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The Missing Lab That Looks Like Half the DSM: Why 1 in 3 Women May Be Misdiagnosed · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:11
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:13
  to
• 0:14
  practice.
• 0:14
  Well,
• 0:15
  my
• 0:15
  friends,
• 0:15
  I
• 0:15
  went
• 0:16
  on
• 0:16
  a
• 0:16
  major
• 0:17
  pearl
• 0:17
  dive
• 0:17
  the
• 0:18
  other
• 0:18
  day.
• 0:18
  And
• 0:19
  as
• 0:19
  you
• 0:19
  know,
• 0:19
  my
• 0:19
  goal
• 0:20
  during
• 0:20
  these
• 0:20
  pearl
• 0:21
  dives
• 0:21
  is
• 0:22
  to
• 0:22
  scour
• 0:23
  the
• 0:23
  depths
• 0:24
  of
• 0:24
  the
• 0:24
  ocean
• 0:24
  floor
• 0:25
  and
• 0:25
  find
• 0:25
  a
• 0:25
  big,
• 0:26
  shiny,
• 0:26
  high
• 0:26
  yield,
• 0:27
  practical
• 0:27
  pearl
• 0:28
  to
• 0:28
  bring
• 0:28
  to
• 0:28
  you.
• 0:29
  To
• 0:29
  talk
• 0:29
  with
• 0:30
  you
• 0:30
  about.
• 0:31
  That,
• 0:31
  I
• 0:31
  think
• 0:32
  could
• 0:32
  fundamentally
• 0:33
  change
• 0:33
  the
• 0:33
  way
• 0:33
  we
• 0:33
  practice.
• 0:34
  Something
• 0:35
  that's
• 0:35
  overlooked,
• 0:36
  something
• 0:37
  that
• 0:37
  we
• 0:37
  need
• 0:37
  to
• 0:37
  discuss
• 0:38
  that
• 0:38
  we
• 0:38
  aren't
• 0:39
  discussing
• 0:39
  enough
• 0:39
  about.
• 0:40
  And
• 0:40
  if
• 0:40
  we
• 0:40
  share
• 0:40
  it
• 0:41
  with
• 0:41
  each
• 0:41
  other,
• 0:41
  we
• 0:42
  could
• 0:42
  do
• 0:42
  a
• 0:42
  lot
• 0:42
  of
• 0:42
  good
• 0:43
  for
• 0:43
  the
• 0:43
  patients
• 0:44
  in
• 0:44
  our
• 0:44
  community.
• 0:45
  And
• 0:45
  so
• 0:46
  today,
• 0:46
  we're
• 0:46
  going
• 0:46
  to
• 0:46
  talk
• 0:47
  about
• 0:47
  ferritin.
• 0:48
  Ferritin
• 0:49
  is
• 0:50
  critically
• 0:50
  important.
• 0:51
  It's
• 0:52
  one
• 0:52
  of
• 0:52
  the
• 0:52
  most
• 0:52
  important
• 0:53
  labs
• 0:53
  we
• 0:53
  are
• 0:54
  not
• 0:54
  talking
• 0:54
  about
• 0:54
  and
• 0:54
  we
• 0:55
  need
• 0:55
  to
• 0:55
  talk
• 0:55
  about
• 0:56
  because
• 0:57
  it
• 0:57
  can
• 0:57
  absolutely
• 0:58
  matter
• 0:59
  in
• 0:59
  a
• 0:59
  major
• 1:00
  way
• 1:00
  in
• 1:01
  our
• 1:01
  outpatient
• 1:01
  practice
• 1:02
  if
• 1:02
  we
• 1:03
  are
• 1:03
  not
• 1:03
  checking
• 1:03
  on
• 1:03
  it
• 1:04
  to
• 1:04
  see
• 1:04
  how
• 1:05
  it
• 1:05
  might
• 1:05
  be
• 1:05
  affecting
• 1:06
  our
• 1:06
  patient.
• 1:07
  Now,
• 1:08
  I'm
• 1:08
  going
• 1:08
  to
• 1:08
  keep
• 1:08
  this
• 1:09
  really
• 1:09
  simple,
• 1:10
  okay?
• 1:10
  Because
• 1:10
  it
• 1:11
  is
• 1:11
  pretty
• 1:11
  simple.
• 1:12
  But
• 1:12
  ferritin
• 1:13
  is
• 1:14
  your
• 1:14
  iron
• 1:15
  storage.
• 1:15
  Your
• 1:16
  iron
• 1:17
  is
• 1:17
  literally
• 1:17
  stored
• 1:18
  in
• 1:19
  ferritin,
• 1:20
  okay?
• 1:21
  And
• 1:21
  so
• 1:22
  ferritin
• 1:22
  is
• 1:22
  a
• 1:23
  protein.
• 1:23
  It
• 1:23
  just
• 1:23
  stores
• 1:24
  your
• 1:24
  iron
• 1:24
  safely
• 1:25
  in
• 1:25
  your
• 1:25
  cells,
• 1:26
  and
• 1:26
  then
• 1:26
  it
• 1:26
  kind
• 1:26
  of
• 1:26
  releases
• 1:27
  the
• 1:27
  iron
• 1:28
  when
• 1:28
  your
• 1:29
  body
• 1:29
  runs
• 1:29
  low.
• 1:30
  So
• 1:31
  the
• 1:32
  fastest
• 1:33
  way
• 1:33
  and
• 1:33
  the
• 1:33
  earliest
• 1:34
  way
• 1:34
  you
• 1:34
  can
• 1:34
  figure
• 1:35
  out
• 1:35
  if
• 1:35
  your
• 1:35
  patient
• 1:36
  is
• 1:36
  iron
• 1:36
  depleted
• 1:37
  is
• 1:37
  to
• 1:37
  check
• 1:37
  the
• 1:37
  warehouse,
• 1:38
  to
• 1:38
  check
• 1:39
  the
• 1:39
  inventory
• 1:39
  in
• 1:39
  the
• 1:39
  warehouse.
• 1:40
  That
• 1:40
  would
• 1:40
  be
• 1:40
  the
• 1:40
  ferritin
• 1:41
  level.
• 1:41
  And
• 1:42
  if
• 1:42
  that
• 1:42
  level
• 1:42
  is
• 1:42
  dropping,
• 1:43
  if
• 1:43
  we're
• 1:43
  getting
• 1:43
  below
• 1:44
  50,
• 1:44
  because
• 1:44
  it's
• 1:45
  ideal
• 1:45
  between
• 1:45
  50
• 1:46
  and
• 1:46
  100,
• 1:46
  if
• 1:47
  we're
• 1:47
  getting
• 1:47
  below
• 1:47
  50,
• 1:48
  then
• 1:48
  psychiatric
• 1:49
  symptoms
• 1:49
  can
• 1:50
  start
• 1:50
  to
• 1:50
  happen.
• 1:51
  And
• 1:51
  you're
• 1:51
  gonna
• 1:51
  see
• 1:51
  your
• 1:52
  patients
• 1:52
  show
• 1:52
  up
• 1:52
  in
• 1:52
  your
• 1:53
  clinic
• 1:53
  and
• 1:53
  they're
• 1:54
  gonna
• 1:54
  be
• 1:54
  complaining
• 1:54
  of
• 1:55
  low
• 1:55
  motivation,
• 1:56
  inability
• 1:57
  to
• 1:57
  focus.
• 1:57
  You're
• 1:58
  gonna
• 1:58
  think
• 1:58
  they
• 1:58
  have
• 1:58
  adhd.
• 1:59
  They
• 1:59
  might
• 1:59
  say
• 2:00
  they're
• 2:00
  not
• 2:00
  as
• 2:00
  calm,
• 2:00
  they're
• 2:01
  moody,
• 2:02
  they
• 2:02
  feel
• 2:04
  just
• 2:05
  really
• 2:05
  lethargic,
• 2:07
  and
• 2:07
  their
• 2:07
  sleep
• 2:08
  is
• 2:08
  impaired
• 2:08
  and
• 2:08
  they
• 2:08
  have
• 2:09
  restless
• 2:09
  legs
• 2:10
  and
• 2:10
  maybe
• 2:11
  they're
• 2:11
  even
• 2:11
  short
• 2:11
  of
• 2:12
  breath.
• 2:12
  And
• 2:13
  you're
• 2:13
  gonna
• 2:14
  misconstrue
• 2:14
  that
• 2:14
  for
• 2:15
  so
• 2:15
  many
• 2:15
  other
• 2:15
  diagnoses.
• 2:16
  Maybe
• 2:17
  you're
• 2:17
  gonna
• 2:17
  prescribe
• 2:17
  SSRIs
• 2:18
  or
• 2:18
  put
• 2:18
  them
• 2:18
  on
• 2:19
  a
• 2:19
  stimulant
• 2:20
  or
• 2:20
  send
• 2:21
  out
• 2:21
  all
• 2:21
  these
• 2:21
  referrals
• 2:22
  when
• 2:22
  this
• 2:23
  whole
• 2:23
  time
• 2:23
  we
• 2:24
  could
• 2:24
  have
• 2:24
  checked
• 2:25
  if
• 2:25
  they
• 2:25
  had
• 2:26
  an
• 2:26
  iron
• 2:26
  depletion.
• 2:27
  Now,
• 2:28
  so
• 2:28
  many
• 2:28
  clinicians
• 2:29
  will
• 2:29
  just
• 2:29
  get
• 2:29
  a
• 2:30
  cbc,
• 2:30
  look
• 2:31
  at
• 2:31
  the
• 2:31
  hemoglobin,
• 2:32
  and
• 2:32
  say,
• 2:33
  good
• 2:33
  to
• 2:33
  go.
• 2:33
  We
• 2:33
  don't
• 2:34
  have
• 2:34
  anemia
• 2:34
  here.
• 2:34
  Let's
• 2:35
  carry
• 2:35
  on.
• 2:36
  Right.
• 2:36
  It's
• 2:37
  good
• 2:37
  that
• 2:37
  we
• 2:37
  check.
• 2:38
  B12,
• 2:38
  folate,
• 2:39
  vitamin
• 2:39
  D,
• 2:39
  TSH,
• 2:41
  all
• 2:41
  of
• 2:42
  those
• 2:42
  things
• 2:42
  are
• 2:42
  really
• 2:43
  good.
