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Trazodone Isn’t Just a Sleep Med… So What Is It Really? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:10
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Now,
• 0:15
  today
• 0:16
  we
• 0:16
  are
• 0:16
  going
• 0:16
  to
• 0:16
  be
• 0:16
  talking
• 0:17
  about
• 0:18
  Trazodone.
• 0:19
  And
• 0:19
  it's
• 0:19
  an
• 0:19
  exciting
• 0:20
  conversation
• 0:20
  because
• 0:21
  I
• 0:21
  truly
• 0:21
  believe
• 0:22
  if
• 0:22
  you
• 0:23
  understand
• 0:23
  Trazodone,
• 0:25
  then
• 0:25
  you
• 0:25
  can
• 0:25
  understand
• 0:26
  psychopharmacology
• 0:27
  so
• 0:28
  much
• 0:28
  better.
• 0:29
  And
• 0:29
  it's
• 0:29
  so
• 0:29
  much
• 0:30
  fun
• 0:30
  to
• 0:31
  peel
• 0:31
  back
• 0:31
  the
• 0:31
  layers
• 0:32
  of
• 0:32
  Trazodone.
• 0:33
  How
• 0:33
  it's
• 0:33
  used,
• 0:33
  how
• 0:34
  it's
• 0:34
  not
• 0:34
  used.
• 0:35
  It's
• 0:35
  very
• 0:35
  misunderstood,
• 0:36
  it's
• 0:36
  kind
• 0:37
  of
• 0:37
  underutilized.
• 0:38
  And
• 0:38
  there's
• 0:39
  so
• 0:39
  much
• 0:39
  more
• 0:39
  to
• 0:39
  it
• 0:40
  than
• 0:40
  being
• 0:40
  just
• 0:40
  that
• 0:41
  sleep
• 0:41
  med.
• 0:42
  And
• 0:42
  we
• 0:43
  should
• 0:43
  get
• 0:43
  into
• 0:43
  it
• 0:43
  and
• 0:43
  talk
• 0:44
  about
• 0:44
  it
• 0:44
  because,
• 0:44
  again,
• 0:45
  I
• 0:45
  think
• 0:45
  it's
• 0:45
  going
• 0:45
  to
• 0:46
  really
• 0:46
  help
• 0:47
  you
• 0:47
  understand
• 0:47
  and
• 0:47
  appreciate
• 0:48
  psychopharmacology
• 0:49
  so
• 0:49
  much
• 0:49
  more.
• 0:50
  So
• 0:51
  the
• 0:51
  first
• 0:51
  thing
• 0:51
  we
• 0:52
  should
• 0:52
  talk
• 0:52
  about
• 0:52
  with
• 0:52
  Trazodone
• 0:53
  is
• 0:53
  what
• 0:54
  is
• 0:54
  it?
• 0:54
  Right?
• 0:55
  In
• 0:55
  clinic,
• 0:56
  you're
• 0:56
  going
• 0:56
  to
• 0:56
  look
• 0:56
  at
• 0:57
  trazodone,
• 0:57
  you're
• 0:57
  going
• 0:57
  to
• 0:58
  reach
• 0:58
  for
• 0:58
  Trazodone
• 0:59
  when
• 0:59
  your
• 1:00
  patient
• 1:00
  needs
• 1:00
  to
• 1:00
  sleep.
• 1:01
  And
• 1:01
  so
• 1:02
  many
• 1:02
  prescribers
• 1:03
  just
• 1:03
  kind
• 1:03
  of
• 1:03
  prescribe
• 1:04
  it
• 1:04
  because
• 1:05
  it's
• 1:05
  Trazodone
• 1:06
  and
• 1:06
  it
• 1:06
  helps
• 1:06
  you
• 1:06
  sleep,
• 1:07
  but
• 1:07
  they
• 1:07
  underappreciate
• 1:09
  exactly
• 1:10
  how
• 1:11
  it's
• 1:11
  helping
• 1:11
  that
• 1:11
  patient
• 1:12
  sleep.
• 1:12
  And
• 1:13
  if
• 1:13
  we
• 1:13
  understand
• 1:13
  that
• 1:14
  by
• 1:15
  the
• 1:15
  receptor,
• 1:16
  we
• 1:16
  can
• 1:16
  make
• 1:16
  a
• 1:16
  much
• 1:17
  more
• 1:17
  informed
• 1:18
  decision
• 1:19
  whether
• 1:19
  or
• 1:19
  not
• 1:19
  we
• 1:19
  even
• 1:20
  choose
• 1:20
  it
• 1:21
  and
• 1:21
  why.
• 1:21
  And
• 1:21
  we
• 1:22
  can
• 1:22
  explain
• 1:22
  that
• 1:22
  to
• 1:22
  the
• 1:23
  patient,
• 1:23
  and
• 1:23
  we
• 1:23
  can
• 1:23
  use
• 1:23
  it
• 1:24
  in
• 1:24
  our
• 1:24
  clinical
• 1:24
  arsenal
• 1:25
  in
• 1:25
  very
• 1:25
  intentional
• 1:26
  and
• 1:27
  interesting
• 1:27
  ways.
• 1:28
  Right?
• 1:28
  Because
• 1:28
  there's
• 1:29
  many
• 1:29
  different
• 1:29
  ways
• 1:29
  a
• 1:29
  patient
• 1:30
  can
• 1:30
  sleep,
• 1:30
  right?
• 1:30
  A
• 1:31
  patient
• 1:31
  can
• 1:31
  take
• 1:31
  Benadryl,
• 1:32
  A
• 1:32
  patient
• 1:32
  can
• 1:32
  take
• 1:34
  Atarax,
• 1:34
  a
• 1:35
  patient
• 1:35
  can
• 1:35
  take
• 1:35
  Ramelteon,
• 1:36
  a
• 1:36
  patient
• 1:36
  can
• 1:37
  take
• 1:37
  Trazodone,
• 1:38
  a
• 1:38
  patient
• 1:38
  can
• 1:38
  take
• 1:39
  Melatonin.
• 1:39
  Over
• 1:40
  the
• 1:40
  counter.
• 1:40
  People
• 1:41
  drink
• 1:41
  alcohol
• 1:42
  to
• 1:42
  sleep.
• 1:42
  Now,
• 1:42
  I
• 1:42
  didn't
• 1:43
  say
• 1:43
  any
• 1:43
  of
• 1:43
  those
• 1:43
  are
• 1:43
  good
• 1:43
  or
• 1:44
  bad
• 1:44
  ways
• 1:44
  to
• 1:44
  fall
• 1:44
  asleep.
• 1:45
  What
• 1:45
  I'm
• 1:45
  saying
• 1:46
  is
• 1:46
  there's
• 1:46
  many
• 1:47
  blunt
• 1:47
  ways
• 1:48
  we
• 1:48
  can
• 1:48
  just
• 1:49
  fall
• 1:49
  asleep.
• 1:50
  In
• 1:50
  the
• 1:50
  old
• 1:50
  days,
• 1:50
  they'd
• 1:51
  knock
• 1:51
  you
• 1:51
  out
• 1:51
  with
• 1:51
  a
• 1:51
  hammer.
• 1:52
  You
• 1:52
  ever
• 1:52
  watch
• 1:52
  the
• 1:52
  Three
• 1:53
  Stooges?
• 1:54
  So
• 1:55
  it's
• 1:55
  not
• 1:55
  enough
• 1:56
  to
• 1:56
  just
• 1:56
  say,
• 1:56
  well,
• 1:56
  here's
• 1:57
  a
• 1:57
  sleep
• 1:57
  med.
• 1:57
  I'm
• 1:57
  gonna
• 1:57
  prescribe
• 1:58
  it
• 1:58
  because
• 1:58
  it's
• 1:58
  a
• 1:58
  sleep
• 1:59
  med.
• 1:59
  We
• 1:59
  need
• 1:59
  to
• 2:00
  understand
• 2:00
  the
• 2:00
  nuances
• 2:01
  behind
• 2:01
  it
• 2:01
  and
• 2:01
  appreciate
• 2:02
  those
• 2:02
  nuances,
• 2:03
  because
• 2:03
  those
• 2:03
  nuances
• 2:04
  can
• 2:04
  actually
• 2:05
  empower
• 2:05
  us
• 2:05
  as
• 2:06
  prescribers
• 2:06
  and
• 2:06
  get
• 2:08
  better
• 2:08
  outcomes
• 2:08
  for
• 2:09
  our
• 2:09
  patients.
• 2:10
  And
• 2:10
  what's
• 2:10
  fascinating
• 2:11
  about
• 2:11
  Trazodone
• 2:12
  is
• 2:13
  it
• 2:13
  behaves
• 2:14
  very
• 2:14
  differently
• 2:15
  depending
• 2:15
  on
• 2:15
  the
• 2:16
  dose.
• 2:16
  And
• 2:16
  this
• 2:17
  is
• 2:17
  one
• 2:17
  of
• 2:17
  the
• 2:17
  first
• 2:17
  things
• 2:18
  you'll
• 2:18
  learn
• 2:19
  about
• 2:19
  in
• 2:19
  psychopharmacology.
• 2:21
  And
• 2:21
  you'll
• 2:21
  often
• 2:22
  hear
• 2:22
  about
• 2:23
  Seroquel
• 2:24
  and
• 2:24
  how
• 2:24
  Seroquel
• 2:25
  can
• 2:25
  behave
• 2:26
  radically
• 2:27
  in
• 2:27
  radically
• 2:28
  different
• 2:28
  ways
• 2:28
  depending
• 2:28
  on
• 2:29
  the
• 2:29
  dose.
• 2:29
  Right.
• 2:29
  You
• 2:29
  have
• 2:30
  the
• 2:30
  50
• 2:30
  milligrams
• 2:31
  of
• 2:32
  Seroquel,
• 2:32
  which
• 2:32
  is
• 2:33
  like
• 2:33
  an
• 2:33
  ultra
• 2:33
  expensive
• 2:34
  version
• 2:34
  of
• 2:34
  Benadryl.
• 2:35
  And
• 2:35
  then
• 2:35
  you
• 2:35
  have
• 2:36
  the
• 2:36
  300
• 2:37
  milligrams,
• 2:37
  which
• 2:38
  is
• 2:38
  more
• 2:38
  like
• 2:38
  mood
• 2:38
  stabilization.
• 2:39
  You
• 2:39
  have
• 2:40
  the
• 2:40
  6
• 2:41
  to
• 2:41
  800,
• 2:41
  which
• 2:41
  gets
• 2:42
  more
• 2:42
  into
• 2:42
  the
• 2:43
  antipsychotic
• 2:44
  territory.
• 2:45
  And
• 2:45
  there's
• 2:45
  even
• 2:46
  a
• 2:46
  metabolite
• 2:47
  nor
• 2:47
  quetiapine
• 2:48
  that
• 2:49
  acts
• 2:49
  like
• 2:49
  an
• 2:49
  Snri.
• 2:50
  So
• 2:50
  Seroquel
• 2:51
  is
• 2:51
  one
• 2:51
  of
• 2:51
  those
• 2:51
  fascinating
• 2:52
  medications
• 2:53
  that
• 2:53
  does
• 2:53
  many
• 2:53
  different
• 2:54
  things
• 2:54
  depending
• 2:54
  on
• 2:54
  the
• 2:55
  dose.
• 2:55
  And
• 2:55
  Trazodone
• 2:56
  is
• 2:56
  a
• 2:56
  little
• 2:57
  bit
• 2:57
  similar
• 2:57
  to
• 2:57
  that
• 2:58
  in
• 2:58
  that
• 2:58
  if
• 2:59
  you're
• 2:59
  prescribing
• 2:59
  50
• 3:00
  milligrams
• 3:00
  of
• 3:00
  trazodone,
• 3:01
  well,
• 3:01
  that's
• 3:01
  radically
• 3:02
  different
• 3:02
  than
• 3:03
  what
• 3:03
  you
• 3:03
  might
• 3:03
  expect
• 3:03
  by
• 3:04
  prescribing
• 3:04
  300
• 3:05
  milligrams
• 3:05
  of
• 3:05
  trazodone.
• 3:06
  And
• 3:06
  we
• 3:06
  typically
• 3:07
  perceive
• 3:08
  Trazodone
• 3:09
  as
• 3:09
  a
• 3:10
  basic
• 3:10
  sleep
• 3:10
  med
• 3:11
  in
• 3:11
  the
• 3:11
  neighborhood
• 3:11
  of
• 3:11
  50
• 3:12
  to
• 3:12
  100
• 3:12
  milligrams.
• 3:13
  The
• 3:13
  vast
• 3:13
  majority
• 3:14
  of
• 3:14
  my
• 3:14
  prescriptions
• 3:15
  are
• 3:15
  for
• 3:15
  50
• 3:16
  to
• 3:16
  100
• 3:16
  milligrams
• 3:17
  of
• 3:17
  trazodone.
• 3:17
  I
• 3:18
  almost
• 3:18
  never
• 3:18
  go
• 3:19
  up
• 3:19
  to
• 3:19
  150
• 3:20
  or
• 3:20
  200.
• 3:21
  I
• 3:21
  have
• 3:21
  in
• 3:21
  the
• 3:22
  past,
• 3:22
  and
• 3:22
  we'll
• 3:22
  talk
• 3:22
  about
• 3:23
  why
• 3:23
  that
• 3:23
  might
• 3:23
  make
• 3:24
  sense,
• 3:25
  but
• 3:25
  I
• 3:25
  rarely
• 3:26
  go
• 3:26
  up
• 3:26
  there.
• 3:27
  But
• 3:27
  again,
• 3:27
  it
• 3:27
  behaves
• 3:28
  very
• 3:28
  differently
• 3:29
  as
• 3:29
  you
• 3:29
  increase
• 3:30
  the
• 3:30
  dose.
• 3:31
  And
• 3:32
  so
• 3:33
  that's
• 3:33
  what
• 3:33
  we
• 3:33
  want
• 3:33
  to
• 3:34
  continue
• 3:34
  to
• 3:34
  talk
• 3:34
  about
• 3:34
  here.
• 3:35
  And
• 3:35
  the
• 3:35
  principle
• 3:36
  that
• 3:37
  governs
• 3:38
  how
• 3:39
  medications
• 3:40
  behave
• 3:41
  at
• 3:41
  various
• 3:42
  receptors
• 3:42
  and
• 3:43
  the
• 3:43
  therapeutic
• 3:44
  effects
• 3:44
  that
• 3:45
  they
• 3:45
  produce
• 3:47
  are
• 3:47
  really
• 3:47
  governed
• 3:48
  by
• 3:48
  the
• 3:48
  affinity
• 3:48
  principle.
• 3:49
  And
• 3:49
  we've
• 3:49
  gone
• 3:49
  over
• 3:50
  this
• 3:50
  in
• 3:51
  other
• 3:51
  discussions,
• 3:52
  but
• 3:52
  the
• 3:52
  idea
• 3:52
  is
• 3:53
  that
• 3:53
  a
• 3:53
  drug
• 3:53
  occupies
• 3:54
  receptors
• 3:55
  in
• 3:55
  order
• 3:55
  of
• 3:55
  binding
• 3:56
  affinity,
• 3:57
  okay?
• 3:57
  And
• 3:57
  we've,
• 3:58
  we've
• 3:58
  defined.
• 3:59
  Defined
• 3:59
  the
• 3:59
  binding
• 3:59
  binding
• 4:00
  affinity
• 4:00
  as
• 4:01
  a
• 4:01
  Ki.
