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BONUS EPISODE: This untreated issue can DOUBLE your patient’s risk of depression · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  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
  your
• 0:09
  go
• 0:09
  to
• 0:09
  place
• 0:10
  for
• 0:10
  Pearls
• 0:11
  that
• 0:11
  prep
• 0:11
  you
• 0:12
  to
• 0:12
  practice.
• 0:12
  This
• 0:12
  is
• 0:13
  NPZ
• 0:13
  here.
• 0:14
  You
• 0:14
  know
• 0:14
  I
• 0:14
  love
• 0:15
  these
• 0:15
  multiple
• 0:15
  choice
• 0:16
  questions.
• 0:16
  They
• 0:17
  keep
• 0:17
  us
• 0:17
  on
• 0:17
  our
• 0:18
  toes,
• 0:18
  they
• 0:19
  keep
• 0:19
  us
• 0:19
  at
• 0:19
  the,
• 0:20
  at
• 0:20
  the
• 0:20
  top
• 0:21
  of
• 0:21
  our
• 0:21
  game.
• 0:22
  So
• 0:22
  this
• 0:22
  one
• 0:23
  is
• 0:23
  a
• 0:23
  kind
• 0:24
  of
• 0:24
  brain
• 0:24
  teaser
• 0:25
  for
• 0:25
  you.
• 0:26
  Feel
• 0:26
  free
• 0:26
  to
• 0:26
  pause
• 0:27
  this
• 0:28
  podcast
• 0:28
  and
• 0:29
  think
• 0:30
  before
• 0:30
  you
• 0:30
  just
• 0:30
  impulsively
• 0:31
  blurt
• 0:32
  out
• 0:32
  the
• 0:32
  answer.
• 0:33
  Okay,
• 0:34
  but
• 0:34
  no,
• 0:34
  this
• 0:35
  is
• 0:35
  an
• 0:35
  interesting
• 0:35
  one.
• 0:36
  So
• 0:37
  According
• 0:37
  to
• 0:38
  a
• 0:38
  2025
• 0:39
  population
• 0:40
  based
• 0:40
  study
• 0:41
  of
• 0:41
  over
• 0:42
  7
• 0:42
  million
• 0:42
  individuals,
• 0:43
  which
• 0:44
  of
• 0:44
  the
• 0:44
  following
• 0:45
  conditions
• 0:46
  approximately
• 0:47
  doubles
• 0:48
  the
• 0:48
  risk
• 0:48
  of
• 0:48
  developing
• 0:49
  a
• 0:49
  depressive
• 0:50
  disorder?
• 0:51
  Is
• 0:51
  it
• 0:52
  A,
• 0:53
  chronic
• 0:53
  low
• 0:53
  back
• 0:54
  pain?
• 0:54
  Is
• 0:54
  it
• 0:55
  B,
• 0:55
  irritable
• 0:56
  bowel
• 0:56
  syndrome?
• 0:56
  Is
• 0:57
  it
• 0:57
  C,
• 0:57
  obstructive
• 0:58
  sleep
• 0:58
  apnea?
• 0:59
  Or
• 0:59
  is
• 0:59
  it
• 0:59
  D,
• 1:00
  a
• 1:00
  vitamin
• 1:01
  D
• 1:01
  deficiency?
• 1:03
  Take
• 1:04
  your
• 1:04
  time.
• 1:06
  Maybe
• 1:06
  have
• 1:06
  a
• 1:06
  little
• 1:07
  debate
• 1:07
  with
• 1:07
  your
• 1:07
  friend,
• 1:09
  call
• 1:09
  your
• 1:09
  mom
• 1:10
  and
• 1:10
  ask
• 1:10
  her
• 1:10
  what
• 1:11
  she
• 1:11
  thinks.
• 1:12
  Okay?
• 1:13
  It's
• 1:13
  kind
• 1:13
  of
• 1:13
  an
• 1:14
  interesting
• 1:15
  question
• 1:16
  even
• 1:16
  if
• 1:17
  you're
• 1:17
  not
• 1:17
  in
• 1:17
  the
• 1:17
  mental
• 1:18
  health
• 1:18
  field,
• 1:18
  right?
• 1:19
  A
• 1:19
  lot
• 1:19
  of
• 1:19
  people
• 1:19
  have
• 1:20
  low
• 1:20
  back
• 1:20
  pain,
• 1:21
  A
• 1:21
  lot
• 1:21
  of
• 1:21
  people
• 1:22
  have
• 1:22
  irritable
• 1:22
  bowels.
• 1:24
  Not
• 1:24
  everybody
• 1:25
  knows
• 1:25
  if
• 1:25
  they
• 1:25
  have
• 1:25
  a
• 1:25
  vitamin
• 1:26
  D
• 1:26
  deficiency.
• 1:27
  We
• 1:27
  did
• 1:27
  talk
• 1:27
  about
• 1:27
  this,
• 1:28
  that
• 1:28
  up
• 1:28
  to
• 1:29
  80%
• 1:29
  of
• 1:30
  mental
• 1:30
  health
• 1:31
  patients
• 1:31
  have
• 1:31
  a
• 1:32
  vitamin
• 1:32
  D
• 1:32
  deficiency.
• 1:33
  That's
• 1:33
  striking
• 1:34
  and
• 1:34
  crazy.
• 1:34
  I
• 1:35
  had
• 1:35
  no
• 1:35
  idea.
• 1:36
  But
• 1:36
  anyway,
• 1:37
  the
• 1:37
  answer
• 1:38
  is
• 1:38
  actually
• 1:38
  obstructive
• 1:39
  sleep
• 1:39
  apnea.
• 1:40
  And
• 1:41
  this
• 1:41
  was
• 1:41
  a
• 1:41
  Korean
• 1:42
  study
• 1:42
  done
• 1:43
  an
• 1:43
  8
• 1:44
  year
• 1:44
  follow
• 1:45
  up
• 1:45
  window
• 1:45
  where
• 1:46
  27.4%
• 1:47
  of
• 1:48
  obstructive
• 1:48
  sleep
• 1:48
  apnea
• 1:49
  patients
• 1:49
  developed
• 1:50
  a
• 1:50
  depressive
• 1:50
  disorder
• 1:51
  compared
• 1:51
  to
• 1:52
  15%
• 1:53
  of
• 1:53
  match
• 1:53
  control.
• 1:54
  So
• 1:54
  that's
• 1:54
  a
• 1:54
  hazard
• 1:55
  ratio
• 1:55
  or
• 1:55
  increased
• 1:56
  risk
• 1:56
  of
• 1:56
  1.9
• 1:57
  or
• 1:57
  basically
• 1:58
  at
• 1:58
  two
• 1:58
  times
• 1:59
  the
• 1:59
  risk
• 2:00
  if
• 2:00
  you
• 2:00
  suffered
• 2:00
  from
• 2:01
  obstructive
• 2:01
  sleep
• 2:02
  apnea.
• 2:03
  Now
• 2:03
  the
• 2:03
  obvious
• 2:04
  way
• 2:04
  to
• 2:04
  look
• 2:04
  at
• 2:05
  this
• 2:05
  is
• 2:05
  to
• 2:05
  go,
• 2:05
  well
• 2:06
  duh,
• 2:07
  if
• 2:07
  you're
• 2:07
  not
• 2:07
  sleeping,
• 2:08
  you're
• 2:09
  gonna
• 2:09
  wake
• 2:09
  up
• 2:09
  kind
• 2:09
  of
• 2:10
  moody.
• 2:10
  We've
• 2:11
  seen
• 2:11
  studies
• 2:12
  that
• 2:12
  poor
• 2:13
  sleep
• 2:13
  can
• 2:13
  even
• 2:14
  lead
• 2:14
  to
• 2:14
  increased
• 2:15
  next
• 2:15
  day
• 2:15
  suicidal
• 2:16
  ideations.
• 2:16
  There's
• 2:17
  some
• 2:17
  evidence
• 2:17
  for
• 2:18
  that.
• 2:18
  I
• 2:18
  find
• 2:18
  that
• 2:18
  pretty
• 2:19
  fascinating.
• 2:19
  So
• 2:20
  it's
• 2:20
  not
• 2:20
  really
• 2:21
  lost
• 2:21
  on
• 2:21
  anybody.
• 2:22
  I
• 2:22
  mean
• 2:22
  you
• 2:23
  don't
• 2:23
  need
• 2:23
  a
• 2:23
  degree
• 2:24
  to
• 2:24
  know
• 2:25
  that
• 2:25
  when
• 2:25
  you
• 2:25
  can't
• 2:25
  sleep,
• 2:26
  you
• 2:26
  feel
• 2:26
  like
• 2:27
  crap
• 2:27
  the
• 2:27
  next
• 2:27
  day.
