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MDD with Mixed Features: What Do You Reach for When SSRIs Stop Making Sense? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back
• 0:06
  my
• 0:06
  friends
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:11
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:14
  prep
• 0:14
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  Now
• 0:17
  my
• 0:17
  friends,
• 0:18
  there
• 0:18
  is
• 0:19
  this
• 0:20
  frustrating
• 0:21
  yet
• 0:21
  fascinating
• 0:23
  gray
• 0:23
  area
• 0:24
  in
• 0:24
  mental
• 0:24
  health.
• 0:26
  And
• 0:26
  I
• 0:26
  swear
• 0:27
  it's
• 0:27
  one
• 0:27
  of
• 0:27
  the
• 0:27
  most
• 0:28
  common
• 0:28
  things
• 0:28
  I
• 0:29
  see
• 0:29
  in
• 0:29
  outpatient
• 0:30
  practice.
• 0:30
  A
• 0:31
  patient
• 0:31
  with
• 0:31
  major
• 0:32
  depressive
• 0:32
  disorder
• 0:33
  with
• 0:34
  mixed
• 0:34
  features.
• 0:35
  You
• 0:36
  see
• 0:36
  it
• 0:36
  all
• 0:37
  the
• 0:37
  time.
• 0:39
  And
• 0:39
  it's
• 0:39
  said
• 0:40
  that
• 0:40
  Even
• 0:40
  up
• 0:40
  to
• 0:41
  1
• 0:41
  in
• 0:41
  5
• 0:42
  of
• 0:42
  all
• 0:43
  of
• 0:43
  MDD
• 0:43
  has
• 0:44
  mixed
• 0:44
  features.
• 0:45
  Of
• 0:45
  course
• 0:45
  the
• 0:46
  prevalence
• 0:47
  of
• 0:47
  that
• 0:47
  is
• 0:47
  sort
• 0:47
  of
• 0:47
  all
• 0:47
  over
• 0:48
  the
• 0:48
  place
• 0:48
  depending
• 0:48
  on
• 0:49
  who
• 0:49
  you,
• 0:49
  who
• 0:50
  you
• 0:50
  listen
• 0:50
  to.
• 0:51
  But
• 0:51
  roughly
• 0:52
  one
• 0:52
  in
• 0:52
  five
• 0:53
  of
• 0:53
  all
• 0:53
  major
• 0:54
  depressive
• 0:54
  disorders
• 0:55
  has
• 0:55
  mixed
• 0:56
  features.
• 0:57
  Now
• 0:58
  that
• 0:58
  is
• 0:59
  pretty
• 0:59
  scary.
• 0:59
  I
• 0:59
  don't
• 1:00
  know
• 1:00
  if
• 1:00
  you
• 1:00
  guys
• 1:00
  have
• 1:00
  ever
• 1:00
  played
• 1:01
  that
• 1:02
  game
• 1:03
  on
• 1:03
  the
• 1:03
  old
• 1:03
  school
• 1:04
  computers
• 1:04
  like
• 1:04
  the
• 1:05
  old
• 1:05
  school
• 1:06
  PCs
• 1:07
  where
• 1:08
  it
• 1:08
  was
• 1:09
  called
• 1:09
  like
• 1:09
  a
• 1:10
  minesweeper,
• 1:10
  I
• 1:10
  think
• 1:11
  it
• 1:11
  was.
• 1:12
  And
• 1:12
  you'd
• 1:12
  have
• 1:12
  these
• 1:12
  squares
• 1:13
  and
• 1:14
  you'd
• 1:14
  click
• 1:14
  the
• 1:14
  squares.
• 1:15
  They're
• 1:15
  all
• 1:15
  empty
• 1:15
  at
• 1:15
  first.
• 1:16
  You
• 1:16
  click
• 1:16
  them
• 1:17
  and
• 1:17
  you're
• 1:17
  hoping
• 1:17
  you
• 1:17
  don't
• 1:18
  land
• 1:18
  on
• 1:18
  a
• 1:18
  mine.
• 1:19
  And
• 1:19
  if
• 1:19
  you
• 1:19
  land
• 1:19
  on
• 1:19
  the
• 1:20
  mine,
• 1:20
  you
• 1:21
  die.
• 1:22
  The
• 1:22
  game
• 1:22
  is
• 1:22
  over.
• 1:23
  You
• 1:23
  don't
• 1:23
  die,
• 1:23
  but
• 1:23
  the
• 1:24
  game
• 1:24
  is
• 1:24
  over
• 1:25
  and
• 1:25
  you
• 1:26
  lose
• 1:26
  the
• 1:26
  game.
• 1:27
  And
• 1:27
  that
• 1:28
  is
• 1:28
  how
• 1:28
  I
• 1:28
  feel
• 1:28
  sometimes
• 1:29
  with
• 1:30
  MDD
• 1:30
  and
• 1:31
  mixed
• 1:31
  features,
• 1:31
  right?
• 1:32
  You're
• 1:32
  really
• 1:33
  dancing,
• 1:33
  you're
• 1:34
  walking
• 1:34
  a
• 1:34
  tightrope.
• 1:35
  It's
• 1:35
  really,
• 1:36
  you
• 1:36
  have
• 1:36
  to
• 1:36
  be
• 1:36
  really
• 1:37
  careful
• 1:37
  because
• 1:38
  it's
• 1:38
  in
• 1:39
  real
• 1:39
  life.
• 1:39
  It's
• 1:40
  not
• 1:40
  always
• 1:41
  the
• 1:41
  case
• 1:41
  that
• 1:41
  you
• 1:41
  have
• 1:41
  a
• 1:41
  patient
• 1:42
  who's
• 1:42
  just
• 1:43
  has
• 1:43
  this
• 1:43
  clear
• 1:43
  unipolar
• 1:44
  depression,
• 1:45
  right?
• 1:45
  They
• 1:45
  might
• 1:45
  be
• 1:45
  self
• 1:46
  harmful,
• 1:46
  they
• 1:46
  might
• 1:46
  be
• 1:46
  suicidal,
• 1:47
  their,
• 1:48
  their
• 1:48
  speech
• 1:48
  may
• 1:49
  be
• 1:49
  pressured,
• 1:49
  they
• 1:49
  might
• 1:50
  have
• 1:50
  days
• 1:50
  where
• 1:50
  they
• 1:50
  tell
• 1:51
  you
• 1:51
  they
• 1:51
  really
• 1:51
  don't
• 1:51
  need
• 1:52
  to
• 1:52
  sleep
• 1:52
  at
• 1:52
  all.
• 1:52
  And
• 1:52
  you're
• 1:53
  wondering
• 1:53
  if
• 1:53
  it's,
• 1:53
  you
• 1:54
  know,
• 1:54
  is
• 1:54
  it
• 1:54
  depressive
• 1:55
  rumination
• 1:55
  and
• 1:56
  they're
• 1:56
  thinking
• 1:56
  about
• 1:56
  the
• 1:57
  past
• 1:57
  and
• 1:58
  they
• 1:58
  just
• 1:58
  can't
• 1:58
  sleep
• 1:59
  because
• 1:59
  they
• 1:59
  don't
• 2:00
  know
• 2:00
  why
• 2:00
  they
• 2:00
  can't
• 2:00
  sleep
• 2:01
  or
• 2:01
  is
• 2:01
  it
• 2:02
  because
• 2:02
  they
• 2:02
  truly
• 2:03
  have
• 2:03
  so
• 2:03
  much
• 2:03
  energy,
• 2:04
  they
• 2:04
  have
• 2:04
  goal
• 2:05
  directed
• 2:05
  activity,
• 2:06
  they're
• 2:07
  doing
• 2:07
  stuff,
• 2:07
  they're
• 2:07
  planning
• 2:08
  stuff,
• 2:09
  they're
• 2:09
  energized.
• 2:09
  And
• 2:10
  that
• 2:10
  can
• 2:10
  be
• 2:10
  very
• 2:10
  hard
• 2:11
  to
• 2:11
  tell
• 2:11
  in
• 2:11
  practice
• 2:12
  because
• 2:13
  the
• 2:13
  patients
• 2:13
  are
• 2:14
  only
• 2:14
  using
• 2:14
  hindsight,
• 2:15
  right?
• 2:15
  You're
• 2:15
  asking
• 2:15
  a
• 2:16
  patient
• 2:16
  with
• 2:17
  depression
• 2:17
  who
• 2:18
  has
• 2:18
  maybe
• 2:19
  psychomotor
• 2:19
  retardation,
• 2:21
  cognitive
• 2:21
  brain
• 2:21
  fog.
• 2:22
  And
• 2:22
  you're
• 2:22
  asking
• 2:23
  them
• 2:23
  when
• 2:23
  they're
• 2:23
  sitting
• 2:23
  in
• 2:24
  that
• 2:24
  seat
• 2:24
  to
• 2:25
  think
• 2:25
  about
• 2:26
  something
• 2:26
  that
• 2:27
  may
• 2:27
  have
• 2:27
  happened
• 2:28
  174
• 2:29
  days
• 2:29
  ago
• 2:30
  and
• 2:30
  they
• 2:30
  were
• 2:31
  barely
• 2:32
  paying
• 2:32
  attention
• 2:33
  or
• 2:33
  had
• 2:33
  any
• 2:34
  self
• 2:34
  awareness
• 2:34
  about
• 2:34
  it.
• 2:35
  And
• 2:35
  you're
• 2:35
  asking
• 2:35
  them
• 2:35
  to
• 2:35
  recall
• 2:36
  a
• 2:36
  moment
• 2:37
  and
• 2:37
  wondering
• 2:37
  if
• 2:38
  that
• 2:38
  moment
• 2:38
  was
• 2:39
  four
• 2:39
  or
• 2:39
  more
• 2:40
  days
• 2:40
  in
• 2:40
  a
• 2:40
  row
• 2:41
  of
• 2:41
  that
• 2:41
  behavior.
• 2:42
  So
• 2:42
  you
• 2:43
  already
• 2:43
  have
• 2:43
  very
• 2:43
  little
• 2:44
  insight
• 2:44
  when
• 2:44
  that
• 2:45
  stuff
• 2:45
  is
• 2:45
  going
• 2:45
  on.
• 2:46
  If
• 2:46
  you
• 2:46
  already
• 2:46
  have
• 2:47
  that
• 2:47
  little
• 2:47
  insight,
• 2:48
  how
• 2:48
  hard
• 2:48
  is
• 2:48
  it
• 2:48
  going
• 2:48
  to
• 2:49
  be
• 2:49
  176
• 2:50
  days
• 2:51
  later
• 2:51
  to
• 2:51
  recount
• 2:51
  that
• 2:52
  and
• 2:53
  reliably
• 2:53
  and
• 2:54
  tell
• 2:54
  you,
• 2:54
  right?
• 2:55
  So
• 2:55
  MDD
• 2:55
  mix
• 2:56
  features.
• 2:56
  It
• 2:56
  is,
• 2:57
  again,
• 2:57
  one
• 2:57
  of
• 2:57
  the
• 2:57
  most
• 2:58
  fascinating
• 2:59
  and
• 3:00
  one
• 3:00
  of
• 3:00
  the
• 3:01
  most
• 3:01
  frustrating
• 3:03
  places
• 3:03
  to
• 3:03
  be
• 3:03
  in
• 3:04
  all
• 3:04
  of
• 3:04
  psychiatry.
• 3:05
  But
• 3:05
  rest
• 3:06
  assured,
• 3:07
  there
• 3:07
  is
• 3:07
  an
• 3:08
  rct.
• 3:08
  There
• 3:09
  is
• 3:09
  some
• 3:09
  preliminary
• 3:10
  data.
• 3:10
  It's
• 3:11
  very
• 3:11
  scant,
• 3:11
  it's
• 3:12
  very
• 3:12
  weak,
• 3:13
  it's
• 3:13
  very
• 3:13
  preliminary.
• 3:14
  But
• 3:15
  there
• 3:15
  is
• 3:15
  some
• 3:15
  data
• 3:16
  that
• 3:16
  we
• 3:16
  can,
• 3:17
  we
• 3:17
  can
• 3:18
  point
• 3:18
  to
• 3:18
  when
• 3:18
  it
• 3:19
  comes
• 3:19
  to
• 3:19
  what
• 3:19
  do
• 3:19
  we
• 3:20
  do
• 3:20
  in
• 3:20
  mdd,
• 3:21
  not
• 3:21
  bipolar,
• 3:21
  but
• 3:21
  MDD
• 3:22
  with
• 3:23
  mixed
• 3:23
  features.
• 3:24
  And
• 3:24
  there
• 3:24
  is
• 3:24
  one
• 3:25
  rct,
• 3:25
  and
• 3:25
  I
• 3:25
  won't
• 3:26
  go
• 3:27
  really
• 3:27
  deep
• 3:27
  into
• 3:27
  that
• 3:27
  rct.
• 3:28
  This
• 3:28
  isn't
• 3:28
  like
• 3:29
  a
• 3:29
  of
• 3:29
  lecture
• 3:30
  where
• 3:30
  you're
• 3:30
  going
• 3:30
  to
• 3:30
  be
• 3:30
  pop
• 3:31
  quiz.
