Late onset bipolar

[nexus73]

Patient in their 70s. Chronic cannabis user. Chronic depression, insomnia, anxiety, possible narcissistic personality traits. Over previous few months increased use of high potency cannabis products (e.g. 80% THC pen, flower marijuana soaked in cannabis oil). Manic episode emerges and leads to inpatient hospitalization. Dad had "bipolar", but best history I can get is dad was a heavy drinker and physically abusive, and had some good days.

Where do you put your money? This person has new onset bipolar in their 70s VS cannabis induced manic episode?

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[Celexa]

I have had one patient who legit had their first manic episode in their 80s. Symptoms were textbook. Prior to that, had clear depressive eps but no clear mania. Strong and legitimate family hx (child with true bipolar 1). Was initially admitted to medicine bc we were, obviously, skeptical it was psychiatric in origin. Extremely thorough workup all negative.

That being said, for the pt you described, substance induced is waaaaaay more likely and where I would put my money lol.

 

[SmallBird]

There is data and theory to support a psychosis endophenotype for which marijuana is a particularly prominent or even essential risk factor. The possibility of mild cognitive impairments and a personality disorder suggests that even with an agent for mania prophylaxis the baseline will likely include significant mood lability and overall perceived high symptom burden but I would still start a medication.

 

[allantois]

Who is really to say they’ve never had a manic/hypomanic episode before?

 

[nexus73]

Who is really to say they’ve never had a manic/hypomanic episode before?

that’s fair…spouse of 50 years allegedly

 

[annoyedpsychiatrist]

suspect its substance induced or hes had hypomanic episodes in the past but still been functional. Im going with substance induced though. UDS was negative for other stuff?

 

[psychmd03]

This is an interesting topic I’ve been slowly digging into I’ve had two recent patients similar to the OP. Very interesting both seem to have some mood issues, depressive, for their life and collateral from the family reported no mania. I know we learn that depression precedes mania in most cases but this is extreme. My thoughts wander to the age related changes to the brain in someone that has the correct genetics, to have new mania manifest.

 

[nexus73]

I considered checking a MOCA as he's clearing, but on inpatient I've seen it just add insult to injury, now you're telling me I'm manic, I've gotta quit THC, and I've got MCI and maybe early dementia? With mild cases better to leave to outpatient who has better rapport and will follow up.

I've seen a handful of patients in the last 6-12 months, not just elderly patients, admitted with frank mania/psychosis and the history includes long time cannabis use, but recent transition from regular flower marijuana to high potency pens, wax, dabs, etc. Who then clear completely, in line with a manic episode rather than residual symptoms seen in schizophrenia/schaffective.

I'll never see the long term outcome, but history seems more in line with drug induced. Wonder if the cannabis strains are changing.

 

[Mad Jack]

I considered checking a MOCA as he's clearing, but on inpatient I've seen it just add insult to injury, now you're telling me I'm manic, I've gotta quit THC, and I've got MCI and maybe early dementia? With mild cases better to leave to outpatient who has better rapport and will follow up.

I've seen a handful of patients in the last 6-12 months, not just elderly patients, admitted with frank mania/psychosis and the history includes long time cannabis use, but recent transition from regular flower marijuana to high potency pens, wax, dabs, etc. Who then clear completely, in line with a manic episode rather than residual symptoms seen in schizophrenia/schaffective.

I'll never see the long term outcome, but history seems more in line with drug induced. Wonder if the cannabis strains are changing.

