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Five Essential Medications for Managing Acute Bipolar Depression - And how to Think of Them · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  My
• 0:05
  friends,
• 0:06
  welcome
• 0:06
  back
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:09
  Npz.
• 0:09
  Here
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:10
  your
• 0:11
  pocket
• 0:11
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:13
  pearls
• 0:13
  that
• 0:13
  prep
• 0:14
  you
• 0:14
  to
• 0:15
  practice.
• 0:16
  So
• 0:16
  today
• 0:16
  is
• 0:16
  more
• 0:17
  of
• 0:17
  a
• 0:17
  discussion
• 0:18
  than
• 0:18
  a
• 0:18
  lecture.
• 0:19
  You
• 0:20
  know
• 0:20
  my
• 0:20
  style,
• 0:20
  I
• 0:20
  like
• 0:21
  to
• 0:21
  kind
• 0:21
  of
• 0:21
  just
• 0:21
  chat
• 0:22
  and
• 0:22
  riff
• 0:23
  off
• 0:23
  of
• 0:23
  a
• 0:23
  lot
• 0:23
  of
• 0:23
  these
• 0:24
  medications
• 0:24
  and
• 0:25
  a
• 0:25
  lot
• 0:25
  of
• 0:25
  these
• 0:25
  mock
• 0:26
  case
• 0:26
  studies
• 0:27
  and
• 0:27
  potential
• 0:28
  diagnoses
• 0:29
  and
• 0:29
  things.
• 0:29
  I
• 0:29
  find
• 0:30
  it
• 0:30
  to
• 0:30
  be
• 0:30
  really
• 0:30
  fun
• 0:30
  and
• 0:31
  creative
• 0:31
  and
• 0:31
  interesting.
• 0:32
  Hopefully
• 0:32
  you
• 0:32
  you
• 0:33
  agree.
• 0:34
  And
• 0:34
  so
• 0:34
  today
• 0:34
  we're
• 0:35
  going
• 0:35
  to
• 0:35
  do
• 0:35
  kind
• 0:35
  of
• 0:35
  a
• 0:36
  deeper
• 0:36
  dive
• 0:37
  into
• 0:38
  what
• 0:38
  we
• 0:39
  do
• 0:39
  with
• 0:40
  acute
• 0:40
  bipolar
• 0:41
  depression.
• 0:42
  And
• 0:42
  what
• 0:42
  the
• 0:42
  heck
• 0:42
  do
• 0:43
  I
• 0:43
  mean
• 0:43
  by
• 0:43
  that
• 0:43
  for
• 0:43
  the
• 0:44
  students
• 0:44
  still
• 0:45
  learning
• 0:45
  this
• 0:45
  in
• 0:45
  school?
• 0:46
  What
• 0:46
  I
• 0:46
  mean
• 0:46
  by
• 0:47
  that
• 0:47
  is
• 0:47
  you
• 0:48
  have
• 0:48
  a
• 0:48
  patient
• 0:48
  who
• 0:48
  can
• 0:49
  swing
• 0:49
  to
• 0:49
  both
• 0:50
  poles.
• 0:50
  They
• 0:50
  can
• 0:50
  be
• 0:51
  depressed
• 0:52
  and
• 0:52
  they
• 0:52
  can
• 0:52
  be
• 0:52
  manic.
• 0:53
  Whether
• 0:53
  it
• 0:54
  be
• 0:54
  hypomanic
• 0:54
  or
• 0:55
  manic,
• 0:55
  that
• 0:55
  doesn't
• 0:55
  matter
• 0:56
  right
• 0:56
  now.
• 0:56
  But
• 0:56
  they
• 0:56
  swing
• 0:56
  to
• 0:57
  both
• 0:57
  poles
• 0:58
  and
• 0:58
  they're
• 0:58
  coming
• 0:59
  to
• 0:59
  you
• 0:59
  like
• 1:00
  most
• 1:00
  folks
• 1:00
  come
• 1:01
  to
• 1:01
  you
• 1:01
  with
• 1:01
  bipolar
• 1:02
  I
• 1:02
  or
• 1:02
  bipolar
• 1:03
  2
• 1:03
  and
• 1:03
  they're
• 1:04
  in
• 1:04
  the
• 1:04
  acute
• 1:04
  depressive
• 1:05
  phase,
• 1:05
  meaning
• 1:05
  they're
• 1:06
  super
• 1:06
  depressed
• 1:07
  and
• 1:07
  they
• 1:07
  really
• 1:08
  need
• 1:08
  you
• 1:08
  to
• 1:08
  treat
• 1:08
  their
• 1:08
  depression
• 1:09
  right
• 1:09
  now.
• 1:10
  It's
• 1:10
  not
• 1:10
  to
• 1:11
  say
• 1:11
  you
• 1:11
  should
• 1:11
  ignore
• 1:12
  their
• 1:13
  mania
• 1:13
  or
• 1:13
  hypomania
• 1:14
  or
• 1:14
  the
• 1:14
  fact
• 1:14
  that
• 1:15
  they
• 1:15
  can
• 1:15
  swing
• 1:15
  to
• 1:15
  hypomania
• 1:16
  or
• 1:16
  mania,
• 1:17
  but
• 1:17
  right
• 1:17
  now,
• 1:18
  what's
• 1:18
  in
• 1:18
  front
• 1:18
  of
• 1:19
  them,
• 1:19
  the
• 1:19
  debilitating
• 1:20
  feature
• 1:21
  that
• 1:21
  they're
• 1:21
  grappling
• 1:22
  with
• 1:22
  is
• 1:22
  their
• 1:22
  depression.
• 1:23
  They
• 1:23
  can't
• 1:23
  get
• 1:23
  out
• 1:24
  of
• 1:24
  bed,
• 1:24
  they're
• 1:24
  extremely
• 1:25
  self
• 1:25
  critical.
• 1:25
  Maybe
• 1:26
  they're
• 1:26
  thinking
• 1:26
  of
• 1:26
  suicide
• 1:27
  a
• 1:27
  lot,
• 1:27
  they
• 1:28
  just
• 1:28
  can't
• 1:28
  hold
• 1:28
  a
• 1:29
  job.
• 1:29
  Maybe
• 1:29
  they're
• 1:29
  on
• 1:29
  disability
• 1:30
  or
• 1:30
  leave
• 1:31
  and
• 1:31
  it's
• 1:32
  a
• 1:32
  pretty
• 1:32
  serious
• 1:32
  problem.
• 1:33
  And
• 1:33
  I
• 1:33
  will
• 1:33
  admit
• 1:34
  I
• 1:34
  was
• 1:34
  a
• 1:34
  little
• 1:35
  flummoxed
• 1:35
  by
• 1:36
  this.
• 1:36
  As
• 1:36
  a
• 1:36
  new
• 1:36
  grad,
• 1:37
  I
• 1:38
  did
• 1:38
  very
• 1:38
  well
• 1:38
  in
• 1:39
  psychopharmacology.
• 1:40
  I
• 1:40
  did
• 1:40
  very
• 1:40
  well
• 1:40
  in
• 1:40
  my
• 1:41
  diagnostic
• 1:42
  classes.
• 1:42
  But
• 1:43
  I
• 1:43
  was
• 1:43
  still
• 1:43
  a
• 1:43
  little
• 1:43
  stumped
• 1:44
  sometimes
• 1:44
  cuz
• 1:45
  I'm
• 1:45
  thinking
• 1:45
  to
• 1:45
  myself,
• 1:45
  wait
• 1:46
  a
• 1:46
  minute,
• 1:46
  you're
• 1:46
  so
• 1:47
  overwhelmed.
• 1:48
  And
• 1:48
  you're
• 1:48
  like,
• 1:48
  wait,
• 1:48
  I
• 1:49
  can't
• 1:49
  give
• 1:49
  an
• 1:49
  antidepressant
• 1:50
  here,
• 1:50
  really.
• 1:50
  I
• 1:51
  mean,
• 1:51
  maybe
• 1:51
  I
• 1:51
  could
• 1:52
  go
• 1:52
  for
• 1:52
  some
• 1:52
  Wellbutrin.
• 1:53
  It's
• 1:53
  the
• 1:53
  least
• 1:54
  likely
• 1:54
  to
• 1:54
  induce
• 1:55
  mania
• 1:55
  or
• 1:55
  hypomania.
• 1:56
  At
• 1:56
  the
• 1:56
  same
• 1:57
  time,
• 1:57
  like
• 1:57
  what
• 1:57
  are
• 1:57
  my
• 1:57
  other
• 1:58
  options
• 1:58
  here?
• 1:58
  What
• 1:58
  if
• 1:59
  I
• 1:59
  wanted
• 1:59
  to
• 1:59
  prescribe
• 2:00
  Wellbutrin,
• 2:00
  but
• 2:01
  the
• 2:01
  patient
• 2:01
  has
• 2:01
  a
• 2:01
  history
• 2:02
  of
• 2:02
  seizures
• 2:02
  or
• 2:02
  eating
• 2:03
  disorders
• 2:03
  and
• 2:03
  it's
• 2:04
  like,
• 2:04
  well,
• 2:04
  there
• 2:04
  goes
• 2:04
  that.
• 2:05
  I
• 2:05
  can't
• 2:05
  prescribe
• 2:06
  Wellbutrin
• 2:07
  anymore.
• 2:07
  What
• 2:08
  if
• 2:08
  they
• 2:08
  have
• 2:08
  tried
• 2:09
  Wellbutrin
• 2:09
  in
• 2:09
  the
• 2:10
  past
• 2:10
  and
• 2:10
  it
• 2:10
  just
• 2:10
  did
• 2:10
  nothing
• 2:11
  or
• 2:11
  it
• 2:11
  made
• 2:11
  them
• 2:11
  Highly
• 2:12
  anxious.
• 2:12
  You
• 2:12
  know,
• 2:12
  some
• 2:12
  people
• 2:13
  compare
• 2:14
  Wellbutrin
• 2:14
  to,
• 2:14
  like,
• 2:15
  a
• 2:15
  pot
• 2:15
  of
• 2:15
  coffee,
• 2:15
  a
• 2:16
  whole
• 2:16
  pot
• 2:16
  of
• 2:16
  coffee
• 2:16
  in
• 2:17
  the
• 2:17
  morning,
• 2:17
  and
• 2:17
  they
• 2:17
  can't
• 2:17
  tolerate
• 2:18
  it,
• 2:18
  especially
• 2:19
  if
• 2:19
  they're
• 2:19
  more
• 2:19
  anxious.
• 2:20
  Not
• 2:20
  to
• 2:21
  add
• 2:21
  layers
• 2:21
  of
• 2:22
  confusion
• 2:22
  or
• 2:22
  complexity
• 2:23
  to
• 2:23
  this,
• 2:23
  but
• 2:23
  in
• 2:24
  the
• 2:24
  real
• 2:24
  world,
• 2:24
  you'll
• 2:25
  also
• 2:25
  hear
• 2:25
  patients
• 2:26
  swear
• 2:26
  by
• 2:27
  the
• 2:27
  fact
• 2:27
  that
• 2:27
  Wellbutrin
• 2:28
  makes
• 2:28
  them
• 2:28
  feel
• 2:28
  a
• 2:28
  lot
• 2:29
  less
• 2:29
  anxious,
• 2:30
  which
• 2:30
  doesn't
• 2:30
  make
• 2:30
  a
• 2:31
  lot
• 2:31
  of
• 2:31
  sense
• 2:31
  on
• 2:31
  paper.
