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Board Bombs: Can you get these 3, high-yield board-style questions right today? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back
• 0:05
  my
• 0:06
  friends
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  prep
• 0:08
  npz.
• 0:09
  Here
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  the
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:15
  practice.
• 0:15
  My
• 0:16
  friends,
• 0:16
  back
• 0:17
  by
• 0:17
  popular
• 0:17
  demand,
• 0:17
  we
• 0:18
  have
• 0:18
  board
• 0:18
  bombs,
• 0:19
  three
• 0:19
  high
• 0:19
  yield
• 0:20
  psych
• 0:21
  NP
• 0:21
  questions
• 0:22
  that
• 0:23
  will
• 0:24
  help
• 0:24
  you
• 0:25
  be
• 0:25
  at
• 0:25
  the
• 0:25
  top
• 0:25
  of
• 0:25
  your
• 0:26
  game
• 0:26
  clinically,
• 0:27
  maybe
• 0:28
  serve
• 0:28
  as
• 0:28
  a
• 0:28
  refresher
• 0:29
  of
• 0:29
  sorts
• 0:30
  and
• 0:30
  get
• 0:31
  you
• 0:31
  ready
• 0:31
  for
• 0:31
  those
• 0:32
  psychiatry
• 0:33
  boards.
• 0:34
  These
• 0:34
  are
• 0:34
  pretty
• 0:34
  meta
• 0:35
  heavy
• 0:35
  today
• 0:36
  and
• 0:36
  I'm
• 0:36
  pretty
• 0:37
  passionate
• 0:37
  about
• 0:37
  medications,
• 0:38
  so
• 0:38
  let's
• 0:38
  do
• 0:39
  this.
• 0:39
  So
• 0:40
  question
• 0:40
  one.
• 0:41
  Question
• 0:42
  one
• 0:42
  deals
• 0:42
  with
• 0:42
  antipsychotic
• 0:43
  side
• 0:44
  effects.
• 0:44
  You
• 0:44
  have
• 0:45
  a
• 0:45
  28
• 0:45
  year
• 0:45
  old
• 0:45
  woman
• 0:46
  who's
• 0:47
  on
• 0:47
  the
• 0:47
  heavier
• 0:48
  side.
• 0:48
  She
• 0:48
  has
• 0:48
  a
• 0:49
  BMI
• 0:49
  of
• 0:49
  31.
• 0:51
  She
• 0:51
  has
• 0:51
  schizophrenia,
• 0:52
  but
• 0:52
  she
• 0:52
  has
• 0:52
  been
• 0:53
  stable
• 0:53
  on
• 0:53
  Risperdal
• 0:55
  4mg
• 0:55
  for
• 0:56
  about
• 0:56
  six
• 0:56
  months.
• 0:57
  But
• 0:57
  she
• 0:57
  comes
• 0:57
  to
• 0:58
  you
• 0:58
  saying
• 0:59
  she's
• 1:00
  really
• 1:00
  distressed
• 1:01
  about
• 1:01
  the
• 1:01
  side
• 1:02
  effects.
• 1:02
  She
• 1:02
  has
• 1:02
  breast
• 1:03
  tenderness,
• 1:03
  milky
• 1:04
  nipple
• 1:04
  discharge
• 1:05
  and
• 1:05
  missed
• 1:06
  periods
• 1:06
  for
• 1:06
  the
• 1:06
  last
• 1:07
  three
• 1:07
  months.
• 1:07
  Her
• 1:07
  pregnancy
• 1:08
  test
• 1:08
  is
• 1:08
  negative.
• 1:09
  Her
• 1:09
  prolactin
• 1:10
  level
• 1:10
  is
• 1:10
  98
• 1:11
  and
• 1:11
  the
• 1:11
  normal
• 1:12
  prolactin
• 1:12
  level
• 1:12
  hovers
• 1:13
  around
• 1:13
  below
• 1:14
  25.
• 1:15
  So
• 1:15
  what's
• 1:15
  the
• 1:16
  most
• 1:16
  appropriate
• 1:16
  next
• 1:17
  step
• 1:17
  for
• 1:17
  you
• 1:17
  here?
• 1:18
  Do
• 1:19
  you
• 1:19
  continue
• 1:19
  Risperdal
• 1:20
  and
• 1:20
  just
• 1:21
  add
• 1:22
  Cabergoline?
• 1:24
  That
• 1:24
  would
• 1:24
  be
• 1:24
  a
• 1:24
  dopamine
• 1:25
  agonist.
• 1:25
  Do
• 1:26
  you
• 1:26
  switch
• 1:26
  to
• 1:26
  Abilify?
• 1:28
  Do
• 1:28
  you
• 1:28
  reduce
• 1:29
  the
• 1:29
  risperidol
• 1:30
  dose
• 1:30
  to
• 1:30
  2
• 1:30
  milligrams
• 1:31
  daily?
• 1:31
  Or
• 1:31
  do
• 1:31
  you
• 1:32
  switch
• 1:32
  to
• 1:32
  Quetiapine
• 1:33
  or
• 1:33
  Seroquel?
• 1:35
  And
• 1:35
  you
• 1:35
  can
• 1:35
  pause
• 1:35
  this
• 1:36
  if
• 1:36
  you'd
• 1:36
  like,
• 1:36
  discuss
• 1:37
  it
• 1:37
  with
• 1:37
  your
• 1:37
  cohort.
• 1:38
  You
• 1:39
  guys
• 1:39
  can
• 1:39
  flesh
• 1:40
  out
• 1:40
  the
• 1:40
  answers
• 1:40
  together
• 1:40
  and
• 1:41
  come
• 1:41
  back
• 1:41
  to
• 1:41
  this.
• 1:42
  All
• 1:42
  right,
• 1:42
  welcome
• 1:43
  back.
• 1:44
  All
• 1:44
  right,
• 1:44
  my
• 1:45
  friends,
• 1:45
  so
• 1:46
  there's
• 1:47
  a
• 1:47
  few
• 1:47
  answers
• 1:47
  here
• 1:48
  that
• 1:48
  might
• 1:48
  make
• 1:48
  sense
• 1:49
  at
• 1:49
  face
• 1:49
  value.
• 1:50
  Let's
• 1:50
  start
• 1:51
  with
• 1:51
  the
• 1:51
  idea
• 1:52
  of
• 1:52
  reducing
• 1:53
  risperidone
• 1:53
  to
• 1:54
  2
• 1:54
  milligrams
• 1:54
  daily.
• 1:55
  Now,
• 1:57
  at
• 1:58
  first
• 1:58
  glance,
• 1:58
  this
• 1:58
  might
• 1:59
  make
• 1:59
  sense.
• 1:59
  Okay,
• 2:00
  what
• 2:00
  are
• 2:00
  we
• 2:00
  told
• 2:01
  in
• 2:01
  our
• 2:01
  coursework
• 2:02
  or
• 2:02
  in
• 2:02
  our
• 2:02
  clinicals?
• 2:03
  Reducing
• 2:04
  the
• 2:04
  dose
• 2:04
  of
• 2:04
  side
• 2:04
  effects
• 2:05
  definitely
• 2:06
  makes
• 2:07
  sense.
• 2:07
  It
• 2:07
  makes
• 2:07
  intuitive
• 2:08
  sense.
• 2:08
  It's
• 2:08
  usually
• 2:09
  the
• 2:09
  first
• 2:09
  thing
• 2:09
  that
• 2:09
  we
• 2:09
  think
• 2:09
  about
• 2:10
  or
• 2:10
  the
• 2:10
  first
• 2:10
  thing
• 2:10
  that
• 2:11
  we
• 2:11
  do.
• 2:12
  The
• 2:12
  problem
• 2:12
  with
• 2:13
  this,
• 2:13
  my
• 2:13
  friends,
• 2:13
  is
• 2:14
  in
• 2:14
  the
• 2:14
  question
• 2:14
  itself.
• 2:15
  She's
• 2:15
  28.
• 2:16
  She's
• 2:16
  been
• 2:17
  stable
• 2:18
  on
• 2:18
  4
• 2:18
  milligrams
• 2:18
  of
• 2:19
  risperidone
• 2:20
  for
• 2:20
  six
• 2:20
  months.
• 2:21
  And
• 2:21
  she
• 2:21
  has
• 2:21
  a
• 2:21
  pretty
• 2:21
  severe
• 2:22
  mental
• 2:22
  illness.
• 2:22
  Schizophrenia.
• 2:23
  Right.
• 2:24
  So
• 2:24
  reducing
• 2:25
  the
• 2:25
  dose
• 2:26
  is
• 2:27
  not
• 2:27
  always
• 2:27
  advisable
• 2:28
  when
• 2:28
  the
• 2:28
  stakes
• 2:29
  are
• 2:29
  so
• 2:29
  high.
• 2:29
  In
• 2:29
  my
• 2:29
  experience,
• 2:30
  I'm
• 2:30
  very
• 2:30
  careful
• 2:31
  about
• 2:32
  changing
• 2:32
  the
• 2:32
  dose
• 2:33
  with
• 2:33
  any
• 2:33
  patient
• 2:34
  if
• 2:34
  I
• 2:34
  feel
• 2:35
  like
• 2:35
  the
• 2:35
  stakes
• 2:36
  are
• 2:36
  really
• 2:36
  high.
• 2:37
  This
• 2:37
  is
• 2:37
  so
• 2:37
  different
• 2:38
  than
• 2:38
  if
• 2:38
  you
• 2:38
  have
• 2:38
  a
• 2:38
  patient
• 2:39
  who's,
• 2:39
  let's
• 2:39
  say
• 2:39
  on
• 2:40
  Prozac
• 2:41
  40
• 2:41
  or
• 2:41
  Prozac
• 2:42
  60.
• 2:43
  And
• 2:43
  their
• 2:43
  depression's
• 2:44
  kind
• 2:44
  of
• 2:44
  mild.
• 2:45
  They're
• 2:45
  complaining
• 2:46
  of
• 2:46
  a
• 2:46
  side
• 2:46
  effect.
