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Exploring Remeron: Eight Things Every Practitioner Should Know · Pearls and Prep

• 0:00
  Foreign.
• 0:06
  My
• 0:06
  friends,
• 0:06
  welcome
• 0:07
  back
• 0:07
  to
• 0:07
  another
• 0:08
  episode
• 0:08
  of
• 0:09
  Pearls
• 0:09
  and
• 0:10
  prep
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:13
  pearls
• 0:13
  that
• 0:13
  prep
• 0:14
  you
• 0:14
  for
• 0:14
  your
• 0:14
  boards
• 0:15
  and
• 0:15
  prep
• 0:15
  you
• 0:16
  to
• 0:16
  practice.
• 0:17
  My
• 0:17
  friends,
• 0:18
  the
• 0:18
  title
• 0:19
  of
• 0:19
  Today's
• 0:19
  episode
• 0:20
  is
• 0:20
  8
• 0:20
  things
• 0:21
  you
• 0:21
  may
• 0:21
  not
• 0:22
  know
• 0:22
  about
• 0:22
  Remaron.
• 0:24
  And
• 0:25
  we're
• 0:25
  going
• 0:25
  to
• 0:25
  lead
• 0:25
  off
• 0:26
  like
• 0:26
  we
• 0:26
  always
• 0:26
  do
• 0:26
  with
• 0:27
  a
• 0:27
  mock
• 0:27
  case.
• 0:28
  Lenny
• 0:29
  comes
• 0:29
  to
• 0:29
  you
• 0:29
  in
• 0:29
  the
• 0:29
  outpatient
• 0:30
  clinic.
• 0:30
  He
• 0:31
  can't
• 0:31
  sleep,
• 0:32
  he's
• 0:32
  not
• 0:32
  eating
• 0:32
  much,
• 0:33
  and
• 0:34
  his
• 0:35
  Lexapro
• 0:35
  just
• 0:36
  isn't
• 0:37
  totally
• 0:38
  cutting
• 0:38
  the.
• 0:40
  Cutting
• 0:40
  the
• 0:40
  mustard.
• 0:41
  He
• 0:41
  feels
• 0:41
  a
• 0:42
  little
• 0:42
  less
• 0:42
  depressed,
• 0:43
  a
• 0:43
  little
• 0:43
  less
• 0:43
  anxious.
• 0:44
  He's
• 0:44
  at
• 0:44
  about
• 0:44
  15
• 0:45
  milligrams,
• 0:46
  but
• 0:47
  it's
• 0:47
  not
• 0:47
  quite
• 0:47
  doing
• 0:48
  what
• 0:48
  he
• 0:48
  wants
• 0:48
  it
• 0:48
  to
• 0:48
  do.
• 0:49
  And
• 0:49
  he's
• 0:49
  coming
• 0:49
  to
• 0:50
  you
• 0:50
  for
• 0:50
  help.
• 0:50
  He's
• 0:50
  lost
• 0:50
  £12
• 0:51
  in
• 0:51
  the
• 0:51
  last
• 0:52
  six
• 0:52
  weeks.
• 0:52
  He's
• 0:53
  sleeping
• 0:53
  three
• 0:53
  to
• 0:54
  four
• 0:54
  hours
• 0:54
  a
• 0:54
  night.
• 0:55
  He
• 0:55
  has
• 0:55
  kind
• 0:55
  of
• 0:55
  a
• 0:55
  flat
• 0:56
  affect,
• 0:56
  some
• 0:56
  psychomotor
• 0:57
  retardation.
• 0:57
  He's
• 0:58
  moving
• 0:58
  slowly,
• 0:58
  thinking
• 0:59
  slowly.
• 1:00
  He
• 1:01
  told
• 1:01
  you
• 1:01
  he
• 1:01
  doesn't
• 1:02
  want
• 1:02
  anything
• 1:02
  activating.
• 1:03
  He
• 1:03
  doesn't
• 1:04
  want
• 1:04
  the
• 1:04
  jitters.
• 1:05
  He
• 1:05
  wants
• 1:05
  something
• 1:06
  that's
• 1:06
  kind
• 1:06
  of
• 1:06
  more
• 1:06
  mellow.
• 1:08
  And
• 1:08
  he's
• 1:08
  struggling
• 1:09
  to
• 1:09
  eat,
• 1:10
  care
• 1:10
  for
• 1:10
  the
• 1:10
  kids,
• 1:11
  or
• 1:11
  really
• 1:11
  function
• 1:12
  at
• 1:12
  work.
• 1:13
  So
• 1:14
  Lenny
• 1:15
  needs
• 1:15
  calories,
• 1:16
  he
• 1:16
  needs
• 1:16
  rest,
• 1:16
  he
• 1:16
  needs
• 1:17
  some
• 1:17
  relief.
• 1:18
  What
• 1:18
  do
• 1:18
  you
• 1:18
  do
• 1:18
  with
• 1:18
  this?
• 1:19
  Right?
• 1:19
  Here
• 1:19
  you
• 1:19
  are
• 1:20
  in
• 1:20
  the
• 1:20
  outpatient
• 1:20
  clinic,
• 1:21
  and
• 1:22
  you
• 1:22
  might
• 1:22
  start
• 1:23
  panicking
• 1:23
  as
• 1:23
  a
• 1:23
  new
• 1:23
  grab,
• 1:24
  you
• 1:24
  might
• 1:24
  look
• 1:24
  at
• 1:24
  this
• 1:25
  and
• 1:25
  go,
• 1:25
  oh,
• 1:25
  my
• 1:25
  God,
• 1:26
  you
• 1:27
  know,
• 1:27
  phone
• 1:27
  a
• 1:27
  friend.
• 1:27
  What
• 1:28
  do
• 1:28
  I
• 1:28
  do?
• 1:29
  Here's
• 1:29
  a
• 1:29
  guy,
• 1:30
  he's
• 1:30
  already
• 1:30
  on
• 1:30
  Lexapro.
• 1:31
  He
• 1:31
  has
• 1:32
  very
• 1:32
  specific
• 1:33
  complaints
• 1:34
  that
• 1:34
  I'm
• 1:35
  not
• 1:35
  so
• 1:35
  sure
• 1:36
  can
• 1:36
  be
• 1:36
  addressed
• 1:36
  with
• 1:37
  the
• 1:37
  Lexapro
• 1:37
  he's
• 1:38
  on.
• 1:39
  He
• 1:39
  can't
• 1:40
  sleep
• 1:40
  and
• 1:41
  he's
• 1:41
  not
• 1:41
  eating.
• 1:41
  And
• 1:42
  those
• 1:42
  seem
• 1:42
  to
• 1:42
  be
• 1:42
  the
• 1:42
  two
• 1:43
  things
• 1:43
  that
• 1:43
  bother
• 1:43
  him
• 1:44
  the
• 1:44
  most
• 1:44
  because,
• 1:45
  I
• 1:45
  mean,
• 1:45
  even
• 1:45
  if
• 1:45
  it's
• 1:46
  not,
• 1:46
  he's
• 1:46
  losing
• 1:46
  a
• 1:46
  lot
• 1:47
  of
• 1:47
  weight,
• 1:48
  and
• 1:48
  that
• 1:48
  can't
• 1:48
  be
• 1:48
  great.
• 1:49
  A
• 1:49
  lot
• 1:50
  of
• 1:50
  the
• 1:50
  precursors
• 1:50
  in
• 1:51
  our
• 1:51
  diet
• 1:51
  are
• 1:51
  essential
• 1:53
  for
• 1:54
  building
• 1:54
  neurotransmitters
• 1:55
  to
• 1:55
  get
• 1:55
  him
• 1:56
  better,
• 1:56
  Right?
• 1:57
  So
• 1:57
  you
• 1:57
  look
• 1:57
  at
• 1:57
  this
• 1:57
  holistically
• 1:58
  and
• 1:58
  you're
• 1:58
  like,
• 1:58
  this
• 1:59
  doesn't
• 1:59
  look
• 1:59
  right.
• 2:00
  And
• 2:00
  let's
• 2:00
  just
• 2:00
  assume
• 2:01
  medically,
• 2:01
  everything's
• 2:02
  been
• 2:02
  ruled
• 2:02
  out.
• 2:03
  Let's
• 2:03
  assume
• 2:03
  that
• 2:03
  we're
• 2:03
  looking
• 2:04
  at
• 2:04
  depression
• 2:05
  and
• 2:05
  anxiety
• 2:06
  and
• 2:06
  there's
• 2:06
  no
• 2:06
  other
• 2:06
  psychiatric
• 2:07
  diagnosis.
• 2:08
  For
• 2:08
  sake
• 2:08
  of
• 2:08
  simplicity
• 2:09
  and
• 2:09
  sake
• 2:09
  of
• 2:09
  learning,
• 2:10
  this
• 2:10
  is
• 2:11
  depression,
• 2:11
  right?
• 2:11
  When
• 2:12
  you
• 2:12
  hear
• 2:12
  hooves,
• 2:13
  think
• 2:13
  horses,
• 2:14
  not
• 2:14
  unicorns.
• 2:15
  This
• 2:15
  is
• 2:15
  depression.
• 2:15
  You've
• 2:16
  known
• 2:16
  Lenny
• 2:16
  for
• 2:16
  a
• 2:16
  while,
• 2:17
  and
• 2:17
  he
• 2:17
  needs
• 2:18
  your
• 2:18
  help.
• 2:18
  Well,
• 2:19
  there's
• 2:20
  all
• 2:20
  kinds
• 2:20
  of
• 2:20
  adjunct
• 2:21
  medications
• 2:22
  you
• 2:22
  can
• 2:22
  slap
• 2:22
  on
• 2:23
  to
• 2:23
  an
• 2:23
  ssri.
• 2:24
  And
• 2:25
  with
• 2:25
  practice,
• 2:25
  you're
• 2:26
  going
• 2:26
  to
• 2:26
  get
• 2:26
  more
• 2:26
  familiar
• 2:27
  with
• 2:27
  thinking
• 2:28
  about
• 2:28
  them
• 2:28
  more
• 2:28
  spontaneously.
• 2:30
  As
• 2:30
  a
• 2:30
  new
• 2:30
  grad,
• 2:31
  it
• 2:31
  might
• 2:31
  be
• 2:31
  a
• 2:31
  little
• 2:31
  frightening.