• 2:27
  You're
• 2:28
  irritable,
• 2:28
  you're
• 2:29
  moody,
• 2:29
  you're
• 2:29
  probably
• 2:29
  more
• 2:30
  impulsive.
• 2:30
  I
• 2:30
  know
• 2:30
  I
• 2:31
  tend
• 2:31
  to
• 2:31
  eat
• 2:31
  more
• 2:32
  carbohydrates,
• 2:33
  I'm
• 2:33
  a
• 2:33
  little
• 2:33
  more
• 2:34
  short
• 2:34
  fused
• 2:34
  with
• 2:35
  people.
• 2:35
  Maybe
• 2:36
  I'm
• 2:36
  not
• 2:36
  as
• 2:36
  sociable.
• 2:37
  So
• 2:38
  it's
• 2:39
  just
• 2:39
  on
• 2:39
  the
• 2:39
  surface,
• 2:40
  it's
• 2:40
  not
• 2:41
  insane
• 2:41
  to
• 2:41
  assume
• 2:42
  that
• 2:42
  obstructive
• 2:43
  sleep
• 2:43
  apnea
• 2:44
  leads
• 2:44
  to
• 2:45
  a
• 2:45
  double
• 2:45
  the
• 2:46
  rate
• 2:46
  of
• 2:46
  a
• 2:46
  depressive
• 2:47
  disorder
• 2:48
  more
• 2:48
  generally,
• 2:49
  right?
• 2:49
  But
• 2:49
  I
• 2:50
  always
• 2:50
  talk
• 2:51
  on
• 2:51
  this
• 2:51
  podcast
• 2:52
  about
• 2:53
  trying
• 2:54
  to
• 2:54
  get
• 2:54
  all
• 2:54
  of
• 2:54
  us
• 2:55
  to
• 2:56
  understand
• 2:56
  the
• 2:56
  how
• 2:56
  and
• 2:57
  the
• 2:57
  why,
• 2:57
  right?
• 2:57
  This
• 2:57
  is
• 2:58
  what
• 2:58
  I
• 2:58
  say
• 2:59
  all
• 2:59
  the
• 2:59
  time
• 3:00
  that
• 3:00
  separates
• 3:01
  the
• 3:01
  good
• 3:01
  clinicians
• 3:02
  from
• 3:02
  the
• 3:02
  great
• 3:03
  clinicians,
• 3:04
  right?
• 3:04
  Any
• 3:05
  Joe
• 3:05
  Schmo
• 3:06
  in
• 3:06
  an
• 3:06
  alley
• 3:07
  knows
• 3:08
  that
• 3:08
  poor
• 3:08
  sleep
• 3:09
  means
• 3:09
  bad
• 3:09
  mental
• 3:09
  health.
• 3:10
  But
• 3:10
  if
• 3:10
  you
• 3:10
  can
• 3:10
  explain
• 3:11
  the
• 3:11
  mechanisms
• 3:12
  to
• 3:13
  your
• 3:13
  patient,
• 3:14
  the
• 3:14
  how,
• 3:14
  and
• 3:15
  flesh
• 3:15
  that
• 3:15
  out,
• 3:15
  it
• 3:15
  gives
• 3:16
  them
• 3:16
  a
• 3:16
  sense
• 3:16
  of
• 3:17
  reassurance
• 3:18
  to
• 3:19
  see
• 3:19
  that
• 3:19
  you
• 3:20
  have
• 3:20
  a
• 3:20
  command
• 3:21
  on
• 3:21
  what's
• 3:21
  happening
• 3:22
  here
• 3:22
  and
• 3:22
  why.
• 3:22
  And
• 3:23
  it
• 3:23
  allows
• 3:23
  you
• 3:23
  to
• 3:23
  get
• 3:24
  a
• 3:24
  little
• 3:24
  more
• 3:24
  precise
• 3:25
  in
• 3:25
  your
• 3:25
  treatment,
• 3:26
  in
• 3:26
  your
• 3:26
  questioning.
• 3:27
  It
• 3:27
  allows
• 3:27
  you
• 3:27
  to
• 3:27
  be
• 3:27
  a
• 3:27
  little
• 3:27
  bit
• 3:28
  more
• 3:28
  on
• 3:28
  guard
• 3:29
  when
• 3:29
  you
• 3:29
  have
• 3:29
  somebody
• 3:30
  who's
• 3:30
  depressed
• 3:30
  and
• 3:31
  they're
• 3:31
  not
• 3:31
  getting
• 3:32
  better,
• 3:32
  when
• 3:32
  you're
• 3:32
  putting
• 3:33
  them
• 3:33
  on
• 3:33
  Zoloft
• 3:33
  or
• 3:34
  Prozac
• 3:34
  and
• 3:35
  you
• 3:35
  don't
• 3:35
  see
• 3:35
  any
• 3:35
  bipolarity,
• 3:36
  and
• 3:37
  so
• 3:37
  you're
• 3:37
  scratching
• 3:37
  your
• 3:38
  head,
• 3:38
  like,
• 3:38
  what
• 3:38
  could
• 3:38
  this
• 3:39
  be?
• 3:39
  Right?
• 3:39
  You've
• 3:40
  already
• 3:40
  tested
• 3:40
  them
• 3:41
  for
• 3:41
  vitamin
• 3:41
  D,
• 3:41
  B12,
• 3:42
  folate.
• 3:43
  They're
• 3:43
  not
• 3:43
  anemic,
• 3:44
  and
• 3:45
  their
• 3:45
  thyroid's
• 3:46
  fine.
• 3:46
  And
• 3:47
  you're
• 3:47
  like,
• 3:47
  well,
• 3:47
  what
• 3:47
  else
• 3:48
  could
• 3:48
  this
• 3:48
  be?
• 3:48
  We've
• 3:48
  tried
• 3:49
  Zoloft,
• 3:49
  we've
• 3:49
  tried
• 3:50
  Prozac,
• 3:50
  we've
• 3:50
  tried
• 3:50
  Effexor.
• 3:51
  Nothing's
• 3:52
  budging
• 3:52
  here.
• 3:52
  Hell,
• 3:53
  the
• 3:53
  patient
• 3:53
  doesn't
• 3:53
  even
• 3:54
  have
• 3:54
  a
• 3:54
  family
• 3:55
  member
• 3:55
  with
• 3:55
  depression.
• 3:56
  Now
• 3:56
  I'm
• 3:56
  super
• 3:56
  confused,
• 3:57
  right?
• 3:58
  And
• 3:58
  so
• 3:58
  obstructive
• 3:59
  sleep
• 3:59
  apnea
• 4:00
  is
• 4:01
  actually
• 4:01
  a
• 4:01
  great
• 4:02
  opportunity
• 4:03
  for
• 4:03
  you
• 4:03
  to
• 4:03
  kind
• 4:04
  of
• 4:04
  dial
• 4:04
  into
• 4:05
  and
• 4:06
  understand
• 4:06
  it
• 4:06
  and
• 4:06
  ask
• 4:07
  the
• 4:07
  questions
• 4:08
  that
• 4:08
  you
• 4:08
  need
• 4:08
  to
• 4:09
  to
• 4:09
  get
• 4:09
  to
• 4:09
  the
• 4:09
  bottom
• 4:10
  of
• 4:10
  it.
• 4:10
  It's
• 4:10
  a
• 4:10
  very
• 4:11
  exciting
• 4:12
  opportunity,
• 4:13
  actually,
• 4:13
  because
• 4:13
  double
• 4:14
  the
• 4:14
  risk
• 4:14
  is
• 4:14
  a
• 4:14
  big
• 4:14
  problem.
• 4:15
  And
• 4:15
  as
• 4:15
  we
• 4:15
  know,
• 4:16
  obstructive
• 4:16
  sleep
• 4:17
  apnea
• 4:17
  is
• 4:17
  also
• 4:17
  very
• 4:18
  common.
• 4:18
  It's.
• 4:19
  You
• 4:19
  see
• 4:19
  it
• 4:19
  all
• 4:19
  the
• 4:20
  time
• 4:20
  in
• 4:20
  your
• 4:20
  outpatient
• 4:21
  practice,
• 4:21
  right?
• 4:22
  And
• 4:22
  the
• 4:22
  big
• 4:22
  takeaway
• 4:23
  here
• 4:23
  is
• 4:23
  that
• 4:23
  obstructive
• 4:24
  sleep
• 4:24
  apnea,
• 4:25
  also
• 4:25
  known
• 4:25
  as
• 4:25
  osa,
• 4:27
  we're
• 4:27
  not
• 4:27
  talking
• 4:28
  about
• 4:28
  just
• 4:28
  getting
• 4:28
  bad
• 4:29
  sleep,
• 4:29
  right?
