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Why Your Meds ‘Aren’t Working (It’s Not What You Think) · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  prep.
• 0:09
  Npc.
• 0:09
  Here
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:12
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:13
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Now
• 0:16
  you
• 0:17
  have
• 0:17
  a
• 0:18
  mock
• 0:18
  patient
• 0:18
  at
• 0:19
  your
• 0:19
  door.
• 0:20
  Her
• 0:20
  name
• 0:20
  is
• 0:20
  Maria.
• 0:21
  She's
• 0:21
  a
• 0:22
  42
• 0:22
  year
• 0:22
  old
• 0:22
  female
• 0:23
  with
• 0:24
  a
• 0:24
  history
• 0:24
  of
• 0:24
  generalized
• 0:25
  anxiety
• 0:25
  disorder.
• 0:26
  She
• 0:27
  presents
• 0:27
  to
• 0:27
  your
• 0:27
  clinic.
• 0:28
  She's
• 0:28
  been
• 0:28
  on
• 0:28
  Zoloft
• 0:29
  for
• 0:29
  10
• 0:29
  weeks
• 0:30
  for
• 0:30
  major
• 0:30
  depressive
• 0:31
  disorder.
• 0:32
  She
• 0:32
  was
• 0:33
  started
• 0:33
  on
• 0:33
  50
• 0:34
  milligrams
• 0:35
  of
• 0:35
  Zoloft
• 0:36
  by
• 0:36
  her
• 0:36
  previous
• 0:36
  provider
• 0:38
  in
• 0:38
  primary
• 0:38
  care.
• 0:39
  She's
• 0:39
  telling
• 0:40
  you,
• 0:40
  hey,
• 0:40
  the
• 0:40
  meds
• 0:40
  aren't
• 0:41
  really
• 0:41
  working.
• 0:41
  I
• 0:41
  still
• 0:41
  feel
• 0:42
  terrible.
• 0:42
  Her
• 0:42
  PHQ,
• 0:43
  9,
• 0:43
  16,
• 0:44
  it's
• 0:45
  moderately
• 0:45
  severe
• 0:46
  depression.
• 0:46
  Granted,
• 0:47
  it
• 0:47
  was
• 0:47
  at
• 0:47
  21
• 0:48
  before,
• 0:48
  so
• 0:49
  now
• 0:49
  it's
• 0:49
  at
• 0:49
  16
• 0:50
  and
• 0:50
  she
• 0:50
  wants
• 0:51
  something
• 0:51
  stronger.
• 0:53
  Talk
• 0:53
  about
• 0:53
  a
• 0:53
  high
• 0:54
  yield
• 0:54
  case
• 0:55
  study.
• 0:55
  I
• 0:56
  am
• 0:56
  foaming
• 0:57
  at
• 0:57
  the
• 0:57
  mouth
• 0:58
  with
• 0:58
  excitement
• 0:59
  about
• 0:59
  this
• 0:59
  one
• 1:00
  because
• 1:01
  it's
• 1:01
  one
• 1:01
  of
• 1:01
  those
• 1:02
  cases
• 1:02
  that
• 1:02
  looks
• 1:03
  so
• 1:03
  darn
• 1:03
  simple
• 1:04
  and
• 1:04
  yet
• 1:05
  it's
• 1:06
  not
• 1:06
  right.
• 1:07
  And
• 1:07
  yet
• 1:07
  there's.
• 1:08
  So
• 1:08
  the
• 1:08
  devil's
• 1:09
  in
• 1:09
  the
• 1:09
  details
• 1:09
  here
• 1:10
  to
• 1:10
  take
• 1:11
  you
• 1:11
  from
• 1:11
  a
• 1:11
  good
• 1:12
  prescriber
• 1:13
  to
• 1:13
  a
• 1:14
  great
• 1:14
  prescriber.
• 1:15
  Right
• 1:16
  now,
• 1:16
  the
• 1:17
  average
• 1:17
  prescriber
• 1:19
  might
• 1:19
  look
• 1:19
  at
• 1:19
  this.
• 1:19
  Maybe
• 1:20
  a
• 1:20
  prescriber
• 1:20
  who's
• 1:21
  being
• 1:21
  really
• 1:21
  rushed
• 1:22
  or
• 1:22
  jaded
• 1:23
  or
• 1:23
  burnt
• 1:23
  out
• 1:24
  or
• 1:24
  not
• 1:24
  up,
• 1:25
  not
• 1:25
  up
• 1:25
  to
• 1:25
  the
• 1:25
  evidence
• 1:25
  might
• 1:26
  look
• 1:26
  at
• 1:26
  this
• 1:26
  and
• 1:26
  go,
• 1:26
  you
• 1:27
  know
• 1:27
  what?
• 1:27
  You're
• 1:27
  damn
• 1:28
  right,
• 1:28
  Maria.
• 1:29
  We're
• 1:29
  going
• 1:29
  to
• 1:30
  go
• 1:30
  ahead
• 1:30
  and
• 1:31
  get
• 1:31
  you
• 1:31
  on
• 1:31
  something
• 1:32
  stronger.
• 1:32
  Here's
• 1:33
  a
• 1:33
  benzodiazepine,
• 1:34
  that'll
• 1:34
  do
• 1:34
  it.
• 1:34
  Okay,
• 1:35
  that's
• 1:36
  not
• 1:36
  where
• 1:36
  we
• 1:36
  want
• 1:36
  to
• 1:36
  go
• 1:37
  here.
• 1:37
  She
• 1:38
  wants
• 1:38
  something
• 1:38
  stronger.
• 1:39
  So
• 1:39
  I
• 1:40
  have
• 1:40
  mentioned
• 1:40
  this
• 1:40
  in
• 1:41
  previous
• 1:41
  discussions
• 1:42
  that
• 1:44
  you
• 1:44
  always
• 1:45
  want
• 1:45
  to
• 1:45
  be
• 1:45
  a
• 1:45
  little
• 1:46
  wary
• 1:47
  of
• 1:47
  the
• 1:47
  anchoring
• 1:48
  bias.
• 1:48
  Right?
• 1:48
  The
• 1:49
  anchoring
• 1:49
  bias
• 1:49
  is
• 1:50
  kind
• 1:50
  of
• 1:50
  the
• 1:50
  first
• 1:50
  thing
• 1:51
  you
• 1:51
  hear
• 1:51
  in
• 1:51
  session.
• 1:52
  And
• 1:53
  although
• 1:53
  it
• 1:53
  is
• 1:53
  important,
• 1:54
  and
• 1:54
  I
• 1:54
  want
• 1:54
  to
• 1:54
  really
• 1:55
  emphasize
• 1:55
  this,
• 1:55
  it
• 1:55
  is
• 1:56
  very
• 1:56
  important
• 1:57
  what
• 1:57
  your
• 1:57
  patient
• 1:58
  chooses
• 1:58
  to
• 1:58
  say
• 1:58
  right
• 1:59
  away
• 1:59
  at
• 1:59
  the
• 1:59
  start
• 2:00
  of
• 2:00
  session.
• 2:01
  Because
• 2:01
  typically
• 2:02
  that
• 2:02
  does
• 2:02
  tend
• 2:02
  to
• 2:03
  reflect
• 2:03
  the
• 2:03
  meat
• 2:03
  and
• 2:03
  potatoes
• 2:04
  of
• 2:04
  what
• 2:05
  they
• 2:05
  need
• 2:05
  you
• 2:05
  to
• 2:05
  do.
• 2:05
  Right.
• 2:06
  If
• 2:06
  somebody's
• 2:07
  going
• 2:07
  to
• 2:07
  lead
• 2:07
  off
• 2:07
  and
• 2:08
  tell
• 2:08
  you
• 2:08
  that
• 2:08
  they're.
• 2:08
  They've
• 2:09
  been
• 2:09
  panicking
• 2:09
  nonstop
• 2:10
  lately,
• 2:11
  sure.
• 2:11
  Panic
• 2:12
  is
• 2:13
  certainly
• 2:14
  of
• 2:14
  critical
• 2:14
  importance
• 2:15
  for
• 2:15
  you
• 2:15
  to
• 2:16
  evaluate
• 2:17
  and
• 2:18
  do
• 2:18
  a
• 2:18
  full
• 2:18
  inventory
• 2:19
  of
• 2:19
  those
• 2:19
  symptoms.
• 2:19
  And
• 2:20
  think
• 2:20
  panic
• 2:20
  disorder
• 2:21
  and
• 2:21
  think
• 2:21
  anxiety
• 2:21
  or
• 2:22
  social
• 2:22
  anxiety,
• 2:23
  whatever.
• 2:23
  Okay.
• 2:24
  At
• 2:24
  the
• 2:24
  same
• 2:25
  time,
• 2:25
  remember
• 2:26
  that
• 2:26
  often
• 2:27
  what
• 2:27
  a
• 2:27
  patient
• 2:27
  will
• 2:28
  anchor
• 2:28
  you
• 2:28
  to
• 2:29
  is
• 2:29
  their
• 2:29
  own
• 2:30
  interpretation
• 2:31
  of
• 2:31
  what's
• 2:31
  happening.
• 2:31
  Again,
• 2:32
  very
• 2:32
  important.
• 2:33
  But
• 2:33
  some
• 2:34
  people
• 2:34
  will
• 2:34
  be
• 2:34
  describing
• 2:35
  anxiety
• 2:36
  or
• 2:36
  panic
• 2:37
  when
• 2:37
  they're
• 2:37
  really
• 2:38
  describing
• 2:39
  akaesthesia.
• 2:40
  Right.
• 2:40
  So
• 2:40
  when
• 2:40
  you
• 2:41
  get
• 2:41
  more
• 2:41
  specific,
• 2:42
  when
• 2:42
  you,
• 2:42
  when
• 2:43
  you
• 2:43
  access
• 2:44
  more
• 2:44
  verbiage
• 2:45
  and
• 2:46
  more
• 2:46
  of
• 2:46
  their
• 2:47
  own
• 2:47
  subjective
• 2:47
  experience
• 2:48
  through
• 2:48
  careful
• 2:49
  prompting
• 2:49
  in
• 2:49
  context
• 2:50
  of
• 2:50
  their
• 2:50
  recent
• 2:51
  medications
• 2:51
  and
• 2:52
  their,
• 2:53
  and
• 2:53
  how
• 2:53
  they
• 2:53
  feel
• 2:54
  subjectively
• 2:54
  on
• 2:55
  those
• 2:55
  medications.
• 2:55
  Lo
• 2:56
  and
• 2:56
  behold,
• 2:57
  you
• 2:57
  realize
• 2:57
  that
• 2:57
  they
• 2:58
  described
• 2:59
  their
• 2:59
  symptoms
• 3:00
  as
• 3:00
  anxiety,
• 3:00
  but
• 3:00
  it
• 3:01
  was
• 3:01
  really
• 3:01
  AKA
• 3:01
  seizure.
• 3:02
  They
• 3:02
  described
• 3:03
  their
• 3:03
  symptoms
• 3:03
  as
• 3:03
  anxiety,
• 3:04
  but
• 3:05
  it
• 3:05
  really
• 3:05
  wasn't
• 3:05
  fear
• 3:06
  based
• 3:06
  catastrophic
• 3:07
  thinking.
• 3:07
  It
• 3:07
  was
• 3:08
  more
• 3:08
  like,
• 3:08
  oh,
• 3:08
  I'm
• 3:08
  falling
• 3:09
  behind
• 3:09
  because
• 3:10
  of
• 3:10
  ADHD
• 3:10
  symptoms
• 3:11
  and
• 3:11
  disorganized
• 3:12
  disorganization,
• 3:13
  lack
• 3:13
  of
• 3:13
  prioritization
• 3:14
  that's
• 3:15
  leading
• 3:15
  to
• 3:15
  overwhelm.
• 3:15
  Right
• 3:16
  now
• 3:16
  that
• 3:17
  patient
• 3:17
  has
• 3:17
  used
• 3:17
  the
• 3:17
  word
• 3:18
  anxiety.
• 3:19
  And,
• 3:19
  and
• 3:20
  though
• 3:20
  it
• 3:20
  is
• 3:21
  very
• 3:21
  important
• 3:22
  to
• 3:22
  understand
• 3:22
  experientially,
• 3:23
  hey,
• 3:24
  this
• 3:24
  patient
• 3:24
  is
• 3:24
  anxious,
• 3:25
  diagnostically
• 3:26
  and
• 3:26
  clinically,
• 3:26
  that
• 3:27
  could
• 3:27
  mean
• 3:27
  a
• 3:27
  radically
• 3:28
  different
• 3:28
  thing
• 3:28
  when
• 3:29
  you
• 3:29
  really
• 3:30
  boil
• 3:30
  down
• 3:31
  the
• 3:31
  semantics
• 3:32
  of
• 3:32
  that
• 3:32
  word
• 3:32
  and
• 3:33
  what
• 3:33
  it
• 3:33
  really
• 3:33
  means
• 3:33
  to
• 3:34
  the
• 3:34
  patient.
• 3:34
  And
• 3:34
  part
• 3:35
  of
• 3:35
  our
• 3:35
  job
• 3:35
  as
• 3:35
  clinicians
• 3:36
  is
• 3:36
  to
• 3:36
  offer
• 3:37
  a
• 3:38
  wide
• 3:38
  menu
• 3:38
  of
• 3:39
  vocabulary
• 3:40
  and
• 3:40
  really
• 3:41
  gentle
• 3:42
  prompting
• 3:42
  so
• 3:43
  that
• 3:43
  the
• 3:43
  patient
• 3:44
  has
• 3:44
  a
• 3:44
  full
• 3:44
  opportunity
• 3:45
  to
• 3:46
  accurately
• 3:46
  characterize
• 3:47
  how
• 3:47
  they
• 3:47
  actually
• 3:48
  feel.
• 3:48
  And
• 3:48
  if
• 3:49
  it
• 3:49
  is
• 3:49
  anxiety,
• 3:49
  it's
• 3:49
  anxiety
• 3:50
  like
• 3:50
  ding,
• 3:51
  ding,
• 3:51
  ding,
• 3:51
  ding,
• 3:52
  right?
• 3:53
  Like
• 3:53
  that's
• 3:54
  great
• 3:54
  if
• 3:54
  the
• 3:54
  patient
• 3:55
  is
• 3:55
  dead
• 3:55
  on
• 3:55
  the
• 3:55
  money
• 3:55
  and
• 3:56
  characterizing
• 3:56
  their
• 3:57
  symptoms
• 3:57
  perfectly
• 3:57
  to
• 3:58
  you.
• 3:58
  Okay,
• 3:59
  so
• 3:59
  the
• 3:59
  patient
• 3:59
  wants
• 4:00
  something
• 4:00
  stronger.
• 4:01
  Maria,
• 4:02
  42
• 4:02
  years
• 4:03
  old,
• 4:03
  has
• 4:03
  GAD.
