Latest / Pearls and Prep / Modafinil versus Armodafinil: This Subtle Difference Makes a BIG Impact

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Modafinil versus Armodafinil: This Subtle Difference Makes a BIG Impact · Pearls and Prep

• 0:00
  Foreign.
• 0:06
  My
• 0:06
  friends,
• 0:06
  welcome
• 0:07
  back
• 0:07
  to
• 0:07
  another
• 0:08
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:09
  and
• 0:09
  prep
• 0:09
  your
• 0:10
  go
• 0:10
  to
• 0:10
  place
• 0:11
  for
• 0:11
  Pearls
• 0:12
  that
• 0:12
  prep
• 0:12
  you
• 0:12
  to
• 0:13
  practice.
• 0:13
  My
• 0:14
  friends,
• 0:14
  you
• 0:15
  have
• 0:15
  a
• 0:15
  mock
• 0:16
  patient
• 0:16
  here.
• 0:16
  She's
• 0:17
  32
• 0:17
  years
• 0:17
  old.
• 0:18
  She's
• 0:19
  actually
• 0:20
  also
• 0:20
  a
• 0:21
  psychiatric
• 0:21
  nurse
• 0:22
  practitioner.
• 0:22
  She's
• 0:23
  working
• 0:23
  rotating
• 0:24
  night
• 0:24
  shifts,
• 0:24
  7pm
• 0:25
  to
• 0:26
  7am
• 0:27
  and
• 0:27
  she
• 0:27
  actually
• 0:28
  works
• 0:28
  at
• 0:28
  a
• 0:28
  busy
• 0:29
  emergency
• 0:30
  department.
• 0:30
  Okay,
• 0:31
  and
• 0:31
  she's
• 0:31
  coming
• 0:31
  to
• 0:31
  you,
• 0:31
  telling
• 0:32
  you,
• 0:32
  hey,
• 0:32
  I
• 0:33
  can
• 0:33
  barely
• 0:33
  stay
• 0:33
  awake
• 0:34
  during
• 0:34
  my
• 0:34
  shifts
• 0:35
  and
• 0:35
  I'm
• 0:36
  worried
• 0:36
  I'm
• 0:36
  going
• 0:36
  to
• 0:36
  make
• 0:36
  a
• 0:36
  med
• 0:37
  error.
• 0:37
  Her
• 0:37
  depression's
• 0:38
  not
• 0:38
  so
• 0:38
  bad,
• 0:39
  but
• 0:39
  she's
• 0:39
  just
• 0:39
  exhausted
• 0:40
  all
• 0:40
  of
• 0:41
  the
• 0:41
  time.
• 0:41
  And
• 0:41
  she's
• 0:42
  asking
• 0:42
  you
• 0:42
  for
• 0:42
  help
• 0:43
  in
• 0:43
  the
• 0:43
  outpatient
• 0:44
  space.
• 0:44
  Now,
• 0:44
  a
• 0:44
  little
• 0:45
  bit
• 0:45
  of
• 0:45
  information
• 0:46
  you
• 0:46
  should
• 0:46
  know
• 0:46
  about
• 0:46
  her.
• 0:47
  She
• 0:48
  was
• 0:49
  diagnosed
• 0:49
  with
• 0:49
  bipolar
• 0:50
  1
• 0:50
  disorder
• 0:51
  three
• 0:51
  years
• 0:51
  ago,
• 0:52
  and
• 0:52
  she's
• 0:52
  currently
• 0:53
  in
• 0:53
  a
• 0:53
  bit
• 0:53
  of
• 0:53
  a
• 0:53
  depressive
• 0:54
  episode
• 0:55
  despite
• 0:55
  six
• 0:56
  weeks
• 0:56
  of
• 0:56
  being
• 0:56
  on
• 0:57
  an
• 0:57
  adequate
• 0:58
  mood
• 0:58
  stabilizer.
• 0:59
  In
• 0:59
  this
• 0:59
  case,
• 0:59
  it's
• 0:59
  lithium,
• 1:00
  900
• 1:00
  milligrams
• 1:01
  daily,
• 1:01
  and
• 1:02
  her
• 1:02
  level
• 1:02
  is
• 1:03
  0.8
• 1:04
  milliequivalents
• 1:05
  per
• 1:05
  liter.
• 1:05
  She
• 1:06
  works
• 1:06
  about
• 1:06
  four
• 1:06
  to
• 1:07
  five
• 1:07
  permanent
• 1:07
  night
• 1:07
  shifts
• 1:08
  per
• 1:08
  month.
• 1:09
  And
• 1:09
  she
• 1:10
  reports
• 1:10
  severe
• 1:11
  sleepiness
• 1:11
  during
• 1:12
  her
• 1:12
  shifts.
• 1:13
  Around
• 1:13
  three
• 1:14
  to
• 1:14
  six
• 1:14
  o'clock
• 1:15
  in
• 1:15
  the
• 1:15
  morning,
• 1:15
  towards
• 1:16
  the
• 1:16
  tail
• 1:16
  end
• 1:17
  of
• 1:17
  her
• 1:17
  night
• 1:17
  shift,
• 1:18
  she
• 1:18
  has
• 1:18
  brain
• 1:19
  fog.
• 1:19
  It's
• 1:19
  hard
• 1:19
  to
• 1:19
  focus
• 1:20
  when
• 1:21
  she's
• 1:21
  trying
• 1:21
  to
• 1:21
  review
• 1:21
  patient
• 1:22
  charts.
• 1:22
  And
• 1:22
  she
• 1:23
  nearly
• 1:23
  makes
• 1:23
  meta
• 1:24
  errors
• 1:24
  every
• 1:24
  week.
• 1:24
  And
• 1:25
  that's
• 1:25
  kind
• 1:25
  of
• 1:25
  what
• 1:25
  got
• 1:25
  this
• 1:26
  party
• 1:26
  started.
• 1:26
  She's
• 1:27
  like,
• 1:27
  hey,
• 1:27
  I
• 1:27
  need
• 1:27
  some
• 1:27
  help,
• 1:28
  right?
• 1:28
  A
• 1:28
  lot
• 1:28
  of
• 1:28
  patients
• 1:29
  are
• 1:29
  going
• 1:29
  to
• 1:29
  come
• 1:29
  to
• 1:29
  you
• 1:30
  because
• 1:30
  of
• 1:30
  a
• 1:30
  specific
• 1:31
  moment.
• 1:32
  Not
• 1:32
  just
• 1:32
  that
• 1:32
  they're
• 1:32
  referred
• 1:33
  to
• 1:33
  by
• 1:33
  their
• 1:33
  therapist
• 1:34
  or
• 1:34
  their
• 1:34
  pcp,
• 1:35
  but
• 1:35
  they
• 1:35
  had
• 1:35
  a
• 1:35
  specific
• 1:36
  come
• 1:36
  to
• 1:37
  Jesus
• 1:37
  moment.
• 1:37
  In
• 1:37
  this
• 1:38
  case,
• 1:38
  we'll
• 1:38
  call
• 1:39
  her
• 1:39
  Betty,
• 1:39
  a
• 1:39
  mock
• 1:40
  patient
• 1:40
  Betty.
• 1:41
  And
• 1:41
  Betty's
• 1:41
  coming
• 1:41
  to
• 1:42
  you
• 1:42
  because
• 1:42
  she's
• 1:42
  like,
• 1:42
  hey,
• 1:43
  I
• 1:43
  almost
• 1:43
  made
• 1:45
  a
• 1:45
  med
• 1:45
  error.
• 1:45
  I
• 1:46
  almost
• 1:46
  gave
• 1:46
  somebody
• 1:47
  epinephrine
• 1:48
  when
• 1:48
  she
• 1:48
  was
• 1:49
  supposed
• 1:49
  to
• 1:49
  give
• 1:49
  Tylenol.
• 1:50
  Okay,
• 1:50
  that's
• 1:50
  pretty.
• 1:51
  That's
• 1:51
  pretty
• 1:51
  horrible.
• 1:52
  We
• 1:52
  really
• 1:52
  need
• 1:52
  to
• 1:52
  help
• 1:52
  Betty,
• 1:53
  like
• 1:53
  right
• 1:53
  now.
• 1:54
  Might
• 1:54
  even
• 1:54
  want
• 1:54
  to
• 1:54
  take
• 1:54
  her
• 1:55
  license
• 1:55
  away.
• 1:55
  But
• 1:56
  listen,
• 1:56
  okay,
• 1:56
  we
• 1:57
  got
• 1:57
  to
• 1:57
  help
• 1:57
  Betty
• 1:58
  now.
• 1:58
  Her
• 1:59
  daytime
• 1:59
  sleep
• 1:59
  is
• 2:00
  super
• 2:00
  fragmented.
• 2:01
  When
• 2:01
  she
• 2:01
  does
• 2:01
  get
• 2:02
  home
• 2:02
  and
• 2:02
  finally
• 2:02
  sleep,
• 2:03
  she
• 2:03
  sleeps
• 2:03
  maybe
• 2:04
  four
• 2:04
  to
• 2:04
  five
• 2:04
  hours
• 2:05
  after
• 2:05
  her
• 2:05
  shifts.
• 2:06
  She
• 2:06
  has
• 2:06
  blackout
• 2:07
  curtains.
• 2:07
  She's
• 2:08
  done
• 2:08
  all
• 2:08
  the
• 2:08
  good
• 2:08
  stuff
• 2:08
  she
• 2:09
  needs
• 2:09
  to
• 2:09
  do.
• 2:10
  Sleep,
• 2:10
  hygiene,
• 2:11
  etc.
• 2:11
  It's
• 2:11
  challenging.
• 2:12
  You
• 2:12
  know,
• 2:12
  she's
• 2:12
  on
• 2:12
  a
• 2:12
  night
• 2:13
  shift
• 2:13
  and
• 2:13
  she's
• 2:13
  really
• 2:14
  dysregulated
• 2:14
  now.
• 2:15
  Her
• 2:15
  commute
• 2:15
  home
• 2:15
  is
• 2:15
  45
• 2:16
  minutes.
• 2:16
  And
• 2:17
  she
• 2:17
  does
• 2:17
  report
• 2:17
  to
• 2:18
  you
• 2:18
  that
• 2:18
  she
• 2:18
  has
• 2:18
  nodded
• 2:18
  off
• 2:19
  at
• 2:19
  red
• 2:19
  lights
• 2:19
  twice
• 2:20
  in
• 2:20
  the
• 2:20
  past
• 2:20
  month.
• 2:21
  So
• 2:21
  that
• 2:22
  should
• 2:22
  be
• 2:22
  kind
• 2:23
  of
• 2:23
  hair
• 2:23
  on
• 2:23
  fire
• 2:23
  emergency
• 2:24
  for
• 2:24
  you,
• 2:24
  right?
• 2:25
  Of
• 2:25
  all
• 2:25
  the
• 2:25
  things
• 2:25
  that
• 2:25
  she
• 2:26
  just
• 2:26
  shared,
• 2:27
  that's
• 2:27
  the
• 2:27
  one
• 2:27
  that
• 2:28
  deserves
• 2:28
  a
• 2:30
  significant
• 2:30
  degree
• 2:31
  of
• 2:31
  your
• 2:31
  attention,
• 2:31
  all
• 2:32
  right?
• 2:32
  That's
• 2:32
  potentially
• 2:32
  life
• 2:33
  or
• 2:33
  death.
• 2:33
  Now,
• 2:33
  this
• 2:33
  isn't
• 2:34
  just
• 2:34
  a
• 2:34
  circadian
• 2:36
  alignment
• 2:36
  problem.
