Key moments, in order
Low-dose titration: start at 150 mg and go up 150 mg every four to seven days until something good happens, something bad happens (then go back down one step), or you reach 600 mg a day, and then check a level.
At non-manic doses, the 20-year risk of renal dysfunction is much tinier than people realize, and renal damage is extremely unlikely as long as you watch for NSAIDs and antihypertensives and check levels.
Pitch it as "the second you get a side effect, we go back down to the lower dose," and let the patient keep a hand on the knob. That makes a huge difference.
Low-dose lithium works across the whole mood spectrum. It is least appreciated and most valuable in the middle of the spectrum, sometimes alongside social rhythm therapy or lamotrigine.
The low-dose approach makes lithium safer for you and your patients, and works like exposure therapy for prescribing it.
Lithium orotate has almost no rigorous data, but it is really important to understand.
Patient reports online of benefit at very small doses are not a guide to practice, but a loud, numerous and persistent signal from users is a credible source of information, and placebo has real value too.
Mood stabilizers are not only pills. Sleep and diet are mood stabilizers too, and simplified social rhythm therapy is the first-choice one, ahead of lamotrigine and low-dose lithium.
It comes in levels, from full IPSRT to SRT to a simplified version. Everyone agrees sleep is the central ingredient, so you can start with just a regular pattern of sleep.
Do not lecture; listen. Ask why they are going to bed at two in the morning and how they got there, and acknowledge that they already know it would be a good idea to change.
Move sleep gradually: not from 2 a.m. to 10:30 p.m. in one step, but in 15-minute steps every couple of nights, so the patient can see progress.
Building structure and stability helps every aspect of mental health. It is a big focus for patients with personality disorders and trauma, not only mood disorders.
Sleep is fundamental to daytime function. Before starting a stimulant, see what targets remain once the patient gets seven and a half hours of sleep.
In bipolar disorder, a formal light box carries the same risks as antidepressants: not just hypomania or mania, but mixity and a mess of mood stability, with anxiety, irritability, agitation and attention problems.
Light therapy has no risk of inducing hypomania that we have seen any indication of, and most people like it. These are robust treatments with no side effects or long-term risks.
The only harm of a dawn simulator is a bed partner on a different schedule, and a sleep mask solves that.
Two randomized trials of darkness for inpatient mania have shown efficacy against placebo; the most recent one did not.
Glasses that block just the blue wavelength and let everything else through let patients keep their light: when you do not see blue, your brain thinks you are in the dark.
Make the bedroom really dark: in one study, three lux or more raised the risk of a manic recurrence. Use dark curtains, or for a desperate patient who rents and has no money, literally tinfoil on the windows.
In our experience it works for only about half of patients. The other half come back saying it did nothing; responders call the glasses amazing and say they fall asleep almost an hour earlier, fall asleep more quickly and stay asleep better.
Make cycling the treatment goal: "We're focusing on fewer ups and downs, not on how you're feeling on a particular day."
Do not treat the mood du jour. Stop the cycling, then reassess: there may still be a depressive component, such as a dysthymia tied to childhood trauma, to address without restarting the cycling.
With apparent comorbidities, stop the cycling first and see what is left. What looked like ADHD may diminish to the point it needs no further intervention.
True PTSD is not that common among people who have had a traumatic experience. With bipolar disorder and a trauma history, stabilize mood first and see how problematic the trauma still is.
Think of it as a trait on a spectrum, "borderlineity," with no real cutoff. Toward the milder end it becomes a temperament, much like the temperament studies in bipolarity, and people can learn to combat rejection sensitivity, overvaluation and devaluation, and crisis-oriented thinking.
People who work indoors under fluorescent office lighting are simply not getting enough light during the day.
The ideal is to go outside and do something active in the morning. Even on an overcast day the blue wavelength gets through. The Western solution is to buy a light box and stay on your computer.
Fish oil does not have enough clout per pill. Where it fits is when you do not want to introduce anything new and need to be sure the addition will not make things worse: then fish oil is a great placebo.
Results in psychosis-prone adolescents were astounding, with a jaw-dropping difference, though they did not replicate.
Every added pill has to carry its weight. People get tired of juggling pills, and that is one reason they stop everything.
Our job is to help the patient, not to be right and smart and say research-backed things.
The ketogenic diet clearly does something and is not a placebo, but it is out of reach for most people. Use it as a lead-in to a more rational, Mediterranean-style diet, and keep it in mind for patients where multiple things have failed.
Its anti-manic efficacy is not fantastic, but its antidepressant effect in bipolar depression is relatively robust. Studies show it is not effective for acute depression, yet our clinical experience contradicts that: there is a really big mismatch between experience with it and the trial data that guidelines rely on.
Manage it the way you manage low-dose lithium: do not let people have side effects, because that will blow the ballgame.
We are big fans of lamotrigine and low-dose lithium. In bipolar I, use lamotrigine as an adjunct to other tools: it does not have enough anti-manic prophylactic value to be monotherapy.
If a patient is already on a lot, get rid of something first so lamotrigine gets a fairer trial, especially an antidepressant: being on one makes it less likely lamotrigine will show what it can do.
Psychotherapy is the treatment for unipolar depression, and people ought to get trials of three different psychotherapies before a first antidepressant trial.
It is not never; it is after you have tried multiple other things, and for a specific subset of patients. When it finally comes to that, bupropion.
The big problem is not just mania but induced mood instability and mixed states. Almost all antidepressants are pro-cycling.
The mood stabilizers with antidepressant efficacy, the 'three Ls and a Q', named here as lithium, lamotrigine, trazodone and quetiapine.
Pulling an antidepressant off quickly is itself an acute stressor, so be mindful of that.
Head for 600 mg from the start, but get there slowly: 200 mg steps, or 100 mg steps from zero to 600 if you want to be extra careful and are not in a hurry.
It can cause Stevens-Johnson syndrome and it is a teratogen, so using it in women of reproductive age is a different ballgame. Start thinking of it more like valproate.
Sooner or later someone on it will get dizzy and nauseous, and it will be low blood sodium.
A more skeptical view: there is only one large randomized trial, and it was negative, so the randomized evidence says it does not work.
When a patient does not follow the plan, it is the clinician's problem: you did not work out what was really going to happen once they left the office.
Passive tracking helps: an app that sits on the phone and tracks bedtime and the sleep window.
Sleep trackers that need no effort work with patients who dislike tracking: have the patient send the monthly PDF.
Group psychoeducation has striking data: a five-year difference in episode-free survival compared with people who did not get the program.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.