Latest / Pearls and Prep / The HOW and WHY of Remeron: Who It’s Perfect For (and Who It’s Not)

Transcript

The HOW and WHY of Remeron: Who It’s Perfect For (and Who It’s Not) · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:10
  your
• 0:11
  pocket,
• 0:11
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:13
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Today
• 0:16
  we
• 0:16
  are
• 0:16
  going
• 0:16
  to
• 0:16
  talk
• 0:17
  about
• 0:17
  Remaron.
• 0:17
  It's
• 0:18
  our
• 0:18
  inside
• 0:18
  the
• 0:19
  capsule
• 0:19
  edition.
• 0:20
  What
• 0:20
  does
• 0:20
  Remaron
• 0:21
  do?
• 0:22
  Why
• 0:22
  does
• 0:22
  it
• 0:22
  matter?
• 0:23
  And
• 0:24
  we're
• 0:24
  just
• 0:24
  going
• 0:24
  to
• 0:24
  have
• 0:24
  some
• 0:24
  real
• 0:25
  talk
• 0:25
  about
• 0:25
  how
• 0:25
  it's
• 0:26
  helped
• 0:26
  me
• 0:27
  as
• 0:27
  a
• 0:27
  clinician
• 0:28
  and
• 0:28
  what
• 0:28
  it
• 0:28
  can
• 0:28
  do
• 0:28
  for
• 0:29
  you
• 0:29
  as
• 0:29
  well.
• 0:30
  As
• 0:30
  always,
• 0:31
  my
• 0:31
  friends,
• 0:32
  we
• 0:32
  have
• 0:32
  a
• 0:33
  wonderful
• 0:33
  Patreon
• 0:34
  membership.
• 0:35
  It's
• 0:35
  full
• 0:35
  of
• 0:35
  freebies,
• 0:36
  but
• 0:36
  it
• 0:36
  also
• 0:36
  has,
• 0:37
  for
• 0:37
  just
• 0:37
  $3
• 0:38
  a
• 0:38
  month,
• 0:38
  some
• 0:39
  really
• 0:39
  awesome
• 0:40
  extra
• 0:40
  tools.
• 0:41
  Deep
• 0:42
  dives,
• 0:42
  beautiful
• 0:43
  slide
• 0:43
  decks
• 0:43
  to
• 0:43
  empower
• 0:44
  you
• 0:44
  to
• 0:45
  pass
• 0:45
  your
• 0:45
  boards
• 0:46
  to
• 0:46
  be
• 0:46
  a
• 0:46
  sharper
• 0:46
  clinician
• 0:47
  for
• 0:47
  three
• 0:47
  bucks
• 0:48
  a
• 0:48
  month.
• 0:48
  It's
• 0:48
  a
• 0:48
  steal.
• 0:49
  Highly
• 0:50
  recommend
• 0:50
  you
• 0:51
  become
• 0:51
  a
• 0:51
  member.
• 0:51
  Go
• 0:52
  to
• 0:52
  our
• 0:52
  show
• 0:52
  notes
• 0:53
  and
• 0:53
  get
• 0:54
  all
• 0:54
  the
• 0:54
  goodies
• 0:55
  that
• 0:55
  come
• 0:55
  with
• 0:55
  that
• 0:55
  because
• 0:56
  you
• 0:56
  can
• 0:56
  really
• 0:56
  nerd
• 0:56
  out
• 0:57
  and
• 0:57
  have
• 0:57
  a
• 0:57
  blast.
• 0:57
  So
• 0:57
  without
• 0:58
  further
• 0:58
  ado,
• 0:58
  my
• 0:58
  friends,
• 0:59
  let's
• 1:00
  talk
• 1:00
  about
• 1:00
  Remeron.
• 1:01
  So
• 1:02
  now,
• 1:03
  before
• 1:03
  I
• 1:03
  go
• 1:04
  into
• 1:04
  the
• 1:04
  nitty
• 1:04
  gritty
• 1:05
  receptor
• 1:05
  class,
• 1:07
  why
• 1:07
  do
• 1:07
  I
• 1:07
  love
• 1:07
  Remeron?
• 1:08
  Well,
• 1:09
  it's
• 1:09
  one
• 1:09
  of
• 1:09
  my
• 1:10
  most
• 1:10
  prescribed
• 1:11
  medications
• 1:11
  to
• 1:11
  my
• 1:12
  patients.
• 1:12
  And
• 1:13
  one
• 1:13
  big
• 1:14
  surprise
• 1:14
  that
• 1:15
  really
• 1:15
  struck
• 1:16
  me
• 1:16
  as
• 1:16
  a
• 1:17
  new
• 1:17
  grad
• 1:17
  when
• 1:18
  I
• 1:18
  started
• 1:18
  practicing
• 1:19
  is,
• 1:19
  is
• 1:19
  there's
• 1:20
  a
• 1:20
  really
• 1:20
  big
• 1:20
  difference
• 1:21
  between
• 1:21
  what
• 1:22
  your
• 1:22
  textbooks
• 1:23
  tell
• 1:23
  you
• 1:24
  to
• 1:24
  do
• 1:24
  and
• 1:25
  then
• 1:25
  what
• 1:25
  you
• 1:25
  actually
• 1:26
  see
• 1:26
  in
• 1:26
  practice.
• 1:27
  Okay.
• 1:28
  And
• 1:28
  I
• 1:28
  don't
• 1:28
  want
• 1:28
  you
• 1:28
  to
• 1:28
  overthink
• 1:29
  that
• 1:29
  too
• 1:29
  much.
• 1:29
  But
• 1:30
  what
• 1:30
  I
• 1:30
  mean
• 1:30
  by
• 1:30
  that
• 1:31
  is
• 1:31
  not
• 1:32
  everyone
• 1:33
  is
• 1:33
  going
• 1:33
  to
• 1:34
  walk
• 1:34
  in
• 1:35
  to
• 1:35
  your
• 1:35
  clinic
• 1:36
  and
• 1:36
  be
• 1:37
  the
• 1:37
  perfect
• 1:38
  candidate
• 1:39
  for
• 1:40
  some
• 1:40
  kind
• 1:41
  of
• 1:41
  SSRI
• 1:43
  like
• 1:43
  Alexa
• 1:44
  Pro
• 1:44
  or
• 1:45
  Prozac.
• 1:46
  There's
• 1:46
  always
• 1:46
  going
• 1:46
  to
• 1:46
  be
• 1:47
  some
• 1:47
  nuance
• 1:47
  there.
• 1:48
  There's
• 1:48
  always
• 1:49
  going
• 1:49
  to
• 1:49
  be
• 1:49
  real
• 1:50
  life
• 1:50
  side
• 1:51
  effects,
• 1:51
  concerns
• 1:52
  that
• 1:53
  you
• 1:53
  have
• 1:53
  to
• 1:53
  consider
• 1:53
  before
• 1:54
  you
• 1:54
  prescribe
• 1:54
  any
• 1:55
  of
• 1:55
  your
• 1:55
  medications.
• 1:55
  And
• 1:56
  I
• 1:56
  find
• 1:56
  that
• 1:57
  almost
• 1:57
  everyone
• 1:58
  who
• 1:58
  comes
• 1:58
  to
• 1:58
  me
• 1:59
  has
• 1:59
  some
• 2:00
  form
• 2:00
  of
• 2:00
  insomnia.
• 2:01
  And
• 2:01
  unfortunately,
• 2:02
  you
• 2:03
  prescribe
• 2:03
  medications
• 2:04
  like
• 2:04
  Prozac
• 2:04
  or
• 2:05
  Zoloft,
• 2:05
  they
• 2:06
  don't
• 2:06
  really
• 2:06
  help
• 2:06
  people
• 2:07
  sleep.
• 2:07
  They
• 2:07
  indirectly
• 2:08
  may
• 2:08
  help
• 2:09
  you
• 2:09
  sleep
• 2:09
  because
• 2:09
  they
• 2:10
  calm
• 2:10
  a
• 2:10
  lot
• 2:10
  of
• 2:10
  those
• 2:10
  brain
• 2:11
  circuits
• 2:11
  and
• 2:12
  that
• 2:12
  are
• 2:12
  implicated
• 2:12
  in
• 2:13
  rumination
• 2:13
  and
• 2:13
  anxiety
• 2:14
  or
• 2:15
  guilty
• 2:15
  ruminations
• 2:16
  that
• 2:16
  you
• 2:16
  see
• 2:16
  in
• 2:17
  depression.