• 4:04
  She's
• 4:05
  also
• 4:06
  was
• 4:06
  placed
• 4:06
  on
• 4:06
  this
• 4:07
  Zoloft
• 4:07
  here
• 4:07
  at
• 4:07
  50
• 4:07
  milligrams
• 4:08
  for
• 4:08
  MDD.
• 4:10
  Now,
• 4:10
  here
• 4:11
  are
• 4:12
  really
• 4:12
  four
• 4:13
  rules
• 4:13
  that
• 4:14
  you
• 4:14
  want
• 4:15
  to
• 4:15
  consider
• 4:16
  when
• 4:16
  a
• 4:16
  patient
• 4:17
  has
• 4:17
  been
• 4:18
  placed
• 4:18
  on
• 4:18
  a
• 4:18
  medication
• 4:19
  and
• 4:21
  it's
• 4:21
  up
• 4:21
  to
• 4:21
  you
• 4:21
  whether
• 4:22
  to
• 4:22
  like
• 4:22
  switch
• 4:23
  it
• 4:24
  or
• 4:24
  whatever
• 4:24
  you
• 4:25
  do
• 4:25
  next.
• 4:25
  Because
• 4:25
  they're
• 4:25
  asking
• 4:26
  you
• 4:26
  to
• 4:26
  do
• 4:26
  something,
• 4:26
  right?
• 4:27
  They're
• 4:27
  not
• 4:27
  really
• 4:28
  pleased
• 4:28
  with
• 4:29
  the
• 4:29
  medication
• 4:29
  they're
• 4:30
  on.
• 4:30
  And
• 4:30
  this
• 4:30
  happens
• 4:30
  all
• 4:31
  of
• 4:31
  the
• 4:31
  time
• 4:31
  in
• 4:31
  practice,
• 4:32
  Right.
• 4:32
  This
• 4:32
  is
• 4:32
  a
• 4:33
  very
• 4:33
  common
• 4:33
  starting
• 4:34
  dose.
• 4:35
  Sertraline,
• 4:36
  50
• 4:36
  milligrams.
• 4:36
  It's
• 4:37
  a
• 4:37
  very
• 4:37
  common
• 4:37
  medication.
• 4:38
  It's
• 4:38
  going
• 4:38
  to
• 4:38
  show
• 4:38
  up
• 4:39
  all
• 4:39
  the
• 4:39
  time
• 4:39
  and
• 4:40
  the
• 4:40
  patients
• 4:40
  are
• 4:40
  going
• 4:40
  to
• 4:40
  go,
• 4:40
  wait
• 4:41
  a
• 4:41
  minute,
• 4:41
  what
• 4:41
  do
• 4:42
  I
• 4:42
  really
• 4:42
  do
• 4:42
  here?
• 4:43
  Right?
• 4:43
  Because
• 4:44
  remember,
• 4:45
  a
• 4:46
  good
• 4:46
  chunk
• 4:46
  of
• 4:46
  patients
• 4:47
  are
• 4:47
  not
• 4:47
  going
• 4:47
  to
• 4:47
  be
• 4:48
  in
• 4:48
  remission
• 4:49
  at
• 4:49
  all
• 4:50
  after
• 4:50
  they
• 4:51
  were
• 4:51
  first
• 4:51
  placed
• 4:51
  on
• 4:51
  an
• 4:52
  antidepressant.
• 4:52
  It
• 4:52
  just
• 4:53
  doesn't
• 4:53
  happen
• 4:53
  right
• 4:53
  away.
• 4:54
  Okay?
• 4:54
  It
• 4:54
  takes
• 4:55
  four
• 4:55
  to
• 4:55
  six
• 4:56
  weeks
• 4:56
  at
• 4:56
  a,
• 4:56
  at
• 4:56
  a
• 4:57
  stable
• 4:57
  dose.
• 4:58
  And
• 4:58
  it
• 4:58
  also
• 4:59
  just
• 4:59
  doesn't
• 4:59
  happen
• 5:00
  in
• 5:00
  the
• 5:00
  majority
• 5:00
  of
• 5:00
  patients
• 5:01
  that
• 5:01
  they
• 5:01
  get
• 5:01
  and
• 5:01
  they
• 5:02
  enter
• 5:02
  into
• 5:02
  a,
• 5:02
  a
• 5:03
  remission
• 5:03
  state
• 5:04
  in,
• 5:04
  in
• 5:04
  just
• 5:05
  several
• 5:05
  weeks.
• 5:05
  Okay?
• 5:06
  So
• 5:07
  here
• 5:07
  are
• 5:08
  your
• 5:08
  four
• 5:08
  core
• 5:08
  principles.
• 5:10
  Okay.
• 5:10
  When
• 5:10
  you're
• 5:11
  presented
• 5:11
  with
• 5:11
  a
• 5:11
  case
• 5:12
  like
• 5:12
  this,
• 5:12
  the
• 5:12
  first
• 5:12
  thing
• 5:13
  you
• 5:13
  need
• 5:13
  to
• 5:13
  be
• 5:13
  asking
• 5:13
  is,
• 5:14
  is
• 5:14
  Maria
• 5:15
  actually
• 5:15
  taking
• 5:15
  the
• 5:16
  medication?
• 5:17
  The
• 5:17
  second
• 5:17
  thing
• 5:17
  is,
• 5:17
  is
• 5:18
  the
• 5:18
  dose
• 5:18
  Maria
• 5:19
  is
• 5:19
  taking
• 5:19
  adequate?
• 5:20
  The
• 5:21
  Third
• 5:21
  thing
• 5:21
  you
• 5:21
  need
• 5:21
  to
• 5:21
  think
• 5:22
  about
• 5:22
  is,
• 5:22
  is
• 5:23
  the
• 5:23
  duration
• 5:23
  sufficient
• 5:24
  that
• 5:24
  Maria
• 5:25
  is
• 5:25
  taking
• 5:25
  the
• 5:25
  medication?
• 5:26
  And
• 5:26
  then
• 5:27
  the
• 5:27
  fourth
• 5:27
  thing
• 5:27
  you
• 5:27
  should
• 5:28
  think
• 5:28
  about
• 5:28
  is,
• 5:28
  is
• 5:28
  my
• 5:29
  diagnosis
• 5:29
  correct?
• 5:30
  And
• 5:31
  of
• 5:31
  course,
• 5:31
  within
• 5:31
  each
• 5:32
  of
• 5:32
  those
• 5:32
  sections,
• 5:33
  there's
• 5:33
  a
• 5:34
  lot
• 5:34
  of
• 5:34
  juice
• 5:35
  in
• 5:35
  the
• 5:35
  orange,
• 5:35
  as
• 5:36
  I
• 5:36
  say.
• 5:36
  Right.
• 5:36
  There's
• 5:36
  a
• 5:37
  lot
• 5:37
  to
• 5:37
  squeeze
• 5:38
  from
• 5:38
  those
• 5:38
  four
• 5:39
  core
• 5:39
  principles
• 5:40
  that
• 5:40
  you
• 5:40
  need
• 5:40
  to
• 5:41
  examine
• 5:43
  or
• 5:43
  think
• 5:43
  about
• 5:43
  when
• 5:44
  your
• 5:44
  patient
• 5:44
  is
• 5:44
  coming
• 5:45
  to
• 5:45
  you
• 5:45
  and
• 5:45
  they're
• 5:45
  not
• 5:45
  satisfied
• 5:46
  with
• 5:46
  their
• 5:46
  first
• 5:46
  medication.
• 5:47
  Now,
• 5:48
  the
• 5:48
  first
• 5:48
  thing
• 5:48
  that
• 5:48
  really
• 5:49
  jumps
• 5:49
  out
• 5:49
  is
• 5:50
  medication
• 5:50
  adherence,
• 5:51
  and
• 5:51
  they
• 5:52
  absolutely
• 5:52
  are
• 5:52
  going
• 5:52
  to
• 5:52
  change
• 5:53
  the
• 5:53
  way
• 5:53
  I
• 5:53
  practice.
• 5:53
  Okay?
• 5:54
  So
• 5:55
  I
• 5:55
  had
• 5:55
  no
• 5:55
  idea
• 5:56
  the
• 5:56
  extent
• 5:56
  of
• 5:56
  the
• 5:56
  problem.
• 5:57
  I
• 5:57
  knew
• 5:57
  non
• 5:57
  adherence
• 5:58
  was
• 5:58
  an
• 5:58
  issue
• 5:59
  in
• 5:59
  mental
• 6:00
  health,
• 6:01
  but
• 6:01
  the
• 6:02
  most
• 6:02
  common
• 6:02
  and
• 6:03
  most
• 6:03
  underappreciated
• 6:04
  factor,
• 6:04
  I
• 6:05
  think,
• 6:05
  in
• 6:05
  mental
• 6:05
  health
• 6:05
  as
• 6:06
  it
• 6:06
  relates
• 6:06
  to
• 6:06
  these
• 6:06
  medications
• 6:07
  is
• 6:07
  that
• 6:08
  non
• 6:08
  adherence
• 6:08
  rates
• 6:09
  for
• 6:09
  antidepressants
• 6:10
  are
• 6:10
  estimated
• 6:11
  around
• 6:11
  46%.
• 6:15
  That
• 6:15
  is
• 6:15
  a
• 6:16
  shocking,
• 6:17
  shocking
• 6:18
  statistic.
• 6:18
  Right?
• 6:19
  So
• 6:19
  almost
• 6:19
  one
• 6:20
  in
• 6:20
  every
• 6:20
  two
• 6:20
  of
• 6:21
  the
• 6:21
  patients
• 6:22
  that
• 6:22
  you
• 6:22
  deal
• 6:22
  with
• 6:23
  in
• 6:24
  the
• 6:25
  outpatient
• 6:25
  setting.
• 6:26
  And
• 6:27
  I
• 6:27
  don't
• 6:27
  mean
• 6:27
  deal
• 6:27
  with
• 6:27
  in
• 6:28
  a
• 6:28
  negative
• 6:28
  way.
• 6:28
  That
• 6:28
  came
• 6:29
  out
• 6:29
  kind
• 6:29
  of
• 6:29
  negative.
• 6:29
  When
• 6:30
  I
• 6:30
  say
• 6:30
  deal
• 6:30
  with,
• 6:30
  I
• 6:31
  mean
• 6:31
  you
• 6:31
  have
• 6:32
  the
• 6:32
  pleasure
• 6:32
  to
• 6:33
  engage
• 6:33
  with
• 6:33
  and
• 6:34
  hear
• 6:34
  their
• 6:34
  story.
• 6:35
  Okay.
• 6:35
  And
• 6:36
  be
• 6:36
  on
• 6:36
  their
• 6:36
  journey
• 6:36
  with
• 6:37
  them
• 6:37
  during
• 6:37
  their
• 6:37
  darkest
• 6:38
  hours.
• 6:38
  One
• 6:38
  out
• 6:38
  of
• 6:39
  every
• 6:39
  two
• 6:39
  of
• 6:39
  them
• 6:40
  are
• 6:41
  going
• 6:41
  to
• 6:42
  be
• 6:42
  non
• 6:42
  adherent.
• 6:43
  Now,
• 6:43
  that
• 6:43
  doesn't
• 6:44
  mean
• 6:44
  they're
• 6:44
  crossing
• 6:44
  their
• 6:45
  arms
• 6:45
  and
• 6:45
  shaking
• 6:46
  their
• 6:46
  head
• 6:46
  at
• 6:46
  the
• 6:47
  pill
• 6:47
  every
• 6:47
  morning
• 6:47
  and
• 6:48
  just
• 6:48
  refusing
• 6:48
  to
• 6:49
  take
• 6:49
  their
• 6:49
  pill
• 6:50
  like
• 6:50
  a
• 6:50
  toddler
• 6:50
  refuses
• 6:51
  to
• 6:51
  eat
• 6:51
  broccoli.
• 6:52
  I'm
• 6:52
  talking
• 6:53
  about
• 6:54
  the
• 6:54
  fact
• 6:54
  that
• 6:54
  they're
• 6:54
  just
• 6:55
  not
• 6:55
  taking
• 6:55
  it
• 6:55
  regularly
• 6:56
  in
• 6:56
  the
• 6:56
  sense
• 6:57
  that
• 6:57
  this
• 6:57
  would
• 6:57
  be
• 6:57
  a
• 6:57
  therapeutic
• 6:58
  dose
• 6:58
  for
• 6:59
  them.
• 6:59
  Right.
• 6:59
  That
• 7:00
  it
• 7:00
  just.
• 7:00
  It's
• 7:00
  not.
• 7:01
  They're
• 7:01
  not
• 7:01
  going
• 7:01
  to
• 7:02
  do
• 7:02
  what
• 7:02
  they
• 7:02
  need
• 7:03
  to
• 7:03
  do
• 7:04
  to
• 7:04
  have
• 7:04
  the
• 7:05
  sustained
• 7:05
  plasma
• 7:06
  levels,
• 7:06
  if
• 7:06
  you
• 7:06
  will,
• 7:07
  for
• 7:07
  the
• 7:07
  medication
• 7:07
  to
• 7:07
  be
• 7:08
  efficacious.
• 7:08
  That's
• 7:08
  almost
• 7:09
  half.
• 7:09
  Can
• 7:09
  you
• 7:10
  believe
• 7:10
  that?
• 7:10
  How.
• 7:11
  I
• 7:11
  mean,
• 7:11
  and
• 7:11
  I
• 7:11
  don't.
• 7:12
  I
• 7:12
  don't
• 7:12
  mean
• 7:12
  to
• 7:12
  share
• 7:12
  this
• 7:13
  statistic
• 7:14
  in
• 7:14
  a
• 7:14
  demoralizing
• 7:15
  sense
• 7:15
  to
• 7:15
  any
• 7:16
  of
• 7:16
  you.
• 7:16
  Right.
• 7:16
  This
• 7:16
  is
• 7:17
  an
• 7:17
  opportunity,
• 7:18
  right?
• 7:18
  This
• 7:18
  is
• 7:18
  like
• 7:18
  an
• 7:19
  amazing
• 7:19
  opportunity
• 7:20
  to
• 7:20
  shore
• 7:20
  up
• 7:20
  why
• 7:20
  they're
• 7:21
  non
• 7:21
  adherent.
• 7:22
  And
• 7:22
  you
• 7:23
  can
• 7:23
  imagine
• 7:23
  one
• 7:23
  of
• 7:24
  the
• 7:24
  main
• 7:24
  reasons
• 7:25
  they're
• 7:25
  non
• 7:25
  adherent
• 7:25
  is
• 7:26
  the
• 7:26
  side
• 7:26
  effects.
• 7:26
  Right?
• 7:26
  These
• 7:27
  medications
• 7:27
  reliably
• 7:28
  cause
• 7:28
  sexual
• 7:28
  dysfunction.
