Good evening.

I'm psychiatrist Jay Fawver, and welcome to Matters of the Mind.

Matters of the Mind is a weekly mental health program where you get to choose the topic for discussion.

So if you have any questions concerning mental health issues that I can answer on the air, you may write me via the internet at MattersOfTheMind - all one word - @wfwa.org.

That's MattersOfTheMind@wfwa.org.

And if you're able to do so during the program, you are welcome to call or text me.

Let's begin tonight's program with an email that I received just recently.

It reads Dear Dr.

Fawver, When people have trouble with distractibility and impulsivity, how can you tell the difference between bipolar disorder, borderline personality disorder and ADHD attention deficit hyperactivity disorder?

That's a very important question that we have to ask ourselves.

When somebody says they're having trouble with concentration, they're distractible, they're moody, they're irritable.

We have to sort out what's going on, and you can rule out all the different medical conditions people might be experiencing.

But when we're trying to differentiate between the three conditions in which you referred, we have to sort out what's what.

Because it's going to differentiate how we treat somebody.

So beginning with bipolar disorder, if somebody has distracted and impulsivity due to bipolar disorder, that distracted and impulsivity typically will come, typically will come and go.

In other words, you'll have a few days where you're distracted or you're impulsive, you're irritable, you're moody, and then you'll have other days where you're not.

It comes and goes, typically with ADHD, attention deficit hyperactivity disorder, those symptoms will be there more often than not, especially when you're mentally challenged or you're doing something that's a little bit outside of your range of interest.

So with attention deficit hyperactivity disorder, the distractibility, the impulsivity, the moodiness can be there day by day by day, no matter what your mood might be.

And then you mentioned borderline personality disorder.

Borderline personality disorder is a term that's been used for several decades.

I don't care for the term because I think it's really part of a bipolar disorder spectrum condition.

In other words, borderline personality disorder is where somebody will have moodiness that might last only a matter of minutes or hours, or maybe no more than a day.

But that moodiness is typically provoked by situational disturbances with people or stuff going on in your life.

It's stressful events that will bring it on, and along with symptoms of distractibility and moodiness and impulsivity, might come difficulty with situational abandonment depression, where you get devastatingly depressed.

If you're alone, you can have ongoing distrust, ongoing anxiety.

People with borderline personality disorder, not uncommonly, will have roller coaster moods, and they have what's called a chameleon personality, where they kind of take on the personality of the of the person who with whom they're accompanied.

So they'll they'll take on the personalities of people who are around them based on the situation itself.

So borderline personality disorder is a phenomenon that typically starts in childhood, thought to be related somewhat to lack of attachment to the parents.

And it starts in the early childhood years, and then you have difficulty with interpersonal relationships that will lead to moodiness and distracted and impulsivity later on in life.

So borderline personality disorder, bipolar disorder, ADHD are entirely different conditions, and we do treat them entirely differently, whether we use medications and with psychotherapy.

So those are entirely different conditions that we would treat accordingly.

Thanks for a email.

Let's go to our first caller.

Hello, Robert.

Welcome to Matters of the Mind.

Robert, you want to know about Trileptal also known as Oxcarbazepine.

Can it reduce anxiety?

Trileptal is a medication that will affect ionic channels in the brain, Robert.

And in doing so they will decrease not only seizures but potentially can help with anxiety.

Trileptal is a medication that has been used historically as a relatively non sedating medication for anxiety.

That's not thought to be addictive at all.

It doesn't work on the GABA receptors, as will Xanax, Ativan, Valium, Klonopin.

The benzodiazepine medications work on GABA, and they work on chloride channels and enhance the transmission of chloride channels.

That kind of slows down the whole brain when you're using Trileptal or you're mainly affecting sodium channels.

And in doing so, you're decreasing the electrical inflow of the ions and decreasing the excitability of the brain.

So that can help with anxiety.

So that's how Trileptal (Oxcarbazepine) and its chemical cousin, Tegretol (Carbamazepine), can help with seizures and to some degree, help with anxiety.

Now Tegretol or carbamazepine for decades has been used for bipolar disorder.

The issues we always have with carbamazepine and to a lesser degree, Oxcarbazepine or Trileptal can be.

These medications can enhance the metabolism of other medications.

In other words, they can make other medications not work so well.

And that includes oral contraceptive medications.

Now, carbamazepine or Tegretol, much more potent at inducing those enzymes and chewing up other medications but Trileptal or Oxcarbazepine can do that to a lesser degree.