• 2:17
  So,
• 2:17
  sure,
• 2:18
  indirectly
• 2:18
  they
• 2:19
  can
• 2:19
  definitely
• 2:19
  help
• 2:19
  with
• 2:20
  sleep,
• 2:20
  but
• 2:20
  especially
• 2:21
  in
• 2:21
  the
• 2:21
  beginning,
• 2:21
  they
• 2:22
  can
• 2:22
  worsen
• 2:22
  sleep.
• 2:22
  They
• 2:23
  can
• 2:23
  make
• 2:23
  you
• 2:23
  more
• 2:23
  activated.
• 2:24
  And
• 2:25
  I
• 2:25
  find
• 2:25
  that's
• 2:26
  a
• 2:26
  major
• 2:26
  problem
• 2:27
  because
• 2:27
  sleep
• 2:28
  is
• 2:28
  one
• 2:28
  of
• 2:28
  the
• 2:28
  chief
• 2:29
  concerns
• 2:30
  with
• 2:30
  depression
• 2:30
  and
• 2:31
  anxiety.
• 2:31
  It's
• 2:32
  almost
• 2:32
  more
• 2:32
  common
• 2:33
  that
• 2:33
  a
• 2:33
  patient's
• 2:34
  going
• 2:34
  to
• 2:34
  come
• 2:34
  to
• 2:34
  you
• 2:34
  and
• 2:34
  say,
• 2:34
  hey,
• 2:34
  I
• 2:35
  just
• 2:35
  can't
• 2:35
  sleep.
• 2:35
  I'LL
• 2:35
  do
• 2:36
  anything
• 2:36
  to
• 2:36
  just
• 2:36
  sleep.
• 2:37
  Right?
• 2:38
  Of
• 2:38
  course
• 2:39
  they
• 2:39
  come
• 2:39
  to
• 2:39
  you
• 2:39
  and
• 2:39
  also
• 2:40
  say,
• 2:40
  I'm
• 2:40
  really
• 2:40
  depressed,
• 2:41
  I'm
• 2:41
  really
• 2:41
  anxious.
• 2:42
  No
• 2:42
  doubt
• 2:42
  about
• 2:42
  it.
• 2:43
  But
• 2:43
  if
• 2:44
  I
• 2:44
  had
• 2:44
  a
• 2:44
  nickel
• 2:44
  for
• 2:45
  every
• 2:45
  time
• 2:45
  that
• 2:46
  even
• 2:46
  people
• 2:46
  with
• 2:46
  depression
• 2:47
  and
• 2:47
  anxiety
• 2:48
  focused
• 2:48
  on
• 2:48
  sleep
• 2:49
  more
• 2:49
  than
• 2:49
  anything
• 2:49
  else.
• 2:50
  That
• 2:50
  is
• 2:51
  just
• 2:51
  such
• 2:51
  a
• 2:51
  salient,
• 2:52
  urgent
• 2:53
  matter.
• 2:54
  In
• 2:54
  the
• 2:54
  outpatient
• 2:55
  space,
• 2:55
  it's
• 2:55
  trans
• 2:55
  diagnostic.
• 2:56
  You
• 2:56
  see
• 2:57
  it
• 2:57
  in
• 2:57
  bipolar,
• 2:58
  you
• 2:58
  see
• 2:58
  it
• 2:58
  in
• 2:59
  anxiety,
• 2:59
  you
• 2:59
  see
• 2:59
  it
• 2:59
  in
• 3:00
  depression.
• 3:00
  Heck,
• 3:00
  there's
• 3:01
  even
• 3:01
  a
• 3:01
  primary
• 3:01
  insomnia,
• 3:02
  right?
• 3:02
  Where
• 3:02
  your
• 3:03
  only
• 3:03
  issue
• 3:03
  is,
• 3:04
  is
• 3:04
  insomnia.
• 3:05
  Now,
• 3:05
  I
• 3:05
  don't
• 3:06
  really
• 3:06
  believe
• 3:06
  in
• 3:06
  that
• 3:06
  diagnosis.
• 3:07
  I
• 3:07
  always
• 3:08
  feel
• 3:08
  like
• 3:08
  there
• 3:08
  is
• 3:08
  a
• 3:08
  reason
• 3:09
  people
• 3:09
  can't
• 3:09
  sleep.
• 3:10
  Maybe
• 3:10
  in
• 3:10
  unicorn
• 3:11
  cases
• 3:12
  there
• 3:12
  is
• 3:12
  a
• 3:13
  real
• 3:13
  primary
• 3:13
  insomnia,
• 3:14
  but
• 3:14
  I
• 3:14
  find
• 3:14
  the
• 3:15
  vast
• 3:15
  majority
• 3:15
  of
• 3:15
  people
• 3:16
  I
• 3:16
  see
• 3:16
  have
• 3:17
  depression,
• 3:17
  anxiety,
• 3:18
  trauma,
• 3:18
  bipolar.
• 3:19
  There's
• 3:19
  some
• 3:19
  reason
• 3:20
  specifically
• 3:20
  they
• 3:21
  can't
• 3:21
  sleep
• 3:21
  or
• 3:21
  medical
• 3:22
  reason
• 3:23
  that
• 3:23
  is
• 3:23
  just
• 3:24
  not
• 3:24
  accounted
• 3:24
  for
• 3:25
  yet,
• 3:25
  whether
• 3:25
  it
• 3:25
  be
• 3:25
  sleep
• 3:26
  apnea,
• 3:26
  et
• 3:26
  cetera.
• 3:27
  Suffice
• 3:27
  it
• 3:28
  to
• 3:28
  say,
• 3:28
  my
• 3:28
  friends,
• 3:28
  Remeron
• 3:29
  is
• 3:29
  a
• 3:29
  weapon
• 3:30
  because
• 3:31
  sleep
• 3:31
  is
• 3:31
  such
• 3:32
  a
• 3:32
  transdiagnostic
• 3:33
  problem.
• 3:34
  Eeny,
• 3:34
  meeny,
• 3:34
  miny,
• 3:35
  mo.
• 3:35
  Just
• 3:35
  open
• 3:35
  up
• 3:36
  the
• 3:36
  DSM
• 3:36
  5
• 3:37
  and
• 3:37
  chances
• 3:38
  are
• 3:38
  you
• 3:38
  are
• 3:38
  gonna
• 3:39
  find
• 3:40
  some
• 3:40
  kind
• 3:41
  of
• 3:41
  a
• 3:41
  syndrome
• 3:42
  in
• 3:42
  there
• 3:43
  that
• 3:43
  absolutely
• 3:44
  implicates
• 3:45
  sleep
• 3:45
  as
• 3:45
  a
• 3:45
  major
• 3:46
  problem
• 3:47
  associated
• 3:47
  with
• 3:48
  it.
• 3:48
  So
• 3:48
  that's
• 3:49
  why
• 3:49
  I
• 3:49
  love
• 3:49
  it.
• 3:49
  And
• 3:49
  you
• 3:49
  really
• 3:50
  can't
• 3:50
  find
• 3:51
  antidepressants
• 3:52
  that
• 3:53
  help
• 3:53
  you
• 3:53
  sleep
• 3:54
  unless
• 3:54
  you
• 3:54
  really
• 3:54
  go
• 3:54
  into
• 3:55
  like
• 3:55
  the
• 3:55
  TCAs,
• 3:56
  which
• 3:56
  there's
• 3:56
  definitely
• 3:57
  a
• 3:57
  time
• 3:57
  and
• 3:57
  place
• 3:58
  for
• 3:58
  that,
• 3:58
  but
• 3:58
  they're
• 3:58
  most
• 3:59
  certainly
• 3:59
  not
• 3:59
  first
• 4:00
  line.
• 4:00
  So
• 4:00
  Remeron,
• 4:01
  to
• 4:01
  me
• 4:01
  is
• 4:02
  this
• 4:02
  really
• 4:02
  approachable
• 4:03
  medication
• 4:03
  that
• 4:04
  I
• 4:04
  find
• 4:04
  prescribing
• 4:05
  all
• 4:05
  the
• 4:06
  time.
• 4:07
  Now,
• 4:07
  one
• 4:07
  thing
• 4:07
  we
• 4:08
  do
• 4:08
  have
• 4:08
  to
• 4:09
  be
• 4:09
  very
• 4:10
  mindful
• 4:10
  of
• 4:10
  with
• 4:11
  Remeron,
• 4:11
  of
• 4:11
  course,
• 4:12
  is
• 4:12
  the
• 4:13
  weight
• 4:13
  gain.
