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Demystifying Major Depressive Disorder with Mixed Features · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back
• 0:05
  to
• 0:05
  another
• 0:06
  episode
• 0:06
  of
• 0:06
  Pearls.
• 0:07
  And
• 0:08
  this
• 0:08
  is
• 0:09
  going
• 0:09
  to
• 0:09
  be
• 0:09
  a
• 0:09
  fun
• 0:09
  one.
• 0:09
  Today
• 0:10
  we're
• 0:10
  going
• 0:10
  to
• 0:10
  talk
• 0:10
  about
• 0:11
  major
• 0:12
  depressive
• 0:12
  disorder
• 0:13
  with
• 0:13
  mixed
• 0:13
  features.
• 0:14
  As
• 0:14
  a
• 0:15
  new
• 0:15
  grad,
• 0:16
  you
• 0:16
  might
• 0:17
  get
• 0:17
  spun
• 0:17
  up
• 0:18
  when
• 0:18
  seeing
• 0:19
  your
• 0:19
  first
• 0:19
  patient
• 0:20
  and
• 0:21
  asking
• 0:21
  yourself,
• 0:22
  what
• 0:22
  am
• 0:22
  I
• 0:22
  looking
• 0:22
  at
• 0:23
  here?
• 0:23
  Is
• 0:23
  this
• 0:23
  depression?
• 0:24
  Is
• 0:24
  this
• 0:24
  bipolar?
• 0:25
  What
• 0:25
  kind
• 0:26
  of
• 0:26
  bipolar
• 0:26
  is
• 0:26
  it?
• 0:27
  Is
• 0:27
  it
• 0:27
  cyclothymia?
• 0:28
  Is
• 0:28
  it
• 0:28
  borderline?
• 0:29
  What
• 0:30
  am
• 0:30
  I
• 0:30
  looking
• 0:30
  at?
• 0:31
  Your
• 0:31
  head
• 0:31
  can
• 0:32
  really
• 0:32
  spin
• 0:32
  because
• 0:32
  there's
• 0:33
  a
• 0:33
  lot
• 0:33
  of
• 0:33
  overlap
• 0:34
  and
• 0:34
  then
• 0:34
  you're
• 0:34
  trying
• 0:35
  to
• 0:35
  think
• 0:35
  back
• 0:35
  to
• 0:35
  the
• 0:35
  DSM
• 0:36
  5
• 0:36
  TR
• 0:37
  criteria
• 0:38
  and
• 0:38
  everything
• 0:39
  seems
• 0:39
  a
• 0:39
  little
• 0:39
  bit
• 0:39
  murky.
• 0:40
  Today
• 0:40
  we're
• 0:40
  going
• 0:41
  to
• 0:41
  try
• 0:41
  and
• 0:42
  demystify
• 0:43
  some
• 0:43
  of
• 0:43
  this
• 0:43
  stuff
• 0:44
  to
• 0:44
  make
• 0:44
  it
• 0:45
  more
• 0:45
  clear.
• 0:46
  Mock
• 0:46
  case
• 0:46
  study
• 0:47
  we
• 0:47
  have
• 0:47
  today.
• 0:48
  We'll
• 0:48
  call
• 0:48
  her
• 0:49
  janelle.
• 0:49
  She's
• 0:50
  a
• 0:50
  29
• 0:50
  year
• 0:50
  old
• 0:50
  dance
• 0:51
  instructor.
• 0:52
  She's
• 0:52
  fatigued,
• 0:53
  she's
• 0:53
  hopeless,
• 0:53
  she
• 0:53
  feels
• 0:54
  guilty
• 0:54
  for
• 0:55
  the
• 0:55
  last
• 0:55
  three
• 0:55
  weeks.
• 0:56
  She's
• 0:56
  kind
• 0:56
  of
• 0:56
  sad
• 0:56
  and
• 0:57
  down,
• 0:57
  cries
• 0:57
  daily.
• 0:58
  She
• 0:58
  feels
• 0:59
  like
• 0:59
  she's
• 0:59
  a
• 1:00
  burden.
• 1:00
  She
• 1:01
  has
• 1:01
  no
• 1:01
  appetite,
• 1:01
  she
• 1:02
  has
• 1:02
  low
• 1:02
  energy,
• 1:02
  her
• 1:03
  sleep
• 1:03
  is
• 1:03
  kind
• 1:03
  of
• 1:03
  fragmented.
• 1:04
  So
• 1:04
  you're
• 1:05
  thinking
• 1:05
  major
• 1:05
  depressive
• 1:06
  disorder
• 1:06
  right
• 1:06
  off
• 1:07
  the
• 1:07
  bat
• 1:08
  until
• 1:08
  she
• 1:08
  adds,
• 1:09
  she's
• 1:09
  barely
• 1:10
  sleeping
• 1:10
  though
• 1:10
  three
• 1:10
  hours,
• 1:11
  but
• 1:11
  she
• 1:11
  still
• 1:11
  has
• 1:12
  energy
• 1:12
  to
• 1:12
  choreograph
• 1:13
  all
• 1:13
  night
• 1:13
  and
• 1:13
  her
• 1:14
  mind
• 1:14
  won't
• 1:14
  shut
• 1:15
  up
• 1:15
  with
• 1:15
  creative
• 1:16
  ideas.
• 1:17
  She
• 1:17
  says
• 1:17
  she
• 1:17
  can't
• 1:18
  stop
• 1:18
  talking
• 1:18
  in
• 1:19
  class,
• 1:19
  she's
• 1:19
  been
• 1:19
  flirting
• 1:20
  a
• 1:20
  lot
• 1:21
  and
• 1:21
  she's
• 1:21
  been
• 1:21
  engaged
• 1:22
  in
• 1:22
  some
• 1:22
  risky
• 1:23
  habits.
• 1:23
  She
• 1:24
  denies
• 1:24
  feeling
• 1:24
  euphoric,
• 1:25
  but
• 1:26
  her
• 1:26
  thoughts
• 1:26
  race
• 1:27
  like
• 1:27
  music.
• 1:28
  She
• 1:28
  has
• 1:28
  no
• 1:28
  history
• 1:29
  of
• 1:29
  mania,
• 1:29
  but
• 1:30
  her
• 1:30
  cousin
• 1:30
  has
• 1:31
  bipolar
• 1:32
  1
• 1:32
  and
• 1:33
  in
• 1:33
  her
• 1:33
  PHQ9
• 1:34
  is
• 1:34
  a
• 1:34
  21.
• 1:35
  So
• 1:36
  this
• 1:36
  is
• 1:37
  not
• 1:37
  really
• 1:37
  classic
• 1:38
  major
• 1:38
  depressive
• 1:39
  disorder.
• 1:39
  The
• 1:39
  red
• 1:40
  flags
• 1:40
  should
• 1:40
  be
• 1:40
  popping
• 1:41
  up
• 1:41
  when
• 1:42
  she's
• 1:42
  telling
• 1:42
  you
• 1:42
  that
• 1:43
  she
• 1:43
  has
• 1:43
  so
• 1:43
  much
• 1:44
  energy
• 1:44
  and
• 1:45
  creative
• 1:45
  ideas
• 1:46
  that
• 1:46
  she
• 1:46
  can't
• 1:47
  really
• 1:47
  sleep.
• 1:47
  Well.
• 1:47
  That's
• 1:48
  a
• 1:48
  little
• 1:48
  unusual
• 1:49
  in
• 1:49
  the
• 1:49
  middle
• 1:49
  of
• 1:49
  the
• 1:49
  night,
• 1:49
  right?
• 1:50
  To
• 1:50
  have
• 1:50
  these
• 1:51
  episodes
• 1:51
  where
• 1:52
  you
• 1:52
  get
• 1:52
  creative,
• 1:53
  can't
• 1:53
  stop
• 1:54
  talking
• 1:55
  and
• 1:55
  even
• 1:55
  engage
• 1:56
  in
• 1:56
  some
• 1:56
  risky
• 1:57
  spending
• 1:57
  habits.
• 1:57
  This
• 1:57
  is
• 1:58
  episodic.
• 1:59
  She's
• 1:59
  telling
• 1:59
  you
• 1:59
  that
• 2:00
  this
• 2:00
  is
• 2:00
  happening
• 2:01
  lately
• 2:02
  at
• 2:02
  night.
• 2:02
  This
• 2:02
  is
• 2:02
  not
• 2:03
  happening
• 2:03
  every
• 2:03
  day.
• 2:04
  This
• 2:04
  is
• 2:04
  not
• 2:04
  a
• 2:04
  part
• 2:05
  of
• 2:05
  her
• 2:05
  personality.
• 2:06
  But
• 2:06
  these
• 2:06
  are
• 2:06
  episodic.
