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Trazodone: Receptors, Sleep and Choosing Medications Wisely. · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  My
• 0:06
  friends,
• 0:06
  welcome
• 0:06
  back
• 0:07
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:09
  and
• 0:09
  Prep.
• 0:09
  We're
• 0:10
  going
• 0:10
  to
• 0:10
  explore
• 0:10
  a
• 0:11
  medication
• 0:11
  you've
• 0:11
  probably
• 0:12
  heard
• 0:12
  about
• 0:12
  5,000
• 0:13
  times,
• 0:14
  but
• 0:14
  you
• 0:14
  may
• 0:15
  not
• 0:16
  understand
• 0:16
  or
• 0:17
  appreciate
• 0:18
  the
• 0:18
  beautiful
• 0:19
  intricacies
• 0:19
  of
• 0:20
  this
• 0:20
  particular
• 0:20
  medication.
• 0:21
  What
• 0:21
  medication
• 0:22
  am
• 0:22
  I
• 0:22
  talking
• 0:22
  about?
• 0:23
  You're
• 0:23
  about
• 0:24
  to
• 0:24
  find
• 0:24
  out.
• 0:25
  But
• 0:25
  first,
• 0:25
  let's
• 0:26
  open
• 0:26
  up
• 0:27
  with
• 0:27
  Randall.
• 0:28
  Randall
• 0:28
  is
• 0:28
  our
• 0:28
  mock
• 0:29
  patient.
• 0:29
  He's
• 0:29
  a
• 0:30
  46
• 0:30
  year
• 0:30
  old
• 0:30
  man.
• 0:31
  He's
• 0:31
  got
• 0:31
  generalized
• 0:32
  anxiety.
• 0:33
  He's
• 0:33
  coming
• 0:33
  to
• 0:34
  you
• 0:34
  in
• 0:34
  the
• 0:34
  outpatient
• 0:35
  space.
• 0:36
  He
• 0:36
  worries.
• 0:36
  He
• 0:37
  has
• 0:37
  recurrent
• 0:38
  nightmares.
• 0:39
  Middle
• 0:39
  insomnia,
• 0:40
  where
• 0:40
  he
• 0:40
  wakes
• 0:41
  up
• 0:41
  in
• 0:41
  the
• 0:41
  middle
• 0:41
  of
• 0:41
  the
• 0:41
  night
• 0:42
  and
• 0:42
  can't
• 0:42
  go
• 0:42
  back
• 0:42
  to
• 0:43
  sleep.
• 0:43
  He
• 0:44
  tends
• 0:44
  to
• 0:44
  worry
• 0:45
  a
• 0:45
  lot
• 0:45
  before
• 0:45
  he
• 0:46
  goes
• 0:46
  to
• 0:46
  sleep.
• 0:47
  That's
• 0:47
  been
• 0:48
  driving
• 0:48
  him
• 0:48
  really
• 0:49
  crazy
• 0:50
  lately.
• 0:50
  He's
• 0:51
  been
• 0:51
  on
• 0:51
  Silenor,
• 0:53
  6
• 0:53
  milligrams
• 0:54
  for
• 0:54
  sleep
• 0:54
  maintenance
• 0:55
  to
• 0:55
  help
• 0:55
  him
• 0:56
  when
• 0:56
  he
• 0:56
  wakes
• 0:56
  up
• 0:56
  in
• 0:57
  the
• 0:57
  middle
• 0:57
  of
• 0:57
  the
• 0:57
  night.
• 0:57
  He's
• 0:58
  also
• 0:58
  been
• 0:58
  on
• 0:58
  Lexapro
• 0:59
  for
• 1:00
  his
• 1:00
  generalized
• 1:00
  anxiety.
• 1:01
  But
• 1:02
  he's
• 1:02
  reporting
• 1:02
  some
• 1:03
  sexual
• 1:03
  dysfunction
• 1:04
  on
• 1:04
  Lexapro
• 1:05
  which
• 1:06
  is
• 1:06
  making
• 1:06
  him
• 1:06
  more
• 1:07
  frustrated
• 1:07
  and
• 1:07
  more
• 1:08
  irritable.
• 1:09
  Now
• 1:10
  he's
• 1:10
  coming
• 1:10
  to
• 1:10
  you
• 1:11
  saying,
• 1:11
  what
• 1:11
  do
• 1:11
  I
• 1:12
  do?
• 1:12
  My
• 1:12
  insomnia
• 1:13
  is
• 1:14
  really
• 1:14
  not
• 1:14
  that
• 1:14
  much
• 1:15
  better
• 1:15
  on
• 1:15
  Silenor
• 1:17
  and
• 1:17
  I
• 1:17
  need
• 1:17
  some
• 1:18
  help.
• 1:18
  I
• 1:18
  have
• 1:18
  sexual
• 1:19
  dysfunction
• 1:20
  and.
• 1:20
  And
• 1:20
  I'm
• 1:20
  still
• 1:20
  a
• 1:21
  little
• 1:21
  anxious
• 1:22
  as
• 1:22
  I
• 1:22
  try
• 1:22
  to
• 1:22
  go
• 1:23
  to
• 1:23
  bed.
• 1:23
  What
• 1:23
  do
• 1:24
  you
• 1:24
  feel
• 1:24
  would
• 1:24
  be
• 1:24
  the
• 1:25
  most
• 1:25
  important
• 1:25
  thing
• 1:26
  to
• 1:26
  ask
• 1:26
  a
• 1:27
  patient
• 1:27
  like
• 1:27
  this
• 1:27
  right
• 1:28
  off
• 1:28
  the
• 1:28
  bat?
• 1:28
  And
• 1:28
  let's
• 1:29
  assume
• 1:29
  we've
• 1:30
  ruled
• 1:30
  out
• 1:30
  all
• 1:30
  the
• 1:30
  medical
• 1:31
  stuff,
• 1:31
  right?
• 1:32
  For
• 1:32
  simplicity's
• 1:33
  sake,
• 1:34
  this
• 1:34
  is
• 1:35
  all
• 1:35
  the
• 1:35
  information
• 1:36
  in
• 1:36
  front
• 1:36
  of
• 1:36
  us
• 1:37
  right
• 1:37
  now.
• 1:38
  And
• 1:39
  let's
• 1:39
  just
• 1:40
  say
• 1:40
  we
• 1:40
  need.
• 1:40
  We
• 1:40
  are
• 1:41
  tasked
• 1:41
  with
• 1:42
  addressing
• 1:42
  his
• 1:43
  core
• 1:43
  symptoms,
• 1:43
  assuming
• 1:44
  that
• 1:45
  this
• 1:45
  is
• 1:45
  not
• 1:45
  some
• 1:45
  medical
• 1:46
  problem.
• 1:48
  Now,
• 1:48
  I
• 1:48
  know
• 1:49
  that
• 1:49
  when
• 1:49
  a
• 1:49
  patient
• 1:49
  asks
• 1:50
  for
• 1:51
  assistance
• 1:51
  with
• 1:51
  sleep
• 1:52
  and
• 1:52
  they
• 1:53
  can't
• 1:53
  sleep
• 1:53
  and
• 1:53
  they're
• 1:53
  on
• 1:54
  an
• 1:54
  ssri,
• 1:54
  of
• 1:55
  course
• 1:55
  it's
• 1:55
  always
• 1:55
  good
• 1:56
  to
• 1:56
  double,
• 1:57
  triple
• 1:57
  check
• 1:58
  that
• 1:58
  this
• 1:58
  is
• 1:58
  not
• 1:59
  part
• 1:59
  of
• 1:59
  some
• 1:59
  kind
• 1:59
  of
• 2:00
  bipolar
• 2:01
  disorder,
• 2:01
  right?
• 2:01
  Where
• 2:02
  they're
• 2:02
  really
• 2:02
  revved
• 2:02
  up
• 2:03
  and
• 2:03
  they
• 2:03
  don't
• 2:03
  feel
• 2:03
  like
• 2:03
  they
• 2:03
  even
• 2:04
  need
• 2:04
  to
• 2:04
  sleep.
• 2:04
  Maybe
• 2:05
  they're
• 2:05
  doing
• 2:05
  impulsive
• 2:06
  things
• 2:06
  in
• 2:06
  the
• 2:06
  wee
• 2:06
  hours
• 2:07
  of
• 2:07
  the
• 2:07
  night.
• 2:08
  You
• 2:08
  know,
• 2:08
  they're
• 2:09
  challenging
• 2:09
  Bobby
• 2:09
  Fischer
• 2:10
  to
• 2:10
  a
• 2:10
  chess
• 2:10
  match.
• 2:11
  They're
• 2:11
  buying
• 2:12
  whole
• 2:12
  lines
• 2:13
  of
• 2:13
  perfume
• 2:14
  by
• 2:14
  the
• 2:14
  thousands,
• 2:15
  starting
• 2:15
  their
• 2:16
  own
• 2:16
  companies.
• 2:16
  Okay?
• 2:17
  So
• 2:17
  that's
• 2:17
  always
• 2:17
  a
• 2:17
  good
• 2:17
  thing.