• 3:31
  I
• 3:31
  don't
• 3:32
  spank
• 3:32
  anybody
• 3:32
  in
• 3:32
  here
• 3:33
  with
• 3:33
  a
• 3:33
  ruler.
• 3:34
  We're
• 3:34
  not
• 3:34
  going
• 3:35
  that
• 3:35
  route.
• 3:36
  That,
• 3:36
  that.
• 3:36
  Those
• 3:36
  are
• 3:36
  the
• 3:37
  old
• 3:37
  days.
• 3:37
  They're
• 3:37
  not
• 3:37
  even
• 3:38
  the
• 3:38
  good
• 3:38
  old
• 3:38
  days.
• 3:38
  Those
• 3:38
  are
• 3:39
  the
• 3:39
  old
• 3:39
  days.
• 3:40
  And
• 3:40
  so
• 3:41
  what
• 3:41
  we're
• 3:41
  going
• 3:41
  to
• 3:41
  do
• 3:42
  instead
• 3:43
  is
• 3:43
  we're
• 3:43
  going
• 3:43
  to
• 3:44
  talk
• 3:44
  about
• 3:44
  what
• 3:44
  you
• 3:44
  do
• 3:45
  in
• 3:45
  the
• 3:45
  chair,
• 3:45
  because
• 3:46
  here
• 3:46
  you
• 3:46
  are,
• 3:46
  and
• 3:47
  I'm
• 3:47
  going
• 3:47
  to
• 3:47
  give
• 3:47
  you
• 3:47
  a
• 3:47
  mock
• 3:48
  patient
• 3:48
  real
• 3:48
  quick.
• 3:48
  Her
• 3:49
  name
• 3:49
  is
• 3:49
  Polly.
• 3:50
  She's
• 3:51
  28.
• 3:51
  She's
• 3:52
  on
• 3:52
  Zoloft
• 3:52
  50
• 3:53
  milligrams
• 3:53
  for
• 3:53
  three
• 3:54
  months
• 3:54
  with
• 3:54
  MDD.
• 3:55
  She,
• 3:56
  she's
• 3:56
  still
• 3:56
  depressed,
• 3:57
  but
• 3:57
  something
• 3:57
  else
• 3:57
  is
• 3:58
  happening
• 3:58
  too.
• 3:59
  Okay?
• 4:00
  She
• 4:00
  has
• 4:00
  racing
• 4:01
  thoughts
• 4:01
  at
• 4:01
  night.
• 4:01
  She's
• 4:02
  irritable,
• 4:02
  kind
• 4:02
  of
• 4:03
  out
• 4:03
  of
• 4:03
  nowhere,
• 4:03
  only
• 4:03
  sleeping
• 4:04
  about
• 4:04
  five
• 4:04
  hours.
• 4:05
  But
• 4:05
  she
• 4:05
  feels
• 4:06
  super
• 4:06
  wired
• 4:07
  afterwards.
• 4:08
  Remember,
• 4:08
  it's
• 4:09
  not
• 4:09
  enough
• 4:09
  to
• 4:09
  just
• 4:09
  say
• 4:10
  your
• 4:10
  patient's
• 4:10
  not
• 4:10
  sleeping.
• 4:11
  If
• 4:11
  a
• 4:11
  patient
• 4:11
  is,
• 4:12
  is
• 4:12
  feeling
• 4:13
  super
• 4:13
  energized
• 4:14
  off
• 4:14
  of
• 4:14
  a
• 4:14
  little
• 4:15
  bit
• 4:15
  of
• 4:15
  sleep,
• 4:16
  that
• 4:16
  also
• 4:16
  is
• 4:17
  sufficient
• 4:18
  for
• 4:18
  the
• 4:18
  criteria,
• 4:18
  right?
• 4:19
  It's
• 4:19
  not
• 4:19
  like
• 4:19
  you
• 4:19
  need
• 4:20
  four
• 4:20
  days
• 4:20
  or
• 4:20
  more
• 4:20
  without
• 4:21
  any
• 4:21
  sleep
• 4:21
  at
• 4:21
  all.
• 4:22
  People
• 4:22
  who
• 4:22
  can
• 4:23
  sleep
• 4:23
  very
• 4:23
  little
• 4:23
  and
• 4:23
  still
• 4:24
  feel
• 4:24
  really
• 4:24
  energized,
• 4:25
  like
• 4:25
  they
• 4:25
  don't
• 4:25
  even
• 4:26
  need
• 4:26
  it.
• 4:26
  Okay,
• 4:27
  so
• 4:27
  Polly's
• 4:27
  got
• 4:28
  a
• 4:28
  little
• 4:28
  bit
• 4:28
  of
• 4:28
  that.
• 4:28
  She's
• 4:29
  got
• 4:29
  pressured
• 4:29
  speech
• 4:30
  during
• 4:30
  arguments.
• 4:31
  She's
• 4:31
  not
• 4:32
  euphoric.
• 4:32
  She's
• 4:32
  not
• 4:33
  grandiose.
• 4:33
  She's
• 4:33
  not
• 4:33
  overspending.
• 4:34
  She
• 4:35
  doesn't
• 4:35
  have
• 4:35
  any
• 4:35
  prior
• 4:35
  manic
• 4:36
  episodes
• 4:36
  to
• 4:37
  point
• 4:37
  to.
• 4:37
  But
• 4:37
  again,
• 4:38
  right
• 4:38
  now
• 4:38
  she
• 4:39
  doesn't
• 4:39
  really
• 4:39
  feel
• 4:40
  like
• 4:40
  she
• 4:40
  has
• 4:40
  to
• 4:40
  sleep.
• 4:41
  She's
• 4:41
  a
• 4:41
  little
• 4:41
  irritable.
• 4:42
  And
• 4:42
  she
• 4:42
  does
• 4:42
  have
• 4:42
  a
• 4:42
  maternal
• 4:43
  aunt
• 4:43
  with
• 4:43
  bipolar
• 4:44
  disorder.
• 4:45
  Okay?
• 4:46
  So
• 4:46
  as
• 4:47
  of
• 4:47
  now,
• 4:47
  she
• 4:48
  meets
• 4:48
  DSM
• 4:49
  5
• 4:49
  criteria
• 4:50
  for
• 4:50
  MDD.
• 4:50
  With
• 4:51
  mixed
• 4:51
  features.
• 4:51
  That's
• 4:52
  the
• 4:52
  specifier.
• 4:53
  Okay.
• 4:53
  That's
• 4:53
  relatively
• 4:54
  new.
• 4:54
  That
• 4:55
  did
• 4:55
  not
• 4:55
  exist
• 4:56
  prior
• 4:56
  to
• 4:57
  the
• 4:58
  updates
• 4:58
  to
• 4:58
  the
• 4:58
  DSM
• 4:59
  5
• 4:59
  over
• 4:59
  a
• 4:59
  decade
• 5:00
  ago.
• 5:00
  So
• 5:00
  she
• 5:00
  has
• 5:01
  three
• 5:01
  concurrent
• 5:02
  manic
• 5:02
  symptoms,
• 5:03
  the
• 5:03
  racing
• 5:03
  thoughts,
• 5:04
  decreased
• 5:04
  need
• 5:04
  for
• 5:04
  sleep
• 5:05
  and
• 5:05
  irritability
• 5:06
  during
• 5:06
  a
• 5:06
  major
• 5:06
  depressive
• 5:07
  episode.
• 5:07
  Again,
• 5:08
  the
• 5:08
  key
• 5:08
  here
• 5:08
  with
• 5:08
  mixed
• 5:09
  features
• 5:09
  is
• 5:09
  that
• 5:09
  it's
• 5:09
  happening
• 5:10
  concurrently
• 5:11
  with
• 5:12
  a
• 5:12
  depressive
• 5:12
  episode.
• 5:13
  It's
• 5:13
  not
• 5:13
  a
• 5:13
  separate
• 5:13
  entity.
• 5:14
  Okay,
• 5:15
  so
• 5:15
  it's
• 5:15
  like
• 5:15
  cookie,
• 5:15
  the
• 5:15
  dough,
• 5:16
  the
• 5:16
  cookie,
• 5:16
  the
• 5:16
  chocolate
• 5:17
  chips
• 5:17
  are
• 5:18
  in
• 5:18
  the
• 5:18
  dough.
• 5:19
  They're
• 5:19
  not
• 5:19
  a
• 5:19
  separate
• 5:19
  chocolate
• 5:20
  chip
• 5:20
  pile
• 5:21
  on
• 5:22
  the
• 5:22
  side.
• 5:22
  They're
• 5:22
  mixed
• 5:23
  in
• 5:23
  the
• 5:23
  dough,
• 5:23
  Right?
• 5:24
  Or
• 5:24
  else
• 5:24
  it
• 5:24
  would
• 5:24
  be
• 5:25
  a
• 5:25
  different
• 5:25
  dessert.
• 5:26
  Right?
• 5:26
  Cookie
• 5:26
  dough
• 5:27
  is
• 5:27
  its
• 5:27
  own
• 5:27
  thing.
• 5:28
  Chocolate
• 5:28
  chip
• 5:28
  cookie
• 5:29
  dough
• 5:29
  is
• 5:29
  its
• 5:29
  own
• 5:29
  dessert.
• 5:30
  That's
• 5:30
  MDD
• 5:30
  with
• 5:31
  mixed
• 5:31
  features.
• 5:31
  Chocolate
• 5:32
  chips
• 5:33
  just
• 5:33
  hanging
• 5:34
  out
• 5:34
  on
• 5:34
  your
• 5:34
  counter.
• 5:35
  That
• 5:35
  is
• 5:36
  a
• 5:36
  whole
• 5:36
  separate
• 5:37
  thing.
• 5:37
  That's
• 5:37
  not
• 5:37
  really
• 5:37
  a
• 5:38
  dessert,
• 5:38
  right?
• 5:38
  It's
• 5:38
  just
• 5:39
  this
• 5:39
  whole
• 5:39
  separate
• 5:39
  thing.
• 5:40
  You
• 5:40
  put
• 5:40
  them
• 5:40
  together,
• 5:40
  you
• 5:41
  have
• 5:41
  chocolate
• 5:41
  chip,
• 5:41
  cookie
• 5:42
  dough.
• 5:42
  So
• 5:42
  remember,
• 5:42
  the
• 5:42
  mixed
• 5:43
  features
• 5:44
  is
• 5:44
  exactly
• 5:44
  what
• 5:44
  it
• 5:45
  says.
• 5:45
  It
• 5:45
  has
• 5:46
  to
• 5:46
  be
• 5:46
  embedded
• 5:46
  in
• 5:47
  the
• 5:47
  depression.
• 5:47
  If
• 5:47
  it's
• 5:47
  happening
• 5:48
  separate,
• 5:48
  we're
• 5:49
  talking
• 5:49
  about
• 5:49
  a
• 5:49
  different
• 5:50
  thing.
• 5:50
  Now
• 5:51
  here's
• 5:51
  the
• 5:51
  problem.
• 5:52
  You
• 5:52
  have
• 5:52
  Polly
• 5:52
  in
• 5:53
  your
• 5:53
  office.
• 5:53
  She
• 5:53
  needs
• 5:53
  help.
• 5:54
  She's
• 5:54
  on
• 5:54
  Zoloft.
• 5:55
  And
• 5:55
  you're
• 5:56
  seeing
• 5:56
  these
• 5:56
  mixed
• 5:56
  features
• 5:57
  and
• 5:57
  you're
• 5:57
  like,
• 5:57
  oh,
• 5:58
  God
• 5:58
  Almighty.
• 5:59
  I
• 5:59
  know
• 5:59
  from
• 6:00
  school.
• 6:00
  This
• 6:00
  is
• 6:01
  not
• 6:02
  a
• 6:02
  good
• 6:02
  thing,
• 6:02
  right?
• 6:03
  This
• 6:03
  is
• 6:03
  not
• 6:03
  a
• 6:03
  good
• 6:04
  idea.
• 6:04
  There
• 6:04
  are
• 6:04
  clinical
• 6:05
  guidelines
• 6:05
  out
• 6:05
  there
• 6:05
  that
• 6:06
  scream
• 6:06
  from
• 6:07
  the
• 6:07
  mountaintops
• 6:07
  to
• 6:08
  be
• 6:08
  careful
• 6:08
  when
• 6:09
  it,
• 6:09
  when
• 6:09
  it
• 6:09
  comes
• 6:09
  to
• 6:10
  monotherapy,
• 6:11
  antidepressant
• 6:12
  monotherapy,
• 6:12
  when
• 6:12
  there's
• 6:13
  a
• 6:13
  whiff
• 6:14
  of
• 6:14
  these
• 6:14
  manic
• 6:15
  symptoms,
• 6:15
  right?