• 2:07
  She
• 2:07
  tells
• 2:08
  you
• 2:08
  that
• 2:08
  this
• 2:08
  happens
• 2:09
  for
• 2:09
  days
• 2:09
  at
• 2:09
  a
• 2:10
  time
• 2:10
  and
• 2:10
  then
• 2:10
  it
• 2:10
  kind
• 2:10
  of,
• 2:11
  you
• 2:11
  know,
• 2:11
  it
• 2:11
  just,
• 2:12
  it,
• 2:12
  it's
• 2:12
  happening
• 2:13
  with
• 2:13
  her
• 2:13
  depression,
• 2:13
  I
• 2:14
  guess
• 2:14
  is,
• 2:14
  is
• 2:14
  the
• 2:14
  best
• 2:14
  way
• 2:15
  to
• 2:15
  put
• 2:15
  it,
• 2:15
  right.
• 2:16
  It's
• 2:16
  happening
• 2:16
  with
• 2:16
  her
• 2:16
  depression
• 2:17
  exclusively
• 2:18
  and
• 2:19
  not
• 2:19
  separate.
• 2:20
  So
• 2:20
  you're
• 2:20
  scratching
• 2:21
  your
• 2:21
  head
• 2:21
  and
• 2:21
  going,
• 2:22
  wait
• 2:22
  a
• 2:22
  minute,
• 2:22
  is
• 2:22
  this
• 2:22
  bipolar?
• 2:23
  Is
• 2:23
  this
• 2:23
  major
• 2:23
  depression?
• 2:24
  What
• 2:24
  is
• 2:24
  it?
• 2:25
  And
• 2:25
  it's
• 2:25
  okay
• 2:26
  if
• 2:26
  you
• 2:26
  Get
• 2:26
  a
• 2:26
  little
• 2:26
  confused.
• 2:27
  At
• 2:28
  least
• 2:28
  for
• 2:28
  me,
• 2:29
  it
• 2:30
  adds
• 2:30
  to
• 2:30
  my
• 2:30
  radar.
• 2:31
  It
• 2:31
  helps
• 2:32
  me
• 2:32
  scratch
• 2:32
  my
• 2:32
  head
• 2:33
  and
• 2:33
  say,
• 2:33
  wait
• 2:33
  a
• 2:33
  minute,
• 2:34
  maybe
• 2:34
  this
• 2:34
  is
• 2:34
  something
• 2:34
  I
• 2:35
  don't
• 2:35
  see
• 2:35
  every
• 2:35
  day.
• 2:36
  I
• 2:36
  need
• 2:36
  to
• 2:36
  zoom
• 2:36
  out
• 2:37
  and
• 2:37
  think
• 2:37
  more
• 2:37
  critically
• 2:38
  if
• 2:38
  something
• 2:38
  is
• 2:38
  a
• 2:38
  little
• 2:38
  unusual.
• 2:39
  If
• 2:39
  I'm
• 2:39
  expecting
• 2:40
  major
• 2:40
  depressive
• 2:41
  disorder,
• 2:42
  unipolar
• 2:42
  depression,
• 2:43
  without
• 2:44
  any
• 2:45
  hypomania
• 2:45
  mixed
• 2:46
  in,
• 2:46
  then
• 2:47
  the
• 2:47
  fact
• 2:47
  that
• 2:47
  I'm
• 2:48
  getting
• 2:48
  these
• 2:48
  other
• 2:48
  symptoms
• 2:49
  deserves
• 2:49
  more
• 2:50
  scrutiny.
• 2:50
  And
• 2:51
  yet
• 2:51
  it's
• 2:51
  even
• 2:51
  more
• 2:52
  bizarre
• 2:52
  with
• 2:53
  this
• 2:53
  mock
• 2:53
  patient,
• 2:53
  Janelle.
• 2:55
  We're
• 2:55
  not
• 2:55
  getting
• 2:56
  full
• 2:56
  blown
• 2:57
  bipolar
• 2:57
  one.
• 2:57
  That's
• 2:58
  landing
• 2:58
  her
• 2:58
  in
• 2:58
  the
• 2:58
  hospital.
• 2:59
  This
• 2:59
  isn't
• 2:59
  so
• 3:00
  obvious
• 3:00
  that
• 3:01
  you
• 3:01
  would
• 3:01
  diagnose
• 3:02
  her
• 3:02
  with
• 3:02
  bipolar
• 3:03
  I
• 3:03
  or
• 3:03
  bipolar
• 3:04
  2.
• 3:04
  Rather
• 3:05
  than
• 3:05
  be
• 3:05
  discouraged
• 3:06
  or
• 3:06
  confused,
• 3:06
  I
• 3:07
  want
• 3:07
  you
• 3:07
  to
• 3:07
  use
• 3:07
  that
• 3:08
  uneasy
• 3:08
  feeling
• 3:09
  and
• 3:10
  get
• 3:10
  excited
• 3:10
  about
• 3:10
  it,
• 3:10
  get
• 3:11
  intrigued
• 3:11
  by
• 3:11
  it
• 3:11
  and
• 3:11
  say,
• 3:12
  wait
• 3:12
  a
• 3:12
  minute,
• 3:12
  this
• 3:12
  deserves
• 3:13
  some
• 3:13
  more
• 3:13
  curiosity
• 3:14
  and
• 3:14
  some
• 3:14
  more
• 3:14
  scrutiny
• 3:15
  here.
• 3:15
  I'm
• 3:16
  definitely
• 3:16
  seeing
• 3:17
  some
• 3:17
  bipolarity
• 3:18
  here.
• 3:19
  But
• 3:19
  you
• 3:19
  know,
• 3:19
  when
• 3:20
  you
• 3:20
  prompt
• 3:20
  her
• 3:20
  a
• 3:20
  little
• 3:21
  more,
• 3:21
  you're
• 3:21
  not
• 3:21
  getting
• 3:22
  the
• 3:22
  full
• 3:22
  blown
• 3:23
  criteria
• 3:24
  that
• 3:24
  you
• 3:25
  might
• 3:25
  expect.
• 3:26
  Maybe
• 3:26
  this
• 3:27
  isn't
• 3:27
  a
• 3:27
  four
• 3:27
  day
• 3:27
  duration
• 3:28
  of
• 3:28
  hypomanic
• 3:29
  symptoms.
• 3:30
  Maybe
• 3:31
  you're
• 3:31
  not
• 3:31
  getting
• 3:32
  enough
• 3:32
  of
• 3:32
  the
• 3:33
  symptoms
• 3:33
  on
• 3:34
  top
• 3:34
  of
• 3:34
  the
• 3:34
  duration
• 3:35
  and,
• 3:35
  and
• 3:35
  you're
• 3:35
  getting
• 3:35
  frustrated
• 3:36
  going,
• 3:36
  what
• 3:36
  do
• 3:37
  I
• 3:37
  do
• 3:37
  with
• 3:37
  this?
• 3:37
  Well,
• 3:38
  have
• 3:39
  no
• 3:39
  fear,
• 3:39
  the
• 3:40
  DSM
• 3:40
  5
• 3:41
  in
• 3:41
  2013,
• 3:41
  when
• 3:42
  it
• 3:42
  rolled
• 3:42
  out,
• 3:43
  gave
• 3:43
  a
• 3:44
  home.
• 3:44
  It
• 3:45
  has
• 3:45
  a
• 3:45
  home
• 3:46
  for
• 3:46
  this
• 3:46
  particular
• 3:47
  case
• 3:47
  and
• 3:48
  it's
• 3:48
  called
• 3:48
  major
• 3:49
  depressive
• 3:49
  disorder
• 3:49
  with
• 3:50
  mixed
• 3:50
  features.
• 3:51
  Now,
• 3:51
  in
• 3:52
  the
• 3:52
  old
• 3:52
  dsm,
• 3:52
  they
• 3:53
  didn't
• 3:53
  have
• 3:53
  any
• 3:54
  real
• 3:54
  estate
• 3:54
  for
• 3:55
  this
• 3:55
  kind
• 3:55
  of
• 3:55
  problem.
• 3:55
  It
• 3:56
  was
• 3:56
  more
• 3:56
  of
• 3:56
  a
• 3:56
  dichotomy
• 3:57
  between
• 3:57
  full
• 3:58
  blown
• 3:58
  depression
• 3:59
  and
• 3:59
  full
• 4:00
  blown
• 4:01
  hypomania
• 4:01
  or
• 4:02
  bipolar
• 4:02
  too.
• 4:03
  Right.
• 4:03
  But
• 4:03
  now
• 4:04
  we
• 4:04
  have
• 4:04
  this
• 4:05
  beautiful
• 4:05
  distinction
• 4:06
  that
• 4:06
  you
• 4:06
  can
• 4:06
  carve
• 4:07
  out
• 4:07
  where
• 4:08
  it's
• 4:08
  much
• 4:08
  more
• 4:09
  on
• 4:09
  a
• 4:09
  spectrum
• 4:10
  where
• 4:10
  you
• 4:10
  can
• 4:10
  actually
• 4:11
  mark
• 4:11
  major
• 4:11
  depressive
• 4:12
  disorder
• 4:13
  with
• 4:13
  mixed
• 4:14
  features,
• 4:14
  where
• 4:14
  you
• 4:15
  have
• 4:15
  at
• 4:15
  least
• 4:15
  three
• 4:15
  manic
• 4:16
  or
• 4:16
  hypomanic
• 4:17
  symptoms
• 4:17
  that
• 4:17
  don't
• 4:17
  meet
• 4:18
  full
• 4:18
  criteria
• 4:18
  for
• 4:19
  a
• 4:19
  manic
• 4:19
  or
• 4:19
  hypomanic
• 4:20
  episode.
