 Hi and welcome to the class today. Today we're going to be talking about some of the more common medications that our clients might be on. Antidepressants, atypical antipsychotics, and a little bit with the typical antipsychotics, if you will, and mood stabilizers. And so the first thing you might say is why do I care? Why is this important to me? Well, in my opinion, for several reasons. Number one, because we need to know what these medications are supposed to be doing for our clients. But number two, a lot of our clients have this white coat phobia, if you will. And if they're on a medication that's not working for them, they don't speak up to their doctors. So educating them about the fact that there are multiple different types of antidepressants, atypical antipsychotics, mood stabilizers, all that act a little bit differently, all that may or may not have similar or different side effects. And some people find that there are certain side effects that are just intolerable. So at that point, they end up being medication non-compliant, which in and of itself causes a problem with our end of treatment. So again, we want to know what the medication is supposed to do. We want to educate our patients to enable them to advocate for themselves. And we also want to be aware from a clinical standpoint, if when they're taking the medication, they actually seem to be getting worse and not better. So for each of the following antidepressants, antipsychotics and mood stabilizers, we'll look at their method of action in general, explore the types of disorders they're used to treat. And let me tell you, there are a lot of them and review the most common medications in those classes. That way you have a general idea when you're doing someone's intake, if they say they're on risk per doll, you can go, okay, I know that one. Well, identify where to get more information for patients. There are some really good resources on the web that not only provide basically your box information, but also provide patient reviews where they say, this is how I felt when I started taking it. These are the side effects that I personally experienced yada yada. And they talk about their experience with it, as well as their experiences with other medications. Obviously, they're patients, not doctors. So it's not medical advice. But it does help normalize what some of our patients are going through, especially when they first start taking a medication, and they may start feeling foggy or weird. And then we'll discuss, if we've got time, the benefits and drawbacks to off-label prescribing. Some people feel very adamant about off-label prescribing and or not off-label prescribing. So if we have time, I will open the floor up for discussion. As always, if you have any questions while I'm presenting, feel free to type it in the chat window and I will try to answer it as we go along. So we're going to do a brief review of, pardon me, dopamine and some of our neurotransmitters. And let me see if I can move this move to new window. And so in your course, in the classroom, there is a PDF that's your neurotransmitter quick guide. I'm one of those people who likes lists. I really do, because it gives me the ability to visualize things and see that, for example, depression pops up in a lot of different places. Anxiety pops up in a lot of different places. But you can also get a feeling for the neurotransmitters that excess dopamine tends to, in one way or another, sort of rev people up. Hypersexuality, unnecessary movements, repetitive ticks. Whereas not enough dopamine slows them down. And then you've got your negative symptoms of schizophrenia, ADHD, lack of attention, lack of motivation, fatigue, serotonin. You've got anxiety if there's not enough. And if you've got excess, you can also have depression because you're basically revving the system up too much. Noripinephrine. Again, you see anxiety if there is an excess. So it's a rev upper, rev upper, same thing with acetylcholine. Both of those are rev uppers. You're a fight or fight or flight chemicals. But if you don't have enough, you're pretty slow, loss of alertness, difficulty focusing, difficulty concentrating. So you can see where there's a lot of overlap in these. One of the things I want you to really consider is the fact that most mental health issues that come up are probably not due to just one of these chemicals being too low or too high. It's probably a lack of balance between a lot of them. So helping clients understand that we need to figure out kind of what's out of whack and get it back in balance is going to be a big part of kind of what we talk about today. So dopamine is implicated in cognitive control. So if you've got too much dopamine, you may have racing thoughts, attentional control, impulse control and working memory, symptoms of excess dopamine, unnecessary movements, psychosis, hypersexuality, most of your anti psychotics and your atypicals that we're going to talk about are dopamine antagonists. It reduces the amount of dopamine available. Symptoms of insufficient dopamine, we're talking about your