21.1 Dr. Robert Post, MD: Youth-Onset Bipolar Illness

[00:00:00] Another thing that's not that well researched yet is they found that there's a substance in people's blood of depressed patients called acetyl-L-carnitine that's low. And it's low in treatment-resistant patients. And if you treat with this drug, it shuts off over excitation of glutamate neurons and has antidepressant effects.

[00:00:27] And it's actually very interesting because in an animal model of depression, if you put a little mouse next to a big guy for 10 days, it starts acting depressed.

[00:00:43] Somebody get this guy some help!

[00:00:52] So today on the podcast, I have Dr. Robert Post. He is an MD with a long and illustrious career working in the field of psychiatry. Graduated from Yale in 1965.

[00:01:06] He went to University of Pennsylvania for medical school. Interned at the Einstein School of Medicine and completed his psychiatric residency at Mass General, the NIMH, and George Washington University.

[00:01:21] Dr. Post spent 35 years at the NIMH, or the National Institutes of Mental Health, with 20 serving as the chief of the biological psychiatry branch.

[00:01:33] He founded the Bipolar Collaborative Network almost 30 years ago, which is an international network of researchers and clinicians trying to make sense of all the pervasive mysteries of bipolar illness.

[00:01:48] And you've also contributed more than 1,000 articles to the psychiatric literature with an H-index of 171.

[00:01:57] That's a high H-index, Dr. Post.

[00:02:00] He is a huge proponent of early lithium utilization, especially in bipolar illness and psychiatry, and wrote one of the more influential papers for myself and my patients in 2017 titled,

[00:02:16] The New News About Lithium, with several other publications promoting the idea that it is vastly underutilized, needs to be initiated earlier in high risk and early bipolar patients.

[00:02:30] And you recognize lithium as one of, if not the most important drug in all of psychiatry.

[00:02:37] You are also noted to have pioneered the use of another old repurposed drug, an anticonvulsant carbamazepine or tegratol, for lithium-resistant bipolar patients.

[00:02:49] You've won multiple awards from the American Psychiatric Association, the Society of Biological Psychiatry, the National Alliance on Mental Illness.

[00:03:00] And actually, similar to last week's guest, your longstanding colleague, Yanis Rybikowski,

[00:03:08] maybe the most prestigious award or the award for which you are both most proud is being the 2017 recipient of the Mogan Scow Award.

[00:03:18] Yeah, thank you.

[00:03:20] For our listeners who have forgotten Mogan Scow, he was the Danish psychiatrist who helped pioneer the European use of lithium in manic depressive spectrum illness,

[00:03:31] motivated primarily by helping his brother, who suffered from a severe form of the illness.

[00:03:37] So, Dr. Post, I'm excited to have you on today and talk about some of the current and historical issues in the field of psychiatry.

[00:03:45] Yeah, I look forward to it.

[00:03:49] And I've got a number of points to make.

[00:03:54] The first is that you have to look for childhood bipolar illness in the United States.

[00:03:59] There's more childhood onsets in the U.S. than in Europe.

[00:04:03] A quarter of it starts before age 13, two-thirds before age 19.

[00:04:08] And in the U.S., we don't get it right early enough.

[00:04:14] And the longer the delay to first treatment, the worse somebody does in adulthood.

[00:04:20] So treating it early, looking for it is key.

[00:04:24] And in particular, distinguishing it from ADHD, which is often comorbid with it in kids.

[00:04:33] You got to look for insomnia, periods of elation, hypersexuality, depression, suicidality, those kinds of things.

[00:04:44] They don't go with ADHD.

[00:04:47] So you need the mood stabilized first and then go with ADHD meds.

[00:04:54] Another key issue is something that is not in the literature yet, but it should be,

[00:05:02] is that you need to treat the first mania that somebody has for the long term.

[00:05:11] Because they've done studies in Canada that you lose some cognition with a first mania.

[00:05:18] You get it back over the next year as long as you don't have any more episodes.

[00:05:23] The more episodes you have, the more cognitive dysfunction you have.

[00:05:28] And I guess the next key thing is to view this illness as progressive.

[00:05:36] Lars Kessing has it as the more episodes you have, the faster they occur, the more spontaneously they occur,

[00:05:46] the more severe they occur, and the more cognitive dysfunction you have in treatment resistance.

[00:05:54] So the name of the game is preventing episodes.

[00:05:57] And more medicines are usually required in order to do that.

[00:06:06] Lithium is a great drug.

[00:06:07] It should be in there early, as you say, but it's almost always not enough.

[00:06:12] It needs to be augmented with other mood stabilizers or atypicals.

[00:06:16] And you really want to stop this illness for progressing because the episodes, stresses, and substance abuse,

[00:06:28] which occur at a high rate with this illness, all contribute to illness progression.

[00:06:35] And interestingly enough, they all have an epigenetic basis.

[00:06:41] Epigenetic means that your genes get marks on them that makes the genes more or less likely to turn on or off.

[00:06:51] And these epigenetic marks make stresses more likely to occur, substance abuse worse over time, episodes worse over time.

[00:07:03] So you really want to stop these episodes and their associated epigenetic changes in the brain.

[00:07:10] It's a key issue about stopping illness progression.

[00:07:15] And when it's done well and right, Lars Kessing has it, that it decreases the rate of relapse rather remarkably.

[00:07:26] He did one of the few randomized trials of lithium clinic or clinic treatment with psychotherapy, pharmacotherapy, mood charting, all the rest.