So if you're on other medications with Trileptal , we just want to make sure, okay, do those medications go through the pathway that's called Cytochrome P450 3A4.

Do they go through that particular pathway in which Trileptal can induce.

Thanks for your call.

Let's go.

Next caller.

Hello, Roy.

Welcome to Matters of the Mind.

Roy, you want to know how do you start helping someone who's reached out for help with their mental health?

Well, the first thing I would do, Roy, is applaud that they're getting some help for the mental health.

And you want to know what kind of problems are having.

The first place you'd go typically would be with a primary care clinician.

Now, the primary care clinicians will be the primary gatekeepers for mental health.

We know now that primary care clinicians will be the prescribers of between 75 and 90% of all antidepressants, and that's kind of the role they currently will, will, will possess, because there are fewer and fewer psychiatric outpatient mental health clinicians.

Now, there are some primarily nurse practitioners, but there are fewer and fewer psychiatrists who are on the outpatient side for mental health treatment nowadays, at least outside of the big cities.

So with that in mind, you start with your primary care clinician to try to determine what's going on.

Is it a situation or difficulty?

Is it a treatment that warrants the use of medications right off the bat.

Usually primary care clinicians can at least initiate treatment or initiate your referral on where you need to go so they can get you referred to a mental health clinic counselor or whatever you need to whoever you need to see.

If you have an available mental health clinic in your community.

Sure, you could always start there, but you want to know what kind of mental health difficulty it is.

Is it a situational disturbance?

Is it a recent problem?

Is it a long term problem?

Was it brought on by trauma?

Is it causing difficulty with sleep?

A lot of different factors we want to consider to determine what kind of treatment somebody would immediately need.

Thanks for your call.

Let's go to our next caller.

Hello, Sam.

Welcome to Matters of the Mind.

Sam, you want to know about vitamin deficiencies?

Can they prevent antidepressants from working?

Vitamin deficiencies can not so much prevent antidepressants from working, but maybe just not allow antidepressants to work as well as you'd expect.

It's not that they will cause antidepressants not to work, it's just that they will not allow them to work to their full potential.

One particular vitamin disturbance that people can have would be if they have a particul MTHFR (methylenetetrahydrofolate reductase) enzyme.

If they have a disturbance genetically of that particular enzyme, they will not be able to metabolize folic acid adequately to its active metabolite, L-methylfolate.

Now, when you think about that, the L-methylfolate phenomenon there, if they think about a big stadium that has the turnstiles in it, folic acid is on the outside and needs to go through a turnstile.

That's MTHFR enzyme to get on the inside to be active.

So L-methylfolate is the active form of folic acid.

So sometimes you'll hear about a clinician saying well we just want to get you on some L-methylfolate as a means of making sure you don't have that particular mutation, because about one out of three people in the United States will have some form of mutation, maybe one out of ten, one out of 15 people might need actual treatment with L-methylfolate on a day to day basis.

With pregnant women, you certainly want to make sure they do either do not have that particular mutation or you simply give them right up front, L-methylfolate.

And in 2026, most pregnant women now are not simply getting folic acid.

They're getting L-methylfolate just in case they have that mutation.

And it's a very safe means of treating people.

If you have that mutation and you're pregnant, you're at a higher risk for miscarriage, and later on you're at a higher risk for depression itself.

And maybe under some medical conditions like heart attack and stroke.

So we do want to address the genetic mutation of MTHFR deficiency which affects folic acid.

Now there's other vitamins that can be factors themselves in terms of inhibiting or at least preventing the vitamins or preventing the antidepressants from working to their full extent, vitamin D deficiency.

If you have low vitamin D that could cause you to have difficulty with ongoing fatigue, motivation and concentration, so low vitamin D can be a factor in why an antidepressant medication might not work as well as you'd hope.

If you have thiamin, which is vitamin B1 or riboflavin, vitamin B2 disturbances.

We often hear about those disturbances with people who are drinking high amounts of alcohol.

They can be factors the vitamin B6.

This has been discussed over the course of time here, but potentially pyridoxine or vitamin B6 can be a factor in helping antidepressant medications work.

But generally in the United States, people don't have Vitamin B6 deficiencies.

So you've got some of the B vitamins.

We've got folic acid being one of those.

You've got vitamin D deficiency.

Once in a while we might hear about vitamins C. Vitamin C disturbances may indeed affect iron absorption and will occasionally hear about iron disturbances being a factor and why people might not start feeling better from their antidepressant medications.

So antidepressant medications can work so well themselves.

