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Paxil Withdrawal or Depression Relapse? The Difference Changes Everything · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:05
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  Prep.
• 0:08
  NPZ
• 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
• 0:12
  prep
• 0:13
  you
• 0:13
  to
• 0:13
  practice.
• 0:14
  Now,
• 0:14
  my
• 0:14
  friends,
• 0:15
  knocking
• 0:16
  on
• 0:16
  your
• 0:16
  door
• 0:16
  in
• 0:17
  the
• 0:17
  outpatient
• 0:17
  clinic
• 0:18
  is
• 0:19
  a
• 0:19
  woman
• 0:19
  named
• 0:20
  Terry.
• 0:21
  She's
• 0:21
  38
• 0:22
  years
• 0:22
  old
• 0:22
  and
• 0:23
  she
• 0:23
  needs
• 0:23
  your
• 0:23
  help.
• 0:24
  She
• 0:24
  needs
• 0:24
  your
• 0:25
  help
• 0:25
  badly.
• 0:26
  Okay?
• 0:27
  She
• 0:28
  has
• 0:29
  had
• 0:29
  one
• 0:30
  major
• 0:30
  depressive
• 0:31
  episode
• 0:31
  in
• 0:31
  her
• 0:31
  life.
• 0:31
  About
• 0:32
  two
• 0:32
  years
• 0:32
  ago,
• 0:33
  her
• 0:33
  doctor
• 0:33
  at
• 0:34
  the
• 0:34
  time
• 0:34
  put
• 0:34
  her
• 0:35
  on
• 0:35
  Paxil,
• 0:35
  which
• 0:36
  is
• 0:36
  a
• 0:36
  very
• 0:36
  strange
• 0:36
  thing
• 0:37
  to
• 0:37
  do
• 0:38
  for
• 0:38
  a
• 0:38
  female
• 0:39
  of
• 0:39
  reproductive
• 0:39
  age,
• 0:40
  as
• 0:40
  a
• 0:40
  first
• 0:41
  line
• 0:41
  treatment,
• 0:41
  but
• 0:42
  okay.
• 0:42
  It's
• 0:42
  possible.
• 0:43
  It's
• 0:43
  technically
• 0:44
  okay
• 0:44
  in
• 0:44
  the
• 0:44
  textbook,
• 0:45
  depending
• 0:45
  on
• 0:45
  the
• 0:46
  context,
• 0:46
  but
• 0:47
  they.
• 0:47
  He
• 0:47
  put
• 0:47
  her
• 0:48
  on
• 0:48
  Paxil
• 0:48
  20.
• 0:49
  She
• 0:49
  had
• 0:49
  a
• 0:50
  full
• 0:50
  remission
• 0:50
  of
• 0:50
  symptoms
• 0:51
  within
• 0:51
  eight
• 0:51
  weeks,
• 0:52
  which
• 0:52
  is
• 0:52
  great.
• 0:53
  And
• 0:53
  she's
• 0:53
  really
• 0:53
  been
• 0:53
  stable
• 0:54
  since
• 0:54
  then.
• 0:55
  But
• 0:56
  in
• 0:56
  the
• 0:56
  meantime,
• 0:57
  that
• 0:58
  provider
• 0:58
  has
• 0:59
  tapered
• 0:59
  down
• 1:00
  her
• 1:00
  Paxil
• 1:01
  week
• 1:01
  by
• 1:01
  week.
• 1:02
  Okay.
• 1:03
  She
• 1:04
  started
• 1:04
  at
• 1:04
  20,
• 1:04
  then
• 1:05
  she
• 1:05
  did
• 1:05
  10
• 1:05
  for
• 1:05
  a
• 1:06
  week,
• 1:06
  and
• 1:06
  then
• 1:06
  she
• 1:06
  kind
• 1:06
  of
• 1:06
  stopped
• 1:07
  entirely.
• 1:08
  Okay,
• 1:08
  so
• 1:08
  that's
• 1:08
  a
• 1:08
  fairly
• 1:09
  rapid
• 1:09
  taper.
• 1:10
  Okay.
• 1:11
  Over
• 1:11
  the
• 1:11
  course
• 1:11
  of
• 1:11
  about
• 1:12
  two
• 1:12
  weeks.
• 1:13
  Now
• 1:13
  it's
• 1:13
  been
• 1:13
  five
• 1:14
  days
• 1:14
  since.
• 1:14
  Since
• 1:14
  she's
• 1:15
  been
• 1:15
  on
• 1:15
  any
• 1:15
  Paxil
• 1:16
  at
• 1:16
  all.
• 1:17
  And
• 1:17
  she's
• 1:17
  coming
• 1:17
  to
• 1:17
  you
• 1:18
  crying.
• 1:19
  She's
• 1:19
  distraught.
• 1:20
  Her
• 1:20
  mood
• 1:21
  is
• 1:21
  terrible.
• 1:21
  She
• 1:22
  hasn't
• 1:22
  been
• 1:22
  sleeping.
• 1:23
  She
• 1:23
  can't
• 1:23
  concentrate
• 1:24
  or
• 1:24
  focus.
• 1:24
  She's
• 1:25
  really
• 1:25
  edgy
• 1:25
  and
• 1:26
  irritable
• 1:26
  and
• 1:26
  anxious.
• 1:27
  She's
• 1:27
  telling
• 1:27
  you
• 1:27
  about
• 1:28
  this
• 1:28
  buzzing
• 1:28
  sensation
• 1:29
  in
• 1:29
  her
• 1:29
  head.
• 1:30
  She's
• 1:30
  been
• 1:30
  nauseous
• 1:31
  here
• 1:31
  and
• 1:31
  there,
• 1:31
  throwing
• 1:32
  up,
• 1:32
  dizzy.
• 1:33
  And
• 1:33
  she's
• 1:34
  convinced
• 1:34
  her
• 1:34
  depression
• 1:35
  is
• 1:35
  back.
• 1:35
  And
• 1:35
  guess
• 1:36
  what?
• 1:36
  She
• 1:36
  wants
• 1:36
  you
• 1:37
  to
• 1:37
  put
• 1:37
  her
• 1:37
  back
• 1:38
  on
• 1:38
  Paxil.
• 1:40
  So
• 1:40
  what
• 1:40
  do
• 1:40
  you
• 1:40
  do
• 1:40
  here?
• 1:41
  What
• 1:41
  do
• 1:42
  you
• 1:42
  do
• 1:42
  here?
• 1:42
  Is
• 1:43
  this
• 1:43
  a
• 1:43
  resurgence
• 1:44
  of
• 1:44
  her
• 1:44
  depression
• 1:46
  or
• 1:47
  is
• 1:48
  this
• 1:48
  antidepressant
• 1:49
  SSRI
• 1:50
  discontinuation
• 1:51
  syndrome?
• 1:52
  Well,
• 1:52
  that's
• 1:52
  what
• 1:53
  you
• 1:53
  need
• 1:53
  to
• 1:53
  figure
• 1:53
  out.
• 1:54
  And
• 1:54
  if
• 1:55
  you're
• 1:55
  kind
• 1:55
  of
• 1:55
  new
• 1:55
  to
• 1:55
  the
• 1:56
  game,
• 1:56
  you
• 1:57
  might
• 1:57
  be
• 1:57
  very
• 1:57
  confused
• 1:58
  by
• 1:58
  this
• 1:59
  because
• 1:59
  the
• 2:00
  two
• 2:00
  symptoms
• 2:01
  or
• 2:01
  responses
• 2:02
  can
• 2:02
  look
• 2:03
  identical.
• 2:04
  Dysphoria,
• 2:05
  irritability,
• 2:06
  not
• 2:06
  sleeping,
• 2:07
  poor
• 2:08
  concentration,
• 2:09
  brain
• 2:09
  fog,
• 2:10
  just
• 2:10
  your
• 2:11
  mood
• 2:11
  is
• 2:11
  crap.
• 2:12
  Right?
• 2:12
  And
• 2:13
  again,
• 2:13
  your.
• 2:13
  Your
• 2:13
  patient's
• 2:14
  not
• 2:14
  gonna
• 2:14
  walk
• 2:14
  into
• 2:15
  your
• 2:15
  office
• 2:15
  and
• 2:15
  be
• 2:16
  able
• 2:16
  to
• 2:16
  distinguish
• 2:17
  that
• 2:17
  as
• 2:17
  easily
• 2:18
  as
• 2:18
  you
• 2:19
  can.
• 2:19
  Number
• 2:19
  one,
• 2:19
  they're
• 2:20
  in
• 2:20
  distress.
• 2:21
  Right?
• 2:21
  It's
• 2:21
  very
• 2:22
  difficult
• 2:22
  for
• 2:22
  someone
• 2:22
  to
• 2:23
  articulate
• 2:23
  anything
• 2:24
  when
• 2:24
  they're
• 2:24
  in
• 2:24
  distress,
• 2:25
  but
• 2:25
  you're
• 2:25
  not
• 2:25
  gonna
• 2:25
  get
• 2:26
  this
• 2:26
  silver
• 2:27
  platter.
• 2:27
  Symptom.
• 2:28
  Description
• 2:29
  of
• 2:29
  a
• 2:29
  patient
• 2:30
  who
• 2:30
  goes,
• 2:30
  well,
• 2:30
  you
• 2:30
  know
• 2:31
  what?
• 2:32
  I
• 2:33
  don't
• 2:33
  have
• 2:33
  anhedonia,
• 2:35
  and
• 2:35
  it's
• 2:35
  not
• 2:35
  quite
• 2:36
  fatigue.
• 2:36
  That's
• 2:37
  similar
• 2:37
  to
• 2:38
  my
• 2:38
  Depression,
• 2:38
  it's
• 2:38
  more
• 2:39
  fatigue
• 2:39
  that's
• 2:39
  physiological
• 2:40
  and
• 2:40
  it
• 2:41
  more
• 2:41
  of
• 2:41
  a
• 2:41
  withdrawal.
• 2:42
  You're
• 2:42
  not
• 2:43
  going
• 2:43
  to
• 2:43
  get
• 2:43
  that
• 2:43
  luxury.
• 2:44
  So
• 2:44
  it's
• 2:44
  up
• 2:45
  to
• 2:45
  you
• 2:45
  to
• 2:45
  really
• 2:45
  figure
• 2:46
  out,
• 2:46
  is
• 2:46
  this
• 2:46
  the
• 2:47
  patient's
• 2:47
  depression
• 2:48
  presentation
• 2:49
  or
• 2:50
  is
• 2:50
  it
• 2:50
  not?
• 2:50
  You
• 2:51
  can
• 2:51
  imagine.
