Why ADHD Kids Say I DON’T KNOW So Often

ide his bike (Who wouldn’t?). I asked Matt why he kept cancelling and he said, “I don’t know.” That got me thinking about how, in the past, I would have been slightly irritated at him wasting my time, not accepting my help, and being generally defiant.

We often become distressed by our children’s seeming inability to do simple things, like ask for help, put away their clothes, or turn in homework. We become disappointed and ultimately angry, and we confront our child.

“Why can’t you do this? It’s so simple. Everyone else is doing it with no trouble at all. Why can’t you?”

And you know the response, right?

“I don’t know.”

Gah! Why do they DO that?

ADHD children are very sensitive and having an angry parent is overwhelming to the senses. They may yell at you or try to distract you by talking about your faults. They may hide in their rooms or they may do what you want but give you the silent treatment. ADHD children are rarely able to manage their emotions in the moment, as they’re actually happeningIn confusion, frustration, and sadness that they’ve disappointed you, “I don’t know” becomes an easy way to slow things down, to stop the barrage of parental expectations.

Here’s what “I don’t know” really means:

  • I can’t help you. I don’t seem to be able to make myself do what I want to do.
  • Please don’t be mad.
  • I can’t take more nagging.
  • Do we have to keep having the same conversation? That won’t change me.
  • You can keep asking but I don’t have a different answer.
  • I feel like a loser and I’m trying to cover it up.
  • I don’t want to say the wrong thing.
  • I’m embarrassed by being a failure.
  • If I could answer to your satisfaction, I would.
  • My mind is (actually) blank.

This is why ADHD kids say “I don’t know” so often.boy with post-its

It has little to do with defiance and a lot to do with self-esteem and/or not being able to access information in a timely manner.

The truth is that Matt wasn’t wasting my time. I still had my time.

He wasn’t refusing my help. He just couldn’t handle this particular responsibility.

He wasn’t being defiant either. In fact, his response had nothing to do with me. He was simply postponing relief and prolonging his misery because he didn’t know how to make a different decision.

Change your response

The solution is to change the way you respond. Believe me, I know this is difficult. Sometimes it’s like pulling teeth to get an answer that contains some real information!

Instead of being frustrated, put yourself in your child’s shoes.

  • Imagine what it must be like to know that you’re having a regular conversation but you can’t respond in a regular way.
  • Imagine what it’s like to disappoint your parents, yet again.
  • Imagine experiencing this for an extended period of time.

My childhood experience

I remember, very well, the absolute confusion and disappointment I felt when I vowed to be good and couldn’t manage to hold it together for even 30 minutes. I had NO IDEA how I got from Point A to Point B, from my vow to my misbehavior.

This isn’t a moral issue or a problem with your child’s integrity. This is an Executive Function challenge. The pre-frontal cortex hasn’t developed enough to handle the demands being made.

One thing you can do to help your child is to say, “I’m sorry. I didn’t give you much time to think about this. I would really appreciate it if you’d take some time to think this over and let me know your answer. I’ll check back with you tomorrow/in an hour/after I get home…”

The moral of the story is:

Don’t take it personally, Don’t assume defiance, Practice patience, Be encouraging, and Give your child or teen the grace and dignity to JUST. NOT. KNOW.

When they do know, they’ll tell you.

Do you have any thoughts on this issue that you can share with another parent? Just scroll down to the comments section. I love hearing from you.

xo, Yafa

Copyright 2018 Yafa Luria/Margit Crane All Rights Reserved


What troubles you about parenting an ADHD child or teen?

Let’s talk! No judgment, no salesy come-on. However you WILL receive a good deal of TLC and a slew of strategies. You can say anything. You can cry. You can swear. Your confidentiality is guaranteed, and I promise to listen and give you hope and relief. (You might even find yourself spontaneously doing a happy dance).

“Thank you Yafa. You’ve given me incredibly helpful tools! It was really a pleasure to speak with you. I’ll be back in touch in the coming weeks.” Stella R, Portland, OR.

“I really appreciate that I could be vulnerable and you didn’t shoot me down. I feel comfortable with you and your humor brightened the call.” Danielle A, Bellingham, WA.

“I talked with you a year ago, Yafa, and your voice is always in my head, guiding me. I just wanted to email and thank you.” April W, Queensland, Australia

“Thank you for your encouraging, enlightening suggestions.” Jill E, Seattle, WA.

Thank you for ‘being there’ to share your wealth of knowledge and personal experience with us who are ‘floundering’ and ‘lost in the forest’ when it comes to ‘dealing with special and difficult circumstances’.Gratefully yours, Rochelle H, Alberta, Canada xox ((((BIG HUGS)))

Is it anxiety, depression, or bipolar disorder?

