Dr. Kelly Dunn on IHI FM Board Review 6/11/26

Speaker A: The angel's question where is. Always. Yes, you can tell me about this.

Speaker B: Was it like a subsection of your board? Off the charts.

Speaker A: Literally got like. So, first of all, congratulations. You guys have almost completed another year of residency here. So you did it. M. So that's exciting. It's always kind of a crazy time of year to kind of be moving on next year, but it's always good. Um, I'm Dr. Kelly Dunn, if you don't recognize me. So I serve as vice chair at OSU Health. Um, and so I've been doing this for years now. Yeah. Now some of the medical students that I've even teaching are now part of the residency. So like. Okay, that's a weird moment. That is great. No, I've been. I think I've, ah, you know, I've only been at OSU since I finished residency. I didn't do residency at osu, but faculty. But I've probably had like, different jobs at OSU since I've been there. So, um, it's been in a really fun ride to really explore different interests. So where, um, I've kind of really landed as addiction medicine is really kind of my love for medicine. And so I build out all. Have built all our addiction medicine services at osu. And then I serve the department in all psychiatry supports as well. Um, I've done wellness stuff. I've done sports psychiatry for NCAA athletes. So, um, done a variety of things. So, um, uh, kind of provide psychiatry lectures for you guys. I usually have one where I really talk a lot about antidepressants because that's a lot of what you guys see in primary care. So really kind of trying to give you the tips and tricks in the field. Um, then I usually do one on like, mood stabilizers and antipsychotics because you get a lot of the clinical lectures, right? This is really like the pharmacology lectures they've asked me to do. Um, and then usually the third lecture of the year that I do. Four of your. I do some kind of substance use because it's, um, almost more prevalent than depression in a lot of ways. So trying to increase, uh, awareness of all that's available. So that kind of rotates based on what substance, um, I talk about each year. So maybe, hopefully if you're here a couple years, you get to hear about several different substances. And then one on board review questions because it just really covers a lot of territory. So today is the board. So PGY M1's over here, PGY2 is over there, and PGY3 is in the middle, in the back middle. And so that's what we're talking about today. Um, and I'm going to go ahead and tell you guys so I don't forget at the moment. Uh, you might have heard me talk about our statewide hotline called spark.okspark.org we're launching that. Uh, well, it is launched is live. Um, we've expanded to adult, um, psychiatry, peripartum, psychiatry, addiction medicine. We've already been doing child adolescent consults for a couple years now. So like call us. Uh, our goal is that we're able to give you as real time, um, peer to peer discussion so you can staff a case, um, as real time as possible. Um, or if you want to call us like later on your break, you know, and can staff it there. Um, and then. Or if you just like you have, you have a, you know, a 14 year old who's um, engaging in cutting behaviors, they need a therapist and no one here is quite fitting it. So you know like call us. They have all those resources too and can help give you resources you guys need or you have someone moving or a different part of the state. Yeah. Is that geared toward. Questions? Yeah.

Speaker C: I've done a Spark consult before. It's very helpful.

Speaker A: Yay.

Speaker C: We kind of tested out the system.

Speaker A: Um, and if I, I challenge, if you, all of you do at least once too, it will really help our grant funding so we can. So you know, the first time y', all, you know, it's a pretty speedy process too, especially if you call back, they help, they save all your information. So, and then they'll give you a written. So like the recommendation so they get sent to you written as well. So that's always nice. So you can document it or um, we get all kinds of questions. Um, we even had like a primary care doctor like start someone else o loft and was like they're doing a little bit better. Like what do I do next? Right. And our, and our recommendation was like go ahead and increase so often. So there's no simple, too simple question. So if you just need a couple of friends, you feel good about what you're doing, like don't hesitate. And then also I think on the medical legal side, basically a psychiatric consultant that also can really help kind of support your plan if you're not sure. Um, it always helps.

Speaker B: So.

Speaker A: So let's get into for you. So we're going to kind of do a very old classic approach here. I really want to see um, how my PG ones are doing so not to put you guys on the spot, but I'm going to put you on the spot because I teach you guys for several years too. So I'm also kind of trying to understand where you guys are knowledge wise too, so that I can continue editing my lectures to really make sure by the end of providing the best education for you guys. So it's okay if you don't know all this yet. Um, and then they're going to answer you guys, and then we'll have you guys come up with a group answer. And then you guys, My seniors are here. So, um, so These are the 24 most recent ones I have. Sorry if the font's a little small, but you guys can talk about it. And then you guys can also like all have your answers. Okay. A, B, C, D, E, we'll do numbers. Okay. But I want to kind of, I want them to kind of come up with their answers without the upperclassmen support. 732 year old female comes to your office with her husband after a recent week along elevated mood and energy. That meets the diagnostic criteria for mania. Great. You don't even have to know the diagnostic criteria. She's never had any absence of depression, low mood or anhedonia. Okay. The patient's presentation is most consistent with following. Uh, My second year,

Speaker B: We're foreign, but.

Speaker A: My seniors, a.

Speaker C: All of the above.

Speaker A: Correct. Yeah, exactly. Uh-huh. Yes. And I, I exited my PowerPoint. Okay, so the screen sharing stopped. So does anyone want to make sure I'm still screen sharing?

Speaker B: Because I.

