Latest / Pearls and Prep / Why Luvox Hits Different: Sigma Receptors, OCD, and the Anxious Brain

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Why Luvox Hits Different: Sigma Receptors, OCD, and the Anxious Brain · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back
• 0:06
  my
• 0:06
  friends
• 0:07
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  Prep
• 0:09
  npz.
• 0:09
  Here
• 0:10
  your
• 0:10
  preceptor
• 0:10
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Today
• 0:15
  my
• 0:15
  friends,
• 0:16
  we
• 0:16
  are
• 0:16
  going
• 0:16
  to
• 0:16
  enter
• 0:17
  the
• 0:17
  fascinating
• 0:18
  world
• 0:19
  of
• 0:19
  Luvox,
• 0:20
  An
• 0:20
  SSRI
• 0:21
  that
• 0:22
  you
• 0:22
  have
• 0:22
  probably
• 0:23
  never
• 0:23
  prescribed
• 0:24
  in
• 0:24
  your
• 0:24
  life.
• 0:25
  You
• 0:25
  might
• 0:25
  have
• 0:25
  only
• 0:26
  seen
• 0:26
  it
• 0:26
  in
• 0:26
  the
• 0:26
  movies
• 0:27
  or,
• 0:27
  or
• 0:27
  in
• 0:27
  your
• 0:28
  lectures.
• 0:28
  It
• 0:29
  is
• 0:29
  also
• 0:29
  known
• 0:29
  as
• 0:30
  Fluvoxamine.
• 0:31
  It's
• 0:31
  a
• 0:31
  super
• 0:32
  uncommonly
• 0:33
  prescribed
• 0:33
  SSRI
• 0:34
  for
• 0:35
  known
• 0:35
  reasons
• 0:36
  and
• 0:36
  a
• 0:36
  lot
• 0:36
  of
• 0:36
  unknown
• 0:37
  reasons.
• 0:37
  I
• 0:37
  don't
• 0:37
  think
• 0:38
  this
• 0:38
  medication
• 0:38
  quite
• 0:39
  gets
• 0:40
  the
• 0:40
  credit
• 0:41
  it
• 0:41
  deserves.
• 0:42
  And
• 0:42
  we're
• 0:42
  gonna
• 0:42
  take
• 0:43
  a
• 0:43
  critical
• 0:43
  look
• 0:43
  at
• 0:43
  it
• 0:44
  and
• 0:44
  at
• 0:45
  least
• 0:45
  empower
• 0:45
  you
• 0:46
  to
• 0:47
  keep
• 0:47
  it
• 0:47
  as
• 0:47
  an
• 0:47
  option
• 0:48
  in
• 0:48
  select
• 0:49
  patients
• 0:49
  where
• 0:50
  it
• 0:50
  might
• 0:50
  make
• 0:51
  the
• 0:51
  most
• 0:51
  sense.
• 0:52
  Now
• 0:54
  I
• 0:54
  can
• 0:54
  tell
• 0:54
  you
• 0:55
  off
• 0:55
  the
• 0:55
  bat
• 0:56
  that
• 0:57
  a
• 0:57
  lot
• 0:57
  of
• 0:57
  the
• 0:58
  reasons
• 0:58
  people
• 0:58
  don't
• 0:59
  prescribe
• 0:59
  Luvox
• 1:00
  is
• 1:01
  because
• 1:01
  of
• 1:01
  its
• 1:01
  CYP
• 1:03
  metabolic
• 1:03
  interactions.
• 1:04
  It
• 1:05
  can
• 1:05
  be
• 1:05
  very
• 1:05
  problematic.
• 1:06
  It
• 1:06
  can
• 1:06
  inhibit
• 1:07
  a
• 1:07
  lot
• 1:07
  of
• 1:07
  other
• 1:08
  medications.
• 1:09
  However,
• 1:09
  if
• 1:09
  you
• 1:09
  work
• 1:10
  with
• 1:10
  a
• 1:10
  population
• 1:10
  that
• 1:11
  is
• 1:11
  not
• 1:11
  very
• 1:12
  acute,
• 1:12
  there's
• 1:12
  not
• 1:13
  a
• 1:13
  lot
• 1:13
  of
• 1:13
  polypharmacy.
• 1:14
  I
• 1:14
  think
• 1:14
  it's
• 1:15
  something
• 1:15
  we
• 1:15
  should
• 1:15
  definitely
• 1:16
  reconsider.
• 1:16
  It's
• 1:17
  an
• 1:17
  SSRI
• 1:18
  just
• 1:18
  like
• 1:18
  the
• 1:18
  rest
• 1:19
  of
• 1:19
  the
• 1:19
  and
• 1:19
  it
• 1:19
  even
• 1:19
  has
• 1:20
  some
• 1:20
  really
• 1:21
  unique
• 1:21
  properties
• 1:22
  that
• 1:23
  we
• 1:23
  can
• 1:24
  exploit
• 1:25
  and
• 1:25
  leverage
• 1:26
  to
• 1:26
  improve
• 1:27
  our
• 1:27
  patients
• 1:27
  lives.
• 1:28
  So
• 1:29
  let's
• 1:29
  get
• 1:29
  into
• 1:29
  it,
• 1:29
  my
• 1:30
  friend.
• 1:30
  So
• 1:31
  Luvox
• 1:32
  is
• 1:32
  actually
• 1:32
  FDA
• 1:33
  approved
• 1:33
  for
• 1:34
  OCD
• 1:34
  and
• 1:35
  for
• 1:35
  social
• 1:35
  anxiety
• 1:36
  disorder.
• 1:36
  Very
• 1:36
  interestingly,
• 1:37
  it's
• 1:37
  not
• 1:38
  FDA
• 1:38
  approved
• 1:39
  for
• 1:39
  mdd.
• 1:39
  And
• 1:40
  that
• 1:40
  might
• 1:40
  be
• 1:40
  why
• 1:41
  some
• 1:41
  people
• 1:41
  are
• 1:41
  hesitant,
• 1:42
  why
• 1:42
  they
• 1:42
  don't
• 1:42
  go
• 1:42
  straight
• 1:43
  to
• 1:43
  Luvox
• 1:44
  when
• 1:44
  they
• 1:44
  could
• 1:44
  be
• 1:44
  going
• 1:45
  to
• 1:46
  other
• 1:47
  medications.
• 1:48
  Obviously
• 1:49
  Lexapro,
• 1:49
  Prozac,
• 1:51
  Zoloft,
• 1:51
  those
• 1:52
  are
• 1:52
  the
• 1:52
  most
• 1:53
  common
• 1:54
  medications
• 1:54
  that
• 1:54
  people
• 1:55
  reach
• 1:55
  to
• 1:55
  for
• 1:55
  depression
• 1:56
  or
• 1:56
  GAD
• 1:56
  or
• 1:57
  ptsd.
• 1:58
  Luvox
• 1:58
  doesn't
• 1:59
  seem
• 1:59
  to
• 1:59
  be
• 1:59
  on
• 1:59
  the
• 1:59
  radar.
• 2:00
  And
• 2:00
  I
• 2:00
  think
• 2:00
  part
• 2:00
  of
• 2:00
  that
• 2:00
  is
• 2:01
  because
• 2:01
  of
• 2:01
  all
• 2:01
  the
• 2:01
  drug
• 2:02
  interactions.
• 2:02
  You've
• 2:03
  got
• 2:03
  to
• 2:03
  run
• 2:03
  these
• 2:03
  complex
• 2:04
  interaction
• 2:05
  checks.
• 2:05
  And
• 2:06
  once
• 2:06
  you
• 2:06
  place
• 2:06
  somebody
• 2:07
  on
• 2:07
  Luvox,
• 2:08
  especially
• 2:08
  if
• 2:08
  they're
• 2:08
  older
• 2:09
  and
• 2:09
  there's
• 2:09
  more
• 2:09
  polypharmacy,
• 2:10
  then
• 2:11
  you
• 2:11
  definitely
• 2:13
  are
• 2:14
  having
• 2:14
  to
• 2:14
  play
• 2:14
  a
• 2:15
  lot
• 2:15
  of
• 2:15
  dodgeball.
• 2:15
  Right?
• 2:16
  There's
• 2:16
  a
• 2:16
  lot
• 2:16
  of
• 2:16
  medications
• 2:17
  they
• 2:17
  can't
• 2:18
  necessarily
• 2:19
  pursue
• 2:19
  anymore
• 2:20
  and
• 2:20
  that
• 2:20
  puts
• 2:20
  your
• 2:21
  patient
• 2:21
  in
• 2:21
  a
• 2:21
  difficult
• 2:22
  situation.
• 2:22
  And
• 2:22
  why
• 2:22
  would
• 2:22
  you
• 2:23
  want
• 2:23
  to
• 2:23
  do
• 2:23
  that
• 2:23
  when
• 2:24
  all
• 2:24
  the
• 2:24
  SSRIs
• 2:25
  are
• 2:25
  more
• 2:26
  or
• 2:26
  less
• 2:26
  equally
• 2:27
  efficacious?
• 2:28
  So
• 2:29
  pick
• 2:29
  the
• 2:30
  ones
• 2:30
  that
• 2:30
  have
• 2:30
  minimal
• 2:31
  CYP
• 2:31
  interactions.
• 2:32
  Right.
• 2:32
  Something
• 2:32
  maybe
• 2:33
  like
• 2:33
  Lexapro
• 2:34
  would
• 2:34
  be
• 2:34
  a
• 2:35
  lot
• 2:35
  cleaner
• 2:35
  and
• 2:35
  a
• 2:35
  lot
• 2:35
  more
• 2:36
  simple
• 2:36
  in
• 2:36
  this
• 2:36
  case.
• 2:37
  You
• 2:37
  could
• 2:37
  even
• 2:37
  go
• 2:38
  for
• 2:38
  Remeron.
• 2:38
  Right?
