Good evening, I'm psychiatrist Jeff Alver live from the Bruce Haines studio in Fort Wayne , Indiana.

Welcome to Matters of the Mind now in its 10th year matters 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 the Fort Wayne area by dialing (969) 27 two zero and if going any place coast to coast you still 866- (969) 27 two zero and tonight we have a new technology feature where you can text me during the program by dialing as you see on the right side of the screen two six zero (969) 27 three zero.

You can text me using that number.

All we ask is you give us your first name and let us know from what town you're texting so we look forward to hearing any about any text that might come through tonight.

You're always welcome to call as well.

Let's start with tonight's program with an email question.

Our first email question on her father.

I'm 22 years old and I've had major depressive disorder, social anxiety and suicidal thoughts throughout most of my life I've used several medications from different psychiatrists and in and out of therapy since the age of 12 years old.

I recently tried ketamine infusions and did pharmacogenomics genomics testing.

>> Nothing I've tried has helped and it's even harder as an adult I've I'm at a loss said what to try next and it has been a financial hardship.

>> What would what would you suggest for someone who has treatment resistant depression where a medication and therapy have not helped?

I don't like the term treatment resistant depression.

I know it's an official diagnosis treatment resistant depression is term is used for the purpose of getting certain medications like bravado which is ketamine approved for treatment treatment resistant depression simply alludes to you're not having adequate success with the treatments you've trialed so you kind of go back to square one.

Square one would be make sure you have a thorough diagnostic assessment is a truly major depressive disorder where you exclusively have major depression because there are roughly nine different specifiers and in other words subtypes of major depressive disorder that can sometimes complicate treatments for for instance, those with anxious distress as with psychotic features there's with mixed features.

>> There's all these different subtypes that will sometimes influence our treatment choices.

>> Secondly, make sure you do have major depressive disorder and have bipolar spectrum features.

>> If you have bipolar spectrum features you can try.

One of the many different antidepressants was over twenty five different antidepressants that can be tried at this time.

None of them will work if you're having highs and lows at one point you might want to try a mood stabilizer if you've not done so because when somebody has depression and it's just not getting effectively treated with antidepressant after antidepressant after antidepressants, sometimes you need a mood stabilizer because someone is a cruise control to keep you from going to a high unnaturally high and keep you from going to unnaturally low.

And it's not uncommon that we'll sometimes use a mood stabilizing medication such as antiepileptic medication or medication.

It blocks dopamine receptors.

We use that in conjunction with an antidepressant medication.

Thirdly, you mentioned add genetic testing.

That's great genetic testing is not definitive.

Genetic testing will not tell you what diagnosis you have but genetic testing can very nicely tell us what dosage we need to use on certain medications.

Do we need to go high on a dosage because you're a fast metabolism you chew it up really fast or do we need to go on low on certain medications because you're a slow metabolism on those.

So genetic testing will tell us how high or low of a dosage we need to go with various medications and sometimes certain types of genetic testing will tell us what mechanism of action might work the best for you.

However, genetic testing does not definitively tell you what condition you have or specifically what medications should be use.

It just kind of tips the scale for us one way or another when we're kind of on the fence trying to determine what medication might be helpful.

You had mentioned you've tried a lot of medications.

You've had depression since you were 12.

You try to like different therapies.

I want to know do you have any family members who have difficulty with depression?

Because if you do, I'd want to be I'd be curious about what medications they've tried and how they did for the family members that they do poorly on certain medications.

Did they do better on their medications?

With that being said, that sometimes will help us determine which way to go with medications as well.

>> I'd want to certainly take a look at any medical comorbidities you have such as sleep apnea, thyroid disturbances, ion disturbances.

>> Some people will have difficulty with glucose.

>> There's a lot of different factors that can sometimes influence a person's recovery from depression.

>> It's undoubtable since you've had depression for a long time you have other things going on so you might have post-traumatic stress disorder.

You mentioned you have social anxiety which often goes along with PTSD, attention deficit disorder can be a factor.

So we want to address all these other factors as well and them not only align the best medication for you but also try to determine what therapy will work the best and sometimes it's a matter of methodically going back and looking at medication by medication, by medication you've tried and determine which one might have worked better which might not might not work so well.

>> Some people will actually go off of certain medication because they work so well they didn't feel like they needed them anymore.

