Latest / Pearls and Prep / Inside the Ring 🥊: Lamictal vs. Seroquel — A Deep-Dive into 2 of The Bipolar Depression Heavyweights.

Transcript

Inside the Ring 🥊: Lamictal vs. Seroquel — A Deep-Dive into 2 of The Bipolar Depression Heavyweights. · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:09
  and
• 0:09
  Prep.
• 0:09
  Npc.
• 0:10
  Here
• 0:11
  your
• 0:11
  preceptor
• 0:12
  in
• 0:12
  your
• 0:12
  pocket,
• 0:12
  your
• 0:12
  go
• 0:13
  to
• 0:13
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:15
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  Well
• 0:16
  today,
• 0:17
  back
• 0:17
  by
• 0:17
  popular
• 0:18
  demand
• 0:19
  is
• 0:19
  our
• 0:19
  Inside
• 0:20
  the
• 0:20
  Ring
• 0:20
  edition
• 0:21
  Friday
• 0:21
  night
• 0:22
  fight.
• 0:23
  In
• 0:23
  the
• 0:23
  left
• 0:24
  corner
• 0:24
  we
• 0:24
  have
• 0:25
  Seroquel.
• 0:26
  In
• 0:26
  the
• 0:26
  right
• 0:26
  corner
• 0:26
  we
• 0:27
  have
• 0:27
  Lamictal.
• 0:28
  And
• 0:28
  we're
• 0:28
  trying
• 0:28
  to
• 0:29
  figure
• 0:29
  out
• 0:29
  which
• 0:29
  one
• 0:29
  of
• 0:30
  these
• 0:30
  bad
• 0:30
  boys
• 0:31
  is
• 0:32
  the
• 0:32
  best
• 0:33
  for
• 0:34
  bipolar
• 0:34
  depression.
• 0:36
  It's
• 0:36
  going
• 0:36
  to
• 0:37
  be
• 0:37
  a
• 0:37
  fun
• 0:37
  one.
• 0:37
  I
• 0:38
  hope
• 0:38
  you
• 0:38
  enjoy
• 0:38
  it.
• 0:38
  There's
• 0:39
  a
• 0:39
  lot
• 0:39
  of
• 0:39
  meat
• 0:40
  on
• 0:40
  the
• 0:40
  bone
• 0:40
  here
• 0:41
  and
• 0:41
  as
• 0:42
  you
• 0:42
  all
• 0:42
  know,
• 0:42
  yeah,
• 0:43
  I'm
• 0:43
  pitting
• 0:43
  this
• 0:44
  as
• 0:44
  a
• 0:44
  fight
• 0:45
  against
• 0:46
  two
• 0:46
  heavyweights,
• 0:47
  although
• 0:47
  only
• 0:48
  one
• 0:48
  of
• 0:48
  them
• 0:48
  really
• 0:48
  causes
• 0:49
  weight
• 0:49
  gain.
• 0:50
  But
• 0:52
  at
• 0:52
  the
• 0:53
  end
• 0:53
  of
• 0:53
  the
• 0:53
  day,
• 0:53
  as
• 0:53
  you
• 0:54
  all
• 0:54
  know,
• 0:55
  I'm
• 0:55
  a
• 0:55
  big
• 0:56
  believer
• 0:56
  that
• 0:56
  there
• 0:56
  is
• 0:56
  no
• 0:57
  perfect
• 0:57
  medication
• 0:58
  and
• 0:58
  that
• 0:58
  there
• 0:58
  is
• 0:59
  no
• 0:59
  best
• 0:59
  medication.
• 1:00
  And
• 1:00
  I'm
• 1:01
  a
• 1:01
  big
• 1:01
  believer
• 1:01
  that
• 1:01
  the
• 1:02
  best
• 1:02
  medication
• 1:02
  is
• 1:03
  the
• 1:03
  medication
• 1:03
  your
• 1:03
  patient
• 1:04
  is
• 1:04
  willing
• 1:05
  to
• 1:05
  take.
• 1:05
  I'm
• 1:05
  very
• 1:06
  big
• 1:06
  on
• 1:06
  adherence
• 1:07
  on
• 1:07
  this
• 1:07
  podcast.
• 1:08
  Adherence,
• 1:08
  adherence,
• 1:09
  adherence,
• 1:09
  whatever
• 1:10
  you
• 1:10
  can
• 1:10
  do
• 1:11
  to
• 1:11
  find
• 1:11
  the
• 1:11
  most
• 1:11
  efficacious
• 1:12
  medication
• 1:12
  that
• 1:13
  your
• 1:13
  patient
• 1:13
  will
• 1:13
  take.
• 1:14
  And
• 1:14
  that
• 1:15
  last
• 1:15
  part
• 1:15
  is
• 1:15
  critical.
• 1:16
  To
• 1:16
  figure
• 1:16
  out
• 1:16
  all
• 1:16
  the
• 1:17
  deal
• 1:17
  breakers
• 1:18
  with
• 1:18
  respect
• 1:18
  to
• 1:18
  what
• 1:19
  they
• 1:19
  will
• 1:19
  and
• 1:19
  will
• 1:19
  not
• 1:19
  tolerate.
• 1:20
  All
• 1:20
  very
• 1:21
  important
• 1:21
  because
• 1:21
  adherence
• 1:22
  is
• 1:23
  the
• 1:23
  whole
• 1:23
  ball
• 1:23
  game
• 1:24
  here.
• 1:24
  Our
• 1:24
  ability
• 1:25
  to
• 1:25
  find
• 1:26
  a
• 1:26
  medication
• 1:26
  and
• 1:27
  tailor
• 1:27
  it
• 1:27
  specifically
• 1:28
  to
• 1:29
  the
• 1:29
  parts
• 1:30
  of
• 1:30
  the
• 1:30
  patient's
• 1:31
  life
• 1:31
  where
• 1:31
  they
• 1:31
  are
• 1:31
  being
• 1:32
  functionally
• 1:32
  impaired
• 1:33
  or
• 1:33
  distressed.
• 1:34
  That
• 1:34
  is
• 1:34
  our
• 1:34
  goal
• 1:34
  and
• 1:35
  it's
• 1:35
  our
• 1:35
  goal
• 1:35
  to
• 1:36
  flesh
• 1:36
  that
• 1:36
  out
• 1:37
  collaboratively
• 1:37
  with
• 1:38
  the
• 1:38
  patient
• 1:38
  every
• 1:39
  time
• 1:39
  we
• 1:40
  sit
• 1:40
  with
• 1:40
  them.
• 1:41
  So
• 1:42
  without
• 1:42
  further
• 1:43
  ado,
• 1:43
  let's
• 1:43
  talk
• 1:43
  about
• 1:44
  these
• 1:45
  two
• 1:45
  medications.
• 1:46
  Let's
• 1:46
  compare
• 1:46
  them.
• 1:47
  Let's
• 1:47
  think
• 1:47
  about
• 1:48
  which
• 1:49
  one
• 1:49
  is
• 1:49
  really
• 1:49
  ideal.
• 1:51
  Now,
• 1:53
  round
• 1:53
  one
• 1:53
  of
• 1:53
  this
• 1:53
  fight,
• 1:54
  we
• 1:54
  have
• 1:54
  to
• 1:54
  talk
• 1:54
  about
• 1:55
  FDA
• 1:55
  indications.
• 1:56
  That
• 1:56
  does
• 1:56
  guide
• 1:57
  a
• 1:57
  lot
• 1:57
  of
• 1:57
  our
• 1:57
  prescribing.
• 1:58
  As
• 1:58
  you
• 1:58
  know,
• 1:59
  it
• 1:59
  guides
• 2:00
  a
• 2:00
  lot
• 2:00
  of
• 2:00
  decisions
• 2:00
  with
• 2:01
  respect
• 2:01
  to
• 2:01
  our
• 2:01
  patients
• 2:02
  insurance
• 2:02
  and
• 2:02
  what
• 2:03
  they're
• 2:03
  reimbursed
• 2:03
  for.
• 2:04
  And
• 2:05
  remember
• 2:05
  that
• 2:05
  there
• 2:05
  are
• 2:05
  large
• 2:06
  scale
• 2:06
  placebo
• 2:07
  controlled
• 2:07
  trials
• 2:08
  that
• 2:09
  the
• 2:10
  drug
• 2:10
  companies
• 2:11
  bring
• 2:11
  to
• 2:11
  the
• 2:11
  FDA
• 2:12
  in
• 2:12
  the
• 2:12
  first
• 2:12
  place
• 2:13
  to
• 2:14
  allow
• 2:14
  these
• 2:15
  drugs
• 2:15
  to
• 2:15
  even
• 2:15
  come
• 2:16
  to
• 2:16
  market.
• 2:16
  Right?
• 2:17
  So
• 2:17
  there
• 2:17
  is
• 2:17
  data
• 2:18
  that,
• 2:18
  that
• 2:19
  is
• 2:19
  very
• 2:19
  important
• 2:19
  for
• 2:20
  us
• 2:20
  to
• 2:20
  listen
• 2:20
  to.
• 2:21
  And
• 2:21
  then
• 2:21
  also
• 2:22
  remember
• 2:22
  that
• 2:23
  some
• 2:23
  medications
• 2:24
  are
• 2:24
  not
• 2:24
  FDA
• 2:25
  approved
• 2:25
  for
• 2:25
  specific
• 2:26
  things
• 2:27
  and
• 2:27
  yet
• 2:27
  they
• 2:28
  can
• 2:28
  be
• 2:28
  highly
• 2:28
  efficacious.
• 2:29
  We
• 2:29
  talked
• 2:29
  recently
• 2:30
  about
• 2:30
  Cymbalta.
• 2:31
  It's
• 2:31
  not
• 2:31
  FDA
• 2:31
  approved
• 2:32
  for
• 2:32
  social
• 2:32
  anxiety
• 2:33
  disorder
• 2:33
  because
• 2:34
  it
• 2:34
  ran
• 2:35
  trials
• 2:36
  specifically
• 2:36
  indicated
• 2:37
  for
• 2:37
  pain.
• 2:38
  And
• 2:38
  that's
• 2:38
  where,
• 2:39
  where
• 2:39
  it
• 2:39
  got
• 2:39
  a
• 2:40
  lot
• 2:40
  of
• 2:40
  its
• 2:40
  approvals.
• 2:40
  That
• 2:41
  doesn't
• 2:41
  mean
• 2:41
  Cymbalta
• 2:42
  isn't
• 2:42
  effective
• 2:43
  for
• 2:43
  social
• 2:43
  anxiety
• 2:44
  Disorder.
• 2:44
  It's
• 2:44
  just
• 2:45
  not
• 2:45
  FDA
• 2:45
  approved
• 2:46
  for
• 2:46
  it.
• 2:46
  It
• 2:46
  would
• 2:46
  be
• 2:46
  used
• 2:46
  off
• 2:47
  label.
• 2:47
  And
• 2:48
  so
• 2:49
  round
• 2:49
  one
• 2:50
  here,
• 2:50
  when
• 2:50
  we're
• 2:50
  talking
• 2:50
  about
• 2:51
  FDA
• 2:51
  approvals
• 2:51
  for
• 2:52
  bipolar
• 2:52
  depression,
• 2:53
  we
• 2:53
  have
• 2:54
  Seroquel
• 2:54
  that
• 2:55
  holds
• 2:55
  an
• 2:55
  FDA
• 2:55
  approval
• 2:56
  for
• 2:56
  acute
• 2:56
  bipolar
• 2:57
  depression,
• 2:57
  both
• 2:58
  bipolar
• 2:58
  one
• 2:58
  and
• 2:58
  bipolar
• 2:59
  two,
• 3:00
  and
• 3:00
  acute
• 3:00
  mania,
• 3:01
  and
• 3:02
  maintenance
• 3:02
  treatment
• 3:02
  for
• 3:03
  bipolar
• 3:03
  one
• 3:03
  disorder.
• 3:04
  Okay?
• 3:05
  So
• 3:06
  that.
• 3:07
  Those
• 3:07
  are
• 3:07
  a
• 3:07
  lot
• 3:07
  of
• 3:07
  indications
• 3:08
  that
• 3:08
  basically
• 3:09
  runs
• 3:09
  the
• 3:09
  whole
• 3:09
  gamut
• 3:10
  of
• 3:10
  what
• 3:10
  you
• 3:10
  would
• 3:10
  need
• 3:10
  to
• 3:11
  do
• 3:11
  in
• 3:12
  session.