• 2:39
  It
• 2:39
  helps
• 2:39
  you
• 2:40
  sleep.
• 2:40
  So
• 2:40
  does
• 2:40
  Luvox.
• 2:41
  So
• 2:41
  why
• 2:41
  would
• 2:41
  we
• 2:41
  go
• 2:42
  for
• 2:42
  Luvox?
• 2:43
  All
• 2:44
  very
• 2:44
  fair
• 2:44
  questions,
• 2:45
  but
• 2:45
  again,
• 2:45
  the
• 2:46
  devil's
• 2:46
  in
• 2:46
  the
• 2:46
  details
• 2:47
  here.
• 2:47
  And
• 2:47
  although
• 2:48
  I
• 2:48
  would.
• 2:48
  Although
• 2:49
  I
• 2:49
  can't
• 2:49
  argue
• 2:49
  with
• 2:49
  the
• 2:50
  fact
• 2:50
  that
• 2:51
  we
• 2:51
  were
• 2:51
  all
• 2:51
  taught
• 2:52
  that
• 2:52
  SSRIs
• 2:52
  are
• 2:53
  mostly
• 2:53
  all
• 2:53
  equally
• 2:54
  efficacious,
• 2:55
  I
• 2:55
  would
• 2:55
  argue
• 2:56
  that
• 2:56
  that
• 2:56
  is
• 2:56
  true
• 2:57
  in
• 2:57
  theory
• 2:57
  in
• 2:57
  your
• 2:58
  textbook,
• 2:58
  but
• 2:58
  it
• 2:59
  is
• 2:59
  not
• 2:59
  necessarily
• 3:00
  true
• 3:00
  in
• 3:00
  person
• 3:01
  with
• 3:01
  your
• 3:01
  patient.
• 3:02
  Because
• 3:02
  remember,
• 3:02
  your
• 3:03
  patient
• 3:03
  is
• 3:04
  going
• 3:04
  to
• 3:04
  have
• 3:04
  the.
• 3:05
  Their
• 3:05
  own
• 3:05
  preferences
• 3:07
  and
• 3:07
  their
• 3:07
  own
• 3:08
  deal
• 3:08
  breakers.
• 3:08
  Right.
• 3:09
  Some
• 3:09
  patients
• 3:09
  will
• 3:09
  absolutely
• 3:10
  refuse
• 3:11
  to
• 3:11
  gain
• 3:11
  weight
• 3:11
  on
• 3:12
  an
• 3:12
  antidepressant.
• 3:13
  Well,
• 3:13
  then
• 3:13
  Remeron
• 3:14
  is
• 3:14
  really
• 3:14
  not
• 3:14
  as
• 3:14
  efficacious,
• 3:15
  at
• 3:15
  least
• 3:16
  for
• 3:16
  that
• 3:16
  patient.
• 3:17
  It
• 3:17
  might
• 3:17
  be
• 3:17
  in
• 3:17
  population
• 3:18
  based
• 3:18
  studies
• 3:18
  and
• 3:19
  RCTs,
• 3:19
  that's
• 3:20
  fine,
• 3:20
  but
• 3:20
  that
• 3:21
  lives
• 3:21
  in
• 3:22
  research
• 3:22
  studies.
• 3:23
  What
• 3:23
  lives
• 3:23
  in
• 3:23
  your
• 3:23
  office,
• 3:24
  in
• 3:24
  your
• 3:24
  outpatient
• 3:25
  practice
• 3:26
  is
• 3:26
  a
• 3:26
  flesh
• 3:27
  and
• 3:27
  bone
• 3:28
  patient
• 3:29
  who's
• 3:29
  going
• 3:29
  through
• 3:29
  something.
• 3:30
  And.
• 3:30
  And
• 3:30
  so
• 3:31
  not
• 3:31
  all
• 3:31
  SSRIs
• 3:32
  are
• 3:32
  equal,
• 3:33
  actually,
• 3:34
  when
• 3:34
  you
• 3:34
  have
• 3:34
  a
• 3:35
  patient
• 3:35
  in
• 3:35
  front
• 3:35
  of
• 3:35
  you
• 3:35
  who
• 3:36
  has
• 3:36
  a
• 3:36
  certain
• 3:36
  deal
• 3:37
  breaker.
• 3:37
  Okay.
• 3:38
  And
• 3:38
  I'm
• 3:38
  using
• 3:38
  SSRIs
• 3:39
  very
• 3:39
  broadly
• 3:40
  here.
• 3:40
  Technically,
• 3:41
  Remeron
• 3:42
  is
• 3:42
  not
• 3:42
  an
• 3:42
  SSRI
• 3:44
  by
• 3:44
  a
• 3:44
  conventional
• 3:45
  definition.
• 3:46
  Okay.
• 3:48
  But
• 3:48
  my
• 3:48
  greater
• 3:49
  point
• 3:49
  is
• 3:49
  with
• 3:50
  all
• 3:50
  of
• 3:50
  the
• 3:50
  common
• 3:51
  medications
• 3:51
  that
• 3:52
  we
• 3:52
  typically
• 3:52
  prescribe,
• 3:53
  statistically
• 3:54
  they
• 3:54
  might
• 3:54
  be
• 3:55
  more
• 3:55
  or
• 3:55
  less
• 3:55
  equal,
• 3:55
  but
• 3:56
  with,
• 3:56
  with
• 3:56
  respect
• 3:56
  to
• 3:56
  your
• 3:57
  individual
• 3:57
  patient,
• 3:57
  they
• 3:58
  are
• 3:58
  not.
• 3:58
  And
• 3:59
  so
• 3:59
  this
• 3:59
  is
• 3:59
  where
• 4:00
  Luvox
• 4:01
  might
• 4:01
  have
• 4:01
  an
• 4:02
  important
• 4:02
  play
• 4:02
  in
• 4:02
  a
• 4:03
  particular
• 4:03
  patient.
• 4:04
  So
• 4:04
  what
• 4:04
  really
• 4:05
  separates
• 4:05
  Luvox
• 4:06
  from
• 4:06
  Prozac
• 4:07
  or
• 4:08
  Lexapro?
• 4:09
  There's
• 4:10
  a
• 4:11
  very
• 4:11
  important
• 4:11
  feature
• 4:12
  of
• 4:12
  it,
• 4:13
  and
• 4:13
  it
• 4:13
  is
• 4:14
  the
• 4:14
  fact
• 4:14
  that
• 4:14
  Luvox
• 4:15
  has
• 4:15
  a
• 4:15
  pretty
• 4:15
  high
• 4:16
  affinity
• 4:16
  for
• 4:17
  the
• 4:17
  sigma
• 4:17
  1
• 4:18
  receptor
• 4:18
  receptor.
• 4:19
  What
• 4:19
  is
• 4:20
  that?
• 4:20
  It's
• 4:20
  not
• 4:21
  a
• 4:21
  very
• 4:21
  common
• 4:21
  thing
• 4:22
  we
• 4:22
  talk
• 4:22
  about
• 4:22
  in
• 4:22
  psychiatry.
• 4:23
  I
• 4:23
  think
• 4:23
  there
• 4:23
  is
• 4:24
  growing
• 4:24
  interest
• 4:24
  in
• 4:24
  the
• 4:25
  sigma
• 4:25
  1
• 4:25
  receptor.
• 4:26
  I
• 4:26
  think
• 4:26
  we
• 4:26
  should
• 4:27
  all
• 4:27
  kind
• 4:27
  of
• 4:27
  do
• 4:27
  nerdy
• 4:28
  deep
• 4:28
  dives
• 4:28
  into
• 4:29
  it
• 4:29
  to
• 4:29
  explore
• 4:29
  it
• 4:30
  more.
• 4:30
  It's
• 4:30
  very
• 4:30
  fascinating,
• 4:31
  but
• 4:31
  it
• 4:31
  has
• 4:32
  the
• 4:33
  most
• 4:33
  potent
• 4:33
  sigma
• 4:34
  1
• 4:34
  receptor
• 4:35
  agonism
• 4:36
  among
• 4:36
  all
• 4:36
  the
• 4:36
  SSRIs,
• 4:37
  but
• 4:37
  it's
• 4:38
  really
• 4:38
  not
• 4:38
  even
• 4:38
  close.
• 4:38
  So
• 4:39
  if
• 4:39
  we're
• 4:39
  talking
• 4:39
  about
• 4:39
  sigma
• 4:40
  1
• 4:40
  receptor,
• 4:40
  Luvox
• 4:41
  is
• 4:41
  the
• 4:41
  name
• 4:41
  of
• 4:42
  the
• 4:42
  game.
• 4:42
  And
• 4:43
  with
• 4:43
  Sigma
• 4:43
  1,
• 4:44
  what
• 4:44
  we're
• 4:44
  talking
• 4:44
  about
• 4:45
  in
• 4:45
  particular
• 4:45
  is
• 4:45
  neuroprotection
• 4:46
  and
• 4:47
  neuroplasticity.
• 4:47
  Well,
• 4:48
  you
• 4:48
  can
• 4:48
  imagine
• 4:49
  if
• 4:50
  the
• 4:50
  evidence
• 4:50
  suggests
• 4:50
  that
• 4:51
  sigma
• 4:51
  1
• 4:52
  agonism
• 4:54
  eventually
• 4:55
  leads
• 4:56
  to
• 4:56
  neuroprotection
• 4:57
  and
• 4:57
  neuroplasticity.
• 4:58
  Well,
• 4:58
  that
• 4:58
  is
• 4:58
  fundamentally
• 4:59
  critical
• 5:00
  in
• 5:01
  a
• 5:02
  condition
• 5:02
  like
• 5:03
  depression
• 5:03
  or
• 5:03
  anxiety
• 5:04
  or
• 5:04
  O
• 5:04
  C
• 5:04
  D,
• 5:05
  because
• 5:06
  all
• 5:06
  of
• 5:06
  those
• 5:07
  disorders
• 5:08
  are
• 5:08
  essentially
• 5:09
  thought
• 5:10
  disorders
• 5:11
  on
• 5:11
  some
• 5:12
  level.
