Latest / Pearls and Prep / Exploring the Nuances of Depression: Specifiers and Their Implications

Transcript

Exploring the Nuances of Depression: Specifiers and Their Implications · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:09
  This
• 0:09
  is
• 0:09
  npz
• 0:10
  here,
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:12
  pocket.
• 0:12
  This
• 0:13
  is
• 0:13
  your
• 0:13
  go
• 0:13
  to
• 0:13
  place
• 0:14
  for
• 0:14
  pearls
• 0:15
  that
• 0:15
  prep
• 0:15
  you
• 0:16
  to
• 0:16
  practice.
• 0:17
  All
• 0:17
  right,
• 0:17
  my
• 0:17
  friends,
• 0:18
  today
• 0:18
  we're
• 0:18
  going
• 0:18
  to
• 0:19
  talk
• 0:19
  about
• 0:20
  major
• 0:20
  depressive
• 0:21
  disorder
• 0:22
  and
• 0:23
  there
• 0:23
  and
• 0:23
  its
• 0:24
  specifiers.
• 0:25
  Okay?
• 0:26
  So
• 0:26
  as
• 0:27
  you
• 0:27
  all
• 0:27
  know,
• 0:27
  depression
• 0:28
  is
• 0:28
  not
• 0:29
  just
• 0:30
  depression,
• 0:30
  right?
• 0:31
  When
• 0:31
  you
• 0:31
  get
• 0:32
  out
• 0:32
  there
• 0:32
  into
• 0:32
  practice,
• 0:33
  into
• 0:33
  the
• 0:33
  wilderness,
• 0:34
  you're
• 0:35
  going
• 0:35
  to
• 0:35
  see
• 0:35
  that
• 0:36
  there
• 0:36
  are
• 0:36
  many
• 0:37
  different
• 0:37
  flavors
• 0:38
  of
• 0:38
  depression.
• 0:38
  Same
• 0:39
  like
• 0:39
  when
• 0:39
  you
• 0:39
  go
• 0:40
  to
• 0:40
  the
• 0:40
  ice
• 0:40
  cream
• 0:41
  shop.
• 0:42
  You're,
• 0:42
  it
• 0:42
  ain't
• 0:43
  just
• 0:43
  vanilla
• 0:43
  there,
• 0:44
  right?
• 0:45
  There's
• 0:45
  chocolate,
• 0:46
  there's
• 0:46
  rocky
• 0:47
  road,
• 0:47
  there's
• 0:47
  cotton
• 0:48
  candy,
• 0:49
  there's
• 0:49
  mint,
• 0:50
  there's
• 0:50
  butter
• 0:50
  pecan.
• 0:52
  My
• 0:52
  point
• 0:52
  is,
• 0:53
  you
• 0:53
  get
• 0:53
  to
• 0:53
  the
• 0:53
  ice
• 0:53
  cream
• 0:54
  shop,
• 0:54
  and
• 0:54
  it's
• 0:54
  not
• 0:54
  as
• 0:55
  simple
• 0:55
  as
• 0:55
  ice
• 0:55
  cream.
• 0:56
  There's
• 0:56
  cones,
• 0:57
  there's
• 0:57
  cups,
• 0:58
  there's
• 0:58
  sprinkles.
• 0:59
  So
• 1:00
  there's
• 1:00
  just
• 1:00
  a
• 1:01
  lot
• 1:01
  of
• 1:01
  curveballs
• 1:01
  thrown
• 1:02
  your
• 1:02
  way.
• 1:02
  And
• 1:02
  it's
• 1:03
  really
• 1:03
  important
• 1:03
  we
• 1:03
  understand
• 1:04
  what
• 1:05
  we're
• 1:05
  looking
• 1:05
  at.
• 1:05
  And
• 1:06
  the
• 1:06
  reason
• 1:06
  it's
• 1:06
  important,
• 1:07
  my
• 1:07
  friends,
• 1:08
  is
• 1:08
  because
• 1:09
  when
• 1:09
  you
• 1:09
  specify
• 1:10
  the
• 1:11
  kind
• 1:11
  of
• 1:11
  depression,
• 1:12
  it
• 1:13
  allows
• 1:14
  you
• 1:14
  and
• 1:14
  the
• 1:15
  prescribers,
• 1:16
  after
• 1:16
  you
• 1:16
  to
• 1:17
  have
• 1:17
  a
• 1:17
  better
• 1:17
  idea
• 1:18
  about
• 1:18
  how
• 1:18
  to
• 1:19
  approach.
• 1:20
  And
• 1:20
  that
• 1:20
  could
• 1:20
  mean
• 1:21
  a
• 1:21
  different
• 1:21
  kind
• 1:21
  of
• 1:22
  medication.
• 1:23
  If
• 1:23
  your
• 1:23
  specifier
• 1:24
  is
• 1:25
  something
• 1:25
  like
• 1:25
  mixed
• 1:26
  features,
• 1:27
  it
• 1:27
  could
• 1:27
  mean
• 1:29
  also
• 1:30
  sort
• 1:30
  of
• 1:30
  a
• 1:30
  diagnostic
• 1:31
  warning.
• 1:31
  If
• 1:32
  it's
• 1:32
  mixed
• 1:32
  features.
• 1:33
  Right.
• 1:33
  Like
• 1:33
  a,
• 1:33
  hey,
• 1:34
  this
• 1:34
  patient
• 1:35
  might
• 1:35
  be
• 1:35
  a
• 1:36
  prime
• 1:36
  candidate
• 1:37
  to
• 1:38
  turn
• 1:38
  into
• 1:39
  a
• 1:39
  bipolar
• 1:39
  disorder.
• 1:40
  Now,
• 1:41
  the
• 1:41
  evidence
• 1:41
  is
• 1:41
  sort
• 1:41
  of
• 1:42
  all
• 1:42
  over
• 1:42
  the
• 1:42
  place,
• 1:42
  but
• 1:42
  I've
• 1:43
  seen
• 1:43
  up
• 1:43
  to
• 1:43
  25%
• 1:44
  in
• 1:44
  three
• 1:45
  years
• 1:45
  of
• 1:45
  patients
• 1:45
  who
• 1:46
  have
• 1:46
  mixed
• 1:46
  features
• 1:47
  go
• 1:47
  on
• 1:47
  to
• 1:48
  have
• 1:48
  bipolar
• 1:48
  disorder.
• 1:49
  Well,
• 1:49
  if
• 1:49
  you're
• 1:49
  in
• 1:49
  primary
• 1:50
  care
• 1:50
  or
• 1:50
  if
• 1:50
  you're
• 1:51
  even
• 1:51
  a
• 1:51
  psych,
• 1:52
  NP
• 1:52
  or
• 1:52
  psychiatrist,
• 1:53
  it's
• 1:53
  very
• 1:53
  important
• 1:54
  that
• 1:54
  you
• 1:54
  add
• 1:55
  that
• 1:55
  specifier
• 1:56
  on
• 1:56
  there,
• 1:56
  because
• 1:56
  the
• 1:56
  patient
• 1:57
  could
• 1:57
  move
• 1:57
  3,000
• 1:58
  miles
• 1:59
  away.
• 1:59
  And
• 2:00
  hopefully,
• 2:00
  if
• 2:00
  their
• 2:01
  records
• 2:01
  accompany
• 2:02
  them,
• 2:02
  the
• 2:02
  new
• 2:03
  prescriber,
• 2:03
  who's
• 2:04
  really
• 2:05
  short
• 2:05
  for
• 2:05
  time
• 2:06
  and
• 2:06
  exasperated
• 2:07
  and
• 2:07
  you
• 2:07
  can
• 2:08
  barely
• 2:08
  focus
• 2:08
  on
• 2:09
  working
• 2:09
  that
• 2:09
  day,
• 2:10
  he
• 2:10
  might
• 2:11
  really
• 2:11
  help
• 2:11
  him
• 2:11
  to
• 2:11
  go,
• 2:12
  oh,
• 2:12
  wait
• 2:12
  a
• 2:12
  minute,
• 2:12
  somebody
• 2:13
  spotted
• 2:13
  mixed
• 2:14
  features
• 2:14
  here.
• 2:14
  And.
• 2:15
  And
• 2:15
  it's
• 2:15
  even
• 2:15
  more
• 2:15
  important
• 2:16
  because
• 2:16
  maybe
• 2:16
  mixed
• 2:17
  features
• 2:17
  is
• 2:17
  not
• 2:17
  the
• 2:18
  constant
• 2:18
  presentation
• 2:19
  of
• 2:19
  that
• 2:19
  patient,
• 2:20
  right?
• 2:20
  The
• 2:20
  patient
• 2:20
  might
• 2:20
  move
• 2:21
  and
• 2:21
  only
• 2:21
  show
• 2:22
  depression.
• 2:22
  Well,
• 2:22
  if
• 2:23
  it's
• 2:23
  not
• 2:23
  ever
• 2:23
  flagged
• 2:24
  in
• 2:24
  the
• 2:25
  record,
• 2:25
  that
• 2:25
  patient's
• 2:26
  gonna
• 2:26
  go
• 2:26
  to
• 2:27
  a
• 2:27
  new
• 2:27
  provider
• 2:27
  and
• 2:27
  they're
• 2:28
  gonna
• 2:28
  think,
• 2:28
  oh,
• 2:28
  this
• 2:28
  is
• 2:29
  depression.
• 2:29
  And
• 2:30
  patients
• 2:30
  don't
• 2:31
  voluntarily
• 2:31
  offer
• 2:32
  the
• 2:32
  fact
• 2:32
  that
• 2:32
  they
• 2:33
  have
• 2:33
  MDD
• 2:33
  with
• 2:34
  mixed
• 2:34
  features.
• 2:35
  I
• 2:35
  have
• 2:35
  yet
• 2:35
  to
• 2:35
  find
• 2:36
  a
• 2:36
  patient
• 2:36
  who
• 2:36
  tells
• 2:37
  me
• 2:37
  I
• 2:37
  have
• 2:37
  mdd,
• 2:38
  recurrent,
• 2:39
  moderate
• 2:39
  with
• 2:40
  mixed
• 2:40
  Features.
• 2:40
  It
• 2:41
  just
• 2:41
  doesn't
• 2:41
  happen,
• 2:42
  okay?
• 2:43
  And
• 2:44
  that's
• 2:44
  why
• 2:45
  we
• 2:45
  want
• 2:45
  to
• 2:45
  get
• 2:45
  really
• 2:45
  precise
• 2:46
  with
• 2:47
  these
• 2:47
  specifiers.
• 2:48
  And
• 2:48
  again,
• 2:48
  there's
• 2:48
  many
• 2:49
  different
• 2:49
  kinds
• 2:49
  of
• 2:49
  specifiers.
• 2:50
  There's
• 2:50
  many
• 2:51
  different
• 2:51
  flavors
• 2:51
  of
• 2:51
  depression,
• 2:53
  period.
• 2:54
  And
• 2:54
  we're
• 2:54
  going
• 2:54
  to
• 2:54
  go
• 2:54
  over
• 2:55
  some
• 2:55
  of
• 2:55
  them
• 2:55
  today.
• 2:55
  So
• 2:56
  the
• 2:56
  first
• 2:56
  big
• 2:56
  revelation
• 2:57
  when
• 2:57
  I
• 2:57
  graduated
• 2:58
  was,
• 2:58
  wow,
• 2:58
  there
• 2:58
  are
• 2:59
  many
• 2:59
  different
• 2:59
  kinds
• 2:59
  of
• 2:59
  depression.
• 3:00
  And,
• 3:00
  wow,
• 3:01
  when
• 3:01
  there
• 3:02
  are
• 3:02
  different
• 3:02
  kinds
• 3:02
  of
• 3:02
  depression,
• 3:03
  you've
• 3:03
  really
• 3:03
  got
• 3:03
  to
• 3:03
  put
• 3:04
  your
• 3:04
  thinking
• 3:04
  cap
• 3:04
  on
• 3:05
  here
• 3:05
  because
• 3:06
  it
• 3:06
  sort
• 3:06
  of
• 3:06
  muddies
• 3:07
  the
• 3:07
  diagnostic
• 3:07
  clarity,
• 3:08
  right?
• 3:08
  You
• 3:08
  have
• 3:09
  MDD
• 3:09
  with
• 3:09
  anxious
• 3:10
  distress,
• 3:11
  and
• 3:11
  part
• 3:11
  of
• 3:11
  you
• 3:11
  scratches
• 3:12
  your
• 3:12
  head
• 3:12
  and
• 3:12
  goes,
• 3:12
  wait
• 3:13
  a
• 3:13
  minute,
• 3:13
  Am
• 3:13
  I
• 3:13
  looking
• 3:13
  at
• 3:14
  GAD
• 3:14
  or
• 3:14
  am
• 3:15
  I
• 3:15
  looking
• 3:15
  at
• 3:16
  mdd?
• 3:17
  Well,
• 3:17
  one
• 3:17
  of
• 3:17
  the
• 3:18
  core
• 3:18
  questions
• 3:19
  you
• 3:19
  want
• 3:19
  to
• 3:20
  ask
• 3:20
  yourself
• 3:20
  is,
• 3:20
  what
• 3:21
  is
• 3:21
  the
• 3:21
  root
• 3:21
  problem
• 3:22
  here?
