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Easter Egg Hunt: Find the 4 Clinical Errors in This Case · 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
• 0:09
  Prep.
• 0:09
  Npz.
• 0:10
  Here,
• 0:10
  your
• 0:11
  preceptor
• 0:11
  in
• 0:11
  your
• 0:12
  pocket,
• 0:12
  your
• 0:13
  go
• 0:13
  to
• 0:13
  place
• 0:14
  for
• 0:14
  pearls
• 0:14
  that
• 0:15
  prep
• 0:15
  you
• 0:16
  to
• 0:16
  practice.
• 0:17
  This
• 0:17
  is
• 0:17
  a
• 0:17
  special
• 0:18
  Easter
• 0:19
  egg
• 0:19
  hunt,
• 0:20
  if
• 0:20
  you
• 0:20
  will.
• 0:21
  We've
• 0:21
  been
• 0:21
  getting
• 0:22
  a
• 0:22
  lot
• 0:22
  of
• 0:22
  great
• 0:22
  feedback
• 0:23
  on
• 0:23
  this.
• 0:24
  You
• 0:24
  can
• 0:24
  share
• 0:24
  them
• 0:24
  with
• 0:24
  your
• 0:25
  friends,
• 0:25
  with
• 0:25
  your
• 0:25
  teachers,
• 0:26
  you
• 0:26
  can
• 0:26
  challenge
• 0:26
  them
• 0:27
  and
• 0:27
  to
• 0:27
  spot
• 0:28
  the
• 0:29
  four
• 0:29
  errors
• 0:30
  in
• 0:31
  this
• 0:31
  case
• 0:31
  study.
• 0:32
  So
• 0:32
  that's
• 0:33
  what
• 0:33
  I
• 0:33
  challenge
• 0:33
  you
• 0:33
  to
• 0:34
  do.
• 0:34
  Find
• 0:34
  four
• 0:35
  errors
• 0:35
  in
• 0:36
  this
• 0:36
  short
• 0:36
  little
• 0:36
  case
• 0:37
  study
• 0:38
  of
• 0:38
  things
• 0:38
  that
• 0:39
  the
• 0:39
  clinician
• 0:40
  did
• 0:40
  wrong
• 0:40
  or
• 0:41
  could
• 0:41
  do
• 0:41
  better.
• 0:42
  They're
• 0:42
  pretty
• 0:43
  identifiable
• 0:44
  and
• 0:44
  I
• 0:44
  ask
• 0:45
  that
• 0:45
  you
• 0:45
  just
• 0:45
  go
• 0:45
  off
• 0:46
  of
• 0:46
  the
• 0:46
  information
• 0:47
  I
• 0:47
  give
• 0:47
  you.
• 0:47
  Okay,
• 0:48
  but
• 0:48
  there
• 0:48
  are
• 0:48
  four
• 0:49
  errors
• 0:49
  in
• 0:49
  these
• 0:50
  small
• 0:50
  little
• 0:50
  case
• 0:51
  vignettes
• 0:52
  that
• 0:52
  you
• 0:52
  can
• 0:53
  spot
• 0:54
  pretty
• 0:54
  obviously
• 0:55
  with
• 0:55
  a
• 0:55
  little
• 0:56
  more
• 0:56
  practice.
• 0:56
  And
• 0:57
  this
• 0:57
  kind
• 0:57
  of
• 0:58
  helps
• 0:58
  us
• 0:58
  stay
• 0:59
  on
• 0:59
  top
• 0:59
  of
• 0:59
  our
• 0:59
  game.
• 1:00
  They're
• 1:00
  short,
• 1:00
  they're
• 1:01
  playful,
• 1:01
  and
• 1:01
  I
• 1:01
  hope
• 1:02
  you
• 1:02
  enjoy
• 1:02
  these.
• 1:02
  They
• 1:03
  keep
• 1:03
  your
• 1:04
  skills
• 1:04
  sharp.
• 1:05
  And
• 1:05
  before
• 1:05
  we
• 1:06
  jump
• 1:06
  into
• 1:06
  them,
• 1:06
  my
• 1:06
  friends,
• 1:07
  always
• 1:07
  remember,
• 1:07
  you
• 1:08
  can
• 1:08
  become
• 1:08
  a
• 1:08
  free
• 1:08
  Patreon
• 1:09
  member.
• 1:09
  Get
• 1:09
  to
• 1:09
  our
• 1:10
  show
• 1:10
  notes,
• 1:10
  and
• 1:11
  for
• 1:11
  three
• 1:11
  bucks
• 1:12
  a
• 1:12
  month,
• 1:13
  oh,
• 1:13
  you
• 1:13
  get
• 1:13
  all
• 1:13
  kinds
• 1:14
  of
• 1:14
  goodies
• 1:14
  in
• 1:15
  our
• 1:15
  Patreon.
• 1:15
  You
• 1:15
  get
• 1:16
  tons
• 1:16
  of
• 1:16
  bonus
• 1:17
  materials,
• 1:17
  reference
• 1:18
  materials,
• 1:18
  cool
• 1:19
  slide
• 1:19
  decks,
• 1:19
  charts,
• 1:20
  screening
• 1:21
  tools.
• 1:21
  Anyway,
• 1:22
  without
• 1:22
  further
• 1:22
  ado,
• 1:23
  here's
• 1:23
  the
• 1:23
  patient
• 1:24
  profile.
• 1:25
  And
• 1:25
  I
• 1:25
  want
• 1:25
  you
• 1:26
  to
• 1:26
  start
• 1:26
  thinking
• 1:26
  about
• 1:27
  what
• 1:27
  are
• 1:28
  the
• 1:28
  four
• 1:28
  things
• 1:28
  that
• 1:29
  went
• 1:29
  wrong
• 1:29
  here?
• 1:29
  And
• 1:30
  you
• 1:30
  can
• 1:30
  pause
• 1:30
  it
• 1:31
  afterwards
• 1:31
  if
• 1:32
  you
• 1:32
  need
• 1:32
  a
• 1:32
  little
• 1:33
  time
• 1:33
  to
• 1:34
  brainstorm
• 1:35
  with
• 1:35
  your
• 1:35
  colleagues.
• 1:36
  Maybe
• 1:36
  you're
• 1:36
  in
• 1:36
  a
• 1:37
  zoom
• 1:37
  session.
• 1:37
  You
• 1:37
  all
• 1:37
  can
• 1:38
  hit
• 1:38
  pause.
• 1:38
  It'd
• 1:38
  be
• 1:38
  a
• 1:39
  great
• 1:39
  time.
• 1:39
  Okay,
• 1:40
  so
• 1:40
  here
• 1:41
  we
• 1:41
  go.
• 1:42
  Now,
• 1:42
  this
• 1:43
  patient
• 1:43
  is
• 1:43
  a
• 1:43
  23
• 1:44
  year
• 1:44
  old
• 1:45
  female.
• 1:46
  She's
• 1:46
  coming
• 1:46
  to
• 1:46
  you
• 1:46
  in
• 1:46
  the
• 1:47
  outpatient
• 1:47
  space.
• 1:48
  And
• 1:48
  she
• 1:49
  says,
• 1:49
  I've
• 1:49
  always
• 1:49
  been
• 1:50
  a
• 1:50
  really
• 1:50
  nervous
• 1:51
  person
• 1:51
  my
• 1:51
  whole
• 1:52
  life,
• 1:52
  but
• 1:52
  it's
• 1:52
  been
• 1:52
  a
• 1:52
  lot
• 1:53
  worse
• 1:53
  lately.
• 1:54
  Okay.
• 1:54
  She
• 1:54
  just
• 1:55
  started
• 1:55
  a
• 1:55
  new
• 1:55
  job
• 1:55
  as
• 1:56
  a
• 1:56
  director
• 1:56
  of
• 1:56
  an
• 1:57
  HR
• 1:57
  department.
• 1:58
  Lots
• 1:58
  of
• 1:58
  responsibility,
• 1:59
  very
• 1:59
  detail
• 1:59
  heavy,
• 2:00
  a
• 2:00
  lot
• 2:00
  of
• 2:00
  increased
• 2:01
  scrutiny.
• 2:02
  She
• 2:02
  says
• 2:02
  she
• 2:02
  can't
• 2:03
  keep
• 2:03
  up.
• 2:03
  She
• 2:04
  says
• 2:04
  I'm
• 2:04
  constantly
• 2:05
  worrying
• 2:06
  all
• 2:06
  day
• 2:06
  and
• 2:06
  night
• 2:07
  about
• 2:07
  missing
• 2:07
  things
• 2:07
  and
• 2:08
  falling
• 2:08
  behind.