negative symptoms of schizophrenia, your flatness, and just lack of movement, lack of your catatonia, those sorts of things. More sense of pain, symptoms of Parkinson's disease. Restless legs, interestingly, that's the one where it's more revved up than down. And ADD, where people are having difficulty focusing their attention. Other more common signs of low levels of dopamine, lack of motivation, fatigue. Remember, dopamine is our feel good chemical. It's our reward chemical. So if we don't have enough of it, we don't have a lot of motivation to get off the couch. We don't have a lot of motivation to concentrate. And it may be more difficult to sleep because that is throwing a lot of other neurochemicals out of balance, which is going to affect our circadian rhythms, our serotonin levels, our melatonin levels, and so on. Medications. And we're going to talk more about these. Risperdone, Haldols, Iprexa, these are the ones we're going to talk about as some of your more common dopamine antagonists, your atypical anti psychotics. Agonists, just so you can be aware, if your client has Parkinson's syndrome or restless leg syndrome, and I see restless legs a fair amount, they will be taking a dopamine agonist. So if they're also taking an anti psychotic, they're probably canceling themselves out. So we need to help educate our clients, especially ones that go to multiple doctors. Mechanism of action of serotonin helps regulate mood, sleep patterns, appetite, and pain. A lot of your serotonin is in your gut. There are a lot of interactions with serotonin and you can see implications with serotonin in irritable bowel and a variety of different neurological problems, which you'll see when we talk about what things SSRIs are prescribed for. They're prescribed for a lot of neurological pain as well as a whole host of other things. Symptoms of excess, depression, apathy, emotional flatness. When serotonin goes up, some of the other happy chemicals go down. So we got to remember that just because someone's depressed doesn't necessarily mean they have too little serotonin. Difficulty concentrating and learning, poor memory, difficulty making decisions, and sexual dysfunction. Insufficiency, that's a short list, depression, anxiety, and pain sensitivity. Norepinephrine, this is one of your get up and go, fight or flight chemicals. It mobilizes the brain and body for action. It increases arousal, alertness, but also anxiety and restlessness. It can promote hypervigilance and vigilance and focus attention. So if you're reading through this, you might go, well, that kind of sounds like some of the PTSD symptoms. Then I'm like, yeah, it kind of does. We need to look at norepinephrine if we've got a client who is hypervigilant, who startles really easily, seems like they're keyed up and on edge a lot. Excess anxiety, increased startle reflex and jumpiness, impaired concentration, restless sleep, rapidly fatigued. They get up, they start going in the morning, and by 10 o'clock they're like, I need a nap. Now, you know, some of us would like to have a nap, but this is regular for them. They just, they can't get through a day without just being completely exhausted. Muscle tension and cramps because this hypervigilance and startle response, they tend to be tighter in their chest, neck area, you know, holding a lot of that tension, which can contribute, in my opinion, to irritability and edginess. So your norepinephrine medications are going to be your alpha two agonists, which have a sedating effect and are commonly used in anesthesia, as well as in the treatment of drug or alcohol dependents. So, again, talk about those in a few minutes. I just wanted to review the neurotransmitters. Stimulants and antidepressants increase dopamine and serotonin, as well as increasing levels of norepinephrine. So remember, I talked about how you can't, well, you can try at least, to increase just one. But when somebody is taking an antidepressant or a stimulant, like an ADHD medication, not only are they increasing serotonin, but they're also probably increasing norepinephrine and dopamine. So I found this one interesting. So just bear with me for a brief little second. There are different receptors in the brain. Pre-synaptic terminal excretes neurotransmitters into the synaptic space, and then there are all kinds of different locks, if you want to envision it as lock and key, on the receiving neurons. Your D receptors, D1 through D4, are typically associated with dopamine. I'm like, thank you for giving me a clue there. Then you go down to 5HT1 and through 5HT7 with subtypes like 5HT1A, 5HT2A, lots of subtypes. Those are serotonin. Now I don't know how they got serotonin from HT, but alpha receptors, and you'll see the little alpha sign and a little sub number, are associated with your adrenergic receptors, your adrenaline, norepinephrine, norepinephrine, epinephrine, and adrenaline. So if you see a little alpha, that's your get up and go receptors, and whether you're increasing them or working against them. And your M1 through your M3 are your muscarinic receptors, which