• 7:29
  They
• 7:29
  can
• 7:30
  cause
• 7:30
  weight
• 7:30
  gain,
• 7:30
  they
• 7:30
  can
• 7:31
  cause
• 7:31
  nausea,
• 7:31
  loose
• 7:32
  stools,
• 7:33
  dizziness,
• 7:33
  insomnia.
• 7:34
  Right?
• 7:34
  How
• 7:35
  many
• 7:35
  people
• 7:35
  start
• 7:35
  an
• 7:35
  SSRI
• 7:36
  and
• 7:36
  they
• 7:36
  just.
• 7:36
  Their
• 7:36
  sleep
• 7:37
  isn't
• 7:37
  right
• 7:37
  all
• 7:37
  of
• 7:37
  a
• 7:37
  sudden,
• 7:38
  Especially
• 7:38
  with
• 7:39
  more
• 7:39
  of
• 7:39
  the
• 7:39
  activating
• 7:39
  SSRIs,
• 7:40
  maybe
• 7:40
  like
• 7:41
  Prozac
• 7:41
  and
• 7:41
  Zoloft.
• 7:42
  You
• 7:42
  can
• 7:42
  hear
• 7:42
  that
• 7:42
  quite
• 7:43
  often
• 7:43
  now.
• 7:43
  There's
• 7:44
  a
• 7:44
  perceived
• 7:44
  stigma,
• 7:45
  right?
• 7:45
  People
• 7:45
  will
• 7:45
  tell
• 7:46
  you
• 7:46
  all
• 7:46
  the
• 7:46
  time.
• 7:46
  They
• 7:46
  just,
• 7:47
  they
• 7:47
  already
• 7:47
  kind
• 7:47
  of
• 7:48
  feel
• 7:48
  squeamish
• 7:49
  about
• 7:49
  being
• 7:49
  put
• 7:49
  on
• 7:49
  a
• 7:50
  medication
• 7:51
  and
• 7:51
  so
• 7:51
  taking
• 7:52
  it
• 7:52
  every
• 7:52
  day.
• 7:53
  It's.
• 7:53
  You're
• 7:53
  already
• 7:54
  kind
• 7:54
  of
• 7:54
  paddling
• 7:54
  upstream
• 7:55
  because
• 7:55
  they,
• 7:55
  they
• 7:56
  feel
• 7:56
  a
• 7:56
  certain
• 7:56
  way
• 7:56
  about
• 7:57
  needing
• 7:57
  to
• 7:57
  take
• 7:58
  medication.
• 7:58
  I
• 7:58
  see
• 7:58
  that
• 7:59
  all
• 7:59
  of
• 7:59
  the
• 7:59
  time
• 7:59
  in
• 7:59
  my
• 8:00
  office,
• 8:00
  right?
• 8:00
  People
• 8:01
  squeamish
• 8:01
  about
• 8:02
  taking
• 8:02
  medication,
• 8:03
  then
• 8:03
  they
• 8:03
  just
• 8:03
  forget,
• 8:04
  right?
• 8:05
  I
• 8:05
  forget
• 8:05
  taking
• 8:05
  my
• 8:06
  vitamin
• 8:06
  D.
• 8:07
  Right.
• 8:07
  And
• 8:08
  vitamin
• 8:09
  D
• 8:09
  is
• 8:09
  not
• 8:10
  nearly.
• 8:10
  I
• 8:11
  mean,
• 8:11
  it's
• 8:11
  definitely
• 8:11
  important,
• 8:12
  okay?
• 8:12
  But
• 8:13
  it's
• 8:13
  probably
• 8:13
  not
• 8:14
  nearly
• 8:14
  as
• 8:14
  important
• 8:15
  as
• 8:15
  somebody
• 8:16
  who
• 8:17
  is
• 8:17
  really
• 8:17
  living
• 8:18
  on
• 8:18
  the
• 8:18
  margins
• 8:18
  with
• 8:19
  like,
• 8:19
  bipolar
• 8:20
  disorder
• 8:21
  and
• 8:21
  they
• 8:21
  get
• 8:21
  manic
• 8:22
  every
• 8:22
  three
• 8:22
  months
• 8:22
  and
• 8:22
  they
• 8:23
  have
• 8:23
  to
• 8:23
  take
• 8:23
  their
• 8:23
  lithium
• 8:24
  on
• 8:24
  time
• 8:25
  and
• 8:25
  regularly,
• 8:26
  right.
• 8:26
  To
• 8:26
  remain
• 8:27
  in
• 8:27
  a
• 8:27
  therapeutic
• 8:28
  window.
• 8:28
  So
• 8:28
  if
• 8:29
  it's
• 8:29
  that
• 8:29
  hard
• 8:29
  for
• 8:30
  me
• 8:30
  to
• 8:30
  just
• 8:31
  wake
• 8:31
  up
• 8:31
  and
• 8:31
  have
• 8:32
  nothing
• 8:32
  better
• 8:32
  to
• 8:32
  do
• 8:33
  other
• 8:33
  than
• 8:33
  take
• 8:33
  my
• 8:33
  vitamin
• 8:34
  D.
• 8:34
  And
• 8:34
  I'm
• 8:34
  not
• 8:34
  trying
• 8:34
  to
• 8:35
  say
• 8:35
  that,
• 8:35
  like,
• 8:35
  I
• 8:35
  don't
• 8:36
  have
• 8:36
  a
• 8:36
  life,
• 8:36
  that
• 8:37
  I
• 8:37
  don't
• 8:37
  have
• 8:37
  important
• 8:38
  things
• 8:38
  that
• 8:38
  matter
• 8:39
  to
• 8:39
  me.
• 8:40
  You
• 8:40
  know,
• 8:40
  I
• 8:40
  don't
• 8:40
  wake
• 8:40
  up
• 8:41
  and
• 8:41
  just
• 8:41
  watch
• 8:41
  cartoons
• 8:42
  and
• 8:42
  eat
• 8:42
  ice
• 8:42
  cream
• 8:43
  at
• 8:43
  the
• 8:44
  same
• 8:44
  time.
• 8:44
  If
• 8:45
  it's
• 8:45
  hard
• 8:45
  enough
• 8:46
  for
• 8:46
  me.
• 8:46
  And
• 8:46
  I
• 8:46
  have
• 8:47
  loads
• 8:47
  of
• 8:47
  time
• 8:48
  when
• 8:48
  I'm
• 8:48
  waking
• 8:49
  up
• 8:49
  to
• 8:49
  just
• 8:50
  literally
• 8:50
  swallow
• 8:51
  a
• 8:52
  pill
• 8:52
  that
• 8:52
  I'm
• 8:52
  already
• 8:53
  going
• 8:53
  to
• 8:53
  have
• 8:53
  water.
• 8:54
  I'm
• 8:55
  already
• 8:55
  going
• 8:55
  to
• 8:55
  have
• 8:55
  water
• 8:56
  anyway
• 8:56
  in,
• 8:57
  in
• 8:57
  that
• 8:57
  exact
• 8:57
  same
• 8:58
  moment.
• 8:58
  And
• 8:58
  I
• 8:58
  can't
• 8:59
  just
• 8:59
  take
• 8:59
  a
• 8:59
  vitamin
• 9:00
  D
• 9:00
  pill
• 9:00
  regularly
• 9:01
  for
• 9:01
  my
• 9:01
  health,
• 9:02
  for
• 9:02
  my
• 9:02
  inflammatory
• 9:03
  system.
• 9:05
  Imagine
• 9:05
  someone
• 9:06
  who
• 9:06
  already
• 9:07
  has,
• 9:08
  you
• 9:08
  know,
• 9:08
  severe
• 9:09
  cognitive
• 9:09
  impairments
• 9:10
  from
• 9:11
  decades
• 9:12
  of
• 9:12
  reoccurring
• 9:13
  manic
• 9:14
  episodes
• 9:14
  that
• 9:14
  we
• 9:15
  know
• 9:15
  can
• 9:15
  actually
• 9:16
  cause,
• 9:17
  like,
• 9:17
  cascades
• 9:18
  of
• 9:18
  neuroinflammation
• 9:18
  in
• 9:19
  the
• 9:19
  brain
• 9:19
  that
• 9:19
  almost
• 9:19
  resemble
• 9:20
  an
• 9:20
  ADHD
• 9:20
  brain
• 9:21
  after
• 9:21
  a
• 9:21
  while.
• 10:16
  Right?
• 10:16
  And
• 10:16
  it
• 10:16
  makes
• 10:17
  it
• 10:17
  even
• 10:17
  hard
• 10:17
  to
• 10:17
  tell
• 10:17
  if
• 10:17
  someone
• 10:18
  has
• 10:18
  ADHD
• 10:18
  or
• 10:18
  mania
• 10:19
  or,
• 10:20
  or
• 10:20
  bipolar
• 10:21
  because
• 10:21
  it's
• 10:22
  such
• 10:22
  a
• 10:22
  cognitive
• 10:23
  tax
• 10:23
  on
• 10:23
  the
• 10:23
  system.
• 10:24
  So
• 10:24
  imagine
• 10:25
  someone
• 10:25
  who's
• 10:25
  already
• 10:25
  dealing
• 10:26
  with
• 10:26
  impulse
• 10:26
  control
• 10:27
  issues
• 10:27
  and
• 10:27
  the
• 10:28
  dysregulated
• 10:28
  mood
• 10:29
  states
• 10:29
  where
• 10:29
  you
• 10:29
  don't
• 10:29
  even
• 10:29
  want
• 10:29
  to
• 10:30
  get
• 10:30
  out
• 10:30
  of
• 10:30
  bed,
• 10:30
  let
• 10:30
  alone
• 10:31
  regularly.
• 10:31
  Take
• 10:32
  your
• 10:32
  lithium.
• 10:33
  So
• 10:33
  non
• 10:33
  adherence
• 10:34
  is
• 10:35
  not
• 10:35
  only
• 10:36
  a
• 10:36
  problem
• 10:37
  because
• 10:37
  of
• 10:37
  side
• 10:37
  effects,
• 10:38
  perceived
• 10:38
  stigma
• 10:38
  and
• 10:39
  forgetfulness,
• 10:39
  but
• 10:40
  also
• 10:40
  the
• 10:40
  fact
• 10:40
  that
• 10:41
  the
• 10:41
  patients
• 10:41
  that
• 10:42
  we
• 10:42
  treat
• 10:43
  often
• 10:43
  have
• 10:43
  a
• 10:44
  lot
• 10:44
  of
• 10:44
  these
• 10:44
  concerns
• 10:45
  baked
• 10:45
  into
• 10:46
  their
• 10:46
  diagnosis
• 10:46
  that
• 10:47
  they
• 10:47
  can't
• 10:47
  focus,
• 10:48
  they're
• 10:48
  not
• 10:48
  getting
• 10:48
  out
• 10:48
  of
• 10:49
  bed,
• 10:49
  right?
• 10:50
  And
• 10:50
  then,
• 10:50
  of
• 10:50
  course,
• 10:51
  it's
• 10:51
  the
• 10:51
  delayed
• 10:52
  onset
• 10:52
  of
• 10:53
  action.
• 10:53
  It's
• 10:54
  another
• 10:54
  reason
• 10:54
  people
• 10:54
  don't
• 10:55
  love
• 10:55
  taking
• 10:55
  their
• 10:55
  medications,
• 10:56
  right?
• 10:57
  I
• 10:57
  don't
• 10:57
  love
• 10:58
  going
• 10:58
  to
• 10:58
  the
• 10:58
  Gym
• 10:58
  for
• 10:59
  the
• 10:59
  reason
• 10:59
  that
• 10:59
  I
• 11:00
  have
• 11:00
  to
• 11:00
  wait
• 11:00
  like
• 11:00
  six
• 11:01
  months
• 11:01
  to
• 11:01
  even
• 11:02
  be
• 11:03
  pleased
• 11:03
  at
• 11:03
  the
• 11:04
  way
• 11:04
  I
• 11:04
  look
• 11:05
  when
• 11:05
  I
• 11:05
  take
• 11:06
  my
• 11:06
  shirt
• 11:06
  off.
• 11:06
  Right?
• 11:07
  Well,
• 11:07
  that's
• 11:07
  not
• 11:07
  a
• 11:07
  really
• 11:07
  good
• 11:08
  incentive
• 11:08
  to
• 11:08
  go
• 11:08
  to
• 11:08
  the
• 11:09
  gym.
• 11:09
  Hey,
• 11:09
  go
• 11:10
  to
• 11:10
  the
• 11:10
  gym
• 11:11
  and
• 11:12
  beat
• 11:12
  yourself
• 11:13
  to
• 11:13
  death
• 11:13
  with
• 11:13
  weights
• 11:14
  that
• 11:14
  are
• 11:14
  way
• 11:15
  too
• 11:15
  heavy
• 11:15
  for
• 11:15
  you
• 11:15
  to
• 11:16
  lift
• 11:17
  and
• 11:17
  sweat
• 11:17
  and
• 11:18
  groan
• 11:18
  and
• 11:19
  wait
• 11:19
  for
• 11:19
  these
• 11:19
  machines
• 11:20
  while
• 11:20
  everybody
• 11:21
  is.
• 11:22
  Is
• 11:22
  on
• 11:22
  them
• 11:23
  and
• 11:23
  you're
• 11:24
  already
• 11:24
  bored
• 11:24
  and
• 11:24
  you
• 11:24
  don't
• 11:25
  want
• 11:25
  to
• 11:25
  be
• 11:25
  there
• 11:25
  and
• 11:25
  you
• 11:25
  want
• 11:25
  to
• 11:26
  be
• 11:26
  anywhere
• 11:26
  else
• 11:26
  but
• 11:26
  there.
• 11:27
  Oh,
• 11:27
  and
• 11:27
  then
• 11:27
  in
• 11:28
  six
• 11:28
  months,
• 11:28
  you
• 11:28
  might
• 11:28
  look
• 11:29
  better
• 11:29
  if
• 11:29
  you
• 11:29
  can
• 11:29
  control
• 11:30
  your
• 11:30
  diet.
• 11:30
  And,
• 11:30
  and
• 11:31
  so
• 11:31
  imagine
• 11:31
  that,
• 11:31
  right,
• 11:32
  that
• 11:32
  we're
• 11:32
  telling
• 11:32
  people
• 11:33
  you
• 11:33
  have
• 11:33
  to
• 11:34
  take
• 11:34
  this
• 11:35
  medication.
• 11:35
  And
• 11:35
  the
• 11:36
  first,
• 11:36
  you
• 11:36
  know,
• 11:36
  two
• 11:37
  to
• 11:37
  four
• 11:37
  weeks
• 11:37
  might
• 11:37
  be
• 11:37
  kind
• 11:38
  of
• 11:38
  rough,
• 11:38
  right?