• 3:12
  I'm
• 3:13
  a
• 3:13
  personal
• 3:13
  big,
• 3:14
  big
• 3:14
  fan
• 3:15
  of
• 3:15
  Seroquel.
• 3:15
  I
• 3:16
  know
• 3:16
  many
• 3:16
  prescribers
• 3:17
  who
• 3:17
  absolutely
• 3:18
  loathe
• 3:18
  the
• 3:19
  medication.
• 3:20
  I
• 3:20
  understand
• 3:21
  why
• 3:21
  they
• 3:21
  would
• 3:21
  loathe
• 3:22
  the
• 3:22
  medication.
• 3:23
  It
• 3:23
  causes
• 3:24
  weight
• 3:24
  gain
• 3:25
  quite
• 3:25
  reliably.
• 3:26
  It's
• 3:26
  very
• 3:26
  sedating
• 3:27
  quite
• 3:27
  reliably.
• 3:28
  I
• 3:28
  love
• 3:29
  it.
• 3:29
  It's
• 3:30
  one
• 3:30
  of
• 3:30
  the
• 3:30
  five
• 3:30
  medications
• 3:31
  I
• 3:31
  would
• 3:31
  bring
• 3:31
  on
• 3:32
  my
• 3:32
  island,
• 3:32
  if
• 3:32
  I
• 3:33
  had
• 3:33
  an
• 3:33
  island
• 3:33
  full
• 3:34
  of
• 3:34
  patients
• 3:34
  with
• 3:34
  mental
• 3:35
  health
• 3:35
  problems.
• 3:36
  But
• 3:36
  it
• 3:36
  would
• 3:36
  be
• 3:36
  my
• 3:37
  top
• 3:37
  five.
• 3:38
  And
• 3:38
  the
• 3:38
  reason
• 3:39
  it
• 3:39
  would
• 3:39
  be
• 3:39
  my
• 3:39
  top
• 3:39
  five
• 3:40
  is
• 3:40
  because
• 3:40
  it
• 3:40
  is
• 3:40
  a
• 3:41
  very
• 3:41
  versatile
• 3:41
  medication.
• 3:42
  At
• 3:42
  low
• 3:42
  doses,
• 3:43
  it
• 3:43
  is
• 3:44
  very
• 3:44
  good
• 3:45
  at
• 3:45
  helping
• 3:46
  your
• 3:46
  patients
• 3:46
  fall
• 3:46
  asleep.
• 3:47
  It
• 3:47
  behaves
• 3:48
  like
• 3:48
  an
• 3:48
  snri
• 3:49
  a
• 3:49
  little
• 3:49
  bit
• 3:50
  higher
• 3:50
  doses,
• 3:50
  which
• 3:50
  is
• 3:51
  kind
• 3:51
  of
• 3:51
  like
• 3:51
  an
• 3:51
  antidepressant.
• 3:52
  And
• 3:52
  then
• 3:52
  it
• 3:53
  stabilizes
• 3:53
  your
• 3:53
  mood
• 3:54
  in
• 3:55
  the
• 3:55
  300
• 3:55
  plus
• 3:56
  range.
• 3:56
  And
• 3:56
  it's
• 3:56
  even
• 3:57
  an
• 3:57
  antipsychotic
• 3:58
  when
• 3:58
  you
• 3:58
  get
• 3:58
  up
• 3:58
  into
• 3:59
  like
• 3:59
  the
• 3:59
  6
• 3:59
  and
• 3:59
  800
• 4:00
  range.
• 4:00
  Okay.
• 4:01
  More
• 4:01
  or
• 4:01
  less.
• 4:02
  Every
• 4:02
  patient
• 4:02
  responds
• 4:03
  to
• 4:03
  it
• 4:03
  a
• 4:03
  little
• 4:03
  differently.
• 4:04
  Yes,
• 4:05
  sedation
• 4:05
  absolutely
• 4:06
  wipes
• 4:06
  people
• 4:06
  out,
• 4:06
  and
• 4:07
  it
• 4:07
  can
• 4:07
  be
• 4:07
  a
• 4:08
  really
• 4:09
  tough
• 4:09
  ceiling
• 4:10
  for
• 4:10
  your
• 4:10
  patient
• 4:10
  to
• 4:11
  get
• 4:11
  past.
• 4:11
  But
• 4:11
  in
• 4:11
  my
• 4:11
  experience,
• 4:12
  a
• 4:13
  lot
• 4:13
  of
• 4:13
  these
• 4:13
  folks
• 4:13
  cannot
• 4:14
  sleep
• 4:14
  for
• 4:14
  the
• 4:14
  life
• 4:15
  of
• 4:15
  them,
• 4:15
  and
• 4:15
  they
• 4:15
  need
• 4:16
  to
• 4:16
  get
• 4:16
  sleep
• 4:16
  back
• 4:16
  on
• 4:16
  board.
• 4:17
  Sleep
• 4:17
  is
• 4:17
  one
• 4:18
  of
• 4:18
  the
• 4:18
  most
• 4:19
  common
• 4:20
  trans.
• 4:21
  Trans
• 4:21
  diagnostic
• 4:23
  problems
• 4:24
  that
• 4:24
  your
• 4:24
  patients
• 4:25
  will
• 4:25
  complain
• 4:25
  about.
• 4:26
  Always
• 4:26
  hunting
• 4:27
  for
• 4:27
  medications
• 4:27
  that
• 4:28
  help
• 4:28
  people
• 4:28
  fall
• 4:28
  asleep,
• 4:29
  because
• 4:29
  sleep
• 4:29
  in
• 4:29
  and
• 4:30
  of
• 4:30
  itself
• 4:30
  is
• 4:31
  like
• 4:31
  nature's
• 4:31
  pharmacy,
• 4:32
  right?
• 4:32
  Irrespective
• 4:33
  of
• 4:33
  all
• 4:33
  the
• 4:33
  other
• 4:34
  things
• 4:34
  our
• 4:34
  meds
• 4:34
  do.
• 4:35
  If
• 4:35
  you
• 4:35
  can
• 4:35
  find
• 4:35
  a
• 4:36
  medication
• 4:36
  that
• 4:36
  helps
• 4:36
  with
• 4:37
  sleep
• 4:37
  and
• 4:37
  also
• 4:38
  helps
• 4:38
  regulate
• 4:39
  mood,
• 4:39
  then
• 4:39
  win,
• 4:40
  win.
• 4:40
  Okay.
• 4:40
  Of
• 4:41
  course
• 4:41
  you
• 4:41
  have
• 4:41
  to
• 4:41
  watch
• 4:41
  the
• 4:41
  metabolic
• 4:42
  side
• 4:42
  effects,
• 4:43
  and
• 4:43
  that's
• 4:43
  why
• 4:43
  people
• 4:44
  are
• 4:44
  a
• 4:44
  little
• 4:44
  turned
• 4:44
  off
• 4:45
  to
• 4:45
  Seroquel
• 4:46
  as
• 4:46
  well.
• 4:46
  It's
• 4:46
  a
• 4:46
  pretty
• 4:47
  big
• 4:47
  offender
• 4:47
  as
• 4:47
  it
• 4:48
  relates
• 4:48
  to
• 4:48
  metabolic
• 4:48
  side
• 4:49
  effects.
• 4:49
  But
• 4:49
  my
• 4:50
  friends,
• 4:50
  in
• 4:50
  terms
• 4:50
  of
• 4:50
  FDA
• 4:51
  indications,
• 4:52
  round
• 4:52
  one,
• 4:53
  the
• 4:53
  winner
• 4:53
  goes
• 4:53
  to
• 4:54
  Seroquel.
• 4:54
  It
• 4:54
  has
• 4:55
  broad
• 4:55
  indications
• 4:56
  for
• 4:56
  all
• 4:56
  of
• 4:56
  these
• 4:57
  conditions.
• 4:58
  Lamotrigine
• 4:58
  or
• 4:58
  Lamictal
• 4:59
  is
• 4:59
  actually
• 5:00
  not
• 5:00
  FDA
• 5:00
  approved
• 5:01
  for
• 5:01
  acute
• 5:01
  bipolar
• 5:01
  depression.
• 5:02
  And
• 5:02
  the
• 5:03
  real
• 5:03
  difference
• 5:03
  is
• 5:03
  some
• 5:04
  patients
• 5:04
  come
• 5:04
  to
• 5:04
  you
• 5:05
  and
• 5:05
  they're
• 5:05
  not
• 5:05
  currently
• 5:05
  in
• 5:06
  a
• 5:06
  depressed
• 5:06
  mood
• 5:06
  state.
• 5:07
  Okay.
• 5:07
  Things
• 5:08
  are
• 5:08
  kind
• 5:08
  of
• 5:09
  euthymic
• 5:10
  or
• 5:10
  More
• 5:10
  or
• 5:10
  less
• 5:10
  normal,
• 5:11
  but
• 5:11
  they
• 5:11
  do
• 5:11
  suffer
• 5:12
  from
• 5:12
  reoccurring
• 5:12
  lapses
• 5:13
  of
• 5:13
  depression
• 5:13
  that
• 5:14
  are
• 5:14
  very
• 5:14
  debilitating.
• 5:15
  Okay.
• 5:16
  And
• 5:16
  in
• 5:16
  that
• 5:16
  case,
• 5:17
  Lamictal
• 5:17
  might
• 5:18
  be
• 5:18
  a
• 5:18
  little
• 5:18
  better.
• 5:18
  Okay.
• 5:19
  It
• 5:19
  might
• 5:19
  be
• 5:19
  a
• 5:19
  decent
• 5:20
  choice
• 5:20
  because
• 5:20
  they're
• 5:21
  not
• 5:21
  currently
• 5:21
  depressed,
• 5:21
  and
• 5:22
  Lamictal
• 5:22
  is
• 5:22
  pretty
• 5:23
  decent
• 5:24
  at
• 5:24
  maintenance
• 5:25
  treatment.
• 5:25
  In
• 5:25
  other
• 5:25
  words,
• 5:26
  kind
• 5:26
  of
• 5:26
  preventing
• 5:27
  that
• 5:27
  patient
• 5:28
  from
• 5:29
  sliding
• 5:30
  into
• 5:30
  a
• 5:31
  depression.
• 5:31
  Okay.
• 5:32
  That.
• 5:32
  That
• 5:32
  it
• 5:33
  does
• 5:33
  have
• 5:34
  an
• 5:34
  fda,
• 5:34
  FDA
• 5:35
  indication,
• 5:35
  which
• 5:36
  is
• 5:36
  quite
• 5:36
  limited
• 5:36
  to
• 5:37
  maintenance
• 5:37
  treatment
• 5:38
  in
• 5:38
  bipolar
• 5:39
  one
• 5:39
  disorder.
• 5:39
  And
• 5:39
  it
• 5:40
  kind
• 5:40
  of
• 5:40
  delays
• 5:40
  the
• 5:40
  time
• 5:41
  to
• 5:41
  an
• 5:41
  occurrence
• 5:42
  of
• 5:42
  a
• 5:42
  mood
• 5:43
  episode.
• 5:44
  Okay.
• 5:45
  Now,
• 5:45
  even
• 5:46
  despite
• 5:46
  the
• 5:47
  fact
• 5:47
  that
• 5:47
  this
• 5:48
  is
• 5:48
  not
• 5:48
  FDA
• 5:48
  approved
• 5:49
  for.
• 5:49
  For
• 5:49
  acute
• 5:50
  bipolar
• 5:50
  depression,
• 5:51
  there
• 5:51
  are
• 5:51
  GA
• 5:51
  guidelines
• 5:52
  out
• 5:52
  there,
• 5:52
  clinical
• 5:53
  guidelines.
• 5:53
  You
• 5:53
  can
• 5:53
  look
• 5:54
  at
• 5:54
  the
• 5:54
  APA
• 5:54
  CanMat
• 5:55
  that
• 5:56
  actually
• 5:57
  do
• 5:57
  recommend
• 5:57
  it.
• 5:58
  First
• 5:58
  line
• 5:58
  therapy
• 5:59
  for
• 5:59
  acute
• 5:59
  bipolar
• 6:00
  depression.