>> If the clinician doesn't ask about that they sometimes will neglect trying that medication again in the future.

Same with therapy.

There are certain therapies that work better for certain conditions eye movement desensitization and reprocessing MDR works very well for PTSD will use cognitive behavioral therapy for people with anxiety conditions.

>> We will use certain treatments for obsessive compulsive disorder.

>> It depends on what kind of conditions you have going on.

So I think at this point you've tried a lot of different clinicians over the course of time ketamine infusions can be extremely effective for people with depression and post-traumatic stress disorder.

But there is an FDA approved treatment which is an intranasal spray of ketamine.

It's the left side of piece of ketamine.

It has been methodically studied for treatment resistant depression which by definition means you failed on two or more antidepressants.

That's pretty broad but basically is something that's been shown to be effective for people who have not shown benefit from the traditional type of antidepressant medications that affect serotonin, norepinephrine and dopamine.

>> So we have medications now such as US ketamine and a newer medication called Valide that will enhance the transmission of glutamate.

>> So if you enhance glutamate transmission that's like pushing on the accelerator the brain and for many people they find it gives them better relief.

The depression for depression compared to serotonin norepinephrine or dopamine antidepressant medication.

So there's a lot of different options out there.

Talk it over with your clinician.

You might need to see another clinician to really get a thorough overview on what's been going on.

But make sure when you go do the best you can to document to your best of recollection what medications you've tried before, what therapies you've tried before, how long you took the medications, what dosage they might have been, why you went off of them but also bring in a copy of your genetic testing to that next clinician to review things overall.

>> Thanks for your call.

Let's go to our first text question.

Hello Tom from Columbia City.

>> You have a question about attention deficit disorder and you've asked how does one find out if they have ADHD attention deficit hyperactivity disorder?

Tom, when you have ADHD by definition you have to have had it since you're about 12 years of age.

Think of it it is kind of like being near-sightedness if you have near-sightedness you have difficulty seeing things at a distance and usually you don't all of a sudden acquire nearsightedness when or 30 or 40 years of age you've had nearsightedness not uncommonly since you were a child and it doesn't come and go nearsightedness is there more often than not day by day by day where it's problematic for you?

>> Well, that's kind.

>> Our ADHD is ADHD symptoms will include symptoms of poor attention span, distractibility you might be more impulsive, might lack social tact.

>> You have a difficult time getting things done.

You get them started to have trouble getting them done.

>> You'll be particularly focused on things that are challenging, new and exciting that you have a hard time getting things completed when the initial things are completed.

>> So the boring aspects of vigilance and completing task will often be neglected so you often will procrastinate, get behind on things and you feel stressed out because you have difficulty getting things done.

>> People with ADHD often have it running in families.

ADHD is of all medical conditions there it's second only to psoriasis.

Psoriasis is considered to be the most medically genetically transmitted condition that we know of existing but ADHD is right behind us or ADHD is up there with the genetics of height.

>> So height is fairly genetic.

So is ADHD.

So ADHD is something that's there more often than not since you were a child based on your current life challenges if you're in a new job you might notice more symptoms if you're in a new situation that's requiring a lot more attention than previously that can sometimes bring it out.

>> It's a myth that people with ADHD will be poor students because people with ADHD it can be very good students.

It's just that they have to work three times harder to get things done.

So again going back to the Near-sightedness analogy with near-sightedness you wear corrective lenses, eyeglasses or contact lenses to correct the vision with ADHD in a similar manner will use medications to correct the focus on ADHD basically is condition where the front part of the brain is a little bit underactive now ADHD is also it's not only genetic but it's also associated with a higher IQ so people with ADHD will not uncommonly have a higher IQ.

>> They're smarter than you'd expect them to be based on their level of performance.

>> So it's kind of like going through life be nearsighted, not wearing corrective lenses and having to squint and you're stumbling over things like ADHD with nearsightedness.

There's different severities.

Some people are just a little bit nearsighted.

>> Other people are so nearsighted they have to put their eyeglasses on first thing every morning you be able to get around that's the way ADHD will be with ADHD.

Some people will need treatment on a day to day basis because they just can't focus.

>> They can't drive, they can't interact with people.

They can't follow conversations.

Other people will need ADHD medications just on certain days when they're under a lot of academic pressure or there are other challenges that are taxing their bandwidth so to speak of their brain abilities.

