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class="mt-4 max-w-[125px]"></div></div></div></div></div></nav><div id="bipolar" class="container mx-auto flex m-1 min-h-[57vh] px-4"><div class="flex-auto w-[calc(100%-300px)] pr-0 md:pr-6 mt-16 sm:mt-0"><div class="pb-24 my-2"><div class="flex"><h1 class="text-[19px] mt-1 md:mt-0 md:text-3xl mb-2">Bipolar Disorder</h1><div class="flex justify-center px-0 -mt-1 sm:-mt-2 align-center"><span class="mt-3 ml-4 text-gray-700 md:mt-4 font-sm md:font-md">></span><nav class="relative inline-flex justify-center px-0 py-1 ml-1 sm:justify-end dropdown"><button aria-controls="specialty-dropdown" class="py-2 px-4 inline-flex items-center mt-[3px] md:mt-[4px] ml-auto w-auto text-left"><span class="w-full mr-1 text-sm md:text-lg sm:w-auto">All Subspecialties</span><svg class="w-4 h-4 fill-current" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 20 20"><path d="M9.293 12.95l.707.707L15.657 8l-1.414-1.414L10 10.828 5.757 6.586 4.343 8z"></path></svg></button><ul aria-expanded="false" 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href="/view/bipolar-awakenings-the-quest-to-heal-bipolar-disorder"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%] md:rounded-bl-none md:rounded-tl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="Bipolar Awakenings" title="Bipolar Awakenings" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:cover"/><noscript><img alt="Bipolar Awakenings" title="Bipolar Awakenings" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F881791d564bb71049108c101798dbcb2b3aea3f8-4205x6150.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F881791d564bb71049108c101798dbcb2b3aea3f8-4205x6150.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F881791d564bb71049108c101798dbcb2b3aea3f8-4205x6150.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:cover" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/bipolar-awakenings-the-quest-to-heal-bipolar-disorder">Bipolar Awakenings: The Quest to Heal Bipolar Disorder</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/john-calvin-chatlos-md">John Calvin Chatlos, MD</a></span></div><p class="text-sm text-gray-500">November 21st 2024</p><p class="text-md block">Can "healing" life trauma help improve bipolar disorder symptoms? </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/4-ways-to-cope-with-bipolar-uncertainty"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="bipolar" title="bipolar" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="bipolar" title="bipolar" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F404e1c0468b1b692448c95b34c56c94c7d55a7bd-462x451.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F404e1c0468b1b692448c95b34c56c94c7d55a7bd-462x451.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F404e1c0468b1b692448c95b34c56c94c7d55a7bd-462x451.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/4-ways-to-cope-with-bipolar-uncertainty">4 Ways to Cope With Bipolar Uncertainty</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/james-phelps-md">James Phelps, MD</a></span></div><p class="text-sm text-gray-500">November 19th 2024</p><p class="text-md hidden">Here are 4 means of coping with the diagnostic uncertainty of bipolar mixed states.</p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="questions" title="questions" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="questions" title="questions" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F0ed42755e5073b545ec9cabf17e17101c1af23d2-4000x2667.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/differential-diagnosis-of-mixed-states-is-nearly-impossible-heres-how-to-cope">Differential Diagnosis of Mixed States is Nearly Impossible. Here’s How to Cope. </a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/james-phelps-md">James Phelps, MD</a></span></div><p class="text-sm text-gray-500">November 12th 2024</p><p class="text-md hidden">How can you distinguish bipolar mixed states? Stay tuned in this short series. </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/what-is-cardio-metabolic-depression"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="obesity" title="obesity" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="obesity" title="obesity" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe882a13d16535d0b0e44349e93b673ddb43e2268-5472x2047.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe882a13d16535d0b0e44349e93b673ddb43e2268-5472x2047.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe882a13d16535d0b0e44349e93b673ddb43e2268-5472x2047.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/what-is-cardio-metabolic-depression">What Is Cardio-Metabolic Depression?</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/susan-j-noonan-md-mph">Susan J. Noonan, MD, MPH</a></span></div><p class="text-sm text-gray-500">November 5th 2024</p><p class="text-md hidden">Learn more about a specific subset of mood disorders.</p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/saint-itbs-protocol-shows-promise-for-bipolar-i-depression"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="bipolar" title="bipolar" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="bipolar" title="bipolar" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F738ebb291ae9b226a64c2958546f0756b62b47fc-2000x2000.jpg%3Frect%3D0%2C251%2C2000%2C1448%26fit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F738ebb291ae9b226a64c2958546f0756b62b47fc-2000x2000.jpg%3Frect%3D0%2C251%2C2000%2C1448%26fit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F738ebb291ae9b226a64c2958546f0756b62b47fc-2000x2000.jpg%3Frect%3D0%2C251%2C2000%2C1448%26fit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/saint-itbs-protocol-shows-promise-for-bipolar-i-depression">SAINT iTBS Protocol Shows Promise for Bipolar I Depression</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/kenneth-j-bender-pharmd-ma">Kenneth J. Bender, PharmD, MA</a></span></div><p class="text-sm text-gray-500">November 4th 2024</p><p class="text-md hidden">A refined rTMS protocol, the Stanford Accelerated Intelligent Neuromodulation Therapy for major depressive disorder, shows promise in bipolar disorder.</p></div></div></div></div><div class="jsx-19ede9f0a5a45918 py-4 relative px-0"><div class="jsx-19ede9f0a5a45918 "><div class="flex justify-between items-center py-1 space-x-4 border-0 select-none sm:border-b border-secondary"><div class="text-3xl text-primary ">Video Interviews</div></div></div><div style="scroll-snap-type:none" class="jsx-19ede9f0a5a45918 flex items-start overflow-x-auto space-x-4 py-4 relative mx-auto w-[calc(100%-64px)]"><a id="" class="w-[200px] h-fit space-y-3 flex-none select-none no-underline" style="scroll-snap-align:center;text-decoration:none" href="/view/a-patients-heroic-journey-continues"><div class="w-full shadow-md shadow-gray-800 overflow-hidden relative bg-white aspect-video"><span 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Varas, MD</a></div><a href="/view/dont-fear-older-medications-and-treatments-for-our-senior-patients"><span class="text-sm text-gray-500 pl-4">October 22nd 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">“Older medications” like ECT, lithium, second generation antipsychotics such as the olanzapine/fluoxetine combination, have proven efficacy.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/dont-fear-older-medications-and-treatments-for-our-senior-patients"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/low-dose-lithium-a-new-frontier-in-mental-health-treatment"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:66.71428571428571%"></span><img alt="lithium" title="lithium" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="lithium" title="lithium" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcf8995b241091a183d4d717ba742dbb75b4b5025-2800x1868.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/low-dose-lithium-a-new-frontier-in-mental-health-treatment">Low-Dose Lithium: A New Frontier in Mental Health Treatment</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/james-m-greenblatt-md">James M. 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patient population." title="A poster presented at the 2024 ASCP Annual Meeting discussed the results of a study analyzing the treatment’s safety and efficacy in this patient population." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="A poster presented at the 2024 ASCP Annual Meeting discussed the results of a study analyzing the treatment’s safety and efficacy in this patient population." title="A poster presented at the 2024 ASCP Annual Meeting discussed the results of a study analyzing the treatment’s safety and efficacy in this patient population." 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hover:border-primary" href="/view/efficacy-of-modafinil-for-treatment-of-neurocognitive-impairment-in-bipolar-disorder"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/revisiting-modafinil-armodafinil-for-the-treatment-of-bipolar-disorder"><div class=""><span 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href="/view/fda-approves-fanapt-for-mixed-manic-episodes-associated-with-bipolar-i-disorder">FDA Approves Fanapt for Mixed, Manic Episodes Associated With Bipolar I Disorder</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/fda-approves-fanapt-for-mixed-manic-episodes-associated-with-bipolar-i-disorder"><span class="text-sm text-gray-500 pl-4">April 2nd 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">The atypical antipsychotic was approved for the acute treatment of schizophrenia in 2009.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/fda-approves-fanapt-for-mixed-manic-episodes-associated-with-bipolar-i-disorder"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/an-update-on-bipolar-i-disorder"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:67.29027176053565%"></span><img alt="Our Mood Disorders Section Editor discusses the disorder in honor of World Bipolar Day." title="Our Mood Disorders Section Editor discusses the disorder in honor of World Bipolar Day." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="Our Mood Disorders Section Editor discusses the disorder in honor of World Bipolar Day." title="Our Mood Disorders Section Editor discusses the disorder in honor of World Bipolar Day." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdba7acc1e08c847d2bd54ddc1f97e9193f8affbe-5078x3417.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdba7acc1e08c847d2bd54ddc1f97e9193f8affbe-5078x3417.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdba7acc1e08c847d2bd54ddc1f97e9193f8affbe-5078x3417.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdba7acc1e08c847d2bd54ddc1f97e9193f8affbe-5078x3417.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fdba7acc1e08c847d2bd54ddc1f97e9193f8affbe-5078x3417.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, 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flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Our Mood Disorders Section Editor discusses the disorder in honor of World Bipolar Day.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/an-update-on-bipolar-i-disorder"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="flex md:hidden justify-center items-center"></div><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/bipolar-disorder-research-roundup-march-29-2024"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:40.121580547112465%"></span><img alt="What is new in research on bipolar disorder?" title="What is new in research on bipolar disorder?" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="What is new in research on bipolar disorder?" title="What is new in research on bipolar disorder?" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, 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Disorder Research Roundup: March 29, 2024</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/bipolar-disorder-research-roundup-march-29-2024"><span class="text-sm text-gray-500 pl-4">March 29th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">What is new in research on bipolar disorder?</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/bipolar-disorder-research-roundup-march-29-2024"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/recap-mood-disorders-2024"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:56.25%"></span><img alt="Here’s a look back at selections from our March content series on mood disorders." title="Here’s a look back at selections from our March content series on mood disorders." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" 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class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/recap-mood-disorders-2024"><span class="text-sm text-gray-500 pl-4">March 29th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Here’s a look back at selections from our March content series on mood disorders.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/recap-mood-disorders-2024"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div 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Here are 5 key takeaways." title="Expiring on May 20, 2024, this CME discusses how to apply several novel treatment approaches in the treatment of patients with bipolar depression. Here are 5 key takeaways." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="Expiring on May 20, 2024, this CME discusses how to apply several novel treatment approaches in the treatment of patients with bipolar depression. Here are 5 key takeaways." title="Expiring on May 20, 2024, this CME discusses how to apply several novel treatment approaches in the treatment of patients with bipolar depression. Here are 5 key takeaways." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d4be39459f4d77d18d9eefe643f698dd7fd5626-720x405.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/evidence-based-novel-therapies-for-bipolar-depression-top-5-takeaways">Evidence-Based Novel Therapies for Bipolar Depression: Top 5 Takeaways</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/evidence-based-novel-therapies-for-bipolar-depression-top-5-takeaways"><span class="text-sm text-gray-500 pl-4">March 26th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Expiring on May 20, 2024, this CME discusses how to apply several novel treatment approaches in the treatment of patients with bipolar depression. Here are 5 key takeaways.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/evidence-based-novel-therapies-for-bipolar-depression-top-5-takeaways"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/assessing-treating-and-managing-spring-mania-in-patients-with-bipolar-disorder"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:66.66666666666666%"></span><img alt="What is spring mania, and what are some effective clinical strategies for addressing it?" title="What is spring mania, and what are some effective clinical strategies for addressing it?" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="What is spring mania, and what are some effective clinical strategies for addressing it?" title="What is spring mania, and what are some effective clinical strategies for addressing it?" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F1286287da5890323c63db2e9b24e2b18bfaefc41-3318x2212.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F1286287da5890323c63db2e9b24e2b18bfaefc41-3318x2212.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, 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/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F1286287da5890323c63db2e9b24e2b18bfaefc41-3318x2212.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F1286287da5890323c63db2e9b24e2b18bfaefc41-3318x2212.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/assessing-treating-and-managing-spring-mania-in-patients-with-bipolar-disorder">Assessing, Treating, and Managing Spring Mania in Patients With Bipolar Disorder</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/roger-rivera-pmhnp">Roger Rivera, PMHNP</a></div><a href="/view/assessing-treating-and-managing-spring-mania-in-patients-with-bipolar-disorder"><span class="text-sm text-gray-500 pl-4">March 19th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">What is spring mania, and what are some effective clinical strategies for addressing it?</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/assessing-treating-and-managing-spring-mania-in-patients-with-bipolar-disorder"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/mood-disorders-in-psychiatric-times"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:56.25%"></span><img alt="Take a look back at our recent coverage relating to our March content theme." title="Take a look back at our recent coverage relating to our March content theme." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="Take a look back at our recent coverage relating to our March content theme." title="Take a look back at our recent coverage relating to our March content theme." sizes="100vw" 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theme.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/mood-disorders-in-psychiatric-times"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/adhd-research-roundup-march-1-2024"><div class=""><span 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on mood disorders this month.