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Exploring Mixed Features in Major Depressive Disorder: The Case of Gus · Pearls and Prep

• 0:00
  Foreign.
• 0:04
  Welcome
• 0:04
  back,
• 0:04
  my
• 0:04
  friends,
• 0:05
  to
• 0:05
  another
• 0:05
  episode
• 0:06
  of
• 0:06
  Pearls
• 0:06
  and
• 0:07
  Prep.
• 0:07
  It's
• 0:07
  NPZ
• 0:08
  here
• 0:08
  and
• 0:09
  boy,
• 0:09
  do
• 0:09
  we
• 0:09
  have
• 0:09
  an
• 0:10
  exciting
• 0:10
  case
• 0:10
  for
• 0:10
  you.
• 0:11
  Today
• 0:11
  we're
• 0:11
  going
• 0:12
  to
• 0:12
  talk
• 0:12
  about
• 0:12
  Gus.
• 0:13
  Gus
• 0:14
  is
• 0:14
  a
• 0:15
  23
• 0:15
  year
• 0:15
  old
• 0:16
  male
• 0:16
  in
• 0:17
  the
• 0:17
  outpatient
• 0:18
  space.
• 0:18
  Complaining,
• 0:20
  feeling
• 0:20
  just
• 0:21
  really
• 0:22
  down
• 0:22
  and
• 0:23
  empty.
• 0:24
  Just
• 0:25
  doesn't
• 0:25
  feel
• 0:25
  very
• 0:25
  good.
• 0:25
  He's
• 0:26
  been
• 0:26
  on
• 0:26
  WellButrin
• 0:27
  for
• 0:27
  about
• 0:27
  nine
• 0:27
  months
• 0:27
  now
• 0:28
  and
• 0:29
  says
• 0:29
  it
• 0:30
  worked
• 0:30
  at
• 0:30
  first
• 0:30
  and
• 0:30
  it's
• 0:31
  not
• 0:31
  really
• 0:31
  working
• 0:32
  very
• 0:32
  well
• 0:32
  anymore.
• 0:33
  He's
• 0:33
  taking
• 0:34
  300mg
• 0:35
  XL
• 0:35
  of
• 0:36
  Wellbutrin
• 0:38
  and
• 0:38
  things
• 0:38
  just
• 0:38
  aren't
• 0:39
  going
• 0:39
  very
• 0:40
  good.
• 0:40
  He
• 0:40
  uses
• 0:40
  cannabis
• 0:41
  occasionally.
• 0:42
  He
• 0:43
  is
• 0:43
  on
• 0:44
  no
• 0:44
  other
• 0:44
  medications
• 0:45
  other
• 0:45
  than
• 0:45
  the
• 0:45
  Wellbutrin.
• 0:47
  He
• 0:47
  does
• 0:48
  report
• 0:48
  that
• 0:49
  a
• 0:50
  couple
• 0:50
  days
• 0:50
  a
• 0:50
  week
• 0:50
  he
• 0:51
  kind
• 0:51
  of
• 0:51
  gets
• 0:51
  his
• 0:51
  energy
• 0:52
  back,
• 0:52
  but
• 0:53
  for
• 0:53
  the
• 0:53
  most
• 0:53
  part
• 0:53
  he's
• 0:54
  just
• 0:54
  done.
• 0:55
  He
• 0:55
  just
• 0:55
  doesn't
• 0:55
  feel
• 0:56
  good
• 0:56
  at
• 0:56
  all.
• 0:57
  That's
• 0:58
  what
• 0:58
  you
• 0:58
  know
• 0:58
  about
• 0:58
  Gus.
• 0:59
  You
• 0:59
  know
• 0:59
  that
• 0:59
  he
• 0:59
  has
• 1:00
  a
• 1:00
  mom
• 1:00
  with
• 1:00
  depression
• 1:00
  and
• 1:01
  an
• 1:01
  uncle
• 1:01
  with
• 1:01
  mood
• 1:01
  problems.
• 1:02
  He
• 1:02
  said
• 1:02
  his
• 1:02
  uncle
• 1:03
  was
• 1:03
  pretty
• 1:03
  moody
• 1:04
  and
• 1:04
  his
• 1:04
  mom
• 1:05
  was
• 1:05
  depressed
• 1:05
  a
• 1:06
  lot.
• 1:07
  Now
• 1:08
  Gus
• 1:08
  is
• 1:09
  also
• 1:09
  sharing
• 1:09
  that
• 1:09
  he
• 1:10
  is
• 1:10
  seeing
• 1:10
  shadows,
• 1:11
  that
• 1:12
  he
• 1:12
  is
• 1:13
  seeing
• 1:13
  shadow
• 1:13
  figures
• 1:14
  at
• 1:14
  the
• 1:14
  edge
• 1:14
  of
• 1:14
  his
• 1:15
  bed
• 1:15
  a
• 1:16
  lot
• 1:16
  of
• 1:16
  times
• 1:16
  and
• 1:17
  they're
• 1:17
  bothering
• 1:17
  him
• 1:18
  quite
• 1:18
  a
• 1:18
  lot.
• 1:18
  He
• 1:18
  also
• 1:19
  hears
• 1:19
  a
• 1:19
  voice,
• 1:20
  a
• 1:20
  male
• 1:20
  voice
• 1:21
  that
• 1:21
  makes
• 1:22
  fun
• 1:22
  of
• 1:22
  him
• 1:22
  a
• 1:22
  little
• 1:23
  bit.
• 1:23
  And
• 1:23
  that's
• 1:24
  what
• 1:24
  you
• 1:24
  know
• 1:24
  about
• 1:24
  Gus.
• 1:25
  So
• 1:25
  my
• 1:25
  friends
• 1:26
  out
• 1:26
  there,
• 1:26
  what
• 1:26
  are
• 1:26
  you
• 1:27
  thinking
• 1:27
  before
• 1:27
  you
• 1:27
  whip
• 1:28
  out
• 1:28
  the
• 1:28
  textbook,
• 1:28
  before
• 1:29
  you
• 1:29
  get
• 1:29
  real
• 1:29
  granular
• 1:30
  or
• 1:30
  get
• 1:30
  all
• 1:31
  nervous
• 1:31
  or
• 1:31
  excited,
• 1:33
  just
• 1:34
  freely
• 1:34
  associate.
• 1:35
  What
• 1:36
  diagnoses
• 1:36
  just
• 1:37
  pop
• 1:37
  out
• 1:37
  at
• 1:37
  your
• 1:37
  mind.
• 1:38
  There's
• 1:38
  no
• 1:38
  wrong
• 1:38
  answers
• 1:39
  here.
• 1:39
  At
• 1:39
  worst
• 1:40
  case
• 1:40
  scenario,
• 1:41
  we
• 1:42
  just
• 1:42
  rule
• 1:42
  things
• 1:42
  out,
• 1:43
  right?
• 1:43
  But
• 1:43
  think,
• 1:44
  just
• 1:44
  start
• 1:44
  to
• 1:45
  think
• 1:45
  in
• 1:45
  your
• 1:45
  mind
• 1:46
  little
• 1:46
  placeholders
• 1:47
  of
• 1:47
  what
• 1:47
  diagnosis
• 1:48
  might
• 1:48
  be
• 1:48
  relevant.
• 1:49
  He
• 1:49
  clearly
• 1:49
  says
• 1:50
  he's
• 1:50
  down
• 1:50
  so
• 1:50
  we
• 1:51
  can
• 1:51
  put
• 1:51
  depression
• 1:52
  on
• 1:52
  the
• 1:52
  table.
• 1:52
  He
• 1:53
  clearly
• 1:53
  said
• 1:54
  he's
• 1:54
  hearing
• 1:55
  voices
• 1:55
  and
• 1:55
  seeing
• 1:56
  things.
• 1:56
  We've
• 1:56
  got
• 1:56
  to
• 1:56
  put
• 1:57
  schizophrenia
• 1:58
  on
• 1:58
  the
• 1:58
  table.
• 1:59
  Think
• 1:59
  about
• 1:59
  some
• 2:00
  other
• 2:00
  stuff
• 2:00
  here.
• 2:00
  He
• 2:01
  talked
• 2:01
  about
• 2:01
  cannabis.
• 2:02
  So
• 2:02
  there's
• 2:03
  a
• 2:03
  few
• 2:03
  diagnoses
• 2:04
  already
• 2:04
  that
• 2:05
  we
• 2:05
  should
• 2:05
  just
• 2:06
  let
• 2:06
  them
• 2:06
  marinate
• 2:07
  a
• 2:07
  little
• 2:07
  as
• 2:07
  he
• 2:07
  continues
• 2:08
  to
• 2:08
  talk.
• 2:08
  He
• 2:08
  did
• 2:09
  mention
• 2:09
  his
• 2:09
  mother
• 2:10
  with
• 2:10
  depression,
• 2:11
  his
• 2:11
  uncle
• 2:11
  with
• 2:11
  mood
• 2:12
  problems.
• 2:12
  Now,
• 2:12
  more
• 2:12
  commonly
• 2:13
  than
• 2:13
  not,
• 2:13
  you're
• 2:13
  going
• 2:14
  to
• 2:14
  have
• 2:14
  a
• 2:14
  patient
• 2:14
  come
• 2:14
  to
• 2:15
  you
• 2:15
  and
• 2:15
  they're
• 2:15
  not
• 2:15
  going
• 2:16
  to
• 2:16
  come
• 2:16
  out
• 2:16
  and
• 2:16
  say,
• 2:16
  my
• 2:16
  uncle
• 2:17
  has
• 2:17
  bipolar
• 2:18
  2
• 2:19
  disorder.
• 2:20
  You
• 2:20
  cannot
• 2:21
  have
• 2:21
  bipolar
• 2:21
  2
• 2:22
  with
• 2:22
  psychotic
• 2:22
  features.
• 2:23
  If
• 2:23
  there's
• 2:24
  psychosis,
• 2:24
  it
• 2:24
  is
• 2:25
  bipolar
• 2:25
  1,
• 2:26
  right?
• 2:26
  So
• 2:26
  if
• 2:26
  the
• 2:27
  mood
• 2:27
  states
• 2:27
  involve
• 2:28
  psychosis,
• 2:28
  it's
• 2:28
  bipolar
• 2:29
  one,
• 2:30
  it's
• 2:30
  not
• 2:30
  bipolar
• 2:31
  two.
• 2:31
  So
• 2:32
  get
• 2:32
  that
• 2:32
  out
• 2:32
  of
• 2:32
  your
• 2:32
  head.
• 2:33
  You
• 2:33
  cannot
• 2:33
  have
• 2:34
  a
• 2:34
  patient
• 2:34
  with
• 2:34
  bipolar
• 2:35
  2
• 2:35
  with
• 2:36
  psychotic
• 2:36
  features.
• 2:36
  That
• 2:37
  is
• 2:37
  not
• 2:37
  a
• 2:37
  thing.
• 2:37
  Gus
• 2:38
  tells
• 2:38
  you
• 2:38
  that
• 2:38
  his
• 2:39
  mother
• 2:39
  has
• 2:40
  depression
• 2:40
  and
• 2:40
  his
• 2:41
  uncle
• 2:41
  has
• 2:41
  mood
• 2:41
  problems,
• 2:42
  and
• 2:42
  he's
• 2:42
  not
• 2:43
  going
• 2:43
  to
• 2:43
  come
• 2:43
  out
• 2:43
  and
• 2:43
  tell
• 2:43
  you,
• 2:44
  I
• 2:45
  have
• 2:46
  an
• 2:46
  uncle
• 2:47
  with
• 2:47
  alcohol
• 2:48
  use
• 2:48
  disorder
• 2:49
  severe,
• 2:50
  in
• 2:50
  partial
• 2:51
  remission.
• 2:52
  They
• 2:52
  don't
• 2:52
  talk
• 2:53
  in
• 2:53
  specifiers.
• 2:54
  Take
• 2:54
  mental
• 2:54
  note
• 2:55
  of
• 2:55
  that.
• 2:55
  He
• 2:55
  has
• 2:55
  an
• 2:55
  uncle
• 2:56
  with
• 2:56
  mood
• 2:56
  problems.
• 2:56
  Later
• 2:57
  on
• 2:57
  the
• 2:57
  interview,
• 2:57
  if
• 2:58
  you
• 2:58
  start
• 2:58
  going
• 2:58
  down
• 2:59
  the
• 2:59
  bipolar
• 3:00
  rabbit
• 3:00
  hole
• 3:00
  here,
• 3:00
  it
• 3:01
  might
• 3:01
  be
• 3:01
  worth
• 3:01
  it
• 3:02
  for
• 3:02
  you
• 3:02
  to
• 3:02
  ask
• 3:02
  a
• 3:02
  few
• 3:03
  more
• 3:03
  probing
• 3:03
  questions
• 3:04
  about
• 3:04
  his
• 3:04
  uncle.
• 3:04
  How
• 3:04
  much
• 3:05
  time
• 3:05
  did
• 3:05
  you
• 3:05
  spend
• 3:05
  with
• 3:05
  your
• 3:06
  uncle
• 3:06
  when
• 3:06
  you
• 3:06
  say
• 3:06
  he
• 3:07
  had
• 3:07
  mood
• 3:07
  problems?
• 3:07
  Can
• 3:08
  you
• 3:08
  describe
• 3:08
  what
• 3:08
  you
• 3:09
  mean
• 3:09
  by
• 3:09
  that?
• 3:10
  Was
• 3:10
  his
• 3:10
  mood
• 3:11
  really
• 3:11
  down?
• 3:12
  Was
• 3:12
  it
• 3:12
  really
• 3:12
  hyper
• 3:13
  and
• 3:13
  excitable
• 3:14
  at
• 3:14
  times?
• 3:15
  You
• 3:15
  know,
• 3:15
  how
• 3:15
  would
• 3:16
  you
• 3:16
  describe
• 3:16
  his
• 3:17
  mood
• 3:17
  states?
