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Board Bomb Bonus Episode: This One Wrong Medication Choice Can Blow Up Your Treatment Plan · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:07
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:09
  prep.
• 0:10
  Npc.
• 0:10
  Here,
• 0:10
  your
• 0:11
  preceptor
• 0:11
  in
• 0:11
  your
• 0:12
  pocket,
• 0:12
  your
• 0:12
  go
• 0:12
  to
• 0:13
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:16
  Now
• 0:16
  my
• 0:16
  friends,
• 0:16
  this
• 0:16
  one
• 0:17
  is
• 0:17
  short
• 0:17
  and
• 0:17
  this
• 0:17
  one
• 0:18
  is
• 0:18
  sweet.
• 0:19
  It
• 0:19
  is
• 0:19
  high
• 0:19
  yield.
• 0:20
  It
• 0:20
  gets
• 0:20
  you
• 0:20
  critically
• 0:21
  thinking.
• 0:21
  This
• 0:22
  is
• 0:22
  a
• 0:22
  board
• 0:22
  bomb.
• 0:23
  You
• 0:23
  all
• 0:23
  love
• 0:23
  our
• 0:23
  board
• 0:24
  bombs
• 0:24
  here.
• 0:26
  It's
• 0:26
  always
• 0:26
  fun
• 0:27
  to
• 0:27
  kind
• 0:27
  of
• 0:27
  pick
• 0:28
  your
• 0:28
  brain,
• 0:28
  get
• 0:28
  you
• 0:28
  thinking.
• 0:29
  If
• 0:30
  you're
• 0:30
  in
• 0:30
  zoom
• 0:30
  sessions
• 0:31
  to
• 0:32
  break
• 0:32
  out,
• 0:32
  talk
• 0:33
  to
• 0:33
  your
• 0:33
  peers,
• 0:34
  talk
• 0:34
  to
• 0:34
  your
• 0:35
  fellow
• 0:36
  students,
• 0:36
  clinicians,
• 0:37
  and
• 0:38
  think
• 0:38
  about
• 0:38
  this
• 0:38
  one.
• 0:38
  This
• 0:39
  one's
• 0:39
  gonna
• 0:39
  really
• 0:39
  challenge
• 0:40
  you
• 0:40
  to
• 0:40
  think
• 0:40
  beyond
• 0:41
  the
• 0:41
  medication
• 0:41
  itself,
• 0:42
  maybe
• 0:43
  the
• 0:43
  context.
• 0:44
  And
• 0:45
  so
• 0:45
  here
• 0:45
  we
• 0:45
  go.
• 0:45
  Without
• 0:45
  further
• 0:46
  ado.
• 0:46
  So
• 0:46
  you
• 0:46
  have
• 0:46
  a
• 0:47
  34
• 0:47
  year
• 0:47
  old
• 0:48
  man,
• 0:48
  we're
• 0:49
  gonna
• 0:49
  call
• 0:49
  him
• 0:49
  Lenny.
• 0:50
  And
• 0:51
  he's
• 0:51
  got
• 0:51
  bipolar
• 0:52
  one
• 0:52
  disorder.
• 0:53
  He's
• 0:53
  coming
• 0:53
  to
• 0:53
  the
• 0:53
  community
• 0:53
  health
• 0:54
  clinic
• 0:54
  for
• 0:54
  med
• 0:55
  management.
• 0:56
  For
• 0:56
  the
• 0:56
  last
• 0:56
  three
• 0:57
  weeks
• 0:57
  he's
• 0:57
  been
• 0:57
  depressed,
• 0:59
  he's
• 0:59
  been
• 1:00
  sleeping
• 1:00
  a
• 1:00
  lot,
• 1:01
  he
• 1:01
  can't
• 1:02
  get
• 1:02
  joy
• 1:02
  out
• 1:02
  of
• 1:02
  anything.
• 1:03
  He
• 1:03
  denies
• 1:04
  any
• 1:04
  si
• 1:04
  hi
• 1:05
  of
• 1:05
  note.
• 1:06
  He
• 1:06
  did
• 1:06
  lose
• 1:06
  his
• 1:06
  apartment
• 1:07
  two
• 1:07
  months
• 1:07
  ago.
• 1:08
  He's
• 1:08
  been
• 1:08
  staying
• 1:08
  at
• 1:09
  various
• 1:09
  shelters.
• 1:10
  Occasionally
• 1:11
  he
• 1:11
  sleeps
• 1:11
  outside,
• 1:12
  he
• 1:12
  eats
• 1:13
  when
• 1:13
  he
• 1:13
  can,
• 1:13
  when
• 1:14
  there's
• 1:14
  an
• 1:14
  available
• 1:14
  soup
• 1:15
  kitchen
• 1:15
  or
• 1:15
  something.
• 1:16
  But
• 1:16
  otherwise
• 1:16
  his
• 1:17
  appetite
• 1:17
  is
• 1:17
  fine.
• 1:18
  His
• 1:18
  BMI
• 1:19
  is
• 1:19
  19
• 1:20
  and
• 1:20
  he
• 1:20
  has
• 1:20
  no
• 1:21
  other
• 1:21
  major
• 1:21
  medical
• 1:21
  comorbidities
• 1:23
  and
• 1:23
  he
• 1:23
  doesn't
• 1:24
  take
• 1:24
  any
• 1:24
  other
• 1:24
  medications.
• 1:26
  He
• 1:26
  was
• 1:26
  adherent
• 1:27
  the
• 1:27
  last
• 1:28
  time
• 1:28
  he
• 1:28
  had
• 1:28
  access
• 1:28
  to
• 1:29
  medications
• 1:29
  and
• 1:29
  he
• 1:29
  does
• 1:30
  prefer
• 1:30
  once
• 1:30
  daily
• 1:31
  dosing.
• 1:32
  So
• 1:32
  which
• 1:32
  of
• 1:32
  the
• 1:32
  following
• 1:33
  medications,
• 1:34
  my
• 1:34
  friends,
• 1:35
  is
• 1:35
  the
• 1:35
  least
• 1:35
  appropriate
• 1:36
  pharmacotherapy
• 1:37
  for
• 1:38
  Lenny?
• 1:38
  Is
• 1:39
  it
• 1:39
  A
• 1:39
  seroquel,
• 1:41
  B
• 1:41
  lamictal,
• 1:43
  C
• 1:43
  latuda
• 1:45
  or
• 1:45
  D,
• 1:46
  V
• 1:48
  or
• 1:48
  E
• 1:49
  lumatephrone?
• 1:50
  Okay,
• 1:51
  I'm
• 1:51
  about
• 1:52
  to
• 1:52
  kind
• 1:53
  of
• 1:53
  go
• 1:53
  over
• 1:53
  the
• 1:53
  answers.
• 1:54
  And
• 1:55
  you
• 1:55
  know
• 1:55
  how
• 1:55
  I
• 1:55
  do
• 1:55
  things,
• 1:56
  I
• 1:56
  like
• 1:56
  to
• 1:56
  go
• 1:56
  over
• 1:56
  the
• 1:56
  wrong
• 1:57
  ones
• 1:57
  first
• 1:57
  to
• 1:57
  give
• 1:57
  you
• 1:58
  an
• 1:58
  idea
• 1:58
  of
• 1:58
  why
• 1:58
  the
• 1:58
  right
• 1:58
  one
• 1:59
  is
• 1:59
  right?
• 2:01
  So
• 2:01
  here
• 2:01
  we
• 2:01
  go,
• 2:01
  my
• 2:02
  friends.
• 2:02
  Now,
• 2:03
  when
• 2:04
  we
• 2:04
  eyeball
• 2:04
  this
• 2:06
  question,
• 2:07
  things
• 2:07
  get
• 2:07
  really
• 2:07
  interesting
• 2:08
  very
• 2:09
  quickly.
