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The Most Dangerous Window in Psychiatry. Can you guess what it is? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:05
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  Prep.
• 0:08
  It's
• 0:08
  NPZ
• 0:09
  here,
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:11
  your
• 0:11
  pocket,
• 0:12
  the
• 0:12
  go
• 0:12
  to
• 0:13
  place
• 0:13
  for
• 0:14
  pearls
• 0:14
  that
• 0:14
  prep
• 0:15
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  Now
• 0:16
  this
• 0:16
  is
• 0:16
  kind
• 0:17
  of
• 0:17
  a
• 0:17
  bonus
• 0:17
  episode.
• 0:18
  I
• 0:18
  have
• 0:18
  a
• 0:19
  really
• 0:19
  juicy
• 0:20
  multiple
• 0:20
  choice
• 0:20
  question
• 0:21
  that
• 0:22
  is
• 0:22
  not
• 0:22
  very
• 0:22
  easy
• 0:23
  actually.
• 0:24
  It's
• 0:24
  going
• 0:24
  to
• 0:24
  really
• 0:24
  challenge
• 0:25
  you.
• 0:26
  It
• 0:26
  really
• 0:26
  challenged
• 0:27
  me.
• 0:27
  And
• 0:28
  I'll
• 0:28
  be
• 0:28
  honest,
• 0:28
  the.
• 0:29
  The
• 0:29
  answer
• 0:30
  to
• 0:30
  this,
• 0:30
  to
• 0:31
  me
• 0:31
  was
• 0:31
  pretty
• 0:31
  mind
• 0:32
  blowing.
• 0:32
  The
• 0:32
  statistics
• 0:33
  involved
• 0:34
  in
• 0:34
  this
• 0:34
  were
• 0:35
  pretty
• 0:35
  mind
• 0:35
  blowing.
• 0:36
  And
• 0:36
  I
• 0:36
  think
• 0:36
  it's
• 0:37
  going
• 0:37
  to
• 0:37
  make
• 0:37
  for
• 0:37
  a
• 0:37
  brief
• 0:38
  good
• 0:38
  conversation
• 0:39
  between
• 0:39
  us
• 0:39
  today.
• 0:40
  I'm
• 0:40
  really
• 0:40
  excited
• 0:40
  for
• 0:41
  it,
• 0:41
  actually.
• 0:42
  To
• 0:42
  find
• 0:43
  the
• 0:43
  pearls
• 0:44
  on
• 0:44
  the
• 0:44
  ocean
• 0:44
  floor.
• 0:45
  Hence
• 0:45
  why
• 0:45
  it's
• 0:45
  called
• 0:46
  Pearls
• 0:46
  and
• 0:46
  Prep.
• 0:46
  Right?
• 0:47
  Find
• 0:47
  the
• 0:48
  pearls
• 0:48
  on
• 0:48
  the
• 0:48
  ocean
• 0:49
  floor
• 0:49
  in
• 0:49
  the
• 0:49
  deep
• 0:49
  ocean
• 0:50
  of
• 0:50
  knowledge.
• 0:51
  God,
• 0:51
  there's
• 0:51
  so
• 0:52
  much
• 0:52
  knowledge
• 0:52
  nowadays,
• 0:53
  right?
• 0:53
  There's
• 0:54
  so
• 0:54
  much
• 0:54
  experience
• 0:54
  nowadays.
• 0:55
  But
• 0:56
  how
• 0:56
  do
• 0:56
  we
• 0:56
  find
• 0:56
  those
• 0:57
  shiny
• 0:57
  pearls,
• 0:58
  the
• 0:58
  ones
• 0:59
  that
• 0:59
  matter
• 0:59
  the
• 1:00
  most,
• 1:00
  that
• 1:00
  can
• 1:01
  fundamentally
• 1:01
  change
• 1:02
  the
• 1:02
  way
• 1:02
  we
• 1:03
  practice
• 1:03
  psychiatry,
• 1:05
  fundamentally
• 1:05
  change
• 1:06
  the
• 1:06
  way
• 1:06
  we
• 1:06
  approach
• 1:06
  our
• 1:07
  patients?
• 1:07
  That's
• 1:08
  really
• 1:08
  the
• 1:08
  point
• 1:08
  here
• 1:09
  of
• 1:09
  this
• 1:09
  entire
• 1:09
  podcast,
• 1:10
  is
• 1:10
  to
• 1:11
  find
• 1:11
  those
• 1:12
  shiny
• 1:12
  pearls
• 1:13
  and
• 1:14
  go
• 1:14
  from
• 1:14
  there
• 1:15
  to
• 1:15
  separate
• 1:16
  the
• 1:16
  noise
• 1:17
  and
• 1:17
  the
• 1:17
  signal
• 1:19
  and.
• 1:19
  And
• 1:19
  just
• 1:20
  figure
• 1:20
  out
• 1:21
  what
• 1:21
  is
• 1:21
  really
• 1:22
  important
• 1:22
  to
• 1:23
  look
• 1:23
  at
• 1:23
  here.
• 1:23
  And
• 1:23
  I
• 1:23
  think
• 1:24
  this
• 1:24
  little
• 1:24
  multiple
• 1:25
  choice
• 1:25
  question
• 1:25
  today
• 1:26
  is
• 1:27
  key,
• 1:27
  and
• 1:27
  I'm
• 1:28
  very
• 1:28
  interested
• 1:28
  to
• 1:28
  see
• 1:29
  if
• 1:29
  you
• 1:29
  all
• 1:30
  will
• 1:30
  get
• 1:30
  it
• 1:30
  right.
• 1:30
  Which
• 1:31
  of
• 1:31
  the
• 1:31
  following
• 1:31
  periods
• 1:32
  represents
• 1:33
  the
• 1:33
  highest
• 1:33
  suicide
• 1:34
  risk
• 1:34
  in
• 1:35
  all
• 1:35
  of
• 1:35
  psychiatry?
• 1:37
  Is
• 1:37
  it
• 1:37
  A,
• 1:38
  the
• 1:38
  first
• 1:38
  year
• 1:39
  postpartum
• 1:40
  in
• 1:40
  women
• 1:40
  with
• 1:41
  perinatal
• 1:41
  depression?
• 1:42
  Is
• 1:42
  it
• 1:42
  B,
• 1:43
  the
• 1:43
  first
• 1:43
  week
• 1:44
  after
• 1:44
  psychiatric
• 1:45
  hospital
• 1:45
  discharge?
• 1:46
  Is
• 1:46
  it
• 1:47
  C,
• 1:47
  period
• 1:48
  of
• 1:48
  antidepressant
• 1:49
  discontinuation
• 1:50
  or
• 1:50
  medication
• 1:51
  changes?
• 1:52
  Or
• 1:52
  is
• 1:52
  it
• 1:52
  D,
• 1:53
  the
• 1:53
  schizophrenia
• 1:54
  prodrome?
• 1:55
  Okay,
• 1:55
  if
• 1:55
  you
• 1:56
  want,
• 1:56
  you
• 1:56
  can
• 1:56
  pause
• 1:56
  this
• 1:57
  audio
• 1:58
  a
• 1:58
  little
• 1:58
  bit.
• 1:58
  You
• 1:59
  guys
• 1:59
  can
• 1:59
  discuss
• 1:59
  it
• 2:00
  with
• 2:00
  your
• 2:00
  peers,
• 2:01
  whether
• 2:01
  it's
• 2:02
  in
• 2:02
  grand
• 2:02
  rounds,
• 2:03
  whether
• 2:03
  you're
• 2:03
  in
• 2:03
  school,
• 2:04
  if
• 2:04
  you're
• 2:05
  alone,
• 2:05
  just
• 2:06
  hit
• 2:06
  the
• 2:06
  pause
• 2:06
  button.
• 2:07
  Just
• 2:08
  give
• 2:08
  it
• 2:08
  some
• 2:08
  thought,
• 2:09
  think
• 2:09
  critically
• 2:10
  and
• 2:11
  come
• 2:11
  back
• 2:11
  to
• 2:11
  this.
