Latest / Pearls and Prep / The Nuances of Treating ADHD in Patients with Bipolar Disorder

Transcript

The Nuances of Treating ADHD in Patients with Bipolar Disorder · Pearls and Prep

• 0:00
  Foreign
• 0:06
  S
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  prep.
• 0:08
  This
• 0:09
  one
• 0:09
  is
• 0:09
  going
• 0:10
  to
• 0:10
  be
• 0:10
  pretty
• 0:11
  fun
• 0:11
  and
• 0:11
  pretty
• 0:12
  insightful.
• 0:13
  Let's
• 0:14
  pretend
• 0:14
  we
• 0:15
  have
• 0:15
  a
• 0:15
  patient
• 0:16
  that
• 0:16
  has
• 0:16
  bipolar
• 0:17
  disorder
• 0:17
  and
• 0:18
  needs
• 0:18
  help
• 0:19
  with
• 0:19
  adhd.
• 0:20
  They've
• 0:20
  had
• 0:20
  ADHD
• 0:21
  their
• 0:21
  whole
• 0:21
  lives.
• 0:22
  They
• 0:22
  need
• 0:22
  assistance
• 0:23
  and
• 0:24
  they're
• 0:24
  reaching
• 0:24
  out
• 0:24
  to
• 0:25
  you
• 0:25
  for
• 0:25
  help
• 0:25
  and
• 0:25
  you're
• 0:25
  a
• 0:26
  deer
• 0:26
  in
• 0:26
  headlights.
• 0:26
  You're
• 0:26
  going,
• 0:27
  oh,
• 0:27
  my
• 0:27
  God,
• 0:27
  I
• 0:27
  don't
• 0:28
  think
• 0:28
  I
• 0:28
  can
• 0:28
  give
• 0:28
  this
• 0:28
  guy
• 0:28
  stimulant
• 0:29
  because
• 0:30
  stimulants
• 0:30
  could
• 0:31
  cause
• 0:32
  mania
• 0:33
  and
• 0:33
  that
• 0:34
  would
• 0:34
  be
• 0:34
  correct,
• 0:34
  but
• 0:35
  there's
• 0:35
  some
• 0:35
  nuances
• 0:35
  to
• 0:36
  that
• 0:36
  and
• 0:36
  we
• 0:36
  all
• 0:36
  need
• 0:37
  to
• 0:37
  talk
• 0:37
  about
• 0:37
  it.
• 0:37
  So
• 0:38
  let's
• 0:38
  pretend
• 0:38
  we
• 0:39
  have
• 0:39
  a
• 0:39
  patient
• 0:39
  named
• 0:40
  Elliot.
• 0:40
  He's
• 0:41
  a
• 0:41
  mock
• 0:41
  patient.
• 0:41
  He's
• 0:42
  a
• 0:42
  41
• 0:42
  year
• 0:42
  old
• 0:43
  software
• 0:44
  engineer.
• 0:44
  He
• 0:44
  has
• 0:44
  bipolar
• 0:45
  2
• 0:45
  disorder.
• 0:46
  It's
• 0:46
  well
• 0:46
  controlled
• 0:48
  with
• 0:48
  lamotrigine,
• 0:50
  200
• 0:50
  milligrams
• 0:51
  every
• 0:51
  day.
• 0:51
  His
• 0:52
  mood,
• 0:52
  sleep
• 0:52
  and
• 0:52
  circadian
• 0:53
  rhythm
• 0:53
  remains
• 0:54
  stable,
• 0:54
  but
• 0:54
  he
• 0:55
  continues
• 0:55
  to
• 0:55
  struggle
• 0:56
  with
• 0:56
  with
• 0:56
  distractibility,
• 0:57
  impulsivity,
• 0:58
  multitasking
• 0:59
  and
• 0:59
  task
• 1:00
  paralysis
• 1:00
  that
• 1:01
  have
• 1:01
  persisted
• 1:01
  since
• 1:02
  he
• 1:02
  was
• 1:02
  a
• 1:02
  child.
• 1:03
  Prior
• 1:04
  stimulant
• 1:04
  trials
• 1:05
  led
• 1:05
  to
• 1:05
  subtle
• 1:05
  irritability
• 1:06
  and
• 1:06
  racing
• 1:07
  thoughts.
• 1:07
  He
• 1:08
  tried
• 1:08
  methylphenidate
• 1:09
  or
• 1:09
  Ritalin
• 1:09
  and
• 1:09
  it
• 1:10
  made
• 1:10
  him
• 1:10
  irritable.
• 1:10
  He
• 1:10
  had
• 1:11
  racing
• 1:11
  thoughts.
• 1:11
  He
• 1:12
  wasn't
• 1:12
  quite
• 1:13
  manic
• 1:13
  on
• 1:13
  methylphenidate,
• 1:14
  but
• 1:15
  he
• 1:15
  was
• 1:15
  a
• 1:15
  little
• 1:16
  more
• 1:16
  revved
• 1:16
  up.
• 1:17
  So
• 1:17
  here
• 1:17
  we
• 1:17
  are
• 1:17
  going,
• 1:18
  okay,
• 1:19
  we
• 1:19
  have
• 1:19
  evidence
• 1:19
  that
• 1:20
  this
• 1:20
  individual
• 1:22
  needs
• 1:22
  some
• 1:22
  further
• 1:22
  stability.
• 1:23
  He's
• 1:24
  distractible,
• 1:25
  he's
• 1:25
  impulsive,
• 1:26
  he
• 1:26
  can't
• 1:27
  get
• 1:27
  things
• 1:27
  done.
• 1:28
  That's
• 1:28
  pretty
• 1:29
  critical
• 1:29
  information.
• 1:30
  Going
• 1:30
  down
• 1:30
  the
• 1:30
  stimulant
• 1:31
  path
• 1:31
  is
• 1:32
  definitely
• 1:32
  not
• 1:33
  his
• 1:33
  friend.
• 1:34
  Right.
• 1:34
  If
• 1:35
  he
• 1:35
  was
• 1:35
  on
• 1:35
  a
• 1:35
  methylphenidate
• 1:36
  in
• 1:36
  the
• 1:36
  past,
• 1:37
  that
• 1:38
  could
• 1:38
  mean
• 1:38
  we
• 1:38
  don't
• 1:39
  want
• 1:39
  to
• 1:39
  do
• 1:39
  methylphenidate
• 1:40
  again
• 1:40
  and
• 1:41
  we
• 1:41
  don't
• 1:41
  want
• 1:41
  to
• 1:42
  do
• 1:42
  Adderall.
• 1:43
  Right.
• 1:43
  Because
• 1:43
  Adderall
• 1:44
  is
• 1:44
  double
• 1:44
  the
• 1:44
  potency
• 1:45
  of
• 1:45
  a
• 1:45
  methylphenidate
• 1:46
  or
• 1:46
  Ritalin.
• 1:47
  So
• 1:47
  Adderall
• 1:47
  wouldn't
• 1:48
  be
• 1:48
  a
• 1:48
  good
• 1:48
  idea.
• 1:48
  When
• 1:49
  you
• 1:49
  have
• 1:49
  a
• 1:49
  patient
• 1:49
  who
• 1:49
  has
• 1:50
  bipolar
• 1:50
  2
• 1:51
  or
• 1:51
  bipolar
• 1:51
  1,
• 1:52
  stimulants
• 1:52
  are
• 1:53
  known
• 1:53
  to
• 1:54
  potentially
• 1:54
  induce
• 1:55
  mania.
• 1:55
  Not
• 1:56
  all
• 1:56
  of
• 1:56
  the
• 1:56
  time,
• 1:56
  but
• 1:57
  consistently
• 1:58
  enough.
• 1:59
  Where
• 1:59
  you
• 1:59
  would
• 1:59
  like
• 2:00
  to
• 2:00
  avoid
• 2:01
  stimulants
• 2:02
  in
• 2:02
  these
• 2:03
  populations
• 2:03
  as
• 2:04
  much
• 2:04
  as
• 2:04
  you
• 2:04
  can.
