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Don’t Panic During the Cross-Taper: 4 Antipsychotic Switching Pearls · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  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
  npc.
• 0:09
  Here,
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:11
  place
• 0:12
  for
• 0:12
  pearls
• 0:12
  that
• 0:13
  prep
• 0:13
  you
• 0:13
  to
• 0:13
  practice.
• 0:14
  Today
• 0:15
  we
• 0:15
  have
• 0:15
  six
• 0:16
  shiny
• 0:17
  pearls
• 0:17
  about
• 0:18
  antipsychotic
• 0:19
  switching.
• 0:20
  Things
• 0:20
  you're
• 0:21
  going
• 0:21
  to
• 0:21
  have
• 0:21
  to
• 0:21
  know
• 0:22
  and
• 0:22
  think
• 0:22
  about.
• 0:23
  Now,
• 0:23
  the
• 0:24
  first
• 0:24
  thing,
• 0:24
  my
• 0:24
  friends,
• 0:25
  before
• 0:25
  we
• 0:26
  even
• 0:26
  talk
• 0:27
  about
• 0:28
  pearl
• 0:28
  number
• 0:29
  one,
• 0:29
  is
• 0:30
  to
• 0:30
  understand
• 0:30
  that
• 0:31
  antipsychotic
• 0:32
  switching,
• 0:32
  I
• 0:33
  believe,
• 0:33
  is
• 0:34
  inherently
• 0:34
  more
• 0:35
  challenging
• 0:35
  than
• 0:35
  SSRI
• 0:36
  switching.
• 0:37
  Right?
• 0:37
  Switching
• 0:38
  from
• 0:38
  like
• 0:38
  a
• 0:38
  Zoloft
• 0:39
  to
• 0:39
  a
• 0:39
  Lexapro
• 0:40
  is
• 0:41
  not
• 0:41
  as
• 0:41
  complicated.
• 0:42
  Some
• 0:43
  prescribers
• 0:43
  do
• 0:44
  it
• 0:44
  immediately,
• 0:45
  some
• 0:45
  will
• 0:46
  do
• 0:46
  a
• 0:46
  cross
• 0:46
  taper.
• 0:47
  Kind
• 0:47
  of
• 0:47
  depends
• 0:47
  on
• 0:48
  the
• 0:48
  person,
• 0:48
  it
• 0:48
  depends
• 0:48
  on
• 0:49
  the
• 0:49
  patient.
• 0:49
  But
• 0:50
  by
• 0:51
  and
• 0:51
  large,
• 0:52
  broad
• 0:52
  strokes,
• 0:53
  you're
• 0:53
  really
• 0:53
  dealing
• 0:54
  with
• 0:54
  serotonin,
• 0:55
  more
• 0:56
  or
• 0:56
  less,
• 0:56
  right?
• 0:57
  Unless
• 0:57
  you're
• 0:58
  prescribing
• 0:58
  Paxil
• 0:59
  or
• 0:59
  Effexor,
• 1:00
  which
• 1:01
  has
• 1:01
  a
• 1:01
  short
• 1:01
  half
• 1:01
  life
• 1:01
  and
• 1:02
  Paxil
• 1:02
  has
• 1:03
  these
• 1:03
  anticholinergic
• 1:04
  side
• 1:04
  effects,
• 1:05
  you
• 1:05
  know,
• 1:05
  unless
• 1:05
  you're
• 1:06
  dealing
• 1:06
  with
• 1:06
  that,
• 1:07
  the
• 1:07
  switches
• 1:08
  for
• 1:08
  antidepressants
• 1:09
  are
• 1:09
  pretty
• 1:09
  clean,
• 1:10
  pretty
• 1:10
  predictable,
• 1:11
  not
• 1:12
  crazy.
• 1:13
  Not
• 1:13
  that
• 1:13
  complex
• 1:14
  patients
• 1:15
  can
• 1:15
  often
• 1:16
  endorse
• 1:17
  an
• 1:17
  excruciating
• 1:18
  withdrawal
• 1:19
  taper.
• 1:20
  And
• 1:20
  you
• 1:20
  have
• 1:21
  to
• 1:21
  slow
• 1:21
  things
• 1:21
  down
• 1:22
  and
• 1:22
  you
• 1:23
  have
• 1:23
  to
• 1:23
  make
• 1:23
  sure
• 1:23
  you're
• 1:24
  cognizant
• 1:24
  of
• 1:24
  half
• 1:25
  lives.
• 1:25
  But
• 1:25
  I
• 1:26
  feel
• 1:26
  like
• 1:27
  antipsychotics
• 1:28
  are
• 1:28
  a
• 1:28
  lot
• 1:28
  more
• 1:29
  complicated
• 1:29
  and
• 1:29
  there's
• 1:30
  a
• 1:30
  lot
• 1:30
  more
• 1:30
  things
• 1:30
  you
• 1:30
  have
• 1:30
  to
• 1:31
  pay
• 1:31
  attention
• 1:31
  to.
• 1:32
  Not
• 1:32
  in
• 1:33
  a
• 1:33
  way
• 1:33
  that
• 1:33
  it'll
• 1:33
  make
• 1:33
  your
• 1:34
  head
• 1:34
  spin
• 1:34
  or
• 1:34
  you're
• 1:34
  gonna
• 1:35
  wanna
• 1:35
  quit
• 1:35
  this
• 1:35
  profession
• 1:36
  and
• 1:36
  become
• 1:36
  like
• 1:36
  a
• 1:36
  tax
• 1:37
  accountant,
• 1:38
  but
• 1:39
  enough
• 1:39
  to
• 1:39
  where
• 1:40
  you
• 1:40
  should
• 1:40
  keep
• 1:41
  your
• 1:41
  ear
• 1:41
  to
• 1:41
  the
• 1:41
  ground,
• 1:42
  understand
• 1:42
  receptor
• 1:43
  mechanics,
• 1:44
  understand
• 1:45
  the
• 1:45
  rich
• 1:45
  complexity
• 1:46
  of
• 1:46
  the
• 1:46
  medications
• 1:47
  that
• 1:47
  you
• 1:47
  are
• 1:47
  prescribing,
• 1:48
  and
• 1:49
  anticipate
• 1:50
  what
• 1:50
  your
• 1:50
  patient
• 1:51
  will
• 1:52
  do
• 1:52
  when
• 1:52
  you
• 1:53
  make
• 1:53
  these
• 1:53
  changes.
• 1:53
  How
• 1:54
  your
• 1:54
  patient
• 1:54
  will
• 1:54
  respond
• 1:55
  is
• 1:55
  really
• 1:56
  key
• 1:56
  because
• 1:56
  there's
• 1:57
  a
• 1:57
  lot
• 1:57
  more
• 1:57
  going
• 1:57
  on
• 1:58
  when
• 1:58
  it
• 1:58
  comes
• 1:59
  to
• 1:59
  a
• 1:59
  switch
• 1:59
  with
• 1:59
  antipsychotics.
• 2:00
  It's
• 2:00
  kind
• 2:00
  of
• 2:01
  like
• 2:01
  juggling
• 2:02
  three
• 2:02
  bowling
• 2:02
  pins.
• 2:03
  And,
• 2:04
  and
• 2:04
  I.
• 2:04
  I
• 2:05
  think
• 2:05
  antidepressants
• 2:05
  are
• 2:06
  more
• 2:06
  like
• 2:06
  juggling
• 2:06
  two
• 2:07
  bowling
• 2:07
  pins.
• 2:08
  You
• 2:08
  can
• 2:08
  juggle
• 2:09
  two
• 2:09
  bowling
• 2:09
  pins.
• 2:09
  You
• 2:09
  might
• 2:10
  drop
• 2:10
  one
• 2:10
  on
• 2:10
  your
• 2:10
  shoe,
• 2:11
  on
• 2:11
  your
• 2:12
  foot,
• 2:12
  that
• 2:12
  might
• 2:13
  hurt,
• 2:13
  one
• 2:14
  might
• 2:14
  hit
• 2:14
  you
• 2:14
  in
• 2:14
  the
• 2:14
  head.
• 2:15
  Sh.
• 2:15
  Sure,
• 2:15
  there's
• 2:16
  some
• 2:16
  risks
• 2:16
  there,
• 2:16
  but
• 2:17
  then
• 2:17
  now
• 2:17
  you
• 2:17
  have
• 2:17
  three.
• 2:18
  Three
• 2:18
  is
• 2:18
  really
• 2:18
  hard.
• 2:19
  You
• 2:19
  really
• 2:19
  gotta
• 2:19
  focus,
• 2:20
  you
• 2:20
  really
• 2:20
  gotta
• 2:20
  practice,
• 2:21
  you
• 2:21
  really
• 2:21
  gotta
• 2:21
  know
• 2:22
  what
• 2:22
  you're
• 2:22
  doing.
• 2:23
  You
• 2:23
  have
• 2:23
  histamine
• 2:24
  and
• 2:24
  dopamine,
• 2:25
  the
• 2:25
  M1
• 2:26
  muscarinic
• 2:26
  receptors,
• 2:27
  alpha
• 2:27
  1
• 2:27
  adrenergic
• 2:28
  receptor,
• 2:28
  right?
• 2:29
  So
• 2:29
  you
• 2:29
  could
• 2:29
  argue
• 2:30
  and
• 2:30
  switching
• 2:31
  antipsychotics
• 2:31
  is
• 2:32
  like
• 2:32
  juggling
• 2:32
  nine
• 2:32
  bowling
• 2:33
  pins
• 2:33
  or
• 2:33
  five
• 2:33
  bowling
• 2:34
  pins.
• 2:34
  But
• 2:35
  whatever
• 2:35
  the
• 2:35
  case,
• 2:36
  it
• 2:36
  is
• 2:36
  just
• 2:36
  more
• 2:36
  complicated.
• 2:37
  But
• 2:37
  we're
• 2:38
  gonna
• 2:38
  make
• 2:38
  this
• 2:38
  a
• 2:38
  little
• 2:38
  more
• 2:39
  simple
• 2:39
  for
• 2:39
  you,
• 2:40
  and
• 2:40
  hopefully
• 2:40
  it's
• 2:41
  all
• 2:41
  gonna
• 2:41
  click
• 2:41
  by
• 2:41
  the
• 2:41
  end
• 2:42
  of
• 2:42
  this
• 2:42
  episode.
• 2:42
  So.
• 2:43
  So
• 2:43
  the
• 2:43
  very
• 2:43
  first
• 2:43
  thing
• 2:43
  you
• 2:44
  should
• 2:44
  think
• 2:44
  about,
• 2:44
  Pearl,
• 2:45
  number
• 2:45
  one,
• 2:45
  is
• 2:47
  confirm
• 2:47
  that
• 2:47
  the
• 2:48
  switch
• 2:48
  is
• 2:48
  actually
• 2:48
  needed
• 2:49
  in
• 2:49
  the
• 2:49
  first
• 2:49
  place.
• 2:50
  Don't
• 2:50
  just
• 2:51
  rush
• 2:51
  to
• 2:51
  the
• 2:51
  algorithms
• 2:52
  and
• 2:52
  panic
• 2:52
  and
• 2:53
  wonder
• 2:53
  about
• 2:53
  the
• 2:54
  half
• 2:54
  lives.
• 2:54
  And
• 2:54
  what
• 2:55
  do
• 2:55
  I
• 2:55
  do
• 2:55
  next?
• 2:56
  Make
• 2:56
  sure
• 2:56
  your
• 2:57
  patient
• 2:57
  actually
• 2:57
  has
• 2:58
  an
• 2:58
  adequate
• 2:59
  trial
• 2:59
  on
• 3:00
  board,
• 3:00
  a
• 3:00
  sufficient
• 3:01
  dose,
• 3:01
  at
• 3:01
  least
• 3:02
  four
• 3:02
  to
• 3:02
  six
• 3:02
  weeks
• 3:02
  at
• 3:03
  a
• 3:03
  therapeutic
• 3:03
  dose.
• 3:04
  And
• 3:05
  so
• 3:05
  if
• 3:05
  the
• 3:05
  patient
• 3:06
  is
• 3:06
  not
• 3:06
  adherent,
• 3:07
  we've.
• 3:08
  We've
• 3:08
  seen
• 3:08
  adherence
• 3:09
  rates
• 3:10
  are,
• 3:10
  like,
• 3:10
  near
• 3:11
  50%.
• 3:11
  They're
• 3:12
  not
• 3:12
  that
• 3:12
  impressive
• 3:13
  with
• 3:13
  antidepressants.
• 3:13
  It's
• 3:14
  similar
• 3:14
  for
• 3:14
  antipsychotics.
• 3:15
  So
• 3:16
  make
• 3:16
  sure
• 3:16
  that
• 3:17
  the
• 3:17
  patient
• 3:17
  is
• 3:17
  taking
• 3:17
  the
• 3:18
  medication
• 3:18
  often
• 3:18
  enough
• 3:19
  to
• 3:19
  where
• 3:19
  we
• 3:19
  even
• 3:20
  know
• 3:20
  that
• 3:20
  this
• 3:20
  is
• 3:20
  a
• 3:20
  fair
• 3:21
  fight,
• 3:21
  that
• 3:21
  the
• 3:22
  therapeutic
• 3:22
  plasma
• 3:23
  levels
• 3:23
  are
• 3:23
  even
• 3:24
  meaningful
• 3:24
  and
• 3:25
  consistent
• 3:25
  in
• 3:25
  the
• 3:25
  first
• 3:26
  place.
• 3:26
  Because
• 3:26
  the
• 3:27
  last
• 3:27
  thing
• 3:27
  you
• 3:27
  want
• 3:27
  to
• 3:27
  do
• 3:28
  is,
• 3:28
  number
• 3:28
  one,
• 3:29
  abandon
• 3:29
  a
• 3:29
  medication
• 3:30
  that
• 3:30
  could
• 3:30
  otherwise
• 3:31
  be
• 3:31
  fine
• 3:31
  and
• 3:32
  therapeutic
• 3:33
  with.
