Latest / Pearls and Prep / Optimizing Antidepressant Therapy: To Increase, Switch or Augment?

Transcript

Optimizing Antidepressant Therapy: To Increase, Switch or Augment? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:10
  This
• 0:10
  one
• 0:10
  is
• 0:10
  going
• 0:11
  to
• 0:11
  be
• 0:11
  very
• 0:12
  interesting
• 0:13
  and
• 0:13
  very
• 0:13
  insightful.
• 0:14
  We're
• 0:14
  going
• 0:14
  to
• 0:14
  talk
• 0:14
  about
• 0:15
  partial
• 0:16
  response
• 0:16
  to
• 0:16
  treatment
• 0:17
  with
• 0:17
  antidepressants,
• 0:19
  what
• 0:19
  it
• 0:19
  means,
• 0:20
  what
• 0:20
  to
• 0:21
  do
• 0:21
  when
• 0:21
  your
• 0:21
  patient
• 0:22
  is
• 0:22
  a
• 0:22
  partial
• 0:23
  responder,
• 0:24
  what
• 0:24
  to
• 0:24
  think
• 0:24
  about
• 0:26
  by
• 0:26
  the
• 0:26
  end
• 0:26
  of
• 0:26
  this
• 0:26
  episode.
• 0:27
  My
• 0:28
  goal
• 0:28
  is
• 0:29
  that
• 0:29
  you
• 0:29
  have
• 0:29
  a
• 0:29
  finer
• 0:30
  appreciation
• 0:31
  for
• 0:31
  what
• 0:31
  this
• 0:32
  is,
• 0:32
  why
• 0:32
  it's
• 0:33
  important,
• 0:33
  and
• 0:33
  what
• 0:34
  to
• 0:34
  do
• 0:34
  in
• 0:35
  these
• 0:35
  critical
• 0:35
  moments.
• 0:36
  A
• 0:36
  partial
• 0:37
  response
• 0:38
  to
• 0:38
  treatment
• 0:39
  is
• 0:39
  defined
• 0:40
  as
• 0:41
  less
• 0:41
  than
• 0:42
  a
• 0:42
  50%
• 0:43
  reduction
• 0:44
  in
• 0:44
  depression
• 0:45
  rating
• 0:46
  scores,
• 0:48
  typically
• 0:48
  25
• 0:49
  to
• 0:49
  50%.
• 0:50
  That
• 0:51
  is
• 0:51
  how
• 0:52
  the
• 0:52
  STAR
• 0:52
  D
• 0:52
  trial
• 0:53
  defined
• 0:54
  it.
• 0:54
  And
• 0:55
  that's
• 0:55
  typically
• 0:55
  by
• 0:56
  week
• 0:56
  four
• 0:56
  or
• 0:57
  six.
• 0:57
  Right.
• 0:57
  You
• 0:58
  have
• 0:58
  to
• 0:58
  be
• 0:58
  very
• 0:58
  careful
• 0:58
  about
• 0:59
  timelines
• 0:59
  because
• 1:00
  you
• 1:00
  can't
• 1:00
  define
• 1:01
  a
• 1:02
  partial
• 1:02
  response
• 1:03
  or
• 1:04
  a
• 1:04
  complete
• 1:04
  response
• 1:05
  by
• 1:06
  just
• 1:07
  one
• 1:07
  week
• 1:07
  or
• 1:07
  two.
• 1:08
  We're
• 1:08
  talking
• 1:08
  about
• 1:09
  four
• 1:10
  to
• 1:10
  six
• 1:10
  weeks
• 1:11
  as
• 1:11
  defined
• 1:12
  by
• 1:12
  the
• 1:12
  STARD
• 1:12
  trial.
• 1:13
  The
• 1:13
  STARD
• 1:13
  trial
• 1:14
  is
• 1:14
  abbreviated
• 1:15
  for
• 1:15
  Sequenced
• 1:16
  Treatment
• 1:16
  Alternatives
• 1:17
  to
• 1:17
  Relieve
• 1:18
  Depression.
• 1:18
  It
• 1:19
  was
• 1:19
  the
• 1:19
  largest
• 1:19
  antidepressant
• 1:20
  clinical
• 1:20
  trial
• 1:21
  ever
• 1:21
  conducted
• 1:22
  in
• 1:22
  the
• 1:23
  United
• 1:23
  States.
• 1:24
  What
• 1:24
  was
• 1:24
  really
• 1:24
  cool
• 1:24
  about
• 1:25
  stardee
• 1:25
  is
• 1:26
  it
• 1:26
  studied
• 1:27
  the
• 1:27
  strategies
• 1:28
  involved
• 1:28
  in
• 1:28
  prescribing
• 1:29
  not
• 1:29
  just
• 1:29
  the
• 1:29
  drugs,
• 1:30
  but
• 1:30
  the
• 1:30
  steps
• 1:31
  that
• 1:31
  go
• 1:31
  into
• 1:32
  what
• 1:33
  we
• 1:33
  do
• 1:34
  when
• 1:34
  we
• 1:34
  see
• 1:35
  a
• 1:35
  partial
• 1:35
  response,
• 1:36
  whether
• 1:36
  it
• 1:36
  be
• 1:37
  augmentation,
• 1:38
  whether
• 1:38
  it
• 1:38
  be
• 1:38
  switching
• 1:39
  the
• 1:39
  medication
• 1:39
  entirely.
• 1:40
  So
• 1:40
  in
• 1:40
  other
• 1:40
  words,
• 1:41
  it
• 1:41
  wasn't
• 1:41
  there
• 1:41
  to
• 1:41
  just
• 1:42
  compare
• 1:42
  Lexapro
• 1:43
  and
• 1:43
  Paxil.
• 1:44
  It
• 1:45
  was
• 1:45
  there
• 1:45
  to
• 1:45
  analyze
• 1:46
  how
• 1:46
  to
• 1:46
  handle
• 1:47
  various
• 1:47
  steps
• 1:47
  of
• 1:48
  the
• 1:48
  prescribing
• 1:48
  process.
• 1:49
  And
• 1:50
  that's
• 1:50
  what
• 1:50
  makes
• 1:50
  Stardee
• 1:51
  so
• 1:51
  incredible.
• 1:51
  Right.
• 1:52
  It
• 1:52
  was
• 1:52
  about
• 1:52
  4,000
• 1:53
  some
• 1:53
  patients,
• 1:54
  and
• 1:54
  there
• 1:54
  were
• 1:54
  some
• 1:55
  very
• 1:55
  unique
• 1:56
  pearls
• 1:56
  that
• 1:57
  came
• 1:57
  from
• 1:57
  Stardee.
• 1:58
  I
• 1:58
  want
• 1:59
  to
• 1:59
  back
• 1:59
  up
• 1:59
  a
• 1:59
  little
• 1:59
  and
• 2:00
  talk
• 2:00
  to
• 2:00
  you
• 2:00
  about
• 2:01
  how
• 2:01
  a
• 2:01
  partial
• 2:01
  Response
• 2:02
  is
• 2:02
  typically
• 2:03
  25
• 2:03
  to
• 2:03
  50%
• 2:04
  reduction
• 2:05
  in
• 2:05
  depression
• 2:06
  rating
• 2:06
  scores.
• 2:07
  Right.
• 2:07
  Not
• 2:07
  just
• 2:08
  depression,
• 2:09
  you
• 2:09
  know,
• 2:09
  so
• 2:09
  this
• 2:10
  isn't
• 2:10
  like
• 2:10
  you're
• 2:10
  just
• 2:10
  interviewing
• 2:11
  your
• 2:11
  patient
• 2:11
  and
• 2:11
  they
• 2:12
  go,
• 2:12
  I'm
• 2:12
  a
• 2:12
  little
• 2:12
  better.
• 2:13
  It's
• 2:14
  more
• 2:14
  carefully
• 2:15
  defined
• 2:15
  as
• 2:15
  a
• 2:16
  25
• 2:16
  to
• 2:16
  50%
• 2:17
  reduction.
• 2:17
  We
• 2:18
  want
• 2:18
  a
• 2:18
  metric
• 2:18
  that
• 2:19
  really
• 2:19
  substantiates
• 2:21
  what
• 2:21
  exactly
• 2:22
  is
• 2:22
  getting
• 2:22
  better.
• 2:23
  Right.
• 2:24
  And
• 2:24
  why.
• 2:25
  A
• 2:25
  patient
• 2:26
  who
• 2:26
  says
• 2:26
  they're
• 2:26
  a
• 2:26
  little
• 2:26
  better,
• 2:27
  lo
• 2:27
  and
• 2:27
  behold,
• 2:28
  you
• 2:28
  look
• 2:28
  at
• 2:28
  their
• 2:28
  PHQ9
• 2:29
  and
• 2:29
  it
• 2:29
  might
• 2:30
  be
• 2:30
  just
• 2:30
  as
• 2:30
  bad
• 2:31
  as
• 2:31
  before.
• 2:31
  I've
• 2:32
  had
• 2:32
  patients
• 2:32
  that
• 2:33
  say
• 2:33
  they're
• 2:34
  a
• 2:34
  little
• 2:34
  better
• 2:34
  and
• 2:34
  their
• 2:34
  PHQ9s
• 2:35
  are
• 2:35
  worse.
• 2:36
  Right.
• 2:36
  We've
• 2:36
  got
• 2:37
  to
• 2:37
  bring
• 2:37
  metrics
• 2:38
  into
• 2:38
  our
• 2:38
  practice
• 2:39
  as
• 2:39
  much
• 2:39
  as
• 2:39
  possible
• 2:40
  so
• 2:40
  we
• 2:40
  know
• 2:41
  what's
• 2:41
  going
• 2:41
  on.
• 2:42
  On
• 2:42
  the
• 2:42
  flip
• 2:42
  side,
• 2:43
  we
• 2:43
  don't
• 2:43
  want
• 2:43
  to
• 2:43
  overly
• 2:44
  rely
• 2:44
  on
• 2:45
  a
• 2:45
  metric
• 2:45
  at
• 2:45
  the
• 2:45
  patient's
• 2:46
  expense.
• 2:46
  If
• 2:47
  your
• 2:47
  metric
• 2:47
  Looks
• 2:48
  wonderful.
• 2:48
  But
• 2:48
  your
• 2:48
  patient
• 2:49
  is
• 2:49
  not
• 2:49
  really
• 2:50
  reflecting
• 2:50
  that.
• 2:51
  We
• 2:51
  need
• 2:51
  to
• 2:52
  pause
• 2:52
  and
• 2:52
  really
• 2:53
  listen
• 2:53
  to
• 2:54
  the
• 2:54
  patient
• 2:54
  and
• 2:54
  what
• 2:55
  they
• 2:55
  prefer
• 2:56
  as
• 2:56
  it
• 2:56
  pertains
• 2:57
  to
• 2:57
  their
• 2:57
  treatment.
• 2:57
  Right.
• 2:58
  Because
• 2:58
  you
• 2:58
  could
• 2:58
  have
• 2:58
  this
• 2:59
  impressive
• 2:59
  25,
• 3:00
  30%
• 3:00
  reduction
• 3:01
  in
• 3:01
  the
• 3:02
  nine
• 3:02
  scores.
