What we’ve said about Bipolar disorder

“a better way to think of it is the mood spectrum because really there's no dividing line between the bipolar part and the unipolar part. It's a continuum from one end to another. So bipolarity is the pigment in your basic paint color that shifts it from being white in the direction of red”

“Emil Kreplin, his formulation of manic depressive illness was defined not by polarity, but by episodic mood episodes. And Nasir Ghaimi is also now a big proponent of this, that bipolar is defined as recurrent mood episodes, not by the polarity of hypomania or mania”

“He said, cyclicity is more important than polarity. This is more important than that. Try to define whether or not someone's had a manic episode and define bipolar disorder on the basis of, no, I couldn't find a manic episode. That's the wrong approach to this mood spectrum. We're looking for how bumpy is it”

“Genes, inflammation, metabolism. Reward hypersensitivity. People with bipolarity have an increased probability of latching on to the potential for reward, overestimating the probability of a good outcome. Reward hypersensitivity”

“And the easy threshold is, was there anything destructive, damaging, dangerous... Negative consequences. How much would a person want to really avoid having that happen again? If it's like, oh, yeah, for sure needs to be avoided, I think that takes you into the bipolar one that was manic”

“it's interesting to find that the majority of people with a true bipolar disorder, most of them, mostly experience depression, especially major depression and usually major depression in episodic way, discrete episodes, multiple across a lifetime”

“the bipolar 1 and 2 categories in the DSM have been created to give an adequately reliable sample set and definition of a specific manic depressive type illness that can then be used for studies and research”

“I really feel that for psychotic and bipolar disorders, as a society, we've been incorrectly conceptualizing these conditions as psychological. They're not psychological. These are brain disorders”

“Otherwise, you kind of get an acquired ADHD if you don't treat those mood episodes early enough. Their cognitive functioning seems to decline”

“bipolar I now understand as two different, it's almost like two different moods, like two different self-states, two different ways of being”

“Irritable Being Really Activated That's Why Bipolar And Agitated Depressions Are The Most Dangerous In Terms Of Treatable Medical Conditions Towards Suicidality”

“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”

“If the difference between having a really good day and being hypomanic is so slim that it's basically undetectable, then how are we supposed to make this diagnosis? That I think is the fundamental problem of hypomania”

“It doesn't exist. Yeah, you can't do that with confidence. What you can do is gather all the other data that will help you Adjust your assessment of probabilities. And you're trying to get the greatest confidence either because, of course, we're making a treatment decision, right”

“A doctor can't talk to you for 45 minutes and know with 100% confidence what your diagnoses are. And you essentially can't rule out conditions by meeting and talking to someone with 45 minutes”

“it's as if unless this doctor sees mania and hypomania in front of them, the bipolar disorder cannot exist. That's not how you should practice medicine, right”

“This will catch your most severe bipolar ones. I get a sense that a lot of people, especially the ones that mostly work inpatient, kind of feel like this is the only person who should have a bipolar diagnosis. I think that's a big mistake”

“It is overdiagnosed and underdiagnosed. What we see is patients with a lot of personality pathology, with borderline personality disorder, oftentimes it's overdiagnosed in that context. In those patients in treatment resistant depression, I see it severely underdiagnosed in”

“You can't simply ask, are you having this? And you can trust the answer. Because these are the two conditions that come with memory deficits about impairments and also lack of insight into impairments”

“The first part is that people with real bipolar disorders can genuinely lack memory of past episodes. Right. That that's an issue in itself. We don't know exactly why you could come up with psychological mechanisms. I'm a little bit favorable towards the state dependent memory hypothesis”

“I can turn the logic tables around the other way and say, ultimately it becomes incumbent upon me to disprove my My potential leap to the diagnosis. So as you were saying, you're listening to this history and there were a couple of nights in college and now I'm on the bloodhound trail and I'm sniffing along”

“You do have to update your diagnoses and pay attention over time. You can't just hang your hat on your first impressions”

“This can be the case for even people who never actually meet DSM criteria for a full bipolar two or bipolar one. Because unfortunately, there just seems to be a set of people who don't respond very well to the typical first-line antidepressant treatments”

“what's most valid? Well, certainly the organic diseases like Alzheimer's disease. But beyond the organic conditions in psychiatry, I think we have to begin with schizophrenia. With manic depressive illness, which is not necessarily equivalent to bipolar disorder”