• 2:37
  It's
• 2:37
  not
• 2:37
  just
• 2:37
  a
• 2:38
  depressive
• 2:39
  phase
• 2:39
  of
• 2:39
  her
• 2:40
  bipolar
• 2:40
  one.
• 2:40
  This
• 2:41
  is
• 2:41
  a
• 2:42
  practical
• 2:43
  problem
• 2:43
  that
• 2:43
  she's
• 2:44
  coming
• 2:44
  to
• 2:44
  you
• 2:44
  with,
• 2:45
  right?
• 2:45
  So
• 2:45
  as
• 2:46
  new
• 2:46
  grads
• 2:46
  especially,
• 2:47
  we
• 2:47
  can
• 2:47
  get
• 2:47
  really
• 2:47
  caught
• 2:48
  up
• 2:48
  in.
• 2:48
  What
• 2:48
  am
• 2:49
  I
• 2:49
  looking
• 2:49
  at?
• 2:50
  Is
• 2:50
  this
• 2:50
  depression?
• 2:51
  Is
• 2:51
  this
• 2:51
  bipolar?
• 2:51
  Is
• 2:52
  this
• 2:52
  adhd?
• 2:53
  Right?
• 2:54
  Now,
• 2:54
  it's
• 2:55
  really
• 2:55
  important
• 2:55
  that
• 2:56
  we
• 2:56
  focus
• 2:56
  on
• 2:56
  this,
• 2:56
  right?
• 2:57
  She
• 2:57
  has
• 2:57
  a
• 2:58
  long
• 2:58
  commute
• 2:58
  home,
• 2:58
  she
• 2:59
  can't
• 2:59
  stay
• 2:59
  awake,
• 3:00
  and
• 3:00
  she's
• 3:00
  nodding
• 3:01
  off
• 3:02
  at
• 3:02
  red
• 3:02
  lights
• 3:02
  twice
• 3:03
  a
• 3:03
  month.
• 3:03
  So
• 3:03
  I
• 3:04
  would
• 3:04
  challenge
• 3:04
  you
• 3:04
  all.
• 3:04
  I
• 3:05
  know
• 3:05
  it's
• 3:05
  very
• 3:05
  hard,
• 3:05
  right?
• 3:06
  We
• 3:06
  feel
• 3:06
  rushed
• 3:07
  to
• 3:07
  think
• 3:07
  of
• 3:07
  a
• 3:07
  diagnosis.
• 3:08
  And
• 3:08
  of
• 3:09
  course,
• 3:09
  that's
• 3:09
  important
• 3:09
  to
• 3:10
  frame
• 3:10
  these
• 3:10
  kinds
• 3:11
  of
• 3:11
  things
• 3:11
  in
• 3:11
  our
• 3:12
  minds
• 3:12
  proactively
• 3:13
  so
• 3:13
  we
• 3:13
  align
• 3:14
  it
• 3:14
  with
• 3:14
  the
• 3:14
  appropriate
• 3:15
  treatment.
• 3:15
  But
• 3:16
  sometimes
• 3:16
  it's
• 3:16
  also
• 3:17
  helpful
• 3:17
  to
• 3:18
  just
• 3:18
  take
• 3:18
  a
• 3:19
  specific
• 3:19
  problem.
• 3:19
  In
• 3:20
  this
• 3:20
  case,
• 3:20
  you
• 3:21
  could
• 3:21
  frame
• 3:21
  it
• 3:21
  as
• 3:22
  a
• 3:22
  question
• 3:22
  to
• 3:22
  the
• 3:23
  problem
• 3:23
  and
• 3:23
  say,
• 3:23
  well,
• 3:23
  what
• 3:24
  can
• 3:24
  we
• 3:24
  do
• 3:24
  for
• 3:24
  somebody
• 3:25
  who
• 3:25
  needs
• 3:26
  to
• 3:26
  stay
• 3:26
  awake
• 3:27
  during
• 3:29
  a
• 3:29
  critical
• 3:30
  time
• 3:30
  of
• 3:30
  day?
• 3:31
  Right?
• 3:31
  And
• 3:31
  that
• 3:32
  sparks
• 3:32
  a
• 3:32
  bunch
• 3:32
  of
• 3:32
  other
• 3:33
  questions
• 3:33
  that
• 3:33
  we
• 3:33
  can
• 3:33
  get
• 3:33
  into
• 3:34
  later.
• 3:34
  But
• 3:35
  it
• 3:35
  just
• 3:36
  invites
• 3:36
  all
• 3:36
  kinds
• 3:36
  of
• 3:36
  creative
• 3:37
  questions
• 3:37
  because
• 3:37
  you're
• 3:38
  thinking,
• 3:38
  okay,
• 3:38
  well,
• 3:38
  maybe
• 3:38
  I
• 3:39
  can
• 3:39
  give
• 3:39
  her
• 3:39
  a
• 3:39
  stimulant.
• 3:40
  Maybe
• 3:40
  I
• 3:40
  can
• 3:40
  give
• 3:40
  her
• 3:41
  whatever.
• 3:41
  But
• 3:42
  then
• 3:42
  you're
• 3:42
  thinking,
• 3:43
  well,
• 3:43
  wait,
• 3:43
  she's
• 3:43
  on
• 3:44
  her
• 3:44
  commute
• 3:44
  home.
• 3:44
  I
• 3:44
  can't
• 3:44
  really
• 3:45
  give
• 3:45
  her
• 3:45
  a
• 3:45
  stimulant.
• 3:45
  She's
• 3:46
  about
• 3:46
  to
• 3:46
  fall
• 3:46
  asleep.
• 3:47
  That
• 3:47
  will
• 3:47
  bring
• 3:48
  us
• 3:48
  eventually
• 3:48
  to
• 3:48
  the
• 3:49
  answer
• 3:49
  of
• 3:49
  this
• 3:49
  question.
• 3:50
  But
• 3:50
  again,
• 3:50
  it's
• 3:50
  good
• 3:50
  to
• 3:51
  just
• 3:51
  ask
• 3:51
  questions,
• 3:52
  even
• 3:52
  if
• 3:52
  the
• 3:52
  questions
• 3:53
  don't
• 3:53
  lead
• 3:53
  to
• 3:53
  an
• 3:53
  immediate
• 3:54
  answer,
• 3:55
  even
• 3:55
  if
• 3:55
  you're
• 3:55
  asking
• 3:55
  questions
• 3:56
  that
• 3:56
  lead
• 3:56
  to
• 3:56
  really
• 3:57
  ridiculous
• 3:57
  answers,
• 3:58
  right?
• 3:58
  Maybe
• 3:58
  on
• 3:58
  the
• 3:59
  surface,
• 3:59
  it's
• 3:59
  ridiculous
• 4:00
  that
• 4:00
  you
• 4:00
  would
• 4:00
  say,
• 4:01
  well,
• 4:01
  maybe
• 4:01
  we
• 4:01
  should
• 4:01
  give
• 4:02
  her
• 4:02
  a
• 4:02
  stimulant.
• 4:02
  But
• 4:02
  that's
• 4:03
  okay.
• 4:03
  That's
• 4:03
  how
• 4:03
  we
• 4:04
  critically
• 4:04
  think,
• 4:04
  right?
• 4:05
  We
• 4:05
  get
• 4:05
  to
• 4:05
  the
• 4:05
  implausible
• 4:06
  answer,
• 4:07
  which
• 4:07
  is
• 4:08
  a
• 4:08
  stimulant,
• 4:08
  which
• 4:09
  is
• 4:09
  not
• 4:09
  what
• 4:09
  we
• 4:09
  should
• 4:09
  do
• 4:09
  in
• 4:10
  this
• 4:10
  case
• 4:10
  because
• 4:10
  she
• 4:10
  does
• 4:11
  have
• 4:11
  to
• 4:11
  fall
• 4:11
  asleep
• 4:12
  pretty
• 4:12
  soon
• 4:12
  thereafter
• 4:13
  after
• 4:13
  coming
• 4:13
  home.
• 4:14
  Right?
• 4:14
  But
• 4:15
  at
• 4:15
  the
• 4:15
  same
• 4:15
  time,
• 4:16
  that
• 4:16
  gets
• 4:16
  us
• 4:17
  a
• 4:17
  little
• 4:17
  bit
• 4:17
  closer
• 4:17
  to
• 4:18
  where
• 4:18
  we
• 4:18
  do
• 4:18
  need
• 4:18
  to
• 4:19
  go.
• 4:19
  And
• 4:19
  again,
• 4:20
  that'll
• 4:20
  bring
• 4:20
  us
• 4:21
  to
• 4:21
  the
• 4:21
  answer
• 4:21
  later
• 4:22
  on.
• 4:22
  Now,
• 4:23
  in
• 4:23
  her
• 4:23
  psychiatric
• 4:24
  history,
• 4:24
  she
• 4:24
  did
• 4:25
  explain
• 4:25
  to
• 4:25
  you
• 4:25
  she
• 4:26
  does
• 4:26
  have
• 4:26
  bipolar
• 4:26
  one
• 4:27
  disorder.
• 4:27
  She
• 4:27
  had
• 4:27
  one
• 4:27
  prior
• 4:28
  manic
• 4:28
  episode
• 4:29
  three
• 4:29
  years
• 4:29
  ago.
• 4:29
  She
• 4:30
  was
• 4:30
  hospitalized
• 4:31
  for
• 4:31
  that.
• 4:32
  She
• 4:32
  has
• 4:32
  low
• 4:32
  Energy.
• 4:33
  It's
• 4:33
  very
• 4:33
  difficult
• 4:34
  for
• 4:34
  her
• 4:34
  currently
• 4:35
  to
• 4:35
  get
• 4:35
  joy
• 4:36
  out
• 4:36
  of
• 4:36
  anything.
• 4:36
  And
• 4:36
  she,
• 4:36
  of
• 4:37
  course,
• 4:37
  can't
• 4:37
  concentrate.
• 4:38
  There's
• 4:38
  no
• 4:38
  acute
• 4:39
  safety
• 4:39
  concerns
• 4:39
  beyond
• 4:40
  her
• 4:40
  falling
• 4:40
  asleep
• 4:41
  at
• 4:41
  the
• 4:41
  wheel,
• 4:42
  which
• 4:42
  is
• 4:42
  a
• 4:42
  big
• 4:42
  issue.
• 4:43
  But
• 4:43
  she
• 4:43
  does
• 4:43
  score
• 4:44
  for
• 4:44
  moderate
• 4:44
  depression
• 4:45
  here.
• 4:46
  Now,
• 4:46
  a
• 4:46
  couple
• 4:46
  other
• 4:47
  details
• 4:47
  you
• 4:47
  may
• 4:48
  want
• 4:48
  to
• 4:49
  know
• 4:50
  about
• 4:50
  her.
• 4:51
  Her
• 4:51
  sleep
• 4:51
  efficiency
• 4:52
  is
• 4:52
  not
• 4:52
  great.
• 4:53
  Um,
• 4:54
  she
• 4:54
  took
• 4:54
  a
• 4:54
  daytime
• 4:55
  polysomnogram
• 4:57
  and
• 4:57
  her
• 4:57
  sleep
• 4:57
  efficiency
• 4:58
  is
• 4:58
  about
• 4:58
  72%.
• 4:59
  So
• 4:59
  that's
• 4:59
  not
• 4:59
  normal.