Once fun-loving, outgoing, and energetic, Ms. R says she began feeling unusually anxious 3 years ago. A psychiatrist diagnosed bipolar disorder type II based on her racing thoughts, irritability, low energy, and history of mood swings. Over 2 years, the psychiatrist tried combining valproic acid with bupropion, citalopram, or extended-release venlafaxine, then tried lithium monotherapy. Nothing worked.

Frustrated, Ms. R left the psychiatrist and consulted her primary care physician, who prescribed gabapentin, 200 mg each morning and 300 mg at night; fluoxetine, 50 mg/d; and quetiapine, 12.5 mg/d. Ms. R noticed no improvement and stopped the medications after 6 weeks. The physician urged her to see another psychiatrist, and she presented to us 2 weeks after stopping the medications.

Ms. R also has been feeling depressed and irritable the past 4 months and has trouble falling and staying asleep at night. She sleeps 4 to 5 hours nightly, constantly feels tired, cannot concentrate, and overeats to try to alleviate her stress. She has gained 6 pounds over 2 to 3 months and weighs 160 lb; her body mass index of 26 indicates she is overweight.

She says her worries overwhelm her and cause heart palpitations and muscle tension in her neck and shoulders. She admits to feeling “worthless,” but denies suicidal thoughts.

Ms. R describes her husband and two teenage daughters as “very supportive,” but admits that her fatigue and irritability have strained these relationships; she says she snaps at them for minor things, such as coming to dinner 1 minute late. She misses her job, which she recently quit because of her decreasing ability to function.

ADHD Medications: 5 Vital Questions and Answers

The news that 11 percent of U.S. children are now diagnosed with attention-deficit/hyperactivity disorder (ADHD) comes at a time when doctors are increasingly concerned about overuse of medication for the condition.

An analysis of 2012 data from the Centers for Disease Control and Prevention revealed that 11 percent of U.S. children ages 4 to 17 have ADHD, the New York Times reported. About 65 percent of kids with ADHD receive stimulants, such as Ritalin or Adderall, the Times said.

Just last month, a group of neurologists warned against prescribing the medications for kids who don’t need them.

The decision of whether to put children with ADHD on medication is not one that’s taken lightly. Here are five things to know about the medications:

What are the short- and long-term effects of ADHD medications?

Short-term side effects of ADHD medication include nervousness, appetite suppression, insomnia and increases in blood pressure and heart rate.

Because ADHD stimulants such as Ritalin have been used for decades, they are thought to be relatively safe over the long term, said Dr. Michael Duchowny, a pediatric neurologist at Miami Children’s Hospital.

However, some say that, because conditions such as heart attacks are and strokes are rare in children, it’s hard to know whether stimulants actually increase the risk of these events, said Dr. William Graf, a professor of pediatrics and neurology at Yale School of Medicine.

Children who are inappropriately diagnosed with ADHD, or those who have other mental health conditions, may be at increased risk for mood disorders or aggressive behavior while on the medication, Duchowny said.

And more research is needed to determine whether taking the medications for a “mental boost” could affect the developing brain, Graf said.

At what point should children with ADHD be put on medication?

There are some children who truly benefit from ADHD medication, Graf said. The conversation about beginning ADHD medication begins when a child’s symptoms interfere with his or her ability to function in everyday life, Graf said.

For instance, a child’s behavior may interfere with his learning to the extent that he won’t advance to the next grade if action isn’t taken. If a child’s behavior is determined to be a result of ADHD and not some other cause, a low dose of ADHD medication can be prescribed for a trial period (such as a one-month period), Graf said.

Once a child starts medication, does he or she need to continue them?

A child should be re-evaluated shortly after starting ADHD medication. The medication should only be continued if there is clear proof that the child benefits from it, and that the benefits outweigh the side effects, Graf said.

Do children with less severe ADHD need medication?

No, in general, children with mild ADHD often do not need medication, Graf said. (Although he noted this may not be true in every case.)

“Contrary to some popular wisdom, behavioral treatments, alone or in combination with low doses of medication, can be effective in the long-term reduction of core ADHD symptoms, Graf said.

Duchowny said the decision of whether to prescribe medication should be made on an individual basis. Changes such as placing the child in a smaller class, or getting the child a tutor may be ways to improve the child’s behavior, but are not always feasible, Duchowny said.

What can be done to prevent inappropriate use of ADHD medication?

Multiple factors are likely behind the recent rise in ADHD diagnosis, including societal pressures and medication advertising, Duchowny said. He said it’s important that children be evaluated by a health care practitioner who is experienced in diagnosing ADHD.

Graf said that a child’s care should be multifaceted, and include input from parents, teachers, physicians and social workers.

Secret To A Happy, Healthy Marriage With A Bipolar Spouse

I receive a lot of comments and emails from the spouses of bipolar people on my You Tube Channel.  The questions vary from how I handle it, to general inquiries about symptoms. Usually when someone seeks out my videos, they are in a time of crisis and are reaching out. They want to know if things can or will get better. They want to know if their marriage will survive. They want to know if their struggle is worth it. Though I can’t foretell what will occur for each individual couple, I hope to show them that you can have a happy, healthy marriage with a bipolar spouse.

