Welcome to the Psychofarm podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality. Hello, Dr. Fulps. I'm super excited to have you on the podcast today.
Thank you, Dr. Malzberg. Pleasure to be here. Appreciate the invite.
I feel like I should give you a little bit of an introduction. So Dr. Phelps is a semi-retired psychiatrist, has over 30 years of psychiatric experience. And I think what I love about your teaching, and I'll say where your teachings are in You can always tell when someone sees a lot of patients. And there's so many educators out there. You can tell they've read the literature. But when someone sees the patients and listens to patients, they teach very differently.
And I think what I love about your teaching is you can tell it's just extremely clinically grounded. So... When I looked into your history, you've worked in a ton of different settings. You've worked inpatient, outpatient, hospital, private practice. You have a ton of awesome books out there. Spectrum Approach to Mood Disorders, Bipolar Not So Much. The website org. And actually where I found you is the YouTube channel Psych Education, which doesn't have nearly enough use as it should.
Thank you, and I appreciate the tip of the hat toward the clinical experience. That is, if there's anything that makes me different in terms of hundreds, you know, that would be it. Thanks.
Yeah, it's just so clear that I don't know. I feel like I have a good knack for when someone's an excellent clinician. And it's very clear you listen and pay attention to patients and that you see patients because there's so many there's a flexibility in clinicians, how they communicate. And just to me, it comes across in your teachings. So everyone check out those those that website and that YouTube video.
Unless people say, gosh, I wish I was able to do that. I had the luxury of 25 to 30 minute visits with nearly everyone and 55 to 60 when I thought necessary and never shorter than those. So I actually had the time to listen. I know that's a luxury that many people don't have anymore.
Yeah, and I think as clinicians, I think we should be promoting that and not losing that. Indeed. So today, I'm doing something a little clickbaity with you. We're doing the tier lists, and I want to do bipolar treatments. And I gave Dr. Phelps a little rundown on how tier lists work, but we might be figuring it out together. So I put together... There's a few things I've learned from your videos that aren't in your standard conventional psychiatric treatments and then some things that are standard treatments that I think you just have brilliant commentary on it.
So what we'll do is I'll give you one of We're going to start out with low-dose lithium.
And my grade is S. And you put it in that upper left hand corner on purpose because we had talked about what things are likely to change people's clinical practice. Becoming familiar with this option is one of those for sure. I don't know how much you want to give me, you want me to go on on each one of these, but that would be the short version.
No, I want you to go on as long as possible. I'll interrupt you. So talk to me about where you see it work, how you think about it, how you use it.
Good. What is it? What do I use it for? Why do I think it's so important? What is it? Starting with 150 milligrams, because that's the smallest dose we can engineer, and going up by 150 milligram steps every four to seven days and nights. Until something good happens, something bad happens, go back down one step, or you get to 600 milligrams daily and then check a level.
So it's starting low and going up fast or slow, depending on how anxious the circumstances are. And with a target of a relatively low dose, 600 or so, before you arrive at any other evaluations of its efficacy or its potential risks, And in so doing, we're thereby keep the risks low. The probability of doing renal damage with this is extremely low unless you're not watching out for nonsteroidals and antihypertensives.
I mean, you do need to check the levels. And of course, that means you need to get blood tests. So that's one of the biggest downsides. And I think one of the reasons why people don't do this so much is because you need a free blood test and then you need some follow-up blood tests, but not as many as the guidelines usually suggest. So that's how I do it.
I'm inviting the patient to really be in charge. They've got their hand on the knob. So as you turn it up, if something bad happens, turn it back down a step. Keep going because we want to see if even that lower dose might get us somewhere. But if nothing is happening, you can turn it up. And if you're really in a hurry because your symptoms are so bad, Every four nights is about as fast as you'd want to go.
You can go as much slower than that as you want in order to make sure we don't cause any trouble as we're evaluating the possibility of using this tool and then checking a level at 600 just to make sure you know where you are and figuring it out from there.
What's it for?
The entire mood spectrum, all the way from clearly bipolar one to clearly plain old unipolar Pure not bipolar depressions, because as you, I think most listeners will know, there are efficacy data for lithium as an adjunct, usually at low doses to antidepressants. So we could be thinking about the data from unipolar or in bipolar one. It's very clear that lithium generally regarded as the number one tool for the management of bipolar disorders.
Depending on the levels and the purposes, and everyone along in between. Where I think it's least appreciated and most valuable is in the middle of this mood spectrum, where sometimes this might be along with modified social rhythm therapy, for example, or Lamotrigine. All you need. So you can stay away from antipsychotics and you can stay away from other potentially aggressive treatments and you can stay away from antidepressants using this tool there.
I think that's enough for that one.
Awesome. And what I love, I think I took something that you had said in one of the videos of when I talk to patients about it, I say, once we get, if we get a side effect, that's when we stop. And The comfort it's made me with prescribing lithium is drastic because before starting to do this, I felt like it was this big gun intervention that it's like when I would prescribe it, I had to talk about monitoring, I had to talk about interactions, I had to talk about all these different toxicities.
It scares the patient away. If you have a patient with a bipolar 2, a lot of them hear lithium and they're like, I don't want to get my blood drawn. I can't take NSAIDs, all these misconceptions. And when you pitch it to a patient as the second you get a side effect, we're going to go back down to the lower dose. Whoa, what a difference that makes.
And It's allowed me to enter the conversation of lithium to so many patients that otherwise would be imposed to it. I think it's a tool that should be in every psychiatric provider's toolkit.
Absolutely. And I'm sure you know the work of Nasir Agami, and you may have heard him say on his podcast, if you don't know how to use lithium, you shouldn't be treating bipolar. And then he goes on to quote his mentor, Fred Goodwin, who said, if you don't know how to use lithium, you should get out of psychiatry.
Absolutely. It's a little harsh,
you know, but again, the point is, Dr. Malzberg, by using this other, this low-dose approach that I just described, it makes it safer for you, for your patients, and gives you the opportunity. It's like exposure therapy for using lithium.