• 2:32
  Sometimes
• 2:33
  you
• 2:33
  have
• 2:33
  to
• 2:33
  think
• 2:33
  about
• 2:33
  it
• 2:34
  and
• 2:34
  wonder
• 2:34
  about
• 2:34
  that.
• 2:35
  But
• 2:35
  it's
• 2:35
  a
• 2:35
  coin
• 2:36
  flip,
• 2:36
  right?
• 2:36
  It
• 2:36
  either
• 2:37
  can
• 2:37
  worsen
• 2:37
  anxiety
• 2:38
  a
• 2:38
  lot
• 2:39
  or
• 2:39
  it
• 2:39
  will
• 2:40
  make
• 2:40
  people
• 2:40
  feel
• 2:41
  really
• 2:41
  calm.
• 2:42
  I
• 2:42
  tend
• 2:42
  the
• 2:43
  folks
• 2:43
  who
• 2:43
  say
• 2:43
  Wellbutrin
• 2:44
  is
• 2:44
  calming
• 2:45
  in
• 2:45
  many,
• 2:45
  many
• 2:46
  times.
• 2:46
  I
• 2:46
  think
• 2:46
  they're
• 2:46
  almost
• 2:47
  describing
• 2:47
  their
• 2:47
  adhd,
• 2:48
  which
• 2:48
  is
• 2:48
  getting
• 2:49
  a
• 2:49
  little
• 2:49
  easier
• 2:50
  to
• 2:50
  handle.
• 2:50
  Their
• 2:50
  thoughts
• 2:51
  are
• 2:51
  getting
• 2:51
  more
• 2:51
  focused,
• 2:52
  more
• 2:52
  lasered
• 2:52
  in,
• 2:53
  and
• 2:53
  they
• 2:53
  don't
• 2:53
  feel
• 2:54
  as
• 2:54
  overwhelmed
• 2:55
  by
• 2:55
  so
• 2:56
  many
• 2:56
  thoughts
• 2:56
  that
• 2:57
  make
• 2:57
  them
• 2:57
  feel
• 2:57
  very
• 2:57
  disorganized
• 2:58
  or
• 2:58
  chaotic.
• 2:59
  And
• 3:00
  I've
• 3:00
  learned
• 3:00
  through
• 3:00
  history,
• 3:01
  through
• 3:01
  experience,
• 3:02
  that
• 3:02
  a
• 3:02
  lot
• 3:02
  of
• 3:02
  patients
• 3:03
  mischaracterize
• 3:04
  the
• 3:04
  adhd,
• 3:05
  hyperarousal
• 3:06
  and
• 3:07
  lack
• 3:08
  of
• 3:09
  ability
• 3:09
  to
• 3:09
  prioritize
• 3:10
  easily
• 3:11
  with
• 3:11
  anxiety.
• 3:11
  They
• 3:12
  kind
• 3:12
  of
• 3:12
  equate
• 3:12
  those
• 3:12
  two,
• 3:13
  so
• 3:13
  they
• 3:13
  might
• 3:13
  tell
• 3:13
  you
• 3:14
  it
• 3:14
  helps
• 3:14
  for
• 3:14
  anxiety.
• 3:15
  Nonetheless,
• 3:15
  my
• 3:15
  friends,
• 3:16
  again,
• 3:17
  you're
• 3:17
  confronted
• 3:18
  with
• 3:18
  this
• 3:18
  acute
• 3:18
  bipolar
• 3:19
  depression.
• 3:19
  You've
• 3:20
  got
• 3:20
  to
• 3:20
  treat
• 3:20
  the
• 3:20
  depression
• 3:21
  in
• 3:21
  front
• 3:21
  of
• 3:21
  you.
• 3:22
  And
• 3:22
  I'll
• 3:22
  be
• 3:23
  honest,
• 3:23
  some
• 3:23
  of
• 3:23
  these
• 3:23
  patients,
• 3:23
  it
• 3:24
  can
• 3:24
  be
• 3:24
  very
• 3:24
  difficult
• 3:25
  because
• 3:25
  it's
• 3:25
  pretty
• 3:25
  rare
• 3:25
  they
• 3:26
  come
• 3:26
  to
• 3:26
  you
• 3:26
  for
• 3:26
  the
• 3:26
  very
• 3:27
  first
• 3:27
  time,
• 3:27
  right?
• 3:28
  So
• 3:29
  they
• 3:29
  often
• 3:30
  have
• 3:30
  two
• 3:30
  or
• 3:31
  three
• 3:31
  medications.
• 3:31
  They're
• 3:32
  already
• 3:32
  telling
• 3:32
  you
• 3:32
  they're
• 3:33
  not
• 3:33
  going
• 3:33
  to
• 3:33
  try
• 3:33
  again.
• 3:34
  They
• 3:34
  don't
• 3:34
  want
• 3:34
  to
• 3:34
  try
• 3:35
  them
• 3:35
  again.
• 3:35
  They're
• 3:36
  either
• 3:36
  failed
• 3:36
  trials
• 3:37
  because
• 3:38
  it
• 3:38
  just
• 3:38
  didn't
• 3:38
  work,
• 3:39
  or
• 3:39
  the
• 3:39
  side
• 3:39
  effect
• 3:40
  profile
• 3:40
  was
• 3:40
  ruthless.
• 3:41
  And
• 3:42
  so
• 3:42
  here
• 3:43
  you
• 3:43
  are,
• 3:43
  it's
• 3:44
  one
• 3:44
  of
• 3:44
  your
• 3:44
  first
• 3:44
  new
• 3:44
  patients.
• 3:45
  You
• 3:46
  have
• 3:46
  a
• 3:46
  patient
• 3:46
  who
• 3:46
  can
• 3:46
  swing
• 3:47
  to
• 3:47
  both
• 3:47
  poles.
• 3:48
  And
• 3:49
  let's
• 3:49
  say
• 3:49
  you've
• 3:49
  done
• 3:49
  the
• 3:50
  interview,
• 3:50
  you've
• 3:50
  ruled
• 3:51
  out
• 3:51
  medical
• 3:51
  stuff,
• 3:51
  and
• 3:51
  you've
• 3:52
  got
• 3:52
  to
• 3:52
  ask
• 3:53
  yourself,
• 3:53
  well,
• 3:53
  what
• 3:53
  do
• 3:53
  we
• 3:54
  do
• 3:54
  here?
• 3:54
  I
• 3:54
  can't
• 3:54
  do
• 3:55
  Wellbutrin.
• 3:56
  Well,
• 3:56
  my
• 3:56
  friends,
• 3:57
  there's
• 3:57
  typically
• 3:58
  five
• 3:59
  main
• 3:59
  medications
• 4:00
  we
• 4:00
  can
• 4:00
  focus
• 4:01
  on
• 4:01
  at
• 4:01
  least
• 4:01
  for
• 4:01
  this
• 4:02
  discussion
• 4:03
  today,
• 4:03
  five
• 4:03
  medications
• 4:04
  that
• 4:05
  we
• 4:06
  can
• 4:06
  look
• 4:06
  at
• 4:07
  to
• 4:07
  treat
• 4:08
  the
• 4:08
  patient's
• 4:09
  acute
• 4:09
  bipolar
• 4:10
  depression
• 4:10
  in
• 4:10
  front
• 4:10
  of
• 4:11
  you.
• 4:11
  And
• 4:11
  before
• 4:12
  I
• 4:12
  overwhelm
• 4:12
  you
• 4:13
  with
• 4:13
  a
• 4:13
  bunch
• 4:13
  of
• 4:13
  receptor
• 4:14
  talk,
• 4:14
  and
• 4:15
  I
• 4:15
  want
• 4:15
  to
• 4:15
  really
• 4:15
  make
• 4:16
  this
• 4:16
  simple
• 4:16
  and
• 4:16
  clean,
• 4:17
  because
• 4:17
  it
• 4:18
  really
• 4:18
  can
• 4:18
  be
• 4:18
  simple
• 4:18
  and
• 4:19
  clean.
• 4:19
  When
• 4:20
  in
• 4:20
  doubt,
• 4:20
  my
• 4:21
  friends,
• 4:21
  just
• 4:22
  zoom
• 4:22
  out.
• 4:23
  When
• 4:23
  in
• 4:23
  doubt,
• 4:23
  zoom
• 4:24
  out
• 4:24
  and
• 4:24
  ask
• 4:25
  yourself,
• 4:26
  okay,
• 4:27
  what
• 4:27
  do
• 4:27
  I
• 4:27
  need
• 4:28
  here?
• 4:28
  Right?
• 4:29
  And
• 4:29
  the
• 4:29
  patient
• 4:29
  will
• 4:30
  tell
• 4:30
  you,
• 4:30
  this
• 4:30
  is
• 4:30
  the
• 4:31
  beauty
• 4:31
  of
• 4:31
  what
• 4:31
  we
• 4:32
  do
• 4:32
  in
• 4:33
  mental
• 4:33
  health,
• 4:33
  right?
• 4:34
  You're
• 4:34
  not
• 4:34
  some
• 4:35
  genie
• 4:35
  with
• 4:35
  a
• 4:35
  magic
• 4:36
  wand
• 4:36
  who
• 4:36
  just
• 4:36
  invents
• 4:37
  these
• 4:37
  treatment
• 4:38
  targets
• 4:38
  and
• 4:39
  treatment
• 4:39
  plans
• 4:39
  to
• 4:40
  make
• 4:40
  people
• 4:40
  better.
• 4:40
  They're
• 4:41
  going
• 4:41
  to
• 4:41
  come
• 4:41
  to
• 4:41
  you
• 4:41
  and
• 4:41
  give
• 4:42
  you
• 4:42
  the
• 4:42
  answers
• 4:43
  unwittingly,
• 4:44
  right?
• 4:44
  They're
• 4:44
  going
• 4:44
  to
• 4:44
  tell
• 4:45
  you,
• 4:45
  hey,
• 4:45
  buddy,
• 4:46
  I
• 4:46
  can't
• 4:47
  get
• 4:47
  out
• 4:47
  of
• 4:47
  bed.
• 4:48
  I'm
• 4:48
  sleeping
• 4:49
  all
• 4:49
  day.
• 4:50
  Nothing
• 4:50
  is
• 4:50
  enjoyable
• 4:51
  to
• 4:51
  me
• 4:51
  anymore.
• 4:52
  I
• 4:52
  used
• 4:52
  to
• 4:52
  play
• 4:52
  guitar.
• 4:53
  I
• 4:53
  don't
• 4:53
  even
• 4:54
  want
• 4:54
  to
• 4:55
  look
• 4:55
  at
• 4:55
  my
• 4:55
  guitar
• 4:55
  anymore.
• 4:56
  I
• 4:56
  won't
• 4:56
  even
• 4:56
  shake
• 4:56
  a
• 4:57
  maraca,
• 4:57
  for
• 4:58
  God's
• 4:58
  sake.
• 4:59
  I
• 4:59
  don't
• 4:59
  like
• 4:59
  music.
• 5:00
  I
• 5:00
  don't
• 5:01
  like
• 5:01
  waking
• 5:01
  up.
• 5:02
  So
• 5:02
  they
• 5:02
  will
• 5:03
  clue
• 5:03
  you
• 5:03
  in
• 5:04
  on
• 5:04
  the
• 5:04
  symptoms.