• 6:00
  I
• 6:00
  don't
• 6:00
  want
• 6:01
  to
• 6:01
  confuse
• 6:01
  you,
• 6:01
  but
• 6:02
  what
• 6:02
  I
• 6:02
  will
• 6:02
  say
• 6:03
  is,
• 6:03
  for
• 6:03
  me
• 6:03
  as
• 6:04
  a
• 6:04
  prescriber,
• 6:04
  I
• 6:05
  don't
• 6:05
  love
• 6:05
  Lamictal.
• 6:06
  When
• 6:06
  the
• 6:06
  patient
• 6:06
  is
• 6:06
  in
• 6:07
  the
• 6:07
  throes
• 6:08
  of
• 6:08
  an
• 6:08
  acute
• 6:08
  episode
• 6:09
  of
• 6:09
  bipolar
• 6:10
  depression,
• 6:10
  I
• 6:10
  don't
• 6:10
  like
• 6:11
  it
• 6:11
  because
• 6:11
  you
• 6:11
  have
• 6:12
  to
• 6:12
  wait
• 6:12
  four
• 6:12
  to
• 6:13
  six
• 6:13
  weeks
• 6:13
  to
• 6:13
  titrate
• 6:14
  it
• 6:14
  because
• 6:14
  of
• 6:14
  Stevens
• 6:15
  Johnson
• 6:15
  syndrome.
• 6:15
  Risk
• 6:16
  the
• 6:16
  rash.
• 6:17
  Right.
• 6:17
  So
• 6:17
  you
• 6:17
  have
• 6:18
  to
• 6:18
  wait
• 6:18
  a
• 6:18
  lot
• 6:18
  before.
• 6:19
  I
• 6:19
  think
• 6:19
  it
• 6:19
  can
• 6:20
  be
• 6:20
  efficacious.
• 6:20
  And
• 6:21
  I
• 6:21
  don't
• 6:21
  want
• 6:21
  my
• 6:21
  patient
• 6:21
  to
• 6:22
  wait
• 6:22
  that
• 6:22
  long.
• 6:22
  It's
• 6:23
  also
• 6:23
  not
• 6:23
  that
• 6:23
  sedating.
• 6:24
  So
• 6:25
  here
• 6:25
  I
• 6:26
  am
• 6:26
  waiting
• 6:26
  six
• 6:27
  weeks,
• 6:27
  and
• 6:28
  I
• 6:28
  don't
• 6:28
  like
• 6:28
  to
• 6:28
  buy
• 6:29
  that.
• 6:29
  I
• 6:29
  don't.
• 6:29
  I
• 6:29
  don't
• 6:30
  like
• 6:30
  to
• 6:30
  have
• 6:31
  that
• 6:31
  kind
• 6:31
  of
• 6:31
  time.
• 6:32
  You
• 6:32
  know,
• 6:32
  it's
• 6:33
  hard
• 6:33
  enough
• 6:33
  to
• 6:33
  wait
• 6:33
  in.
• 6:34
  In
• 6:34
  a.
• 6:34
  In
• 6:34
  a
• 6:34
  line
• 6:34
  at
• 6:34
  the
• 6:35
  DMV
• 6:35
  for
• 6:36
  an
• 6:36
  hour,
• 6:36
  and
• 6:37
  now
• 6:37
  you're
• 6:37
  by.
• 6:37
  You're
• 6:38
  in
• 6:38
  acute
• 6:38
  depression,
• 6:38
  and
• 6:39
  you
• 6:39
  have
• 6:39
  to
• 6:39
  wait
• 6:39
  six
• 6:39
  weeks
• 6:40
  or
• 6:40
  four
• 6:40
  weeks
• 6:41
  to
• 6:41
  get
• 6:41
  Lamictal
• 6:42
  into
• 6:42
  a
• 6:42
  potentially
• 6:43
  therapeutic
• 6:44
  zone.
• 6:44
  So
• 6:44
  I
• 6:44
  find
• 6:44
  that
• 6:44
  Seroquel
• 6:45
  is
• 6:45
  much
• 6:46
  better
• 6:46
  at
• 6:46
  kind
• 6:46
  of
• 6:47
  treating
• 6:47
  the
• 6:47
  acute
• 6:48
  side
• 6:48
  of
• 6:48
  the
• 6:48
  bipolar
• 6:49
  depression
• 6:49
  at,
• 6:49
  if
• 6:50
  nothing
• 6:50
  else,
• 6:50
  the
• 6:51
  hypnotic
• 6:51
  piece,
• 6:52
  the
• 6:52
  sleep
• 6:52
  component,
• 6:53
  can
• 6:53
  get
• 6:53
  stabilized
• 6:53
  really
• 6:54
  quickly.
• 6:54
  And
• 6:54
  as
• 6:54
  you
• 6:55
  guys
• 6:55
  know,
• 6:55
  in
• 6:56
  any
• 6:56
  patient
• 6:56
  who
• 6:56
  has
• 6:57
  a
• 6:57
  proclivity
• 6:58
  to
• 6:58
  swing
• 6:59
  to
• 6:59
  the
• 6:59
  bipolar
• 7:00
  manic
• 7:00
  mood
• 7:00
  states
• 7:01
  to
• 7:01
  the
• 7:01
  depression
• 7:02
  mood
• 7:02
  states,
• 7:02
  sleep
• 7:03
  is
• 7:03
  so
• 7:03
  central.
• 7:04
  The
• 7:04
  C.
• 7:04
  Restoring
• 7:05
  a
• 7:05
  circadian
• 7:05
  rhythm
• 7:06
  is
• 7:06
  so
• 7:06
  central
• 7:07
  to
• 7:07
  stabilizing
• 7:08
  these
• 7:08
  patients
• 7:09
  more
• 7:09
  broadly
• 7:09
  that
• 7:10
  I
• 7:10
  find
• 7:10
  Seroquel
• 7:11
  is
• 7:11
  a
• 7:11
  reliable
• 7:12
  partner.
• 7:12
  So
• 7:13
  in
• 7:13
  terms
• 7:13
  of
• 7:13
  FDA
• 7:14
  indications
• 7:14
  and
• 7:15
  regulatory
• 7:15
  stuff,
• 7:16
  round
• 7:17
  one
• 7:17
  definitely
• 7:17
  goes
• 7:17
  to
• 7:18
  Seroquel.
• 7:19
  On
• 7:19
  paper,
• 7:19
  it
• 7:20
  has
• 7:20
  that
• 7:20
  regulatory
• 7:21
  stamp.
• 7:21
  Definitely
• 7:22
  good
• 7:22
  guidelines
• 7:23
  endorsing
• 7:23
  Lamictal
• 7:24
  here,
• 7:24
  but
• 7:24
  it
• 7:24
  doesn't
• 7:25
  have
• 7:25
  quite
• 7:25
  the
• 7:25
  FDA
• 7:26
  indication
• 7:27
  for.
• 7:27
  For
• 7:27
  the
• 7:27
  broad
• 7:28
  range
• 7:29
  of
• 7:29
  mood
• 7:30
  rainbows
• 7:30
  that
• 7:31
  you're
• 7:31
  gonna
• 7:31
  see.
• 8:26
  And
• 8:26
  also,
• 8:27
  again,
• 8:27
  I
• 8:27
  Don't
• 8:28
  like
• 8:28
  that
• 8:28
  delay
• 8:29
  when
• 8:29
  the
• 8:29
  patient
• 8:29
  is
• 8:29
  acutely
• 8:30
  depressed.
• 8:31
  Just
• 8:31
  know
• 8:31
  that
• 8:32
  the
• 8:32
  FDA
• 8:33
  stuff,
• 8:33
  the
• 8:33
  regulatory
• 8:34
  stuff.
• 8:34
  I,
• 8:35
  I
• 8:35
  get
• 8:35
  the
• 8:35
  warm
• 8:35
  and
• 8:35
  fuzzies
• 8:36
  with
• 8:36
  Seroquel
• 8:37
  in
• 8:37
  round
• 8:37
  one.
• 8:38
  So
• 8:38
  round
• 8:38
  one
• 8:38
  goes
• 8:39
  to
• 8:39
  Seroquel
• 8:40
  here
• 8:40
  on
• 8:41
  Inside
• 8:41
  the
• 8:41
  Ring.
• 8:41
  Now,
• 8:42
  round
• 8:42
  two,
• 8:42
  let's
• 8:43
  talk
• 8:43
  efficacy
• 8:43
  in
• 8:44
  round
• 8:44
  two.
• 8:45
  Both
• 8:45
  of
• 8:45
  these
• 8:46
  are
• 8:47
  pretty
• 8:47
  darn
• 8:47
  efficacious.
• 8:48
  I
• 8:48
  just
• 8:48
  find
• 8:49
  anecdotally,
• 8:50
  clinically
• 8:50
  that
• 8:51
  Lamictal
• 8:52
  is
• 8:52
  fantastic.
• 8:53
  I
• 8:53
  find
• 8:53
  that
• 8:53
  it's
• 8:54
  particularly
• 8:54
  fantastic
• 8:55
  at
• 8:56
  keeping
• 8:56
  my
• 8:56
  patients
• 8:57
  very.
• 8:57
  Even
• 8:57
  if
• 8:57
  this
• 8:58
  was
• 8:58
  like
• 8:58
  a
• 8:58
  seesaw,
• 8:58
  right?
• 8:59
  Where
• 8:59
  when
• 8:59
  the
• 9:00
  seesaw
• 9:00
  is
• 9:00
  too,
• 9:01
  too
• 9:01
  far
• 9:02
  up,
• 9:02
  your
• 9:02
  patient
• 9:02
  gets
• 9:03
  launched
• 9:03
  into
• 9:03
  the
• 9:03
  sky
• 9:04
  in
• 9:04
  a
• 9:04
  manic
• 9:04
  episode
• 9:05
  or
• 9:05
  your
• 9:05
  seesaw
• 9:06
  gets
• 9:06
  like
• 9:06
  stuck
• 9:07
  in
• 9:07
  the
• 9:07
  mud
• 9:07
  because
• 9:07
  it's
• 9:07
  too
• 9:08
  weighed
• 9:08
  down
• 9:08
  and
• 9:08
  it's
• 9:08
  depressed.
• 9:09
  Lamictal
• 9:10
  is
• 9:11
  pretty
• 9:11
  darn
• 9:11
  good
• 9:12
  at
• 9:12
  especially
• 9:13
  preventing
• 9:13
  your
• 9:13
  patient
• 9:14
  from
• 9:14
  getting
• 9:14
  stuck
• 9:15
  in
• 9:15
  the
• 9:15
  mud
• 9:15
  or
• 9:15
  preventing
• 9:16
  a
• 9:16
  depressive
• 9:16
  relapse.
• 9:17
  And
• 9:18
  so
• 9:18
  I
• 9:18
  think
• 9:19
  it
• 9:19
  really
• 9:19
  excels
• 9:20
  there.
• 9:21
  The
• 9:21
  evidence,
• 9:21
  you
• 9:22
  can
• 9:22
  comb
• 9:22
  through
• 9:22
  the
• 9:22
  evidence.
• 9:23
  You
• 9:23
  know,
• 9:23
  we
• 9:23
  looked
• 9:24
  at
• 9:24
  a
• 9:24
  network
• 9:25
  meta
• 9:25
  analysis
• 9:25
  of
• 9:26
  101
• 9:26
  RCTs,
• 9:27
  you
• 9:27
  know,
• 9:28
  20,000
• 9:28
  people.
• 9:29
  The
• 9:30
  response
• 9:30
  rates
• 9:30
  are
• 9:30
  pretty
• 9:31
  similar
• 9:31
  with
• 9:31
  Seroquel
• 9:32
  at
• 9:32
  49%,
• 9:33
  Lamictal
• 9:34
  at
• 9:34
  44%,
• 9:35
  placebo
• 9:36
  at
• 9:36
  34%.
• 9:36
  So
• 9:37
  it's
• 9:37
  markedly
• 9:37
  better
• 9:37
  than
• 9:38
  placebo.
• 9:38
  They're
• 9:38
  both
• 9:39
  pretty
• 9:39
  impressive.
• 9:39
  Again,
• 9:39
  this
• 9:40
  was
• 9:40
  a
• 9:40
  network
• 9:40
  meta
• 9:41
  analysis
• 9:41
  out
• 9:42
  of
• 9:42
  the
• 9:42
  JAMA
• 9:43
  Journal.
