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In the Ring: Lexapro vs. Prozac - A Comprehensive Analysis · Pearls and Prep

• 0:00
  Foreign,
• 0:04
  my
• 0:04
  friends.
• 0:05
  Welcome
• 0:05
  back
• 0:05
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:09
  This
• 0:09
  segment
• 0:10
  is
• 0:10
  called
• 0:10
  in
• 0:11
  the
• 0:11
  Ring,
• 0:12
  where
• 0:12
  we
• 0:13
  analyze
• 0:13
  two
• 0:14
  medications
• 0:15
  and
• 0:16
  figure
• 0:17
  out
• 0:17
  which
• 0:17
  one
• 0:18
  would
• 0:18
  be
• 0:18
  better.
• 0:19
  Based
• 0:19
  on
• 0:19
  the
• 0:20
  unique
• 0:20
  case
• 0:21
  study
• 0:21
  in
• 0:21
  front
• 0:21
  of
• 0:21
  us.
• 0:22
  This
• 0:23
  will
• 0:23
  be
• 0:23
  a
• 0:23
  doozy.
• 0:23
  I
• 0:24
  think
• 0:24
  you
• 0:24
  guys
• 0:24
  are
• 0:24
  going
• 0:24
  to
• 0:25
  really
• 0:25
  love
• 0:26
  this
• 0:26
  one.
• 0:27
  So
• 0:27
  today
• 0:27
  we're
• 0:27
  going
• 0:27
  to
• 0:27
  analyze
• 0:28
  Lexapro
• 0:29
  versus
• 0:30
  Prozac
• 0:31
  and
• 0:31
  we're
• 0:31
  going
• 0:32
  to
• 0:32
  think
• 0:32
  about
• 0:32
  which
• 0:32
  one
• 0:33
  of
• 0:33
  these
• 0:33
  might
• 0:33
  be
• 0:33
  better
• 0:34
  for
• 0:34
  a
• 0:34
  mock
• 0:35
  patient
• 0:36
  named
• 0:36
  Benny.
• 0:36
  Now,
• 0:37
  Benny
• 0:38
  is
• 0:38
  a
• 0:38
  32
• 0:39
  year
• 0:39
  old
• 0:40
  volunteer
• 0:41
  at
• 0:41
  his
• 0:41
  local
• 0:42
  zoo.
• 0:43
  Okay.
• 0:43
  It's
• 0:44
  very
• 0:44
  important
• 0:44
  job.
• 0:45
  Actually
• 0:46
  a
• 0:46
  lot
• 0:46
  of
• 0:46
  people's
• 0:46
  dream
• 0:47
  job.
• 0:48
  He
• 0:48
  got
• 0:49
  laid
• 0:49
  off
• 0:50
  from
• 0:50
  his
• 0:50
  consulting
• 0:51
  firm
• 0:51
  and
• 0:51
  he's
• 0:51
  in
• 0:51
  between
• 0:52
  jobs.
• 0:53
  Why
• 0:53
  not
• 0:53
  volunteer
• 0:53
  at
• 0:54
  the
• 0:54
  zoo?
• 0:54
  Okay.
• 0:55
  He
• 0:55
  works
• 0:55
  in
• 0:56
  the
• 0:56
  Panda.
• 0:56
  Okay,
• 0:57
  let
• 0:58
  me.
• 0:58
  I
• 0:58
  don't
• 0:58
  want
• 0:59
  to
• 0:59
  digress
• 0:59
  so
• 0:59
  much
• 1:00
  here
• 1:01
  he
• 1:01
  is
• 1:02
  coming
• 1:02
  to
• 1:02
  you
• 1:02
  in
• 1:02
  the
• 1:02
  outpatient
• 1:03
  space
• 1:03
  today
• 1:03
  because
• 1:04
  he
• 1:04
  is
• 1:05
  low
• 1:05
  energy,
• 1:06
  he's
• 1:06
  not
• 1:06
  motivated.
• 1:07
  He's
• 1:08
  emotionally
• 1:08
  muted.
• 1:09
  For
• 1:09
  months
• 1:09
  now,
• 1:10
  he
• 1:10
  sleeps
• 1:10
  about
• 1:10
  10
• 1:11
  hours
• 1:11
  a
• 1:11
  night.
• 1:11
  He
• 1:12
  wakes
• 1:12
  up
• 1:12
  tired.
• 1:13
  He's
• 1:13
  been
• 1:13
  snacking
• 1:14
  constantly
• 1:15
  on
• 1:15
  zebra
• 1:15
  cakes,
• 1:16
  Funyuns
• 1:17
  and
• 1:17
  Haagen
• 1:17
  Dazs
• 1:18
  ice
• 1:18
  cream.
• 1:19
  I'm
• 1:19
  more
• 1:19
  of
• 1:19
  a
• 1:19
  Ben
• 1:20
  and
• 1:20
  Jerry's
• 1:20
  fan,
• 1:20
  but
• 1:21
  that's
• 1:21
  not
• 1:21
  relevant
• 1:22
  at
• 1:22
  all.
• 1:23
  Chunky
• 1:23
  Monkey's
• 1:24
  good.
• 1:24
  I
• 1:24
  don't
• 1:24
  mean
• 1:25
  to
• 1:25
  include
• 1:26
  a
• 1:26
  lot
• 1:26
  of
• 1:27
  foods,
• 1:27
  by
• 1:28
  the
• 1:28
  way,
• 1:28
  that
• 1:28
  have
• 1:29
  animals
• 1:29
  in
• 1:29
  them.
• 1:29
  I
• 1:30
  think
• 1:30
  just
• 1:30
  because
• 1:30
  I
• 1:30
  mentioned
• 1:31
  he's
• 1:31
  a
• 1:31
  zoo
• 1:31
  volunteer,
• 1:32
  I
• 1:32
  thought
• 1:33
  of
• 1:33
  zebra
• 1:33
  cakes
• 1:34
  and
• 1:34
  Chunky
• 1:34
  Monkey
• 1:35
  and
• 1:35
  I
• 1:36
  don't
• 1:36
  even
• 1:36
  like
• 1:36
  zebra
• 1:37
  cakes.
• 1:37
  So
• 1:37
  that
• 1:37
  was
• 1:38
  probably
• 1:38
  because
• 1:39
  I
• 1:39
  talked
• 1:40
  about
• 1:41
  the
• 1:41
  zoo
• 1:42
  thing.
• 1:42
  But
• 1:43
  I
• 1:43
  do
• 1:43
  like
• 1:43
  Chunky
• 1:44
  Monkey
• 1:44
  ice
• 1:44
  cream.
• 1:45
  So
• 1:45
  that
• 1:45
  had
• 1:45
  nothing
• 1:46
  to
• 1:46
  do
• 1:46
  with
• 1:46
  the
• 1:46
  fact
• 1:47
  that
• 1:47
  I
• 1:47
  mentioned
• 1:48
  he
• 1:48
  volunteers
• 1:48
  at
• 1:49
  a
• 1:49
  zoo.
• 1:49
  Just
• 1:50
  so
• 1:50
  you
• 1:50
  all
• 1:50
  know,
• 1:50
  that
• 1:51
  would
• 1:51
  be
• 1:51
  my
• 1:51
  pick
• 1:51
  today
• 1:52
  if
• 1:52
  I
• 1:52
  walked
• 1:52
  into
• 1:53
  a
• 1:53
  Safeway.
• 1:54
  Now,
• 1:55
  he's
• 1:55
  not
• 1:55
  anxious,
• 1:56
  he's
• 1:56
  not
• 1:56
  jumpy.
• 1:57
  He's
• 1:57
  just
• 1:57
  kind
• 1:58
  of
• 1:58
  feels
• 1:58
  heavy.
• 1:59
  He's
• 1:59
  gaining
• 1:59
  weight,
• 2:00
  he's
• 2:00
  foggy.
• 2:01
  He
• 2:01
  says
• 2:02
  his
• 2:02
  creativity
• 2:02
  is
• 2:03
  kind
• 2:03
  of
• 2:03
  gone.
• 2:03
  He
• 2:04
  forgets
• 2:04
  to
• 2:04
  take
• 2:05
  his
• 2:05
  supplements.
• 2:05
  I
• 2:06
  want
• 2:06
  you
• 2:06
  to
• 2:06
  think
• 2:06
  about
• 2:06
  that
• 2:07
  for
• 2:07
  a
• 2:07
  little
• 2:07
  bit
• 2:08
  as
• 2:08
  we
• 2:08
  continue
• 2:08
  through
• 2:09
  this
• 2:09
  case.
• 2:09
  But
• 2:09
  he
• 2:09
  forgets
• 2:10
  to
• 2:10
  take
• 2:10
  his
• 2:11
  functional
• 2:11
  mushroom
• 2:12
  supplements
• 2:12
  at
• 2:12
  times.
• 2:12
  He
• 2:13
  wants
• 2:13
  to
• 2:13
  take
• 2:13
  them
• 2:13
  every
• 2:14
  day,
• 2:14
  but
• 2:14
  he
• 2:14
  doesn't
• 2:14
  always
• 2:14
  do
• 2:15
  that.
• 2:15
  He
• 2:16
  drinks
• 2:17
  a
• 2:17
  little
• 2:17
  too
• 2:17
  much
• 2:17
  coffee.
• 2:18
  Says
• 2:18
  he
• 2:18
  doesn't
• 2:19
  really
• 2:19
  feel
• 2:19
  like
• 2:19
  himself
• 2:20
  anymore.
• 2:20
  He
• 2:20
  doesn't
• 2:20
  have
• 2:21
  any
• 2:21
  mania
• 2:21
  or
• 2:21
  psychosis,
• 2:22
  just
• 2:23
  slow,
• 2:24
  heavy,
• 2:25
  low
• 2:25
  drive
• 2:26
  depression
• 2:27
  that
• 2:27
  feels
• 2:28
  really
• 2:28
  heavy,
• 2:28
  like
• 2:29
  he's
• 2:29
  kind
• 2:29
  of
• 2:29
  walking
• 2:30
  through
• 2:30
  mud.
• 2:31
  And
• 2:31
  so
• 2:32
  for
• 2:32
  simplicity's
• 2:33
  sake,
• 2:34
  let's
• 2:34
  not
• 2:34
  assume
• 2:34
  anything
• 2:35
  else
• 2:35
  is
• 2:35
  going
• 2:35
  on
• 2:35
  here.
• 2:36
  We've
• 2:36
  ruled
• 2:36
  out
• 2:37
  again,
• 2:37
  we've
• 2:37
  ruled
• 2:37
  out
• 2:37
  bipolar
• 2:38
  psychosis,
• 2:39
  we've
• 2:39
  ruled
• 2:39
  out
• 2:39
  medical
• 2:40
  problems.
• 2:40
  We're
• 2:41
  looking
• 2:41
  at
• 2:41
  depression.
• 2:42
  And
• 2:43
  so
• 2:43
  we're
• 2:44
  trying
• 2:44
  to
• 2:44
  figure
• 2:44
  out
• 2:44
  is
• 2:45
  Lexapro
• 2:45
  or
• 2:45
  Prozac
• 2:46
  better
• 2:46
  for
• 2:46
  Benny
• 2:47
  in
• 2:47
  this
• 2:47
  situation.
• 2:49
  Now,
• 2:49
  what
• 2:50
  separates
• 2:51
  the
• 2:52
  psychopharmacologists
• 2:54
  from
• 2:54
  the
• 2:55
  layman
• 2:55
  on
• 2:55
  the
• 2:56
  street
• 2:56
  are
• 2:57
  that
• 2:57
  we
• 2:57
  are
• 2:57
  supposed
• 2:58
  to
• 2:58
  have
• 2:58
  a
• 2:58
  finer
• 2:59
  appreciation
• 3:01
  for
• 3:01
  the
• 3:01
  differences
• 3:01
  between
• 3:02
  something
• 3:02
  like
• 3:02
  a
• 3:03
  Lexa
• 3:03
  Pro
• 3:03
  and
• 3:03
  a
• 3:03
  Prozac.
• 3:04
  Because
• 3:04
  in
• 3:04
  the
• 3:05
  textbook,
• 3:05
  they
• 3:05
  might
• 3:05
  look
• 3:06
  very
• 3:06
  much
• 3:06
  the
• 3:07
  same.
• 3:07
  They're
• 3:07
  both
• 3:08
  selective
• 3:09
  serotonin
• 3:09
  reuptake
• 3:10
  inhibitors,
• 3:11
  right?
• 3:12
  Binding
• 3:12
  to
• 3:13
  the
• 3:13
  transporter
• 3:14
  and
• 3:14
  preventing
• 3:14
  it
• 3:15
  from
• 3:16
  recycling
• 3:17
  the
• 3:17
  serotonin
• 3:18
  back
• 3:18
  into
• 3:18
  the
• 3:18
  neuron
• 3:19
  so
• 3:19
  that
• 3:19
  serotonin
• 3:20
  stays
• 3:20
  in
• 3:20
  the
• 3:20
  synapse
• 3:21
  longer,
• 3:22
  enhancing
• 3:22
  mood,
• 3:23
  promoting
• 3:23
  feelings
• 3:24
  of
• 3:24
  calm
• 3:24
  and
• 3:25
  emotional
• 3:25
  balance.
• 3:26
  We
• 3:26
  have
• 3:26
  to
• 3:27
  remember
• 3:28
  that
• 3:28
  no
• 3:29
  two
• 3:29
  SSRIs
• 3:30
  are
• 3:31
  same.
• 3:32
  There's
• 3:32
  a
• 3:32
  big
• 3:32
  difference
• 3:33
  in
• 3:33
  how
• 3:34
  tightly
• 3:34
  they
• 3:34
  bind
• 3:35
  to
• 3:35
  that
• 3:35
  transporter,
• 3:36
  how
• 3:37
  long
• 3:37
  they
• 3:37
  stay
• 3:38
  in
• 3:38
  your
• 3:38
  system,
• 3:38
  how
• 3:38
  long
• 3:39
  it
• 3:39
  takes
• 3:39
  for
• 3:39
  them
• 3:39
  to
• 3:40
  get
• 3:40
  out
• 3:40
  of
• 3:40
  your
• 3:40
  system.
• 3:41
  Do
• 3:41
  they
• 3:42
  hit
• 3:42
  other
• 3:43
  receptors?
• 3:44
  How
• 3:44
  aggressively
• 3:45
  do
• 3:45
  they
• 3:45
  hit
• 3:45
  those
• 3:46
  other
• 3:46
  receptors,
• 3:46
  and
• 3:46
  what
• 3:47
  do
• 3:47
  those
• 3:47
  other
• 3:47
  receptors
• 3:48
  do?
• 3:48
  Because
• 3:48
  it's
• 3:48
  not
• 3:48
  as
• 3:49
  simple
• 3:49
  as
• 3:49
  you
• 3:50
  bind
• 3:50
  to
• 3:50
  cert
• 3:51
  and
• 3:51
  you
• 3:52
  prevent
• 3:52
  the
• 3:52
  recycling
• 3:53
  of
• 3:53
  serotonin.
• 3:54
  If
• 3:54
  it
• 3:54
  was
• 3:54
  that
• 3:55
  simple,
• 3:55
  these
• 3:55
  would
• 3:55
  all
• 3:56
  be
• 3:56
  the
• 3:56
  same,
• 3:56
  and
• 3:56
  you
• 3:56
  could
• 3:57
  just
• 3:57
  any
• 3:57
  give
• 3:58
  any
• 3:58
  kind
• 3:58
  of
• 3:59
  of
• 4:00
  SSRI
• 4:00
  to
• 4:01
  any
• 4:01
  kind
• 4:01
  of
• 4:01
  patient.