• 3:03
  But
• 3:03
  the
• 3:03
  patient's
• 3:04
  really
• 3:04
  like,
• 3:04
  I'm
• 3:05
  not
• 3:05
  satisfied.
• 3:05
  I
• 3:06
  don't
• 3:06
  like
• 3:06
  this
• 3:06
  medication
• 3:07
  because
• 3:07
  of
• 3:07
  X,
• 3:07
  Y,
• 3:07
  Z.
• 3:08
  Right.
• 3:08
  I
• 3:08
  don't
• 3:08
  like
• 3:08
  the
• 3:08
  sexual
• 3:09
  side
• 3:09
  effects.
• 3:10
  I
• 3:10
  don't
• 3:10
  like
• 3:10
  how
• 3:11
  I'm
• 3:11
  super
• 3:11
  anxious
• 3:12
  on
• 3:12
  this
• 3:12
  medication
• 3:12
  all
• 3:13
  of
• 3:13
  a
• 3:13
  sudden,
• 3:13
  or
• 3:13
  I'm
• 3:13
  super
• 3:14
  flat
• 3:14
  all
• 3:15
  of
• 3:15
  the
• 3:15
  sudden.
• 3:16
  That
• 3:16
  is
• 3:17
  problematic.
• 3:18
  And
• 3:18
  the
• 3:19
  reduction
• 3:19
  in
• 3:19
  PHQ9
• 3:20
  then
• 3:21
  is
• 3:21
  not
• 3:21
  as
• 3:21
  impressive.
• 3:22
  So,
• 3:22
  yes,
• 3:23
  metrics
• 3:23
  matter.
• 3:23
  They
• 3:24
  absolutely
• 3:24
  matter.
• 3:25
  They
• 3:25
  give
• 3:25
  you
• 3:25
  a
• 3:25
  very
• 3:26
  good
• 3:27
  understanding
• 3:27
  and
• 3:27
  appreciation
• 3:28
  for
• 3:28
  where
• 3:28
  your
• 3:29
  patient
• 3:29
  is
• 3:29
  in
• 3:30
  treatment.
• 3:31
  But
• 3:31
  you
• 3:31
  have
• 3:31
  to
• 3:32
  be
• 3:32
  mindful
• 3:32
  of
• 3:32
  the
• 3:33
  fact
• 3:33
  that
• 3:33
  the
• 3:34
  patient
• 3:34
  also
• 3:34
  has
• 3:35
  a
• 3:35
  very
• 3:35
  important,
• 3:36
  if
• 3:36
  not
• 3:36
  more
• 3:36
  important,
• 3:37
  perspective.
• 3:38
  It's
• 3:38
  very
• 3:38
  reassuring
• 3:39
  if
• 3:39
  you
• 3:39
  have
• 3:39
  a
• 3:40
  40%
• 3:40
  reduction
• 3:40
  in
• 3:41
  PHQ9
• 3:41
  scores
• 3:42
  by
• 3:42
  week
• 3:42
  four
• 3:43
  to
• 3:43
  six
• 3:43
  and
• 3:44
  your
• 3:44
  patient's
• 3:44
  telling
• 3:45
  you
• 3:45
  that
• 3:45
  they
• 3:45
  actually
• 3:46
  do
• 3:46
  feel
• 3:46
  better.
• 3:47
  That's
• 3:48
  what
• 3:48
  we
• 3:48
  want
• 3:48
  to
• 3:48
  see
• 3:49
  in
• 3:49
  practice.
• 3:50
  I
• 3:50
  want
• 3:50
  you
• 3:50
  all
• 3:50
  to
• 3:51
  remember
• 3:51
  to
• 3:52
  wait
• 3:52
  four
• 3:52
  to
• 3:52
  six
• 3:53
  weeks.
• 3:53
  We
• 3:53
  can't
• 3:53
  just
• 3:54
  assess
• 3:54
  the
• 3:55
  patient's
• 3:55
  response
• 3:55
  at
• 3:56
  two
• 3:56
  weeks.
• 3:56
  Granted,
• 3:57
  there's
• 3:58
  some
• 3:58
  mixed
• 3:58
  evidence
• 3:58
  on
• 3:59
  this,
• 3:59
  but
• 3:59
  a
• 4:00
  lot
• 4:00
  of
• 4:00
  patients
• 4:00
  do
• 4:01
  report
• 4:01
  some
• 4:01
  kind
• 4:01
  of
• 4:02
  response
• 4:02
  at
• 4:02
  two
• 4:02
  weeks.
• 4:03
  It's
• 4:03
  very
• 4:03
  early.
• 4:03
  Not
• 4:03
  all
• 4:04
  of
• 4:04
  them
• 4:04
  do.
• 4:05
  There's
• 4:05
  a
• 4:05
  little
• 4:05
  bit
• 4:05
  of
• 4:05
  controversy
• 4:06
  about
• 4:06
  that.
• 4:07
  But
• 4:07
  at
• 4:07
  two
• 4:07
  weeks,
• 4:08
  there
• 4:08
  is
• 4:08
  what
• 4:09
  I
• 4:09
  perceive
• 4:10
  as
• 4:10
  sort
• 4:11
  of
• 4:11
  this
• 4:11
  elbow
• 4:11
  nudge
• 4:12
  that
• 4:12
  the
• 4:12
  patient
• 4:13
  gets
• 4:13
  like
• 4:13
  a,
• 4:13
  hey,
• 4:13
  this
• 4:14
  is
• 4:14
  kind
• 4:14
  of
• 4:14
  what
• 4:14
  the
• 4:14
  med
• 4:15
  is
• 4:15
  doing.
• 4:15
  And
• 4:15
  they
• 4:15
  have
• 4:15
  this
• 4:15
  aha
• 4:16
  moment.
• 4:17
  So
• 4:17
  we
• 4:17
  want
• 4:17
  to
• 4:18
  look
• 4:18
  between
• 4:18
  weeks
• 4:19
  four
• 4:19
  and
• 4:19
  six
• 4:20
  and
• 4:20
  then
• 4:20
  ask
• 4:20
  the
• 4:21
  patient
• 4:22
  what's
• 4:22
  going
• 4:22
  on.
• 4:23
  Look
• 4:23
  at
• 4:23
  the
• 4:23
  metrics.
• 4:24
  If
• 4:24
  you
• 4:24
  see
• 4:25
  a
• 4:25
  partial
• 4:26
  response,
• 4:26
  that's
• 4:26
  25
• 4:27
  to
• 4:27
  49%
• 4:27
  reduction.
• 4:28
  That's
• 4:29
  when
• 4:29
  we
• 4:29
  need
• 4:29
  to
• 4:29
  decide,
• 4:30
  do
• 4:30
  we
• 4:30
  increase
• 4:30
  this?
• 4:31
  Do
• 4:31
  we
• 4:31
  augment
• 4:32
  this?
• 4:33
  You
• 4:33
  may
• 4:33
  see
• 4:33
  the
• 4:33
  patient
• 4:34
  prior
• 4:34
  to
• 4:34
  four
• 4:34
  weeks,
• 4:35
  and
• 4:35
  if
• 4:35
  you're
• 4:35
  lucky,
• 4:36
  at
• 4:36
  week
• 4:37
  two
• 4:37
  or
• 4:37
  three,
• 4:38
  they
• 4:38
  might
• 4:39
  say,
• 4:39
  hey,
• 4:39
  I
• 4:39
  feel
• 4:39
  a
• 4:40
  little
• 4:40
  bit
• 4:40
  better.
• 4:40
  You
• 4:41
  could
• 4:41
  increase
• 4:41
  the
• 4:42
  dose
• 4:42
  if
• 4:42
  they're
• 4:42
  tolerating
• 4:43
  it.
• 4:43
  Well,
• 4:43
  if
• 4:43
  they
• 4:44
  don't
• 4:44
  have
• 4:44
  any
• 4:45
  issues
• 4:45
  at
• 4:45
  two
• 4:46
  to
• 4:46
  three
• 4:46
  weeks,
• 4:46
  they're
• 4:46
  not
• 4:47
  nauseous,
• 4:47
  they
• 4:47
  don't
• 4:48
  have
• 4:48
  a
• 4:48
  lot
• 4:48
  of
• 4:48
  insomnia
• 4:49
  or
• 4:50
  other
• 4:50
  issues,
• 4:50
  then
• 4:51
  it
• 4:51
  might
• 4:51
  be
• 4:52
  a
• 4:52
  good
• 4:52
  time
• 4:52
  to
• 4:53
  increase
• 4:53
  the
• 4:53
  dose,
• 4:54
  depending
• 4:55
  on
• 4:55
  the
• 4:55
  medication
• 4:55
  you
• 4:56
  choose
• 4:56
  and
• 4:56
  its
• 4:56
  half
• 4:57
  life.
• 4:57
  But
• 4:57
  around
• 4:58
  week
• 4:58
  two
• 4:58
  or
• 4:58
  three,
• 4:59
  they
• 4:59
  don't
• 5:00
  have
• 5:00
  those
• 5:00
  side
• 5:00
  effects.
• 5:00
  Maybe
• 5:01
  their
• 5:01
  response
• 5:01
  isn't
• 5:02
  wonderful,
• 5:02
  but
• 5:03
  I
• 5:03
  always
• 5:03
  tell
• 5:03
  my
• 5:03
  patients,
• 5:04
  you
• 5:04
  Know
• 5:04
  what?
• 5:05
  The
• 5:05
  fact
• 5:05
  that
• 5:05
  you
• 5:05
  don't
• 5:05
  have
• 5:06
  any
• 5:06
  side
• 5:06
  effects
• 5:06
  is
• 5:07
  kind
• 5:07
  of
• 5:07
  a
• 5:07
  nice
• 5:07
  luxury
• 5:08
  that
• 5:08
  we
• 5:09
  can
• 5:09
  increase
• 5:09
  this
• 5:10
  and
• 5:10
  at
• 5:11
  least
• 5:11
  get
• 5:11
  you
• 5:11
  to
• 5:11
  a
• 5:11
  more
• 5:12
  optimal
• 5:12
  dose.
• 5:13
  We've
• 5:13
  sort
• 5:14
  of
• 5:14
  been
• 5:14
  cleared
• 5:14
  by
• 5:14
  virtue
• 5:15
  of
• 5:15
  the
• 5:15
  fact
• 5:15
  that
• 5:15
  you
• 5:15
  don't
• 5:16
  have
• 5:16
  a
• 5:16
  lot
• 5:16
  of
• 5:16
  side
• 5:16
  effects.
• 5:17
  Now,
• 5:17
  they
• 5:17
  could
• 5:18
  always
• 5:18
  have
• 5:18
  side
• 5:18
  effects
• 5:19
  when
• 5:19
  you
• 5:19
  increase
• 5:19
  it.
• 5:19
  So
• 5:20
  don't
• 5:20
  pretend
• 5:20
  that
• 5:21
  they're
• 5:21
  completely
• 5:22
  in
• 5:22
  the
• 5:22
  clear
• 5:22
  either.