• 2:18
  It's
• 2:18
  always
• 2:18
  a
• 2:18
  good
• 2:18
  thing
• 2:18
  to
• 2:19
  make
• 2:19
  sure
• 2:19
  that
• 2:19
  it's
• 2:19
  not
• 2:20
  substance
• 2:20
  abuse,
• 2:21
  whether
• 2:21
  it
• 2:21
  be
• 2:21
  some
• 2:22
  severe
• 2:23
  substance
• 2:23
  use
• 2:23
  or
• 2:24
  even
• 2:24
  caffeine
• 2:24
  that
• 2:25
  kind
• 2:25
  of
• 2:25
  creeps
• 2:25
  into
• 2:26
  the
• 2:26
  wee
• 2:26
  hours.
• 2:26
  Some
• 2:27
  energy
• 2:27
  drink,
• 2:27
  the
• 2:28
  patient
• 2:28
  might
• 2:28
  be
• 2:28
  a
• 2:28
  hypometabolizer.
• 2:30
  Of
• 2:30
  caffeine
• 2:31
  we
• 2:31
  talked
• 2:31
  about
• 2:31
  in
• 2:31
  previous
• 2:32
  episodes,
• 2:32
  right?
• 2:33
  How
• 2:33
  the
• 2:34
  caffeine
• 2:34
  metabolism
• 2:35
  can
• 2:35
  vary
• 2:36
  40
• 2:36
  fold
• 2:37
  between
• 2:37
  people.
• 2:37
  That
• 2:38
  is
• 2:38
  shocking
• 2:38
  to
• 2:38
  me.
• 2:39
  40
• 2:39
  fold.
• 2:39
  That
• 2:40
  doesn't
• 2:40
  mean
• 2:40
  that
• 2:41
  you
• 2:41
  and
• 2:41
  me
• 2:41
  right
• 2:41
  now
• 2:42
  can
• 2:42
  go
• 2:42
  for
• 2:42
  a
• 2:42
  cup
• 2:43
  of
• 2:43
  coffee
• 2:43
  and
• 2:44
  I
• 2:44
  get
• 2:45
  a
• 2:45
  decaf
• 2:45
  americano
• 2:46
  and
• 2:46
  you
• 2:47
  get
• 2:47
  a
• 2:47
  decaf
• 2:47
  americano
• 2:48
  and
• 2:48
  you
• 2:48
  don't
• 2:48
  feel
• 2:49
  it
• 2:49
  and
• 2:49
  I
• 2:49
  have
• 2:49
  a
• 2:49
  raging
• 2:50
  panic
• 2:50
  attack.
• 2:50
  That's
• 2:51
  not
• 2:51
  necessarily
• 2:52
  what
• 2:52
  that
• 2:52
  means,
• 2:53
  but
• 2:53
  it
• 2:53
  also
• 2:53
  kind
• 2:54
  of
• 2:54
  means
• 2:54
  that
• 2:54
  too,
• 2:54
  right?
• 2:55
  Where
• 2:56
  it
• 2:56
  can
• 2:57
  vary
• 2:57
  40
• 2:57
  to
• 2:58
  1.
• 2:58
  It
• 2:58
  doesn't
• 2:58
  mean
• 2:58
  that
• 2:58
  in
• 3:00
  ranging
• 3:00
  from
• 3:00
  40
• 3:01
  to
• 3:01
  1
• 3:01
  is
• 3:01
  the
• 3:01
  most
• 3:01
  common
• 3:02
  type
• 3:02
  of
• 3:03
  clinical
• 3:03
  case
• 3:03
  you're
• 3:03
  going
• 3:04
  to
• 3:04
  see.
• 3:05
  Now,
• 3:06
  I
• 3:07
  want
• 3:07
  you
• 3:07
  all
• 3:07
  to
• 3:07
  appreciate
• 3:08
  the
• 3:08
  fact
• 3:08
  that
• 3:09
  although
• 3:09
  this
• 3:09
  seems
• 3:10
  like
• 3:10
  a
• 3:10
  big
• 3:10
  tangent,
• 3:11
  we're
• 3:11
  talking
• 3:11
  about
• 3:11
  energy
• 3:12
  drinks,
• 3:12
  hypomania,
• 3:13
  or
• 3:13
  mania.
• 3:14
  This
• 3:14
  is
• 3:14
  the
• 3:15
  thought
• 3:15
  process
• 3:16
  that
• 3:17
  will
• 3:17
  often
• 3:17
  govern
• 3:18
  the
• 3:19
  way
• 3:19
  you
• 3:20
  are
• 3:20
  thinking
• 3:21
  in
• 3:21
  real
• 3:21
  time
• 3:22
  in
• 3:22
  front
• 3:22
  of
• 3:22
  your
• 3:22
  patient.
• 3:23
  You
• 3:23
  have
• 3:23
  this
• 3:23
  clinical
• 3:24
  case
• 3:24
  in
• 3:24
  front
• 3:24
  of
• 3:24
  you.
• 3:25
  You
• 3:25
  have
• 3:25
  a
• 3:25
  set
• 3:25
  of
• 3:26
  issues
• 3:26
  that
• 3:26
  the
• 3:26
  patient
• 3:27
  is
• 3:27
  articulating.
• 3:28
  But
• 3:29
  before
• 3:29
  you
• 3:29
  act,
• 3:30
  so
• 3:30
  many
• 3:30
  other
• 3:31
  ideas
• 3:31
  are
• 3:32
  swirling
• 3:32
  in
• 3:32
  your
• 3:32
  mind
• 3:33
  and
• 3:33
  they're
• 3:33
  competing
• 3:34
  for
• 3:35
  your
• 3:35
  attention.
• 3:36
  Elucidate
• 3:37
  from
• 3:37
  that
• 3:37
  patient,
• 3:37
  right?
• 3:38
  So
• 3:38
  you've
• 3:38
  got
• 3:38
  to
• 3:39
  always
• 3:39
  assess,
• 3:40
  do
• 3:41
  we
• 3:41
  have
• 3:41
  bipolarity
• 3:42
  here?
• 3:42
  Do
• 3:42
  we
• 3:42
  have
• 3:42
  substance
• 3:43
  use
• 3:43
  here?
• 3:43
  Even
• 3:43
  if
• 3:44
  you've
• 3:44
  evaluated
• 3:44
  them
• 3:45
  before,
• 3:45
  in
• 3:46
  theory,
• 3:46
  they
• 3:47
  could
• 3:47
  absolutely
• 3:48
  be
• 3:48
  activated
• 3:48
  by
• 3:49
  the
• 3:49
  Lexapro
• 3:50
  and
• 3:51
  this
• 3:51
  could
• 3:51
  be
• 3:51
  a
• 3:51
  manifestation
• 3:52
  of
• 3:52
  something
• 3:53
  greater.
• 3:53
  And
• 3:53
  remember,
• 3:54
  patients,
• 3:55
  God
• 3:55
  bless
• 3:55
  them,
• 3:55
  but
• 3:56
  they're
• 3:56
  not
• 3:57
  trained,
• 3:57
  as
• 3:57
  we
• 3:57
  are,
• 3:58
  to
• 3:59
  clearly
• 3:59
  define
• 3:59
  these
• 4:00
  terms.
• 4:00
  Right?
• 4:00
  They
• 4:00
  might
• 4:00
  say,
• 4:01
  oh,
• 4:01
  my
• 4:01
  thoughts
• 4:02
  are
• 4:02
  racing
• 4:03
  at
• 4:03
  night.
• 4:04
  And
• 4:06
  their
• 4:06
  definition
• 4:06
  of
• 4:07
  racing
• 4:07
  thoughts
• 4:07
  might
• 4:08
  be
• 4:08
  different
• 4:09
  than
• 4:09
  yours.
• 4:09
  It
• 4:10
  might
• 4:10
  be
• 4:10
  different
• 4:10
  than
• 4:11
  how
• 4:11
  the
• 4:11
  DSM5TR
• 4:12
  would
• 4:12
  interpret
• 4:13
  it.
• 4:13
  The
• 4:13
  context,
• 4:14
  the
• 4:14
  situational
• 4:16
  degree
• 4:17
  by
• 4:17
  which
• 4:17
  they
• 4:17
  are
• 4:18
  explaining
• 4:19
  this
• 4:19
  stuff
• 4:20
  just
• 4:20
  varies
• 4:20
  all
• 4:21
  the
• 4:21
  time.
• 4:21
  So
• 4:22
  that's
• 4:22
  what
• 4:22
  makes
• 4:23
  this
• 4:23
  field
• 4:23
  so
• 4:23
  interesting.
• 4:24
  Right.
• 4:24
  It'd
• 4:24
  be
• 4:24
  boring
• 4:24
  if
• 4:25
  we
• 4:25
  just
• 4:25
  grabbed
• 4:25
  a
• 4:25
  clipboard,
• 4:26
  collected
• 4:27
  a
• 4:27
  bunch
• 4:27
  of
• 4:27
  symptoms
• 4:28
  and
• 4:28
  said,
• 4:28
  here
• 4:28
  you
• 4:28
  go,
• 4:28
  here's
• 4:29
  a
• 4:29
  great
• 4:29
  medication
• 4:30
  for
• 4:30
  you.