• 2:12
  All
• 2:12
  right,
• 2:13
  we're
• 2:13
  about
• 2:13
  to
• 2:13
  give
• 2:13
  you
• 2:13
  the
• 2:14
  answer
• 2:14
  here,
• 2:14
  my
• 2:14
  friends.
• 2:15
  I
• 2:15
  guess
• 2:16
  before
• 2:16
  we
• 2:16
  do,
• 2:16
  we
• 2:17
  should
• 2:17
  just
• 2:17
  say
• 2:17
  that
• 2:18
  all
• 2:18
  of
• 2:18
  these
• 2:18
  are
• 2:19
  pretty
• 2:20
  risky
• 2:21
  windows
• 2:22
  in
• 2:22
  clinic
• 2:22
  in
• 2:23
  psychiatry,
• 2:23
  right?
• 2:24
  Particularly
• 2:24
  the
• 2:25
  first
• 2:25
  year
• 2:25
  postpartum
• 2:26
  with
• 2:26
  women.
• 2:27
  Women
• 2:27
  are
• 2:28
  much
• 2:28
  more
• 2:28
  likely
• 2:28
  to
• 2:29
  be
• 2:29
  psychiatrically
• 2:30
  hospitalized
• 2:30
  in
• 2:30
  the
• 2:31
  postpartum
• 2:32
  or
• 2:32
  peripartum
• 2:33
  phase
• 2:34
  of
• 2:35
  their
• 2:35
  lives,
• 2:35
  irregardless
• 2:36
  of
• 2:36
  a
• 2:37
  past
• 2:37
  mental
• 2:37
  health
• 2:37
  history.
• 2:38
  It
• 2:38
  is
• 2:38
  an
• 2:38
  extremely
• 2:39
  vulnerable
• 2:39
  time
• 2:40
  for
• 2:40
  women
• 2:41
  in
• 2:41
  the
• 2:41
  postpartum
• 2:42
  window.
• 2:42
  Of
• 2:42
  course,
• 2:42
  anytime
• 2:43
  you
• 2:43
  do
• 2:43
  any
• 2:43
  kind
• 2:43
  of
• 2:44
  antidepressant
• 2:44
  discontinuation
• 2:45
  or
• 2:45
  medication
• 2:46
  changes,
• 2:46
  you
• 2:47
  can
• 2:47
  see
• 2:47
  manic
• 2:47
  induction,
• 2:48
  you
• 2:48
  can
• 2:48
  see
• 2:49
  antidepressant
• 2:50
  withdrawal
• 2:51
  makes
• 2:51
  people
• 2:51
  very
• 2:52
  irritable,
• 2:52
  very
• 2:53
  anxious,
• 2:53
  sometimes
• 2:53
  very
• 2:54
  hopeless,
• 2:54
  very
• 2:55
  out
• 2:55
  of
• 2:55
  sorts.
• 2:56
  That's
• 2:56
  a
• 2:56
  very
• 2:56
  destabilizing
• 2:57
  time
• 2:57
  for
• 2:57
  some
• 2:58
  as
• 2:58
  well.
• 2:59
  Schizophrenia
• 3:00
  prodrome,
• 3:00
  we
• 3:01
  know
• 3:01
  with
• 3:01
  schizophrenia,
• 3:02
  period.
• 3:02
  I
• 3:02
  remember
• 3:03
  learning
• 3:03
  in
• 3:03
  nursing
• 3:04
  school,
• 3:05
  not
• 3:05
  even
• 3:05
  NP
• 3:06
  school,
• 3:06
  but
• 3:06
  in
• 3:06
  nursing
• 3:07
  school,
• 3:08
  that
• 3:08
  10%
• 3:09
  of
• 3:09
  people
• 3:10
  diagnosed
• 3:10
  with
• 3:11
  schizophrenia
• 3:11
  ultimately
• 3:12
  kill
• 3:12
  themselves
• 3:12
  one
• 3:13
  day,
• 3:13
  which
• 3:13
  I
• 3:13
  remember
• 3:14
  as
• 3:14
  a
• 3:14
  student
• 3:14
  was
• 3:14
  completely
• 3:15
  shocking.
• 3:16
  I
• 3:16
  know
• 3:16
  the
• 3:16
  evidence
• 3:17
  today
• 3:17
  kind
• 3:18
  of
• 3:18
  dances
• 3:18
  around
• 3:18
  6
• 3:19
  to
• 3:19
  10%.
• 3:20
  The
• 3:20
  life
• 3:20
  side
• 3:21
  lifetime
• 3:21
  suicidal
• 3:22
  ideations
• 3:22
  around
• 3:23
  58%.
• 3:24
  With
• 3:24
  schizophrenia,
• 3:25
  attempts
• 3:26
  are
• 3:26
  at
• 3:26
  25%.
• 3:28
  And
• 3:29
  so,
• 3:30
  you
• 3:30
  know,
• 3:30
  I
• 3:30
  mean,
• 3:30
  it's,
• 3:31
  it's
• 3:31
  shocking,
• 3:31
  right?
• 3:31
  These
• 3:31
  are
• 3:32
  very
• 3:32
  vulnerable
• 3:33
  windows.
• 3:33
  These
• 3:34
  are
• 3:34
  very
• 3:34
  critical
• 3:35
  illnesses
• 3:36
  and
• 3:36
  things
• 3:36
  of
• 3:37
  that
• 3:37
  nature.
• 3:38
  But
• 3:38
  my
• 3:38
  friends,
• 3:39
  the
• 3:40
  most
• 3:40
  critical
• 3:41
  time
• 3:42
  by
• 3:42
  far
• 3:43
  in
• 3:43
  all
• 3:43
  of
• 3:43
  psychiatry.
• 3:44
  Drumroll.
• 3:45
  Is
• 3:46
  the
• 3:46
  first
• 3:47
  week
• 3:47
  after
• 3:48
  hospital
• 3:48
  discharge.
• 3:49
  In
• 3:50
  the
• 3:50
  first
• 3:50
  three
• 3:50
  months
• 3:51
  after
• 3:51
  psychiatric
• 3:52
  discharge,
• 3:52
  patients
• 3:53
  die
• 3:53
  by
• 3:53
  suicide
• 3:54
  at
• 3:54
  a
• 3:54
  rate
• 3:54
  100
• 3:55
  times
• 3:55
  higher
• 3:56
  than
• 3:56
  the
• 3:57
  general
• 3:57
  population.
• 3:58
  Now
• 3:58
  this,
• 3:59
  this
• 3:59
  kind
• 3:59
  of
• 3:59
  makes
• 4:00
  us
• 4:00
  all
• 4:00
  go
• 4:00
  a
• 4:00
  little
• 4:00
  bit
• 4:01
  crazy
• 4:01
  because
• 4:02
  you
• 4:02
  look
• 4:03
  at
• 4:03
  inpatient
• 4:04
  hospitalization
• 4:04
  and
• 4:05
  in
• 4:05
  our
• 4:05
  minds
• 4:06
  it's
• 4:06
  like
• 4:06
  the
• 4:06
  gold
• 4:06
  standard
• 4:07
  of
• 4:07
  safety,
• 4:07
  right?
• 4:08
  You're
• 4:08
  in
• 4:08
  24
• 4:08
  hour
• 4:09
  lockdown,
• 4:09
  eyes
• 4:10
  are
• 4:10
  all
• 4:10
  over
• 4:10
  you.
• 4:11
  There's
• 4:11
  structure,
• 4:12
  there's
• 4:12
  teams
• 4:13
  of
• 4:13
  people
• 4:13
  collaborating
• 4:14
  compassionately
• 4:15
  to
• 4:16
  get
• 4:16
  your
• 4:16
  medications,
• 4:16
  right?
• 4:17
  To
• 4:17
  figure
• 4:17
  this
• 4:17
  out
• 4:18
  diagnostically,
• 4:18
  to
• 4:19
  kind
• 4:19
  of
• 4:19
  help
• 4:19
  peel
• 4:19
  you
• 4:19
  off
• 4:20
  the
• 4:20
  wall
• 4:20
  and
• 4:21
  get
• 4:21
  your
• 4:21
  resources.