• 3:22
  Right?
• 3:23
  What
• 3:23
  came
• 3:23
  first
• 3:23
  and
• 3:24
  what's
• 3:24
  the
• 3:24
  primary
• 3:24
  problem?
• 3:25
  If
• 3:25
  the
• 3:25
  person's
• 3:26
  coming
• 3:26
  to
• 3:26
  you,
• 3:26
  and
• 3:27
  they're
• 3:27
  usually
• 3:27
  very
• 3:27
  honest
• 3:28
  and
• 3:28
  forthright,
• 3:28
  they're
• 3:29
  gonna
• 3:29
  come
• 3:29
  to
• 3:29
  you
• 3:29
  and
• 3:29
  say,
• 3:30
  hey,
• 3:30
  look,
• 3:30
  anxiety
• 3:30
  is
• 3:31
  crushing
• 3:31
  me.
• 3:31
  I
• 3:31
  am
• 3:32
  nervous
• 3:32
  all
• 3:32
  the
• 3:32
  time.
• 3:32
  I'm
• 3:33
  a
• 3:33
  nervous
• 3:33
  wreck.
• 3:33
  Right?
• 3:34
  Then
• 3:34
  you
• 3:34
  can
• 3:35
  kind
• 3:35
  of
• 3:35
  look
• 3:35
  more
• 3:35
  towards
• 3:36
  the
• 3:36
  gad.
• 3:36
  But
• 3:37
  if
• 3:37
  the
• 3:37
  patient
• 3:37
  is
• 3:37
  telling
• 3:38
  you
• 3:38
  that
• 3:38
  they're
• 3:38
  coming
• 3:39
  to
• 3:39
  you
• 3:39
  because
• 3:39
  they've
• 3:39
  just
• 3:40
  been
• 3:40
  depressed,
• 3:40
  they
• 3:40
  can't
• 3:41
  get
• 3:41
  out
• 3:41
  of
• 3:41
  bed,
• 3:41
  and
• 3:42
  then
• 3:42
  you
• 3:42
  notice
• 3:42
  kind
• 3:43
  of
• 3:43
  a
• 3:43
  sprinkle
• 3:44
  of
• 3:44
  anxiety,
• 3:45
  right?
• 3:45
  It's
• 3:46
  not
• 3:46
  the
• 3:46
  whole
• 3:46
  ice
• 3:46
  cream.
• 3:46
  The
• 3:46
  whole
• 3:47
  ice
• 3:47
  cream
• 3:47
  is
• 3:47
  the
• 3:47
  depression.
• 3:48
  The
• 3:48
  sprinkles
• 3:49
  are
• 3:49
  the
• 3:49
  anxiety
• 3:50
  that
• 3:50
  you
• 3:50
  want
• 3:50
  to
• 3:51
  really
• 3:51
  add
• 3:51
  as
• 3:51
  a
• 3:52
  specifier
• 3:53
  onto
• 3:53
  that,
• 3:54
  because,
• 3:54
  again,
• 3:54
  it
• 3:55
  kind
• 3:55
  of
• 3:56
  helps
• 3:56
  you
• 3:57
  figure
• 3:57
  out
• 3:58
  what
• 3:58
  else
• 3:58
  you're
• 3:59
  looking
• 3:59
  at.
• 3:59
  It
• 3:59
  clues
• 4:00
  you
• 4:00
  in.
• 4:00
  Okay?
• 4:01
  Now,
• 4:01
  it
• 4:01
  doesn't
• 4:01
  help
• 4:01
  the
• 4:02
  fact
• 4:02
  that
• 4:02
  anxious
• 4:03
  distress
• 4:03
  is
• 4:04
  in
• 4:04
  75%
• 4:05
  of
• 4:05
  major
• 4:06
  depressive
• 4:06
  disorder
• 4:06
  cases.
• 4:07
  That
• 4:07
  is
• 4:07
  wild.
• 4:08
  That
• 4:08
  is
• 4:08
  a
• 4:08
  wild
• 4:09
  statistic.
• 4:09
  You're
• 4:10
  going
• 4:10
  into
• 4:10
  the.
• 4:10
  To
• 4:11
  see
• 4:11
  your
• 4:11
  first
• 4:11
  patient
• 4:12
  that
• 4:12
  you've
• 4:12
  ever
• 4:12
  seen
• 4:12
  before,
• 4:13
  and
• 4:13
  lo
• 4:14
  and
• 4:14
  behold,
• 4:14
  depression
• 4:15
  is
• 4:15
  so
• 4:15
  common.
• 4:15
  And
• 4:16
  in
• 4:16
  75%
• 4:17
  of
• 4:17
  cases,
• 4:17
  there
• 4:17
  will
• 4:18
  be
• 4:18
  anxious
• 4:18
  distress.
• 4:20
  Now,
• 4:21
  I
• 4:21
  find
• 4:21
  that
• 4:21
  to
• 4:22
  be
• 4:22
  kind
• 4:22
  of
• 4:22
  a
• 4:22
  funny
• 4:23
  statistic.
• 4:23
  I
• 4:23
  definitely
• 4:24
  agree
• 4:24
  with
• 4:24
  it,
• 4:24
  based
• 4:25
  on
• 4:25
  my
• 4:25
  experience,
• 4:25
  of
• 4:26
  course.
• 4:26
  But
• 4:26
  I
• 4:27
  would
• 4:27
  also
• 4:27
  argue
• 4:27
  that
• 4:28
  so
• 4:28
  many
• 4:28
  of
• 4:28
  those
• 4:28
  patients
• 4:29
  actually
• 4:29
  have
• 4:29
  generalized
• 4:30
  anxiety
• 4:30
  disorder.
• 4:31
  And
• 4:31
  maybe
• 4:31
  the
• 4:32
  full
• 4:32
  diagnosis.
• 4:32
  Diagnosis
• 4:33
  hasn't
• 4:33
  been
• 4:33
  fleshed
• 4:34
  out,
• 4:34
  because,
• 4:34
  remember,
• 4:35
  depression
• 4:35
  and
• 4:35
  anxiety,
• 4:36
  they
• 4:36
  share
• 4:37
  so
• 4:37
  many
• 4:37
  of
• 4:38
  those
• 4:38
  circuits.
• 4:39
  The
• 4:39
  anxiety
• 4:39
  disorders
• 4:40
  and
• 4:40
  the
• 4:40
  depressive
• 4:40
  disorders
• 4:41
  share
• 4:41
  so
• 4:41
  many
• 4:42
  of
• 4:42
  the
• 4:42
  neural
• 4:42
  circuitry
• 4:43
  in
• 4:43
  the
• 4:43
  brain.
• 4:44
  Lucky
• 4:44
  for
• 4:44
  us,
• 4:45
  if
• 4:45
  we're
• 4:46
  confused
• 4:46
  about
• 4:46
  what
• 4:47
  we're
• 4:47
  looking
• 4:47
  at,
• 4:47
  whether
• 4:47
  it's
• 4:48
  GAD
• 4:48
  or
• 4:48
  MDD
• 4:49
  with
• 4:49
  anxious
• 4:49
  distress,
• 4:50
  guess
• 4:50
  what?
• 4:51
  The
• 4:51
  first
• 4:51
  line
• 4:51
  medications
• 4:52
  are
• 4:52
  basically
• 4:52
  the
• 4:53
  same
• 4:53
  anyway.
• 4:53
  SSRIs
• 4:54
  SNRIs.
• 4:55
  Right.
• 4:56
  So
• 4:56
  even
• 4:57
  if
• 4:57
  we
• 4:57
  get
• 4:57
  spun
• 4:57
  up
• 4:57
  diagnostically,
• 4:58
  what
• 4:59
  I
• 4:59
  like
• 4:59
  to
• 4:59
  always
• 4:59
  think
• 5:00
  to
• 5:00
  myself
• 5:00
  is,
• 5:00
  hey,
• 5:01
  at
• 5:01
  the
• 5:01
  end
• 5:01
  of
• 5:01
  the
• 5:02
  day,
• 5:02
  you
• 5:02
  want
• 5:03
  to
• 5:03
  be
• 5:03
  as
• 5:04
  correct
• 5:04
  as
• 5:04
  you
• 5:04
  can
• 5:04
  be,
• 5:05
  and
• 5:05
  you
• 5:06
  want
• 5:06
  to
• 5:06
  at
• 5:06
  least
• 5:06
  pair
• 5:07
  the
• 5:07
  patient
• 5:07
  with
• 5:08
  the
• 5:08
  right
• 5:08
  diagnosis.
• 5:09
  So
• 5:09
  if
• 5:09
  you're
• 5:09
  wrestling
• 5:10
  between
• 5:10
  anxious
• 5:11
  distress
• 5:11
  and
• 5:11
  gad,
• 5:12
  and
• 5:12
  you
• 5:12
  recognize
• 5:12
  that
• 5:13
  depression
• 5:13
  and
• 5:13
  anxiety
• 5:14
  are
• 5:14
  both
• 5:14
  problems,
• 5:15
  and
• 5:15
  you
• 5:15
  start
• 5:15
  them
• 5:15
  on
• 5:16
  Zoloft
• 5:16
  or
• 5:17
  you
• 5:17
  start
• 5:17
  them
• 5:17
  on,
• 5:18
  you
• 5:18
  know,
• 5:18
  Prozac,
• 5:19
  that's
• 5:20
  fine,
• 5:20
  right?
• 5:20
  I
• 5:20
  mean,
• 5:21
  it's
• 5:21
  clearly
• 5:21
  a
• 5:21
  depression
• 5:22
  or
• 5:22
  anxiety,
• 5:22
  anxious
• 5:23
  distress,
• 5:23
  yada
• 5:24
  yada.
• 5:24
  So
• 5:25
  you,
• 5:25
  you
• 5:25
  look
• 5:25
  at
• 5:25
  the
• 5:26
  primary
• 5:26
  treatments,
• 5:26
  right?
• 5:27
  And
• 5:27
  so
• 5:27
  don't
• 5:27
  kick
• 5:28
  yourself
• 5:28
  at
• 5:28
  the
• 5:28
  end
• 5:28
  of
• 5:28
  the
• 5:29
  day
• 5:29
  when
• 5:29
  you're
• 5:29
  going
• 5:29
  to
• 5:29
  bed
• 5:29
  at
• 5:30
  night.
• 5:31
  What
• 5:31
  matters
• 5:31
  most
• 5:31
  is
• 5:32
  that
• 5:32
  the
• 5:32
  patient
• 5:32
  in
• 5:32
  front
• 5:32
  of
• 5:33
  you
• 5:33
  is
• 5:33
  being
• 5:33
  treated
• 5:34
  accordingly,
• 5:35
  and
• 5:35
  you've
• 5:36
  summoned
• 5:36
  the
• 5:37
  evidence
• 5:37
  and
• 5:37
  your
• 5:37
  education
• 5:38
  to
• 5:38
  match
• 5:39
  the
• 5:40
  medication
• 5:41
  with
• 5:41
  the
• 5:42
  pain
• 5:42
  point.
• 5:43
  And
• 5:43
  so
• 5:43
  SSRIs
• 5:44
  are
• 5:44
  good.
• 5:45
  No
• 5:45
  matter
• 5:45
  if
• 5:45
  it's
• 5:45
  anxious
• 5:46
  distress
• 5:46
  with
• 5:46
  MDD
• 5:47
  or
• 5:47
  GAD
• 5:47
  or
• 5:48
  both,
• 5:48
  you
• 5:48
  will
• 5:48
  see
• 5:49
  a
• 5:49
  lot.
• 5:49
  MDD
• 5:50
  and
• 5:50
  GAD
• 5:50
  are
• 5:50
  like
• 5:50
  the
• 5:50
  peanut
• 5:51
  butter
• 5:51
  and
• 5:51
  jelly
• 5:52
  of
• 5:52
  what
• 5:52
  you're
• 5:52
  about
• 5:52
  to
• 5:52
  walk
• 5:53
  into.
• 5:53
  Right?
• 5:53
  They're
• 5:53
  the
• 5:54
  peanut
• 5:54
  butter
• 5:54
  and
• 5:54
  jelly
• 5:55
  sandwich
• 5:55
  that
• 5:56
  you
• 5:56
  always
• 5:56
  see.
• 5:57
  It's
• 5:57
  kind
• 5:57
  of
• 5:57
  even
• 5:58
  rare
• 5:58
  that
• 5:58
  you
• 5:59
  just
• 5:59
  see
• 5:59
  gad.
• 5:59
  I've
• 6:00
  seen
• 6:00
  it
• 6:00
  a
• 6:00
  hundred
• 6:00
  times,
• 6:01
  don't
• 6:01
  get
• 6:01
  me
• 6:01
  wrong.
• 6:02
  But
• 6:02
  almost
• 6:02
  always
• 6:03
  that
• 6:03
  patient
• 6:04
  has
• 6:04
  some
• 6:04
  sort
• 6:04
  of
• 6:04
  depressive
• 6:05
  disorder.
