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 it's 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. Welcome back to the podcast, Dr. Phelps. Excited to have you back here.
Thank you very much, Dr. Maltzberg. I appreciate the chance to talk with you and the people who listen to you.
We have the obligatory opening of checking in on pickleball.
I'm still playing it. I can still do it. That's enough on that. But yeah, I appreciate it. Thanks.
If you want to hear a bit of a tragedy, because my mom's a big pickleballer, torn meniscus. She's out for the next six weeks. Devastating.
Oh, man. You know, this adds to the litany of stories of people injuring themselves playing this game. You know, that's the numerator. You have to know what the denominator is to appreciate whether or not that's a big deal. And my denominator is very large. A lot of people playing and nobody's getting hurt.
Yeah, they're going to see like all these like different like injuries and old age that are. It's actually a good thing that people are tearing their meniscus.
Yeah, that's right, Yeah. Or at least out there. Yeah. Many of us are out there having a lot of fun.
Well, so my goal for the podcast today, and I guess for the listener to fletch in a little bit, we prepare very little. We're going to do this on a whim, but I think this makes it a little bit more spontaneous and a little bit easier to listen to. My goal for today is we're going to be talking about social rhythms therapy, and I almost want to So that it's helpful for both providers and patients.
You know, the crossover where there's enough science that providers feel like they're learning, but then it's not too big to the science that a patient can listen and walk away with like a better understanding of what this looks like and how they can implement it in their lives.
Good, good. And I'll apologize in advance for, I'm really interested in the details. It might be too detailed in some respects. Hit forward on the little recording or whatever, but stick around because the total story of social rhythm therapy is getting more and more prominent in the understanding of bipolar. The circadian rhythm, the role of circadian rhythm in What is bipolar is getting more prominent and social rhythm therapy is a way to go right after that basic cause of the mood disturbances.
So yeah, it is, this is really important stuff. I was just telling Dr. Maltzberg, I just came back from the International Society for Bipolar Disorders meeting and discussions of circadian rhythm are getting more prominent in that setting as an indication of everybody recognizes this is a really big deal, big, important territory.
Yeah. And the thing how I think about this, I think, you know, when I was in medical school, I thought IPSRT, which is the acronym. It was just this like bipolar specific treatment. When I actually learned the specifics, I was like, oh, this actually applies to absolute. Absolutely everyone. I think these things apply to all mood disorders. It kind of applies to all individuals. I think of it as bipolar individuals are the most susceptible to circadian disruptions.
So that IPSRT and this stuff is most helpful to those patients. But in my practice, any patient with any sort of mood disorder, I think even ADHD, personality disorders, these principles are so important to absolutely everyone.
Well, that's really interesting because I'm sort of a bipolar focused guy. I don't think I'd appreciate that. But I'm going to tell you about a randomized trial that is just mind blowing that reinforces exactly that idea. You'll see now.
All right. Awesome. I actually wanted to start with a quote. It's a bit of a long quote. It's the sort of thing that when I hear, when you start reading about things, you kind of see it everywhere. This was a comedian on a podcast. And I was like, you know, I think he's actually hitting on some of the ideas here. All right. So it says, well, human animals are part of the earth.
It's our home. And then you're watching the grass go green and then go gray. You're watching the trees die. It's a part of it. It tells your brain how life works. People are texting right before bedtime and it's like, ah, but being out there in nature, it's like, no, it's getting dark, cool off, it's getting dark. There's no sense of things getting dark in a city. In nature, you watch the world go to sleep, you hear the different sounds, you hear the birds go to bed, the insects come out.
All these things are reminding you how your system works and what's going on in your chemistry. It's connected to all that. Completely random quote, but I was like, I really hear the principles of social rhythm therapy in there.
Absolutely. Darkness is a central ingredient in this rhythm process. And as humans, except for a few places in the world anymore, we just don't get enough darkness. We're not doing the natural thing in that respect.
Yeah. And it really made me think of like, you know, we evolved on the earth and the earth has all these rhythms. There's the, you know, the seasons, there's the rhythm of a day, there's all these rhythms. And now modern man is trying to act as if we're completely separate from the earth and we can ignore the sun. We can ignore, we can be inside and we can work all day.
And that's not how we evolved.
That's exactly right. So let me... I'm thinking somebody's going to listen to this and go, yeah, yeah, yeah.
Get into it. Come on. Keep each other on track. So yeah, let's get you into it.
So social rhythm therapy... You can think of it in terms of layers of complexity from the simplest versions to the most detailed versions. At the bottom of that is IPSRT, Interpersonal and Social Rhythm Therapy. They're kind of the original, the way this was originally formulated as you pointed out as a treatment for bipolar. In the middle is There's a workbook available entitled Social Rhythm Therapy by Holly Schwartz, the president of the International Society for Bipolar Disorders and one of the most knowledgeable people coming out of the IPSRT tradition and group.
And if somebody wanted the detailed manual of how to do this therapy, that's it. So fortunately, that's available, inexpensive, and it's a workbook. It walks people through the whole process. And then in my head, at least, there's a simple version of this that says, what are the most important ingredients in that book? What are the ones that are like, if you're going to rank order them in terms of their impact on rhythm, which ones should you start with?
So you can focus on the ones that have the most clout. And then if you want to add some more, you can add the more. And Dr. Schwartz's book is organized somewhat that way, but it's sort of a big picture emphasis from the beginning. I like to start in simplified social rhythm therapy with one target, and that is And I'm sure you know what it is. And I wonder how many of our listeners know what it is, because there is one variable, one Zeitgeber, one time giver that sets our circadian rhythm more powerfully than the rest.
And that one is light, the appearance of light in the morning and the disappearance of light in the evening. So light as a time giver is central to this process of setting your circadian rhythm more powerfully than the other variables. Like when do you have your meals? When do you see your first person? When do you get physical activity? Those also are time givers. They set circadian rhythm, but the most powerful of them by a substantial margin is exposure to light and darkness.
So why don't we just start there and help people really work out their exposure to light and darkness and the way it affects rhythm, which is through sleep. So we should focus on sleep and light and darkness as they set sleep timing. And then we can worry about the rest if we need to, because things aren't good enough yet. And that's good. We'll add on those other rhythms, but let's get the core one straight first.
So that's my conception of simplified social rhythm therapy. Does that make sense?
Yeah, absolutely. And I think this is so important because this stuff should be taught by clinicians in appointments with patients. We don't need to be IPSRT trained therapists to be teaching these things. Yes. The big message, you're saying circadian rhythm. Circadian is circle of the day. That's kind of what it translates. You picture a circle, and throughout the day, you kept saying timekeepers, zeitgeivers. I don't know why we have to use strange words for these things.
But there's just that there's these cues that help set our circadian rhythm. And there's external cues that are natural, like the sun and darkness. And then we can also set up our own little cues. And the point you're making now is... If you want to teach the importance of the social rhythms, you should start with the cues that are the most important. Yes, you can eat at the same time every day.