Yeah, and I think those provocative statements, like, you hear that and it's like, okay, I should never be not doing lithium because I'm scared of it. Yeah, yeah, exactly. That leads me to the next... Treatment I want you to talk about in regards to how you rank it. And that's lithium orotate.
Let's see. We don't have a tiers category for, who knows? Let's put it in the middle then. Let's give it a B for now. B, okay. Because we don't have... The clinical experience with it, which I think, you know, that's the road testing. That's when you really learn how to use things, not by reading the literature, which is important as a starting place. But what does this stuff really do?
It would have gotten an F in that respect because we have no data in terms of rigorous understanding of it, almost no data at all. But it gets a B because, man, this is really important to understand. We need to keep our ear to the road. If this stuff could end up replacing lithium carbonate, we just don't know yet.
Yeah, one thing that I guess do you have when you do use have you have you when you prescribe low dose lithium, do you ever recommend lithium orientate or do you always use carbonate as your recommendation?
I'm sorry to report, I have to be honest, I tapered my way out of clinical practice about over five years ago. Really, that was before the new mouse data from the Nature paper from Bruce Yankner's lab at Harvard, before that paper came out. And so I knew of lithium orotate, I might occasionally And I don't think anyone With the exception of a fellow in Australia that I've been corresponding with, has done it enough to be able to speak from that perspective.
One thing that I found funny is I don't know if you know about Reddit. I'll search sometimes like different supplements and search like what Reddit is saying. So like just what your average user is. And I've been really impressed. Not that this is anything to guide practice, but people are raving about it. People are mentioning just like five milligrams, 10 milligrams, making a huge difference. So I'm excited.
I hope that more research makes it so we have a better idea of where it fits in.
Yeah, you know, the traditional academic would poo-poo something like Reddit anecdata, right? It's not really been studied. But, you know, if you just listen to it and the voices there get loud enough and numerous enough and go on for long enough, that's a credible source of information. You know, like that's not nothing.
Yeah.
You know, but, you know, placebos have incredible value. So who knows? It's hard to. Compare the two.
Yeah, I use it as a helpful, like, you know, thinking of just the voice of, you know, being able to collect, seeing what 30 people say about something that I've seen one patient in my clinical practice actually using. All right, for our next one, I want to do one of the ones for sleep because I feel like one of the big things I learned for you is you call, you don't call for the mood stabilizer category.
Calling not just medications mood stabilizers. That to me was such an important... It's something I use in my clinical practice all the time. Talk to patients about mood stabilizers. When I say mood stabilizers, I'm not saying lithium and Depakote. I'm saying things like sleep. I'm saying things like diet. And framing it that way is so helpful. So I want to pick... I guess you mentioned this one earlier.
You mentioned... The social rhythm therapy kind of adapted. Maybe just give us a grade and talk to me about how you can, not the full therapy, but what a clinician can talk about in an appointment.
Yeah, excellent distinction. Thank you. So you can think of it as sort of like three levels. There's IPSRT, Interpersonal and Social Rhythm Therapy. That was the original. That's what most of the manuals are written about. Then there's social rhythm therapy, SRT. And there is now, fortunately, a workbook from Molly Schwartz that is just about that. It's just the SRT portion, not IPSRT. And then I think you can go a step further in terms of saying, what are the most essential ingredients in SRT?
And everyone, I think, would agree that sleep is the central one. So instead of getting into the whole SRT, let alone the whole IPSRT, we could just start with just a regular pattern of sleep. And that's within the reach of most clinicians, even most clinicians who think they're supposed to be just prescribing medications. So we can get out of the mode of thinking about mood stabilizers as pills and talk about mood stabilizers generally.
So helping people get regular sleep hours. It sounds simple, but it turns out if you have much clinical experience, you know how hard that is, that people really struggle to do that. So I've written about and made a video on my channel about just teaching people and helping them to get to a regular pattern of sleep, a regular bedtime and a regular rise time. So that's the very simplified version.
So I think of it as like a simplified social rhythm therapy.
Now, what has helped when you talk with patients in terms of actually things that they can follow and that they listen to? Is it simply recommending a time to go to bed and a time to wake up? If you have a patient that you want to communicate something, what's the meat of what you're telling them to do?
My knee jerk reaction is simple. Don't talk to them. Listen to them. Why is it that you are going to bed at two in the morning? How did you get there? And acknowledge because they certainly recognize it would be a good idea not to be doing that. What is getting in the way of you being able to get to bed and get into bed and hopefully fall asleep earlier?
So start by understanding where the patient is and approach it, as we always generally do think in terms of psychotherapy, with empathy and positive regard, right? Okay, it's understandable how you got here. So I think that's crucial. It's just like when you're tapering antidepressants. We'll get into that one later. You want to start by building confidence that this is possible and knowing what might make the person not confident that this is doable.
And then there are some tools and tricks. So try to help people understand that we're not going to go from 2 m. to 30 m. In one step, we're going to do it in 15 minute steps every couple of nights and that you can see yourself making progress. And here are a couple of tools to help you do that. And those tools would be increased darkness before you go to bed and a regular pattern of getting right out of the bed when the alarm goes off and maybe using a dawn simulator to facilitate that.
And in between, we have a really dark bedroom. I think those are the three main ingredients, more darkness before More bed, really good darkness during sleep, and then using light strategically to help get going in the morning because good evidence that that actually makes it easier to get your morning time going. And once you can really fix morning time, it gets easier to move to evening time.
pharm. All right, back to the show. Yeah, it's really funny. When I was in med school, I heard the acronym IPSRT and thought it was this very fancy highfalutin therapy. And then when I learned the principles, I... To me, I feel like it helped me with patients outside of mood disorders because everyone benefits, not necessarily from the importance of focusing on a super staple sleep. That is super important.
But building structure and stability, it helps every aspect of mental health. It's a big focus for my patients with personality disorders, with trauma. Taking the principles of keeping lifestyle things as stable as possible, that's a part of all of my treatment for every patient now. Amen. Please put ADHD on the list, right? ADHD. Oh, big time.