• 4:22
  And
• 4:22
  so
• 4:22
  it's
• 4:22
  really
• 4:23
  discouraging
• 4:24
  to
• 4:24
  think
• 4:25
  that
• 4:25
  the
• 4:26
  three
• 4:26
  months
• 4:26
  after
• 4:27
  psychiatric
• 4:28
  discharge,
• 4:28
  the
• 4:29
  suicide
• 4:29
  rate
• 4:29
  is
• 4:29
  100
• 4:30
  times
• 4:31
  higher
• 4:31
  than
• 4:31
  the
• 4:31
  general
• 4:31
  population.
• 4:32
  At
• 4:32
  the
• 4:33
  same
• 4:33
  time,
• 4:33
  it
• 4:33
  does
• 4:33
  make
• 4:34
  a
• 4:34
  little
• 4:34
  bit
• 4:34
  of
• 4:34
  sense
• 4:35
  because
• 4:36
  folks
• 4:36
  who
• 4:36
  are
• 4:36
  just
• 4:37
  hospitalized
• 4:37
  psychiatrically
• 4:38
  were
• 4:39
  the
• 4:39
  most
• 4:39
  recently
• 4:40
  acute,
• 4:41
  right?
• 4:41
  I
• 4:41
  mean,
• 4:41
  they
• 4:41
  are
• 4:42
  the
• 4:42
  most
• 4:42
  acute
• 4:43
  of
• 4:43
  the
• 4:43
  entire
• 4:44
  general
• 4:44
  population,
• 4:45
  at
• 4:45
  least
• 4:46
  in
• 4:46
  a
• 4:46
  recent
• 4:47
  sense.
• 4:47
  Yes,
• 4:48
  they're
• 4:48
  being
• 4:48
  discharged,
• 4:49
  but
• 4:49
  that
• 4:49
  does
• 4:49
  not
• 4:49
  necessarily
• 4:50
  mean,
• 4:50
  hey,
• 4:50
  we
• 4:51
  admitted
• 4:51
  you,
• 4:51
  we
• 4:51
  cured
• 4:52
  you,
• 4:52
  you're
• 4:52
  perfect,
• 4:53
  you're
• 4:53
  back
• 4:53
  to
• 4:53
  baseline.
• 4:54
  You're
• 4:54
  just
• 4:55
  like
• 4:55
  the
• 4:55
  general
• 4:55
  population.
• 4:56
  So,
• 4:56
  of
• 4:56
  course,
• 4:56
  it
• 4:57
  does
• 4:57
  make
• 4:57
  some
• 4:58
  sense
• 4:58
  that
• 4:59
  this
• 4:59
  population
• 4:59
  would
• 5:00
  be
• 5:00
  very
• 5:00
  high
• 5:00
  risk.
• 5:01
  And
• 5:01
  sure
• 5:01
  enough,
• 5:01
  the
• 5:02
  folks
• 5:02
  I've
• 5:02
  sent
• 5:03
  inpatient
• 5:03
  over
• 5:03
  the
• 5:04
  years,
• 5:05
  you
• 5:05
  send
• 5:05
  them
• 5:05
  there
• 5:05
  for
• 5:06
  a
• 5:06
  reason,
• 5:06
  right?
• 5:06
  Maybe
• 5:06
  they
• 5:07
  just
• 5:07
  had
• 5:07
  an
• 5:07
  attempt
• 5:07
  or.
• 5:08
  We
• 5:08
  already
• 5:08
  know
• 5:09
  that
• 5:09
  having
• 5:09
  a
• 5:09
  suicide
• 5:10
  attempt
• 5:10
  is
• 5:10
  the
• 5:11
  single
• 5:11
  greatest
• 5:11
  risk
• 5:12
  factor
• 5:12
  to
• 5:13
  eventually
• 5:13
  die
• 5:13
  by
• 5:14
  suicide
• 5:14
  or
• 5:15
  experience
• 5:15
  a
• 5:16
  subsequent
• 5:17
  attempt,
• 5:17
  right?
• 5:18
  It's
• 5:18
  a
• 5:18
  massive
• 5:19
  underlying
• 5:20
  risk
• 5:20
  factor.
• 5:21
  But
• 5:21
  again,
• 5:21
  a
• 5:21
  lot
• 5:22
  of
• 5:22
  folks
• 5:22
  who
• 5:22
  are
• 5:22
  hospitalized,
• 5:23
  they're
• 5:24
  there
• 5:24
  for
• 5:24
  a
• 5:24
  reason,
• 5:25
  right?
• 5:25
  They
• 5:25
  were
• 5:25
  psychotic.
• 5:26
  They.
• 5:27
  Something
• 5:27
  broke
• 5:28
  down
• 5:28
  in
• 5:28
  their
• 5:29
  lives
• 5:29
  that
• 5:29
  precipitated
• 5:30
  the
• 5:30
  admission.
• 5:31
  Maybe
• 5:31
  they
• 5:31
  don't
• 5:31
  have
• 5:32
  secure
• 5:32
  housing
• 5:33
  or
• 5:33
  social
• 5:33
  relationships
• 5:35
  or
• 5:35
  they
• 5:35
  just
• 5:35
  lost
• 5:35
  their
• 5:36
  job.
• 5:36
  There
• 5:36
  was
• 5:36
  a
• 5:36
  Divorce.
• 5:37
  And
• 5:38
  so
• 5:38
  a
• 5:38
  lot
• 5:38
  of
• 5:39
  life
• 5:39
  problems
• 5:39
  that
• 5:40
  are
• 5:40
  quite
• 5:40
  frankly
• 5:40
  beyond
• 5:41
  a
• 5:41
  lot
• 5:41
  of
• 5:41
  our
• 5:41
  control,
• 5:42
  as
• 5:42
  helpless
• 5:42
  as
• 5:43
  that
• 5:43
  makes
• 5:43
  us
• 5:43
  feel.
• 5:44
  And
• 5:45
  of
• 5:45
  course
• 5:46
  it's
• 5:46
  not
• 5:46
  news
• 5:47
  to
• 5:47
  anyone,
• 5:47
  it's
• 5:48
  not
• 5:48
  lost
• 5:48
  on
• 5:48
  any
• 5:48
  of
• 5:49
  us
• 5:49
  that
• 5:49
  when
• 5:49
  they're
• 5:49
  discharged,
• 5:50
  those
• 5:51
  problems
• 5:51
  don't
• 5:51
  just
• 5:51
  magically
• 5:52
  go
• 5:52
  away.
• 5:53
  Right?
• 5:53
  You've
• 5:53
  heard
• 5:54
  the
• 5:54
  horror
• 5:54
  stories
• 5:54
  of
• 5:55
  people
• 5:55
  discharging
• 5:56
  in
• 5:56
  an
• 5:56
  Uber
• 5:56
  in
• 5:57
  a
• 5:57
  parking
• 5:57
  lot
• 5:57
  and
• 5:58
  they're
• 5:58
  homeless
• 5:59
  and
• 5:59
  they
• 5:59
  don't
• 5:59
  really
• 6:00
  even
• 6:00
  have
• 6:00
  the
• 6:00
  means
• 6:01
  to
• 6:02
  afford
• 6:02
  a
• 6:03
  copay.
• 6:03
  And
• 6:03
  so
• 6:04
  they
• 6:04
  do
• 6:04
  they
• 6:04
  really
• 6:04
  pick
• 6:05
  up
• 6:05
  their
• 6:05
  medications
• 6:06
  afterwards?
• 6:06
  Do
• 6:07
  they
• 6:07
  really
• 6:07
  attend
• 6:07
  follow
• 6:07
  up
• 6:08
  appointments
• 6:08
  with
• 6:09
  a
• 6:09
  therapist
• 6:09
  or
• 6:09
  go
• 6:10
  to
• 6:10
  IOP
• 6:10
  or
• 6:10
  php?
• 6:11
  What
• 6:12
  does
• 6:12
  their
• 6:12
  insurance
• 6:12
  even
• 6:12
  cover?
• 6:13
  Do
• 6:13
  their
• 6:13
  insurance
• 6:14
  kick
• 6:15
  them
• 6:15
  out
• 6:15
  of
• 6:15
  the
• 6:15
  hospital
• 6:15
  faster
• 6:16
  because
• 6:16
  they
• 6:17
  wouldn't
• 6:17
  cover
• 6:17
  an
• 6:17
  additional
• 6:18
  bed
• 6:18
  day?