• 4:13
  Oh,
• 4:14
  boy.
• 4:14
  This
• 4:14
  will
• 4:14
  definitely
• 4:15
  cause
• 4:16
  weight
• 4:16
  gain.
• 4:16
  The
• 4:16
  evidence
• 4:17
  suggests
• 4:18
  about
• 4:18
  a
• 4:19
  7.5%
• 4:21
  weight
• 4:21
  gain.
• 4:22
  So
• 4:22
  7%
• 4:23
  of
• 4:23
  your
• 4:23
  body
• 4:23
  weight
• 4:24
  you
• 4:24
  can
• 4:24
  increase.
• 4:24
  That's
• 4:25
  pretty
• 4:25
  significant
• 4:25
  if
• 4:25
  you
• 4:26
  weigh
• 4:26
  200
• 4:26
  pounds,
• 4:26
  it's
• 4:27
  about
• 4:27
  a
• 4:27
  14
• 4:28
  pound
• 4:29
  weight
• 4:30
  gain
• 4:30
  that
• 4:31
  can
• 4:31
  definitely
• 4:31
  be
• 4:31
  noticeable
• 4:32
  and
• 4:32
  fast.
• 4:33
  And
• 4:33
  sure
• 4:33
  enough,
• 4:33
  patients
• 4:34
  do
• 4:34
  not
• 4:34
  enjoy
• 4:35
  that.
• 4:35
  So
• 4:35
  your
• 4:36
  ideal
• 4:36
  Remeron
• 4:37
  patient
• 4:38
  would
• 4:38
  be
• 4:38
  someone
• 4:38
  who's
• 4:39
  really
• 4:39
  complaining
• 4:39
  of
• 4:40
  sleep.
• 4:40
  Maybe
• 4:40
  they're
• 4:40
  depressed
• 4:41
  and
• 4:41
  anxious
• 4:42
  and
• 4:42
  they're
• 4:42
  not
• 4:43
  eating
• 4:43
  as
• 4:43
  a
• 4:43
  result
• 4:44
  of
• 4:44
  their
• 4:44
  low
• 4:44
  mood
• 4:45
  states
• 4:45
  or
• 4:45
  their
• 4:46
  anxiety.
• 4:46
  And
• 4:46
  bam,
• 4:46
  you
• 4:47
  have
• 4:47
  a
• 4:47
  good
• 4:47
  recipe
• 4:48
  to
• 4:48
  bring
• 4:48
  Remeron
• 4:49
  on
• 4:49
  board.
• 4:50
  And
• 4:50
  if
• 4:50
  nothing
• 4:50
  else,
• 4:51
  it
• 4:51
  might
• 4:51
  restore
• 4:51
  the
• 4:52
  appetite
• 4:52
  back
• 4:52
  to
• 4:53
  its
• 4:53
  usual
• 4:53
  baseline.
• 4:54
  You've
• 4:54
  definitely
• 4:55
  got
• 4:55
  to
• 4:56
  monitor
• 4:56
  that.
• 4:56
  Be
• 4:57
  careful
• 4:57
  about
• 4:57
  that.
• 4:57
  You
• 4:58
  know,
• 4:58
  lipid
• 4:58
  changes.
• 4:59
  15%,
• 4:59
  the
• 5:00
  evidence
• 5:00
  show,
• 5:01
  have
• 5:01
  a
• 5:01
  20%
• 5:02
  or
• 5:02
  greater
• 5:02
  cholesterol
• 5:03
  increase.
• 5:03
  Well,
• 5:04
  that's
• 5:04
  pretty
• 5:04
  scary.
• 5:04
  I
• 5:04
  mean,
• 5:05
  my
• 5:05
  LDL
• 5:05
  is
• 5:06
  always
• 5:06
  a
• 5:06
  little
• 5:07
  bit
• 5:07
  too
• 5:07
  high.
• 5:07
  It's
• 5:07
  like
• 5:08
  170.
• 5:09
  I
• 5:09
  would
• 5:09
  hate
• 5:09
  to
• 5:10
  have
• 5:10
  a
• 5:11
  20%
• 5:11
  cholesterol
• 5:12
  increase
• 5:12
  if
• 5:13
  I
• 5:13
  was
• 5:13
  taking
• 5:13
  Remeron.
• 5:14
  That
• 5:14
  would
• 5:14
  be
• 5:14
  devastating
• 5:15
  for
• 5:15
  me.
• 5:15
  I'm
• 5:16
  very
• 5:16
  self
• 5:16
  conscious
• 5:17
  about
• 5:17
  that
• 5:17
  ldl,
• 5:17
  even
• 5:18
  if
• 5:18
  I
• 5:18
  don't
• 5:18
  symptomatically
• 5:19
  feel
• 5:19
  it
• 5:20
  at
• 5:20
  all
• 5:20
  throughout
• 5:20
  the
• 5:20
  day.
• 5:21
  I
• 5:21
  probably
• 5:21
  feel
• 5:21
  happy
• 5:22
  because
• 5:22
  of
• 5:22
  it,
• 5:22
  because
• 5:22
  I'm
• 5:23
  eating
• 5:23
  a
• 5:23
  lot
• 5:23
  of
• 5:23
  junk
• 5:23
  food
• 5:24
  that
• 5:24
  makes
• 5:24
  it
• 5:25
  go
• 5:25
  up.
• 5:25
  But
• 5:25
  anyway,
• 5:26
  my
• 5:27
  friends,
• 5:28
  you
• 5:28
  gotta
• 5:28
  be
• 5:28
  mindful
• 5:29
  of
• 5:29
  this,
• 5:29
  right?
• 5:29
  So
• 5:29
  you
• 5:29
  don't
• 5:30
  want
• 5:30
  to
• 5:30
  just
• 5:30
  hand
• 5:30
  out
• 5:30
  Rembron
• 5:31
  anytime
• 5:32
  somebody
• 5:32
  says
• 5:33
  they
• 5:33
  can't
• 5:33
  sleep
• 5:33
  and
• 5:33
  they're
• 5:34
  depressed
• 5:34
  and
• 5:34
  anxious.
• 5:35
  You've
• 5:35
  got
• 5:36
  to
• 5:36
  selectively
• 5:36
  tailor
• 5:37
  its
• 5:37
  side
• 5:37
  effect
• 5:38
  profile.
• 5:38
  That
• 5:38
  could
• 5:38
  otherwise
• 5:39
  be
• 5:39
  very
• 5:39
  annoying
• 5:40
  to
• 5:40
  someone
• 5:41
  who
• 5:41
  would
• 5:41
  welcome
• 5:41
  it,
• 5:42
  right?
• 5:42
  Some
• 5:42
  people
• 5:42
  might
• 5:43
  be
• 5:43
  annoyed
• 5:43
  by
• 5:43
  the
• 5:44
  fact
• 5:44
  that
• 5:44
  increases
• 5:44
  their
• 5:45
  appetite.
• 5:46
  However,
• 5:46
  some
• 5:47
  people
• 5:47
  might
• 5:48
  actually
• 5:49
  really
• 5:50
  enjoy
• 5:50
  that
• 5:51
  because
• 5:51
  they've
• 5:51
  lost
• 5:52
  their
• 5:52
  appetite.
• 5:52
  So
• 5:53
  definitely
• 5:54
  think
• 5:54
  about
• 5:55
  that,
• 5:55
  my
• 5:55
  friends.
• 5:56
  So
• 5:56
  there's
• 5:56
  a
• 5:56
  few
• 5:57
  other
• 5:57
  reasons.
• 5:57
  I
• 5:57
  just
• 5:58
  love
• 5:58
  Remeron.
• 5:59
  For
• 5:59
  one,
• 5:59
  you
• 6:00
  almost
• 6:00
  never
• 6:00
  hear
• 6:00
  anybody
• 6:01
  have
• 6:01
  sexual
• 6:01
  dysfunction
• 6:02
  on
• 6:02
  Remeron.
• 6:03
  Well,
• 6:03
  that's
• 6:04
  amazing,
• 6:04
  because
• 6:05
  as
• 6:05
  you
• 6:05
  all
• 6:05
  know,
• 6:06
  activating
• 6:07
  the
• 6:07
  5ht2a
• 6:08
  receptor
• 6:09
  with
• 6:09
  the
• 6:09
  rest
• 6:10
  of
• 6:10
  your
• 6:10
  SSRIs
• 6:11
  reliably
• 6:12
  causes
• 6:12
  sexual
• 6:13
  dysfunction.