In many ways, my marriage is no different from anyone else’s marriage. This is the second marriage for both my husband and I. We both have children from previous marriages. We both have ex-spouses that are still involved in our lives on a daily basis. We have extended families with varied backgrounds, sprinkled all around the world. We have jobs and mortgages and commitments that pull us in all sorts of directions.

Just like any other marriage, there are things that bug me!

My husband leaves the toilet seat up, doesn’t put the cap back on the toothpaste and leaves dishes around the house like he’s expecting the maid to pick up after him. We don’t have one. I guess he thinks that’s me. We have disagreements about finances and children. See, just like the rest, except for one difference: my husband has Bipolar Disorder.

12 Things You Should Never Say to Someone with Bipolar Disorder

Bipolar disorder is a genetic medical condition. People with it experience cycles ranging from being depressed with low energy to hyperactive or manic. According to TheMighty.com, “about 5.7 million adults in the U.S. live with bipolar disorder, but the illness is often misunderstood.”

Here are 12 things you should never say to someone with bipolar disorder:

1) Are you bipolar?

People are not bipolar disorder. They have bipolar disorder.

2) You’re crazy.

This Article

  • Improved My Health1
  • Changed My Life
  • Saved My Life1

First of all, it’s rude. Second of all, it’s not true. Don’t say anything similar to this to someone who has bipolar disorder.

3) I have mood swings too.

At times, everyone can experience a mood swing wrote Bipolar.About.com, but “only people with bipolar disorder, have repeated and severe mood swings between mania or hypomania and depression.”

Is Your Brain Fog From Menopause, Dementia, or ADHD?

Attention deficit/hyperactivity disorder, or ADHD, has long been studied, mainly in children, but experts have come to realize it occurs in women more often than previously thought. If you begin having trouble focusing during menopause, you may be wondering whether it’s a result of hormones, dementia, or something else. That something else could be ADHD.

Cognitive issues like brain fog are very common among women going through menopause, says Mary Rosser, MD, PhD, an ob-gyn at the Montefiore Women’s Center in Scarsdale, New York.

“This is something that is wide-ranging, but people are worried that they’re developing dementia,” Dr. Rosser says. “They rush to tell us their memory is declining, they can’t concentrate, they’re not as organized, and that they have a lower attention span.”

The good news is that in most cases, it’s not early-stage dementia. The symptoms are more often a normal part of menopause, or a result of undiagnosed ADHD, Rosser says.

ADHD Before and After Menopause

Women struggle the most with memory problems during the first year after their last menstrual period, according to a study published in the journal Menopause in 2013.

Although experts don’t yet know why menopause brings on cognitive problems, it may be in part due to falling estrogen levels. Estrogen works with the areas of the brain that affect verbal memory and executive function, which helps with organizing information, according to the researchers.

In addition, other menopausal symptoms, such as depression, hot flashes, and trouble sleeping, can affect your ability to focus.

But having trouble focusing and paying attention are also the hallmarks of ADHD. It’s not just a condition of childhood: About 2.5 percent of adults have ADHD, according to the American Psychiatric Association.

Men have been diagnosed with ADHD twice as often as women, with the majority of the studies being done in men. Researchers now believe many women may have gone undiagnosed, according to an article in Frontiers in Human Neuroscience published in 2014.

Brain fog related to menopause and ADHD brain fog look similar, Rosser says. So how do you know whether what you’re experiencing is menopause or an attention disorder?


Ask yourself whether you had these symptoms before menopause. If the symptoms are new, they’re probably related to changing hormones, Rosser says. But if you’ve always been this way and it’s gotten worse with menopause, it could be a result of ADHD. “The only way to really know is to see a psychiatrist who is an expert in ADHD,” Rosser adds.

What to Do About Brain Fog

First, remember that menopause is a normal, healthy stage of life, says Nada Stotland, MD, MPH, a past president of the American Psychiatric Association and professor of psychiatry at Rush University in Chicago.

“We have symptoms and some of them can be hot flashes and night sweats that can be disruptive and tiring and draining, but I don’t think anything significant happens to our brains,” Dr. Stotland says. “I think it’s a normal, passing phenomenon.”

In fact, menopause symptoms of brain fog usually get better over time, Rosser says.

If the symptoms are bothersome enough that you want to get treatment and they’re related to menopause, hormone replacement therapy (HRT) can help, she says.

However, women are understandably nervous about HRT because of the potential increased risk of blood clots, stroke, heart attack, and breast cancer, according to the National Institutes of Health.

Other drug options include anti-anxiety drugs and antidepressants. When it comes to lifestyle factors, taking care of yourself by exercising, eating healthily, getting enough sleep, and limiting alcohol and caffeine can also help improve symptoms, Rosser says.