are associated with acetylcholine. Muscarinic receptors are more active when we talk about GABA, and we're not talking about that today. And your H receptors are associated with your histamines. Remember, histamines are the things that your body excretes to when there's an allergy or something that kind of make you itchy, just to be aware. So these are the different receptors that they look at when they're evaluating the efficacy and what receptors are being affected when people take different psychotropic meds. And one last review, higher acetylcholine and higher norepinephrine, so those are your two get up and go neurochemicals, together with low serotonin. So your happy chemicals low and your fight or flight chemicals are high, produces anxiety, irritability, anger, aggressiveness, go figure. When epinephrine, which norepinephrine is your get up and go and your motivation chemical, dopamine is your reward chemical and serotonin is your happy chemical for lack of a better term. But acetylcholine is low. The result is depression. And you're like, Well, how did that happen? You've got get up and go reward and happiness, but we're depressed. So you see how the balance is so important. And increasing serotonin levels will lower acetylcholine levels. So it's important to understand that there is an interaction and it will also potentially lower norepinephrine over here and your dopamine. So you can't just increase one without affecting the other three. So now on to antidepressants. Yay! Your selective serotonin reuptake inhibitors decrease serotonin blockers in the brain. It makes it so there is more serotonin getting through that into that post synaptic terminal. It's going through there. The ones we talk about or the, you know, ones we first learn about in in school, and a lot of doctors still kind of prescribe as your first line because they're the older, more researched are your Zoloft, Prozac and Paxil, sertraline, fluxitine and peroxitine. Heuristic evidence when we talk to patients is that Zoloft tends to be more neutral as far as making people sleepy, making people gain weight. Prozac tends to be more stimulating and a lot of people report they have a lot more anxiety when they're taking that. But if you've got a client who just can't get out of bed or who has no motivation, sometimes Prozac is the kick in the butt that helps them. Paxil, on the other hand, tends to sedate a lot of our clients. One of the suggestions that the docs I've worked with have made to clients is to take their Paxil at night before bed. They won't feel as sleepy the next day. But if you've got a client who is complaining that they're on an antidepressant, they're on Paxil and they just can't wake up and they even try taking it at night and they just can't wake up, encourage them to talk with their docs so they don't discontinue because of the side effects and look at some of the others that are available. Satalapram, I'm just going to go with the trade names, they're easier to pronounce. Cilexa, Lexapro, Luvox, and Ulptro are all available and they are all pretty commonly prescribed as well. All of them work slightly differently. Some of them work on slightly different 5-HT receptors. Remember there's 5-HT1 through 5-HT7 plus subtypes of those. So there's lots of serotonin receptors and we got to figure out which locks are broken in our particular clients and we haven't figured out a great way to really identify that yet with that kind of pinpoint accuracy. We're trying to figure that out. Which takes us to our SNRIs, your serotonin and norepinephrine reuptake inhibitors. So maybe somebody has not enough serotonin but they also are not, don't have enough norepinephrine, not enough get up and go if you will. Pristique, Zimbalta, and Afexer have come on the market recently compared with Zoloft, Prozac, and Paxil and have been found to be very effective. Zimbalta also has the added benefit of pain relief in addition to treating depression. Now again, I'm using the trade names simply because they're easier to pronounce. I'm sorry. And I'm not advocating for any particular pharmaceutical company. And you want to look at the generic name anyway to see if it's available in generic for your clients. While I'm on this little side note and tirade, if your clients cannot afford their medication, go to the website of the pharmaceutical company that makes it. Almost every pharmaceutical company has a patient assistance program. Print out the form, have the doctor sign it. It's usually a one page form that indicates that the patient can't afford their medication. The doctor faxes it in and they usually are able to get a voucher for either free or low cost access to that medication. And when I say low cost, I mean like four bucks, not anything huge. Also make sure to compare the different formularies at places like Walgreens, Publix, Walmart, Sam's Club, and you know, the list goes on the different drug stores to see which medications are on the low cost plans like $4 for 30 days worth or $12 for 90 days worth. A lot of patients don't have prescription coverage. So making