• 3:34
  With
• 3:34
  proper
• 3:34
  adherence.
• 3:35
  I
• 3:35
  mean,
• 3:35
  there's
• 3:35
  a
• 3:35
  reason
• 3:35
  you
• 3:36
  chose
• 3:36
  it
• 3:36
  first
• 3:36
  to
• 3:36
  begin
• 3:37
  with,
• 3:37
  I
• 3:37
  would
• 3:37
  assume.
• 3:38
  Right?
• 3:38
  So
• 3:38
  jumping
• 3:39
  ship
• 3:39
  on
• 3:39
  the
• 3:40
  medication
• 3:40
  you
• 3:40
  ch
• 3:42
  for
• 3:42
  your
• 3:42
  patient
• 3:43
  because
• 3:43
  you
• 3:43
  think
• 3:43
  it's
• 3:44
  not
• 3:44
  effective,
• 3:44
  when
• 3:45
  in
• 3:45
  reality,
• 3:45
  no
• 3:46
  medication
• 3:46
  will
• 3:46
  be
• 3:46
  effective
• 3:47
  if
• 3:47
  they're
• 3:47
  not
• 3:48
  properly
• 3:48
  adhering
• 3:49
  to
• 3:49
  it
• 3:49
  would
• 3:49
  be
• 3:49
  a
• 3:50
  major
• 3:50
  shame.
• 3:50
  Right?
• 3:51
  It's
• 3:51
  like
• 3:51
  not
• 3:52
  taking
• 3:52
  Motrin
• 3:53
  for
• 3:53
  migraines.
• 3:54
  And
• 3:54
  you.
• 3:54
  You
• 3:55
  know,
• 3:55
  you
• 3:55
  took
• 3:55
  Motrin
• 3:56
  once
• 3:56
  a
• 3:57
  week.
• 3:57
  You
• 3:57
  had
• 3:57
  a
• 3:57
  migraine
• 3:58
  every
• 3:58
  other
• 3:58
  day.
• 3:58
  Well,
• 3:59
  yeah,
• 3:59
  it's
• 3:59
  not
• 4:00
  the
• 4:00
  med
• 4:00
  that's
• 4:00
  the
• 4:00
  problem.
• 4:01
  It's
• 4:01
  the
• 4:01
  adherence.
• 4:01
  Maybe
• 4:02
  it's
• 4:02
  the
• 4:02
  dose,
• 4:02
  too.
• 4:03
  You're
• 4:03
  not
• 4:03
  at
• 4:03
  an
• 4:03
  adequate
• 4:04
  dose.
• 4:04
  Maybe
• 4:04
  you
• 4:04
  took
• 4:05
  400
• 4:05
  milligrams
• 4:05
  of
• 4:06
  Motrin
• 4:06
  every
• 4:07
  other
• 4:07
  day
• 4:08
  when
• 4:08
  you
• 4:08
  should
• 4:08
  have
• 4:08
  taken
• 4:09
  800
• 4:09
  milligrams
• 4:10
  of
• 4:10
  Motrin
• 4:10
  every
• 4:11
  day.
• 4:11
  It's
• 4:11
  not
• 4:11
  Motrin's
• 4:12
  fault.
• 4:12
  It's.
• 4:13
  The
• 4:13
  dose
• 4:13
  was
• 4:14
  too
• 4:14
  low,
• 4:14
  it
• 4:15
  was
• 4:15
  too
• 4:15
  inconsistent
• 4:16
  for
• 4:16
  the
• 4:17
  symptom
• 4:17
  presentation
• 4:17
  in
• 4:18
  front
• 4:18
  of
• 4:18
  it,
• 4:18
  and
• 4:18
  it
• 4:19
  just
• 4:19
  wasn't
• 4:19
  dosed
• 4:20
  properly
• 4:20
  as
• 4:20
  it
• 4:21
  should
• 4:21
  be
• 4:21
  dosed.
• 4:22
  So
• 4:22
  you
• 4:22
  have
• 4:22
  to
• 4:23
  get
• 4:23
  a
• 4:23
  very
• 4:23
  clear
• 4:24
  inventory.
• 4:24
  And
• 4:25
  I
• 4:25
  don't
• 4:25
  like
• 4:25
  to
• 4:26
  ask
• 4:26
  my
• 4:26
  patients,
• 4:26
  are
• 4:26
  you
• 4:27
  taking
• 4:27
  the
• 4:27
  meds
• 4:27
  every
• 4:27
  day?
• 4:28
  That
• 4:28
  sounds
• 4:28
  a
• 4:28
  little
• 4:28
  pedantic.
• 4:29
  Sounds
• 4:29
  a
• 4:29
  little
• 4:30
  bit
• 4:30
  authoritative.
• 4:32
  I
• 4:32
  say,
• 4:32
  how
• 4:32
  often
• 4:33
  have
• 4:33
  you
• 4:33
  been
• 4:33
  able
• 4:33
  to
• 4:34
  take
• 4:34
  your
• 4:34
  medications?
• 4:34
  I
• 4:35
  find
• 4:35
  that
• 4:35
  that
• 4:36
  gives
• 4:36
  them
• 4:36
  a
• 4:36
  little
• 4:36
  bit
• 4:36
  of
• 4:37
  an
• 4:37
  out
• 4:37
  where
• 4:38
  they
• 4:38
  can
• 4:38
  say,
• 4:38
  oh,
• 4:39
  you
• 4:39
  know,
• 4:39
  six
• 4:39
  days
• 4:39
  a
• 4:40
  week.
• 4:40
  I
• 4:40
  do
• 4:40
  forget
• 4:40
  sometimes
• 4:41
  it
• 4:42
  gives
• 4:42
  them
• 4:43
  this
• 4:44
  opportunity
• 4:44
  to
• 4:45
  tell
• 4:45
  you
• 4:45
  the
• 4:45
  truth,
• 4:45
  if,
• 4:46
  in
• 4:46
  fact
• 4:46
  they
• 4:46
  haven't
• 4:47
  been
• 4:47
  able
• 4:47
  to
• 4:47
  take
• 4:48
  it.
• 4:48
  It
• 4:48
  almost
• 4:48
  assumes
• 4:49
  that
• 4:49
  maybe
• 4:49
  they
• 4:49
  didn't
• 4:50
  take
• 4:50
  it
• 4:50
  all
• 4:50
  of
• 4:50
  the
• 4:50
  time.
• 4:51
  Typically
• 4:51
  my
• 4:52
  patients
• 4:52
  will
• 4:52
  say
• 4:53
  I
• 4:53
  either
• 4:53
  forgot
• 4:54
  or
• 4:54
  no,
• 4:54
  I
• 4:54
  take
• 4:54
  it
• 4:55
  every
• 4:55
  day.
• 4:55
  And
• 4:56
  so
• 4:56
  that,
• 4:56
  to
• 4:56
  me,
• 4:57
  that
• 4:57
  open
• 4:57
  ended
• 4:58
  question
• 4:58
  is
• 4:58
  a
• 4:58
  lot
• 4:58
  more
• 4:59
  productive.
• 5:00
  It
• 5:00
  normalizes
• 5:01
  the
• 5:01
  idea
• 5:01
  that
• 5:01
  maybe
• 5:02
  they
• 5:03
  could
• 5:03
  forget
• 5:03
  that
• 5:03
  it's
• 5:04
  not
• 5:04
  assumed
• 5:04
  that
• 5:05
  they're
• 5:05
  going
• 5:05
  to
• 5:05
  take
• 5:05
  it
• 5:05
  every
• 5:06
  day.
• 5:06
  But
• 5:06
  I
• 5:07
  like
• 5:07
  asking
• 5:07
  that
• 5:08
  question.
• 5:08
  And
• 5:09
  then
• 5:09
  you
• 5:09
  can
• 5:09
  identify,
• 5:10
  well,
• 5:10
  let's
• 5:11
  get
• 5:11
  adherence
• 5:11
  back
• 5:11
  on
• 5:12
  track
• 5:12
  if
• 5:12
  adherence
• 5:13
  is
• 5:13
  a
• 5:13
  consistent
• 5:13
  problem
• 5:14
  and
• 5:14
  what
• 5:14
  is
• 5:14
  underlying
• 5:15
  their
• 5:15
  non
• 5:16
  adherence.
• 5:16
  Exactly.
• 5:17
  And
• 5:17
  you
• 5:17
  could
• 5:17
  find
• 5:18
  many
• 5:18
  different
• 5:18
  very
• 5:19
  fascinating
• 5:19
  answers
• 5:20
  about
• 5:20
  that
• 5:20
  from
• 5:20
  like,
• 5:21
  oh,
• 5:21
  I
• 5:21
  just
• 5:21
  forgot
• 5:22
  this
• 5:22
  is
• 5:22
  a
• 5:22
  new
• 5:22
  med.
• 5:23
  I've
• 5:23
  never
• 5:23
  been
• 5:23
  on
• 5:23
  meds.
• 5:24
  I
• 5:24
  don't
• 5:24
  know
• 5:24
  how
• 5:24
  to
• 5:24
  really
• 5:25
  do
• 5:25
  this
• 5:26
  yet
• 5:26
  to.
• 5:27
  Well,
• 5:28
  I'm
• 5:28
  still
• 5:28
  worried
• 5:28
  about
• 5:29
  weight
• 5:29
  gain
• 5:29
  or
• 5:29
  I
• 5:30
  don't
• 5:30
  like
• 5:30
  how
• 5:31
  sedated
• 5:31
  it
• 5:31
  makes
• 5:31
  me
• 5:32
  or
• 5:32
  I
• 5:32
  still
• 5:32
  have
• 5:33
  questions
• 5:33
  about
• 5:33
  why
• 5:33
  I'm
• 5:34
  on
• 5:34
  this
• 5:34
  and
• 5:34
  how
• 5:35
  long
• 5:35
  I
• 5:35
  have
• 5:35
  to
• 5:35
  be
• 5:35
  on
• 5:36
  it.
• 5:36
  Oh,
• 5:36
  and
• 5:36
  I
• 5:36
  thought
• 5:37
  it
• 5:37
  was
• 5:37
  more
• 5:37
  like
• 5:37
  a
• 5:37
  benzo
• 5:38
  where
• 5:38
  I
• 5:38
  just
• 5:38
  take
• 5:38
  it
• 5:39
  as
• 5:39
  needed.
• 5:39
  I
• 5:39
  didn't
• 5:39
  know
• 5:39
  I
• 5:39
  had
• 5:40
  to
• 5:40
  take
• 5:40
  it
• 5:40
  every
• 5:40
  day.
• 5:41
  Those
• 5:42
  things
• 5:42
  might
• 5:42
  seem
• 5:43
  really
• 5:43
  obvious
• 5:44
  to
• 5:44
  you
• 5:44
  as
• 5:44
  the
• 5:44
  prescriber,
• 5:45
  but
• 5:45
  to
• 5:45
  a
• 5:46
  patient,
• 5:46
  this
• 5:46
  is
• 5:47
  not
• 5:47
  necessarily
• 5:47
  their
• 5:48
  field,
• 5:48
  right.
• 5:49
  They
• 5:50
  might
• 5:50
  do
• 5:50
  something
• 5:51
  radically
• 5:51
  different
• 5:53
  in
• 5:53
  their
• 5:53
  lives.
• 5:54
  Right?
• 5:54
  They,
• 5:54
  they
• 5:55
  might
• 5:55
  be
• 5:57
  car
• 5:57
  mechanics
• 5:58
  or
• 5:58
  public
• 5:58
  school
• 5:59
  teachers.
• 5:59
  Like
• 5:59
  they,
• 5:59
  they're,
• 6:00
  they
• 6:00
  don't,
• 6:00
  they
• 6:00
  don't
• 6:01
  study
• 6:01
  psychopharmacology
• 6:02
  every
• 6:03
  day.
• 6:03
  So
• 6:04
  don't
• 6:04
  just
• 6:04
  assume
• 6:05
  that
• 6:05
  every
• 6:05
  patient
• 6:05
  knows
• 6:06
  that
• 6:06
  a
• 6:06
  medication
• 6:07
  has
• 6:07
  to
• 6:07
  be
• 6:07
  taken
• 6:07
  every
• 6:08
  day.
• 6:08
  If
• 6:08
  you
• 6:08
  didn't
• 6:08
  tell
• 6:08
  them
• 6:09
  that
• 6:09
  in
• 6:09
  session,
• 6:10
  I'll
• 6:10
  tell
• 6:10
  you
• 6:10
  from
• 6:11
  experience,
• 6:11
  that's
• 6:11
  kind
• 6:12
  of
• 6:12
  a
• 6:12
  problem.
• 6:13
  Right?
• 6:14
  Because
• 6:15
  think
• 6:15
  about
• 6:15
  how
• 6:15
  many
• 6:15
  medications
• 6:16
  actually
• 6:16
  don't
• 6:17
  have
• 6:17
  to
• 6:17
  be
• 6:17
  taken
• 6:17
  every
• 6:18
  day
• 6:18
  for
• 6:18
  them
• 6:18
  to
• 6:18
  be
• 6:18
  effective.
• 6:19
  Migraine
• 6:20
  meds
• 6:20
  don't
• 6:20
  need
• 6:20
  to
• 6:21
  be
• 6:21
  taken
• 6:21
  every
• 6:21
  day
• 6:21
  necessarily.
• 6:22
  Maybe
• 6:22
  when
• 6:22
  you
• 6:23
  have
• 6:23
  an
• 6:23
  aura
• 6:23
  and
• 6:23
  you
• 6:24
  sense
• 6:24
  a
• 6:24
  migraine
• 6:24
  is
• 6:24
  coming
• 6:25
  or
• 6:25
  a
• 6:25
  benzo.