But if you have a vitamin disturbance on top of the antidepressant use, the vitamin disturbance won't hinder the antidepressant from going to work.

It's just maybe the treatment of depression wouldn't be progressing as well as you'd hope over the course of time.

Thanks for your call.

Let's go to the next email question.

Our next email question reads Dear Dr.

Fawver, is someone has low ion stores but their CBC (complete blood count) is okay.

Can they have symptoms of anemia?

Low iron stores?

I think you're referring to low ferritin.

So ferritin is a protein that stores iron.

So if you think about low iron stores, if you know anything about our strategic oil reserves, the United States, we have this vast supply of strategic oil reserves that we should, as a country, be kept up to speed and keep relatively full.

In the case of a emergency where we need oil all of a sudden, well, the strategic oil reserves aren't being used and they're not used, but they're in the background in the case that they're needed.

That's the way ferritin is.

Ferritin is storing iron.

Ferritin being a protein that stores iron.

And your iron levels in your blood might look pretty good.

Your total iron might be your iron capacity might be good.

Your red blood cells look good.

Everything looked fine.

But if your ferritin is low, it just means in the case that you need more iron, you're not going to have that quick access to iron.

And even people have normal CBCs, but low ferritin levels.

They can have some of the early symptoms of anemia such as fatigue, poor concentration, lack of get up and go.

We often hear about restless legs when people have a low ferritin, low iron storage, even though their iron in their bloodstream looks pretty good, they can have restless legs.

So when somebody tells me about restless legs, I often will check a ferritin level just to see what their iron stores appear to be.

Now, if somebody has low iron stores and low ferritin, we're going to think, okay, number one, is there a reason for that?

Is are they having excessive bleeding, for instance a heavily menstruating woman, are they having a gastrointestinal bleed, for instance?

Is there a reason for the low iron from a physiological standpoint, did they get less absorption of iron?

Are they taking any medications that might be decreasing the absorption of iron.

Perhaps they could have a gastric bypass that's decreasing the absorption of iron.

Some people who are more prone toward vegetarian meals and they have less they have fewer red meats.

They might have low iron.

They're not getting the green leafy vegetables.

That might be a factor.

So we're always looking at the different reasons why people might have low iron stores in the form of ferritin.

But you can treat low iron under your clinicians supervision with iron sulfate, 325mg gives you 65mg of elemental iron per tablet.

People nowadays typically are taking those all at the same time three tablets a day at the same time, preferably without a couple of hours after they've eaten, or an hour before they've eaten, and preferably with vitamin C 500mg, because vitamin C will help the absorption of iron itself.

So there's ways to treat it, and it takes up to a month or two to start seeing meaningful benefits.

I will warn you though, if you do start taking an iron supplement again under your clinicians supervision.

Number one, be aware you'll likely have very black stools and that really scares people a lot of times.

Number two, you can be somewhat constipated from the iron.

But number three, make sure to get the iron level, the ferritin level rechecked in about 2 or 3 months, because by that time you should see some meaningful increases in the iron stores.

But if you have low iron in the form of storage iron, which is ferritin, yeah, you can have some early symptoms of anemia, even though your other blood tests for iron might not show it.

We do see that in psychiatry.

And as a psychiatrist, that's something I'll check.

I mean, people will tell me they're depressed, they don't feel very good.

They don't enjoy things, they have low motivation.

But along with that, they might be tired and they might have trouble with concentration.

So we have to think outside the box about other medical conditions.

And low iron will be one of those medical conditions that we will consider when people are having symptoms of depression will also consider sleep apnea.

We'll consider diabetes, we'll consider thyroid disturbances.

We'll consider other medical conditions that might be contributing to the mood disturbance.

Because when you have a physiological condition causing those kind of symptoms, it's going to make you feel tired and depressed and you'll have trouble coping with day to day challenges.

So it's something we certainly want to address one way or another.

Phil, thanks for your call.

Let's go to our next.

Well, I guess the next the next question is from Phil.

Phil, you want to know about low iron in a little bit different way?

Can it cause psychological issues?

The psychological issues that would be from low iron, Phil would indeed be where somebody is having fatigue first and foremost.

Poor concentration will be secondly, second on the list.

And sometimes people will have difficulty with motivation and they just have trouble with get up and go in a lot of a lot of different ways.

But when people have restless legs, often they will describe themselves as feeling anxious.

But the restless legs will be most prominent at bedtime when you're trying to sleep, and you'll have this achy, quivering sensation in your legs.