• 2:04
  Some
• 2:05
  people
• 2:05
  say
• 2:05
  that
• 2:06
  there
• 2:06
  is
• 2:06
  evidence
• 2:06
  that
• 2:07
  methylphenidate
• 2:07
  is
• 2:08
  the
• 2:08
  stimulant
• 2:08
  to
• 2:08
  go
• 2:09
  to
• 2:09
  if
• 2:09
  you
• 2:09
  need
• 2:09
  to.
• 2:10
  Long
• 2:10
  acting
• 2:10
  is
• 2:10
  a
• 2:11
  little
• 2:11
  smoother.
• 2:11
  It
• 2:12
  keeps
• 2:12
  the
• 2:12
  peak
• 2:12
  plasma
• 2:13
  concentrations
• 2:14
  a
• 2:14
  little
• 2:14
  smoother,
• 2:15
  which
• 2:15
  makes
• 2:16
  it
• 2:16
  little
• 2:16
  less
• 2:17
  likely
• 2:17
  you're
• 2:18
  going
• 2:18
  to
• 2:18
  induce
• 2:18
  irritability,
• 2:19
  mania,
• 2:20
  insomnia
• 2:20
  or
• 2:20
  mood
• 2:21
  disturbances.
• 2:22
  If
• 2:22
  you're
• 2:22
  going
• 2:22
  to
• 2:22
  pick
• 2:23
  a
• 2:23
  stimulant,
• 2:24
  the
• 2:24
  big
• 2:24
  takeaway
• 2:25
  here
• 2:25
  is
• 2:25
  go
• 2:26
  to
• 2:26
  the
• 2:26
  methylphenidate
• 2:27
  class,
• 2:27
  the
• 2:27
  Ritalin
• 2:27
  class.
• 2:28
  Go
• 2:28
  to
• 2:28
  an
• 2:28
  extended
• 2:29
  release
• 2:30
  monitor
• 2:30
  very
• 2:31
  closely,
• 2:31
  go
• 2:32
  low
• 2:32
  and
• 2:32
  slow,
• 2:33
  and
• 2:33
  recognize
• 2:34
  that
• 2:34
  it
• 2:34
  may
• 2:34
  not
• 2:35
  be
• 2:35
  the
• 2:35
  best
• 2:35
  idea
• 2:36
  because
• 2:36
  there
• 2:36
  are
• 2:36
  non
• 2:37
  stimulant
• 2:37
  options
• 2:38
  here.
• 2:38
  And
• 2:39
  just
• 2:39
  like
• 2:39
  we
• 2:39
  go
• 2:39
  over
• 2:40
  in
• 2:40
  so
• 2:40
  many
• 2:40
  of
• 2:40
  our
• 2:41
  different
• 2:41
  episodes,
• 2:42
  you
• 2:42
  want
• 2:42
  to
• 2:42
  tailor
• 2:43
  the
• 2:43
  medication
• 2:43
  to
• 2:44
  the
• 2:44
  patient.
• 2:44
  In
• 2:44
  this
• 2:44
  case,
• 2:45
  Elliot
• 2:45
  is
• 2:46
  telling
• 2:46
  you
• 2:46
  he's
• 2:46
  distractible,
• 2:47
  he's
• 2:47
  impulsive,
• 2:48
  there's
• 2:48
  some
• 2:48
  task
• 2:49
  paralysis,
• 2:50
  his
• 2:50
  circadian
• 2:51
  rhythm
• 2:51
  is
• 2:52
  stable,
• 2:52
  which
• 2:52
  is
• 2:53
  a
• 2:53
  good
• 2:53
  sign,
• 2:54
  but
• 2:54
  he
• 2:54
  still
• 2:55
  needs
• 2:55
  some
• 2:56
  help.
• 2:56
  And
• 2:57
  we
• 2:57
  need
• 2:57
  to
• 2:57
  smoothen
• 2:58
  out
• 2:58
  the
• 2:58
  edges
• 2:59
  a
• 2:59
  little
• 2:59
  bit
• 2:59
  here.
• 3:00
  Recognize
• 3:01
  that
• 3:01
  10
• 3:01
  to
• 3:01
  20%
• 3:02
  of
• 3:02
  your
• 3:02
  patients
• 3:03
  with
• 3:03
  bipolar
• 3:03
  disorder
• 3:04
  are
• 3:04
  also
• 3:05
  going
• 3:05
  to
• 3:05
  have
• 3:05
  adhd.
• 3:06
  Now,
• 3:07
  there
• 3:07
  are
• 3:07
  some
• 3:07
  genetic
• 3:09
  overlaps
• 3:10
  between
• 3:11
  these
• 3:11
  two
• 3:11
  populations
• 3:12
  that
• 3:12
  research
• 3:12
  is
• 3:13
  starting
• 3:13
  to
• 3:13
  uncover
• 3:14
  10
• 3:14
  to
• 3:14
  20%
• 3:15
  of
• 3:15
  your
• 3:16
  patients
• 3:16
  that
• 3:16
  are
• 3:17
  going
• 3:17
  to
• 3:17
  have
• 3:17
  ADHD
• 3:18
  with
• 3:18
  their
• 3:19
  bipolarity.
• 3:19
  And
• 3:19
  it
• 3:20
  can
• 3:20
  be
• 3:20
  very
• 3:20
  hard
• 3:20
  to
• 3:20
  tease
• 3:21
  out
• 3:21
  the
• 3:21
  difference
• 3:22
  between
• 3:22
  those
• 3:22
  two.
• 3:23
  We
• 3:23
  do
• 3:23
  have
• 3:23
  podcast
• 3:24
  episodes
• 3:24
  in
• 3:24
  the
• 3:25
  past
• 3:25
  and
• 3:25
  in
• 3:25
  the
• 3:25
  future
• 3:25
  coming
• 3:26
  out
• 3:26
  that
• 3:26
  are
• 3:27
  going
• 3:27
  to
• 3:27
  help
• 3:27
  you
• 3:27
  parse
• 3:27
  out
• 3:28
  ADHD
• 3:28
  and
• 3:28
  bipolar.
• 3:29
  So
• 3:29
  we
• 3:30
  won't
• 3:30
  go
• 3:30
  into
• 3:30
  deep
• 3:30
  dives
• 3:31
  with
• 3:31
  that
• 3:31
  today.
• 3:32
  For
• 3:32
  me,
• 3:32
  the
• 3:32
  main
• 3:33
  thing
• 3:33
  is
• 3:34
  one
• 3:34
  is
• 3:34
  a
• 3:34
  trait
• 3:35
  and
• 3:35
  one
• 3:35
  is
• 3:35
  a
• 3:35
  state,
• 3:36
  in
• 3:36
  a
• 3:36
  sense.
• 3:36
  Right.
• 3:37
  ADHD
• 3:38
  is
• 3:38
  long
• 3:39
  time
• 3:39
  coming.
• 3:40
  Folks
• 3:40
  have
• 3:40
  had
• 3:41
  these
• 3:41
  attentional
• 3:41
  issues
• 3:42
  before
• 3:42
  the
• 3:42
  age
• 3:42
  of
• 3:43
  12.
• 3:43
  They
• 3:44
  have
• 3:44
  parents
• 3:44
  and
• 3:44
  teachers
• 3:45
  typically
• 3:45
  that
• 3:46
  are
• 3:46
  concerned
• 3:46
  about
• 3:47
  their
• 3:47
  lack
• 3:47
  of
• 3:47
  attention,
• 3:48
  their
• 3:48
  distractibility,
• 3:49
  their
• 3:49
  hyperactivity.
• 3:50
  So
• 3:51
  it's
• 3:51
  a
• 3:51
  long
• 3:51
  time.
• 3:52
  It's
• 3:52
  day
• 3:52
  to
• 3:52
  day.
• 3:53
  It's
• 3:53
  not
• 3:53
  episodic
• 3:54
  like
• 3:54
  bipolar,
• 3:55
  where
• 3:56
  you
• 3:56
  have
• 3:56
  episodes
• 3:57
  for
• 3:57
  four
• 3:58
  days,
• 3:58
  seven
• 3:58
  days,
• 3:59
  12
• 3:59
  days,
• 3:59
  where
• 3:59
  they're
• 4:00
  just
• 4:00
  really
• 4:00
  distractible.