• 5:23
  But
• 5:23
  to
• 5:24
  me,
• 5:24
  it's
• 5:24
  not
• 5:24
  all
• 5:25
  for
• 5:25
  nothing
• 5:25
  when
• 5:25
  they
• 5:26
  come
• 5:26
  back
• 5:26
  and
• 5:26
  they're
• 5:26
  like,
• 5:26
  well,
• 5:27
  I'm
• 5:27
  not
• 5:27
  worse,
• 5:27
  I'm
• 5:27
  not
• 5:27
  better,
• 5:28
  but
• 5:28
  I
• 5:28
  don't
• 5:28
  have
• 5:28
  side
• 5:28
  effects.
• 5:29
  To
• 5:29
  me,
• 5:29
  that's
• 5:30
  a
• 5:30
  small
• 5:30
  win
• 5:31
  because
• 5:31
  it
• 5:31
  gives
• 5:31
  us
• 5:31
  more
• 5:32
  flexibility
• 5:33
  in
• 5:33
  getting
• 5:34
  that
• 5:34
  dose
• 5:35
  to
• 5:35
  a
• 5:35
  therapeutic
• 5:36
  level.
• 5:36
  Week
• 5:37
  four
• 5:37
  tends
• 5:38
  to
• 5:38
  be
• 5:38
  the
• 5:38
  inflection
• 5:39
  point.
• 5:40
  In
• 5:40
  my
• 5:40
  view
• 5:40
  and
• 5:41
  in
• 5:41
  the
• 5:41
  view
• 5:41
  of
• 5:42
  a
• 5:42
  lot
• 5:42
  of
• 5:42
  the
• 5:42
  evidence,
• 5:43
  week
• 5:43
  four
• 5:44
  is
• 5:44
  the
• 5:45
  inflection
• 5:45
  point
• 5:45
  to
• 5:46
  some
• 5:46
  extent
• 5:47
  where
• 5:47
  you
• 5:48
  do
• 5:48
  have
• 5:48
  to
• 5:48
  decide
• 5:48
  whether
• 5:49
  to
• 5:49
  increase
• 5:49
  or
• 5:50
  augment.
• 5:51
  Now,
• 5:51
  my
• 5:51
  personal
• 5:51
  rule,
• 5:52
  my
• 5:52
  personal
• 5:53
  philosophy
• 5:54
  is
• 5:54
  that
• 5:54
  if
• 5:55
  the
• 5:55
  patient
• 5:55
  is
• 5:55
  singing
• 5:56
  the
• 5:56
  the
• 5:56
  medications
• 5:57
  praises,
• 5:58
  if
• 5:58
  the
• 5:58
  patient
• 5:58
  says,
• 6:00
  I
• 6:00
  like
• 6:00
  this
• 6:00
  medication,
• 6:01
  I
• 6:01
  am
• 6:01
  definitely
• 6:01
  less
• 6:02
  anxious,
• 6:02
  my
• 6:02
  mood
• 6:02
  is
• 6:03
  definitely
• 6:03
  better,
• 6:03
  my
• 6:04
  energy
• 6:04
  is
• 6:04
  better.
• 6:04
  I
• 6:05
  went
• 6:05
  to
• 6:05
  play
• 6:05
  pickleball
• 6:06
  for
• 6:06
  the
• 6:06
  first
• 6:06
  time
• 6:06
  in
• 6:07
  eight
• 6:07
  months.
• 6:08
  I
• 6:08
  don't
• 6:09
  worry
• 6:09
  and
• 6:09
  ruminate
• 6:10
  as
• 6:10
  much.
• 6:10
  I
• 6:11
  look
• 6:11
  at
• 6:11
  that
• 6:11
  as
• 6:11
  a
• 6:12
  very
• 6:12
  good
• 6:12
  opportunity
• 6:13
  to
• 6:13
  increase
• 6:13
  the
• 6:14
  dose.
• 6:14
  There's
• 6:14
  no
• 6:14
  need
• 6:15
  to
• 6:15
  augment
• 6:15
  at
• 6:15
  that
• 6:15
  point.
• 6:16
  Let's
• 6:16
  accentuate
• 6:17
  the
• 6:18
  progress
• 6:18
  the
• 6:18
  patient
• 6:19
  has
• 6:19
  already
• 6:19
  felt.
• 6:20
  Let's
• 6:20
  capitalize
• 6:21
  on
• 6:21
  the
• 6:21
  fact
• 6:21
  that
• 6:22
  there
• 6:22
  are
• 6:22
  no
• 6:22
  major
• 6:23
  side
• 6:23
  effects.
• 6:24
  So
• 6:24
  if
• 6:24
  they're
• 6:25
  all
• 6:25
  about
• 6:25
  the
• 6:25
  medication,
• 6:26
  but
• 6:26
  it's
• 6:26
  just
• 6:26
  not
• 6:27
  a
• 6:27
  full
• 6:27
  throttled
• 6:28
  thing,
• 6:28
  hit
• 6:29
  the
• 6:29
  gas
• 6:29
  a
• 6:29
  little
• 6:30
  bit
• 6:30
  and
• 6:30
  get
• 6:30
  that
• 6:30
  dose
• 6:31
  to
• 6:31
  a
• 6:32
  more
• 6:32
  appropriate
• 6:32
  level.
• 6:33
  That's
• 6:33
  what
• 6:34
  I
• 6:34
  say
• 6:34
  at
• 6:34
  week
• 6:34
  four,
• 6:35
  if
• 6:35
  it's
• 6:35
  very
• 6:35
  positive.
• 6:37
  Now,
• 6:37
  when
• 6:38
  I
• 6:38
  get
• 6:38
  more
• 6:38
  into
• 6:38
  augmenting
• 6:40
  is
• 6:40
  when
• 6:41
  the
• 6:41
  patient
• 6:41
  is
• 6:41
  feeling
• 6:42
  better.
• 6:43
  They're
• 6:43
  doing
• 6:43
  really
• 6:44
  well,
• 6:45
  but
• 6:45
  there
• 6:46
  might
• 6:47
  be
• 6:47
  something
• 6:48
  to
• 6:48
  be
• 6:48
  desired.
• 6:49
  That's
• 6:49
  when
• 6:49
  I
• 6:50
  think
• 6:50
  about
• 6:50
  augmentation.
• 6:51
  What
• 6:51
  do
• 6:51
  I
• 6:51
  mean
• 6:51
  by
• 6:51
  that?
• 6:51
  Let's
• 6:52
  say
• 6:52
  you
• 6:52
  give
• 6:52
  somebody
• 6:53
  Lexapro
• 6:54
  and
• 6:54
  they
• 6:54
  say,
• 6:54
  I
• 6:55
  feel
• 6:55
  really
• 6:55
  good.
• 6:56
  I'm
• 6:56
  way
• 6:56
  less
• 6:57
  anxious,
• 6:57
  but
• 6:58
  I'm
• 6:58
  kind
• 6:58
  of
• 6:58
  emotionally
• 6:59
  fl.
• 6:59
  I
• 7:00
  don't
• 7:00
  really
• 7:00
  feel
• 7:00
  a
• 7:00
  lot
• 7:00
  of
• 7:01
  emotions.
• 7:01
  I
• 7:01
  kind
• 7:01
  of
• 7:02
  wish
• 7:02
  I
• 7:02
  did.
• 7:02
  And
• 7:03
  I'm
• 7:03
  kind
• 7:03
  of
• 7:03
  tired
• 7:04
  in
• 7:04
  the
• 7:04
  morning.
• 7:04
  I'm
• 7:04
  still
• 7:04
  very
• 7:05
  tired
• 7:05
  in
• 7:05
  the
• 7:05
  morning.
• 7:06
  I
• 7:06
  don't
• 7:06
  have
• 7:06
  a
• 7:06
  lot
• 7:06
  of
• 7:06
  energy,
• 7:07
  but
• 7:07
  hey,
• 7:07
  my
• 7:07
  anxiety
• 7:08
  is
• 7:08
  way
• 7:08
  better.
• 7:10
  Now
• 7:10
  I'm
• 7:10
  thinking
• 7:11
  augmentation.
• 7:11
  Why
• 7:12
  is
• 7:12
  that?
• 7:12
  Because
• 7:13
  the
• 7:14
  residual
• 7:15
  complaint
• 7:16
  that
• 7:16
  the
• 7:17
  patient
• 7:17
  is
• 7:17
  presenting
• 7:18
  is
• 7:18
  more
• 7:18
  suitable
• 7:19
  for
• 7:19
  something
• 7:19
  like
• 7:20
  dopamine.
• 7:21
  To
• 7:21
  handle
• 7:22
  than
• 7:22
  more
• 7:22
  Lexapro,
• 7:23
  Right.
• 7:23
  They
• 7:23
  have
• 7:24
  early
• 7:24
  morning
• 7:24
  low
• 7:25
  energy,
• 7:26
  maybe
• 7:26
  brain
• 7:27
  fog.
• 7:27
  They're
• 7:28
  still
• 7:28
  a
• 7:28
  little
• 7:28
  bit
• 7:28
  depressed.
• 7:29
  They're
• 7:29
  slow
• 7:30
  in
• 7:30
  the
• 7:31
  mornings
• 7:32
  and
• 7:32
  could
• 7:32
  use
• 7:33
  more
• 7:33
  energy
• 7:33
  and
• 7:34
  a
• 7:34
  sense
• 7:34
  of
• 7:34
  reward,
• 7:35
  a
• 7:35
  sense
• 7:36
  of
• 7:36
  motivation.
• 7:37
  Now
• 7:37
  I'm
• 7:38
  thinking
• 7:38
  dopamine,
• 7:39
  right.
• 7:39
  A
• 7:39
  little
• 7:40
  more
• 7:40
  pleasure
• 7:41
  serotonin
• 7:42
  can
• 7:42
  blunt
• 7:43
  the
• 7:44
  dopaminergic
• 7:45
  drive,
• 7:45
  which
• 7:46
  can
• 7:46
  hamper
• 7:47
  your
• 7:47
  reward
• 7:47
  sensitivity.
• 7:49
  So
• 7:49
  augmentation
• 7:49
  becomes
• 7:50
  much
• 7:50
  more
• 7:50
  of
• 7:51
  a
• 7:53
  possible
• 7:53
  way
• 7:54
  of
• 7:54
  doing
• 7:54
  things
• 7:55
  when
• 7:55
  your
• 7:55
  current
• 7:55
  medication
• 7:56
  is
• 7:57
  not
• 7:57
  suitable
• 7:58
  for
• 7:58
  their
• 7:58
  residual
• 7:59
  complaints.
• 8:00
  And
• 8:00
  so
• 8:00
  that's
• 8:01
  why
• 8:01
  it's
• 8:01
  really
• 8:01
  critical
• 8:02
  that
• 8:02
  when
• 8:03
  you're
• 8:03
  in
• 8:03
  school
• 8:03
  and
• 8:03
  when
• 8:04
  you
• 8:04
  get
• 8:04
  out
• 8:04
  of
• 8:04
  school,
• 8:04
  you
• 8:05
  have
• 8:05
  a
• 8:05
  fine
• 8:05
  appreciation
• 8:06
  for
• 8:07
  these
• 8:07
  neurotransmitters
• 8:08
  and
• 8:08
  what
• 8:08
  they
• 8:09
  do.