“There are four of them, and the When you put them together with symptoms, which count, they don't not count, especially when clear-cut manic symptoms are present. But the other four of these five dimensions”

“So substances and then sleep. You figure out your whole life. Has there ever been a time where you weren't not yourself, et cetera, et cetera. Sleep disruption, decreased sleep with preserved or increased activity”

“Now, things that point in the direction of a bipolar illness, the biggest one is family history. So if there's a sprawling family history of bipolar disorder, it really raises the chances of what we call bipolarity”

“look for family history and get collateral. Those are the most important things because you'll get a history from a patient and then you'll speak to a family member or partner and you'll hear clear cut episodes of mania”

“You do that by looking at how recurrent their actual major depressive episodes of neurovegetative symptoms are, when they started, how long they last, and how frequently they occur, and looking at things like family history, life course, and response to different types of medications”

“you say you have depression. How many depressive episodes have you experienced? And the answer to that will give you a ton of information because some patients will look at you very confused and go like, what do you mean episodes”

“if we are identifying properly a manic depressive illness, a bipolar disorder, the changes in their functioning, their mood, their activity levels and sleep should be happening in episodes”

“if you are able to detect a episodic and recurrent major depressive picture, that starts to raise the possibility that there is a bipolar spectrum disorder or at least a possibility of mixed depression or refractory or biological seeming depression rather than depression secondary to life circumstances or personality”

“Age of onset means first episode of depression. Family history. Is there anyone in there who's got, well, a first degree relative with a shortcut diagnosis of bipolar disorder? That would be nice. But, you know, of course, this is the realm of fuzziness as it's part of our job”

“I'm listening for three or more episodes of depression to simplify it. That's the frequency part of cyclicity. And then there are two other variables that went into the bipolarity index under that heading. One was postpartum onset of depressions, which is a bipolar marker in the sense that it raises the probability of bipolarity”

“So the one that I like to look at is the offset of the depression. In other words, I'm asking, You know, these depressions that you've had. Have you ever had the experience of going, boom, out of it”

“So what we're really looking for in this response to treatment finger is an adverse reaction to an antidepressant. Something weird happened. What a primary care colleague called antidepressant misadventures. Oh, you know, something really strange happened. That's all I'm listening for”

“The answer is it depends on what your index of suspicion of bipolarity was before you started the whole thing. If your suspicion was very, very low, then you can, you and your client patient can kind of tolerate some of this and explore and carry it on a little farther and see what direction this is going”

“If I hear a lot of substance use disorder, it will point me a little bit more into bipolarity”

“Have you ever had at least three days in a row where you were not your normal self and you didn't sleep, didn't really need it, or you couldn't sleep even if you wanted to, yet you still had energy”

“what is actually necessary or sufficient is a marked change in mood, irritable, elevated, overconfident, that's not the wording in the DSM, with increased or preserved activity”

“if you see substantially worsening sleep and physiologically improbable sleep, like three, four, five hours in somebody, especially when they don't have a trauma disorder, You really need to start considering the possibility of bipolar”

“The first things that you have to do, that you have to prioritize, are getting a thorough medical history, a thorough medication treatment history, including non-psychiatric medications, and probably the most important, depending on your patient population, a really detailed substance use timeline”

“Bipolar disorders largely do not appear as a minor in adolescence or childhood, so we need to know about adulthood, usually from the 20s and onwards”

“I feel like the patients that I have answer yes, when I get more narrative, it doesn't at all fit with bipolar. And the patients who say no, if I get more narrative, a lot of times I'll be able to figure out episodes. So screener questions are particularly bad in bipolar”

“To me, I don't find it helpful at all with bipolar to walk through the specific DSM criteria. I just don't find it helpful. It is for a lot of conditions where you can walk through the symptoms exactly and then see what they say. For bipolar, I don't find it helpful”

“i'm still not going personally to ask about mania or hypomania to be frank i only do that in the beginning when i think with this particular patient there's extremely low Pre-interview probability that they have a bipolar type disorder”

“there are many patients where you'll even specify time frame at least 48 hours in a row and they'll still say oh yeah i totally had a lot of energy well how long did it last three hours okay you really have to ask follow-up questions”

“early identify some theme in their life that I can use as an anchor. And I start there and then I fill in the pictures using that anchor of the other variables”