• 2:32
  We
• 2:33
  always
• 2:33
  think
• 2:33
  of,
• 2:33
  like,
• 2:33
  Wellbutrin
• 2:34
  or
• 2:34
  Buspirone
• 2:35
  if
• 2:35
  someone
• 2:36
  has
• 2:36
  anxiety,
• 2:36
  or
• 2:36
  Wellbutrin
• 2:37
  if
• 2:37
  they
• 2:37
  have,
• 2:38
  you
• 2:38
  know,
• 2:38
  low
• 2:38
  energy
• 2:39
  and
• 2:39
  difficulty
• 2:39
  concentrating
• 2:40
  or
• 2:41
  sexual
• 2:41
  side
• 2:41
  effects.
• 2:42
  But.
• 2:42
  But
• 2:42
  you
• 2:43
  can't
• 2:43
  really
• 2:43
  do
• 2:43
  some
• 2:43
  of
• 2:44
  that
• 2:44
  stuff
• 2:44
  here.
• 2:45
  This
• 2:45
  patient
• 2:46
  is
• 2:46
  losing
• 2:46
  weight,
• 2:46
  so
• 2:46
  Wellbutrin
• 2:47
  is
• 2:47
  not
• 2:47
  gonna
• 2:48
  help.
• 2:48
  They
• 2:48
  might
• 2:48
  even
• 2:48
  lose
• 2:48
  weight
• 2:49
  on
• 2:49
  Wellbutrin,
• 2:50
  so
• 2:50
  that's
• 2:50
  not
• 2:50
  really
• 2:51
  gonna
• 2:51
  do
• 2:52
  the
• 2:52
  trick
• 2:52
  here.
• 2:52
  Lenny's
• 2:53
  asking
• 2:53
  you
• 2:53
  for
• 2:53
  help
• 2:54
  with
• 2:54
  sleep,
• 2:54
  too,
• 2:54
  and
• 2:55
  Wellbutrin.
• 2:56
  Eh,
• 2:56
  some
• 2:56
  people
• 2:57
  can
• 2:57
  say
• 2:57
  they're
• 2:57
  a
• 2:57
  little.
• 2:58
  It's
• 2:58
  a
• 2:58
  little
• 2:58
  harder
• 2:59
  to
• 2:59
  sleep
• 2:59
  on
• 2:59
  Wellbutrin,
• 3:00
  especially
• 3:00
  in
• 3:00
  the
• 3:00
  beginning.
• 3:01
  So
• 3:02
  that's
• 3:02
  not
• 3:02
  a
• 3:02
  very
• 3:02
  good
• 3:03
  augmentation
• 3:03
  strategy.
• 3:05
  Buspirone's
• 3:06
  good
• 3:06
  for
• 3:06
  anxiety.
• 3:08
  It's
• 3:08
  good
• 3:08
  for,
• 3:09
  you
• 3:09
  know,
• 3:09
  to
• 3:09
  counter
• 3:10
  sexual
• 3:10
  side
• 3:10
  effects.
• 3:11
  Lenny
• 3:12
  didn't
• 3:12
  really
• 3:12
  talk
• 3:12
  about
• 3:13
  sexual
• 3:13
  side
• 3:13
  effects
• 3:14
  here.
• 3:14
  I
• 3:15
  should
• 3:15
  also
• 3:15
  note
• 3:15
  Lenny's
• 3:16
  pretty
• 3:16
  nauseous
• 3:17
  throughout
• 3:17
  the
• 3:18
  day,
• 3:18
  and
• 3:18
  when
• 3:18
  his
• 3:19
  anxiety
• 3:19
  spikes,
• 3:19
  he
• 3:20
  gets
• 3:20
  particularly
• 3:21
  nauseous.
• 3:22
  So
• 3:22
  I
• 3:22
  didn't
• 3:22
  mention
• 3:22
  that.
• 3:23
  But
• 3:23
  it
• 3:23
  doesn't
• 3:24
  matter
• 3:24
  that
• 3:24
  I
• 3:24
  didn't
• 3:24
  mention
• 3:24
  it,
• 3:25
  because
• 3:25
  I
• 3:25
  just
• 3:25
  did.
• 3:26
  Now,
• 3:27
  my
• 3:27
  friends,
• 3:28
  what
• 3:28
  do
• 3:28
  we
• 3:28
  do?
• 3:28
  Well,
• 3:29
  Remeron
• 3:30
  is
• 3:30
  our
• 3:31
  answer.
• 3:31
  If
• 3:31
  you
• 3:31
  were
• 3:32
  thinking
• 3:32
  of
• 3:32
  Remaron,
• 3:33
  you
• 3:33
  are
• 3:33
  a
• 3:33
  smart
• 3:34
  chapter,
• 3:35
  and
• 3:35
  you
• 3:35
  are
• 3:35
  already
• 3:36
  halfway
• 3:37
  to
• 3:37
  passing
• 3:38
  your
• 3:38
  boards
• 3:39
  because
• 3:39
  you
• 3:39
  had
• 3:39
  a
• 3:39
  great
• 3:40
  idea,
• 3:40
  and
• 3:40
  that
• 3:40
  was
• 3:41
  to
• 3:41
  start
• 3:42
  Remmer
• 3:42
  on.
• 3:42
  Now,
• 3:42
  I
• 3:43
  love
• 3:43
  Remoram
• 3:44
  quite
• 3:44
  personally.
• 3:44
  Everybody
• 3:45
  has
• 3:45
  their
• 3:45
  favorites.
• 3:46
  Everybody
• 3:46
  has
• 3:47
  their
• 3:47
  favorite
• 3:47
  child.
• 3:48
  We're
• 3:48
  all
• 3:48
  supposed
• 3:49
  to
• 3:49
  say
• 3:49
  we
• 3:49
  love
• 3:49
  our
• 3:49
  children
• 3:50
  equally,
• 3:50
  and
• 3:50
  I
• 3:51
  definitely
• 3:51
  do
• 3:51
  because
• 3:52
  I
• 3:52
  only
• 3:52
  have
• 3:52
  one.
• 3:53
  But
• 3:53
  I
• 3:53
  won't
• 3:54
  put
• 3:54
  anyone
• 3:55
  on
• 3:55
  blast
• 3:55
  today,
• 3:57
  especially
• 3:57
  our
• 3:57
  middle
• 3:58
  child
• 3:58
  and
• 3:58
  our
• 3:58
  family.
• 4:00
  But
• 4:00
  you
• 4:00
  get
• 4:00
  my
• 4:00
  point
• 4:01
  right
• 4:01
  there.
• 4:01
  We
• 4:02
  have
• 4:02
  favorites.
• 4:03
  Now,
• 4:03
  I
• 4:03
  love
• 4:03
  Remeron.
• 4:04
  I
• 4:04
  look
• 4:04
  at
• 4:04
  it
• 4:04
  as
• 4:05
  a
• 4:05
  Swiss
• 4:05
  army
• 4:06
  knife
• 4:06
  in
• 4:07
  psychiatry
• 4:08
  because
• 4:08
  it
• 4:08
  does
• 4:08
  so
• 4:09
  many
• 4:09
  things
• 4:09
  that
• 4:10
  not
• 4:11
  all
• 4:11
  of
• 4:11
  your
• 4:11
  medications
• 4:12
  do,
• 4:12
  and
• 4:12
  it
• 4:12
  really
• 4:12
  gets
• 4:13
  you
• 4:13
  out
• 4:13
  of
• 4:13
  a
• 4:13
  jam
• 4:14
  in
• 4:14
  a
• 4:14
  lot
• 4:15
  of
• 4:15
  cases.
• 4:15
  Now,
• 4:15
  the
• 4:15
  drawback,
• 4:16
  of
• 4:16
  course,
• 4:16
  if
• 4:16
  you
• 4:17
  have
• 4:17
  a
• 4:17
  patient
• 4:17
  who's
• 4:17
  on
• 4:17
  the
• 4:17
  heavier
• 4:18
  side,
• 4:18
  if
• 4:19
  you
• 4:19
  have
• 4:19
  a
• 4:19
  patient
• 4:19
  who's
• 4:19
  already
• 4:20
  sleeping
• 4:20
  too
• 4:21
  much,
• 4:21
  Remron's
• 4:22
  not
• 4:22
  the
• 4:22
  best,
• 4:23
  right?
• 4:23
  Because
• 4:23
  it
• 4:24
  can
• 4:24
  cause
• 4:24
  weight
• 4:25
  gain
• 4:25
  and
• 4:25
  it
• 4:25
  can
• 4:25
  cause
• 4:26
  you
• 4:27
  can,
• 4:27
  you
• 4:27
  know,
• 4:27
  if
• 4:27
  they're
• 4:27
  already
• 4:28
  sleeping
• 4:28
  too
• 4:28
  much,
• 4:28
  you're
• 4:29
  going
• 4:29
  to
• 4:29
  make
• 4:29
  them
• 4:29
  sleep
• 4:30
  even
• 4:30
  more.
• 4:30
  But
• 4:30
  let's
• 4:31
  go
• 4:31
  right
• 4:31
  into
• 4:31
  the
• 4:32
  title
• 4:32
  of
• 4:32
  this
• 4:32
  episode,
• 4:33
  eight
• 4:33
  things
• 4:33
  you
• 4:33
  didn't
• 4:34
  know
• 4:34
  about
• 4:34
  Remeron.
• 4:35
  Now,
• 4:36
  you've
• 4:36
  probably
• 4:36
  heard
• 4:36
  this
• 4:37
  in
• 4:37
  your
• 4:37
  textbooks.
• 4:38
  Low
• 4:38
  dose
• 4:39
  equals
• 4:39
  more
• 4:39
  sedation,
• 4:40
  not
• 4:40
  less
• 4:41
  Isn't
• 4:41
  that
• 4:41
  strange?
• 4:42
  You
• 4:42
  take
• 4:43
  a
• 4:43
  Benadryl
• 4:43
  and
• 4:43
  the
• 4:43
  higher
• 4:44
  the
• 4:44
  dose,
• 4:44
  usually
• 4:44
  the
• 4:44
  higher
• 4:45
  the
• 4:45
  sedation.
• 4:46
  Not
• 4:46
  so
• 4:46
  with
• 4:46
  Remeron,
• 4:47
  lower
• 4:47
  doses
• 4:48
  equal
• 4:49
  more
• 4:50
  sedation.
• 4:51
  So
• 4:51
  7.5
• 4:52
  milligrams
• 4:52
  to
• 4:52
  15
• 4:53
  milligrams,
• 4:53
  7.5
• 4:54
  to
• 4:54
  15.
• 4:55
  Remeron
• 4:56
  hits
• 4:56
  the
• 4:57
  histamine
• 4:57
  receptors
• 4:58
  heart.