• 4:20
  Sort
• 4:21
  of
• 4:21
  like
• 4:21
  a
• 4:21
  sprinkle
• 4:22
  of
• 4:22
  mania
• 4:23
  in
• 4:23
  a
• 4:23
  bowl
• 4:23
  of
• 4:24
  depression.
• 4:24
  And
• 4:24
  the
• 4:25
  DSM
• 4:25
  4,
• 4:26
  the
• 4:26
  person
• 4:26
  simultaneously
• 4:28
  met
• 4:28
  full
• 4:28
  criteria
• 4:29
  for
• 4:29
  both
• 4:29
  a
• 4:29
  manic
• 4:30
  and
• 4:30
  major
• 4:30
  depressive
• 4:31
  episode
• 4:31
  for
• 4:32
  at
• 4:32
  least
• 4:32
  one
• 4:33
  week.
• 4:33
  It
• 4:33
  was
• 4:33
  a
• 4:33
  mixed
• 4:34
  episode.
• 4:35
  So
• 4:35
  you
• 4:35
  had
• 4:35
  to
• 4:35
  have
• 4:35
  both
• 4:36
  boxes
• 4:37
  checked
• 4:37
  completely
• 4:38
  and
• 4:38
  not
• 4:39
  just
• 4:39
  a
• 4:39
  few
• 4:39
  symptoms
• 4:40
  from
• 4:40
  the
• 4:40
  opposite
• 4:40
  pole.
• 4:41
  This
• 4:42
  was
• 4:42
  kind
• 4:42
  of
• 4:42
  a
• 4:43
  revolutionary
• 4:43
  change
• 4:44
  because
• 4:44
  it
• 4:44
  gave
• 4:44
  clinicians
• 4:45
  a
• 4:45
  vocabulary
• 4:46
  for
• 4:46
  subthreshold
• 4:47
  bipolarity
• 4:48
  within
• 4:48
  depression.
• 4:50
  And
• 4:50
  that's
• 4:50
  super
• 4:51
  useful
• 4:51
  because
• 4:52
  these
• 4:53
  mixed
• 4:53
  features
• 4:54
  are
• 4:55
  signifiers
• 4:56
  that
• 4:56
  a
• 4:56
  lot
• 4:56
  more
• 4:56
  can
• 4:57
  go
• 4:57
  wrong.
• 4:57
  Right.
• 4:58
  We
• 4:58
  know
• 4:58
  that
• 4:58
  folks
• 4:59
  with
• 4:59
  mixed
• 4:59
  features
• 4:59
  are
• 5:00
  much
• 5:00
  more
• 5:00
  likely
• 5:01
  to
• 5:01
  have
• 5:01
  suicidal
• 5:02
  ideation.
• 5:03
  Studies
• 5:04
  have
• 5:04
  shown
• 5:04
  they're
• 5:04
  more
• 5:04
  likely
• 5:05
  to
• 5:05
  be
• 5:05
  hospitalized,
• 5:07
  that
• 5:07
  the
• 5:07
  treatment
• 5:08
  course
• 5:08
  is
• 5:08
  a
• 5:08
  lot
• 5:08
  more
• 5:09
  complicated.
• 5:10
  Right?
• 5:10
  They're
• 5:10
  elevated
• 5:11
  suicidal
• 5:11
  risk,
• 5:12
  more
• 5:13
  so
• 5:13
  than
• 5:13
  pure
• 5:13
  bipolar
• 5:14
  or
• 5:14
  even
• 5:14
  unipolar
• 5:15
  depression.
• 5:15
  That's
• 5:15
  what
• 5:15
  some
• 5:16
  studies
• 5:16
  have
• 5:17
  suggested.
• 5:18
  We've
• 5:18
  also
• 5:18
  learned,
• 5:19
  of
• 5:19
  course,
• 5:19
  that
• 5:19
  monotherapy
• 5:20
  with
• 5:20
  SSRIs
• 5:21
  or
• 5:21
  SNRIs
• 5:23
  can
• 5:23
  exacerbate
• 5:24
  these
• 5:24
  mixed
• 5:25
  features.
• 5:25
  These
• 5:25
  are
• 5:26
  so
• 5:26
  important
• 5:26
  because
• 5:26
  imagine
• 5:27
  you
• 5:27
  see
• 5:27
  this
• 5:27
  patient
• 5:28
  and
• 5:29
  you
• 5:29
  only
• 5:29
  had
• 5:30
  an
• 5:30
  option
• 5:30
  to
• 5:30
  say
• 5:31
  they
• 5:31
  were
• 5:32
  depressed
• 5:32
  or
• 5:33
  bipolar
• 5:33
  and
• 5:34
  they
• 5:34
  didn't
• 5:34
  give
• 5:34
  you
• 5:34
  the
• 5:35
  luxury
• 5:35
  of
• 5:36
  writing
• 5:36
  that
• 5:37
  asterisk
• 5:37
  by
• 5:38
  the
• 5:38
  diagnosis
• 5:39
  for
• 5:39
  the
• 5:39
  next
• 5:39
  clinician
• 5:40
  to
• 5:40
  say,
• 5:40
  hey,
• 5:40
  by
• 5:40
  the
• 5:41
  way,
• 5:41
  I'm
• 5:41
  recognizing
• 5:42
  some
• 5:42
  bipolarity
• 5:43
  here
• 5:43
  that
• 5:43
  you
• 5:43
  need
• 5:43
  to
• 5:44
  definitely
• 5:45
  be
• 5:45
  aware
• 5:45
  of.
• 5:45
  Think
• 5:46
  about
• 5:46
  how
• 5:46
  great
• 5:46
  that
• 5:47
  is
• 5:47
  in
• 5:47
  psychiatry,
• 5:48
  where
• 5:49
  you
• 5:49
  can
• 5:49
  put
• 5:49
  up
• 5:49
  a
• 5:50
  warning
• 5:50
  sign
• 5:51
  in
• 5:51
  this
• 5:51
  person's
• 5:52
  plan
• 5:52
  of
• 5:52
  care
• 5:52
  for
• 5:53
  the
• 5:53
  future,
• 5:53
  where
• 5:53
  that
• 5:54
  other
• 5:54
  clinician
• 5:54
  can
• 5:54
  go,
• 5:55
  you
• 5:55
  know
• 5:55
  what?
• 5:55
  I'm
• 5:55
  going
• 5:55
  to
• 5:55
  be
• 5:56
  mindful
• 5:56
  of
• 5:56
  this
• 5:56
  because
• 5:57
  maybe
• 5:57
  putting
• 5:58
  an
• 5:58
  antidepressant
• 5:58
  on
• 5:59
  here
• 5:59
  alone
• 5:59
  can
• 6:00
  exacerbate
• 6:01
  the
• 6:01
  patient's
• 6:02
  agitation,
• 6:02
  irritability,
• 6:03
  insomnia,
• 6:04
  maybe
• 6:04
  induce
• 6:04
  a
• 6:05
  full
• 6:05
  blown
• 6:05
  manic
• 6:05
  episode.
• 6:06
  We
• 6:06
  don't
• 6:07
  want
• 6:07
  that.
• 6:07
  This
• 6:08
  innovation
• 6:09
  in
• 6:09
  the
• 6:10
  DSM
• 6:10
  5,
• 6:11
  again,
• 6:11
  I
• 6:12
  think
• 6:12
  is
• 6:12
  revolutionary
• 6:13
  in
• 6:13
  looking
• 6:13
  at
• 6:14
  this
• 6:14
  more
• 6:14
  as
• 6:14
  a
• 6:14
  spectrum
• 6:15
  and
• 6:15
  recognizing
• 6:15
  that
• 6:16
  major
• 6:16
  depression
• 6:17
  can
• 6:17
  have
• 6:17
  mixed
• 6:18
  features
• 6:18
  and
• 6:18
  that
• 6:19
  there's
• 6:19
  something
• 6:19
  we
• 6:19
  can
• 6:20
  do
• 6:20
  about
• 6:20
  it
• 6:20
  as
• 6:21
  well.
• 6:21
  So
• 6:22
  it's
• 6:22
  very
• 6:22
  important
• 6:23
  that
• 6:23
  we
• 6:24
  are
• 6:24
  able
• 6:24
  to
• 6:24
  characterize
• 6:25
  this
• 6:25
  stuff.