sure that they're able to get a medication, which is almost always going to be a generic at an affordable price is going to be like really huge. So off my tirade back to our drugs. Tricyclics. Now, once you exhaust your SSRIs and SNRIs and if they're not working as well, and in some cases the doctor may decide to start with your tricyclics, they tend to have more significant side effects and be harder to manage for a lot of patients than your regular SSRIs and SNRIs. But I know I've had clients on Pamelaur before. I've had clients on Tophrenil. Being aware that they're there, they may be prescribed. You really, in my experience at least, working with clients with co-occurring disorders, most of the time I would see SSRIs in atypical antipsychotics. If I saw tricyclics, I would start to really think about whether this person had treatment-resistant depression and want to talk to them about what else helps them. Vupropion or Wellbutrin is a dopamine reuptake blocker. So it prevents the dopamine from being sucked up, which means it's more available in that synaptic space. It has been used for depression, seasonal affective disorder, and also smoking cessation. However, because people with bulimia, when they purge, can make their electrolytes get out of whack, something about this medication makes it more likely for them to have seizures if their electrolytes are imbalanced. So it's not advised for people with history of bulimia. MAOIs prevent the breakdown of norepinephrine dopamine and serotonin. If you've read the back of just about any over-the-counter medication, it says don't take this if you're on an MAOI. It doesn't play nice with others. It doesn't play nice with a lot of foods, including cheeses and wines. It's just not a play nice in the sandbox kind of med. It may be a last resort for some of our clients, so you need to be aware of it. Again, I know I've had clients before on Nardal, so being aware that sometimes, for whatever reason, the psychiatrist may choose the MAOI, likely they've already exhausted most of the other options because there is a lot of risk associated with the MAOIs. But again, it makes norepinephrine. Your fight-or-flight, your active, your peppy sort of neurochemical, dopamine, your reward chemical, and serotonin, your happy chemical, and also your I don't feel a lot of pain and I've got decent sleep. So these three chemicals are pretty important, and it makes them more available. And then remeron. I felt the need to put this in because, and it's not as much anymore, but in the past, I had seen a lot of our attendings, and I don't know about your attendings, had prescribed remeron for patients that were having difficulty sleeping, etc., and had some, you know, ongoing depression. Remeron gave a lot of our clients really bad munchies. Not every client, but that was one of the big complaints with remeron. It is a noradrenergic antagonist, which means it's going to try to prevent noradrenaline. Like I said, I don't see it used as much anymore, but it's still out there, and you'll still see it. So how do you find the right one? Well, because depression can cause, because by an imbalance in one or more neurotransmitters, we need to take a lot of things into consideration. First and foremost, being patient treatment compliance. Can they afford it, and are they going to be able to deal with the side effects? Please advise your clients, because a lot of times, and I don't mean to diss doctors here, but a lot of times, the doctors that are prescribing the anti, the psychotropic medications, don't tell people that the first couple of days you're taking it are going to feel wonky. Some, not very much at all. Sometimes it feels like flu-like symptoms, and for some medications like Zoloft, if you miss a dose, or if you're more than 12 hours late on a dose, you may start feeling kind of lightheaded and like you've got the flu. I like to tell my patients that right up front, when they start taking a medication, I'm like, let's talk about what other people have reported that they have experienced, just so you know. That first three days may not feel so good, but after that three days, those side effects often go away. If they don't, let's talk about it before you DC, because if you discontinue, and then you decide to start up again, you're going to have those side effects again. So we need to talk to them about what are intolerable side effects. Some clients will tell you from the get-go, I will not take something that makes me gain weight. Okay, good to know. We want to talk with them about if they have any close blood relatives that have used an antidepressant that's worked for them. If so, that's probably a good place to start, because we know there is some sort of a genetic component. We also need to look at what other medications they're taking, and look at any contraindications. Like I told you, if you have somebody on medication for restless leg syndrome, you're going to have to figure out how to handle that if they also need an antipsychotic, because both of them are working in opposite ways on dopamine. And we need