• 6:15
  So
• 6:16
  once
• 6:16
  you
• 6:17
  make
• 6:17
  sure
• 6:17
  that
• 6:17
  you're
• 6:18
  not
• 6:18
  looking
• 6:18
  at
• 6:18
  borderline
• 6:19
  personality
• 6:19
  disorder,
• 6:20
  then
• 6:20
  you
• 6:20
  need
• 6:21
  to
• 6:21
  start
• 6:21
  thinking
• 6:21
  about
• 6:22
  how
• 6:22
  do
• 6:22
  we
• 6:23
  help
• 6:23
  out
• 6:24
  poly
• 6:25
  and
• 6:25
  not
• 6:25
  make
• 6:25
  this
• 6:25
  worse
• 6:26
  and
• 6:27
  potentially
• 6:27
  get
• 6:27
  her
• 6:27
  off
• 6:28
  of
• 6:28
  an
• 6:28
  ssri,
• 6:29
  because
• 6:29
  monotherapy
• 6:30
  with
• 6:30
  mixed
• 6:31
  features,
• 6:31
  watch
• 6:31
  out.
• 6:32
  And
• 6:32
  I
• 6:32
  can't
• 6:33
  emphasize
• 6:33
  enough
• 6:33
  how
• 6:34
  badly
• 6:34
  you
• 6:34
  need
• 6:34
  to
• 6:35
  make
• 6:35
  sure
• 6:35
  this
• 6:35
  isn't
• 6:36
  borderline,
• 6:36
  right?
• 6:37
  Because
• 6:37
  borderline
• 6:37
  is
• 6:37
  one
• 6:38
  of
• 6:38
  those
• 6:38
  really
• 6:39
  important
• 6:39
  diagnoses
• 6:40
  to
• 6:40
  make
• 6:40
  sure
• 6:41
  you're
• 6:41
  not
• 6:41
  looking
• 6:41
  at
• 6:42
  here.
• 6:42
  Because
• 6:42
  you
• 6:43
  will
• 6:43
  go
• 6:43
  down
• 6:43
  an
• 6:43
  entirely
• 6:44
  different
• 6:45
  diagnostic
• 6:46
  path.
• 6:46
  If
• 6:46
  this
• 6:47
  is
• 6:47
  in
• 6:47
  fact
• 6:47
  borderline
• 6:48
  and
• 6:48
  you
• 6:49
  think
• 6:49
  it's
• 6:49
  mixed
• 6:49
  features
• 6:50
  and
• 6:50
  now
• 6:50
  you're
• 6:51
  giving
• 6:51
  a
• 6:51
  patient
• 6:52
  maybe
• 6:52
  a
• 6:52
  second
• 6:53
  generation
• 6:53
  antipsychotic,
• 6:54
  which
• 6:54
  we'll
• 6:54
  get
• 6:54
  to
• 6:54
  in
• 6:55
  a
• 6:55
  moment,
• 6:55
  because
• 6:55
  you
• 6:55
  think
• 6:56
  it's
• 6:56
  mixed
• 6:56
  features
• 6:57
  and
• 6:57
  it's
• 6:57
  really
• 6:57
  borderline,
• 6:58
  and
• 6:58
  they
• 6:58
  should
• 6:58
  have
• 6:58
  gotten
• 6:59
  DBT
• 6:59
  dialectical
• 7:00
  behavioral
• 7:00
  therapy,
• 7:01
  because
• 7:02
  we
• 7:02
  misdiagnosed
• 7:03
  this,
• 7:03
  we're
• 7:03
  going
• 7:03
  to
• 7:04
  go
• 7:04
  down
• 7:04
  an
• 7:04
  entirely
• 7:05
  different
• 7:05
  treatment
• 7:05
  path.
• 7:06
  Where
• 7:06
  there's
• 7:06
  not
• 7:06
  a
• 7:06
  lot
• 7:07
  of
• 7:07
  evidence
• 7:07
  at
• 7:08
  all
• 7:08
  to
• 7:08
  start
• 7:09
  a
• 7:09
  mood
• 7:09
  stabilizer
• 7:10
  in
• 7:10
  someone
• 7:10
  with
• 7:10
  bpd.
• 7:11
  So
• 7:12
  make
• 7:12
  sure.
• 7:12
  And
• 7:13
  it's
• 7:13
  extremely
• 7:14
  hard.
• 7:14
  I
• 7:14
  would
• 7:14
  argue
• 7:14
  it's
• 7:15
  one
• 7:15
  of
• 7:15
  the
• 7:15
  most
• 7:15
  challenging
• 7:16
  diagnoses
• 7:16
  in
• 7:17
  all
• 7:17
  of
• 7:17
  psychiatry.
• 7:18
  But
• 7:19
  make
• 7:19
  sure
• 7:20
  you
• 7:21
  are
• 7:21
  ruling
• 7:22
  out
• 7:22
  borderline
• 7:23
  personality
• 7:24
  disorder.
• 7:25
  And
• 7:25
  I
• 7:26
  will
• 7:26
  admit,
• 7:27
  again,
• 7:27
  not
• 7:27
  to
• 7:27
  beat
• 7:28
  the
• 7:28
  dead
• 7:28
  horse,
• 7:29
  that
• 7:29
  ruling
• 7:30
  out
• 7:30
  borderline
• 7:31
  personality
• 7:31
  disorder
• 7:32
  is
• 7:33
  inherently
• 7:34
  challenging.
• 7:35
  I
• 7:35
  find.
• 7:35
  It's
• 7:36
  just
• 7:36
  there's
• 7:36
  so
• 7:37
  much
• 7:37
  significant
• 7:38
  overlap.
• 7:39
  And
• 7:40
  so
• 7:41
  you
• 7:41
  remember
• 7:42
  your
• 7:42
  job
• 7:42
  is
• 7:43
  not
• 7:43
  to
• 7:43
  declare
• 7:44
  victory
• 7:44
  in
• 7:45
  the
• 7:45
  very
• 7:45
  first
• 7:45
  encounter.
• 7:46
  I
• 7:46
  mean,
• 7:46
  that
• 7:46
  would,
• 7:47
  you
• 7:47
  know,
• 7:47
  massive
• 7:47
  bonus
• 7:48
  points
• 7:48
  to
• 7:48
  you
• 7:48
  if
• 7:48
  you
• 7:48
  can
• 7:49
  do
• 7:49
  that.
• 7:49
  The
• 7:50
  point
• 7:50
  is
• 7:50
  not
• 7:51
  to
• 7:51
  do
• 7:51
  this
• 7:52
  quickly,
• 7:52
  it's
• 7:52
  to
• 7:52
  do
• 7:52
  this
• 7:53
  correctly.
• 7:53
  Right?
• 7:53
  So
• 7:53
  if
• 7:54
  you
• 7:54
  need
• 7:54
  to
• 7:54
  rely
• 7:54
  on
• 7:55
  a
• 7:55
  follow
• 7:55
  up,
• 7:55
  maybe
• 7:56
  a
• 7:56
  one
• 7:56
  week
• 7:56
  follow
• 7:56
  up,
• 7:57
  you,
• 7:57
  you
• 7:58
  make
• 7:58
  the
• 7:58
  call
• 7:58
  there.
• 7:58
  But
• 7:58
  if
• 7:59
  you
• 7:59
  need
• 7:59
  to
• 7:59
  rely
• 7:59
  on
• 7:59
  a
• 7:59
  follow
• 8:00
  up
• 8:00
  to
• 8:00
  get
• 8:01
  this
• 8:01
  right,
• 8:01
  definitely
• 8:02
  get
• 8:02
  it
• 8:02
  right,
• 8:03
  so
• 8:03
  long
• 8:03
  as
• 8:04
  you're
• 8:04
  not
• 8:04
  letting
• 8:04
  a
• 8:04
  patient
• 8:05
  remain
• 8:05
  unstable
• 8:06
  or
• 8:06
  unsafe.
• 8:06
  But
• 8:07
  to
• 8:07
  get
• 8:07
  the
• 8:07
  diagnosis
• 8:08
  right
• 8:08
  is
• 8:08
  very
• 8:09
  important.
• 8:09
  Okay?
• 8:10
  And
• 8:10
  that's
• 8:10
  where
• 8:10
  you
• 8:10
  really
• 8:11
  have
• 8:11
  to
• 8:11
  get
• 8:11
  a
• 8:11
  good
• 8:11
  assessment
• 8:12
  of
• 8:12
  their
• 8:12
  functional
• 8:12
  impairment.
• 8:13
  You
• 8:14
  obviously
• 8:14
  there's
• 8:14
  some
• 8:14
  things
• 8:14
  you
• 8:15
  can't
• 8:15
  wait
• 8:15
  one
• 8:16
  week
• 8:16
  or
• 8:16
  three
• 8:16
  weeks
• 8:16
  for.
• 8:17
  If
• 8:17
  there's
• 8:17
  significant
• 8:18
  functional
• 8:18
  impairment,
• 8:19
  there's
• 8:20
  acute
• 8:20
  deterioration
• 8:21
  or
• 8:21
  acute
• 8:21
  safety
• 8:22
  concerns.
• 8:22
  Of
• 8:22
  course,
• 8:23
  that's
• 8:23
  case
• 8:23
  by
• 8:23
  case.
• 8:24
  But
• 8:25
  this
• 8:25
  is
• 8:26
  a
• 8:27
  very
• 8:28
  big
• 8:28
  gray
• 8:29
  area
• 8:29
  in
• 8:30
  mental
• 8:30
  health
• 8:30
  and
• 8:31
  I
• 8:31
  again
• 8:31
  love
• 8:32
  it.
• 8:32
  But
• 8:32
  it
• 8:33
  is
• 8:33
  challenging
• 8:33
  because
• 8:34
  I
• 8:34
  will
• 8:34
  scratch
• 8:34
  my
• 8:34
  head
• 8:34
  and
• 8:35
  say,
• 8:35
  wait
• 8:35
  a
• 8:35
  minute,
• 8:35
  what
• 8:35
  do
• 8:35
  I
• 8:36
  do
• 8:36
  here?
• 8:36
  I
• 8:36
  can't
• 8:37
  do
• 8:37
  more
• 8:37
  Zoloft.
• 8:38
  And
• 8:38
  I'll
• 8:38
  even
• 8:39
  look
• 8:39
  at
• 8:39
  it
• 8:39
  and
• 8:39
  say,
• 8:39
  wait
• 8:39
  a
• 8:40
  minute,
• 8:40
  is
• 8:40
  this
• 8:40
  patient
• 8:40
  irritable
• 8:42
  as
• 8:42
  a
• 8:42
  feature
• 8:42
  of
• 8:43
  their
• 8:43
  depression?
• 8:43
  You
• 8:44
  know,
• 8:44
  it's
• 8:44
  not
• 8:44
  really
• 8:44
  a
• 8:44
  diagnostic
• 8:45
  feature,
• 8:45
  but
• 8:45
  sure
• 8:46
  enough,
• 8:46
  a
• 8:46
  lot
• 8:46
  of
• 8:46
  people
• 8:46
  with
• 8:47
  depression
• 8:47
  are
• 8:48
  irritable.
• 8:48
  It
• 8:49
  is
• 8:49
  a
• 8:49
  diagnostic
• 8:50
  feature
• 8:51
  of
• 8:51
  generalized
• 8:52
  anxiety
• 8:52
  disorder.
• 8:53
  So
• 8:53
  sometimes
• 8:54
  when
• 8:54
  I
• 8:54
  have
• 8:54
  patients,
• 8:54
  I
• 8:54
  ask
• 8:55
  myself,
• 8:55
  is
• 8:55
  this
• 8:56
  irritability
• 8:56
  a
• 8:57
  bipolar
• 8:57
  irritability
• 8:58
  or
• 8:58
  is
• 8:59
  it
• 8:59
  an
• 8:59
  irritability
• 9:00
  that
• 9:00
  is
• 9:01
  part
• 9:01
  of
• 9:01
  gad?
• 9:02
  Okay.
• 9:03
  And
• 9:03
  of
• 9:03
  course,
• 9:03
  the
• 9:04
  way
• 9:04
  to
• 9:04
  answer
• 9:04
  that
• 9:04
  is
• 9:05
  to
• 9:05
  see
• 9:05
  if
• 9:05
  the
• 9:05
  other
• 9:05
  constellation
• 9:06
  of
• 9:06
  symptoms
• 9:07
  are
• 9:07
  occurring
• 9:08
  together
• 9:09
  as
• 9:09
  part
• 9:09
  of
• 9:09
  the
• 9:10
  mixed
• 9:10
  features.
• 9:10
  Right?
• 9:11
  So
• 9:11
  if
• 9:11
  they're
• 9:11
  irritable
• 9:12
  in
• 9:12
  very
• 9:12
  discreet
• 9:13
  episodes,
• 9:13
  as
• 9:14
  opposed
• 9:14
  to
• 9:14
  every
• 9:15
  single
• 9:15
  day
• 9:15
  with
• 9:15
  their
• 9:16
  anxiety,
• 9:17
  it's
• 9:17
  definitely
• 9:17
  more
• 9:18
  likely
• 9:18
  to
• 9:18
  be
• 9:18
  the
• 9:19
  mixed
• 9:19
  features
• 9:20
  or
• 9:20
  bipolarity.