• 9:43
  And
• 9:45
  really,
• 9:45
  again,
• 9:45
  it
• 9:46
  comes
• 9:46
  down
• 9:46
  to
• 9:46
  the
• 9:46
  fact
• 9:46
  that
• 9:47
  Seroquel
• 9:47
  is
• 9:47
  just
• 9:47
  a
• 9:48
  little
• 9:48
  bit
• 9:48
  faster.
• 9:48
  So
• 9:49
  when
• 9:49
  I
• 9:49
  think
• 9:49
  of
• 9:49
  efficacious,
• 9:50
  I
• 9:50
  don't
• 9:50
  just
• 9:50
  care
• 9:51
  about
• 9:51
  what
• 9:51
  the
• 9:51
  trials
• 9:52
  say
• 9:52
  and
• 9:53
  what's
• 9:53
  more
• 9:53
  effective.
• 9:53
  I
• 9:54
  care
• 9:54
  about
• 9:54
  what
• 9:54
  you're
• 9:55
  going
• 9:55
  to
• 9:55
  do
• 9:55
  from
• 9:55
  the
• 9:55
  patient
• 9:56
  that's
• 9:56
  in
• 9:56
  front
• 9:56
  of
• 9:56
  me
• 9:56
  now
• 9:57
  who's
• 9:57
  suffering
• 9:58
  and
• 9:58
  needs
• 9:58
  help
• 9:59
  and
• 9:59
  may
• 9:59
  not
• 10:00
  have
• 10:00
  the
• 10:00
  patience
• 10:00
  to
• 10:00
  wait
• 10:01
  for
• 10:01
  six
• 10:02
  weeks.
• 10:03
  And
• 10:03
  so
• 10:03
  that
• 10:03
  six
• 10:03
  week
• 10:04
  mandatory
• 10:04
  titration
• 10:05
  to
• 10:06
  mitigate
• 10:06
  Stevens
• 10:06
  Johnson,
• 10:07
  I
• 10:08
  think
• 10:08
  kind
• 10:08
  of
• 10:09
  makes
• 10:09
  it
• 10:09
  to
• 10:10
  me
• 10:10
  less
• 10:10
  efficacious.
• 10:11
  When
• 10:11
  we're
• 10:11
  talking
• 10:11
  about
• 10:12
  acute
• 10:12
  bipolar
• 10:13
  depression.
• 10:14
  If
• 10:14
  we're
• 10:14
  talking
• 10:14
  about
• 10:15
  just
• 10:15
  preventing
• 10:16
  depression
• 10:16
  more
• 10:17
  broadly
• 10:17
  in
• 10:18
  bipolar
• 10:19
  disorder,
• 10:19
  then
• 10:19
  Lamictal
• 10:20
  is
• 10:21
  much
• 10:21
  more
• 10:21
  comforting.
• 10:22
  And
• 10:23
  I,
• 10:23
  I'm
• 10:24
  a
• 10:24
  big
• 10:24
  fan
• 10:24
  of
• 10:24
  it.
• 10:24
  But
• 10:25
  no,
• 10:25
  I
• 10:25
  think
• 10:25
  in
• 10:25
  this
• 10:26
  case
• 10:26
  efficacy.
• 10:27
  I
• 10:28
  like
• 10:28
  the
• 10:28
  fact
• 10:28
  that
• 10:28
  Seroquel
• 10:29
  prevents
• 10:29
  both
• 10:30
  manic
• 10:30
  and
• 10:30
  depressive
• 10:31
  relapses.
• 10:31
  Lamictal
• 10:32
  tends
• 10:32
  to
• 10:32
  prevent
• 10:33
  the
• 10:33
  depressive
• 10:34
  relapses
• 10:34
  a
• 10:34
  lot
• 10:35
  more
• 10:35
  effectively.
• 10:36
  So
• 10:36
  Seroquel
• 10:37
  is
• 10:37
  more
• 10:37
  of
• 10:37
  that
• 10:37
  broad
• 10:37
  spectrum
• 10:38
  coverage.
• 10:39
  Lamictal
• 10:39
  is
• 10:40
  not
• 10:40
  known
• 10:40
  to
• 10:40
  prevent
• 10:41
  mania
• 10:41
  very,
• 10:42
  very
• 10:42
  well
• 10:42
  or
• 10:43
  very
• 10:43
  easily.
• 10:43
  Right.
• 10:44
  So
• 10:44
  it's
• 10:44
  not
• 10:44
  really
• 10:45
  good
• 10:45
  at
• 10:45
  preventing
• 10:45
  that
• 10:45
  seesaw.
• 10:46
  From
• 10:47
  going
• 10:47
  up.
• 10:48
  So
• 10:48
  that's
• 10:48
  something
• 10:49
  that
• 10:49
  again,
• 10:49
  just
• 10:49
  comes
• 10:50
  down
• 10:50
  to
• 10:50
  my
• 10:51
  own
• 10:52
  philosophy
• 10:52
  as
• 10:52
  a
• 10:53
  prescriber.
• 10:53
  I
• 10:54
  think
• 10:54
  that
• 10:54
  Seroquel
• 10:55
  wins
• 10:56
  in
• 10:56
  acute
• 10:56
  bipolar
• 10:57
  depression.
• 10:58
  Lamictal
• 10:59
  is
• 10:59
  more
• 10:59
  of
• 10:59
  a
• 10:59
  long
• 10:59
  distance
• 11:00
  runner
• 11:00
  for
• 11:00
  depression
• 11:01
  prevention
• 11:01
  more
• 11:02
  broadly.
• 11:02
  But
• 11:03
  they're
• 11:03
  a
• 11:03
  good
• 11:03
  tag
• 11:03
  team.
• 11:03
  You
• 11:04
  know,
• 11:04
  these
• 11:04
  two
• 11:04
  together
• 11:04
  are
• 11:05
  a
• 11:05
  really
• 11:05
  good
• 11:05
  tag
• 11:05
  team
• 11:06
  for
• 11:06
  that
• 11:06
  reason,
• 11:07
  right
• 11:07
  now,
• 11:08
  when
• 11:08
  it
• 11:08
  comes
• 11:08
  to
• 11:08
  sleep
• 11:09
  and
• 11:09
  sedation,
• 11:10
  this
• 11:10
  is
• 11:10
  a
• 11:11
  very
• 11:11
  interesting
• 11:11
  one.
• 11:11
  This
• 11:12
  is
• 11:12
  round
• 11:12
  three,
• 11:12
  sleep
• 11:13
  and
• 11:13
  sedation.
• 11:15
  Now,
• 11:15
  as
• 11:15
  we've
• 11:15
  talked
• 11:15
  about,
• 11:16
  Seroquel
• 11:16
  is
• 11:17
  profoundly
• 11:17
  sedating.
• 11:19
  Okay?
• 11:19
  It
• 11:19
  is
• 11:19
  by
• 11:20
  far
• 11:20
  the
• 11:21
  most
• 11:21
  common
• 11:21
  side
• 11:22
  effect
• 11:22
  that
• 11:22
  I
• 11:22
  have
• 11:22
  seen
• 11:23
  with
• 11:24
  Seroquel.
• 11:25
  And
• 11:25
  the
• 11:25
  good
• 11:25
  news
• 11:26
  is
• 11:26
  that
• 11:26
  so
• 11:26
  many
• 11:27
  people
• 11:27
  who
• 11:28
  would
• 11:28
  otherwise
• 11:28
  be
• 11:29
  good
• 11:29
  candidates
• 11:29
  for
• 11:30
  Seroquel
• 11:31
  actually
• 11:33
  lean
• 11:34
  into
• 11:34
  the
• 11:34
  fact
• 11:35
  that
• 11:35
  it
• 11:35
  will
• 11:35
  reliably
• 11:36
  make
• 11:36
  them
• 11:36
  sleep.
• 11:36
  And
• 11:36
  I
• 11:37
  often
• 11:37
  tell
• 11:37
  my
• 11:37
  patients,
• 11:37
  hey,
• 11:38
  we
• 11:38
  might
• 11:38
  have
• 11:38
  the
• 11:38
  opposite
• 11:39
  problem
• 11:39
  here.
• 11:39
  Now,
• 11:40
  your
• 11:40
  problem
• 11:40
  now
• 11:40
  is
• 11:41
  you
• 11:41
  can't
• 11:41
  sleep.
• 11:41
  For
• 11:41
  the
• 11:41
  life
• 11:42
  of
• 11:42
  you.
• 11:42
  Maybe
• 11:42
  you're
• 11:42
  too
• 11:43
  energized,
• 11:43
  you're
• 11:44
  talking
• 11:44
  too
• 11:44
  fast,
• 11:45
  you're
• 11:45
  cleaning
• 11:46
  your
• 11:46
  house
• 11:46
  in
• 11:46
  the
• 11:46
  wee
• 11:46
  hours
• 11:46
  of
• 11:47
  the
• 11:47
  night.
• 11:47
  I
• 11:47
  and
• 11:47
  I
• 11:48
  brace
• 11:48
  them,
• 11:48
  I
• 11:48
  give
• 11:48
  them
• 11:48
  anticipatory
• 11:49
  guidance
• 11:49
  and
• 11:50
  say,
• 11:50
  now
• 11:50
  look.
• 11:51
  Now
• 11:51
  we
• 11:51
  may
• 11:51
  be
• 11:52
  faced
• 11:52
  with
• 11:52
  the
• 11:52
  opposite
• 11:52
  problem
• 11:53
  of
• 11:53
  sleeping
• 11:53
  too
• 11:54
  much,
• 11:54
  but
• 11:54
  hey,
• 11:55
  on
• 11:55
  the
• 11:55
  flip
• 11:56
  side,
• 11:56
  it
• 11:56
  is
• 11:56
  a
• 11:56
  very
• 11:57
  good
• 11:57
  thing
• 11:57
  that
• 11:58
  we
• 11:58
  can
• 11:58
  at
• 11:58
  least
• 11:58
  stabilize
• 11:59
  your
• 11:59
  circadian
• 11:59
  rhythm
• 12:00
  and
• 12:00
  we
• 12:00
  can
• 12:00
  fine
• 12:00
  tune
• 12:01
  it
• 12:01
  later.
• 12:01
  We
• 12:01
  can
• 12:01
  peel
• 12:02
  back
• 12:02
  the
• 12:02
  dose
• 12:02
  a
• 12:02
  little
• 12:02
  bit,
• 12:03
  we
• 12:03
  can
• 12:03
  just
• 12:03
  get
• 12:03
  this
• 12:04
  stabilized
• 12:05
  while
• 12:05
  we
• 12:05
  look
• 12:05
  at
• 12:05
  other
• 12:05
  ways
• 12:06
  to
• 12:06
  prevent
• 12:07
  mania
• 12:08
  or
• 12:08
  depression.
• 12:08
  You
• 12:08
  know,
• 12:09
  we
• 12:09
  can
• 12:09
  talk
• 12:09
  about
• 12:09
  all
• 12:09
  the
• 12:10
  details
• 12:10
  of
• 12:10
  the,
• 12:11
  the
• 12:11
  actual
• 12:11
  mood
• 12:11
  swings.
• 12:12
  But
• 12:12
  the
• 12:12
  first
• 12:12
  thing
• 12:12
  that
• 12:13
  I
• 12:13
  think
• 12:13
  is
• 12:14
  really
• 12:14
  grounding
• 12:14
  in
• 12:15
  our
• 12:15
  conversations
• 12:15
  together
• 12:16
  is
• 12:16
  let's
• 12:16
  just
• 12:16
  get
• 12:17
  your
• 12:17
  sleep
• 12:17
  right.
• 12:18
  Right.
• 12:18
  Because
• 12:19
  you
• 12:19
  know,
• 12:19
  the
• 12:19
  patient
• 12:19
  doesn't
• 12:20
  typically
• 12:20
  come
• 12:20
  in
• 12:21
  and
• 12:21
  beg
• 12:21
  you
• 12:22
  to
• 12:22
  prevent
• 12:22
  their
• 12:23
  long
• 12:23
  term
• 12:23
  mania
• 12:24
  or
• 12:24
  their
• 12:24
  long
• 12:24
  term
• 12:24
  depression.
• 12:25
  Although
• 12:25
  that
• 12:25
  is
• 12:25
  a
• 12:25
  good
• 12:26
  goal.