• 4:30
  No,
• 4:31
  it's
• 4:31
  kind
• 4:31
  of
• 4:32
  an
• 4:32
  art
• 4:32
  and
• 4:32
  a
• 4:32
  science.
• 4:33
  Right.
• 4:33
  We
• 4:33
  have
• 4:33
  evidence
• 4:34
  based
• 4:34
  tools
• 4:34
  that
• 4:35
  target
• 4:35
  specific
• 4:36
  receptors
• 4:36
  and
• 4:37
  they
• 4:37
  target
• 4:37
  specific
• 4:38
  clusters
• 4:39
  of
• 4:39
  mental
• 4:39
  health
• 4:39
  issues.
• 4:40
  Your
• 4:40
  patient
• 4:41
  is
• 4:42
  sort
• 4:42
  of
• 4:43
  a
• 4:43
  moving
• 4:43
  target
• 4:43
  every
• 4:44
  time
• 4:44
  they
• 4:44
  come
• 4:44
  in
• 4:44
  because
• 4:46
  so
• 4:46
  many
• 4:46
  different
• 4:46
  things
• 4:47
  could
• 4:47
  potentially
• 4:48
  be
• 4:48
  manifesting
• 4:49
  right
• 4:49
  before
• 4:49
  your
• 4:50
  eyes.
• 4:50
  And
• 4:50
  here
• 4:51
  you
• 4:51
  are
• 4:51
  assuming
• 4:52
  that
• 4:52
  the
• 4:52
  same
• 4:52
  old
• 4:53
  diagnosis
• 4:53
  you
• 4:54
  started
• 4:54
  Randall
• 4:54
  with
• 4:55
  is
• 4:55
  the
• 4:55
  same
• 4:55
  one
• 4:55
  he's
• 4:56
  coming
• 4:56
  in
• 4:56
  with
• 4:56
  right
• 4:57
  now,
• 4:57
  going
• 4:58
  back
• 4:58
  from
• 4:58
  the
• 4:58
  beginning,
• 4:59
  make
• 5:00
  sure
• 5:00
  he's
• 5:00
  not
• 5:00
  bipolar
• 5:01
  and
• 5:01
  being
• 5:01
  activated
• 5:02
  that
• 5:02
  way
• 5:02
  get
• 5:02
  granular.
• 5:03
  What
• 5:04
  does
• 5:04
  his
• 5:04
  anxiety
• 5:05
  specifically
• 5:05
  look
• 5:05
  like?
• 5:06
  Man,
• 5:06
  he's
• 5:06
  telling
• 5:06
  You.
• 5:06
  I
• 5:06
  ruminate.
• 5:07
  I
• 5:08
  ruminate.
• 5:08
  I'm
• 5:09
  worried
• 5:09
  about
• 5:10
  the
• 5:10
  next
• 5:10
  day.
• 5:11
  I'm
• 5:11
  just
• 5:12
  worried
• 5:12
  that
• 5:12
  things
• 5:12
  are
• 5:13
  going
• 5:13
  to
• 5:13
  go
• 5:13
  wrong,
• 5:13
  that
• 5:14
  our
• 5:14
  house
• 5:14
  is
• 5:14
  going
• 5:15
  to
• 5:15
  go
• 5:15
  bankrupt
• 5:15
  and
• 5:15
  we're
• 5:16
  not
• 5:16
  going
• 5:16
  to
• 5:16
  be
• 5:16
  able
• 5:16
  to
• 5:16
  pay
• 5:16
  the
• 5:16
  bills.
• 5:17
  I'm
• 5:17
  worried
• 5:18
  about
• 5:19
  my
• 5:19
  health.
• 5:19
  Right.
• 5:20
  That
• 5:20
  sounds
• 5:20
  like
• 5:20
  generalized
• 5:21
  anxious
• 5:22
  rumination.
• 5:23
  If
• 5:23
  it's
• 5:23
  ADHD
• 5:25
  the
• 5:26
  way
• 5:26
  I
• 5:26
  normally
• 5:27
  experience
• 5:28
  this
• 5:28
  in
• 5:28
  my,
• 5:29
  my
• 5:29
  outpatient
• 5:30
  setting,
• 5:30
  folks
• 5:31
  with
• 5:31
  ADHD
• 5:31
  will
• 5:32
  worry
• 5:32
  about
• 5:32
  things
• 5:33
  they're
• 5:33
  falling
• 5:33
  behind
• 5:34
  on.
• 5:34
  It's
• 5:34
  more
• 5:35
  of
• 5:35
  a
• 5:35
  productivity
• 5:36
  issue.
• 5:36
  They
• 5:36
  can't
• 5:37
  shut
• 5:37
  their
• 5:37
  minds
• 5:37
  off.
• 5:38
  But
• 5:38
  it's
• 5:38
  not
• 5:38
  fear
• 5:39
  based,
• 5:39
  like
• 5:39
  generalized
• 5:40
  anxiety.
• 5:40
  It's
• 5:41
  more,
• 5:41
  I'm
• 5:41
  falling
• 5:41
  behind.
• 5:42
  I
• 5:42
  can't
• 5:42
  organize
• 5:43
  my
• 5:43
  mind
• 5:43
  very
• 5:43
  well
• 5:44
  and
• 5:44
  therefore
• 5:45
  my
• 5:45
  thoughts
• 5:45
  are
• 5:45
  just
• 5:45
  kind
• 5:46
  of
• 5:46
  running
• 5:46
  around.
• 5:47
  They
• 5:47
  will
• 5:47
  say
• 5:47
  they're
• 5:48
  anxious,
• 5:48
  but
• 5:48
  they're
• 5:49
  actually
• 5:50
  trying
• 5:51
  to
• 5:51
  characterize
• 5:51
  hyperarousal
• 5:52
  and
• 5:53
  a
• 5:53
  lack
• 5:53
  of
• 5:53
  being
• 5:53
  able
• 5:54
  to
• 5:54
  prioritize
• 5:54
  their
• 5:55
  thoughts.
• 5:55
  So
• 5:56
  we're
• 5:56
  going
• 5:56
  through
• 5:56
  the
• 5:56
  motions
• 5:57
  with
• 5:57
  Randall.
• 5:58
  And
• 5:58
  he
• 5:58
  emphasizes,
• 5:59
  no,
• 5:59
  it's
• 6:00
  not
• 6:00
  adhd,
• 6:01
  it's
• 6:01
  not
• 6:01
  bipolar,
• 6:02
  it's
• 6:03
  not
• 6:03
  a
• 6:03
  substance
• 6:04
  use
• 6:04
  problem.
• 6:04
  I'm
• 6:05
  just
• 6:05
  anxious.
• 6:05
  I
• 6:05
  have
• 6:05
  sexual
• 6:06
  side
• 6:06
  effects.
• 6:06
  And
• 6:07
  lo
• 6:07
  and
• 6:07
  behold,
• 6:07
  he
• 6:07
  tells
• 6:08
  you
• 6:08
  that
• 6:08
  the
• 6:08
  Lexapro
• 6:09
  is
• 6:09
  actually
• 6:09
  working
• 6:10
  pretty
• 6:10
  well.
• 6:11
  He's
• 6:11
  less
• 6:12
  anxious
• 6:12
  during
• 6:13
  the
• 6:13
  day,
• 6:14
  he's
• 6:14
  a
• 6:15
  little
• 6:15
  more
• 6:15
  resilient
• 6:16
  in
• 6:16
  the
• 6:16
  face
• 6:16
  of
• 6:17
  his
• 6:17
  stressors,
• 6:17
  but
• 6:17
  he
• 6:18
  does
• 6:18
  get
• 6:18
  a
• 6:18
  little
• 6:18
  anxious
• 6:19
  at
• 6:19
  nighttime.
• 6:20
  So
• 6:20
  what
• 6:20
  are
• 6:20
  we
• 6:21
  going
• 6:21
  to
• 6:21
  do
• 6:21
  for
• 6:21
  him
• 6:21
  now?
• 6:22
  My
• 6:22
  friends,
• 6:22
  it's
• 6:23
  not
• 6:23
  enough
• 6:23
  for
• 6:24
  you
• 6:24
  to
• 6:24
  see
• 6:24
  a
• 6:24
  patient
• 6:25
  who
• 6:25
  is
• 6:25
  still
• 6:26
  having
• 6:26
  trouble
• 6:26
  with
• 6:26
  sleep
• 6:27
  and
• 6:27
  just
• 6:27
  eeny,
• 6:28
  meeny,
• 6:28
  miny,
• 6:28
  mowing
• 6:29
  the
• 6:29
  next
• 6:29
  sleep
• 6:29
  medication.
• 6:30
  Just
• 6:30
  picking
• 6:31
  Melatonin
• 6:32
  because
• 6:32
  you
• 6:32
  know
• 6:32
  it's
• 6:32
  a
• 6:32
  sleep
• 6:33
  medication.
• 6:33
  Just
• 6:33
  picking
• 6:34
  Trazodone
• 6:35
  because
• 6:35
  you
• 6:35
  know
• 6:35
  it's
• 6:35
  a
• 6:35
  sleep
• 6:35
  medication.