Speaker A: So bipolar disorder. Um, the diagnostic criteria for bipolar is they have to have one episode of mania. You don't have to have any episodes of depression to have disorder, which you think you need both, but you don't. You just have to have an episode of mania. Um, mania lasts for a week. Right. Anything less than that, um, or if it's interrupted by hospitalization or treatment that counts, it can't be diagnosed usually during substance use. Right. So if there's substance active substances going on, you can't really say this is meaning. It could very much be like intoxication from the substances. Um, and, um, generally for bipolar, I like, the episodes have to really interfere with functioning. Um, bipolar two, you. For bipolar differences, you have to have depression to get a bipolar 2 diagnosis. Okay. So that one's, you have to have it. Um, and then you have hypomanic episodes, which is a minimum of four days less interfering than mania and the time is short. So, um, those are the biggest differences. And I think it's so important you guys know that because you guys are seeing depression and most bipolar patients are presenting in a depressive episode, so they're not. You know, the manic episodes often are a little more, um, obvious for bipolar 1, but most time you're going to see them depressed. So, um, treatments are completely different for monopolar depression versus bipolar depression. Right. So really being able to do a good screener and feel good that this is monopolar depression, it's important you can make bipolar depression worse. Um, let's see.

Speaker C: Science gathering history. Is it like, how do we know they just have never had a manic episode?

Speaker A: Yeah. Ah, it's all history, Led. Right?

Speaker C: Yeah.

Speaker A: Yeah, there are some, um, screenings. I'm missing the algorithm. Not the acronym, the acronym or the bipolar one that I use. Well, that's the acronym for manic, but there's an actual screen for like a, like a phq9 only for like blanking. Um, but yeah, I just screamed for dig fast, basically. So usually it's like, hey, have you had any episodes where periods of time where you just didn't need much sleep, but your energy felt pretty good? Or like, maybe you felt like on top of the world? Or maybe you had a lot of ideas. Maybe, uh, people thought you were talking much faster than normal, or maybe you were engaging in like, activities that aren't normal for you. Like you were spending more money than usual for you, you engaged, maybe, um, increased sexual activity either with the same partners. And um. And so those are kind of different questions that I'm kind of seeing if they say yes to. And then I kind of ask them like, oh, no, this is more personality things that have highs every day. Um, or if this is sounding more episodic. Right. Uh, so like, um, rapid cycling bipolar disorder is like four more episodes a year. Right. So bipolar patients aren't doing this right. They're up and they are down, not going. So if someone's rapid like daily, every other day, it's, uh, not. It's not bipolar disorder. There's something else going on. All right, I'll let you read this question. Let you guys talk in your groups. It. Depression. Mhm. Excellent. So often it's an accessory, right? Which kind of tips you off for that one. Right? Because, uh, accessories will make worse, um, or can flip someone into mania. So you have to make sure they're not manic or prescribed or have a history of mania. So, uh, sometimes, uh, when I'm through history, if a patient took an ssri, like, maybe they didn't Have a history. Meaning when I gave them an ssri, it kind of gave them manic symptoms. It doesn't mean they're bipolar because we kind of genetically caused it. But I am almost thinking they might be on the bipolar spectrum. Right? So sometimes, like, if people are sounding bipolar, something like, hey, have you ever been on an ssri? And like, what happened? And if they're like, had a reaction like that to an ssri, I'm also kind of more suspicious they might be on the bipolar spectrum. I'm sorry the spot is so small. It's okay.

Speaker C: Other than what's your go to? But, uh, anti psychotic for, uh, bipolar. Like, is there a specific one you like?

Speaker A: Uh, well, it depends which episode you're seeing them in. Right?

Speaker C: Yeah.

Speaker A: So the, the recommendations for bipolar depression aren't the same thing for mania, which are for maintenance, which is why it gets tricky. And that's when it's kind of like, okay, how can I stabilize them and give them a psych. Um, but if they are like bipolar depressed and not like hospital level, I love Lamictal. I think it's the best tolerated. Um, if there is any kind of mania that I'm going to probably do have a mood stabilizer and an antipsychotic on board. Um, if it's short term, like in the hospital or whatnot, I love Zyprexas. I practice one of the best tolerated ones, but metabolically horrible. So, like, long term, Zyprex is not great. Um, if we're thinking long term for bipolar depression, um, there's a couple that are FDA approved. So Latuda is FDA approved. I like Latuda. Um, Loraxidone.

Speaker C: Would you do monotherapy?

Speaker A: Yeah, for depression you can.

Speaker C: Yeah, for depression and bipolar depression.

Speaker A: Yeah, for bipolar depression you could do Latuda monotherapy and then see if that's covering them. Seroquel's FDA approved. And then Symbiax, which is Zyprexin and Prozac actually together. So if you have an ss, you can and sometimes have an SSRI in board of bipolar, but you need to make sure there's a mood stabilizer on board or anisotic. Um, and then criprazine is the newest one that's now FD approved for bipolar depression. I m. Think Latuda has a really good weight. Weight profile. So I liked that one a lot. You can get it approved, um, because of its like, least likely to cause weight gain. What is latuda?

Speaker B: So because SSRIs are contraindicated in patients with bipolar disorder, is it wise to screen for mania and if it's presto, absolutely.

Speaker A: You should be screening any depressed patient for mania.

Speaker C: It's really, it's hard to know what to start as model therapy if we don't know what we need to piece out where the bipolar they're at.

Speaker A: Yes.

Speaker C: Okay.

Speaker A: That's if they're manic. You know, again, like a lot of Achille manic people are probably in the hospital.