• 2:43
  But
• 2:44
  so
• 2:44
  often
• 2:44
  we
• 2:45
  don't
• 2:45
  include
• 2:45
  ferritin
• 2:47
  and
• 2:47
  until
• 2:47
  it's
• 2:48
  too
• 2:48
  late.
• 2:49
  And
• 2:49
  I
• 2:49
  think
• 2:49
  it
• 2:49
  should
• 2:50
  be
• 2:50
  more
• 2:50
  regularly
• 2:51
  incorporated
• 2:52
  in
• 2:53
  the
• 2:54
  assessments
• 2:54
  that
• 2:55
  we
• 2:55
  conduct
• 2:56
  and
• 2:56
  in
• 2:56
  the
• 2:57
  questions
• 2:57
  that
• 2:57
  we
• 2:57
  ask.
• 2:58
  It's
• 2:59
  very
• 2:59
  important.
• 3:00
  One
• 3:00
  of
• 3:00
  the
• 3:00
  most
• 3:01
  earth
• 3:01
  shattering
• 3:02
  pearls
• 3:02
  I
• 3:02
  will
• 3:02
  share
• 3:02
  with
• 3:03
  you
• 3:03
  today
• 3:03
  are
• 3:03
  that
• 3:04
  one
• 3:04
  out
• 3:04
  of
• 3:04
  every
• 3:05
  three,
• 3:05
  up
• 3:05
  to
• 3:06
  one
• 3:06
  out
• 3:06
  of
• 3:06
  every
• 3:06
  three
• 3:07
  of
• 3:07
  your
• 3:07
  menstruating
• 3:08
  females
• 3:09
  in
• 3:09
  your
• 3:10
  outpatient
• 3:10
  practice
• 3:11
  may
• 3:11
  have
• 3:12
  a
• 3:12
  ferritin
• 3:12
  deficiency.
• 3:14
  So
• 3:14
  they
• 3:14
  have
• 3:14
  a
• 3:15
  normal
• 3:15
  cbc,
• 3:15
  their
• 3:16
  hemoglobin
• 3:16
  looks
• 3:16
  fine.
• 3:17
  You
• 3:17
  might
• 3:18
  think,
• 3:18
  oh,
• 3:18
  there's
• 3:18
  no
• 3:18
  anemia
• 3:19
  going
• 3:19
  on
• 3:19
  here
• 3:19
  at
• 3:19
  all.
• 3:20
  And
• 3:20
  lo
• 3:20
  and
• 3:20
  behold,
• 3:21
  their
• 3:22
  warehouse
• 3:22
  iron
• 3:23
  levels
• 3:23
  are
• 3:23
  being
• 3:24
  depleted
• 3:25
  rapidly.
• 3:26
  And
• 3:26
  you
• 3:27
  see
• 3:27
  them
• 3:27
  have
• 3:28
  no
• 3:28
  motivation
• 3:29
  or
• 3:29
  energy
• 3:29
  to
• 3:30
  do
• 3:30
  anything
• 3:30
  anymore.
• 3:30
  They
• 3:31
  tell
• 3:31
  you
• 3:31
  that
• 3:31
  they've
• 3:31
  been
• 3:31
  like
• 3:31
  this
• 3:32
  maybe
• 3:32
  for
• 3:32
  the
• 3:32
  last
• 3:32
  two
• 3:33
  years.
• 3:33
  They
• 3:34
  can't
• 3:34
  focus.
• 3:35
  They
• 3:36
  aren't
• 3:36
  able
• 3:36
  to
• 3:37
  retain
• 3:37
  information
• 3:37
  when
• 3:38
  they're
• 3:38
  reading
• 3:38
  books
• 3:39
  or
• 3:39
  studying
• 3:40
  for
• 3:40
  their
• 3:40
  exams
• 3:41
  and
• 3:41
  they're
• 3:42
  panicking.
• 3:42
  And
• 3:43
  maybe
• 3:43
  they're
• 3:43
  telling
• 3:44
  you
• 3:44
  that
• 3:44
  they've
• 3:45
  always
• 3:45
  thought
• 3:45
  they
• 3:45
  had
• 3:45
  adhd
• 3:46
  and
• 3:46
  you
• 3:46
  just,
• 3:46
  you
• 3:47
  started
• 3:47
  Concerta
• 3:48
  or
• 3:48
  Vyvanse
• 3:48
  now,
• 3:49
  and
• 3:49
  they
• 3:49
  have
• 3:50
  side
• 3:50
  effects
• 3:50
  and
• 3:50
  it's
• 3:51
  impairing
• 3:51
  their
• 3:51
  sleep.
• 3:51
  And
• 3:52
  now
• 3:52
  they
• 3:52
  have
• 3:52
  sexual
• 3:52
  dysfunction
• 3:53
  from
• 3:53
  the
• 3:53
  SSRI
• 3:54
  because
• 3:54
  their
• 3:55
  anxiety
• 3:56
  was
• 3:57
  misconstrued
• 3:58
  as
• 3:58
  gad.
• 3:59
  But
• 3:59
  really
• 4:00
  what's
• 4:01
  happening
• 4:01
  is
• 4:01
  they
• 4:01
  don't
• 4:02
  have
• 4:02
  enough
• 4:02
  iron
• 4:03
  stores
• 4:03
  to
• 4:03
  build
• 4:04
  dopamine,
• 4:05
  to
• 4:05
  build
• 4:05
  serotonin,
• 4:06
  to
• 4:06
  build
• 4:07
  norepinephrine,
• 4:08
  to
• 4:08
  build
• 4:08
  the
• 4:09
  insulation
• 4:09
  around
• 4:10
  your
• 4:10
  nerve
• 4:10
  wires
• 4:11
  that
• 4:11
  help
• 4:11
  thinking
• 4:12
  happen
• 4:13
  quickly
• 4:14
  and
• 4:14
  in
• 4:14
  a
• 4:14
  streamlined
• 4:15
  fashion.
• 4:15
  Right?
• 4:16
  Because
• 4:16
  iron
• 4:17
  is
• 4:17
  a
• 4:18
  major
• 4:18
  player
• 4:19
  in
• 4:19
  making
• 4:19
  dopamine,
• 4:20
  serotonin,
• 4:20
  norepinephrine,
• 4:21
  and
• 4:22
  the
• 4:22
  insulation
• 4:22
  around
• 4:23
  your
• 4:23
  nerves
• 4:23
  and
• 4:24
  powering
• 4:24
  your
• 4:24
  mitochondria.
• 4:25
  As
• 4:25
  you
• 4:25
  can
• 4:26
  imagine,
• 4:26
  that
• 4:26
  covers
• 4:27
  basically
• 4:27
  every
• 4:27
  symptom
• 4:28
  in
• 4:28
  mental
• 4:28
  health.
• 4:28
  You
• 4:28
  can
• 4:29
  imagine
• 4:29
  if
• 4:30
  our
• 4:30
  wiring
• 4:31
  is
• 4:31
  off
• 4:32
  in
• 4:32
  our
• 4:33
  neurons,
• 4:34
  if
• 4:34
  our,
• 4:34
  if
• 4:34
  we're
• 4:34
  not
• 4:35
  making
• 4:35
  enough
• 4:35
  dopamine,
• 4:35
  serotonin,
• 4:36
  and
• 4:36
  norepinephrine,
• 4:37
  that
• 4:37
  can
• 4:37
  mimic
• 4:38
  nearly
• 4:38
  every
• 4:39
  single
• 4:39
  mental
• 4:39
  health
• 4:40
  problem
• 4:40
  that
• 4:40
  we
• 4:40
  see.
• 4:41
  And
• 4:41
  so
• 4:42
  getting
• 4:42
  an
• 4:42
  iron
• 4:43
  level,
• 4:43
  getting
• 4:44
  a
• 4:44
  ferritin
• 4:44
  level
• 4:45
  more
• 4:45
  specifically
• 4:46
  to
• 4:47
  check
• 4:47
  the
• 4:47
  amount
• 4:48
  of
• 4:48
  iron
• 4:48
  in
• 4:48
  the
• 4:48
  warehouse
• 4:49
  is
• 4:49
  incredibly
• 4:50
  important
• 4:51
  because,
• 4:51
  again,
• 4:51
  it
• 4:52
  will
• 4:52
  drop
• 4:52
  first
• 4:52
  and
• 4:53
  earliest.
• 4:54
  Your
• 4:54
  body
• 4:54
  is
• 4:55
  not
• 4:55
  going
• 4:56
  to
• 4:56
  pull
• 4:57
  that
• 4:57
  from
• 4:57
  hemoglobin.
• 4:58
  And
• 4:58
  so
• 4:59
  until
• 4:59
  the
• 4:59
  very
• 4:59
  end.
• 5:00
  Right.
• 5:00
  Because
• 5:00
  hemoglobin's
• 5:01
  what
• 5:01
  you're
• 5:02
  actively
• 5:02
  using
• 5:02
  to
• 5:02
  oxygenate
• 5:03
  your
• 5:03
  body
• 5:04
  right
• 5:04
  now
• 5:05
  as
• 5:05
  you
• 5:05
  hear
• 5:05
  this
• 5:05
  podcast
• 5:06
  episode.
• 5:06
  Right.
• 5:07
  So
• 5:07
  it's
• 5:07
  not
• 5:07
  gonna
• 5:07
  go
• 5:07
  there
• 5:08
  first,
• 5:08
  it's
• 5:08
  gonna
• 5:08
  go
• 5:08
  there
• 5:09
  last.
• 5:09
  And
• 5:09
  it'll
• 5:09
  be
• 5:10
  way
• 5:10
  too
• 5:10
  late
• 5:10
  at
• 5:11
  that
• 5:11
  point.
• 5:11
  Right?
• 5:12
  So
• 5:12
  when
• 5:12
  patients
• 5:13
  dip
• 5:13
  under
• 5:14
  50.