• 6:36
  Just
• 6:36
  picking
• 6:37
  Remeltion
• 6:38
  or
• 6:38
  Remeron
• 6:39
  because
• 6:39
  you
• 6:39
  know
• 6:39
  it's
• 6:39
  helpful
• 6:40
  in
• 6:40
  sleep.
• 6:41
  It's
• 6:41
  not
• 6:41
  enough
• 6:42
  to
• 6:42
  do
• 6:42
  that.
• 6:42
  In
• 6:43
  order
• 6:43
  for
• 6:43
  us
• 6:43
  to
• 6:44
  be
• 6:44
  effective,
• 6:45
  we
• 6:45
  have
• 6:45
  to
• 6:45
  think
• 6:45
  about
• 6:46
  receptor
• 6:46
  targets.
• 6:47
  We
• 6:48
  have
• 6:48
  to
• 6:48
  know
• 6:48
  which
• 6:49
  medications
• 6:50
  in
• 6:50
  our
• 6:51
  arsenal
• 6:51
  attack
• 6:52
  which
• 6:52
  receptors
• 6:53
  and
• 6:53
  by
• 6:53
  attacking
• 6:53
  or
• 6:54
  targeting
• 6:54
  those
• 6:54
  receptors,
• 6:55
  what
• 6:55
  that's
• 6:56
  going
• 6:56
  to
• 6:56
  translate
• 6:57
  in
• 6:58
  to
• 6:58
  tangibly
• 6:59
  benefit
• 6:59
  your
• 6:59
  patient.
• 7:00
  So
• 7:01
  we
• 7:01
  have
• 7:02
  talked
• 7:02
  about
• 7:02
  this
• 7:02
  in
• 7:02
  many
• 7:03
  previous
• 7:03
  episodes.
• 7:04
  When
• 7:04
  it
• 7:04
  comes
• 7:05
  to
• 7:05
  sleep,
• 7:06
  we
• 7:06
  have
• 7:06
  a
• 7:07
  few
• 7:07
  options.
• 7:07
  Namely,
• 7:08
  the
• 7:08
  histamine
• 7:09
  receptor.
• 7:09
  Right.
• 7:10
  The
• 7:10
  H1
• 7:10
  receptor,
• 7:11
  antagonizing
• 7:12
  it.
• 7:12
  Well,
• 7:12
  the
• 7:13
  patient
• 7:13
  was
• 7:13
  on
• 7:13
  Silenor
• 7:14
  and
• 7:14
  it's
• 7:15
  a
• 7:15
  really
• 7:15
  potent
• 7:16
  histamine
• 7:17
  receptor
• 7:17
  receptor
• 7:18
  antagonist.
• 7:18
  How
• 7:18
  do
• 7:19
  we
• 7:19
  know
• 7:19
  that?
• 7:19
  Because
• 7:19
  Silenor
• 7:20
  is
• 7:20
  really
• 7:20
  clean
• 7:21
  for
• 7:21
  histamine.
• 7:22
  It
• 7:23
  goes
• 7:23
  straight
• 7:24
  for
• 7:24
  the
• 7:24
  histamine
• 7:24
  receptor.
• 7:25
  Very
• 7:25
  high
• 7:25
  affinity,
• 7:26
  very
• 7:26
  powerful,
• 7:27
  and
• 7:27
  it
• 7:28
  doesn't
• 7:28
  really
• 7:28
  hit
• 7:29
  a
• 7:29
  lot
• 7:29
  of
• 7:29
  the
• 7:29
  other
• 7:29
  receptors.
• 7:30
  It's
• 7:30
  just
• 7:30
  kind
• 7:31
  of
• 7:31
  makes
• 7:31
  you
• 7:31
  sedated.
• 7:33
  And
• 7:33
  we
• 7:33
  know
• 7:33
  that
• 7:34
  with
• 7:34
  that
• 7:35
  level
• 7:35
  of
• 7:36
  anti
• 7:36
  histaminergic
• 7:37
  pull,
• 7:37
  it
• 7:38
  didn't
• 7:38
  really
• 7:38
  help.
• 7:38
  Randall,
• 7:39
  he
• 7:39
  still
• 7:39
  has
• 7:40
  rumination
• 7:40
  before
• 7:41
  he
• 7:41
  sleeps.
• 7:42
  Is
• 7:42
  there
• 7:43
  a
• 7:43
  mechanism
• 7:44
  or
• 7:45
  receptor
• 7:45
  target
• 7:46
  that
• 7:46
  deals
• 7:47
  with
• 7:47
  anxious
• 7:48
  rumination,
• 7:49
  promotes
• 7:50
  sleep,
• 7:50
  and
• 7:51
  maybe
• 7:52
  limits
• 7:53
  the
• 7:53
  amount
• 7:53
  of
• 7:53
  hyperarousal
• 7:54
  at
• 7:54
  nighttime?
• 7:56
  Maybe
• 7:56
  it
• 7:56
  limits
• 7:56
  the
• 7:57
  amount
• 7:57
  of
• 7:57
  rumination
• 7:57
  and
• 7:58
  anxiety
• 7:58
  in
• 7:58
  specific
• 7:59
  cortical
• 8:00
  circuits
• 8:00
  at
• 8:00
  nighttime.
• 8:01
  What
• 8:01
  is
• 8:01
  that
• 8:01
  receptor?
• 8:02
  Do
• 8:02
  we
• 8:02
  have
• 8:02
  a
• 8:03
  sleep
• 8:03
  medication
• 8:04
  that
• 8:04
  acts
• 8:04
  on
• 8:05
  that
• 8:05
  receptor?
• 8:06
  I
• 8:06
  don't
• 8:06
  think
• 8:06
  melatonin
• 8:07
  is
• 8:07
  a
• 8:07
  good
• 8:07
  candidate
• 8:08
  for
• 8:08
  that.
• 8:08
  Remeron
• 8:09
  certainly
• 8:10
  has
• 8:10
  its
• 8:10
  virtues.
• 8:11
  It
• 8:11
  would
• 8:11
  not
• 8:11
  be
• 8:11
  a
• 8:12
  terribly
• 8:12
  wrong
• 8:13
  answer
• 8:13
  here.
• 8:13
  Right.
• 8:13
  Because
• 8:14
  you
• 8:14
  do
• 8:14
  have
• 8:15
  a
• 8:15
  patient
• 8:15
  with
• 8:15
  sexual
• 8:16
  dysfunction.
• 8:16
  Remeron
• 8:17
  tends
• 8:17
  to
• 8:17
  counter
• 8:18
  sexual
• 8:18
  dysfunction.
• 8:19
  It
• 8:19
  definitely
• 8:19
  will
• 8:20
  help
• 8:20
  sleep.
• 8:21
  But
• 8:21
  it
• 8:21
  might
• 8:22
  be
• 8:22
  kind
• 8:22
  of
• 8:22
  shooting
• 8:23
  squirrels
• 8:23
  with
• 8:23
  shotguns
• 8:24
  a
• 8:24
  little
• 8:24
  bit,
• 8:24
  maybe.
• 8:25
  But
• 8:25
  it's
• 8:25
  not
• 8:25
  entirely
• 8:26
  inappropriate.
• 8:27
  Every
• 8:27
  patient's
• 8:27
  different.
• 8:28
  I
• 8:29
  highly
• 8:29
  encourage
• 8:29
  you
• 8:30
  to
• 8:30
  do
• 8:30
  a
• 8:30
  deep
• 8:30
  dive
• 8:31
  on
• 8:31
  Remeron
• 8:31
  and
• 8:32
  assess
• 8:32
  whether
• 8:32
  Remeron
• 8:33
  would
• 8:33
  be
• 8:33
  good
• 8:33
  for
• 8:33
  this
• 8:34
  patient
• 8:34
  in
• 8:34
  particular.
• 8:34
  I
• 8:35
  certainly
• 8:35
  don't
• 8:35
  think
• 8:35
  it
• 8:35
  could
• 8:36
  hurt
• 8:36
  for
• 8:37
  all
• 8:37
  intents
• 8:37
  and
• 8:37
  purposes
• 8:38
  today.
• 8:38
  What
• 8:39
  about
• 8:39
  Trazodone?
• 8:40
  This
• 8:40
  is
• 8:40
  a
• 8:40
  medication
• 8:41
  that,
• 8:41
  when
• 8:41
  I
• 8:42
  first
• 8:42
  learned
• 8:42
  about
• 8:42
  it,
• 8:43
  I
• 8:43
  had
• 8:43
  an
• 8:44
  overly
• 8:44
  simplistic
• 8:45
  appreciation
• 8:46
  for
• 8:46
  Trazodone.
• 8:47
  Or
• 8:47
  maybe
• 8:47
  you
• 8:47
  could
• 8:47
  say
• 8:48
  I
• 8:48
  didn't
• 8:48
  have
• 8:48
  that
• 8:49
  fine
• 8:49
  of
• 8:49
  an
• 8:50
  appreciation
• 8:50
  for
• 8:50
  Trazodone
• 8:51
  because
• 8:51
  trazodone
• 8:52
  does
• 8:52
  many
• 8:53
  things
• 8:53
  at
• 8:53
  once.