• 4:01
  Their
• 4:01
  thoughts
• 4:01
  are
• 4:02
  racing,
• 4:02
  one
• 4:02
  is
• 4:02
  coming
• 4:03
  in
• 4:03
  spurts
• 4:03
  and
• 4:04
  kind
• 4:04
  of
• 4:04
  suddenly
• 4:04
  and
• 4:04
  then
• 4:05
  resolves
• 4:05
  as
• 4:05
  opposed
• 4:06
  to
• 4:06
  the
• 4:06
  other
• 4:06
  one
• 4:07
  happening
• 4:07
  longitudinally
• 4:08
  over
• 4:08
  time.
• 4:09
  That's
• 4:09
  just
• 4:10
  one
• 4:10
  crisp
• 4:10
  way
• 4:10
  to
• 4:11
  think
• 4:11
  about
• 4:11
  it.
• 4:11
  But
• 4:11
  again,
• 4:11
  these
• 4:12
  can
• 4:12
  happen
• 4:12
  together.
• 4:13
  And
• 4:13
  that's
• 4:14
  when
• 4:14
  things
• 4:14
  get
• 4:14
  murky.
• 4:15
  Bipolar
• 4:16
  with
• 4:16
  the
• 4:16
  racing
• 4:16
  thoughts,
• 4:17
  the
• 4:17
  distractibility,
• 4:18
  and
• 4:18
  the
• 4:19
  fact
• 4:19
  that
• 4:19
  it's
• 4:19
  really
• 4:20
  hard
• 4:20
  on
• 4:20
  your
• 4:21
  brain
• 4:21
  over
• 4:21
  time,
• 4:22
  is
• 4:22
  another
• 4:23
  reason
• 4:23
  that
• 4:23
  bipolarity
• 4:24
  can
• 4:24
  slowly
• 4:25
  and
• 4:25
  chronically
• 4:26
  look
• 4:26
  more
• 4:26
  and
• 4:27
  more
• 4:27
  like
• 4:27
  ADHD
• 4:28
  as
• 4:29
  people
• 4:29
  get
• 4:29
  more
• 4:30
  executively
• 4:31
  impaired
• 4:31
  over
• 4:32
  time,
• 4:32
  which
• 4:33
  with
• 4:33
  more
• 4:33
  rapid
• 4:34
  cycling
• 4:34
  or
• 4:34
  bipolarity,
• 4:36
  they
• 4:36
  start
• 4:36
  to
• 4:36
  have
• 4:37
  a
• 4:37
  harder
• 4:37
  time
• 4:37
  with
• 4:38
  their
• 4:38
  cognition.
• 4:38
  And
• 4:38
  it
• 4:38
  can
• 4:39
  even
• 4:39
  look
• 4:39
  like
• 4:39
  adhd,
• 4:40
  even
• 4:40
  if
• 4:40
  they
• 4:40
  don't
• 4:41
  have
• 4:41
  real
• 4:41
  adhd.
• 4:42
  So
• 4:43
  I
• 4:43
  hope
• 4:44
  you
• 4:44
  appreciate
• 4:44
  the
• 4:44
  layers
• 4:45
  to
• 4:45
  this.
• 4:46
  Always
• 4:46
  remember,
• 4:47
  in
• 4:47
  a
• 4:47
  case
• 4:47
  like
• 4:47
  Elliot,
• 4:48
  this
• 4:48
  mock
• 4:48
  patient,
• 4:49
  you
• 4:49
  always
• 4:49
  want
• 4:49
  to
• 4:50
  stabilize
• 4:50
  mood
• 4:50
  first.
• 4:51
  It's
• 4:51
  really
• 4:51
  great
• 4:51
  that
• 4:52
  he's
• 4:52
  coming
• 4:52
  to
• 4:52
  you
• 4:53
  with
• 4:53
  lamictal
• 4:54
  and
• 4:54
  that
• 4:54
  his
• 4:55
  mood
• 4:55
  is
• 4:55
  stable.
• 4:56
  But
• 4:56
  it's
• 4:56
  really
• 4:57
  important
• 4:58
  that
• 4:59
  if
• 4:59
  both
• 4:59
  of
• 4:59
  these
• 5:00
  things
• 5:00
  are
• 5:00
  raging
• 5:00
  at
• 5:00
  the
• 5:01
  same
• 5:01
  time,
• 5:01
  you've
• 5:01
  got
• 5:01
  to
• 5:01
  put
• 5:02
  out
• 5:02
  the
• 5:02
  mood
• 5:03
  fire
• 5:04
  first.
• 5:04
  That
• 5:05
  is
• 5:05
  critically
• 5:06
  important
• 5:06
  because
• 5:07
  you
• 5:07
  won't
• 5:08
  really
• 5:08
  know
• 5:08
  what's
• 5:08
  left
• 5:09
  to
• 5:09
  treat
• 5:09
  if
• 5:09
  you
• 5:10
  don't
• 5:10
  put
• 5:10
  out
• 5:10
  mood
• 5:11
  and
• 5:11
  you're
• 5:11
  seeing
• 5:12
  ADHD
• 5:12
  symptoms.
• 5:13
  And
• 5:13
  you
• 5:13
  could
• 5:13
  actually
• 5:13
  make
• 5:14
  the
• 5:14
  mood
• 5:14
  way
• 5:14
  worse
• 5:15
  if
• 5:15
  you're
• 5:15
  untreating
• 5:16
  adhd.
• 5:17
  Excuse
• 5:17
  me,
• 5:18
  if
• 5:18
  you're
• 5:18
  not
• 5:18
  treating
• 5:18
  the
• 5:19
  mood
• 5:19
  and
• 5:19
  you're
• 5:20
  giving
• 5:20
  ADHD
• 5:21
  medications,
• 5:22
  you
• 5:22
  could
• 5:22
  make
• 5:22
  the
• 5:22
  hypomania
• 5:23
  or
• 5:23
  mania
• 5:24
  worse.
• 5:25
  Bad
• 5:25
  idea.
• 5:25
  Right?
• 5:26
  Treat
• 5:26
  the
• 5:26
  mood
• 5:26
  first.
• 5:27
  See
• 5:27
  what
• 5:27
  ADHD
• 5:28
  symptoms
• 5:29
  are
• 5:29
  lingering.
• 5:30
  And
• 5:30
  sometimes
• 5:31
  you
• 5:31
  may
• 5:31
  not
• 5:31
  see
• 5:31
  that
• 5:31
  any
• 5:32
  are
• 5:32
  lingering
• 5:32
  and
• 5:32
  the
• 5:32
  patient's
• 5:33
  just
• 5:33
  fine.
• 5:33
  Other
• 5:34
  times
• 5:34
  you
• 5:35
  will
• 5:35
  see
• 5:35
  these
• 5:35
  gaping
• 5:36
  holes
• 5:36
  that
• 5:36
  deserve
• 5:37
  further
• 5:37
  pharmacotherapy.
• 5:38
  It's
• 5:39
  kind
• 5:39
  of
• 5:39
  case
• 5:40
  by
• 5:40
  case
• 5:40
  basis
• 5:41
  here.
• 5:41
  There
• 5:42
  again,
• 5:42
  please
• 5:43
  appreciate
• 5:43
  the
• 5:43
  overlap
• 5:44
  between
• 5:44
  ADHD
• 5:45
  and
• 5:45
  bipolarity.
• 5:46
  The
• 5:46
  distractibility,
• 5:47
  the
• 5:47
  restlessness.
• 5:48
  People
• 5:48
  with
• 5:49
  ADHD
• 5:49
  can
• 5:49
  kind
• 5:50
  of
• 5:50
  speak
• 5:50
  quickly.
• 5:51
  It's
• 5:51
  not
• 5:51
  necessarily
• 5:52
  the
• 5:52
  rapid,
• 5:52
  tangential
• 5:53
  speech
• 5:53
  you
• 5:54
  would
• 5:54
  hear
• 5:54
  in
• 5:54
  bipolar.
• 5:55
  You
• 5:55
  could
• 5:55
  really
• 5:56
  get
• 5:56
  flighty.