• 9:21
  But
• 9:21
  if
• 9:21
  their
• 9:21
  irritability
• 9:22
  is
• 9:22
  sort
• 9:22
  of
• 9:23
  longitudinal,
• 9:23
  it's
• 9:23
  sort
• 9:24
  of
• 9:24
  every
• 9:24
  day,
• 9:24
  it's
• 9:24
  more
• 9:24
  of
• 9:24
  a
• 9:25
  trait.
• 9:25
  I
• 9:25
  find
• 9:26
  that
• 9:26
  in
• 9:26
  general,
• 9:26
  as
• 9:27
  anxiety
• 9:27
  is
• 9:27
  more
• 9:27
  persistent
• 9:28
  and
• 9:28
  consistent,
• 9:30
  irritability
• 9:31
  is
• 9:31
  kind
• 9:31
  of
• 9:31
  baked
• 9:31
  into
• 9:32
  the
• 9:32
  cake
• 9:32
  when
• 9:33
  you're
• 9:33
  very
• 9:34
  nervous
• 9:34
  all
• 9:34
  of
• 9:35
  the
• 9:35
  time.
• 9:35
  So
• 9:36
  these
• 9:36
  are
• 9:36
  things
• 9:36
  to
• 9:37
  think
• 9:37
  about
• 9:38
  as
• 9:38
  you
• 9:38
  mull
• 9:39
  over
• 9:39
  what
• 9:40
  to
• 9:40
  do
• 9:40
  with
• 9:40
  MDD
• 9:41
  and
• 9:41
  mixed
• 9:41
  features.
• 9:41
  Now,
• 9:42
  the
• 9:42
  interesting
• 9:43
  piece
• 9:43
  about
• 9:44
  this
• 9:44
  is
• 9:45
  we
• 9:46
  need
• 9:46
  to
• 9:46
  switch
• 9:46
  to
• 9:47
  a
• 9:47
  medication
• 9:47
  that
• 9:48
  is
• 9:48
  safe
• 9:48
  in
• 9:48
  mixed
• 9:49
  features.
• 9:49
  And
• 9:50
  because
• 9:50
  there
• 9:50
  is
• 9:51
  scant
• 9:51
  evidence.
• 9:51
  There
• 9:52
  are
• 9:52
  really
• 9:52
  scant.
• 9:53
  There's
• 9:54
  no
• 9:54
  FDA
• 9:54
  approvals
• 9:55
  for
• 9:55
  this
• 9:55
  for
• 9:55
  mixed
• 9:56
  MDD
• 9:56
  with
• 9:56
  mixed
• 9:57
  features.
• 9:57
  There's
• 9:58
  just
• 9:58
  not
• 9:58
  a
• 9:58
  lot
• 9:59
  of
• 9:59
  evidence
• 9:59
  or
• 10:00
  drug
• 10:00
  trials
• 10:00
  or.
• 10:01
  And
• 10:01
  so
• 10:01
  what
• 10:02
  do
• 10:02
  we
• 10:02
  do?
• 10:02
  Latuda,
• 10:03
  my
• 10:03
  friends,
• 10:03
  Latuda
• 10:04
  is
• 10:04
  the
• 10:05
  place
• 10:05
  to
• 10:05
  go.
• 10:05
  There
• 10:06
  is
• 10:06
  an
• 10:06
  RCT
• 10:07
  specifically
• 10:08
  done
• 10:08
  for
• 10:08
  MDD
• 10:09
  with
• 10:09
  mixed
• 10:09
  features
• 10:10
  that
• 10:10
  tested
• 10:11
  Latuda.
• 10:12
  Okay,
• 10:13
  they
• 10:13
  tested
• 10:13
  Latuda
• 10:14
  20
• 10:14
  to
• 10:14
  60
• 10:15
  milligrams
• 10:15
  a
• 10:15
  day
• 10:15
  versus
• 10:16
  placebo
• 10:16
  for
• 10:17
  six
• 10:17
  weeks,
• 10:17
  and
• 10:18
  we
• 10:19
  got
• 10:19
  a
• 10:19
  big
• 10:19
  fat
• 10:20
  response
• 10:21
  of
• 10:21
  64.8%.
• 10:22
  That's
• 10:23
  a
• 10:23
  very
• 10:23
  good
• 10:23
  response
• 10:24
  rate
• 10:24
  versus
• 10:24
  placebo
• 10:25
  at
• 10:26
  30%
• 10:26
  with
• 10:26
  a
• 10:27
  very
• 10:27
  large
• 10:27
  effect
• 10:27
  size
• 10:28
  of
• 10:28
  0.8.
• 10:29
  That
• 10:29
  is
• 10:30
  monumental,
• 10:31
  my
• 10:31
  friends.
• 10:32
  For
• 10:32
  context,
• 10:32
  most
• 10:33
  SSRI
• 10:33
  trials
• 10:34
  and
• 10:34
  MDD
• 10:35
  show
• 10:35
  an
• 10:35
  effect
• 10:35
  size
• 10:36
  of
• 10:36
  0.3
• 10:37
  or
• 10:37
  0.4.
• 10:38
  So
• 10:38
  as
• 10:38
  we've
• 10:38
  gone
• 10:39
  over
• 10:39
  in
• 10:39
  previous
• 10:39
  episodes,
• 10:40
  effect
• 10:41
  sizes
• 10:41
  give
• 10:41
  you
• 10:41
  an
• 10:42
  idea
• 10:42
  of
• 10:43
  just
• 10:43
  how
• 10:43
  large
• 10:44
  of
• 10:44
  a
• 10:45
  benefit
• 10:45
  you
• 10:45
  may
• 10:45
  be
• 10:46
  able
• 10:46
  to
• 10:46
  expect
• 10:46
  comparable
• 10:47
  to
• 10:47
  placebo.
• 10:48
  Point
• 10:49
  8
• 10:50
  is.
• 10:51
  Them
• 10:51
  are
• 10:51
  fighting
• 10:51
  words.
• 10:52
  Those
• 10:52
  are
• 10:52
  really
• 10:52
  good
• 10:52
  effect
• 10:53
  sizes.
• 10:53
  So
• 10:54
  latuda
• 10:54
  is
• 10:55
  your
• 10:55
  go
• 10:55
  to
• 10:55
  if
• 10:55
  you
• 10:56
  have
• 10:56
  MDD
• 10:56
  with
• 10:57
  mixed
• 10:57
  features.
• 10:58
  There's
• 10:58
  a
• 10:58
  lot
• 10:58
  of
• 10:58
  good
• 10:58
  evidence
• 10:59
  behind
• 10:59
  it.
• 10:59
  There
• 10:59
  is
• 10:59
  one
• 11:00
  RCT
• 11:00
  and
• 11:00
  there's
• 11:01
  really
• 11:01
  not
• 11:01
  a
• 11:01
  lot
• 11:01
  of
• 11:01
  evidence
• 11:02
  anywhere
• 11:03
  else.
• 11:04
  And
• 11:04
  the
• 11:04
  idea
• 11:04
  here
• 11:05
  is
• 11:05
  that
• 11:05
  you
• 11:05
  want
• 11:06
  to
• 11:06
  avoid
• 11:06
  SSRIs
• 11:07
  because
• 11:08
  again,
• 11:08
  SSRIs
• 11:10
  sort
• 11:10
  of
• 11:10
  flood
• 11:11
  your
• 11:12
  whole
• 11:13
  system
• 11:13
  with
• 11:13
  serotonin,
• 11:14
  which
• 11:14
  can
• 11:14
  be
• 11:14
  really
• 11:14
  good
• 11:15
  where
• 11:15
  you
• 11:15
  need
• 11:15
  it,
• 11:15
  and
• 11:16
  it's
• 11:16
  really
• 11:16
  not
• 11:16
  good
• 11:16
  where
• 11:17
  you
• 11:17
  don't
• 11:17
  need
• 11:18
  it.
• 11:18
  And
• 11:19
  it
• 11:19
  can
• 11:19
  actually
• 11:19
  precipitate
• 11:20
  manic
• 11:21
  switches.
• 11:22
  And
• 11:22
  we
• 11:23
  don't
• 11:23
  want
• 11:23
  that.
• 11:23
  Right.
• 11:23
  We
• 11:24
  want
• 11:24
  to
• 11:25
  be
• 11:25
  able
• 11:25
  to
• 11:25
  hedge
• 11:26
  or
• 11:26
  control
• 11:27
  the
• 11:28
  risk
• 11:28
  of
• 11:28
  switching
• 11:29
  into
• 11:29
  mania.
• 11:30
  And
• 11:30
  you
• 11:30
  can
• 11:30
  do
• 11:30
  that
• 11:30
  with
• 11:31
  a
• 11:31
  mood
• 11:31
  stabilizer,
• 11:32
  hence
• 11:32
  the
• 11:32
  word
• 11:32
  mood
• 11:33
  stabilizer.
• 11:33
  Right.
• 11:34
  So
• 11:36
  you
• 11:36
  don't
• 11:36
  want
• 11:37
  the
• 11:37
  patient
• 11:37
  to
• 11:37
  hang
• 11:37
  out
• 11:37
  on
• 11:38
  Zoloft.
• 11:38
  Clearly
• 11:39
  poly.
• 11:40
  In
• 11:40
  our
• 11:40
  example,
• 11:40
  she's
• 11:41
  not
• 11:41
  in
• 11:41
  remission.
• 11:42
  She's
• 11:43
  still
• 11:43
  very
• 11:43
  agitated
• 11:44
  and
• 11:45
  irritable
• 11:45
  and
• 11:46
  wired
• 11:47
  because
• 11:47
  she's
• 11:47
  not
• 11:47
  sleeping.
• 11:49
  So
• 11:49
  red
• 11:50
  flag
• 11:50
  number
• 11:50
  one
• 11:50
  is
• 11:51
  Zoloft
• 11:52
  hasn't
• 11:52
  really
• 11:52
  helped
• 11:53
  her.
• 11:53
  I'll
• 11:53
  even
• 11:53
  ask
• 11:53
  patients
• 11:54
  very
• 11:54
  directly,
• 11:54
  has
• 11:55
  Zoloft
• 11:55
  helped
• 11:55
  you?
• 11:55
  How
• 11:56
  do
• 11:56
  you
• 11:56
  feel
• 11:56
  Zoloft
• 11:57
  has
• 11:57
  affected
• 11:58
  your
• 11:58
  symptoms
• 11:58
  overall
• 11:59
  since
• 11:59
  you've
• 11:59
  started
• 12:00
  it.
• 12:00
  And
• 12:00
  if
• 12:01
  it's
• 12:01
  sort
• 12:01
  of
• 12:01
  a
• 12:01
  shoulder
• 12:02
  shrug
• 12:02
  or,
• 12:02
  hey,
• 12:02
  I
• 12:03
  just
• 12:03
  Feel
• 12:03
  like
• 12:03
  I'm
• 12:03
  even
• 12:03
  more
• 12:03
  edgy,
• 12:04
  I'm
• 12:04
  even
• 12:04
  more
• 12:04
  anxious,
• 12:05
  I'm
• 12:05
  even
• 12:05
  more
• 12:05
  agitated.
• 12:06
  Now
• 12:06
  you've
• 12:07
  put
• 12:07
  this
• 12:07
  through
• 12:07
  a,
• 12:08
  a
• 12:08
  filter.
• 12:09
  And
• 12:09
  your
• 12:09
  patient
• 12:10
  also
• 12:10
  has
• 12:10
  a
• 12:11
  family
• 12:11
  history
• 12:11
  of,
• 12:12
  in
• 12:12
  this
• 12:12
  case,
• 12:12
  Polly
• 12:13
  has
• 12:13
  an
• 12:13
  aunt
• 12:13
  with
• 12:13
  bipolarity.
• 12:14
  So
• 12:14
  that's
• 12:15
  another
• 12:15
  red
• 12:15
  flag.
• 12:16
  If
• 12:16
  they
• 12:16
  have
• 12:16
  early
• 12:17
  depressive
• 12:17
  episodes,
• 12:18
  if
• 12:19
  they've
• 12:19
  had
• 12:19
  several
• 12:20
  depressive
• 12:21
  episodes
• 12:22
  in
• 12:22
  the
• 12:22
  past,
• 12:22
  maybe
• 12:23
  with
• 12:23
  suicidal
• 12:24
  ideation
• 12:24
  and
• 12:24
  substance
• 12:25
  use,
• 12:26
  they,
• 12:26
  they
• 12:27
  haven't
• 12:27
  responded
• 12:28
  maybe
• 12:28
  to
• 12:28
  previous
• 12:28
  antidepressants,
• 12:29
  they've
• 12:29
  been
• 12:30
  really
• 12:30
  activated
• 12:31
  or
• 12:31
  agitated
• 12:32
  on
• 12:32
  multiple
• 12:32
  antidepressants.