So there's different severities of ADHD just like there's different severities of nearsighted US for ADHD men are more likely have the hyperactive form as kids but as we go through life the hyperactive impulsivity symptoms will often fade.

But the inattentive inattentive symptoms can persist.

So you can have ADHD as a child where can affect you in school it's got to work harder to get through it not uncommonly but later on it can affect you socially.

It can affect with relationships.

It can affect you on job situations ADHD people often will have more moodiness and more impatience and that sometimes gets them in trouble with their spouses and their coworkers.

>> So there's a lot of different dimensions we will examine with ADHD but it's something we're recognizing with adults much better now than we did 25 years ago until about the year 2000 it was thought that ADHD didn't occur in adults at all.

>> It was thought to be a childhood and adolescence condition and then around the year 2000 that all changed when we realized that with studies with ADHD adults had similar brain activity as children with those type of symptoms and by golly we realize that ADHD could occur and adults as well .

>> Now we know that 90 percent of the of children and adolescents with ADHD will carry into the adult years to some degree it's not always impairing if it's not impairing you don't need treatment.

If it's impairing with your work with your socialization you could be benefited by treatment.

So that's something we always will try to look at on a personalized case by case basis .

>> Tom, thanks for your call.

Our thanks for your text.

Let's go our next caller.

Hello Robert.

Welcome to Matters of Mind.

>> Robert, you want to know what I suggest?

A different people take different medications based on their age depends on what kind of conditions are being treated.

Robert, as a general rule older people might get by with lower doses of medications.

>> Now older people we're talking about people over 55 or 60 years of age typically don't do so well on the sedating medications like the benzodiazepines like Xanax, Ativan, Valium, Klonopin.

So we've got to be really careful about the sedating medications because they affect the concentration.

They can affect the memory they can give you a greater likelihood for having falling episodes.

So the benzodiazepine medications for people who are older we're going to be very cautious in using we're going to look at everybody's liver function tests liver but he's renal function tests as they get older because sometimes consider medications that are more metabolized by the liver or medications are metabolized by the kidneys and dose them accordingly.

But it really comes down to what kind of medications people are taking now there's a lot of talk more recently about what's called GLP one agonist medications like Mongerer Mozambique these medications are getting very popular people of all ages and with those medications I'm I'm hearing and I'm hearing other psychiatrist talk about this as you lose weight on the JLP agonists you feel better in some ways because you're losing fat but you're also potentially losing muscle, especially older adults and we older adults you get older, you get past thirty five years of age, you start to lose muscle naturally with a GOP one agonist you can start losing even more muscle and that can be a problem for older adults.

>> So we're watching that very carefully.

We love the weight loss.

We love that.

We love the loss of adipose tissue for people because adipose tissue or fat cells release inflammatory proteins themselves.

>> That makes you feel lousy.

It makes you feel tired.

You can't concentrate.

You feel more depressed.

So we want you you'll lose the fat cells but we don't want you to lose muscle and I haven't heard it discussed much but to me it would make sense that if people are on one agonist like Mozambique Munjal, these medications commonly being used we go Vehbi in another one.

Why wouldn't they be strongly advised to participate in a resistance weight training?

In other words they need to lift weights to be able to maintain the muscle mass.

I think that would be very strong advised for those people because that's the biggest issue that I hear about with older adults.

If you lose muscle mass it tends to cause you to lose a sense of vitality all in itself and the GOP one agonist there's a lot of excitement right now in psychiatry because they can also be used not just for weight loss but they can use for addictions OCD or other conditions which is wonderful.

>> However, they kind of remind me of what happened with the serotonin medications back in the 1980s in the nineteen eighties with this medication come come out in nineteen eighty seven called Prozac.

>> Prozac was a serotonin based antidepressant medication and people were talking about it as being a miracle drug.

>> It would change people's personalities for the better.

Hopefully it would help people put up with things better.

It was tolerable it wouldn't cause dry mouth and weight gain and sedation like the older antidepressant medication.

So nineteen eighty seven Prozac was thought to be the medication that people should be taking many psychologists around around the country were advocating legalization for there to be able to prescribe because they thought well gee they can prescribe twenty milligrams once a day on a piece of paper of Prozac.

