Mind Dive

Episode 58: Better Living with Bipolar Disorder with Dr. David Miklowitz

• The Menninger Clinic

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David Miklowitz, Ph.D., has been pioneering family psychoeducational treatments for bipolar disorder by integrating psychotherapy and family therapy with medication. Dr. Miklowitz’s research emphasizes the critical role families play in identifying the early signs of bipolar disorder and how family members can help a patient implement effective strategies in managing their symptoms. 

 

This episode of Menninger Clinic’s Mind Dive Podcast features Dr. Miklowitz, accomplished psychologist and author, joining Menninger Clinic clinicians and co-hosts Dr. Kerry Horrell  and Dr. Bob Boland for a comprehensive look at bipolar disorder, its effect on family dynamics and how patients and their families can work together to better navigate life after a diagnosis.

 

Dr. Miklowitz is a professor of Psychiatry at the University of California, Los Angeles (UCLA) School of Medicine and a senior clinical researcher at the University of Oxford. He directs the Child and Adolescent Mood Disorders Program and the Integrative Study Center in Mood Disorders at the UCLA Semel Institute for Neuroscience and Human Behavior. Dr. Miklowitz is also a renowned author and his latest book, “Living Well with Bipolar Disorder: Practical Strategies for Improving Your Daily Life”, will be available September 16th, 2024.  

 

“There is a grief over the lost healthy self where people start thinking of their lives as bifurcated before and after they became ill,” Dr. Miklowitz mentioned. “We try to help normalize it and help them figure out what is their personality versus their disorder.” 

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Dr. Bob Boland: 0:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, dr Bob Bowen and Dr Keri Harrell.

Dr. Kerry Horrell: 0:11

Monthly we explore intriguing topics from across the mental health field and dive into hidden realities of patient treatment.

Dr. Bob Boland: 0:18

We also discuss the latest research and perspectives from the minds of distinguished colleagues near and far.

Dr. Kerry Horrell: 0:23

So thanks for joining us.

Dr. Bob Boland: 0:26

Let's dive in. Welcome back to the podcast. Today we have Dr Mikulwicz, who is a professor of psychiatry in the Division of Child and Adolescent Psychiatry at UCLA's Semmel Institute and a senior Clinical Research Fellow in the Department of Psychiatry at Oxford University. He completed his undergraduate work at Brandeis University and his doctoral and postdoctoral work at UCLA. His research focuses on family environmental factors and family psychoeducational treatments for adult onset and child onset bipolar disorder. Welcome, Dr Mikulic. Thank you. Thanks for having me. Yes, it's delighted to.

Dr. Kerry Horrell: 1:11

Are you currently in LA? Is that where you are? I?

Dr. Bob Boland: 1:13

am.

Dr. David Miklowitz: 1:15

Okay, All right great.

Dr. Bob Boland: 1:17

Well then, good morning.

Dr. David Miklowitz: 1:19

You tell by the guitar in the background.

Dr. Bob Boland: 1:21

I have Wel, can you just tell us a little of career you know as a psychologist and how you became interested in bipolar disorders?

Dr. David Miklowitz: 1:31

Sure. Well, it's kind of a long story, but I got interested in bipolar disorder when I was an intern meaning I was a trainee at UCLA. When I was my doctorate there I was working in a lab that studied schizophrenia in families, how families interacted with each other and whether family therapy was a useful adjunct to medications. But I got interested when I was doing my internship. One of my rotations was running a support group for adults with bipolar disorder and I got very excited about that group because first, these were people who were very articulate about their emotions, about their experiences. They had great senses of humor. There was a real sense of cohesion in this group.

Dr. David Miklowitz: 2:18

It wasn't a population I'd worked with before, but when they went into their manic and depressive phases it was almost like they became different people. There was very dramatic change that occurred. People who'd been very polite would become very angry and hostile sometimes, or people who'd been depressed would suddenly look very elated and excited. But, as an aside, one of the things they talked about was their family and how their family played a role, both positively and negatively, in how they did. Some of them had very supportive families and encouraged them to take medications, help them get medications filled, help them get to doctor appointments, and others felt that their families just didn't understand and that they thought they were appointments.

Dr. David Miklowitz: 3:03

And others felt that their families just didn't understand and that they thought they were faking it or felt that they could try harder and it was all in their head. This became what I studied. I studied what family environments are like in bipolar disorder and found out, in fact, that environments were associated with outcomes, with relapse rates, how people did over time, how they did socially. If they came from highly critical, conflictual homes, they didn't do as well, and if they came from supportive homes, needless to say, they did better. So that's how we ended up designing treatment for the family.