If your symptoms are related to ADHD, keep in mind that many women can benefit from treatment even if they’ve never previously been treated for the disorder.

“If you’ve gotten to menopausal age, unless you’re still having a lot of problems with attention, you can probably go along the same way, but you may feel better now that you recognize it,” Stotland says. Also, while people with ADHD have a hard time concentrating at times, they may also have the ability to focus very deeply at other times, she says.

If you want treatment for ADHD, you can see a psychiatrist, who may recommend a prescription medication. Also, much of the same lifestyle changes that help menopause can also help with ADHD.


When thinking of bipolar disorder, some of the unfortunate associations that spring to mind include Kathy Bates in Misery and Carrie Mathison from Homeland. IRL, Bipolar disorder isn’t anything like as scary or dramatic. Here are 15 things you may not have known about the condition.

1. There is no single or specific cause for bipolar disorder

From psychological stress to childhood abuse and social circumstances, the causes of bipolar disorder are vast. Biologically speaking, bipolar disorder is caused when our teeny tiny chemical messengers (neurotransmitters) fail to do their job and send the happy stuff (serotonin and dopamine) to the brain (you had ONE job, neurotransmitters).

The disorder may lie dormant until activated, usually by an outside trigger (major life event, change in circumstances, increased stress, altered health habits, alcohol or drug abuse, hormonal problems, etc) but can also flare up on its own.

 2. Bipolar disorder can can be genetic… but also not

Sure, if there’s a family history of bipolar disorder, then there’s an increased chance of having it, but studies conducted on identical twins have shown that if one twin is bipolar, the disorder does not always develop in the other twin, even though they have the exact same genes. Both men and women can be diagnosed as bipolar and diagnoses usually take place just before or in their early twenties.

 3. Bipolar disorder is NOT multiple personality (dissociative identity) disorder

These two disorders are usually linked because of the split personality element. However, people who are bipolar have highs and lows (but still know they are the same person) whereas people with multiple personality disorder (MPD) can think they are more than one person, with distinctly different personalities, traits and memories.

MPD is extremely rare whereas bipolar disorder affects approximately one in every 100 people.

 4. Bipolar symptoms: the highs and the lows

The main symptoms of bipolar disorder are the highs and lows; the highs being mania and the lows being a depressive state. Let’s break it down.

 The ups/highs (manic state)

Bipolar disorder is sometimes misdiagnosed as schizophrenia because of the following symptoms which connect the two:

• Feeling extremely happy or high, bubbly and outgoing for a long period of time

• Feeling irritable

• Fast talking and jumping from subject to subject

• Getting easily distracted

• Taking on new projects, increasing activities out of the blue

• Extreme restlessness

• Not being tired and sleeping very little

• An unrealistic belief of being able to take on the world

• Being impulsive

• Engaging in high-risk pleasurable activities (high spending, drug/alcohol abuse and sexual promiscuity)

 The downs/lows (depressive state)

When in a bipolar ‘low’, the symptoms are very similar to clinical depression, which is why bipolar disorder is sometimes misdiagnosed as as such.

• Lack of or too much sleep

• Feeling sad and/or hopeless

• Loss of interest in formerly enjoyable activities (ie sex)

• No energy

• No desire to even get out of bed

• Change in appetite/weight

• Feeling worthless or guilty for no reason

• Lack of concentration

• Indecisiveness

• Suicidal thoughts/thoughts of death

5. You can have bipolar ups and downs at the same time

Having mania and depression at the same time is possible with bipolar disorder and this is called a ‘mixed state’. So, while feeling ‘high’, sleepless, agitated, energetic, and having lack of concentration, you could also feel sad, have no motivation and/or have suicidal thoughts.

 6. You can be bipolar and NOT actually have mood swings

You could, in fact, feel absolutely great. This could be something called ‘hypomania’, which is a really toned-down version of bipolar mania. If you’re having a hypomanic episode, you might feel really good and highly productive and that you are functioning really well.

If this is out of the norm for someone with bipolar, a doctor should be consulted because without proper treatment, it could develop into severe mania or depression.

7. Substances can trigger a bipolar manic depressive episode

These include:

• Drugs like cocaine, ecstasy and amphetamines

• Over-the-counter drugs in large doses

• Medicine for thyroid issues and corticosteroids

• Excessive amounts of caffeine (although normal amounts are fine)

8. People with bipolar disorder and more likely to have substance abuse issues

The reasons for this are as yet scientifically unclear, but it is thought that sufferers of bipolar disorder are more likely to want to self-medicate with drugs and alcohol.



9. Bipolar sufferers are also at higher risk for other diseases

Thyroid issues, headaches and migraines, diabetes, heart disease and obesity are a few of the other illnesses which could result from treatment for bipolar disorder, as well as causing some of the same symptoms as the highs and lows (mania or depression).

