.

Good evening, I'm psychiatrist Jay Fawver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind Now in its 25th year of Matters of the Mind is a live call-in program where you have the chance to choose the topic for discussion.

So if you have any questions concerning mental health issues, give me a call here at Fort Wayne by dialing in the Fort Wayne area (969) 27 two zero if you're calling coast to coast you may call toll free at 866- (969) 27 two zero on a fairly regular basis.

I am broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Fort Wayne campus.

And if you'd like to contact me with an email question that I can answer on the air, you may write me via the Internet at matters of the mind all one word at WFYI Big That's Matters of the mind at WSW ECG and I'll start tonight's program with a question I recently received.

>> It reads Dear Dr. Fauver, if a medication is working well for me, do I need to see my therapist anymore?

That's a very good question.

If your medication is working well for you, you want to define how the medication is working well for you.

>> Is it helping you with your symptoms of depression, anxiety ,sleep, irritability, focus?

>> That's great.

But is it also helping you be able to do the kind of things that you intend to do?

>> Many people when they have mood disturbances for instance, they'll give pleasurable activities.

>> They'll no longer do things that used to be fun and as they're coming out of the depression itself, sometimes there's a delay in their getting involved in those kind of pleasurable activities.

>> The goal therapy is to help you gain a perspective on the world around you that you might have found a bit altered when you were depressed, when you were anxious when you're having emotional disturbance and difficulty with concentration you'll often have a different perspective, a different view of the world around you.

>> And the idea of therapy is to help have this independent objective observer who is not your friend, who's not your family member or somebody who's just an independent objective observer kind of look at your life circumstances as they are and give you some ideas on how you might perceive things differently and give you some specific direction on what you can do to even further your overall functional functionality is where you're doing all you can to to be able to work, to be able to socialize, to be able to interact with others, to have fun.

>> These are all the kind of measures will often try to examine as people are recovering from their mood disturbances.

Now how long should you be in therapy?

Well, the rule of thumb as you want to be in therapy at least half a dozen times but for many people they find that if if they continue to progress in therapy it might continue over the course of six months to a year.

When I was in my training way back in the 1980s, I was in psychoanalysis and I would go see my analyst every Tuesday and Friday morning first thing in the morning and I did that for two and a half years.

Would I recommend that for everybody?

No, because I think we have more efficient means of directing therapy nowadays.

>> But it was it was helpful for me because I was in the role of a patient and by my having analysis myself it was a very long drawn out process.

But I got got a feeling of what it's like to go through the whole process of therapy as a patient course in those days 1980s I was training to be a psychotherapist because in the nineteen eighties prior to nineteen eighty seven we didn't have that many medications available.

We had a maybe twenty medication we use for depression and psychosis and bipolar disorder.

I've had a handful for attention deficit disorder but then in nineteen eighty seven Prozac came out and it was the first of now sixteen different oral antidepressants to become available for the treatment of depression and we've had a lot of different medications become available for mood stabilization and psychosis.

So since nineteen eighty seven the field has exploded in psychiatry more toward psychopharmacology the medication treatment.

>> So the idea now is we'll treat people with medication to allow their brains to work better and to function better and once you get stabilized with medication treatment then you'll find that many times the counseling and the psychotherapy can work more efficiently because you can process through the information a lot better.

The whole idea of medication is to fire up the thinking part of the brain in the front and dial down the anxiety volume control which is down here in the amygdala the side part of the brain and it tends to normalize the overall top down type of functionality of the brain and allows you to think before you act and it doesn't allow you to be hijacked by your emotions as many people will will feel when they are very anxious and they're depressed.

>> So psychotherapy not uncommonly does follow the use of medication and psychiatry and if you're doing well with your medication, that's fantastic.

Talk to your clinician about how long you need to stay on the medication.

The rule of thumb is you want to stay on the medication for at least a year with most conditions and then review the pros and cons of going off the medication or not.

Now some medications need to continue ongoing.

We try to limit the number of medications.

>> The dose is the best we can as people are doing well.

But for many chronic conditions you do need to stay on medication long term.

>> Thank you for your question.

Let's go to our first caller.

Hello Tom.

Welcome to Matters of Mind.

>> Tom, you've been experiencing tinnitus and that's where you have ringing the ears ringing or buzzing in the ears.

You've been prescribed antidepressants.

You're concerned that the medication will make it worse.