• 4:30
  This
• 4:30
  is
• 4:30
  a
• 4:31
  medical
• 4:31
  condition
• 4:32
  that
• 4:32
  physically
• 4:32
  changes
• 4:33
  your
• 4:33
  brain
• 4:33
  chemistry,
• 4:34
  your
• 4:34
  brain
• 4:35
  structure,
• 4:35
  your
• 4:35
  body's
• 4:36
  whole
• 4:37
  more
• 4:37
  generally,
• 4:38
  Right?
• 4:39
  And
• 4:39
  all
• 4:39
  of
• 4:39
  those
• 4:39
  things
• 4:40
  kind
• 4:40
  of
• 4:40
  converge
• 4:40
  to
• 4:41
  produce
• 4:41
  what
• 4:41
  looks
• 4:42
  exactly
• 4:42
  like
• 4:43
  major
• 4:43
  depression,
• 4:44
  Right?
• 4:44
  And
• 4:45
  one
• 4:45
  of
• 4:45
  them,
• 4:45
  I
• 4:45
  think,
• 4:46
  is
• 4:46
  particularly
• 4:46
  important
• 4:47
  for
• 4:47
  us
• 4:47
  to
• 4:47
  understand.
• 4:48
  Right?
• 4:49
  This
• 4:49
  is
• 4:49
  pretty
• 4:49
  fascinating.
• 4:50
  So
• 4:51
  when
• 4:51
  your
• 4:51
  brain
• 4:52
  is
• 4:52
  essentially
• 4:53
  suffocating
• 4:54
  hundreds
• 4:54
  of
• 4:54
  times
• 4:55
  a
• 4:55
  night
• 4:55
  during
• 4:55
  obstructive
• 4:56
  sleep
• 4:56
  apnea,
• 4:57
  right,
• 4:57
  there's
• 4:58
  actual
• 4:58
  chemical
• 4:59
  changes
• 4:59
  that
• 4:59
  take
• 4:59
  place.
• 5:00
  So
• 5:01
  again,
• 5:01
  we
• 5:01
  know
• 5:01
  this
• 5:02
  as
• 5:02
  hypoxia,
• 5:02
  right?
• 5:03
  Your
• 5:03
  airway
• 5:03
  collapses
• 5:04
  during
• 5:04
  sleep,
• 5:04
  oxygen's
• 5:05
  dropping,
• 5:06
  kind
• 5:06
  of
• 5:06
  surges
• 5:06
  back.
• 5:07
  It's
• 5:07
  sort
• 5:07
  of
• 5:07
  like
• 5:08
  dunking
• 5:08
  your
• 5:08
  brain
• 5:09
  underwater
• 5:09
  for
• 5:10
  10
• 5:10
  or
• 5:10
  30
• 5:10
  seconds,
• 5:11
  and
• 5:11
  then
• 5:11
  pulling
• 5:11
  it
• 5:11
  back
• 5:11
  up
• 5:12
  repeatedly,
• 5:12
  sometimes
• 5:13
  hundreds
• 5:14
  of
• 5:14
  times
• 5:14
  per
• 5:14
  night,
• 5:15
  right?
• 5:15
  The
• 5:16
  problem
• 5:16
  with
• 5:16
  this
• 5:16
  process,
• 5:17
  right,
• 5:18
  this
• 5:18
  kind
• 5:18
  of
• 5:18
  oxygen.
• 5:19
  Yo.
• 5:19
  Yo.
• 5:19
  Is
• 5:20
  it.
• 5:20
  Is
• 5:20
  that
• 5:20
  it
• 5:20
  triggers
• 5:21
  inflammation.
• 5:22
  Byproducts
• 5:22
  of
• 5:23
  that
• 5:23
  that
• 5:23
  I
• 5:23
  think
• 5:24
  is
• 5:24
  like
• 5:24
  a
• 5:24
  shocking
• 5:24
  pearl
• 5:25
  that's
• 5:25
  very
• 5:25
  helpful
• 5:26
  for
• 5:26
  us
• 5:26
  to
• 5:26
  understand
• 5:27
  is
• 5:27
  that
• 5:28
  it
• 5:28
  cranks
• 5:28
  up
• 5:29
  an
• 5:29
  enzyme
• 5:29
  called
• 5:30
  MAOA
• 5:32
  in
• 5:32
  your
• 5:33
  hippocampus,
• 5:33
  right?
• 5:34
  The
• 5:34
  monoamine
• 5:35
  oxidase
• 5:37
  enzyme.
• 5:37
  And
• 5:37
  as
• 5:38
  we
• 5:38
  know,
• 5:38
  right,
• 5:38
  we
• 5:38
  use
• 5:39
  maois
• 5:40
  to
• 5:41
  inhibit
• 5:41
  that
• 5:41
  enzyme,
• 5:42
  right?
• 5:42
  But
• 5:42
  we
• 5:43
  know
• 5:43
  that
• 5:43
  maois,
• 5:45
  those
• 5:45
  famous
• 5:46
  medications
• 5:47
  that
• 5:47
  scare
• 5:47
  the
• 5:48
  crap
• 5:48
  out
• 5:48
  of
• 5:49
  everybody
• 5:49
  because
• 5:49
  you
• 5:50
  have
• 5:50
  to
• 5:50
  avoid
• 5:50
  all
• 5:50
  kinds
• 5:51
  of
• 5:51
  foods
• 5:51
  or
• 5:52
  you.
• 5:52
  You
• 5:52
  have
• 5:52
  a
• 5:52
  hypertensive
• 5:53
  crisis
• 5:53
  on
• 5:54
  your
• 5:54
  hands.
• 5:54
  We
• 5:55
  know
• 5:55
  that
• 5:55
  MAOIs
• 5:57
  inhibit
• 5:57
  this
• 5:57
  enzyme.
• 5:58
  And
• 5:58
  what
• 5:58
  this
• 5:58
  enzyme
• 5:59
  does,
• 5:59
  the
• 5:59
  MAO
• 6:00
  enzyme,
• 6:01
  right,
• 6:02
  they
• 6:02
  break
• 6:02
  down
• 6:03
  the
• 6:03
  good
• 6:03
  neurotransmitters
• 6:04
  that
• 6:04
  we
• 6:05
  need
• 6:05
  to
• 6:05
  feel
• 6:05
  good,
• 6:06
  right?
• 6:06
  Mal
• 6:07
  was
• 6:07
  not
• 6:07
  a
• 6:07
  great
• 6:07
  guy,
• 6:08
  right?
• 6:08
  And
• 6:09
  so,
• 6:09
  same
• 6:09
  thing
• 6:10
  here
• 6:10
  is
• 6:10
  the
• 6:11
  monoamine
• 6:11
  oxidase
• 6:12
  enzyme
• 6:13
  is
• 6:13
  breaking
• 6:13
  down
• 6:14
  serotonin,
• 6:15
  dopamine,
• 6:15
  norepinephrine,
• 6:16
  and
• 6:16
  that
• 6:16
  kind
• 6:16
  of
• 6:16
  thing,
• 6:17
  right?
• 6:17
  And
• 6:17
  we
• 6:17
  don't
• 6:17
  want
• 6:18
  it
• 6:18
  to
• 6:18
  break
• 6:18
  that
• 6:18
  down.
• 6:18
  That's
• 6:19
  why
• 6:19
  we
• 6:19
  inhibit
• 6:19
  that
• 6:20
  enzyme
• 6:20
  with
• 6:20
  maois.
• 6:21
  And
• 6:22
  in
• 6:22
  this
• 6:22
  case,
• 6:23
  when
• 6:23
  you
• 6:23
  are
• 6:24
  engaged
• 6:24
  in
• 6:25
  this
• 6:25
  hypoxic
• 6:25
  event
• 6:26
  over
• 6:26
  and
• 6:26
  over
• 6:26
  in
• 6:27
  your
• 6:27
  obstructive
• 6:27
  sleep
• 6:28
  apnea,
• 6:28
  it's
• 6:29
  cranking
• 6:29
  up
• 6:29
  the
• 6:29
  enzyme.
• 6:30
  And
• 6:30
  so
• 6:30
  what's
• 6:30
  happening
• 6:31
  is
• 6:31
  that
• 6:31
  enzyme
• 6:32
  is
• 6:32
  destroying
• 6:32
  serotonin
• 6:34
  faster
• 6:34
  than
• 6:34
  your
• 6:34
  brain
• 6:35
  can
• 6:35
  make
• 6:35
  it.
• 6:35
  So
• 6:36
  here
• 6:36
  you
• 6:36
  are,
• 6:37
  and
• 6:37
  you're
• 6:38
  prescribing
• 6:39
  Zoloft
• 6:40
  or
• 6:40
  Prozac
• 6:40
  or
• 6:41
  Effexor,
• 6:41
  and
• 6:41
  you're
• 6:41
  like,
• 6:42
  what
• 6:42
  the
• 6:42
  heck?