That is important. But first, let's get the low-hanging fruit, the ones that really, really set the clock. And light is the biggest, the strongest setter of the circadian circle. So yeah, give us the principles of using light to strengthen the circadian rhythm.
Yeah, I'll just point out why we use the fancy word Zeitgebers is like, well, it makes me sound smart. You know, I can pronounce German sort of, probably not very well, but it's because it ties us into the Scientific understanding of circadian rhythm that stretches back decades and decades. People have been studying this for a long time, recognizing its importance. And we can stand on all of that research when we then now try to use it.
So, you know, that's in my, that's why we, that's why you use the word in any case. Right. Okay. So let's talk about this simplified approach. Clinically, and you're absolutely right. I so appreciate it. This is something that people and clinicians working with people with bipolar are gonna do in sessions. This is not a separate therapy. This is a core ingredient in the treatment of bipolar for everybody.
So it actually helps us psychiatrists look good because we're not just about pills. We're about using natural factors to facilitate good outcomes. Yeah, so really important. So we're basically just going to go, okay, it's really important that you have regular sleep hours, a regular bedtime and a regular rise time for about seven to eight hours, preferably a little closer to eight. Okay. Regular sleep hours, regular bedtime, regular rise time.
That sounds kind of simple, simple social rhythm. Well, as you know, as a clinician and as people know from their personal experience, having a regular bedtime and a regular rise time is not that simple. And for people with bipolar, The research is also clear that people with bipolarity have kind of looser circadian rhythm. It's more susceptible to being knocked around by variables like you stayed up too late and particularly exposure to light and darkness.
There's fascinating research going on, but what's different about the retina, not just the central system, but even the retina is different in people with bipolar in terms of sensitivity to light. We're going to talk about a regular bedtime and a regular rise time, recognizing that even though it sounds simple, it is actually very difficult for many people to actually do it. So our job as clinicians is to facilitate people's ability to get those things regular.
And so a system of teaching people, helping people move toward a regular bedtime and a regular rise time, that's what in my head is simplified social rhythm therapy. So we're going to talk now about the tools for facilitating the regular bedtime and the regular rise time. So let's start with bedtime. Well, people with bipolar and people with mood disorders and people with other psychiatric disorders, as you were pointing out, Dr.
Malzberg, have a tendency to stay up too late in part because they have bad things going on in their head. If they are alone by themselves, physically in the dark, They don't like the internal experience. They're listening to all these horrible thoughts. They're having images. They're having recall. So people tend to stay up late in order to hope that when they finally turn out So lots and lots of our patients are staying up late on purpose.
There's a reason for it. And when we tell them to go to bed at a regular time like earlier, we're inviting them to do something that is dysphoric for them. It will make them feel bad. And that's why they're not going to do it unless you give them some help. In terms of how to negotiate that. So the regular bedtime, let's just start with whatever your current most common bedtime is.
And if it's 2 in the morning, okay, we're going to go with that. So don't start out by saying, you know, you got to get up at 30, 7 in the morning. So you should be going to bed at, you know, 10, 30, at 11, say. No, we're going to start with whatever your most common bedtime is and go from there. But we're gonna start by making it regular.
So let's say it's two in the morning and people who are going to bed earlier, they can just start this whole process earlier. So two in the morning and then you're getting up at 10 in the following morning because your symptoms have been so bad, you've been unable to work, unable to go to school, so whatever. So we recognize that not only are people going to bed late, they're also getting out of bed Quite late, often 10, 11, 12 in the morning.
We're not going to judge that as like laziness is part of the consequence of this shifted rhythm. We're going to help people cope with that. Two in the morning. Okay. And you were going to bed earlier. You can just factor into earlier hours. Let's just start doing that on a regular basis. And that one doesn't invite people to do anything that is so difficult for them. It's just making it regular.
Okay, fine. Now let's talk about what time you're getting up in the morning. So this is shifting now to rise time. We're going to make that regular also. Now, if you make the late night, if you make the bedtime late enough, then the rise time is going to, let me put this the other way. If you make the late, the going to bedtime regular, And then just pick seven to eight hours after that as the rise time.
Then physiologically, you're in the right window for this to be relatively easy. If people are staying up late and then trying to get up early, like 30 or 7 to go to work or go to school or take care of their family, then they find it difficult to get out of bed. It's hard to wake up because you haven't had enough sleep. Your body is still trying to sleep and your circadian rhythm hasn't said, it's daytime now, it's time to get up.
So that too early bedtime makes this whole process really, I'm sorry, too early rise time relative to the bedtime makes this really difficult to do. So this is where we can start by trying to give people the most help. They're still going to bed at two in the morning. They're getting up at 10. Let's give them help about getting out of bed at 10. Well, the first thing we need to do is see that during that whole interval, they were asleep in the dark.
So the very first question for your clients and your patients and you is how dark is your bedroom? If your bedroom isn't dark, you've been working against the tide the whole time. So let's get the tide working with you. You need a dark bedroom, like a really dark bedroom. One research study says that people who were exposed to more than three candles worth of light at one meter, like three yards, three feet, more than that, like you could just barely read by it.
More than that light overnight is associated with more frequent manic episodes, a higher likelihood of having another manic episode after the initial start of this study. So that defines for us then, for people with bipolar, you need a really dark bedroom. How are you going to do that? Well, you can buy blackout curtains, you can blinds for people who are renting and can't afford anything. You can go ahead and put tinfoil on your windows.
Yeah, yeah, they're going to think, What's going on in there? And they're running a meth lab or whatever. It's okay. It's just your bedroom window. You're going to make it really dark in there. But of course, people, there are many of our patients, clients who don't like darkness of that degree. They need some light. Well, that's okay. We're going to give you some nightlights, but a particular kind of nightlight that doesn't emit blue light.
And we'll come back to the blue light story in a moment. But you can have nightlights. They just can't emit blue light. So we'll tell you where to get those amber colored nightlights. And you can have as many of those as you want. So you don't have black, black darkness. You just have no blue light darkness in that sleep window. All right, so it's been dark all night.
Well, now you need a dawn signal. You need to have light showing up at the time when it should in your dark bedroom, matching your current circadian rhythm, even if it's 2 m. to 10 m. So where are you going to get that light? You need a dawn signal, something that simulates dawn. Well, those are commercially available. They are called dawn simulators. So now you need a dawn simulator.
Now you're going to spend another $50 or so to buy a dawn simulator, a gizmo that will gradually turn on your bedside lamp over this period of about 30 minutes, simulating dawn, and that sets the morning signal for you. Not everybody has to buy a dawn simulator. If your sleep rhythm currently is somewhere around 10 to 6 because you've been getting up on a regular basis, then maybe the dawn signal that you get out of your light that's leaking through your windows So, not everybody needs to just go out and buy a Dawn Simulator to start this process.
But it helps people understand this is an important aspect of the process. It's rise time. You need a signal that the light is coming now. And that will make it easier to get out of bed. This morning torture of trying to turn off the alarm clock and then hit snooze and then I don't want to get out of bed yet. That whole torturous process, we're trying to make that easier by having your body recognize it's dawn now.