Dr. Kerry Horrell: 3:45

Yeah.

Dr. Kerry Horrell: 3:45

I want to say more about that because I'm thinking back when I did my comprehensive exams when I was doing my PhD and you go through all sorts of treatment plans for different disorders. I actually remember being struck that bipolar seemed very unique in that most disorders the gold standard treatment was psychotherapy and medication. But I remember specifically for bipolar, like the first line of treatment was medication and then family therapy and then psychotherapy, and that always stood out to me and so I wonder if you can tell us a little bit more about kind of your sense of that above.

Dr. Kerry Horrell: 4:21

I'm glad to hear for this population and maybe especially for young people.

Dr. David Miklowitz: 4:26

Yeah, I'm glad to hear that they mentioned family therapy in your training. When I was coming up, they only talked about medications. Like my training, yeah, I did most of my graduate training in the mid-80s and basically what you heard about bipolar disorder was it was genetic and you were supposed to take lithium and then there were a couple of alternatives to lithium antipsychotics mainly, but psychotherapy, if it existed at all, was just to help people stay on their medications. There wasn't really anything about exploring or understanding stressors or coping strategies, about exploring or understanding stressors or coping strategies. So this became a wide open area. People were kind of. Some people tried to talk me out of studying it. When I first started they said you know, why are you so interested in that? You know what is it? Do you have it or something, or does he leave?

Dr. Kerry Horrell: 5:21

it to the psychiatrist.

Dr. David Miklowitz: 5:26

I called somebody family, haven't you're trying to help them or whatever, and I said no, I thought you know it was a really uncharted territory. We knew a lot about schizophrenia and families. Why not at least look at it as a comparison group? But how about in its own right and um? But there there were others working in this area that were working on individual therapies and group therapies, and now I think it's a much bigger field. Now I think there's more of a recognition that therapy is an important role, plays an important role.

Dr. Kerry Horrell: 5:56

And what about the family component? I mean again like as far as family therapy kind of at this point considered sort of like part of the first-line treatment of bipolar disorder.

Dr. David Miklowitz: 6:06

Well, I'd like to think it's part of the first-line treatment, whether everybody agrees with me or not. I think it partly depends upon how old the patient is. You mentioned the younger patients. We work a lot with teenagers who are first diagnosed, and also young adults, and there I think the family is critical because, hey, they live in a family environment. Their family tells them whether they're behaving in an appropriate way, or whether their families know when they're taking medications or not, and how the family reacts plays a very big role in their course of illness.

Dr. David Miklowitz: 6:46

If they're from a family where people are saying you know, this is, you need to try harder, you're being lazy, you're not, it's not, you're not depressed, you're just like sleeping late or you aren't trying hard enough, you aren't motivated, you don't know what you want to do.

Dr. David Miklowitz: 7:01

That kind of stuff really hurts when you have an illness. Likewise, when people get manic, the family doesn't know what you want to do. That kind of stuff really hurts when you have an illness. Likewise, when people get manic, the family doesn't know what to do. They often respond very angrily, critically or, you know, sort of shun the person for a while, and I think families need to know what to do when the person is ill. Now, some families are more natural at it. I don't like to dichotomize it, as they're good and bad families but there are families where people just seem naturally to know to give the person room, to be encouraging, to give structure in the home, to encourage predictability, and those patients, I think, do much better. And so our program. I don't know if you want me to jump in to talk about our program.

Dr. Bob Boland: 7:48

Yeah, I'd like to hear more about the interventions.

Dr. David Miklowitz: 7:51

Sure, so our program is called Family-Focused Therapy. It's FFT we call it, and right now it is a four-month-long treatment program. It's got 12 sessions and they're divided into three modules. It's what we call psychoeducation, communication, training and problem solving. So a typical family will be coming in after a patient's had an episode of either depression or mania, and that's when the family's most motivated to figure out. You know what am I going to do? I know he needs medication or she needs medication, but what else do we do? How do we understand this? And so the first part is just talking about what has been the patient's experience. How did they know something was different? What was going on in their head? How did the family recognize something was different? And they often are very good at recognizing those changes.