• 5:00
  She
• 5:00
  took
• 5:00
  a
• 5:00
  multiple
• 5:01
  sleep
• 5:01
  latency
• 5:01
  test,
• 5:02
  which
• 5:02
  does
• 5:03
  kind
• 5:03
  of
• 5:03
  measure
• 5:03
  how
• 5:03
  long
• 5:04
  it
• 5:04
  takes
• 5:04
  you
• 5:04
  to
• 5:04
  fall
• 5:05
  asleep.
• 5:05
  Hers
• 5:06
  was
• 5:06
  4.2
• 5:06
  minutes.
• 5:07
  That's
• 5:07
  rather
• 5:08
  quick.
• 5:08
  We
• 5:08
  go
• 5:09
  all
• 5:09
  into
• 5:09
  the
• 5:09
  MSLT
• 5:10
  and
• 5:10
  narcolepsy
• 5:11
  in
• 5:11
  previous
• 5:11
  episodes.
• 5:12
  I
• 5:12
  highly
• 5:12
  recommend
• 5:12
  you
• 5:13
  look
• 5:13
  into
• 5:13
  that.
• 5:14
  And
• 5:14
  she
• 5:14
  does
• 5:15
  meet
• 5:15
  DSM
• 5:15
  5
• 5:16
  criteria
• 5:16
  for
• 5:16
  a
• 5:16
  chronic
• 5:17
  shift
• 5:17
  work
• 5:17
  disorder.
• 5:18
  And
• 5:18
  we'll
• 5:18
  definitely
• 5:18
  go
• 5:19
  into
• 5:19
  that
• 5:19
  in
• 5:20
  future
• 5:20
  episodes,
• 5:21
  which
• 5:22
  I
• 5:22
  think
• 5:22
  would
• 5:22
  be
• 5:22
  really
• 5:23
  important
• 5:23
  to
• 5:23
  look
• 5:23
  at.
• 5:24
  She
• 5:24
  took
• 5:24
  an
• 5:24
  Epworth
• 5:25
  sleepiness
• 5:25
  scale
• 5:26
  and
• 5:26
  she
• 5:26
  scored
• 5:26
  a
• 5:27
  16.
• 5:27
  So
• 5:27
  she
• 5:27
  has
• 5:27
  excessive
• 5:28
  daytime
• 5:29
  sleepiness.
• 5:29
  It's
• 5:29
  also
• 5:29
  good
• 5:30
  to
• 5:30
  measure
• 5:30
  these
• 5:31
  with
• 5:31
  metrics
• 5:32
  as
• 5:32
  well.
• 5:32
  She's
• 5:33
  on
• 5:33
  lithium
• 5:33
  900,
• 5:34
  no
• 5:34
  other
• 5:34
  psychotropics
• 5:35
  other
• 5:35
  than
• 5:35
  lithium,
• 5:36
  and
• 5:37
  she
• 5:37
  can't
• 5:38
  really
• 5:38
  switch
• 5:38
  to
• 5:38
  day
• 5:38
  shifts.
• 5:39
  That's
• 5:39
  not
• 5:39
  in
• 5:39
  the
• 5:39
  cards.
• 5:40
  So
• 5:40
  we
• 5:40
  can't
• 5:40
  really
• 5:41
  use
• 5:41
  that
• 5:41
  as
• 5:41
  an
• 5:41
  intervention
• 5:42
  today.
• 5:43
  She's
• 5:43
  on
• 5:43
  night
• 5:43
  shift
• 5:44
  for
• 5:44
  financial
• 5:44
  reasons.
• 5:45
  In
• 5:45
  a
• 5:45
  lot
• 5:46
  of
• 5:46
  these
• 5:46
  real
• 5:46
  world
• 5:47
  cases,
• 5:47
  your
• 5:48
  patients
• 5:48
  can't
• 5:49
  just
• 5:49
  magically
• 5:49
  do
• 5:50
  the
• 5:50
  thing
• 5:50
  that
• 5:50
  you
• 5:50
  wish
• 5:51
  they
• 5:51
  could
• 5:51
  do
• 5:51
  to
• 5:52
  solve
• 5:52
  the
• 5:52
  problem
• 5:52
  quickly.
• 5:53
  Right?
• 5:53
  The
• 5:54
  best
• 5:54
  thing
• 5:55
  beyond
• 5:55
  a
• 5:55
  medication
• 5:56
  is
• 5:56
  let's
• 5:57
  do
• 5:57
  some
• 5:57
  lifestyle
• 5:58
  realignment,
• 5:58
  right?
• 5:59
  Let's
• 5:59
  work
• 5:59
  on
• 5:59
  day
• 5:59
  shifts.
• 6:00
  Let's
• 6:00
  get
• 6:00
  you
• 6:00
  into
• 6:00
  a
• 6:01
  regular
• 6:01
  circadian
• 6:02
  rhythm.
• 6:03
  But
• 6:03
  it's
• 6:03
  not
• 6:03
  always
• 6:03
  that
• 6:04
  simple.
• 6:04
  Right?
• 6:05
  So
• 6:05
  before
• 6:06
  we
• 6:07
  intervene,
• 6:07
  we
• 6:07
  really
• 6:08
  have
• 6:08
  to
• 6:08
  understand
• 6:08
  the
• 6:08
  patient
• 6:09
  socially
• 6:09
  to
• 6:10
  understand
• 6:11
  if
• 6:11
  what
• 6:11
  we're
• 6:12
  about
• 6:12
  to
• 6:12
  propose
• 6:12
  is
• 6:12
  even
• 6:13
  feasible
• 6:13
  or
• 6:13
  desirable.
• 6:14
  In
• 6:14
  this
• 6:14
  case,
• 6:14
  it's
• 6:15
  neither
• 6:15
  feasible
• 6:15
  nor
• 6:15
  really
• 6:16
  desirable.
• 6:16
  She
• 6:17
  has
• 6:17
  financial
• 6:17
  constraints,
• 6:18
  she
• 6:19
  wants
• 6:19
  to
• 6:19
  work
• 6:19
  night
• 6:19
  shift,
• 6:20
  so
• 6:20
  we
• 6:20
  have
• 6:20
  to
• 6:20
  work
• 6:21
  within
• 6:21
  her
• 6:21
  given
• 6:21
  parameters.
• 6:22
  And
• 6:22
  that's
• 6:22
  perfectly
• 6:23
  fine.
• 6:23
  Here
• 6:24
  is
• 6:24
  the
• 6:24
  clinical
• 6:24
  question
• 6:25
  that
• 6:25
  confronts
• 6:26
  you
• 6:26
  today.
• 6:27
  You
• 6:27
  are
• 6:27
  considering
• 6:28
  pharmacological
• 6:29
  augmentation
• 6:30
  to
• 6:30
  address
• 6:30
  the
• 6:30
  patient's
• 6:31
  excessive
• 6:31
  sleepiness
• 6:32
  during
• 6:33
  night
• 6:33
  shifts
• 6:33
  and
• 6:34
  residual
• 6:35
  depressive
• 6:35
  symptoms.
• 6:36
  Which
• 6:36
  of
• 6:36
  these
• 6:36
  interventions
• 6:37
  would
• 6:37
  be
• 6:37
  the
• 6:37
  most
• 6:38
  appropriate
• 6:38
  for
• 6:39
  Betty?
• 6:40
  Is
• 6:40
  it
• 6:40
  A,
• 6:40
  modafinil
• 6:41
  200
• 6:41
  milligrams
• 6:42
  taken
• 6:42
  one
• 6:43
  hour
• 6:43
  before
• 6:44
  her
• 6:44
  night
• 6:44
  shift?
• 6:45
  Is
• 6:45
  it
• 6:45
  b
• 6:46
  r?
• 6:46
  Modafinil,
• 6:47
  150mg
• 6:49
  taken
• 6:49
  one
• 6:50
  hour
• 6:50
  before
• 6:50
  each
• 6:51
  night
• 6:51
  shift?
• 6:51
  Is
• 6:52
  it
• 6:52
  C?
• 6:52
  Increase
• 6:53
  her
• 6:53
  lithium
• 6:53
  dose
• 6:54
  to
• 6:54
  achieve
• 6:54
  a
• 6:54
  level
• 6:55
  of
• 6:55
  1
• 6:56
  to
• 6:56
  1.2
• 6:57
  mil
• 6:57
  equivalents
• 6:58
  per
• 6:58
  liter.
• 6:58
  Or
• 6:59
  is
• 6:59
  it
• 6:59
  D,
• 6:59
  add
• 6:59
  Quetiapine,
• 7:00
  also
• 7:00
  known
• 7:01
  as
• 7:01
  Seroquel,
• 7:01
  50
• 7:02
  milligrams
• 7:02
  at
• 7:03
  bedtime
• 7:03
  once
• 7:03
  she
• 7:04
  comes
• 7:04
  home
• 7:04
  after
• 7:05
  her
• 7:05
  shift
• 7:05
  to
• 7:06
  improve
• 7:06
  her
• 7:06
  daytime
• 7:07
  sleep.
• 7:08
  Now,
• 7:08
  my
• 7:08
  friends,
• 7:09
  I
• 7:09
  love
• 7:09
  this
• 7:09
  question
• 7:10
  because
• 7:10
  at
• 7:11
  first
• 7:11
  glance,
• 7:13
  three
• 7:13
  of
• 7:13
  these
• 7:14
  look
• 7:14
  like
• 7:15
  somewhat
• 7:15
  reasonable
• 7:16
  answers.
• 7:16
  Modafinil,
• 7:18
  sure,
• 7:18
  that
• 7:18
  looks
• 7:18
  pretty
• 7:19
  reasonable.
• 7:19
  Armodafinil,
• 7:20
  that
• 7:20
  also
• 7:21
  looks
• 7:21
  reasonable.
• 7:21
  But
• 7:22
  if
• 7:22
  you're
• 7:22
  new
• 7:22
  to
• 7:23
  the
• 7:23
  game,
• 7:23
  you
• 7:24
  might
• 7:24
  be
• 7:24
  asking,
• 7:24
  well,
• 7:24
  heck,
• 7:25
  what
• 7:25
  the
• 7:25
  hell's
• 7:25
  the
• 7:25
  difference
• 7:25
  between
• 7:26
  Modafinil
• 7:26
  and
• 7:26
  Armodafinil?
• 7:27
  And
• 7:28
  it
• 7:28
  might
• 7:28
  make
• 7:28
  you
• 7:29
  kind
• 7:29
  of
• 7:29
  scramble
• 7:29
  and
• 7:30
  think
• 7:30
  about
• 7:30
  that
• 7:30
  for
• 7:30
  a
• 7:31
  second.
• 7:31
  Now,
• 7:31
  the
• 7:32
  lithium
• 7:32
  dose.
• 7:33
  Increasing
• 7:33
  the
• 7:34
  lithium
• 7:34
  dose.
• 7:35
  Remember,
• 7:35
  my
• 7:35
  friends,
• 7:36
  that
• 7:37
  is.
• 7:38
  Yeah,
• 7:39
  let's
• 7:39
  be
• 7:39
  careful
• 7:40
  with
• 7:40
  that
• 7:40
  one.
• 7:41
  And
• 7:41
  the
• 7:41
  reason
• 7:41
  we
• 7:41
  should
• 7:42
  be
• 7:42
  careful
• 7:42
  with
• 7:42
  that
• 7:42
  one.
• 7:43
  Nothing
• 7:44
  in
• 7:44
  this
• 7:44
  clinical
• 7:45
  picture
• 7:45
  suggests
• 7:46
  that
• 7:46
  her
• 7:47
  mania
• 7:48
  is
• 7:48
  unregulated.