• 12:26
  They're
• 12:26
  coming
• 12:27
  to
• 12:27
  you
• 12:27
  cause
• 12:27
  they're
• 12:27
  saying,
• 12:27
  hey,
• 12:28
  I
• 12:28
  can't
• 12:28
  sleep.
• 12:28
  Can
• 12:28
  you
• 12:29
  please
• 12:29
  help
• 12:29
  me
• 12:29
  sleep?
• 12:30
  Right?
• 12:30
  And
• 12:31
  although
• 12:31
  there
• 12:32
  are
• 12:32
  a
• 12:32
  ton
• 12:32
  of
• 12:32
  sleep
• 12:32
  meds
• 12:33
  out
• 12:33
  there,
• 12:33
  doxepin,
• 12:35
  ramellon,
• 12:36
  lunesta,
• 12:36
  like
• 12:37
  trazodone,
• 12:37
  there's
• 12:38
  tons
• 12:38
  of
• 12:38
  things
• 12:38
  you
• 12:38
  could
• 12:38
  do,
• 12:39
  but
• 12:39
  you
• 12:39
  definitely
• 12:40
  don't
• 12:40
  want
• 12:41
  to
• 12:41
  waste
• 12:41
  this
• 12:41
  opportunity
• 12:42
  because
• 12:43
  Seroquel
• 12:43
  is
• 12:44
  an
• 12:44
  opportunity
• 12:44
  to
• 12:44
  get
• 12:44
  them
• 12:44
  to
• 12:45
  sleep.
• 12:45
  And
• 12:45
  it's
• 12:45
  an
• 12:45
  opportunity
• 12:46
  also,
• 12:46
  as
• 12:47
  you
• 12:47
  titrate
• 12:47
  it
• 12:48
  up
• 12:48
  as
• 12:48
  they
• 12:49
  tolerate
• 12:49
  it,
• 12:49
  to
• 12:50
  more
• 12:50
  stabilize
• 12:51
  their
• 12:51
  mood
• 12:51
  more
• 12:52
  broadly.
• 12:52
  Right?
• 12:52
  So
• 12:53
  you
• 12:53
  don't
• 12:53
  want
• 12:53
  to
• 12:53
  just
• 12:53
  keep
• 12:54
  slapping
• 12:54
  new
• 12:54
  meds
• 12:55
  on
• 12:55
  that
• 12:55
  all
• 12:56
  do
• 12:56
  different
• 12:56
  things.
• 12:56
  Try
• 12:57
  to
• 12:57
  find
• 12:57
  a
• 12:57
  med
• 12:57
  that
• 12:57
  does
• 12:58
  everything
• 12:58
  at
• 12:58
  once.
• 12:59
  So
• 12:59
  long
• 12:59
  as
• 12:59
  the
• 12:59
  patient
• 13:00
  can
• 13:00
  tolerate
• 13:00
  it.
• 13:01
  In
• 13:01
  this
• 13:01
  case,
• 13:01
  the
• 13:02
  metabolic
• 13:02
  side
• 13:02
  effects,
• 13:03
  of
• 13:03
  course,
• 13:03
  would
• 13:03
  be
• 13:03
  something
• 13:04
  they
• 13:04
  may
• 13:04
  not
• 13:04
  want
• 13:04
  to
• 13:05
  tolerate.
• 13:05
  But
• 13:06
  that's
• 13:06
  again,
• 13:06
  why
• 13:06
  I
• 13:06
  love
• 13:07
  Seroquel,
• 13:08
  because
• 13:08
  it
• 13:08
  is
• 13:08
  sedating.
• 13:09
  It
• 13:09
  helps
• 13:09
  the
• 13:09
  patient
• 13:10
  fall
• 13:10
  asleep.
• 13:10
  It's
• 13:10
  a
• 13:10
  near
• 13:11
  immediate
• 13:12
  relief
• 13:12
  in
• 13:12
  terms
• 13:12
  of
• 13:13
  sleep.
• 13:13
  And
• 13:13
  that
• 13:14
  can
• 13:14
  be
• 13:14
  very
• 13:15
  reinforcing
• 13:15
  for
• 13:15
  your
• 13:16
  therapeutic
• 13:16
  report.
• 13:17
  It
• 13:17
  can
• 13:17
  give
• 13:17
  the
• 13:17
  patient
• 13:17
  hope.
• 13:18
  It's
• 13:18
  hard
• 13:19
  to
• 13:19
  ask
• 13:19
  a
• 13:19
  patient
• 13:20
  who's
• 13:20
  already
• 13:20
  suffering
• 13:20
  to
• 13:20
  wait
• 13:21
  six
• 13:21
  weeks
• 13:21
  to
• 13:21
  feel
• 13:22
  better.
• 13:22
  But
• 13:23
  there's
• 13:23
  no
• 13:23
  contest
• 13:23
  here
• 13:24
  that
• 13:24
  in
• 13:24
  terms
• 13:25
  of
• 13:25
  sleep
• 13:25
  and
• 13:25
  sedation,
• 13:26
  Seroquel
• 13:26
  is
• 13:27
  superior.
• 13:28
  However,
• 13:29
  if
• 13:29
  your
• 13:29
  patient
• 13:29
  has
• 13:29
  sleep
• 13:30
  apnea,
• 13:31
  that
• 13:31
  could
• 13:31
  be
• 13:31
  a
• 13:32
  little
• 13:32
  problematic
• 13:32
  with
• 13:33
  Seroquel.
• 13:34
  Okay?
• 13:35
  Another
• 13:36
  issue
• 13:36
  here
• 13:37
  is
• 13:37
  that
• 13:37
  some
• 13:37
  patients
• 13:38
  don't
• 13:38
  want
• 13:38
  to
• 13:38
  be
• 13:39
  sedated
• 13:39
  and
• 13:39
  fall
• 13:40
  asleep,
• 13:40
  and
• 13:40
  they
• 13:40
  wake
• 13:40
  up
• 13:40
  the
• 13:41
  next
• 13:41
  day
• 13:41
  extremely
• 13:41
  drowsy.
• 13:42
  They
• 13:42
  can't
• 13:42
  commute
• 13:43
  to
• 13:43
  work
• 13:43
  in
• 13:44
  a
• 13:44
  functional
• 13:44
  way.
• 13:45
  Just
• 13:45
  wiped
• 13:45
  out.
• 13:46
  I've
• 13:46
  had
• 13:46
  people
• 13:46
  come
• 13:46
  back
• 13:47
  in
• 13:47
  a
• 13:47
  week
• 13:47
  saying,
• 13:47
  hey,
• 13:47
  look,
• 13:48
  I
• 13:48
  cannot
• 13:48
  do
• 13:48
  the
• 13:48
  cerecal
• 13:49
  thing.
• 13:49
  I'm
• 13:49
  completely
• 13:50
  wiped
• 13:50
  out.
• 13:50
  It's
• 13:50
  a
• 13:50
  deal
• 13:50
  breaker.
• 13:51
  I
• 13:51
  just
• 13:51
  can't.
• 13:51
  Even
• 13:52
  at
• 13:52
  50,
• 13:52
  I'm
• 13:53
  wiped
• 13:53
  out.
• 13:53
  I
• 13:53
  can't.
• 13:53
  I
• 13:53
  don't
• 13:54
  even
• 13:54
  know
• 13:54
  what
• 13:54
  a
• 13:54
  hundred
• 13:54
  is
• 13:55
  going
• 13:55
  to
• 13:55
  look
• 13:55
  like
• 13:55
  if
• 13:55
  at
• 13:55
  50
• 13:56
  is
• 13:56
  this
• 13:56
  intense,
• 13:57
  right?
• 13:58
  And
• 13:58
  in
• 13:58
  that
• 13:58
  sense,
• 13:59
  Lamictal
• 14:00
  starts
• 14:00
  to
• 14:00
  look
• 14:01
  very
• 14:01
  appealing.
• 14:02
  To
• 14:02
  say
• 14:03
  nothing
• 14:03
  of
• 14:03
  the
• 14:03
  fact
• 14:03
  that
• 14:03
  Seroquel
• 14:04
  makes
• 14:04
  you
• 14:04
  gain
• 14:04
  weight
• 14:05
  quite
• 14:05
  reliably.
• 14:05
  And
• 14:06
  Lamictal
• 14:06
  is
• 14:06
  more
• 14:07
  weight
• 14:07
  neutral.
• 14:07
  There's
• 14:08
  no
• 14:08
  significant
• 14:08
  sedation
• 14:09
  with
• 14:09
  Lamictal.
• 14:10
  It
• 14:10
  doesn't
• 14:10
  really
• 14:10
  have
• 14:10
  any
• 14:11
  hypnotic
• 14:11
  properties.
• 14:11
  I
• 14:12
  don't
• 14:12
  think
• 14:12
  I've
• 14:12
  ever
• 14:13
  met
• 14:13
  anyone
• 14:13
  yet
• 14:14
  who's
• 14:14
  told
• 14:14
  me
• 14:14
  that
• 14:14
  Lamictal
• 14:15
  made
• 14:15
  them
• 14:15
  tired.
• 14:16
  So
• 14:17
  if
• 14:17
  you
• 14:17
  want
• 14:18
  a
• 14:18
  medication
• 14:18
  with
• 14:19
  a
• 14:19
  little
• 14:19
  less
• 14:19
  drama
• 14:20
  in
• 14:20
  the
• 14:20
  sleep
• 14:20
  department
• 14:20
  and
• 14:21
  then
• 14:21
  the
• 14:21
  weight
• 14:21
  department,
• 14:22
  then
• 14:23
  Lamictal
• 14:24
  is
• 14:24
  your.
• 14:24
  Is,
• 14:25
  is
• 14:25
  the
• 14:25
  place
• 14:25
  to
• 14:25
  go.
• 14:26
  But
• 14:26
  if
• 14:26
  we
• 14:26
  are
• 14:26
  targeting
• 14:27
  sleep
• 14:27
  and
• 14:27
  sedation
• 14:28
  in
• 14:28
  round
• 14:28
  three,
• 14:29
  the
• 14:29
  clear
• 14:29
  winner
• 14:30
  is
• 14:30
  Seroquel
• 14:30
  by
• 14:31
  design.
• 14:31
  And
• 14:32
  Lamictvil
• 14:33
  doesn't
• 14:33
  even
• 14:33
  need
• 14:33
  to
• 14:33
  be
• 14:33
  that
• 14:33
  insecure
• 14:34
  about
• 14:34
  it.
• 14:34
  It's
• 14:35
  not
• 14:35
  what
• 14:35
  it
• 14:35
  does,
• 14:35
  so
• 14:36
  it's
• 14:36
  not
• 14:36
  a
• 14:36
  big
• 14:36
  deal.
• 14:37
  Now,
• 14:37
  if
• 14:37
  we
• 14:37
  go
• 14:37
  to
• 14:37
  round
• 14:38
  four
• 14:38
  and
• 14:38
  we
• 14:38
  talk
• 14:38
  about
• 14:39
  overall
• 14:39
  side
• 14:39
  effect
• 14:40
  and
• 14:40
  metabolic
• 14:41
  burden,
• 14:41
  this
• 14:41
  is
• 14:41
  where
• 14:41
  things
• 14:42
  get
• 14:42
  really
• 14:43
  interesting.
• 14:44
  Because
• 14:44
  if
• 14:44
  I'm
• 14:44
  a
• 14:45
  patient,
• 14:45
  I
• 14:45
  would
• 14:45
  definitely
• 14:46
  be
• 14:46
  turned
• 14:47
  off
• 14:47
  by
• 14:47
  the
• 14:48
  Stevens
• 14:48
  Johnson
• 14:48
  syndrome.
• 14:49
  It
• 14:49
  is
• 14:49
  not
• 14:49
  that
• 14:49
  common.
• 14:50
  You
• 14:50
  know,
• 14:50
  they
• 14:50
  say
• 14:51
  about
• 14:51
  1
• 14:51
  in
• 14:51
  10
• 14:52
  patients
• 14:52
  will
• 14:52
  develop
• 14:52
  a
• 14:53
  benign
• 14:53
  rash.
• 14:54
  I
• 14:54
  think
• 14:54
  the
• 14:54
  latest
• 14:55
  evidence
• 14:55
  is
• 14:55
  1
• 14:55
  in
• 14:56
  3,000
• 14:56
  may
• 14:56
  develop
• 14:57
  the
• 14:57
  serious
• 14:57
  rash.