• 2:47
  You
• 2:47
  might
• 2:47
  be
• 2:47
  able
• 2:47
  to
• 2:47
  get
• 2:47
  away
• 2:48
  with
• 2:48
  lowering
• 2:48
  the
• 2:48
  dose
• 2:49
  there
• 2:49
  and
• 2:49
  not
• 2:50
  markedly
• 2:50
  changing
• 2:51
  their
• 2:51
  mood.
• 2:51
  They
• 2:51
  might
• 2:52
  have
• 2:52
  been
• 2:52
  just
• 2:52
  fine
• 2:53
  at
• 2:53
  40
• 2:53
  versus
• 2:53
  60.
• 2:54
  And
• 2:54
  hey,
• 2:55
  they
• 2:55
  have
• 2:55
  less
• 2:55
  sexual
• 2:55
  side
• 2:56
  effects
• 2:56
  at
• 2:56
  40
• 2:56
  rather
• 2:57
  than
• 2:57
  60.
• 2:57
  But
• 2:58
  you
• 2:58
  always
• 2:58
  have
• 2:58
  to
• 2:58
  watch
• 2:59
  and
• 2:59
  make
• 2:59
  sure
• 2:59
  your
• 3:00
  patient's
• 3:00
  not
• 3:00
  decompensating.
• 3:01
  It's
• 3:01
  a
• 3:01
  bad
• 3:02
  idea
• 3:02
  if
• 3:02
  you
• 3:02
  lower
• 3:03
  a
• 3:03
  dose
• 3:03
  for
• 3:03
  the
• 3:04
  sake
• 3:04
  of
• 3:04
  a
• 3:04
  side
• 3:04
  effect.
• 3:05
  And
• 3:05
  all
• 3:05
  of
• 3:05
  a
• 3:05
  sudden
• 3:06
  your
• 3:06
  patient
• 3:06
  is
• 3:06
  way
• 3:07
  worse.
• 3:07
  They're
• 3:07
  way
• 3:07
  more
• 3:08
  depressed,
• 3:08
  they're
• 3:08
  more
• 3:08
  agitated.
• 3:09
  You
• 3:10
  don't
• 3:10
  want
• 3:10
  that.
• 3:10
  So
• 3:11
  I'm
• 3:11
  a
• 3:11
  little
• 3:11
  skeptical
• 3:12
  of
• 3:12
  reducing
• 3:12
  or
• 3:12
  spirit
• 3:13
  al
• 3:13
  to
• 3:13
  2
• 3:13
  milligrams
• 3:14
  here
• 3:15
  because,
• 3:15
  again,
• 3:16
  the
• 3:16
  stakes
• 3:16
  are
• 3:16
  kind
• 3:16
  of
• 3:17
  high.
• 3:17
  You
• 3:17
  have
• 3:17
  a
• 3:17
  patient
• 3:18
  who's
• 3:18
  stable.
• 3:18
  The
• 3:19
  last
• 3:19
  thing
• 3:19
  you
• 3:19
  want
• 3:20
  to
• 3:20
  do
• 3:20
  here
• 3:20
  is
• 3:20
  make
• 3:21
  the
• 3:21
  patient
• 3:21
  unstable
• 3:21
  with
• 3:22
  a
• 3:22
  smi,
• 3:23
  or
• 3:23
  serious
• 3:24
  mental
• 3:24
  illness
• 3:24
  like
• 3:24
  schizophrenia.
• 3:25
  No,
• 3:26
  thank
• 3:26
  you.
• 3:26
  I'm
• 3:26
  not
• 3:26
  a
• 3:27
  fan
• 3:27
  of
• 3:27
  that.
• 3:28
  You
• 3:28
  also
• 3:28
  have
• 3:29
  her
• 3:30
  BMI
• 3:30
  is
• 3:30
  very
• 3:30
  high.
• 3:31
  So
• 3:31
  it's
• 3:32
  the
• 3:32
  question
• 3:33
  sort
• 3:33
  of
• 3:33
  hinting,
• 3:33
  it's
• 3:34
  kind
• 3:34
  of
• 3:34
  elbowing
• 3:35
  you
• 3:35
  to
• 3:35
  go,
• 3:35
  hmm,
• 3:36
  Is
• 3:36
  risperidone
• 3:37
  really
• 3:37
  the
• 3:37
  best
• 3:37
  option
• 3:38
  here?
• 3:38
  Because
• 3:38
  Risperidone
• 3:39
  is
• 3:40
  metabolically
• 3:41
  harmful
• 3:42
  in
• 3:42
  many
• 3:42
  respects.
• 3:43
  It
• 3:43
  might
• 3:43
  not
• 3:43
  be
• 3:44
  as
• 3:44
  bad
• 3:44
  as
• 3:44
  Zyprexa
• 3:45
  or
• 3:46
  Clozaril
• 3:46
  or
• 3:47
  something,
• 3:47
  but
• 3:47
  it's
• 3:47
  certainly
• 3:48
  not
• 3:48
  metabolically
• 3:49
  friendly.
• 3:50
  Okay,
• 3:50
  so
• 3:50
  it's
• 3:51
  all.
• 3:51
  The
• 3:51
  question's
• 3:51
  kind
• 3:52
  of
• 3:52
  already
• 3:52
  nudging
• 3:52
  you
• 3:53
  away
• 3:53
  from
• 3:53
  Risperdal,
• 3:54
  and
• 3:54
  reducing
• 3:55
  it
• 3:55
  to
• 3:55
  two
• 3:55
  is
• 3:55
  just.
• 3:56
  It's
• 3:56
  incomplete.
• 3:57
  It's
• 3:57
  just
• 3:57
  an
• 3:57
  incomplete
• 3:58
  answer.
• 3:58
  You
• 3:59
  could.
• 3:59
  Now
• 3:59
  let's
• 3:59
  go
• 3:59
  to
• 4:00
  our
• 4:00
  next
• 4:00
  possibility.
• 4:00
  Should
• 4:01
  we
• 4:01
  switch
• 4:01
  to
• 4:01
  Seroquel?
• 4:02
  Eh,
• 4:02
  I
• 4:02
  don't
• 4:03
  really
• 4:03
  love
• 4:03
  that
• 4:03
  idea
• 4:04
  either.
• 4:04
  Why?
• 4:05
  Because
• 4:05
  again,
• 4:05
  your
• 4:05
  patient
• 4:06
  has
• 4:06
  a
• 4:06
  very
• 4:06
  high
• 4:07
  bmi,
• 4:08
  and
• 4:08
  we
• 4:09
  know
• 4:09
  Seroquel
• 4:10
  is
• 4:10
  definitely
• 4:11
  not
• 4:11
  a
• 4:11
  metabolically
• 4:12
  friendly
• 4:12
  antipsychotic.
• 4:13
  It
• 4:13
  has
• 4:14
  its
• 4:14
  virtues.
• 4:15
  I
• 4:15
  will
• 4:15
  do
• 4:15
  a
• 4:15
  whole
• 4:16
  other
• 4:16
  episode
• 4:16
  in
• 4:16
  the
• 4:16
  future
• 4:17
  on
• 4:17
  Seroquel.
• 4:18
  Seroquel
• 4:18
  is
• 4:18
  a
• 4:18
  very
• 4:19
  exciting
• 4:19
  medication.
• 4:20
  It's
• 4:20
  kind
• 4:20
  of
• 4:20
  like
• 4:20
  a
• 4:20
  Swiss
• 4:20
  army
• 4:21
  knife.
• 4:21
  It's
• 4:22
  great,
• 4:22
  in
• 4:23
  my
• 4:23
  experience,
• 4:24
  at
• 4:24
  allowing
• 4:25
  patients
• 4:25
  to
• 4:26
  go
• 4:26
  to
• 4:26
  sleep
• 4:26
  because
• 4:27
  so
• 4:27
  often
• 4:27
  they
• 4:27
  come
• 4:28
  to
• 4:28
  you,
• 4:28
  they're
• 4:28
  extremely
• 4:29
  depressed,
• 4:29
  maybe
• 4:29
  they're
• 4:30
  agitated,
• 4:30
  hypomanic
• 4:31
  or
• 4:31
  mixed
• 4:32
  features.
• 4:32
  And
• 4:32
  it's
• 4:33
  such
• 4:33
  a
• 4:33
  great,
• 4:33
  reliable
• 4:34
  medication
• 4:34
  to.
• 4:34
  To
• 4:35
  let
• 4:35
  somebody
• 4:36
  sleep
• 4:36
  and
• 4:37
  stabilize
• 4:38
  their
• 4:38
  circadian
• 4:39
  rhythm
• 4:39
  a
• 4:39
  little
• 4:40
  bit.
• 4:40
  But
• 4:40
  in
• 4:41
  this
• 4:41
  case,
• 4:41
  it
• 4:41
  just.
• 4:41
  The.
• 4:42
  The
• 4:42
  shoe
• 4:42
  doesn't
• 4:43
  fit.
• 4:43
  You
• 4:43
  know,
• 4:43
  Seroquel
• 4:44
  is.
• 4:45
  It
• 4:45
  might
• 4:45
  have
• 4:46
  little
• 4:46
  bit
• 4:46
  less
• 4:47
  prolactin
• 4:47
  elevation
• 4:48
  than
• 4:48
  Risperidone.
• 4:49
  It
• 4:49
  definitely
• 4:50
  can
• 4:50
  still
• 4:50
  cause
• 4:50
  prolactin
• 4:51
  elevation,
• 4:51
  but
• 4:51
  less
• 4:52
  so
• 4:52
  than
• 4:52
  risperidone.
• 4:53
  And
• 4:53
  that's
• 4:53
  good.
• 4:54
  But
• 4:55
  it.
• 4:55
  It
• 4:55
  doesn't
• 4:56
  actively
• 4:56
  lower
• 4:57
  prolactin
• 4:58
  either.
• 4:58
  It
• 4:58
  just
• 4:59
  causes
• 4:59
  less
• 4:59
  elevation.
• 5:00
  Keep
• 5:00
  that
• 5:00
  in
• 5:01
  mind.
• 5:01
  And
• 5:01
  it
• 5:01
  has
• 5:01
  more
• 5:02
  metabolic
• 5:02
  side
• 5:02
  effects.