• 12:33
  I
• 12:33
  know
• 12:34
  one
• 12:34
  big
• 12:34
  red
• 12:35
  flag
• 12:35
  for
• 12:35
  me
• 12:35
  that
• 12:35
  we're
• 12:36
  dealing
• 12:36
  with
• 12:36
  mixed
• 12:36
  features
• 12:37
  is
• 12:37
  just
• 12:37
  a
• 12:38
  patient
• 12:38
  who
• 12:38
  has
• 12:38
  tried
• 12:38
  tons
• 12:39
  of
• 12:39
  antidepressants
• 12:40
  at
• 12:40
  therapeutic
• 12:40
  doses,
• 12:41
  SNRIs,
• 12:42
  SSRIs,
• 12:42
  and
• 12:43
  they
• 12:43
  just
• 12:43
  aren't
• 12:44
  getting
• 12:44
  better.
• 12:45
  Now,
• 12:45
  of
• 12:46
  course,
• 12:46
  you
• 12:46
  have
• 12:46
  to
• 12:46
  make
• 12:46
  sure
• 12:46
  your
• 12:47
  diagnosis
• 12:48
  is
• 12:48
  also
• 12:48
  accurate.
• 12:49
  That's
• 12:49
  again
• 12:49
  why
• 12:49
  we
• 12:49
  talk
• 12:50
  about
• 12:50
  borderline
• 12:50
  and
• 12:51
  ruling
• 12:51
  that
• 12:51
  out.
• 12:52
  But
• 12:53
  big
• 12:53
  red
• 12:53
  flag
• 12:54
  that
• 12:54
  I'm
• 12:54
  dealing
• 12:54
  with
• 12:54
  mixed
• 12:55
  features
• 12:55
  or
• 12:56
  a
• 12:56
  patient
• 12:56
  who
• 12:56
  could
• 12:57
  very
• 12:57
  well
• 12:57
  become
• 12:58
  bipolar
• 12:59
  eventually
• 12:59
  in
• 13:00
  is
• 13:00
  if
• 13:00
  they
• 13:01
  have
• 13:01
  had
• 13:02
  failed
• 13:02
  many
• 13:02
  antidepressants.
• 13:03
  Cause
• 13:04
  it's
• 13:04
  like,
• 13:04
  wait
• 13:04
  a
• 13:04
  minute,
• 13:04
  why
• 13:05
  is
• 13:05
  this
• 13:06
  so
• 13:07
  hard
• 13:07
  to
• 13:07
  treat?
• 13:07
  Of
• 13:08
  course
• 13:08
  you
• 13:08
  could
• 13:08
  have
• 13:08
  treatment
• 13:09
  resistant
• 13:09
  depression,
• 13:10
  that's
• 13:10
  possible.
• 13:11
  But
• 13:11
  you
• 13:12
  also
• 13:12
  could
• 13:12
  ask
• 13:13
  yourself
• 13:13
  if
• 13:13
  the
• 13:14
  patient
• 13:14
  is
• 13:14
  in
• 13:15
  this
• 13:15
  bipolar
• 13:16
  spectrum
• 13:17
  group
• 13:18
  and
• 13:18
  you
• 13:18
  know,
• 13:19
  sure
• 13:19
  enough,
• 13:19
  with
• 13:20
  MDD,
• 13:21
  somewhere
• 13:22
  between
• 13:22
  5
• 13:22
  and
• 13:22
  9%
• 13:23
  of
• 13:23
  them
• 13:23
  do
• 13:24
  convert
• 13:24
  to
• 13:24
  bipolar
• 13:25
  within
• 13:25
  10
• 13:25
  to
• 13:25
  15
• 13:26
  years.
• 13:26
  That's
• 13:27
  what
• 13:27
  the
• 13:27
  evidence
• 13:27
  seems
• 13:28
  to
• 13:28
  show
• 13:28
  5
• 13:29
  to
• 13:29
  9%.
• 13:30
  It's
• 13:30
  even
• 13:30
  higher
• 13:31
  in
• 13:31
  adolescents,
• 13:32
  closer
• 13:33
  to
• 13:33
  maybe
• 13:33
  14%
• 13:34
  over
• 13:34
  11
• 13:35
  years.
• 13:35
  That's
• 13:35
  pretty,
• 13:36
  pretty
• 13:36
  intense.
• 13:37
  Right?
• 13:37
  And
• 13:37
  in
• 13:37
  these
• 13:38
  high
• 13:38
  risk
• 13:38
  subgroups,
• 13:39
  right,
• 13:39
  if
• 13:39
  patients
• 13:40
  have
• 13:40
  depression
• 13:41
  to
• 13:41
  where
• 13:41
  they're
• 13:41
  in
• 13:41
  pa,
• 13:42
  they're,
• 13:42
  they're
• 13:42
  hospitalized
• 13:43
  for
• 13:43
  it,
• 13:43
  inpatient
• 13:44
  psychotic
• 13:45
  features,
• 13:45
  if
• 13:45
  they
• 13:46
  have
• 13:46
  a
• 13:46
  parent
• 13:46
  with
• 13:46
  borderline
• 13:47
  or,
• 13:47
  excuse
• 13:48
  me,
• 13:48
  with
• 13:48
  bipolarity,
• 13:49
  maybe
• 13:49
  up
• 13:49
  to
• 13:50
  20
• 13:50
  to
• 13:50
  30%
• 13:51
  of
• 13:51
  them
• 13:51
  will
• 13:52
  become
• 13:52
  bipolar
• 13:53
  within
• 13:53
  three
• 13:53
  years.
• 13:54
  So
• 13:54
  this
• 13:54
  is
• 13:54
  a
• 13:55
  frustrating
• 13:55
  place
• 13:56
  to
• 13:56
  be.
• 13:56
  Again,
• 13:56
  a
• 13:56
  fascinating
• 13:57
  place
• 13:57
  to
• 13:58
  be
• 13:58
  because
• 13:59
  it
• 13:59
  is
• 13:59
  not
• 14:00
  really
• 14:00
  red,
• 14:01
  it's
• 14:01
  not
• 14:01
  really
• 14:01
  blue.
• 14:02
  It's
• 14:03
  this
• 14:03
  kind
• 14:03
  of
• 14:03
  weird
• 14:04
  hue
• 14:04
  in
• 14:04
  the
• 14:04
  middle
• 14:05
  and
• 14:05
  you
• 14:05
  can't
• 14:05
  tell
• 14:06
  whether
• 14:06
  it's
• 14:06
  going
• 14:06
  to,
• 14:06
  going
• 14:07
  to
• 14:07
  go
• 14:07
  back
• 14:07
  to
• 14:07
  red
• 14:08
  or
• 14:08
  be
• 14:08
  blue
• 14:09
  or
• 14:09
  remain
• 14:09
  purple.
• 14:10
  And
• 14:10
  it's
• 14:10
  like,
• 14:10
  what
• 14:11
  do
• 14:11
  we
• 14:11
  do
• 14:11
  with
• 14:11
  this?
• 14:11
  Right?
• 14:12
  There
• 14:12
  are
• 14:12
  medications
• 14:13
  like
• 14:13
  Latuda,
• 14:14
  Latuda
• 14:15
  in
• 14:15
  particular
• 14:16
  that
• 14:16
  will
• 14:17
  help
• 14:17
  you
• 14:18
  stabilize
• 14:18
  mood
• 14:19
  and
• 14:19
  not
• 14:20
  potentiate
• 14:21
  a
• 14:21
  manic
• 14:21
  switch.
• 14:22
  And
• 14:22
  Latuda
• 14:22
  does
• 14:22
  that
• 14:23
  through
• 14:23
  five
• 14:23
  different
• 14:24
  receptor
• 14:25
  effects,
• 14:26
  which
• 14:26
  is
• 14:27
  why
• 14:27
  it's
• 14:27
  kind
• 14:27
  of
• 14:28
  interesting
• 14:28
  and
• 14:29
  pretty
• 14:29
  incredible.
• 14:30
  Okay,
• 14:30
  you
• 14:31
  do
• 14:31
  have
• 14:31
  the,
• 14:31
  dopamine
• 14:32
  blockade,
• 14:32
  that's
• 14:33
  a
• 14:33
  big
• 14:33
  target
• 14:33
  for
• 14:34
  Latuda.
• 14:34
  It's
• 14:35
  the
• 14:35
  brake
• 14:35
  pedal.
• 14:35
  It's
• 14:36
  going
• 14:36
  to
• 14:36
  calm
• 14:36
  the
• 14:36
  dopaminergic
• 14:37
  overdrive
• 14:38
  behind
• 14:38
  the
• 14:38
  racing
• 14:39
  thoughts,
• 14:39
  the
• 14:39
  irritability,
• 14:40
  the
• 14:40
  agitation.
• 14:41
  This
• 14:41
  is
• 14:41
  kind
• 14:41
  of
• 14:41
  the
• 14:42
  anti
• 14:42
  manic
• 14:42
  part.
• 14:43
  You're
• 14:43
  kind
• 14:43
  of
• 14:43
  gently
• 14:44
  tapping
• 14:44
  the
• 14:44
  brakes.
• 14:45
  You're
• 14:45
  not
• 14:46
  slamming
• 14:46
  the
• 14:46
  brakes
• 14:47
  like
• 14:47
  Haldol,
• 14:48
  right.
• 14:48
  Those
• 14:49
  older
• 14:49
  first
• 14:50
  generation
• 14:50
  antipsychotics
• 14:51
  that
• 14:51
  cause
• 14:51
  stiffness
• 14:52
  and
• 14:52
  emotional
• 14:52
  flatness.
• 14:53
  You're
• 14:53
  gently
• 14:54
  tapping
• 14:54
  the
• 14:55
  brakes
• 14:55
  with
• 14:55
  latuda,
• 14:56
  with
• 14:56
  that
• 14:56
  D2
• 14:56
  blockade.
• 14:57
  Okay.
• 14:58
  But
• 14:58
  you
• 14:58
  also
• 14:58
  have
• 14:58
  the
• 14:59
  5ht2a
• 15:00
  blocker,
• 15:01
  right.
• 15:01
  And
• 15:01
  this
• 15:02
  is
• 15:02
  really
• 15:02
  clever.
• 15:03
  This
• 15:03
  is
• 15:03
  what
• 15:03
  Latuda
• 15:04
  does
• 15:04
  also,
• 15:04
  because
• 15:05
  that
• 15:05
  actually
• 15:05
  increases
• 15:06
  the
• 15:07
  dopamine
• 15:07
  and
• 15:07
  norepinephrine
• 15:08
  in
• 15:09
  the
• 15:10
  prefrontal
• 15:10
  cortex.
• 15:12
  That's
• 15:12
  really
• 15:12
  important.
• 15:13
  Okay.
• 15:14
  Because
• 15:15
  now
• 15:15
  not
• 15:15
  only
• 15:15
  are
• 15:15
  you
• 15:16
  calming
• 15:16
  the
• 15:16
  limbic
• 15:17
  or
• 15:17
  emotional
• 15:18
  part
• 15:18
  of
• 15:18
  the
• 15:18
  brain
• 15:19
  with
• 15:19
  the
• 15:20
  D2
• 15:20
  blockade,
• 15:21
  but
• 15:21
  you're
• 15:22
  also
• 15:22
  boosting
• 15:23
  the
• 15:23
  thinking
• 15:24
  and
• 15:24
  mood
• 15:25
  part
• 15:25
  of
• 15:25
  the
• 15:25
  brain,
• 15:25
  the
• 15:26
  executive
• 15:26
  functioning,
• 15:27
  via
• 15:27
  dopamine.
• 15:28
  So
• 15:28
  now
• 15:29
  your
• 15:29
  patient
• 15:29
  is
• 15:29
  less
• 15:29
  agitated,
• 15:30
  they're
• 15:30
  in
• 15:30
  a
• 15:30
  better
• 15:31
  mood,
• 15:31
  they're
• 15:31
  a
• 15:31
  little
• 15:31
  bit
• 15:32
  more
• 15:32
  clear.
• 15:33
  Right?
• 15:33
  So
• 15:33
  it's
• 15:34
  a
• 15:34
  very
• 15:34
  elegant
• 15:35
  pharmacology
• 15:36
  here.
• 15:36
  You're
• 15:36
  tapping
• 15:37
  the
• 15:37
  brakes
• 15:37
  a
• 15:37
  little
• 15:38
  bit
• 15:38
  and
• 15:38
  you're
• 15:38
  allowing
• 15:39
  the
• 15:39
  patient's
• 15:39
  mood
• 15:40
  to
• 15:40
  be
• 15:40
  improved,
• 15:41
  but
• 15:42
  not
• 15:42
  in
• 15:42
  a
• 15:42
  way
• 15:43
  that
• 15:43
  is
• 15:43
  this
• 15:44
  surge
• 15:44
  of
• 15:45
  serotonin
• 15:46
  that
• 15:46
  can
• 15:46
  in
• 15:47
  fact
• 15:47
  precipitate
• 15:48
  a
• 15:48
  manic
• 15:49
  switch,
• 15:49
  which
• 15:49
  is
• 15:49
  not
• 15:50
  good.
• 15:50
  Now,
• 15:50
  what
• 15:50
  I
• 15:50
  love
• 15:51
  about
• 15:51
  Latuda
• 15:52
  is
• 15:52
  its
• 15:52
  5ht7
• 15:54
  blockade.
• 15:55
  That's
• 15:55
  Latuda's
• 15:56
  secret
• 15:57
  weapon.
