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6 Pearls You May Have Not Known about Major Depressive Disorder with Psychotic Features · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back
• 0:05
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
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  episode
• 0:07
  of
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  Pearls
• 0:07
  and
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  Prep
• 0:08
  npz.
• 0:09
  Here
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  your
• 0:10
  preceptor
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  in
• 0:11
  your
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  pocket.
• 0:11
  Before
• 0:12
  we
• 0:12
  start
• 0:12
  the
• 0:12
  show,
• 0:12
  I
• 0:13
  highly
• 0:13
  encourage
• 0:14
  all
• 0:14
  of
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  you
• 0:15
  to
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  get
• 0:16
  into
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  the
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  show
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  notes
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  after
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  this
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  to
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  find
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  our
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  Patreon
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  page
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  become
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  Patreon
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  members.
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  Why?
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  Because
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  you
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  get
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  beautiful
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  slide
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  decks
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  full
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  of
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  amazing
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  study
• 0:24
  materials
• 0:26
  that
• 0:26
  really
• 0:26
  makes
• 0:27
  all
• 0:27
  of
• 0:27
  this
• 0:27
  stuff
• 0:27
  click
• 0:28
  and
• 0:28
  make
• 0:28
  sense.
• 0:29
  It'll
• 0:29
  prepare
• 0:29
  you
• 0:29
  for
• 0:30
  boards,
• 0:30
  it'll
• 0:30
  empower
• 0:31
  you
• 0:31
  in
• 0:31
  your
• 0:31
  practice.
• 0:31
  You
• 0:32
  also
• 0:32
  get
• 0:32
  early
• 0:32
  episode
• 0:33
  drops,
• 0:34
  sometimes
• 0:34
  six
• 0:34
  months
• 0:35
  in
• 0:35
  advance
• 0:36
  that
• 0:36
  no
• 0:36
  one
• 0:36
  else
• 0:36
  gets.
• 0:37
  Without
• 0:37
  further
• 0:38
  ado,
• 0:38
  let's
• 0:38
  get
• 0:39
  into
• 0:39
  today's
• 0:39
  episode.
• 0:40
  So
• 0:41
  today
• 0:41
  we're
• 0:41
  going
• 0:41
  to
• 0:41
  talk
• 0:41
  about
• 0:42
  six
• 0:42
  pearls
• 0:43
  you
• 0:43
  need
• 0:43
  to
• 0:43
  know
• 0:44
  as
• 0:44
  it
• 0:44
  relates
• 0:44
  to
• 0:45
  major
• 0:45
  depressive
• 0:45
  disorder
• 0:46
  with
• 0:46
  psychotic
• 0:47
  features.
• 0:48
  This
• 0:48
  is
• 0:48
  a
• 0:49
  doozy.
• 0:49
  This
• 0:50
  is
• 0:51
  a
• 0:51
  very,
• 0:51
  very
• 0:52
  good
• 0:52
  one.
• 0:53
  So
• 0:54
  pearl
• 0:54
  number
• 0:55
  one
• 0:55
  is
• 0:55
  that
• 0:56
  depression
• 0:56
  with
• 0:57
  psychotic
• 0:57
  features
• 0:58
  is
• 0:59
  depression
• 1:00
  with
• 1:00
  a
• 1:00
  reality
• 1:01
  twist.
• 1:01
  It
• 1:01
  is
• 1:02
  more
• 1:03
  of
• 1:03
  a
• 1:04
  severe
• 1:04
  problem.
• 1:05
  Why?
• 1:05
  Because
• 1:05
  two
• 1:06
  times
• 1:06
  higher
• 1:06
  risk
• 1:07
  of
• 1:07
  relapse
• 1:08
  of
• 1:08
  depressive
• 1:09
  symptoms,
• 1:09
  the
• 1:10
  odds
• 1:10
  of
• 1:10
  hospitalization
• 1:11
  go
• 1:11
  up.
• 1:11
  The
• 1:11
  mortality
• 1:12
  risk
• 1:12
  goes
• 1:13
  up
• 1:13
  relative
• 1:14
  to
• 1:14
  non
• 1:14
  psychotic
• 1:15
  depression
• 1:15
  and
• 1:15
  that
• 1:15
  is
• 1:16
  specifically
• 1:16
  mortality
• 1:17
  as
• 1:17
  it
• 1:17
  relates
• 1:17
  to
• 1:18
  suicide,
• 1:18
  accidents
• 1:19
  and
• 1:19
  and
• 1:19
  cardiovascular
• 1:20
  disease.
• 1:20
  But
• 1:21
  all
• 1:21
  cause
• 1:21
  mortality
• 1:22
  spikes.
• 1:23
  When
• 1:23
  major
• 1:23
  depressive
• 1:24
  disorder
• 1:24
  with
• 1:24
  psychotic
• 1:25
  features
• 1:26
  is
• 1:26
  not
• 1:27
  all
• 1:27
  patients
• 1:29
  with
• 1:29
  MDD
• 1:29
  and
• 1:30
  psychosis
• 1:30
  need
• 1:31
  to
• 1:31
  be
• 1:31
  rushed
• 1:31
  to
• 1:31
  the
• 1:32
  er.
• 1:32
  That
• 1:33
  is
• 1:33
  definitely
• 1:33
  not
• 1:34
  the
• 1:34
  case.
• 1:34
  But
• 1:34
  as
• 1:35
  you
• 1:35
  will
• 1:35
  learn
• 1:35
  in
• 1:35
  our
• 1:36
  new
• 1:36
  pearls
• 1:37
  coming
• 1:37
  up
• 1:37
  here,
• 1:38
  this
• 1:38
  is
• 1:38
  just
• 1:38
  pearl
• 1:39
  number
• 1:39
  one
• 1:39
  of
• 1:39
  six.
• 1:40
  As
• 1:40
  we
• 1:40
  progress,
• 1:41
  you
• 1:41
  will
• 1:41
  see
• 1:41
  that
• 1:42
  maybe
• 1:42
  your
• 1:42
  patient
• 1:43
  does
• 1:43
  need
• 1:43
  to
• 1:43
  go
• 1:43
  to
• 1:43
  the
• 1:44
  hospital
• 1:44
  based
• 1:44
  on
• 1:45
  specific
• 1:45
  things
• 1:45
  you
• 1:46
  need
• 1:46
  to
• 1:46
  look
• 1:46
  for
• 1:47
  and
• 1:47
  ask
• 1:47
  about.
• 1:48
  But
• 1:48
  the
• 1:48
  first
• 1:48
  pearl
• 1:49
  you
• 1:49
  should
• 1:49
  recognize
• 1:50
  is
• 1:50
  that
• 1:50
  this
• 1:50
  is
• 1:50
  not
• 1:50
  your
• 1:51
  run
• 1:51
  of
• 1:51
  the
• 1:51
  mill
• 1:51
  depression.
• 1:52
  This
• 1:52
  changes
• 1:53
  the
• 1:53
  treatment
• 1:53
  algorithm,
• 1:54
  this
• 1:54
  changes
• 1:55
  your
• 1:55
  future
• 1:56
  decisions
• 1:56
  because
• 1:56
  it's
• 1:57
  more
• 1:57
  serious,
• 1:57
  right?
• 1:58
  The
• 1:58
  mortality
• 1:58
  risk,
• 1:59
  the
• 1:59
  hospitalization
• 2:00
  risk,
• 2:00
  the
• 2:00
  suicide
• 2:01
  risk,
• 2:02
  this
• 2:02
  is
• 2:02
  a
• 2:02
  bigger
• 2:03
  deal.
• 2:03
  So
• 2:03
  you
• 2:04
  have
• 2:04
  to
• 2:04
  be
• 2:04
  prepared
• 2:04
  with
• 2:04
  anyone
• 2:05
  who
• 2:05
  has
• 2:05
  depression
• 2:06
  period.
• 2:06
  But
• 2:06
  when
• 2:06
  there's
• 2:07
  psychotic
• 2:07
  features,
• 2:08
  definitely
• 2:09
  pause,
• 2:09
  take
• 2:09
  your
• 2:10
  time
• 2:10
  with
• 2:10
  the
• 2:10
  patient
• 2:11
  and
• 2:11
  assess
• 2:11
  things
• 2:12
  very
• 2:12
  carefully
• 2:12
  and
• 2:13
  clearly.
• 2:13
  And
• 2:14
  you
• 2:14
  know,
• 2:14
  in
• 2:14
  the
• 2:14
  event
• 2:15
  you
• 2:15
  ever
• 2:15
  want
• 2:15
  to
• 2:15
  tape
• 2:16
  your
• 2:16
  antidepressant
• 2:17
  in
• 2:17
  the
• 2:17
  future
• 2:17
  when
• 2:17
  the
• 2:18
  patient
• 2:18
  asks
• 2:18
  you,
• 2:18
  do
• 2:18
  I
• 2:19
  have
• 2:19
  to
• 2:19
  be
• 2:19
  on
• 2:19
  this
• 2:19
  medication
• 2:20
  for
• 2:20
  life?
• 2:20
  What
• 2:20
  does
• 2:20
  this
• 2:21
  look
• 2:21
  like?
• 2:21
  Well,
• 2:22
  definitely
• 2:22
  keep
• 2:22
  it
• 2:22
  in
• 2:22
  your
• 2:23
  back
• 2:23
  pocket
• 2:23
  and
• 2:24
  in
• 2:24
  your
• 2:24
  notes
• 2:24
  that
• 2:25
  this
• 2:25
  patient
• 2:25
  has
• 2:26
  psychosis
• 2:27
  associated
• 2:28
  with
• 2:28
  their
• 2:28
  depressive
• 2:28
  episode.