“Also, you want to use the modified version. Per our article in the Journal of Bipolar Disorders, not the original one. It's sensitivity is too low”

“he used to say, oh, it's the rule of threes. Three marriages, three languages, three credit card defaults, three college degrees”

“typical duration of a major episode of major depression is more like six months, whereas for bipolar is more like two or three months. I've never found that particularly helpful”

“share your uncertainty with your patient as you do and recruit them to become, recruit them to be part of the bloodhound team. So they're gonna go look around once they know what they're looking for, for mixedness, like four A's, how prominent are those”

“I'm going to say I'm agnostic on it. I can't say what's causing that when I don't have enough medical evidence to say one thing or another. So what am I going to do? Well, I'm just going to watch and I'm going to use the minimum amount of safest medications I can”

“I often document, I reviewed with patients why I think that there's, for this individual patient, an increased risk of some sort of bipolarity. However, the patient understood the alternatives and still wanted to pursue the major depressive treatment with an understanding that we're going to keep a very close eye and monitor”

“I have my usual message, you know, call it whatever you want, but just give the right treatment. And if your mood stabilizer is helping, maybe they do need a mood stabilizer”

“the important part and the thing that distinguishes this from, you know, depression or bipolar is that these mood changes are in a social context and the mood changes reflect interpersonal events in that the trigger is usually the result of an interpersonal event”

“I think you really need to have at least some evidence of like a, you know, neurobiological type depression where there's episodes or stark changes in total functioning rather than simple mood or reactivity between human beings, interpersonal issues”

“mostly it's because people are ignoring episodes. They're just taking yeses at face value and they think that mood lability is a major feature in bipolar, which it is for some people”

“some inpatient providers think that pressured speech means the person's talking a bazillion miles per hour there's a lot of patients with bipolar who present with in terms of it just in the moment they feel like they're borderline”

“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”

“they may have those personality tendencies, but without the added weight of a untreated mood disorder, it doesn't really come out with the same severity. So you got to have nuance and you have to monitor or treat and, you know, think over time”

“most people in the community, at least where I am, when they say bipolar, they mean mood swings of a person with personality type issues or trauma”

“calling a bipolar disorder is problems of concentration adhd yes yes very very common especially today please don't do that”

“bipolar disorders, of course, have depressive episodes. 95% do. And... We already talked about how that impairs concentration and attention task switching. But of course, mania and hippomania causes significant distractibility”

“college age, you know, like the 18 to 25 range is when a lot of the more serious mental illnesses start to develop. And there often is a prodromal phase where the core symptoms that they experience might be inattention”

“it's not uncommon for people with bipolar who haven't fully accepted their diagnosis to, after a long period of time, find a psychiatrist and think that they were misdiagnosed”

“a patient will come and say, I have anxiety. They could be blatantly manic and it's like, oh, their problem is anxiety. To me, it's irresponsible To me, it's It's irresponsible to be treating someone without them knowing your diagnosis”

“Another major mimic that I think you really want to make sure you're not inappropriately treating is severe insomnia related to a trauma disorder. OK, people with a severe trauma disorder can be in such a hypervigilant state that they won't sleep for even a couple of days in a row”

“you really need to consider the possibility of both medication and substance-induced bipolar-type disorders. You should also consider medically-induced bipolar-type disorders, for example, from strokes, head injuries, and seizure disorders”

“you can't just assume that person doesn't have bipolar disorder, but you also can't assume that they do. So you'll have to really try to nail down periods where they were clearly sober from problematic substances that could likely trigger bipolar type disorder episodes”

“don't attribute everything to a substance-induced hypomanic episode just because there were medications or substances that could explain it. So when patients are hypomanic or manic, they're more likely to use those substances. even if those substances weren't the trigger”

“even bipolar mania can mimic psychotic features uh the speed of distractible thoughts, rushing thoughts and speech can appear and has been defined in the literature as thought disorientation”

“Do we mean true, recurrent, Biological type major depressive disorder, the cousin to bipolar disorder, or do we mean dime stored depression from personality and stressors that happens to meet major depressive episode criteria”

“He wasn't your typical picture of mania where you have this pressured speech, you have this flight of ideas, almost the opposite. He was essentially not talking that much and incredibly quick to violence”

“American psychiatrists were diagnosing schizophrenia basically twice as often as their British counterparts. A lot of what we would now call bipolar disorder and borderline personality disorder was being called schizophrenia at that time”