• 2:09
  And
• 2:09
  this
• 2:09
  is
• 2:09
  why
• 2:10
  I
• 2:10
  love
• 2:10
  psychiatry
• 2:11
  so
• 2:11
  much,
• 2:11
  right?
• 2:11
  Because
• 2:12
  it's
• 2:12
  not
• 2:13
  ever
• 2:13
  as
• 2:13
  simple
• 2:14
  as,
• 2:14
  oh,
• 2:14
  what's
• 2:15
  the
• 2:15
  FDA
• 2:15
  indication?
• 2:16
  Oh,
• 2:16
  let's
• 2:17
  go
• 2:17
  ahead
• 2:17
  and
• 2:17
  prescribe
• 2:18
  that
• 2:18
  one.
• 2:19
  It's
• 2:19
  never
• 2:19
  that
• 2:20
  simple
• 2:20
  because
• 2:21
  you
• 2:21
  have
• 2:21
  a
• 2:21
  living,
• 2:21
  breathing
• 2:22
  human
• 2:22
  being
• 2:22
  in
• 2:22
  front
• 2:23
  of
• 2:23
  you
• 2:23
  who
• 2:23
  has
• 2:23
  a
• 2:23
  very
• 2:24
  nuanced
• 2:24
  world.
• 2:25
  And
• 2:26
  in
• 2:26
  this
• 2:27
  case,
• 2:27
  the
• 2:27
  question
• 2:27
  is
• 2:28
  really
• 2:28
  trying
• 2:28
  to
• 2:29
  get
• 2:29
  you
• 2:29
  to
• 2:29
  sniff
• 2:29
  out
• 2:29
  the
• 2:30
  social
• 2:30
  determinants
• 2:31
  of
• 2:31
  health,
• 2:31
  right?
• 2:32
  What
• 2:32
  separates
• 2:32
  Lenny
• 2:33
  from
• 2:33
  an
• 2:33
  average
• 2:34
  Joe
• 2:35
  is
• 2:35
  the
• 2:35
  fact
• 2:36
  that
• 2:36
  he
• 2:36
  is
• 2:36
  housing
• 2:38
  insecure,
• 2:39
  right?
• 2:39
  He's
• 2:39
  at
• 2:39
  various
• 2:40
  shelters,
• 2:41
  he
• 2:41
  sleeps
• 2:41
  outside,
• 2:42
  he
• 2:42
  eats
• 2:43
  when
• 2:43
  he
• 2:43
  can.
• 2:44
  And
• 2:45
  so
• 2:45
  there's
• 2:46
  A
• 2:46
  bit
• 2:46
  of
• 2:46
  a
• 2:46
  nuance
• 2:47
  in
• 2:47
  this
• 2:47
  question.
• 2:48
  It
• 2:48
  also
• 2:49
  shared
• 2:49
  with
• 2:49
  you
• 2:49
  his
• 2:50
  BMI
• 2:51
  and
• 2:51
  that
• 2:51
  he
• 2:52
  has
• 2:52
  no
• 2:52
  problem
• 2:54
  being
• 2:54
  adherent
• 2:54
  and
• 2:55
  he
• 2:55
  does
• 2:55
  have
• 2:55
  access
• 2:55
  to
• 2:56
  his
• 2:56
  medications
• 2:56
  and
• 2:57
  he
• 2:57
  wants.
• 2:57
  Wants
• 2:57
  daily
• 2:58
  dosing.
• 2:58
  So
• 2:59
  with
• 2:59
  those
• 3:00
  details
• 3:00
  in
• 3:00
  mind,
• 3:01
  which,
• 3:02
  you
• 3:02
  know,
• 3:02
  we
• 3:02
  gotta
• 3:03
  look
• 3:03
  at
• 3:03
  all
• 3:03
  of
• 3:03
  these
• 3:04
  medications
• 3:04
  and
• 3:04
  just
• 3:05
  think,
• 3:05
  like,
• 3:05
  which.
• 3:05
  Which
• 3:06
  one
• 3:06
  of
• 3:06
  these
• 3:06
  would
• 3:06
  be
• 3:07
  not
• 3:08
  appropriate?
• 3:08
  And
• 3:09
  by
• 3:09
  just
• 3:09
  eyeballing
• 3:10
  these
• 3:10
  medications,
• 3:11
  Seroquel
• 3:12
  is
• 3:12
  not
• 3:12
  a
• 3:12
  good
• 3:12
  fit
• 3:13
  for
• 3:13
  him.
• 3:13
  Right?
• 3:14
  It
• 3:14
  may
• 3:14
  not
• 3:14
  be
• 3:14
  the
• 3:14
  least
• 3:15
  appropriate
• 3:15
  pharmacotherapy
• 3:16
  for
• 3:16
  him,
• 3:17
  but
• 3:17
  Seroquel's
• 3:18
  not
• 3:18
  a
• 3:18
  great
• 3:18
  medication
• 3:19
  for
• 3:19
  him
• 3:19
  because
• 3:20
  he's
• 3:20
  already
• 3:20
  sleeping
• 3:21
  too
• 3:21
  much.
• 3:22
  Now,
• 3:22
  his
• 3:22
  BMI
• 3:22
  is
• 3:23
  only
• 3:23
  19.
• 3:23
  That's
• 3:24
  actually
• 3:24
  not
• 3:24
  that
• 3:25
  high.
• 3:25
  So
• 3:26
  metabolically,
• 3:27
  from
• 3:27
  what
• 3:27
  we
• 3:27
  know
• 3:27
  about
• 3:28
  him,
• 3:28
  he
• 3:29
  can.
• 3:29
  He
• 3:29
  may
• 3:29
  be
• 3:29
  able
• 3:29
  to
• 3:30
  tolerate
• 3:30
  the
• 3:30
  weight
• 3:30
  gain.
• 3:31
  He
• 3:31
  also
• 3:32
  wants
• 3:32
  once
• 3:32
  daily
• 3:32
  dosing.
• 3:33
  That's
• 3:34
  totally
• 3:34
  fine
• 3:34
  with
• 3:34
  Seroquel,
• 3:35
  we
• 3:35
  can
• 3:35
  lump
• 3:36
  the
• 3:36
  dose
• 3:37
  all
• 3:37
  at
• 3:37
  night.
• 3:38
  So,
• 3:38
  okay,
• 3:39
  two
• 3:39
  good
• 3:39
  things
• 3:39
  there
• 3:40
  potentially.
• 3:41
  But
• 3:41
  he's
• 3:41
  sleeping
• 3:41
  too
• 3:42
  much.
• 3:42
  So
• 3:42
  do
• 3:42
  you
• 3:42
  want
• 3:42
  him
• 3:42
  to
• 3:43
  just
• 3:43
  sleep
• 3:43
  all
• 3:43
  the
• 3:43
  time?
• 3:44
  And
• 3:44
  now
• 3:45
  we
• 3:45
  have
• 3:45
  to
• 3:46
  ask
• 3:46
  the
• 3:46
  question,
• 3:46
  where
• 3:46
  is
• 3:47
  he
• 3:47
  sleeping?
• 3:47
  Right.
• 3:48
  A
• 3:48
  lot
• 3:48
  of
• 3:48
  folks
• 3:49
  who
• 3:49
  are
• 3:49
  dealing
• 3:49
  with
• 3:49
  homelessness
• 3:50
  are
• 3:50
  sleeping
• 3:50
  out
• 3:51
  in
• 3:51
  the
• 3:51
  street
• 3:51
  or
• 3:51
  in
• 3:51
  alleys
• 3:52
  or
• 3:52
  in
• 3:52
  very
• 3:53
  unsafe
• 3:53
  conditions
• 3:54
  or
• 3:54
  environments.