• 7:49
  She
• 7:49
  had
• 7:49
  a
• 7:49
  manic
• 7:50
  episode
• 7:50
  about
• 7:50
  three
• 7:51
  years
• 7:51
  ago.
• 7:51
  She's
• 7:52
  not
• 7:53
  talking
• 7:53
  really
• 7:53
  fast,
• 7:54
  her
• 7:54
  speech
• 7:54
  isn't
• 7:55
  pressured.
• 7:55
  She's
• 7:56
  not
• 7:56
  coming
• 7:56
  to
• 7:56
  you
• 7:56
  with
• 7:57
  loads
• 7:57
  of
• 7:57
  impulsivity
• 7:58
  or
• 7:58
  mood
• 7:58
  dysregulation.
• 8:00
  This
• 8:00
  presenting
• 8:01
  complaint
• 8:02
  seems
• 8:02
  quite
• 8:03
  circumscribed
• 8:04
  to
• 8:05
  attentional
• 8:06
  issues
• 8:07
  and
• 8:07
  to
• 8:08
  functional
• 8:08
  problems
• 8:09
  at
• 8:09
  work
• 8:09
  related
• 8:10
  to
• 8:10
  those
• 8:10
  attentional
• 8:11
  issues.
• 8:11
  And
• 8:11
  of
• 8:12
  course,
• 8:12
  there
• 8:12
  is
• 8:12
  some
• 8:12
  residual
• 8:13
  depression.
• 8:13
  So
• 8:14
  it's
• 8:14
  not
• 8:14
  insane
• 8:14
  to
• 8:15
  think
• 8:15
  of
• 8:15
  lithium.
• 8:16
  But
• 8:16
  you
• 8:16
  also
• 8:16
  have
• 8:17
  to
• 8:17
  consider,
• 8:17
  what
• 8:18
  else
• 8:18
  does
• 8:18
  lithium
• 8:18
  do?
• 8:19
  Right?
• 8:19
  It's
• 8:19
  not
• 8:19
  just
• 8:20
  about
• 8:20
  treating
• 8:21
  bipolar
• 8:22
  disorder.
• 8:22
  It's
• 8:23
  also
• 8:23
  about
• 8:24
  this
• 8:24
  potential
• 8:25
  side
• 8:25
  effects
• 8:25
  of
• 8:25
  lithium.
• 8:26
  And
• 8:26
  as
• 8:26
  we
• 8:26
  raise
• 8:27
  the
• 8:27
  dose,
• 8:28
  there
• 8:28
  is
• 8:28
  certainly
• 8:29
  a
• 8:29
  possibility
• 8:30
  that
• 8:31
  she
• 8:31
  might
• 8:31
  have
• 8:32
  some
• 8:32
  cognitive
• 8:33
  impairment
• 8:33
  by
• 8:34
  increasing
• 8:34
  the
• 8:35
  lithium.
• 8:35
  Right?
• 8:36
  Cognitive
• 8:36
  dulling
• 8:37
  tremors,
• 8:38
  that
• 8:38
  could
• 8:38
  worsen
• 8:38
  her
• 8:39
  functional
• 8:40
  and
• 8:41
  that
• 8:41
  could
• 8:41
  worsen
• 8:41
  her
• 8:42
  occupational
• 8:43
  issues
• 8:43
  even
• 8:43
  more.
• 8:44
  So
• 8:44
  I
• 8:44
  wouldn't
• 8:45
  jump
• 8:45
  to
• 8:45
  lithium.
• 8:45
  It's
• 8:46
  not
• 8:46
  an
• 8:46
  insane
• 8:46
  answer,
• 8:47
  but
• 8:47
  again,
• 8:47
  it's
• 8:47
  not
• 8:47
  really,
• 8:49
  it's
• 8:50
  not
• 8:50
  really
• 8:50
  addressing
• 8:52
  what
• 8:52
  I
• 8:52
  always
• 8:52
  tell
• 8:52
  my
• 8:53
  students.
• 8:53
  The
• 8:53
  center
• 8:53
  of
• 8:54
  gravity
• 8:54
  or
• 8:54
  the
• 8:54
  center
• 8:55
  of
• 8:55
  gravity
• 8:56
  of
• 8:56
  her
• 8:56
  complaint
• 8:56
  is
• 8:56
  not
• 8:57
  really
• 8:57
  mood
• 8:57
  dysregulate
• 8:58
  dysregulation.
• 8:59
  It's
• 9:00
  concentration,
• 9:00
  focus,
• 9:01
  cognitive
• 9:01
  performance,
• 9:02
  and
• 9:02
  the
• 9:03
  need
• 9:03
  in
• 9:03
  particular
• 9:04
  to
• 9:04
  stay
• 9:04
  awake.
• 9:05
  Now,
• 9:06
  it
• 9:06
  is,
• 9:07
  it
• 9:07
  makes
• 9:08
  some
• 9:08
  sense
• 9:08
  that
• 9:08
  you
• 9:08
  would
• 9:09
  add
• 9:09
  Seroquel
• 9:10
  here
• 9:10
  and
• 9:11
  if
• 9:11
  your
• 9:11
  angle
• 9:11
  of
• 9:11
  attack
• 9:12
  was,
• 9:12
  let's
• 9:12
  get
• 9:13
  her
• 9:13
  to
• 9:13
  sleep
• 9:13
  more
• 9:13
  deeply
• 9:15
  and
• 9:15
  maybe
• 9:15
  she'll
• 9:16
  be
• 9:16
  more
• 9:16
  alert
• 9:17
  as
• 9:17
  a
• 9:17
  result
• 9:17
  of
• 9:18
  that
• 9:18
  if
• 9:18
  her
• 9:18
  sleep
• 9:18
  is
• 9:19
  more
• 9:19
  restorative
• 9:19
  and
• 9:20
  restful.
• 9:20
  The
• 9:21
  problem
• 9:21
  with
• 9:21
  that
• 9:21
  is
• 9:22
  the
• 9:23
  anti
• 9:23
  histaminergic
• 9:24
  effect
• 9:24
  of
• 9:24
  Seroquel
• 9:25
  is
• 9:25
  problematic.
• 9:26
  And
• 9:27
  now
• 9:27
  we're
• 9:27
  getting
• 9:27
  into
• 9:28
  all
• 9:28
  kinds
• 9:28
  of
• 9:28
  problems
• 9:29
  where
• 9:29
  she
• 9:29
  wakes
• 9:29
  up
• 9:30
  really
• 9:30
  groggy,
• 9:30
  she's
• 9:31
  behind
• 9:31
  the
• 9:31
  wheel,
• 9:32
  and
• 9:32
  you
• 9:32
  have
• 9:32
  A
• 9:32
  problem
• 9:33
  now
• 9:33
  going
• 9:33
  to
• 9:33
  work,
• 9:34
  and
• 9:34
  you
• 9:34
  might
• 9:34
  have
• 9:34
  a
• 9:34
  problem
• 9:34
  coming
• 9:35
  back
• 9:35
  from
• 9:35
  work.
• 9:36
  It
• 9:36
  could
• 9:37
  deepen
• 9:37
  her
• 9:37
  sleep
• 9:38
  or
• 9:38
  allow
• 9:38
  her
• 9:39
  to
• 9:39
  sleep
• 9:39
  more
• 9:39
  fully
• 9:40
  and
• 9:40
  in
• 9:40
  theory
• 9:41
  make
• 9:41
  her
• 9:41
  feel
• 9:42
  more
• 9:42
  alert
• 9:42
  throughout
• 9:43
  the
• 9:43
  day.
• 9:43
  But
• 9:43
  that
• 9:44
  could
• 9:44
  also
• 9:44
  have
• 9:45
  a
• 9:46
  much
• 9:46
  different
• 9:46
  effect
• 9:47
  on
• 9:47
  her,
• 9:47
  an
• 9:47
  unintended
• 9:48
  effect
• 9:48
  that
• 9:48
  we
• 9:48
  don't
• 9:49
  really
• 9:49
  want.
• 9:50
  It's
• 9:50
  probably
• 9:50
  gonna
• 9:51
  actually
• 9:51
  worsen
• 9:51
  her
• 9:51
  daytime
• 9:52
  sleepiness
• 9:52
  at
• 9:53
  the
• 9:53
  job.
• 9:53
  It's
• 9:53
  gonna
• 9:54
  make
• 9:54
  her
• 9:54
  feel
• 9:54
  more
• 9:54
  groggy.
• 9:55
  A
• 9:55
  lot
• 9:55
  of
• 9:55
  patients
• 9:56
  talk
• 9:56
  about
• 9:56
  that
• 9:57
  carryover
• 9:57
  sedation,
• 9:58
  and
• 9:58
  that's
• 9:59
  not
• 9:59
  gonna
• 9:59
  be
• 9:59
  good.
• 9:59
  During
• 9:59
  her
• 10:00
  night
• 10:00
  shift,
• 10:01
  she's
• 10:01
  not
• 10:01
  gonna
• 10:01
  be
• 10:02
  as
• 10:02
  alert
• 10:02
  because
• 10:02
  of
• 10:03
  the
• 10:03
  antihistaminergic
• 10:04
  properties.
• 10:05
  So
• 10:05
  it's
• 10:05
  not
• 10:06
  my
• 10:06
  favorite,
• 10:06
  and
• 10:07
  it
• 10:07
  would
• 10:07
  be
• 10:07
  pretty
• 10:07
  ill
• 10:08
  advised
• 10:08
  here.
• 10:08
  So
• 10:09
  that
• 10:09
  really
• 10:09
  leads
• 10:10
  us
• 10:10
  to
• 10:11
  two
• 10:11
  possible
• 10:12
  answers,
• 10:13
  and
• 10:13
  that
• 10:13
  would
• 10:13
  be
• 10:14
  modafinil
• 10:15
  200
• 10:16
  or
• 10:16
  are
• 10:16
  modafinil
• 10:17
  150.
• 10:18
  Now,
• 10:18
  there's
• 10:18
  plenty
• 10:19
  of
• 10:19
  you
• 10:19
  who
• 10:19
  may
• 10:19
  choose
• 10:20
  modafinil
• 10:21
  200.
• 10:21
  And
• 10:21
  I'm
• 10:22
  not
• 10:22
  going
• 10:22
  to
• 10:22
  sit
• 10:22
  here
• 10:22
  and
• 10:22
  say
• 10:23
  it
• 10:23
  would
• 10:23
  be
• 10:23
  the
• 10:24
  most
• 10:24
  outrageous
• 10:24
  choice
• 10:25
  at
• 10:25
  all.
• 10:25
  A
• 10:26
  lot
• 10:26
  of
• 10:26
  people
• 10:26
  prescribe
• 10:26
  Modafinil,
• 10:28
  and
• 10:28
  that's
• 10:29
  certainly
• 10:30
  somewhat
• 10:31
  appropriate.
• 10:32
  I
• 10:32
  would.
• 10:32
  This
• 10:33
  is
• 10:33
  where
• 10:34
  being
• 10:35
  a
• 10:35
  good
• 10:35
  psychopharmacologist
• 10:36
  really
• 10:37
  pays
• 10:37
  off,
• 10:37
  however,
• 10:38
  because
• 10:38
  there
• 10:38
  is
• 10:39
  one
• 10:39
  chief
• 10:39
  difference
• 10:40
  between
• 10:40
  Armodafinil
• 10:41
  and
• 10:41
  Modafinil.
