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After the Antidepressant Works: The Clinical Decision That Prevents Relapse · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:11
  your
• 0:11
  pocket.
• 0:11
  This
• 0:11
  is
• 0:12
  the
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  with
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  My
• 0:16
  friends,
• 0:16
  we
• 0:17
  have
• 0:17
  a
• 0:17
  very
• 0:17
  good
• 0:18
  topic
• 0:19
  today.
• 0:19
  It's
• 0:20
  a
• 0:20
  juicy
• 0:20
  one.
• 0:20
  Antidepressant
• 0:21
  continuation.
• 0:23
  Let's
• 0:23
  say
• 0:23
  you
• 0:23
  have
• 0:23
  a
• 0:24
  patient
• 0:24
  in
• 0:24
  your
• 0:24
  clinic
• 0:25
  named
• 0:25
  Ralph,
• 0:26
  and
• 0:26
  Ralph
• 0:27
  is
• 0:27
  asking
• 0:27
  you,
• 0:28
  hey,
• 0:28
  buddy.
• 0:29
  Not
• 0:29
  a
• 0:29
  lot
• 0:29
  of
• 0:30
  patients
• 0:30
  call
• 0:30
  me
• 0:30
  buddy,
• 0:31
  but
• 0:31
  let's
• 0:31
  just
• 0:31
  say
• 0:31
  Ralph
• 0:32
  said,
• 0:32
  hey,
• 0:32
  buddy.
• 0:33
  How
• 0:33
  long
• 0:33
  do
• 0:33
  I
• 0:34
  have
• 0:34
  to
• 0:34
  be
• 0:34
  on
• 0:34
  this
• 0:34
  antidepressant
• 0:35
  for?
• 0:35
  Are
• 0:36
  we
• 0:36
  talking
• 0:36
  the
• 0:37
  rest
• 0:37
  of
• 0:37
  my
• 0:37
  life?
• 0:38
  Do
• 0:38
  I
• 0:38
  just
• 0:39
  have
• 0:39
  to
• 0:39
  take
• 0:39
  this,
• 0:39
  like,
• 0:40
  for
• 0:40
  two
• 0:40
  months?
• 0:41
  Do
• 0:41
  I
• 0:41
  take
• 0:42
  it
• 0:42
  as
• 0:42
  needed?
• 0:42
  What
• 0:42
  do
• 0:42
  I
• 0:43
  do?
• 0:43
  A
• 0:43
  lot
• 0:44
  of
• 0:44
  patients
• 0:44
  have
• 0:44
  absolutely
• 0:45
  no
• 0:45
  clue
• 0:45
  what
• 0:45
  this
• 0:46
  looks
• 0:46
  like
• 0:46
  and
• 0:46
  why.
• 0:47
  And
• 0:47
  it
• 0:48
  helps
• 0:48
  to
• 0:48
  really
• 0:48
  understand
• 0:50
  where
• 0:51
  we
• 0:51
  get
• 0:51
  this
• 0:51
  information
• 0:52
  and
• 0:52
  what
• 0:52
  it
• 0:53
  means
• 0:53
  for
• 0:53
  them
• 0:54
  and
• 0:54
  to
• 0:54
  explain
• 0:54
  it
• 0:55
  in
• 0:55
  a
• 0:55
  way
• 0:56
  that
• 0:56
  I
• 0:56
  think
• 0:56
  really
• 0:57
  resonates
• 0:57
  so
• 0:57
  they
• 0:58
  know
• 0:58
  what
• 0:58
  to
• 0:58
  do
• 0:58
  with
• 0:58
  this
• 0:59
  medication.
• 0:59
  So
• 1:00
  we're
• 1:00
  gonna
• 1:00
  talk
• 1:00
  about
• 1:00
  three
• 1:01
  pearls
• 1:01
  in
• 1:01
  particular
• 1:02
  today
• 1:03
  that
• 1:03
  are
• 1:04
  gonna
• 1:04
  help
• 1:04
  you
• 1:04
  see
• 1:06
  this
• 1:06
  topic
• 1:07
  with
• 1:07
  a
• 1:07
  lot
• 1:07
  more
• 1:08
  clarity.
• 1:08
  You're
• 1:08
  gonna
• 1:08
  be
• 1:08
  able
• 1:08
  to
• 1:09
  answer
• 1:09
  this
• 1:09
  question
• 1:10
  with
• 1:10
  a
• 1:10
  lot
• 1:10
  more
• 1:11
  fidelity
• 1:11
  and
• 1:11
  reliability.
• 1:12
  So
• 1:12
  what
• 1:12
  do
• 1:13
  you
• 1:13
  say
• 1:13
  to
• 1:13
  Ralph?
• 1:14
  Well,
• 1:14
  it
• 1:14
  kind
• 1:14
  of
• 1:14
  depends
• 1:15
  on
• 1:15
  what
• 1:16
  Ralph's
• 1:17
  whole
• 1:17
  presentation
• 1:19
  looks
• 1:19
  like
• 1:20
  with
• 1:20
  respect
• 1:20
  to
• 1:20
  how
• 1:20
  long
• 1:21
  he
• 1:21
  has
• 1:21
  to
• 1:21
  be
• 1:21
  on
• 1:21
  antidepressants.
• 1:23
  And
• 1:23
  one
• 1:23
  thing
• 1:23
  that
• 1:23
  I
• 1:24
  always
• 1:24
  look
• 1:24
  for,
• 1:24
  and
• 1:25
  this
• 1:25
  is
• 1:25
  pearl
• 1:25
  number
• 1:25
  one,
• 1:26
  my
• 1:26
  friends,
• 1:27
  is
• 1:28
  there's
• 1:28
  a
• 1:28
  certain
• 1:29
  profile
• 1:29
  of
• 1:29
  patients
• 1:30
  who
• 1:31
  are
• 1:31
  more
• 1:31
  high
• 1:31
  risk
• 1:32
  that
• 1:32
  might
• 1:32
  not
• 1:33
  be
• 1:33
  a
• 1:33
  very
• 1:34
  good
• 1:34
  fit
• 1:35
  to
• 1:35
  discontinue
• 1:36
  antidepressants,
• 1:38
  maybe
• 1:38
  at
• 1:38
  all,
• 1:39
  right
• 1:40
  away
• 1:40
  after
• 1:40
  the
• 1:41
  remission
• 1:41
  of
• 1:41
  their
• 1:41
  symptoms.
• 1:42
  And
• 1:42
  so
• 1:43
  patients
• 1:43
  who
• 1:43
  are
• 1:43
  not
• 1:44
  ideal
• 1:44
  candidates
• 1:45
  to
• 1:45
  discontinue
• 1:45
  their
• 1:46
  SSRIs.
• 1:47
  Patients
• 1:47
  who
• 1:47
  have
• 1:47
  a
• 1:48
  dramatically
• 1:48
  higher
• 1:48
  relapse
• 1:49
  rate
• 1:49
  after
• 1:50
  discontinuation
• 1:51
  and
• 1:51
  are
• 1:51
  poor
• 1:51
  candidates
• 1:52
  for
• 1:52
  stopping
• 1:52
  SSRIs,
• 1:53
  typically
• 1:54
  have
• 1:55
  multiple
• 1:56
  prior
• 1:56
  episodes,
• 1:57
  so
• 1:57
  certainly
• 1:58
  greater
• 1:58
  than
• 1:58
  or
• 1:59
  equal
• 1:59
  to
• 1:59
  three
• 1:59
  prior
• 2:00
  major
• 2:00
  depressive
• 2:01
  episodes.
• 2:01
  And
• 2:01
  remember,
• 2:02
  we're
• 2:02
  talking
• 2:03
  weeks
• 2:03
  at
• 2:03
  a
• 2:03
  time,
• 2:04
  so
• 2:04
  really
• 2:04
  make
• 2:05
  sure
• 2:05
  you're
• 2:05
  fleshing
• 2:06
  out
• 2:06
  what
• 2:06
  these
• 2:06
  antidepressant
• 2:07
  episodes
• 2:08
  look
• 2:08
  like.
• 2:08
  Patients
• 2:08
  will
• 2:08
  tell
• 2:09
  you
• 2:09
  all
• 2:09
  the
• 2:09
  time
• 2:09
  they've
• 2:10
  been
• 2:10
  depressed
• 2:10
  multiple
• 2:11
  times
• 2:11
  in
• 2:11
  their
• 2:11
  lives.
• 2:12
  And
• 2:12
  they're
• 2:12
  really
• 2:12
  describing
• 2:13
  maybe
• 2:14
  acute
• 2:14
  stressors
• 2:15
  that
• 2:15
  are
• 2:15
  hour
• 2:15
  by
• 2:15
  hour
• 2:16
  or
• 2:16
  day
• 2:17
  by
• 2:17
  day,
• 2:17
  not
• 2:17
  really
• 2:18
  weeks
• 2:18
  of
• 2:18
  patterns,
• 2:19
  episodic
• 2:20
  mood
• 2:21
  irregularities.
• 2:22
  Okay,
• 2:22
  so
• 2:22
  you
• 2:22
  gotta
• 2:23
  really
• 2:23
  carefully
• 2:24
  define
• 2:24
  depression,
• 2:25
  but
• 2:25
  once
• 2:25
  you
• 2:25
  do,
• 2:25
  if
• 2:25
  they've
• 2:26
  really
• 2:26
  met
• 2:26
  criteria
• 2:27
  three
• 2:27
  or
• 2:27
  more
• 2:28
  times
• 2:29
  in
• 2:29
  the
• 2:29
  past,
• 2:29
  then
• 2:30
  that's
• 2:30
  certainly
• 2:30
  not
• 2:30
  someone
• 2:31
  who
• 2:31
  I
• 2:31
  would
• 2:31
  say
• 2:31
  is
• 2:32
  an
• 2:32
  ideal
• 2:32
  candidate
• 2:33
  to
• 2:33
  just
• 2:33
  discontinue
• 2:34
  Antidepressants.
• 2:35
  Keep
• 2:36
  in
• 2:36
  mind
• 2:36
  that
• 2:36
  patients
• 2:37
  with
• 2:37
  five
• 2:37
  or
• 2:38
  more
• 2:38
  episodes,
• 2:38
  the
• 2:38
  evidence
• 2:39
  shows,
• 2:39
  have
• 2:39
  84%
• 2:40
  higher
• 2:40
  relapse
• 2:41
  rate
• 2:42
  compared
• 2:42
  to
• 2:42
  those
• 2:42
  with
• 2:42
  only
• 2:43
  two
• 2:43
  episodes.