• 6:05
  It's
• 6:06
  peanut
• 6:06
  butter
• 6:06
  and
• 6:06
  jelly.
• 6:07
  It's
• 6:07
  rare
• 6:07
  somebody
• 6:07
  hands
• 6:08
  you
• 6:08
  just
• 6:08
  a
• 6:08
  jelly
• 6:08
  sandwich
• 6:09
  or
• 6:09
  just
• 6:09
  a
• 6:09
  peanut
• 6:10
  butter
• 6:10
  jelly
• 6:10
  sandwich.
• 6:11
  You
• 6:11
  know,
• 6:11
  maybe
• 6:12
  with
• 6:12
  anxious
• 6:12
  distress,
• 6:13
  it
• 6:13
  would
• 6:13
  be
• 6:13
  like
• 6:13
  mainly
• 6:14
  a
• 6:14
  peanut
• 6:14
  butter
• 6:14
  sandwich
• 6:15
  with
• 6:15
  a
• 6:15
  little
• 6:15
  bit
• 6:15
  of
• 6:15
  jelly,
• 6:16
  whatever.
• 6:16
  It's
• 6:17
  still
• 6:17
  kind
• 6:17
  of
• 6:17
  pbmj
• 6:19
  and,
• 6:19
  you
• 6:20
  know,
• 6:20
  same
• 6:20
  thing
• 6:21
  goes.
• 6:21
  So
• 6:21
  just
• 6:22
  keep
• 6:22
  an
• 6:22
  eye
• 6:22
  out
• 6:22
  for
• 6:22
  that
• 6:22
  and
• 6:23
  don't
• 6:23
  overthink
• 6:23
  it.
• 6:23
  But
• 6:24
  remember
• 6:24
  that
• 6:24
  anxious
• 6:24
  distress,
• 6:25
  the
• 6:25
  primary
• 6:26
  problem
• 6:26
  is
• 6:26
  depression.
• 6:27
  Anxious
• 6:27
  symptoms
• 6:28
  kind
• 6:28
  of
• 6:28
  arise
• 6:28
  within
• 6:29
  the
• 6:29
  mdd,
• 6:30
  but
• 6:30
  it's
• 6:31
  part
• 6:31
  of
• 6:31
  the
• 6:31
  depressive
• 6:32
  episode.
• 6:32
  Right?
• 6:33
  And
• 6:33
  anxiety
• 6:34
  symptoms
• 6:34
  did
• 6:34
  not
• 6:35
  usually
• 6:35
  precede
• 6:35
  the
• 6:36
  major
• 6:36
  depressive
• 6:36
  episode.
• 6:37
  They
• 6:37
  emerged
• 6:38
  with
• 6:38
  the
• 6:38
  depressive
• 6:39
  episode.
• 6:39
  So
• 6:39
  that's
• 6:40
  kind
• 6:40
  of
• 6:40
  key
• 6:40
  too,
• 6:40
  Right?
• 6:41
  And
• 6:41
  it
• 6:41
  doesn't
• 6:42
  require
• 6:42
  a
• 6:42
  six
• 6:42
  month
• 6:42
  duration.
• 6:43
  So
• 6:43
  if
• 6:43
  the
• 6:43
  patient
• 6:44
  is
• 6:44
  not
• 6:44
  really,
• 6:45
  you
• 6:45
  know,
• 6:45
  one
• 6:45
  of
• 6:46
  those
• 6:46
  people
• 6:46
  who's
• 6:46
  anxious
• 6:46
  their
• 6:47
  whole
• 6:47
  life,
• 6:47
  and
• 6:48
  they
• 6:48
  just
• 6:48
  mentioned
• 6:48
  being
• 6:49
  kind
• 6:49
  of
• 6:49
  keyed
• 6:49
  up
• 6:49
  or
• 6:50
  restless
• 6:50
  during
• 6:51
  their
• 6:51
  depressive
• 6:51
  episode,
• 6:52
  then
• 6:52
  bam,
• 6:52
  there
• 6:52
  you
• 6:53
  go,
• 6:53
  you
• 6:53
  got
• 6:53
  MDD
• 6:53
  with
• 6:54
  anxious
• 6:54
  distress.
• 6:55
  And
• 6:55
  I
• 6:55
  will
• 6:55
  tell
• 6:55
  you
• 6:55
  from
• 6:56
  experience,
• 6:57
  my
• 6:57
  patients
• 6:57
  know
• 6:58
  when
• 6:58
  they're
• 6:58
  anxious.
• 6:58
  They
• 6:59
  will
• 6:59
  tell
• 6:59
  you
• 7:00
  it
• 7:00
  seems
• 7:00
  like
• 7:01
  one
• 7:01
  of
• 7:01
  the
• 7:01
  easiest
• 7:02
  mental
• 7:02
  health
• 7:03
  disorders
• 7:04
  to,
• 7:04
  to
• 7:04
  Get
• 7:05
  a
• 7:05
  timeline
• 7:05
  on,
• 7:06
  Right.
• 7:06
  And
• 7:07
  the
• 7:07
  reason
• 7:07
  is
• 7:08
  my
• 7:08
  patients
• 7:09
  just
• 7:09
  tend
• 7:09
  to
• 7:09
  know
• 7:09
  that
• 7:09
  they've
• 7:10
  worried
• 7:10
  their
• 7:10
  whole
• 7:10
  life
• 7:11
  or
• 7:11
  for
• 7:11
  at
• 7:11
  least
• 7:11
  10
• 7:11
  years
• 7:12
  or
• 7:12
  15
• 7:12
  years
• 7:12
  or
• 7:13
  since
• 7:13
  high
• 7:13
  school
• 7:13
  or
• 7:14
  since
• 7:14
  middle
• 7:14
  school.
• 7:14
  When
• 7:15
  you
• 7:15
  ask
• 7:15
  people
• 7:15
  to
• 7:15
  slap
• 7:16
  a
• 7:16
  timeline
• 7:16
  on
• 7:16
  depression,
• 7:17
  it
• 7:17
  gets
• 7:17
  a
• 7:17
  little
• 7:18
  squishier.
• 7:18
  You
• 7:19
  know,
• 7:19
  the
• 7:19
  ones
• 7:19
  with
• 7:19
  recurring
• 7:20
  recurrent
• 7:21
  depression
• 7:21
  are
• 7:21
  pretty
• 7:21
  clear.
• 7:22
  You
• 7:22
  get
• 7:22
  a
• 7:22
  very
• 7:22
  fast
• 7:23
  answer.
• 7:23
  Oh,
• 7:23
  absolutely.
• 7:24
  Recurrent.
• 7:25
  Many
• 7:25
  times,
• 7:26
  many
• 7:26
  cycles
• 7:26
  in
• 7:26
  my
• 7:27
  life.
• 7:27
  They
• 7:27
  kind
• 7:27
  of
• 7:27
  get
• 7:27
  it,
• 7:28
  they
• 7:28
  know
• 7:28
  it,
• 7:28
  but
• 7:28
  it's
• 7:29
  a
• 7:29
  little
• 7:29
  squishier.
• 7:29
  Right.
• 7:30
  Sometimes
• 7:31
  they
• 7:31
  aren't
• 7:31
  quite
• 7:32
  sure
• 7:32
  because
• 7:32
  they
• 7:33
  had
• 7:33
  like
• 7:33
  an
• 7:33
  acute
• 7:34
  adjustment
• 7:34
  related
• 7:34
  stressor.
• 7:35
  And
• 7:35
  so
• 7:35
  they're
• 7:35
  not
• 7:36
  like
• 7:36
  positive.
• 7:36
  Is
• 7:36
  that
• 7:37
  depression
• 7:37
  or
• 7:37
  not?
• 7:38
  Well,
• 7:38
  my
• 7:38
  grandma
• 7:39
  died.
• 7:39
  I
• 7:39
  was
• 7:39
  sad
• 7:40
  for
• 7:40
  a
• 7:40
  couple
• 7:40
  weeks,
• 7:41
  maybe
• 7:41
  one
• 7:41
  week.
• 7:42
  Then
• 7:42
  it
• 7:42
  was
• 7:42
  kind
• 7:43
  of
• 7:43
  coming
• 7:43
  in
• 7:43
  waves.
• 7:44
  So
• 7:44
  of
• 7:45
  all
• 7:45
  the
• 7:45
  disorders,
• 7:45
  I
• 7:46
  find
• 7:46
  anxiety
• 7:46
  is
• 7:47
  pretty
• 7:47
  easy
• 7:47
  to
• 7:48
  figure
• 7:48
  out.
• 7:48
  This
• 7:48
  person's
• 7:49
  been
• 7:49
  struggling
• 7:49
  with
• 7:49
  worry
• 7:50
  and
• 7:50
  nervousness
• 7:50
  for
• 7:51
  well
• 7:51
  over
• 7:51
  six
• 7:52
  months.
• 7:52
  And
• 7:52
  then
• 7:52
  the
• 7:53
  associated
• 7:53
  symptoms
• 7:54
  kind
• 7:54
  of
• 7:54
  fall
• 7:54
  in
• 7:54
  line
• 7:54
  as
• 7:55
  you
• 7:55
  do
• 7:55
  your
• 7:55
  interview.
• 7:56
  So
• 7:56
  keep
• 7:57
  that
• 7:57
  in
• 7:57
  mind.
• 7:57
  Am
• 7:57
  I
• 7:57
  looking
• 7:58
  at
• 7:58
  GAD
• 7:59
  or
• 7:59
  am
• 7:59
  I
• 7:59
  looking
• 7:59
  at
• 7:59
  just
• 8:00
  sprinkles
• 8:00
  on
• 8:00
  the
• 8:00
  ice
• 8:01
  cream
• 8:01
  cone
• 8:02
  that
• 8:02
  don't
• 8:03
  seem
• 8:03
  to
• 8:03
  be
• 8:03
  the
• 8:04
  main
• 8:04
  squeeze
• 8:04
  here.
• 8:04
  This
• 8:05
  isn't
• 8:05
  the
• 8:05
  double
• 8:05
  scoop
• 8:06
  of
• 8:06
  chocolate.
• 8:06
  It
• 8:06
  seems
• 8:07
  like
• 8:07
  it's
• 8:07
  kind
• 8:07
  of
• 8:07
  a
• 8:07
  sideshow.
• 8:08
  That's
• 8:09
  a
• 8:09
  sign.
• 8:09
  It's
• 8:09
  more
• 8:09
  anxious
• 8:10
  distress.
• 8:10
  So
• 8:11
  we
• 8:11
  talked
• 8:11
  about
• 8:11
  mixed
• 8:12
  features
• 8:12
  a
• 8:12
  little
• 8:12
  bit.
• 8:13
  We
• 8:13
  talked
• 8:13
  about
• 8:13
  anxious
• 8:14
  distress.
• 8:15
  Don't
• 8:15
  forget
• 8:15
  there's
• 8:15
  with
• 8:15
  psychotic
• 8:16
  features.
• 8:16
  So
• 8:17
  that's
• 8:17
  its
• 8:17
  whole
• 8:17
  other
• 8:17
  animal,
• 8:18
  right?
• 8:18
  When
• 8:18
  I
• 8:18
  see
• 8:19
  a
• 8:19
  patient
• 8:19
  with
• 8:19
  psychotic
• 8:19
  features,
• 8:20
  especially
• 8:20
  for
• 8:21
  the
• 8:21
  first
• 8:21
  time,
• 8:21
  I'm
• 8:22
  thinking,
• 8:22
  oh,
• 8:22
  God,
• 8:23
  you
• 8:23
  know,
• 8:23
  what
• 8:23
  am
• 8:23
  I
• 8:23
  looking
• 8:23
  at
• 8:24
  here?
• 8:24
  Is
• 8:24
  this
• 8:24
  a
• 8:24
  prodrome
• 8:25
  that's
• 8:26
  emerging?
• 8:26
  Right.
• 8:27
  Is
• 8:27
  this
• 8:27
  schizophrenia?
• 8:28
  Is
• 8:28
  this
• 8:29
  bipolar?
• 8:29
  Right,
• 8:30
  you,
• 8:30
  you
• 8:30
  start.
• 8:30
  Is
• 8:30
  this
• 8:30
  delusional
• 8:31
  disorder?
• 8:31
  Is
• 8:31
  it
• 8:32
  like,
• 8:32
  what
• 8:32
  is
• 8:32
  this?
• 8:32
  And
• 8:33
  you,
• 8:33
  you
• 8:33
  know,
• 8:33
  it
• 8:33
  kind
• 8:34
  of
• 8:34
  opens
• 8:34
  up
• 8:34
  a
• 8:34
  Pandora's
• 8:35
  box.
• 8:36
  Now,
• 8:36
  one
• 8:37
  way
• 8:37
  that
• 8:37
  I
• 8:37
  try
• 8:38
  to
• 8:38
  think
• 8:38
  about
• 8:38
  this
• 8:39
  is
• 8:40
  these
• 8:40
  folks
• 8:41
  tend
• 8:41
  to
• 8:41
  not
• 8:42
  be
• 8:42
  psychotic
• 8:42
  at
• 8:43
  all
• 8:43
  in
• 8:43
  the
• 8:43
  absence
• 8:44
  of
• 8:44
  their
• 8:44
  mood
• 8:45
  episodes.