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/presenting-our-march-theme-mood-disorders"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/the-week-in-review-february-19-23"><div class=""><span 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md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/the-week-in-review-february-19-23">The Week in Review: February 19-23</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/the-week-in-review-february-19-23"><span class="text-sm text-gray-500 pl-4">February 24th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">From connections between bipolar disorder and cardiometabolic issues to management of agitation in emergency departments, here are highlights from the week in Psychiatric Times.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/the-week-in-review-february-19-23"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="flex md:hidden justify-center items-center"></div><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/bipolar-disorder-and-risk-of-cardiometabolic-disease-heart-failure-and-mortality"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span 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style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="“Listen to your heart.” Researchers investigated the risks of cardiometabolic disease, heart failure, and mortality in bipolar disorder in a population-based cohort study." title="“Listen to your heart.” Researchers investigated the risks of cardiometabolic disease, heart failure, and mortality in bipolar disorder in a population-based cohort study." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F98096c3af97690e41a7343d9de7f0641ada01088-5315x4000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, 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w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/bipolar-disorder-and-risk-of-cardiometabolic-disease-heart-failure-and-mortality">Bipolar Disorder and Risk of Cardiometabolic Disease, Heart Failure, and Mortality</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/brian-miller-md-phd-mph">Brian Miller, MD, PhD, MPH</a></div><a href="/view/bipolar-disorder-and-risk-of-cardiometabolic-disease-heart-failure-and-mortality"><span class="text-sm text-gray-500 pl-4">February 19th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">“Listen to your heart.” Researchers investigated the risks of cardiometabolic disease, heart failure, and mortality in bipolar disorder in a population-based cohort study.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/bipolar-disorder-and-risk-of-cardiometabolic-disease-heart-failure-and-mortality"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/bipolar-disorder-research-roundup-february-9-2024"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:40.121580547112465%"></span><img alt="What is new in research on bipolar disorder?" title="What is new in research on bipolar disorder?" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="What is new in research on bipolar disorder?" title="What is new in research on bipolar disorder?" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F66909114ce9d51481bad0717d663d2ddf567d8d9-7896x3168.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, 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style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/bipolar-disorder-research-roundup-february-9-2024">Bipolar Disorder Research Roundup: February 9, 2024</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/bipolar-disorder-research-roundup-february-9-2024"><span class="text-sm text-gray-500 pl-4">February 9th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">What is new in research on bipolar disorder?</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/bipolar-disorder-research-roundup-february-9-2024"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/the-week-in-review-january-29-february-2"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:54.93333333333334%"></span><img alt="From the impact of BMI on clinical features of bipolar disorder to FDA approval of the first integrated TMS system for MDD and OCD, here are highlights from the week in Psychiatric Times." title="From the impact of BMI on clinical features of bipolar disorder to FDA approval of the first integrated TMS system for MDD and OCD, here are highlights from the week in Psychiatric Times." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="From the impact of BMI on clinical features of bipolar disorder to FDA approval of the first integrated TMS system for MDD and OCD, here are highlights from the week in Psychiatric Times." title="From the impact of BMI on clinical features of bipolar disorder to FDA approval of the first integrated TMS system for MDD and OCD, here are highlights from the week in Psychiatric Times." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, 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text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/the-impact-of-bmi-on-clinical-features-of-bipolar-disorder"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span 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Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study." title="“Weight” a minute! Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="“Weight” a minute! Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study." title="“Weight” a minute! Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe417fbe3301dcf4ec6cd72272e541e369e287487-5208x3512.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/the-impact-of-bmi-on-clinical-features-of-bipolar-disorder">The Impact of BMI on Clinical Features of Bipolar Disorder</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/brian-miller-md-phd-mph">Brian Miller, MD, PhD, MPH</a></div><a href="/view/the-impact-of-bmi-on-clinical-features-of-bipolar-disorder"><span class="text-sm text-gray-500 pl-4">February 1st 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">“Weight” a minute! Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/the-impact-of-bmi-on-clinical-features-of-bipolar-disorder"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/psychiatry-in-the-news-january-2024"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:67.01235657546337%"></span><img alt="Here are some updates from the world of psychiatry throughout the month of January." title="Here are some updates from the world of psychiatry throughout the month of January." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="Here are some updates from the world of psychiatry throughout the month of January." title="Here are some updates from the world of psychiatry throughout the month of January." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe7b500cdc6fd0137272c9abec27693c2b565e76c-4532x3037.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe7b500cdc6fd0137272c9abec27693c2b565e76c-4532x3037.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, 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January 2024</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/psychiatry-in-the-news-january-2024"><span class="text-sm text-gray-500 pl-4">January 30th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Here are some updates from the world of psychiatry throughout the month of January.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/psychiatry-in-the-news-january-2024"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/chemotherapy-induced-psychosis-treated-with-clozapine"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:45.34222881146528%"></span><img alt="youth chemotherapy" title="youth chemotherapy" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="youth chemotherapy" title="youth chemotherapy" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcff1805ec69da31b1e8fcfc9ffec223440c3dee7-4047x1835.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcff1805ec69da31b1e8fcfc9ffec223440c3dee7-4047x1835.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fcff1805ec69da31b1e8fcfc9ffec223440c3dee7-4047x1835.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, 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href="/authors/gabrielle-young">Gabrielle Young, MS-4</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/kyle-hodges-md">Kyle Hodges, MD, PGY-4, CAP Fellow</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/taha-ansari-md">Taha Ansari, MD</a></div><a href="/view/chemotherapy-induced-psychosis-treated-with-clozapine"><span class="text-sm text-gray-500 pl-4">January 15th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Examine a case of an adolescent with psychosis that seemed to develop during chemotherapy treatment. </p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/chemotherapy-induced-psychosis-treated-with-clozapine"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div></div><div class="w-full text-center flex justify-center pb-24"><a class="px-4 py-2 border-y border-r bg-primary text-white" href="/topics/bipolar?page=1">1</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=2">2</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=3">3</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=4">4</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=5">5</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=6">6</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=7">7</a><a class="px-4 py-2 border-y border-r " href="/topics/bipolar?page=8">8</a><div class="px-4 py-2 border-y border-r">...</div><a class="px-4 py-2 border-y border-r" href="/topics/bipolar?page=38">38</a><a class="px-4 py-2 border-y border-r" href="/topics/bipolar?page=2">></a></div></div></div><div class="flex-none w-[300px] 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","published":"2024-01-15T15:00:00.000Z","_id":"ae4b05f5-617f-4150-8887-19eb913722ff","title":"Chemotherapy-Induced Psychosis Treated With Clozapine in an Adolescent With Metastatic Nasopharyngeal Carcinoma "}],"targeting":{"content_placement":["topics/bipolar"],"document_url":["topics/bipolar"],"document_group":[],"rootDocumentGroup":[],"hostname":"www.psychiatrictimes.com"},"currentTopic":{"name":"Bipolar Disorder","thumbnail":null,"summary":null,"url":"topics/bipolar","ptceKeywordMapping":null,"parent":{"_id":"pst_taxonomy_53202_clinical","name":"Topics","url":"topics","parent":null},"_id":"pst_taxonomy_52_bipolardisorder","cmeType":"per","perKeywordMapping":["Psychiatry","Neurology"],"pixelTrackingCode":null},"filterData":[{"filter":{"filterKey":"content_category","_key":"2753613c2144","filterLabel":"Content Type","filterType":"Content Category"},"data":[{"_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","label":"Articles","value":"8bdaa7fc-960a-4b57-b076-75fdce3741bb"},{"_id":"93d57b69-2d72-45fe-8b8a-d18e7e7e5f20","label":"Podcasts","value":"93d57b69-2d72-45fe-8b8a-d18e7e7e5f20"},{"_id":"9e4880fc-85b8-4ffb-a066-79af8dfaa4e1","label":"Poll","value":"9e4880fc-85b8-4ffb-a066-79af8dfaa4e1"},{"_id":"61085300-0cae-4cd1-b0e8-26323ac5c2e6","label":"Slideshows","value":"61085300-0cae-4cd1-b0e8-26323ac5c2e6"},{"_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","label":"Videos","value":"42000fd0-0d05-4832-9f2c-62c21079b76c"}]}],"relatedTopics":[{"name":"Mania","url":"topics/mania"}],"podcastsData":[{"_createdAt":"2021-08-04T21:01:40Z","_rev":"2e3RFwNshS6Ov2zYmS3Wlz","url":{"current":"blue-light-depression-bipolar-disorder","_type":"slug"},"seoTag":["blue light","bipolar disorder","light therapy","depression"],"updatedOn":null,"summary":"Blue light is associated with a host of physical health maladies, including obesity, diabetes, and cancer. But what does it do to patients with depression or bipolar disorder? ","authorMapping":[{"_ref":"pst_author_319066","_type":"reference","_key":"2bcb06930366"},{"_type":"reference","_key":"74b220fd3407","_ref":"036e6709-7d53-4bc6-8207-b973c4a31149"}],"body":[{"_type":"iframe","_key":"cbb7372e32a8","url":"https://embeds.audioboom.com/posts/7916773/embed/v4"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"PSYCHPEARLS PODCAST","_key":"4f21a026bfd5"}],"_type":"block","style":"normal","_key":"c6141bf73f39"},{"style":"normal","_key":"0ce7ac78ec27","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Blue light is getting blamed for everything from eye strain to cancer lately, but what does it do to our patients with depression and bipolar disorder. A lot, as you will see in this podcast, but it depends on what time of day it is shining.","_key":"42ef81dde900"}],"_type":"block"},{"_type":"block","style":"normal","_key":"c3b8c78f0b23","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Welcome to ","_key":"cf7c6d416e77"},{"_type":"span","marks":["em"],"text":"PsychPearls","_key":"421a89ac820f"},{"_type":"span","marks":[],"text":" podcast with ","_key":"658381dface0"},{"text":"Psychiatric Times","_key":"0b34a41d150b","_type":"span","marks":["em"]},{"_type":"span","marks":["superscript"],"text":"TM","_key":"f1c17b9b6f6d"},{"_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.","_key":"09b937be1cc2"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"I am Chris Aiken, the Mood Disorders Section Editor for ","_key":"45f747d6d2870"},{"_key":"45f747d6d2871","_type":"span","marks":["em"],"text":"Psychiatric Times"},{"_type":"span","marks":["superscript"],"text":"TM","_key":"45f747d6d2872"},{"text":" and the editor-in-chief of the ","_key":"32b93f150fca","_type":"span","marks":[]},{"_key":"45f747d6d2873","_type":"span","marks":["em"],"text":"Carlat Psychiatry Report"},{"_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","style":"normal","_key":"39ad44d598f1"},{"markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/27003509/","_key":"bac1b3c2ef23","blank":true,"_type":"link"}],"children":[{"marks":["strong"],"text":"KELLIE NEWSOME","_key":"d1455b93455a0","_type":"span"},{"_type":"span","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"},{"_key":"d1455b93455a2","_type":"span","marks":["em"],"text":"fragile circadian rhythm disorder"},{"_key":"d1455b93455a3","_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 "},{"marks":["bac1b3c2ef23"],"text":"helps repair","_key":"d1455b93455a4","_type":"span"},{"_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"}],"_type":"block","style":"normal","_key":"239eecfdf79a"},{"_type":"block","style":"normal","_key":"8e6c07968206","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/31752508/","_key":"ed28a788ed94"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/22928852/","_key":"ed3b68891817"},{"_key":"ee35d391dbe3","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/9491067/ "},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33445959/","_key":"b4a08f32b065"},{"_key":"0800ecbbb104","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/28327443/"},{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33511988/","_key":"557de951cfbb","blank":true}],"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,"},{"text":" ","_key":"a3bc99ec315c","_type":"span","marks":[]},{"marks":["ee35d391dbe3"],"text":"substance use disorders","_key":"b00f7a39ed7d4","_type":"span"},{"_type":"span","marks":[],"text":", ","_key":"b00f7a39ed7d5"},{"marks":["b4a08f32b065"],"text":"schizophrenia","_key":"b00f7a39ed7d6","_type":"span"},{"marks":[],"text":", ","_key":"b00f7a39ed7d7","_type":"span"},{"_type":"span","marks":["0800ecbbb104"],"text":"ADHD","_key":"b00f7a39ed7d8"},{"marks":[],"text":", and ","_key":"b00f7a39ed7d9","_type":"span"},{"_type":"span","marks":["557de951cfbb"],"text":"PTSD","_key":"b00f7a39ed7d10"},{"_key":"b00f7a39ed7d11","_type":"span","marks":[],"text":"."}]},{"style":"normal","_key":"0c418fb55b98","markDefs":[],"children":[{"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":"span"}],"_type":"block"},{"_key":"6832c40ad7fd","markDefs":[],"children":[{"text":"Blue Light and Melatonin","_key":"ce5ee2435bd30","_type":"span","marks":["strong"]}],"_type":"block","style":"normal"},{"_type":"block","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"}]},{"_key":"a03b7244f79a","markDefs":[],"children":[{"_type":"span","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":"block","style":"normal"},{"style":"normal","_key":"89a43ad76a43","markDefs":[],"children":[{"_type":"span","marks":[],"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":"block"},{"_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"},{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197518/","_key":"8d3959b7359f","blank":true}],"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"},{"marks":["e505517b5683"],"text":"position statement","_key":"fdf67374f36d2","_type":"span"},{"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","marks":[]},{"_key":"fdf67374f36d4","_type":"span","marks":["9934cc4b7b79"],"text":"pediatric sleep recommendations"},{"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","_type":"span"},{"_key":"fdf67374f36d6","_type":"span","marks":["8d3959b7359f"],"text":"stronger recommendations"},{"_type":"span","marks":[],"text":".","_key":"fdf67374f36d7"}],"_type":"block","style":"normal"},{"_key":"ca56139394bd","markDefs":[],"children":[{"_key":"e4e192be989a0","_type":"span","marks":["strong"],"text":"KELLIE NEWSOME"},{"_type":"span","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","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","style":"normal"},{"_type":"block","style":"normal","_key":"5c36e1cc6f17","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"A Slightly Broken Biological Clock","_key":"bd85a0227fe70"}]},{"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN","_key":"327d4b3110350"},{"_key":"327d4b3110351","_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."