• 9:49
  And
• 9:49
  that
• 9:49
  can
• 9:50
  be
• 9:50
  bad
• 9:50
  sometimes,
• 8:56
  because
• 9:51
  when
• 9:52
  a
• 9:52
  medication
• 9:52
  hits
• 9:53
  a
• 9:53
  lot
• 9:53
  of
• 9:53
  different
• 9:53
  receptors,
• 9:54
  you
• 9:54
  can
• 9:55
  get
• 9:55
  some
• 9:55
  extra
• 9:56
  baggage.
• 9:56
  Right?
• 9:57
  Trazodone
• 9:58
  does
• 9:58
  have
• 9:58
  an
• 9:58
  affinity
• 9:59
  for
• 9:59
  the
• 9:59
  alpha
• 9:59
  1
• 10:00
  adrenergic
• 10:00
  receptors.
• 10:01
  It
• 10:01
  antagonizes
• 10:02
  them,
• 10:02
  which
• 10:02
  can
• 10:03
  at
• 10:03
  times
• 10:04
  make
• 10:04
  people
• 10:04
  feel
• 10:05
  a
• 10:05
  little
• 10:05
  groggy,
• 10:06
  kind
• 10:06
  of
• 10:06
  a
• 10:06
  hangover,
• 10:07
  feeling
• 10:07
  the
• 10:07
  next
• 10:07
  morning
• 10:08
  a
• 10:08
  little
• 10:08
  foggy.
• 10:09
  But
• 10:10
  on
• 10:10
  the
• 10:10
  flip
• 10:10
  side,
• 10:11
  antagonizing
• 10:12
  alpha
• 10:12
  1
• 10:12
  can
• 10:13
  also
• 10:13
  decrease
• 10:14
  the
• 10:14
  adrenergic
• 10:15
  tone
• 10:15
  a
• 10:15
  little
• 10:15
  bit.
• 10:15
  It
• 10:15
  can
• 10:16
  suppress
• 10:16
  nightmares.
• 10:17
  It
• 10:17
  can
• 10:18
  reduce
• 10:18
  the
• 10:19
  physiological
• 10:19
  arousal
• 10:20
  that
• 10:21
  somebody
• 10:21
  has
• 10:22
  before
• 10:22
  they
• 10:22
  go
• 10:23
  to
• 10:23
  sleep.
• 10:23
  And
• 10:23
  in
• 10:24
  this
• 10:24
  patient's
• 10:24
  case,
• 10:24
  Randall,
• 10:25
  he
• 10:25
  does
• 10:25
  tell
• 10:25
  you
• 10:25
  he
• 10:26
  has
• 10:26
  nightmares.
• 10:26
  Now,
• 10:27
  Trazodone
• 10:27
  is
• 10:27
  not
• 10:28
  FDA
• 10:28
  approved
• 10:28
  for
• 10:29
  nightmares.
• 10:29
  It's
• 10:29
  approved
• 10:30
  for
• 10:30
  depression.
• 10:31
  However,
• 10:32
  it
• 10:32
  might
• 10:32
  be
• 10:33
  a
• 10:33
  nice
• 10:33
  added
• 10:34
  benefit
• 10:35
  that
• 10:35
  Trazodone
• 10:36
  has
• 10:36
  a
• 10:37
  receptor
• 10:38
  antagonist
• 10:39
  quality
• 10:39
  to
• 10:39
  it
• 10:39
  that
• 10:40
  might
• 10:40
  make
• 10:40
  your
• 10:40
  patient
• 10:41
  less
• 10:41
  physiologically
• 10:42
  aroused,
• 10:42
  and
• 10:43
  therefore
• 10:43
  they
• 10:43
  might
• 10:44
  be
• 10:44
  able
• 10:44
  to
• 10:44
  sleep
• 10:45
  a
• 10:45
  little
• 10:45
  bit
• 10:45
  better
• 10:46
  because
• 10:46
  of
• 10:46
  that.
• 10:47
  That
• 10:47
  is
• 10:47
  pretty
• 10:48
  darn
• 10:48
  cool.
• 10:49
  Remember,
• 10:49
  that
• 10:49
  can
• 10:50
  go
• 10:50
  both
• 10:50
  ways,
• 10:50
  and
• 10:51
  it
• 10:51
  could
• 10:51
  be
• 10:51
  the
• 10:51
  reason
• 10:52
  your
• 10:52
  patient's
• 10:52
  waking
• 10:53
  up
• 10:53
  in
• 10:53
  not
• 10:54
  the
• 10:54
  best
• 10:54
  Mood
• 10:54
  feeling
• 10:55
  kind
• 10:55
  of
• 10:55
  sluggish
• 10:56
  and
• 10:56
  down.
• 10:56
  It's
• 10:56
  an
• 10:57
  added
• 10:57
  effect
• 10:58
  for
• 10:59
  their
• 10:59
  fatigue
• 11:00
  in
• 11:00
  addition
• 11:00
  to
• 11:00
  Trazodone's
• 11:01
  histaminergic
• 11:02
  effects.
• 11:03
  But
• 11:03
  there's
• 11:04
  a
• 11:04
  little
• 11:04
  secret
• 11:04
  here,
• 11:05
  that
• 11:05
  Trazodone
• 11:06
  has
• 11:06
  a
• 11:07
  little
• 11:07
  arrow
• 11:08
  in
• 11:08
  its
• 11:08
  quiver,
• 11:08
  if
• 11:08
  you
• 11:09
  will.
• 11:09
  And
• 11:10
  it
• 11:10
  is
• 11:11
  a
• 11:11
  5ht
• 11:12
  2a
• 11:14
  antagonist.
• 11:15
  And
• 11:15
  that
• 11:16
  is
• 11:16
  pretty
• 11:17
  darn
• 11:17
  cool,
• 11:17
  my
• 11:18
  friends,
• 11:19
  very
• 11:19
  darn
• 11:19
  cool.
• 11:20
  Why?
• 11:21
  Because
• 11:21
  when
• 11:22
  5ht2a
• 11:23
  is
• 11:23
  stimulated,
• 11:24
  which
• 11:24
  a
• 11:24
  lot
• 11:25
  of
• 11:25
  SSRIs
• 11:25
  like
• 11:25
  Lexapro
• 11:26
  can
• 11:26
  do,
• 11:27
  Lexapro
• 11:28
  does
• 11:28
  not
• 11:28
  stimulate
• 11:28
  it
• 11:29
  directly.
• 11:29
  Lexapro
• 11:30
  inhibits
• 11:31
  the
• 11:31
  reuptake
• 11:31
  of
• 11:32
  serotonin,
• 11:32
  thereby
• 11:33
  indirectly,
• 11:34
  with
• 11:34
  more
• 11:35
  serotonin
• 11:35
  in
• 11:35
  the
• 11:36
  synapse
• 11:36
  all
• 11:36
  around,
• 11:37
  there
• 11:38
  is
• 11:38
  more
• 11:38
  serotonin
• 11:39
  to
• 11:39
  stimulate
• 11:39
  that
• 11:39
  5ht2a
• 11:40
  receptor.
• 11:41
  So
• 11:41
  I
• 11:41
  want
• 11:41
  to
• 11:41
  be
• 11:41
  clear,
• 11:42
  Alexapro
• 11:42
  does
• 11:43
  not
• 11:43
  explicitly
• 11:44
  directly
• 11:45
  target
• 11:45
  5ht2a,
• 11:47
  but
• 11:47
  it
• 11:47
  does
• 11:47
  lead
• 11:47
  to
• 11:47
  the
• 11:48
  increased
• 11:48
  stimulation
• 11:49
  of
• 11:49
  that
• 11:49
  receptor.
• 11:50
  With
• 11:50
  Trazodone
• 11:52
  you
• 11:52
  antagonize
• 11:53
  it
• 11:53
  because
• 11:54
  when
• 11:54
  you
• 11:54
  excite
• 11:54
  that
• 11:55
  receptor,
• 11:55
  you
• 11:56
  have
• 11:56
  over
• 11:56
  activation,
• 11:57
  increased
• 11:57
  glutamate,
• 11:58
  cortical
• 11:58
  excitability,
• 11:59
  emotional
• 12:00
  ability.
• 12:00
  And
• 12:01
  so
• 12:01
  you
• 12:01
  have
• 12:01
  a
• 12:01
  little
• 12:02
  bit
• 12:02
  more
• 12:03
  rumination
• 12:03
  and
• 12:04
  anxiety
• 12:04
  when
• 12:05
  that
• 12:05
  receptor
• 12:06
  is
• 12:06
  stimulated.
• 12:06
  And
• 12:07
  lo
• 12:07
  and
• 12:07
  behold,
• 12:07
  Trazodone
• 12:08
  actually
• 12:09
  antagonizes
• 12:09
  that.
• 12:10
  Well,
• 12:10
  that's
• 12:11
  really
• 12:11
  nice
• 12:11
  because
• 12:11
  those
• 12:12
  cortical
• 12:13
  circuits
• 12:14
  can
• 12:14
  very
• 12:14
  much
• 12:15
  be
• 12:15
  implicated
• 12:15
  in
• 12:16
  why
• 12:16
  Randall
• 12:17
  is
• 12:17
  having
• 12:17
  anxious
• 12:18
  rumination
• 12:18
  at
• 12:19
  night,
• 12:19
  why
• 12:19
  it's
• 12:19
  much
• 12:19
  more
• 12:20
  difficult
• 12:20
  for
• 12:20
  him
• 12:20
  to
• 12:21
  fall
• 12:21
  asleep.