• 2:51
  This
• 2:52
  is
• 2:52
  why
• 2:52
  you
• 2:52
  need
• 2:52
  to
• 2:52
  take
• 2:52
  really
• 2:53
  good
• 2:53
  notes.
• 2:53
  You
• 2:54
  need
• 2:54
  to
• 2:54
  be
• 2:54
  like
• 2:55
  Pablo
• 2:55
  Picasso
• 2:56
  and
• 2:57
  paint
• 2:58
  really
• 2:58
  good
• 2:58
  portraits
• 2:59
  of
• 2:59
  your
• 2:59
  patient
• 3:00
  when
• 3:00
  they
• 3:00
  are
• 3:01
  depressed
• 3:01
  so
• 3:02
  that
• 3:02
  you
• 3:02
  know
• 3:04
  later
• 3:04
  on
• 3:04
  after
• 3:04
  you
• 3:05
  discontinue
• 3:05
  the
• 3:05
  medication.
• 3:06
  Whether
• 3:07
  or
• 3:07
  not
• 3:08
  the
• 3:09
  rebound
• 3:09
  symptoms
• 3:10
  are
• 3:10
  discontinuation
• 3:11
  or
• 3:12
  her
• 3:13
  signature
• 3:13
  depressive
• 3:14
  symptoms
• 3:15
  that
• 3:15
  are
• 3:16
  part
• 3:16
  and
• 3:16
  partial
• 3:17
  of
• 3:17
  how
• 3:18
  she
• 3:18
  presents
• 3:18
  herself
• 3:19
  at
• 3:19
  her
• 3:19
  worst
• 3:19
  during
• 3:20
  a
• 3:20
  depressive
• 3:20
  mood
• 3:21
  spell.
• 3:21
  Okay.
• 3:22
  There's
• 3:22
  other
• 3:22
  clues
• 3:23
  though,
• 3:23
  where
• 3:23
  you
• 3:24
  can
• 3:24
  figure
• 3:24
  this
• 3:24
  out,
• 3:24
  where
• 3:25
  you
• 3:25
  don't
• 3:25
  need
• 3:25
  to
• 3:25
  be
• 3:25
  Pablo
• 3:25
  Picasso.
• 3:27
  Picasso
• 3:27
  painted
• 3:28
  mainly
• 3:28
  in
• 3:28
  shapes
• 3:29
  and
• 3:29
  cubes
• 3:29
  anyway.
• 3:30
  So
• 3:30
  that
• 3:30
  would
• 3:30
  be
• 3:31
  pretty
• 3:32
  irrelevant
• 3:33
  to
• 3:33
  how
• 3:34
  you
• 3:34
  are
• 3:34
  portraying
• 3:35
  this
• 3:35
  and
• 3:35
  it
• 3:35
  might
• 3:35
  even
• 3:35
  be
• 3:36
  downright
• 3:36
  misleading.
• 3:37
  So
• 3:39
  one
• 3:39
  way
• 3:40
  you
• 3:40
  can
• 3:40
  really
• 3:40
  tell
• 3:41
  my
• 3:41
  friends
• 3:41
  is
• 3:42
  that
• 3:42
  discontinuation
• 3:43
  syndrome
• 3:45
  happens
• 3:46
  in
• 3:46
  days,
• 3:46
  typically
• 3:47
  two
• 3:47
  to
• 3:47
  four
• 3:47
  days
• 3:48
  after
• 3:48
  stopping
• 3:48
  a
• 3:48
  medication.
• 3:49
  Depression
• 3:50
  takes
• 3:50
  longer
• 3:51
  than
• 3:51
  that
• 3:51
  to
• 3:51
  relapse.
• 3:51
  It's
• 3:52
  usually
• 3:52
  weeks
• 3:52
  or
• 3:53
  months.
• 3:53
  So
• 3:53
  that's
• 3:54
  one
• 3:54
  pearl
• 3:54
  you
• 3:54
  can
• 3:55
  just
• 3:55
  tuck
• 3:55
  in
• 3:55
  your
• 3:55
  pocket
• 3:56
  right
• 3:56
  now
• 3:57
  if
• 3:57
  your
• 3:57
  patient
• 3:57
  just
• 3:58
  got
• 3:58
  off
• 3:59
  their
• 3:59
  antidepressant
• 4:00
  and
• 4:00
  within
• 4:01
  days
• 4:01
  they're
• 4:02
  calling
• 4:02
  your
• 4:02
  office
• 4:03
  frantically
• 4:04
  saying,
• 4:04
  I
• 4:04
  knew
• 4:04
  this
• 4:05
  was
• 4:05
  a
• 4:05
  bad
• 4:05
  idea.
• 4:05
  Here
• 4:05
  comes
• 4:06
  my
• 4:06
  depression.
• 4:06
  I'm
• 4:07
  absolutely
• 4:07
  miserable.
• 4:08
  We
• 4:08
  need
• 4:08
  to
• 4:09
  really
• 4:09
  get
• 4:09
  granular.
• 4:10
  We
• 4:10
  really
• 4:10
  need
• 4:11
  to
• 4:11
  be
• 4:11
  very
• 4:11
  careful
• 4:12
  with
• 4:12
  semantics
• 4:13
  and
• 4:13
  we
• 4:13
  really
• 4:14
  need
• 4:14
  to
• 4:14
  parse
• 4:14
  out
• 4:14
  exactly
• 4:15
  what
• 4:15
  they
• 4:15
  are
• 4:16
  going
• 4:16
  through.
• 4:17
  Because
• 4:17
  if
• 4:17
  you
• 4:17
  ask
• 4:18
  very
• 4:18
  specific
• 4:18
  questions,
• 4:19
  very
• 4:21
  calmly
• 4:21
  and
• 4:22
  clearly
• 4:22
  because
• 4:22
  they're
• 4:23
  in
• 4:23
  duress,
• 4:25
  then
• 4:25
  you
• 4:25
  may
• 4:25
  find
• 4:26
  out
• 4:26
  that
• 4:26
  this
• 4:26
  is
• 4:26
  actually
• 4:27
  discontinuation
• 4:28
  syndrome.
• 4:28
  And
• 4:29
  it
• 4:29
  has
• 4:29
  nothing
• 4:29
  to
• 4:29
  do
• 4:30
  with
• 4:31
  how
• 4:31
  difficult
• 4:32
  it
• 4:32
  is
• 4:32
  for
• 4:33
  them
• 4:33
  to
• 4:33
  live
• 4:34
  without
• 4:35
  an
• 4:35
  antidepressant
• 4:36
  in
• 4:36
  the
• 4:36
  context
• 4:37
  of
• 4:37
  their
• 4:37
  depression.
• 4:37
  Right.
• 4:38
  In
• 4:38
  other
• 4:38
  words,
• 4:38
  the
• 4:39
  withdrawal
• 4:39
  could
• 4:39
  be
• 4:39
  really
• 4:40
  bad.
• 4:40
  But
• 4:40
  that
• 4:40
  doesn't
• 4:40
  mean
• 4:41
  you're
• 4:41
  a
• 4:41
  bad
• 4:41
  candidate
• 4:41
  to
• 4:42
  get
• 4:42
  off
• 4:42
  your
• 4:42
  medication.
• 4:43
  That's
• 4:43
  a
• 4:43
  whole
• 4:43
  other
• 4:44
  conversation
• 4:44
  entirely.
• 4:45
  Right.
• 4:45
  Which
• 4:45
  you
• 4:46
  should
• 4:46
  have
• 4:46
  had
• 4:46
  before
• 4:46
  you
• 4:47
  even
• 4:47
  decided
• 4:48
  to
• 4:48
  have
• 4:48
  the
• 4:48
  patient
• 4:49
  get
• 4:49
  off
• 4:49
  of
• 4:49
  her
• 4:49
  Paxil.
• 4:50
  Right?
• 4:50
  Right.
• 4:51
  And
• 4:51
  that's
• 4:51
  another
• 4:51
  episode.
• 4:52
  That's
• 4:52
  another
• 4:52
  conversation.
• 4:53
  But
• 4:54
  I
• 4:54
  will
• 4:54
  say
• 4:54
  before
• 4:55
  I
• 4:55
  even
• 4:55
  decide
• 4:56
  whether
• 4:56
  a
• 4:56
  patient
• 4:57
  is
• 4:57
  a
• 4:58
  good
• 4:58
  candidate
• 4:58
  for
• 4:58
  this
• 4:59
  or
• 4:59
  we
• 4:59
  decide
• 4:59
  together,
• 5:00
  I
• 5:00
  should
• 5:00
  say
• 5:01
  we
• 5:01
  have
• 5:01
  a
• 5:01
  discussion
• 5:02
  about,
• 5:02
  well,
• 5:02
  how
• 5:02
  bad
• 5:03
  is
• 5:03
  your
• 5:03
  depression
• 5:04
  when
• 5:04
  you're
• 5:04
  not
• 5:04
  on
• 5:05
  your
• 5:05
  medication?
• 5:05
  I
• 5:05
  mean,
• 5:05
  is
• 5:06
  it
• 5:06
  really
• 5:06
  disabling
• 5:07
  where
• 5:07
  you
• 5:07
  can't
• 5:07
  get
• 5:07
  out
• 5:07
  of
• 5:08
  bed,
• 5:08
  you
• 5:08
  quit
• 5:09
  your
• 5:09
  job,
• 5:09
  you
• 5:09
  stop
• 5:09
  talking
• 5:10
  to
• 5:10
  your
• 5:10
  family,
• 5:11
  you
• 5:11
  get
• 5:11
  suicidal
• 5:12
  and
• 5:12
  self
• 5:13
  harmful.
• 5:13
  How
• 5:14
  many
• 5:14
  episodes
• 5:14
  have
• 5:14
  you
• 5:15
  had?
• 5:15
  Right.
• 5:15
  That's
• 5:16
  another
• 5:16
  huge
• 5:16
  question.
• 5:17
  The
• 5:17
  data
• 5:17
  is
• 5:17
  pretty
• 5:18
  unequivocal
• 5:18
  that
• 5:18
  if
• 5:19
  you've
• 5:19
  had
• 5:19
  three
• 5:20
  or
• 5:20
  more
• 5:20
  major
• 5:20
  depressive
• 5:21
  episodes
• 5:22
  properly
• 5:22
  diagnosed,
• 5:24
  then
• 5:25
  you
• 5:25
  have
• 5:25
  about
• 5:25
  a
• 5:25
  90%
• 5:26
  chance
• 5:26
  of
• 5:26
  relapse
• 5:27
  without
• 5:27
  your
• 5:27
  medication.