• 8:09
  Exactly.
• 8:09
  And
• 8:10
  the
• 8:10
  unique
• 8:11
  receptor
• 8:11
  profiles
• 8:12
  where
• 8:12
  they
• 8:12
  act.
• 8:13
  A
• 8:13
  lot
• 8:13
  of
• 8:13
  our
• 8:13
  work
• 8:14
  here
• 8:14
  on
• 8:14
  this
• 8:14
  podcast
• 8:16
  relates
• 8:16
  to
• 8:17
  unique
• 8:17
  receptor
• 8:18
  profiles
• 8:19
  and
• 8:20
  targets.
• 8:21
  For
• 8:21
  that
• 8:21
  reason,
• 8:21
  it's
• 8:22
  very
• 8:22
  helpful
• 8:22
  if
• 8:22
  you
• 8:22
  can
• 8:23
  go,
• 8:23
  oh,
• 8:23
  you
• 8:23
  know
• 8:23
  what?
• 8:23
  In
• 8:24
  this
• 8:24
  key
• 8:24
  brain
• 8:24
  region,
• 8:25
  if
• 8:25
  we
• 8:25
  stimulated
• 8:26
  this
• 8:26
  receptor,
• 8:27
  in
• 8:27
  theory,
• 8:27
  this
• 8:28
  medication
• 8:28
  could
• 8:29
  actually
• 8:29
  address
• 8:30
  exactly
• 8:31
  what
• 8:32
  she's
• 8:32
  talking
• 8:33
  about
• 8:33
  here.
• 8:33
  And
• 8:34
  so
• 8:34
  Lexapro,
• 8:35
  she
• 8:35
  comes
• 8:35
  at
• 8:35
  us
• 8:35
  in
• 8:36
  four
• 8:36
  weeks.
• 8:37
  Let's
• 8:37
  say
• 8:37
  we
• 8:37
  have
• 8:37
  a
• 8:37
  mock
• 8:38
  patient
• 8:38
  named
• 8:39
  Mary.
• 8:40
  She
• 8:40
  comes
• 8:40
  to
• 8:40
  you
• 8:40
  in
• 8:41
  four
• 8:41
  weeks.
• 8:41
  She,
• 8:41
  she's
• 8:42
  doing
• 8:42
  well
• 8:42
  on
• 8:42
  the
• 8:42
  Lexa
• 8:43
  Pro.
• 8:43
  She's
• 8:43
  ruminating
• 8:43
  a
• 8:44
  lot
• 8:44
  less,
• 8:44
  but
• 8:45
  she
• 8:45
  has
• 8:46
  early
• 8:47
  morning
• 8:48
  low
• 8:48
  energy
• 8:48
  fatigue,
• 8:50
  a
• 8:50
  little
• 8:50
  depression.
• 8:51
  She
• 8:51
  feels
• 8:51
  kind
• 8:52
  of
• 8:52
  flat.
• 8:52
  Dopamine
• 8:53
  might
• 8:53
  be
• 8:53
  our
• 8:54
  friend.
• 8:54
  In
• 8:54
  that
• 8:54
  case,
• 8:55
  assuming
• 8:55
  we've
• 8:55
  ruled
• 8:56
  out
• 8:56
  medical
• 8:56
  stuff,
• 8:57
  dopamine
• 8:58
  is
• 8:58
  a
• 8:58
  good
• 8:58
  augmentation
• 8:59
  strategy
• 8:59
  there.
• 8:59
  You
• 9:00
  might
• 9:00
  have
• 9:00
  a
• 9:00
  patient
• 9:01
  the
• 9:01
  reverse
• 9:02
  of
• 9:02
  this,
• 9:02
  right?
• 9:03
  You
• 9:03
  start
• 9:03
  them
• 9:03
  on
• 9:03
  Wellbutrin.
• 9:04
  Four
• 9:05
  weeks
• 9:05
  later,
• 9:07
  I
• 9:07
  can't
• 9:07
  sleep.
• 9:08
  I
• 9:08
  have
• 9:08
  a
• 9:09
  lot
• 9:09
  more
• 9:09
  joy,
• 9:09
  but
• 9:09
  I
• 9:10
  can't
• 9:10
  sleep
• 9:11
  and
• 9:11
  I
• 9:11
  have
• 9:11
  no
• 9:12
  appetite.
• 9:13
  And.
• 9:13
  Well,
• 9:14
  do.
• 9:14
  Do
• 9:14
  you
• 9:14
  really
• 9:14
  want
• 9:15
  to
• 9:15
  raise
• 9:15
  WellButrin
• 9:16
  at
• 9:16
  week
• 9:16
  four
• 9:17
  then?
• 9:17
  Because
• 9:17
  it's
• 9:17
  not
• 9:18
  going
• 9:18
  to
• 9:18
  help
• 9:18
  their
• 9:18
  insomnia
• 9:19
  anymore
• 9:20
  if
• 9:20
  they're
• 9:20
  talking
• 9:20
  about
• 9:20
  rumination.
• 9:21
  I'd
• 9:22
  probably
• 9:22
  go
• 9:22
  more
• 9:23
  towards
• 9:23
  the
• 9:23
  serotonergic
• 9:24
  medications,
• 9:24
  and
• 9:25
  I'll
• 9:25
  probably
• 9:25
  augment
• 9:26
  with
• 9:26
  Remeron.
• 9:27
  So
• 9:27
  I
• 9:27
  hope
• 9:27
  you
• 9:27
  can
• 9:28
  see
• 9:28
  the
• 9:28
  difference
• 9:28
  of
• 9:28
  what
• 9:29
  I'm
• 9:29
  talking
• 9:29
  about
• 9:29
  here.
• 9:29
  Right.
• 9:30
  When
• 9:30
  increasing
• 9:31
  a
• 9:31
  medication
• 9:32
  makes
• 9:32
  sense
• 9:32
  versus
• 9:33
  augmenting.
• 9:34
  And
• 9:34
  week
• 9:34
  four
• 9:34
  is
• 9:35
  sort
• 9:35
  of
• 9:35
  that
• 9:35
  point
• 9:35
  that
• 9:36
  you
• 9:36
  got
• 9:36
  to
• 9:36
  figure
• 9:36
  it
• 9:37
  out.
• 9:37
  Now,
• 9:37
  if
• 9:37
  you're
• 9:38
  already
• 9:38
  at
• 9:38
  week
• 9:38
  six,
• 9:39
  God
• 9:39
  forbid,
• 9:40
  you're
• 9:40
  at
• 9:40
  week
• 9:40
  eight
• 9:40
  and
• 9:41
  there's
• 9:41
  just
• 9:41
  no
• 9:41
  response
• 9:42
  at
• 9:42
  all.
• 9:43
  You're
• 9:43
  late,
• 9:44
  you
• 9:44
  don't
• 9:44
  want
• 9:44
  to
• 9:44
  be
• 9:44
  at
• 9:44
  week
• 9:45
  six
• 9:45
  and
• 9:45
  there's
• 9:45
  no
• 9:45
  response.
• 9:46
  Week
• 9:46
  eight
• 9:47
  and
• 9:47
  there's
• 9:47
  no
• 9:47
  response.
• 9:48
  I
• 9:48
  understand
• 9:48
  that
• 9:49
  these
• 9:49
  Medications
• 9:50
  can
• 9:50
  take
• 9:50
  a
• 9:50
  long
• 9:50
  time
• 9:51
  to
• 9:51
  kind
• 9:51
  of
• 9:51
  kick
• 9:51
  in.
• 9:52
  But
• 9:52
  if
• 9:52
  your
• 9:52
  patient's
• 9:53
  sitting
• 9:53
  there
• 9:53
  for
• 9:53
  six
• 9:53
  weeks
• 9:54
  and
• 9:54
  there's
• 9:54
  nothing,
• 9:54
  it's
• 9:55
  crickets.
• 9:56
  I
• 9:56
  view
• 9:56
  that
• 9:56
  as
• 9:56
  a
• 9:56
  bit
• 9:57
  of
• 9:57
  a
• 9:57
  waste
• 9:57
  of
• 9:57
  time.
• 9:57
  I
• 9:57
  like
• 9:58
  to
• 9:58
  see
• 9:58
  some
• 9:58
  glimmer
• 9:59
  of
• 9:59
  hope
• 9:59
  before
• 9:59
  then
• 10:00
  and
• 10:00
  capitalize
• 10:01
  on
• 10:01
  it.
• 10:02
  And
• 10:02
  so
• 10:03
  you
• 10:03
  want
• 10:03
  to
• 10:04
  at
• 10:04
  least
• 10:04
  have
• 10:04
  something,
• 10:05
  you
• 10:05
  know,
• 10:06
  brewing
• 10:06
  by
• 10:06
  week
• 10:07
  four,
• 10:07
  something
• 10:08
  tangible
• 10:08
  that
• 10:09
  the
• 10:09
  patient
• 10:09
  recognizes
• 10:10
  is
• 10:10
  shifting.
• 10:11
  If
• 10:11
  you're
• 10:11
  waiting
• 10:11
  by
• 10:11
  week
• 10:12
  six,
• 10:12
  that's
• 10:13
  really
• 10:13
  not
• 10:14
  good.
• 10:14
  Now,
• 10:15
  if
• 10:15
  you're
• 10:15
  kind
• 10:15
  of
• 10:15
  on
• 10:16
  the
• 10:16
  ledge,
• 10:17
  you're
• 10:17
  at
• 10:17
  week
• 10:17
  six
• 10:18
  and
• 10:18
  we're
• 10:18
  not
• 10:18
  quite
• 10:18
  at
• 10:19
  50%,
• 10:19
  but
• 10:20
  maybe
• 10:20
  we're
• 10:20
  getting
• 10:20
  close,
• 10:21
  then
• 10:22
  we've.
• 10:22
  We've
• 10:23
  got
• 10:23
  to
• 10:23
  already
• 10:24
  be
• 10:24
  thinking
• 10:24
  about
• 10:24
  a
• 10:25
  second
• 10:25
  augmentation
• 10:26
  at
• 10:26
  that
• 10:26
  point,
• 10:26
  if
• 10:26
  we
• 10:26
  haven't
• 10:27
  started
• 10:27
  already,
• 10:27
  or
• 10:27
  a
• 10:28
  med
• 10:28
  switch
• 10:28
  entirely.
• 10:29
  Typically,
• 10:29
  for
• 10:29
  me,
• 10:30
  if
• 10:30
  I'm
• 10:30
  at
• 10:30
  week
• 10:30
  six,
• 10:31
  I
• 10:31
  don't
• 10:31
  have
• 10:32
  a
• 10:32
  50%
• 10:32
  improvement.