• 15:57
  And
• 15:57
  it
• 15:58
  is
• 15:58
  specifically
• 15:58
  implicated,
• 15:59
  they
• 15:59
  say,
• 16:00
  in
• 16:00
  circadian
• 16:01
  rhythm
• 16:01
  regulation.
• 16:02
  And
• 16:03
  I
• 16:03
  love
• 16:03
  that
• 16:03
  because
• 16:04
  more
• 16:04
  and
• 16:04
  more
• 16:04
  evidence
• 16:05
  is
• 16:05
  being
• 16:05
  published
• 16:06
  every
• 16:06
  day
• 16:06
  that
• 16:07
  a
• 16:07
  lot
• 16:07
  of
• 16:07
  mental
• 16:08
  health
• 16:08
  disorders,
• 16:09
  particularly
• 16:09
  bipolarity,
• 16:10
  has
• 16:11
  some
• 16:11
  sort
• 16:11
  of
• 16:11
  circadian
• 16:12
  rhythm
• 16:13
  misalignment.
• 16:14
  And
• 16:14
  so
• 16:14
  we
• 16:15
  all
• 16:15
  know
• 16:15
  that
• 16:15
  if
• 16:16
  there's
• 16:16
  one
• 16:16
  thing
• 16:16
  you
• 16:16
  can
• 16:17
  do
• 16:17
  to
• 16:17
  help
• 16:17
  someone
• 16:17
  who
• 16:17
  has
• 16:18
  bipolar
• 16:18
  2
• 16:19
  or
• 16:19
  bipolar
• 16:19
  1
• 16:19
  and
• 16:19
  they're
• 16:20
  agitated
• 16:20
  and
• 16:20
  they
• 16:20
  don't
• 16:21
  feel
• 16:21
  like
• 16:21
  they
• 16:21
  need
• 16:21
  to
• 16:21
  sleep,
• 16:22
  it's
• 16:22
  to
• 16:22
  restore
• 16:23
  their
• 16:23
  circadian
• 16:24
  rhythm.
• 16:24
  So
• 16:24
  I
• 16:25
  will
• 16:25
  welcome
• 16:26
  any
• 16:26
  medication
• 16:27
  that
• 16:27
  helps
• 16:27
  restore
• 16:28
  circadian
• 16:29
  rhythm
• 16:30
  and
• 16:30
  one
• 16:30
  that
• 16:30
  helps
• 16:30
  with
• 16:31
  mood
• 16:31
  and
• 16:31
  one
• 16:31
  that
• 16:32
  can
• 16:32
  control
• 16:33
  the.
• 16:34
  The
• 16:34
  agitated
• 16:35
  manic
• 16:36
  features
• 16:36
  that
• 16:37
  I'm
• 16:37
  seeing
• 16:37
  in
• 16:37
  an
• 16:37
  MDD
• 16:38
  with
• 16:38
  mixed
• 16:39
  features.
• 16:40
  So
• 16:40
  I
• 16:40
  really,
• 16:41
  absolutely
• 16:42
  love
• 16:43
  that
• 16:43
  the
• 16:44
  5ht7
• 16:45
  blockade
• 16:46
  has
• 16:46
  direct
• 16:47
  antidepressant
• 16:48
  effects
• 16:48
  that
• 16:48
  have
• 16:49
  actually
• 16:49
  been
• 16:49
  proven
• 16:49
  in
• 16:50
  animal
• 16:50
  models.
• 16:51
  And
• 16:51
  it'll
• 16:52
  even
• 16:52
  show
• 16:52
  in
• 16:52
  these
• 16:52
  animal
• 16:53
  models
• 16:53
  that
• 16:53
  Latuda's
• 16:54
  antidepressant
• 16:55
  effect
• 16:55
  is
• 16:55
  completely
• 16:56
  gone
• 16:57
  in
• 16:57
  mice
• 16:58
  who
• 16:58
  lack
• 16:58
  that
• 16:59
  5ht7
• 17:00
  receptor.
• 17:00
  So
• 17:00
  there's
• 17:01
  a
• 17:01
  lot
• 17:01
  going
• 17:01
  on,
• 17:01
  we
• 17:02
  suspect
• 17:02
  with
• 17:03
  that
• 17:03
  receptor
• 17:04
  regulating
• 17:05
  the
• 17:05
  sleep
• 17:05
  wake
• 17:05
  cycle.
• 17:06
  Really
• 17:06
  key
• 17:07
  for
• 17:07
  Poly
• 17:07
  in
• 17:08
  particular,
• 17:08
  who
• 17:08
  has
• 17:08
  a
• 17:08
  decreased
• 17:09
  need
• 17:09
  for
• 17:09
  sleep.
• 17:10
  They
• 17:10
  suspect
• 17:11
  that
• 17:11
  the
• 17:11
  5ht7
• 17:12
  blockade
• 17:13
  eventually
• 17:14
  boosts
• 17:14
  serotonin
• 17:15
  transmission
• 17:16
  in
• 17:16
  the
• 17:16
  prefrontal
• 17:16
  cortex.
• 17:17
  So
• 17:17
  now
• 17:17
  you
• 17:18
  have
• 17:18
  more
• 17:18
  serotonin
• 17:19
  transmission
• 17:19
  in
• 17:20
  the
• 17:20
  pfc.
• 17:20
  That's
• 17:21
  kind
• 17:21
  of
• 17:21
  a
• 17:21
  gentle,
• 17:22
  more
• 17:22
  regulated
• 17:23
  serotonin
• 17:23
  boost
• 17:24
  than
• 17:24
  the
• 17:24
  brute
• 17:25
  force
• 17:25
  flooding
• 17:26
  that
• 17:26
  you
• 17:26
  get
• 17:26
  from
• 17:27
  Zoloft.
• 17:27
  But
• 17:28
  again,
• 17:28
  you
• 17:28
  also
• 17:29
  have
• 17:29
  that
• 17:30
  really
• 17:31
  nice
• 17:32
  dopamine
• 17:33
  prefrontal
• 17:34
  cortex
• 17:34
  enhancement
• 17:35
  from
• 17:35
  the
• 17:36
  5ht
• 17:36
  2a
• 17:37
  blockade.
• 17:38
  So
• 17:38
  it's
• 17:38
  really
• 17:39
  elegant.
• 17:39
  It's
• 17:39
  kind
• 17:39
  of
• 17:40
  doing
• 17:40
  things
• 17:40
  off
• 17:40
  of
• 17:41
  many
• 17:41
  different
• 17:41
  receptors
• 17:42
  in
• 17:42
  a
• 17:42
  fine
• 17:42
  tuned
• 17:43
  way.
• 17:43
  Latuda
• 17:44
  even
• 17:44
  has
• 17:44
  some
• 17:44
  5ht1
• 17:45
  partial
• 17:46
  agonism,
• 17:47
  which
• 17:47
  as
• 17:48
  you
• 17:48
  guys
• 17:48
  probably
• 17:49
  know,
• 17:50
  sort
• 17:50
  of
• 17:50
  regulates
• 17:51
  the
• 17:51
  amount
• 17:51
  of
• 17:51
  serotonin
• 17:52
  signaling.
• 17:52
  It
• 17:52
  normalizes
• 17:53
  it
• 17:53
  a
• 17:53
  little
• 17:53
  bit.
• 17:54
  It's
• 17:54
  a
• 17:54
  little
• 17:55
  bit
• 17:55
  of
• 17:55
  an
• 17:55
  anxiolytic
• 17:56
  effect.
• 17:56
  There's
• 17:57
  some
• 17:57
  alpha
• 17:58
  C
• 17:58
  blockade
• 17:58
  with
• 17:59
  Latuda.
• 17:59
  So
• 17:59
  you're
• 18:00
  enhancing
• 18:00
  norepinephrine
• 18:01
  in
• 18:01
  the
• 18:01
  prefrontal
• 18:02
  cortex,
• 18:03
  which
• 18:03
  is
• 18:03
  really
• 18:03
  cool
• 18:04
  because
• 18:04
  focus
• 18:04
  and
• 18:04
  concentration
• 18:05
  and
• 18:05
  brain
• 18:06
  fog
• 18:06
  are
• 18:06
  challenged
• 18:06
  a
• 18:07
  little
• 18:07
  bit.
• 18:07
  Again,
• 18:08
  this
• 18:08
  is
• 18:08
  really
• 18:08
  key
• 18:09
  because
• 18:09
  you
• 18:09
  don't
• 18:09
  want
• 18:10
  a
• 18:11
  prescription
• 18:11
  that's
• 18:11
  just
• 18:12
  going
• 18:12
  to
• 18:12
  take
• 18:12
  away
• 18:12
  the
• 18:12
  mixed
• 18:13
  features.
• 18:13
  You've
• 18:13
  got
• 18:14
  to
• 18:14
  also
• 18:14
  treat
• 18:14
  the
• 18:14
  depression.
• 18:15
  Right?
• 18:15
  The
• 18:16
  mixed
• 18:16
  features
• 18:16
  are
• 18:16
  what
• 18:17
  we're
• 18:17
  biased
• 18:17
  to
• 18:18
  try
• 18:18
  and
• 18:18
  extinguish,
• 18:18
  right?
• 18:19
  I
• 18:19
  know
• 18:19
  with
• 18:19
  me
• 18:19
  as
• 18:19
  a
• 18:20
  prescriber,
• 18:20
  I
• 18:20
  see
• 18:21
  mixed
• 18:21
  features
• 18:21
  and
• 18:21
  I'm
• 18:21
  like,
• 18:22
  oh,
• 18:22
  we've
• 18:22
  got
• 18:22
  to
• 18:22
  get
• 18:22
  rid
• 18:22
  of
• 18:23
  that
• 18:23
  fast.
• 18:24
  Right?
• 18:24
  That's
• 18:24
  the
• 18:24
  big
• 18:24
  scary
• 18:25
  stuff.
• 18:25
  You
• 18:25
  don't
• 18:25
  want
• 18:26
  to
• 18:26
  switch
• 18:26
  into
• 18:26
  a
• 18:26
  mania.
• 18:27
  And
• 18:27
  now
• 18:28
  we,
• 18:28
  we
• 18:28
  imagine
• 18:29
  some
• 18:29
  guy
• 18:30
  standing
• 18:30
  on
• 18:30
  his
• 18:30
  car
• 18:30
  with
• 18:31
  a
• 18:31
  baseball
• 18:31
  bat,
• 18:31
  yelling
• 18:32
  at
• 18:32
  cops,
• 18:33
  jumping
• 18:33
  up
• 18:33
  and
• 18:33
  down,
• 18:34
  trying
• 18:34
  to
• 18:34
  sell
• 18:34
  his
• 18:34
  house
• 18:35
  for
• 18:35
  a
• 18:35
  dollar.
• 18:35
  Right?
• 18:36
  All
• 18:36
  these
• 18:37
  manic
• 18:37
  symptoms
• 18:38
  are
• 18:38
  very
• 18:38
  flashy
• 18:39
  and
• 18:39
  scary.
• 18:39
  But
• 18:40
  we
• 18:40
  can't
• 18:40
  underestimate
• 18:41
  the
• 18:41
  depression,
• 18:42
  which
• 18:42
  is
• 18:42
  absolutely
• 18:43
  a
• 18:43
  big
• 18:44
  problem
• 18:44
  for
• 18:44
  Poly
• 18:45
  also.
• 18:45
  So
• 18:45
  don't
• 18:46
  think
• 18:46
  Latuda
• 18:47
  is
• 18:47
  just
• 18:47
  there
• 18:47
  to
• 18:48
  stop
• 18:48
  the
• 18:48
  mania.
• 18:49
  It's
• 18:49
  also
• 18:50
  there
• 18:50
  to
• 18:50
  ensure
• 18:51
  there's
• 18:51
  a
• 18:51
  robust
• 18:52
  antidepressant
• 18:53
  response
• 18:54
  too.
• 18:54
  Okay.
• 18:55
  And
• 18:55
  it's
• 18:56
  not
• 18:56
  so
• 18:56
  big
• 18:56
  on
• 18:57
  hitting
• 18:58
  H1.
• 18:58
  It
• 18:58
  doesn't
• 18:58
  really
• 18:59
  blockade
• 18:59
  H1
• 19:00
  at
• 19:00
  all
• 19:01
  or
• 19:01
  M1.
• 19:02
  So
• 19:02
  the
• 19:02
  histaminergic
• 19:03
  muscarinic
• 19:04
  blockade
• 19:05
  is
• 19:05
  pretty
• 19:05
  absent.
• 19:05
  You
• 19:05
  don't
• 19:06
  get
• 19:06
  a
• 19:06
  lot
• 19:06
  of
• 19:06
  weight
• 19:06
  gain
• 19:06
  or
• 19:07
  sedation,
• 19:08
  one
• 19:08
  of
• 19:08
  the
• 19:08
  more
• 19:08
  metabolically
• 19:09
  friendly
• 19:09
  mood
• 19:10
  stabilizers.
