Quick list Pearls

“All anticholinergics are potentially unhealthy. We give tons of anticholinergics without calling them poison. Benztropine is perfectly fine. You just shouldn't give a medication that people don't need”

“paroxetine is anti-muscarinic, and that helps me to organize all the information that you kind of just mentioned. So it is sedating. It does have bad withdrawal because we know any anti-muscarinic medication is going to have bad withdrawal”

“100 milligrams of clozapine is actually equal to 2 milligrams of benztropine. And this can be helpful to know because if you ever need to stop the clozapine suddenly”

“They're very anticholinergic as well, which is also part of why they work, and I don't like that for patients, so they go into the C tier”

“You're basically kind of doing a synthetic second generation style receptor profile by adding buspirone to something that has D2 blockade. And then by pushing the dose, it's almost a second antipsychotic”

“The people who wore the amber lenses, in addition to the rest of treatments that happened on this inpatient unit routine, had half the number of antipsychotics that the group with the control lens got and got out of the hospital earlier”

“Do you really want to treat that with a mood stabilizer or an antipsychotic? Probably not, but there is a risk in some patients with mood temperaments that they actually do develop full-blown mood disorders”

“100 milligrams of clozapine is actually equal to 2 milligrams of benztropine. And this can be helpful to know because if you ever need to stop the clozapine suddenly”

“2D6 inhibitor, and thus can be used to increase effective dose of your Abilifying antenna and Aristata, which maxes out at a 15 to 20 milligram daily dose”

“You're basically kind of doing a synthetic second generation style receptor profile by adding buspirone to something that has D2 blockade. And then by pushing the dose, it's almost a second antipsychotic”

“Cariprazine has D3 partial agonism. For some reason, the D3, even though I have no idea what D3 actually does, helps you remember it might be helpful for negative symptoms”

“I find that sertraline has less side effects overall and sertraline is a little bit better tolerated even though it is the quote unquote most pure SSRI. I've had patients who tolerate citalopram better than escitalopram which goes against what we're taught”

“a lot of people's different responses at different times to the same medications, and you see this all the time with many different medications, It's more because there's a lot more going on with patients, with people than a single medication”

“clomipramine is the most serotonergic TCA. So it consists of clomipramine, and then it's broken down by CYP1A2 into norclomipramine. So... Norclomiprimine is a secondary TCA, so it's less serotonergic”

“fluvoxamine is a CYP1A2 inhibitor. So if you inhibit CYP1A2, you're going to increase the ratio of the serotonergic clomipramine and theoretically get more of that serotonergic activity that's better for OCD”

“Eight hours of a slightly modified sleep architecture is better than five hours of a terrible sleep architecture. But that said, if a patient could be getting nine hours, but they're staying up because they're on their phone, then why should we mess with their sleep architecture”

“she's seen a ton of patients that had tried Lexapro in the past and had completely different response to Celexa. She brought up one case that like the patient felt super uncomfortable on Lexapro, had terrible sexual side effects, and then Celexa worked great for them”

“a lot of people's different responses at different times to the same medications, and you see this all the time with many different medications, It's more because there's a lot more going on with patients, with people than a single medication”

“get rid of something first so that Lamotrigine gets a fairer trial. In particular, antidepressants. Patients who are already on an antidepressant makes it less likely that lamotrigine will demonstrate its remarkable capacities”

“lithium is one of the only psych meds that regulates the circadian rhythm the genes for bipolar the closest we've come to finding the genes for bipolar is linking them to the clock genes that regulate the circadian rhythm. And we know that lithium normalizes the expression of those clock genes”

“by using this other, this low-dose approach that I just described, it makes it safer for you, for your patients, and gives you the opportunity. It's like exposure therapy for using lithium”

“You give lithium to a bipolar disorder patient, they get better. You give lithium to a patient with schizophrenia and nothing really happens. And so you have to look across validators”

“he views these medications as like point blank, the most effective antidepressants and thinks that we reach for other medications. We keep switching other medications when these patients deserve a trial of MAOIs earlier in the treatment algorithm”

“it is possible that it could be competitive use. I believe of cytochrome 1A2 because both caffeine and melatonin are metabolized by 1A2”

“when they are invited to stay up all night and do paper and pencil tests all night in a lit environment, their melatonin never goes up at all. You've suppressed it. Even a little bit of light, more than the three candles, is enough to suppress your melatonin”

“The combo that is a little famous is the California rocket fuel as coined by Stephen Stahl, which is mirtazapine and venlafaxine. Anyone who's using an SSRI and SNRI, stop it. Stop it”

“also has a pathetic, but still statistically significant reduction in some populations for meth use disorder. You can get like three less meth days in the month”

“whenever you're talking to a bipolar specialist, they emphasize the importance of mood stabilizers. And you'll see as you treat more and more patients, you start to use antidepressants less and you focus the mainstay of treatment on mood stabilizers, mood stabilizers, mood stabilizers”