• 4:01
  It's
• 4:01
  a
• 4:02
  disassociative
• 4:02
  constant.
• 4:03
  You'll
• 4:03
  see
• 4:03
  that
• 4:04
  in
• 4:04
  your
• 4:05
  textbooks.
• 4:05
  Ki.
• 4:06
  And
• 4:06
  the
• 4:06
  lower
• 4:06
  the
• 4:07
  Ki,
• 4:07
  the
• 4:07
  higher
• 4:07
  the
• 4:07
  affinity.
• 4:08
  Right?
• 4:08
  We've
• 4:09
  gone
• 4:09
  over
• 4:09
  this
• 4:09
  before
• 4:10
  how
• 4:10
  Doxepin
• 4:11
  is
• 4:11
  a
• 4:11
  good
• 4:11
  example,
• 4:12
  right?
• 4:12
  It's
• 4:12
  a
• 4:12
  tricyclic
• 4:13
  antidepressant,
• 4:14
  but
• 4:14
  people
• 4:14
  can
• 4:14
  prescribe
• 4:15
  it
• 4:15
  for
• 4:15
  sleep
• 4:15
  at
• 4:16
  low
• 4:16
  doses,
• 4:16
  3
• 4:16
  and
• 4:17
  6
• 4:17
  milligrams.
• 4:17
  And
• 4:17
  it
• 4:18
  has
• 4:18
  this
• 4:18
  exorbitantly
• 4:19
  high
• 4:19
  affinity
• 4:20
  for
• 4:20
  histamine.
• 4:21
  It's
• 4:21
  an
• 4:21
  anti
• 4:21
  histaminergic
• 4:22
  drug.
• 4:22
  It's
• 4:23
  a
• 4:23
  very
• 4:23
  potent
• 4:24
  anti
• 4:24
  histaminergic
• 4:25
  drug
• 4:25
  that
• 4:25
  really
• 4:26
  helps
• 4:27
  people
• 4:27
  remain
• 4:28
  asleep.
• 4:29
  It
• 4:29
  is
• 4:29
  FDA
• 4:29
  approved
• 4:30
  for
• 4:30
  middle
• 4:30
  insomnia.
• 4:31
  So
• 4:31
  again,
• 4:32
  its
• 4:32
  highest
• 4:33
  affinity
• 4:33
  is
• 4:34
  for
• 4:34
  those
• 4:35
  histamine
• 4:35
  receptors.
• 4:36
  And
• 4:36
  so
• 4:36
  the
• 4:36
  drug
• 4:36
  will
• 4:36
  occupy
• 4:37
  those
• 4:37
  receptors
• 4:38
  first
• 4:39
  because
• 4:39
  the
• 4:39
  highest
• 4:39
  affinity
• 4:40
  is
• 4:40
  for
• 4:40
  histamine.
• 4:42
  Same
• 4:42
  thing
• 4:42
  goes
• 4:43
  for
• 4:43
  trazodone.
• 4:44
  In
• 4:44
  Trazodone's
• 4:44
  case,
• 4:45
  the
• 4:45
  receptor
• 4:45
  it
• 4:46
  engages
• 4:46
  is
• 4:46
  the
• 4:46
  5ht2a
• 4:47
  receptor.
• 4:48
  And
• 4:48
  we'll
• 4:48
  go
• 4:48
  into
• 4:48
  that
• 4:48
  in
• 4:48
  a
• 4:49
  moment.
• 4:49
  I
• 4:49
  have
• 4:49
  an
• 4:49
  entire
• 4:50
  slide
• 4:50
  deck
• 4:51
  or
• 4:51
  presentation,
• 4:53
  beautiful
• 4:53
  one
• 4:54
  that
• 4:54
  is
• 4:54
  dedicated
• 4:55
  towards
• 4:55
  5ht
• 4:55
  2a
• 4:56
  because
• 4:56
  I
• 4:56
  think
• 4:56
  it's
• 4:56
  so
• 4:57
  darn
• 4:57
  important
• 4:57
  in
• 4:58
  psychopharmacology.
• 4:59
  It's
• 5:00
  important
• 5:00
  in,
• 5:01
  with
• 5:01
  respect
• 5:01
  to
• 5:01
  its
• 5:02
  how
• 5:02
  it
• 5:02
  mediates
• 5:03
  motor
• 5:03
  side
• 5:03
  effects
• 5:04
  with
• 5:04
  antipsychotics.
• 5:05
  It
• 5:05
  helps
• 5:05
  with
• 5:06
  anxiety
• 5:06
  when
• 5:07
  SSRIs
• 5:08
  are
• 5:08
  too
• 5:08
  activating.
• 5:08
  It
• 5:09
  is
• 5:09
  just
• 5:09
  an
• 5:09
  extremely
• 5:10
  important
• 5:11
  receptor.
• 5:12
  So
• 5:13
  Trazodone
• 5:14
  goes
• 5:14
  to
• 5:14
  the
• 5:14
  5ht2a
• 5:16
  receptor
• 5:16
  first.
• 5:17
  That's
• 5:18
  where
• 5:18
  its
• 5:18
  highest
• 5:19
  affinity
• 5:20
  lies.
• 5:20
  And
• 5:20
  that's
• 5:21
  very
• 5:21
  important.
• 5:21
  It's
• 5:22
  a
• 5:22
  very
• 5:22
  important
• 5:22
  receptor
• 5:23
  actually
• 5:24
  to
• 5:24
  engage.
• 5:25
  And
• 5:25
  we're
• 5:26
  gonna
• 5:26
  talk
• 5:26
  all
• 5:26
  about
• 5:26
  that.
• 5:27
  Because
• 5:27
  SSRIs,
• 5:28
  as
• 5:28
  you
• 5:29
  all
• 5:29
  know,
• 5:30
  okay.
• 5:31
  Can
• 5:31
  activate
• 5:32
  serotonin
• 5:33
  receptors
• 5:34
  broadly,
• 5:34
  everywhere.
• 5:35
  And
• 5:35
  that's
• 5:35
  good.
• 5:35
  But
• 5:35
  it
• 5:36
  can
• 5:36
  be
• 5:36
  bad
• 5:36
  because
• 5:36
  you're
• 5:37
  also
• 5:37
  activating
• 5:37
  ones
• 5:38
  that
• 5:38
  can
• 5:38
  make
• 5:39
  you
• 5:39
  more
• 5:39
  anxious,
• 5:40
  namely
• 5:40
  5ht2a.
• 5:41
  When
• 5:42
  serotonin
• 5:43
  activates
• 5:44
  5ht2a
• 5:45
  receptors,
• 5:46
  you
• 5:46
  can
• 5:46
  actually
• 5:47
  get
• 5:47
  more
• 5:47
  arousal
• 5:48
  and
• 5:48
  stimulation
• 5:49
  and
• 5:49
  anxiety.
• 5:50
  Well,
• 5:51
  Trazodone
• 5:52
  is
• 5:52
  excellent.
• 5:53
  It
• 5:53
  swoops
• 5:53
  right
• 5:53
  in
• 5:54
  and
• 5:54
  it
• 5:54
  can
• 5:54
  actually
• 5:55
  antagonize
• 5:55
  that
• 5:56
  receptor.
• 5:56
  So
• 5:56
  it
• 5:56
  can
• 5:57
  actually
• 5:57
  restore
• 5:58
  a
• 5:58
  sense
• 5:58
  of
• 5:58
  balance
• 5:59
  and
• 5:59
  reduce
• 5:59
  anxiety.
• 6:00
  Again,
• 6:01
  I
• 6:01
  can't
• 6:01
  emphasize
• 6:01
  how
• 6:02
  important
• 6:02
  that
• 6:02
  is
• 6:03
  because
• 6:03
  how
• 6:03
  many
• 6:03
  times
• 6:04
  are
• 6:04
  we
• 6:04
  in
• 6:04
  clinic
• 6:04
  and
• 6:05
  we're
• 6:05
  starting
• 6:05
  Prozac,
• 6:05
  we're
• 6:06
  starting
• 6:06
  Zoloft,
• 6:07
  and
• 6:07
  we
• 6:07
  have
• 6:07
  to
• 6:07
  tell
• 6:08
  the
• 6:08
  patient,
• 6:08
  well,
• 6:08
  it's
• 6:08
  going
• 6:08
  to
• 6:08
  take
• 6:09
  a
• 6:09
  few
• 6:09
  weeks
• 6:09
  before
• 6:10
  you
• 6:10
  feel
• 6:10
  better,
• 6:11
  and
• 6:11
  you
• 6:11
  might
• 6:11
  even
• 6:11
  feel
• 6:11
  worse
• 6:12
  at
• 6:12
  first.
• 6:12
  You
• 6:12
  might
• 6:12
  even
• 6:13
  have
• 6:13
  more
• 6:13
  anxiety
• 6:13
  in
• 6:14
  the
• 6:14
  beginning.
• 6:14
  But
• 6:14
  lo
• 6:15
  and
• 6:15
  behold,
• 6:15
  we
• 6:15
  have
• 6:15
  a
• 6:15
  medication
• 6:16
  called
• 6:16
  Trazodone
• 6:17
  that
• 6:17
  can
• 6:17
  undo
• 6:18
  that
• 6:18
  process.
• 6:19
  It
• 6:19
  can
• 6:19
  battle
• 6:20
  the
• 6:20
  act,
• 6:20
  the
• 6:21
  activation
• 6:21
  of
• 6:21
  5ht2a
• 6:22
  so
• 6:23
  the
• 6:23
  patient
• 6:23
  is
• 6:23
  less
• 6:24
  anxious
• 6:25
  and
• 6:25
  has
• 6:25
  less
• 6:26
  insomnia.
• 6:27
  And
• 6:27
  by
• 6:27
  countering
• 6:28
  the
• 6:29
  activation
• 6:29
  of
• 6:29
  2A,
• 6:30
  you
• 6:30
  are
• 6:31
  helping
• 6:31
  the
• 6:31
  patient
• 6:31
  feel
• 6:32
  less
• 6:32
  anxious.
• 6:32
  You're
• 6:32
  helping
• 6:32
  the
• 6:33
  patient
• 6:33
  go
• 6:33
  to
• 6:33
  sleep
• 6:33
  and
• 6:34
  enhance
• 6:34
  slow
• 6:34
  wave
• 6:35
  sleep
• 6:35
  in
• 6:35
  particular,
• 6:36
  which
• 6:36
  we'll
• 6:36
  talk
• 6:36
  about.
• 6:37
  And
• 6:37
  SSRIs
• 6:38
  like
• 6:38
  Prozac
• 6:38
  and
• 6:38
  Zoloft,
• 6:39
  they
• 6:39
  broadly
• 6:39
  increase
• 6:40
  serotonin.
• 6:41
  It's
• 6:41
  not
• 6:42
  so
• 6:42
  great
• 6:42
  because
• 6:42
  it's
• 6:43
  not
• 6:43
  so
• 6:43
  precise.
• 6:44
  You're
• 6:44
  also
• 6:44
  activating
• 6:45
  serotonin
• 6:45
  in
• 6:45
  the
• 6:45
  gut.
• 6:46
  You
• 6:46
  can
• 6:46
  have
• 6:46
  loose
• 6:46
  stools.
• 6:47
  You're
• 6:47
  activating
• 6:48
  it
• 6:48
  at
• 6:49
  certain
• 6:49
  receptors
• 6:49
  that
• 6:50
  make
• 6:50
  you
• 6:50
  more
• 6:50
  anxious
• 6:51
  that
• 6:51
  might
• 6:51
  cause
• 6:51
  sexual
• 6:52
  side
• 6:52
  effects
• 6:52
  on
• 6:53
  top
• 6:53
  of
• 6:53
  that,
• 6:53
  that's
• 6:53
  5ht
• 6:54
  2a.
• 6:55
  Another
• 6:55
  benefit
• 6:55
  of
• 6:56
  trazodone
• 6:56
  is
• 6:56
  again,
• 6:56
  it
• 6:57
  antagonizes
• 6:57
  5ht
• 6:58
  2a.
• 6:58
  So
• 6:59
  you're,
• 6:59
  you're
• 6:59
  not
• 7:00
  only
• 7:00
  getting,
• 7:01
  you're
• 7:01
  not
• 7:01
  only
• 7:02
  starting
• 7:02
  a
• 7:03
  medication
• 7:03
  that
• 7:03
  helps
• 7:03
  them
• 7:04
  sleep,
• 7:04
  but
• 7:04
  it's
• 7:05
  literally
• 7:06
  undoing
• 7:07
  or
• 7:07
  helping
• 7:07
  to
• 7:07
  challenge
• 7:08
  or
• 7:08
  mitigate
• 7:09
  the
• 7:10
  very
• 7:10
  common
• 7:10
  problematic
• 7:11
  side
• 7:11
  effects
• 7:12
  that
• 7:12
  are
• 7:12
  caused
• 7:13
  by
• 7:13
  activating
• 7:14
  the
• 7:14
  5ht2a
• 7:15
  receptor
• 7:15
  through
• 7:16
  SSRI.
• 7:16
  So
• 7:17
  the
• 7:17
  complement
• 7:17
  of
• 7:17
  those
• 7:18
  is
• 7:18
  absolutely
• 7:19
  wonderful.
• 7:19
  It's
• 7:20
  so
• 7:20
  welcome
• 7:21
  because
• 7:21
  how
• 7:21
  many
• 7:21
  times
• 7:22
  do
• 7:22
  your
• 7:22
  patients
• 7:23
  come
• 7:23
  to
• 7:23
  you
• 7:23
  with
• 7:24
  anxiety
• 7:24
  and
• 7:24
  insomnia
• 7:25
  and
• 7:25
  then
• 7:26
  now
• 7:26
  you're
• 7:26
  trying
• 7:26
  to
• 7:27
  get
• 7:27
  them
• 7:27
  to
• 7:27
  adhere
• 7:28
  to
• 7:28
  a
• 7:28
  new
• 7:28
  medication
• 7:29
  they've
• 7:29
  never
• 7:29
  tried?
• 7:30
  Maybe
• 7:30
  they're
• 7:30
  skeptical
• 7:31
  about.
• 7:31
  Oftentimes
• 7:32
  they
• 7:32
  are
• 7:32
  skeptical
• 7:33
  about.
• 7:34
  And
• 7:34
  so
• 7:34
  this,
• 7:35
  this
• 7:35
  intro,
• 7:35
  this
• 7:36
  first
• 7:36
  impression
• 7:37
  of
• 7:37
  the
• 7:37
  medication
• 7:37
  is
• 7:38
  often
• 7:38
  kind
• 7:38
  of
• 7:38
  rocky.
• 7:39
  It's
• 7:39
  like,
• 7:39
  oh
• 7:39
  my
• 7:39
  God,
• 7:39
  I'm
• 7:40
  more
• 7:40
  anxious
• 7:40
  now.
• 7:40
  I
• 7:40
  hate
• 7:41
  this
• 7:41
  thing.
• 7:41
  I
• 7:41
  gotta
• 7:41
  wait
• 7:42
  four
• 7:42
  weeks
• 7:42
  for
• 7:42
  this
• 7:42
  to
• 7:43
  work.
• 7:43
  I'm
• 7:43
  gonna
• 7:44
  quit,
• 7:44
  I'm
• 7:44
  not
• 7:44
  gonna
• 7:44
  adhere
• 7:45
  fully.