• 19:11
  You
• 19:11
  don't
• 19:11
  get
• 19:11
  a
• 19:11
  lot
• 19:11
  of
• 19:11
  the
• 19:11
  dry
• 19:12
  mouth,
• 19:12
  constipation,
• 19:13
  cognitive
• 19:13
  dulling.
• 19:14
  It's
• 19:14
  a
• 19:14
  very
• 19:15
  big
• 19:15
  win
• 19:16
  And
• 19:16
  I
• 19:16
  like
• 19:16
  Latuda.
• 19:17
  I
• 19:17
  find
• 19:17
  it
• 19:17
  can
• 19:17
  be
• 19:17
  hit
• 19:18
  or
• 19:18
  miss
• 19:18
  depending
• 19:19
  on
• 19:19
  how
• 19:19
  you
• 19:19
  prescribe
• 19:20
  it,
• 19:20
  who
• 19:20
  you
• 19:20
  prescribe
• 19:21
  it
• 19:21
  to.
• 19:21
  Some
• 19:21
  people
• 19:21
  can't
• 19:22
  tolerate
• 19:22
  it.
• 19:23
  It's
• 19:23
  not
• 19:23
  always
• 19:23
  clear
• 19:23
  why
• 19:24
  they
• 19:24
  can't.
• 19:24
  Just
• 19:24
  some
• 19:25
  people,
• 19:25
  some
• 19:25
  meds
• 19:25
  don't
• 19:26
  react
• 19:26
  well
• 19:26
  with
• 19:26
  them
• 19:26
  in
• 19:27
  practice
• 19:27
  and
• 19:28
  some
• 19:29
  people
• 19:29
  swear
• 19:29
  by
• 19:30
  it.
• 19:30
  It's
• 19:30
  relatively
• 19:31
  low
• 19:31
  drama
• 19:32
  that
• 19:32
  of
• 19:32
  course
• 19:33
  you
• 19:33
  have
• 19:33
  to
• 19:33
  take
• 19:33
  it
• 19:33
  with
• 19:34
  food,
• 19:34
  but
• 19:34
  it
• 19:35
  has
• 19:35
  a
• 19:35
  much
• 19:35
  cleaner
• 19:36
  metabolic
• 19:36
  profile
• 19:36
  than
• 19:37
  something
• 19:37
  like
• 19:37
  Zyprexa
• 19:38
  or
• 19:38
  Seroquel.
• 19:40
  So
• 19:40
  that
• 19:40
  really
• 19:40
  helps.
• 19:41
  You
• 19:41
  know,
• 19:42
  I
• 19:42
  would
• 19:42
  still
• 19:42
  check
• 19:43
  lipids
• 19:43
  and
• 19:44
  blood
• 19:44
  sugars
• 19:45
  and
• 19:45
  things
• 19:45
  of
• 19:45
  that
• 19:45
  nature,
• 19:46
  but
• 19:46
  again,
• 19:46
  it's
• 19:47
  less
• 19:47
  dramatic
• 19:48
  than
• 19:48
  that.
• 19:48
  And
• 19:49
  you
• 19:49
  know,
• 19:49
  unlike
• 19:50
  Zoloft,
• 19:50
  which
• 19:50
  is
• 19:51
  sort
• 19:51
  of
• 19:51
  a
• 19:51
  fire
• 19:51
  hose
• 19:52
  aimed
• 19:52
  at
• 19:52
  one
• 19:53
  target,
• 19:53
  serotonin
• 19:54
  reuptake.
• 19:54
  Latuda
• 19:55
  is
• 19:55
  more
• 19:55
  of
• 19:55
  like
• 19:56
  a
• 19:56
  smart
• 19:56
  sprinkler
• 19:57
  system.
• 19:57
  Okay.
• 19:58
  It's
• 19:58
  got
• 19:58
  like
• 19:58
  five
• 19:59
  receptors
• 19:59
  or
• 19:59
  five
• 20:00
  nozzles
• 20:00
  that
• 20:00
  each
• 20:01
  aim
• 20:01
  at
• 20:01
  a
• 20:01
  different
• 20:01
  part
• 20:02
  of
• 20:02
  the
• 20:02
  brain.
• 20:03
  You
• 20:03
  know,
• 20:03
  it's
• 20:03
  calming
• 20:03
  dopamine
• 20:04
  in
• 20:04
  one
• 20:04
  corner
• 20:05
  where
• 20:05
  it's
• 20:05
  too
• 20:05
  high,
• 20:05
  it's
• 20:06
  boosting
• 20:06
  serotonin
• 20:07
  where
• 20:07
  it's
• 20:08
  too
• 20:08
  low.
• 20:09
  And
• 20:09
  it
• 20:09
  even
• 20:09
  stabilizes
• 20:10
  glutamate
• 20:11
  in
• 20:11
  some
• 20:11
  areas.
• 20:12
  So
• 20:12
  it
• 20:12
  can
• 20:12
  be
• 20:12
  very,
• 20:13
  very
• 20:13
  helpful.
• 20:14
  And
• 20:14
  we
• 20:14
  have
• 20:14
  one
• 20:14
  lone
• 20:15
  RCT
• 20:16
  that
• 20:16
  was
• 20:16
  specifically
• 20:17
  looking
• 20:18
  at
• 20:18
  MDD
• 20:19
  with
• 20:19
  mixed
• 20:19
  features.
• 20:19
  I'm
• 20:20
  grateful
• 20:20
  for
• 20:20
  that
• 20:20
  RCT
• 20:21
  because
• 20:21
  it's
• 20:22
  just
• 20:22
  such
• 20:22
  a
• 20:22
  prevalent
• 20:23
  issue.
• 20:23
  I
• 20:24
  feel
• 20:24
  like
• 20:24
  we
• 20:24
  need
• 20:24
  so
• 20:25
  much
• 20:25
  more
• 20:25
  evidence
• 20:25
  about
• 20:26
  this.
• 20:26
  What
• 20:26
  works,
• 20:26
  what
• 20:27
  doesn't
• 20:27
  work.
• 20:28
  I
• 20:28
  know
• 20:28
  some
• 20:28
  people
• 20:28
  when
• 20:29
  they
• 20:29
  see
• 20:30
  depression
• 20:30
  and
• 20:30
  they
• 20:31
  need
• 20:31
  to
• 20:31
  treat
• 20:31
  depression,
• 20:31
  but
• 20:32
  there's
• 20:32
  a
• 20:32
  little
• 20:32
  agitation
• 20:33
  and
• 20:34
  mixed
• 20:34
  features
• 20:34
  in
• 20:34
  there.
• 20:35
  Some
• 20:35
  people
• 20:35
  will
• 20:35
  reach
• 20:36
  for
• 20:36
  Wellbutrin
• 20:37
  because
• 20:37
  it's
• 20:37
  less
• 20:38
  likely
• 20:38
  to
• 20:39
  precipitate
• 20:39
  mania.
• 20:40
  Eh,
• 20:40
  that's
• 20:41
  not
• 20:41
  a
• 20:41
  terrible
• 20:41
  idea.
• 20:42
  But
• 20:43
  I
• 20:43
  think
• 20:43
  it's
• 20:43
  sort
• 20:43
  of
• 20:43
  a
• 20:43
  half
• 20:44
  measure
• 20:44
  because
• 20:45
  you're
• 20:46
  kind
• 20:46
  of
• 20:46
  neglecting
• 20:47
  the
• 20:47
  mixed
• 20:47
  features
• 20:48
  part.
• 20:48
  You
• 20:49
  may
• 20:49
  be
• 20:49
  able
• 20:49
  to
• 20:49
  help
• 20:49
  a
• 20:50
  little
• 20:50
  bit
• 20:50
  with
• 20:50
  the
• 20:50
  underlying
• 20:51
  depression,
• 20:51
  but
• 20:52
  that
• 20:52
  agitated,
• 20:52
  impulsive,
• 20:54
  potentially
• 20:54
  self
• 20:55
  harmful
• 20:55
  piece
• 20:56
  is
• 20:56
  really
• 20:56
  not
• 20:57
  being
• 20:57
  addressed
• 20:57
  by
• 20:57
  just
• 20:58
  adding
• 20:58
  Wellbutrin.
• 20:58
  So
• 20:59
  I
• 20:59
  think
• 20:59
  it's
• 20:59
  an
• 20:59
  incomplete
• 21:00
  intervention.
• 21:01
  I
• 21:02
  definitely
• 21:02
  think
• 21:02
  Latuda
• 21:03
  is
• 21:03
  a
• 21:03
  little
• 21:03
  bit
• 21:04
  better
• 21:05
  in
• 21:05
  that
• 21:05
  regard.
• 21:06
  But
• 21:06
  you
• 21:06
  know,
• 21:07
  then
• 21:07
  we're
• 21:07
  kind
• 21:07
  of
• 21:07
  grasping
• 21:08
  at
• 21:08
  straws
• 21:08
  after
• 21:08
  that.
• 21:09
  Right?
• 21:09
  Because
• 21:09
  if
• 21:09
  a
• 21:09
  patient
• 21:10
  tells
• 21:10
  you,
• 21:10
  oh,
• 21:10
  well,
• 21:10
  I've
• 21:11
  already
• 21:11
  been
• 21:11
  on
• 21:11
  Latuda,
• 21:12
  so
• 21:12
  what
• 21:12
  do
• 21:12
  you
• 21:13
  have
• 21:13
  for
• 21:13
  me
• 21:13
  next?
• 21:14
  Right,
• 21:14
  that's
• 21:14
  where
• 21:14
  the
• 21:15
  real
• 21:15
  world
• 21:15
  prescribing
• 21:16
  can
• 21:16
  get
• 21:16
  really
• 21:17
  muddy
• 21:17
  and
• 21:18
  really
• 21:18
  scary
• 21:18
  quickly.
• 21:19
  And
• 21:19
  so
• 21:20
  that's
• 21:20
  why
• 21:20
  we
• 21:20
  need
• 21:20
  more
• 21:20
  evidence
• 21:21
  on
• 21:21
  this
• 21:21
  stuff.
• 21:22
  And
• 21:22
  we
• 21:22
  can't
• 21:22
  just
• 21:22
  Grasp
• 21:23
  at
• 21:23
  straws
• 21:23
  and
• 21:23
  guess
• 21:24
  and,
• 21:24
  and
• 21:25
  throw
• 21:25
  in
• 21:25
  a
• 21:25
  medication
• 21:26
  for
• 21:26
  good
• 21:26
  measure.
• 21:27
  I
• 21:27
  mean,
• 21:27
  could
• 21:27
  you,
• 21:28
  could
• 21:28
  you
• 21:28
  help
• 21:29
  Polly
• 21:29
  in
• 21:29
  other
• 21:29
  ways?
• 21:30
  Could
• 21:30
  you
• 21:30
  restore
• 21:30
  her
• 21:30
  circadian
• 21:31
  rhythm
• 21:31
  with,
• 21:32
  like,
• 21:32
  Ramelteon?
• 21:33
  Sure.
• 21:34
  You
• 21:34
  could
• 21:34
  do
• 21:34
  that
• 21:34
  incidentally
• 21:35
  and
• 21:35
  directly.
• 21:36
  There's
• 21:36
  evidence
• 21:36
  that
• 21:36
  it
• 21:37
  can
• 21:37
  restore
• 21:37
  her
• 21:37
  circadian
• 21:38
  rhythm,
• 21:38
  but
• 21:39
  there's
• 21:39
  not
• 21:39
  a
• 21:39
  lot
• 21:39
  of
• 21:39
  evidence
• 21:40
  that
• 21:40
  Ramelteon
• 21:41
  would
• 21:41
  be
• 21:42
  a,
• 21:42
  by
• 21:42
  any
• 21:43
  means,
• 21:43
  like
• 21:43
  a
• 21:43
  bipolar
• 21:44
  or
• 21:45
  an
• 21:45
  MDD
• 21:45
  mixed
• 21:46
  features
• 21:46
  medication.
• 21:47
  Right.
• 21:47
  But
• 21:47
  again,
• 21:47
  if
• 21:47
  you
• 21:48
  have
• 21:48
  to
• 21:48
  kind
• 21:48
  of
• 21:48
  crudely
• 21:49
  improvise
• 21:50
  and,
• 21:50
  and
• 21:51
  figure
• 21:51
  out
• 21:51
  like,
• 21:51
  well,
• 21:51
  how
• 21:52
  do
• 21:52
  I
• 21:52
  stabilize
• 21:52
  this
• 21:52
  patient
• 21:53
  without
• 21:53
  making
• 21:54
  things
• 21:54
  worse,
• 21:55
  then
• 21:55
  you
• 21:56
  really
• 21:56
  have
• 21:56
  to
• 21:56
  get
• 21:57
  a
• 21:57
  bit
• 21:57
  creative
• 21:58
  and
• 21:58
  you
• 21:58
  have
• 21:58
  to
• 21:59
  find
• 21:59
  agents
• 21:59
  that
• 21:59
  don't
• 22:00
  precipitate
• 22:00
  mania
• 22:01
  and
• 22:01
  they
• 22:02
  can
• 22:02
  stabilize
• 22:03
  things.