[00:07:38] And those people in the clinic had fewer relapses than treatment as usual.

[00:07:46] So he also had psychotherapy in there.

[00:07:50] He also had therapy after the first episode to get them through.

[00:07:56] And my view is that after the first episode, you should treat people as if they had diabetes insipidus.

[00:08:03] You know, leave them alone.

[00:08:05] You give them good education and you create a good treatment team around them and get after it right from the get-go.

[00:08:15] And one of the things that people can do, patients can do that helps docs really well is if you can get them to chart their mood on a regular basis, you can get these mood charts on our website,

[00:08:33] bipolarnews.org, and click on personal calendar or mood chart, and you can rate the mania, depression, sleep, anxiety, all these other things,

[00:08:47] and then show those things to the doc at each visit.

[00:08:51] And that'll help get things exactly right.

[00:08:54] And it'll help with early warning for when things are starting to slide.

[00:09:00] So that's a key issue.

[00:09:03] The other issue is that this website also has something for parents of young kids,

[00:09:13] where they can enter the kids into a system where they rate their young children age 2 to 12 every week on depression, mania, anxiety, oppositional behavior, that kind of stuff.

[00:09:29] This will help primary care docs who see most of these kids figure out how the illness is going, what's working, and what's not working.

[00:09:39] So getting after this illness early and well is the key thing.

[00:09:47] And as you mentioned, lithium is way underutilized.

[00:09:52] And my view is that we have to actually help patients learn about the assets of lithium.

[00:10:01] All they know is that it's a bad drug and it's toxic.

[00:10:05] That's what the literature that they first see says.

[00:10:09] And it turns out that the side effects are overestimated, but the good effects are underestimated.

[00:10:17] And I actually tell people all the specific things that lithium does that's good for you and your brain.

[00:10:27] Like it increases neurogenesis.

[00:10:30] New neurons that you make increases the volume of the hippocampus.

[00:10:34] It protects your memory.

[00:10:36] It lengthens your telomeres, which are important to overall health.

[00:10:41] And it actually, if you're on lithium long-term, it decreases all-cause mortality.

[00:10:49] And that's a huge one because people with bipolar illness can lose a decade of moral life to the various medical illnesses.

[00:10:59] So use lithium more and in conjunction with other agents right from the get-go.

[00:11:07] The other thing is that this illness is very complex and it's often associated with all kinds of comorbidities, including anxiety, substance use, all those things.

[00:11:21] And those need to be treated as well.

[00:11:26] And there's actually some vitamin-type supplements that people can get on their own that can address some of these.

[00:11:35] One of those is called N-acetylcysteine, NAC.

[00:11:40] 500 milligram capsules, two in the morning, two at night.

[00:11:45] And this is great because it decreases depression and anxiety in bipolar patients.

[00:11:50] But it also helps cut substance craving and substance use.

[00:11:56] And it does this across the board for alcohol, cocaine, even helps adolescents avoid marijuana.

[00:12:05] And all these things are in controlled clinical trials.

[00:12:09] So using some of these supplements is a good idea.

[00:12:15] I also put people on vitamin D, 4,000 units rather routinely because often our patients are vitamin D3 deficient.

[00:12:27] Put them on L-methylfolate because that helps lithium and antidepressants work better.

[00:12:33] And if they have slow folate metabolism, methyl tetrahydrofolate reductase deficiency, the L-methylfolate will get around that.

[00:12:43] Another thing that's not that well researched yet is they found that there's a substance in people's blood of depressed patients called acetyl-L-carnitine that's low.

[00:12:56] And it's low in treatment-resistant patients.

[00:13:00] And if you treat with this drug, it shuts off over-excitation of glutamate neurons and has antidepressant effects.

[00:13:11] And it's actually very interesting because in an animal model of depression, if you put a little mouse next to a big guy for 10 days, it starts acting depressed.

[00:13:24] It doesn't socialize.

[00:13:26] It doesn't explore.

[00:13:27] It doesn't run around.

[00:13:28] It doesn't like sugar, water, all that kind of thing.

[00:13:30] If you give that animal an antidepressant, it takes two to three weeks to get rid of it.

[00:13:35] If you give that animal acetyl-L-carnitine, it turns on this gene that inhibits glutamate release and it works in two or three days.

[00:13:47] So we need to study that drug more for resistant depression as well.

[00:13:54] So getting after things that come with this illness.

[00:13:59] We have all kinds of things for alcohol avoidance now.

[00:14:03] NAC, gabapentin, topiramate, lots of things that need to be treated as well.

[00:14:12] So I've been running on for quite a while here, sort of on my own.

[00:14:18] Do you have any questions for me?

[00:14:20] I only have about 12 follow-up questions.

[00:14:26] So, well, first, do you feel like we are, as an American society, do you feel like we are over-medicated or rely too much on prescription medication?

[00:14:40] No, the opposite.

[00:14:41] We don't get serious illness treated well enough, early enough, with enough meds.

[00:14:47] If you use more medicines judiciously, you can target more neurotransmitter systems, get better results, and guess what?

[00:14:58] Fewer side effects.

[00:15:00] So if you do it carefully, you can get fewer side effects.

[00:15:05] We're not over-medicated.

[00:15:06] We're under-medicated.

[00:15:08] They've done studies in 13 to 18-year-old kids, Kathleen Merrick, Hengist.