• 2:44
  So
• 2:44
  that's
• 2:45
  a
• 2:45
  pretty
• 2:45
  scary
• 2:46
  statistic.
• 2:47
  Right.
• 2:47
  So
• 2:47
  the
• 2:47
  idea
• 2:48
  of
• 2:48
  maintenance
• 2:48
  on
• 2:48
  an
• 2:49
  SSRI
• 2:49
  is
• 2:49
  particularly
• 2:50
  important.
• 2:51
  Okay.
• 2:51
  And
• 2:51
  remember
• 2:52
  that
• 2:52
  with
• 2:52
  each
• 2:52
  depressive
• 2:53
  episode,
• 2:54
  it
• 2:54
  brings
• 2:54
  future
• 2:55
  risk.
• 2:55
  And
• 2:56
  more
• 2:56
  than
• 2:56
  half
• 2:57
  the
• 2:57
  patients
• 2:57
  with
• 2:57
  just
• 2:57
  the
• 2:58
  first
• 2:58
  episode
• 2:58
  experience
• 2:59
  a
• 2:59
  second.
• 2:59
  And
• 3:00
  the
• 3:00
  risk
• 3:00
  kind
• 3:00
  of
• 3:00
  climbs
• 3:01
  further
• 3:01
  and
• 3:01
  further
• 3:02
  with
• 3:02
  each
• 3:03
  subsequent
• 3:03
  episode.
• 3:04
  There's
• 3:04
  a
• 3:04
  kindling
• 3:05
  effect.
• 3:05
  Right.
• 3:05
  I
• 3:06
  always
• 3:06
  like
• 3:06
  to
• 3:06
  use
• 3:07
  fire
• 3:08
  analogies
• 3:09
  with
• 3:09
  my
• 3:09
  patient
• 3:09
  because
• 3:09
  I
• 3:10
  feel
• 3:10
  like
• 3:10
  it
• 3:10
  describes
• 3:11
  the
• 3:11
  brain
• 3:11
  very,
• 3:12
  very
• 3:12
  clearly
• 3:13
  in
• 3:13
  some
• 3:13
  respects.
• 3:14
  Right.
• 3:14
  You
• 3:14
  have
• 3:15
  like
• 3:15
  this
• 3:15
  tinder,
• 3:15
  you
• 3:16
  have
• 3:16
  this
• 3:16
  hot
• 3:17
  ash,
• 3:17
  you
• 3:17
  have
• 3:17
  little
• 3:17
  burning
• 3:18
  embers.
• 3:19
  And
• 3:19
  each
• 3:19
  time
• 3:19
  the
• 3:20
  depression
• 3:20
  comes
• 3:20
  along,
• 3:21
  it's
• 3:22
  kind
• 3:22
  of
• 3:22
  like
• 3:22
  blowing
• 3:22
  at
• 3:23
  the
• 3:23
  base
• 3:23
  of
• 3:23
  a
• 3:23
  fire.
• 3:24
  The
• 3:24
  bottom
• 3:24
  line,
• 3:25
  though,
• 3:25
  is
• 3:25
  when
• 3:25
  you
• 3:25
  blow
• 3:25
  at
• 3:25
  the
• 3:26
  base
• 3:26
  of
• 3:26
  a
• 3:26
  fire,
• 3:26
  from
• 3:27
  my
• 3:27
  limited
• 3:28
  experience
• 3:28
  camping
• 3:29
  back
• 3:29
  in
• 3:29
  the
• 3:29
  day,
• 3:30
  the
• 3:30
  fire
• 3:30
  grows
• 3:31
  a
• 3:31
  little
• 3:31
  bit.
• 3:31
  So
• 3:32
  each
• 3:32
  time
• 3:32
  that
• 3:32
  depression
• 3:33
  comes,
• 3:33
  it
• 3:34
  kind
• 3:34
  of.
• 3:34
  It
• 3:35
  gives
• 3:35
  the
• 3:35
  fire
• 3:35
  a
• 3:36
  little
• 3:36
  more
• 3:36
  oxygen
• 3:36
  and
• 3:37
  it
• 3:37
  burns
• 3:37
  brighter.
• 3:38
  Right.
• 3:38
  And
• 3:39
  so
• 3:39
  that
• 3:39
  kind
• 3:40
  of
• 3:40
  a
• 3:40
  patient
• 3:40
  just
• 3:41
  has
• 3:41
  more
• 3:41
  embers
• 3:42
  glowing
• 3:42
  and
• 3:42
  burning.
• 3:43
  And
• 3:43
  it's
• 3:43
  not
• 3:44
  really
• 3:44
  the
• 3:44
  best
• 3:44
  situation
• 3:45
  to
• 3:45
  just
• 3:45
  get
• 3:46
  them
• 3:46
  off
• 3:46
  their
• 3:46
  antidepressants
• 3:47
  necessarily.
• 3:48
  Okay.
• 3:49
  You
• 3:49
  gotta
• 3:49
  also
• 3:49
  keep
• 3:50
  in
• 3:50
  mind
• 3:50
  residual
• 3:51
  depressive
• 3:51
  symptoms.
• 3:52
  That
• 3:52
  would
• 3:52
  be
• 3:52
  the
• 3:52
  equivalent
• 3:53
  of
• 3:53
  this
• 3:53
  fire
• 3:54
  that
• 3:54
  has
• 3:54
  not
• 3:55
  been
• 3:55
  put
• 3:55
  out
• 3:55
  yet.
• 3:55
  Right.
• 3:56
  That's
• 3:57
  the
• 3:57
  easiest
• 3:57
  way
• 3:57
  to
• 3:57
  look
• 3:57
  at
• 3:58
  it.
• 3:58
  So
• 3:58
  we're
• 3:59
  not
• 3:59
  just
• 3:59
  talking
• 3:59
  about
• 3:59
  reoccurring
• 4:01
  depressive
• 4:01
  symptoms
• 4:02
  where
• 4:02
  the
• 4:02
  base
• 4:03
  of
• 4:03
  the
• 4:03
  fire
• 4:03
  is
• 4:03
  just
• 4:04
  always
• 4:04
  glowing,
• 4:04
  but
• 4:05
  we're
• 4:05
  talking
• 4:05
  about
• 4:05
  a
• 4:05
  fire
• 4:06
  that
• 4:06
  was
• 4:06
  never
• 4:06
  even
• 4:06
  really
• 4:07
  put
• 4:07
  out.
• 4:07
  Right.
• 4:08
  You're
• 4:08
  giving
• 4:08
  the
• 4:08
  patient
• 4:09
  antidepressants
• 4:10
  and
• 4:10
  the
• 4:10
  fire
• 4:10
  never
• 4:11
  really
• 4:11
  dies
• 4:11
  down.
• 4:11
  That
• 4:12
  would
• 4:12
  be
• 4:12
  the
• 4:12
  residual
• 4:12
  depressive
• 4:13
  symptoms.
• 4:13
  Those
• 4:14
  are
• 4:14
  also
• 4:14
  folks
• 4:15
  that
• 4:15
  are
• 4:15
  not
• 4:15
  really
• 4:15
  great
• 4:16
  candidates
• 4:16
  to
• 4:16
  stop
• 4:16
  their,
• 4:17
  their
• 4:17
  antidepressants
• 4:18
  right
• 4:18
  away.
• 4:19
  Okay.
• 4:19
  Because
• 4:20
  even
• 4:20
  mild
• 4:21
  lingering
• 4:21
  symptoms
• 4:22
  at
• 4:22
  a,
• 4:22
  a,
• 4:23
  a
• 4:23
  remission,
• 4:24
  remission
• 4:25
  type
• 4:26
  trajectory
• 4:26
  can
• 4:27
  predict
• 4:27
  relapse.
• 4:28
  And
• 4:28
  that's
• 4:29
  pretty
• 4:29
  scary
• 4:29
  too.
• 4:30
  So
• 4:31
  now
• 4:31
  each
• 4:31
  point
• 4:32
  increase
• 4:32
  in
• 4:32
  residual
• 4:33
  symptoms,
• 4:33
  the
• 4:33
  evidence
• 4:34
  shows,
• 4:34
  increases
• 4:35
  relapse
• 4:35
  risk
• 4:35
  by
• 4:36
  about
• 4:36
  5
• 4:36
  to
• 4:36
  7%.
• 4:37
  Now,
• 4:38
  no
• 4:38
  need
• 4:38
  to
• 4:38
  get
• 4:38
  into
• 4:38
  the
• 4:38
  nitty
• 4:39
  gritty
• 4:39
  numerically
• 4:40
  here,
• 4:40
  but
• 4:41
  the
• 4:41
  greater
• 4:41
  point
• 4:42
  is
• 4:42
  that
• 4:43
  each
• 4:43
  point
• 4:44
  in
• 4:45
  residual
• 4:45
  symptoms
• 4:46
  that
• 4:46
  you're
• 4:46
  looking
• 4:47
  at
• 4:47
  these
• 4:47
  commonly
• 4:48
  delivered
• 4:48
  scales
• 4:49
  in
• 4:49
  your
• 4:49
  clinic
• 4:50
  should,
• 4:50
  should
• 4:51
  make
• 4:51
  you
• 4:51
  think,
• 4:51
  oh,
• 4:51
  wait
• 4:51
  a
• 4:52
  minute,
• 4:52
  maybe
• 4:52
  it's
• 4:52
  not
• 4:53
  time
• 4:53
  to
• 4:53
  get
• 4:53
  off
• 4:53
  of
• 4:53
  these.
• 4:54
  Right.
• 4:54
  Think
• 4:54
  of
• 4:54
  the
• 4:54
  fire
• 4:55
  that
• 4:55
  hasn't
• 4:55
  really
• 4:56
  petered
• 4:56
  out
• 4:56
  yet.
• 4:57
  You
• 4:57
  also
• 4:57
  have
• 4:57
  to
• 4:58
  look
• 4:58
  at
• 4:58
  younger
• 4:58
  age
• 4:58
  of
• 4:59
  onset.
• 4:59
  The
• 4:59
  earlier
• 5:00
  the
• 5:00
  Onset,
• 5:00
  childhood
• 5:01
  and
• 5:01
  adolescent.
• 5:01
  It
• 5:02
  predicts
• 5:02
  a
• 5:02
  higher
• 5:02
  relapse
• 5:03
  risk.