• 5:12
  Right.
• 5:12
  There's
• 5:13
  they're
• 5:13
  brain
• 5:13
  network
• 5:14
  disorders
• 5:15
  that
• 5:15
  ought
• 5:15
  to
• 5:15
  be
• 5:16
  reconfigured
• 5:16
  and
• 5:16
  reorganized.
• 5:17
  It's
• 5:17
  the
• 5:17
  same
• 5:18
  reason
• 5:18
  people
• 5:19
  pursue
• 5:19
  psychotherapy.
• 5:20
  Well,
• 5:20
  now
• 5:21
  you
• 5:21
  have
• 5:21
  a
• 5:21
  medication
• 5:22
  that
• 5:22
  can
• 5:23
  more
• 5:23
  directly
• 5:24
  enhance
• 5:25
  neuroplasticity
• 5:26
  and
• 5:26
  neuroprotection
• 5:27
  more
• 5:27
  broadly.
• 5:28
  That's
• 5:29
  a
• 5:29
  really
• 5:29
  big
• 5:29
  deal.
• 5:29
  And
• 5:29
  that
• 5:30
  happens
• 5:30
  exclusively
• 5:31
  through
• 5:31
  the
• 5:32
  sigma
• 5:32
  1
• 5:33
  receptor.
• 5:34
  Very
• 5:34
  neat.
• 5:35
  Another
• 5:36
  important
• 5:36
  piece
• 5:37
  of
• 5:37
  the
• 5:37
  sigma
• 5:37
  1
• 5:38
  receptor
• 5:39
  is
• 5:40
  cognitive
• 5:40
  enhancement.
• 5:41
  Okay,
• 5:42
  so
• 5:42
  you
• 5:42
  have
• 5:43
  a
• 5:43
  lot
• 5:43
  of
• 5:43
  patients,
• 5:43
  of
• 5:43
  course,
• 5:44
  that
• 5:44
  come
• 5:44
  to
• 5:44
  you
• 5:44
  with
• 5:44
  cognitive
• 5:45
  deficits.
• 5:46
  And
• 5:46
  right
• 5:46
  now
• 5:46
  we
• 5:47
  kind
• 5:47
  of
• 5:47
  gravitate
• 5:47
  towards
• 5:48
  Trintellix
• 5:48
  when
• 5:49
  they
• 5:49
  have
• 5:49
  cognitive
• 5:49
  deficits
• 5:51
  instead
• 5:51
  of
• 5:51
  getting
• 5:51
  a
• 5:52
  prior
• 5:52
  authorization
• 5:53
  and
• 5:53
  waiting
• 5:53
  several
• 5:54
  weeks
• 5:54
  or
• 5:55
  having
• 5:55
  your
• 5:55
  patient's
• 5:56
  insurance
• 5:57
  not
• 5:58
  approve
• 5:58
  of
• 5:58
  Trintellix.
• 5:59
  We
• 5:59
  do
• 5:59
  have
• 6:00
  Luvox
• 6:01
  here
• 6:01
  that
• 6:01
  has
• 6:01
  sigma
• 6:02
  1
• 6:02
  receptor
• 6:03
  agonism
• 6:03
  and
• 6:04
  it
• 6:04
  has
• 6:04
  shown
• 6:05
  to
• 6:05
  actually
• 6:06
  improve
• 6:07
  cognitive
• 6:08
  deficits.
• 6:09
  And
• 6:09
  that's
• 6:09
  really
• 6:09
  exciting.
• 6:10
  It's
• 6:10
  also
• 6:10
  anti
• 6:11
  inflammatory.
• 6:11
  It's
• 6:12
  a
• 6:12
  very
• 6:13
  interesting
• 6:14
  mechanism
• 6:14
  of
• 6:14
  action
• 6:15
  here
• 6:15
  because
• 6:16
  sigma
• 6:16
  1
• 6:16
  receptors
• 6:17
  actually
• 6:17
  sit
• 6:18
  on
• 6:18
  your
• 6:18
  immune
• 6:19
  cells.
• 6:19
  Well,
• 6:20
  that's
• 6:21
  really
• 6:21
  cool
• 6:22
  actually,
• 6:23
  because
• 6:24
  by
• 6:24
  agonizing
• 6:25
  the
• 6:25
  sigma
• 6:26
  1
• 6:26
  receptor,
• 6:27
  you
• 6:27
  put
• 6:27
  a
• 6:28
  kind
• 6:28
  of
• 6:28
  a
• 6:28
  hard
• 6:28
  break
• 6:29
  on
• 6:29
  the
• 6:29
  inflammatory
• 6:30
  cascade
• 6:30
  before
• 6:30
  it
• 6:30
  starts.
• 6:31
  And
• 6:31
  we
• 6:31
  know
• 6:32
  that
• 6:32
  neuroinflammation
• 6:33
  is
• 6:33
  such
• 6:34
  a
• 6:34
  problem
• 6:34
  in
• 6:34
  a
• 6:35
  certain
• 6:35
  phenotype
• 6:36
  of
• 6:36
  depressed
• 6:36
  people,
• 6:37
  right?
• 6:37
  Not
• 6:37
  all
• 6:38
  depression
• 6:38
  is
• 6:38
  created
• 6:39
  equally.
• 6:39
  There's
• 6:39
  many
• 6:39
  different
• 6:40
  kinds
• 6:40
  and
• 6:40
  flavors
• 6:41
  of
• 6:41
  depression.
• 6:41
  And,
• 6:42
  and
• 6:42
  there's
• 6:42
  a
• 6:42
  particular
• 6:42
  subtype
• 6:43
  of
• 6:43
  depressed
• 6:44
  patients
• 6:44
  who
• 6:45
  are
• 6:45
  known
• 6:45
  to
• 6:46
  have
• 6:46
  more
• 6:46
  inflammatory
• 6:48
  conditions
• 6:49
  that
• 6:49
  actually
• 6:49
  destroy
• 6:50
  their
• 6:50
  neurotransmitters,
• 6:51
  that
• 6:51
  prevent
• 6:51
  neurotransmitter
• 6:52
  synthesis,
• 6:53
  they
• 6:53
  degrade
• 6:53
  existing
• 6:54
  neurotransmitters
• 6:55
  and
• 6:55
  particularly
• 6:56
  dopamine,
• 6:57
  which
• 6:57
  can
• 6:57
  cause
• 6:58
  anhedonia
• 6:58
  in
• 6:58
  the
• 6:59
  prefrontal
• 6:59
  cortex.
• 6:59
  It
• 7:00
  can
• 7:00
  lead
• 7:00
  to
• 7:00
  brain
• 7:00
  fog.
• 7:01
  We
• 7:01
  know
• 7:01
  COVID
• 7:02
  19
• 7:02
  had
• 7:02
  some
• 7:03
  evidence
• 7:03
  that
• 7:03
  suggested
• 7:04
  it
• 7:04
  was
• 7:04
  a
• 7:04
  very
• 7:04
  inflammatory
• 7:05
  condition
• 7:05
  that
• 7:06
  made
• 7:06
  it
• 7:06
  difficult
• 7:07
  to
• 7:07
  think
• 7:08
  long.
• 7:08
  Covid
• 7:08
  folks
• 7:09
  have
• 7:09
  very
• 7:09
  low
• 7:09
  energy.
• 7:10
  They're
• 7:10
  a
• 7:10
  lot
• 7:10
  less
• 7:11
  likely
• 7:11
  to
• 7:11
  enjoy
• 7:12
  certain
• 7:13
  hobbies
• 7:13
  they
• 7:13
  used
• 7:14
  to
• 7:14
  enjoy.
• 7:14
  They
• 7:14
  just
• 7:14
  don't
• 7:15
  have
• 7:15
  the
• 7:15
  physical
• 7:15
  energy
• 7:16
  or
• 7:16
  cognitive
• 7:17
  reserve
• 7:17
  that
• 7:17
  they
• 7:17
  used
• 7:18
  to
• 7:18
  have.
• 7:18
  So
• 7:18
  if
• 7:18
  you
• 7:19
  have
• 7:19
  a
• 7:19
  patient
• 7:19
  who
• 7:19
  has
• 7:20
  an
• 7:20
  inflammatory
• 7:21
  type
• 7:21
  of
• 7:21
  depression,
• 7:22
  maybe
• 7:22
  an
• 7:22
  elevated
• 7:23
  CRP
• 7:24
  or
• 7:24
  IL6,
• 7:25
  then
• 7:26
  there
• 7:26
  is
• 7:26
  some
• 7:27
  evidence
• 7:27
  to
• 7:27
  support
• 7:28
  that
• 7:28
  Sigma
• 7:29
  1
• 7:29
  receptor
• 7:29
  agonism
• 7:30
  via
• 7:31
  Luvox
• 7:31
  is
• 7:32
  a
• 7:32
  little
• 7:32
  bit
• 7:32
  better
• 7:33
  suited
• 7:33
  for
• 7:33
  that
• 7:34
  patient.
• 7:35
  And
• 7:35
  there's
• 7:36
  even
• 7:36
  evidence
• 7:36
  to
• 7:37
  suggest
• 7:37
  that
• 7:37
  Luvox,
• 7:38
  through
• 7:38
  its
• 7:39
  SIRT
• 7:39
  inhibition,
• 7:40
  and
• 7:40
  remember,
• 7:41
  it
• 7:41
  does,
• 7:41
  it
• 7:41
  is
• 7:41
  still
• 7:41
  an
• 7:42
  ssri.