• 6:13
  I
• 6:14
  one
• 6:14
  time
• 6:14
  I
• 6:14
  read,
• 6:15
  and
• 6:15
  it
• 6:15
  might
• 6:15
  be
• 6:15
  worth
• 6:16
  fact
• 6:16
  checking,
• 6:16
  that
• 6:17
  SSRIs
• 6:17
  are
• 6:17
  even
• 6:18
  better
• 6:18
  at
• 6:18
  messing
• 6:19
  up
• 6:19
  sex
• 6:19
  drive
• 6:19
  than
• 6:19
  they
• 6:20
  are
• 6:20
  at
• 6:20
  treating
• 6:21
  depression
• 6:21
  or
• 6:21
  anxiety
• 6:22
  based
• 6:22
  on
• 6:22
  effect
• 6:23
  size.
• 6:23
  Someone
• 6:24
  can
• 6:24
  definitely
• 6:24
  fact
• 6:24
  check
• 6:25
  me
• 6:25
  on
• 6:25
  that.
• 6:25
  But
• 6:26
  the
• 6:26
  fact
• 6:26
  that
• 6:26
  that's
• 6:26
  even
• 6:27
  up
• 6:27
  in
• 6:28
  the
• 6:28
  air
• 6:28
  for
• 6:28
  discussion
• 6:29
  is
• 6:29
  problematic.
• 6:30
  So
• 6:30
  remeron
• 6:31
  actually
• 6:31
  blocks
• 6:32
  5ht2a
• 6:33
  and
• 6:34
  it
• 6:34
  actually
• 6:34
  blocks
• 6:36
  5ht2c,
• 6:37
  which
• 6:38
  is
• 6:38
  also
• 6:38
  kind
• 6:38
  of
• 6:39
  interesting.
• 6:39
  Now
• 6:40
  remember,
• 6:40
  when
• 6:40
  you
• 6:40
  block
• 6:41
  5ht
• 6:41
  2c,
• 6:42
  my
• 6:42
  friends,
• 6:43
  that's
• 6:43
  the
• 6:43
  part
• 6:43
  that
• 6:44
  causes
• 6:44
  the
• 6:44
  weight
• 6:44
  gain.
• 6:45
  That's
• 6:45
  not
• 6:45
  exactly
• 6:46
  the
• 6:46
  fun
• 6:46
  part
• 6:46
  of
• 6:46
  Rembron,
• 6:47
  but
• 6:47
  it
• 6:48
  does
• 6:48
  also
• 6:48
  increase
• 6:49
  the
• 6:49
  amount
• 6:49
  of
• 6:49
  dopamine
• 6:50
  in
• 6:50
  the
• 6:50
  prefrontal
• 6:51
  cortex
• 6:51
  and
• 6:51
  norepinephrine.
• 6:52
  So
• 6:53
  that
• 6:53
  can
• 6:53
  help
• 6:53
  with
• 6:53
  some
• 6:53
  cognitive
• 6:55
  symptoms
• 6:56
  too,
• 6:56
  which
• 6:56
  is
• 6:56
  pretty
• 6:57
  helpful.
• 6:57
  There's
• 6:58
  a
• 6:58
  mild
• 6:58
  blockade
• 6:59
  5ht
• 6:59
  2c
• 7:00
  here.
• 7:00
  But
• 7:01
  another
• 7:01
  neat
• 7:01
  thing,
• 7:01
  and
• 7:02
  I
• 7:02
  use
• 7:02
  this
• 7:02
  to
• 7:02
  my
• 7:03
  advantage
• 7:03
  all
• 7:03
  the
• 7:03
  time,
• 7:03
  is
• 7:04
  Remeron
• 7:04
  is
• 7:04
  also
• 7:05
  easy
• 7:05
  on
• 7:05
  GI
• 7:06
  issues.
• 7:07
  There's
• 7:07
  really
• 7:07
  no
• 7:07
  GI
• 7:08
  upset
• 7:08
  or
• 7:08
  nausea
• 7:09
  with
• 7:09
  Remeron.
• 7:09
  Not
• 7:10
  very
• 7:10
  common.
• 7:10
  Okay.
• 7:11
  And
• 7:11
  a
• 7:11
  lot
• 7:11
  of
• 7:11
  your
• 7:12
  patients
• 7:12
  are
• 7:12
  going
• 7:12
  to
• 7:12
  come
• 7:12
  to
• 7:13
  you
• 7:13
  with
• 7:13
  ibs,
• 7:14
  Crohn's
• 7:14
  disease.
• 7:15
  They're
• 7:15
  going
• 7:15
  to
• 7:15
  come
• 7:15
  to
• 7:15
  you
• 7:15
  with
• 7:16
  GI
• 7:16
  problems.
• 7:17
  Right?
• 7:17
  There's
• 7:17
  such
• 7:17
  a
• 7:17
  strong
• 7:18
  bidirectional
• 7:18
  relationship
• 7:19
  between
• 7:20
  the
• 7:20
  gut
• 7:20
  and
• 7:21
  mental
• 7:21
  health
• 7:21
  problems.
• 7:22
  And
• 7:22
  I
• 7:23
  find
• 7:23
  that
• 7:23
  this
• 7:23
  is
• 7:23
  a
• 7:24
  really
• 7:24
  good
• 7:24
  medication
• 7:25
  to
• 7:25
  propose
• 7:25
  to
• 7:26
  folks
• 7:26
  who
• 7:26
  are
• 7:27
  tormented
• 7:27
  by,
• 7:28
  especially
• 7:28
  the
• 7:28
  ones
• 7:28
  who
• 7:29
  are
• 7:29
  getting
• 7:29
  nauseous
• 7:30
  every
• 7:30
  time
• 7:30
  they're
• 7:31
  anxious.
• 7:31
  Maybe
• 7:31
  they're
• 7:31
  having
• 7:32
  panic
• 7:32
  attacks
• 7:32
  and
• 7:32
  they're
• 7:33
  nauseous.
• 7:34
  Well,
• 7:34
  look
• 7:34
  no
• 7:34
  further,
• 7:34
  my
• 7:35
  friends.
• 7:35
  Remeron
• 7:36
  is
• 7:37
  the
• 7:37
  way
• 7:37
  to
• 7:38
  go
• 7:38
  here
• 7:38
  because
• 7:39
  it
• 7:39
  also
• 7:39
  blocks
• 7:40
  5ht,
• 7:41
  5ht
• 7:41
  3
• 7:43
  receptors.
• 8:38
  And
• 8:38
  remember,
• 8:39
  folks,
• 8:39
  5ht
• 8:40
  2a
• 8:40
  and
• 8:41
  5ht
• 8:41
  3
• 8:42
  receptors
• 8:42
  are
• 8:43
  those
• 8:43
  receptors
• 8:44
  that
• 8:44
  are
• 8:44
  stimulated
• 8:45
  by
• 8:45
  SSRIs
• 8:46
  and
• 8:46
  causing
• 8:46
  all
• 8:46
  those
• 7:53
  side
• 8:47
  effects,
• 8:48
  the
• 8:48
  sexual
• 8:48
  dysfunction
• 8:49
  and
• 8:49
  the
• 8:50
  nausea,
• 8:50
  GI
• 8:50
  issues.
• 8:51
  So,
• 8:51
  I
• 8:51
  mean,
• 8:52
  what
• 8:52
  an
• 8:52
  ideal
• 8:52
  medication
• 8:54
  that
• 8:54
  it
• 8:54
  can
• 8:55
  actually
• 8:55
  block
• 8:55
  that.
• 8:56
  It's
• 8:56
  almost
• 8:56
  like
• 8:56
  it
• 8:57
  just
• 8:57
  blocks
• 8:58
  serotonin
• 8:59
  from
• 8:59
  opening
• 8:59
  those
• 9:00
  doors
• 9:00
  that
• 9:00
  cause
• 9:01
  those
• 9:01
  unpleasant
• 9:01
  symptoms.
• 9:02
  And
• 9:03
  in
• 9:03
  the
• 9:03
  meantime,
• 9:04
  serotonin
• 9:04
  is
• 9:05
  kind
• 9:05
  of
• 9:05
  shunted
• 9:05
  to
• 9:05
  the
• 9:06
  areas
• 9:06
  of
• 9:07
  the
• 9:07
  brain
• 9:07
  and
• 9:07
  body
• 9:07
  that
• 9:08
  are
• 9:08
  not
• 9:08
  as
• 9:08
  problematic.