• 3:55
  And
• 3:55
  I've
• 3:56
  heard
• 3:56
  from
• 3:56
  them
• 3:56
  personally
• 3:57
  say
• 3:58
  that
• 3:58
  sedating
• 3:58
  medications
• 3:59
  are
• 3:59
  a
• 3:59
  big
• 3:59
  problem
• 4:00
  because
• 4:00
  they're
• 4:01
  sitting
• 4:01
  targets,
• 4:01
  right?
• 4:02
  They
• 4:02
  have
• 4:02
  valuables
• 4:03
  that
• 4:03
  are
• 4:03
  already
• 4:03
  stolen.
• 4:04
  Quite
• 4:04
  often
• 4:05
  they
• 4:05
  are
• 4:05
  exposed
• 4:05
  to
• 4:06
  violence
• 4:06
  and
• 4:07
  assaults
• 4:08
  and
• 4:08
  all
• 4:09
  kinds
• 4:09
  of
• 4:09
  social
• 4:10
  determinants
• 4:11
  that
• 4:11
  are
• 4:12
  much
• 4:12
  more
• 4:12
  frequent
• 4:13
  in
• 4:13
  the
• 4:13
  homeless
• 4:13
  population
• 4:14
  than
• 4:14
  they
• 4:14
  are
• 4:14
  in
• 4:14
  the
• 4:15
  regular
• 4:15
  population.
• 4:15
  So
• 4:16
  giving
• 4:16
  somebody
• 4:17
  a
• 4:17
  medication
• 4:17
  that
• 4:17
  is
• 4:17
  heavily
• 4:18
  sedating
• 4:18
  when
• 4:18
  they're
• 4:19
  already
• 4:19
  too
• 4:20
  tired
• 4:20
  is
• 4:21
  probably
• 4:21
  not
• 4:21
  a
• 4:22
  good
• 4:22
  idea.
• 4:22
  There
• 4:22
  is
• 4:22
  also
• 4:23
  some
• 4:23
  literature
• 4:23
  that
• 4:24
  Seroquilzit
• 4:25
  is
• 4:25
  being
• 4:25
  abused
• 4:25
  on
• 4:26
  the
• 4:26
  street.
• 4:27
  So
• 4:27
  if
• 4:27
  you
• 4:27
  give
• 4:27
  him
• 4:28
  30
• 4:28
  pills
• 4:28
  or
• 4:29
  60
• 4:29
  pills
• 4:29
  or
• 4:29
  90
• 4:30
  pills,
• 4:30
  whatever
• 4:30
  it
• 4:30
  is
• 4:31
  you
• 4:31
  decide
• 4:31
  to
• 4:31
  give
• 4:31
  him,
• 4:32
  and
• 4:32
  he's
• 4:32
  on
• 4:32
  the
• 4:33
  street,
• 4:33
  he
• 4:33
  also
• 4:33
  becomes
• 4:34
  a
• 4:34
  target
• 4:34
  to
• 4:35
  a
• 4:35
  robbery.
• 4:35
  And
• 4:36
  a
• 4:36
  lot
• 4:36
  of
• 4:36
  patients
• 4:37
  who
• 4:37
  are
• 4:37
  houseless
• 4:37
  do
• 4:38
  get
• 4:38
  robbed.
• 4:39
  And
• 4:39
  so
• 4:40
  especially
• 4:40
  now
• 4:41
  you're
• 4:41
  making
• 4:41
  him
• 4:41
  a
• 4:42
  target
• 4:42
  because
• 4:42
  he's
• 4:42
  carrying
• 4:42
  a
• 4:43
  medication
• 4:44
  that
• 4:44
  can
• 4:44
  be
• 4:45
  stolen
• 4:45
  and
• 4:46
  abused
• 4:46
  on
• 4:46
  the
• 4:46
  street.
• 4:47
  So
• 4:47
  there's
• 4:47
  even
• 4:47
  a
• 4:47
  higher
• 4:47
  value.
• 4:48
  It's
• 4:48
  not
• 4:48
  to
• 4:48
  say
• 4:49
  that
• 4:49
  everybody's
• 4:49
  going
• 4:49
  to
• 4:50
  know
• 4:50
  that
• 4:50
  Lenny's
• 4:51
  taking
• 4:51
  Seroquel,
• 4:52
  but
• 4:53
  again,
• 4:53
  it
• 4:53
  might
• 4:53
  be
• 4:53
  this
• 4:54
  needless
• 4:55
  intervention
• 4:56
  when
• 4:56
  you
• 4:56
  could
• 4:56
  have
• 4:56
  picked
• 4:57
  something
• 4:57
  different.
• 4:57
  Now,
• 4:58
  believe
• 4:58
  it
• 4:58
  or
• 4:58
  not,
• 4:59
  Seroquel
• 5:00
  is
• 5:00
  actually
• 5:00
  not
• 5:01
  the
• 5:01
  answer
• 5:01
  here.
• 5:01
  It
• 5:01
  is
• 5:02
  not
• 5:02
  the
• 5:02
  least
• 5:02
  appropriate
• 5:03
  pharmacotherapy,
• 5:03
  although
• 5:04
  I
• 5:04
  would
• 5:04
  argue
• 5:04
  it's
• 5:05
  not
• 5:05
  the
• 5:05
  most
• 5:05
  ideal
• 5:06
  one
• 5:06
  on
• 5:06
  the
• 5:06
  list.
• 5:06
  Either.
• 5:07
  Okay,
• 5:08
  what
• 5:08
  about
• 5:08
  lamictal?
• 5:09
  Lamictal
• 5:09
  is
• 5:10
  perfectly
• 5:10
  fine.
• 5:10
  I
• 5:11
  don't
• 5:11
  have
• 5:11
  a
• 5:11
  major
• 5:11
  problem
• 5:12
  with
• 5:12
  lamictal
• 5:13
  here.
• 5:13
  It's
• 5:13
  reasonable.
• 5:14
  It's
• 5:14
  recommended
• 5:14
  by
• 5:15
  multiple
• 5:15
  guidelines
• 5:16
  for
• 5:16
  bipolar
• 5:16
  depression,
• 5:17
  and
• 5:19
  it's
• 5:19
  not
• 5:19
  a
• 5:19
  bad
• 5:19
  idea.
• 5:20
  Now,
• 5:20
  one
• 5:20
  thing
• 5:20
  I
• 5:21
  don't
• 5:21
  love
• 5:21
  about
• 5:21
  lamictal,
• 5:22
  if
• 5:22
  your
• 5:22
  patient
• 5:23
  is
• 5:23
  housing
• 5:24
  insecure
• 5:24
  or
• 5:25
  food
• 5:25
  insecure,
• 5:25
  or
• 5:26
  just
• 5:26
  their
• 5:26
  life
• 5:27
  is
• 5:27
  insecure,
• 5:28
  is
• 5:28
  you
• 5:28
  are
• 5:29
  asking
• 5:29
  them
• 5:29
  to
• 5:29
  adhere
• 5:30
  to
• 5:30
  a
• 5:31
  little
• 5:31
  bit
• 5:31
  more
• 5:32
  of
• 5:32
  a
• 5:32
  complex
• 5:33
  titration
• 5:33
  regimen.
• 5:34
  25
• 5:34
  milligrams
• 5:35
  for
• 5:35
  the
• 5:35
  first
• 5:35
  two
• 5:35
  weeks,
• 5:36
  then
• 5:36
  50
• 5:36
  milligrams
• 5:37
  for
• 5:37
  the
• 5:37
  next
• 5:37
  two
• 5:37
  weeks,
• 5:37
  then
• 5:38
  maybe
• 5:38
  100
• 5:38
  milligrams
• 5:39
  and,
• 5:39
  oh,
• 5:39
  watch
• 5:39
  out
• 5:39
  for
• 5:40
  the
• 5:40
  rash.