• 5:03
  So
• 5:03
  I'm
• 5:03
  going
• 5:03
  to
• 5:03
  get
• 5:03
  rid
• 5:03
  of
• 5:03
  that
• 5:04
  question,
• 5:04
  too.
• 5:04
  Which
• 5:05
  leaves
• 5:05
  us
• 5:05
  with,
• 5:06
  do
• 5:06
  we
• 5:07
  continue
• 5:07
  Risperdal
• 5:08
  and
• 5:08
  add
• 5:09
  cabergoline,
• 5:10
  which
• 5:10
  is
• 5:10
  a
• 5:11
  dopamine
• 5:11
  agonist,
• 5:12
  or
• 5:12
  do
• 5:13
  we
• 5:13
  just
• 5:13
  switch
• 5:13
  to
• 5:13
  Abilify?
• 5:14
  Okay,
• 5:15
  now
• 5:15
  you
• 5:16
  why
• 5:17
  ask?
• 5:17
  Ask
• 5:18
  ourselves.
• 5:19
  We
• 5:19
  should
• 5:19
  ask
• 5:19
  ourselves
• 5:20
  why
• 5:20
  a
• 5:20
  patient
• 5:21
  would
• 5:21
  be
• 5:22
  taking
• 5:23
  Risperdal
• 5:23
  to
• 5:24
  begin
• 5:24
  with.
• 5:24
  Well,
• 5:25
  with
• 5:25
  schizophrenia,
• 5:26
  we
• 5:26
  do
• 5:26
  know
• 5:26
  that
• 5:27
  we
• 5:27
  are
• 5:28
  trying
• 5:28
  to
• 5:29
  aim
• 5:30
  for
• 5:30
  potent
• 5:31
  D2
• 5:31
  blockade,
• 5:32
  right?
• 5:33
  That's
• 5:33
  what
• 5:33
  we
• 5:33
  want
• 5:33
  to
• 5:34
  do
• 5:34
  in
• 5:34
  the
• 5:34
  mesolimbic
• 5:35
  pathway
• 5:35
  in
• 5:35
  the
• 5:35
  brain,
• 5:36
  right?
• 5:36
  We
• 5:36
  have
• 5:37
  excess
• 5:37
  dopaminergic
• 5:38
  activity
• 5:39
  there.
• 5:39
  We're
• 5:39
  trying
• 5:39
  to
• 5:39
  block
• 5:40
  D2
• 5:40
  receptors
• 5:40
  to
• 5:41
  quell
• 5:41
  psychotic
• 5:42
  thoughts
• 5:42
  and
• 5:43
  hallucinations
• 5:43
  and
• 5:44
  delusions,
• 5:44
  et
• 5:44
  cetera.
• 5:45
  So
• 5:46
  adding
• 5:46
  a
• 5:46
  dopamine
• 5:47
  agonist
• 5:47
  doesn't
• 5:47
  make
• 5:48
  a
• 5:48
  lot
• 5:48
  of
• 5:48
  sense
• 5:48
  here.
• 5:49
  And
• 5:49
  even
• 5:49
  if
• 5:49
  you
• 5:50
  don't
• 5:50
  know
• 5:50
  that
• 5:50
  Cabergoline
• 5:51
  is
• 5:51
  a
• 5:51
  dopamine
• 5:52
  agonist,
• 5:53
  the
• 5:53
  name
• 5:53
  of
• 5:54
  the
• 5:54
  drug
• 5:54
  is
• 5:54
  Cabergoline.
• 5:55
  And
• 5:55
  how
• 5:56
  often
• 5:56
  do
• 5:56
  you
• 5:56
  really
• 5:56
  hear
• 5:56
  about
• 5:57
  that
• 5:57
  medication
• 5:57
  in
• 5:58
  your
• 5:58
  PowerPoint
• 5:58
  slides
• 5:59
  or
• 5:59
  in
• 5:59
  your
• 5:59
  clinicals?
• 5:59
  Almost
• 6:00
  never.
• 6:01
  So
• 6:01
  I
• 6:01
  don't
• 6:01
  want
• 6:01
  to
• 6:01
  throw
• 6:02
  anybody
• 6:02
  off
• 6:02
  here,
• 6:03
  but
• 6:03
  just
• 6:03
  my
• 6:04
  own
• 6:04
  npz
• 6:05
  little
• 6:06
  kind
• 6:06
  of
• 6:07
  test
• 6:07
  tip
• 6:07
  is,
• 6:08
  if
• 6:08
  you've
• 6:08
  never
• 6:09
  heard
• 6:09
  of
• 6:09
  something
• 6:09
  in
• 6:10
  an
• 6:10
  answer,
• 6:10
  there's
• 6:11
  probably
• 6:11
  a
• 6:11
  reason
• 6:11
  for
• 6:12
  it,
• 6:12
  and
• 6:12
  you're
• 6:12
  probably
• 6:12
  being
• 6:13
  tricked.
• 6:13
  Maybe
• 6:13
  you
• 6:14
  just
• 6:14
  didn't
• 6:14
  study
• 6:14
  that
• 6:14
  slide
• 6:15
  and
• 6:15
  you
• 6:15
  should
• 6:15
  have,
• 6:15
  and
• 6:15
  you
• 6:16
  passed
• 6:16
  it
• 6:16
  over,
• 6:16
  and
• 6:16
  shame
• 6:17
  on
• 6:17
  you.
• 6:17
  But
• 6:18
  cabergling,
• 6:19
  really?
• 6:19
  What
• 6:19
  the
• 6:20
  heck
• 6:20
  is
• 6:20
  that?
• 6:20
  I
• 6:20
  had
• 6:20
  no
• 6:21
  idea.
• 6:21
  And
• 6:22
  so
• 6:22
  this
• 6:23
  is
• 6:23
  just
• 6:23
  not
• 6:23
  my
• 6:23
  favorite
• 6:24
  answer.
• 6:24
  And
• 6:24
  then
• 6:24
  certainly
• 6:25
  the
• 6:25
  minute
• 6:25
  we
• 6:25
  know
• 6:26
  it's
• 6:26
  a
• 6:26
  dopamine
• 6:26
  agonist,
• 6:27
  forget
• 6:28
  it.
• 6:28
  Get
• 6:28
  out
• 6:28
  of
• 6:28
  town.
• 6:29
  We're
• 6:29
  not
• 6:30
  trying
• 6:30
  to
• 6:30
  worsen
• 6:31
  psychosis
• 6:31
  here
• 6:31
  by
• 6:31
  adding
• 6:32
  a
• 6:32
  dopamine
• 6:32
  agonist.
• 6:33
  So
• 6:33
  that
• 6:34
  leaves
• 6:35
  switch
• 6:35
  to
• 6:35
  Abilify.
• 6:36
  That's
• 6:36
  the
• 6:36
  answer.
• 6:37
  And
• 6:37
  I
• 6:37
  love
• 6:38
  this
• 6:38
  answer
• 6:38
  for
• 6:38
  two
• 6:38
  reasons.
• 6:39
  Number
• 6:39
  one,
• 6:39
  Abilify
• 6:40
  is
• 6:40
  much
• 6:40
  more
• 6:40
  metabolically
• 6:41
  friendly
• 6:42
  than
• 6:42
  all
• 6:43
  the
• 6:43
  other
• 6:43
  medications
• 6:44
  we
• 6:44
  talked
• 6:44
  about.
• 6:44
  More
• 6:45
  so
• 6:45
  than
• 6:45
  Risperidol,
• 6:46
  more
• 6:46
  so
• 6:46
  than
• 6:46
  Quetiapine.
• 6:48
  It's
• 6:48
  just
• 6:49
  much
• 6:49
  more
• 6:49
  metabolically
• 6:50
  friendly.
• 6:50
  In
• 6:50
  my
• 6:51
  experience,
• 6:51
  there
• 6:51
  still
• 6:52
  can
• 6:52
  be
• 6:52
  weight
• 6:52
  gain.
• 6:52
  I
• 6:53
  have
• 6:53
  had
• 6:53
  patients
• 6:53
  gain
• 6:53
  weight
• 6:54
  on
• 6:54
  it
• 6:54
  somehow,
• 6:55
  but
• 6:55
  not
• 6:55
  as
• 6:56
  reliably
• 6:56
  as
• 6:56
  Zyprexa
• 6:57
  or
• 6:58
  Quetiapine
• 6:58
  or
• 6:58
  Spirit
• 6:59
  Al.
• 6:59
  You
• 6:59
  give
• 6:59
  somebody
• 6:59
  Zyprexa,
• 7:00
  and
• 7:00
  it
• 7:00
  is
• 7:01
  just
• 7:01
  watch
• 7:01
  out,
• 7:02
  Brace
• 7:02
  for
• 7:02
  impact.
• 7:03
  Fantastic.
• 7:04
  Antipsychotic
• 7:05
  reliably
• 7:06
  causes
• 7:07
  weight
• 7:07
  gain,
• 7:07
  and
• 7:07
  I
• 7:07
  mean
• 7:08
  rapid
• 7:08
  weight
• 7:08
  gain.
• 7:08
  And
• 7:09
  it's
• 7:09
  extremely
• 7:10
  intolerable
• 7:10
  to
• 7:10
  many
• 7:11
  people.
• 7:11
  Okay,
• 7:12
  so
• 7:13
  Abilify
• 7:13
  is
• 7:13
  our
• 7:14
  best
• 7:14
  bet
• 7:14
  here.
• 7:14
  Switching
• 7:15
  to
• 7:15
  Abilify.
• 7:16
  I'll
• 7:16
  leave
• 7:16
  you
• 7:17
  with
• 7:17
  your
• 7:18
  drug
• 7:18
  manuals
• 7:18
  to
• 7:19
  figure
• 7:19
  out
• 7:19
  the
• 7:20
  exact
• 7:20
  cross
• 7:20
  switch
• 7:21
  there.
• 7:21
  Board
• 7:22
  bomb
• 7:22
  kind
• 7:23
  of
• 7:23
  question
• 7:23
  for
• 7:24
  a
• 7:24
  lot
• 7:24
  of
• 7:24
  the
• 7:24
  folks
• 7:25
  listening
• 7:25
  here
• 7:25
  today.