• 14:58
  That
• 14:58
  is
• 14:58
  enough,
• 14:59
  though,
• 14:59
  to
• 14:59
  really
• 14:59
  spook
• 15:00
  me
• 15:00
  away
• 15:00
  from
• 15:00
  Lamictal.
• 15:01
  I
• 15:01
  would
• 15:02
  also
• 15:02
  be
• 15:02
  very
• 15:02
  spooked
• 15:03
  by
• 15:04
  my
• 15:04
  cholesterol
• 15:05
  doubling
• 15:06
  in
• 15:06
  a
• 15:06
  year.
• 15:07
  I
• 15:07
  want
• 15:07
  no
• 15:08
  part
• 15:08
  of
• 15:08
  that.
• 15:08
  I
• 15:08
  don't
• 15:08
  know
• 15:09
  the
• 15:09
  exact
• 15:09
  measure
• 15:10
  by
• 15:10
  which
• 15:10
  Seroquel
• 15:11
  does
• 15:12
  increase
• 15:12
  cholesterol,
• 15:13
  but
• 15:13
  it
• 15:13
  does
• 15:14
  worsen
• 15:14
  the
• 15:14
  metabolic
• 15:15
  profile
• 15:15
  in
• 15:15
  many
• 15:15
  patients.
• 15:16
  So
• 15:16
  I'd
• 15:16
  be
• 15:17
  spooked
• 15:17
  by
• 15:17
  both
• 15:17
  of
• 15:17
  those
• 15:18
  things,
• 15:18
  no
• 15:18
  doubt
• 15:18
  about
• 15:19
  it.
• 15:19
  But
• 15:19
  you
• 15:19
  do
• 15:20
  have
• 15:20
  a
• 15:20
  boxed
• 15:21
  warning
• 15:21
  with
• 15:21
  Lamictal
• 15:22
  and
• 15:23
  that
• 15:23
  would
• 15:23
  very
• 15:24
  much
• 15:24
  spook
• 15:24
  me.
• 15:25
  With
• 15:25
  Seroquel,
• 15:26
  you
• 15:26
  don't
• 15:26
  really
• 15:26
  have
• 15:27
  that
• 15:27
  serious
• 15:27
  rash.
• 15:28
  It's
• 15:28
  extremely
• 15:29
  rare,
• 15:30
  only
• 15:31
  really
• 15:31
  in
• 15:31
  post
• 15:31
  marketing
• 15:32
  reports.
• 15:33
  But
• 15:34
  again,
• 15:34
  you
• 15:34
  have
• 15:34
  very
• 15:35
  real
• 15:36
  lipids,
• 15:36
  waist
• 15:37
  circumference,
• 15:38
  glucose
• 15:38
  levels
• 15:39
  can
• 15:39
  all
• 15:39
  get
• 15:40
  very
• 15:40
  dysregulated
• 15:41
  and
• 15:41
  that's
• 15:41
  a
• 15:42
  real
• 15:42
  problem.
• 15:42
  Right.
• 15:42
  We
• 15:42
  know
• 15:43
  that
• 15:43
  the
• 15:43
  number
• 15:43
  one
• 15:43
  killer
• 15:44
  of
• 15:45
  in
• 15:45
  mental
• 15:45
  health
• 15:45
  is
• 15:45
  essentially
• 15:46
  cardiovascular
• 15:47
  disease,
• 15:48
  right?
• 15:48
  It's
• 15:48
  not
• 15:48
  suicide,
• 15:49
  it's
• 15:49
  not
• 15:50
  bear
• 15:50
  attacks,
• 15:50
  it's
• 15:51
  not
• 15:51
  alcoholism,
• 15:51
  it's
• 15:52
  cardiovascular
• 15:53
  disease.
• 15:53
  So
• 15:53
  that's
• 15:54
  already
• 15:54
  problematic.
• 15:55
  Right?
• 15:56
  Our
• 15:56
  patients
• 15:56
  are
• 15:57
  less
• 15:57
  likely
• 15:57
  to
• 15:57
  be
• 15:57
  engaged
• 15:58
  in
• 15:58
  healthcare
• 15:58
  and
• 15:59
  get
• 15:59
  their
• 15:59
  cholesterol
• 16:00
  checked.
• 16:00
  They're
• 16:00
  more
• 16:00
  likely
• 16:01
  to
• 16:01
  smoke
• 16:01
  and
• 16:01
  drink.
• 16:02
  And
• 16:02
  the
• 16:02
  stress
• 16:03
  response
• 16:03
  itself
• 16:03
  is
• 16:04
  extremely
• 16:04
  corrosive.
• 16:05
  Being
• 16:05
  in
• 16:05
  fight
• 16:06
  or
• 16:06
  flight,
• 16:06
  we
• 16:06
  know
• 16:06
  is
• 16:07
  neurotoxic.
• 16:08
  It's
• 16:08
  very
• 16:08
  difficult
• 16:09
  on
• 16:09
  the
• 16:09
  body.
• 16:10
  It
• 16:10
  causes
• 16:10
  weight
• 16:10
  gain
• 16:11
  in
• 16:11
  and
• 16:11
  of
• 16:11
  itself
• 16:11
  through
• 16:12
  the
• 16:12
  increased
• 16:13
  cortisol
• 16:13
  and
• 16:14
  all
• 16:14
  of
• 16:14
  the
• 16:14
  horrible
• 16:15
  mind
• 16:15
  body
• 16:16
  bi
• 16:17
  directional
• 16:17
  manifestations
• 16:18
  of
• 16:18
  stress
• 16:19
  and
• 16:19
  chronic
• 16:19
  stress.
• 16:20
  So
• 16:20
  when
• 16:20
  that's
• 16:21
  already
• 16:21
  such
• 16:21
  a
• 16:21
  problem,
• 16:22
  adding
• 16:22
  a
• 16:23
  metabolic
• 16:23
  beast
• 16:24
  to
• 16:24
  that
• 16:24
  is
• 16:25
  a
• 16:25
  little
• 16:25
  scary.
• 16:26
  So
• 16:26
  as
• 16:27
  I
• 16:27
  always
• 16:27
  say,
• 16:27
  psychiatry
• 16:28
  is
• 16:28
  all
• 16:28
  about
• 16:29
  trade
• 16:29
  offs.
• 16:29
  And
• 16:30
  these
• 16:30
  two
• 16:30
  are
• 16:30
  a
• 16:30
  good
• 16:31
  example.
• 16:31
  I
• 16:31
  mean,
• 16:31
  you
• 16:31
  have
• 16:32
  one
• 16:32
  kind
• 16:32
  of
• 16:32
  freakishly
• 16:33
  scary
• 16:34
  where
• 16:34
  your
• 16:34
  skin
• 16:35
  is
• 16:35
  sloughing
• 16:35
  off
• 16:36
  kind
• 16:36
  of
• 16:36
  side
• 16:37
  effect
• 16:37
  with
• 16:37
  lamictal
• 16:38
  versus
• 16:39
  you
• 16:39
  being
• 16:39
  obese
• 16:40
  in
• 16:40
  a
• 16:40
  year
• 16:41
  with
• 16:41
  a
• 16:41
  blood
• 16:41
  sugar
• 16:42
  of
• 16:42
  9,000.
• 16:43
  None
• 16:43
  of
• 16:43
  these
• 16:43
  are
• 16:43
  fun.
• 16:44
  But
• 16:44
  we
• 16:45
  have
• 16:45
  to
• 16:45
  weigh
• 16:45
  that
• 16:45
  against
• 16:46
  how
• 16:46
  destructive
• 16:47
  it
• 16:47
  is
• 16:48
  to
• 16:48
  have
• 16:48
  bipolar
• 16:49
  I
• 16:49
  or
• 16:49
  bipolar
• 16:49
  2
• 16:49
  disorder
• 16:50
  when
• 16:51
  you
• 16:51
  take
• 16:52
  a
• 16:53
  second
• 16:54
  mortgage
• 16:55
  out
• 16:55
  of
• 16:55
  your
• 16:55
  home
• 16:56
  and
• 16:56
  put
• 16:56
  it
• 16:57
  all
• 16:57
  on
• 16:57
  the
• 16:57
  green
• 16:57
  at
• 16:58
  the
• 16:58
  Bellagio,
• 16:58
  right?
• 16:59
  So
• 16:59
  we're
• 17:00
  really,
• 17:00
  we're
• 17:00
  really
• 17:00
  weighing
• 17:01
  this
• 17:01
  stuff.
• 17:01
  We're
• 17:01
  having
• 17:01
  real
• 17:02
  conversations
• 17:02
  with
• 17:02
  our
• 17:03
  patients
• 17:04
  and
• 17:04
  we're
• 17:05
  empowering
• 17:05
  them
• 17:05
  to
• 17:06
  make
• 17:06
  the
• 17:06
  best
• 17:06
  decisions
• 17:07
  they
• 17:07
  can
• 17:07
  for
• 17:07
  themselves.
• 17:08
  So
• 17:09
  at
• 17:09
  the
• 17:09
  end
• 17:09
  of
• 17:09
  the
• 17:10
  day
• 17:10
  though,
• 17:10
  in
• 17:10
  round
• 17:11
  four
• 17:11
  as
• 17:11
  it
• 17:11
  relates
• 17:12
  to
• 17:12
  side
• 17:12
  effects,
• 17:12
  I've
• 17:13
  got
• 17:13
  to
• 17:13
  give
• 17:13
  round
• 17:14
  four
• 17:14
  to
• 17:14
  lamictal
• 17:15
  because
• 17:15
  I
• 17:16
  think
• 17:16
  one
• 17:16
  of
• 17:16
  the
• 17:17
  appeals
• 17:17
  for
• 17:17
  lamictal
• 17:18
  that
• 17:19
  I
• 17:19
  hear
• 17:19
  from
• 17:19
  my
• 17:19
  patients,
• 17:19
  that
• 17:20
  I
• 17:20
  hear
• 17:20
  from
• 17:20
  other
• 17:20
  clinicians
• 17:21
  is
• 17:21
  that
• 17:22
  that
• 17:22
  is
• 17:22
  relatively
• 17:23
  drama
• 17:24
  free
• 17:24
  if
• 17:24
  you
• 17:24
  can
• 17:24
  get
• 17:24
  past
• 17:25
  the
• 17:25
  rash,
• 17:25
  if
• 17:26
  your
• 17:26
  patient
• 17:26
  can
• 17:26
  avoid
• 17:27
  any
• 17:27
  like
• 17:27
  new
• 17:27
  skin
• 17:28
  creams
• 17:28
  and
• 17:28
  lotions
• 17:29
  while
• 17:29
  they're
• 17:29
  titrating
• 17:30
  it.
• 17:30
  Because
• 17:31
  if
• 17:31
  they
• 17:31
  do
• 17:31
  that,
• 17:31
  we
• 17:31
  don't
• 17:31
  really
• 17:31
  know
• 17:32
  if
• 17:32
  the
• 17:32
  rash
• 17:32
  is
• 17:32
  benign
• 17:33
  or
• 17:33
  not.
• 17:33
  Is
• 17:33
  it
• 17:33
  because
• 17:33
  of
• 17:33
  the
• 17:34
  skin
• 17:34
  creams?
• 17:34
  You
• 17:35
  know,
• 17:35
  if
• 17:35
  your
• 17:35
  patient
• 17:35
  can
• 17:36
  get
• 17:36
  through
• 17:36
  rash
• 17:37
  free,
• 17:38
  you
• 17:38
  kind
• 17:38
  of.
• 17:38
  You
• 17:39
  kind
• 17:39
  of
• 17:39
  bypass
• 17:39
  most
• 17:40
  of
• 17:40
  the
• 17:40
  drama.
• 17:41
  There
• 17:41
  are
• 17:41
  some
• 17:42
  potential
• 17:42
  side
• 17:42
  effects
• 17:42
  with
• 17:43
  Lamictal,
• 17:44
  okay?
• 17:44
  Headaches,
• 17:45
  nausea,
• 17:45
  blurred
• 17:46
  vision,
• 17:46
  mild
• 17:47
  ataxia.
• 17:48
  Sometimes
• 17:48
  there's
• 17:49
  word
• 17:49
  finding,
• 17:49
  difficulty.