},{"_type":"span","marks":["superscript"],"text":"6","_key":"061e4cc8e525"},{"marks":[],"text":" Circadian disruptions often trigger new episodes of mania and depression, such as shift work, seasonal changes, and travel across multiple time zones.","_key":"cc05a5b4574e","_type":"span"},{"_type":"span","marks":["superscript"],"text":"8","_key":"13c497d81396"}],"_type":"block","style":"normal","_key":"41b0a3f52869","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"5d7ea200881d0"},{"_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.","_key":"5d7ea200881d1"}],"_type":"block","style":"normal","_key":"463c9808423c"},{"style":"normal","_key":"4510d4cf2335","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN","_key":"f86bd6a2eb6f0"},{"_type":"span","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","marks":["superscript"],"text":"9","_key":"3ec1792dafeb"},{"_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":"dae029234345"},{"_type":"span","marks":["superscript"],"text":"6,10","_key":"cd909c8f133c"},{"_type":"span","marks":[],"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":["superscript"],"text":"8,10","_key":"f7c07077d71d"}],"_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"}],"_type":"block"},{"style":"normal","_key":"642d28d32295","markDefs":[{"_type":"link","href":"http://www.psychiatrictimes.com/bipolar-disorder/new-tool-springtime-mania","_key":"4b9113897ed0"}],"children":[{"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"},{"_key":"b2ae5bd61f74","_type":"span","marks":["superscript"],"text":"12"},{"_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"},{"_type":"span","marks":[],"text":" Human studies have found a strong link between rapid flux of ","_key":"e01792ee464a"},{"marks":["4b9113897ed0"],"text":"spring sunlight","_key":"77863a8772a61","_type":"span"},{"text":" and earlier onset of bipolar disorder.","_key":"77863a8772a62","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"14","_key":"cf783fc01f15"}],"_type":"block"},{"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","style":"normal","_key":"1b720ab37bf1"},{"_key":"83db89ed004f","markDefs":[],"children":[{"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. 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Today, we will address 4 of them.","_key":"71338ce3cff21"}],"_type":"block","style":"normal"},{"_key":"34fc570ee2b6","markDefs":[],"children":[{"text":"Welcome to ","_key":"e9fd90e430050","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"PsychPearls","_key":"e9fd90e430051"},{"_type":"span","marks":[],"text":" podcast with ","_key":"e9fd90e430052"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"e9fd90e430053"},{"_type":"span","marks":["superscript"],"text":"TM","_key":"e9fd90e430054"},{"_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 it.","_key":"55b4e2909f49"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"308fc4380485","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"},{"_key":"ea53b84443742","_type":"span","marks":["superscript"],"text":"TM"},{"_key":"2a1d567b6175","_type":"span","marks":[],"text":" and the editor-in-chief of the "},{"marks":["em"],"text":"Carlat Psychiatry Report","_key":"ea53b84443743","_type":"span"},{"_key":"ea53b84443744","_type":"span","marks":[],"text":", and I am Kellie Newsome, a psychiatric NP and the cohost of the "},{"text":"Carlat Psychiatry Podcast","_key":"ea53b84443745","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":".","_key":"ea53b84443746"}]},{"_type":"block","style":"normal","_key":"9e73ca7194e2","markDefs":[],"children":[{"marks":["strong"],"text":"A Quiet Launch","_key":"86ea5d507ff30","_type":"span"}]},{"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"}],"_type":"block","style":"normal","_key":"a63f35be65e5"},{"children":[{"_type":"span","marks":[],"text":"But bipolar disorder (BD) is a chronic condition, and that is where the medication succeeded: in the maintenance phase.","_key":"9d8e4fd3af040"}],"_type":"block","style":"normal","_key":"c0eb9ce72ebb","markDefs":[]},{"style":"normal","_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"},{"_key":"73fb7856ebbe","_type":"span","marks":["superscript"],"text":"1"},{"_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"},{"_type":"block","style":"normal","_key":"184030a32757","markDefs":[],"children":[{"marks":["strong"],"text":"CHRIS AIKEN:","_key":"e07cb217d3d60","_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.","_key":"e07cb217d3d61","_type":"span"}]},{"children":[{"text":"A Warning","_key":"75b3c80a10a30","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"233f91ee925a","markDefs":[]},{"_key":"7117c4dbf031","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"3959c05423550"},{"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","_type":"span"},{"_type":"span","marks":["superscript"],"text":"2","_key":"0fbe71658c79"},{"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","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_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"}]},{"_key":"c81541e1df53","markDefs":[],"children":[{"_type":"span","marks":[],"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":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"6fbf95ee9eec0","_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:"},{"_type":"span","marks":[],"text":" And now let us get into those myths. There are 4 of them.","_key":"6fbf95ee9eec1"}],"_type":"block","style":"normal","_key":"fc3dcfb76df8"},{"_key":"842419cc5dfe","markDefs":[],"children":[{"marks":[],"text":"Myth #1: Lamotrigine does not help mania","_key":"9731eb6e18c90","_type":"span"}],"_type":"block","style":"normal"},{"style":"normal","_key":"28425af347c4","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Myth #2: Lamotrigine does not treat acute episodes of bipolar depression","_key":"1d6c4971e1980"}],"_type":"block"},{"_type":"block","style":"normal","_key":"90e174ac7e84","markDefs":[],"children":[{"marks":[],"text":"Myth #3: Lamotrigine is a weak mood stabilizer","_key":"a2875e7deb100","_type":"span"}]},{"_key":"fa86dd8111b0","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"},{"style":"normal","_key":"eb46f4b7a0af","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Myth #1: Lamotrigine Does not Help Mania","_key":"6e5992c2c46f0"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"ae0762d35ea90"},{"_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":[]},{"children":[{"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":[]},{"text":"4,5","_key":"b9fcb60198b3","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"3011d070f04a","markDefs":[]},{"children":[{"marks":["strong"],"text":"Myth #2: Lamotrigine Does Treat Acute Episodes of Bipolar Depression","_key":"facc22eea3890","_type":"span"}],"_type":"block","style":"normal","_key":"bc02774e1673","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"1512b45c33820"},{"_key":"1512b45c33821","_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."}],"_type":"block","style":"normal","_key":"16a54e6b696b"},{"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"},{"text":"6,7","_key":"3f7f57eb6ddf","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"5943f97d91b3"},{"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"1672bd87395e0"},{"_type":"span","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":"block","style":"normal","_key":"0b93e13917dc","markDefs":[]},{"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","_key":"80917ad9e22c"},{"_key":"c117b51331c0","markDefs":[],"children":[{"_key":"2d03b35c77350","_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:"},{"_type":"span","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","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","style":"normal"},{"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"}],"_type":"block"},{"_type":"block","style":"normal","_key":"2629a4935e8d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"b8f816b9efef0"},{"_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.","_key":"b8f816b9efef1"},{"_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"}]},{"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"602738f0ff8b0"},{"marks":[],"text":": Are you off your soap box yet?","_key":"602738f0ff8b1","_type":"span"}],"_type":"block","style":"normal","_key":"e770fed2200f","markDefs":[]},{"_key":"d5851fb382bb","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"c1859d28767c0"},{"_key":"c1859d28767c1","_type":"span","marks":[],"text":" No, I have one more thing to say. The "},{"_type":"span","marks":["em"],"text":"DSM","_key":"c1859d28767c2"},{"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":"span"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"281873e8c0d3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"69bc2c73c4fe0"},{"_key":"69bc2c73c4fe1","_type":"span","marks":[],"text":" OK, can we get back to lamotrigine now."}]},{"children":[{"_key":"a045c4658a1e0","_type":"span","marks":["strong"],"text":"Myth #3: Lamotrigine Is a Weak Mood Stabilizer"}],"_type":"block","style":"normal","_key":"1c2d625d230e","markDefs":[]},{"_key":"22b7dd918fb9","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"af6b65c916ab0"},{"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"}],"_type":"block","style":"normal"},{"style":"normal","_key":"28aae8f32b92","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Individuals with bipolar disorder die 10 years earlier on average, and not from suicide. Kellie, can you read the top causes of death in bipolar disorder","_key":"6dbec22f80e90"},{"_type":"span","marks":["superscript"],"text":"10","_key":"88e0210b2ee1"},{"_type":"span","marks":[],"text":":","_key":"6c7ff3169e66"}],"_type":"block"},{"markDefs":[],"children":[{"text":"Stroke","_key":"cc0d7696d8210","_type":"span","marks":["em"]}],"_type":"block","style":"normal","_key":"5b8045ad2141"},{"children":[{"text":"Heart disease","_key":"279f0a7387960","_type":"span","marks":["em"]}],"_type":"block","style":"normal","_key":"a334e977573d","markDefs":[]},{"children":[{"_type":"span","marks":["em"],"text":"Cancer","_key":"fc3cd57353fe0"}],"_type":"block","style":"normal","_key":"d478f377ef13","markDefs":[]},{"children":[{"text":"Diabetes","_key":"f20c00c3b8e90","_type":"span","marks":["em"]}],"_type":"block","style":"normal","_key":"e7d523a20836","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["em"],"text":"Chronic obstructive pulmonary disease (COPD)","_key":"4e21580caa460"}],"_type":"block","style":"normal","_key":"93584cb57e2c"},{"children":[{"text":"Pneumonia and influenza","_key":"6f7027a8179e0","_type":"span","marks":["em"]}],"_type":"block","style":"normal","_key":"37211411d6f4","markDefs":[]},{"style":"normal","_key":"31192940618e","markDefs":[],"children":[{"text":"Accidental injuries","_key":"bc3d2a45ab910","_type":"span","marks":["em"]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["em"],"text":"Suicide","_key":"af30477033fe0"}],"_type":"block","style":"normal","_key":"5f68a3d04a0b"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/28976944/","_key":"0fb886e1546c"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/26394555/","_key":"d41529e80f4d"}],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"c84f7e8587670"},{"text":" Right, so if you can find a mood stabilizer that reduces those risks, or at least does not increase them, that is golden. Lamotrigine is neutral on all of them, and ","_key":"c84f7e8587671","_type":"span","marks":[]},{"marks":["0fb886e1546c"],"text":"lithium brings down","_key":"c84f7e8587672","_type":"span"},{"text":" most of them. Specifically, lithium lowers the risk of heart disease, ","_key":"c84f7e8587673","_type":"span","marks":[]},{"_type":"span","marks":["d41529e80f4d"],"text":"stroke","_key":"c84f7e8587674"},{"_type":"span","marks":[],"text":", cancer, viral infections, and suicide.","_key":"c84f7e8587675"}],"_type":"block","style":"normal","_key":"3c9ab1d299ba"},{"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"49567e5202790"},{"_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"},{"_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":"0696b2340ef6"},{"_type":"span","marks":["superscript"],"text":"3","_key":"e33cb03a7664"}],"_type":"block","style":"normal","_key":"0c8384d790a6","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"922aa9e34a480"},{"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":"836bb2d48eed","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"And that brings us to the fourth myth.","_key":"4208a7ebf9fb0"}],"_type":"block","style":"normal","_key":"2fecb70096c1"},{"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","markDefs":[]},{"style":"normal","_key":"87a3bcf042c3","markDefs":[],"children":[{"marks":["strong"],"text":"KELLIE NEWSOME:","_key":"e6e53933eaea0","_type":"span"},{"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","_type":"span","marks":[]}],"_type":"block"},{"style":"blockquote","_key":"0027df6157f5","markDefs":[],"children":[{"_type":"span","marks":[],"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":"block"},{"style":"normal","_key":"adc73736bb44","markDefs":[],"children":[{"_type":"span","marks":[],"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":["em"],"text":"The Pocket Psychiatrist","_key":"2befe2137c4f1"},{"_type":"span","marks":[],"text":" in your podcast store.","_key":"2befe2137c4f2"}],"_type":"block"},{"_type":"block","style":"normal","_key":"0bae815f4e09","markDefs":[],"children":[{"_key":"6413e50b25ef0","_type":"span","marks":["strong"],"text":"CHRIS AIKEN:"},{"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"}]},{"markDefs":[],"children":[{"text":"KELLIE NEWSOME:","_key":"b02c937742660","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" What is that?","_key":"b02c937742661"}],"_type":"block","style":"normal","_key":"2cc02bd19ecc"},{"_key":"29ed580449f0","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18402630/","_key":"3c66a7c96c61"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/20846461/","_key":"230edd4b803d"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/29944976/","_key":"b9eb677aeb0e"}],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN:","_key":"db377cc4db680"},{"text":" They say they still feel the same about whatever problems they were having in life, but the feelings are less overwhelming. They see things in perspective better. And that matches up with what we see in neuroimaging studies of lamotrigine. The ","_key":"db377cc4db681","_type":"span","marks":[]},{"marks":["3c66a7c96c61"],"text":"amygdala","_key":"db377cc4db682","_type":"span"},{"marks":[],"text":" is less reactive to emotionally disturbing images, there is a rise in brain-strengthening ","_key":"db377cc4db683","_type":"span"},{"marks":["230edd4b803d"],"text":"BDNF","_key":"db377cc4db684","_type":"span"},{"_type":"span","marks":[],"text":" in the amygdala and frontal lobes. Overall, there are volumetric changes in ","_key":"db377cc4db685"},{"_type":"span","marks":["b9eb677aeb0e"],"text":"both the amygdala","_key":"db377cc4db686"},{"text":", which react to emotional events, and the frontal lobes, which temper those emotions and help individuals see things in perspective.","_key":"db377cc4db687","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"a0300ccfb78f","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"93a934eb15090"},{"text":" That sounds like something we could all use.","_key":"93a934eb15091","_type":"span","marks":[]}]},{"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN: ","_key":"1642a9ca5c050"},{"_type":"span","marks":[],"text":"Hold it there! This medication is not for everyone, and those imaging studies were done in individuals with bipolar disorder.","_key":"1642a9ca5c051"}],"_type":"block","style":"normal","_key":"c2f1a26e12a2","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME:","_key":"e6fe8654b7a60"},{"_type":"span","marks":[],"text":" Always on your soapbox. 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Raised in Tasmania, Australia, Kellie moved to the United States in 1998."}],"_type":"block","style":"normal","_key":"5e4b37aba878"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"0086abeb16ef0"}],"_type":"block","style":"normal","_key":"b6fb9b783ff9"},{"_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"},{"text":"A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder.","_key":"0086abeb16ef2","_type":"span","marks":["cae9f0acfc3e"]},{"_type":"span","marks":[],"text":" ","_key":"cc80060fd5b1"},{"marks":["em"],"text":"J Clin Psychiatry. ","_key":"0086abeb16ef3","_type":"span"},{"_type":"span","marks":[],"text":"2004;65(3):432-441.","_key":"0086abeb16ef4"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"65bca383bfcd","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/23945444","_key":"cb083527de84"}],"children":[{"_type":"span","marks":[],"text":"2. Reid JG, Gitlin MJ, Altshuler LL. ","_key":"cb46d4e52c3d0"},{"_type":"span","marks":["cb083527de84"],"text":"Lamotrigine in psychiatric disorders.","_key":"cb46d4e52c3d1"},{"_type":"span","marks":[],"text":" ","_key":"d028c0590145"},{"_key":"cb46d4e52c3d2","_type":"span","marks":["em"],"text":"J Clin Psychiatry. "},{"_type":"span","marks":[],"text":"2013;74:675-684.","_key":"cb46d4e52c3d3"}]},{"markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/20532155","_key":"3676c2e5698d","blank":true}],"children":[{"text":"3. Aiken CB, Orr C. ","_key":"66b2ea74dbaa0","_type":"span","marks":[]},{"_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"},{"_key":"66b2ea74dbaa2","_type":"span","marks":["em"],"text":"Psychiatry (Edgmont)."