It's time to get going. You can get out of bed now. So, so far we have two tools that I've been suggesting, a black bedroom, and however you're going to achieve that, and a dawn simulator. I'm going to add just one more for the trio of tools that facilitate simplified social rhythm therapy in a minute. So, so far we got a regular bedtime and now a regular rise time that is associated with a dawn signal.
How have you organized that? And just one more tangent. People with bipolar are more susceptible to seasonal changes in the rhythm of the sun. So seasonal affective disorder is more common with people with bipolar. People who have seasonal affective disorder are more likely to have some other features of bipolarity. These are directly related to one another. So the treatment for seasonal affective disorder, as we are now all entering the fall and though vulnerable to this, and the Time change makes it even worse, the coming daylight savings time loss.
So we're going to be prepared for that with our dawn simulator because we are no longer tied to the sun in terms of the seasons of the year. We are able to set the timing of light in the morning and basically prevent winter. From a circadian point of view, by saying that the sun's arrival in the morning is not shifting. It's arriving at the same time, which is one of the strongest seasonal signals for us.
So the Dawn Simulator has been used in multiple randomized trials and shown to be better than interesting placebo arrangements for the treatment of seasonal affective disorders. So if you're vulnerable to that, to any degree, the Dawn Simulator is a bonus for you in that respect. So that was the tangent about, hey, dawn simulators are good for seasonal affective disorder as well. And it prevents this potential shift in mood and energy that is so common for people with bipolar in the fall as we shift into winter.
So, so far we got a black bedroom and a dark bedroom and a dawn signal of one fashion or another to make it easier to get out of bed. I think the hardest part of regular social rhythm therapy, this simple version is getting out of bed at a regular time. That's the difficult, the thing that people find the most difficult. So we're trying to make it easy.
We got a dawn signal. Next thing we're going to do to make it easy is a rule, no snooze. Once that alarm goes off, you got to get up. As you work on this, your regular, regular hours are going to make it easier so that you don't feel so strongly that you have to hit snooze because your circadian rhythm is in tune and it's telling you that it's okay to wake up and get going.
So it will get easier, but no snooze. In fact, once the alarm goes off or your dawn simulator is going to help you because you've got it timed so that it peaks right when your alarm goes off, Once that all happens, you have to get out of bed. Get out of bed and make the bed. Fancy it up, all your little throw pillows, make it look pretty, put it all back together so you're not going to get back into it.
And so that's the first thing. And then you're going to march off and go to the kitchen and get the water boiling or whatever, have a cup of tea, have a ritual that you always do the minute you leave that bed. And you don't have to think about what you're going to do next. You just do the ritual. You're not fully awake yet. Go ahead. Just do the ritual.
So a ritual around rise time will also facilitate that, making that regular. And the more regular it gets, the easier it gets.
So now we got a regular bedtime and a regularized time in a dark bedroom. This is the beginning of this focus on a regular sleep rhythm. The problem is for most people whom we are working with in our Psychiatric clientele, that rhythm is shifted too late. People with bipolar have clocks that invite them to stay up late, the night owls. They're not really morning people. They have a statistical probability of more likely to be night people.
And that means that their clock, when we start talking about all this, is likely shifted late. And since most people are trying to have a regular life, they have to take care of their family, have to go to school or go to work. They're just not getting enough sleep. And so that's where your ADHD people come in. The very first thing to do in the treatment of ADHD is to get people to have enough sleep because when you don't get it, it makes your ability to focus your attention more difficult.
So this fact that the whole thing is shifted late, like 2 m. to 10 m. or just, what, 11 to 7 even happens. Is part of the problem. We're not in sync with the natural rhythm of the world because we've been staying up so late with our electric lights. So we want to start cranking this rhythm backwards. We want to start cranking it forward, I suppose you might say, in the sense that an earlier bedtime and an earlier rise time.
This in the technical literature is called a phase advance. The phase of sleep has been delayed and we're going to advance it in the reverse direction, bring it back toward natural, bring it back toward the sun and the sun's disappearance in the evening and the sun's arrival in the morning. So cranking the rhythm backwards, at least I think that's what people experience is the next step in this simplified social rhythm therapy.
So not only is it regular, but it's a little earlier. Now, this is really hard to do. You're again, working against the tide. Your circadian rhythm is not helping you be ready to go to sleep and be ready to get out of bed. So we do this in really small steps. It's going to take a while. And if you rush it, it'll be harder. If you move it slowly, it will be easier and eventually you'll get there.
So 15 minute increments, say 15 minute steps, move your Dawn Simulator to 15 minutes earlier. It's going to go off 15 minutes earlier. And if that's just too jangly, make it five minutes earlier. And you're going to crank your rhythm earlier until you're going to bed an interval that allows you to get eight hours of sleep before your Dawn Simulator says it's time to get up. Now we're getting enough sleep and we're getting it at a regular time.
And then you can do the whole rest of social rhythm therapy there.
Perfect.
I have one more ingredient to add, but that's the, that's the series of events.
All right. Add the ingredient.
The, the last of these three tools. So we've got a black bedroom and a dawn simulator or something like it, enough light that it will help you get up. And the last is, um, well, This will be even easier if you can get more darkness at the front end. So we had more light showing at the right time at the back end in the morning hours. So we need more darkness in order to make it easier to fall asleep at the required bedtime to stick with this regular rhythm.
So how do we make it easier to fall asleep by getting more darkness? But nobody wants to just get more darkness. As I pointed out, people don't like darkness generally, and it's not as much fun as all the stuff that we do when we're Having light in the evening. And it was obviously how we got into this mess in the first place. We were using things to stay awake so that we could Play video games, read books, hang out with friends.
And Dr. Mulsberg just waltzed off to go get his amber lenses so he can demonstrate what we're talking about here. Thank you. We'll come right to that. So we want more darkness at night. If you think about this, what's natural? What's natural is that when the sun goes down, it gets dark. And what's not natural is what we all have been doing, which is staying up using electric light to stay awake until we choose to go to bed.
In that interval, when we are awake, when it should be dark, we're not doing what's natural. So simply by doing what is more natural, we will facilitate our regular bedtime and regular rise time. So inviting people to spend more time in the darkness before they actually get in bed and go to sleep is a It's a dud of an invitation. People don't want to do that. And so as clinicians, we know when you invite people to do stuff that they don't want to do, that's your fault.
They're just not going to do it. At a relatively great rate. So when we talk about adherence, we used to talk about compliance. Now we talk about adherence. We should recognize that adherence is a iatrogenic phenomenon. It's up to you to figure out the regimen that you're inviting people to participate in and make it something that they want to do, not something that they don't want to do.
Like going to bed in the dark. Okay, we got that. Getting more darkness before bed. Ooh, this is going to be tough. Well, you could just invite people to start dimming the lights after say 8 m. if they're going to try to have a regular bedtime at 10 m. Yeah, in my experience, people don't do that very well either. Having really bright lights in the bathroom, the shaving lights, the put on your makeup lights right before you go to bed when you're brushing your teeth, bad idea.