[00:15:16] And 2% or 3% of these kids have a bipolar spectrum disorder.

[00:15:22] But guess what?

[00:15:23] Less than 20% of them are in any kind of treatment whatsoever.

[00:15:29] So it's not over-medicated.

[00:15:31] It's under-recognized and under-medicated.

[00:15:34] I meant more as a society, not just in reference to childhood bipolar, but our rush to jump to medication treatment before looking at alternatives, lifestyle.

[00:15:48] One of the major kind of bones that I have to pick with how we practice medicine in the U.S.

[00:15:55] is going from 0.2% of Medicaid-insured use on a psychiatric medication in 1987, closing in on 20% today.

[00:16:06] And maybe where you and I reconcile with that is that most of those medications in used mental health medications are SSRI antidepressants,

[00:16:15] which do not have good long-term efficacy in mood disorders, have potentially disastrous side effects in mood disorders.

[00:16:25] And so maybe the reconciliation there is, I agree with you, we should be using more mood stabilizers for these depressive or manic states as opposed to traditional antidepressants.

[00:16:41] But I still feel like we as a society are too reliant, and you see it compared to other countries of the world.

[00:16:49] We gobble up medications at a much higher clip than any other country, and we have worse health outcomes to show for it.

[00:17:00] Yep, yep, definitely.

[00:17:02] I'm not so much on too many meds because every morning I take about 18 pills.

[00:17:11] I had a heart attack when I was 50.

[00:17:14] I'm 82 now, and I like taking all these pills because I haven't had another heart attack.

[00:17:19] I wouldn't go off of them or antidepressants or blood pressure or cholesterol, any of those meds, if you paid me.

[00:17:28] So I'm for more meds carefully given, and if you can get away with no side effects like me, it's all to the good.

[00:17:38] Yeah. How do you balance the kind of subjective reporting that can come, especially from a parent in a child who may be exhibiting some symptoms of bipolar?

[00:17:51] How do you balance the environmental influences?

[00:17:57] I know you've written a lot about the impact of trauma in adverse childhood experiences as accelerating the symptoms of bipolar disorder in somebody who already comes from a family with a history of mood disorders.

[00:18:13] How do you balance the parent who doesn't know how to manage a troubled child or a child that's traumatized with behavioral problems and get good information to decide whether or not somebody that young needs to be started on a mood stabilizer?

[00:18:34] Yeah, that's a really good question.

[00:18:37] The data of California by Dave Mikkelwitz is that if you do family-focused therapy or something like that right from the get-go with early symptoms, kids do better, have less depression, anxiety, all that kind of stuff.

[00:18:53] So even if it's ambiguous, getting people into treatment and helping parents with management strategies, things like that is really big time.

[00:19:06] And this is one area where if the parents rate the kids on this child network thing, and if they rate the kid longitudinally, that'll really separate out what's a transient problem for what's a big time chronic problem.

[00:19:27] So parents are really the best observers of their kids, and having them give good data to their docs is key to good outcomes.

[00:19:40] So before we get to more questions about lithium or its use in bipolar use, I want to get your take on a longstanding kind of burning question that I've had.

[00:19:52] So, you know, I do believe that what we now call schizophrenia and bipolar disorder, they almost require a certain level of consciousness to manifest.

[00:20:03] So as humans, we kind of start out as these completely reliant beings on our parents and authority figures to meet basic needs, food, water, shelter, love.

[00:20:16] Then as a very young child, we learn to use and express language to better explicitly state those needs to the outside world.

[00:20:26] But at some point, and I have always kind of put this point usually around the time of puberty, there's this massive expanse of awareness of both the world that we live in and the world that lives within us.

[00:20:40] And that external language kind of evolves or morphs inwardly, and we develop this system of constant communication ongoing internally with what many reference as the mind.

[00:20:56] From what I've seen, from what I've learned, not that that is anywhere near the end-all be-all of the truth, it seems that this expansion of consciousness or self-awareness or the recognition of the mind as a quasi-independently functioning aspect of ourselves is almost a necessary component to developing these conditions.

[00:21:19] And again, there may be some reconciliation with your stance on us needing to more aggressively treat childhood bipolar illness in that those adverse childhood experiences or those, you know, AKA traumas also can instigate a young person to go through puberty earlier.

[00:21:39] Maybe some sort of evolutionary response that will allow them to escape an abusive environment more quickly.

[00:21:46] But I'm just little old Ethan Short from Louisville, Kentucky, and you're Robert Post.

[00:21:53] So what is your opinion on the role of an individual's level of consciousness or awareness of their own mind in their ability to develop symptoms of bipolar or schizophrenia?

[00:22:05] Yeah, adolescence is at a very vulnerable time.

[00:22:09] And part of the problem is that the brain develops in different stages in different areas.

[00:22:18] And part of the problem is that the emotional brain or the limbic system develops faster than the frontal cortical system.

[00:22:28] So the consciousness that you're talking about where you need consciousness for good decision-making, for doing all kinds of things, friends at school, that kind of stuff, that's often slowed down relative to the limbic system, which is pushing, anger, irritability, impulsiveness, that kind of stuff.

[00:22:55] That's where people can get into a lot of difficulty with substance abuse.

[00:23:00] And this antithelial cysteine actually cools off the limbic system and allows the cortex to have more control.

[00:23:08] So you're right.

[00:23:09] If you can get more cortical control in there, that's all to the good.