• 2:29
  So
• 2:29
  you
• 2:29
  have
• 2:29
  to
• 2:29
  weigh
• 2:30
  that
• 2:30
  when
• 2:30
  you
• 2:31
  eventually
• 2:31
  make
• 2:32
  the
• 2:32
  call,
• 2:33
  whether
• 2:33
  or
• 2:33
  not
• 2:33
  a
• 2:33
  patient
• 2:34
  is
• 2:34
  tapered
• 2:34
  down
• 2:35
  and
• 2:35
  that
• 2:35
  risk
• 2:36
  level,
• 2:36
  if
• 2:36
  they
• 2:36
  are
• 2:37
  tapered,
• 2:37
  of
• 2:38
  how
• 2:38
  severe
• 2:38
  their
• 2:39
  depression
• 2:39
  gets
• 2:40
  and
• 2:40
  what
• 2:40
  that
• 2:41
  looks
• 2:41
  like.
• 2:41
  So
• 2:41
  again,
• 2:41
  it's
• 2:42
  a
• 2:42
  very
• 2:42
  Important
• 2:43
  specifier
• 2:43
  in
• 2:43
  the
• 2:44
  DSM
• 2:44
  5,
• 2:45
  you
• 2:45
  should
• 2:45
  use
• 2:46
  and
• 2:46
  highlight
• 2:47
  in
• 2:47
  the
• 2:47
  patient's
• 2:48
  chart
• 2:48
  if
• 2:48
  applicable,
• 2:49
  and
• 2:49
  use
• 2:49
  it
• 2:50
  to
• 2:50
  inform
• 2:50
  your
• 2:51
  diagnostics
• 2:51
  and
• 2:52
  your
• 2:52
  future
• 2:52
  treatment
• 2:52
  plan,
• 2:53
  because
• 2:53
  it
• 2:54
  is
• 2:54
  definitely
• 2:54
  a
• 2:54
  very
• 2:55
  big
• 2:55
  deal.
• 2:55
  Now,
• 2:56
  the
• 2:56
  second
• 2:56
  pearl
• 2:57
  I
• 2:57
  want
• 2:57
  you
• 2:57
  to
• 2:57
  think
• 2:58
  about
• 2:59
  is
• 2:59
  distinguishing
• 3:00
  between
• 3:00
  mood
• 3:01
  congruent
• 3:01
  and
• 3:01
  mood
• 3:02
  incongruent
• 3:02
  psychosis.
• 3:03
  Now,
• 3:03
  this
• 3:03
  is
• 3:03
  an
• 3:04
  actual
• 3:04
  specifier
• 3:04
  in
• 3:05
  the
• 3:05
  DSM
• 3:06
  where
• 3:06
  you
• 3:06
  have
• 3:06
  to
• 3:07
  specify
• 3:07
  if
• 3:08
  their
• 3:08
  psychosis
• 3:09
  is
• 3:09
  mood
• 3:09
  congruent
• 3:09
  or
• 3:10
  mood
• 3:10
  incongruent.
• 3:11
  Mood
• 3:12
  congruent,
• 3:12
  a
• 3:12
  form
• 3:12
  of
• 3:12
  psychosis
• 3:13
  would
• 3:14
  be
• 3:14
  somebody
• 3:14
  who's
• 3:14
  already
• 3:15
  depressed.
• 3:15
  Your
• 3:15
  patient's
• 3:16
  depressed,
• 3:16
  and
• 3:17
  they
• 3:18
  are
• 3:18
  starting
• 3:18
  to
• 3:19
  have
• 3:20
  maybe
• 3:21
  nihilistic
• 3:22
  delusions
• 3:23
  where
• 3:24
  they
• 3:24
  feel
• 3:24
  like
• 3:24
  they're
• 3:24
  rotting
• 3:25
  from
• 3:25
  the
• 3:25
  inside
• 3:26
  and
• 3:26
  that
• 3:27
  they're
• 3:27
  already
• 3:27
  dead.
• 3:28
  That
• 3:29
  would
• 3:29
  be
• 3:29
  a
• 3:29
  mood
• 3:30
  congruent
• 3:30
  psychotic
• 3:31
  feature.
• 3:32
  It's
• 3:32
  consistent
• 3:33
  with
• 3:33
  their
• 3:33
  mood.
• 3:33
  It's
• 3:34
  kind
• 3:34
  of
• 3:34
  down
• 3:34
  morose,
• 3:35
  nihilistic,
• 3:36
  death
• 3:36
  oriented.
• 3:37
  That's
• 3:37
  more
• 3:38
  mood
• 3:38
  congruent.
• 3:39
  You
• 3:39
  can
• 3:39
  specify
• 3:40
  in
• 3:40
  the
• 3:41
  DSM
• 3:42
  whether
• 3:42
  it's
• 3:42
  mood
• 3:43
  congruent
• 3:43
  or
• 3:43
  mood
• 3:44
  incongruent.
• 3:44
  Now,
• 3:44
  a
• 3:44
  mood
• 3:45
  incongruent
• 3:46
  psychotic
• 3:46
  theme
• 3:47
  would
• 3:47
  be
• 3:47
  a
• 3:48
  patient
• 3:48
  who
• 3:48
  thinks
• 3:48
  aliens
• 3:49
  control
• 3:49
  them.
• 3:49
  Right?
• 3:50
  It
• 3:50
  doesn't
• 3:50
  really
• 3:50
  have
• 3:50
  a
• 3:51
  whole
• 3:51
  lot
• 3:51
  to
• 3:51
  do
• 3:52
  with
• 3:52
  the
• 3:52
  guilt
• 3:54
  or
• 3:54
  the
• 3:54
  nihilism
• 3:55
  or
• 3:56
  death
• 3:56
  themes
• 3:57
  in
• 3:57
  classical
• 3:58
  depression.
• 3:58
  This
• 3:59
  is
• 3:59
  a
• 3:59
  little
• 3:59
  bit
• 3:59
  off
• 3:59
  the
• 3:59
  beaten
• 4:00
  path,
• 4:00
  right?
• 4:00
  It's
• 4:00
  like,
• 4:00
  where
• 4:01
  did
• 4:01
  aliens
• 4:01
  come
• 4:01
  from?
• 4:02
  Where
• 4:02
  did
• 4:02
  the
• 4:02
  FBI
• 4:02
  putting
• 4:03
  a
• 4:03
  chip
• 4:03
  in
• 4:03
  my
• 4:03
  brain
• 4:04
  come
• 4:04
  from?
• 4:04
  It's
• 4:05
  not
• 4:05
  exactly
• 4:05
  congruent
• 4:06
  with
• 4:06
  a
• 4:07
  guilty,
• 4:07
  sad,
• 4:07
  morose,
• 4:08
  death
• 4:09
  content
• 4:09
  type
• 4:10
  of
• 4:10
  depression
• 4:10
  that
• 4:10
  you
• 4:11
  would
• 4:11
  see.
• 4:11
  So
• 4:11
  it's
• 4:12
  again,
• 4:12
  the
• 4:12
  words
• 4:13
  mean
• 4:13
  what
• 4:13
  they
• 4:13
  mean,
• 4:13
  which
• 4:13
  is
• 4:14
  very
• 4:14
  helpful.
• 4:15
  So
• 4:15
  anytime
• 4:15
  you
• 4:16
  have
• 4:16
  a
• 4:16
  patient
• 4:16
  who
• 4:16
  meets
• 4:17
  major
• 4:17
  depressive
• 4:17
  criteria
• 4:18
  and
• 4:18
  they
• 4:19
  have
• 4:19
  psychosis,
• 4:20
  whether
• 4:20
  it
• 4:20
  be
• 4:20
  a
• 4:20
  delusion,
• 4:21
  whether
• 4:21
  it
• 4:21
  be
• 4:21
  a
• 4:21
  hallucination,
• 4:22
  auditory
• 4:23
  or
• 4:23
  visual,
• 4:23
  you
• 4:24
  can
• 4:24
  specify
• 4:24
  it
• 4:24
  with
• 4:25
  mood
• 4:25
  congruent
• 4:26
  or
• 4:26
  mood
• 4:26
  incongruent.
• 4:27
  And
• 4:27
  that's
• 4:27
  your
• 4:27
  second
• 4:28
  pearl
• 4:29
  today.
• 4:30
  Okay,
• 4:31
  now
• 4:32
  for
• 4:32
  the
• 4:32
  third
• 4:33
  pearl.
• 4:33
  It's
• 4:34
  important
• 4:34
  that
• 4:34
  you
• 4:35
  focus
• 4:35
  on
• 4:36
  three
• 4:36
  things
• 4:36
  when
• 4:37
  your
• 4:37
  patient
• 4:37
  has
• 4:38
  psychosis
• 4:39
  mixed
• 4:39
  in
• 4:39
  with
• 4:39
  their
• 4:40
  major
• 4:40
  depressive
• 4:41
  disorder.
• 4:42
  First
• 4:42
  of
• 4:42
  all,
• 4:42
  any
• 4:43
  patient
• 4:43
  who's
• 4:43
  ever
• 4:43
  coming
• 4:44
  into
• 4:44
  your
• 4:44
  office
• 4:44
  who
• 4:45
  has
• 4:45
  any
• 4:45
  form
• 4:45
  of
• 4:46
  hallucination
• 4:47
  or
• 4:47
  delusion,
• 4:48
  you
• 4:48
  want
• 4:48
  to
• 4:48
  ask,
• 4:49
  are
• 4:49
  your
• 4:50
  voices,
• 4:51
  what
• 4:51
  are
• 4:51
  they
• 4:51
  telling
• 4:51
  you
• 4:52
  to
• 4:52
  do?
• 4:52
  Are
• 4:52
  they
• 4:52
  telling
• 4:52
  you
• 4:53
  to
• 4:53
  harm
• 4:53
  yourself?
• 4:54
  Are
• 4:54
  they
• 4:54
  encouraging
• 4:55
  you
• 4:55
  to
• 4:55
  run
• 4:56
  into
• 4:56
  traffic
• 4:56
  or
• 4:56
  to
• 4:57
  do
• 4:57
  dangerous
• 4:57
  things,
• 4:57
  Right?