• 5:28
  So
• 5:29
  I
• 5:29
  definitely
• 5:29
  have
• 5:29
  that
• 5:30
  conversation
• 5:30
  with
• 5:30
  my
• 5:31
  patients
• 5:31
  and
• 5:32
  that's
• 5:32
  very
• 5:32
  clear.
• 5:33
  And
• 5:33
  we
• 5:34
  really
• 5:34
  assess
• 5:34
  the
• 5:34
  pros
• 5:35
  and
• 5:35
  cons,
• 5:35
  right?
• 5:35
  Because
• 5:36
  of
• 5:36
  course
• 5:36
  there
• 5:36
  is
• 5:37
  this
• 5:37
  stigma
• 5:37
  about
• 5:38
  staying
• 5:38
  on
• 5:38
  medications
• 5:39
  that
• 5:39
  is
• 5:39
  particularly
• 5:40
  important
• 5:40
  to
• 5:40
  the
• 5:40
  patient
• 5:41
  and
• 5:41
  we
• 5:41
  have
• 5:41
  to
• 5:41
  be
• 5:41
  very
• 5:42
  sensitive
• 5:42
  to
• 5:42
  that.
• 5:42
  But
• 5:43
  there's
• 5:43
  also
• 5:44
  a
• 5:44
  stigma
• 5:45
  of
• 5:45
  being
• 5:45
  the
• 5:45
  person
• 5:46
  under
• 5:46
  your
• 5:46
  covers
• 5:47
  all
• 5:47
  day
• 5:47
  who's
• 5:48
  reoccurring,
• 5:49
  who
• 5:49
  has
• 5:49
  reoccurring
• 5:50
  suicidal
• 5:50
  ideations
• 5:51
  and
• 5:51
  your
• 5:52
  life
• 5:52
  is
• 5:52
  falling
• 5:52
  apart
• 5:53
  around
• 5:53
  you.
• 5:53
  Right?
• 5:53
  So
• 5:53
  we
• 5:54
  really
• 5:54
  have
• 5:54
  to
• 5:54
  have
• 5:54
  a
• 5:54
  fair
• 5:54
  fight
• 5:55
  and
• 5:55
  an
• 5:55
  honest
• 5:56
  conversation
• 5:56
  about
• 5:57
  what
• 5:57
  is
• 5:57
  more
• 5:58
  intolerable,
• 5:58
  the
• 5:58
  idea
• 5:59
  of
• 5:59
  being
• 5:59
  on
• 5:59
  medications
• 6:00
  or
• 6:00
  the
• 6:00
  idea
• 6:00
  of
• 6:01
  being
• 6:01
  depressed
• 6:02
  to
• 6:02
  have
• 6:03
  this
• 6:03
  intractable
• 6:04
  depression
• 6:04
  the
• 6:04
  rest
• 6:04
  of
• 6:04
  your
• 6:05
  life.
• 6:05
  So
• 6:05
  I
• 6:05
  need
• 6:05
  to
• 6:05
  know
• 6:06
  how
• 6:06
  many
• 6:06
  episodes
• 6:06
  of
• 6:07
  depression,
• 6:07
  how
• 6:07
  debilitating
• 6:08
  it
• 6:08
  is.
• 6:08
  I
• 6:09
  also
• 6:09
  get
• 6:09
  really
• 6:09
  picky
• 6:10
  and
• 6:10
  I
• 6:10
  want
• 6:10
  to
• 6:11
  really
• 6:11
  make
• 6:11
  sure
• 6:11
  that
• 6:12
  those
• 6:12
  are
• 6:12
  accurately
• 6:15
  characterize
• 6:15
  depressive
• 6:16
  episodes.
• 6:16
  In
• 6:16
  other
• 6:17
  words,
• 6:17
  was
• 6:17
  it
• 6:18
  two
• 6:18
  weeks
• 6:18
  or
• 6:18
  more?
• 6:19
  A
• 6:19
  lot
• 6:20
  of
• 6:20
  times
• 6:20
  your
• 6:20
  patients
• 6:20
  will
• 6:20
  say
• 6:21
  they
• 6:21
  were
• 6:21
  depressed,
• 6:21
  but
• 6:21
  when
• 6:22
  you
• 6:22
  really
• 6:23
  ask
• 6:23
  the
• 6:24
  questions,
• 6:24
  you
• 6:25
  find
• 6:25
  out,
• 6:25
  well,
• 6:26
  oh
• 6:26
  no,
• 6:26
  it
• 6:26
  was
• 6:26
  just
• 6:26
  one
• 6:27
  or
• 6:27
  two
• 6:27
  days,
• 6:27
  it
• 6:27
  was
• 6:27
  never
• 6:28
  two
• 6:28
  weeks.
• 6:28
  And
• 6:29
  it
• 6:29
  was
• 6:29
  in
• 6:29
  the
• 6:29
  context
• 6:30
  of
• 6:30
  their
• 6:30
  grandmother
• 6:30
  dying
• 6:31
  or
• 6:31
  their,
• 6:32
  their
• 6:32
  cat
• 6:32
  dying.
• 6:32
  Not
• 6:33
  to
• 6:33
  say
• 6:33
  you
• 6:33
  can't
• 6:33
  be
• 6:33
  depressed
• 6:34
  when
• 6:34
  your
• 6:34
  cat
• 6:34
  dies,
• 6:35
  but
• 6:36
  like,
• 6:36
  you
• 6:36
  know,
• 6:37
  that's
• 6:37
  a
• 6:37
  different
• 6:37
  kind
• 6:38
  of
• 6:38
  depression,
• 6:39
  right?
• 6:39
  It's
• 6:39
  more
• 6:39
  grief
• 6:40
  related.
• 6:40
  It
• 6:40
  comes
• 6:40
  in
• 6:41
  waves.
• 6:41
  It
• 6:42
  doesn't
• 6:42
  affect
• 6:43
  their
• 6:43
  self
• 6:43
  esteem.
• 6:44
  They're
• 6:44
  not
• 6:44
  as
• 6:44
  self
• 6:44
  critical.
• 6:45
  It's
• 6:45
  not
• 6:45
  this
• 6:45
  broad
• 6:46
  constellation
• 6:46
  of
• 6:47
  depressive
• 6:47
  symptoms.
• 6:48
  It
• 6:48
  has
• 6:48
  this
• 6:48
  different
• 6:49
  diagnostic
• 6:50
  arc
• 6:50
  entirely.
• 6:51
  That's
• 6:52
  more
• 6:52
  of
• 6:52
  a
• 6:52
  grief
• 6:52
  path
• 6:53
  than
• 6:53
  a
• 6:53
  depression
• 6:53
  path
• 6:54
  or
• 6:54
  more
• 6:54
  of
• 6:54
  an
• 6:54
  adjustment
• 6:55
  related
• 6:55
  path.
• 6:56
  Right.
• 6:56
  They
• 6:56
  lost
• 6:56
  their
• 6:56
  job
• 6:57
  and
• 6:57
  they
• 6:57
  were
• 6:57
  down
• 6:58
  for
• 6:58
  days
• 6:58
  or
• 6:58
  weeks
• 6:59
  at
• 6:59
  a
• 6:59
  time.
• 6:59
  But
• 6:59
  it
• 6:59
  doesn't
• 7:00
  quite
• 7:00
  carry
• 7:01
  the
• 7:01
  same
• 7:02
  neurobiological
• 7:03
  signature
• 7:04
  that
• 7:04
  depression
• 7:05
  even
• 7:05
  has.
• 7:05
  Right.
• 7:06
  Depression
• 7:06
  has
• 7:06
  its
• 7:06
  own
• 7:07
  biomarkers
• 7:08
  that
• 7:08
  they
• 7:08
  suspect
• 7:08
  are
• 7:09
  driving
• 7:09
  depression.
• 7:10
  Right.
• 7:10
  That
• 7:10
  early
• 7:10
  cortisol
• 7:11
  rise,
• 7:12
  the
• 7:12
  early
• 7:12
  morning
• 7:13
  awakening.
• 7:14
  I
• 7:14
  think
• 7:14
  there's
• 7:14
  a
• 7:15
  delayed
• 7:15
  melatonin
• 7:16
  release
• 7:16
  in
• 7:17
  some
• 7:17
  folks
• 7:17
  with
• 7:18
  biological,
• 7:19
  you
• 7:19
  know,
• 7:20
  endogenous
• 7:20
  depression
• 7:21
  that
• 7:21
  they
• 7:21
  suspect
• 7:21
  that
• 7:22
  some
• 7:22
  evidence
• 7:22
  shows.
• 7:22
  Right.
• 7:23
  So
• 7:23
  we're
• 7:23
  talking
• 7:23
  two
• 7:24
  different
• 7:24
  tracks.
• 7:24
  You
• 7:24
  got
• 7:25
  to
• 7:25
  get
• 7:25
  granular
• 7:25
  and
• 7:26
  assess
• 7:26
  how
• 7:27
  many
• 7:27
  depressive
• 7:27
  episodes
• 7:28
  did
• 7:28
  they
• 7:28
  actually
• 7:29
  have
• 7:29
  that
• 7:30
  meet
• 7:30
  diagnostic
• 7:30
  criteria?
• 7:31
  And
• 7:31
  if
• 7:32
  they've
• 7:32
  had
• 7:32
  three
• 7:32
  and
• 7:32
  they're
• 7:33
  debilitating,
• 7:34
  watch
• 7:34
  out
• 7:34
  they
• 7:34
  might
• 7:34
  not
• 7:35
  be
• 7:35
  the
• 7:35
  best
• 7:35
  candidate
• 7:35
  to
• 7:36
  get
• 7:36
  off
• 7:36
  SSRIs.
• 7:37
  Okay,
• 7:38
  if
• 7:38
  I
• 7:38
  find
• 7:38
  that
• 7:38
  depression
• 7:39
  is
• 7:39
  more
• 7:40
  trauma
• 7:40
  related,
• 7:41
  in
• 7:41
  other
• 7:41
  words,
• 7:41
  it's
• 7:42
  a
• 7:42
  little
• 7:42
  unclear.
• 7:42
  It
• 7:43
  might
• 7:43
  not
• 7:43
  be
• 7:43
  straight
• 7:44
  up
• 7:44
  depression,
• 7:45
  and
• 7:45
  it
• 7:45
  turns
• 7:45
  out
• 7:45
  to
• 7:45
  be
• 7:46
  these
• 7:46
  low
• 7:46
  mood
• 7:47
  states
• 7:47
  you
• 7:47
  see
• 7:47
  in
• 7:47
  ptsd,
• 7:48
  then
• 7:49
  actually
• 7:50
  it's
• 7:51
  a
• 7:51
  different
• 7:51
  conversation.