• 5:56
  The
• 5:56
  ideas
• 5:57
  aren't
• 5:57
  connected
• 5:57
  that
• 5:58
  much
• 5:58
  in
• 5:58
  acute
• 5:59
  mania,
• 5:59
  but
• 6:00
  it
• 6:00
  can
• 6:00
  be
• 6:00
  hard
• 6:00
  to
• 6:01
  tell
• 6:01
  sometimes
• 6:01
  because
• 6:01
  folks
• 6:02
  with
• 6:02
  ADHD
• 6:03
  do
• 6:03
  also
• 6:04
  talk
• 6:04
  pretty
• 6:05
  quickly
• 6:05
  sometimes.
• 6:06
  Right.
• 6:06
  So
• 6:07
  that's
• 6:07
  why
• 6:07
  you
• 6:07
  want
• 6:07
  to
• 6:07
  get
• 6:07
  a
• 6:08
  good
• 6:08
  childhood
• 6:08
  history
• 6:08
  of
• 6:09
  their
• 6:09
  ADHD
• 6:10
  and
• 6:10
  how
• 6:11
  they're
• 6:11
  being
• 6:11
  impaired
• 6:12
  and
• 6:12
  et
• 6:12
  cetera,
• 6:13
  et
• 6:13
  cetera.
• 6:14
  Now,
• 6:14
  there
• 6:14
  are
• 6:15
  a
• 6:15
  few
• 6:15
  different
• 6:15
  options.
• 6:16
  If
• 6:16
  you're
• 6:16
  not
• 6:17
  going
• 6:17
  the
• 6:17
  stimulant
• 6:17
  path
• 6:18
  because
• 6:18
  you're
• 6:18
  worried
• 6:18
  that
• 6:19
  it
• 6:19
  can
• 6:19
  induce
• 6:19
  mania,
• 6:20
  you
• 6:20
  can
• 6:20
  go
• 6:21
  the
• 6:21
  non
• 6:21
  stimulant
• 6:22
  path.
• 6:22
  Your
• 6:22
  options
• 6:23
  would
• 6:23
  be
• 6:23
  like
• 6:23
  clonidine
• 6:24
  or
• 6:24
  guanfacine.
• 6:25
  You
• 6:26
  know,
• 6:26
  those
• 6:26
  are
• 6:26
  alpha
• 6:26
  2
• 6:27
  adrenergic
• 6:27
  receptor
• 6:28
  agonists
• 6:29
  that
• 6:29
  tend
• 6:30
  to
• 6:30
  modulate
• 6:31
  norepinephrine
• 6:32
  and
• 6:32
  indirectly
• 6:33
  dopamine
• 6:34
  signaling
• 6:34
  in
• 6:35
  the
• 6:35
  prefrontal
• 6:35
  cortex
• 6:36
  to
• 6:36
  work
• 6:36
  on
• 6:37
  attention,
• 6:37
  memory
• 6:38
  and
• 6:38
  impulse
• 6:38
  control.
• 6:39
  And
• 6:39
  they
• 6:39
  can
• 6:39
  tend
• 6:40
  to
• 6:40
  dampen
• 6:40
  the
• 6:40
  noisy
• 6:41
  neurotransmitter
• 6:42
  overdrive,
• 6:43
  which
• 6:43
  could
• 6:44
  be
• 6:44
  really
• 6:44
  helpful
• 6:44
  in
• 6:45
  adhd.
• 6:46
  Right.
• 6:46
  So
• 6:47
  improvements
• 6:47
  in
• 6:47
  executive
• 6:48
  functioning
• 6:48
  that
• 6:48
  can
• 6:49
  also
• 6:49
  maybe
• 6:49
  help
• 6:49
  people
• 6:49
  sleep
• 6:50
  and
• 6:50
  feel
• 6:50
  a
• 6:50
  little
• 6:51
  less
• 6:51
  physiologically
• 6:52
  aroused,
• 6:52
  but
• 6:53
  without
• 6:53
  that
• 6:53
  mania
• 6:54
  risk.
• 6:54
  Now,
• 6:55
  of
• 6:55
  course,
• 6:55
  the
• 6:55
  drawback
• 6:56
  is
• 6:56
  that
• 6:57
  they're
• 6:57
  not
• 6:57
  as
• 6:57
  effective
• 6:58
  in
• 6:58
  treating
• 6:59
  ADHD
• 6:59
  via
• 7:00
  effect
• 7:00
  size
• 7:01
  as
• 7:01
  methylphenidate
• 7:02
  would
• 7:03
  be.
• 7:03
  Right.
• 7:04
  So
• 7:04
  you
• 7:04
  have
• 7:04
  to
• 7:05
  assess
• 7:05
  the
• 7:05
  degree
• 7:05
  of
• 7:06
  impairment
• 7:06
  if
• 7:06
  ADHD
• 7:07
  is
• 7:07
  raging
• 7:08
  in
• 7:08
  a
• 7:08
  raging
• 7:09
  impairment.
• 7:10
  And
• 7:10
  again,
• 7:11
  that's
• 7:11
  case
• 7:11
  by
• 7:11
  case.
• 7:12
  With
• 7:12
  each
• 7:12
  patient.
• 7:13
  You
• 7:13
  may
• 7:13
  want
• 7:14
  to
• 7:14
  consider
• 7:14
  methylphenidate
• 7:15
  going
• 7:16
  low,
• 7:16
  going
• 7:16
  slow,
• 7:17
  with
• 7:17
  robust
• 7:17
  mood
• 7:18
  stabilization
• 7:18
  already
• 7:19
  on
• 7:19
  board.
• 7:20
  The
• 7:20
  evidence
• 7:20
  suggests
• 7:21
  that
• 7:21
  it
• 7:21
  can
• 7:22
  still
• 7:22
  induce
• 7:22
  mania
• 7:23
  or
• 7:24
  hypomania.
• 7:25
  It
• 7:25
  is
• 7:25
  not
• 7:26
  always
• 7:27
  like
• 7:27
  it's
• 7:27
  not
• 7:27
  always
• 7:28
  going
• 7:28
  to
• 7:28
  and
• 7:28
  can
• 7:28
  in
• 7:29
  fact
• 7:29
  treat
• 7:29
  adhd.
• 7:30
  But
• 7:30
  you
• 7:30
  have
• 7:30
  to
• 7:30
  monitor
• 7:31
  that
• 7:31
  super
• 7:31
  close
• 7:32
  and
• 7:32
  work
• 7:32
  with
• 7:33
  your
• 7:33
  team
• 7:33
  and
• 7:34
  consult
• 7:34
  your
• 7:35
  resources.
• 7:35
  My
• 7:35
  friends
• 7:36
  don't
• 7:36
  go
• 7:36
  off
• 7:36
  this
• 7:36
  podcast.
• 7:37
  Just
• 7:38
  have
• 7:38
  that
• 7:38
  in
• 7:39
  mind.
• 7:39
  And
• 7:39
  so
• 7:40
  gravitating
• 7:41
  more
• 7:41
  towards
• 7:42
  the
• 7:42
  non
• 7:42
  stimulants
• 7:43
  if
• 7:43
  you
• 7:43
  are
• 7:43
  a
• 7:43
  little
• 7:44
  concerned
• 7:45
  about
• 7:46
  inducing
• 7:47
  mania.
• 7:47
  And
• 7:47
  sleep
• 7:48
  protective.
• 7:48
  The
• 7:49
  sleep
• 7:49
  protective
• 7:49
  components
• 7:50
  in
• 7:51
  clonidine
• 7:51
  are
• 7:52
  pretty
• 7:52
  appealing,
• 7:52
  right?
• 8:47
  Because
• 8:48
  they
• 8:48
  promote
• 8:48
  a
• 8:49
  parasympathetic
• 8:50
  tone,
• 8:50
  they
• 8:50
  reduce
• 8:50
  the
• 8:51
  sympathetic
• 7:57
  hyperarousal.
• 8:52
  That's
• 8:53
  really
• 8:53
  important
• 8:53
  with
• 8:53
  bipolarity,
• 8:54
  right?
• 8:54
  We're
• 8:55
  finding
• 8:55
  out
• 8:55
  more
• 8:55
  and
• 8:56
  more
• 8:56
  often
• 8:57
  that
• 8:57
  sleep
• 8:58
  and
• 8:58
  circadian
• 8:59
  alignment
• 8:59
  is
• 8:59
  critical
• 9:00
  in
• 9:00
  bipolarity.