• 11:37
  Now,
• 11:37
  as
• 11:37
  you
• 11:37
  all
• 11:38
  know,
• 11:38
  these
• 11:39
  medications
• 11:39
  are
• 11:40
  very
• 11:40
  effective
• 11:41
  and
• 11:41
  they're
• 11:41
  FDA
• 11:42
  approved,
• 11:42
  as
• 11:43
  a
• 10:48
  matter
• 11:43
  of
• 11:43
  fact,
• 11:44
  for
• 11:45
  narcolepsy,
• 11:45
  obstructive
• 11:46
  sleep
• 11:46
  apnea,
• 11:47
  and
• 11:47
  shift
• 11:47
  work
• 11:47
  sleep
• 11:48
  disorder.
• 11:49
  So
• 11:49
  you
• 11:49
  might
• 11:49
  think
• 11:49
  tomato,
• 11:50
  tomato,
• 11:50
  and
• 11:50
  sure
• 11:51
  enough,
• 11:51
  they
• 11:51
  are
• 11:52
  very
• 11:52
  similar
• 11:53
  agents.
• 11:54
  The
• 11:54
  big
• 11:54
  difference
• 11:54
  is
• 11:55
  R.
• 11:55
  Modafinil
• 11:56
  is
• 11:56
  the
• 11:56
  R
• 11:56
  enantiomer
• 11:57
  of
• 11:57
  Modafinil.
• 11:58
  Okay?
• 11:58
  So
• 11:58
  it's
• 11:58
  kind
• 11:59
  of
• 11:59
  got
• 11:59
  this
• 11:59
  longer
• 11:59
  acting
• 12:00
  isomer,
• 12:01
  which
• 12:01
  is
• 12:01
  a
• 12:01
  fancy
• 12:02
  way
• 12:02
  of
• 12:02
  saying
• 12:02
  it
• 12:02
  has
• 12:02
  properties
• 12:03
  within
• 12:03
  it
• 12:04
  that
• 12:04
  tend
• 12:04
  to
• 12:04
  act
• 12:05
  a
• 12:05
  little
• 12:05
  bit
• 12:05
  longer
• 12:06
  than
• 12:06
  the
• 12:06
  Modafinil
• 12:07
  and
• 12:07
  have
• 12:07
  higher
• 12:07
  peak
• 12:08
  concentrations
• 12:09
  than
• 12:09
  the
• 12:09
  Modafinil.
• 12:10
  Well,
• 12:10
  that's
• 12:11
  kind
• 12:11
  of
• 12:11
  important
• 12:12
  because
• 12:12
  the
• 12:12
  devil's
• 12:13
  in
• 12:13
  the
• 12:13
  details
• 12:14
  with
• 12:14
  this
• 12:14
  patient,
• 12:14
  right?
• 12:15
  Her
• 12:16
  chief
• 12:16
  impairment
• 12:17
  is
• 12:18
  really
• 12:18
  in
• 12:19
  that
• 12:19
  3am
• 12:19
  to
• 12:20
  6am
• 12:20
  window,
• 12:21
  right?
• 12:21
  Maybe
• 12:21
  during
• 12:22
  one
• 12:22
  of
• 12:22
  her
• 12:22
  last
• 12:22
  med
• 12:23
  passes
• 12:23
  when
• 12:23
  it's
• 12:23
  extra
• 12:24
  hard
• 12:24
  to
• 12:24
  stay
• 12:24
  awake
• 12:25
  and
• 12:25
  she
• 12:26
  still
• 12:26
  needs
• 12:26
  to
• 12:26
  be
• 12:26
  on
• 12:26
  her
• 12:27
  game.
• 12:27
  She's
• 12:27
  working
• 12:27
  in
• 12:28
  an
• 12:28
  ER
• 12:28
  or,
• 12:29
  you
• 12:30
  know,
• 12:30
  she's
• 12:30
  consulting
• 12:31
  and
• 12:31
  very
• 12:31
  difficult
• 12:32
  cases
• 12:32
  come
• 12:32
  in
• 12:33
  or
• 12:33
  whatever
• 12:33
  her
• 12:33
  role
• 12:33
  is
• 12:34
  there.
• 12:34
  3
• 12:34
  to
• 12:34
  6am
• 12:35
  that's
• 12:35
  when
• 12:35
  it's
• 12:36
  hardest
• 12:36
  to
• 12:36
  stay
• 12:36
  awake.
• 12:37
  So
• 12:37
  you
• 12:38
  may
• 12:38
  really
• 12:38
  need
• 12:38
  an
• 12:38
  agent
• 12:39
  that
• 12:40
  has
• 12:40
  higher
• 12:40
  peak
• 12:41
  concentrations,
• 12:41
  maintains
• 12:42
  higher
• 12:42
  plasma
• 12:43
  concentrations
• 12:44
  compared
• 12:45
  to
• 12:45
  another
• 12:46
  agent,
• 12:46
  in
• 12:47
  this
• 12:47
  case
• 12:47
  Armadafinil.
• 12:48
  Sure
• 12:48
  enough,
• 12:48
  does
• 12:48
  maintain.
• 12:49
  Some
• 12:49
  studies
• 12:49
  have
• 12:50
  shown
• 12:50
  44%
• 12:51
  higher
• 12:51
  plasma
• 12:52
  concentrations
• 12:53
  7
• 12:53
  to
• 12:53
  11
• 12:53
  hours
• 12:54
  post
• 12:54
  dose
• 12:54
  compared
• 12:55
  to
• 12:55
  modafinil.
• 12:56
  Well,
• 12:57
  that's
• 12:57
  exceptionally
• 12:58
  important
• 12:58
  here
• 12:59
  because,
• 12:59
  again,
• 13:00
  during
• 13:00
  those
• 13:00
  critical
• 13:00
  late
• 13:01
  shift
• 13:01
  hours
• 13:02
  when
• 13:02
  the
• 13:02
  patient
• 13:02
  is
• 13:03
  most
• 13:03
  vulnerable,
• 13:04
  the
• 13:04
  pharmacokinetic
• 13:05
  pharmacodynamic
• 13:06
  modeling
• 13:06
  here
• 13:07
  really
• 13:07
  demonstrates
• 13:08
  that
• 13:08
  armodafin
• 13:09
  A150
• 13:10
  is
• 13:11
  the
• 13:11
  superior
• 13:11
  agent
• 13:12
  in
• 13:12
  this
• 13:12
  case,
• 13:12
  because
• 13:13
  those
• 13:13
  last
• 13:13
  hours
• 13:13
  matter
• 13:14
  the
• 13:14
  most.
• 13:15
  Okay.
• 13:15
  Of
• 13:16
  course,
• 13:16
  everybody
• 13:17
  metabolizes
• 13:18
  medications
• 13:18
  differently.
• 13:19
  You
• 13:20
  may
• 13:20
  have
• 13:20
  a
• 13:20
  patient
• 13:21
  that
• 13:21
  you're
• 13:21
  treating
• 13:22
  for
• 13:22
  shift
• 13:23
  work
• 13:23
  sleep
• 13:23
  disorder
• 13:24
  who's
• 13:24
  perfectly
• 13:24
  fine
• 13:24
  on
• 13:25
  Modafinil,
• 13:25
  and
• 13:25
  that's
• 13:26
  okay.
• 13:26
  But
• 13:26
  in
• 13:26
  the
• 13:27
  event
• 13:27
  that
• 13:27
  you
• 13:28
  had
• 13:28
  a
• 13:28
  patient
• 13:28
  that
• 13:28
  needs
• 13:29
  a
• 13:29
  little
• 13:29
  bit
• 13:29
  more
• 13:29
  coverage
• 13:30
  and
• 13:30
  the
• 13:30
  modafinil's
• 13:31
  wearing
• 13:31
  off,
• 13:32
  modafinil,
• 13:33
  of
• 13:34
  course,
• 13:34
  might
• 13:35
  be
• 13:35
  a
• 13:35
  better
• 13:36
  idea
• 13:37
  here.
• 13:37
  So
• 13:38
  that's
• 13:38
  pretty
• 13:38
  neat.
• 13:39
  Now,
• 13:39
  you
• 13:39
  might
• 13:39
  also
• 13:40
  be
• 13:40
  asking,
• 13:40
  well,
• 13:40
  what
• 13:41
  do
• 13:41
  we
• 13:41
  do
• 13:41
  here
• 13:41
  about
• 13:41
  the
• 13:41
  bipolar
• 13:42
  disorder?
• 13:43
  Right.
• 13:43
  That's
• 13:43
  scary.
• 13:43
  Isn't
• 13:44
  Modafinil
• 13:45
  like
• 13:45
  a
• 13:45
  stimulant?
• 13:45
  Couldn't
• 13:46
  this
• 13:46
  throw
• 13:46
  her
• 13:47
  into
• 13:48
  a
• 13:48
  manic
• 13:48
  episode?
• 13:49
  And
• 13:50
  of
• 13:50
  course,
• 13:50
  in
• 13:50
  theory,
• 13:51
  that
• 13:51
  is
• 13:51
  possible.
• 13:51
  We
• 13:52
  always
• 13:52
  want
• 13:52
  to
• 13:52
  be
• 13:52
  mindful
• 13:53
  anytime
• 13:53
  we
• 13:53
  introduce
• 13:54
  an
• 13:54
  antidepressant
• 13:56
  or
• 13:56
  raise
• 13:56
  an
• 13:57
  antidepressant,
• 13:57
  and
• 13:57
  we're
• 13:58
  not
• 13:58
  even
• 13:58
  sure
• 13:58
  if
• 13:58
  our
• 13:58
  patient
• 13:59
  has
• 13:59
  bipolar.
• 13:59
  Watch
• 14:00
  out
• 14:00
  for
• 14:00
  that
• 14:00
  stimulants.
• 14:01
  Of
• 14:01
  course,
• 14:02
  you
• 14:02
  know,
• 14:02
  amphetamines
• 14:03
  can
• 14:03
  raise
• 14:03
  the
• 14:03
  risk
• 14:04
  of
• 14:04
  inducing
• 14:05
  a
• 14:05
  manic
• 14:05
  episode,
• 14:06
  but
• 14:06
  modafinil
• 14:07
  is
• 14:08
  not
• 14:08
  nearly
• 14:09
  as
• 14:09
  likely
• 14:09
  to
• 14:09
  do
• 14:10
  that.
• 14:10
  It
• 14:10
  is
• 14:10
  commonly
• 14:11
  given
• 14:11
  for
• 14:11
  bipolar
• 14:12
  depression,
• 14:12
  and
• 14:12
  the
• 14:12
  reason
• 14:13
  is
• 14:13
  Modafinil
• 14:14
  or
• 14:14
  nr.
• 14:14
  Modafinil.
• 14:16
  They
• 14:16
  tend
• 14:16
  to
• 14:16
  support
• 14:17
  wakefulness
• 14:17
  rather
• 14:18
  than
• 14:18
  stimulation,
• 14:19
  and
• 14:19
  they're
• 14:19
  a
• 14:19
  little
• 14:20
  bit
• 14:20
  more
• 14:20
  selective
• 14:21
  with
• 14:21
  respect
• 14:21
  to
• 14:22
  the
• 14:22
  areas
• 14:22
  of
• 14:22
  the
• 14:22
  brain
• 14:23
  they
• 14:23
  work
• 14:23
  on.