[00:23:14] And some of that cortical control, as you're saying, if it's not quite on track, can lead to difficulties.

[00:23:22] It sounds a lot of the things that we're talking about in reference to what may instigate earlier onset of bipolarity kind of revolving around inflammation and just kind of that inflammation that extends into neuroinflammation, as well as some of the treatments that we're talking about, whether it be lithium, N-acetylcysteine, have this anti-inflammatory component to it.

[00:23:47] Now, I was absolutely blown away by some of the slides.

[00:23:55] You had told me that you wanted to talk about how all aspects of bipolar illness are more prevalent in the U.S. compared to Europe.

[00:24:04] But when you sent me that PowerPoint, I was blown away by the degree of difference in that symptomatology here versus Europe and the rest of the world.

[00:24:16] So is there more to it than just having the genetics?

[00:24:22] Is it our diet that is creating inflammation at such a young age?

[00:24:26] Is it the massive influx of SSRI use more prevalent in America than other nations over the last 25 to 30 years that contribute to more people being diagnosed with bipolar or the greater severity or more rapid cycling in the U.S. population?

[00:24:45] Is it the massive expanse of information driving that subconscious to be even more aware of more threats to our survival?

[00:24:55] Yeah.

[00:24:56] In terms of more threats and stuff, we have more genetic vulnerability in the U.S.

[00:25:04] Both our parents and our grandparents have more psychiatric illness.

[00:25:08] And in the U.S., we tend to marry other people who also have mood disorders.

[00:25:13] So we get genetic vulnerability from two sides.

[00:25:16] And we have more psychosocial stress twice as much as in Europe.

[00:25:23] And if you just have verbal abuse, neglect, bullying, stuff like that, and no physical or sexual abuse, just the verbal abuse gives you earlier onset of illness and a worse course.

[00:25:39] And the inflammation thing is also prevalent there because we have a lot more obesity in the United States.

[00:25:46] And with the bad diet and obesity, you get more inflammation as well.

[00:25:52] So I think it's a whole complex combination of things that are leading us in this direction where we like to think that in the U.S.

[00:26:04] we're better at everything, but it's not a good idea that we're better at everything like illness.

[00:26:10] And it turns out that adults in the U.S. are sicker than adults in England, for example.

[00:26:19] More diabetes, lung disease, heart disease, every kind of disease.

[00:26:23] So it's not just kids that are sicker.

[00:26:27] It's we in the U.S. in general.

[00:26:30] So if we can do things to live better, have a healthier diet, more exercise, all kinds of things like that, that might, you know, help out a whole ton.

[00:26:41] The inflammation story is very interesting because it turns out that if you do this defeat stress study that I mentioned that makes the animals depressed,

[00:26:55] monocytes or white cells for your blood and bone marrow secrete an inflammatory substance, interleukin-6, that causes that depression.

[00:27:07] And if you block that interleukin-6 secretion, the animals don't get depressed.

[00:27:13] So that's another thing is depression is not only in the mind, but it contributes, is contributed to by your blood and your white cells and the inflammation that comes with it.

[00:27:29] Because those inflammatory cytokines can get into brain and hurt its function.

[00:27:36] So the inflammation part of the story is a key one, as you're saying.

[00:27:41] Yeah, and it may be one of the major reasons, you know, why lithium is effective, especially as a prophylactic against depression,

[00:27:49] because it has that GSK3 beta inhibition, which downstream does downregulate IL-6 and reduces that form of inflammation.

[00:28:00] But it takes time.

[00:28:01] It takes time for that to manifest.

[00:28:04] And that is, you know, time that you've got to reassure your patient.

[00:28:09] One thing that you mentioned that I know that we're not better at in America is living longer lives.

[00:28:14] We tragically live much shorter lives, I think four years shorter than other developed nations.

[00:28:20] And I think part of that has to do with, you know, like I was saying earlier, are just overconsumption of everything.

[00:28:29] Everything is marketed and advertised very aggressively.

[00:28:32] And I believe that we overdiagnose conditions or we misdiagnose conditions here in America often.

[00:28:41] We're the only country outside of New Zealand who allows companies to directly market to consumers,

[00:28:49] which I think that plays an influence on driving up some of those diagnoses.

[00:28:54] But I do see what you're saying with some of these other factors that would cause us to also have greater incidence and severity of bipolar.

[00:29:04] How much do you think that our numbers are influenced by a culture of either patients seeking out diagnoses that may be given out a little bit more liberally or us just in general diagnosing more things as clinicians?

[00:29:25] Yeah, I think the increased illness in the U.S., both early onset illness in kids and more severe illness in adults is real.

[00:29:40] And it's a complication of us not getting people into treatment early enough and well enough.

[00:29:48] And some of it's stigma where people don't necessarily want to admit that they're depressed or they're hypomanic.

[00:29:59] You know, it's one thing to treat a cancer seriously and try to get it out before it metastasizes.

[00:30:07] It's another thing to have somebody with a first major episode of mood disorder.

[00:30:13] We don't take that seriously enough.

[00:30:16] It's a major issue of it being a reality and having all kinds of consequences, including what you're saying is that we live less long than in Europe.

[00:30:30] So to go back to the earlier question, you know, I'm just sitting here imagining a very neurotic parent filling out the questionnaires repeatedly and always maybe exaggerating the symptoms or even projecting their own symptoms onto their child.

[00:30:49] I guess like how how can you really have the utmost confidence in initiating?