What antidepressants would you OK for someone with tinnitus there's one medication that can make ringing in the ears worse, Tom and that's a medication called Wellbutrin or bupropion Wellbutrin.

>> I think the likelihood is six percent.

>> So roughly three out of fifty people on Wellbutrin can have ringing in the ears as a side effect and that's kind of a unique side effect to Wellbutrin as an antidepressant.

I quite frankly don't hear about tinnitus with other antidepressant medications.

So I would say I am quite frankly pretty much any antidepressant would be OK with tinnitus except for Wellbutrin and Wellbutrin could be fine.

You might be one of the forty seven out of 50 people who don't get tinnitus with Wellbutrin.

But if you notice tinnitus gets worse with a medication like Wellbutrin you'd want to go another direction.

But other than that any of the other antidepressants should be OK with tinnitus.

We don't really know what causes tinnitus.

I think it's more of a neurological condition the ear, nose and throat people have been trying to sort out what causes it and how to treat it for a long time they've perceived in the ear, nose and throat feel that maybe it's an inner ear problem.

>> Maybe it's a structural problem with the ear but they just haven't figured that out.

So I think the neurologists are the ones mainly try to figure it out because the neurologists have to sort out when the actual sensory input for for the auditory stimulation gets to the brain.

>> Something has happening and causing that ringing and buzzing.

>> So it seems to be a brain issue as opposed to an ear issue with tinnitus.

>> Now historically medications like Xanax have been used because it's been found that if to decrease anxiety you might have less tinnitus.

But it's not really an anxiety condition.

It seems to be a more structural brain condition when people are having ringing in the ears as the little nerve cells in the ear are are dying off, they will as a final salute have a little buzzing ringing sound and the ringing sound in the ear is indicative of the little nerve cells dying off.

And I have heard that over the course of the past few decades that that's kind of a symptom that some of the nerve cells are dying off when you hear that high pitched ringing but ongoing ringing such as tinnitus, ongoing buzzing that seems to be more of a different kind of condition and it seems to be more of a neurological condition than it is an ear, nose and throat or a psychiatric condition.

Tom, thanks for your call.

Let's go to our next email.

Our next e-mail reads Dear Dr. Fauver, I have recently been prescribed medications for bipolar disorder.

>> How will I know if it's working for me?

How long should the medication take to help?

>> It depends what kind of phase of bipolar disorder you might be experiencing.

If you're on the high side, your thoughts will be racing.

You won't need to sleep .

>> You'll do things very quickly.

You'll do this then you'll do this.

You'll talk very, very fast.

You'll go from topic to topic to topic.

You'll be intrusive in other people's conversations and this will occur only episodically every now and then for a few days at a time.

Those are the so-called manic highs.

If you have a manic high lasting from one to six days that's called hypomania if you have a manic high lasting for seven days or more and it's causing you to get in all sorts of trouble that's called mania itself.

So there's different types of the manic highs and we might treat them differently.

So on one hand if you're having a manic high you can come down off of that manic high with a matter of one or two days depending on how aggressively we treat you with medications and then you can have the depressive lows and those are what often bring people to treatment that have had the highs and lows crashing into the lows not unlike somebody coming off of cocaine where they just want to sleep all the time.

They're extremely depressed.

They don't want to be around anybody.

They can't concentrate is a horrible feeling to experience ,especially if you've been to the mountaintop on the manic high.

Now that is the price people typically pay when they're the manic high they crash into these depressive lows.

>> People sometimes ask me well why can't I have a little bit of a high higher than normal all the time?

>> Well, if you do that you're going to eventually run out of gas.

The goal is to try to get you kind of in that mid range and it's kind of like a speed on a car.

You can't be driving 80 miles an hour all the time.

You can't be driving thirty miles an all the time when you especially when you're on the interstate you've got to go the speed limit and the speed limits around 55 or 60.

That's where we want you to be and we don't want you to feel unnaturally high.

We don't want you feel unnaturally low but you want to be able to have emotions as the situations around you call for for them.

So we want you to have normal emotions but we don't want you to have unnatural highs where you don't need to sleep and you do things impulsively and you get yourself in trouble.

>> We don't want you have these these unnatural lows where you're just in the pits all the time.

So we want to stabilize it and we try to stabilize out with mood stabilizers now mood stabilizers include lithium and lamotrigine.

>> Lithium is a salt been around since nineteen forty nine Lamotrigine is an anti seizure medication.