Before we start thinking about giving a stimulant, how about if we see if we can get you seven and a half hours of sleep and then we'll see what targets remain?
Yeah, and I like that. So I guess it's funny when it comes to something like ADHD, I think the underlying message aside from the helpfulness of that intervention is your attention isn't just a deficit or problem. You make choices that will impact these things. With bipolar, it's a little bit harder because it's a lot more of the like, these things can get completely thrown off and it's not entirely up to you.
So yeah, I guess with social rhythm therapy, are we putting that nest here? Oh yes, an S, please. Awesome. Why don't we use that as a jumping op? You mentioned a few things. You mentioned like how you use light strategically. So I want to hear you talk a little bit about dawn simulators, about light boxes, where you think they fit in and how you grade them.
So a dawn simulator, which as I think most people would know and sort of the name implies, is a gizmo that turns on your bedside lamp over a period of about 30 minutes prior to your waking. Which means that light therapy and done in this fashion is done by the time you wake up. Very different in that respect from light therapy using a 10,000 lux light box and sitting 18 inches in front of it for 30 minutes, which would be the standard treatment for seasonal affective disorder, for example.
As I'm sure you know, Dr. Muhlsberg, light therapy in the latter fashion, the formal light box, has been studied for the treatment of bipolar and shown to basically be an antidepressant. It functions like an antidepressant. It carries the same risks of antidepressants, including not just inducing hypomania or mania, But inducing mixity, making a mess of mood stability, including inducing anxiety, irritability, agitation, and attention problems. So we have to be careful about light therapy in the formal sense of the formal light box, especially for 30 minutes first thing in the morning.
That's light therapy, as distinct from the dawn simulator, has no risk of inducing hypomania that I've ever seen any indication of, let alone evidence for. Most people actually like it. Even if it doesn't actually help with sleep all that much, they go, yeah, well, I'd rather wake up to this than to an alarm clock. And it's cheap and it's done by the time you wake up. So it has huge advantages relative to formal light therapy with a light box.
And so you can gather my enthusiasm for it. And so, yeah, for sure, it's going to get an S unless I'm like limited to only five S's and I can only.
No, no, you get unlimited. Because most of the ones I picked were I knew you were to put an S, but I want to hear you talk about it. So I'm fine with that.
Yeah, good. So I guess an S too. It's just such a beautiful tool. And what else do we have in psychiatry that we can talk about that has an antidepressant effect at least In terms of randomized trial data and seasonal affective disorder. And it's cheap and it's harmless. The only harm would be if your bed partner is not on the same schedule and might not appreciate having this thing go off and then they need a sleep mask and you can continue to do what you need to do.
So yeah, Dawn Simulator is way up there and people can figure out which one, how much you want to spend and how to figure out how to use it.
You mentioned mixed states. Your teaching on mixed states is brilliant and so missing in the DSM doesn't quite capture it. And your talk on mood spectrum. I'm hoping that this talk gets people very excited and we can do a follow up that's only about mixed states or maybe only about mood spectrums. But we'll see. All right. Our next one is dark therapy.
Thank you. Very similar to Dawn Simulators. And in fact, it's really actually just the same idea turned upside down to look at using darkness deliberately and the way that we're using light deliberately to say, hey, it's daytime now, time to get going. We need to use darkness at night. It's nighttime now. It's time to slow down and prepare your nervous system for being able to go to sleep.
So dark therapy in the broadest sense is merely using darkness strategically as part of a package to help make sleep regular. And as you know, Dr. Maltzberg, there have been some very interesting studies of using darkness in terms of like randomized trials showing that, yeah, okay, this really actually does work. There's one recent negative trial that just got published to the great disappointment of the people who'd done the earlier Arduous randomized trial on an inpatient unit for mania and a paper coming out with an explanation of why we think the newest study didn't work.
But there are two randomized trials of darkness for the treatment of inpatient mania that did show efficacy and then this most recent one that did not, efficacy relative to placebo. So, and the point being, we do have data that darkness can be useful as a tool. But then, you know, again, we're talking about what's it like with clinical experience? Well, everybody can relate to this. Trying to tell people that when it gets dark outside, you need to be in a dark place and you need to stay in it until you actually try to get into your dark bedroom.
No one wants to do that. We have electric lights now. We don't have to live like that. So, of course, the problem is that what's natural is to be in the dark from the time the sun goes down. So dark therapy is really just an attempt to kind of return to a more natural approach to sleep. Meaning a natural approach to a nighttime environment that is dark.
But you can cheat. And so this is the way I'm telling you this story, kind of the way that I would tell it to patients.
Keep talking. I'm going to grab something.
Okay. So you can cheat. You can have your darkness and eat it too. Because it turns out that only one wavelength of light Tells your central nervous system that it's daytime out there. And that wavelength of light is the one that you can block with these, as Dr. Maltzberg is demonstrating, you can block the blue wavelength with Glasses that block just that wavelength and let everything else through.
So you can have your light as long as you take the blue out of it, because then physiologically, when you don't see blue, your brain thinks you are in the dark. And there's some marvelous experiments showing exactly that, that physiologically, you really are in the dark when you put those things on. Now, it sounds great. The clinical practice experience says, People can only wear these things for a while.
They're not going to become a permanent user of amber lenses. It's just too clunky and where I put them and they're not always most comfortable. But you can use them to get the whole ball rolling in terms of making it easier to fall asleep by simulating darkness for two hours, say, before you get an actual real darkness. So dark therapy is, in my hands, something that I'm thinking primarily here, outpatients, something that you do to get yourself in the dark, so to speak, before bedtime, And then you want to make sure that you really actually do have a very dark bedroom in which to sleep.
It's so dark that you have no more than the equivalent of two candles. Two candles is At one meter is one lux. So two candles at a meter is two lux. And anything three lux or more actually was shown in one study to raise the risk of having a manic recurrence. So a really dark bedroom, whether that's dark curtains or if you're desperate and you rent your place and you don't have any money, literally putting tinfoil on the windows.