• 22:03
  Maybe
• 22:03
  have
• 22:04
  Polly
• 22:04
  go
• 22:04
  to
• 22:04
  psychotherapy
• 22:05
  more
• 22:05
  frequently
• 22:06
  and
• 22:07
  definitely
• 22:07
  do
• 22:07
  a
• 22:07
  full
• 22:07
  inventory
• 22:08
  on
• 22:08
  substances,
• 22:09
  if
• 22:09
  there's
• 22:09
  even
• 22:10
  any
• 22:10
  kind
• 22:10
  of
• 22:11
  caffeine
• 22:11
  use
• 22:12
  that's
• 22:12
  interfering
• 22:13
  with
• 22:13
  sleep
• 22:13
  architecture,
• 22:14
  you
• 22:15
  know,
• 22:15
  sleep
• 22:15
  hygiene.
• 22:16
  You've.
• 22:17
  You've
• 22:17
  got
• 22:17
  to
• 22:17
  kind
• 22:17
  of
• 22:18
  pull
• 22:18
  out
• 22:18
  every
• 22:18
  stop
• 22:18
  you
• 22:19
  can
• 22:19
  to
• 22:20
  help
• 22:20
  her
• 22:20
  as
• 22:21
  much
• 22:21
  as
• 22:21
  you
• 22:21
  can.
• 22:22
  If
• 22:22
  you're
• 22:22
  not
• 22:22
  sure
• 22:23
  where
• 22:23
  else
• 22:23
  you
• 22:23
  can
• 22:23
  go
• 22:24
  from
• 22:24
  a
• 22:25
  medication
• 22:25
  standpoint.
• 22:26
  Again,
• 22:26
  this
• 22:26
  is
• 22:27
  pretty
• 22:27
  common.
• 22:27
  Right?
• 22:27
  One
• 22:28
  in
• 22:28
  six
• 22:28
  patients
• 22:28
  with
• 22:28
  MDD
• 22:29
  has
• 22:30
  mixed
• 22:30
  features.
• 22:30
  That's
• 22:31
  what
• 22:31
  the
• 22:31
  evidence
• 22:31
  says.
• 22:32
  They're
• 22:33
  hiding
• 22:33
  in
• 22:33
  plain
• 22:33
  sight
• 22:34
  in
• 22:34
  every
• 22:34
  outpatient
• 22:35
  practice.
• 22:35
  Right.
• 22:35
  They
• 22:36
  tend
• 22:36
  to
• 22:36
  be
• 22:36
  more
• 22:36
  suicidal,
• 22:37
  more
• 22:37
  treatment
• 22:37
  resistant,
• 22:38
  more
• 22:39
  functionally
• 22:39
  impaired
• 22:40
  than
• 22:40
  folks
• 22:40
  who
• 22:40
  just
• 22:40
  have
• 22:40
  unipolar
• 22:41
  depression.
• 22:42
  Okay.
• 22:43
  And
• 22:43
  the
• 22:44
  scary
• 22:44
  thing
• 22:44
  is
• 22:45
  most
• 22:45
  of
• 22:45
  these
• 22:45
  folks
• 22:45
  are
• 22:46
  actually
• 22:46
  being
• 22:46
  treated
• 22:47
  out
• 22:47
  there
• 22:47
  with
• 22:47
  SSRI
• 22:48
  monotherapy,
• 22:49
  and
• 22:49
  the
• 22:49
  guidelines
• 22:50
  do
• 22:50
  not
• 22:50
  recommend
• 22:51
  that.
• 22:51
  Right.
• 22:51
  So
• 22:52
  we
• 22:52
  have
• 22:52
  to
• 22:52
  do
• 22:52
  something
• 22:53
  about
• 22:53
  that.
• 22:53
  And
• 22:54
  so
• 22:54
  I
• 22:54
  want
• 22:54
  you
• 22:54
  to
• 22:54
  think
• 22:55
  latuda.
• 22:56
  When
• 22:56
  you
• 22:56
  think
• 22:56
  about
• 22:56
  that,
• 22:57
  I
• 22:57
  want
• 22:57
  you
• 22:57
  to
• 22:57
  think
• 22:57
  of
• 22:58
  the
• 22:58
  5ht7
• 23:00
  circadian
• 23:02
  realignment
• 23:03
  and
• 23:03
  how
• 23:04
  that
• 23:04
  helps
• 23:04
  people
• 23:04
  with
• 23:05
  mood
• 23:05
  and
• 23:05
  cognition
• 23:06
  and
• 23:06
  restoring
• 23:07
  their
• 23:07
  circadian
• 23:09
  alignment
• 23:09
  and
• 23:10
  just
• 23:10
  reach
• 23:10
  for
• 23:11
  latuda
• 23:11
  if
• 23:11
  you
• 23:12
  need
• 23:12
  to
• 23:12
  talk
• 23:12
  about
• 23:12
  the
• 23:13
  need
• 23:13
  to
• 23:13
  eat
• 23:13
  it
• 23:13
  with
• 23:13
  at
• 23:14
  least
• 23:14
  350
• 23:14
  calories,
• 23:15
  get
• 23:16
  a
• 23:16
  good
• 23:16
  idea
• 23:17
  of
• 23:17
  what
• 23:17
  your
• 23:17
  patient
• 23:18
  is
• 23:18
  going
• 23:18
  through,
• 23:19
  and
• 23:19
  continue
• 23:20
  to
• 23:20
  look
• 23:20
  at
• 23:20
  the
• 23:20
  evidence.
• 23:21
  Right.
• 23:22
  Because
• 23:22
  right
• 23:23
  around
• 23:23
  the
• 23:23
  corner,
• 23:24
  there
• 23:24
  could
• 23:24
  be
• 23:25
  a
• 23:25
  new
• 23:25
  medication
• 23:26
  next
• 23:26
  year
• 23:27
  that
• 23:27
  is
• 23:27
  FDA
• 23:27
  approved
• 23:28
  for
• 23:29
  MDD
• 23:29
  with
• 23:30
  mixed
• 23:30
  features.
• 23:30
  And
• 23:30
  we're
• 23:31
  all
• 23:31
  going
• 23:31
  to
• 23:31
  throw
• 23:31
  a
• 23:31
  party.
• 23:32
  But
• 23:32
  right
• 23:32
  now
• 23:32
  we're
• 23:32
  in
• 23:32
  this
• 23:33
  gray
• 23:33
  zone
• 23:34
  and
• 23:34
  we've
• 23:34
  gotta
• 23:35
  do
• 23:35
  the
• 23:35
  very
• 23:35
  best
• 23:36
  we
• 23:36
  can.
• 23:36
  And
• 23:37
  I
• 23:37
  think
• 23:37
  step
• 23:37
  one
• 23:38
  is
• 23:38
  peeling
• 23:39
  these
• 23:39
  patients
• 23:39
  off
• 23:40
  of
• 23:40
  their
• 23:40
  SSRIs.
• 24:36
  When
• 24:36
  we
• 24:36
  start
• 24:36
  to
• 24:37
  really
• 24:37
  hone
• 24:38
  in
• 24:38
  on
• 24:38
  that
• 24:38
  mixed
• 24:39
  features
• 23:45
  specifier.
• 24:40
  It's
• 24:41
  definitely
• 24:41
  a
• 24:41
  check
• 24:41
  engine
• 24:42
  light,
• 24:42
  and
• 24:42
  we've
• 24:42
  gotta
• 24:43
  do
• 24:43
  something
• 24:44
  about
• 24:44
  it
• 24:45
  rather
• 24:45
  quickly.
• 24:45
  There
• 24:46
  is
• 24:46
  evidence
• 24:46
  for
• 24:46
  Vralar
• 24:47
  as
• 24:47
  an
• 24:47
  adjunct
• 24:48
  to
• 24:48
  MDD
• 24:49
  that,
• 24:49
  you
• 24:49
  know,
• 24:49
  we
• 24:49
  can
• 24:50
  talk
• 24:50
  about.
• 24:50
  It's
• 24:50
  a
• 24:50
  very
• 24:50
  interesting
• 24:51
  medication,
• 24:51
  actually.
• 24:52
  It's
• 24:52
  a
• 24:52
  D3
• 24:53
  receptor
• 24:53
  profile
• 24:54
  is
• 24:54
  very
• 24:54
  interesting
• 24:56
  with
• 24:56
  respect
• 24:56
  to,
• 24:56
  like,
• 24:56
  anhedonia
• 24:58
  and
• 24:58
  very
• 24:58
  neat.
• 24:59
  And
• 24:59
  we,
• 24:59
  we're
• 24:59
  gonna
• 24:59
  do
• 25:00
  whole
• 25:00
  deep
• 25:00
  dives
• 25:00
  on
• 25:00
  that
• 25:01
  medication
• 25:01
  later.
• 25:01
  I
• 25:02
  hope
• 25:02
  this
• 25:02
  was
• 25:02
  helpful
• 25:02
  to
• 25:03
  you.
• 25:03
  Um,
• 25:04
  if
• 25:04
  it
• 25:04
  was,
• 25:04
  I
• 25:05
  highly
• 25:05
  recommend,
• 25:06
  my
• 25:06
  friends,
• 25:07
  you
• 25:08
  go
• 25:08
  into
• 25:08
  the
• 25:08
  show
• 25:09
  notes
• 25:09
  before
• 25:09
  you
• 25:09
  go
• 25:09
  to
• 25:10
  bed
• 25:10
  tonight
• 25:10
  and
• 25:11
  click
• 25:11
  our
• 25:11
  Patreon
• 25:12
  link
• 25:12
  and
• 25:12
  become
• 25:12
  a
• 25:13
  Patreon
• 25:13
  member.
• 25:13
  Why
• 25:14
  do
• 25:14
  I
• 25:14
  say
• 25:14
  that?
• 25:14
  Because
• 25:16
  we
• 25:16
  have
• 25:16
  a
• 25:16
  full
• 25:17
  clinical
• 25:17
  library
• 25:18
  there
• 25:18
  to
• 25:18
  help
• 25:19
  you
• 25:19
  distinguish
• 25:19
  yourself
• 25:20
  from
• 25:20
  a
• 25:20
  good
• 25:20
  to
• 25:21
  a
• 25:21
  great
• 25:21
  clinician.
• 25:22
  Why?
• 25:22
  Because
• 25:22
  good
• 25:23
  clinicians
• 25:23
  just
• 25:23
  remember
• 25:24
  the
• 25:24
  algorithms
• 25:25
  they
• 25:25
  just
• 25:25
  prescribe,
• 25:26
  they
• 25:26
  just
• 25:26
  diagnose.
• 25:27
  Great
• 25:27
  clinicians
• 25:28
  understand
• 25:28
  the
• 25:28
  how
• 25:28
  and
• 25:29
  the
• 25:29
  why.
• 25:29
  Your
• 25:30
  patients
• 25:30
  can
• 25:30
  smell
• 25:30
  that
• 25:31
  a
• 25:31
  mile
• 25:31
  away.
• 25:32
  My
• 25:32
  friends,
• 25:33
  I
• 25:33
  built
• 25:33
  this
• 25:34
  Patreon
• 25:35
  library
• 25:35
  for
• 25:35
  myself
• 25:36
  and
• 25:36
  I
• 25:36
  don't
• 25:37
  know
• 25:37
  where
• 25:37
  I
• 25:37
  would
• 25:38
  be
• 25:38
  in
• 25:38
  the
• 25:38
  world
• 25:38
  without
• 25:38
  it.
• 25:39
  I
• 25:39
  feel
• 25:39
  so
• 25:39
  much
• 25:39
  more
• 25:40
  confident,
• 25:40
  so
• 25:41
  much
• 25:41
  more
• 25:41
  prepared.
• 25:42
  Um,
• 25:42
  I
• 25:42
  would
• 25:42
  be
• 25:43
  so
• 25:44
  far
• 25:44
  behind
• 25:44
  if
• 25:45
  I
• 25:45
  didn't
• 25:46
  create
• 25:46
  this
• 25:46
  and
• 25:46
  go
• 25:46
  over
• 25:47
  it
• 25:47
  all
• 25:47
  the
• 25:47
  time.
• 25:47
  And
• 25:47
  it's
• 25:48
  all
• 25:48
  available
• 25:48
  to
• 25:49
  you.
• 25:49
  If
• 25:49
  you
• 25:49
  join
• 25:50
  our
• 25:50
  Patreon
• 25:50
  page
• 25:50
  and
• 25:51
  become
• 25:51
  a
• 25:51
  member,
• 25:52
  you
• 25:52
  will
• 25:52
  not
• 25:52
  regret
• 25:52
  it.
• 25:53
  It
• 25:53
  will
• 25:53
  transform
• 25:54
  the
• 25:54
  way
• 25:54
  you
• 25:54
  practice.
• 25:55
  And
• 25:55
  I
• 25:55
  hope
• 25:56
  this
• 25:56
  really
• 25:56
  helped
• 25:57
  my
• 25:57
  friends.
• 25:57
  Until
• 25:58
  next
• 25:58
  time,
• 25:58
  take
• 25:58
  care.
• 25:59
  Bye.
• 25:59
  Bye.