It's very good for stabilizing the mood for a lot of people it does better for the lows and the highs and then you have four of the antipsychotic medications that are approved long term for mood stabilization in various forms or within the combinations they can include Abilify Seroquel, Risperdal and Zyprexa.

>> So these are medications that can be used for long term mood stabilization.

>> The goal with mood stabilization is that you don't notice the unnatural highs and lows you are sleeping more often than not you can tolerate stress reasonably well and the bottom line is you don't get in trouble in your job with your marriage and with other people based on your mood.

>> So that's an indication that you're doing OK over the course of time.

So for the depressive low it might take a week or so to come out of it upon getting treatment for that.

But it's very difficult to study a lot of types of bipolar disorder because let's say you're trying to study bipolar depression.

>> You know you might come out of it anyway when you have a highs and lows you might come out of the low anyway.

So if you're using a medication and you're trying to study how well that medication works for the bipolar depression, it's difficult to study because you might come out of it naturally.

The problem is we want to get people stabilized and keep them from having highs and lows overall there's a lot of the medications used for bipolar disorder that are very effective.

There's can supply to those Braila.

There's a lot of other medications that have come out .

The medications all have pros and cons and they work differently for a lot of people some of the medications are more associated weight gain but some are not.

But the ones that are not might be more associated with restlessness and difficulty with being able to sit still.

So we have to look at every individual to determine what medications might work for them and go from there.

We do genetic testing for some people and we can find some genetic testing who might do better on an antipsychotic medication and who might be better better served with a medication like lithium or lamotrigine.

There's a danger with antipsychotic medications, with any mood disorder like bipolar disorder.

The danger would be a phenomenon called tardive dyskinesia.

Tardive dyskinesia is basically where you have an excessive stimulation of dopamine and it sounds weird because antipsychotic medications block dopamine.

Well, if you use an antipsychotic medication like Abilify, Risperdal, Seroquel or Zyprexa long term you're blocking blocking blocking dopamine receptors in the brain is very smart because the brain is noticing that receptors are getting blocked.

It starts to grow more of those receptors and if you go more the dopamine receptors, your brain can actually get more sensitive in some areas to dopamine and that cause you to have twitches and tics and can be problematic for people especially if they've been on the medications for for bipolar mood disturbances at high doses and they're in their older years.

So people in their older years are more likely to get tardive dyskinesia.

These are twitches in their mouth and eyes and tics.

Sometimes they can have shoulder shrugs.

It's more common with older people, it's more common with women.

But we do have genetic testing .

>> It can identify that.

Ah so there are some genetics that can predict who might get tardive dyskinesia more so than others other risk factors for tardive dyskinesia.

>> Can it be type two diabetes smoking can increase your risk of tardive dyskinesia and being overweight can be a risk factor for tardive dyskinesia so those are the main risk factors that we consider with certain medications.

>> But if you don't have those risk factors or you feel like a good it looks like you're a good candidate for the antipsychotic medications, they can be very, very good mood stabilizers and a mood stabilizer can be very helpful for people having these unnatural highs and lows and allow them to have their lives back.

>> Thanks for your question.

Let's go to our next caller.

Hello Marie.

Welcome to Matters of Mind and Marie, you mentioned you've been taking Lexapro also known as escitalopram since 20/20 and you started taking Metronet does all this month and you got really dizzy and felt really sick.

Could it be the combination of those medications?

Yeah, I mean Flagyl is a name for Metronet zoll and flagellate easier to say but flagellar the medication that can cause as a side effect dizziness and make you feel sick.

>> And here's how this works Marie.

There's not a direct drug interaction there between the two of them.

>> Lexapro is a medication that increases serotonin and if you'd been on Lexapro for a couple of years as you'd mentioned and you weren't having those problems and all of a sudden a medication is added to it, it's probably the medication was added to it if the onset of those side effects such as dizziness and feeling sick started with the newer medications, now you're spot on because the other can be drug interaction between two medications because occasionally if you add a medication to another it'll cause the first medications blood levels to go sky high.

That's not the case in a calm and combining Flagyl with Lexapro though that wouldn't be the case.

I would say in your case it was probably the addition of the Flagyl.

Another Flagyl could be a very good medication for the purposes in which used in which it's used.

It's used as a medication to decrease the likelihood of yeast infections and and it's used for various other conditions.

But you look at the pros and cons of still taking it but it's probably the flagyl causing you those specific side effects.

>> Marie Marie, thanks for your question.

Let's go to our next email.