},{"marks":[],"text":" 2010;7:27-32.","_key":"66b2ea74dbaa3","_type":"span"}],"_type":"block","style":"normal","_key":"2f89a580de66"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/15708424","_key":"96923a3ac473"}],"children":[{"text":"4. Manning JS, Haykal RF, Connor PD, et al. ","_key":"c24cc23d45300","_type":"span","marks":[]},{"marks":["96923a3ac473"],"text":"Sustained remission with lamotrigine augmentation or monotherapy in female resistant depressives with mixed cyclothymic-dysthymic temperament.","_key":"c24cc23d45301","_type":"span"},{"marks":[],"text":" ","_key":"bfeb38779038","_type":"span"},{"_type":"span","marks":["em"],"text":"J Affect Disord","_key":"c24cc23d45302"},{"_key":"c24cc23d45303","_type":"span","marks":[],"text":". 2005;84:259-266."}],"_type":"block","style":"normal","_key":"a15b3b40d8a6"},{"markDefs":[{"href":"https://www.ncbi.nlm.nih.gov/pubmed/17543894","_key":"187a40acf134","blank":true,"_type":"link"}],"children":[{"text":"5. Goldberg JF, Bowden CL, Calabrese JR. ","_key":"6ace62fc6dc00","_type":"span","marks":[]},{"_type":"span","marks":["187a40acf134"],"text":"Six-month prospective life charting of mood symptoms with lamotrigine monotherapy versus placebo in rapid cycling bipolar disorder.","_key":"6ace62fc6dc01"},{"_type":"span","marks":[],"text":" ","_key":"5fc86f51e0d0"},{"text":"Biol Psychiatry. ","_key":"6ace62fc6dc02","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":"2008;63:125-130.","_key":"6ace62fc6dc03"}],"_type":"block","style":"normal","_key":"3ee2ca0f1314"},{"_type":"block","style":"normal","_key":"f84a85c441b5","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/19200421/","_key":"4f3e3374b5eb"}],"children":[{"_type":"span","marks":[],"text":"6. van der Loos ML, Mulder PG, Hartong EG, et al. 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","_key":"5c04356878640"},{"marks":["d25b8125fe71"],"text":"Comparative evaluation of quetiapine plus lamotrigine combination versus quetiapine monotherapy (and folic acid versus placebo) in bipolar depression (CEQUEL): a 2 × 2 factorial randomised trial.","_key":"5c04356878641","_type":"span"},{"marks":[],"text":" ","_key":"75925d39e853","_type":"span"},{"_type":"span","marks":["em"],"text":"Lancet Psychiatry.","_key":"5c04356878642"},{"text":" 2016;3(1):31-39.","_key":"5c04356878643","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"bd050daa3174"},{"_type":"block","style":"normal","_key":"d0c83638a87c","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/19118318/","_key":"f93d20109330","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"8. Geddes JR, Calabrese JR, Goodwin GM. ","_key":"cb2ec9751ef50"},{"_type":"span","marks":["f93d20109330"],"text":"Lamotrigine for treatment of bipolar depression: independent meta-analysis and meta-regression of individual patient data from five randomised trials.","_key":"cb2ec9751ef51"},{"_key":"5d14dda89d2d","_type":"span","marks":[],"text":" "},{"_key":"cb2ec9751ef52","_type":"span","marks":["em"],"text":"Br J Psychiatry."},{"text":" 2009;194(1):4-9.","_key":"cb2ec9751ef53","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"ae060359e6cb","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/30295208/","_key":"dcc11945c08e"}],"children":[{"marks":[],"text":"9. Chen PH, Tsai SY, Pan CH, et al. ","_key":"623952ebbc6c0","_type":"span"},{"marks":["dcc11945c08e"],"text":"Mood stabilisers and risk of stroke in bipolar disorder.","_key":"623952ebbc6c1","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"6999516a6498"},{"_type":"span","marks":["em"],"text":"Br J Psychiatry. ","_key":"623952ebbc6c2"},{"_type":"span","marks":[],"text":"2019;215(1):409-414.","_key":"623952ebbc6c3"}]},{"_key":"18aa6e256b3d","markDefs":[{"_type":"link","href":"https://www.amazon.com/gp/product/0393711749/ref=as_li_tl?ie=UTF8\u0026camp=1789\u0026creative=9325\u0026creativeASIN=0393711749\u0026linkCode=as2\u0026tag=moodtreat-20\u0026linkId=88606ece52b85700862e59ad28605234","_key":"47fc633a7344","blank":true}],"children":[{"_key":"6421bc0dc8380","_type":"span","marks":[],"text":"10. Aiken C, Phelps J. "},{"text":"Bipolar, Not So Much","_key":"6421bc0dc8381","_type":"span","marks":["47fc633a7344","em"]},{"_type":"span","marks":[],"text":". W.W. Norton \u0026 Company; 2017.","_key":"6421bc0dc8382"}],"_type":"block","style":"normal"}],"title":"Four Myths About Lamotrigine","_type":"article","link":"/view/four-myths-lamotrigine","published":"2021-08-03T16:27:09.998Z","pdfUrl":{"_type":"media","poster":{"_type":"image","asset":{"_ref":"image-882c03d79aad20809abba7ed419641756c66f364-3000x3000-jpg","_type":"reference"}}}},{"_createdAt":"2021-05-18T19:28:50Z","is_visible":true,"published":"2021-05-18T19:47:55.144Z","_rev":"QlxMIJwdKik1eFFIotg54n","_type":"article","body":[{"_type":"iframe","_key":"dbf24f849db4","url":"https://embeds.audioboom.com/posts/7869103/embed/v4"},{"style":"normal","_key":"fb2ef79ea2e6","markDefs":[{"href":"https://www.psychiatrictimes.com/view/sedation-ups-downs-side-effect","_key":"7238a2d6c2cc","_type":"link"}],"children":[{"_type":"span","marks":["strong"],"text":"PSYCHPEARLS PODCAST","_key":"ba315bd5f28a"}],"_type":"block"},{"style":"normal","_key":"186186786d31","markDefs":[],"children":[{"_type":"span","marks":["em"],"text":"Transcript edited for clarity. -Ed","_key":"c22b4187f86e"}],"_type":"block"},{"children":[{"marks":["strong"],"text":"CHRIS AIKEN: ","_key":"ee1890ee0612","_type":"span"},{"_type":"span","marks":[],"text":"I have an unhealthy fear of certain medications. Tricyclics, MAOIs, and lithium. All of these have a reputation for adverse effects that is – perhaps – unearned. In practice, I’m constantly surprised by how well-tolerated they turn out to be. In the case of lithium, that surprise has been confirmed both in medical research and patient surveys. When it comes to the side effects that matter most to patients – sedation,","_key":"8198f79be790"},{"_type":"span","marks":["superscript"],"text":"1","_key":"e887100f1779"},{"text":" weight gain,","_key":"757305e083e5","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"1","_key":"cef7757bd28c"},{"_type":"span","marks":[],"text":" and cognition","_key":"ee268409f3fa"},{"marks":["superscript"],"text":"2,3","_key":"ff7195515315","_type":"span"},{"_type":"span","marks":[],"text":" – lithium’s tolerability ranks right behind lamotrigine if we look at the clinical research. For example, the ","_key":"3e323b3d2ddc"},{"_type":"span","marks":["7238a2d6c2cc"],"text":"risk of sedation","_key":"3bfc12f67106"},{"_type":"span","marks":[],"text":" is only 1 in 16 to 1 in 27 on lithium, compared to 1 in 5 for many other mood stabilizers.","_key":"6edc1d3e2a46"}],"_type":"block","style":"normal","_key":"1da49aa8c5a1","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/sedation-ups-downs-side-effect","_key":"7238a2d6c2cc"}]},{"children":[{"_type":"span","marks":[],"text":"But let’s look beyond the clinical research. A few years ago a Google company called CureTogether posted ","_key":"ac2dce52fe0d0"},{"marks":["394727f8513d"],"text":"an online survey","_key":"ac2dce52fe0d1","_type":"span"},{"_type":"span","marks":[],"text":" asking people with bipolar disorder what they found most helpful in their recovery. Over 3000 responded, and only 2 medications made their top 10 list: Lamotrigine and lithium. The rest of the top 10 were behavioral tools.","_key":"ac2dce52fe0d2"}],"_type":"block","style":"normal","_key":"e99092d0dcaa","markDefs":[{"_key":"394727f8513d","blank":true,"_type":"link","href":"http://curetogether.com/bipolar-disorder/ig/treatment-effectiveness-vs-popularity"}]},{"style":"normal","_key":"24790e457688","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME: ","_key":"5fef0907e0110"},{"_type":"span","marks":[],"text":"Let’s read all 10 of them:","_key":"5fef0907e0111"}],"_type":"block"},{"_key":"fb8df089dbae","markDefs":[],"children":[{"_type":"span","marks":[],"text":"1. Regimented sleep","_key":"e904cbd740b60"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Reducing alcohol","_key":"380de632bb010"}],"_type":"block","style":"normal","_key":"0bd946a74d1a"},{"_key":"df64729c4602","markDefs":[],"children":[{"marks":[],"text":"3. Exercise","_key":"b24f73ec41a20","_type":"span"}],"_type":"block","style":"normal"},{"_key":"eebffa4d1355","markDefs":[],"children":[{"text":"4. Lamotrigine","_key":"e9134dd9a9d10","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"305925cc063f","markDefs":[],"children":[{"marks":[],"text":"5. Sunlight","_key":"b131c1ac19cf0","_type":"span"}]},{"children":[{"_key":"8aad23c2924a0","_type":"span","marks":[],"text":"6. Mindfulness"}],"_type":"block","style":"normal","_key":"0c7343cf7c6b","markDefs":[]},{"children":[{"_key":"a4f272a4b84f0","_type":"span","marks":[],"text":"7. Psychotherapy"}],"_type":"block","style":"normal","_key":"0a08a693d2d1","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"8. Self-tracking \u0026 journaling","_key":"28f57398dc8d0"}],"_type":"block","style":"normal","_key":"9c3131f5eaf4"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"9. Reducing caffeine","_key":"9b26dcbc65df0"}],"_type":"block","style":"normal","_key":"c8e289375400"},{"children":[{"_type":"span","marks":[],"text":"10. Lithium","_key":"d6640c05b85f0"}],"_type":"block","style":"normal","_key":"3a2ed32000ee","markDefs":[]},{"_key":"9456846de4b1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Most of the lithium’s adverse effects are manageable, and in this podcast we’ll show you how to do it. To start with, titrate lithium slowly. Lithium’s main benefits are in long-term prevention, so there’s usually no reason to rush it (unless you are trying to help a manic patient stay out of the hospital). Start with 300 mg at night and raise it by 300 mg every 5-7 days. Cut those numbers in half if the patient is frail, elderly, or is taking a medication like a thiazide diuretic that can raise lithium.","_key":"f43ad7aa970c0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"4f619373b4eb","markDefs":[],"children":[{"text":"The main reason people stop lithium in the early phase is nausea. A slow release version will reduce that risk, as will taking the lithium after a meal or with a glass of milk. Most other adverse effects improve with slow release as well – it cuts their overall rate by about 50% - except one: diarrhea. 4 Patients with diarrhea on lithium due better with instant release lithium that gets in and out of their system faster.","_key":"bda7c41c76580","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"8","_key":"78e4a9a2e802"}]},{"_type":"block","style":"normal","_key":"3954693d16b3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Common remedies for nausea (eg, ondansetron, promethazine, ginger capsules) or diarrhea (eg, loperamide, milk of magnesia) are safe to take with lithium.","_key":"2e0ecbe661ab0"}]},{"_key":"c9dc13860299","markDefs":[],"children":[{"text":"CHRIS AIKEN: ","_key":"5a6e34674f560","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"Another way to improve side effects is to lower the dose. For most patients, the optimal blood level for long-term prevention is 0.6, or somewhere in the range of 0.4-0.8. The same blood level is ideal for treating depression – whether bipolar depression or unipolar. The only place where you’ll need a high dose is in acute mania, where serum levels of 0.8-1.2 are usually necessary.","_key":"5a6e34674f561"}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/6-pearls-consider-when-treating-pediatric-bipolar-disorder","_key":"da9550b44be1"}],"children":[{"text":"Children","_key":"231cb3abd4c20","_type":"span","marks":["da9550b44be1"]},{"_type":"span","marks":[],"text":" need the same blood levels as adults, but the elderly are different. Aim for a serum level that’s 30% below the usual in patients over age 60, and then further personalize that dose based on their response.","_key":"231cb3abd4c21"},{"_type":"span","marks":["superscript"],"text":"6","_key":"7640e8b40da1"},{"_type":"span","marks":[],"text":" The blood-brain barrier becomes more permeable as we age, so more lithium gets into the older brain at lower serum levels. Conservative dosing in the elderly has another benefit: These patients are much more sensitive to lithium’s side effects, particularly imbalance and tremor.","_key":"259c7ad03628"}],"_type":"block","style":"normal","_key":"e2cd2fc4a755"},{"style":"normal","_key":"e74fdd7bf9ba","markDefs":[],"children":[{"text":"KELLIE NEWSOME: ","_key":"ca03425c8f790","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"Tremor is one of the most common side effects with lithium, and it is very sensitive to the dose. The first step is to lower caffeine and – if possible – other tremor-promoting medications like bupropion (Wellbutrin) or atypical antipsychotics. Beta-blockers help lithium tremor, and although propranolol is the most commonly used, there is research supporting other beta blockers like atenolol, metoprolol, and nadolol for lithium tremor.","_key":"ca03425c8f791"},{"marks":["superscript"],"text":"7","_key":"b5fbd731d4ce","_type":"span"},{"_type":"span","marks":[],"text":" The average dose of propranolol is around 120 mg/day. Usually we start with instant release propranolol and then change to the extended release after figuring out how much they need.","_key":"c933accc375f"}],"_type":"block"},{"markDefs":[],"children":[{"text":"You may read that beta-blockers interact with lithium, and this is true, but the interaction is minor. They usually raise its levels by about 20%.","_key":"bc7d3e4a9df90","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"c3d5eec64079"},{"style":"normal","_key":"abcf6251860b","markDefs":[{"blank":true,"_type":"link","href":"moodtreatmentcenter.com/products","_key":"b2223d88e470"}],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN: ","_key":"ae24c3a2058e0"},{"_type":"span","marks":[],"text":"Another option with dual-benefits for lithium tremor is nimodipine. This calcium-channel blocker has good research for essential tremor, and is used third-line for mania and mania and rapid cycling.","_key":"ae24c3a2058e1"},{"marks":["superscript"],"text":"7","_key":"ceeb9ab27dd2","_type":"span"},{"_type":"span","marks":[],"text":" It’s well tolerated, and a typical target dose is 120mg a day. If your patient doesn’t want to add another medication in and prefers natural remedies, there’s high-dose vitamin B6. In doses from 900-1200 mg/day vitamin B6 improved lithium-related tremor, and it may reduce adverse effects on antipsychotics as well. B6 has open-label data for akathisia and tardive dyskinesia.","_key":"4219161d6dc1"},{"_type":"span","marks":["superscript"],"text":"7","_key":"442eb3dc2e33"},{"_type":"span","marks":[],"text":" Although natural, high-dose B6 is not risk free and can rarely cause neuropathy which usually resolves with discontinuation of the vitamin. It is hard to find B6 in a dose that high, so I keep a list of products on my ","_key":"6f20727ea0b6"},{"_type":"span","marks":["b2223d88e470"],"text":"website","_key":"ae24c3a2058e2"},{"_key":"ae24c3a2058e3","_type":"span","marks":[],"text":" (moodtreatmentcenter.com/products)."