• 7:42
  So
• 7:42
  it
• 7:42
  is
• 7:42
  still
• 7:43
  inhibiting
• 7:43
  the
• 7:44
  reuptake
• 7:45
  of
• 7:45
  serotonin,
• 7:45
  just
• 7:46
  like
• 7:46
  Lexapro,
• 7:46
  just
• 7:47
  like
• 7:47
  Prozac,
• 7:47
  just
• 7:47
  like
• 7:48
  Zoloft.
• 7:48
  But
• 7:49
  it
• 7:49
  also
• 7:49
  has
• 7:49
  that
• 7:49
  sigma
• 7:50
  1
• 7:50
  receptor
• 7:51
  activation
• 7:51
  and
• 7:52
  the
• 7:52
  combination
• 7:52
  of
• 7:52
  those
• 7:53
  actually
• 7:53
  enhances
• 7:54
  prefrontal
• 7:55
  dopaminergic
• 7:56
  neurotransmission.
• 7:57
  That
• 7:57
  is
• 7:58
  pretty
• 7:58
  cool.
• 7:58
  We
• 7:58
  don't
• 7:58
  see
• 7:59
  that
• 7:59
  a
• 7:59
  lot
• 7:59
  with
• 7:59
  other
• 7:59
  SSRIs.
• 8:01
  That
• 8:01
  is
• 8:01
  certainly
• 8:02
  an
• 8:02
  edge.
• 8:02
  And
• 8:02
  again,
• 8:02
  it's
• 8:03
  the
• 8:03
  cognitive
• 8:03
  enhancement
• 8:04
  there
• 8:05
  that
• 8:05
  can
• 8:05
  really
• 8:05
  help.
• 8:05
  So
• 8:06
  now
• 8:06
  you
• 8:06
  have
• 8:06
  neuroprotection,
• 8:07
  neuroplasticity,
• 8:08
  cognitive
• 8:08
  enhancement.
• 8:09
  It's
• 8:09
  good
• 8:09
  in
• 8:10
  inflammatory
• 8:10
  subtype
• 8:11
  of
• 8:11
  depression.
• 8:12
  So
• 8:12
  when
• 8:12
  SSRIs
• 8:13
  aren't
• 8:13
  really
• 8:13
  working
• 8:14
  for
• 8:14
  particular
• 8:14
  patients
• 8:15
  and
• 8:15
  you've
• 8:15
  already
• 8:15
  ruled
• 8:16
  out
• 8:16
  the
• 8:16
  fact
• 8:16
  that
• 8:16
  they're
• 8:17
  being
• 8:17
  non
• 8:17
  adherent
• 8:18
  and
• 8:18
  you're
• 8:18
  like,
• 8:19
  wait
• 8:19
  a
• 8:19
  minute,
• 8:19
  this
• 8:19
  patient's
• 8:19
  not
• 8:20
  bipolar,
• 8:20
  they're
• 8:20
  not
• 8:20
  borderline.
• 8:21
  I
• 8:21
  don't
• 8:22
  see
• 8:22
  B12
• 8:22
  folate
• 8:23
  deficiencies,
• 8:23
  I
• 8:23
  don't
• 8:23
  see
• 8:23
  vitamin
• 8:24
  D
• 8:24
  deficiencies.
• 8:25
  What
• 8:25
  else
• 8:25
  is
• 8:25
  going
• 8:25
  on
• 8:25
  here?
• 8:26
  Like
• 8:26
  how
• 8:27
  come
• 8:27
  they're
• 8:27
  not
• 8:27
  responding?
• 8:28
  Well,
• 8:28
  maybe
• 8:28
  they
• 8:28
  have
• 8:29
  the
• 8:29
  inflammatory
• 8:30
  subtype
• 8:30
  of
• 8:30
  depression.
• 8:31
  Don't
• 8:32
  quote
• 8:32
  me,
• 8:32
  but
• 8:32
  I
• 8:32
  think
• 8:32
  past
• 8:33
  evidence
• 8:33
  suggests
• 8:34
  it's
• 8:34
  anywhere
• 8:34
  up
• 8:35
  to
• 8:35
  33%
• 8:35
  or
• 8:36
  so
• 8:36
  of
• 8:36
  patients
• 8:37
  I
• 8:37
  think
• 8:37
  is
• 8:37
  what
• 8:38
  I
• 8:38
  read
• 8:38
  in
• 8:38
  the
• 8:38
  past,
• 8:39
  have
• 8:39
  that
• 8:39
  inflammatory
• 8:40
  subtype
• 8:41
  potentially
• 8:41
  contributing
• 8:42
  to
• 8:42
  their
• 8:42
  depression.
• 8:42
  You
• 8:43
  may
• 8:43
  need
• 8:43
  to
• 8:43
  reach
• 8:43
  for
• 8:43
  Luvox
• 8:44
  because
• 8:44
  it's
• 8:45
  a
• 8:45
  different
• 8:45
  mechanism
• 8:46
  of
• 8:46
  action.
• 8:46
  You
• 8:47
  can
• 8:47
  actually
• 8:47
  put
• 8:47
  brakes
• 8:48
  on
• 8:48
  that
• 8:48
  inflammatory
• 8:49
  cascade,
• 8:49
  enhance
• 8:50
  prefrontal
• 8:51
  dopamine
• 8:52
  and
• 8:52
  cognitively
• 8:53
  the
• 8:53
  patient
• 8:53
  will
• 8:53
  be
• 8:53
  more
• 8:54
  flexible.
• 8:55
  And
• 8:56
  that
• 8:56
  of
• 8:56
  course
• 8:56
  changes
• 8:57
  the
• 8:57
  game
• 8:57
  of
• 8:57
  really
• 8:57
  any
• 8:58
  mental
• 8:58
  illness.
• 8:58
  I
• 8:58
  would
• 8:59
  argue
• 8:59
  every
• 8:59
  mental
• 8:59
  illness
• 9:00
  on
• 9:00
  some
• 9:00
  level
• 9:01
  has
• 9:01
  to
• 9:02
  deal
• 9:02
  with
• 9:02
  inflexibility
• 9:03
  in
• 9:03
  the
• 9:03
  way
• 9:03
  we
• 9:03
  think,
• 9:04
  most
• 9:04
  notably
• 9:05
  in
• 9:05
  ocd.
• 9:05
  Right.
• 9:06
  It's
• 9:06
  very
• 9:06
  rigid,
• 9:07
  it's
• 9:07
  very
• 9:07
  entrenched.
• 9:08
  The
• 9:08
  ways
• 9:08
  we
• 9:08
  think,
• 9:09
  we
• 9:09
  feel
• 9:09
  compelled
• 9:10
  to
• 9:10
  neutralize
• 9:11
  obsessive
• 9:11
  thoughts.
• 9:12
  Right.
• 9:12
  This
• 9:12
  is
• 9:12
  a
• 9:12
  defined
• 9:13
  circuit,
• 9:14
  very
• 9:14
  well
• 9:14
  known
• 9:14
  in
• 9:14
  the
• 9:15
  literature
• 9:15
  called
• 9:16
  the
• 9:16
  CSTC
• 9:17
  circuit,
• 9:17
  the
• 9:18
  corticostriatothalamocortical
• 9:20
  pathway.
• 9:20
  It's
• 9:21
  quite
• 9:21
  literally
• 9:21
  a
• 9:21
  brain
• 9:22
  circuit
• 9:22
  where
• 9:23
  our
• 9:23
  thoughts
• 9:23
  get
• 9:24
  kind
• 9:24
  of
• 9:24
  stuck.
• 9:24
  We
• 9:24
  feel
• 9:25
  compelled
• 9:25
  to
• 9:25
  continue
• 9:26
  to
• 9:26
  engage
• 9:26
  in
• 9:26
  those
• 9:27
  thoughts
• 9:27
  and
• 9:27
  we
• 9:27
  don't
• 9:28
  really
• 9:28
  have
• 9:28
  a
• 9:28
  break
• 9:29
  to
• 9:29
  stop
• 9:29
  the
• 9:29
  thought.
• 9:30
  But
• 9:30
  lo
• 9:31
  and
• 9:31
  behold,
• 9:31
  through
• 9:31
  your
• 9:32
  prefrontal
• 9:32
  dopamine
• 9:33
  enhancement
• 9:33
  with
• 9:34
  sigma
• 9:34
  1
• 9:34
  receptor
• 9:35
  agonism,
• 9:35
  bam,
• 9:36
  you
• 9:36
  have
• 9:36
  that
• 9:36
  dopamine
• 9:37
  in
• 9:37
  the
• 9:37
  prefrontal
• 9:37
  cortex,
• 9:38
  that
• 9:38
  top
• 9:38
  down
• 9:39
  CEO
• 9:40
  that
• 9:40
  can
• 9:40
  inhibit
• 9:40
  those
• 9:41
  obsessive
• 9:41
  thoughts
• 9:42
  more
• 9:42
  readily.
• 9:42
  And
• 9:43
  so
• 9:43
  why
• 9:43
  is
• 9:43
  this?
• 9:44
  One
• 9:44
  of
• 9:44
  the
• 9:44
  reasons
• 9:44
  this
• 9:45
  is
• 9:45
  FDA
• 9:45
  approved
• 9:45
  for
• 9:46
  ocd
• 9:47
  might
• 9:47
  have
• 9:47
  to
• 9:47
  do
• 9:47
  with
• 9:47
  the
• 9:48
  prefrontal
• 9:48
  dopamine
• 9:49
  enhancement.
• 9:49
  Right.
• 9:50
  That's
• 9:50
  extremely
• 9:51
  important
• 9:52
  because
• 9:52
  again,
• 9:52
  that's
• 9:52
  a
• 9:53
  very
• 9:53
  entrenched
• 9:53
  pathway.