Dr. David Miklowitz: 8:46

When the person is getting manic, they say you talk louder, you stand closer to people, there's an aggressiveness in your voice, you're talking very fast, you're loaded with all these things you're going to do the projects that get dropped. I know when you're getting that way, and the patient will often say well, I couldn't sleep, or I thought sleep was a waste of time, so I stopped sleeping, or I knew all the things I wanted to do and suddenly everything was clear to me. And knowing those early warning signs is really, I think, where you have leverage to try to prevent a full episode, because even though it may feel good, it may feel wonderful to be getting manic, that's when you start you need medication the most. Just try to stave off a more serious episode that might land you in the hospital or get you in an accident or get you hurting someone else or any number of other things. So we want the families to know what it looks like when somebody is going into mania and what to do.

Dr. David Miklowitz: 9:51

You know when to call the doc, how to arrange emergency medication in advance. You know prescriptions can be written in advance for. You know rescue, so to speak. How to keep the environment structured so that person doesn't stay up all night.

Dr. David Miklowitz: 10:09

How to make expectations very clear and not to get riled by the person's sort of aggressive behavior, to recognize it as part of an illness and likewise, in depression, to be encouraging but not critical, not to say to the person. You know get up and get out of bed, because that's not going to work. To give them sort of help, them shape their environment and their goals so that they can gradually reenter society, which might mean maybe they have to sleep late for a while or have to sleep more than usual. Maybe you can gradually encourage them to set the clock back a little bit each day to try to eventually get up or to have goals like today I'm going to take a walk or I'm going to call a friend, or any number of other things that can gradually help them get out of a depressive episode. That's what we talk about in psychoeducation. Did you want to ask about that?

Dr. Bob Boland: 11:08

Yeah, why? Well, I also want to hear I mean more about the communication training. I think you've kind of touched on it a little bit already, but yeah, maybe I'll interject here. Okay.

Dr. Kerry Horrell: 11:17

I work a lot with bipolar young adults Like this has been more and more common as part of the population that I've been treating and I would say, like, clinically, two of the major things as a therapist that I see are grief and shame. Like, just the grief of like I have this, I probably have this my whole life. And then shame, um of like because, even if I know this is a disorder, you know like there's a sense like something's wrong with me that I have this and that I, I experience this and so, yeah, I'm, I'm even in this communication style. I feel like both can be so implicated of like, how do you reduce shame? How do you help people even think through, like as families, like yeah, this does impact us and it impacts you, and like there's grief to acknowledge. Anyways, I'm curious if that relates to the communication.

Dr. David Miklowitz: 12:02

Definitely. I've seen both grief and shame operate in our family sessions and in individual work I've done with patients. I mean grief, I think you've hit it on the head. There's this. We call it grieving over the lost healthy self, which actually is Ellen Frank's term. She developed a treatment called interpersonal and social rhythm therapy.

Dr. David Miklowitz: 12:22

People start thinking about their lives almost as bifurcated into the periods before they got ill and after they became ill and wishing they were the person they used to be.

Dr. David Miklowitz: 12:33

But often the person they think they were before was slightly hypomanic and kind of over the top and, you know, full of life and in positive ways, and they kind of wish things were back to those ways and sometimes that drives medication non-adherence. They kind of say, well, maybe if I go off these stupid medications I can get back to who I used to be. The shame I think comes about partly because when they recognize they've let down their parents. Their parents had expectations for them they may not be able to fulfill, but also the stigma in society about having a disorder and other people being afraid or people not wanting to go out on dates with you because you have this illness, or having trouble getting jobs because people somehow figure it out or know about you, and of course that brings about quite a bit of shame and we try to help normalize it and help them know what their rights are when they go in for a job, for example, that they don't have to disclose their illness and how to deal with it as a family.

Dr. Kerry Horrell: 13:43

Yeah, before I jump to another kind of question, I'm curious if we did cover the different modules that you were discussing.

Dr. Bob Boland: 13:49

Yeah, I want to hear more about communication.

Dr. David Miklowitz: 13:54

Well, the communication we particularly target towards families that are high in conflict, where there's just been a lot of sort of winging mud back and forth and, you know, arguments that have gotten out of hand and sometimes those are related to not fully understanding the illness or what is and isn't the illness. A big question that we get is how do I know what's him and what's his disorder? You know he's always been kind of in your face and aggressive. You know this is just sort of an exaggeration of what we saw before and what communication training is. It's really a fairly old technique in the family therapy literature. It's teaching people how to listen and how to make requests of each other and how to balance positive and negative feedback.