}],"_type":"block"},{"_type":"block","style":"normal","_key":"81e73be23edc","markDefs":[],"children":[{"_key":"dc2d64f513670","_type":"span","marks":["strong"],"text":"KELLIE NEWSOME: "},{"_type":"span","marks":[],"text":"Weight gain is a side effect on most patient’s minds when considering lithium, but the risk of significant weight gain is much lower than most patients expect. I start with some reassuring data: In a large meta-analysis, patients actually lost weight on lithium during the acute phase of treatment.","_key":"dc2d64f513671"},{"text":"20","_key":"c1199fb31d18","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" Over the long-term, however, weight gain is possible. About 1 in 3 patients will gain 4-10 lbs on lithium, and most of that weight gain occurs in the first few years of treatment.","_key":"032a947aeb4c"},{"_type":"span","marks":["superscript"],"text":"9","_key":"a78d4b83b771"},{"_type":"span","marks":[],"text":" ","_key":"1564161779d5"}]},{"style":"normal","_key":"120510a0daba","markDefs":[],"children":[{"text":"But the most important part of this education is to let your patient know that there is something they can do about it. Lithium will make them thirsty, so if they stick with water and avoid caloric beverages they can lower that risk – and that includes avoiding diet soft drinks which actually cause weight gain through indirect metabolic effects even though they have no calories of their own. ","_key":"73f5d8f9c68c","_type":"span","marks":[]}],"_type":"block"},{"children":[{"marks":[],"text":"Another way to reduce weight gain is to optimize thyroid function on lithium. Beyond that, any reasonable approaches for weight loss can be used, such as diet, exercise, or medications like topiramate 50-100 mg/day.","_key":"e6da76d42b07","_type":"span"}],"_type":"block","style":"normal","_key":"4494cd6a153d","markDefs":[]},{"_type":"block","style":"normal","_key":"9fa4d0caa1de","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Like most psychiatric medications, lithium can cause sexual dysfunction. We know of one evidence-based remedy for this: Aspirin, at least for men. In a randomized, double-blind trial of men with sexual dysfunction on lithium aspirin 240 mg/day improved the problem.","_key":"6067d28113e10"},{"_type":"span","marks":["superscript"],"text":"10","_key":"35b5a1694c40"}]},{"style":"normal","_key":"6b189e24f686","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) can also be used.","_key":"56ec9018ae8e0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN: ","_key":"deed8e236c070"},{"_type":"span","marks":[],"text":"Now we get to the most serious risk with lithium: Renal insufficiency. Here is what I tell patients. As you age, the kidneys tend to slow down, and lithium can make them slow down even more in some patients who take it long term. We will monitor the kidneys and may need to lower or stop it if we see this happening, because if we don’t catch it it could – very rarely – go on to kidney failure.","_key":"deed8e236c071"}],"_type":"block","style":"normal","_key":"8ec6aa1deffc"},{"_key":"2633f8ebedfa","markDefs":[],"children":[{"_type":"span","marks":[],"text":"There are at least 3 ways to protect against renal problems on lithium.","_key":"6ec2c908ae180"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"First, give the entire dose at night. This strategy improved renal function in a few long term comparison studies.","_key":"60ec1fdcdb480"},{"text":"4,8","_key":"e91ebfd2c651","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"1a75917e44be"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Next, avoid toxic levels. High levels of lithium can kill kidney cells, and that may be why one large study found a direct correlation between number of toxic episodes on lithium and renal problems. It also looked like the kidneys were spared in that study if the lithium levels were kept at or below 0.8.","_key":"358192166e2a0"}],"_type":"block","style":"normal","_key":"75f294875f9c"},{"children":[{"_key":"d2715755c8340","_type":"span","marks":[],"text":"Watch out for extreme polyuria and polydipsia. These are signs of nephrogenic diabetes insipidus, which is both an adverse effect on lithium and a risk factor for renal insufficiency. A laboratory test will reveal elevated sodium in the blood and very dilute urine; check for urine osmolality, urine sodium, basic metabolic panel. Nephrogenic diabetes insipidus is a risk factor for future renal insufficiency, and there is some evidence that treating the syndrome can reduce that risk by preventing fibrotic changes in the kidneys, such as with amiloride."},{"_type":"span","marks":["superscript"],"text":"11","_key":"d9aba5ff4268"}],"_type":"block","style":"normal","_key":"da4629084261","markDefs":[]},{"_key":"18923ae206c8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"If the serum creatinine starts to rise, lower the lithium to the lowest effective dose and check it more often. Consult a nephrologist if the serum creatinine rises to 1.5 mg/dl.","_key":"3287ca4901ec0"},{"_key":"f3fdb88fc731","_type":"span","marks":["superscript"],"text":"8"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Another medical risk with lithium is hypothyroidism. This is usually treatable with a thyroid supplement, and you don’t need to stop lithium because the thyroid function goes down. If you do come off lithium, the hypothyroidism usually resolves – but not always – so you can gingerly try to come off the thyroid medication while checking levels. ","_key":"298fc9e7e2ab0"}],"_type":"block","style":"normal","_key":"00e0837e3328"},{"children":[{"_type":"span","marks":[],"text":"Hypothyroidism may be worth addressing on lithium even when it is subclinical. A controlled study from the Mayo Clinic found that patients prescribed lithium were less likely to relapse into depression if their TSH was close to 2.4 microIU/ml.","_key":"7979ce1973dc"},{"text":"12","_key":"eda3057cf6c1","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"4d9809b89f10","markDefs":[]},{"_key":"9c38e5a5d2d2","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME: ","_key":"1513553efd0e0"},{"_type":"span","marks":[],"text":"Lithium has several dermatologic risks. It can cause acne and psoriasis, and some patients report thinner, brittle hair on it although overt hair loss is rare.","_key":"1513553efd0e1"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"Any standard treatments for acne can be used with lithium,10 but one to consider is minocycline. This antibiotic has neuroprotective and antiinflammatory effects, and it may treat depression, according to a handful of small-to-medium size controlled trials in bipolar and unipolar depression (the dose of minocycline for depression is 200 mg/day;","_key":"02c8630eaa4c0"},{"_type":"span","marks":["superscript"],"text":"13","_key":"c0cd08f90a2a"},{"_type":"span","marks":[],"text":" lower doses are used for acne, eg, 1 mg/kg/day).","_key":"b01c7d177511"},{"_type":"span","marks":["superscript"],"text":"14","_key":"2db53a4aacea"},{"_type":"span","marks":[],"text":" ","_key":"d74ce50ae3e5"}],"_type":"block","style":"normal","_key":"1b293c63a0c2","markDefs":[{"href":"http://www.moodtreatmentcenter.com/probiotics.pdf","_key":"c99f64f997ed","_type":"link"},{"_type":"link","href":"http://www.moodtreatmentcenter.com/inositol.pdf","_key":"cccab4ba2b70"},{"_key":"ff09cf336367","_type":"link","href":"http://www.moodtreatmentcenter.com/omega3.pdf"}]},{"_type":"block","style":"normal","_key":"d36e7086ffb4","markDefs":[{"blank":true,"_type":"link","href":"http://www.moodtreatmentcenter.com/probiotics.pdf","_key":"c99f64f997ed"},{"_type":"link","href":"http://www.moodtreatmentcenter.com/inositol.pdf","_key":"cccab4ba2b70","blank":true},{"blank":true,"_type":"link","href":"http://www.moodtreatmentcenter.com/omega3.pdf","_key":"ff09cf336367"}],"children":[{"_type":"span","marks":[],"text":"I advise patients to take a ","_key":"3c1ec9a669ba"},{"_type":"span","marks":["c99f64f997ed"],"text":"probiotics","_key":"02c8630eaa4c1"},{"marks":[],"text":" along with their antibiotic to avoid problems in the gut microbiome. Probiotics also have a growing evidence base in depression, anxiety, and bipolar, and there’s some evidence that probiotics help acne. Psoriasis – those scaly, dry patches of skin that worsen in the winter and tend to show up on the elbows, knees, palms, face, or back - is a relative contraindication with lithium. For this I will refer to a dermatologist, but I may suggest 2 CAM treatments that can help bipolar and psoriasis. In a few small trials, psoriasis improved with ","_key":"02c8630eaa4c2","_type":"span"},{"_type":"span","marks":["cccab4ba2b70"],"text":"inositol","_key":"02c8630eaa4c3"},{"_type":"span","marks":[],"text":" (6 g/day)8 and high dose ","_key":"02c8630eaa4c4"},{"_type":"span","marks":["ff09cf336367"],"text":"omega-3 fatty acids","_key":"02c8630eaa4c5"},{"text":" (4-6 g/day)","_key":"02c8630eaa4c6","_type":"span","marks":[]},{"text":"15","_key":"f9832a0efd12","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" – both of which are fairly risk free and have small studies in bipolar depression.","_key":"1708675abf72"}]},{"markDefs":[],"children":[{"marks":[],"text":"Although lithium is a first-line treatment that ranks high on the list of patient’s favorites, it has fallen out of general use, particularly in the United States.","_key":"94a68a1f2cca0","_type":"span"},{"_type":"span","marks":["superscript"],"text":"16,17","_key":"126c73f5fd27"},{"text":" When drugs meet that fate, they are often reserved for the most refractory patients, such as patients with severe mania who require high doses, which doesn’t help lithium’s reputation. Adverse effects should not stand in the way of its usage – when they are managed carefully and I have found that surprisingly tolerable.","_key":"095b44b73ade","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"b5f3e1c9ccff"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"But still, about 1 in 10 patients don’t tolerate it and have to stop the medication.","_key":"0d3c2a7947320"}],"_type":"block","style":"normal","_key":"67a26b20d61d"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"About 1 in 3 patients with bipolar disorder respond very well to lithium – and these tend to be the patients with classic, “textbook case” bipolar – with euphoric manias that are cleanly separated from depressions, and low rates of rapid cycling, mixed states, and major psychiatric comorbidities. These need not be patients with bipolar I though – patients with bipolar II can have classic hypomanias, and in one study lithium worked better for bipolar II than bipolar I.","_key":"471b892accf10"}],"_type":"block","style":"normal","_key":"0c06187299ff"},{"children":[{"marks":[],"text":"When lithium works well, its benefits tend to last. It is among the top medications that prevent hospitalization.","_key":"42a33c4cf83f0","_type":"span"},{"_type":"span","marks":["superscript"],"text":"19","_key":"4e735d1a6cbb"},{"_type":"span","marks":[],"text":" Its preventative effects have outshined other mood stabilizers, like valproate, in head-to-head trials, and it has added benefits that are relevant to bipolar disorder. Lithium prevents suicide, dementia, and some new evidence suggests it may lower the stroke risk and aid cardiac remodeling after a heart attack – that’s good news if it holds up, because stroke is the #1 cause of death in bipolar disorder, and cardiovascular disease tends to start 20 years earlier in patients with bipolar disorder than it does in the general population.","_key":"133c710af010"},{"_key":"d4520cf9d525","_type":"span","marks":["superscript"],"text":"17-18"}],"_type":"block","style":"normal","_key":"3e58cce215fd","markDefs":[]},{"_type":"block","style":"normal","_key":"1c88feae234a","markDefs":[{"_type":"link","href":"https://www.thecarlatreport.com/podcast/","_key":"49ac6df29ac9","blank":true}],"children":[{"_key":"a3325ef8ab210","_type":"span","marks":["strong"],"text":"KELLIE NEWSOME: "},{"_key":"a3325ef8ab211","_type":"span","marks":[],"text":"I hope you will join us again for more practical updates on PsychPearls, and you can also catch us every Monday on the "},{"_key":"dd393bdf88e7","_type":"span","marks":["49ac6df29ac9","em"],"text":"Carlat Psychiatry "},{"_type":"span","marks":["49ac6df29ac9"],"text":"Podcast.","_key":"c49690ef22c3"}]},{"style":"normal","_key":"c24efc9d5785","markDefs":[{"blank":true,"_type":"link","href":"https://thecarlatreport.com/","_key":"f6e662ab37fc"},{"blank":true,"_type":"link","href":"http://www.moodtreatmentcenter.com/","_key":"eccf254b4733"},{"blank":true,"_type":"link","href":"https://www.amazon.com/Depression-Bipolar-Workbook-Strengthen-Brain/dp/1683732359","_key":"9d1cad96799e"},{"blank":true,"_type":"link","href":"https://podcasts.apple.com/us/podcast/the-carlat-psychiatry-podcast/id1463414537","_key":"458224eac10a"},{"blank":true,"_type":"link","href":"https://www.amazon.com/Depression-Bipolar-Workbook-Strengthen-Brain/dp/1683732359","_key":"5ae9e3869d79"},{"blank":true,"_type":"link","href":"https://www.amazon.com/Bipolar-Not-Much-Understanding-Depression/dp/0393711749/ref=sr_1_1?ie=UTF8\u0026qid=1483750639\u0026sr=8-1\u0026keywords=bipolar+not+so+much","_key":"eb3a434649e1"}],"children":[{"_type":"span","marks":["strong"],"text":"Chris Aiken, MD, ","_key":"16f561c65084"},{"_type":"span","marks":[],"text":"is the Mood Disorders Section Editor for ","_key":"870bd553ffa0"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"a1f658d8a908"},{"_type":"span","marks":["em","superscript"],"text":"TM","_key":"87f7c4e8c64b"},{"_type":"span","marks":["em"],"text":", ","_key":"10ccea62b4a9"},{"_type":"span","marks":[],"text":"the Editor in Chief of ","_key":"015faa48fa3f"},{"_key":"94fe9041b64c","_type":"span","marks":["em","f6e662ab37fc"],"text":"The Carlat Psychiatry Report,"},{"_key":"490eb5b9893c","_type":"span","marks":[],"text":"and the Director of the "},{"_type":"span","marks":["eccf254b4733"],"text":"Mood Treatment Center.","_key":"d207a9dfae0e"},{"_type":"span","marks":[],"text":" He has written several books on mood disorders, most recently ","_key":"25918b9e707b"},{"_type":"span","marks":["em","9d1cad96799e"],"text":"The Depression and Bipolar Workbook","_key":"c1ceed1838fa"},{"_type":"span","marks":["em"],"text":".","_key":"365dca8b0eec"},{"_type":"span","marks":[],"text":" He can be heard in the weekly ","_key":"f655865002f5"},{"_type":"span","marks":["em","458224eac10a"],"text":"Carlat Psychiatry Podcast","_key":"33a966bad996"},{"_type":"span","marks":[],"text":" with his cohost Kellie Newsome, PMH-NP. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for ","_key":"35ab0181eed2"},{"_type":"span","marks":["em","5ae9e3869d79"],"text":"The Depression and Bipolar Workbook","_key":"e12da9d39371"},{"_type":"span","marks":[],"text":"and from W.W. Norton \u0026 Co. for ","_key":"6293b0f060cd"},{"_type":"span","marks":["em","eb3a434649e1"],"text":"Bipolar, Not So Much","_key":"55f9c98f0b66"},{"_type":"span","marks":["em"],"text":".","_key":"9ddef4e9413b"}],"_type":"block"},{"style":"normal","_key":"393c8c124f1e","markDefs":[],"children":[{"text":"Kellie L. Newsome, PMH-NP","_key":"1a616388fc800","_type":"span","marks":["strong"]},{"marks":[],"text":", is the cohost of the ","_key":"1a616388fc801","_type":"span"},{"_type":"span","marks":["em"],"text":"Carlat Psychiatry Podcast","_key":"1a616388fc802"},{"_type":"span","marks":[],"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":"1a616388fc803"}],"_type":"block"},{"_key":"384dcf4d3876","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"c131ed704a880"}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/22177379","_key":"14770d6e96c2"}],"children":[{"marks":[],"text":"1. Srivastava S, Ketter TA. ","_key":"6fd46d137bb70","_type":"span"},{"_type":"span","marks":["14770d6e96c2"],"text":"Clinical relevance of treatments for acute bipolar disorder: balancing therapeutic and adverse effects.","_key":"6fd46d137bb71"},{"text":" Clin Ther.","_key":"6fd46d137bb72","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":" 2011;33(12):B40-8.","_key":"6fd46d137bb73"}],"_type":"block","style":"normal","_key":"7f3e1fdbb49a"},{"_key":"269ff9a95486","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/17406176","_key":"5aef082cade4"}],"children":[{"marks":[],"text":"2. Gualtieri CT, Johnson LG. ","_key":"1e73690f22210","_type":"span"},{"_type":"span","marks":["5aef082cade4"],"text":"Comparative neurocognitive effects of 5 psychotropic anticonvulsants and lithium.","_key":"1e73690f22211"},{"_type":"span","marks":[],"text":" ","_key":"1e73690f22212"},{"_type":"span","marks":["em"],"text":"MedGenMed.","_key":"1e73690f22213"},{"_type":"span","marks":[],"text":" 2006;8(3):46.","_key":"1e73690f22214"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"55fe258bb324","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/19689922","_key":"e1e46b867c11"}],"children":[{"text":"3. Wingo AP, Wingo TS, Harvey PD. ","_key":"27fb7967d50f0","_type":"span","marks":[]},{"_type":"span","marks":["e1e46b867c11"],"text":"Effects of lithium on cognitive performance: a meta-analysis.","_key":"27fb7967d50f1"},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry.","_key":"27fb7967d50f2"},{"_key":"27fb7967d50f3","_type":"span","marks":[],"text":" 2009;70(11):1588-97."}]},{"style":"normal","_key":"648eabf27362","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/27770296","_key":"300acf6ec540"}],"children":[{"_type":"span","marks":[],"text":"4. Girardi P, Brugnoli R, Manfredi G, et al. ","_key":"fe1dbce0b3240"},{"marks":["300acf6ec540"],"text":"Lithium in bipolar disorder: optimizing therapy using prolonged-release formulations.","_key":"fe1dbce0b3241","_type":"span"},{"_key":"fe1dbce0b3242","_type":"span","marks":["em"],"text":" Drugs R D."},{"_type":"span","marks":[],"text":" 2016;16(4):293-302.","_key":"fe1dbce0b3243"}],"_type":"block"},{"_key":"9d1d7ef04a02","markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/18271901","_key":"3ab18a4c5a0e"}],"children":[{"_type":"span","marks":[],"text":"5. Severus WE, Kleindienst N, Seemüller F. ","_key":"bf5a567934d10"},{"_key":"bf5a567934d11","_type":"span","marks":["3ab18a4c5a0e"],"text":"What is the optimal serum lithium level in the long-term treatment of bipolar disorder--a review?"