• 9:54
  And
• 9:55
  so
• 9:55
  if
• 9:55
  you
• 9:55
  can
• 9:56
  try
• 9:56
  and
• 9:56
  modulate
• 9:57
  obsessional
• 9:58
  thoughts
• 9:58
  and
• 9:58
  compulsions
• 9:59
  in
• 9:59
  Any
• 9:59
  way
• 9:59
  you
• 9:59
  can
• 10:00
  beyond
• 10:00
  just
• 10:01
  serotonin
• 10:01
  reuptake
• 10:02
  inhibition,
• 10:03
  then
• 10:03
  if
• 10:04
  Sigma
• 10:04
  1
• 10:04
  is
• 10:05
  a
• 10:05
  great
• 10:05
  way
• 10:05
  to
• 10:05
  do
• 10:05
  that,
• 10:06
  which
• 10:06
  leads
• 10:06
  to
• 10:07
  again,
• 10:07
  more
• 10:07
  prefrontal
• 10:08
  dopamine,
• 10:09
  very
• 10:09
  important,
• 10:10
  even
• 10:10
  bigger
• 10:11
  bonus
• 10:11
  that
• 10:11
  you
• 10:12
  can
• 10:12
  stop
• 10:12
  the
• 10:12
  inflammatory
• 10:13
  cascade
• 10:13
  that
• 10:14
  might
• 10:14
  be
• 10:14
  detrimental
• 10:14
  to
• 10:15
  neurotransmitters
• 10:15
  and
• 10:15
  make
• 10:16
  it
• 10:16
  even
• 10:16
  harder
• 10:17
  to
• 10:17
  promote
• 10:18
  dopamine
• 10:18
  synthesis
• 10:19
  and
• 10:19
  thereby
• 10:20
  exhibit
• 10:21
  top
• 10:21
  down
• 10:21
  control
• 10:22
  of
• 10:22
  those
• 10:22
  circuits.
• 10:23
  So
• 10:23
  very
• 10:24
  neat
• 10:24
  thing
• 10:24
  that
• 10:24
  Luvox
• 10:25
  is
• 10:26
  actually
• 10:26
  doing
• 10:26
  here
• 10:27
  and
• 10:27
  I
• 10:27
  think
• 10:27
  it's
• 10:28
  a
• 10:28
  pretty
• 10:28
  useful
• 10:29
  weapon
• 10:30
  in
• 10:30
  O
• 10:30
  C
• 10:30
  D.
• 10:31
  Again,
• 10:32
  you
• 10:32
  can
• 10:32
  imagine
• 10:32
  how
• 10:32
  it's
• 10:33
  effective
• 10:33
  in
• 10:33
  social
• 10:33
  anxiety
• 10:34
  disorder
• 10:35
  to
• 10:35
  kind
• 10:35
  of
• 10:35
  stop
• 10:36
  that
• 10:36
  anxiety
• 10:37
  response
• 10:37
  with
• 10:37
  just
• 10:38
  more
• 10:38
  top
• 10:38
  down
• 10:39
  inhibition,
• 10:40
  the
• 10:40
  block
• 10:41
  of
• 10:41
  the
• 10:41
  reuptake
• 10:42
  of
• 10:42
  serotonin.
• 10:42
  Of
• 10:43
  course,
• 10:43
  we've
• 10:43
  talked
• 10:43
  about
• 10:43
  in
• 10:44
  our
• 10:44
  recent
• 10:44
  episode
• 10:45
  how
• 10:45
  serotonin
• 10:46
  is
• 10:46
  less
• 10:46
  of
• 10:47
  a
• 10:47
  happy
• 10:47
  neurotransmitter
• 10:49
  in
• 10:49
  and
• 10:49
  of
• 10:49
  itself
• 10:50
  and
• 10:50
  instead
• 10:50
  it
• 10:50
  sort
• 10:51
  of
• 10:51
  attenuates
• 10:51
  or
• 10:52
  lessens
• 10:52
  the
• 10:52
  emotional
• 10:53
  reactivity
• 10:54
  to
• 10:54
  a
• 10:54
  situation.
• 10:55
  So
• 10:55
  you
• 10:55
  can
• 10:55
  imagine
• 10:56
  how
• 10:56
  that's
• 10:56
  very
• 10:56
  helpful
• 10:57
  in
• 10:57
  social
• 10:57
  anxiety
• 10:58
  disorder
• 10:58
  where
• 10:58
  maybe
• 10:59
  we
• 10:59
  have
• 10:59
  obsessional
• 11:00
  thoughts
• 11:00
  about
• 11:00
  how
• 11:01
  we're
• 11:01
  being
• 11:01
  perceived.
• 11:02
  And
• 11:03
  well,
• 11:03
  lo
• 11:03
  and
• 11:03
  behold,
• 11:03
  now
• 11:04
  we
• 11:04
  have
• 11:04
  more
• 11:04
  top
• 11:04
  down
• 11:05
  control
• 11:05
  with
• 11:05
  dopamine
• 11:06
  in
• 11:06
  the
• 11:06
  prefrontal
• 11:06
  cortex
• 11:07
  via
• 11:07
  sigma
• 11:08
  agonism.
• 11:09
  And
• 11:09
  then
• 11:09
  boom.
• 11:09
  We
• 11:10
  also
• 11:10
  have
• 11:11
  serotonin
• 11:11
  reuptake
• 11:12
  inhibition
• 11:12
  where
• 11:12
  there's
• 11:12
  more
• 11:13
  serotonin
• 11:13
  in
• 11:13
  the
• 11:13
  synapse
• 11:14
  that's
• 11:14
  telling
• 11:14
  us,
• 11:14
  hey,
• 11:15
  everything's
• 11:15
  gonna
• 11:15
  be
• 11:15
  okay,
• 11:16
  kind
• 11:16
  of
• 11:16
  attenuating
• 11:17
  or
• 11:18
  modifying
• 11:19
  our
• 11:19
  extreme
• 11:20
  reactions
• 11:21
  to,
• 11:21
  to
• 11:22
  our
• 11:22
  sources
• 11:22
  of
• 11:22
  anxiety
• 11:23
  and
• 11:23
  things
• 11:23
  like
• 11:24
  that.
• 11:24
  So
• 11:24
  that's
• 11:25
  pretty
• 11:25
  darn
• 11:26
  cool.
• 11:26
  Also,
• 11:27
  Luvox
• 11:28
  is
• 11:28
  known.
• 11:28
  Some
• 11:29
  of
• 11:29
  the
• 11:29
  evidence
• 11:29
  shows
• 11:30
  that
• 11:30
  it's
• 11:30
  not
• 11:30
  as
• 11:30
  likely
• 11:31
  to
• 11:31
  cause
• 11:31
  weight
• 11:31
  gain
• 11:32
  or
• 11:32
  sexual
• 11:32
  side
• 11:32
  effects.
• 11:33
  So
• 11:33
  that
• 11:33
  can
• 11:34
  be
• 11:34
  a
• 11:34
  pretty
• 11:34
  neat
• 11:35
  added
• 11:35
  benefit
• 11:35
  to
• 11:36
  prescribe
• 11:36
  Luvox.
• 11:38
  Another
• 11:38
  really
• 11:38
  neat
• 11:39
  thing
• 11:39
  that
• 11:39
  can
• 11:40
  be
• 11:40
  a
• 11:40
  problem,
• 11:40
  don't
• 11:41
  get
• 11:41
  me
• 11:41
  wrong,
• 11:41
  but
• 11:41
  it
• 11:41
  also
• 11:41
  can
• 11:42
  be
• 11:42
  used
• 11:42
  to
• 11:42
  your
• 11:42
  advantage.
• 11:43
  Is
• 11:43
  there's
• 11:44
  evidence
• 11:44
  that
• 11:44
  Luvox
• 11:45
  potently
• 11:46
  inhibits
• 11:47
  the
• 11:47
  hepatic
• 11:47
  metabolism
• 11:48
  of
• 11:48
  melatonin,
• 11:49
  okay.
• 11:49
  Via
• 11:49
  the
• 11:49
  CYP1A2
• 11:51
  blockade.
• 11:51
  Now
• 11:51
  my
• 11:52
  friends,
• 11:53
  you
• 11:53
  probably
• 11:54
  already
• 11:54
  know
• 11:54
  this.
• 11:54
  It's
• 11:55
  worth
• 11:55
  reinforcing
• 11:56
  though
• 11:56
  that
• 11:56
  not
• 11:57
  all
• 11:57
  CYP
• 11:59
  interactions
• 11:59
  are
• 12:00
  negative.
• 12:00
  We
• 12:00
  can
• 12:00
  actually
• 12:01
  leverage
• 12:01
  those
• 12:02
  to
• 12:03
  be
• 12:03
  quite
• 12:03
  beneficial.
• 12:04
  As
• 12:04
  a
• 12:04
  matter
• 12:05
  of
• 12:05
  fact,
• 12:05
  there
• 12:05
  are
• 12:06
  some
• 12:06
  folks
• 12:06
  who
• 12:06
  intentionally
• 12:07
  use
• 12:08
  CYP
• 12:08
  inhibition
• 12:09
  with
• 12:09
  Clozapine
• 12:10
  and
• 12:10
  Luvox
• 12:11
  to,
• 12:12
  to
• 12:12
  achieve
• 12:13
  therapeutic
• 12:14
  goals
• 12:14
  with
• 12:14
  Clozapine
• 12:15
  at
• 12:16
  lower
• 12:16
  doses
• 12:17
  because
• 12:17
  they
• 12:18
  know
• 12:18
  that
• 12:18
  the
• 12:19
  Luvox
• 12:19
  is
• 12:19
  inhibiting
• 12:20
  it.
• 12:20
  So
• 12:21
  lower
• 12:21
  doses
• 12:21
  are
• 12:22
  required
• 12:22
  to
• 12:22
  achieve
• 12:23
  the
• 12:23
  therapeutic
• 12:24
  effects,
• 12:25
  but
• 12:25
  via
• 12:25
  that
• 12:25
  inhibition
• 12:26
  without
• 12:26
  the
• 12:26
  extra
• 12:27
  side
• 12:27
  effects.