• 7:45
  Oh,
• 7:45
  now
• 7:45
  I'm
• 7:46
  not
• 7:46
  adhering
• 7:46
  fully.
• 7:46
  And
• 7:47
  it's
• 7:47
  really
• 7:47
  not
• 7:47
  working.
• 7:47
  And
• 7:48
  it's
• 7:48
  this
• 7:48
  vicious
• 7:49
  self
• 7:49
  fulfilling
• 7:50
  prophecy
• 7:50
  because
• 7:50
  the
• 7:51
  side
• 7:51
  effects
• 7:51
  are
• 7:51
  turning
• 7:52
  them
• 7:52
  off.
• 7:52
  Oh,
• 7:53
  and
• 7:53
  by
• 7:53
  the
• 7:53
  way,
• 7:54
  waiting
• 7:54
  four
• 7:54
  weeks
• 7:55
  is
• 7:55
  a
• 7:55
  huge
• 7:56
  drag.
• 7:56
  When
• 7:56
  Trazodone
• 7:57
  can
• 7:58
  help
• 7:58
  them
• 7:58
  sleep
• 7:59
  right
• 7:59
  away.
• 7:59
  The
• 7:59
  first
• 8:00
  night
• 8:00
  it
• 8:00
  helps
• 8:00
  them
• 8:00
  sleep,
• 8:01
  which
• 8:01
  is
• 8:01
  great
• 8:02
  in,
• 8:02
  in
• 8:02
  psychiatry
• 8:03
  because
• 8:04
  a
• 8:04
  lot
• 8:04
  of
• 8:04
  times
• 8:04
  they're
• 8:04
  going
• 8:05
  to
• 8:05
  come
• 8:05
  to
• 8:05
  you
• 8:05
  pretty
• 8:05
  desperate.
• 8:06
  And
• 8:06
  I
• 8:07
  find
• 8:07
  that
• 8:07
  giving
• 8:08
  them
• 8:08
  Trazodone,
• 8:09
  if
• 8:09
  the
• 8:09
  moment
• 8:10
  is
• 8:10
  right,
• 8:10
  if
• 8:11
  the
• 8:11
  clinical
• 8:11
  picture
• 8:11
  warrants
• 8:12
  it,
• 8:12
  is
• 8:12
  it
• 8:13
  actually
• 8:13
  helps
• 8:13
  rapport
• 8:14
  because
• 8:14
  you're
• 8:14
  bringing
• 8:14
  immediate
• 8:15
  relief
• 8:15
  to
• 8:15
  that
• 8:15
  patient,
• 8:16
  at
• 8:16
  least
• 8:17
  with
• 8:17
  respect
• 8:17
  to
• 8:17
  sleep.
• 8:18
  So
• 8:19
  the
• 8:19
  affinity
• 8:20
  principle,
• 8:21
  Trazodone
• 8:21
  rushes
• 8:22
  over
• 8:22
  to
• 8:22
  five
• 8:22
  HT2A
• 8:23
  antagonizes
• 8:24
  it,
• 8:24
  that's
• 8:24
  its
• 8:25
  highest
• 8:25
  affinity.
• 8:26
  And
• 8:26
  that
• 8:26
  enhances
• 8:27
  slow
• 8:27
  wave
• 8:27
  sleep.
• 8:28
  It
• 8:28
  makes
• 8:28
  the
• 8:29
  patient
• 8:29
  less
• 8:29
  anxious,
• 8:30
  it
• 8:30
  helps
• 8:30
  them
• 8:30
  actually
• 8:30
  go
• 8:31
  to
• 8:31
  sleep
• 8:31
  a
• 8:31
  little
• 8:31
  bit
• 8:32
  easier
• 8:32
  because
• 8:32
  they're
• 8:33
  not
• 8:33
  as
• 8:33
  anxious,
• 8:34
  which
• 8:34
  is
• 8:35
  very,
• 8:35
  very
• 8:36
  nice
• 8:37
  to
• 8:37
  say
• 8:37
  the
• 8:37
  least.
• 8:38
  Another
• 8:39
  kind
• 8:39
  of
• 8:39
  benefit
• 8:40
  too,
• 8:40
  I
• 8:40
  should
• 8:41
  add.
• 8:41
  At
• 8:41
  doses
• 8:42
  of
• 8:43
  50
• 8:43
  milligrams,
• 8:45
  we
• 8:45
  also
• 8:46
  have
• 8:46
  a
• 8:46
  little
• 8:47
  bit
• 8:47
  of
• 8:47
  Alpha
• 8:47
  1
• 8:47
  blockade.
• 8:48
  And
• 8:48
  it's
• 8:49
  a
• 8:49
  mild
• 8:49
  antihistaminergic
• 8:50
  effect,
• 8:51
  which
• 8:51
  again
• 8:51
  provides
• 8:52
  immediate
• 8:53
  sedation
• 8:53
  that
• 8:54
  helps
• 8:54
  them
• 8:55
  fall
• 8:55
  asleep
• 8:55
  in
• 8:55
  a
• 8:55
  more
• 8:56
  physiological
• 8:56
  sense,
• 8:57
  kind
• 8:57
  of
• 8:57
  antagonizing
• 8:58
  the
• 8:58
  wakefulness
• 8:59
  response
• 9:00
  receptor
• 9:00
  there.
• 9:00
  And
• 9:01
  Alpha
• 9:01
  1
• 9:02
  is
• 9:02
  implicated
• 9:02
  a
• 9:03
  lot.
• 9:03
  You
• 9:03
  know,
• 9:03
  we've
• 9:03
  heard
• 9:03
  that
• 9:03
  with
• 9:04
  Praz
• 9:04
  Presyn,
• 9:05
  where
• 9:05
  it,
• 9:06
  it's
• 9:06
  implicated
• 9:06
  in,
• 9:07
  in
• 9:07
  arousal.
• 9:08
  So
• 9:08
  it
• 9:08
  kind
• 9:08
  of
• 9:08
  lowers
• 9:09
  the
• 9:09
  arousal,
• 9:10
  the,
• 9:10
  the
• 9:10
  arousal
• 9:11
  circuits.
• 9:11
  And
• 9:12
  so
• 9:12
  you're
• 9:12
  creating
• 9:12
  this
• 9:13
  dynamic
• 9:14
  environment
• 9:14
  by
• 9:14
  which
• 9:15
  the
• 9:15
  patient
• 9:15
  can
• 9:15
  sleep
• 9:16
  a
• 9:16
  Lot
• 9:16
  of
• 9:16
  your
• 9:16
  patients
• 9:16
  have
• 9:16
  PTSD
• 9:17
  and
• 9:18
  they
• 9:18
  have
• 9:18
  hyperarousal.
• 9:19
  So
• 9:19
  you're
• 9:19
  doing
• 9:19
  this
• 9:20
  in
• 9:20
  three
• 9:20
  different
• 9:20
  ways.
• 9:21
  Sedation
• 9:21
  through
• 9:21
  the
• 9:21
  anti
• 9:22
  histaminergic
• 9:22
  effect
• 9:23
  5ht2amakes
• 9:25
  you
• 9:25
  less
• 9:25
  anxious.
• 9:25
  It
• 9:26
  brings
• 9:26
  on
• 9:27
  by,
• 9:27
  by
• 9:27
  extension,
• 9:28
  it
• 9:28
  helps
• 9:28
  you
• 9:28
  sleep
• 9:28
  a
• 9:29
  little
• 9:29
  bit
• 9:29
  better.
• 9:29
  And
• 9:30
  the
• 9:30
  alpha
• 9:30
  one
• 9:30
  kind
• 9:31
  of
• 9:31
  mitigates
• 9:31
  or,
• 9:31
  or
• 9:32
  softens
• 9:32
  your
• 9:32
  level
• 9:32
  of
• 9:33
  arousal.
• 9:33
  And
• 9:34
  Notice
• 9:34
  how
• 9:34
  at
• 9:34
  50mg
• 9:35
  there
• 9:35
  is
• 9:36
  no
• 9:36
  meaningful
• 9:36
  serotonin
• 9:37
  reuptake
• 9:37
  inhibition
• 9:38
  at
• 9:38
  all.
• 9:38
  This
• 9:39
  is
• 9:39
  not
• 9:39
  behaving
• 9:40
  as
• 9:40
  an
• 9:40
  SSRI
• 9:41
  at
• 9:41
  all.
• 9:42
  In
• 9:42
  fact,
• 9:42
  the
• 9:42
  FDA
• 9:43
  label
• 9:43
  technically
• 9:44
  does
• 9:44
  label
• 9:44
  it
• 9:44
  an
• 9:44
  ssri,
• 9:45
  but
• 9:45
  that's
• 9:45
  a
• 9:45
  bit
• 9:46
  misleading
• 9:46
  because
• 9:47
  at
• 9:47
  clinically
• 9:47
  common
• 9:48
  doses,
• 9:48
  it
• 9:48
  functions
• 9:49
  primarily
• 9:49
  as
• 9:49
  a
• 9:49
  serotonin
• 9:50
  antagonist,
• 9:51
  not
• 9:51
  a
• 9:51
  reuptake
• 9:52
  inhibitor.
• 9:53
  So
• 9:53
  that's
• 9:53
  a
• 9:53
  fine
• 9:54
  distinction
• 9:54
  because
• 9:54
  an
• 9:55
  SSRI
• 9:55
  is
• 9:55
  only
• 9:56
  an
• 9:56
  SSRI
• 9:57
  at
• 9:57
  specific
• 9:58
  doses.
• 9:59
  It's
• 9:59
  technically
• 10:00
  an
• 10:00
  ssri,
• 10:01
  but
• 10:01
  not
• 10:01
  really
• 10:01
  at
• 10:02
  that
• 10:02
  dose
• 10:02
  until
• 10:02
  it
• 10:02
  has
• 10:03
  meaningful
• 10:04
  serotonin
• 10:05
  reuptake
• 10:05
  inhibition.
• 10:06
  So
• 10:06
  just
• 10:06
  a
• 10:06
  little
• 10:06
  thought
• 10:07
  there.
• 10:07
  And
• 10:07
  the
• 10:08
  most
• 10:08
  common
• 10:08
  prescriptions
• 10:09
  you'll
• 10:09
  see
• 10:09
  are
• 10:10
  25-100mg
• 10:11
  when
• 10:11
  it
• 10:11
  comes
• 10:12
  to
• 10:12
  trazodone.
• 10:13
  And
• 10:13
  it
• 10:14
  has
• 10:14
  this
• 10:14
  antidepressant
• 10:16
  effect
• 10:16
  indirectly
• 10:17
  at
• 10:17
  those
• 10:17
  doses
• 10:18
  because
• 10:18
  it
• 10:18
  helps
• 10:19
  with
• 10:19
  sleep.
• 10:20
  And
• 10:20
  if
• 10:20
  we
• 10:20
  can
• 10:21
  restore
• 10:21
  sleep,
• 10:22
  many
• 10:23
  studies,
• 10:23
  there's
• 10:23
  lots
• 10:24
  of
• 10:24
  evidence
• 10:24
  that
• 10:24
  suggests
• 10:25
  that
• 10:25
  sleep
• 10:26
  preservation
• 10:26
  alone
• 10:27
  or
• 10:27
  restoration
• 10:27
  alone
• 10:28
  can
• 10:29
  lead
• 10:29
  to
• 10:29
  a
• 10:30
  reduction
• 10:30
  in
• 10:31
  depressive
• 10:32
  symptoms
• 10:32
  more
• 10:32
  broadly.
• 10:33
  So
• 10:33
  again,
• 10:33
  anything
• 10:34
  that
• 10:34
  more
• 10:34
  immediately
• 10:35
  helps
• 10:35
  your
• 10:35
  patients
• 10:36
  builds
• 10:36
  that
• 10:36
  rapport.
• 10:37
  And
• 10:38
  how
• 10:38
  many
• 10:38
  of
• 10:38
  them
• 10:39
  can't
• 10:39
  sleep?
• 10:39
  It's
• 10:40
  the
• 10:40
  most
• 10:40
  transdiagnostic
• 10:41
  problem
• 10:41
  you
• 10:41
  see
• 10:42
  in
• 10:42
  psychiatry.
• 10:42
  All
• 10:43
  of
• 10:43
  the
• 10:43
  time
• 10:43
  you
• 10:43
  have
• 10:43
  patients
• 10:43
  who
• 10:44
  come
• 10:44
  to
• 10:44
  you
• 10:44
  who
• 10:44
  cannot
• 10:44
  sleep.
• 10:45
  Well,
• 10:45
  you
• 10:45
  know,
• 10:45
  ptsd,
• 10:46
  anxiety,
• 10:47
  depression,
• 10:48
  it's
• 10:48
  just
• 10:48
  always
• 10:48
  there.
• 10:49
  So
• 10:49
  this
• 10:49
  is
• 10:50
  a
• 10:50
  very
• 10:50
  helpful
• 10:50
  thing
• 10:51
  now.
• 10:51
  And
• 10:52
  slow
• 10:52
  wave
• 10:52
  sleep
• 10:53
  is
• 10:53
  particularly
• 10:54
  important.
• 10:54
  And
• 10:54
  I
• 10:54
  love
• 10:54
  this
• 10:55
  little
• 10:55
  factoid.
• 10:56
  It's
• 10:56
  the
• 10:56
  non
• 10:56
  REM
• 10:56
  sleep.
• 10:57
  It's
• 10:57
  the
• 10:57
  slow
• 10:57
  wave
• 10:58
  sleep
• 10:58
  where
• 10:58
  your
• 10:58
  memories
• 10:59
  are
• 10:59
  being
• 10:59
  consolidated.
• 11:00
  One
• 11:00
  really
• 11:01
  neat
• 11:01
  effect
• 11:02
  of
• 11:02
  slow
• 11:02
  wave
• 11:02
  sleep
• 11:03
  is
• 11:03
  throughout
• 11:04
  the
• 11:04
  day,
• 11:04
  you,
• 11:05
  you
• 11:05
  develop
• 11:05
  all
• 11:06
  this
• 11:06
  mental
• 11:06
  clutter,
• 11:06
  right?
• 11:07
  There's
• 11:07
  all
• 11:07
  these
• 11:07
  new
• 11:07
  names,
• 11:08
  you're
• 11:08
  meeting
• 11:08
  new
• 11:08
  people,
• 11:09
  there's
• 11:09
  new
• 11:09
  tasks,
• 11:09
  new
• 11:10
  errands.
• 11:10
  You
• 11:10
  have
• 11:10
  to
• 11:10
  remember
• 11:12
  important
• 11:12
  deadlines,
• 11:14
  things
• 11:14
  that
• 11:15
  you
• 11:15
  just
• 11:15
  have
• 11:15
  to
• 11:15
  do
• 11:15
  to
• 11:16
  run
• 11:16
  your
• 11:16
  house
• 11:16
  and
• 11:16
  your,
• 11:17
  and
• 11:17
  your
• 11:17
  family.
• 11:18
  And
• 11:18
  at
• 11:18
  night
• 11:19
  there's
• 11:19
  like
• 11:19
  this
• 11:20
  synaptic
• 11:20
  pruning.