• 3:18
  If
• 3:18
  your
• 3:18
  patient
• 3:18
  tells
• 3:19
  you,
• 3:19
  my
• 3:19
  uncle
• 3:19
  would
• 3:20
  buy
• 3:20
  $10,000
• 3:21
  worth
• 3:22
  of
• 3:22
  grand
• 3:22
  pianos
• 3:23
  at
• 3:23
  3
• 3:23
  in
• 3:23
  the
• 3:23
  morning,
• 3:24
  well,
• 3:24
  now
• 3:24
  you
• 3:24
  have
• 3:25
  a
• 3:25
  pretty
• 3:25
  good
• 3:25
  index
• 3:26
  of
• 3:26
  suspicion
• 3:26
  that
• 3:27
  you
• 3:27
  need
• 3:27
  to
• 3:27
  probe
• 3:27
  a
• 3:28
  little
• 3:28
  heavier
• 3:29
  on
• 3:29
  the
• 3:29
  bipolar
• 3:30
  spectrum
• 3:30
  here.
• 3:31
  Mom's
• 3:31
  depressed.
• 3:31
  Most
• 3:33
  bipolar
• 3:35
  patients
• 3:36
  will
• 3:36
  be
• 3:36
  hanging
• 3:36
  out
• 3:36
  in
• 3:37
  depression
• 3:37
  for
• 3:37
  most
• 3:38
  of
• 3:38
  the
• 3:38
  time,
• 3:39
  right?
• 3:39
  So
• 3:41
  that
• 3:41
  can
• 3:41
  be
• 3:41
  a
• 3:41
  bit
• 3:41
  of
• 3:42
  a
• 3:42
  red
• 3:42
  herring
• 3:42
  when
• 3:42
  a
• 3:42
  patient
• 3:43
  says,
• 3:43
  oh,
• 3:44
  my
• 3:44
  mother
• 3:45
  has
• 3:45
  depression.
• 3:47
  Well,
• 3:47
  there
• 3:47
  might
• 3:47
  be
• 3:48
  more
• 3:48
  than
• 3:48
  meets
• 3:49
  the
• 3:49
  eye
• 3:49
  to
• 3:49
  that.
• 3:49
  And
• 3:50
  he's
• 3:50
  telling
• 3:50
  you
• 3:51
  that
• 3:51
  he's
• 3:51
  hearing
• 3:51
  voices
• 3:52
  that
• 3:53
  are
• 3:53
  deprecating,
• 3:54
  he's
• 3:55
  seeing
• 3:55
  shadows.
• 3:56
  So
• 3:56
  it's
• 3:56
  not
• 3:56
  insane
• 3:57
  for
• 3:57
  you
• 3:57
  to
• 3:57
  ask,
• 3:58
  you
• 3:58
  know,
• 3:58
  when
• 3:58
  your
• 3:59
  mother
• 3:59
  was
• 3:59
  depressed,
• 3:59
  did
• 4:00
  she
• 4:00
  ever
• 4:00
  hear
• 4:00
  voices?
• 4:02
  You
• 4:02
  know,
• 4:03
  did
• 4:03
  your
• 4:03
  mother
• 4:03
  ever
• 4:04
  see
• 4:04
  shadows
• 4:05
  or
• 4:05
  things
• 4:05
  of
• 4:05
  that
• 4:06
  nature?
• 4:07
  And
• 4:07
  that's
• 4:07
  very
• 4:08
  important
• 4:08
  because
• 4:09
  if
• 4:09
  there's
• 4:09
  a
• 4:09
  genetic
• 4:10
  component
• 4:10
  here,
• 4:11
  heritability.
• 4:12
  We
• 4:12
  know
• 4:12
  a
• 4:12
  lot
• 4:12
  of
• 4:12
  these
• 4:13
  DSM
• 4:14
  5
• 4:14
  syndromes
• 4:15
  are
• 4:15
  highly
• 4:15
  heritable,
• 4:16
  including
• 4:16
  bipolar.
• 4:17
  It's
• 4:17
  a
• 4:17
  highly
• 4:18
  heritable
• 4:18
  diagnosis.
• 4:19
  So
• 4:19
  these
• 4:20
  clue
• 4:20
  you
• 4:20
  in,
• 4:21
  right,
• 4:21
  to
• 4:21
  what
• 4:22
  your
• 4:22
  main
• 4:22
  suspects
• 4:23
  might
• 4:24
  be.
• 4:25
  When
• 4:25
  Gus
• 4:25
  is
• 4:26
  sharing
• 4:26
  with
• 4:26
  you
• 4:26
  that
• 4:26
  he's
• 4:27
  hearing
• 4:27
  voices
• 4:28
  and
• 4:28
  seeing
• 4:28
  shadows,
• 4:29
  you
• 4:29
  always
• 4:29
  want
• 4:29
  to
• 4:29
  ask
• 4:30
  your
• 4:30
  patients,
• 4:31
  what
• 4:32
  are
• 4:32
  the
• 4:32
  voices
• 4:32
  saying?
• 4:33
  Are
• 4:33
  they
• 4:34
  asking
• 4:35
  you
• 4:35
  to
• 4:35
  hurt
• 4:35
  yourself?
• 4:36
  Are
• 4:36
  they
• 4:36
  command
• 4:37
  hallucinations?
• 4:38
  How
• 4:38
  do
• 4:38
  you
• 4:39
  feel
• 4:39
  when
• 4:39
  you
• 4:39
  hear
• 4:39
  these
• 4:40
  voices?
• 4:40
  How
• 4:40
  often
• 4:40
  are
• 4:41
  they
• 4:41
  happening?
• 4:42
  Are
• 4:42
  they
• 4:42
  happening
• 4:43
  in
• 4:43
  the
• 4:43
  context
• 4:43
  of
• 4:44
  substance
• 4:44
  use?
• 4:45
  Are
• 4:45
  they
• 4:45
  happening
• 4:46
  independent
• 4:46
  of
• 4:46
  substance
• 4:47
  use?
• 4:47
  He's
• 4:47
  on
• 4:47
  cannabis.
• 4:48
  We
• 4:48
  know
• 4:49
  cannabis
• 4:49
  can
• 4:49
  precipitate
• 4:50
  psychosis
• 4:51
  to
• 4:51
  some
• 4:51
  extent,
• 4:51
  so
• 4:52
  we
• 4:52
  really
• 4:52
  want
• 4:52
  to
• 4:52
  know
• 4:52
  what
• 4:53
  came
• 4:53
  first.
• 4:53
  Did
• 4:53
  you
• 4:54
  start
• 4:54
  smoking
• 4:54
  cannabis?
• 4:55
  How
• 4:55
  old
• 4:55
  were
• 4:55
  you
• 4:56
  when
• 4:56
  you
• 4:56
  started
• 4:56
  smoking
• 4:56
  cannabis?
• 4:58
  Have
• 4:58
  you
• 4:58
  ever
• 4:58
  had
• 4:58
  a
• 4:58
  30
• 4:58
  day
• 4:59
  window
• 5:00
  where
• 5:00
  you
• 5:00
  weren't
• 5:00
  smoking
• 5:00
  cannabis
• 5:01
  and
• 5:01
  were
• 5:01
  you
• 5:01
  still
• 5:01
  hearing
• 5:02
  these
• 5:02
  voices?
• 5:02
  Do
• 5:03
  you
• 5:03
  only
• 5:03
  hear
• 5:03
  these
• 5:03
  voices
• 5:04
  in
• 5:04
  the
• 5:04
  context
• 5:05
  of
• 5:05
  your
• 5:05
  depression
• 5:06
  or
• 5:07
  have
• 5:08
  you
• 5:08
  heard
• 5:08
  these
• 5:08
  voices
• 5:09
  outside
• 5:09
  of
• 5:09
  the
• 5:10
  Context
• 5:10
  of
• 5:10
  your
• 5:10
  depression,
• 5:11
  too.
• 5:12
  So
• 5:12
  there's
• 5:12
  a
• 5:12
  lot
• 5:13
  of
• 5:13
  rich
• 5:13
  questions
• 5:14
  to
• 5:14
  ask
• 5:14
  Gus,
• 5:15
  and
• 5:15
  he's
• 5:16
  clearly
• 5:17
  telling
• 5:17
  you
• 5:17
  that
• 5:18
  there
• 5:18
  are
• 5:18
  a
• 5:18
  couple
• 5:19
  days
• 5:19
  that
• 5:19
  he
• 5:19
  feels
• 5:20
  pretty
• 5:20
  good.
• 5:20
  Now,
• 5:21
  what
• 5:21
  does
• 5:21
  pretty
• 5:21
  good
• 5:21
  look
• 5:22
  like?
• 5:22
  For
• 5:22
  some
• 5:22
  people,
• 5:22
  that's
• 5:23
  a
• 5:23
  return
• 5:24
  to
• 5:24
  their
• 5:24
  baseline.
• 5:25
  They're
• 5:25
  depressed,
• 5:26
  and
• 5:26
  then
• 5:26
  a
• 5:26
  couple
• 5:26
  days
• 5:27
  later,
• 5:27
  they
• 5:27
  don't
• 5:27
  feel
• 5:27
  as
• 5:28
  dark
• 5:28
  or
• 5:28
  as
• 5:28
  depressed.
• 5:29
  You
• 5:30
  mentioned
• 5:30
  that
• 5:30
  you
• 5:30
  have
• 5:30
  a
• 5:30
  couple
• 5:31
  days
• 5:31
  where
• 5:31
  you
• 5:31
  have
• 5:31
  your
• 5:31
  energy
• 5:32
  back.
• 5:32
  Describe
• 5:33
  to
• 5:33
  me
• 5:33
  what
• 5:33
  those
• 5:34
  days
• 5:34
  look
• 5:34
  like
• 5:35
  in
• 5:35
  Gus's
• 5:36
  case.
• 5:36
  He's
• 5:36
  going
• 5:36
  to
• 5:37
  tell
• 5:37
  you
• 5:37
  that
• 5:37
  he
• 5:37
  has
• 5:38
  surges
• 5:38
  of
• 5:38
  energy
• 5:39
  in
• 5:39
  those
• 5:39
  days.
• 5:39
  He's
• 5:40
  really
• 5:40
  energized,
• 5:40
  he's
• 5:41
  really
• 5:41
  confident,
• 5:41
  and
• 5:42
  he
• 5:42
  feels
• 5:42
  like
• 5:42
  he
• 5:42
  can
• 5:43
  conquer
• 5:43
  the
• 5:43
  world.
• 5:44
  Now,
• 5:44
  that's
• 5:45
  very
• 5:45
  different.
• 5:46
  Right?
• 5:46
  That
• 5:46
  is
• 5:46
  not
• 5:47
  your
• 5:47
  run
• 5:47
  of
• 5:47
  the
• 5:47
  mill
• 5:48
  Joe
• 5:48
  and
• 5:48
  Jane
• 5:49
  answer.
• 5:50
  That
• 5:50
  is
• 5:51
  definitely
• 5:51
  merging
• 5:52
  into
• 5:52
  the
• 5:52
  bipolar
• 5:53
  territory.
• 5:54
  But
• 5:54
  he
• 5:54
  says
• 5:54
  it's
• 5:54
  happening
• 5:55
  only
• 5:55
  a
• 5:55
  couple
• 5:55
  of
• 5:56
  days
• 5:56
  that
• 5:56
  he
• 5:56
  feels
• 5:56
  like
• 5:57
  he
• 5:57
  can
• 5:57
  conquer
• 5:57
  the
• 5:58
  world.
• 5:58
  Now,
• 5:58
  a
• 5:58
  good
• 5:59
  question
• 5:59
  to
• 5:59
  ask
• 5:59
  Gus.
• 6:00
  I
• 6:00
  find
• 6:00
  that
• 6:00
  I
• 6:00
  love
• 6:01
  asking
• 6:01
  about
• 6:01
  sleep.
• 6:02
  When
• 6:03
  patients
• 6:03
  go
• 6:03
  down
• 6:03
  the
• 6:04
  bipolar
• 6:04
  rabbit
• 6:05
  hole
• 6:05
  a
• 6:05
  little
• 6:05
  bit.
• 6:06
  I
• 6:06
  like
• 6:06
  to
• 6:06
  ask
• 6:06
  about
• 6:07
  sleep
• 6:07
  in
• 6:07
  those
• 6:07
  one
• 6:07
  to
• 6:08
  two
• 6:08
  days
• 6:08
  that
• 6:08
  you
• 6:09
  have
• 6:09
  a
• 6:09
  lot
• 6:10
  of
• 6:10
  energy
• 6:10
  and
• 6:10
  you
• 6:10
  feel
• 6:11
  like
• 6:11
  you
• 6:11
  can
• 6:11
  conquer
• 6:11
  the
• 6:12
  world.
• 6:13
  What
• 6:13
  does
• 6:13
  your
• 6:14
  sleep
• 6:14
  look
• 6:14
  like
• 6:14
  during
• 6:14
  those
• 6:15
  days?
• 6:16
  Let
• 6:16
  them
• 6:16
  answer.
• 6:17
  And
• 6:18
  a
• 6:18
  lot
• 6:18
  of
• 6:18
  times
• 6:18
  they're
• 6:18
  going
• 6:18
  to
• 6:19
  say,
• 6:19
  oh,
• 6:19
  I'm
• 6:19
  not
• 6:19
  sleeping
• 6:20
  much
• 6:20
  at
• 6:20
  all.
• 6:20
  Okay,
• 6:21
  well,
• 6:21
  it's
• 6:21
  really
• 6:21
  important
• 6:21
  that
• 6:22
  you
• 6:22
  ask
• 6:22
  them,
• 6:23
  what
• 6:23
  are
• 6:23
  you
• 6:23
  doing
• 6:23
  when
• 6:24
  you're
• 6:24
  not
• 6:24
  sleeping?
• 6:24
  What
• 6:25
  are
• 6:25
  some
• 6:25
  of
• 6:25
  the
• 6:25
  activities
• 6:26
  that
• 6:26
  you
• 6:26
  do
• 6:26
  during
• 6:27
  those
• 6:27
  periods?