• 6:25
  Right.
• 6:26
  So
• 6:26
  it's
• 6:26
  not
• 6:27
  implicitly
• 6:28
  agreed
• 6:28
  upon
• 6:29
  or
• 6:29
  assumed
• 6:29
  by
• 6:29
  the
• 6:30
  masses
• 6:30
  that
• 6:31
  you
• 6:31
  have
• 6:31
  to
• 6:31
  take
• 6:31
  meds
• 6:32
  every
• 6:32
  day.
• 6:32
  So
• 6:33
  adherence,
• 6:33
  adherence,
• 6:33
  you
• 6:34
  are
• 6:34
  going
• 6:34
  to
• 6:34
  hear
• 6:34
  me
• 6:34
  talk
• 6:34
  about
• 6:35
  that
• 6:35
  all
• 6:35
  of
• 6:35
  the
• 6:35
  time.
• 6:36
  It's
• 6:36
  so
• 6:36
  darn
• 6:37
  important.
• 6:38
  Ask
• 6:38
  about
• 6:38
  the
• 6:38
  side
• 6:38
  effects
• 6:39
  that
• 6:39
  maybe
• 6:40
  they're
• 6:40
  not
• 6:41
  really
• 6:41
  willing
• 6:42
  to
• 6:42
  talk
• 6:42
  about.
• 6:43
  You
• 6:43
  may
• 6:43
  have
• 6:43
  to
• 6:43
  normalize
• 6:44
  that.
• 6:44
  We
• 6:44
  see
• 6:44
  this
• 6:44
  a
• 6:44
  lot
• 6:44
  with
• 6:45
  SSRIs,
• 6:45
  right?
• 6:46
  I
• 6:47
  will
• 6:47
  talk
• 6:48
  about
• 6:48
  sexual
• 6:48
  side
• 6:48
  effects.
• 6:49
  I'll
• 6:49
  create
• 6:49
  the
• 6:49
  floor
• 6:50
  and
• 6:50
  I'll
• 6:50
  say
• 6:51
  many,
• 6:51
  many
• 6:52
  people
• 6:52
  that
• 6:52
  walk
• 6:52
  into
• 6:52
  this
• 6:53
  office
• 6:53
  complain
• 6:53
  that
• 6:54
  their
• 6:54
  sex
• 6:55
  drive
• 6:55
  is
• 6:55
  not
• 6:56
  as
• 6:56
  healthy
• 6:57
  or
• 6:58
  profound
• 6:58
  as
• 6:59
  before.
• 7:00
  They
• 7:00
  are
• 7:00
  having
• 7:01
  issues
• 7:01
  finishing,
• 7:02
  they're
• 7:02
  having
• 7:02
  issues
• 7:03
  just
• 7:04
  being
• 7:05
  aroused,
• 7:05
  maybe
• 7:06
  staying
• 7:06
  erect.
• 7:07
  But
• 7:07
  we're
• 7:07
  all
• 7:07
  adults
• 7:08
  here.
• 7:08
  And
• 7:09
  so
• 7:09
  I
• 7:09
  will
• 7:09
  normalize
• 7:10
  that
• 7:11
  very
• 7:12
  quickly
• 7:12
  because
• 7:12
  again,
• 7:13
  if
• 7:13
  you
• 7:13
  don't
• 7:14
  normalize
• 7:14
  that
• 7:14
  or
• 7:15
  bring
• 7:15
  it
• 7:15
  up,
• 7:15
  what
• 7:16
  are
• 7:16
  the
• 7:16
  odds
• 7:16
  your
• 7:16
  patient's
• 7:17
  going
• 7:17
  to
• 7:17
  really
• 7:17
  want
• 7:17
  to
• 7:17
  bring
• 7:17
  that
• 7:18
  up?
• 7:18
  A
• 7:18
  lot
• 7:18
  of
• 7:19
  times
• 7:19
  they
• 7:19
  don't.
• 7:21
  So
• 7:21
  I
• 7:21
  will
• 7:21
  do
• 7:21
  that.
• 7:21
  And
• 7:21
  if
• 7:22
  that's
• 7:22
  the
• 7:22
  reason
• 7:22
  they're
• 7:23
  having
• 7:23
  problems
• 7:24
  adhering,
• 7:25
  you
• 7:25
  can
• 7:26
  put
• 7:26
  out
• 7:26
  that
• 7:26
  fire
• 7:26
  right
• 7:27
  away.
• 7:27
  You
• 7:28
  can
• 7:28
  offer
• 7:28
  medications
• 7:29
  that
• 7:29
  can
• 7:29
  counter
• 7:30
  sexual
• 7:30
  side
• 7:30
  effects,
• 7:31
  you
• 7:31
  can
• 7:31
  educate
• 7:32
  them
• 7:32
  on
• 7:32
  sexual
• 7:32
  side
• 7:32
  effects,
• 7:33
  drug
• 7:33
  holidays,
• 7:34
  alternative,
• 7:36
  maybe
• 7:36
  alternative
• 7:37
  medications
• 7:38
  if
• 7:38
  needed,
• 7:38
  but
• 7:38
  at
• 7:38
  least
• 7:38
  you
• 7:39
  get
• 7:39
  the
• 7:39
  conversation
• 7:39
  going.
• 7:40
  So
• 7:40
  investigate
• 7:41
  the
• 7:42
  hesitancy
• 7:43
  behind
• 7:43
  their
• 7:44
  non
• 7:44
  adherence,
• 7:45
  investigate
• 7:45
  if
• 7:45
  they're
• 7:46
  non
• 7:46
  adherent,
• 7:46
  non
• 7:46
  adherent
• 7:47
  at
• 7:47
  all.
• 7:48
  Talk
• 7:48
  about
• 7:48
  their
• 7:48
  deal
• 7:48
  breaker
• 7:49
  side
• 7:49
  effects.
• 7:49
  You
• 7:49
  can
• 7:50
  imagine
• 7:50
  how
• 7:50
  all
• 7:50
  of
• 7:50
  these
• 7:50
  conversations
• 7:51
  would
• 7:51
  be
• 7:51
  much
• 7:51
  better
• 7:52
  before
• 7:52
  you
• 7:52
  even
• 7:53
  hit
• 7:53
  the
• 7:53
  prescribe
• 7:54
  button.
• 7:54
  So
• 7:54
  I
• 7:55
  know
• 7:55
  these
• 7:55
  appointments
• 7:56
  are
• 7:56
  often
• 7:56
  rushed,
• 7:57
  you
• 7:57
  know,
• 7:57
  30
• 7:57
  minutes,
• 7:58
  45
• 7:58
  minutes,
• 7:58
  60
• 7:58
  minutes,
• 7:59
  whatever.
• 8:54
  But
• 8:54
  if
• 8:55
  you
• 8:55
  spend
• 8:56
  a
• 8:56
  good
• 8:56
  five
• 8:56
  to
• 8:57
  10
• 8:57
  minutes
• 8:57
  going
• 8:58
  through
• 8:58
  a
• 8:58
  thorough
• 8:59
  checklist
• 8:59
  that
• 8:59
  feels
• 9:00
  more
• 9:00
  and
• 9:00
  more
• 9:00
  automatic
• 9:01
  to
• 9:01
  you,
• 9:01
  after
• 9:01
  each
• 9:01
  session
• 9:02
  it
• 9:02
  will
• 9:03
  start
• 9:03
  to
• 9:03
  click.
• 9:03
  You
• 9:03
  will
• 9:04
  start
• 9:04
  to
• 9:04
  get
• 9:04
  more,
• 9:05
  more
• 9:05
  competent.
• 9:07
  And
• 9:07
  I,
• 9:07
  I
• 9:08
  think
• 9:08
  it's
• 9:08
  very
• 9:08
  important
• 9:08
  to
• 9:09
  go
• 9:09
  over
• 9:09
  these
• 9:09
  things
• 9:09
  and
• 9:10
  establish
• 9:10
  that
• 9:10
  trust
• 9:11
  and
• 9:11
  those
• 9:11
  expectations
• 9:12
  right
• 9:12
  away
• 9:13
  because
• 9:13
  we
• 9:13
  don't
• 9:14
  want
• 9:14
  to
• 9:14
  just
• 9:14
  switch
• 9:14
  the
• 9:14
  medication
• 9:15
  if
• 9:15
  it's
• 9:15
  otherwise
• 9:16
  going
• 9:16
  well
• 9:17
  and
• 9:17
  we
• 9:17
  can
• 9:17
  put
• 9:17
  the
• 9:17
  fires
• 9:18
  out
• 9:18
  without
• 9:18
  this
• 9:19
  complicated
• 9:20
  cross
• 9:20
  switch.
• 9:21
  So
• 9:21
  make
• 9:22
  sure
• 9:22
  your
• 9:22
  medication
• 9:23
  is
• 9:23
  actually
• 9:23
  a
• 9:24
  failure.
• 9:24
  That's
• 9:24
  Pearl
• 9:25
  1.
• 9:26
  Okay.
• 9:26
  Now
• 9:27
  Pearl
• 9:27
  2.
• 9:28
  And
• 9:28
  I
• 9:28
  learned
• 9:28
  this
• 9:29
  the
• 9:29
  hard
• 9:29
  way,
• 9:29
  unfortunately,
• 9:31
  is
• 9:31
  you
• 9:32
  need
• 9:32
  to
• 9:32
  make
• 9:32
  sure
• 9:33
  you
• 9:33
  know
• 9:33
  the
• 9:33
  receptor
• 9:34
  binding
• 9:34
  profiles
• 9:35
  of
• 9:35
  both
• 9:35
  of
• 9:35
  your
• 9:35
  medications.
• 9:36
  Okay.
• 9:37
  If
• 9:37
  you're
• 9:38
  switching
• 9:39
  from
• 9:40
  Zyprexa
• 9:41
  to
• 9:41
  Abilify,
• 9:42
  you
• 9:42
  should
• 9:43
  have
• 9:43
  an
• 9:43
  understanding
• 9:44
  of
• 9:44
  the
• 9:44
  affinity
• 9:45
  that
• 9:46
  Zyprexa
• 9:47
  has
• 9:47
  towards
• 9:47
  various
• 9:48
  receptors
• 9:48
  relative
• 9:49
  to
• 9:49
  Abilify.
• 9:50
  So
• 9:50
  you
• 9:50
  can
• 9:50
  understand
• 9:51
  where
• 9:52
  the
• 9:52
  withdrawal
• 9:52
  symptoms
• 9:53
  might
• 9:53
  be
• 9:54
  coming
• 9:54
  from
• 9:54
  if
• 9:54
  you
• 9:54
  stop
• 9:55
  XYZ
• 9:55
  drug
• 9:56
  and
• 9:56
  what
• 9:57
  new
• 9:57
  symptoms
• 9:57
  might
• 9:58
  be
• 9:58
  encountered
• 9:58
  on
• 9:59
  XYZ
• 9:59
  new
• 10:00
  drug.
• 10:00
  Very
• 10:01
  important,
• 10:01
  I
• 10:02
  always
• 10:02
  say,
• 10:02
  before
• 10:02
  you
• 10:03
  prescribe
• 10:03
  a
• 10:03
  medication,
• 10:04
  understand
• 10:05
  the
• 10:05
  binding
• 10:05
  affinities
• 10:06
  for
• 10:07
  the
• 10:07
  receptors
• 10:08
  of
• 10:08
  the
• 10:08
  drug
• 10:08
  in
• 10:08
  your
• 10:08
  hand.
• 10:09
  Right.
• 10:09
  Very
• 10:10
  important.
• 10:10
  We
• 10:10
  know
• 10:10
  Zyprexa
• 10:11
  is
• 10:11
  a
• 10:11
  really
• 10:12
  potent
• 10:12
  D2
• 10:13
  blocker.
• 10:13
  We
• 10:13
  know
• 10:14
  that
• 10:14
  it
• 10:14
  also
• 10:14
  blocks
• 10:15
  5ht2a,
• 10:15
  which
• 10:16
  mitigates
• 10:17
  some
• 10:17
  of
• 10:17
  the
• 10:17
  motor
• 10:17
  side
• 10:18
  effects
• 10:18
  from
• 10:18
  the
• 10:19
  D2
• 10:19
  blockade.
• 10:20
  Right.
• 10:20
  It
• 10:20
  also
• 10:20
  enhances
• 10:21
  cognition
• 10:22
  a
• 10:22
  little
• 10:22
  bit
• 10:22
  in
• 10:22
  the
• 10:22
  prefrontal
• 10:23
  cortex,
• 10:23
  which
• 10:24
  is
• 10:24
  very
• 10:24
  helpful.
• 10:25
  We
• 10:25
  talked
• 10:25
  about
• 10:25
  how
• 10:25
  that
• 10:26
  can
• 10:26
  be
• 10:26
  very
• 10:26
  helpful
• 10:27
  in
• 10:27
  negative
• 10:27
  symptoms
• 10:28
  of
• 10:28
  schizophrenia.
• 10:29
  So
• 10:29
  that's
• 10:29
  a
• 10:29
  Big
• 10:29
  pearl
• 10:30
  to
• 10:30
  understand
• 10:31
  is
• 10:31
  what
• 10:32
  is
• 10:32
  this
• 10:32
  drug
• 10:32
  doing?
• 10:33
  What
• 10:33
  receptors
• 10:34
  does
• 10:34
  it
• 10:34
  act
• 10:35
  upon,
• 10:35
  and
• 10:35
  what
• 10:35
  is
• 10:36
  the
• 10:36
  affinity
• 10:37
  of
• 10:37
  that
• 10:37
  the
• 10:38
  medication
• 10:38
  has
• 10:38
  with
• 10:39
  respect
• 10:39
  to
• 10:39
  those
• 10:40
  receptors?