• 6:26
  Now
• 6:26
  on
• 6:27
  the
• 6:27
  flip
• 6:27
  side,
• 6:28
  this
• 6:28
  stuff
• 6:28
  can
• 6:28
  get
• 6:28
  so
• 6:29
  complicated,
• 6:30
  right?
• 6:31
  This
• 6:31
  is
• 6:31
  just
• 6:31
  ripe
• 6:32
  for
• 6:32
  misdiagnoses
• 6:33
  when
• 6:34
  we
• 6:34
  have
• 6:35
  someone
• 6:35
  who
• 6:35
  presents
• 6:36
  this
• 6:36
  way
• 6:36
  as
• 6:36
  our
• 6:36
  mock
• 6:37
  patient,
• 6:37
  Janelle,
• 6:38
  right?
• 6:38
  Racing
• 6:38
  thoughts,
• 6:39
  maybe
• 6:40
  she's
• 6:40
  also
• 6:40
  distractible,
• 6:41
  irritable
• 6:42
  and
• 6:42
  agitated.
• 6:43
  We
• 6:43
  can
• 6:43
  see
• 6:44
  that
• 6:44
  in
• 6:44
  so
• 6:44
  many
• 6:44
  other
• 6:45
  mental
• 6:45
  illnesses,
• 6:45
  right?
• 6:46
  Ptsd,
• 6:46
  we
• 6:46
  can
• 6:47
  see
• 6:47
  agitation,
• 6:47
  anger,
• 6:48
  anxiety
• 6:48
  and
• 6:49
  attention
• 6:49
  problems.
• 6:50
  We
• 6:50
  can
• 6:51
  see
• 6:51
  inability
• 6:51
  to
• 6:51
  experience
• 6:52
  positive
• 6:52
  emotions
• 6:53
  in
• 6:53
  ptsd.
• 6:53
  Here
• 6:54
  we
• 6:54
  are
• 6:54
  thinking
• 6:55
  this
• 6:55
  is
• 6:55
  depression
• 6:56
  solely
• 6:56
  and
• 6:57
  exclusively.
• 6:57
  But
• 6:58
  the
• 6:58
  inability
• 6:58
  to
• 6:58
  experience
• 6:59
  those
• 6:59
  positive
• 7:00
  emotions
• 7:00
  like
• 7:00
  happiness
• 7:01
  or
• 7:01
  engagement
• 7:02
  in
• 7:02
  social
• 7:02
  activities
• 7:03
  could
• 7:04
  very
• 7:04
  well
• 7:04
  be
• 7:04
  part
• 7:04
  of
• 7:05
  a
• 7:05
  PTSD
• 7:06
  construct.
• 7:07
  And
• 7:07
  again,
• 7:08
  we
• 7:08
  talked
• 7:08
  about
• 7:08
  borderline,
• 7:09
  right?
• 7:09
  Borderline
• 7:10
  has
• 7:10
  these
• 7:11
  mood
• 7:11
  fluctuations
• 7:12
  as
• 7:12
  well.
• 7:12
  Impulsivity
• 7:14
  and
• 7:14
  ADHD
• 7:15
  has
• 7:15
  the
• 7:15
  impulsivity.
• 7:16
  It
• 7:16
  has
• 7:17
  attentional
• 7:17
  problems.
• 7:18
  That
• 7:18
  can
• 7:18
  look
• 7:19
  like
• 7:19
  bipolarity
• 7:20
  too.
• 7:21
  It
• 7:21
  can
• 7:21
  look
• 7:22
  like
• 7:22
  a
• 7:22
  mixed
• 7:22
  state.
• 7:23
  On
• 7:23
  top
• 7:23
  of
• 7:23
  that,
• 7:24
  you're
• 7:24
  more
• 7:24
  likely
• 7:25
  to
• 7:25
  have
• 7:25
  these
• 7:25
  comorbidities
• 7:27
  when
• 7:27
  you
• 7:27
  have
• 7:28
  bipolar
• 7:28
  disorders
• 7:29
  or
• 7:29
  you're
• 7:29
  on
• 7:29
  a
• 7:29
  bipolar
• 7:30
  spectrum,
• 7:30
  right?
• 7:31
  Statistically
• 7:31
  more
• 7:31
  likely
• 7:32
  to
• 7:32
  have
• 7:33
  multiple
• 7:34
  diagnoses.
• 7:35
  And
• 7:36
  so
• 7:36
  it
• 7:36
  gets
• 7:36
  really
• 7:37
  complicated
• 7:38
  being
• 7:38
  careful
• 7:39
  about
• 7:39
  how
• 7:39
  we
• 7:40
  make
• 7:40
  these
• 7:40
  distinctions
• 7:41
  can
• 7:41
  mean
• 7:41
  all
• 7:41
  the
• 7:42
  difference
• 7:42
  with
• 7:42
  the
• 7:42
  patient
• 7:43
  and
• 7:43
  categorizing
• 7:44
  it
• 7:44
  well.
• 8:39
  So
• 8:39
  getting
• 8:39
  back
• 8:40
  to
• 8:40
  the
• 8:40
  original
• 8:40
  diagnosis,
• 8:41
  again,
• 8:41
  we're
• 7:47
  talking
• 8:42
  about
• 8:42
  major
• 8:42
  depressive
• 8:43
  disorder
• 8:44
  that
• 8:44
  is
• 8:44
  co
• 8:44
  occurring
• 8:45
  on
• 8:45
  more
• 8:45
  days
• 8:46
  than
• 8:46
  not
• 8:46
  with
• 8:47
  these
• 8:47
  hypomanic
• 8:48
  or
• 8:48
  manic
• 8:49
  symptoms
• 8:49
  that
• 8:49
  don't
• 8:50
  quite
• 8:50
  meet
• 8:50
  threshold.
• 8:51
  And
• 8:51
  we're
• 8:51
  talking
• 8:51
  about
• 8:52
  three
• 8:52
  or
• 8:53
  more
• 8:53
  of
• 8:53
  the
• 8:54
  symptoms
• 8:55
  that
• 8:55
  are
• 8:56
  co
• 8:56
  occurring
• 8:56
  with
• 8:56
  the
• 8:57
  major
• 8:57
  depressive
• 8:57
  episode.
• 8:58
  And
• 8:58
  remember
• 8:58
  that
• 8:58
  major
• 8:59
  depressive
• 8:59
  disorder
• 9:00
  must
• 9:00
  meet
• 9:01
  criteria
• 9:01
  as
• 9:01
  well.
• 9:02
  You
• 9:02
  can't
• 9:02
  fail
• 9:03
  to
• 9:03
  meet
• 9:03
  major
• 9:03
  depressive
• 9:04
  criteria
• 9:05
  and
• 9:06
  manic
• 9:06
  or
• 9:07
  hypomanic
• 9:07
  criteria
• 9:08
  because
• 9:08
  then
• 9:08
  you
• 9:08
  have
• 9:08
  more
• 9:08
  of
• 9:08
  a
• 9:08
  cyclothymia.
• 9:10
  Right?
• 9:10
  Cyclothymia
• 9:11
  is
• 9:11
  when
• 9:11
  you
• 9:11
  don't
• 9:12
  really
• 9:12
  meet
• 9:12
  a
• 9:12
  full
• 9:13
  blown
• 9:13
  major
• 9:13
  depressive
• 9:14
  disorder
• 9:15
  or
• 9:15
  hypomania.
• 9:16
  You
• 9:17
  have
• 9:17
  symptoms
• 9:17
  of
• 9:17
  both,
• 9:17
  but
• 9:18
  you're
• 9:18
  not
• 9:18
  really
• 9:18
  hitting
• 9:19
  full
• 9:19
  threshold
• 9:20
  for
• 9:20
  either
• 9:20
  of
• 9:20
  them.
• 9:21
  But
• 9:21
  again,
• 9:22
  for
• 9:22
  MDD
• 9:22
  with
• 9:23
  mixed
• 9:23
  features,
• 9:23
  you
• 9:23
  have
• 9:24
  to
• 9:24
  hit
• 9:24
  that
• 9:24
  full
• 9:25
  MDD
• 9:25
  criteria.
• 9:26
  Right?
• 9:27
  Five
• 9:27
  or
• 9:27
  greater
• 9:28
  symptoms
• 9:29
  in
• 9:29
  a
• 9:29
  two
• 9:29
  week
• 9:29
  time
• 9:30
  span
• 9:31
  occurring
• 9:31
  together,
• 9:31
  that's
• 9:32
  major
• 9:32
  depression.