• 9:09
  Now,
• 9:09
  of
• 9:09
  course,
• 9:10
  we
• 9:10
  talked
• 9:10
  about
• 9:10
  the
• 9:10
  weight
• 9:11
  gain
• 9:11
  trade
• 9:11
  off,
• 9:11
  so
• 9:12
  it's
• 9:12
  not
• 9:12
  all
• 9:12
  hunky
• 9:12
  dory
• 9:13
  and
• 9:13
  you
• 9:13
  have
• 9:13
  to
• 9:14
  be
• 9:14
  very
• 9:14
  selective,
• 9:14
  but
• 9:15
  sure
• 9:15
  enough,
• 9:15
  that's
• 9:15
  pretty
• 9:16
  good.
• 9:16
  Now,
• 9:16
  one
• 9:17
  thing
• 9:17
  you
• 9:17
  should
• 9:17
  know
• 9:17
  about
• 9:17
  Remeron,
• 9:18
  it
• 9:18
  doesn't
• 9:19
  behave
• 9:19
  as
• 9:20
  a
• 9:20
  classical
• 9:20
  SSRI
• 9:21
  because
• 9:21
  it's
• 9:22
  not
• 9:22
  an
• 9:22
  ssri.
• 9:23
  Actually,
• 9:23
  it's
• 9:24
  not
• 9:24
  an
• 9:24
  SSRI
• 9:25
  at
• 9:25
  all.
• 9:26
  It
• 9:26
  actually
• 9:26
  has
• 9:27
  this
• 9:27
  weird
• 9:28
  other
• 9:28
  nomenclature.
• 9:29
  It
• 9:29
  is
• 9:29
  an
• 9:29
  N
• 9:30
  A
• 9:30
  S
• 9:30
  S
• 9:30
  A
• 9:31
  short.
• 9:31
  It's
• 9:31
  short
• 9:32
  for
• 9:32
  noradrenergic
• 9:33
  and
• 9:33
  specific
• 9:34
  serotonergic
• 9:35
  antidepressant.
• 9:35
  Okay.
• 9:36
  It
• 9:36
  was
• 9:36
  developed
• 9:36
  in
• 9:37
  1996.
• 9:38
  And
• 9:39
  so
• 9:39
  it's
• 9:40
  actually
• 9:40
  different.
• 9:40
  It
• 9:41
  does
• 9:41
  not
• 9:41
  block
• 9:41
  the
• 9:42
  reuptake
• 9:43
  of
• 9:44
  serotonin
• 9:44
  via
• 9:45
  serotonin
• 9:45
  transporters.
• 9:47
  It
• 9:47
  actually
• 9:47
  removes
• 9:48
  the
• 9:48
  brakes
• 9:49
  that
• 9:49
  slow
• 9:50
  down
• 9:50
  the
• 9:50
  release
• 9:50
  of
• 9:50
  norepinephrine
• 9:51
  and
• 9:51
  serotonin.
• 9:52
  So
• 9:52
  it
• 9:52
  actually
• 9:53
  allows
• 9:53
  your
• 9:53
  brain
• 9:53
  to
• 9:54
  naturally
• 9:54
  produce
• 9:55
  more
• 9:55
  serotonin
• 9:56
  and
• 9:56
  norepinephrine,
• 9:57
  which
• 9:57
  is
• 9:57
  pretty
• 9:58
  cool.
• 9:59
  You
• 9:59
  gotta
• 9:59
  remember,
• 9:59
  norepinephrine
• 10:00
  neurons
• 10:01
  and
• 10:01
  serotonin
• 10:02
  neurons
• 10:02
  have
• 10:02
  these
• 10:02
  off
• 10:03
  switches
• 10:03
  and
• 10:04
  they're
• 10:04
  called
• 10:04
  the
• 10:04
  Alpha
• 10:04
  2
• 10:04
  Adrenergic
• 10:05
  Autoreceptors.
• 10:06
  Mirtazapine,
• 10:07
  also
• 10:07
  known
• 10:08
  as
• 10:08
  Remeron,
• 10:08
  it
• 10:09
  kind
• 10:09
  of
• 10:09
  blocks
• 10:09
  these
• 10:09
  autoreceptors.
• 10:10
  So
• 10:11
  it
• 10:11
  prevents
• 10:11
  that
• 10:12
  break
• 10:12
  from
• 10:12
  engaging.
• 10:13
  It
• 10:13
  prevents
• 10:13
  the
• 10:13
  break
• 10:14
  from.
• 10:14
  From
• 10:15
  kind
• 10:15
  of
• 10:15
  putting
• 10:16
  the
• 10:16
  boot
• 10:16
  on
• 10:16
  the
• 10:16
  neck
• 10:17
  of
• 10:17
  norepinephrine
• 10:18
  and
• 10:18
  serotonin.
• 10:19
  So
• 10:19
  that
• 10:20
  produces
• 10:20
  feelings
• 10:21
  of
• 10:21
  energy,
• 10:21
  alertness,
• 10:22
  focus,
• 10:23
  and
• 10:23
  it
• 10:23
  supports
• 10:24
  mood,
• 10:24
  emotional
• 10:25
  balance
• 10:25
  and
• 10:25
  anxiety
• 10:26
  relief.
• 10:27
  Because
• 10:27
  we
• 10:27
  are
• 10:28
  blocking
• 10:28
  the
• 10:28
  brakes.
• 10:29
  Without
• 10:29
  those
• 10:30
  breaks,
• 10:30
  you
• 10:30
  have
• 10:30
  more
• 10:31
  serotonin
• 10:31
  and
• 10:31
  norepinephrine
• 10:32
  that
• 10:32
  flows.
• 10:33
  Now
• 10:33
  here's
• 10:34
  a
• 10:34
  nice
• 10:34
  little
• 10:34
  pearl
• 10:34
  for
• 10:35
  remeron
• 10:35
  and
• 10:35
  this
• 10:35
  is
• 10:36
  going
• 10:36
  to
• 10:36
  get
• 10:36
  a
• 10:36
  lot
• 10:36
  of
• 10:36
  your
• 10:36
  patients.
• 10:37
  You've
• 10:37
  got
• 10:37
  to
• 10:37
  really
• 10:38
  mention
• 10:38
  this
• 10:38
  beforehand.
• 10:39
  Think
• 10:39
  of
• 10:40
  melatonin
• 10:40
  for
• 10:40
  a
• 10:41
  second,
• 10:41
  right?
• 10:41
  How
• 10:41
  many
• 10:41
  patients
• 10:42
  do
• 10:42
  you
• 10:42
  have
• 10:42
  that
• 10:42
  they
• 10:42
  take
• 10:42
  melatonin
• 10:43
  over
• 10:43
  the
• 10:43
  counter?
• 10:44
  They
• 10:44
  take
• 10:44
  1
• 10:44
  milligram.
• 10:45
  They're
• 10:45
  like,
• 10:45
  Ah,
• 10:45
  that
• 10:46
  doesn't
• 10:46
  help
• 10:46
  help.
• 10:46
  So
• 10:47
  then
• 10:47
  they
• 10:47
  take
• 10:47
  two
• 10:48
  or
• 10:48
  three,
• 10:48
  hoping
• 10:48
  that
• 10:49
  it
• 10:49
  makes
• 10:49
  them
• 10:49
  more
• 10:49
  sedated.
• 10:50
  And
• 10:51
  most
• 10:51
  of
• 10:51
  the
• 10:51
  time,
• 10:51
  when
• 10:51
  you
• 10:52
  take
• 10:52
  medications
• 10:52
  that
• 10:53
  sedate
• 10:53
  you
• 10:53
  and
• 10:53
  you
• 10:53
  take
• 10:54
  more
• 10:54
  of
• 10:54
  them,
• 10:54
  you'll
• 10:54
  get
• 10:54
  more
• 10:55
  sedated.
• 10:56
  That
• 10:56
  is
• 10:56
  not
• 10:56
  actually
• 10:57
  the
• 10:57
  case
• 10:58
  with,
• 10:58
  with
• 10:59
  Remeron.
• 11:00
  It's
• 11:01
  a
• 11:01
  little
• 11:01
  bit
• 11:01
  counterintuitive.