• 11:27
  If
• 11:28
  they're
• 11:28
  still
• 11:28
  not
• 11:28
  where
• 11:28
  they
• 11:29
  need
• 11:29
  to
• 11:29
  be
• 11:30
  at
• 11:30
  week
• 11:30
  six,
• 11:31
  side
• 11:31
  effects
• 11:32
  are
• 11:32
  problematic
• 11:33
  and
• 11:34
  there's
• 11:34
  not
• 11:34
  a
• 11:35
  50%
• 11:35
  improvement,
• 11:36
  then
• 11:36
  switching
• 11:37
  makes
• 10:43
  a
• 11:37
  lot
• 11:37
  more
• 11:38
  sense.
• 11:38
  Notice
• 11:39
  when
• 11:39
  augmentation
• 11:40
  makes
• 11:40
  sense,
• 11:41
  when
• 11:41
  there's
• 11:42
  a
• 11:42
  neurotransmitter
• 11:43
  implicated
• 11:44
  that
• 11:44
  still
• 11:45
  begs
• 11:46
  to
• 11:46
  be
• 11:47
  nurtured
• 11:47
  versus
• 11:49
  an
• 11:49
  optimization
• 11:50
  strategy
• 11:50
  where
• 11:51
  things
• 11:51
  are
• 11:51
  going
• 11:51
  really
• 11:52
  well
• 11:52
  and
• 11:53
  increasing
• 11:53
  the
• 11:53
  dose
• 11:53
  will
• 11:54
  only
• 11:54
  accentuate
• 11:54
  those
• 11:55
  effects.
• 11:55
  You're
• 11:55
  getting
• 11:56
  side
• 11:56
  effects
• 11:56
  that
• 11:56
  are
• 11:57
  in
• 11:57
  your
• 11:57
  way,
• 11:57
  and
• 11:58
  the
• 11:58
  improvement
• 11:59
  is
• 11:59
  really
• 11:59
  lackluster,
• 12:00
  where
• 12:00
  the
• 12:00
  patient
• 12:01
  says,
• 12:01
  maybe
• 12:01
  I
• 12:01
  have
• 12:02
  a
• 12:02
  little
• 12:02
  more
• 12:02
  energy,
• 12:02
  but
• 12:02
  I'm
• 12:03
  still
• 12:03
  down.
• 12:03
  I'm
• 12:03
  still
• 12:03
  ruminating,
• 12:04
  I'm
• 12:04
  still
• 12:04
  anxious.
• 12:05
  Those
• 12:06
  are
• 12:06
  three
• 12:06
  red
• 12:07
  flags
• 12:07
  where
• 12:08
  you
• 12:08
  would
• 12:08
  probably
• 12:09
  want
• 12:09
  to
• 12:09
  switch
• 12:10
  entirely.
• 12:11
  So
• 12:12
  the
• 12:12
  answer
• 12:12
  is
• 12:12
  it
• 12:12
  depends.
• 12:13
  These
• 12:13
  start
• 12:13
  D
• 12:14
  trials
• 12:14
  can
• 12:14
  come
• 12:14
  out.
• 12:14
  They
• 12:15
  have
• 12:15
  valuable
• 12:15
  information
• 12:16
  attached
• 12:16
  to
• 12:16
  them,
• 12:17
  but
• 12:17
  the
• 12:18
  answer
• 12:18
  depends,
• 12:18
  because
• 12:19
  every
• 12:19
  patient
• 12:19
  is
• 12:19
  a
• 12:19
  little
• 12:20
  bit
• 12:20
  different
• 12:20
  in
• 12:20
  what
• 12:20
  they're
• 12:21
  willing
• 12:21
  to
• 12:21
  tolerate,
• 12:22
  what
• 12:22
  their
• 12:23
  particular
• 12:23
  symptoms
• 12:24
  mean
• 12:24
  to
• 12:25
  them,
• 12:25
  and
• 12:25
  how
• 12:25
  much
• 12:25
  they
• 12:26
  matter.
• 12:26
  Always
• 12:27
  ask
• 12:27
  yourself,
• 12:28
  what
• 12:28
  is
• 12:28
  the
• 12:28
  single
• 12:29
  most
• 12:29
  distressing
• 12:30
  symptom
• 12:30
  my
• 12:30
  patient
• 12:31
  is
• 12:31
  sharing
• 12:31
  with
• 12:32
  me?
• 12:32
  If
• 12:32
  you
• 12:32
  have
• 12:32
  a
• 12:33
  30%
• 12:33
  reduction
• 12:34
  in
• 12:34
  PHQ9,
• 12:35
  but
• 12:35
  the
• 12:36
  patient's
• 12:37
  anhedonia
• 12:38
  is
• 12:38
  their
• 12:38
  chief
• 12:39
  thing
• 12:40
  that
• 12:40
  is
• 12:40
  in
• 12:40
  their
• 12:41
  way
• 12:41
  and
• 12:41
  making
• 12:41
  life
• 12:42
  more
• 12:42
  distressing
• 12:43
  and
• 12:43
  miserable
• 12:43
  for
• 12:43
  them,
• 12:44
  don't
• 12:44
  ignore
• 12:45
  that
• 12:45
  anhedonia.
• 12:45
  Don't
• 12:46
  be
• 12:46
  satisfied
• 12:46
  with
• 12:47
  your
• 12:47
  PHQ9
• 12:47
  that
• 12:48
  went
• 12:48
  down
• 12:48
  33%
• 12:49
  or
• 12:49
  even
• 12:49
  50
• 12:50
  or
• 12:50
  60%.
• 12:51
  Anhedonia
• 12:52
  is
• 12:52
  just
• 12:52
  dangling
• 12:53
  there
• 12:53
  as
• 12:53
  a
• 12:54
  major
• 12:54
  problem,
• 12:54
  unaddressed.
• 12:55
  Your
• 12:55
  patient
• 12:56
  doesn't
• 12:56
  care
• 12:56
  about
• 12:56
  metrics
• 12:57
  like
• 12:57
  you
• 12:58
  do.
• 12:58
  They
• 12:58
  care
• 12:58
  about
• 12:58
  feeling
• 12:59
  better,
• 13:00
  being
• 13:00
  better
• 13:00
  husbands,
• 13:01
  better
• 13:01
  wives,
• 13:02
  better
• 13:03
  cousins,
• 13:03
  better
• 13:03
  neighbors,
• 13:04
  better
• 13:04
  students.
• 13:05
  Think
• 13:05
  about
• 13:05
  those
• 13:05
  neurotransmitters
• 13:06
  think
• 13:07
  about
• 13:07
  how
• 13:07
  to
• 13:07
  selectively
• 13:08
  target
• 13:08
  them
• 13:09
  for
• 13:10
  your
• 13:10
  patients.
• 13:11
  We
• 13:11
  talked
• 13:12
  a
• 13:12
  little
• 13:12
  bit
• 13:12
  about
• 13:13
  how
• 13:13
  SSRIs
• 13:14
  can
• 13:15
  blunt
• 13:16
  the
• 13:16
  dopamine
• 13:16
  effect,
• 13:17
  and
• 13:17
  I
• 13:18
  want
• 13:18
  you
• 13:18
  to
• 13:18
  be
• 13:18
  especially
• 13:19
  vigilant
• 13:19
  for
• 13:19
  that.
• 13:20
  Suppressing
• 13:20
  dopamine
• 13:21
  via
• 13:21
  the
• 13:21
  5
• 13:22
  HT2C
• 13:22
  receptor.
• 13:23
  SSRIs
• 13:24
  enable
• 13:25
  more
• 13:25
  serotonin
• 13:26
  in
• 13:26
  that
• 13:26
  synapse.
• 13:27
  The
• 13:27
  5
• 13:28
  HT2C
• 13:29
  receptor
• 13:29
  is
• 13:30
  indirectly
• 13:30
  stimulated,
• 13:31
  which
• 13:32
  puts
• 13:32
  the
• 13:32
  brake
• 13:32
  on
• 13:33
  dopamine
• 13:33
  in
• 13:33
  the
• 13:33
  prefrontal
• 13:34
  cortex.
• 13:35
  That's
• 13:35
  why
• 13:35
  a
• 13:35
  lot
• 13:35
  of
• 13:35
  your
• 13:36
  patients
• 13:36
  will
• 13:36
  say
• 13:37
  they
• 13:37
  have
• 13:37
  decreased
• 13:37
  motivation
• 13:38
  and
• 13:38
  energy,
• 13:38
  maybe
• 13:39
  some
• 13:39
  cognitive
• 13:39
  dulling.
• 13:40
  There's
• 13:41
  also
• 13:41
  some
• 13:42
  reactions
• 13:42
  implicated
• 13:43
  in
• 13:43
  reward
• 13:44
  circuits
• 13:44
  where
• 13:45
  things
• 13:45
  don't
• 13:46
  feel
• 13:46
  as
• 13:47
  gratifying
• 13:48
  for
• 13:48
  pumping
• 13:48
  the
• 13:49
  brakes
• 13:49
  in
• 13:49
  specific
• 13:50
  reward
• 13:51
  circuits
• 13:52
  or
• 13:52
  in
• 13:52
  the
• 13:52
  striatum,
• 13:53
  where
• 13:53
  physical
• 13:53
  drive
• 13:54
  is
• 13:54
  reduced.
• 13:55
  We
• 13:55
  have
• 13:56
  agents
• 13:56
  like
• 13:56
  remeron
• 13:57
  that
• 13:57
  antagonize
• 13:58
  5ht
• 13:59
  2c.
• 13:59
  Now,
• 13:59
  of
• 14:00
  course,
• 14:00
  as
• 14:01
  you'll
• 14:01
  learn
• 14:01
  in
• 14:01
  our
• 14:02
  previous
• 14:02
  episodes,
• 14:02
  that
• 14:03
  can
• 14:03
  cause
• 14:03
  weight
• 14:03
  gain,
• 14:04
  right?
• 14:04
  So
• 14:04
  there's
• 14:04
  drawbacks.
• 14:05
  It's
• 14:05
  not
• 14:05
  as
• 14:05
  simple
• 14:05
  as
• 14:06
  augment
• 14:06
  with
• 14:07
  this
• 14:07
  and
• 14:07
  we're
• 14:07
  going
• 14:07
  to
• 14:08
  be
• 14:08
  better,
• 14:08
  right?
• 14:09
  There's
• 14:09
  always
• 14:10
  trade
• 14:10
  offs
• 14:11
  with
• 14:11
  anything
• 14:11
  that
• 14:12
  you
• 14:12
  choose
• 14:12
  in
• 14:12
  psychiatry.
• 14:13
  And
• 14:13
  we
• 14:14
  have
• 14:14
  to
• 14:14
  be
• 14:14
  comfortable
• 14:14
  with
• 14:14
  that.
• 14:15
  And
• 14:15
  we
• 14:15
  have
• 14:15
  to
• 14:15
  be
• 14:16
  honest
• 14:16
  with
• 14:16
  our
• 14:16
  patients.