},{"_type":"span","marks":["em"],"text":" Bipolar Disord. ","_key":"bf5a567934d12"},{"_type":"span","marks":[],"text":"2008;10(2):231-7.","_key":"bf5a567934d13"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"966e98bc5d53","markDefs":[{"_key":"bcbc60901c23","blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/28331326"}],"children":[{"marks":[],"text":"6. De Fazio P, Gaetano R, Caroleo M. ","_key":"504b13ba35f70","_type":"span"},{"text":"Lithium in late-life mania: a systematic review.","_key":"504b13ba35f71","_type":"span","marks":["bcbc60901c23"]},{"_type":"span","marks":["em"],"text":" Neuropsychiatr Dis Treat.","_key":"504b13ba35f72"},{"_type":"span","marks":[],"text":" 2017;13:755-766.","_key":"504b13ba35f73"}]},{"style":"normal","_key":"53a197bcfebd","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/23834617","_key":"26453e4b89aa"}],"children":[{"marks":[],"text":"7. Baek JH, Kinrys G, Nierenberg AA. ","_key":"18764a2306cf0","_type":"span"},{"_type":"span","marks":["26453e4b89aa"],"text":"Lithium tremor revisited: pathophysiology and treatment.","_key":"18764a2306cf1"},{"_type":"span","marks":["em"],"text":" Acta Psychiatr Scand.","_key":"18764a2306cf2"},{"text":" 2014;129(1):17-23.","_key":"18764a2306cf3","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"a90df25c6bee","markDefs":[{"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pubmed/27900734","_key":"db7364955cde","blank":true}],"children":[{"text":"8. Gitlin M. ","_key":"ba8d501d1fcc0","_type":"span","marks":[]},{"_type":"span","marks":["db7364955cde"],"text":"Lithium side effects and toxicity: prevalence and management strategies.","_key":"ba8d501d1fcc1"},{"_type":"span","marks":["em"],"text":" Int J Bipolar Disord. 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In this podcast, Dr Aiken and Ms Newsome will discuss how to dose one of them: lithium.","_key":"c1f728c30dc7"}],"_type":"block","style":"normal","_key":"72f19a64c4aa"},{"markDefs":[],"children":[{"_type":"span","marks":["em"],"text":"Transcript (edited for clarity).","_key":"c0573fe8adca0"}],"_type":"block","style":"normal","_key":"b9c870736b28"},{"markDefs":[],"children":[{"text":"Kellie Newsome, PMH-NP:","_key":"b8e48b613c52","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" Dr Aiken, how do you start a patient on lithium?","_key":"1b92d615cff5"}],"_type":"block","style":"normal","_key":"aa3290c33b42"},{"children":[{"_type":"span","marks":["strong"],"text":"Chris Aiken, MD:","_key":"aedea78c30fd"},{"_type":"span","marks":[],"text":" I start patients on lithium very slowly. This is a medication that is meant to work for the long term. It is not that effective for acute episodes, so there's no reason to rush it. Patients are often afraid of lithium; it has kind of a bad reputation out there, which isn't necessary because it's relatively well tolerated. For example, it has a chance of causing sedation around 1 in 28 patients, compared with 1 in 5 or 1 in 10 for most other mood stabilizers. It is also a little friendlier when it comes to weight gain and cognitive side effects than many of the other mood stabilizers. ","_key":"51a7aa57544e"}],"_type":"block","style":"normal","_key":"214ff445b5d7","markDefs":[]},{"style":"normal","_key":"60fa6cb79c50","markDefs":[],"children":[{"marks":[],"text":"If you start lithium too quickly, the patient is liable to stop it because of one big side effect: nausea. That is the one you need to prepare them for. Nausea shouldn't be a reason to stop lithium, because it almost always gets better with time. So if you can just get your patient through that whether it's using ","_key":"427d0c27376b","_type":"span"},{"_type":"span","marks":[],"text":"ondansetron ","_key":"72fd8385f658"},{"_type":"span","marks":[],"text":"or ginger tablets or taking it after food or raising the dose real slowly, it'll pay off in the long term.","_key":"ec1e8d18c7cf"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Generally, I'll start with 300 mg at night and raise it by 300 mg each week until I reach 900 mg, at which point, I'll check the level. If the patient is on a drug that interacts with lithium, such as ","_key":"7d1640e11df20"},{"_type":"span","marks":[],"text":"hydrochlorothiazide, ","_key":"0e9cd2ca4af2"},{"_type":"span","marks":[],"text":"or if they're older or frail or afraid of side effects, I'll start lower cutting all of those doses in half. Of course, if your patient is actively manic or you're trying to keep them out of the hospital, you might go faster with this.","_key":"6453d931aab2"}],"_type":"block","style":"normal","_key":"21b4aba0bd7d"},{"style":"normal","_key":"8c9a71f0557c","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kellie Newsome, PMH-NP:","_key":"28bb667a6f94"},{"_type":"span","marks":[],"text":" ","_key":"4c2d7500f797"},{"_type":"span","marks":[],"text":"Do you give lithium all at night or twice a day. ","_key":"6a70f2659d670"}],"_type":"block"},{"_key":"ca39963950a7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Chris Aiken, MD:","_key":"b34024481a00"},{"marks":[],"text":" ","_key":"6b35cd89a54b","_type":"span"},{"_type":"span","marks":[],"text":"Lithium is often dosed twice a day, but I think that's out of convention rather than science. Its half-life is 24 hours so there's no reason to do that. And in a few long term studies, patients actually had lower rates of renal problems if the lithium was dosed entirely at night rather than twice a day. It seems that the kidneys do better when they get a bolus of lithium at night, rather than spread evenly throughout the day.","_key":"6fad5a61a8ae"}],"_type":"block","style":"normal"},{"style":"normal","_key":"430e0ff8be09","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kellie Newsome, PMH-NP: ","_key":"823348075371"},{"marks":[],"text":"So what if you're using a high dose? Wouldn't you need to spread that out? ","_key":"0da7887cedc80","_type":"span"}],"_type":"block"},{"_key":"028a7190f9cd","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Chris Aiken, MD:","_key":"a380828863c3"},{"_type":"span","marks":[],"text":" First of all, the dose doesn't really matter in lithium; it's the blood level. So that is a good question though, what if the blood level is high, would we need to spread that out. Nobody knows the answer to that. But what I do is if the blood level is going above 0.8, I will spread it out and give a little bit of the dose in the morning. The reason is that we do have long term studies where if lithium level is kept at 0.8 or below, there is much lower risk of renal problems. So we don't know for sure, but I'm hedging my bets and saying let's try to keep that level, less than 0.8 throughout the day to save the kidneys.","_key":"85c9b8dc9472"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Kellie Newsome, PMH-NP: ","_key":"10132fd55ed9"},{"_type":"span","marks":[],"text":"Lithium comes in several forms, instant release, lithobid, and eskalith. Which one do you prefer?","_key":"50ea159859dc0"}],"_type":"block","style":"normal","_key":"3f96a648247f"},{"_key":"cba498136e7f","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Chris Aiken, MD:","_key":"d333882de728"},{"_type":"span","marks":[],"text":" Generally, I'll use lithobid, but each has its advantage. Lithobid and eskalith are the extended released versions, and they're going to cut most of the side effects in half so they're better tolerated overall. However, if the patient has constipation, that often improves with the instant release, whereas diarrhea and nausea tend to improve with the controlled release. Another reason you might use the instant release is if you're starting real low like 150 mg, that dose only comes as an instant release, and eskoleth. I can't see much reason to prefer eskoleth over lithobid, other than the tablet size, which does matter to patients. Most patients, rather take 2 pills than 3. And since eskoleth comes as a 450 often use 2 of those rather than 3 of the lithobids, once they get to the dose of 900.","_key":"d9cba96bf919"}],"_type":"block","style":"normal"},{"_key":"a4afd16af7b0","markDefs":[],"children":[{"_key":"25ed4f5f1537","_type":"span","marks":["strong"],"text":"Kellie Newsome, PMH-NP: "},{"_type":"span","marks":[],"text":"Once you get to 900 and you check the level, what levels are you actually looking for? ","_key":"34b0dab122520"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Chris Aiken, MD: ","_key":"0334b2925992"},{"_type":"span","marks":[],"text":"This is something we have a lot of research on so there are good numbers to know here. The target level for lithium is 0.6, to 0.8 for depression as well as for the maintenance phase. You want to keep it in that sweet spot. If the patient has active mania, you should go up to 0.8 to 1.2. But you might want to bring it down after they've recovered, again to save the kidneys. Children by the way require the same levels as adults, but if the patient is over 65, they might need levels that are 20% to 30% lower than the ones I just quoted for an interesting reason. 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takeaways from the roundtable discussion we had that stood out to me after hearing from colleagues is that there is still a fair amount of use of the older medicines out there like lithium. Part of the problem is, however, when we take a look at agents with a low therapeutic index. There is the possibility of no benefit depending on too low a level, or the possibility of serious life-threatening issues with too high a dose; thus the need for monitoring. There is also a need to consider issues based on thyroid function and renal function aside from the litany of thins, including dermatological and central nervous system issues associated with this basic elemental solve.","_key":"6e4420cd69b71"}],"_type":"block","style":"normal","_key":"a9241d87e4da"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The use of anticonvulsants also came up. In individuals that may be “self-medicating” with alcohol, some agents like depakote might be more useful in individuals with underlying hostility or explosiveness aimed at potentially harming others. Agents like carbamazepine or divalproex might be useful agents. There was discussion about lamotrigine, but that is a medicine that is also FDA approved for bipolar depressive maintenance. There are several studies where it did not show solid efficacy; additionally, you have to titrate up very gradually to avert the likelihood of Stevens-Johnson syndrome. The possibility of these additional factors might become problematic for individuals, keeping it mind that it certainly could be something useful.","_key":"b4725079038e0"}],"_type":"block","style":"normal","_key":"aca6964caaf5"},{"style":"normal","_key":"88566b2aacd9","markDefs":[],"children":[{"marks":[],"text":"The utilization of atypical antipsychotics has now garnered a bit more attention; certainly, the advent of Seroquel XR (quetiapine) helped lead a charge of taking a look at the malleability associated with atypical antipsychotics prior to that olanzapine combined with fluoxetine would certainly be a consideration. Trying to keep things as simple as possible can be a challenge when mixing in additional medicine. That is where single agents may be worthwhile. With Seroquel XR, unfortunately, 1 out of 2 people feel very sleepy, 1 out of 3 have severe dry mouth. Sometimes, finding the right dose can be difficult. That is where the dosing becomes a little bit trickier. It is a medicine given with food and can give a severe hungover feeling in individuals later on; that is where clinicians may feel reticent.","_key":"972a76f6e5d80","_type":"span"}],"_type":"block"},{"style":"normal","_key":"609dce8421ff","markDefs":[],"children":[{"_key":"a12ed4a081ba0","_type":"span","marks":[],"text":"Latuda (lurasidone) has a decent track record. Unlike Seroquel XR, it should be given with food for it to work well. Otherwise, you only get half the benefit. And then the question is: what does will you need. And sometimes people may experience nausea and sedation associated with the use of the medicine, thereby limiting sometimes the possible full use of the agent. Vraylar (cariprazine) is a newer medicine that does not have the same track record a Latuda based on how long it has been available, but it certainly is one of the few medicines that has a broader spectrum of utilization, not just in the depressive episode but also the manic mixed episode state. That, to a degree, also brings a sense of comfort for clinicians, because Latuda is only approved for bipolar depression. Sometimes clinicians may feel gun-shy: might this medicine activate individuals and flip them over into a manic episode, and, if so, do we really have a sufficient amount of data associated with its use? Vraylar can be given once-daily it is not sedating, not activating, and it has a very long half-life, which means that sometimes people forget to take their medicine, that is ok. The flip side to that, though, side effects might linger for a week. It is a drug that has been well studied in doses even up to 3 times its highest dose. It is currently FDA recommended as not really compromise when it comes to cardiac status and has a placebo like effect on metabolics. It looks quite attractive for individuals where you don’t want gaining weight or having specific issues that might compromise metabolics. The other nice use of that particular medicine is that when patients show up with predominantly depressive symptoms, they will start out at the lowest dose and for the most part stay there. We certainly note that 1.5 mg but up to 3 mg will work there. If patients are having more mixed symptoms that is where the 3 mg dose might be better. If they are having more manic symptoms, that is where 4.5 mg or 6 mg might be a better fit."}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Latest entrant in this game is Caplyta (lumateperone). It has a fixed dose of 42 mg and is only indicated for bipolar depression, but it is indicated for bipolar type 1 and type 2, which is interesting because only Seroquel XR and Caplyta have been studied in bipolar 2 patients and you see benefit there. You also note a very clean metabolic profile associated with the medicine. Part of the discussion with the colleagues was taking a look at all of the different options we have, keeping in mind that lithium is the only medication we have that averts suicidality in bipolar disorder. Sometimes patients don’t just respond to one medicine. That is where additional data with other agents are useful.","_key":"11d87d568e430"}],"_type":"block","style":"normal","_key":"cc93442ff95d"},{"children":[{"_type":"span","marks":[],"text":"The important thing is that when we take into consideration bipolar depression, this is a topic that on the surface looks simple but, in reality, can be complex but at the same time training individuals even in the primary care setting to take into consideration these options can help someone so that they are not necessarily lingering in a state in which they are experiencing different difficulties because of financial or interpersonal problem or even the likelihood of suicidality.","_key":"758c15e9e5790"}],"_type":"block","style":"normal","_key":"5ab877de1209","markDefs":[]},{"_key":"e7014de98c63","markDefs":[],"children":[{"text":"Wrapping it all up, there is a current sentiment that we have evolved to the point at which that although some individuals may be treatment refractory and require things including ECT or otherwise. Other modalities like repetitive transcranial magnetic stimulation, intranasal esketamine are not FDA approved in bipolar disorder. It resolves some discussion that ECT-intravenous ketamine might sometimes be useful for some individuals. But the important point is that we have additional tools in our psych-armamentarium and that readily help many individuals in the past that have been mired in suffering and might have experienced additional problems.","_key":"43e225d419d30","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"style":"normal","_key":"b82095a5ddd8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Causes like this represent to us the fact that moderate depressive symptoms are not always what they seem. We need to instruct our colleagues and counterparts about the differential associated with depressive symptomatology to take into consideration prior history, family history, and the comorbidity that the induvial experiences, also keeping in mind the aspirational note of what were trying to accomplish: above all, do no harm, and when presenting someone with options, make sure out option list is comprehensive and readily understood.","_key":"3c4ccaeb4ca70"}],"_type":"block"},{"_key":"0eb933c64f48","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I appreciate the opportunity of taking part in this didactic experience and the fact that we continue to move down a path in which additional tools are set before us as clinicians. Thank you.","_key":"1fd8702676f70"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity","_key":"1fa43dac5414"}],"_type":"block","style":"normal","_key":"b7e0a59fb884"}],"contentCategory":{"name":"Videos","_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","_updatedAt":"2020-02-25T09:35:54Z","_createdAt":"2020-02-10T10:49:36Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory"},"documentGroup":{"_ref":"e483c1db-ca23-4dda-9619-f77e909b958d","_type":"reference"},"_rev":"LKxYTkUF9yNVUfdboSHOmj","link":"/view/clinical-insights-regarding-the-management-of-bipolar-disorder","_id":"6ab8dc48-0f3e-4d63-bdf5-834250dc8ac3","ExcludeFromPubMedXML":false,"factCheckAuthorMapping":null,"_updatedAt":"2022-06-13T19:35:29Z","authorMapping":[{"lastName":"Alva","_createdAt":"2021-10-18T18:25:12Z","_id":"bad11b63-e675-48df-a734-7876fd7b1bc4","_updatedAt":"2021-10-18T18:25:12Z","firstName":"Gustavo","displayName":"Gustavo 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Alva, MD, DFAPA: ","_key":"b0bacb660f6c0"},{"_type":"span","marks":[],"text":"I think that this particular clinical history encapsulates some