• 7:52
  It's
• 7:52
  like,
• 7:52
  well,
• 7:52
  how
• 7:53
  much
• 7:53
  trauma
• 7:53
  have
• 7:53
  you
• 7:53
  processed
• 7:54
  over
• 7:54
  the
• 7:54
  years?
• 7:54
  Are
• 7:55
  you
• 7:55
  getting
• 7:55
  to
• 7:55
  a
• 7:55
  point
• 7:55
  where
• 7:56
  you're
• 7:56
  not
• 7:56
  as
• 7:56
  avoidant,
• 7:57
  where
• 7:58
  you're
• 7:59
  able
• 7:59
  to
• 7:59
  access
• 7:59
  more
• 8:00
  positive
• 8:00
  mood
• 8:00
  states
• 8:00
  because
• 8:01
  you're
• 8:01
  not
• 8:01
  as
• 8:01
  hyper
• 8:01
  vigilant?
• 8:02
  You've
• 8:02
  had.
• 8:03
  You've
• 8:03
  been
• 8:03
  able
• 8:04
  to
• 8:04
  do
• 8:04
  work,
• 8:04
  right?
• 8:04
  That
• 8:05
  I
• 8:05
  want
• 8:05
  to
• 8:05
  know
• 8:05
  that,
• 8:06
  because
• 8:06
  they
• 8:07
  might
• 8:07
  be
• 8:07
  a
• 8:07
  better
• 8:07
  candidate
• 8:08
  to
• 8:08
  get
• 8:08
  off
• 8:08
  of
• 8:08
  this
• 8:09
  if
• 8:09
  they've
• 8:09
  done
• 8:09
  a
• 8:09
  lot
• 8:09
  of
• 8:09
  the
• 8:09
  trauma
• 8:10
  work
• 8:10
  and
• 8:10
  they're
• 8:11
  functioning
• 8:11
  a
• 8:12
  lot
• 8:12
  better.
• 8:12
  Right?
• 8:13
  Because
• 8:13
  remember,
• 8:13
  in
• 8:14
  the
• 8:14
  PTSD
• 8:15
  diagnostic
• 8:15
  criteria,
• 8:16
  you
• 8:16
  have
• 8:16
  those
• 8:17
  negative
• 8:17
  alterations
• 8:18
  in
• 8:18
  mood
• 8:18
  and
• 8:18
  cognition,
• 8:19
  right?
• 8:19
  You
• 8:19
  have
• 8:19
  the
• 8:20
  inability
• 8:20
  to
• 8:20
  experience
• 8:21
  positive
• 8:22
  emotions.
• 8:22
  You
• 8:23
  have
• 8:23
  guilt,
• 8:23
  fear,
• 8:24
  or
• 8:24
  horror,
• 8:25
  like
• 8:25
  a.
• 8:25
  Like
• 8:25
  a
• 8:25
  way
• 8:26
  of
• 8:26
  seeing
• 8:26
  the
• 8:26
  world
• 8:27
  that
• 8:27
  is
• 8:27
  usually
• 8:27
  more
• 8:28
  negative
• 8:28
  in
• 8:28
  nature.
• 8:29
  That
• 8:29
  makes
• 8:29
  it
• 8:29
  hard
• 8:29
  to
• 8:30
  connect
• 8:30
  to
• 8:30
  other
• 8:30
  people
• 8:30
  and
• 8:31
  enjoy
• 8:31
  things
• 8:31
  you
• 8:32
  used
• 8:32
  to
• 8:32
  enjoy.
• 8:32
  And
• 8:33
  that
• 8:33
  is
• 8:33
  qualitatively
• 8:34
  different
• 8:34
  than
• 8:35
  depression
• 8:35
  or
• 8:36
  reoccurring
• 8:36
  major
• 8:36
  depression.
• 8:37
  So
• 8:37
  again,
• 8:38
  a
• 8:38
  lot
• 8:38
  of
• 8:39
  patients
• 8:39
  will
• 8:39
  use
• 8:39
  shorthand,
• 8:40
  and
• 8:40
  clinicians
• 8:41
  will
• 8:41
  even
• 8:41
  use
• 8:41
  shorthand
• 8:42
  wrongly.
• 8:43
  So
• 8:43
  and
• 8:43
  say,
• 8:44
  well,
• 8:44
  this
• 8:44
  is
• 8:44
  just
• 8:44
  depression.
• 8:45
  Well,
• 8:45
  it's
• 8:45
  not
• 8:45
  necessarily
• 8:46
  depression.
• 8:47
  We
• 8:47
  have
• 8:47
  to
• 8:47
  define
• 8:48
  that
• 8:48
  very
• 8:48
  carefully
• 8:48
  and
• 8:49
  precisely
• 8:49
  and
• 8:50
  do
• 8:50
  as
• 8:50
  best
• 8:50
  as
• 8:50
  we
• 8:51
  can.
• 8:51
  And
• 8:51
  then,
• 8:52
  and
• 8:52
  only
• 8:52
  then,
• 8:52
  can
• 8:52
  we
• 8:53
  assess
• 8:53
  if
• 8:53
  they're
• 8:53
  a
• 8:53
  really
• 8:54
  good
• 8:54
  candidate
• 8:54
  to
• 8:54
  get
• 8:55
  off
• 8:55
  that
• 8:55
  medication.
• 8:55
  That's
• 8:56
  how
• 8:56
  I
• 8:56
  look
• 8:56
  at
• 8:56
  it.
• 8:56
  That's
• 8:57
  how
• 8:57
  I
• 8:57
  do
• 8:57
  things.
• 8:58
  You
• 8:58
  know,
• 8:58
  I'm
• 8:58
  open
• 8:59
  to
• 8:59
  feedback.
• 8:59
  But
• 9:00
  again,
• 9:00
  that's
• 9:00
  kind
• 9:00
  of
• 9:00
  how
• 9:01
  I
• 9:01
  look
• 9:01
  at
• 9:01
  the
• 9:01
  diagnostic
• 9:02
  criteria.
• 9:03
  Now,
• 9:04
  Terry
• 9:05
  over
• 9:05
  here
• 9:05
  is
• 9:06
  experiencing
• 9:07
  a
• 9:07
  pretty
• 9:07
  rapid
• 9:08
  descent
• 9:09
  after
• 9:10
  several
• 9:10
  days
• 9:10
  of
• 9:10
  stopping
• 9:11
  her
• 9:11
  Paxil.
• 9:12
  Well,
• 9:12
  that
• 9:12
  should
• 9:12
  be
• 9:12
  a
• 9:12
  red
• 9:12
  flag,
• 9:13
  too,
• 9:13
  right
• 9:13
  away,
• 9:13
  right?
• 9:14
  This
• 9:14
  is
• 9:15
  days,
• 9:15
  not
• 9:15
  weeks
• 9:15
  or
• 9:16
  months.
• 9:16
  So
• 9:16
  it's
• 9:16
  already
• 9:17
  looking
• 9:17
  like
• 9:17
  discontinuation
• 9:18
  syndrome,
• 9:19
  not
• 9:20
  depression
• 9:21
  relapse.
• 9:21
  She's
• 9:22
  also
• 9:22
  talking
• 9:22
  about
• 9:23
  somatic
• 9:23
  symptoms.
• 9:24
  Again,
• 9:24
  that
• 9:24
  is
• 9:25
  way
• 9:25
  more
• 9:25
  of
• 9:26
  a
• 9:26
  hallmark
• 9:26
  for
• 9:26
  discontinuation
• 9:27
  syndrome
• 9:28
  and
• 9:28
  not
• 9:28
  depressive
• 9:29
  relapse.
• 9:30
  There
• 9:30
  are
• 9:30
  not
• 9:30
  a
• 9:30
  lot
• 9:30
  of
• 9:30
  somatic
• 9:31
  symptoms
• 9:31
  at
• 9:31
  all
• 9:32
  in
• 9:32
  the
• 9:32
  DSM
• 9:33
  criteria
• 9:33
  for
• 9:33
  depression,
• 9:34
  right?
• 9:35
  Yes.
• 9:35
  There's
• 9:35
  psychomotor
• 9:36
  retardation.
• 9:37
  You
• 9:37
  kind
• 9:37
  of
• 9:37
  slow
• 9:37
  down,
• 9:37
  you
• 9:38
  have
• 9:38
  brain
• 9:38
  fog,
• 9:38
  you
• 9:38
  have
• 9:39
  fatigue.
• 9:39
  Yes,
• 9:39
  that's
• 9:39
  part
• 9:40
  of
• 9:40
  it.
• 9:40
  But
• 9:40
  I'm
• 9:40
  talking
• 9:41
  about,
• 9:41
  like,
• 9:41
  electric
• 9:42
  shocks,
• 9:42
  brain
• 9:43
  zaps,
• 9:43
  nausea,
• 9:44
  these
• 9:44
  paresthesias.
• 9:45
  Right?
• 9:46
  That
• 9:46
  is
• 9:46
  very
• 9:47
  much
• 9:47
  a
• 9:47
  feature
• 9:48
  of
• 9:48
  Discontinuation
• 9:49
  syndrome
• 9:49
  and
• 9:49
  not
• 9:50
  a
• 9:50
  hallmark
• 9:50
  of
• 9:50
  depression.
• 9:51
  And
• 9:51
  you
• 9:51
  should
• 9:52
  also
• 9:52
  probably
• 9:53
  already
• 9:53
  know
• 9:53
  that
• 9:53
  with
• 9:53
  Terry,
• 9:54
  if
• 9:54
  you've
• 9:54
  been
• 9:54
  working
• 9:54
  with
• 9:55
  Terry,
• 9:55
  because
• 9:56
  Terri
• 9:57
  would
• 9:57
  have
• 9:57
  told
• 9:58
  you
• 9:58
  already
• 9:59
  or
• 9:59
  not
• 10:00
  told
• 10:00
  you
• 10:00
  that
• 10:00
  nausea
• 10:01
  has,
• 10:02
  you
• 10:02
  know,
• 10:02
  just
• 10:02
  like
• 10:02
  if,
• 10:03
  hey,
• 10:03
  nausea's
• 10:03
  like
• 10:03
  never
• 10:04
  been
• 10:04
  a
• 10:04
  problem
• 10:04
  and
• 10:04
  now
• 10:05
  all
• 10:05
  of
• 10:05
  a
• 10:05
  sudden
• 10:05
  it
• 10:05
  is.