• 5:40
  Say
• 5:40
  that
• 5:41
  Lenny
• 5:41
  develops
• 5:41
  a
• 5:41
  rash
• 5:42
  within
• 5:42
  the
• 5:42
  fifth
• 5:42
  or
• 5:43
  fourth
• 5:43
  or
• 5:43
  fifth
• 5:43
  day
• 5:44
  and
• 5:44
  he
• 5:44
  wants
• 5:44
  you
• 5:44
  to
• 5:44
  look
• 5:44
  at
• 5:44
  it.
• 5:45
  Does
• 5:45
  he
• 5:45
  have
• 5:45
  regular
• 5:46
  access
• 5:46
  to
• 5:46
  the
• 5:47
  clinic?
• 5:47
  How
• 5:48
  far
• 5:48
  is
• 5:48
  his
• 5:48
  transportation?
• 5:49
  Is
• 5:49
  it
• 5:49
  reliable?
• 5:50
  Is
• 5:51
  he
• 5:51
  able
• 5:52
  to
• 5:53
  identify
• 5:53
  those
• 5:54
  signs
• 5:55
  or
• 5:55
  symptoms
• 5:55
  of
• 5:55
  a
• 5:55
  rash?
• 5:56
  Can
• 5:57
  you
• 5:57
  send
• 5:57
  him
• 5:57
  home
• 5:57
  with
• 5:57
  any
• 5:57
  kind
• 5:58
  of
• 5:58
  literature
• 5:58
  that
• 5:58
  he
• 5:58
  can
• 5:59
  even
• 5:59
  carry
• 5:59
  with
• 5:59
  him
• 6:00
  or
• 6:00
  he
• 6:00
  can
• 6:01
  remember
• 6:01
  or
• 6:02
  have,
• 6:02
  like,
• 6:02
  reinforcement
• 6:04
  of
• 6:04
  guidelines
• 6:04
  that
• 6:05
  you
• 6:05
  want
• 6:05
  to
• 6:05
  share
• 6:05
  with
• 6:05
  him
• 6:05
  regarding
• 6:06
  lamictal
• 6:06
  and
• 6:07
  all
• 6:07
  the
• 6:07
  various
• 6:07
  nuances?
• 6:08
  I
• 6:08
  just
• 6:08
  think
• 6:08
  it's
• 6:09
  kind
• 6:09
  of
• 6:09
  more
• 6:09
  of
• 6:09
  a
• 6:09
  heavy
• 6:10
  duty
• 6:10
  medication
• 6:11
  for
• 6:11
  someone
• 6:12
  who
• 6:12
  is.
• 6:13
  Who
• 6:13
  doesn't
• 6:13
  have
• 6:13
  regular
• 6:14
  housing.
• 6:14
  You
• 6:14
  can
• 6:15
  do
• 6:15
  really
• 6:15
  good,
• 6:15
  robust
• 6:16
  psychoeducation
• 6:17
  with
• 6:17
  him
• 6:17
  in
• 6:17
  the
• 6:18
  clinic.
• 6:18
  He
• 6:19
  can
• 6:19
  come
• 6:19
  back
• 6:19
  every
• 6:19
  two
• 6:20
  weeks.
• 6:20
  You
• 6:20
  can
• 6:20
  arrange
• 6:20
  that
• 6:21
  to
• 6:21
  increase
• 6:21
  the
• 6:22
  dose
• 6:22
  if
• 6:22
  you're
• 6:23
  tracking
• 6:23
  really
• 6:23
  well
• 6:24
  and
• 6:24
  the
• 6:24
  patient's
• 6:25
  receptive
• 6:26
  and,
• 6:27
  you
• 6:27
  know,
• 6:28
  it's
• 6:28
  not
• 6:28
  a
• 6:28
  deal
• 6:29
  breaker.
• 6:29
  But
• 6:29
  again,
• 6:29
  I
• 6:30
  don't
• 6:30
  think
• 6:30
  it's
• 6:30
  the
• 6:30
  most
• 6:31
  ideal
• 6:31
  on
• 6:31
  the
• 6:31
  list.
• 6:32
  However,
• 6:32
  it
• 6:33
  is
• 6:33
  not
• 6:33
  the
• 6:33
  least
• 6:33
  appropriate
• 6:35
  medication
• 6:35
  on
• 6:35
  the
• 6:36
  list.
• 6:36
  But.
• 6:36
  So
• 6:37
  if
• 6:37
  you
• 6:37
  have
• 6:37
  to
• 6:37
  do
• 6:37
  it,
• 6:37
  fine.
• 6:38
  But
• 6:38
  I
• 6:38
  tend
• 6:39
  to
• 6:39
  go
• 6:39
  with
• 6:40
  lamictal
• 6:40
  when
• 6:41
  there
• 6:41
  is.
• 6:42
  When
• 6:42
  there's
• 6:42
  a
• 6:42
  patient
• 6:43
  who
• 6:43
  can
• 6:44
  definitely
• 6:44
  read
• 6:44
  you
• 6:45
  loud
• 6:45
  and
• 6:45
  clear,
• 6:46
  they
• 6:46
  have
• 6:46
  the
• 6:46
  mental
• 6:47
  and,
• 6:47
  you
• 6:47
  know,
• 6:47
  cognitive
• 6:48
  emotional
• 6:48
  space
• 6:49
  to
• 6:49
  deal
• 6:50
  with
• 6:50
  the
• 6:51
  titration
• 6:51
  changes
• 6:52
  and
• 6:53
  their
• 6:53
  tracking.
• 6:54
  But
• 6:54
  I
• 6:54
  try
• 6:54
  to
• 6:54
  reduce
• 6:55
  as
• 6:55
  much
• 6:55
  friction
• 6:56
  as
• 6:56
  possible
• 6:56
  between
• 6:57
  the
• 6:57
  medication
• 6:58
  I
• 6:58
  prescribe
• 6:59
  and
• 6:59
  the
• 6:59
  patient
• 6:59
  receiving
• 7:00
  it.
• 7:00
  Right.
• 7:00
  And
• 7:01
  lamictal
• 7:01
  is
• 7:01
  wonderful
• 7:02
  if
• 7:02
  you
• 7:02
  have
• 7:02
  a
• 7:02
  patient
• 7:03
  who
• 7:03
  is
• 7:03
  fed
• 7:04
  up
• 7:04
  with
• 7:04
  mood
• 7:05
  stabilizer
• 7:06
  side
• 7:06
  effects,
• 7:06
  like
• 7:06
  metabolic
• 7:07
  side
• 7:07
  effects
• 7:08
  or
• 7:09
  over,
• 7:09
  you
• 7:09
  know,
• 7:09
  sedation
• 7:10
  or
• 7:10
  cognitive
• 7:11
  impairment.
• 7:11
  Lamictal
• 7:12
  tends
• 7:12
  to
• 7:12
  go
• 7:12
  easy
• 7:13
  on
• 7:13
  all
• 7:13
  of
• 7:13
  those
• 7:13
  things.
• 7:14
  And
• 7:14
  it
• 7:14
  can
• 7:14
  be
• 7:14
  a
• 7:15
  great
• 7:15
  medication
• 7:16
  for
• 7:16
  the
• 7:16
  right
• 7:16
  person
• 7:16
  at
• 7:17
  the
• 7:17
  right
• 7:17
  time.
• 7:18
  I'm
• 7:18
  just
• 7:18
  not
• 7:18
  sure
• 7:18
  it's
• 7:19
  the
• 7:19
  best
• 7:19
  patient.