• 5:05
  And
• 5:05
  your
• 5:05
  goal,
• 5:05
  and
• 5:06
  it
• 5:06
  gets
• 5:06
  easier
• 5:06
  with
• 5:07
  time,
• 5:07
  I
• 5:07
  can
• 5:07
  assure
• 5:07
  you,
• 5:08
  is
• 5:09
  to
• 5:09
  tailor
• 5:10
  those
• 5:11
  life
• 5:11
  experiences
• 5:12
  into
• 5:13
  receptor
• 5:13
  targets
• 5:14
  by
• 5:15
  which
• 5:15
  you
• 5:15
  can
• 5:15
  then
• 5:16
  match
• 5:16
  that
• 5:17
  patient
• 5:18
  with
• 5:18
  a
• 5:18
  medication
• 5:19
  that
• 5:20
  can
• 5:21
  really
• 5:21
  change
• 5:21
  the
• 5:21
  game
• 5:22
  for
• 5:22
  them.
• 5:23
  And
• 5:23
  so
• 5:23
  that's
• 5:24
  what
• 5:24
  I
• 5:24
  want
• 5:24
  you
• 5:24
  to
• 5:24
  do
• 5:24
  at
• 5:24
  first,
• 5:25
  is
• 5:25
  paint
• 5:25
  the
• 5:26
  picture
• 5:26
  in
• 5:26
  your
• 5:26
  mind
• 5:27
  based
• 5:28
  off
• 5:28
  of
• 5:28
  the
• 5:28
  patient's
• 5:29
  experience.
• 5:30
  They're
• 5:30
  sharing
• 5:30
  with
• 5:31
  you
• 5:31
  about
• 5:31
  how
• 5:32
  they
• 5:32
  go
• 5:32
  about
• 5:32
  their
• 5:33
  day.
• 5:33
  Are
• 5:33
  they
• 5:34
  sleeping
• 5:34
  a
• 5:34
  lot?
• 5:35
  What's
• 5:35
  their
• 5:36
  energy
• 5:36
  level
• 5:36
  look
• 5:37
  like?
• 5:37
  Or
• 5:37
  do
• 5:38
  they
• 5:38
  have
• 5:38
  insomnia?
• 5:39
  Can
• 5:39
  they
• 5:39
  not
• 5:40
  focus?
• 5:40
  Do
• 5:40
  they
• 5:40
  have
• 5:40
  a
• 5:40
  job
• 5:41
  where
• 5:41
  they
• 5:42
  really
• 5:42
  need
• 5:42
  to
• 5:42
  focus
• 5:43
  and
• 5:43
  that's
• 5:43
  their
• 5:44
  main
• 5:44
  source
• 5:44
  of
• 5:44
  impairment?
• 5:45
  Remember,
• 5:45
  the
• 5:45
  main
• 5:45
  source
• 5:46
  of
• 5:46
  impairment
• 5:46
  is
• 5:46
  not
• 5:47
  what
• 5:47
  you
• 5:47
  think
• 5:47
  it
• 5:47
  is,
• 5:47
  it's
• 5:48
  what
• 5:48
  they
• 5:48
  tell
• 5:48
  you
• 5:48
  it
• 5:49
  is.
• 5:49
  They
• 5:49
  could
• 5:50
  tell
• 5:50
  you
• 5:50
  20
• 5:51
  which
• 5:51
  ways
• 5:51
  from
• 5:51
  Sunday
• 5:52
  that
• 5:53
  they're
• 5:53
  depressed
• 5:53
  or
• 5:54
  they're
• 5:54
  anxious,
• 5:55
  but
• 5:55
  it's
• 5:55
  your
• 5:55
  job
• 5:56
  to
• 5:56
  get
• 5:56
  kind
• 5:56
  of
• 5:57
  granular
• 5:57
  and
• 5:57
  figure
• 5:58
  out
• 5:58
  what
• 5:58
  part
• 5:58
  of
• 5:59
  their
• 5:59
  anxiety
• 5:59
  or
• 6:00
  depression
• 6:00
  based
• 6:01
  on
• 6:01
  what
• 6:01
  they
• 6:01
  told
• 6:01
  you,
• 6:01
  is
• 6:02
  the
• 6:02
  most
• 6:02
  impairing.
• 6:03
  So
• 6:03
  again,
• 6:03
  if
• 6:03
  someone's
• 6:04
  getting
• 6:04
  laid
• 6:04
  off
• 6:04
  from
• 6:04
  their
• 6:05
  job
• 6:05
  and
• 6:06
  their
• 6:06
  main
• 6:06
  priority
• 6:07
  is
• 6:07
  to
• 6:07
  get
• 6:07
  back
• 6:07
  to
• 6:07
  work
• 6:08
  and
• 6:08
  not
• 6:08
  be
• 6:08
  on
• 6:08
  disability,
• 6:09
  you
• 6:09
  might
• 6:10
  say,
• 6:10
  okay,
• 6:10
  well,
• 6:11
  hey,
• 6:11
  actually,
• 6:11
  the
• 6:12
  patient's
• 6:12
  ability
• 6:12
  to
• 6:13
  focus,
• 6:13
  that's
• 6:13
  the
• 6:13
  most
• 6:14
  important
• 6:14
  here.
• 6:15
  So
• 6:15
  when
• 6:15
  I
• 6:15
  choose
• 6:15
  a
• 6:16
  medication,
• 6:16
  I'm
• 6:16
  not
• 6:17
  going
• 6:17
  to
• 6:17
  choose
• 6:17
  one
• 6:18
  that
• 6:18
  has
• 6:19
  serious
• 6:19
  anticholinergic
• 6:20
  side
• 6:20
  effects
• 6:21
  or
• 6:21
  blocks
• 6:21
  histamine
• 6:22
  with
• 6:22
  a
• 6:22
  high
• 6:22
  affinity.
• 6:23
  I'm
• 6:23
  going
• 6:23
  to
• 6:23
  go
• 6:24
  for
• 6:24
  a
• 6:24
  medication
• 6:24
  maybe
• 6:25
  like
• 6:25
  Latuda,
• 6:26
  right,
• 6:26
  Which
• 6:27
  is
• 6:27
  actually
• 6:27
  known
• 6:28
  to
• 6:28
  spare
• 6:29
  patients
• 6:29
  from
• 6:29
  some
• 6:30
  of
• 6:30
  those
• 6:30
  most
• 6:31
  significant
• 6:31
  side
• 6:32
  effects,
• 6:32
  the
• 6:32
  muscarinic
• 6:33
  and
• 6:33
  anticholinergic
• 6:34
  side
• 6:34
  effects,
• 6:35
  the
• 6:35
  histaminergic
• 6:35
  side
• 6:36
  effects.
• 6:37
  As
• 6:37
  they're
• 6:37
  sharing
• 6:38
  their
• 6:38
  portrait
• 6:39
  of
• 6:39
  their
• 6:40
  depression
• 6:40
  with
• 6:40
  you,
• 6:41
  you
• 6:41
  can
• 6:42
  start
• 6:42
  to
• 6:42
  kind
• 6:42
  of
• 6:43
  eliminate
• 6:43
  certain
• 6:43
  medications
• 6:44
  and
• 6:44
  bring
• 6:45
  other
• 6:45
  ones
• 6:46
  into
• 6:46
  your
• 6:46
  mind
• 6:47
  as
• 6:47
  possible
• 6:47
  candidates.
• 6:48
  I
• 6:49
  know
• 6:49
  for
• 6:49
  me,
• 6:49
  one
• 6:49
  of
• 6:49
  the
• 6:50
  Most
• 6:50
  intuitive
• 6:50
  things
• 6:51
  I
• 6:51
  think
• 6:51
  about
• 6:52
  is
• 6:52
  when
• 6:52
  a
• 6:52
  patient's
• 6:53
  in
• 6:53
  front
• 6:53
  of
• 6:53
  me
• 6:53
  and
• 6:54
  they
• 6:54
  just
• 6:54
  can't
• 6:54
  sleep,
• 6:55
  and
• 6:55
  the
• 6:55
  lack
• 6:55
  of
• 6:55
  sleep
• 6:56
  is
• 6:56
  tormenting
• 6:56
  them.
• 6:57
  And
• 6:57
  I
• 6:57
  know
• 6:57
  they're
• 6:58
  in
• 6:58
  bipolar
• 6:58
  depression.
• 6:59
  I
• 6:59
  always
• 7:00
  think
• 7:00
  about
• 7:00
  Seroquel.
• 7:01
  Seroquel
• 7:02
  is
• 7:02
  one
• 7:02
  of
• 7:02
  my
• 7:02
  personal
• 7:03
  favorites.
• 7:04
  For
• 7:05
  me,
• 7:05
  it
• 7:05
  reliably
• 7:06
  helps
• 7:06
  your
• 7:07
  patients
• 7:07
  go
• 7:07
  back
• 7:07
  to
• 7:08
  sleep.
• 7:08
  It's
• 7:09
  very
• 7:09
  appealing
• 7:10
  to
• 7:10
  me.
• 7:11
  And
• 7:11
  I
• 7:12
  just.
• 7:12
  I
• 7:12
  think
• 7:12
  the
• 7:12
  world
• 7:12
  of
• 7:13
  Seroquel.
• 7:13
  It
• 7:14
  acts
• 7:14
  the
• 7:14
  same
• 7:15
  night,
• 7:15
  like,
• 7:15
  the
• 7:15
  same
• 7:15
  night
• 7:16
  you
• 7:16
  prescribe
• 7:16
  it.
• 7:16
  It
• 7:17
  helps
• 7:17
  people
• 7:17
  fall
• 7:17
  asleep.
• 7:18
  It
• 7:18
  has
• 7:18
  a
• 7:18
  metabolite
• 7:19
  called
• 7:19
  Norcotiope
• 7:20
  that
• 7:21
  has
• 7:21
  a
• 7:21
  high
• 7:21
  affinity
• 7:22
  for
• 7:22
  norepinephrine.
• 7:23
  So,
• 7:23
  again,
• 7:23
  we're
• 7:23
  not
• 7:23
  even
• 7:23
  just
• 7:24
  talking
• 7:24
  receptors,
• 7:25
  my
• 7:25
  friends.
• 7:25
  We're
• 7:25
  talking
• 7:26
  about
• 7:26
  metabolites
• 7:27
  that
• 7:27
  sometimes
• 7:28
  get
• 7:28
  into
• 7:28
  the
• 7:28
  picture
• 7:28
  here
• 7:29
  that
• 7:29
  also
• 7:30
  exert
• 7:30
  pharmacological
• 7:31
  effects,
• 7:31
  which
• 7:32
  is
• 7:32
  so
• 7:32
  neat.
• 7:33
  So
• 7:33
  I
• 7:33
  love
• 7:33
  Seroquel,
• 7:34
  right?
• 7:34
  I
• 7:34
  have
• 7:34
  a
• 7:34
  patient
• 7:35
  in
• 7:35
  front
• 7:35
  of
• 7:35
  me.
• 7:35
  They're
• 7:35
  bipolar
• 7:36
  depression.
• 7:37
  I
• 7:37
  don't
• 7:37
  want
• 7:37
  them
• 7:37
  to
• 7:38
  swing
• 7:38
  to
• 7:38
  mania.
• 7:39
  I
• 7:39
  want
• 7:39
  a
• 7:39
  medication
• 7:41
  that's
• 7:41
  going
• 7:41
  to
• 7:41
  prevent
• 7:42
  them
• 7:42
  from
• 7:42
  swinging
• 7:42
  to
• 7:43
  mania,
• 7:43
  but
• 7:43
  also
• 7:43
  that's
• 7:44
  going
• 7:44
  to
• 7:44
  treat
• 7:44
  their
• 7:44
  depression.