• 10:06
  If
• 10:06
  she's
• 10:06
  never
• 10:07
  been
• 10:07
  this
• 10:07
  edgy
• 10:07
  and
• 10:07
  irritable
• 10:08
  as
• 10:08
  part
• 10:08
  of
• 10:08
  her
• 10:08
  depression,
• 10:09
  but
• 10:09
  now
• 10:09
  she
• 10:09
  is.
• 10:10
  That's
• 10:10
  a
• 10:10
  huge
• 10:12
  way
• 10:12
  to
• 10:12
  differentiate
• 10:13
  that.
• 10:13
  This
• 10:13
  is
• 10:14
  not
• 10:14
  a
• 10:14
  research
• 10:14
  resurgence
• 10:15
  of
• 10:15
  depression.
• 10:16
  It's
• 10:16
  very
• 10:16
  important
• 10:17
  you
• 10:17
  explain
• 10:18
  this
• 10:18
  to
• 10:18
  her
• 10:19
  too,
• 10:19
  so
• 10:19
  she
• 10:19
  doesn't
• 10:20
  panic
• 10:20
  and
• 10:20
  assume
• 10:21
  she
• 10:21
  has
• 10:21
  to
• 10:21
  be
• 10:21
  on
• 10:21
  medications
• 10:22
  her
• 10:22
  whole
• 10:22
  life.
• 10:23
  Because
• 10:23
  this
• 10:23
  is
• 10:23
  not
• 10:24
  what's
• 10:24
  happening.
• 10:25
  Right.
• 10:25
  Another
• 10:25
  way
• 10:26
  to
• 10:26
  test
• 10:27
  whether
• 10:27
  this
• 10:28
  is
• 10:28
  actually
• 10:28
  discontinuation
• 10:29
  syndrome
• 10:29
  or
• 10:30
  depressive
• 10:30
  relapse
• 10:31
  is
• 10:31
  just
• 10:32
  adding,
• 10:32
  you
• 10:33
  know,
• 10:33
  going
• 10:33
  back
• 10:33
  to
• 10:34
  10
• 10:34
  milligrams
• 10:34
  of
• 10:34
  Paxil.
• 10:35
  And
• 10:36
  if
• 10:36
  her
• 10:36
  symptoms
• 10:37
  rapidly
• 10:37
  improve,
• 10:38
  what
• 10:38
  she
• 10:38
  just
• 10:38
  dealt
• 10:39
  with
• 10:39
  was
• 10:39
  discontinuation
• 10:40
  syndrome,
• 10:41
  not
• 10:41
  a
• 10:41
  depressive
• 10:42
  relapse.
• 10:42
  Right.
• 10:43
  Because
• 10:43
  improving
• 10:44
  on
• 10:44
  the
• 10:45
  Paxil
• 10:45
  from
• 10:46
  a
• 10:46
  depressive
• 10:46
  standpoint
• 10:47
  would
• 10:47
  take
• 10:47
  several
• 10:47
  weeks,
• 10:48
  usually
• 10:48
  it'd
• 10:48
  be
• 10:48
  more
• 10:48
  gradual.
• 10:49
  It
• 10:49
  wouldn't
• 10:49
  be
• 10:50
  to
• 10:50
  be
• 10:50
  this
• 10:50
  like
• 10:50
  immediate,
• 10:51
  oh
• 10:51
  God,
• 10:51
  I'm
• 10:51
  so
• 10:51
  much
• 10:52
  better.
• 10:52
  Thank
• 10:53
  you
• 10:53
  for
• 10:53
  adding
• 10:53
  Paxil.
• 10:54
  Right.
• 10:54
  If,
• 10:55
  if
• 10:55
  she's
• 10:55
  getting
• 10:55
  an
• 10:55
  immediate
• 10:56
  relief,
• 10:56
  her
• 10:57
  somatic
• 10:58
  symptoms
• 10:58
  are
• 10:58
  probably
• 10:59
  resolving.
• 10:59
  Her
• 11:00
  discontinuation
• 11:01
  syndrome,
• 11:01
  like
• 11:02
  it's
• 11:02
  less
• 11:02
  withdrawal.
• 11:03
  Right.
• 11:03
  As
• 11:03
  opposed
• 11:04
  to
• 11:04
  if
• 11:04
  you
• 11:05
  resumed
• 11:05
  her
• 11:05
  Paxil
• 11:06
  and
• 11:06
  it
• 11:06
  was
• 11:06
  depression
• 11:07
  that
• 11:07
  was
• 11:07
  driving
• 11:07
  this,
• 11:07
  it
• 11:07
  would
• 11:08
  take
• 11:08
  weeks
• 11:08
  for
• 11:08
  her
• 11:08
  depression
• 11:09
  to
• 11:09
  get
• 11:09
  better.
• 11:09
  Right.
• 11:10
  So
• 11:10
  a
• 11:10
  quick
• 11:10
  resolution
• 11:11
  is
• 11:11
  another
• 11:11
  red
• 11:12
  flag
• 11:12
  that
• 11:12
  this
• 11:12
  was
• 11:13
  discontinuation
• 11:13
  syndrome.
• 11:14
  You
• 11:14
  can
• 11:15
  always
• 11:15
  have
• 11:16
  the
• 11:16
  patient
• 11:16
  go
• 11:16
  right
• 11:16
  back
• 11:16
  to
• 11:17
  10
• 11:18
  to
• 11:18
  kind
• 11:18
  of
• 11:18
  ease
• 11:18
  the
• 11:18
  suffering
• 11:19
  a
• 11:19
  little
• 11:19
  bit
• 11:19
  and
• 11:20
  then
• 11:20
  go
• 11:20
  back
• 11:20
  to
• 11:21
  the
• 11:21
  drawing
• 11:21
  board.
• 11:21
  Okay.
• 11:23
  Another
• 11:24
  clue
• 11:24
  that
• 11:24
  this
• 11:24
  is
• 11:25
  discontinuation
• 11:25
  syndrome
• 11:26
  and
• 11:26
  not
• 11:26
  depressive
• 11:27
  relapse
• 11:27
  is
• 11:28
  that
• 11:28
  in
• 11:28
  discontinuation
• 11:29
  syndrome
• 11:29
  it's
• 11:29
  usually
• 11:30
  self
• 11:30
  limited
• 11:30
  days
• 11:31
  to
• 11:31
  weeks.
• 11:31
  I
• 11:32
  have
• 11:32
  seen
• 11:32
  some
• 11:32
  people
• 11:32
  withdrawal
• 11:33
  for
• 11:33
  longer.
• 11:33
  It's
• 11:34
  more
• 11:34
  persistent.
• 11:34
  It's
• 11:35
  hellish
• 11:35
  in
• 11:35
  their
• 11:35
  description.
• 11:36
  Right.
• 11:37
  I
• 11:37
  don't
• 11:37
  want
• 11:37
  to
• 11:37
  downplay
• 11:38
  the
• 11:38
  fact
• 11:38
  like,
• 11:38
  oh,
• 11:38
  this
• 11:39
  is
• 11:39
  just
• 11:39
  a
• 11:39
  few
• 11:39
  days,
• 11:39
  you're
• 11:40
  going
• 11:40
  to
• 11:40
  be
• 11:40
  okay.
• 11:40
  Some
• 11:41
  people
• 11:42
  can
• 11:42
  spend
• 11:43
  months
• 11:44
  or
• 11:44
  even
• 11:44
  longer
• 11:45
  in
• 11:45
  this
• 11:46
  discontinuation
• 11:46
  phase
• 11:47
  and
• 11:47
  it
• 11:47
  is
• 11:47
  really
• 11:47
  hellish
• 11:48
  for
• 11:48
  them.
• 11:48
  It's
• 11:48
  no
• 11:49
  joke.
• 11:49
  Right.
• 11:50
  And
• 11:50
  so,
• 11:51
  and
• 11:51
  then
• 11:51
  I've
• 11:51
  seen
• 11:52
  people
• 11:52
  who
• 11:52
  just
• 11:52
  like
• 11:52
  quit
• 11:53
  on
• 11:53
  their
• 11:53
  own
• 11:53
  and
• 11:54
  they
• 11:54
  seem
• 11:54
  to
• 11:54
  be
• 11:54
  fine
• 11:55
  and
• 11:55
  it's
• 11:55
  kind
• 11:55
  of
• 11:55
  a
• 11:55
  miracle,
• 11:56
  right?
• 11:56
  It's
• 11:57
  like,
• 11:57
  how
• 11:57
  did
• 11:57
  you
• 11:57
  do
• 11:57
  that?
• 11:57
  No
• 11:58
  one
• 11:58
  else
• 11:58
  can
• 11:58
  do
• 11:58
  that
• 11:58
  it's
• 11:59
  not
• 11:59
  advisable
• 11:59
  at
• 12:00
  all
• 12:00
  to
• 12:00
  do
• 12:00
  that.
• 12:01
  Some
• 12:01
  people
• 12:01
  do
• 12:01
  that,
• 12:02
  so
• 12:02
  you'll
• 12:02
  see
• 12:03
  all
• 12:03
  colors
• 12:03
  of
• 12:03
  the
• 12:03
  rainbow
• 12:04
  in
• 12:04
  practice.
• 12:05
  And
• 12:06
  of
• 12:06
  course,
• 12:06
  be
• 12:06
  mindful
• 12:07
  that
• 12:07
  agents
• 12:07
  like
• 12:07
  Paxil
• 12:08
  and
• 12:08
  Effexor
• 12:09
  have
• 12:09
  shorter
• 12:09
  half
• 12:10
  life,
• 12:10
  so
• 12:10
  they
• 12:10
  are
• 12:10
  especially
• 12:11
  brutal
• 12:11
  to
• 12:11
  just
• 12:12
  stop
• 12:12
  quickly.
• 12:13
  Right.
• 12:13
  So
• 12:14
  in
• 12:14
  this
• 12:14
  case,
• 12:14
  we
• 12:15
  chose
• 12:15
  Paxil
• 12:15
  in
• 12:16
  the
• 12:16
  mock
• 12:16
  case
• 12:16
  study
• 12:16
  because
• 12:17
  Paxil
• 12:17
  is
• 12:17
  a
• 12:18
  unique
• 12:18
  offender
• 12:19
  and
• 12:19
  even
• 12:19
  more
• 12:19
  reason
• 12:20
  that
• 12:20
  it
• 12:20
  is
• 12:21
  responsible
• 12:22
  for
• 12:22
  her
• 12:22
  discontinuation
• 12:23
  syndrome.
• 12:24
  Okay.