• 5:03
  If
• 5:03
  you've
• 5:03
  had
• 5:04
  patients
• 5:04
  who
• 5:04
  have
• 5:05
  that
• 5:05
  early
• 5:05
  onset
• 5:06
  depression,
• 5:06
  look
• 5:07
  out.
• 5:07
  Right.
• 5:07
  That's
• 5:08
  a
• 5:08
  predictor
• 5:09
  that
• 5:09
  their
• 5:09
  relapse
• 5:10
  risk
• 5:10
  is
• 5:10
  inherently
• 5:11
  higher.
• 5:12
  Okay.
• 5:13
  And
• 5:13
  it
• 5:13
  is.
• 5:14
  The
• 5:14
  evidence
• 5:14
  does
• 5:14
  seem
• 5:15
  to
• 5:15
  suggest
• 5:15
  that
• 5:15
  adolescents
• 5:16
  show
• 5:16
  dramatically
• 5:17
  higher
• 5:17
  relapse
• 5:17
  rates
• 5:18
  than
• 5:18
  adults
• 5:18
  when
• 5:19
  discontinuing
• 5:19
  medication.
• 5:20
  So
• 5:20
  that's
• 5:20
  also
• 5:21
  something
• 5:21
  to
• 5:21
  consider.
• 5:22
  Make
• 5:22
  sure
• 5:22
  your
• 5:23
  depression
• 5:23
  is
• 5:24
  in
• 5:24
  full
• 5:24
  remission.
• 5:25
  Ask
• 5:26
  about
• 5:26
  how
• 5:26
  many
• 5:26
  prior
• 5:27
  episodes.
• 5:27
  Ask
• 5:27
  about
• 5:28
  the
• 5:28
  age
• 5:29
  of
• 5:29
  onset
• 5:29
  for
• 5:29
  depressive
• 5:30
  symptoms.
• 5:31
  Child
• 5:31
  maltreatment
• 5:32
  is
• 5:32
  also
• 5:32
  a
• 5:32
  strong
• 5:32
  prognostic
• 5:33
  indicator
• 5:34
  that
• 5:34
  predicts
• 5:34
  both
• 5:35
  initial
• 5:35
  depression
• 5:35
  and
• 5:36
  the
• 5:36
  recurrence
• 5:36
  risk.
• 5:37
  So
• 5:37
  understanding
• 5:37
  that
• 5:38
  good
• 5:38
  psychosocial
• 5:39
  history,
• 5:39
  the
• 5:39
  child
• 5:40
  developmental
• 5:40
  history,
• 5:41
  what
• 5:41
  was
• 5:41
  going
• 5:42
  on
• 5:42
  in
• 5:42
  the
• 5:42
  home
• 5:42
  at
• 5:42
  a
• 5:43
  young
• 5:43
  age.
• 5:43
  Right.
• 5:44
  A
• 5:44
  lot
• 5:44
  of
• 5:44
  these
• 5:44
  patients
• 5:45
  may
• 5:45
  have
• 5:45
  chronic
• 5:46
  HPA
• 5:46
  access.
• 5:47
  Dysregulation
• 5:48
  makes
• 5:48
  it
• 5:48
  a
• 5:49
  little
• 5:49
  harder
• 5:49
  for
• 5:50
  them
• 5:50
  to
• 5:51
  really
• 5:51
  deal
• 5:52
  with
• 5:52
  residual
• 5:52
  stressors
• 5:53
  in
• 5:53
  their
• 5:53
  environment.
• 5:54
  They're
• 5:54
  more
• 5:54
  prone
• 5:55
  to
• 5:55
  big
• 5:55
  upsets
• 5:56
  in
• 5:56
  their
• 5:57
  neurochemistry.
• 5:57
  Right.
• 5:58
  Again,
• 5:58
  getting
• 5:58
  back
• 5:58
  to
• 5:58
  that
• 5:59
  fire
• 5:59
  analogy,
• 5:59
  it's
• 6:00
  almost
• 6:00
  like
• 6:00
  the
• 6:00
  base
• 6:00
  of
• 6:00
  their
• 6:01
  fire
• 6:01
  is
• 6:01
  glowing
• 6:02
  and
• 6:02
  burning
• 6:02
  a
• 6:02
  little
• 6:03
  more
• 6:03
  than
• 6:03
  most
• 6:03
  people.
• 6:04
  Or
• 6:04
  maybe
• 6:04
  the
• 6:05
  types
• 6:05
  of
• 6:06
  material
• 6:06
  in
• 6:06
  that
• 6:07
  campfire
• 6:08
  is
• 6:08
  more
• 6:08
  flammable.
• 6:09
  I
• 6:09
  think
• 6:09
  that's
• 6:09
  an
• 6:09
  even
• 6:09
  better
• 6:10
  analogy
• 6:10
  to
• 6:10
  think
• 6:11
  of
• 6:11
  when
• 6:11
  we
• 6:11
  think
• 6:11
  of
• 6:11
  childhood
• 6:12
  maltreatment.
• 6:13
  Shorter
• 6:13
  times
• 6:14
  in
• 6:14
  remission.
• 6:14
  If
• 6:14
  you
• 6:14
  have
• 6:15
  a
• 6:15
  patient
• 6:15
  with
• 6:15
  fewer
• 6:16
  months
• 6:16
  in
• 6:16
  stable
• 6:17
  remission
• 6:18
  before
• 6:18
  discontinuation,
• 6:19
  that
• 6:20
  also
• 6:20
  could
• 6:20
  indicate
• 6:21
  a
• 6:21
  higher
• 6:21
  relapse
• 6:22
  rate.
• 6:22
  So
• 6:23
  that
• 6:23
  kind
• 6:23
  of
• 6:24
  matters.
• 6:24
  Right.
• 6:24
  How
• 6:24
  much
• 6:24
  out
• 6:25
  of
• 6:25
  the
• 6:25
  woods
• 6:25
  are
• 6:25
  they
• 6:25
  here?
• 6:26
  That's
• 6:26
  something
• 6:26
  to
• 6:27
  consider.
• 6:27
  Okay,
• 6:28
  so
• 6:28
  that's
• 6:28
  Pearl
• 6:28
  1.
• 6:29
  I
• 6:29
  know
• 6:29
  it's
• 6:29
  kind
• 6:29
  of
• 6:29
  dripping
• 6:30
  with
• 6:30
  pearls.
• 6:30
  Pearl
• 6:31
  1
• 6:31
  is
• 6:31
  dripping
• 6:31
  with
• 6:32
  pearls.
• 6:32
  But
• 6:32
  the
• 6:33
  big
• 6:33
  idea
• 6:33
  with
• 6:34
  Pearl
• 6:34
  1
• 6:34
  is
• 6:35
  if
• 6:35
  a
• 6:36
  patient
• 6:36
  is
• 6:36
  asking
• 6:37
  you
• 6:37
  about
• 6:37
  whether
• 6:37
  or
• 6:38
  not
• 6:38
  they
• 6:38
  can
• 6:38
  get
• 6:38
  off
• 6:38
  antidepressants,
• 6:39
  there's
• 6:39
  a
• 6:40
  lot
• 6:40
  of
• 6:40
  variables
• 6:40
  at
• 6:41
  play.
• 6:41
  Some
• 6:41
  are
• 6:41
  biographical,
• 6:42
  what
• 6:43
  their
• 6:43
  depression.
• 6:43
  Depression
• 6:44
  has
• 6:44
  looked
• 6:44
  like,
• 6:45
  how
• 6:45
  many
• 6:45
  episodes
• 6:46
  they've
• 6:46
  had,
• 6:46
  how
• 6:47
  young
• 6:47
  they
• 6:47
  were
• 6:47
  when
• 6:48
  they
• 6:48
  had
• 6:48
  it
• 6:48
  with
• 6:48
  their
• 6:48
  childhood
• 6:49
  maltreatment
• 6:50
  history
• 6:50
  looks
• 6:51
  like.
• 6:51
  Also,
• 6:51
  what
• 6:52
  symptoms
• 6:52
  are
• 6:52
  still
• 6:53
  being
• 6:53
  talked
• 6:54
  about.
• 6:54
  I
• 6:54
  would
• 6:55
  also
• 6:55
  add
• 6:55
  a
• 6:55
  little
• 6:56
  clinical
• 6:56
  sprinkle
• 6:57
  in
• 6:57
  there
• 6:57
  that
• 6:57
  I've
• 6:58
  heard
• 6:58
  and
• 6:58
  seen
• 6:58
  firsthand.
• 6:59
  But
• 7:00
  one
• 7:00
  thing,
• 7:00
  what
• 7:00
  I
• 7:00
  also
• 7:01
  like
• 7:01
  to
• 7:01
  know
• 7:01
  is
• 7:01
  how
• 7:01
  severe
• 7:02
  are
• 7:02
  these
• 7:02
  depressive
• 7:03
  episodes?
• 7:03
  Right.
• 7:04
  And
• 7:04
  I'm
• 7:04
  not
• 7:04
  sure
• 7:05
  that's
• 7:05
  really
• 7:05
  in
• 7:05
  the
• 7:05
  evidence
• 7:06
  we're
• 7:06
  looking
• 7:06
  at
• 7:06
  right
• 7:06
  now.
• 7:07
  But
• 7:07
  the
• 7:07
  severity
• 7:07
  of
• 7:08
  depressive
• 7:08
  episodes
• 7:09
  is
• 7:09
  definitely
• 7:09
  on
• 7:09
  my
• 7:10
  mind
• 7:10
  when
• 7:10
  we're
• 7:11
  talking
• 7:11
  about
• 7:11
  whether
• 7:11
  or
• 7:12
  not
• 7:12
  you
• 7:12
  can
• 7:13
  discontinue
• 7:13
  your
• 7:13
  antidepressants
• 7:14
  or
• 7:14
  you
• 7:14
  should
• 7:15
  discontinue,
• 7:15
  discontinue
• 7:16
  your
• 7:16
  antidepressants
• 7:17
  because
• 7:17
  a
• 7:17
  patient
• 7:18
  could
• 7:18
  tell
• 7:18
  you,
• 7:18
  well,
• 7:18
  you
• 7:19
  know,
• 7:19
  I've
• 7:19
  been
• 7:19
  depressed
• 7:20
  severely
• 7:21
  three
• 7:21
  or
• 7:22
  four
• 7:22
  times
• 7:22
  in
• 7:22
  my
• 7:22
  life,
• 7:23
  or
• 7:23
  maybe
• 7:23
  two
• 7:23
  times
• 7:24
  in
• 7:24
  my
• 7:24
  life,
• 7:24
  but
• 7:24
  both
• 7:24
  times
• 7:25
  I
• 7:25
  had
• 7:25
  suicidal
• 7:26
  ideations
• 7:26
  and
• 7:27
  attempts.