• 9:01
  It's
• 9:01
  wonderful
• 9:02
  if
• 9:02
  we
• 9:02
  can
• 9:02
  find
• 9:03
  a
• 9:03
  medication
• 9:03
  that
• 9:04
  can
• 9:04
  enhance
• 9:05
  prefrontal
• 9:06
  cortex
• 9:07
  efficiency
• 9:08
  and
• 9:08
  at
• 9:08
  the
• 9:09
  same
• 9:09
  time
• 9:09
  help
• 9:10
  a
• 9:10
  patient
• 9:11
  not
• 9:11
  be
• 9:11
  as
• 9:11
  hyper
• 9:12
  aroused
• 9:12
  and
• 9:12
  sleep
• 9:12
  a
• 9:13
  little
• 9:13
  bit.
• 9:13
  So
• 9:13
  clonidine
• 9:14
  is
• 9:14
  a
• 9:14
  good
• 9:14
  choice,
• 9:15
  right?
• 9:15
  0.1
• 9:16
  milligrams
• 9:17
  every
• 9:17
  night,
• 9:18
  titrating
• 9:19
  slowly
• 9:19
  to
• 9:19
  get
• 9:20
  up
• 9:20
  to
• 9:20
  maybe
• 9:20
  a
• 9:20
  B
• 9:21
  I
• 9:21
  D
• 9:21
  regimen
• 9:22
  where
• 9:22
  you
• 9:22
  can
• 9:23
  promote
• 9:23
  those
• 9:24
  kinds
• 9:24
  of
• 9:25
  benefits
• 9:26
  across
• 9:26
  the
• 9:26
  day.
• 9:26
  That
• 9:27
  could
• 9:27
  be
• 9:27
  a
• 9:27
  very
• 9:27
  good
• 9:28
  idea.
• 9:28
  You
• 9:28
  could
• 9:28
  also
• 9:28
  think
• 9:28
  of
• 9:29
  guanfacine
• 9:30
  every
• 9:30
  night
• 9:31
  again
• 9:31
  in
• 9:31
  the
• 9:31
  same
• 9:32
  class.
• 9:32
  Those
• 9:32
  alpha
• 9:33
  2
• 9:33
  adrenergic
• 9:34
  receptor
• 9:34
  agonists
• 9:35
  working
• 9:35
  on
• 9:36
  the
• 9:36
  prefrontal
• 9:36
  cortex,
• 9:37
  working
• 9:37
  on
• 9:37
  impulsivity,
• 9:38
  working
• 9:39
  on
• 9:39
  attention
• 9:39
  and
• 9:39
  memory.
• 9:40
  It's
• 9:40
  all
• 9:41
  about
• 9:41
  enhancing
• 9:41
  the
• 9:42
  signal
• 9:42
  and
• 9:42
  dampening
• 9:43
  the
• 9:43
  noise.
• 9:44
  That's
• 9:44
  what
• 9:45
  these
• 9:45
  medications
• 9:46
  tend
• 9:47
  to
• 9:47
  do.
• 9:47
  So
• 9:47
  pretty
• 9:48
  cool,
• 9:48
  right?
• 9:49
  And
• 9:49
  of
• 9:49
  course
• 9:49
  clonidine
• 9:50
  helping
• 9:50
  with
• 9:50
  anxiety
• 9:51
  a
• 9:51
  little
• 9:51
  bit,
• 9:51
  which
• 9:52
  is
• 9:52
  very
• 9:52
  good.
• 9:53
  All
• 9:53
  things
• 9:53
  that
• 9:53
  are
• 9:53
  protective
• 9:54
  against
• 9:55
  some
• 9:55
  kind
• 9:55
  of
• 9:55
  bipolar
• 9:56
  relapse
• 9:57
  and
• 9:57
  the
• 9:57
  really
• 9:58
  horrific
• 9:59
  day
• 9:59
  to
• 9:59
  day
• 9:59
  of
• 9:59
  a
• 10:00
  bipolar
• 10:00
  existence.
• 10:01
  Just
• 10:01
  that
• 10:01
  restlessness,
• 10:02
  that
• 10:02
  racing
• 10:03
  thoughts
• 10:03
  and
• 10:03
  destructive
• 10:04
  behaviors.
• 10:05
  I
• 10:05
  think
• 10:05
  in
• 10:05
  this
• 10:05
  case
• 10:05
  Elliot
• 10:06
  would
• 10:06
  benefit
• 10:06
  from
• 10:07
  clonidine.
• 10:07
  That
• 10:08
  would
• 10:08
  be
• 10:08
  good.
• 10:08
  We've
• 10:09
  got
• 10:09
  to
• 10:09
  make
• 10:09
  sure
• 10:09
  his
• 10:09
  lamictal
• 10:10
  is
• 10:10
  doing
• 10:10
  his
• 10:11
  doing
• 10:11
  its
• 10:11
  job.
• 10:12
  Anytime
• 10:13
  you
• 10:13
  see
• 10:13
  a
• 10:13
  patient,
• 10:13
  make
• 10:14
  sure
• 10:14
  that
• 10:14
  mood
• 10:14
  stabilizer
• 10:15
  is
• 10:15
  at
• 10:15
  a
• 10:16
  robust
• 10:16
  dose,
• 10:17
  that
• 10:17
  they've
• 10:17
  been
• 10:17
  on
• 10:17
  it
• 10:18
  long
• 10:18
  enough
• 10:18
  for
• 10:18
  you
• 10:19
  to
• 10:19
  feel
• 10:19
  assured
• 10:20
  that
• 10:20
  their
• 10:20
  mood
• 10:21
  is
• 10:21
  stable
• 10:22
  and
• 10:22
  that
• 10:22
  it's
• 10:23
  going
• 10:23
  to
• 10:23
  do
• 10:23
  its
• 10:23
  job
• 10:24
  before
• 10:24
  you
• 10:24
  do
• 10:25
  start
• 10:25
  treating
• 10:25
  adhd.
• 10:26
  Right?
• 10:27
  And
• 10:27
  that's
• 10:27
  very
• 10:27
  important.
• 10:28
  Now
• 10:28
  there
• 10:28
  are
• 10:29
  folks
• 10:29
  who
• 10:29
  like
• 10:30
  Modafinil
• 10:31
  in
• 10:31
  with
• 10:32
  respect
• 10:32
  to
• 10:33
  ADHD
• 10:34
  and,
• 10:35
  and,
• 10:36
  and
• 10:36
  bipolarity.
• 10:37
  And
• 10:37
  so
• 10:38
  Modafinil
• 10:38
  fell
• 10:39
  short
• 10:39
  of
• 10:39
  getting
• 10:39
  an
• 10:39
  FDA
• 10:40
  approval
• 10:41
  for
• 10:41
  adhd,
• 10:42
  largely
• 10:42
  due
• 10:43
  to
• 10:43
  the
• 10:43
  fact
• 10:43
  that
• 10:44
  it
• 10:44
  caused
• 10:44
  Steven
• 10:45
  Johnson
• 10:45
  syndrome
• 10:46
  in
• 10:46
  one
• 10:46
  case
• 10:47
  that
• 10:47
  spooked
• 10:47
  a
• 10:47
  lot
• 10:47
  of
• 10:48
  folks.
• 10:48
  Modafinil
• 10:49
  has
• 10:49
  been
• 10:50
  Used
• 10:50
  routinely
• 10:51
  as
• 10:51
  a
• 10:51
  means
• 10:52
  to
• 10:52
  kind
• 10:52
  of
• 10:52
  regulate
• 10:53
  the
• 10:53
  circadian
• 10:54
  rhythm.
• 10:54
  Promote
• 10:55
  wakefulness.
• 10:55
  When
• 10:55
  you
• 10:56
  promote
• 10:56
  wakefulness,
• 10:56
  it
• 10:57
  allows
• 10:57
  the
• 10:57
  circadian
• 10:58
  rhythm
• 10:58
  to
• 10:58
  be
• 10:59
  a
• 10:59
  little
• 10:59
  bit
• 10:59
  more
• 10:59
  aligned
• 11:00
  so
• 11:01
  that
• 11:01
  you're
• 11:01
  enhancing
• 11:02
  that
• 11:02
  drive
• 11:02
  to
• 11:03
  sleep
• 11:03
  and
• 11:03
  thereby
• 11:03
  going
• 11:04
  to
• 11:04
  bed.