• 11:21
  In
• 11:21
  other
• 11:21
  words,
• 11:21
  at
• 11:22
  night,
• 11:22
  your
• 11:22
  brain
• 11:22
  during
• 11:23
  slow
• 11:23
  wave
• 11:23
  sleep
• 11:23
  is
• 11:24
  kind
• 11:24
  of
• 11:24
  clearing
• 11:24
  the
• 11:24
  clutter
• 11:25
  and
• 11:25
  allowing
• 11:26
  you
• 11:26
  to
• 11:27
  kind
• 11:27
  of
• 11:27
  wake
• 11:27
  up
• 11:28
  the
• 11:28
  next
• 11:28
  day
• 11:28
  with
• 11:29
  less
• 11:29
  mental
• 11:29
  clutter,
• 11:30
  less
• 11:30
  brain
• 11:30
  fog,
• 11:31
  and
• 11:31
  just
• 11:31
  less
• 11:31
  of
• 11:32
  this
• 11:32
  buildup
• 11:32
  that's
• 11:33
  Making
• 11:33
  it
• 11:33
  harder
• 11:34
  to
• 11:34
  function
• 11:35
  and
• 11:35
  giving
• 11:35
  you
• 11:35
  brain
• 11:36
  fog
• 11:36
  and
• 11:36
  making
• 11:36
  everything
• 11:37
  really
• 11:37
  hazy.
• 11:37
  And
• 11:38
  that's
• 11:38
  what
• 11:38
  slow
• 11:39
  wave
• 11:39
  sleep
• 11:39
  is
• 11:39
  supposed
• 11:40
  to
• 11:40
  do.
• 11:40
  Just
• 11:41
  processing,
• 11:41
  memory
• 11:42
  consolidation,
• 11:43
  emotional
• 11:43
  processing,
• 11:44
  a
• 11:44
  little
• 11:44
  bit
• 11:44
  of
• 11:45
  bdnf,
• 11:45
  brain
• 11:46
  derived
• 11:46
  neurotropic
• 11:46
  factor
• 11:47
  release,
• 11:47
  where
• 11:47
  your
• 11:48
  brain
• 11:48
  can
• 11:48
  become
• 11:48
  more
• 11:48
  plastic.
• 11:49
  Well,
• 11:49
  you
• 11:50
  can
• 11:50
  imagine
• 11:50
  how
• 11:51
  critically
• 11:51
  important
• 11:52
  it
• 11:52
  is
• 11:52
  for
• 11:52
  all
• 11:52
  of
• 11:52
  those
• 11:53
  things
• 11:53
  to
• 11:54
  happen
• 11:54
  when
• 11:55
  your
• 11:55
  patient
• 11:55
  is
• 11:55
  dealing
• 11:56
  with
• 11:56
  a
• 11:56
  mental
• 11:56
  health
• 11:56
  disorder.
• 11:57
  They
• 11:57
  will
• 11:57
  wake
• 11:57
  up
• 11:58
  the
• 11:58
  next
• 11:58
  day
• 11:58
  feeling
• 11:58
  better.
• 11:59
  Depression
• 12:00
  scores
• 12:00
  can
• 12:00
  improve
• 12:01
  modestly.
• 12:01
  It's
• 12:02
  a
• 12:02
  real
• 12:02
  clinical
• 12:02
  improvement.
• 12:03
  Right.
• 12:03
  It's
• 12:03
  not
• 12:04
  a
• 12:04
  pharmacological
• 12:04
  antidepressant
• 12:05
  effect.
• 12:05
  It's
• 12:06
  a
• 12:06
  sleep
• 12:06
  mediated
• 12:07
  effect.
• 12:08
  And
• 12:08
  so
• 12:08
  that
• 12:08
  is
• 12:08
  a
• 12:09
  very
• 12:09
  big
• 12:10
  deal,
• 12:10
  I
• 12:10
  would
• 12:10
  argue.
• 12:11
  And
• 12:11
  so
• 12:12
  slow
• 12:12
  wave
• 12:12
  sleep
• 12:13
  is
• 12:13
  absolutely
• 12:14
  critical.
• 12:14
  There's
• 12:15
  evidence
• 12:15
  that
• 12:15
  slow
• 12:16
  wave
• 12:16
  sleep
• 12:16
  and
• 12:17
  it
• 12:17
  helps
• 12:17
  with
• 12:17
  overall
• 12:18
  executive
• 12:18
  functioning
• 12:19
  and
• 12:20
  reduces
• 12:20
  the
• 12:20
  reactivity
• 12:21
  of
• 12:21
  your
• 12:21
  amygdala,
• 12:22
  that
• 12:22
  fight
• 12:22
  or
• 12:22
  flight
• 12:23
  response.
• 12:23
  Right.
• 12:24
  Really
• 12:24
  important
• 12:24
  stuff.
• 12:25
  And
• 12:25
  there
• 12:25
  are
• 12:25
  meds
• 12:26
  that
• 12:26
  actually
• 12:27
  can
• 12:27
  interfere
• 12:27
  with
• 12:28
  slow
• 12:28
  wave
• 12:28
  sleep.
• 12:28
  There's
• 12:29
  some
• 12:29
  evidence
• 12:29
  that
• 12:29
  SSRIs
• 12:30
  definitely
• 12:31
  suppress
• 12:31
  REM
• 12:32
  sleep
• 12:32
  and
• 12:33
  also
• 12:33
  slow
• 12:33
  wave
• 12:33
  sleep.
• 12:33
  Z
• 12:34
  drugs
• 12:35
  can
• 12:35
  actually
• 12:36
  also
• 12:36
  disrupt
• 12:37
  slow
• 12:37
  wave
• 12:37
  sleep.
• 12:38
  So
• 12:38
  we
• 12:39
  really,
• 12:39
  we
• 12:40
  really
• 12:40
  want
• 12:41
  that
• 12:41
  to
• 12:42
  improve.
• 12:43
  And
• 12:43
  it
• 12:44
  sure
• 12:44
  enough,
• 12:45
  improving
• 12:45
  prefrontal
• 12:46
  control
• 12:46
  over
• 12:47
  the
• 12:47
  amygdala.
• 12:47
  In
• 12:47
  other
• 12:48
  words,
• 12:48
  being
• 12:49
  able
• 12:49
  to
• 12:49
  govern
• 12:49
  your
• 12:50
  emotions
• 12:50
  or
• 12:50
  impulsivity
• 12:51
  or
• 12:51
  reactivity,
• 12:52
  emotional
• 12:53
  regulation
• 12:53
  more
• 12:53
  broadly
• 12:54
  is
• 12:54
  something
• 12:54
  we
• 12:55
  always
• 12:55
  have
• 12:55
  to
• 12:55
  target.
• 12:56
  It
• 12:56
  can
• 12:56
  always
• 12:56
  benefit
• 12:57
  the
• 12:57
  patients
• 12:58
  that
• 12:58
  come
• 12:58
  and
• 12:58
  see
• 12:58
  us.
• 12:59
  And
• 12:59
  so,
• 13:00
  yes,
• 13:00
  slow
• 13:00
  wave
• 13:01
  sleep,
• 13:01
  big
• 13:01
  stickler
• 13:02
  for
• 13:02
  that.
• 13:02
  Very,
• 13:03
  very
• 13:03
  important.
• 13:04
  So
• 13:05
  as
• 13:05
  you
• 13:05
  increase
• 13:05
  the
• 13:06
  dose
• 13:06
  of
• 13:06
  trazodone,
• 13:07
  you
• 13:07
  are
• 13:07
  getting
• 13:08
  more
• 13:08
  of
• 13:08
  an
• 13:08
  antidepressant
• 13:09
  effect.
• 13:10
  But
• 13:10
  we're
• 13:10
  talking
• 13:11
  like
• 13:11
  3-400mg
• 13:13
  is
• 13:13
  when
• 13:13
  you
• 13:13
  get
• 13:13
  the
• 13:14
  full
• 13:14
  multimodal
• 13:14
  antidepressant.
• 13:15
  You
• 13:15
  get
• 13:16
  the
• 13:16
  serotonin
• 13:17
  reuptake,
• 13:17
  inhibit
• 13:18
  inhibition.
• 13:18
  That's
• 13:19
  more
• 13:19
  classic
• 13:19
  with
• 13:19
  SSRIs.
• 13:20
  So
• 13:21
  at
• 13:21
  3
• 13:21
  to
• 13:21
  400,
• 13:22
  your
• 13:22
  SIRT
• 13:23
  occupancy
• 13:24
  is
• 13:24
  about
• 13:24
  60
• 13:24
  to
• 13:24
  70%.
• 13:25
  It's
• 13:25
  now
• 13:26
  functioning
• 13:26
  more
• 13:26
  like
• 13:27
  a
• 13:27
  true
• 13:27
  SSRI.
• 13:28
  Okay,
• 13:28
  but
• 13:28
  when
• 13:29
  you
• 13:29
  combined
• 13:29
  the
• 13:30
  blockade
• 13:30
  of
• 13:30
  5
• 13:31
  HT2A,
• 13:32
  so
• 13:32
  you're
• 13:32
  mitigating
• 13:32
  sexual
• 13:33
  side
• 13:33
  effects,
• 13:33
  you're
• 13:33
  mitigating
• 13:34
  again
• 13:35
  that
• 13:35
  activation.
• 13:36
  Right.
• 13:36
  When
• 13:37
  SSRIs
• 13:37
  activate
• 13:38
  5HT2A,
• 13:39
  you
• 13:39
  get
• 13:39
  more
• 13:39
  arousal,
• 13:40
  you
• 13:40
  get
• 13:40
  more
• 13:41
  anxiety,
• 13:42
  maybe
• 13:43
  some
• 13:43
  overthinking,
• 13:43
  more
• 13:44
  rumination.
• 13:44
  Well,
• 13:45
  trazodone
• 13:45
  is
• 13:45
  blocking
• 13:46
  that
• 13:46
  in
• 13:47
  addition
• 13:47
  to
• 13:47
  behaving
• 13:48
  like
• 13:48
  an
• 13:48
  ssri.
• 13:49
  Now,
• 13:49
  of
• 13:49
  course,
• 13:50
  the
• 13:50
  hard
• 13:50
  clinical
• 13:50
  reality
• 13:51
  is
• 13:51
  as
• 13:51
  you
• 13:51
  raise
• 13:52
  Trazodone,
• 13:52
  you're
• 13:52
  going
• 13:52
  to
• 13:53
  notice
• 13:53
  the
• 13:53
  same
• 13:53
  kind
• 13:53
  of
• 13:54
  thing
• 13:54
  you
• 13:54
  notice
• 13:54
  with
• 13:54
  Seroquel
• 13:55
  and
• 13:55
  is
• 13:55
  people
• 13:56
  are
• 13:56
  too
• 13:56
  wiped
• 13:56
  out,
• 13:56
  they're
• 13:57
  too
• 13:57
  tired
• 13:57
  the
• 13:57
  next
• 13:58
  day,
• 13:58
  they're
• 13:58
  too
• 13:58
  tired.
• 13:59
  And
• 13:59
  so
• 13:59
  there
• 14:00
  is
• 14:00
  a
• 14:00
  bit
• 14:00
  of
• 14:00
  a
• 14:01
  actual
• 14:01
  ceiling
• 14:02
  on
• 14:02
  what
• 14:02
  you
• 14:02
  can
• 14:02
  do
• 14:03
  with
• 14:03
  Trazodone
• 14:04
  because
• 14:04
  patients
• 14:05
  can
• 14:05
  often
• 14:05
  not
• 14:06
  clinically
• 14:06
  tolerate
• 14:07
  it
• 14:07
  at
• 14:07
  higher
• 14:07
  doses.
• 14:08
  And
• 14:09
  that's
• 14:09
  definitely
• 14:10
  a
• 14:11
  real
• 14:11
  problem.
• 14:12
  But
• 14:12
  again,
• 14:12
  there's
• 14:13
  a
• 14:13
  lot
• 14:13
  of
• 14:13
  juice
• 14:13
  here.
• 14:13
  There's
• 14:14
  a
• 14:14
  lot
• 14:14
  of
• 14:14
  layers
• 14:15
  of
• 14:15
  clinical
• 14:15
  utility
• 14:16
  here.
• 14:16
  We
• 14:16
  didn't
• 14:17
  even
• 14:17
  talk
• 14:17
  about
• 14:17
  5ht1a,
• 14:18
  but
• 14:19
  it
• 14:19
  has
• 14:19
  a
• 14:19
  5ht1a,
• 14:20
  a
• 14:20
  partial
• 14:21
  agonism,
• 14:21
  which
• 14:22
  has
• 14:22
  been
• 14:22
  implicated
• 14:23
  in
• 14:23
  helping
• 14:23
  with
• 14:24
  anxiety.
• 14:25
  Right.
• 14:25
  The
• 14:26
  5ht
• 14:26
  2c
• 14:27
  antagonism
• 14:27
  evidence
• 14:28
  has
• 14:28
  shown
• 14:28
  it
• 14:28
  kind
• 14:28
  of
• 14:29
  reduces
• 14:29
  your
• 14:29
  amygdala,
• 14:30
  that
• 14:30
  fight
• 14:30
  or
• 14:30
  flight
• 14:30
  fear
• 14:31
  signaling,
• 14:32
  and
• 14:32
  it
• 14:32
  can
• 14:32
  even
• 14:32
  enhance
• 14:33
  dopamine
• 14:34
  and
• 14:34
  norepinephine,
• 14:34
  epinephrine
• 14:35
  release
• 14:35
  in
• 14:35
  the
• 14:36
  prefrontal
• 14:36
  cortex.
• 14:37
  So
• 14:37
  talk
• 14:37
  about
• 14:37
  like
• 14:38
  a
• 14:38
  Swiss
• 14:38
  army
• 14:38
  knife
• 14:39
  here.
• 14:39
  It's
• 14:39
  really
• 14:39
  handy.
• 14:40
  I
• 14:40
  know
• 14:41
  that
• 14:41
  I
• 14:41
  will
• 14:41
  often
• 14:42
  slap
• 14:42
  Trazodone
• 14:43
  on
• 14:44
  when
• 14:44
  a
• 14:44
  patient
• 14:44
  can't
• 14:45
  sleep
• 14:45
  and
• 14:45
  they're
• 14:45
  having
• 14:46
  sexual
• 14:46
  side
• 14:46
  effects.
• 14:47
  Right.
• 14:47
  Those
• 14:47
  are
• 14:47
  two
• 14:48
  big
• 14:49
  common.
• 14:50
  There's
• 14:50
  complaints
• 14:51
  that
• 14:51
  your
• 14:51
  patients
• 14:51
  will,
• 14:52
  will
• 14:52
  speak
• 14:52
  to
• 14:53
  and
• 14:53
  you
• 14:53
  need
• 14:54
  to
• 14:54
  do
• 14:54
  something
• 14:54
  about
• 14:54
  it.
• 14:55
  And
• 14:55
  in
• 14:55
  comes
• 14:55
  Trazodone.
• 14:56
  It's
• 14:56
  like,
• 14:56
  oh,
• 14:56
  you
• 14:56
  still
• 14:57
  can't
• 14:57
  sleep.
• 14:57
  You're
• 14:57
  being
• 14:57
  activated
• 14:58
  by
• 14:58
  your
• 14:58
  SSRIs.
• 14:59
  You're.
• 14:59
  You're
• 15:00
  feeling
• 15:00
  a
• 15:00
  little
• 15:00
  more
• 15:00
  anxiety.