• 6:19
  There's
• 6:19
  all
• 6:19
  kinds
• 6:20
  of
• 6:20
  socio,
• 6:21
  demographic,
• 6:21
  socioeconomic
• 6:22
  factors
• 6:23
  that
• 6:24
  make
• 6:24
  this
• 6:24
  an
• 6:24
  even
• 6:25
  more
• 6:26
  dangerous
• 6:26
  time.
• 6:27
  Right
• 6:27
  after
• 6:28
  discharge,
• 6:28
  right?
• 6:28
  Patients
• 6:29
  are
• 6:29
  often
• 6:29
  still
• 6:29
  adjusting
• 6:30
  to
• 6:30
  their
• 6:30
  medications.
• 6:31
  Some
• 6:32
  of
• 6:32
  them
• 6:32
  may
• 6:32
  get
• 6:32
  a
• 6:32
  second
• 6:33
  wind
• 6:33
  of
• 6:33
  energy
• 6:33
  before
• 6:34
  their
• 6:35
  depression
• 6:35
  can
• 6:35
  really
• 6:36
  be
• 6:36
  treated.
• 6:36
  And
• 6:36
  so
• 6:37
  maybe,
• 6:37
  maybe
• 6:37
  they
• 6:37
  have
• 6:37
  the
• 6:38
  energy
• 6:38
  to
• 6:38
  end
• 6:38
  their
• 6:38
  lives,
• 6:39
  but
• 6:39
  their
• 6:39
  mood
• 6:39
  hasn't.
• 6:40
  And
• 6:40
  again,
• 6:40
  unfortunately,
• 6:41
  we
• 6:41
  live
• 6:42
  in
• 6:42
  a
• 6:42
  system
• 6:43
  that
• 6:43
  is
• 6:43
  not
• 6:44
  always
• 6:44
  equal
• 6:44
  and
• 6:45
  not
• 6:45
  always
• 6:45
  fair,
• 6:46
  right?
• 6:46
  We
• 6:46
  don't
• 6:47
  always
• 6:47
  have
• 6:47
  the
• 6:48
  time,
• 6:48
  money
• 6:48
  and
• 6:48
  resources
• 6:49
  and
• 6:49
  clinical
• 6:50
  personnel
• 6:50
  to
• 6:51
  just
• 6:51
  keep
• 6:51
  someone
• 6:52
  in
• 6:52
  hospital
• 6:53
  for
• 6:53
  a
• 6:53
  long
• 6:53
  enough
• 6:53
  time
• 6:54
  where
• 6:54
  they
• 6:54
  can
• 6:54
  be
• 6:55
  completely
• 6:55
  stabilized
• 6:56
  and
• 6:57
  ready
• 6:57
  to
• 6:57
  go
• 6:57
  with
• 6:58
  perfect
• 6:58
  follow
• 6:59
  up
• 6:59
  care.
• 7:00
  So
• 7:00
  things
• 7:00
  get
• 7:00
  missed
• 7:01
  and
• 7:01
  people
• 7:02
  go
• 7:02
  home
• 7:02
  who
• 7:02
  shouldn't
• 7:03
  go
• 7:03
  home.
• 7:04
  And
• 7:05
  maybe
• 7:05
  they
• 7:05
  were
• 7:06
  put
• 7:06
  on
• 7:06
  meds
• 7:06
  that
• 7:06
  were
• 7:07
  not
• 7:07
  appropriate
• 7:08
  diagnostically.
• 7:09
  They
• 7:09
  might
• 7:09
  even
• 7:09
  be
• 7:10
  inducing
• 7:11
  significant
• 7:11
  problems.
• 7:12
  Think
• 7:12
  about
• 7:12
  lithium,
• 7:13
  think
• 7:13
  about
• 7:13
  Depakote,
• 7:14
  think
• 7:14
  about
• 7:15
  antipsychotics
• 7:16
  and
• 7:16
  dystonias
• 7:17
  and
• 7:17
  all
• 7:17
  the
• 7:17
  things
• 7:17
  that
• 7:18
  can
• 7:18
  go
• 7:18
  wrong.
• 7:18
  Think
• 7:18
  about
• 7:19
  akaesthesia,
• 7:19
  right?
• 7:20
  You,
• 7:20
  you
• 7:20
  put
• 7:21
  someone
• 7:21
  on
• 7:21
  a
• 7:21
  second
• 7:21
  generation
• 7:22
  antipsychotic
• 7:23
  or
• 7:23
  first
• 7:23
  generation
• 7:23
  antipsychotic
• 7:24
  and
• 7:25
  they
• 7:25
  have
• 7:25
  akasthesia,
• 7:26
  they're
• 7:26
  restless,
• 7:26
  they
• 7:26
  feel
• 7:27
  like
• 7:27
  jumping
• 7:27
  out
• 7:27
  of
• 7:27
  their
• 7:28
  skin
• 7:28
  and
• 7:28
  lo
• 7:28
  and
• 7:29
  behold,
• 7:29
  you
• 7:29
  discharge
• 7:30
  them
• 7:30
  with
• 7:30
  that.
• 7:31
  And
• 7:31
  three
• 7:31
  days
• 7:31
  after
• 7:32
  discharge
• 7:32
  we
• 7:32
  know
• 7:33
  that
• 7:33
  AKA
• 7:34
  in
• 7:34
  and
• 7:34
  of
• 7:34
  itself
• 7:35
  is
• 7:35
  a
• 7:35
  major
• 7:35
  risk
• 7:36
  factor
• 7:36
  to
• 7:36
  commit
• 7:36
  suicide.
• 7:37
  They
• 7:37
  don't
• 7:37
  know
• 7:38
  what
• 7:38
  it
• 7:38
  is.
• 7:39
  They
• 7:39
  maybe
• 7:39
  they
• 7:39
  don't
• 7:39
  have
• 7:39
  a
• 7:40
  follow
• 7:40
  up
• 7:40
  appointment
• 7:41
  yet
• 7:41
  scheduled
• 7:42
  or
• 7:42
  access
• 7:42
  to
• 7:42
  an
• 7:43
  immediate
• 7:43
  provider
• 7:44
  and
• 7:44
  they
• 7:44
  might
• 7:45
  really
• 7:45
  lose
• 7:45
  hope.
• 7:45
  It's
• 7:46
  like,
• 7:46
  hey,
• 7:46
  I
• 7:46
  just
• 7:46
  left
• 7:46
  the
• 7:47
  hospital,
• 7:47
  I'm
• 7:47
  supposed
• 7:48
  to
• 7:48
  be,
• 7:48
  you
• 7:48
  know,
• 7:48
  treated
• 7:49
  and
• 7:49
  better
• 7:49
  and
• 7:50
  here
• 7:50
  I
• 7:50
  am,
• 7:50
  AKA
• 7:51
  what
• 7:51
  is
• 7:51
  this?
• 8:46
  I
• 7:52
  want
• 8:46
  to
• 8:47
  jump
• 8:47
  out
• 8:47
  of
• 8:47
  my
• 8:47
  skin,
• 8:47
  I'm
• 8:48
  suicidal
• 8:48
  and
• 8:49
  bam.
• 8:49
  All
• 8:50
  of
• 8:50
  the
• 8:50
  sudden
• 8:50
  you
• 8:50
  have
• 8:51
  a
• 8:51
  recipe
• 8:52
  for
• 8:52
  disaster.
• 8:53
  So
• 8:54
  if,
• 8:54
  you
• 8:54
  know,
• 8:54
  take
• 8:54
  a
• 8:55
  few
• 8:55
  moments
• 8:55
  today
• 8:55
  when
• 8:56
  the
• 8:56
  dust
• 8:56
  settles
• 8:56
  and
• 8:57
  we'd
• 8:57
  all
• 8:57
  turn
• 8:57
  off
• 8:57
  our
• 8:58
  smartphones
• 8:58
  and
• 8:58
  we
• 8:58
  really
• 8:59
  think
• 8:59
  and
• 8:59
  meditate
• 9:00
  about
• 9:00
  what
• 9:00
  the
• 9:01
  inpatient
• 9:01
  space
• 9:02
  looks
• 9:02
  like.