• 6:42
  Why
• 6:42
  is
• 6:42
  this
• 6:43
  not
• 6:43
  working?
• 6:44
  You
• 6:44
  know,
• 6:44
  I've
• 6:44
  tried
• 6:45
  several
• 6:45
  metabolic
• 6:46
  pathways
• 6:46
  here,
• 6:47
  right?
• 6:47
  But
• 6:48
  I
• 6:48
  don't
• 6:48
  think
• 6:48
  it's
• 6:49
  like
• 6:49
  a
• 6:49
  CYP
• 6:50
  issue
• 6:50
  here.
• 6:51
  I'm
• 6:51
  not
• 6:52
  seeing
• 6:52
  any
• 6:52
  diagnostic
• 6:53
  maybe,
• 6:53
  you
• 6:54
  know,
• 6:54
  I
• 6:54
  feel
• 6:54
  like
• 6:54
  my
• 6:54
  diagnosis
• 6:55
  is
• 6:55
  correct.
• 6:56
  Like
• 6:56
  there's
• 6:56
  clearly
• 6:57
  depressive
• 6:57
  symptoms,
• 6:58
  right?
• 6:58
  And
• 6:58
  that's
• 6:58
  what
• 6:58
  complicates
• 6:59
  this
• 6:59
  even
• 6:59
  more.
• 7:00
  When
• 7:00
  you're
• 7:00
  not
• 7:00
  sleeping,
• 7:01
  you
• 7:01
  know,
• 7:01
  you
• 7:01
  have
• 7:01
  no
• 7:01
  energy,
• 7:02
  really
• 7:02
  don't
• 7:02
  have
• 7:03
  any
• 7:03
  motivation
• 7:03
  to
• 7:03
  do
• 7:04
  anything
• 7:05
  because
• 7:05
  you
• 7:05
  just.
• 7:05
  You
• 7:05
  just
• 7:05
  don't
• 7:06
  have
• 7:06
  the
• 7:06
  energy
• 7:06
  to
• 7:06
  do
• 7:06
  it.
• 7:06
  You're.
• 7:07
  You're.
• 7:07
  You
• 7:07
  have
• 7:08
  brain
• 7:08
  fog,
• 7:08
  right?
• 7:08
  Some
• 7:09
  of
• 7:09
  that
• 7:09
  psychomotor
• 7:10
  retardation
• 7:10
  that
• 7:10
  overlaps
• 7:11
  with
• 7:11
  depression.
• 7:12
  So
• 7:12
  this
• 7:12
  stuff
• 7:13
  looks
• 7:13
  the
• 7:13
  same.
• 7:14
  And
• 7:14
  here
• 7:14
  you
• 7:14
  are
• 7:15
  wondering
• 7:15
  why
• 7:15
  your
• 7:16
  medication
• 7:16
  is
• 7:16
  not
• 7:16
  doing
• 7:17
  anything.
• 7:17
  Maybe
• 7:17
  you're
• 7:17
  up
• 7:18
  to
• 7:18
  80
• 7:18
  milligrams
• 7:19
  of
• 7:19
  Prozac,
• 7:19
  you're
• 7:19
  up
• 7:19
  to
• 7:20
  200
• 7:20
  milligrams
• 7:20
  of
• 7:21
  Zoloft,
• 7:21
  and
• 7:22
  none
• 7:22
  of
• 7:22
  those
• 7:22
  have
• 7:22
  worked
• 7:23
  for
• 7:23
  your
• 7:23
  patient.
• 7:23
  Well,
• 7:24
  lo
• 7:24
  and
• 7:24
  behold,
• 7:25
  now
• 7:25
  you
• 7:26
  have
• 7:26
  this
• 7:26
  patient
• 7:27
  in
• 7:27
  front
• 7:27
  of
• 7:27
  you
• 7:28
  who
• 7:28
  has
• 7:28
  osa,
• 7:29
  and
• 7:29
  the
• 7:30
  MAOA
• 7:31
  enzyme
• 7:31
  is
• 7:31
  literally
• 7:32
  destroying
• 7:32
  serotonin
• 7:33
  faster.
• 7:34
  Then
• 7:34
  you're
• 7:34
  able
• 7:35
  to
• 7:35
  stop
• 7:36
  it
• 7:36
  from
• 7:36
  being
• 7:36
  recycled
• 7:37
  back
• 7:37
  into
• 7:37
  the
• 7:38
  cell.
• 7:38
  So
• 7:38
  it's
• 7:39
  really
• 7:39
  not
• 7:39
  good.
• 7:40
  You
• 7:40
  can
• 7:40
  throw
• 7:40
  more
• 7:41
  serotonin,
• 7:42
  you
• 7:42
  can
• 7:43
  reuptake
• 7:44
  inhibition
• 7:45
  at
• 7:45
  your
• 7:45
  patient.
• 7:46
  It
• 7:46
  doesn't
• 7:47
  really
• 7:47
  matter,
• 7:47
  though,
• 7:47
  if
• 7:47
  your
• 7:48
  serotonin's
• 7:48
  being
• 7:49
  destroyed,
• 7:50
  right?
• 7:50
  So
• 7:51
  that's
• 7:51
  a
• 7:52
  very
• 7:52
  big
• 7:52
  problem.
• 7:53
  There's
• 7:54
  another
• 7:54
  kind
• 7:54
  of
• 7:55
  nitty
• 7:55
  gritty
• 7:56
  feature
• 7:56
  of
• 7:56
  this
• 7:56
  too,
• 7:57
  where
• 7:57
  these
• 7:57
  inflammatory
• 7:58
  signals
• 7:58
  that
• 7:58
  are
• 7:59
  happening
• 7:59
  because
• 7:59
  of
• 7:59
  the
• 8:00
  a
• 8:00
  hypoxia,
• 8:01
  they're
• 8:01
  activating
• 8:02
  a
• 8:02
  secondary
• 8:03
  enzyme
• 8:03
  which
• 8:04
  kind
• 8:04
  of
• 8:04
  diverts
• 8:05
  tryptophan,
• 8:05
  that's
• 8:06
  the
• 8:06
  raw
• 8:06
  material
• 8:07
  for
• 8:07
  making
• 8:07
  serotonin,
• 8:08
  and
• 8:08
  it
• 8:08
  diverts
• 8:09
  that
• 8:09
  away
• 8:09
  from
• 8:09
  serotonin
• 8:10
  production
• 8:10
  entirely.
• 8:11
  So
• 8:11
  not
• 8:11
  only
• 8:12
  are
• 8:12
  we
• 8:12
  destroying
• 8:13
  serotonin,
• 8:14
  but
• 8:14
  we're
• 8:14
  also
• 8:14
  diverting
• 8:15
  the
• 8:16
  materials
• 8:17
  that
• 8:17
  are
• 8:17
  involved
• 8:17
  in
• 8:17
  making
• 8:18
  serotonin.
• 8:19
  So
• 8:19
  that's
• 8:19
  bad.
• 8:20
  We're
• 8:20
  manufacturing
• 8:21
  less
• 8:21
  of
• 8:21
  it,
• 8:21
  we're
• 8:21
  destroying
• 8:22
  more
• 8:22
  of
• 8:22
  it.
• 8:22
  It's
• 8:22
  a
• 8:23
  double
• 8:23
  whammy.
• 8:24
  All
• 8:24
  because
• 8:24
  of
• 8:24
  hypoxia.
• 8:26
  And
• 8:26
  so
• 8:26
  more.
• 8:27
  More
• 8:27
  SSRI
• 8:27
  won't
• 8:28
  work.
• 8:28
  Just
• 8:28
  not
• 8:29
  gonna
• 8:29
  work
• 8:30
  now.
• 8:30
  It.
• 8:31
  It.
• 8:31
  The.
• 8:31
  The
• 8:32
  second
• 8:32
  thing
• 8:32
  to
• 8:32
  consider
• 8:32
  here
• 8:33
  is
• 8:33
  that
• 8:33
  with
• 8:33
  osa,
• 8:35
  the.
• 8:36
  The
• 8:36
  intermittent
• 8:37
  hypoxia,
• 8:37
  it
• 8:37
  doesn't
• 8:38
  just
• 8:38
  deplete
• 8:38
  serotonin,
• 8:39
  but
• 8:39
  this
• 8:40
  is
• 8:40
  a
• 8:40
  neuroinflammatory
• 8:41
  cascade.
• 8:42
  It's
• 8:42
  a
• 8:42
  disaster.
• 8:43
  Right?
• 8:44
  So
• 8:45
  this.
• 8:45
  This
• 8:45
  pro.
• 8:46
  Inflammatory
• 8:46
  state,
• 8:47
  you've
• 8:47
  probably
• 8:47
  heard
• 8:48
  of
• 8:48
  inflammatory
• 8:48
  cytokines,
• 8:49
  right?