Speaker C: Yeah.

Speaker A: You're probably seeing a lot of them in the depressed phase. Psychiatrist of the group. Everyone's nodding.

Speaker C: Yeah.

Speaker A: If they're manic about. The algorithm will probably tell you to do a dual. Dual therapy and a key mania. So stabilizer plus an antipsychotic. And once they're kind of stable, you might be able to peel it back. And that's why bipolar is little, I wouldn't say tricky, but like, if you know what you're doing, you're constantly dancing with the medications because you don't want them to be over medicated, um, when they don't need it. And so the medicine's supposed to help decrease the episodes, make them less severe and shorter. But generally like, we don't get rid of all the episodes. So, you know, you're kind of trying to like, okay, adjust if things are starting to get bad or whatnot. Um, and so you might be heavily medicating them in a manic phase to get their mania to stop and then peeling it back for like a maintenance medication.

Speaker C: I see.

Speaker A: So. So it's generally like in mania, uh, it would be Epicote or lithium. Psychotic or lamictal is not really indicated for acute mania, but I love it for bipolar, depression and maintenance. I see the side effect profile.

Speaker C: Sure, sure.

Speaker A: So the other thing is if, depending on how stable the patient is, um, they might need a long acting injectable. Right. Then I'm more going to think about getting them on and Vega. Uh, yeah. Or Abilify. Right. Because they have long acting injectables. So there's also that consideration if I think I might be ordering that long term. If we have a patient where it's not, uh, crystal clear that there's a bipolar component, but it sounds like there's a bipolar component. They're seeing us for the depressive episode. And it's not so severe that there's high impact in life, but enough that there's impact. And if it was just a depressive patient, I would start searching. This is complex enough.

Speaker B: I want them to see psychiatrist or

Speaker A: see psychologist and start something to be supporting them in that time. Uh, I mean, I would. If they're probably seeing you, they're probably distressed enough that they're talking about it. I think as long as you're not starting any controlled substances, I think that's the biggest thing I have an issue with. When primary care start those and then refer out, you're like, you already started stimulants or you restarted a benzo and then you're handing them to me. Like, I don't appreciate. But if you started like lamictal and because Lamictal takes six weeks to really titrate up, right, it's 25 milligrams for two weeks, then 50 for two weeks and then 100 for two weeks and, uh, then 200. 200 is usually your goal in bipolar. So if you went ahead and started lamictal titration and before they got to me, I'm like, great, you're already on 50 milligrams. That's like just kiss, right? Um, so, you know, if. Yeah. Ah, and it's something we manipulate or change if we wanted to go a different route. Uh, yeah.

Speaker B: And it's like if I'm. Once they're there, they tease out, okay,

Speaker A: this isn't a bipolar. This is just a monopoly that doesn't get the way. Okay, yeah. Is that the medication you prefer for us starting in that type of situation? Um, I would say if they're bipolar depression and they're. They haven't been on much. Um, yes. I tend to lean to lamictal because it's the best tolerated. I tend to prefer the mood stabilizers in general, like lithium or lamictal, because the antipsychotics just have a lot more side effects. I mean, lithium has side effects too, but, um, so that's usually my preference if there's no psychosis going on. If there's any, like, depression plus, like psychotic depression happening, I'm gonna include. I also do lamictal and some like, personality disorders for, like, just mood instability and like, you clearly have just mood dysregulation, but it's not bipolar disorder. Sometimes people also benefit from lamictal in those scenarios. So I like to be my go to, um, if they've never been on anything and they're not acutely psychotic. Now lamictal has a, ah, side effect, rare side effect of Stevens Johnson syndrome. So you've got to have, uh, informed consent that they're looking out for a rash. Most of the time the rash is not severe, but it can be. And you need to Stop and immediately go to the ER if they get a rash. So but like generally other people like super well tolerated, so that's why I like it. And if they stop it for five days, you got to retitrate it. So that's the thing.

Speaker B: Right.

Speaker A: I've seen some med cases on that. Bacon jot syndrome. Yeah. It was not disclosed.

Speaker C: Prepaid lawsuits.

Speaker A: Yeah,

Speaker C: Just have a dot uh, phrase Disgust risk. Just have a dot phrase on your note. Discussed risk of medications.

Speaker A: And again, it's really rare if you're titrating it appropriately, but recommended for bipolar when they present with more mania. So if they're acutely manic, you probably want to mood stabilizer, antipsychotic. Um, so generally you're picking lithium or depakote for your mood stabilizer. Depakote is not great for women of childbearing agenic and I think I've seen a lot of weight gain with Epakote, so I tend to offer lithium first if I can. Um, and then you add an antipsychotic.

Speaker C: Um,

Speaker A: great. Short term, not the best long term. Um, resperidol or invega. That's great because I can convert that to long acting injectable. So like a second generation generally is what you're looking for. Um, then I'll m. Try and take the others. Cerecle is great for helpless, but like you're wanting 300 milligrams to get to mood, so sometimes I'm not using that one quickly. But it does help us sleep. So Seropolis still eats a lot.

Speaker C: You start at 300 milligrams. Like 100 or something.

Speaker A: Yeah, Depends on the setting too. Even if they're in the hospital then you can be a little aggressive outpatient.