• 10:40
  So
• 10:41
  that
• 10:41
  you
• 10:41
  have
• 10:41
  an
• 10:41
  idea,
• 10:42
  because
• 10:42
  I'll
• 10:43
  tell
• 10:43
  you
• 10:43
  right
• 10:43
  now,
• 10:43
  my
• 10:43
  friends,
• 10:44
  if
• 10:44
  you
• 10:45
  are
• 10:45
  trying
• 10:46
  to
• 10:46
  get
• 10:46
  off
• 10:46
  of
• 10:46
  Zyprexa
• 10:47
  and
• 10:48
  let's
• 10:48
  say
• 10:48
  onto
• 10:48
  Seroquel,
• 10:50
  watch
• 10:50
  out.
• 10:50
  Because
• 10:51
  you
• 10:51
  are
• 10:51
  going
• 10:51
  from
• 10:52
  a
• 10:52
  very
• 10:53
  strong
• 10:54
  D2
• 10:54
  blockader
• 10:55
  in
• 10:55
  Zyprexa
• 10:56
  to
• 10:56
  a
• 10:56
  relatively
• 10:57
  weak
• 10:57
  one
• 10:57
  that
• 10:57
  requires
• 10:58
  you
• 10:58
  to
• 10:58
  go
• 10:59
  up
• 10:59
  at
• 10:59
  pretty
• 11:00
  high
• 11:00
  doses
• 11:00
  of
• 11:00
  Seroquel
• 11:01
  to
• 11:01
  achieve
• 11:02
  that
• 11:02
  antipsychotic
• 11:02
  effect.
• 11:03
  And
• 11:03
  you
• 11:04
  may
• 11:04
  not
• 11:04
  get
• 11:04
  there
• 11:04
  in
• 11:04
  time
• 11:05
  because
• 11:05
  of
• 11:05
  how
• 11:06
  sedating
• 11:06
  it
• 11:06
  is.
• 11:07
  It
• 11:07
  takes
• 11:08
  a
• 11:08
  little
• 11:08
  time
• 11:08
  to
• 11:08
  get
• 11:08
  up
• 11:08
  to
• 11:09
  the
• 11:09
  6
• 11:09
  to
• 11:09
  800
• 11:10
  range
• 11:10
  if
• 11:10
  your
• 11:10
  patient
• 11:11
  can
• 11:11
  tolerate
• 11:11
  it
• 11:11
  at
• 11:12
  all.
• 11:12
  So
• 11:13
  you've
• 11:13
  got
• 11:13
  to
• 11:13
  know
• 11:14
  that,
• 11:14
  because
• 11:15
  if
• 11:15
  you
• 11:15
  prematurely
• 11:16
  discontinue
• 11:17
  Zyprexa,
• 11:18
  you're
• 11:19
  not
• 11:19
  giving
• 11:19
  Seroquel
• 11:20
  enough
• 11:20
  time
• 11:21
  to
• 11:21
  necessarily
• 11:22
  build
• 11:22
  up
• 11:22
  if
• 11:22
  they
• 11:22
  can't
• 11:23
  tolerate
• 11:23
  it.
• 11:23
  And.
• 11:24
  And
• 11:24
  it
• 11:24
  doesn't
• 11:24
  have
• 11:24
  as
• 11:25
  strong
• 11:25
  of
• 11:25
  a
• 11:25
  D2
• 11:26
  binding
• 11:27
  affinity.
• 11:27
  If
• 11:28
  you,
• 11:28
  if
• 11:28
  you
• 11:28
  go
• 11:29
  from
• 11:29
  Zyprexa
• 11:29
  to
• 11:30
  Abilify,
• 11:30
  also
• 11:31
  watch
• 11:31
  out
• 11:31
  a
• 11:32
  little
• 11:32
  bit,
• 11:32
  right?
• 11:32
  Abilify
• 11:33
  kind
• 11:33
  of
• 11:33
  takes
• 11:33
  its
• 11:34
  time
• 11:34
  to
• 11:34
  get
• 11:35
  on
• 11:35
  board
• 11:35
  and
• 11:36
  it
• 11:36
  might
• 11:36
  not
• 11:36
  cover
• 11:37
  your
• 11:37
  patient
• 11:38
  quickly
• 11:38
  enough.
• 11:39
  You
• 11:39
  have
• 11:39
  to
• 11:39
  be
• 11:39
  very
• 11:39
  careful
• 11:40
  with
• 11:40
  that,
• 11:40
  right?
• 11:41
  You
• 11:41
  can't
• 11:41
  just
• 11:42
  like
• 11:42
  get
• 11:42
  rid
• 11:42
  of
• 11:43
  the
• 11:43
  Zyprexa
• 11:44
  that
• 11:44
  quickly.
• 11:45
  You
• 11:45
  might
• 11:45
  get
• 11:45
  some
• 11:45
  rebound
• 11:46
  psychosis
• 11:46
  because
• 11:47
  they're
• 11:47
  very
• 11:47
  sensitive
• 11:48
  from
• 11:48
  being
• 11:49
  blocked
• 11:49
  all
• 11:49
  the
• 11:49
  time,
• 11:50
  that
• 11:50
  when
• 11:50
  you
• 11:50
  finally
• 11:51
  unblock
• 11:51
  them,
• 11:52
  they're
• 11:52
  just
• 11:52
  more
• 11:53
  sensitive
• 11:53
  to
• 11:53
  any
• 11:53
  kind
• 11:54
  of
• 11:54
  dopamine.
• 11:54
  And
• 11:54
  that
• 11:54
  rebound
• 11:55
  psychosis
• 11:55
  can
• 11:56
  be
• 11:56
  a
• 11:56
  very
• 11:56
  big
• 11:57
  deal.
• 11:57
  But
• 11:58
  that's
• 11:58
  not
• 11:58
  the
• 11:58
  only
• 11:58
  receptor
• 11:59
  that
• 12:00
  Zyprexa
• 12:01
  is
• 12:01
  acting
• 12:01
  upon,
• 12:01
  right?
• 12:02
  There's
• 12:02
  H1,
• 12:03
  right?
• 12:03
  The
• 12:04
  anti
• 12:04
  histaminergic
• 12:05
  effect.
• 12:05
  So
• 12:05
  the
• 12:06
  patient
• 12:06
  went
• 12:06
  from
• 12:07
  being
• 12:07
  reliably
• 12:08
  sedated
• 12:08
  and
• 12:09
  now
• 12:09
  they're
• 12:09
  off
• 12:09
  of
• 12:09
  it.
• 12:09
  All
• 12:09
  of
• 12:09
  a
• 12:10
  sudden
• 12:10
  they're
• 12:10
  going
• 12:10
  to
• 12:10
  have
• 12:10
  rebound
• 12:11
  insomnia,
• 12:12
  right?
• 12:12
  That's
• 12:13
  another
• 12:14
  really
• 12:14
  big
• 12:14
  deal.
• 12:15
  If
• 12:15
  you
• 12:15
  have
• 12:15
  a
• 12:15
  antipsychotic
• 12:17
  that
• 12:17
  has
• 12:18
  anticholinergic
• 12:19
  effects,
• 12:20
  right?
• 12:20
  M1
• 12:21
  blockade,
• 12:21
  dry
• 12:21
  mouth
• 12:22
  constipation,
• 12:22
  you
• 12:22
  suddenly
• 12:23
  get
• 12:23
  off
• 12:23
  of
• 12:24
  that
• 12:24
  medication,
• 12:25
  expect
• 12:25
  the
• 12:25
  opposite.
• 12:26
  Expect
• 12:26
  nausea,
• 12:27
  vomiting,
• 12:27
  diaphoresis,
• 12:28
  diarrhea,
• 12:29
  right?
• 12:30
  Stomach
• 12:31
  cramps.
• 12:31
  So
• 12:31
  you're
• 12:32
  gonna
• 12:32
  have
• 12:32
  the
• 12:32
  opposite
• 12:33
  of
• 12:33
  the
• 12:33
  thing
• 12:33
  you
• 12:33
  just
• 12:34
  blocked.
• 12:34
  If
• 12:35
  you
• 12:35
  get
• 12:35
  off
• 12:35
  of
• 12:35
  that
• 12:35
  medication
• 12:36
  too
• 12:36
  quickly,
• 12:37
  and
• 12:37
  especially
• 12:38
  if
• 12:38
  you
• 12:38
  transition
• 12:39
  to
• 12:39
  a
• 12:39
  medication
• 12:39
  that
• 12:40
  doesn't
• 12:40
  share
• 12:40
  that
• 12:40
  same
• 12:41
  receptor
• 12:41
  binding
• 12:42
  profile.
• 12:42
  If
• 12:43
  you
• 12:43
  go
• 12:43
  from
• 12:43
  a
• 12:43
  medication
• 12:44
  that
• 12:44
  has
• 12:45
  Histam
• 12:45
  anti
• 12:45
  histaminergic
• 12:46
  blockade
• 12:47
  and
• 12:48
  the
• 12:48
  M1
• 12:49
  blockade,
• 12:50
  and
• 12:50
  you're
• 12:50
  going
• 12:51
  to
• 12:51
  a
• 12:51
  new
• 12:51
  medication
• 12:51
  that
• 12:52
  doesn't
• 12:52
  really
• 12:52
  share
• 12:53
  that
• 12:53
  as
• 12:53
  much,
• 12:54
  then
• 12:54
  you're
• 12:55
  going
• 12:55
  to
• 12:55
  expect
• 12:55
  a
• 12:56
  really
• 12:56
  big
• 12:56
  difference
• 12:57
  in
• 12:57
  your
• 12:57
  patient's
• 12:58
  presentation.
• 12:58
  Right.
• 12:59
  Case
• 12:59
  in
• 13:00
  point,
• 13:00
  Zyprexa.
• 13:01
  Again,
• 13:02
  H1M1
• 13:03
  blockade.
• 13:03
  You
• 13:04
  go
• 13:04
  to
• 13:04
  Latuda.
• 13:05
  Latuda
• 13:05
  doesn't
• 13:05
  really
• 13:05
  have
• 13:06
  as
• 13:06
  much
• 13:06
  muscarinic
• 13:07
  blockade.
• 13:08
  Right.
• 13:08
  Anticholinergic
• 13:09
  effects.
• 13:10
  So
• 13:10
  you
• 13:10
  go
• 13:10
  from
• 13:10
  Zyprexa
• 13:11
  to
• 13:11
  Latuda
• 13:12
  and
• 13:12
  all
• 13:12
  of
• 13:12
  a
• 13:12
  sudden
• 13:13
  your
• 13:13
  patient's
• 13:13
  not
• 13:13
  sedated
• 13:14
  anymore
• 13:14
  that
• 13:15
  much.
• 13:15
  Right.
• 13:16
  And
• 13:16
  so
• 13:16
  they
• 13:17
  might
• 13:17
  have
• 13:17
  some
• 13:17
  rebound
• 13:18
  insomnia.
• 13:18
  Well,
• 13:18
  you
• 13:18
  need
• 13:18
  to
• 13:19
  make
• 13:19
  a
• 13:19
  plan
• 13:19
  for
• 13:19
  that.
• 13:20
  You
• 13:20
  can't
• 13:20
  just
• 13:20
  cross
• 13:21
  titrate
• 13:21
  and
• 13:21
  go,
• 13:21
  oh,
• 13:21
  I
• 13:22
  hope
• 13:22
  everything's
• 13:22
  going
• 13:22
  to
• 13:22
  be
• 13:22
  okay.
• 13:23
  You've
• 13:23
  got
• 13:24
  to
• 13:24
  factor
• 13:24
  in
• 13:25
  that
• 13:25
  there's
• 13:25
  other
• 13:26
  receptors
• 13:26
  being
• 13:26
  implicated
• 13:27
  here
• 13:27
  that
• 13:27
  are
• 13:27
  no
• 13:27
  longer
• 13:28
  really
• 13:29
  being
• 13:29
  contained
• 13:30
  or
• 13:30
  controlled
• 13:31
  or
• 13:31
  looked
• 13:31
  at
• 13:32
  or
• 13:32
  being
• 13:32
  treated
• 13:32
  with.
• 13:33
  So
• 13:33
  what's
• 13:34
  next?
• 13:34
  You've,
• 13:34
  you
• 13:34
  need
• 13:35
  a
• 13:35
  plan
• 13:35
  for
• 13:36
  how
• 13:36
  you're
• 13:36
  going
• 13:36
  to
• 13:36
  deal
• 13:36
  with
• 13:36
  that
• 13:37
  rebound
• 13:37
  insomnia,
• 13:38
  that
• 13:38
  rebound
• 13:38
  agitation
• 13:39
  once
• 13:39
  the
• 13:40
  histamine
• 13:40
  blockade
• 13:41
  has
• 13:41
  been
• 13:41
  lifted.
• 13:42
  It's
• 13:42
  been
• 13:43
  so
• 13:43
  your
• 13:43
  body's
• 13:43
  been,
• 13:44
  and
• 13:44
  your
• 13:44
  brain
• 13:44
  has
• 13:44
  been
• 13:45
  so
• 13:45
  used
• 13:45
  to
• 13:45
  the
• 13:45
  histamine
• 13:46
  blockade
• 13:46
  on
• 13:46
  Zyprexa
• 13:47
  and
• 13:47
  in
• 13:48
  comes
• 13:48
  Latuda,
• 13:48
  you're
• 13:48
  like,
• 13:49
  wait
• 13:49
  a
• 13:49
  minute,
• 13:49
  where
• 13:49
  is
• 13:49
  all
• 13:49
  this?
• 13:50
  You
• 13:50
  get
• 13:50
  agitated,
• 13:51
  you
• 13:51
  have
• 13:51
  insomnia
• 13:52
  that
• 13:52
  can
• 13:53
  be
• 13:53
  mistaken
• 13:53
  for
• 13:54
  psychosis
• 13:55
  or,
• 13:55
  you
• 13:55
  know,
• 13:55
  it
• 13:55
  just,
• 13:56
  it
• 13:56
  could
• 13:56
  be
• 13:56
  messy.