• 17:50
  Okay?
• 17:50
  But
• 17:51
  by
• 17:51
  and
• 17:51
  large,
• 17:51
  it
• 17:52
  is
• 17:52
  drama
• 17:52
  free.
• 17:52
  You
• 17:52
  have
• 17:53
  patients
• 17:53
  who
• 17:53
  are
• 17:53
  on
• 17:53
  Lamictal
• 17:54
  and
• 17:54
  they
• 17:54
  feel
• 17:54
  pretty
• 17:54
  darn
• 17:55
  even
• 17:56
  Steven.
• 17:57
  And
• 17:57
  they're
• 17:58
  not
• 17:58
  gaining
• 17:58
  weight.
• 17:58
  They
• 17:59
  just
• 17:59
  feel
• 17:59
  pretty
• 18:00
  good
• 18:00
  and
• 18:00
  pretty
• 18:00
  functional
• 18:01
  once
• 18:01
  they're
• 18:01
  there.
• 18:01
  You
• 18:01
  know,
• 18:02
  once
• 18:02
  you
• 18:02
  get
• 18:02
  past
• 18:03
  the
• 18:03
  titration,
• 18:03
  they're
• 18:04
  on
• 18:04
  like
• 18:04
  a
• 18:04
  hundred
• 18:04
  or
• 18:04
  two
• 18:05
  hundred
• 18:05
  milligrams
• 18:05
  a
• 18:05
  day,
• 18:06
  and
• 18:07
  the
• 18:07
  skies
• 18:07
  are
• 18:08
  relatively
• 18:08
  clear.
• 18:08
  So
• 18:09
  I
• 18:09
  have
• 18:09
  to
• 18:09
  say
• 18:10
  for
• 18:10
  how
• 18:11
  good
• 18:11
  of
• 18:11
  a
• 18:11
  job
• 18:11
  it
• 18:12
  does
• 18:12
  at
• 18:12
  preventing
• 18:13
  depression
• 18:13
  and
• 18:13
  keeping
• 18:14
  the
• 18:14
  moods
• 18:14
  pretty
• 18:14
  even,
• 18:16
  once
• 18:16
  you
• 18:16
  get
• 18:16
  past
• 18:17
  that
• 18:17
  rash,
• 18:17
  it
• 18:17
  is
• 18:17
  a
• 18:18
  remarkable
• 18:19
  medication.
• 18:19
  Like,
• 18:20
  absolutely
• 18:20
  remarkable.
• 18:21
  And
• 18:21
  it
• 18:21
  has
• 18:22
  saved
• 18:22
  lives.
• 18:23
  And
• 18:23
  so
• 18:23
  I.
• 18:23
  I
• 18:23
  really
• 18:24
  admire
• 18:24
  both
• 18:25
  of
• 18:25
  these
• 18:25
  meds
• 18:26
  in
• 18:26
  a
• 18:26
  major
• 18:26
  way
• 18:27
  for
• 18:27
  the
• 18:27
  right
• 18:27
  patient
• 18:27
  at
• 18:28
  the
• 18:28
  right
• 18:28
  time.
• 18:29
  And
• 18:29
  so
• 18:30
  round
• 18:30
  four
• 18:30
  definitely
• 18:31
  goes
• 18:31
  to
• 18:31
  Lamictal
• 18:32
  here.
• 18:32
  Absolutely.
• 18:33
  But
• 18:33
  I
• 18:33
  do
• 18:33
  want
• 18:33
  you
• 18:34
  to
• 18:34
  appreciate
• 18:34
  the
• 18:34
  fact
• 18:35
  that
• 18:35
  for
• 18:35
  people
• 18:36
  who
• 18:36
  want
• 18:36
  to
• 18:36
  fall
• 18:37
  asleep,
• 18:37
  side
• 18:37
  effects
• 18:38
  are
• 18:38
  not
• 18:38
  always
• 18:38
  bad.
• 18:39
  Sometimes
• 18:39
  we
• 18:39
  leverage
• 18:39
  those
• 18:40
  side
• 18:40
  effects
• 18:41
  to
• 18:41
  actually
• 18:42
  improve
• 18:42
  the
• 18:42
  whole
• 18:43
  treatment
• 18:43
  plan.
• 18:44
  You
• 18:45
  know
• 18:45
  what
• 18:45
  I
• 18:45
  mean?
• 18:46
  So
• 18:47
  somebody
• 18:47
  might
• 18:47
  get
• 18:48
  really
• 18:48
  anxious
• 18:48
  on
• 18:48
  Wellbutrin
• 18:49
  because
• 18:49
  it's
• 18:49
  more
• 18:49
  energizing,
• 18:50
  and
• 18:51
  that's
• 18:51
  a
• 18:51
  side
• 18:51
  effect
• 18:51
  they
• 18:51
  don't
• 18:52
  like.
• 18:52
  And
• 18:52
  with
• 18:53
  someone
• 18:53
  else,
• 18:53
  they
• 18:53
  are
• 18:53
  fatigued
• 18:54
  and
• 18:54
  their
• 18:54
  depression
• 18:55
  is
• 18:55
  very
• 18:56
  anhedonic
• 18:57
  and
• 18:57
  low
• 18:57
  energy.
• 18:58
  Now,
• 18:59
  round
• 18:59
  five,
• 19:00
  we
• 19:00
  can
• 19:00
  talk
• 19:00
  about
• 19:01
  mania
• 19:01
  protection,
• 19:02
  maybe
• 19:02
  cognition.
• 19:04
  And
• 19:04
  this
• 19:04
  is
• 19:04
  kind
• 19:04
  of
• 19:04
  an
• 19:05
  interesting
• 19:05
  conversation.
• 19:07
  Again,
• 19:07
  I
• 19:07
  have
• 19:07
  had
• 19:07
  patients
• 19:08
  who
• 19:08
  feel
• 19:08
  kind
• 19:08
  of
• 19:08
  foggy
• 19:09
  on
• 19:09
  Lamictal,
• 19:10
  whether
• 19:10
  that's
• 19:10
  the
• 19:10
  medication
• 19:11
  or
• 19:11
  not.
• 19:11
  It's
• 19:12
  a
• 19:12
  little
• 19:12
  hard
• 19:12
  for
• 19:12
  me
• 19:12
  to
• 19:12
  understand
• 19:13
  that.
• 19:14
  Some
• 19:14
  people
• 19:14
  say
• 19:14
  that
• 19:15
  they're
• 19:15
  actually
• 19:15
  their
• 19:15
  thought.
• 19:16
  You
• 19:16
  know,
• 19:16
  they're
• 19:16
  just
• 19:16
  a
• 19:16
  lot
• 19:16
  more
• 19:17
  clear
• 19:17
  on
• 19:18
  Lamictal.
• 19:18
  They're
• 19:18
  not
• 19:19
  getting
• 19:19
  depressed
• 19:19
  as
• 19:19
  much.
• 19:19
  Maybe
• 19:20
  the
• 19:20
  depression
• 19:20
  with
• 19:21
  the
• 19:21
  psychomotor
• 19:21
  retardation,
• 19:22
  they're
• 19:22
  just
• 19:23
  feeling
• 19:23
  better
• 19:23
  and
• 19:24
  they're
• 19:24
  less
• 19:24
  slowed
• 19:24
  down
• 19:25
  by
• 19:25
  depression.
• 19:25
  So
• 19:25
  that
• 19:26
  can
• 19:26
  go
• 19:26
  both
• 19:26
  ways.
• 19:27
  Now,
• 19:28
  Seroquel,
• 19:29
  with
• 19:29
  respect
• 19:30
  to
• 19:30
  mania
• 19:30
  protection
• 19:31
  is
• 19:31
  one
• 19:32
  of
• 19:32
  the
• 19:32
  most
• 19:32
  effective
• 19:33
  agents
• 19:33
  we
• 19:33
  have
• 19:33
  to
• 19:33
  prevent
• 19:34
  manic
• 19:34
  relapse.
• 19:35
  Of
• 19:35
  course,
• 19:35
  lithium
• 19:36
  is
• 19:36
  freaking
• 19:37
  fantastic.
• 19:38
  I.
• 19:38
  I
• 19:38
  don't
• 19:38
  even
• 19:39
  think
• 19:39
  it's
• 19:39
  worthy
• 19:39
  to
• 19:40
  dedicate
• 19:40
  a
• 19:40
  podcast
• 19:41
  episode
• 19:41
  to
• 19:41
  lithium.
• 19:41
  It
• 19:42
  may.
• 19:42
  It's
• 19:42
  probably
• 19:42
  worthy
• 19:43
  to
• 19:43
  just
• 19:43
  dedicate
• 19:43
  A
• 19:43
  whole
• 19:44
  podcast
• 19:45
  show,
• 19:46
  like
• 19:46
  a
• 19:47
  podcast
• 19:47
  named
• 19:47
  the
• 19:48
  Lithium
• 19:48
  Podcast,
• 19:49
  because
• 19:49
  it's
• 19:49
  just
• 19:49
  so
• 19:50
  wonderful.
• 19:50
  It's
• 19:50
  like
• 19:50
  the
• 19:51
  Hamlet
• 19:51
  of
• 19:53
  psychiatric
• 19:53
  medications,
• 19:54
  right?
• 19:54
  Hamlet
• 19:54
  is
• 19:55
  like
• 19:55
  in
• 19:55
  a
• 19:55
  league
• 19:55
  of
• 19:55
  its
• 19:56
  own.
• 19:56
  Like
• 19:56
  who
• 19:56
  list.
• 19:57
  Who
• 19:57
  reads
• 19:57
  the
• 19:58
  Midsummer,
• 19:58
  Midsummer
• 19:59
  Night's
• 19:59
  Dream
• 19:59
  when
• 19:59
  there's
• 20:00
  Hamlet,
• 20:00
  right?
• 20:01
  Macbeth
• 20:01
  is
• 20:01
  great.
• 20:01
  I'm
• 20:02
  a
• 20:02
  fan
• 20:02
  of
• 20:02
  Othello.
• 20:03
  I
• 20:03
  love
• 20:03
  Shakespeare.
• 20:04
  He's
• 20:04
  kind
• 20:04
  of
• 20:05
  like
• 20:05
  the,
• 20:05
  the
• 20:06
  world's
• 20:06
  first
• 20:06
  psychologist.
• 20:07
  Everyone
• 20:07
  thinks
• 20:08
  of
• 20:08
  him
• 20:08
  as
• 20:08
  like
• 20:08
  a
• 20:08
  literary
• 20:10
  guy,
• 20:11
  literary
• 20:11
  nerd.
• 20:12
  But
• 20:12
  I
• 20:12
  love
• 20:12
  him
• 20:13
  for
• 20:13
  his
• 20:13
  take
• 20:13
  on
• 20:13
  human
• 20:14
  nature
• 20:14
  and
• 20:14
  psychology.
• 20:15
  And
• 20:15
  Lithium
• 20:16
  to
• 20:16
  me
• 20:16
  is
• 20:16
  like
• 20:16
  Hamlet.
• 20:17
  It's
• 20:17
  timeless,
• 20:18
  it's
• 20:19
  a
• 20:19
  thing.
• 20:19
  It's
• 20:19
  in
• 20:19
  a
• 20:20
  league
• 20:20
  of
• 20:20
  its
• 20:20
  own.
• 20:20
  But
• 20:21
  don't
• 20:21
  underestimate
• 20:21
  Seroquel
• 20:22
  as
• 20:22
  one
• 20:22
  of
• 20:23
  the
• 20:23
  most
• 20:23
  effective
• 20:23
  agents
• 20:24
  for
• 20:24
  preventing
• 20:24
  a
• 20:24
  manic
• 20:25
  relapse.
• 20:25
  Mictal
• 20:26
  does
• 20:26
  not
• 20:26
  do
• 20:27
  that,
• 20:27
  really.
• 20:28
  Certain
• 20:28
  clinical
• 20:29
  guidelines
• 20:29
  even
• 20:30
  recommend
• 20:30
  against
• 20:30
  using
• 20:31
  it
• 20:31
  to
• 20:31
  prevent
• 20:31
  mania
• 20:32
  because
• 20:32
  that's
• 20:32
  not
• 20:32
  really
• 20:32
  what
• 20:33
  it
• 20:33
  does.