• 2:09
  As
• 2:10
  far
• 2:10
  as
• 2:10
  her
• 2:10
  medical
• 2:11
  history
• 2:11
  goes,
• 2:11
  she
• 2:12
  has
• 2:12
  high
• 2:12
  cholesterol,
• 2:13
  some
• 2:13
  uncontrolled
• 2:14
  hypertension,
• 2:15
  some
• 2:15
  migraines,
• 2:16
  an
• 2:16
  irritable
• 2:17
  bowel
• 2:17
  syndrome.
• 2:18
  She
• 2:18
  has
• 2:18
  some
• 2:18
  chronic
• 2:19
  knee
• 2:19
  pain.
• 2:19
  That's
• 2:20
  pretty
• 2:20
  bothersome
• 2:21
  as
• 2:21
  well.
• 2:21
  In
• 2:22
  terms
• 2:22
  of
• 2:22
  mental
• 2:22
  health
• 2:22
  history,
• 2:23
  what
• 2:23
  you
• 2:23
  need
• 2:23
  to
• 2:24
  know
• 2:24
  is
• 2:24
  she
• 2:24
  did
• 2:24
  try
• 2:24
  Lexapro
• 2:25
  in
• 2:25
  the
• 2:25
  past.
• 2:25
  She
• 2:26
  did
• 2:26
  try
• 2:26
  Prozac
• 2:26
  in
• 2:27
  the
• 2:27
  past.
• 2:27
  She
• 2:28
  said
• 2:28
  they
• 2:28
  didn't
• 2:28
  quite
• 2:29
  work.
• 2:29
  And
• 2:29
  maybe
• 2:30
  she's
• 2:30
  interested
• 2:30
  in
• 2:30
  trying
• 2:31
  a
• 2:31
  new
• 2:31
  ssri.
• 2:32
  She's
• 2:33
  pretty
• 2:33
  wary
• 2:33
  about
• 2:33
  medications,
• 2:34
  and
• 2:34
  she
• 2:34
  doesn't
• 2:35
  take
• 2:35
  them
• 2:35
  regularly.
• 2:36
  She
• 2:36
  has
• 2:36
  a
• 2:36
  hard
• 2:36
  time
• 2:37
  being
• 2:37
  consistent
• 2:38
  with
• 2:38
  medications.
• 2:39
  So
• 2:40
  the
• 2:40
  clinician
• 2:40
  looks
• 2:40
  at
• 2:41
  this
• 2:41
  and
• 2:41
  basically
• 2:42
  says
• 2:42
  this.
• 2:43
  The
• 2:43
  clinician's
• 2:44
  basically
• 2:44
  going,
• 2:44
  okay,
• 2:45
  this
• 2:45
  is
• 2:46
  likely
• 2:46
  generalized
• 2:47
  anxiety
• 2:47
  disorder.
• 2:48
  Based
• 2:48
  on
• 2:48
  the
• 2:48
  information
• 2:49
  we
• 2:49
  have,
• 2:49
  maybe
• 2:49
  it's
• 2:50
  an
• 2:50
  adjustment
• 2:50
  disorder,
• 2:51
  given
• 2:51
  the
• 2:51
  fact
• 2:52
  that
• 2:52
  it's
• 2:52
  her
• 2:52
  new
• 2:53
  job
• 2:53
  in
• 2:53
  an
• 2:54
  HR
• 2:54
  department,
• 2:54
  a
• 2:55
  new
• 2:55
  role.
• 2:55
  So
• 2:56
  that's
• 2:56
  what
• 2:56
  the
• 2:56
  clinician
• 2:56
  concludes
• 2:57
  provisionally,
• 2:58
  okay,
• 2:58
  this
• 2:58
  is
• 2:58
  gad.
• 2:59
  This
• 2:59
  is
• 2:59
  an
• 2:59
  adjustment
• 3:00
  disorder.
• 3:00
  And
• 3:01
  the
• 3:01
  clinician
• 3:01
  starts
• 3:02
  the
• 3:02
  patient
• 3:02
  on
• 3:03
  effexor
• 3:04
  immediate
• 3:04
  release,
• 3:05
  37.5mg
• 3:06
  and
• 3:07
  increasing
• 3:07
  to
• 3:07
  75mg
• 3:08
  by
• 3:09
  the
• 3:09
  end
• 3:09
  of
• 3:09
  the
• 3:09
  week.
• 3:10
  Okay,
• 3:11
  so
• 3:12
  given
• 3:12
  what
• 3:12
  I've
• 3:12
  shared
• 3:13
  with
• 3:13
  you,
• 3:13
  here's
• 3:13
  when
• 3:13
  you
• 3:14
  can
• 3:14
  pause
• 3:15
  this
• 3:16
  podcast
• 3:17
  and
• 3:17
  discuss.
• 3:18
  But
• 3:18
  I
• 3:18
  have
• 3:18
  given
• 3:18
  you
• 3:19
  enough,
• 3:19
  my
• 3:19
  friends,
• 3:20
  enough
• 3:20
  information,
• 3:21
  enough
• 3:21
  meat
• 3:22
  on
• 3:22
  the
• 3:22
  bone
• 3:22
  here
• 3:22
  to
• 3:23
  infer
• 3:23
  that
• 3:23
  about
• 3:24
  four
• 3:24
  things
• 3:24
  went
• 3:25
  wrong
• 3:25
  here.
• 3:26
  You
• 3:26
  might
• 3:26
  be
• 3:26
  able
• 3:26
  to
• 3:26
  find
• 3:27
  five
• 3:27
  or
• 3:27
  six,
• 3:27
  but
• 3:28
  there's
• 3:28
  really
• 3:28
  four
• 3:29
  identifiable,
• 3:30
  pretty
• 3:30
  clear
• 3:32
  in
• 3:32
  some
• 3:32
  sense.
• 3:33
  And
• 3:33
  I
• 3:33
  don't
• 3:33
  want
• 3:33
  to
• 3:33
  give
• 3:33
  it
• 3:33
  away
• 3:33
  to
• 3:34
  you,
• 3:34
  but
• 3:35
  I
• 3:35
  just
• 3:35
  want
• 3:35
  you
• 3:35
  to
• 3:35
  chew
• 3:36
  on
• 3:36
  that.
• 3:36
  Press
• 3:36
  pause
• 3:37
  if
• 3:37
  needed.
• 3:38
  All
• 3:38
  right,
• 3:38
  I'm
• 3:38
  going
• 3:38
  to
• 3:38
  give
• 3:39
  you
• 3:39
  now
• 3:39
  the
• 3:40
  four
• 3:40
  errors.
• 3:41
  So,
• 3:42
  my
• 3:42
  friends,
• 3:42
  I
• 3:42
  see
• 3:43
  this
• 3:43
  all
• 3:43
  the
• 3:43
  time
• 3:44
  as
• 3:44
  an
• 3:44
  np.
• 3:44
  All
• 3:45
  the
• 3:45
  time,
• 3:45
  you
• 3:45
  have
• 3:46
  a
• 3:46
  patient
• 3:46
  who
• 3:47
  kind
• 3:47
  of
• 3:47
  tips
• 3:47
  you
• 3:47
  off
• 3:48
  in
• 3:48
  the
• 3:48
  wrong
• 3:48
  way.
• 3:48
  I
• 3:48
  think
• 3:49
  in
• 3:49
  school,
• 3:49
  we
• 3:49
  talked
• 3:50
  about
• 3:50
  this
• 3:50
  as
• 3:50
  like
• 3:50
  the
• 3:51
  anchoring
• 3:51
  bias.
• 3:52
  The
• 3:52
  anchoring
• 3:53
  bias
• 3:53
  is
• 3:53
  very
• 3:53
  real
• 3:54
  in
• 3:54
  psychiatry,
• 3:55
  right?
• 3:55
  In
• 3:55
  other
• 3:55
  words,
• 3:56
  your
• 3:56
  patient
• 3:57
  comes
• 3:57
  to
• 3:57
  you
• 3:57
  with
• 3:58
  verbiage
• 3:58
  or
• 3:59
  a
• 3:59
  complaint
• 4:00
  that
• 4:00
  almost
• 4:01
  leads
• 4:01
  you
• 4:01
  astray
• 4:02
  if
• 4:02
  you
• 4:02
  don't
• 4:02
  stop
• 4:02
  and
• 4:03
  think
• 4:03
  critically.
• 4:04
  Right.