• 8:50
  These
• 8:50
  damage
• 8:50
  your
• 8:50
  neurons,
• 8:51
  and
• 8:51
  you've
• 8:52
  gotta
• 8:52
  wonder
• 8:53
  what
• 8:53
  neurons
• 8:53
  they're
• 8:53
  damaging.
• 8:54
  Well,
• 8:54
  the
• 8:54
  hippocampus,
• 8:55
  the
• 8:55
  prefrontal
• 8:55
  cortex,
• 8:56
  right?
• 8:56
  This.
• 8:57
  The
• 8:57
  exact
• 8:57
  regions
• 8:58
  in
• 8:58
  your
• 8:58
  brain
• 8:59
  that
• 8:59
  you
• 8:59
  need
• 8:59
  those
• 8:59
  neurons
• 9:00
  to
• 9:00
  remain
• 9:00
  intact
• 9:01
  and
• 9:01
  healthy
• 9:01
  because
• 9:01
  they
• 9:02
  govern
• 9:02
  mood
• 9:02
  and
• 9:03
  motivation
• 9:03
  and
• 9:03
  emotional
• 9:04
  processing,
• 9:05
  impulse
• 9:05
  control,
• 9:06
  right?
• 9:06
  So
• 9:07
  if,
• 9:08
  man,
• 9:08
  we're
• 9:08
  not
• 9:08
  making
• 9:09
  serotonin
• 9:10
  as
• 9:10
  much
• 9:10
  we're.
• 9:11
  We're
• 9:12
  destroying
• 9:12
  it
• 9:12
  faster.
• 9:13
  We
• 9:13
  have
• 9:13
  a
• 9:13
  neuroinflammatory
• 9:15
  cascade.
• 9:15
  Of
• 9:15
  course
• 9:16
  you're
• 9:16
  gonna
• 9:16
  induce
• 9:16
  a
• 9:17
  neuroinflammatory
• 9:17
  cascade,
• 9:18
  because
• 9:18
  this
• 9:18
  is
• 9:18
  fight
• 9:19
  or
• 9:19
  flight,
• 9:19
  my
• 9:19
  friends,
• 9:19
  right?
• 9:20
  If.
• 9:20
  If
• 9:21
  you're
• 9:21
  being
• 9:21
  suffocated
• 9:22
  at
• 9:22
  night,
• 9:22
  of
• 9:22
  course
• 9:23
  your
• 9:23
  body
• 9:23
  is
• 9:23
  going
• 9:24
  to
• 9:24
  trigger
• 9:25
  an
• 9:25
  inflammatory
• 9:26
  cascade
• 9:26
  of
• 9:26
  panic,
• 9:27
  right?
• 9:27
  And
• 9:28
  that's
• 9:28
  gonna
• 9:28
  be
• 9:29
  extremely
• 9:29
  detrimental.
• 9:31
  It's
• 9:31
  going
• 9:31
  to
• 9:31
  quite
• 9:32
  literally
• 9:32
  damage
• 9:33
  your
• 9:34
  body
• 9:34
  and
• 9:34
  your
• 9:35
  brain,
• 9:35
  and
• 9:35
  that's
• 9:35
  what's
• 9:36
  happening.
• 9:36
  So
• 9:37
  if
• 9:37
  you
• 9:37
  have
• 9:37
  a
• 9:37
  patient
• 9:37
  with
• 9:38
  ptsd,
• 9:39
  you
• 9:39
  know,
• 9:39
  they
• 9:39
  kind
• 9:39
  of
• 9:39
  rely
• 9:40
  on
• 9:40
  their
• 9:41
  hippocampus
• 9:42
  to
• 9:42
  build
• 9:42
  new
• 9:43
  memory
• 9:44
  circuits
• 9:44
  and
• 9:44
  encode
• 9:45
  new
• 9:45
  context
• 9:46
  in
• 9:46
  trauma
• 9:46
  memories
• 9:47
  and
• 9:47
  reconsolidation
• 9:48
  and
• 9:48
  wow,
• 9:49
  now
• 9:49
  we're.
• 9:49
  It's
• 9:50
  like
• 9:50
  we're
• 9:50
  taking
• 9:50
  a
• 9:50
  sledgehammer
• 9:51
  to
• 9:51
  those
• 9:51
  parts
• 9:51
  of
• 9:51
  the.
• 9:52
  That
• 9:52
  really
• 9:52
  need
• 9:52
  to
• 9:53
  be
• 9:53
  intact,
• 9:54
  right?
• 9:54
  We're.
• 9:55
  We're
• 9:55
  taking
• 9:55
  a
• 9:56
  sledgehammer
• 9:56
  to
• 9:56
  the
• 9:57
  brain
• 9:57
  and
• 9:57
  those
• 9:57
  neurons
• 9:58
  involved
• 9:58
  in
• 9:58
  the
• 9:58
  prefrontal
• 9:59
  cortex,
• 9:59
  involved
• 10:00
  in
• 10:00
  judgment
• 10:01
  and
• 10:01
  creativity
• 10:02
  and
• 10:02
  impulse
• 10:02
  control.
• 10:03
  So
• 10:03
  now
• 10:03
  your
• 10:03
  patient
• 10:03
  may
• 10:04
  appear
• 10:04
  more
• 10:04
  irritable
• 10:05
  and
• 10:05
  you
• 10:05
  might
• 10:06
  confuse
• 10:06
  that
• 10:07
  for
• 10:07
  bipolarity
• 10:08
  or
• 10:08
  they
• 10:09
  just
• 10:09
  can't
• 10:09
  think
• 10:09
  straight
• 10:10
  enough.
• 10:10
  And
• 10:10
  now
• 10:10
  you
• 10:10
  think
• 10:11
  it's
• 10:11
  adhd.
• 10:11
  And
• 10:12
  so
• 10:12
  you
• 10:12
  can
• 10:12
  imagine
• 10:13
  how
• 10:13
  clinically
• 10:14
  muddy
• 10:14
  this
• 10:14
  gets,
• 10:15
  right?
• 10:15
  Because
• 10:16
  this
• 10:16
  is
• 10:16
  so
• 10:16
  trans
• 10:17
  diagnostic.
• 10:17
  So
• 10:18
  you
• 10:18
  have
• 10:18
  this
• 10:18
  one
• 10:18
  culprit
• 10:19
  that's
• 10:19
  doing
• 10:20
  all
• 10:20
  this
• 10:20
  crazy
• 10:20
  stuff
• 10:21
  behind
• 10:21
  the
• 10:21
  scenes,
• 10:22
  and
• 10:22
  it's
• 10:23
  just
• 10:23
  making
• 10:23
  you
• 10:23
  think
• 10:24
  of
• 10:24
  every
• 10:24
  diagnosis
• 10:25
  at
• 10:25
  once.
• 10:25
  And
• 10:26
  maybe
• 10:26
  you'll
• 10:26
  put
• 10:26
  your
• 10:26
  patient
• 10:27
  on
• 10:27
  like
• 10:27
  a
• 10:27
  mood
• 10:27
  stabilizer
• 10:28
  now
• 10:28
  because
• 10:28
  they're
• 10:28
  so
• 10:29
  irritable
• 10:29
  or
• 10:30
  impulsive
• 10:31
  and,
• 10:31
  and
• 10:31
  wow,
• 10:32
  all
• 10:32
  this
• 10:32
  time
• 10:33
  it
• 10:33
  was
• 10:33
  obstructive
• 10:34
  sleep
• 10:35
  apnea
• 10:35
  because
• 10:35
  it's
• 10:36
  neurotoxic
• 10:37
  and
• 10:37
  it's
• 10:38
  specifically
• 10:38
  targeting
• 10:39
  parts
• 10:39
  of
• 10:39
  the
• 10:39
  brain
• 10:40
  that
• 10:41
  are
• 10:41
  mimicking
• 10:42
  so
• 10:42
  many
• 10:42
  other
• 10:43
  pathological
• 10:44
  states.
• 10:45
  Big
• 10:45
  problem,
• 10:45
  right?
• 10:46
  Big
• 10:46
  problem.
• 10:47
  And
• 10:47
  so
• 10:47
  you
• 10:48
  might
• 10:48
  think
• 10:48
  this
• 10:48
  is
• 10:48
  treatment
• 10:49
  resistant
• 10:49
  depression,
• 10:50
  and
• 10:50
  instead
• 10:50
  it's
• 10:50
  like
• 10:50
  this
• 10:51
  inflammatory
• 10:51
  fire
• 10:52
  that
• 10:52
  you
• 10:53
  need
• 10:53
  to
• 10:53
  just
• 10:53
  put
• 10:53
  out
• 10:53
  with
• 10:54
  a
• 10:54
  CPAP
• 10:54
  machine.
• 10:55
  Okay?