• 7:25
  How
• 7:26
  would
• 7:26
  you
• 7:26
  do
• 7:26
  this
• 7:26
  cross
• 7:27
  switch
• 7:27
  from
• 7:27
  Risperidon
• 7:28
  4
• 7:28
  to
• 7:29
  the
• 7:29
  Abilify
• 7:29
  equivalent?
• 7:30
  How
• 7:30
  would
• 7:30
  you
• 7:30
  do
• 7:30
  that?
• 7:31
  How
• 7:31
  long
• 7:31
  would
• 7:31
  you
• 7:31
  take?
• 7:31
  Whip
• 7:32
  out
• 7:32
  your
• 7:32
  textbooks,
• 7:33
  figure
• 7:33
  that
• 7:33
  out
• 7:33
  and
• 7:34
  get
• 7:34
  back
• 7:34
  to
• 7:34
  me,
• 7:34
  my
• 7:34
  friends.
• 7:35
  But
• 7:35
  Abilify
• 7:36
  is
• 7:36
  great
• 7:36
  here
• 7:37
  because
• 7:37
  it's
• 7:37
  a
• 7:37
  dopamine
• 7:38
  partial
• 7:38
  agonist.
• 7:39
  We
• 7:39
  go
• 7:39
  over
• 7:39
  partial
• 7:40
  agonism
• 7:40
  extensively
• 7:41
  in
• 7:41
  previous
• 7:41
  episodes,
• 7:42
  and
• 7:42
  it
• 7:42
  actually
• 7:43
  lowers
• 7:43
  the
• 7:43
  prolactin
• 7:44
  levels
• 7:45
  here.
• 7:45
  And
• 7:45
  it's
• 7:46
  really
• 7:46
  the
• 7:46
  best
• 7:46
  choice
• 7:46
  for
• 7:46
  switching
• 7:47
  when
• 7:47
  hyperprolactinemia
• 7:49
  occurs.
• 7:49
  Okay,
• 7:50
  now
• 7:51
  we
• 7:51
  know
• 7:51
  that
• 7:51
  risperidone
• 7:52
  and
• 7:52
  paliperidone,
• 7:53
  very
• 7:53
  interesting,
• 7:54
  right?
• 7:55
  In
• 7:55
  Vega,
• 7:55
  causes
• 7:56
  the
• 7:56
  highest
• 7:56
  rates
• 7:57
  of
• 7:57
  prolactinemia.
• 7:58
  Okay.
• 7:58
  And
• 7:59
  so
• 8:00
  it
• 8:01
  blocking
• 8:02
  dopamine,
• 8:02
  the
• 8:03
  potent
• 8:03
  dopamine
• 8:04
  blockade
• 8:05
  in
• 8:05
  the
• 8:05
  tubero
• 8:06
  fundibular
• 8:07
  pathway.
• 8:08
  That's
• 8:08
  always
• 8:08
  the
• 8:09
  most
• 8:09
  impossible
• 8:10
  word
• 8:10
  to
• 8:10
  say
• 8:10
  in
• 8:11
  the
• 8:11
  English
• 8:11
  language.
• 8:12
  I
• 8:12
  try
• 8:12
  to
• 8:12
  avoid
• 8:12
  saying
• 8:13
  it
• 8:13
  to
• 8:13
  the
• 8:13
  patients.
• 8:14
  It's
• 8:14
  really
• 8:14
  not
• 8:14
  as
• 8:14
  necessary
• 8:15
  anyway.
• 8:16
  I
• 8:16
  don't
• 8:16
  know
• 8:16
  if
• 8:16
  they
• 8:16
  need
• 8:16
  to
• 8:17
  know
• 8:17
  the
• 8:17
  pathway.
• 8:18
  If
• 8:18
  they
• 8:18
  ask,
• 8:18
  I'm
• 8:19
  open
• 8:19
  to
• 8:19
  butchering
• 8:20
  it
• 8:20
  in
• 8:20
  front
• 8:20
  of
• 8:20
  them.
• 8:21
  But
• 8:22
  you
• 8:22
  know,
• 8:22
  Abilify
• 8:23
  is
• 8:23
  really
• 8:23
  good
• 8:24
  because
• 8:24
  it
• 8:24
  can
• 8:24
  help
• 8:25
  maintain
• 8:25
  the
• 8:25
  psychotic
• 8:26
  efficacy
• 8:27
  with
• 8:27
  your
• 8:27
  patient,
• 8:28
  but
• 8:28
  it
• 8:28
  also
• 8:28
  resolves
• 8:29
  these
• 8:29
  really
• 8:29
  unpleasant
• 8:30
  side
• 8:30
  effects.
• 8:31
  Remember,
• 8:32
  it
• 8:32
  kind
• 8:32
  of
• 8:32
  attenuates
• 8:33
  the
• 8:33
  dopamine
• 8:34
  tone
• 8:34
  or
• 8:34
  kind
• 8:35
  of
• 8:35
  fine
• 8:35
  tunes
• 8:35
  it
• 8:36
  in
• 8:36
  various
• 8:36
  circuits.
• 8:36
  When
• 8:37
  it's
• 8:37
  too
• 8:37
  high,
• 8:37
  it
• 8:37
  lowers
• 8:37
  it.
• 8:38
  When
• 8:38
  it's
• 8:38
  too
• 8:38
  low,
• 8:38
  it
• 8:39
  raises
• 8:39
  it.
• 8:39
  It's
• 8:39
  like
• 8:40
  a
• 8:40
  dimmer
• 8:40
  switch.
• 8:40
  We
• 8:40
  talk
• 8:41
  about
• 8:41
  partial
• 8:41
  agonism.
• 8:42
  It's
• 8:42
  a
• 8:42
  beautiful
• 8:43
  concept
• 8:43
  in
• 8:44
  psychopharmacology.
• 8:45
  So
• 8:45
  the
• 8:45
  answer
• 8:45
  here
• 8:46
  is
• 8:46
  to
• 8:46
  switch
• 8:46
  to
• 8:46
  Abilify,
• 8:47
  my
• 8:47
  friends.
• 8:47
  Let's
• 8:48
  move
• 8:48
  on
• 8:48
  to
• 8:49
  question
• 8:49
  two.
• 8:50
  This
• 8:50
  has
• 8:50
  to
• 8:50
  do
• 8:50
  with
• 8:50
  mood
• 8:51
  stabilizer
• 8:51
  monitoring.
• 8:52
  A
• 8:53
  35
• 8:53
  year
• 8:53
  old
• 8:53
  man
• 8:54
  with
• 8:54
  bipolar
• 8:54
  one
• 8:55
  has
• 8:55
  been
• 8:55
  taking
• 8:55
  lithium,
• 8:56
  900
• 8:56
  milligrams
• 8:57
  twice
• 8:57
  daily
• 8:57
  for
• 8:58
  eight
• 8:58
  weeks
• 8:58
  with
• 8:58
  a
• 8:59
  good
• 8:59
  response.
• 9:00
  He
• 9:00
  presents
• 9:00
  for
• 9:01
  routine
• 9:01
  follow
• 9:01
  up.
• 9:01
  Lithium
• 9:02
  level
• 9:02
  drawn
• 9:03
  10
• 9:03
  hours
• 9:04
  post
• 9:04
  dose
• 9:04
  is
• 9:04
  1.83
• 9:07
  mil
• 9:07
  equivalents
• 9:07
  per
• 9:08
  liter.
• 9:08
  Okay.
• 9:09
  And
• 9:09
  we
• 9:09
  know
• 9:09
  the
• 9:09
  therapeutic
• 9:10
  range
• 9:10
  is
• 9:10
  0.6
• 9:11
  to
• 9:11
  1.2.
• 9:12
  He
• 9:13
  reports
• 9:13
  a
• 9:13
  mild
• 9:14
  hand
• 9:14
  tremor,
• 9:14
  but
• 9:14
  no
• 9:15
  other
• 9:15
  symptoms.
• 9:15
  His
• 9:16
  creatinine
• 9:16
  is
• 9:16
  1.4,
• 9:18
  his
• 9:18
  TSH
• 9:18
  is
• 9:19
  6.8.
• 9:20
  What's
• 9:20
  your
• 9:20
  most
• 9:20
  appropriate
• 9:21
  next
• 9:21
  step?
• 9:22
  Okay,
• 9:23
  so
• 9:23
  we
• 9:23
  can
• 9:23
  definitely
• 9:24
  see
• 9:24
  Here,
• 9:24
  the
• 9:24
  patient
• 9:25
  again.
• 9:25
  He's
• 9:26
  on
• 9:26
  a
• 9:26
  pretty
• 9:26
  good
• 9:26
  dose
• 9:26
  of
• 9:27
  lithium.
• 9:27
  900
• 9:27
  milligrams,
• 9:28
  twice
• 9:28
  daily
• 9:29
  for
• 9:29
  eight
• 9:29
  weeks.
• 10:24
  He's
• 10:24
  pretty
• 10:24
  stable,
• 10:25
  except
• 10:25
  for
• 10:25
  the
• 10:26
  fact
• 10:26
  that
• 10:26
  his
• 10:26
  lithium
• 10:27
  level's
• 10:27
  a
• 10:27
  little
• 10:27
  higher
• 10:28
  than
• 9:34
  we'd
• 10:29
  like
• 10:29
  it
• 10:29
  to
• 10:29
  be.
• 10:29
  It's
• 10:29
  outside
• 10:30
  of
• 10:30
  the
• 10:30
  therapeutic
• 10:31
  parameters.
• 10:32
  Okay,
• 10:32
  the
• 10:32
  hand
• 10:32
  tremor
• 10:33
  is
• 10:33
  a
• 10:33
  concern.
• 10:34
  His
• 10:34
  creatinine
• 10:35
  is
• 10:35
  creeping
• 10:35
  up.
• 10:36
  Remember,
• 10:37
  1.4
• 10:38
  is
• 10:38
  a
• 10:38
  little
• 10:38
  bit
• 10:38
  elevated,
• 10:39
  so
• 10:39
  that's
• 10:39
  something
• 10:40
  of
• 10:40
  concern.