• 4:04
  The
• 4:04
  goal
• 4:04
  is
• 4:05
  obviously
• 4:05
  not
• 4:05
  to
• 4:06
  challenge
• 4:06
  your
• 4:06
  patient
• 4:07
  for
• 4:07
  the
• 4:07
  sake
• 4:07
  of
• 4:07
  it,
• 4:07
  but
• 4:08
  they
• 4:08
  are
• 4:08
  coming
• 4:08
  to
• 4:09
  you
• 4:09
  in
• 4:09
  the
• 4:09
  context
• 4:09
  of
• 4:10
  trying
• 4:10
  to
• 4:10
  figure
• 4:11
  out
• 4:11
  a
• 4:11
  problem,
• 4:12
  maybe
• 4:12
  guide
• 4:12
  them
• 4:13
  to
• 4:13
  figure
• 4:13
  out
• 4:13
  their
• 4:14
  own
• 4:14
  problem.
• 4:14
  Whatever
• 4:15
  the
• 4:15
  case,
• 4:16
  they
• 4:16
  need
• 4:16
  that
• 4:17
  outside
• 4:17
  perspective,
• 4:18
  and
• 4:18
  they
• 4:18
  often
• 4:19
  label
• 4:19
  their
• 4:20
  issues
• 4:20
  or
• 4:20
  characterize
• 4:21
  their
• 4:21
  issues
• 4:21
  differently
• 4:22
  than
• 4:23
  how
• 4:23
  the
• 4:24
  experience
• 4:24
  is
• 4:24
  actually
• 4:25
  borne
• 4:25
  out
• 4:25
  in
• 4:26
  a
• 4:26
  clinical
• 4:26
  sense.
• 4:26
  So
• 4:26
  this
• 4:27
  person's
• 4:27
  kind
• 4:27
  of
• 4:27
  anchoring
• 4:28
  you
• 4:29
  to
• 4:29
  perceive
• 4:29
  them
• 4:30
  as
• 4:30
  a
• 4:30
  really
• 4:30
  nervous
• 4:31
  person.
• 4:32
  Okay,
• 4:32
  but
• 4:32
  maybe
• 4:33
  nervousness
• 4:33
  is
• 4:33
  not
• 4:34
  the
• 4:34
  exact
• 4:34
  verbiage
• 4:36
  that
• 4:36
  really
• 4:36
  applies
• 4:37
  here.
• 4:37
  If
• 4:37
  you
• 4:37
  dig
• 4:38
  deeply,
• 4:38
  because
• 4:39
  everything
• 4:39
  on
• 4:39
  the.
• 4:40
  On
• 4:40
  the.
• 4:40
  On
• 4:41
  the
• 4:41
  center
• 4:41
  of
• 4:41
  this
• 4:42
  or
• 4:42
  on
• 4:42
  the
• 4:42
  surface
• 4:43
  of
• 4:43
  this
• 4:43
  rather
• 4:44
  doesn't
• 4:45
  really
• 4:45
  scream
• 4:46
  gad.
• 4:46
  The
• 4:47
  clinician
• 4:47
  diagnosed
• 4:48
  the
• 4:48
  patient
• 4:48
  with
• 4:48
  gad,
• 4:49
  but
• 4:49
  based
• 4:49
  off
• 4:49
  of
• 4:49
  the
• 4:50
  information
• 4:50
  we
• 4:50
  have
• 4:50
  here,
• 4:51
  this
• 4:51
  is.
• 4:52
  This
• 4:52
  isn't
• 4:52
  the
• 4:52
  flavor
• 4:53
  of
• 4:53
  gad.
• 4:54
  Now,
• 4:54
  notice
• 4:54
  how
• 4:55
  I
• 4:55
  didn't
• 4:55
  give
• 4:55
  you
• 4:55
  a
• 4:56
  thousand
• 4:57
  diagnostic
• 4:57
  criteria
• 4:58
  here.
• 4:58
  That's
• 4:58
  not
• 4:58
  the
• 4:59
  point
• 4:59
  of
• 4:59
  these
• 4:59
  exercises.
• 5:00
  The
• 5:00
  point
• 5:00
  of
• 5:00
  this
• 5:00
  exercise
• 5:01
  is
• 5:02
  to
• 5:02
  get
• 5:02
  you
• 5:03
  acclimated
• 5:04
  to
• 5:04
  the
• 5:04
  flavor
• 5:04
  of
• 5:04
  a
• 5:05
  presentation
• 5:05
  right
• 5:05
  off
• 5:06
  the
• 5:06
  bat.
• 5:06
  We
• 5:06
  can
• 5:06
  all
• 5:07
  look
• 5:07
  at
• 5:07
  the
• 5:07
  textbooks
• 5:08
  later,
• 5:08
  we
• 5:08
  can
• 5:08
  all
• 5:09
  memorize
• 5:09
  rote
• 5:10
  memory,
• 5:10
  all
• 5:10
  these.
• 5:11
  You
• 5:11
  know.
• 5:11
  The
• 5:11
  point
• 5:12
  of
• 5:12
  this,
• 5:12
  though,
• 5:12
  is
• 5:12
  I
• 5:12
  want
• 5:12
  you
• 5:13
  all
• 5:13
  to
• 5:13
  have
• 5:13
  a
• 5:13
  conceptual
• 5:14
  appreciation
• 5:14
  for
• 5:15
  the
• 5:15
  flavor
• 5:15
  or
• 5:15
  the
• 5:16
  root
• 5:16
  of
• 5:16
  what
• 5:17
  your
• 5:17
  patient
• 5:17
  is
• 5:18
  coming
• 5:18
  to
• 5:18
  you
• 5:18
  with.
• 5:18
  You
• 5:19
  should
• 5:19
  know
• 5:19
  if
• 5:19
  the
• 5:19
  taste
• 5:20
  is
• 5:20
  like
• 5:20
  licorice
• 5:21
  versus
• 5:21
  mashed
• 5:22
  potatoes.
• 5:23
  Okay.
• 5:24
  And
• 5:24
  this
• 5:25
  is
• 5:26
  a
• 5:26
  little
• 5:26
  different
• 5:27
  than
• 5:27
  gad,
• 5:28
  right?
• 5:28
  She's
• 5:28
  clearly
• 5:29
  telling
• 5:29
  you
• 5:29
  I
• 5:29
  can't
• 5:30
  keep
• 5:30
  up.
• 5:30
  I'm
• 5:30
  worrying
• 5:31
  all
• 5:31
  day
• 5:32
  and
• 5:32
  night
• 5:32
  about
• 5:32
  missing
• 5:33
  things
• 5:33
  and
• 5:33
  falling
• 5:34
  behind.
• 5:35
  Well,
• 5:35
  that
• 5:35
  doesn't
• 5:36
  really
• 5:36
  sound
• 5:37
  like
• 5:38
  fear
• 5:38
  based
• 5:39
  anxiety
• 5:39
  that
• 5:40
  you
• 5:40
  would
• 5:40
  see
• 5:40
  in
• 5:40
  generalized
• 5:41
  anxiety
• 5:41
  disorder.
• 5:42
  Typically,
• 5:42
  what
• 5:43
  you
• 5:43
  see
• 5:43
  in
• 5:43
  generalized
• 5:44
  anxiety
• 5:44
  disorder
• 5:45
  is
• 5:45
  fear
• 5:46
  of
• 5:46
  being
• 5:47
  fired,
• 5:48
  fear
• 5:48
  of
• 5:49
  your
• 5:50
  health
• 5:50
  going
• 5:50
  in
• 5:51
  decline
• 5:51
  or
• 5:51
  having
• 5:51
  cancer
• 5:52
  or
• 5:53
  somebody,
• 5:53
  you
• 5:53
  know,
• 5:53
  someone
• 5:54
  close
• 5:54
  to
• 5:55
  you
• 5:55
  dying
• 5:55
  in
• 5:55
  a
• 5:55
  car
• 5:55
  accident
• 5:56
  when
• 5:56
  there's
• 5:56
  really
• 5:56
  no
• 5:57
  evidence
• 5:57
  that
• 5:57
  that
• 5:57
  would
• 5:57
  happen.
• 5:58
  It's
• 5:58
  catastrophic.
• 5:59
  Ruminations
• 6:00
  of
• 6:00
  things
• 6:00
  that
• 6:01
  could
• 6:01
  go
• 6:01
  wrong
• 6:01
  that
• 6:01
  are
• 6:01
  very
• 6:02
  fear
• 6:02
  based.
• 6:02
  That's
• 6:03
  how
• 6:03
  I
• 6:03
  look
• 6:03
  at
• 6:03
  it,
• 6:03
  at
• 6:03
  least.