Dr. David Miklowitz: 14:43

So a typical exercise and these are more like role play exercises we'll say to two people who are fighting a lot we'll say, okay, I want one of you to be the speaker and the other one to be the listener, and what the listener has to do is paraphrase, ask questions, clarify, not interrupt, and just let them say their piece. So then we run a little role play like that, ask everyone, how did it feel to be in that spot? And you get a person saying well, I could listen, but he didn't mention what he did the other day. And so we say hold on that, your point of view in just a minute. But how did it feel to be a listener? And then to the patient, how did it feel to be listened to? Now, let's switch. Now you be a listener and listen to you, mom, you tell the patient how it felt, you know, the other day, when he was up late at night selling things on the internet or, you know, speaking to people all over the country on the phone.

Dr. David Miklowitz: 15:46

So, and then, and then, when there are things like I want you to get out of bed earlier or you're being lazy, we get them to phrase that as a request rather than something negative, to say, okay, what do you want the person to do? Explain specifically how you think they could get out of bed earlier and how it would make you feel if they did, and have them role play that and that might lead into problem solving. What could the family do to get this person to get out of bed? What could they do to help them take their medications, help them find a job. Help them, you know, deal with their day-to-day requirements. Them, you know, deal with their day-to-day requirements. You know, if they're taking care of children, how are they going to continue doing that even though they're depressed? Various problems arise in the aftermath of an episode, and the family can really help, you know, generate solutions and evaluate which ones are going to work or not.

Dr. Bob Boland: 16:44

Yeah, it sounds very practically based. Yes, it is.

Dr. Kerry Horrell: 16:47

I am going back to that question because I think I hear that too from a lot of our patients which is is this me or is this bipolar, and is that a distinction that matters to look at? And some of the I think very painful trying to like open that up of was that really me? Is that me? Who am I? In this kind of mess of these episodes, I wonder how you counsel patients and families on that.

Dr. David Miklowitz: 17:11

First. I think it's very important because it's up with whether the person is going to take treatment or not. If they think this is just me, me being me, and I happen to be, my personality is to be aggressive or hyper or whatever they describe it as. Yeah, they'll be less likely to take medication. So we try to. First.

Dr. David Miklowitz: 17:35

There are concrete things you can do, like I can think of a patient where I ask them to make a list of your personality as you understand it. What are the features of your personality Like? Are you intellectual, are you a good friend? Are you dependable? Are you easily angered or impulsive or conscientious? And how are you different when you're in your manic states or in your depressive states? That tells you something about whether this is you or your personality. It gets even trickier in kids well, adolescents really where the question is what's being a teenager and what's being a bipolar teenager? There's one way to think about it which is typical in teenage years is three things Family conflict, risk-taking and instability. Those are features of just being an adolescent, and those things all get exaggerated in bipolar disorder.

Dr. Bob Boland: 18:35

Yeah, unfortunately they all overlap right.

Dr. Kerry Horrell: 18:38

And you kind of think of it in this question too, like identity development.

Dr. Bob Boland: 18:41

Yeah, yes, and what that means. Yeah, it's interesting too, like because it sounds like some of the strategies I could call early on, I think still as a trainee, having a patient who is a businessman and he would always, he would come in every now and then and say those kind of things like okay, I know you're gonna say, I know you're gonna say I'm manic, but I've got this great opportunity. So I'm like selling everything here and I'm going down to Florida and I'm going to, like, you know, throw everything into this, like particular real estate development or something like that, and it's really going to take and it's a great idea, that kind of thing, you know. And you'd be like, well, you're right about one thing, like I do think you're manicured, but it's like but then it just became like a back and forth where like, no, I'm not, yes, I am. But then it just became like a back and forth where we're like no, I'm not, yes, I am, which wasn't terribly helpful to either of us.

Dr. David Miklowitz: 19:31

I was frustrated and he still went down to Florida. I'll tell you I wouldn't say we have a great solution to that, but I can tell you what we do in those circumstances is somebody's saying, yeah, I'm going to throw everything away, I'm going to leave my wife, I'm going to go, you know, become a rock musician, and you know selling all my stuff, and so on. We tell them two things Can you wait till Thursday to do that? I mean, if it's a good idea now, it'll be a good idea on Thursday too, won't it? And the other is name two people you know whose judgment you trust, outside your family preferably.

Dr. David Miklowitz: 20:08

Well, my uncle, my former roommate, all right. So would you be willing to call them and ask them what their opinion is? And that doesn't mean you have to do what they say, but would you at least find out what they think about this plan? And sometimes there's still a part of them that's logical enough to hear that everyone else thinks this is a crazy idea and maybe I shouldn't jump in. Maybe I can do part of it and not the whole thing. Maybe I don't have to move. Maybe I can take guitar lessons if I want to become a musician or something like that. So you know, partly it's just. But if you know, if they're in a psychotic mania, all that's going to fall flat, which is why you have to really try to get before it's out of hand.