• 14:16
  We
• 14:17
  don't
• 14:17
  want
• 14:17
  to
• 14:17
  sell
• 14:17
  them
• 14:17
  a
• 14:17
  bill
• 14:18
  of
• 14:18
  goods
• 14:18
  and
• 14:18
  say,
• 14:18
  I
• 14:18
  have
• 14:19
  just
• 14:19
  the
• 14:19
  pill
• 14:19
  for
• 14:19
  you.
• 14:20
  This
• 14:20
  is
• 14:20
  going
• 14:21
  to
• 14:21
  solve
• 14:21
  your
• 14:21
  problem.
• 14:21
  Well,
• 14:22
  there's
• 14:22
  trade
• 14:22
  offs.
• 14:22
  There's
• 14:23
  discussions
• 14:23
  that
• 14:23
  need
• 14:23
  to
• 14:24
  be
• 14:24
  had.
• 14:24
  Remeron
• 14:25
  is
• 14:25
  great
• 14:25
  for
• 14:26
  antagonizing
• 14:26
  that
• 14:27
  5ht
• 14:27
  2c.
• 14:28
  Getting
• 14:28
  a
• 14:28
  little
• 14:28
  more
• 14:29
  dopamine,
• 14:29
  norepinephrine
• 14:30
  in
• 14:30
  the
• 14:30
  prefrontal
• 14:31
  cortex.
• 14:31
  Potentially,
• 14:32
  it's
• 14:32
  great
• 14:33
  to
• 14:33
  counter
• 14:33
  sexual
• 14:34
  side
• 14:34
  effects,
• 14:35
  but
• 14:35
  it
• 14:35
  does
• 14:35
  come
• 14:35
  with
• 14:36
  weight
• 14:36
  gain,
• 14:36
  sometimes
• 14:37
  intolerable
• 14:37
  sedation.
• 14:38
  So
• 14:38
  you
• 14:38
  want
• 14:39
  to
• 14:39
  understand
• 14:39
  where
• 14:40
  the
• 14:40
  seesaw
• 14:41
  is
• 14:41
  here.
• 14:41
  And
• 14:41
  if
• 14:41
  Wellbutrin
• 14:42
  is
• 14:43
  really
• 14:44
  begging
• 14:45
  you
• 14:45
  to
• 14:46
  do
• 14:46
  something
• 14:46
  for
• 14:47
  sleep,
• 14:47
  you
• 14:47
  really
• 14:48
  need
• 14:48
  to
• 14:48
  keep
• 14:48
  Wellbutrin
• 14:49
  on
• 14:49
  hand
• 14:49
  with
• 14:49
  this
• 14:50
  patient
• 14:50
  because
• 14:50
  it's
• 14:50
  benefited
• 14:51
  the
• 14:51
  patient.
• 14:51
  Well,
• 14:51
  then
• 14:51
  Remeron
• 14:52
  makes
• 14:52
  a
• 14:52
  little
• 14:53
  bit
• 14:53
  of
• 14:53
  sense
• 14:53
  in
• 14:53
  that
• 14:53
  regard.
• 14:55
  Now,
• 14:55
  what
• 14:56
  else
• 14:56
  is
• 14:56
  on
• 14:57
  the
• 14:57
  agenda
• 14:57
  here?
• 14:58
  My
• 14:58
  friends
• 14:59
  remember
• 14:59
  one
• 15:00
  thing,
• 15:00
  and
• 15:00
  this
• 15:01
  was
• 15:01
  confused
• 15:01
  me
• 15:01
  at
• 15:02
  first,
• 15:03
  but
• 15:04
  serotonin
• 15:06
  medications,
• 15:06
  SSRIs
• 15:07
  might
• 15:07
  all
• 15:08
  look
• 15:08
  the
• 15:08
  same.
• 15:08
  There
• 15:09
  are
• 15:09
  studies
• 15:09
  that
• 15:09
  show
• 15:09
  they're
• 15:10
  broadly
• 15:10
  as
• 15:10
  efficacious
• 15:11
  as
• 15:11
  each
• 15:11
  other.
• 15:12
  There
• 15:12
  are
• 15:12
  definitely
• 15:13
  some
• 15:13
  that
• 15:13
  are
• 15:13
  superior
• 15:14
  in
• 15:14
  certain
• 15:14
  cases.
• 15:15
  You
• 15:15
  could
• 15:15
  argue
• 15:16
  clinically,
• 15:17
  why
• 15:17
  do
• 15:17
  we
• 15:18
  switch?
• 15:18
  In
• 15:18
  my
• 15:18
  mind
• 15:19
  as
• 15:19
  a
• 15:19
  new
• 15:19
  grad,
• 15:19
  I
• 15:20
  was
• 15:20
  like,
• 15:20
  that
• 15:20
  doesn't
• 15:20
  make
• 15:21
  sense.
• 15:21
  I
• 15:21
  feel
• 15:21
  like
• 15:21
  I'm
• 15:21
  wasting
• 15:22
  the
• 15:22
  patient's
• 15:22
  time.
• 15:23
  Why
• 15:23
  would
• 15:23
  I
• 15:24
  switch
• 15:24
  From
• 15:24
  Lexapro
• 15:25
  to
• 15:25
  Zoloft
• 15:26
  or
• 15:26
  Zoloft
• 15:26
  to
• 15:26
  Prozac
• 15:27
  or
• 15:27
  Pro
• 15:27
  Prozac
• 15:28
  to
• 15:28
  effects
• 15:29
  her.
• 15:30
  Sometimes
• 15:30
  we
• 15:31
  do
• 15:31
  switch
• 15:31
  because
• 15:31
  there
• 15:31
  are
• 15:32
  subtle
• 15:32
  differences
• 15:33
  in
• 15:33
  the
• 15:33
  ways
• 15:34
  these
• 15:35
  receptors
• 15:35
  are
• 15:36
  activated
• 15:36
  and
• 15:36
  implicated.
• 15:37
  You
• 15:38
  have
• 15:38
  a
• 15:38
  little
• 15:38
  dopaminergic
• 15:39
  activity
• 15:40
  with
• 15:40
  Zoloft
• 15:40
  at
• 15:41
  certain
• 15:41
  doses,
• 15:41
  which
• 15:41
  a
• 15:42
  lot
• 15:42
  of
• 15:42
  people
• 15:42
  don't
• 15:42
  know
• 15:42
  about.
• 15:43
  You
• 15:43
  have
• 15:44
  a
• 15:44
  sigma
• 15:45
  receptor
• 15:45
  in
• 15:46
  Luvox.
• 15:46
  That's
• 15:47
  kind
• 15:47
  of
• 15:47
  mysterious.
• 15:47
  We
• 15:48
  can
• 15:48
  go
• 15:48
  into
• 15:48
  that
• 15:48
  in
• 15:48
  future
• 15:48
  episodes.
• 15:49
  Switching
• 15:50
  to
• 15:50
  Wellbutrin,
• 15:51
  you're
• 15:51
  getting
• 15:52
  dopamine
• 15:52
  on
• 15:52
  board.
• 15:53
  Moving
• 15:53
  this
• 15:53
  effects
• 15:54
  are.
• 15:54
  You're
• 15:54
  getting
• 15:54
  more
• 15:54
  norepinephrine
• 15:55
  drive.
• 15:56
  But
• 15:56
  remember
• 15:56
  to
• 15:57
  switch
• 15:57
  from
• 15:58
  Lexapro
• 15:58
  to
• 15:58
  Zoloft
• 16:00
  polymorphisms.
• 16:01
  Right.
• 16:01
  The
• 16:01
  way
• 16:01
  we
• 16:02
  genetically
• 16:03
  handle
• 16:03
  these
• 16:04
  medications
• 16:04
  and
• 16:04
  metabolize
• 16:05
  them
• 16:05
  varies
• 16:06
  from
• 16:06
  person
• 16:06
  to
• 16:06
  person.
• 16:07
  And
• 16:07
  within
• 16:07
  the
• 16:07
  person,
• 16:08
  somebody
• 16:08
  might
• 16:08
  take
• 16:09
  Lexapro
• 16:09
  and
• 16:10
  can't
• 16:10
  handle
• 16:10
  it.
• 16:11
  They
• 16:11
  slowly
• 16:12
  metabolize
• 16:12
  it.
• 16:13
  The
• 16:13
  side
• 16:13
  effects
• 16:14
  are
• 16:14
  terrible.
• 16:15
  That
• 16:15
  blunting
• 16:16
  is
• 16:16
  even
• 16:17
  worse
• 16:17
  for
• 16:17
  them.
• 16:18
  I've
• 16:19
  had
• 16:19
  patients
• 16:19
  get
• 16:20
  super
• 16:20
  sedated
• 16:20
  on
• 16:21
  one
• 16:21
  medication.
• 16:21
  You
• 16:22
  change
• 16:22
  the
• 16:22
  med
• 16:23
  and
• 16:23
  they're
• 16:23
  fine.
• 16:24
  That
• 16:24
  might
• 16:24
  indicate
• 16:25
  that
• 16:25
  they.
• 16:25
  It
• 16:25
  might
• 16:26
  indicate.
• 16:26
  Right.
• 16:27
  Emphasis
• 16:27
  on
• 16:27
  the
• 16:27
  mite.
• 16:28
  It's
• 16:28
  a
• 16:28
  little
• 16:28
  bit
• 16:29
  harder
• 16:29
  to
• 16:29
  prove,
• 16:29
  but,
• 16:30
  you
• 16:31
  know,
• 16:31
  polymorphisms
• 16:32
  are
• 16:32
  implicated
• 16:32
  there
• 16:33
  potentially.
• 16:33
  Right.
• 16:34
  Where
• 16:34
  they
• 16:34
  metabolize
• 16:35
  one
• 16:35
  med
• 16:35
  radically
• 16:36
  different
• 16:36
  than
• 16:36
  the
• 16:36
  other.
• 16:37
  And
• 16:37
  that's
• 16:37
  one
• 16:37
  of
• 16:37
  the
• 16:38
  reasons
• 16:38
  that
• 16:39
  we
• 16:39
  switch.
• 16:40
  But
• 16:40
  before
• 16:40
  you
• 16:41
  even
• 16:42
  confront
• 16:43
  this
• 16:43
  situation
• 16:44
  where
• 16:44
  you
• 16:44
  have
• 16:44
  a
• 16:44
  partial
• 16:45
  responder,
• 16:46
  there's
• 16:46
  so
• 16:46
  many
• 16:46
  other
• 16:47
  questions
• 16:47
  that
• 16:48
  should
• 16:48
  be
• 16:48
  swirling
• 16:48
  in
• 16:49
  your
• 16:49
  mind.
• 16:49
  I
• 16:49
  don't
• 16:49
  want
• 16:49
  to
• 16:50
  overwhelm
• 16:50
  you
• 16:50
  today.
• 16:51
  I
• 16:51
  think
• 16:52
  that
• 16:53
  going
• 16:53
  over
• 16:54
  augmentation
• 16:54
  versus
• 16:55
  optimization
• 16:56
  versus
• 16:56
  switching
• 16:57
  is
• 16:57
  very
• 16:57
  helpful.