• 7:27
  I'll
• 7:28
  start
• 7:28
  using
• 7:28
  recreational
• 7:29
  substances
• 7:29
  more
• 7:30
  aggressively.
• 7:31
  I'm
• 7:31
  impulsive.
• 7:32
  Maybe
• 7:32
  there's
• 7:32
  mixed
• 7:32
  features
• 7:33
  there.
• 7:33
  And
• 7:34
  so
• 7:34
  you
• 7:34
  really
• 7:34
  want
• 7:34
  to
• 7:34
  figure
• 7:35
  out
• 7:35
  how
• 7:35
  debilitating
• 7:35
  and
• 7:36
  severe
• 7:36
  this
• 7:36
  is.
• 7:37
  It's
• 7:38
  more
• 7:38
  of
• 7:38
  a
• 7:38
  common
• 7:38
  sense
• 7:39
  look
• 7:39
  at
• 7:39
  this,
• 7:39
  right?
• 7:40
  Forget
• 7:40
  about
• 7:40
  all
• 7:40
  the
• 7:41
  evidence
• 7:41
  for
• 7:41
  a
• 7:41
  second,
• 7:42
  but
• 7:42
  just
• 7:42
  common
• 7:42
  sense
• 7:43
  right
• 7:43
  in
• 7:43
  front
• 7:43
  of
• 7:43
  you.
• 7:44
  You
• 7:44
  have
• 7:44
  a
• 7:44
  patient
• 7:44
  who's
• 7:45
  just
• 7:45
  severely
• 7:45
  depressed.
• 7:46
  Debilitating
• 7:47
  depression.
• 7:47
  And
• 7:48
  if
• 7:48
  that's
• 7:48
  the
• 7:48
  only
• 7:48
  two
• 7:49
  depressions
• 7:49
  that
• 7:50
  they've
• 7:50
  ever
• 7:50
  experienced
• 7:51
  without
• 7:51
  any
• 7:51
  mild
• 7:52
  depression,
• 7:53
  or
• 7:53
  it
• 7:53
  hasn't
• 7:53
  been
• 7:53
  this
• 7:54
  low
• 7:54
  grade
• 7:54
  dysthymia,
• 7:55
  but
• 7:55
  this
• 7:55
  more
• 7:55
  severe
• 7:56
  debilitating
• 7:57
  depression,
• 7:57
  maybe
• 7:58
  they're
• 7:58
  raising
• 7:58
  three
• 7:59
  kids
• 7:59
  and
• 7:59
  they
• 7:59
  have
• 7:59
  a
• 8:00
  really
• 8:01
  lots
• 8:01
  of
• 8:01
  responsibilities
• 8:02
  in
• 8:02
  their
• 8:02
  job.
• 8:03
  That's
• 8:03
  not
• 8:03
  a
• 8:03
  very
• 8:03
  good
• 8:04
  candidate
• 8:04
  if
• 8:04
  the
• 8:05
  margins
• 8:05
  are
• 8:06
  very
• 8:06
  thin
• 8:07
  there
• 8:07
  to
• 8:07
  just
• 8:08
  get
• 8:08
  rid
• 8:08
  of
• 8:08
  their
• 8:08
  antidepressants.
• 8:09
  Pearl
• 8:10
  2
• 8:11
  is,
• 8:11
  what
• 8:11
  about
• 8:12
  if
• 8:12
  Ralph
• 8:13
  is
• 8:13
  coming
• 8:13
  to
• 8:14
  you
• 8:14
  and
• 8:14
  he's
• 8:14
  really
• 8:14
  only
• 8:15
  had
• 8:15
  depression
• 8:15
  like
• 8:16
  one
• 8:16
  time
• 8:16
  in
• 8:16
  his
• 8:16
  life,
• 8:17
  hasn't
• 8:17
  been
• 8:18
  very
• 8:18
  severe,
• 8:19
  hasn't
• 8:19
  been
• 8:19
  reoccurring,
• 8:20
  not
• 8:21
  debilitating.
• 8:22
  He
• 8:22
  doesn't
• 8:22
  have
• 8:22
  that
• 8:22
  early
• 8:23
  onset
• 8:23
  depression.
• 8:24
  He
• 8:24
  doesn't
• 8:24
  have
• 8:25
  child
• 8:25
  maltreatment
• 8:25
  or
• 8:26
  like
• 8:26
  a
• 8:26
  history
• 8:26
  of
• 8:26
  significant
• 8:27
  trauma
• 8:27
  or
• 8:27
  abuse.
• 8:28
  He's
• 8:28
  just
• 8:29
  asking
• 8:29
  kind
• 8:29
  of
• 8:29
  a
• 8:29
  run
• 8:29
  of
• 8:30
  the
• 8:30
  mill
• 8:30
  question.
• 8:30
  Hey,
• 8:30
  first
• 8:31
  time
• 8:31
  depressed,
• 8:31
  but
• 8:31
  a
• 8:32
  real
• 8:32
  MDD
• 8:32
  here,
• 8:33
  and
• 8:33
  single
• 8:34
  episode,
• 8:34
  moderate,
• 8:35
  severe,
• 8:35
  whatever.
• 8:36
  And
• 8:36
  he's
• 8:37
  asking
• 8:37
  you,
• 8:37
  how
• 8:37
  long
• 8:37
  do
• 8:37
  we
• 8:38
  have
• 8:38
  to
• 8:38
  be
• 8:38
  on
• 8:38
  this?
• 8:39
  Well,
• 8:39
  the
• 8:39
  general
• 8:40
  rule,
• 8:41
  according
• 8:41
  to
• 8:41
  the
• 8:41
  evidence
• 8:42
  that
• 8:42
  we
• 8:42
  scoured,
• 8:43
  is
• 8:43
  basically
• 8:44
  six
• 8:44
  months.
• 8:45
  Okay,
• 8:45
  so
• 8:45
  now
• 8:45
  what
• 8:46
  I
• 8:46
  mean
• 8:46
  by
• 8:46
  that
• 8:46
  is
• 8:46
  you
• 8:46
  continue
• 8:47
  your
• 8:47
  SSRI
• 8:48
  for
• 8:48
  at
• 8:48
  least
• 8:48
  6
• 8:49
  months
• 8:49
  after
• 8:49
  achieving
• 8:50
  remission
• 8:51
  for
• 8:51
  a
• 8:51
  first
• 8:51
  episode
• 8:52
  of
• 8:52
  depression.
• 8:53
  So
• 8:53
  the
• 8:53
  guidelines
• 8:53
  seem
• 8:54
  to
• 8:54
  suggest
• 8:55
  that
• 8:55
  you
• 8:55
  generally
• 8:56
  continue
• 8:56
  the
• 8:56
  for
• 8:57
  at
• 8:57
  least
• 8:57
  six
• 8:57
  months
• 8:57
  after
• 8:58
  achieving
• 8:58
  remission
• 8:59
  for
• 8:59
  a
• 9:00
  first
• 9:00
  episode
• 9:00
  depression
• 9:01
  that's
• 9:01
  at
• 9:01
  least
• 9:01
  six
• 9:01
  months
• 9:02
  after.
• 9:03
  Okay,
• 9:03
  so
• 9:03
  typically
• 9:04
  that
• 9:04
  could
• 9:04
  look
• 9:04
  like
• 9:04
  nine
• 9:04
  to
• 9:05
  12
• 9:05
  months.
• 9:05
  It
• 9:05
  could
• 9:05
  be
• 9:05
  a
• 9:06
  little
• 9:06
  more,
• 9:06
  a
• 9:06
  little
• 9:06
  less.
• 9:07
  Again,
• 9:07
  every
• 9:07
  patient's
• 9:08
  a
• 9:08
  little
• 9:08
  different,
• 9:08
  Right.
• 9:08
  These
• 9:09
  are
• 9:09
  simply
• 9:09
  guidelines
• 9:10
  that
• 9:10
  give
• 9:11
  you
• 9:11
  a
• 9:11
  conceptual
• 9:11
  appreciation
• 9:12
  for
• 9:12
  how
• 9:13
  to
• 9:13
  proceed.
• 9:13
  But
• 9:14
  that
• 9:14
  means
• 9:14
  six
• 9:14
  months
• 9:15
  after
• 9:15
  remission,
• 9:17
  okay.
• 9:17
  And
• 9:17
  at
• 9:18
  least
• 9:18
  two
• 9:18
  years
• 9:18
  for
• 9:19
  patients
• 9:19
  with
• 9:19
  reoccurring
• 9:20
  episodes
• 9:21
  or
• 9:21
  high
• 9:21
  risk
• 9:22
  features.
• 9:22
  So
• 9:22
  for
• 9:23
  the
• 9:23
  folks
• 9:23
  that
• 9:23
  were
• 9:23
  a
• 9:24
  little
• 9:24
  more
• 9:24
  had
• 9:25
  that
• 9:25
  checkered
• 9:25
  history,
• 9:26
  two
• 9:26
  years
• 9:26
  after
• 9:27
  full
• 9:27
  remission
• 9:28
  is
• 9:28
  really
• 9:28
  what
• 9:28
  the
• 9:29
  guidelines
• 9:29
  suggest.
• 10:24
  And
• 10:24
  remember,
• 10:25
  the
• 10:25
  guidelines
• 10:25
  Also
• 10:25
  suggest
• 10:27
  that
• 10:27
  if
• 10:27
  you've
• 10:27
  had
• 10:27
  three
• 10:27
  or
• 10:28
  more,
• 9:34
  this
• 10:29
  could
• 10:29
  look
• 10:29
  like
• 10:29
  indefinite
• 10:30
  treatment
• 10:30
  with
• 10:30
  SSRIs
• 10:31
  as
• 10:32
  a
• 10:32
  regular
• 10:32
  form
• 10:33
  of
• 10:33
  maintenance.
• 10:33
  Again,
• 10:33
  every
• 10:34
  patient's
• 10:34
  different,
• 10:34
  but
• 10:34
  this
• 10:35
  gives
• 10:35
  you
• 10:35
  an
• 10:35
  appreciation
• 10:36
  for
• 10:36
  the
• 10:36
  fact
• 10:36
  that
• 10:37
  you
• 10:37
  really
• 10:37
  want
• 10:37
  to
• 10:37
  quantify
• 10:38
  the
• 10:38
  number
• 10:38
  of
• 10:39
  episodes.