• 4:58
  So
• 4:58
  you
• 4:58
  have
• 4:58
  to
• 4:59
  get
• 4:59
  like
• 4:59
  a
• 4:59
  detective,
• 5:00
  a
• 5:00
  really
• 5:01
  good
• 5:01
  report,
• 5:01
  almost
• 5:02
  like
• 5:02
  a
• 5:02
  police
• 5:02
  report.
• 5:03
  Obviously,
• 5:03
  don't
• 5:04
  tell
• 5:04
  your
• 5:04
  patient
• 5:05
  or
• 5:05
  pretend
• 5:05
  you're
• 5:06
  the
• 5:06
  police
• 5:06
  if
• 5:06
  the
• 5:06
  patient's
• 5:07
  already
• 5:07
  having
• 5:07
  persecutory
• 5:08
  delusions
• 5:08
  here,
• 5:09
  be
• 5:09
  like
• 5:10
  a
• 5:10
  really
• 5:10
  diligent
• 5:11
  FBI
• 5:11
  agent
• 5:13
  that
• 5:14
  is
• 5:15
  making
• 5:15
  sure
• 5:16
  that
• 5:16
  the
• 5:16
  content
• 5:16
  of
• 5:17
  what
• 5:17
  they're
• 5:17
  hearing
• 5:17
  or
• 5:18
  seeing
• 5:18
  or
• 5:19
  what
• 5:19
  they
• 5:19
  believe
• 5:19
  in
• 5:19
  the
• 5:20
  form
• 5:20
  of
• 5:20
  a
• 5:20
  delusion
• 5:20
  is
• 5:21
  not
• 5:21
  something
• 5:21
  that
• 5:22
  that
• 5:22
  could
• 5:22
  potentially
• 5:23
  lead
• 5:23
  them
• 5:23
  into
• 5:24
  harm's
• 5:24
  way
• 5:25
  where
• 5:25
  they
• 5:25
  refuse
• 5:26
  to
• 5:26
  eat,
• 5:26
  they
• 5:26
  refuse
• 5:27
  to
• 5:27
  drink,
• 5:27
  they're
• 5:27
  running
• 5:27
  into
• 5:28
  traffic,
• 5:28
  they
• 5:29
  believe
• 5:29
  someone's
• 5:29
  out
• 5:29
  to
• 5:29
  hurt
• 5:30
  them
• 5:30
  or
• 5:30
  someone
• 5:30
  they
• 5:30
  love.
• 5:31
  Because
• 5:31
  remember,
• 5:31
  if
• 5:32
  you
• 5:32
  actually
• 5:32
  believe
• 5:33
  those
• 5:33
  things,
• 5:33
  you
• 5:33
  might
• 5:34
  take
• 5:34
  specific
• 5:35
  actions
• 5:35
  and
• 5:35
  precautions
• 5:36
  to
• 5:36
  protect
• 5:37
  yourself
• 5:37
  or
• 5:37
  others,
• 5:38
  which
• 5:38
  could
• 5:39
  result
• 5:39
  in
• 5:39
  something
• 5:39
  violent
• 5:40
  or
• 5:40
  harmful.
• 5:41
  This
• 5:41
  is
• 5:41
  an
• 5:41
  emergency,
• 5:42
  right?
• 5:42
  You
• 5:43
  don't
• 5:43
  need
• 5:43
  to
• 5:43
  wheel
• 5:43
  in
• 5:43
  the
• 5:43
  stretcher
• 5:44
  and
• 5:44
  go
• 5:44
  straight
• 5:44
  to
• 5:44
  the
• 5:45
  ER
• 5:45
  the
• 5:45
  second
• 5:45
  you
• 5:46
  see
• 5:46
  psychosis
• 5:46
  in
• 5:46
  your
• 5:46
  office,
• 5:47
  you
• 5:47
  may
• 5:48
  find
• 5:48
  that
• 5:48
  the
• 5:48
  psychosis
• 5:49
  is
• 5:49
  isolated.
• 5:49
  It's
• 5:50
  not
• 5:50
  happening
• 5:50
  in
• 5:50
  the
• 5:50
  office,
• 5:51
  but
• 5:51
  it's
• 5:51
  happening
• 5:52
  in
• 5:52
  the
• 5:52
  wee
• 5:52
  hours
• 5:52
  of
• 5:53
  the
• 5:53
  night.
• 5:53
  It's
• 5:54
  happening
• 5:54
  only
• 5:54
  twice
• 5:55
  a
• 5:55
  week,
• 5:55
  right?
• 5:56
  It's
• 5:56
  not
• 5:56
  like
• 5:56
  the
• 5:56
  patient's
• 5:57
  gonna
• 5:57
  be
• 5:57
  completely
• 5:58
  psychotic
• 5:58
  in
• 5:59
  your
• 5:59
  office.
• 6:00
  You
• 6:00
  need
• 6:01
  to
• 6:01
  be
• 6:01
  a
• 6:01
  detective
• 6:01
  here,
• 6:01
  and
• 6:02
  you
• 6:02
  need
• 6:02
  to
• 6:02
  understand,
• 6:03
  does
• 6:03
  this
• 6:04
  accompany
• 6:04
  suicidal
• 6:05
  ideation
• 6:06
  command
• 6:06
  hallucinations,
• 6:07
  and
• 6:07
  is
• 6:07
  this
• 6:08
  affecting
• 6:08
  the
• 6:09
  patient's
• 6:09
  overall
• 6:09
  functioning?
• 6:10
  In
• 6:10
  other
• 6:10
  words,
• 6:10
  if
• 6:10
  the
• 6:10
  patient
• 6:11
  leaves
• 6:11
  my
• 6:11
  office
• 6:12
  right
• 6:12
  now,
• 6:12
  will
• 6:13
  they
• 6:13
  be
• 6:13
  able
• 6:13
  to
• 6:13
  properly
• 6:14
  take
• 6:14
  care
• 6:14
  of
• 6:14
  themselves?
• 6:15
  Very
• 6:16
  important,
• 6:17
  right?
• 6:17
  And
• 6:18
  I
• 6:18
  just
• 6:18
  can't
• 6:18
  stress
• 6:19
  that
• 6:19
  enough
• 6:19
  because
• 6:20
  think
• 6:20
  about
• 6:20
  it,
• 6:21
  my
• 6:21
  friends.
• 6:21
  Think
• 6:22
  about
• 6:22
  it
• 6:22
  without
• 6:22
  overthinking
• 6:23
  about
• 6:23
  it,
• 6:23
  right?
• 6:24
  If
• 6:24
  you
• 6:24
  have
• 6:25
  a
• 6:25
  fixed
• 6:25
  false
• 6:26
  belief
• 6:27
  that
• 6:28
  aliens
• 6:28
  are
• 6:29
  about
• 6:29
  to
• 6:29
  harm
• 6:29
  you.
• 6:30
  No,
• 6:30
  no,
• 6:30
  no,
• 6:31
  no.
• 6:31
  Imagine
• 6:32
  if
• 6:32
  you
• 6:32
  actually
• 6:32
  believe
• 6:33
  that
• 6:33
  aliens
• 6:34
  were
• 6:34
  out
• 6:34
  to
• 6:34
  kill
• 6:34
  you
• 6:35
  on
• 6:35
  your
• 6:35
  way
• 6:36
  home
• 6:36
  from
• 6:36
  work.
• 6:37
  You're
• 6:37
  gonna
• 6:37
  speed
• 6:38
  home,
• 6:39
  you're
• 6:39
  going
• 6:39
  to
• 6:39
  make
• 6:40
  unsafe
• 6:40
  maneuvers
• 6:41
  on
• 6:41
  the
• 6:41
  highway,
• 6:41
  potentially.
• 6:42
  You
• 6:43
  may
• 6:43
  not
• 6:43
  talk
• 6:43
  to
• 6:44
  certain
• 6:44
  people
• 6:44
  who
• 6:44
  you
• 6:44
  believe
• 6:45
  are
• 6:45
  aliens
• 6:45
  and
• 6:46
  you
• 6:46
  may
• 6:46
  even
• 6:46
  want
• 6:46
  to
• 6:46
  harm
• 6:47
  them
• 6:47
  because
• 6:48
  you
• 6:48
  believe
• 6:48
  you
• 6:48
  are
• 6:49
  under
• 6:49
  direct
• 6:49
  threat.
• 6:50
  So
• 6:50
  again,
• 6:50
  when
• 6:51
  we
• 6:51
  say
• 6:51
  psychosis,
• 6:52
  them
• 6:52
  is
• 6:52
  fighting
• 6:53
  words,
• 6:53
  my
• 6:53
  friends.
• 6:54
  Those
• 6:54
  is
• 6:54
  fighting
• 6:55
  words.
• 6:55
  Think
• 6:55
  about
• 6:56
  all
• 6:56
  the
• 6:56
  potential
• 6:56
  manifestations
• 6:57
  of
• 6:58
  a
• 6:58
  fixed
• 6:58
  false
• 6:58
  belief,
• 6:59
  like
• 6:59
  a
• 6:59
  delusion
• 7:00
  or
• 7:00
  hallucination.
• 7:01
  Think
• 7:01
  about
• 7:01
  how
• 7:02
  disorienting
• 7:02
  that
• 7:03
  is.
• 7:03
  Think
• 7:03
  about
• 7:03
  how
• 7:04
  hard
• 7:04
  it
• 7:04
  is
• 7:04
  to
• 7:04
  even
• 7:04
  eat
• 7:05
  a
• 7:05
  cheeseburger
• 7:05
  while
• 7:06
  you're
• 7:06
  being
• 7:06
  taunted
• 7:07
  by
• 7:07
  and
• 7:07
  auditory
• 7:08
  hallucination.