• 8:45
  In
• 8:45
  other
• 8:45
  words,
• 8:46
  the
• 8:47
  mood
• 8:47
  is
• 8:48
  the.
• 8:48
  The
• 8:48
  psychosis
• 8:49
  is
• 8:49
  always
• 8:49
  happening,
• 8:50
  almost
• 8:50
  always
• 8:51
  happening
• 8:51
  with
• 8:52
  their
• 8:53
  depression.
• 8:54
  And
• 8:54
  so
• 8:54
  it's
• 8:54
  unusual
• 8:55
  if
• 8:55
  you
• 8:55
  have
• 8:55
  a
• 8:55
  patient
• 8:56
  who
• 8:56
  has
• 8:56
  not
• 8:56
  been.
• 8:56
  Who's
• 8:57
  not
• 8:57
  depressed
• 8:57
  and
• 8:58
  they're
• 8:58
  psychotic,
• 8:58
  that's.
• 8:59
  Now
• 8:59
  you
• 8:59
  got
• 8:59
  to
• 8:59
  look
• 9:00
  at
• 9:00
  substance
• 9:00
  use.
• 9:00
  Now
• 9:00
  you
• 9:01
  got
• 9:01
  to
• 9:01
  look
• 9:01
  at.
• 9:01
  Is
• 9:01
  this
• 9:01
  a
• 9:01
  delusional
• 9:02
  disorder?
• 9:03
  Right.
• 9:03
  What
• 9:03
  are
• 9:03
  we
• 9:04
  looking
• 9:04
  at?
• 9:04
  Right.
• 9:04
  It's
• 9:04
  this
• 9:04
  bipolar
• 9:05
  mania
• 9:05
  and
• 9:05
  they're
• 9:06
  psychotic.
• 9:06
  But
• 9:07
  again,
• 9:08
  in.
• 9:08
  If
• 9:08
  a
• 9:08
  patient
• 9:09
  is
• 9:09
  depressed
• 9:10
  and
• 9:10
  especially
• 9:10
  at
• 9:11
  the
• 9:11
  worst
• 9:11
  of
• 9:11
  their
• 9:11
  depression,
• 9:12
  they
• 9:12
  tell
• 9:12
  you
• 9:12
  they
• 9:13
  See
• 9:13
  shadows,
• 9:13
  they
• 9:13
  hear
• 9:14
  critic
• 9:14
  self
• 9:14
  critical
• 9:15
  voices.
• 9:16
  Usually
• 9:16
  when
• 9:16
  it's
• 9:17
  accompanied
• 9:17
  by
• 9:17
  mood
• 9:18
  and
• 9:18
  only
• 9:18
  accompanied
• 9:19
  by
• 9:19
  mood.
• 9:20
  That's
• 9:20
  how
• 9:20
  I
• 9:20
  know
• 9:20
  it's
• 9:20
  more
• 9:20
  of
• 9:20
  an
• 9:21
  MDD
• 9:21
  with
• 9:21
  psychotic
• 9:22
  features.
• 9:22
  If
• 9:23
  it's
• 9:23
  independent
• 9:24
  and
• 9:24
  they're
• 9:24
  not
• 9:24
  depressed,
• 9:25
  then
• 9:26
  I'm
• 9:26
  kind
• 9:26
  of
• 9:26
  like,
• 9:27
  you
• 9:27
  know,
• 9:27
  the
• 9:27
  sirens,
• 9:28
  the
• 9:28
  alarm
• 9:28
  bells
• 9:29
  kind
• 9:29
  of
• 9:29
  go
• 9:29
  off
• 9:29
  and
• 9:29
  I'm
• 9:30
  thinking,
• 9:30
  okay,
• 9:30
  this
• 9:31
  could
• 9:31
  be
• 9:31
  more
• 9:31
  of
• 9:31
  a
• 9:31
  primary
• 9:32
  psychotic
• 9:32
  disorder.
• 9:33
  I'm
• 9:33
  definitely
• 9:33
  concerned
• 9:34
  about
• 9:34
  substance
• 9:34
  use.
• 9:35
  I'm
• 9:35
  looking
• 9:35
  at
• 9:35
  cannabis,
• 9:36
  I'm
• 9:36
  looking
• 9:36
  at
• 9:36
  all
• 9:37
  the
• 9:37
  things
• 9:37
  on
• 9:37
  the
• 9:37
  market
• 9:38
  nowadays.
• 9:39
  And
• 9:39
  so
• 9:39
  you
• 9:40
  gotta
• 9:40
  definitely
• 9:41
  keep
• 9:41
  your
• 9:41
  ear
• 9:41
  to
• 9:42
  the
• 9:42
  ground
• 9:42
  with
• 9:42
  that.
• 9:42
  But
• 9:43
  with
• 9:43
  psychotic
• 9:43
  features
• 9:44
  is
• 9:44
  very
• 9:44
  important
• 9:45
  again
• 9:45
  that
• 9:45
  we
• 9:45
  add
• 9:46
  that
• 9:46
  specifier
• 9:46
  for
• 9:47
  yourself,
• 9:47
  for
• 9:48
  your,
• 9:48
  for
• 9:48
  the
• 9:48
  next
• 9:49
  prescribers
• 9:49
  because
• 9:50
  that
• 9:50
  indicates
• 9:50
  it's
• 9:51
  probably
• 9:51
  a
• 9:51
  good
• 9:51
  idea
• 9:52
  to
• 9:52
  add
• 9:52
  combination
• 9:53
  therapy.
• 9:53
  Right?
• 9:54
  That's
• 9:54
  the
• 9:54
  standard
• 9:54
  of
• 9:55
  care.
• 9:55
  So
• 9:55
  you
• 9:56
  would
• 9:56
  do
• 9:56
  like
• 9:57
  your
• 9:57
  Zoloft
• 9:58
  with
• 9:58
  Olanzapine
• 9:58
  or
• 9:59
  you
• 9:59
  would
• 9:59
  add
• 9:59
  an
• 9:59
  antipsychotic,
• 10:00
  maybe
• 10:00
  abilify
• 10:01
  for
• 10:01
  some
• 10:01
  folks.
• 10:02
  And
• 10:02
  it
• 10:02
  kind
• 10:02
  of
• 10:03
  just
• 10:03
  depends.
• 10:03
  It's,
• 10:03
  it's,
• 10:04
  it,
• 10:04
  you
• 10:04
  know,
• 10:04
  idiosyncratic
• 10:05
  per
• 10:06
  your
• 10:06
  patient.
• 10:07
  But
• 10:08
  you
• 10:08
  definitely
• 10:09
  want
• 10:09
  to
• 10:09
  cover
• 10:09
  that
• 10:10
  piece
• 10:10
  of
• 10:10
  the
• 10:10
  depression
• 10:11
  and
• 10:11
  with
• 10:12
  an
• 10:12
  antipsychotic
• 10:13
  of
• 10:13
  some
• 10:13
  kind
• 10:13
  of.
• 10:14
  Because
• 10:14
  there
• 10:14
  is
• 10:15
  of
• 10:15
  course
• 10:15
  a
• 10:15
  high
• 10:16
  suicide
• 10:16
  risk
• 10:16
  for
• 10:17
  untreated
• 10:17
  psychotic
• 10:18
  depression.
• 10:19
  Always
• 10:19
  remember
• 10:20
  to
• 10:20
  look
• 10:20
  past
• 10:21
  just
• 10:21
  a
• 10:21
  symptom,
• 10:22
  right?
• 10:22
  Ask
• 10:22
  yourself
• 10:23
  what
• 10:23
  else
• 10:23
  does
• 10:23
  this
• 10:23
  mean
• 10:24
  for
• 10:24
  the
• 10:24
  treatment
• 10:25
  plan?
• 10:25
  Okay,
• 10:25
  I
• 10:25
  see
• 10:25
  psychosis
• 10:26
  on
• 10:26
  top
• 10:26
  of
• 10:26
  depression,
• 10:27
  but
• 10:27
  what
• 10:28
  else
• 10:28
  does
• 10:28
  that
• 10:28
  mean
• 10:28
  for
• 10:29
  me
• 10:29
  and
• 10:29
  for
• 10:29
  the
• 10:29
  patient?
• 10:30
  Well,
• 10:30
  it
• 10:30
  means
• 10:30
  that
• 10:31
  this
• 10:31
  patient
• 10:31
  is
• 10:31
  now
• 10:32
  in
• 10:32
  kind
• 10:32
  of
• 10:32
  a
• 10:32
  new
• 10:32
  risk
• 10:32
  category.
• 10:33
  There's
• 10:34
  added
• 10:34
  complications,
• 10:35
  right.
• 10:35
  And
• 10:35
  you
• 10:35
  want
• 10:36
  to
• 10:36
  always
• 10:36
  assess.
• 10:37
  This
• 10:37
  is
• 10:37
  one
• 10:37
  of
• 10:37
  my
• 10:38
  golden
• 10:38
  rules.
• 10:38
  If
• 10:39
  there's
• 10:39
  psychosis
• 10:39
  and
• 10:40
  depression,
• 10:40
  I'm
• 10:41
  asking,
• 10:41
  you
• 10:41
  know,
• 10:42
  are
• 10:42
  the
• 10:42
  voices
• 10:42
  telling
• 10:43
  you
• 10:43
  to
• 10:43
  do
• 10:43
  anything?
• 10:44
  It's
• 10:44
  absolutely
• 10:45
  essential
• 10:45
  you
• 10:45
  ask
• 10:45
  that
• 10:46
  because
• 10:46
  sometimes
• 10:47
  you
• 10:47
  will
• 10:47
  have
• 10:47
  a
• 10:47
  patient
• 10:47
  who
• 10:48
  says
• 10:48
  yes,
• 10:48
  the
• 10:48
  my
• 10:49
  voices
• 10:49
  are
• 10:49
  telling
• 10:49
  me
• 10:49
  to
• 10:50
  end
• 10:50
  my
• 10:50
  life.
• 10:50
  And
• 10:51
  you
• 10:51
  have
• 10:51
  to
• 10:51
  really
• 10:52
  assess
• 10:52
  for
• 10:52
  safety
• 10:53
  at
• 10:53
  that
• 10:53
  point.
• 10:53
  Right.
• 10:54
  How
• 10:54
  likely
• 10:54
  are
• 10:54
  they
• 10:55
  to
• 10:55
  listen
• 10:55
  to
• 10:55
  those
• 10:55
  voices?
• 10:56
  Are
• 10:56
  they
• 10:57
  disturbed
• 10:57
  by
• 10:57
  those
• 10:57
  voices
• 10:58
  or
• 10:58
  is
• 10:58
  their
• 10:59
  reality
• 10:59
  testing
• 10:59
  so
• 11:00
  impaired
• 11:00
  that
• 11:00
  they
• 11:00
  want
• 11:01
  to
• 11:01
  listen
• 11:01
  to
• 11:01
  those
• 11:01
  voices?
• 11:02
  They've
• 11:02
  developed
• 11:02
  a
• 11:02
  plan.
• 11:03
  They're
• 11:03
  like
• 11:04
  enmeshed
• 11:04
  with
• 11:04
  those
• 11:04
  voices.
• 11:05
  That's
• 11:06
  very
• 11:06
  much
• 11:06
  a
• 11:07
  five
• 11:07
  alarm
• 11:07
  fire.
• 11:08
  You
• 11:08
  need
• 11:08
  to
• 11:08
  figure
• 11:09
  out
• 11:09
  and
• 11:10
  assess
• 11:10
  for.
• 11:11
  Definitely
• 11:11
  assess
• 11:12
  if
• 11:12
  they
• 11:12
  need
• 11:12
  to
• 11:12
  be
• 11:12
  hospitalized,
• 11:13
  right.
• 11:13
  If
• 11:13
  they're
• 11:13
  how
• 11:14
  psychotic
• 11:14
  are
• 11:14
  we?
• 11:14
  Are
• 11:15
  we
• 11:15
  able
• 11:15
  to
• 11:16
  engage
• 11:16
  in
• 11:16
  self
• 11:17
  care?
• 11:17
  Are
• 11:17
  we
• 11:17
  gravely
• 11:17
  disabled?
• 11:18
  Do
• 11:18
  we
• 11:18
  feel
• 11:19
  someone's
• 11:19
  trying
• 11:19
  to
• 11:19
  hurt?
• 11:20
  Does
• 11:20
  the
• 11:20
  patient
• 11:20
  feel
• 11:21
  like
• 11:21
  someone's
• 11:21
  trying
• 11:21
  to
• 11:21
  hurt
• 11:22
  somebody
• 11:22
  else
• 11:22
  and
• 11:22
  they
• 11:23
  Might
• 11:23
  need
• 11:23
  to.
• 11:23
  They
• 11:24
  might
• 11:24
  be
• 11:24
  aggressive
• 11:24
  and
• 11:24
  they
• 11:25
  might
• 11:25
  want
• 11:25
  to
• 11:25
  hurt
• 11:25
  that
• 11:25
  person
• 11:26
  to
• 11:26
  defend
• 11:26
  themselves.