• 5:15
  Cause
• 5:15
  we
• 5:15
  really
• 5:16
  want
• 5:16
  ferritin
• 5:16
  to
• 5:16
  be
• 5:17
  around
• 5:17
  50
• 5:17
  to
• 5:17
  a
• 5:17
  hundred,
• 5:18
  generally
• 5:19
  speaking.
• 5:21
  But
• 5:21
  when
• 5:21
  you
• 5:21
  dip
• 5:21
  below
• 5:22
  50,
• 5:23
  that
• 5:24
  iron
• 5:24
  storage,
• 5:25
  that
• 5:25
  piggy
• 5:25
  bank,
• 5:25
  is
• 5:26
  getting
• 5:26
  low.
• 5:27
  Okay?
• 5:27
  Your
• 5:28
  CBC
• 5:28
  can
• 5:28
  still
• 5:28
  look
• 5:29
  perfect,
• 5:29
  but
• 5:29
  your
• 5:30
  brain
• 5:30
  is
• 5:30
  starting
• 5:30
  to
• 5:31
  feel
• 5:31
  the
• 5:31
  pinch.
• 5:32
  Okay?
• 5:33
  And
• 5:33
  that's
• 5:33
  a
• 5:33
  problem.
• 5:34
  Your
• 5:34
  patient
• 5:34
  might
• 5:35
  start
• 5:35
  to
• 5:35
  get
• 5:35
  mildly
• 5:36
  anxious
• 5:36
  at
• 5:36
  that
• 5:36
  point.
• 5:37
  Kind
• 5:37
  of
• 5:37
  this
• 5:37
  vague
• 5:37
  unease,
• 5:38
  this
• 5:38
  restlessness.
• 5:39
  They
• 5:39
  can't
• 5:40
  really
• 5:40
  relax.
• 5:41
  They
• 5:41
  might
• 5:41
  feel
• 5:41
  fatigued.
• 5:42
  They
• 5:43
  might
• 5:43
  not
• 5:43
  be
• 5:43
  able
• 5:43
  to
• 5:43
  really
• 5:44
  concentrate.
• 5:44
  They
• 5:44
  might
• 5:44
  even
• 5:45
  be
• 5:45
  snapping
• 5:45
  at
• 5:45
  people,
• 5:46
  kind
• 5:46
  of
• 5:46
  irritable.
• 5:47
  These
• 5:47
  are
• 5:47
  all
• 5:47
  signs
• 5:48
  of,
• 5:48
  like,
• 5:48
  generalized
• 5:49
  anxiety
• 5:49
  disorder.
• 5:50
  You
• 5:50
  could
• 5:50
  basically
• 5:51
  diagnose
• 5:51
  GAD
• 5:52
  right
• 5:52
  there
• 5:52
  on
• 5:52
  the
• 5:52
  spot.
• 5:53
  Now
• 5:53
  it's
• 5:53
  this
• 5:53
  permanent
• 5:54
  diagnosis
• 5:54
  in
• 5:54
  their
• 5:55
  record.
• 5:55
  Clinicians
• 5:56
  are
• 5:56
  going
• 5:56
  to
• 5:56
  meet
• 5:56
  them
• 5:57
  10
• 5:57
  years
• 5:57
  from
• 5:57
  now
• 5:57
  and
• 5:58
  go,
• 5:58
  oh,
• 5:58
  this
• 5:58
  patient
• 5:58
  has
• 5:59
  GAD.
• 5:59
  They've
• 5:59
  always
• 5:59
  had
• 6:00
  GAD.
• 6:00
  Let's
• 6:01
  try
• 6:01
  them
• 6:01
  on
• 6:01
  Effexor
• 6:02
  now.
• 6:02
  And
• 6:02
  then
• 6:02
  they
• 6:02
  get
• 6:03
  on
• 6:03
  Effexor.
• 6:03
  That
• 6:04
  doesn't
• 6:04
  really
• 6:04
  help
• 6:04
  because
• 6:05
  they
• 6:05
  have
• 6:06
  low
• 6:06
  ferritin
• 6:07
  and
• 6:08
  they
• 6:08
  don't
• 6:08
  have
• 6:08
  enough
• 6:08
  iron
• 6:09
  to
• 6:09
  even
• 6:09
  make
• 6:09
  serotonin
• 6:10
  in
• 6:10
  the
• 6:10
  first
• 6:11
  place.
• 6:11
  So
• 6:11
  what
• 6:11
  are
• 6:11
  you
• 6:11
  doing?
• 6:12
  Inhibiting
• 6:12
  the
• 6:13
  reuptake
• 6:13
  of
• 6:14
  norepinephrine
• 6:14
  and
• 6:15
  serotonin.
• 6:15
  We
• 6:15
  don't
• 6:15
  even
• 6:16
  have
• 6:16
  enough
• 6:16
  of
• 6:16
  it
• 6:16
  to
• 6:17
  begin
• 6:17
  with.
• 6:17
  Right.
• 6:18
  That's
• 6:18
  like
• 6:19
  planting
• 6:19
  a
• 6:19
  flower
• 6:20
  in
• 6:20
  concrete.
• 6:21
  It's
• 6:21
  not
• 6:21
  going
• 6:21
  to
• 6:21
  do
• 6:21
  anything
• 6:22
  because.
• 6:22
  Or
• 6:23
  it's
• 6:23
  going
• 6:23
  to
• 6:23
  do
• 6:23
  a
• 6:23
  lot
• 6:23
  less
• 6:24
  because
• 6:24
  iron,
• 6:25
  the
• 6:25
  important
• 6:25
  cofactor,
• 6:26
  is
• 6:26
  not
• 6:27
  being
• 6:28
  delivered
• 6:28
  enough
• 6:28
  and
• 6:28
  circulated
• 6:29
  enough
• 6:29
  to
• 6:30
  make
• 6:30
  these
• 6:30
  things
• 6:31
  happen.
• 6:31
  Right?
• 6:32
  So
• 6:32
  it
• 6:32
  really
• 6:32
  makes
• 6:32
  us
• 6:33
  powerless.
• 6:33
  If
• 6:33
  we
• 6:33
  don't
• 6:34
  check
• 6:34
  this,
• 6:34
  we're
• 6:34
  really
• 6:34
  going
• 6:35
  in
• 6:35
  blind
• 6:36
  because
• 6:36
  it's
• 6:36
  such
• 6:36
  an
• 6:36
  important
• 6:37
  CO
• 6:37
  factor
• 6:38
  in
• 6:38
  all
• 6:38
  of
• 6:38
  the
• 6:38
  things
• 6:39
  we
• 6:39
  need
• 6:39
  to
• 6:40
  make
• 6:40
  good
• 6:40
  mental
• 6:41
  health.
• 6:41
  And
• 6:41
  all
• 6:42
  of
• 6:42
  our
• 6:42
  interventions,
• 6:43
  our.
• 6:43
  Our
• 6:44
  psychopharma
• 6:45
  pharmacological
• 6:46
  interventions
• 6:47
  are
• 6:47
  a
• 6:47
  lot
• 6:48
  more
• 6:48
  impotent
• 6:48
  because
• 6:49
  we
• 6:49
  don't
• 6:49
  have
• 6:49
  the
• 6:49
  ingredients
• 6:50
  to
• 6:51
  even
• 6:51
  make
• 6:51
  them
• 6:51
  work
• 6:52
  that
• 6:52
  well.
• 6:53
  Why
• 6:53
  would
• 6:53
  we
• 6:54
  want
• 6:54
  to
• 6:54
  add
• 6:54
  a
• 6:54
  stimulant
• 6:55
  when
• 6:55
  the
• 6:55
  core
• 6:55
  reason
• 6:56
  your
• 6:56
  patient
• 6:56
  can't
• 6:57
  focus
• 6:57
  is
• 6:57
  that
• 6:57
  they
• 6:58
  don't
• 6:58
  have
• 6:58
  enough
• 6:59
  iron
• 6:59
  to
• 7:00
  make
• 7:00
  dopamine.
• 7:01
  That.
• 7:02
  That's
• 7:02
  a
• 7:02
  big
• 7:02
  thing.
• 7:02
  Right.
• 7:03
  And
• 7:03
  so
• 7:03
  let's
• 7:04
  not
• 7:04
  be
• 7:04
  fooled
• 7:04
  by
• 7:05
  a
• 7:05
  normal
• 7:05
  CBC.
• 7:07
  Now,
• 7:07
  as
• 7:07
  ferritin
• 7:08
  depletion
• 7:09
  continues,
• 7:10
  let's
• 7:10
  say
• 7:10
  into
• 7:10
  the
• 7:11
  15
• 7:11
  to
• 7:11
  30
• 7:12
  range,
• 7:12
  you're
• 7:13
  getting
• 7:14
  to
• 7:14
  the
• 7:14
  point
• 7:14
  where
• 7:15
  symptoms
• 7:15
  are
• 7:16
  really
• 7:16
  mimicking
• 7:17
  the
• 7:17
  actual
• 7:18
  disorders.
• 7:19
  Worsening
• 7:19
  anxiety,
• 7:20
  restless
• 7:20
  legs,
• 7:21
  insomnia,
• 7:22
  iron
• 7:22
  deficiencies
• 7:23
  found
• 7:23
  in
• 7:23
  about
• 7:24
  a
• 7:24
  Quarter
• 7:24
  of
• 7:24
  restless
• 7:25
  leg
• 7:25
  patients,
• 7:26
  right?
• 7:26
  So
• 7:26
  definitely
• 7:26
  ask
• 7:26
  about
• 7:27
  restless
• 7:27
  legs,
• 7:28
  but
• 7:28
  you're
• 7:28
  getting
• 7:28
  worsening
• 7:29
  symptoms
• 7:30
  to
• 7:30
  the
• 7:30
  point
• 7:30
  where
• 7:30
  it
• 7:30
  is
• 7:31
  genuinely
• 7:31
  hard
• 7:32
  to
• 7:32
  figure
• 7:33
  out
• 7:33
  the
• 7:33
  difference
• 7:33
  between
• 7:33
  ADHD
• 7:34
  and
• 7:35
  this
• 7:35
  low
• 7:35
  ferritin
• 7:36
  level.
• 7:36
  And
• 7:36
  the
• 7:37
  patient,
• 7:37
  of
• 7:37
  course,
• 7:37
  has
• 7:37
  really
• 7:38
  no
• 7:38
  idea.