• 6:04
  The
• 6:04
  quality
• 6:05
  of
• 6:05
  GAD
• 6:06
  worries.
• 6:07
  The
• 6:07
  quality
• 6:07
  of
• 6:07
  the
• 6:08
  worries.
• 6:08
  The
• 6:08
  content
• 6:08
  is
• 6:09
  very
• 6:09
  fear
• 6:09
  based.
• 6:09
  It's
• 6:10
  worst
• 6:10
  case
• 6:10
  scenario
• 6:11
  type
• 6:11
  thinking.
• 6:11
  It's
• 6:12
  also
• 6:12
  very
• 6:12
  broad.
• 6:13
  This
• 6:13
  is
• 6:14
  more
• 6:14
  narrow.
• 6:14
  She's
• 6:14
  coming
• 6:15
  to
• 6:15
  you
• 6:15
  in
• 6:15
  a
• 6:15
  very
• 6:15
  narrow
• 6:16
  capacity.
• 6:17
  Again,
• 6:17
  a
• 6:18
  new
• 6:18
  job,
• 6:18
  which
• 6:19
  adjustment
• 6:19
  I
• 6:19
  think
• 6:20
  is
• 6:20
  on
• 6:20
  the
• 6:20
  table
• 6:20
  here.
• 6:21
  Let's
• 6:21
  not
• 6:21
  call
• 6:21
  that
• 6:21
  a
• 6:21
  mistake.
• 6:22
  It's
• 6:23
  not
• 6:23
  one
• 6:23
  of
• 6:23
  our
• 6:23
  errors.
• 6:24
  But
• 6:24
  again,
• 6:25
  this
• 6:25
  is
• 6:25
  a
• 6:26
  new
• 6:26
  job
• 6:26
  where
• 6:26
  she
• 6:27
  can't
• 6:27
  keep
• 6:27
  up
• 6:27
  and
• 6:27
  she's
• 6:28
  worrying
• 6:28
  about
• 6:28
  falling
• 6:29
  behind.
• 6:30
  Okay.
• 6:30
  She's
• 6:31
  not
• 6:31
  worrying
• 6:32
  that
• 6:33
  something
• 6:33
  awful
• 6:34
  is
• 6:34
  going
• 6:34
  to
• 6:34
  happen
• 6:35
  or,
• 6:35
  you
• 6:36
  know,
• 6:37
  there's
• 6:37
  contamination
• 6:38
  or
• 6:38
  germs,
• 6:38
  or
• 6:39
  she
• 6:39
  didn't
• 6:39
  mention
• 6:39
  panic
• 6:40
  attacks
• 6:40
  or,
• 6:41
  you
• 6:41
  know,
• 6:41
  sudden
• 6:42
  surges
• 6:42
  of
• 6:42
  anxiety
• 6:43
  that
• 6:43
  feel
• 6:43
  random
• 6:44
  or
• 6:44
  undefinable.
• 6:45
  That
• 6:45
  would
• 6:45
  be
• 6:46
  more
• 6:46
  of
• 6:46
  like
• 6:46
  the
• 6:46
  panic
• 6:47
  route.
• 6:47
  She's
• 6:47
  not
• 6:47
  worried
• 6:48
  about
• 6:48
  having
• 6:48
  cancer,
• 6:49
  which
• 6:49
  would
• 6:49
  be
• 6:50
  like
• 6:50
  an
• 6:50
  illness
• 6:50
  anxiety
• 6:51
  route.
• 6:51
  She's
• 6:51
  not
• 6:51
  worried
• 6:52
  about
• 6:52
  a
• 6:52
  somatic
• 6:52
  symptom
• 6:53
  or
• 6:53
  fixated
• 6:54
  on
• 6:54
  a
• 6:54
  somatic
• 6:55
  symptom
• 6:55
  like
• 6:55
  back
• 6:56
  pain
• 6:56
  or
• 6:56
  indigestion.
• 6:57
  Again,
• 6:58
  so
• 6:58
  all
• 6:59
  of
• 6:59
  those
• 6:59
  based
• 6:59
  on
• 7:00
  what
• 7:00
  I've
• 7:00
  given
• 7:00
  you.
• 7:00
  Right.
• 7:01
  This
• 7:01
  should
• 7:01
  not
• 7:02
  have
• 7:02
  put
• 7:02
  us
• 7:02
  down
• 7:02
  the
• 7:02
  generalized
• 7:03
  anxiety
• 7:04
  track,
• 7:04
  but
• 7:04
  she
• 7:04
  did
• 7:05
  kind
• 7:05
  of
• 7:05
  give
• 7:05
  you,
• 7:06
  she
• 7:06
  anchored
• 7:07
  you
• 7:07
  with
• 7:07
  generalized
• 7:08
  anxiety.
• 7:09
  My
• 7:09
  friends,
• 7:10
  if
• 7:10
  you
• 7:11
  haven't
• 7:11
  figured
• 7:11
  it
• 7:12
  out
• 7:12
  yet,
• 7:13
  based
• 7:13
  on
• 7:13
  the
• 7:13
  limited
• 7:14
  information
• 7:14
  I
• 7:14
  gave
• 7:15
  you,
• 7:15
  you
• 7:15
  may
• 7:15
  recognize
• 7:16
  this
• 7:16
  is
• 7:16
  much
• 7:16
  more
• 7:17
  an
• 7:17
  ADHD
• 7:18
  track.
• 7:18
  Right?
• 7:18
  And
• 7:19
  this
• 7:19
  is
• 7:19
  what
• 7:19
  you
• 7:19
  hear
• 7:19
  all
• 7:20
  the
• 7:20
  time
• 7:20
  from
• 7:20
  your
• 7:20
  patients
• 7:21
  in
• 7:21
  real
• 7:21
  life.
• 7:22
  Right.
• 7:22
  The
• 7:22
  classic
• 7:23
  difference
• 7:23
  between
• 7:24
  ADHD
• 7:24
  and
• 7:24
  anxiety
• 7:25
  is
• 7:25
  anxiety
• 7:26
  is
• 7:26
  More
• 7:26
  fear
• 7:27
  based
• 7:27
  of
• 7:27
  bad
• 7:28
  things
• 7:28
  that
• 7:28
  could.
• 7:29
  That
• 7:29
  are
• 7:29
  very
• 7:30
  broad
• 7:30
  and
• 7:30
  generalizable.
• 7:31
  When
• 7:31
  one
• 7:31
  worry's
• 7:32
  gone,
• 7:32
  the
• 7:32
  next
• 7:32
  one
• 7:32
  pops
• 7:33
  up
• 7:33
  like
• 7:33
  Hungry
• 7:33
  Hungry
• 7:34
  Hippo
• 7:34
  style.
• 7:35
  And
• 7:35
  ADHD
• 7:36
  is
• 7:36
  more
• 7:36
  productivity
• 7:37
  based.
• 8:32
  It's
• 8:32
  like
• 8:32
  detail
• 8:33
  missing
• 8:34
  details,
• 8:34
  carelessness,
• 8:35
  being
• 8:36
  overwhelmed
• 8:37
  by
• 8:37
  information
• 8:38
  that
• 8:38
  you
• 8:38
  can't
• 8:39
  quite
• 8:39
  prioritize
• 8:39
  and
• 8:40
  you
• 8:40
  fall
• 8:40
  behind.
• 8:41
  And
• 8:41
  there's
• 8:42
  a
• 8:42
  famous
• 8:42
  scene
• 8:42
  in
• 8:42
  I
• 8:42
  Love
• 8:43
  Lucy.
• 8:43
  You
• 8:43
  could
• 8:43
  probably
• 8:43
  go
• 8:44
  on
• 8:44
  the
• 8:44
  YouTube.com
• 8:45
  and
• 8:46
  find
• 8:46
  it
• 8:46
  where
• 8:46
  Lucy,
• 8:47
  like
• 8:47
  works
• 8:47
  at
• 8:47
  a
• 8:47
  chocolate
• 8:48
  factory
• 8:49
  and
• 8:49
  the
• 8:49
  assembly
• 8:50
  line
• 8:50
  is
• 8:50
  just
• 8:50
  moving
• 8:50
  so
• 8:51
  fast
• 8:51
  and
• 8:51
  it's
• 8:51
  really
• 8:51
  frantic
• 8:52
  and
• 8:52
  she
• 8:52
  like
• 8:52
  loses
• 8:53
  her
• 8:53
  mind
• 8:53
  and.
• 8:54
  Right.