• 11:04
  And
• 11:04
  now
• 11:04
  your
• 11:05
  alignment,
• 11:05
  your
• 11:06
  circadian
• 11:06
  alignment
• 11:07
  is
• 11:07
  working
• 11:08
  out
• 11:08
  in
• 11:08
  your
• 11:08
  favor.
• 11:09
  So
• 11:09
  modafinil
• 11:10
  is
• 11:10
  not
• 11:10
  a
• 11:10
  bad
• 11:11
  choice.
• 11:11
  It's
• 11:11
  less
• 11:11
  likely
• 11:12
  to
• 11:12
  induce
• 11:12
  mania
• 11:13
  or
• 11:13
  hypomania.
• 11:14
  Again,
• 11:14
  it's
• 11:14
  still
• 11:15
  possible.
• 11:15
  There
• 11:15
  are
• 11:15
  case
• 11:15
  reports
• 11:16
  that
• 11:16
  Modafinil
• 11:17
  can
• 11:17
  induce
• 11:18
  mania
• 11:18
  and
• 11:18
  hypomania,
• 11:19
  but
• 11:19
  it's
• 11:19
  less
• 11:19
  likely
• 11:20
  to
• 11:20
  do
• 11:20
  so
• 11:21
  because
• 11:21
  it
• 11:22
  acts
• 11:22
  on
• 11:22
  wakefulness
• 11:23
  and
• 11:23
  arousal
• 11:23
  circuits
• 11:24
  rather
• 11:25
  than
• 11:25
  the
• 11:25
  reward
• 11:25
  pathways.
• 11:26
  And
• 11:27
  the
• 11:27
  potent
• 11:27
  dopaminergic
• 11:28
  increases
• 11:29
  that
• 11:29
  you
• 11:29
  could
• 11:30
  see
• 11:30
  with
• 11:30
  Adderall,
• 11:31
  particularly
• 11:32
  Adderall.
• 11:32
  Right.
• 11:33
  And
• 11:33
  so
• 11:33
  modafinil
• 11:33
  is
• 11:34
  safer
• 11:34
  in
• 11:34
  that
• 11:34
  sense,
• 11:35
  but
• 11:35
  again,
• 11:35
  not
• 11:35
  without
• 11:36
  its
• 11:36
  risk.
• 11:36
  So
• 11:36
  be
• 11:36
  careful
• 11:37
  with
• 11:37
  Modafinil.
• 11:38
  Still
• 11:38
  monitor,
• 11:38
  still
• 11:38
  go
• 11:39
  low
• 11:39
  and
• 11:39
  slow.
• 11:40
  Make
• 11:40
  sure
• 11:40
  you
• 11:40
  have
• 11:40
  mood
• 11:41
  stabilizers
• 11:41
  on
• 11:41
  board.
• 11:42
  A
• 11:42
  lot
• 11:42
  of
• 11:43
  people
• 11:43
  prefer
• 11:43
  the
• 11:43
  R.
• 11:43
  Modafinil.
• 11:44
  It
• 11:44
  has
• 11:44
  smoother
• 11:45
  blood
• 11:45
  levels
• 11:46
  and
• 11:46
  a
• 11:46
  bit
• 11:46
  longer
• 11:47
  of
• 11:47
  a
• 11:47
  duration.
• 11:48
  So
• 11:49
  that
• 11:49
  again
• 11:49
  is
• 11:49
  a
• 11:50
  nice
• 11:50
  little
• 11:50
  pearl
• 11:50
  to
• 11:51
  think
• 11:51
  of
• 11:51
  the
• 11:51
  Modafinils.
• 11:52
  Think
• 11:52
  of
• 11:52
  guanfacine.
• 11:53
  Think
• 11:53
  of
• 11:54
  clonidine
• 11:55
  as
• 11:55
  alternatives.
• 11:56
  If
• 11:56
  you
• 11:56
  want
• 11:56
  to
• 11:56
  hedge
• 11:57
  and
• 11:57
  not
• 11:58
  walk
• 11:58
  the
• 11:59
  line
• 11:59
  with
• 11:59
  a
• 12:00
  stimulant,
• 12:00
  again,
• 12:00
  you're
• 12:01
  sacrificing
• 12:01
  efficacy
• 12:02
  a
• 12:02
  little
• 12:02
  bit
• 12:03
  because
• 12:03
  those
• 12:03
  stimulants
• 12:04
  are
• 12:04
  first
• 12:04
  line.
• 12:04
  They're
• 12:05
  wonderful
• 12:05
  medications
• 12:06
  for
• 12:06
  ADHD
• 12:07
  by
• 12:07
  and
• 12:07
  large.
• 12:07
  With
• 12:08
  respect
• 12:08
  to
• 12:08
  how
• 12:08
  effective
• 12:09
  they
• 12:09
  are,
• 12:10
  you've
• 12:10
  got
• 12:10
  to
• 12:10
  weigh
• 12:11
  the
• 12:11
  pros
• 12:11
  and
• 12:11
  cons.
• 12:12
  Know
• 12:12
  your
• 12:12
  patient,
• 12:13
  know
• 12:13
  where
• 12:13
  their
• 12:15
  main
• 12:15
  distress
• 12:16
  and
• 12:16
  functional
• 12:16
  impairment
• 12:17
  resides.
• 12:17
  And
• 12:18
  if
• 12:18
  you
• 12:18
  have
• 12:18
  glaring
• 12:19
  functional
• 12:19
  impairment
• 12:20
  with
• 12:20
  adhd,
• 12:21
  don't
• 12:21
  underestimate
• 12:21
  that.
• 12:22
  That's
• 12:22
  a
• 12:22
  very
• 12:22
  big
• 12:23
  deal.
• 12:23
  Don't
• 12:24
  settle
• 12:24
  for
• 12:24
  a
• 12:25
  treatment
• 12:25
  that
• 12:25
  is
• 12:26
  going
• 12:26
  to
• 12:26
  keep
• 12:27
  them
• 12:27
  super
• 12:27
  impaired.
• 12:28
  We
• 12:28
  have
• 12:28
  to
• 12:28
  have
• 12:29
  these
• 12:29
  conversations
• 12:29
  with
• 12:29
  our
• 12:30
  patients.
• 12:30
  Schedule
• 12:31
  tight
• 12:31
  follow
• 12:32
  ups,
• 12:32
  monitor
• 12:33
  them
• 12:33
  closely,
• 12:33
  loop
• 12:34
  in
• 12:34
  the
• 12:34
  family
• 12:34
  to
• 12:34
  make
• 12:34
  sure
• 12:35
  at
• 12:35
  the
• 12:35
  slightest
• 12:35
  delay
• 12:36
  you
• 12:36
  can
• 12:37
  intervene.
• 12:38
  And
• 12:38
  make
• 12:38
  sure
• 12:39
  that
• 12:40
  you
• 12:40
  know
• 12:40
  you're
• 12:41
  removing
• 12:41
  any
• 12:41
  offending
• 12:42
  agent
• 12:42
  that's
• 12:42
  inducing
• 12:43
  mania
• 12:43
  or
• 12:43
  hypomania.
• 12:45
  So
• 12:45
  we
• 12:46
  went
• 12:46
  over
• 12:46
  a
• 12:46
  bunch
• 12:46
  of
• 12:46
  pearls
• 12:47
  already.
• 12:47
  I
• 12:47
  think
• 12:48
  this
• 12:48
  is
• 12:48
  a
• 12:48
  pretty
• 12:48
  good
• 12:48
  start
• 12:49
  for
• 12:49
  you
• 12:49
  guys.
• 12:50
  Just
• 12:50
  remember
• 12:51
  the
• 12:51
  big
• 12:51
  pearls,
• 12:52
  of
• 12:52
  course.
• 12:53
  Low
• 12:53
  and
• 12:53
  slow,
• 12:54
  monitor
• 12:54
  signs
• 12:55
  for
• 12:55
  mood
• 12:55
  elevation.
• 12:56
  Monitor
• 12:56
  your
• 12:56
  patient
• 12:57
  more
• 12:57
  carefully,
• 12:57
  more
• 12:57
  frequently.