very fascinating points. Among these points might be what our first impression of this case might be, and what types of challenges a patient like this presents when they come into treatment. This is a young female patient of child-bearing age, who, upon speaking about her current symptomatology, one would immediately latch onto the concept that depressive symptoms are in play, as she has had several episodes that look like this. Upon further investigation, it turns out that there might be some mood oscillation in the background, which is a very important point, particularly in the primary care setting but also in the specialist setting. Our patients are not going to be the best historians; that means that sometimes we miss subtle points of import, such as periods of either mood oscillation, excessive activity, decreased need for sleep, irritability, and impulsivity. In the case of our patient, we certainly note that aside from depressive episodes she has had, she has certainly had some mood oscillatory issues that we need to keep in mind.","_key":"b0bacb660f6c1"}],"_type":"block","style":"normal","_key":"85c9741c515b","markDefs":[]},{"_type":"block","style":"normal","_key":"a50c8cecab9e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Some of the red flags to keep in mind include different factors, such as lingering vegetative symptoms. She has been fine with treatment that might actually work for most individuals. She has been exposed to an SSRI agent that has been ramped up sufficiently. We note, however, that as dose was being ramped up, a bit of activation occurred. Sometimes, the thought in mind should be: Are we potentially evoking medication that doesn’t work for our patient as opposed to actually reconsidering the possibility that in our differential of major depressive order that bipolar disorder may not have been captured previously. We know that family history is strongly burdened by the possibility of mood oscillatory states, and this would be indicative of problem. We know that her age and medical comorbidities are of great import. We obviously want to make sure that someone who is already weighing a little extra is not exposed to agents that might pack on more weight, and, as a consequence of that compromise, the possibility of continued use of medications that otherwise would be highly advantageous. We know that when someone walks into clinical setting and say they have been depressed the past 2 weeks, are experiencing vegetative symptoms that are impacting their day-to-day life and interactions with others, we don’t always jump to the conclusion of unipolar depression. DSM-5 stipulates that differential diagnosis of bipolar disorder of depressive episode be kept in mind. Our case her illustrates those very points.","_key":"7152b44310a00"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"You’ll note that initially she was managed with psychotherapy but then, subsequently, the thought was, are we barking up the wrong tree? Should we seek out some specialty care that was done in appropriate manner. In the past, we would have thought that different types of mood stabilizing medications, which typically would be a but more useful in individual who are experiencing a bit more manic or mixed symptomatology. Sometimes we don’t capture the essence of countering specific problems with an agent that might actually have a profile that is attractive for an individual like our patient.","_key":"6cbf506cfcaa0"}],"_type":"block","style":"normal","_key":"cc1c3b8f1d2d"},{"children":[{"_type":"span","marks":[],"text":"In the primary care setting, when someone sees a PHQ9 of 18 that designates severe depression. But we now see couched behind that the mood disorder questionnaire as a way of propelling additional dialogue about the possibility of bipolar disorder based on current depressive symptoms the patient is experiences. Obviously, an SSRI would not be the indicated agent to utilize in this patient at this particular juncture, because she has been experiencing more depressive symptoms that are tied in with bipolar disorder. In this case, a mood stabilizer that could have a nice impact on lifting depressive symptoms would probably be of greater benefit, keeping in mind the weight related issues and the fact that she is already diabetic and we don’t want to aggravative underlying metabolic issues. There are also other agents that might actually help out in stabilizing mood, particularly when someone is experiencing a depressive episode. We know that within the family of the antipsychotics would be agents that would address symptomatology that this patient is experiencing. But we want to keep in mind the overall ambulatory state of the individual. if someone is having problems with sleep, they will seek out an agent that helps with sleep but then subsequently might complain that they feel “out of it”; that is where agents that have a profile that is not necessarily evoking too much sedation might be useful. Sometimes, taking a medication with or without food could create an impediment for someone to actually comply with their utilization with the medicine and the dosing associated with the medicine would be of great import. Taking into context the overall profile of these medications based on the data available is also of great aid.","_key":"bbe7ef6a71830"}],"_type":"block","style":"normal","_key":"cd8c4e4e3386","markDefs":[]},{"markDefs":[],"children":[{"_key":"62becf0284570","_type":"span","marks":[],"text":"This case illustrated that if it walks, quacks, moves around like a duck, it might well be a chicken. In this case, it is well worth while reconsidering what our diagnosis is and consider the possibility of a mood disorder like bipolar disorder. We noted that at the very least she had had flares with her mood, where she did not need to sleep as much and felt more active and productive. Peering into those periods would be a great benefit for us in solidifying a diagnosis. Ultimately, when we try to get someone on the right trajectory. It is about getting the right questions in front of the person, to be able to unmask underlying issues that may have been in play. Although the lifetime problems for major depressive disorder are far greater than for bipolar disorder with depressive episodes, those of us who manage specialty settings often see individuals who bounce back between different clinicians and are now surprised that some people take 5 to 10 years before right diagnosis is made. This case readily illustrates multiple points that we need to keep in mind and helps solidify the approach that should be held with patients. There is no preset way of diagnosing individuals; our diagnosis can sometimes be fluid. That is why it is so important to look at family history and previous symptomatology, and maybe the possibility of individuals who have been misdiagnosed, having had psychiatric comorbidities that would be indicative of the likelihood of a condition like bipolar disorder."}],"_type":"block","style":"normal","_key":"b8e8be913470"},{"_key":"845c5a563912","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity","_key":"f24ecb088b58"}],"_type":"block","style":"normal"}],"_createdAt":"2022-06-13T19:32:06Z","updatedOn":null,"summary":"Dr. Gus Alva shares his initial impressions on this case and treatment approaches to bipolar 1 disorder.","ExcludeFromPubMedXML":false,"documentGroup":{"_ref":"e483c1db-ca23-4dda-9619-f77e909b958d","_type":"reference"},"_type":"article","taxonomyMapping":[{"_id":"622449b3-ea9c-4cc2-a722-db1923e845d9","_updatedAt":"2024-02-21T20:41:50Z","_createdAt":"2022-02-28T20:58:37Z","_rev":"IakUcQKwj7kr3xQjaaVtjW","_type":"taxonomy","name":"Bipolar I Disorder","identifier":"topics/bipolar-i-disorder","perKeywordMapping":["Psychiatry","Neurology"],"cmeType":"per"},{"parent":{"_ref":"pst_taxonomy_53202_clinical","_type":"reference"},"_id":"pst_taxonomy_52_bipolardisorder","_updatedAt":"2023-03-31T19:08:00Z","name":"Bipolar Disorder","identifier":"topics/bipolar","perKeywordMapping":["Psychiatry","Neurology"],"cmeType":"per","_createdAt":"2020-03-26T06:11:21Z","_rev":"77mZ7PORfofI3dBGfWalU3","_type":"taxonomy"}],"link":"/view/clinical-impressions-from-the-patient-case","source":null,"documentGroupMapping":[{"_ref":"e483c1db-ca23-4dda-9619-f77e909b958d","_type":"reference","_key":"ac612722652f"}],"title":"Clinical Impressions From the Patient Case","seoTag":["bipolar disorder","symptoms","mood disorders","primary care","physiologist","treatment resistant","SSRI","SNRI","activation","antipsychotics","depression","PHQ9","moderate-to-severe","mood stabilizer","metabolic issues"],"is_visible":true,"url":{"current":"clinical-impressions-from-the-patient-case","_type":"slug"},"contentCategory":{"_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","_updatedAt":"2020-02-25T09:35:54Z","_createdAt":"2020-02-10T10:49:36Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Videos"},"published":"2022-06-13T19:30:28.002Z","authorMapping":[{"lastName":"Alva","_createdAt":"2021-10-18T18:25:12Z","_id":"bad11b63-e675-48df-a734-7876fd7b1bc4","_updatedAt":"2021-10-18T18:25:12Z","firstName":"Gustavo","displayName":"Gustavo Alva, MD, DFAPA","_rev":"ME0BaLFsbaRdJono5OYiWQ","_type":"author","url":{"current":"gustavo-alva-md-dfapa","_type":"slug"}}],"_rev":"6uwRxsZd4dJaf44JVwNCLD"},{"url":{"current":"case-presentation-a-23-year-old-with-bipolar-disorder","_type":"slug"},"authorMapping":[{"lastName":"Alva","_createdAt":"2021-10-18T18:25:12Z","_id":"bad11b63-e675-48df-a734-7876fd7b1bc4","_updatedAt":"2021-10-18T18:25:12Z","firstName":"Gustavo","displayName":"Gustavo Alva, MD, DFAPA","_rev":"ME0BaLFsbaRdJono5OYiWQ","_type":"author","url":{"current":"gustavo-alva-md-dfapa","_type":"slug"}}],"contentCategory":{"_type":"contentCategory","name":"Videos","_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","_updatedAt":"2020-02-25T09:35:54Z","_createdAt":"2020-02-10T10:49:36Z","_rev":"snQqhhB4O8T5bi1viURsgs"},"title":"Case Presentation: A 23-Year-Old With Bipolar Disorder","source":null,"is_visible":true,"body":[{"_type":"video","videoID":"6307413522112","source":"brightcove","_key":"605c4883ff4e"},{"children":[{"text":"Gus Alva, MD, DFAPA:","_key":"d850fbab802c0","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" Psychiatric Times presents this roundtable on the management of bipolar disorder, a phenomenal dialogue allowing clinicals a perspective regarding current trends and where we may be headed in the future.","_key":"d850fbab802c1"}],"_type":"block","style":"normal","_key":"fa4f0bacb0ce","markDefs":[]},{"style":"normal","_key":"4a9c94d23a90","markDefs":[],"children":[{"text":"This is an interesting case, as we take a look at this 23-year-old female who first comes in to see her psychiatrist with moderate depressive symptoms. At the time of the interview, her chief complaint included feeling like she’s lacking energy, she’s feeling depressed. She’s also reporting difficulty in paying attention, organizing her day, and accomplishing her tasks at work. Notably these symptoms started abruptly. Three weeks early, prior to that, she had been functioning better than usual, requiring very little sleep and getting more accomplished. Of significance, she reported two brief episodes of depression over the past 2 years. Each lasting about 2 months. And although the patient reported these depressive episodes as coming out of the blue, she learned after consulting with her therapist that they were related to significant psychosocial stress, stemming from the loss of her job and the deaths of 2 uncles, both of which were related to the COVID-19 pandemic. The patient reported that she still finds enjoyment talking to friends and socializing and she has hope of finding a new job and she’s constantly looking.","_key":"d7a2f8210b7f0","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"8760c4b4702f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"It’s noteworthy to bear in mind that in her first depressive episode she was treated with methylphenidate 25mg titrated up to 50 m and she stated feeling improved on this does with psychotherapy. Her second depressive episode, her does was bumped up to 100 mg which we saw improvement in depression, but she noted she felt a little activated and had trouble sleeping. With her third depressive episode, the therapist and PCP referred the patient over to a psychiatrist. Of great note should be her past psychological history: she was diagnosed with ADHD in middle school, during which time she responded well to methylphenidate. She continued to do well until her college years at which time she began experiencing difficulty falling asleep as well as irritability. At that time, she discontinued methylphenidate and was psychiatric drug free. She found that practicing mindfulness and yoga on a daily basis helped her residual ADHD symptoms. Of note, she had no history of suicidal thoughts or behavior, self-injurious behaviors, psychiatric hospitalization, or problems with substance abuse. Of note, regarding medical comorbidities, she was diagnosed a year earlier with type 2 diabetes, which was managed with metformin 1000 mg twice daily and her hemoglobin A1C was not poorly controlled. She was also diagnosed with high blood pressure 2 years earlier, that is managed by lisinopril 20 mg once daily. We noted that her BMI is 31, which is indicative of obesity. All other lab values were within normal limit. Significantly, her TSH was in the normal range and her urine toxicology screening was negative. Upon further querying of her family history, her maternal grandmother was diagnosed with a nervous breakdown and spent 2 months in a psychiatric hospital in her 30s. Her mother required little sleep, had a history of impulsive spending, and had a history of starting projects that she didn’t finish. The patient’s paternal uncles had a history of depression as well as alcohol abuse. Upon doing assessments, her PHQ9 is indicative of 18 points and her mood questionnaire she scored an 8.","_key":"f02e422a3e920"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity","_key":"ca65b5f37591"}],"_type":"block","style":"normal","_key":"45deb75cea38","markDefs":[]}],"summary":"Gus Alva, MD, DFAPA, presents the case of a 23-year-old female diagnosed with bipolar 1 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I really enjoyed how thorough everybody was. There were a lot of questions about “Well, how did you make the diagnosis of bipolar I? Give me more details about the mania. Flesh out the case for me.” I would not want to give someone a diagnosis of bipolar I, which is a lifelong disorder, without knowing exactly what they've been through, and I thought that was nice. People talked about dilution of care and how quick encounters where patients are not given the time that they need is not a good thing, and I agree. People also talked about how important it is to educate patients and work with them and establish that nice rapport that makes you know your doctor is on your side. Your doctor is really trying to get you to be functional and happy. I also thought it was interesting that you have people who are willing to start with atypical second-generation antipsychotics and people who are willing to start with lithium, and I'd say the room was evenly split. That probably indicates that the trends in treatment of bipolar disorder are changing throughout our country.","_key":"35295e71a4181"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"fcde7791f67a","markDefs":[],"children":[{"_key":"c33761e24bb3","_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity"}]}],"contentCategory":{"_createdAt":"2020-02-10T10:49:36Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Videos","_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","_updatedAt":"2020-02-25T09:35:54Z"},"_type":"article","ExcludeFromPubMedXML":false,"seoTag":["bipolar disorder","bipolar 1 disorder","diagnosis","dilution of care","takeaways"],"authorMapping":[{"_createdAt":"2020-02-21T11:23:21Z","_rev":"dbU7y9dyfwZfti8ybHu5UX","_type":"author","_id":"pst_author_687591","biography":[{"children":[{"text":"Dr Moukaddam","_key":"1b7c00dcf8780","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" ","_key":"1b7c00dcf8781"},{"_type":"span","marks":["em"],"text":"is a professor of psychiatry at Baylor College of Medicine, Department of Psychiatry, and the Director of Outpatient Psychiatry at Harris Health System. 