I think it's just the potency more than anything. You literally couldn't smoke the amount of pure THC these people are getting in a single pen if you were smoking every minute of the day in the 80s. Unfortunately people don't seem to understand the concept of more not equaling better and have been gravitating to high potency products that scramble their brains. Even regular cannabis is several times stronger than older strains. It boggles the mind that people think infinite use of escalating amounts of THC will have no consequences

As to OP, most likely it's going to end up being substance-induced mood disorder but if you scramble your brain enough times and it occasionally breaks for good, so only time will tell

 

[calvnandhobbs68]

I think it's just the potency more than anything. You literally couldn't smoke the amount of pure THC these people are getting in a single pen if you were smoking every minute of the day in the 80s. Unfortunately people don't seem to understand the concept of more not equaling better and have been gravitating to high potency products that scramble their brains. Even regular cannabis is several times stronger than older strains. It boggles the mind that people think infinite use of escalating amounts of THC will have no consequences

As to OP, most likely it's going to end up being substance-induced mood disorder but if you scramble your brain enough times and it occasionally breaks for good, so only time will tell

Yeah the percentages these days are crazy. I had a teenager tell me yesterday her vape is 80% THC and she's puffing on this thing all day long at school and home. People have very little understanding that this is way more potent and concentrated in terms of efficiency than taking an few inefficient hits of your friends low potency joint or bowl. And way more people are vaping or dabbing...that's like the primary THC consumption for teenagers because they can hide it at school and home way easier.

 

[Merovinge]

Yeah the percentages these days are crazy. I had a teenager tell me yesterday her vape is 80% THC and she's puffing on this thing all day long at school and home. People have very little understanding that this is way more potent and concentrated in terms of efficiency than taking an few inefficient hits of your friends low potency joint or bowl. And way more people are vaping or dabbing...that's like the primary THC consumption for teenagers because they can hide it at school and home way easier.

I explain it that if every can of light beer was replaced with vodka but you kept drinking the same number of beer cans, how do you think someone would feel? Even teenagers who "just" use THC readily understand the analogy. There are very few substances where you can just 10-100x the intake compared to 20-30 years ago and think anything should be expected to come out alright.

 

[clausewitz2]

Patient in their 70s. Chronic cannabis user. Chronic depression, insomnia, anxiety, possible narcissistic personality traits. Over previous few months increased use of high potency cannabis products (e.g. 80% THC pen, flower marijuana soaked in cannabis oil). Manic episode emerges and leads to inpatient hospitalization. Dad had "bipolar", but best history I can get is dad was a heavy drinker and physically abusive, and had some good days.

Where do you put your money? This person has new onset bipolar in their 70s VS cannabis induced manic episode?

I've definitely had an inpatient like this before. Bouts of depression and sleep disruptions, chronic cannabis, a touch of grandiosity from time to time, but no real history of mental health treatment and high level of functioning. Survives cancer that is cured but leaves him with chronic pain, gets into Rick Simpson oil in his early 70s to "treat" it, thinks it's miraculous. Starts evangelizing it to anybody who will listen...then stops listening and starts evangelizing it to everybody else as well. Gets hospitalized after he breaks into his neighbor's house in the middle of the night to give them pamphlets about it because it seemed very urgent they have them at 3 AM, they understandably call the police. Totally off the chain in the unit for a while, floridly manic, doesn't clear for a good long while until he gets to a healthy dose of Depakote. Starts sleeping again, still pretty irritable and talkative, settles down after a few weeks. Goes home, stops taking his depakote, does not use more THC, hospitalized again a month later.

When I hear about narcissistic personality traits of long-standing in the setting of chronic depression and insomnia I remember the literature I have posted links to before about co-occurrence of bipolar I and NPD and it makes me wonder if there might have been some hypomania after all.

 

[whopper]

I've had a patient develop Schizophrenia in his mid 30s. Only one ever. Of course it could be a misdiagnosis, but he meets all the criteria of it. Extreme situation happened to him. Was in the middle of a battle (he's a vet) and one of his buddies exploded in front of him. He had hallucinations ever since.

Due to extreme situations these days we sometimes see strange results.

Edit: Should've mentioned this is a male patient. I've had about a dozen late-onset female schizophrenic patients.

I don't endorse this TV show but on Biggest Loser there were several cases of insulin-dependent diabetics no longer needing insulin. These were people exercising about 5 hours a day eating less than 1,000 calorie a day diets with almost no carbs. While back in residency the saying was once you need insulin it's impossible to get off of it.