• 6:28
  Now,
• 6:28
  in
• 6:28
  folks
• 6:28
  who
• 6:28
  don't
• 6:29
  have
• 6:29
  bipolar,
• 6:29
  you're
• 6:30
  frequently
• 6:30
  going
• 6:30
  to
• 6:30
  hear,
• 6:31
  oh,
• 6:32
  when
• 6:32
  I'm
• 6:32
  not
• 6:32
  sleeping,
• 6:32
  I'm
• 6:33
  tossing
• 6:33
  and
• 6:33
  turning,
• 6:33
  or
• 6:34
  I'll
• 6:34
  turn
• 6:34
  on
• 6:34
  Netflix
• 6:35
  or
• 6:35
  I'll
• 6:36
  make
• 6:36
  a
• 6:36
  pot
• 6:36
  of
• 6:36
  coffee
• 6:37
  or
• 6:37
  I'll
• 6:38
  cook
• 6:38
  an
• 6:38
  omelet
• 6:38
  or
• 6:39
  I'll
• 6:39
  order
• 6:39
  GrubHub.
• 6:40
  But
• 6:41
  when
• 6:41
  you
• 6:42
  have
• 6:42
  patients
• 6:42
  with
• 6:42
  more
• 6:42
  of
• 6:43
  a
• 6:43
  bipolar
• 6:43
  disorder,
• 6:44
  the
• 6:45
  answers
• 6:45
  are
• 6:45
  a
• 6:45
  little
• 6:46
  more
• 6:46
  extreme
• 6:46
  and
• 6:46
  off
• 6:47
  the
• 6:47
  beaten
• 6:47
  path.
• 6:47
  Right?
• 6:48
  Oh,
• 6:48
  I'm
• 6:48
  starting
• 6:49
  projects.
• 6:49
  I'm
• 6:49
  cleaning
• 6:50
  the
• 6:50
  entire
• 6:50
  garage.
• 6:51
  I
• 6:52
  am
• 6:52
  starting
• 6:52
  an
• 6:53
  Etsy
• 6:53
  business.
• 6:54
  You
• 6:54
  know,
• 6:54
  I'm
• 6:55
  online
• 6:55
  trying
• 6:55
  to
• 6:55
  figure
• 6:56
  out
• 6:56
  how
• 6:56
  to
• 6:56
  start
• 6:57
  my
• 6:57
  own
• 6:57
  theme
• 6:57
  park
• 6:58
  with
• 6:59
  giraffes
• 7:00
  that
• 7:02
  are
• 7:02
  double
• 7:02
  the
• 7:02
  size
• 7:03
  because
• 7:03
  I'm
• 7:03
  genetically
• 7:04
  engineering
• 7:05
  them.
• 7:05
  They're
• 7:05
  just
• 7:06
  very
• 7:07
  different
• 7:07
  than
• 7:07
  what
• 7:08
  patients
• 7:08
  are
• 7:08
  normally
• 7:09
  doing.
• 7:09
  Right.
• 7:10
  If
• 7:10
  you
• 7:10
  have
• 7:10
  a
• 7:10
  patient
• 7:10
  who
• 7:11
  works
• 7:11
  night
• 7:11
  shift
• 7:11
  and
• 7:12
  they
• 7:12
  just
• 7:12
  happen
• 7:12
  to
• 7:12
  be
• 7:12
  up,
• 7:13
  that's
• 7:13
  totally
• 7:14
  different.
• 7:14
  You're
• 7:14
  trying
• 7:14
  to
• 7:15
  sniff
• 7:15
  out
• 7:15
  how
• 7:16
  unusual
• 7:16
  is
• 7:17
  this,
• 7:17
  how
• 7:17
  extreme
• 7:17
  is
• 7:18
  this,
• 7:18
  how
• 7:18
  impairing
• 7:19
  is
• 7:19
  this?
• 7:20
  How
• 7:20
  much
• 7:20
  of
• 7:21
  a
• 7:21
  departure
• 7:21
  from
• 7:21
  baseline
• 7:22
  is
• 7:22
  this
• 7:22
  and
• 7:23
  a
• 7:23
  lot
• 7:23
  of
• 7:23
  your
• 7:23
  questions
• 7:24
  are
• 7:24
  trying
• 7:25
  to
• 7:25
  elicit
• 7:25
  that
• 7:26
  information
• 7:26
  from
• 7:26
  the
• 7:26
  patient.
• 7:27
  Right.
• 7:27
  They're
• 7:28
  very
• 7:28
  much
• 7:28
  geared
• 7:29
  towards
• 7:29
  that.
• 7:30
  Right.
• 7:31
  So
• 7:31
  Gus
• 7:31
  has
• 7:31
  given
• 7:31
  you
• 7:32
  some
• 7:32
  weird
• 7:32
  stuff
• 7:32
  here.
• 7:32
  On
• 7:33
  one
• 7:33
  hand,
• 7:33
  he's
• 7:33
  depressed.
• 7:33
  He's
• 7:34
  on
• 7:34
  Wellbutrin.
• 7:35
  I
• 7:35
  would
• 7:35
  also
• 7:36
  ask
• 7:36
  him
• 7:36
  questions,
• 7:36
  how
• 7:37
  is
• 7:37
  it
• 7:37
  with
• 7:37
  Wellbutrin?
• 7:38
  Walk
• 7:38
  me
• 7:38
  through
• 7:39
  what
• 7:39
  Wellbutrin
• 7:40
  has
• 7:40
  looked
• 7:41
  like
• 7:41
  since
• 7:41
  you
• 7:41
  started
• 7:41
  it.
• 7:42
  Did
• 7:42
  it
• 7:42
  ever
• 7:42
  help
• 7:42
  with
• 7:42
  your
• 7:43
  depression?
• 7:43
  And
• 7:43
  sure
• 7:43
  enough,
• 7:44
  he
• 7:44
  says,
• 7:44
  yes,
• 7:44
  I
• 7:45
  was
• 7:45
  a
• 7:45
  lot
• 7:45
  less
• 7:46
  depressed
• 7:46
  for
• 7:46
  the
• 7:46
  first
• 7:46
  three
• 7:47
  months,
• 7:47
  but
• 7:47
  something
• 7:47
  happened.
• 7:48
  I
• 7:48
  just
• 7:48
  don't
• 7:48
  feel
• 7:48
  good
• 7:48
  anymore.
• 7:49
  And
• 7:49
  you
• 7:49
  might
• 7:50
  also
• 7:50
  ask
• 7:50
  him
• 7:50
  what
• 7:51
  happened.
• 7:51
  Walk
• 7:51
  me
• 7:51
  through
• 7:51
  what
• 7:52
  might
• 7:52
  be
• 7:52
  going
• 7:52
  on
• 7:52
  in
• 7:53
  your
• 7:53
  life
• 7:53
  right
• 7:53
  now
• 7:53
  that
• 7:54
  might
• 7:54
  explain
• 7:56
  this
• 7:56
  worsening
• 7:57
  of
• 7:57
  your
• 7:57
  mental
• 7:58
  health.
• 7:58
  He
• 7:58
  might
• 7:58
  say,
• 7:58
  oh,
• 7:59
  I
• 7:59
  just
• 7:59
  broke
• 7:59
  up
• 7:59
  with
• 7:59
  a
• 8:00
  girlfriend,
• 8:00
  or
• 8:00
  I'm
• 8:00
  just
• 8:00
  not
• 8:01
  sleeping
• 8:01
  very
• 8:02
  well
• 8:02
  because
• 8:02
  I'm
• 8:03
  stressed
• 8:03
  about
• 8:04
  getting
• 8:05
  a
• 8:05
  job
• 8:05
  in
• 8:05
  a
• 8:05
  few
• 8:05
  months.
• 8:06
  Gus
• 8:06
  is
• 8:06
  telling
• 8:06
  us
• 8:07
  he
• 8:07
  doesn't
• 8:08
  really
• 8:08
  know.
• 8:08
  He
• 8:08
  just
• 8:08
  has
• 8:09
  depression
• 8:10
  that
• 8:10
  seems
• 8:10
  to
• 8:10
  be
• 8:10
  getting
• 8:11
  worse.
• 8:11
  One
• 8:11
  question
• 8:12
  I
• 8:12
  would
• 8:12
  like
• 8:12
  to
• 8:12
  ask
• 8:12
  him
• 8:13
  is,
• 8:13
  do
• 8:13
  you
• 8:13
  find
• 8:14
  a
• 8:14
  relationship
• 8:15
  between
• 8:15
  your
• 8:15
  voices
• 8:16
  or
• 8:17
  those
• 8:17
  shadow
• 8:17
  figures
• 8:18
  and
• 8:18
  how
• 8:18
  bad
• 8:18
  your
• 8:18
  mood
• 8:19
  gets?
• 8:19
  I
• 8:20
  would
• 8:20
  definitely
• 8:20
  want
• 8:20
  to
• 8:20
  know
• 8:21
  that.
• 8:21
  I
• 8:21
  would
• 8:21
  like
• 8:21
  to
• 8:22
  know
• 8:22
  if
• 8:23
  his
• 8:23
  psychotic
• 8:24
  symptoms
• 8:25
  are
• 8:25
  worsening
• 8:25
  in
• 8:26
  tandem
• 8:26
  with
• 8:26
  his
• 8:26
  mood.
• 8:27
  To
• 8:27
  me,
• 8:27
  that's
• 8:27
  very
• 8:27
  important.
• 8:28
  And
• 8:28
  that
• 8:29
  would.
• 8:29
  That
• 8:29
  would
• 8:29
  suggest
• 8:30
  more
• 8:30
  of
• 8:31
  a,
• 8:31
  you
• 8:31
  know,
• 8:31
  MDD
• 8:32
  with
• 8:32
  psychotic
• 8:33
  features
• 8:34
  type
• 8:35
  presentation.
• 8:36
  Right.
• 8:37
  I
• 8:37
  also
• 8:38
  want
• 8:38
  to
• 8:38
  have
• 8:38
  an
• 8:38
  idea.
• 8:40
  You
• 8:40
  know,
• 8:40
  of
• 8:40
  course,
• 8:40
  you
• 8:41
  can't
• 8:41
  rule
• 8:41
  out
• 8:41
  schizophrenia,
• 8:42
  and
• 8:43
  that's
• 8:43
  a
• 8:43
  whole
• 8:43
  different
• 8:43
  cluster
• 8:44
  of
• 8:44
  symptoms.
• 8:45
  There's
• 8:45
  a
• 8:45
  little
• 8:46
  overlap,
• 8:46
  too.
• 8:47
  You
• 8:47
  have
• 8:47
  those
• 8:47
  negative
• 8:48
  symptoms
• 8:49
  where
• 8:49
  you're
• 8:49
  not
• 8:50
  as
• 8:50
  talkative,
• 8:50
  you're
• 8:51
  not
• 8:51
  initiating
• 8:51
  tasks
• 8:52
  as
• 8:52
  much,
• 8:52
  you're
• 8:52
  a
• 8:52
  little
• 8:53
  disorganized
• 8:54
  as
• 8:54
  well.
• 8:55
  Right.
• 8:55
  And
• 8:55
  it's
• 8:56
  more
• 8:56
  of
• 8:56
  a
• 8:56
  chronic
• 8:56
  deterioration.
• 8:57
  And
• 8:58
  with
• 8:58
  schizophrenia,
• 8:59
  it's
• 8:59
  irrespective
• 9:00
  of
• 9:00
  mood.
• 9:00
  So
• 9:01
  when
• 9:01
  he's
• 9:01
  not
• 9:01
  even
• 9:01
  depressed,
• 9:02
  he's
• 9:02
  having
• 9:02
  these
• 9:03
  delusions
• 9:03
  or
• 9:03
  hallucinations.
• 9:04
  He's
• 9:05
  having
• 9:05
  these
• 9:05
  hallucinations
• 9:07
  in
• 9:07
  the
• 9:07
  context
• 9:08
  of
• 9:08
  his
• 9:08
  mood.
• 9:09
  Not
• 9:09
  to
• 9:10
  get
• 9:10
  anybody
• 9:10
  confused
• 9:11
  here,
• 9:11
  but
• 9:11
  you
• 9:11
  can
• 9:11
  have
• 9:12
  a
• 9:12
  schizoaffective
• 9:13
  disorder
• 9:13
  where
• 9:14
  you
• 9:14
  have
• 9:14
  both
• 9:14
  of
• 9:15
  these
• 9:15
  things
• 9:15
  happening
• 9:16
  at
• 9:16
  specific
• 9:17
  times.
• 9:17
  But
• 9:17
  again,
• 9:17
  this
• 9:18
  is
• 9:18
  for
• 9:19
  simplicity's
• 9:19
  sake.
• 9:20
  The
• 9:20
  depression
• 9:20
  is
• 9:20
  happening
• 9:21
  with
• 9:22
  his
• 9:22
  psychosis.
• 9:22
  So
• 9:23
  I
• 9:23
  would
• 9:23
  definitely
• 9:24
  think
• 9:24
  that
• 9:25
  MDD
• 9:26
  with
• 9:26
  psychotic
• 9:27
  features
• 9:27
  is
• 9:27
  a
• 9:28
  very
• 9:29
  solid
• 9:30
  differential
• 9:31
  here.
• 9:31
  It's
• 9:31
  a
• 9:31
  very
• 9:32
  good
• 9:32
  bet
• 9:32
  that
• 9:32
  that's
• 9:33
  what
• 9:33
  we're
• 9:33
  looking
• 9:33
  at.
• 9:33
  But
• 9:33
  by
• 9:33
  no
• 9:34
  means
• 9:34
  are
• 9:34
  we
• 9:34
  done.
• 9:35
  Cannabis
• 9:35
  can
• 9:36
  completely
• 9:36
  distort
• 9:37
  this.
• 9:37
  Right.