• 11:27
  A
• 11:27
  lot
• 11:27
  of
• 11:27
  things
• 11:28
  happen
• 11:28
  here.
• 11:29
  ECT
• 11:29
  gets
• 11:30
  on
• 11:30
  the
• 11:30
  table
• 11:30
  as
• 11:31
  a
• 11:31
  possible
• 11:31
  treatment
• 11:32
  option.
• 11:33
  So
• 11:34
  again,
• 11:34
  psychotic
• 11:35
  features,
• 11:35
  it
• 11:35
  is
• 11:36
  a
• 11:36
  little
• 11:36
  more
• 11:36
  obvious
• 11:37
  and
• 11:37
  not
• 11:37
  as
• 11:37
  subtle
• 11:38
  as
• 11:38
  maybe
• 11:38
  the
• 11:38
  anxious
• 11:39
  distress.
• 11:40
  But
• 11:40
  nonetheless,
• 11:40
  it's
• 11:41
  really
• 11:41
  important
• 11:41
  to
• 11:41
  flag
• 11:42
  that
• 11:42
  you
• 11:42
  also
• 11:43
  have
• 11:43
  with
• 11:43
  catatonic
• 11:44
  features.
• 11:44
  I
• 11:44
  won't
• 11:45
  beat
• 11:45
  the
• 11:45
  dead
• 11:45
  horse
• 11:45
  on
• 11:46
  that.
• 11:46
  That's
• 11:46
  kind
• 11:46
  of
• 11:46
  its
• 11:46
  own
• 11:47
  episode,
• 11:47
  its
• 11:47
  own
• 11:48
  animal.
• 11:48
  It
• 11:48
  is
• 11:49
  very
• 11:49
  intricate.
• 11:50
  It's
• 11:50
  a
• 11:50
  very
• 11:51
  really
• 11:51
  thorough
• 11:52
  criteria
• 11:53
  requiring
• 11:53
  three
• 11:54
  or
• 11:54
  more
• 11:54
  of
• 11:54
  12
• 11:55
  psychomotor
• 11:56
  features
• 11:56
  during
• 11:57
  a
• 11:57
  depressive
• 11:57
  episode.
• 11:58
  You've
• 11:58
  probably
• 11:58
  heard
• 11:58
  of
• 11:58
  these
• 11:59
  before.
• 11:59
  My
• 11:59
  friends.
• 12:00
  Stupor,
• 12:00
  where
• 12:01
  there's
• 12:01
  like
• 12:01
  no
• 12:01
  psychomotor
• 12:02
  activity
• 12:02
  at
• 12:03
  all.
• 12:03
  There's
• 12:04
  waxy
• 12:04
  flexibility,
• 12:05
  right.
• 12:06
  So
• 12:06
  there's
• 12:06
  like
• 12:06
  slight
• 12:07
  even
• 12:07
  resistance
• 12:08
  to
• 12:08
  repositioning.
• 12:08
  Kind
• 12:09
  of
• 12:09
  like
• 12:09
  you're
• 12:09
  moving
• 12:09
  a
• 12:09
  wax
• 12:10
  figure.
• 12:10
  Mutism.
• 12:11
  They're
• 12:11
  not,
• 12:11
  not
• 12:12
  a
• 12:12
  lot
• 12:12
  of
• 12:12
  you
• 12:12
  kind
• 12:13
  of
• 12:13
  see
• 12:13
  patients
• 12:13
  like
• 12:13
  staring
• 12:14
  often
• 12:14
  in
• 12:14
  the
• 12:14
  distance.
• 12:14
  They're
• 12:15
  not
• 12:15
  talking
• 12:15
  at
• 12:15
  all.
• 12:16
  They
• 12:16
  don't
• 12:16
  respond
• 12:17
  to
• 12:17
  instructions
• 12:18
  when
• 12:18
  you
• 12:18
  ask
• 12:18
  them
• 12:18
  to
• 12:18
  get
• 12:19
  up
• 12:19
  and,
• 12:19
  or,
• 12:20
  or
• 12:20
  to
• 12:20
  extend
• 12:20
  their
• 12:21
  arm
• 12:21
  to,
• 12:21
  to
• 12:21
  get
• 12:22
  vital
• 12:22
  signs.
• 12:22
  So
• 12:23
  I
• 12:23
  won't
• 12:23
  go
• 12:23
  into
• 12:23
  all
• 12:23
  of
• 12:24
  those
• 12:24
  psychomotor
• 12:24
  features,
• 12:25
  but
• 12:25
  suffice
• 12:26
  it
• 12:26
  to
• 12:26
  say
• 12:26
  that
• 12:26
  is
• 12:27
  its
• 12:27
  own
• 12:27
  treatment
• 12:27
  algorithm.
• 12:28
  Right?
• 12:28
  You're
• 12:28
  talking
• 12:29
  Ativan
• 12:29
  IV
• 12:30
  or
• 12:30
  im.
• 12:30
  You're
• 12:31
  talking
• 12:31
  ect,
• 12:31
  which
• 12:32
  is
• 12:32
  highly
• 12:32
  effective
• 12:33
  for
• 12:33
  refractory
• 12:34
  or
• 12:34
  severe
• 12:35
  catatonia.
• 12:36
  So
• 12:36
  again,
• 12:37
  just
• 12:37
  a
• 12:37
  way
• 12:38
  to
• 12:38
  specify
• 12:38
  what
• 12:38
  kind
• 12:39
  of
• 12:39
  treatment,
• 12:39
  but
• 12:39
  I'm
• 12:40
  sure
• 12:40
  you're
• 12:40
  kind
• 12:40
  of
• 12:40
  already
• 12:41
  beginning
• 12:41
  to
• 12:41
  understand
• 12:42
  and
• 12:42
  appreciate
• 12:43
  how
• 12:44
  the
• 12:44
  specifiers
• 12:45
  inform
• 12:45
  different
• 12:46
  categories
• 12:46
  of
• 12:46
  treatment.
• 12:47
  Now,
• 12:47
  for
• 12:47
  mixed
• 12:47
  features,
• 12:48
  we
• 12:48
  touched
• 12:48
  on
• 12:48
  this
• 12:48
  briefly.
• 12:49
  I
• 12:49
  know
• 12:50
  for
• 12:50
  me,
• 12:50
  I
• 12:50
  feel
• 12:50
  like
• 12:51
  this
• 12:51
  is
• 12:51
  a
• 12:51
  really
• 12:51
  common
• 12:52
  presentation
• 12:53
  that
• 12:53
  you
• 12:53
  will
• 12:54
  see
• 12:54
  in
• 12:54
  the
• 12:55
  outpatient
• 12:55
  space.
• 12:55
  At
• 12:55
  least
• 12:56
  common
• 12:56
  for
• 12:56
  me.
• 12:57
  Not
• 12:57
  every
• 12:58
  day.
• 12:58
  I'm
• 12:58
  not
• 12:58
  saying
• 12:58
  you're
• 12:59
  going
• 12:59
  to
• 12:59
  see
• 12:59
  this
• 12:59
  every
• 12:59
  day,
• 13:00
  but
• 13:00
  I
• 13:00
  would
• 13:00
  argue
• 13:01
  if
• 13:01
  I
• 13:01
  could
• 13:01
  go
• 13:01
  to
• 13:02
  every
• 13:02
  NP
• 13:02
  school
• 13:02
  in
• 13:02
  the
• 13:03
  psych
• 13:03
  NP
• 13:03
  school
• 13:04
  in
• 13:04
  the
• 13:04
  country,
• 13:04
  I
• 13:04
  would
• 13:04
  tell
• 13:04
  the
• 13:05
  students,
• 13:05
  listen,
• 13:06
  of
• 13:06
  course,
• 13:07
  this
• 13:07
  is
• 13:07
  messier
• 13:07
  than
• 13:08
  your
• 13:08
  textbooks.
• 13:09
  I
• 13:09
  feel
• 13:09
  like
• 13:09
  mixed
• 13:10
  features
• 13:10
  is
• 13:10
  very
• 13:10
  common,
• 13:11
  or
• 13:11
  at
• 13:11
  least
• 13:11
  maybe
• 13:12
  not
• 13:12
  full
• 13:13
  blown
• 13:13
  mixed
• 13:13
  features,
• 13:14
  but
• 13:14
  the.
• 13:14
  I
• 13:14
  feel
• 13:15
  like
• 13:15
  one
• 13:15
  of
• 13:15
  the
• 13:15
  most
• 13:15
  common
• 13:16
  patients
• 13:16
  you're
• 13:16
  going
• 13:16
  to
• 13:16
  see
• 13:17
  is
• 13:17
  someone
• 13:17
  with
• 13:17
  depression
• 13:18
  who
• 13:18
  tends
• 13:19
  to
• 13:19
  exhibit
• 13:20
  some
• 13:20
  of
• 13:20
  these
• 13:20
  more
• 13:21
  hypomanic
• 13:22
  traits.
• 13:23
  And
• 13:23
  they.
• 13:23
  It'll
• 13:24
  stump
• 13:24
  you
• 13:24
  and
• 13:24
  it'll
• 13:25
  make
• 13:25
  you
• 13:25
  really
• 13:26
  put
• 13:26
  on
• 13:26
  your
• 13:26
  thinking
• 13:27
  caps.
• 13:27
  And
• 13:27
  this
• 13:27
  is
• 13:27
  where
• 13:27
  asking
• 13:28
  the
• 13:28
  right
• 13:28
  questions
• 13:29
  is
• 13:29
  really
• 13:29
  important.
• 13:30
  And
• 13:31
  just
• 13:31
  like
• 13:31
  with
• 13:32
  anxious
• 13:32
  features,
• 13:33
  I
• 13:33
  wouldn't
• 13:33
  overthink
• 13:34
  mixed
• 13:34
  features
• 13:35
  a
• 13:35
  whole
• 13:35
  lot.
• 13:36
  It
• 13:36
  definitely
• 13:37
  matters
• 13:37
  because
• 13:38
  if
• 13:38
  you
• 13:38
  do
• 13:38
  have
• 13:39
  mixed
• 13:39
  features,
• 13:40
  you
• 13:40
  want
• 13:40
  to
• 13:40
  avoid
• 13:41
  antidepressant
• 13:42
  monotherapy
• 13:43
  alone.
• 13:43
  That
• 13:44
  can
• 13:44
  worsen
• 13:44
  mixed
• 13:45
  features,
• 13:45
  right?
• 13:45
  You
• 13:45
  can
• 13:46
  cycle
• 13:46
  more
• 13:46
  in
• 13:46
  and
• 13:46
  out
• 13:47
  of
• 13:47
  your
• 13:47
  moods.
• 13:47
  It
• 13:48
  can
• 13:48
  precipitate
• 13:48
  a
• 13:48
  hypomanic
• 13:49
  or
• 13:49
  manic
• 13:50
  switch.
• 13:51
  So,
• 13:51
  you
• 13:51
  know,
• 13:52
  I
• 13:52
  would
• 13:52
  argue
• 13:52
  that
• 13:53
  mixed
• 13:53
  features
• 13:54
  is
• 13:54
  kind
• 13:54
  of
• 13:54
  a
• 13:54
  flashing
• 13:55
  light
• 13:56
  for.
• 13:57
  I
• 13:57
  wouldn't
• 13:57
  even
• 13:58
  say
• 13:58
  flashing
• 13:58
  yellow
• 13:59
  light,
• 13:59
  right?
• 13:59
  You
• 13:59
  don't
• 14:00
  really.
• 14:01
  You've
• 14:01
  got
• 14:01
  to
• 14:01
  kind
• 14:01
  of
• 14:01
  stop
• 14:02
  almost.
• 14:02
  It's
• 14:03
  like
• 14:03
  a
• 14:03
  flashing
• 14:03
  red
• 14:03
  light.
• 14:04
  You
• 14:04
  want
• 14:04
  to
• 14:04
  stop
• 14:05
  and
• 14:06
  kind
• 14:06
  of
• 14:06
  reconsider
• 14:07
  your
• 14:07
  treatment
• 14:07
  plan
• 14:08
  here
• 14:08
  because
• 14:08
  it's
• 14:08
  not
• 14:09
  wise
• 14:09
  to
• 14:09
  just
• 14:09
  start
• 14:09
  Prozac.
• 14:10
  In
• 14:10
  that
• 14:10
  case,
• 14:11
  you
• 14:12
  want
• 14:12
  to
• 14:12
  probably
• 14:13
  look
• 14:13
  at
• 14:13
  lurazidone,
• 14:14
  which
• 14:14
  seems
• 14:14
  to
• 14:15
  have
• 14:15
  the
• 14:15
  best
• 14:15
  evidence
• 14:15
  for
• 14:16
  mixed
• 14:16
  features
• 14:16
  with
• 14:17
  mdt
• 14:17
  with
• 14:17
  mixed
• 14:18
  features,
• 14:19
  it
• 14:19
  has
• 14:19
  actually
• 14:20
  RCT
• 14:20
  evidence,
• 14:21
  randomized
• 14:21
  controlled
• 14:21
  trial
• 14:22
  evidence
• 14:22
  for
• 14:23
  MDD
• 14:23
  with
• 14:23
  mixed
• 14:24
  features.