Yes, your neighbors will think that you're trying to turn into a meth lab. You might have to explain. But it is possible to make your bedroom really dark. And then you will need a dawn simulator in the morning so that you have that dawn signal. So that's kind of the whole spectrum of dark therapy in the context of regular bedtime and rise time.
Yeah, this is awesome. And the way I really pitch it with patients is thinking of your circadian rhythm as this thing you need to protect yourself and you need to build it and make it really strong. I think probably most psychiatrists or anyone who worked overnight Yeah. Yeah. Little things. To me, the big things that I'm trying to teach with patients that I like about dark therapy is because it's kind of showing the patient the principles.
Morning, light as soon as you first wake up within 30 minutes of waking up. I actually do like these glasses. My wife finds me funnier when I wear them. They look pretty cool. Yeah, these things are really important, even if the patient isn't able to follow them perfectly, but it communicates the big principles that we're kind of trying to get across the patient.
That is so important because the actual lenses, my experience was, yeah, about 50% of people would come back and go, yeah, that really didn't do anything. The other 50% came back and said, these are amazing. When I wear these things, I fall asleep an hour earlier. But 50% of people, it's not like you can really rely on this stuff. I'm not starting a medication that I'm really, really thinking is going to help.
I'm hoping for a 50% probability of response. But in the meantime, I've really got people's attention while I'm explaining the value of circadian rhythm, protecting it like a baby. That's really good.
And another thing I think I've learned from your videos is bipolar is all about the long game. And I think it's important to communicate this with patients. Like when I recommend these glasses or recommend light in the morning, As you said, I don't say expect to wear these glasses and fall asleep like a baby the first few nights. If you do these things, over time, you'll see improvement.
It's not going to be overnight. It's not wear these glasses or go out in the sunlight in the morning and And boom, everything's fixed. But if you start building in these habits, you'll start to see things improve over time. So, you know, I think how we pitch is important because, like, as you said, yeah, if a patient buys these glasses, puts them on, it's like, wait, I slept the same.
But with bipolar, you're teaching about the long game. I think he had a quote. I think he said I got it from a mentor of you're not trying to treat the symptoms. You're trying to stop the cycling, I think was it.
Amen, yes. And I think that's so important. Yeah, that was Fred Goodwin, the head of the National Institutes of Mental Health, wrote the book, the Bible, called Manic Depressive Illness. Yeah, he said, polarity is not the problem, it's cyclicity. Yeah, and so Gary Sachs said, he was the head of the Harvard program, bipolar program. He said, yeah, don't treat the mood du jour, stop the cycling.
Yeah, and I think that's so important for clinicians to understand because a lot of our patients, a lot of patients that, especially with bipolarity, are comorbid personality disorders, comorbid ADHD, comorbid XYZ. And if I focus on that and focus on the symptoms, I'm going to lose the long game. And learning about the long game makes you such a better provider. That's my opinion, at least.
Can we do a tangent or do you want to confine ourselves?
I'm loving tangents.
So comorbidity. I have a knee-jerk reaction to this one as well. When you have a patient that's got these potential comorbidities, my framework is, okay, stop the cycling first, primary target, and then you can see what's left over after that. Because in my experience, what looked like ADHD, well, it doesn't always go away, but it may diminish to the point where it doesn't need a further intervention.
Same thing for generalized anxiety. In fact, that's probably the most common, that anxiety is an intended problem to mood disorders. It's not a comorbidity. It's just part of the deal. So when we treat the deal, then we can look to see what's left. And in my experience with people living with bipolar, the anxiety most often goes away to the extent that it doesn't require an additional intervention.
And if it did, then cognitive behavioral therapy would be the obvious intervention. We don't need to add anything, particularly not an antidepressant. Even trauma nowadays is politically more correct to attribute people suffering to an external problem rather than a potential internal problem. And I understand the logic of that when talking with patients and in terms of a patient's own experience. Trauma is not entirely universal, but it's so common.
But having true PTSD in terms of the physiologic reactivity and the burden of re-exposure and all that that goes with true PTSD is not that common when you look at people who've had a traumatic experience. It's only a subset who get the PTSD symptoms that go with it. So I approach trauma the same way. If it's bipolar with the trauma history, well, let's see how problematic the trauma history is after we've got mood stable.
And maybe then it's amenable to a psychotherapy alone, obviously my preferred approach at that point. And then lastly, personality disorders. First of all, we need to change the lingo. Personality disorders is a really dumb thing to use as a label for these things when we psychiatrists haven't been entirely free from our own personality problems historically. I think the people went into psychiatry were a little more... I've had people say, oh, you're a psychiatrist?
Well, you're so normal.
No, no, no,
no, no. Yeah.
So the misconception like psychiatrists are just weird people. And now we're going around saying who's got a personality disorder. That's just a it's a bad. The optics are bad. So let's call it borderlineity because that's really the one that we're talking about. And then we can recognize that borderlineity exists on a spectrum. And when you bring it back down closer to the not so extreme end of the spectrum, it becomes a Temperament, very similar to the studies of temperament and bipolarity.
So that the distance between bipolar and temperament and borderlineity ends up being these are difficult distinctions in the middle. It's almost an impossible distinction.
I would love to do a full episode on your thoughts in regards to trauma and comorbidities and borderlineity, but let's keep it running.
You can edit that out.
This is spectacular. I think people are going to love this. All right, so where did we put dark therapy?
Oh, yeah, definitely up there.
Yeah. All right. Where would you put morning light boxes? We talked about that. I don't know if... Yeah. C. C. All right.
Yeah. Because they work and it's a useful potential tool, but they're a hassle. They actually carry some risks. They're expensive. Hard to get people to actually use them really correctly. Yeah. But it's very clear that people who live in an indoor environment lit with fluorescent lights, as people do where they work in an office, they're just not getting enough light during the day. So in terms of protecting and making your circadian rhythm more robust, One of the problems is just not enough light during the day.
So I'm sure you've had patients saying, oh yeah, I really love my light box. I just stick it on my desk there at work and I just leave it on all the time, which is not how we're supposed to be doing light therapy. But for them, it may actually just be getting them back to the kind of light exposure they might've experienced if they were outdoors more.