[00:30:57] Because it's a big decision to initiate a psychiatric medication in a child.

[00:31:03] Less so than an adolescent, I guess, in somebody, you know, let's say under the age of 10.

[00:31:08] I just don't know that I would have that much comfort in trusting the subjective report of the parent, depending on who the parent is and what their background is.

[00:31:19] But yeah, I don't know.

[00:31:20] It just seems like it would be difficult to tease out.

[00:31:24] Obviously, it'd be great if we could just take the child's blood and say, yep, you got this thing.

[00:31:28] Yeah, yeah.

[00:31:30] Well, they've done studies of this in North Carolina.

[00:31:33] And it turns out that if you look at clinicians ratings, teachers ratings and parents ratings and kids ratings, the ones who get it right the most are the parents.

[00:31:45] So the longitudinal rating of parents, I think, is a good guideline.

[00:31:51] And if somebody is having a lot of dysfunction, that's the key thing.

[00:31:59] You know, if they can't go to school or they beat up kids at school or all these kinds of things, and that happens repeatedly, that's a key element in trying to help that kid more.

[00:32:12] I actually rely on parental ratings of the kids pretty much.

[00:32:18] The literature actually supports that.

[00:32:21] What about the overuse of antidepressants, which is a very disturbing trend in mood disorders over the last really 20 plus years, is that we as a profession, or I guess you could add primary care physicians in there, are treating these conditions with SSRI and antidepressants at increasing rates.

[00:32:44] And we're seeing drastically reduced rates of mood stabilizer treatment.

[00:32:49] What can you say about that class of medications, the SSRIs, which have been dubbed as antidepressants, may have more anti-anxiety and be good at treating something like an anxiety-driven or neurotic depression.

[00:33:03] What can you say about the influence of using SSRIs as monotherapy for some of these younger patients who are at high risk or already exhibiting symptoms of bipolarity?

[00:33:18] Yeah, well, the last word is the key.

[00:33:23] Bipolarity.

[00:33:24] Because if the kid is just having struggles with depression and anxiety, the SSRIs actually have some FDA approval for treatment of those youngsters.

[00:33:36] But if they're bipolar, then I would tend to avoid them like the plague, actually.

[00:33:44] That's where I think they have the most problem, that we're using the antidepressants way too much and the mood stabilizers and lithium and the atypicals way too little.

[00:33:57] The data actually are like this.

[00:34:01] All the atypicals are going up and antidepressants are going up and the mood stabilizers are going down.

[00:34:12] And this has been shown in clear-cut data over the last decade.

[00:34:17] It's a problem, but I think it's not so much a problem for unipolar depressed kids who do have good responses to antidepressants and psychotherapy.

[00:34:29] But if there's a bipolar history, then it's a different story.

[00:34:34] So my next question, if you are evaluating the person, then I have a lot more confidence in your ability to tease out what is unipolar versus bipolar depression.

[00:34:47] But unfortunately, you are one man and there are, you know, 350 million Americans.

[00:34:52] So it's going to tend to be more primary care physicians, especially in this very young population.

[00:35:00] What is your degree of confidence that your run-of-the-mill primary care physician is going to be able to tell the difference between a kid who's suffering from unipolar versus bipolar?

[00:35:13] Because the reality is, if the kid does have the bipolar genetics, that again, it's not like they're wearing a sign on their head that says this, or we can take their blood and know that they are bipolar.

[00:35:25] But if they take those, you have very, very serious potential consequences in terms of creating a manic state or exacerbating suicidality or contributing to potential suicide attempt.

[00:35:42] So is it a situation where maybe we should consider changing from the knee-jerk reaction to use SSRIs as antidepressants into initiating with a mood stabilizer if you had to take a very simple algorithmic approach to a family care practitioner?

[00:36:04] Yeah, that's a key issue because the family care practitioners are not equipped to deal with psychiatric illness very well.

[00:36:14] And even if they make a bipolar diagnosis, as you're saying, it's all too often that the treatment is either not there or it's an antidepressant.

[00:36:23] So my take is that in any teenager or adult with depression, if you only have one minute of time, ask them, have they ever had a period of increased energy and decreased need for sleep?

[00:36:40] That one question will screen.

[00:36:43] You can then look more in detail for bipolar history.

[00:36:47] But if there's that bipolar history in the family and evidence of bipolarity, then I think you need to stay away from the antidepressants and go in these other directions that you're talking about.

[00:37:00] Yeah, it's a tough issue because the primary care docs know about stimulants and antidepressants and they don't know much about these other issues.

[00:37:13] Or they're terrified of lithium.

[00:37:16] And as you mentioned earlier, they put it into this category of bad.

[00:37:20] I like to ask because I've had a couple of primary care docs, even when I'm using 150 milligrams in an autistic patient that will reach out and they'll be worried about the dangerousness of it.

[00:37:33] I always ask them, I say, well, is sodium bad?

[00:37:36] Is potassium bad?

[00:37:38] And I say, well, no.

[00:37:39] And it's like, well, it can be bad if it's not in the right range in the bloodstream.

[00:37:44] It can be very, very bad.

[00:37:47] But I worry that even psychiatrists don't know some of these basic fundamental ideas.

[00:37:53] And, you know, I trained at a time where essentially the answer was almost always SSRI for the vast majority of conditions.

[00:38:01] And as I get older, I feel more confident and comfortable with recognizing some of those early signs of bipolarity.