• 4:02
  But
• 4:02
  there
• 4:02
  are
• 4:02
  major
• 4:02
  distinctions
• 4:03
  here,
• 4:03
  and
• 4:04
  Benny
• 4:05
  deserves
• 4:06
  a
• 4:07
  psychopharmacologist
• 4:08
  who
• 4:09
  appreciates
• 4:09
  the
• 4:10
  fine
• 4:10
  distinctions
• 4:11
  between
• 4:11
  the
• 4:12
  Lexapros
• 4:12
  and
• 4:12
  the
• 4:13
  Prozacs
• 4:13
  of
• 4:13
  the
• 4:13
  world.
• 4:14
  Now,
• 4:14
  in
• 4:15
  all
• 4:15
  honesty,
• 4:16
  could
• 4:16
  you
• 4:17
  possibly
• 4:18
  give
• 4:18
  him
• 4:18
  one
• 4:18
  or
• 4:19
  the
• 4:19
  other?
• 4:19
  And
• 4:19
  you'd
• 4:19
  probably
• 4:20
  be
• 4:20
  okay,
• 4:21
  barring
• 4:21
  any
• 4:22
  major
• 4:23
  unknowns,
• 4:23
  right?
• 4:24
  Barring
• 4:24
  any
• 4:24
  other
• 4:25
  conditions?
• 4:26
  Yeah,
• 4:26
  sure.
• 4:26
  If
• 4:27
  all
• 4:27
  other
• 4:27
  things
• 4:27
  were
• 4:27
  equal
• 4:28
  and
• 4:28
  they
• 4:29
  were
• 4:29
  both
• 4:29
  safe
• 4:29
  and
• 4:29
  suitable
• 4:30
  for
• 4:30
  him,
• 4:31
  sure,
• 4:32
  you
• 4:32
  can't
• 4:32
  really
• 4:32
  go
• 4:33
  wrong
• 4:33
  with
• 4:34
  either
• 4:34
  of
• 4:34
  these.
• 4:35
  But
• 4:35
  there
• 4:36
  are
• 4:36
  things
• 4:36
  to
• 4:36
  consider,
• 4:37
  and
• 4:37
  that's
• 4:37
  what
• 4:37
  we're
• 4:38
  going
• 4:38
  to
• 4:38
  really
• 4:39
  wade
• 4:39
  into
• 4:40
  today.
• 4:41
  Remember,
• 4:41
  my
• 4:42
  friends,
• 4:42
  these
• 4:43
  podcast
• 4:43
  episodes
• 4:44
  are
• 4:45
  conversations.
• 4:46
  This
• 4:46
  is
• 4:46
  not
• 4:46
  a
• 4:46
  lecture
• 4:47
  hall.
• 4:47
  I'm
• 4:48
  not
• 4:48
  going
• 4:48
  to
• 4:48
  quiz
• 4:48
  you
• 4:49
  or
• 4:49
  call
• 4:49
  on
• 4:49
  you,
• 4:50
  so
• 4:50
  don't
• 4:50
  be
• 4:51
  nervous.
• 4:51
  This
• 4:51
  is
• 4:51
  a
• 4:51
  conversation.
• 4:52
  Pretend
• 4:52
  you
• 4:52
  and
• 4:52
  I
• 4:53
  are
• 4:53
  at
• 4:53
  a
• 4:53
  coffee
• 4:53
  shop
• 4:54
  and
• 4:54
  we're
• 4:54
  just
• 4:55
  having
• 4:55
  a
• 4:55
  friendly
• 4:56
  debate
• 4:56
  about
• 4:56
  which
• 4:57
  medication
• 4:58
  might
• 4:58
  be
• 4:58
  better
• 4:59
  for
• 4:59
  Benny,
• 5:00
  Lexapro
• 5:00
  or
• 5:01
  Prozac.
• 5:01
  You
• 5:02
  will
• 5:03
  have
• 5:03
  a
• 5:03
  fine
• 5:03
  appreciation
• 5:04
  by
• 5:04
  the
• 5:04
  end
• 5:05
  of
• 5:05
  this
• 5:05
  episode
• 5:06
  as
• 5:06
  to
• 5:06
  why
• 5:06
  one
• 5:07
  might
• 5:07
  be
• 5:07
  better
• 5:08
  than
• 5:08
  the
• 5:08
  other,
• 5:09
  why
• 5:09
  that
• 5:10
  might
• 5:10
  be.
• 5:11
  And
• 5:11
  so
• 5:11
  don't
• 5:12
  expect
• 5:12
  something
• 5:13
  that's,
• 5:13
  like,
• 5:13
  super
• 5:13
  organized.
• 5:14
  It
• 5:15
  would
• 5:15
  be
• 5:15
  boring
• 5:15
  if
• 5:15
  I
• 5:16
  just
• 5:16
  read
• 5:16
  this
• 5:16
  off
• 5:17
  like
• 5:17
  a
• 5:17
  lecture.
• 5:18
  We're
• 5:18
  going
• 5:18
  to
• 5:18
  have
• 5:18
  fun
• 5:18
  with
• 5:19
  this.
• 5:19
  What's
• 5:19
  the
• 5:19
  first
• 5:20
  thing
• 5:20
  that's
• 5:20
  jumping
• 5:20
  out
• 5:20
  at
• 5:21
  me
• 5:21
  here?
• 5:21
  Benny
• 5:22
  is
• 5:23
  not
• 5:23
  motivated.
• 5:24
  Right?
• 5:24
  He
• 5:24
  needs
• 5:24
  energy.
• 5:25
  He's
• 5:25
  low
• 5:25
  energy.
• 5:26
  Benny,
• 5:26
  he's
• 5:27
  not
• 5:27
  motivated.
• 5:28
  He's
• 5:28
  snacking
• 5:29
  a
• 5:29
  lot
• 5:29
  on
• 5:30
  carbs
• 5:31
  and
• 5:32
  he's
• 5:32
  feeling
• 5:33
  kind
• 5:33
  of
• 5:33
  heavy
• 5:33
  and
• 5:33
  he's
• 5:34
  sleeping
• 5:34
  a
• 5:34
  lot.
• 5:35
  So
• 5:35
  I
• 5:35
  immediately,
• 5:36
  right
• 5:36
  off
• 5:36
  the
• 5:37
  bat,
• 5:37
  I
• 5:37
  want
• 5:37
  to
• 5:37
  find
• 5:38
  an
• 5:38
  antidepressant
• 5:40
  that
• 5:40
  is
• 5:40
  a
• 5:40
  little
• 5:41
  more
• 5:41
  activating.
• 5:42
  And
• 5:43
  you
• 5:43
  might
• 5:43
  be
• 5:43
  scratching
• 5:43
  your
• 5:44
  head
• 5:44
  and
• 5:44
  saying,
• 5:44
  well,
• 5:44
  wait
• 5:45
  a
• 5:45
  minute,
• 5:46
  he's
• 5:46
  depressed.
• 5:47
  Can't
• 5:47
  we
• 5:47
  give
• 5:47
  him
• 5:47
  any
• 5:48
  antidepressant?
• 5:48
  Technically,
• 5:49
  right?
• 5:51
  Increasing
• 5:51
  the
• 5:51
  amount
• 5:51
  of
• 5:52
  serotonin
• 5:52
  that
• 5:52
  stays
• 5:53
  in
• 5:53
  the
• 5:53
  synapse
• 5:54
  is
• 5:54
  broadly
• 5:54
  going
• 5:55
  to
• 5:55
  improve
• 5:56
  his
• 5:56
  mood.
• 5:57
  But
• 5:58
  if
• 5:58
  we
• 5:58
  fine
• 5:58
  tune
• 5:59
  it
• 5:59
  and
• 5:59
  look
• 6:00
  more
• 6:00
  closely,
• 6:00
  we
• 6:00
  will
• 6:01
  see
• 6:01
  that
• 6:02
  Prozac
• 6:02
  actually
• 6:04
  does
• 6:04
  something
• 6:05
  more
• 6:05
  sophisticated
• 6:06
  and
• 6:07
  antagonizes
• 6:08
  the
• 6:08
  5ht2c
• 6:10
  receptor.
• 6:12
  Now,
• 6:12
  that
• 6:13
  receptor
• 6:13
  normally
• 6:15
  inhibits
• 6:15
  the
• 6:16
  dopamine
• 6:16
  and
• 6:16
  norepinephrine
• 6:17
  release
• 6:17
  in
• 6:18
  the
• 6:18
  prefrontal
• 6:18
  cortex.
• 6:19
  So
• 6:20
  that's
• 6:20
  when
• 6:20
  it's
• 6:21
  activated.
• 6:21
  Right.
• 6:22
  So
• 6:22
  when
• 6:23
  it's
• 6:23
  activated,
• 6:24
  you're
• 6:24
  inhibiting
• 6:24
  dopamine,
• 6:25
  and
• 6:25
  it
• 6:26
  can
• 6:26
  blunt
• 6:26
  your
• 6:27
  emotions,
• 6:27
  motivation
• 6:28
  and
• 6:28
  drive
• 6:28
  if
• 6:29
  you're
• 6:29
  activating
• 6:30
  that
• 6:30
  receptor.
• 6:31
  Well,
• 6:31
  no,
• 6:31
  no,
• 6:31
  no.
• 6:31
  Prozac
• 6:32
  actually
• 6:33
  blocks
• 6:33
  that.
• 6:34
  So
• 6:34
  it
• 6:34
  disinhibits
• 6:35
  dopamine
• 6:36
  and
• 6:36
  norepinephrine.
• 6:37
  In
• 6:37
  other
• 6:37
  words,
• 6:37
  it
• 6:37
  increases,
• 6:39
  lets
• 6:40
  it
• 6:40
  loose,
• 6:40
  it
• 6:40
  releases
• 6:41
  the
• 6:41
  brake.
• 6:42
  The
• 6:42
  break
• 6:42
  is
• 6:42
  normally
• 6:43
  on.
• 6:43
  Prozac
• 6:44
  antagonizes
• 6:45
  that
• 6:45
  break.
• 6:45
  He
• 6:45
  says,
• 6:46
  get
• 6:46
  out
• 6:46
  of
• 6:46
  the
• 6:46
  way.
• 6:46
  Break.
• 6:47
  I'm
• 6:47
  antagonizing
• 6:48
  you.
• 6:49
  As
• 6:49
  a
• 6:49
  result,
• 6:50
  you
• 6:50
  have
• 6:50
  more
• 6:50
  dopamine
• 6:51
  and
• 6:51
  norepinephrine,
• 6:52
  and
• 6:52
  you
• 6:52
  get
• 6:52
  a
• 6:52
  subtle
• 6:53
  boost
• 6:53
  in
• 6:53
  mood,
• 6:54
  energy,
• 6:55
  motivation,
• 6:56
  and
• 6:56
  even
• 6:56
  a
• 6:57
  little
• 6:57
  bit
• 6:57
  of
• 6:57
  appetite
• 6:58
  suppression,
• 6:58
  which
• 6:59
  is
• 6:59
  kind
• 6:59
  of
• 6:59
  key,
• 7:00
  right?
• 7:00
  Because
• 7:00
  Benny
• 7:01
  is
• 7:01
  snacking
• 7:02
  on
• 7:02
  zebra
• 7:03
  cakes.
• 7:03
  He's
• 7:03
  eating
• 7:04
  them
• 7:04
  by
• 7:04
  the
• 7:04
  sleeve,
• 7:05
  he's
• 7:05
  gaining
• 7:05
  weight.
• 7:06
  He's
• 7:06
  also,
• 7:07
  he
• 7:07
  drinking
• 7:08
  coffee.
• 7:08
  He
• 7:08
  clearly
• 7:09
  is
• 7:09
  grasping
• 7:10
  for
• 7:10
  some
• 7:11
  kind
• 7:11
  of
• 7:11
  assistance
• 7:12
  in
• 7:12
  the
• 7:12
  morning,
• 7:13
  some
• 7:13
  kind
• 7:13
  of
• 7:13
  energy
• 7:14
  boost.
• 7:14
  Now,
• 7:15
  here's
• 7:15
  a
• 7:15
  little
• 7:15
  pearl
• 7:16
  that
• 7:16
  I
• 7:16
  learn
• 7:16
  on
• 7:16
  the
• 7:16
  street,
• 7:17
  right,
• 7:18
  in
• 7:18
  prescribing,
• 7:19
  it's,
• 7:20
  you
• 7:20
  always
• 7:20
  want
• 7:21
  to
• 7:21
  pay
• 7:21
  attention
• 7:22
  to
• 7:22
  the
• 7:22
  kinds
• 7:22
  of
• 7:22
  substances
• 7:23
  that
• 7:23
  your
• 7:23
  patients
• 7:24
  gravitate
• 7:24
  towards.
• 7:26
  It's
• 7:26
  not
• 7:26
  a
• 7:26
  perfect
• 7:26
  science,
• 7:27
  but
• 7:28
  you
• 7:28
  got
• 7:28
  to
• 7:28
  ask
• 7:29
  yourself,
• 7:29
  why
• 7:29
  is
• 7:29
  caffeine
• 7:30
  so
• 7:30
  appealing
• 7:31
  to
• 7:31
  Benny?
• 7:31
  You
• 7:32
  can
• 7:32
  ask
• 7:32
  him
• 7:32
  directly,
• 7:33
  but
• 7:33
  you
• 7:33
  can
• 7:34
  also
• 7:34
  infer
• 7:35
  sometimes,
• 7:35
  if
• 7:35
  you
• 7:35
  don't
• 7:36
  have
• 7:36
  a
• 7:36
  lot
• 7:36
  of
• 7:36
  time
• 7:37
  to
• 7:37
  say,
• 7:37
  okay,
• 7:37
  well,
• 7:38
  most
• 7:38
  people,
• 7:38
  you
• 7:38
  know,
• 7:39
  caffeine
• 7:39
  is
• 7:39
  a
• 7:39
  stimulant.
• 7:41
  They
• 7:41
  expect
• 7:41
  some
• 7:41
  degree
• 7:42
  of
• 7:42
  arousal
• 7:42
  and
• 7:43
  stimulation
• 7:43
  and
• 7:43
  maybe
• 7:44
  cognitive
• 7:45
  enhancement.
• 7:45
  Of
• 7:46
  course,
• 7:46
  ask
• 7:46
  him.
• 7:47
  But
• 7:47
  that
• 7:47
  might
• 7:47
  Be
• 7:47
  a
• 7:47
  sign
• 7:48
  that
• 7:48
  he's
• 7:48
  already
• 7:49
  craving
• 7:50
  some
• 7:50
  kind
• 7:50
  of
• 7:50
  physiological
• 7:51
  mechanism
• 7:52
  by
• 7:52
  which
• 7:52
  he
• 7:52
  could
• 7:52
  be
• 7:53
  a
• 7:53
  little
• 7:53
  more
• 7:53
  alert,
• 7:53
  a
• 7:53
  little
• 7:54
  more
• 7:54
  motivated.
• 7:55
  That's
• 7:56
  where
• 7:56
  the
• 7:57
  5ht2c
• 7:59
  antagonism
• 8:00
  comes
• 8:00
  in.
• 8:00
  And
• 8:00
  Prozac
• 8:01
  is
• 8:01
  unique
• 8:02
  in
• 8:02
  that
• 8:02
  regard
• 8:03
  because
• 8:03
  guess
• 8:04
  what?
• 8:04
  Medication
• 8:04
  does
• 8:05
  not
• 8:05
  do
• 8:05
  that.
• 8:06
  Lexapro.