>> Our next email reads Dear Dr. Fauver, how has psychiatric treatment changed since you came out of training?

>> I came out of training in nineteen eighty seven.

So what was thirty five years ago is a long time ago in nineteen eighty seven as I was mentioning before I was trained primarily as a psychotherapist in the 1980s.

>> Now I was a pharmacist before I went to medical school.

A lot of people perceived that I was wasting my pharmacy background by going into psychiatry because in psychiatry in the middle 1980s there weren't that many medications used.

There were the so-called tricyclic antidepressants monoamine oxidase inhibitors.

There were a few of the older antipsychotics.

There was lithium carbamazepine.

Depakote had come out so there were a handful of medications used in psychiatry in nineteen eighty seven nineteen eighty seven Prozac came out and it wasn't that it worked any better than the prior antidepressants, it was just more tolerable and for the first time psychiatrists started thinking about using medications as a means of changing the brain chemistry to help somebody think and thereby get them into counseling or psychotherapy prior to the time it was always as I was trained get them into psychotherapy first and only as a last resort.

You had people go on medication.

What we found was there were missed opportunities by doing that people would go into counseling, they go into therapy, they'd get stuck.

They weren't making any progress.

They couldn't concentrate.

They still weren't sleeping and they would be in therapy for weeks and weeks or months and months and they just weren't making progress.

We found with Prozac when people were on Prozac and it was working for them they would actually respond very nicely to psychotherapy and the joke back then was oh, in psychotherapy they finally started to get some benefits from it.

And the psychotherapist would they take the credit for it at that point?

Actually it was the Prozac that helped them feel better and with Prozac you'll have better perspective on the world around you.

You won't be as negative this week.

You'll have less less of a of a difficulty with motivation.

>> You'll be able to have an improved self-esteem in some ways it's not an artificial feeling of happiness that many people misperceive with Prozac .

It's just that your brain is working better and you're able to dial down the anxiety and focus on things.

Now here's the issue one out of three people do great on Prozac.

Two out of three people don't.

So not everybody does great on Prozac.

So it's the two to three people who needed something else.

And for that reason over the course of the past thirty five years there have been a total of sixteen newer oral antidepressants that have come out Prozac being one of them and they work in different ways.

>> But the newer and depressants work primarily on serotonin, norepinephrine and dopamine.

>> You're going to hear over the next few months about a new medication called Orville's although it is a medication that doesn't work directly on serotonin, norepinephrine or dopamine, it's a medication for the first time in 50 years as an oral medication it works entirely on a different type of chemical called glutamate which is very important for brain functioning and it has an effect on this particular receptor called sigma one receptors in the brain.

Now what's that all mean?

All basically the ability for depression will hopefully and supposedly based on the clinical trials work faster.

>> So instead of having to wait four to six to eight weeks for an antidepressant to work although Valide should work for a lot of people within a couple weeks and secondly, although it might be something that will work or other medications did not, we've been using ketamine I've and ketamine as a nasal spray but using ketamine as a needle spray is called bravado for the past three years and we find that that will help people who did not get prior benefits from the traditional oral antidepressants, ketamine and ketamine primarily work on dopamine.

>> They work a little bit differently than all of them.

So it's not that novelty will totally replace ketamine or ketamine treatment but it gives us another option.

So we're excited about that possibility.

Of course there's other medications coming down the line that work more on the steroid system that in a non addicting manner can also help depression with a different mechanism of action.

But what I have found over the past thirty five years is that we're not just focusing on the norepinephrine dopamine and serotonin system.

We have other opportunities to treat people for mood disturbances.

Previously I think we would have considered people to have an agitated depression where nowadays we realize that they have more of a bipolar type of condition.

So rather than giving them more and more antidepressants as we might have thirty five years ago now we give them medications that are mood stabilizing to level out the mood as opposed to trying to just to help them on the depression side we don't use benzodiazepines like Klonopin, Xanax, Valium and Ativan so much anymore.

>> Um, we we found that the benzodiazepine medications help for a while but over the course of time they caused somebody to have difficulty with speed of processing in their brains.

The processing speed decreases.

So it's kind of like having slow Internet where everything just moves slower if you're on Xanax, Klonopin, Ativan, Valium, you don't worry about anything and you're less anxious.

But we find that it actually enhances depression, decreases concentration and it just doesn't allow people to function at their highest level in many people as they slowly get off of those kind of medications that they might have been on for years.