• 12:25
  So
• 12:25
  I
• 12:25
  hope
• 12:25
  that
• 12:25
  kind
• 12:26
  of
• 12:26
  helps
• 12:26
  you
• 12:27
  parse
• 12:27
  out
• 12:28
  the
• 12:28
  difference
• 12:29
  between
• 12:30
  a
• 12:30
  depressive
• 12:30
  relapse
• 12:31
  and
• 12:31
  discontinuation
• 12:32
  syndrome.
• 12:33
  You're
• 12:33
  going
• 12:33
  to
• 12:33
  have
• 12:34
  to
• 12:34
  wait
• 12:34
  longer
• 12:34
  to
• 12:34
  really
• 12:35
  understand.
• 12:35
  If
• 12:35
  her
• 12:36
  depression
• 12:36
  is
• 12:36
  creeping
• 12:36
  back
• 12:37
  in
• 12:37
  my
• 12:38
  patients
• 12:38
  after
• 12:38
  a
• 12:39
  few
• 12:39
  weeks,
• 12:40
  they
• 12:40
  might
• 12:41
  start
• 12:41
  to
• 12:41
  say,
• 12:41
  you
• 12:42
  know,
• 12:42
  I'm
• 12:42
  kind
• 12:42
  of
• 12:42
  more
• 12:43
  sad,
• 12:43
  I'm
• 12:43
  crying
• 12:43
  a
• 12:44
  lot.
• 12:44
  I
• 12:44
  think
• 12:44
  that
• 12:44
  would
• 12:44
  be
• 12:45
  a
• 12:45
  big
• 12:45
  red
• 12:45
  flag
• 12:45
  for
• 12:46
  me.
• 12:46
  They're
• 12:46
  not
• 12:46
  crying
• 12:47
  because
• 12:47
  of
• 12:47
  their
• 12:48
  hellish
• 12:48
  physical
• 12:49
  symptoms
• 12:49
  and
• 12:50
  their
• 12:50
  misery
• 12:50
  of,
• 12:51
  of
• 12:51
  withdrawal,
• 12:52
  insomnia
• 12:53
  and
• 12:53
  brain
• 12:53
  zaps,
• 12:54
  but
• 12:54
  they're
• 12:54
  crying
• 12:54
  because
• 12:55
  they're
• 12:55
  just
• 12:55
  crying
• 12:55
  like
• 12:56
  they
• 12:56
  did
• 12:56
  when
• 12:56
  they
• 12:56
  were
• 12:56
  depressed.
• 12:57
  Everything's
• 12:58
  kind
• 12:58
  of
• 12:58
  has
• 12:58
  like
• 12:59
  a
• 12:59
  sad
• 12:59
  tinge,
• 13:00
  especially
• 13:01
  if
• 13:01
  they
• 13:01
  start
• 13:01
  feeling
• 13:01
  kind
• 13:02
  of
• 13:02
  worthless
• 13:02
  or
• 13:02
  self
• 13:03
  critical.
• 13:04
  That's
• 13:04
  such
• 13:04
  a,
• 13:05
  I
• 13:05
  feel
• 13:05
  like
• 13:05
  that's
• 13:05
  such
• 13:05
  a
• 13:06
  common
• 13:06
  feature
• 13:06
  in
• 13:06
  a
• 13:06
  lot
• 13:06
  of
• 13:07
  my
• 13:07
  depressed
• 13:07
  patients.
• 13:08
  If
• 13:08
  they
• 13:08
  start
• 13:08
  saying
• 13:09
  that
• 13:09
  and
• 13:09
  it's
• 13:09
  been
• 13:09
  several
• 13:10
  weeks
• 13:10
  without
• 13:10
  their
• 13:10
  antidepressant,
• 13:11
  then
• 13:12
  watch
• 13:12
  out.
• 13:12
  Right.
• 13:13
  I
• 13:13
  think
• 13:13
  you're
• 13:13
  definitely
• 13:14
  looking
• 13:14
  more
• 13:14
  towards
• 13:15
  a
• 13:15
  depressive
• 13:15
  rebound.
• 13:16
  And
• 13:17
  I
• 13:17
  always
• 13:17
  tell
• 13:18
  my
• 13:18
  patients,
• 13:18
  look,
• 13:19
  the
• 13:19
  withdrawal
• 13:19
  sometimes
• 13:20
  is
• 13:20
  very
• 13:20
  unpleasant.
• 13:21
  It's
• 13:21
  not
• 13:21
  fun.
• 13:22
  It's,
• 13:22
  it's
• 13:22
  gonna
• 13:22
  stink.
• 13:23
  We
• 13:23
  can
• 13:23
  try
• 13:23
  to
• 13:24
  mitigate
• 13:24
  it
• 13:24
  by
• 13:24
  going
• 13:24
  down
• 13:25
  really
• 13:25
  slowly
• 13:26
  and
• 13:27
  you
• 13:28
  know,
• 13:28
  and
• 13:28
  that's
• 13:28
  great.
• 13:29
  Uh,
• 13:29
  I,
• 13:29
  I
• 13:30
  always
• 13:30
  tell
• 13:30
  em
• 13:30
  that,
• 13:30
  but
• 13:31
  I'm
• 13:31
  like,
• 13:31
  look,
• 13:31
  worst
• 13:31
  case
• 13:32
  scenario,
• 13:32
  if
• 13:32
  we're
• 13:32
  really
• 13:33
  wrong
• 13:33
  about
• 13:33
  this,
• 13:34
  we
• 13:34
  can
• 13:34
  just
• 13:34
  get
• 13:35
  back
• 13:35
  on
• 13:35
  the
• 13:35
  medication
• 13:35
  and
• 13:36
  regroup.
• 13:36
  You
• 13:36
  know,
• 13:37
  a
• 13:37
  lot
• 13:37
  of
• 13:38
  patients
• 13:38
  seem
• 13:38
  to
• 13:38
  come
• 13:38
  to
• 13:39
  this
• 13:39
  decision
• 13:40
  as
• 13:40
  if
• 13:40
  it's
• 13:41
  climbing
• 13:41
  Mount
• 13:41
  Everest.
• 13:41
  And
• 13:42
  I
• 13:42
  don't
• 13:42
  blame
• 13:42
  them
• 13:42
  because
• 13:42
  it
• 13:43
  is,
• 13:43
  it
• 13:43
  is
• 13:43
  a
• 13:43
  huge
• 13:43
  decision.
• 13:44
  I'm
• 13:44
  not
• 13:44
  downplaying
• 13:45
  that.
• 13:45
  But
• 13:45
  you
• 13:45
  can
• 13:46
  reassure
• 13:46
  them
• 13:46
  and
• 13:46
  say,
• 13:47
  hey,
• 13:47
  look,
• 13:47
  worst
• 13:48
  case
• 13:48
  scenario,
• 13:48
  we
• 13:48
  check
• 13:49
  in
• 13:49
  a
• 13:49
  little
• 13:49
  more
• 13:49
  often,
• 13:50
  we
• 13:50
  go
• 13:50
  back
• 13:50
  to
• 13:51
  a
• 13:51
  lower
• 13:51
  dose
• 13:52
  or
• 13:52
  higher
• 13:52
  dose.
• 13:53
  We,
• 13:53
  look,
• 13:53
  we
• 13:53
  figured
• 13:54
  this
• 13:54
  out,
• 13:54
  right?
• 13:54
  It's
• 13:55
  not,
• 13:55
  you're
• 13:55
  not
• 13:55
  going
• 13:56
  to
• 13:56
  do
• 13:56
  permanent
• 13:56
  damage
• 13:57
  here.
• 13:58
  We
• 13:59
  can
• 13:59
  get
• 13:59
  flexible
• 14:00
  with
• 14:00
  this.
• 14:00
  We
• 14:00
  can
• 14:00
  change
• 14:01
  the
• 14:01
  timing,
• 14:01
  we
• 14:01
  can
• 14:01
  change
• 14:02
  the
• 14:02
  dosage
• 14:02
  to
• 14:02
  make
• 14:03
  this
• 14:03
  a
• 14:03
  little
• 14:03
  easier
• 14:04
  to
• 14:04
  kind
• 14:05
  of
• 14:05
  see
• 14:05
  where
• 14:05
  you
• 14:05
  hang
• 14:05
  out.
• 14:06
  Maybe
• 14:06
  you
• 14:06
  hang
• 14:06
  out
• 14:06
  at
• 14:06
  a
• 14:07
  lower
• 14:07
  dose
• 14:07
  at
• 14:07
  your
• 14:07
  baseline
• 14:08
  and
• 14:08
  that's
• 14:08
  just
• 14:08
  fine.
• 14:09
  Maybe
• 14:09
  you
• 14:10
  don't
• 14:10
  and
• 14:10
  we
• 14:10
  need
• 14:10
  to
• 14:10
  keep
• 14:11
  it
• 14:11
  on
• 14:11
  for
• 14:11
  a
• 14:11
  little
• 14:11
  while
• 14:12
  and
• 14:12
  do
• 14:12
  more
• 14:12
  psychotherapy.
• 14:13
  And
• 14:13
  that's
• 14:13
  another
• 14:14
  pearl.
• 14:15
  Definitely
• 14:15
  consider
• 14:15
  adding
• 14:16
  CBT
• 14:17
  during
• 14:17
  your
• 14:17
  taper.
• 14:18
  Right.
• 14:18
  There
• 14:18
  have
• 14:19
  been
• 14:19
  meta
• 14:19
  analysis
• 14:20
  on
• 14:20
  this
• 14:21
  that
• 14:21
  found
• 14:22
  that
• 14:22
  patients
• 14:22
  receiving
• 14:23
  CBT
• 14:23
  during
• 14:24
  or
• 14:24
  after
• 14:24
  antidepressant
• 14:25
  discontinuation
• 14:26
  were
• 14:26
  significantly
• 14:27
  less
• 14:27
  likely
• 14:27
  to
• 14:28
  relapse
• 14:28
  compared
• 14:29
  to
• 14:29
  those
• 14:30
  receiving
• 14:30
  continued
• 14:31
  pharmacotherapy
• 14:32
  alone.
• 14:32
  So
• 14:33
  there's
• 14:33
  a
• 14:33
  lot
• 14:33
  of
• 14:33
  data
• 14:34
  on
• 14:34
  that.
• 14:34
  I
• 14:34
  would
• 14:35
  whip
• 14:35
  out
• 14:35
  the
• 14:35
  CBT
• 14:36
  tools
• 14:36
  immediately
• 14:37
  when
• 14:37
  this
• 14:37
  is
• 14:37
  happening
• 14:38
  and
• 14:38
  gradual,
• 14:39
  you
• 14:39
  know,
• 14:40
  start
• 14:40
  a
• 14:40
  gradual
• 14:41
  taper,
• 14:42
  right?