• 7:39
  And
• 7:39
  culturally,
• 7:39
  they're
• 7:40
  going
• 7:40
  on
• 7:40
  Reddit,
• 7:40
  they're
• 7:41
  going
• 7:41
  on
• 7:41
  TikTok,
• 7:41
  and
• 7:42
  they're
• 7:42
  only
• 7:42
  being
• 7:42
  reinforced
• 7:43
  to
• 7:43
  believe
• 7:44
  that.
• 7:44
  That
• 7:44
  they've
• 7:44
  always
• 7:45
  had
• 7:45
  ADHD
• 7:45
  or
• 7:46
  that
• 7:46
  they
• 7:46
  have
• 7:46
  depression,
• 7:47
  right?
• 7:47
  They
• 7:48
  have
• 7:48
  emotional
• 7:48
  dysregulation,
• 7:49
  and
• 7:49
  pretty
• 7:49
  soon
• 7:50
  somebody
• 7:50
  thinks
• 7:50
  they
• 7:50
  have
• 7:51
  borderline
• 7:51
  personality
• 7:52
  disorder.
• 7:53
  Big
• 7:53
  problems,
• 7:54
  my
• 7:54
  friend.
• 7:54
  Now,
• 7:55
  when
• 7:55
  you
• 7:55
  get
• 7:55
  below
• 7:56
  15,
• 7:58
  you
• 7:58
  are
• 7:59
  in
• 7:59
  some
• 7:59
  more
• 8:00
  serious
• 8:00
  territory,
• 8:02
  okay?
• 8:02
  This
• 8:02
  is
• 8:03
  where
• 8:03
  the.
• 8:03
  You're
• 8:04
  not
• 8:04
  only
• 8:05
  confused
• 8:06
  diagnostically
• 8:06
  about
• 8:07
  what
• 8:07
  you
• 8:07
  were
• 8:07
  seeing,
• 8:08
  but
• 8:09
  the
• 8:09
  severity
• 8:10
  level
• 8:11
  increases.
• 8:11
  And
• 8:11
  I
• 8:11
  have
• 8:12
  seen
• 8:12
  this
• 8:12
  clinically.
• 8:12
  I
• 8:13
  have
• 8:13
  seen
• 8:13
  people
• 8:14
  with
• 8:14
  very
• 8:15
  severe
• 8:15
  depression.
• 8:16
  And
• 8:17
  what's
• 8:17
  more,
• 8:18
  I
• 8:18
  think,
• 8:19
  useful
• 8:19
  to
• 8:20
  think
• 8:20
  about
• 8:20
  is
• 8:20
  it's
• 8:21
  not
• 8:21
  even
• 8:21
  just
• 8:21
  the
• 8:22
  severity,
• 8:22
  it's
• 8:23
  the
• 8:23
  level
• 8:23
  of
• 8:23
  treatment
• 8:24
  resistance,
• 8:24
  right?
• 8:25
  If
• 8:25
  this
• 8:25
  has
• 8:25
  been
• 8:26
  going
• 8:26
  on
• 8:27
  uncorrected
• 8:28
  for
• 8:28
  years
• 8:29
  and
• 8:29
  you've
• 8:29
  tried
• 8:30
  multiple
• 8:30
  medications
• 8:31
  and
• 8:31
  nothing
• 8:32
  is
• 8:33
  giving,
• 8:33
  you're
• 8:34
  looking
• 8:34
  at
• 8:34
  the
• 8:34
  diagnosis
• 8:35
  again,
• 8:35
  and
• 8:36
  it's
• 8:36
  not.
• 8:37
  It's
• 8:37
  not
• 8:37
  bipolarity.
• 8:38
  You're
• 8:39
  looking
• 8:39
  at
• 8:39
  personality
• 8:40
  traits,
• 8:40
  and
• 8:40
  you're
• 8:40
  pretty
• 8:41
  convinced
• 8:41
  it's
• 8:41
  not
• 8:41
  borderline
• 8:42
  personality
• 8:42
  disorder.
• 8:43
  You're
• 8:43
  just
• 8:44
  going
• 8:44
  in
• 8:44
  circles,
• 8:45
  right?
• 8:46
  You're
• 8:46
  making
• 8:46
  sure
• 8:46
  it's
• 8:46
  not
• 8:47
  substance
• 8:47
  use
• 8:47
  or
• 8:47
  substance
• 8:48
  withdrawal
• 8:48
  or
• 8:48
  some
• 8:48
  underreported
• 8:49
  supplement
• 8:50
  they're
• 8:50
  taking,
• 8:51
  whatever
• 8:51
  that
• 8:51
  might
• 8:52
  be,
• 8:52
  right?
• 8:53
  And
• 8:53
  at
• 8:53
  this
• 8:54
  point,
• 8:54
  you're
• 8:55
  looking
• 8:55
  at
• 8:56
  very
• 8:56
  severe
• 8:57
  symptoms
• 8:58
  in
• 8:59
  ferritin
• 8:59
  levels,
• 9:00
  15
• 9:00
  nanograms
• 9:01
  per
• 9:01
  milliliter
• 9:01
  or
• 9:02
  lower.
• 9:03
  Severe
• 9:03
  depression,
• 9:04
  severe
• 9:04
  cognitive
• 9:05
  impairment,
• 9:05
  severe
• 9:05
  ADHD
• 9:06
  presentation.
• 9:07
  Maybe
• 9:08
  they
• 9:08
  have,
• 9:08
  like,
• 9:08
  pica,
• 9:09
  which
• 9:09
  is
• 9:09
  where
• 9:09
  they're
• 9:09
  craving
• 9:10
  ice
• 9:10
  chips
• 9:10
  or
• 9:11
  clay.
• 9:11
  I've
• 9:12
  never
• 9:12
  had
• 9:12
  a
• 9:12
  patient
• 9:12
  walk
• 9:13
  into
• 9:13
  my
• 9:13
  office
• 9:14
  that
• 9:14
  said
• 9:14
  they're
• 9:15
  craving
• 9:15
  clay,
• 9:16
  but
• 9:16
  if
• 9:16
  they
• 9:16
  ever
• 9:16
  do,
• 9:17
  you
• 9:17
  heard
• 9:17
  it
• 9:18
  here.
• 9:18
  Check
• 9:18
  the
• 9:18
  Ferritin,
• 9:19
  among
• 9:20
  other
• 9:20
  things,
• 9:20
  probably.
• 9:21
  But
• 9:21
  my
• 9:21
  friends,
• 9:22
  when
• 9:22
  you
• 9:22
  are
• 9:22
  15
• 9:23
  or
• 9:23
  below,
• 9:24
  okay,
• 9:24
  in
• 9:25
  ferritin,
• 9:25
  you
• 9:25
  will
• 9:25
  see
• 9:26
  severe
• 9:26
  symptoms.
• 9:27
  And
• 9:28
  let
• 9:28
  that
• 9:29
  be
• 9:29
  a
• 9:29
  red
• 9:29
  flag
• 9:30
  to
• 9:30
  you.
• 9:31
  And
• 9:31
  I
• 9:31
  would
• 9:31
  add
• 9:31
  another
• 9:32
  qualifier.
• 9:32
  If
• 9:33
  you
• 9:33
  have
• 9:33
  a
• 9:34
  patient
• 9:34
  who's
• 9:34
  just
• 9:35
  been
• 9:35
  taking
• 9:36
  multiple
• 9:36
  psychotropic
• 9:37
  medications
• 9:38
  throughout
• 9:38
  their
• 9:38
  life
• 9:39
  and
• 9:39
  they
• 9:39
  have
• 9:40
  this
• 9:40
  diagnosis
• 9:40
  that
• 9:40
  looks
• 9:41
  declarative
• 9:42
  from
• 9:42
  a
• 9:42
  primary
• 9:42
  care
• 9:43
  doc
• 9:43
  or
• 9:43
  from
• 9:43
  their
• 9:44
  past
• 9:44
  psych
• 9:44
  doc,
• 9:45
  and
• 9:45
  for
• 9:45
  whatever
• 9:46
  reason,
• 9:46
  nothing's
• 9:47
  working,
• 9:48
  I
• 9:48
  think
• 9:48
  it's
• 9:48
  very
• 9:48
  healthy
• 9:49
  to
• 9:49
  be
• 9:49
  suspicious
• 9:50
  that
• 9:50
  something
• 9:51
  was
• 9:51
  never
• 9:51
  checked.
• 9:52
  It's
• 9:52
  pretty
• 9:52
  typical
• 9:53
  that
• 9:53
  people
• 9:53
  do
• 9:54
  check
• 9:54
  at
• 9:54
  some
• 9:54
  point
• 9:55
  a
• 9:55
  CBC
• 9:56
  or
• 9:56
  CMP
• 9:56
  or
• 9:56
  thyroid
• 9:57
  or
• 9:57
  vitamin
• 9:57
  D,
• 9:58
  but
• 9:58
  it's
• 9:59
  not
• 9:59
  always
• 9:59
  the
• 10:00
  case
• 10:00
  that
• 10:00
  they're
• 10:00
  checking
• 10:01
  a
• 10:01
  ferritin
• 10:01
  level
• 10:02
  because
• 10:03
  they
• 10:03
  saw
• 10:03
  the
• 10:03
  hemoglobin
• 10:04
  and
• 10:04
  were
• 10:04
  like,
• 10:04
  hey,
• 10:05
  this
• 10:05
  is
• 10:05
  fine,
• 10:06
  no
• 10:06
  problems
• 10:07
  here.
• 10:07
  Let's
• 10:07
  move
• 10:08
  on
• 10:08
  to
• 10:08
  the
• 10:08
  next
• 10:08
  thing.
• 10:09
  So
• 10:09
  now
• 10:09
  you
• 10:09
  know
• 10:10
  that
• 10:10
  ferritin
• 10:12
  is
• 10:12
  that
• 10:12
  one
• 10:12
  little
• 10:13
  detail
• 10:13
  that
• 10:14
  can
• 10:14
  sink
• 10:14
  the
• 10:14
  ship
• 10:14
  if
• 10:15
  we
• 10:15
  don't
• 10:15
  think
• 10:15
  about
• 10:15
  it.