• 10:56
  Now
• 10:57
  another
• 10:57
  thing
• 10:57
  to
• 10:57
  consider
• 10:58
  with
• 10:58
  obstructive
• 10:59
  sleep
• 10:59
  apnea
• 11:00
  is
• 11:01
  that
• 11:01
  it
• 11:02
  fragments
• 11:02
  your
• 11:02
  sleep.
• 11:03
  When
• 11:03
  you're
• 11:03
  being
• 11:04
  suffocated
• 11:05
  hundreds
• 11:05
  of
• 11:05
  times
• 11:05
  per
• 11:05
  night,
• 11:06
  your
• 11:06
  REM
• 11:07
  cycle
• 11:07
  is
• 11:08
  really
• 11:08
  going
• 11:08
  to
• 11:08
  be
• 11:09
  fragmented
• 11:10
  and
• 11:10
  it's
• 11:10
  going
• 11:10
  to
• 11:10
  really
• 11:10
  hijack
• 11:11
  the
• 11:11
  REM
• 11:11
  cycle.
• 11:12
  Now,
• 11:13
  I
• 11:13
  won't
• 11:13
  go
• 11:13
  into
• 11:13
  the
• 11:14
  thousand
• 11:14
  reasons
• 11:15
  that
• 11:15
  REM
• 11:15
  sleep
• 11:16
  is
• 11:16
  so
• 11:16
  beneficial,
• 11:17
  but
• 11:17
  as
• 11:17
  you
• 11:18
  know,
• 11:18
  REM
• 11:18
  sleep
• 11:19
  is
• 11:19
  kind
• 11:19
  of
• 11:19
  sacred.
• 11:19
  It's
• 11:20
  kind
• 11:20
  of
• 11:20
  emotional
• 11:21
  therapy
• 11:21
  for
• 11:21
  people.
• 11:22
  Right.
• 11:22
  This
• 11:23
  is
• 11:23
  particularly
• 11:24
  important
• 11:24
  for
• 11:24
  people
• 11:24
  with
• 11:25
  ptsd,
• 11:25
  Right?
• 11:26
  Because
• 11:27
  our
• 11:27
  REM
• 11:27
  sleep
• 11:28
  is
• 11:28
  really
• 11:28
  the
• 11:29
  one
• 11:29
  time
• 11:29
  in
• 11:29
  our
• 11:30
  24
• 11:30
  hour
• 11:30
  cycle
• 11:31
  at
• 11:31
  all
• 11:31
  where
• 11:32
  your
• 11:32
  norepinephrine
• 11:34
  in
• 11:34
  your
• 11:34
  brain
• 11:34
  kind
• 11:35
  of
• 11:35
  goes
• 11:35
  quiet.
• 11:35
  And
• 11:36
  it
• 11:36
  allows
• 11:36
  you
• 11:36
  to
• 11:37
  process
• 11:38
  emotional
• 11:38
  memories
• 11:39
  in
• 11:40
  a
• 11:40
  safer
• 11:40
  way
• 11:40
  without
• 11:41
  the
• 11:41
  kind
• 11:41
  of
• 11:41
  fight
• 11:41
  or
• 11:42
  flight
• 11:42
  response
• 11:43
  coursing
• 11:43
  through
• 11:44
  your
• 11:44
  blood.
• 11:45
  It
• 11:45
  kind
• 11:46
  of
• 11:46
  allows
• 11:46
  the
• 11:46
  amygdala
• 11:47
  to
• 11:47
  process
• 11:48
  those
• 11:48
  difficult
• 11:49
  emotional
• 11:49
  experiences
• 11:50
  in
• 11:50
  the
• 11:50
  absence
• 11:51
  of
• 11:51
  that
• 11:51
  fight
• 11:51
  or
• 11:52
  flight
• 11:52
  norepinephrine
• 11:53
  surge.
• 11:54
  Right.
• 11:54
  And
• 11:55
  that's
• 11:55
  how
• 11:55
  it
• 11:55
  should
• 11:55
  work
• 11:56
  in
• 11:56
  our
• 11:56
  brains.
• 11:56
  The
• 11:57
  problem
• 11:57
  is
• 11:58
  in
• 11:58
  obstructive
• 11:58
  sleep
• 11:59
  apnea,
• 11:59
  REM
• 12:00
  gets
• 12:00
  interrupted
• 12:01
  constantly.
• 12:01
  So
• 12:02
  norepinephrine
• 12:03
  never
• 12:03
  really
• 12:03
  drops,
• 12:04
  and
• 12:04
  so
• 12:04
  your
• 12:04
  amygdala
• 12:05
  stays
• 12:06
  in
• 12:06
  this
• 12:06
  hyperreactive
• 12:07
  state.
• 12:08
  Right.
• 12:08
  And
• 12:08
  that's
• 12:09
  problematic
• 12:09
  because
• 12:10
  if
• 12:10
  you're
• 12:10
  trying
• 12:10
  to
• 12:10
  Repair
• 12:11
  emotional
• 12:11
  memories
• 12:12
  and
• 12:13
  change
• 12:14
  the
• 12:14
  context
• 12:15
  of
• 12:15
  your
• 12:16
  trauma
• 12:16
  reconsolidate,
• 12:18
  then,
• 12:18
  well,
• 12:19
  you're
• 12:19
  kind
• 12:19
  of
• 12:19
  playing
• 12:20
  with
• 12:20
  one
• 12:20
  hand
• 12:21
  tied
• 12:21
  behind
• 12:21
  your
• 12:22
  back.
• 12:22
  And
• 12:23
  so
• 12:23
  that's
• 12:23
  a
• 12:23
  big
• 12:23
  problem.
• 12:24
  Again,
• 12:24
  a
• 12:24
  lot
• 12:25
  of
• 12:25
  your
• 12:25
  patients
• 12:26
  will
• 12:26
  also
• 12:26
  come
• 12:27
  into
• 12:27
  their
• 12:27
  clinic
• 12:27
  with
• 12:28
  obstructive
• 12:28
  sleep
• 12:28
  apnea
• 12:29
  and
• 12:29
  ptsd.
• 12:30
  I've
• 12:30
  seen
• 12:30
  them
• 12:30
  co
• 12:30
  occur
• 12:31
  all
• 12:31
  the
• 12:31
  time.
• 12:31
  Right.
• 12:32
  So
• 12:33
  you
• 12:33
  really
• 12:33
  don't
• 12:33
  want
• 12:34
  them
• 12:35
  on
• 12:35
  like
• 12:35
  Soloft
• 12:36
  or
• 12:36
  Prozac,
• 12:37
  and
• 12:37
  you're
• 12:37
  doing
• 12:37
  everything
• 12:38
  you
• 12:38
  can.
• 12:38
  And
• 12:38
  they're
• 12:39
  in
• 12:39
  therapy
• 12:39
  once
• 12:39
  a
• 12:40
  week,
• 12:40
  they're
• 12:40
  working
• 12:40
  so
• 12:40
  hard.
• 12:41
  And
• 12:41
  lo
• 12:41
  and
• 12:41
  behold,
• 12:42
  we're
• 12:42
  not
• 12:42
  even
• 12:42
  oxygenating
• 12:43
  their
• 12:43
  brain
• 12:44
  properly.
• 12:44
  We're
• 12:44
  not
• 12:45
  even
• 12:45
  manufacturing
• 12:46
  serotonin
• 12:46
  enough.
• 12:46
  We're
• 12:47
  depleting
• 12:47
  it
• 12:47
  too
• 12:47
  quickly.
• 12:48
  And
• 12:48
  on
• 12:49
  top
• 12:49
  of
• 12:49
  that,
• 12:49
  we're
• 12:50
  fragmenting
• 12:50
  the
• 12:51
  crucial
• 12:51
  part
• 12:52
  of
• 12:52
  their
• 12:52
  sleep
• 12:52
  periods
• 12:53
  that
• 12:53
  could
• 12:54
  be
• 12:54
  reconsolidating
• 12:55
  these
• 12:55
  memories
• 12:56
  and
• 12:56
  putting
• 12:56
  different
• 12:57
  emotional
• 12:57
  contexts
• 12:58
  and
• 12:58
  tags
• 12:59
  on
• 12:59
  them
• 12:59
  so
• 12:59
  that
• 13:00
  they
• 13:00
  won't
• 13:00
  be
• 13:00
  as
• 13:00
  traumatized.
• 13:01
  So
• 13:02
  it's
• 13:02
  just
• 13:03
  obliterating
• 13:03
  such
• 13:04
  an
• 13:04
  integral
• 13:04
  part
• 13:05
  of
• 13:05
  their
• 13:05
  sleep
• 13:06
  cycle.
• 13:07
  Very
• 13:07
  big
• 13:07
  problem.