• 7:10
  This
• 7:10
  is
• 7:10
  real
• 7:10
  deal
• 7:11
  stuff.
• 7:11
  It
• 7:11
  comes
• 7:11
  with
• 7:12
  real
• 7:12
  statistical
• 7:13
  increases
• 7:13
  in
• 7:13
  mortality
• 7:14
  and
• 7:15
  morbidity
• 7:15
  and
• 7:16
  a
• 7:16
  decline
• 7:16
  in
• 7:16
  functioning.
• 7:17
  So
• 7:17
  ask
• 7:18
  those
• 7:18
  safety
• 7:18
  questions
• 7:19
  and
• 7:19
  make
• 7:19
  sure
• 7:20
  that
• 7:21
  your
• 7:21
  patient
• 7:22
  is
• 7:23
  like,
• 7:23
  there's
• 7:24
  no
• 7:24
  stone
• 7:24
  unturned
• 7:25
  as
• 7:25
  it
• 7:25
  relates
• 7:25
  to
• 7:26
  these
• 7:26
  specific
• 7:27
  manifestations
• 7:28
  of
• 7:28
  their
• 7:28
  psychosis.
• 7:29
  Pearl
• 7:29
  number
• 7:30
  four,
• 7:30
  My
• 7:30
  friends,
• 7:31
  this
• 7:32
  is
• 7:32
  a
• 7:32
  diagnostic.
• 7:32
  Pearl.
• 7:33
  A
• 7:33
  little
• 7:33
  bit.
• 7:33
  And
• 7:33
  I'll
• 7:33
  be
• 7:34
  honest,
• 7:34
  as
• 7:34
  a
• 7:34
  student,
• 7:34
  it
• 7:35
  really
• 7:35
  confused
• 7:35
  me
• 7:36
  when
• 7:36
  you
• 7:37
  first
• 7:37
  see
• 7:37
  psychosis
• 7:38
  in
• 7:38
  your
• 7:38
  office,
• 7:39
  you're
• 7:39
  not
• 7:39
  gonna
• 7:40
  have
• 7:40
  some
• 7:40
  cheat
• 7:41
  sheet
• 7:41
  that
• 7:41
  says,
• 7:41
  oh,
• 7:42
  by
• 7:42
  the
• 7:42
  way,
• 7:43
  this
• 7:43
  is
• 7:43
  MDD
• 7:44
  with
• 7:45
  psychotic
• 7:46
  features,
• 7:47
  Mood
• 7:47
  congruent
• 7:48
  specifier.
• 7:49
  Like
• 7:49
  you're
• 7:49
  not
• 7:50
  gonna
• 7:50
  have
• 7:50
  the
• 7:50
  luxury
• 7:51
  of
• 7:51
  someone
• 7:52
  just
• 7:52
  telling
• 7:52
  you
• 7:52
  that
• 7:53
  and
• 7:53
  it
• 7:53
  very
• 7:53
  well
• 7:54
  may
• 7:54
  trip
• 7:54
  you
• 7:54
  up.
• 7:54
  And
• 7:55
  you
• 7:55
  might
• 7:55
  say,
• 7:55
  wait
• 7:55
  a
• 7:55
  minute,
• 7:56
  is
• 7:56
  this
• 7:56
  patient
• 7:56
  schizophrenic?
• 7:57
  Is
• 7:57
  this
• 7:58
  patient
• 7:58
  bipolar
• 7:59
  manic?
• 8:00
  Is
• 8:00
  this
• 8:00
  a
• 8:00
  delusional
• 8:01
  disorder?
• 8:01
  Or
• 8:02
  what
• 8:02
  am
• 8:02
  I
• 8:02
  looking
• 8:02
  at
• 8:02
  here?
• 8:02
  Is
• 8:03
  this
• 8:03
  substance
• 8:03
  induced?
• 8:04
  And
• 8:04
  of
• 8:04
  course
• 8:04
  you
• 8:05
  have
• 8:05
  to
• 8:05
  go
• 8:05
  through
• 8:05
  the
• 8:05
  motions
• 8:06
  and
• 8:06
  ask
• 8:06
  the
• 8:07
  questions,
• 8:07
  but
• 8:08
  again,
• 8:09
  what
• 8:09
  I
• 8:09
  always
• 8:09
  say
• 8:09
  is
• 8:10
  just
• 8:11
  think
• 8:11
  about
• 8:11
  it,
• 8:11
  but
• 8:12
  don't
• 8:12
  overthink
• 8:12
  it.
• 8:12
  If
• 8:13
  psychosis
• 8:13
  is
• 8:14
  happening
• 8:14
  only
• 8:15
  during
• 8:15
  the
• 8:15
  depressive
• 8:16
  episodes,
• 8:17
  you
• 8:18
  have
• 8:18
  MDD
• 8:18
  with
• 8:19
  psychotic
• 8:19
  features,
• 8:20
  right?
• 8:21
  If
• 8:21
  psychosis
• 8:21
  is
• 8:22
  only
• 8:22
  happening
• 8:23
  during
• 8:23
  the
• 8:23
  depression.
• 8:24
  But
• 8:24
  if
• 8:24
  psychosis
• 8:25
  is
• 8:26
  happening
• 8:26
  no
• 8:26
  matter
• 8:27
  what
• 8:27
  you
• 8:27
  feel,
• 8:28
  you
• 8:28
  could
• 8:28
  be
• 8:28
  totally
• 8:29
  not
• 8:29
  depressed
• 8:29
  anymore.
• 8:30
  Your
• 8:30
  depression's
• 8:30
  in
• 8:31
  remission,
• 8:31
  but
• 8:32
  you
• 8:32
  still
• 8:33
  have
• 8:33
  fixed
• 8:33
  false
• 8:34
  beliefs
• 8:34
  that
• 8:34
  the
• 8:35
  people
• 8:35
  at
• 8:35
  the
• 8:35
  dollar
• 8:35
  tree
• 8:36
  are
• 8:36
  trying
• 8:37
  to
• 8:37
  strangle
• 8:37
  you
• 8:38
  or
• 8:38
  that
• 8:39
  the
• 8:39
  ice
• 8:39
  cream
• 8:40
  man
• 8:41
  is
• 8:42
  giving
• 8:42
  you
• 8:42
  cyanide
• 8:44
  and
• 8:44
  you're
• 8:45
  not
• 8:45
  depressed,
• 8:46
  then
• 8:46
  you
• 8:46
  might
• 8:46
  have
• 8:47
  an
• 8:47
  independent
• 8:47
  schizoaffective
• 8:48
  or
• 8:48
  schizophrenic
• 8:49
  spectrum
• 8:50
  type
• 8:50
  disorder
• 8:51
  and
• 8:51
  that
• 8:51
  deserves
• 8:51
  its
• 8:52
  own
• 8:52
  workup.
• 8:53
  There's
• 8:53
  clusters
• 8:53
  of
• 8:54
  symptoms
• 8:54
  you
• 8:54
  have
• 8:54
  to
• 8:54
  look
• 8:54
  at
• 8:55
  there.
• 8:55
  Their
• 8:55
  ability
• 8:56
  to
• 8:56
  engage
• 8:56
  in
• 8:56
  self
• 8:57
  care,
• 8:57
  initiate
• 8:57
  conversations,
• 8:58
  organize
• 8:59
  themselves.
• 9:00
  Of
• 9:00
  course
• 9:00
  you
• 9:00
  have
• 9:00
  to
• 9:01
  assess
• 9:01
  substances
• 9:02
  and
• 9:02
  all
• 9:02
  that
• 9:02
  jazz.
• 9:03
  But
• 9:03
  my
• 9:04
  friends,
• 9:04
  it's
• 9:04
  very
• 9:05
  simple
• 9:05
  that
• 9:05
  if
• 9:06
  depression
• 9:07
  and
• 9:07
  if
• 9:07
  the
• 9:08
  psychosis
• 9:08
  is
• 9:08
  happening
• 9:09
  only
• 9:09
  during
• 9:09
  the
• 9:10
  depression,
• 9:11
  and
• 9:11
  you
• 9:11
  likely
• 9:11
  have
• 9:12
  MDD
• 9:12
  with
• 9:12
  psychotic
• 9:13
  features.
• 9:14
  Okay?
• 10:09
  If
• 10:09
  you
• 10:09
  have
• 10:09
  manic
• 10:10
  symptoms
• 10:10
  mixed
• 10:11
  in,
• 10:11
  don't
• 10:11
  overthink
• 9:17
  it.
• 10:12
  You
• 10:12
  guys
• 10:13
  know
• 10:13
  what
• 10:13
  mania
• 10:13
  looks
• 10:14
  like
• 10:14
  and
• 10:14
  feels
• 10:14
  like
• 10:15
  and
• 10:15
  sounds
• 10:15
  like,
• 10:16
  right?
• 10:16
  Maybe
• 10:16
  you
• 10:16
  don't
• 10:17
  know
• 10:17
  what
• 10:17
  it
• 10:17
  feels
• 10:17
  like.
• 10:17
  Sorry,
• 10:18
  but
• 10:18
  maybe
• 10:19
  you
• 10:19
  know
• 10:19
  what
• 10:19
  it
• 10:20
  looks
• 10:20
  like,
• 10:20
  right?
• 10:21
  You're
• 10:21
  overspending,
• 10:22
  you
• 10:23
  have
• 10:23
  grandiose
• 10:24
  thoughts,
• 10:25
  you
• 10:25
  feel
• 10:25
  euphoric
• 10:26
  or
• 10:26
  highly
• 10:26
  irritable,
• 10:27
  you
• 10:27
  can
• 10:27
  take
• 10:27
  on
• 10:27
  the
• 10:27
  world,
• 10:28
  you're
• 10:28
  promiscuous.