• 9:02
  And
• 9:03
  it
• 9:03
  is
• 9:03
  deeply
• 9:03
  therapeutic.
• 9:04
  Thank
• 9:04
  God
• 9:04
  we
• 9:05
  have
• 9:05
  inpatient
• 9:06
  psychiatry
• 9:06
  to
• 9:07
  help
• 9:07
  stabilize
• 9:07
  folks.
• 9:08
  But
• 9:08
  also
• 9:08
  think
• 9:08
  about
• 9:08
  all
• 9:09
  of
• 9:09
  the
• 9:09
  precarious
• 9:11
  features
• 9:11
  of
• 9:11
  being
• 9:12
  in
• 9:12
  an
• 9:13
  inpatient
• 9:13
  environment
• 9:13
  and
• 9:14
  what
• 9:14
  could
• 9:14
  go
• 9:14
  wrong
• 9:15
  and
• 9:15
  just
• 9:15
  the
• 9:16
  reality
• 9:16
  of
• 9:16
  even
• 9:16
  if
• 9:16
  everything
• 9:17
  goes
• 9:17
  right,
• 9:18
  you
• 9:18
  know,
• 9:18
  what
• 9:18
  could
• 9:19
  go
• 9:19
  wrong
• 9:19
  when
• 9:19
  you
• 9:19
  leave.
• 9:20
  Right.
• 9:21
  And
• 9:22
  so
• 9:22
  this
• 9:22
  is
• 9:23
  what
• 9:23
  makes
• 9:23
  a
• 9:23
  follow
• 9:24
  up
• 9:24
  appointment
• 9:25
  so
• 9:25
  incredibly
• 9:26
  important.
• 9:26
  Right.
• 9:27
  When
• 9:27
  we
• 9:27
  talk
• 9:27
  about
• 9:27
  discharging
• 9:28
  folks
• 9:28
  from
• 9:28
  a
• 9:29
  hospital,
• 9:30
  it
• 9:30
  is
• 9:30
  absolutely
• 9:31
  critical
• 9:32
  that
• 9:32
  these
• 9:32
  patients
• 9:32
  are
• 9:33
  seen
• 9:33
  within
• 9:33
  seven
• 9:34
  days,
• 9:34
  maybe
• 9:34
  even
• 9:34
  three
• 9:35
  to
• 9:35
  five
• 9:35
  days.
• 9:35
  Ideally,
• 9:36
  some
• 9:36
  institutions
• 9:37
  will
• 9:37
  mandate
• 9:38
  24
• 9:38
  hours,
• 9:38
  if
• 9:39
  that's
• 9:39
  even
• 9:39
  feasible.
• 9:40
  But
• 9:41
  I
• 9:41
  mean,
• 9:41
  we've
• 9:42
  got
• 9:42
  to
• 9:42
  put
• 9:43
  eyes
• 9:43
  and
• 9:43
  ears
• 9:43
  and
• 9:44
  see
• 9:44
  these,
• 9:44
  see
• 9:45
  these
• 9:45
  individuals
• 9:46
  outpatient
• 9:47
  when
• 9:47
  they
• 9:47
  leave.
• 9:47
  It's
• 9:48
  so
• 9:48
  incredibly
• 9:49
  important
• 9:49
  to
• 9:49
  catch
• 9:49
  these
• 9:49
  side
• 9:50
  effects,
• 9:50
  to
• 9:50
  catch
• 9:50
  how
• 9:50
  they're
• 9:51
  doing,
• 9:51
  to
• 9:51
  catch
• 9:52
  the
• 9:52
  socioeconomic
• 9:54
  factors,
• 9:55
  the
• 9:55
  social
• 9:55
  determinants
• 9:56
  of
• 9:56
  health
• 9:56
  that
• 9:56
  you
• 9:57
  all
• 9:57
  learn
• 9:57
  about
• 9:57
  all
• 9:58
  the
• 9:58
  time.
• 9:58
  Lethal
• 9:59
  means
• 9:59
  counseling
• 10:00
  is
• 10:00
  something
• 10:01
  good
• 10:01
  to
• 10:01
  do
• 10:01
  before
• 10:01
  discharge,
• 10:03
  making
• 10:03
  sure
• 10:03
  their
• 10:04
  contact
• 10:04
  information
• 10:05
  is
• 10:05
  up
• 10:05
  to
• 10:06
  date,
• 10:06
  that
• 10:06
  we
• 10:06
  have
• 10:06
  a
• 10:06
  plan,
• 10:07
  that
• 10:07
  we
• 10:07
  can
• 10:07
  for
• 10:08
  sure
• 10:08
  see
• 10:08
  this
• 10:08
  patient,
• 10:09
  that
• 10:09
  they
• 10:10
  have
• 10:10
  resources
• 10:11
  that
• 10:11
  they're
• 10:11
  privy
• 10:11
  to
• 10:12
  in
• 10:12
  the
• 10:12
  event
• 10:13
  there's
• 10:13
  a
• 10:13
  crisis
• 10:14
  and
• 10:14
  we
• 10:14
  don't
• 10:15
  discharge
• 10:15
  them
• 10:15
  unless
• 10:15
  all
• 10:16
  of
• 10:16
  that
• 10:16
  is
• 10:16
  really
• 10:17
  teed
• 10:17
  up.
• 10:17
  Right.
• 10:18
  A
• 10:18
  phone
• 10:18
  call,
• 10:18
  not
• 10:19
  just
• 10:19
  a
• 10:19
  text,
• 10:19
  but
• 10:20
  a
• 10:20
  phone
• 10:20
  call
• 10:21
  documenting
• 10:21
  their
• 10:22
  contact,
• 10:22
  answer,
• 10:23
  calling
• 10:23
  them
• 10:24
  again
• 10:24
  if
• 10:24
  they
• 10:24
  don't
• 10:24
  answer,
• 10:25
  trying
• 10:25
  again
• 10:26
  the
• 10:26
  same
• 10:26
  day
• 10:26
  or
• 10:27
  the
• 10:27
  next
• 10:27
  day.
• 10:27
  Right.
• 10:28
  And
• 10:28
  really
• 10:28
  assessing
• 10:29
  suicide
• 10:30
  robustly
• 10:31
  with
• 10:31
  evidence
• 10:31
  based
• 10:32
  tools
• 10:32
  and
• 10:33
  a
• 10:33
  good
• 10:33
  interview,
• 10:33
  it's
• 10:34
  also
• 10:34
  important.
• 10:35
  But
• 10:35
  I,
• 10:35
  you
• 10:35
  know,
• 10:36
  I
• 10:36
  just
• 10:36
  couldn't
• 10:36
  believe
• 10:37
  that.
• 10:38
  100
• 10:38
  times
• 10:39
  higher
• 10:39
  than
• 10:39
  the
• 10:40
  general
• 10:40
  population
• 10:40
  in
• 10:41
  the
• 10:41
  first
• 10:41
  three
• 10:41
  months
• 10:42
  after
• 10:42
  discharge.
• 10:43
  Pretty
• 10:43
  scary
• 10:44
  statistic.
• 10:45
  And
• 10:45
  you
• 10:46
  know,
• 10:46
  let's
• 10:46
  not
• 10:46
  forget
• 10:47
  that
• 10:47
  postpartum
• 10:48
  women
• 10:48
  in
• 10:49
  perinatal
• 10:49
  depression,
• 10:50
  right,
• 10:51
  they
• 10:51
  have
• 10:51
  a
• 10:51
  sevenfold
• 10:51
  increase
• 10:52
  of
• 10:52
  suicidal
• 10:53
  behavior.
• 10:53
  That's
• 10:54
  a
• 10:54
  big
• 10:54
  deal.
• 10:55
  The
• 10:55
  other
• 10:55
  answers
• 10:56
  aren't.
• 10:56
  No,
• 10:56
  aren't
• 10:56
  a
• 10:56
  picnic
• 10:57
  either.
• 10:57
  Right.