 

[clausewitz2]

I don't endorse this TV show but on Biggest Loser there were several cases of insulin-dependent diabetics no longer needing insulin. These were people exercising about 5 hours a day eating less than 1,000 calorie a day diets with almost no carbs. While back in residency the saying was once you need insulin it's impossible to get off of it.

A lot of people would have an easier time making change in their lives if they regularly appeared on TV and had to check in about the progress they are making.

 

[Merovinge]

I don't endorse this TV show but on Biggest Loser there were several cases of insulin-dependent diabetics no longer needing insulin. These were people exercising about 5 hours a day eating less than 1,000 calorie a day diets with almost no carbs. While back in residency the saying was once you need insulin it's impossible to get off of it.

I don't think that's an accurate take. There are certainly DM2 patients who dip into needing insulin but then make big lifestyle or medication changes who go on to not needing medication, it's not a miracle nor does it need a profoundly unhealthy relationship with food to make it happen.

 

[sloh]

I don't think that's an accurate take. There are certainly DM2 patients who dip into needing insulin but then make big lifestyle or medication changes who go on to not needing medication, it's not a miracle nor does it need a profoundly unhealthy relationship with food to make it happen.

Yup.

Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial

Our findings show that, at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care.

www.thelancet.com

"Our findings show that, at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care."

 

[SmallBird]

I've had a patient develop Schizophrenia in his mid 30s. Only one ever. Of course it could be a misdiagnosis, but he meets all the criteria of it. Extreme situation happened to him. Was in the middle of a battle (he's a vet) and one of his buddies exploded in front of him. He had hallucinations ever since.

Due to extreme situations these days we sometimes see strange results.

Edit: Should've mentioned this is a male patient. I've had about a dozen late-onset female schizophrenic patients.

I don't endorse this TV show but on Biggest Loser there were several cases of insulin-dependent diabetics no longer needing insulin. These were people exercising about 5 hours a day eating less than 1,000 calorie a day diets with almost no carbs. While back in residency the saying was once you need insulin it's impossible to get off of it.

None of what you are saying resonates. In most large studies late 20s is the mean age of onset for schizophrenia and the standard deviation is several years. That you have only seen one is odd. Further, having hallucinations following an event like that doesn't sound like schizophrenia at all.

What are you talking about? Patients with diabetes can absolutely require insulin and then not require insulin.

 

[whopper]

Guy was 35, serving in the middle east. No prior history of mental illness. His best friend exploded from an IED. From there on the patient had auditory hallucinations having a running commentary that occurred most of the day. While hallucinations sometimes occur in PTSD, no these weren't PTSD-related hallucinations. They made commentary that had nothing to do with the event, continued even after his PTSD went into remission.

Patient has no prior manic episodes.

What are you talking about? Patients with diabetes can absolutely require insulin and then not require insulin.

The point is this was new territory years ago. There wasn't an evidenced-based regiment to get off of insulin until you started seeing people start doing extreme measures. Years ago once someone was on insulin doctors said they'd be on it for life. Now the talk is the patient can get off of insulin but they're going to have to take some extreme measures.

 

[Stagg737]

I explain it that if every can of light beer was replaced with vodka but you kept drinking the same number of beer cans, how do you think someone would feel? Even teenagers who "just" use THC readily understand the analogy. There are very few substances where you can just 10-100x the intake compared to 20-30 years ago and think anything should be expected to come out alright.

I love this analogy and will be stealing it when dealing with the young members of the cannabis cult. I've had a few older patients in their 60's+ in the past few years who retried cannabis for the first time since the 60's-80's and were pretty incredulous about how different it is today. Even the stuff that's "just" 8-10% THC seemed like pretty heavy stuff to them.

 

[Merovinge]

I love this analogy and will be stealing it when dealing with the young members of the cannabis cult. I've had a few older patients in their 60's+ in the past few years who retried cannabis for the first time since the 60's-80's and were pretty incredulous about how different it is today. Even the stuff that's "just" 8-10% THC seemed like pretty heavy stuff to them.

It's honestly hard to get plant THC at 8-10% these days. Average runs in the high teens and right around 20 is typical for my area at the dispensaries.