• 11:38
  You
• 11:38
  might
• 11:38
  have
• 11:39
  insomnia,
• 11:39
  you
• 11:39
  might
• 11:39
  be
• 11:39
  nauseous,
• 11:40
  you
• 11:40
  might
• 11:40
  be
• 11:40
  having
• 11:41
  loose
• 11:41
  stools,
• 11:42
  right?
• 11:42
  There
• 11:42
  might
• 11:42
  be
• 11:43
  sexual
• 11:43
  dysfunction
• 11:43
  creeping
• 11:44
  in.
• 11:44
  And,
• 11:44
  oh,
• 11:45
  after
• 11:45
  two
• 11:46
  to
• 11:46
  four
• 11:46
  weeks
• 11:46
  or
• 11:46
  so,
• 11:47
  you
• 11:47
  may
• 11:47
  get
• 11:47
  a
• 11:47
  response,
• 11:48
  you
• 11:48
  know,
• 11:48
  a
• 11:48
  little
• 11:48
  bit
• 11:48
  of
• 11:49
  benefit
• 11:49
  might
• 11:49
  start
• 11:49
  creeping
• 11:50
  in
• 11:50
  when
• 11:51
  you're
• 11:51
  already
• 11:51
  kind
• 11:51
  of
• 11:52
  hopeless.
• 11:52
  You're
• 11:52
  already
• 11:52
  dealing
• 11:53
  with
• 11:53
  mental
• 11:54
  health
• 11:54
  struggles.
• 11:54
  The
• 11:55
  delayed
• 11:55
  onset
• 11:56
  can
• 11:56
  make
• 11:56
  it
• 11:56
  hard
• 11:56
  to
• 11:56
  adhere,
• 11:57
  right?
• 11:57
  Again,
• 11:58
  imagine
• 11:58
  how
• 11:59
  hard
• 11:59
  it
• 11:59
  is
• 11:59
  for
• 11:59
  these
• 11:59
  folks
• 12:00
  to
• 12:00
  regularly
• 12:01
  take
• 12:01
  their
• 12:01
  meds.
• 12:02
  That
• 12:02
  boils
• 12:02
  down
• 12:02
  to
• 12:02
  46%
• 12:03
  of
• 12:03
  your
• 12:03
  patients.
• 12:04
  So
• 12:04
  a
• 12:04
  good
• 12:05
  thing
• 12:05
  to
• 12:05
  ask
• 12:06
  Maria
• 12:06
  is
• 12:07
  how
• 12:07
  often
• 12:07
  are
• 12:07
  you
• 12:07
  taking
• 12:08
  this?
• 12:08
  And
• 12:09
  if
• 12:09
  Maria
• 12:10
  is
• 12:10
  not
• 12:10
  taking
• 12:11
  this
• 12:11
  every
• 12:12
  day,
• 12:12
  if
• 12:12
  she
• 12:12
  forgets
• 12:13
  a
• 12:13
  couple
• 12:13
  of
• 12:13
  times
• 12:13
  a
• 12:14
  week,
• 12:14
  maybe
• 12:14
  doesn't
• 12:15
  take
• 12:15
  it
• 12:15
  on
• 12:15
  the
• 12:15
  weekends
• 12:15
  because
• 12:16
  she's
• 12:16
  nauseous
• 12:16
  in
• 12:17
  the
• 12:17
  morning,
• 12:17
  well,
• 12:18
  then
• 12:18
  she's
• 12:18
  taking
• 12:18
  like
• 12:19
  60
• 12:19
  to
• 12:19
  70%
• 12:20
  of
• 12:20
  her
• 12:20
  prescribed
• 12:21
  dose.
• 12:21
  And
• 12:21
  we
• 12:22
  really
• 12:22
  need
• 12:22
  80%
• 12:23
  or
• 12:23
  better
• 12:24
  because
• 12:24
  that
• 12:24
  is
• 12:24
  what
• 12:25
  the
• 12:25
  literature
• 12:25
  suggests
• 12:26
  is
• 12:26
  associated
• 12:27
  with
• 12:27
  a
• 12:27
  2.6-3.1
• 12:29
  times
• 12:29
  higher
• 12:29
  odds
• 12:30
  of
• 12:30
  treatment
• 12:30
  response.
• 12:31
  Think
• 12:32
  about
• 12:32
  that
• 12:32
  for
• 12:32
  a
• 12:33
  second,
• 12:33
  my
• 12:33
  friends.
• 12:33
  That
• 12:34
  one
• 12:34
  out
• 12:34
  of
• 12:34
  two
• 12:34
  of
• 12:35
  your
• 12:35
  patients
• 12:35
  is
• 12:35
  non
• 12:36
  adherent
• 12:36
  to
• 12:36
  your
• 12:36
  medications.
• 12:37
  And
• 12:37
  if
• 12:37
  they
• 12:37
  were
• 12:38
  adherent
• 12:39
  at
• 12:39
  least
• 12:39
  80%
• 12:40
  of
• 12:40
  the
• 12:40
  time,
• 12:41
  that
• 12:41
  they
• 12:41
  would
• 12:42
  have
• 12:42
  almost
• 12:42
  double
• 12:43
  or
• 12:43
  triple
• 12:43
  the
• 12:43
  odds
• 12:44
  of
• 12:44
  a
• 12:44
  treatment
• 12:44
  response.
• 12:46
  That
• 12:46
  is
• 12:46
  why
• 12:47
  we
• 12:47
  do
• 12:47
  pearls
• 12:47
  and
• 12:48
  prep,
• 12:48
  my
• 12:48
  friends.
• 12:48
  That
• 12:49
  is
• 12:49
  why
• 12:49
  we
• 12:49
  have
• 12:49
  a
• 12:49
  Patreon
• 12:50
  page,
• 12:50
  right?
• 12:51
  We
• 12:51
  have
• 12:51
  a
• 12:51
  Patreon
• 12:52
  page
• 12:52
  dripping
• 12:53
  with
• 12:53
  these
• 12:53
  pearls
• 12:55
  because
• 12:55
  the
• 12:55
  difference
• 12:55
  between
• 12:56
  a
• 12:56
  good
• 12:56
  clinician
• 12:57
  and
• 12:57
  a
• 12:57
  great
• 12:57
  clinician
• 12:58
  is
• 12:58
  somebody
• 12:58
  who
• 12:59
  sift
• 12:59
  through
• 12:59
  sifts
• 13:00
  through
• 13:00
  these
• 13:00
  pearls.
• 13:00
  They
• 13:01
  understand
• 13:01
  the
• 13:01
  devil
• 13:02
  is
• 13:02
  in
• 13:03
  the
• 13:03
  details,
• 13:03
  and
• 13:04
  patients
• 13:04
  smell
• 13:05
  that
• 13:05
  a
• 13:05
  mile
• 13:05
  away.
• 13:06
  But
• 13:06
  this
• 13:06
  is
• 13:06
  what
• 13:06
  I'm
• 13:06
  talking
• 13:07
  about,
• 13:07
  right?
• 13:07
  Half
• 13:08
  your
• 13:08
  patients
• 13:08
  non
• 13:09
  adherent,
• 13:09
  okay?
• 13:10
  If
• 13:10
  they're
• 13:10
  adherent
• 13:10
  80%
• 13:11
  of
• 13:11
  the
• 13:11
  time
• 13:11
  or
• 13:11
  more,
• 13:12
  then
• 13:12
  2,
• 13:13
  6
• 13:13
  to
• 13:13
  3
• 13:13
  times
• 13:14
  higher
• 13:14
  odds
• 13:14
  of
• 13:14
  a
• 13:15
  treatment
• 13:15
  response.
• 13:15
  And
• 13:15
  that
• 13:16
  hinges
• 13:16
  on
• 13:16
  you
• 13:17
  being
• 13:17
  able
• 13:18
  to
• 13:18
  talk
• 13:18
  about
• 13:18
  these
• 13:19
  side
• 13:19
  effects
• 13:20
  in
• 13:20
  advance,
• 13:21
  the
• 13:21
  stigma
• 13:21
  in
• 13:21
  advance,
• 13:22
  address
• 13:22
  their
• 13:22
  concerns.
• 13:23
  What
• 13:23
  makes
• 13:24
  you
• 13:24
  particularly
• 13:26
  squeamish
• 13:27
  about
• 13:27
  trying
• 13:28
  medications?
• 13:28
  What
• 13:28
  do
• 13:29
  you
• 13:29
  think
• 13:29
  it
• 13:29
  says
• 13:29
  about
• 13:29
  you
• 13:30
  that
• 13:30
  you
• 13:30
  may
• 13:31
  be
• 13:31
  taking
• 13:31
  medications,
• 13:32
  that
• 13:32
  you
• 13:32
  may
• 13:33
  worry
• 13:33
  that
• 13:33
  others
• 13:33
  think
• 13:34
  of
• 13:34
  you?
• 13:34
  Right?
• 13:34
  Get
• 13:35
  to
• 13:35
  the
• 13:35
  root
• 13:35
  of
• 13:35
  this
• 13:36
  in
• 13:36
  the
• 13:36
  beginning.
• 13:37
  It's
• 13:37
  called
• 13:37
  anticipatory
• 13:38
  guidance.
• 13:39
  Have
• 13:39
  your
• 13:39
  patients
• 13:40
  air
• 13:41
  out
• 13:41
  in
• 13:41
  that
• 13:41
  first
• 13:42
  evaluation
• 13:43
  what
• 13:43
  all
• 13:43
  their
• 13:44
  reservations
• 13:44
  might
• 13:45
  be
• 13:45
  about
• 13:45
  taking
• 13:46
  medications
• 13:46
  and
• 13:47
  create
• 13:47
  a
• 13:47
  comfortable
• 13:47
  environment
• 13:48
  for
• 13:48
  them.
• 13:48
  Because
• 13:49
  some
• 13:49
  patients,
• 13:49
  I
• 13:50
  feel
• 13:50
  they
• 13:51
  think
• 13:51
  they're
• 13:51
  letting
• 13:51
  you
• 13:52
  down
• 13:52
  by
• 13:52
  saying
• 13:52
  they
• 13:52
  don't
• 13:53
  like
• 13:53
  those
• 13:53
  medications,
• 13:54
  right?
• 13:54
  They
• 13:55
  feel
• 13:55
  weird,
• 13:55
  almost
• 13:56
  like
• 13:56
  you're
• 13:56
  offending
• 13:56
  you.
• 13:57
  So
• 13:57
  I
• 13:57
  always
• 13:57
  go
• 13:57
  out
• 13:57
  of
• 13:57
  my
• 13:58
  way
• 13:58
  to
• 13:58
  create
• 13:58
  a
• 13:58
  really
• 13:59
  welcoming
• 13:59
  environment.
• 14:00
  I
• 14:00
  go,
• 14:00
  hey,
• 14:00
  I
• 14:00
  get
• 14:01
  it.
• 14:01
  These
• 14:01
  medications
• 14:02
  have
• 14:02
  a
• 14:02
  stigma
• 14:02
  that
• 14:03
  some
• 14:03
  folks
• 14:03
  don't
• 14:04
  feel
• 14:04
  comfortable
• 14:04
  on
• 14:04
  them.
• 14:05
  They
• 14:05
  can
• 14:05
  cause
• 14:05
  side
• 14:06
  effects.
• 14:06
  I
• 14:06
  totally
• 14:06
  get
• 14:07
  it.
• 14:07
  Please,
• 14:07
  this
• 14:08
  is
• 14:08
  a
• 14:08
  safe
• 14:08
  place.
• 14:09
  Air
• 14:09
  out
• 14:10
  any
• 14:10
  concerns
• 14:11
  you
• 14:11
  may
• 14:11
  have
• 14:11
  about
• 14:11
  antidepressants.
• 14:12
  And
• 14:12
  by
• 14:12
  the
• 14:12
  way,
• 14:13
  I
• 14:13
  am
• 14:13
  not
• 14:13
  even
• 14:13
  here
• 14:13
  to
• 14:14
  prescribe
• 14:14
  them
• 14:14
  if
• 14:14
  you're
• 14:14
  not
• 14:14
  comfortable.
• 14:15
  Right.
• 14:16
  The
• 14:16
  good
• 14:16
  news
• 14:16
  is
• 14:16
  psychotherapy
• 14:17
  can
• 14:17
  be
• 14:18
  just,
• 14:18
  just
• 14:19
  as
• 14:19
  efficacious
• 14:21
  in
• 14:21
  treating
• 14:22
  your
• 14:22
  symptoms,
• 14:22
  my
• 14:23
  friend.
• 14:23
  So
• 14:23
  I,
• 14:24
  I
• 14:24
  am
• 14:24
  all
• 14:25
  ears.
• 14:25
  What
• 14:25
  are
• 14:25
  your
• 14:25
  reservations?
• 14:26
  And
• 14:27
  that
• 14:27
  way
• 14:27
  you
• 14:27
  have
• 14:27
  an
• 14:27
  opportunity,
• 14:28
  a
• 14:28
  very
• 14:28
  unique
• 14:29
  opportunity
• 14:30
  to
• 14:31
  address
• 14:31
  these
• 14:32
  concerns
• 14:32
  so
• 14:32
  they're
• 14:33
  not
• 14:33
  surprised
• 14:33
  by
• 14:33
  them.
• 14:34
  So
• 14:34
  that
• 14:34
  when
• 14:34
  they're
• 14:35
  nauseous
• 14:35
  one
• 14:35
  morning,
• 14:35
  they
• 14:36
  don't
• 14:36
  go,
• 14:36
  oh,
• 14:36
  my
• 14:36
  God,
• 14:37
  I
• 14:37
  can't
• 14:37
  do
• 14:37
  this
• 14:37
  medication.
• 14:38
  Because
• 14:38
  they
• 14:38
  will
• 14:38
  have
• 14:39
  remembered
• 14:39
  that
• 14:39
  you
• 14:39
  educated
• 14:40
  them
• 14:40
  that,
• 14:40
  hey,
• 14:40
  the
• 14:41
  nausea
• 14:41
  normally
• 14:41
  goes
• 14:42
  away
• 14:42
  in
• 14:42
  two
• 14:42
  weeks.
• 14:42
  Most
• 14:43
  of
• 14:43
  these
• 14:43
  side
• 14:43
  effects
• 14:44
  go
• 14:44
  away
• 14:44
  in
• 14:44
  about
• 14:44
  two
• 14:45
  weeks
• 14:45
  with
• 14:45
  just
• 14:45
  a
• 14:45
  little
• 14:46
  bit
• 14:46
  of
• 14:46
  waiting
• 14:46
  right.
• 14:47
  As
• 14:47
  your,
• 14:47
  as
• 14:47
  your
• 14:48
  body
• 14:48
  gets
• 14:48
  habituated
• 14:49
  to
• 14:49
  them,
• 14:50
  okay?