• 14:24
  And
• 14:24
  there's
• 14:25
  some
• 14:25
  other
• 14:25
  medications
• 14:25
  to
• 14:26
  look
• 14:26
  at
• 14:26
  with
• 14:26
  some
• 14:26
  evidence
• 14:27
  out
• 14:27
  there.
• 14:28
  Now
• 14:28
  that
• 14:28
  would
• 14:28
  be
• 14:29
  in
• 14:29
  our
• 14:30
  Pearls
• 14:30
  plus
• 14:30
  membership
• 14:31
  for
• 14:31
  three
• 14:31
  bucks
• 14:32
  a
• 14:32
  month.
• 14:32
  It's
• 14:32
  a
• 14:32
  steal,
• 14:33
  my
• 14:33
  friends.
• 14:33
  Even
• 14:33
  if
• 14:33
  you
• 14:33
  get
• 14:34
  one
• 14:34
  good
• 14:34
  pearl
• 14:34
  out
• 14:35
  of
• 14:35
  there,
• 14:35
  oh,
• 14:35
  it
• 14:35
  makes
• 14:35
  your
• 14:36
  day
• 14:36
  and
• 14:36
  your
• 14:36
  week
• 14:37
  so
• 14:37
  much
• 14:37
  easier.
• 14:38
  So
• 14:38
  I
• 14:38
  highly
• 14:39
  recommend
• 14:39
  you
• 14:39
  go
• 14:39
  to
• 14:40
  our
• 14:40
  show
• 14:40
  notes,
• 14:40
  become
• 14:41
  Patreon
• 14:41
  members,
• 14:42
  and
• 14:42
  there's
• 14:42
  all
• 14:43
  kinds
• 14:43
  of
• 14:43
  cool
• 14:43
  Patreon
• 14:44
  memberships
• 14:45
  for
• 14:45
  you.
• 14:45
  But
• 14:45
  my
• 14:45
  friends,
• 14:46
  Latuda,
• 14:47
  mixed
• 14:48
  features,
• 14:48
  it's
• 14:48
  a
• 14:48
  decent
• 14:49
  thing
• 14:49
  and
• 14:49
  it
• 14:50
  gives
• 14:50
  you
• 14:50
  a
• 14:50
  peace
• 14:50
  of
• 14:50
  mind,
• 14:50
  right?
• 14:51
  Because
• 14:52
  Latuda,
• 14:52
  remember
• 14:53
  all
• 14:53
  these
• 14:53
  meds,
• 14:54
  they
• 14:54
  act
• 14:54
  on
• 14:54
  many
• 14:54
  different
• 14:55
  receptors
• 14:55
  and
• 14:55
  Latuda
• 14:56
  is
• 14:57
  going
• 14:57
  in
• 14:57
  there
• 14:57
  and
• 14:57
  it's
• 14:58
  stabilizing
• 14:59
  mood
• 14:59
  for
• 14:59
  you,
• 15:00
  right,
• 15:00
  with
• 15:00
  D2
• 15:01
  antagonism.
• 15:02
  But
• 15:02
  it's
• 15:02
  also,
• 15:03
  you
• 15:03
  know,
• 15:04
  antagonizing
• 15:04
  5ht7,
• 15:05
  which
• 15:06
  is
• 15:06
  an
• 15:06
  antidepressant
• 15:07
  way.
• 15:07
  It's
• 15:08
  kind
• 15:08
  of
• 15:08
  an
• 15:08
  antidepressant
• 15:09
  approach.
• 15:09
  So
• 15:10
  you're
• 15:10
  getting
• 15:10
  control,
• 15:11
  right?
• 15:11
  You're
• 15:11
  getting
• 15:11
  the,
• 15:12
  you're
• 15:13
  getting
• 15:13
  the
• 15:13
  mood
• 15:13
  stabilization
• 15:14
  with
• 15:14
  the
• 15:15
  antidepressant.
• 15:16
  And
• 15:16
  you
• 15:16
  can
• 15:16
  kind
• 15:16
  of
• 15:17
  sleep
• 15:17
  easy
• 15:17
  at
• 15:17
  night
• 15:18
  because
• 15:18
  you're
• 15:18
  not
• 15:19
  having
• 15:19
  to
• 15:19
  cross
• 15:19
  your
• 15:20
  fingers
• 15:20
  and
• 15:20
  go,
• 15:20
  oh,
• 15:20
  wait,
• 15:21
  did
• 15:21
  I
• 15:21
  just
• 15:21
  prescribe
• 15:21
  Prozac
• 15:22
  to
• 15:22
  someone?
• 15:22
  That
• 15:22
  kind
• 15:23
  of
• 15:23
  gave
• 15:23
  me
• 15:23
  the
• 15:23
  hibby
• 15:23
  jibbies
• 15:24
  about
• 15:24
  having
• 15:25
  bipolar.
• 15:26
  And
• 15:26
  yet
• 15:26
  they
• 15:26
  don't.
• 15:27
  So
• 15:27
  I
• 15:28
  think
• 15:28
  that's
• 15:28
  really
• 15:28
  important.
• 15:29
  And
• 15:30
  so
• 15:30
  definitely,
• 15:31
  again,
• 15:31
  for
• 15:32
  obvious
• 15:32
  reasons,
• 15:33
  the
• 15:33
  mix
• 15:33
  features
• 15:34
  will
• 15:34
  inform
• 15:34
  you
• 15:35
  to
• 15:35
  hedge
• 15:36
  against,
• 15:37
  you
• 15:38
  know,
• 15:38
  accidentally
• 15:38
  inducing
• 15:39
  hypomania
• 15:40
  or
• 15:40
  mania.
• 15:41
  Now,
• 15:41
  mixed
• 15:42
  features
• 15:42
  can
• 15:42
  be
• 15:42
  confusing
• 15:43
  when
• 15:43
  they
• 15:43
  happen
• 15:43
  when
• 15:44
  a
• 15:44
  patient's
• 15:44
  in
• 15:44
  front
• 15:44
  of
• 15:44
  you
• 15:45
  and
• 15:45
  they
• 15:45
  also
• 15:46
  have
• 15:46
  an
• 15:46
  elevated
• 15:46
  or
• 15:47
  expansive
• 15:47
  mood.
• 15:48
  Their
• 15:48
  self
• 15:48
  esteem
• 15:49
  is
• 15:49
  unusually
• 15:49
  high.
• 15:50
  They're
• 15:50
  grandiose.
• 15:51
  Maybe
• 15:51
  they're
• 15:51
  trying
• 15:52
  to
• 15:52
  start
• 15:52
  a
• 15:52
  business
• 15:53
  on
• 15:53
  the
• 15:53
  side.
• 15:53
  And
• 15:53
  it's
• 15:54
  a
• 15:54
  little
• 15:54
  unusual
• 15:54
  behavior.
• 15:55
  They
• 15:56
  feel
• 15:56
  like
• 15:56
  they
• 15:56
  don't
• 15:56
  need
• 15:56
  to
• 15:56
  sleep
• 15:57
  as
• 15:57
  much
• 15:57
  or
• 15:58
  they
• 15:58
  feel
• 15:58
  rested
• 15:58
  with
• 15:59
  very
• 15:59
  little
• 15:59
  sleep.
• 16:00
  And
• 16:00
  so
• 16:00
  you
• 16:00
  might
• 16:00
  go,
• 16:01
  wait
• 16:01
  a
• 16:01
  minute,
• 16:01
  is
• 16:01
  this
• 16:01
  bipolar?
• 16:02
  One
• 16:02
  of
• 16:03
  the
• 16:03
  key
• 16:03
  questions
• 16:04
  that
• 16:04
  you
• 16:04
  need
• 16:04
  to
• 16:05
  ask
• 16:05
  yourself
• 16:06
  is,
• 16:06
  are
• 16:07
  the
• 16:07
  patient's
• 16:07
  up
• 16:08
  symptoms
• 16:08
  happening
• 16:09
  at
• 16:09
  the
• 16:09
  same
• 16:09
  time
• 16:09
  as
• 16:09
  depression
• 16:10
  or
• 16:10
  separately?
• 16:11
  And
• 16:11
  that's
• 16:11
  gonna
• 16:11
  really
• 16:11
  help
• 16:12
  you.
• 16:12
  Are
• 16:12
  the
• 16:12
  patient's
• 16:13
  up
• 16:13
  symptoms
• 16:14
  happening
• 16:14
  at
• 16:14
  the
• 16:15
  same
• 16:15
  time
• 16:15
  as
• 16:16
  the
• 16:16
  depression
• 16:16
  or
• 16:17
  separately?
• 16:17
  If
• 16:18
  this
• 16:18
  is
• 16:18
  coming
• 16:18
  within
• 16:19
  the
• 16:19
  depression,
• 16:20
  kind
• 16:20
  of
• 16:20
  mixed
• 16:21
  within
• 16:21
  the
• 16:21
  depression,
• 16:21
  it's
• 16:22
  more
• 16:22
  like
• 16:22
  mixed
• 16:22
  features,
• 16:23
  right?
• 16:23
  However,
• 16:24
  if
• 16:24
  this
• 16:24
  is
• 16:24
  coming
• 16:25
  separately
• 16:25
  of
• 16:26
  the
• 16:26
  depression,
• 16:27
  then
• 16:27
  it's
• 16:28
  probably
• 16:28
  more
• 16:29
  suspicious
• 16:29
  for
• 16:29
  like
• 16:30
  a
• 16:30
  hypomania
• 16:30
  or
• 16:30
  mania.
• 16:31
  Of
• 16:31
  course,
• 16:31
  it
• 16:31
  has
• 16:31
  to
• 16:31
  meet
• 16:32
  that
• 16:32
  criteria.
• 16:33
  That
• 16:33
  has
• 16:33
  its
• 16:33
  own
• 16:33
  independent
• 16:34
  criteria.
• 16:35
  Fair
• 16:35
  enough.
• 16:35
  Now
• 16:36
  remember,
• 16:37
  regardless
• 16:38
  whether
• 16:38
  it's
• 16:39
  separate,
• 16:39
  whether
• 16:39
  it's
• 16:39
  mixed,
• 16:40
  it
• 16:40
  still
• 16:40
  orients
• 16:41
  you
• 16:41
  to
• 16:42
  a
• 16:42
  different
• 16:42
  kind
• 16:42
  of
• 16:42
  treatment.
• 16:43
  So
• 16:43
  this
• 16:43
  is
• 16:43
  another
• 16:44
  example
• 16:44
  of
• 16:44
  not
• 16:44
  having.
• 16:45
  Not
• 16:45
  needing
• 16:45
  to
• 16:45
  overthink
• 16:46
  this
• 16:46
  so
• 16:46
  much.
• 16:47
  And
• 16:47
  remember
• 16:48
  that
• 16:48
  somewhere
• 16:48
  between
• 16:49
  25%
• 16:50
  of
• 16:50
  these
• 16:51
  folks,
• 16:51
  even
• 16:51
  up
• 16:52
  to
• 16:52
  40%
• 16:52
  of
• 16:53
  the
• 16:53
  folks
• 16:53
  with
• 16:53
  mixed
• 16:53
  features,
• 16:54
  the
• 16:54
  evidence
• 16:54
  that
• 16:54
  has
• 16:55
  kind
• 16:55
  of
• 16:55
  a
• 16:55
  range
• 16:55
  to
• 16:55
  it
• 16:56
  will
• 16:56
  convert
• 16:56
  to
• 16:56
  a
• 16:57
  bipolar
• 16:57
  diagnosis.
• 16:58
  So
• 16:58
  antidepressant
• 16:59
  monotherapy
• 17:00
  for
• 17:00
  these
• 17:00
  folks
• 17:01
  is.
• 17:02
  Is
• 17:02
  very
• 17:02
  dicey.
• 17:03
  It's
• 17:03
  kind
• 17:03
  of
• 17:03
  playing
• 17:04
  with
• 17:04
  fire.
• 17:04
  I
• 17:05
  know
• 17:05
  every
• 17:05
  patient's
• 17:05
  different,
• 17:06
  but
• 17:06
  you
• 17:06
  really
• 17:06
  gotta
• 17:07
  take
• 17:07
  a
• 17:07
  hard
• 17:07
  look
• 17:07
  at
• 17:08
  this.
• 17:08
  Now,
• 17:08
  another
• 17:08
  specifier
• 17:09
  is
• 17:09
  melancholic
• 17:10
  features,
• 17:11
  right?
• 17:11
  These
• 17:11
  are
• 17:11
  folks
• 17:11
  who
• 17:11
  have
• 17:12
  a
• 17:12
  distinct
• 17:12
  loss
• 17:12
  of
• 17:13
  pleasure
• 17:13
  in
• 17:13
  almost
• 17:13
  all
• 17:14
  activities.
• 17:15
  They
• 17:15
  don't
• 17:15
  even
• 17:15
  react
• 17:16
  to
• 17:16
  positive
• 17:16
  events.
