enjoy."}]},{"style":"normal","_key":"39ad44d598f1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I am Chris Aiken, the Mood Disorders Section Editor for ","_key":"45f747d6d2870"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"45f747d6d2871"},{"_type":"span","marks":["superscript"],"text":"TM","_key":"45f747d6d2872"},{"_type":"span","marks":[],"text":" and the editor-in-chief of the ","_key":"32b93f150fca"},{"_type":"span","marks":["em"],"text":"Carlat Psychiatry Report","_key":"45f747d6d2873"},{"_type":"span","marks":[],"text":", and I am Kellie Newsome, a psychiatric NP and the cohost of the ","_key":"45f747d6d2874"},{"marks":["em"],"text":"Carlat Psychiatry Podcast","_key":"45f747d6d2875","_type":"span"},{"_type":"span","marks":[],"text":".","_key":"45f747d6d2876"}],"_type":"block"},{"_type":"block","style":"normal","_key":"239eecfdf79a","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/27003509/","_key":"bac1b3c2ef23","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"d1455b93455a0"},{"marks":[],"text":": The biological clock is set by the daily rhythms of light and dark – morning sunrise and evening sunset. And this clock is so integral to bipolar disorder that you could almost rename it ","_key":"d1455b93455a1","_type":"span"},{"_type":"span","marks":["em"],"text":"fragile circadian rhythm disorder","_key":"d1455b93455a2"},{"_type":"span","marks":[],"text":". Actually, patients prefer that name over bipolar disorder, and it gets to the heart of the problem. Bipolar is tightly linked to the genes that regulate the biological clock, and lithium actually ","_key":"d1455b93455a3"},{"_type":"span","marks":["bac1b3c2ef23"],"text":"helps repair","_key":"d1455b93455a4"},{"_type":"span","marks":[],"text":" the clock by altering the expression of those genes.1 Many of the behavioral therapies for bipolar disorder, like dark therapy and social rhythm therapy, also work through the biological clock, helping patients to keep it running smoothly by regulating their exposure to light, darkness, and the timing of daily activities.","_key":"d1455b93455a5"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/31752508/","_key":"ed28a788ed94"},{"href":"https://pubmed.ncbi.nlm.nih.gov/22928852/","_key":"ed3b68891817","blank":true,"_type":"link"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/9491067/ ","_key":"ee35d391dbe3"},{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33445959/","_key":"b4a08f32b065","blank":true},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/28327443/","_key":"0800ecbbb104"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33511988/","_key":"557de951cfbb"}],"children":[{"text":"But bipolar is not the only mental illness that is linked to disrupted circadian rhythms. ","_key":"b00f7a39ed7d0","_type":"span","marks":[]},{"_type":"span","marks":["ed28a788ed94"],"text":"Unipolar depression","_key":"b00f7a39ed7d1"},{"_type":"span","marks":[],"text":" is as well, though to a lesser extent – for example, rates of circadian rhythm disorders like the phase-delay night owl syndrome are more common in bipolar and unipolar, but they are about 20% less common in unipolar. And research is exploring circadian rhythm therapies in ","_key":"b00f7a39ed7d2"},{"_key":"b00f7a39ed7d3","_type":"span","marks":["ed3b68891817"],"text":"borderline personality disorder,"},{"_type":"span","marks":[],"text":" ","_key":"a3bc99ec315c"},{"_type":"span","marks":["ee35d391dbe3"],"text":"substance use disorders","_key":"b00f7a39ed7d4"},{"_key":"b00f7a39ed7d5","_type":"span","marks":[],"text":", "},{"_type":"span","marks":["b4a08f32b065"],"text":"schizophrenia","_key":"b00f7a39ed7d6"},{"_type":"span","marks":[],"text":", ","_key":"b00f7a39ed7d7"},{"_type":"span","marks":["0800ecbbb104"],"text":"ADHD","_key":"b00f7a39ed7d8"},{"_type":"span","marks":[],"text":", and ","_key":"b00f7a39ed7d9"},{"_key":"b00f7a39ed7d10","_type":"span","marks":["557de951cfbb"],"text":"PTSD"},{"_type":"span","marks":[],"text":".","_key":"b00f7a39ed7d11"}],"_type":"block","style":"normal","_key":"8e6c07968206"},{"style":"normal","_key":"0c418fb55b98","markDefs":[],"children":[{"_type":"span","marks":[],"text":"But while researching is advancing in the circadian direction, society is moving the other way. Indoor living and nocturnal light are dampening the natural signals that set the biological clock, and there is evidence that this is causing harm in our patients. In this podcast, we will explore those dangers, but first a little background on how light – and in particular blue light – set the biological clock.","_key":"59f29b8144ed0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Blue Light and Melatonin","_key":"ce5ee2435bd30"}],"_type":"block","style":"normal","_key":"6832c40ad7fd"},{"style":"normal","_key":"bf3cea22e1fa","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"f0ba9bbf432b0"},{"_type":"span","marks":[],"text":" Light suppresses melatonin, but not just any light. It is the color that matters here, and blue light in the 460-480 nm range is particularly good at suppressing melatonin and promoting wakefulness. In the 1990s, a new photoreceptor called melanopsin was discovered that only responds to blue light, and it is this receptor that regulates melatonin production through the suprachiasmatic nucleus, the time-keeper of the biological clock.","_key":"f0ba9bbf432b1"},{"_type":"span","marks":["superscript"],"text":"2","_key":"cab007c80519"}],"_type":"block"},{"children":[{"marks":[],"text":"What that means is that the body’s internal clock depends on strong shifts in blue-spectrum light at the bookends of the day: morning and night. High levels of evening blue light, and low levels in the morning, disrupt not just circadian rhythms but also the clock genes implicated in bipolar and other psychiatric disorders.","_key":"8e973d72ce5b0","_type":"span"},{"marks":["superscript"],"text":"3,4","_key":"6007e3d8e849","_type":"span"}],"_type":"block","style":"normal","_key":"a03b7244f79a","markDefs":[]},{"style":"normal","_key":"89a43ad76a43","markDefs":[],"children":[{"text":"The main source of that blue light are electronic gadgets that were not available 20 years ago. Smart phones, LED screens, and energy-efficient bulbs emit a blue haze of light that is very different from the yellow starlight that we evolved under. This light may look white, like fluorescent bulbs, but white light has a lot of the blue wavelength within it. Distance also matters here. A cell phone close to your face emits about as much blue light as a large screen TV across the living room.","_key":"d8c6c0455f100","_type":"span","marks":[]}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN","_key":"fdf67374f36d0"},{"_type":"span","marks":[],"text":": The problem is not just psychiatric. Blue light is associated with physical health risks including obesity, diabetes, cancer, cardiovascular and neurologic diseases, gastrointestinal ulcers, and adverse reproductive outcomes.","_key":"fdf67374f36d1"},{"_type":"span","marks":["superscript"],"text":"5","_key":"921f7c9d5a0f"},{"marks":[],"text":" The American Medical Association released a ","_key":"0b634b6fc31b","_type":"span"},{"_type":"span","marks":["e505517b5683"],"text":"position statement","_key":"fdf67374f36d2"},{"marks":[],"text":" calling for reductions in nocturnal blue light, and psychiatry is catching on as well. The American Academy of Child and Adolescent Psychiatry updated their ","_key":"fdf67374f36d3","_type":"span"},{"_type":"span","marks":["9934cc4b7b79"],"text":"pediatric sleep recommendations","_key":"fdf67374f36d4"},{"_type":"span","marks":[],"text":" in 2018. They no longer recommend night lights for anxious children and instead emphasize elimination of blue-light sources in the bedroom. Child psychiatrists in Canada have even ","_key":"fdf67374f36d5"},{"text":"stronger recommendations","_key":"fdf67374f36d6","_type":"span","marks":["8d3959b7359f"]},{"_type":"span","marks":[],"text":".","_key":"fdf67374f36d7"}],"_type":"block","style":"normal","_key":"e3d412010de8","markDefs":[{"blank":true,"_type":"link","href":"https://www.ama-assn.org/ama-adopts-guidance-reduce-harm-high-intensity-street-lights","_key":"e505517b5683"},{"blank":true,"_type":"link","href":"https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Childrens-Sleep-Problems-034.aspx","_key":"9934cc4b7b79"},{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197518/","_key":"8d3959b7359f"}]},{"style":"normal","_key":"ca56139394bd","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"e4e192be989a0"},{"marks":[],"text":": It is the young and old that are most vulnerable to these light changes, as we will see in the research here.","_key":"e4e192be989a1","_type":"span"},{"_type":"span","marks":["superscript"],"text":"6,7","_key":"25ecc98efebf"},{"marks":[],"text":" But they are also the patients who are more likely to sleep with some lights on. So, if your patient needs a light at night – whether because of a childhood phobia or a fall risk – they can purchase amber nightlights that do not emit the blue wavelength.","_key":"dbc05e7bb744","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"5c36e1cc6f17","markDefs":[],"children":[{"marks":["strong"],"text":"A Slightly Broken Biological Clock","_key":"bd85a0227fe70","_type":"span"}]},{"style":"normal","_key":"41b0a3f52869","markDefs":[],"children":[{"marks":["strong"],"text":"CHRIS AIKEN","_key":"327d4b3110350","_type":"span"},{"_type":"span","marks":[],"text":": Psychiatric patients in general are more sensitive to the circadian disrupting effects of evening blue light, particularly patients with bipolar disorder. Melatonin is delayed, diminished, and more easily suppressed by blue light in these patients.","_key":"327d4b3110351"},{"_type":"span","marks":["superscript"],"text":"6","_key":"061e4cc8e525"},{"_key":"cc05a5b4574e","_type":"span","marks":[],"text":" Circadian disruptions often trigger new episodes of mania and depression, such as shift work, seasonal changes, and travel across multiple time zones."