• 16:58
  I
• 16:58
  want
• 16:58
  you
• 16:58
  to
• 16:58
  have
• 16:59
  an
• 16:59
  appreciation
• 16:59
  for
• 17:00
  the
• 17:00
  fact
• 17:00
  that
• 17:00
  when
• 17:00
  someone
• 17:01
  has
• 17:01
  a
• 17:01
  partial
• 17:02
  response,
• 17:02
  you
• 17:03
  should
• 17:03
  also
• 17:03
  be
• 17:03
  thinking,
• 17:04
  are
• 17:04
  they
• 17:05
  adherent?
• 17:06
  That's
• 17:06
  an
• 17:06
  important
• 17:06
  question
• 17:07
  because
• 17:07
  some
• 17:07
  patients
• 17:08
  might
• 17:08
  think
• 17:08
  they're
• 17:08
  adherent.
• 17:09
  They
• 17:09
  might
• 17:09
  tell
• 17:09
  you,
• 17:09
  oh,
• 17:10
  yeah,
• 17:10
  I'm
• 17:10
  taking
• 17:10
  my
• 17:10
  meds.
• 17:11
  But
• 17:11
  in
• 17:12
  reality,
• 17:12
  they're
• 17:12
  maybe
• 17:13
  taking
• 17:13
  the
• 17:13
  med
• 17:13
  five
• 17:14
  days
• 17:14
  out
• 17:14
  of
• 17:14
  the
• 17:14
  week
• 17:15
  and
• 17:15
  not
• 17:15
  seven
• 17:15
  days
• 17:16
  out
• 17:16
  of
• 17:16
  the
• 17:16
  week.
• 17:16
  Maybe
• 17:17
  they're
• 17:17
  not
• 17:17
  taking
• 17:17
  it
• 17:17
  at
• 17:18
  the
• 17:18
  right
• 17:18
  time.
• 17:19
  Maybe
• 17:20
  the
• 17:20
  patient
• 17:20
  is
• 17:20
  abusing
• 17:21
  substances
• 17:22
  and
• 17:22
  you
• 17:22
  don't
• 17:22
  have
• 17:22
  as
• 17:22
  good
• 17:23
  enough
• 17:23
  report
• 17:23
  that
• 17:23
  you
• 17:24
  think
• 17:24
  that
• 17:25
  you
• 17:25
  think
• 17:25
  you
• 17:25
  had
• 17:25
  with
• 17:25
  the
• 17:25
  patient.
• 17:26
  That
• 17:26
  the
• 17:26
  patient
• 17:27
  would
• 17:27
  feel
• 17:27
  comfortable
• 17:28
  telling
• 17:28
  you
• 17:28
  that
• 17:28
  they're
• 17:29
  utilizing
• 17:29
  substances
• 17:30
  to
• 17:30
  that
• 17:30
  degree
• 17:31
  and
• 17:31
  that
• 17:31
  those
• 17:31
  substances
• 17:32
  are
• 17:32
  undermining
• 17:33
  the
• 17:33
  medication.
• 17:34
  Maybe
• 17:34
  your
• 17:34
  patient
• 17:35
  is
• 17:36
  exhibiting
• 17:36
  a
• 17:36
  different
• 17:37
  diagnosis
• 17:37
  and
• 17:37
  you
• 17:38
  haven't
• 17:38
  caught
• 17:38
  onto
• 17:38
  it
• 17:38
  yet.
• 17:38
  Maybe
• 17:39
  there's
• 17:39
  some
• 17:39
  creeping
• 17:40
  bipolarity.
• 17:40
  There's.
• 17:41
  Right.
• 17:41
  Maybe
• 17:42
  they
• 17:42
  have
• 17:42
  newfound
• 17:42
  psychosocial
• 17:43
  stressors
• 17:43
  where
• 17:44
  they're
• 17:44
  not
• 17:44
  sleeping
• 17:44
  a
• 17:45
  lot.
• 17:45
  There's
• 17:45
  a
• 17:45
  lot
• 17:46
  of
• 17:46
  things
• 17:46
  that
• 17:46
  could
• 17:47
  cloud
• 17:47
  and
• 17:48
  confuse
• 17:49
  the
• 17:49
  response.
• 17:49
  Here
• 17:50
  we
• 17:50
  are
• 17:50
  beating
• 17:50
  up
• 17:51
  our
• 17:51
  medication
• 17:51
  for
• 17:51
  not
• 17:52
  being
• 17:52
  that
• 17:52
  effective.
• 17:53
  In
• 17:53
  reality,
• 17:54
  there's
• 17:54
  other
• 17:54
  things
• 17:54
  that
• 17:55
  tend
• 17:55
  to
• 17:55
  torpedo
• 17:56
  the
• 17:56
  patient's
• 17:57
  progress
• 17:57
  that
• 17:58
  are
• 17:58
  not
• 17:58
  so
• 17:58
  readily
• 17:59
  obvious
• 17:59
  unless
• 17:59
  we
• 18:00
  do
• 18:00
  some
• 18:00
  really
• 18:00
  good
• 18:01
  clinical
• 18:01
  digging.
• 18:02
  I
• 18:02
  want
• 18:02
  us
• 18:02
  to
• 18:02
  have
• 18:03
  a
• 18:03
  fine
• 18:03
  appreciation
• 18:04
  for
• 18:04
  this.
• 18:04
  There's
• 18:04
  so
• 18:05
  much
• 18:05
  going
• 18:05
  on
• 18:05
  and
• 18:05
  I
• 18:05
  think
• 18:05
  that's
• 18:06
  what
• 18:06
  makes
• 18:06
  psychiatry
• 18:07
  so
• 18:07
  interesting.
• 18:08
  That's
• 18:08
  why
• 18:08
  we
• 18:08
  love
• 18:08
  mental
• 18:09
  health.
• 18:09
  Right.
• 18:10
  It
• 18:10
  depends
• 18:10
  on
• 18:11
  really
• 18:11
  fruitful
• 18:12
  conversations
• 18:12
  and
• 18:12
  clever
• 18:13
  questions
• 18:13
  that
• 18:13
  you
• 18:14
  ask
• 18:14
  the
• 18:14
  patient
• 18:15
  and
• 18:15
  mutual
• 18:16
  collaboration
• 18:17
  responsible
• 18:18
  for
• 18:18
  a
• 18:18
  patient
• 18:19
  who's
• 18:19
  just
• 18:19
  not
• 18:19
  totally
• 18:20
  responding
• 18:21
  to
• 18:21
  a
• 18:21
  medication.
• 18:22
  Right.
• 18:23
  If
• 18:23
  we're
• 18:23
  at
• 18:23
  a
• 18:24
  certain
• 18:24
  timeline
• 18:24
  here,
• 18:25
  we
• 18:25
  talked
• 18:26
  about
• 18:26
  week
• 18:26
  four
• 18:26
  being
• 18:26
  that
• 18:27
  decision
• 18:27
  point
• 18:28
  tied
• 18:28
  with
• 18:28
  good
• 18:29
  metrics
• 18:29
  like
• 18:29
  a
• 18:29
  PHQ9.
• 18:31
  That's
• 18:31
  when
• 18:32
  we
• 18:32
  really
• 18:32
  need
• 18:32
  to
• 18:32
  decide
• 18:33
  what,
• 18:33
  what
• 18:33
  are
• 18:34
  we
• 18:34
  going
• 18:35
  to
• 18:35
  do
• 18:36
  here?
• 18:36
  Very
• 18:37
  valid,
• 18:38
  very
• 18:38
  valid
• 18:38
  question.
• 18:39
  You
• 18:40
  can
• 18:40
  increase
• 18:41
  after
• 18:41
  a
• 18:41
  couple
• 18:41
  weeks
• 18:42
  and
• 18:43
  you
• 18:43
  know,
• 18:43
  a
• 18:43
  couple
• 18:44
  weeks
• 18:44
  is
• 18:44
  early.
• 18:45
  Don't
• 18:45
  expect
• 18:46
  this
• 18:47
  mind
• 18:47
  blowing
• 18:47
  response
• 18:48
  in
• 18:48
  two
• 18:48
  weeks.
• 18:48
  But
• 18:49
  if
• 18:49
  they're
• 18:49
  tolerating
• 18:50
  it
• 18:50
  well,
• 18:50
  you
• 18:51
  can
• 18:51
  start
• 18:51
  to
• 18:51
  increase
• 18:51
  it
• 18:52
  a
• 18:52
  little
• 18:52
  bit
• 18:53
  and
• 18:53
  see
• 18:53
  how
• 18:53
  it
• 18:53
  goes.
• 18:55
  My
• 18:55
  friends
• 18:55
  don't
• 18:56
  under
• 18:56
  treat.
• 18:57
  That's
• 18:58
  a
• 18:58
  very
• 18:58
  important
• 18:58
  point
• 18:59
  too.
• 18:59
  Don't
• 18:59
  be
• 18:59
  satisfied
• 19:01
  with
• 19:01
  a
• 19:01
  50%
• 19:02
  response.
• 19:03
  Take
• 19:04
  action
• 19:04
  with
• 19:04
  respect
• 19:05
  to
• 19:05
  augmentation,
• 19:06
  switching,
• 19:07
  optimizing.
• 19:09
  Don't
• 19:09
  be
• 19:09
  satisfied
• 19:10
  with
• 19:10
  the
• 19:10
  50%
• 19:10
  response.
• 19:11
  That
• 19:12
  is
• 19:12
  not
• 19:12
  acceptable.
• 19:13
  We
• 19:14
  want
• 19:14
  complete
• 19:14
  remission
• 19:15
  of
• 19:15
  symptoms.
• 19:16
  When
• 19:16
  you
• 19:16
  don't
• 19:17
  completely
• 19:17
  extinguish
• 19:18
  the
• 19:18
  fire,
• 19:18
  it
• 19:19
  can
• 19:19
  rage
• 19:19
  on
• 19:19
  again.
• 19:20
  It
• 19:20
  takes
• 19:20
  a
• 19:20
  few
• 19:20
  psychosocial
• 19:21
  stressors,
• 19:21
  some
• 19:22
  substance
• 19:22
  use,
• 19:22
  a
• 19:22
  lack
• 19:23
  of
• 19:23
  adherence,
• 19:23
  and
• 19:23
  all
• 19:24
  of
• 19:24
  a
• 19:24
  sudden
• 19:24
  the
• 19:24
  fire
• 19:24
  starts
• 19:25
  to
• 19:25
  kindle
• 19:25
  and
• 19:25
  you
• 19:25
  have
• 19:26
  this
• 19:26
  big
• 19:26
  raging
• 19:27
  blaze
• 19:27
  and,
• 19:27
  and
• 19:27
  it's
• 19:28
  out
• 19:28
  of
• 19:28
  control.
• 19:28
  We
• 19:29
  want
• 19:29
  to
• 19:29
  extinguish
• 19:30
  these
• 19:30
  symptoms.
• 19:31
  When
• 19:31
  we
• 19:31
  don't,
• 19:32
  the
• 19:32
  evidence
• 19:32
  suggests
• 19:33
  very
• 19:33
  clearly
• 19:34
  that
• 19:34
  the
• 19:35
  patient
• 19:35
  is
• 19:35
  at
• 19:35
  risk
• 19:36
  for
• 19:36
  recurrence,
• 19:37
  relapse,
• 19:38
  further
• 19:38
  disability
• 19:39
  and
• 19:39
  distress.