• 8:07
  Lexapro
• 8:08
  does
• 8:08
  not
• 8:08
  antagonize
• 8:09
  5ht
• 8:09
  2c.
• 8:10
  Now,
• 8:10
  on
• 8:10
  the
• 8:11
  contrary,
• 8:11
  Lexapro
• 8:12
  is
• 8:12
  known
• 8:13
  and
• 8:13
  in
• 8:14
  fact
• 8:14
  praised
• 8:15
  by
• 8:15
  the
• 8:15
  fact
• 8:16
  that
• 8:16
  it's
• 8:16
  very
• 8:16
  clean.
• 8:17
  And
• 8:17
  what
• 8:17
  do
• 8:18
  people
• 8:18
  mean
• 8:18
  when
• 8:18
  they
• 8:18
  say
• 8:18
  it's
• 8:19
  clean?
• 8:19
  It's
• 8:19
  kind
• 8:20
  of
• 8:20
  drama
• 8:20
  free.
• 8:21
  Lexapro
• 8:22
  is
• 8:22
  very
• 8:22
  specific.
• 8:23
  It
• 8:23
  goes
• 8:23
  in
• 8:23
  there
• 8:24
  and.
• 8:24
  And
• 8:25
  binds
• 8:25
  to
• 8:26
  the
• 8:26
  SIRT
• 8:26
  protein.
• 8:27
  And
• 8:27
  again,
• 8:27
  it
• 8:28
  blocks
• 8:28
  the
• 8:29
  SIRT
• 8:29
  transporter
• 8:30
  from
• 8:30
  recycling
• 8:31
  serotonin
• 8:32
  back
• 8:32
  into
• 8:32
  the
• 8:33
  neuron.
• 8:33
  And
• 8:33
  it
• 8:33
  does
• 8:33
  it
• 8:34
  exclusively
• 8:35
  and
• 8:35
  it
• 8:36
  does
• 8:36
  it
• 8:36
  powerfully.
• 8:37
  And
• 8:37
  that's
• 8:37
  very
• 8:37
  important
• 8:38
  because
• 8:39
  you
• 8:39
  don't
• 8:39
  get
• 8:39
  the
• 8:39
  drama
• 8:40
  with
• 8:40
  Lexapro,
• 8:41
  right?
• 8:41
  Because
• 8:42
  some
• 8:42
  other
• 8:42
  medications
• 8:43
  like
• 8:44
  Paxil
• 8:45
  out
• 8:46
  there,
• 8:46
  it'll
• 8:47
  do
• 8:47
  more,
• 8:47
  it'll
• 8:48
  do
• 8:48
  too
• 8:48
  much
• 8:48
  Paxil
• 8:49
  will
• 8:49
  go
• 8:49
  in
• 8:49
  there
• 8:49
  and
• 8:50
  it'll
• 8:50
  broadly
• 8:51
  increase
• 8:52
  the
• 8:52
  amount
• 8:52
  of
• 8:52
  serotonin
• 8:53
  in
• 8:53
  the
• 8:53
  synapse.
• 8:53
  You're
• 8:54
  like,
• 8:54
  wow,
• 8:54
  that's
• 8:54
  great.
• 8:55
  That's
• 8:55
  what
• 8:55
  I
• 8:55
  want,
• 8:55
  right?
• 8:55
  I
• 8:56
  want
• 8:56
  more
• 8:56
  serotonin,
• 8:57
  the
• 8:57
  synapse,
• 8:57
  but
• 8:58
  it
• 8:58
  also
• 8:59
  goes
• 8:59
  in
• 9:00
  there
• 9:00
  and
• 9:00
  does
• 9:00
  other
• 9:00
  stuff.
• 9:01
  It
• 9:01
  unlocks
• 9:01
  other
• 9:02
  doors
• 9:02
  that
• 9:02
  you
• 9:02
  didn't
• 9:03
  really
• 9:03
  want
• 9:03
  to
• 9:03
  be
• 9:03
  unlocked,
• 9:04
  right?
• 9:05
  It
• 9:05
  messes
• 9:06
  with
• 9:06
  histamine,
• 9:07
  it
• 9:07
  makes
• 9:07
  you
• 9:07
  drowsy
• 9:08
  and
• 9:08
  tired,
• 9:09
  and
• 9:09
  you
• 9:09
  don't
• 9:09
  want
• 9:09
  that
• 9:10
  always.
• 9:10
  You
• 9:11
  want
• 9:11
  to
• 9:13
  have
• 9:13
  some
• 9:13
  control
• 9:14
  here
• 9:14
  because
• 9:14
  the
• 9:14
  patient
• 9:15
  doesn't
• 9:15
  want
• 9:15
  to
• 9:15
  be
• 9:15
  groggy
• 9:16
  or
• 9:16
  gain
• 9:16
  weight
• 9:17
  and.
• 9:17
  And
• 9:17
  crave
• 9:18
  foods
• 9:19
  in
• 9:19
  the
• 9:19
  middle
• 9:19
  of
• 9:19
  the
• 9:19
  night
• 9:20
  and
• 9:20
  be
• 9:20
  sluggish,
• 9:21
  right?
• 9:22
  The
• 9:22
  muscarinic
• 9:23
  receptors
• 9:23
  that
• 9:24
  Paxil
• 9:24
  interacts
• 9:25
  with,
• 9:25
  also,
• 9:26
  that
• 9:26
  can
• 9:27
  make
• 9:27
  them
• 9:27
  not
• 9:27
  want
• 9:27
  to
• 9:28
  physically
• 9:28
  move.
• 9:28
  It
• 9:28
  can
• 9:29
  give
• 9:29
  them
• 9:29
  dry
• 9:29
  mouth,
• 9:30
  constipation.
• 9:30
  You
• 9:31
  don't
• 9:31
  want
• 9:31
  that
• 9:31
  stuff,
• 9:32
  right?
• 9:32
  So
• 9:32
  when
• 9:33
  we
• 9:33
  talk
• 9:33
  about
• 9:33
  Lexapro
• 9:34
  being
• 9:34
  clean,
• 9:35
  one
• 9:35
  of
• 9:35
  its
• 9:35
  virtues
• 9:36
  is
• 9:36
  that
• 9:36
  it's
• 9:36
  clean.
• 9:37
  It
• 9:37
  doesn't
• 9:37
  give
• 9:37
  you
• 9:37
  a
• 9:37
  lot
• 9:37
  of
• 9:38
  other
• 9:38
  drama.
• 9:38
  And
• 9:39
  here's
• 9:39
  a
• 9:40
  little
• 9:40
  tip.
• 9:40
  In
• 9:40
  Lexapro's
• 9:41
  jar,
• 9:42
  it
• 9:42
  is.
• 9:43
  It.
• 9:43
  It
• 9:43
  has
• 9:44
  a
• 9:44
  very
• 9:44
  powerful,
• 9:45
  in
• 9:45
  fact,
• 9:45
  the
• 9:45
  most
• 9:45
  powerful
• 9:46
  affinity
• 9:47
  for
• 9:47
  the
• 9:47
  CERT
• 9:48
  transporter.
• 9:49
  Now,
• 9:49
  what
• 9:49
  does
• 9:49
  that
• 9:50
  mean
• 9:50
  exactly?
• 9:51
  When
• 9:51
  I
• 9:51
  think
• 9:51
  of
• 9:52
  affinity,
• 9:52
  I
• 9:53
  think
• 9:53
  of
• 9:53
  like
• 9:53
  a
• 9:53
  magnet.
• 9:54
  It
• 9:54
  sticks
• 9:55
  to
• 9:55
  that
• 9:55
  transporter
• 9:57
  more
• 9:57
  tightly
• 9:58
  than
• 9:58
  any
• 9:59
  other
• 9:59
  of
• 9:59
  the
• 9:59
  ssri.
• 10:00
  Well,
• 10:00
  that's
• 10:01
  really
• 10:01
  important,
• 10:01
  that
• 10:01
  it
• 10:02
  has
• 10:02
  a
• 10:02
  high
• 10:02
  affinity
• 10:03
  for
• 10:03
  cert.
• 10:04
  Why?
• 10:04
  Because
• 10:04
  it
• 10:05
  binds
• 10:05
  there
• 10:05
  firmly.
• 10:06
  It
• 10:06
  stays
• 10:07
  attached
• 10:07
  longer,
• 10:08
  s
• 10:09
  stays
• 10:09
  blocked,
• 10:10
  and
• 10:11
  Serotonin
• 10:11
  levels
• 10:12
  stay
• 10:12
  steady,
• 10:13
  right?
• 10:13
  Because
• 10:14
  affinity
• 10:14
  is
• 10:14
  about
• 10:15
  how
• 10:15
  tightly
• 10:15
  a
• 10:15
  drug
• 10:16
  binds
• 10:16
  to
• 10:16
  its
• 10:17
  target.
• 10:17
  Higher
• 10:17
  affinity
• 10:18
  means
• 10:18
  it
• 10:19
  sticks
• 10:19
  longer
• 10:19
  and
• 10:19
  blocks
• 10:20
  more
• 10:20
  effectively.
• 10:21
  So
• 10:22
  if
• 10:22
  you're
• 10:22
  thinking
• 10:22
  about
• 10:23
  the
• 10:23
  S
• 10:23
  transporter,
• 10:24
  like
• 10:24
  a
• 10:24
  vacuum
• 10:25
  cleaner,
• 10:25
  vacuum
• 10:26
  the
• 10:26
  serotonin
• 10:27
  up
• 10:27
  so
• 10:27
  that
• 10:27
  it's
• 10:28
  no
• 10:28
  longer
• 10:29
  in
• 10:29
  the
• 10:29
  synapse,
• 10:30
  making
• 10:30
  you
• 10:30
  feel
• 10:30
  nice
• 10:31
  and
• 10:31
  calm
• 10:31
  and
• 10:31
  happy,
• 10:32
  right?
• 10:32
  If
• 10:32
  you
• 10:33
  think
• 10:33
  of
• 10:33
  the
• 10:33
  vacuum
• 10:33
  cleaner,
• 10:34
  like
• 10:34
  the
• 10:34
  SIR
• 10:34
  transporter,
• 10:36
  then
• 10:36
  Lexapro
• 10:37
  is
• 10:37
  like
• 10:38
  this
• 10:38
  awesome
• 10:39
  plug.
• 10:39
  It's
• 10:39
  like
• 10:39
  a
• 10:40
  heavy
• 10:40
  duty
• 10:40
  wool
• 10:41
  sock
• 10:41
  that
• 10:42
  totally
• 10:42
  plugs
• 10:43
  up
• 10:43
  that
• 10:43
  vacuum
• 10:43
  cleaner
• 10:44
  so
• 10:44
  that
• 10:44
  it
• 10:45
  can't
• 10:45
  recycle
• 10:46
  the
• 10:46
  serotonin
• 10:47
  back.
• 10:48
  And
• 10:48
  that's
• 10:48
  good,
• 10:49
  right?
• 10:49
  You
• 10:49
  want
• 10:49
  something
• 10:49
  really
• 10:50
  heavy
• 10:50
  duty
• 10:50
  that
• 10:51
  just
• 10:51
  sticks
• 10:51
  into
• 10:51
  that
• 10:51
  vacuum
• 10:52
  cleaner
• 10:52
  so
• 10:52
  it
• 10:52
  cannot
• 10:53
  suck
• 10:54
  the
• 10:54
  serotonin
• 10:55
  out.
• 10:56
  Well,
• 10:56
  that,
• 10:57
  my
• 10:57
  friends,
• 10:57
  is
• 10:58
  where
• 10:58
  Lexapro
• 10:59
  shines.
• 10:59
  If
• 11:00
  you
• 11:00
  want
• 11:00
  a
• 11:00
  dependable
• 11:01
  high
• 11:01
  affinity
• 11:02
  serotonin,
• 11:03
  something
• 11:04
  that
• 11:04
  selectively
• 11:04
  blocks
• 11:05
  the
• 11:05
  serotonin
• 11:05
  transporter
• 11:06
  at
• 11:07
  a
• 11:07
  higher
• 11:07
  affinity
• 11:08
  more
• 11:08
  reliably,
• 11:09
  then
• 11:09
  boom.
• 11:10
  That
• 11:10
  is
• 11:11
  exactly
• 11:11
  what
• 11:12
  you
• 11:12
  want,
• 11:13
  right?
• 11:13
  I
• 11:14
  won't
• 11:14
  get
• 11:14
  into
• 11:14
  too
• 11:15
  much
• 11:15
  technical
• 11:15
  detail,
• 11:16
  but
• 11:16
  it
• 11:16
  also
• 11:16
  has
• 11:17
  a
• 11:17
  second
• 11:17
  allosteric
• 11:18
  site
• 11:18
  that
• 11:19
  acts
• 11:19
  as
• 11:19
  a
• 11:19
  double
• 11:20
  locking
• 11:20
  mechanism
• 11:21
  that
• 11:21
  other
• 11:21
  SSRIs
• 11:22
  don't
• 11:22
  have.
• 11:23
  So
• 11:23
  it
• 11:24
  grabs
• 11:24
  the
• 11:24
  serotonin
• 11:25
  transporter
• 11:25
  with
• 11:26
  two
• 11:26
  hands.
• 11:26
  It's
• 11:26
  like
• 11:27
  this
• 11:27
  double
• 11:27
  lock
• 11:27
  is
• 11:28
  deadbolt.
• 11:29
  Therefore
• 11:29
  it
• 11:29
  is
• 11:29
  quite
• 11:30
  dependable.
• 11:31
  It's
• 11:31
  a
• 11:31
  very
• 11:31
  dependable
• 11:32
  medication.
• 11:33
  When
• 11:33
  you
• 11:33
  have
• 11:33
  this
• 11:33
  reliable
• 11:34
  plug
• 11:34
  in
• 11:34
  the
• 11:35
  vacuum
• 11:35
  cleaner
• 11:35
  is
• 11:36
  you
• 11:36
  have
• 11:36
  more
• 11:36
  steady
• 11:37
  concentrations
• 11:38
  of
• 11:38
  serotonin
• 11:39
  out
• 11:39
  in
• 11:39
  that
• 11:39
  synapse
• 11:40
  for
• 11:41
  more
• 11:41
  prolonged
• 11:41
  periods
• 11:42
  of
• 11:42
  time.
• 11:42
  Well,
• 11:42
  that
• 11:43
  really
• 11:43
  matters
• 11:43
  because
• 11:44
  if
• 11:44
  you
• 11:44
  have
• 11:44
  something
• 11:45
  that's
• 11:45
  a
• 11:45
  little
• 11:45
  bit
• 11:45
  weaker
• 11:46
  affinity,
• 11:46
  like
• 11:47
  Prozac,
• 11:47
  that
• 11:47
  doesn't
• 11:48
  bind
• 11:48
  as
• 11:48
  tightly.
• 11:49
  It's
• 11:49
  like
• 11:49
  a
• 11:49
  flimsy
• 11:50
  sock,
• 11:50
  you
• 11:50
  know,
• 11:51
  at
• 11:51
  the
• 11:51
  thrift
• 11:51
  store
• 11:52
  for
• 11:53
  a
• 11:53
  dollar
• 11:53
  for
• 11:53
  12
• 11:54
  of
• 11:54
  them,
• 11:54
  right?
• 11:55
  And
• 11:55
  they're
• 11:56
  kind
• 11:56
  of
• 11:56
  thready,
• 11:56
  they
• 11:56
  have
• 11:56
  holes
• 11:57
  in
• 11:57
  them.