• 17:17
  These
• 17:17
  guys
• 17:17
  could
• 17:17
  win
• 17:17
  the
• 17:18
  Powerball.
• 17:19
  They
• 17:19
  could
• 17:19
  be
• 17:19
  in
• 17:19
  Fiji
• 17:21
  sipping
• 17:21
  a
• 17:21
  pina
• 17:21
  colada,
• 17:22
  and
• 17:22
  they
• 17:22
  just.
• 17:22
  Their
• 17:23
  moods
• 17:23
  don't
• 17:24
  react.
• 17:24
  They
• 17:24
  wake
• 17:25
  up
• 17:25
  early,
• 17:26
  they
• 17:26
  have
• 17:26
  weight
• 17:26
  loss,
• 17:27
  they
• 17:27
  have
• 17:27
  a
• 17:27
  lot
• 17:27
  of
• 17:27
  guilt.
• 17:28
  Their
• 17:28
  mood's
• 17:28
  usually
• 17:29
  worse
• 17:29
  in
• 17:29
  the
• 17:29
  morning.
• 17:30
  SSRIs
• 17:31
  are
• 17:31
  pretty
• 17:31
  good
• 17:31
  for
• 17:31
  these
• 17:32
  practical
• 17:32
  first
• 17:32
  line
• 17:33
  options.
• 17:33
  This
• 17:33
  is
• 17:33
  where
• 17:34
  the
• 17:34
  evidence
• 17:35
  seems
• 17:35
  to
• 17:35
  suggest
• 17:36
  that
• 17:36
  more
• 17:37
  or
• 17:37
  less
• 17:37
  any
• 17:37
  of
• 17:37
  the
• 17:38
  SSRIs
• 17:38
  are
• 17:39
  pretty
• 17:39
  good
• 17:39
  for
• 17:40
  this
• 17:40
  one.
• 17:40
  I
• 17:40
  personally,
• 17:41
  if
• 17:41
  I
• 17:41
  had
• 17:41
  a
• 17:41
  patient
• 17:42
  who
• 17:42
  was,
• 17:42
  you
• 17:43
  know,
• 17:45
  had
• 17:45
  a
• 17:45
  high
• 17:46
  weight
• 17:46
  or
• 17:46
  was
• 17:46
  gaining
• 17:47
  weight
• 17:47
  and
• 17:48
  had
• 17:48
  a
• 17:48
  lot
• 17:48
  of
• 17:48
  anhedonia,
• 17:49
  I
• 17:49
  would
• 17:49
  probably
• 17:50
  look
• 17:50
  at
• 17:50
  Wellbutrin.
• 17:51
  SSRIs
• 17:52
  are
• 17:52
  pretty
• 17:52
  good.
• 17:53
  TCAs
• 17:53
  have
• 17:53
  robust
• 17:54
  evidence
• 17:54
  in
• 17:54
  melancholic.
• 17:55
  Melancholic
• 17:56
  colic
• 17:56
  depression,
• 17:57
  they
• 17:57
  might
• 17:57
  outperform
• 17:58
  SSRIs
• 17:59
  in
• 17:59
  severe
• 17:59
  cases.
• 17:59
  But
• 18:00
  again,
• 18:00
  I
• 18:00
  personally
• 18:01
  like
• 18:01
  to
• 18:01
  start
• 18:01
  with
• 18:01
  the
• 18:01
  SSRIs
• 18:02
  before
• 18:03
  I
• 18:03
  dabble
• 18:03
  in
• 18:03
  those.
• 18:04
  Now,
• 18:04
  there's
• 18:04
  atypical
• 18:05
  features,
• 18:05
  right?
• 18:06
  You've
• 18:06
  probably
• 18:06
  heard
• 18:06
  of
• 18:06
  that
• 18:07
  specifier
• 18:07
  what
• 18:08
  is
• 18:08
  that?
• 18:08
  Well,
• 18:08
  this
• 18:09
  is
• 18:09
  kind
• 18:09
  of
• 18:09
  the
• 18:09
  opposite
• 18:09
  of
• 18:09
  the
• 18:10
  melancholic,
• 18:10
  where
• 18:11
  your
• 18:11
  mood
• 18:11
  actually
• 18:12
  does
• 18:13
  respond
• 18:14
  and
• 18:14
  brighten
• 18:14
  to
• 18:15
  positive
• 18:15
  events.
• 18:16
  So
• 18:16
  this
• 18:16
  is
• 18:16
  the
• 18:16
  guy
• 18:17
  who
• 18:17
  wins
• 18:17
  the
• 18:17
  Powerball
• 18:18
  and
• 18:19
  they
• 18:20
  are
• 18:20
  super
• 18:20
  happy
• 18:21
  about
• 18:21
  it,
• 18:21
  actually,
• 18:22
  but
• 18:22
  they
• 18:22
  sleep
• 18:23
  a
• 18:23
  lot.
• 18:23
  They
• 18:23
  feel
• 18:23
  kind
• 18:24
  of
• 18:24
  heavy
• 18:25
  in
• 18:25
  their
• 18:25
  arms
• 18:25
  or
• 18:25
  legs.
• 18:26
  Their
• 18:26
  appetite
• 18:26
  is
• 18:26
  really
• 18:27
  increased.
• 18:28
  It's
• 18:28
  like
• 18:28
  the
• 18:28
  word
• 18:29
  describes,
• 18:29
  right?
• 18:29
  I
• 18:30
  don't
• 18:30
  think
• 18:30
  it
• 18:30
  needs
• 18:30
  a
• 18:30
  mnemonic.
• 18:31
  I
• 18:31
  think
• 18:31
  of
• 18:31
  atypical.
• 18:32
  This
• 18:32
  does
• 18:33
  sound
• 18:33
  kind
• 18:33
  of
• 18:33
  atypical
• 18:34
  because
• 18:34
  when
• 18:34
  I
• 18:34
  think
• 18:34
  depressed,
• 18:35
  at
• 18:35
  least
• 18:35
  I
• 18:35
  don't
• 18:36
  think
• 18:36
  of
• 18:36
  someone
• 18:36
  who's
• 18:36
  going
• 18:37
  to
• 18:37
  get
• 18:37
  happy
• 18:37
  about
• 18:37
  the
• 18:37
  Powerball.
• 18:38
  So
• 18:38
  I
• 18:38
  say,
• 18:38
  oh,
• 18:39
  that's
• 18:39
  not
• 18:39
  typical,
• 18:40
  right?
• 18:40
  So
• 18:40
  that's
• 18:41
  how
• 18:41
  I
• 18:41
  think
• 18:42
  about
• 18:42
  atypical.
• 18:42
  I
• 18:42
  think
• 18:43
  of
• 18:43
  someone
• 18:43
  who
• 18:44
  can't
• 18:44
  sleep
• 18:44
  because
• 18:45
  they're
• 18:45
  just
• 18:45
  so
• 18:45
  depressed
• 18:46
  and
• 18:46
  they're
• 18:46
  worrying
• 18:46
  about
• 18:46
  the
• 18:47
  past.
• 18:47
  But.
• 18:47
  But
• 18:47
  it's
• 18:48
  atypical
• 18:48
  that
• 18:48
  they
• 18:48
  sleep
• 18:49
  too
• 18:49
  much
• 18:49
  and
• 18:50
  that
• 18:50
  they're
• 18:50
  eating
• 18:50
  so
• 18:51
  much,
• 18:51
  right?
• 18:52
  Someone
• 18:52
  who
• 18:52
  eats
• 18:52
  a
• 18:52
  lot.
• 18:53
  They
• 18:53
  can
• 18:53
  get
• 18:54
  happy
• 18:54
  when,
• 18:55
  when
• 18:55
  good
• 18:55
  things
• 18:55
  happen.
• 18:56
  They
• 18:56
  sleep
• 18:56
  a
• 18:56
  lot,
• 18:56
  they
• 18:57
  feel
• 18:57
  kind
• 18:57
  of
• 18:57
  heavy.
• 18:58
  And
• 18:58
  so
• 18:59
  I
• 18:59
  find
• 18:59
  that
• 18:59
  is
• 18:59
  a
• 18:59
  little
• 19:00
  bit
• 19:00
  atypical.
• 19:00
  I
• 19:01
  consider,
• 19:01
  like,
• 19:01
  I
• 19:01
  think
• 19:02
  about
• 19:02
  your
• 19:03
  typical
• 19:03
  depression
• 19:04
  as
• 19:04
  someone
• 19:04
  who's
• 19:05
  really
• 19:05
  not
• 19:05
  eating
• 19:06
  a
• 19:06
  lot,
• 19:06
  not
• 19:06
  sleeping
• 19:07
  a
• 19:07
  lot,
• 19:07
  and
• 19:07
  just
• 19:08
  sad
• 19:08
  all
• 19:08
  the
• 19:08
  time,
• 19:09
  right?
• 19:09
  That's
• 19:10
  just
• 19:10
  kind
• 19:10
  of
• 19:10
  all
• 19:10
  the
• 19:10
  negative,
• 19:11
  the
• 19:11
  negative
• 19:11
  depression,
• 19:12
  when
• 19:12
  it's
• 19:13
  atypical,
• 19:13
  it's
• 19:13
  more
• 19:14
  positive
• 19:14
  that,
• 19:14
  yes,
• 19:15
  they're
• 19:15
  sleeping
• 19:15
  a
• 19:15
  lot,
• 19:15
  yes,
• 19:16
  they're
• 19:16
  eating
• 19:16
  a
• 19:16
  lot.
• 19:16
  Remember,
• 19:17
  there's
• 19:17
  also
• 19:17
  with
• 19:18
  seasonal
• 19:18
  pattern.
• 19:18
  Now,
• 19:19
  this
• 19:19
  is
• 19:19
  kind
• 19:19
  of
• 19:19
  important
• 19:19
  because
• 19:20
  Wellbutrin
• 19:21
  is
• 19:21
  the
• 19:21
  only
• 19:21
  FDA
• 19:22
  approved
• 19:22
  medication
• 19:23
  specifically
• 19:24
  for
• 19:24
  seasonal
• 19:25
  depression.
• 19:25
  So
• 19:26
  this
• 19:26
  is
• 19:26
  a
• 19:26
  nice
• 19:27
  little
• 19:27
  elbow
• 19:27
  nudge
• 19:28
  to
• 19:28
  your
• 19:28
  future
• 19:29
  providers.
• 19:30
  Again,
• 19:31
  when
• 19:31
  the
• 19:31
  patients
• 19:32
  tell
• 19:32
  you
• 19:32
  that,
• 19:33
  and
• 19:33
  patients
• 19:33
  are
• 19:33
  pretty
• 19:33
  good
• 19:34
  at
• 19:34
  volunteering
• 19:34
  this
• 19:35
  information.
• 19:35
  They
• 19:35
  have
• 19:36
  been
• 19:36
  very
• 19:37
  clear
• 19:37
  in
• 19:37
  the
• 19:37
  past
• 19:37
  about
• 19:38
  saying,
• 19:38
  hey,
• 19:38
  I
• 19:39
  get
• 19:39
  depressed
• 19:39
  at
• 19:39
  very
• 19:40
  specific
• 19:40
  times
• 19:40
  a
• 19:40
  year.
• 19:41
  And
• 19:41
  I
• 19:41
  appreciate
• 19:42
  when
• 19:42
  they
• 19:42
  say
• 19:42
  that.
• 19:42
  I
• 19:43
  still
• 19:43
  kind
• 19:43
  of
• 19:43
  make
• 19:43
  sure
• 19:44
  that
• 19:44
  there
• 19:44
  aren't
• 19:44
  depressive
• 19:45
  cycles,
• 19:46
  you
• 19:46
  know,
• 19:47
  in
• 19:47
  other
• 19:47
  seasons
• 19:47
  too.
• 19:48
  Because
• 19:48
  again,
• 19:49
  real
• 19:49
  clinical
• 19:50
  stuff
• 19:50
  is
• 19:50
  messy.
• 19:50
  It's
• 19:51
  not
• 19:51
  always
• 19:51
  simple.
• 19:52
  But
• 19:52
  patients
• 19:52
  will
• 19:53
  often
• 19:53
  tell
• 19:53
  you
• 19:53
  around
• 19:54
  the
• 19:54
  holidays
• 19:54
  they
• 19:54
  get
• 19:54
  really
• 19:55
  depressed
• 19:55
  or
• 19:55
  in
• 19:55
  the
• 19:55
  springtime
• 19:56
  they
• 19:56
  get
• 19:56
  really
• 19:56
  depressed
• 19:57
  and,
• 19:57
  you
• 19:58
  know,
• 19:58
  definitely,
• 19:58
  you
• 19:59
  know,
• 19:59
  look
• 19:59
  at
• 19:59
  their
• 19:59
  symptoms
• 20:00
  and
• 20:00
  still
• 20:01
  try
• 20:01
  to
• 20:01
  align
• 20:02
  the
• 20:02
  medications
• 20:03
  with
• 20:03
  them.
• 20:03
  Because,
• 20:03
  yeah,
• 20:04
  okay,
• 20:04
  depression's
• 20:05
  probably
• 20:05
  the
• 20:05
  best
• 20:05
  for
• 20:05
  these.