• 9:33
  With
• 9:33
  the
• 9:33
  mixed
• 9:34
  features,
• 9:34
  you
• 9:34
  have
• 9:35
  to
• 9:35
  add
• 9:36
  three
• 9:36
  or
• 9:36
  greater
• 9:36
  manic
• 9:37
  or
• 9:37
  hypomanic
• 9:38
  symptoms
• 9:38
  during
• 9:39
  that
• 9:39
  depressive
• 9:39
  episode,
• 9:40
  which
• 9:40
  include
• 9:41
  elevated
• 9:42
  or
• 9:42
  expansive
• 9:42
  mood,
• 9:43
  inflated
• 9:43
  self
• 9:44
  esteem,
• 9:44
  grandiosity,
• 9:45
  more
• 9:45
  talkative
• 9:46
  or
• 9:46
  pressure
• 9:47
  speech,
• 9:47
  flight
• 9:48
  of
• 9:48
  ideas
• 9:48
  or
• 9:48
  racing
• 9:49
  thoughts,
• 9:49
  increased
• 9:50
  energy
• 9:50
  or
• 9:50
  goal
• 9:50
  directed
• 9:51
  activities,
• 9:52
  risky
• 9:52
  behaviors,
• 9:53
  decreased
• 9:53
  need
• 9:53
  for
• 9:53
  sleep.
• 9:54
  We're
• 9:54
  not
• 9:54
  talking
• 9:55
  about
• 9:55
  just
• 9:55
  insomnia
• 9:56
  like
• 9:56
  you
• 9:57
  might
• 9:57
  see
• 9:58
  in
• 9:58
  depression.
• 9:59
  We're
• 10:00
  talking
• 10:00
  about
• 10:00
  somebody
• 10:01
  who
• 10:01
  doesn't
• 10:01
  feel
• 10:01
  like
• 10:01
  they
• 10:02
  need
• 10:02
  that
• 10:02
  much
• 10:03
  sleep
• 10:03
  at
• 10:03
  all.
• 10:04
  They're
• 10:04
  wired,
• 10:04
  energized
• 10:05
  and
• 10:06
  not
• 10:06
  sleeping
• 10:06
  much
• 10:07
  and
• 10:07
  don't
• 10:07
  feel
• 10:07
  like
• 10:07
  they
• 10:08
  need
• 10:08
  to
• 10:09
  sleep.
• 10:09
  These
• 10:09
  symptoms
• 10:10
  must
• 10:10
  be
• 10:10
  observable
• 10:11
  by
• 10:11
  others.
• 10:12
  That's
• 10:12
  another
• 10:12
  key
• 10:13
  with
• 10:13
  MDD
• 10:13
  with
• 10:14
  mixed
• 10:14
  features.
• 10:15
  And
• 10:15
  so
• 10:15
  you
• 10:15
  put
• 10:16
  this
• 10:16
  all
• 10:16
  together
• 10:17
  and
• 10:17
  it's
• 10:17
  actually
• 10:18
  quite
• 10:18
  simple.
• 10:18
  It's
• 10:19
  basically
• 10:19
  someone
• 10:20
  with
• 10:20
  depression
• 10:20
  in
• 10:20
  front
• 10:21
  of
• 10:21
  you
• 10:21
  who
• 10:21
  has
• 10:22
  bipolar
• 10:22
  features,
• 10:23
  but
• 10:23
  they
• 10:23
  don't
• 10:23
  meet
• 10:23
  full
• 10:24
  criteria
• 10:24
  for
• 10:24
  bipolarity,
• 10:25
  plain
• 10:26
  and
• 10:26
  simple.
• 10:26
  And
• 10:26
  you
• 10:27
  need
• 10:27
  three
• 10:27
  or
• 10:27
  more
• 10:28
  of
• 10:28
  these
• 10:29
  symptoms
• 10:30
  to
• 10:30
  diagnose
• 10:30
  it.
• 10:31
  No
• 10:31
  need
• 10:31
  to
• 10:32
  overthink
• 10:32
  that
• 10:32
  as
• 10:32
  long
• 10:33
  as
• 10:33
  you
• 10:33
  know
• 10:33
  the
• 10:33
  symptoms.
• 10:34
  To
• 10:34
  diagnose
• 10:34
  bipolarity
• 10:35
  and
• 10:36
  the
• 10:36
  symptoms
• 10:36
  of
• 10:36
  depression,
• 10:37
  you
• 10:37
  know
• 10:37
  how
• 10:38
  to
• 10:38
  combine
• 10:38
  these.
• 10:39
  And
• 10:39
  you
• 10:39
  know
• 10:39
  why
• 10:40
  we're
• 10:40
  doing
• 10:40
  it,
• 10:40
  right?
• 10:41
  Because
• 10:41
  this
• 10:41
  is
• 10:41
  more
• 10:42
  a
• 10:42
  dimensional
• 10:44
  approach,
• 10:44
  more
• 10:44
  of
• 10:45
  a
• 10:45
  spectrum.
• 10:46
  That's
• 10:46
  why
• 10:46
  we're,
• 10:47
  we're,
• 10:47
  you
• 10:47
  know,
• 10:48
  the
• 10:48
  DSM
• 10:48
  5
• 10:49
  in
• 10:49
  2013
• 10:50
  kind
• 10:50
  of
• 10:50
  changed
• 10:51
  the
• 10:51
  game
• 10:51
  there.
• 10:51
  And
• 10:52
  they
• 10:52
  want
• 10:52
  you
• 10:52
  to
• 10:52
  highlight
• 10:53
  that
• 10:53
  some
• 10:53
  patients
• 10:54
  are
• 10:54
  prone
• 10:55
  to
• 10:56
  potentially
• 10:56
  experiencing
• 10:57
  bipolarity.
• 10:58
  And
• 10:58
  there's
• 10:58
  other
• 10:59
  soft
• 10:59
  signs
• 11:00
  that
• 11:00
  someone
• 11:01
  may
• 11:02
  be
• 11:03
  more
• 11:04
  on
• 11:04
  that
• 11:04
  bipolar
• 11:04
  spectrum.
• 11:05
  Right.
• 11:05
  If
• 11:05
  they
• 11:05
  have
• 11:06
  earlier
• 11:06
  onset
• 11:07
  depression
• 11:07
  if
• 11:07
  they
• 11:07
  have
• 11:07
  a
• 11:08
  family
• 11:08
  history.
• 11:08
  Family
• 11:09
  history
• 11:10
  of
• 11:10
  bipolarity
• 11:11
  is
• 11:11
  such
• 11:11
  a
• 11:11
  good
• 11:12
  clue
• 11:13
  that
• 11:13
  something
• 11:13
  more
• 11:14
  could
• 11:14
  be
• 11:14
  at
• 11:14
  play
• 11:15
  here.
• 11:15
  Right.
• 11:15
  So
• 11:16
  you're
• 11:16
  not
• 11:16
  just
• 11:17
  looking
• 11:17
  at
• 11:17
  the
• 11:17
  DSM5
• 11:18
  all
• 11:18
  the
• 11:19
  time
• 11:19
  to
• 11:20
  make
• 11:20
  diagnoses
• 11:22
  and
• 11:22
  living
• 11:23
  off
• 11:23
  the
• 11:23
  DSM
• 11:23
  5TR.
• 11:24
  Of
• 11:24
  course
• 11:24
  that's
• 11:25
  important,
• 11:25
  of
• 11:25
  course
• 11:25
  we
• 11:26
  need
• 11:26
  that.
• 11:26
  But
• 11:26
  you
• 11:27
  want
• 11:27
  to
• 11:27
  put
• 11:27
  all
• 11:27
  of
• 11:27
  this
• 11:28
  stuff
• 11:28
  together
• 11:28
  too.
• 11:28
  And
• 11:29
  with
• 11:29
  bipolarity,
• 11:30
  that
• 11:30
  earlier
• 11:31
  onset
• 11:31
  of
• 11:31
  depression
• 11:32
  is
• 11:32
  so
• 11:33
  important.
• 11:33
  Family
• 11:34
  history
• 11:34
  of
• 11:35
  depression,
• 11:35
  multiple
• 11:36
  episodes.
• 11:36
  If
• 11:36
  you
• 11:36
  have
• 11:37
  a
• 11:37
  patient
• 11:37
  who
• 11:38
  has
• 11:38
  been
• 11:38
  hard
• 11:38
  to
• 11:38
  treat
• 11:39
  or,
• 11:39
  or
• 11:39
  they've
• 11:39
  had
• 11:40
  antidepressants
• 11:41
  in
• 11:41
  the
• 11:41
  past
• 11:42
  and
• 11:43
  they
• 11:43
  haven't
• 11:43
  been
• 11:44
  treated
• 11:44
  easily
• 11:45
  with
• 11:45
  antidepressants,
• 11:46
  they
• 11:46
  get
• 11:46
  really
• 11:46
  agitated,
• 11:47
  more
• 11:47
  suicidal,
• 11:48
  more
• 11:49
  impulsive,
• 11:49
  more
• 11:50
  dysphoric.
• 11:50
  That
• 11:51
  agitation,
• 11:52
  that
• 11:52
  anxiety,
• 11:53
  those
• 11:53
  are
• 11:54
  soft
• 11:54
  signs
• 11:55
  that
• 11:55
  we
• 11:56
  are
• 11:56
  looking
• 11:56
  at
• 11:56
  someone
• 11:57
  who's
• 11:57
  much
• 11:57
  more
• 11:58
  inclined
• 11:59
  to
• 11:59
  experience
• 12:00
  bipolarity.