• 7:45
  And
• 7:45
  I
• 7:45
  know
• 7:45
  Seroquel
• 7:46
  is
• 7:47
  going
• 7:47
  to
• 7:47
  help
• 7:47
  them
• 7:47
  sleep.
• 7:47
  I
• 7:48
  know
• 7:48
  it
• 7:48
  has
• 7:48
  a
• 7:48
  metabolite
• 7:49
  called
• 7:49
  Nor
• 7:49
  Quetiapine
• 7:50
  that
• 7:50
  might
• 7:51
  give
• 7:51
  them
• 7:51
  a
• 7:51
  little
• 7:51
  more
• 7:51
  pep
• 7:52
  in
• 7:52
  their
• 7:52
  step.
• 7:52
  As
• 7:52
  I
• 7:53
  raise
• 7:53
  the
• 7:53
  dose,
• 7:53
  I
• 7:53
  might
• 7:53
  be
• 7:54
  able
• 7:54
  to
• 7:54
  prevent
• 7:54
  mania.
• 7:55
  I
• 7:55
  might
• 7:55
  also
• 7:55
  be
• 7:55
  able
• 7:56
  to
• 7:56
  provide
• 7:57
  some
• 7:57
  robust
• 7:57
  coverage
• 7:58
  for
• 7:58
  their
• 7:58
  depression.
• 7:59
  Right?
• 8:00
  But
• 8:00
  if
• 8:00
  you're
• 8:00
  eyeballing
• 8:01
  your
• 8:01
  patient
• 8:01
  and
• 8:01
  the
• 8:01
  patient's
• 8:02
  on
• 8:02
  the
• 8:02
  heavier
• 8:02
  side,
• 8:03
  well,
• 8:03
  now
• 8:03
  you
• 8:03
  got
• 8:03
  to
• 8:04
  put
• 8:04
  that
• 8:04
  through
• 8:04
  a
• 8:04
  filter
• 8:04
  and
• 8:05
  go,
• 8:05
  ooh,
• 8:06
  I
• 8:06
  don't
• 8:07
  know
• 8:07
  about
• 8:07
  this
• 8:07
  Seroquel.
• 8:09
  And,
• 8:09
  you
• 8:09
  know,
• 8:10
  that's
• 8:10
  where
• 8:11
  you
• 8:11
  have
• 8:11
  to
• 8:11
  have
• 8:11
  a
• 8:11
  discussion
• 8:12
  with
• 8:12
  your
• 8:12
  patient,
• 8:13
  right?
• 8:13
  Because
• 8:13
  you
• 8:13
  can
• 8:14
  say,
• 8:14
  hey,
• 8:14
  buddy,
• 8:14
  this
• 8:15
  is
• 8:15
  a
• 8:15
  pretty
• 8:16
  reliable
• 8:16
  weight
• 8:17
  gainer.
• 8:17
  It's
• 8:18
  one
• 8:18
  of
• 8:18
  the
• 8:18
  worst
• 8:18
  offenders.
• 8:19
  Is
• 8:19
  this
• 8:19
  something
• 8:20
  you're
• 8:20
  comfortable
• 8:20
  with
• 8:21
  continuing,
• 8:22
  or
• 8:22
  do
• 8:23
  you
• 8:23
  want
• 8:23
  us
• 8:23
  to
• 8:23
  talk
• 8:23
  about
• 8:23
  other
• 8:24
  options?
• 8:25
  Now,
• 8:26
  I
• 8:26
  personally
• 8:27
  think
• 8:27
  it's
• 8:27
  really
• 8:27
  not
• 8:28
  good
• 8:28
  to
• 8:28
  set
• 8:28
  any
• 8:29
  patient
• 8:29
  up
• 8:29
  with
• 8:30
  the
• 8:30
  metabolic
• 8:32
  damage
• 8:32
  that
• 8:32
  some
• 8:32
  of
• 8:33
  these
• 8:33
  medications
• 8:33
  can
• 8:34
  confer
• 8:34
  on
• 8:34
  them
• 8:35
  if
• 8:35
  they're
• 8:35
  already
• 8:36
  kind
• 8:36
  of
• 8:36
  heavy
• 8:36
  or
• 8:36
  they
• 8:37
  have
• 8:37
  wacky
• 8:38
  lipid
• 8:38
  profiles.
• 8:39
  So
• 8:40
  you
• 8:40
  may
• 8:40
  have
• 8:40
  to
• 8:41
  kind
• 8:41
  of
• 8:41
  make
• 8:41
  the
• 8:41
  call
• 8:41
  there
• 8:42
  and
• 8:42
  do
• 8:42
  no
• 8:42
  harm
• 8:42
  and
• 8:43
  not
• 8:43
  put
• 8:43
  them
• 8:43
  on
• 8:43
  quetiapine,
• 8:44
  even
• 8:44
  if
• 8:44
  they
• 8:44
  really
• 8:45
  want
• 8:45
  to
• 8:45
  be
• 8:45
  on
• 8:45
  quetiapine.
• 8:46
  So
• 8:46
  just
• 8:46
  think
• 8:46
  about
• 8:47
  these
• 8:47
  things.
• 8:47
  I
• 8:47
  think
• 8:48
  it's
• 8:48
  kind
• 8:48
  of
• 8:48
  an
• 8:48
  art
• 8:48
  and
• 8:49
  a
• 8:49
  science.
• 8:49
  You're
• 8:50
  putting
• 8:50
  all
• 8:51
  of
• 8:51
  this
• 8:51
  information
• 8:51
  through
• 8:52
  a
• 8:52
  filter.
• 8:53
  You're
• 8:53
  having
• 8:53
  a
• 8:53
  creative,
• 8:54
  engaging
• 8:55
  discussion
• 8:55
  with
• 8:55
  your
• 8:55
  patient,
• 8:56
  and
• 8:56
  you're
• 8:56
  figuring
• 8:56
  this
• 8:57
  out.
• 8:57
  So
• 8:57
  again,
• 8:57
  there's
• 8:58
  really
• 8:58
  five
• 8:58
  medications,
• 8:59
  my
• 8:59
  friends,
• 9:00
  with
• 9:00
  acute
• 9:00
  bipolar
• 9:01
  depression.
• 9:01
  We
• 9:01
  talked
• 9:02
  about
• 9:02
  Seroquel,
• 9:03
  we
• 9:03
  talked
• 9:03
  about
• 9:03
  Latuda.
• 9:04
  There's
• 9:05
  the
• 9:05
  Prozac,
• 9:06
  Zyprexa
• 9:06
  combination,
• 9:07
  Olanzapine,
• 9:08
  Fluoxetine,
• 9:09
  abbreviated
• 9:10
  ofc.
• 9:11
  There's
• 9:12
  Vraylar,
• 9:13
  there's
• 9:13
  our
• 9:13
  Lumateperone.
• 9:14
  So
• 9:14
  those
• 9:14
  are
• 9:14
  five,
• 9:14
  right?
• 9:15
  Those
• 9:15
  are
• 9:15
  the
• 9:15
  five
• 9:15
  I
• 9:15
  want
• 9:15
  you
• 9:15
  to
• 9:16
  focus
• 9:16
  on
• 9:16
  right
• 9:16
  now.
• 9:17
  Oh,
• 9:17
  that's
• 9:17
  a
• 9:17
  lot
• 9:18
  of
• 9:18
  pharm.
• 9:18
  Ooh,
• 9:19
  That's
• 9:19
  a
• 9:19
  lot
• 9:19
  of.
• 9:20
  A
• 9:20
  lot
• 9:20
  of
• 9:20
  stuff
• 9:21
  to
• 9:21
  remember.
• 9:21
  But
• 9:21
  have
• 9:22
  no
• 9:22
  fear,
• 9:22
  my
• 9:22
  friends,
• 9:23
  it's
• 9:23
  really
• 9:23
  just
• 9:23
  five
• 9:24
  medications
• 9:25
  and
• 9:25
  none
• 9:25
  of
• 9:25
  them
• 9:26
  are
• 9:26
  antidepressants.
• 9:27
  They're
• 9:27
  all
• 9:27
  really
• 9:28
  second
• 9:28
  generation
• 9:29
  antipsychotics.
• 9:30
  Yes,
• 9:30
  the
• 9:31
  Prozac
• 9:31
  that
• 9:31
  is
• 9:32
  embedded
• 9:32
  in
• 9:32
  the
• 9:33
  Olanzapine
• 9:33
  or
• 9:34
  the
• 9:34
  Zyprexa.
• 9:35
  Sure,
• 9:35
  that
• 9:36
  one
• 9:36
  is
• 9:37
  a
• 9:38
  ssri,
• 9:38
  but
• 9:38
  it
• 9:39
  is
• 9:39
  fused
• 9:39
  with
• 9:40
  the
• 9:40
  Zyprexa.
• 9:41
  We'll
• 9:41
  get
• 9:41
  into
• 9:41
  that
• 9:41
  in
• 9:41
  a
• 9:41
  little
• 9:42
  bit.
• 9:42
  But
• 9:43
  again,
• 9:43
  folks,
• 9:43
  five
• 9:44
  simple
• 9:44
  acute
• 9:45
  bipolar
• 9:45
  depression
• 9:46
  meds.
• 9:46
  Seroquel,
• 9:47
  Lutuda,
• 9:48
  the
• 9:48
  Zyprexa,
• 9:49
  Prozac
• 9:49
  combination,
• 9:50
  Vraylar
• 9:51
  and
• 9:51
  Lumatep,
• 9:52
  Bron,
• 9:52
  Bam.
• 9:53
  Five.
• 9:54
  Okay.
• 9:55
  And
• 9:55
  they
• 9:55
  all
• 9:55
  kind
• 9:55
  of
• 9:56
  do
• 9:56
  different
• 9:56
  things.
• 9:57
  You
• 9:57
  could
• 9:57
  become
• 9:57
  a
• 9:57
  free
• 9:58
  Patreon
• 9:58
  member.
• 9:58
  But
• 9:59
  we
• 9:59
  have
• 9:59
  a
• 9:59
  brand
• 9:59
  new
• 10:00
  service
• 10:00
  for
• 10:01
  five
• 10:01
  bucks
• 10:01
  a
• 10:01
  month
• 10:02
  called
• 10:02
  off
• 10:02
  the
• 10:02
  Farm,
• 10:03
  where
• 10:03
  you're
• 10:03
  going
• 10:03
  to
• 10:03
  get
• 10:03
  weekly
• 10:04
  deep
• 10:05
  dives
• 10:05
  in
• 10:05
  psychopharmacology
• 10:06
  where
• 10:07
  you
• 10:07
  can
• 10:07
  put
• 10:07
  this
• 10:07
  all
• 10:07
  together,
• 10:08
  understand
• 10:08
  the
• 10:08
  receptors
• 10:09
  really
• 10:09
  cleanly
• 10:10
  and
• 10:10
  intuitively.
• 10:11
  Highly
• 10:12
  recommend
• 10:12
  you
• 10:12
  go
• 10:12
  into
• 10:13
  our
• 10:13
  show
• 10:13
  notes
• 10:13
  and
• 10:13
  become
• 10:14
  a
• 10:14
  Patreon
• 10:14
  member
• 10:14
  for
• 10:15
  this
• 10:15
  because
• 10:15
  that's
• 10:15
  where
• 10:15
  you'll
• 10:15
  get
• 10:16
  these
• 10:16
  deep
• 10:16
  dives
• 10:17
  and
• 10:17
  a
• 10:17
  lot
• 10:17
  more
• 10:18
  specifics.