},{"_type":"span","marks":["superscript"],"text":"8","_key":"13c497d81396"}],"_type":"block"},{"_type":"block","style":"normal","_key":"463c9808423c","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"5d7ea200881d0"},{"_key":"5d7ea200881d1","_type":"span","marks":[],"text":": Travel across time zones is only a problem with air travel, because the clock has time to adjust when you travel by land or sea unless you are driving at 300 miles per hour. And on average it only causes problems when patients travel across 2 or more time zones. Mania is more common with west to east travel, and depression more likely when travelling east to west. A simple rhyme can help you remember it – west is depressed – because travelling westbound can trigger depression."}]},{"_type":"block","style":"normal","_key":"4510d4cf2335","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN","_key":"f86bd6a2eb6f0"},{"marks":[],"text":": We can add nocturnal blue light and ambient bedroom light to that list of circadian disruptors. Evening use of smartphones delays and reduces melatonin secretion, and impairs sleep and cognition with a medium effect size (0.5), which means the effect should be noticeable to the casual observer.","_key":"f86bd6a2eb6f1","_type":"span"},{"_type":"span","marks":["superscript"],"text":"9","_key":"3ec1792dafeb"},{"_key":"dae029234345","_type":"span","marks":[],"text":" A viscous cycle is at play here, as evening-types (night owls) have a greater tendency to use electronics at night, and that use independently shifts circadian rhythms toward the evening type (phase delay)."},{"_key":"cd909c8f133c","_type":"span","marks":["superscript"],"text":"6,10"},{"text":" The evening chronotype is prominent in adolescents, and being a night owl is a risk factor for bipolar disorder, depression, and substance abuse.","_key":"37db6879b3da","_type":"span","marks":[]},{"text":"8,10","_key":"f7c07077d71d","_type":"span","marks":["superscript"]}]},{"_type":"block","style":"normal","_key":"8c38f9e2c6ca","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Ambient bedroom light is also a problem, as it passes through the eyelids and suppresses melatonin during sleep. In controlled animal studies, ambient nocturnal light causes depression, impedes learning, and has detrimental effects on the brain. It lowers BDNF and shortens the dendritic spines that are essential for learning and cognition.","_key":"57545239954f0"},{"_type":"span","marks":["superscript"],"text":"11","_key":"95f4fdd946cd"}]},{"markDefs":[{"_type":"link","href":"http://www.psychiatrictimes.com/bipolar-disorder/new-tool-springtime-mania","_key":"4b9113897ed0"}],"children":[{"_type":"span","marks":[],"text":"The circadian system is also involved in critical periods of brain development, and disruptions of light signals may play a role in the onset of psychiatric illnesses as well as their exacerbation.","_key":"77863a8772a60"},{"_type":"span","marks":["superscript"],"text":"12","_key":"b2ae5bd61f74"},{"_type":"span","marks":[],"text":" When mice are exposed to nocturnal dim light as infants, they grow up to have more anxiety as adults.","_key":"6df7e43358a5"},{"_key":"228c72244b7c","_type":"span","marks":["superscript"],"text":"13"},{"_key":"e01792ee464a","_type":"span","marks":[],"text":" Human studies have found a strong link between rapid flux of "},{"_type":"span","marks":["4b9113897ed0"],"text":"spring sunlight","_key":"77863a8772a61"},{"_key":"77863a8772a62","_type":"span","marks":[],"text":" and earlier onset of bipolar disorder."},{"text":"14","_key":"cf783fc01f15","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"642d28d32295"},{"style":"normal","_key":"1b720ab37bf1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"A study from Japan illustrates the problem for our patients.15 They followed 863 older adults for several years, carefully measuring how much light they were exposed to in their bedrooms. On follow up, the risk of depression was directly correlated with how much light they were exposed to in their bedrooms. Those who slept in pitch darkness had the lowest risk, but what is interesting is how little light was necessary to accomplish the shift: 5 lux – which is equivalent to a night light – was the cut off. Those who slept with at least 5 lux in their bedroom had double the risk of depression 2 years later.","_key":"9ca95d3b62f00"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"That study was not controlled, although they attempted to control for confounders that might otherwise explain the association. But buried in the discussion was a sentence that struck me. The authors believed that the health risks of evening light are so well documented in animal and epidemiologic human studies that a controlled trial would be unethical in humans. In other words, we already know too much to learn anymore.","_key":"4451112aafd30"},{"marks":["superscript"],"text":"15","_key":"be8e396de3f7","_type":"span"}],"_type":"block","style":"normal","_key":"83db89ed004f"},{"style":"normal","_key":"b2332c2d3be4","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Instead, it is time for action, to educate our patients to follow the natural flow of day and night. That means bright light in the morning, low levels of blue light in the evening, and pitch dark in the bedroom. 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","_key":"98b5722a34790"},{"_type":"span","marks":["93993709451b"],"text":"Lithium and bipolar disorder: Impacts from molecular to behavioural circadian rhythms.","_key":"98b5722a34791"},{"_type":"span","marks":[],"text":" ","_key":"151382fb14ba"},{"_type":"span","marks":["em"],"text":"Chronobiol Int","_key":"98b5722a34792"},{"_type":"span","marks":[],"text":". 2016;33(4):351-373.","_key":"98b5722a34793"}],"_type":"block","style":"normal","_key":"fc6c28f6eaf0","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27003509/","_key":"93993709451b"}]},{"children":[{"marks":[],"text":"2. Charrier A, Olliac B, Roubertoux P, et al. ","_key":"7457352c71cd0","_type":"span"},{"_type":"span","marks":["aeabf5fd63f0"],"text":"Clock genes and altered sleep-wake rhythms: their role in the development of psychiatric disorders.","_key":"7457352c71cd1"},{"_type":"span","marks":[],"text":" ","_key":"32802a606af1"},{"_type":"span","marks":["em"],"text":"Int J Mol Sci","_key":"7457352c71cd2"},{"_type":"span","marks":[],"text":". 2017;18(5).","_key":"7457352c71cd3"}],"_type":"block","style":"normal","_key":"de1e42694d84","markDefs":[{"_key":"aeabf5fd63f0","blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/28468274"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/?term=Suicide+attempts+in+children+and+adolescents%3A+The+place+of+clock+genes+and+early+rhythm+dysfunction","_key":"79cc863ec6aa"}],"children":[{"marks":[],"text":"3. Olliac B, Ouss L, Charrier A. ","_key":"cebfb24003850","_type":"span"},{"_type":"span","marks":["79cc863ec6aa"],"text":"Suicide attempts in children and adolescents: The place of clock genes and early rhythm dysfunction.","_key":"cebfb24003851"},{"_key":"f55e5382b008","_type":"span","marks":[],"text":" "},{"_key":"cebfb24003852","_type":"span","marks":["em"],"text":"J Physiol Paris"},{"_type":"span","marks":[],"text":". 2016;110(4 Pt B):461-466.","_key":"cebfb24003853"}],"_type":"block","style":"normal","_key":"cf3c92f1fd91"},{"_key":"0810081cdc19","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/28724246","_key":"2e91685d13d9"}],"children":[{"_type":"span","marks":[],"text":"4. Lunn RM, Blask DE, Coogan AN, et al. ","_key":"740734e518100"},{"_type":"span","marks":["2e91685d13d9"],"text":"Health consequences of electric lighting practices in the modern world: A report on the National Toxicology Program's workshop on shift work at night, artificial light at night, and circadian disruption.","_key":"740734e518101"},{"_type":"span","marks":[],"text":" ","_key":"3360463e40d2"},{"_key":"740734e518102","_type":"span","marks":["em"],"text":"Sci Total Environ"},{"_key":"740734e518103","_type":"span","marks":[],"text":". 2017;607-608:1073-1084."}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/28487255 ","_key":"b9dd2cfc5e49"}],"children":[{"_key":"bc00b97dfba40","_type":"span","marks":[],"text":"5. Touitou Y, Touitou D, Reinberg A. "},{"text":"Disruption of adolescents' circadian clock: The vicious circle of media use, exposure to light at night, sleep loss and risk behaviors.","_key":"bc00b97dfba41","_type":"span","marks":["b9dd2cfc5e49"]},{"_type":"span","marks":[],"text":" ","_key":"13dc8227867e"},{"text":"J Physiol Paris","_key":"bc00b97dfba42","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 2016;110(4 Pt B):467-479.","_key":"bc00b97dfba43"}],"_type":"block","style":"normal","_key":"45c705ddd926"},{"_type":"block","style":"normal","_key":"660274ea41d4","markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/26241867","_key":"46f5a848049c","blank":true}],"children":[{"_key":"14a472567a270","_type":"span","marks":[],"text":"6. Abreu T, Bragança M. "},{"_key":"14a472567a271","_type":"span","marks":["46f5a848049c"],"text":"The bipolarity of light and dark: A review on bipolar disorder and circadian cycles."