• 12:22
  That's
• 12:22
  vital
• 12:22
  information.
• 12:23
  That's
• 12:23
  why
• 12:23
  we
• 12:24
  have
• 12:24
  to
• 12:24
  ask
• 12:25
  patients
• 12:26
  questions
• 12:26
  carefully
• 12:27
  and
• 12:27
  assess
• 12:28
  them
• 12:28
  carefully
• 12:29
  and
• 12:29
  not
• 12:29
  be
• 12:30
  satisfied
• 12:30
  with
• 12:30
  I
• 12:30
  can't
• 12:31
  sleep.
• 12:31
  Here's
• 12:31
  a
• 12:31
  sleep
• 12:32
  med
• 12:32
  that
• 12:32
  I
• 12:32
  know
• 12:32
  nothing
• 12:32
  about.
• 12:33
  Rather,
• 12:34
  let's
• 12:35
  explore
• 12:35
  the
• 12:36
  process
• 12:36
  of
• 12:37
  your
• 12:39
  sleep.
• 12:39
  What's
• 12:40
  happening
• 12:40
  right
• 12:40
  before
• 12:40
  you
• 12:41
  fall
• 12:41
  asleep?
• 12:42
  What
• 12:42
  are
• 12:42
  you
• 12:42
  thinking
• 12:43
  about?
• 12:44
  Because
• 12:44
  you
• 12:44
  might
• 12:45
  find
• 12:45
  some
• 12:45
  patients
• 12:45
  aren't
• 12:46
  ruminating
• 12:46
  that
• 12:46
  much.
• 12:47
  They're
• 12:47
  not
• 12:47
  that
• 12:47
  anxious
• 12:48
  right
• 12:48
  before
• 12:48
  they
• 12:48
  go
• 12:48
  to
• 12:48
  sleep.
• 12:49
  They
• 12:49
  don't
• 12:49
  have
• 12:49
  nightmares,
• 12:50
  they're
• 12:50
  not
• 12:50
  waking
• 12:50
  up
• 12:50
  in
• 12:51
  the
• 12:51
  middle
• 12:51
  of
• 12:51
  the
• 12:51
  night.
• 12:52
  So
• 12:52
  getting
• 12:52
  the
• 12:52
  unique
• 12:53
  sleep
• 12:53
  or
• 12:54
  insomnia
• 12:54
  signature
• 12:55
  rather
• 12:56
  is
• 12:56
  very
• 12:56
  important
• 12:57
  because
• 12:57
  then
• 12:57
  you
• 12:57
  can
• 12:57
  tailor
• 12:58
  make
• 12:59
  your
• 12:59
  response
• 12:59
  to
• 13:00
  those
• 13:00
  specific
• 13:00
  receptors.
• 13:01
  Trazodone's
• 13:02
  pretty
• 13:02
  good
• 13:02
  at
• 13:02
  that
• 13:02
  5ht2a
• 13:03
  antagonism,
• 13:05
  it
• 13:05
  has
• 13:05
  more
• 13:05
  of
• 13:05
  a
• 13:05
  calming
• 13:06
  effect.
• 13:06
  It
• 13:06
  can
• 13:07
  better
• 13:07
  sleep
• 13:07
  continuity,
• 13:08
  add
• 13:08
  to
• 13:08
  a
• 13:09
  little
• 13:09
  bit
• 13:09
  more
• 13:09
  of
• 13:09
  a
• 13:10
  deeper
• 13:10
  sleep,
• 13:10
  a
• 13:11
  more
• 13:11
  refreshing
• 13:11
  sleep,
• 13:12
  increased
• 13:13
  slow
• 13:13
  wave
• 13:13
  sleep.
• 13:14
  So
• 13:14
  that's
• 13:14
  really
• 13:15
  neat,
• 13:15
  a
• 13:16
  neat
• 13:16
  little
• 13:16
  pearl.
• 13:17
  As
• 13:17
  it
• 13:17
  relates
• 13:17
  to
• 13:18
  trazodone,
• 13:19
  we
• 13:19
  talked
• 13:19
  about
• 13:19
  Alpha
• 13:19
  1
• 13:20
  antagonism
• 13:21
  2.
• 13:21
  It
• 13:22
  also
• 13:22
  antagonizes
• 13:23
  H1
• 13:24
  or
• 13:24
  histamine,
• 13:24
  so
• 13:25
  it
• 13:25
  does
• 13:25
  sedate
• 13:25
  U2.
• 13:26
  So
• 13:26
  do
• 13:26
  you
• 13:27
  notice
• 13:27
  how
• 13:27
  it's
• 13:27
  doing?
• 13:27
  Kind
• 13:28
  of
• 13:28
  the
• 13:28
  Swiss
• 13:28
  army
• 13:29
  knife
• 13:29
  effect
• 13:30
  of
• 13:30
  things
• 13:31
  with
• 13:31
  really
• 13:32
  big
• 13:32
  clinical
• 13:33
  implications.
• 13:34
  In
• 13:34
  addition,
• 13:34
  it's
• 13:35
  quite
• 13:35
  good
• 13:35
  for
• 13:36
  minimizing
• 13:37
  sexual
• 13:37
  dysfunction.
• 13:38
  It
• 13:38
  does
• 13:39
  that
• 13:39
  by
• 13:39
  antagonizing
• 13:40
  the
• 13:40
  5ht2c
• 13:42
  receptor.
• 13:43
  Again,
• 13:43
  pretty
• 13:44
  cool.
• 13:45
  And,
• 13:45
  you
• 13:45
  know,
• 13:46
  does
• 13:46
  it
• 13:46
  do
• 13:47
  that
• 13:47
  immediately?
• 13:47
  Not
• 13:48
  necessarily
• 13:48
  right.
• 13:48
  Trazodone
• 13:49
  has
• 13:49
  a
• 13:49
  wide
• 13:50
  dosing
• 13:50
  range,
• 13:51
  so
• 13:51
  you're
• 13:51
  getting
• 13:51
  mostly
• 13:52
  the
• 13:52
  hypnotic
• 13:53
  effects
• 13:53
  at
• 13:53
  these
• 13:54
  lower
• 13:54
  doses,
• 13:55
  50
• 13:55
  to
• 13:55
  100.
• 13:56
  But
• 13:56
  you
• 13:56
  do
• 13:56
  get
• 13:57
  a
• 13:57
  little
• 13:57
  bit
• 13:57
  of
• 13:57
  5ht2a
• 13:58
  antagonism
• 13:59
  in
• 14:00
  the
• 14:00
  100
• 14:00
  range.
• 14:01
  And
• 14:01
  as
• 14:01
  you
• 14:01
  increase
• 14:02
  Trazodone,
• 14:03
  which
• 14:03
  is
• 14:03
  less
• 14:03
  commonly
• 14:04
  done
• 14:04
  clinically,
• 14:05
  you
• 14:05
  start
• 14:06
  to
• 14:06
  recruit
• 14:07
  more
• 14:07
  of
• 14:07
  these
• 14:07
  receptors
• 14:08
  that
• 14:08
  are
• 14:08
  antidepressant
• 14:09
  in
• 14:10
  nature.
• 14:11
  So
• 14:11
  25
• 14:11
  to
• 14:12
  100
• 14:12
  is
• 14:12
  mostly
• 14:13
  hypnotic.
• 14:13
  As
• 14:13
  you
• 14:13
  push
• 14:14
  it
• 14:14
  to
• 14:14
  150
• 14:14
  and
• 14:15
  higher,
• 14:15
  with
• 14:16
  more
• 14:16
  of
• 14:16
  a
• 14:16
  target
• 14:16
  around
• 14:17
  300,
• 14:18
  you
• 14:18
  are
• 14:18
  getting
• 14:18
  more
• 14:18
  of
• 14:19
  the
• 14:19
  antidepressant
• 14:21
  effects.
• 14:22
  It's
• 14:22
  very
• 14:22
  important
• 14:22
  to
• 14:23
  remember
• 14:23
  that
• 14:23
  5ht2a
• 14:24
  antagonism
• 14:25
  does
• 14:25
  not
• 14:25
  directly
• 14:25
  sedate,
• 14:26
  but
• 14:26
  it
• 14:27
  does
• 14:27
  turn
• 14:27
  down
• 14:27
  the
• 14:28
  brain's
• 14:28
  internal
• 14:28
  amplifier
• 14:30
  that
• 14:30
  drives
• 14:30
  anxious
• 14:31
  ruminations
• 14:32
  and
• 14:32
  hyperarousal.
• 14:33
  So
• 14:33
  the
• 14:34
  secondary
• 14:34
  effect
• 14:35
  is
• 14:35
  that
• 14:35
  you
• 14:35
  feel
• 14:35
  a
• 14:36
  little
• 14:36
  bit
• 14:36
  more
• 14:36
  ready
• 14:37
  to
• 14:37
  fall
• 14:37
  asleep.