• 10:40
  And
• 10:40
  so
• 10:40
  you
• 10:40
  get
• 10:40
  to
• 10:41
  full
• 10:41
  remission.
• 10:42
  And
• 10:42
  what
• 10:42
  is
• 10:42
  full
• 10:43
  remission?
• 10:43
  Well,
• 10:43
  there's
• 10:43
  not
• 10:44
  this
• 10:44
  clean
• 10:44
  operational
• 10:45
  definition
• 10:45
  of
• 10:46
  full
• 10:46
  remission
• 10:46
  that
• 10:47
  everybody
• 10:47
  agrees
• 10:48
  with.
• 10:48
  Okay,
• 10:48
  so
• 10:48
  I
• 10:48
  won't
• 10:49
  go
• 10:49
  into
• 10:49
  the
• 10:49
  weeds
• 10:50
  on
• 10:50
  what
• 10:51
  certain
• 10:51
  guidelines
• 10:52
  say.
• 10:53
  The
• 10:53
  DSM
• 10:53
  5
• 10:53
  tends
• 10:54
  to
• 10:54
  give
• 10:54
  clinicians
• 10:55
  more
• 10:55
  discretion
• 10:56
  into
• 10:57
  what
• 10:57
  full
• 10:57
  remission
• 10:58
  really
• 10:58
  looks
• 10:58
  like.
• 10:58
  It's
• 10:59
  generally
• 10:59
  understood
• 11:00
  to
• 11:00
  mean
• 11:00
  a
• 11:00
  complete
• 11:00
  absence
• 11:01
  of
• 11:01
  significant
• 11:02
  symptoms
• 11:02
  of
• 11:02
  major
• 11:02
  depression.
• 11:03
  So
• 11:03
  they're
• 11:04
  not
• 11:04
  really
• 11:04
  meeting
• 11:04
  criteria
• 11:05
  for
• 11:05
  MDD
• 11:06
  as
• 11:06
  opposed
• 11:07
  to
• 11:07
  partial
• 11:07
  remission,
• 11:08
  which
• 11:08
  really
• 11:09
  indicates
• 11:09
  that
• 11:09
  some
• 11:09
  symptoms
• 11:10
  remain
• 11:10
  present,
• 11:10
  but
• 11:11
  the
• 11:11
  full
• 11:11
  diagnostic
• 11:12
  criteria
• 11:12
  are
• 11:12
  not
• 11:12
  met.
• 11:13
  Right.
• 11:14
  So
• 11:14
  a
• 11:14
  patient
• 11:15
  in
• 11:15
  full
• 11:15
  remission
• 11:15
  would
• 11:16
  not
• 11:16
  be
• 11:16
  endorsing
• 11:17
  pervasive
• 11:17
  sadness
• 11:18
  or
• 11:18
  anhedonia
• 11:19
  or
• 11:19
  major
• 11:19
  sleep
• 11:20
  and
• 11:20
  appetite
• 11:20
  fluctuations
• 11:21
  related
• 11:21
  to
• 11:22
  abnormal
• 11:22
  mood
• 11:22
  states.
• 11:23
  Right.
• 11:23
  So
• 11:23
  when
• 11:23
  we're
• 11:24
  talking
• 11:24
  about
• 11:24
  full
• 11:24
  remission,
• 11:25
  again,
• 11:25
  first
• 11:26
  episode
• 11:26
  depression,
• 11:27
  get
• 11:27
  it
• 11:27
  to
• 11:28
  remission,
• 11:28
  and
• 11:29
  then
• 11:29
  six
• 11:29
  months
• 11:30
  of
• 11:31
  treatment
• 11:31
  thereafter
• 11:32
  is
• 11:32
  generally
• 11:32
  what
• 11:32
  the
• 11:32
  guidelines
• 11:33
  look
• 11:33
  like.
• 11:33
  If
• 11:34
  we're
• 11:34
  talking
• 11:34
  about
• 11:35
  folks
• 11:35
  with
• 11:36
  recurring
• 11:37
  or
• 11:37
  high
• 11:37
  risk
• 11:37
  features
• 11:38
  of
• 11:38
  depression,
• 11:39
  that's
• 11:39
  two
• 11:39
  years
• 11:39
  after
• 11:40
  remission
• 11:40
  and
• 11:41
  get
• 11:41
  an
• 11:41
  understanding
• 11:41
  of
• 11:42
  what
• 11:42
  that
• 11:42
  looks
• 11:42
  like.
• 11:42
  That's
• 11:43
  really
• 11:43
  gonna
• 11:43
  help
• 11:43
  you
• 11:43
  out.
• 11:44
  And
• 11:44
  again,
• 11:44
  this
• 11:44
  kind
• 11:45
  of
• 11:45
  comes
• 11:45
  back
• 11:45
  to
• 11:45
  that
• 11:45
  fire
• 11:46
  analogy
• 11:46
  a
• 11:46
  little
• 11:47
  bit.
• 11:47
  Right.
• 11:48
  Where
• 11:48
  we
• 11:49
  want
• 11:49
  to
• 11:49
  fully
• 11:50
  extinguish
• 11:50
  this.
• 11:50
  It's
• 11:51
  not
• 11:51
  enough
• 11:51
  to
• 11:51
  just
• 11:51
  get
• 11:52
  the
• 11:52
  fire
• 11:52
  out.
• 11:52
  Right.
• 11:53
  Like
• 11:53
  the
• 11:53
  fire
• 11:53
  is
• 11:53
  not
• 11:54
  burning
• 11:54
  anymore.
• 11:54
  Okay,
• 11:55
  but
• 11:55
  we're
• 11:55
  not
• 11:55
  really
• 11:55
  out
• 11:55
  of
• 11:56
  the
• 11:56
  woods
• 11:56
  per
• 11:56
  se.
• 11:57
  Right.
• 11:57
  We
• 11:57
  want
• 11:57
  six
• 11:58
  months
• 11:58
  after
• 11:59
  we
• 11:59
  don't
• 11:59
  see
• 12:00
  any
• 12:00
  embers
• 12:00
  or
• 12:00
  flames.
• 12:01
  Right.
• 12:02
  And
• 12:02
  any
• 12:02
  smoke.
• 12:03
  We
• 12:03
  want
• 12:03
  to
• 12:03
  make
• 12:04
  sure
• 12:04
  for
• 12:04
  six
• 12:04
  months
• 12:05
  that
• 12:05
  buckets
• 12:06
  of
• 12:06
  water
• 12:06
  are
• 12:07
  being
• 12:07
  dumped
• 12:07
  on
• 12:07
  that
• 12:08
  fire
• 12:08
  and
• 12:08
  that
• 12:08
  fire
• 12:08
  is
• 12:09
  out.
• 12:09
  Right.
• 12:10
  That's
• 12:10
  when
• 12:10
  we're
• 12:10
  really
• 12:10
  out
• 12:11
  of
• 12:11
  the
• 12:11
  woods.
• 12:12
  And
• 12:12
  so
• 12:12
  it's
• 12:13
  very
• 12:13
  important
• 12:14
  that
• 12:14
  we
• 12:14
  remember
• 12:15
  that.
• 12:15
  So
• 12:16
  the
• 12:16
  six
• 12:16
  month
• 12:16
  rule
• 12:17
  for
• 12:17
  the
• 12:17
  Ralph
• 12:17
  who's
• 12:18
  coming
• 12:18
  to
• 12:18
  you
• 12:18
  for
• 12:18
  the
• 12:18
  first
• 12:18
  time,
• 12:19
  one
• 12:19
  depression.
• 12:20
  And
• 12:20
  maybe
• 12:20
  a
• 12:20
  two
• 12:21
  year
• 12:21
  rule
• 12:22
  for
• 12:22
  folks
• 12:22
  who
• 12:23
  are
• 12:23
  kind
• 12:23
  of
• 12:23
  high
• 12:23
  risk
• 12:23
  and
• 12:24
  reoccurring.
• 12:24
  Okay,
• 12:25
  now
• 12:25
  remember,
• 12:26
  without
• 12:26
  continued
• 12:27
  treatment,
• 12:27
  the
• 12:27
  evidence
• 12:28
  suggests
• 12:28
  that
• 12:28
  41%
• 12:29
  of
• 12:29
  patients
• 12:30
  relapse
• 12:31
  within
• 12:31
  six
• 12:31
  months
• 12:32
  after
• 12:32
  stopping
• 12:32
  antidepressants.
• 12:34
  Now,
• 12:34
  continuation
• 12:34
  treatment
• 12:35
  reduces
• 12:36
  that
• 12:36
  relapse
• 12:36
  rate
• 12:37
  by
• 12:37
  approximately
• 12:37
  70%
• 12:38
  compared
• 12:39
  to
• 12:39
  placebo.
• 12:40
  Is.
• 12:40
  That's
• 12:40
  a
• 12:40
  pretty
• 12:40
  big
• 12:41
  deal,
• 12:41
  right?
• 12:42
  70%
• 12:42
  compared
• 12:43
  to
• 12:43
  placebo.
• 12:44
  So
• 12:44
  keep
• 12:45
  that
• 12:45
  in
• 12:45
  mind.
• 12:45
  41%
• 12:46
  of
• 12:46
  patients
• 12:47
  will
• 12:47
  relapse
• 12:47
  within
• 12:48
  six
• 12:48
  months
• 12:49
  after
• 12:50
  stopping
• 12:51
  antidepressants.
• 12:52
  Okay?
• 12:52
  And
• 12:52
  just
• 12:53
  by
• 12:53
  continuing
• 12:53
  treatment,
• 12:54
  you
• 12:55
  can
• 12:55
  go
• 12:55
  ahead
• 12:55
  and
• 12:55
  reduce
• 12:56
  that
• 12:56
  by
• 12:56
  up
• 12:56
  to
• 12:57
  70%
• 12:57
  compared
• 12:58
  to
• 12:58
  placebo.
• 12:59
  Okay?
• 13:00
  And
• 13:00
  with
• 13:00
  SSRI,
• 13:01
  it
• 13:01
  translates
• 13:02
  into
• 13:02
  about
• 13:02
  a
• 13:02
  21%
• 13:03
  absolute
• 13:04
  risk
• 13:04
  reduction.