• 14:42
  Maybe
• 14:42
  reducing
• 14:43
  by
• 14:43
  25%
• 14:44
  of
• 14:44
  the
• 14:44
  dose
• 14:45
  for
• 14:46
  every
• 14:46
  four
• 14:47
  weeks,
• 14:47
  as
• 14:47
  opposed
• 14:47
  to
• 14:48
  this
• 14:48
  rapid
• 14:48
  two
• 14:48
  week
• 14:49
  taper,
• 14:49
  which
• 14:49
  is
• 14:49
  almost
• 14:50
  as
• 14:50
  bad
• 14:50
  as
• 14:50
  just
• 14:50
  abruptly
• 14:51
  stopping
• 14:51
  it.
• 14:52
  Right.
• 14:52
  You
• 14:53
  want
• 14:53
  to
• 14:53
  consider
• 14:53
  a
• 14:54
  slow
• 14:55
  taper,
• 14:55
  which
• 14:56
  would
• 14:56
  really
• 14:56
  be
• 14:56
  good.
• 14:56
  And
• 14:57
  remember,
• 14:58
  the
• 14:59
  tapers
• 14:59
  usually
• 14:59
  get
• 15:00
  worse
• 15:00
  as
• 15:00
  you
• 15:00
  get
• 15:00
  lower
• 15:01
  in
• 15:01
  dose.
• 15:01
  So
• 15:01
  if
• 15:02
  you're
• 15:02
  at
• 15:02
  like
• 15:02
  200
• 15:02
  Zoloft,
• 15:03
  generally
• 15:04
  speaking,
• 15:04
  going
• 15:05
  from
• 15:05
  200
• 15:05
  to
• 15:05
  150
• 15:06
  isn't
• 15:06
  so
• 15:06
  bad,
• 15:07
  150
• 15:07
  to
• 15:07
  100
• 15:08
  is
• 15:08
  not
• 15:08
  so
• 15:08
  bad.
• 15:09
  But
• 15:09
  as
• 15:09
  you
• 15:09
  get
• 15:09
  to
• 15:09
  those
• 15:10
  lower
• 15:10
  doses,
• 15:11
  the
• 15:11
  receptor
• 15:11
  occupancy
• 15:12
  radically
• 15:13
  changes.
• 15:13
  And
• 15:14
  that's
• 15:14
  when
• 15:14
  patients
• 15:15
  start
• 15:15
  to
• 15:15
  feel
• 15:15
  symptoms.
• 15:16
  So
• 15:16
  that's
• 15:16
  when
• 15:16
  you
• 15:16
  might
• 15:17
  need
• 15:17
  a
• 15:17
  compound
• 15:17
  pharmacy,
• 15:18
  you
• 15:18
  might
• 15:18
  need
• 15:18
  to
• 15:18
  introduce
• 15:19
  Prozac
• 15:19
  to
• 15:20
  cross
• 15:21
  taper.
• 15:21
  And
• 15:22
  you
• 15:22
  know,
• 15:22
  consult
• 15:23
  your,
• 15:23
  your
• 15:23
  resources
• 15:24
  to
• 15:24
  do
• 15:24
  that.
• 15:24
  We'll
• 15:25
  go
• 15:25
  over
• 15:25
  that
• 15:25
  in
• 15:25
  a
• 15:25
  future
• 15:25
  episode.
• 15:26
  But
• 15:27
  that's
• 15:27
  when
• 15:27
  you
• 15:27
  gotta
• 15:28
  really
• 15:29
  slow
• 15:29
  down
• 15:29
  the
• 15:29
  taper
• 15:30
  because
• 15:30
  it's
• 15:30
  especially
• 15:31
  difficult
• 15:31
  for
• 15:31
  people
• 15:32
  at
• 15:32
  the
• 15:32
  end
• 15:32
  there.
• 15:33
  Right.
• 15:33
  Um,
• 15:34
  so
• 15:35
  just
• 15:35
  be
• 15:35
  mindful
• 15:36
  of
• 15:36
  all
• 15:36
  those
• 15:36
  tools
• 15:36
  you
• 15:37
  have
• 15:37
  at
• 15:37
  your
• 15:38
  disposal.
• 15:38
  Be
• 15:39
  mindful
• 15:39
  of
• 15:39
  the
• 15:39
  timing
• 15:40
  of
• 15:40
  the
• 15:40
  symptoms.
• 15:40
  That's
• 15:41
  the
• 15:41
  strongest
• 15:41
  differentiator
• 15:42
  between
• 15:42
  depression
• 15:43
  and
• 15:43
  discontinuation
• 15:44
  symptoms.
• 15:45
  Those
• 15:45
  somatic
• 15:46
  symptoms
• 15:46
  are
• 15:46
  huge
• 15:47
  red
• 15:47
  flags
• 15:47
  that
• 15:47
  you're
• 15:48
  dealing
• 15:48
  with.
• 15:48
  Withdrawal
• 15:49
  re
• 15:49
  challenging
• 15:50
  the
• 15:50
  patient
• 15:50
  is
• 15:51
  pretty
• 15:51
  diagnostic.
• 15:52
  You
• 15:52
  know,
• 15:52
  just
• 15:53
  restarting
• 15:53
  the
• 15:53
  Paxil
• 15:54
  is
• 15:54
  going
• 15:54
  to
• 15:54
  tell
• 15:55
  you
• 15:55
  what
• 15:55
  you
• 15:55
  were
• 15:55
  dealing
• 15:55
  with
• 15:56
  there
• 15:56
  pretty
• 15:56
  quickly.
• 15:57
  And
• 15:58
  if
• 15:58
  this
• 15:59
  is
• 15:59
  a
• 15:59
  problem
• 15:59
  for
• 15:59
  your
• 16:00
  patient,
• 16:00
  the
• 16:00
  kind
• 16:01
  of
• 16:01
  withdrawal,
• 16:02
  then
• 16:02
  definitely
• 16:03
  avoid
• 16:04
  Effexor
• 16:04
  or
• 16:04
  Paxil
• 16:05
  and
• 16:05
  look
• 16:05
  for
• 16:06
  something
• 16:06
  like
• 16:06
  Prozac.
• 16:07
  What
• 16:07
  has
• 16:07
  has
• 16:07
  that
• 16:07
  built
• 16:08
  in
• 16:08
  taper.
• 16:09
  And
• 16:09
  this
• 16:09
  is
• 16:09
  why
• 16:09
  I
• 16:10
  say
• 16:10
  no
• 16:10
  two
• 16:10
  SSRIs
• 16:11
  are
• 16:11
  equal.
• 16:12
  Yes,
• 16:12
  in
• 16:13
  a
• 16:13
  textbook
• 16:13
  sense
• 16:14
  they're
• 16:14
  equal.
• 16:14
  You
• 16:14
  know,
• 16:14
  they're
• 16:15
  equally
• 16:15
  efficacious,
• 16:16
  more
• 16:16
  or
• 16:16
  less
• 16:17
  in
• 16:17
  dealing
• 16:17
  with
• 16:18
  GAD
• 16:18
  or
• 16:18
  depression
• 16:19
  or
• 16:19
  what
• 16:19
  have
• 16:19
  you,
• 16:20
  but
• 16:20
  they're
• 16:20
  not
• 16:20
  equally
• 16:21
  efficacious.
• 16:21
  If
• 16:21
  you
• 16:22
  have
• 16:22
  a
• 16:22
  patient
• 16:22
  who
• 16:22
  is
• 16:23
  uniquely
• 16:25
  averse
• 16:26
  to
• 16:26
  a
• 16:26
  withdrawal
• 16:27
  problem,
• 16:27
  then
• 16:27
  Effexor
• 16:28
  is
• 16:28
  not
• 16:28
  going
• 16:28
  to
• 16:29
  be
• 16:29
  the
• 16:29
  same
• 16:29
  as
• 16:29
  Prozac.
• 16:30
  In
• 16:30
  that
• 16:31
  case,
• 16:31
  Prozac,
• 16:32
  all
• 16:32
  other
• 16:32
  things
• 16:32
  being
• 16:33
  equal,
• 16:33
  would
• 16:34
  be
• 16:34
  more
• 16:34
  ideal.
• 16:35
  Right.
• 16:35
  So
• 16:36
  you've
• 16:36
  got
• 16:36
  to
• 16:36
  really
• 16:36
  know
• 16:36
  your
• 16:37
  patient,
• 16:37
  what
• 16:37
  their
• 16:37
  deal
• 16:37
  breakers
• 16:38
  are,
• 16:38
  what
• 16:39
  they
• 16:39
  can
• 16:39
  and
• 16:39
  cannot
• 16:40
  tolerate.
• 16:41
  And
• 16:41
  don't
• 16:42
  set
• 16:42
  them
• 16:42
  up
• 16:42
  to
• 16:42
  fail
• 16:43
  and
• 16:43
  give
• 16:43
  them
• 16:43
  something
• 16:43
  like
• 16:43
  Effexor.
• 16:44
  And
• 16:44
  if
• 16:45
  they
• 16:45
  told
• 16:45
  you
• 16:45
  they
• 16:45
  used
• 16:45
  to
• 16:46
  be
• 16:46
  on
• 16:46
  Paxil
• 16:46
  and
• 16:46
  they
• 16:47
  had
• 16:47
  this
• 16:47
  brutal
• 16:47
  withdrawal
• 16:48
  and
• 16:48
  they
• 16:48
  never
• 16:49
  want
• 16:49
  to
• 16:49
  go
• 16:49
  through
• 16:49
  that
• 16:49
  again,
• 16:50
  well,
• 16:50
  the
• 16:50
  worst
• 16:51
  thing
• 16:51
  you
• 16:51
  can
• 16:51
  do
• 16:51
  is
• 16:51
  start
• 16:51
  them
• 16:51
  on
• 16:52
  Effexor.
• 16:53
  At
• 16:53
  that
• 16:53
  point,
• 16:53
  pick
• 16:53
  a
• 16:54
  long
• 16:54
  half
• 16:54
  life
• 16:55
  SSRI
• 16:55
  like
• 16:55
  Prozac,
• 16:56
  which
• 16:56
  rarely
• 16:57
  causes
• 16:57
  significant
• 16:58
  withdrawals,
• 16:58
  still
• 16:59
  can
• 16:59
  happen,
• 16:59
  but
• 16:59
  it's
• 17:00
  a
• 17:00
  little
• 17:00
  more
• 17:00
  rare.