• 15:01
  Oh,
• 15:01
  and
• 15:01
  sexual
• 15:02
  dysfunction,
• 15:02
  starting
• 15:02
  to
• 15:03
  sleep
• 15:03
  in.
• 15:03
  Well,
• 15:04
  I
• 15:04
  have
• 15:04
  the
• 15:04
  perfect
• 15:04
  thing
• 15:05
  for
• 15:05
  you.
• 15:05
  Right.
• 15:05
  It
• 15:06
  would
• 15:06
  be
• 15:06
  Trazodone.
• 15:07
  Right.
• 15:07
  Trazodone
• 15:08
  is
• 15:09
  a
• 15:09
  really
• 15:09
  nice
• 15:09
  compliment
• 15:10
  to
• 15:10
  that.
• 15:11
  There's
• 15:11
  other
• 15:11
  compliments
• 15:12
  in
• 15:12
  psychiatry.
• 15:13
  Wellbutrin
• 15:14
  is
• 15:14
  a
• 15:14
  very
• 15:14
  common
• 15:14
  one.
• 15:15
  But
• 15:15
  that's
• 15:15
  typically
• 15:16
  when
• 15:16
  your
• 15:16
  patient
• 15:17
  still
• 15:17
  has
• 15:17
  a
• 15:17
  lot
• 15:18
  of
• 15:18
  low
• 15:18
  energy,
• 15:18
  they
• 15:19
  have
• 15:19
  a
• 15:19
  lot
• 15:19
  of
• 15:19
  anhedonia,
• 15:20
  they're
• 15:20
  not
• 15:20
  getting
• 15:20
  joy
• 15:21
  out
• 15:21
  of
• 15:21
  things.
• 15:21
  When
• 15:21
  you
• 15:22
  have
• 15:22
  that
• 15:22
  kind
• 15:22
  of
• 15:23
  low
• 15:23
  energy
• 15:23
  depression
• 15:24
  with
• 15:24
  anhedonia,
• 15:25
  the
• 15:25
  augmentation
• 15:26
  strategy
• 15:26
  with
• 15:26
  Wellbutrin
• 15:27
  is
• 15:27
  great.
• 15:27
  And
• 15:28
  so
• 15:28
  if
• 15:28
  you
• 15:28
  have
• 15:28
  a
• 15:28
  patient
• 15:28
  with
• 15:29
  sexual
• 15:29
  dysfunction
• 15:30
  and
• 15:30
  you
• 15:30
  have
• 15:30
  to
• 15:31
  choose
• 15:31
  between
• 15:31
  Trazodone
• 15:32
  or
• 15:32
  Wellbutrin,
• 15:33
  I
• 15:33
  would
• 15:33
  choose
• 15:34
  Wellbutrin.
• 15:34
  If
• 15:35
  that
• 15:35
  patient
• 15:35
  is
• 15:35
  low
• 15:35
  energy,
• 15:36
  they
• 15:36
  still
• 15:37
  can't
• 15:37
  get
• 15:37
  joy
• 15:37
  out
• 15:37
  of
• 15:38
  their
• 15:38
  activities.
• 15:38
  They
• 15:38
  have
• 15:39
  a
• 15:39
  motivational
• 15:40
  issue.
• 15:40
  Right.
• 15:41
  It's
• 15:41
  hard
• 15:41
  to
• 15:41
  motivate
• 15:42
  to
• 15:42
  tasks.
• 15:42
  They
• 15:42
  don't
• 15:42
  have
• 15:42
  the
• 15:42
  energy
• 15:43
  to
• 15:43
  get
• 15:43
  to
• 15:43
  tasks.
• 15:44
  That's
• 15:44
  when
• 15:44
  I
• 15:45
  would
• 15:45
  turn
• 15:45
  on
• 15:45
  Wellbutrin
• 15:46
  and
• 15:46
  counter
• 15:47
  those
• 15:47
  sexual
• 15:47
  side
• 15:47
  effects.
• 15:48
  And
• 15:48
  not
• 15:49
  necessarily
• 15:49
  Trazodone.
• 15:50
  Right.
• 15:50
  Because
• 15:51
  Trazodone
• 15:51
  may
• 15:52
  make
• 15:52
  you
• 15:52
  more
• 15:52
  tired
• 15:53
  and
• 15:53
  less
• 15:53
  likely
• 15:53
  to
• 15:54
  get
• 15:54
  up
• 15:54
  and
• 15:54
  want
• 15:55
  to
• 15:55
  do
• 15:55
  things
• 15:55
  the
• 15:55
  next
• 15:55
  day.
• 15:56
  The
• 15:56
  higher
• 15:56
  you
• 15:56
  raise
• 15:57
  the
• 15:57
  dose,
• 15:57
  it
• 15:58
  you
• 15:58
  can
• 15:58
  clearly
• 15:58
  see
• 15:59
  it
• 15:59
  has
• 15:59
  really
• 16:00
  good
• 16:01
  utility.
• 16:02
  I
• 16:02
  love
• 16:02
  the
• 16:03
  idea
• 16:03
  of
• 16:03
  trazodone
• 16:04
  because
• 16:04
  the
• 16:05
  devil's
• 16:05
  really
• 16:05
  in
• 16:05
  the
• 16:06
  details
• 16:06
  here.
• 16:06
  I
• 16:06
  love
• 16:07
  that
• 16:07
  the
• 16:07
  Alpha
• 16:07
  1
• 16:07
  blockade
• 16:09
  is
• 16:09
  a
• 16:09
  little
• 16:10
  bit
• 16:10
  of
• 16:10
  a
• 16:10
  weapon
• 16:10
  you
• 16:10
  can
• 16:11
  use
• 16:11
  in
• 16:12
  patients
• 16:12
  with
• 16:12
  trauma
• 16:13
  response
• 16:13
  and
• 16:13
  ptsd.
• 16:14
  If
• 16:15
  for
• 16:15
  whatever
• 16:15
  reason,
• 16:16
  your
• 16:16
  patient
• 16:16
  is
• 16:16
  not
• 16:17
  responding
• 16:17
  to
• 16:17
  prazosin.
• 16:18
  Believe
• 16:18
  it
• 16:18
  or
• 16:18
  not,
• 16:18
  as
• 16:18
  good
• 16:19
  as
• 16:19
  it
• 16:19
  is
• 16:19
  for
• 16:19
  nightmares,
• 16:20
  some
• 16:20
  patients
• 16:20
  just
• 16:21
  tell
• 16:21
  me
• 16:21
  they
• 16:21
  can't
• 16:21
  tolerate
• 16:22
  it,
• 16:22
  they
• 16:22
  just
• 16:22
  can't
• 16:23
  do
• 16:23
  it.
• 16:23
  They
• 16:23
  have
• 16:23
  all
• 16:23
  kinds
• 16:24
  of
• 16:24
  different
• 16:24
  concerns
• 16:25
  about
• 16:25
  it.
• 16:25
  Some
• 16:26
  love
• 16:26
  it,
• 16:26
  some
• 16:26
  swear
• 16:27
  by
• 16:27
  it.
• 16:27
  I've
• 16:27
  seen
• 16:27
  it
• 16:28
  change
• 16:28
  lives.
• 16:28
  But
• 16:29
  for
• 16:29
  whatever
• 16:29
  reason,
• 16:30
  if
• 16:30
  prazosin
• 16:30
  is
• 16:30
  intolerable
• 16:31
  to
• 16:31
  the
• 16:31
  patient,
• 16:32
  Trazodone,
• 16:33
  there
• 16:33
  is
• 16:33
  some
• 16:33
  evidence
• 16:34
  that
• 16:34
  you
• 16:34
  can
• 16:35
  assist.
• 16:36
  It's
• 16:36
  not
• 16:36
  really
• 16:37
  FDA
• 16:37
  approved
• 16:37
  for
• 16:38
  this
• 16:38
  reason,
• 16:38
  but
• 16:39
  off
• 16:39
  label
• 16:39
  there
• 16:39
  is
• 16:40
  some
• 16:40
  evidence
• 16:40
  that
• 16:40
  it
• 16:41
  has
• 16:41
  helped
• 16:41
  with
• 16:41
  nightmares.
• 16:42
  I
• 16:42
  have
• 16:42
  had
• 16:42
  patients
• 16:43
  who
• 16:43
  swear
• 16:43
  by
• 16:44
  trazodone
• 16:44
  for
• 16:44
  nightmares.
• 16:45
  And
• 16:45
  the
• 16:45
  Alpha
• 16:46
  one
• 16:46
  adrenergic
• 16:47
  blockade
• 16:48
  is
• 16:49
  very
• 16:49
  effective,
• 16:50
  Right.
• 16:50
  Because
• 16:51
  it
• 16:51
  is
• 16:51
  mitigating
• 16:52
  the
• 16:52
  hyperarousal
• 16:53
  commonly
• 16:54
  seen
• 16:54
  in
• 16:54
  trauma.
• 16:55
  This
• 16:55
  is
• 16:55
  why
• 16:55
  we
• 16:55
  have
• 16:55
  to
• 16:56
  always
• 16:56
  pay
• 16:56
  attention
• 16:57
  to
• 16:57
  receptor
• 16:58
  affinity.
• 16:59
  One
• 16:59
  of
• 16:59
  the
• 16:59
  first
• 16:59
  questions
• 17:00
  you
• 17:00
  need
• 17:00
  to
• 17:00
  ask
• 17:00
  when
• 17:00
  you're
• 17:01
  holding
• 17:01
  a
• 17:01
  medication
• 17:01
  in
• 17:02
  your
• 17:02
  hands,
• 17:02
  metaphorically,
• 17:03
  is
• 17:03
  what
• 17:04
  doors
• 17:04
  is
• 17:04
  this
• 17:05
  medication
• 17:05
  going
• 17:05
  to
• 17:06
  unlock
• 17:06
  for
• 17:06
  my
• 17:06
  patient
• 17:07
  and
• 17:07
  at
• 17:07
  what
• 17:07
  doses?
• 17:08
  Right.
• 17:08
  Because
• 17:09
  if
• 17:09
  it
• 17:09
  opens
• 17:09
  a
• 17:10
  magical
• 17:10
  door
• 17:10
  that
• 17:11
  cures
• 17:11
  every
• 17:11
  problem
• 17:11
  in
• 17:12
  the
• 17:12
  world,
• 17:12
  but
• 17:12
  it's
• 17:12
  at
• 17:12
  this
• 17:13
  extremely
• 17:13
  high
• 17:14
  dose
• 17:14
  that
• 17:15
  your
• 17:15
  patient
• 17:15
  will
• 17:15
  never
• 17:15
  tolerate,
• 17:16
  it's
• 17:17
  not
• 17:17
  that
• 17:17
  useful
• 17:18
  to
• 17:18
  you,
• 17:18
  right?
• 17:18
  I
• 17:18
  love
• 17:18
  Seroquel.
• 17:19
  It's
• 17:19
  one
• 17:19
  of
• 17:20
  my
• 17:20
  favorite
• 17:20
  medications
• 17:20
  to
• 17:21
  prescribe.
• 17:21
  But
• 17:22
  as
• 17:22
  an
• 17:22
  antipsychotic,
• 17:23
  can
• 17:23
  I
• 17:23
  really
• 17:23
  get
• 17:23
  somebody
• 17:24
  up
• 17:24
  to
• 17:24
  600?
• 17:24
  It's
• 17:25
  really
• 17:25
  challenging.
• 17:26
  It's
• 17:26
  like
• 17:27
  climbing
• 17:27
  Mount
• 17:27
  Everest.
• 17:28
  As
• 17:28
  a
• 17:28
  prescriber,
• 17:29
  I
• 17:29
  can't
• 17:29
  always
• 17:29
  do
• 17:30
  it
• 17:30
  right?
• 17:30
  So
• 17:31
  in
• 17:31
  a
• 17:31
  textbook,
• 17:31
  it
• 17:32
  looks
• 17:32
  perfect.
• 17:32
  Oh
• 17:32
  my
• 17:32
  God.
• 17:33
  It's
• 17:33
  a
• 17:33
  acts
• 17:34
  like
• 17:34
  an
• 17:34
  snri.
• 17:34
  At
• 17:35
  lower
• 17:35
  doses,
• 17:35
  it's
• 17:36
  a
• 17:36
  hypnotic,
• 17:36
  at
• 17:36
  really
• 17:37
  low
• 17:37
  doses,
• 17:38
  it's
• 17:38
  a
• 17:38
  mood
• 17:38
  stabilizer.
• 17:39
  It
• 17:39
  takes
• 17:39
  away
• 17:39
  psychosis.
• 17:40
  Yeah,
• 17:40
  but
• 17:40
  in
• 17:40
  practice,
• 17:41
  your
• 17:41
  patients
• 17:41
  are
• 17:42
  gonna
• 17:42
  be
• 17:42
  kicking
• 17:42
  and
• 17:42
  screaming
• 17:43
  at
• 17:43
  400
• 17:44
  more
• 17:44
  often
• 17:44
  than
• 17:44
  not.
• 17:44
  And
• 17:45
  they're
• 17:45
  not
• 17:45
  gonna
• 17:45
  want
• 17:45
  you
• 17:45
  to
• 17:46
  raise
• 17:46
  it
• 17:46
  to
• 17:46
  antipsychotic
• 17:47
  levels
• 17:47
  cuz
• 17:48
  they're
• 17:48
  too
• 17:48
  wiped
• 17:48
  out.
• 17:49
  And
• 17:50
  the
• 17:50
  same
• 17:50
  thing
• 17:50
  goes
• 17:50
  when
• 17:51
  you
• 17:51
  hold
• 17:51
  that
• 17:51
  medication,
• 17:52
  ask
• 17:52
  what
• 17:53
  receptors
• 17:54
  does
• 17:54
  this
• 17:54
  act
• 17:55
  on?
• 17:55
  What
• 17:55
  are
• 17:55
  the
• 17:55
  affinities?
• 17:56
  In
• 17:56
  other
• 17:56
  words,
• 17:57
  how
• 17:57
  quickly
• 17:58
  will
• 17:58
  my
• 17:58
  dose
• 17:59
  increases
• 17:59
  get
• 18:00
  to
• 18:00
  these
• 18:00
  receptors
• 18:01
  so
• 18:01
  that
• 18:01
  it
• 18:01
  exerts
• 18:02
  a
• 18:02
  therapeutic
• 18:03
  effect.
• 18:03
  And
• 18:03
  so
• 18:04
  with
• 18:04
  trazodone
• 18:04
  you
• 18:05
  get
• 18:05
  that
• 18:05
  5ht2a
• 18:06
  where
• 18:06
  you're
• 18:06
  countering
• 18:06
  the
• 18:07
  SSRI
• 18:08
  sexual
• 18:08
  side
• 18:08
  effects
• 18:09
  and
• 18:09
  activation
• 18:10
  and
• 18:10
  anxiety,
• 18:11
  you've
• 18:11
  got
• 18:11
  the
• 18:11
  Alpha
• 18:12
  1
• 18:12
  adrenergic
• 18:13
  antagonism
• 18:14
  that
• 18:14
  again,
• 18:15
  mitigates
• 18:15
  the
• 18:16
  hyperarousal
• 18:17
  a
• 18:17
  little
• 18:17
  bit.
• 18:17
  And
• 18:18
  it.