“they share a third of their, a third of associated genes. They diverge on two thirds of their associated genes. They share some symptoms, but their courses are different. They have completely different longitudinal courses”

“Do they have a father and grandfather and uncle with bipolar illness? And this patient has some subsyndromal bipolar condition where they're always cycling and they're also anxious and they can't sleep sometimes because their mind is racing”

“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”

“Do not focus on the mood du jour. Focus on the cycling, stop the cycling, and then you have to reassess. Maybe you're going to stop the cycling and there's still a depressive component there. It could be a dysthymia associated with a horrible childhood trauma history”

“The big part about treating bipolar and what changes you from a novice to experienced in treating bipolar is focusing on maintenance. So the wins in bipolar is by improving a patient's maintenance and decreasing the number of episodes”

“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”

“Please seek mood stabilization primarily, even if you don't have clear mood symptoms remaining. If you have any problems with the sleep, you might benefit broadly from more mood stabilization or lifestyle changes and different skills”

“It's rare for me to find a serious bipolar disorder that needs only one or two medications. Polypharmacy seems to be more the rule than the exception. This doesn't mean you should jump to polypharmacy, okay? But you shouldn't necessarily be afraid of it in the service of getting somebody better”

“if you treat enough schizophrenia and bipolar disorders, you're going to find that everyone is an individual. And one medication that works really, really great in 90% of people may work terribly in one person”

“If you can reasonably identify a classical primary psychotic disorder or a serious bipolar disorder, tapering is actually quite dangerous. Generally speaking, in my opinion, those conditions do require lifetime medications”

“you kind of pick how conservative of a practitioner you want to be. And if you're conservative, then you're going to have more patients on unnecessary medications, but more stable patients”

“if a patient comes to you with what's clearly a neurobiological condition that responds handily to medications, And then you say, well, why don't you try this? It would be like going to an oncologist, having a malignant cancer and saying, well, you could try fasting”

“when there are psychotic features of a severe mood disorder, episode, that's probably closer to what we consider psychosis. And that does absolutely warrant treatment with an antipsychotic. But don't neglect the primary treatment of the mood with either SSRI or mood stabilizer”

“I want to see them in euthymia for probably two or three months at minimum. And I just go off of patient comfort at that point. But sooner is usually better”

“there's a directional effect where if you disrupt the sleep of someone with a bipolar disorder, they're more likely to cycle, right? So if that's the case, then I also want to stabilize the sleep”

“Is it harmful to ask for a strict waking time in a bipolar disorder? Could severe sleep deprivation cause mania or hypomania? In theory, possibly. I think if you're doing appropriate medical treatment, it's not a concern”

“we treat whatever side of the disease phase that we're in, we treat to symptom remission plus three”

“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”

“That's how I define it. So it treats or prevents episodes of bipolar without flipping someone into the opposite pole”

“whenever you're talking to a bipolar specialist, they emphasize the importance of mood stabilizers. And you'll see as you treat more and more patients, you start to use antidepressants less and you focus the mainstay of treatment on mood stabilizers, mood stabilizers, mood stabilizers”

“My answer to bipolar disorder is mood stabilizer. My answer to bipolar disorder not responding to one mood stabilizer is not antipsychotic. It's two mood stabilizers. So do not neglect the mood stabilizers”

“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”

“So it does help prevent the episodes of mania. But if a patient's manic or hypomanic, it's not going to work. So the best way to think of it, all these medications typically is you're preventing episodes more so than stopping them”

“But I say to people with bipolar disorder and to the clinicians, please give the mood stabilizers a fighting chance. You may find that things go better for you body health wise, mind health wise in the long term”

“the idealistic bipolar patient, the patient with euphoric mania and then with intermittent episodes of depression. That is considered the idealistic lithium patient. Depakote has some evidence with rapid cycling. It has some evidence with mixed episodes”

“you have to actually try to use it. And if you treat enough bipolar disorders, you're going to know that some people don't respond to one mood stabilizer and respond to another. I've had people not respond to lithium”

“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”

“I'm a big glomotrigine and low-dose lithium fan. I think we talked about those some in our labs go around. And if people find it useful, more detail on how to do simplified social rhythm therapy”

“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”

“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”

“lithium is one of the only psych meds that regulates the circadian rhythm the genes for bipolar the closest we've come to finding the genes for bipolar is linking them to the clock genes that regulate the circadian rhythm. And we know that lithium normalizes the expression of those clock genes”