},{"_key":"01565363f132","_type":"span","marks":[],"text":" "},{"marks":["em"],"text":"J Affect Disord","_key":"14a472567a272","_type":"span"},{"_type":"span","marks":[],"text":". 2015;185:219-29.","_key":"14a472567a273"}]},{"children":[{"_type":"span","marks":[],"text":"7. Takaesu Y. ","_key":"b7b9a675830c0"},{"text":"Circadian rhythm in bipolar disorder: A review of the literature.","_key":"b7b9a675830c1","_type":"span","marks":["562fa2704f9b"]},{"text":" ","_key":"8a6c26aa8998","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"Psychiatry Clin Neurosci","_key":"b7b9a675830c2"},{"_type":"span","marks":[],"text":". 2018 Jun 5.","_key":"b7b9a675830c3"}],"_type":"block","style":"normal","_key":"c57052a16693","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/29869403 ","_key":"562fa2704f9b"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/28017916","_key":"67ee87563824"}],"children":[{"_key":"091e4cb696330","_type":"span","marks":[],"text":"8. Heo JY, Kim K, Fava M, et al. 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","_key":"51b7a7ab83560"},{"_type":"span","marks":["955c4b97783e"],"text":"Outdoor light at night (LAN) is correlated with eveningness in adolescents.","_key":"51b7a7ab83561"},{"_type":"span","marks":[],"text":" ","_key":"9e9f6852fb48"},{"_key":"51b7a7ab83562","_type":"span","marks":["em"],"text":"Chronobiol Int"},{"marks":[],"text":". 2012;29(4):502-508.","_key":"51b7a7ab83563","_type":"span"}],"_type":"block"},{"style":"normal","_key":"1f3e146c4f98","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/29888167","_key":"f1b3c7dd1f1f"}],"children":[{"_type":"span","marks":[],"text":"10. Kivelä L, Papadopoulos MR, Antypa N. 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Strategies to manage uncertainty include gathering comprehensive patient data, engaging in shared decision-making, considering psychotherapy, and comparing treatment risks. These steps aim to improve diagnostic accuracy and treatment outcomes in complex mood disorders.","audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/49c8e59f-b6ad-462a-8e30-5ee18c311069_1731355915867.7377ecea-5eb8-44ac-b031-90dbf00733d0.mp3","factCheckAuthorMapping":null,"documentGroup":null,"_type":"article","published":"2024-11-12T15:00:00.000Z","body":[{"_type":"figure","alt":"questions","asset":{"_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg","_type":"reference"},"imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"sergign/AdobeStock","_key":"74efa4830b5e0"}],"_type":"block","style":"normal","_key":"427f5aada048"}],"alignment":"left","widthP":50,"disableTextWrap":false,"disableLightBox":true,"_key":"e018e0b3ac21"},{"children":[{"_type":"span","marks":[],"text":"This first of 3 articles will demonstrate that bipolar mixed states are nearly impossible to differentiate from depression that is comorbid with ","_key":"44f622088b110"},{"_type":"span","marks":["6feebe99dafd"],"text":"posttraumatic stress disorder","_key":"fdd2b88018b6"},{"_type":"span","marks":[],"text":" (PTSD), or generalized anxiety disorder (GAD), or attention-deficit disorder (ADD). 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Broadening the answer broadens overlap with other conditions."}],"_type":"block"},{"_type":"block","style":"normal","_key":"0f4f2c7bf720","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3680c918333d0"}]},{"_type":"block","style":"normal","_key":"3f53cb9fc7d5","markDefs":[],"children":[{"marks":["strong"],"text":"Which Symptoms?","_key":"48637dc11e5b0","_type":"span"}]},{"_type":"block","style":"normal","_key":"49751ce53d5c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In the words of some of the of the ","_key":"5fac634596b20"},{"_type":"span","marks":["em"],"text":"DSM-5 ","_key":"5fac634596b21"},{"_type":"span","marks":[],"text":"crafters: “The mixed features specifier, it was decided, would define clinical entities … that merited clear and more precise definition—especially in order to ","_key":"5fac634596b22"},{"marks":["em"],"text":"establish clear entities for future outcome studies","_key":"5fac634596b23","_type":"span"},{"marks":[],"text":".”","_key":"5fac634596b24","_type":"span"},{"text":"1","_key":"a78fdb3fb139","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" [emphasis mine] In other words, the new criteria were more a research guideline than a clinical guideline.","_key":"440b4b104242"}]},{"_type":"block","style":"normal","_key":"762764c75e70","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"bf3aa43e992a0"}]},{"style":"normal","_key":"59d2c6a123d3","markDefs":[],"children":[{"_key":"90a8ddb8e7830","_type":"span","marks":[],"text":"This helps explain the exclusion of some of the high-energy symptoms commonly observed in research on mixed states since 2013. According to three such studies,"},{"_type":"span","marks":["superscript"],"text":"2-4","_key":"f07d368f97d2"},{"_type":"span","marks":[],"text":" common symptoms of mixed states include:","_key":"20bf79f2973d"}],"_type":"block"},{"listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Agitation, both psychic (anxiety) and physical","_key":"ec326abfbaf20"}],"level":1,"_type":"block","style":"normal","_key":"52313093d9a2"},{"children":[{"_type":"span","marks":[],"text":"Irritability","_key":"53ef1f4683b30"}],"level":1,"_type":"block","style":"normal","_key":"436f140cdb65","listItem":"bullet","markDefs":[]},{"_type":"block","style":"normal","_key":"a912666c4707","listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Nonstop ideas and distractibility","_key":"87be4f9619ed0"}],"level":1},{"children":[{"_type":"span","marks":[],"text":"Decreased sleep","_key":"91e2439ba3430"}],"level":1,"_type":"block","style":"normal","_key":"dee860043232","listItem":"bullet","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"d02f5f26a0960"}],"_type":"block","style":"normal","_key":"a5b2bbb9b57e"},{"markDefs":[],"children":[{"text":"Roger McIntyre, coauthor of one of those studies4 suggests these be remembered as “The 4 A’s”: anxiety, anger, agitation and attention problems. (Evidently including insomnia would ruin a good acronym).","_key":"6ee014f46e070","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"175235fd3736"},{"children":[{"text":"","_key":"1205afaf20b10","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"eb3d2c02451d","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"How Many?","_key":"65a0e45587150"}],"_type":"block","style":"normal","_key":"7aa52566c9be"},{"_type":"block","style":"normal","_key":"bfcb72eba6eb","markDefs":[{"_key":"70622a62e60c","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Ff1e3b9dd4ffeae34f537001797be01c2ea6cdc5e-690x482.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=1920\u0026q=75"}],"children":[{"_key":"2eda03a95c9a0","_type":"span","marks":[],"text":"Three treatment guidelines for mixed states published since 2017 suggest that any admixture of manic and depressive symptoms is possible."},{"_type":"span","marks":["superscript"],"text":"5-7","_key":"98f9c926ee3a"},{"_type":"span","marks":[],"text":" This dimensional view is shown in the ","_key":"6d4cd368663a"},{"_type":"span","marks":["strong","70622a62e60c"],"text":"Figure","_key":"2eda03a95c9a1"},{"marks":[],"text":".","_key":"2eda03a95c9a2","_type":"span"},{"text":"8","_key":"d43be1daba0a","_type":"span","marks":["superscript"]}]},{"asset":{"_type":"reference","_ref":"image-f1e3b9dd4ffeae34f537001797be01c2ea6cdc5e-690x482-png"},"widthP":50,"disableTextWrap":false,"imgcaption":[{"children":[{"_type":"span","marks":["strong"],"text":"Figure.","_key":"e56fda3bddfa0"},{"_type":"span","marks":[],"text":" A Dimensional View of Mixed States","_key":"692fbf6cfc15"}],"_type":"block","style":"normal","_key":"e54c273880ac","markDefs":[]}],"_key":"e0919b735d37","_type":"figure","alt":"Figure. A Dimensional View of Mixed States","alignment":"right","disableLightBox":true,"blank":true},{"markDefs":[],"children":[{"text":"In this view, there is no lower limit on the number of manic symptoms necessary to make an otherwise “unipolar” depression a mixed depression. This compounds the problem that the ","_key":"3a0ab0055d1f0","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"DSM-5","_key":"3a0ab0055d1f1"},{"_type":"span","marks":[],"text":" authors were trying to avoid: overlapping symptoms.","_key":"3a0ab0055d1f2"}],"_type":"block","style":"normal","_key":"28a0f368cc73"},{"_type":"block","style":"normal","_key":"4d699b15c278","markDefs":[],"children":[{"marks":[],"text":"","_key":"09f283e8a5010","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Overlap With Common Conditions","_key":"91fa4844cc2f0"}],"_type":"block","style":"normal","_key":"52328c735351"},{"_type":"block","style":"normal","_key":"c3bff32ee2fd","markDefs":[{"_key":"00e550146000","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd030bfc505bdc5e912f1a3d8da755ba41dc254b9-624x304.