• 10:40
  And
• 10:41
  his
• 10:41
  TSH
• 10:42
  is
• 10:42
  certainly
• 10:43
  high,
• 10:43
  indicating
• 10:44
  that
• 10:44
  maybe
• 10:45
  a
• 10:45
  hypothyroid
• 10:46
  type
• 10:46
  side
• 10:46
  effect
• 10:46
  here
• 10:47
  we've
• 10:47
  gotta
• 10:47
  be
• 10:47
  very
• 10:47
  careful
• 10:48
  about.
• 10:49
  So
• 10:50
  what
• 10:50
  do
• 10:50
  we
• 10:50
  do
• 10:50
  here?
• 10:50
  Do
• 10:50
  we,
• 10:51
  A,
• 10:51
  discontinue
• 10:51
  lithium
• 10:52
  immediately.
• 10:53
  B,
• 10:53
  reduce
• 10:54
  the
• 10:54
  lithium
• 10:54
  dose
• 10:55
  and
• 10:55
  recheck
• 10:55
  levels
• 10:56
  in
• 10:56
  five
• 10:56
  to
• 10:56
  seven
• 10:56
  days.
• 10:57
  C,
• 10:58
  continue
• 10:58
  current
• 10:58
  dose
• 10:59
  and
• 10:59
  add
• 10:59
  propranolol
• 11:00
  for
• 11:00
  the
• 11:00
  tremor.
• 11:01
  Or
• 11:01
  D,
• 11:02
  switch
• 11:02
  to
• 11:02
  Depakote,
• 11:03
  also
• 11:03
  known
• 11:03
  as
• 11:03
  valproic
• 11:04
  acid.
• 11:05
  Okay,
• 11:05
  what
• 11:06
  do
• 11:06
  we
• 11:06
  do
• 11:06
  here?
• 11:06
  You
• 11:06
  can
• 11:06
  pause
• 11:07
  this.
• 11:07
  You
• 11:07
  can
• 11:07
  come
• 11:07
  back
• 11:07
  to
• 11:08
  it.
• 11:08
  It's
• 11:08
  perfectly
• 11:08
  fine.
• 11:10
  All
• 11:10
  right,
• 11:11
  so
• 11:12
  let's
• 11:12
  look
• 11:12
  at
• 11:12
  these
• 11:12
  questions,
• 11:13
  these.
• 11:13
  These
• 11:13
  answers
• 11:14
  a
• 11:14
  little
• 11:14
  bit,
• 11:15
  and
• 11:15
  maybe
• 11:15
  eliminate
• 11:16
  some
• 11:16
  that
• 11:16
  seem
• 11:16
  silly
• 11:17
  to
• 11:17
  us.
• 11:18
  Now,
• 11:18
  switching
• 11:19
  to
• 11:19
  Depakote.
• 11:20
  You
• 11:20
  know,
• 11:20
  my
• 11:20
  friends,
• 11:21
  as
• 11:21
  a
• 11:21
  general
• 11:22
  rule,
• 11:23
  the
• 11:23
  way
• 11:23
  I
• 11:23
  look
• 11:23
  at
• 11:23
  things,
• 11:23
  in
• 11:24
  my
• 11:24
  experience,
• 11:25
  I
• 11:26
  don't
• 11:26
  really
• 11:27
  like
• 11:27
  to
• 11:27
  throw
• 11:27
  the
• 11:27
  baby
• 11:28
  out
• 11:28
  with
• 11:28
  the
• 11:28
  bathwater
• 11:29
  here.
• 11:29
  You
• 11:29
  don't
• 11:30
  have
• 11:30
  major
• 11:30
  lithium
• 11:31
  toxicity
• 11:31
  here,
• 11:32
  okay?
• 11:33
  You
• 11:33
  don't
• 11:33
  have
• 11:33
  ataxia.
• 11:35
  You
• 11:35
  don't
• 11:36
  have
• 11:36
  vomiting.
• 11:37
  You
• 11:37
  don't
• 11:37
  have
• 11:38
  seizures
• 11:38
  or
• 11:38
  coma
• 11:39
  or
• 11:40
  really
• 11:40
  drastic
• 11:41
  signs,
• 11:41
  Confusion
• 11:42
  or
• 11:43
  arrhythmias.
• 11:44
  You
• 11:44
  don't
• 11:44
  have
• 11:44
  these
• 11:44
  drastic
• 11:45
  lithium
• 11:46
  toxicity
• 11:48
  signs
• 11:48
  here.
• 11:49
  Right?
• 11:49
  This
• 11:49
  is
• 11:49
  a
• 11:49
  mild
• 11:50
  tremor,
• 11:50
  okay?
• 11:51
  And
• 11:51
  even
• 11:51
  the
• 11:52
  labs
• 11:52
  that
• 11:53
  you're
• 11:53
  gathering
• 11:53
  here
• 11:53
  aren't
• 11:54
  apocalyptically
• 11:55
  terrible,
• 11:56
  okay?
• 11:56
  They're
• 11:56
  just.
• 11:57
  They
• 11:57
  need
• 11:57
  to
• 11:57
  be
• 11:57
  corrected
• 11:58
  a
• 11:58
  little
• 11:58
  bit.
• 11:58
  So
• 11:59
  I'm
• 11:59
  a
• 11:59
  little
• 11:59
  suspicious.
• 12:00
  The
• 12:00
  intervention
• 12:01
  seems
• 12:01
  too
• 12:01
  drastic
• 12:02
  for
• 12:03
  the
• 12:03
  problem
• 12:03
  at
• 12:04
  hand,
• 12:04
  okay?
• 12:05
  It's
• 12:05
  kind
• 12:05
  of
• 12:05
  like,
• 12:06
  hey,
• 12:06
  my
• 12:06
  fingernails
• 12:06
  are
• 12:07
  too
• 12:07
  long.
• 12:07
  Well,
• 12:08
  what's
• 12:08
  the
• 12:08
  answer?
• 12:09
  Cut
• 12:09
  off
• 12:09
  my
• 12:10
  hand.
• 12:10
  Well,
• 12:10
  that
• 12:10
  sounds
• 12:10
  a
• 12:11
  little
• 12:11
  bit
• 12:11
  insane.
• 12:12
  Okay?
• 12:12
  If
• 12:12
  your
• 12:12
  fingernails
• 12:13
  are
• 12:13
  a
• 12:14
  little
• 12:14
  long,
• 12:15
  cut
• 12:15
  them
• 12:15
  more
• 12:15
  frequently.
• 12:16
  You
• 12:16
  don't
• 12:17
  need
• 12:17
  to
• 12:17
  cut
• 12:17
  your
• 12:17
  hand
• 12:17
  off,
• 12:18
  okay?
• 12:19
  And
• 12:20
  I
• 12:20
  would
• 12:20
  like
• 12:20
  you
• 12:20
  to
• 12:21
  apply
• 12:21
  that
• 12:21
  same
• 12:21
  logic
• 12:22
  to
• 12:22
  this
• 12:22
  kind
• 12:23
  of
• 12:23
  stuff.
• 12:23
  Switching
• 12:24
  the
• 12:24
  Depakote.
• 12:24
  You
• 12:25
  don't
• 12:25
  have
• 12:25
  enough
• 12:25
  on
• 12:25
  here?
• 12:26
  He
• 12:26
  didn't
• 12:26
  say
• 12:26
  he's
• 12:26
  unstable.
• 12:27
  He
• 12:27
  hates
• 12:27
  lithium.
• 12:28
  He's
• 12:28
  gaining
• 12:28
  50
• 12:29
  pounds
• 12:29
  a
• 12:29
  month.
• 12:30
  He
• 12:30
  didn't
• 12:30
  tell
• 12:30
  you
• 12:31
  that?
• 12:31
  And
• 12:31
  objectively,
• 12:32
  he
• 12:32
  looks
• 12:33
  pretty
• 12:33
  decent.
• 12:34
  So
• 12:34
  again,
• 12:34
  the
• 12:35
  stakes
• 12:35
  are
• 12:35
  high.
• 12:35
  Bipolar
• 12:36
  one
• 12:36
  is
• 12:36
  very
• 12:36
  serious
• 12:37
  mental
• 12:37
  illness.
• 12:38
  You
• 12:38
  don't
• 12:38
  want
• 12:38
  to
• 12:38
  just
• 12:39
  on
• 12:40
  a
• 12:40
  whim,
• 12:40
  be
• 12:40
  like
• 12:40
  okay,
• 12:40
  I'm
• 12:41
  not
• 12:41
  dealing
• 12:41
  with
• 12:41
  this
• 12:41
  lithium
• 12:42
  anymore.
• 12:42
  I'm
• 12:42
  going
• 12:42
  to
• 12:42
  switch
• 12:42
  to
• 12:43
  Depakote.
• 12:43
  Depakote,
• 12:44
  by
• 12:44
  the
• 12:44
  way,
• 12:44
  has
• 12:45
  a
• 12:45
  lot
• 12:45
  of
• 12:45
  its
• 12:45
  own
• 12:46
  issues.
• 12:46
  Hair
• 12:46
  loss
• 12:47
  and
• 12:47
  liver
• 12:48
  problems.
• 12:48
  So
• 12:49
  let's
• 12:49
  not
• 12:49
  jump
• 12:50
  to
• 12:50
  conclusions
• 12:50
  here,
• 12:51
  okay?
• 12:51
  Do
• 12:52
  you
• 12:52
  discontinue
• 12:52
  lithium
• 12:53
  immediately?
• 12:54
  Again,
• 12:54
  that's
• 12:55
  kind
• 12:55
  of
• 12:55
  like
• 12:55
  amputating
• 12:56
  your
• 12:56
  hand
• 12:56
  when
• 12:57
  your
• 12:57
  fingernails
• 12:57
  are
• 12:57
  too
• 12:58
  long.
• 12:58
  It's
• 12:59
  just
• 12:59
  not
• 12:59
  necessary.
• 12:59
  He's.
• 13:00
  The
• 13:00
  key
• 13:01
  term
• 13:01
  here
• 13:02
  is
• 13:02
  in
• 13:03
  our
• 13:03
  question
• 13:03
  is
• 13:03
  he
• 13:03
  had
• 13:04
  a
• 13:04
  good
• 13:04
  response.