• 7:19
  It's
• 7:20
  the
• 7:20
  best
• 7:20
  medication
• 7:21
  for
• 7:21
  Lenny
• 7:22
  right
• 7:22
  now.
• 7:23
  So,
• 7:23
  again,
• 7:24
  it's
• 7:25
  not
• 7:25
  the
• 7:25
  right
• 7:25
  answer
• 7:26
  here,
• 7:26
  my
• 7:26
  friends,
• 7:27
  but
• 7:27
  it
• 7:27
  is
• 7:27
  you
• 7:28
  wouldn't
• 7:28
  be
• 7:28
  wrong
• 7:28
  to
• 7:29
  say
• 7:29
  it's
• 7:29
  not
• 7:29
  the
• 7:29
  best
• 7:30
  pharmacotherapy
• 7:31
  for
• 7:31
  him
• 7:31
  either.
• 7:33
  Now,
• 7:33
  what
• 7:33
  about
• 7:34
  Vraylar?
• 7:34
  Raylar
• 7:35
  is
• 7:35
  reasonable,
• 7:35
  okay?
• 7:36
  It's
• 7:36
  FDA
• 7:36
  approved
• 7:37
  for
• 7:37
  bipolar
• 7:38
  one
• 7:38
  depression.
• 7:38
  It's
• 7:38
  kind
• 7:39
  of
• 7:39
  one
• 7:39
  of
• 7:39
  the
• 7:39
  new
• 7:39
  kids
• 7:39
  on
• 7:39
  the
• 7:40
  block.
• 7:40
  Okay?
• 7:41
  Mood
• 7:41
  stabilizer,
• 7:42
  antipsychotic,
• 7:43
  perfectly
• 7:44
  serviceable.
• 7:44
  I
• 7:44
  don't
• 7:45
  have
• 7:45
  a
• 7:45
  lot
• 7:45
  of
• 7:45
  negative
• 7:45
  things
• 7:46
  to
• 7:46
  really
• 7:47
  say
• 7:47
  about
• 7:47
  it
• 7:48
  either.
• 7:48
  It
• 7:49
  does
• 7:49
  have
• 7:49
  a
• 7:49
  pretty
• 7:50
  favorable
• 7:50
  metabolic
• 7:51
  profile.
• 7:51
  But
• 7:51
  again,
• 7:52
  even
• 7:52
  if
• 7:52
  your
• 7:52
  patient
• 7:53
  doesn't
• 7:53
  have
• 7:53
  metabolic
• 7:54
  issues,
• 7:54
  why
• 7:55
  give
• 7:55
  them
• 7:55
  something
• 7:55
  extra
• 7:56
  to
• 7:56
  deal
• 7:56
  with?
• 7:57
  Because
• 7:57
  it,
• 7:57
  you
• 7:58
  know,
• 7:58
  think
• 7:58
  a
• 7:58
  medication
• 7:59
  like
• 7:59
  Seroquel
• 8:00
  or
• 8:00
  Zyprexa
• 8:00
  will
• 8:01
  reliably
• 8:02
  mess
• 8:02
  with
• 8:03
  their
• 8:03
  metabolic
• 8:03
  profile.
• 8:04
  And
• 8:04
  now
• 8:04
  you
• 8:04
  have
• 8:04
  Lenny
• 8:05
  out
• 8:05
  there
• 8:05
  who's
• 8:06
  already
• 8:06
  house
• 8:06
  and,
• 8:07
  you
• 8:07
  know,
• 8:07
  home
• 8:08
  insecure.
• 8:09
  Maybe
• 8:09
  his
• 8:09
  diet
• 8:10
  is
• 8:10
  processed
• 8:11
  and.
• 8:11
  And
• 8:12
  it.
• 8:12
  It's
• 8:12
  just
• 8:13
  like,
• 8:13
  well,
• 8:13
  why
• 8:13
  give
• 8:13
  him
• 8:14
  something?
• 8:14
  Why
• 8:14
  give
• 8:15
  him
• 8:15
  another
• 8:15
  problem?
• 8:15
  So
• 8:16
  I
• 8:16
  think
• 8:16
  Vlar's
• 8:17
  perfectly
• 8:17
  suitable.
• 8:18
  It
• 8:18
  does
• 8:19
  have
• 8:19
  an
• 8:20
  extremely
• 8:20
  long,
• 8:21
  effective
• 8:21
  half
• 8:22
  life.
• 8:23
  So
• 8:23
  if
• 8:23
  he
• 8:23
  misses
• 8:24
  a
• 8:24
  dose
• 8:24
  and
• 8:24
  he's
• 8:25
  not
• 8:25
  as
• 8:25
  compliant
• 8:26
  because
• 8:26
  he
• 8:26
  can't
• 8:27
  be,
• 8:27
  again
• 8:27
  because
• 8:28
  of
• 8:28
  social
• 8:29
  determinants
• 8:29
  where
• 8:30
  he
• 8:30
  just
• 8:30
  can't
• 8:30
  secure
• 8:31
  the
• 8:31
  medication
• 8:32
  quickly
• 8:32
  enough,
• 8:32
  or
• 8:32
  there's
• 8:33
  something
• 8:33
  that
• 8:33
  pops
• 8:33
  up
• 8:34
  or
• 8:34
  he's.
• 8:35
  People
• 8:35
  steal
• 8:35
  from
• 8:36
  him,
• 8:36
  or
• 8:36
  he's,
• 8:37
  you
• 8:37
  know,
• 8:37
  he.
• 8:37
  He.
• 8:38
  He
• 8:38
  has
• 8:39
  to.
• 8:39
  He
• 8:39
  gets,
• 8:39
  like,
• 8:40
  evicted
• 8:40
  by
• 8:40
  the
• 8:40
  police
• 8:41
  out
• 8:41
  of
• 8:41
  a
• 8:41
  certain
• 8:41
  location
• 8:42
  in
• 8:42
  the
• 8:42
  park.
• 8:43
  Right?
• 8:43
  There's
• 8:43
  a
• 8:43
  lot
• 8:44
  that
• 8:44
  can
• 8:44
  go
• 8:44
  wrong
• 8:44
  when
• 8:44
  you're
• 8:45
  homeless.
• 8:45
  And
• 8:45
  so
• 8:46
  an
• 8:46
  effective
• 8:46
  half
• 8:46
  life,
• 8:47
  a
• 8:47
  higher
• 8:48
  effective
• 8:48
  half
• 8:48
  life.
• 8:48
  There
• 8:49
  is
• 8:49
  a
• 8:49
  little
• 8:49
  bit
• 8:49
  of
• 8:49
  a
• 8:49
  grace
• 8:50
  period
• 8:50
  there.
• 8:51
  So
• 8:51
  that
• 8:52
  could
• 8:52
  work
• 8:52
  for
• 8:52
  you.
• 8:52
  I
• 8:52
  don't
• 8:53
  mind
• 8:53
  very
• 8:53
  large
• 8:53
  here.
• 8:54
  There's
• 8:54
  nothing
• 8:54
  that
• 8:54
  jumps
• 8:55
  out
• 8:55
  at
• 8:55
  me
• 8:55
  that
• 8:55
  says
• 8:55
  it's
• 8:55
  inappropriate.
• 8:56
  Lumateperone
• 8:57
  or,
• 8:58
  you
• 8:58
  know,
• 8:58
  that's.
• 8:58
  That's
• 8:59
  the
• 8:59
  last
• 8:59
  one.
• 9:00
  One
• 9:00
  of
• 9:00
  the
• 9:00
  last
• 9:00
  ones.
• 9:01
  Another
• 9:01
  reasonable
• 9:02
  choice.
• 9:02
  Also
• 9:03
  known
• 9:03
  as
• 9:03
  Caplita.