 10. There are five variations of bipolar disorder:

Starting from the mildest to the most severe, the five types of bipolar disorder are:

(i) Cyclothymia/cyclothymic disorder

Cyclothymia is mild form of bipolar disorder with ongoing, long-term symptoms (minimum 2 years) which aren’t severe enough to be classed as bipolar disorder.

(ii) Bipolar I disorder

Manic or mixed episodes that last a minimum of seven days usually requiring immediate hospital care.

(iii) Bipolar II disorder

Depressive and hypomanic episodes with no manic or mixed episodes.

(iv) Bipolar disorder (not otherwise specified)

Some bipolar symptoms exist but not enough to be classed as bipolar I or II.

(v) Rapid-cycling bipolar disorder

Rapid-cycling is when someone has four or more episodes of major depression, hypomania, mania, or mixed states within a year. Rapid-cycling can come and go and is more common in women than men.

 11. The most effective test to diagnose bipolar disorder is seeing a psychiatrist

Although many tests can be carried out including brain scans, blood tests and physical examinations, none are as effective in correctly diagnosing bipolar disorder as having a thorough interview session with a psychiatrist.

The shrink will take the patient’s family and personal history and will find out everything they need to know to be able to diagnose the patient and create the best treatment plan.

 12. Although bipolar disorder can not be cured, it can be treated

Patients are advised to keep a life chart to help their doctor and psychiatrist provide the best possible treatment. There’s a wide array of bipolar disorder treatments available, from scary sounding ones like electroconvulsive therapy, atypical antipsychotics, and light therapy to the more common mood stabilisers, anti-depressants, sleep supplements, cognitive behavioural therapy, and psycho-education (just getting yourself fully in the know). There are also some new, up and coming bipolar disorder treatments that are gaining popularity.



13. Bipolar disorder can get worse if left undiagnosed/untreated

Although patients will often opt for self-help, it is advised that bipolar disorder should not go untreated as episodes could become more frequent or severe over time. The sooner it is diagnosed and treated, the sooner someone with the condition can go about living a normal, healthy and productive life.

 14. Here are 20 celebrities with bipolar disorder

1. Catherine Zeta-Jones

2. Demi Lovato

3. Jean-Clause Van Damme

4. Linda Hamilton

5. Sinéad O’Connor

6. Azealia Banks

7. ussell Brand

8. Chris Brown

9. Jim Carrey

10. DMX

11. Tom Fletcher

12. Stephen Fry

13. Macy Gray

14. Kerry Katona

15. Gail Porter

16. Axl Rose

17. Rene Russo

18. Nina Simone

19.P ete Wentz

20. Britney Spears

15. There’s a plethora of information available on bipolar disorder

And here are a few to get you started:

National Institute of Mental Health

Psych Central


For something a bit lighter, check out this blog by bipolar sufferer Beth Evans. It’ll make you laugh and cry. At the same time.

Top 5 articles to read during ADHD Awareness month

In honor of ADHD Awareness Month, Healio.com/Psychiatry collected the top five articles about ADHD in children and adults for psychiatrists.

Behavioral intervention, not medication, improves homework performance in ADHD

Homework performance significantly improved among children with ADHD who received behavior treatment focused on homework, while typical ADHD medication had no significant effect on homework performance. Read more

Suicide in young children more common in males, blacks, those with ADD, ADHD

Recent findings on suicide in elementary school-aged children suggest a need for common and developmentally-specific suicide prevention strategies for this age group. Read more

Combination therapy more effective than monotherapy for ADHD

A combination of d-methylphenidate and guanfacine was more effective for attention-deficit/hyperactivity disorder than either treatment alone, according to recent findings. Read more

Methylphenidate affects dopaminergic system in children, not adults

Recent findings indicated treatment with methylphenidate for attention-deficit/hyperactivity disorder significantly affected the dopaminergic system in children but not adults. Read more

Childhood ADHD diagnosis does not always precede adult ADHD

Recent findings showed a significant proportion of individuals with late-onset attention-deficit/hyperactivity disorder did not meet criteria in childhood, suggesting that a lack of a childhood diagnosis should not preclude late-onset diagnosis in adulthood.

A Guide to Treating Unipolar and Bipolar Depression

Hello. I am Dr Stephen Strakowski, from the University of Texas at Austin. Those of you who have seen any of my videos before know that this is a new location for me. I am here now as the founding chair and professor of psychiatry, where we are building the brand-new Dell Medical School. In future videos, I will talk about how we are thinking about building this new medical school, and how psychiatry plays a major role in its creation.

But today, I’m going to talk about something else: differences and similarities in managing unipolar and bipolar depression. This is a common clinical problem. Information has evolved over the past few years, and we are really starting to think about these two conditions differently.