• 4:59
  It's
• 4:59
  a
• 4:59
  potent
• 4:59
  anti
• 5:00
  histaminergic
• 5:01
  sedation
• 5:02
  mechanism
• 5:03
  here.
• 5:03
  Okay,
• 5:04
  it's
• 5:04
  pretty
• 5:04
  potent
• 5:04
  and
• 5:04
  it's
• 5:05
  pretty
• 5:05
  immediate,
• 5:06
  right?
• 5:06
  So
• 5:07
  that's
• 5:07
  kind
• 5:07
  of
• 5:08
  interesting.
• 5:09
  But
• 5:09
  as
• 5:09
  you
• 5:10
  raise
• 5:10
  Remeron,
• 5:11
  it
• 5:11
  actually
• 5:12
  ramps
• 5:12
  up
• 5:13
  the
• 5:13
  norepinephrine
• 5:14
  release
• 5:14
  and
• 5:14
  it
• 5:14
  makes
• 5:15
  it
• 5:15
  less
• 5:15
  sedating.
• 5:16
  So
• 5:16
  when
• 5:16
  you
• 5:16
  get
• 5:16
  to
• 5:16
  the
• 5:17
  30
• 5:17
  to
• 5:17
  45
• 5:18
  milligram
• 5:18
  range,
• 5:19
  you
• 5:19
  start
• 5:20
  to
• 5:20
  find
• 5:20
  that
• 5:20
  your
• 5:21
  patients
• 5:21
  may
• 5:21
  get
• 5:21
  a
• 5:21
  little
• 5:22
  more
• 5:22
  energized
• 5:23
  on
• 5:24
  Remeron.
• 5:24
  And
• 5:25
  it
• 5:25
  takes
• 5:25
  some
• 5:25
  education
• 5:26
  because
• 5:26
  they
• 5:26
  don't
• 5:26
  always
• 5:27
  equate
• 5:27
  that.
• 5:27
  They
• 5:28
  actually
• 5:28
  might
• 5:28
  think
• 5:29
  raising
• 5:29
  the
• 5:29
  dose
• 5:30
  is
• 5:30
  going
• 5:30
  to
• 5:30
  make
• 5:30
  them
• 5:31
  more
• 5:31
  sedated.
• 5:32
  And
• 5:32
  I've
• 5:32
  actually
• 5:32
  seen
• 5:33
  that
• 5:33
  in
• 5:33
  practice
• 5:33
  where
• 5:34
  you
• 5:34
  want
• 5:34
  to
• 5:34
  raise
• 5:35
  the
• 5:35
  dose
• 5:35
  and
• 5:35
  they're
• 5:36
  complaining
• 5:36
  of
• 5:36
  sedation
• 5:37
  and
• 5:37
  they
• 5:37
  look
• 5:37
  at
• 5:37
  you
• 5:37
  like
• 5:38
  you
• 5:38
  have
• 5:38
  a
• 5:38
  booger
• 5:38
  in
• 5:38
  your
• 5:39
  nose
• 5:39
  and
• 5:39
  you're
• 5:40
  like,
• 5:40
  whoa,
• 5:40
  whoa,
• 5:40
  whoa,
• 5:40
  whoa,
• 5:40
  whoa.
• 5:42
  This
• 5:42
  is
• 5:42
  actually
• 5:43
  going
• 5:43
  to
• 5:43
  make
• 5:43
  you
• 5:43
  less
• 5:43
  sedated
• 5:44
  because
• 5:44
  they
• 5:44
  go,
• 5:45
  oh,
• 5:45
  you
• 5:45
  know,
• 5:45
  I
• 5:45
  like
• 5:45
  the
• 5:46
  medication,
• 5:46
  I'm
• 5:46
  less
• 5:47
  anxious,
• 5:47
  my
• 5:47
  mood's
• 5:48
  a
• 5:48
  little
• 5:48
  better.
• 5:48
  But
• 5:49
  God,
• 5:49
  I'm
• 5:49
  just,
• 5:50
  I'm
• 5:50
  a
• 5:50
  zombie.
• 5:51
  And
• 5:51
  you
• 5:51
  go,
• 5:52
  well,
• 5:52
  let's
• 5:52
  raise
• 5:52
  the
• 5:52
  dose.
• 5:53
  They,
• 5:53
  they,
• 5:53
  they
• 5:53
  want
• 5:54
  to
• 5:54
  fire
• 5:54
  you
• 5:54
  on
• 5:54
  the
• 5:55
  spot.
• 5:55
  But
• 5:55
  in
• 5:56
  reality,
• 5:56
  you
• 5:56
  have
• 5:56
  a
• 5:57
  very
• 5:57
  smart
• 5:59
  idea.
• 5:59
  And
• 6:00
  that
• 6:00
  is
• 6:00
  it's
• 6:00
  you're
• 6:01
  going
• 6:01
  to
• 6:01
  increase
• 6:01
  the
• 6:02
  norepinephrine
• 6:02
  release
• 6:03
  if
• 6:03
  you
• 6:03
  raise
• 6:03
  it.
• 6:04
  And
• 6:04
  that
• 6:04
  norepinephrine
• 6:05
  release
• 6:06
  happens
• 6:06
  via
• 6:07
  alpha
• 6:07
  adrenergic
• 6:09
  antagonism.
• 6:10
  Okay,
• 6:11
  a
• 6:11
  2
• 6:11
  antagonism
• 6:12
  that
• 6:12
  ramps
• 6:12
  up
• 6:13
  the
• 6:13
  norepinephrine
• 6:14
  release
• 6:14
  release,
• 6:15
  making
• 6:15
  the
• 6:16
  medication
• 6:16
  less
• 6:17
  sedating.
• 6:18
  Now,
• 6:19
  alpha
• 6:19
  adrenergic
• 6:20
  receptors
• 6:21
  are
• 6:22
  actually
• 6:22
  usually
• 6:23
  a
• 6:23
  break
• 6:24
  on
• 6:24
  norepinephrine
• 6:25
  and
• 6:25
  serotonin
• 6:26
  release.
• 6:26
  And
• 6:27
  so
• 6:27
  by
• 6:27
  antagonizing
• 6:28
  them,
• 6:28
  the
• 6:29
  alpha
• 6:29
  2
• 6:29
  receptors,
• 6:31
  Reviron
• 6:31
  is
• 6:32
  releasing
• 6:32
  the
• 6:32
  brake
• 6:33
  so
• 6:33
  that
• 6:33
  more
• 6:33
  norepinephrine
• 6:34
  and
• 6:35
  serotonin
• 6:35
  can
• 6:35
  be
• 6:35
  released,
• 6:36
  which
• 6:36
  is
• 6:36
  really
• 6:37
  cool.
• 6:37
  It's
• 6:37
  kind
• 6:38
  of
• 6:38
  a
• 6:38
  unique
• 6:38
  mechanism
• 6:39
  of
• 6:39
  action.
• 6:39
  The
• 6:40
  higher
• 6:40
  the
• 6:40
  dose,
• 6:40
  you're
• 6:41
  actually
• 6:41
  going
• 6:41
  to
• 6:41
  energize
• 6:42
  them
• 6:42
  a
• 6:42
  little
• 6:42
  more.
• 6:43
  And
• 6:43
  it's
• 6:43
  kind
• 6:43
  of
• 6:43
  cool.
• 6:44
  Again,
• 6:44
  I
• 6:44
  call
• 6:44
  it
• 6:44
  a
• 6:44
  Swiss
• 6:45
  army
• 6:45
  knife,
• 6:45
  because
• 6:45
  early
• 6:46
  on
• 6:46
  on
• 6:47
  you
• 6:47
  can
• 6:47
  that,
• 6:47
  that
• 6:48
  histamine
• 6:48
  piece.
• 6:49
  The
• 6:49
  antagonizing,
• 6:50
  the
• 6:50
  histamine
• 6:51
  receptor
• 6:51
  kicks
• 6:52
  in
• 6:52
  pretty
• 6:52
  quickly
• 6:52
  so
• 6:53
  you
• 6:53
  can
• 6:53
  actually
• 6:53
  get
• 6:53
  them
• 6:53
  to
• 6:54
  sleep
• 6:54
  Pretty
• 6:55
  fast.
• 6:55
  When
• 6:55
  somebody's
• 6:56
  in
• 6:56
  front
• 6:56
  of
• 6:56
  you
• 6:56
  and
• 6:56
  they're
• 6:57
  tearful
• 6:57
  and
• 6:58
  they're
• 6:58
  depressed,
• 6:59
  it
• 6:59
  breaks
• 6:59
  your
• 7:00
  heart
• 7:00
  to
• 7:00
  have
• 7:00
  to
• 7:00
  tell
• 7:01
  them
• 7:01
  that
• 7:01
  they
• 7:01
  have
• 7:01
  to
• 7:01
  wait
• 7:01
  four
• 7:02
  to
• 7:02
  six
• 7:02
  weeks
• 7:02
  for
• 7:02
  some
• 7:03
  kind
• 7:03
  of
• 7:03
  relief.
• 7:04
  Having
• 7:04
  them
• 7:04
  get
• 7:04
  to
• 7:05
  sleep
• 7:05
  is
• 7:06
  wonderful.
• 7:07
  And
• 7:07
  so
• 7:08
  histamine
• 7:09
  is
• 7:09
  our
• 7:09
  friend
• 7:09
  in
• 7:10
  that
• 7:10
  regard.
• 7:11
  Remember,
• 7:12
  antagonizing
• 7:12
  histamine
• 7:13
  can
• 7:13
  also
• 7:13
  lead
• 7:13
  to
• 7:14
  increased
• 7:15
  appetite.
• 7:16
  In
• 7:16
  Lenny's
• 7:16
  case,
• 7:16
  that's
• 7:17
  good
• 7:17
  because
• 7:17
  he's
• 7:17
  losing
• 7:17
  too
• 7:18
  much
• 7:18
  weight.
• 7:18
  So
• 7:18
  it's
• 7:19
  bam.
• 7:19
  You
• 7:19
  get
• 7:20
  a
• 7:20
  skinny.
• 7:21
  Someone
• 7:21
  who's
• 7:21
  losing
• 7:22
  weight
• 7:22
  and
• 7:22
  they
• 7:22
  can't
• 7:23
  sleep.
• 7:23
  That
• 7:23
  is.
• 7:23
  Just
• 7:24
  think
• 7:24
  of
• 7:24
  that
• 7:24
  right
• 7:24
  away.