• 13:07
  And,
• 13:08
  you
• 13:08
  know,
• 13:08
  if
• 13:08
  you're
• 13:08
  giving
• 13:08
  them
• 13:09
  prazosin,
• 13:09
  which
• 13:09
  is
• 13:10
  supposed
• 13:10
  to
• 13:10
  kind
• 13:10
  of
• 13:10
  take
• 13:10
  the
• 13:11
  norepinephrine
• 13:11
  piece
• 13:12
  out
• 13:12
  of
• 13:12
  the
• 13:12
  equation
• 13:13
  and
• 13:14
  calm
• 13:14
  the
• 13:14
  amygdala
• 13:15
  so
• 13:15
  they
• 13:15
  can
• 13:15
  reprocess
• 13:16
  again,
• 13:16
  we're
• 13:16
  undermining
• 13:17
  prazosin
• 13:17
  too,
• 13:18
  because
• 13:18
  we're
• 13:19
  just
• 13:19
  taking
• 13:19
  a
• 13:19
  sledgehammer
• 13:20
  to
• 13:20
  the
• 13:21
  various
• 13:21
  parts
• 13:21
  of
• 13:21
  the
• 13:21
  brain
• 13:22
  and
• 13:22
  the
• 13:22
  actual
• 13:22
  REM
• 13:23
  cycle
• 13:24
  itself.
• 13:24
  So
• 13:25
  your
• 13:25
  meds.
• 13:26
  We
• 13:26
  have
• 13:26
  to
• 13:26
  create
• 13:26
  the
• 13:27
  condition
• 13:27
  by
• 13:27
  which
• 13:27
  our
• 13:28
  meds
• 13:28
  can
• 13:28
  be
• 13:28
  successful.
• 13:29
  That's
• 13:29
  why
• 13:29
  we
• 13:29
  get
• 13:30
  our
• 13:30
  labs,
• 13:30
  right?
• 13:30
  Our
• 13:31
  vitamin
• 13:31
  B12,
• 13:31
  our
• 13:32
  folate,
• 13:33
  our
• 13:33
  vitamin
• 13:33
  D.
• 13:33
  Right.
• 13:34
  We
• 13:34
  need
• 13:34
  to
• 13:34
  make
• 13:34
  sure
• 13:34
  that
• 13:34
  the
• 13:35
  chemical
• 13:35
  precursors
• 13:36
  are
• 13:36
  there
• 13:37
  to
• 13:37
  even
• 13:37
  help
• 13:37
  us
• 13:38
  in
• 13:38
  the
• 13:38
  event.
• 13:38
  We
• 13:39
  prescribe
• 13:40
  a
• 13:40
  reuptake
• 13:41
  inhibitor
• 13:41
  so
• 13:42
  that
• 13:42
  there
• 13:42
  is
• 13:42
  serotonin
• 13:43
  to
• 13:43
  even
• 13:43
  stop
• 13:44
  from
• 13:44
  being
• 13:45
  recycled
• 13:45
  back
• 13:45
  into
• 13:46
  the
• 13:46
  cells.
• 13:46
  Right.
• 13:47
  That's
• 13:48
  kind
• 13:48
  of
• 13:48
  important.
• 13:49
  And
• 13:49
  so
• 13:50
  with
• 13:50
  obstructive
• 13:51
  sleep
• 13:51
  apnea,
• 13:52
  the
• 13:52
  REM
• 13:52
  gets
• 13:53
  interrupted
• 13:54
  and
• 13:54
  the
• 13:54
  HPA
• 13:55
  access
• 13:55
  too.
• 13:55
  Right.
• 13:56
  That
• 13:56
  gets
• 13:57
  kind
• 13:57
  of
• 13:57
  stuck
• 13:57
  in
• 13:58
  a
• 13:58
  fight
• 13:58
  or
• 13:58
  flight
• 13:59
  mode
• 13:59
  too.
• 13:59
  The
• 13:59
  constant
• 14:00
  arousals
• 14:00
  and
• 14:00
  oxygen
• 14:01
  drops
• 14:02
  kind
• 14:02
  of
• 14:02
  chronically
• 14:03
  activate
• 14:03
  the
• 14:04
  HPA
• 14:05
  axis.
• 14:05
  Right?
• 14:06
  The
• 14:06
  hypothalamic
• 14:07
  pituitary
• 14:07
  axis.
• 14:08
  And
• 14:08
  so
• 14:09
  what
• 14:09
  that
• 14:09
  leads
• 14:10
  to
• 14:10
  really,
• 14:10
  is
• 14:11
  cortisol
• 14:11
  spikes.
• 14:12
  And
• 14:12
  we
• 14:12
  know
• 14:12
  cortisol,
• 14:13
  if
• 14:13
  any
• 14:13
  one
• 14:13
  of
• 14:14
  us
• 14:14
  were
• 14:14
  injected
• 14:15
  with
• 14:15
  cortisol,
• 14:15
  we
• 14:15
  would
• 14:16
  really
• 14:16
  get
• 14:16
  fat.
• 14:16
  It
• 14:17
  makes
• 14:17
  you
• 14:17
  gain
• 14:17
  weight.
• 14:18
  It's
• 14:18
  also
• 14:18
  neurotoxic
• 14:19
  in
• 14:20
  certain
• 14:20
  contexts
• 14:20
  where
• 14:21
  it
• 14:21
  can
• 14:21
  really
• 14:21
  destroy
• 14:22
  those
• 14:22
  good
• 14:22
  neurotransmitters
• 14:23
  which
• 14:23
  are
• 14:24
  already
• 14:24
  being
• 14:24
  destroyed
• 14:25
  by
• 14:26
  your
• 14:26
  maoa
• 14:27
  enzyme
• 14:27
  that
• 14:27
  we
• 14:27
  talked
• 14:28
  about
• 14:28
  earlier.
• 14:28
  Right.
• 14:29
  And
• 14:29
  so
• 14:29
  when
• 14:29
  cortisol
• 14:30
  is
• 14:31
  elevated
• 14:32
  chronically,
• 14:32
  that
• 14:33
  also
• 14:33
  tends
• 14:33
  to
• 14:34
  mimic
• 14:35
  the
• 14:35
  exact
• 14:35
  symptoms
• 14:36
  of
• 14:36
  depression,
• 14:37
  fatigue,
• 14:37
  poor
• 14:38
  concentration,
• 14:38
  irritability,
• 14:39
  weight
• 14:39
  gain,
• 14:39
  low
• 14:40
  motivation,
• 14:40
  all
• 14:40
  of
• 14:41
  that.
• 14:41
  And
• 14:42
  so
• 14:42
  your
• 14:42
  patient's
• 14:43
  going
• 14:43
  to
• 14:43
  come
• 14:43
  to
• 14:43
  you
• 14:43
  very
• 14:43
  overwhelmed,
• 14:44
  very
• 14:44
  down,
• 14:45
  very
• 14:45
  irritable.
• 14:46
  And
• 14:46
  rather
• 14:47
  than
• 14:47
  go
• 14:47
  down
• 14:47
  this
• 14:47
  diagnostic
• 14:48
  rabbit
• 14:48
  hole,
• 14:49
  let's
• 14:49
  make
• 14:49
  our
• 14:50
  job
• 14:50
  a
• 14:50
  lot
• 14:50
  easier
• 14:51
  and
• 14:51
  let's
• 14:52
  rule
• 14:52
  these
• 14:52
  things
• 14:52
  out
• 14:52
  right
• 14:53
  away.
• 14:53
  In
• 14:53
  my
• 14:54
  experience,
• 14:55
  I
• 14:55
  really
• 14:55
  like
• 14:55
  to
• 14:55
  rule
• 14:56
  out
• 14:56
  the
• 14:56
  vitamin
• 14:57
  D,
• 14:57
  folate,
• 14:58
  B12,
• 14:58
  thyroid
• 14:59
  anemia,
• 15:00
  the
• 15:01
  obstructive
• 15:01
  sleep
• 15:01
  apnea.
• 15:02
  I
• 15:02
  like
• 15:02
  to
• 15:02
  get
• 15:02
  that
• 15:03
  done
• 15:03
  quickly
• 15:04
  so
• 15:04
  that
• 15:05
  we
• 15:05
  don't
• 15:05
  put
• 15:05
  the
• 15:06
  cart
• 15:06
  before
• 15:06
  the
• 15:06
  horse
• 15:07
  here.
• 15:07
  Right?
• 15:08
  We
• 15:09
  want
• 15:09
  the.
• 15:09
  The
• 15:10
  horse
• 15:10
  pulling
• 15:10
  the
• 15:11
  cart.
• 15:11
  We
• 15:11
  don't
• 15:11
  want
• 15:12
  the
• 15:12
  cart
• 15:12
  pulling
• 15:12
  the
• 15:13
  horse
• 15:13
  because
• 15:13
  it
• 15:13
  won't.
• 15:14
  Carts
• 15:14
  don't
• 15:15
  pull
• 15:15
  horses.