to think about health conditions and pregnancy. Anything that may affect blood pressure, and if the person's pregnant, what the drug category is. I'm not going to get into that a lot, because that's something the doctor will talk about with them. If you're not familiar, drugs are rated in pregnancy category, pregnancy safety category. I think it's A through D. D being just completely unacceptable, but some of your SSRIs are in the category B, where they're pretty sure it's not going to cause big problems in the infant, but they can't ethically test on pregnant women. So all they're going from is any reports that may have come in from someone who was taking the medication while they were pregnant. So again, that's something for the doctor to worry about, but do know that there are considerations for pregnancy, especially with your mood stabilizers and your atypical antipsychotics. So what antidepressants treat everything? It's like throwing the kitchen sink. Anorexia and feeding problems. We know that serotonin's involved in hunger, anxiety and panic, anxiety and stress, binge eating. So again, with the food. So we've got anxiety, food, mood swings, body dysmorphic disorder. And I was reading the best practice on that recently, that the SSRIs that are used to address body dysmorphic disorder are often used, prescribed at much higher levels than you would see for, quote, normal depression treatment. I'll be doing a class on that, but just kind of be aware if your patient says they've got BDD and they report taking Zoloft at, you know, 400 milligrams, which is like a huge, huge dose of Zoloft, that might not actually be incorrect. Borderline personality disorder, bulimia, again, with the food, depression, fibromyalgia with the pain, anxiety, again, hot flashes. So, you know, not sure how that works, but it is prescribed for hot flashes, intermittent explosive disorder, irritable bowel. Remember, I said a lot of your serotonin is in your gut, like 80% of it. Depression, OCD, PTSD, postpartum, premature ejaculation, PMDD, schizoaffective social anxiety, and somatiform pain disorder. So basically, there's depression, anxiety, mood swings, and food issues, pain and food issues. Now onto your atypical antipsychotics. Generally known as major tranquilizers, and if you've been around clients who are on these, you will know that they can really slow somebody down. While I'm on that, some resourceful patients with co-occurring disorders may take their atypical antipsychotic in combination with another depressant in order to get high. In treatment, in residential treatment, it is not uncommon for clients to cheek their saraquil and save it for later. And then they take it in the morning, and they stay up through that sleepy period. And they're in sort of a weird, hypnotic state at that point is what one of my patients described it as. So being aware that atypical antipsychotics as well as typical antipsychotics can be abused because they're a tranquilizer, combining them with other depressants can be deadly, but it can also be a way that some of our patients try to get high. And neuroleptics. Now these are more your first generation antipsychotics, but it's important to know that they do have some neurological effects. Atypical antipsychotics, your antipsychotics in general when you're talking about them, block receptors in the brain's dopamine pathways causing a reduction in dopamine stimulation. They're reducing the amount of dopamine available. But interestingly, they failed to significantly improve the negative symptoms and cognitive dysfunction. Now, we've found out recently that a lot of that has to do with receptor, dopamine receptor 3. So if they're reducing the amount of dopamine and dopamine receptor 3 is involved in the cognitive problems and the negative symptoms, so they need to ramp that one up, they've got to figure out how to find something that's a selective dopamine inhibitor, if it's even possible. So what do we have available to us? Zeprexa is one that a lot of my clients have been on. Cerroquil, Risperdology, Adon, Abilify, any of these that you see your clients on are going to be your atypical antipsychotics. And you may have a client in there and you're thinking to yourself, well, this client doesn't have schizophrenia, so why are they on an atypical antipsychotic? That's a good question because they are used to treat a whole host of things. Partially, because those neurotransmitters work in synchrony, but partially because antipsychotics are good at sort of slowing people down. They're good for treating agitation, anxiety, bipolar disorder, especially the manic symptoms. Interestingly, body dysmorphic disorder, borderline, depression. Sometimes you will see an atypical antipsychotic with a NSSRI for people with, quote, treatment-resistant depression. Anxiety, again, intermittent explosive disorder. People who have nightmares, night terrors, maybe prescribe these to help them sleep. OCD, post-traumatic stress disorder, psychosis, schizoaffective disorder, schizophrenia. Again, with a social anxiety, tick disorder, and Tourette