Unipolar Depression: Incidence, Heritability, and Causes

Major depression is among the most common conditions affecting humankind. In the United States, about 7% of people will develop depression in any given year; there is around a 17%-20% lifetime risk.

The genetic risk for depression is relatively low among psychiatric disorders. Heritability runs in the 30%-40% range—meaning that in a collection of people, depression genetics explain only about one third of the variants. If the depression is recurrent, and commonly recurrent, however, the impact of genetics raises to about 66%.[1]

However, many cases of depression (we have talked about this in other venues[2]) may simply be representative of an insult to the brain and the kinetic current, [or from] a whole variety of conditions. In fact, if you look at medical, neurologic, and psychiatric disorders, virtually anything that affects the brain is associated with higher levels of depression. So part of managing depression, as we will talk about, is trying to identify the potential cause.

Bipolar Depression: Incidence, Heritability, and Diagnosis

In contrast to unipolar major depression, bipolar disorder and subsequently bipolar depression is much less common, affecting somewhere in the neighborhood of 1%-2% of people over a lifetime. Type I bipolar disorder is defined by the occurrence of mania and cannot be diagnosed in the absence of mania. We will discuss how that affects thinking about depression in a moment. In bipolar disorder type II, there has to be episodes of hypomania that are also then accompanied by depressive episodes.

The heritability of bipolar disorder is much higher than unipolar depression, and runs in the range of about 85%.[3] Bipolar disorder is the most heritable condition in psychiatry. The diagnostic reliability of bipolar disorder tends to be higher (at least of mania) than unipolar depression, but the diagnostic reliability of hypomania is relatively low. The two types of bipolar disorder can be differentially examined; it is often harder to make a diagnosis of type II that someone else will agree with. Nonetheless, because of this high heritability, environmental factors are probably less important, at least in the initiation of episodes of bipolar illness, including depression. However, stress and other environmental factors (eg, drug abuse) certainly can affect the course of either illness.

Depressive Episodes: Do They Look Different?

In general, the depressive episodes of bipolar individuals and unipolar individuals look very similar. From a strict kind of cross-sectional clinical assessment perspective, it’s really not possible to distinguish them without other information.

That said, there are some types of presentations that are suggestive of an evolving or emerging bipolar illness. These include depression at an early age (particularly prepubertal or early teens), postpartum mood changes, and [depression associated with] seasonality. Bipolar depression may have more severe anhedonia, hypersomnia, and psychomotor slowing—”melancholic” types of variants. The presence of catatonia, often in fact a mania syndrome in severe cases, is probably the best predictor despite all of those suggestive symptoms—which again, in a given individual, are often not particularly helpful.

n contrast to that, a family history of bipolar disorder in someone who is young and developing recurrent depressive episodes might suggest that this may be a bipolar individual. However, until mania or hypomania occurs, a diagnosis of bipolar disorder would be premature.

Unipolar Depression: Antidepressant Therapy

When we start talking about treatment, you can see that there are a large number of antidepressants for unipolar depression approved by the US Food and Drug Administration (FDA). There are many different classes, with the selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) being the most commonly prescribed today. Tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) tend to be used increasingly less, primarily because of tolerance. There are some other good antidepressants that do not fit neatly in a class, such as bupropion or mirtazapine.

The take-home [message] from this slide is that there are a lot of good established antidepressant therapies. In general, something can be found that is tolerated and effective in any given patient.

Unipolar Depression: The Role of Psychotherapy

In addition to medications, psychotherapy is helpful in major depressive episodes. Cognitive-behavioral therapy (CBT), particularly in mild to moderate cases, is well established, and the evidence suggests it is as good as any antidepressants and may actually help better in some cases with relapse prevention. It does appear to save money when administrated with antidepressants. Even though there are some initial upfront costs for the therapy, costs get evened out over time by better recovery.

Interpersonal therapy also has a strong evidence base. This is not the same as psychodynamic therapy—it is a focus on interpersonal interactions without assumptions of causality. It essentially bases its “core” on the fact that interaction with other humans represents a major part of our stressors and social supports. This therapy focuses on improving those [interactions] and leads to improvement in depression. In fact, for psychodynamic psychotherapy in the purest sense, there is really only limited evidence that it is efficacious in depression.

There is also a strong interest right now in nutraceuticals and lifestyle management. But so far, unfortunately, those have not been able to hold up in studies particularly well for the treatment of depression. That said, however, they are generally good for you, and so there is no reason not to include them in a treatment paradigm.