• 12:27
  So
• 12:28
  when
• 12:28
  you
• 12:28
  use
• 12:29
  this
• 12:29
  Intentionally
• 12:30
  and
• 12:30
  purposefully.
• 12:31
  CYP
• 12:31
  interactions
• 12:32
  can
• 12:32
  actually
• 12:32
  benefit
• 12:33
  you,
• 12:33
  but
• 12:33
  of
• 12:33
  course,
• 12:34
  they
• 12:34
  can
• 12:34
  also
• 12:34
  cause
• 12:34
  headaches,
• 12:35
  unforeseen
• 12:36
  challenges.
• 12:37
  The
• 12:37
  biggest
• 12:38
  being
• 12:38
  that,
• 12:38
  you
• 12:38
  know,
• 12:38
  you
• 12:38
  start
• 12:39
  someone
• 12:39
  on
• 12:39
  an
• 12:39
  inhibitor,
• 12:40
  you
• 12:40
  know,
• 12:41
  you
• 12:41
  see
• 12:41
  them
• 12:41
  regularly,
• 12:41
  but
• 12:42
  maybe
• 12:42
  they
• 12:42
  don't
• 12:42
  tell
• 12:42
  you
• 12:43
  about
• 12:43
  their,
• 12:43
  their
• 12:44
  PCP
• 12:44
  appointment
• 12:45
  they
• 12:45
  had
• 12:45
  in
• 12:45
  between
• 12:46
  sessions,
• 12:46
  or
• 12:47
  they
• 12:47
  don't
• 12:47
  tell
• 12:47
  their
• 12:47
  primary
• 12:48
  care
• 12:48
  doc
• 12:48
  that
• 12:48
  they're
• 12:48
  on
• 12:48
  luvox.
• 12:49
  Maybe
• 12:50
  the
• 12:50
  EHRs
• 12:50
  aren't
• 12:51
  integrating
• 12:51
  together,
• 12:51
  they're
• 12:52
  two
• 12:52
  separate
• 12:52
  systems.
• 12:53
  Right?
• 12:53
  So
• 12:54
  you
• 12:54
  can
• 12:54
  see
• 12:54
  how
• 12:54
  this
• 12:55
  can
• 12:55
  get
• 12:55
  really
• 12:55
  fuzzy
• 12:56
  really
• 12:56
  quickly.
• 12:56
  Maybe
• 12:57
  they're
• 12:57
  paying
• 12:57
  you
• 12:57
  cash,
• 12:58
  pay,
• 12:58
  and
• 12:59
  your
• 12:59
  documentation
• 13:00
  is
• 13:00
  not
• 13:00
  even
• 13:00
  visible
• 13:01
  by
• 13:01
  their
• 13:01
  primary
• 13:02
  care
• 13:02
  doc.
• 13:02
  And
• 13:03
  oh
• 13:03
  my
• 13:03
  God,
• 13:03
  now
• 13:04
  they
• 13:04
  have
• 13:04
  this
• 13:04
  major
• 13:04
  inhibitor
• 13:05
  on
• 13:05
  board.
• 13:05
  The
• 13:05
  patient
• 13:06
  doesn't
• 13:06
  really
• 13:06
  think
• 13:06
  about
• 13:07
  CYP
• 13:08
  inhibition
• 13:08
  all
• 13:08
  day.
• 13:09
  And
• 13:10
  you
• 13:10
  haven't
• 13:10
  called
• 13:11
  that
• 13:11
  provider.
• 13:11
  Maybe
• 13:12
  you
• 13:12
  didn't
• 13:12
  even
• 13:12
  know
• 13:12
  they
• 13:12
  had
• 13:12
  a
• 13:13
  new
• 13:13
  provider.
• 13:13
  Maybe
• 13:13
  when
• 13:14
  you
• 13:14
  did
• 13:14
  your
• 13:14
  intake,
• 13:15
  they
• 13:15
  didn't
• 13:15
  have
• 13:15
  a
• 13:15
  provider.
• 13:16
  Now
• 13:16
  they
• 13:16
  do.
• 13:17
  And
• 13:17
  so
• 13:18
  this
• 13:18
  is
• 13:18
  all
• 13:18
  getting
• 13:18
  lost
• 13:19
  in
• 13:19
  the
• 13:19
  sauce
• 13:19
  that
• 13:19
  there's
• 13:20
  this
• 13:20
  potent
• 13:20
  inhibitor.
• 13:21
  And
• 13:21
  maybe
• 13:22
  the
• 13:22
  PCP
• 13:23
  didn't,
• 13:23
  didn't
• 13:23
  ask
• 13:24
  about
• 13:24
  psychiatric
• 13:24
  medications
• 13:25
  or
• 13:25
  didn't
• 13:25
  quite
• 13:26
  catch
• 13:26
  it,
• 13:26
  or
• 13:26
  maybe
• 13:27
  the
• 13:27
  patient
• 13:27
  assumed
• 13:27
  this
• 13:28
  PCP
• 13:29
  had
• 13:30
  record
• 13:30
  of
• 13:30
  that
• 13:30
  already,
• 13:31
  and
• 13:31
  they
• 13:31
  don't.
• 13:31
  And
• 13:32
  lo
• 13:32
  and
• 13:32
  behold,
• 13:32
  you
• 13:33
  have
• 13:33
  this
• 13:33
  big
• 13:33
  problem.
• 13:34
  But
• 13:34
  with
• 13:34
  melatonin,
• 13:35
  this
• 13:36
  is
• 13:36
  a
• 13:36
  bit
• 13:36
  of
• 13:36
  leverage,
• 13:36
  because
• 13:37
  if
• 13:37
  you
• 13:38
  have
• 13:38
  Luvox
• 13:38
  on
• 13:39
  board
• 13:39
  and
• 13:39
  the
• 13:39
  patient's
• 13:39
  taking
• 13:40
  Melatonin,
• 13:41
  some
• 13:41
  evidence
• 13:41
  suggests
• 13:42
  a
• 13:42
  three
• 13:42
  fold
• 13:43
  higher
• 13:44
  nocturnal
• 13:44
  melatonin
• 13:45
  peak
• 13:45
  after
• 13:45
  a
• 13:46
  single
• 13:46
  dose.
• 13:46
  And
• 13:47
  that's
• 13:47
  not
• 13:47
  the
• 13:47
  case
• 13:47
  with,
• 13:48
  you
• 13:48
  know,
• 13:48
  Celexa
• 13:49
  or
• 13:49
  paxil
• 13:49
  or
• 13:49
  other
• 13:50
  SSRIs.
• 13:51
  So
• 13:52
  that's
• 13:52
  a
• 13:52
  way
• 13:52
  that
• 13:53
  you
• 13:53
  could
• 13:54
  actually
• 13:54
  leverage
• 13:55
  Melatonin
• 13:56
  to
• 13:56
  realign
• 13:56
  your
• 13:57
  patient's
• 13:57
  circadian
• 13:57
  rhythm.
• 13:58
  That
• 13:58
  can
• 13:58
  also
• 13:58
  backfire,
• 13:59
  though,
• 13:59
  if
• 14:00
  the
• 14:00
  peak
• 14:00
  levels
• 14:01
  are
• 14:01
  way
• 14:02
  too
• 14:02
  high
• 14:03
  and
• 14:03
  the
• 14:03
  overall,
• 14:04
  you
• 14:04
  know,
• 14:04
  what
• 14:04
  we
• 14:05
  call
• 14:05
  area
• 14:06
  under
• 14:06
  the
• 14:07
  curve.
• 14:07
  In
• 14:08
  other
• 14:08
  words,
• 14:08
  just
• 14:09
  how
• 14:10
  much
• 14:10
  medication
• 14:12
  is,
• 14:12
  is
• 14:12
  being
• 14:13
  therapeutically
• 14:15
  exerted
• 14:15
  at,
• 14:16
  at
• 14:17
  any
• 14:17
  given
• 14:17
  time
• 14:17
  during
• 14:17
  the
• 14:18
  entire
• 14:18
  administration.
• 14:19
  Right?
• 14:19
  So
• 14:19
  the
• 14:19
  area
• 14:20
  under
• 14:20
  the
• 14:21
  curve
• 14:21
  is
• 14:21
  also
• 14:22
  going
• 14:22
  to
• 14:22
  increase
• 14:23
  because
• 14:23
  that
• 14:23
  could
• 14:23
  mean
• 14:24
  daytime
• 14:24
  sedation
• 14:25
  if
• 14:25
  you
• 14:25
  inhibited
• 14:26
  melatonin
• 14:27
  and
• 14:27
  it
• 14:27
  went
• 14:27
  overboard.
• 14:28
  Of
• 14:28
  course
• 14:28
  that
• 14:28
  can
• 14:29
  be
• 14:29
  different.
• 14:29
  And
• 14:29
  remember,
• 14:29
  it's
• 14:30
  different
• 14:30
  in
• 14:30
  every
• 14:30
  patient.
• 14:31
  It's
• 14:31
  not
• 14:31
  like
• 14:31
  every
• 14:32
  patient's
• 14:32
  going
• 14:32
  to
• 14:32
  have
• 14:32
  a
• 14:32
  threefold
• 14:33
  higher
• 14:33
  melatonin
• 14:34
  peak.
• 14:35
  Right?
• 14:35
  That
• 14:35
  could
• 14:36
  be
• 14:36
  six
• 14:36
  fold
• 14:36
  for
• 14:36
  someone
• 14:37
  else,
• 14:37
  it
• 14:37
  could
• 14:37
  be
• 14:37
  twofold
• 14:38
  for
• 14:38
  another
• 14:38
  person.
• 14:39
  It
• 14:39
  all
• 14:39
  kind
• 14:39
  of
• 14:39
  depends
• 14:40
  on
• 14:40
  how
• 14:40
  we
• 14:40
  metabolize
• 14:41
  our
• 14:41
  medications.