• 11:57
  Well,
• 11:57
  if
• 11:58
  you
• 11:58
  put
• 11:58
  that
• 11:58
  sock
• 11:59
  into
• 11:59
  the
• 11:59
  vacuum
• 11:59
  cleaner,
• 12:00
  the
• 12:00
  vacuum
• 12:01
  cleaner
• 12:01
  then
• 12:02
  is
• 12:02
  not
• 12:02
  going
• 12:02
  to
• 12:03
  be
• 12:03
  fully
• 12:03
  plugged.
• 12:04
  So
• 12:04
  it's
• 12:04
  actually
• 12:05
  going
• 12:05
  to
• 12:06
  keep
• 12:06
  sucking
• 12:06
  up
• 12:06
  some
• 12:07
  of
• 12:07
  the
• 12:07
  serotonin.
• 12:07
  You
• 12:08
  want
• 12:08
  a
• 12:08
  tight
• 12:08
  sock,
• 12:09
  you
• 12:09
  want
• 12:09
  a
• 12:09
  wool
• 12:10
  sock.
• 12:10
  So
• 12:10
  none
• 12:10
  of
• 12:10
  the
• 12:10
  serotonin
• 12:11
  gets
• 12:11
  recycled
• 12:12
  back
• 12:12
  into
• 12:12
  the
• 12:12
  neuron.
• 12:13
  But
• 12:13
  Prozac
• 12:14
  has
• 12:14
  a
• 12:14
  lower
• 12:14
  affinity.
• 12:15
  So
• 12:15
  it's
• 12:15
  kind
• 12:15
  of
• 12:15
  putting
• 12:16
  this
• 12:16
  thready
• 12:16
  sock
• 12:17
  where
• 12:18
  the
• 12:18
  vacuum
• 12:18
  cleaner
• 12:19
  can
• 12:19
  still
• 12:19
  vacuum,
• 12:19
  and
• 12:20
  you're
• 12:20
  like,
• 12:20
  oh,
• 12:20
  no,
• 12:21
  don't
• 12:21
  vacuum
• 12:21
  up
• 12:21
  that
• 12:22
  serotonin.
• 12:22
  I
• 12:22
  need
• 12:23
  that.
• 12:23
  But
• 12:23
  you
• 12:24
  put
• 12:24
  a
• 12:24
  lower
• 12:24
  affinity
• 12:25
  SSRI
• 12:26
  in
• 12:26
  there
• 12:26
  and
• 12:27
  boom,
• 12:27
  some
• 12:28
  of
• 12:28
  that
• 12:28
  serotonin
• 12:29
  is
• 12:29
  being
• 12:29
  sucked
• 12:30
  back
• 12:30
  in.
• 12:30
  And
• 12:30
  why
• 12:31
  is
• 12:31
  that
• 12:31
  bad?
• 12:31
  Well,
• 12:31
  that's
• 12:32
  Problematic
• 12:32
  for
• 12:33
  side
• 12:33
  effects
• 12:34
  because
• 12:34
  you
• 12:34
  want
• 12:35
  your
• 12:35
  serotonin
• 12:36
  levels
• 12:36
  to
• 12:36
  be
• 12:36
  kind
• 12:36
  of
• 12:36
  even.
• 12:37
  You
• 12:37
  want
• 12:37
  a
• 12:37
  steady
• 12:37
  serotonin
• 12:38
  tone,
• 12:38
  something
• 12:39
  dependable,
• 12:39
  something
• 12:40
  tolerable.
• 12:40
  And
• 12:41
  you
• 12:41
  don't
• 12:41
  want
• 12:41
  these
• 12:41
  gyrations
• 12:43
  where
• 12:44
  you
• 12:44
  know,
• 12:45
  you
• 12:45
  know,
• 12:45
  if
• 12:45
  an
• 12:46
  SSRI
• 12:46
  is
• 12:47
  binding
• 12:47
  loosely,
• 12:48
  it's
• 12:48
  kind
• 12:48
  of
• 12:48
  that
• 12:48
  sock
• 12:49
  is
• 12:49
  falling
• 12:49
  off
• 12:50
  a
• 12:50
  little
• 12:50
  bit
• 12:50
  and,
• 12:51
  and
• 12:51
  the
• 12:51
  occupancy
• 12:52
  on
• 12:52
  that
• 12:53
  cert
• 12:53
  transporter
• 12:54
  can
• 12:54
  swing.
• 12:54
  Maybe
• 12:55
  90%
• 12:55
  of
• 12:56
  them
• 12:56
  are
• 12:57
  blocked
• 12:57
  in
• 12:58
  the
• 12:58
  morning,
• 12:58
  but
• 12:58
  only
• 12:59
  60%
• 12:59
  are
• 13:00
  blocked
• 13:00
  in
• 13:00
  the
• 13:00
  evening
• 13:01
  because
• 13:01
  of
• 13:01
  this
• 13:01
  kind
• 13:02
  of
• 13:02
  thready,
• 13:03
  not
• 13:04
  really
• 13:04
  high
• 13:04
  affinity
• 13:05
  SSRI
• 13:06
  in
• 13:06
  there.
• 13:06
  Right.
• 13:07
  And
• 13:07
  so
• 13:07
  when
• 13:07
  the
• 13:07
  percentage
• 13:08
  of
• 13:08
  block
• 13:08
  transporters
• 13:09
  rises
• 13:10
  and
• 13:10
  falls,
• 13:11
  then
• 13:11
  your
• 13:11
  drug
• 13:12
  is
• 13:13
  not
• 13:13
  going
• 13:13
  to
• 13:13
  be
• 13:13
  as
• 13:14
  steady
• 13:14
  and
• 13:14
  they're
• 13:15
  going
• 13:15
  to
• 13:15
  have
• 13:15
  variable
• 13:15
  serotonin
• 13:16
  levels
• 13:16
  in
• 13:17
  the
• 13:17
  synapse.
• 13:18
  Those
• 13:18
  rises
• 13:18
  and
• 13:19
  drops
• 13:19
  in
• 13:20
  the
• 13:20
  brain
• 13:20
  can
• 13:20
  feel
• 13:20
  like
• 13:21
  agitation,
• 13:21
  jitteriness
• 13:22
  and
• 13:23
  emotional
• 13:23
  ability
• 13:24
  in
• 13:24
  sensitive
• 13:24
  people.
• 13:25
  So
• 13:25
  that,
• 13:26
  my
• 13:26
  friends,
• 13:26
  is
• 13:27
  why
• 13:27
  a
• 13:27
  high
• 13:27
  affinity
• 13:28
  tight
• 13:29
  wool
• 13:29
  sock
• 13:30
  like
• 13:30
  Alexa
• 13:30
  Pro
• 13:31
  is
• 13:31
  going
• 13:32
  to
• 13:32
  result
• 13:32
  in
• 13:32
  steadier
• 13:33
  levels
• 13:34
  with
• 13:35
  less
• 13:36
  crazy
• 13:36
  swings
• 13:37
  that
• 13:37
  cause
• 13:38
  these
• 13:39
  jitters,
• 13:39
  racing
• 13:40
  thoughts
• 13:40
  and
• 13:40
  stomach
• 13:40
  upset.
• 13:41
  Now
• 13:41
  of
• 13:41
  course
• 13:42
  Lexapro
• 13:42
  can
• 13:42
  still
• 13:43
  cause
• 13:43
  those
• 13:43
  things.
• 13:43
  It's
• 13:44
  not
• 13:44
  this
• 13:44
  like,
• 13:45
  you
• 13:45
  know,
• 13:45
  it's
• 13:45
  not
• 13:45
  Vitamin
• 13:46
  Wonka
• 13:47
  where
• 13:47
  it's
• 13:47
  just
• 13:47
  going
• 13:48
  to
• 13:48
  solve
• 13:48
  every
• 13:48
  problem
• 13:48
  in
• 13:49
  the
• 13:49
  world,
• 13:49
  but
• 13:50
  it's,
• 13:50
  it's
• 13:50
  also
• 13:52
  by
• 13:52
  virtue
• 13:52
  of
• 13:52
  what
• 13:52
  I
• 13:53
  just
• 13:53
  described,
• 13:53
  not
• 13:54
  as
• 13:54
  likely
• 13:54
  to
• 13:54
  cause
• 13:55
  those
• 13:55
  things
• 13:56
  when
• 13:56
  it
• 13:56
  comes
• 13:56
  to
• 13:56
  that
• 13:57
  specific
• 13:58
  mechanism
• 13:58
  of
• 13:58
  action.
• 13:59
  This
• 14:00
  is
• 14:00
  where
• 14:00
  things
• 14:00
  get
• 14:00
  kind
• 14:00
  of
• 14:01
  fun
• 14:01
  and
• 14:01
  complicated.
• 14:02
  But
• 14:03
  Lex
• 14:03
  or
• 14:03
  Prozac
• 14:04
  has
• 14:04
  that
• 14:05
  longer
• 14:05
  half
• 14:05
  life,
• 14:06
  right?
• 14:06
  It's
• 14:06
  got
• 14:07
  the
• 14:07
  law,
• 14:07
  one
• 14:07
  of
• 14:07
  the
• 14:07
  longer
• 14:08
  half
• 14:08
  lives
• 14:08
  of
• 14:08
  any
• 14:09
  of
• 14:09
  these
• 14:09
  psychotropic
• 14:10
  medications.
• 14:11
  So
• 14:12
  that's
• 14:12
  actually
• 14:12
  a
• 14:12
  virtue
• 14:13
  because
• 14:13
  it
• 14:13
  comes
• 14:14
  on
• 14:14
  steady
• 14:14
  and
• 14:14
  it
• 14:14
  leaves
• 14:15
  steady,
• 14:15
  right?
• 14:16
  If
• 14:16
  Benny
• 14:16
  tells
• 14:17
  you,
• 14:17
  hey,
• 14:17
  I
• 14:17
  have
• 14:18
  one
• 14:18
  deal
• 14:18
  breaker.
• 14:19
  I
• 14:20
  used
• 14:20
  to
• 14:20
  be
• 14:20
  on
• 14:20
  Effexor
• 14:22
  and
• 14:22
  the
• 14:22
  half
• 14:23
  life
• 14:23
  was
• 14:23
  super
• 14:23
  short
• 14:24
  and
• 14:24
  it
• 14:24
  was
• 14:24
  brutal.
• 14:25
  Getting
• 14:25
  off
• 14:25
  Effexor,
• 14:26
  it
• 14:26
  took
• 14:26
  me
• 14:26
  a
• 14:26
  year
• 14:26
  to
• 14:27
  get
• 14:27
  off
• 14:27
  effect
• 14:28
  and
• 14:28
  I'm
• 14:28
  never
• 14:28
  going
• 14:29
  to
• 14:29
  go
• 14:29
  through
• 14:29
  with
• 14:29
  that
• 14:29
  again.
• 14:30
  Well,
• 14:30
  if
• 14:30
  Benny
• 14:31
  tells
• 14:31
  you
• 14:31
  something
• 14:31
  like
• 14:31
  that,
• 14:32
  you
• 14:32
  better
• 14:32
  gravitate
• 14:33
  towards
• 14:33
  Prozac
• 14:34
  because
• 14:35
  Prozac
• 14:35
  has
• 14:35
  a
• 14:35
  longer
• 14:36
  half
• 14:36
  life.
• 14:37
  It's
• 14:37
  going
• 14:37
  to
• 14:37
  potentially
• 14:38
  allow
• 14:38
  him
• 14:38
  to
• 14:39
  self
• 14:39
  taper.
• 14:40
  Not
• 14:40
  always,
• 14:41
  but
• 14:41
  it
• 14:41
  has
• 14:42
  a
• 14:42
  longer
• 14:42
  half
• 14:43
  life,
• 14:43
  right?
• 14:43
  We're
• 14:43
  talking
• 14:44
  four
• 14:45
  to
• 14:45
  six
• 14:45
  day
• 14:45
  half
• 14:46
  life.
• 14:46
  It
• 14:46
  has
• 14:46
  a
• 14:47
  metabolite
• 14:48
  that
• 14:48
  has
• 14:48
  a
• 14:48
  16
• 14:49
  day
• 14:49
  half
• 14:49
  life
• 14:50
  as
• 14:50
  opposed
• 14:50
  to
• 14:51
  Lexapro.
• 14:51
  The
• 14:51
  27
• 14:52
  is
• 14:52
  set,
• 14:52
  32
• 14:53
  hour
• 14:53
  half
• 14:53
  life,
• 14:54
  right?
• 15:49
  So
• 15:49
  when
• 15:49
  you
• 15:49
  have
• 15:49
  a
• 15:49
  long
• 15:49
  half
• 15:50
  life,
• 15:50
  the
• 15:50
  medication
• 15:51
  kind
• 15:51
  of
• 15:51
  gets
• 15:51
  off
• 15:51
  the
• 15:52
  bus
• 14:57
  slowly.
• 15:53
  It
• 15:53
  doesn't
• 15:53
  just
• 15:53
  Burst
• 15:54
  through
• 15:54
  the
• 15:54
  window
• 15:54
  and
• 15:54
  jump
• 15:55
  out
• 15:55
  the
• 15:55
  window
• 15:55
  and
• 15:55
  cause
• 15:56
  a
• 15:56
  scene,
• 15:56
  right?
• 15:56
  What
• 15:56
  the
• 15:57
  hell
• 15:57
  just
• 15:57
  happened?
• 15:58
  Why'd
• 15:58
  that
• 15:58
  guy
• 15:58
  just
• 15:59
  jump
• 15:59
  out
• 15:59
  of
• 15:59
  the
• 15:59
  window
• 15:59
  of
• 15:59
  the
• 16:00
  bus?
• 16:00
  Let's.
• 16:01
  Prozac
• 16:01
  is
• 16:01
  just
• 16:02
  like
• 16:02
  this
• 16:02
  little
• 16:02
  old
• 16:02
  lady
• 16:03
  that
• 16:03
  slowly
• 16:04
  walks
• 16:04
  off
• 16:04
  the
• 16:05
  bus.
• 16:05
  So
• 16:05
  slowly
• 16:05
  that
• 16:06
  it's
• 16:06
  driving
• 16:06
  you
• 16:07
  nuts,
• 16:07
  but
• 16:07
  at
• 16:08
  the
• 16:08
  same
• 16:08
  time,
• 16:08
  it's
• 16:08
  graceful,
• 16:10
  right?
• 16:10
  And
• 16:10
  maybe
• 16:10
  that's
• 16:11
  not
• 16:11
  my
• 16:11
  best
• 16:11
  analogy,
• 16:12
  because
• 16:12
  little
• 16:12
  old
• 16:12
  ladies
• 16:13
  can
• 16:13
  fall,
• 16:14
  and
• 16:14
  that's
• 16:14
  not
• 16:15
  the
• 16:15
  analogy
• 16:15
  I'm
• 16:15
  going
• 16:16
  for.
• 16:16
  But
• 16:16
  think
• 16:16
  of
• 16:17
  just
• 16:17
  a
• 16:17
  little
• 16:17
  old
• 16:17
  lady
• 16:18
  with
• 16:18
  a
• 16:18
  nice
• 16:18
  steady
• 16:19
  cane,
• 16:20
  and
• 16:20
  she's
• 16:20
  just
• 16:21
  calmly
• 16:23
  walking
• 16:23
  off
• 16:23
  the
• 16:24
  bus.
• 16:25
  And
• 16:25
  it's
• 16:25
  an
• 16:26
  even
• 16:26
  ramp
• 16:26
  to
• 16:26
  get
• 16:26
  off
• 16:27
  the.
• 16:27
  But
• 16:27
  the
• 16:27
  ramp.