• 20:06
  Wellbutrin's
• 20:07
  probably
• 20:07
  the
• 20:07
  best
• 20:07
  for
• 20:07
  these
• 20:07
  folks.
• 20:08
  But
• 20:08
  maybe
• 20:09
  not
• 20:09
  always.
• 20:09
  Maybe
• 20:09
  the
• 20:10
  patient's
• 20:10
  gonna
• 20:10
  say
• 20:10
  they
• 20:10
  get
• 20:11
  really
• 20:11
  depressed
• 20:12
  and
• 20:13
  they
• 20:13
  don't
• 20:13
  eat
• 20:14
  in,
• 20:14
  in,
• 20:15
  in
• 20:15
  those
• 20:15
  seasons,
• 20:16
  right?
• 20:16
  And
• 20:16
  they
• 20:16
  don't
• 20:16
  sleep
• 20:17
  in
• 20:17
  those
• 20:17
  seasons.
• 20:17
  Well,
• 20:17
  if
• 20:17
  they
• 20:18
  tell
• 20:18
  you
• 20:18
  that,
• 20:18
  then
• 20:18
  Wellbutrin
• 20:19
  suddenly
• 20:19
  does
• 20:20
  not
• 20:20
  become
• 20:20
  the
• 20:20
  best
• 20:20
  medication.
• 20:21
  So
• 20:21
  you
• 20:22
  have
• 20:22
  to
• 20:22
  kind
• 20:22
  of
• 20:22
  align
• 20:23
  your
• 20:23
  medica.
• 20:23
  Your
• 20:23
  medications
• 20:24
  to
• 20:24
  their
• 20:24
  symptoms,
• 20:25
  no
• 20:25
  matter
• 20:25
  what
• 20:25
  the
• 20:26
  textbooks
• 20:26
  say.
• 20:27
  Right?
• 20:27
  So
• 20:28
  think
• 20:28
  about
• 20:28
  that.
• 20:29
  They
• 20:29
  have
• 20:29
  to
• 20:29
  have
• 20:30
  at
• 20:30
  least
• 20:30
  two
• 20:30
  seasonal
• 20:31
  major
• 20:31
  depressive
• 20:32
  episodes
• 20:33
  in
• 20:33
  the
• 20:33
  last
• 20:33
  two
• 20:33
  years.
• 20:34
  And
• 20:35
  the
• 20:35
  seasonal
• 20:35
  episodes
• 20:36
  have
• 20:36
  to
• 20:36
  outnumber
• 20:36
  the
• 20:37
  non
• 20:37
  seasonal
• 20:37
  ones.
• 20:37
  There's
• 20:38
  also
• 20:38
  the
• 20:38
  peripartum
• 20:39
  onset
• 20:40
  specifier.
• 20:41
  Right.
• 20:41
  Depression
• 20:41
  with
• 20:42
  onset
• 20:42
  during
• 20:42
  pregnancy
• 20:43
  or
• 20:43
  within
• 20:43
  four
• 20:44
  weeks
• 20:44
  of
• 20:44
  postpartum.
• 20:45
  This
• 20:45
  is,
• 20:45
  this
• 20:45
  kind
• 20:45
  of
• 20:45
  a.
• 20:46
  Is
• 20:46
  interesting
• 20:46
  one
• 20:47
  because
• 20:47
  if
• 20:47
  it's
• 20:48
  five
• 20:48
  weeks
• 20:48
  postpartum,
• 20:49
  it's
• 20:49
  technically
• 20:49
  not
• 20:50
  peripartum
• 20:51
  onset.
• 20:51
  It's
• 20:51
  its
• 20:51
  own
• 20:52
  major
• 20:52
  depressive
• 20:53
  problem.
• 20:53
  But
• 20:54
  you
• 20:55
  know,
• 20:55
  clinically
• 20:55
  many
• 20:56
  providers
• 20:56
  extend
• 20:56
  that
• 20:57
  window
• 20:57
  to
• 20:57
  even
• 20:57
  12
• 20:58
  months
• 20:58
  post
• 20:58
  delivery.
• 20:59
  And
• 20:59
  again,
• 21:00
  this
• 21:00
  changes
• 21:00
  the
• 21:00
  treatment
• 21:01
  outcome
• 21:01
  too,
• 21:01
  or
• 21:01
  the
• 21:02
  treatment
• 21:02
  choices.
• 21:03
  Sure.
• 21:03
  SSRIs
• 21:04
  are
• 21:04
  still
• 21:05
  first
• 21:05
  line.
• 21:06
  Zoloft's
• 21:06
  often
• 21:06
  preferred
• 21:07
  because
• 21:07
  of
• 21:07
  the
• 21:07
  lowest
• 21:08
  breast
• 21:08
  milk
• 21:09
  transfer
• 21:09
  data
• 21:10
  on
• 21:10
  there.
• 21:11
  Zoloft's
• 21:11
  pretty
• 21:11
  well
• 21:12
  tolerated.
• 21:12
  But
• 21:12
  then
• 21:13
  you
• 21:13
  gotta
• 21:13
  talk
• 21:13
  about
• 21:13
  things
• 21:14
  like
• 21:14
  the
• 21:14
  IV
• 21:14
  neuroactive
• 21:15
  steroid
• 21:15
  brexanolone.
• 21:16
  And
• 21:17
  of
• 21:17
  course,
• 21:17
  psychotherapy
• 21:18
  is
• 21:18
  a
• 21:18
  great
• 21:19
  thing.
• 21:19
  This
• 21:19
  affects
• 21:20
  10
• 21:20
  to
• 21:20
  15%
• 21:20
  of
• 21:21
  postpartum
• 21:21
  women.
• 21:21
  It's
• 21:22
  a
• 21:22
  very
• 21:22
  big
• 21:22
  deal.
• 21:22
  So
• 21:23
  peripartum
• 21:23
  onset
• 21:24
  is
• 21:24
  another
• 21:24
  one.
• 21:24
  Don't
• 21:25
  forget
• 21:25
  the,
• 21:26
  don't
• 21:26
  forget
• 21:26
  the
• 21:26
  other
• 21:27
  big
• 21:27
  details.
• 21:27
  The
• 21:28
  mild,
• 21:28
  moderate
• 21:28
  or
• 21:29
  severe
• 21:29
  forms
• 21:29
  of
• 21:29
  depression,
• 21:30
  you
• 21:30
  have
• 21:30
  to
• 21:30
  kind
• 21:30
  of
• 21:30
  categorize
• 21:31
  the
• 21:31
  severity.
• 21:32
  It
• 21:32
  has
• 21:32
  to
• 21:32
  do
• 21:32
  with
• 21:33
  the
• 21:33
  number
• 21:33
  of
• 21:33
  symptoms.
• 21:34
  So
• 21:34
  if
• 21:34
  it's
• 21:34
  just
• 21:35
  a
• 21:35
  small
• 21:35
  number
• 21:35
  of
• 21:35
  symptoms,
• 21:36
  it's
• 21:36
  usually
• 21:36
  mild
• 21:37
  depression.
• 21:38
  A
• 21:38
  medium
• 21:38
  number
• 21:39
  of
• 21:39
  symptom
• 21:39
  criteria
• 21:40
  met,
• 21:40
  it's
• 21:40
  moderate,
• 21:40
  and
• 21:41
  a
• 21:41
  large
• 21:41
  number,
• 21:42
  it's
• 21:42
  severe.
• 21:42
  But
• 21:43
  remember,
• 21:43
  you're
• 21:43
  not
• 21:43
  just
• 21:44
  tethering
• 21:44
  it
• 21:44
  to
• 21:44
  the
• 21:44
  number,
• 21:45
  it's
• 21:45
  also
• 21:45
  the
• 21:45
  degree
• 21:46
  of
• 21:46
  impairment.
• 21:46
  So
• 21:47
  if
• 21:47
  you
• 21:47
  have
• 21:47
  a
• 21:47
  patient
• 21:48
  who
• 21:48
  can't
• 21:48
  work,
• 21:48
  it's
• 21:49
  their
• 21:49
  depression
• 21:50
  is
• 21:50
  so
• 21:50
  unmanageable,
• 21:51
  markedly
• 21:51
  interferes
• 21:52
  with
• 21:52
  social
• 21:52
  and
• 21:52
  occupational
• 21:53
  functioning,
• 21:53
  then
• 21:53
  bam.
• 21:54
  Absolutely,
• 21:55
  we're
• 21:55
  looking
• 21:55
  at
• 21:55
  a
• 21:56
  severe
• 21:56
  mdd.
• 21:57
  So
• 21:58
  keep
• 21:58
  that
• 21:58
  in
• 21:58
  mind.
• 21:58
  It's
• 21:59
  the
• 21:59
  number,
• 21:59
  but
• 21:59
  it's
• 21:59
  also
• 22:00
  the
• 22:00
  level
• 22:00
  of
• 22:00
  distress.
• 22:01
  So,
• 22:01
  you
• 22:02
  know,
• 22:02
  putting
• 22:02
  this
• 22:02
  all
• 22:02
  together,
• 22:03
  my
• 22:03
  friends,
• 22:03
  you
• 22:03
  have
• 22:04
  severity,
• 22:05
  you
• 22:05
  have
• 22:05
  the
• 22:06
  various
• 22:06
  types
• 22:07
  of,
• 22:07
  of
• 22:07
  depression.
• 22:08
  There's
• 22:09
  a
• 22:09
  lot
• 22:09
  to
• 22:09
  focus
• 22:09
  on
• 22:10
  here.
• 22:10
  But
• 22:10
  again,
• 22:10
  it's
• 22:10
  kind
• 22:11
  of
• 22:11
  fun.
• 22:11
  And
• 22:11
  it's
• 22:12
  good
• 22:12
  to
• 22:12
  get
• 22:12
  granular
• 22:12
  because
• 22:13
  your
• 22:13
  treatment
• 22:13
  outcomes
• 22:14
  follow,
• 22:15
  your
• 22:15
  treatment
• 22:16
  plans
• 22:16
  follow,
• 22:16
  you
• 22:17
  can
• 22:17
  really
• 22:17
  change
• 22:17
  a
• 22:18
  lot
• 22:18
  of
• 22:18
  lives
• 22:18
  for
• 22:18
  the
• 22:18
  better
• 22:19
  if
• 22:19
  you
• 22:19
  get
• 22:19
  kind
• 22:20
  of
• 22:20
  granular
• 22:20
  with
• 22:21
  this
• 22:21
  stuff.
• 22:21
  And
• 22:22
  I
• 22:22
  find
• 22:22
  it
• 22:22
  to
• 22:22
  be
• 22:23
  very
• 22:23
  rewarding.
• 22:24
  So
• 22:24
  remember
• 22:25
  the
• 22:25
  specifiers
• 22:26
  Remember
• 22:26
  the
• 22:27
  impairment
• 22:27
  stuff?
• 22:28
  You
• 22:28
  know,
• 22:28
  the
• 22:29
  mild,
• 22:30
  moderate,
• 22:31
  mild,
• 22:31
  moderate
• 22:31
  and
• 22:31
  severe.
• 22:31
  We
• 22:32
  have
• 22:32
  evidence
• 22:32
  and
• 22:33
  slides
• 22:33
  on
• 22:33
  Latuda,
• 22:34
  which
• 22:34
  is
• 22:34
  really
• 22:35
  exciting
• 22:35
  too.
• 22:35
  In
• 22:36
  our
• 22:36
  off
• 22:36
  the
• 22:36
  farm
• 22:37
  Patreon
• 22:38
  membership,
• 22:38
  we
• 22:39
  have
• 22:39
  a
• 22:39
  street
• 22:39
  tips
• 22:39
  membership
• 22:40
  where
• 22:40
  we
• 22:40
  just
• 22:40
  kind
• 22:40
  of
• 22:41
  roll
• 22:41
  out
• 22:41
  really
• 22:41
  practical,
• 22:42
  high
• 22:42
  Yield
• 22:42
  Clinical
• 22:43
  Tips.
• 22:43
  $3
• 22:44
  a
• 22:44
  month.
• 22:44
  It's
• 22:44
  a
• 22:44
  steal.
• 22:45
  Can't
• 22:45
  wait
• 22:46
  to
• 22:46
  have
• 22:46
  you
• 22:46
  guys
• 22:46
  for
• 22:46
  more
• 22:47
  episodes
• 22:47
  to
• 22:47
  welcome
• 22:48
  you
• 22:48
  into
• 22:48
  our
• 22:48
  Patreon
• 22:49
  community.
• 22:50
  Appreciate
• 22:50
  each
• 22:50
  and
• 22:50
  every
• 22:51
  one
• 22:51
  of
• 22:51
  you.
• 22:51
  And
• 22:51
  with
• 22:51
  that
• 22:52
  next,
• 22:52
  we
• 22:52
  will
• 22:53
  see
• 22:53
  you
• 22:53
  next
• 22:53
  time
• 22:53
  on
• 22:54
  Pearls
• 22:54
  and
• 22:54
  Prep.
• 22:54
  Bye.
• 22:55
  Bye.