Bipolar Depression: Medications

In this chart of medications commonly used in bipolar disorder, only three products at the moment are FDA-approved for treatment of bipolar depression: the combination of olanzapine and fluoxetine, quetiapine, and more recently lurasidone. As you can see, there are a number of other medications, such as lithium and lamotrigine, that have apparent antidepressant efficacy. In general, mood stabilizers that are effective for maintenance seem to be effective for treating depression

Recently, there have been some interesting studies. Historically, we have often used antidepressants in the treatment of bipolar depression. However, as shown in this chart from Gary Sachs and colleagues in the New England Journal of Medicine in 2007, the STEP-BD study[4] showed us that the addition of an antidepressant to a good mood stabilizer in patients with bipolar disorder really added very little improvement of depression. It also did not increase the risk for switching or adverse effects.

The take-home messages were that antidepressants add very little to effective use of mood stabilizers, and that the treatment of bipolar depression is very different from unipolar depression. Antidepressants appear to be much less effective for bipolar depression than unipolar depression. This helps us think differently about treatment guidelines and algorithms.

Bipolar Depression: Switch Risk

There is still an ongoing discussion on what the risk [associated with] antidepressant therapy is of switching into mania from depression. Again, in that previous slide from Sachs and colleagues, it really looked like the antidepressants, at least in the setting of a mood stabilizer, did not increase the risk at all. The risk in studies has ranged from as high as 30%-40% with the older tricyclics to as low as placebo rates with SSRIs and newer antidepressants.[3] Probably somewhere in [between] there is a true rate.

Unfortunately, the natural switch rate of depression into mania in the absence of treatment may be as high as 40%, which was observed in the collaborative depression study in the 1980s.[5] The confounder is that even though we tend to think of patients moving from depression through euthymia through mania, that is not actually how it happens. It’s more of a toggle from one state to the other, and depression itself increases the risk for mania. So the effects of antidepressants just remain confounded because typically, people do not get antidepressants until they are depressed.

That said, certainly with the older antidepressants, there may be a switch risk. The newer antidepressants in the setting of a mood stabilizer seem to have a fairly low risk. Regardless, from STEP-BD and other studies, the benefit of adding an antidepressant appears to be low. SSRIs may be better anxiolytics long-term than antidepressants—they may have an anxiolytic role in bipolar disorder, and we need more studies to determine whether that is true and whether they are safe [in that setting].

Bipolar Depression: Role of Psychotherapy

Psychotherapy is very important. In bipolar depression, CBT has a good evidence base. Interpersonal therapy and social rhythm therapy that came out of Pittsburgh[6] also have a good evidence base, as do family-focused therapies. All of these have been shown to decrease relapse, improve functioning, and help with treatment compliance. They are all used in conjunction with mood-stabilizing drugs, which are necessary in bipolar disorder as a first step. Psychotherapy is a nice second addition.

With that in mind, I have included brief guidelines for treatments on each of these conditions. With unipolar depression, the first key is to either start or optimize the antidepressant. Treatment failures are often simply from not waiting long enough, or not using a high enough dose. Again, it’s important to remember that these are not rapidly-acting agents, and it often takes 3-6 weeks to even see the initial response.

The first-line therapies that most people are familiar with are SSRIs, SNRIs, bupropion, and CBT. Then there are what I call “1b” options, which are a little less established—you can read those on the slide. If there is literally no response in 4-6 weeks—the patient is no better, or even worse—probably switching rather than maintaining the current antidepressant is the best step.

If there is a partial response, think about augmentation strategies—which is adding another antidepressant, ideally from a different class. Other things, such as psychotherapy, thyroid hormone, or perhaps one of the approved atypical antipsychotics, have been shown to be helpful augmenting agents. Lithium augmentation continues to be the best-studied augmenting strategy.

Eventually, we get to such things as ketamine, which is experimental but maybe something to consider; repetitive transcranial magnetic stimulation (rTMS); or electroconvulsive therapy (ECT). If ECT had less stigma and was easier to administer, particularly in severe cases, I would move it up this chart to be used earlier.

With recurrent and even single-episode patients, try to use three or fewer drugs and be systematic. Take your time making changes, and [achieve] an adequate dose. Do not chase symptoms. I have talked about this in another video.

Managing Bipolar Depression

The guideline for treating bipolar depression is very different. The first step is optimizing current mood stabilizers or starting mood stabilizers—ideally, those that have some evidence of maintenance efficacy. Those typically roll into being reasonable antidepressants.

Lithium and CBT are good things. It’s a good idea to add CBT to an existing mood-stabilizer program that has generally been effective. If you are not using lithium, consider it. These FDA-approved agents are also good choices: olanzapine, olanzapine in combination with fluoxetine, lamotrigine, lurasidone, and quetiapine.

Maximizing mood stabilization appears to be the best intervention. ECT in severe cases should not be delayed too long. I have it as third-line in my chart—but again, only because it’s not widely available. If it’s available, then it’s a good choice to move up the chart.

Again, like unipolar depression where there are similarities, if it’s not working in 3-6 weeks, get rid of the drug that is not working and add a new one. If it’s working partially, consider augmenting. But keep in mind, you need to keep your mood stabilizer base on board. Augmentation approaches that are listed here are not terribly dissimilar from [those for] unipolar depression. [Remember] the three-medication maximum, and make systematic changes.