• 16:27
  And
• 16:27
  you
• 16:28
  know
• 16:28
  those
• 16:28
  buses
• 16:28
  that
• 16:28
  have
• 16:29
  ramps,
• 16:30
  and
• 16:30
  she's
• 16:30
  just
• 16:30
  kind
• 16:30
  of
• 16:31
  slowly
• 16:31
  going
• 16:32
  down
• 16:32
  that
• 16:32
  ramp.
• 16:32
  It's
• 16:33
  a
• 16:33
  really
• 16:33
  wide,
• 16:34
  long
• 16:34
  ramp.
• 16:35
  It
• 16:35
  gives
• 16:35
  her
• 16:35
  a
• 16:35
  lot
• 16:35
  of
• 16:36
  time
• 16:36
  to
• 16:36
  get
• 16:36
  off
• 16:36
  the
• 16:36
  bus.
• 16:37
  Nobody's
• 16:37
  rushing
• 16:38
  her,
• 16:38
  hassling
• 16:39
  her.
• 16:39
  And
• 16:39
  affects
• 16:40
  her.
• 16:40
  Is
• 16:40
  like
• 16:40
  the
• 16:40
  dude
• 16:41
  who
• 16:41
  jumps
• 16:41
  out
• 16:41
  of
• 16:41
  the
• 16:42
  bus
• 16:42
  window,
• 16:42
  right?
• 16:43
  Very
• 16:43
  short
• 16:43
  half
• 16:44
  life,
• 16:44
  very
• 16:44
  abrasive.
• 16:44
  It's
• 16:45
  like,
• 16:45
  why
• 16:45
  did
• 16:45
  you
• 16:45
  get
• 16:45
  off
• 16:46
  the
• 16:46
  bus
• 16:46
  that
• 16:46
  way?
• 16:47
  So
• 16:47
  if
• 16:48
  Prozac
• 16:49
  has
• 16:49
  that
• 16:49
  long
• 16:49
  half
• 16:50
  life,
• 16:50
  which
• 16:50
  it
• 16:50
  does,
• 16:51
  consider
• 16:51
  that,
• 16:52
  right?
• 16:52
  Because
• 16:52
  you
• 16:52
  have
• 16:52
  some
• 16:53
  patients
• 16:53
  who
• 16:53
  do
• 16:53
  not
• 16:53
  want
• 16:54
  to
• 16:54
  go
• 16:54
  through
• 16:54
  withdrawal.
• 16:54
  They
• 16:55
  will
• 16:55
  ask
• 16:55
  you
• 16:55
  that
• 16:55
  many
• 16:56
  times,
• 16:56
  like,
• 16:56
  is
• 16:56
  this
• 16:56
  hard
• 16:57
  to
• 16:57
  get
• 16:57
  off
• 16:57
  of?
• 16:58
  How
• 16:58
  do
• 16:58
  I
• 16:58
  get
• 16:58
  off
• 16:58
  of
• 16:58
  that?
• 16:59
  What's
• 16:59
  the
• 16:59
  game
• 16:59
  plan?
• 16:59
  I
• 17:00
  get
• 17:00
  that
• 17:00
  question
• 17:01
  all
• 17:01
  the
• 17:01
  time
• 17:02
  from
• 17:02
  patients
• 17:02
  who
• 17:03
  want
• 17:03
  to
• 17:03
  know
• 17:03
  the
• 17:03
  exit
• 17:04
  ramp.
• 17:04
  And
• 17:04
  Prozac
• 17:05
  has
• 17:05
  a
• 17:05
  great
• 17:05
  exit
• 17:06
  ramp.
• 17:06
  We
• 17:06
  also
• 17:06
  talked
• 17:07
  about
• 17:07
  how
• 17:07
  it
• 17:07
  antagonizes
• 17:08
  5ht2C.
• 17:09
  And
• 17:10
  normally,
• 17:11
  5ht2C
• 17:12
  inhibits
• 17:12
  dopamine
• 17:13
  and
• 17:13
  norepinephrine
• 17:14
  release
• 17:14
  in
• 17:14
  the
• 17:14
  PFC
• 17:15
  or
• 17:15
  the
• 17:15
  prefrontal
• 17:15
  cortex
• 17:16
  while
• 17:16
  we're
• 17:17
  blocking
• 17:17
  it.
• 17:17
  So
• 17:18
  again,
• 17:18
  more
• 17:18
  dopamine
• 17:19
  and
• 17:19
  norepinephrine.
• 17:20
  It's
• 17:20
  going
• 17:21
  to
• 17:21
  give
• 17:21
  Benny
• 17:21
  that
• 17:22
  subtle
• 17:22
  boost
• 17:22
  of
• 17:22
  energy
• 17:22
  and
• 17:23
  motivation
• 17:23
  that
• 17:23
  he
• 17:23
  needs
• 17:24
  and
• 17:24
  maybe
• 17:25
  even
• 17:25
  a
• 17:25
  little
• 17:25
  appetite
• 17:26
  suppression,
• 17:26
  too.
• 17:27
  We
• 17:27
  talked
• 17:27
  about
• 17:27
  Lexapro
• 17:28
  and
• 17:28
  how
• 17:28
  clean
• 17:29
  it
• 17:29
  is
• 17:30
  and
• 17:30
  how
• 17:30
  it
• 17:30
  doesn't
• 17:31
  mess
• 17:31
  with
• 17:32
  histamine,
• 17:33
  which
• 17:33
  would
• 17:33
  cause
• 17:34
  fatigue
• 17:34
  and
• 17:35
  weight
• 17:35
  gain.
• 17:35
  There's
• 17:36
  no
• 17:36
  anticholinergic
• 17:37
  fog.
• 17:37
  So
• 17:38
  Benny's
• 17:38
  thinking
• 17:38
  would
• 17:39
  be
• 17:39
  a
• 17:39
  little
• 17:39
  more
• 17:39
  clear
• 17:40
  on
• 17:40
  Lexapro.
• 17:41
  There's
• 17:41
  also
• 17:42
  no
• 17:42
  dopamine,
• 17:42
  norepinephrine
• 17:43
  splash,
• 17:43
  which
• 17:44
  in
• 17:44
  this
• 17:44
  case
• 17:44
  is
• 17:45
  great
• 17:45
  for
• 17:45
  Benny.
• 17:46
  But
• 17:46
  someone
• 17:47
  might
• 17:47
  not
• 17:47
  like
• 17:47
  that.
• 17:47
  It
• 17:48
  might
• 17:48
  cause
• 17:48
  jitters.
• 17:48
  It
• 17:49
  might
• 17:49
  cause
• 17:49
  activation,
• 17:50
  right?
• 17:51
  So
• 17:51
  think
• 17:51
  about
• 17:51
  that.
• 17:52
  If
• 17:52
  you
• 17:52
  have
• 17:52
  a
• 17:52
  patient
• 17:52
  who's
• 17:53
  kind
• 17:53
  of
• 17:53
  anxious
• 17:53
  and
• 17:54
  you're
• 17:54
  giving
• 17:54
  them
• 17:54
  Prozac,
• 17:55
  they
• 17:55
  might
• 17:55
  not
• 17:56
  like
• 17:56
  it
• 17:56
  because
• 17:56
  it
• 17:57
  causes
• 17:58
  a
• 17:58
  little
• 17:58
  bit
• 17:58
  of
• 17:59
  that
• 17:59
  pep
• 17:59
  in
• 17:59
  their
• 17:59
  step
• 18:00
  can
• 18:00
  be
• 18:00
  interpreted
• 18:00
  as
• 18:01
  anxiety
• 18:01
  early
• 18:01
  on
• 18:02
  and
• 18:02
  they
• 18:02
  might
• 18:03
  not
• 18:03
  like
• 18:03
  that.
• 18:04
  Right.
• 18:04
  So,
• 18:05
  but
• 18:05
  again,
• 18:05
  I've
• 18:05
  had
• 18:05
  patients
• 18:06
  that
• 18:06
  have
• 18:06
  no
• 18:06
  problem
• 18:07
  with
• 18:07
  Prozac
• 18:08
  and
• 18:08
  are
• 18:08
  quite
• 18:09
  anxious,
• 18:09
  and
• 18:09
  in
• 18:09
  fact,
• 18:09
  they're
• 18:10
  even
• 18:10
  a
• 18:10
  lot
• 18:10
  less
• 18:10
  anxious
• 18:11
  with
• 18:11
  Prozac.
• 18:12
  So
• 18:12
  there's
• 18:12
  going
• 18:13
  to
• 18:13
  be
• 18:13
  a
• 18:13
  difference
• 18:13
  between
• 18:13
  what
• 18:14
  you
• 18:14
  see
• 18:14
  pharmacologically
• 18:15
  in
• 18:15
  your
• 18:15
  textbook
• 18:16
  and
• 18:16
  what
• 18:16
  is
• 18:17
  actually
• 18:17
  borne
• 18:17
  out
• 18:18
  in
• 18:18
  practice.
• 18:18
  It's
• 18:19
  not
• 18:19
  always
• 18:19
  going
• 18:19
  to
• 18:19
  be
• 18:20
  the
• 18:20
  same,
• 18:20
  as
• 18:21
  you
• 18:21
  can
• 18:21
  appreciate.
• 18:22
  So
• 18:22
  far
• 18:22
  from
• 18:22
  what
• 18:22
  we're
• 18:23
  talking
• 18:23
  about,
• 18:24
  this
• 18:24
  stuff
• 18:24
  is
• 18:24
  not
• 18:24
  so
• 18:25
  cut
• 18:25
  and
• 18:25
  dried.
• 18:25
  We
• 18:26
  didn't
• 18:26
  even
• 18:26
  talk
• 18:26
  about
• 18:26
  the
• 18:27
  fact
• 18:27
  that
• 18:27
  people
• 18:28
  metabolize
• 18:28
  these
• 18:29
  things
• 18:29
  in
• 18:30
  rather
• 18:30
  unpredictable
• 18:31
  ways.
• 18:31
  Right.
• 18:31
  You
• 18:32
  could
• 18:32
  have
• 18:32
  a
• 18:32
  patient
• 18:32
  who
• 18:33
  rapidly
• 18:34
  metabolizes
• 18:35
  Prozac
• 18:35
  and
• 18:35
  you
• 18:35
  don't
• 18:36
  even
• 18:36
  really
• 18:36
  know
• 18:36
  that,
• 18:37
  and
• 18:37
  someone
• 18:38
  who
• 18:39
  rapidly
• 18:39
  metabolizes
• 18:40
  Lexapro.
• 18:41
  And
• 18:41
  all
• 18:41
  bets
• 18:41
  are
• 18:41
  often
• 18:42
  about
• 18:43
  with
• 18:43
  how
• 18:43
  these
• 18:43
  side
• 18:44
  effects
• 18:44
  are
• 18:45
  affected
• 18:46
  and
• 18:46
  when
• 18:46
  they
• 18:46
  present
• 18:47
  and
• 18:47
  how
• 18:47
  long
• 18:47
  they
• 18:47
  last.
• 18:48
  You
• 18:48
  could
• 18:48
  have
• 18:49
  someone
• 18:49
  who's
• 18:49
  a
• 18:49
  poor
• 18:49
  metabolizer
• 18:50
  and
• 18:51
  all
• 18:51
  bets
• 18:51
  are
• 18:51
  off.
• 18:51
  They
• 18:52
  just
• 18:52
  cannot
• 18:52
  handle
• 18:52
  Lexapro.
• 18:53
  And
• 18:53
  you're
• 18:53
  thinking,
• 18:54
  oh,
• 18:54
  my
• 18:54
  God,
• 18:54
  it's
• 18:54
  a
• 18:54
  clean
• 18:55
  medication.
• 18:55
  Pearls
• 18:56
  and
• 18:56
  Prep
• 18:56
  Podcast
• 18:57
  told
• 18:57
  me
• 18:58
  it
• 18:58
  was
• 18:58
  a
• 18:58
  clean
• 18:58
  medication.
• 18:59
  Well,
• 18:59
  it
• 18:59
  is
• 18:59
  clean,
• 19:00
  but
• 19:00
  if
• 19:00
  you
• 19:00
  have
• 19:00
  someone
• 19:01
  who's
• 19:01
  a
• 19:01
  hypometabolizer
• 19:02
  or
• 19:02
  slow
• 19:03
  metabolizer,
• 19:04
  then
• 19:04
  these
• 19:04
  side
• 19:04
  effects
• 19:05
  that
• 19:05
  are
• 19:05
  borne
• 19:06
  out
• 19:06
  by
• 19:07
  broadly
• 19:07
  increasing
• 19:08
  serotonin
• 19:09
  in
• 19:09
  the
• 19:09
  synapses
• 19:10
  can
• 19:11
  still
• 19:11
  wreak
• 19:11
  havoc
• 19:12
  and
• 19:12
  indirectly
• 19:13
  because
• 19:13
  you
• 19:13
  are
• 19:13
  increasing
• 19:14
  the
• 19:14
  amount
• 19:14
  of
• 19:14
  serotonin
• 19:15
  in
• 19:15
  a
• 19:16
  lot
• 19:16
  of
• 19:16
  the
• 19:16
  gut
• 19:17
  too.
• 19:17
  Right.
• 19:18
  So
• 19:18
  there's.
• 19:18
  There's
• 19:18
  a
• 19:19
  lot
• 19:19
  of
• 19:19
  different
• 19:19
  ways
• 19:19
  that
• 19:19
  this
• 19:20
  can
• 19:20
  happen,
• 19:20
  and
• 19:20
  it's
• 19:20
  not
• 19:21
  so
• 19:21
  simple.
• 19:21
  But
• 19:21
  I
• 19:21
  think
• 19:21
  the
• 19:22
  subtlety
• 19:22
  is
• 19:22
  beautiful.
• 19:23
  The
• 19:23
  subtlety
• 19:24
  is
• 19:24
  why
• 19:24
  we're
• 19:24
  in
• 19:24
  this
• 19:24
  field,
• 19:25
  why
• 19:25
  it's
• 19:25
  fun,
• 19:26
  why
• 19:26
  it's
• 19:26
  intellectually
• 19:27
  stimulating.
• 19:28
  We
• 19:28
  talked
• 19:29
  about
• 19:29
  pros
• 19:30
  and
• 19:30
  cons
• 19:30
  between
• 19:30
  Prozac
• 19:31
  and
• 19:31
  Lexapro.
• 19:32
  Prozac
• 19:33
  is
• 19:33
  really
• 19:33
  best
• 19:33
  for
• 19:33
  that.
• 19:34
  Low
• 19:34
  drive
• 19:34
  apathy,
• 19:35
  flat
• 19:35
  depression,
• 19:36
  the
• 19:36
  atypical
• 19:37
  kinds
• 19:37
  of
• 19:37
  depression
• 19:38
  where
• 19:38
  there's
• 19:38
  hypersomnia
• 19:39
  or
• 19:39
  a
• 19:39
  lot
• 19:39
  of
• 19:39
  sleeping
• 19:40
  or
• 19:40
  weight
• 19:41
  gain.
• 19:41
  Keep
• 19:42
  in
• 19:42
  mind,
• 19:42
  too,
• 19:42
  Prozac
• 19:43
  has
• 19:44
  much
• 19:44
  more
• 19:44
  FDA
• 19:45
  approval
• 19:45
  than
• 19:46
  Lexapro
• 19:46
  and
• 19:47
  can
• 19:47
  be
• 19:47
  used
• 19:47
  for
• 19:47
  a
• 19:48
  wide
• 19:48
  variety
• 19:49
  of
• 19:50
  mental
• 19:50
  health
• 19:51
  problems.