• 13:56
  Right
• 13:57
  now
• 13:57
  you
• 13:57
  have
• 13:57
  akasthesia
• 13:58
  in
• 13:58
  the
• 13:58
  mix.
• 13:59
  And
• 13:59
  so
• 13:59
  things
• 13:59
  can
• 14:00
  get
• 14:00
  murky
• 14:00
  very
• 14:00
  quickly.
• 14:01
  So
• 14:01
  having
• 14:01
  an
• 14:02
  appreciation
• 14:02
  for
• 14:03
  the
• 14:03
  receptor
• 14:03
  binding
• 14:04
  profiles
• 14:04
  of
• 14:05
  both
• 14:05
  of
• 14:05
  the
• 14:05
  medications
• 14:05
  you
• 14:06
  have
• 14:06
  are
• 14:06
  going
• 14:07
  to
• 14:07
  really
• 14:07
  help
• 14:07
  you
• 14:08
  plan
• 14:08
  in
• 14:08
  advance
• 14:09
  to
• 14:10
  say,
• 14:10
  okay,
• 14:10
  what
• 14:10
  is
• 14:10
  the
• 14:11
  worst
• 14:11
  thing
• 14:11
  that
• 14:11
  can
• 14:11
  happen
• 14:11
  with
• 14:12
  this
• 14:12
  patient
• 14:12
  right
• 14:12
  now
• 14:13
  that
• 14:13
  they
• 14:13
  can
• 14:13
  have
• 14:13
  a
• 14:13
  rebound
• 14:14
  psychosis?
• 14:14
  Right.
• 14:15
  D2,
• 14:15
  I
• 14:15
  would
• 14:15
  say,
• 14:15
  I
• 14:16
  would
• 14:16
  always
• 14:16
  start
• 14:16
  with
• 14:16
  D2.
• 14:17
  And
• 14:17
  we
• 14:18
  did
• 14:18
  start
• 14:18
  with
• 14:18
  D2
• 14:19
  just
• 14:19
  now
• 14:19
  in
• 14:19
  this,
• 14:19
  in
• 14:20
  this
• 14:20
  second
• 14:20
  pearl.
• 14:21
  Right.
• 14:21
  You
• 14:22
  start
• 14:22
  with
• 14:22
  D2
• 14:23
  because
• 14:23
  you
• 14:24
  don't
• 14:24
  want
• 14:24
  that
• 14:24
  rebound
• 14:25
  psychosis.
• 14:25
  That's
• 14:26
  really
• 14:27
  essential.
• 14:27
  Okay.
• 14:28
  And
• 14:28
  so
• 14:29
  make
• 14:29
  sure
• 14:30
  that
• 14:30
  the
• 14:30
  medication
• 14:31
  you
• 14:31
  are
• 14:31
  switching
• 14:32
  to
• 14:33
  has
• 14:33
  the
• 14:33
  level
• 14:34
  of
• 14:34
  D2
• 14:34
  blockade
• 14:35
  needed.
• 14:35
  And
• 14:35
  if
• 14:36
  not,
• 14:36
  you
• 14:36
  have
• 14:36
  to,
• 14:37
  you
• 14:37
  know,
• 14:38
  you,
• 14:38
  you
• 14:38
  have
• 14:38
  to
• 14:39
  cross
• 14:39
  titrate
• 14:40
  accordingly
• 14:41
  to
• 14:41
  make
• 14:41
  sure
• 14:41
  that
• 14:41
  D2
• 14:42
  blockade
• 14:42
  is
• 14:43
  always
• 14:43
  being
• 14:43
  covered
• 14:44
  throughout
• 14:44
  the
• 14:45
  titration.
• 14:45
  Because
• 14:46
  if
• 14:46
  you
• 14:46
  mismatch
• 14:47
  the,
• 14:48
  the
• 14:48
  cross
• 14:48
  titration
• 14:49
  timing,
• 14:49
  you'll
• 14:50
  have
• 14:50
  a
• 14:50
  patient
• 14:50
  who's
• 14:51
  being
• 14:51
  underdosed
• 14:51
  and
• 14:52
  they
• 14:52
  have
• 14:52
  rebound
• 14:52
  psychosis.
• 14:53
  And
• 14:53
  I've
• 14:53
  seen
• 14:53
  this
• 14:53
  in
• 14:53
  practice,
• 14:54
  I've
• 14:54
  seen
• 14:55
  this
• 14:55
  where
• 14:55
  patients
• 14:56
  become
• 14:56
  more
• 14:57
  manic,
• 14:57
  they
• 14:57
  become
• 14:57
  more
• 14:57
  psychotic,
• 14:58
  they
• 14:58
  pace
• 14:59
  in
• 14:59
  the
• 14:59
  wee
• 14:59
  hours
• 14:59
  of
• 15:00
  the
• 15:00
  night,
• 15:00
  they
• 15:00
  become
• 15:00
  more
• 15:01
  agitated,
• 15:01
  potentially
• 15:02
  more
• 15:02
  violent.
• 15:03
  They
• 15:03
  might
• 15:03
  do
• 15:03
  more
• 15:03
  impulsive
• 15:04
  things
• 15:04
  because
• 15:05
  we're
• 15:05
  not
• 15:05
  blocking
• 15:06
  D2
• 15:06
  enough.
• 15:07
  Especially
• 15:07
  if
• 15:07
  you
• 15:08
  go
• 15:08
  from,
• 15:08
  like,
• 15:09
  Risperdal
• 15:10
  to.
• 15:10
  To
• 15:11
  Quetiapine.
• 15:12
  Watch
• 15:12
  out
• 15:13
  if
• 15:13
  you
• 15:13
  make
• 15:13
  that
• 15:13
  switch
• 15:14
  too
• 15:14
  quick.
• 15:14
  Your
• 15:15
  patient's
• 15:15
  kind
• 15:15
  of
• 15:15
  hanging
• 15:16
  out
• 15:16
  without
• 15:16
  a
• 15:17
  D2
• 15:17
  blockade.
• 15:17
  All
• 15:17
  of
• 15:18
  a
• 15:18
  sudden,
• 15:18
  as
• 15:18
  you're
• 15:18
  waiting
• 15:19
  for
• 15:19
  the
• 15:19
  Seroquel
• 15:20
  to.
• 15:20
  To
• 15:20
  climb
• 15:21
  up
• 15:21
  to
• 15:21
  those
• 15:21
  D2
• 15:22
  blockade
• 15:23
  levels,
• 15:23
  well,
• 15:24
  that's
• 15:24
  a
• 15:24
  major
• 15:25
  problem.
• 15:25
  And
• 15:26
  you
• 15:26
  can
• 15:26
  run
• 15:26
  into
• 15:26
  big
• 15:27
  issues.
• 15:27
  So
• 15:27
  know
• 15:28
  your
• 15:28
  receptor
• 15:29
  binding
• 15:29
  profiles
• 15:30
  cold,
• 15:30
  my
• 15:30
  friends.
• 15:30
  And
• 15:31
  the
• 15:31
  more
• 15:31
  you
• 15:31
  do
• 15:31
  that,
• 15:31
  the
• 15:32
  more
• 15:32
  empowered
• 15:32
  you're.
• 15:33
  You're
• 15:33
  going
• 15:33
  to
• 15:33
  be
• 15:33
  to
• 15:34
  expect
• 15:34
  side
• 15:34
  effects
• 15:35
  and
• 15:35
  to
• 15:35
  do
• 15:35
  clean
• 15:36
  cross
• 15:36
  titrations.
• 15:37
  Also
• 15:37
  follow
• 15:38
  cross
• 15:38
  titration
• 15:39
  guides.
• 15:39
  Those
• 15:39
  are
• 15:40
  very
• 15:40
  helpful.
• 15:41
  Now,
• 15:41
  the
• 15:41
  third
• 15:41
  pearl
• 15:42
  is
• 15:42
  to
• 15:42
  compare
• 15:42
  the
• 15:42
  half
• 15:43
  lives
• 15:43
  of
• 15:43
  your
• 15:43
  medications.
• 15:44
  Half
• 15:45
  lives
• 15:45
  matter.
• 15:46
  They
• 15:46
  absolutely
• 15:47
  matter.
• 15:48
  Because
• 15:49
  what
• 15:50
  you
• 15:50
  do
• 15:50
  here
• 15:51
  is
• 15:51
  a
• 15:52
  good
• 15:52
  example,
• 15:52
  is
• 15:52
  like
• 15:52
  Zyprexa
• 15:53
  and
• 15:53
  abilify,
• 15:54
  right?
• 15:54
  Zyprexa,
• 15:56
  30
• 15:56
  hours,
• 15:57
  half
• 15:57
  life,
• 15:58
  abilify
• 15:58
  about
• 15:59
  75
• 15:59
  hours.
• 16:00
  Okay?
• 16:01
  So
• 16:02
  you
• 16:02
  want
• 16:03
  to
• 16:03
  watch
• 16:03
  that.
• 16:03
  Because
• 16:04
  Abilify
• 16:05
  has
• 16:05
  a
• 16:05
  much
• 16:05
  higher
• 16:05
  half
• 16:06
  life.
• 16:06
  It's
• 16:06
  going
• 16:06
  to
• 16:06
  take
• 16:07
  longer
• 16:07
  to
• 16:07
  get
• 16:07
  on
• 16:07
  the
• 16:07
  bus.
• 16:08
  Abilify
• 16:08
  takes
• 16:09
  longer
• 16:09
  to
• 16:09
  get
• 16:10
  on
• 16:10
  the
• 16:10
  bus
• 16:10
  and
• 16:11
  to
• 16:11
  fill
• 16:11
  up
• 16:11
  the
• 16:12
  seats.
• 16:12
  So
• 16:13
  again,
• 16:13
  you
• 16:13
  don't
• 16:13
  want
• 16:13
  to,
• 16:13
  like,
• 16:14
  do
• 16:14
  this
• 16:14
  direct
• 16:14
  switch.
• 16:15
  I
• 16:15
  probably
• 16:15
  wouldn't
• 16:16
  do
• 16:16
  a
• 16:16
  direct
• 16:16
  switch
• 16:17
  overnight
• 16:17
  because
• 16:18
  Zyprexa
• 16:19
  levels
• 16:19
  are
• 16:19
  going
• 16:20
  to
• 16:20
  fall,
• 16:20
  and
• 16:20
  Abilify
• 16:21
  is
• 16:21
  going
• 16:21
  to
• 16:21
  take
• 16:21
  its
• 16:21
  sweet
• 16:22
  time
• 16:22
  to
• 16:23
  really
• 16:23
  occupy
• 16:24
  enough
• 16:24
  of
• 16:25
  the
• 16:25
  T2
• 16:25
  receptors
• 16:26
  to
• 16:27
  give
• 16:27
  you
• 16:27
  an
• 16:27
  antipsychotic
• 16:28
  effect.
• 16:29
  You
• 16:29
  also
• 16:29
  have
• 16:29
  to
• 16:30
  be
• 16:30
  careful
• 16:30
  not
• 16:30
  to
• 16:31
  confuse
• 16:31
  you,
• 16:31
  but
• 16:32
  you
• 16:32
  have
• 16:32
  to
• 16:32
  be
• 16:33
  careful
• 16:34
  because
• 16:34
  Abilify
• 16:35
  is
• 16:35
  also
• 16:36
  a
• 16:36
  partial
• 16:36
  agonist,
• 16:37
  right?
• 16:37
  We've
• 16:38
  talked
• 16:38
  about
• 16:38
  that
• 16:39
  extensively.
• 16:40
  So
• 16:40
  when
• 16:40
  you
• 16:40
  have
• 16:40
  this
• 16:40
  heavy
• 16:41
  D2
• 16:41
  blocker
• 16:42
  like
• 16:42
  Zyprexa,
• 16:43
  it's
• 16:43
  blocking
• 16:43
  those
• 16:43
  D2
• 16:44
  receptors
• 16:44
  really
• 16:45
  tightly
• 16:45
  and
• 16:46
  robustly.
• 16:46
  And
• 16:47
  you
• 16:47
  introduce
• 16:47
  something
• 16:47
  like
• 16:47
  Abilify.
• 16:48
  If
• 16:48
  you
• 16:48
  introduce
• 16:49
  it
• 16:49
  too
• 16:49
  quickly,
• 16:50
  also
• 16:50
  you
• 16:51
  run
• 16:51
  into
• 16:51
  problems,
• 16:52
  because
• 16:52
  Abilify
• 16:53
  is
• 16:53
  like
• 16:53
  that
• 16:53
  magic
• 16:54
  dial,
• 16:54
  right?
• 16:55
  It's
• 16:55
  going
• 16:55
  to
• 16:55
  put
• 16:55
  dopamine
• 16:56
  into
• 16:56
  sort
• 16:57
  of
• 16:57
  a
• 16:57
  sweet
• 16:57
  spot.
• 16:58
  So
• 16:58
  it's
• 16:58
  going
• 16:58
  to
• 16:58
  lower
• 16:59
  the
• 16:59
  D2
• 16:59
  blockade
• 17:00
  pretty
• 17:01
  quickly
• 17:01
  because
• 17:02
  Zyprexa
• 17:02
  has
• 17:03
  been
• 17:04
  blocking
• 17:04
  it
• 17:04
  so
• 17:05
  fiercely.
• 17:05
  And
• 17:06
  Abilify
• 17:06
  is
• 17:07
  going
• 17:07
  to
• 17:07
  turn
• 17:07
  that
• 17:07
  dial.