You're trying to sleep, and you have those kind of symptoms that could be from low iron and iron supplementation for those kind of symptoms sometimes will improve those symptoms within a matter of 2 or 3 weeks.

So we've certainly seen that with some people.

Thanks for your call, Phil.

Let's go to the next email question.

Our next email question reads.

How long can somebody be on Ambien Ambien, also known as zolpidem.

Ambien is one of the so-called Z drugs.

It's very selective in terms of which GABA subunit it will stimulate.

Unlike Xanax, Klonopin, Ativan, the Valium, the benzodiazepines.

Ambien more selective than the benzodiazepines in terms of what receptor it hits.

It used to be thought that you could take Ambien long term 30 years ago, but now we've realized that generally you don't want to take Ambien for more than just a few weeks.

If you can get by with it, Ambien will knock you out.

Ambien will get you to sleep very quickly.

That's what people love about it.

They can be worrying and thinking about all sorts of things, and they take an Ambien and their head hits the pillow and they're out.

So people like that Ambien in the immediate release formulation will last for about four hours.

Then it's gone.

It gets in your system very quickly, last for about four hours, and it's gone.

It has a CR formulation, which is called a controlled release formulation, where half of the Ambien releases immediately, and then the other half of the Ambien releases about four hours later.

So the whole idea of the controlled release formulation was to give you hopefully, an eight hour restful sleep.

Women generally shouldn't take any more in the immediate release formulation of Ambien than five milligrams mentioned.

Take any more than ten milligrams every night.

Women will tend to metabolize Ambien slower, so five milligrams at bedtime for a woman is like ten milligrams for a man.

So with that in mind, how long could you take it?

Should you take it?

Generally, we don't recommend people taking it for more than a couple of weeks.

And many, many, many of you out there might be taking Ambien for a years.

And I'm just saying, okay, in the long run, you might want to look for something else.

Now, here's the problem.

When you've been on Ambien for years and you try to stop it, maybe go to something else, something else isn't going to work.

I wouldn't recommend stopping Ambien abruptly.

I would recommend, if you've been on it for eight years, shaving it down, shaving the tablet down under your clinician supervision, shaving the tablet down over the course of maybe eight weeks.

So if you've been on it for eight years, shave it down to a lesser or lesser amount over the course of eight weeks.

If you've been on the Ambien for ten years, shave it down week by week by week over the course of ten weeks.

So go do it.

Go very slowly on taper and off the Ambien.

Now Ambien will be scored.

It has a line down the middle of it, but I often recommend people to get a pill cutter and literally shaving it down over the course of time.

How do you replace it?

Many people will replace Ambien at bedtime with safer options such as tragedy and perhaps gabapentin.

We will look for not addicting alternatives.

The issue is zolpidem or Ambien is the longer you take him, the more likely you'll want or need to take a higher amount of it.

So we prefer to people for people to get on other ones.

The drawback of Ambien is it can cause you to forget what the heck you're doing for the next four hours after you take it.

So it's not uncommon.

People can have sleepwalking, they can have sleep eating.

People will do things and sometimes even say things they ordinarily wouldn't do or say, and they don't remember doing or saying these things the next day because they'll be up and around.

So Ambien is fantastic.

If you need something short term just to knock you out for whatever reason.

But in the long run, it's something we wouldn't recommend nowadays, and that's different.

I mean, there is a medicine where we're giving different advice now compared to 30 years ago.

30 years ago, we thought Ambien was okay for long term use, but now we're preferring people not to take it long term.

So if you're on Ambien and you've been on it for a long time, talk to your clinician about some other alternatives.

But what you don't want to do, I wouldn't recommend if you've been on Ambien for more than 3 or 4 months.

You don't want to stop it abruptly because you might have some rebound insomnia and you'll kind of feel miserable.

I'd recommend a slow tapering under your clinician supervision.

Thanks for your call.

Let's go to our next caller.

Hello, Leo.

Welcome to Matters of the Mind.

Leo, you want to know if someone gets a head injury?

Should they continue to to take their medication?

And should they take other medications instead?

When somebody has a head injury, there are certain medications you don't want to take for the possibility of those medications provoking a seizure.

Number one, you don't want to take a medication that is going to provoke seizures in some ways.

For instance, if you're on high levels of Wellbutrin or high doses of Wellbutrin, also known as bupropion, you might want to be careful taking the bupropion, at least for the next week, because you might be at a higher likelihood of having a head injury.

When you have a head injury, what happens?

This is the brain here and brain's mushy.

It has the consistency of jello, and the skull around it is rock hard.