• 19:51
  MDD,
• 19:52
  OCD,
• 19:53
  panic
• 19:54
  disorder,
• 19:54
  bulimia
• 19:55
  at
• 19:55
  doses
• 19:55
  of
• 19:55
  60
• 19:56
  milligrams
• 19:56
  or
• 19:57
  greater,
• 19:57
  which
• 19:57
  is
• 19:57
  a
• 19:57
  fascinating
• 19:58
  thing
• 19:58
  we'll
• 19:58
  go
• 19:59
  into
• 19:59
  in
• 19:59
  a
• 19:59
  future
• 19:59
  podcast.
• 20:00
  Pmdd.
• 20:02
  Right.
• 20:02
  That's
• 20:02
  Premenstrual
• 20:03
  dysphoric
• 20:03
  disorder.
• 20:04
  Bipolar
• 20:05
  depression
• 20:05
  if
• 20:05
  combined
• 20:06
  with
• 20:06
  olanzapine,
• 20:07
  also
• 20:07
  known
• 20:07
  as
• 20:07
  symbiotes,
• 20:08
  treatment
• 20:09
  resistant
• 20:09
  Depression.
• 20:10
  So
• 20:10
  huge
• 20:11
  FDA
• 20:11
  uses,
• 20:12
  as
• 20:12
  opposed
• 20:12
  to
• 20:12
  Lexapro,
• 20:13
  which
• 20:13
  is
• 20:13
  FDA
• 20:14
  approved
• 20:15
  for
• 20:15
  generalized
• 20:15
  anxiety
• 20:16
  disorder
• 20:16
  and
• 20:16
  major
• 20:17
  depressive
• 20:17
  disorder.
• 20:17
  That
• 20:18
  does
• 20:18
  not
• 20:18
  mean
• 20:18
  that
• 20:19
  you
• 20:19
  can't
• 20:19
  use
• 20:19
  Lexapro
• 20:20
  for
• 20:20
  some
• 20:20
  of
• 20:21
  those
• 20:21
  other
• 20:21
  things
• 20:21
  in
• 20:22
  specific
• 20:22
  cases.
• 20:23
  It
• 20:23
  just
• 20:23
  means
• 20:24
  they
• 20:24
  would
• 20:24
  be
• 20:24
  used
• 20:24
  off
• 20:24
  label.
• 20:25
  That's
• 20:25
  a
• 20:26
  whole
• 20:26
  other
• 20:26
  podcast
• 20:26
  episode,
• 20:28
  but
• 20:28
  that's
• 20:29
  where
• 20:29
  we're
• 20:29
  at
• 20:29
  with
• 20:30
  the
• 20:30
  pros
• 20:31
  and
• 20:31
  cons.
• 20:32
  We've
• 20:32
  already
• 20:32
  talked
• 20:33
  about
• 20:33
  some
• 20:34
  of
• 20:34
  the
• 20:34
  good
• 20:35
  old
• 20:35
  clean
• 20:35
  properties
• 20:36
  of
• 20:37
  Lexapro.
• 20:38
  It
• 20:38
  plugs
• 20:39
  that
• 20:39
  vacuum
• 20:40
  cleaner
• 20:40
  and
• 20:41
  it
• 20:41
  gives
• 20:41
  you
• 20:41
  those
• 20:41
  steady
• 20:42
  serotonin
• 20:43
  levels
• 20:44
  throughout
• 20:44
  the
• 20:44
  day
• 20:45
  without
• 20:45
  the
• 20:45
  crazy
• 20:46
  fluctuations
• 20:47
  that
• 20:47
  are
• 20:48
  sometimes
• 20:49
  more
• 20:50
  reminiscent
• 20:50
  of
• 20:50
  other
• 20:51
  medications.
• 20:51
  It
• 20:52
  has
• 20:52
  an
• 20:52
  allosteric
• 20:53
  binding
• 20:53
  site
• 20:54
  in
• 20:54
  addition
• 20:55
  to
• 20:55
  where
• 20:55
  it
• 20:55
  binds
• 20:56
  onto
• 20:56
  sirt.
• 20:56
  So
• 20:57
  there's
• 20:57
  some
• 20:57
  pretty
• 20:57
  cool
• 20:58
  mechanisms
• 20:59
  that
• 20:59
  are
• 20:59
  different
• 21:00
  about
• 21:00
  Lexapro
• 21:01
  than
• 21:02
  Prozac.
• 21:03
  We
• 21:03
  also
• 21:03
  talked
• 21:03
  about
• 21:04
  Prozac
• 21:04
  being
• 21:04
  really
• 21:05
  good
• 21:05
  for
• 21:05
  low
• 21:06
  drive
• 21:06
  and
• 21:06
  having
• 21:07
  apathy
• 21:07
  or
• 21:07
  flat
• 21:08
  depression,
• 21:08
  atypical
• 21:09
  depression
• 21:10
  as
• 21:10
  we
• 21:10
  described
• 21:11
  it.
• 21:11
  We
• 21:11
  also
• 21:11
  talked
• 21:12
  about
• 21:12
  how
• 21:12
  it's
• 21:12
  FDA
• 21:12
  approved
• 21:13
  for
• 21:13
  more
• 21:13
  indications,
• 21:14
  so
• 21:14
  it
• 21:14
  can
• 21:14
  get
• 21:15
  you
• 21:15
  out
• 21:15
  of
• 21:15
  a
• 21:15
  lot
• 21:15
  of
• 21:15
  different
• 21:16
  jams.
• 21:17
  And
• 21:17
  there's
• 21:17
  reasons
• 21:17
  behind
• 21:18
  that.
• 21:18
  We
• 21:18
  did
• 21:18
  talk
• 21:18
  a
• 21:19
  little
• 21:19
  bit
• 21:19
  about
• 21:20
  Prozac
• 21:21
  5
• 21:21
  HT2C
• 21:22
  antagonism
• 21:23
  and
• 21:23
  how
• 21:23
  that
• 21:24
  allows
• 21:24
  for
• 21:25
  more
• 21:25
  dopamine
• 21:25
  and
• 21:25
  norepinephrine
• 21:26
  release
• 21:26
  in
• 21:26
  the
• 21:27
  prefrontal
• 21:27
  cortex.
• 21:27
  Well,
• 21:28
  that
• 21:28
  can
• 21:28
  also
• 21:28
  help
• 21:28
  with
• 21:29
  impulsivity.
• 21:30
  Right.
• 21:30
  And
• 21:31
  impulsivity
• 21:32
  is
• 21:32
  a
• 21:32
  problem,
• 21:33
  of
• 21:33
  course,
• 21:34
  in
• 21:35
  bulimia.
• 21:35
  As
• 21:36
  an
• 21:36
  example,
• 21:36
  There's
• 21:37
  a
• 21:37
  lot
• 21:37
  more,
• 21:38
  mechanistically
• 21:38
  that
• 21:39
  we
• 21:39
  could
• 21:39
  talk
• 21:39
  about
• 21:39
  in
• 21:39
  the
• 21:39
  future
• 21:40
  as
• 21:40
  it
• 21:40
  relates
• 21:40
  to
• 21:41
  bulimia
• 21:41
  and
• 21:42
  why
• 21:42
  it's
• 21:42
  60
• 21:42
  milligrams
• 21:43
  as
• 21:44
  an
• 21:44
  FDA
• 21:44
  approval
• 21:45
  and.
• 21:45
  And
• 21:45
  why
• 21:46
  Prozac
• 21:46
  versus
• 21:47
  other
• 21:47
  medications.
• 21:47
  But
• 21:47
  it's
• 21:48
  in
• 21:48
  part
• 21:48
  because
• 21:49
  of
• 21:49
  that
• 21:49
  5ht
• 21:50
  2c
• 21:51
  antagonism
• 21:51
  that
• 21:52
  makes
• 21:52
  Prozac
• 21:52
  a
• 21:53
  little
• 21:53
  bit
• 21:53
  more
• 21:53
  unique.
• 21:54
  Notice
• 21:55
  how
• 21:55
  it's
• 21:55
  not
• 21:55
  as
• 21:55
  simple
• 21:56
  as
• 21:56
  Lexapro
• 21:57
  is
• 21:57
  better
• 21:57
  because
• 21:58
  it's
• 21:58
  cleaner
• 21:59
  and
• 21:59
  it
• 21:59
  doesn't
• 21:59
  affect
• 22:00
  histamine.
• 22:00
  That's
• 22:01
  too
• 22:01
  reductionist.
• 22:02
  It
• 22:02
  doesn't
• 22:02
  really
• 22:02
  make
• 22:03
  a
• 22:03
  lot
• 22:03
  of
• 22:03
  sense
• 22:03
  to
• 22:03
  talk
• 22:03
  about
• 22:04
  it
• 22:04
  that
• 22:04
  way,
• 22:05
  but
• 22:05
  in
• 22:05
  the
• 22:05
  right
• 22:06
  patient,
• 22:06
  it's
• 22:06
  great.
• 22:06
  One
• 22:07
  major
• 22:07
  pro
• 22:07
  of
• 22:08
  Lexapro
• 22:09
  is
• 22:10
  that
• 22:10
  it's
• 22:10
  clean
• 22:11
  and
• 22:11
  it
• 22:11
  doesn't
• 22:11
  interact
• 22:12
  with
• 22:12
  a
• 22:12
  lot
• 22:12
  of
• 22:13
  other
• 22:13
  medications
• 22:14
  either.
• 22:15
  It's
• 22:15
  CYP
• 22:16
  interference
• 22:16
  is
• 22:17
  minimal,
• 22:18
  which
• 22:18
  is
• 22:18
  really
• 22:18
  great.
• 22:19
  And
• 22:20
  I
• 22:20
  would
• 22:20
  call
• 22:20
  that
• 22:21
  clean
• 22:21
  for
• 22:22
  a
• 22:22
  different
• 22:22
  reason.
• 22:22
  If
• 22:22
  you
• 22:23
  have
• 22:23
  a
• 22:23
  patient
• 22:23
  who's
• 22:23
  a
• 22:23
  little
• 22:24
  bit
• 22:24
  older
• 22:24
  who's
• 22:24
  on
• 22:25
  a
• 22:25
  lot
• 22:25
  of
• 22:25
  different
• 22:25
  medications
• 22:26
  and
• 22:26
  your
• 22:26
  head
• 22:26
  is
• 22:26
  spinning
• 22:27
  and
• 22:27
  you're
• 22:27
  saying,
• 22:28
  oh,
• 22:28
  my
• 22:28
  God,
• 22:28
  what
• 22:29
  do
• 22:29
  I
• 22:29
  do?
• 22:29
  About
• 22:29
  this.
• 22:30
  You
• 22:30
  know,
• 22:31
  of
• 22:31
  course,
• 22:31
  it's
• 22:31
  really
• 22:31
  important
• 22:32
  you
• 22:32
  utilize
• 22:32
  your
• 22:32
  resources
• 22:33
  and
• 22:33
  always
• 22:33
  do
• 22:34
  interaction
• 22:35
  checks.
• 22:35
  If
• 22:35
  your
• 22:35
  head
• 22:36
  is
• 22:36
  spinning
• 22:36
  and
• 22:37
  you're
• 22:37
  like,
• 22:37
  I
• 22:37
  don't
• 22:38
  know
• 22:38
  what
• 22:38
  to
• 22:38
  do
• 22:38
  with
• 22:39
  all
• 22:39
  these
• 22:39
  other
• 22:39
  medications,
• 22:40
  remember,
• 22:41
  Lexapro
• 22:41
  has
• 22:42
  minimal
• 22:43
  CYP
• 22:44
  interactions,
• 22:45
  and
• 22:46
  that
• 22:46
  is
• 22:47
  a
• 22:47
  virtue
• 22:47
  because
• 22:47
  Proac
• 22:48
  is
• 22:48
  an
• 22:48
  inhibitor
• 22:49
  of
• 22:50
  D2,
• 22:51
  D6,
• 22:52
  and
• 22:52
  3A4.
• 22:53
  So
• 22:53
  if
• 22:54
  you
• 22:54
  have
• 22:54
  Respir
• 22:54
  at
• 22:55
  all
• 22:55
  on
• 22:55
  board
• 22:56
  or
• 22:56
  Abilify
• 22:57
  on
• 22:57
  board,
• 22:57
  or
• 22:57
  Halol
• 22:58
  on
• 22:58
  board,
• 22:59
  well,
• 22:59
  Proac
• 23:00
  can
• 23:00
  lead
• 23:00
  to
• 23:01
  those
• 23:01
  medications
• 23:03
  rising
• 23:03
  in
• 23:03
  your
• 23:04
  serum,
• 23:04
  which
• 23:04
  can
• 23:04
  cause
• 23:05
  rigidity
• 23:05
  or
• 23:06
  all
• 23:06
  kinds
• 23:06
  of
• 23:06
  problems,
• 23:07
  right?
• 23:07
  It
• 23:08
  can
• 23:08
  interfere
• 23:08
  with
• 23:09
  codeine
• 23:09
  and
• 23:09
  tramadol
• 23:10
  and
• 23:10
  hydrocodone,
• 23:12
  and
• 23:12
  it
• 23:13
  can
• 23:13
  interfere
• 23:13
  with
• 23:14
  breast
• 23:14
  cancer
• 23:14
  treatment,
• 23:15
  reduce
• 23:15
  the
• 23:16
  effectiveness
• 23:17
  of
• 23:17
  tamoxifen.
• 23:18
  So
• 23:18
  these
• 23:18
  are
• 23:18
  Prozac
• 23:19
  liabilities,
• 23:20
  right?
• 23:20
  On
• 23:21
  one
• 23:21
  hand
• 23:21
  you
• 23:21
  go,
• 23:21
  oh,
• 23:22
  great,
• 23:22
  Prozac's
• 23:23
  great,
• 23:23
  right?
• 23:23
  It's
• 23:24
  got
• 23:24
  this
• 23:24
  long
• 23:24
  half
• 23:25
  life.
• 23:25
  My
• 23:25
  patient,
• 23:26
  who
• 23:26
  hates
• 23:27
  tapering
• 23:27
  medications,
• 23:28
  he
• 23:28
  doesn't
• 23:28
  have
• 23:28
  to
• 23:29
  deal
• 23:29
  with
• 23:29
  it,
• 23:29
  but
• 23:29
  my
• 23:29
  patient
• 23:30
  is
• 23:30
  on
• 23:30
  Abilify.
• 23:31
  He's
• 23:31
  sensitive
• 23:31
  to
• 23:32
  Abilify
• 23:32
  side
• 23:33
  effects,
• 23:33
  barely
• 23:33
  able
• 23:34
  to
• 23:34
  tolerate
• 23:34
  akaesthesia
• 23:35
  and
• 23:35
  restlessness.
• 23:36
  Now
• 23:36
  we're
• 23:37
  going
• 23:37
  to
• 23:37
  give
• 23:37
  him
• 23:37
  Prozac
• 23:38
  and.
• 23:38
  And
• 23:38
  Prozac
• 23:39
  is
• 23:39
  going
• 23:39
  to
• 23:39
  elevate
• 23:39
  those
• 23:40
  levels
• 23:40
  of
• 23:40
  Abilify
• 23:41
  potentially
• 23:41
  and
• 23:42
  cause
• 23:42
  worsening
• 23:43
  side
• 23:43
  effects.
• 23:43
  And
• 23:43
  that's
• 23:44
  not
• 23:44
  good.