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=1920\u0026q=75"}],"children":[{"_type":"span","marks":[],"text":"Several common conditions share nearly every symptom with bipolar mixed states, when the latter are defined as including the 4 A’s. These include depression with PTSD, GAD, or ADD, and borderline personality disorder. This overlap is shown in the ","_key":"3988f7f80a0e0"},{"marks":["strong","00e550146000"],"text":"Table","_key":"3988f7f80a0e1","_type":"span"},{"_key":"3988f7f80a0e2","_type":"span","marks":[],"text":" (symptoms of MDD are shown in blue)."}]},{"_type":"figure","alignment":"right","asset":{"_ref":"image-d030bfc505bdc5e912f1a3d8da755ba41dc254b9-624x304-png","_type":"reference"},"_key":"8c55210a1c6d","alt":"Table. Overlap With Common Conditions","imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Table. ","_key":"05e203f194bf0"},{"marks":[],"text":"Overlap With Common Conditions","_key":"610923f8f2e8","_type":"span"}],"_type":"block","style":"normal","_key":"dc79e72c720e"}],"blank":true,"disableTextWrap":false,"disableLightBox":true,"widthP":50},{"children":[{"text":"Because of this overlap, differentiating these conditions based on symptoms alone is nearly impossible. Even supplementing symptom findings with family, social, and past psychiatric history may not help much. Trauma histories are unfortunately common across all 4 conditions. Family histories can be helpful but are often uncertain. Illness course is obviously limited in young patients. Response to previous treatments may be illuminating, but you might be the first provider.","_key":"e00ed7c5bee80","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"5ad20716741e","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3cc206c717580"}],"_type":"block","style":"normal","_key":"dcb9e1884977"},{"_type":"block","style":"normal","_key":"023ad74e5dc9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Is this “farewell to differential diagnosis,” as one author lamented?9 Not necessarily; rather, one can simply acknowledge that diagnostic certainty is almost impossible to attain in the face of depression with anxiety or anger or agitation or attention problems. When dealing with these symptoms, one must think of diagnoses in this context as ","_key":"ce646d5f4c280"},{"text":"tentative","_key":"ce646d5f4c281","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":", holding open the possibility of alternative explanations until a good outcome is obtained.","_key":"ce646d5f4c282"}]},{"_type":"block","style":"normal","_key":"161a6beed092","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"108c8aea94a00"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Coping With Diagnostic Uncertainty","_key":"213c27ec64940"}],"_type":"block","style":"normal","_key":"82b770c020ff"},{"children":[{"_key":"3fed91887d020","_type":"span","marks":[],"text":"Here are 4 steps to take or consider before initiating treatment that can help manage diagnostic uncertainty."}],"_type":"block","style":"normal","_key":"99f8b3e29e2b","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"1. ","_key":"a474ebbea0ed0"},{"marks":["em"],"text":"Routinely gather data","_key":"a474ebbea0ed1","_type":"span"},{"text":" that differentiate bipolar and unipolar depressions: family history, age of onset of depression, illness course (episodic or postpartum), and response to treatment (especially adverse responses to antidepressants).","_key":"a474ebbea0ed2","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"dd7ae6e4c1fd"},{"_type":"block","style":"normal","_key":"3551645b5866","markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. ","_key":"ca62a65d4c200"},{"marks":["em"],"text":"Engage the patient","_key":"ca62a65d4c201","_type":"span"},{"marks":[],"text":" (and perhaps family) in shared decision-making through psychoeducation. Help them understand that the possibility of bipolar should be approached not as a categorical yes-or-no but dimensionally, as in “how much bipolarity might you have, if any?”","_key":"ca62a65d4c202","_type":"span"}]},{"children":[{"marks":[],"text":"3. ","_key":"1b5b081af7a70","_type":"span"},{"_type":"span","marks":["em"],"text":"Consider beginning with psychotherapy","_key":"1b5b081af7a71"},{"_type":"span","marks":[],"text":". If you do not offer psychotherapy yourself and cannot easily refer for it, there are now inexpensive digital therapies for depression, PTSD, anxiety, and ADD. There is also a simple initial behavioral therapy for bipolarity, social rhythm therapy.","_key":"1b5b081af7a72"}],"_type":"block","style":"normal","_key":"b17d06a2bbe9","markDefs":[]},{"_key":"c5d6f7477039","markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. 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For example, though it may not be clear if a patient has a truly unipolar depression or a bipolar depression, the risks of antidepressants and lamotrigine are both relevant to an initial treatment decision."}],"_type":"block","style":"normal"},{"_key":"697478050bb7","markDefs":[],"children":[{"_key":"9df0ac389bf40","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"style":"normal","_key":"5fb041e0213b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"More on each of these approaches follows in Part 2, including practical clinical tools for each.","_key":"26d77f1cb5ec0"}],"_type":"block"},{"markDefs":[],"children":[{"_key":"2d34923151370","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"51e87d5c7f48"},{"style":"normal","_key":"9510c309631a","markDefs":[{"href":"https://wwnorton.com/books/A-Spectrum-Approach-to-Mood-Disorders/","_key":"5d71b04ccb28","_type":"link"},{"_type":"link","href":"https://wwnorton.com/books/Bipolar-Not-So-Much/","_key":"3a0716fd7b8a"}],"children":[{"marks":["strong"],"text":"Dr Phelps","_key":"a984a48aec0f0","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"a984a48aec0f1"},{"_type":"span","marks":["em"],"text":"is retiring from 30 years of treating complex mood disorders, and recently founded another website, DepressionEducation.org. 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Ostacher MJ, Suppes T. ","_key":"88282183e0c40"},{"_type":"span","marks":["2c8fd933df1b"],"text":"Depression with mixed features in major depressive disorder: a new diagnosis or there all along?","_key":"88282183e0c41"},{"text":" ","_key":"b73176a99cbb","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry","_key":"88282183e0c42"},{"_key":"88282183e0c43","_type":"span","marks":[],"text":". 2018;79(2):17ac11974."}],"_type":"block","style":"normal","_key":"656d46b79976"},{"_key":"adde073c18c0","markDefs":[{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/25830457/","_key":"22e363f239c1","blank":true}],"children":[{"_type":"span","marks":[],"text":"2. Perugi G, Angst J, Azorin JM, et al; BRIDGE-II-Mix Study Group. 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"},{"_type":"span","marks":["153b4a361101"],"text":"Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations.","_key":"8d5906efe0d91"},{"_type":"span","marks":[],"text":" ","_key":"baf6282be962"},{"_type":"span","marks":["em"],"text":"Bipolar Disord","_key":"8d5906efe0d92"},{"_type":"span","marks":[],"text":". 2021;23(8):767-788.","_key":"8d5906efe0d93"}],"_type":"block","style":"normal","_key":"dce2df9373dc"},{"_key":"08a349bde045","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/28421980/","_key":"db6729198ab2"}],"children":[{"_type":"span","marks":[],"text":"6. Stahl SM, Morrissette DA, Faedda G, et al. 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","_key":"c027b560b8960"},{"text":"The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders.","_key":"c027b560b8961","_type":"span","marks":["3e03d96b5676"]},{"_type":"span","marks":[],"text":" ","_key":"1628de8f3e8d"},{"marks":["em"],"text":"Aust N Z J Psychiatry","_key":"c027b560b8962","_type":"span"},{"marks":[],"text":". 2021;55(1):7-117.","_key":"c027b560b8963","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"d76acb9c4dbe","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/27866502/","_key":"0a4d108911ef","blank":true,"_type":"link"}],"children":[{"text":"8. McElroy SL, Keck PE. ","_key":"a31cb06f95000","_type":"span","marks":[]},{"_type":"span","marks":["0a4d108911ef"],"text":"Dysphoric mania, mixed states, and mania with mixed features specifier: are we mixing things up?","_key":"a31cb06f95001"},{"marks":[],"text":" ","_key":"702013efc487","_type":"span"},{"_type":"span","marks":["em"],"text":"CNS Spectr","_key":"a31cb06f95002"},{"_type":"span","marks":[],"text":". 2017;22(2):170-176.","_key":"a31cb06f95003"}]},{"style":"normal","_key":"b4bdb24555cf","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/25830464/","_key":"68a4a6ba8fdf"}],"children":[{"_type":"span","marks":[],"text":"9. Goldberg JF. ","_key":"7af272f175710"},{"_type":"span","marks":["68a4a6ba8fdf"],"text":"Mixed depression: a farewell to differential diagnosis?","_key":"7af272f175711"},{"_type":"span","marks":[],"text":" ","_key":"ec01dfade2fe"},{"marks":["em"],"text":"J Clin Psychiatry","_key":"7af272f175712","_type":"span"},{"_type":"span","marks":[],"text":". 