• 11:02
  But
• 11:02
  when
• 11:02
  you
• 11:03
  increase
• 11:03
  Remeron,
• 11:04
  what's
• 11:04
  happening
• 11:05
  then
• 11:06
  is
• 11:06
  you
• 11:07
  have
• 11:07
  more
• 11:07
  of
• 11:07
  the
• 11:07
  affinity
• 11:08
  for
• 11:09
  this
• 11:09
  Alpha
• 11:09
  2
• 11:09
  blockade.
• 11:10
  The
• 11:10
  Alpha
• 11:10
  2
• 11:11
  blockade
• 11:11
  is
• 11:11
  what
• 11:11
  I
• 11:11
  just
• 11:12
  talked
• 11:12
  about,
• 11:12
  right?
• 11:12
  Removing
• 11:13
  the
• 11:13
  brakes.
• 11:14
  So
• 11:14
  as
• 11:14
  you
• 11:14
  increase
• 11:15
  the
• 11:15
  dose
• 11:15
  of
• 11:16
  remeron,
• 11:16
  the
• 11:17
  alpha
• 11:17
  2
• 11:17
  blockade
• 11:18
  gets
• 11:18
  a
• 11:18
  little
• 11:18
  more
• 11:18
  prominent,
• 11:19
  okay?
• 11:20
  Blocking
• 11:20
  the
• 11:20
  alpha
• 11:21
  2
• 11:21
  adrenergic
• 11:22
  receptors.
• 11:22
  Okay.
• 11:23
  And
• 11:23
  so
• 11:23
  think
• 11:24
  about
• 11:24
  it.
• 11:24
  It's
• 11:24
  common
• 11:24
  sense,
• 11:25
  right?
• 11:25
  As
• 11:25
  you
• 11:25
  recruit
• 11:26
  those,
• 11:27
  those
• 11:28
  I
• 11:28
  always
• 11:28
  call
• 11:28
  them,
• 11:28
  like
• 11:28
  doors,
• 11:29
  right?
• 11:29
  As
• 11:29
  those
• 11:29
  new
• 11:30
  doors
• 11:30
  open,
• 11:30
  as
• 11:31
  you
• 11:31
  increase
• 11:31
  the
• 11:31
  dose,
• 11:32
  more
• 11:32
  norepinephrine
• 11:33
  is
• 11:34
  flowing.
• 11:34
  So
• 11:34
  it's
• 11:34
  actually
• 11:34
  less
• 11:35
  sedating
• 11:35
  at
• 11:35
  higher
• 11:36
  doses.
• 11:36
  This
• 11:36
  is
• 11:36
  not
• 11:37
  like
• 11:37
  melatonin
• 11:37
  or
• 11:38
  other
• 11:38
  medications
• 11:40
  like
• 11:40
  Seroquel.
• 11:41
  When
• 11:41
  Seroquel,
• 11:42
  50
• 11:42
  to
• 11:42
  100,
• 11:42
  typically
• 11:43
  you
• 11:43
  get
• 11:43
  more
• 11:43
  sedated,
• 11:44
  right?
• 11:44
  Trazodone,
• 11:45
  50
• 11:45
  to
• 11:45
  100,
• 11:46
  you
• 11:46
  get
• 11:46
  more
• 11:46
  sedated.
• 11:47
  Not
• 11:47
  so
• 11:47
  with
• 11:48
  Remeron.
• 11:48
  Typically,
• 11:49
  what
• 11:49
  happens
• 11:49
  is
• 11:49
  the
• 11:49
  alpha
• 11:50
  2
• 11:50
  adrenergic
• 11:51
  blockade
• 11:52
  is
• 11:52
  taking
• 11:52
  effect,
• 11:53
  which
• 11:53
  means
• 11:54
  norepinephrine
• 11:55
  is
• 11:55
  becoming
• 11:55
  more
• 11:55
  prominent,
• 11:56
  which
• 11:56
  means
• 11:56
  you're
• 11:56
  getting
• 11:57
  less
• 11:57
  sedated,
• 11:58
  more
• 11:58
  alert.
• 11:59
  So
• 11:59
  it's
• 11:59
  very
• 11:59
  important
• 12:00
  to
• 12:00
  educate
• 12:00
  your
• 12:00
  patients
• 12:01
  of
• 12:01
  this.
• 12:01
  Like
• 12:01
  it
• 12:01
  or
• 12:02
  not,
• 12:02
  you
• 12:02
  can
• 12:02
  do
• 12:02
  all
• 12:03
  the
• 12:03
  best
• 12:03
  education
• 12:03
  in
• 12:03
  the
• 12:04
  world.
• 12:04
  You
• 12:04
  will
• 12:04
  have
• 12:04
  that
• 12:04
  patient
• 12:05
  who
• 12:05
  comes
• 12:06
  in
• 12:06
  and
• 12:06
  says,
• 12:06
  well,
• 12:06
  I
• 12:06
  just
• 12:06
  took
• 12:07
  an
• 12:07
  extra
• 12:07
  pill
• 12:07
  thinking
• 12:07
  it
• 12:08
  would
• 12:08
  help.
• 12:08
  It
• 12:09
  just
• 12:09
  doesn't
• 12:09
  work
• 12:09
  that
• 12:09
  way.
• 12:10
  And
• 12:10
  you
• 12:10
  can
• 12:10
  prevent
• 12:11
  them
• 12:11
  from
• 12:11
  doing
• 12:11
  that
• 12:11
  needlessly
• 12:12
  by
• 12:13
  educating
• 12:13
  them
• 12:13
  that
• 12:14
  it
• 12:14
  actually
• 12:14
  won't
• 12:14
  make
• 12:15
  you
• 12:15
  any
• 12:16
  more
• 12:17
  sedated
• 12:17
  by
• 12:17
  increasing
• 12:18
  the
• 12:18
  dose.
• 12:19
  Actually,
• 12:19
  worse
• 12:20
  than
• 12:20
  that.
• 12:20
  I've
• 12:20
  had
• 12:20
  patients
• 12:20
  that
• 12:21
  get
• 12:21
  really
• 12:21
  activated,
• 12:22
  right?
• 12:22
  Because
• 12:22
  you
• 12:22
  don't
• 12:22
  want
• 12:23
  to
• 12:23
  raise
• 12:23
  serotonin
• 12:24
  too
• 12:24
  quickly.
• 12:24
  So
• 12:24
  I've
• 12:25
  had
• 12:25
  patients
• 12:25
  that
• 12:25
  get,
• 12:25
  like,
• 12:26
  really
• 12:26
  anxious,
• 12:26
  even
• 12:27
  borderline
• 12:27
  suicidal
• 12:28
  when
• 12:28
  they
• 12:28
  do
• 12:28
  that.
• 12:29
  So
• 12:29
  you've
• 12:29
  really
• 12:29
  got
• 12:30
  to
• 12:30
  do
• 12:30
  your
• 12:31
  education.
• 12:32
  Just
• 12:32
  be
• 12:32
  very
• 12:32
  mindful
• 12:33
  of
• 12:33
  that.
• 12:33
  Because
• 12:33
  patients
• 12:34
  don't
• 12:35
  know
• 12:35
  what
• 12:35
  they
• 12:35
  don't
• 12:35
  know
• 12:35
  all
• 12:36
  the
• 12:36
  time.
• 12:36
  They
• 12:37
  rely
• 12:37
  on
• 12:37
  us.
• 12:38
  And
• 12:38
  they
• 12:38
  might
• 12:38
  make
• 12:38
  assumptions
• 12:39
  in
• 12:40
  the
• 12:40
  absence
• 12:40
  of
• 12:40
  our
• 12:41
  education.
• 12:41
  So
• 12:42
  we
• 12:42
  really
• 12:42
  want
• 12:42
  to
• 12:43
  make
• 12:43
  sure
• 12:43
  they
• 12:43
  understand
• 12:44
  how
• 12:44
  that
• 12:44
  works.
• 12:45
  But,
• 12:45
  you
• 12:45
  know,
• 12:45
  I
• 12:45
  love
• 12:46
  Remeron.
• 12:46
  I
• 12:47
  find
• 12:47
  that
• 12:47
  it's,
• 12:48
  again,
• 12:48
  it
• 12:49
  avoids
• 12:49
  a
• 12:49
  lot
• 12:49
  of
• 12:50
  the
• 12:50
  major
• 12:50
  side
• 12:50
  effects
• 12:51
  that
• 12:51
  are
• 12:51
  very
• 12:51
  off
• 12:52
  putting
• 12:52
  to
• 12:52
  patients.