• 23:44
  So
• 23:44
  notice
• 23:45
  how
• 23:45
  Prozac
• 23:46
  went
• 23:46
  from
• 23:46
  a
• 23:46
  great
• 23:46
  med
• 23:47
  all
• 23:47
  of
• 23:47
  a
• 23:47
  sudden
• 23:47
  to
• 23:48
  a
• 23:48
  not
• 23:48
  so
• 23:48
  great
• 23:49
  med
• 23:49
  very
• 23:50
  quickly
• 23:50
  because
• 23:50
  it
• 23:50
  interacts
• 23:52
  with
• 23:52
  these
• 23:53
  other
• 23:53
  metabolic
• 23:54
  pathways.
• 23:54
  Well,
• 23:54
  that
• 23:55
  is
• 23:55
  a
• 23:55
  problem,
• 23:56
  right?
• 23:57
  If
• 23:57
  Benny
• 23:58
  had
• 23:58
  a
• 23:58
  different
• 23:58
  presentation,
• 23:59
  if
• 23:59
  he
• 23:59
  wasn't
• 23:59
  eating
• 24:00
  a
• 24:00
  lot,
• 24:00
  if
• 24:01
  he
• 24:01
  was
• 24:01
  super
• 24:01
  anxious,
• 24:02
  super
• 24:02
  agitated,
• 24:03
  he
• 24:04
  had
• 24:04
  a
• 24:04
  lot
• 24:04
  of
• 24:04
  insomnia.
• 24:06
  Well,
• 24:06
  guess
• 24:06
  what?
• 24:06
  Proac
• 24:07
  all
• 24:07
  of
• 24:07
  a
• 24:07
  sudden
• 24:07
  does
• 24:08
  not
• 24:08
  become
• 24:08
  a
• 24:08
  very
• 24:08
  good
• 24:09
  medication
• 24:09
  for
• 24:09
  him.
• 24:10
  Why?
• 24:10
  Because
• 24:11
  it
• 24:11
  can
• 24:11
  worsen
• 24:12
  insomnia.
• 24:12
  It
• 24:13
  can
• 24:13
  worsen
• 24:13
  anxiety
• 24:14
  and
• 24:14
  agitation
• 24:15
  like
• 24:15
  we
• 24:15
  talked
• 24:15
  about
• 24:15
  with
• 24:16
  that
• 24:16
  unsteady
• 24:16
  serotonergic
• 24:17
  tone.
• 24:17
  We
• 24:18
  also
• 24:18
  Talked
• 24:18
  about
• 24:18
  the
• 24:19
  5ht
• 24:19
  2c
• 24:20
  antagonism,
• 24:20
  which
• 24:21
  can
• 24:21
  be
• 24:21
  interpreted
• 24:22
  as
• 24:22
  kind
• 24:22
  of
• 24:23
  activating
• 24:23
  for
• 24:23
  patients
• 24:24
  who
• 24:24
  are
• 24:24
  more
• 24:24
  sensitive,
• 24:25
  patients
• 24:25
  who
• 24:26
  can
• 24:26
  get
• 24:26
  more
• 24:26
  anxious
• 24:27
  and
• 24:27
  agitated.
• 24:28
  So
• 24:28
  again,
• 24:29
  again,
• 24:29
  Prozac
• 24:30
  is
• 24:30
  a
• 24:30
  balancing
• 24:30
  act
• 24:31
  here.
• 24:31
  It's
• 24:31
  great
• 24:31
  for
• 24:32
  one
• 24:32
  type
• 24:32
  of
• 24:32
  person,
• 24:33
  not
• 24:33
  so
• 24:34
  great
• 24:34
  for
• 24:34
  someone
• 24:34
  else.
• 24:35
  Same
• 24:35
  thing
• 24:35
  goes
• 24:35
  for
• 24:36
  Lexapro.
• 24:36
  You
• 24:37
  have
• 24:37
  someone
• 24:37
  in
• 24:37
  front
• 24:37
  of
• 24:38
  you
• 24:38
  who's
• 24:38
  heavy
• 24:39
  and
• 24:39
  snacking
• 24:40
  a
• 24:40
  lot
• 24:40
  and
• 24:41
  sleeping
• 24:41
  a
• 24:42
  lot
• 24:42
  and
• 24:43
  needs
• 24:43
  a
• 24:43
  little
• 24:43
  pep
• 24:44
  in
• 24:44
  their
• 24:44
  step
• 24:44
  in
• 24:44
  the
• 24:44
  morning.
• 24:44
  Well,
• 24:45
  Lexapro
• 24:45
  is
• 24:45
  not
• 24:46
  really
• 24:46
  going
• 24:46
  to
• 24:46
  give
• 24:46
  it
• 24:46
  to
• 24:46
  them
• 24:47
  as
• 24:47
  much
• 24:47
  as
• 24:48
  Prozac.
• 24:48
  Could
• 24:49
  it
• 24:49
  help?
• 24:49
  Absolutely,
• 24:50
  it
• 24:50
  could
• 24:50
  help,
• 24:51
  but
• 24:52
  it's
• 24:52
  probably
• 24:52
  not
• 24:53
  as
• 24:53
  ideal
• 24:54
  as
• 24:54
  Prozac,
• 24:55
  Prozac
• 24:56
  is
• 24:56
  tried
• 24:56
  and
• 24:57
  true.
• 24:57
  It's
• 24:57
  the
• 24:57
  oldest
• 24:57
  SSRI,
• 24:58
  it's
• 24:59
  widely
• 24:59
  used.
• 25:00
  It
• 25:00
  still
• 25:01
  does
• 25:01
  bind
• 25:01
  to
• 25:01
  cert,
• 25:02
  of
• 25:02
  course,
• 25:02
  that's
• 25:02
  what
• 25:03
  SSRIs
• 25:03
  do.
• 25:03
  And
• 25:04
  it
• 25:04
  does
• 25:04
  have
• 25:04
  a
• 25:04
  decent
• 25:05
  strength,
• 25:05
  but
• 25:06
  it's
• 25:06
  just
• 25:06
  not
• 25:06
  perfectly
• 25:07
  selective.
• 25:08
  It
• 25:08
  does
• 25:08
  have
• 25:09
  that
• 25:09
  weak
• 25:09
  norepinephrine
• 25:10
  and
• 25:11
  dopamine
• 25:11
  effect
• 25:12
  which
• 25:12
  can
• 25:12
  be
• 25:12
  off
• 25:13
  putting
• 25:13
  to
• 25:13
  some.
• 25:14
  It
• 25:14
  has
• 25:14
  a
• 25:14
  long
• 25:14
  half
• 25:15
  life.
• 25:15
  So
• 25:16
  that's
• 25:16
  a
• 25:16
  double
• 25:17
  edged
• 25:17
  sword,
• 25:17
  right?
• 25:17
  On
• 25:18
  one
• 25:18
  hand,
• 25:18
  when
• 25:19
  you're
• 25:19
  tapering,
• 25:20
  it's
• 25:20
  this
• 25:20
  smooth
• 25:20
  taper.
• 25:21
  A
• 25:21
  little
• 25:21
  old
• 25:21
  lady
• 25:22
  getting
• 25:22
  off
• 25:22
  the
• 25:22
  bus
• 25:22
  really
• 25:23
  slowly.
• 25:24
  But
• 25:24
  on
• 25:24
  the
• 25:24
  other
• 25:25
  hand,
• 25:26
  if
• 25:26
  it's
• 25:26
  causing
• 25:27
  side
• 25:27
  effects
• 25:27
  and
• 25:28
  you
• 25:28
  need
• 25:28
  to
• 25:28
  get
• 25:28
  it
• 25:28
  out
• 25:28
  of
• 25:29
  your
• 25:29
  system,
• 25:29
  you've
• 25:29
  got
• 25:29
  to
• 25:30
  sit
• 25:30
  there
• 25:30
  and
• 25:30
  stare
• 25:30
  at
• 25:31
  your
• 25:31
  watch,
• 25:32
  right?
• 25:33
  So
• 25:34
  if
• 25:34
  you're
• 25:34
  on
• 25:34
  the
• 25:34
  bus
• 25:35
  and
• 25:36
  the
• 25:36
  little
• 25:37
  old
• 25:37
  lady's
• 25:37
  smoking,
• 25:38
  you're
• 25:39
  gonna
• 25:39
  be
• 25:39
  like,
• 25:39
  oh
• 25:40
  God,
• 25:40
  shit's
• 25:41
  gonna
• 25:41
  take
• 25:41
  her
• 25:41
  forever
• 25:41
  to
• 25:41
  get
• 25:42
  off
• 25:42
  the
• 25:42
  bus.
• 25:42
  You
• 25:42
  know,
• 25:43
  she's
• 25:43
  a
• 25:43
  little
• 25:43
  old
• 25:44
  lady.
• 25:44
  Little
• 25:44
  old
• 25:44
  ladies
• 25:45
  don't
• 25:45
  just
• 25:45
  sprint
• 25:45
  off
• 25:46
  of
• 25:46
  the
• 25:46
  public
• 25:46
  bus.
• 25:47
  They
• 25:47
  take
• 25:47
  their
• 25:48
  time,
• 25:48
  as
• 25:48
  they
• 25:48
  should.
• 25:48
  We
• 25:49
  don't
• 25:49
  want
• 25:49
  them
• 25:49
  to
• 25:49
  fall.
• 25:50
  But
• 25:50
  she's
• 25:50
  smoking
• 25:51
  and
• 25:52
  everyone
• 25:52
  around
• 25:52
  her
• 25:53
  is
• 25:53
  coughing
• 25:53
  and
• 25:54
  hacking,
• 25:54
  covering
• 25:55
  their
• 25:55
  nose,
• 25:55
  inside
• 25:56
  their
• 25:56
  hoodie
• 25:57
  because
• 25:58
  they
• 25:58
  can't
• 25:58
  wait
• 25:58
  for
• 25:59
  this
• 25:59
  little
• 25:59
  old
• 25:59
  lady
• 25:59
  to
• 26:00
  get
• 26:00
  off
• 26:00
  the
• 26:00
  bus.
• 26:00
  She's
• 26:01
  getting
• 26:01
  off
• 26:01
  really
• 26:01
  slow
• 26:02
  and
• 26:02
  she's
• 26:03
  smoking,
• 26:03
  right?
• 26:04
  So
• 26:04
  everybody's
• 26:04
  coughing
• 26:05
  longer
• 26:05
  and
• 26:05
  longer.
• 26:06
  The
• 26:06
  side
• 26:07
  effects
• 26:07
  are
• 26:08
  lingering.
• 26:08
  Longer
• 26:09
  and
• 26:09
  longer
• 26:09
  because
• 26:09
  the
• 26:10
  half
• 26:10
  life
• 26:10
  is
• 26:10
  so
• 26:11
  slow,
• 26:11
  right?
• 26:12
  As
• 26:12
  opposed
• 26:12
  to
• 26:12
  somebody
• 26:13
  on
• 26:13
  Lexapro,
• 26:14
  half
• 26:14
  life
• 26:14
  is
• 26:15
  a
• 26:15
  lot
• 26:15
  shorter.
• 26:16
  So
• 26:16
  you're
• 26:16
  going
• 26:16
  to
• 26:16
  wash
• 26:17
  Lexapro
• 26:17
  out
• 26:17
  in
• 26:18
  a
• 26:18
  matter
• 26:18
  of
• 26:18
  days.
• 26:19
  It
• 26:19
  would
• 26:19
  be
• 26:19
  more
• 26:20
  like
• 26:20
  just
• 26:20
  a
• 26:20
  regular
• 26:20
  guy
• 26:21
  in
• 26:21
  his
• 26:21
  40s
• 26:21
  getting
• 26:22
  off
• 26:22
  the
• 26:22
  bus
• 26:23
  who
• 26:23
  might
• 26:23
  be
• 26:23
  smoking
• 26:24
  and
• 26:24
  you're
• 26:25
  like,
• 26:25
  whatever.
• 26:25
  I
• 26:25
  mean,
• 26:25
  I
• 26:26
  don't
• 26:26
  like
• 26:26
  smoke.
• 26:26
  But
• 26:26
  he's
• 26:27
  going
• 26:27
  to
• 26:27
  get
• 26:27
  off
• 26:27
  the
• 26:27
  bus
• 26:27
  pretty
• 26:28
  quickly
• 26:28
  here,
• 26:28
  right?
• 26:29
  So
• 26:29
  you
• 26:29
  get
• 26:29
  my
• 26:29
  point,
• 26:30
  right?
• 26:30
  When
• 26:30
  you
• 26:30
  hear
• 26:31
  the
• 26:31
  word
• 26:31
  half
• 26:31
  life,
• 26:32
  I
• 26:32
  want
• 26:32
  you
• 26:32
  to
• 26:33
  think
• 26:33
  beyond
• 26:33
  like
• 26:34
  just,
• 26:34
  just
• 26:34
  think
• 26:35
  of
• 26:35
  it
• 26:36
  not
• 26:36
  as
• 26:36
  a,
• 26:36
  in
• 26:37
  a
• 26:37
  textbook
• 26:37
  way,
• 26:38
  but
• 26:38
  in
• 26:38
  this
• 26:38
  beautiful,
• 26:39
  more
• 26:39
  encompassing
• 26:40
  broad
• 26:40
  way,
• 26:41
  right?
• 26:41
  How
• 26:42
  it's,
• 26:43
  it's
• 26:43
  going
• 26:43
  to
• 26:43
  take
• 26:43
  a
• 26:44
  little
• 26:44
  more
• 26:44
  time
• 26:44
  to
• 26:45
  achieve
• 26:45
  a
• 26:45
  steady
• 26:46
  state,
• 26:47
  right?
• 26:47
  Steady
• 26:47
  state's
• 26:48
  the
• 26:48
  point
• 26:48
  at
• 26:48
  which
• 26:48
  the
• 26:48
  amount
• 26:49
  of
• 26:49
  drug
• 26:49
  coming
• 26:50
  in
• 26:50
  equals
• 26:50
  the
• 26:50
  amount
• 26:51
  being
• 26:51
  cleared.
• 26:52
  So
• 26:52
  the
• 26:52
  blood
• 26:52
  level's
• 26:53
  a
• 26:53
  little
• 26:53
  bit
• 26:53
  stable.
• 26:54
  And
• 26:54
  of
• 26:54
  course
• 26:55
  that
• 26:55
  depends
• 26:55
  on
• 26:55
  the
• 26:55
  half
• 26:56
  lives,
• 26:56
  right?
• 26:57
  If
• 26:58
  a
• 26:58
  medication
• 26:58
  has
• 26:59
  a
• 26:59
  longer
• 27:00
  half
• 27:00
  life,
• 27:00
  it's
• 27:00
  going
• 27:01
  to
• 27:01
  take
• 27:01
  longer
• 27:01
  to
• 27:02
  get
• 27:02
  that
• 27:02
  medication
• 27:02
  to
• 27:03
  a
• 27:03
  steady
• 27:03
  state
• 27:04
  where
• 27:04
  your
• 27:04
  blood
• 27:04
  levels
• 27:05
  are
• 27:05
  stable.
• 27:06
  So
• 27:06
  onboarding
• 27:07
  Prozac
• 27:07
  is
• 27:07
  going
• 27:08
  to
• 27:08
  take
• 27:08
  a
• 27:08
  little
• 27:08
  bit
• 27:08
  of
• 27:08
  time
• 27:09
  because
• 27:09
  it
• 27:10
  takes
• 27:10
  forever.
• 27:10
  Again,
• 27:11
  the
• 27:11
  old
• 27:11
  ladies
• 27:11
  having
• 27:12
  a
• 27:12
  hard
• 27:12
  time
• 27:12
  getting
• 27:13
  onto
• 27:13
  the
• 27:13
  bus
• 27:14
  takes
• 27:14
  her
• 27:14
  a
• 27:14
  little
• 27:15
  more
• 27:15
  time,
• 27:16
  Right?