• 8:54
  And
• 8:54
  that's
• 8:55
  much
• 8:55
  more
• 8:55
  the
• 8:55
  ADHD
• 8:56
  kind
• 8:57
  of
• 8:57
  problem.
• 8:58
  Right.
• 8:58
  And
• 8:58
  so
• 8:58
  the,
• 8:59
  again,
• 8:59
  the
• 8:59
  little
• 8:59
  vignette
• 9:00
  I
• 9:00
  gave
• 9:00
  you,
• 9:01
  it,
• 9:01
  if,
• 9:01
  if,
• 9:02
  if
• 9:02
  you
• 9:02
  had
• 9:02
  like
• 9:02
  a
• 9:03
  taste,
• 9:03
  if
• 9:03
  this
• 9:03
  was
• 9:03
  like
• 9:03
  a
• 9:04
  taste
• 9:04
  test,
• 9:04
  right,
• 9:05
  where
• 9:05
  you're
• 9:05
  at
• 9:05
  a
• 9:05
  little
• 9:06
  ice
• 9:06
  cream
• 9:06
  parlor
• 9:07
  and,
• 9:07
  and
• 9:07
  you're
• 9:07
  blindfolded
• 9:08
  and
• 9:08
  you're
• 9:08
  like,
• 9:09
  okay,
• 9:09
  is
• 9:09
  that,
• 9:10
  is
• 9:10
  that
• 9:10
  vanilla
• 9:11
  cream
• 9:11
  or
• 9:11
  banana?
• 9:12
  I.
• 9:12
  My
• 9:12
  hope
• 9:13
  is
• 9:13
  that
• 9:13
  when
• 9:13
  you
• 9:13
  hear
• 9:14
  this
• 9:14
  kind
• 9:14
  of
• 9:15
  thing
• 9:15
  from
• 9:15
  a
• 9:15
  patient,
• 9:15
  I
• 9:16
  can't
• 9:16
  keep
• 9:16
  up.
• 9:17
  I'm
• 9:17
  worrying
• 9:17
  about
• 9:17
  falling
• 9:18
  behind.
• 9:19
  That
• 9:19
  is
• 9:20
  much
• 9:20
  more
• 9:20
  likely
• 9:20
  the
• 9:21
  ADHD
• 9:22
  track
• 9:22
  and
• 9:22
  definitely
• 9:23
  go
• 9:23
  down
• 9:23
  that
• 9:23
  rabbit
• 9:24
  hole.
• 9:24
  So
• 9:24
  that's
• 9:24
  error
• 9:25
  one
• 9:25
  is
• 9:25
  that
• 9:25
  this
• 9:25
  is
• 9:26
  not
• 9:26
  a
• 9:26
  GAD
• 9:27
  is
• 9:27
  not
• 9:27
  the
• 9:27
  best
• 9:28
  provisional
• 9:28
  diagnosis.
• 9:29
  The
• 9:29
  ADHD
• 9:29
  track
• 9:30
  is
• 9:30
  more
• 9:30
  appropriate.
• 9:31
  We'll
• 9:31
  let
• 9:31
  adjustment
• 9:32
  disorder
• 9:32
  slide
• 9:33
  because
• 9:33
  it
• 9:33
  could
• 9:33
  very
• 9:33
  well
• 9:34
  be
• 9:34
  the
• 9:34
  fact
• 9:34
  that
• 9:34
  this
• 9:35
  job
• 9:35
  is
• 9:35
  so
• 9:36
  overwhelming.
• 9:36
  Maybe
• 9:37
  it's
• 9:37
  the
• 9:37
  wrong
• 9:37
  fit
• 9:38
  for
• 9:38
  her
• 9:38
  and
• 9:38
  she
• 9:38
  doesn't
• 9:39
  have
• 9:39
  adhd.
• 9:40
  And
• 9:40
  sure,
• 9:41
  we'll
• 9:41
  keep
• 9:41
  that
• 9:41
  as
• 9:41
  a
• 9:42
  provisional.
• 9:42
  You're
• 9:42
  not
• 9:42
  wrong
• 9:43
  for
• 9:43
  thinking
• 9:43
  adjustment.
• 9:44
  There's
• 9:45
  nothing
• 9:45
  in
• 9:45
  the
• 9:45
  vignette
• 9:45
  that
• 9:46
  suggested
• 9:46
  though
• 9:46
  she.
• 9:47
  She's
• 9:47
  not
• 9:47
  functioning
• 9:48
  in
• 9:48
  other
• 9:49
  aspects
• 9:50
  of
• 9:50
  life.
• 9:50
  But
• 9:51
  again,
• 9:51
  this
• 9:51
  was
• 9:51
  pretty
• 9:52
  narrow.
• 9:52
  It
• 9:52
  was
• 9:52
  a
• 9:53
  pretty
• 9:53
  narrow
• 9:53
  domain
• 9:54
  of
• 9:54
  worrying
• 9:54
  about
• 9:55
  not
• 9:55
  being
• 9:55
  able
• 9:55
  to
• 9:55
  keep
• 9:56
  up.
• 9:56
  Okay,
• 9:57
  so
• 9:58
  now
• 9:58
  what
• 9:58
  else?
• 9:59
  What's
• 9:59
  another
• 9:59
  error
• 10:00
  here?
• 10:00
  You
• 10:00
  might
• 10:00
  have
• 10:01
  caught
• 10:01
  it.
• 10:02
  So
• 10:02
  this
• 10:02
  is
• 10:03
  not
• 10:03
  a
• 10:03
  good
• 10:03
  medication
• 10:04
  choice.
• 10:04
  And
• 10:05
  a
• 10:05
  few
• 10:05
  of
• 10:05
  the
• 10:05
  errors
• 10:06
  in
• 10:06
  this
• 10:07
  involve
• 10:07
  the
• 10:07
  medication
• 10:08
  that
• 10:08
  was
• 10:08
  chosen,
• 10:09
  Venlafaxine
• 10:10
  or
• 10:10
  Effexor.
• 10:11
  Error
• 10:11
  number
• 10:12
  two
• 10:12
  is
• 10:12
  you
• 10:12
  don't
• 10:13
  give
• 10:13
  Effexor
• 10:13
  to
• 10:14
  a
• 10:14
  patient
• 10:14
  who
• 10:14
  has
• 10:14
  trouble
• 10:15
  staying
• 10:16
  consistent
• 10:16
  with
• 10:16
  medications.
• 10:17
  A
• 10:17
  Venlafaxine
• 10:18
  has
• 10:18
  a
• 10:18
  very
• 10:19
  short
• 10:19
  half
• 10:19
  life
• 10:20
  and
• 10:20
  patients
• 10:21
  feel
• 10:21
  miserable
• 10:21
  when
• 10:22
  they
• 10:22
  accidentally
• 10:22
  miss
• 10:23
  a
• 10:23
  dose.
• 10:24
  So
• 10:24
  when
• 10:25
  you
• 10:25
  have
• 10:25
  a
• 10:25
  patient
• 10:25
  with
• 10:25
  poor
• 10:26
  adherence,
• 10:26
  it's
• 10:26
  even
• 10:27
  worse
• 10:27
  to
• 10:27
  put
• 10:27
  them
• 10:27
  on
• 10:27
  Effexor
• 10:29
  because
• 10:30
  they're
• 10:30
  not
• 10:30
  as
• 10:31
  likely
• 10:31
  to
• 10:32
  adhere
• 10:33
  and
• 10:33
  you're
• 10:33
  kind
• 10:33
  of
• 10:33
  setting
• 10:34
  them
• 10:34
  up
• 10:34
  to
• 10:35
  feel
• 10:35
  quite
• 10:35
  miserable
• 10:36
  on,
• 10:36
  on
• 10:36
  occasion.
• 10:37
  Now
• 10:37
  this
• 10:37
  is
• 10:38
  going
• 10:38
  to
• 10:38
  sound
• 10:38
  really
• 10:38
  twisted
• 10:39
  and
• 10:39
  crazy.
• 10:39
  I
• 10:40
  have
• 10:40
  heard
• 10:41
  practitioners
• 10:42
  out
• 10:42
  there
• 10:42
  and
• 10:42
  psychiatrists
• 10:43
  out
• 10:43
  there
• 10:44
  actually
• 10:44
  use
• 10:44
  that
• 10:45
  to
• 10:45
  their
• 10:45
  advantage.