• 13:05
  Okay?
• 13:05
  Pick
• 13:06
  which
• 13:06
  ones
• 13:06
  you
• 13:06
  like.
• 13:07
  But
• 13:07
  the
• 13:07
  number
• 13:08
  needed
• 13:08
  to
• 13:08
  treat
• 13:08
  is
• 13:09
  3,
• 13:09
  6.
• 13:09
  And
• 13:09
  what
• 13:10
  that
• 13:10
  really
• 13:10
  means
• 13:10
  is
• 13:11
  for
• 13:11
  every
• 13:11
  three
• 13:11
  to
• 13:12
  four
• 13:12
  patients
• 13:12
  who
• 13:12
  continue
• 13:13
  treatment,
• 13:13
  one
• 13:14
  relapse
• 13:14
  is
• 13:15
  essentially
• 13:15
  prevented
• 13:16
  just
• 13:16
  by
• 13:16
  continuing
• 13:17
  those
• 13:17
  antidepressants.
• 13:18
  Again,
• 13:18
  for
• 13:19
  every
• 13:19
  three
• 13:19
  to
• 13:19
  four
• 13:19
  patients
• 13:20
  in
• 13:20
  your
• 13:20
  outpatient
• 13:20
  practice,
• 13:22
  one
• 13:22
  relapse
• 13:23
  would
• 13:23
  be
• 13:23
  prevented
• 13:23
  entirely,
• 13:24
  which
• 13:25
  is
• 13:25
  a
• 13:25
  pretty
• 13:25
  big
• 13:25
  number,
• 13:26
  Right?
• 13:26
  That's
• 13:26
  a
• 13:26
  fourth
• 13:27
  of
• 13:27
  your
• 13:27
  panel
• 13:28
  who
• 13:28
  has
• 13:28
  depression
• 13:29
  just
• 13:29
  by
• 13:30
  continuing
• 13:30
  treatment.
• 13:31
  Okay?
• 13:32
  And
• 13:32
  that
• 13:32
  would
• 13:32
  reduce
• 13:33
  those
• 13:33
  relapse
• 13:34
  rates
• 13:34
  by
• 13:34
  70%
• 13:35
  compared
• 13:35
  to
• 13:35
  placebo.
• 13:36
  Pretty
• 13:36
  big
• 13:37
  deal,
• 13:37
  right?
• 13:37
  So
• 13:37
  this
• 13:37
  is
• 13:38
  not
• 13:38
  an
• 13:38
  arbitrary
• 13:39
  number.
• 13:39
  The
• 13:39
  six
• 13:40
  month
• 13:40
  continuation
• 13:40
  phase
• 13:41
  after
• 13:41
  remission.
• 13:42
  It's
• 13:42
  a
• 13:42
  minimum
• 13:43
  duration
• 13:43
  to
• 13:43
  consolidate
• 13:44
  remission
• 13:45
  and
• 13:45
  allow
• 13:45
  the
• 13:46
  neurobiological
• 13:47
  changes.
• 13:48
  Okay?
• 13:49
  Now
• 13:50
  this
• 13:50
  is
• 13:50
  the
• 13:50
  third
• 13:51
  pearl.
• 13:51
  And
• 13:52
  that
• 13:52
  really
• 13:52
  ties
• 13:53
  into
• 13:53
  our
• 13:53
  third
• 13:53
  pearl,
• 13:54
  that
• 13:54
  last
• 13:55
  sentence
• 13:55
  I
• 13:55
  shared
• 13:56
  when
• 13:56
  we
• 13:56
  talk
• 13:56
  about
• 13:57
  neurobiological
• 13:58
  changes,
• 13:58
  Right.
• 13:59
  It's
• 13:59
  really
• 13:59
  important,
• 14:00
  this
• 14:00
  is
• 14:00
  Pearl
• 14:00
  3,
• 14:01
  to
• 14:01
  remember
• 14:01
  that
• 14:01
  SSRIs
• 14:02
  do
• 14:02
  not
• 14:02
  just
• 14:02
  increase
• 14:03
  serotonin,
• 14:04
  right?
• 14:04
  But
• 14:05
  they're
• 14:05
  actually
• 14:06
  triggering
• 14:07
  a
• 14:07
  cascade
• 14:08
  of
• 14:08
  beautiful
• 14:08
  brain
• 14:09
  changes
• 14:09
  that
• 14:10
  allow
• 14:10
  new
• 14:10
  neural
• 14:11
  networks
• 14:11
  to
• 14:11
  reorganize
• 14:12
  and
• 14:12
  adapt.
• 14:13
  Okay?
• 14:13
  And
• 14:13
  now
• 14:14
  we're
• 14:14
  going
• 14:14
  to
• 14:14
  move
• 14:14
  away
• 14:14
  from
• 14:15
  the
• 14:15
  fire
• 14:15
  analogy
• 14:16
  for
• 14:16
  a
• 14:16
  moment
• 14:16
  and
• 14:16
  we're
• 14:16
  going
• 14:17
  to
• 14:17
  go
• 14:17
  to
• 14:17
  the
• 14:17
  snow
• 14:17
  analogy.
• 14:18
  Now,
• 14:18
  I
• 14:18
  want
• 14:19
  you
• 14:19
  all
• 14:19
  to
• 14:19
  think
• 14:19
  of
• 14:19
  depression
• 14:20
  as
• 14:20
  a
• 14:20
  deeply
• 14:21
  entrenched
• 14:21
  ski
• 14:21
  trail,
• 14:22
  okay?
• 14:23
  It's
• 14:23
  carved
• 14:23
  into
• 14:23
  the
• 14:23
  mountainside
• 14:24
  over
• 14:24
  years,
• 14:25
  okay?
• 14:25
  And
• 14:25
  these
• 14:26
  kind
• 14:26
  of
• 14:26
  represent
• 14:26
  maladaptive
• 14:27
  neural
• 14:28
  pathways,
• 14:28
  right?
• 14:29
  You're
• 14:29
  very
• 14:29
  quick
• 14:29
  to
• 14:29
  fight
• 14:30
  or
• 14:30
  flight.
• 14:30
  You're
• 14:31
  very
• 14:31
  quick
• 14:31
  to
• 14:31
  ruminate
• 14:32
  or
• 14:32
  be
• 14:32
  rigid
• 14:32
  or
• 14:32
  feel
• 14:33
  down,
• 14:33
  right?
• 14:33
  Those
• 14:34
  are
• 14:34
  those
• 14:34
  ski
• 14:35
  trails
• 14:35
  carved
• 14:35
  in
• 14:35
  the
• 14:35
  mountain
• 14:36
  over
• 14:36
  years
• 14:37
  from
• 14:37
  trauma,
• 14:38
  from
• 14:38
  maybe
• 14:39
  a
• 14:39
  genetic
• 14:39
  predisposition.
• 14:40
  And
• 14:40
  you
• 14:41
  have
• 14:41
  these
• 14:41
  hardened
• 14:42
  ski
• 14:42
  trails
• 14:42
  in
• 14:43
  the
• 14:43
  mountain
• 14:43
  that
• 14:44
  your
• 14:44
  brain
• 14:44
  is
• 14:44
  so
• 14:44
  used
• 14:45
  to
• 14:45
  going
• 14:45
  down
• 14:45
  those
• 14:45
  trails.
• 14:46
  Now,
• 14:46
  the
• 14:46
  SSRIs
• 14:47
  are
• 14:48
  more
• 14:48
  than
• 14:48
  just
• 14:49
  keeping
• 14:49
  more
• 14:50
  serotonin
• 14:50
  in
• 14:50
  the
• 14:50
  synapse
• 14:51
  and
• 14:51
  stopping
• 14:52
  the
• 14:52
  recycling
• 14:53
  of
• 14:53
  that
• 14:53
  serotonin
• 14:54
  by
• 14:54
  the
• 14:54
  transporters.
• 14:55
  It's
• 14:55
  more
• 14:56
  than
• 14:56
  that,
• 14:56
  right?
• 14:56
  SSRIs
• 14:57
  kind
• 14:58
  of
• 14:58
  act
• 14:58
  like
• 14:58
  a
• 14:58
  fresh
• 14:58
  snowfall,
• 14:59
  okay?
• 15:00
  And
• 15:00
  it
• 15:00
  covers
• 15:00
  those
• 15:01
  old
• 15:01
  trails,
• 15:02
  carved
• 15:02
  out
• 15:02
  ski
• 15:03
  trails.
• 15:03
  So
• 15:03
  it's
• 15:04
  nice.
• 15:04
  It's
• 15:04
  kind
• 15:04
  of
• 15:04
  a
• 15:04
  clean
• 15:05
  slate,
• 15:05
  okay?
• 15:06
  And
• 15:06
  it
• 15:06
  kind
• 15:06
  of
• 15:06
  allows
• 15:07
  the
• 15:07
  brain,
• 15:07
  by
• 15:08
  extension,
• 15:08
  to
• 15:08
  then
• 15:08
  carve
• 15:09
  new,
• 15:09
  healthier
• 15:10
  roots
• 15:10
  throughout
• 15:10
  the
• 15:10
  mountain.
• 15:11
  New
• 15:11
  paths
• 15:12
  entirely.
• 15:13
  Right?
• 15:13
  But
• 15:13
  the
• 15:13
  problem
• 15:14
  is
• 15:14
  you
• 15:14
  don't
• 15:15
  want
• 15:15
  to
• 15:15
  stop
• 15:15
  SSRIs
• 15:16
  too
• 15:16
  soon.
• 15:16
  Because
• 15:17
  that
• 15:17
  fresh
• 15:17
  snow,
• 15:18
  snowfall,
• 15:19
  it
• 15:19
  needs
• 15:20
  time.
• 15:20
  When
• 15:21
  the
• 15:21
  brain
• 15:21
  is
• 15:21
  being
• 15:21
  reorganized
• 15:22
  like
• 15:22
  this
• 15:23
  and
• 15:23
  neural
• 15:23
  networks
• 15:24
  are
• 15:24
  being
• 15:24
  changed
• 15:24
  and
• 15:24
  challenged,
• 15:25
  you
• 15:25
  really
• 15:26
  want
• 15:26
  that
• 15:26
  time
• 15:27
  to
• 15:28
  reorganize
• 15:28
  and
• 15:29
  lay
• 15:29
  down
• 15:29
  those
• 15:29
  new
• 15:30
  trails.