• 19:39
  And
• 19:40
  we
• 19:40
  just
• 19:40
  don't
• 19:40
  want
• 19:40
  that.
• 19:41
  These
• 19:41
  patients
• 19:41
  are
• 19:41
  often
• 19:41
  in
• 19:42
  school
• 19:43
  or
• 19:43
  have
• 19:44
  kids
• 19:44
  to
• 19:44
  raise,
• 19:45
  or
• 19:46
  they're
• 19:46
  little
• 19:47
  league
• 19:47
  coaches,
• 19:47
  they're
• 19:48
  in
• 19:48
  our
• 19:48
  communities.
• 19:49
  These
• 19:49
  are
• 19:49
  real
• 19:49
  symptoms.
• 19:50
  Even
• 19:50
  if
• 19:50
  the
• 19:50
  metrics
• 19:51
  look
• 19:51
  good,
• 19:52
  we
• 19:52
  have
• 19:52
  a
• 19:52
  unique
• 19:53
  opportunity
• 19:53
  to
• 19:54
  leverage
• 19:55
  our
• 19:55
  knowledge
• 19:55
  to
• 19:55
  make
• 19:56
  their
• 19:56
  lives
• 19:56
  better.
• 19:57
  Right?
• 19:57
  Think
• 19:57
  about
• 19:58
  how
• 19:58
  much
• 19:58
  greater
• 19:59
  your
• 19:59
  life
• 19:59
  could
• 19:59
  be
• 20:00
  if
• 20:00
  you
• 20:00
  can
• 20:00
  just
• 20:00
  focus
• 20:01
  better.
• 20:01
  If
• 20:01
  you're
• 20:02
  not
• 20:02
  as
• 20:02
  tired
• 20:02
  in
• 20:02
  the
• 20:02
  morning,
• 20:03
  if
• 20:03
  you're
• 20:03
  not
• 20:03
  as
• 20:04
  irritable
• 20:04
  with
• 20:05
  your
• 20:05
  spouse,
• 20:06
  if
• 20:06
  you're
• 20:06
  not
• 20:06
  drinking
• 20:06
  as
• 20:07
  much
• 20:07
  because
• 20:07
  your
• 20:07
  mood
• 20:08
  is
• 20:08
  elevated
• 20:08
  and
• 20:09
  now
• 20:09
  you're
• 20:09
  going
• 20:10
  to
• 20:10
  church
• 20:10
  and
• 20:10
  participating
• 20:12
  in
• 20:13
  community
• 20:14
  activities
• 20:14
  and
• 20:15
  getting
• 20:15
  exercise.
• 20:16
  These
• 20:16
  are
• 20:16
  really
• 20:17
  force
• 20:17
  multiplying
• 20:18
  amazing
• 20:19
  benefits.
• 20:20
  I
• 20:20
  want
• 20:20
  you
• 20:20
  to
• 20:20
  be
• 20:20
  very
• 20:21
  attuned
• 20:22
  to
• 20:23
  what
• 20:23
  your
• 20:23
  patients
• 20:24
  continue
• 20:24
  to
• 20:25
  complain
• 20:25
  of.
• 20:26
  Pair
• 20:26
  them
• 20:26
  to
• 20:26
  neurotransmitters.
• 20:28
  Ask
• 20:28
  if
• 20:28
  your
• 20:28
  current
• 20:28
  medication
• 20:29
  is
• 20:29
  able
• 20:30
  to
• 20:30
  satisfy
• 20:31
  that
• 20:31
  void
• 20:32
  and
• 20:32
  at
• 20:33
  what
• 20:33
  dose,
• 20:33
  and
• 20:34
  make
• 20:34
  sure
• 20:34
  it's
• 20:34
  a
• 20:34
  therapeutic
• 20:35
  dose.
• 20:35
  So
• 20:36
  many
• 20:37
  of
• 20:37
  these
• 20:38
  treatment
• 20:38
  resistant
• 20:39
  cases
• 20:39
  are
• 20:39
  really
• 20:39
  just
• 20:40
  underdosing,
• 20:41
  right?
• 20:41
  We
• 20:41
  just
• 20:42
  didn't
• 20:42
  really
• 20:42
  give
• 20:42
  them
• 20:43
  an
• 20:43
  adequate
• 20:43
  trial
• 20:43
  to
• 20:44
  begin
• 20:44
  with.
• 20:44
  If
• 20:45
  you're
• 20:45
  hanging
• 20:45
  out
• 20:45
  at
• 20:45
  5
• 20:46
  milligrams
• 20:46
  of
• 20:46
  Lexapro
• 20:47
  or
• 20:48
  10
• 20:48
  milligrams
• 20:48
  of
• 20:48
  Prozac
• 20:49
  and
• 20:49
  you're
• 20:50
  wondering
• 20:50
  why
• 20:51
  you're
• 20:52
  not
• 20:52
  getting
• 20:52
  where
• 20:52
  you
• 20:52
  want
• 20:53
  to
• 20:53
  be,
• 20:54
  definitely
• 20:54
  look
• 20:54
  at
• 20:55
  that
• 20:55
  dose
• 20:55
  and
• 20:55
  don't
• 20:56
  be
• 20:56
  satisfied
• 20:57
  and
• 20:57
  go
• 20:58
  up
• 20:58
  accordingly
• 20:59
  as
• 20:59
  your
• 20:59
  patient's
• 21:00
  able
• 21:00
  to
• 21:00
  tolerate.
• 21:01
  Walk
• 21:01
  them
• 21:01
  through
• 21:02
  the
• 21:02
  side
• 21:02
  effect
• 21:02
  profiles
• 21:03
  so
• 21:04
  that
• 21:04
  there's
• 21:04
  no
• 21:04
  big
• 21:04
  surprises
• 21:05
  around
• 21:05
  the
• 21:05
  corner.
• 21:06
  Let
• 21:07
  them
• 21:07
  know
• 21:07
  what
• 21:07
  to
• 21:07
  do
• 21:07
  if
• 21:08
  they
• 21:08
  experience
• 21:09
  side
• 21:09
  effects
• 21:10
  and
• 21:10
  how
• 21:10
  to
• 21:10
  handle
• 21:11
  that.
• 21:12
  It's
• 21:12
  a
• 21:12
  dance.
• 21:12
  It's
• 21:13
  critically
• 21:14
  important
• 21:15
  and
• 21:15
  I
• 21:15
  hope
• 21:16
  you
• 21:16
  have
• 21:16
  a
• 21:16
  finer
• 21:16
  appreciation
• 21:17
  now
• 21:18
  for
• 21:19
  what
• 21:19
  to
• 21:20
  do,
• 21:20
  when
• 21:21
  to
• 21:21
  do
• 21:21
  it,
• 21:21
  why
• 21:21
  you're
• 21:22
  doing
• 21:22
  it,
• 21:23
  and
• 21:23
  nerd
• 21:24
  out.
• 21:24
  You
• 21:24
  know
• 21:24
  this
• 21:25
  is
• 21:25
  just
• 21:25
  one
• 21:25
  episode,
• 21:26
  but
• 21:26
  do
• 21:27
  some
• 21:27
  private
• 21:27
  research.
• 21:28
  It's
• 21:28
  so
• 21:28
  much
• 21:28
  fun.
• 21:29
  Nerd
• 21:29
  out
• 21:29
  on
• 21:29
  augmentation
• 21:30
  agents
• 21:30
  and
• 21:31
  what
• 21:31
  they
• 21:31
  do
• 21:31
  and
• 21:31
  why
• 21:32
  some
• 21:32
  are
• 21:32
  better
• 21:32
  than
• 21:32
  others.
• 21:33
  Look
• 21:33
  at
• 21:33
  our
• 21:33
  old
• 21:34
  episodes
• 21:34
  about
• 21:35
  serotonin
• 21:36
  and
• 21:36
  how
• 21:36
  it
• 21:36
  blunts
• 21:37
  specific
• 21:37
  circuits
• 21:38
  and
• 21:38
  what
• 21:38
  you
• 21:38
  can
• 21:38
  do
• 21:39
  about
• 21:39
  that.
• 21:39
  Our
• 21:39
  old
• 21:39
  episodes
• 21:40
  are
• 21:40
  treasure
• 21:40
  trove
• 21:41
  of
• 21:41
  good
• 21:41
  information,
• 21:42
  receptor
• 21:42
  deep
• 21:43
  dot
• 21:43
  case
• 21:43
  studies
• 21:44
  that
• 21:44
  are
• 21:44
  really
• 21:44
  invigorating.
• 21:45
  I
• 21:45
  really
• 21:46
  encourage
• 21:46
  you
• 21:46
  to
• 21:46
  become
• 21:47
  Patreon
• 21:47
  members
• 21:48
  in
• 21:48
  our
• 21:48
  Patreon
• 21:49
  membership.
• 21:49
  We
• 21:50
  have
• 21:50
  beautiful
• 21:51
  slide
• 21:51
  decks
• 21:51
  full
• 21:52
  of
• 21:52
  this
• 21:52
  research,
• 21:52
  full
• 21:53
  of
• 21:53
  these
• 21:53
  receptor
• 21:54
  profiles
• 21:55
  and
• 21:55
  we
• 21:55
  really
• 21:56
  nerd
• 21:56
  out
• 21:56
  and
• 21:56
  have
• 21:56
  fun.
• 21:57
  You
• 21:57
  can
• 21:57
  also
• 21:58
  message
• 21:58
  me
• 21:58
  directly,
• 21:59
  we
• 21:59
  can
• 21:59
  talk
• 21:59
  about
• 22:00
  future
• 22:00
  episode
• 22:01
  ideas
• 22:01
  or
• 22:01
  we
• 22:02
  can
• 22:02
  troubleshoot
• 22:02
  issues
• 22:03
  you
• 22:03
  may
• 22:03
  be
• 22:03
  having.
• 22:04
  We
• 22:04
  also
• 22:05
  have
• 22:05
  a
• 22:05
  private
• 22:05
  podcast
• 22:06
  audio
• 22:06
  feed
• 22:07
  for
• 22:07
  Patreon
• 22:07
  members
• 22:08
  so
• 22:08
  it
• 22:08
  would
• 22:08
  be
• 22:08
  really
• 22:08
  beneficial
• 22:09
  if
• 22:10
  you
• 22:10
  joined
• 22:11
  and
• 22:11
  rated
• 22:11
  us
• 22:11
  on
• 22:11
  Apple
• 22:12
  five
• 22:12
  stars
• 22:12
  with
• 22:13
  a
• 22:13
  comment.
• 22:13
  Thank
• 22:13
  you
• 22:13
  all
• 22:14
  so
• 22:14
  much.
• 22:14
  It's
• 22:14
  always
• 22:14
  a
• 22:14
  pleasure.
• 22:15
  Take
• 22:15
  care.
• 22:15
  Bye
• 22:16
  bye.