• 13:05
  So
• 13:05
  there's
• 13:06
  no
• 13:06
  need
• 13:06
  to
• 13:07
  yank
• 13:08
  him
• 13:08
  off
• 13:08
  of
• 13:08
  lithium
• 13:08
  when
• 13:09
  he's
• 13:09
  had
• 13:09
  a
• 13:09
  good
• 13:09
  response.
• 13:10
  We,
• 13:10
  we
• 13:11
  need
• 13:11
  a
• 13:11
  more
• 13:11
  proportionate
• 13:12
  intervention
• 13:13
  here.
• 13:13
  Discontinuing
• 13:14
  lithium
• 13:14
  is
• 13:15
  just
• 13:15
  not
• 13:16
  a,
• 13:16
  it's
• 13:16
  a
• 13:16
  bit
• 13:16
  too
• 13:17
  aggressive.
• 13:17
  Okay?
• 13:18
  These
• 13:18
  are
• 13:18
  elevated
• 13:19
  lithium
• 13:20
  levels
• 13:20
  without
• 13:21
  any
• 13:21
  signs
• 13:21
  of
• 13:21
  severe
• 13:22
  toxicity.
• 13:23
  And
• 13:23
  by
• 13:23
  the
• 13:23
  way,
• 13:23
  if
• 13:24
  you
• 13:24
  abruptly
• 13:25
  conti
• 13:25
  discontinue
• 13:25
  lithium,
• 13:26
  that
• 13:26
  carries
• 13:26
  a
• 13:26
  very
• 13:27
  high
• 13:27
  risk
• 13:27
  of
• 13:27
  relapse
• 13:28
  and
• 13:28
  bipolar.
• 13:28
  We're
• 13:29
  talking
• 13:29
  some
• 13:29
  studies
• 13:30
  showing
• 13:30
  like
• 13:30
  50%
• 13:31
  relapse
• 13:31
  within
• 13:31
  five
• 13:32
  months.
• 13:32
  That's
• 13:33
  not
• 13:33
  a
• 13:33
  good
• 13:33
  idea.
• 13:34
  Okay,
• 13:35
  so
• 13:35
  what
• 13:35
  we're
• 13:35
  looking
• 13:36
  is
• 13:36
  for
• 13:37
  here
• 13:37
  is
• 13:37
  probably
• 13:38
  a
• 13:38
  gradual
• 13:38
  dose
• 13:38
  reduction.
• 13:40
  What
• 13:40
  about
• 13:40
  option
• 13:40
  C?
• 13:41
  Continue
• 13:41
  the
• 13:41
  current
• 13:41
  dose
• 13:42
  and
• 13:42
  add
• 13:42
  propranolol.
• 13:43
  Somewhat
• 13:44
  reasonable,
• 13:44
  but
• 13:44
  you're
• 13:45
  not
• 13:45
  correcting
• 13:45
  the
• 13:46
  fact
• 13:46
  that
• 13:46
  the
• 13:47
  patient's
• 13:47
  lithium
• 13:48
  level
• 13:48
  is
• 13:48
  out
• 13:49
  of
• 13:49
  therapeutic
• 13:50
  range.
• 13:50
  And
• 13:50
  you
• 13:50
  gotta
• 13:50
  watch
• 13:50
  out
• 13:51
  for
• 13:51
  that.
• 13:51
  Right?
• 13:51
  Cause
• 13:52
  it
• 13:52
  could
• 13:52
  just
• 13:52
  take
• 13:53
  one,
• 13:53
  you
• 13:53
  know,
• 13:54
  level
• 13:54
  of
• 13:55
  dehydration
• 13:55
  or
• 13:56
  not
• 13:56
  enough
• 13:56
  salt
• 13:57
  intake,
• 13:57
  or
• 13:57
  maybe
• 13:57
  the
• 13:58
  patient
• 13:58
  takes
• 13:58
  an
• 13:58
  NSAID
• 13:59
  and
• 13:59
  bam.
• 13:59
  Now
• 13:59
  you're
• 14:00
  in
• 14:00
  this
• 14:00
  brutally
• 14:01
  toxic
• 14:01
  level.
• 14:02
  You're
• 14:02
  not
• 14:02
  within
• 14:03
  a
• 14:03
  safe
• 14:03
  margin
• 14:03
  here.
• 14:04
  Right?
• 14:04
  You've
• 14:04
  gotta
• 14:04
  get
• 14:04
  the
• 14:05
  patient
• 14:05
  off
• 14:05
  of
• 14:05
  the
• 14:05
  edge
• 14:06
  a
• 14:06
  little
• 14:06
  bit.
• 14:06
  Get
• 14:06
  them
• 14:07
  off
• 14:07
  the
• 14:07
  edge
• 14:07
  of
• 14:07
  a
• 14:08
  cliff
• 14:08
  and
• 14:08
  like,
• 14:08
  closer
• 14:09
  to
• 14:09
  safe
• 14:09
  territory.
• 14:10
  So
• 14:10
  just
• 14:10
  masking
• 14:11
  the
• 14:11
  tremor
• 14:12
  is
• 14:12
  not
• 14:12
  going
• 14:12
  to
• 14:12
  help
• 14:12
  the
• 14:13
  lithium
• 14:13
  level
• 14:13
  do
• 14:13
  anything
• 14:14
  or
• 14:14
  the
• 14:14
  kidney
• 14:15
  function
• 14:15
  get
• 14:15
  better.
• 14:16
  So
• 14:17
  always
• 14:17
  look
• 14:17
  at
• 14:18
  the
• 14:18
  root
• 14:18
  of
• 14:18
  the
• 14:18
  problem.
• 14:19
  The
• 14:19
  root
• 14:19
  of
• 14:19
  the
• 14:19
  problem
• 14:19
  here
• 14:20
  is
• 14:20
  not
• 14:20
  the
• 14:20
  tremor.
• 14:21
  The
• 14:21
  root
• 14:21
  of
• 14:21
  the
• 14:21
  problem
• 14:22
  here
• 14:22
  is
• 14:22
  your
• 14:22
  lithium
• 14:23
  level
• 14:23
  is
• 14:23
  out
• 14:23
  of
• 14:24
  the
• 14:24
  therapeutic
• 14:24
  range
• 14:25
  and
• 14:25
  it's
• 14:25
  causing
• 14:25
  more
• 14:25
  systemic
• 14:26
  problems
• 14:26
  that
• 14:27
  if
• 14:27
  they're
• 14:27
  not
• 14:27
  treated
• 14:28
  quickly
• 14:28
  or
• 14:29
  corrected
• 14:29
  quickly,
• 14:30
  you
• 14:30
  have
• 14:30
  an
• 14:30
  issue.
• 14:31
  So
• 14:31
  the
• 14:31
  answer
• 14:31
  here
• 14:32
  is
• 14:32
  to
• 14:32
  reduce
• 14:32
  the
• 14:32
  lithium
• 14:33
  dose
• 14:33
  and
• 14:33
  recheck
• 14:34
  after
• 14:34
  about
• 14:34
  five
• 14:35
  half
• 14:35
  lives,
• 14:35
  five
• 14:36
  to
• 14:36
  seven
• 14:36
  days.
• 14:37
  So
• 14:37
  you'd
• 14:37
  want
• 14:37
  to
• 14:37
  recheck
• 14:38
  in
• 14:38
  five
• 14:38
  to
• 14:38
  seven
• 14:38
  days
• 14:39
  after.
• 14:39
  And
• 14:40
  that
• 14:40
  would
• 14:40
  be
• 14:40
  about
• 14:40
  12
• 14:41
  hours
• 14:41
  after
• 14:41
  the
• 14:42
  last
• 14:42
  lithium
• 14:42
  dose.
• 14:43
  Patient
• 14:43
  takes
• 14:43
  it
• 14:44
  around
• 14:44
  7pm
• 14:45
  you'd
• 14:46
  take
• 14:46
  it
• 14:46
  around
• 14:46
  7am
• 14:47
  or
• 14:47
  8am
• 14:47
  the
• 14:48
  next
• 14:48
  morning,
• 14:48
  five
• 14:49
  days
• 14:49
  later,
• 14:49
  of
• 14:49
  course,
• 14:50
  to
• 14:50
  get
• 14:50
  a
• 14:50
  sense
• 14:50
  of
• 14:51
  the
• 14:51
  lithium
• 14:51
  dose,
• 14:51
  you
• 14:51
  want
• 14:52
  to
• 14:52
  see
• 14:52
  lithium
• 14:53
  level.
• 14:53
  And
• 14:53
  again,
• 14:54
  you
• 14:54
  want
• 14:54
  to
• 14:54
  reduce
• 14:55
  the
• 14:55
  dose
• 14:55
  a
• 14:55
  little
• 14:55
  bit
• 14:56
  and,
• 14:56
  and
• 14:57
  then
• 14:57
  get
• 14:58
  into
• 14:58
  more
• 14:58
  therapeutic
• 14:59
  range.
• 15:00
  So
• 15:00
  I
• 15:00
  hope
• 15:00
  you
• 15:01
  enjoyed
• 15:01
  that
• 15:01
  question.
• 15:01
  Let's
• 15:02
  move
• 15:02
  to
• 15:02
  question
• 15:02
  three,
• 15:03
  our
• 15:03
  final
• 15:03
  question.
• 15:04
  This
• 15:04
  is
• 15:04
  about
• 15:05
  antidepressant
• 15:05
  selection.
• 15:06
  A
• 15:06
  45
• 15:07
  year
• 15:07
  old
• 15:07
  woman
• 15:07
  with
• 15:08
  major
• 15:08
  depressive
• 15:08
  disorder
• 15:09
  and
• 15:09
  chronic
• 15:09
  pain
• 15:10
  from
• 15:10
  fibromyalgia
• 15:11
  requests
• 15:12
  medication
• 15:13
  management
• 15:13
  from
• 15:13
  you.
• 15:14
  She
• 15:14
  has
• 15:14
  a
• 15:15
  low
• 15:15
  mood,
• 15:15
  she's
• 15:16
  anhedonic,
• 15:17
  poor
• 15:17
  sleep
• 15:17
  and
• 15:18
  widespread
• 15:18
  muscle
• 15:19
  pain.