• 9:38
  Whether
• 9:38
  you're
• 9:38
  withdrawing
• 9:39
  from
• 9:39
  cannabis
• 9:40
  and
• 9:40
  you
• 9:40
  have
• 9:40
  a
• 9:40
  lot
• 9:40
  of
• 9:41
  irritability
• 9:42
  or
• 9:42
  Just
• 9:43
  cannabis
• 9:43
  and
• 9:43
  its
• 9:44
  ability
• 9:44
  to
• 9:44
  worsen
• 9:45
  anxiety,
• 9:46
  to
• 9:46
  worsen
• 9:46
  mood
• 9:47
  states,
• 9:47
  to
• 9:48
  alter
• 9:48
  dopamine
• 9:49
  signaling.
• 9:49
  We
• 9:49
  talked
• 9:50
  about
• 9:50
  that
• 9:50
  in
• 9:50
  previous
• 9:50
  episodes.
• 9:51
  So
• 9:52
  it
• 9:52
  can
• 9:52
  really
• 9:52
  muddy
• 9:53
  the
• 9:53
  diagnostic
• 9:53
  picture
• 9:54
  in
• 9:54
  a
• 9:54
  major
• 9:54
  way,
• 9:55
  this
• 9:55
  whole
• 9:55
  cannabis
• 9:56
  use.
• 9:56
  So
• 9:56
  I
• 9:56
  would
• 9:56
  ask,
• 9:57
  when
• 9:57
  did
• 9:57
  you
• 9:57
  start?
• 9:58
  What's
• 9:58
  the
• 9:58
  potency
• 9:58
  of
• 9:59
  your
• 9:59
  thc?
• 10:00
  How
• 10:00
  often
• 10:00
  do
• 10:00
  you
• 10:01
  use
• 10:01
  cannabis?
• 10:01
  And
• 10:01
  again
• 10:02
  importantly,
• 10:03
  have
• 10:03
  you
• 10:03
  experienced
• 10:04
  these
• 10:04
  symptoms
• 10:05
  in
• 10:05
  the
• 10:05
  absence
• 10:05
  of
• 10:06
  cannabis
• 10:06
  in
• 10:06
  the
• 10:06
  past?
• 10:07
  Those
• 10:07
  are
• 10:07
  all
• 10:08
  very
• 10:08
  important
• 10:09
  questions
• 10:10
  that
• 10:10
  you
• 10:10
  need
• 10:10
  to
• 10:11
  ask
• 10:11
  now.
• 10:12
  The
• 10:12
  curious
• 10:12
  thing
• 10:13
  here
• 10:13
  that
• 10:13
  we
• 10:13
  should
• 10:13
  be
• 10:14
  thinking
• 10:14
  about
• 10:14
  is
• 10:15
  Gus
• 10:15
  is
• 10:16
  experiencing
• 10:17
  one
• 10:17
  to
• 10:17
  two
• 10:17
  days
• 10:17
  of
• 10:18
  heightened
• 10:18
  energy.
• 10:19
  And
• 10:19
  you
• 10:19
  really
• 10:19
  want
• 10:19
  to
• 10:20
  go
• 10:20
  down
• 10:20
  the
• 10:21
  bipolar
• 10:22
  type
• 10:23
  DSM
• 10:23
  questions,
• 10:24
  right?
• 10:24
  Because
• 10:24
  he's
• 10:24
  telling
• 10:25
  you
• 10:25
  he's
• 10:25
  got
• 10:25
  more
• 10:25
  energy,
• 10:26
  he's
• 10:26
  telling
• 10:27
  you
• 10:27
  he
• 10:27
  doesn't
• 10:28
  feel
• 10:28
  like
• 10:28
  he
• 10:28
  needs
• 10:28
  to
• 10:28
  sleep
• 10:29
  as
• 10:29
  much.
• 10:29
  He's
• 10:29
  got
• 10:29
  surges
• 10:30
  of
• 10:30
  energy.
• 10:31
  So
• 10:31
  you
• 10:31
  want
• 10:31
  to
• 10:31
  ask,
• 10:32
  do
• 10:32
  you
• 10:32
  find
• 10:32
  that
• 10:33
  you're
• 10:33
  talking
• 10:33
  very
• 10:33
  fast
• 10:34
  during
• 10:35
  those
• 10:35
  one
• 10:35
  or
• 10:35
  two
• 10:36
  days
• 10:36
  where
• 10:36
  you
• 10:36
  have
• 10:36
  more
• 10:37
  energy?
• 10:37
  What
• 10:38
  else
• 10:38
  are
• 10:38
  you
• 10:38
  doing
• 10:38
  that
• 10:39
  is
• 10:39
  unusual?
• 10:40
  I
• 10:40
  like
• 10:40
  to
• 10:40
  ask
• 10:40
  open
• 10:41
  ended
• 10:41
  questions
• 10:41
  because
• 10:43
  you
• 10:43
  don't
• 10:43
  want
• 10:43
  to
• 10:44
  give
• 10:45
  him
• 10:45
  an
• 10:45
  opportunity
• 10:46
  to
• 10:46
  give
• 10:46
  you
• 10:46
  too
• 10:47
  many
• 10:47
  false
• 10:47
  positives.
• 10:48
  You
• 10:48
  really
• 10:48
  want
• 10:48
  him
• 10:48
  to
• 10:49
  elicit
• 10:49
  what
• 10:50
  is
• 10:50
  unusual
• 10:50
  about
• 10:51
  his
• 10:51
  presentation
• 10:52
  rather
• 10:52
  than
• 10:52
  being
• 10:53
  led
• 10:53
  to
• 10:53
  the
• 10:54
  question.
• 10:54
  Sometimes
• 10:55
  you
• 10:55
  have
• 10:55
  to
• 10:55
  ask
• 10:55
  pointed
• 10:56
  questions.
• 10:56
  Sometimes
• 10:57
  when
• 10:57
  people
• 10:58
  feel
• 11:00
  really
• 11:00
  energized
• 11:01
  like
• 11:01
  you're
• 11:02
  describing,
• 11:03
  they
• 11:03
  also
• 11:03
  have
• 11:03
  other
• 11:04
  symptoms,
• 11:04
  like
• 11:05
  doing
• 11:05
  high
• 11:05
  risk
• 11:05
  stuff
• 11:06
  they
• 11:06
  later
• 11:06
  regret.
• 11:07
  Is
• 11:07
  that
• 11:07
  the
• 11:08
  case?
• 11:08
  Case
• 11:08
  with
• 11:08
  you?
• 11:09
  Walk
• 11:09
  me
• 11:09
  through
• 11:10
  what
• 11:10
  other
• 11:10
  unusual
• 11:11
  behaviors
• 11:12
  you
• 11:12
  have
• 11:12
  experienced
• 11:13
  in
• 11:14
  the
• 11:14
  context
• 11:14
  of
• 11:15
  these
• 11:15
  energy
• 11:15
  states.
• 11:16
  That's
• 11:16
  a
• 11:16
  really
• 11:16
  good
• 11:17
  question
• 11:17
  because
• 11:18
  you
• 11:18
  want
• 11:18
  them
• 11:19
  to
• 11:19
  paint
• 11:19
  you
• 11:19
  the
• 11:20
  picture.
• 11:20
  You
• 11:20
  want
• 11:20
  a
• 11:20
  really
• 11:21
  good
• 11:21
  picture
• 11:21
  of
• 11:22
  what
• 11:22
  is
• 11:22
  going
• 11:22
  on
• 11:23
  because
• 11:23
  it's
• 11:23
  normally
• 11:23
  a
• 11:23
  cluster.
• 11:24
  If
• 11:24
  he's
• 11:24
  telling
• 11:25
  you
• 11:25
  he
• 11:25
  just
• 11:25
  has
• 11:25
  surges
• 11:25
  of
• 11:26
  energy
• 11:26
  for
• 11:26
  two
• 11:26
  days,
• 11:27
  that
• 11:27
  could
• 11:27
  be
• 11:27
  too
• 11:27
  much
• 11:27
  caffeine,
• 11:28
  right?
• 11:29
  It
• 11:29
  could
• 11:29
  be
• 11:29
  that
• 11:30
  he
• 11:30
  just
• 11:30
  feels
• 11:30
  a
• 11:30
  lot
• 11:31
  better
• 11:31
  those
• 11:31
  days.
• 11:31
  For
• 11:31
  whatever
• 11:32
  reason,
• 11:33
  he's
• 11:33
  not
• 11:33
  really
• 11:33
  articulating
• 11:34
  a
• 11:35
  manic
• 11:35
  state.
• 11:35
  He's
• 11:36
  articulating
• 11:36
  his
• 11:36
  return
• 11:37
  to
• 11:37
  baseline,
• 11:38
  right?
• 11:38
  And
• 11:38
  that's
• 11:38
  where
• 11:38
  you
• 11:39
  have
• 11:39
  to
• 11:39
  say,
• 11:39
  Gus,
• 11:39
  when
• 11:40
  you
• 11:40
  say
• 11:40
  one
• 11:40
  or
• 11:41
  two
• 11:41
  days
• 11:41
  of
• 11:41
  energy,
• 11:41
  do
• 11:41
  you
• 11:42
  just
• 11:42
  mean
• 11:42
  you're
• 11:42
  feeling
• 11:43
  like
• 11:44
  your
• 11:44
  old
• 11:44
  self
• 11:44
  again
• 11:44
  or
• 11:45
  do
• 11:45
  you
• 11:45
  mean
• 11:45
  you're
• 11:45
  hyper?
• 11:46
  Do
• 11:46
  you
• 11:46
  mean
• 11:46
  you're
• 11:47
  happier
• 11:47
  than
• 11:48
  happy?
• 11:48
  That's
• 11:49
  my
• 11:49
  key
• 11:49
  distinction
• 11:50
  where
• 11:50
  I
• 11:50
  like
• 11:50
  to
• 11:50
  ask
• 11:50
  them,
• 11:51
  what
• 11:51
  are
• 11:51
  we
• 11:51
  looking
• 11:52
  at
• 11:52
  here?
• 11:52
  Is
• 11:52
  this
• 11:52
  beyond
• 11:53
  happy?
• 11:53
  Is
• 11:54
  this
• 11:54
  more
• 11:54
  of
• 11:54
  a
• 11:54
  mood
• 11:55
  state?
• 11:55
  And
• 11:55
  we've
• 11:56
  got
• 11:56
  to
• 11:56
  think
• 11:56
  about
• 11:56
  that
• 11:57
  now.
• 11:58
  We
• 11:58
  go
• 11:58
  through
• 11:58
  the
• 11:59
  motions
• 11:59
  with
• 12:00
  Gus
• 12:00
  and
• 12:01
  lo
• 12:01
  and
• 12:01
  behold,
• 12:02
  we
• 12:03
  realize
• 12:03
  that
• 12:04
  Gus
• 12:04
  doesn't
• 12:04
  have
• 12:05
  all
• 12:05
  These
• 12:05
  other
• 12:06
  symptoms
• 12:06
  he's
• 12:06
  just
• 12:07
  talking
• 12:07
  about,
• 12:08
  maybe
• 12:08
  he
• 12:08
  talks
• 12:09
  a
• 12:09
  little
• 12:09
  fast
• 12:09
  during
• 12:10
  these
• 12:10
  episodes
• 12:10
  and
• 12:11
  he
• 12:11
  doesn't
• 12:11
  feel
• 12:11
  like
• 12:11
  he
• 12:12
  needs
• 12:12
  to
• 12:12
  sleep
• 12:12
  and
• 12:13
  his
• 12:13
  mood
• 12:13
  is
• 12:13
  kind
• 12:14
  of
• 12:14
  confident.
• 12:15
  So
• 12:15
  that's
• 12:16
  really
• 12:16
  three
• 12:16
  symptoms
• 12:17
  that
• 12:18
  would
• 12:18
  meet
• 12:18
  criteria
• 12:19
  for
• 12:19
  a
• 12:19
  major
• 12:19
  depressive
• 12:20
  disorder
• 12:21
  with
• 12:21
  mixed
• 12:21
  features.
• 12:22
  Assuming
• 12:22
  that
• 12:23
  he
• 12:23
  told
• 12:23
  you
• 12:23
  he
• 12:24
  has
• 12:24
  felt
• 12:24
  down
• 12:25
  or
• 12:25
  depressed
• 12:26
  for
• 12:26
  at
• 12:26
  least
• 12:27
  two
• 12:27
  weeks
• 12:28
  with
• 12:28
  those
• 12:28
  cluster
• 12:29
  of
• 12:29
  depressive
• 12:29
  symptoms
• 12:30
  now,
• 12:30
  we
• 12:30
  won't
• 12:30
  go
• 12:30
  into
• 12:30
  every
• 12:31
  symptom
• 12:31
  of
• 12:31
  depression.
• 12:32
  We're
• 12:32
  going
• 12:32
  to
• 12:32
  assume
• 12:32
  that
• 12:33
  he's
• 12:33
  already
• 12:33
  coming
• 12:34
  to
• 12:34
  you
• 12:34
  with
• 12:34
  a
• 12:35
  true
• 12:35
  diagnosis
• 12:36
  of
• 12:36
  depression.
• 12:37
  Right?
• 12:37
  So
• 12:37
  you're
• 12:37
  looking
• 12:38
  at
• 12:38
  this
• 12:38
  and
• 12:38
  you're
• 12:38
  going,
• 12:38
  wait
• 12:39
  a
• 12:39
  minute,
• 12:39
  am
• 12:39
  I
• 12:39
  looking
• 12:39
  at
• 12:39
  bipolar?
• 12:40
  Am
• 12:40
  I
• 12:41
  looking
• 12:41
  at
• 12:41
  depression?
• 12:42
  Am
• 12:42
  I
• 12:42
  looking
• 12:42
  at
• 12:42
  schizophrenia?
• 12:43
  What
• 12:43
  am
• 12:44
  I
• 12:44
  looking
• 12:44
  at
• 12:44
  here?
• 12:44
  One
• 12:45
  thing
• 12:45
  that
• 12:45
  makes
• 12:45
  it
• 12:45
  a
• 12:46
  little
• 12:46
  more
• 12:46
  simple
• 12:47
  is
• 12:48
  he's
• 12:48
  describing
• 12:49
  depression.