• 7:25
  Your
• 7:25
  ideal
• 7:26
  Remron
• 7:26
  candidate.
• 7:27
  So
• 7:27
  that's
• 7:27
  the
• 7:27
  first
• 7:27
  thing.
• 7:27
  The
• 7:28
  low
• 7:28
  dose
• 7:28
  can
• 7:28
  be
• 7:28
  more
• 7:28
  sedating.
• 7:29
  The
• 7:29
  second
• 7:29
  thing
• 7:30
  you
• 7:30
  probably
• 7:30
  didn't
• 7:30
  know
• 7:30
  is
• 7:31
  that
• 7:31
  it
• 7:31
  has
• 7:31
  minimal
• 7:31
  side
• 7:32
  effects.
• 7:32
  Unlike
• 7:33
  SSRIs
• 7:33
  and
• 7:33
  SNRIs,
• 7:34
  Remeron
• 7:35
  does
• 7:35
  not
• 7:35
  stimulate
• 7:36
  the
• 7:36
  5
• 7:37
  HT2A
• 7:37
  receptor.
• 7:38
  It
• 7:38
  can
• 7:39
  actually
• 7:39
  even
• 7:39
  reverse
• 7:39
  SSRI
• 7:40
  induced
• 7:40
  sexual
• 7:41
  dysfunction
• 7:42
  when
• 7:42
  added
• 7:42
  on.
• 7:43
  So
• 7:44
  if
• 7:44
  I
• 7:44
  was
• 7:44
  smart
• 7:44
  and
• 7:45
  if
• 7:45
  I
• 7:45
  had
• 7:46
  procured
• 7:46
  this
• 7:47
  case
• 7:47
  study
• 7:47
  intelligently
• 7:48
  enough,
• 7:49
  I
• 7:49
  would
• 7:49
  have
• 7:49
  told
• 7:49
  you
• 7:49
  that
• 7:50
  Lenny
• 7:50
  also
• 7:50
  has
• 7:50
  sexual
• 7:51
  side
• 7:51
  effects.
• 7:52
  And
• 7:52
  I
• 7:52
  would
• 7:52
  have
• 7:52
  said,
• 7:52
  bambons.
• 7:54
  It's
• 7:55
  like
• 7:55
  Vitamin
• 7:55
  Wonka.
• 7:56
  It's
• 7:56
  perfect,
• 7:56
  right?
• 7:56
  Because
• 7:57
  it's
• 7:57
  also
• 7:57
  going
• 7:58
  to
• 7:59
  antagonize
• 8:00
  5ht2a,
• 8:01
  which
• 8:01
  can
• 8:01
  reverse
• 8:02
  some
• 8:02
  of
• 8:02
  that
• 8:02
  SSRI
• 8:03
  induced
• 8:03
  sexual
• 8:03
  dysfunction.
• 8:04
  I
• 8:04
  didn't
• 8:04
  want
• 8:04
  to,
• 8:05
  like,
• 8:05
  make
• 8:05
  Lenny
• 8:05
  have
• 8:06
  this
• 8:06
  perfect,
• 8:06
  perfect
• 8:06
  presentation,
• 8:07
  though,
• 8:08
  where
• 8:08
  everything
• 8:09
  you
• 8:09
  do
• 8:09
  for
• 8:09
  him
• 8:09
  is
• 8:10
  like,
• 8:10
  perfect
• 8:10
  in
• 8:10
  one
• 8:11
  pill.
• 8:11
  Because
• 8:12
  that's
• 8:12
  not
• 8:12
  really
• 8:13
  the
• 8:13
  universe
• 8:14
  and
• 8:14
  it's
• 8:14
  certainly
• 8:14
  not
• 8:14
  psychiatry,
• 8:15
  Right.
• 8:16
  It's
• 8:16
  very
• 8:16
  rare
• 8:17
  somebody
• 8:17
  walks
• 8:17
  into
• 8:18
  your
• 8:18
  office
• 8:18
  who
• 8:19
  is
• 8:19
  a
• 8:19
  perfect
• 8:20
  fit
• 8:20
  for
• 8:20
  a
• 8:20
  medication.
• 8:21
  Usually
• 8:21
  it's
• 8:22
  a
• 8:22
  little
• 8:22
  sloppier.
• 8:23
  It's
• 8:23
  a
• 8:23
  little
• 8:24
  bit
• 8:24
  more
• 8:24
  difficult.
• 8:25
  You
• 8:25
  have
• 8:25
  a
• 8:25
  patient,
• 8:26
  in
• 8:26
  this
• 8:26
  case,
• 8:26
  Lenny,
• 8:27
  let's
• 8:27
  mock
• 8:27
  patient
• 8:28
  where
• 8:29
  it.
• 8:29
  It's
• 8:30
  kind
• 8:30
  of
• 8:30
  a
• 8:30
  good
• 8:30
  saying.
• 8:31
  Like,
• 8:31
  he,
• 8:31
  you
• 8:31
  know,
• 8:32
  you
• 8:32
  have
• 8:32
  the
• 8:33
  weight
• 8:33
  gain
• 8:34
  that
• 8:34
  you
• 8:34
  want
• 8:35
  and
• 8:35
  the
• 8:35
  sleepiness
• 8:36
  that
• 8:36
  you
• 8:36
  want.
• 8:36
  But
• 8:37
  maybe
• 8:37
  something
• 8:37
  else
• 8:38
  about
• 8:38
  Rembron
• 8:39
  is,
• 8:39
  like,
• 8:39
  not
• 8:39
  great
• 8:39
  for
• 8:40
  him,
• 8:40
  right?
• 8:40
  In
• 8:40
  reality,
• 8:41
  right.
• 8:41
  It's
• 8:42
  what
• 8:42
  I'm
• 8:42
  trying
• 8:43
  to
• 8:43
  tell
• 8:43
  you
• 8:43
  is
• 8:43
  it's
• 8:44
  never
• 8:44
  as
• 8:44
  easy
• 8:45
  as
• 8:45
  the
• 8:45
  textbooks
• 8:45
  make
• 8:45
  it
• 8:46
  out
• 8:46
  to
• 8:46
  be.
• 8:46
  But
• 8:47
  sure
• 8:47
  enough,
• 8:47
  I
• 8:48
  found
• 8:48
  plenty
• 8:49
  of
• 8:49
  patients
• 8:49
  who
• 8:49
  are
• 8:50
  very
• 8:50
  good
• 8:51
  candidates
• 8:51
  for
• 8:51
  this.
• 8:52
  And
• 8:52
  they
• 8:52
  will
• 8:52
  tell
• 8:52
  you,
• 8:52
  yes,
• 8:53
  I
• 8:53
  would
• 8:53
  like
• 8:53
  to
• 8:53
  gain
• 8:54
  that
• 8:54
  weight
• 8:54
  back.
• 8:54
  I
• 8:54
  would
• 8:54
  like
• 8:55
  to
• 8:55
  have
• 8:55
  my
• 8:55
  appetite
• 8:56
  back.
• 8:56
  Right?
• 8:57
  And
• 8:57
  it
• 8:57
  doesn't
• 8:58
  always
• 8:58
  mean
• 8:58
  that
• 8:58
  they
• 8:58
  have
• 8:58
  this
• 8:59
  raging
• 8:59
  appetite
• 8:59
  and
• 9:00
  they
• 9:00
  start
• 9:00
  gaining
• 9:00
  a
• 9:00
  lot
• 9:00
  of
• 9:00
  weight.
• 9:01
  Sometimes
• 9:02
  it's
• 9:02
  just
• 9:02
  like,
• 9:03
  have
• 9:03
  you
• 9:03
  ever
• 9:03
  been
• 9:04
  in,
• 9:04
  like,
• 9:04
  a
• 9:04
  really
• 9:04
  bad
• 9:05
  mood?
• 9:05
  Even
• 9:05
  if
• 9:05
  you've
• 9:06
  never
• 9:06
  been
• 9:06
  clinically
• 9:06
  depressed.
• 9:07
  But
• 9:07
  whether
• 9:07
  it's
• 9:08
  like
• 9:08
  grief
• 9:08
  or
• 9:08
  you
• 9:08
  just
• 9:09
  had
• 9:09
  a
• 9:09
  horrible
• 9:09
  day
• 9:09
  and
• 9:09
  your
• 9:10
  appetite
• 9:10
  goes
• 9:10
  to
• 9:10
  hell,
• 9:11
  well,
• 9:11
  that's
• 9:12
  kind
• 9:12
  of
• 9:12
  what
• 9:13
  we're
• 9:13
  looking
• 9:13
  for
• 9:13
  with
• 9:14
  Remeron
• 9:14
  to
• 9:14
  an
• 9:14
  extent.
• 9:15
  Right.
• 9:15
  It
• 9:16
  brings
• 9:16
  the
• 9:16
  appetite
• 9:17
  back
• 9:17
  on
• 9:17
  board
• 9:18
  so
• 9:18
  that
• 9:18
  part
• 9:19
  of
• 9:19
  their
• 9:19
  depression
• 9:20
  is
• 9:20
  not
• 9:20
  as
• 9:20
  pronounced.
• 9:21
  It
• 9:21
  doesn't
• 9:22
  mean
• 9:22
  you
• 9:22
  won't
• 9:22
  gorge
• 9:23
  on
• 9:23
  carbs,
• 9:23
  which
• 9:23
  you
• 9:24
  might,
• 9:24
  you
• 9:24
  might
• 9:24
  gain
• 9:24
  weight
• 9:24
  on
• 9:25
  Remeron.
• 9:25
  But
• 9:26
  I
• 9:26
  want
• 9:26
  you
• 9:26
  to
• 9:26
  have
• 9:26
  a
• 9:27
  kind
• 9:27
  of
• 9:27
  a
• 9:27
  more
• 9:27
  balanced
• 9:28
  view
• 9:28
  too,
• 9:29
  of
• 9:29
  the
• 9:29
  kind
• 9:29
  of
• 9:29
  increase
• 9:30
  in
• 9:30
  appetite
• 9:30
  we're
• 9:31
  looking
• 9:31
  for.
• 9:31
  It's
• 9:31
  not
• 9:31
  like
• 9:31
  we
• 9:32
  want
• 9:32
  them
• 9:32
  to
• 9:32
  binge
• 9:32
  on
• 9:33
  zebra
• 9:33
  cakes
• 9:33
  all
• 9:33
  night.
• 9:34
  We
• 9:34
  want
• 9:34
  them
• 9:35
  to
• 9:35
  have
• 9:36
  an
• 9:36
  appetite
• 9:36
  that
• 9:37
  comes
• 9:37
  back.