• 15:19
  Rated
• 15:19
  a
• 15:20
  7
• 15:20
  out
• 15:20
  of
• 15:20
  10.
• 15:21
  She
• 15:21
  has
• 15:21
  no
• 15:21
  history
• 15:21
  of
• 15:22
  mania
• 15:22
  or
• 15:22
  suicidal
• 15:23
  ideations.
• 15:23
  Her
• 15:23
  BMI
• 15:24
  is
• 15:24
  pretty
• 15:24
  high
• 15:24
  at
• 15:24
  32.
• 15:25
  Which
• 15:25
  antidepressant
• 15:26
  is
• 15:26
  the
• 15:26
  most
• 15:26
  appropriate?
• 15:27
  Is
• 15:28
  it
• 15:28
  Prozac?
• 15:28
  A,
• 15:29
  is
• 15:29
  it
• 15:29
  B,
• 15:30
  Wellbutrin,
• 15:31
  is
• 15:31
  it
• 15:32
  C,
• 15:32
  Cymbalta
• 15:33
  or
• 15:33
  is
• 15:33
  it
• 15:34
  D,
• 15:34
  Remeron?
• 15:36
  Okay,
• 15:37
  so
• 15:37
  we
• 15:37
  have
• 15:38
  a
• 15:38
  patient.
• 15:38
  Here's
• 15:38
  a
• 15:38
  little
• 15:38
  clue
• 15:39
  in
• 15:39
  the
• 15:39
  question.
• 15:39
  Again,
• 15:40
  the
• 15:40
  BMI
• 15:41
  is
• 15:41
  32.
• 15:41
  So
• 15:42
  having
• 15:42
  a
• 15:42
  familiarity
• 15:43
  with
• 15:43
  what
• 15:43
  a
• 15:43
  really
• 15:44
  high
• 15:44
  BMI
• 15:44
  is
• 15:44
  helps
• 15:45
  you
• 15:45
  here
• 15:45
  because
• 15:46
  her
• 15:46
  BMI
• 15:47
  is
• 15:47
  too
• 15:47
  high.
• 15:48
  So
• 15:48
  you
• 15:48
  can
• 15:48
  eliminate
• 15:49
  Remeron
• 15:49
  or
• 15:50
  Mirtazapine.
• 15:50
  That's
• 15:51
  option
• 15:51
  D.
• 15:52
  It
• 15:52
  helps
• 15:53
  with
• 15:53
  sleep
• 15:53
  and
• 15:53
  depression.
• 15:54
  Yes,
• 15:54
  it's
• 15:54
  a
• 15:54
  fine
• 15:55
  antidepressant,
• 15:57
  but
• 15:57
  it
• 15:57
  causes
• 15:57
  significant
• 15:58
  weight
• 15:58
  gain,
• 15:58
  usually
• 15:59
  about
• 15:59
  2
• 15:59
  to
• 15:59
  4
• 16:00
  milligrams
• 16:00
  in
• 16:00
  the
• 16:00
  first
• 16:00
  month
• 16:01
  through
• 16:01
  its
• 16:02
  antihistaminergic
• 16:04
  effect.
• 16:04
  Right.
• 16:05
  H1
• 16:05
  antagonism,
• 16:06
  and
• 16:06
  it's
• 16:06
  5
• 16:07
  HT2C
• 16:07
  antagonism.
• 16:08
  Okay,
• 16:08
  so
• 16:08
  it's
• 16:09
  not
• 16:09
  a
• 16:09
  good
• 16:09
  choice
• 16:09
  for
• 16:09
  a
• 16:10
  patient
• 16:10
  with
• 16:10
  a
• 16:10
  BMI
• 16:10
  of
• 16:11
  32.
• 16:11
  Well,
• 16:12
  what
• 16:12
  about
• 16:12
  Wellbutrin?
• 16:13
  Is
• 16:13
  Wellbutrin
• 16:14
  a
• 16:14
  good
• 16:14
  choice?
• 16:15
  It's
• 16:16
  an
• 16:16
  excellent
• 16:16
  medication
• 16:17
  for
• 16:17
  depression.
• 16:18
  It's
• 16:18
  weight
• 16:19
  neutral.
• 16:19
  Some
• 16:19
  people
• 16:19
  even
• 16:20
  lose
• 16:20
  weight
• 16:20
  on
• 16:20
  Wellbutrin
• 16:21
  that
• 16:21
  I
• 16:21
  give
• 16:21
  Wellbutrin
• 16:22
  to.
• 16:22
  But
• 16:23
  the
• 16:23
  problem
• 16:23
  is
• 16:23
  there's
• 16:23
  really
• 16:23
  no
• 16:24
  indication
• 16:25
  or
• 16:25
  efficacy
• 16:25
  for
• 16:26
  Wellbutrin
• 16:27
  helping
• 16:27
  you
• 16:27
  with
• 16:27
  pain.
• 16:28
  It
• 16:28
  helps
• 16:28
  with
• 16:29
  dopamine,
• 16:29
  norepinephrine
• 16:30
  mechanisms,
• 16:31
  but
• 16:31
  it
• 16:31
  doesn't
• 16:32
  really
• 16:33
  provide
• 16:33
  pain
• 16:34
  relief
• 16:34
  that
• 16:34
  the
• 16:34
  patient
• 16:35
  needs.
• 16:35
  It
• 16:36
  can
• 16:36
  also
• 16:36
  worsen
• 16:37
  insomnia,
• 16:38
  which
• 16:38
  is
• 16:38
  not
• 16:39
  a
• 16:39
  good
• 16:39
  thing
• 16:39
  either,
• 16:40
  and
• 16:40
  the
• 16:40
  patient
• 16:41
  has
• 16:41
  poor
• 16:41
  sleep.
• 16:41
  So
• 16:42
  again,
• 16:42
  look
• 16:42
  back
• 16:43
  to
• 16:43
  the
• 16:43
  question
• 16:44
  as
• 16:44
  you
• 16:45
  kind
• 16:45
  of
• 16:45
  pair
• 16:46
  these
• 16:46
  with
• 16:46
  the
• 16:46
  appropriate
• 16:47
  medication
• 16:47
  and
• 16:47
  you'll
• 16:48
  go,
• 16:48
  oh,
• 16:48
  yeah,
• 16:48
  that's
• 16:48
  not
• 16:49
  a
• 16:49
  good
• 16:49
  idea.
• 16:50
  All
• 16:50
  right,
• 16:50
  so
• 16:50
  that
• 16:50
  leaves
• 16:51
  us
• 16:51
  with
• 16:51
  Prozac
• 16:51
  or
• 16:52
  Cymbalta.
• 16:52
  Well,
• 16:53
  Prozac,
• 16:53
  also
• 16:54
  one
• 16:54
  of
• 16:54
  my
• 16:54
  personal
• 16:55
  favorites.
• 16:55
  It's
• 16:55
  a
• 16:56
  great
• 16:56
  medication,
• 16:56
  but
• 16:56
  there's
• 16:57
  just
• 16:57
  no
• 16:57
  significant
• 16:57
  benefit
• 16:58
  that
• 16:58
  we
• 16:59
  can
• 16:59
  see
• 16:59
  with
• 17:00
  respect
• 17:00
  to
• 17:00
  Prozac
• 17:01
  and
• 17:01
  fibromyalgia
• 17:02
  or
• 17:02
  chronic
• 17:02
  pain.
• 17:03
  What
• 17:03
  you're
• 17:04
  looking
• 17:04
  for
• 17:04
  here
• 17:05
  is
• 17:06
  norepinephrine
• 17:08
  and
• 17:08
  how
• 17:08
  it
• 17:09
  can
• 17:09
  contribute
• 17:09
  to
• 17:09
  pain.
• 17:10
  Modulation
• 17:11
  in
• 17:11
  the
• 17:11
  descending
• 17:12
  inhibitory
• 17:13
  pathways.
• 17:13
  Right.
• 17:13
  So
• 17:14
  I
• 17:14
  know
• 17:14
  for
• 17:15
  me,
• 17:15
  it
• 17:15
  was
• 17:15
  a
• 17:15
  really
• 17:15
  big
• 17:15
  deal
• 17:16
  in
• 17:16
  grad
• 17:16
  school
• 17:17
  learning
• 17:17
  about
• 17:18
  how
• 17:18
  all
• 17:18
  of
• 17:18
  these
• 17:19
  nervous
• 17:20
  system
• 17:21
  kind
• 17:21
  of
• 17:21
  pain
• 17:22
  syndromes,
• 17:23
  all
• 17:23
  the
• 17:23
  anatomy
• 17:24
  and
• 17:24
  physiology
• 17:24
  governing
• 17:25
  the
• 17:25
  pain
• 17:25
  response,
• 17:26
  they're
• 17:27
  studded
• 17:27
  with
• 17:28
  neurotransmitters
• 17:29
  or
• 17:29
  receptors
• 17:30
  that
• 17:30
  our
• 17:31
  neurotransmitters
• 17:31
  act
• 17:31
  on,
• 17:32
  I
• 17:32
  should
• 17:32
  say,
• 17:32
  that
• 17:33
  modulate
• 17:33
  how
• 17:34
  we
• 17:34
  experience
• 17:34
  pain.
• 17:34
  I
• 17:35
  thought
• 17:35
  that
• 17:35
  was
• 17:35
  always
• 17:35
  very
• 17:36
  interesting.
• 17:37
  Our
• 17:37
  spinal
• 17:37
  cord,
• 17:38
  right,
• 17:38
  it's
• 17:39
  innervated
• 17:40
  by
• 17:40
  these
• 17:40
  receptors
• 17:41
  that
• 17:41
  norepinephrine
• 17:42
  actually
• 17:42
  acts
• 17:43
  on
• 17:43
  to.
• 17:43
  To
• 17:44
  soften
• 17:44
  or
• 17:44
  modulate
• 17:45
  the
• 17:45
  pain
• 17:45
  response.
• 17:46
  So
• 17:46
  you're
• 17:46
  really
• 17:46
  chasing
• 17:46
  an
• 17:47
  SNRI
• 17:47
  here.