They'll often say that it's feel like they have a new brain because they can think more clearly now we want to still address the anxiety and you as a general rule don't want to come off of Xanax or Klonopin or Ativan, you know, within a week or two .

That's how the textbooks often describe the detoxification those medications the general rule should be if you've been on Xanax for twenty years, maybe you need a twenty week detoxification from that.

So maybe you need to taper off the Xanax for 20 weeks if you've been on Xanax for twenty years.

>> So a slow tapering of the benzodiazepines can be helpful for a lot of people but you'll often find that the brain can readjust and adapt over the course of time.

>> Thanks for your email.

Let's go to next caller.

Hello Tom.

>> Welcome to Matters of Mind.

Well, Tom, you know about my opinion about the use of lithium Orteig versus lithium carbonate lithium or était has one fifth of the need for the dosage that you might find with lithium carbonate.

Lithium carbonate is what we prescribe as a prescription product for bipolar disorder and bipolar mood stabilization.

Lithium carbonate is a very effective medication for mania because it's thought that when people have mania they have true inflammation of the brain and when the brain is inflamed it will cause you to have mania and there's a particular inflammatory protein called one 100 that will decrease if you get adequate treatment for mania.

So that is one hundred protein is associated with inflammation lithium very specifically will decrease as one hundred and decrease inflammation.

So we love lithium for the treatment of mood disturbances.

Lithium carbonate has been well studied for a bipolar disorder.

It's something that we will often dose at 300 to 600 milligrams initially for bipolar disorder in a controlled release form often given at bedtime and sometimes we go higher on the dosage.

>> So with lithium carbonate we'll get blood levels on the lithium expecting the blood levels to be between typically point four million gallons per liter and ideally no more than one point oh you get above 1.0 you start having side effects like headache, diarrhea, nausea ,tremulousness, poor concentrations.

We like that blood level.

We're on point six for a lot of people for bipolar mood stabilization.

How about lithium, Werritty, lithium, Werritty?

The Orte version was researched over fifty years ago at really high doses and they gave people kidney problems but then was realized wait a minute, lithium water gets to the brain much more efficient than lithium citrate and lithium carbonate.

>> So the idea was maybe you could dose lithium Werritty to really tiny amounts and lithium irritate in very tiny doses if you have the brain of a mouse where it's been studied, it's and shown to actually increase the length of telomeres in mice and telomeres are the caps on our chromosomes and as we naturally age our caps on our chromosomes get shorter and shorter and shorter and that's part of the aging process.

>> How can you lengthen those caps now everybody speculated you what is the fountain of youth for lengthening those caps, those telomeres on our chromosomes one thing has been shown to lengthen the caps based on bipolar studies has been the use of lithium.

So the speculation is based on animal studies.

>> How about using a tiny amount of lithium authority which gets to the brain really effectively but yet you can use very tiny doses.

>> So a dosage of lithium authoritative doses of 120 milligrams would give you one fifth of lithium load that you'd get with lithium carbonate so you could use this tiny amount of lithium or state as a means of getting it to the brain and possibly lengthening lateral telomeres and giving the equivalent dosage of lithium as you'd get with lithium lithium carbonate of maybe twenty five milligrams which is a very small dosage.

>> We do use lithium carbonated one hundred fifty milligrams which is the lowest tap tablet or capsule form you can get.

>> We use one hundred fifty milligrams to decrease suicidal thinking and it's thought that maybe people that have this chronic suicidal thinking they're always thinking about death, they're always thinking about ways to kill themselves.

>> They don't intend to kill themselves but they're always thinking about it.

It might be a little bit of an inflammation going on in the brain and one hundred and fifty milligrams of lithium carbonate might diminish that inflammation just enough because I've seen people have dramatic effects by taking a small amount of lithium carbonate for that purpose.

Now that's tried and true.

Could you use lithium or attain that kind of condition?

I don't know.

It'd be a small amount a small dosage of the equivalent dosage for lithium irritate lithium frittatas over the counter at these very small doses.

But it's something that I hope will be studied more because the initial studies on Lithium Werritty were dosed way too high because it's so effective in getting into the brain.

>> Thanks for your call.

Unfortunately I'm out of time for this evening.

>> If you have any questions concerning mental health issues that I can answer on the air you may write me a via the Internet at matters of the mind all one word at WSW Edgard I'm psychiatrist Jeff offer and you've been watching Matters of the Mind on PBS Fort Wayne God willing and PBS willing.

I'll be back again next week.

Thanks for watching.

Goodnight