Yeah, light boxes really show how Western medicine works of like, the important thing is getting your ass outside. And seeing the sun. And we always take the one variable and put it in a box. But with my patients, it's like, if you have a balcony, go outside. Even on an overcast day, the blue wavelength still gets through. The ideal thing is go outside and do something active in the morning.
The Western solution is buy a light box and stay on your computer. Yes. And maybe get a treadmill if you are really trying to, yeah. All right, for our next one, omega-3, fish oil.
That gets a C. It's a great tool. You know, it's regarded as unethical to prescribe a placebo. Well, fish oil is not a placebo. We have randomized trial evidence for its efficacy in the treatment of several different forms of depression. If you look at the randomest trials in aggregate, like with a meta-analysis, most of them don't work. And then there's this subset that works. So if you wanted to prescribe a medication that you knew for sure had some potential for efficacy, you would have to use that particular version, DHA-EPA, EPA-GHA ratio, as you described, at least 150, 700 milligrams.
That's really hard to get in two pills. And the sheer number of pills becomes a burden to people when we're prescribing other things. So I count every pill as it's got to have some clout because otherwise we're going to just overburden people. So fish oil just doesn't have enough clout per pill. But when I want to use a placebo, when I really actually don't want to introduce anything new and I want to be sure that if we're introducing something like fish oil, it's not going to make things worse.
Then fish oil is a great placebo, and the time to be using it in my clinical practice was when tapering an antidepressant. But the person is really suffering and wants to do something more aggressive than just tapering the antidepressant, but all I want to do is buy some time, then I would think about using fish oil in that context. The other place where it deserves attention is the astounding data, which didn't replicate, but that doesn't matter because it's now one against one, in adolescents who were psychosis prone.
You know those studies. It's just jaw-dropping the difference. And then even follow-up studies showing the difference was still there. So I can imagine that a child and adolescent psychiatrist would be much more sanguine about fish oil and given a much higher grade on the scale than I just did.
Yeah, I think fish oil is like one of those universal supplements that is probably beneficial for everyone. And that there's very few supplements that I would recommend for nearly everyone. And that's one of them. And I think there's probably a little bit of extra help with bipolar. But I certainly don't think of it as a treatment because you're saying. But for patients who are into all this stuff and they want to maximize and do absolutely everything right.
I have a lot of patients that I tell to take fish oil. Make sure they take the right one.
As long as the absolute pill number problem is not being brushed up against.
Don't use it in replacement of a better treatment. But for patients who are the type A's, the ones who keep their journals and all that stuff, it's a good option. It's not a treatment, but it's a good long-term supplement.
You know, there's the continual risk in the background of people just going, you know, I'm tired of this label. I'm tired of these treatments. I'm just going to stop everything. That happens. And I think one of the reasons it happens is because people just get tired of juggling all those pills. So I just want to highlight the risk that doesn't sound like such a big risk, particularly with fish oil.
Like, yeah, one pill. OK, fine. That's a placebo. Fine. We'll just let it go.
This is what I love about talking about with clinicians because I feel like there's so many things I learned early on. I'm actually not thinking about pills. Early on with lifestyle interventions, I would overwhelm a patient because I would say, let's get you exercising. Let's get you sleeping right. Let's get you eating right. And I would do that on like a first or second appointment and it would overwhelm a patient.
And I've had too many patients come back being like, Dr. Malzberg, I'm so sorry, I wasn't able to do it, that I was like, oh, this is not helpful for the patient. Yes, what I'm saying is right. No one's gonna disagree with what I'm saying. It's not helpful. And at the end of the day, as clinicians, we're supposed to help the patient not be right and smart and say things that research is backed.
So I think that's a great, I love that you're bringing that up of like, for a patient that's not following what they need to be doing, adding something that's not vital is a bad move. All right, for our next one, the ketogenic diet.
Yeah, you can stop there at C. Because cool idea. I think by this time, really no question anymore as to whether or not it really actually does something. This is not a placebo intervention. When people, and as you may know, actually, I wrote a paper. I'm sort of proud of this. I'll just mention it. I wrote what I think is the first paper on use of ketogenic diet and the treatment of bipolar.
It was just two patients, one of whom just wrote me on my old website and said, hey, did you know I've been doing this? I mean, I said, whoa, look at your numbers. We should write this up. So that was a long time ago. So I've been a fan of the idea for a really long time. But the practical doing it as a long-term intervention, well, people are doing it.
Ian Campbell in the UK is doing it with spectacular results. And we are so grateful to him for the research that he's done, for his bravery in Describing his own personal experience and rounding up some serious research funding support from the Buzuki Foundation. It's just fantastic work that Ian Campbell has done. And then, well, what's this like for our patients? It's so far out of reach for most people.
That it's a cool idea, but it's like, let's not tantalize people with something that is so difficult to really do. Unless they're in circumstances like Ian Campbell where multiple things didn't work, it's really great to know that there's something like this. So really important to understand. Some patients need to understand it. And then if we use it as merely as an approach to a more rational diet, you know, potentially more like Mediterranean style diet, which is, as you know, it's like good.
This is good for everybody. You don't have to have a mood disorder. You don't have to have a psychiatric condition. You don't have to have anything. This is just a healthy thing to do for anybody. But as you say, Dr. Malzberg, trying to think about the timing. When are we going to bring in this discussion, which is a pretty major lifestyle intervention for most people nowadays?
Yeah. All right. I like the idea of mixing up between fun ones and more grounded ones. How about Lamotrigine?
Can you give that an S, please? S-T-R. Yeah. So we've got low-dose lithium up there already. If we hadn't talked about that one first, Lamotrigine would go first. This is my absolute numero uno S category medication. Because what else do we? Oh, yeah. OK, great. We put it over there. Thank you. Because what else do we have that has such low risk? It used to be that we could say zero long-term risk, but if you scrabble through the literature, you can find some things that maybe we can't quite say zero anymore.
Okay, so extremely low long-term risk, especially by comparison with any other psychotropic that I can think of, with the exception of fish oil, I think would be an exception, and maybe lithium orotate. But okay, so lamotrigine. After that promo, well, we should actually point out that it's not good for everything. It's only good for some things. But for those things, it seems to be, in my experience, really good.