• 10:57
  There's
• 10:57
  1.6
• 10:58
  fold
• 10:59
  increased
• 10:59
  risk
• 11:00
  in
• 11:00
  suicide
• 11:01
  attempts
• 11:01
  with
• 11:01
  antidepressant
• 11:02
  discontinuation
• 11:03
  compared
• 11:03
  to
• 11:03
  continued
• 11:04
  therapy.
• 11:04
  Right.
• 11:05
  And
• 11:05
  that
• 11:05
  highest
• 11:05
  risk
• 11:06
  is
• 11:06
  also
• 11:06
  kind
• 11:06
  of
• 11:07
  in
• 11:07
  the
• 11:07
  first
• 11:07
  place,
• 11:08
  28
• 11:08
  days.
• 11:08
  So,
• 11:09
  you
• 11:09
  know,
• 11:09
  we
• 11:10
  can't
• 11:10
  just
• 11:10
  think
• 11:11
  about
• 11:11
  like
• 11:11
  little
• 11:12
  side
• 11:12
  effects
• 11:12
  and
• 11:13
  brain
• 11:14
  zaps
• 11:14
  and
• 11:14
  being
• 11:15
  dizzy
• 11:15
  and
• 11:15
  irritable.
• 11:16
  People
• 11:16
  get
• 11:17
  suicidal,
• 11:17
  right?
• 11:18
  I
• 11:18
  mean,
• 11:18
  they
• 11:18
  come
• 11:18
  to
• 11:19
  you
• 11:19
  with
• 11:19
  a
• 11:20
  lot
• 11:20
  of
• 11:20
  times
• 11:20
  suicidality
• 11:21
  baked
• 11:21
  into
• 11:21
  the
• 11:21
  cake
• 11:22
  with
• 11:22
  their
• 11:22
  major
• 11:22
  depression.
• 11:23
  And
• 11:24
  so
• 11:24
  when
• 11:24
  we
• 11:25
  transition
• 11:25
  them
• 11:25
  off
• 11:26
  medications,
• 11:26
  we've
• 11:26
  got
• 11:27
  to
• 11:27
  be
• 11:27
  very
• 11:27
  sensitive
• 11:28
  to
• 11:28
  the
• 11:28
  fact
• 11:28
  that
• 11:29
  they
• 11:29
  might
• 11:29
  already
• 11:29
  be
• 11:30
  inclined
• 11:31
  to
• 11:31
  harm
• 11:32
  themselves
• 11:33
  in
• 11:33
  some
• 11:33
  way.
• 11:34
  So
• 11:36
  definitely
• 11:37
  a
• 11:37
  very
• 11:37
  big
• 11:37
  deal
• 11:38
  there.
• 11:38
  You
• 11:39
  know,
• 11:39
  another
• 11:39
  aspect
• 11:40
  to
• 11:40
  this,
• 11:40
  another
• 11:40
  little
• 11:41
  nerdy
• 11:41
  statistic
• 11:41
  here,
• 11:42
  is
• 11:42
  of
• 11:42
  all
• 11:42
  the
• 11:42
  patients
• 11:43
  who
• 11:43
  do
• 11:43
  die
• 11:43
  by
• 11:43
  suicide
• 11:44
  within
• 11:44
  two
• 11:44
  years
• 11:45
  of
• 11:45
  psychiatric
• 11:45
  discharge,
• 11:46
  9%
• 11:47
  will
• 11:47
  die
• 11:47
  in
• 11:48
  that
• 11:48
  first
• 11:48
  week
• 11:48
  alone,
• 11:49
  23%
• 11:50
  die
• 11:50
  in
• 11:50
  that
• 11:50
  first
• 11:51
  month.
• 11:51
  So
• 11:51
  again,
• 11:52
  not
• 11:52
  to
• 11:52
  beat
• 11:52
  the
• 11:52
  dead
• 11:53
  horse,
• 11:53
  but
• 11:54
  certainly
• 11:55
  psychiatric
• 11:56
  discharge,
• 11:58
  hair
• 11:58
  on
• 11:58
  fire,
• 12:00
  lights
• 12:00
  and
• 12:00
  sirens.
• 12:01
  It's
• 12:02
  a
• 12:02
  really
• 12:02
  ripe
• 12:03
  area
• 12:03
  for
• 12:03
  PI
• 12:04
  projects
• 12:05
  and
• 12:06
  really
• 12:06
  digging
• 12:06
  into
• 12:07
  the
• 12:07
  evidence
• 12:07
  and
• 12:08
  figuring
• 12:08
  out
• 12:08
  the
• 12:08
  best
• 12:09
  way
• 12:09
  we
• 12:09
  can
• 12:10
  protect
• 12:10
  and
• 12:10
  prepare
• 12:11
  these
• 12:11
  folks.
• 12:12
  Because
• 12:12
  it's
• 12:13
  a
• 12:13
  really
• 12:13
  big
• 12:14
  deal,
• 12:14
  right?
• 12:14
  And
• 12:14
  you
• 12:15
  can
• 12:15
  imagine
• 12:15
  that
• 12:15
  every
• 12:16
  patient
• 12:16
  is
• 12:16
  like
• 12:16
  a
• 12:16
  snowflake.
• 12:17
  Their,
• 12:18
  their
• 12:18
  circumstances
• 12:19
  are
• 12:19
  completely
• 12:20
  different,
• 12:21
  right?
• 12:21
  Where
• 12:21
  they're
• 12:21
  going
• 12:22
  to
• 12:22
  when
• 12:22
  they
• 12:22
  get
• 12:22
  discharged,
• 12:23
  right.
• 12:24
  You
• 12:24
  know,
• 12:24
  what
• 12:25
  their
• 12:25
  triggers
• 12:25
  and
• 12:26
  risk
• 12:26
  factors
• 12:26
  are,
• 12:26
  what
• 12:26
  their
• 12:27
  resources
• 12:27
  look
• 12:27
  like.
• 12:28
  Just
• 12:28
  really
• 12:29
  important
• 12:29
  to
• 12:29
  map
• 12:29
  that
• 12:30
  out.
• 12:30
  And,
• 12:30
  you
• 12:30
  know,
• 12:30
  I'll
• 12:31
  be
• 12:31
  honest
• 12:31
  with
• 12:31
  you,
• 12:31
  it's
• 12:32
  not,
• 12:32
  you're
• 12:33
  not
• 12:33
  going
• 12:33
  to
• 12:33
  find
• 12:33
  a
• 12:33
  magical
• 12:34
  checklist
• 12:34
  out
• 12:35
  there
• 12:35
  that
• 12:36
  is
• 12:36
  going
• 12:36
  to
• 12:36
  be
• 12:36
  able
• 12:37
  to
• 12:37
  get
• 12:37
  all
• 12:37
  of
• 12:38
  this
• 12:38
  down
• 12:38
  for
• 12:38
  you.
• 12:38
  As
• 12:39
  much
• 12:39
  as
• 12:39
  I
• 12:39
  wish
• 12:39
  there
• 12:40
  was
• 12:40
  one
• 12:40
  little
• 12:41
  checklist
• 12:42
  that
• 12:42
  could
• 12:42
  get
• 12:42
  all
• 12:43
  of
• 12:43
  this
• 12:43
  and
• 12:44
  make
• 12:44
  us
• 12:44
  all
• 12:44
  feel
• 12:44
  warm
• 12:45
  and
• 12:45
  fuzzy,
• 12:45
  we
• 12:45
  need
• 12:45
  human
• 12:46
  contact.
• 12:46
  We
• 12:47
  need
• 12:47
  initiative.
• 12:47
  We
• 12:47
  need,
• 12:48
  we
• 12:48
  need
• 12:49
  to
• 12:49
  reach
• 12:49
  out
• 12:49
  to
• 12:49
  people.
• 12:49
  We
• 12:50
  need
• 12:50
  to
• 12:50
  get
• 12:50
  to
• 12:50
  know
• 12:50
  them.