• 12:49
  He
• 12:50
  doesn't
• 12:50
  quite
• 12:50
  meet
• 12:51
  criteria
• 12:52
  for
• 12:52
  bipolar
• 12:53
  one
• 12:53
  or
• 12:54
  two
• 12:54
  because
• 12:54
  he
• 12:54
  doesn't
• 12:55
  have
• 12:55
  enough
• 12:55
  symptoms
• 12:56
  and
• 12:56
  he
• 12:56
  also
• 12:56
  doesn't
• 12:57
  have
• 12:57
  enough
• 12:57
  days.
• 12:57
  With
• 13:52
  bipolar
• 13:53
  2,
• 13:53
  you
• 13:53
  need
• 13:54
  four
• 13:54
  or
• 13:54
  more
• 13:54
  days.
• 13:55
  That's
• 13:55
  the
• 13:55
  cutoff
• 13:55
  in
• 13:56
  the
• 13:56
  DSM
• 13:56
  5.
• 13:56
  He's
• 13:57
  telling
• 13:57
  you
• 13:57
  he
• 13:57
  only
• 13:57
  has
• 13:58
  one
• 13:58
  or
• 13:58
  two
• 13:58
  days.
• 13:59
  Make
• 13:59
  sure
• 13:59
  you're
• 13:59
  getting
• 14:00
  a
• 14:00
  careful
• 14:00
  history
• 14:00
  that
• 14:01
  he
• 14:01
  really
• 14:01
  gets
• 14:01
  a
• 14:02
  chance
• 14:03
  to
• 14:03
  snuff
• 14:03
  this
• 14:03
  out.
• 14:04
  And
• 14:04
  think
• 14:04
  about
• 14:04
  it.
• 14:05
  You
• 14:05
  will
• 14:05
  feel
• 14:05
  a
• 14:05
  lot
• 14:06
  of
• 14:06
  pressure
• 14:06
  in
• 14:06
  60
• 14:07
  minute
• 14:07
  appointments,
• 14:07
  30
• 14:08
  minute
• 14:08
  appointments
• 14:09
  for
• 14:09
  you
• 14:09
  to
• 14:10
  get
• 14:10
  an
• 14:10
  accurate
• 14:11
  timeline.
• 14:11
  Because
• 14:12
  even
• 14:12
  for
• 14:12
  patients,
• 14:13
  they're,
• 14:13
  they're
• 14:13
  not
• 14:13
  always
• 14:14
  going
• 14:14
  to
• 14:14
  give
• 14:14
  you
• 14:14
  the
• 14:14
  best
• 14:15
  timelines.
• 14:15
  They're
• 14:15
  coming
• 14:15
  to
• 14:16
  you
• 14:16
  because
• 14:16
  their
• 14:16
  thoughts
• 14:17
  are
• 14:17
  not
• 14:17
  organized.
• 14:17
  In
• 14:18
  depression,
• 14:18
  you
• 14:19
  have
• 14:19
  psychomotor
• 14:19
  retardation,
• 14:20
  you're
• 14:20
  moving
• 14:21
  slowly,
• 14:21
  you're
• 14:21
  thinking
• 14:22
  slowly,
• 14:22
  your
• 14:23
  answers
• 14:23
  are
• 14:23
  delayed,
• 14:23
  you're
• 14:24
  not
• 14:24
  concentrating
• 14:25
  very
• 14:25
  well.
• 14:25
  So
• 14:26
  it's
• 14:26
  not
• 14:26
  always
• 14:26
  easy
• 14:26
  for
• 14:27
  these
• 14:27
  patients
• 14:27
  to
• 14:27
  come
• 14:27
  up
• 14:28
  with
• 14:28
  exact
• 14:28
  hard
• 14:29
  timelines.
• 14:29
  For
• 14:30
  all
• 14:30
  intents
• 14:30
  and
• 14:30
  purposes,
• 14:31
  he
• 14:31
  says
• 14:31
  one
• 14:31
  to
• 14:32
  two
• 14:32
  days.
• 14:33
  And
• 14:33
  so
• 14:33
  you're
• 14:33
  falling
• 14:34
  short
• 14:34
  of
• 14:34
  that
• 14:34
  four
• 14:35
  day
• 14:35
  hypomania.
• 14:36
  You're
• 14:36
  also
• 14:36
  falling
• 14:37
  short
• 14:38
  of
• 14:38
  a
• 14:38
  diagnosis
• 14:39
  of
• 14:39
  bipolar
• 14:40
  one.
• 14:40
  Because
• 14:41
  now
• 14:41
  you
• 14:41
  could
• 14:41
  say,
• 14:42
  okay,
• 14:43
  let's
• 14:43
  throw
• 14:43
  all
• 14:43
  the
• 14:44
  symptoms
• 14:44
  out
• 14:44
  for
• 14:44
  a
• 14:44
  second.
• 14:45
  If
• 14:45
  he's
• 14:45
  ever
• 14:46
  been
• 14:47
  manic
• 14:47
  and
• 14:48
  hospitalized,
• 14:48
  bam,
• 14:49
  it's
• 14:49
  bipolar
• 14:50
  one,
• 14:50
  right?
• 14:50
  If
• 14:50
  he's
• 14:50
  in
• 14:51
  a
• 14:51
  manic
• 14:51
  state
• 14:51
  and
• 14:51
  he's
• 14:51
  hospitalized,
• 14:52
  he's
• 14:52
  automatically
• 14:53
  going
• 14:54
  down.
• 14:55
  The
• 14:55
  bipolar
• 14:55
  one
• 14:56
  diagnosis.
• 14:56
  He
• 14:57
  does
• 14:57
  need
• 14:57
  that
• 14:57
  cluster
• 14:57
  of
• 14:57
  symptoms,
• 14:58
  of
• 14:58
  course,
• 14:58
  but
• 14:59
  if
• 14:59
  it
• 14:59
  ends
• 14:59
  up
• 14:59
  in
• 14:59
  hospitalization,
• 15:01
  it's
• 15:01
  mania.
• 15:02
  Now,
• 15:02
  he
• 15:02
  did
• 15:02
  tell
• 15:03
  you
• 15:03
  he
• 15:03
  got
• 15:03
  hospitalized
• 15:04
  in
• 15:04
  the
• 15:04
  past,
• 15:04
  and
• 15:05
  patients
• 15:05
  a
• 15:05
  lot
• 15:05
  of
• 15:06
  times
• 15:06
  are
• 15:06
  going
• 15:06
  to
• 15:06
  tell
• 15:06
  you
• 15:08
  and
• 15:08
  they're
• 15:08
  being
• 15:08
  truthful,
• 15:09
  but
• 15:09
  again,
• 15:09
  they're
• 15:10
  not
• 15:10
  going
• 15:10
  to
• 15:10
  speak
• 15:10
  to
• 15:10
  you.
• 15:10
  Like
• 15:11
  a
• 15:11
  DSM
• 15:11
  5TR,
• 15:12
  they're
• 15:12
  going
• 15:13
  to
• 15:13
  say,
• 15:13
  oh
• 15:13
  well
• 15:13
  I
• 15:13
  was
• 15:13
  hospitalized
• 15:14
  because
• 15:15
  my
• 15:15
  mental
• 15:15
  health
• 15:15
  was
• 15:16
  just
• 15:16
  getting
• 15:16
  worse
• 15:16
  at
• 15:16
  that
• 15:17
  time.
• 15:17
  Let
• 15:17
  me
• 15:17
  tell
• 15:18
  you
• 15:18
  folks,
• 15:18
  as
• 15:18
  a
• 15:18
  clinician,
• 15:19
  that's
• 15:19
  not
• 15:19
  good
• 15:20
  enough.
• 15:20
  You
• 15:20
  need
• 15:21
  to
• 15:21
  do
• 15:21
  better.
• 15:21
  You
• 15:21
  have
• 15:22
  to
• 15:22
  elicit
• 15:22
  out
• 15:23
  of
• 15:23
  the
• 15:23
  patient.
• 15:24
  Walk
• 15:24
  me
• 15:24
  through
• 15:24
  what
• 15:25
  led
• 15:25
  to
• 15:25
  your
• 15:25
  admission
• 15:26
  that
• 15:26
  day.
• 15:26
  Was
• 15:27
  it
• 15:27
  during
• 15:27
  one
• 15:27
  of
• 15:27
  these
• 15:27
  high
• 15:28
  energy
• 15:28
  states?
• 15:29
  Were
• 15:29
  you
• 15:29
  admitted
• 15:30
  because
• 15:30
  you
• 15:30
  felt
• 15:31
  more
• 15:31
  and
• 15:31
  more
• 15:31
  depressed?
• 15:31
  Was
• 15:32
  this
• 15:32
  tied
• 15:32
  to
• 15:32
  a
• 15:32
  suicide
• 15:33
  attempt
• 15:33
  or
• 15:33
  self
• 15:34
  harm?
• 15:34
  Remember
• 15:35
  that
• 15:36
  suicide
• 15:36
  is
• 15:37
  impulsive,
• 15:37
  high
• 15:37
  risk
• 15:38
  activity
• 15:39
  mania,
• 15:39
  a
• 15:39
  manic
• 15:40
  break
• 15:40
  or
• 15:41
  manic
• 15:41
  cluster
• 15:41
  of
• 15:42
  symptoms
• 15:42
  could
• 15:42
  also
• 15:43
  include
• 15:43
  suicide.
• 15:45
  And
• 15:45
  so
• 15:46
  you
• 15:46
  want
• 15:46
  to
• 15:46
  really
• 15:46
  parse
• 15:47
  that
• 15:47
  out.
• 15:47
  Was
• 15:48
  his
• 15:48
  admission
• 15:48
  related
• 15:49
  to
• 15:49
  a
• 15:50
  manic
• 15:50
  episode?
• 15:51
  That
• 15:51
  may
• 15:52
  have
• 15:52
  not
• 15:52
  been
• 15:52
  four
• 15:53
  days
• 15:53
  or
• 15:53
  seven
• 15:53
  days,
• 15:54
  but
• 15:54
  it
• 15:54
  was
• 15:54
  manic
• 15:54
  and
• 15:55
  therefore
• 15:55
  if
• 15:55
  you
• 15:56
  corroborate
• 15:56
  it
• 15:56
  well
• 15:57
  enough,
• 15:57
  you
• 15:58
  could
• 15:58
  potentially
• 16:00
  declare
• 16:00
  this
• 16:00
  bipolar
• 16:01
  one.
• 16:01
  That's
• 16:02
  an
• 16:02
  important
• 16:02
  differential.
• 16:03
  But
• 16:03
  right
• 16:04
  now
• 16:05
  he's
• 16:05
  not
• 16:05
  quite
• 16:06
  meeting
• 16:06
  that
• 16:06
  criteria.
• 16:07
  We
• 16:08
  don't
• 16:08
  know
• 16:08
  if
• 16:08
  back
• 16:09
  then
• 16:09
  he
• 16:09
  even
• 16:09
  was
• 16:10
  diagnosed
• 16:10
  with
• 16:10
  bipolar
• 16:11
  2.
• 16:11
  So
• 16:11
  we
• 16:11
  have
• 16:11
  a
• 16:12
  clear
• 16:12
  depression,
• 16:12
  clear
• 16:13
  psychotic
• 16:13
  features
• 16:14
  and
• 16:14
  some
• 16:14
  mixed
• 16:15
  manic
• 16:16
  energy,
• 16:16
  but
• 16:16
  it
• 16:17
  doesn't
• 16:17
  quite
• 16:17
  meet
• 16:18
  threshold.
• 16:18
  Now
• 16:19
  the
• 16:19
  key,
• 16:19
  Pearl,
• 16:20
  I
• 16:20
  want
• 16:20
  you
• 16:20
  to
• 16:20
  remember
• 16:20
  is
• 16:21
  that
• 16:21
  major
• 16:21
  depressive
• 16:22
  with
• 16:22
  mixed
• 16:22
  features
• 16:23
  have
• 16:24
  to
• 16:24
  occur
• 16:24
  together.
• 16:25
  They're
• 16:25
  not
• 16:26
  separate.
• 16:26
  Right.
• 16:27
  And
• 16:27
  so
• 16:27
  if
• 16:27
  these,
• 16:27
  if
• 16:28
  this
• 16:28
  manic,
• 16:28
  if,
• 16:29
  if
• 16:29
  this
• 16:29
  manic
• 16:29
  activity
• 16:30
  was
• 16:30
  happening
• 16:30
  separate
• 16:31
  of
• 16:31
  his
• 16:31
  depression,
• 16:32
  we
• 16:32
  would
• 16:32
  definitely
• 16:33
  go
• 16:33
  down
• 16:33
  the
• 16:33
  bipolar
• 16:34
  spectrum.
• 16:34
  Diagnoses
• 16:36
  you
• 16:36
  would
• 16:36
  do
• 16:36
  like
• 16:36
  an
• 16:36
  other
• 16:37
  specified
• 16:37
  bipolar
• 16:38
  disorder
• 16:38
  or
• 16:38
  something
• 16:39
  of
• 16:39
  that
• 16:39
  nature.
• 16:40
  But
• 16:40
  because
• 16:40
  this
• 16:40
  is
• 16:41
  co
• 16:41
  occurring
• 16:42
  with
• 16:42
  his
• 16:42
  depression
• 16:42
  and
• 16:42
  he's
• 16:43
  telling
• 16:43
  you
• 16:43
  I'm
• 16:43
  depressed
• 16:44
  and
• 16:44
  at
• 16:44
  the
• 16:44
  same
• 16:44
  time
• 16:44
  I
• 16:45
  have
• 16:45
  one
• 16:45
  to
• 16:45
  two
• 16:45
  days
• 16:46
  where
• 16:46
  I'm
• 16:47
  not
• 16:47
  sleeping
• 16:47
  as
• 16:47
  much,
• 16:48
  I
• 16:48
  have
• 16:48
  energy.
• 16:49
  But
• 16:49
  he's
• 16:50
  telling
• 16:50
  you
• 16:50
  at
• 16:50
  the
• 16:50
  same
• 16:51
  time
• 16:51
  I'm
• 16:52
  also
• 16:52
  depressed
• 16:52
  those
• 16:52
  days.