• 10:46
  And
• 10:46
  for
• 10:46
  folks
• 10:46
  who
• 10:47
  are
• 10:47
  not
• 10:47
  very
• 10:47
  adherent,
• 10:48
  they'll
• 10:48
  even
• 10:48
  paradoxically
• 10:49
  practice
• 10:50
  as
• 10:50
  though
• 10:51
  they'll
• 10:51
  say,
• 10:51
  hey,
• 10:52
  let's
• 10:52
  give
• 10:52
  effects
• 10:53
  here,
• 10:53
  because
• 10:53
  that
• 10:53
  will
• 10:53
  enforce
• 10:54
  adherence
• 10:54
  in
• 10:55
  a
• 10:55
  way,
• 10:55
  right?
• 10:55
  And
• 10:55
  if
• 10:56
  you
• 10:56
  have,
• 10:56
  you
• 10:57
  know,
• 10:57
  an
• 10:57
  open
• 10:57
  conversation
• 10:58
  with
• 10:58
  your
• 10:58
  patient,
• 10:58
  say,
• 10:59
  hey,
• 10:59
  look,
• 10:59
  we
• 11:00
  could
• 11:00
  go
• 11:00
  two
• 11:00
  ways
• 11:00
  with
• 11:00
  this,
• 11:01
  right?
• 11:01
  Almost
• 11:01
  like
• 11:01
  a
• 11:01
  disulfiram
• 11:02
  approach,
• 11:03
  right?
• 11:03
  With
• 11:03
  alcohol.
• 11:04
  You
• 11:04
  know,
• 11:04
  when
• 11:04
  we
• 11:04
  take
• 11:05
  disulfiram
• 11:05
  and
• 11:05
  you
• 11:06
  vomit
• 11:06
  if
• 11:06
  you
• 11:07
  drink,
• 11:07
  if
• 11:07
  you.
• 11:07
  It's
• 11:08
  almost
• 11:08
  an
• 11:08
  aversive
• 11:08
  treatment
• 11:09
  at
• 11:09
  that
• 11:09
  point.
• 11:09
  It's
• 11:09
  like,
• 11:10
  hey,
• 11:10
  I,
• 11:10
  you
• 11:10
  know,
• 11:11
  have
• 11:11
  an
• 11:11
  open
• 11:11
  discussion
• 11:12
  with
• 11:12
  your
• 11:12
  patient,
• 11:12
  say,
• 11:12
  look,
• 11:13
  if
• 11:13
  you
• 11:13
  really
• 11:13
  want
• 11:13
  to
• 11:14
  focus
• 11:14
  on
• 11:14
  adherence,
• 11:15
  I
• 11:15
  can
• 11:15
  give
• 11:15
  you
• 11:15
  a
• 11:15
  medication
• 11:16
  that's
• 11:16
  really
• 11:16
  unpleasant
• 11:17
  if
• 11:17
  you
• 11:17
  miss
• 11:18
  a
• 11:18
  dose,
• 11:18
  thus
• 11:19
  compelling
• 11:19
  you
• 11:20
  to.
• 11:20
  To
• 11:20
  be
• 11:20
  more
• 11:20
  adherent.
• 11:21
  And
• 11:21
  I
• 11:21
  think
• 11:21
  if
• 11:21
  your
• 11:22
  patient
• 11:22
  is
• 11:22
  motivated
• 11:23
  by
• 11:23
  that
• 11:23
  and
• 11:24
  on
• 11:24
  board
• 11:24
  with
• 11:24
  that,
• 11:25
  and
• 11:25
  that's
• 11:25
  kind
• 11:25
  of
• 11:25
  the
• 11:25
  way
• 11:25
  they're
• 11:26
  wired,
• 11:26
  I
• 11:26
  don't
• 11:26
  see
• 11:26
  any
• 11:27
  problem
• 11:27
  with
• 11:27
  that.
• 11:27
  But
• 11:28
  I
• 11:28
  would,
• 11:28
  for
• 11:28
  ethical
• 11:29
  reasons,
• 11:29
  I
• 11:29
  would
• 11:29
  certainly
• 11:30
  encourage
• 11:30
  you
• 11:30
  to
• 11:30
  have
• 11:31
  a
• 11:31
  radically
• 11:32
  transparent
• 11:33
  conversation
• 11:33
  with
• 11:33
  your
• 11:34
  patient
• 11:34
  about
• 11:34
  that.
• 11:35
  Okay,
• 11:35
  so
• 11:36
  that's
• 11:36
  the
• 11:36
  second
• 11:36
  error,
• 11:37
  right?
• 11:37
  The
• 11:37
  first
• 11:37
  error
• 11:37
  is
• 11:38
  that
• 11:38
  this
• 11:38
  is
• 11:38
  likely
• 11:38
  an
• 11:38
  ADHD
• 11:39
  railroad
• 11:40
  track
• 11:40
  and
• 11:41
  not
• 11:41
  a
• 11:41
  GAD
• 11:41
  one.
• 11:42
  The
• 11:42
  second
• 11:42
  error
• 11:43
  is
• 11:43
  that
• 11:43
  Effexor
• 11:44
  is
• 11:44
  not
• 11:44
  a
• 11:44
  good
• 11:45
  medication
• 11:46
  if
• 11:46
  your
• 11:46
  patient
• 11:47
  has
• 11:47
  poor
• 11:47
  adherence.
• 11:48
  The
• 11:48
  third
• 11:48
  error
• 11:49
  is
• 11:49
  that
• 11:49
  your
• 11:49
  patient
• 11:49
  has
• 11:50
  uncontrolled
• 11:50
  hypertension,
• 11:51
  and
• 11:52
  Effexor
• 11:53
  is
• 11:54
  pretty
• 11:54
  notorious
• 11:55
  for
• 11:56
  contributing
• 11:56
  to
• 11:56
  hypertension.
• 11:57
  And
• 11:58
  it's.
• 11:58
  So
• 11:58
  it's.
• 11:58
  It's
• 11:58
  certainly
• 11:59
  not
• 11:59
  the
• 11:59
  best
• 12:00
  medication
• 12:00
  you
• 12:00
  could
• 12:00
  choose
• 12:01
  here.
• 12:01
  And
• 12:01
  then
• 12:01
  the
• 12:01
  fourth
• 12:02
  issue
• 12:03
  is
• 12:03
  the
• 12:03
  patient
• 12:03
  said
• 12:04
  they
• 12:04
  had
• 12:04
  ibs,
• 12:05
  and,
• 12:05
  well,
• 12:05
  for
• 12:06
  GI
• 12:06
  issues,
• 12:06
  effects
• 12:07
  can
• 12:07
  often
• 12:07
  worsen
• 12:08
  that.
• 12:08
  It
• 12:08
  can
• 12:08
  cause
• 12:08
  nausea,
• 12:09
  GI
• 12:09
  distress.
• 12:10
  So
• 12:10
  having
• 12:11
  an
• 12:11
  appreciation
• 12:12
  for
• 12:12
  what
• 12:13
  your
• 12:13
  patient's
• 12:13
  medical
• 12:14
  history
• 12:14
  is
• 12:14
  and
• 12:15
  what
• 12:15
  medications
• 12:16
  you
• 12:16
  have
• 12:16
  that
• 12:16
  may
• 12:16
  not
• 12:16
  be
• 12:17
  compatible
• 12:17
  with
• 12:18
  that
• 12:18
  history
• 12:18
  is
• 12:19
  super
• 12:19
  important.
• 12:19
  And
• 12:19
  that
• 12:20
  comes
• 12:20
  practice,
• 12:21
  right?
• 12:21
  Because
• 12:22
  at
• 12:22
  the
• 12:22
  end
• 12:22
  of
• 12:22
  the
• 12:22
  day,
• 12:23
  the
• 12:23
  studies
• 12:23
  tend
• 12:24
  to
• 12:24
  suggest
• 12:24
  that
• 12:24
  all
• 12:24
  SSRIs
• 12:25
  and
• 12:25
  SNRIs
• 12:26
  are
• 12:27
  more
• 12:27
  or
• 12:27
  less
• 12:27
  efficacious,
• 12:29
  have
• 12:29
  the
• 12:29
  same
• 12:29
  efficacy,
• 12:30
  right?
• 12:30
  The
• 12:30
  same
• 12:30
  effect
• 12:31
  sizes,
• 12:31
  more
• 12:31
  or
• 12:32
  less.
• 12:32
  There's
• 12:32
  some
• 12:32
  variations.
• 12:33
  There's
• 12:33
  some
• 12:33
  studies
• 12:34
  that
• 12:34
  say
• 12:34
  Lexapro
• 12:35
  is
• 12:35
  better
• 12:35
  or
• 12:35
  that
• 12:36
  SNRIs
• 12:36
  are
• 12:36
  better
• 12:37
  in
• 12:37
  depression.