• 14:24
  And
• 14:24
  they
• 14:24
  typically
• 14:25
  work
• 14:25
  on
• 14:25
  the
• 14:26
  areas
• 14:26
  of
• 14:26
  the
• 14:26
  brain
• 14:27
  implicated
• 14:27
  in
• 14:27
  sleep,
• 14:28
  wakefulness,
• 14:29
  not
• 14:29
  so
• 14:29
  much
• 14:30
  the
• 14:30
  nucleus
• 14:31
  accumbens
• 14:31
  or
• 14:32
  the
• 14:32
  reward
• 14:32
  center
• 14:33
  of
• 14:33
  the
• 14:33
  brain
• 14:33
  that
• 14:34
  amphetamines
• 14:34
  are
• 14:35
  privy
• 14:35
  to
• 14:35
  target,
• 14:36
  which
• 14:36
  can
• 14:36
  induce
• 14:37
  mania
• 14:38
  or
• 14:38
  hypomania
• 14:39
  in
• 14:39
  specific
• 14:40
  cases.
• 14:40
  So
• 14:41
  with
• 14:41
  Modafinil
• 14:42
  and
• 14:42
  armedafinil,
• 14:43
  we're
• 14:43
  talking
• 14:43
  about
• 14:43
  mildly
• 14:44
  blockading
• 14:45
  the
• 14:45
  dopamine
• 14:46
  transporter.
• 14:47
  It
• 14:47
  does
• 14:48
  not
• 14:48
  cause
• 14:49
  vesicular
• 14:49
  release
• 14:50
  like
• 14:50
  Adderall
• 14:51
  does.
• 14:51
  Adderall
• 14:52
  has
• 14:52
  that
• 14:52
  dual
• 14:52
  mechanism
• 14:53
  of
• 14:53
  action
• 14:53
  where
• 14:53
  not
• 14:54
  only
• 14:54
  does
• 14:54
  it
• 14:54
  block
• 14:54
  the
• 14:54
  dopamine
• 14:55
  transporter,
• 14:56
  so
• 14:56
  it
• 14:56
  prevents
• 14:56
  dopamine
• 14:57
  from
• 14:57
  being
• 14:57
  recycled,
• 14:58
  but
• 14:58
  it
• 14:58
  also
• 14:59
  increases
• 15:00
  the
• 15:00
  vesicular
• 15:01
  release
• 15:01
  of
• 15:01
  dopamine.
• 15:02
  It's
• 15:02
  kind
• 15:02
  of
• 15:02
  a
• 15:02
  double
• 15:02
  whammy,
• 15:03
  which
• 15:03
  is
• 15:03
  different
• 15:04
  than
• 15:04
  the
• 15:05
  Ritalin
• 15:05
  or
• 15:05
  methylphenidate
• 15:06
  family,
• 15:06
  which
• 15:07
  is
• 15:07
  exclusively
• 15:08
  working
• 15:08
  on
• 15:08
  the
• 15:09
  dopamine
• 15:10
  transporters
• 15:11
  there.
• 15:11
  And
• 15:11
  not
• 15:12
  the
• 15:12
  vesicular
• 15:13
  release.
• 15:14
  We're
• 15:14
  talking
• 15:15
  with
• 15:15
  the
• 15:15
  Modafinil
• 15:16
  and
• 15:16
  the
• 15:16
  Armodafinils
• 15:17
  we're
• 15:17
  dealing,
• 15:17
  we're
• 15:18
  targeting
• 15:18
  more
• 15:19
  wakefulness
• 15:19
  rather
• 15:20
  than
• 15:20
  stimulation.
• 15:21
  And
• 15:21
  with
• 15:21
  the
• 15:22
  R
• 15:22
  Modafinil
• 15:23
  in
• 15:23
  particular,
• 15:24
  we
• 15:25
  are
• 15:25
  interested
• 15:26
  in
• 15:26
  that
• 15:27
  because
• 15:27
  it
• 15:27
  tends
• 15:27
  to
• 15:28
  last
• 15:28
  longer
• 15:28
  and
• 15:28
  have
• 15:29
  higher
• 15:29
  peak
• 15:30
  concentrations
• 15:30
  for
• 15:31
  a
• 15:31
  longer
• 15:31
  period
• 15:31
  of
• 15:32
  time.
• 15:32
  And
• 15:32
  so
• 15:33
  the
• 15:33
  subtlety
• 15:33
  here
• 15:33
  is
• 15:34
  in
• 15:34
  the
• 15:34
  details
• 15:35
  of
• 15:35
  looking
• 15:36
  at
• 15:36
  the
• 15:36
  pharmacology
• 15:38
  kinetics,
• 15:38
  pharmacodynamics,
• 15:39
  and
• 15:39
  understanding
• 15:40
  how
• 15:40
  these
• 15:40
  medications
• 15:41
  work
• 15:42
  on
• 15:42
  a
• 15:42
  very
• 15:43
  granular
• 15:43
  level.
• 15:44
  And
• 15:44
  so
• 15:44
  Armodafinil
• 15:45
  is
• 15:45
  the
• 15:45
  better
• 15:45
  choice.
• 15:46
  Of
• 15:46
  course,
• 15:46
  it
• 15:47
  may
• 15:47
  not
• 15:47
  be
• 15:47
  because
• 15:48
  you
• 15:48
  always
• 15:48
  have
• 15:48
  to
• 15:48
  look
• 15:49
  at
• 15:49
  cost
• 15:49
  and
• 15:49
  what
• 15:49
  the
• 15:50
  patient's
• 15:50
  insurance
• 15:50
  company
• 15:51
  will
• 15:51
  even
• 15:51
  tolerate.
• 15:52
  So
• 15:52
  you've
• 15:52
  gotta
• 15:53
  look
• 15:53
  at
• 15:53
  that
• 15:53
  because
• 15:54
  it
• 15:54
  may
• 15:54
  not
• 15:54
  be
• 15:54
  as
• 15:55
  affordable
• 15:55
  as
• 15:56
  the
• 15:56
  Modafinil
• 15:57
  in
• 15:57
  specific
• 15:58
  cases.
• 15:58
  So
• 15:58
  we
• 15:58
  have
• 15:59
  to
• 15:59
  kind
• 15:59
  of
• 15:59
  put
• 15:59
  all
• 15:59
  of
• 16:00
  this
• 16:00
  through
• 16:00
  a
• 16:00
  filter.
• 16:01
  But
• 16:01
  this
• 16:02
  is
• 16:02
  really
• 16:02
  good
• 16:02
  too
• 16:03
  if
• 16:03
  you
• 16:03
  have
• 16:03
  patients
• 16:04
  who
• 16:04
  have
• 16:05
  residual
• 16:05
  depression,
• 16:06
  right?
• 16:06
  Because
• 16:06
  again,
• 16:07
  not
• 16:07
  all
• 16:07
  of
• 16:08
  depression
• 16:08
  is
• 16:09
  treated
• 16:09
  right
• 16:09
  away.
• 16:10
  We
• 16:10
  only
• 16:10
  get
• 16:11
  about
• 16:11
  a
• 16:11
  third
• 16:11
  of
• 16:11
  our
• 16:11
  patients
• 16:12
  into
• 16:12
  remission
• 16:13
  with
• 16:13
  our
• 16:14
  first
• 16:14
  try
• 16:14
  with
• 16:15
  our
• 16:15
  antidepressants.
• 16:16
  So
• 16:16
  that
• 16:16
  leads
• 16:16
  about
• 16:16
  two
• 16:17
  thirds
• 16:17
  of
• 16:17
  patients
• 16:17
  that
• 16:18
  need
• 16:18
  to
• 16:18
  either
• 16:18
  switch
• 16:19
  or
• 16:19
  augment.
• 16:19
  And
• 16:20
  a
• 16:20
  lot
• 16:20
  of
• 16:20
  times
• 16:20
  you
• 16:20
  will
• 16:21
  have
• 16:21
  patients
• 16:21
  that
• 16:22
  are
• 16:22
  telling
• 16:22
  you,
• 16:22
  you
• 16:22
  know,
• 16:22
  things
• 16:23
  are
• 16:23
  pretty
• 16:23
  good.
• 16:23
  But
• 16:23
  I
• 16:23
  still
• 16:24
  feel
• 16:25
  a
• 16:25
  little
• 16:25
  groggy.
• 16:25
  I
• 16:25
  can't
• 16:26
  concentrate
• 16:26
  as
• 16:26
  well.
• 16:27
  I
• 16:27
  don't
• 16:27
  have
• 16:27
  as
• 16:27
  much
• 16:27
  motivation.
• 16:28
  It's
• 16:28
  very
• 16:29
  hard
• 16:29
  to
• 16:29
  stay
• 16:29
  awake
• 16:29
  during
• 16:30
  the
• 16:30
  morning.
• 16:30
  And,
• 16:30
  and
• 16:31
  Modafinil
• 16:31
  or
• 16:31
  Armedafinil
• 16:32
  could
• 16:32
  be
• 16:33
  good
• 16:33
  for
• 16:34
  augmentation.
• 16:35
  So
• 16:35
  I
• 16:35
  think
• 16:36
  that
• 16:36
  this
• 16:36
  is
• 16:36
  a
• 16:37
  pretty
• 16:37
  neat
• 16:37
  test
• 16:38
  case
• 16:38
  for
• 16:39
  you
• 16:39
  guys
• 16:39
  to
• 16:39
  kind
• 16:39
  of
• 16:39
  chew
• 16:40
  on.
• 16:40
  You
• 16:40
  know,
• 16:40
  it's
• 16:40
  just
• 16:41
  a
• 16:41
  nice
• 16:41
  little
• 16:41
  pearl
• 16:42
  about
• 16:42
  Modafinil
• 16:43
  and
• 16:43
  Armedafinil.
• 16:44
  Remember,
• 16:45
  two
• 16:45
  different
• 16:46
  situations
• 16:46
  here
• 16:47
  where
• 16:47
  Modafinil
• 16:48
  is,
• 16:49
  has
• 16:49
  two
• 16:50
  of
• 16:50
  the
• 16:50
  enantiomers,
• 16:51
  right,
• 16:51
  The
• 16:51
  R
• 16:52
  and
• 16:52
  the
• 16:52
  S
• 16:53
  enantiomer.
• 16:54
  And
• 16:54
  Armodafinil
• 16:55
  has
• 16:55
  the
• 16:55
  R
• 16:56
  enantiomer
• 16:56
  only.
• 16:57
  Right?
• 16:57
  So
• 16:58
  RR
• 16:59
  R
• 16:59
  Modafinil,
• 17:00
  right,
• 17:00
  is
• 17:00
  the
• 17:00
  R
• 17:00
  enantiomer
• 17:02
  and
• 17:02
  the
• 17:03
  Modafinil
• 17:03
  is
• 17:04
  the
• 17:04
  RNS
• 17:04
  enantiomers
• 17:05
  again.
• 17:05
  So
• 17:06
  because
• 17:06
  of
• 17:06
  that,
• 17:07
  the,
• 17:07
  the
• 17:08
  pharmacokinetic
• 17:09
  timing
• 17:09
  of
• 17:09
  these
• 17:10
  medications
• 17:10
  is
• 17:10
  a
• 17:10
  little
• 17:11
  bit
• 17:11
  different.
• 17:11
  Right,
• 17:12
  With
• 17:13
  R
• 17:13
  Modafinil
• 17:14
  because
• 17:14
  it
• 17:14
  just
• 17:15
  has
• 17:15
  the
• 17:15
  R
• 17:15
  enantiomer.
• 17:16
  It's
• 17:16
  a
• 17:16
  little
• 17:17
  bit
• 17:17
  more
• 17:17
  consistent
• 17:17
  in
• 17:18
  terms
• 17:18
  of
• 17:18
  plasma
• 17:19
  levels
• 17:19
  throughout
• 17:19
  a
• 17:19
  12
• 17:19
  hour
• 17:20
  shift.