• 16:53
  I'm
• 16:53
  also
• 16:54
  kind
• 16:54
  of
• 16:54
  down
• 16:54
  those
• 16:54
  days.
• 16:55
  It
• 16:55
  doesn't
• 16:55
  really
• 16:56
  go
• 16:56
  away.
• 16:56
  I
• 16:56
  just
• 16:56
  get
• 16:57
  these
• 16:57
  surges
• 16:57
  of
• 16:57
  energy.
• 16:57
  I
• 16:58
  talk
• 16:58
  fast
• 16:58
  a
• 16:58
  little
• 16:59
  bit,
• 16:59
  but
• 16:59
  I'm
• 17:00
  honestly
• 17:00
  also
• 17:01
  feeling
• 17:03
  kind
• 17:03
  of
• 17:03
  energized
• 17:04
  those
• 17:04
  days.
• 17:05
  So
• 17:06
  yes,
• 17:07
  that
• 17:07
  would
• 17:07
  be
• 17:07
  more
• 17:07
  of
• 17:08
  MDD
• 17:09
  with
• 17:09
  mixed
• 17:10
  features.
• 17:11
  So
• 17:11
  keep
• 17:11
  that
• 17:11
  in
• 17:12
  mind
• 17:12
  my
• 17:12
  friends.
• 17:12
  That's
• 17:12
  a
• 17:12
  very
• 17:13
  important
• 17:13
  pearl.
• 17:14
  My
• 17:14
  friends,
• 17:15
  this
• 17:15
  is
• 17:16
  an
• 17:16
  evolving
• 17:18
  field.
• 17:19
  We
• 17:19
  used
• 17:19
  to
• 17:19
  believe
• 17:20
  these
• 17:20
  mood
• 17:20
  states
• 17:21
  were
• 17:21
  more
• 17:21
  clearly
• 17:21
  demarcated.
• 17:22
  Depression
• 17:23
  in
• 17:23
  one
• 17:23
  corner,
• 17:24
  bipolar
• 17:24
  in
• 17:24
  another,
• 17:25
  schizophrenia
• 17:25
  in
• 17:25
  another,
• 17:26
  and
• 17:26
  mixed
• 17:26
  features.
• 17:27
  Here
• 17:27
  we're
• 17:28
  starting
• 17:28
  to
• 17:28
  understand
• 17:29
  that
• 17:30
  a
• 17:30
  lot
• 17:30
  of
• 17:30
  this
• 17:30
  is
• 17:30
  on
• 17:31
  a
• 17:31
  spectrum.
• 17:32
  So
• 17:32
  the
• 17:32
  DSM
• 17:32
  5TR
• 17:33
  might
• 17:33
  say,
• 17:34
  you
• 17:34
  know,
• 17:34
  in
• 17:34
  order
• 17:35
  for
• 17:35
  you
• 17:35
  to
• 17:35
  have
• 17:35
  mixed
• 17:36
  features,
• 17:36
  you
• 17:36
  need
• 17:37
  depression
• 17:37
  with
• 17:38
  at
• 17:38
  least
• 17:38
  three
• 17:39
  manic
• 17:40
  symptoms
• 17:40
  that
• 17:41
  CO
• 17:41
  occur
• 17:42
  or
• 17:42
  three
• 17:43
  of
• 17:43
  the
• 17:44
  bipolar
• 17:44
  1
• 17:44
  or
• 17:45
  2
• 17:45
  symptoms
• 17:46
  that
• 17:46
  CO
• 17:46
  occur,
• 17:47
  that
• 17:47
  would
• 17:47
  be
• 17:47
  your
• 17:47
  mixed
• 17:48
  features
• 17:49
  diagnosis.
• 17:49
  But
• 17:50
  as
• 17:50
  we
• 17:50
  know,
• 17:51
  life
• 17:51
  is
• 17:52
  a
• 17:52
  little
• 17:52
  more
• 17:52
  complicated
• 17:53
  than
• 17:53
  that.
• 17:54
  Colors
• 17:54
  blending
• 17:55
  into
• 17:55
  each
• 17:55
  other
• 17:55
  and
• 17:56
  they're
• 17:56
  not
• 17:56
  distinct
• 17:57
  blocks.
• 17:58
  A
• 17:58
  lot
• 17:58
  of
• 17:58
  the
• 17:58
  neurocircuitry
• 17:59
  is
• 18:00
  shared
• 18:00
  in
• 18:00
  the
• 18:00
  brain.
• 18:01
  We
• 18:01
  know
• 18:02
  that
• 18:02
  bipolar
• 18:02
  disorder
• 18:03
  often
• 18:03
  shares
• 18:03
  characteristics
• 18:04
  with
• 18:05
  schizophrenia
• 18:06
  and
• 18:06
  that
• 18:07
  certain
• 18:07
  types
• 18:07
  of
• 18:07
  bipolar
• 18:08
  disorder
• 18:08
  can
• 18:08
  look
• 18:09
  very
• 18:09
  similar
• 18:09
  to
• 18:09
  major
• 18:09
  depressive
• 18:10
  disorder.
• 18:11
  I
• 18:11
  would
• 18:11
  urge
• 18:11
  you
• 18:11
  to
• 18:12
  kind
• 18:12
  of,
• 18:12
  even
• 18:13
  though
• 18:13
  we
• 18:13
  do
• 18:13
  have
• 18:13
  to
• 18:14
  look
• 18:14
  at
• 18:14
  our
• 18:14
  textbooks
• 18:15
  and
• 18:15
  help
• 18:15
  orient
• 18:16
  ourselves
• 18:16
  to
• 18:16
  what
• 18:17
  we're
• 18:17
  looking
• 18:17
  at,
• 18:18
  we've
• 18:18
  got
• 18:18
  to
• 18:18
  look
• 18:19
  at
• 18:20
  what
• 18:20
  else
• 18:20
  this
• 18:20
  stuff
• 18:21
  could
• 18:22
  be
• 18:22
  on
• 18:22
  more
• 18:23
  of
• 18:23
  a
• 18:23
  spectrum
• 18:23
  approach.
• 18:25
  Those
• 18:25
  mixed
• 18:25
  features.
• 18:26
  By
• 18:26
  the
• 18:26
  way,
• 18:26
  there's
• 18:27
  a
• 18:27
  much
• 18:27
  higher
• 18:27
  proclivity
• 18:28
  for
• 18:28
  that
• 18:28
  patient
• 18:29
  to
• 18:29
  spin
• 18:30
  out
• 18:30
  into
• 18:30
  a
• 18:30
  full
• 18:30
  blown
• 18:31
  bipolar
• 18:31
  I
• 18:31
  or
• 18:31
  bipolar
• 18:32
  2
• 18:32
  disorder.
• 18:33
  So
• 18:33
  those
• 18:33
  mixed
• 18:34
  features
• 18:34
  are
• 18:34
  important
• 18:34
  because
• 18:35
  this
• 18:35
  patient,
• 18:36
  Gus
• 18:36
  could
• 18:36
  pack
• 18:37
  up
• 18:37
  and
• 18:37
  move
• 18:37
  to
• 18:37
  Alaska
• 18:38
  in
• 18:38
  a
• 18:38
  week.
• 18:39
  But
• 18:39
  because
• 18:40
  you
• 18:40
  flagged
• 18:40
  his
• 18:41
  his
• 18:41
  case
• 18:42
  with
• 18:42
  a
• 18:42
  mixed
• 18:42
  feature
• 18:43
  specifier,
• 18:44
  that
• 18:45
  next
• 18:45
  provider
• 18:46
  could
• 18:46
  really
• 18:46
  be
• 18:47
  helped
• 18:47
  by
• 18:47
  that
• 18:48
  and
• 18:49
  understand
• 18:49
  that
• 18:50
  this
• 18:50
  very
• 18:51
  well
• 18:51
  could
• 18:51
  turn
• 18:51
  into
• 18:52
  a
• 18:52
  full
• 18:52
  blown
• 18:53
  bipolar
• 18:54
  disorder.
• 18:55
  Very
• 18:55
  important
• 18:56
  stuff
• 18:56
  here,
• 18:56
  my
• 18:56
  friends.
• 18:57
  Now
• 18:58
  what
• 18:58
  do
• 18:58
  we
• 18:58
  do
• 18:58
  for
• 18:58
  a
• 18:59
  patient
• 18:59
  like
• 18:59
  this,
• 18:59
  for
• 19:00
  someone
• 19:00
  who's
• 19:00
  severely
• 19:01
  depressed
• 19:01
  and
• 19:01
  not
• 19:02
  quite
• 19:02
  making
• 19:02
  the
• 19:03
  bipolar
• 19:04
  one
• 19:04
  or
• 19:04
  two
• 19:05
  diagnosed
• 19:05
  diagnostic
• 19:06
  threshold,
• 19:07
  you
• 19:07
  could
• 19:07
  optimize
• 19:08
  his
• 19:08
  Wellbutrin
• 19:08
  to
• 19:09
  450.
• 19:09
  Now
• 19:10
  there
• 19:10
  is
• 19:10
  a
• 19:10
  slight
• 19:10
  risk
• 19:11
  of
• 19:11
  manic
• 19:11
  induction
• 19:12
  with
• 19:12
  that,
• 19:12
  but
• 19:13
  the
• 19:13
  risk
• 19:13
  for
• 19:13
  induction
• 19:14
  is
• 19:14
  markedly
• 19:15
  lower
• 19:15
  in
• 19:15
  an
• 19:15
  NDRI
• 19:16
  like
• 19:16
  Wellbutrin
• 19:17
  than
• 19:17
  it
• 19:17
  would
• 19:17
  be
• 19:17
  in
• 19:17
  an
• 19:18
  ssri.
• 19:19
  So
• 19:19
  you
• 19:19
  could
• 19:20
  optimize
• 19:20
  his
• 19:21
  dose
• 19:21
  of
• 19:21
  Wellbutrin,
• 19:22
  especially
• 19:22
  if
• 19:22
  he
• 19:22
  told
• 19:23
  you
• 19:23
  in
• 19:23
  the
• 19:23
  beginning
• 19:24
  it
• 19:24
  definitely
• 19:24
  helped
• 19:25
  with
• 19:25
  his
• 19:25
  depression
• 19:26
  and
• 19:26
  he
• 19:26
  did
• 19:26
  not
• 19:26
  feel
• 19:27
  more
• 19:27
  energizer
• 19:27
  manic
• 19:28
  on
• 19:28
  that
• 19:28
  Wellbutrin.
• 19:29
  That
• 19:29
  would
• 19:29
  not
• 19:29
  be
• 19:30
  a
• 19:30
  crazy
• 19:30
  decision
• 19:31
  at
• 19:31
  all.
• 19:32
  For
• 19:32
  simplicity's
• 19:33
  sake,
• 19:33
  I
• 19:33
  would
• 19:34
  choose
• 19:34
  something
• 19:34
  like
• 19:34
  Abilify
• 19:35
  to
• 19:35
  immediately
• 19:36
  stabilize
• 19:37
  his
• 19:37
  psychotic
• 19:39
  symptoms
• 19:40
  and
• 19:40
  to
• 19:41
  provide
• 19:41
  a
• 19:41
  bit
• 19:41
  of
• 19:41
  an
• 19:41
  adjunct
• 19:42
  to
• 19:42
  his
• 19:42
  depression.
• 19:43
  I
• 19:43
  would
• 19:43
  add
• 19:43
  on
• 19:44
  the
• 19:44
  abil
• 19:45
  to
• 19:45
  target
• 19:45
  any
• 19:46
  kind
• 19:46
  of
• 19:46
  agitation,
• 19:46
  irritability,
• 19:47
  dysphoria,
• 19:48
  and
• 19:49
  some
• 19:49
  of
• 19:49
  his
• 19:49
  psychotic
• 19:50
  symptoms.
• 19:50
  I
• 19:50
  would
• 19:50
  aim
• 19:51
  for
• 19:51
  maybe
• 19:51
  2
• 19:52
  to
• 19:52
  5
• 19:52
  milligrams
• 19:52
  daily.
• 19:53
  I
• 19:53
  would
• 19:53
  target
• 19:53
  5
• 19:54
  to
• 19:54
  15
• 19:54
  milligrams
• 19:55
  per
• 19:55
  day,
• 19:55
  depending
• 19:55
  on
• 19:56
  his
• 19:56
  response.
• 19:57
  You
• 19:57
  know
• 19:57
  that
• 19:57
  Abilify
• 19:58
  can
• 19:58
  always
• 19:58
  cause
• 19:58
  akaesthesia
• 19:59
  or
• 19:59
  inner
• 20:00
  restlessness.
• 20:00
  Very
• 20:01
  common,
• 20:01
  especially
• 20:02
  as
• 20:02
  you
• 20:02
  increase
• 20:02
  the
• 20:03
  dose.
• 20:03
  So
• 20:03
  I
• 20:04
  definitely
• 20:04
  get
• 20:04
  a
• 20:04
  feel
• 20:04
  for
• 20:05
  the
• 20:05
  patient
• 20:06
  as
• 20:06
  to
• 20:06
  whether
• 20:06
  or
• 20:07
  not
• 20:07
  he's
• 20:08
  tolerating
• 20:08
  the
• 20:08
  Wellbutrin
• 20:09
  and
• 20:09
  titrate
• 20:10
  accordingly.
• 20:11
  Not
• 20:11
  delaying
• 20:12
  so
• 20:12
  much,
• 20:12
  but
• 20:12
  also
• 20:12
  going
• 20:13
  at
• 20:13
  his
• 20:14
  pace.
• 20:14
  So
• 20:14
  we're
• 20:15
  not
• 20:15
  knocking
• 20:15
  him
• 20:15
  out
• 20:16
  early
• 20:16
  and
• 20:17
  he
• 20:17
  doesn't
• 20:17
  want
• 20:17
  to
• 20:18
  try
• 20:18
  meds
• 20:18
  anymore
• 20:18
  and
• 20:19
  his
• 20:19
  symptoms
• 20:19
  are
• 20:20
  just
• 20:20
  going
• 20:20
  to
• 20:20
  get
• 20:20
  worse.