syndrome. So, what I want you to notice, and I think I highlighted that, is the fact that a lot of these mood disorders, quote, unquote, that we work with, that we typically think SSRI, may also be treated or affected by antipsychotics, which tells us that dopamine's involved in this whole process. So it may not just be a serotonin thing for somebody. Side effects. Unfortunately, even the newer antipsychotics have many side effects. And just because they're atypicals, doesn't mean that they have fewer side effects than some of your older ones, like your prolixin. Bear that in mind. Drowsiness, dizziness, restlessness, weight gain, constipation, nausea, vomiting, blurred vision, low blood pressure, uncontrollable movements, such as ticks and tremors. Yeah, wanted to sound like a commercial. But be aware of your normal side effects. There is a checklist that I put in the classroom. It is wonderful. I wish I would have had it in all the years I was actually working in residential facilities, is the antipsychotic side effect checklist. And it breaks it down into layman's terms for our clients to be able to say, yeah, I'm experiencing that. And for our counselors, to be reminded of all the different symptoms that actually may be a side effect of the antipsychotic, for example, switching back and forth, being restlessness and switching back and forth in their chair. A lot of times, counselors, not knowing, may attribute that to either anxiety, or lack of attention and being disruptive in group. When we go back and we look and say, oh, well, Jim Bob was just started on an atypical, then we might be able to talk with Jim Bob and talk with the doctor and figure out if that side effect is going to pass for him. But it's also a way to avoid blaming the client for something that's not their fault. They're not trying to be disruptive. They just literally cannot sit still. So you can print that out. It's a great checklist to have. Clausapine and onizapine are associated with the greatest effects on weight gain and decreased insulin sensitivity followed by Risperdone and Quedepoctin. I got to work on those. Anyway, Risperdoll is one we see a lot. So it's important to recognize that these four are going to likely have the side effect of producing more weight gain. They also are likely going to have the side effect of increasing insulin sensitivity, which may exacerbate diabetes or hyperglycemia. Again, this is something the doctor is going to be more concerned with than you are. But if you're in a residential facility, someone just started on an atypical antipsychotic, they're in group and they go into some sort of a diabetic crisis. It's important to understand, oh, this may be what's happening instead of just going, I don't know, he just fell out. So these are important things for the paramedics to know, for your staff to know if someone has recently started on an atypical antipsychotic. Mood stabilizers. They're comprised of a variety of drugs used to reduce mood swings. Most of them are GABA receptor agonists. They're going to increase the amount of GABA available. They all kind of fall into different categories, but you have lithium, which is just a straight up mineral. Lithium can be really hard on the kidneys. So there are a lot of, it's very important for our clients to be well monitored by their doctor. Now you may think, well, that's the doctor's problem. We see the clients a lot more than they probably see their attending physician or psychiatrist. And so if they cancel with their psychiatrist, it may be another month before they can get in. If they cancel with us, we may only miss a week with them. So it's important for us to keep talking to them about their medication compliance, how it's going, how they're feeling, if they're having any side effects. Your anticonvulsants. Depicote is the one that was most commonly used where I was from. I've seen lamyctal and tegritol also used. These typically have sedating effects, but are typically well tolerated in general by our clients. They are not recommended for women who are pregnant or nursing, nor is lithium. So it's, when people are pregnant and nursing and have bipolar disorder, it's a sticky wicket to figure out what's going to happen. So far, I have never run into an attending physician that's willing to prescribe any mood stabilizers during pregnancy and or if the person is nursing. The recommendation usually is for the person to not nurse so they can get on their medication and be emotionally stable to be there for the infant. So just being aware of someone is pregnant and they were on mood stabilizers, they will probably come off. So they're going to need some tips and tools to figure out how to deal during their pregnancy and during the unmedicated state. Mood stabilizer side effects, itching and rash, excessive thirst, frequent urination, shakiness, nausea and vomiting, slurred speech, changes in heartbeat, changes in vision, potentially seizures, hallucinations, loss of coordination, and swelling of the eyes, face, lips, tongue, throat, hands, feet, etc. So mood stabilizers, stabilizers, wow