Dr. Kerry Horrell: 20:56

I will say, just to pick your brain on this a little bit more, because this is a bit anecdotal, but it's what I've seen, Especially again, for some reason, over the last few years I've worked with a lot of young adults who come in after a manic episode and I think they really are like genuinely very creative, very talented, very smart, and they describe again like across multiple patients I've heard them describe something akin to when I'm manic, I can sort of access some level of my mind thinking creativity that I can't access otherwise and I certainly don't think I can access when I'm on medication and it's one of the huge, I wouldn't even say conflict points. And I certainly don't think I can access when I'm on medication. And it's one of the huge, I wouldn't even say conflict points. Cause I, as a therapist, I'm not trying to argue with them about like yeah, you should do this.

Dr. Kerry Horrell: 21:34

I'm trying to be like what's the pros and cons? You know like what? Let's look at like what you, what really aligns with your values, Cause when you become manic, you become oftentimes pretty destructive, it's traumatizing to your family, it's not good for you and it is getting in the way of your success. And like I'm hearing you say like I make better music when I'm manic and I can, I feel like I have more of a chance to you really make it when I'm manic. And so this is the conflict. I I feel like I'm I'm seeing the most that these people do seem like they, they can access something in their mind. They're really quite.

Dr. David Miklowitz: 22:08

I agree with that. I have a couple of responses. First, I think it's great that you develop a relationship with your patients and sort of take them through that Is this good for you? Pro and con type of thinking, because if they have a good relationship with you, they're going to listen. Even if they're combating you, they're they, you, they're going to listen.

Dr. Bob Boland: 22:28

Even if they're combating you.

Dr. David Miklowitz: 22:29

They're going to hear what you're saying. Now. The first thing is you know creativity. There is no question that there's a link between bipolar disorder and creativity and you know, just Kay Jamison has written dozens of books about this. Maybe not dozens, but quite a few books on bipolar disorder and artistic creativity and the various people in history who've had bipolar disorder Tchaikovsky, strauss. You know dancer Nijinsky, the dancer.

Dr. Kerry Horrell: 23:00

Amy Winehouse.

Dr. David Miklowitz: 23:02

Yeah, Amy Winehouse, lots of Kurt Cobain, I think no-transcript. But when you're manic, what's going to happen is your mind is going so fast you're going to produce a lot of things, but then you're going to throw them all out when you feel. Well, If anything, you want to harvest the creativity when you're hypomanic. But how do you do that without going off your medications? Well, sometimes you can make a deal, essentially with your doctor that if, say, you're on lithium, can you be maintained at a lower lithium level and still have protection, Like some people particularly those with bipolar 2, may be able to get away with a lower lithium level and during hypomania they still experience that burst of creativity. It's not the medication takes it all away. So those kinds of arrangements with their doc and recognize the importance of playing music or doing their art, they may be able to have both Right, playing music or doing their art, they may be able to have both Right.

Dr. Bob Boland: 24:29

So you know, speaking of books and stuff, I know you have a new book out it's Living Well with Bipolar Disorder Practical Strategies for Improving your Daily Life and you know it's really an update. You know on what we know about bipolar treatments, and so can you say a little bit about what you know, your decision to write a book and why you felt there's a need for it?

Dr. David Miklowitz: 24:49

Right, sure, I've been writing books about bipolar disorder for quite a while. I wrote that really, I think had the biggest mark was the Bipolar Disorder Survival Guide, which was in the early, early 2000s. That was a more informational book. What should families know about bipolar disorder? What should the patient know about depression and mania and suicide prevention, or if you have a bipolar disorder in a child? The new book is really oriented specifically towards the patient.

Dr. David Miklowitz: 25:24

And how do you deal with the crises that occur or even the minor changes that occur on a day-to-day basis to cope with this disorder? So what do you do if, during the day, you feel your anger rising because maybe your hypomania isn't completely under control? But there's still the question what do you do? You don't just keep taking more and more pills. There have to be strategies. You use Meditation perhaps might be a good one. Put yourself down.

Dr. David Miklowitz: 25:55

Distraction, walking away from a conflict that you know is likely to occur and dealing with it later. Likewise, suicidal ideation when it comes up on a daily basis. How do you distract yourself? What are the things you can do internally or with the help of your family? What do you do when your family is telling you things that make you feel bad and that you find difficult to come home as a result. How do you talk to them in a way that they're going to be able to hear you and acknowledges your illness? For example, people often complain my parents are constantly reminding me to take my medications Every day it's did you take your medication?