• 14:50
  And
• 14:51
  so
• 14:51
  they
• 14:51
  won't
• 14:51
  be
• 14:51
  as
• 14:51
  panicked,
• 14:52
  they
• 14:52
  won't
• 14:52
  be
• 14:52
  as
• 14:53
  hopeless,
• 14:53
  and
• 14:53
  they
• 14:53
  will
• 14:54
  remain
• 14:54
  a
• 14:54
  little
• 14:54
  adherent.
• 14:55
  And
• 14:55
  when
• 14:55
  they're
• 14:55
  adherent
• 14:56
  enough,
• 14:56
  bam,
• 14:56
  two,
• 14:57
  six
• 14:57
  to
• 14:57
  three
• 14:58
  point
• 14:58
  times
• 14:58
  the
• 14:58
  odds
• 14:58
  of
• 14:59
  treatment
• 14:59
  response.
• 15:00
  Okay?
• 15:00
  Now
• 15:00
  the
• 15:01
  other
• 15:01
  thing
• 15:01
  we
• 15:01
  talked
• 15:02
  about
• 15:02
  that
• 15:02
  you've
• 15:02
  gotta
• 15:02
  make
• 15:03
  sure
• 15:03
  with
• 15:03
  Maria
• 15:04
  is
• 15:04
  that
• 15:04
  her
• 15:05
  dose
• 15:05
  is
• 15:05
  adequate.
• 15:06
  Now,
• 15:07
  depending
• 15:07
  on
• 15:07
  how
• 15:08
  these
• 15:08
  medications
• 15:08
  are
• 15:09
  metabolized
• 15:09
  by
• 15:09
  your
• 15:10
  patient,
• 15:10
  50
• 15:10
  milligrams
• 15:11
  may
• 15:11
  or
• 15:12
  may
• 15:12
  not
• 15:12
  be
• 15:13
  the
• 15:13
  magic
• 15:13
  sweet
• 15:14
  spot
• 15:14
  with
• 15:14
  Zoloft.
• 15:15
  Now,
• 15:15
  in
• 15:15
  my
• 15:15
  experience,
• 15:16
  it
• 15:16
  is
• 15:16
  not
• 15:16
  the
• 15:17
  sweet
• 15:17
  spot
• 15:17
  with
• 15:17
  Zoloft,
• 15:18
  right?
• 15:18
  In
• 15:18
  my
• 15:19
  experience,
• 15:19
  generally
• 15:20
  speaking,
• 15:20
  Zoloft
• 15:21
  can
• 15:21
  go
• 15:21
  anywhere
• 15:22
  from
• 15:22
  like
• 15:22
  50
• 15:22
  milligrams
• 15:23
  to
• 15:23
  200
• 15:23
  milligrams
• 15:24
  a
• 15:24
  day.
• 15:25
  I
• 15:25
  find
• 15:25
  that
• 15:25
  the
• 15:25
  vast
• 15:26
  majority
• 15:26
  of
• 15:26
  my
• 15:26
  patients,
• 15:27
  however
• 15:27
  anecdotal
• 15:28
  it
• 15:28
  is,
• 15:28
  are
• 15:29
  not
• 15:29
  really
• 15:30
  in
• 15:30
  their
• 15:30
  sweet
• 15:31
  spot
• 15:31
  at
• 15:31
  50.
• 15:32
  Now,
• 15:33
  if
• 15:33
  you
• 15:33
  guys
• 15:33
  want
• 15:34
  to
• 15:34
  nerd
• 15:34
  out
• 15:34
  in
• 15:34
  the
• 15:35
  literature
• 15:35
  one
• 15:35
  day
• 15:36
  and
• 15:36
  we
• 15:36
  may
• 15:36
  do
• 15:36
  a
• 15:37
  future
• 15:37
  episode
• 15:37
  on
• 15:37
  this,
• 15:38
  it's
• 15:38
  good
• 15:38
  for
• 15:39
  you
• 15:39
  to
• 15:39
  look
• 15:39
  at
• 15:39
  what
• 15:40
  is
• 15:40
  the
• 15:40
  mean
• 15:40
  effective
• 15:41
  dose
• 15:42
  and,
• 15:42
  and
• 15:42
  find,
• 15:43
  find.
• 15:43
  What
• 15:43
  dose
• 15:44
  are
• 15:44
  these
• 15:45
  research
• 15:45
  trials
• 15:46
  finding
• 15:46
  is
• 15:47
  the
• 15:47
  mean
• 15:48
  or
• 15:48
  average
• 15:48
  dose
• 15:49
  by
• 15:49
  which
• 15:50
  your
• 15:50
  patients
• 15:50
  will,
• 15:51
  will
• 15:51
  receive
• 15:52
  a
• 15:52
  maximum
• 15:53
  therapeutic
• 15:53
  benefit.
• 15:54
  Right.
• 15:54
  And
• 15:54
  every
• 15:55
  medication
• 15:56
  has
• 15:56
  a,
• 15:57
  an
• 15:57
  approximate
• 15:58
  mean
• 15:58
  dose
• 15:58
  by
• 15:58
  which
• 15:59
  the
• 15:59
  evidence
• 16:00
  shows
• 16:00
  it
• 16:00
  is
• 16:01
  effective.
• 16:01
  Right.
• 16:01
  And
• 16:02
  it's
• 16:02
  not
• 16:02
  the
• 16:02
  whole
• 16:02
  ball
• 16:02
  game.
• 16:03
  Again,
• 16:03
  your
• 16:03
  patients
• 16:03
  are
• 16:03
  all
• 16:04
  going
• 16:04
  to
• 16:04
  metabolize
• 16:04
  these
• 16:04
  differently.
• 16:05
  They
• 16:05
  have
• 16:05
  different,
• 16:06
  you
• 16:06
  know,
• 16:06
  genetic
• 16:06
  polymorphisms,
• 16:07
  et
• 16:07
  cetera.
• 16:08
  But
• 16:08
  it's
• 16:08
  a
• 16:08
  cool
• 16:09
  number
• 16:09
  to
• 16:09
  have
• 16:09
  an
• 16:09
  idea
• 16:10
  in
• 16:10
  your
• 16:10
  mind
• 16:10
  of,
• 16:11
  because
• 16:12
  if
• 16:12
  you're
• 16:12
  sitting
• 16:12
  at
• 16:13
  50
• 16:13
  milligrams
• 16:13
  of
• 16:13
  Zoloft,
• 16:15
  and
• 16:15
  I
• 16:15
  think
• 16:15
  I
• 16:15
  read
• 16:16
  in
• 16:16
  the
• 16:16
  past
• 16:16
  that
• 16:17
  the
• 16:17
  mean
• 16:17
  effective
• 16:17
  dose
• 16:18
  of
• 16:18
  Zoloft
• 16:18
  in
• 16:18
  some
• 16:19
  studies
• 16:19
  is
• 16:19
  somewhere
• 16:19
  around
• 16:20
  75
• 16:20
  or
• 16:20
  100,
• 16:21
  then
• 16:21
  it'll
• 16:22
  give
• 16:22
  you
• 16:22
  an
• 16:22
  idea
• 16:22
  like,
• 16:22
  hey,
• 16:23
  this
• 16:23
  might
• 16:23
  be,
• 16:23
  this
• 16:23
  might
• 16:24
  be
• 16:24
  being
• 16:24
  underdosed
• 16:25
  in
• 16:25
  this
• 16:25
  case.
• 16:26
  Right?
• 16:26
  So
• 16:27
  not.
• 16:27
  It's
• 16:27
  not
• 16:27
  enough
• 16:28
  to
• 16:28
  just
• 16:28
  say,
• 16:28
  are
• 16:28
  you
• 16:28
  taking
• 16:29
  the
• 16:29
  medications?
• 16:30
  It's
• 16:30
  also
• 16:30
  important
• 16:31
  to
• 16:31
  say,
• 16:31
  are
• 16:31
  we
• 16:31
  at
• 16:31
  a
• 16:32
  therapeutic
• 16:32
  dose?
• 16:33
  Okay,
• 16:33
  the
• 16:34
  good
• 16:34
  news
• 16:34
  with
• 16:34
  Maria
• 16:35
  here
• 16:35
  is
• 16:35
  she's
• 16:35
  had
• 16:35
  a
• 16:36
  partial
• 16:36
  response.
• 16:36
  She's
• 16:37
  gone
• 16:37
  from
• 16:37
  21
• 16:37
  to
• 16:37
  16
• 16:38
  in
• 16:39
  the
• 16:39
  PHQ9.
• 16:39
  So
• 16:40
  something's
• 16:40
  working.
• 16:40
  When
• 16:40
  I
• 16:41
  see
• 16:41
  that
• 16:41
  happen,
• 16:41
  I
• 16:42
  press
• 16:42
  the
• 16:42
  gas.
• 16:42
  As
• 16:43
  long
• 16:43
  as
• 16:43
  side
• 16:43
  effects
• 16:44
  aren't
• 16:44
  in
• 16:44
  our
• 16:44
  way
• 16:45
  and
• 16:45
  the
• 16:45
  patient's
• 16:45
  on
• 16:46
  board,
• 16:47
  I
• 16:47
  say,
• 16:47
  look,
• 16:47
  you've
• 16:48
  had
• 16:48
  a
• 16:48
  nice
• 16:48
  fat
• 16:48
  reduction
• 16:49
  in
• 16:49
  depressive
• 16:50
  symptoms.
• 16:50
  I
• 16:50
  know,
• 16:51
  I
• 16:51
  know
• 16:52
  we're
• 16:52
  not
• 16:52
  where
• 16:52
  we
• 16:52
  need
• 16:53
  to
• 16:53
  be.
• 16:53
  And
• 16:53
  I
• 16:53
  always
• 16:53
  acknowledge
• 16:54
  that
• 16:54
  because
• 16:54
  sometimes
• 16:55
  patients
• 16:55
  won't
• 16:56
  appreciate
• 16:56
  the
• 16:56
  fact
• 16:56
  that
• 16:56
  you,
• 16:57
  you
• 16:57
  love
• 16:57
  their
• 16:57
  numbers,
• 16:58
  but
• 16:58
  their
• 16:58
  subjective
• 16:59
  experience
• 16:59
  is
• 17:00
  still
• 17:00
  miserable.
• 17:00
  Right?
• 17:01
  They
• 17:01
  still
• 17:01
  can't
• 17:02
  get
• 17:02
  out
• 17:02
  of
• 17:02
  bed,
• 17:03
  they're
• 17:03
  still
• 17:03
  overeating.
• 17:04
  They're.
• 17:04
  They're
• 17:04
  really
• 17:04
  not
• 17:05
  enjoying
• 17:05
  their
• 17:05
  lives.
• 17:06
  And
• 17:06
  here
• 17:06
  you
• 17:06
  are,
• 17:07
  you
• 17:07
  know,
• 17:07
  throwing
• 17:08
  a,
• 17:08
  throwing
• 17:09
  a
• 17:09
  party
• 17:09
  with
• 17:09
  your
• 17:10
  party
• 17:10
  hat
• 17:10
  on,
• 17:11
  and
• 17:11
  you're,
• 17:12
  you're
• 17:12
  sipping
• 17:12
  a
• 17:12
  Capri
• 17:13
  sun
• 17:13
  and,
• 17:14
  and
• 17:14
  you're
• 17:14
  just
• 17:14
  giddy
• 17:15
  that
• 17:15
  their
• 17:16
  PHQ9
• 17:16
  dropped
• 17:17
  from
• 17:17
  a
• 17:17
  21
• 17:17
  to
• 17:18
  16.
• 17:18
  But
• 17:19
  they're
• 17:19
  slouched
• 17:19
  in
• 17:20
  their
• 17:20
  chair
• 17:20
  and
• 17:20
  disheveled
• 17:21
  and
• 17:21
  they
• 17:21
  want
• 17:21
  to
• 17:21
  punch
• 17:22
  you
• 17:22
  in
• 17:22
  the
• 17:22
  face.
• 17:22
  So
• 17:23
  you
• 17:23
  have
• 17:23
  to
• 17:23
  be
• 17:23
  careful
• 17:24
  not
• 17:24
  to
• 17:24
  over
• 17:24
  celebrate
• 17:25
  their
• 17:26
  PHQ9
• 17:26
  score.
• 17:27
  However,
• 17:27
  it's
• 17:28
  also
• 17:28
  important
• 17:29
  if
• 17:29
  you
• 17:29
  say
• 17:29
  it
• 17:30
  in
• 17:30
  a
• 17:30
  measured
• 17:30
  way
• 17:31
  that,
• 17:32
  you
• 17:32
  know,
• 17:32
  it's
• 17:32
  important
• 17:32
  to
• 17:33
  highlight
• 17:33
  the
• 17:33
  fact
• 17:34
  that
• 17:34
  they
• 17:34
  are
• 17:34
  progressing
• 17:35
  at
• 17:35
  least
• 17:35
  from
• 17:35
  a
• 17:36
  clinical,
• 17:36
  objective
• 17:37
  sense.
• 17:37
  Sometimes
• 17:37
  there's.
• 17:38
  That
• 17:38
  will,
• 17:38
  can
• 17:38
  Also
• 17:38
  build
• 17:39
  hope.
• 17:40
  And
• 17:40
  it
• 17:40
  can
• 17:40
  be
• 17:40
  very
• 17:41
  reinforcing
• 17:42
  for.
• 17:42
  Because
• 17:42
  patients
• 17:42
  do
• 17:43
  have
• 17:43
  a
• 17:43
  hard
• 17:43
  time
• 17:44
  really
• 17:44
  assessing
• 17:45
  their
• 17:45
  own
• 17:45
  trajectory.
• 17:46
  Right.
• 17:46
  It's
• 17:46
  a
• 17:47
  lot
• 17:47
  harder
• 17:47
  even,
• 17:48
  you
• 17:48
  know,
• 17:48
  if,
• 17:48
  let's
• 17:48
  say,
• 17:49
  if
• 17:49
  you're
• 17:49
  trying
• 17:49
  to
• 17:50
  lose
• 17:50
  weight,
• 17:50
  then,
• 17:50
  you
• 17:51
  know,
• 17:51
  I've
• 17:51
  been
• 17:51
  on
• 17:51
  my
• 17:52
  own
• 17:52
  weight
• 17:52
  loss
• 17:52
  journey
• 17:53
  for
• 17:53
  a
• 17:53
  long
• 17:53
  time.
• 17:53
  It's
• 17:53
  been
• 17:54
  largely
• 17:54
  unsuccessful.
• 17:55
  But
• 17:56
  the
• 17:56
  few
• 17:56
  times
• 17:57
  in
• 17:57
  my
• 17:57
  life
• 17:57
  I
• 17:57
  have
• 17:58
  lost
• 17:58
  weight,
• 17:59
  I'm
• 17:59
  not
• 17:59
  the
• 17:59
  first
• 17:59
  one
• 18:00
  who
• 18:00
  notices
• 18:00
  that,
• 18:00
  right?