• 9:37
  Now,
• 9:38
  the
• 9:38
  third
• 9:38
  thing
• 9:38
  you
• 9:38
  may
• 9:39
  have
• 9:39
  not
• 9:39
  known
• 9:39
  is
• 9:39
  that
• 9:39
  Remeron
• 9:40
  is
• 9:40
  an
• 9:40
  anti
• 9:40
  nausea
• 9:41
  superpower.
• 10:36
  Via
• 10:36
  5ht3
• 10:38
  blockade,
• 9:44
  Remeron
• 10:39
  blocks
• 10:40
  the
• 10:40
  5ht3
• 10:41
  receptor
• 10:41
  like
• 10:42
  Zofran,
• 10:42
  making
• 10:43
  it
• 10:43
  a
• 10:43
  great
• 10:43
  choice
• 10:43
  for
• 10:43
  patients
• 10:44
  with
• 10:44
  ssri,
• 10:45
  SSRI
• 10:46
  induced
• 10:47
  GI
• 10:47
  side
• 10:47
  effects,
• 10:48
  maybe
• 10:48
  even
• 10:49
  comorbid
• 10:50
  medical
• 10:51
  problems.
• 10:51
  It's
• 10:51
  actually
• 10:52
  one
• 10:52
  of
• 10:52
  the
• 10:52
  more
• 10:52
  popular
• 10:53
  medications
• 10:53
  for
• 10:53
  folks
• 10:54
  getting
• 10:54
  chemo
• 10:55
  or,
• 10:55
  or
• 10:56
  people
• 10:56
  who
• 10:56
  have
• 10:56
  chronic
• 10:57
  nausea.
• 10:57
  I've
• 10:57
  prescribed
• 10:58
  it
• 10:58
  to
• 10:58
  folks
• 10:58
  who,
• 10:59
  who
• 10:59
  have
• 10:59
  nausea
• 11:00
  as
• 11:00
  a
• 11:00
  major
• 11:00
  feature
• 11:01
  of
• 11:01
  their
• 11:01
  anxiety
• 11:01
  or
• 11:02
  their
• 11:02
  depression.
• 11:03
  So
• 11:03
  if
• 11:03
  you
• 11:03
  have
• 11:03
  a
• 11:04
  patient
• 11:04
  coming
• 11:04
  to
• 11:04
  you
• 11:04
  who,
• 11:05
  whose
• 11:05
  unique
• 11:06
  signature
• 11:07
  in
• 11:07
  their,
• 11:08
  in
• 11:08
  their
• 11:08
  anxieties
• 11:09
  that
• 11:09
  they
• 11:09
  get
• 11:09
  super
• 11:09
  nauseous
• 11:10
  when
• 11:10
  they're
• 11:10
  anxious,
• 11:11
  Remeron
• 11:12
  is
• 11:12
  not
• 11:12
  a
• 11:12
  bad
• 11:12
  choice.
• 11:13
  Again,
• 11:14
  all
• 11:14
  things
• 11:14
  considered
• 11:15
  though,
• 11:15
  you
• 11:15
  got
• 11:15
  to
• 11:15
  put
• 11:15
  it
• 11:15
  through
• 11:15
  a
• 11:16
  filter.
• 11:16
  Because
• 11:17
  if
• 11:17
  Lenny
• 11:18
  comes
• 11:18
  to
• 11:18
  you
• 11:18
  and
• 11:18
  he
• 11:19
  goes,
• 11:19
  hey,
• 11:20
  I
• 11:20
  get
• 11:20
  super
• 11:21
  nauseous
• 11:21
  every
• 11:21
  time
• 11:22
  I'm
• 11:22
  anxious
• 11:23
  and
• 11:24
  I
• 11:24
  really
• 11:25
  can't
• 11:25
  sleep,
• 11:25
  and
• 11:26
  you're
• 11:26
  thinking,
• 11:26
  oh
• 11:26
  my
• 11:26
  God,
• 11:27
  Remaron
• 11:27
  is
• 11:27
  the
• 11:27
  best
• 11:27
  thing
• 11:28
  since
• 11:28
  sliced
• 11:29
  bread.
• 11:30
  But
• 11:30
  his
• 11:31
  one
• 11:31
  deal
• 11:31
  breaker
• 11:31
  is
• 11:32
  that
• 11:32
  he
• 11:32
  will
• 11:32
  not
• 11:32
  accept
• 11:33
  weight
• 11:33
  gain
• 11:33
  as
• 11:34
  a
• 11:34
  side
• 11:34
  effect.
• 11:35
  That's
• 11:35
  the
• 11:35
  kind
• 11:36
  of
• 11:36
  psychiatry
• 11:36
  I'm
• 11:37
  talking
• 11:37
  about.
• 11:38
  It's
• 11:38
  not
• 11:38
  always
• 11:39
  black
• 11:39
  and
• 11:39
  white
• 11:39
  and
• 11:40
  you
• 11:40
  have
• 11:40
  to
• 11:40
  be
• 11:40
  a
• 11:41
  little
• 11:41
  careful.
• 11:42
  So
• 11:42
  I
• 11:43
  don't
• 11:43
  want
• 11:43
  to
• 11:43
  discourage
• 11:44
  you
• 11:44
  either,
• 11:44
  my
• 11:44
  friends,
• 11:44
  because
• 11:45
  it's
• 11:45
  not
• 11:45
  like
• 11:46
  you're
• 11:46
  going
• 11:46
  to
• 11:46
  be
• 11:46
  checkmated
• 11:47
  by
• 11:47
  every
• 11:47
  patient
• 11:48
  you
• 11:48
  meet.
• 11:49
  Your
• 11:49
  med
• 11:50
  wants
• 11:50
  them
• 11:50
  to
• 11:50
  meet
• 11:51
  at
• 11:51
  the
• 11:51
  same
• 11:51
  time,
• 11:51
  right?
• 11:52
  A
• 11:53
  lot
• 11:53
  of
• 11:53
  times
• 11:53
  this
• 11:54
  is
• 11:54
  a
• 11:54
  balance.
• 11:55
  These
• 11:55
  are
• 11:55
  trade
• 11:55
  offs.
• 11:56
  You
• 11:56
  have
• 11:56
  to
• 11:57
  have
• 11:57
  good
• 11:57
  therapeutic
• 11:57
  conversations
• 11:58
  and
• 11:58
  robust
• 11:59
  psycho
• 11:59
  education
• 11:59
  with
• 12:00
  your
• 12:00
  patients.
• 12:01
  Because
• 12:01
  a
• 12:02
  lot
• 12:02
  of
• 12:02
  this
• 12:02
  is
• 12:02
  just
• 12:02
  informed
• 12:03
  consent.
• 12:03
  And
• 12:04
  like,
• 12:04
  hey,
• 12:04
  let's
• 12:05
  weigh
• 12:05
  the
• 12:05
  pros
• 12:05
  and
• 12:05
  cons
• 12:06
  of
• 12:06
  this.
• 12:06
  Let's
• 12:07
  talk
• 12:07
  about
• 12:07
  it.
• 12:08
  Patients
• 12:08
  are
• 12:08
  totally
• 12:09
  understanding
• 12:09
  that
• 12:09
  there
• 12:10
  are
• 12:10
  drawbacks
• 12:10
  and
• 12:11
  sometimes
• 12:11
  a
• 12:11
  little
• 12:12
  bit
• 12:12
  of
• 12:12
  weight
• 12:12
  gain
• 12:12
  is
• 12:13
  worth
• 12:14
  a
• 12:14
  lot
• 12:14
  less
• 12:14
  of
• 12:14
  a
• 12:15
  panic
• 12:15
  attack.
• 12:16
  Last
• 12:16
  I
• 12:16
  checked,
• 12:17
  panic
• 12:17
  attacks
• 12:17
  were
• 12:17
  like
• 12:17
  the
• 12:18
  worst
• 12:18
  thing
• 12:18
  on
• 12:18
  the
• 12:18
  universe
• 12:19
  for
• 12:20
  anybody
• 12:20
  to
• 12:20
  experience.
• 12:21
  Right.
• 12:22
  Okay.
• 12:22
  The
• 12:22
  fourth
• 12:22
  thing
• 12:23
  you
• 12:23
  may
• 12:23
  not
• 12:23
  know
• 12:23
  about
• 12:23
  Remeron
• 12:24
  is
• 12:24
  it
• 12:24
  makes
• 12:24
  you
• 12:25
  hungry.
• 12:25
  And
• 12:25
  if
• 12:25
  you
• 12:26
  don't
• 12:26
  know,
• 12:26
  it's
• 12:26
  because
• 12:26
  you
• 12:26
  weren't
• 12:27
  paying
• 12:27
  attention
• 12:27
  or
• 12:28
  I
• 12:28
  didn't
• 12:28
  explain
• 12:28
  it
• 12:29
  well.
• 12:29
  But
• 12:29
  it
• 12:29
  makes
• 12:29
  you
• 12:29
  hungry
• 12:30
  because
• 12:30
  it
• 12:30
  blocks
• 12:30
  the
• 12:31
  5HT2C
• 12:32
  receptor
• 12:32
  and
• 12:33
  the
• 12:33
  histamine
• 12:33
  receptor
• 12:34
  H1,
• 12:35
  both
• 12:35
  of
• 12:35
  which
• 12:35
  normally
• 12:36
  suppress
• 12:36
  appetite.
• 12:37
  Affinity
• 12:37
  is
• 12:37
  such
• 12:37
  a
• 12:38
  cool
• 12:38
  concept.
• 12:39
  I
• 12:39
  really
• 12:39
  encourage
• 12:39
  you
• 12:40
  to
• 12:40
  go
• 12:40
  to
• 12:40
  our
• 12:41
  past
• 12:41
  episodes
• 12:41
  and
• 12:42
  to
• 12:42
  become
• 12:42
  a
• 12:42
  Patreon
• 12:43
  member
• 12:43
  so
• 12:43
  you
• 12:44
  can
• 12:44
  dig
• 12:44
  more
• 12:44
  deeply
• 12:45
  into
• 12:46
  what
• 12:46
  these
• 12:46
  receptors
• 12:47
  do.
• 12:47
  And
• 12:47
  we
• 12:47
  have
• 12:48
  good
• 12:48
  mnemonics
• 12:48
  for
• 12:48
  this
• 12:49
  stuff.
• 12:49
  But
• 12:50
  Remeron
• 12:50
  makes
• 12:50
  you
• 12:51
  hungry.