• 14:42
  But
• 14:42
  that
• 14:42
  is
• 14:42
  something
• 14:43
  you
• 14:43
  could
• 14:43
  potentially
• 14:43
  use
• 14:44
  to
• 14:44
  your
• 14:44
  advantage.
• 14:45
  I
• 14:45
  know,
• 14:45
  I'm
• 14:45
  a
• 14:46
  sucker.
• 14:46
  And
• 14:47
  I
• 14:47
  have
• 14:47
  a
• 14:47
  soft
• 14:48
  spot
• 14:48
  for
• 14:48
  any
• 14:49
  antidepressant
• 14:50
  that
• 14:50
  helps
• 14:50
  you
• 14:50
  sleep.
• 14:51
  I'm
• 14:51
  a
• 14:51
  big
• 14:51
  believer
• 14:52
  in
• 14:52
  that.
• 14:52
  And
• 14:53
  my
• 14:53
  hesitancy
• 14:54
  with
• 14:54
  prescribing
• 14:54
  Luvox
• 14:55
  is
• 14:55
  because
• 14:55
  of
• 14:55
  the
• 14:56
  drug
• 14:56
  interactions.
• 14:57
  I
• 14:57
  think
• 14:57
  if
• 14:57
  you
• 14:57
  have
• 14:58
  a
• 14:58
  patient
• 14:58
  that
• 14:59
  can't
• 14:59
  sleep
• 15:00
  and
• 15:00
  really
• 15:00
  needs
• 15:01
  to
• 15:01
  sleep
• 15:02
  and
• 15:03
  they,
• 15:04
  and
• 15:04
  you're,
• 15:04
  you
• 15:04
  know,
• 15:05
  I
• 15:06
  maybe
• 15:06
  obsessional
• 15:07
  thought
• 15:07
  circuits
• 15:08
  too.
• 15:08
  You
• 15:08
  think
• 15:09
  they
• 15:09
  have
• 15:09
  OCD
• 15:09
  or
• 15:10
  they
• 15:10
  might
• 15:10
  have
• 15:10
  obsessional
• 15:10
  thought
• 15:11
  processes.
• 15:11
  Maybe
• 15:12
  you
• 15:12
  didn't
• 15:12
  declaratively
• 15:13
  diagnose
• 15:14
  ocd,
• 15:14
  but
• 15:14
  you
• 15:15
  highly
• 15:15
  suspect
• 15:15
  it,
• 15:16
  which
• 15:16
  is
• 15:16
  so
• 15:16
  often
• 15:17
  the
• 15:17
  case.
• 15:17
  Right.
• 15:17
  We
• 15:17
  don't
• 15:18
  just
• 15:18
  come
• 15:18
  in
• 15:18
  and
• 15:19
  cleanly
• 15:19
  diagnose
• 15:20
  everyone
• 15:20
  on
• 15:20
  day
• 15:20
  one.
• 15:21
  This
• 15:21
  could
• 15:21
  be
• 15:22
  a
• 15:22
  good
• 15:22
  hedge.
• 15:22
  Cause
• 15:23
  it's
• 15:23
  like,
• 15:23
  okay,
• 15:23
  I'm
• 15:23
  gonna
• 15:23
  get
• 15:23
  my
• 15:24
  patient
• 15:24
  to
• 15:24
  fall
• 15:24
  asleep.
• 15:25
  I'm
• 15:25
  going
• 15:25
  to
• 15:26
  potentially
• 15:27
  inhibit
• 15:27
  some
• 15:28
  of
• 15:28
  those
• 15:28
  obsessional
• 15:28
  thought
• 15:29
  patterns
• 15:29
  and
• 15:29
  break
• 15:30
  the.
• 15:30
  Break
• 15:31
  those
• 15:31
  obsessional
• 15:31
  compulsion,
• 15:32
  compulsive
• 15:33
  thought
• 15:33
  cycles
• 15:34
  in,
• 15:35
  in
• 15:35
  the
• 15:35
  CTSC
• 15:37
  circuit.
• 15:37
  I
• 15:38
  think
• 15:38
  sleep
• 15:38
  is
• 15:38
  just
• 15:38
  so
• 15:39
  transdiagnostic,
• 15:39
  it
• 15:40
  can
• 15:40
  independently
• 15:41
  improve
• 15:41
  depressive
• 15:42
  symptoms
• 15:43
  regardless.
• 15:44
  And
• 15:44
  so
• 15:45
  that
• 15:45
  alone
• 15:45
  is,
• 15:45
  is
• 15:46
  a
• 15:46
  very
• 15:46
  appealing
• 15:47
  piece
• 15:47
  of
• 15:47
  Remeron.
• 15:48
  And
• 15:48
  also
• 15:48
  why
• 15:48
  I
• 15:49
  love
• 15:49
  Luvox,
• 15:49
  because
• 15:50
  most
• 15:50
  of
• 15:50
  the
• 15:50
  other
• 15:51
  antidepressants
• 15:51
  I
• 15:51
  prescribe,
• 15:52
  Prozac,
• 15:52
  Zoloft,
• 15:53
  Lexapro,
• 15:53
  they
• 15:54
  don't
• 15:54
  make
• 15:54
  people
• 15:54
  sleepy.
• 15:55
  In
• 15:55
  fact,
• 15:55
  they
• 15:55
  can
• 15:55
  make
• 15:55
  them
• 15:56
  more
• 15:56
  wired,
• 15:56
  can
• 15:57
  make
• 15:57
  it
• 15:57
  harder
• 15:57
  to
• 15:57
  sleep
• 15:58
  at
• 15:58
  times.
• 15:59
  So
• 15:59
  that,
• 16:00
  to
• 16:00
  me
• 16:00
  is
• 16:00
  one
• 16:00
  of
• 16:00
  my
• 16:01
  biggest
• 16:01
  things
• 16:01
  I
• 16:02
  wish
• 16:02
  I
• 16:02
  could
• 16:02
  change
• 16:02
  if
• 16:02
  I
• 16:03
  had
• 16:03
  a
• 16:03
  magic
• 16:03
  wand,
• 16:03
  is
• 16:03
  if
• 16:04
  antidepressants
• 16:05
  could
• 16:05
  reliably
• 16:06
  make
• 16:06
  people
• 16:06
  sleep
• 16:07
  and
• 16:07
  improve
• 16:07
  sleep
• 16:08
  architecture.
• 16:09
  Of
• 16:09
  course,
• 16:10
  that's
• 16:10
  not
• 16:10
  always
• 16:11
  realistic,
• 16:12
  but
• 16:12
  hey,
• 16:13
  it's
• 16:13
  something
• 16:13
  I,
• 16:13
  I
• 16:14
  wish
• 16:14
  for.
• 16:14
  So
• 16:15
  I
• 16:15
  hope
• 16:15
  you
• 16:15
  have
• 16:15
  a
• 16:15
  better
• 16:16
  idea
• 16:16
  of
• 16:16
  what
• 16:17
  Luvox
• 16:17
  can
• 16:18
  offer,
• 16:18
  what
• 16:18
  it
• 16:18
  does.
• 16:19
  I
• 16:19
  think
• 16:19
  your
• 16:19
  ideal
• 16:21
  patient
• 16:21
  with,
• 16:22
  you
• 16:22
  know,
• 16:22
  who
• 16:22
  you
• 16:22
  may
• 16:23
  prescribe
• 16:23
  Luvox
• 16:24
  for
• 16:24
  is
• 16:25
  probably
• 16:25
  someone
• 16:25
  with
• 16:25
  OCD
• 16:26
  or
• 16:26
  social
• 16:27
  anxiety,
• 16:27
  maybe
• 16:28
  depression
• 16:28
  with
• 16:29
  a
• 16:29
  lot
• 16:29
  of
• 16:29
  cognitive
• 16:30
  complaints
• 16:30
  and
• 16:30
  comorbid
• 16:31
  insomnia.
• 16:32
  And
• 16:32
  the
• 16:32
  most
• 16:33
  important
• 16:33
  thing,
• 16:33
  of
• 16:33
  course,
• 16:34
  is
• 16:34
  that
• 16:34
  they're
• 16:35
  not
• 16:35
  on
• 16:35
  medications
• 16:36
  that
• 16:36
  are
• 16:36
  metabolized
• 16:37
  by,
• 16:37
  you
• 16:37
  know,
• 16:38
  1A2
• 16:38
  or
• 16:39
  C,
• 16:39
  C1
• 16:40
  9
• 16:40
  or
• 16:40
  3A4.
• 16:41
  Right.
• 16:42
  Those
• 16:42
  are
• 16:42
  the
• 16:43
  inhib.
• 16:43
  You
• 16:43
  know,
• 16:43
  Luvox
• 16:44
  can
• 16:44
  inhibit
• 16:45
  those.
• 16:46
  And
• 16:46
  so
• 16:46
  those
• 16:46
  medications
• 16:47
  and
• 16:47
  raise
• 16:47
  their
• 16:48
  levels
• 16:48
  to
• 16:49
  toxic
• 16:50
  levels
• 16:50
  or
• 16:51
  increase
• 16:51
  major
• 16:51
  side
• 16:52
  effects.
• 16:52
  That's
• 16:53
  a
• 16:53
  big
• 16:53
  problem,
• 16:54
  right?
• 16:54
  It
• 16:54
  is
• 16:55
  a
• 16:55
  new
• 16:55
  arrow
• 16:55
  in
• 16:56
  your
• 16:56
  quiver,
• 16:56
  and
• 16:56
  I
• 16:56
  think
• 16:56
  you
• 16:57
  should
• 16:57
  consider
• 16:57
  it
• 16:57
  for
• 16:58
  sure
• 16:58
  when
• 16:59
  it
• 16:59
  makes
• 16:59
  sense.