• 10:16
  Okay?
• 10:17
  Now,
• 10:17
  not
• 10:17
  every
• 10:17
  iron
• 10:18
  deficient
• 10:18
  patient
• 10:18
  is
• 10:18
  going
• 10:19
  to
• 10:19
  have
• 10:19
  psychiatric
• 10:20
  symptoms.
• 10:20
  Some
• 10:20
  are
• 10:21
  going
• 10:21
  to
• 10:21
  be
• 10:21
  asymptomatic.
• 10:22
  Okay?
• 10:22
  But
• 10:23
  the
• 10:23
  data
• 10:23
  does
• 10:23
  consistently
• 10:24
  show
• 10:24
  that
• 10:24
  iron
• 10:25
  deficient
• 10:26
  patients
• 10:26
  do
• 10:27
  have
• 10:27
  significantly
• 10:28
  higher
• 10:28
  rates
• 10:29
  of
• 10:29
  depression,
• 10:30
  anxiety,
• 10:30
  adhd,
• 10:31
  sleep
• 10:32
  disorders
• 10:32
  than
• 10:33
  patients
• 10:33
  without
• 10:34
  iron
• 10:35
  deficiency.
• 10:35
  And,
• 10:36
  and
• 10:36
  treating
• 10:36
  this
• 10:37
  deficiency
• 10:37
  is
• 10:38
  really
• 10:38
  going
• 10:38
  to
• 10:38
  improve
• 10:38
  their
• 10:38
  symptoms.
• 10:39
  Right?
• 10:39
  It's
• 10:39
  not
• 10:39
  always
• 10:40
  about,
• 10:40
  oh,
• 10:40
  their
• 10:40
  depression
• 10:41
  is
• 10:41
  going
• 10:41
  to
• 10:41
  magically
• 10:42
  go
• 10:42
  away.
• 10:43
  It's
• 10:43
  not
• 10:43
  that
• 10:43
  simple.
• 10:44
  In
• 10:44
  practice,
• 10:44
  there's
• 10:44
  usually
• 10:45
  a
• 10:45
  few
• 10:45
  things
• 10:45
  going
• 10:46
  on
• 10:46
  at
• 10:46
  once,
• 10:46
  but
• 10:47
  you
• 10:47
  might
• 10:47
  be
• 10:47
  able
• 10:48
  to
• 10:48
  significantly
• 10:49
  alter
• 10:50
  the
• 10:50
  trajectory
• 10:50
  of
• 10:51
  their
• 10:51
  symptoms,
• 10:51
  soften
• 10:52
  their
• 10:52
  symptoms
• 10:52
  and,
• 10:53
  and
• 10:53
  give
• 10:53
  them
• 10:53
  hope
• 10:54
  really
• 10:54
  quickly
• 10:55
  because
• 10:55
  this
• 10:56
  is
• 10:56
  a
• 10:56
  very
• 10:56
  big
• 10:56
  deal.
• 10:57
  Now,
• 10:57
  we
• 10:57
  talked
• 10:58
  about
• 10:58
  this
• 10:58
  before,
• 10:59
  how
• 10:59
  one
• 10:59
  in
• 11:00
  three
• 11:00
  menstruating
• 11:01
  women
• 11:02
  are
• 11:02
  iron
• 11:03
  deficient
• 11:04
  according
• 11:04
  to
• 11:04
  the
• 11:05
  evidence.
• 11:05
  And
• 11:06
  that
• 11:06
  is
• 11:06
  a
• 11:07
  massive
• 11:07
  pearl,
• 11:07
  my
• 11:08
  friends,
• 11:08
  that
• 11:08
  should
• 11:08
  be
• 11:08
  on
• 11:09
  every
• 11:09
  billboard
• 11:10
  in
• 11:10
  the
• 11:10
  country.
• 11:11
  Okay?
• 11:12
  Maybe
• 11:12
  it's
• 11:12
  not
• 11:12
  as,
• 11:14
  it's
• 11:14
  not
• 11:14
  as
• 11:14
  snazzy
• 11:15
  as,
• 11:15
  like,
• 11:15
  a
• 11:16
  white
• 11:16
  claw
• 11:16
  billboard
• 11:17
  or
• 11:17
  a
• 11:17
  malpractice
• 11:18
  lawyer
• 11:19
  telling
• 11:19
  you
• 11:19
  he's
• 11:19
  going
• 11:20
  to
• 11:20
  get
• 11:20
  money
• 11:20
  for
• 11:21
  your.
• 11:21
  For,
• 11:21
  for
• 11:22
  you,
• 11:22
  even
• 11:22
  though
• 11:22
  it
• 11:22
  was
• 11:23
  your
• 11:23
  fault
• 11:23
  that
• 11:24
  you
• 11:24
  crashed
• 11:25
  into
• 11:25
  the
• 11:25
  little
• 11:25
  old
• 11:25
  lady
• 11:26
  who
• 11:26
  had
• 11:26
  a
• 11:26
  walk
• 11:26
  signal.
• 11:28
  Right.
• 11:28
  It
• 11:28
  might
• 11:29
  not
• 11:29
  be
• 11:29
  as
• 11:29
  flashy,
• 11:30
  but
• 11:30
  it's
• 11:30
  so
• 11:30
  important.
• 11:31
  Can
• 11:31
  you
• 11:31
  imagine?
• 11:31
  I
• 11:32
  mean,
• 11:32
  one
• 11:32
  in
• 11:32
  three
• 11:32
  menstruating
• 11:33
  women
• 11:33
  are
• 11:33
  iron
• 11:34
  deficient.
• 11:34
  And
• 11:35
  if
• 11:35
  you
• 11:35
  see
• 11:35
  30
• 11:36
  patients
• 11:36
  a
• 11:36
  week,
• 11:37
  let's
• 11:37
  say
• 11:37
  15
• 11:37
  of
• 11:38
  them
• 11:38
  are
• 11:38
  females,
• 11:39
  one
• 11:40
  in
• 11:40
  three.
• 11:41
  So
• 11:41
  five
• 11:41
  of
• 11:41
  the
• 11:42
  15
• 11:42
  females
• 11:43
  you
• 11:43
  see
• 11:43
  this
• 11:43
  week
• 11:43
  in
• 11:43
  your
• 11:44
  outpatient
• 11:44
  practice
• 11:46
  may
• 11:46
  have
• 11:46
  an
• 11:47
  iron
• 11:47
  deficiency.
• 11:48
  And
• 11:48
  that
• 11:49
  iron
• 11:49
  deficiency
• 11:50
  means
• 11:50
  they're
• 11:50
  not
• 11:50
  making
• 11:50
  enough
• 11:51
  dopamine,
• 11:51
  serotonin,
• 11:52
  norepinephrine,
• 11:53
  they're
• 11:53
  not
• 11:53
  getting
• 11:53
  a
• 11:53
  full
• 11:54
  night's
• 11:54
  sleep.
• 11:54
  And,
• 11:54
  oh,
• 11:55
  by
• 11:55
  the
• 11:55
  way,
• 11:55
  that
• 11:55
  compounds
• 11:56
  mental
• 11:56
  health
• 11:57
  problems
• 11:57
  even
• 11:57
  more.
• 11:58
  Then
• 11:59
  again,
• 11:59
  it
• 11:59
  begets
• 12:00
  polypharmacy
• 12:01
  and
• 12:01
  all
• 12:02
  these
• 12:02
  side
• 12:02
  effects
• 12:03
  now,
• 12:03
  and
• 12:04
  it's
• 12:04
  harder
• 12:05
  and
• 12:05
  harder
• 12:05
  for
• 12:05
  them
• 12:05
  to
• 12:05
  manage.
• 12:06
  And
• 12:06
  the
• 12:06
  metabolic
• 12:07
  burden
• 12:07
  that
• 12:08
  some
• 12:08
  of
• 12:08
  these
• 12:08
  patients
• 12:09
  have
• 12:09
  to
• 12:09
  endure
• 12:10
  by
• 12:10
  being
• 12:11
  put
• 12:11
  on
• 12:11
  an
• 12:11
  sga,
• 12:12
  maybe
• 12:12
  somebody
• 12:13
  out
• 12:13
  there
• 12:13
  is
• 12:13
  going,
• 12:13
  oh,
• 12:14
  well,
• 12:14
  let's
• 12:14
  go
• 12:14
  ahead
• 12:15
  and
• 12:15
  augment
• 12:16
  this,
• 12:17
  this
• 12:17
  SSRI
• 12:18
  with
• 12:18
  a
• 12:18
  second
• 12:19
  generation
• 12:19
  antipsychotic,
• 12:20
  because
• 12:20
  they're
• 12:21
  interpreting
• 12:22
  some
• 12:22
  of
• 12:23
  the,
• 12:23
  you
• 12:23
  know,
• 12:23
  this
• 12:23
  excess
• 12:24
  irritability
• 12:25
  as
• 12:26
  something
• 12:26
  that
• 12:26
  can
• 12:27
  be
• 12:27
  fixed
• 12:27
  with
• 12:27
  an
• 12:28
  SGA
• 12:28
  or
• 12:29
  something.
• 12:29
  Or
• 12:29
  maybe
• 12:29
  they're
• 12:30
  adding
• 12:30
  a
• 12:30
  benzo.
• 12:30
  And
• 12:31
  now
• 12:31
  this
• 12:31
  patient's
• 12:31
  on
• 12:31
  this
• 12:32
  benzo
• 12:33
  treadmill
• 12:33
  where
• 12:34
  they're
• 12:35
  going
• 12:35
  to
• 12:35
  need
• 12:35
  more
• 12:35
  and
• 12:36
  more
• 12:36
  and
• 12:36
  they
• 12:36
  develop
• 12:36
  a
• 12:37
  tolerance,
• 12:37
  and
• 12:37
  then
• 12:37
  they
• 12:37
  fall
• 12:38
  and
• 12:38
  they're
• 12:38
  cognitively
• 12:39
  impaired,
• 12:39
  and
• 12:40
  God
• 12:40
  forbid
• 12:40
  they
• 12:40
  have
• 12:40
  ptsd.