• 17:48
  In
• 17:48
  particular,
• 17:48
  you're
• 17:48
  chasing
• 17:49
  Cymbalta.
• 17:50
  Okay.
• 17:51
  Cymbalta
• 17:52
  is
• 17:52
  the
• 17:52
  choice
• 17:52
  here.
• 17:54
  Really
• 17:54
  significant
• 17:54
  norepinephrine
• 17:55
  reuptake.
• 17:56
  It's
• 17:57
  been
• 17:57
  a
• 17:57
  pretty
• 17:57
  good
• 17:57
  medication,
• 17:58
  I
• 17:58
  have
• 17:58
  to
• 17:58
  say.
• 17:58
  Anytime
• 17:59
  you
• 17:59
  see
• 17:59
  pain
• 17:59
  or
• 18:00
  fibromyalgia
• 18:00
  in
• 18:01
  the
• 18:01
  question
• 18:02
  and
• 18:02
  you're
• 18:02
  finding
• 18:02
  a
• 18:03
  medication
• 18:03
  that's
• 18:03
  specifically
• 18:04
  suited
• 18:04
  for
• 18:04
  that,
• 18:05
  Cymbalta's
• 18:06
  the
• 18:06
  go
• 18:06
  to.
• 18:07
  It's
• 18:07
  excellent.
• 18:08
  So
• 18:08
  that's
• 18:08
  the
• 18:09
  answer
• 18:09
  to
• 18:09
  that
• 18:09
  one.
• 18:10
  And
• 18:10
  that
• 18:10
  wasn't.
• 18:11
  That
• 18:11
  shouldn't
• 18:11
  have
• 18:11
  been
• 18:11
  too
• 18:11
  hard.
• 18:12
  But
• 18:12
  if
• 18:12
  you're
• 18:13
  just
• 18:13
  learning
• 18:13
  psychopharmacology,
• 18:14
  it
• 18:14
  might
• 18:14
  have
• 18:14
  been
• 18:15
  a
• 18:15
  little
• 18:15
  challenging.
• 18:16
  But
• 18:16
  these
• 18:16
  will
• 18:16
  click
• 18:17
  faster
• 18:18
  and
• 18:18
  faster
• 18:19
  with
• 18:19
  time
• 18:20
  to
• 18:20
  kind
• 18:20
  of
• 18:20
  understand
• 18:21
  the
• 18:21
  nuances
• 18:22
  in
• 18:22
  that
• 18:22
  last
• 18:23
  question.
• 18:23
  Remeron.
• 18:24
  I
• 18:24
  love
• 18:24
  it
• 18:25
  when
• 18:25
  you
• 18:25
  have
• 18:25
  a
• 18:25
  patient
• 18:25
  that
• 18:26
  comes
• 18:26
  to
• 18:26
  you
• 18:26
  who's
• 18:27
  kind
• 18:27
  of
• 18:27
  skinny,
• 18:27
  not
• 18:28
  eating
• 18:28
  a
• 18:28
  lot
• 18:28
  because
• 18:29
  of
• 18:29
  their
• 18:29
  depression
• 18:29
  or
• 18:30
  mood,
• 18:30
  and
• 18:30
  they're
• 18:31
  not
• 18:31
  sleeping.
• 18:31
  Remeron
• 18:32
  is
• 18:32
  such
• 18:32
  a
• 18:32
  great
• 18:32
  combo
• 18:33
  for
• 18:33
  those
• 18:33
  people
• 18:33
  because
• 18:34
  Bamboo
• 18:35
  appetite
• 18:35
  gets
• 18:35
  back
• 18:35
  on
• 18:36
  board,
• 18:36
  they
• 18:36
  start
• 18:37
  sleeping.
• 18:37
  You
• 18:37
  have
• 18:38
  anxiety
• 18:38
  and
• 18:39
  depression
• 18:39
  treatment
• 18:40
  baked
• 18:40
  in
• 18:40
  there.
• 18:41
  It's
• 18:41
  ideal
• 18:41
  for
• 18:41
  that
• 18:41
  kind
• 18:42
  of
• 18:42
  patient.
• 18:42
  Right.
• 18:43
  Prozac
• 18:44
  is
• 18:44
  really
• 18:44
  good
• 18:44
  for
• 18:45
  folks
• 18:45
  who
• 18:45
  are
• 18:45
  sleeping
• 18:45
  in
• 18:46
  a
• 18:46
  little
• 18:46
  too
• 18:46
  much.
• 18:46
  They
• 18:46
  don't
• 18:47
  have
• 18:47
  as
• 18:47
  much
• 18:47
  energy
• 18:47
  in
• 18:47
  the
• 18:48
  morning.
• 18:48
  Right.
• 18:49
  Maybe
• 18:49
  they're
• 18:49
  binge
• 18:49
  eating
• 18:50
  a
• 18:50
  lot.
• 18:50
  And
• 18:51
  so
• 18:52
  Prozac
• 18:52
  can
• 18:52
  really
• 18:53
  be
• 18:53
  good
• 18:53
  for
• 18:53
  those
• 18:53
  people.
• 18:54
  Wellbutrin,
• 18:54
  if
• 18:54
  you
• 18:54
  have
• 18:55
  a
• 18:55
  patient
• 18:55
  who
• 18:55
  can't
• 18:56
  focus
• 18:56
  very
• 18:56
  well
• 18:57
  and
• 18:57
  you
• 18:58
  feel
• 18:58
  like
• 18:58
  ADHD
• 18:59
  is
• 18:59
  kind
• 18:59
  of
• 18:59
  in
• 18:59
  the
• 18:59
  cards,
• 19:00
  but
• 19:00
  not
• 19:00
  completely,
• 19:01
  maybe
• 19:01
  you
• 19:01
  fall
• 19:01
  short
• 19:01
  of
• 19:02
  a
• 19:02
  full
• 19:02
  fledged
• 19:02
  ADHD
• 19:03
  diagnosis.
• 19:04
  But
• 19:04
  you
• 19:04
  also
• 19:05
  smell
• 19:05
  some
• 19:05
  depression
• 19:06
  in
• 19:06
  there.
• 19:06
  The
• 19:06
  depression
• 19:07
  has
• 19:07
  that
• 19:07
  kind
• 19:08
  of
• 19:08
  foggy
• 19:08
  thinking,
• 19:09
  slowly
• 19:09
  type
• 19:10
  psychomotor
• 19:11
  retardation
• 19:11
  depression,
• 19:12
  well,
• 19:12
  then,
• 19:13
  bam.
• 19:13
  Wellbutrin's
• 19:14
  the
• 19:14
  best,
• 19:14
  right?
• 19:14
  Wellbutrin
• 19:15
  can
• 19:15
  be
• 19:15
  great
• 19:15
  for
• 19:15
  that.
• 19:16
  But
• 19:16
  this
• 19:16
  question
• 19:16
  asked
• 19:16
  about
• 19:17
  pain,
• 19:17
  and
• 19:18
  so
• 19:18
  Cymbalta
• 19:18
  is
• 19:18
  definitely
• 19:19
  the
• 19:19
  best.
• 19:20
  All
• 19:20
  right,
• 19:20
  well,
• 19:20
  thank
• 19:20
  you
• 19:21
  all
• 19:21
  for
• 19:21
  tuning
• 19:21
  in
• 19:21
  again.
• 19:22
  Please
• 19:22
  don't
• 19:22
  hesitate
• 19:23
  to
• 19:23
  become
• 19:23
  Patreon
• 19:24
  members.
• 19:24
  My
• 19:24
  promise
• 19:25
  with
• 19:25
  anybody
• 19:26
  signing
• 19:26
  up
• 19:26
  for
• 19:26
  Patreon
• 19:27
  is
• 19:27
  it's
• 19:27
  only
• 19:28
  three
• 19:28
  bucks
• 19:28
  a
• 19:28
  month.
• 19:29
  And
• 19:30
  even
• 19:30
  if
• 19:30
  you
• 19:30
  just
• 19:31
  get
• 19:31
  like
• 19:31
  one
• 19:31
  good
• 19:32
  pearl
• 19:32
  that
• 19:32
  month,
• 19:33
  that
• 19:33
  might
• 19:34
  save
• 19:34
  you
• 19:34
  an
• 19:34
  extra
• 19:34
  hour
• 19:35
  at
• 19:35
  work
• 19:36
  and
• 19:36
  being
• 19:36
  able
• 19:37
  to
• 19:37
  just
• 19:37
  give
• 19:37
  better
• 19:38
  patient
• 19:38
  education
• 19:39
  or
• 19:39
  pick
• 19:39
  a
• 19:40
  medication
• 19:40
  that's
• 19:40
  more
• 19:40
  suitable
• 19:41
  that
• 19:41
  helps
• 19:41
  a
• 19:42
  patient
• 19:42
  live
• 19:42
  a
• 19:43
  better
• 19:43
  life.
• 19:43
  So
• 19:44
  just
• 19:44
  one
• 19:44
  pearl
• 19:45
  for
• 19:45
  three
• 19:45
  bucks
• 19:46
  a
• 19:46
  month
• 19:46
  and
• 19:46
  you'll
• 19:46
  probably
• 19:47
  get
• 19:47
  a
• 19:47
  thousand
• 19:47
  good
• 19:48
  pearls.
• 19:48
  But
• 19:49
  just
• 19:49
  one,
• 19:49
  I
• 19:50
  think
• 19:50
  makes
• 19:50
  such
• 19:50
  a
• 19:50
  great
• 19:51
  difference.
• 19:51
  And
• 19:51
  that
• 19:51
  $3
• 19:52
  goes
• 19:52
  a
• 19:52
  lot
• 19:52
  further
• 19:53
  than
• 19:53
  you
• 19:53
  think
• 19:53
  for
• 19:53
  you
• 19:54
  and
• 19:54
  your
• 19:54
  patient.
• 19:55
  Thank
• 19:55
  you
• 19:55
  all
• 19:55
  for
• 19:56
  tuning
• 19:56
  in.
• 19:56
  Until
• 19:57
  next
• 19:57
  time,
• 19:57
  take
• 19:57
  care.