• 10:29
  All
• 10:29
  of
• 10:29
  the
• 10:29
  sudden,
• 10:30
  you're
• 10:30
  talking
• 10:30
  super
• 10:31
  fast,
• 10:31
  you're
• 10:31
  starting
• 10:32
  your
• 10:32
  own
• 10:32
  Soap
• 10:33
  Company
• 10:33
  at
• 10:33
  2:30
• 10:33
  in
• 10:34
  the
• 10:34
  morning.
• 10:34
  Well,
• 10:35
  don't
• 10:35
  be
• 10:35
  confused
• 10:36
  because
• 10:36
  now
• 10:37
  you
• 10:37
  have
• 10:38
  more
• 10:38
  of
• 10:38
  a
• 10:38
  bipolar.
• 10:39
  And
• 10:39
  remember,
• 10:39
  if
• 10:39
  it's
• 10:40
  psychosis
• 10:40
  and
• 10:40
  bipolar,
• 10:41
  it's
• 10:41
  bipolar
• 10:41
  I.
• 10:42
  There
• 10:42
  is
• 10:42
  no
• 10:42
  such
• 10:42
  thing
• 10:42
  as
• 10:43
  bipolar
• 10:43
  2
• 10:43
  with
• 10:44
  psychosis,
• 10:45
  so
• 10:45
  don't
• 10:45
  overthink
• 10:45
  it.
• 10:46
  If
• 10:46
  it
• 10:46
  smells
• 10:46
  like
• 10:46
  mania
• 10:47
  and
• 10:47
  you
• 10:47
  go
• 10:47
  down
• 10:47
  that
• 10:48
  rabbit
• 10:48
  hole
• 10:48
  and
• 10:48
  it
• 10:48
  sure
• 10:49
  enough
• 10:49
  is
• 10:49
  mania
• 10:50
  and
• 10:50
  they're
• 10:50
  meeting
• 10:50
  criteria,
• 10:51
  don't
• 10:51
  panic,
• 10:52
  don't
• 10:52
  get
• 10:52
  confused
• 10:53
  and
• 10:53
  say,
• 10:53
  what
• 10:53
  Is
• 10:53
  this.
• 10:53
  I
• 10:54
  thought
• 10:54
  this
• 10:54
  was
• 10:54
  depression.
• 10:55
  Again,
• 10:56
  assuming
• 10:56
  this
• 10:56
  isn't
• 10:56
  medical,
• 10:57
  assuming
• 10:57
  this
• 10:57
  isn't
• 10:58
  substance
• 10:58
  related,
• 10:58
  yada
• 10:59
  yada,
• 10:59
  yada.
• 11:00
  So
• 11:01
  keep
• 11:01
  it
• 11:01
  simple.
• 11:02
  If
• 11:03
  the
• 11:03
  depression
• 11:04
  and
• 11:04
  psychosis
• 11:05
  are
• 11:05
  married
• 11:06
  to
• 11:06
  each
• 11:06
  other
• 11:06
  exclusively
• 11:07
  and
• 11:08
  there's
• 11:08
  no
• 11:09
  other
• 11:09
  monkey
• 11:09
  business
• 11:10
  going
• 11:10
  on
• 11:11
  with
• 11:11
  the
• 11:11
  psychosis
• 11:12
  in
• 11:12
  other
• 11:12
  areas
• 11:13
  you
• 11:13
  have
• 11:13
  MDD
• 11:13
  with
• 11:13
  psychotic
• 11:14
  features.
• 11:14
  The
• 11:15
  fifth
• 11:15
  pearl,
• 11:15
  my
• 11:15
  friends,
• 11:17
  is
• 11:18
  the
• 11:18
  treatment
• 11:19
  strategies
• 11:20
  that
• 11:20
  are
• 11:20
  commonly
• 11:20
  involved
• 11:21
  in
• 11:21
  MDD
• 11:21
  with
• 11:21
  psychosis.
• 11:22
  And
• 11:23
  they
• 11:23
  typically
• 11:23
  fall
• 11:24
  into
• 11:25
  two
• 11:25
  categories.
• 11:26
  An
• 11:26
  ssri,
• 11:27
  SNRI
• 11:28
  with
• 11:28
  a
• 11:29
  second
• 11:29
  generation
• 11:29
  antipsychotic
• 11:31
  or
• 11:31
  ect.
• 11:33
  Now,
• 11:33
  ECT
• 11:34
  is
• 11:34
  the
• 11:34
  fastest,
• 11:35
  it
• 11:35
  tends
• 11:35
  to
• 11:35
  be
• 11:36
  the
• 11:36
  most
• 11:36
  effective.
• 11:36
  It
• 11:36
  has
• 11:37
  very
• 11:37
  high
• 11:37
  response
• 11:37
  rates,
• 11:38
  up
• 11:38
  to
• 11:38
  80%
• 11:38
  response
• 11:39
  rates
• 11:40
  for
• 11:40
  severe
• 11:40
  depression
• 11:41
  or
• 11:41
  suicidal
• 11:41
  cases.
• 11:42
  The
• 11:42
  evidence
• 11:43
  is
• 11:43
  pretty
• 11:43
  compelling
• 11:43
  for
• 11:44
  ect,
• 11:45
  but
• 11:45
  of
• 11:45
  course
• 11:45
  there
• 11:46
  are
• 11:46
  stigma
• 11:46
  associated
• 11:47
  with
• 11:47
  ect,
• 11:47
  there's
• 11:48
  cost,
• 11:48
  there's
• 11:49
  a
• 11:49
  lot
• 11:49
  of
• 11:49
  insurance
• 11:50
  companies
• 11:50
  that
• 11:50
  don't
• 11:50
  accept
• 11:51
  it.
• 11:51
  There's
• 11:52
  state
• 11:52
  and
• 11:52
  county
• 11:52
  rules
• 11:53
  out
• 11:53
  there
• 11:53
  that
• 11:53
  are
• 11:53
  mixed
• 11:54
  about
• 11:54
  what's
• 11:55
  covered
• 11:55
  and
• 11:55
  what's
• 11:55
  done,
• 11:56
  where
• 11:56
  and
• 11:56
  why.
• 11:57
  So
• 11:57
  ECT
• 11:58
  is
• 11:58
  not
• 11:58
  always
• 11:58
  the
• 11:58
  most
• 11:59
  practical
• 12:00
  immediate
• 12:01
  strategy
• 12:02
  or
• 12:02
  the
• 12:02
  most
• 12:02
  available
• 12:03
  strategy,
• 12:03
  despite
• 12:04
  the
• 12:04
  compelling
• 12:04
  evidence
• 12:05
  and
• 12:05
  the
• 12:05
  fact
• 12:05
  that
• 12:06
  the
• 12:06
  evidence
• 12:07
  suggests
• 12:07
  it's
• 12:07
  being
• 12:08
  underutilized.
• 12:09
  So
• 12:09
  what
• 12:10
  often
• 12:10
  ends
• 12:10
  up
• 12:11
  being
• 12:11
  more
• 12:11
  practical
• 12:11
  is
• 12:12
  an
• 12:12
  SSRI
• 12:12
  plus
• 12:13
  an
• 12:13
  SGA
• 12:13
  or
• 12:14
  an
• 12:14
  SNRI
• 12:14
  plus
• 12:15
  an
• 12:15
  SGA.
• 12:16
  Now,
• 12:16
  the
• 12:16
  two
• 12:16
  most
• 12:17
  studied
• 12:17
  SGAs,
• 12:18
  from
• 12:18
  what
• 12:18
  we
• 12:19
  can
• 12:19
  tell,
• 12:19
  the
• 12:20
  evidence
• 12:20
  is
• 12:20
  suggesting,
• 12:21
  are
• 12:22
  Zyprexa
• 12:23
  and
• 12:23
  Seroquel.
• 12:24
  So
• 12:24
  let's
• 12:25
  say
• 12:25
  you
• 12:25
  would
• 12:25
  have
• 12:25
  a
• 12:25
  Zoloft
• 12:26
  plus
• 12:26
  a
• 12:27
  Seroquel,
• 12:27
  or
• 12:27
  you'd
• 12:27
  have
• 12:28
  a
• 12:28
  Zoloft
• 12:28
  plus
• 12:29
  a
• 12:29
  Zyprexa,
• 12:30
  that
• 12:30
  kind
• 12:30
  of
• 12:30
  thing,
• 12:31
  or
• 12:31
  a
• 12:31
  Prozac
• 12:31
  and
• 12:32
  a
• 12:32
  Zyprexa
• 12:33
  Symbiax.
• 12:34
  There's
• 12:34
  actually
• 12:34
  a
• 12:34
  combination
• 12:35
  medication
• 12:35
  that
• 12:35
  includes
• 12:36
  Zyprexa
• 12:36
  or
• 12:37
  Olanzapine
• 12:37
  and
• 12:37
  Fluoxetine
• 12:39
  called
• 12:39
  Symbiax.
• 12:40
  So
• 12:40
  that
• 12:40
  would
• 12:41
  be
• 12:41
  one
• 12:41
  of
• 12:41
  the
• 12:42
  treatment
• 12:42
  strategies
• 12:43
  you
• 12:44
  can
• 12:44
  go
• 12:44
  for.
• 12:44
  Real
• 12:45
  life.
• 12:45
  Prescribing
• 12:46
  is
• 12:46
  muddy.
• 12:47
  You
• 12:47
  always
• 12:48
  want
• 12:48
  to
• 12:48
  follow
• 12:48
  the
• 12:48
  evidence.
• 12:49
  You
• 12:49
  don't
• 12:50
  want
• 12:50
  to
• 12:50
  run
• 12:50
  in
• 12:50
  blind
• 12:50
  and
• 12:51
  do
• 12:51
  things
• 12:51
  that
• 12:51
  are
• 12:51
  not
• 12:52
  based
• 12:52
  on
• 12:52
  the
• 12:52
  evidence.