• 9:04
  FDA
• 9:04
  approved
• 9:05
  for
• 9:05
  depress
• 9:06
  depressive
• 9:07
  episodes
• 9:07
  associated
• 9:07
  with
• 9:08
  bipolar
• 9:08
  I
• 9:08
  or
• 9:08
  ii.
• 9:09
  Not
• 9:10
  a
• 9:10
  bad
• 9:10
  idea.
• 9:10
  It
• 9:10
  is
• 9:10
  dosed
• 9:11
  once
• 9:11
  daily.
• 9:12
  That's
• 9:12
  what
• 9:12
  Lenny
• 9:12
  wanted.
• 9:13
  It
• 9:13
  is
• 9:13
  expensive,
• 9:14
  though.
• 9:14
  Typically
• 9:15
  it's
• 9:15
  a
• 9:15
  newer
• 9:16
  kid
• 9:16
  on
• 9:16
  the
• 9:16
  block.
• 9:17
  So
• 9:18
  when
• 9:18
  we
• 9:18
  talk
• 9:18
  about
• 9:18
  what's
• 9:19
  the
• 9:19
  least
• 9:19
  appropriate
• 9:20
  pharmacotherapy?
• 9:21
  I
• 9:21
  think
• 9:21
  it's
• 9:21
  an
• 9:22
  appropriate
• 9:22
  pharmacotherapy.
• 9:23
  It
• 9:23
  just
• 9:23
  might
• 9:24
  be
• 9:24
  inappropriate
• 9:25
  because
• 9:25
  it's
• 9:25
  too
• 9:25
  expensive.
• 9:26
  So
• 9:26
  it's
• 9:26
  just
• 9:27
  yet
• 9:27
  another
• 9:27
  filter
• 9:27
  you
• 9:28
  have
• 9:28
  to
• 9:28
  put
• 9:29
  these
• 9:29
  medications
• 9:29
  through,
• 9:30
  right?
• 9:30
  In
• 9:31
  addition
• 9:31
  to
• 9:31
  the
• 9:31
  side
• 9:31
  effects,
• 9:32
  in
• 9:32
  addition
• 9:33
  to
• 9:33
  the
• 9:33
  patient's
• 9:33
  preference
• 9:34
  in
• 9:34
  dosing,
• 9:35
  you
• 9:35
  have
• 9:35
  to
• 9:35
  ask,
• 9:36
  like,
• 9:36
  is
• 9:36
  this
• 9:36
  too
• 9:36
  expensive?
• 9:37
  Because,
• 9:37
  again,
• 9:38
  it
• 9:38
  could
• 9:38
  be
• 9:38
  the
• 9:38
  best
• 9:39
  medication
• 9:39
  in
• 9:39
  the
• 9:40
  universe
• 9:41
  for
• 9:41
  your
• 9:41
  particular
• 9:41
  patient,
• 9:42
  but
• 9:42
  not
• 9:42
  if
• 9:42
  it's
• 9:43
  $5,000
• 9:43
  a
• 9:44
  month.
• 9:44
  Right?
• 9:45
  So
• 9:45
  my
• 9:45
  friends,
• 9:45
  the
• 9:45
  answer
• 9:46
  to
• 9:46
  this
• 9:46
  question
• 9:46
  is
• 9:47
  latuda.
• 9:47
  Latuda
• 9:48
  option
• 9:48
  C
• 9:49
  is
• 9:49
  the
• 9:50
  least
• 9:50
  appropriate
• 9:51
  pharmacotherapy
• 9:51
  for
• 9:52
  this
• 9:52
  patient.
• 9:52
  It's
• 9:53
  FDA
• 9:53
  approved
• 9:53
  in
• 9:54
  bipolar
• 9:54
  I
• 9:54
  depression,
• 9:55
  so
• 9:55
  why
• 9:55
  not?
• 9:55
  Well,
• 9:56
  the
• 9:56
  CA
• 9:56
  caveat
• 9:56
  here,
• 9:57
  and
• 9:57
  it
• 9:57
  is
• 9:57
  a
• 9:57
  total
• 9:57
  deal
• 9:58
  breaker,
• 9:58
  is
• 9:58
  that
• 9:59
  latuda
• 9:59
  must
• 9:59
  be
• 10:00
  taken
• 10:00
  with
• 10:00
  at
• 10:00
  least
• 10:00
  350
• 10:01
  calories
• 10:02
  of
• 10:02
  food
• 10:03
  to
• 10:03
  achieve
• 10:03
  adequate
• 10:04
  absorption.
• 10:05
  If
• 10:06
  you
• 10:06
  take
• 10:06
  latuda
• 10:07
  when
• 10:07
  you
• 10:07
  fast
• 10:08
  your
• 10:08
  the
• 10:08
  max
• 10:09
  latuda
• 10:09
  that
• 10:09
  ever
• 10:10
  gets
• 10:10
  into
• 10:10
  your
• 10:10
  system
• 10:11
  drops
• 10:11
  by
• 10:12
  a
• 10:12
  factor
• 10:12
  of
• 10:12
  three
• 10:13
  and
• 10:14
  it's
• 10:14
  just
• 10:14
  not
• 10:15
  as
• 10:15
  orally
• 10:16
  bioavailable
• 10:17
  at
• 10:17
  all.
• 10:18
  It's
• 10:18
  so
• 10:18
  low
• 10:19
  that
• 10:19
  it's
• 10:20
  basically
• 10:20
  not
• 10:20
  going
• 10:21
  to
• 10:21
  exert
• 10:21
  any
• 10:21
  effect
• 10:22
  on
• 10:22
  you
• 10:22
  if
• 10:22
  you're
• 10:22
  fasting
• 10:23
  or
• 10:23
  you're
• 10:24
  skipping
• 10:24
  meals
• 10:24
  and
• 10:24
  you
• 10:25
  can't
• 10:25
  secure
• 10:25
  a
• 10:25
  meal.
• 10:25
  So
• 10:26
  it
• 10:26
  just
• 10:26
  takes
• 10:26
  one
• 10:27
  day
• 10:27
  where
• 10:28
  Lenny
• 10:28
  cannot
• 10:29
  secure
• 10:29
  a
• 10:30
  soup
• 10:30
  kitchen
• 10:31
  and
• 10:31
  boom,
• 10:32
  his
• 10:32
  ship
• 10:32
  is
• 10:32
  sunk.
• 10:33
  The
• 10:33
  medication
• 10:34
  that
• 10:34
  he
• 10:34
  takes,
• 10:34
  no
• 10:35
  matter
• 10:35
  how
• 10:35
  adherent
• 10:36
  he
• 10:36
  is
• 10:36
  to
• 10:36
  it,
• 10:36
  is
• 10:37
  not
• 10:37
  going
• 10:37
  to
• 10:37
  be
• 10:38
  orally
• 10:38
  bioavailable
• 10:39
  enough.
• 10:39
  And
• 10:40
  that
• 10:40
  is
• 10:40
  a
• 10:40
  huge
• 10:41
  deal
• 10:41
  breaker,
• 10:42
  my
• 10:42
  friends.
• 10:42
  We
• 10:42
  already
• 10:43
  talked
• 10:43
  in
• 10:43
  previous
• 10:43
  episodes
• 10:44
  about
• 10:45
  the
• 10:45
  difficulty
• 10:45
  with
• 10:46
  adherence,
• 10:46
  right?
• 10:47
  Like
• 10:47
  46%
• 10:48
  of
• 10:48
  your
• 10:48
  patients
• 10:48
  taking
• 10:49
  an
• 10:49
  antidepressant
• 10:50
  are
• 10:50
  not
• 10:50
  regularly
• 10:50
  adherent
• 10:51
  to
• 10:51
  IT
• 10:52
  to
• 10:52
  achieve
• 10:52
  80%
• 10:53
  the
• 10:54
  levels
• 10:54
  required
• 10:55
  for
• 10:55
  a
• 10:55
  true
• 10:56
  full
• 10:57
  trial.