• 18:01
  Usually
• 18:01
  my
• 18:01
  friend
• 18:01
  will
• 18:02
  say,
• 18:02
  hey,
• 18:02
  your
• 18:02
  chin
• 18:02
  is
• 18:02
  less
• 18:03
  thick.
• 18:03
  You're,
• 18:04
  you're,
• 18:05
  you
• 18:05
  know,
• 18:05
  I
• 18:05
  can,
• 18:06
  I
• 18:06
  can
• 18:06
  see
• 18:06
  your
• 18:06
  neck
• 18:07
  a
• 18:07
  little
• 18:07
  better.
• 18:08
  I
• 18:08
  kind
• 18:08
  of
• 18:09
  wish
• 18:09
  my
• 18:09
  friends
• 18:09
  would
• 18:10
  give
• 18:10
  me
• 18:11
  more
• 18:11
  positive
• 18:11
  feedback
• 18:12
  that,
• 18:13
  yeah,
• 18:13
  those
• 18:13
  are
• 18:13
  kind
• 18:14
  of
• 18:14
  just
• 18:14
  less
• 18:14
  negative
• 18:15
  ones.
• 18:15
  But
• 18:16
  my
• 18:16
  point
• 18:16
  is
• 18:17
  it
• 18:17
  can
• 18:17
  be
• 18:17
  very,
• 18:18
  it
• 18:18
  can
• 18:18
  reinforce
• 18:18
  a
• 18:19
  sense
• 18:19
  of
• 18:19
  hope
• 18:19
  and
• 18:19
  say,
• 18:19
  look,
• 18:20
  I
• 18:20
  know
• 18:20
  your
• 18:20
  subjective
• 18:21
  experience
• 18:21
  is
• 18:21
  not
• 18:21
  great,
• 18:22
  and
• 18:22
  we
• 18:22
  have
• 18:23
  so
• 18:23
  much
• 18:23
  more,
• 18:23
  more
• 18:24
  work
• 18:24
  to
• 18:24
  do,
• 18:25
  but
• 18:25
  the
• 18:25
  good
• 18:25
  news
• 18:25
  is
• 18:25
  it
• 18:26
  does
• 18:26
  look
• 18:26
  like
• 18:26
  this
• 18:26
  helped
• 18:27
  in
• 18:27
  some
• 18:27
  sense.
• 18:27
  These
• 18:28
  are
• 18:28
  your
• 18:28
  answers.
• 18:28
  These
• 18:28
  are
• 18:29
  your
• 18:29
  scores.
• 18:29
  You
• 18:30
  know,
• 18:30
  we're
• 18:30
  not
• 18:30
  speaking
• 18:30
  for
• 18:31
  you,
• 18:31
  but
• 18:31
  this,
• 18:31
  this,
• 18:32
  this
• 18:32
  is
• 18:32
  what
• 18:32
  you
• 18:33
  had
• 18:33
  shared
• 18:33
  with
• 18:33
  us,
• 18:33
  and
• 18:33
  it
• 18:34
  looks
• 18:34
  pretty
• 18:34
  promising,
• 18:34
  right?
• 18:36
  So
• 18:37
  definitely
• 18:38
  make
• 18:38
  sure,
• 18:38
  especially
• 18:39
  if
• 18:39
  you
• 18:39
  have
• 18:39
  a
• 18:40
  response
• 18:40
  in
• 18:40
  the
• 18:40
  first
• 18:41
  four
• 18:41
  weeks
• 18:41
  via
• 18:42
  the
• 18:42
  PHQ9,
• 18:43
  via
• 18:43
  maybe
• 18:43
  a
• 18:43
  little
• 18:44
  bit
• 18:44
  of
• 18:44
  subjective
• 18:44
  report
• 18:45
  from
• 18:45
  your
• 18:45
  patient
• 18:45
  that
• 18:45
  you
• 18:45
  press
• 18:46
  the
• 18:46
  gas
• 18:47
  and
• 18:48
  maybe
• 18:49
  move
• 18:49
  this
• 18:49
  dose
• 18:49
  up
• 18:49
  to
• 18:49
  75
• 18:50
  milligrams
• 18:50
  or
• 18:50
  100
• 18:51
  milligrams,
• 18:51
  depending
• 18:52
  on
• 18:52
  how
• 18:52
  they,
• 18:53
  how
• 18:53
  they
• 18:54
  tolerate
• 18:54
  it.
• 18:55
  Now,
• 18:55
  once
• 18:55
  adherence
• 18:56
  is
• 18:56
  optimized,
• 18:57
  if
• 18:58
  a
• 18:58
  partial
• 18:58
  response
• 18:59
  persists
• 18:59
  after
• 18:59
  two
• 19:00
  to
• 19:00
  four
• 19:00
  weeks
• 19:00
  of
• 19:00
  consistent
• 19:01
  dosing,
• 19:02
  that's
• 19:02
  when
• 19:02
  we
• 19:02
  would
• 19:02
  increase
• 19:03
  it
• 19:03
  to
• 19:03
  a
• 19:03
  hundred
• 19:03
  milligrams
• 19:04
  or
• 19:04
  so.
• 19:04
  Okay?
• 19:05
  Now,
• 19:05
  the
• 19:06
  third
• 19:06
  principle
• 19:06
  we
• 19:06
  shared
• 19:07
  is,
• 19:07
  is
• 19:07
  the
• 19:07
  duration
• 19:08
  sufficient?
• 19:08
  This
• 19:09
  is
• 19:09
  also
• 19:09
  important,
• 19:09
  right?
• 19:10
  And
• 19:10
  if
• 19:10
  you
• 19:11
  do
• 19:11
  good
• 19:11
  anticipatory
• 19:12
  guidance
• 19:12
  right
• 19:12
  away,
• 19:13
  your
• 19:13
  patients
• 19:14
  kind
• 19:14
  of
• 19:14
  understand,
• 19:14
  hey,
• 19:15
  this
• 19:15
  isn't
• 19:15
  going
• 19:15
  to
• 19:15
  be
• 19:16
  like,
• 19:16
  I'm
• 19:17
  not
• 19:17
  going
• 19:17
  to
• 19:17
  go
• 19:17
  to
• 19:17
  the
• 19:17
  gym,
• 19:18
  do
• 19:18
  bicep
• 19:19
  curls,
• 19:19
  and
• 19:20
  then
• 19:20
  look
• 19:20
  like
• 19:20
  Arnold
• 19:21
  Schwarzenegger
• 19:22
  the
• 19:22
  next
• 19:22
  morning.
• 19:22
  Right?
• 19:23
  They
• 19:23
  kind
• 19:23
  of
• 19:23
  get
• 19:23
  that.
• 19:24
  But
• 19:24
  you'd
• 19:25
  be
• 19:25
  surprised,
• 19:26
  right?
• 19:26
  And
• 19:26
  there
• 19:26
  are
• 19:27
  meds
• 19:27
  out
• 19:27
  there
• 19:27
  that
• 19:27
  you
• 19:28
  do
• 19:28
  feel
• 19:28
  immediately
• 19:29
  better,
• 19:29
  right?
• 19:29
  ADHD
• 19:30
  meds.
• 19:30
  Within
• 19:30
  one
• 19:31
  hour,
• 19:31
  you
• 19:31
  will
• 19:31
  feel
• 19:31
  better
• 19:32
  if
• 19:32
  they
• 19:32
  were
• 19:32
  working
• 19:32
  correctly.
• 19:34
  So
• 19:34
  don't
• 19:35
  assume
• 19:35
  that
• 19:35
  your
• 19:35
  patients
• 19:36
  have
• 19:37
  read
• 19:37
  all
• 19:37
  the
• 19:37
  randomized
• 19:38
  control
• 19:39
  trials
• 19:41
  and
• 19:42
  that
• 19:42
  they
• 19:42
  just
• 19:43
  assume
• 19:43
  that
• 19:44
  they,
• 19:44
  you
• 19:44
  know,
• 19:44
  they
• 19:45
  know
• 19:45
  what,
• 19:45
  you
• 19:45
  know.
• 19:46
  It's
• 19:47
  not
• 19:47
  like
• 19:47
  that,
• 19:47
  Right?
• 19:48
  So
• 19:48
  an
• 19:48
  adequate
• 19:49
  trial
• 19:49
  is
• 19:50
  four
• 19:50
  to
• 19:50
  12
• 19:50
  weeks
• 19:51
  at
• 19:51
  a
• 19:51
  therapeutic
• 19:51
  dose.
• 19:52
  I
• 19:52
  want
• 19:52
  to
• 19:52
  repeat
• 19:52
  that
• 19:53
  an
• 19:53
  adequate
• 19:54
  trial
• 19:54
  is
• 19:55
  four
• 19:55
  to
• 19:55
  12
• 19:56
  weeks
• 19:56
  at
• 19:56
  a
• 19:56
  therapeutic
• 19:57
  dose
• 19:57
  with
• 19:58
  Consistent
• 19:58
  adherence.
• 19:59
  Remember,
• 19:59
  that
• 19:59
  is
• 20:00
  all
• 20:00
  thrown
• 20:00
  out
• 20:00
  the
• 20:00
  window.
• 20:01
  The
• 20:01
  clock
• 20:01
  is
• 20:01
  reset.
• 20:02
  If
• 20:02
  the
• 20:02
  patient
• 20:03
  has
• 20:03
  been
• 20:03
  prescribed
• 20:04
  the
• 20:04
  medication
• 20:04
  for
• 20:04
  12
• 20:05
  weeks,
• 20:05
  but
• 20:05
  they've
• 20:06
  only
• 20:06
  taken
• 20:06
  it
• 20:06
  half
• 20:06
  the
• 20:07
  time.
• 20:07
  I
• 20:07
  don't
• 20:07
  care
• 20:07
  that
• 20:08
  it's
• 20:08
  12
• 20:08
  weeks.
• 20:08
  I
• 20:08
  don't
• 20:09
  care
• 20:09
  that
• 20:09
  it's
• 20:09
  prescribed
• 20:09
  at
• 20:10
  50
• 20:10
  or
• 20:10
  100
• 20:11
  for
• 20:11
  12
• 20:11
  weeks.
• 20:11
  If
• 20:12
  the
• 20:12
  patient
• 20:12
  is
• 20:12
  only
• 20:13
  taking
• 20:13
  it
• 20:13
  35%
• 20:14
  of
• 20:14
  the
• 20:14
  time,
• 20:15
  that
• 20:15
  is
• 20:15
  not
• 20:15
  consistent
• 20:16
  adherence
• 20:17
  and
• 20:17
  therefore
• 20:17
  it
• 20:17
  is
• 20:17
  not
• 20:18
  an
• 20:18
  adequate
• 20:19
  trial.
• 20:19
  Right,
• 20:20
  adequate
• 20:20
  trial.
• 20:21
  Four
• 20:21
  to
• 20:21
  12
• 20:22
  weeks
• 20:22
  at
• 20:22
  a
• 20:22
  therapeutic
• 20:23
  dose
• 20:23
  with
• 20:23
  consistent
• 20:24
  adherence.
• 20:25
  No,
• 20:25
  that
• 20:25
  is
• 20:25
  not
• 20:25
  a
• 20:26
  robust
• 20:26
  dose.
• 20:27
  It's
• 20:27
  not
• 20:27
  for
• 20:28
  four
• 20:28
  to
• 20:28
  12
• 20:28
  weeks
• 20:29
  at
• 20:29
  a
• 20:29
  therapeutic
• 20:29
  dose.
• 20:30
  And
• 20:30
  if
• 20:31
  the
• 20:31
  patient's
• 20:31
  not
• 20:31
  adherent,
• 20:32
  forget
• 20:32
  about
• 20:32
  it.
• 20:33
  Right,
• 20:33
  so
• 20:33
  the
• 20:33
  clock
• 20:34
  on
• 20:34
  an
• 20:34
  adequate
• 20:34
  trial
• 20:35
  starts
• 20:35
  when
• 20:35
  the
• 20:35
  patient
• 20:36
  is
• 20:36
  taking
• 20:36
  a
• 20:36
  therapeutic
• 20:37
  dose
• 20:37
  consistently,
• 20:38
  not
• 20:39
  from
• 20:39
  the
• 20:39
  date
• 20:39
  the
• 20:39
  prescription
• 20:40
  was
• 20:40
  written.
• 20:40
  And
• 20:41
  this
• 20:41
  is
• 20:41
  why
• 20:41
  you
• 20:41
  have
• 20:41
  to
• 20:42
  be
• 20:42
  very
• 20:42
  technical.
• 20:42
  You
• 20:43
  have
• 20:43
  to
• 20:43
  be
• 20:43
  very
• 20:43
  careful
• 20:44
  when
• 20:45
  you're
• 20:45
  asking
• 20:45
  the
• 20:45
  questions
• 20:46
  to
• 20:46
  figure
• 20:47
  out
• 20:47
  the
• 20:47
  timeline.
• 20:48
  Again,
• 20:48
  patients
• 20:48
  who
• 20:49
  come
• 20:49
  in
• 20:49
  with
• 20:49
  depression,
• 20:50
  they're
• 20:50
  psychomotor
• 20:51
  retardation,
• 20:52
  they
• 20:52
  have
• 20:52
  a
• 20:52
  hard
• 20:53
  time
• 20:53
  thinking
• 20:53
  clearly.
• 20:54
  They
• 20:54
  can,
• 20:54
  they
• 20:55
  can
• 20:55
  have
• 20:55
  a
• 20:55
  difficulty
• 20:56
  concentrating
• 20:56
  with
• 20:56
  generalized
• 20:57
  anxiety.
• 20:57
  Maria
• 20:58
  has
• 20:58
  both.
• 20:58
  Right.
• 20:59
  So
• 20:59
  it's
• 20:59
  not
• 20:59
  always
• 21:00
  easy
• 21:00
  for
• 21:00
  them
• 21:00
  to
• 21:00
  go,
• 21:00
  you
• 21:01
  know
• 21:01
  what,
• 21:01
  19
• 21:02
  days
• 21:02
  ago,
• 21:02
  I
• 21:03
  started
• 21:03
  Zoloft
• 21:03
  at
• 21:04
  a
• 21:04
  sub
• 21:04
  therapeutic
• 21:05
  dose
• 21:05
  and
• 21:05
  I
• 21:06
  take
• 21:06
  my
• 21:06
  medication
• 21:07
  75%
• 21:07
  of
• 21:08
  the
• 21:08
  time.
• 21:08
  They're
• 21:09
  not,
• 21:09
  they're
• 21:10
  not
• 21:10
  going
• 21:10
  to
• 21:10
  be
• 21:10
  able
• 21:10
  to
• 21:10
  like,
• 21:10
  spitball
• 21:11
  this
• 21:11
  to
• 21:11
  you.
• 21:11
  You
• 21:11
  have
• 21:12
  to
• 21:12
  be
• 21:12
  very
• 21:12
  careful.