• 15:30
  The
• 15:30
  old
• 15:30
  trails
• 15:31
  took
• 15:31
  years
• 15:32
  to
• 15:32
  kind
• 15:32
  of
• 15:32
  stubbornly
• 15:33
  cement
• 15:33
  themselves
• 15:34
  in
• 15:34
  your
• 15:34
  brain
• 15:34
  and
• 15:35
  lead
• 15:35
  you
• 15:35
  to
• 15:35
  anxiety
• 15:36
  and
• 15:36
  rigidity
• 15:36
  and
• 15:36
  trauma
• 15:37
  pathways.
• 15:38
  So
• 15:38
  this
• 15:38
  new
• 15:38
  SSRI
• 15:39
  treatment,
• 15:40
  right,
• 15:40
  it's
• 15:40
  coming
• 15:40
  into
• 15:41
  your
• 15:41
  system
• 15:41
  and
• 15:41
  it's
• 15:41
  like
• 15:42
  a
• 15:42
  fresh
• 15:42
  snow,
• 15:42
  and
• 15:42
  you
• 15:42
  go,
• 15:42
  oh,
• 15:43
  wow.
• 15:43
  All
• 15:43
  those
• 15:44
  ingrained
• 15:45
  paths
• 15:45
  are
• 15:45
  not
• 15:45
  as
• 15:46
  ingrained
• 15:46
  anymore.
• 15:47
  However,
• 15:48
  you're
• 15:48
  not
• 15:48
  out
• 15:48
  of
• 15:48
  the
• 15:49
  woods
• 15:49
  just
• 15:49
  yet,
• 15:49
  right?
• 15:49
  If
• 15:50
  you
• 15:50
  stop
• 15:50
  the
• 15:50
  antidepressant
• 15:51
  too
• 15:51
  soon,
• 15:51
  it's
• 15:51
  almost
• 15:52
  like
• 15:52
  that
• 15:52
  snow
• 15:52
  melts.
• 15:53
  And
• 15:53
  lo
• 15:53
  and
• 15:53
  behold,
• 15:54
  there
• 15:54
  you
• 15:54
  go
• 15:54
  again.
• 15:54
  You
• 15:55
  have
• 15:55
  those
• 15:55
  deeply
• 15:55
  entrenched
• 15:56
  ski
• 15:56
  trails
• 15:57
  that
• 15:57
  are
• 15:57
  still
• 15:58
  carved
• 15:58
  out
• 15:58
  because
• 15:58
  they're
• 15:59
  so
• 15:59
  dominant
• 15:59
  for
• 15:59
  so
• 15:59
  many
• 16:00
  years,
• 16:00
  okay?
• 16:01
  And
• 16:01
  so
• 16:02
  that's
• 16:02
  why
• 16:03
  we
• 16:03
  look
• 16:03
  at
• 16:03
  the
• 16:03
  SSRIs,
• 16:04
  kind
• 16:04
  of
• 16:04
  like
• 16:04
  a
• 16:04
  fresh
• 16:05
  snow
• 16:05
  and
• 16:05
  why
• 16:06
  we
• 16:06
  don't
• 16:06
  get
• 16:06
  rid
• 16:06
  of
• 16:06
  them.
• 16:07
  Because
• 16:07
  then
• 16:07
  those
• 16:07
  old
• 16:07
  pathways
• 16:08
  reassert
• 16:09
  themselves,
• 16:09
  okay?
• 16:10
  And
• 16:10
  remember,
• 16:10
  with
• 16:10
  SSRIs,
• 16:11
  more
• 16:11
  and
• 16:11
  more
• 16:12
  evidence
• 16:12
  is
• 16:12
  suggesting
• 16:13
  that
• 16:13
  they
• 16:13
  increase
• 16:14
  neurogenesis
• 16:15
  in
• 16:15
  the
• 16:15
  hippocampus,
• 16:16
  right?
• 16:16
  So
• 16:16
  you
• 16:16
  have
• 16:16
  the
• 16:16
  birth
• 16:16
  of
• 16:17
  these
• 16:17
  new
• 16:17
  neurons
• 16:18
  in
• 16:18
  the
• 16:18
  hippocampus,
• 16:19
  these
• 16:20
  new
• 16:20
  memory
• 16:21
  and
• 16:21
  learning
• 16:21
  pathways
• 16:22
  to
• 16:22
  contextualize
• 16:23
  old
• 16:24
  traumas
• 16:24
  that
• 16:24
  can
• 16:24
  really
• 16:25
  change
• 16:25
  the
• 16:26
  way
• 16:26
  we
• 16:26
  even
• 16:26
  relate
• 16:27
  to
• 16:27
  those
• 16:27
  traumas.
• 16:28
  There's
• 16:28
  enhanced
• 16:28
  bdnf,
• 16:29
  that
• 16:29
  brain
• 16:30
  derived
• 16:30
  neurotropic
• 16:31
  factor,
• 16:31
  right?
• 16:31
  That
• 16:32
  molecule
• 16:32
  that's
• 16:33
  responsible
• 16:34
  for
• 16:34
  promoting
• 16:35
  new
• 16:35
  connections
• 16:35
  and
• 16:36
  synaptic
• 16:36
  growth.
• 16:37
  It's
• 16:38
  said
• 16:38
  that
• 16:38
  mature
• 16:38
  neurons
• 16:39
  start
• 16:39
  to
• 16:39
  revert
• 16:40
  to,
• 16:40
  like,
• 16:40
  a
• 16:40
  more
• 16:40
  flexible,
• 16:41
  juvenile,
• 16:41
  like
• 16:42
  state
• 16:42
  with
• 16:42
  ssri.
• 16:43
  So
• 16:43
  your
• 16:43
  brain's
• 16:44
  becoming
• 16:44
  more
• 16:44
  flexible.
• 16:45
  It's
• 16:45
  able
• 16:46
  to
• 16:46
  meet,
• 16:47
  potentially
• 16:48
  create
• 16:48
  new
• 16:48
  pathways.
• 16:49
  Really
• 16:50
  exciting
• 16:50
  stuff
• 16:50
  here.
• 16:51
  And
• 16:51
  why
• 16:51
  would
• 16:51
  we
• 16:52
  want
• 16:52
  that
• 16:52
  to
• 16:52
  be
• 16:52
  interrupted
• 16:53
  too
• 16:53
  soon,
• 16:54
  right?
• 16:54
  We
• 16:54
  would
• 16:54
  not
• 16:54
  want
• 16:55
  that.
• 16:55
  We
• 16:55
  want
• 16:55
  that
• 16:56
  snow
• 16:56
  to
• 16:56
  fall.
• 16:57
  We
• 16:57
  want
• 16:57
  to
• 16:57
  be
• 16:57
  able
• 16:57
  to
• 16:58
  carve
• 16:58
  out
• 16:58
  new
• 16:58
  paths
• 16:59
  in
• 16:59
  the
• 16:59
  way
• 16:59
  we
• 16:59
  relate
• 16:59
  to
• 17:00
  the
• 17:00
  world.
• 17:00
  Whether
• 17:01
  we
• 17:01
  do
• 17:01
  that
• 17:01
  on
• 17:01
  our
• 17:01
  own,
• 17:02
  whether
• 17:02
  we
• 17:02
  do
• 17:02
  that
• 17:02
  with
• 17:02
  the
• 17:03
  assistance
• 17:03
  of
• 17:03
  psychotherapy,
• 17:04
  we
• 17:04
  want
• 17:05
  to
• 17:05
  cement
• 17:06
  those
• 17:06
  new
• 17:07
  pathways
• 17:08
  into
• 17:08
  our
• 17:08
  brain.
• 17:09
  We
• 17:09
  want
• 17:09
  to
• 17:09
  create
• 17:09
  the
• 17:10
  new
• 17:10
  ski
• 17:10
  trails
• 17:11
  override
• 17:11
  the
• 17:11
  old
• 17:12
  ones.
• 17:12
  And.
• 17:12
  And
• 17:12
  so
• 17:13
  now
• 17:13
  you
• 17:13
  hopefully
• 17:14
  have
• 17:14
  a
• 17:14
  good
• 17:14
  appreciation
• 17:15
  for
• 17:15
  why
• 17:15
  we
• 17:16
  don't
• 17:16
  discontinue
• 17:17
  these
• 17:17
  too
• 17:18
  soon,
• 17:18
  right?
• 17:19
  Because
• 17:19
  when
• 17:19
  we
• 17:19
  do
• 17:20
  that,
• 17:20
  the
• 17:20
  snow
• 17:21
  melts
• 17:21
  and
• 17:22
  those
• 17:22
  entrenched
• 17:22
  trails
• 17:23
  are
• 17:24
  surfacing
• 17:24
  again.
• 17:25
  And,
• 17:25
  you
• 17:25
  know,
• 17:26
  to
• 17:26
  me,
• 17:26
  this
• 17:26
  was
• 17:26
  a
• 17:26
  very
• 17:26
  valuable
• 17:27
  discovery.
• 17:28
  It's
• 17:28
  not
• 17:28
  enough
• 17:29
  to
• 17:29
  just
• 17:29
  prescribe
• 17:30
  Lexapro
• 17:30
  or
• 17:31
  Prozac.
• 17:31
  Or
• 17:31
  Zoloft
• 17:32
  and
• 17:32
  cross
• 17:32
  your
• 17:33
  fingers
• 17:33
  and
• 17:33
  say
• 17:33
  a
• 17:33
  prayer
• 17:34
  and
• 17:34
  tell
• 17:34
  the
• 17:35
  patient
• 17:35
  that
• 17:35
  this
• 17:35
  is
• 17:35
  a
• 17:35
  first
• 17:36
  line
• 17:36
  medication
• 17:36
  for
• 17:37
  depression
• 17:37
  or
• 17:37
  anxiety
• 17:38
  or
• 17:38
  trauma.
• 17:39
  It's
• 17:39
  much
• 17:39
  better
• 17:39
  to
• 17:39
  have
• 17:39
  this
• 17:40
  fleshed
• 17:40
  out
• 17:40
  appreciation
• 17:41
  for
• 17:41
  what
• 17:41
  is
• 17:41
  actually
• 17:42
  happening,
• 17:43
  why
• 17:43
  it
• 17:43
  needs
• 17:43
  to
• 17:43
  happen
• 17:44
  for
• 17:44
  a
• 17:44
  given
• 17:44
  amount
• 17:44
  of
• 17:45
  time,
• 17:45
  and
• 17:45
  what
• 17:46
  could
• 17:46
  happen
• 17:46
  if
• 17:46
  it's
• 17:46
  discontinued
• 17:47
  too
• 17:47
  quickly.