• 11:13
  But
• 11:13
  let's
• 11:14
  get
• 11:14
  back
• 10:19
  to
• 11:14
  the
• 11:14
  lecture
• 11:15
  here.
• 11:15
  So
• 11:15
  you
• 11:16
  have
• 11:16
  five
• 11:16
  choices.
• 11:17
  The
• 11:18
  goal
• 11:18
  here
• 11:18
  is
• 11:18
  to
• 11:18
  give
• 11:19
  them
• 11:19
  something,
• 11:19
  right?
• 11:20
  You
• 11:20
  want
• 11:20
  to
• 11:20
  undo
• 11:20
  the
• 11:21
  depression,
• 11:21
  you
• 11:21
  want
• 11:21
  to
• 11:21
  create
• 11:22
  some
• 11:22
  joy,
• 11:23
  you
• 11:23
  want
• 11:23
  to
• 11:23
  reduce
• 11:24
  the
• 11:24
  depressive
• 11:25
  rumination,
• 11:25
  you
• 11:25
  want
• 11:25
  to
• 11:26
  bring
• 11:26
  sleep
• 11:26
  back
• 11:26
  on
• 11:27
  board,
• 11:27
  right?
• 11:27
  And
• 11:28
  just
• 11:28
  know
• 11:28
  that
• 11:28
  within
• 11:29
  all
• 11:29
  five
• 11:29
  of
• 11:29
  these
• 11:30
  medications,
• 11:30
  there
• 11:30
  are
• 11:31
  unique
• 11:31
  receptor
• 11:32
  targets
• 11:32
  that
• 11:32
  can
• 11:33
  get
• 11:33
  this
• 11:33
  done.
• 11:34
  Or
• 11:34
  there's
• 11:34
  that
• 11:35
  active
• 11:35
  metabolite
• 11:36
  we
• 11:36
  talked
• 11:36
  about
• 11:36
  with
• 11:36
  Seroquel.
• 11:37
  Right.
• 11:37
  The
• 11:37
  Quetiapine
• 11:38
  becomes
• 11:38
  nor
• 11:39
  Quetiapine.
• 11:39
  It
• 11:40
  behaves
• 11:40
  like
• 11:40
  an
• 11:40
  snri.
• 11:42
  Okay.
• 11:42
  No
• 11:42
  need
• 11:43
  to
• 11:43
  fear
• 11:43
  of
• 11:43
  inducing
• 11:44
  mania
• 11:44
  as
• 11:44
  much
• 11:44
  with
• 11:45
  that
• 11:45
  because
• 11:46
  you
• 11:46
  also
• 11:46
  have
• 11:46
  embedded,
• 11:47
  depending
• 11:48
  on
• 11:48
  the
• 11:48
  dose,
• 11:49
  embedded
• 11:49
  blockades
• 11:51
  of
• 11:51
  5ht2a.
• 11:52
  And
• 11:53
  so
• 11:53
  you're
• 11:53
  blocking
• 11:54
  dopamine
• 11:54
  mildly
• 11:55
  with
• 11:55
  Seroquel,
• 11:55
  again,
• 11:56
  depending
• 11:56
  on
• 11:56
  the
• 11:56
  dose,
• 11:57
  but
• 11:57
  it's
• 11:57
  baked
• 11:58
  into
• 11:58
  the
• 11:58
  cake
• 11:58
  that
• 11:58
  do
• 11:59
  that.
• 11:59
  The
• 11:59
  Seroquel
• 12:00
  is
• 12:00
  also
• 12:00
  going
• 12:00
  to
• 12:00
  help
• 12:00
  kind
• 12:01
  of
• 12:01
  prevent
• 12:01
  the
• 12:01
  mania
• 12:02
  as
• 12:02
  well,
• 12:03
  which
• 12:03
  is
• 12:03
  very
• 12:04
  helpful
• 12:05
  every
• 12:05
  Patient's
• 12:05
  going
• 12:06
  to
• 12:06
  respond
• 12:06
  a
• 12:06
  little
• 12:06
  differently
• 12:07
  depending
• 12:07
  on
• 12:07
  that
• 12:07
  dose
• 12:08
  and
• 12:08
  how
• 12:08
  they
• 12:08
  metabolize
• 12:09
  it.
• 12:09
  But
• 12:10
  again,
• 12:10
  I
• 12:11
  love
• 12:11
  these
• 12:11
  medications.
• 12:12
  And
• 12:12
  I
• 12:12
  will
• 12:12
  be
• 12:12
  honest
• 12:12
  with
• 12:13
  you,
• 12:13
  I
• 12:13
  raved
• 12:13
  about
• 12:14
  Seroquel
• 12:14
  already.
• 12:15
  I
• 12:15
  also
• 12:16
  absolutely
• 12:16
  love
• 12:17
  the
• 12:18
  Olanzapine
• 12:19
  fluoxetine,
• 12:20
  also
• 12:20
  known
• 12:20
  as
• 12:20
  Zyprexa
• 12:21
  Prozac
• 12:22
  combination.
• 12:23
  Ofc.
• 12:24
  I
• 12:25
  love
• 12:25
  ofc.
• 12:26
  It
• 12:26
  has
• 12:26
  gotten
• 12:27
  me
• 12:27
  out
• 12:27
  of
• 12:27
  some
• 12:27
  very
• 12:28
  serious
• 12:28
  jams.
• 12:29
  Now,
• 12:29
  I
• 12:30
  will
• 12:30
  be
• 12:30
  honest
• 12:30
  with
• 12:30
  you.
• 12:31
  The
• 12:31
  Zyprexa
• 12:32
  piece
• 12:32
  of
• 12:33
  that
• 12:33
  combination
• 12:34
  is
• 12:34
  a
• 12:35
  whopping
• 12:36
  weight
• 12:37
  gainer.
• 12:37
  It
• 12:37
  is
• 12:38
  not
• 12:38
  fun,
• 12:38
  okay?
• 12:39
  It
• 12:39
  can.
• 12:39
  It
• 12:39
  can
• 12:40
  definitely
• 12:41
  wreak
• 12:41
  havoc.
• 12:41
  It
• 12:41
  does
• 12:42
  have
• 12:42
  the
• 12:42
  highest
• 12:43
  response
• 12:43
  rate.
• 12:44
  The
• 12:44
  evidence
• 12:45
  shows
• 12:45
  it
• 12:45
  has
• 12:45
  the
• 12:45
  highest
• 12:46
  response
• 12:46
  rate
• 12:46
  of
• 12:46
  the
• 12:47
  bipolar
• 12:47
  depression
• 12:48
  agents,
• 12:49
  around
• 12:49
  56.7,
• 12:50
  which
• 12:50
  is
• 12:51
  a
• 12:51
  really
• 12:51
  good
• 12:52
  response
• 12:52
  rate,
• 12:52
  actually.
• 12:53
  But
• 12:54
  about
• 12:54
  30%
• 12:55
  of
• 12:56
  your
• 12:56
  patients
• 12:57
  are
• 12:57
  going
• 12:57
  to
• 12:57
  experience
• 12:58
  greater
• 12:59
  than
• 12:59
  7%
• 12:59
  of
• 13:00
  weight
• 13:00
  gain,
• 13:00
  and
• 13:00
  that
• 13:01
  exceeds
• 13:01
  all
• 13:01
  other
• 13:02
  of
• 13:02
  these
• 13:02
  choices
• 13:03
  by
• 13:04
  a
• 13:04
  mile.
• 13:04
  So
• 13:05
  keep
• 13:05
  that
• 13:05
  in
• 13:05
  mind
• 13:06
  if
• 13:06
  you're
• 13:06
  going
• 13:06
  to
• 13:06
  pursue
• 13:07
  Seroquel.
• 13:07
  If
• 13:07
  you're
• 13:07
  going
• 13:08
  to
• 13:08
  pursue
• 13:08
  the
• 13:08
  OFC
• 13:09
  combination,
• 13:10
  watch
• 13:10
  out
• 13:10
  for
• 13:10
  weight
• 13:11
  gain.
• 13:11
  Get
• 13:11
  that
• 13:11
  fasting
• 13:12
  glucose,
• 13:12
  the
• 13:12
  lipids,
• 13:13
  the
• 13:13
  waist
• 13:13
  circumference,
• 13:14
  the
• 13:14
  BMI,
• 13:14
  baseline
• 13:15
  again,
• 13:16
  maybe
• 13:16
  at
• 13:16
  12
• 13:16
  weeks.
• 13:17
  These
• 13:18
  are
• 13:18
  heavy
• 13:18
  hitters,
• 13:19
  my
• 13:19
  friends.
• 13:19
  And
• 13:20
  unfortunately,
• 13:21
  as
• 13:21
  it
• 13:22
  goes
• 13:22
  a
• 13:22
  lot
• 13:22
  in
• 13:22
  life,
• 13:23
  some
• 13:23
  of
• 13:24
  your
• 13:24
  most
• 13:24
  effective
• 13:24
  agents
• 13:25
  come
• 13:25
  with
• 13:25
  a
• 13:25
  lot
• 13:26
  of
• 13:26
  side
• 13:26
  effects,
• 13:26
  right?
• 13:27
  And
• 13:27
  we
• 13:27
  have
• 13:27
  to
• 13:27
  have
• 13:28
  those
• 13:28
  conversations
• 13:29
  with
• 13:29
  our
• 13:29
  patients.
• 13:30
  We
• 13:30
  have
• 13:30
  to
• 13:30
  balance
• 13:31
  this
• 13:31
  out.
• 13:32
  And
• 13:33
  it
• 13:33
  can
• 13:33
  be
• 13:33
  a
• 13:33
  dicey
• 13:34
  conversation.
• 13:34
  It
• 13:34
  can
• 13:35
  spook
• 13:35
  a
• 13:35
  lot
• 13:35
  of
• 13:35
  people.
• 13:36
  One
• 13:36
  thing
• 13:36
  that
• 13:37
  really
• 13:37
  helps
• 13:37
  have
• 13:38
  a
• 13:38
  fair
• 13:38
  discussion
• 13:39
  between
• 13:39
  you
• 13:39
  and
• 13:39
  your
• 13:40
  patient
• 13:40
  is
• 13:40
  assessing
• 13:41
  how
• 13:41
  severe
• 13:42
  the
• 13:42
  side
• 13:42
  effects
• 13:43
  may
• 13:43
  or
• 13:43
  may
• 13:43
  not
• 13:44
  be
• 13:44
  in
• 13:45
  light
• 13:45
  of
• 13:45
  how
• 13:46
  severe
• 13:46
  the
• 13:46
  disease
• 13:47
  state
• 13:47
  can
• 13:47
  progress
• 13:48
  as
• 13:48
  well
• 13:48
  if
• 13:48
  we
• 13:49
  don't
• 13:49
  pick
• 13:49
  the
• 13:49
  right
• 13:49
  medication.
• 13:50
  Right?
• 13:50
  There's
• 13:51
  two
• 13:51
  sides
• 13:51
  to
• 13:51
  every
• 13:52
  story.
• 13:52
  The
• 13:53
  potential
• 13:54
  weight
• 13:54
  gain,
• 13:55
  metabolic
• 13:55
  problems,
• 13:56
  right?