Oh, sorry. Then there's the literature that says that it's not that good. And I frankly do not know how to reconcile my clinical experience with it and the randomized trial data that It tends to get relied upon when people are drawing up treatment guidelines, for example, where there's just a really big mismatch. Most of the meta-analyses, one found it didn't work at all better than placebo in terms of a meta-analytic result.
And the other one said, well, for people with relatively severe depressions, it did work better than placebo. So those studies just Put this weight on lamotrigine and drag it down out of where it deserves to be, I think, in part because of its very low long-term risk and properly handled Close to zero side effects. I think of it very much in the way that we talked about low-dose lithium in terms of how to manage it.
Don't let people have side effects. That'll blow the ballgame. This is too good a tool for that. So let's make sure that doesn't happen. And then finally, I'll just say, so what treatment territory are we talking about? The middle of the mood spectrum, for sure. Not unipolar, where I think the data are somewhat more clear that it does not have value relative to placebo. And then for bipolar one, as an adjunct to other tools, but it doesn't have enough anti-manic prophylactic value by itself to be monotherapy.
Lamotrigine.
And what patients, are there patients with bipolar that you think it's not a good fit?
They're a challenging question. Yeah, yes. If they've already got five medications on board, and I don't want to add another one, maybe even four prior medications, get rid of something first so that Lamotrigine gets a fairer trial. In particular, antidepressants. Patients who are already on an antidepressant makes it less likely that lamotrigine will demonstrate its remarkable capacities.
Have you heard, I wonder, this might even come from me, the L-mood spectrum? So if they're on the bipolar side, it's lithium. If they're in the middle, it's lamictal. If they're on the unipolar side, it's lexapro. It's all L's. Yeah.
Well, that's interesting. I'm with you on the first two. I would just want to say, you know, when you get to the unipolar end of the mood spectrum, what justification do you have for using an antidepressant relative to any of several different psychotherapies that have shown equal evidence, blah, blah, blah. Psychotherapy is the treatment for unipolar depression, and people ought to get trials of three different Psychotherapies before they get a first trial of an antidepressant.
They're my little soapbox.
That's a great take. All right. So we'll use that to, we've got, where do you want to put SSRIs on our, this is for bipolar. So I guess just treatments. We got F tier.
Yeah, definitely do. Psychotherapies. And we should say SSRIs, antidepressants generally for treatment of bipolar, it's not a never use them. It's a use them after you've tried multiple other things. And there's a specific subset of patients for whom I think there is a potential role. And when I finally come around to that, it would be bupropion. Before really anything else and venlafaxine dead last. The justification for using venlafaxine in nearly anybody is difficult to come up with.
But for someone with bipolar, it is almost inexcusable in terms of my personal clinical experience.
Where are we putting bupropion? Is that C then?
Yeah. Yeah. Now, if we're thinking just Yeah, yeah. They can live with that group there. That's good.
Now, could you elaborate on why SSRIs are bad in bipolar?
Because they make things worse. Once in a while, I could try to strive for a short answer. I may just have achieved one, and then I can go, of course, beyond that and say, okay, everybody who worries that antidepressants can induce a manic episode. The frequency of that is just not very large. And you could look at different studies, different definitions of mania, and particularly those that have different definitions of hypomania.
But in my view, that's not the big problem. The big problem is inducing mood instability and mixed states. You make cycling more likely to happen because antidepressants are Antidepressant, all antidepressants with almost no exceptions are pro cycling. So either you have to have a big lid on it in order to keep the antidepressant from making things worse. And what the big lids are tend to be the antipsychotics with long term risks and bad side effects.
Or you just do some other way to get your antidepressant tool. So we need a whole different category that I think deserves its own acronym, namely mood stabilizers with antidepressant effects, MSAEs. We got SSRIs. We should have MSAEs. Which are the MSAEs? This I thought was where you were going with the Ls. Three Ls and a Q for the mood stabilizers with antidepressant efficacy. I missed trazodone.
Lithium, lamotrigine, trazodone, and we have to put quetiapine on there because of its efficacy data. All of those come, if I can wave my hands around, all of those come after social rhythm therapy, which is your numero uno Mood stabilizer with antidepressant efficacy, even in its simplified form and brief tangent, in addition to getting regular bedtime and regular rise time to get an antidepressant effect, you have to crank those back so that they happen earlier, a so-called phase advance.
By moving bedtime earlier and rise time earlier, there's several different studies showing that it has an antidepressant effect. So the antidepressant effect of the simplified social rhythm therapy puts it in this category of MSAEs, mood stabilizers with antidepressant effects. And then you get to the three Ls and a Q. And after all that, then we can talk about antidepressants.
Yeah, and the reason why I ask that question is I think it's important for providers to be able to explain that SSRIs hurt the overall course of bipolarity. Because if you just say to a patient, like, oh, they don't work or, oh, they increase mania, that might not resonate with the patient's lived experience, especially if they were on SSRIs with the past. So understanding, like I said...
In treatment, talking about the long game, like, yes, it might have helped you in the short term. It might have actually treated your depression in the short term, but it hurts you in the long run. And I think you've talked about this too, but also be careful. It doesn't mean you just pull the SSRI, which can also induce tons of problems. You still need to be careful because yes, having the SSRI on board can worsen the long-term prognosis, but pulling it off quickly is also an acute stressor.
So you need to be mindful of that. All right, let's see. Oxcarbazepine. I probably should have put carbamazepine in first. Let's do carbamazepine.
Carbamazepine. B. Because it requires serious careful management. You have to dart low, go slow. And then the best trick I ever heard... Quote, get to 1200. I only saw that in print once, but I think that's the key to really seeing if this stuff can work. But you can't head for that from the get-go. You have to head for 600 from the get-go and get there quite slowly.
A 200 milligram pill, or if I'm really anxious and I really want to make sure that the patient doesn't have trouble with this and we're not in a super big hurry, A 100 milligram increments from zero to 600. And then you know that in the meantime, enzyme induction is going to, as you're moving it up, the enzyme induction is moving your level down. So you're chasing this target that's receding away from you.