• 12:53
  But
• 12:53
  remember,
• 12:53
  the
• 12:54
  best
• 12:54
  medication
• 12:54
  is
• 12:55
  the
• 12:55
  medication
• 12:55
  that
• 12:56
  your
• 12:56
  patient
• 12:56
  will
• 12:56
  take.
• 12:57
  You
• 12:57
  might
• 12:57
  think
• 12:57
  Zyprexa
• 12:58
  is
• 12:58
  the
• 12:58
  best
• 12:58
  medication,
• 12:59
  but
• 12:59
  your
• 12:59
  patient
• 13:00
  might
• 13:00
  also
• 13:00
  be
• 13:00
  80
• 13:01
  pounds
• 13:01
  overweight
• 13:01
  and
• 13:02
  have
• 13:02
  a
• 13:02
  zero
• 13:02
  tolerance
• 13:03
  policy
• 13:03
  for
• 13:03
  weight
• 13:03
  gain.
• 13:04
  Well,
• 13:04
  then
• 13:05
  you're
• 13:05
  kind
• 13:05
  of
• 13:05
  struck
• 13:05
  out.
• 13:06
  You
• 13:06
  can't
• 13:06
  really
• 13:06
  give
• 13:06
  them
• 13:06
  Zyprexa
• 13:07
  if
• 13:07
  their
• 13:07
  metabolic
• 13:08
  panel's
• 13:08
  already
• 13:09
  a
• 13:09
  mess.
• 13:09
  Their
• 13:10
  BMI
• 13:10
  is
• 13:10
  36
• 13:11
  and
• 13:11
  they've
• 13:12
  already
• 13:13
  tried
• 13:13
  Seroquel
• 13:14
  in
• 13:14
  the
• 13:14
  past
• 13:14
  and
• 13:14
  gained
• 13:15
  tons
• 13:15
  of
• 13:15
  weight.
• 13:15
  Good
• 13:16
  luck
• 13:16
  selling
• 13:16
  them
• 13:16
  on
• 13:17
  Zyprexa.
• 13:18
  But
• 13:18
  again,
• 13:18
  you
• 13:18
  have
• 13:19
  a
• 13:19
  pretty
• 13:19
  big
• 13:20
  problem
• 13:20
  in
• 13:20
  front
• 13:20
  of
• 13:20
  you.
• 13:21
  Major
• 13:21
  depressive
• 13:21
  disorder
• 13:22
  with
• 13:22
  psychotic
• 13:22
  features.
• 13:23
  And
• 13:23
  let's
• 13:23
  say
• 13:23
  their
• 13:24
  insurance
• 13:24
  doesn't
• 13:24
  accept
• 13:25
  any
• 13:25
  kind
• 13:26
  of
• 13:26
  reimbursement
• 13:26
  for
• 13:26
  ect.
• 13:27
  This
• 13:27
  is
• 13:27
  where
• 13:28
  real
• 13:28
  life
• 13:28
  prescribing
• 13:29
  comes
• 13:29
  into
• 13:29
  play.
• 13:29
  Right.
• 13:30
  It's
• 13:30
  almost
• 13:30
  like
• 13:30
  a
• 13:30
  game
• 13:30
  of
• 13:31
  chess
• 13:31
  where
• 13:32
  the
• 13:32
  textbook
• 13:32
  says,
• 13:32
  do
• 13:33
  this,
• 13:33
  and
• 13:34
  your
• 13:34
  patients
• 13:34
  and
• 13:34
  insurance
• 13:35
  companies
• 13:36
  and
• 13:36
  the
• 13:36
  realities
• 13:36
  on
• 13:37
  the
• 13:37
  ground
• 13:37
  are
• 13:37
  kind
• 13:37
  of
• 13:37
  putting
• 13:38
  your
• 13:38
  king
• 13:38
  in
• 13:38
  check,
• 13:39
  where
• 13:39
  you
• 13:39
  can't
• 13:39
  make
• 13:39
  certain
• 13:40
  moves.
• 13:40
  So
• 13:41
  you
• 13:41
  have
• 13:41
  to
• 13:41
  put
• 13:41
  this
• 13:41
  through
• 13:42
  a
• 13:42
  filter
• 13:42
  of
• 13:42
  the
• 13:42
  kinds
• 13:43
  of
• 13:43
  insurance,
• 13:43
  what
• 13:44
  the
• 13:44
  evidence
• 13:44
  says,
• 13:45
  what
• 13:45
  your
• 13:45
  patient
• 13:45
  will
• 13:46
  tolerate,
• 13:46
  and
• 13:47
  also,
• 13:47
  of
• 13:48
  course,
• 13:48
  basic
• 13:49
  pharmacology,
• 13:50
  pharmacokinetics,
• 13:51
  and
• 13:51
  pharmacodynamics
• 13:52
  of
• 13:53
  these
• 13:53
  medications
• 13:54
  and
• 13:54
  how
• 13:54
  patient
• 13:55
  will
• 13:55
  respond
• 13:55
  to
• 13:55
  them.
• 13:56
  So
• 13:57
  here.
• 13:57
  Here
• 13:57
  you
• 13:57
  are
• 13:57
  with
• 13:57
  Zyprex
• 13:58
  and
• 13:58
  Seroquel,
• 13:59
  and
• 13:59
  your
• 13:59
  patient
• 13:59
  goes,
• 13:59
  arms
• 14:00
  crossed.
• 14:00
  I'm
• 14:01
  not
• 14:01
  doing
• 14:01
  this.
• 14:02
  I'm
• 14:03
  leaving.
• 14:04
  Well,
• 14:05
  what
• 14:05
  other
• 14:05
  antipsychotics
• 14:06
  do
• 14:06
  you
• 14:07
  have
• 14:07
  access
• 14:07
  to
• 14:07
  that
• 14:08
  you
• 14:08
  could
• 14:08
  potentially
• 14:09
  utilize
• 14:10
  here?
• 14:11
  And
• 14:11
  you
• 14:11
  may
• 14:12
  want
• 14:12
  to
• 14:12
  look
• 14:12
  at
• 14:12
  Abilify.
• 14:13
  It
• 14:13
  has
• 14:14
  some
• 14:14
  evidence
• 14:14
  in
• 14:15
  mitigating
• 14:16
  psychosis
• 14:17
  and
• 14:17
  depression.
• 14:17
  It
• 14:18
  is
• 14:18
  a
• 14:18
  common
• 14:18
  augmentation
• 14:19
  strategy
• 14:20
  in
• 14:20
  depression.
• 14:21
  So
• 14:21
  it
• 14:21
  can.
• 14:22
  It
• 14:22
  can
• 14:22
  actually
• 14:22
  improve
• 14:23
  depression
• 14:23
  on
• 14:24
  its
• 14:24
  own.
• 14:24
  And
• 14:25
  with
• 14:25
  enough
• 14:25
  D2
• 14:25
  blockade,
• 14:26
  we
• 14:27
  know
• 14:27
  it's
• 14:27
  a
• 14:27
  partial
• 14:27
  agonist,
• 14:28
  but
• 14:28
  it
• 14:28
  can
• 14:28
  attenuate
• 14:30
  psychotic
• 14:30
  symptoms.
• 14:31
  So.
• 14:31
  And
• 14:32
  it
• 14:32
  has
• 14:32
  a
• 14:32
  lot
• 14:32
  less
• 14:32
  metabolic
• 14:33
  baggage.
• 14:33
  Remember
• 14:34
  in
• 14:34
  previous
• 14:34
  episodes,
• 14:35
  we
• 14:35
  talked
• 14:35
  about
• 14:35
  how
• 14:35
  it
• 14:36
  weakly
• 14:36
  antagonizes
• 14:37
  5ht
• 14:37
  2c,
• 14:38
  and
• 14:38
  therefore
• 14:39
  it
• 14:39
  doesn't
• 14:39
  cause
• 14:39
  as
• 14:39
  much
• 14:40
  weight
• 14:40
  gain.
• 14:40
  And
• 14:40
  we
• 14:40
  have
• 14:41
  a
• 14:41
  very
• 14:41
  good
• 14:41
  mnemonic
• 14:42
  device
• 14:42
  for
• 14:42
  you
• 14:43
  to
• 14:43
  remember
• 14:44
  if
• 14:44
  you
• 14:44
  zip
• 14:45
  over
• 14:45
  to
• 14:45
  those
• 14:45
  episodes,
• 14:46
  I
• 14:46
  highly
• 14:46
  recommend
• 14:47
  you
• 14:47
  binge
• 14:47
  all
• 14:47
  of
• 14:47
  these
• 14:47
  and
• 14:48
  share
• 14:48
  all
• 14:48
  of
• 14:48
  these.
• 14:48
  They
• 14:49
  all
• 14:49
  kind
• 14:49
  of
• 14:49
  come
• 14:49
  together.
• 14:50
  And
• 14:51
  so
• 14:51
  you
• 14:51
  may
• 14:52
  find,
• 14:52
  hey,
• 14:52
  I'm
• 14:53
  gonna
• 14:53
  pitch
• 14:53
  Abilify.
• 14:54
  But
• 14:54
  remember,
• 14:55
  you've
• 14:55
  gotta
• 14:55
  look
• 14:56
  at
• 14:56
  Abilify
• 14:56
  and
• 14:56
  go,
• 14:56
  okay,
• 14:57
  wait.
• 14:57
  How
• 14:57
  much
• 14:57
  dopamine
• 14:58
  you
• 14:59
  know,
• 14:59
  how
• 14:59
  much
• 14:59
  D2
• 15:00
  can
• 15:00
  I
• 15:00
  block
• 15:01
  here?
• 15:01
  What's
• 15:01
  the
• 15:02
  affinity
• 15:02
  for
• 15:02
  D2?
• 15:04
  What
• 15:04
  circuits
• 15:04
  am
• 15:04
  I
• 15:05
  targeting
• 15:05
  here?