• 13:56
  The
• 13:57
  sedation
• 13:58
  versus
• 13:59
  how
• 13:59
  bad
• 13:59
  is
• 14:00
  this
• 14:01
  bipolar
• 14:02
  depression
• 14:03
  without
• 14:03
  a
• 14:03
  medication
• 14:04
  like
• 14:04
  this?
• 14:04
  What
• 14:04
  if
• 14:04
  ofc,
• 14:05
  which
• 14:05
  is
• 14:05
  a
• 14:06
  big
• 14:06
  weight
• 14:06
  gainer,
• 14:07
  what
• 14:07
  if
• 14:07
  OFC
• 14:08
  is
• 14:08
  the
• 14:08
  most
• 14:08
  efficacious
• 14:09
  of
• 14:09
  all
• 14:09
  the
• 14:09
  other
• 14:09
  medications
• 14:10
  that
• 14:10
  we
• 14:10
  can
• 14:11
  try
• 14:11
  with
• 14:11
  this
• 14:11
  patient?
• 14:11
  What
• 14:12
  if
• 14:12
  they've
• 14:12
  tried
• 14:13
  Latuda
• 14:13
  and
• 14:14
  Vraylar
• 14:14
  and
• 14:14
  Seroquel,
• 14:15
  and
• 14:15
  we
• 14:15
  just
• 14:15
  need
• 14:16
  to
• 14:16
  figure
• 14:16
  this
• 14:16
  out?
• 14:17
  And
• 14:17
  maybe
• 14:17
  they're
• 14:17
  responding
• 14:18
  very
• 14:18
  well
• 14:18
  to
• 14:18
  OFC
• 14:19
  with
• 14:19
  some
• 14:19
  weight
• 14:19
  gain.
• 14:20
  Again,
• 14:20
  we
• 14:21
  can
• 14:21
  add.
• 14:21
  We
• 14:22
  can
• 14:22
  add
• 14:22
  medications
• 14:23
  like
• 14:23
  Metformin
• 14:23
  on
• 14:24
  there.
• 14:24
  We
• 14:24
  can.
• 14:24
  Now
• 14:25
  there's
• 14:25
  all
• 14:25
  kinds
• 14:26
  of
• 14:26
  GLP1s
• 14:27
  and
• 14:27
  other
• 14:28
  weight
• 14:28
  loss
• 14:28
  conversations
• 14:29
  we
• 14:29
  can
• 14:29
  have
• 14:30
  with
• 14:30
  our.
• 14:30
  We
• 14:31
  can
• 14:31
  collaborate
• 14:31
  with
• 14:31
  our
• 14:31
  care
• 14:32
  team.
• 14:32
  We
• 14:32
  have
• 14:32
  other
• 14:33
  choices.
• 14:33
  Diet,
• 14:33
  exercise.
• 14:34
  It's
• 14:35
  not
• 14:35
  like
• 14:35
  we
• 14:35
  have
• 14:35
  to
• 14:35
  sign
• 14:36
  the
• 14:36
  dotted
• 14:36
  line
• 14:37
  and
• 14:37
  never
• 14:37
  pursue
• 14:38
  OFC
• 14:39
  with
• 14:39
  the
• 14:39
  highest
• 14:40
  response
• 14:40
  rate.
• 14:40
  But
• 14:41
  we've
• 14:41
  gotta
• 14:41
  get
• 14:41
  creative,
• 14:41
  we've
• 14:42
  gotta
• 14:42
  get
• 14:42
  thorough,
• 14:42
  we've
• 14:43
  gotta
• 14:43
  have
• 14:43
  good
• 14:43
  conversations
• 14:44
  with
• 14:44
  our
• 14:44
  patients.
• 14:45
  But
• 14:45
  just
• 14:45
  know
• 14:45
  there
• 14:45
  are
• 14:46
  downsides
• 14:46
  to
• 14:47
  each
• 14:47
  of
• 14:47
  these
• 14:47
  potentially.
• 14:48
  Uh,
• 14:49
  latuda
• 14:50
  is
• 14:50
  another
• 14:50
  one
• 14:50
  of
• 14:50
  the
• 14:51
  five
• 14:51
  that
• 14:51
  we're
• 14:51
  chatting
• 14:52
  about
• 14:52
  today.
• 14:53
  I
• 14:53
  have
• 14:53
  mixed
• 14:53
  results
• 14:54
  with
• 14:54
  Latuda.
• 14:54
  Again,
• 14:55
  this
• 14:55
  is
• 14:55
  just
• 14:55
  anecdotal,
• 14:56
  right?
• 14:56
  I'm
• 14:56
  not
• 14:56
  a
• 14:57
  walking
• 14:57
  RCT
• 14:57
  or
• 14:58
  meta
• 14:58
  analysis,
• 14:59
  but
• 14:59
  I'm
• 14:59
  just
• 14:59
  telling
• 15:00
  you
• 15:00
  I
• 15:00
  have
• 15:00
  a
• 15:00
  coin
• 15:01
  flip
• 15:01
  with
• 15:01
  Latuda.
• 15:02
  A
• 15:02
  lot
• 15:02
  of
• 15:02
  people
• 15:02
  swear
• 15:03
  by
• 15:03
  it,
• 15:03
  they
• 15:03
  love
• 15:03
  it,
• 15:03
  it
• 15:04
  works
• 15:04
  very
• 15:04
  well.
• 15:05
  It's
• 15:05
  particularly
• 15:06
  good
• 15:06
  to
• 15:06
  kind
• 15:06
  of
• 15:06
  restore
• 15:07
  the
• 15:07
  circadian
• 15:08
  rhythm
• 15:08
  in
• 15:08
  some
• 15:09
  patients
• 15:09
  via
• 15:10
  that
• 15:10
  like
• 15:10
  5ht7
• 15:12
  receptor
• 15:13
  work
• 15:14
  that
• 15:14
  it
• 15:14
  does.
• 15:15
  And
• 15:15
  we
• 15:15
  already
• 15:15
  talked
• 15:15
  about
• 15:16
  how
• 15:16
  it
• 15:17
  spares
• 15:17
  you
• 15:17
  with
• 15:18
  a
• 15:18
  lot
• 15:18
  of
• 15:18
  the
• 15:19
  sedating
• 15:20
  side
• 15:20
  effects.
• 15:20
  So
• 15:20
  if
• 15:21
  you
• 15:21
  have
• 15:21
  a
• 15:21
  patient
• 15:21
  who
• 15:21
  really
• 15:22
  needs
• 15:22
  their
• 15:22
  cognition
• 15:23
  to
• 15:23
  be
• 15:24
  shored
• 15:24
  up
• 15:25
  and
• 15:25
  not
• 15:25
  interfered
• 15:26
  with,
• 15:26
  and
• 15:27
  that's
• 15:27
  taking
• 15:27
  up
• 15:28
  a
• 15:28
  lot
• 15:28
  of
• 15:28
  the
• 15:28
  discussion
• 15:29
  with
• 15:30
  respect
• 15:30
  to
• 15:31
  their
• 15:31
  treatment
• 15:32
  plan,
• 15:32
  they
• 15:32
  need
• 15:32
  to
• 15:32
  be
• 15:32
  focused,
• 15:33
  they
• 15:33
  can't
• 15:33
  afford
• 15:33
  to
• 15:34
  be
• 15:34
  sedated,
• 15:34
  they
• 15:34
  have
• 15:35
  a
• 15:35
  job.
• 15:35
  That
• 15:35
  really
• 15:35
  depends
• 15:36
  on
• 15:36
  them
• 15:36
  being
• 15:36
  alert.
• 15:37
  I'm
• 15:37
  definitely
• 15:38
  looking
• 15:38
  at
• 15:38
  latuda
• 15:39
  at
• 15:39
  that
• 15:39
  point
• 15:40
  for
• 15:40
  sure.
• 15:41
  It's
• 15:41
  not
• 15:42
  as
• 15:42
  effective
• 15:42
  at
• 15:43
  stopping
• 15:44
  mania
• 15:45
  or
• 15:45
  preventing
• 15:45
  mania,
• 15:46
  I
• 15:46
  should
• 15:46
  say.
• 15:47
  So
• 15:47
  there's
• 15:48
  that,
• 15:48
  that's
• 15:49
  another
• 15:49
  conversation.
• 15:50
  But
• 15:50
  again,
• 15:50
  the
• 15:50
  5ht7
• 15:51
  antagonism,
• 15:52
  restoring
• 15:53
  their
• 15:53
  circadian
• 15:54
  rhythm,
• 15:54
  their
• 15:54
  mood,
• 15:55
  their
• 15:55
  cognition,
• 15:55
  it's
• 15:56
  a
• 15:56
  little
• 15:56
  more
• 15:56
  favorable
• 15:57
  on
• 15:57
  weight.
• 15:57
  You
• 15:57
  know,
• 15:57
  if
• 15:57
  you're
• 15:58
  going
• 15:58
  to
• 15:58
  look
• 15:58
  at
• 15:58
  antipsychotics
• 15:59
  more
• 15:59
  broadly,
• 16:00
  maybe
• 16:00
  not
• 16:00
  just
• 16:01
  in
• 16:01
  bipolar
• 16:01
  depression,
• 16:01
  but
• 16:02
  more
• 16:02
  broadly
• 16:02
  the
• 16:03
  abilifies,
• 16:03
  the
• 16:04
  latudas,
• 16:04
  the
• 16:04
  geodons
• 16:05
  are
• 16:06
  a
• 16:06
  little
• 16:06
  better
• 16:06
  when
• 16:07
  we're
• 16:07
  talking
• 16:07
  about
• 16:07
  weight.
• 16:08
  But
• 16:08
  if
• 16:08
  you
• 16:09
  have
• 16:09
  a
• 16:09
  patient
• 16:09
  who's
• 16:10
  maybe
• 16:10
  food
• 16:10
  insecure,
• 16:11
  doesn't
• 16:11
  eat
• 16:12
  all
• 16:12
  the
• 16:12
  time,
• 16:12
  you
• 16:12
  know,
• 16:12
  I
• 16:12
  used
• 16:13
  to
• 16:13
  work
• 16:13
  with
• 16:13
  folks
• 16:13
  who
• 16:13
  were,
• 16:14
  who
• 16:14
  were
• 16:14
  homeless,
• 16:15
  suffering
• 16:15
  from
• 16:15
  homelessness
• 16:16
  and
• 16:16
  so
• 16:16
  latuda
• 16:17
  wasn't
• 16:17
  the
• 16:17
  best
• 16:17
  choice
• 16:18
  for
• 16:18
  them.
• 16:18
  Why?
• 16:19
  Because
• 16:19
  you
• 16:19
  gotta
• 16:19
  eat
• 16:19
  350
• 16:20
  calories
• 16:21
  or
• 16:21
  more
• 16:21
  for
• 16:22
  it
• 16:22
  to
• 16:22
  the
• 16:22
  bioavailability
• 16:23
  to
• 16:24
  be
• 16:24
  robust.
• 16:25
  Right?
• 16:25
  It
• 16:25
  kind
• 16:26
  of
• 16:26
  drops
• 16:26
  by
• 16:26
  50%
• 16:27
  if
• 16:27
  you
• 16:27
  don't
• 16:27
  eat
• 16:27
  food.
• 16:28
  So
• 16:28
  your
• 16:28
  dose
• 16:28
  is
• 16:28
  like
• 16:29
  cut
• 16:29
  in
• 16:29
  half
• 16:29
  at
• 16:29
  that
• 16:29
  point.