Like the Red Queen in Alice in Wonderland. The faster I run, the farther behind I get. So yes, you will be chasing it. Until that enzyme process saturates. And then every step after that is going to get you a bump like you never saw before. So you're still careful bumping it up. And then you do it just like the low dose lithium approach. Turn it up if it's not working.
Come back down a step if you run into any kind of side effects because of the enzyme induction, that side effect may go away because the level is going to come back down. But just keep going until you get to 1200 in order to give this thing a fair trial. So that's carbamazepine. And it's, you know, frankly, you could even maybe, I wouldn't do it, but you could justify giving it an A just because we got to give it near press.
It's, yeah, we'll leave it as a B. Thanks. Because it's an underappreciated tool. Yes, it can cause Stevens-Johnson syndrome. Yes, it is a teratogen. So using it in reproductive age women is a whole different ballgame. So we should start thinking of it a little bit more like valproid. Just don't use it in reproductive age women unless you're driven, absolutely driven into it and you can And feel free to bump it to A because
some people will just look at the end result. So should we want to bump it to A just to be provocative? Yeah, let's. All right. Now, where's oxcarbazepine?
That one we can give a B because... Far more tolerable, same general idea, many of the same cautions that tend it. I think the most provocative thing that I can say about it is, so you're a child and adolescent psychiatrist. Or a psychiatric nurse practitioner. And you were told that you don't have to get lab tests with oxcarbazepine. Well, great. I hope that just keeps working for you.
One of these days, you're going to have somebody get dizzy and nauseous. And it'll be because they have developed type 1 atremia, low blood sodium. And okay, cool. You're really attentive to your patients. And so you turn the dose back down and you got away from that. But in theory, one of these days, that whole process could continue until somebody has a seizure. Now, oxcarbazepine is an anticonvulsant.
So how big a risk is that? I never saw one. I never even heard one. But in theory, that's a problem. And so you actually, in theory, need to know where the blood sodium is. And now you're back into the realm of blood tests. So it's not quite as scot-free. Moreover, it only has one randomized trial that I know of, one large one anyway. It was negative.
So you're using something that has randomized trial evidence for it. It doesn't work. Why are you using this? Because it's a little bit like Lamotrigine. If you use it enough, you're going to find somebody who gets a good response to it. Is that a placebo or is that oxcarbazepine? Well, I think if you like where you were talking about, Dr. Melzberg, well, why don't you go to Reddit?
It would be an interesting exercise to go to Reddit and see what people say about oxcarbazepine. My suspicion would be there's a voice out there that you could hear that says, yeah, there is efficacy for some people.
Yeah, absolutely. I'm paying attention to time. We've been going for an hour. How's your stamina?
Yeah. I presume that you're going to do some serious editing and release these in reasonably sized bites. So your call, let's do another 10 minutes or so. Another 10 minutes? Yeah, and happy to come back whenever you wish.
Awesome. Okay, awesome. I appreciate it. All right, so we've got 10 minutes. We've been doing a few medications. Why don't we do mood tracking as our next one?
Oh, fascinating. Good question. Yeah, let's give that an because I'm sure you've had this experience. You ask people, you give them a piece of paper and, you know, the paper and pencil version and say, here, can you do this until you come back to see me next time? And in your experience, Dr. Maltzberg, about what percentage of patients come back with that thing?
It's, yeah, what I did at the start is very different than what I do now.
The paper and pencil here, just put a mark on this every day and do it for the next, what, 30 days or even a couple of weeks and come back. So the adherence rate is low and a little soapbox about adherence, a patient's Failure to adhere to the game plan is the problem of a clinician, not of the patient. It's the clinician's fault when the patient doesn't adhere to a game plan because you didn't suss out what was really gonna happen when they left the office.
So suss it out before they leave. Are you really gonna do this? And then adjust accordingly. So doing, we know from clinical experience, doing that mood chart is difficult. I used to tell people, Put it on a clipboard and hang it on the back of the bathroom door so it'll platter around every time you go in the bathroom and it's got a pencil hanging on it and try to do that every day for just the next two weeks and then let's see what we can see.
But long term, that kind of approach I think is manifestly not successful for the vast majority of patients. So that's one extreme. The other extreme is cool. You may not have seen this because I don't think we have any published data on it yet. Imagine an app for your phone that you can just put on your phone and then leave it alone. But it will track bedtime, It'll track a sleep window.
What's the window during which you finally put the phone down and don't touch it again until the following day, one hopes, right? So it'll track that passively. You don't have to do anything. It'll track the regularity of your Patterns, including your daily physical activity, for example. And it'll do that all possibly and you don't have to pay any attention to it. And then it will make a record for you that you can take to your clinician and say, well, you asked for me to do this.
Here it is. That program is called Mind Numbers. Mind Numbers, all one word. And it's free. It was built by... Peter Westlake, who's a wonderful person and a great engineer and many other superlatives. And he built it because he has a relative who has bipolar who he wanted to be able to know when things are going well and when not. Without having to say every morning, oh, how did you sleep?
And did you take your medication today? And what's your mood like today? So he built this whole program so that a parent or a loved significant other could have some sense of what their loved one is doing and experiencing without any intervention at all, just because the person picked the app on their phone and gave permission for the results to be going to their loved one. Cool idea, I think.
And because it can be passive, we solve the problem of having to go back to the same every day because people don't like mood tracking because they don't like to be reminded that they're living with bipolar all the time. So on the other hand, the results could be tremendously valuable to the patient and to us as clinicians if we did actually have Effective mood tracking, right? So let's get this app and use it.
And final plug, if you really want to use it, you just have to record yourself saying you make a journal entry every day for two minutes right before you brush your teeth, before you go to bed, saying this is what I did today and this is what I thought of it. And this is what I'm thinking is going to happen tomorrow. It doesn't matter what you say.