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Moukaddam, MD, PhD:","_key":"4bf04c5d3ce90","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" In the United States, medications would be approved by the FDA [Food and Drug Administration]. If you were in Europe, they’d be approved by the EMA [European Medicines Agency]. That’s the equivalent of the FDA here. The medications can be approved for the initial stage of bipolar disorder, which is mania. That would be acute treatment, but a medication could also have an approval for maintenance treatment. Obviously, one would want to initially go with treatments that have FDA approval. That being said, when a patient is very sick, sometimes you end up with some off-label prescribing, but that should not be your first step. The field has evolved a lot. As I’ve said, we have a lot of options now. You have your mood stabilizers: lithium, Depakote, carbamazepine, and lamotrigine. You also have your atypical antipsychotics and second-generation antipsychotics. Second-generation antipsychotics are a fascinating drug class because they take what the previous class of antipsychotics have done, which is dopamine agonism, and work on dopamine but not in the same way, not to the same extent, and not on the same receptors. Now, as a clinician I have a lot of choices. I can start with a mood stabilizer: lithium, as in the case of this young man. Or I could start with an atypical antipsychotic. Usually, what you’ll see is that patients don’t know. Thus, it is up to us, but we develop algorithms depending on where we’ve trained and how we’ve trained and the populations that we treat: very sick or not very sick.","_key":"4bf04c5d3ce91"}],"_type":"block","style":"normal","_key":"f7736062a169","markDefs":[]},{"_type":"block","style":"normal","_key":"7cd88fcd4862","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"6e068cd354810"}]},{"_key":"593becf0b4a4","markDefs":[],"children":[{"marks":[],"text":"Where do we go from here? Based on the metabolic profile of the patient, their family history, their medical history, and what I’m seeing right now, I would have to pick an agent that hopefully catches the symptomatology and controls it. First, we want it to be monotherapy. It’s always better to do monotherapy instead of 2 or 3 agents. People don’t like it when you give them 3 or 4 prescriptions because they feel that they’re broken; they feel that they’re really sick. Sometimes we need that, but ideally, monotherapy is what your patient will stay with. We’re thinking a little about dopamine, glutamate, and serotonin here, and it’s beyond the scope of this talk to talk about all the receptors. But with dopamine agonism, the older agents used to focus on the detour receptors. The newer agents would lean toward D3 receptor agonism, and instead of having full agonism or full antagonism, now we have partial agonism and partial receptor agonism, which is extremely precious because it gives you more nuanced effects. Some of the newer atypical ones will have partial agonism, and that’s helpful. Also, in this type of treatment, we really value the effect on serotonin receptors, and when the atypical and the second-generation antipsychotics first came out, it was a really big deal that they worked on 5HD2 and conversely on 5HD2C. 2A and 2C are the 2 serotonin receptors that are opposing in action, but activation of 5HD2C as in the case of olanzapine could trigger some of the weight gain.","_key":"47f658b7b2590","_type":"span"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"","_key":"71337f59f0950"}],"_type":"block","style":"normal","_key":"54b0dd0d248b","markDefs":[]},{"_key":"61ad71509ae0","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Why do we care about serotonin? We care about serotonin because it modulates dopamine release. Dopamine is a big agent in bipolar disorder. It’s a neurotransmitter that causes a lot of these symptoms, and modulating dopamine is one of our goals. We do it via serotonin and glutamate, but because there are so many other receptor subtypes involved when we pick an agent, we want that agent to cover a wide variety of profiles. We want that profile to cover some dopamine, some serotonin. We would like to have some histaminergic agent to help with sleep but not too much, and we definitely don’t want a muscarinic agent because this is when you get your anticholinergic adverse effects.","_key":"091b2267a4390"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"01258dedb7150"}],"_type":"block","style":"normal","_key":"1a35abf7c143"},{"_key":"45a527df1f01","markDefs":[],"children":[{"_type":"span","marks":[],"text":"One of the considerations we have not talked about, but it would change how you approach things, is age. You want to make sure the person knows that this is potentially a lifelong treatment and that if they are female and of childbearing age, this will change. They would have to use contraception, and if they get pregnant, then it could affect them. The treatment could affect the pregnancy, and bipolar I disorder could also affect the pregnancy, and the pregnancy in turn could affect the bipolar I symptomatology. Thus, with women, you want to caution them that the postpartum period would be a very high-risk period for depression, etc.","_key":"0f627358d9590"}],"_type":"block","style":"normal"},{"_key":"dcdc9c4ebb09","markDefs":[],"children":[{"_key":"3b6735a0102c0","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"My approach to the treatment of patients who have failed multiple therapies is to make sure that I’m maximizing the use of psychosocial treatments, especially psychotherapy, and then to deviate from monotherapy to maybe adding other agents.","_key":"6f886622d6e90"}],"_type":"block","style":"normal","_key":"2f2cbcc55dc8","markDefs":[]},{"style":"normal","_key":"b4eef11479b3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4c4bb499df570"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"My first step would be to add psychotherapy. I would want to make sure that the patient really understands what’s going on and is maximizing the use of their own psychological resources. Then, I would go beyond monotherapy, and I would consider adding a second or perhaps a third agent. In the case of this young man, we have lamotrigine and quetiapine. I would consider 2 agents and then maybe consider an adjunct. Maybe this person needs a little bit of help for anxiety or for sleep, so I would like to combine psychosocial treatment with psychotherapy and then change agents. I would also talk to the patient about how realistic it is when we talk about mood control and adverse effects, and this is where the tough conversation of benefit outweighs risk comes in. If they have a 5-lb weight gain, could that be acceptable? If they tell me a 20-lb weight gain I would say, “No, that’s really too much.” But if it’s a small weight gain or if it’s an adverse effect that’s mild, could we then accept it if the medication gives us benefit? That conversation has to be very customized and very tailored to the patient’s presentation and it relies on your rapport with the patient. If you have a good rapport with the patient, usually you end up with a much better outcome when treating those conditions. There are other things we have not talked about; ECT, which is electroconvulsive therapy for mania, is there when somebody is really ill. There is hospitalization, but we’re assuming for the purposes of this case that this is outpatient.","_key":"0f14d2b156af0"}],"_type":"block","style":"normal","_key":"65e485cb912d","markDefs":[]},{"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity","_key":"0146132985b6"}],"_type":"block","style":"normal","_key":"2d7c28e4bfd4","markDefs":[]}],"ExcludeFromPubMedXML":false,"link":"/view/treatment-selection-for-bipolar-disorder","title":"Treatment Selection for Bipolar Disorder","_rev":"cXOCgk8cFlqqyM1IPiCsRo","_type":"article","documentGroup":{"_type":"reference","_ref":"75620a42-71d6-478b-b16b-23f3aee786fd"},"source":null,"_id":"89241fc7-2e81-4f89-a585-28f4b17538cf","_createdAt":"2022-05-09T14:00:52Z","_updatedAt":"2022-06-02T12:53:21Z","taxonomyMapping":[{"_createdAt":"2022-02-28T20:58:37Z","_rev":"IakUcQKwj7kr3xQjaaVtjW","_type":"taxonomy","name":"Bipolar I Disorder","_id":"622449b3-ea9c-4cc2-a722-db1923e845d9","_updatedAt":"2024-02-21T20:41:50Z","identifier":"topics/bipolar-i-disorder","perKeywordMapping":["Psychiatry","Neurology"],"cmeType":"per"},{"parent":{"_ref":"pst_taxonomy_53202_clinical","_type":"reference"},"_id":"pst_taxonomy_52_bipolardisorder","_updatedAt":"2023-03-31T19:08:00Z","identifier":"topics/bipolar","perKeywordMapping":["Psychiatry","Neurology"],"cmeType":"per","_createdAt":"2020-03-26T06:11:21Z","_rev":"77mZ7PORfofI3dBGfWalU3","_type":"taxonomy","name":"Bipolar Disorder"}],"contentCategory":{"_type":"contentCategory","name":"Videos","_id":"42000fd0-0d05-4832-9f2c-62c21079b76c","_updatedAt":"2020-02-25T09:35:54Z","_createdAt":"2020-02-10T10:49:36Z","_rev":"snQqhhB4O8T5bi1viURsgs"},"published":"2022-05-09T13:59:52.271Z","seoTag":["bipolar disorder","bipolar 1","FDA","EMA","mania","acute treatment","maintenance treatment","second-generation antipsychotics","mood stabilizer","monotherapy","dopamine agonists","glutamate","serotonin","age","pregnancy","postpartum","depression","psychotherapy"],"summary":"Nidal Moukaddam, MD, PhD, provides insight on the evolving treatment landscape for bipolar disorder and optimizing therapies for disease management.","is_visible":true,"updatedOn":null,"factCheckAuthorMapping":null,"authorMapping":[{"_type":"author","_id":"pst_author_687591","biography":[{"_type":"block","style":"normal","_key":"ff467783b8e9","markDefs":[],"children":[{"text":"Dr Moukaddam","_key":"1b7c00dcf8780","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" ","_key":"1b7c00dcf8781"},{"_type":"span","marks":["em"],"text":"is a professor of psychiatry at Baylor College of Medicine, Department of Psychiatry, and the Director of Outpatient Psychiatry at Harris Health System. She also serves on the Psychiatric Times Editorial Board.","_key":"1b7c00dcf8782"}]}],"_updatedAt":"2024-09-04T16:39:43Z","url":{"current":"nidal-moukaddam-md-phd","_type":"slug"},"displayName":"Nidal Moukaddam, MD, PhD","_createdAt":"2020-02-21T11:23:21Z","_rev":"dbU7y9dyfwZfti8ybHu5UX"}],"internalTag":["treatment selection","bipolar disorder","bipolar 1"],"url":{"current":"treatment-selection-for-bipolar-disorder","_type":"slug"}},{"_updatedAt":"2022-06-02T12:52:33Z","ExcludeFromPubMedXML":false,"_rev":"8F4yeKwlkKXWnqQAFsZYuN","body":[{"_type":"video","videoID":"6307050948112","source":"brightcove","_key":"3799344c42b4"},{"style":"normal","_key":"781742d496c3","markDefs":[],"children":[{"text":"Nidal Moukaddam, MD, PhD:","_key":"6a653bf5e27a0","_type":"span","marks":["strong"]},{"text":" The art of psychiatry is making sure to look at the patient holistically and having a comprehensive history that then links to treatment, because you don’t want to ignore important things such as their medical history, metabolic profile, constraints on their job, and family history. Let me go into some of these. If you think that the treatment that they would benefit from is a pill that’s given 3 times a day, but their work does not allow them to do that, then you would not want to proceed because the patient would not be adherent. Similarly, financial considerations are very important. If I think a particular pill would be fantastic for the patient, but they cannot afford it for more than a month, then it would not be sustainable.","_key":"6a653bf5e27a1","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"1fcfd1b1365f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"2e5bd20232100"}],"_type":"block"},{"children":[{"text":"These would be your first considerations: Can they afford it, will it mesh with their schedule, and does it fit well with their medical profile? We have not talked about this patient’s medical history but somebody who has obesity, diabetes, or other conditions could not potentially take an agent that causes weight gain. Because even though the agent could be beneficial for psychiatric symptoms, the weight gain would be unacceptable and make the other conditions worse. Those are huge considerations: the metabolic profile and medical history. As mentioned in the case, this patient developed hyperthyroidism, so that’s one of the things we consider with lithium, especially long-term treatment.","_key":"e5df5855401e0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"25c8fc359b14","markDefs":[]},{"_type":"block","style":"normal","_key":"c6d99e2f1dd9","markDefs":[],"children":[{"marks":[],"text":"","_key":"09b8e4b369430","_type":"span"}]},{"style":"normal","_key":"d6780fc338ff","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The one other thing you discuss with the patient, which is really important, is that bipolar disorder doesn’t typically go away. You will have to be on medications for an extended period of time, perhaps for the rest of your life, so we really want to find a medication regimen that is comfortable for you. When I say treatment, treatment is not only medications. We have to consider whether there’s any therapy that could work. Psychotherapeutic modalities are extremely effective for certain things, especially for rhythm therapy and making sure people know how to manage their sleep and energy and how to catch symptoms before they start. Psychoeducation is your first step. 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A 30-year-old man has taken short-term disability leave from work due to the progression of a depressive episode. He received a diagnosis of bipolar I disorder about 10 years ago. He had his first episode of mania at the age of 20 and 2 subsequent episodes of mania between the ages of 21 and 29. He was treated with lithium, which was highly effective, but he experienced excessive thirst and developed hyperthyroidism. His lithium level at the time was in the therapeutic range of 0.8 mEq/L. He was switched to valproate; however, valproate lacked the efficacy of lithium and caused adverse effects of sedation and weight gain. During his third manic episode, he started on olanzapine but experienced excessive weight gain. He was then cross-titrated to quetiapine, which improved his manic symptoms. However, weight gain again became an adverse effect, and he also complained of sedation. The patient reported sleeplessness and made unnecessary online purchases when unable to sleep, but the quetiapine sleepiness was unacceptable. Despite these adverse effects, he continued taking] quetiapine until he decompensated into his third depressive episode. The quetiapine was then augmented with lamotrigine, which was titrated up to 300 mg per day but demonstrated no efficacy. At the time of presentation, the patient was adhering to the medications. He did not have a substance use disorder, which was confirmed by a negative toxicology screen. His TSH [thyroid-stimulating hormone] level was in the middle of the normal range, and he had no suicidal ideations or psychotic symptoms.","_key":"1686c356abed1"}]},{"style":"normal","_key":"ea8ba45f7458","markDefs":[],"children":[{"_key":"f31999fb6d0a0","_type":"span","marks":[],"text":""}],"_type":"block"},{"style":"normal","_key":"206eb79d1eaf","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I think the most important thing to do when somebody comes to you, even if they tell you they have a diagnosis, is to confirm the diagnosis. You want to start by making up your own mind, and sometimes the patient is not a good source of information. But in the case of bipolar disorder without psychosis, you expect the patient to be able to give you a solid history. Typically, the part of the history that’s hardest to nail down is mania. When people experience mania, they have excessive energy and excessive activation that creates the need for sleep, and sometimes they like it. They feel that this is the way it should be, so they don’t point it out as pathological. Now, the ","_key":"f218dd5b62af0"},{"_type":"span","marks":["em"],"text":"DSM-5","_key":"f218dd5b62af1"},{"text":" [","_key":"f218dd5b62af2","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition","_key":"f218dd5b62af3"},{"_type":"span","marks":[],"text":"] criteria tell us that mania that leads to hospitalization or some negative consequence like incarceration is problematic no matter what the duration is. Assuming the patient did not end up in the hospital or in prison, we want to verify the story of mania. In the current case presentation, I can see many of my colleagues saying, “Hey, you’re not giving us enough symptoms of mania. He’s a bit sleepless. He makes frivolous purchases. That’s bipolar disorder but not bipolar I; maybe it’s bipolar II.”","_key":"f218dd5b62af4"}],"_type":"block"},{"style":"normal","_key":"3d26ded4dbfb","markDefs":[],"children":[{"marks":[],"text":"","_key":"c03ab97f85850","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"37558fefd333","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Thus, my first step would be to explain that this patient had at least a week without sleep. During that week, he was spacing, had pressured speech, and was talking fast to the point that others around him commented about it. He became more impulsive, and buying things was the tip of the iceberg. He also became more sexual to the point where it got him in trouble in his relationships, he spent more money than he had planned, etc. These examples of impulsivity often nail down the diagnosis of bipolar disorder. Of course, these symptoms change with the time that we live in. For example, before unlimited plans on cell phones, you would have been taught to ask: “Do you get a very high bill on your phone when you’re manic?” Because patients with mania talk a lot, and the bills would be higher when they call across state lines or internationally. First, I would recommend verifying the diagnosis. My impression of the patient is that this is somebody with a set diagnosis of bipolar I. Three manic episodes is a lot. He has impairment because of it, and it’s affected his job. Thus, my first step is confirming the diagnosis. 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