• 27:16
  But
• 27:17
  it's
• 27:17
  kind
• 27:17
  of
• 27:17
  nice
• 27:17
  because
• 27:18
  if
• 27:18
  you're
• 27:18
  sprinting
• 27:18
  your
• 27:19
  way
• 27:19
  on
• 27:19
  the
• 27:19
  bus,
• 27:19
  maybe
• 27:20
  you're
• 27:20
  going
• 27:20
  to
• 27:20
  hit
• 27:20
  your
• 27:20
  head
• 27:20
  on
• 27:21
  the
• 27:21
  steering
• 27:21
  wheel
• 27:21
  on
• 27:21
  your
• 27:22
  way
• 27:22
  in.
• 27:22
  Maybe
• 27:23
  you're
• 27:23
  going
• 27:23
  to
• 27:23
  forget
• 27:23
  to
• 27:23
  pay
• 27:24
  and
• 27:24
  the
• 27:25
  driver
• 27:25
  is
• 27:25
  going
• 27:25
  to
• 27:25
  come
• 27:26
  beat
• 27:26
  you
• 27:26
  with
• 27:26
  a
• 27:26
  club.
• 27:27
  Because,
• 27:28
  by
• 27:28
  the
• 27:28
  way,
• 27:28
  none
• 27:28
  of
• 27:28
  this
• 27:29
  is
• 27:29
  supposed
• 27:29
  to
• 27:29
  be
• 27:29
  violent
• 27:30
  or
• 27:30
  offensive.
• 27:31
  It's
• 27:31
  supposed
• 27:31
  to
• 27:32
  be.
• 27:32
  Some
• 27:32
  of
• 27:32
  these
• 27:33
  images
• 27:33
  are
• 27:33
  supposed
• 27:33
  to
• 27:34
  be
• 27:34
  a
• 27:34
  little
• 27:34
  bit
• 27:34
  chaotic
• 27:35
  and
• 27:35
  crazy
• 27:36
  because
• 27:36
  they
• 27:36
  stick
• 27:37
  in
• 27:37
  your
• 27:37
  brain
• 27:37
  a
• 27:37
  little
• 27:37
  longer.
• 27:38
  Right?
• 27:38
  We
• 27:39
  talked
• 27:39
  about
• 27:39
  the
• 27:39
  jumping
• 27:40
  out
• 27:40
  of
• 27:40
  the
• 27:40
  bus
• 27:40
  window.
• 27:41
  That's
• 27:42
  not
• 27:42
  meant
• 27:42
  to
• 27:42
  give
• 27:42
  you,
• 27:43
  like
• 27:43
  a
• 27:43
  creepy
• 27:44
  experience
• 27:45
  here.
• 27:45
  It's
• 27:45
  meant
• 27:45
  to
• 27:46
  stick
• 27:46
  into
• 27:46
  your
• 27:47
  mind
• 27:47
  more,
• 27:47
  Right?
• 27:48
  There's
• 27:48
  a.
• 27:48
  There's
• 27:48
  a
• 27:49
  method
• 27:49
  to
• 27:49
  this,
• 27:49
  my
• 27:50
  friends.
• 27:51
  Well,
• 27:51
  anyway,
• 27:52
  so
• 27:52
  I
• 27:53
  hope
• 27:53
  you
• 27:53
  appreciated
• 27:54
  this.
• 27:54
  There's
• 27:55
  some
• 27:55
  more
• 27:55
  pros
• 27:55
  and
• 27:55
  cons
• 27:56
  that
• 27:56
  we
• 27:56
  can
• 27:56
  sprinkle
• 27:56
  in
• 27:57
  before
• 27:57
  we
• 27:57
  go.
• 27:57
  By
• 27:58
  the
• 27:58
  way,
• 27:58
  if
• 27:59
  you
• 27:59
  wanted
• 27:59
  to.
• 28:00
  Lexapro,
• 28:01
  I
• 28:02
  don't
• 28:02
  mean
• 28:02
  to
• 28:02
  beat
• 28:02
  up
• 28:03
  on
• 28:03
  it.
• 28:03
  I
• 28:03
  think
• 28:03
  I
• 28:03
  gave
• 28:03
  it
• 28:04
  a
• 28:04
  fair
• 28:04
  assessment.
• 28:04
  It
• 28:04
  can
• 28:05
  be
• 28:05
  really
• 28:06
  low
• 28:06
  drama,
• 28:06
  really
• 28:07
  good,
• 28:07
  really
• 28:07
  clean,
• 28:08
  and
• 28:09
  it's
• 28:09
  arguably
• 28:10
  one
• 28:10
  of
• 28:10
  the
• 28:10
  best
• 28:10
  tolerated
• 28:11
  SSRIs.
• 28:12
  And
• 28:13
  remember
• 28:13
  that
• 28:13
  old
• 28:14
  adage,
• 28:14
  that
• 28:15
  old
• 28:15
  saying,
• 28:16
  what's
• 28:17
  the
• 28:17
  best
• 28:17
  medication?
• 28:18
  Trick
• 28:18
  question.
• 28:19
  It's
• 28:19
  the
• 28:19
  med
• 28:20
  your
• 28:20
  patient
• 28:20
  is
• 28:20
  willing
• 28:21
  to
• 28:21
  take,
• 28:21
  right?
• 28:22
  So
• 28:22
  if
• 28:22
  Lexapro
• 28:23
  is
• 28:24
  the
• 28:24
  most
• 28:24
  tolerated
• 28:25
  medication,
• 28:25
  it
• 28:26
  doesn't
• 28:26
  matter.
• 28:27
  If
• 28:27
  Prozac
• 28:28
  is
• 28:28
  so
• 28:28
  fancy
• 28:29
  on
• 28:29
  paper
• 28:29
  and
• 28:30
  it
• 28:30
  has
• 28:30
  all
• 28:30
  these
• 28:30
  FDA
• 28:31
  indications,
• 28:32
  if
• 28:32
  your
• 28:32
  patient
• 28:32
  won't
• 28:33
  tolerate
• 28:33
  Prozac
• 28:34
  and
• 28:34
  they
• 28:35
  end
• 28:35
  up
• 28:35
  tolerating
• 28:36
  Lexapro
• 28:36
  and
• 28:37
  they're
• 28:37
  pleased
• 28:37
  with
• 28:37
  it,
• 28:38
  well,
• 28:38
  guess
• 28:38
  what?
• 28:39
  Throw
• 28:39
  out
• 28:39
  all
• 28:40
  this
• 28:40
  textbook
• 28:40
  stuff,
• 28:41
  just
• 28:41
  throw
• 28:41
  it
• 28:41
  out
• 28:41
  the
• 28:42
  window.
• 28:42
  Because
• 28:42
  guess
• 28:42
  what?
• 28:43
  They
• 28:44
  like
• 28:44
  Lexapro
• 28:45
  better.
• 28:45
  And
• 28:45
  you
• 28:45
  could
• 28:45
  just
• 28:46
  point
• 28:46
  to
• 28:46
  all
• 28:46
  the
• 28:47
  textbooks,
• 28:49
  all
• 28:49
  the
• 28:49
  highlighted
• 28:50
  pages
• 28:50
  and
• 28:51
  graphics
• 28:51
  and
• 28:52
  figures.
• 28:52
  It
• 28:53
  doesn't
• 28:53
  matter.
• 28:53
  Because
• 28:54
  the
• 28:54
  best
• 28:55
  medication
• 28:55
  is
• 28:56
  the
• 28:56
  one
• 28:56
  your
• 28:56
  patient
• 28:56
  is
• 28:57
  willing
• 28:57
  to
• 28:57
  take.
• 28:58
  And
• 28:58
  Lexapro
• 28:59
  is
• 28:59
  cited
• 29:00
  in
• 29:00
  a
• 29:00
  lot
• 29:00
  of
• 29:00
  very
• 29:01
  compelling
• 29:01
  studies
• 29:02
  as
• 29:02
  being
• 29:02
  some
• 29:02
  of
• 29:03
  the
• 29:03
  best
• 29:03
  tolerated
• 29:04
  medication
• 29:04
  out
• 29:05
  there
• 29:05
  in
• 29:06
  the
• 29:06
  psychotropic
• 29:06
  land.
• 29:07
  And
• 29:08
  it's
• 29:08
  better
• 29:08
  for
• 29:08
  polypharmacy.
• 29:10
  It's
• 29:10
  a
• 29:10
  little
• 29:10
  more
• 29:11
  pure.
• 29:12
  For
• 29:12
  Benny,
• 29:12
  we're
• 29:13
  going
• 29:13
  to
• 29:13
  start
• 29:13
  him
• 29:13
  on
• 29:13
  Prozac
• 29:14
  at
• 29:14
  10
• 29:14
  milligrams.
• 29:15
  We're
• 29:15
  going
• 29:15
  to
• 29:15
  boost
• 29:15
  him
• 29:16
  up
• 29:16
  to
• 29:16
  20
• 29:16
  milligrams
• 29:17
  after
• 29:17
  a
• 29:17
  week.
• 29:17
  If
• 29:17
  he
• 29:17
  tolerates
• 29:18
  it
• 29:18
  well,
• 29:19
  we
• 29:19
  really
• 29:19
  want
• 29:20
  to
• 29:20
  take
• 29:20
  advantage
• 29:20
  of
• 29:20
  that.
• 29:21
  5ht
• 29:21
  2c
• 29:22
  blockade.
• 29:22
  Give
• 29:23
  him
• 29:23
  a
• 29:23
  little
• 29:23
  pep
• 29:23
  in
• 29:23
  his
• 29:24
  step.
• 29:24
  We're
• 29:25
  going
• 29:25
  to
• 29:25
  monitor
• 29:25
  any
• 29:25
  medications
• 29:26
  that
• 29:26
  he
• 29:26
  does
• 29:27
  on
• 29:27
  board
• 29:28
  to
• 29:28
  make
• 29:28
  sure
• 29:28
  that
• 29:29
  we're
• 29:29
  not
• 29:29
  inhibiting
• 29:29
  other
• 29:30
  medications
• 29:30
  down
• 29:31
  the
• 29:31
  road.
• 29:32
  We're
• 29:32
  going
• 29:32
  to
• 29:32
  give
• 29:32
  him
• 29:33
  that
• 29:33
  education.
• 29:34
  We're
• 29:34
  going
• 29:34
  to
• 29:35
  see
• 29:35
  how
• 29:35
  he
• 29:35
  onboards
• 29:36
  the
• 29:36
  medication.
• 29:37
  But
• 29:38
  you
• 29:38
  know,
• 29:39
  that's
• 29:39
  what
• 29:40
  we're
• 29:40
  doing.
• 29:40
  I
• 29:40
  hope
• 29:41
  you
• 29:41
  have
• 29:41
  a
• 29:41
  finer
• 29:41
  appreciation
• 29:42
  for
• 29:42
  why
• 29:42
  we
• 29:43
  did
• 29:43
  it,
• 29:44
  an
• 29:44
  even
• 29:44
  finer
• 29:45
  appreciation
• 29:45
  for
• 29:45
  the
• 29:46
  fact
• 29:46
  that
• 29:46
  there
• 29:47
  are
• 29:47
  many
• 29:47
  other
• 29:47
  meds
• 29:48
  out
• 29:48
  there.
• 29:48
  Right?
• 29:48
  We
• 29:49
  talked
• 29:49
  about
• 29:49
  Paxil,
• 29:49
  Effexor,
• 29:51
  Pristique.
• 29:51
  There's
• 29:52
  all
• 29:52
  kinds
• 29:52
  of
• 29:52
  meds
• 29:53
  out
• 29:53
  there
• 29:53
  that
• 29:53
  are
• 29:53
  all
• 29:53
  unique
• 29:54
  in
• 29:54
  their
• 29:54
  own
• 29:54
  ways
• 29:55
  and
• 29:55
  it's
• 29:55
  fun
• 29:56
  to
• 29:56
  nerd
• 29:56
  out
• 29:56
  and
• 29:56
  talk
• 29:57
  about
• 29:57
  them
• 29:57
  and
• 29:57
  why
• 29:58
  some
• 29:58
  are
• 29:58
  cooler
• 29:59
  than
• 29:59
  others
• 29:59
  or
• 29:59
  better
• 29:59
  than
• 30:00
  others
• 30:00
  or
• 30:00
  more
• 30:01
  suitable
• 30:01
  than
• 30:01
  others,
• 30:01
  depending
• 30:02
  on
• 30:02
  the
• 30:02
  patient.
• 30:03
  So
• 30:03
  I
• 30:03
  really
• 30:03
  hope
• 30:03
  you
• 30:04
  enjoyed
• 30:04
  this.
• 30:05
  Don't
• 30:05
  forget,
• 30:05
  Please
• 30:06
  don't
• 30:06
  forget
• 30:06
  to
• 30:07
  subscribe
• 30:07
  to
• 30:07
  us
• 30:07
  to
• 30:08
  give
• 30:08
  us
• 30:08
  a
• 30:08
  good
• 30:08
  rating
• 30:09
  on
• 30:09
  Apple.
• 30:10
  That's
• 30:10
  the
• 30:10
  best
• 30:10
  way
• 30:10
  you
• 30:10
  can
• 30:10
  help
• 30:11
  us.
• 30:11
  Becoming
• 30:11
  a
• 30:12
  Patreon
• 30:12
  member
• 30:12
  would
• 30:13
  be
• 30:13
  a
• 30:13
  great
• 30:13
  idea.
• 30:14
  Why?
• 30:14
  Because
• 30:15
  you
• 30:15
  get
• 30:15
  these
• 30:16
  lectures
• 30:16
  in
• 30:17
  slide
• 30:17
  deck
• 30:17
  form
• 30:17
  form
• 30:18
  beautiful
• 30:18
  slide
• 30:19
  decks,
• 30:19
  chock
• 30:20
  full
• 30:20
  of
• 30:20
  pearls
• 30:21
  and
• 30:22
  ways
• 30:22
  you
• 30:23
  can
• 30:23
  boost
• 30:23
  your
• 30:23
  practice.
• 30:24
  They're
• 30:24
  great
• 30:24
  to
• 30:24
  have
• 30:25
  if
• 30:25
  you're
• 30:25
  in
• 30:25
  school.
• 30:26
  We
• 30:26
  keep
• 30:26
  things
• 30:27
  affordable,
• 30:27
  we
• 30:27
  keep
• 30:28
  things
• 30:28
  fun.
• 30:28
  But
• 30:29
  you
• 30:29
  get
• 30:29
  slide
• 30:29
  decks.
• 30:30
  You
• 30:30
  even
• 30:30
  get
• 30:30
  a
• 30:30
  bonus
• 30:31
  podcast
• 30:32
  where
• 30:32
  you're
• 30:32
  going
• 30:33
  to
• 30:33
  get
• 30:33
  more
• 30:34
  case
• 30:34
  studies,
• 30:34
  more
• 30:35
  knowledge
• 30:35
  to
• 30:35
  really
• 30:36
  prep
• 30:36
  you
• 30:37
  up
• 30:37
  and
• 30:37
  make
• 30:37
  you
• 30:38
  feel
• 30:38
  empowered
• 30:38
  to
• 30:38
  pass
• 30:39
  your
• 30:39
  boards
• 30:39
  and
• 30:39
  practice.
• 30:40
  It's
• 30:40
  always
• 30:40
  a
• 30:41
  pleasure
• 30:41
  being
• 30:41
  here
• 30:41
  with
• 30:42
  my
• 30:42
  friends.
• 30:43
  Tune
• 30:43
  in
• 30:43
  next
• 30:44
  time.
• 30:45
  Au
• 30:45
  revoir.