• 18:18
  Which
• 18:18
  is
• 18:19
  very
• 18:19
  helpful
• 18:20
  because
• 18:20
  again,
• 18:20
  it
• 18:21
  kind
• 18:21
  of
• 18:22
  allows
• 18:22
  your
• 18:23
  prefrontal
• 18:23
  cortex
• 18:24
  to
• 18:24
  come
• 18:24
  back
• 18:24
  on
• 18:24
  board
• 18:25
  and
• 18:25
  govern
• 18:25
  the
• 18:26
  amygdala
• 18:26
  a
• 18:26
  little
• 18:27
  bit
• 18:27
  better.
• 18:27
  That
• 18:27
  top
• 18:27
  down
• 18:28
  break
• 18:28
  we
• 18:28
  always
• 18:28
  talk
• 18:28
  about.
• 18:29
  So
• 18:29
  that's
• 18:29
  really
• 18:30
  one
• 18:30
  of
• 18:30
  the
• 18:30
  big
• 18:30
  takeaways
• 18:31
  from
• 18:31
  this
• 18:31
  episode.
• 18:33
  It's
• 18:33
  that
• 18:33
  we
• 18:33
  want
• 18:34
  to
• 18:34
  appreciate
• 18:34
  all
• 18:35
  of
• 18:35
  the
• 18:35
  receptors
• 18:36
  that
• 18:36
  are
• 18:37
  implicated
• 18:37
  in
• 18:37
  the
• 18:37
  medications
• 18:38
  that
• 18:38
  we
• 18:38
  prescribe,
• 18:39
  the
• 18:39
  affinity
• 18:40
  for
• 18:40
  each
• 18:40
  receptor.
• 18:41
  Again,
• 18:42
  because
• 18:42
  a
• 18:43
  low
• 18:43
  affinity
• 18:43
  is
• 18:45
  functionally
• 18:46
  irrelevant
• 18:46
  sometimes.
• 18:48
  If
• 18:48
  it's
• 18:48
  such
• 18:49
  a
• 18:49
  low
• 18:49
  affinity
• 18:49
  that
• 18:49
  you
• 18:49
  have
• 18:50
  to
• 18:50
  go
• 18:50
  to
• 18:50
  such
• 18:50
  a
• 18:50
  high
• 18:50
  dose
• 18:51
  and
• 18:51
  the
• 18:51
  therapeutic
• 18:52
  effect
• 18:52
  is,
• 18:53
  you
• 18:53
  know,
• 18:53
  mixed
• 18:54
  or
• 18:54
  nebulous
• 18:55
  at
• 18:55
  best,
• 18:56
  then
• 18:57
  why
• 18:57
  are
• 18:57
  we
• 18:57
  interested
• 18:58
  in
• 18:58
  the
• 18:58
  medication?
• 18:58
  Right.
• 18:59
  But
• 18:59
  I
• 18:59
  think
• 18:59
  the
• 18:59
  reason
• 18:59
  I
• 19:00
  love
• 19:00
  this
• 19:00
  trazodone
• 19:01
  discussion
• 19:02
  so
• 19:02
  much,
• 19:02
  my
• 19:02
  friends,
• 19:03
  is
• 19:03
  because
• 19:04
  in
• 19:04
  the
• 19:04
  world
• 19:04
  of
• 19:05
  sleep
• 19:05
  medication,
• 19:06
  they
• 19:06
  all
• 19:07
  seem
• 19:07
  to
• 19:07
  be
• 19:07
  one
• 19:08
  big
• 19:08
  blur.
• 19:08
  Right.
• 19:08
  When
• 19:09
  you're
• 19:09
  talking
• 19:09
  about
• 19:09
  doxepin
• 19:10
  versus
• 19:10
  ramelion
• 19:11
  versus
• 19:12
  trazodone
• 19:12
  versus
• 19:13
  Atarax,
• 19:14
  it's
• 19:14
  very
• 19:14
  easy
• 19:15
  to
• 19:15
  get
• 19:15
  dizzy,
• 19:16
  no
• 19:16
  pun
• 19:17
  intended.
• 19:18
  That,
• 19:19
  and
• 19:19
  you
• 19:19
  don't
• 19:19
  know
• 19:19
  which
• 19:19
  one
• 19:20
  to
• 19:20
  pick
• 19:20
  and
• 19:20
  why
• 19:21
  you're
• 19:21
  picking
• 19:21
  it.
• 19:21
  And
• 19:22
  so
• 19:22
  it's
• 19:22
  really
• 19:22
  important
• 19:23
  to
• 19:24
  get
• 19:24
  nitty
• 19:25
  gritty
• 19:25
  about
• 19:26
  what
• 19:26
  we're
• 19:26
  dealing
• 19:26
  with
• 19:27
  here
• 19:27
  and
• 19:28
  compare
• 19:28
  and
• 19:29
  contrast
• 19:30
  the
• 19:30
  various
• 19:30
  medications
• 19:32
  so
• 19:32
  you
• 19:33
  know
• 19:33
  what
• 19:33
  you're
• 19:33
  doing.
• 19:33
  Right.
• 19:34
  If
• 19:34
  you're
• 19:34
  trying
• 19:34
  to
• 19:35
  restore
• 19:36
  circadian
• 19:36
  functioning,
• 19:38
  then
• 19:38
  Ramelteon
• 19:39
  is
• 19:39
  pretty
• 19:40
  good.
• 19:40
  It's
• 19:40
  a
• 19:40
  melatonin
• 19:41
  agonist.
• 19:41
  Right.
• 19:42
  So
• 19:42
  now
• 19:43
  that
• 19:43
  it
• 19:43
  has
• 19:43
  probably
• 19:43
  the
• 19:44
  weakest
• 19:44
  evidence
• 19:45
  of
• 19:46
  all
• 19:46
  the
• 19:46
  other
• 19:47
  medications
• 19:47
  you
• 19:48
  could
• 19:48
  choose
• 19:48
  there.
• 19:49
  But
• 19:49
  nonetheless,
• 19:50
  that's
• 19:51
  more
• 19:51
  of
• 19:51
  a
• 19:51
  circadian
• 19:52
  alignment
• 19:52
  option
• 19:53
  if
• 19:53
  you
• 19:53
  have
• 19:53
  a
• 19:54
  patient
• 19:54
  that
• 19:55
  has
• 19:55
  anxiety.
• 19:56
  Well,
• 19:56
  hydroxyzine
• 19:57
  is
• 19:57
  a
• 19:58
  pretty
• 19:58
  good.
• 19:59
  It's,
• 19:59
  it's
• 19:59
  a
• 19:59
  pretty
• 20:00
  good
• 20:00
  one
• 20:00
  to,
• 20:01
  to
• 20:01
  think
• 20:02
  about.
• 20:02
  Absolutely
• 20:03
  is.
• 20:03
  But
• 20:04
  you
• 20:04
  know,
• 20:04
  it
• 20:04
  does
• 20:04
  cause
• 20:05
  a
• 20:05
  dry
• 20:05
  mouth
• 20:05
  and
• 20:06
  snex
• 20:06
  day
• 20:06
  sedation,
• 20:07
  and
• 20:07
  that
• 20:08
  can
• 20:08
  be
• 20:08
  very
• 20:08
  problematic
• 20:09
  to
• 20:09
  people.
• 20:09
  Right.
• 20:10
  It
• 20:10
  does
• 20:10
  have
• 20:10
  a
• 20:10
  fast
• 20:10
  onset.
• 20:11
  It
• 20:11
  works
• 20:11
  pretty
• 20:12
  quickly.
• 20:12
  It
• 20:12
  does,
• 20:12
  again,
• 20:13
  make
• 20:13
  people
• 20:14
  a
• 20:14
  lot
• 20:14
  less
• 20:14
  anxious
• 20:15
  with
• 20:15
  no
• 20:15
  abuse
• 20:15
  potential,
• 20:16
  but
• 20:16
  there's
• 20:17
  no
• 20:17
  real
• 20:17
  antidepressant
• 20:18
  effect
• 20:18
  and
• 20:18
  it
• 20:18
  has
• 20:18
  that
• 20:19
  anticholinergic
• 20:19
  burden,
• 20:20
  which
• 20:20
  is
• 20:20
  especially
• 20:21
  bad
• 20:21
  if
• 20:21
  you're
• 20:21
  older.
• 20:22
  Right.
• 20:22
  So
• 20:22
  it's
• 20:23
  not
• 20:23
  really
• 20:23
  the
• 20:23
  best
• 20:24
  idea.
• 20:24
  Dry
• 20:25
  mouth,
• 20:26
  right.
• 20:26
  Next
• 20:26
  day
• 20:27
  kind
• 20:27
  of
• 20:27
  hangover.
• 20:28
  Not
• 20:28
  my
• 20:28
  favorite
• 20:29
  med.
• 20:29
  It
• 20:29
  definitely
• 20:29
  has
• 20:29
  its
• 20:30
  place
• 20:30
  though.
• 20:31
  Doxepin.
• 20:32
  Great.
• 20:32
  It's
• 20:32
  clean.
• 20:33
  Anti
• 20:33
  histaminergic
• 20:34
  Effect
• 20:34
  really
• 20:35
  clean
• 20:35
  at
• 20:35
  3
• 20:35
  and
• 20:36
  6
• 20:36
  milligrams.
• 20:37
  Very
• 20:37
  good
• 20:37
  for
• 20:38
  patients
• 20:38
  who
• 20:38
  wake
• 20:39
  up
• 20:39
  in
• 20:39
  the
• 20:39
  middle
• 20:39
  of
• 20:39
  the
• 20:39
  night.
• 20:40
  Right.
• 20:40
  But
• 20:40
  then
• 20:40
  Trazodone
• 20:41
  seems
• 20:41
  more
• 20:42
  like
• 20:42
  a
• 20:42
  Swiss
• 20:42
  army
• 20:42
  knife
• 20:43
  where
• 20:43
  you
• 20:44
  are
• 20:44
  again
• 20:44
  antagonizing
• 20:45
  5ht
• 20:46
  2a.
• 20:46
  There's
• 20:47
  a
• 20:47
  little
• 20:47
  Alpha
• 20:47
  1
• 20:47
  blockade,
• 20:48
  a
• 20:48
  little
• 20:48
  histamine
• 20:49
  blockade.
• 20:50
  So
• 20:50
  you're
• 20:50
  allowing
• 20:51
  the
• 20:51
  hyperarousal
• 20:52
  to
• 20:52
  be
• 20:52
  contained,
• 20:53
  you're
• 20:54
  mitigating
• 20:54
  anxiety,
• 20:55
  you're
• 20:55
  enhancing
• 20:55
  slow
• 20:56
  wave
• 20:56
  sleep.
• 20:56
  It
• 20:57
  preserves
• 20:57
  the
• 20:58
  REM
• 20:58
  sleep
• 20:59
  too.
• 20:59
  I
• 20:59
  don't
• 20:59
  know
• 20:59
  if
• 20:59
  I
• 20:59
  mentioned
• 21:00
  that,
• 21:00
  which
• 21:00
  is
• 21:00
  really
• 21:01
  key
• 21:01
  cuz
• 21:01
  a
• 21:01
  lot
• 21:01
  of
• 21:01
  your
• 21:01
  SSRIs
• 21:02
  don't
• 21:03
  preserve
• 21:03
  REM.
• 21:04
  So
• 21:04
  it's,
• 21:04
  you
• 21:05
  know,
• 21:05
  doing
• 21:05
  a
• 21:05
  lot
• 21:06
  of
• 21:06
  things
• 21:06
  at
• 21:06
  once
• 21:06
  that
• 21:06
  are
• 21:07
  actually
• 21:07
  very
• 21:08
  good.
• 21:08
  And
• 21:08
  worst
• 21:09
  case
• 21:09
  scenario
• 21:09
  you
• 21:09
  can
• 21:10
  increase
• 21:10
  the
• 21:10
  dose.
• 21:11
  Of
• 21:11
  course
• 21:11
  you
• 21:12
  have
• 21:12
  to
• 21:12
  be
• 21:12
  careful
• 21:13
  what
• 21:13
  else
• 21:13
  they're
• 21:13
  taking
• 21:13
  and
• 21:14
  always
• 21:14
  look
• 21:14
  for
• 21:14
  medication
• 21:15
  interactions.
• 21:15
  But
• 21:16
  worst
• 21:16
  case,
• 21:16
  you
• 21:16
  can
• 21:17
  make
• 21:17
  it
• 21:17
  act
• 21:17
  like
• 21:17
  an
• 21:18
  SSRI
• 21:18
  at
• 21:18
  higher
• 21:19
  doses.
• 21:19
  So
• 21:19
  it's
• 21:19
  pretty,
• 21:20
  actually
• 21:21
  pretty
• 21:21
  neat
• 21:21
  there.
• 21:22
  It's
• 21:22
  similar
• 21:22
  in
• 21:23
  that
• 21:23
  it
• 21:23
  antagonizes
• 21:24
  5ht
• 21:24
  2a
• 21:24
  just
• 21:25
  like
• 21:25
  Trazodone.
• 21:25
  It
• 21:25
  can
• 21:26
  be
• 21:26
  added
• 21:26
  on
• 21:26
  to
• 21:26
  reverse
• 21:27
  sexual
• 21:27
  side
• 21:27
  effects
• 21:28
  or
• 21:28
  treat
• 21:28
  sexual
• 21:28
  side
• 21:28
  effects.
• 21:29
  It
• 21:30
  also
• 21:30
  has
• 21:30
  that
• 21:31
  anxiolytic
• 21:32
  effect
• 21:32
  at
• 21:32
  5ht2a
• 21:33
  that
• 21:33
  helps
• 21:33
  people
• 21:34
  prepare
• 21:34
  for
• 21:34
  sleep
• 21:34
  a
• 21:35
  little
• 21:35
  better
• 21:35
  because
• 21:35
  they're
• 21:35
  not
• 21:35
  as
• 21:36
  anxiously
• 21:36
  ruminating
• 21:37
  Again,
• 21:37
  just
• 21:37
  like
• 21:38
  Trazodone.
• 21:38
  But
• 21:39
  Remeron
• 21:39
  has
• 21:40
  like
• 21:40
  four
• 21:40
  times
• 21:40
  the
• 21:40
  risk
• 21:41
  of
• 21:41
  weight
• 21:41
  gain,
• 21:41
  the
• 21:41
  evidence
• 21:42
  seems
• 21:42
  to
• 21:42
  suggest,
• 21:43
  than
• 21:43
  Trazodone.
• 21:44
  So
• 21:44
  if
• 21:45
  you're
• 21:45
  looking
• 21:45
  for
• 21:45
  a
• 21:45
  med
• 21:46
  and
• 21:46
  weight
• 21:46
  gain
• 21:46
  is
• 21:46
  a
• 21:46
  deal
• 21:47
  breaker
• 21:47
  and
• 21:48
  they're
• 21:48
  anxious
• 21:48
  and
• 21:49
  maybe
• 21:49
  there's
• 21:49
  some
• 21:49
  hyperarousal
• 21:50
  in
• 21:50
  there,
• 21:51
  Trazodone
• 21:52
  is
• 21:52
  actually
• 21:52
  really
• 21:53
  good
• 21:53
  and
• 21:53
  I
• 21:53
  think
• 21:53
  it's
• 21:53
  particularly
• 21:54
  good
• 21:55
  when
• 21:55
  you
• 21:55
  are
• 21:55
  initiating
• 21:56
  SSRIs
• 21:57
  and
• 21:57
  you're
• 21:57
  dealing
• 21:57
  with
• 21:57
  that,
• 21:58
  those,
• 21:58
  those
• 21:59
  crazy
• 21:59
  side
• 21:59
  effects
• 22:00
  that
• 22:00
  kick
• 22:00
  up.