• 17:08
  If
• 17:08
  you
• 17:08
  raise
• 17:08
  it
• 17:08
  too
• 17:09
  fast,
• 17:09
  too
• 17:09
  high,
• 17:10
  too
• 17:10
  fast,
• 17:10
  it's
• 17:11
  going
• 17:11
  to
• 17:11
  turn
• 17:11
  that
• 17:11
  dial
• 17:12
  and
• 17:12
  you
• 17:12
  might
• 17:13
  have
• 17:13
  some
• 17:13
  rebound
• 17:13
  psychosis
• 17:14
  too
• 17:14
  quickly,
• 17:15
  right?
• 17:15
  So
• 17:15
  you
• 17:15
  don't
• 17:15
  want
• 17:15
  to
• 17:16
  do
• 17:16
  that.
• 17:16
  You
• 17:16
  got
• 17:16
  to
• 17:16
  be
• 17:16
  very
• 17:17
  mindful
• 17:17
  of
• 17:17
  the
• 17:17
  mechanics
• 17:18
  that
• 17:18
  Zyprexa
• 17:19
  is
• 17:19
  a
• 17:19
  very
• 17:19
  potent
• 17:20
  D2
• 17:20
  blocker.
• 17:21
  And
• 17:21
  now
• 17:21
  you're
• 17:21
  adding
• 17:21
  a
• 17:22
  partial
• 17:22
  agonist.
• 17:23
  That's
• 17:23
  a
• 17:23
  bit
• 17:23
  of
• 17:24
  a
• 17:24
  problem,
• 17:24
  right?
• 17:24
  That's.
• 17:25
  That's
• 17:26
  an
• 17:26
  issue.
• 17:26
  It's
• 17:26
  the
• 17:27
  same
• 17:27
  principle
• 17:27
  with
• 17:28
  partial
• 17:28
  agonism
• 17:28
  with
• 17:29
  buprenorphine
• 17:29
  in
• 17:30
  the
• 17:30
  opioid
• 17:30
  use
• 17:31
  arena,
• 17:32
  where
• 17:33
  if
• 17:33
  you
• 17:34
  add
• 17:35
  a,
• 17:36
  like
• 17:36
  naltrexone,
• 17:37
  it's.
• 17:38
  It's
• 17:38
  a
• 17:38
  little
• 17:38
  bit
• 17:38
  different,
• 17:39
  but
• 17:39
  you
• 17:39
  add
• 17:39
  naltrexone
• 17:40
  too
• 17:41
  quickly
• 17:41
  and
• 17:42
  you
• 17:42
  can
• 17:42
  completely
• 17:43
  antagonize
• 17:44
  the
• 17:44
  opioid
• 17:45
  receptor
• 17:45
  and
• 17:45
  put
• 17:46
  somebody
• 17:46
  into
• 17:46
  a
• 17:46
  precipitous
• 17:47
  withdrawal.
• 17:48
  So
• 17:48
  you
• 17:48
  have
• 17:48
  to
• 17:48
  be
• 17:49
  very
• 17:49
  mindful
• 17:50
  over
• 17:50
  about
• 17:51
  which
• 17:51
  medications
• 17:52
  are
• 17:52
  partial
• 17:52
  agonists,
• 17:53
  how
• 17:53
  do
• 17:53
  those
• 17:54
  behave,
• 17:54
  you
• 17:55
  know,
• 17:55
  which
• 17:55
  ones
• 17:55
  are
• 17:55
  antagonists,
• 17:56
  how
• 17:57
  do
• 17:57
  those
• 17:57
  behave?
• 17:58
  And
• 17:59
  same
• 17:59
  thing
• 17:59
  goes
• 18:00
  for
• 18:00
  Abilify.
• 18:01
  Okay?
• 18:01
  So
• 18:01
  look
• 18:01
  at
• 18:02
  the
• 18:02
  half
• 18:02
  life
• 18:02
  of
• 18:02
  half
• 18:03
  lives
• 18:03
  of
• 18:03
  your
• 18:03
  medication.
• 18:04
  Same
• 18:04
  thing
• 18:04
  goes
• 18:04
  with
• 18:04
  SSRIs,
• 18:05
  right?
• 18:06
  If
• 18:06
  you're
• 18:06
  switching
• 18:07
  from
• 18:07
  Effexor
• 18:09
  to
• 18:09
  Prozac,
• 18:10
  watch
• 18:10
  out,
• 18:11
  because
• 18:11
  Effexor
• 18:12
  is
• 18:12
  going
• 18:12
  to
• 18:12
  get
• 18:13
  out
• 18:13
  of
• 18:13
  the
• 18:13
  system
• 18:13
  very
• 18:13
  quickly
• 18:14
  and
• 18:14
  leave
• 18:14
  you
• 18:15
  kind
• 18:15
  of
• 18:16
  cold
• 18:16
  and
• 18:16
  naked
• 18:16
  and
• 18:16
  afraid,
• 18:17
  and
• 18:18
  you're
• 18:19
  going
• 18:19
  to
• 18:19
  be
• 18:19
  waiting
• 18:19
  for
• 18:19
  Prozac
• 18:20
  to
• 18:20
  reach
• 18:20
  a
• 18:20
  steady
• 18:21
  state
• 18:21
  for
• 18:21
  a
• 18:21
  pretty
• 18:22
  long
• 18:22
  time.
• 18:22
  They
• 18:23
  don't
• 18:23
  want
• 18:23
  to
• 18:23
  really
• 18:23
  stop
• 18:24
  Effexor
• 18:24
  that
• 18:25
  quickly.
• 18:25
  You
• 18:25
  want
• 18:26
  the
• 18:26
  Prozac
• 18:26
  to
• 18:26
  be
• 18:27
  able
• 18:27
  to
• 18:27
  accumulate
• 18:28
  and
• 18:28
  reach
• 18:28
  steady
• 18:29
  state
• 18:29
  and
• 18:30
  not
• 18:30
  strip
• 18:30
  that
• 18:31
  patient
• 18:31
  down
• 18:31
  with
• 18:32
  the
• 18:32
  Effexor
• 18:32
  too
• 18:32
  quickly,
• 18:33
  especially
• 18:33
  with
• 18:34
  all
• 18:34
  of
• 18:34
  the
• 18:35
  potential
• 18:35
  side
• 18:35
  effects
• 18:36
  and
• 18:36
  the
• 18:36
  withdrawal
• 18:37
  effects
• 18:37
  that
• 18:37
  Effexor
• 18:38
  is
• 18:38
  known
• 18:38
  for.
• 18:39
  So
• 18:39
  know
• 18:39
  your
• 18:39
  half
• 18:39
  lives,
• 18:40
  my
• 18:40
  friend.
• 18:40
  Know
• 18:41
  your
• 18:41
  receptor
• 18:41
  affinities.
• 18:42
  Know
• 18:42
  your
• 18:43
  half
• 18:43
  lives.
• 18:43
  Very
• 18:44
  important,
• 18:44
  okay?
• 18:45
  You
• 18:46
  want
• 18:46
  them
• 18:46
  to
• 18:46
  kind
• 18:46
  of
• 18:46
  match
• 18:47
  and
• 18:47
  consult
• 18:48
  your
• 18:48
  drug
• 18:48
  guides
• 18:49
  when
• 18:49
  they
• 18:49
  don't
• 18:49
  match
• 18:49
  about
• 18:50
  how
• 18:50
  you
• 18:50
  do
• 18:50
  this.
• 18:51
  There's
• 18:51
  always
• 18:51
  a
• 18:51
  way
• 18:52
  forward.
• 18:52
  You
• 18:52
  can
• 18:53
  absolutely
• 18:54
  knock
• 18:54
  it
• 18:54
  out
• 18:54
  of
• 18:54
  the
• 18:55
  park
• 18:55
  if
• 18:55
  you
• 18:55
  just,
• 18:56
  you
• 18:56
  know,
• 18:57
  look
• 18:57
  at
• 18:57
  your
• 18:57
  half
• 18:58
  lives
• 18:58
  and
• 18:58
  the
• 18:58
  cross
• 18:59
  titration
• 19:00
  guidance.
• 19:00
  Okay?
• 19:00
  Pro
• 19:01
  4
• 19:01
  was
• 19:02
  the
• 19:02
  watch
• 19:02
  out
• 19:03
  for
• 19:03
  a
• 19:03
  dopamine
• 19:03
  partial
• 19:04
  agonist
• 19:04
  switch.
• 19:05
  Right?
• 19:05
  We
• 19:05
  just
• 19:05
  kind
• 19:05
  of
• 19:05
  talked
• 19:06
  about
• 19:06
  this.
• 19:07
  I
• 19:07
  would
• 19:07
  just
• 19:07
  add
• 19:08
  that
• 19:08
  Abilify,
• 19:09
  Brexpriprazole,
• 19:10
  and
• 19:10
  Vraylar
• 19:11
  are
• 19:11
  all
• 19:11
  partial
• 19:12
  D2
• 19:12
  agonists,
• 19:13
  right?
• 19:13
  So
• 19:13
  they
• 19:14
  bind
• 19:14
  to
• 19:14
  D2
• 19:15
  receptors
• 19:15
  tightly,
• 19:16
  but
• 19:16
  they
• 19:16
  only
• 19:17
  partially
• 19:17
  activate
• 19:18
  them.
• 19:18
  Right.
• 19:19
  And
• 19:19
  so
• 19:20
  that's
• 19:20
  again,
• 19:20
  why
• 19:21
  you
• 19:21
  have
• 19:21
  to
• 19:21
  be
• 19:21
  a
• 19:21
  little
• 19:22
  bit
• 19:22
  careful,
• 19:23
  because
• 19:23
  Zyprexa
• 19:24
  is
• 19:24
  a
• 19:24
  potent
• 19:25
  D2
• 19:25
  antagonist.
• 19:26
  So
• 19:26
  when
• 19:27
  you
• 19:27
  add
• 19:27
  abilify,
• 19:29
  it
• 19:29
  competes
• 19:29
  for
• 19:30
  D2
• 19:30
  receptors,
• 19:31
  okay?
• 19:32
  And
• 19:32
  it's
• 19:32
  going
• 19:32
  to
• 19:32
  increase
• 19:33
  the
• 19:33
  dopaminergic
• 19:34
  tone.
• 19:34
  But
• 19:34
  if
• 19:34
  you're.
• 19:35
  If
• 19:35
  your
• 19:36
  mind
• 19:36
  and
• 19:36
  body
• 19:36
  has
• 19:36
  been
• 19:37
  so
• 19:37
  used
• 19:37
  to
• 19:37
  that,
• 19:37
  dopamine
• 19:38
  being
• 19:38
  blocked.
• 19:39
  And
• 19:39
  now
• 19:39
  all
• 19:40
  of
• 19:40
  a
• 19:40
  sudden
• 19:40
  Abilify
• 19:41
  kind
• 19:41
  of
• 19:41
  comes
• 19:41
  in
• 19:41
  there
• 19:41
  and
• 19:41
  starts
• 19:42
  increasing
• 19:42
  the
• 19:42
  dopaminergic
• 19:43
  tone.
• 19:44
  You
• 19:44
  might
• 19:45
  have
• 19:45
  this
• 19:45
  super
• 19:45
  sensitivity,
• 19:46
  this
• 19:46
  worsening
• 19:47
  of
• 19:47
  psychosis,
• 19:48
  agitation,
• 19:49
  insomnia.
• 19:50
  And
• 19:50
  just
• 19:50
  like
• 19:51
  we
• 19:51
  talked
• 19:51
  about
• 19:51
  the
• 19:51
  receptor
• 19:52
  affinity
• 19:52
  from
• 19:52
  before,
• 19:53
  right.
• 19:53
  If
• 19:53
  you're
• 19:54
  going
• 19:54
  from
• 19:54
  Zyprexa
• 19:55
  to
• 19:55
  Abilify,
• 19:56
  you're
• 19:56
  going
• 19:57
  from
• 19:57
  a
• 19:57
  strong
• 19:57
  H1
• 19:58
  and
• 19:58
  M1
• 19:58
  blockade
• 19:59
  with
• 19:59
  Zyprexa.
• 20:00
  And
• 20:00
  Abilify
• 20:01
  kind
• 20:01
  of
• 20:01
  lacks
• 20:01
  that.
• 20:02
  So
• 20:03
  the
• 20:03
  first
• 20:03
  thing
• 20:03
  you
• 20:04
  should
• 20:04
  think
• 20:04
  about
• 20:04
  is,
• 20:04
  wait
• 20:04
  a
• 20:04
  minute,
• 20:05
  I'm
• 20:05
  going
• 20:05
  from
• 20:05
  a
• 20:05
  medication
• 20:06
  that's
• 20:06
  really
• 20:06
  blocking
• 20:07
  H1
• 20:07
  and
• 20:07
  M1
• 20:08
  and
• 20:08
  this
• 20:09
  new
• 20:09
  one
• 20:09
  doesn't.
• 20:10
  So
• 20:10
  what
• 20:10
  am
• 20:10
  I
• 20:11
  going
• 20:11
  to
• 20:11
  expect?
• 20:12
  You're
• 20:13
  going
• 20:13
  to
• 20:13
  expect
• 20:13
  some
• 20:13
  rebound
• 20:14
  cholinergic
• 20:15
  and
• 20:15
  histaminergic
• 20:16
  rebound.
• 20:17
  You're
• 20:17
  going
• 20:17
  to
• 20:17
  have
• 20:18
  the
• 20:18
  wetness,
• 20:18
  right.
• 20:19
  When
• 20:19
  you
• 20:19
  the
• 20:20
  cholinergic
• 20:21
  side
• 20:21
  effects
• 20:22
  as
• 20:22
  opposed
• 20:22
  to
• 20:22
  anticholinergic
• 20:23
  side
• 20:23
  effects.
• 20:24
  Cholinergic
• 20:24
  side
• 20:25
  effects
• 20:25
  are
• 20:25
  the
• 20:26
  nausea,
• 20:26
  diarrhea,
• 20:27
  vomiting.
• 20:28
  Right.
• 20:29
  Stomach
• 20:29
  cramps.