• 20:20
  Be
• 20:21
  mindful
• 20:22
  of
• 20:22
  Abilify's
• 20:23
  potential
• 20:23
  metabolic
• 20:24
  side
• 20:24
  effects.
• 20:25
  Weight
• 20:25
  gain,
• 20:25
  dyslipidemia,
• 20:26
  hyperglycemia
• 20:27
  with
• 20:27
  long
• 20:28
  term
• 20:28
  use,
• 20:28
  and
• 20:29
  anesthesia,
• 20:30
  among
• 20:30
  other
• 20:30
  things.
• 20:30
  Right.
• 20:31
  Again,
• 20:31
  I
• 20:31
  think
• 20:31
  Abilify
• 20:32
  really
• 20:32
  works
• 20:32
  for
• 20:33
  this
• 20:33
  stuff
• 20:33
  and
• 20:34
  it
• 20:34
  could
• 20:35
  help
• 20:35
  stabilize
• 20:36
  the
• 20:36
  patient
• 20:37
  given
• 20:37
  his
• 20:37
  mixed
• 20:38
  presentation
• 20:38
  by
• 20:38
  normalizing
• 20:39
  some
• 20:40
  of
• 20:40
  his
• 20:40
  dopaminergic
• 20:41
  dysregulation
• 20:42
  rather
• 20:42
  than
• 20:42
  just
• 20:43
  blocking
• 20:43
  all
• 20:43
  of
• 20:43
  his
• 20:44
  dopamine
• 20:44
  outright.
• 20:44
  As
• 20:45
  you
• 20:45
  all
• 20:45
  know,
• 20:45
  Abilify
• 20:46
  is
• 20:46
  a
• 20:46
  partial
• 20:47
  agonist,
• 20:47
  right?
• 20:47
  So
• 20:48
  it
• 20:48
  tends
• 20:48
  to
• 20:48
  increase
• 20:48
  dopamine
• 20:49
  in
• 20:49
  certain
• 20:50
  parts
• 20:50
  of
• 20:50
  the
• 20:50
  brain
• 20:50
  and
• 20:50
  decrease
• 20:51
  it
• 20:52
  in
• 20:52
  other
• 20:52
  parts
• 20:52
  of
• 20:52
  the
• 20:52
  brain.
• 20:53
  It's
• 20:53
  a
• 20:53
  bit
• 20:53
  of
• 20:53
  a
• 20:53
  dimmer
• 20:54
  switch
• 20:54
  for
• 20:54
  dopamine,
• 20:55
  which
• 20:55
  is
• 20:56
  pretty
• 20:56
  fascinating,
• 20:57
  actually.
• 20:57
  If
• 20:58
  you
• 20:58
  become
• 20:58
  a
• 20:58
  Patreon
• 20:59
  member,
• 20:59
  you
• 20:59
  will
• 21:00
  see
• 21:00
  in
• 21:00
  more
• 21:00
  detail
• 21:01
  a
• 21:01
  pharmacology
• 21:02
  deep
• 21:02
  dive
• 21:03
  as
• 21:03
  to
• 21:03
  what
• 21:04
  Abilify
• 21:04
  can
• 21:05
  do.
• 21:05
  We
• 21:05
  go
• 21:06
  into
• 21:06
  a
• 21:06
  lot
• 21:06
  more
• 21:07
  about
• 21:08
  dosing
• 21:08
  and
• 21:08
  pharmacokinetics
• 21:09
  and
• 21:09
  dynamics.
• 21:10
  It
• 21:10
  is
• 21:10
  well
• 21:10
  worth
• 21:11
  your
• 21:11
  time.
• 21:11
  Go
• 21:11
  to
• 21:12
  the
• 21:12
  Show
• 21:12
  Notes
• 21:13
  and
• 21:13
  click
• 21:13
  the
• 21:13
  link
• 21:14
  and
• 21:14
  become
• 21:14
  a
• 21:14
  Patreon
• 21:15
  member.
• 21:15
  Tell
• 21:15
  your
• 21:15
  NP
• 21:16
  friends
• 21:16
  this
• 21:17
  podcast
• 21:17
  has
• 21:17
  gotten
• 21:18
  really
• 21:18
  hot
• 21:18
  really
• 21:18
  fast
• 21:19
  because
• 21:20
  of
• 21:20
  these
• 21:20
  resources.
• 21:21
  These
• 21:21
  slide
• 21:21
  decks
• 21:22
  are
• 21:22
  beautiful.
• 21:22
  They're
• 21:23
  accessible
• 21:23
  to
• 21:23
  you
• 21:24
  in
• 21:24
  one
• 21:24
  place
• 21:24
  to
• 21:25
  study
• 21:25
  and
• 21:25
  to
• 21:25
  really
• 21:25
  break
• 21:26
  this
• 21:26
  down
• 21:27
  into
• 21:27
  human
• 21:27
  words
• 21:28
  and
• 21:28
  language.
• 21:29
  So
• 21:29
  getting
• 21:29
  back
• 21:30
  to
• 21:30
  it,
• 21:30
  the
• 21:30
  dopamine
• 21:31
  dimmer
• 21:31
  switch,
• 21:31
  Abilify.
• 21:32
  That's
• 21:32
  what
• 21:32
  we
• 21:32
  want
• 21:33
  to
• 21:33
  do.
• 21:33
  We
• 21:33
  want
• 21:34
  to
• 21:34
  titrate
• 21:34
  as
• 21:35
  tolerated
• 21:36
  for
• 21:36
  the
• 21:36
  patient,
• 21:37
  and
• 21:38
  we
• 21:39
  want
• 21:39
  to
• 21:40
  see
• 21:40
  whether
• 21:40
  this
• 21:41
  works
• 21:42
  out.
• 21:42
  We
• 21:42
  found
• 21:43
  that
• 21:43
  Abilify
• 21:44
  can
• 21:44
  really,
• 21:45
  through
• 21:45
  its
• 21:45
  partial
• 21:46
  agonism,
• 21:46
  provide
• 21:47
  superior
• 21:47
  mood
• 21:47
  stabilization
• 21:48
  in
• 21:48
  mixed
• 21:49
  states.
• 21:50
  It's
• 21:50
  more
• 21:50
  of
• 21:50
  a
• 21:50
  nuanced
• 21:51
  regulation
• 21:51
  of
• 21:51
  dopaminergic
• 21:52
  activity,
• 21:53
  thereby
• 21:53
  reducing
• 21:54
  depressive
• 21:55
  inertia
• 21:55
  and
• 21:56
  manic
• 21:56
  agitation.
• 21:57
  Right.
• 21:57
  And
• 21:57
  in
• 21:58
  your
• 21:58
  mind,
• 21:58
  I
• 21:58
  want
• 21:58
  you
• 21:59
  to
• 21:59
  remember,
• 22:00
  don't
• 22:00
  think
• 22:00
  like
• 22:01
  I
• 22:01
  don't
• 22:01
  know
• 22:01
  what
• 22:01
  this
• 22:01
  is.
• 22:01
  Is
• 22:02
  this
• 22:02
  depression?
• 22:02
  Is
• 22:02
  this
• 22:03
  bipolar?
• 22:03
  What
• 22:03
  is
• 22:04
  this?
• 22:04
  We
• 22:04
  have
• 22:04
  to
• 22:05
  worry
• 22:05
  about
• 22:05
  that
• 22:05
  to
• 22:06
  an
• 22:06
  extent,
• 22:06
  of
• 22:06
  course.
• 22:07
  But
• 22:07
  I
• 22:07
  want
• 22:08
  you
• 22:08
  to
• 22:08
  also
• 22:08
  keep
• 22:09
  in
• 22:09
  mind
• 22:09
  that
• 22:10
  we're
• 22:10
  treating
• 22:10
  symptoms.
• 22:11
  We're
• 22:11
  treating
• 22:11
  a
• 22:11
  human
• 22:11
  in
• 22:12
  front
• 22:12
  of
• 22:12
  us
• 22:12
  who's
• 22:12
  suffering
• 22:13
  from
• 22:13
  symptoms
• 22:14
  at
• 22:14
  the
• 22:14
  end
• 22:14
  of
• 22:15
  the
• 22:15
  day.
• 22:15
  As
• 22:15
  long
• 22:15
  as
• 22:16
  you
• 22:16
  know
• 22:16
  broadly
• 22:17
  what
• 22:17
  these
• 22:18
  medications
• 22:18
  are
• 22:18
  intended
• 22:19
  for,
• 22:19
  what
• 22:19
  they're
• 22:20
  used
• 22:20
  for,
• 22:20
  the
• 22:20
  neurotransmitters
• 22:21
  that
• 22:21
  they
• 22:22
  target,
• 22:23
  whether
• 22:24
  or
• 22:24
  not
• 22:24
  he's
• 22:24
  full
• 22:25
  blown
• 22:25
  bipolar
• 22:26
  1,
• 22:26
  bipolar
• 22:27
  2,
• 22:27
  depression
• 22:28
  with
• 22:28
  mixed
• 22:28
  features.
• 22:29
  Putting
• 22:30
  on
• 22:31
  Abilify
• 22:31
  into
• 22:32
  this
• 22:32
  mix
• 22:32
  should
• 22:33
  be
• 22:33
  helpful.
• 22:34
  Of
• 22:34
  course,
• 22:34
  there
• 22:34
  are
• 22:35
  other
• 22:35
  potential
• 22:36
  diagnoses
• 22:37
  Abilify
• 22:37
  may
• 22:38
  be
• 22:38
  completely
• 22:38
  inappropriate,
• 22:39
  right?
• 22:39
  If
• 22:39
  you
• 22:40
  find
• 22:40
  out
• 22:40
  that
• 22:40
  your
• 22:40
  patient
• 22:41
  just
• 22:41
  has
• 22:41
  a
• 22:41
  personality
• 22:42
  disorder,
• 22:42
  well,
• 22:42
  Abilify
• 22:43
  might
• 22:43
  not
• 22:43
  be
• 22:43
  your
• 22:44
  jam.
• 22:44
  You
• 22:44
  might
• 22:44
  have
• 22:44
  to
• 22:45
  push
• 22:45
  for
• 22:46
  DBT
• 22:46
  or
• 22:46
  something
• 22:47
  different.
• 22:47
  But
• 22:48
  in
• 22:48
  this
• 22:48
  case
• 22:48
  with
• 22:48
  Gus,
• 22:49
  he's
• 22:49
  confirmed
• 22:50
  he's
• 22:50
  depressed.
• 22:51
  He
• 22:51
  cycles
• 22:52
  in
• 22:52
  and
• 22:52
  out
• 22:52
  of
• 22:52
  it
• 22:53
  for
• 22:53
  months
• 22:53
  at
• 22:53
  a
• 22:54
  time.
• 22:54
  He's
• 22:54
  experiencing
• 22:55
  psychosis
• 22:56
  with
• 22:56
  it.
• 22:56
  Of
• 22:56
  course,
• 22:57
  you
• 22:57
  also
• 22:57
  want
• 22:57
  to
• 22:58
  make
• 22:58
  sure,
• 22:58
  does
• 22:58
  he
• 22:58
  need
• 22:58
  to
• 22:59
  be
• 22:59
  hospitalized?
• 22:59
  Are
• 23:00
  the
• 23:00
  voices
• 23:00
  getting
• 23:00
  to
• 23:01
  the
• 23:01
  point
• 23:01
  where
• 23:01
  he
• 23:01
  can't
• 23:01
  eat,
• 23:02
  he
• 23:02
  can't
• 23:02
  sleep,
• 23:02
  he
• 23:02
  can't
• 23:03
  function,
• 23:03
  he
• 23:03
  can't
• 23:04
  change
• 23:04
  his
• 23:04
  bed,
• 23:04
  he
• 23:04
  can't
• 23:05
  prepare
• 23:05
  a
• 23:05
  meal?
• 23:06
  You've
• 23:06
  got
• 23:06
  to
• 23:06
  put
• 23:06
  that
• 23:06
  on
• 23:07
  the
• 23:07
  table.
• 23:07
  If
• 23:07
  a
• 23:07
  patient's
• 23:08
  psychotic.
• 23:08
  Not
• 23:09
  every
• 23:09
  patient
• 23:09
  who's
• 23:10
  psychotic
• 23:10
  needs
• 23:10
  to
• 23:10
  go
• 23:11
  to
• 23:11
  the
• 23:11
  hospital.
• 23:12
  You
• 23:12
  probably
• 23:12
  know
• 23:12
  that
• 23:12
  by
• 23:12
  now,
• 23:13
  if
• 23:13
  you're
• 23:13
  an
• 23:13
  NP
• 23:14
  school,
• 23:14
  right,
• 23:15
  that
• 23:15
  there's
• 23:16
  plenty
• 23:16
  of
• 23:16
  people
• 23:16
  who
• 23:17
  do
• 23:17
  not
• 23:17
  need
• 23:17
  to
• 23:17
  be
• 23:17
  hospitalized
• 23:18
  and
• 23:18
  they're
• 23:19
  hearing
• 23:19
  voices
• 23:19
  or
• 23:19
  seeing
• 23:20
  shadows.
• 23:20
  They
• 23:21
  can
• 23:21
  be
• 23:21
  stabilized
• 23:21
  on
• 23:22
  the
• 23:22
  outpatient
• 23:22
  side.
• 23:22
  But
• 23:23
  you
• 23:23
  definitely
• 23:23
  have
• 23:23
  to
• 23:23
  consider
• 23:24
  that
• 23:24
  when
• 23:24
  some
• 23:24
  of
• 23:25
  these
• 23:25
  big
• 23:25
  gun
• 23:25
  symptoms
• 23:26
  are
• 23:26
  on
• 23:27
  the
• 23:27
  table,
• 23:27
  even
• 23:28
  though
• 23:28
  they
• 23:28
  may
• 23:29
  have
• 23:29
  mixed
• 23:29
  features
• 23:29
  and
• 23:30
  they
• 23:30
  may
• 23:30
  have
• 23:31
  bipolar
• 23:31
  disorder,
• 23:32
  bipolar
• 23:32
  I
• 23:32
  or
• 23:32
  ii,
• 23:33
  you're
• 23:33
  mainly
• 23:33
  seeing
• 23:34
  them
• 23:34
  when
• 23:34
  you're
• 23:34
  depressed.