So that you can get rid of by inviting people to recognize that too much light late is the wrong idea. Don't brush your teeth with the shaving or makeup lights on. In fact, if you could just let the hall light illuminate your bathroom while you go in there and brush your teeth and take your late night medications, that would be good. So you're not getting additional light just there at the last moment.
But in general, we should be dimming the lights all the way for several hours before we go to bed. And of course, this is where people learn that they're supposed to not be using their phone, their television, their iPad, whatever. These light-emitting devices, particularly the ones that are so close to us, like an iPad or an iPhone, because light becomes much more powerful. Its intensity goes up at the square of distance, like nine feet away.
Somebody do the math for me. Three feet away is like twice as bright starting from farther away. So a television farther away is actually much less a problem than a little phone right here, which is what so many of us are doing late anymore. So the television is enough of a problem, but these things are even more of a problem. But when you invite people to not use them, well, again, you're going against the tide.
So here's where we can cheat. And this is where we have to do the whole story of blue light and circadian rhythm and amber lenses that many of you have already heard about. But it is a great story. And in my clinical experience, people's attention is held very strongly by this story. So when you want to tell a story to facilitate a behavior change, this is a story that really actually is worth telling.
And if you don't have the time to do it yourself in your clinical visit with your clients and patients, then send them somewhere to go hear it because it really reinforces this entire circadian rhythm story that lies behind a regular bedtime and a regular rise time. So here's the story in my version of it. I'll try to do the short one. Ah, lo and behold, in the year of about 2000, it was discovered that not all light is created equal.
The different wavelengths of light affect our brain differently, and only one of them sets circadian rhythm, and that is blue light. All the other wavelengths have... Either no or just a little like green light effect on our circadian rhythm. It's blue light that our entire system is tuned to. And that's a fascinating evolutionary story that we won't go into right now. So if it's blue light that sets your circadian rhythm, then the absence of blue light is physiologic darkness.
And this has been shown in some fascinating experiments where you have people stay up all night like college students. And measure their melatonin onset. It's a marker of what's your circadian rhythm doing. And show that when they are invited to stay up all night and do paper and pencil tests all night in a lit environment, their melatonin never goes up at all. You've suppressed it. Even a little bit of light, more than the three candles, is enough to suppress your melatonin.
And thereby suppress your circadian rhythm doing what it's supposed to do. So if you then bring those same college students back three weeks later and have them stay up all night doing paper and pencil tests, but you have them put on these amber lenses that block blue light at the level of your eyeball. And now Dr. Malzberg, would you put on the lenses please for our audience?
They look like this. So when the college students were invited to come back and wear amber colored lenses like this, that block just the blue wavelength of light, you can have all the rest of them. Theirs were a little bit better than Dr. Maltzberg's. They actually cover, they're more like safety glasses, right? It's really blocking nearly all that blue light that's coming into the eyeball. When they wore the amber lenses, stayed up all night, just like before, paper and pencil tests all night, their melatonin went up when it was supposed to.
They were in physiologic darkness, even though they were awake and doing paper and pencil tests. So this demonstrates that even someone who's having to stay up and work When it's supposed to be dark can be in physiologic darkness by blocking blue light. So this and several other similar experiments prove to us that blocking blue light produces physiologic darkness. Well, now we have a trick. We can trick our circadian rhythm into thinking that we are in the dark, even when we're messing around doing the stuff that we shouldn't be doing if we're trying to live in a natural environment.
We can have our darkness and eat it too, if you will. So you can stay up from 8 until 10 m. using electric lights if you block the blue part of it by putting on your amber lenses. So cool story. Now, what do we do with this clinically? Well, the sad part of this is that people are not going to wear these clunky looking plastic things that slip on over your corrective lenses.
They're just not going to do this for very long in my experience. They'll do it for a couple of weeks. But the cool thing is that's enough to show that there is really an impact from these things. The other unfortunate part of the story clinically is that this only works for, in my experience, about 50% of people. Um, I'm not sure exactly why the research literature on this looks better than that.
Um, and I'll tell you a cool story about that in just a moment. Um, um, and I hope Dr. Malzberg is going to edit all this somehow.
I'm not keeping this running.
Okay. Um, and so, um, Where was I? So the people are using these amber lenses for maybe two hours because they're not that comfortable. You can buy them for as little as 10 bucks. Some of the fancier ones are 20 or 30. And if you expose yourself to eye If you want amber lenses, you'll get the ones that cost 80 or 90 bucks. You don't need that.
So you're going to put these things on at 8 if you're trying to go to bed at 10 and you have now your virtual darkness, your artificial darkness through that period of time. Well, people will do that for a couple of weeks. That is enough for them to discover that people are going to respond. And I think it's about 50% in my experience. Whoa, when I put these things on at 8, I fall asleep like almost an hour earlier and I fall asleep more quickly and I stay asleep better.
So there are some people who are going to come back with their amber lenses and go, yeah, darn it, this really works. They're now converted. They understand this thing in a direct personal experience way. That's exactly what we want. I've had the other people come back and say, you know, these amber lenses things that you gave me. Well, I used them when I was mowing the lawn.
At least I had some safety glasses on, but they didn't do anything. So that's the game plan then is we're going to use these between the hours of 8 and 10 , some two-hour window before bedtime in order to facilitate your circadian rhythm, recognizing that it is dark and it's time to go to sleep. This is the exact analog to the dawn simulator in the morning. It should be light when the sun is, the sun should be coming up when it's time to be light.
Well, it should be dark when it's time to go to bed. So we're facilitating this now on both ends. So we ended up with the three things are dark bedroom and dawn simulator or something like that that gives you a morning light signal and More darkness, including artificial darkness if you need to make it dark because you're not willing to give up your electronic devices, as so many people are unwilling to do.
So those are the three things. They're really, they're all inexpensive. And the beauty of this is these are harmless. How many treatments do we have in psychiatry? And these are robust treatments as the research literature shows. How many treatments do we have that are this robust? They have no side effects or long-term risks. This is like almost nothing. Lamotrigine gets close, but otherwise it's almost nothing. So these are great tools and people, when they understand the rationale, this is just trying to do something that's natural.
This fits into people's wishes for the kinds of treatments that they want really well. So it's worth the expenditure of those things for your patients who can afford them. And to facilitate that, and this is where I was going, um, It's really worth it for you as a clinician to go ahead and buy 10 pairs of the amber lenses that you want people to try and have them in your front office and then sell them back at your cost so that when you've given this whole story, people walk out.
Either you've just given them these things. They're not that expensive. You could just, you know, you're rich enough. You can just buy a bunch of these things and say, here, try these. If they don't work, bring them back. And some of them will come back, not many, or your office is doing this at cost, so you're making this workable long-term. Because it's a great idea, and people will go, yeah, cool, I like that idea, I'd like to try that.
But if they don't have them in their hands, you know what that will happen. It just doesn't happen for any of a myriad of reasons, right? So facilitate that. You as a clinician, when you want people to do something, make it, the lower the barriers, make it as easy as possible for them to actually do it. So you're handing out amber lenses. We actually used to sell Dawn simulators from our front office as well.