• 20:30
  Okay?
• 20:30
  That's
• 20:30
  what
• 20:30
  you're
• 20:30
  going
• 20:31
  to
• 20:31
  expect
• 20:31
  because
• 20:32
  you
• 20:32
  had
• 20:32
  the
• 20:33
  opposite
• 20:33
  of
• 20:33
  that
• 20:33
  for
• 20:34
  so
• 20:34
  long
• 20:34
  with
• 20:34
  Zyprexa,
• 20:35
  and
• 20:35
  now
• 20:35
  you're
• 20:35
  switching
• 20:36
  Zyprexa
• 20:36
  to
• 20:37
  a
• 20:37
  medication
• 20:37
  where
• 20:38
  that's
• 20:38
  not
• 20:39
  a
• 20:39
  big
• 20:40
  drug
• 20:40
  affinity.
• 20:40
  Right.
• 20:40
  Abilify
• 20:41
  does
• 20:41
  not
• 20:41
  have
• 20:42
  a
• 20:42
  big
• 20:42
  affinity
• 20:42
  for
• 20:43
  M1
• 20:43
  or
• 20:43
  H1
• 20:44
  blockade.
• 20:45
  Right.
• 20:45
  Zyprexa
• 20:46
  was
• 20:46
  so
• 20:46
  good
• 20:47
  at
• 20:48
  sedating
• 20:48
  somebody
• 20:49
  with
• 20:49
  that
• 20:50
  H1
• 20:50
  blockade.
• 20:51
  Well,
• 20:51
  we're
• 20:51
  moving
• 20:52
  to
• 20:52
  Abilify
• 20:52
  and
• 20:53
  it's
• 20:53
  not
• 20:53
  all
• 20:53
  about
• 20:53
  that
• 20:53
  H1
• 20:54
  blockade.
• 20:55
  So
• 20:55
  the
• 20:55
  patient
• 20:56
  is
• 20:56
  going
• 20:56
  to
• 20:57
  may
• 20:57
  very
• 20:57
  well
• 20:57
  have
• 20:57
  rebound
• 20:58
  insomnia.
• 20:59
  And
• 20:59
  you've
• 20:59
  got
• 20:59
  to
• 21:00
  educate
• 21:00
  them
• 21:00
  about
• 21:00
  that
• 21:00
  and
• 21:01
  you've
• 21:01
  got
• 21:01
  to
• 21:01
  have
• 21:01
  a
• 21:01
  plan
• 21:01
  for
• 21:02
  that
• 21:02
  because
• 21:02
  guess
• 21:02
  what?
• 21:03
  If
• 21:03
  you
• 21:03
  don't
• 21:03
  give
• 21:04
  them
• 21:04
  that
• 21:04
  anticipatory
• 21:05
  guidance,
• 21:05
  they
• 21:05
  might
• 21:06
  go,
• 21:06
  oh,
• 21:06
  my
• 21:06
  God,
• 21:06
  this
• 21:06
  abilifies
• 21:07
  terrible.
• 21:07
  I
• 21:08
  can't
• 21:08
  get
• 21:08
  out
• 21:08
  of,
• 21:08
  out
• 21:09
  off
• 21:09
  of
• 21:09
  this
• 21:09
  med
• 21:09
  quickly
• 21:10
  enough.
• 21:10
  And
• 21:11
  really
• 21:11
  what
• 21:11
  they're
• 21:11
  describing
• 21:12
  is
• 21:12
  this
• 21:13
  mismatch
• 21:14
  between
• 21:14
  receptor
• 21:15
  affinities
• 21:15
  of
• 21:15
  your
• 21:15
  first
• 21:15
  and
• 21:16
  second
• 21:16
  drug.
• 21:16
  It's
• 21:16
  not
• 21:17
  really
• 21:17
  an
• 21:17
  indictment
• 21:17
  on
• 21:18
  Abilify.
• 21:18
  It's
• 21:19
  just
• 21:19
  this
• 21:19
  kind
• 21:20
  of
• 21:20
  nasty
• 21:20
  withdrawal
• 21:21
  period
• 21:21
  that
• 21:21
  we
• 21:21
  didn't
• 21:21
  prepare
• 21:22
  for
• 21:23
  to
• 21:23
  help
• 21:23
  mitigate
• 21:23
  those
• 21:23
  side
• 21:24
  effects.
• 21:24
  So
• 21:24
  again,
• 21:25
  if
• 21:25
  you're
• 21:25
  going
• 21:26
  from
• 21:26
  a
• 21:26
  potent
• 21:26
  H1
• 21:27
  blockader
• 21:28
  to
• 21:28
  a
• 21:29
  non
• 21:29
  potent
• 21:29
  H1
• 21:30
  blockader,
• 21:31
  I
• 21:31
  would
• 21:31
  definitely
• 21:32
  look
• 21:33
  at
• 21:33
  an
• 21:33
  insomnia
• 21:34
  strategy.
• 21:35
  How
• 21:35
  can
• 21:35
  we
• 21:35
  contain
• 21:36
  this
• 21:36
  person's
• 21:36
  insomnia
• 21:37
  agitation?
• 21:38
  Maybe
• 21:38
  think
• 21:38
  about
• 21:38
  Trazodone
• 21:39
  or
• 21:39
  Remeron
• 21:40
  or
• 21:40
  something
• 21:41
  of
• 21:41
  that
• 21:41
  nature,
• 21:41
  depending
• 21:42
  on
• 21:42
  your
• 21:42
  patient,
• 21:42
  okay?
• 21:43
  So
• 21:43
  just
• 21:43
  be
• 21:43
  very
• 21:44
  careful
• 21:44
  about
• 21:44
  that.
• 21:45
  It's
• 21:45
  Very,
• 21:46
  very
• 21:46
  important.
• 21:47
  Okay.
• 21:49
  Now,
• 21:49
  a
• 21:49
  pearl
• 21:50
  number
• 21:50
  five
• 21:50
  would
• 21:50
  be
• 21:50
  just
• 21:51
  to
• 21:51
  choose
• 21:51
  a
• 21:51
  switching
• 21:52
  strategy.
• 21:52
  I
• 21:53
  can't
• 21:53
  say
• 21:53
  that
• 21:53
  I
• 21:53
  have
• 21:54
  one.
• 21:54
  That
• 21:54
  is
• 21:54
  always
• 21:55
  a
• 21:56
  gold
• 21:56
  standard
• 21:56
  because
• 21:57
  every
• 21:57
  patient's
• 21:57
  a
• 21:57
  little
• 21:57
  different.
• 21:58
  Every
• 21:58
  situation
• 21:58
  is
• 21:59
  a
• 21:59
  little
• 21:59
  different.
• 21:59
  I
• 22:00
  think
• 22:00
  the
• 22:00
  cross
• 22:00
  titration
• 22:01
  we've
• 22:01
  already
• 22:01
  talked
• 22:02
  about
• 22:03
  is
• 22:04
  usually
• 22:04
  the
• 22:05
  most
• 22:05
  common
• 22:05
  way
• 22:05
  we
• 22:06
  do
• 22:06
  things
• 22:06
  with
• 22:08
  second
• 22:08
  generation
• 22:08
  antipsychotics.
• 22:09
  I
• 22:09
  do
• 22:10
  more
• 22:10
  of
• 22:10
  a
• 22:10
  abrupt
• 22:11
  switch
• 22:11
  with
• 22:11
  SSRIs.
• 22:12
  Not
• 22:12
  all
• 22:13
  of
• 22:13
  the
• 22:13
  time,
• 22:13
  but
• 22:13
  a
• 22:13
  lot
• 22:13
  of
• 22:14
  times
• 22:14
  I'll
• 22:14
  do
• 22:14
  an
• 22:14
  abrupt
• 22:14
  switch
• 22:15
  with
• 22:15
  ssri,
• 22:15
  especially
• 22:16
  if
• 22:16
  it's
• 22:16
  early
• 22:16
  in
• 22:16
  the
• 22:16
  game,
• 22:17
  the
• 22:17
  patient's
• 22:18
  not
• 22:18
  at
• 22:18
  high
• 22:18
  doses.
• 22:19
  The
• 22:19
  two
• 22:19
  meds
• 22:20
  are
• 22:20
  roughly
• 22:20
  comparable
• 22:21
  in
• 22:21
  half
• 22:21
  lives.
• 22:22
  I'll
• 22:22
  do
• 22:22
  more
• 22:22
  of
• 22:22
  an
• 22:22
  abrupt
• 22:23
  switch
• 22:23
  with
• 22:24
  SSRIs,
• 22:25
  but
• 22:26
  I
• 22:26
  do
• 22:26
  more
• 22:26
  cross
• 22:27
  titration,
• 22:27
  typically
• 22:28
  with
• 22:28
  antipsychotics.
• 22:29
  Again,
• 22:29
  because
• 22:30
  you
• 22:30
  have
• 22:30
  to
• 22:30
  be
• 22:30
  mindful
• 22:31
  of
• 22:31
  the
• 22:31
  different
• 22:31
  half
• 22:31
  lives,
• 22:32
  the
• 22:32
  different
• 22:32
  receptor
• 22:32
  profiles.
• 22:33
  But
• 22:33
  there
• 22:33
  are
• 22:33
  times
• 22:34
  when
• 22:34
  you're
• 22:34
  going
• 22:34
  to
• 22:34
  have
• 22:34
  to
• 22:35
  do
• 22:35
  a
• 22:35
  very
• 22:36
  abrupt
• 22:37
  switch.
• 22:37
  You
• 22:37
  know,
• 22:37
  if
• 22:37
  you
• 22:38
  have
• 22:38
  like
• 22:38
  a
• 22:38
  granulocytosis
• 22:39
  or
• 22:39
  neuroleptic
• 22:40
  malignant
• 22:40
  syndrome
• 22:41
  that
• 22:41
  nms,
• 22:42
  you
• 22:42
  don't
• 22:42
  have
• 22:42
  the
• 22:42
  luxury
• 22:43
  of
• 22:43
  just
• 22:43
  waiting
• 22:43
  forever.
• 22:44
  And
• 22:44
  you
• 22:44
  may
• 22:44
  have
• 22:44
  to
• 22:45
  do
• 22:45
  an
• 22:45
  abrupt
• 22:46
  switch.
• 22:46
  You
• 22:46
  might
• 22:46
  have
• 22:47
  to
• 22:47
  stop
• 22:47
  the
• 22:47
  old
• 22:47
  one,
• 22:47
  start
• 22:48
  the
• 22:48
  new
• 22:48
  one.
• 22:49
  And
• 22:49
  there's
• 22:50
  a
• 22:50
  much
• 22:50
  higher
• 22:50
  risk
• 22:51
  of
• 22:51
  withdrawal
• 22:51
  and
• 22:51
  rebound
• 22:52
  problems.
• 22:52
  Rebound
• 22:53
  psychosis,
• 22:54
  you
• 22:54
  know,
• 22:54
  anticholinergic
• 22:55
  rebound,
• 22:55
  anti
• 22:55
  histaminergic
• 22:56
  rebound.
• 22:56
  Right.
• 22:57
  Insomnia,
• 22:57
  agitation,
• 22:58
  nausea,
• 22:59
  drooling.
• 23:00
  Sure.
• 23:01
  But
• 23:02
  you
• 23:02
  may
• 23:02
  not
• 23:02
  have
• 23:02
  the
• 23:02
  luxury
• 23:03
  of
• 23:03
  just
• 23:03
  waiting
• 23:03
  for
• 23:03
  several
• 23:04
  weeks
• 23:04
  if
• 23:04
  you're
• 23:04
  in
• 23:05
  more
• 23:05
  of
• 23:05
  an
• 23:05
  emergency.
• 23:06
  Okay.
• 23:07
  So
• 23:07
  I
• 23:07
  would
• 23:08
  just
• 23:08
  say
• 23:08
  those
• 23:09
  are
• 23:09
  the
• 23:10
  two
• 23:10
  common
• 23:11
  strategies,
• 23:12
  the
• 23:12
  abrupt
• 23:12
  switch
• 23:12
  or
• 23:12
  the
• 23:13
  cross
• 23:13
  titration
• 23:13
  that
• 23:13
  you
• 23:14
  can
• 23:14
  keep
• 23:14
  in
• 23:14
  mind.
• 23:14
  And
• 23:15
  I
• 23:15
  don't
• 23:15
  think
• 23:16
  you're
• 23:16
  gonna
• 23:16
  be
• 23:16
  pinned
• 23:16
  down
• 23:17
  on
• 23:17
  one
• 23:17
  of
• 23:17
  them
• 23:17
  your
• 23:17
  whole
• 23:18
  career.
• 23:18
  You're
• 23:18
  gonna
• 23:18
  find
• 23:18
  that
• 23:19
  different
• 23:19
  situations
• 23:20
  challenge
• 23:21
  you
• 23:21
  at
• 23:22
  different
• 23:22
  times.
• 23:22
  Okay.
• 23:23
  And
• 23:23
  that's
• 23:24
  just
• 23:24
  something
• 23:24
  I
• 23:24
  would
• 23:24
  look
• 23:24
  at
• 23:26
  now,
• 23:26
  the
• 23:26
  sixth
• 23:27
  pearl,
• 23:28
  we
• 23:28
  touched
• 23:29
  on
• 23:29
  it
• 23:29
  a
• 23:29
  little
• 23:29
  bit
• 23:29
  already,
• 23:30
  but
• 23:30
  it's
• 23:30
  worth
• 23:30
  emphasizing
• 23:31
  again
• 23:31
  is
• 23:32
  anticipate
• 23:32
  and
• 23:33
  manage
• 23:33
  your
• 23:33
  side
• 23:33
  effect
• 23:34
  transitions.