• 12:01
  And
• 12:01
  so
• 12:01
  I
• 12:02
  love
• 12:02
  this
• 12:03
  diagnostic
• 12:04
  feature
• 12:04
  here
• 12:05
  that
• 12:05
  gives
• 12:06
  us
• 12:06
  the
• 12:06
  ability
• 12:06
  to
• 12:07
  flag
• 12:07
  these
• 12:07
  patients
• 12:08
  because
• 12:09
  it's
• 12:10
  just
• 12:10
  so
• 12:10
  important
• 12:11
  to
• 12:11
  catch
• 12:11
  these
• 12:11
  guys
• 12:12
  while
• 12:12
  we
• 12:13
  can
• 12:14
  right
• 12:14
  in
• 12:14
  their
• 12:14
  tracks
• 12:15
  and
• 12:16
  flag
• 12:16
  them
• 12:17
  for
• 12:17
  their
• 12:17
  own
• 12:17
  safety,
• 12:18
  actually.
• 12:19
  Right.
• 12:19
  I
• 12:19
  think
• 12:19
  that's
• 12:20
  the
• 12:20
  most
• 12:20
  important.
• 12:21
  There's
• 12:22
  some
• 12:22
  evidence
• 12:22
  that
• 12:23
  20
• 12:23
  to
• 12:23
  30%
• 12:23
  of
• 12:24
  patients
• 12:24
  with
• 12:24
  MDD
• 12:25
  might
• 12:25
  fall
• 12:26
  on
• 12:26
  the
• 12:26
  bipolarity
• 12:27
  spectrum.
• 12:28
  We've
• 12:28
  seen
• 12:28
  that
• 12:28
  in
• 12:28
  NP
• 12:29
  school.
• 12:29
  That's
• 12:29
  a
• 12:29
  lot
• 12:29
  of
• 12:30
  people
• 12:30
  that
• 12:30
  might
• 12:31
  fall
• 12:31
  on
• 12:31
  this
• 12:31
  spectrum.
• 12:32
  What
• 12:32
  makes
• 12:32
  it
• 12:32
  so
• 12:33
  complicated
• 12:33
  is
• 12:33
  that
• 12:34
  the
• 12:34
  vast
• 12:34
  majority
• 12:35
  of
• 12:35
  the
• 12:35
  time
• 12:35
  they
• 12:36
  come
• 12:36
  to
• 12:36
  us,
• 12:36
  they're
• 12:36
  depressed.
• 12:37
  We
• 12:37
  immediately
• 12:38
  assume
• 12:39
  that
• 12:39
  we're
• 12:39
  looking
• 12:39
  at
• 12:39
  depression
• 12:40
  and
• 12:40
  not
• 12:41
  necessarily
• 12:41
  bipolarity.
• 12:42
  Remember,
• 12:43
  a
• 12:43
  lot
• 12:43
  of
• 12:43
  people
• 12:43
  who
• 12:44
  are
• 12:44
  euphoric
• 12:44
  don't
• 12:45
  even
• 12:45
  come
• 12:45
  and
• 12:46
  tell
• 12:46
  you,
• 12:46
  I'm
• 12:46
  in
• 12:46
  your
• 12:46
  office
• 12:47
  today
• 12:47
  because
• 12:47
  I'm
• 12:47
  euphoric
• 12:48
  and
• 12:48
  I'm
• 12:48
  feeling
• 12:48
  great.
• 12:49
  They
• 12:49
  just
• 12:49
  feel
• 12:50
  great.
• 12:50
  Maybe
• 12:50
  they
• 12:50
  don't
• 12:50
  have
• 12:51
  insight
• 12:51
  into
• 12:51
  the
• 12:51
  fact
• 12:52
  that
• 12:52
  they're
• 12:52
  experiencing
• 12:53
  more
• 12:53
  of
• 12:53
  a
• 12:53
  mixed
• 12:54
  episode
• 12:54
  or
• 12:55
  MDT
• 12:56
  with
• 12:56
  mixed
• 12:56
  features.
• 12:57
  And,
• 12:57
  and
• 12:57
  so
• 12:58
  that
• 12:58
  euphoria
• 12:58
  is
• 12:58
  not
• 12:59
  going
• 12:59
  to
• 12:59
  be
• 12:59
  handed
• 12:59
  to
• 12:59
  you
• 13:00
  for
• 13:00
  free.
• 13:00
  When
• 13:01
  they're
• 13:01
  irritable,
• 13:01
  you
• 13:02
  might
• 13:02
  be
• 13:02
  looking
• 13:02
  at
• 13:02
  them
• 13:02
  saying,
• 13:03
  well,
• 13:03
  irritability,
• 13:04
  okay,
• 13:04
  you
• 13:05
  know,
• 13:05
  that's
• 13:05
  so
• 13:05
  common
• 13:06
  in
• 13:06
  anxiety.
• 13:06
  It's,
• 13:07
  it's
• 13:07
  one
• 13:07
  of
• 13:08
  the
• 13:08
  diagnostic
• 13:09
  features
• 13:09
  of
• 13:10
  generalized
• 13:10
  anxiety.
• 13:11
  And
• 13:11
  generalized
• 13:11
  anxiety
• 13:12
  is
• 13:12
  so
• 13:12
  common
• 13:13
  with
• 13:13
  major
• 13:13
  depression.
• 13:14
  Maybe
• 13:14
  I'm
• 13:15
  just
• 13:15
  looking
• 13:15
  at
• 13:15
  somebody
• 13:15
  who's
• 13:16
  irritable.
• 13:16
  Irritability
• 13:17
  is
• 13:17
  also
• 13:17
  a
• 13:18
  diagnostic
• 13:18
  feature
• 13:18
  of
• 13:18
  ptsd.
• 13:19
  You
• 13:20
  see
• 13:20
  it
• 13:20
  commonly
• 13:21
  in
• 13:21
  borderline,
• 13:21
  you
• 13:22
  see
• 13:22
  it
• 13:22
  commonly
• 13:22
  in
• 13:22
  ADHD
• 13:23
  irritability.
• 13:24
  And
• 13:24
  so
• 13:24
  irritability
• 13:25
  might
• 13:25
  not
• 13:25
  be
• 13:25
  the
• 13:26
  best
• 13:26
  tip
• 13:26
  off,
• 13:26
  even
• 13:27
  though
• 13:27
  it's
• 13:27
  in
• 13:27
  the
• 13:27
  DSM
• 13:28
  5TR
• 13:29
  because
• 13:29
  it's
• 13:30
  just
• 13:30
  not
• 13:30
  that
• 13:30
  specific.
• 13:32
  So
• 13:32
  I
• 13:32
  hope
• 13:32
  you're
• 13:33
  getting
• 13:33
  an
• 13:33
  appreciation
• 13:34
  for
• 13:34
  why
• 13:34
  this
• 13:35
  diagnosis
• 13:35
  is
• 13:35
  so
• 13:36
  important
• 13:36
  and
• 13:36
  why
• 13:36
  it
• 13:36
  can
• 13:36
  be
• 13:37
  so
• 13:37
  tricky
• 13:37
  and
• 13:37
  loaded.
• 13:38
  Right.
• 13:38
  Because
• 13:39
  the
• 13:39
  patients
• 13:40
  aren't
• 13:40
  going
• 13:40
  to
• 13:40
  come
• 13:40
  up
• 13:41
  to
• 13:41
  you
• 13:41
  and
• 13:41
  say,
• 13:41
  I
• 13:41
  have
• 13:41
  major
• 13:42
  depressive
• 13:42
  disorder
• 13:42
  with
• 13:43
  mixed
• 13:43
  features.
• 13:43
  I
• 13:43
  don't
• 13:44
  think
• 13:44
  I've
• 13:44
  ever
• 13:44
  heard
• 13:44
  that,
• 13:45
  actually.
• 13:45
  And
• 13:45
  yet
• 13:46
  there
• 13:46
  are
• 13:46
  so
• 13:46
  many
• 13:47
  patients
• 13:47
  out
• 13:47
  there
• 13:47
  who
• 13:47
  I
• 13:48
  think
• 13:48
  could
• 13:48
  easily
• 13:49
  meet
• 13:49
  this
• 13:49
  criteria
• 13:50
  where
• 13:51
  they
• 13:51
  don't
• 13:51
  fully
• 13:52
  meet
• 13:52
  hypomanic
• 13:53
  or
• 13:53
  bipolar
• 13:54
  spectrum
• 13:55
  symptoms.
• 13:56
  They
• 13:56
  don't
• 13:56
  fully
• 13:56
  meet
• 13:57
  bipolar
• 13:57
  I
• 13:58
  or
• 13:58
  bipolar
• 13:58
  2
• 13:58
  criteria.