• 14:38
  Adding
• 14:39
  Trazodone
• 14:39
  to
• 14:40
  Randall's
• 14:41
  medications
• 14:42
  might
• 14:42
  have
• 14:43
  this
• 14:43
  unique
• 14:43
  effect
• 14:44
  of
• 14:44
  potentially
• 14:45
  reversing
• 14:45
  sexual
• 14:46
  dysfunction
• 14:46
  or
• 14:46
  mitigating
• 14:47
  it,
• 14:48
  potentially
• 14:48
  allowing
• 14:49
  him
• 14:49
  to
• 14:49
  sleep
• 14:49
  and
• 14:50
  stay
• 14:50
  asleep
• 14:51
  via
• 14:51
  5ht2a
• 14:52
  antagonism.
• 14:54
  It
• 14:54
  may
• 14:55
  hopefully
• 14:56
  have
• 14:56
  some
• 14:56
  kind
• 14:57
  of
• 14:57
  a
• 14:57
  positive
• 14:57
  effect
• 14:58
  on
• 14:58
  his
• 14:58
  nightmares.
• 14:58
  Now,
• 14:58
  it's
• 14:59
  not
• 14:59
  a
• 14:59
  guarantee,
• 15:00
  but
• 15:00
  there
• 15:00
  have
• 15:00
  been
• 15:00
  case
• 15:01
  reports
• 15:01
  and
• 15:01
  some
• 15:01
  evidence
• 15:02
  that
• 15:02
  Trazodone
• 15:02
  can
• 15:03
  help
• 15:03
  with
• 15:03
  nightmares.
• 15:04
  But
• 15:04
  again,
• 15:04
  you're
• 15:05
  going
• 15:05
  for
• 15:05
  a
• 15:05
  two
• 15:06
  or
• 15:06
  three
• 15:06
  for
• 15:06
  one
• 15:06
  here.
• 15:07
  And
• 15:07
  it's
• 15:08
  finally
• 15:08
  targeted.
• 15:09
  It's
• 15:09
  FDA
• 15:10
  approved
• 15:10
  for
• 15:10
  middle
• 15:11
  insomnia,
• 15:11
  which
• 15:11
  is
• 15:12
  really
• 15:12
  cool.
• 15:13
  So
• 15:13
  Salanor,
• 15:13
  being
• 15:14
  the
• 15:14
  brand
• 15:14
  name
• 15:14
  of
• 15:14
  Doxepan,
• 15:15
  which
• 15:15
  is
• 15:15
  the
• 15:16
  generic
• 15:16
  tricyclic
• 15:17
  antidepressant,
• 15:18
  was
• 15:18
  used
• 15:18
  at
• 15:19
  a
• 15:19
  lower
• 15:19
  dose
• 15:19
  for
• 15:20
  sleep
• 15:20
  maintenance.
• 15:21
  I
• 15:21
  want
• 15:21
  you
• 15:22
  to
• 15:22
  have
• 15:22
  a
• 15:22
  good
• 15:22
  understanding.
• 15:23
  All
• 15:23
  of
• 15:23
  your
• 15:23
  sleep
• 15:23
  meds
• 15:24
  have
• 15:25
  very
• 15:25
  different
• 15:25
  signatures
• 15:26
  that,
• 15:27
  depending
• 15:28
  on
• 15:28
  the
• 15:28
  context
• 15:28
  with
• 15:28
  your
• 15:29
  patient,
• 15:29
  can
• 15:29
  be
• 15:29
  very
• 15:30
  useful
• 15:31
  for
• 15:31
  you.
• 15:31
  Trazodone
• 15:32
  is
• 15:32
  not
• 15:32
  without
• 15:33
  its
• 15:33
  warnings.
• 15:34
  I
• 15:34
  encourage
• 15:34
  you
• 15:35
  to
• 15:35
  always
• 15:35
  look
• 15:35
  at
• 15:35
  black
• 15:36
  box
• 15:36
  warnings.
• 15:36
  In
• 15:37
  this
• 15:37
  case,
• 15:37
  increased
• 15:38
  suicidal
• 15:38
  warning
• 15:39
  thoughts
• 15:39
  or
• 15:39
  behaviors
• 15:40
  in
• 15:40
  individuals
• 15:41
  24
• 15:41
  or
• 15:41
  younger.
• 15:41
  Please
• 15:42
  do
• 15:42
  your
• 15:42
  research
• 15:42
  on
• 15:43
  these
• 15:43
  black
• 15:43
  box
• 15:43
  warnings.
• 15:44
  It
• 15:44
  does
• 15:44
  have
• 15:45
  a
• 15:45
  QT
• 15:45
  prolongation
• 15:46
  and
• 15:46
  arrhythmia
• 15:47
  risk
• 15:47
  to
• 15:48
  it
• 15:48
  in
• 15:48
  overdose.
• 15:49
  I
• 15:49
  urge
• 15:50
  you
• 15:50
  to
• 15:50
  consult
• 15:50
  any
• 15:51
  risks.
• 15:51
  Don't
• 15:51
  depend
• 15:52
  on
• 15:52
  this
• 15:52
  podcast
• 15:53
  for
• 15:53
  that
• 15:53
  kind
• 15:53
  of
• 15:54
  stuff.
• 15:54
  The
• 15:54
  point
• 15:55
  of
• 15:55
  this
• 15:55
  episode,
• 15:55
  my
• 15:56
  friends,
• 15:56
  is
• 15:57
  to
• 15:57
  give
• 15:57
  you
• 15:57
  a
• 15:57
  more
• 15:58
  unique
• 15:58
  conceptual
• 15:59
  appreciation
• 16:00
  for
• 16:00
  what
• 16:00
  these
• 16:00
  medications
• 16:01
  can
• 16:01
  do
• 16:01
  and
• 16:01
  how
• 16:02
  they
• 16:02
  do
• 16:02
  it.
• 16:03
  And
• 16:03
  for
• 16:03
  you
• 16:03
  to
• 16:03
  get
• 16:03
  a
• 16:03
  little
• 16:04
  curious
• 16:05
  before
• 16:05
  you
• 16:05
  prescribe
• 16:06
  something
• 16:06
  and
• 16:06
  go,
• 16:06
  you
• 16:06
  know
• 16:07
  what?
• 16:07
  I'm
• 16:07
  not
• 16:07
  satisfied
• 16:08
  with
• 16:08
  the
• 16:09
  fact
• 16:09
  that
• 16:09
  I
• 16:09
  know
• 16:09
  Trazodone
• 16:10
  will
• 16:10
  help
• 16:10
  you
• 16:11
  sleep.
• 16:11
  I
• 16:11
  need
• 16:11
  to
• 16:11
  know
• 16:12
  why
• 16:12
  in
• 16:13
  particular
• 16:13
  it's
• 16:13
  going
• 16:13
  to
• 16:14
  help
• 16:14
  you
• 16:14
  sleep
• 16:14
  and
• 16:14
  how
• 16:15
  and
• 16:15
  what
• 16:16
  other
• 16:16
  things
• 16:16
  it
• 16:17
  might
• 16:17
  do
• 16:18
  to
• 16:18
  make
• 16:19
  your
• 16:19
  life
• 16:19
  a
• 16:19
  little
• 16:20
  bit
• 16:20
  easier.
• 16:21
  So
• 16:21
  that's
• 16:22
  Randall's
• 16:23
  case.
• 16:23
  Today.
• 16:24
  We
• 16:24
  targeted
• 16:25
  his
• 16:25
  anxious
• 16:25
  ruminations,
• 16:26
  his
• 16:26
  nightmares,
• 16:27
  his
• 16:27
  sexual
• 16:27
  dysfunction.
• 16:28
  We
• 16:29
  started
• 16:29
  him
• 16:29
  on
• 16:29
  Trazodone
• 16:30
  50,
• 16:30
  maybe
• 16:31
  bumped
• 16:31
  him
• 16:31
  up
• 16:31
  to
• 16:31
  100.
• 16:32
  We'll
• 16:32
  watch
• 16:32
  the
• 16:32
  Lexapro
• 16:33
  dose.
• 16:33
  We
• 16:33
  want
• 16:34
  to
• 16:34
  watch
• 16:34
  the
• 16:34
  serotonin
• 16:35
  load
• 16:35
  given
• 16:36
  that
• 16:36
  these
• 16:36
  are
• 16:36
  both
• 16:36
  serotonergic
• 16:37
  medications.
• 16:38
  As
• 16:38
  you
• 16:38
  push
• 16:38
  the
• 16:39
  Trazodone
• 16:39
  dose
• 16:39
  up
• 16:40
  higher
• 16:40
  to
• 16:40
  an
• 16:40
  antidepressant
• 16:41
  type,
• 16:42
  you
• 16:42
  do
• 16:42
  have
• 16:43
  to
• 16:43
  be
• 16:43
  very
• 16:43
  mindful
• 16:44
  of
• 16:44
  what
• 16:44
  you're
• 16:44
  doing
• 16:45
  with
• 16:45
  Lexapro.
• 16:45
  So
• 16:45
  you
• 16:46
  gotta
• 16:46
  be
• 16:46
  very
• 16:46
  judicious.