• 23:34
  Remember
• 23:35
  too,
• 23:35
  when
• 23:35
  you
• 23:35
  go
• 23:35
  from
• 23:36
  something
• 23:36
  like
• 23:36
  Zyprexa
• 23:37
  to
• 23:37
  Latuda,
• 23:38
  you're
• 23:38
  going
• 23:39
  from
• 23:39
  a
• 23:39
  heavy
• 23:39
  weight
• 23:39
  gainer
• 23:40
  to
• 23:40
  one
• 23:40
  that
• 23:40
  is
• 23:40
  a
• 23:40
  little
• 23:41
  more
• 23:41
  metabolically
• 23:41
  friendly.
• 23:42
  Okay?
• 23:43
  So
• 23:43
  anticipate
• 23:44
  that
• 23:44
  your
• 23:44
  patient
• 23:45
  may
• 23:45
  not
• 23:45
  lose
• 23:46
  that
• 23:46
  weight
• 23:46
  that
• 23:46
  quickly.
• 23:47
  They
• 23:47
  will
• 23:48
  not
• 23:48
  gain
• 23:48
  weight
• 23:48
  as
• 23:49
  aggressively
• 23:49
  as
• 23:49
  they
• 23:50
  did
• 23:50
  on
• 23:50
  Zyprexa,
• 23:50
  and
• 23:50
  they
• 23:51
  may
• 23:51
  start
• 23:51
  to
• 23:51
  lose
• 23:51
  weight
• 23:52
  and
• 23:52
  their
• 23:52
  lipid
• 23:53
  profile
• 23:53
  might
• 23:53
  start
• 23:54
  to
• 23:54
  improve.
• 23:54
  But
• 23:55
  that
• 23:55
  also
• 23:55
  might
• 23:55
  take
• 23:56
  some
• 23:56
  time.
• 23:56
  So
• 23:56
  provide
• 23:57
  some
• 23:57
  education
• 23:57
  that
• 23:58
  they're
• 23:58
  not
• 23:58
  gonna
• 23:58
  Just
• 23:59
  like
• 23:59
  melt
• 23:59
  all
• 24:00
  the
• 24:00
  weight
• 24:00
  off
• 24:00
  right
• 24:00
  away.
• 24:01
  Weight
• 24:01
  loss
• 24:01
  is
• 24:01
  usually
• 24:02
  slower
• 24:02
  than
• 24:02
  weight
• 24:03
  gain
• 24:03
  and
• 24:03
  the
• 24:03
  weight
• 24:04
  gain
• 24:04
  is
• 24:04
  pretty
• 24:04
  rapid
• 24:05
  on
• 24:05
  the
• 24:05
  Zyprexa.
• 24:06
  Okay,
• 24:06
  so
• 24:07
  educate
• 24:07
  them
• 24:08
  about
• 24:08
  that
• 24:08
  as
• 24:09
  well.
• 24:09
  Okay.
• 24:10
  Educate
• 24:11
  them
• 24:11
  about
• 24:11
  EPS
• 24:12
  signs
• 24:12
  and
• 24:13
  symptoms.
• 24:13
  Tardive
• 24:14
  dyskinesia.
• 24:14
  Right,
• 24:15
  Those
• 24:15
  high
• 24:15
  EPS
• 24:16
  agents
• 24:16
  like
• 24:16
  Haldol,
• 24:17
  if
• 24:17
  you're
• 24:17
  switching
• 24:17
  to,
• 24:18
  to
• 24:18
  those,
• 24:18
  you
• 24:19
  gotta
• 24:19
  provide
• 24:19
  the
• 24:19
  proper
• 24:20
  education.
• 24:21
  Very
• 24:21
  important.
• 24:22
  That's
• 24:22
  a
• 24:22
  whole
• 24:23
  new
• 24:23
  ballgame.
• 24:24
  If,
• 24:24
  especially
• 24:24
  if
• 24:25
  you're
• 24:25
  coming
• 24:25
  from
• 24:25
  something
• 24:26
  like
• 24:26
  Seroquel,
• 24:26
  which
• 24:27
  is
• 24:27
  a
• 24:27
  lot
• 24:27
  lower
• 24:28
  EPS
• 24:29
  incidence
• 24:29
  and
• 24:29
  you're
• 24:29
  going
• 24:30
  to
• 24:30
  Haldol,
• 24:30
  you've
• 24:31
  got
• 24:31
  to
• 24:31
  provide
• 24:31
  that
• 24:31
  education.
• 24:32
  And
• 24:32
  that
• 24:32
  should
• 24:32
  be
• 24:32
  a
• 24:33
  big
• 24:33
  part
• 24:33
  of,
• 24:33
  of
• 24:34
  your
• 24:34
  switch.
• 24:34
  Asking
• 24:35
  yourself
• 24:35
  intuitively,
• 24:36
  what
• 24:36
  is
• 24:36
  the
• 24:36
  biggest
• 24:36
  difference
• 24:37
  between
• 24:37
  this
• 24:37
  agent
• 24:38
  and
• 24:38
  the
• 24:38
  agent
• 24:39
  I'm
• 24:39
  about
• 24:39
  to
• 24:39
  go
• 24:39
  to?
• 24:40
  What
• 24:40
  might
• 24:40
  be
• 24:41
  the
• 24:41
  big
• 24:41
  surprises
• 24:42
  around
• 24:42
  the
• 24:42
  corner
• 24:42
  I
• 24:42
  need
• 24:43
  to
• 24:43
  educate
• 24:43
  my
• 24:43
  patient
• 24:44
  about?
• 24:44
  Let
• 24:44
  me
• 24:45
  look
• 24:45
  at
• 24:45
  the
• 24:45
  receptor
• 24:45
  profiles,
• 24:46
  let
• 24:46
  me
• 24:46
  look
• 24:46
  at
• 24:46
  the
• 24:46
  half
• 24:47
  lives,
• 24:47
  let
• 24:47
  me
• 24:48
  look
• 24:48
  at
• 24:48
  the
• 24:48
  symptoms
• 24:48
  that
• 24:48
  might
• 24:49
  be
• 24:49
  deal
• 24:49
  breakers
• 24:49
  to
• 24:50
  my
• 24:50
  patient.
• 24:50
  And
• 24:50
  let
• 24:51
  me
• 24:51
  make
• 24:51
  sure
• 24:51
  those
• 24:51
  symptoms
• 24:52
  are
• 24:52
  not
• 24:52
  what
• 24:53
  the
• 24:53
  patient
• 24:53
  thinks
• 24:53
  this
• 24:54
  new
• 24:54
  drug
• 24:54
  represents.
• 24:55
  This
• 24:55
  is
• 24:55
  a
• 24:55
  transitionary
• 24:56
  period.
• 24:56
  This
• 24:57
  is
• 24:57
  not
• 24:57
  how
• 24:58
  this
• 24:58
  patient's
• 24:58
  going
• 24:59
  to
• 24:59
  feel
• 24:59
  on
• 24:59
  the
• 24:59
  new
• 24:59
  drug
• 25:00
  indefinitely.
• 25:01
  Very
• 25:01
  important
• 25:01
  that
• 25:02
  you
• 25:02
  mention
• 25:02
  that
• 25:02
  and
• 25:03
  I
• 25:03
  think
• 25:03
  you'll
• 25:03
  be
• 25:04
  in
• 25:04
  really
• 25:05
  good
• 25:05
  shape.
• 25:05
  Well,
• 25:06
  I
• 25:06
  hope
• 25:06
  this
• 25:06
  helped
• 25:07
  you
• 25:07
  guys
• 25:07
  because
• 25:08
  as
• 25:08
  you
• 25:08
  can
• 25:08
  see,
• 25:09
  it
• 25:09
  is
• 25:09
  not
• 25:09
  as
• 25:10
  simple
• 25:10
  as
• 25:10
  we're
• 25:10
  going
• 25:11
  to
• 25:11
  switch
• 25:11
  this
• 25:11
  antipsychotic.
• 25:12
  You're
• 25:12
  psychotic.
• 25:13
  You
• 25:13
  didn't
• 25:14
  like
• 25:14
  the
• 25:14
  first
• 25:14
  antipsychotic,
• 25:15
  so
• 25:15
  we're
• 25:15
  going
• 25:15
  to
• 25:15
  try
• 25:15
  you
• 25:16
  on
• 25:16
  a
• 25:16
  new
• 25:16
  antipsychotic.
• 25:18
  It's
• 25:18
  not
• 25:18
  that
• 25:19
  simple.
• 25:19
  And
• 25:19
  the
• 25:20
  difference
• 25:20
  between
• 25:20
  a
• 25:20
  good
• 25:21
  clinician
• 25:22
  and
• 25:22
  a
• 25:22
  great
• 25:22
  clinician
• 25:23
  is
• 25:24
  the
• 25:24
  knowing
• 25:24
  the
• 25:25
  how
• 25:25
  and
• 25:25
  the
• 25:25
  why
• 25:25
  of
• 25:26
  what
• 25:26
  you're
• 25:26
  doing.
• 25:26
  And
• 25:26
  that
• 25:26
  is
• 25:27
  exactly
• 25:27
  why
• 25:28
  we
• 25:28
  built
• 25:29
  a
• 25:29
  beautiful
• 25:30
  Patreon
• 25:30
  library.
• 25:31
  To
• 25:32
  empower
• 25:32
  you
• 25:32
  to
• 25:32
  understand
• 25:33
  the
• 25:33
  how
• 25:33
  and
• 25:33
  the
• 25:33
  why.
• 25:34
  To
• 25:34
  not
• 25:34
  just
• 25:34
  read
• 25:35
  algorithms
• 25:36
  and
• 25:36
  spreadsheets,
• 25:37
  but
• 25:37
  to
• 25:37
  have
• 25:38
  like
• 25:38
  this
• 25:38
  high
• 25:38
  definition
• 25:40
  view
• 25:40
  of
• 25:40
  what
• 25:41
  you're
• 25:41
  doing
• 25:41
  every
• 25:42
  day.
• 25:42
  They
• 25:42
  smell
• 25:43
  that
• 25:43
  a
• 25:43
  mile
• 25:43
  away.
• 25:44
  The
• 25:44
  clinicians
• 25:45
  who
• 25:45
  understand
• 25:45
  the
• 25:45
  how
• 25:46
  and
• 25:46
  the
• 25:46
  why.
• 25:46
  That's
• 25:46
  why
• 25:46
  we
• 25:47
  built
• 25:47
  Patreon.
• 25:47
  I
• 25:48
  don't
• 25:48
  know
• 25:48
  where
• 25:48
  I
• 25:48
  would
• 25:48
  be
• 25:49
  as
• 25:49
  a
• 25:49
  clinician
• 25:49
  if
• 25:49
  I
• 25:49
  hadn't
• 25:50
  built
• 25:50
  this
• 25:50
  Patreon
• 25:51
  library
• 25:51
  to
• 25:52
  review
• 25:52
  things,
• 25:52
  to
• 25:53
  stay
• 25:53
  at
• 25:53
  the
• 25:53
  top
• 25:53
  of
• 25:53
  my
• 25:54
  game.
• 25:54
  It's
• 25:54
  a
• 25:55
  really
• 25:55
  growing
• 25:55
  library.
• 25:56
  There's
• 25:56
  a
• 25:56
  lot
• 25:56
  of
• 25:56
  members
• 25:57
  that
• 25:57
  are
• 25:57
  feasting
• 25:58
  on
• 25:58
  our
• 25:58
  material.
• 25:59
  So
• 25:59
  if
• 25:59
  there's
• 25:59
  one
• 25:59
  thing
• 26:00
  you
• 26:00
  don't
• 26:00
  forget
• 26:00
  tonight,
• 26:01
  definitely
• 26:02
  march
• 26:02
  over
• 26:03
  to
• 26:03
  our
• 26:03
  show
• 26:03
  notes
• 26:04
  and
• 26:04
  become
• 26:04
  a
• 26:04
  Patreon
• 26:05
  member
• 26:05
  again.
• 26:05
  I
• 26:05
  am
• 26:06
  genuinely
• 26:07
  afraid
• 26:07
  to
• 26:07
  consider
• 26:08
  who
• 26:08
  I
• 26:08
  would
• 26:09
  be
• 26:09
  as
• 26:09
  a
• 26:09
  clinician
• 26:09
  if
• 26:10
  I
• 26:10
  didn't
• 26:10
  have
• 26:11
  this
• 26:11
  Patreon
• 26:11
  library
• 26:12
  to
• 26:12
  review
• 26:13
  because
• 26:13
  it
• 26:14
  has
• 26:14
  transformed
• 26:15
  the
• 26:16
  way
• 26:16
  I
• 26:16
  conceptualize
• 26:17
  this
• 26:17
  stuff
• 26:18
  and
• 26:18
  practice.
• 26:19
  Knowledge
• 26:19
  is
• 26:20
  power,
• 26:20
  and
• 26:20
  knowledge
• 26:21
  will
• 26:21
  go
• 26:21
  a
• 26:21
  long
• 26:21
  way
• 26:21
  in
• 26:22
  empowering
• 26:22
  you
• 26:22
  in
• 26:22
  your
• 26:23
  career.
• 26:23
  So
• 26:24
  there's
• 26:24
  one
• 26:24
  thing
• 26:24
  you
• 26:24
  don't
• 26:24
  forget,
• 26:25
  my
• 26:25
  friends.
• 26:25
  Head
• 26:25
  over
• 26:25
  to
• 26:26
  the
• 26:26
  Show
• 26:26
  Notes,
• 26:26
  become
• 26:27
  a
• 26:27
  Patreon
• 26:27
  member.
• 26:27
  And
• 26:28
  with
• 26:28
  that,
• 26:28
  we
• 26:28
  will
• 26:28
  see
• 26:28
  you
• 26:29
  next
• 26:29
  time
• 26:29
  here
• 26:29
  on
• 26:29
  Pearls
• 26:30
  and
• 26:30
  Proud.
• 26:30
  Thank
• 26:31
  you.