• 17:00
  Watch
• 17:01
  out
• 17:01
  for
• 17:01
  inflammation
• 17:02
  and
• 17:02
  how
• 17:03
  this
• 17:03
  can
• 17:03
  potentially
• 17:04
  help
• 17:04
  with
• 17:04
  that.
• 17:05
  Embrace
• 17:05
  the
• 17:05
  neuroprotection,
• 17:06
  the
• 17:06
  neuroplasticity,
• 17:07
  the
• 17:07
  prefrontal
• 17:08
  dopamine
• 17:08
  enhancement,
• 17:09
  that
• 17:09
  sigma
• 17:09
  1
• 17:10
  receptor,
• 17:10
  that
• 17:10
  potent
• 17:11
  affinity
• 17:11
  for
• 17:11
  sigma
• 17:12
  1,
• 17:12
  which
• 17:12
  separates
• 17:13
  this
• 17:13
  from
• 17:13
  other
• 17:14
  from
• 17:14
  other
• 17:15
  SSRIs.
• 17:16
  And
• 17:16
  that's
• 17:16
  a
• 17:16
  really
• 17:17
  big
• 17:17
  deal
• 17:17
  when
• 17:17
  you're
• 17:17
  battling
• 17:18
  OCD,
• 17:18
  because
• 17:19
  as
• 17:19
  we
• 17:19
  know,
• 17:19
  it's
• 17:20
  not
• 17:20
  that
• 17:20
  simple
• 17:21
  with
• 17:21
  OCD,
• 17:21
  right?
• 17:22
  It's
• 17:22
  not
• 17:22
  as
• 17:22
  simple
• 17:22
  that
• 17:22
  this
• 17:23
  is
• 17:23
  a
• 17:23
  serotonergic
• 17:24
  deficiency.
• 17:25
  This
• 17:25
  is
• 17:25
  a
• 17:25
  much
• 17:26
  more
• 17:26
  ingrained
• 17:27
  neurobiological
• 17:28
  thought
• 17:29
  loop
• 17:29
  that
• 17:30
  has
• 17:30
  a
• 17:30
  distinct
• 17:30
  pattern
• 17:31
  and
• 17:31
  neurobiological
• 17:32
  signature
• 17:33
  in
• 17:33
  the
• 17:33
  brain.
• 17:33
  Again,
• 17:33
  the
• 17:34
  ctsc,
• 17:34
  the
• 17:35
  corticostriatothalamocortical
• 17:36
  pathway,
• 17:37
  it's.
• 17:38
  It's
• 17:38
  much
• 17:38
  more
• 17:38
  ingrained
• 17:39
  and
• 17:39
  it
• 17:39
  requires
• 17:40
  the
• 17:40
  modulation
• 17:41
  of
• 17:42
  a
• 17:42
  lot
• 17:42
  more
• 17:42
  than
• 17:43
  just
• 17:43
  serotonin,
• 17:44
  right?
• 17:44
  There's
• 17:44
  glutamate,
• 17:45
  there's
• 17:45
  dopamine.
• 17:46
  And
• 17:46
  so
• 17:46
  we
• 17:46
  can't
• 17:47
  attack
• 17:47
  that,
• 17:47
  usually
• 17:48
  through
• 17:48
  one
• 17:48
  mechanism.
• 17:49
  So
• 17:49
  I
• 17:49
  think.
• 17:50
  I
• 17:50
  think
• 17:50
  Luvox
• 17:51
  does
• 17:51
  offer
• 17:51
  a
• 17:51
  little
• 17:52
  bit
• 17:52
  more
• 17:52
  in
• 17:52
  that
• 17:52
  regard.
• 17:54
  And
• 17:54
  so
• 17:55
  just
• 17:55
  keep
• 17:55
  it
• 17:56
  in
• 17:56
  mind.
• 17:56
  Keep
• 17:56
  it
• 17:56
  in
• 17:56
  your
• 17:57
  back
• 17:57
  pocket.
• 17:57
  And
• 17:58
  now,
• 17:58
  my
• 17:58
  friends,
• 17:59
  I
• 17:59
  can't
• 17:59
  emphasize
• 18:00
  enough.
• 18:01
  If
• 18:01
  there's
• 18:01
  one
• 18:01
  thing
• 18:01
  you
• 18:02
  don't
• 18:02
  forget
• 18:02
  to
• 18:02
  do
• 18:03
  before
• 18:03
  you
• 18:03
  go
• 18:03
  to
• 18:03
  bed
• 18:04
  tonight,
• 18:04
  highly
• 18:04
  recommend
• 18:05
  you
• 18:05
  go
• 18:05
  into
• 18:05
  our
• 18:06
  Show
• 18:06
  Notes
• 18:06
  and
• 18:06
  become
• 18:06
  a
• 18:07
  Patreon
• 18:07
  member.
• 18:08
  I
• 18:08
  will
• 18:08
  tell
• 18:08
  you
• 18:09
  now,
• 18:09
  I
• 18:09
  am
• 18:10
  genuinely
• 18:10
  terrified
• 18:11
  of
• 18:11
  who
• 18:11
  I
• 18:11
  would
• 18:11
  be
• 18:11
  as
• 18:12
  a
• 18:12
  clinician
• 18:12
  if
• 18:12
  I
• 18:12
  didn't
• 18:13
  have
• 18:13
  access
• 18:13
  to
• 18:14
  this
• 18:14
  full
• 18:14
  clinical
• 18:15
  library.
• 18:15
  It
• 18:16
  makes
• 18:16
  all
• 18:16
  of
• 18:16
  these
• 18:17
  concepts
• 18:17
  sticky
• 18:18
  and
• 18:18
  fun
• 18:18
  and
• 18:18
  visually
• 18:19
  incredible.
• 18:20
  I
• 18:20
  would
• 18:21
  be
• 18:21
  lost
• 18:21
  without
• 18:21
  this
• 18:22
  today.
• 18:22
  And,
• 18:23
  you
• 18:23
  know,
• 18:24
  the
• 18:24
  difference
• 18:24
  between
• 18:25
  a
• 18:25
  good
• 18:25
  and
• 18:25
  a
• 18:26
  great
• 18:27
  clinician
• 18:27
  is
• 18:27
  are
• 18:27
  the
• 18:28
  ones
• 18:28
  who
• 18:28
  really
• 18:28
  understand
• 18:29
  the
• 18:29
  how
• 18:29
  and
• 18:29
  the
• 18:29
  why
• 18:30
  of
• 18:30
  what
• 18:30
  we're
• 18:30
  doing.
• 18:30
  And
• 18:31
  patients
• 18:31
  smell
• 18:31
  that
• 18:31
  a
• 18:32
  mile
• 18:32
  away.
• 18:33
  And
• 18:33
  I
• 18:33
  built
• 18:34
  this
• 18:34
  library
• 18:35
  so
• 18:35
  that
• 18:35
  you
• 18:35
  would
• 18:36
  understand
• 18:36
  the
• 18:36
  how
• 18:36
  and
• 18:36
  the
• 18:37
  why.
• 18:37
  The
• 18:37
  nitty
• 18:37
  gritty.
• 18:38
  Why
• 18:38
  are
• 18:38
  we
• 18:38
  switching?
• 18:39
  You
• 18:39
  know,
• 18:39
  the
• 18:39
  patient
• 18:40
  might
• 18:40
  wonder,
• 18:40
  why
• 18:40
  are
• 18:41
  we
• 18:41
  going
• 18:41
  to
• 18:41
  Luvox?
• 18:41
  What
• 18:42
  can
• 18:42
  you
• 18:42
  tell
• 18:42
  me?
• 18:42
  Well,
• 18:42
  how
• 18:42
  is
• 18:43
  that
• 18:43
  different
• 18:43
  than
• 18:43
  Prozac?
• 18:44
  They
• 18:45
  ask
• 18:45
  a
• 18:45
  lot
• 18:45
  of
• 18:45
  questions,
• 18:46
  and
• 18:47
  it's
• 18:47
  important
• 18:48
  that
• 18:48
  you're
• 18:48
  empowered
• 18:49
  to
• 18:49
  answer
• 18:49
  them.
• 18:49
  And
• 18:49
  it
• 18:50
  will
• 18:50
  transform
• 18:50
  your
• 18:51
  sense
• 18:51
  of
• 18:51
  confidence
• 18:51
  and
• 18:51
  efficacy
• 18:52
  in
• 18:52
  what
• 18:52
  you
• 18:52
  do.
• 18:53
  Go
• 18:53
  to
• 18:53
  the
• 18:53
  Show
• 18:53
  Notes,
• 18:54
  click
• 18:55
  the
• 18:55
  Show
• 18:55
  Notes,
• 18:56
  link
• 18:56
  to
• 18:57
  Patreon.
• 18:57
  Become
• 18:58
  a
• 18:58
  member.
• 18:58
  You
• 18:58
  will
• 18:58
  not
• 18:58
  regret
• 18:59
  it.
• 18:59
  We
• 18:59
  have
• 18:59
  rap
• 19:00
  songs,
• 19:00
  we
• 19:00
  have
• 19:00
  visual,
• 19:01
  really
• 19:02
  sticky
• 19:02
  visual
• 19:03
  mnemonics
• 19:04
  lectures.
• 19:04
  It
• 19:05
  is
• 19:05
  just
• 19:05
  a
• 19:06
  hoot
• 19:06
  on
• 19:07
  Patreon
• 19:07
  and
• 19:08
  it's
• 19:08
  growing
• 19:08
  fast.
• 19:09
  So
• 19:09
  without
• 19:09
  further
• 19:10
  ado,
• 19:10
  my
• 19:10
  friends,
• 19:10
  thank
• 19:10
  you
• 19:11
  for
• 19:11
  tuning
• 19:11
  in
• 19:11
  to
• 19:11
  Pearls
• 19:12
  and
• 19:12
  Prep.
• 19:12
  Bye
• 19:13
  bye.