• 12:53
  I
• 12:53
  find
• 12:53
  that
• 12:54
  it's
• 12:54
  kind
• 12:54
  of
• 12:55
  the
• 12:55
  jack
• 12:55
  of
• 12:55
  all
• 12:55
  trades
• 12:56
  in
• 12:56
  that,
• 12:57
  you
• 12:57
  know,
• 12:57
  you're
• 12:57
  attacking
• 12:58
  several
• 12:58
  neurotransmitters
• 12:59
  at
• 13:00
  once
• 13:00
  that
• 13:00
  are
• 13:00
  usually
• 13:00
  implicated
• 13:01
  in
• 13:01
  anxiety
• 13:02
  or
• 13:02
  depression.
• 13:03
  I
• 13:03
  also
• 13:03
  find
• 13:03
  that
• 13:04
  just
• 13:04
  by
• 13:04
  getting
• 13:04
  sleep
• 13:04
  back
• 13:05
  on
• 13:05
  board,
• 13:05
  you
• 13:06
  kind
• 13:06
  of
• 13:06
  indirectly
• 13:07
  help
• 13:07
  anxiety
• 13:08
  and
• 13:08
  depression.
• 13:08
  Right.
• 13:09
  People's.
• 13:10
  People
• 13:10
  just
• 13:11
  feel
• 13:11
  less
• 13:11
  stressed
• 13:11
  out
• 13:12
  when
• 13:12
  they're
• 13:12
  getting
• 13:12
  a
• 13:12
  good
• 13:12
  night's
• 13:13
  sleep.
• 13:13
  There's
• 13:13
  all
• 13:13
  kinds
• 13:14
  of
• 13:14
  deeply
• 13:15
  restorative
• 13:15
  processes
• 13:16
  that
• 13:16
  are
• 13:16
  happening
• 13:17
  when
• 13:17
  you
• 13:17
  sleep.
• 13:17
  I
• 13:17
  think
• 13:18
  about
• 13:18
  how
• 13:18
  many
• 13:18
  of
• 13:18
  your
• 13:18
  patients
• 13:19
  have
• 13:19
  PTSD
• 13:20
  and
• 13:20
  now
• 13:20
  they're
• 13:21
  sleeping.
• 13:21
  It's
• 13:21
  not
• 13:22
  indicated
• 13:22
  for
• 13:22
  nightmares
• 13:23
  per
• 13:23
  se,
• 13:24
  but
• 13:24
  I
• 13:24
  can't
• 13:24
  tell
• 13:24
  you
• 13:25
  how
• 13:25
  many
• 13:25
  patients
• 13:25
  actually
• 13:26
  tell
• 13:26
  me.
• 13:26
  They
• 13:26
  either
• 13:27
  don't
• 13:27
  remember
• 13:27
  their
• 13:27
  dreams
• 13:28
  anymore
• 13:28
  and
• 13:28
  it's
• 13:28
  a
• 13:28
  huge
• 13:29
  relief,
• 13:29
  or
• 13:30
  their
• 13:30
  nightmares
• 13:31
  have
• 13:31
  actually
• 13:32
  gone
• 13:32
  down.
• 13:33
  Of
• 13:33
  course,
• 13:33
  this
• 13:33
  is
• 13:34
  not
• 13:34
  as
• 13:34
  simple
• 13:35
  science.
• 13:35
  You
• 13:35
  will
• 13:35
  have
• 13:35
  patients
• 13:36
  who
• 13:36
  say
• 13:36
  it's
• 13:36
  gotten
• 13:36
  worse.
• 13:37
  But
• 13:37
  in
• 13:38
  my
• 13:38
  anecdotal
• 13:39
  experience,
• 13:40
  it
• 13:40
  actually
• 13:40
  is
• 13:41
  pretty
• 13:41
  effective
• 13:42
  for
• 13:42
  nightmares
• 13:42
  off
• 13:43
  label.
• 13:43
  I
• 13:43
  have
• 13:43
  seen
• 13:44
  patients
• 13:44
  very
• 13:45
  much
• 13:45
  applaud
• 13:46
  Remeron
• 13:46
  for
• 13:47
  that,
• 13:47
  incidentally.
• 13:48
  Again,
• 13:49
  I
• 13:49
  don't
• 13:49
  go
• 13:49
  to
• 13:49
  this
• 13:50
  to
• 13:50
  get
• 13:50
  rid
• 13:50
  of
• 13:50
  nightmares.
• 13:52
  That's
• 13:52
  what
• 13:52
  Prazosin's
• 13:53
  job
• 13:53
  is.
• 13:53
  We
• 13:53
  have
• 13:53
  really
• 13:54
  good
• 13:54
  past
• 13:54
  episodes
• 13:54
  on
• 13:55
  that.
• 13:55
  But
• 13:55
  again,
• 13:56
  you
• 13:56
  know,
• 13:56
  hey,
• 13:56
  if
• 13:57
  it
• 13:57
  works,
• 13:57
  it
• 13:57
  works.
• 13:58
  What
• 13:58
  matters
• 13:58
  more
• 13:58
  than
• 13:59
  anything
• 13:59
  is
• 13:59
  that
• 13:59
  your
• 13:59
  patient's
• 14:00
  life
• 14:00
  is
• 14:00
  getting
• 14:00
  better,
• 14:01
  that
• 14:01
  they
• 14:01
  don't
• 14:02
  dread
• 14:02
  going
• 14:02
  to
• 14:02
  sleep,
• 14:03
  that
• 14:03
  they're
• 14:04
  not
• 14:04
  reliving
• 14:04
  their
• 14:04
  traumas
• 14:05
  every
• 14:05
  night
• 14:05
  when
• 14:05
  they
• 14:06
  should
• 14:06
  be
• 14:06
  having
• 14:06
  restorative
• 14:07
  sleep.
• 14:07
  That's
• 14:08
  what
• 14:08
  matters
• 14:08
  more
• 14:08
  than
• 14:09
  whether
• 14:09
  or
• 14:09
  not
• 14:10
  you
• 14:10
  happen
• 14:11
  to
• 14:11
  benefit
• 14:12
  from
• 14:12
  the
• 14:12
  medication
• 14:13
  that
• 14:13
  is
• 14:14
  FDA
• 14:14
  approved
• 14:14
  for
• 14:15
  a
• 14:15
  specific
• 14:15
  thing.
• 14:16
  You
• 14:16
  always
• 14:16
  want
• 14:16
  to
• 14:16
  tailor
• 14:17
  your
• 14:17
  medications
• 14:18
  exactly
• 14:18
  based
• 14:19
  on
• 14:19
  the
• 14:19
  evidence.
• 14:19
  That's
• 14:20
  what
• 14:20
  good
• 14:21
  scientists
• 14:21
  do
• 14:22
  and
• 14:22
  clinicians
• 14:22
  do.
• 14:23
  But
• 14:23
  again,
• 14:23
  if
• 14:24
  you
• 14:24
  are
• 14:24
  treating
• 14:25
  depression,
• 14:25
  anxiety,
• 14:26
  panic,
• 14:26
  the
• 14:27
  patient
• 14:27
  can't
• 14:27
  sleep,
• 14:28
  they're
• 14:28
  not
• 14:28
  eating,
• 14:29
  and
• 14:29
  Remeron
• 14:29
  is
• 14:30
  their
• 14:30
  jam.
• 14:30
  It
• 14:31
  makes
• 14:31
  sense
• 14:31
  in
• 14:31
  the
• 14:31
  moment.
• 14:32
  Even
• 14:32
  bigger
• 14:32
  win
• 14:33
  that
• 14:33
  it
• 14:33
  quells
• 14:33
  their
• 14:34
  nightmares,
• 14:34
  that's
• 14:34
  even
• 14:35
  better.
• 14:36
  So
• 14:36
  there's
• 14:37
  many
• 14:37
  other
• 14:38
  little
• 14:38
  pearls
• 14:38
  about
• 14:39
  Remeron
• 14:39
  and
• 14:40
  also
• 14:40
  some
• 14:40
  amazing
• 14:41
  deep
• 14:41
  dives
• 14:41
  about
• 14:41
  how
• 14:42
  this
• 14:42
  works.