Speaker C: So

Speaker A: for insurance to cover the injectables, do you have to typically fail other treatments with algae first? Oh, I haven't ordered an injectable for this in a while. We do a lot of addiction injectables. Um, so I'm sure you could justify it somehow about stable or non adherence to pills before they probably pay for it. Yeah. Uh, okay, this question. Most effective treatment of mid sleep awakening due to hyper arousal or nightmares. Yeah, we said D as well and yeah, prazosin. So um, for prazosin I hear it both ways, I say it both ways. Um, yep. So that one helps. I mean also nightmares. So um, in the studies they actually really push the dose up like 8 or 9 milligrams, which I hardly ever get that high. But if you look at the original size. I'm like, wow, their blood pressure's holding out. You can kind of push it. Um, but just start with like a milligram qhs. Uh, I can really help with some of that. Remember, when we think about sleep, there's meds to help you fall asleep and there's so. And kind of help with um, insomnia that way there's meds to help you stay asleep. So kind of knowing what the problem is can help you medication. Some will just be really short acting, help you fall asleep. Others that are longer acting while we stay asleep. So if there's a lot of awakening.

Speaker B: I had a patient the other day who said like, no when I offered this, but, um, I was kind of like, well, as a backup, we can just talk about general insomnia stuff including like cbti. Does like the CBTI have any impact on the mid sleep stuff or is that really just like sleep initiation?

Speaker A: I think it helps all.

Speaker B: Okay. It does. Does it do anything for nightmares? Usually.

Speaker A: I don't know if they looked at that. Okay.

Speaker B: I don't. Yeah, I could see it being like a fun like, oh, yeah, it does. Or like, no, because it's the quality, but you're still having the trauma. So anyway, um, yeah,

Speaker A: question. Yes, it. Generally in psych, we,

Speaker C: I would say

Speaker A: we're not worried about it, but we're not worried about causing other stuff. Methadone is, uh, notorious for QTC prolongation. So um, you generally want to monitor with baseline EKG and then route treatment. Ah. If they're getting methadone for oud, the should be keeping an eye on this. But they are. Right. So sometimes you might want to just double check that. Also, sometimes they can't do the ekg, so they're relying on you guys. So you might get a patient's like, oh, my methadone clinic told me to come get an ekg. Like, probably that's true. Right. Um, even in the psych clinic, I'm like, I probably want an EKG to check your qtc because our psych meds all prolong qtc. And so I'm like, well, I don't just go through your primary care to get it ordered. Right. So that, that is, that, um, happens. We're going with e. Uh, generally, if we're talking about adolescence, it's probably going to be some kind of failing. So it's lying. For anorexia nervous in adolescents and some young adults. So they've shown that family based therapy results in higher remission rates, weight gain than Individual therapy such as self guided therapy, cognitive behavioral therapy, psychodynamic psychotherapy, interpersonal therapy, family based therapy, signing blame instead focuses uniting the family against the disorder. Eventually parents take the lead in promoting healthy eating behaviors. The patient slowly gains greater autonomy and feeding. So that probably makes sense if you've worked with adolescents with eating one. This was like the hardest fields in the psychiatry that I experienced was adolescent eating disorders. Um, anorexia is the most fatal psychiatric disorder that we have and it's just like heartbreaking. Um, often the families are part of the problem though, right? So just kind of treating the individual, not the family unit. So that makes sense why family based therapy works. It.

Speaker C: Uh,

Speaker A: Hold up your numbers on the count of three. One, two, three. M. Yeah. So uh, speech delay, um, x 1 in 8 children. School age children with speech and language delays are greater risk for difficulty learning to read, at risk for less skilled jobs in adulthood. Development of speech language occurs in the first year and is marked by distinction according to age. Exposure to language and early childhood influences a child's language mastery. Parents and caregivers play an important role in development, um, if they have concerns for delays. Early referrals are important to mitigate the adverse effects of development. A large study found that the most important risk factor for speech language impairment was male sex. Other risk factors include hearing problems, birth weights under 2 uh.5 kg, birth order does not have an appear to have an association, um, and bilingual households milestones at the same rate. There's a joke here, but for so I don't get fired, I will move on to the next question.

Speaker C: Mhm.

Speaker A: Someone's talking to D. Well with you guys later. So yes, for anything or chances. Right. Um, so you can pair these together. It's okay. Um, varinicline is the most effective medical option and it's safe in patients with mental health conditions. Right. Sometimes it has weird side effects, but that doesn't mean it's a contraindication. Um, current evidence suggests nicotine replacement, um, adding improved smoking cessation rates. So um, wellbutrin or bupropion is also approved but not as effective as gen ticks. So don't forget about gentics. So the um, it's not recommended in pregnancy. First slide for pregnant women is correct. Can you say that again? Replacement doesn't seem to work in pregnant patients. Interesting, right? I wonder, is it like absorbed? Yeah. So first line. Uh, like psychosocial interventions for pregnant women. If they come in or admitted and they're asking us for nicotine patch, we can say that they're not admitted. Well, it's probably not effective for certainty. So I have to look back on. I have to look back on the like. So it doesn't appear to help a, uh, group of attempts coming here too. So not saying don't try it. The literature doesn't. It's oddly doesn't work. Yeah, I'd probably still give them something. Yes.

Speaker B: I've heard that vareniclean is only super effective if the person's ready to quit and like, wants to try. And if somebody's like, uh, ah, maybe I'll quit, like, you shouldn't give them for anything because they'll probably like fail and then be on it for a longer period than they should be on it. Um, is that true or is that.