• 14:00
  And
• 14:00
  yet
• 14:00
  it's
• 14:01
  so
• 14:01
  important
• 14:01
  we
• 14:02
  flag
• 14:02
  this
• 14:02
  because
• 14:02
  they're
• 14:03
  significantly
• 14:04
  elevated
• 14:04
  suicide
• 14:05
  risks.
• 14:05
  This
• 14:06
  is
• 14:06
  not
• 14:06
  fun.
• 14:06
  Right?
• 14:06
  It's
• 14:07
  not
• 14:07
  fun
• 14:07
  to
• 14:07
  live
• 14:07
  with
• 14:08
  irritability,
• 14:09
  agitation
• 14:10
  and
• 14:10
  impulsivity
• 14:11
  while
• 14:11
  you're
• 14:11
  depressed.
• 14:12
  It's
• 14:12
  a
• 14:13
  big
• 14:13
  problem.
• 14:13
  I
• 14:14
  love
• 14:14
  analogies.
• 14:14
  And
• 14:15
  I
• 14:15
  thought
• 14:15
  to
• 14:15
  myself,
• 14:16
  how
• 14:16
  can
• 14:16
  I
• 14:16
  boil
• 14:17
  this
• 14:17
  down
• 14:17
  to
• 14:17
  the
• 14:17
  best
• 14:18
  analogy?
• 14:18
  Before
• 14:19
  this,
• 14:19
  we
• 14:20
  only
• 14:20
  had
• 14:20
  road
• 14:20
  signs
• 14:21
  that
• 14:21
  told
• 14:21
  us
• 14:22
  it
• 14:22
  was
• 14:22
  either
• 14:22
  raining
• 14:23
  or
• 14:23
  snowing,
• 14:24
  which
• 14:24
  is
• 14:24
  kind
• 14:25
  of
• 14:25
  helpful.
• 14:25
  You
• 14:25
  need
• 14:25
  to
• 14:25
  know
• 14:26
  when
• 14:26
  it's
• 14:26
  raining.
• 14:26
  Rain
• 14:27
  would
• 14:27
  be
• 14:27
  like
• 14:27
  unipolar
• 14:28
  depression
• 14:29
  or
• 14:30
  it's
• 14:30
  snowing.
• 14:31
  We
• 14:31
  gotta
• 14:31
  be
• 14:31
  cautious
• 14:32
  because
• 14:32
  it's
• 14:32
  snowing
• 14:33
  and
• 14:34
  we
• 14:35
  gotta
• 14:35
  drive
• 14:35
  a
• 14:35
  certain
• 14:36
  way.
• 14:36
  So
• 14:36
  both
• 14:37
  of
• 14:37
  those
• 14:37
  are
• 14:37
  helpful.
• 14:37
  And
• 14:37
  this
• 14:38
  analogy
• 14:38
  snow
• 14:38
  would
• 14:39
  be
• 14:39
  bipolar
• 14:39
  one
• 14:39
  or
• 14:40
  bipolar
• 14:40
  too.
• 14:41
  But
• 14:41
  mixed
• 14:41
  features
• 14:42
  is
• 14:42
  almost
• 14:42
  like
• 14:42
  freezing
• 14:43
  rain
• 14:43
  or
• 14:43
  sleet.
• 14:44
  We
• 14:44
  don't
• 14:44
  want
• 14:44
  to
• 14:44
  ignore
• 14:45
  that.
• 14:45
  That's
• 14:45
  extremely
• 14:46
  vital
• 14:46
  information.
• 14:47
  We
• 14:47
  need
• 14:47
  a
• 14:47
  sign
• 14:48
  that
• 14:48
  tells
• 14:48
  us
• 14:49
  it's
• 14:49
  freezing
• 14:49
  rain
• 14:50
  because
• 14:50
  it
• 14:51
  can
• 14:51
  get
• 14:51
  icy.
• 14:51
  We
• 14:51
  can
• 14:52
  slip
• 14:52
  off
• 14:52
  the
• 14:52
  road.
• 14:53
  It
• 14:53
  might
• 14:53
  not
• 14:53
  be
• 14:54
  this
• 14:54
  full
• 14:54
  blown
• 14:55
  snowstorm
• 14:56
  that
• 14:56
  is
• 14:57
  such
• 14:57
  a
• 14:57
  beautiful
• 14:58
  contrast
• 14:58
  between
• 14:58
  rainstorm.
• 14:59
  Right.
• 14:59
  We
• 15:00
  totally
• 15:00
  get
• 15:00
  that
• 15:00
  contrast,
• 15:01
  rain
• 15:01
  and
• 15:01
  snow.
• 15:02
  But
• 15:02
  the
• 15:02
  sleet
• 15:03
  or
• 15:03
  the
• 15:03
  freezing
• 15:04
  rain,
• 15:04
  it's
• 15:05
  this
• 15:05
  in
• 15:06
  between
• 15:06
  state
• 15:07
  that
• 15:07
  is
• 15:07
  super,
• 15:08
  super
• 15:08
  hazardous.
• 15:09
  And
• 15:09
  we
• 15:10
  have
• 15:10
  to
• 15:10
  know
• 15:10
  about
• 15:10
  it
• 15:10
  because
• 15:11
  that
• 15:11
  freezing
• 15:11
  rain
• 15:12
  can
• 15:12
  absolutely
• 15:13
  morph
• 15:14
  into
• 15:14
  snow.
• 15:14
  And
• 15:14
  it's
• 15:15
  much
• 15:15
  more
• 15:15
  likely
• 15:15
  to
• 15:15
  do
• 15:16
  so
• 15:16
  too
• 15:16
  because
• 15:16
  it's
• 15:16
  already
• 15:17
  kind
• 15:17
  of
• 15:17
  cold.
• 15:17
  Right.
• 15:18
  To
• 15:18
  me,
• 15:18
  the
• 15:19
  DSM
• 15:20
  did
• 15:20
  this
• 15:20
  magical
• 15:21
  thing
• 15:21
  where
• 15:22
  it
• 15:22
  introduced
• 15:23
  a
• 15:23
  freezing
• 15:23
  rain
• 15:24
  or
• 15:24
  ice
• 15:25
  category
• 15:25
  that
• 15:25
  is
• 15:26
  very
• 15:26
  helpful
• 15:26
  as
• 15:27
  we
• 15:27
  navigate
• 15:27
  these
• 15:27
  roads.
• 15:28
  I
• 15:28
  just
• 15:29
  think
• 15:29
  it's
• 15:29
  wonderful.
• 15:29
  40%
• 15:30
  of
• 15:30
  patients
• 15:30
  with
• 15:31
  bipolar
• 15:31
  spectrum
• 15:32
  disorders
• 15:32
  are
• 15:32
  initially
• 15:33
  diagnosed
• 15:33
  just
• 15:33
  with
• 15:34
  major
• 15:34
  depressive
• 15:34
  disorder.
• 15:35
  So
• 15:35
  the
• 15:36
  fact
• 15:36
  that
• 15:36
  we
• 15:36
  have
• 15:36
  this
• 15:36
  new
• 15:37
  sleet
• 15:37
  icon
• 15:38
  on
• 15:38
  the
• 15:38
  roads
• 15:38
  or
• 15:39
  freezing
• 15:39
  rain
• 15:40
  icon
• 15:40
  is
• 15:40
  really
• 15:41
  good
• 15:41
  because
• 15:41
  mixed
• 15:42
  features
• 15:42
  are
• 15:42
  often
• 15:43
  under
• 15:43
  recognized.
• 15:44
  And
• 15:44
  you
• 15:45
  put
• 15:45
  that
• 15:45
  with
• 15:46
  the
• 15:46
  clusters
• 15:46
  of
• 15:47
  earlier
• 15:47
  onset
• 15:48
  depression
• 15:48
  difficulty
• 15:49
  to
• 15:49
  treat
• 15:49
  depression.
• 15:50
  You
• 15:50
  cluster
• 15:50
  that
• 15:51
  with
• 15:51
  a
• 15:51
  family
• 15:51
  history
• 15:51
  of
• 15:52
  bipolarity,
• 15:53
  past
• 15:53
  suicide
• 15:54
  attempts,
• 15:54
  substance
• 15:54
  use,
• 15:55
  anxiety,
• 15:55
  panic
• 15:56
  attacks.
• 15:56
  All
• 15:57
  of
• 15:57
  these
• 15:57
  things
• 15:57
  are
• 15:57
  red
• 15:58
  flags
• 15:58
  that
• 15:58
  we're
• 15:58
  probably
• 15:59
  in
• 15:59
  a
• 16:00
  bipolar
• 16:01
  spectrum
• 16:02
  area.
• 16:03
  And
• 16:03
  that
• 16:04
  matters,
• 16:04
  right?
• 16:04
  It
• 16:05
  matters
• 16:05
  not
• 16:05
  just
• 16:05
  for
• 16:06
  diagnostics,
• 16:06
  but
• 16:06
  treatment,
• 16:07
  because
• 16:07
  we
• 16:07
  don't
• 16:08
  want
• 16:08
  to
• 16:08
  necessarily
• 16:09
  give
• 16:09
  someone
• 16:09
  an
• 16:09
  antidepressant
• 16:10
  when
• 16:10
  they're
• 16:10
  prone
• 16:10
  to
• 16:11
  this.