• 12:51
  And,
• 12:52
  you
• 12:52
  know,
• 12:52
  weight
• 12:53
  gain
• 12:53
  is
• 12:53
  common,
• 12:53
  right.
• 12:54
  And
• 12:54
  it
• 12:54
  does
• 12:54
  that
• 12:55
  through
• 12:55
  two
• 12:55
  different
• 12:55
  mechanisms.
• 12:56
  So
• 12:57
  it's
• 12:57
  great
• 12:57
  if
• 12:58
  you're
• 12:58
  maybe
• 12:59
  a
• 12:59
  little
• 12:59
  bit
• 12:59
  elderly
• 13:00
  and
• 13:00
  you're
• 13:01
  not
• 13:01
  eating
• 13:01
  a
• 13:01
  lot
• 13:02
  and
• 13:02
  you're
• 13:02
  kind
• 13:02
  of
• 13:02
  have
• 13:03
  muscle
• 13:03
  wasting
• 13:03
  and
• 13:04
  things
• 13:04
  like
• 13:04
  that.
• 13:05
  But
• 13:06
  again,
• 13:06
  not
• 13:07
  good
• 13:07
  for
• 13:07
  everyone.
• 13:08
  Just
• 13:08
  keep
• 13:08
  that
• 13:08
  in
• 13:09
  mind.
• 13:09
  The
• 13:09
  fifth
• 13:09
  thing
• 13:09
  you
• 13:09
  may
• 13:10
  not
• 13:10
  know
• 13:11
  is
• 13:11
  that
• 13:11
  it
• 13:12
  works
• 13:12
  pretty
• 13:12
  fast
• 13:12
  on
• 13:13
  appetite
• 13:13
  and
• 13:13
  sleep,
• 13:14
  even
• 13:14
  before
• 13:15
  the
• 13:15
  full
• 13:15
  antidepressant
• 13:16
  effect.
• 13:17
  So
• 13:17
  that's
• 13:18
  kind
• 13:18
  of
• 13:18
  nice
• 13:18
  too.
• 13:18
  We
• 13:19
  did
• 13:19
  talk
• 13:19
  about
• 13:19
  how
• 13:20
  it
• 13:20
  works
• 13:20
  a
• 13:20
  little
• 13:21
  quicker.
• 13:21
  Now,
• 13:21
  the
• 13:21
  actual
• 13:22
  antidepressant
• 13:22
  effect,
• 13:23
  I
• 13:23
  think
• 13:23
  that's
• 13:23
  more
• 13:24
  debatable.
• 13:24
  I
• 13:25
  don't
• 13:25
  necessarily
• 13:26
  think
• 13:26
  that
• 13:26
  kicks
• 13:26
  in.
• 13:27
  Some
• 13:27
  patients
• 13:27
  will
• 13:28
  swear
• 13:28
  that
• 13:28
  Day
• 13:29
  three,
• 13:29
  they
• 13:29
  feel
• 13:29
  better.
• 13:30
  Could
• 13:30
  be
• 13:30
  a
• 13:30
  placebo.
• 13:31
  It's
• 13:31
  not
• 13:31
  really
• 13:32
  borne
• 13:32
  out
• 13:32
  in
• 13:32
  the
• 13:32
  literature.
• 13:33
  But,
• 13:33
  you
• 13:34
  know,
• 13:34
  again,
• 13:34
  the
• 13:34
  nice
• 13:35
  thing
• 13:35
  is
• 13:35
  you
• 13:36
  have
• 13:36
  a
• 13:36
  medication
• 13:36
  that
• 13:37
  can
• 13:37
  address
• 13:38
  some
• 13:38
  of
• 13:38
  these
• 13:38
  core
• 13:39
  deficiencies
• 13:40
  early
• 13:40
  on,
• 13:40
  and
• 13:41
  they're
• 13:41
  not
• 13:41
  sitting
• 13:41
  there
• 13:41
  staring
• 13:42
  at
• 13:42
  their
• 13:42
  watch
• 13:43
  for
• 13:44
  four
• 13:44
  to
• 13:44
  six
• 13:44
  weeks.
• 13:45
  So
• 13:45
  that's
• 13:45
  kind
• 13:46
  of
• 13:46
  a
• 13:46
  nice
• 13:46
  thing.
• 13:47
  The
• 13:47
  sixth
• 13:47
  thing
• 13:48
  you
• 13:48
  didn't
• 13:48
  know
• 13:48
  about
• 13:48
  Remeron
• 13:49
  potentially
• 13:51
  is
• 13:51
  that
• 13:52
  it
• 13:52
  has
• 13:52
  very
• 13:52
  minimal
• 13:53
  CYP450
• 13:54
  drama.
• 13:54
  If
• 13:54
  you're
• 13:55
  in
• 13:55
  psych
• 13:55
  and
• 13:55
  P
• 13:55
  school,
• 13:55
  you're
• 13:56
  probably
• 13:56
  learning
• 13:56
  all
• 13:56
  about
• 13:57
  these
• 13:57
  metabolic
• 13:58
  pathways
• 13:58
  in
• 13:59
  the
• 13:59
  liver,
• 13:59
  the
• 13:59
  CYP450
• 14:01
  enzymes
• 14:02
  and
• 14:02
  Remeron,
• 14:03
  there's
• 14:03
  not
• 14:03
  a
• 14:03
  lot
• 14:03
  of
• 14:04
  drama
• 14:04
  there,
• 14:04
  right?
• 14:04
  With
• 14:05
  Prozac,
• 14:05
  with
• 14:05
  Paxil,
• 14:06
  there's
• 14:06
  a
• 14:06
  lot
• 14:06
  of
• 14:06
  drama.
• 14:07
  Anytime
• 14:07
  you
• 14:08
  add
• 14:08
  a
• 14:08
  medication
• 14:09
  on
• 14:09
  board,
• 14:09
  you
• 14:09
  got
• 14:09
  to
• 14:10
  wonder
• 14:10
  whether
• 14:10
  Prozac
• 14:11
  or
• 14:11
  Paxil
• 14:12
  is
• 14:12
  going
• 14:12
  to
• 14:13
  interact
• 14:13
  with
• 14:13
  it
• 14:14
  in
• 14:14
  some
• 14:14
  way.
• 14:15
  But
• 14:15
  Remeron
• 14:16
  is
• 14:16
  a
• 14:16
  little
• 14:17
  more
• 14:17
  clean.
• 14:17
  It
• 14:17
  has
• 14:18
  minimal
• 14:18
  drug
• 14:18
  interactions.
• 14:19
  That's
• 14:19
  really
• 14:20
  important.
• 14:20
  Again,
• 14:21
  especially
• 14:21
  for
• 14:21
  who?
• 14:22
  Ding,
• 14:22
  ding,
• 14:22
  ding
• 14:22
  and
• 14:23
  ding.
• 14:23
  Bonus
• 14:23
  question.
• 14:24
  Who
• 14:24
  would
• 14:25
  that
• 14:25
  be
• 14:25
  especially
• 14:27
  relevant
• 14:28
  towards
• 14:29
  when
• 14:29
  you
• 14:29
  don't
• 14:29
  have
• 14:30
  a
• 14:30
  lot
• 14:30
  of
• 14:30
  CYP
• 14:31
  450
• 14:31
  interactions.
• 14:33
  Which
• 14:33
  population
• 14:34
  would
• 14:35
  have
• 14:35
  a
• 14:35
  lot
• 14:35
  of
• 14:35
  those
• 14:36
  potential
• 14:36
  interactions
• 14:36
  that
• 14:37
  you
• 14:37
  don't
• 14:37
  want
• 14:37
  that
• 14:37
  drama
• 14:38
  with?
• 14:38
  If
• 14:38
  you
• 14:39
  said
• 14:39
  the
• 14:39
  elderly,
• 14:39
  you
• 14:40
  are
• 14:40
  correct.
• 14:40
  Or
• 14:40
  patients
• 14:41
  with
• 14:41
  polypharmacy.
• 14:42
  So
• 14:43
  elderly
• 14:43
  or
• 14:43
  polypharmacy.
• 14:44
  Or
• 14:44
  elderly
• 14:45
  with
• 14:45
  polypharmacy.
• 14:46
  And
• 14:46
  you're
• 14:46
  going,
• 14:47
  oh,
• 14:47
  my
• 14:47
  God,
• 14:47
  my
• 14:47
  head
• 14:47
  is
• 14:48
  spinning.
• 14:48
  I
• 14:48
  don't
• 14:48
  know
• 14:48
  all
• 14:48
  these
• 14:49
  other
• 14:49
  medication
• 14:50
  names.
• 14:50
  What's
• 14:50
  that
• 14:51
  for?
• 14:51
  Lupus.
• 14:53
  Yada,
• 14:53
  yada,
• 14:54
  yada.
• 14:55
  Well,
• 14:55
  Remeron
• 14:56
  is
• 14:57
  a
• 14:57
  little
• 14:57
  bit
• 14:57
  better.
• 14:58
  Always
• 14:58
  run
• 14:59
  your
• 14:59
  interaction
• 14:59
  checks.
• 15:00
  Don't
• 15:00
  just
• 15:00
  assume
• 15:00
  it's
• 15:01
  perfect.
• 15:01
  But,
• 15:02
  you
• 15:02
  know,
• 15:02
  for
• 15:03
  certain
• 15:03
  prescribing
• 15:04
  philosophies,
• 15:04
  it's
• 15:04
  very
• 15:05
  nice
• 15:05
  to
• 15:05
  take
• 15:06
  a
• 15:06
  more
• 15:06
  minimalist
• 15:06
  approach
• 15:07
  and
• 15:07
  go
• 15:08
  for
• 15:08
  a
• 15:08
  medication
• 15:09
  that
• 15:09
  is
• 15:10
  clean
• 15:10
  in
• 15:10
  this
• 15:10
  regard.
• 15:11
  So
• 15:11
  that's
• 15:11
  pretty
• 15:12
  cool.
• 15:12
  It's
• 15:12
  a
• 15:12
  nice
• 15:12
  little
• 15:12
  pearl
• 15:13
  to
• 15:13
  keep
• 15:13
  in
• 15:13
  your
• 15:13
  back
• 15:14
  pocket,
• 15:14
  right?