• 12:41
  Now
• 12:41
  they're
• 12:41
  on
• 12:41
  a
• 12:41
  benzo
• 12:42
  because
• 12:42
  we
• 12:42
  thought
• 12:42
  they
• 12:43
  were
• 12:43
  anxious.
• 12:43
  And
• 12:44
  this
• 12:44
  whole
• 12:44
  time
• 12:45
  they
• 12:45
  had
• 12:45
  a
• 12:45
  low
• 12:45
  ferritin
• 12:46
  level,
• 12:46
  Their
• 12:47
  iron
• 12:47
  is
• 12:47
  being
• 12:48
  depleted,
• 12:48
  and
• 12:49
  now
• 12:49
  we
• 12:49
  have
• 12:49
  really
• 12:49
  hijacked
• 12:50
  and
• 12:50
  handicapped
• 12:51
  their
• 12:51
  entire
• 12:51
  plan
• 12:52
  of
• 12:52
  care
• 12:53
  because
• 12:53
  we
• 12:53
  didn't
• 12:53
  care
• 12:54
  to
• 12:54
  check
• 12:54
  a
• 12:55
  ferritin
• 12:55
  level,
• 12:56
  and
• 12:57
  we
• 12:57
  have
• 12:57
  to
• 12:58
  be
• 12:58
  a
• 12:58
  little
• 12:58
  picky,
• 12:58
  like
• 12:59
  we
• 12:59
  said.
• 12:59
  I
• 12:59
  mean,
• 12:59
  ideally,
• 13:00
  50
• 13:00
  to
• 13:00
  100
• 13:01
  nanograms
• 13:01
  per
• 13:02
  milliliter,
• 13:02
  that's
• 13:02
  great.
• 13:03
  But
• 13:03
  if
• 13:03
  we're
• 13:03
  dipping
• 13:04
  below
• 13:04
  50,
• 13:05
  we
• 13:05
  need
• 13:05
  to
• 13:05
  do
• 13:05
  something
• 13:06
  about
• 13:06
  it.
• 13:06
  We
• 13:07
  definitely
• 13:07
  need
• 13:07
  to
• 13:07
  do
• 13:07
  something
• 13:08
  about
• 13:08
  it.
• 13:09
  And
• 13:09
  so
• 13:10
  looking
• 13:10
  at
• 13:10
  this
• 13:10
  as
• 13:10
  a
• 13:11
  spectrum,
• 13:11
  not
• 13:12
  this
• 13:12
  declarative
• 13:13
  cutoff
• 13:13
  of,
• 13:14
  oh,
• 13:14
  well,
• 13:14
  if
• 13:14
  it's
• 13:14
  not
• 13:15
  lower
• 13:15
  than
• 13:15
  10,
• 13:15
  I'm
• 13:16
  not
• 13:16
  worried
• 13:16
  about
• 13:16
  it.
• 13:16
  No.
• 13:17
  Psychiatric
• 13:18
  symptoms
• 13:18
  can
• 13:18
  absolutely
• 13:19
  manifest
• 13:19
  in
• 13:20
  the
• 13:20
  30
• 13:20
  to
• 13:20
  50
• 13:20
  range.
• 13:21
  And
• 13:21
  they
• 13:21
  get
• 13:22
  more
• 13:22
  and
• 13:22
  more
• 13:22
  severe
• 13:22
  as
• 13:23
  you
• 13:23
  get
• 13:23
  into
• 13:23
  the
• 13:23
  15
• 13:24
  to
• 13:24
  30
• 13:24
  range.
• 13:24
  Below
• 13:25
  15,
• 13:25
  watch
• 13:26
  out.
• 13:26
  Right?
• 13:26
  And
• 13:27
  it's
• 13:27
  only
• 13:27
  late
• 13:27
  in
• 13:27
  the
• 13:28
  game
• 13:28
  that
• 13:28
  hemoglobin
• 13:29
  starts
• 13:30
  to
• 13:31
  go
• 13:31
  down.
• 13:32
  Okay,
• 13:32
  that's
• 13:33
  late
• 13:33
  in
• 13:33
  the
• 13:33
  game
• 13:33
  when
• 13:33
  the
• 13:33
  patient
• 13:34
  has
• 13:34
  tachycardia
• 13:35
  and
• 13:35
  dyspnea
• 13:35
  and
• 13:35
  psychomotor
• 13:36
  retardation,
• 13:36
  maybe
• 13:37
  delirium.
• 13:38
  That's
• 13:38
  very
• 13:38
  late
• 13:38
  in
• 13:39
  the
• 13:39
  game.
• 13:39
  That
• 13:40
  is
• 13:40
  the
• 13:40
  postpartum
• 13:42
  period.
• 13:42
  Postpartum
• 13:43
  period.
• 13:44
  That
• 13:44
  low
• 13:45
  ferritin
• 13:45
  measured
• 13:46
  at
• 13:46
  48
• 13:47
  hours
• 13:47
  postpartum,
• 13:48
  not
• 13:48
  during
• 13:48
  pregnancy.
• 13:49
  But
• 13:49
  48
• 13:50
  hours
• 13:50
  postpartum
• 13:51
  was
• 13:51
  the
• 13:51
  strongest
• 13:52
  predictor
• 13:53
  in
• 13:53
  one
• 13:53
  study
• 13:53
  of
• 13:54
  PPD
• 13:55
  postpartum
• 13:56
  depression.
• 13:57
  Okay,
• 13:58
  the
• 13:58
  strongest
• 13:58
  predictor,
• 13:59
  48
• 14:00
  hours
• 14:00
  postpartum
• 14:01
  was
• 14:01
  a
• 14:01
  low
• 14:01
  ferritin
• 14:02
  level.
• 14:02
  Again,
• 14:03
  those
• 14:03
  iron
• 14:03
  stores
• 14:04
  are
• 14:04
  being
• 14:04
  depleted
• 14:04
  first,
• 14:05
  whether
• 14:05
  or
• 14:06
  not
• 14:06
  the
• 14:06
  CBC
• 14:06
  is
• 14:07
  normal.
• 14:07
  And.
• 14:08
  And
• 14:08
  why?
• 14:08
  Because
• 14:08
  there's
• 14:09
  a
• 14:09
  major
• 14:09
  iron
• 14:10
  catastrophe
• 14:11
  that
• 14:11
  happens
• 14:11
  at
• 14:11
  delivery.
• 14:12
  The
• 14:12
  blood
• 14:12
  loss.
• 14:12
  Right.
• 14:13
  She
• 14:14
  could
• 14:14
  lose
• 14:14
  up
• 14:14
  to
• 14:15
  1
• 14:15
  liter
• 14:16
  of
• 14:16
  blood
• 14:16
  at
• 14:16
  delivery,
• 14:17
  and
• 14:17
  her
• 14:17
  iron
• 14:18
  stores
• 14:18
  will
• 14:18
  crash
• 14:18
  in
• 14:19
  one
• 14:19
  single
• 14:20
  event.
• 14:21
  Okay,
• 14:22
  so,
• 14:22
  yes,
• 14:23
  checking
• 14:23
  ferritin
• 14:24
  during
• 14:24
  pregnancy
• 14:24
  is
• 14:25
  important,
• 14:26
  but
• 14:26
  that
• 14:26
  critical
• 14:26
  window
• 14:27
  for
• 14:27
  postpartum
• 14:28
  depression
• 14:29
  prediction
• 14:30
  is
• 14:30
  in
• 14:30
  that
• 14:30
  first
• 14:31
  48
• 14:31
  hours.
• 14:32
  So
• 14:32
  knowing
• 14:33
  what
• 14:33
  that
• 14:33
  is
• 14:34
  and
• 14:34
  collaborating
• 14:35
  with
• 14:35
  OB
• 14:36
  beforehand
• 14:36
  and
• 14:37
  saying,
• 14:37
  hey,
• 14:37
  look,
• 14:38
  this
• 14:38
  patient
• 14:39
  has
• 14:39
  already
• 14:39
  a
• 14:40
  predisposition
• 14:41
  to
• 14:41
  being
• 14:42
  anemic.
• 14:43
  In
• 14:43
  the
• 14:43
  past,
• 14:44
  it's
• 14:44
  been
• 14:44
  corrected,
• 14:45
  but
• 14:45
  we're
• 14:45
  worried
• 14:45
  about
• 14:46
  blood
• 14:46
  loss
• 14:46
  and
• 14:46
  those
• 14:47
  tendencies.
• 14:47
  Can
• 14:47
  we
• 14:48
  communicate
• 14:48
  what
• 14:48
  the
• 14:49
  ferritin
• 14:49
  level
• 14:49
  is?
• 14:49
  Can
• 14:50
  we
• 14:50
  get
• 14:50
  a
• 14:50
  ferritin
• 14:50
  level
• 14:51
  within
• 14:51
  48
• 14:52
  hours,
• 14:52
  I'd
• 14:52
  like
• 14:52
  a
• 14:53
  predictive
• 14:53
  measure
• 14:54
  of
• 14:54
  her
• 14:54
  depressive
• 14:55
  depression
• 14:56
  and
• 14:56
  making
• 14:56
  sure
• 14:57
  everybody's
• 14:57
  on
• 14:57
  board.
• 14:58
  That
• 14:58
  could
• 14:58
  really
• 14:58
  go
• 14:59
  a
• 14:59
  long
• 14:59
  way.
• 15:00
  This
• 15:00
  is
• 15:01
  a
• 15:01
  ferritin
• 15:02
  crashing
• 15:03
  event
• 15:04
  at
• 15:05
  delivery.
• 15:06
  So
• 15:06
  really
• 15:07
  high
• 15:07
  yield.
• 15:07
  Pearl
• 15:08
  there
• 15:09
  makes
• 15:09
  you
• 15:09
  really
• 15:09
  wonder,
• 15:10
  right?
• 15:10
  At
• 15:10
  such
• 15:10
  a
• 15:11
  vulnerable
• 15:12
  period
• 15:12
  as
• 15:12
  it,
• 15:13
  as
• 15:13
  it
• 15:14
  stands,
• 15:14
  the
• 15:14
  postpartum
• 15:15
  or
• 15:15
  peripartum
• 15:16
  period
• 15:17
  is
• 15:17
  so
• 15:18
  vulnerable
• 15:18
  for
• 15:19
  most
• 15:19
  women.