• 10:57
  Right?
• 10:57
  Same
• 10:57
  thing
• 10:58
  goes
• 10:58
  with
• 10:58
  antipsychotics.
• 10:59
  We
• 10:59
  see
• 11:00
  similar
• 11:00
  rates
• 11:01
  of
• 11:01
  non
• 11:01
  adherence
• 11:02
  that
• 11:02
  I
• 11:02
  think
• 11:02
  are
• 11:02
  appalling
• 11:03
  in
• 11:03
  the
• 11:03
  literature.
• 11:04
  Right?
• 11:04
  I
• 11:04
  think
• 11:04
  adherence,
• 11:05
  you've
• 11:05
  heard
• 11:05
  me
• 11:05
  on
• 11:06
  this
• 11:06
  podcast
• 11:06
  multiple
• 11:07
  times.
• 11:07
  Adherence
• 11:08
  is
• 11:08
  such
• 11:08
  a
• 11:09
  big
• 11:09
  deal.
• 11:09
  I'm
• 11:09
  such
• 11:10
  a
• 11:10
  stickler
• 11:10
  for
• 11:11
  adherence
• 11:11
  because
• 11:12
  it's
• 11:13
  a,
• 11:13
  it's
• 11:13
  just
• 11:13
  a
• 11:13
  big
• 11:13
  deal,
• 11:14
  right?
• 11:14
  Our
• 11:15
  medications
• 11:15
  are
• 11:15
  worthless
• 11:16
  unless
• 11:16
  the
• 11:16
  patient
• 11:17
  is
• 11:17
  able
• 11:17
  to
• 11:17
  adhere
• 11:17
  to
• 11:18
  them.
• 11:18
  Which
• 11:18
  means
• 11:18
  we
• 11:19
  have
• 11:19
  to
• 11:19
  pick
• 11:19
  medications
• 11:20
  that,
• 11:20
  that
• 11:21
  have
• 11:21
  side
• 11:21
  effect
• 11:22
  profiles
• 11:22
  that
• 11:22
  are
• 11:23
  not
• 11:23
  deal
• 11:23
  breakers
• 11:24
  for
• 11:24
  your
• 11:24
  patient.
• 11:24
  Your
• 11:25
  patient
• 11:25
  knows
• 11:25
  about
• 11:25
  them.
• 11:26
  They
• 11:26
  understand
• 11:26
  that
• 11:27
  the
• 11:27
  benefits
• 11:27
  of
• 11:27
  a
• 11:28
  lot
• 11:28
  of
• 11:28
  these
• 11:28
  medications
• 11:28
  take
• 11:29
  weeks.
• 11:29
  So
• 11:29
  we
• 11:29
  got
• 11:29
  to
• 11:30
  provide
• 11:30
  good
• 11:30
  education
• 11:31
  and
• 11:31
  then
• 11:31
  the
• 11:31
  pharmacokinetics,
• 11:33
  we
• 11:34
  have
• 11:34
  to
• 11:34
  educate
• 11:35
  them
• 11:35
  that
• 11:36
  you
• 11:36
  must
• 11:36
  take
• 11:36
  Latuda
• 11:37
  with
• 11:37
  350
• 11:38
  calories
• 11:38
  of
• 11:38
  food
• 11:39
  or
• 11:39
  more
• 11:39
  because
• 11:40
  they
• 11:40
  might
• 11:40
  come
• 11:40
  to
• 11:40
  you
• 11:40
  in
• 11:41
  two
• 11:41
  weeks
• 11:41
  thinking
• 11:41
  that
• 11:41
  this
• 11:42
  medication
• 11:42
  is
• 11:42
  doing
• 11:43
  nothing.
• 11:43
  They
• 11:44
  are
• 11:44
  extremely
• 11:45
  depressed
• 11:45
  still.
• 11:47
  And
• 11:47
  that's
• 11:47
  a
• 11:47
  deal
• 11:47
  breaker.
• 11:48
  Right?
• 11:48
  We've
• 11:48
  got
• 11:49
  to
• 11:49
  be
• 11:49
  able
• 11:49
  to
• 11:50
  be
• 11:50
  there
• 11:51
  for
• 11:51
  our
• 11:51
  patients
• 11:51
  on
• 11:52
  more
• 11:52
  than
• 11:52
  one
• 11:52
  level
• 11:53
  and
• 11:53
  quickly,
• 11:54
  you
• 11:54
  know,
• 11:54
  in
• 11:54
  a
• 11:54
  30
• 11:55
  minute
• 11:55
  follow
• 11:55
  up
• 11:55
  or
• 11:55
  60
• 11:56
  or
• 11:56
  90
• 11:56
  minute
• 11:56
  eval,
• 11:57
  we've
• 11:57
  gotta
• 11:58
  be
• 11:58
  able
• 11:58
  to
• 11:58
  kind
• 11:58
  of
• 11:58
  rapidly
• 11:59
  correlate
• 12:00
  all
• 12:00
  of
• 12:00
  these
• 12:00
  variables
• 12:01
  and
• 12:02
  to
• 12:02
  determine
• 12:02
  which
• 12:03
  one
• 12:03
  is
• 12:03
  the
• 12:03
  most
• 12:03
  appropriate
• 12:04
  And
• 12:04
  I
• 12:04
  promise
• 12:04
  you
• 12:05
  my
• 12:05
  friends,
• 12:05
  this
• 12:05
  will
• 12:05
  get
• 12:05
  easier
• 12:06
  with
• 12:06
  time.
• 12:07
  It
• 12:07
  feels
• 12:07
  overwhelming
• 12:08
  at
• 12:08
  first,
• 12:09
  having
• 12:09
  to
• 12:09
  remember
• 12:10
  the
• 12:10
  half
• 12:10
  life
• 12:11
  and
• 12:11
  the
• 12:11
  bioavailabilities
• 12:13
  and
• 12:13
  the
• 12:14
  drug
• 12:14
  interactions,
• 12:15
  the
• 12:15
  CYP450
• 12:17
  metabolism,
• 12:18
  right?
• 12:19
  It,
• 12:19
  it,
• 12:19
  it
• 12:20
  feels
• 12:20
  overwhelming,
• 12:21
  but
• 12:21
  it
• 12:21
  will
• 12:21
  click.
• 12:22
  Just
• 12:22
  like
• 12:22
  when
• 12:22
  you
• 12:23
  drove
• 12:23
  a
• 12:23
  car
• 12:23
  for
• 12:23
  the
• 12:24
  first
• 12:24
  time
• 12:24
  and
• 12:24
  you
• 12:25
  had
• 12:25
  to
• 12:25
  merge
• 12:25
  on
• 12:25
  the
• 12:25
  highway.
• 12:26
  But
• 12:26
  you
• 12:26
  know
• 12:26
  what?
• 12:27
  Pretty
• 12:27
  soon
• 12:27
  it
• 12:28
  becomes
• 12:28
  automatic,
• 12:28
  right?
• 12:29
  Everything
• 12:29
  becomes
• 12:30
  more
• 12:30
  second
• 12:30
  nature
• 12:31
  and
• 12:31
  it
• 12:31
  frees
• 12:32
  up
• 12:32
  more
• 12:32
  cognitive
• 12:33
  bandwidth
• 12:33
  for
• 12:33
  you
• 12:33
  to
• 12:34
  discover
• 12:34
  more
• 12:34
  parts
• 12:35
  of
• 12:35
  psychiatry
• 12:36
  and
• 12:36
  gain
• 12:36
  additional
• 12:37
  mastery.