• 21:13
  You
• 21:14
  might
• 21:14
  have
• 21:14
  to
• 21:14
  anchor
• 21:15
  the
• 21:15
  times
• 21:15
  they
• 21:16
  started
• 21:16
  these
• 21:16
  medications
• 21:18
  on,
• 21:19
  you
• 21:19
  know,
• 21:19
  to
• 21:19
  their
• 21:20
  birthday
• 21:20
  or
• 21:21
  to
• 21:21
  a
• 21:21
  holiday,
• 21:22
  so
• 21:22
  they,
• 21:22
  they're
• 21:22
  a
• 21:22
  little
• 21:23
  more
• 21:23
  oriented
• 21:23
  rather
• 21:24
  than
• 21:24
  just
• 21:24
  like,
• 21:24
  how
• 21:24
  many
• 21:24
  days.
• 21:27
  So
• 21:29
  just
• 21:29
  think
• 21:29
  about
• 21:30
  that,
• 21:30
  get
• 21:31
  to
• 21:31
  technical,
• 21:31
  get
• 21:32
  nitty
• 21:32
  gritty
• 21:33
  about
• 21:34
  the
• 21:34
  duration
• 21:35
  and
• 21:36
  remember,
• 21:37
  four
• 21:37
  to
• 21:38
  12
• 21:38
  weeks,
• 21:39
  adherent,
• 21:39
  therapeutic.
• 21:41
  Because
• 21:41
  my
• 21:42
  friends,
• 21:43
  if
• 21:43
  you
• 21:43
  don't
• 21:43
  do
• 21:43
  this,
• 21:44
  what's
• 21:45
  going
• 21:45
  to
• 21:45
  happen
• 21:46
  is
• 21:47
  your
• 21:47
  patient
• 21:48
  is
• 21:48
  going
• 21:49
  to
• 21:49
  move
• 21:49
  from
• 21:49
  another
• 21:49
  provider.
• 21:50
  Maybe
• 21:50
  they
• 21:50
  lose
• 21:51
  their
• 21:51
  job,
• 21:51
  they
• 21:51
  lose
• 21:51
  their
• 21:52
  insurance.
• 21:52
  They
• 21:52
  start
• 21:53
  set
• 21:53
  up,
• 21:53
  they
• 21:53
  sign
• 21:53
  up
• 21:53
  for
• 21:54
  a
• 21:54
  telehealth
• 21:54
  service,
• 21:56
  and
• 21:56
  then
• 21:56
  what
• 21:57
  you're
• 21:57
  going
• 21:57
  to
• 21:57
  have
• 21:57
  is
• 21:58
  the
• 21:58
  new
• 21:58
  provider's
• 21:59
  gonna
• 21:59
  look
• 21:59
  at
• 21:59
  this
• 21:59
  and
• 21:59
  go,
• 22:00
  hmm,
• 22:02
  she's
• 22:02
  been
• 22:02
  on
• 22:02
  four
• 22:02
  different
• 22:03
  medications.
• 22:04
  Let's
• 22:04
  try
• 22:04
  her
• 22:04
  on
• 22:05
  tms.
• 22:06
  Let's
• 22:07
  try
• 22:07
  on
• 22:07
  ketamine.
• 22:08
  They're
• 22:08
  going
• 22:08
  to
• 22:08
  be
• 22:09
  labeled
• 22:09
  as
• 22:09
  treatment
• 22:10
  resistant
• 22:11
  when
• 22:12
  the
• 22:12
  details
• 22:12
  were
• 22:12
  never
• 22:13
  truly
• 22:13
  fleshed
• 22:13
  out.
• 22:15
  Do
• 22:15
  you
• 22:15
  know
• 22:15
  the
• 22:16
  kind
• 22:16
  of
• 22:16
  stigma
• 22:16
  that's
• 22:16
  associated
• 22:17
  with
• 22:17
  patients
• 22:18
  that
• 22:19
  feel
• 22:20
  as
• 22:20
  though
• 22:20
  they
• 22:20
  have
• 22:20
  been
• 22:20
  diagnosed
• 22:21
  and
• 22:21
  written
• 22:21
  off
• 22:21
  as
• 22:22
  treatment
• 22:22
  resistant?
• 22:24
  I
• 22:24
  mean,
• 22:24
  the
• 22:24
  name
• 22:25
  is
• 22:25
  really
• 22:26
  demoralizing.
• 22:26
  The
• 22:27
  characterization
• 22:27
  is
• 22:28
  really
• 22:28
  difficult.
• 22:29
  I've
• 22:29
  had
• 22:29
  patients
• 22:30
  tell
• 22:30
  me
• 22:30
  how
• 22:31
  demoralized
• 22:32
  they
• 22:32
  feel
• 22:32
  being
• 22:33
  labeled
• 22:33
  as
• 22:33
  treatment
• 22:34
  resistant.
• 22:34
  You
• 22:34
  know,
• 22:34
  they
• 22:35
  feel
• 22:35
  like
• 22:35
  they're
• 22:35
  in
• 22:35
  the
• 22:35
  special
• 22:36
  category
• 22:36
  of
• 22:36
  people
• 22:36
  who
• 22:37
  are
• 22:37
  not
• 22:37
  only
• 22:37
  so
• 22:37
  unfortunate
• 22:38
  to
• 22:38
  be
• 22:38
  depressed,
• 22:39
  but
• 22:40
  that
• 22:40
  they
• 22:40
  have
• 22:40
  this
• 22:40
  special
• 22:41
  kind
• 22:41
  of
• 22:43
  subtype
• 22:44
  of
• 22:44
  depression
• 22:44
  that
• 22:45
  is
• 22:45
  especially
• 22:46
  difficult.
• 22:47
  So
• 22:49
  hopelessness
• 22:50
  is
• 22:50
  already
• 22:50
  baked
• 22:50
  into
• 22:51
  the
• 22:51
  depression
• 22:52
  criteria,
• 22:53
  and
• 22:53
  now
• 22:54
  you're
• 22:55
  adding
• 22:55
  this
• 22:56
  truly
• 22:56
  discouraging
• 22:57
  label.
• 22:57
  And
• 22:57
  the
• 22:58
  worst
• 22:58
  part
• 22:58
  is,
• 22:58
  it's
• 22:58
  not
• 22:59
  even
• 22:59
  earned.
• 22:59
  Right.
• 23:00
  We've
• 23:00
  never
• 23:00
  really
• 23:01
  verified
• 23:01
  if
• 23:02
  Maria
• 23:02
  has
• 23:02
  been
• 23:02
  at
• 23:03
  a
• 23:04
  therapeutic
• 23:04
  dose
• 23:05
  for
• 23:05
  4
• 23:05
  to
• 23:05
  12
• 23:05
  weeks
• 23:06
  at
• 23:06
  80%
• 23:07
  more
• 23:07
  of
• 23:07
  adherence.
• 23:08
  Right.
• 23:09
  And
• 23:09
  so.
• 23:10
  Oh,
• 23:10
  so
• 23:10
  now
• 23:10
  we're
• 23:11
  gonna
• 23:11
  make
• 23:11
  the
• 23:11
  mistake
• 23:11
  and.
• 23:12
  And
• 23:12
  set.
• 23:12
  Put
• 23:12
  her
• 23:13
  on
• 23:13
  Prozac
• 23:13
  prematurely
• 23:14
  when
• 23:14
  she
• 23:14
  could
• 23:14
  have
• 23:15
  very
• 23:15
  well
• 23:16
  at
• 23:16
  an
• 23:16
  optimal
• 23:16
  dose
• 23:17
  here
• 23:17
  with
• 23:17
  Sertraline.
• 23:18
  Been
• 23:18
  doing
• 23:19
  really
• 23:19
  well.
• 23:19
  Her
• 23:19
  PHQ9
• 23:20
  dropped,
• 23:21
  and
• 23:21
  we're
• 23:21
  switching
• 23:21
  prematurely.
• 23:23
  And
• 23:23
  so
• 23:23
  this
• 23:23
  is
• 23:23
  even
• 23:24
  more
• 23:24
  reason
• 23:24
  we've
• 23:24
  got
• 23:24
  to
• 23:25
  get
• 23:25
  clinical
• 23:25
  measurements,
• 23:26
  right?
• 23:26
  Because
• 23:27
  the
• 23:27
  amateur
• 23:27
  thing
• 23:28
  to
• 23:28
  do
• 23:28
  here
• 23:28
  would
• 23:28
  be
• 23:28
  like,
• 23:29
  you
• 23:29
  know,
• 23:29
  you
• 23:29
  need
• 23:29
  something
• 23:30
  stronger.
• 23:30
  You
• 23:30
  don't
• 23:30
  really
• 23:30
  like
• 23:31
  Sertraline.
• 23:32
  Let's
• 23:33
  try
• 23:33
  Prozac.
• 23:33
  Now.
• 23:34
  We're
• 23:34
  waiting
• 23:34
  even
• 23:34
  longer
• 23:35
  for
• 23:35
  a
• 23:36
  medication.
• 23:36
  We've
• 23:37
  got
• 23:37
  to
• 23:37
  get
• 23:37
  off
• 23:37
  of
• 23:38
  this
• 23:38
  one.
• 23:38
  There
• 23:38
  might
• 23:38
  be
• 23:38
  some
• 23:39
  irritability,
• 23:40
  sleeplessness,
• 23:40
  brain
• 23:41
  zaps.
• 23:41
  It
• 23:41
  might
• 23:41
  be
• 23:41
  unpleasant
• 23:42
  to
• 23:42
  get
• 23:42
  off
• 23:42
  of
• 23:42
  this
• 23:43
  one,
• 23:43
  but
• 23:43
  that
• 23:43
  might
• 23:44
  even
• 23:44
  color
• 23:44
  her
• 23:45
  perception
• 23:45
  of
• 23:45
  the
• 23:45
  next
• 23:46
  medication
• 23:46
  coming
• 23:46
  in.
• 23:47
  She
• 23:47
  might
• 23:47
  think,
• 23:47
  oh,
• 23:47
  Prozac
• 23:48
  sucks
• 23:48
  because
• 23:49
  I'm
• 23:49
  all
• 23:49
  irritable
• 23:50
  now.
• 23:50
  And
• 23:50
  pretty
• 23:51
  soon,
• 23:51
  you
• 23:51
  have
• 23:51
  created
• 23:52
  this
• 23:52
  perfect
• 23:53
  storm
• 23:53
  of
• 23:54
  treatment
• 23:54
  resistance
• 23:55
  that
• 23:55
  is
• 23:55
  not
• 23:55
  actually
• 23:56
  treatment
• 23:56
  resistance.
• 23:57
  It's
• 23:57
  sloppy
• 23:58
  prescribing,
• 23:58
  sloppy
• 23:59
  diagnosing,
• 24:00
  sloppy
• 24:01
  analysis
• 24:01
  of
• 24:02
  timelines
• 24:04
  that
• 24:04
  are
• 24:04
  not
• 24:04
  backed.
• 24:05
  Backed
• 24:05
  with
• 24:05
  data.
• 24:06
  And
• 24:07
  so
• 24:07
  really
• 24:07
  holding
• 24:08
  them
• 24:08
  to
• 24:08
  the
• 24:08
  fire
• 24:08
  on
• 24:09
  adherence,
• 24:09
  getting
• 24:09
  nitty
• 24:10
  gritty.
• 24:11
  I
• 24:11
  think
• 24:11
  it'll.
• 24:11
  It'll
• 24:11
  actually
• 24:12
  instill
• 24:12
  a
• 24:12
  lot
• 24:13
  of
• 24:13
  hope
• 24:13
  back
• 24:14
  into
• 24:14
  your
• 24:14
  therapeutic
• 24:15
  relationship,
• 24:16
  especially
• 24:16
  that
• 24:17
  statistic
• 24:17
  about
• 24:17
  2.6
• 24:18
  to
• 24:18
  3.1.
• 24:19
  Higher
• 24:19
  odds
• 24:20
  of
• 24:20
  treatment
• 24:20
  response
• 24:21
  with
• 24:21
  good
• 24:21
  adherence.
• 24:22
  That
• 24:22
  is
• 24:23
  very
• 24:23
  hopeful.
• 24:23
  I
• 24:24
  would
• 24:24
  love
• 24:24
  to
• 24:24
  hear
• 24:24
  that.
• 24:25
  As
• 24:25
  a
• 24:25
  patient,
• 24:25
  it
• 24:26
  would
• 24:26
  motivate
• 24:26
  me
• 24:27
  every
• 24:27
  day
• 24:27
  to
• 24:28
  take
• 24:28
  my
• 24:28
  vitamin
• 24:29
  D
• 24:29
  if
• 24:29
  I
• 24:29
  knew
• 24:30
  that
• 24:30
  I
• 24:30
  would
• 24:30
  be
• 24:30
  three
• 24:31
  times
• 24:31
  more
• 24:31
  successful.
• 24:32
  And
• 24:33
  so
• 24:34
  pearls
• 24:34
  and
• 24:34
  prep,
• 24:35
  Right?
• 24:35
  That's
• 24:35
  why
• 24:35
  we
• 24:35
  do
• 24:35
  this.
• 24:36
  Now,
• 24:37
  aside
• 24:38
  from
• 24:38
  duration,
• 24:39
  the
• 24:40
  fourth
• 24:40
  principle
• 24:40
  we
• 24:40
  talked
• 24:41
  about
• 24:41
  is
• 24:41
  the
• 24:41
  diagnosis
• 24:42
  correct.
• 24:43
  So
• 24:43
  I
• 24:44
  can't
• 24:44
  tell
• 24:44
  you
• 24:44
  how
• 24:44
  many
• 24:45
  times
• 24:45
  I've
• 24:46
  inherited
• 24:46
  a
• 24:46
  patient
• 24:46
  from
• 24:47
  another
• 24:47
  provider
• 24:47
  or
• 24:47
  I've
• 24:48
  been
• 24:48
  working
• 24:48
  with
• 24:48
  a
• 24:48
  patient,
• 24:49
  and
• 24:49
  maybe
• 24:49
  I
• 24:49
  feel
• 24:49
  stuck.
• 24:50
  And
• 24:50
  it
• 24:51
  is
• 24:51
  so
• 24:51
  important
• 24:51
  for
• 24:52
  you
• 24:52
  to
• 24:52
  ask
• 24:52
  if
• 24:53
  you
• 24:53
  get
• 24:53
  stuck
• 24:53
  and
• 24:54
  you're
• 24:54
  getting
• 24:54
  frustrated
• 24:55
  and
• 24:55
  you've
• 24:55
  tried
• 24:56
  this
• 24:56
  SSRI
• 24:57
  that
• 24:57
  SSR
• 24:58
  ssri.
• 24:58
  You
• 24:59
  moved
• 24:59
  over
• 24:59
  to
• 24:59
  an
• 24:59
  snri.