Just go ahead and buy 10 of them and then sell them back at cost and you can keep the whole engine running. Okay, so. Oh, lastly, I mentioned that you can have all the night lights that you want. Well, they just have to be amber-emitting colored night lights, and those are really expensive. So if it's too dark in your bedroom with all this, then just get some amber night lights.
It's the same principle, no blue light. You can have as many as you want, including in the bathroom. That would be a great place to put one. If, for example, your older guys have to get up in the middle of the night and go to the bathroom, You don't want them to walk into a lit environment, but you don't want them falling down on the way there either.
So Amber night lights in the bathroom. So that's the shtick. I tried to make it as short as possible, but that's really what literally I would do in my clinical visits because I had the luxury of a 30-minute visit. So in addition to talking about pills, we could talk about that stuff. And so that is simplified social rhythm therapy a la Jim Phelps.
This is spectacular. And, you know, I actually, I want to encourage providers to just, obviously I'm a little biased, but just send this video to patients because I think this gives a really good overview of how to think about it and how I do this with patients. I think you said this earlier. You can provide the perfect scenario for the perfect things that patients should be doing, but what's important is that they actually do it.
And I think the job of the clinician is to get them to work towards these things. So how I do it with patients is I explain to them, first, let's get what the idealized in a perfect world, how to think about this thing. And I say... Just imagine how we evolved. So how we evolved kind of gives us the roadmap for what's perfect. So what's perfect is you wake up to the sunlight at around 7
m. to a slowly rising sunlight. Then you spend the first time. Just a few hours of your day in sunlight. Then you exercise, you run around, and then around 5 to 6 , the sunlight slowly goes down, and then you have no light whatsoever from 7 to 10. You fall asleep naturally at 10, and then you wake up to the slowly rising sun, and that's the perfect idealized rhythm.
Now, modern world has made it so that no one's doing that, right? We all have phones. We all have to wake up for work. We all want to sleep in on the weekends. We all want to have fun on the weekends. So you have to look at how the patient's living their life and then compare it to the perfect version and say, what's the change that will make the biggest difference and what's a change that's realistic?
I think to start is you need to build motivation. You need to explain why this is important. You can't just say like, okay, let's get you sunglasses. Let's get you waking up at the same time because they'll be like, why? I've woken up early. I hate it. So first you have to build motivation and explain why we're doing this. What's the reason and why is it important?
Then you need to find how motivated are they? Are they super motivated? Are they going to after the appointment, go on Amazon and buy a light box, a dawn simulator, sunglasses, blackout shades? There are patients like that. That is not the majority. The majority are not that motivated. They'll say like, maybe I'll buy the sunglasses. And then they don't. So you need to first off figure out how motivated are they?
And then Build the change. That's how I think of it is always try to find the lowest hanging fruit. What's the one change in the person's schedule that they can implement that will make the biggest change? So you mentioned like to me, waking up at the same time is probably the most important. So, we start there. We see how it goes after a month. If it goes great, great.
Then we go on to the next one, and then the next one, and the next one. If that one doesn't fail, we figure out what made it difficult, what were the reasons, and we tinker and try to figure things out. So, you know, working with the patient and as a patient, you know, figuring out what are now that, you know, the idealized version, what are the changes that you can make to to start working towards building this life with rhythms?
Yeah, yeah. That is really good. In fact, I'm listening to this going, yeah, that's better than what I used to do. I like that. Chunk it out one step at a time. Start with the most important one. Well, I kind of was talking like that, but you got it even more finely chunked out, you know, like the very first simplest thing that takes you in the direction of the ideal.
That's very good. When you talked about you need to help people be motivated, good, how do we do that? Well, so you explain it to them. Oops, let me tweak the explain word to flip it. We need to try to help people understand something. Explaining to some people will do that, but otherwise, There are a lot of ways to help people understand something, and sometimes just talking at them is not the way to do that.
Helping people understand things begins with what is important to them, understanding what's important to them, and then reminding them that they said that, that's important to them. Okay, well, if that's important to them, how might you go in that direction? This is all coming from you, not me, is the spin that I want to put on that explaining, because too often I think we just Men are accused of doing this more often than women, right?
Mansplaining. So explaining is taking power over this relationship. I want to flip that around so that the power is in the hands of the person who has to, because of their bipolarity, make the physiologic changes, make the behavior changes. In that respect, I'm not sure if it's really true, but I really like stories that just knock people over. So I'm going to tell you one. Yeah. So there was a randomized trial of these amber lenses things.
Could you hold them up again there? These things. There was a randomized trial on an inpatient unit in Norway where half the people, people who are admitted with a manic episode, who signed a consent for this, half of them were randomized to get the amber lenses and half of them got a gray control lens that really didn't do anything from a circadian point of view. The results of that study are just jaw-dropping.
The people who wore the amber lenses, in addition to the rest of treatments that happened on this inpatient unit routine, had half the number of antipsychotics that the group with the control lens got and got out of the hospital earlier. Manic rating scale scores, the YMRS, the young mania rating scale scores, went down. The graph is just unbelievable. They go down like that while the control people are just barely inching down.
This is a randomized trial on an inpatient unit. What are we waiting for? Why are we not using amber lenses on every inpatient psychiatric unit for people with bipolarity? Because what are you gonna wait for another randomized trial? Oh, darn, there was another randomized trial. Dr. Joseph Fedorowicz in Canada, Pretty close replication, and it was not so stunning. Oh, darn it. Now we got one positive study and one study that was basically negative.
Well, the paper just today, we just got the approval in my email inbox today of the explanations from all of the circadian rhythm research people, why Dr. Fedorowicz and colleagues study Was negative when the one in Norway was positive, so dramatic. So anyone who's waiting for more data on why that one, is this really true? Is this result really true? Is going to need to read that paper when it comes out.
But here's another jaw-dropping story. Because of the randomized trial in Norway, one of Dr. Henriksen, the lead investigators, one of her colleagues took this to heart so strongly. He happened to be in the process at the very moment the study was being done of building a brand new psychiatric inpatient unit in Norway, a whole 80-bed unit, I think. Maybe it was 40. It was huge. They're building this thing.
And he managed to get the builders, there were two identical wings, to build one wing with conventional lighting and one wing that was lit at night with only amber light. So you don't have to wear the glasses. If you get admitted to the amber light unit, you just get this physiologic darkness thing every night. It's just the way the building is built. Can you imagine what that took?
Okay, so cool. Now they've got this perfect opportunity to do a randomized trial in the whole hospital. People getting randomly admitted to this unit or that unit. Let's just see how they do. Well, so they were going to use as an algorithmic.
Length of stay, how long do you end up in the hospital?
Well, in their unit, they were getting so efficient at getting people to get better. Their average length of stay was only three and a half days. Too short to really see any kind of change based on which unit did you go into. So they had to use a different outcome measure. They used something called the broset checklist. This is a checklist that the nurses complete every shift.
You're nodding your head, Dr. Maltzberg. Have you ever heard of this thing?