Speaker A: So chanting should be started a week before their quit date. So they have to have a quit date. Right. In order to set a quit date, you kind of needed to quit.

Speaker B: Yeah.

Speaker A: Um, so yes, there has to be. It's not kind of one of those things that you hope it decreases cravings and then they want to quit. Um, now we put a ton of people on Wellbutrin and they kind of have decreased cravings naturally. That's okay. But yeah, Chantix

Speaker B: quitting it.

Speaker A: Yeah. And the original kind of round is 12 weeks, but I've repeated that a couple of times. It's just like the studies for 12 week studies. Um, so it's not really one that's indicated long term. But like if you need to repeat a 12 week course, that's okay. Okay, you can repeat it. Yeah. But I just remembered something. Uh, a patient that I was seeing in the hospital had a pretty long like alcohol use history, was saying, ah, but he was also on a GLP one at a time and he was saying that that like markedly reduced his cravings for the alcohol where he was able to like quit poultry several months back. Have you seen a lot of that? Like m. It's like pioneering the study for this. It's almost like you remember, maybe subconsciously try not to bring it up because I talk about it. Yes. Uh, so, uh, we're writing our manuscript right now for our GLP1 and alcohol study. There's been several that have already been published, um, in the literature. So it works? Um, yes, it works. So, um, hedonic.

Speaker B: What could you call it? An anti hedonic?

Speaker A: I think it's headed. Because we are about to start a cannabis and GLP1 study. We're waiting for our notice of award for method study. Um, my colleagues have seen like skin picking stuff with it and other kind of compulsive disorders. So it's kind of a universal compulsion pathway. Um, the question is like, what's the right GLP one? Because now there's multiple generations and if they're not ob, like in our study, I think I can talk about, um, it's recorded. Oh, it's fine. Uh, our older or, uh, obese subjects didn't respond as well as our non obese subjects. So, um, and it could just been like we didn't go high enough or long enough is our kind of theory because it has been shown in other studies to work in obese individuals. Um, and ours is one of the first to show and it's working in non obese individuals. So the question is, how long can you be on it? What does that look like? What's the one that's like not going to make you lose all the weight? Because a lot of our patients are malnourished. So, um, I think in the fall we're going to start offering GLP1s for audience. So. Yeah, or if they're overweight or obese, then. Yeah,

Speaker B: for someone. Because some of these meds are like triple action.

Speaker A: Yes.

Speaker B: Um, do we know which component of the GLP1 mechanism actually helps the studies

Speaker A: that have been done on the GLP1 only and so the ones that are like GLP1. Well, we just finished a GLP1 glucagon agonist. Um, that was double blind, so I don't. And it was a. Ah. So I don't know what the results are. They haven't. Well, that study just closed, so, um, so they should have some results to see how that. The glucagon additive, um, the other. Uh, I think there's one underway for tirzepatide. Lilly has a new molecule that they are enrolling a huge alcohol study. Right. So, yeah, there's a lot of questions about which one, which pathway, what is it impacting? That we don't know yet. Cutting edge right here in Tulsa. Yeah. Yep. So, uh, hopefully by next year I can. Maybe I'll slide in a GLP1, um, topic. Yeah.

Speaker C: Can we send patients to. To you to be enrolled in those studies?

Speaker A: Yes, yes, I can send you guys information. We start enrolling. The Canvas study would love that.

Speaker C: Can you send me. I think you have my email, right?

Speaker A: Yeah, send it to me.

Speaker C: I can send it to you.

Speaker A: Yeah. This will be September at the earliest that we'll be enrolling for a cannabis study. And then we're waiting to hear. Also I'm watching TMS as well. So TMS is transcranial magnetic stimulation. So if someone has failed, they're treatment resistant, which means they've failed. Usually it's different for each ensure on their definition. But it's usually two trials of medication and or therapy. So then their treatment resists another point. Um, and we could do tms. M. Yeah, we're launching that next month. So that's exciting.

Speaker B: All right. So

Speaker A: um, because you guys, you know, I mean how many patients have tried multiple medications? And you guys, since you guys also have your table forward here, they've also been probably doing like what do I do next? TMS is also FDA approved for OCD and smoking cessation.

Speaker B: Oh wow.

Speaker C: Really?

Speaker A: Not always kind of covered for those. But it is widely covered. Not with sooner care yet but uh, all private insurers cover TMS now. Really?

Speaker C: Wow.

Speaker A: What about. Men. Love this. Absolutely. That's. Huh.

Speaker B: It's a long acting. So uh.

Speaker A: So uh.

Speaker B: Very helpful.

Speaker A: Okay.

Speaker B: Either B or C. What do y' all

Speaker A: DG twos? What's your answer? They're going with D. They're going with.

Speaker C: We're going B.