“Lithium-initiated postpartum has the strongest evidence for the prevention of postpartum psychosis. And in postpartum psychosis, highly linked to bipolar disorders”

“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”

“Depakote is historically, and in my opinion, better for irritability, aggression, and people with things like a little bit of TBI history and people that have migraine headaches because Depakote works as a preventative agent for migraine headaches”

“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”

“there's at least some evidence for it. And yes, it's old mixed evidence and people say, oh, I don't like it. But the action is, you know, at least meaningfully close to the carbamazepine”

“They tried it out, but it's just a relatively safe choice, you know. Except for the small amount of withdrawal and tolerance possibility. Think of it as an adjunct in the same category, but certainly not a solo medication. It just doesn't really work”

“quetiapine is one of the only antipsychotics that kind of covers the whole gamut of bipolar. So it covers the depressive episodes. It covers the mania”

“The truth is, it's a really great medication, especially in bipolar. It just was never tested in acute mania”

“I think of it as it's going to be off-label, but it still has a good evidence base as an effective medication for bipolar mania. And we would use it all the time inpatient, especially the LAI, and I saw it work really well”

“You should probably start around 15 and no lower than 10 milligrams. I've seen people respond with lower, but remember, what does that partial agonist mean? It basically means that about 20% of the dopamine receptors that it is bound to is not blocking”

“Tardive dyskinesia, permanent involuntary movements of the face, mouth, or body that come from antipsychotic use. And it's higher risk in people with mood disorders. Interestingly, if you have a schizophrenia, whatever is going on with that seems to not be as vulnerable to tardive dyskinesia”

“And I am willing to take it up to 90 milligrams or so, but you have to look out for the sedation orthostasis. And I actually think it's quite a good augmenting agent in the direct treatment Of schizophrenia spectrum disorders and bipolar disorders for the people who can tolerate it”

“I'm going to avoid them like the plague unless I can't get away without using them. So the first thing I'm going to say is that if someone is on a antidepressant and they're rock solid stable, then fine”

“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”

“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”

“when you persist with SSRI in someone with bipolarity, that's where it becomes more harmful and dangerous. And there are other treatment options”

“Somebody with a bipolar disorder generally can become agitated or worsen if you give SRI, serotonin reuptake inhibitor, So do be careful about that”

“the people who might have a little bipolarity, even if they'll never have a real bipolar disorder or have very high levels of anxiety, then yeah, going too quickly on the medication like Lexapro can definitely, uh, cause some reactions there”

“pulling it off quickly is also an acute stressor. So you need to be mindful of that”

“I'm of the camp that anyone with a manic depressive illness bipolar disorder, regardless of their comorbidities, should not be treated with an SRI whenever possible”

“I wouldn't give peroxidine. A lot of people like to use Paxil kind of for sleep, but this is an SSRI. This is a potent SSRI with a lot of withdrawal effects”

“I do get wary and careful if we're going to TRASM above 150 in bipolar disorder or if we're doing mirtazapine above 15 or 20-ish”

“methylphenidate, which there's at least some preliminary evidence showing is more suitable for use in bipolar disorders, though personally, I never give stimulants to bipolar disorder patients”

“the third category major category in the treatment of any bipolar disorder is lifestyle changes okay i want people regulating tricky their sleep and life cycle okay this is even its own psychotherapy for bipolar disorder i believe it's uh social and interpersonal rhythm therapy”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“Cognitive processing therapy or written exposure therapy or even EMDR, fine, because none of those is likely to make bipolar worse and may help some”

“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”

“mindfulness is not going to treat mania. It's not going to treat a bipolar depression. That said, it's still something worth teaching to someone who has bipolar or who has schizophrenia”

“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”

“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”

“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”

“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”

“focusing on the cycling as the treatment goal and not the particular symptoms. I hope that's the one thing you take away. And I say this with every patient with bipolar, we're focusing on less ups and downs, not on a particular how you're feeling that day”

“The mood stabilizers decrease the number of episodes. Yes, it helps with depression but it's very slow. Yes, it helps with mania but it's pretty slow. The reason why I find treating bipolar so fun is because you say we're playing the long game”

“if you don't tell people that, then it's very normal for them to say, wow, I'm taking this mood stabilizer. I feel tired and depressed. I should stop it”

“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”