2015;76(3):e378-380.","_key":"7af272f175713"}],"_type":"block"}],"documentGroupMapping":null,"_createdAt":"2024-11-11T20:11:45Z","contentCategory":{"_updatedAt":"2020-02-25T09:35:56Z","_createdAt":"2020-02-06T09:15:47Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Articles","_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb"},"authorMapping":[{"_type":"author","_id":"pst_author_323669","_updatedAt":"2020-08-21T07:23:47Z","url":{"current":"james-phelps-md","_type":"slug"},"displayName":"James Phelps, MD","_createdAt":"2020-02-21T11:23:21Z","_rev":"pI9SawGKsTP14Lioy52fLS"}],"summary":"How can you distinguish bipolar mixed states? Stay tuned in this short series. ","_rev":"bcxmLYb4HqB4YfW9fqdbqK","url":"differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope","thumbnail":{"_type":"mainImage","alt":"questions","caption":"sergign/AdobeStock","asset":{"_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg","_type":"reference"}},"gptTakeaways":"• Bipolar mixed states share symptoms with depression comorbid with PTSD, GAD, or ADD, complicating differential diagnosis.\n\n• The DSM-5's mixed features specifier broadens the bipolar spectrum, increasing symptom overlap with other conditions.\n\n• Diagnostic certainty is challenging; a tentative approach to diagnoses is recommended, considering alternative explanations.\n\n• Managing uncertainty involves gathering patient data, shared decision-making, psychotherapy, and comparing treatment risks.","_id":"49c8e59f-b6ad-462a-8e30-5ee18c311069","_updatedAt":"2024-11-11T20:11:59Z","title":"Differential Diagnosis of Mixed States is Nearly Impossible. Here’s How to Cope. 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Here’s How to Cope. ","url":{"current":"differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"questions","caption":"sergign/AdobeStock","asset":{"_type":"reference","_ref":"image-0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667-jpg"}},"published":"2024-11-12T15:00:00.000Z"}]},{"seoTag":["bipolar disorder","depression","mania","psychopharmacology"],"summary":"A deep dive into the history, side effects, and efficacy of a controversial drug. ","is_visible":true,"body":[{"_type":"iframe","_key":"42d61c8c1626","url":"https://embeds.audioboom.com/posts/7917293/embed/v4"},{"markDefs":[],"children":[{"_key":"377bc7a574bc","_type":"span","marks":["strong"],"text":"PSYCHPEARLS PODCAST"}],"_type":"block","style":"normal","_key":"bc74220c2a76"},{"_key":"b1c156561db3","markDefs":[],"children":[{"_type":"span","marks":["em"],"text":"Transcript edited for clarity. - Ed","_key":"bb30c17257b70"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"71338ce3cff20"},{"_type":"span","marks":[],"text":" Lamotrigine was launched for bipolar disorder in 2003, but it was a quiet launch, and since then a few myths have gathered around it as if to fill that vacuum. Today, we will address 4 of them.","_key":"71338ce3cff21"}],"_type":"block","style":"normal","_key":"be5283bf4499","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Welcome to ","_key":"e9fd90e430050"},{"_type":"span","marks":["em"],"text":"PsychPearls","_key":"e9fd90e430051"},{"marks":[],"text":" podcast with ","_key":"e9fd90e430052","_type":"span"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"e9fd90e430053"},{"text":"TM","_key":"e9fd90e430054","_type":"span","marks":["superscript"]},{"marks":[],"text":", the voice of psychiatry. With thoughtful insights into the world of mental health, this podcast provides timely clinical commentary and practical cutting-edge pearls for you and your practice. We hope you enjoy it.","_key":"55b4e2909f49","_type":"span"}],"_type":"block","style":"normal","_key":"34fc570ee2b6","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"I am Chris Aiken, the Mood Disorders Section Editor for ","_key":"ea53b84443740"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"ea53b84443741"},{"_type":"span","marks":["superscript"],"text":"TM","_key":"ea53b84443742"},{"_type":"span","marks":[],"text":" and the editor-in-chief of the ","_key":"2a1d567b6175"},{"_type":"span","marks":["em"],"text":"Carlat Psychiatry Report","_key":"ea53b84443743"},{"_type":"span","marks":[],"text":", and I am Kellie Newsome, a psychiatric NP and the cohost of the ","_key":"ea53b84443744"},{"_type":"span","marks":["em"],"text":"Carlat Psychiatry Podcast","_key":"ea53b84443745"},{"_type":"span","marks":[],"text":".","_key":"ea53b84443746"}],"_type":"block","style":"normal","_key":"308fc4380485"},{"children":[{"_type":"span","marks":["strong"],"text":"A Quiet Launch","_key":"86ea5d507ff30"}],"_type":"block","style":"normal","_key":"9e73ca7194e2","markDefs":[]},{"_type":"block","style":"normal","_key":"a63f35be65e5","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"afec8962a0580"},{"_type":"span","marks":[],"text":" On June 20, 2003, the world had its eyes on the United States’ invasion of Iraq. Some of us were following Martha Stewart’s indictment for insider trading, and quite a few were lining up at bookstores to be the first to buy the 5th installment in the Harry Potter series. But Russell Katz, MD, was busy at his desk on this day at the US Food and Drug Administration (FDA) headquarters, writing a letter to GlaxoSmithKline announcing the approval of their anticonvulsant lamotrigine in bipolar disorder. But the approval was not a slam-dunk. GlaxoSmithKline had submitted 12 trials, and only 2 of them were positive. Lamotrigine did not work in acute mania; it did not work in acute bipolar depression; and it did not work in rapid cycling.","_key":"afec8962a0581"}]},{"style":"normal","_key":"c0eb9ce72ebb","markDefs":[],"children":[{"_key":"9d8e4fd3af040","_type":"span","marks":[],"text":"But bipolar disorder (BD) is a chronic condition, and that is where the medication succeeded: in the maintenance phase."}],"_type":"block"},{"_key":"2b3bbb539720","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The 2 positive studies looked at lamotrigine in the long term, over 1 and a half years. There, lamotrigine helped patients stay well about twice as long as a placebo.","_key":"64d6e68df2480"},{"_type":"span","marks":["superscript"],"text":"1","_key":"73fb7856ebbe"},{"_type":"span","marks":[],"text":" Katz knew that long-term studies like this were expensive and hard to come by, but for patients who have to stay on a mood stabilizer year after year it is this kind of data that matters most. So he gave it an indication for delaying new episodes of depression, hypomania, and mania in BD.","_key":"5db9d5a360d0"}],"_type":"block","style":"normal"},{"children":[{"_key":"e07cb217d3d60","_type":"span","marks":["strong"],"text":"CHRIS AIKEN:"},{"_key":"e07cb217d3d61","_type":"span","marks":[],"text":" And that is how lamotrigine was launched. But there are a lot of loose threads in that story that have tangled into myths, and today we are going to unravel 4 of them so you can use lamotrigine more effectively in practice."}],"_type":"block","style":"normal","_key":"184030a32757","markDefs":[]},{"style":"normal","_key":"233f91ee925a","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"A Warning","_key":"75b3c80a10a30"}],"_type":"block"},{"markDefs":[],"children":[{"_key":"3959c05423550","_type":"span","marks":["strong"],"text":"CHRIS AIKEN:"},{"_type":"span","marks":[],"text":" But first a warning. Lamotrigine is not a panacea. It works in BD, but it does not treat non-bipolar depression. There the studies are mixed: half positive, half negative. It has positive controlled trials in obsessive compulsive disorder, borderline personality disorder, and depersonalization disorder, but those studies are few and small.","_key":"3959c05423551"},{"text":"2","_key":"0fbe71658c79","_type":"span","marks":["superscript"]},{"marks":[],"text":" So do not start prescribing lamotrigine to every moody individual you see, because this medicine has one big risk that makes those uncharted adventures unwise: the potentially fatal rash of Stevens Johnson Syndrome.","_key":"ed9d37b2069d","_type":"span"}],"_type":"block","style":"normal","_key":"7117c4dbf031"},{"_key":"0d9d3c0fa520","markDefs":[],"children":[{"_type":"span","marks":[],"text":"That rash is part of the reason that lamotrigine had such a soft launch. Early on, the manufacturer decided not to market lamotrigine to primary care practices, and to minimize direct to consumer advertising. The decision may have hurt their quarterly profits, but it helped them stay in the market. You see, lamotrigine was nearly yanked off the market after its launch in epilepsy 10 years earlier. Back then, doctors were starting the drug at 100mg a day, which lead to an alarming rise in potentially fatal Stevens Johnson rashes. The medication only survived when the company was able to show that it could lower this risk through the slow titrations that we use today. Now that risk is around 1 in 3000.","_key":"1fb3158d8fbb0"},{"_type":"span","marks":["superscript"],"text":"3","_key":"8c34969f2243"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"text":"GlaxoSmithKline was concerned that if they overhyped the drug, then clinicians with little experience in BD would prescribe it to every moody patient they saw, and if they overlooked the DSM in that way they might also overlook the titration instructions, causing a second flare of serious rashes that would cause the FDA to pull the plug again.","_key":"3a799e7b28970","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"c81541e1df53"},{"_type":"block","style":"normal","_key":"fc3dcfb76df8","markDefs":[],"children":[{"marks":["strong"],"text":"KELLIE NEWSOME:","_key":"6fbf95ee9eec0","_type":"span"},{"_type":"span","marks":[],"text":" And