• 15:20
  And
• 15:20
  then
• 15:20
  you
• 15:20
  add
• 15:20
  the
• 15:21
  blood
• 15:21
  loss
• 15:21
  and
• 15:21
  you
• 15:22
  think
• 15:22
  of
• 15:22
  all
• 15:22
  the,
• 15:23
  the,
• 15:23
  the
• 15:23
  iron,
• 15:24
  all
• 15:25
  the
• 15:25
  fact
• 15:25
  that
• 15:25
  it's
• 15:26
  such
• 15:26
  a
• 15:26
  co
• 15:26
  factor
• 15:27
  in
• 15:28
  all
• 15:28
  of
• 15:28
  these
• 15:28
  critical
• 15:29
  neurotransmitters.
• 15:30
  And
• 15:30
  so
• 15:30
  you
• 15:30
  have,
• 15:31
  you
• 15:31
  add
• 15:31
  that
• 15:31
  on
• 15:31
  top,
• 15:32
  layered
• 15:32
  on
• 15:32
  top
• 15:32
  of
• 15:33
  the
• 15:33
  hormonal
• 15:33
  fluctuations
• 15:34
  that
• 15:34
  are
• 15:34
  already
• 15:35
  happening
• 15:36
  in
• 15:37
  pregnancy
• 15:38
  that
• 15:38
  make
• 15:38
  life
• 15:39
  so
• 15:39
  difficult.
• 15:39
  And
• 15:39
  so
• 15:40
  this
• 15:40
  is
• 15:40
  a
• 15:40
  perfect
• 15:40
  storm
• 15:41
  for
• 15:41
  mental
• 15:42
  illness.
• 15:43
  And
• 15:43
  we
• 15:43
  are
• 15:44
  empowered
• 15:44
  by
• 15:44
  knowing
• 15:45
  about
• 15:46
  it
• 15:46
  so
• 15:46
  we
• 15:46
  can
• 15:46
  help
• 15:47
  correct
• 15:47
  it.
• 15:47
  Right?
• 15:48
  So
• 15:48
  maybe
• 15:49
  they
• 15:49
  can
• 15:50
  supplement
• 15:50
  with
• 15:50
  iron
• 15:51
  and
• 15:51
  get
• 15:52
  that
• 15:52
  postpartum
• 15:53
  woman
• 15:53
  back
• 15:54
  into
• 15:54
  a
• 15:54
  healthy
• 15:55
  state
• 15:55
  and
• 15:55
  restore
• 15:56
  their
• 15:56
  mental
• 15:56
  health.
• 15:56
  So
• 15:57
  that
• 15:57
  when
• 15:57
  you
• 15:57
  do
• 15:57
  prescribe
• 15:58
  the
• 15:58
  ssri,
• 15:58
  if
• 15:59
  they're
• 15:59
  not
• 15:59
  on
• 15:59
  one
• 15:59
  already,
• 16:00
  it's
• 16:00
  going
• 16:01
  to
• 16:01
  actually
• 16:01
  work
• 16:01
  because
• 16:02
  they
• 16:02
  have
• 16:03
  the
• 16:03
  serotonin
• 16:04
  to
• 16:05
  prevent
• 16:05
  the
• 16:05
  reuptake
• 16:06
  in
• 16:07
  the
• 16:07
  first
• 16:07
  place.
• 16:08
  Which
• 16:08
  of
• 16:08
  course
• 16:08
  will
• 16:09
  be
• 16:09
  a
• 16:09
  moot
• 16:09
  point.
• 16:10
  Going
• 16:10
  back
• 16:10
  to
• 16:11
  our
• 16:11
  analogy
• 16:12
  of
• 16:12
  planting
• 16:13
  flowers
• 16:13
  in
• 16:13
  the
• 16:13
  concrete,
• 16:14
  it
• 16:14
  will
• 16:14
  be
• 16:14
  a
• 16:14
  moot
• 16:14
  point
• 16:15
  if
• 16:16
  you
• 16:17
  have
• 16:17
  no
• 16:18
  iron
• 16:18
  to
• 16:18
  make
• 16:19
  the
• 16:19
  serotonin
• 16:20
  in
• 16:20
  in
• 16:20
  the
• 16:21
  first
• 16:21
  place.
• 16:21
  You
• 16:22
  definitely
• 16:22
  always
• 16:22
  want
• 16:23
  to
• 16:23
  keep
• 16:23
  your
• 16:23
  radar
• 16:24
  on.
• 16:24
  For
• 16:25
  again,
• 16:25
  all
• 16:25
  menstruating
• 16:26
  women,
• 16:26
  one
• 16:26
  in
• 16:26
  three
• 16:27
  are
• 16:27
  iron
• 16:27
  deficient.
• 16:27
  The
• 16:28
  evidence
• 16:28
  seems
• 16:29
  to
• 16:29
  suggest.
• 16:29
  We
• 16:30
  just
• 16:30
  talked
• 16:30
  about
• 16:30
  postpartum
• 16:31
  women.
• 16:32
  Anyone
• 16:33
  who
• 16:33
  might
• 16:33
  be
• 16:33
  a
• 16:34
  vegetarian
• 16:34
  or
• 16:34
  a
• 16:34
  vegan,
• 16:36
  that
• 16:36
  could
• 16:36
  be
• 16:37
  a
• 16:37
  high
• 16:37
  risk
• 16:37
  group.
• 16:38
  And
• 16:38
  again,
• 16:39
  if
• 16:39
  you
• 16:39
  see
• 16:39
  treatment
• 16:40
  resistant
• 16:40
  depression
• 16:41
  or
• 16:42
  adhd,
• 16:43
  start
• 16:43
  thinking,
• 16:44
  what
• 16:44
  else
• 16:44
  could
• 16:44
  this
• 16:45
  look
• 16:45
  like?
• 16:45
  There
• 16:46
  absolutely
• 16:47
  is
• 16:47
  treatment
• 16:47
  resistant
• 16:48
  depression.
• 16:48
  That
• 16:48
  is
• 16:49
  real,
• 16:49
  but
• 16:49
  it's
• 16:50
  healthy.
• 16:50
  And
• 16:51
  you're
• 16:51
  helping
• 16:51
  the
• 16:51
  patient
• 16:52
  to
• 16:52
  be
• 16:52
  a
• 16:52
  little
• 16:52
  skeptical
• 16:53
  of
• 16:53
  treatment
• 16:53
  resistant
• 16:54
  depression.
• 16:54
  Not
• 16:54
  everybody
• 16:54
  loves
• 16:55
  that
• 16:55
  label.
• 16:55
  And
• 16:56
  they
• 16:56
  would
• 16:56
  be
• 16:56
  liberated
• 16:57
  if
• 16:57
  you
• 16:57
  told
• 16:58
  them,
• 16:58
  hey,
• 16:58
  by
• 16:58
  the
• 16:58
  way,
• 16:58
  what
• 16:58
  if
• 16:59
  I
• 16:59
  told
• 16:59
  you
• 17:00
  it's
• 17:00
  maybe
• 17:00
  not
• 17:01
  your
• 17:01
  depression,
• 17:02
  that
• 17:02
  you're
• 17:02
  some
• 17:02
  treatment
• 17:03
  resistant
• 17:03
  person
• 17:04
  who's
• 17:04
  one
• 17:05
  of
• 17:05
  the
• 17:05
  few
• 17:05
  that
• 17:05
  can't
• 17:06
  respond
• 17:06
  to
• 17:06
  SSRIs
• 17:07
  or
• 17:08
  SNRIs
• 17:09
  or
• 17:09
  TCAs
• 17:10
  or
• 17:10
  MA
• 17:10
  Y,
• 17:11
  but
• 17:11
  guess
• 17:11
  what,
• 17:12
  your
• 17:12
  ferritin
• 17:13
  is
• 17:13
  low,
• 17:13
  right?
• 17:14
  I
• 17:14
  mean,
• 17:14
  don't
• 17:14
  give
• 17:14
  them
• 17:15
  false
• 17:15
  hope
• 17:15
  ever.
• 17:15
  But
• 17:16
  make
• 17:16
  sure
• 17:16
  that
• 17:17
  you're
• 17:17
  kind
• 17:17
  of
• 17:17
  stubborn,
• 17:18
  that
• 17:18
  you
• 17:19
  yourself
• 17:19
  are
• 17:19
  resistant
• 17:20
  to
• 17:20
  declaring
• 17:21
  someone
• 17:21
  treatment
• 17:22
  resistant
• 17:22
  until
• 17:23
  you've
• 17:23
  done
• 17:23
  your
• 17:24
  homework
• 17:24
  and
• 17:24
  you've
• 17:24
  done
• 17:25
  everything
• 17:25
  you
• 17:25
  can
• 17:26
  before
• 17:26
  you
• 17:27
  declare
• 17:27
  somebody
• 17:27
  treatment
• 17:28
  resistant.
• 17:28
  I
• 17:28
  Know
• 17:29
  just
• 17:29
  my
• 17:29
  personal
• 17:29
  philosophy.
• 17:30
  I'm
• 17:30
  very
• 17:30
  stubborn
• 17:31
  about
• 17:31
  slapping
• 17:32
  that
• 17:32
  label
• 17:32
  on
• 17:33
  someone
• 17:33
  unless
• 17:34
  everything's
• 17:35
  been
• 17:35
  looked
• 17:35
  at.
• 17:36
  Every
• 17:36
  nook
• 17:36
  and
• 17:36
  cranny
• 17:37
  has
• 17:37
  been
• 17:37
  accounted
• 17:38
  for.