• 17:01
  And
• 17:02
  fix
• 17:02
  it
• 17:03
  that
• 17:03
  way.
• 17:04
  Now,
• 17:04
  remember
• 17:05
  that
• 17:05
  withdrawal
• 17:06
  symptoms
• 17:06
  alone
• 17:07
  do
• 17:07
  not
• 17:07
  mean
• 17:07
  your
• 17:08
  patient
• 17:08
  needs
• 17:08
  to
• 17:08
  stay
• 17:08
  on
• 17:09
  medication
• 17:09
  forever.
• 17:10
  Right.
• 17:10
  Withdrawal
• 17:11
  is
• 17:11
  a
• 17:11
  pharmacological
• 17:12
  phenomenon.
• 17:13
  Right.
• 17:13
  It's
• 17:13
  not
• 17:14
  evidence
• 17:14
  that
• 17:14
  their
• 17:14
  underlying
• 17:15
  depression
• 17:15
  has
• 17:16
  reemerged.
• 17:16
  So
• 17:17
  if
• 17:17
  you
• 17:17
  misinterpret
• 17:18
  withdrawal
• 17:18
  as
• 17:18
  relapse,
• 17:19
  then
• 17:20
  you
• 17:20
  might
• 17:20
  continue
• 17:21
  an
• 17:21
  antidepressant
• 17:22
  long
• 17:22
  term.
• 17:22
  That
• 17:23
  is
• 17:23
  not
• 17:23
  as
• 17:23
  necessary.
• 17:24
  Right.
• 17:25
  So
• 17:25
  be
• 17:25
  very
• 17:26
  careful
• 17:26
  here
• 17:26
  because
• 17:27
  we
• 17:27
  need
• 17:27
  to
• 17:28
  be
• 17:28
  just
• 17:28
  as
• 17:28
  vigilant
• 17:29
  about
• 17:29
  deprescribing
• 17:30
  as
• 17:30
  we
• 17:30
  are
• 17:30
  about
• 17:30
  prescribing.
• 17:31
  You're
• 17:31
  adding
• 17:32
  another
• 17:32
  med.
• 17:32
  Well,
• 17:33
  you're.
• 17:33
  It's
• 17:33
  not
• 17:33
  as
• 17:33
  simple
• 17:33
  as
• 17:34
  that.
• 17:34
  Right?
• 17:34
  It
• 17:34
  might
• 17:34
  be
• 17:34
  great.
• 17:35
  You
• 17:35
  might
• 17:35
  be
• 17:35
  helping
• 17:35
  their
• 17:36
  depression
• 17:36
  and
• 17:36
  anxiety.
• 17:37
  You
• 17:37
  also
• 17:37
  might
• 17:37
  be
• 17:37
  giving
• 17:38
  them,
• 17:38
  like,
• 17:38
  lifelong
• 17:39
  sexual
• 17:39
  dysfunction
• 17:40
  and
• 17:40
  the
• 17:41
  stigma
• 17:41
  that
• 17:41
  they
• 17:41
  do
• 17:41
  carry
• 17:42
  that
• 17:43
  they.
• 17:43
  That
• 17:43
  often
• 17:43
  very
• 17:44
  much
• 17:44
  bugs
• 17:44
  them
• 17:44
  that
• 17:44
  they're
• 17:45
  on
• 17:45
  medication
• 17:45
  their
• 17:46
  whole
• 17:46
  lives.
• 17:46
  Right.
• 17:46
  It's
• 17:47
  a.
• 17:47
  It's
• 17:48
  a
• 17:48
  big
• 17:48
  deal
• 17:48
  to
• 17:48
  a
• 17:49
  lot
• 17:49
  of
• 17:49
  patients.
• 17:49
  So
• 17:49
  keep
• 17:50
  that
• 17:50
  all
• 17:50
  in
• 17:50
  mind,
• 17:50
  folks.
• 17:51
  And
• 17:52
  I
• 17:53
  will
• 17:53
  tell
• 17:53
  you
• 17:53
  one
• 17:54
  last
• 17:54
  thing
• 17:54
  before
• 17:54
  we
• 17:54
  go,
• 17:55
  my
• 17:55
  friends.
• 17:55
  I
• 17:56
  highly
• 17:56
  urge
• 17:57
  you
• 17:57
  to
• 17:58
  go
• 17:58
  to
• 17:58
  Pearls
• 17:59
  and.
• 17:59
  Excuse
• 18:00
  me.
• 18:00
  Go
• 18:00
  to
• 18:00
  patreon.com
• 18:02
  pearls
• 18:03
  and
• 18:03
  prep.
• 18:04
  Okay?
• 18:04
  That's
• 18:05
  patreon.com
• 18:06
  pearlsandprep
• 18:07
  if
• 18:07
  you.
• 18:08
  You
• 18:08
  don't
• 18:08
  want
• 18:08
  to
• 18:08
  be
• 18:08
  the
• 18:08
  kind
• 18:08
  of
• 18:09
  prescriber
• 18:09
  who
• 18:09
  just
• 18:10
  presses
• 18:11
  buttons
• 18:11
  and
• 18:11
  memorizes
• 18:12
  meds,
• 18:13
  and
• 18:13
  you
• 18:13
  really
• 18:14
  want
• 18:14
  to
• 18:14
  know
• 18:14
  the
• 18:14
  how
• 18:14
  and
• 18:15
  the
• 18:15
  why
• 18:15
  of
• 18:15
  what
• 18:15
  you're
• 18:15
  doing.
• 18:16
  That's
• 18:17
  why
• 18:17
  we
• 18:17
  built
• 18:17
  that
• 18:17
  Patreon
• 18:18
  library.
• 18:18
  You
• 18:19
  will
• 18:19
  feel
• 18:19
  so
• 18:19
  empowered.
• 19:14
  It's
• 19:15
  completely
• 19:15
  changed
• 18:21
  the
• 19:16
  way
• 19:16
  I
• 19:16
  practice.
• 19:17
  I
• 19:17
  don't
• 19:17
  know
• 19:17
  who
• 19:18
  I
• 19:18
  would
• 19:18
  be
• 19:18
  and
• 19:18
  what
• 19:18
  I
• 19:19
  would
• 19:19
  do
• 19:19
  without
• 19:19
  this
• 19:19
  library
• 19:20
  that
• 19:20
  I
• 19:20
  constantly
• 19:21
  go
• 19:21
  back
• 19:21
  to
• 19:22
  to
• 19:22
  make
• 19:22
  things
• 19:22
  stick
• 19:23
  and
• 19:23
  to
• 19:23
  understand
• 19:23
  things
• 19:24
  clearly.
• 19:25
  That's
• 19:26
  why
• 19:26
  I
• 19:26
  built
• 19:26
  it.
• 19:27
  And
• 19:27
  it
• 19:28
  has
• 19:28
  just
• 19:28
  transformed
• 19:29
  the
• 19:29
  way
• 19:29
  I
• 19:29
  practice.
• 19:30
  Patients
• 19:30
  can
• 19:30
  really
• 19:30
  smell
• 19:31
  you
• 19:31
  a
• 19:31
  mile
• 19:31
  away
• 19:31
  when
• 19:32
  you
• 19:32
  just
• 19:32
  press
• 19:33
  buttons
• 19:33
  and
• 19:33
  switch
• 19:34
  meds,
• 19:34
  but
• 19:34
  you
• 19:35
  don't
• 19:35
  really
• 19:35
  know
• 19:35
  why
• 19:35
  you're
• 19:35
  switching
• 19:36
  them
• 19:36
  or
• 19:36
  you
• 19:36
  don't
• 19:37
  really
• 19:37
  know
• 19:37
  why
• 19:37
  they're
• 19:37
  sweaty
• 19:38
  or
• 19:38
  why
• 19:38
  they're
• 19:39
  fatigued
• 19:39
  or
• 19:39
  what
• 19:40
  labs
• 19:40
  to
• 19:40
  get
• 19:40
  and
• 19:41
  why
• 19:41
  those
• 19:41
  labs
• 19:41
  matter
• 19:42
  when
• 19:42
  they
• 19:42
  ask
• 19:42
  you
• 19:42
  why
• 19:43
  they
• 19:43
  matter.
• 19:43
  Right.
• 19:44
  You
• 19:44
  don't
• 19:44
  want
• 19:44
  to
• 19:44
  be
• 19:44
  that
• 19:44
  clinician.
• 19:45
  You
• 19:45
  want
• 19:45
  to
• 19:45
  be
• 19:45
  the
• 19:46
  one
• 19:46
  who
• 19:46
  gets
• 19:46
  the
• 19:46
  how
• 19:47
  and
• 19:47
  the
• 19:47
  why.
• 19:47
  So.
• 19:48
  Patreon.com
• 19:49
  pearlsandprep
• 19:50
  join
• 19:50
  today.
• 19:51
  We
• 19:52
  have
• 19:52
  been
• 19:52
  flooded
• 19:52
  with
• 19:53
  fans
• 19:53
  lately,
• 19:54
  and
• 19:54
  it's
• 19:54
  been
• 19:54
  wonderful
• 19:55
  to
• 19:55
  welcome
• 19:55
  you
• 19:56
  all
• 19:56
  in.
• 19:57
  Some
• 19:57
  folks
• 19:57
  are
• 19:57
  saying
• 19:58
  it's
• 19:58
  been
• 19:58
  really
• 19:58
  indispensable
• 19:59
  in
• 19:59
  their
• 19:59
  journey,
• 20:00
  and
• 20:01
  they
• 20:01
  don't
• 20:01
  know
• 20:01
  what
• 20:01
  they
• 20:01
  would
• 20:01
  do
• 20:01
  without
• 20:02
  it.
• 20:02
  And
• 20:02
  that's
• 20:02
  exactly
• 20:03
  why
• 20:03
  I
• 20:03
  built
• 20:03
  it.
• 20:03
  So
• 20:04
  that's
• 20:04
  why
• 20:04
  we
• 20:04
  want
• 20:05
  and
• 20:05
  need
• 20:05
  you.
• 20:05
  We'd
• 20:05
  love
• 20:06
  to
• 20:06
  have
• 20:06
  you.
• 20:06
  And
• 20:06
  we
• 20:07
  will
• 20:07
  see
• 20:07
  you
• 20:07
  next
• 20:07
  time
• 20:08
  here
• 20:08
  on
• 20:08
  Pearls
• 20:08
  and
• 20:08
  Prep.
• 20:09
  Thank
• 20:09
  you.
• 20:09
  Bye.
• 20:09
  Bye.