Speaker A: Yes. Uh, so Docsman, specifically Silenor is the FDA approved treatment, uh, for sleep maintenance. Uh, this is. I forget. Six milligrams I think. Um, I just do generic doxepin and tell them to take which I think the lowest it comes might be 10 milligrams. I just do generic. Describe the brand name. But um, it has the FDA approval. So if you look at the American just sleep medicine I think is what it's called and look at their algorithm for treating insomnia. Um, Benadryl and Trazinone aren't like on there. Trazone's actually not recommended but it's. I will say that's my number one sleep um agent. Which is fine because I'm a psychiatrist. They have usually have co occurring stuff. But the reason why it's not recommended in theirs because it's associated with a lot more side effects than maybe some of the others. So it doesn't make the mainstream kind of algorithm that I use them. Oatload of trasp, um, Temazepam? Not occasionally. It's just again benzos. They're going to develop dependence real quick. Um, so you can use it for short term but you don't want to use it long term. Seroquel. I don't love this for sleep. You probably. I hope you had exhausted all the other options before you're thinking about Seroquel because it's an antipsychotic, it has metabolic problems. Right. Do we use it? Yes, we do use it. Low dose, 25 to 50. If you start hiking up the dose then you're going to increase side effects and risks as well. What if you think they kind of have like a psychiatric component? Yeah. Like maybe a little bipolar. There m samples actually I think has evidence of monotherapy depression too. But again with all the side effects that one we go to for um. Uh, yeah. If there's a. If there's another reason to do it easier to justify than this is just like a non psychiatric insomnia.

Speaker C: Other stuff.

Speaker B: Yeah.

Speaker A: Yes. Sickle as actually should be dosed multiple times a day. Right. For psychiatric stuff we tend to try to load it in the evenings because it causes tiredness. But you can dose it multiple times a day too. Yes. Meltdown is when I think the first line, um, treatments um on for algorithm just some. It's sometimes get hard to get covered so. But yeah, you can definitely try to see if it's more helpful than the pattern all the time.

Speaker B: Um, I had a patient tell me sometimes covered but about like a melatonin combo that was like half short acting, half long acting melatonin or something like that. Have you heard about that?

Speaker A: There's uh, there's over the counter long acting. I'm sure there's combos then of just any kind of.

Speaker B: Yeah.

Speaker A: I don't know.

Speaker B: It was like higher than the recommended. It was like 12 milligrams but then it was like six which were acting. Six long acting. It's like I don't know what to make this.

Speaker A: Yeah. I mean again, it's all about price too. Right. All these supplements are not overly regulated. So what are they getting? Who knows. It's not overly cost prohibitive. Right. Right. Um, there is long acting. Sometimes I ask them for that if they're having problems with. If they're taking more than 10 milligrams. There's no point in taking more than 10 milligrams of sleep melatonin. So that's what's.

Speaker C: Have you asked about Ashwagandha?

Speaker A: I haven't lately because I'm more in the addiction clinic. But yeah, I think. Well, I think there are probably some people using it and there's some interactions for that one. It's not bad. It's just you have to be careful interactions. These are all written for your practice exam. So I didn't write these. They're definitely all listed on the a.m. yeah. You guys see a lot of us had to do it.

Speaker B: Interesting.

Speaker A: Y' all got it. So sedative hypnotics, right? Solo. Solo Benzo overdoses are going to make people really tired your tend to not affect respiratory rate. Okay, barbiturates can benzos. I can't. Now you mix benzos with other things and yes, you're going to decrease respiratory drive but benzos alone. So most likely, uh, opioids is your risk here. Adding all this before. Uh, C PGY2S. Yep. C for pain disorder is SSRI. Um, reminder of what panic disorder criteria is. Right. You have to meet a panic attack alone. Attacks alone does not mean you have panic disorder. It's where you have panic attacks that are debilitating. A large amount of the population has experienced a panic attack. It's not a disorder to like you have behaviors now trying to avoid panic. Right. Situations. Um, and often they have panic attacks that aren't um, instigated by anything either. They kind of come out of the. So you're looking forward to kind of move them into the disorder category. And SSRI is our first line. Kids fall down really easily. So elbows, knees, shins. You don't really fall on your neck, right?

Speaker C: Yeah.

Speaker A: Bruising on their shins. Stop reading. All together, I would say the place I feel like we see it the most is that uh, St. Francis of the PE Hospital. Do y' all found that?

Speaker C: I don't know.

Speaker A: We see it a lot.

Speaker C: My patients never have this. They always tell me I don't have them. I'm like, they don't have it. They must not have it. Cuz they never want. You never want to admit that this causes a problem.

Speaker A: We've been here. My pediatrician is kind of texting me cases and seeing a lot of adolescents, like a lot of weight loss, alcohol, like uh, a like an eating disorder kind of picture. But it's, you know, kind of this use. So you know, because initially THC stimulates appetite. It's FDA approved for HIV associated, um, therapy associated, uh, nausea, vomiting. Sorry about that. But long term, cannabis does less likely flips on you. Generally our substances of happens, right. Like bentos help with anxiety and sleep. And then long term they make anxiety worse. Opioids help with pain. Then you have hyperalgesia. Same thing with cannabis, might help you a little bit nausea, help you with your appetite. Now you can't eat because you're nauseated all the time and you're waking up throwing up. So like I'll be able to recruit a lot of people what percent of your patients do you think are seeing cannabis now? Oh my gosh. A lot of trouble. Like 40 to 50%. Yes. How long can this affect them after they quit? How often, like can they smoke? Very. This happens. Generally happens, um, when they're doing it daily. Right. So you kind of are developing some, there's some mechanism happening. Um, I haven't seen the literature. Generally if you quit it gets better. But I've had patients quit and still have GI problems after. Right. So I, I don't know what's going on, but I, I see cannabis causing like GI things that are persistent even after quitting. Um, and so, you know, only time will. I'm sure somebody somewhere is going to figure out that mechanism. But, um, it should be some, um, remittance, um, after they, they quit. Now the problem is they're going to have withdrawal symptoms. Right. Withdrawal symptoms are going to peak day 12 or up to 12 days. Sorry. So you know, you kind of also get them weeks to really know because they're going to feel bad from cannabis withdrawal. So get them through two weeks of sobriety before you can really tell. Was it that or maybe there's something else going on. Right. I think the GI doctors are also like having people quit before they're even taking consults anymore. So. E is my first.