now let us get into those myths. There are 4 of them.","_key":"6fbf95ee9eec1"}]},{"_key":"842419cc5dfe","markDefs":[],"children":[{"_key":"9731eb6e18c90","_type":"span","marks":[],"text":"Myth #1: Lamotrigine does not help mania"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"Myth #2: Lamotrigine does not treat acute episodes of bipolar depression","_key":"1d6c4971e1980"}],"_type":"block","style":"normal","_key":"28425af347c4","markDefs":[]},{"style":"normal","_key":"90e174ac7e84","markDefs":[],"children":[{"marks":[],"text":"Myth #3: Lamotrigine is a weak mood stabilizer","_key":"a2875e7deb100","_type":"span"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Myth #4: It is a good idea to stop lamotrigine when a patient relapses, because it is probably not working","_key":"1cc4573623ed0"}],"_type":"block","style":"normal","_key":"fa86dd8111b0"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Myth #1: Lamotrigine Does not Help Mania","_key":"6e5992c2c46f0"}],"_type":"block","style":"normal","_key":"eb46f4b7a0af"},{"children":[{"_key":"ae0762d35ea90","_type":"span","marks":["strong"],"text":"CHRIS AIKEN:"},{"_type":"span","marks":[],"text":" This one is kind of true. Lamotrigine failed in the acute mania trials, and nothing that we have learned about this drug in the 25 years since suggests that it has any role in acute mania. But lamotrigine does help prevent mania, although it is better at preventing bipolar depression than it is at preventing mania. What that means in practice is that you should not rely on it as the sole maintenance medication in patients with a history of severe mania, but it may be used as monotherapy in bipolar II disorder, where the depressions are more common and the manic symptoms brief and mild.","_key":"ae0762d35ea91"}],"_type":"block","style":"normal","_key":"b38e681b0544","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"In fact, many bipolar experts see good results in cyclothymic patients, who cycle frequently between mild depression, hypomania, and mixed states. That observation only supported by open-label studies, but hey – there are zero controlled medication trials in cyclothymic disorder so that is as good as it gets.","_key":"8aa3f8afb5920"},{"_type":"span","marks":["superscript"],"text":"4,5","_key":"b9fcb60198b3"}],"_type":"block","style":"normal","_key":"3011d070f04a"},{"_key":"bc02774e1673","markDefs":[],"children":[{"_key":"facc22eea3890","_type":"span","marks":["strong"],"text":"Myth #2: Lamotrigine Does Treat Acute Episodes of Bipolar Depression"}],"_type":"block","style":"normal"},{"_key":"16a54e6b696b","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"1512b45c33820"},{"_type":"span","marks":[],"text":" Among the 12 trials on Katz’s desk, 5 of them are good candidates for the most disappointing trials in the history of psychiatry. These were the 5 controlled trials in acute bipolar depression, all funded by the manufacturer, and all of them failed. The trials were never published, but most psychiatrists knew about them when lamotrigine was released, and it gave some of us the impression that lamotrigine was a weak mood stabilizer that barely got approved for an indication that was not at the top of the list for doctors or patients.","_key":"1512b45c33821"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"But we have since learned that lamotrigine does treat acute depression, it just takes a little longer than faster options like the atypical antipsychotics. The problem is that the early studies only lasted 7 weeks, and lamotrigine requires a slow titration that takes 4 to 6 weeks to reach a therapeutic level. Later, lamotrigine did prove efficacious for acute bipolar depression in 2 independently funded randomized placebo-controlled trials.","_key":"ad08da73d7b30"},{"_key":"3f7f57eb6ddf","_type":"span","marks":["superscript"],"text":"6,7"}],"_type":"block","style":"normal","_key":"5943f97d91b3"},{"_type":"block","style":"normal","_key":"0b93e13917dc","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"1672bd87395e0"},{"marks":[],"text":" Wait a minute. You are saying the industry sponsored trials were all negative but the independent ones were positive? That is a first.","_key":"1672bd87395e1","_type":"span"}]},{"_key":"80917ad9e22c","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"7bf5ca1291820"},{"_type":"span","marks":[],"text":" Yes, and the difference is that the independently sponsored trials gave lamotrigine a little more time. They lasted 8 to 12 weeks instead of 7 weeks. Also, lamotrigine was used as augmentation in these trials – in 1 it augmented lithium and the other quetiapine – but I think lamotrigine can work as monotherapy in acute depression and the real difference here was the timespan.","_key":"7bf5ca1291821"}],"_type":"block","style":"normal"},{"style":"normal","_key":"c117b51331c0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"2d03b35c77350"},{"marks":[],"text":" One reason we think it works as monotherapy is that John Geddes, MD, FRCPsych, Joseph Calabrese, MD, and Guy Goodwin, DPhil, reanalyzed the original 5 negative trials in an independently funded meta-analysis.","_key":"2d03b35c77351","_type":"span"},{"_type":"span","marks":["superscript"],"text":"8","_key":"cb882e6e34a5"},{"_type":"span","marks":[],"text":" They found that there was a positive signal in the original studies, but they were too small to detect it. When combined together, totaling 1072 participants, lamotrigine had a small effect, bringing about a meaningful response in 1 out of 11 participants. But hey, cariprazine got FDA approval in bipolar depression with the same number needed to treat, and lamotrigine’s efficacy only starts to build at that 7-week mark. If you use lamotrigine for acute depression, you will probably need to wait about a month and a half to see an effect, and, judging from the longer trials, those benefits are likely to keep building over the next 1 to 4 months.","_key":"ccbd5a89a36a"}],"_type":"block"},{"_type":"block","style":"normal","_key":"2901ac965eb3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"A common strategy then is to start lamotrigine with a faster-acting agent like an atypical antipsychotic, and then slowly taper off the antipsychotic as lamotrigine starts to kick in. This gives you the best of both worlds: lamotrigine has excellent tolerability over the long term, with a low risk of weight gain, fatigue, cognitive problems, sexual dysfunction, or any of the long-term medical problems that show up in the warnings for antipsychotics.","_key":"e869be0741ea0"}]},{"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"b8f816b9efef0"},{"_key":"b8f816b9efef1","_type":"span","marks":[],"text":" One risk we do not think about enough is stroke. Stroke is the #1 cause of death in bipolar disorder, and lamotrigine and lithium are the only mood stabilizers that do not increase the risk of stroke; all the others have some marks against them there."},{"_type":"span","marks":["superscript"],"text":"9","_key":"d99521f436db"},{"_type":"span","marks":[],"text":" I am going to get on a soap box for a minute here and argue that bipolar is not a mental disorder. It’s a physical disorder, and not just because the brain is a physical organ. Heart disease starts 10 to 15 years earlier in individuals with BD, and you can even detect cardiovascular changes in teens with bipolar. Lifestyle may play a part, but I think about all that adrenaline pumping through the veins during mania and mixed states. This is a whole-body illness, and we ought to be thinking about long-term morbidity and mortality when choosing a mood stabilizer, not just relieving acute symptoms.","_key":"ba95c9c01a78"}],"_type":"block","style":"normal","_key":"2629a4935e8d","markDefs":[]},{"_key":"e770fed2200f","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"602738f0ff8b0"},{"_type":"span","marks":[],"text":": Are you off your soap box yet?","_key":"602738f0ff8b1"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"c1859d28767c0"},{"_type":"span","marks":[],"text":" No, I have one more thing to say. The ","_key":"c1859d28767c1"},{"_type":"span","marks":["em"],"text":"DSM","_key":"c1859d28767c2"},{"_type":"span","marks":[],"text":" is often criticized for promoting biological psychiatry through its black-box, symptom check-list approach. But to me, it is not biological enough. You could read the whole book and walk away with little sense that these mental illnesses are wrecking havoc on the heart, the gastrointestinal tract, the immunologic and neuroendocrine systems. You would never get that sense from reading Harrison’s textbook of internal medicine.","_key":"c1859d28767c3"}],"_type":"block","style":"normal","_key":"d5851fb382bb"},{"_key":"281873e8c0d3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"69bc2c73c4fe0"},{"_type":"span","marks":[],"text":" OK, can we get back to lamotrigine now.","_key":"69bc2c73c4fe1"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Myth #3: Lamotrigine Is a Weak Mood Stabilizer","_key":"a045c4658a1e0"}],"_type":"block","style":"normal","_key":"1c2d625d230e"},{"_type":"block","style":"normal","_key":"22b7dd918fb9","markDefs":[],"children":[{"_key":"af6b65c916ab0","_type":"span","marks":["strong"],"text":"CHRIS AIKEN:"},{"marks":[],"text":" Yes, and that segues back to another myth about lamotrigine, which is that treatments that are slow to act are not strong ones. This is not how chronic diseases are approached in other medical specialties, which naturally take a long-term, disease-modifying view. You will never see a diabetes study that looks at change on a symptom check-list over 4 weeks. Or take hypertension. Clonidine lowers blood pressure right away, but most physicians prefer a thiazide for hypertension because it lowers the long-term risks of morbidity and mortality.","_key":"af6b65c916ab1","_type":"span"}]},{"style":"normal","_key":"28aae8f32b92","markDefs":[],"children":[{"text":"Individuals with bipolar disorder die 10 years earlier on average, and not from suicide. 