• 23:34
  So
• 23:35
  you're
• 23:35
  going
• 23:35
  to
• 23:35
  have
• 23:35
  a
• 23:35
  lot
• 23:35
  of
• 23:36
  anchoring
• 23:36
  bias
• 23:36
  here,
• 23:37
  and
• 23:37
  you're
• 23:37
  going
• 23:37
  to
• 23:38
  start
• 23:38
  to
• 23:38
  think,
• 23:38
  well,
• 23:38
  this
• 23:38
  is
• 23:38
  what
• 23:39
  I'm
• 23:39
  anchoring
• 23:39
  to.
• 23:39
  The
• 23:40
  first
• 23:40
  thing
• 23:40
  I
• 23:40
  see,
• 23:41
  I
• 23:41
  think
• 23:42
  this
• 23:42
  person
• 23:42
  just
• 23:43
  has
• 23:43
  depression.
• 23:44
  We
• 23:44
  did
• 23:44
  talk
• 23:44
  about
• 23:45
  dosing
• 23:45
  depression
• 23:46
  augmentation,
• 23:46
  typically
• 23:47
  5-10mg.
• 23:48
  By
• 23:49
  balancing
• 23:49
  the
• 23:49
  side
• 23:49
  effects
• 23:50
  with
• 23:50
  Abilify
• 23:51
  for
• 23:52
  peak
• 23:52
  efficacy
• 23:52
  and
• 23:53
  mixed
• 23:53
  features,
• 23:53
  somewhere
• 23:54
  between
• 23:54
  10
• 23:54
  and
• 23:54
  15
• 23:55
  milligrams
• 23:55
  may
• 23:55
  be
• 23:56
  required.
• 23:56
  All
• 23:57
  clinicians,
• 23:57
  you
• 23:57
  got
• 23:57
  to
• 23:58
  monitor
• 23:58
  this,
• 23:58
  test
• 23:59
  how
• 23:59
  your
• 23:59
  patients
• 23:59
  do
• 24:00
  on
• 24:00
  this.
• 24:00
  Some
• 24:00
  don't
• 24:00
  metabolize
• 24:01
  abilify
• 24:02
  the
• 24:02
  same
• 24:02
  way
• 24:02
  others
• 24:02
  do.
• 24:03
  What's
• 24:04
  5
• 24:04
  milligrams
• 24:04
  for
• 24:04
  someone?
• 24:05
  Could
• 24:05
  be
• 24:05
  like
• 24:05
  15
• 24:06
  for
• 24:06
  someone
• 24:06
  else.
• 24:07
  You've
• 24:07
  gotta
• 24:07
  really
• 24:08
  look
• 24:08
  at
• 24:08
  this,
• 24:08
  go
• 24:09
  over
• 24:09
  the
• 24:09
  side
• 24:09
  effects,
• 24:09
  consult
• 24:10
  your
• 24:10
  resources.
• 24:11
  And
• 24:11
  in
• 24:11
  this
• 24:12
  person's
• 24:12
  case,
• 24:12
  you
• 24:12
  could
• 24:13
  consider
• 24:13
  mood
• 24:13
  stabilization
• 24:14
  on
• 24:14
  the
• 24:15
  side,
• 24:15
  right?
• 24:15
  Lithium,
• 24:16
  lamotrigine?
• 24:17
  It's
• 24:17
  possible,
• 24:18
  right?
• 24:18
  Depending
• 24:18
  on
• 24:19
  your
• 24:19
  patient.
• 24:19
  You've
• 24:19
  gotta
• 24:20
  get
• 24:20
  a
• 24:20
  feel
• 24:20
  for
• 24:20
  how
• 24:20
  they
• 24:20
  respond
• 24:21
  to
• 24:21
  each
• 24:22
  of
• 24:22
  your
• 24:22
  interventions.
• 24:24
  So
• 24:25
  I
• 24:25
  want
• 24:25
  you
• 24:25
  all
• 24:26
  to
• 24:26
  come
• 24:26
  away
• 24:26
  with
• 24:26
  some
• 24:27
  big
• 24:27
  pearls
• 24:27
  from
• 24:27
  this.
• 24:28
  Mainly
• 24:28
  that
• 24:29
  there
• 24:29
  is
• 24:29
  a
• 24:29
  thing
• 24:30
  called
• 24:30
  MDD
• 24:31
  with
• 24:31
  mixed
• 24:31
  features.
• 24:32
  Three
• 24:32
  or
• 24:32
  more
• 24:33
  symptoms
• 24:34
  of
• 24:35
  bipolar
• 24:35
  disorder
• 24:36
  of
• 24:36
  the
• 24:36
  manic
• 24:36
  side
• 24:37
  of
• 24:37
  things.
• 24:37
  Those
• 24:37
  manic
• 24:38
  symptoms
• 24:38
  in
• 24:39
  addition
• 24:40
  happening
• 24:40
  with
• 24:41
  your
• 24:42
  major
• 24:42
  depression,
• 24:43
  but
• 24:43
  they
• 24:43
  don't
• 24:43
  quite
• 24:43
  meet
• 24:43
  criteria
• 24:44
  for
• 24:44
  a
• 24:44
  full
• 24:44
  Bipolar
• 24:45
  disorder.
• 24:46
  Always
• 24:46
  know
• 24:46
  that
• 24:46
  bipolar
• 24:47
  1
• 24:47
  disorder
• 24:48
  usually
• 24:48
  lands
• 24:48
  you
• 24:49
  in
• 24:49
  the
• 24:49
  hospital.
• 24:49
  Right.
• 24:49
  These
• 24:50
  are
• 24:50
  extreme
• 24:50
  states.
• 24:50
  They're
• 24:51
  completely
• 24:51
  impairing
• 24:52
  and
• 24:53
  they
• 24:53
  often
• 24:53
  occur
• 24:54
  with
• 24:54
  psychosis.
• 24:55
  Right.
• 24:56
  So
• 24:56
  it's
• 24:56
  different
• 24:57
  than
• 24:57
  bipolar
• 24:57
  2,
• 24:58
  which
• 24:58
  is
• 24:58
  not
• 24:59
  significantly
• 24:59
  impairing
• 25:00
  to
• 25:01
  the
• 25:01
  extent
• 25:01
  that
• 25:01
  bipolar
• 25:02
  one
• 25:02
  is.
• 25:03
  Although
• 25:03
  I
• 25:03
  would
• 25:03
  argue
• 25:04
  bipolar
• 25:04
  two
• 25:04
  is
• 25:04
  extremely
• 25:05
  damaging.
• 25:05
  We
• 25:06
  go
• 25:06
  over
• 25:06
  in
• 25:06
  other
• 25:06
  lectures,
• 25:07
  make
• 25:08
  sure
• 25:08
  you're
• 25:08
  checking
• 25:08
  your
• 25:09
  labs
• 25:09
  to
• 25:09
  make
• 25:09
  sure
• 25:10
  there's
• 25:10
  no
• 25:10
  medical
• 25:10
  mimics
• 25:11
  here
• 25:11
  that
• 25:11
  could
• 25:12
  be
• 25:12
  worsening
• 25:12
  or
• 25:13
  could
• 25:13
  even
• 25:13
  be
• 25:14
  the
• 25:14
  initial
• 25:15
  source
• 25:15
  of
• 25:15
  these
• 25:15
  symptoms.
• 25:16
  In
• 25:16
  this
• 25:16
  case,
• 25:17
  with
• 25:17
  our
• 25:17
  friend
• 25:17
  Gus,
• 25:18
  we
• 25:18
  gave
• 25:18
  him
• 25:18
  Abilify.
• 25:19
  We
• 25:19
  titrated
• 25:19
  to
• 25:20
  the
• 25:20
  10
• 25:20
  to
• 25:20
  15
• 25:20
  range.
• 25:21
  He
• 25:21
  tolerated
• 25:21
  it
• 25:22
  well.
• 25:23
  He
• 25:23
  did
• 25:23
  have
• 25:23
  some
• 25:23
  aka
• 25:24
  Stezia
• 25:24
  a
• 25:25
  little
• 25:25
  bit
• 25:25
  on
• 25:25
  the
• 25:26
  way
• 25:26
  up.
• 25:26
  We
• 25:26
  lowered
• 25:27
  the
• 25:27
  dose
• 25:28
  initially
• 25:28
  and
• 25:29
  worked
• 25:29
  our
• 25:29
  way
• 25:29
  back
• 25:30
  up.
• 25:30
  We
• 25:30
  added
• 25:30
  propranolol
• 25:32
  for
• 25:32
  some
• 25:32
  concerns.
• 25:33
  Patient
• 25:33
  ultimately
• 25:34
  did
• 25:34
  well.
• 25:34
  We
• 25:35
  optimized
• 25:35
  his
• 25:35
  Wellbutrin
• 25:36
  to
• 25:36
  450
• 25:37
  and
• 25:37
  his
• 25:37
  depression
• 25:38
  remitted
• 25:39
  with
• 25:39
  time
• 25:40
  and
• 25:40
  his
• 25:40
  psychotic
• 25:41
  symptoms
• 25:41
  did
• 25:42
  as
• 25:42
  well.
• 25:42
  I
• 25:43
  can't
• 25:43
  emphasize
• 25:43
  enough,
• 25:44
  my
• 25:44
  friends,
• 25:45
  as
• 25:45
  we
• 25:45
  conclude
• 25:45
  this
• 25:46
  podcast
• 25:46
  episode,
• 25:47
  please
• 25:47
  become
• 25:47
  a
• 25:47
  Patreon
• 25:48
  member.
• 25:48
  You
• 25:48
  are
• 25:48
  going
• 25:49
  to
• 25:49
  have
• 25:49
  an
• 25:49
  access
• 25:50
  to
• 25:50
  to
• 25:50
  beautiful
• 25:51
  slide
• 25:51
  decks
• 25:52
  with
• 25:52
  high
• 25:52
  yield
• 25:53
  clinical
• 25:53
  tools
• 25:53
  and
• 25:54
  research
• 25:54
  studies
• 25:55
  that
• 25:55
  can
• 25:55
  double
• 25:56
  down
• 25:56
  for
• 25:57
  good
• 25:57
  coffee
• 25:57
  breaks.
• 25:58
  You
• 25:58
  will
• 25:58
  also
• 25:59
  have
• 25:59
  access
• 25:59
  to
• 25:59
  a
• 26:00
  private
• 26:00
  podcast
• 26:01
  RSS
• 26:01
  feed
• 26:02
  where
• 26:02
  you
• 26:02
  have
• 26:02
  bonus
• 26:03
  case
• 26:03
  studies
• 26:04
  and
• 26:05
  a
• 26:05
  new
• 26:05
  series
• 26:06
  coming
• 26:06
  out
• 26:06
  about
• 26:07
  to
• 26:07
  roll
• 26:07
  out
• 26:08
  off
• 26:08
  the
• 26:09
  farm
• 26:09
  where
• 26:10
  we
• 26:10
  talk
• 26:10
  about
• 26:10
  pharmacology
• 26:11
  and
• 26:11
  pharmacology
• 26:12
  pearls.
• 26:12
  That
• 26:12
  is
• 26:13
  a
• 26:13
  must
• 26:13
  my
• 26:13
  friends.
• 26:14
  If
• 26:14
  you
• 26:14
  are
• 26:14
  interested
• 26:15
  in
• 26:15
  going
• 26:16
  into
• 26:16
  deeper
• 26:16
  dives
• 26:17
  with
• 26:17
  pharmacology,
• 26:18
  I
• 26:19
  am
• 26:19
  very
• 26:19
  happy
• 26:20
  all
• 26:20
  of
• 26:20
  you
• 26:20
  made
• 26:20
  it
• 26:20
  out
• 26:21
  here.
• 26:21
  Keep
• 26:21
  spreading
• 26:22
  the
• 26:22
  word.
• 26:22
  Please
• 26:22
  give
• 26:22
  us
• 26:23
  a
• 26:23
  rating
• 26:23
  on
• 26:24
  Apple
• 26:24
  Podcasts.
• 26:25
  That's
• 26:25
  a
• 26:25
  great
• 26:25
  way
• 26:25
  to
• 26:25
  support
• 26:26
  this
• 26:26
  podcast
• 26:26
  or
• 26:27
  become
• 26:27
  a
• 26:27
  Patreon
• 26:27
  member
• 26:28
  where
• 26:28
  you
• 26:28
  get
• 26:28
  so
• 26:29
  many
• 26:29
  bonus
• 26:29
  tools.
• 26:30
  Spread
• 26:30
  the
• 26:30
  word
• 26:30
  to
• 26:31
  your
• 26:31
  NP
• 26:31
  colleagues,
• 26:32
  to
• 26:32
  your
• 26:32
  NP
• 26:33
  students.
• 26:33
  This
• 26:33
  has
• 26:33
  already
• 26:34
  gotten
• 26:34
  really
• 26:34
  big,
• 26:34
  really
• 26:35
  fast
• 26:35
  and
• 26:35
  we're
• 26:35
  very
• 26:36
  grateful
• 26:36
  to
• 26:36
  each
• 26:36
  and
• 26:36
  every
• 26:36
  one
• 26:37
  of
• 26:37
  you
• 26:37
  that
• 26:37
  have
• 26:37
  reached
• 26:37
  out.
• 26:38
  You
• 26:38
  all
• 26:38
  take
• 26:38
  care.
• 26:39
  Go
• 26:39
  to
• 26:39
  the
• 26:39
  Show
• 26:39
  Notes
• 26:40
  for
• 26:40
  some
• 26:40
  more
• 26:40
  links
• 26:41
  and
• 26:41
  inspiration.
• 26:42
  Signing
• 26:43
  off
• 26:43
  now,
• 26:43
  npz.
• 26:44
  Thank
• 26:45
  you
• 26:45
  all.