• 17:48
  Right.
• 17:49
  And
• 17:50
  so
• 17:50
  I
• 17:50
  just
• 17:50
  love
• 17:51
  all
• 17:51
  of
• 17:51
  these
• 17:51
  pearls
• 17:52
  kind
• 17:52
  of
• 17:52
  coming
• 17:52
  together
• 17:52
  here
• 17:53
  to
• 17:53
  give
• 17:53
  us
• 17:53
  that
• 17:53
  appreciation
• 17:54
  for
• 17:55
  what
• 17:55
  SSRIs
• 17:56
  do
• 17:56
  and
• 17:56
  why.
• 17:56
  And
• 17:57
  then
• 17:57
  it
• 17:57
  helps
• 17:57
  guide
• 17:58
  our
• 17:58
  treatment
• 17:58
  a
• 17:58
  little
• 17:58
  more.
• 17:59
  I
• 17:59
  don't
• 17:59
  expect
• 17:59
  any
• 18:00
  of
• 18:00
  you
• 18:00
  guys
• 18:00
  to
• 18:00
  remember
• 18:01
  all
• 18:01
  of
• 18:01
  the
• 18:01
  nitty
• 18:01
  gritty
• 18:02
  statistics.
• 18:03
  I
• 18:03
  think
• 18:03
  in
• 18:03
  psychiatry
• 18:04
  it's
• 18:04
  even
• 18:04
  more
• 18:04
  valuable
• 18:05
  to
• 18:05
  just
• 18:05
  have
• 18:05
  an
• 18:06
  understanding
• 18:06
  and
• 18:06
  appreciation
• 18:07
  of
• 18:07
  for
• 18:07
  what
• 18:08
  this
• 18:08
  all
• 18:08
  kind
• 18:08
  of
• 18:09
  means,
• 18:09
  right?
• 18:10
  For
• 18:10
  why
• 18:11
  it
• 18:11
  takes
• 18:12
  time
• 18:12
  for
• 18:13
  SSRIs
• 18:13
  to
• 18:14
  work
• 18:14
  and
• 18:14
  why
• 18:14
  it
• 18:15
  takes
• 18:15
  time
• 18:16
  for
• 18:16
  us
• 18:17
  to
• 18:17
  really
• 18:17
  leverage
• 18:18
  its
• 18:18
  benefits
• 18:19
  and
• 18:20
  why
• 18:20
  we
• 18:20
  don't
• 18:20
  want
• 18:21
  to
• 18:21
  just
• 18:21
  nitty
• 18:21
  gritty
• 18:22
  discontinue
• 18:23
  something.
• 18:24
  We
• 18:24
  really
• 18:24
  want
• 18:25
  the
• 18:25
  brain
• 18:25
  to
• 18:25
  be
• 18:26
  able
• 18:26
  to
• 18:26
  adapt
• 18:26
  to
• 18:26
  any
• 18:27
  sudden
• 18:27
  changes
• 18:28
  that
• 18:28
  we
• 18:29
  enact
• 18:30
  with
• 18:30
  our
• 18:30
  medications.
• 18:32
  I
• 18:32
  hope
• 18:32
  this
• 18:32
  was
• 18:32
  very
• 18:33
  valuable
• 18:33
  to
• 18:34
  all
• 18:34
  of
• 18:34
  you.
• 18:34
  Keep
• 18:35
  these
• 18:35
  three
• 18:35
  pearls
• 18:36
  close
• 18:36
  to
• 18:36
  you
• 18:36
  and
• 18:37
  don't
• 18:37
  forget,
• 18:37
  become
• 18:37
  Patreon
• 18:38
  members.
• 18:38
  We
• 18:38
  have
• 18:39
  tons
• 18:39
  of
• 18:40
  really
• 18:40
  good
• 18:40
  evidence
• 18:41
  based
• 18:41
  pearls,
• 18:42
  street
• 18:42
  tips,
• 18:43
  amazing
• 18:44
  resources
• 18:44
  to
• 18:44
  empower
• 18:45
  your
• 18:45
  practice.
• 18:45
  For
• 18:45
  just
• 18:46
  three
• 18:46
  bucks
• 18:46
  a
• 18:46
  month,
• 18:47
  you'll
• 18:47
  get
• 18:47
  a
• 18:47
  ton
• 18:48
  of
• 18:49
  really
• 18:49
  cool
• 18:49
  evidence
• 18:50
  based
• 18:50
  pearls
• 18:51
  that
• 18:51
  keep
• 18:51
  you
• 18:51
  at
• 18:51
  the
• 18:51
  top
• 18:51
  of
• 18:52
  your
• 18:52
  game
• 18:52
  with
• 18:52
  your
• 18:52
  practice.
• 18:53
  They're
• 18:53
  always
• 18:53
  being
• 18:53
  updated,
• 18:54
  really
• 18:55
  sticky
• 18:55
  pearls
• 18:56
  that
• 18:56
  jump
• 18:57
  out
• 18:57
  at
• 18:57
  you.
• 18:57
  And
• 18:58
  we
• 18:58
  try
• 18:58
  to
• 18:58
  kind
• 18:58
  of
• 18:58
  pick
• 18:59
  the
• 18:59
  most
• 18:59
  fascinating,
• 19:00
  high
• 19:00
  impact
• 19:00
  pearls,
• 19:01
  high
• 19:01
  yield
• 19:01
  pearls
• 19:02
  that
• 19:03
  kind
• 19:03
  of
• 19:03
  change
• 19:03
  the
• 19:03
  way
• 19:04
  you
• 19:04
  look
• 19:04
  at
• 19:04
  your
• 19:04
  practice
• 19:04
  and
• 19:05
  your
• 19:05
  ability
• 19:05
  to
• 19:05
  really
• 19:06
  help
• 19:06
  other
• 19:06
  people.
• 19:06
  That's
• 19:07
  at
• 19:07
  the
• 19:07
  end
• 19:07
  of
• 19:07
  the
• 19:07
  day
• 19:07
  what
• 19:07
  this
• 19:08
  is
• 19:08
  about,
• 19:08
  right?
• 19:08
  It's
• 19:09
  finding
• 19:09
  a
• 19:09
  pearl
• 19:10
  that
• 19:10
  talking
• 19:11
  and
• 19:11
  thinking
• 19:11
  about
• 19:11
  that
• 19:12
  pearl,
• 19:12
  sharing
• 19:12
  it
• 19:12
  with
• 19:13
  your
• 19:13
  friends
• 19:13
  and
• 19:14
  coworkers,
• 19:14
  sharing
• 19:15
  it
• 19:15
  with
• 19:15
  your
• 19:15
  students,
• 19:16
  fellow
• 19:16
  peers,
• 19:17
  and
• 19:17
  saying,
• 19:17
  hey,
• 19:17
  look,
• 19:18
  this
• 19:18
  one
• 19:18
  pearl
• 19:18
  I
• 19:18
  learned
• 19:19
  today,
• 19:19
  this
• 19:19
  could
• 19:20
  actually
• 19:20
  make
• 19:20
  someone's
• 19:21
  life
• 19:21
  a
• 19:21
  lot
• 19:21
  better.
• 19:22
  Yeah,
• 19:22
  it
• 19:22
  might
• 19:22
  get
• 19:22
  me
• 19:22
  an
• 19:23
  A
• 19:23
  on
• 19:23
  my
• 19:23
  exam.
• 19:24
  Yeah,
• 19:24
  I
• 19:24
  might
• 19:24
  pass
• 19:24
  my
• 19:25
  boards
• 19:25
  with
• 19:25
  it.
• 19:25
  I
• 19:26
  might
• 19:26
  flaunt
• 19:27
  it
• 19:27
  as
• 19:27
  some
• 19:27
  cool
• 19:27
  little
• 19:28
  pearl
• 19:28
  that
• 19:28
  I
• 19:28
  know
• 19:29
  someone
• 19:29
  else
• 19:29
  doesn't
• 19:30
  know
• 19:30
  or
• 19:30
  something.
• 19:30
  But
• 19:31
  at
• 19:31
  the
• 19:31
  end
• 19:31
  of
• 19:31
  the
• 19:31
  day,
• 19:31
  the
• 19:31
  coolest
• 19:32
  part
• 19:32
  about
• 19:32
  this
• 19:32
  is
• 19:33
  that
• 19:33
  these
• 19:33
  pearls
• 19:34
  have
• 19:34
  the
• 19:34
  power
• 19:34
  to
• 19:34
  actually
• 19:35
  make
• 19:36
  a
• 19:36
  major
• 19:36
  difference
• 19:36
  in
• 19:37
  our
• 19:37
  patients
• 19:37
  lives.
• 19:37
  And
• 19:38
  today's
• 19:38
  pearl,
• 19:39
  it's
• 19:39
  all
• 19:40
  about
• 19:40
  staying
• 19:41
  with
• 19:41
  treatment,
• 19:42
  past
• 19:42
  remission,
• 19:43
  to
• 19:43
  meaningfully
• 19:44
  reduce
• 19:45
  the
• 19:45
  amount
• 19:45
  of
• 19:45
  misery
• 19:46
  and
• 19:46
  relapse
• 19:46
  in
• 19:46
  our
• 19:47
  patients
• 19:47
  lives
• 19:48
  and
• 19:48
  to
• 19:48
  share
• 19:48
  with
• 19:49
  them
• 19:49
  why
• 19:49
  and
• 19:49
  how.
• 19:50
  And
• 19:50
  that
• 19:50
  would
• 19:50
  be
• 19:50
  the
• 19:51
  best
• 19:51
  part
• 19:51
  of
• 19:51
  all
• 19:51
  of
• 19:51
  this.
• 19:52
  Thank
• 19:52
  you
• 19:52
  all
• 19:52
  very
• 19:53
  much
• 19:53
  for
• 19:53
  tuning
• 19:53
  in
• 19:54
  again.
• 19:54
  We
• 19:54
  appreciate
• 19:54
  each
• 19:54
  and
• 19:55
  every
• 19:55
  one
• 19:55
  of
• 19:55
  you.
• 19:56
  Until
• 19:56
  next
• 19:56
  time,
• 19:57
  just
• 19:57
  see
• 19:57
  you
• 19:57
  soon.
• 19:58
  Bye.
• 19:58
  Bye.