So when you have a head injury, this jello gelatinous type of brain here the weighs about two and a half 3 pounds.

It gets bounced around and when it gets bounced around, you'll have this abrupt release of this excitatory chemical called glutamate.

Glutamate gets released with a head injury and some people will lose consciousness.

That's when you're at a high risk for a seizure.

Glutamate at very high levels, being excitatory can give you a seizure.

So if you're on any medications already that are prone to cause you a seizure, that can be a problem.

If you've had a head injury and you've been drinking alcohol very heavily, then you stop the alcohol abruptly.

Then you'd be at a higher risk for a seizure.

So when you have a head injury, you want to be evaluated by a clinician to determine, okay, what's next?

Do we need to give you a medication that's going to prevent seizures?

Did you lose consciousness?

How many head injuries have you previously previously experienced.

They're going to go through all these different questions concerning your past history with trauma to the head, and what kind of medications you might be taking now.

Now are there certain medications we might give you at this point?

Well, it depends on what kind of symptoms you might be experiencing, not only acutely but long term, acutely.

Some people might be given a medication like acetyl cysteine.

NAC is often used for Tylenol overdoses.

NAC is used to kind of clean up the liver or some because it's a very good antioxidant.

But N-acetylcysteine, as long as you don't have a sulfa allergy, N-acetylcysteine may have as an antioxidant some protective effects on the brain following a traumatic brain injury.

So that's one thing.

Over the course of time, if you indeed are having some moodiness, irritability, some impulsivity, for instance, you can take a medication called lamotrigine.

Lamotrigine stabilizes the glutamate to which I was referring glutamate been very, very stimulatory glutamate being something something that needs to be balanced, just like a teeter totter where it needs to be balanced.

Not too much, not too little after a head injury.

So Lamotrigine can be helpful for the first year or so after somebody experienced a head injury.

Some people who have a lot of difficulty, concentration, and focus might do better after a head injury with Modafinil armodafinil, definitely.

These are medications that are used for sleep apnea, sleepiness related to sleep apnea, and they're also used for narcolepsy.

But they can be useful for people who have difficulty with not just wakefulness, but also with concentration and focus following a head injury.

Once in a while, people could be given stimulants such as Ritalin and methylphenidate products, but those can be kind of tricky.

Following a head injury, you don't want to provoke any further disturbances, like with anxiety or insomnia following at that time.

So having a head injury and being assessed for the medications you're on or what medication you might need at that point all need to be determined by a clinician based on your current symptoms.

Thanks for your call.

Let's go.

Next caller.

Hello, Lucila, welcome to Matters of the Mind.

Lucila, you want to know about low iron?

And you'd mentioned that you have low iron that makes you feel really tired and really rough.

Is there something you can do to help increase your iron levels?

You bet Lucila there is.

And you need to talk to your primary care clinician about that because you could take oral iron tablets.

I mentioned that previously 325mg tablets, three of those at each day.

And used to be we tell people to take one of them three times a day without any recent food.

That was so difficult for people to remember that.

And then we came to find out that people do fine if they take all through the tablets at the same time.

I often tell people, preferably at bedtime, because hopefully they haven't eaten for a couple hours and they take it at bedtime with vitamin C, always take it with vitamin C 500mg or so for the purpose of enhancing the absorption.

But you always want to take iron on an empty stomach for the best absorption.

So there is oral iron that you can take under your clinician supervision.

They give IV iron.

I mean, they put the needle in your arm.

They'll get your iron level up really fast.

You obviously do that in a very supervised setting.

But talk to your primary care clinician if you have low iron, because by golly, I see it as a psychiatrist.

People will feel tired.

They can't think, they think they're depressed.

But then they might mention to me something along the lines of having restless legs.

For me, that's a big tip off.

And they might tell me that they've changed their diet to becoming more vegetarian.

Maybe a woman's having heavier menstrual periods.

I'll get all these clues.

And if I check a ferritin level or an iron store level, I'll I'll see that be low.

And that's when I'll look for the various reasons why they might have low iron, but simply an iron supplement over the course of one month, two months, three months can start to bring that iron up.

But you want to do that under a clinician supervision.

Thanks for your call.

Unfortunately, I'm out of time for this evening.

If you have any questions that I can answer on the air concerning mental health issues, you may write me via the internet at MattersOfTheMind - all one word - @wfwa.org.

I'm psychiatrist Jay Fawver, and you've been watching Matters of the Mind on PBS.

God willing and PBS willing.

I'll be back again next week.

Thanks for watching.

Good night.