• 12:38
  Sure,
• 12:38
  there's
• 12:38
  debates
• 12:39
  like
• 12:39
  that
• 12:39
  out
• 12:39
  there.
• 12:40
  However,
• 12:40
  by
• 12:41
  and
• 12:41
  large,
• 12:41
  the
• 12:42
  efficacy
• 12:42
  of
• 12:42
  SSRIs
• 12:43
  and
• 12:43
  SNRIs
• 12:44
  are
• 12:44
  mainly.
• 12:45
  Are.
• 12:45
  Are.
• 12:45
  Are
• 12:46
  mainly
• 12:46
  similar.
• 12:47
  The
• 12:47
  difference,
• 12:47
  my
• 12:48
  friends,
• 12:48
  the
• 12:48
  reason
• 12:48
  you
• 12:49
  get
• 12:49
  paid
• 12:49
  the
• 12:49
  big
• 12:49
  buck,
• 12:50
  the
• 12:50
  reason
• 12:50
  the
• 12:50
  primary
• 12:51
  care
• 12:51
  doc
• 12:51
  send
• 12:51
  these
• 12:51
  patients
• 12:52
  to
• 12:52
  you
• 12:52
  in
• 12:52
  particular
• 12:53
  is
• 12:53
  so
• 12:53
  you
• 12:54
  can
• 12:54
  understand
• 12:54
  the
• 12:54
  nuances,
• 12:55
  so
• 12:55
  that
• 12:56
  you
• 12:56
  can
• 12:56
  understand
• 12:56
  that,
• 12:57
  hey,
• 12:57
  uncontrolled
• 12:58
  hypertension
• 12:58
  and
• 12:59
  GI
• 12:59
  issues
• 12:59
  are
• 12:59
  not
• 13:00
  particularly
• 13:00
  compatible
• 13:01
  with
• 13:01
  Effexor.
• 13:02
  And
• 13:03
  they're
• 13:03
  probably
• 13:03
  up
• 13:04
  at
• 13:04
  least
• 13:04
  the
• 13:04
  GI
• 13:05
  piece
• 13:05
  is
• 13:05
  much
• 13:05
  more
• 13:05
  compatible
• 13:06
  with
• 13:06
  like
• 13:06
  a
• 13:06
  Remeron,
• 13:07
  right?
• 13:08
  Because
• 13:08
  Remeron
• 13:09
  antagonizes
• 13:09
  the
• 13:10
  5ht3
• 13:11
  receptor,
• 13:12
  the
• 13:12
  vomit
• 13:13
  receptor,
• 13:13
  and
• 13:14
  I
• 13:14
  wish
• 13:14
  I
• 13:14
  had
• 13:14
  a
• 13:14
  good
• 13:14
  mnemonic
• 13:15
  for
• 13:15
  that.
• 13:15
  What,
• 13:16
  what
• 13:16
  the
• 13:16
  number
• 13:16
  three
• 13:17
  and
• 13:17
  vomiting
• 13:18
  have
• 13:18
  in
• 13:19
  common.
• 13:19
  I
• 13:19
  guess
• 13:19
  bad
• 13:19
  things
• 13:20
  come
• 13:20
  in
• 13:20
  three.
• 13:20
  So,
• 13:21
  my
• 13:21
  friends,
• 13:21
  here
• 13:21
  we
• 13:21
  go.
• 13:22
  The
• 13:22
  gi,
• 13:23
  the
• 13:23
  hypertension,
• 13:24
  it's
• 13:24
  the
• 13:24
  wrong
• 13:24
  diagnosis
• 13:25
  and
• 13:25
  poor
• 13:25
  adherence.
• 13:26
  Effexor
• 13:27
  is
• 13:27
  not
• 13:27
  a
• 13:27
  good
• 13:28
  thing
• 13:28
  here.
• 13:29
  As
• 13:29
  a
• 13:29
  little
• 13:29
  bonus,
• 13:30
  fifth
• 13:30
  thing,
• 13:30
  if
• 13:30
  you
• 13:30
  caught
• 13:31
  this,
• 13:31
  but
• 13:32
  the
• 13:32
  fifth
• 13:32
  thing
• 13:33
  is
• 13:33
  if
• 13:33
  you
• 13:33
  do
• 13:33
  prescribe
• 13:34
  Effexor
• 13:34
  and
• 13:35
  somebody
• 13:35
  has
• 13:35
  GI
• 13:35
  issues,
• 13:36
  don't
• 13:36
  give
• 13:36
  them
• 13:37
  the
• 13:37
  immediate
• 13:37
  release,
• 13:38
  give
• 13:38
  them
• 13:38
  the
• 13:38
  xr,
• 13:39
  it's
• 13:39
  a
• 13:39
  little
• 13:39
  smoother.
• 13:40
  And
• 13:40
  another
• 13:40
  thing,
• 13:41
  my
• 13:41
  friends,
• 13:41
  this
• 13:41
  is
• 13:42
  not
• 13:42
  so
• 13:42
  much
• 13:42
  the
• 13:42
  errors
• 13:43
  per
• 13:43
  se,
• 13:43
  but
• 13:44
  I
• 13:44
  want
• 13:44
  you
• 13:44
  to
• 13:44
  think
• 13:44
  about.
• 13:45
  When
• 13:46
  a
• 13:46
  patient
• 13:46
  comes
• 13:46
  to
• 13:46
  you,
• 13:47
  this
• 13:47
  is
• 13:47
  a
• 13:47
  little
• 13:47
  pearl
• 13:47
  to
• 13:48
  prep
• 13:48
  you
• 13:48
  to
• 13:48
  practice,
• 13:49
  right?
• 13:50
  When
• 13:50
  a
• 13:51
  patient
• 13:51
  comes
• 13:51
  to
• 13:51
  you
• 13:51
  with
• 13:52
  a
• 13:52
  ton
• 13:53
  of
• 13:53
  medication
• 13:53
  trials,
• 13:54
  I
• 13:55
  think
• 13:55
  it's
• 13:56
  fair
• 13:56
  for
• 13:56
  you
• 13:57
  as
• 13:57
  a
• 13:57
  natural
• 13:58
  inclination
• 13:58
  to
• 13:58
  question
• 13:59
  the
• 13:59
  core
• 13:59
  diagnosis.
• 14:00
  Of
• 14:01
  course,
• 14:01
  it
• 14:01
  could
• 14:01
  very
• 14:02
  well
• 14:02
  be
• 14:02
  that
• 14:02
  the
• 14:02
  patient
• 14:03
  just
• 14:04
  didn't
• 14:04
  take
• 14:04
  the
• 14:05
  medication
• 14:05
  long
• 14:05
  enough.
• 14:06
  It
• 14:06
  wasn't
• 14:06
  an
• 14:06
  adequate
• 14:06
  trial,
• 14:07
  it
• 14:07
  wasn't
• 14:07
  an
• 14:07
  adequate
• 14:08
  dose.
• 14:08
  I
• 14:08
  see
• 14:08
  that
• 14:09
  all
• 14:09
  the
• 14:09
  time
• 14:09
  in
• 14:09
  practice.
• 14:10
  That
• 14:10
  dose
• 14:10
  is
• 14:11
  just
• 14:11
  never
• 14:11
  where
• 14:11
  it
• 14:11
  needed
• 14:12
  to
• 14:12
  be.
• 14:12
  The
• 14:12
  patient
• 14:12
  was
• 14:13
  being
• 14:13
  underdosed.
• 14:14
  But
• 14:14
  if
• 14:15
  you've
• 14:15
  got
• 14:15
  someone
• 14:16
  coming
• 14:16
  to
• 14:16
  you
• 14:16
  with
• 14:16
  depression
• 14:17
  for
• 14:17
  20
• 14:17
  years
• 14:19
  and
• 14:19
  they've
• 14:19
  tried
• 14:19
  every
• 14:19
  antidepressant
• 14:20
  under
• 14:20
  the,
• 14:21
  under
• 14:21
  the
• 14:21
  hood.
• 14:22
  TCAs
• 14:23
  ma
• 14:23
  y,
• 14:24
  they've
• 14:24
  tried
• 14:25
  everything.
• 14:25
  You've
• 14:26
  got
• 14:26
  to
• 14:26
  wonder,
• 14:26
  is
• 14:27
  there
• 14:27
  bipolarity
• 14:27
  in
• 14:27
  here?
• 14:28
  Is
• 14:28
  there
• 14:28
  substance
• 14:28
  use
• 14:28
  in
• 14:29
  here?
• 14:29
  Is
• 14:29
  there
• 14:30
  something
• 14:30
  we're
• 14:30
  missing?