With these approaches, I think it’s possible to come up with an ideal program for your individual patient. It is important to keep in mind, though, that the treatments are very different and that antidepressants have an increasingly limited role in the treatment of bipolar depression. A good diagnosis is going to be really important for a good treatment outcome.

Much of what I have talked about here, can be found in a couple of books[1,3] we have published, which you might find useful. I hope this is helpful for everyone. From my new place in Texas, I appreciate your time, and thank you all for listening.

5 Complicated Things Only People With Bipolar Disorder Understand

1. Every time you say “I’m bipolar” people respond with a chuckle, until they realize that you’re serious. Describing someone as bipolar has become such a popular saying that I don’t even think people realize that it’s an actual mental illness. The depictions of people with bipolar disorder in the media doesn’t help either. People with bipolar disorder are usually portrayed as angry, over-exaggerated, constantly irritable, and un-approachable.

But in reality most people with the disorder are able to live productively in society just like everyone else. Most people can’t even tell that I’m bipolar until I tell them. And I actually choose not to tell people until I get to know them better, just to show that my bipolar disorder doesn’t necessarily effect my personality or how I interact with other people on a daily basis.

2. Being high off life. The mania (or hypomania). Before I was able to identify my mania I took full advantage of the feelings of over-confidence and indestructibleness. Being so productive and energetic after dealing with such a deep depression felt amazing. It still does. At one point in time I told my therapist that I was excited to be manic again. It’s kind of like being reunited with a friend that you haven’t seen in a while; but that friend happens to be you, just a different version. And of course in those moments of mania nothing matters, you follow your impulsivity without any acknowledgement of possible consequences; until what I like to call a “crash” happens.

Just like being high off of a drug, you suddenly don’t feel high anymore and come to your senses. The feeling of regret is so familiar to me now. The guilt, sadness, and embarrassment that I feel after realizing all of the things that I’ve done while manic ultimately sends me back into depression. And the cycle continues. I find myself seriously questioning if I actually did those things. At this point I know this version of myself so well that I can believe it; but before I felt like a stranger to myself.

3. Blaming my mental illness. I’ve always struggled with this concept. Ever since I was around 11 or 12 years old I’ve built and destroyed so many relationships, platonic and romantic. I never really looked into why I lost so many friends over the years, I just attributed it to “growing apart.” But now that I have a better understanding of my mental illness, I’ve been able to identify some of the things that I’ve done to cause those relationships to end. So many times have I found myself trying to explain to someone that “I wasn’t in my right mind.”

And that excuse works the first couple of times. But after a while people get fed up, and can you expect them not to? You can fuck up time and time again but it’s okay because you’re bipolar, right? Wrong. No one deserves to constantly be hurt by the same person, bipolar or not. No relationship is going to last with this dynamic in place. Yet I still haven’t found a way to handle this issue. I have so much more to learn about managing my bipolar disorder, and I know there’s a long journey ahead. But the thing I fear most is that I will go throughout life not being able to maintain a stable relationship.

4. That one time you stopped taking your meds for a while.Probably one of the worst decisions I’ve ever made. Everyone has their own views on taking medication to treat mental illness. Some people are able to manage without the help of medication which is great for them. While others need medication in order to control their disorder, and there’s nothing wrong with that either. I am one of those people. Medication has helped balance out my mood so much; but at one point I decided that I didn’t need to take them anymore, for a number of reasons that I wont get into.

I hit my lowest point when I wasn’t on my medication and had stopped seeing a therapist. I had no sense of self-control; I had become so reckless. I was risking the well-being of myself and those around me and didn’t think twice about it. By the time I did decide to go back to therapy I had almost hit rock-bottom and I only had a few options. I had to stop judging myself for being on medication and stop worrying about what other people would think if they found out. At the end of the day my mental health is more important than the stigma and negative connotation attached to treating mental illness with medication.

5. Realizing that bipolar disorder doesn’t define you as a person. You are not bipolar; you HAVE bipolar. Don’t let the diagnosis overshadow who you are as a person. Your amazing spirit is still there, don’t let it become masked by your mental illness. When I was first diagnosed and people would ask me to reveal something about myself, my go-to response was to mention that I was bipolar. But being bipolar isn’t a characteristic. So many people in the world have bipolar disorder and we are all not the same, though the stigma attached to mental illness causes us all to feel the same pain and frustration.

If I had the choice to live without bipolar disorder I wouldn’t. Living with this mental illness has allowed me to be so self-aware; I feel as if I know myself so well. The fact that I have to be so aware of my mood and feelings, and how it affects those around me, allows me to grow and learn with every high and low that I experience. It’s not easy, but it’s life. And I hope that reading this will help you feel less alone in dealing with bipolar disorder.