Speaker B: E is E. Stick with the regular group.

Speaker A: Oh yeah. So, been studying and breastfeeding again, sometimes what's best in breastfeeding is not the same thing that's best in pregnancy also just to make things complicated. Um, and uh, like Adderall's been more studied in pregnant women. So, um, Adderall might be more often used in pregnancy, but when it comes to breastfeeding and methylphenidates, about 0.2% of these are used to the. So, um, in some cases undetectable. Um, less is known about amphetamine in breastfeeding, amphetamines like Adderall and breastfeeding, but milk and serum levels are significantly higher than Volphenidate. Etamoxetine and Guampazine have no reliable data in breastfeeding. It should be avoided until more is known. You know, atomoxetine can cause high blood pressure right postpartum. Uh, clonidine has been shown to be present in significant amounts of breast milk and serum from infants. While no adverse events have been shown this high level medication if it raises concerns since experts recommend against colonity and breastfeeding. Sounds like a question I would write, but I didn't. It's mhm.

Speaker B: One patient,

Speaker A: Um, is Correct. Right. Morphine, obviously, would not be the right choice. Yes, I would love to get people. People out. Um, discontinuing both and initiating flumazil. Flumazil is a benzo. Seizure. Ativan now and decreasing Alprasim over six months. You would want to convert it. It's not wrong if you wanted to do Ativan or Xanax, but you'd want to convert an equally potent dose. Right. So that would be a big cut if you just stopped one. Tapering Both is not recommended. Switch to single agent. In general, a longer acting agent's probably going to be the best tolerated. Um, so clonazepam and Valium are usually the two I'm using the most for benzodiazepine discontinuation. And so ASAMs release a really extensive benzodiazepine deprescribing guide. So, um, just look for ACM's deprescribing guide. And so you can go through that and kind of look through the evidence of how to get people off benzos. Also, sign up for our addiction medicine Echo. It's Fridays at noon now, but we have recordings of my past lectures. And I did like a seven series benzo series. Right. Check the deprescribing and kind of go back how to get patients off benzos.

Speaker C: I just want to say you gave us a lecture on this about a year ago. And then I tapered a patient off her clonazam. It took a year, but she is way less anxious. It's awesome to see her get. So I was, I, you know, I was like, took you at face values. Like, is she going to be less anxious? I told her less anxious was true. Her GAD 7 decrease significantly internally, though.

Speaker A: You're like, I'm not sure I believe any of this. It's true. And it might be a little worse before. It's better. Right. Like the, the. Sometimes the tapering process is very anxiety provoking. Some of that psychological. Um, and some of that is like, depending on how fast you're doing it, you might have some, uh, withdrawal and you might have some rebound anxiety. Right. When you get them off.

Speaker C: But long term, we went really slow and she was on board, though

Speaker A: they were not informed because no one told them. They've been on benzos for a decade, so you can imagine taking something from a decade and now you're telling you have to get off of it. Like anxiety. I was probably really used to it. Yeah. So take it slow. But, um, like, wow, I'm not getting into many Arguments with my family now. You know, like, things like that that they're not going to ever attribute to kind of the disinhibition of the those.

Speaker C: So your videos on the Echo website.

Speaker A: Yep. And I can send a link to, uh, like a lot of our recent. We made a website about a year ago until our past recordings. M Are there. So, like, we've talked about. I'm sure you guys are seeing Kratom, because we're seeing a lot of Kratom. Uh, like, hot topics like that. Or what's in the drug supply Hot topic. We're starting a co occurring series. I want to see that later this summer for the rest of the year. So like alcohol and depression, you know, cannabis and anxiety, like those. So that's kind of went live. And then Fridays at noon, if you attend live, you get free CME. So, you know, after you graduate, like my PGY3s, if you keep up your CME, come to our live. They'll give you CME. Um, but if you just want to kind of run through a past topic. So topic echoes. Different talking echoes, too. Yeah, there's a ton. For girl health book the Echoes. Like the psych echo or the child. All right, we have a little bit more time. I forget when this is.

Speaker C: What time?

Speaker A: 40.

Speaker C: Oh, yeah, we're, uh. Yeah, we got another.

Speaker A: We have a bit more time, but. Okay, we'll go through some 20, 22 questions. M. My font is better on these. Just a lot more questions on the next. Sorry, Isaac, you're sitting in between.

Speaker C: Yeah, Dr. Don, maybe if we're, uh, done at 4:30. I just have. We have to do a sur. I just have a survey.

Speaker B: I need.