• 15:14
  The
• 15:15
  seventh
• 15:15
  thing
• 15:16
  you
• 15:16
  didn't
• 15:16
  know
• 15:17
  about
• 15:17
  Remeron
• 15:18
  is
• 15:18
  that
• 15:19
  it
• 15:19
  tends
• 15:20
  to
• 15:21
  actually
• 15:22
  improve
• 15:23
  the
• 15:24
  performance
• 15:25
  of
• 15:25
  some
• 15:26
  SSRIs.
• 15:27
  And
• 15:27
  it
• 15:28
  might
• 15:28
  be
• 15:28
  a
• 15:28
  different
• 15:29
  podcast
• 15:29
  episode,
• 15:30
  but
• 15:30
  the
• 15:31
  way
• 15:31
  it
• 15:31
  goes
• 15:32
  about
• 15:32
  that
• 15:33
  is
• 15:33
  we
• 15:33
  already
• 15:34
  talked
• 15:34
  about
• 15:34
  how
• 15:35
  it
• 15:35
  antagonizes
• 15:36
  the
• 15:36
  alpha
• 15:37
  2
• 15:37
  adrenergic
• 15:37
  receptors,
• 15:38
  which
• 15:39
  releases
• 15:39
  the
• 15:39
  break
• 15:40
  on
• 15:40
  norepinephrine
• 15:41
  and
• 15:41
  serotonin.
• 15:42
  So
• 15:42
  norepinephrine
• 15:42
  and
• 15:43
  serotonin
• 15:43
  can.
• 15:44
  Can
• 15:44
  flow
• 15:45
  more
• 15:45
  freely
• 15:46
  in
• 15:46
  a
• 15:46
  lot
• 15:47
  of
• 15:47
  the
• 15:47
  brain
• 15:47
  regions
• 15:47
  implicated
• 15:48
  in
• 15:48
  mood
• 15:49
  and
• 15:49
  anxiety.
• 15:50
  And
• 15:51
  so
• 15:51
  by
• 15:51
  allowing
• 15:52
  more
• 15:52
  norepinephrine
• 15:53
  and
• 15:53
  serotonin
• 15:53
  into
• 15:54
  the
• 15:54
  synapse,
• 15:55
  that
• 15:56
  will
• 15:56
  then
• 15:57
  allow
• 15:57
  your
• 15:57
  SSRIs
• 15:59
  to
• 16:00
  keep
• 16:00
  them
• 16:00
  in
• 16:01
  that
• 16:01
  synapse
• 16:01
  longer,
• 16:01
  because
• 16:02
  what
• 16:02
  do
• 16:02
  SSRIs
• 16:03
  do?
• 16:03
  They
• 16:03
  prevent
• 16:03
  the
• 16:03
  reuptake
• 16:04
  of
• 16:05
  those
• 16:05
  neurotransmitters.
• 16:06
  So
• 16:06
  you're
• 16:07
  shooting
• 16:07
  out
• 16:07
  more
• 16:07
  neurotransmitters.
• 16:08
  And
• 16:09
  lo
• 16:09
  and
• 16:09
  behold,
• 16:10
  Lenny's
• 16:10
  also
• 16:10
  on
• 16:10
  Lexapro
• 16:11
  15.
• 16:11
  And.
• 16:12
  And
• 16:12
  bam.
• 16:12
  That
• 16:13
  Lexapro
• 16:13
  15
• 16:14
  now
• 16:14
  is
• 16:14
  going
• 16:14
  to
• 16:14
  prevent
• 16:15
  the
• 16:15
  reuptake
• 16:16
  of
• 16:17
  those
• 16:17
  neurotransmitters
• 16:18
  back
• 16:18
  into
• 16:18
  the
• 16:18
  neuron.
• 16:19
  So
• 16:19
  now
• 16:19
  you
• 16:19
  have
• 16:19
  more
• 16:20
  neurotransmitters
• 16:21
  in
• 16:21
  select
• 16:22
  brain
• 16:22
  regions
• 16:22
  that
• 16:23
  are
• 16:23
  working
• 16:23
  for
• 16:24
  you,
• 16:24
  and
• 16:24
  they're
• 16:25
  not
• 16:25
  being
• 16:25
  vacuumed
• 16:26
  up.
• 16:26
  And
• 16:26
  so
• 16:26
  this
• 16:27
  beautiful
• 16:27
  synergy
• 16:28
  of.
• 16:28
  Of
• 16:29
  more
• 16:29
  neurotransmitter
• 16:30
  and
• 16:30
  SSRIs
• 16:31
  that
• 16:31
  don't
• 16:32
  recycle
• 16:32
  them
• 16:32
  back
• 16:33
  into
• 16:33
  the
• 16:33
  neuron.
• 16:34
  Wonderful.
• 16:35
  Right?
• 16:35
  Can
• 16:35
  I
• 16:36
  prescribe
• 16:36
  Remeron
• 16:37
  with.
• 16:38
  With.
• 16:38
  With
• 16:38
  effectsor?
• 16:39
  Well,
• 16:39
  some
• 16:39
  people
• 16:39
  call
• 16:39
  that
• 16:40
  California
• 16:40
  rocket
• 16:41
  fuel,
• 16:41
  right?
• 16:42
  And
• 16:43
  so
• 16:43
  they
• 16:43
  do
• 16:43
  that
• 16:44
  because
• 16:44
  of
• 16:44
  that
• 16:44
  strong
• 16:45
  synergy,
• 16:46
  right,
• 16:46
  where
• 16:47
  you
• 16:47
  have
• 16:47
  the
• 16:47
  SNRI,
• 16:48
  the
• 16:48
  Alpha
• 16:49
  2
• 16:49
  blockade,
• 16:49
  and
• 16:50
  serotonin
• 16:50
  flooding.
• 16:51
  And
• 16:51
  so,
• 16:52
  you
• 16:53
  know,
• 16:53
  I
• 16:53
  won't
• 16:53
  Go
• 16:53
  too
• 16:53
  much
• 16:53
  into
• 16:54
  rocket
• 16:54
  fuel.
• 16:54
  That's
• 16:54
  probably
• 16:55
  its
• 16:55
  own
• 16:55
  podcast
• 16:56
  episode,
• 16:56
  but
• 16:56
  I
• 16:57
  hope
• 16:57
  you
• 16:57
  appreciate
• 16:57
  the
• 16:58
  elegance
• 16:58
  of
• 16:58
  that.
• 16:58
  You
• 16:59
  release
• 16:59
  the
• 16:59
  break
• 16:59
  more
• 17:00
  neurotransmitter
• 17:00
  and
• 17:01
  it's
• 17:01
  not
• 17:01
  recycled
• 17:02
  back
• 17:02
  into
• 17:02
  the
• 17:02
  neuron.
• 17:03
  It
• 17:03
  stays
• 17:03
  in
• 17:03
  that
• 17:04
  synapse
• 17:04
  longer.
• 17:05
  That's
• 17:05
  beautiful.
• 17:05
  And
• 17:06
  so
• 17:06
  you
• 17:06
  can
• 17:06
  know
• 17:06
  intuitively
• 17:07
  not
• 17:08
  just
• 17:09
  that
• 17:09
  you
• 17:09
  can
• 17:09
  prescribe
• 17:10
  Remeron
• 17:10
  and
• 17:11
  effects
• 17:11
  are
• 17:11
  together
• 17:11
  and
• 17:12
  Rembron
• 17:12
  and
• 17:12
  Lexapro
• 17:13
  together,
• 17:13
  but
• 17:13
  why?
• 17:14
  And
• 17:15
  you
• 17:15
  can
• 17:15
  elegantly
• 17:15
  explain
• 17:16
  that
• 17:16
  to
• 17:16
  your
• 17:16
  patients
• 17:17
  so
• 17:17
  they
• 17:17
  understand
• 17:18
  what's
• 17:18
  going
• 17:18
  on
• 17:18
  and
• 17:19
  they
• 17:19
  always
• 17:19
  very
• 17:19
  much
• 17:19
  appreciate
• 17:20
  that
• 17:20
  as
• 17:20
  well.
• 17:20
  The
• 17:21
  eighth
• 17:21
  and
• 17:21
  last
• 17:21
  thing
• 17:21
  you
• 17:22
  may
• 17:22
  not
• 17:22
  know
• 17:22
  about
• 17:23
  Rembron
• 17:24
  is
• 17:24
  it's
• 17:24
  not
• 17:24
  ideal
• 17:25
  for
• 17:25
  atypical
• 17:25
  depression.
• 17:26
  That
• 17:27
  that
• 17:27
  is
• 17:27
  patients
• 17:28
  who
• 17:28
  are
• 17:28
  already
• 17:28
  sleeping
• 17:29
  a
• 17:29
  lot
• 17:29
  and
• 17:29
  overeating
• 17:30
  and
• 17:30
  they're
• 17:30
  heavy
• 17:31
  limbed.
• 17:31
  It
• 17:31
  could
• 17:31
  actually
• 17:32
  kind
• 17:32
  of
• 17:32
  worsen
• 17:32
  that.
• 17:33
  So
• 17:33
  you
• 17:33
  really
• 17:33
  want
• 17:33
  to
• 17:34
  ask
• 17:34
  about
• 17:34
  baseline
• 17:35
  sleep
• 17:35
  and
• 17:35
  appetite
• 17:36
  before
• 17:36
  choosing
• 17:36
  Mirtazapine.
• 17:37
  I
• 17:38
  want
• 17:38
  to
• 17:38
  sprinkle
• 17:39
  in
• 17:39
  just
• 17:39
  one
• 17:40
  more
• 17:40
  little
• 17:41
  thing
• 17:41
  about
• 17:42
  Mirtazapine.
• 17:43
  Call
• 17:43
  it
• 17:43
  the
• 17:43
  ninth
• 17:43
  thing.
• 17:44
  But
• 17:44
  I
• 17:44
  love
• 17:45
  the
• 17:45
  fact
• 17:45
  that
• 17:45
  Mirtazapine,
• 17:46
  or
• 17:46
  also
• 17:47
  called
• 17:47
  Remeron,
• 17:48
  it
• 17:49
  affects
• 17:49
  sleep
• 17:50
  in
• 17:50
  two
• 17:50
  different
• 17:51
  ways.
• 17:51
  It
• 17:51
  affects
• 17:52
  sleep
• 17:52
  via
• 17:52
  histamine
• 17:53
  blockade.
• 17:54
  Right.
• 17:55
  With
• 17:55
  which
• 17:56
  makes
• 17:56
  you
• 17:56
  a
• 17:56
  little
• 17:56
  bit
• 17:57
  sedated.