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Lamotrigine is neutral on all of them, and ","_key":"c84f7e8587671"},{"_key":"c84f7e8587672","_type":"span","marks":["0fb886e1546c"],"text":"lithium brings down"},{"text":" most of them. Specifically, lithium lowers the risk of heart disease, ","_key":"c84f7e8587673","_type":"span","marks":[]},{"_key":"c84f7e8587674","_type":"span","marks":["d41529e80f4d"],"text":"stroke"},{"_type":"span","marks":[],"text":", cancer, viral infections, and suicide.","_key":"c84f7e8587675"}],"_type":"block","style":"normal","_key":"3c9ab1d299ba"},{"markDefs":[],"children":[{"text":"KELLIE NEWSOME:","_key":"49567e5202790","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" But we are getting a bit ahead of ourselves here. I mean, long-term medical risks are important when considering a mood stabilizer, but we also want something that prevents the episodes. Here we have an interesting finding from studies that have compared lithium and lamotrigine.","_key":"49567e5202791"},{"_type":"span","marks":["superscript"],"text":"1","_key":"ec60417890f9"},{"_key":"0696b2340ef6","_type":"span","marks":[],"text":" Lithium offers better prevention against the manic side, while lamotrigine works better against the depressive side, so combining the 2 makes sense. And one study did that – the LamLit trial – and confirmed that there are indeed additional benefits to combining the 2."},{"_key":"e33cb03a7664","_type":"span","marks":["superscript"],"text":"3"}],"_type":"block","style":"normal","_key":"0c8384d790a6"},{"style":"normal","_key":"836bb2d48eed","markDefs":[],"children":[{"marks":["strong"],"text":"CHRIS AIKEN:","_key":"922aa9e34a480","_type":"span"},{"text":" And that is the long-term perspective that we need to take when choosing a mood stabilizer. This does not come naturally in psychiatry. If you work in a hospital, insurance is pressuring you to get the patient better quickly, so lamotrigine is not going to be your go-to agent. And if you work in an outpatient office, ask yourself: When was the last time a patient came in saying “I’d like a medication to prevent bipolar disorder”? In psychiatry, we treat suffering, and our patients want something that will work quickly.","_key":"922aa9e34a481","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"2fecb70096c1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"And that brings us to the fourth myth.","_key":"4208a7ebf9fb0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Myth #4: It Is a Good Idea to Stop Lamotrigine When a Patient Relapses, Because It Is Probably not Working","_key":"e18dfc91b8830"}],"_type":"block","style":"normal","_key":"498a1cd97284"},{"_type":"block","style":"normal","_key":"87a3bcf042c3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"e6e53933eaea0"},{"_type":"span","marks":[],"text":" In the maintenance trials, lamotrigine delayed the time to a new episode by 197 days, about half a year, vs 86 days or 3 months for placebo. So it is about twice as effective as placebo, but it does not provide 100% protection (no mood stabilizer does). In practice, here is what I tell patients when starting it:","_key":"e6e53933eaea1"}]},{"_key":"0027df6157f5","markDefs":[],"children":[{"text":"Lamotrigine’s going to have a slow build because you have to raise it slowly to prevent a serious rash. That means you’re going to feel better gradually over the next 1 to 2 months, but on the other hand you are not likely to have many side effects or medicated feelings. And that is a good thing because you are likely to need something long term to prevent mood problems, and this one does not have any major long-term risks. But keep in mind it is not going to prevent all mood episodes, but it will cut the rate of those episodes in half. So instead of having depression, say, every year, it may be every 2 years. But no medication does everything, and there is a lot you can do to raise those odds of success.","_key":"ccb544652fbd0","_type":"span","marks":[]}],"_type":"block","style":"blockquote"},{"markDefs":[],"children":[{"text":"Then I talk about behavioral strategies for bipolar and depression. If you are interested in that, we have a separate podcast for patients that teaches these strategies. Search for ","_key":"2befe2137c4f0","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"The Pocket Psychiatrist","_key":"2befe2137c4f1"},{"_type":"span","marks":[],"text":" in your podcast store.","_key":"2befe2137c4f2"}],"_type":"block","style":"normal","_key":"adc73736bb44"},{"style":"normal","_key":"0bae815f4e09","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"6413e50b25ef0"},{"marks":[],"text":" A common mistake is to stop lamotrigine when an episode returns, which is a bit like stopping blood pressure and cholesterol medications because a patient had a heart attack. Lamotrigine’s most robust effects are in prevention, and prevention is difficult to measure in psychiatry. You would need a before-and-after mood chart to confirm that the medication is lowering the frequency of episodes as it promises to do. Even then the work is difficult because so many other factors can make mood better or worse. What I look for is improvement in the first 3 to 6 months after starting lamotrigine. If a patient stops it, I watch for worsening over the next 3 to 6 months. And I also listen for something that I have heard a lot of patients say on this medication, particularly those with the frequent ups and downs of cyclothymic disorder.","_key":"6413e50b25ef1","_type":"span"}],"_type":"block"},{"style":"normal","_key":"2cc02bd19ecc","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"b02c937742660"},{"_type":"span","marks":[],"text":" What is that?","_key":"b02c937742661"}],"_type":"block"},{"style":"normal","_key":"29ed580449f0","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18402630/","_key":"3c66a7c96c61"},{"_key":"230edd4b803d","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/20846461/"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/29944976/","_key":"b9eb677aeb0e"}],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"db377cc4db680"},{"_type":"span","marks":[],"text":" They say they still feel the same about whatever problems they were having in life, but the feelings are less overwhelming. 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Overall, there are volumetric changes in "},{"_type":"span","marks":["b9eb677aeb0e"],"text":"both the amygdala","_key":"db377cc4db686"},{"_type":"span","marks":[],"text":", which react to emotional events, and the frontal lobes, which temper those emotions and help individuals see things in perspective.","_key":"db377cc4db687"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"93a934eb15090"},{"_key":"93a934eb15091","_type":"span","marks":[],"text":" That sounds like something we could all use."}],"_type":"block","style":"normal","_key":"a0300ccfb78f"},{"style":"normal","_key":"c2f1a26e12a2","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN: ","_key":"1642a9ca5c050"},{"_key":"1642a9ca5c051","_type":"span","marks":[],"text":"Hold it there! 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Newsome, PMH-NP","_key":"0b534c6e2a1b20"},{"_key":"0b534c6e2a1b21","_type":"span","marks":["em"],"text":", is the cohost of the"},{"_type":"span","marks":[],"text":" ","_key":"0b534c6e2a1b22"},{"text":"Carlat Psychiatry Podcast","_key":"0b534c6e2a1b23","_type":"span","marks":["em"]},{"marks":[],"text":" ","_key":"0b534c6e2a1b24","_type":"span"},{"_type":"span","marks":["em"],"text":"and is also a practicing psychiatric mental health nurse practitioner in Winston Salem, NC, at the Mood Treatment Center. Raised in Tasmania, Australia, Kellie moved to the United States in 1998.","_key":"0b534c6e2a1b25"}],"_type":"block"},{"markDefs":[],"children":[{"text":"References","_key":"0086abeb16ef0","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"b6fb9b783ff9"},{"style":"normal","_key":"3a7c7fb9d401","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/15096085/","_key":"cae9f0acfc3e","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"1. Goodwin GM, Bowden CL, Calabrese JR, et al. ","_key":"0086abeb16ef1"},{"_type":"span","marks":["cae9f0acfc3e"],"text":"A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder.","_key":"0086abeb16ef2"},{"marks":[],"text":" ","_key":"cc80060fd5b1","_type":"span"},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry. ","_key":"0086abeb16ef3"},{"text":"2004;65(3):432-441.","_key":"0086abeb16ef4","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[{"href":"https://www.ncbi.nlm.nih.gov/pubmed/23945444","_key":"cb083527de84","blank":true,"_type":"link"}],"children":[{"_key":"cb46d4e52c3d0","_type":"span","marks":[],"text":"2. Reid JG, Gitlin MJ, Altshuler LL. "},{"_type":"span","marks":["cb083527de84"],"text":"Lamotrigine in psychiatric disorders.","_key":"cb46d4e52c3d1"},{"_type":"span","marks":[],"text":" ","_key":"d028c0590145"},{"marks":["em"],"text":"J Clin Psychiatry. ","_key":"cb46d4e52c3d2","_type":"span"},{"_type":"span","marks":[],"text":"2013;74:675-684.","_key":"cb46d4e52c3d3"}],"_type":"block","style":"normal","_key":"65bca383bfcd"},{"markDefs":[{"href":"https://www.ncbi.nlm.nih.gov/pubmed/20532155","_key":"3676c2e5698d","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"3. Aiken CB, Orr C. ","_key":"66b2ea74dbaa0"},{"_type":"span","marks":["3676c2e5698d"],"text":"Rechallenge with lamotrigine after a rash: a prospective case series and review of the literature.","_key":"66b2ea74dbaa1"},{"_type":"span","marks":[],"text":" ","_key":"d8517851c886"},{"marks":["em"],"text":"Psychiatry (Edgmont).","_key":"66b2ea74dbaa2","_type":"span"},{"marks":[],"text":" 2010;7:27-32.","_key":"66b2ea74dbaa3","_type":"span"}],"_type":"block","style":"normal","_key":"2f89a580de66"},{"markDefs":[{"_key":"96923a3ac473","blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/15708424"}],"children":[{"text":"4. 