Yeah, that's the aggression. I remember like violent patients would get their broset. Got a high broset. Everyone calm down.
Yeah, yeah. So the broset checklist, they did it on everybody on each of these units three times a day, each nursing shift. The checklist looks for behaviors that are associated with a potential violent event, boisterous behavior, agitated behavior, basically too much energy in people's faces, or confrontations, everything short of actually Physically, somebody's striking them, and that's on the list too, but that's less common. But all these predecessors for that, risk factors for that.
So the BROSET checklist, long in use, Dr. Malzberg has used it. So they have a BROSET checklist three times a day for six months on the patients on these two different units. So let's see if there's any difference in their propensity to violence depending on which unit they went on. Result, over six months, the people on the conventional unit, there were 80. How many people had a positive BROSA checklist?
80. How many people on the amber lenses and the amber lit environment? Three. In six months, 80 or three. That, I mean, do we have any more obvious evidence of clinical applicability than that? Moreover, as you were pointing out at the very beginning of this, Dr. Malzberg, this was not limited to people with bipolar. This was everybody. It didn't make any difference what your diagnosis was to see this reduction in events, except for major depression.
Major depression was the one thing where violence didn't change. Well, people with major depression are not going to be all that violent. I didn't pitch any of it. So I wonder we didn't see that. Everybody else, all the other diagnoses showed this effect. So there we go. We have randomized trial evidence. In another setting for the efficacy of amber colored light as a physiologic, a virtual darkness, a way to cheat and get your darkness when it should be in that ideal world that you were just describing.
Yeah. And how I talk about this with patients is we focus on the process of making these changes. And it's very possible, like you said, it probably helps with 50%. So if we keep trying different, different things, eventually you're going to be in one of the 50%. It might not be the amber glasses. It might be the sun simulator. Yeah. Now you may be wondering why I'm taking these off so often.
I don't know. Let's see if we can tell. I've got prescription ones. So the reason I got prescription ones, and I was one of the people guilty of spending too much money, Yeah, yeah. We're talking about the the way to really think about this is we're saying is we're trying to adjust to modern life. And like you actually mentioned the the Dawn Simulator, me and my wife, I somehow got into SwitchBot, which is like this company offers me free stuff.
I don't know why I bought like a weird thing on Amazon a long time ago and I got they sent me a free app. It opens and closes my blinds, something that I would, I think because I got it in Residi, something I would never be able to afford otherwise. And I set it back up and my wife loves it because it basically slowly opens at around like 6
m. and then around 30 the lights on. And then we have it closed at around 6 m. It's really cool. Obviously, it's a lot more expensive than glasses, but you can probably buy used ones. So you don't need to follow a particular tool, but you really just, when you use the principles, it's like, how can we stop the, what can we do to have the light kind of stop at a particular time and then come on at a particular time?
So if you can... People ask, well, can I just like have some gizmo turned on my bedside lamp? Like click... If you're going to do something in that respect, get the one that turns it on gradually because that's more natural. The brain actually interprets those two different kinds of light differently. But I would point out there's this cool study showing just measuring levels of alertness. I don't know what scale they used, some alertness scale, and had randomized people to use a DAWN simulator or a control gizmo.
And lo and behold, from the get-go of being awake, like time zero, when people first wake up and start doing their alertness checklist, as soon as they wake up, The people who had a Dawn simulator had a higher alertness score from the get-go. So there are additional benefits to that approach as opposed to you're waking up and the alarm goes off and then you're trying to turn on the light.
It's just harsh experience anyway. I guess the point there is, even if the Dawn simulator didn't do anything to your circadian rhythm, you might like it anyway because it makes waking up easier.
Yeah, absolutely. Now, the other thing that I noticed that an obvious improvement in my well-being, I have a balcony and I just go out on my balcony for 20 minutes every morning. I do my little breathing exercises. Such a big difference. You know, I think that the thing I said to patients is like 15 to 30 minutes of sunlight in the morning, ideally within an hour of you waking up, makes such a big difference.
So, you know, there are people...
Quick point on that. We can measure your exposure to light and the unit is called lux, but it doesn't matter exactly what that is, but just dig the numbers. If you look at how many lux are you being exposed to, like in the room that you're in, Now, I can't quite tell what that is, but if that's typical indoor electric lighting, that's about a thousand lux, particularly in an office building, for example, or like a hospital, about a thousand lux.
Well, outdoors at the same time, like 10 , 12 or midday, it's 10,000 lux on a gray day. On a blue day, it's 100,000 lux. So the difference between indoors and outdoors is a factor of 100 on a blue day and even at least 10 on a gray day, a gray rainy day. So a gray rainy day, which looks kind of dull, is 10 times brighter than what you're getting when you're indoors.
That might seem weird, but our eye auto adjusts sort of like a good camera. So we think that it's just as bright indoors as it is outdoors, but that's because your eye is auto-adjusting. It's really 10 times brighter out there. Guaranteed, it's 10 times brighter out there. So outdoors is way better than indoors. Now, people are going to then ask, well, if I'm stuck indoors, like in this office cubicle, should I get one of those little And the answer is probably yes.
I'm not aware of anybody ever having studied this, but it does make sense. And you hear about people doing this all the time. If you ask, oh, have you ever tried using a light box? People go, oh, yeah, I have one that I just sit on my desktop. I'm going, whoa, that's not the way they were designed. But if it's at the back of your desk, that might be far away enough that Yeah, okay.
Even though it's admitting 10,000 lux, this is sort of like working outdoors. Okay. You have to be careful because light boxes, when they're used at a closer, at 18 inches, like the way you're supposed to use it first thing in the morning for the treatment of seasonal affective disorder, for example, or bipolar depression. Now, there's a couple of randomized trials there as well. A full-on light box at 18 inches is Can induce a manic episode.
It's just, it's an antidepressant. So light is a powerful tool. Um, no matter how you're getting it and where it's coming from, we just need to be aware of like how much now that we've got you a black bedroom and you were making sure you're asleep in the dark, we can also pay attention. But it's much harder for people to manipulate this. How much light are you getting during the day?
So Dr. Maltzberg's morning routine of getting that light first thing really enforces the circadian rhythm we're trying to help out here.
Yeah. And let's see, maybe I'll attach an image. I have a picture, even in the winter, I throw out my winter coat and I sit outside in the snow. Like it's actually, and I guess this will actually bring us to another point of just, you talked about Having little routines in the morning is really helpful and helps build your circadian rhythm. And also, I used to wake up miserable.
It was just painful to get out of the bed every day. Now, I don't listen to my brain. Yes. And the habits make the routines easier because you don't think, you just do it. Yeah. Yeah, this actually made me want to talk about the social rhythm metric. So we're talking about, you know, this is IPSRT. There's the interpersonal and then the social rhythm. And the social rhythm metric has five items.
And it's actually always helpful to kind of like think of these things as like you can actually learn from these little metrics. So the five items are in terms of what you're supposed to be tracking and paying attention to is when do you get out of bed? When's your And I think that's one of the things that you're supposed to be tracking on the social rhythm metric.