• 12:58
  Look
• 12:58
  for
• 12:59
  increased
• 12:59
  energy,
• 12:59
  decreased
• 13:00
  need
• 13:00
  for
• 13:00
  sleep,
• 13:01
  racing
• 13:01
  thoughts,
• 13:01
  irritability,
• 13:02
  sleep
• 13:02
  disruption.
• 13:03
  Remember,
• 13:03
  it's
• 13:04
  not
• 13:04
  always
• 13:04
  black
• 13:04
  and
• 13:04
  white.
• 13:05
  Let's
• 13:06
  say
• 13:06
  you
• 13:06
  start
• 13:06
  Ritalin.
• 13:07
  I
• 13:07
  highly
• 13:07
  encourage
• 13:08
  you
• 13:08
  not
• 13:08
  to
• 13:08
  start
• 13:09
  Adderall
• 13:09
  with
• 13:09
  the
• 13:09
  patient
• 13:10
  who.
• 13:10
  Bipolar.
• 13:10
  Bipolarity
• 13:12
  but
• 13:12
  if
• 13:12
  you
• 13:12
  started
• 13:12
  Ritalin,
• 13:13
  you
• 13:13
  may
• 13:13
  not
• 13:13
  get
• 13:14
  this,
• 13:14
  oh,
• 13:14
  mania
• 13:15
  or
• 13:15
  not
• 13:15
  mania,
• 13:15
  you
• 13:16
  might
• 13:16
  just
• 13:16
  get
• 13:16
  more
• 13:16
  irritability,
• 13:17
  more
• 13:17
  edginess,
• 13:18
  more
• 13:18
  insomnia,
• 13:18
  more
• 13:19
  racing
• 13:19
  thoughts,
• 13:20
  faster
• 13:21
  speech.
• 13:22
  So
• 13:23
  don't
• 13:23
  just
• 13:23
  think
• 13:24
  of
• 13:24
  Hollywood
• 13:25
  mania
• 13:26
  versus
• 13:27
  normal
• 13:27
  person.
• 13:28
  A
• 13:28
  lot
• 13:29
  of
• 13:29
  this
• 13:29
  is
• 13:29
  on
• 13:29
  a
• 13:29
  spectrum
• 13:30
  too.
• 13:30
  Monitor
• 13:31
  those
• 13:31
  patients
• 13:32
  and
• 13:33
  look
• 13:33
  at
• 13:33
  the
• 13:34
  non
• 13:34
  stimulants
• 13:35
  as
• 13:35
  options.
• 13:36
  One
• 13:36
  of
• 13:36
  the
• 13:36
  big
• 13:37
  themes
• 13:37
  of
• 13:37
  this
• 13:37
  podcast
• 13:38
  is
• 13:39
  appreciating
• 13:39
  the
• 13:40
  mechanisms
• 13:40
  of
• 13:40
  action
• 13:41
  and
• 13:41
  why
• 13:41
  we
• 13:41
  do
• 13:42
  things
• 13:42
  right.
• 13:43
  Because
• 13:43
  at
• 13:43
  the
• 13:43
  end
• 13:43
  of
• 13:43
  the
• 13:43
  day,
• 13:44
  we're
• 13:44
  trying
• 13:44
  to
• 13:44
  modulate
• 13:45
  impulsivity,
• 13:46
  we're
• 13:46
  trying
• 13:46
  to
• 13:47
  promote
• 13:47
  sleep,
• 13:48
  attention
• 13:48
  and
• 13:49
  working
• 13:49
  memory.
• 13:50
  These
• 13:50
  folks
• 13:50
  have
• 13:50
  to
• 13:51
  function,
• 13:51
  they
• 13:51
  have
• 13:51
  lives
• 13:52
  to
• 13:52
  live.
• 13:53
  And
• 13:53
  at
• 13:53
  the
• 13:53
  end
• 13:53
  of
• 13:53
  the
• 13:54
  day,
• 13:54
  pair
• 13:54
  your
• 13:54
  medication
• 13:55
  specifically
• 13:56
  to
• 13:56
  the
• 13:56
  receptors
• 13:57
  that
• 13:57
  are
• 13:58
  distressing
• 13:59
  and
• 13:59
  impairing
• 13:59
  your
• 13:59
  patient.
• 14:00
  Don't
• 14:01
  roll
• 14:01
  the
• 14:01
  dice,
• 14:01
  don't
• 14:02
  go
• 14:02
  in
• 14:02
  blind.
• 14:03
  There's
• 14:03
  ways
• 14:03
  to
• 14:03
  do
• 14:04
  this,
• 14:04
  there's
• 14:04
  conversations
• 14:05
  to
• 14:05
  be
• 14:05
  had.
• 14:06
  And
• 14:06
  so
• 14:06
  I
• 14:06
  hope
• 14:07
  this
• 14:07
  really
• 14:07
  helped
• 14:07
  you
• 14:08
  run
• 14:08
  your
• 14:08
  interaction
• 14:09
  checks
• 14:09
  too,
• 14:09
  with
• 14:10
  your
• 14:10
  patients.
• 14:10
  This
• 14:11
  was
• 14:11
  a
• 14:11
  fun
• 14:11
  one.
• 14:11
  Don't
• 14:12
  be
• 14:12
  afraid
• 14:13
  to
• 14:13
  tackle
• 14:14
  ADHD
• 14:15
  and
• 14:15
  bipolarity.
• 14:16
  Just
• 14:16
  make
• 14:16
  sure
• 14:17
  that
• 14:17
  the
• 14:18
  mood
• 14:18
  is
• 14:19
  stabilized
• 14:19
  first.
• 14:20
  Go
• 14:21
  on
• 14:21
  to
• 14:21
  ADHD
• 14:21
  after
• 14:22
  the
• 14:22
  fact,
• 14:23
  ask
• 14:23
  the
• 14:23
  most
• 14:24
  impairing
• 14:24
  symptoms
• 14:25
  and
• 14:25
  choose
• 14:26
  the
• 14:27
  best
• 14:27
  medication
• 14:28
  that
• 14:28
  you
• 14:28
  can.
• 14:29
  Keep
• 14:29
  your
• 14:29
  ear
• 14:29
  to
• 14:30
  the
• 14:30
  ground.
• 14:31
  Not
• 14:31
  all
• 14:31
  of
• 14:31
  the
• 14:31
  non
• 14:32
  stimulants
• 14:32
  are
• 14:32
  that
• 14:33
  safe.
• 14:33
  Strattera,
• 14:34
  remember,
• 14:34
  is
• 14:34
  also
• 14:35
  used
• 14:35
  for
• 14:35
  treatment
• 14:36
  resistant
• 14:36
  depression.
• 14:37
  It
• 14:37
  has
• 14:37
  been
• 14:38
  shown
• 14:38
  in
• 14:39
  case
• 14:39
  reports
• 14:39
  to
• 14:40
  induce
• 14:40
  mania.
• 14:41
  And
• 14:41
  there's
• 14:41
  some
• 14:41
  criticism
• 14:42
  there
• 14:42
  because
• 14:43
  doing
• 14:43
  Strattera
• 14:44
  just
• 14:45
  because
• 14:45
  it's
• 14:45
  a
• 14:45
  non
• 14:45
  stimulant
• 14:46
  and
• 14:46
  might
• 14:46
  be
• 14:46
  less
• 14:47
  risky
• 14:47
  than
• 14:47
  Adderall
• 14:48
  still
• 14:48
  has
• 14:49
  the
• 14:49
  potential
• 14:49
  to
• 14:49
  cause
• 14:50
  mania
• 14:51
  and
• 14:52
  it's
• 14:52
  not
• 14:52
  as
• 14:52
  effective
• 14:53
  as
• 14:53
  Adderall.
• 14:53
  So
• 14:53
  it's
• 14:54
  like
• 14:54
  the
• 14:54
  worst
• 14:54
  of
• 14:54
  both
• 14:54
  worlds.
• 14:55
  Different
• 14:55
  prescribers
• 14:56
  might
• 14:56
  disagree
• 14:57
  with
• 14:57
  me
• 14:57
  on
• 14:57
  that
• 14:58
  and
• 14:58
  that's
• 14:58
  okay.
• 14:59
  But
• 15:00
  keep
• 15:00
  that
• 15:00
  in
• 15:00
  mind.