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","_key":"a10dac0930b00","_type":"span","marks":[]},{"_key":"d67f353f85cf","_type":"span","marks":["901377e8e724"],"text":"Stanford accelerated intelligent neuromodulatoin therapy for treatment-resistant depression."},{"_type":"span","marks":[],"text":" ","_key":"21f6bd6ab148"},{"text":"Am J Psychiatry. ","_key":"a10dac0930b01","_type":"span","marks":["em"]},{"text":"2020;177(8):716-726.","_key":"a10dac0930b02","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"900c93b9650c","markDefs":[{"blank":true,"_type":"link","href":"https://www.magnusmed.com/press-releases/magnus-medical-receives-fda-clearance-for-the-saint-neuromodulation-system/","_key":"f4f19a63d8b1"}],"children":[{"_type":"span","marks":[],"text":"2. Magnus Medical receives FDA clearance for the SAINT neuromodulation system for non-invasive, individualized and precise treatment of severe depression. Magnus Medical. News release. September 6, 2022. Accessed November 1, 2024. 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Varas, MD","url":"elizabeth-varas-md"}],"title":"Don't Fear Older Medications and Treatments for Our Senior Patients","contentCategory":{"_createdAt":"2020-02-06T09:15:47Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Articles","_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","_updatedAt":"2020-02-25T09:35:56Z"},"audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/d8eb3433-c9f3-4ed5-b9af-e53feaf8ddb3_1729525888078.3720fa1f-4c7b-4920-9629-59379aa157b5.mp3","authorMapping":[{"_rev":"gPN5iHoCggYnhvurDKwV5p","_type":"author","_id":"pst_author_622841","biography":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Varas ","_key":"8caaa62899e20"},{"_key":"8caaa62899e21","_type":"span","marks":["em"],"text":"is a psychiatrist in Westwood, New Jersey."}],"_type":"block","style":"normal","_key":"dba32fdd18d8"}],"_updatedAt":"2023-10-05T13:54:35Z","url":{"current":"elizabeth-varas-md","_type":"slug"},"displayName":"Elizabeth A. Varas, MD","_createdAt":"2020-02-21T11:23:21Z"}],"summary":"“Older medications” like ECT, lithium, second generation antipsychotics such as the olanzapine/fluoxetine combination, have proven efficacy.","documentGroup":null,"_updatedAt":"2024-10-21T17:29:09Z","factCheckAuthors":null,"documentGroupMapping":null,"drugMentions":"{\n \"drug_mentions\": [\"selective serotonin reuptake inhibitor\", \"benzodiazepine\", \"SSRI\", \"Novel antidepressants\", \"atypical antipsychotics\", \"olanzapine\", \"mood stabilizer\", \"lithium\", \"Symbyax\", \"fluoxetine\"]\n}","thumbnail":{"caption":"yana136/AdobeStock","asset":{"_ref":"image-d41a0f9b8e8701c71a0f100ad08e469352e7ee0a-4146x1969-jpg","_type":"reference"},"_type":"mainImage","alt":"older woman"},"_rev":"yfV8wp4eUDtgm1JJ6alOjE","_type":"article","factCheckAuthorMapping":null,"_id":"d8eb3433-c9f3-4ed5-b9af-e53feaf8ddb3","articleType":"Commentary","_createdAt":"2024-10-21T14:21:01Z","is_visible":true,"ExcludeFromPubMedXML":false,"published":"2024-10-22T15:00:00.000Z","body":[{"disableLightBox":true,"imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"yana136/AdobeStock","_key":"59ae32c4f0300"}],"_type":"block","style":"normal","_key":"9474c58ea710"}],"_key":"6b59cb9c79b9","asset":{"_ref":"image-d41a0f9b8e8701c71a0f100ad08e469352e7ee0a-4146x1969-jpg","_type":"reference"},"alignment":"left","widthP":50,"_type":"figure","disableTextWrap":false,"alt":"older woman"},{"markDefs":[],"children":[{"marks":["strong"],"text":"CLINICAL REFLECTIONS","_key":"e7007cd999d30","_type":"span"}],"_type":"block","style":"normal","_key":"b5a72fe8abd9"},{"style":"normal","_key":"f2fc8b54fbe1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Both recurrent depression and bipolar I and II depression are ordeals both for the patient and psychiatrist. This past year, I have had 3 similarly aged women presenting with difficult to treat depression, challenging my psychiatric skills and decision making. All 3 were women over 70 years of age; only 1 had been hospitalized in the past for depression and all were currently on medication for depression.\n\nIt was early in the year when my first patient, aged 77 years, showed a rapid decline in her mood after a small flood in her apartment. She had had 2 episodes of serious depression, usually preceded by insomnia and physical weakness usually quickly relieved with an adjustment in the dose of a selective serotonin reuptake inhibitor (SSRI), short term use of a benzodiazepine, and supportive and behavioral psychotherapy. During the current episode, she regressed in her personal care neglecting to groom in her usual meticulous manner. She was afraid to be left alone and was fully absorbed in the miserableness of her being. Her preoccupation with somatic symptoms and changes in her sleep pattern affected her ability to tolerate new medications. Fortunately, both the patient and spouse were open to the idea of electroconvulsive therapy (ECT) but the logistics of finding a hospital for outpatient ECT after COVID-19 (to mitigate the trauma of inpatient hospitalization) was no easy endeavor. However, once started on a course of 12 ECT sessions, she readily improved. Each session with me notably measured improvement in her physical appearance and a reestablishment of her independence and confidence.\n\nMy second patient was a 76-year-old woman who lost her partner to cancer during COVID-19 and came to treatment with me on an SSRI and a benzodiazepine. At the start of treatment, she was very energetic, involved in Zoom learning, and traveling. Over time, despite compliance with medication, she became more and more depressed. Novel antidepressants and atypical antipsychotics both second and third generation were tried to no avail. ECT was suggested but was too frightening a prospect for the patient. Because of adverse effects, a course of transcranial magnetic stimulation (TMS) was encouraged. Halfway through TMS, a relative called to inform me that the patient's mental state had so seriously declined that she was spending all of her time in bed. She was admitted to a nearby hospital for a week without improvement. I advocated for ECT; she was transferred to a hospital out of county for ECT but was unable to tolerate the conditions of the psychiatric unit and signed out. I again took on the role of social worker and found a hospital within traveling distance for her relative; she was admitted for ECT and after a course of 12 ECT she rapidly improved and was discharged home on an SSRI, olanzapine, and a mood stabilizer.\n\nThe third patient, who was married and 73 years old, presented to me a few years ago after a hospitalization for serious depression and suicidal ideation. Her depression persisted for over 2 years despite trying newer antidepressants and mood stabilizers. I came to believe that depression was her baseline until almost overnight she had a remarkable improvement in her mental state and became happy, motivated, and purposeful. Despite warnings about noncompliance, she disappeared from treatment and discontinued all her medications until she represented this year with anxiety, depression, insomnia, and anhedonia. It was a difficult course; ECT was too frightening for her and her spouse to consider. However, with lithium and Symbyax (combination fluoxetine and olanzapine) and behavioral and supportive interventions, her depression remitted. (Interestingly, Symbyax was the first medication approved by the US Food and Drug Administration in 2003 for the treatment of bipolar I depression.)\n\nOf course with older patients, medical complications causing mental status changes need to be ruled out. However, do not be swayed by the age of the patient and the possibility of adverse effects. Careful titration of lithium, second generation antipsychotics such as the olanzapine/fluoxetine combination and ECT have proven efficacy. Long term relationships between a psychiatrist and patient are also invaluable to provide support and optimism during serious episodes of depression. 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