Dr. David Miklowitz: 26:37

Have you taken your medication? Did you sleep? Have you had any symptoms? And to be able to tell them. I want to have a relationship with you that's not just about my illness. How do you and I find a way to talk about this stuff in a very contained way, maybe only on Sunday or maybe only once a day and for five minutes and I'll give you a brief update, rather than this being the centerpiece of our relationship. Getting a job what are the challenges you run into in the workplace and how do you cope with those? So the book really takes, topic by topic, different ways you can manage your disorder in the face of challenges. Diet there's a chapter on diet. There's a chapter on exercise, on dealing with substance abuse. So what do you say to therapy? What do you say to your therapist? Why should you go to therapy? And what are you going to say to the person. How will you know if it's the wrong person? You're seeing? All those things are in the book.

Dr. Kerry Horrell: 27:42

It sounds incredibly practical and in that way it also sounds very hopeful.

Dr. Bob Boland: 27:48

Like you know, people can have and we've seen this like beautiful, fulfilling, healthy, lives and some agency, alfred, as opposed to feeling helpless, whether which a lot of people do, yeah yeah, especially when it comes to the family.

Dr. David Miklowitz: 28:01

There's every chapter has a section that says, uh, you know, uh, what's the role of the family here and how can you respond to them. But instead of being talking to the family, I talk to the patient and say I mean the person who has a disorder and say, you know, if your parents are saying this, here's how you can respond. Or if your spouse says this, here are good ways to talk to them. And, yes, it tries to be very hopeful but also realistic about what you can and can't do, and I don't think there's anything you can't do with bipolar disorder, but you may have to set your expectations accordingly.

Dr. Kerry Horrell: 28:38

I wonder kind of as we begin to wrap up, if you have kind of any future directions or areas of research that are really exciting to you for this field.

Dr. David Miklowitz: 28:47

We're starting to do some research on diets, about whether you're about to start a study on ketogenic diets, that there's some beginning evidence that they may be effective in bipolar disorder. A colleague of mine is studying psilocybin for depression. That's although it used to be used while still a drug of abuse, but now it's also got a therapeutic value as well. If it's done under very controlled circumstances, people are seeing real improvements in depression, kind of like what they're seeing with ketamine and other drugs. So I'm kind of interested in how that's going to come out.

Dr. David Miklowitz: 29:24

But for the family, one thing we found and I'm really excited about this is the idea that you may be able to prevent episodes of bipolar disorder that occur in kids by working with the family early on.

Dr. David Miklowitz: 29:40

We did a study of kids who were at risk for bipolar disorder because they had early mood instability, they had a family history of the disorder and they were only, say, 13, 14 years old. We were able to show we could prevent episodes of depression in those kids with family therapy. So I'd like to see that go a lot further the prevention of at least the parts of the illness. Some of this, I think, may end up having to be digitized because I know there's a lot of excitement about digital mental health, which is, you know, can any of this be done via smartphones or based protocols? I think basic information can be delivered that way and maybe some interactive tools like sleep-wake cycle management perhaps or, you know, tracking your medication compliance. But there's a whole set of emotional issues that come up with this disorder that I don't think are going to be amenable to digital mental health as we have it now. Looking forward to being challenged on that, but I think we're not there yet in terms of what we can offer.

Dr. Kerry Horrell: 30:50

That is our field man. Yeah, the digital wave is continuing to come.

Dr. Bob Boland: 30:54

Continues to come, but I think we still have a role, yeah.

Dr. Kerry Horrell: 30:58

Yeah, josh, again, I want to just say again in September, your book Living Well with Bipolar Disorder Practical Strategies for Improving your Daily Life comes out, and it sounds again just like an incredible resource for clinicians and families and patients alike. So thank you so much for giving us this new preview and talking with us today.

Dr. Bob Boland: 31:16

Absolutely yeah, once again, we've been listening to Dr David Mikulowi and I'm your host, bob Bolin.

Dr. Kerry Horrell: 31:23

I'm Keri Harre.

Dr. Bob Boland: 31:24

And thanks for diving in.

Dr. Kerry Horrell: 31:26

The Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

Dr. Bob Boland: 31:35

For more episodes like this, visit wwwmenningerclinicorg.

Dr. Kerry Horrell: 31:40

To submit a topic for discussion. Send us an email at podcast at menningeredu.