And those are good things to pay attention to is those are five important aspects of developing that rhythm. So many of my patients, they wake up, they pull out their phone, they sit on their phone for 30 minutes, they close their eyes, they hit the snooze button. Their first contact with a person, especially post-COVID where we're all indoors, is completely random. The downsides of the work from home is sometimes I start work at 11, sometimes I start work at 1.
It kind of depends on when I wake up. And then for dinner, it's like, oh, it's kind of different every day. All these things are, if you can make that circle kind of have consistent little divvies in terms of when those things happen, your body chemistry starts to learn and get used to those little patterns and those waves. Yeah.
Yeah, good. I'll confess, I never put as much emphasis on those as you just described, in part because I was so focused on the sleep thing. Because I think it's got more clout. But certainly, right, they all matter. They're all part of this rhythm thing. You mentioned this social rhythm metric. I also have a knee-jerk response to that. My fear is that it formalizes this whole process and is intimidating both to the clinician who may not be familiar with it and to the In official social rhythm therapy, the official version of this, you're supposed to give people this social rhythm metric piece of paper to fill out and do it like multiple times a day for a week or two weeks, fill this thing out so we can see what your social rhythm looks like.
Well, that's cool. You'll see how regular is it. People are going to start out with a pattern that doesn't look very regular, but But that becomes another barrier to actually just doing some of these behavior changes. This idea that you're supposed to fill out this thing. Well, I forgot to fill it out yesterday. Maybe I just don't want to do this. So I just never used that thing, I confess.
The Fives version that you just described is a simplified social rhythm metric. The original one is Fives. A whole page long. So clinicians can make the judgment as to whether this is going to facilitate the effort for your given patient or client or get in the way. I've never found it all that essential to complete that because we can just get a grok, you know, we can get the big picture view of how regular is this?
We already know it's not going to be very regular and okay, let's help you make it regular. I don't need a tool to demonstrate to myself or to you that we're making progress. Your whole mood stability is the target and we're targeting that because it will help improve your quality of life and your ability to function. Those are the big, big targets. And we're going to go after those by trying to help you get more stable mood.
And so this hierarchy of goals from what the patient really wants, quality of life, function, we get there by stability of mood. We get to there by going after your cicada rhythm. We do that by using social rhythms.
Yeah, awesome. Now, I'm curious, you were a clinician for a long time, so you have a lot of hands-on experience with this stuff. So I 100% agree with what you're saying in that light is the big gun. Light is the thing that makes the biggest difference and is probably the easiest to adjust or easiest to start working on. What did you find while you were working with patients were the biggest sticking points, the parts that patients struggled with and I appreciate the question.
Answer.
Well, the first thing that comes to mind, actually, I should be systematic about this, but maybe it's the biggest because it comes to mind the quickest. That's how our brains work, actually, right? So the first one is going to bed at a regular time. Zillions of reasons to have that not happen in people's lives. The morning rise time, at least there's an alarm clock and usually a fixed need, like work, family, school, to get people going in the morning.
That's more fixed. The bedtime is too loose, suppressing a tangent. So weekends, for example, People want to shift their schedule that they've been sticking with, but then they lose control of it over a weekend because they want to have a social life. Or our world is just offering you these tantalizing reasons to not go to sleep, right? Oh, stay up and watch one more of this. Oh, I'm reading this book.
I got to see where it goes. That isn't so common anymore, is it? The invitations to not go to sleep are sort of like the sirens singing to Ulysses, right? They're everywhere and they're very powerful. So I think that's probably the bigger one in terms of what gets in the way of trying to implement this whole scheme and weekends. So the weekend thing... It's important for people to have a complete life as they wish to have.
And so occasionally you're going to stay up later than your regular bedtime. That's okay. Just like maybe an hour later would be good, not five hours later. Or when you do that, you need to be aware that you're taking a risk to your rhythm. And maybe you need to build in some additional protections for yourself in the subsequent nights of days, right? Really get back on schedule as quickly as possible.
If you're going to go that far out four or five hours out of your regular timing, like on a weekend, um, you know, it's your choice and you don't have to be locked in. Um, but you need to be aware of what you're doing and that, uh, and be careful with it. And that's unfortunate. You have bipolarity. This is something you need to do. That is unfortunate.
On the other hand, bipolarity gives you some really cool benefits too. So there's just a trade-off here to have to be more vigilant around sleep hours. And then really being rigorous with yourself about not allowing the sirens to come after you. And so not exposing yourself to them after, if you're trying to target a bedtime at 10, don't be looking at stuff that's going to be singing the siren song to you starting at 9 or
30. Let's try to remove those from your, you know, you talked about, Dr. Malzberg, your morning routine. You can have an evening routine as well. And that includes the absence of the telephone, the absence of the pad, and the absence of the television after, say, 30. You've got a 30-minute window when you're not exposed to all that come here, come here, come here stuff.
Yeah, this is great. And the thing that I think is important as a clinician, we're teaching patients, self-compassion is really important here when you're trying to make these changes. Because you're saying, one thing I do see come up is I kind of explain... We're trying to get your bedtime the same, trying to wake up at the same time. And patients will say like that this is never happening on the weekends.
Like I need my boy time on Friday night and I need to stay up till four and all these things. And if I were to just, you know, be paternalistic and be like, no, you can't do that. The patient's just they're not going to listen like they're, you know. So the thing that you're trying to teach them is that we're working at this slowly and we're doing what we can.
We don't need to be perfect. Now, there are patients that will change their weekends and they will start drinking less and less. But what I see more often is they get buy-in as they start doing it and seeing improvement and say like, oh, okay, this stuff, these principles are starting to help. And then they start chipping away at the things that are a little bit more difficult.
And the thing you're teaching is everything's pros and cons. Listen, if you need to stay up till two and have a few beers with your friends, just know that it's coming at a cost. And it's ultimately your decision of is the cost worth it. Yes.
And we can be experimental. This is what we learned when we were taught basic cognitive behavioral therapy. You negotiate a plan based on not this is true or that is true, but well, let's find out. So you You can you have your natural behavioral experiments that will show you how risky is it for you to stay up until two and have a couple of beers with your friends.
That might be something that really doesn't throw you all that much, but let's keep an eye on it. And you might discover when you're paying attention that that really does mess you up for a couple of days thereafter. And now you can make the choice. Is it worth it or not?
And then this is a bit of a tangent, but it just popped in my head. As clinicians and patients, we need to have – we can't get rid of common sense when we're approaching patients. And, you know, there's patients who – I actually worked night shift for a while. Patients who change their bedtime all the time. Patients who say, oh, I do night shift, but it actually doesn't impact me that much.
Use common sense. Night shift is the worst thing a human being can do. Yeah. Don't let people convince you of things that go against your common sense. Yeah.
And when necessary, as you say, you know, sometimes the salary is necessary and so on, um, for night shift, at least that one, we can say, okay, you're stuck with that effectively financially. Um, let's try to turn your whole circadian rhythm to match. Yeah. You're going to take the whole principle of darkness and light and just spin it around so that when you're working late into the night in the hospital, starting at when, you start putting on your amber lenses while you're right there in the hospital.