• 17:38
  Okay,
• 17:39
  Anybody
• 17:39
  who's
• 17:39
  telling
• 17:39
  you
• 17:40
  they
• 17:40
  have
• 17:40
  restless
• 17:40
  leg
• 17:41
  syndrome
• 17:42
  or
• 17:43
  hair
• 17:43
  loss
• 17:44
  or
• 17:44
  they
• 17:44
  like
• 17:44
  to
• 17:44
  chew
• 17:45
  ice,
• 17:45
  or
• 17:46
  they
• 17:46
  have
• 17:46
  unexplained
• 17:46
  fatigue,
• 17:47
  again,
• 17:47
  if
• 17:48
  they're
• 17:48
  pale,
• 17:49
  they're
• 17:49
  short
• 17:49
  of
• 17:49
  breath
• 17:50
  on
• 17:50
  exertion,
• 17:51
  definitely
• 17:52
  look
• 17:53
  that
• 17:53
  up.
• 17:54
  Right,
• 17:55
  Heavy
• 17:55
  menstrual
• 17:56
  bleeding.
• 17:56
  I
• 17:56
  know
• 17:56
  a
• 17:57
  lot
• 17:57
  of
• 17:57
  my
• 17:57
  patients
• 17:57
  who
• 17:57
  have
• 17:58
  low
• 17:59
  ferritin
• 17:59
  or
• 17:59
  they've
• 18:00
  been
• 18:00
  a,
• 18:01
  they
• 18:01
  have
• 18:01
  a
• 18:01
  history
• 18:01
  of
• 18:01
  anemia.
• 18:02
  They
• 18:02
  will
• 18:03
  tell
• 18:03
  me
• 18:03
  they
• 18:03
  have
• 18:03
  heavy
• 18:04
  menstrual
• 18:04
  cycles.
• 18:05
  And
• 18:06
  so
• 18:06
  this
• 18:06
  isn't
• 18:07
  always
• 18:07
  this
• 18:08
  mysterious
• 18:09
  black
• 18:09
  box
• 18:10
  you
• 18:10
  have
• 18:10
  to
• 18:10
  uncover.
• 18:11
  A
• 18:11
  lot
• 18:12
  of
• 18:12
  it
• 18:12
  too
• 18:12
  is
• 18:13
  pretty
• 18:14
  well
• 18:14
  known.
• 18:14
  Your
• 18:15
  patients
• 18:15
  have
• 18:15
  their
• 18:16
  own
• 18:16
  experience
• 18:16
  that
• 18:17
  they're
• 18:17
  willing
• 18:17
  to
• 18:17
  share
• 18:18
  with
• 18:18
  you.
• 18:18
  And
• 18:18
  the
• 18:19
  answers
• 18:19
  are
• 18:19
  right
• 18:19
  that
• 18:20
  out
• 18:20
  there
• 18:20
  in
• 18:21
  the
• 18:21
  open.
• 18:21
  I
• 18:22
  think
• 18:22
  there
• 18:22
  were
• 18:22
  so
• 18:23
  many
• 18:23
  rich
• 18:23
  pearls
• 18:24
  here
• 18:24
  that
• 18:24
  can
• 18:25
  empower
• 18:25
  you
• 18:25
  to
• 18:26
  be
• 18:26
  curious
• 18:26
  about
• 18:26
  ferritin,
• 18:27
  to
• 18:27
  understand
• 18:27
  its
• 18:28
  role,
• 18:28
  to
• 18:29
  know
• 18:29
  the
• 18:29
  vulnerable
• 18:29
  populations,
• 18:30
  to
• 18:31
  know
• 18:31
  the
• 18:31
  vulnerable
• 18:31
  times,
• 18:32
  to
• 18:32
  check
• 18:32
  and
• 18:32
  care
• 18:33
  about
• 18:33
  it,
• 18:33
  to
• 18:34
  know
• 18:34
  the
• 18:34
  psychiatric
• 18:35
  mimics
• 18:35
  that
• 18:36
  ferritin
• 18:37
  is
• 18:37
  implicated
• 18:37
  with
• 18:38
  and
• 18:38
  the
• 18:38
  proper
• 18:39
  levels
• 18:40
  and
• 18:40
  how
• 18:40
  we're,
• 18:41
  it's
• 18:41
  all
• 18:41
  on
• 18:41
  a
• 18:41
  spectrum
• 18:42
  and
• 18:42
  as
• 18:42
  it
• 18:42
  drops,
• 18:43
  you're
• 18:43
  looking
• 18:43
  at
• 18:43
  more
• 18:44
  severe
• 18:44
  symptoms,
• 18:45
  more
• 18:45
  treatment
• 18:45
  resistant
• 18:46
  type
• 18:46
  symptoms
• 18:47
  and
• 18:48
  how
• 18:49
  even
• 18:49
  we
• 18:50
  should
• 18:50
  question,
• 18:51
  you
• 18:51
  know,
• 18:51
  chronic
• 18:51
  depression,
• 18:52
  persistent
• 18:53
  depressive
• 18:53
  disorder,
• 18:54
  adhd,
• 18:55
  are
• 18:55
  we
• 18:55
  really
• 18:55
  looking
• 18:56
  at
• 18:56
  these
• 18:56
  long
• 18:57
  term
• 18:57
  mental
• 18:58
  health
• 18:58
  problems
• 18:58
  or
• 18:58
  are
• 18:59
  we
• 18:59
  looking
• 18:59
  at
• 18:59
  a
• 18:59
  long
• 19:00
  term
• 19:00
  problem
• 19:01
  in
• 19:01
  iron
• 19:01
  storage
• 19:02
  that
• 19:02
  hasn't
• 19:02
  really
• 19:02
  been
• 19:03
  identified
• 19:03
  or
• 19:04
  corrected?
• 19:04
  And
• 19:05
  so
• 19:05
  we,
• 19:05
  we,
• 19:05
  we
• 19:06
  need
• 19:06
  to
• 19:06
  keep
• 19:06
  all
• 19:06
  of
• 19:06
  those
• 19:07
  differentials
• 19:07
  on
• 19:07
  the
• 19:08
  table,
• 19:08
  not
• 19:08
  just
• 19:08
  the
• 19:08
  psychiatric
• 19:09
  ones.
• 19:10
  And
• 19:10
  again,
• 19:10
  it
• 19:11
  can
• 19:11
  really
• 19:11
  make
• 19:11
  a
• 19:11
  big
• 19:12
  difference.
• 19:12
  Now
• 19:12
  my
• 19:12
  friends,
• 19:13
  if
• 19:13
  you
• 19:14
  are
• 19:14
  interested
• 19:15
  in
• 19:15
  transforming
• 19:16
  the
• 19:16
  way
• 19:16
  you
• 19:16
  practice
• 19:17
  and
• 19:17
  you
• 19:17
  don't
• 19:17
  want
• 19:17
  to
• 19:18
  be
• 19:18
  just
• 19:18
  a
• 19:18
  clinician
• 19:19
  who
• 19:20
  follows
• 19:21
  a
• 19:21
  spreadsheet
• 19:21
  or
• 19:22
  an
• 19:22
  algo,
• 19:22
  but
• 19:22
  a
• 19:23
  clinician
• 19:23
  who
• 19:23
  understands
• 19:24
  the
• 19:24
  how
• 19:24
  and
• 19:24
  the
• 19:24
  why
• 19:25
  of
• 19:25
  what
• 19:25
  you're
• 19:25
  doing.
• 19:26
  Definitely
• 19:27
  go
• 19:27
  to
• 19:27
  our
• 19:28
  show
• 19:28
  notes.
• 19:28
  If
• 19:28
  there's
• 19:28
  one
• 19:29
  thing
• 19:29
  you
• 19:29
  don't
• 19:29
  forget
• 19:29
  by
• 19:30
  the
• 19:30
  end
• 19:30
  of
• 19:30
  the
• 19:30
  day,
• 19:30
  go
• 19:31
  to
• 19:31
  our
• 19:31
  show
• 19:31
  notes
• 19:31
  and
• 19:32
  become
• 19:32
  a
• 19:32
  Patreon
• 19:33
  member.
• 19:34
  I
• 19:34
  built
• 19:34
  this
• 19:34
  library
• 19:35
  so
• 19:36
  that
• 19:36
  you
• 19:36
  can
• 19:36
  become
• 19:36
  the
• 19:37
  clinician
• 19:37
  that
• 19:37
  understands
• 19:38
  the
• 19:38
  how
• 19:38
  and
• 19:38
  the
• 19:38
  why.
• 19:39
  Patients
• 19:39
  smell
• 19:39
  that
• 19:40
  a
• 19:40
  mile
• 19:41
  away.
• 19:41
  It
• 19:41
  transforms
• 19:42
  the
• 19:42
  way
• 19:42
  you
• 19:42
  practice.
• 19:43
  I
• 19:43
  am
• 19:44
  genuinely
• 19:44
  terrified
• 19:45
  to
• 19:45
  think
• 19:45
  about
• 19:46
  who
• 19:46
  I
• 19:46
  would
• 19:46
  be
• 19:46
  as
• 19:46
  a
• 19:46
  clinician
• 19:47
  if
• 19:47
  I
• 19:47
  didn't
• 19:47
  have
• 19:47
  these
• 19:48
  amazing
• 19:48
  pearls,
• 19:49
  these
• 19:49
  beautiful
• 19:50
  visuals,
• 19:50
  this
• 19:50
  great
• 19:51
  clinical
• 19:51
  library.
• 19:52
  I'd
• 19:52
  be
• 19:52
  afraid
• 19:53
  to
• 19:53
  know
• 19:53
  who
• 19:53
  I
• 19:53
  would
• 19:53
  be
• 19:54
  as
• 19:54
  a
• 19:54
  clinician
• 19:54
  without
• 19:55
  this
• 19:55
  stuff.
• 19:55
  It
• 19:55
  has
• 19:55
  made
• 19:56
  such
• 19:56
  a
• 19:56
  difference.
• 19:57
  Join
• 19:57
  us
• 19:57
  in
• 19:57
  the
• 19:57
  show
• 19:58
  notes.
• 19:58
  Become
• 19:58
  a
• 19:59
  Patreon
• 19:59
  member.
• 20:00
  Until
• 20:00
  next
• 20:00
  time,
• 20:00
  my
• 20:01
  friends.
• 20:01
  Take
• 20:01
  care
• 20:01
  of
• 20:01
  yourselves
• 20:02
  and
• 20:02
  each
• 20:03
  other.
• 20:03
  Bye
• 20:03
  bye.