• 17:20
  But,
• 17:21
  but
• 17:21
  modafinil
• 17:21
  has
• 17:22
  two
• 17:22
  of
• 17:22
  those
• 17:22
  enantiomers,
• 17:23
  the
• 17:23
  R
• 17:23
  and
• 17:23
  the
• 17:23
  S,
• 17:24
  right?
• 17:24
  So
• 17:24
  they
• 17:24
  have
• 17:24
  different
• 17:25
  half
• 17:25
  lives.
• 17:25
  Now,
• 17:26
  I
• 17:26
  don't
• 17:26
  want
• 17:26
  to
• 17:26
  get
• 17:26
  too
• 17:26
  far
• 17:27
  in
• 17:27
  the
• 17:27
  weeds,
• 17:27
  but
• 17:27
  it's
• 17:27
  fun
• 17:28
  to
• 17:28
  kind
• 17:28
  of
• 17:28
  appreciate
• 17:29
  this
• 17:29
  and
• 17:29
  think
• 17:29
  about
• 17:29
  it,
• 17:30
  because
• 17:30
  with
• 17:30
  modafinil,
• 17:31
  the
• 17:31
  S
• 17:31
  enantiomer
• 17:32
  is
• 17:32
  rapidly
• 17:33
  eliminated.
• 17:33
  Okay.
• 17:34
  In
• 17:35
  about
• 17:35
  four
• 17:35
  hours.
• 17:36
  So
• 17:36
  that's
• 17:37
  why
• 17:37
  you
• 17:37
  have
• 17:37
  a
• 17:37
  little
• 17:37
  bit
• 17:37
  of
• 17:37
  a
• 17:38
  dip.
• 17:38
  And
• 17:38
  the
• 17:39
  pharmacokinetics
• 17:39
  of
• 17:39
  these
• 17:40
  two
• 17:40
  are
• 17:40
  a
• 17:40
  little
• 17:40
  bit
• 17:41
  different.
• 17:41
  Our
• 17:41
  arm
• 17:42
  modafinil
• 17:42
  has
• 17:42
  that
• 17:43
  R
• 17:43
  enantiomer
• 17:44
  exclusively,
• 17:45
  also
• 17:45
  known
• 17:45
  as
• 17:45
  monophasic
• 17:46
  elimination
• 17:47
  versus
• 17:48
  the
• 17:48
  modafinil
• 17:49
  biphasic,
• 17:50
  because
• 17:50
  it
• 17:50
  has
• 17:50
  an
• 17:50
  R
• 17:50
  and
• 17:50
  an
• 17:51
  S
• 17:51
  enantiomer,
• 17:52
  and
• 17:52
  it
• 17:52
  has
• 17:52
  different
• 17:52
  half
• 17:53
  lives.
• 17:53
  So
• 17:53
  that's
• 17:53
  a
• 17:53
  cool
• 17:54
  little
• 17:54
  pearl.
• 17:54
  You
• 17:55
  probably
• 17:55
  heard
• 17:55
  of
• 17:55
  biphasic
• 17:56
  or
• 17:57
  monophasic
• 17:57
  elimination,
• 17:58
  and
• 17:59
  now
• 17:59
  you
• 17:59
  can
• 17:59
  kind
• 17:59
  of
• 17:59
  synthesize
• 18:00
  that
• 18:00
  in
• 18:00
  the
• 18:00
  context
• 18:01
  of
• 18:01
  enantiomers
• 18:02
  and
• 18:02
  appreciate
• 18:03
  the
• 18:03
  fact
• 18:03
  that
• 18:05
  if
• 18:05
  a
• 18:05
  medication
• 18:06
  has
• 18:06
  one
• 18:07
  enantiomer
• 18:07
  versus
• 18:07
  two
• 18:08
  enantiomers,
• 18:08
  that
• 18:08
  can
• 18:09
  change
• 18:09
  the
• 18:09
  way
• 18:09
  they
• 18:10
  actually
• 18:11
  exert
• 18:12
  their
• 18:12
  effect
• 18:12
  on
• 18:12
  the
• 18:13
  patient.
• 18:13
  And
• 18:13
  that's
• 18:14
  why
• 18:14
  we
• 18:14
  have
• 18:14
  to
• 18:14
  nerd
• 18:14
  out
• 18:14
  and
• 18:15
  really
• 18:15
  look
• 18:15
  at
• 18:15
  this
• 18:15
  stuff,
• 18:16
  because
• 18:16
  these
• 18:17
  medications
• 18:17
  sound
• 18:18
  almost
• 18:18
  identical,
• 18:19
  right?
• 18:19
  So
• 18:20
  sometimes
• 18:20
  that's
• 18:21
  a
• 18:21
  tip
• 18:21
  off
• 18:21
  that
• 18:21
  there's
• 18:22
  something
• 18:22
  like
• 18:22
  an
• 18:22
  enantiomer
• 18:23
  at
• 18:23
  play
• 18:23
  that
• 18:24
  is
• 18:24
  a
• 18:24
  little
• 18:24
  bit
• 18:25
  different
• 18:26
  with
• 18:26
  respect
• 18:26
  to
• 18:26
  the
• 18:27
  properties
• 18:27
  of
• 18:27
  that
• 18:27
  medication.
• 18:28
  We
• 18:28
  see
• 18:28
  this
• 18:28
  with,
• 18:28
  like,
• 18:29
  racemic
• 18:29
  ketamine
• 18:30
  and
• 18:31
  spravato
• 18:31
  or
• 18:32
  esketamine.
• 18:32
  S
• 18:33
  is
• 18:33
  the
• 18:33
  enantiomer
• 18:34
  of
• 18:35
  the
• 18:35
  spravato.
• 18:36
  And
• 18:36
  then
• 18:36
  there's
• 18:36
  an
• 18:36
  R
• 18:36
  ketamine
• 18:37
  enantiomer
• 18:37
  also.
• 18:38
  Right?
• 18:38
  They
• 18:38
  have
• 18:38
  two
• 18:38
  different
• 18:38
  properties.
• 18:39
  They
• 18:39
  do
• 18:39
  two
• 18:39
  different
• 18:40
  things.
• 18:40
  They
• 18:40
  can
• 18:41
  result
• 18:41
  in
• 18:41
  subtle
• 18:41
  differences.
• 18:42
  But
• 18:43
  that's
• 18:43
  also
• 18:43
  really
• 18:43
  cool
• 18:44
  because
• 18:44
  the
• 18:44
  enantiomers
• 18:45
  involved
• 18:45
  in
• 18:46
  those
• 18:46
  medications
• 18:47
  are
• 18:47
  subtle
• 18:48
  and
• 18:48
  yet
• 18:49
  very
• 18:49
  different.
• 18:49
  Even
• 18:50
  though
• 18:50
  we're
• 18:50
  kind
• 18:50
  of
• 18:50
  talking
• 18:51
  about
• 18:51
  the
• 18:51
  same
• 18:52
  medication,
• 18:52
  we're
• 18:52
  sort
• 18:53
  of
• 18:53
  also
• 18:53
  not
• 18:54
  if
• 18:54
  that
• 18:54
  makes
• 18:54
  sense.
• 18:56
  So
• 18:56
  in
• 18:56
  this
• 18:56
  case,
• 18:56
  I.
• 18:57
  It's
• 18:57
  really
• 18:57
  good
• 18:57
  if
• 18:58
  we
• 18:58
  just
• 18:58
  appreciate,
• 18:59
  my
• 18:59
  friends,
• 18:59
  how
• 19:00
  we
• 19:00
  have
• 19:00
  two
• 19:01
  considerations
• 19:01
  at
• 19:02
  play
• 19:02
  here.
• 19:02
  We
• 19:02
  have
• 19:02
  a
• 19:02
  circadian
• 19:03
  rhythm
• 19:03
  disorder,
• 19:04
  the
• 19:04
  shift
• 19:04
  work
• 19:04
  disorder,
• 19:05
  and
• 19:05
  then
• 19:05
  we
• 19:05
  have
• 19:05
  a
• 19:05
  mood
• 19:05
  disorder
• 19:06
  or
• 19:06
  bipolar
• 19:06
  depression.
• 19:07
  Right.
• 19:08
  And
• 19:08
  how
• 19:08
  our
• 19:08
  modafinil
• 19:09
  addresses
• 19:09
  both
• 19:10
  of
• 19:10
  those
• 19:10
  conditions
• 19:10
  simultaneously.
• 19:12
  Okay.
• 19:12
  And
• 19:12
  so
• 19:13
  it's
• 19:13
  really
• 19:13
  good.
• 19:14
  It's
• 19:14
  a
• 19:14
  really
• 19:14
  good
• 19:15
  medication.
• 19:15
  It
• 19:16
  has
• 19:16
  been
• 19:16
  shown
• 19:16
  in
• 19:17
  meta
• 19:17
  analyses
• 19:18
  to.
• 19:18
  To
• 19:19
  really
• 19:19
  positively
• 19:19
  affect
• 19:20
  fatigue
• 19:21
  symptoms
• 19:21
  and
• 19:21
  depression
• 19:22
  scores,
• 19:22
  which
• 19:23
  is
• 19:23
  really
• 19:23
  cool.
• 19:23
  And
• 19:24
  I'll
• 19:24
  be
• 19:24
  honest,
• 19:25
  a
• 19:25
  lot
• 19:25
  of
• 19:25
  times
• 19:25
  when
• 19:25
  I
• 19:26
  see
• 19:26
  patients,
• 19:26
  I
• 19:26
  feel
• 19:26
  stuck.
• 19:27
  Right?
• 19:27
  You
• 19:28
  have
• 19:28
  this
• 19:28
  patient
• 19:28
  where
• 19:29
  they're
• 19:29
  bipolar
• 19:30
  stabilized.
• 19:30
  Like
• 19:30
  the
• 19:31
  manic
• 19:31
  and
• 19:31
  the
• 19:31
  hypomanic
• 19:32
  episodes
• 19:33
  might
• 19:33
  be
• 19:33
  stabilized,
• 19:34
  but
• 19:34
  they
• 19:34
  just
• 19:34
  don't
• 19:34
  have
• 19:34
  a
• 19:34
  lot
• 19:34
  of
• 19:35
  energy.
• 19:35
  Maybe
• 19:35
  the
• 19:35
  SGAs
• 19:36
  that
• 19:36
  they're
• 19:36
  on
• 19:36
  the
• 19:37
  second
• 19:37
  generation
• 19:38
  antipsychotics
• 19:39
  are
• 19:39
  making
• 19:39
  them
• 19:39
  kind
• 19:39
  of
• 19:39
  groggy.
• 19:40
  Yeah.
• 19:40
  Their
• 19:41
  mood
• 19:41
  is
• 19:41
  subdued.
• 19:41
  They're
• 19:42
  not
• 19:42
  impulsive
• 19:42
  anymore.
• 19:43
  They're
• 19:43
  also
• 19:44
  not
• 19:44
  able
• 19:44
  to
• 19:44
  really
• 19:45
  take
• 19:45
  a
• 19:45
  test
• 19:45
  that
• 19:46
  easily
• 19:46
  or
• 19:46
  drive
• 19:47
  that
• 19:47
  easily
• 19:47
  or
• 19:48
  engage
• 19:48
  socially.
• 19:49
  And
• 19:49
  so
• 19:49
  you're
• 19:50
  only
• 19:50
  halfway
• 19:50
  there,
• 19:50
  right?
• 19:51
  You're
• 19:51
  looking
• 19:51
  for
• 19:51
  something
• 19:52
  and
• 19:52
  you're
• 19:52
  like,
• 19:52
  well,
• 19:52
  darn,
• 19:53
  I
• 19:53
  can't
• 19:53
  give
• 19:53
  them
• 19:54
  a
• 19:54
  stimulant.