• 14:30
  Is
• 14:30
  the
• 14:31
  diagnosis
• 14:31
  not
• 14:31
  right?
• 14:31
  Is
• 14:32
  this
• 14:32
  really
• 14:32
  adhd?
• 14:33
  Is
• 14:33
  it
• 14:33
  being
• 14:33
  communicated
• 14:34
  and
• 14:34
  translated
• 14:35
  differently
• 14:35
  by
• 14:35
  the
• 14:35
  patient?
• 14:36
  What's
• 14:36
  going
• 14:37
  on
• 14:37
  here?
• 14:37
  Exactly
• 14:38
  right?
• 14:38
  Is
• 14:38
  there
• 14:38
  severe
• 14:39
  trauma?
• 14:39
  Lexapro
• 14:40
  and
• 14:40
  Prozac,
• 14:41
  and
• 14:41
  this
• 14:42
  patient
• 14:42
  says
• 14:42
  they're
• 14:43
  anxious
• 14:43
  all
• 14:44
  the
• 14:44
  time
• 14:44
  and
• 14:44
  nothing's
• 14:45
  ever
• 14:45
  worked?
• 14:45
  Well,
• 14:45
  do
• 14:45
  we
• 14:46
  have
• 14:46
  the
• 14:46
  right
• 14:46
  diagnosis
• 14:47
  here?
• 14:47
  I
• 14:47
  mean,
• 14:48
  because
• 14:48
  nothing's
• 14:48
  going
• 14:49
  to
• 14:49
  work
• 14:49
  if
• 14:50
  the
• 14:51
  problem
• 14:51
  being
• 14:52
  addressed
• 14:52
  is
• 14:53
  being
• 14:54
  ignored
• 14:54
  for
• 14:54
  something
• 14:54
  else,
• 14:55
  right?
• 14:55
  You're
• 14:56
  never
• 14:56
  going
• 14:56
  to,
• 14:56
  like,
• 14:57
  inflate
• 14:57
  your
• 14:57
  tires
• 14:58
  if
• 14:58
  you
• 14:58
  go
• 14:58
  to
• 14:58
  Jiffy
• 14:59
  Lube
• 14:59
  and
• 14:59
  you're
• 14:59
  like,
• 14:59
  hey,
• 15:00
  I
• 15:00
  think
• 15:00
  it's
• 15:00
  my
• 15:00
  brakes.
• 15:01
  Well,
• 15:01
  yeah,
• 15:02
  they're
• 15:02
  going
• 15:02
  to
• 15:02
  look
• 15:02
  at
• 15:02
  your
• 15:03
  brakes
• 15:03
  and
• 15:03
  they're
• 15:03
  never
• 15:04
  going
• 15:04
  to.
• 15:04
  Inflate
• 15:04
  your
• 15:04
  tire.
• 15:05
  So
• 15:05
  why
• 15:05
  do
• 15:05
  I
• 15:05
  have
• 15:06
  a
• 15:06
  flat
• 15:06
  tire?
• 15:06
  Well,
• 15:06
  I
• 15:07
  don't
• 15:07
  know.
• 15:07
  Maybe
• 15:07
  because
• 15:08
  all
• 15:08
  of
• 15:08
  the
• 15:08
  times
• 15:09
  you
• 15:09
  went
• 15:09
  to
• 15:09
  Jiffy
• 15:09
  Lube,
• 15:10
  they
• 15:10
  worked
• 15:10
  on
• 15:10
  your
• 15:10
  brakes.
• 15:12
  And
• 15:12
  I
• 15:12
  really
• 15:12
  hope
• 15:12
  you
• 15:13
  pass
• 15:13
  these
• 15:13
  on
• 15:14
  to
• 15:14
  your
• 15:14
  friends
• 15:14
  and
• 15:15
  family.
• 15:15
  You
• 15:16
  know,
• 15:16
  it's
• 15:16
  fun
• 15:16
  to
• 15:16
  pick
• 15:16
  this
• 15:17
  stuff
• 15:17
  apart
• 15:17
  and
• 15:18
  to
• 15:18
  talk
• 15:18
  about
• 15:18
  it
• 15:19
  because
• 15:19
  patients
• 15:20
  are
• 15:20
  so
• 15:20
  varied,
• 15:21
  they're
• 15:21
  so
• 15:21
  interesting.
• 15:21
  There's
• 15:22
  so
• 15:22
  many
• 15:22
  intricacies,
• 15:23
  and
• 15:23
  every
• 15:24
  patient
• 15:24
  presents
• 15:24
  a
• 15:25
  unique
• 15:25
  challenge
• 15:25
  and
• 15:25
  a
• 15:26
  unique
• 15:26
  opportunity
• 15:26
  for
• 15:27
  you
• 15:27
  to
• 15:27
  learn
• 15:27
  and
• 15:27
  prep.
• 15:28
  And
• 15:28
  that's
• 15:29
  why,
• 15:29
  my
• 15:29
  friends,
• 15:30
  I
• 15:30
  highly
• 15:31
  recommend
• 15:32
  Last
• 15:32
  plugin
• 15:33
  to
• 15:33
  become
• 15:34
  Patreon
• 15:34
  members.
• 15:35
  Go
• 15:35
  to
• 15:35
  the
• 15:35
  Show
• 15:35
  Notes.
• 15:37
  You
• 15:37
  could
• 15:38
  become
• 15:38
  a
• 15:38
  free
• 15:38
  member,
• 15:38
  but
• 15:39
  for
• 15:39
  three
• 15:39
  bucks
• 15:39
  a
• 15:39
  month,
• 15:39
  you
• 15:40
  get
• 15:40
  a
• 15:40
  hell
• 15:40
  of
• 15:40
  a
• 15:40
  lot
• 15:40
  more
• 15:41
  pearls
• 15:41
  and
• 15:41
  knowledge
• 15:42
  to
• 15:42
  prep
• 15:42
  you
• 15:42
  to
• 15:42
  practice.
• 15:43
  Highly
• 15:44
  recommend
• 15:44
  it.
• 15:44
  Spread
• 15:45
  this
• 15:45
  podcast
• 15:45
  like
• 15:46
  wildfire.
• 15:46
  We're
• 15:47
  in
• 15:47
  a
• 15:47
  bunch
• 15:47
  of
• 15:47
  different
• 15:47
  countries
• 15:48
  now.
• 15:48
  We're
• 15:49
  a
• 15:49
  big
• 15:49
  hit
• 15:49
  in
• 15:49
  Greece,
• 15:50
  interestingly.
• 15:51
  Shout
• 15:51
  out
• 15:51
  to
• 15:51
  our
• 15:52
  Greek
• 15:52
  listeners
• 15:53
  out
• 15:53
  there
• 15:53
  and,
• 15:54
  yeah,
• 15:54
  we
• 15:54
  hope
• 15:55
  this
• 15:55
  is
• 15:55
  super
• 15:55
  valuable
• 15:56
  to
• 15:56
  you
• 15:56
  and
• 15:56
  you
• 15:57
  all
• 15:57
  have
• 15:57
  a
• 15:57
  great
• 15:58
  weekend.
• 15:58
  I
• 15:59
  mean,
• 15:59
  I
• 15:59
  don't
• 15:59
  even
• 15:59
  know
• 16:00
  what
• 16:00
  else
• 16:00
  I
• 16:00
  can
• 16:00
  say
• 16:01
  other
• 16:01
  than
• 16:01
  have
• 16:01
  a
• 16:01
  great
• 16:02
  weekend,
• 16:03
  do
• 16:03
  some
• 16:03
  great
• 16:03
  things,
• 16:04
  and
• 16:04
  don't
• 16:05
  just
• 16:05
  study
• 16:05
  all
• 16:05
  weekend.
• 16:06
  Don't
• 16:06
  just,
• 16:06
  like,
• 16:07
  bury
• 16:08
  your
• 16:08
  head
• 16:08
  in
• 16:08
  a
• 16:08
  textbook
• 16:09
  and
• 16:09
  learn
• 16:09
  about
• 16:10
  receptor
• 16:10
  affinities
• 16:10
  all
• 16:11
  weekend.
• 16:12
  Go
• 16:12
  do
• 16:12
  something.
• 16:13
  Okay.
• 16:13
  Go
• 16:14
  do
• 16:14
  something.
• 16:14
  All
• 16:15
  right,
• 16:15
  thank
• 16:15
  you
• 16:15
  all
• 16:16
  very
• 16:16
  much.
• 16:16
  Take
• 16:16
  care.
• 16:16
  Bye.