[00:38:10] And just for the listeners, bipolar illness typically manifests as episodes of depression prior to having a manic episode.

[00:38:21] So it's kind of a hard call to say, or I always felt a little bit afraid that I was going to harm a patient that I didn't know existed on that mood disorder spectrum by giving them a drug that has a black box warning for increasing their risk of suicide.

[00:38:41] When I had that other drug that has proven evidence that I was told was so dangerous and I shouldn't use.

[00:38:50] Yeah, yeah, exactly.

[00:38:52] Is there anything else that you wanted to talk about or mention that you didn't have a chance to?

[00:38:59] Oh, no.

[00:39:00] I think we covered a whole lot of it.

[00:39:03] But my mantra is, and I actually tell patients this, is that prevent episodes, protect the brain and body.

[00:39:13] That's the name of the game.

[00:39:14] And the other thing that I've said in here is that sometimes more complex medicines working on different neurotransmitter systems work better,

[00:39:25] and you can get fewer side effects if you do it carefully.

[00:39:28] So those two things are not so obvious.

[00:39:33] But the one other thing is, all your adult patients, you should ask them how their kids are doing.

[00:39:40] And if they're having lots of trouble, see if you can get them on a better pathway.

[00:39:47] Yeah, absolutely.

[00:39:48] The only pushback I got to give to the more medication piece is to provide that nuance of,

[00:39:54] and I assume that this is how you practice it, that you typically start with a monotherapy and add another medicine after that,

[00:40:05] doing it very specifically and with a purpose, as opposed to what I see way too often, which is go to the doctor.

[00:40:13] I'm anxious.

[00:40:15] Get you this medicine.

[00:40:16] Go back to the doctor.

[00:40:17] I'm depressed.

[00:40:18] Get you another one on top of it.

[00:40:19] And we end up stacking, you know, five, six, I've seen 10 different psychiatric meds on top of each other.

[00:40:28] And then it's, I see that person, I'm like, I don't even know where to start.

[00:40:32] Yeah.

[00:40:33] So that's one of the areas where it's very good if you can get the patient to mood chart.

[00:40:38] Then you can see subtle changes in improvement and then try to get more improvement or things are giving them side effects,

[00:40:47] getting them off and getting on to the next thing.

[00:40:50] So if patients can get induced to do these mood charts and give you good feedback, I think that's really, really important.

[00:41:00] But you just triggered my mind to think of something else.

[00:41:03] What do you make of Kukubulos' affective temperaments, that model and these kind of subsyndromal or maybe, you know,

[00:41:12] not to the degree of severity of what we would call bipolar one or two and hyperthymia, cyclothymia, etc.

[00:41:19] Yeah.

[00:41:20] I don't give those a whole lot of thought because I deal with all the tough to treat big time patients.

[00:41:27] I said, don't worry about the subtleties or the personality disorders.

[00:41:34] I've seen people who say, oh, this person's ever going to get better.

[00:41:37] They have a personality disorder, but when they get on the right meds, they're fine.

[00:41:42] So I'm not a big fan in that area.

[00:41:45] Yeah.

[00:41:46] Definitely too many patients being, you know, pushed out saying that they have borderline personality.

[00:41:52] And I like Hagipa Kiskill's bipolar criteria where he expands it to six and he has a category for the patients who may symptomatically appear more borderline.

[00:42:02] And the further along I progress in my career, I see so much more of the bipolar symptomatology in a lot of those patients.

[00:42:10] Yeah.

[00:42:11] Yeah.

[00:42:12] Yeah.

[00:42:12] You can definitely get pure borderlines, pure bipolars, and then a lot who have both in combination.

[00:42:20] Dissecting that out and going after it is a tough one.

[00:42:26] Somebody get this guy some help.

[00:42:36] So I have the utmost appreciation and respect for Dr. Post.

[00:42:42] I think he is brilliant.

[00:42:44] He has dedicated his life to clinical work, research, public service through the NIMH.

[00:42:50] But I wanted to take a few minutes here after part one of our conversation to clarify my professional stance on the topic of early recognition and treatment of childhood bipolar disorder.

[00:43:02] And also specify how I think that some of our professional views can be reconciled.

[00:43:08] The first major overarching point that I want to make that is in contention with Dr. Post's views is that I do not agree with medicating five-year-olds as a whole.

[00:43:22] I think in the United States we are over-medicating the crap out of our kids and adolescents.

[00:43:29] Dr. Post's confidence in his assertions regarding the earlier and sometimes early childhood onset of bipolar disorder have forced me to reconsider the age of onset of these conditions.

[00:43:41] However, I think these childhood and even early adolescent examples of bipolar disorder are absolutely the exception to the rule that puberty is somewhat paramount to the development of the mind and therefore the potential for mania.

[00:44:00] I have the utmost confidence that Dr. Post would do his due diligence, that he would be able to accurately diagnose those with bipolar disorder in their youth as well as adolescents by accumulating as much objective evidence and collateral information as possible to support the diagnosis using a mood tracking chart over time.

[00:44:25] And I also believe that he would be methodical in his approach to these patients, giving treatment time to work before moving on to another treatment or adding to that treatment or taking that treatment away.

[00:44:50] My worry is not in Dr. Post's ability to accurately, safely, and effectively treat this.

[00:45:00] My worry is that there will be too many overconfident child psychiatrists, primary care doctors, and the rapidly growing number of non-physician medical providers like nurse practitioners and physician assistants that will not do their due diligence

[00:45:18] and just hear his messages of bipolar disorder in their due diligence and more meds equates to better outcomes.