Some people quite seriously we're talking about putting it in the drinking water not unlike what's happening with fluoride where you just put fluoride in the drinking water people in the 1980s 1990s we're talking about putting Prozac in the drinking water thinking that it was going to change people's personalities for the better.

>> Well, what do we find out about Prozac and all the serotonin medications they cause the side effect called emotional blunting and actually it could affect your concentration and make you kind of dull in your enthusiasm for life.

That's my biggest concern right now with the GOP ones.

I'm hearing all this excitement in the people using them but I'm just concerned the GOP ones yeah, they're fantastic for weight loss but we just got to be very careful in what they're doing with the muscle wasting and also a person's degree of motivation.

Is it causing them to have emotional blunting like what we saw with Prozac back in the 1980s and 1990s?

>> Thanks for your call.

Let's go our next hello Chuck.

>> Welcome to Matters of Mind.

Chuck, you want to know what what are the what do I think about the advancements in mental health pharmaceuticals?

What's the most exciting advancements that I see coming into the next year?

I think the advancements coming up, Chuck, from my perspective will be the advancements on glutamate because we've talked about serotonin, norepinephrine and dopamine for the past 60 years now for the past six decades those have been the three medications or three neurotransmitters we've discussed serotonin, norepinephrine and dopamine come from the middle part of the brain and they come from what's called the brain stem.

>> The brain is kind of shaped like a cauliflower and the stem part of the brain comes down the middle.

So this the left half of the brain this the stem down here.

Well, norepinephrine serotonin and dopamine come from this middle part of the brain and they spray up to the outside part of the brain called the gray matter and they only consist of about one percent of the transmission in the gray matter.

What they do is they give guidance to glutamate in the gray matter because glutamate is consisting of about 80 percent of the transmission and the gray matter glutamates the accelerator GABA is the break so Gabin glutamate are going hand in hand like a teeter totter up here on the gray matter helping the brain be able to function.

For the past 60 years the medications we've used for depression and anxiety have predominantly affected norepinephrine serotonin and dopamine and those neurotransmitters are coming from the middle of the brain.

They act somewhat as advisers in the passenger seat.

If you can think of the glutamate as being the accelerator the Gabba as being the brake serotonin norepinephrine dopamine actis advisers in the passenger seat telling the glutamate to speed up or the Gabbi to break down a little bit.

And of course we now have psychotherapy talk therapy that acts more like the GPS.

>> Psychotherapy won't necessarily directly affect the mechanics of the brain but it will give you guidance on what direction to go.

>> So if you're in an unfamiliar area of the city for instance of Big City you've never been driving through in the past, you'll need to tell you should turn right, you turn left should you look out for certain warnings?

>> That's what psychotherapy does the psychotherapy helps you cope with situations in which you lack experience and helps you get proper direction.

>> What place to go?

The excitement about the glutamate transmission that I'm seeing occurring in the future will be glutamate transmission occurs very quickly when you enhance it and in doing so it can make the little neurons more fluffy.

We've got over 80 billion neurons in our brain and each individual neuron has between 20 and 50000 connections on it.

So it's a very vast network and the brain of all these branches and if you think of the neurons in the brain as being like the branching on a bush where you have the root system, you have the branches coming out, it's how neurons look and what's happening when you affect glutamate in various ways you'll get increased branching.

So instead of having twenty thousand branches on your bush you might have a growth of fifty thousand branches with these glutamate type medications that will directly affect what's called neuroplasticity.

So it's like a fertilizer for the neurons.

So when you think about these glutamate medications they're putting natural fertilizer in the brain to help fire up certain parts of the brain which are thought to be impaired and not as fluffy when people have depression, anxiety, psychotic conditions and so forth.

>> If you talk to most psychiatrists now, I think they'd say the exciting aspect in the future is the psychedelic medications and that's going to be coming out over the next two to three years.

>> But the psychedelic medications are medication we've known about their use for decades such as LSD, low doses of LSD, low dose of psilocybin.

These are medications that are being studied right now.

I think that we just have to be very careful and very cautious in how we use them.

We're very familiar with the glutamate mechanism of action, the glutamate mechanism action with ketamine.

Acetaminophen is bravado and now we have all valide so those medications we're very comfortable in using the psychedelic medications just need to be used with a lot of caution and we need to observe are long term side effects very, very carefully.

>> Thank thanks for your call.

Let's go our next text question hello Jim from Albian.