I'm having difficulty talking today, do have a lot of side effects. They are potent medications. If people are having side effects, they need to talk with their doctor sooner rather than later to figure out if it's a normal side effect, if their dose is too high for them, and if it's a side effect that's going to go away. Other great resources and I'm going to see is this, oh of course it'll open somewhere else. The drug interacts and interactions checker on drugs.com. Love this thing. You click I agree, it just basically says this is not a drug, this is not a doctor's advice, this is just kind of what we know. So you can type in medications like Sertraline and Remeron. And let's just get in there with Halbal. And then we want to check for interactions. So if somebody happened to be on these, which I would hope you would never see, I intentionally chose things that shouldn't be together, it will tell you if there are major or minor potential interactions between the medications. It tells you which medications may not play nice together. And the clients can use this to educate themselves and to talk with their doctor. Sometimes the risk of the interactions is worth it in the patient and doctor's opinion, and that's totally between them. But this is a cool thing. You can email it to yourself or the patient. You can print it out so they can take it to their doctor. It's a great thing to have. It's a great resource. Another resource that you have available to you, again drugs.com. Find drugs by disease or condition. So let's say we have somebody who has depression. And then we can look and see the medications that are typically prescribed for depression. And you can see the patient rating as far as effectiveness and satisfaction with the medication. And obviously we'll look down at Xanax. We know that Xanax is highly abused, but it gets an 8. People found it to be really, really helpful, probably because they're really, really sort of stoned when they take it. But it does work quickly as opposed to SSRIs that do take four to six weeks to get in your system. So you can click on the reviews, remembering and reminding our clients that these are by patients, not by doctors. And we don't know exactly how accurate they are. But you can get an idea on what it might feel like to take this medication and whether it sounds like it might work for you. You can figure out, it says your pregnancy category here. Yes, D here. So D is positive evidence of risk. If you take Xanax when you're pregnant, there is evidence that it will hurt the fetus. Category C, they can't rule out risk because they just don't have enough data or information. Paxil is a D. So it gives you an idea. And it also gives you an idea about what options are out there for your clients. And if you have a client that comes in that seems to be on a weird cocktail of medications, not that we're doctors, but we do know that some of our clients will doctor shop and not tell Dr. A about Dr. B, C and D. So it's, you know, good to be able to look at some of these medications and try to figure out what's there. And they may not realize that the medication for restless legs is going to impact their antipsychotics. It may not be intentional. But so these are two great resources that I really like to have available. Let me show you really quick. The side effect checklist. Yeah, you know, lots of verbiage talks about the different items and defines what we're talking about. So daytime sedation or droughtiness, whether it's a common side effect, it gives you some information. Scroll down. This is the part for the clients. Loss of energy and drive. Client can say not a problem or it is a problem. And this is why muscles trembling and shaking, being too tense or too stiff, restlessness, jitteriness need to move around and pace and inability to sit still. Is it a problem? Is it not a problem? Most of our clients will understand the explanations that are here because it's not overly like medical jargony. So I like to give it to them, give them a couple of copies and have them rate them their symptoms or lack of symptoms every week. For a couple of weeks when they first start taking atypical antipsychotics, that way we have sort of a record and we can look at the progression to see if some things are wearing off and then they have something to give their doctor and I have something to put in the chart. So those are three of your big ones. Obviously, we didn't talk about your anxiolytics today. But your antidepressants, atypical antipsychotics and mood stabilizers all are occasionally used to address anxiety as well as depression, food issues, pain, and mood swings. So are there any questions? Okay, cool. If you think of any questions, you are more than welcome to send me an email at support.allcews.com. That goes straight, pushes straight to my email and I can answer any questions that you may have. In the meantime, the quiz is open. You can go in and take it and print your certificate of completion and we will be good to go. I'm glad the websites are helpful and let me know if you need anything.