• 16:30
  Well,
• 16:30
  if
• 16:30
  you're
• 16:31
  suffering
• 16:31
  from
• 16:32
  homelessness
• 16:32
  and
• 16:33
  bam,
• 16:33
  you're
• 16:34
  not
• 16:34
  able
• 16:34
  to
• 16:34
  secure
• 16:35
  350
• 16:35
  calories.
• 16:36
  Now
• 16:36
  you've
• 16:37
  just
• 16:37
  cut
• 16:37
  your
• 16:37
  patient's
• 16:37
  dose
• 16:38
  in
• 16:38
  half.
• 16:38
  So
• 16:38
  again,
• 16:38
  these
• 16:39
  are
• 16:39
  the
• 16:39
  kind
• 16:39
  of
• 16:39
  the
• 16:39
  creative
• 16:40
  trade
• 16:40
  offs
• 16:41
  or
• 16:41
  considerations
• 16:42
  you
• 16:42
  have
• 16:42
  to
• 16:42
  think
• 16:42
  about
• 16:43
  when
• 16:43
  you're
• 16:43
  choosing
• 16:44
  medications
• 16:45
  like
• 16:45
  this.
• 16:46
  Now
• 16:46
  when
• 16:46
  do
• 16:46
  you
• 16:46
  look
• 16:46
  at
• 16:47
  Vralar
• 16:47
  as
• 16:48
  a
• 16:48
  bipolar
• 16:48
  depression
• 16:49
  agent.
• 16:49
  Vlar
• 16:49
  is
• 16:50
  a
• 16:50
  kind
• 16:50
  of
• 16:50
  a
• 16:50
  new
• 16:50
  kid
• 16:50
  on
• 16:50
  the
• 16:50
  block.
• 16:51
  I'll
• 16:51
  be
• 16:51
  honest,
• 16:51
  I
• 16:51
  haven't
• 16:52
  prescribed
• 16:52
  it
• 16:52
  much.
• 16:53
  I
• 16:53
  find
• 16:53
  it
• 16:54
  to
• 16:54
  be
• 16:54
  kind
• 16:54
  of
• 16:54
  expensive
• 16:55
  for
• 16:55
  my
• 16:55
  patients.
• 16:55
  They
• 16:56
  can't
• 16:56
  always
• 16:56
  afford
• 16:56
  it.
• 16:57
  It's
• 16:57
  not
• 16:57
  always
• 16:58
  cost
• 16:58
  effective.
• 16:58
  And
• 16:59
  just
• 16:59
  like
• 16:59
  everything
• 16:59
  else
• 17:00
  in
• 17:00
  psychiatry,
• 17:00
  there's
• 17:01
  trade
• 17:01
  offs.
• 17:02
  Ralar,
• 17:02
  according
• 17:03
  to
• 17:03
  all
• 17:03
  the
• 17:03
  drug
• 17:03
  commercials
• 17:04
  and
• 17:05
  the
• 17:05
  textbooks,
• 17:05
  it
• 17:06
  might
• 17:06
  appear
• 17:06
  like
• 17:06
  Vitamin
• 17:07
  Wonka,
• 17:07
  right?
• 17:08
  From,
• 17:08
  from
• 17:09
  Willy
• 17:09
  Wonka,
• 17:10
  where
• 17:10
  it
• 17:10
  does
• 17:10
  everything
• 17:10
  right.
• 17:11
  You
• 17:11
  can
• 17:11
  play
• 17:11
  the
• 17:11
  piano
• 17:12
  with
• 17:12
  your
• 17:12
  toes,
• 17:13
  it
• 17:13
  does
• 17:13
  everything.
• 17:14
  But
• 17:14
  if
• 17:15
  your
• 17:15
  patient
• 17:15
  can't
• 17:15
  afford
• 17:15
  it,
• 17:15
  what
• 17:16
  good
• 17:16
  is
• 17:16
  it?
• 17:16
  However,
• 17:17
  Ralar
• 17:17
  is
• 17:17
  pretty
• 17:18
  neat,
• 17:18
  right?
• 17:19
  We're
• 17:19
  talking
• 17:19
  about
• 17:19
  D3
• 17:20
  partial
• 17:21
  agonism.
• 17:21
  That's
• 17:22
  kind
• 17:22
  of
• 17:22
  new.
• 17:23
  So
• 17:24
  they're
• 17:24
  finding
• 17:24
  out
• 17:25
  that
• 17:25
  D3
• 17:25
  receptors,
• 17:26
  particularly
• 17:27
  in
• 17:27
  like,
• 17:27
  award
• 17:28
  reward
• 17:28
  centers
• 17:28
  in
• 17:29
  the
• 17:29
  brain,
• 17:29
  it
• 17:29
  targets
• 17:30
  anhedonia,
• 17:31
  it
• 17:31
  targets
• 17:32
  those
• 17:32
  motivational
• 17:33
  deficits.
• 17:33
  So
• 17:33
  if
• 17:33
  you
• 17:33
  have
• 17:34
  a
• 17:34
  patient
• 17:34
  who's
• 17:34
  not
• 17:34
  getting
• 17:34
  a
• 17:35
  lot
• 17:35
  of
• 17:35
  joy
• 17:35
  out
• 17:35
  of
• 17:35
  things,
• 17:36
  they
• 17:36
  have
• 17:36
  low
• 17:36
  motivation.
• 17:38
  Then
• 17:38
  again,
• 17:38
  you
• 17:39
  want
• 17:39
  to
• 17:39
  pair
• 17:40
  their
• 17:40
  complaints
• 17:41
  and
• 17:41
  their
• 17:41
  treatment
• 17:42
  plan
• 17:42
  with
• 17:42
  something
• 17:42
  like
• 17:43
  Vlar
• 17:44
  that
• 17:44
  is
• 17:44
  uniquely
• 17:45
  targeting
• 17:45
  their
• 17:46
  lack
• 17:46
  of
• 17:46
  ability
• 17:46
  to
• 17:47
  experience
• 17:47
  joy
• 17:48
  and
• 17:48
  motivation,
• 17:49
  which
• 17:49
  is
• 17:49
  pretty
• 17:50
  cool.
• 17:50
  It
• 17:50
  also
• 17:50
  is
• 17:50
  a
• 17:50
  partial
• 17:51
  agonist,
• 17:51
  5ht1a,
• 17:53
  which
• 17:54
  gives
• 17:54
  them
• 17:54
  a
• 17:54
  little
• 17:54
  prefrontal
• 17:55
  dopamine
• 17:56
  enhancement
• 17:57
  and
• 17:57
  anxiolytic.
• 17:57
  It
• 17:57
  makes
• 17:58
  them
• 17:58
  less
• 17:58
  anxious.
• 17:59
  It's
• 17:59
  got
• 18:00
  a
• 18:00
  pretty
• 18:00
  good
• 18:00
  metabolic
• 18:01
  profile.
• 18:01
  It's
• 18:01
  not
• 18:02
  a
• 18:02
  reliable
• 18:02
  weight
• 18:03
  gainer.
• 18:03
  So
• 18:04
  if
• 18:04
  you
• 18:04
  have
• 18:04
  a
• 18:04
  patient
• 18:04
  who
• 18:04
  goes,
• 18:04
  hey,
• 18:06
  weight
• 18:06
  gain
• 18:06
  is
• 18:07
  a
• 18:07
  deal
• 18:07
  breaker
• 18:07
  for
• 18:08
  me,
• 18:08
  I
• 18:08
  also
• 18:09
  am
• 18:09
  just
• 18:10
  not
• 18:10
  getting
• 18:10
  joy
• 18:10
  out
• 18:11
  of
• 18:11
  anything.
• 18:12
  Think
• 18:12
  about
• 18:12
  Vailar.
• 18:13
  Think
• 18:13
  of
• 18:13
  it
• 18:13
  kind
• 18:13
  of
• 18:13
  like
• 18:14
  the
• 18:14
  Wellbutrin,
• 18:14
  but
• 18:15
  in
• 18:15
  terms
• 18:15
  of
• 18:16
  mood
• 18:16
  stabilization,
• 18:17
  that
• 18:17
  I
• 18:17
  can
• 18:17
  see.
• 18:17
  But
• 18:18
  it
• 18:18
  actually
• 18:18
  can
• 18:19
  and
• 18:19
  does
• 18:19
  reliably
• 18:21
  treat
• 18:21
  mania.
• 18:22
  So
• 18:22
  that's
• 18:22
  a
• 18:22
  good
• 18:22
  thing
• 18:22
  if
• 18:23
  you
• 18:23
  raise
• 18:23
  the
• 18:23
  dose
• 18:23
  right.
• 18:24
  But
• 18:24
  we're
• 18:24
  talking
• 18:24
  bipolar
• 18:25
  depression
• 18:25
  today.
• 18:26
  So
• 18:26
  now
• 18:27
  you
• 18:27
  have
• 18:27
  many
• 18:27
  different
• 18:28
  angles
• 18:29
  of
• 18:29
  attack
• 18:29
  here,
• 18:29
  if
• 18:30
  you
• 18:30
  haven't
• 18:30
  noticed.
• 18:31
  Right?
• 18:31
  My
• 18:31
  friends,
• 18:32
  all
• 18:32
  of
• 18:32
  these
• 18:32
  are
• 18:32
  kind
• 18:33
  of
• 18:33
  different
• 18:33
  in
• 18:33
  their
• 18:33
  own
• 18:34
  way,
• 18:34
  right?
• 18:34
  Some
• 18:35
  help
• 18:35
  you
• 18:35
  sleep,
• 18:35
  like
• 18:36
  Seroquel.
• 18:36
  The
• 18:37
  OFC
• 18:37
  combination
• 18:38
  will
• 18:38
  definitely
• 18:38
  help
• 18:38
  you
• 18:39
  sleep
• 18:39
  too.
• 18:39
  The
• 18:40
  latuda,
• 18:41
  it's
• 18:41
  not
• 18:42
  as
• 18:42
  sedating.
• 18:42
  It
• 18:43
  kind
• 18:43
  of
• 18:43
  helps
• 18:43
  you
• 18:44
  spare
• 18:45
  any
• 18:45
  kind
• 18:45
  of
• 18:46
  sedation.
• 18:47
  It
• 18:47
  helps
• 18:47
  with
• 18:47
  cognition,
• 18:48
  circadian
• 18:49
  realignment.
• 18:49
  And
• 18:50
  then
• 18:50
  of
• 18:50
  course,
• 18:50
  you
• 18:50
  have
• 18:51
  Raylar,
• 18:51
  which
• 18:51
  we
• 18:52
  just
• 18:52
  talked
• 18:52
  about,
• 18:52
  which
• 18:52
  is
• 18:52
  more
• 18:53
  about
• 18:53
  motivational
• 18:53
  reward
• 18:54
  circuits,
• 18:55
  which
• 18:55
  is
• 18:55
  really
• 18:56
  darn
• 18:56
  cool.
• 18:57
  Many
• 18:58
  different
• 18:58
  ways
• 18:58
  to
• 18:59
  skin
• 18:59
  the
• 18:59
  cat,
• 18:59
  if
• 19:00
  you
• 19:00
  will,
• 19:00
  which
• 19:00
  is
• 19:00
  pretty
• 19:01
  cool.