• 12:50
  We
• 12:51
  need
• 12:51
  to
• 12:51
  build
• 12:51
  rapport
• 12:51
  with
• 12:52
  them
• 12:52
  so
• 12:52
  they
• 12:52
  feel
• 12:52
  comfortable
• 12:53
  even
• 12:53
  telling
• 12:53
  us
• 12:54
  that,
• 12:54
  hey,
• 12:55
  when
• 12:55
  I
• 12:55
  get
• 12:55
  out
• 12:55
  of
• 12:55
  here,
• 12:57
  buddy,
• 12:57
  Doc,
• 12:57
  I
• 12:58
  am
• 12:58
  not
• 12:58
  going
• 12:58
  to
• 12:59
  go
• 12:59
  to
• 12:59
  this
• 13:00
  appointment.
• 13:00
  I
• 13:00
  can't
• 13:00
  afford
• 13:01
  it.
• 13:01
  Right?
• 13:02
  We
• 13:02
  can't
• 13:02
  pretend
• 13:03
  and
• 13:03
  just
• 13:03
  counsel
• 13:04
  people.
• 13:04
  And
• 13:05
  you
• 13:06
  know,
• 13:06
  lo
• 13:06
  and
• 13:06
  behold,
• 13:07
  they
• 13:07
  don't
• 13:07
  even
• 13:08
  have
• 13:08
  the
• 13:08
  eight
• 13:09
  bucks.
• 13:09
  I've,
• 13:09
  I've
• 13:09
  had
• 13:10
  patients,
• 13:10
  they
• 13:10
  don't
• 13:10
  even
• 13:10
  have
• 13:11
  12
• 13:11
  bucks
• 13:12
  to
• 13:12
  afford
• 13:12
  a
• 13:12
  copay,
• 13:13
  right?
• 13:13
  Like,
• 13:14
  what
• 13:14
  are
• 13:14
  you
• 13:14
  going
• 13:14
  to
• 13:14
  do,
• 13:14
  right?
• 13:15
  Are
• 13:15
  you
• 13:15
  going
• 13:15
  to
• 13:15
  call
• 13:16
  the
• 13:16
  pharmacy
• 13:16
  and
• 13:17
  negotiate
• 13:17
  with
• 13:18
  them
• 13:18
  or
• 13:19
  their
• 13:19
  insurance
• 13:20
  company?
• 13:20
  And
• 13:20
  when
• 13:21
  you
• 13:21
  get
• 13:21
  to
• 13:21
  practice,
• 13:21
  you're
• 13:22
  going
• 13:22
  to
• 13:22
  see
• 13:22
  how
• 13:23
  layered
• 13:24
  this
• 13:24
  all
• 13:24
  is
• 13:24
  and
• 13:25
  how
• 13:25
  dysfunctional
• 13:26
  it
• 13:26
  can
• 13:26
  be
• 13:27
  at
• 13:27
  times.
• 13:27
  And
• 13:27
  kind
• 13:28
  of
• 13:28
  scary
• 13:29
  because
• 13:29
  a
• 13:29
  lot
• 13:29
  of
• 13:30
  folks
• 13:30
  unfortunately
• 13:31
  slip
• 13:31
  through
• 13:31
  the
• 13:31
  cracks.
• 13:32
  So
• 13:33
  sometimes
• 13:33
  these
• 13:34
  statistics
• 13:34
  are
• 13:34
  meant
• 13:34
  to
• 13:35
  be
• 13:35
  a
• 13:35
  little
• 13:35
  scary
• 13:35
  and
• 13:35
  intimidating.
• 13:36
  I
• 13:36
  think
• 13:36
  it,
• 13:37
  it,
• 13:37
  it
• 13:37
  gives
• 13:37
  us
• 13:38
  a
• 13:38
  positive
• 13:38
  challenge
• 13:39
  to
• 13:39
  rally
• 13:39
  behind
• 13:40
  and
• 13:40
  do
• 13:41
  better
• 13:41
  and
• 13:41
  focus
• 13:41
  our
• 13:42
  efforts.
• 13:42
  So
• 13:43
  in
• 13:43
  a
• 13:43
  way,
• 13:43
  I
• 13:43
  think,
• 13:44
  you
• 13:44
  know,
• 13:44
  it's
• 13:44
  a
• 13:44
  great
• 13:44
  call
• 13:45
  to
• 13:45
  action
• 13:46
  to,
• 13:46
  to
• 13:46
  focus
• 13:47
  on
• 13:48
  the,
• 13:48
  the
• 13:48
  post
• 13:49
  discharge
• 13:49
  window,
• 13:49
  which
• 13:50
  I
• 13:50
  think
• 13:50
  again,
• 13:50
  is,
• 13:51
  is
• 13:51
  so
• 13:51
  critical,
• 13:53
  focusing
• 13:53
  our,
• 13:54
  our
• 13:54
  efforts
• 13:55
  on
• 13:56
  that.
• 13:56
  In
• 13:56
  particular.
• 13:57
  It
• 13:57
  was
• 13:57
  interesting
• 13:58
  to
• 13:58
  hear
• 13:58
  the
• 13:58
  statistic
• 13:59
  too,
• 13:59
  because
• 14:00
  there
• 14:00
  are
• 14:01
  so
• 14:01
  many.
• 14:01
  You
• 14:01
  could,
• 14:01
  we
• 14:02
  could
• 14:02
  probably
• 14:02
  brainstorm
• 14:03
  together
• 14:04
  40
• 14:04
  other
• 14:05
  situations
• 14:06
  in
• 14:06
  psychiatry
• 14:06
  that
• 14:06
  feel
• 14:07
  so
• 14:07
  high
• 14:07
  risk.
• 14:08
  Right.
• 14:09
  This
• 14:09
  state
• 14:09
  like
• 14:10
  being
• 14:10
  in
• 14:10
  a
• 14:10
  manic
• 14:10
  state.
• 14:11
  Right.
• 14:12
  That
• 14:12
  alone,
• 14:13
  grief,
• 14:14
  losing,
• 14:14
  losing
• 14:15
  a
• 14:15
  spouse
• 14:16
  or
• 14:16
  being
• 14:17
  in
• 14:17
  detox.
• 14:17
  I
• 14:18
  mean
• 14:18
  you
• 14:18
  could
• 14:18
  think
• 14:18
  of
• 14:18
  just
• 14:19
  an
• 14:19
  endless
• 14:19
  amount
• 14:19
  of
• 14:20
  really
• 14:20
  acute
• 14:21
  psychiatric
• 14:22
  states
• 14:23
  that
• 14:24
  might
• 14:24
  precipitate
• 14:25
  suicide.
• 14:26
  And
• 14:27
  so
• 14:27
  it's
• 14:27
  kind
• 14:28
  of
• 14:28
  interesting
• 14:28
  to
• 14:28
  pinpoint
• 14:29
  what
• 14:29
  is
• 14:29
  the
• 14:30
  biggest
• 14:30
  emergency.
• 14:31
  If
• 14:31
  you
• 14:31
  work
• 14:32
  in
• 14:32
  an
• 14:32
  outpatient
• 14:32
  clinic,
• 14:33
  you're
• 14:33
  going
• 14:33
  to
• 14:33
  get
• 14:33
  patients
• 14:34
  fresh
• 14:34
  out
• 14:34
  of
• 14:35
  discharge
• 14:35
  all
• 14:35
  of
• 14:35
  the
• 14:35
  time.
• 14:35
  And
• 14:36
  I
• 14:36
  find
• 14:36
  that
• 14:37
  those
• 14:37
  are
• 14:37
  the
• 14:37
  most
• 14:37
  challenging
• 14:38
  patients.
• 14:38
  I
• 14:38
  don't
• 14:38
  mean
• 14:39
  them
• 14:39
  as
• 14:39
  people
• 14:40
  are
• 14:40
  challenging,
• 14:40
  but
• 14:41
  clinically
• 14:42
  by
• 14:42
  far.
• 14:43
  A
• 14:43
  patient
• 14:44
  who's
• 14:44
  just
• 14:44
  out
• 14:44
  of
• 14:45
  the
• 14:45
  hospital
• 14:46
  for
• 14:46
  suicidal
• 14:47
  ideation
• 14:48
  with
• 14:48
  major
• 14:48
  to
• 14:48
  severe
• 14:49
  major
• 14:49
  depression
• 14:49
  is
• 14:50
  more
• 14:50
  challenging
• 14:50
  than
• 14:51
  like
• 14:51
  a
• 14:51
  patient
• 14:51
  on
• 14:51
  lithium
• 14:52
  or
• 14:52
  Depakote.