• 16:11
  We
• 16:11
  want
• 16:11
  to
• 16:11
  maybe
• 16:12
  gravitate
• 16:12
  more
• 16:13
  towards
• 16:13
  mood
• 16:13
  stabilizers
• 16:14
  like
• 16:14
  lithium
• 16:15
  or
• 16:15
  atypical
• 16:15
  antipsychotics.
• 16:16
  Of
• 16:16
  course,
• 16:17
  depending
• 16:17
  on
• 16:17
  the
• 16:18
  patient,
• 16:18
  especially
• 16:18
  if
• 16:19
  there's
• 16:19
  a
• 16:19
  suicide
• 16:19
  risk,
• 16:20
  lithium
• 16:20
  becomes
• 16:21
  more
• 16:21
  appealing.
• 16:21
  But
• 16:22
  there's
• 16:22
  also
• 16:22
  quetiapine,
• 16:23
  there's
• 16:24
  lorazidone.
• 16:25
  Mood
• 16:25
  stabilizers
• 16:26
  are
• 16:26
  our
• 16:26
  way
• 16:26
  to
• 16:26
  kind
• 16:26
  of
• 16:27
  hedge
• 16:27
  this.
• 16:27
  We
• 16:28
  have
• 16:28
  past
• 16:28
  episodes
• 16:29
  where
• 16:29
  you
• 16:29
  can
• 16:30
  really
• 16:30
  dig
• 16:30
  deeply
• 16:30
  into
• 16:31
  mood
• 16:31
  stabilization
• 16:32
  and
• 16:32
  how
• 16:33
  it's
• 16:33
  different
• 16:33
  than
• 16:33
  antidepressants,
• 16:34
  the
• 16:34
  mechanisms
• 16:35
  of
• 16:35
  action
• 16:35
  and
• 16:36
  what
• 16:36
  we're
• 16:36
  specifically
• 16:37
  doing
• 16:37
  there.
• 16:38
  That
• 16:38
  will
• 16:38
  demystify
• 16:39
  a
• 16:39
  lot.
• 16:40
  But
• 16:40
  I
• 16:40
  think
• 16:40
  that's
• 16:41
  pretty
• 16:41
  good
• 16:41
  for
• 16:41
  today.
• 16:42
  I
• 16:42
  hope
• 16:42
  you
• 16:42
  have
• 16:42
  a
• 16:43
  better
• 16:43
  appreciation
• 16:43
  for
• 16:44
  MDD
• 16:45
  with
• 16:45
  mixed
• 16:46
  features.
• 16:47
  Very
• 16:47
  valuable
• 16:48
  diagnosis,
• 16:49
  an
• 16:49
  innovation
• 16:50
  in
• 16:50
  the
• 16:50
  DSM
• 16:51
  5
• 16:51
  from
• 16:51
  2013
• 16:52
  continues
• 16:53
  to
• 16:53
  this
• 16:53
  day.
• 16:54
  I
• 16:54
  hope
• 16:54
  you
• 16:54
  appreciate
• 16:55
  the
• 16:55
  fact
• 16:55
  that
• 16:57
  so
• 16:58
  much
• 16:59
  of
• 16:59
  these
• 16:59
  symptoms
• 17:00
  overlap
• 17:01
  and
• 17:01
  that
• 17:01
  it's
• 17:01
  never
• 17:01
  that
• 17:02
  simple
• 17:02
  and
• 17:02
  you've
• 17:02
  got
• 17:02
  to
• 17:03
  take
• 17:03
  case
• 17:03
  by
• 17:03
  case.
• 17:04
  In
• 17:04
  this
• 17:04
  case
• 17:05
  with
• 17:05
  Janelle,
• 17:05
  we
• 17:06
  probably
• 17:06
  started
• 17:06
  her
• 17:06
  on
• 17:06
  a
• 17:07
  mood
• 17:07
  stabilizer.
• 17:07
  We
• 17:08
  watched
• 17:08
  her
• 17:08
  closely
• 17:09
  and
• 17:09
  ensured
• 17:10
  her
• 17:10
  mood
• 17:10
  would
• 17:10
  even
• 17:11
  out
• 17:11
  and
• 17:12
  definitely
• 17:12
  flag
• 17:12
  this
• 17:13
  with
• 17:13
  the
• 17:14
  appropriate
• 17:14
  diagnosis
• 17:15
  to
• 17:15
  make
• 17:15
  sure
• 17:15
  she's
• 17:16
  captured.
• 17:16
  And
• 17:16
  we
• 17:16
  ruled
• 17:17
  out
• 17:17
  the
• 17:17
  other
• 17:17
  diagnosis
• 17:18
  as
• 17:18
  well.
• 17:19
  If
• 17:19
  you
• 17:19
  love
• 17:19
  this
• 17:20
  podcast,
• 17:20
  please
• 17:21
  share
• 17:21
  it
• 17:21
  with
• 17:21
  your
• 17:22
  colleagues.
• 17:23
  Give
• 17:23
  us
• 17:23
  five
• 17:23
  stars
• 17:24
  on
• 17:24
  Apple.
• 17:24
  That's
• 17:24
  the
• 17:24
  best
• 17:25
  way
• 17:25
  you
• 17:25
  can
• 17:25
  help
• 17:25
  us.
• 17:26
  It
• 17:26
  would
• 17:26
  be
• 17:26
  great
• 17:26
  if
• 17:26
  you
• 17:27
  also
• 17:27
  became
• 17:27
  a
• 17:27
  Patreon
• 17:28
  member.
• 17:28
  Patreon
• 17:29
  members
• 17:29
  have
• 17:30
  elite
• 17:31
  access
• 17:31
  to
• 17:31
  slide
• 17:32
  decks
• 17:32
  with
• 17:32
  this
• 17:32
  information.
• 17:33
  I'm
• 17:34
  a
• 17:34
  visual
• 17:34
  guy.
• 17:34
  I
• 17:35
  love
• 17:35
  to
• 17:35
  see
• 17:35
  this
• 17:35
  in
• 17:36
  slide
• 17:36
  deck
• 17:36
  form.
• 17:37
  It
• 17:37
  helps
• 17:37
  me
• 17:37
  study.
• 17:37
  It
• 17:38
  helps
• 17:38
  me
• 17:38
  appreciate
• 17:39
  what
• 17:39
  I'm
• 17:39
  looking
• 17:40
  at.
• 17:40
  I
• 17:40
  love
• 17:40
  grabbing
• 17:41
  a
• 17:41
  cup
• 17:41
  of
• 17:41
  coffee
• 17:41
  and
• 17:41
  just
• 17:42
  reading
• 17:42
  this.
• 17:42
  We
• 17:42
  include
• 17:43
  really
• 17:43
  cool
• 17:43
  stats
• 17:44
  and
• 17:44
  pearls
• 17:44
  that
• 17:45
  you
• 17:45
  could
• 17:45
  use.
• 17:45
  We
• 17:45
  also
• 17:46
  have
• 17:46
  bonus
• 17:46
  podcast
• 17:47
  episodes
• 17:47
  for
• 17:47
  Patreon
• 17:48
  members
• 17:48
  that
• 17:49
  come
• 17:49
  out
• 17:49
  about
• 17:49
  once
• 17:49
  a
• 17:50
  month,
• 17:50
  which
• 17:50
  are
• 17:51
  really
• 17:51
  exciting
• 17:51
  with
• 17:52
  new
• 17:52
  case
• 17:52
  studies
• 17:53
  for
• 17:53
  us
• 17:53
  to
• 17:53
  comb
• 17:54
  over
• 17:54
  and
• 17:54
  nerd
• 17:55
  out
• 17:55
  about.
• 17:55
  Becoming
• 17:56
  a
• 17:56
  Patreon
• 17:56
  member
• 17:56
  is
• 17:57
  a
• 17:57
  great
• 17:57
  idea.
• 17:58
  A
• 17:58
  big
• 17:58
  bang
• 17:59
  for
• 17:59
  your
• 17:59
  buck
• 18:00
  up
• 18:00
  content
• 18:00
  updated
• 18:01
  regularly
• 18:02
  there.
• 18:03
  So
• 18:03
  thank
• 18:03
  you
• 18:03
  all
• 18:03
  for
• 18:03
  tuning
• 18:04
  in
• 18:04
  to
• 18:05
  Pearls
• 18:06
  and
• 18:06
  Prep.
• 18:06
  We
• 18:06
  appreciate
• 18:07
  every
• 18:07
  one
• 18:07
  of
• 18:07
  you.
• 18:08
  It's
• 18:08
  been
• 18:09
  great.
• 18:09
  We'll
• 18:09
  see
• 18:09
  you
• 18:09
  next
• 18:10
  time.
• 18:10
  Bye
• 18:10
  bye.