It's your style of speech that is turned into a mood rating, like a PHQ-9, like a depression score, and a G87, like an anxiety score. And the program automatically does that and then admits whatever you said so that there's no permanent record of your journal anywhere accessible online. But it's giving us now not just sleep and activity, but also mood and anxiety On a running basis, and you can get a chart of that and take it to your clinician anytime you choose.
So yeah, mind numbers, great tool. So those are the two extremes, from paper to that.
Awesome. And yeah, in terms of what I've seen is, as you mentioned, I never recommended paper, but I'll recommend patients get an app, and then I'll follow up when they never even downloaded the app. What I have had good luck in is there's a lot of tools for tracking sleep. And I tell the patient, you don't have to do anything. Listen, all you have to do is buy the thing.
There's one that you put under your bed. It's like a princess and a pea situation where it detects your sleep just from being under your bed. And I have a lot of patients that like they don't care about the numbers. But I say like, oh, yeah, can you just send me the PDF of the last month? And then I'm able to look at it. And that to me for patients who don't, like you said, don't want to be reminded of tracking or doing or spending more time has worked great.
So yeah, there are a lot of options.
That gizmo is called a sleep mat. Yeah. And it can electronically integrate with the Mind Numbers program. Peter built it that way. So yeah, the idea would be to use the sleep mat. In our experience, inviting people from the bipolar community that we're working with, the sleep mat actually was a problem. It was a barrier. It costs money. You have to figure out how to hook it up.
It requires an electrical source. You've got to plug it in. Where am I going to plug this in next to my bed? I already have a Dawn simulator and a blah, blah, blah and my phone charger. And so my number is that. Yes. Look at your screen. Thank you. So, yeah, Sleepmat integrates it with it. And Dr. Maltzberg, are you wearing an Oura ring?
You got it.
Yeah, yeah. That also integrates with MindNumbers. This seems spectacular. So that MindNumbers can take the data off your ring instead of your – and then instead of a sleep window, you get actual tracking of your sleep. This is awesome. So that you could – yeah, get people to get that one with a sleep mat if they're really enthused. Otherwise, use a ring. But otherwise, if they don't want to use anything, they can still use the sleep window approach in that program.
Spectacular.
All right. I think we're at over an hour. I think maybe we wrap it up here. Maybe we can come back and finish the rest another time. Thank you so much. This was spectacular. I learned a ton. You're a wonderful teacher, and I appreciate you. You've been doing free education for such a long time. It's deeply appreciated.
Well, I appreciate the appreciation. As you can probably gather, I do it just because I really enjoy doing it. It approaches pathology in that respect. Why is this guy spending so much time making all these little PowerPoint slides? But it's just like I don't do sculpture. I don't do painting in my semi-retirement. I do PowerPoint slides.
Anything you want to plug at all? Yeah. I've watched a few of the videos. No, no. There was that movie. I actually want to watch that movie that I've seen you plug a little bit. Oh, yeah. Anything else you want to plug?
Oh, yeah. Well, so the movie that you referred to there is called Brainstorm. Brainstorm the film is our documentary about bipolar for public television and That is going to appear this one in early part of next year on national public television. We're so excited that we got to that level. And so that's the film. And then if they're on the website, one can also find under, I think it's under resources, is Sarah Schley's book about bipolar.
If there's a single book about bipolar 2 that I'd want people to see, it is Brainstorm by Sarah Schley. It is just it's a great read as well as super education about the nature of the experience of Bipolar II. Awesome. And she was the one who then went on to make the film. So there's two different ways to access the teaching of Sarah Schley. Spectacular.
Now, I'm curious, were there any other major treatments that we didn't talk about that you consider Things that you consider really good that aren't part of the mainstream. I don't know if that question made sense.
Oh, interesting. No. Okay. Other than some psychotherapy tools that are not bipolar specific. Well, I suppose, you know, people don't know about this, but if any of your listeners work in a like a public health setting where there's lots of people with bipolar and particularly bipolar one, there is a stunningly good treatment for that called group psychoeducation. And there's a manual for that there was written by Francesc Palome and Edward Vieta.
Years ago, in which they not only describe the content of their group psychotherapy, 20 sessions, they give you the content of every one of the 20 sessions, including the handouts that they made for each one and the jokes that they told and the pitfalls they encountered. So it's like a soup to nuts. If your clinic doesn't offer psychoeducation for bipolar, You could be the champion in that clinic.
Just get the manual, Colom and Vieta. And you don't even have to study it or practice it. You just go, okay, assemble a group. We're going to just walk in and we're going to do lesson one. And you read it the night before and off you go. And the efficacy data for that are some of the best efficacy data of any treatment in psychiatry. Yeah. Five. I'm sorry.
A five-year difference in survival in terms of episode-free recurrence, a five-year difference relative to the people who did not get that program. Yeah, so it's great stuff.
Yeah, it's so unfortunate. I remember learning in med school, like the answer to med school questions, psycho ed would be one of the answers because it has such good evidence. But then in the real world, it's so hard to find good psycho ed groups. I found that like I expected that like I would just Google and that, you know, it would be available. It's not easy. No, maybe I should start one in the city.
Amen. Of course, I think the common experience in trying to do group instead of individual psychotherapy is you spend so much time and energy organizing your group, none of that is paid for. And then you basically, you have to manage this group psychodynamics, which some people enjoy doing, but if you're not good at it, it can be disastrous sometimes. So why take on that added challenge or a liability and do all that extra work for nothing?
But if you're in a public psychiatry clinic where effectively the groups are kind of like already there, you just need to get a list of people whom you would invite to the next thing. And we're going to start it on Tuesday the 20th. And here we go. And you try to get 20 people signed up and you'll have 10 by the end. And then you just turn around and do it again.
The feasibility is much more within reach in that setting. Yeah.
Awesome. All right. Well, I think we're running low on time, but thank you so much for coming. This is a ton of fun. I really hope we find another time to do it again.
Absolutely. Anytime. You can tell. I'm happy to do it. I appreciate your approach to all this. I deeply appreciate the fact that you found my stuff and think that it's useful.
Yeah. And everyone should check it out. I'll put the link in our podcast. Okay. Have a good one.