[00:45:28] I just think that diagnosing bipolar disorder in these young children is such a difficult task, especially when you acknowledge the fact that having more adverse childhood experiences, ACEs, aka traumas, leads to the earlier onset of the illness.

[00:45:47] And the most likely perpetrators of those traumas are going to be family members, most likely mom or dad or both.

[00:45:56] How can one be sure that the reason the kid is having trouble sleeping isn't because they wet the bed and then they got hit for wetting the bed, leading to them having increasing difficulty sleeping,

[00:46:09] and contributing to bad or unmanageable behaviors, which are totally understandable through the lens of repetitive trauma and the brain's mechanisms of trying to escape?

[00:46:21] Additionally, we're relying on these parents' subjective reports above and beyond any others in gathering the information for the diagnosis.

[00:46:32] I think it's a very human thing to want to outsource the reason for something like our child's poor behavior or sleep disturbance to some nebulous biologic disease,

[00:46:44] as opposed to admitting fault, admitting to not just themselves but outsiders of their failures, their abuses, or the things that they're feeding their children,

[00:46:57] or their own dysfunctional example set for those children, all as major contributing factors.

[00:47:04] I cannot promote the message that we don't rely on medications enough in children.

[00:47:11] And Dr. Post has certainly made me think more about this concept, because I agree and do believe that early and effective treatment of bipolar illness leads to better long-term outcomes.

[00:47:24] But I think it's an absolute travesty, and it's been bad for our society going from medicating 0.2% of Medicaid-insured youths in 1987,

[00:47:37] which I will acknowledge is probably a number that's too low, to somewhere around 15% to 20% of youths and adolescents today being on some form of psychiatric medication,

[00:47:48] a number that I think is drastically, aggressively too high.

[00:47:54] Now, let me switch gears and reconcile some of the things that Dr. Post and I absolutely agree on.

[00:48:01] One is in relation to that last point.

[00:48:05] It's not just that we're over-medicating.

[00:48:08] It's the things that we're medicating the kids on are majority antidepressants.

[00:48:15] And these things, I think, should be relatively contraindicated in young children.

[00:48:22] You're talking about a class of medications in the SSRIs and the SNRIs that can trigger people into a manic state,

[00:48:31] into a more impulsive and less predictable mental state,

[00:48:35] and that continue to reveal themselves as agents that, especially in young people,

[00:48:42] can have this allergic-type reaction of worsening suicidality.

[00:48:46] This isn't even to mention the sexual side effects that occur in most SSRI users

[00:48:52] and persist even after discontinuation in some,

[00:48:56] or the potential long-term effects on an adolescent sexual development by manipulating that axis.

[00:49:04] It doesn't mention the emotional numbing that so many people have reported to me on these medications,

[00:49:10] or the weight gain, or the sedation, or the insomnia, depending on the agent.

[00:49:17] All of this is to say the juice is simply not worth the squeeze using SSRIs in young people.

[00:49:24] I don't know for certain what the genetic profile is of any patient that would help me better predict

[00:49:31] who may have these types of responses.

[00:49:33] They may be rare, but when you consider the rarity of a side effect,

[00:49:38] in conjunction with the consequence of that rare side effect,

[00:49:41] you know, a rare side effect of somebody's pee turning orange

[00:49:46] when they discontinued or tapered their SSRI,

[00:49:49] which actually happened in a patient of mine,

[00:49:52] without any additional pain or consequences,

[00:49:55] is a lot different than the rare side effect of a suicide attempt,

[00:50:00] with the potential consequence being fatality or death.

[00:50:04] If I'm going to kill one person for each of those thousand patients that I see,

[00:50:09] I don't think that consequence is worth the rarity of the side effect.

[00:50:13] Using mood stabilizers in youths and adolescents who are depressed and or suicidal

[00:50:20] is going to be much more effective and safer.

[00:50:24] Even the ones who are potentially bipolar,

[00:50:27] if they're depressed, if they're suicidal, they may be bipolar,

[00:50:30] but again, in the general population,

[00:50:32] this is a disorder that on average is diagnosed in people's 20s

[00:50:37] after they've had usually multiple depressive episodes

[00:50:42] and then they have their first manic episode.

[00:50:44] So I don't feel very comfortable introducing an SSRI naive patient

[00:50:50] to that class of medications on such a large scale,

[00:50:54] because I do think that people are going to die

[00:50:58] that otherwise wouldn't have died.

[00:50:59] I'm not saying SSRIs do not have any effectiveness

[00:51:03] or use for children and adolescents,

[00:51:05] but we're doling these things out like candy,

[00:51:08] like they're completely harmless drugs.

[00:51:11] We need to be a lot more careful and methodical about our approaches with kids.

[00:51:16] Mood stabilizers are the most effective treatment for bipolar disorder

[00:51:21] and, in my opinion, unipolar depression.

[00:51:25] And most importantly, they're drastically safer in these young folks.

[00:51:30] Lithium has evidence that it reduces the risk of suicide.

[00:51:34] There is no evidence that it causes suicidal behaviors.

[00:51:39] Early and purposeful treatment in bipolar disorder

[00:51:43] can lead these people to live a much more fulfilling,

[00:51:47] meaningful, and longer life.

[00:51:49] I understand why Dr. Post is so passionate about this topic.