• 17:57
  And
• 17:58
  the
• 17:58
  effect
• 17:58
  is
• 17:58
  within
• 17:59
  hours,
• 17:59
  it's
• 17:59
  quicker
• 18:00
  sleep
• 18:00
  onset.
• 18:00
  So
• 18:01
  that's
• 18:01
  pretty
• 18:01
  cool.
• 18:02
  Can
• 18:02
  cause
• 18:02
  grogginess
• 18:03
  and
• 18:03
  weight
• 18:03
  gain
• 18:03
  and
• 18:03
  dry
• 18:03
  mouth,
• 18:04
  but
• 18:04
  it
• 18:05
  does
• 18:05
  do
• 18:05
  that.
• 18:05
  And
• 18:05
  it
• 18:06
  also
• 18:06
  affects
• 18:07
  sleep
• 18:07
  by
• 18:07
  blocking
• 18:08
  5ht2a,
• 18:09
  which
• 18:09
  a
• 18:09
  lot
• 18:09
  of
• 18:09
  folks
• 18:10
  don't
• 18:10
  know
• 18:10
  about.
• 18:10
  Right.
• 18:10
  We
• 18:11
  talked
• 18:11
  about
• 18:11
  5ht
• 18:11
  2a
• 18:12
  and
• 18:12
  if
• 18:12
  you
• 18:12
  block
• 18:12
  it,
• 18:13
  you're
• 18:13
  mitigating
• 18:14
  sexual
• 18:14
  side
• 18:14
  effects,
• 18:15
  which
• 18:15
  is
• 18:15
  awesome
• 18:16
  because
• 18:16
  activating
• 18:17
  it
• 18:17
  with
• 18:17
  your
• 18:17
  other
• 18:18
  SSRIs
• 18:18
  cause
• 18:19
  sexual
• 18:19
  side
• 18:19
  effects.
• 18:20
  Well,
• 18:20
  no
• 18:20
  Remeron
• 18:20
  blockades
• 18:21
  that
• 18:22
  it
• 18:22
  counters
• 18:22
  sexual
• 18:23
  side
• 18:23
  effects
• 18:23
  and
• 18:23
  it
• 18:23
  results
• 18:24
  in
• 18:24
  smoother,
• 18:24
  deeper
• 18:25
  sleep,
• 18:26
  which,
• 18:26
  you
• 18:26
  know,
• 18:27
  5H2.2A
• 18:28
  receptors
• 18:28
  are
• 18:28
  excitatory
• 18:29
  in
• 18:29
  the
• 18:29
  cortex
• 18:30
  and
• 18:30
  limbic
• 18:30
  system
• 18:30
  when
• 18:31
  they're
• 18:31
  stimulated.
• 18:31
  It
• 18:32
  can
• 18:32
  involve
• 18:32
  sleep
• 18:33
  fragmentation,
• 18:33
  nighttime
• 18:34
  awakenings,
• 18:35
  hyperarousal
• 18:35
  rumination.
• 18:37
  Well,
• 18:37
  blocking
• 18:37
  5ht2a
• 18:38
  via
• 18:39
  remeron
• 18:39
  can
• 18:40
  result
• 18:40
  in
• 18:41
  actually
• 18:41
  improvement
• 18:42
  in
• 18:42
  slow
• 18:42
  wave
• 18:43
  sleep
• 18:43
  and
• 18:44
  overall
• 18:45
  sleep,
• 18:45
  which
• 18:46
  is
• 18:46
  really
• 18:46
  cool.
• 18:47
  So
• 18:47
  it's
• 18:47
  two
• 18:47
  different
• 18:47
  ways
• 18:48
  it's
• 18:48
  doing
• 18:48
  that.
• 18:49
  I
• 18:49
  hope
• 18:49
  you
• 18:49
  really
• 18:50
  enjoyed
• 18:50
  that
• 18:51
  deep
• 18:51
  dive
• 18:51
  on
• 18:52
  Remeron.
• 18:52
  I
• 18:52
  think
• 18:53
  Lenny
• 18:53
  is
• 18:53
  going
• 18:53
  to
• 18:54
  do
• 18:54
  really,
• 18:54
  really
• 18:54
  good
• 18:55
  on
• 18:55
  Remeron
• 18:56
  and
• 18:57
  he's
• 18:57
  going
• 18:57
  to
• 18:57
  feel
• 18:57
  better,
• 18:58
  in
• 18:58
  my
• 18:58
  experience.
• 18:59
  Not
• 18:59
  just
• 18:59
  in
• 19:00
  the
• 19:00
  evidence
• 19:00
  we
• 19:00
  talked
• 19:01
  about
• 19:01
  today
• 19:01
  or
• 19:01
  the,
• 19:02
  the
• 19:02
  pearls
• 19:02
  we
• 19:03
  talked
• 19:03
  about
• 19:03
  today,
• 19:03
  but
• 19:04
  people
• 19:04
  really
• 19:04
  do
• 19:05
  better
• 19:05
  on
• 19:05
  Remeron.
• 19:06
  Not
• 19:06
  better
• 19:06
  than
• 19:06
  the
• 19:07
  average
• 19:07
  SSRI
• 19:08
  necessarily.
• 19:09
  Again,
• 19:09
  that's
• 19:09
  another
• 19:10
  episode
• 19:10
  if
• 19:10
  we
• 19:11
  want
• 19:11
  to
• 19:11
  talk
• 19:11
  about
• 19:11
  head
• 19:12
  to
• 19:12
  head
• 19:12
  efficacy.
• 19:13
  But
• 19:14
  people
• 19:14
  do
• 19:14
  pretty
• 19:14
  well
• 19:15
  and
• 19:15
  it's
• 19:15
  a
• 19:16
  really
• 19:16
  good
• 19:16
  thing
• 19:16
  to
• 19:17
  have
• 19:17
  in
• 19:17
  your
• 19:17
  back
• 19:17
  pocket.
• 19:18
  Again,
• 19:19
  my
• 19:19
  friends,
• 19:19
  I
• 19:19
  can't
• 19:20
  emphasize
• 19:20
  enough
• 19:20
  how
• 19:21
  important
• 19:21
  it
• 19:21
  is
• 19:21
  to
• 19:21
  become
• 19:22
  Patreon
• 19:22
  members.
• 19:23
  There
• 19:23
  are
• 19:24
  very
• 19:25
  affordable
• 19:25
  memberships,
• 19:26
  5
• 19:26
  bucks
• 19:27
  a
• 19:27
  month,
• 19:27
  10
• 19:27
  bucks
• 19:27
  a
• 19:28
  month
• 19:28
  where
• 19:28
  you
• 19:28
  can
• 19:28
  get
• 19:28
  beautiful
• 19:29
  slide
• 19:29
  decks
• 19:29
  chock
• 19:30
  full
• 19:30
  of
• 19:30
  this
• 19:30
  information
• 19:31
  and
• 19:31
  research
• 19:31
  pearls.
• 19:32
  Really
• 19:33
  fascinating
• 19:33
  stuff
• 19:34
  at
• 19:34
  your
• 19:34
  fingertips,
• 19:35
  including
• 19:35
  bone
• 19:36
  bonus
• 19:36
  podcast
• 19:37
  episodes
• 19:38
  to
• 19:38
  further
• 19:38
  empower
• 19:39
  your
• 19:39
  practice.
• 19:39
  I
• 19:39
  can't
• 19:39
  emphasize
• 19:40
  it
• 19:40
  enough.
• 19:40
  This
• 19:40
  podcast
• 19:41
  has
• 19:41
  gotten
• 19:41
  really
• 19:42
  big,
• 19:42
  really
• 19:42
  quick
• 19:42
  and
• 19:43
  psych
• 19:43
  NP
• 19:43
  circles.
• 19:44
  I
• 19:44
  think
• 19:44
  for
• 19:44
  good
• 19:45
  reason
• 19:45
  because
• 19:45
  we're
• 19:46
  working
• 19:46
  hard
• 19:46
  together
• 19:46
  as
• 19:47
  a
• 19:47
  community
• 19:47
  to
• 19:48
  really
• 19:48
  answer
• 19:48
  questions.
• 19:49
  We
• 19:49
  love
• 19:49
  all
• 19:49
  the
• 19:49
  questions
• 19:50
  we
• 19:50
  get
• 19:50
  from
• 19:50
  you.
• 19:50
  All
• 19:50
  the
• 19:51
  Patreon
• 19:51
  members
• 19:52
  very
• 19:52
  much
• 19:52
  appreciate
• 19:53
  all
• 19:53
  of
• 19:53
  you.
• 19:54
  Please,
• 19:54
  if
• 19:54
  you
• 19:54
  can't
• 19:55
  do
• 19:55
  anything
• 19:55
  else,
• 19:56
  we
• 19:56
  would
• 19:56
  love
• 19:56
  if
• 19:56
  you
• 19:56
  would
• 19:57
  just
• 19:57
  give
• 19:58
  us
• 19:58
  a
• 19:58
  rating
• 19:58
  on
• 19:58
  Apple.
• 19:59
  5
• 19:59
  stars
• 20:00
  with
• 20:00
  a
• 20:00
  little
• 20:00
  comment
• 20:00
  is
• 20:01
  even
• 20:01
  better.
• 20:01
  That's
• 20:02
  a
• 20:02
  great
• 20:02
  way
• 20:02
  to
• 20:02
  support
• 20:03
  and
• 20:03
  message
• 20:04
  me
• 20:04
  in
• 20:04
  the
• 20:04
  show
• 20:04
  notes.
• 20:05
  Right?
• 20:05
  I
• 20:05
  have
• 20:05
  an
• 20:05
  email
• 20:05
  there
• 20:06
  and
• 20:06
  you
• 20:06
  can
• 20:07
  talk
• 20:07
  about
• 20:07
  what
• 20:07
  you'd
• 20:08
  like
• 20:08
  to
• 20:08
  see
• 20:09
  in
• 20:09
  the
• 20:09
  next
• 20:09
  episodes,
• 20:10
  what
• 20:11
  you're
• 20:11
  having
• 20:11
  any
• 20:11
  struggles
• 20:12
  with
• 20:12
  or
• 20:13
  questions
• 20:13
  about.
• 20:13
  It's
• 20:14
  always
• 20:14
  fun
• 20:15
  to
• 20:15
  field
• 20:15
  those
• 20:15
  questions.
• 20:16
  Everybody
• 20:17
  take
• 20:17
  care.
• 20:17
  Signing
• 20:18
  off.
• 20:18
  Have
• 20:18
  a
• 20:18
  good
• 20:19
  night.
• 20:19
  Bye
• 20:19
  Bye.