• 15:16
  Right.
• 15:16
  So
• 15:18
  serotonin
• 15:18
  depletion,
• 15:19
  neuroinflammation,
• 15:21
  REM
• 15:21
  and
• 15:21
  cortisol,
• 15:22
  that
• 15:22
  double
• 15:23
  hit.
• 15:23
  These
• 15:23
  are
• 15:24
  all
• 15:24
  the
• 15:25
  kind
• 15:25
  of
• 15:25
  the
• 15:25
  how
• 15:25
  and
• 15:25
  the
• 15:26
  why
• 15:26
  of
• 15:27
  what's
• 15:27
  happening
• 15:27
  in
• 15:27
  sleep
• 15:28
  apnea
• 15:28
  and
• 15:28
  what
• 15:28
  we
• 15:28
  need
• 15:29
  to
• 15:29
  do
• 15:29
  to
• 15:29
  challenge
• 15:30
  that
• 15:30
  to
• 15:30
  make
• 15:31
  our
• 15:31
  patients
• 15:32
  a
• 15:32
  lot
• 15:32
  better.
• 15:33
  Now,
• 15:33
  remember,
• 15:33
  my
• 15:34
  friends,
• 15:34
  there
• 15:34
  is
• 15:34
  a
• 15:35
  gold
• 15:35
  standard
• 15:36
  screening
• 15:37
  tool
• 15:37
  for
• 15:38
  sleep
• 15:38
  apnea,
• 15:39
  and
• 15:39
  it
• 15:39
  takes
• 15:40
  just
• 15:40
  about
• 15:40
  two
• 15:40
  minutes.
• 15:42
  We're
• 15:42
  posting
• 15:42
  it
• 15:43
  on
• 15:43
  our
• 15:43
  Patreon
• 15:44
  membership.
• 15:45
  It
• 15:45
  has
• 15:45
  a
• 15:45
  really
• 15:46
  cool
• 15:46
  name,
• 15:47
  it's
• 15:47
  very
• 15:47
  handy,
• 15:48
  and
• 15:48
  it'll
• 15:48
  help
• 15:48
  you
• 15:48
  catch
• 15:49
  sleep
• 15:49
  apnea
• 15:49
  a
• 15:50
  lot
• 15:50
  faster
• 15:50
  in
• 15:50
  your
• 15:50
  clinic.
• 15:51
  We're
• 15:51
  going
• 15:51
  to
• 15:51
  keep
• 15:51
  that
• 15:52
  in
• 15:52
  our
• 15:52
  Patreon
• 15:53
  page.
• 15:53
  If
• 15:53
  you
• 15:53
  want
• 15:53
  to
• 15:53
  join,
• 15:54
  you
• 15:54
  can
• 15:54
  become
• 15:54
  a
• 15:54
  free
• 15:54
  member
• 15:55
  or
• 15:55
  for
• 15:56
  just
• 15:56
  three
• 15:56
  bucks
• 15:56
  a
• 15:57
  month.
• 15:57
  It's
• 15:57
  kind
• 15:58
  of
• 15:58
  a
• 15:58
  steal,
• 15:59
  my
• 15:59
  friends,
• 15:59
  to
• 15:59
  be
• 16:00
  honest.
• 16:00
  You
• 16:01
  can
• 16:01
  go
• 16:01
  ahead
• 16:01
  and
• 16:01
  get
• 16:02
  that
• 16:02
  next
• 16:02
  clinical
• 16:03
  edge,
• 16:03
  knowing
• 16:03
  the
• 16:03
  how
• 16:04
  and
• 16:04
  the
• 16:04
  why.
• 16:05
  And
• 16:05
  again,
• 16:06
  I
• 16:06
  have
• 16:06
  found
• 16:06
  in
• 16:06
  my
• 16:07
  experience,
• 16:07
  that
• 16:08
  kind
• 16:08
  of
• 16:08
  going
• 16:08
  the
• 16:09
  extra
• 16:09
  mile
• 16:09
  to
• 16:09
  know
• 16:09
  the
• 16:10
  how
• 16:10
  and
• 16:10
  the
• 16:10
  why,
• 16:11
  it
• 16:11
  really
• 16:11
  helps
• 16:12
  you
• 16:13
  build
• 16:13
  trust
• 16:13
  with
• 16:13
  patients.
• 16:14
  They
• 16:14
  definitely
• 16:14
  feel
• 16:15
  a
• 16:15
  little
• 16:15
  bit
• 16:15
  more
• 16:15
  secure
• 16:16
  and
• 16:16
  empowered
• 16:17
  by
• 16:17
  you.
• 16:18
  You
• 16:19
  know,
• 16:19
  sharing
• 16:19
  that
• 16:19
  knowledge
• 16:20
  with
• 16:20
  them.
• 16:20
  It
• 16:20
  leads
• 16:21
  to
• 16:21
  better
• 16:21
  outcomes,
• 16:22
  your
• 16:22
  care
• 16:22
  gets
• 16:23
  more
• 16:23
  granular,
• 16:23
  it
• 16:24
  gets
• 16:24
  more
• 16:24
  sophisticated.
• 16:25
  I
• 16:25
  find
• 16:25
  that
• 16:26
  folks
• 16:26
  want
• 16:26
  to
• 16:26
  hire
• 16:26
  you
• 16:27
  more.
• 16:27
  So
• 16:28
  I
• 16:28
  built
• 16:28
  my
• 16:28
  entire
• 16:29
  Patreon
• 16:29
  page
• 16:29
  for
• 16:30
  you
• 16:30
  to
• 16:30
  kind
• 16:30
  of
• 16:31
  have
• 16:31
  that
• 16:31
  edge.
• 16:32
  And
• 16:32
  so
• 16:32
  that's
• 16:32
  what
• 16:32
  it's
• 16:33
  all
• 16:33
  about,
• 16:33
  right?
• 16:33
  It's
• 16:34
  about
• 16:34
  just
• 16:34
  standing
• 16:35
  out
• 16:36
  and
• 16:36
  knowing
• 16:36
  the
• 16:37
  how
• 16:37
  and
• 16:37
  the
• 16:37
  why
• 16:37
  and
• 16:38
  not
• 16:38
  just
• 16:38
  memorizing
• 16:39
  algos
• 16:39
  and
• 16:40
  prescribing
• 16:40
  a
• 16:40
  med
• 16:41
  and
• 16:41
  not
• 16:41
  really
• 16:41
  understanding
• 16:42
  the
• 16:42
  mechanics
• 16:43
  behind
• 16:43
  it.
• 16:43
  I
• 16:43
  think
• 16:43
  that's
• 16:44
  lazy.
• 16:44
  I
• 16:44
  felt
• 16:45
  lazy
• 16:45
  when
• 16:45
  I
• 16:45
  used
• 16:45
  to
• 16:45
  do
• 16:46
  that.
• 16:46
  I
• 16:46
  wanted
• 16:46
  to
• 16:46
  kind
• 16:46
  of
• 16:47
  go
• 16:47
  the
• 16:47
  extra
• 16:47
  mile
• 16:47
  and
• 16:48
  really
• 16:48
  know
• 16:48
  what
• 16:48
  I
• 16:48
  was
• 16:49
  doing
• 16:49
  behind
• 16:49
  the
• 16:49
  scenes,
• 16:50
  and
• 16:50
  that
• 16:51
  separates
• 16:51
  the
• 16:51
  goods
• 16:52
  from
• 16:52
  the
• 16:52
  greats
• 16:53
  in
• 16:54
  psychiatry.
• 16:55
  And
• 16:55
  so
• 16:55
  I
• 16:55
  highly
• 16:55
  recommend
• 16:56
  you
• 16:56
  jump
• 16:56
  to
• 16:56
  our
• 16:57
  show
• 16:57
  notes,
• 16:57
  become
• 16:58
  Patreon
• 16:58
  members,
• 16:59
  and
• 17:00
  I'd
• 17:00
  love
• 17:00
  to
• 17:00
  have
• 17:00
  you
• 17:00
  there.
• 17:01
  So.
• 17:01
  All
• 17:01
  right,
• 17:02
  my
• 17:02
  friends,
• 17:02
  thank
• 17:03
  you
• 17:03
  for
• 17:03
  tuning
• 17:03
  into
• 17:03
  this.
• 17:03
  It
• 17:04
  was
• 17:04
  a
• 17:04
  doozy.
• 17:05
  And
• 17:05
  I'll
• 17:05
  see
• 17:06
  you
• 17:06
  next
• 17:06
  time
• 17:06
  here
• 17:06
  on
• 17:07
  Pearls
• 17:07
  and
• 17:07
  Prep.
• 17:08
  Have
• 17:08
  a
• 17:08
  good
• 17:08
  one.
• 17:08
  Bye.
• 17:08
  Bye.