• 14:53
  I
• 14:53
  find
• 14:53
  that
• 14:53
  your
• 14:53
  patients
• 14:54
  coming
• 14:54
  out
• 14:54
  of
• 14:54
  the
• 14:55
  hospital
• 14:55
  require
• 14:56
  longer
• 14:57
  appointments,
• 14:57
  much
• 14:58
  more
• 14:58
  thorough
• 14:58
  appointments.
• 14:59
  They're
• 14:59
  not
• 14:59
  always
• 15:00
  able
• 15:00
  to
• 15:01
  really
• 15:01
  register
• 15:02
  everything
• 15:02
  you're
• 15:03
  trying
• 15:03
  to
• 15:03
  put
• 15:03
  down.
• 15:04
  Everything
• 15:04
  is
• 15:04
  kind
• 15:04
  of
• 15:05
  moving
• 15:05
  a
• 15:05
  little
• 15:05
  slower.
• 15:06
  They're
• 15:06
  very
• 15:06
  overwhelmed,
• 15:07
  understandably.
• 15:08
  And
• 15:08
  so
• 15:08
  I
• 15:09
  find
• 15:09
  that
• 15:09
  your
• 15:09
  most
• 15:10
  acute
• 15:10
  patients,
• 15:10
  like
• 15:10
  if
• 15:11
  there
• 15:11
  was
• 15:11
  ever
• 15:11
  a
• 15:11
  time
• 15:12
  to
• 15:12
  have
• 15:12
  a
• 15:12
  two
• 15:13
  hour
• 15:13
  intake
• 15:13
  with
• 15:14
  someone,
• 15:14
  it
• 15:14
  would
• 15:14
  be
• 15:14
  when
• 15:15
  they
• 15:15
  leave
• 15:15
  the
• 15:15
  hospital.
• 15:16
  And
• 15:16
  it's
• 15:16
  exactly
• 15:17
  for
• 15:17
  the
• 15:17
  stuff
• 15:17
  we
• 15:18
  talked
• 15:18
  about
• 15:18
  just
• 15:18
  now,
• 15:19
  right.
• 15:19
  How
• 15:20
  risky
• 15:20
  this
• 15:20
  is,
• 15:20
  how
• 15:21
  many
• 15:21
  variables
• 15:21
  are
• 15:21
  at
• 15:22
  play
• 15:22
  that
• 15:22
  could
• 15:22
  go
• 15:22
  wrong.
• 15:23
  The
• 15:23
  vulnerability.
• 15:24
  Right.
• 15:24
  And
• 15:24
  it
• 15:25
  could
• 15:25
  even
• 15:25
  be
• 15:25
  a
• 15:25
  patient.
• 15:26
  You
• 15:26
  know,
• 15:26
  you
• 15:26
  might
• 15:26
  have
• 15:26
  been
• 15:27
  with
• 15:27
  this
• 15:27
  patient
• 15:27
  for,
• 15:28
  for
• 15:28
  a
• 15:28
  year
• 15:29
  and
• 15:29
  now
• 15:29
  they're
• 15:30
  being
• 15:30
  discharged
• 15:31
  and
• 15:32
  it
• 15:32
  still
• 15:32
  requires
• 15:33
  in
• 15:33
  my
• 15:33
  opinion,
• 15:34
  two
• 15:34
  hours.
• 15:34
  So
• 15:35
  really
• 15:35
  do
• 15:36
  a
• 15:36
  thorough
• 15:36
  job.
• 15:37
  You
• 15:37
  know,
• 15:37
  it's,
• 15:38
  it's,
• 15:38
  it's
• 15:38
  not
• 15:38
  a
• 15:39
  matter
• 15:39
  of
• 15:39
  skills
• 15:39
  and
• 15:40
  experience.
• 15:40
  It's,
• 15:40
  it's,
• 15:41
  it's
• 15:41
  more
• 15:41
  than
• 15:41
  that.
• 15:42
  It's
• 15:42
  the
• 15:42
  amount
• 15:43
  of
• 15:43
  vulnerability
• 15:43
  and
• 15:44
  complexity
• 15:45
  in
• 15:45
  what
• 15:45
  brought
• 15:45
  them
• 15:45
  to
• 15:46
  the
• 15:46
  hospital
• 15:46
  and
• 15:46
  how
• 15:46
  they're
• 15:47
  going
• 15:47
  to
• 15:47
  transition
• 15:47
  out
• 15:47
  of
• 15:48
  the
• 15:48
  hospital
• 15:48
  requires
• 15:49
  a
• 15:49
  lot
• 15:49
  of
• 15:49
  time.
• 15:50
  And
• 15:51
  so
• 15:51
  you'll
• 15:51
  find
• 15:51
  when
• 15:51
  you
• 15:52
  graduate,
• 15:52
  these
• 15:52
  are
• 15:52
  the
• 15:53
  folks
• 15:53
  that
• 15:53
  are
• 15:54
  much
• 15:54
  more
• 15:54
  time
• 15:55
  consuming
• 15:56
  and
• 15:56
  important.
• 15:57
  I
• 15:57
  don't
• 15:57
  want
• 15:57
  to
• 15:57
  say
• 15:57
  one's
• 15:58
  more
• 15:58
  important
• 15:58
  than
• 15:58
  the
• 15:58
  other,
• 15:58
  but
• 15:59
  you
• 15:59
  will
• 15:59
  see
• 16:00
  that
• 16:00
  you're
• 16:00
  going
• 16:00
  to
• 16:00
  be
• 16:00
  really
• 16:01
  flexing
• 16:01
  your,
• 16:02
  your
• 16:02
  brain
• 16:02
  power
• 16:03
  on
• 16:03
  the
• 16:03
  post
• 16:04
  hospital
• 16:04
  discharges
• 16:05
  even
• 16:05
  more
• 16:06
  so
• 16:06
  than
• 16:06
  a
• 16:06
  brand
• 16:06
  new
• 16:06
  intake.
• 16:07
  I
• 16:07
  can't
• 16:08
  emphasize
• 16:08
  enough
• 16:08
  to
• 16:08
  become
• 16:09
  Patreon
• 16:10
  members.
• 16:10
  You
• 16:10
  can
• 16:10
  become
• 16:10
  a
• 16:11
  free
• 16:11
  member,
• 16:11
  but
• 16:11
  the
• 16:11
  paid
• 16:12
  $3
• 16:13
  a
• 16:13
  month,
• 16:13
  it's
• 16:13
  a
• 16:13
  steal.
• 16:14
  That
• 16:14
  membership
• 16:15
  will
• 16:15
  get
• 16:16
  you
• 16:16
  all
• 16:16
  kinds
• 16:16
  of
• 16:16
  amazing
• 16:17
  pearls
• 16:18
  that
• 16:19
  really
• 16:19
  propel
• 16:19
  your
• 16:20
  practice
• 16:20
  to
• 16:20
  a
• 16:20
  new
• 16:20
  level.
• 16:21
  Highly
• 16:21
  recommend
• 16:22
  you
• 16:22
  go
• 16:22
  into
• 16:22
  our
• 16:22
  show
• 16:23
  notes
• 16:23
  and
• 16:23
  become
• 16:23
  members.
• 16:24
  My
• 16:24
  friends.
• 16:25
  So
• 16:25
  glad
• 16:25
  you
• 16:25
  tuned
• 16:26
  in
• 16:26
  again.
• 16:27
  Hope
• 16:27
  you
• 16:27
  enjoy
• 16:27
  this
• 16:28
  one,
• 16:28
  send
• 16:28
  it
• 16:28
  to
• 16:28
  your
• 16:28
  friends
• 16:29
  and
• 16:29
  family.
• 16:30
  It's
• 16:30
  an
• 16:30
  important
• 16:30
  one.
• 16:31
  And
• 16:31
  take
• 16:31
  great
• 16:32
  care
• 16:32
  of
• 16:32
  yourselves.
• 16:32
  Okay,
• 16:33
  Signing
• 16:33
  off.
• 16:33
  Npc.
• 16:34
  Bye.
• 16:34
  Bye.