“I have my usual message, you know, call it whatever you want, but just give the right treatment. And if your mood stabilizer is helping, maybe they do need a mood stabilizer”

“they may have those personality tendencies, but without the added weight of a untreated mood disorder, it doesn't really come out with the same severity. So you got to have nuance and you have to monitor or treat and, you know, think over time”

“Do you really want to treat that with a mood stabilizer or an antipsychotic? Probably not, but there is a risk in some patients with mood temperaments that they actually do develop full-blown mood disorders”

“the astounding data, which didn't replicate, but that doesn't matter because it's now one against one, in adolescents who were psychosis prone. You know those studies. It's just jaw-dropping the difference”

“So the liver does something to throw a 9-hydroxy on the risperidone. So it is risperidone without any sort of liver issues. So there's significantly less drug-drug interactions because it bypasses the liver and it's basically really clear”

“paroxetine is anti-muscarinic, and that helps me to organize all the information that you kind of just mentioned. So it is sedating. It does have bad withdrawal because we know any anti-muscarinic medication is going to have bad withdrawal”

“So the liver does something to throw a 9-hydroxy on the risperidone. So it is risperidone without any sort of liver issues. So there's significantly less drug-drug interactions because it bypasses the liver and it's basically really clear”

“you don't even get the norepinephrine effect on Effexor until you get to a relatively higher dose. And so what's the point”

“ADHD has become a general marker for psychosocial distress of some kind. Right. And so it's almost meaningless in terms of a chief complaint. All it tells us is that this person is not functioning to the degree that they want to be in their work or school”

“the responsible psychiatrist must identify the comorbidities, even if they are subthreshold for a DSM diagnosis, communicate them to the patient, and give recommendations on how to manage that”

“trust your gut and not what the patient is telling you in regards to how these things impact the patient. And I'm not saying don't listen to the patient. I think it's important to collaborate with the patient. But what I'm saying is don't let a patient justify something and have it end there”

“There are high functioning psychopaths and then there actually are mostly low functioning psychopaths. Most psychopaths are low functioning. They're probably incarcerated. They're very impulsive”

“It's not like axis one and axis two are like these islands of like gambling disorder is this little pathology that exists in this part of the brain and that it's isolated from the rest of the personality”

“You can see this in what I would refer to as the burnt-out antisocial or the tired antisocial”

“So the cloud recognizing that it's a cloud and then saying on that basis, we are not going to be able to be certain. Uncertainty is wisdom”

“when she's upset, she moves toward him, and when he's upset, he moves away. And you get these pursuer-distancer dynamics in the dyad. But if you really appreciate that difference, He can learn to come toward her if she's upset and she can learn to give him space if he's upset”

“I would say in many, many cases that you see, especially for adult onset PTSD, the issue is more akin to a panic disorder issue, right? Think of a panic disorder. The panic disorder isn't having the panic attacks”

“just because someone went through something doesn't mean that they can see it clearly. Try to put it into words, get those surface and depth clarifications”

“oftentimes I'll have a patient will push back or or fight with me in the moment and and then the next month i'll see the positive change happen so in some sense you have to have faith that what you're doing is the right thing”

“When you have patients on the inpatient unit and they're smoking for a period, sorry, they're not smoking for a period of time when they're on the unit, they get discharged, they immediately start smoking again, their symptoms get worse and no one really knows why”

“You read things like schizophrenia is just a cultural illness. Let me bring you to the inpatient ward because when you see what goes on in inpatient and the more severe diseases, there's just no question of whether or not these are categorical problems”

“he managed to get the builders, there were two identical wings, to build one wing with conventional lighting and one wing that was lit at night with only amber light”

“And really what we're looking for is capacity building and flexibility, right? You should be able to deploy a certain variety of experience or action for yourself when it is helpful to you, right”

“I just described like it's 4am um I've been sleeping for six hours and it actually worked really well. It helped me calm down, which is not the purpose of it, but it did work”

“i have seen a lot of good clinical improvement from people who sought out traditional spiritual practices engaging with the spiritual community finding safe and trusting relationships and support in that method um which was free to them”

“they have a version for teens okay it's got pretty much the same content and even if you're an adult okay i think it's a lot more fun to read it because it's kind of cute”

“If your past relationships are all with people who habitually use substances, there is a huge risk in engaging in that kind of relationship again, unfortunately”

“the only thing that allowed me to keep up with an exercise routine was was an exercise partner”

“any patient with any sort of mood disorder, I think even ADHD, personality disorders, these principles are so important to absolutely everyone”

“The very first thing to do in the treatment of ADHD is to get people to have enough sleep because when you don't get it, it makes your ability to focus your attention more difficult”

“I did schedule 25-minute visits and I did build psychotherapy codes as well as medication management codes for nearly everybody. It is psychotherapy in that respect”

“it's not uncommon for people to sleep two hours, three hours, and if they have something important, to feel wired, to feel energetic, to feel like they have lots of energy, or to compensate with caffeine”