• 15:05
  Is
• 15:05
  Abilify
• 15:06
  gonna
• 15:06
  target
• 15:06
  those
• 15:07
  things?
• 15:07
  You
• 15:07
  have
• 15:07
  to
• 15:08
  know
• 15:08
  every
• 15:09
  time
• 15:09
  you
• 15:09
  whip
• 15:09
  out
• 15:09
  a
• 15:09
  medication.
• 15:10
  What
• 15:11
  is
• 15:11
  the
• 15:11
  affinity
• 15:11
  of
• 15:11
  this
• 15:12
  medication
• 15:12
  for
• 15:12
  specific
• 15:13
  receptors
• 15:14
  in
• 15:14
  specific
• 15:15
  brain
• 15:15
  circuits
• 15:15
  that
• 15:16
  I'm
• 15:16
  targeting
• 15:17
  to
• 15:17
  alleviate
• 15:17
  the
• 15:18
  patient's
• 15:18
  specific
• 15:19
  symptom
• 15:19
  profile?
• 15:20
  In
• 15:20
  this
• 15:20
  case,
• 15:20
  it
• 15:20
  would
• 15:21
  be
• 15:21
  maybe,
• 15:21
  like,
• 15:21
  an
• 15:21
  overactivation
• 15:22
  of
• 15:22
  dopamine
• 15:23
  in
• 15:23
  the
• 15:23
  mesolimbic
• 15:24
  circuits.
• 15:25
  Well,
• 15:25
  which
• 15:25
  medications
• 15:26
  serve
• 15:26
  to
• 15:27
  block
• 15:27
  dopamine
• 15:28
  in
• 15:28
  those
• 15:29
  circuits
• 15:29
  and
• 15:29
  at
• 15:30
  what
• 15:30
  dose?
• 15:30
  The
• 15:31
  affinity.
• 15:32
  Right,
• 15:32
  and
• 15:33
  that's
• 15:33
  really
• 15:33
  important.
• 15:34
  Right.
• 15:34
  And
• 15:35
  how
• 15:35
  effectively
• 15:35
  do
• 15:36
  they
• 15:36
  block
• 15:36
  that.
• 15:37
  So
• 15:37
  you
• 15:37
  could
• 15:37
  look
• 15:37
  at
• 15:37
  a
• 15:38
  Geodon
• 15:38
  or
• 15:38
  an
• 15:38
  Abilify
• 15:39
  or
• 15:40
  some
• 15:40
  other
• 15:41
  second
• 15:41
  generation
• 15:42
  antipsychotic.
• 15:43
  And
• 15:43
  based
• 15:43
  on
• 15:43
  the
• 15:43
  side
• 15:44
  effect
• 15:44
  profiles,
• 15:44
  and
• 15:45
  you
• 15:45
  have
• 15:45
  to
• 15:45
  contend
• 15:46
  with
• 15:46
  those
• 15:46
  side
• 15:46
  effect
• 15:46
  profiles,
• 15:47
  you
• 15:47
  have
• 15:47
  to
• 15:47
  monitor
• 15:47
  the
• 15:48
  patient
• 15:48
  very
• 15:48
  closely
• 15:49
  and
• 15:49
  figure
• 15:49
  it
• 15:49
  out.
• 15:50
  My
• 15:50
  one
• 15:50
  issue
• 15:50
  with
• 15:51
  Seroquel,
• 15:51
  just
• 15:52
  my
• 15:52
  own
• 15:52
  issue,
• 15:52
  I
• 15:52
  love
• 15:52
  it
• 15:53
  for
• 15:53
  specific
• 15:53
  reasons,
• 15:54
  but
• 15:54
  you
• 15:54
  do
• 15:55
  have
• 15:55
  to
• 15:55
  up
• 15:55
  that
• 15:56
  dose
• 15:56
  quite
• 15:56
  a
• 15:56
  bit
• 15:57
  to
• 15:57
  block
• 15:57
  enough
• 15:58
  D2.
• 15:59
  It
• 15:59
  has
• 15:59
  a
• 15:59
  very
• 15:59
  low
• 16:00
  D2
• 16:00
  affinity.
• 16:01
  And
• 16:01
  a
• 16:01
  lot
• 16:01
  of
• 16:02
  people
• 16:02
  just
• 16:02
  feel
• 16:03
  like
• 16:03
  they're
• 16:03
  pretty
• 16:04
  wiped
• 16:04
  out.
• 16:04
  With
• 16:04
  Seroquel,
• 16:05
  it
• 16:05
  really
• 16:06
  can
• 16:06
  wipe
• 16:06
  you
• 16:06
  out
• 16:06
  and
• 16:07
  make
• 16:07
  you
• 16:07
  tired.
• 16:07
  And
• 16:07
  they
• 16:08
  can't
• 16:08
  tolerate
• 16:08
  going
• 16:09
  all
• 16:09
  the
• 16:09
  way
• 16:09
  up
• 16:09
  to
• 16:09
  300
• 16:10
  very
• 16:10
  easily,
• 16:10
  if
• 16:11
  at
• 16:11
  all.
• 16:12
  So
• 16:12
  again,
• 16:12
  your
• 16:12
  textbook
• 16:13
  might
• 16:13
  say,
• 16:14
  well,
• 16:14
  you
• 16:15
  know,
• 16:15
  get
• 16:15
  Seroquel
• 16:16
  up
• 16:16
  to
• 16:16
  the
• 16:17
  300
• 16:17
  to
• 16:17
  500
• 16:18
  range
• 16:18
  and
• 16:19
  start
• 16:19
  blocking
• 16:19
  dopamine
• 16:20
  more
• 16:21
  efficiently
• 16:21
  and
• 16:22
  get
• 16:22
  rid
• 16:22
  of
• 16:22
  those
• 16:22
  psychotic
• 16:22
  symptoms.
• 16:23
  But
• 16:23
  it's
• 16:24
  what
• 16:24
  your
• 16:24
  patient's
• 16:25
  willing
• 16:25
  to
• 16:25
  tolerate.
• 16:25
  And
• 16:26
  if
• 16:26
  they're
• 16:26
  already
• 16:26
  sleeping
• 16:27
  a
• 16:27
  lot,
• 16:27
  it
• 16:28
  might
• 16:28
  not
• 16:28
  be
• 16:28
  your
• 16:29
  agent
• 16:29
  of
• 16:29
  choice.
• 16:29
  So
• 16:30
  this
• 16:30
  is
• 16:30
  where
• 16:30
  things
• 16:30
  get
• 16:31
  complicated.
• 16:31
  But
• 16:31
  for
• 16:32
  simplicity's
• 16:32
  sake,
• 16:33
  ECT
• 16:34
  is
• 16:34
  really
• 16:34
  reserved
• 16:35
  for
• 16:35
  those
• 16:35
  urgent
• 16:35
  or
• 16:36
  severe
• 16:36
  cases.
• 16:36
  It
• 16:36
  has
• 16:37
  a
• 16:37
  faster
• 16:37
  onset,
• 16:38
  it
• 16:38
  tends
• 16:38
  to
• 16:38
  have
• 16:38
  better
• 16:39
  outcomes.
• 16:40
  It's
• 16:40
  very
• 16:40
  effective
• 16:41
  with
• 16:42
  that
• 16:42
  severe
• 16:42
  suicidality,
• 16:43
  impairment,
• 16:44
  grave
• 16:44
  disability,
• 16:45
  psychosis.
• 16:46
  That
• 16:46
  is
• 16:47
  something
• 16:47
  you
• 16:47
  want
• 16:47
  to
• 16:48
  look
• 16:48
  at.
• 16:48
  And
• 16:48
  you
• 16:49
  may
• 16:49
  not
• 16:49
  have
• 16:49
  the
• 16:49
  luxury
• 16:50
  to
• 16:50
  really
• 16:50
  wait
• 16:51
  for
• 16:51
  these
• 16:51
  second
• 16:51
  generation
• 16:52
  antipsychotics
• 16:52
  and
• 16:53
  titrating
• 16:53
  them
• 16:53
  up
• 16:53
  to
• 16:54
  the
• 16:54
  right
• 16:54
  doses
• 16:55
  to
• 16:55
  achieve
• 16:56
  your
• 16:56
  goals.
• 16:57
  And
• 16:57
  of
• 16:57
  course,
• 16:57
  you
• 16:58
  have
• 16:58
  to
• 16:58
  consider
• 16:58
  hospitalization,
• 16:59
  right,
• 16:59
  where
• 17:00
  you
• 17:00
  can
• 17:00
  titrate
• 17:00
  these
• 17:00
  antipsychotics
• 17:01
  more
• 17:01
  aggressively
• 17:02
  with
• 17:02
  monitoring
• 17:03
  because
• 17:03
  the
• 17:03
  patients
• 17:04
  are
• 17:04
  being
• 17:04
  monitored
• 17:04
  all
• 17:05
  of
• 17:05
  the
• 17:05
  time.
• 17:06
  So
• 17:06
  you
• 17:06
  have
• 17:07
  to
• 17:07
  put
• 17:07
  this
• 17:07
  all
• 17:07
  together.
• 17:07
  And
• 17:08
  again,
• 17:08
  this
• 17:08
  is
• 17:08
  why
• 17:08
  I
• 17:09
  love
• 17:09
  this
• 17:09
  field,
• 17:09
  because
• 17:10
  you're
• 17:10
  putting
• 17:10
  this
• 17:10
  all
• 17:11
  together.
• 17:11
  It's
• 17:12
  rewarding.