[00:51:53] I have no problem with trying to diagnose people earlier

[00:51:58] to recognize and avoid the cyclical, destructive, natural course of bipolar illness,

[00:52:05] but I think that the early treatments need to be tailored towards proven

[00:52:10] and non-pharmacologic alternatives,

[00:52:13] recognizing the impact of trauma

[00:52:16] and ensuring that child is in a safe social environment,

[00:52:19] engaging the family in family-focused therapy,

[00:52:22] which is tremendously effective,

[00:52:25] comparable to good mood-stabilizing treatment,

[00:52:28] focusing on diet and reducing pro-inflammatory dietary habits,

[00:52:33] cutting out all the excess added sugar in processed food,

[00:52:38] ensuring adequate exercise and physical activity.

[00:52:41] And I loved that Dr. Post talked about the use of supplements,

[00:52:46] N-acetylcysteine or NAC,

[00:52:48] a supplement that is very safe,

[00:52:50] that works to reduce inflammation,

[00:52:53] and as emphasized by Dr. Post,

[00:52:56] reveals long-term benefit in safety

[00:52:58] without changing the perception of the patient.

[00:53:02] I loved hearing more about acetyl L-carnitine

[00:53:05] and L-methylfolate,

[00:53:07] the importance of having adequate vitamin D

[00:53:09] and the sunlight exposure necessary

[00:53:11] to convert vitamin D to its active form.

[00:53:14] Getting people into treatment early

[00:53:16] is certainly not problematic.

[00:53:19] If everybody could see Dr. Post,

[00:53:22] that'd be great.

[00:53:23] I'd feel a lot more comfortable with that.

[00:53:25] But that's just not realistic.

[00:53:27] It's not possible.

[00:53:29] And there are too many overconfident

[00:53:31] and uninformed, non-skeptical,

[00:53:34] non-critically thinking practitioners

[00:53:36] that I believe overall this message

[00:53:39] will promote more harm than good.

[00:53:41] There are so many things that I will take forward

[00:53:43] with me in my own practice

[00:53:44] based on this conversation

[00:53:46] with an absolute pioneer

[00:53:48] and well-respected psychiatrist.

[00:53:51] I look forward to using some of the pharmacologic

[00:53:55] and non-pharmacologic tools

[00:53:57] discussed and review

[00:53:58] more of the literature that Dr. Post

[00:54:01] has so graciously sent me on these topics.

[00:54:03] But this podcast is about appreciating nuance

[00:54:07] and embracing uncertainty,

[00:54:09] recognizing that there are not usually

[00:54:12] simple answers to complex questions

[00:54:14] that arise in the fields of mental health.

[00:54:17] Renegade Psych is all about

[00:54:20] being skeptical of newly presented information,

[00:54:23] but also being open to changing my mind,

[00:54:27] learning new concepts and ideas,

[00:54:29] embracing uncertainty that is created

[00:54:32] by those new ideas

[00:54:33] and their inherent challenges

[00:54:35] to previously learned information.

[00:54:38] If I can't do that,

[00:54:40] I'll stop growing.

[00:54:41] I'll become stagnant

[00:54:42] and my patients will be worse off for it.

[00:54:45] Thanks so much to Dr. Post

[00:54:47] for taking time out of his busy schedule

[00:54:49] and sitting down with a peon like myself.

[00:54:53] And thanks to everyone else

[00:54:55] who is listening or watching.

[00:54:57] I really appreciate your all's engagement

[00:54:59] with the platform.

[00:55:00] Keep sending me emails.

[00:55:02] Keep leaving comments.

[00:55:04] Do all that other stuff.

[00:55:06] Like it.

[00:55:06] Subscribe to it.

[00:55:07] Spread the message.

[00:55:10] Get your friends to watch and subscribe

[00:55:12] so that ultimately

[00:55:14] this message can reach

[00:55:16] a larger population

[00:55:18] and protect people

[00:55:20] from some of the pitfalls

[00:55:22] of the American medical system.

[00:55:24] Thank you.

[00:55:26] Thanks again for watching

[00:55:28] and or listening.

[00:55:30] If you're passionate

[00:55:31] about the subjects

[00:55:32] that I discuss on the channel,

[00:55:33] do me a favor

[00:55:35] and like,

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[00:55:38] Do whatever you can

[00:55:40] to make your voice heard

[00:55:42] that these are problems

[00:55:43] that must be addressed

[00:55:45] in our society.

[00:55:47] If you have any questions,

[00:55:49] comments,

[00:55:49] or concerns,

[00:55:50] I want to hear them.

[00:55:53] Feel free to reach out

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[00:55:57] renegadesych

[00:55:58] at gmail.com

[00:56:00] and if you'd like

[00:56:01] to be a guest of the show

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[00:56:03] that you think

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[00:56:08] Thanks again for listening.

[00:56:18] Disclaimer.

[00:56:18] This podcast is for

[00:56:19] informational purposes only.

[00:56:20] The information provided

[00:56:21] in this podcast

[00:56:21] and related materials

[00:56:22] are meant only to educate.

[00:56:23] This information is not intended

[00:56:23] as a substitute

[00:56:24] for professional medical advice.

[00:56:25] While I am a medical doctor

[00:56:26] and many of my guests

[00:56:26] have extensive medical

[00:56:27] training and experience,

[00:56:27] nothing stated in this podcast

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[00:56:33] should be treated

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[00:56:37] All listeners should consult

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