• 16:47
  I
• 16:47
  don't
• 16:47
  like
• 16:47
  carrying
• 16:48
  a
• 16:48
  very
• 16:48
  high
• 16:48
  serotonergic
• 16:49
  load
• 16:50
  due
• 16:50
  to
• 16:50
  the
• 16:50
  risk
• 16:50
  of
• 16:50
  serotonin
• 16:51
  syndrome,
• 16:52
  so
• 16:52
  definitely
• 16:53
  consult
• 16:53
  your
• 16:53
  resources
• 16:54
  before
• 16:54
  you
• 16:54
  proceed.
• 16:55
  I
• 16:55
  hope
• 16:55
  you
• 16:56
  enjoyed
• 16:56
  this
• 16:56
  and
• 16:56
  if
• 16:56
  you
• 16:57
  are
• 16:57
  enjoying
• 16:57
  this
• 16:57
  podcast,
• 16:58
  go
• 16:58
  into
• 16:58
  the
• 16:59
  show
• 16:59
  notes
• 16:59
  after
• 16:59
  this
• 17:00
  and
• 17:00
  become
• 17:01
  a
• 17:01
  Patreon
• 17:01
  member
• 17:02
  because
• 17:02
  you're
• 17:02
  going
• 17:02
  to
• 17:02
  get
• 17:02
  slide
• 17:03
  decks
• 17:03
  full
• 17:03
  of
• 17:04
  evidence
• 17:04
  based
• 17:04
  information
• 17:05
  and
• 17:05
  clinical
• 17:06
  tools
• 17:06
  that
• 17:07
  are
• 17:07
  right
• 17:07
  at
• 17:07
  your
• 17:07
  fingertips.
• 17:08
  This
• 17:08
  one
• 17:08
  stop
• 17:09
  shop
• 17:09
  to
• 17:10
  really
• 17:10
  understand
• 17:10
  these
• 17:11
  receptors
• 17:11
  and
• 17:11
  what
• 17:11
  they
• 17:12
  do,
• 17:12
  their
• 17:12
  affinities,
• 17:13
  the
• 17:13
  pharmacology
• 17:14
  unique
• 17:15
  fun
• 17:15
  case
• 17:15
  studies
• 17:16
  that
• 17:16
  you
• 17:16
  can
• 17:16
  nerd
• 17:16
  out
• 17:17
  over.
• 17:17
  It's
• 17:17
  really
• 17:18
  fun
• 17:18
  to
• 17:18
  become
• 17:18
  a
• 17:18
  Patreon
• 17:19
  member.
• 17:20
  You'll
• 17:20
  even
• 17:20
  get
• 17:20
  episode
• 17:21
  drops
• 17:21
  well
• 17:21
  before
• 17:22
  they
• 17:22
  drop
• 17:22
  into
• 17:23
  your
• 17:23
  news
• 17:23
  feeds
• 17:24
  with
• 17:25
  your
• 17:25
  podcast
• 17:25
  players.
• 17:25
  So
• 17:26
  you
• 17:26
  get
• 17:26
  a
• 17:26
  private
• 17:26
  podcast
• 17:27
  experience
• 17:28
  there
• 17:28
  too,
• 17:28
  which
• 17:28
  is
• 17:28
  really
• 17:29
  cool.
• 17:29
  You
• 17:29
  can
• 17:29
  also
• 17:30
  message
• 17:30
  me
• 17:30
  directly
• 17:31
  for
• 17:31
  podcast
• 17:32
  episode
• 17:32
  recommendations
• 17:33
  and
• 17:33
  we
• 17:34
  can
• 17:34
  build
• 17:34
  an
• 17:34
  amazing
• 17:35
  study
• 17:35
  hall
• 17:35
  together
• 17:36
  and
• 17:36
  make
• 17:37
  school
• 17:37
  a
• 17:37
  little
• 17:37
  easier
• 17:38
  and
• 17:38
  more
• 17:38
  fun
• 17:38
  for
• 17:38
  all
• 17:39
  of
• 17:39
  you.
• 17:39
  I
• 17:39
  depend
• 17:40
  on
• 17:40
  each
• 17:40
  and
• 17:40
  every
• 17:40
  one
• 17:40
  of
• 17:40
  you
• 17:41
  giving
• 17:41
  me
• 17:41
  feedback
• 17:41
  about
• 17:42
  what
• 17:42
  you
• 17:42
  want
• 17:42
  to
• 17:42
  learn
• 17:43
  next,
• 17:43
  what
• 17:43
  your
• 17:43
  questions
• 17:44
  might
• 17:44
  be,
• 17:44
  what
• 17:44
  you
• 17:45
  want
• 17:45
  to
• 17:45
  do
• 17:45
  a
• 17:45
  deep
• 17:45
  dive
• 17:46
  with
• 17:46
  collaboratively.
• 17:46
  It's
• 17:47
  really
• 17:47
  a
• 17:47
  lot
• 17:47
  of
• 17:47
  fun.
• 17:48
  And
• 17:48
  if
• 17:48
  nothing
• 17:48
  else,
• 17:49
  my
• 17:49
  friends,
• 17:49
  I
• 17:49
  know
• 17:49
  you're
• 17:50
  busy,
• 17:50
  I
• 17:50
  know
• 17:50
  you're
• 17:50
  in
• 17:50
  school
• 17:51
  or
• 17:51
  you're
• 17:52
  busy
• 17:52
  in
• 17:52
  your
• 17:52
  practice.
• 17:52
  Go
• 17:53
  over
• 17:53
  to
• 17:53
  Apple
• 17:53
  Podcasts,
• 17:54
  give
• 17:54
  us
• 17:54
  five
• 17:55
  stars
• 17:55
  and
• 17:55
  a
• 17:55
  nice
• 17:55
  rating
• 17:56
  if
• 17:56
  you
• 17:56
  can.
• 17:56
  That
• 17:56
  helps
• 17:57
  a
• 17:57
  lot
• 17:57
  too.
• 17:58
  Remember,
• 17:58
  pearls
• 17:58
  and
• 17:59
  prep
• 17:59
  is
• 17:59
  not
• 17:59
  just
• 18:00
  about
• 18:01
  passing
• 18:01
  your
• 18:01
  boards.
• 18:02
  It's
• 18:02
  not
• 18:02
  just
• 18:02
  about
• 18:03
  arming
• 18:04
  yourself
• 18:04
  with
• 18:04
  a
• 18:04
  little
• 18:04
  more
• 18:05
  knowledge.
• 18:05
  Every
• 18:06
  single
• 18:06
  pearl
• 18:07
  you
• 18:07
  learn,
• 18:07
  even
• 18:07
  if
• 18:07
  you
• 18:07
  just
• 18:08
  learned
• 18:08
  one
• 18:08
  little
• 18:08
  pearl.
• 18:09
  Today,
• 18:09
  with
• 18:10
  this
• 18:10
  episode
• 18:10
  is
• 18:11
  a
• 18:11
  unique
• 18:11
  opportunity
• 18:12
  to
• 18:12
  make
• 18:12
  somebody's
• 18:13
  day
• 18:13
  and
• 18:14
  life
• 18:14
  a
• 18:14
  heck
• 18:14
  of
• 18:15
  a
• 18:15
  lot
• 18:15
  easier
• 18:15
  and
• 18:15
  better.
• 18:16
  If
• 18:16
  you
• 18:16
  can
• 18:16
  restore
• 18:17
  somebody's
• 18:17
  sleep,
• 18:18
  if
• 18:18
  you
• 18:18
  can
• 18:19
  stop
• 18:19
  them
• 18:19
  from
• 18:19
  ruminating,
• 18:20
  you
• 18:20
  can
• 18:21
  help
• 18:21
  them
• 18:21
  become
• 18:22
  a
• 18:22
  better
• 18:22
  partner,
• 18:23
  a
• 18:23
  better
• 18:23
  uncle,
• 18:24
  a
• 18:24
  better
• 18:24
  coworker.
• 18:26
  That's
• 18:26
  what
• 18:26
  we
• 18:26
  want.
• 18:27
  That's
• 18:27
  why
• 18:27
  we
• 18:27
  become
• 18:27
  Patreon
• 18:28
  members
• 18:28
  and
• 18:28
  build
• 18:29
  a
• 18:29
  community.
• 18:30
  We
• 18:30
  appreciate
• 18:30
  all
• 18:30
  of
• 18:30
  you
• 18:31
  for
• 18:31
  making
• 18:31
  this
• 18:32
  podcast
• 18:32
  spread
• 18:33
  to
• 18:33
  schools
• 18:34
  around
• 18:34
  the
• 18:34
  country
• 18:34
  and
• 18:34
  in
• 18:35
  multiple
• 18:35
  countries.
• 18:35
  Now,
• 18:36
  we
• 18:36
  very
• 18:36
  much
• 18:37
  appreciate
• 18:37
  all
• 18:37
  your
• 18:38
  hard
• 18:38
  work.
• 18:38
  Thank
• 18:39
  you
• 18:39
  all
• 18:39
  for
• 18:39
  joining.
• 18:40
  Another
• 18:40
  episode
• 18:40
  of
• 18:41
  Pearls
• 18:41
  and
• 18:41
  Prep.
• 18:42
  Signing
• 18:42
  off.
• 18:42
  Take
• 18:42
  care.
• 18:43
  Bye.
• 18:43
  Bye.