• 14:43
  So
• 14:43
  again,
• 14:43
  if
• 14:43
  you
• 14:43
  become
• 14:44
  a
• 14:44
  Patreon
• 14:44
  member,
• 14:45
  three
• 14:45
  bucks
• 14:46
  a
• 14:46
  month,
• 14:46
  I
• 14:46
  highly
• 14:46
  recommend
• 14:47
  it,
• 14:47
  you
• 14:47
  will
• 14:47
  get
• 14:48
  a
• 14:48
  much
• 14:48
  deeper
• 14:48
  dive
• 14:48
  on
• 14:49
  what
• 14:49
  Remeron
• 14:49
  is
• 14:50
  and
• 14:50
  how
• 14:50
  it
• 14:50
  works
• 14:50
  and
• 14:51
  what
• 14:51
  it
• 14:51
  does.
• 14:52
  Some
• 14:52
  fascinating
• 14:52
  fast
• 14:53
  facts,
• 14:53
  some
• 14:54
  good
• 14:54
  analogies.
• 14:54
  About
• 14:55
  how
• 14:55
  it
• 14:55
  works.
• 14:55
  So
• 14:56
  highly
• 14:56
  recommend
• 14:56
  you,
• 14:57
  you
• 14:57
  join
• 14:57
  and
• 14:58
  sign
• 14:58
  up
• 14:58
  because
• 14:59
  there's
• 14:59
  a
• 14:59
  lot
• 14:59
  more
• 15:00
  meat
• 15:00
  on
• 15:00
  this
• 15:00
  bone
• 15:01
  that
• 15:01
  you
• 15:02
  should
• 15:02
  know
• 15:02
  about.
• 15:03
  This
• 15:03
  is
• 15:03
  a
• 15:03
  very
• 15:04
  important
• 15:04
  arrow
• 15:04
  in
• 15:05
  your
• 15:05
  quiver,
• 15:05
  this
• 15:05
  Mirtazapine
• 15:06
  or
• 15:06
  Remeron.
• 15:07
  And
• 15:08
  I
• 15:08
  just
• 15:08
  love
• 15:09
  it.
• 15:09
  I
• 15:09
  think
• 15:09
  it's
• 15:09
  really
• 15:09
  important.
• 15:10
  It's
• 15:10
  probably
• 15:10
  one
• 15:11
  of
• 15:11
  the
• 15:11
  medications
• 15:11
  I
• 15:12
  would
• 15:12
  take
• 15:12
  with
• 15:12
  me
• 15:12
  on
• 15:12
  an
• 15:13
  island.
• 15:13
  If
• 15:14
  I
• 15:14
  had
• 15:14
  five
• 15:14
  of
• 15:14
  them.
• 15:15
  I
• 15:15
  would
• 15:16
  certainly
• 15:16
  pick
• 15:17
  Remeron
• 15:17
  as
• 15:18
  one
• 15:18
  of
• 15:18
  my
• 15:19
  five.
• 15:19
  And
• 15:19
  we'll
• 15:20
  do
• 15:20
  a
• 15:20
  future
• 15:20
  episode
• 15:21
  on
• 15:21
  what
• 15:21
  those
• 15:21
  other
• 15:21
  four
• 15:21
  are.
• 15:22
  And
• 15:22
  I
• 15:22
  am
• 15:22
  dying
• 15:23
  to
• 15:23
  hear
• 15:23
  what
• 15:23
  your
• 15:24
  five
• 15:24
  would
• 15:24
  be
• 15:24
  too.
• 15:24
  I
• 15:25
  think
• 15:25
  that'd
• 15:25
  be
• 15:25
  the
• 15:25
  most
• 15:25
  exciting
• 15:26
  episode
• 15:26
  ever
• 15:27
  to
• 15:27
  just
• 15:27
  hear
• 15:27
  what,
• 15:28
  what
• 15:28
  are
• 15:28
  the
• 15:28
  most
• 15:28
  useful
• 15:29
  medications
• 15:29
  for
• 15:29
  all
• 15:30
  of
• 15:30
  you
• 15:30
  guys?
• 15:31
  Because
• 15:31
  I
• 15:31
  know
• 15:31
  everybody
• 15:32
  has
• 15:32
  different
• 15:32
  philosophies,
• 15:33
  they've
• 15:33
  encountered
• 15:33
  different
• 15:34
  kinds
• 15:34
  of
• 15:34
  patients
• 15:34
  in
• 15:34
  their
• 15:35
  practice.
• 15:35
  But
• 15:36
  without
• 15:36
  a
• 15:36
  doubt,
• 15:37
  Remeron
• 15:37
  would
• 15:38
  be
• 15:38
  in
• 15:38
  my
• 15:39
  five
• 15:39
  medications
• 15:41
  to
• 15:41
  bring
• 15:41
  on
• 15:41
  an
• 15:41
  island.
• 15:42
  If
• 15:42
  I
• 15:42
  was
• 15:42
  to
• 15:42
  run
• 15:42
  a
• 15:43
  clinic
• 15:43
  in
• 15:43
  the
• 15:44
  middle
• 15:44
  of
• 15:44
  the
• 15:44
  Pacific
• 15:44
  somewhere
• 15:45
  and
• 15:46
  I
• 15:46
  had
• 15:46
  like
• 15:46
  a
• 15:47
  make
• 15:47
  believe
• 15:47
  pharmacy
• 15:49
  surrounded
• 15:49
  by
• 15:49
  coconut
• 15:50
  trees
• 15:51
  and
• 15:51
  my
• 15:51
  volleyball
• 15:52
  that
• 15:52
  I
• 15:52
  talk
• 15:53
  to
• 15:53
  in
• 15:53
  between
• 15:54
  patients,
• 15:54
  I
• 15:54
  would
• 15:55
  definitely
• 15:56
  bring
• 15:56
  Remeron
• 15:57
  on
• 15:57
  board.
• 15:57
  So
• 15:58
  I
• 15:58
  hope
• 15:58
  you
• 15:59
  enjoyed
• 15:59
  this
• 15:59
  version
• 16:00
  of
• 16:00
  Inside
• 16:01
  the
• 16:01
  Capsule.
• 16:02
  Don't
• 16:02
  forget
• 16:03
  why
• 16:04
  this
• 16:05
  works
• 16:05
  so
• 16:05
  well.
• 16:05
  The
• 16:06
  side
• 16:06
  effects
• 16:06
  it
• 16:06
  avoids
• 16:07
  don't
• 16:08
  affect,
• 16:08
  don't
• 16:08
  forget
• 16:09
  the
• 16:09
  drawbacks
• 16:10
  that
• 16:10
  might
• 16:10
  be
• 16:10
  a
• 16:10
  deal
• 16:11
  breaker
• 16:11
  for
• 16:11
  some
• 16:11
  patients,
• 16:12
  but
• 16:13
  remember,
• 16:13
  it's
• 16:14
  fairly
• 16:15
  tolerable
• 16:16
  for
• 16:16
  the
• 16:16
  right
• 16:16
  person.
• 16:17
  And
• 16:18
  hey,
• 16:18
  it
• 16:18
  works
• 16:18
  the
• 16:19
  same
• 16:19
  night,
• 16:19
  right?
• 16:19
  The
• 16:20
  sedation
• 16:21
  getting
• 16:21
  your
• 16:21
  patient
• 16:22
  to
• 16:22
  sleep,
• 16:22
  it
• 16:22
  works
• 16:23
  that
• 16:23
  night
• 16:23
  usually.
• 16:24
  So
• 16:24
  hey,
• 16:25
  if
• 16:25
  you
• 16:25
  need
• 16:25
  something
• 16:25
  quicker,
• 16:26
  which
• 16:26
  can
• 16:27
  encourage
• 16:27
  the
• 16:27
  patient
• 16:28
  to
• 16:28
  be
• 16:28
  more
• 16:28
  adherent,
• 16:28
  this
• 16:29
  is
• 16:29
  a
• 16:29
  good
• 16:29
  way
• 16:29
  to
• 16:29
  go.
• 16:30
  All
• 16:30
  right,
• 16:30
  my
• 16:30
  friends,
• 16:31
  until
• 16:31
  next
• 16:31
  time,
• 16:31
  thanks
• 16:32
  for
• 16:32
  tuning
• 16:32
  in
• 16:33
  to
• 16:33
  another
• 16:33
  episode
• 16:34
  of
• 16:34
  Pearls
• 16:34
  and
• 16:35
  Prep.
• 16:35
  Signing
• 16:35
  off.
• 16:36
  Bye
• 16:36
  Bye.