• 12:38
  So
• 12:38
  anyhow,
• 12:38
  I
• 12:38
  hope
• 12:39
  you
• 12:39
  enjoyed
• 12:39
  this.
• 12:39
  Just
• 12:40
  remember,
• 12:40
  Latuda,
• 12:41
  deal
• 12:41
  breaker.
• 12:41
  Gotta
• 12:42
  have
• 12:42
  food
• 12:42
  with
• 12:42
  it.
• 12:42
  Giudon
• 12:43
  is
• 12:43
  similar.
• 12:43
  It's
• 12:43
  not
• 12:44
  affected
• 12:44
  by
• 12:45
  food
• 12:45
  as,
• 12:46
  as
• 12:46
  powerfully
• 12:47
  as
• 12:47
  Latuda.
• 12:47
  But
• 12:48
  you
• 12:48
  also
• 12:48
  have
• 12:49
  to
• 12:49
  eat
• 12:49
  on
• 12:50
  Geodon.
• 12:50
  That's
• 12:50
  just
• 12:51
  another
• 12:52
  little
• 12:52
  pearl.
• 12:53
  But
• 12:54
  definitely
• 12:54
  keep
• 12:55
  these
• 12:55
  little
• 12:55
  details
• 12:55
  in
• 12:56
  mind.
• 12:56
  They're
• 12:56
  super
• 12:57
  high
• 12:57
  yield.
• 12:57
  They
• 12:57
  will
• 12:57
  make
• 12:58
  or
• 12:58
  break
• 12:58
  your
• 12:58
  care
• 12:59
  in
• 12:59
  specific
• 12:59
  populations.
• 13:00
  This,
• 13:01
  you
• 13:01
  know,
• 13:01
  this
• 13:01
  could
• 13:02
  also
• 13:02
  be
• 13:02
  a
• 13:03
  factor
• 13:03
  even
• 13:03
  if
• 13:03
  Lenny
• 13:04
  wasn't
• 13:04
  food
• 13:04
  insecure,
• 13:05
  right?
• 13:06
  Or
• 13:06
  homeless.
• 13:06
  I
• 13:07
  should
• 13:07
  say
• 13:07
  if
• 13:07
  you
• 13:08
  have
• 13:08
  a
• 13:08
  patient
• 13:08
  whose
• 13:09
  bipolar
• 13:10
  depression
• 13:10
  involves
• 13:11
  like
• 13:12
  catatonic
• 13:13
  features
• 13:13
  where
• 13:14
  they
• 13:14
  just
• 13:14
  won't
• 13:14
  eat
• 13:15
  or
• 13:15
  won't
• 13:15
  move
• 13:15
  and
• 13:16
  won't
• 13:16
  react.
• 13:16
  Or
• 13:17
  maybe
• 13:17
  part
• 13:17
  of
• 13:17
  their
• 13:18
  depression
• 13:18
  is
• 13:18
  that
• 13:18
  they
• 13:19
  just
• 13:19
  never
• 13:19
  eat
• 13:19
  when
• 13:20
  they're
• 13:20
  depressed.
• 13:20
  Well,
• 13:20
  this
• 13:20
  is
• 13:21
  not
• 13:21
  a
• 13:21
  good
• 13:21
  choice
• 13:22
  for
• 13:22
  you,
• 13:22
  right?
• 13:22
  In
• 13:23
  that
• 13:23
  case,
• 13:23
  I
• 13:23
  would
• 13:23
  gravitate
• 13:24
  more
• 13:24
  towards
• 13:25
  Seroquel,
• 13:25
  where
• 13:26
  the
• 13:26
  appetite
• 13:26
  will
• 13:26
  definitely
• 13:27
  come
• 13:27
  back
• 13:27
  on
• 13:27
  board
• 13:28
  rather
• 13:29
  quickly
• 13:29
  and
• 13:29
  stimulate
• 13:30
  it
• 13:30
  so
• 13:30
  that
• 13:30
  they
• 13:31
  can
• 13:31
  get
• 13:31
  to
• 13:31
  a
• 13:31
  healthier
• 13:31
  weight.
• 13:32
  We
• 13:32
  don't
• 13:32
  want
• 13:32
  them
• 13:32
  to
• 13:32
  be
• 13:32
  overweight,
• 13:33
  we
• 13:33
  don't
• 13:33
  want
• 13:33
  to
• 13:33
  mess
• 13:33
  up
• 13:34
  their
• 13:34
  metabolic
• 13:34
  labs.
• 13:35
  But
• 13:35
  if
• 13:36
  a
• 13:36
  lack
• 13:37
  of
• 13:37
  appetite
• 13:37
  is
• 13:37
  a
• 13:38
  huge
• 13:38
  feature
• 13:39
  of
• 13:39
  their
• 13:39
  depression,
• 13:40
  then
• 13:40
  Quetiapine
• 13:41
  or
• 13:41
  Seroquel,
• 13:42
  also
• 13:42
  known
• 13:43
  as,
• 13:43
  is
• 13:43
  a
• 13:43
  very
• 13:44
  welcome
• 13:44
  addition.
• 13:45
  Now
• 13:45
  my
• 13:45
  friends,
• 13:46
  before
• 13:46
  I
• 13:46
  go,
• 13:48
  if
• 13:49
  you
• 13:49
  want
• 13:49
  to
• 13:49
  separate
• 13:50
  yourself
• 13:50
  from
• 13:50
  the
• 13:50
  fray,
• 13:51
  if
• 13:51
  you
• 13:51
  want
• 13:51
  to
• 13:52
  understand
• 13:52
  the
• 13:52
  how
• 13:53
  and
• 13:53
  why
• 13:53
  of
• 13:54
  what
• 13:54
  you
• 13:54
  are
• 13:54
  prescribing
• 13:55
  and
• 13:55
  not
• 13:55
  just
• 13:56
  follow
• 13:56
  algos,
• 13:57
  join
• 13:57
  our
• 13:58
  Patreon.
• 13:58
  It's
• 13:58
  a
• 13:59
  beautiful
• 13:59
  full
• 13:59
  library,
• 14:00
  full
• 14:00
  of
• 14:01
  amazing
• 14:01
  high
• 14:01
  yield
• 14:02
  pearls.
• 14:03
  Patients
• 14:03
  can
• 14:03
  smell
• 14:04
  you
• 14:04
  a
• 14:04
  mile
• 14:04
  away.
• 14:04
  When
• 14:05
  you're
• 14:05
  just
• 14:05
  a
• 14:05
  provider
• 14:06
  reading
• 14:06
  the
• 14:07
  alos
• 14:07
  versus
• 14:07
  the
• 14:08
  ones
• 14:08
  who
• 14:08
  actually
• 14:08
  know
• 14:09
  what
• 14:09
  they're
• 14:09
  doing
• 14:10
  behind
• 14:10
  their
• 14:11
  decisions.
• 14:12
  Definitely
• 14:12
  recommend
• 14:13
  you
• 14:13
  go
• 14:13
  over
• 14:13
  to
• 14:14
  our
• 14:14
  show
• 14:14
  notes
• 14:14
  and
• 14:14
  become
• 14:15
  a
• 14:15
  Patreon
• 14:15
  member
• 14:15
  asap.
• 14:16
  Super
• 14:17
  valuable
• 14:17
  stuff.
• 14:18
  We'd
• 14:18
  love
• 14:18
  to
• 14:18
  have
• 14:18
  you.
• 14:19
  We'll
• 14:19
  see
• 14:19
  you
• 14:20
  next
• 14:20
  time
• 14:20
  here
• 14:20
  on
• 14:20
  Pearls
• 14:21
  and
• 14:21
  Prep.
• 14:21
  Thank
• 14:22
  you.