• 15:01
  If
• 15:01
  you're
• 15:01
  going
• 15:01
  to
• 15:01
  pick
• 15:01
  a
• 15:02
  strategy,
• 15:03
  look
• 15:04
  at
• 15:04
  the
• 15:04
  risk
• 15:04
  and
• 15:04
  reward.
• 15:05
  Is
• 15:05
  it
• 15:05
  worth
• 15:05
  it?
• 15:06
  Does
• 15:06
  the
• 15:06
  patient
• 15:07
  believe
• 15:07
  it's
• 15:07
  worth
• 15:07
  it?
• 15:08
  Is
• 15:08
  this
• 15:08
  going
• 15:09
  to
• 15:09
  make
• 15:09
  sense?
• 15:09
  It's
• 15:09
  like
• 15:10
  if
• 15:10
  I
• 15:10
  was
• 15:10
  a
• 15:10
  patient
• 15:10
  and
• 15:11
  you're
• 15:11
  telling
• 15:11
  me
• 15:11
  that
• 15:11
  this
• 15:12
  could
• 15:12
  cause
• 15:12
  massive
• 15:13
  mood
• 15:13
  destabilization
• 15:14
  and
• 15:14
  it's
• 15:14
  not
• 15:14
  a
• 15:14
  whole
• 15:15
  lot
• 15:15
  effective
• 15:16
  for
• 15:16
  ADHD
• 15:17
  compared
• 15:18
  to
• 15:18
  Ritalin.
• 15:20
  Well,
• 15:20
  I
• 15:20
  might
• 15:20
  not
• 15:21
  like
• 15:21
  that
• 15:21
  if
• 15:21
  my
• 15:21
  ADHD
• 15:22
  is
• 15:22
  very
• 15:22
  impairing.
• 15:23
  Again,
• 15:24
  this
• 15:24
  is
• 15:25
  very
• 15:25
  much
• 15:25
  a
• 15:26
  conversation.
• 15:27
  It's
• 15:27
  a
• 15:27
  matter
• 15:28
  of
• 15:28
  trade
• 15:28
  offs.
• 15:29
  There
• 15:29
  will
• 15:29
  always
• 15:30
  be
• 15:30
  risk
• 15:30
  in
• 15:30
  some
• 15:31
  sense
• 15:31
  when
• 15:31
  we're
• 15:31
  prescribing.
• 15:32
  And
• 15:32
  it's
• 15:33
  a
• 15:33
  matter
• 15:33
  of
• 15:33
  discussing
• 15:33
  those
• 15:34
  risks
• 15:34
  openly
• 15:34
  and
• 15:35
  transparently.
• 15:36
  And
• 15:36
  you
• 15:36
  all
• 15:37
  can
• 15:37
  do
• 15:37
  it.
• 15:37
  You
• 15:37
  Absolutely
• 15:38
  can.
• 15:38
  I
• 15:39
  hope
• 15:39
  you
• 15:39
  had
• 15:39
  a
• 15:40
  really
• 15:40
  good
• 15:41
  time
• 15:41
  with
• 15:41
  this
• 15:42
  one
• 15:42
  today.
• 15:42
  Thanks
• 15:42
  for
• 15:43
  tuning
• 15:43
  in.
• 15:43
  We'll
• 15:43
  catch
• 15:44
  you
• 15:44
  next
• 15:44
  time
• 15:44
  on
• 15:45
  another
• 15:45
  episode
• 15:45
  of
• 15:46
  Pearls
• 15:46
  and
• 15:46
  Prep.
• 15:46
  And
• 15:47
  don't
• 15:47
  forget
• 15:47
  my
• 15:47
  friends,
• 15:48
  join
• 15:48
  Patreon
• 15:49
  where
• 15:49
  you
• 15:49
  get
• 15:49
  slide
• 15:50
  decks
• 15:51
  full
• 15:51
  of
• 15:51
  this
• 15:51
  information
• 15:52
  with
• 15:52
  great
• 15:52
  research
• 15:53
  evidence
• 15:54
  based
• 15:54
  pearls.
• 15:55
  They're
• 15:55
  great
• 15:55
  coffee
• 15:56
  reads.
• 15:56
  We
• 15:57
  update
• 15:57
  our
• 15:57
  Patreon
• 15:58
  all
• 15:58
  the
• 15:58
  time
• 15:58
  so
• 15:58
  the
• 15:58
  evidence
• 15:59
  keeps
• 15:59
  flowing
• 16:00
  at
• 16:00
  your
• 16:00
  fingertips
• 16:01
  and
• 16:01
  it's
• 16:01
  just
• 16:02
  great.
• 16:02
  We
• 16:02
  even
• 16:02
  have
• 16:02
  private
• 16:03
  podcast
• 16:03
  feed.
• 16:04
  There
• 16:04
  some
• 16:04
  private
• 16:04
  podcast
• 16:05
  episodes
• 16:06
  that
• 16:06
  you
• 16:06
  can
• 16:06
  nerd
• 16:06
  out
• 16:07
  on
• 16:07
  with
• 16:07
  more
• 16:08
  practice
• 16:08
  boosting
• 16:09
  information.
• 16:10
  If
• 16:10
  nothing
• 16:11
  else,
• 16:11
  my
• 16:11
  friends,
• 16:12
  we
• 16:12
  would
• 16:12
  appreciate
• 16:12
  if
• 16:13
  you
• 16:13
  marched
• 16:13
  over
• 16:14
  to
• 16:14
  Apple,
• 16:14
  gave
• 16:14
  us
• 16:15
  five
• 16:15
  stars
• 16:15
  and
• 16:15
  wrote
• 16:16
  a
• 16:16
  comment
• 16:16
  that
• 16:16
  is
• 16:16
  a
• 16:16
  great
• 16:17
  way
• 16:17
  to
• 16:17
  support
• 16:17
  our
• 16:17
  podcast.
• 16:18
  Boy,
• 16:18
  we've
• 16:19
  gotten
• 16:19
  really
• 16:19
  big,
• 16:19
  really
• 16:20
  quick.
• 16:21
  Lots
• 16:21
  of
• 16:21
  NP
• 16:21
  schools
• 16:22
  out
• 16:22
  there.
• 16:22
  Good
• 16:23
  feedback
• 16:23
  sharing
• 16:24
  this
• 16:24
  stuff.
• 16:24
  We
• 16:25
  love
• 16:25
  hearing
• 16:25
  from
• 16:25
  you.
• 16:26
  Email
• 16:26
  me
• 16:26
  in
• 16:26
  the
• 16:26
  show
• 16:27
  notes
• 16:27
  if
• 16:27
  you
• 16:27
  have
• 16:27
  any
• 16:28
  questions
• 16:29
  or
• 16:29
  want
• 16:29
  me
• 16:29
  to
• 16:29
  go
• 16:30
  over
• 16:30
  specific
• 16:30
  topics
• 16:31
  from
• 16:31
  your
• 16:31
  programs.
• 16:31
  Feel
• 16:32
  free
• 16:32
  on
• 16:32
  Patreon
• 16:33
  when
• 16:33
  you
• 16:33
  become
• 16:33
  a
• 16:34
  member.
• 16:34
  You
• 16:34
  don't
• 16:34
  have
• 16:34
  to
• 16:34
  be
• 16:34
  a
• 16:35
  paying
• 16:35
  member.
• 16:35
  Access
• 16:36
  those
• 16:36
  great
• 16:36
  materials,
• 16:37
  you
• 16:37
  can
• 16:37
  become
• 16:37
  a
• 16:37
  free
• 16:38
  member
• 16:38
  and
• 16:38
  also
• 16:38
  message
• 16:39
  me
• 16:39
  and
• 16:40
  have
• 16:40
  a
• 16:40
  great
• 16:40
  conversation
• 16:41
  about
• 16:41
  what
• 16:41
  you
• 16:41
  want
• 16:41
  to
• 16:41
  see
• 16:42
  next
• 16:42
  on
• 16:42
  these
• 16:43
  episodes.
• 16:43
  All
• 16:43
  right,
• 16:44
  until
• 16:44
  next
• 16:44
  time
• 16:44
  you
• 16:44
  all
• 16:45
  take
• 16:45
  care.
• 16:45
  Bye
• 16:45
  bye.