“it is possible that it could be competitive use. I believe of cytochrome 1A2 because both caffeine and melatonin are metabolized by 1A2”

“The circadian rhythm, the role of circadian rhythm in What is bipolar is getting more prominent and social rhythm therapy is a way to go right after that basic cause of the mood disturbances”

“people with bipolarity have kind of looser circadian rhythm. It's more susceptible to being knocked around by variables like you stayed up too late and particularly exposure to light and darkness”

“People with bipolar have clocks that invite them to stay up late, the night owls. They're not really morning people”

“don't be afraid to simply reflect back. And why is that important? Not only does it possibly underlie the whole development of thinking and emotional regulation, especially in traumatized individuals, but at the minimum, you're proving that you're actually listening”

“The actual core of motivational interviewing is the ability to do this technical containment, the Rogerian-type mirroring, and in it, allowing patients to actually notice areas of discrepancy within themselves that would not otherwise be noticed without these kinds of reflections”

“go on YouTube and watch Carl Rogers work. OK, Carl Rogers, follow. of client-centered therapy, which spawned motivational interviewing, his therapy technique and theory was only containment in my eyes. It was only reflective statements”

“Usually in the moment, I can't identify what the defense is. It's only kind of after the appointment's over and I have some time to reflect that I'm able to maybe put words to what i was experiencing or identify what the specific defense was”

“If there's something fundamentally more medical, biological that will not respond to a talk therapy alone, ignoring that you're not going to get much progress”

“the challenge of the more complex it is, probably the more accurate it is, but also the less adherent people will be. And it's so complex that the average clinician can't even understand it. It's not going to get used”

“I would prefer for every clinician to have such a broad knowledge Of all humanity in psychopathology, that we would be individually aware of how biased our own practices, that we are seeing specifically this slice of humanity rather than the other”

“there's one more weird one that you only see in forensics. People can develop PTSD from being essentially the assailant, the murderer. Interesting, isn't it”

“If you encounter it because of a delusion, right? A hallucination. It's technically not objectively threatening. But I would say that that's a situation where most people encountering that and unable to tell it apart from reality would be objectively threatened”

“whether or not something is part of a mental disorder or a diagnosis is different from whether or not someone does it willfully or that they don't have control over it. And even that is a separate question from whether or not someone should be responsible for it in some way”

“I think as a society, we have a obligation to detect early on when someone's mental illness makes them unable to actually make a rational decision about treatment. And then we have to intervene, but we don't”

“we can be curious about treatment and treatment theory and treatment recommendations, but I think in the end, we should be practical too. And we need to consider what's reasonable for a patient's values, goals, and their functioning”

“OCD medications are expected to reduce symptoms somewhere in the range of 30 to 40 percent. We're not curing OCD. We're not getting rid of their symptoms. We're reducing them so they can better engage in therapeutic interventions”

“workbooks do work for highly motivated and particular subset of OCD patients. And I also think... For that subset of patients that I identify, I do walk through and explain ERP and then give them the workbooks”

“I say, what do you think you spend the most time on? Or what's causing the most problems right now in your life? Is it hand washing? Is it the checking in on your family not being dead? Is it your thoughts of jumping in front of a train”

“the tier list that you use for medication should really be tailored to your patient population. Patient populations are different, and your diagnostic pool is going to be different, and so your treatment response is going to be different, too”

“formative early experiences are. I had a few early experiences where patients couldn't tolerate Lexapro, so I go slower. You had a formative experience with an SNRI. Those things, for good and for bad, change different clinicians' approaches”

“I think it's important to look for these processes in yourself. Everyone splits with enough strain”

“emotional development is a different set of skills or development than the cognitive intellectual development. So someone can be very high functioning intellectually and still be emotionally childlike or underdeveloped”

“trust is sort of the fundamental thing that you need to establish first, really for any treatment, but especially in the treatment of trauma”

“You can't just say these things. You have to just make them true. You have to be available to the extent that is realistic. You have to actually be interested, investigate, and help in some fashion. And you have to keep your promises”

“reframing things that like the frame and the limitations and the difficulties that you experience in treatment are the treatment itself. They're not disruptions to the real treatment”

“borderline patients require more structured treatments. Right. So even Kernberg and the transference focus people, they talk about the need for a therapy contract at the outset of treatment for for for very careful attention to the frame and the boundaries and the rules, the ground rules of psychotherapy”

“building structure and stability, it helps every aspect of mental health. It's a big focus for my patients with personality disorders, with trauma”

“It is not normal to sit in a room or over Zoom with somebody and talk about all these extremely intimate, embarrassing and painful details about one's life. Right. So don't be afraid to do things that are a little bit socially unusual if they're serving a very important treatment function”

“There have been attempts in some workplaces to institute management styles, rule sets, and also environments that are more conducive to people with autistic traits. However, it should not surprise you to learn that two major companies that have done this include Microsoft and Ernest & Young”