• 25:00
  You've,
• 25:01
  you
• 25:01
  know,
• 25:02
  you've
• 25:02
  tried
• 25:02
  a
• 25:02
  Velta,
• 25:03
  you've
• 25:03
  tried
• 25:03
  symbiotes,
• 25:04
  whatever.
• 25:04
  You've
• 25:05
  tried
• 25:05
  everything.
• 25:06
  I
• 25:06
  can't
• 25:06
  tell
• 25:06
  you
• 25:06
  how
• 25:07
  important
• 25:07
  it
• 25:07
  is
• 25:07
  to
• 25:08
  be
• 25:08
  a
• 25:08
  little
• 25:08
  humble
• 25:09
  and
• 25:09
  walk
• 25:09
  up
• 25:10
  to
• 25:10
  a
• 25:10
  mirror
• 25:10
  and
• 25:11
  stare
• 25:11
  at
• 25:11
  it
• 25:12
  and
• 25:13
  ask
• 25:13
  yourself,
• 25:14
  did
• 25:15
  I
• 25:15
  do
• 25:15
  something
• 25:15
  wrong?
• 25:17
  Did
• 25:17
  I
• 25:17
  get
• 25:17
  this
• 25:17
  all
• 25:18
  wrong?
• 25:19
  I
• 25:20
  think
• 25:20
  it's
• 25:20
  a
• 25:20
  really
• 25:20
  good
• 25:21
  question
• 25:21
  to
• 25:21
  ask
• 25:21
  yourselves,
• 25:22
  like
• 25:22
  a
• 25:22
  critical
• 25:22
  thinking
• 25:23
  question
• 25:23
  that
• 25:23
  you
• 25:24
  should
• 25:24
  ask
• 25:24
  yourself
• 25:25
  at
• 25:25
  every
• 25:25
  visit.
• 25:26
  Like,
• 25:26
  what
• 25:27
  else
• 25:27
  could
• 25:27
  this
• 25:27
  be?
• 25:28
  That,
• 25:28
  that
• 25:28
  I
• 25:28
  am
• 25:29
  not
• 25:29
  looking
• 25:29
  at
• 25:29
  at
• 25:30
  all
• 25:30
  right
• 25:30
  now?
• 25:31
  Right.
• 25:32
  What
• 25:32
  could
• 25:32
  I
• 25:32
  have
• 25:33
  totally
• 25:33
  missed
• 25:33
  here
• 25:34
  that
• 25:34
  would
• 25:34
  embarrass
• 25:35
  me
• 25:35
  to
• 25:35
  my
• 25:35
  core?
• 25:36
  Right?
• 25:37
  That
• 25:37
  is
• 25:37
  a
• 25:37
  beautiful
• 25:37
  question.
• 25:38
  You
• 25:38
  should
• 25:38
  write
• 25:38
  that
• 25:38
  down.
• 25:39
  And,
• 25:39
  you
• 25:39
  know,
• 25:39
  I've
• 25:40
  seen
• 25:40
  this
• 25:40
  patient
• 25:40
  12
• 25:40
  sessions,
• 25:41
  16
• 25:41
  sessions.
• 25:42
  Did
• 25:42
  I
• 25:42
  not,
• 25:42
  Did
• 25:43
  I
• 25:43
  not
• 25:43
  properly
• 25:43
  assess
• 25:44
  sleep
• 25:44
  apnea?
• 25:45
  And
• 25:45
  just
• 25:46
  in
• 25:46
  our
• 25:46
  last
• 25:46
  episode,
• 25:47
  we
• 25:47
  talked
• 25:47
  about
• 25:47
  the
• 25:48
  two
• 25:48
  times
• 25:49
  higher
• 25:49
  risk
• 25:49
  of
• 25:49
  developing
• 25:50
  depression
• 25:50
  with
• 25:50
  untreated
• 25:51
  sleep
• 25:51
  apnea
• 25:51
  and
• 25:52
  how
• 25:52
  it
• 25:52
  actually
• 25:53
  leads
• 25:53
  to
• 25:54
  the
• 25:55
  production
• 25:55
  of
• 25:56
  the
• 25:56
  MAO
• 25:57
  enzyme
• 25:58
  that
• 25:59
  destroys
• 26:00
  neurotransmitters.
• 26:01
  Right?
• 26:02
  That
• 26:02
  was
• 26:02
  a
• 26:02
  crazy
• 26:03
  pearl
• 26:03
  we,
• 26:03
  we
• 26:04
  thought
• 26:04
  about,
• 26:04
  we
• 26:04
  talked
• 26:04
  about
• 26:05
  a
• 26:05
  couple
• 26:05
  weeks
• 26:05
  ago.
• 26:06
  Right?
• 26:07
  So
• 26:07
  did
• 26:07
  I
• 26:07
  miss
• 26:08
  sleep
• 26:08
  apnea
• 26:08
  here?
• 26:09
  Is
• 26:09
  this
• 26:09
  patient
• 26:10
  becoming
• 26:10
  more
• 26:11
  depressed
• 26:11
  or
• 26:12
  becoming
• 26:12
  depressed
• 26:12
  for
• 26:13
  the
• 26:13
  first
• 26:13
  time?
• 26:13
  Because
• 26:13
  what's
• 26:14
  really
• 26:14
  happening
• 26:14
  here
• 26:15
  is
• 26:15
  that
• 26:16
  we're
• 26:16
  not
• 26:16
  properly
• 26:17
  oxygenating
• 26:18
  those
• 26:18
  neurons
• 26:18
  at
• 26:18
  night.
• 26:19
  They're
• 26:19
  constantly
• 26:19
  getting
• 26:20
  almost
• 26:20
  like,
• 26:21
  it's
• 26:21
  almost
• 26:22
  like
• 26:22
  dunking
• 26:22
  their
• 26:22
  heads
• 26:23
  in
• 26:23
  water
• 26:23
  every
• 26:23
  10
• 26:24
  minutes
• 26:24
  and
• 26:24
  lifting
• 26:24
  their
• 26:25
  head
• 26:25
  out
• 26:25
  of
• 26:25
  the
• 26:25
  water.
• 26:25
  And
• 26:26
  it's
• 26:26
  like,
• 26:26
  well,
• 26:26
  that's
• 26:26
  not
• 26:27
  going
• 26:27
  to
• 26:27
  make
• 26:27
  for
• 26:28
  someone
• 26:28
  who's
• 26:28
  calm
• 26:29
  and
• 26:29
  focused
• 26:29
  the
• 26:29
  next
• 26:30
  day.
• 26:30
  And
• 26:30
  a
• 26:30
  lot
• 26:30
  of
• 26:30
  those
• 26:30
  symptoms
• 26:31
  might
• 26:31
  mimic
• 26:31
  depression.
• 26:32
  They're
• 26:32
  fatigued,
• 26:32
  they
• 26:33
  can't
• 26:33
  think
• 26:33
  clearly,
• 26:33
  they're
• 26:34
  not
• 26:34
  in
• 26:34
  a
• 26:34
  great
• 26:34
  mood,
• 26:34
  they're
• 26:35
  irritable.
• 26:35
  Maybe
• 26:36
  they're
• 26:36
  more
• 26:36
  anxious
• 26:36
  because
• 26:37
  they're
• 26:37
  not
• 26:37
  sleeping.
• 26:37
  Their
• 26:37
  cortisol
• 26:38
  levels
• 26:38
  are
• 26:38
  going
• 26:38
  up,
• 26:39
  they're
• 26:39
  gaining
• 26:39
  weight.
• 26:40
  So
• 26:40
  all
• 26:40
  the
• 26:40
  hallmarks
• 26:41
  of
• 26:41
  depression
• 26:42
  can
• 26:42
  now
• 26:42
  be
• 26:42
  confused
• 26:43
  because
• 26:43
  we
• 26:43
  didn't
• 26:44
  do
• 26:44
  a
• 26:45
  sleep
• 26:45
  apnea
• 26:46
  assessment,
• 26:46
  we
• 26:46
  didn't
• 26:47
  assess
• 26:47
  them
• 26:47
  via
• 26:48
  the
• 26:48
  Stop
• 26:48
  Bang
• 26:49
  questionnaire
• 26:50
  with
• 26:50
  respect
• 26:50
  to
• 26:51
  whether
• 26:51
  or
• 26:51
  not,
• 26:51
  you
• 26:52
  know,
• 26:53
  they
• 26:53
  snore
• 26:53
  at
• 26:53
  night,
• 26:54
  whether
• 26:54
  they,
• 26:55
  their
• 26:55
  BMI
• 26:55
  is
• 26:56
  too
• 26:56
  high,
• 26:56
  whether
• 26:56
  they
• 26:57
  wake
• 26:57
  up
• 26:57
  fatigued
• 26:57
  with
• 26:58
  headaches.
• 26:58
  Right?
• 26:59
  The
• 26:59
  sleep
• 27:00
  apnea
• 27:02
  questionnaire.
• 27:02
  Does
• 27:02
  your
• 27:03
  spouse
• 27:03
  observe
• 27:04
  you,
• 27:04
  observe
• 27:04
  you
• 27:04
  gasping?
• 27:05
  All
• 27:06
  important
• 27:06
  questions
• 27:07
  that
• 27:07
  might
• 27:07
  trigger
• 27:08
  a
• 27:08
  sleep
• 27:08
  study
• 27:08
  and
• 27:09
  really
• 27:09
  help
• 27:09
  you
• 27:09
  out.
• 27:10
  Right?
• 27:10
  Is
• 27:10
  this
• 27:10
  hypothyroidism?
• 27:11
  Is
• 27:12
  this
• 27:12
  substance
• 27:12
  use?
• 27:12
  Right.
• 27:13
  Is
• 27:13
  the
• 27:13
  patient,
• 27:14
  is
• 27:14
  the
• 27:14
  patient
• 27:14
  using
• 27:15
  too
• 27:15
  much
• 27:15
  caffeine
• 27:16
  to
• 27:16
  compensate
• 27:16
  for
• 27:17
  being
• 27:17
  fatigued
• 27:18
  and
• 27:18
  now
• 27:18
  they're,
• 27:18
  it's
• 27:19
  interrupting
• 27:19
  their
• 27:20
  sleep
• 27:20
  and
• 27:21
  all
• 27:21
  the
• 27:21
  things
• 27:21
  that
• 27:22
  can,
• 27:22
  you
• 27:22
  know,
• 27:22
  chronic
• 27:23
  pain,
• 27:23
  personality
• 27:23
  disorders,
• 27:24
  are
• 27:24
  they
• 27:25
  bipolar?
• 27:25
  Right.
• 27:25
  We
• 27:26
  know
• 27:26
  that
• 27:26
  like
• 27:27
  25%
• 27:28
  of
• 27:28
  patients
• 27:28
  presenting
• 27:29
  with
• 27:29
  depression
• 27:29
  in
• 27:29
  primary
• 27:30
  care
• 27:30
  may
• 27:31
  have
• 27:31
  unrecognized
• 27:32
  bipolar.
• 27:32
  Right.
• 27:33
  So
• 27:33
  are,
• 27:33
  is
• 27:33
  Zoloft
• 27:34
  even
• 27:34
  the
• 27:34
  right
• 27:35
  thing
• 27:35
  here?
• 27:36
  Right.
• 27:36
  Does
• 27:36
  this
• 27:36
  patient
• 27:37
  have
• 27:37
  a
• 27:37
  family
• 27:37
  history
• 27:37
  of
• 27:38
  bipolarity
• 27:39
  that
• 27:39
  they
• 27:39
  didn't
• 27:39
  share
• 27:40
  or
• 27:40
  that
• 27:40
  their,
• 27:41
  you
• 27:41
  know,
• 27:41
  they,
• 27:42
  they,
• 27:42
  they
• 27:42
  didn't
• 27:43
  represent
• 27:43
  clearly
• 27:44
  on
• 27:44
  assessment?
• 27:45
  You
• 27:46
  know,
• 27:46
  so,
• 27:46
  so
• 27:46
  asking
• 27:47
  that
• 27:47
  maybe
• 27:47
  you
• 27:47
  have
• 27:48
  to
• 27:48
  give
• 27:48
  her
• 27:48
  a
• 27:48
  mood
• 27:48
  disorder
• 27:49
  questionnaire.
• 27:50
  So
• 27:50
  a
• 27:50
  lot
• 27:50
  of
• 27:50
  times
• 27:51
  when
• 27:51
  your
• 27:51
  patient
• 27:51
  is
• 27:53
  not
• 27:53
  responding
• 27:53
  to
• 27:54
  your
• 27:54
  medication
• 27:54
  or
• 27:54
  quote,
• 27:55
  needs
• 27:55
  something
• 27:55
  stronger,
• 27:56
  they
• 27:57
  just
• 27:57
  don't
• 27:57
  have
• 27:57
  the
• 27:57
  right
• 27:57
  diagnosis
• 27:58
  pinned
• 27:58
  down
• 27:59
  on
• 27:59
  them.
• 27:59
  And
• 27:59
  bipolar,
• 28:00
  of
• 28:00
  course,
• 28:00
  is
• 28:00
  a
• 28:01
  really
• 28:01
  big
• 28:01
  one
• 28:02
  to,
• 28:02
  to
• 28:02
  be
• 28:03
  suspicious
• 28:03
  about
• 28:03
  in
• 28:04
  every
• 28:04
  account
• 28:04
  encounter,
• 28:05
  given
• 28:05
  the
• 28:05
  prevalence
• 28:06
  with
• 28:07
  depression.
• 28:07
  And
• 28:08
  so
• 28:08
  between
• 28:09
  adherence,
• 28:09
  between
• 28:09
  the
• 28:10
  right
• 28:10
  dose,
• 28:10
  between
• 28:10
  the
• 28:11
  duration,
• 28:11
  between
• 28:12
  the
• 28:12
  diagnosis,
• 28:13
  I
• 28:13
  think
• 28:13
  that
• 28:14
  you
• 28:14
  have
• 28:15
  a
• 28:15
  lot
• 28:15
  of
• 28:15
  meat
• 28:15
  on
• 28:15
  the
• 28:15
  bone
• 28:16
  to
• 28:16
  think
• 28:16
  about
• 28:16
  here
• 28:17
  to
• 28:17
  chew
• 28:17
  on.
• 28:18
  And
• 28:18
  I
• 28:18
  hope
• 28:18
  you
• 28:19
  really
• 28:19
  enjoyed
• 28:19
  this
• 28:19
  one.
• 28:20
  We
• 28:20
  will
• 28:20
  catch
• 28:20
  all
• 28:21
  of
• 28:21
  you
• 28:22
  next
• 28:22
  time
• 28:23
  on
• 28:23
  Pearls
• 28:24
  and
• 28:24
  Prep.
• 28:25
  Have
• 28:25
  a
• 28:25
  great
• 28:26
  weekend.
• 28:26
  Bye.
• 28:26
  Bye.