Speaker A: Okay, that's not it. M. Okay, so the question, uh, go back in a second. Overdose, methylphenidate, Infectious process, malignant hyperthermia, serotonin. So some keys here. Right? Anxiety, jittering, confused vomiting, fever. Uh, you have a uri. So you have that routine meds. Prozac, Methylphenidate. Uh, doesn't think he overtook those. Blood pressure's off the chart. Heart rate's elevated. Respiratory rate's elevated. Temperature is elevated. Um, O2 sats. Okay, physical exam. He's restless, anxious, sweating, uh, white counts a little bit, elevated by carbs. 20. Um, 20, 22. They were tacking on this sentence on everything. COVID 19. Test was negative. That's funny. At that point, it's like Covid caused everything. So what do you guys think? So, um, dextromethorphan, Serotonergic, right? Prozac. Serotonergic. Your stimulants are serotonergic. Um, so, uh, serotonin syndrome. Just to remind you guys, it's anti life threatening by the use of serotonergic drugs, which causes an overactivation of both the peripheral and control receptors. Um, symptoms include kind of on the spectrum, just feeling like fever, sweating all the way up, hypothermia. You, uh, think it'd be agitated, confused, maybe. You see akathisia, anxiety at the severe end, seizures, coma, death. Ah, right. Diarrhea, tremors. But clonus is probably the pathognomonic symptom. And, um, question stems. Right, because that differentiates it from hyperthermia, where you get more rigidity, you don't get clones. Right. Otherwise they can look very similar. They tend to be in psychiatric patients. Right. And so, uh, malignant hyperthermia is going to be often from antipsychotic drugs versus serotonergic drugs, and they're kind of rigid, um, versus having neuroleptic. Malignant, yes, sorry. Uh, yes, malignant. Oh, yes, sorry. Yes. Malignant hyperthermia is usually from anesthesia. Yeah, right. It's just checking to see if you caught that. There's some other medications that have serotonergic properties. Triptans, um, Busvar as well. Right. Zofran is a big vendor. Um, opioids and suboxone are serotonegic. Uh, again, it shouldn't be surprising, but mdma, meth and cocaine do. But also your some herbal like St. John's Worts that have serotonergic properties. So you should be kind of counseling on this. A single agent can cause serotonin syndrome. It's just most likely phenomenon. Okay, so, um, some of the antibiotics are they like the nasal lid is also serotonertic. They like to throw that in there. Like everyone's a whole nasal.

Speaker C: Dr. Dylan, have you had any patients, like. I don't know, I feel like sometimes we may be too scared about this.

Speaker A: Oh, yeah.

Speaker C: And so do you have any kind of broad strokes advice? I mean, yeah, the antidepressants, I guess antipsychotics aren't on there. That's good. But when we're maybe, uh, you know, people who have polypharmacy?

Speaker A: Yeah.

Speaker C: Oh, they're on Zofran here and there for nausea. I want to start them on an ssri.

Speaker A: Um, so I saw this on consults in the hospital, but I haven't seen it much in the outpatient setting. Um, and so I usually, I do counsel on it, especially after more than one serotonin or taking of. Hey, hey, look out for this. And so a lot of it's just informed consent. Like, hey, this can happen. It's rare, but it's a wordy gadget. Um, and so, I mean, I do have people in multiple agents. I think, uh, the. No. What will get you trouble. Like, if I was in, like, a medical legal case, is there on two SSRIs or SNRIs at the same time. Right? Like, clearly, you don't know what you're doing. Um. Uh, I would say an SSRI plus Trazone all the time. Right. Um, Mirtazapine.

Speaker C: Um,

Speaker A: I'm sometimes pairing that with an SSRI or an snri, so sometimes I'm pairing those. Um, the maois are really bad, but, like, I hardly ever prescribe an maoi. So I would say kind of, you're gonna get in trouble if your polypharmacy is bad prescribing. Okay. If it's indicated and you're justifying it and you're doing informed consent discussion, you're probably okay. Um, I think it's making sure they're not taking any herbal stuff, and then a lot of times, if they're on a lot of serotonergic stuff, we don't, like, do thinner again over Zofran to just avoid kind of loading them up. So some of the other things are unavoidable. But, uh, yeah, I mean, I've had people on SSRI and Buzbar and, you know, buprenorphine. We do a lot of buprenorphine and Trazodone. So, um, you're generally. So a lot of the severe cases that I've seen, it's been like an overdose situation. But again, it can happen on the single agent, so just keep out for it. And hopefully you're just catching it kind of more like if they're having these symptoms, you're just not missing it, that it might be their serotonergic events. And you're seeing kind of a. I mean, because it is really, like, fever, sweating. You're probably not taking serotonin syndrome initially, right? You're thinking infectious cause or other things. Who doesn't have anxiety in 2026? Um, diarrhea. Now you have your whole GI. You know, um, differential. So I think it's just, like, probably gonna get some early signs before. It's just if you're on a, you know, prescribing conservatively. I think that's also why, like, don't prescribe four new things at the same time so often. In psych. Like I'm not doing multiple agents in a single visit, kind of layering them on and that also helps me know what's going on.

Speaker C: I have a patient that's on Sertraline 50 and then Mirtazapine 15 at night.

Speaker A: Just make sure they know about it. We talked about it, but

Speaker B: we have

Speaker A: not seen much of it. You could also add to it. Uh, clearly the answer is on this one. Hopefully you got this one right or else I'd be worried about you. Unless maybe you're colorblind then. Adolescent only keyword, right?

Speaker B: Mhm.

Speaker A: Generally. Especially multiple populations. Like you're mentioning behavioral stuff before medication. It's pretty cool of them. Um, an addiction kind of the opposite. Like should probably be using medication but in like a general psych sense. Like have you done the cool stuff before? You're doing that so we'll stop there. But I'm really. I would love to hear what the where the PGY Threes are practicing when they graduate.

Speaker C: Going to Georgia to do primary care.