• 22:01
  And
• 22:01
  if
• 22:01
  you
• 22:01
  don't
• 22:01
  feel
• 22:01
  comfortable
• 22:02
  prescribing
• 22:02
  a
• 22:02
  benzo,
• 22:03
  and
• 22:03
  I
• 22:03
  know
• 22:03
  I
• 22:03
  don't
• 22:04
  in
• 22:04
  those
• 22:04
  first
• 22:04
  two
• 22:04
  weeks
• 22:04
  all
• 22:05
  the
• 22:05
  time
• 22:06
  because
• 22:06
  of
• 22:06
  the
• 22:06
  various
• 22:06
  concerns
• 22:07
  that
• 22:07
  benzodiazepines
• 22:08
  have,
• 22:08
  then
• 22:09
  Trazodone
• 22:09
  can
• 22:10
  still,
• 22:10
  there's
• 22:10
  still
• 22:11
  a
• 22:11
  good
• 22:11
  place
• 22:12
  for
• 22:12
  Trazodone,
• 22:13
  right?
• 22:13
  Because
• 22:13
  you
• 22:13
  are,
• 22:14
  you
• 22:14
  are
• 22:14
  targeting
• 22:15
  anxiety
• 22:15
  and
• 22:15
  sleep.
• 22:16
  That's
• 22:16
  what
• 22:16
  you
• 22:16
  would
• 22:16
  do
• 22:16
  with
• 22:17
  a
• 22:17
  benzo
• 22:17
  too.
• 22:17
  But
• 22:18
  again,
• 22:18
  without
• 22:18
  that
• 22:18
  extra
• 22:19
  baggage
• 22:19
  that
• 22:20
  we
• 22:20
  associate
• 22:20
  with,
• 22:21
  with
• 22:21
  benzos.
• 22:22
  Now,
• 22:22
  my
• 22:22
  friends,
• 22:23
  there
• 22:23
  are
• 22:24
  some
• 22:24
  things
• 22:24
  to
• 22:24
  be
• 22:25
  mindful
• 22:26
  about
• 22:26
  with
• 22:26
  Trazodone.
• 22:27
  I
• 22:27
  encourage
• 22:27
  you
• 22:27
  to
• 22:27
  look
• 22:27
  at
• 22:28
  the
• 22:29
  prescription
• 22:29
  inserts,
• 22:30
  go
• 22:30
  to
• 22:30
  the
• 22:31
  drug
• 22:31
  website,
• 22:32
  have
• 22:32
  your
• 22:32
  patients
• 22:33
  talk
• 22:34
  to
• 22:34
  the
• 22:34
  pharmacist,
• 22:35
  et
• 22:35
  Cetera.
• 22:36
  But
• 22:36
  there
• 22:36
  are
• 22:36
  some
• 22:37
  deal
• 22:37
  breakers
• 22:38
  with
• 22:38
  Trazodone
• 22:39
  that
• 22:39
  are
• 22:39
  worth
• 22:40
  mentioning
• 22:40
  and
• 22:40
  you've
• 22:40
  probably
• 22:41
  heard
• 22:41
  of
• 22:41
  one
• 22:41
  of
• 22:42
  these
• 22:42
  in
• 22:42
  particular.
• 22:44
  So
• 22:44
  Trazodone
• 22:46
  is
• 22:46
  known
• 22:47
  to
• 22:47
  via
• 22:47
  the
• 22:48
  Alpha
• 22:48
  1
• 22:48
  blockade
• 22:49
  to
• 22:49
  cause
• 22:49
  prolonged
• 22:50
  erections.
• 22:51
  Now,
• 22:52
  I
• 22:53
  want
• 22:53
  all
• 22:53
  of
• 22:53
  you
• 22:53
  to
• 22:53
  be
• 22:54
  very
• 22:54
  careful
• 22:55
  about
• 22:57
  how
• 22:57
  you
• 22:57
  discuss
• 22:58
  side
• 22:58
  effects.
• 22:58
  This
• 22:58
  is
• 22:59
  just
• 22:59
  a
• 22:59
  tip,
• 23:00
  a
• 23:00
  free
• 23:00
  tip.
• 23:00
  Pearls
• 23:01
  and
• 23:01
  prep
• 23:01
  tip.
• 23:02
  This
• 23:02
  is
• 23:03
  at
• 23:03
  least
• 23:03
  how
• 23:03
  I
• 23:03
  look
• 23:03
  at
• 23:03
  it,
• 23:03
  right?
• 23:04
  If,
• 23:05
  if
• 23:05
  a
• 23:05
  side
• 23:06
  effect
• 23:06
  is
• 23:06
  1
• 23:06
  in
• 23:07
  6,000
• 23:07
  or
• 23:08
  1
• 23:08
  in
• 23:08
  8,000,
• 23:09
  like
• 23:09
  a
• 23:09
  prolonged
• 23:10
  erection
• 23:11
  in
• 23:11
  Trazodone,
• 23:12
  you
• 23:13
  want
• 23:13
  to
• 23:13
  frame
• 23:13
  it
• 23:14
  so
• 23:14
  that
• 23:14
  your
• 23:15
  anticipatory
• 23:16
  guidance
• 23:16
  reflects
• 23:17
  the
• 23:17
  fact
• 23:17
  that
• 23:18
  it's
• 23:18
  1
• 23:18
  in
• 23:18
  6,000
• 23:19
  and
• 23:19
  not
• 23:19
  like
• 23:20
  1
• 23:20
  in
• 23:20
  2.
• 23:21
  Because
• 23:21
  there's
• 23:21
  a
• 23:21
  way
• 23:21
  to
• 23:22
  say
• 23:22
  something
• 23:22
  that
• 23:23
  can
• 23:23
  scare
• 23:23
  your
• 23:23
  patient
• 23:24
  out
• 23:24
  of
• 23:24
  treatment.
• 23:25
  They're
• 23:25
  already
• 23:25
  kind
• 23:25
  of
• 23:26
  med
• 23:26
  wary.
• 23:27
  Maybe
• 23:27
  this
• 23:27
  is
• 23:27
  the
• 23:27
  first
• 23:28
  med
• 23:28
  or
• 23:28
  two
• 23:28
  they've
• 23:29
  ever
• 23:29
  tried.
• 23:30
  And
• 23:30
  now
• 23:30
  you
• 23:30
  know.
• 23:30
  So
• 23:31
  there's
• 23:31
  a
• 23:31
  way
• 23:31
  to
• 23:31
  say
• 23:32
  this.
• 23:32
  And
• 23:32
  that's
• 23:33
  why
• 23:33
  I
• 23:33
  think
• 23:33
  memorizing
• 23:34
  the
• 23:34
  statistic
• 23:34
  is
• 23:35
  kind
• 23:35
  of
• 23:35
  handy
• 23:35
  here.
• 23:36
  Because
• 23:37
  it's
• 23:37
  not
• 23:37
  enough
• 23:37
  to
• 23:38
  say
• 23:39
  some
• 23:39
  side
• 23:39
  effects
• 23:40
  may
• 23:40
  include
• 23:41
  a
• 23:43
  prolonged
• 23:43
  erection
• 23:44
  that
• 23:44
  brings
• 23:44
  you
• 23:44
  to
• 23:45
  the
• 23:45
  er.
• 23:46
  I
• 23:46
  mean
• 23:47
  that,
• 23:47
  that
• 23:47
  can
• 23:47
  be
• 23:47
  very
• 23:47
  terrifying.
• 23:48
  And
• 23:49
  side
• 23:49
  effects
• 23:50
  may
• 23:50
  include,
• 23:50
  may
• 23:51
  not
• 23:51
  be
• 23:51
  a
• 23:51
  sufficient
• 23:52
  way
• 23:52
  to
• 23:53
  roll
• 23:54
  that
• 23:54
  out
• 23:55
  at
• 23:56
  the
• 23:56
  conclusion
• 23:56
  of
• 23:56
  your
• 23:57
  interview.
• 23:57
  So
• 23:58
  that's
• 23:58
  when
• 23:58
  I
• 23:58
  like
• 23:58
  to
• 23:59
  say
• 23:59
  1
• 23:59
  in
• 23:59
  6
• 23:59
  to
• 23:59
  8,000.
• 24:00
  The
• 24:00
  evidence
• 24:00
  shows
• 24:01
  1
• 24:01
  to
• 24:01
  6
• 24:01
  and
• 24:02
  8,000.
• 24:02
  Same
• 24:02
  with
• 24:03
  lamotrigine.
• 24:03
  Right?
• 24:04
  There
• 24:04
  is
• 24:04
  that
• 24:04
  life
• 24:04
  threatening
• 24:05
  rash.
• 24:05
  We
• 24:05
  have
• 24:06
  to
• 24:06
  take
• 24:06
  it
• 24:06
  extremely
• 24:07
  seriously.
• 24:07
  We
• 24:08
  have
• 24:08
  to
• 24:08
  be
• 24:08
  vigilant.
• 24:09
  Right?
• 24:09
  But
• 24:10
  I
• 24:10
  make
• 24:10
  it
• 24:10
  known
• 24:11
  to
• 24:11
  them
• 24:11
  that
• 24:11
  the
• 24:11
  evidence
• 24:12
  suggests,
• 24:12
  you
• 24:13
  know,
• 24:13
  one
• 24:13
  in
• 24:13
  n
• 24:13
  thousand
• 24:14
  people
• 24:15
  experience
• 24:17
  a
• 24:17
  life
• 24:17
  threatening
• 24:18
  rash.
• 24:18
  Right?
• 24:19
  Because
• 24:19
  if
• 24:19
  you're
• 24:19
  not
• 24:20
  careful
• 24:20
  with
• 24:20
  your
• 24:21
  tone
• 24:21
  and
• 24:21
  your
• 24:21
  semantics,
• 24:22
  you
• 24:22
  may
• 24:23
  scare
• 24:24
  the
• 24:24
  patient
• 24:24
  away
• 24:24
  from
• 24:24
  a
• 24:25
  medication
• 24:25
  that
• 24:25
  could
• 24:25
  be
• 24:26
  otherwise
• 24:26
  life
• 24:26
  changing.
• 24:27
  Because
• 24:27
  there's
• 24:27
  a
• 24:28
  100%
• 24:28
  chance
• 24:29
  they
• 24:29
  have
• 24:30
  depression
• 24:31
  or
• 24:31
  anxiety.
• 24:31
  Because
• 24:32
  they're
• 24:32
  telling
• 24:32
  you
• 24:32
  they
• 24:33
  do.
• 24:33
  Right.
• 24:33
  And
• 24:33
  their
• 24:33
  PHQ9
• 24:34
  scores
• 24:34
  and
• 24:34
  their
• 24:34
  GAD
• 24:35
  scores
• 24:35
  are
• 24:35
  telling
• 24:35
  you
• 24:36
  they
• 24:36
  do.
• 24:36
  But
• 24:37
  there's
• 24:37
  a
• 24:37
  1
• 24:37
  in
• 24:38
  6
• 24:38
  to
• 24:38
  8,000
• 24:39
  chance
• 24:39
  that
• 24:40
  the
• 24:40
  male
• 24:40
  you
• 24:40
  prescribe
• 24:41
  this
• 24:41
  to
• 24:41
  will
• 24:42
  have
• 24:42
  a
• 24:43
  prolonged
• 24:43
  erection
• 24:44
  where
• 24:44
  he
• 24:44
  needs
• 24:44
  to
• 24:44
  go
• 24:44
  to
• 24:44
  the
• 24:44
  ER
• 24:45
  and
• 24:45
  explain
• 24:45
  himself
• 24:46
  to
• 24:46
  people.
• 24:46
  And
• 24:47
  if
• 24:47
  you
• 24:47
  look
• 24:48
  at
• 24:48
  the
• 24:48
  1
• 24:48
  in
• 24:48
  8,000
• 24:49
  incidents,
• 24:50
  that's
• 24:50
  about
• 24:50
  the
• 24:51
  same
• 24:51
  chances
• 24:53
  that
• 24:53
  you
• 24:53
  flip
• 24:54
  a
• 24:54
  coin
• 24:55
  and
• 24:55
  you
• 24:55
  get
• 24:55
  13
• 24:56
  heads
• 24:56
  in
• 24:56
  a
• 24:57
  row.
• 24:57
  It's
• 24:58
  about
• 24:58
  the
• 24:58
  same
• 24:59
  incidence
• 25:00
  or
• 25:00
  likelihood
• 25:01
  that
• 25:01
  you
• 25:01
  walk
• 25:01
  into
• 25:01
  a
• 25:02
  person
• 25:02
  who's
• 25:02
  7ft
• 25:03
  tall
• 25:03
  on
• 25:03
  the
• 25:04
  side
• 25:04
  of
• 25:04
  the
• 25:04
  street.
• 25:05
  Okay.
• 25:05
  It's
• 25:06
  about
• 25:06
  the
• 25:06
  same
• 25:07
  chance
• 25:07
  that
• 25:08
  someone
• 25:08
  is
• 25:08
  Born
• 25:09
  in
• 25:09
  Albino.
• 25:10
  Or
• 25:11
  that
• 25:11
  you
• 25:11
  shoot
• 25:12
  a
• 25:12
  hole
• 25:12
  in
• 25:12
  one
• 25:12
  at
• 25:13
  a
• 25:13
  golf
• 25:13
  course
• 25:13
  at
• 25:14
  your
• 25:14
  very
• 25:14
  first
• 25:14
  time
• 25:15
  playing
• 25:15
  golf.
• 25:16
  Okay,
• 25:17
  so
• 25:17
  it's
• 25:18
  really
• 25:18
  unlikely
• 25:20
  that
• 25:21
  it
• 25:22
  will
• 25:22
  be
• 25:22
  you,
• 25:22
  but
• 25:23
  it's
• 25:23
  still
• 25:23
  something
• 25:24
  that's
• 25:24
  very
• 25:24
  important.
• 25:24
  And
• 25:24
  if
• 25:25
  that's
• 25:25
  a
• 25:25
  concern,
• 25:26
  Mirtazapine
• 25:27
  is
• 25:28
  probably.
• 25:28
  Or
• 25:28
  Remeron
• 25:29
  is
• 25:29
  probably
• 25:29
  a
• 25:29
  better
• 25:30
  option
• 25:30
  because
• 25:30
  it
• 25:30
  doesn't
• 25:31
  have
• 25:31
  that
• 25:31
  Alpha
• 25:31
  1
• 25:31
  blockade
• 25:33
  that
• 25:33
  Trazodone
• 25:34
  does.
• 25:34
  So
• 25:34
  if
• 25:34
  that's
• 25:34
  a
• 25:34
  deal
• 25:35
  breaker,
• 25:35
  you
• 25:35
  go
• 25:35
  to
• 25:36
  Mirtazapine.
• 25:37
  You
• 25:37
  also
• 25:37
  have
• 25:38
  to
• 25:38
  look
• 25:38
  out
• 25:38
  for
• 25:38
  QT
• 25:39
  prolongation
• 25:40
  with
• 25:40
  Trazodone.
• 25:41
  So
• 25:41
  do
• 25:41
  your
• 25:41
  medication
• 25:42
  interactions.