• 17:12
  And
• 17:13
  you
• 17:13
  have
• 17:13
  a
• 17:13
  human
• 17:13
  in
• 17:14
  front
• 17:14
  of
• 17:14
  you,
• 17:14
  and
• 17:14
  you
• 17:14
  guys
• 17:15
  have
• 17:15
  a
• 17:15
  human
• 17:15
  conversation
• 17:16
  and
• 17:16
  you
• 17:16
  figure
• 17:16
  out
• 17:16
  what's
• 17:17
  best
• 17:17
  for
• 17:17
  that
• 17:17
  particular
• 17:18
  person
• 17:18
  and
• 17:18
  how
• 17:19
  to
• 17:19
  make
• 17:19
  things
• 17:19
  better.
• 17:20
  My
• 17:20
  friends,
• 17:20
  the
• 17:20
  last
• 17:21
  pearl
• 17:21
  today,
• 17:22
  the
• 17:22
  last
• 17:22
  pearl
• 17:23
  is
• 17:23
  that
• 17:23
  you
• 17:23
  don't
• 17:23
  want
• 17:24
  to
• 17:24
  stop
• 17:24
  this
• 17:24
  treatment
• 17:25
  too
• 17:25
  soon,
• 17:26
  okay?
• 17:26
  You
• 17:26
  want
• 17:26
  to
• 17:26
  maintain
• 17:27
  the
• 17:27
  antidepressant
• 17:28
  and
• 17:28
  antipsychotic
• 17:29
  for
• 17:29
  about
• 17:29
  4
• 17:29
  to
• 17:30
  6
• 17:30
  months
• 17:30
  after
• 17:30
  remission,
• 17:31
  9
• 17:32
  to
• 17:32
  12
• 17:32
  months
• 17:32
  if
• 17:33
  multiple
• 17:33
  episodes
• 17:33
  or
• 17:34
  residual
• 17:34
  symptoms
• 17:35
  of
• 17:35
  paranoia
• 17:35
  remain.
• 17:36
  That
• 17:36
  is
• 17:37
  from
• 17:37
  recent
• 17:38
  guidelines.
• 17:39
  The
• 17:39
  evidence
• 17:40
  suggests
• 17:40
  you
• 17:40
  don't
• 17:40
  want
• 17:41
  abrupt
• 17:41
  discontinuation
• 17:42
  of
• 17:42
  these
• 17:42
  agents
• 17:43
  once
• 17:43
  psychosis
• 17:43
  resolves.
• 17:44
  You
• 17:45
  also
• 17:45
  have
• 17:45
  rebound
• 17:45
  psychosis.
• 17:46
  Sometimes
• 17:47
  when
• 17:47
  you're
• 17:47
  blocking
• 17:48
  D2
• 17:49
  for
• 17:49
  prolonged
• 17:49
  periods
• 17:50
  of
• 17:50
  times,
• 17:50
  there's
• 17:50
  upregulation.
• 17:51
  Those
• 17:52
  dopamine
• 17:52
  receptors
• 17:53
  get
• 17:53
  more
• 17:53
  sensitive.
• 17:54
  And
• 17:54
  so
• 17:54
  again,
• 17:55
  you
• 17:55
  don't
• 17:55
  want
• 17:56
  to
• 17:56
  just
• 17:56
  rip
• 17:57
  out
• 17:57
  the
• 17:57
  carpet
• 17:57
  from
• 17:58
  underneath
• 17:58
  these
• 17:58
  patients.
• 17:59
  You
• 17:59
  want
• 17:59
  to
• 17:59
  continue
• 18:00
  care
• 18:00
  both
• 18:01
  the
• 18:01
  antidepressant
• 18:02
  antipsychotic
• 18:02
  for
• 18:03
  greater
• 18:03
  or
• 18:03
  equal
• 18:03
  to
• 18:04
  4
• 18:04
  to
• 18:04
  6
• 18:04
  months
• 18:04
  after
• 18:05
  remission,
• 18:05
  and
• 18:05
  then
• 18:06
  maybe
• 18:06
  9
• 18:06
  to
• 18:06
  12
• 18:06
  months.
• 18:07
  If
• 18:07
  multiple
• 18:08
  episodes
• 18:08
  or
• 18:08
  residual
• 18:09
  symptoms
• 18:09
  are
• 18:10
  present
• 18:10
  and
• 18:11
  every
• 18:11
  patient's
• 18:11
  a
• 18:11
  little
• 18:11
  different,
• 18:12
  the
• 18:12
  guidelines
• 18:13
  can
• 18:13
  change.
• 18:13
  Consult
• 18:14
  your
• 18:14
  guidelines,
• 18:15
  consult
• 18:15
  your
• 18:15
  practice.
• 18:16
  You
• 18:16
  don't
• 18:17
  want
• 18:17
  to
• 18:17
  abruptly
• 18:17
  discontinue.
• 18:18
  And
• 18:18
  a
• 18:18
  general
• 18:19
  conceptual
• 18:19
  appreciation
• 18:20
  for
• 18:21
  what
• 18:21
  this
• 18:21
  is,
• 18:21
  why
• 18:22
  it's
• 18:22
  important
• 18:23
  how
• 18:23
  the
• 18:23
  treatment
• 18:24
  guidelines
• 18:24
  kind
• 18:24
  of
• 18:25
  shift
• 18:25
  and
• 18:25
  change
• 18:25
  the
• 18:25
  things
• 18:26
  you
• 18:26
  need
• 18:26
  to
• 18:26
  specifically
• 18:27
  consider
• 18:28
  when
• 18:28
  you're
• 18:28
  confronting
• 18:28
  MDD
• 18:29
  with
• 18:29
  psychosis.
• 18:29
  It's
• 18:30
  all
• 18:30
  pretty
• 18:30
  interesting.
• 18:31
  It's
• 18:31
  all
• 18:31
  pretty
• 18:32
  high
• 18:32
  stakes,
• 18:32
  and
• 18:32
  I
• 18:33
  hope
• 18:33
  you
• 18:33
  enjoyed
• 18:33
  this.
• 18:33
  I
• 18:33
  hope
• 18:34
  it's
• 18:34
  empowered
• 18:34
  you
• 18:34
  to
• 18:35
  understand
• 18:35
  the
• 18:35
  diagnosis
• 18:36
  a
• 18:36
  little
• 18:36
  better,
• 18:36
  to
• 18:37
  understand
• 18:37
  the
• 18:37
  stakes,
• 18:38
  understand
• 18:38
  the
• 18:38
  treatment
• 18:39
  and
• 18:39
  why
• 18:39
  this
• 18:40
  all
• 18:40
  matters.
• 18:40
  Again,
• 18:41
  I
• 18:41
  can't
• 18:41
  emphasize
• 18:42
  enough.
• 18:42
  My
• 18:42
  friends
• 18:42
  march
• 18:43
  over
• 18:43
  to
• 18:43
  the
• 18:43
  show
• 18:43
  notes,
• 18:44
  become
• 18:44
  Patreon
• 18:45
  members.
• 18:45
  It
• 18:45
  will
• 18:46
  be
• 18:46
  worth
• 18:47
  its
• 18:47
  weight
• 18:47
  in
• 18:48
  gold
• 18:48
  for
• 18:48
  you
• 18:48
  to
• 18:48
  treat
• 18:48
  your
• 18:49
  patients
• 18:49
  a
• 18:49
  little
• 18:49
  better,
• 18:50
  to
• 18:50
  pass
• 18:50
  those
• 18:50
  boards,
• 18:51
  and
• 18:52
  to
• 18:52
  just
• 18:52
  empower
• 18:52
  you.
• 18:53
  Even
• 18:54
  one
• 18:54
  pearl,
• 18:54
  my
• 18:54
  friends,
• 18:55
  can
• 18:55
  radically
• 18:56
  change
• 18:56
  a
• 18:56
  patient's
• 18:57
  day,
• 18:57
  maybe
• 18:57
  a
• 18:57
  patient's
• 18:58
  lives,
• 18:58
  if
• 18:58
  we
• 18:59
  just
• 18:59
  know
• 18:59
  one
• 18:59
  little
• 19:00
  pearl.
• 19:00
  And
• 19:01
  that's
• 19:01
  why
• 19:01
  this
• 19:01
  field
• 19:02
  is
• 19:02
  so
• 19:02
  rewarding.
• 19:02
  This
• 19:03
  is
• 19:03
  so
• 19:03
  much
• 19:03
  more
• 19:03
  than
• 19:03
  just
• 19:04
  passing
• 19:04
  our
• 19:04
  boards.
• 19:05
  It's
• 19:05
  so
• 19:05
  much
• 19:05
  more
• 19:06
  than
• 19:06
  just
• 19:06
  getting
• 19:07
  a
• 19:07
  bunch
• 19:07
  of
• 19:07
  credentials
• 19:08
  and
• 19:08
  going
• 19:08
  to
• 19:08
  school
• 19:08
  and
• 19:08
  earning
• 19:09
  a
• 19:09
  paycheck.
• 19:09
  This
• 19:09
  is
• 19:10
  about
• 19:10
  having
• 19:11
  the
• 19:11
  power
• 19:11
  to
• 19:12
  collect
• 19:12
  pearls
• 19:13
  that
• 19:13
  prep
• 19:13
  you
• 19:14
  to
• 19:14
  change
• 19:14
  lives
• 19:15
  for
• 19:15
  the
• 19:15
  better.
• 19:16
  Signing
• 19:16
  off
• 19:16
  now.
• 19:17
  Thank
• 19:17
  you
• 19:17
  for
• 19:18
  tuning
• 19:18
  in,
• 19:18
  my
• 19:18
  friends.
• 19:19
  Share
• 19:19
  this
• 19:20
  around
• 19:20
  with
• 19:20
  all
• 19:20
  your
• 19:20
  friends.
• 19:21
  It's
• 19:21
  getting
• 19:21
  big
• 19:21
  very
• 19:21
  fast
• 19:22
  and
• 19:22
  we
• 19:22
  appreciate
• 19:23
  all
• 19:23
  of
• 19:23
  you.
• 19:23
  Take
• 19:23
  care.
• 19:24
  Bye
• 19:24
  Bye.