And I know from direct experience of people doing this, you stimulate some conversations with your colleagues perhaps. But that is, people can't tell you not to do that. You're wearing corrective lenses of a different kind of sort. So you're getting your darkness even at the end of your shift so that when you come home, you're ready to go to bed. And then you have your dawn simulator and your blacked out bedroom.
So you can move your whole environment to match that schedule. What's worse is rotating shifts. And I had a guy working in a factory in the community next door and he was committed to that. Now that is, when you talk about common sense, that one violates the common sense principle big time. So then he and I talked about, well, how much risk do you want to take to your job by me writing a letter that says this is incompatible from a medical point of view With this gentleman's existing medical problem, he can't do this rotating shift thing.
If you want me to write that letter, I will, but we need to both be aware that you could lose your job over this. If not immediately, then somehow, you know, oh gosh, they had to downsize and you just, you know, so even those, yeah, so you have to be careful about at all levels when you're making these kinds of changes.
Yeah. And I actually think people who adjust their schedule on different night shifts are the best physical evidence of how important this is. I love the people who work night shift because they were awesome people who were like, you know, they're the free thinkers, the weirdos. I loved all of them. They all had signs of high cortisol. You know, like you see the physical changes in their body because I had a few colleagues who, you know, in residency switched over to night shifts.
And in three years, you see that they look different and it's not good.
Yeah. Weight gain would be one of them. Yeah. Yeah.
Yeah. So, okay. That was actually really helpful. Did you have any other high yield tips? I know we're going over an hour. I think people are going to keep listening. Any other big, big gun things that you saw clinically?
Yeah. Physical activity. You know, we know from a zillion studies that it has an antidepressant effect. Mood, trying to target depression, particularly in bipolar, in doing so, In a way that does not run the risk of inducing mixed states and more recycling and mania. Physical activity is just a great tool. And it's just insane what we're trying to do in our current society, making people think that in order to get physical activity, you have to go to a gym.
That is so low yield in terms of the probability people are actually going to sign up and let alone keep it up once they go. Now, if you've been able to pull that off, more power to you. And some people figure out how to do it. But for the average Joe, this is just like expecting somebody to go to a gym in order to get physical activity.
So we need to get our physical activity in some other way. And just getting up and walking, as Gary Sachs, the Harvard guru of bipolar disorder once said, here's the deal. Go to your door and open it with your shoes on. Walk for seven and a half minutes in any direction and then walk home. Do that every day. That was his recommended exercise regimen. That is more within reach for most people.
And there are a lot of barriers to that for where do you live? Is it safe? Do you have a sidewalk? But something like that as the low hanging fruit of trying to increase physical activity. And then I keep trying to tell my daughter who lives in Chicago and is running a you can dance program, just getting up off your couch and getting off your phone and moving around with other people like we used to do on the social gatherings is is another form of physical activity.
So in my head, physical activity is fun. You opened our session here talking about pickleball. Well, I do it because it's just so much fun. So finding the physical activity that you maybe used to do that is fun and then figuring out how to build that back into your life so that physical activity is not a chore. It's just fun. Yeah, that's you asked about easy ones that have a big impact.
That's one.
Yeah. And I was actually about to say that the only time I've been able to kind of keep up with physical exercise right now, me and my friends, we just text whenever we go for a run and we motivate each other. And it's actually awesome. We have like a group of three people and you do a run and you send It's the only time I've ever actually been able to keep up running.
And I don't go very far, two miles at a 14 minute pace. But just the fact that we see each other's times go down, a little bit of encouragement. And then the other thing is basketball for me. It's like I play every Wednesday. The only time I'm able to keep up these things is when I'm doing it with other people, when it's exciting, when I'm sharing it with other people.
The idea of, yeah, when I plan to go to the gym three times a week, I do it for two weeks and then it falls off as soon as anything comes up.
If you go to the gym and then you see the people there on a regular basis and it becomes a social experience, that's different. That might work. Absolutely.
All right. Keep giving me the big gun tips.
Well, let's see. So this is really off the top of the head, right? Yeah. I think maybe... Recognizing that, as you had pointed out, this is not therapy. This is not psychotherapy. This doesn't require a separate visit. This is something you just build into every clinical experience that you have with people so that you're trying to facilitate these behavior changes. It's not all about medications. It's about facilitating change.
So looking for opportunities in your clinical visits, however you can slip this stuff in there, to me, that's not an additional part of this, but I think it's the key message of all this. Now, I will confess, I did schedule 25-minute visits and I did build psychotherapy codes as well as medication management codes for nearly everybody. It is psychotherapy in that respect. And for sure it is.
We're trying to facilitate behavior change. It is psychotherapy, but it isn't formal. You don't need to go get separate training for it. It just adds to whatever you are already familiar with.
Yeah, absolutely agree. All right. I hope this works. I have the ultimate Zeitgeiber. Let me see if I can pull this off. Hold on.
Oh, it's a dog. Oh, yeah, it's the dog. Melody, come.
Melon, come.
Melon? Melon?
Melon. It just came to me one day. I don't even know how to wear it.
Melon. Okay.
Hey, Melon. The ultimate Psychyber.
Hi, Melon.
Is a puppy. It's hard to motivate for yourself sometimes, but the dog is the alarm clock you got to wake up for every day. You're walking out twice a week. They are a ton of work.
Because they have a circadian rhythm and they're not messing it up with iPhones. So at least you can have one that's actually working. Yeah, good.
And I feel like just because she's nine months old, you learn so much of like what mammals need. Because if we throw her schedule off, we're going to pay for it.
Yeah. In fact, there's a tail wagging behind you. I think your schedule is off a little bit.
All right. I think we're over an hour. I think we should probably wrap things up. Any closing thoughts, closing teachings? Keep going if you want, but...
Thanks. I'm sure we've saturated. And I hope you'll figure out a way to edit this down some because same principle, you know, you want it to be within reach. Yeah. So in any case, thank you very much, Dr. Malzberg, for the invitation. Thank you, if you're listening, for going through all this with us. And we hope that you'll find it useful.
Yeah, it's a ton of fun. I'll release the whole episode and then chop it up and put small chunks out for people to share. Now, I'm going to add some social pressure to keep you coming. What's our next one going to be on?
Well, we could say, okay, I just went to the International Society for Bipolar Disorders meeting. What did we learn there? I think we need to talk about lithium.
Lithium. Oh, I love that.
Because... Our understanding of it, so it was very prominent in that meeting. Everybody talks about how this is the right thing and yet it's only 20% of patients who are taking it, 50% are taking Antidepressants, 60% are taking antipsychotics, 20% are taking lithium. And yet we think that it's one of the best tools that we have. What is with that? And how does it work? And what's this lithium orotate story?
Is that going to come into our clinical utility? Yeah. So there's a lot going on there.
You're going to get the... I get all... Probably the most common comment is, can you do a full video on lithium? So... I'm glad that we're tickling the audience. Okay.
All right. Great. Thank you very much.
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