• 25:43
  That
• 25:43
  might
• 25:44
  be
• 25:44
  another
• 25:44
  reason
• 25:44
  that
• 25:45
  SSRIs
• 25:46
  are
• 25:46
  a
• 25:46
  little
• 25:46
  better.
• 25:46
  They
• 25:46
  have
• 25:46
  more
• 25:47
  minimal
• 25:47
  QTC
• 25:47
  effect
• 25:48
  at
• 25:48
  standard
• 25:48
  doses.
• 25:49
  Again,
• 25:50
  Alpha
• 25:50
  1,
• 25:51
  you
• 25:51
  might
• 25:51
  fall
• 25:52
  orthostasis,
• 25:53
  sedation.
• 25:54
  So
• 25:54
  the
• 25:54
  elderly,
• 25:55
  it's
• 25:55
  not
• 25:55
  really
• 25:56
  necessarily
• 25:57
  the
• 25:57
  best
• 25:57
  thing.
• 25:57
  So
• 25:57
  this
• 25:58
  is
• 25:58
  why
• 25:58
  you
• 25:58
  have
• 25:58
  to
• 25:58
  become
• 25:58
  obsessed
• 25:59
  About
• 25:59
  Affinity.
• 26:00
  Right?
• 26:00
  Alpha
• 26:01
  1
• 26:01
  the
• 26:01
  Elderly,
• 26:02
  you've
• 26:02
  got
• 26:03
  to
• 26:03
  be
• 26:03
  kind
• 26:04
  of
• 26:04
  obsessed
• 26:05
  about
• 26:06
  these
• 26:06
  medications
• 26:08
  and
• 26:09
  how
• 26:09
  they
• 26:09
  interact
• 26:10
  with
• 26:10
  and
• 26:10
  how
• 26:10
  they
• 26:10
  converge
• 26:11
  with
• 26:11
  the
• 26:11
  patient
• 26:11
  who's
• 26:12
  in
• 26:12
  front
• 26:12
  of
• 26:12
  you.
• 26:12
  I
• 26:12
  think
• 26:12
  that's
• 26:13
  so
• 26:13
  important.
• 26:14
  So
• 26:14
  when
• 26:14
  you
• 26:14
  put
• 26:14
  that
• 26:14
  all
• 26:15
  together,
• 26:15
  I
• 26:15
  think
• 26:15
  you
• 26:16
  get
• 26:16
  a
• 26:16
  real
• 26:16
  bang
• 26:17
  for
• 26:17
  your
• 26:17
  buck
• 26:17
  with
• 26:17
  psychopharmacology
• 26:19
  receptors
• 26:20
  and
• 26:20
  affinity
• 26:21
  and
• 26:21
  doses
• 26:22
  and
• 26:23
  how
• 26:23
  these
• 26:24
  medications
• 26:24
  behave
• 26:25
  relative
• 26:26
  to
• 26:26
  other
• 26:26
  medications
• 26:27
  that
• 26:27
  are
• 26:27
  indicated
• 26:27
  for
• 26:28
  the
• 26:28
  same
• 26:28
  things.
• 26:28
  But
• 26:28
  they're
• 26:29
  really
• 26:29
  not
• 26:29
  the
• 26:29
  same
• 26:29
  things
• 26:30
  because
• 26:30
  the
• 26:30
  receptors
• 26:31
  are
• 26:31
  telling
• 26:32
  a
• 26:32
  very
• 26:32
  different
• 26:32
  story
• 26:32
  as
• 26:33
  to
• 26:33
  what
• 26:33
  the
• 26:33
  medication
• 26:33
  can
• 26:34
  specifically
• 26:34
  do
• 26:34
  and
• 26:35
  how
• 26:35
  those
• 26:35
  things
• 26:35
  can
• 26:35
  specifically
• 26:36
  lead
• 26:36
  to
• 26:37
  specifically
• 26:37
  awful
• 26:38
  side
• 26:38
  effects.
• 26:39
  But
• 26:39
  those
• 26:39
  specifically
• 26:40
  awful
• 26:40
  side
• 26:40
  effects
• 26:41
  may
• 26:41
  not
• 26:41
  be
• 26:41
  as
• 26:41
  common
• 26:41
  as
• 26:42
  you
• 26:42
  think.
• 26:42
  Things
• 26:43
  like
• 26:43
  slow
• 26:43
  wave
• 26:44
  sleep
• 26:44
  that
• 26:44
  you
• 26:44
  can
• 26:44
  talk
• 26:44
  to
• 26:45
  your
• 26:45
  patients
• 26:45
  about
• 26:45
  why
• 26:46
  trazodone
• 26:46
  in
• 26:46
  particular
• 26:47
  can
• 26:47
  be
• 26:48
  helpful
• 26:48
  to
• 26:48
  you.
• 26:48
  To
• 26:49
  them.
• 26:49
  That
• 26:50
  isn't
• 26:50
  even
• 26:51
  really
• 26:51
  something
• 26:51
  you
• 26:52
  read
• 26:52
  about
• 26:52
  with
• 26:52
  trazodone
• 26:53
  or
• 26:53
  talk
• 26:53
  about
• 26:53
  with
• 26:53
  Trazodone.
• 26:54
  And
• 26:54
  yet
• 26:54
  it
• 26:54
  can
• 26:54
  be
• 26:55
  such
• 26:55
  a
• 26:55
  game
• 26:55
  changer
• 26:56
  to
• 26:56
  preserve
• 26:57
  that
• 26:57
  slow
• 26:58
  wave
• 26:58
  sleep,
• 26:58
  to
• 26:59
  preserve
• 26:59
  their
• 26:59
  REM
• 27:00
  cycles
• 27:00
  as
• 27:00
  they're
• 27:01
  emotionally
• 27:01
  processing
• 27:02
  to
• 27:02
  make
• 27:02
  the
• 27:03
  quality
• 27:03
  of
• 27:03
  their
• 27:03
  sleep
• 27:04
  better
• 27:04
  and
• 27:04
  maybe
• 27:05
  reduce
• 27:06
  depression
• 27:06
  or
• 27:06
  anxiety
• 27:07
  that
• 27:07
  way.
• 27:07
  To
• 27:07
  spare
• 27:08
  them
• 27:08
  from
• 27:08
  the
• 27:08
  worst
• 27:08
  side
• 27:09
  effects
• 27:09
  of
• 27:09
  the
• 27:10
  SSRIs
• 27:10
  that
• 27:10
  activate
• 27:11
  all
• 27:11
  the
• 27:11
  receptors,
• 27:12
  including
• 27:12
  the
• 27:12
  ones
• 27:12
  that
• 27:13
  make
• 27:13
  you
• 27:13
  anxious
• 27:13
  and
• 27:13
  give
• 27:13
  you
• 27:14
  sexual
• 27:14
  side
• 27:14
  effects.
• 27:15
  Right.
• 27:15
  You
• 27:15
  know
• 27:16
  that
• 27:16
  5ht2a
• 27:17
  antagonism,
• 27:18
  it's
• 27:18
  such
• 27:18
  an
• 27:18
  important
• 27:19
  receptor
• 27:19
  to
• 27:19
  master.
• 27:20
  It's
• 27:21
  all
• 27:21
  the
• 27:21
  rage
• 27:21
  when
• 27:22
  we're
• 27:22
  talking
• 27:22
  about
• 27:22
  antipsychotics
• 27:23
  and
• 27:23
  how
• 27:23
  they
• 27:23
  augment
• 27:24
  major
• 27:25
  depression.
• 27:25
  Quetiapine,
• 27:26
  aripiprazole,
• 27:27
  olanzapine.
• 27:28
  Right.
• 27:28
  They're
• 27:28
  potent.
• 27:29
  5Ht
• 27:29
  2a
• 27:29
  antagonist
• 27:30
  and
• 27:31
  we
• 27:31
  go
• 27:31
  over
• 27:31
  that
• 27:31
  in
• 27:32
  our
• 27:32
  slides.
• 27:33
  And
• 27:33
  it's
• 27:34
  also
• 27:34
  something
• 27:34
  that
• 27:34
  Trazona
• 27:35
  Remeron
• 27:36
  do.
• 27:36
  So
• 27:36
  having
• 27:36
  a
• 27:36
  familiar,
• 27:37
  familiar,
• 27:37
  blah,
• 27:38
  blah,
• 27:38
  blah.
• 27:38
  I
• 27:38
  can't
• 27:38
  talk
• 27:39
  today.
• 27:39
  Familiarity
• 27:40
  with
• 27:41
  those
• 27:41
  medications
• 27:42
  that
• 27:42
  affect
• 27:43
  those
• 27:43
  receptors
• 27:44
  are
• 27:45
  just
• 27:45
  so
• 27:45
  key
• 27:45
  because
• 27:46
  you
• 27:46
  really
• 27:46
  get
• 27:46
  a
• 27:46
  HD
• 27:47
  view
• 27:48
  of
• 27:48
  what
• 27:48
  you're
• 27:48
  doing
• 27:49
  for
• 27:49
  your
• 27:49
  patient.
• 27:49
  You're
• 27:50
  not
• 27:50
  just
• 27:50
  handing
• 27:50
  them
• 27:50
  a
• 27:50
  pill
• 27:51
  and
• 27:51
  saying,
• 27:51
  I
• 27:51
  hope
• 27:51
  your
• 27:52
  sleep
• 27:52
  improves.
• 27:53
  You
• 27:53
  are
• 27:53
  having
• 27:53
  this
• 27:54
  nuanced
• 27:55
  understanding
• 27:56
  of
• 27:56
  exactly
• 27:56
  what
• 27:56
  you're
• 27:57
  doing
• 27:57
  and
• 27:57
  why.
• 27:58
  And
• 27:59
  nitty
• 27:59
  gritty,
• 28:00
  right?
• 28:00
  The
• 28:00
  nitty
• 28:01
  gritty
• 28:01
  of,
• 28:01
  oh,
• 28:02
  there's
• 28:02
  Alpha
• 28:02
  1
• 28:02
  blockade
• 28:03
  in
• 28:03
  this
• 28:03
  Trazodone
• 28:04
  that
• 28:04
  is
• 28:04
  particularly
• 28:05
  good
• 28:05
  for
• 28:05
  someone
• 28:06
  who
• 28:06
  may
• 28:06
  be
• 28:06
  dealing
• 28:07
  with
• 28:07
  trauma.
• 28:07
  Oh,
• 28:08
  well,
• 28:08
  maybe
• 28:08
  we
• 28:09
  should
• 28:09
  go
• 28:09
  to
• 28:09
  Prazosin,
• 28:10
  though,
• 28:10
  because
• 28:10
  it
• 28:10
  has
• 28:10
  much
• 28:10
  more
• 28:11
  potent
• 28:11
  Alpha
• 28:11
  1
• 28:12
  blockade.
• 28:12
  Much
• 28:13
  higher
• 28:13
  affinity
• 28:14
  for
• 28:14
  Alpha
• 28:14
  1
• 28:15
  than
• 28:15
  Trazodone.
• 28:16
  Well,
• 28:16
  hey,
• 28:16
  that
• 28:17
  might
• 28:17
  be
• 28:17
  even
• 28:17
  better
• 28:17
  because
• 28:18
  the
• 28:18
  patient's
• 28:18
  core
• 28:19
  problem
• 28:19
  is
• 28:19
  hyper
• 28:20
  arousal
• 28:20
  today
• 28:21
  and
• 28:21
  nightmares.
• 28:22
  Right.
• 28:22
  So
• 28:23
  because
• 28:23
  you
• 28:23
  have
• 28:23
  an
• 28:23
  appreciation
• 28:24
  for
• 28:24
  the
• 28:24
  affinity
• 28:25
  and
• 28:25
  how
• 28:26
  powerful
• 28:26
  the
• 28:26
  affinity
• 28:27
  is
• 28:27
  for
• 28:28
  various
• 28:28
  drugs,
• 28:29
  you
• 28:29
  are
• 28:29
  empowered
• 28:30
  as
• 28:30
  a
• 28:30
  prescriber
• 28:31
  to
• 28:31
  do
• 28:31
  the
• 28:32
  right
• 28:32
  thing
• 28:32
  for
• 28:32
  the
• 28:32
  right
• 28:32
  patient
• 28:33
  in
• 28:33
  the
• 28:33
  right
• 28:33
  moment
• 28:34
  at
• 28:34
  the
• 28:34
  right
• 28:34
  time.
• 28:35
  Don't
• 28:35
  forget,
• 28:36
  there's
• 28:36
  one
• 28:37
  thing
• 28:37
  that
• 28:38
  you
• 28:38
  do
• 28:38
  tonight
• 28:39
  before
• 28:39
  you
• 28:39
  go
• 28:40
  to
• 28:40
  bed,
• 28:41
  if
• 28:41
  there's
• 28:42
  one
• 28:42
  thing
• 28:42
  you
• 28:42
  can
• 28:42
  do
• 28:42
  to
• 28:43
  make
• 28:43
  your
• 28:43
  studies
• 28:44
  so
• 28:44
  much
• 28:44
  more
• 28:45
  tolerable
• 28:45
  and
• 28:45
  easy.
• 28:46
  And
• 28:46
  it'll
• 28:47
  all
• 28:47
  just
• 28:47
  click.
• 28:48
  And
• 28:48
  you'll
• 28:48
  feel
• 28:49
  so
• 28:49
  empowered
• 28:49
  and
• 28:49
  excited
• 28:50
  to
• 28:50
  study.
• 28:50
  Become
• 28:51
  a
• 28:51
  Patreon
• 28:51
  member.
• 28:52
  Go
• 28:52
  to
• 28:52
  our
• 28:52
  show
• 28:52
  Notes.
• 28:53
  Click
• 28:53
  it,
• 28:53
  Join.
• 28:54
  You'll
• 28:54
  love
• 28:54
  it.
• 28:55
  We
• 28:55
  have
• 28:55
  everything
• 28:56
  from
• 28:57
  receptor
• 28:58
  breakdowns.
• 28:58
  It's
• 28:58
  a
• 28:59
  full
• 28:59
  clinical
• 28:59
  library.
• 29:00
  There's
• 29:00
  rap
• 29:00
  music
• 29:01
  that
• 29:01
  helps
• 29:01
  you
• 29:02
  remember
• 29:02
  these
• 29:02
  receptors
• 29:03
  better.
• 29:03
  And
• 29:04
  it's
• 29:04
  just
• 29:04
  got
• 29:05
  everything.
• 29:05
  And
• 29:05
  it's
• 29:05
  beautiful
• 29:06
  and
• 29:06
  people
• 29:06
  love
• 29:06
  it.
• 29:06
  The
• 29:07
  feedback
• 29:07
  is
• 29:07
  great.
• 29:07
  I
• 29:08
  don't
• 29:08
  know
• 29:08
  what
• 29:08
  I
• 29:08
  would
• 29:08
  have
• 29:09
  done
• 29:09
  without
• 29:09
  this
• 29:10
  library
• 29:11
  to
• 29:11
  stay
• 29:12
  up
• 29:12
  on
• 29:12
  the
• 29:12
  literature.
• 29:12
  It's
• 29:13
  so
• 29:13
  important.
• 29:13
  So
• 29:13
  join
• 29:14
  it,
• 29:14
  click
• 29:14
  it,
• 29:14
  spread
• 29:15
  it.
• 29:15
  Have
• 29:15
  a
• 29:16
  good
• 29:16
  one.
• 29:16
  Bye.
• 29:16
  Bye.