• 19:54
  That
• 19:54
  makes
• 19:55
  me
• 19:55
  nervous.
• 19:56
  So
• 19:56
  this
• 19:57
  is
• 19:57
  where
• 19:57
  Modafinil
• 19:58
  or
• 19:58
  Armodafinil
• 19:58
  can
• 19:59
  really
• 19:59
  come
• 19:59
  into
• 19:59
  play.
• 20:00
  Both
• 20:00
  are
• 20:00
  totally
• 20:01
  suitable.
• 20:01
  You
• 20:01
  always
• 20:01
  want
• 20:02
  to
• 20:02
  monitor
• 20:03
  these
• 20:03
  patients
• 20:04
  again
• 20:05
  for
• 20:05
  potential
• 20:06
  mood
• 20:06
  switch,
• 20:07
  but
• 20:07
  the
• 20:07
  evidence
• 20:08
  does
• 20:08
  show
• 20:08
  there's
• 20:08
  really
• 20:08
  no
• 20:09
  increased
• 20:09
  risk
• 20:09
  of
• 20:09
  mood
• 20:10
  switch
• 20:10
  in
• 20:11
  bipolar
• 20:11
  patients.
• 20:12
  And
• 20:12
  I'll
• 20:12
  definitely
• 20:13
  link
• 20:14
  you
• 20:14
  to
• 20:14
  the
• 20:14
  studies
• 20:14
  that
• 20:15
  demonstrate
• 20:15
  that.
• 20:16
  But
• 20:16
  of
• 20:16
  course,
• 20:16
  always
• 20:17
  be
• 20:17
  careful
• 20:18
  and,
• 20:19
  you
• 20:19
  know,
• 20:19
  work
• 20:19
  to
• 20:19
  protect
• 20:20
  your
• 20:20
  patient
• 20:20
  and
• 20:20
  stay
• 20:21
  close
• 20:21
  to
• 20:21
  the
• 20:21
  evidence
• 20:22
  as
• 20:22
  much
• 20:22
  as
• 20:22
  possible.
• 20:23
  So
• 20:23
  I
• 20:23
  really
• 20:23
  hope
• 20:24
  you
• 20:24
  all
• 20:24
  appreciated
• 20:25
  this.
• 20:26
  I
• 20:26
  certainly
• 20:26
  love
• 20:26
  it.
• 20:27
  It's
• 20:27
  a
• 20:27
  fine
• 20:27
  little
• 20:28
  distinction,
• 20:28
  a
• 20:29
  little
• 20:29
  pearl
• 20:30
  to
• 20:30
  keep
• 20:30
  in
• 20:30
  your
• 20:30
  back
• 20:31
  pockets.
• 20:32
  This
• 20:32
  is
• 20:32
  a
• 20:32
  common
• 20:32
  one.
• 20:32
  I
• 20:33
  will
• 20:33
  tell
• 20:33
  you.
• 20:33
  You're
• 20:33
  going
• 20:33
  to
• 20:34
  always
• 20:34
  have
• 20:34
  patients
• 20:35
  who
• 20:36
  still
• 20:37
  feel
• 20:37
  fatigued.
• 20:38
  They
• 20:38
  still
• 20:38
  feel
• 20:39
  cognitively
• 20:39
  sluggish.
• 20:40
  It's
• 20:40
  hard
• 20:41
  for
• 20:41
  them
• 20:41
  to
• 20:41
  stay
• 20:41
  awake.
• 20:42
  When
• 20:42
  it
• 20:42
  comes
• 20:42
  to
• 20:43
  circadian
• 20:44
  misalignment,
• 20:45
  whether
• 20:45
  it's
• 20:46
  just
• 20:46
  people
• 20:46
  who
• 20:47
  fall
• 20:47
  asleep
• 20:47
  too
• 20:47
  late
• 20:48
  or
• 20:48
  wake
• 20:48
  up
• 20:48
  too
• 20:48
  early
• 20:49
  or
• 20:49
  just,
• 20:50
  you
• 20:50
  name
• 20:50
  it,
• 20:50
  you're
• 20:51
  going
• 20:51
  to
• 20:51
  see
• 20:51
  that
• 20:51
  all
• 20:51
  over
• 20:52
  the
• 20:52
  board.
• 20:52
  It's
• 20:52
  Transdiagnostic
• 20:53
  and
• 20:54
  Modafinil
• 20:54
  or
• 20:55
  Armedafinil,
• 20:56
  they're
• 20:56
  kind
• 20:56
  of
• 20:57
  like
• 20:57
  Swiss
• 20:57
  army
• 20:57
  knives
• 20:58
  that
• 20:58
  can
• 20:58
  really
• 20:58
  fix
• 20:58
  a
• 20:59
  lot
• 20:59
  of
• 20:59
  things
• 20:59
  at
• 21:00
  one
• 21:00
  time.
• 21:00
  That's
• 21:01
  really
• 21:01
  important,
• 21:01
  though.
• 21:01
  These
• 21:02
  Modafinils
• 21:03
  and
• 21:03
  Armodafin,
• 21:04
  they
• 21:05
  are
• 21:05
  not
• 21:05
  a
• 21:05
  replacement
• 21:06
  for
• 21:06
  good
• 21:06
  sleep.
• 21:07
  So
• 21:07
  it
• 21:07
  is
• 21:07
  super
• 21:07
  important
• 21:08
  that
• 21:08
  with
• 21:08
  Betty,
• 21:09
  we
• 21:09
  do
• 21:09
  try
• 21:09
  to
• 21:09
  do
• 21:09
  everything
• 21:10
  in
• 21:10
  our
• 21:10
  power
• 21:11
  to
• 21:11
  make
• 21:11
  sure
• 21:11
  that
• 21:12
  her
• 21:12
  sleep
• 21:12
  hygiene
• 21:13
  is
• 21:13
  on
• 21:13
  point,
• 21:13
  whether
• 21:14
  it's
• 21:14
  CBTI
• 21:15
  that
• 21:15
  we
• 21:15
  refer
• 21:15
  her
• 21:16
  to,
• 21:16
  whether
• 21:16
  we
• 21:17
  just
• 21:17
  give
• 21:17
  her
• 21:17
  strategies
• 21:18
  to
• 21:18
  kind
• 21:19
  of
• 21:19
  relax
• 21:19
  a
• 21:19
  little
• 21:20
  more
• 21:20
  easily
• 21:20
  as
• 21:20
  she's
• 21:21
  preparing
• 21:21
  for
• 21:21
  bed,
• 21:22
  a
• 21:22
  cool,
• 21:22
  dark
• 21:23
  room.
• 21:24
  Only
• 21:25
  associate
• 21:25
  the
• 21:25
  bed
• 21:26
  with
• 21:26
  sleep
• 21:26
  and
• 21:26
  sex
• 21:27
  and
• 21:27
  all
• 21:27
  that
• 21:28
  stuff
• 21:28
  that
• 21:28
  we've
• 21:29
  talked
• 21:29
  about.
• 21:29
  Right.
• 21:29
  So.
• 21:30
  So
• 21:30
  just
• 21:30
  because
• 21:30
  you
• 21:31
  added
• 21:31
  Modafinil
• 21:32
  or
• 21:32
  Modafinil,
• 21:32
  that
• 21:33
  is
• 21:33
  no
• 21:33
  substitution
• 21:34
  for
• 21:35
  good
• 21:35
  sleep.
• 21:35
  There's
• 21:36
  nothing
• 21:36
  better
• 21:36
  than
• 21:36
  just
• 21:36
  getting
• 21:37
  eight
• 21:37
  hours
• 21:38
  of
• 21:38
  robust
• 21:38
  sleep
• 21:38
  where
• 21:39
  you
• 21:39
  are
• 21:39
  alert
• 21:39
  and
• 21:39
  awake
• 21:40
  and
• 21:40
  ready
• 21:40
  to
• 21:40
  go.
• 21:40
  There
• 21:40
  is
• 21:41
  no
• 21:41
  medication
• 21:42
  that
• 21:42
  beats
• 21:43
  that,
• 21:43
  that
• 21:44
  our
• 21:44
  prerogative
• 21:44
  to
• 21:45
  get
• 21:45
  good
• 21:45
  sleep.
• 21:46
  But
• 21:46
  again,
• 21:46
  it
• 21:47
  could
• 21:47
  be
• 21:47
  a
• 21:47
  really
• 21:47
  good
• 21:47
  thing.
• 21:48
  And
• 21:48
  it's
• 21:49
  a
• 21:49
  little
• 21:49
  bit
• 21:49
  less
• 21:50
  of
• 21:50
  an
• 21:50
  abuse
• 21:51
  potential
• 21:51
  than
• 21:51
  stimulants
• 21:52
  with
• 21:52
  respect
• 21:53
  to
• 21:53
  the
• 21:53
  Modafinil
• 21:54
  and
• 21:54
  the
• 21:54
  Armodafinil
• 21:55
  and
• 21:56
  some
• 21:56
  of
• 21:56
  these
• 21:56
  shift
• 21:57
  work
• 21:57
  disorder
• 21:58
  pearls.
• 21:58
  So
• 21:59
  there's
• 21:59
  going
• 21:59
  to
• 21:59
  be
• 21:59
  a
• 21:59
  little
• 21:59
  goodie
• 22:00
  bag
• 22:00
  of
• 22:00
  pearls
• 22:01
  for
• 22:01
  free
• 22:01
  if
• 22:01
  you
• 22:01
  become
• 22:02
  Patreon
• 22:02
  members.
• 22:03
  And
• 22:03
  we're
• 22:03
  going
• 22:04
  to
• 22:04
  continue
• 22:04
  to
• 22:04
  dole
• 22:04
  out
• 22:04
  more
• 22:05
  free
• 22:05
  stuff
• 22:06
  for
• 22:06
  Patreon
• 22:06
  members.
• 22:07
  And
• 22:07
  then
• 22:07
  there's
• 22:07
  a
• 22:07
  paid
• 22:08
  Patreon
• 22:08
  subscription
• 22:09
  too
• 22:09
  where
• 22:09
  you
• 22:09
  get
• 22:10
  access
• 22:10
  to
• 22:10
  a
• 22:10
  whole
• 22:10
  library
• 22:11
  of
• 22:11
  really
• 22:12
  cool
• 22:12
  evidence
• 22:13
  based
• 22:13
  pearls
• 22:14
  to
• 22:14
  power
• 22:14
  you
• 22:14
  further.
• 22:14
  Highly
• 22:15
  recommend
• 22:15
  you
• 22:16
  go
• 22:16
  in
• 22:16
  our
• 22:16
  show
• 22:16
  notes
• 22:17
  and
• 22:17
  become
• 22:17
  a
• 22:17
  Patreon
• 22:18
  member
• 22:18
  today.
• 22:19
  And
• 22:19
  there's
• 22:19
  all
• 22:19
  kinds
• 22:20
  of
• 22:20
  awesome
• 22:21
  pearls
• 22:21
  that
• 22:21
  can
• 22:21
  change
• 22:21
  the
• 22:22
  way
• 22:22
  you
• 22:22
  practice.
• 22:23
  Until
• 22:23
  next
• 22:23
  time
• 22:24
  my
• 22:24
  friends.
• 22:24
  Thank
• 22:24
  you
• 22:25
  for
• 22:25
  tuning
• 22:25
  in.
• 22:25
  Bye
• 22:26
  bye.