• 19:01
  Now,
• 19:02
  of
• 19:02
  course,
• 19:02
  there's
• 19:03
  an
• 19:03
  even
• 19:03
  newer
• 19:04
  kid
• 19:04
  on
• 19:04
  the
• 19:04
  block
• 19:04
  called
• 19:05
  Lumateprone.
• 19:06
  I'M
• 19:06
  going
• 19:06
  to
• 19:06
  leave
• 19:06
  that
• 19:07
  mainly
• 19:07
  for
• 19:07
  the
• 19:08
  folks
• 19:08
  that
• 19:08
  want
• 19:08
  to
• 19:08
  join
• 19:09
  Patreon,
• 19:09
  if
• 19:09
  you're
• 19:10
  interested.
• 19:10
  I
• 19:10
  don't
• 19:10
  want
• 19:10
  to
• 19:11
  talk
• 19:11
  your
• 19:11
  heads
• 19:11
  off
• 19:12
  today.
• 19:12
  But
• 19:13
  also,
• 19:13
  really
• 19:14
  cool
• 19:14
  receptor
• 19:15
  profile
• 19:15
  that
• 19:15
  we
• 19:16
  go
• 19:16
  in
• 19:16
  pretty
• 19:16
  deep
• 19:17
  in
• 19:17
  our
• 19:17
  Patreon
• 19:18
  membership
• 19:19
  for
• 19:19
  you
• 19:19
  to
• 19:19
  look
• 19:19
  at,
• 19:20
  I
• 19:20
  think,
• 19:20
  actually
• 19:21
  amazing.
• 19:22
  It
• 19:22
  is
• 19:22
  more
• 19:22
  expensive.
• 19:23
  I
• 19:24
  definitely
• 19:24
  urge
• 19:24
  you
• 19:25
  to
• 19:25
  go
• 19:25
  into
• 19:25
  our
• 19:26
  slide
• 19:26
  deck
• 19:27
  there
• 19:27
  if
• 19:27
  you're
• 19:27
  a
• 19:27
  member
• 19:27
  of
• 19:27
  off
• 19:28
  the
• 19:28
  Farm
• 19:29
  and
• 19:29
  see
• 19:29
  that
• 19:30
  Lumateperone's
• 19:31
  five
• 19:31
  distinct
• 19:31
  receptor
• 19:32
  and
• 19:32
  transporter
• 19:33
  systems
• 19:33
  that
• 19:34
  it
• 19:34
  acts
• 19:34
  on.
• 19:35
  It's
• 19:35
  one
• 19:35
  of
• 19:35
  the
• 19:35
  most
• 19:36
  unique
• 19:36
  pharmacological
• 19:37
  profiles
• 19:37
  we've
• 19:38
  seen.
• 19:38
  Very
• 19:39
  cool.
• 19:40
  And
• 19:40
  definitely
• 19:41
  add
• 19:41
  that
• 19:41
  to
• 19:41
  your
• 19:41
  repertoire
• 19:42
  and
• 19:42
  nerd
• 19:42
  out
• 19:43
  on
• 19:43
  that
• 19:43
  when
• 19:43
  you
• 19:43
  can.
• 19:44
  I
• 19:45
  hope
• 19:45
  you
• 19:45
  appreciated
• 19:46
  this
• 19:46
  little
• 19:47
  discussion
• 19:47
  about
• 19:47
  bipolar
• 19:48
  depression.
• 19:49
  Remember
• 19:49
  that
• 19:50
  a
• 19:50
  lot
• 19:50
  of
• 19:50
  your
• 19:50
  patients
• 19:51
  are
• 19:51
  going
• 19:51
  to
• 19:51
  come
• 19:51
  to
• 19:51
  you
• 19:52
  and
• 19:52
  you're
• 19:52
  going
• 19:52
  to
• 19:52
  feel
• 19:53
  somewhat
• 19:53
  powerless
• 19:53
  at
• 19:54
  times
• 19:54
  and
• 19:54
  maybe
• 19:54
  scared,
• 19:54
  and
• 19:55
  you're
• 19:55
  going
• 19:55
  to
• 19:55
  say,
• 19:55
  wait
• 19:55
  a
• 19:55
  minute,
• 19:56
  bipolar.
• 19:57
  Oh,
• 19:57
  no,
• 19:58
  I
• 19:58
  got
• 19:58
  to
• 19:58
  avoid
• 19:58
  antidepressants.
• 19:59
  Well,
• 19:59
  first
• 20:00
  of
• 20:00
  all,
• 20:00
  not
• 20:00
  always.
• 20:00
  If
• 20:01
  you
• 20:01
  can
• 20:01
  pair
• 20:01
  it
• 20:01
  with
• 20:02
  Zyprexa,
• 20:03
  the
• 20:03
  Zyprexa
• 20:04
  Prozac
• 20:04
  combination,
• 20:05
  you
• 20:05
  still
• 20:05
  get
• 20:05
  your
• 20:05
  cake
• 20:05
  and
• 20:06
  you
• 20:06
  get
• 20:06
  to
• 20:06
  eat
• 20:06
  it,
• 20:06
  too,
• 20:06
  quite
• 20:07
  literally.
• 20:07
  Right,
• 20:07
  because
• 20:08
  it
• 20:08
  causes
• 20:08
  weight
• 20:08
  gain.
• 20:09
  But
• 20:09
  you
• 20:09
  do
• 20:10
  have
• 20:10
  the
• 20:10
  Prozac
• 20:11
  in
• 20:11
  the
• 20:11
  card,
• 20:11
  so
• 20:11
  you're
• 20:11
  not
• 20:12
  struck
• 20:12
  out.
• 20:12
  And
• 20:13
  you
• 20:13
  have
• 20:13
  the
• 20:13
  Olanzapine.
• 20:14
  That's
• 20:14
  kind
• 20:14
  of
• 20:15
  balancing
• 20:15
  that
• 20:15
  out.
• 20:16
  So
• 20:16
  you
• 20:16
  kind
• 20:16
  of
• 20:16
  control
• 20:16
  for
• 20:17
  mania.
• 20:19
  The
• 20:19
  goal
• 20:19
  is,
• 20:19
  again,
• 20:19
  you
• 20:19
  want
• 20:20
  to
• 20:20
  bring
• 20:20
  joy
• 20:20
  back
• 20:20
  to
• 20:21
  their
• 20:21
  lives.
• 20:21
  Look
• 20:21
  at
• 20:21
  Vrar.
• 20:22
  You
• 20:22
  want
• 20:22
  to
• 20:22
  bring
• 20:23
  sleep
• 20:23
  back,
• 20:23
  maybe
• 20:24
  some
• 20:24
  norepinephrine
• 20:25
  reuptake,
• 20:25
  increase
• 20:25
  their
• 20:26
  motivation
• 20:26
  and
• 20:26
  energy.
• 20:27
  Well,
• 20:27
  hey,
• 20:28
  that's
• 20:28
  Seroquel.
• 20:29
  You
• 20:29
  can
• 20:29
  do
• 20:29
  that
• 20:30
  because
• 20:30
  the
• 20:30
  metabolite
• 20:31
  behaves
• 20:31
  that
• 20:31
  way.
• 20:32
  Right?
• 20:32
  You
• 20:33
  want
• 20:33
  to
• 20:33
  restore
• 20:34
  their
• 20:34
  circadian
• 20:34
  rhythm
• 20:35
  and
• 20:35
  potentially
• 20:36
  protect
• 20:36
  their
• 20:36
  cognition.
• 20:37
  Go
• 20:37
  to
• 20:37
  Latuda.
• 20:38
  It
• 20:39
  has
• 20:39
  a
• 20:39
  clean
• 20:39
  antidepressant
• 20:40
  effect,
• 20:41
  has
• 20:41
  some
• 20:41
  1A
• 20:42
  activation,
• 20:42
  too,
• 20:43
  which
• 20:43
  can
• 20:43
  of
• 20:44
  course
• 20:44
  improve
• 20:45
  mood.
• 20:45
  So
• 20:45
  you
• 20:45
  have
• 20:45
  all
• 20:46
  these
• 20:46
  unique
• 20:47
  mechanisms
• 20:47
  of
• 20:47
  action,
• 20:48
  and
• 20:48
  it
• 20:48
  can
• 20:49
  all
• 20:49
  feel
• 20:49
  like
• 20:49
  a
• 20:49
  blur
• 20:50
  if
• 20:50
  we
• 20:50
  don't
• 20:50
  really
• 20:50
  appreciate
• 20:51
  the
• 20:51
  receptor
• 20:52
  types.
• 20:52
  But
• 20:52
  if
• 20:52
  we
• 20:53
  understand
• 20:53
  that
• 20:54
  and
• 20:54
  we
• 20:54
  study
• 20:55
  it
• 20:55
  a
• 20:55
  little
• 20:55
  bit,
• 20:56
  we
• 20:56
  won't
• 20:56
  feel
• 20:57
  scared
• 20:57
  at
• 20:57
  all.
• 20:57
  We'll
• 20:58
  have
• 20:58
  a
• 20:58
  patient
• 20:58
  in
• 20:58
  front
• 20:58
  of
• 20:58
  us
• 20:59
  and
• 20:59
  we'll
• 20:59
  know
• 20:59
  exactly
• 21:00
  the
• 21:00
  kind
• 21:00
  of
• 21:00
  treatment
• 21:01
  that's
• 21:01
  available.
• 21:01
  These
• 21:02
  won't
• 21:02
  just
• 21:02
  be
• 21:02
  names
• 21:03
  of
• 21:03
  medications
• 21:04
  that
• 21:04
  all
• 21:04
  just
• 21:04
  appear
• 21:05
  like
• 21:05
  they're
• 21:05
  one
• 21:06
  thing.
• 21:06
  No,
• 21:06
  the
• 21:07
  nuances
• 21:07
  will
• 21:07
  be
• 21:08
  felt
• 21:08
  and
• 21:08
  we'll
• 21:09
  feel
• 21:09
  more
• 21:09
  empowered
• 21:10
  to
• 21:10
  prescribe
• 21:10
  these
• 21:11
  in
• 21:11
  a
• 21:11
  way
• 21:11
  that
• 21:12
  really
• 21:12
  makes
• 21:12
  the
• 21:12
  difference
• 21:13
  for
• 21:13
  the
• 21:13
  patient.
• 21:14
  So
• 21:15
  with
• 21:15
  that,
• 21:15
  until
• 21:15
  next
• 21:16
  time,
• 21:16
  definitely
• 21:17
  head
• 21:17
  over
• 21:17
  to
• 21:17
  the
• 21:17
  show
• 21:17
  Notes
• 21:18
  again,
• 21:18
  become
• 21:18
  Free
• 21:18
  Patreon
• 21:19
  member.
• 21:20
  Or
• 21:20
  you
• 21:20
  can
• 21:20
  join
• 21:21
  our
• 21:21
  various
• 21:21
  Patreon
• 21:22
  services
• 21:22
  to
• 21:22
  really
• 21:23
  sharpen
• 21:23
  your
• 21:23
  skills
• 21:24
  and
• 21:24
  take
• 21:24
  your
• 21:24
  prescribing
• 21:25
  and
• 21:25
  diagnosing
• 21:26
  to
• 21:26
  the
• 21:26
  next
• 21:26
  level.
• 21:27
  We'd
• 21:27
  love
• 21:27
  to
• 21:27
  have
• 21:27
  you.
• 21:28
  Until
• 21:28
  next
• 21:28
  time,
• 21:28
  NPZ
• 21:29
  signing
• 21:29
  off.