>> Jim, you have a question right here and you mentioned you have the shakes due to a family genetic problem.

You're currently taking 20 milligrams of premodern five pills a day.

It's not doing well.

>> You have a suggestion for improvement.

Family genetic problem with Shaikh's would be what's called an essential tremor.

>> Jim, I'm a psychiatrist but sometimes we'll deal with people who are having neurological problems like an essential tremor.

Essential tremors are often addressed.

Primadonnas is a medication that indirectly can affect dopamine but it's a medication.

It doesn't help everybody.

So sometimes you have to go with a different type of medication such as a beta blocker.

You might have tried these type of medications previously but a beta blocker would be a medication like propranolol atenolol.

These are medications that will block norepinephrine indirectly increase dopamine whereas premodern is more likely to increase indirectly dopamine transmission gabapentin or Neurontin will block will dampen the effect of of the excitatory neurons in the brain and thereby enhance gabber and kind of give you a little bit of a break on the brain.

>> So there's other things that can be done outside of Primadonna but you can talk to your clinician about some other options out there.

You're giving it a good try with a decent dose.

The primadonna just sounds like it's not working for you and like I said, it doesn't for everybody think.

>> Thanks for your text.

Let's go to our next text.

>> Our next step text is from Susan from Fort Wayne .

Susan, you asked about a treatment plan for anhedonia.

Any doughney is a fancy term, Susan, for not enjoying anything so and means no you don't have means fun and anhedonia has been one of the most difficult to treat symptoms depression that we've encountered for the past 60 years because the medications are primarily affect serotonin and norepinephrine and dopamine don't help with enjoyment.

>> So what is anhedonia?

Anhedonia comes in two forms.

It's where you're having fun while doing something but it's also the ability to anticipate having fun while doing something because of you anticipate having fun doing something it actually gives you a big surge of dopamine and we hear about this all the time with people who have a Christmas let down.

>> You know they have this big all this excitement for three weeks before Christmas following Thanksgiving and the excitement builds and builds and builds they enjoy Christmas Christmas Day is here and then they have this letdown and you I think well they're having the letdown because Christmas is over, right?

>> Well, a lot of it is because the letdown is occurring because they've been anticipating for a long time.

So the anticipation of an enjoyable activity it's called anticipatory he donia but that anticipation actually gives you a greater surge of dopamine than the actual activity itself.

>> So any donia doesn't get very well treated with medications that primarily affect serotonin norepinephrine.

In fact, serotonin medications can dampen down the ability to enjoy things.

So again goes back to the glutamate mechanism of action.

The medications that enhance glutamate appear to be the best ones right now for Anhedonia.

The medications such as ketamine which is used off label is ketamine's bravado.

Valide, we're having some really good luck using Carolita Looma Taproom as an add on medication to help people who are having difficulty with anhedonia but a predictor for relapse of depression even though when you're feeling well a predictor for your getting depressed again will be if you have lingering anhedonia so lingering anhedonia means you're feeling better overall but you're still not enjoying things, you're not taking pleasure in things you don't look forward to things when you have lingering anhedonia you're more likely to relapse into depression in the future.

So we got to get those symptoms under control.

It's kind of like a simmering emperors on a campfire of those simmering embers are not put out in their entirety.

>> You can have a flare up of the campfire later on and that's what any Donio will do.

>> Thanks for your text.

Let's go our next caller.

Hello Bob.

Welcome to Matters of Mind.

Bob, you don't know about a mental health side effects from GLP one drugs like Mozambique?

>> Yeah, I talked about that before, Bob.

>> But from a mental health standpoint my biggest concern is the muscle loss and the loss of vitality people could experience with GOP one agonist the glycogen like peptide type one agonist which means they're getting stimulated Mozambique we Govey Mangeot these are medications that can have dramatic benefits for weight loss and that can give you a good medical outcomes.

>> But we just have to be careful that some people can't kind of feel blah and they have a sense of loss of vitality and I would think if that's occurring by all means take a look at the possibility of resistance training doing some weight training in that case.

>> Bob, thanks for your call inforce.

I'm out of time for this evening.

>> If you have any questions concerning mental health issues, you may message me on the email at matters of mine all one word at a dog.

I'm Psychiatrist Ja'far and you've been watching matters of mine on PBS for Wayne now available on YouTube God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching.

>> Goodnight