• 20:33
  You're
• 20:34
  going
• 20:34
  to
• 20:34
  need
• 20:34
  additional
• 20:34
  antimanic
• 20:35
  coverage.
• 20:36
  You're
• 20:36
  going
• 20:37
  to
• 20:37
  need
• 20:37
  lithium
• 20:37
  or
• 20:38
  Depakote
• 20:38
  or
• 20:38
  an
• 20:38
  antipsychotic
• 20:39
  in
• 20:40
  order
• 20:40
  to
• 20:40
  do
• 20:40
  that.
• 20:41
  But
• 20:41
  again,
• 20:42
  preventing
• 20:42
  depression,
• 20:43
  keeping
• 20:43
  that
• 20:43
  mood
• 20:44
  pretty
• 20:44
  even.
• 20:45
  Lamictal
• 20:45
  is
• 20:46
  pretty
• 20:46
  good
• 20:46
  and
• 20:46
  it
• 20:46
  definitely
• 20:47
  carries
• 20:48
  its
• 20:48
  weight.
• 20:48
  So
• 20:48
  if
• 20:49
  this
• 20:49
  conversation
• 20:49
  is
• 20:50
  about,
• 20:50
  you
• 20:50
  know,
• 20:51
  mania
• 20:51
  protection,
• 20:52
  the
• 20:53
  this
• 20:53
  round
• 20:53
  goes
• 20:54
  to
• 20:55
  Seroquel.
• 20:55
  If
• 20:56
  this
• 20:56
  is
• 20:56
  about
• 20:57
  cognition
• 20:58
  and
• 20:58
  kind
• 20:58
  of
• 20:58
  preserving
• 20:59
  cognition,
• 20:59
  you
• 21:00
  know
• 21:00
  that
• 21:00
  a
• 21:00
  lot
• 21:00
  of
• 21:00
  antipsychotics
• 21:01
  are
• 21:02
  deleterious
• 21:03
  to
• 21:03
  cognition,
• 21:04
  but
• 21:04
  they,
• 21:05
  you
• 21:05
  know,
• 21:05
  if
• 21:05
  you're
• 21:05
  really
• 21:06
  tired
• 21:07
  throughout
• 21:07
  the
• 21:07
  day,
• 21:08
  especially
• 21:08
  if
• 21:08
  you
• 21:08
  have
• 21:08
  like
• 21:09
  next
• 21:09
  day
• 21:09
  sedation,
• 21:09
  you're
• 21:10
  at
• 21:10
  work
• 21:10
  and
• 21:10
  you're
• 21:10
  still
• 21:11
  feeling
• 21:11
  the
• 21:11
  after
• 21:12
  effects
• 21:12
  of
• 21:12
  Seroquel,
• 21:13
  then
• 21:13
  certainly
• 21:13
  I
• 21:14
  would
• 21:14
  give
• 21:14
  Lamictal
• 21:14
  the
• 21:15
  win
• 21:15
  here
• 21:15
  overall.
• 21:16
  But
• 21:16
  again,
• 21:16
  preventing
• 21:17
  mania,
• 21:18
  Seroquel's
• 21:19
  our
• 21:19
  winner.
• 21:20
  Now,
• 21:20
  if
• 21:21
  you
• 21:21
  notice,
• 21:21
  my
• 21:21
  friends,
• 21:22
  the
• 21:22
  fight
• 21:22
  is,
• 21:22
  is,
• 21:23
  is
• 21:24
  about
• 21:24
  to
• 21:24
  end
• 21:24
  and
• 21:25
  nobody
• 21:25
  got
• 21:25
  KO'd
• 21:26
  here.
• 21:27
  If
• 21:27
  I
• 21:27
  had
• 21:27
  to
• 21:27
  choose,
• 21:28
  I,
• 21:28
  I,
• 21:28
  I,
• 21:29
  I
• 21:29
  do
• 21:29
  think
• 21:29
  Seroquel
• 21:30
  is
• 21:31
  the
• 21:31
  more
• 21:31
  versatile
• 21:32
  drug.
• 21:33
  I
• 21:33
  think
• 21:33
  again,
• 21:33
  if
• 21:33
  you're
• 21:34
  on
• 21:34
  an
• 21:34
  island
• 21:35
  and
• 21:35
  you
• 21:35
  only
• 21:36
  have
• 21:36
  five
• 21:36
  meds
• 21:36
  to
• 21:37
  prescribe,
• 21:38
  it's
• 21:38
  pretty
• 21:39
  handy.
• 21:39
  It
• 21:39
  can
• 21:40
  handle
• 21:40
  psychosis,
• 21:41
  it
• 21:41
  can
• 21:41
  handle
• 21:42
  depressive
• 21:43
  symptoms.
• 21:44
  It's
• 21:44
  pretty
• 21:45
  darn
• 21:45
  solid,
• 21:45
  depending
• 21:46
  on
• 21:46
  the
• 21:46
  dose.
• 21:46
  It's
• 21:47
  also
• 21:47
  completely
• 21:47
  intolerable
• 21:48
  to
• 21:48
  a
• 21:48
  select
• 21:49
  group
• 21:49
  of
• 21:49
  people
• 21:49
  who
• 21:50
  just
• 21:50
  don't
• 21:50
  want
• 21:50
  to
• 21:51
  try
• 21:51
  it.
• 21:51
  It's
• 21:52
  just
• 21:52
  wipes
• 21:52
  them
• 21:52
  out.
• 21:53
  But
• 21:53
  Lamictal
• 21:54
  is
• 21:54
  in
• 21:55
  a
• 21:55
  league
• 21:55
  of
• 21:55
  its
• 21:55
  own
• 21:55
  in
• 21:56
  that
• 21:56
  it
• 21:56
  is
• 21:56
  relatively
• 21:57
  drama
• 21:57
  free
• 21:57
  for
• 21:58
  how
• 21:58
  good
• 21:58
  it
• 21:58
  is.
• 21:59
  So
• 21:59
  mad
• 22:00
  respect
• 22:00
  to
• 22:00
  both
• 22:00
  medications.
• 22:01
  I
• 22:02
  think
• 22:02
  Quetiapine
• 22:03
  or
• 22:03
  Seroquel
• 22:04
  probably
• 22:04
  landed
• 22:04
  a
• 22:04
  few
• 22:04
  more
• 22:05
  punches
• 22:05
  here,
• 22:05
  but
• 22:06
  Lamictal
• 22:06
  hit
• 22:07
  Seroquel,
• 22:08
  because
• 22:09
  Seroquel
• 22:10
  does
• 22:10
  have
• 22:10
  some
• 22:10
  deal
• 22:11
  breaker
• 22:11
  side
• 22:11
  effects
• 22:11
  too,
• 22:12
  and
• 22:13
  it
• 22:13
  can
• 22:13
  be
• 22:13
  a
• 22:13
  pretty
• 22:13
  jarring
• 22:14
  experience
• 22:15
  early
• 22:15
  on
• 22:15
  and
• 22:15
  turn
• 22:16
  a
• 22:16
  lot
• 22:16
  of
• 22:16
  people
• 22:16
  off.
• 22:16
  So
• 22:17
  in
• 22:17
  that
• 22:17
  sense,
• 22:18
  you
• 22:18
  know,
• 22:18
  Seroquel's
• 22:19
  kind
• 22:19
  of
• 22:19
  like
• 22:19
  Mike
• 22:19
  Tyson.
• 22:20
  When
• 22:20
  he
• 22:20
  bites
• 22:20
  you
• 22:20
  in
• 22:20
  the
• 22:21
  earth,
• 22:21
  it's
• 22:21
  like,
• 22:22
  whoa,
• 22:22
  I
• 22:22
  didn't
• 22:22
  expect
• 22:23
  this.
• 22:23
  I
• 22:23
  just
• 22:23
  wanted
• 22:23
  to
• 22:24
  fight,
• 22:24
  you
• 22:24
  know,
• 22:25
  and
• 22:25
  so
• 22:26
  whatever.
• 22:27
  You
• 22:27
  love
• 22:27
  these
• 22:28
  analogies.
• 22:28
  I
• 22:28
  love
• 22:28
  these
• 22:29
  analogies.
• 22:30
  It's
• 22:30
  how
• 22:30
  we
• 22:31
  learn.
• 22:31
  It's
• 22:31
  how
• 22:31
  we
• 22:31
  think.
• 22:32
  But,
• 22:32
  hey,
• 22:33
  I
• 22:33
  appreciate
• 22:34
  you
• 22:34
  all
• 22:34
  tuning
• 22:35
  in
• 22:35
  today.
• 22:35
  And
• 22:35
  I
• 22:36
  can't
• 22:36
  emphasize
• 22:37
  enough,
• 22:37
  my
• 22:37
  friends,
• 22:38
  that
• 22:39
  there
• 22:39
  are
• 22:39
  two
• 22:39
  kinds
• 22:40
  of
• 22:40
  clinicians
• 22:40
  out
• 22:40
  there.
• 22:41
  The
• 22:41
  ones
• 22:42
  who
• 22:42
  just
• 22:43
  go
• 22:43
  by
• 22:43
  the
• 22:43
  algorithms
• 22:44
  and
• 22:45
  they
• 22:45
  prescribe
• 22:45
  and
• 22:45
  they
• 22:46
  diagnose,
• 22:46
  and
• 22:46
  then
• 22:47
  the
• 22:47
  second
• 22:47
  kind
• 22:47
  of
• 22:48
  clinician
• 22:48
  knows
• 22:48
  the
• 22:48
  how
• 22:49
  and
• 22:49
  the
• 22:49
  why
• 22:49
  of
• 22:49
  what
• 22:50
  they're
• 22:50
  doing,
• 22:50
  and.
• 22:51
  And
• 22:51
  patients
• 22:51
  smell
• 22:51
  that
• 22:52
  a
• 22:52
  mile
• 22:52
  away.
• 22:52
  And
• 22:53
  so
• 22:53
  we
• 22:53
  built
• 22:53
  an
• 22:53
  entire
• 22:54
  library
• 22:54
  on
• 22:55
  Patreon
• 22:56
  for
• 22:56
  the
• 22:56
  kind
• 22:56
  of
• 22:56
  clinicians
• 22:57
  that
• 22:57
  want
• 22:57
  to
• 22:57
  know
• 22:58
  the
• 22:58
  how
• 22:58
  and
• 22:58
  the
• 22:58
  why.
• 22:58
  It's
• 22:59
  not
• 22:59
  enough
• 22:59
  to
• 22:59
  just
• 22:59
  prescribe,
• 23:00
  but
• 23:00
  to
• 23:00
  understand
• 23:00
  why
• 23:01
  and
• 23:01
  what
• 23:01
  and
• 23:02
  how
• 23:02
  patients
• 23:03
  will
• 23:03
  smell
• 23:03
  that
• 23:04
  a
• 23:04
  mile
• 23:04
  away.
• 23:05
  Our
• 23:05
  library
• 23:06
  is
• 23:06
  amazing.
• 23:07
  It's
• 23:07
  visually
• 23:08
  beautiful.
• 23:08
  It's
• 23:09
  kind
• 23:09
  of
• 23:09
  a
• 23:09
  great
• 23:10
  place
• 23:10
  to
• 23:10
  nerd
• 23:10
  out
• 23:11
  and
• 23:11
  share
• 23:11
  resources
• 23:12
  and
• 23:12
  get
• 23:12
  through
• 23:12
  school
• 23:12
  and
• 23:13
  be
• 23:13
  at
• 23:13
  the
• 23:13
  top
• 23:13
  of
• 23:13
  your
• 23:13
  game.
• 23:13
  As
• 23:14
  a
• 23:14
  clinician,
• 23:14
  I'm
• 23:15
  grateful
• 23:15
  for
• 23:15
  each
• 23:15
  and
• 23:16
  every
• 23:16
  one
• 23:16
  of
• 23:16
  you.
• 23:17
  You
• 23:17
  all
• 23:17
  inspire
• 23:18
  me.
• 23:18
  You
• 23:18
  make
• 23:18
  me
• 23:18
  love
• 23:19
  my
• 23:19
  job.
• 23:19
  We
• 23:20
  will
• 23:20
  see
• 23:20
  you
• 23:20
  next
• 23:20
  time
• 23:21
  here
• 23:21
  on
• 23:21
  Pearls
• 23:22
  and
• 23:22
  Prep.