.

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 of discussion.

So if you have any questions concerning mental health issues, give me a call here in the Fort Wayne area by dialing (969) 27 two zero or if you're calling coast to coast you may dial toll free at 866- (969) 27 to zero now on a fairly regular basis we are 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 a via the Internet at matters of the Mind at WCF org that's matters of the mind at WFA Oregon that starts tonight's program with an email I received this week.

>> It reads Dear Dear Father, is it safe to take Trazodone as a sleep aid while also taking Lyrica that's also known as Pregabalin for neuropathy due to diabetes and in addition to atone for atrial fibrillation?

>> So basically you have three medications here that do entirely different things.

You have proper definition.

You have Lyrica and Trazodone and the short answer is yes.

From my perspective the cardiologist are always the experts and drug interactions and any side effects you might have from the anti arrhythmic medications anti arrhythmia medications basically keep the heart rhythm from getting out of whack and it keeps the heart rhythm normalize.

Trazodone has a slight chance for causing rhythm disturbances that would probably be prevented by any anti rhythmic medication but Trazodone would have to be used at very high doses.

When we use Trazodone for sleep we're using it typically between twenty five up to maybe 200 milligrams bedtime.

>> It was FDA approved for depression back in nineteen eighty one I believe it was four for depression at doses between three hundred and 600 milligrams at at bedtime we often use Trazodone at low doses for the purpose of helping with sleep and people wonder what why Trazodone why would use Trazodone?

Well we now realize that if you block these particular receptors called serotonin toussie receptors they will enhance the depth of sleep and the quality of sleep so that's how Trazodone works but at very high doses.

Yeah, you can give rhythm disturbances for some people prone to rhythm disturbances but if you're already on an anti arrhythmic medication that would prevent that that would make it safer.

Lyrica has no effect on the heart rhythm.

Lyrica, by contrast, is a medication.

It is used for neuropathy.

It basically is a so-called calcium channel modulator.

It's thought that in the nerve cells themselves when you have a tendency toward having neuropathy, the nerves have an itchy trigger finger and the reason they have an itchy trigger finger is because calcium is getting influx to the inside of the neuron excessively.

>> So the idea of Lyrica also known as Pregabalin and its chemical cousin called Neurontin also known as gabapentin these medications basically stabilize the calcium channel so you're not getting excessive calcium going in now despite it calcium being involved, calcium can affect the heart rhythm.

It does not seem to cause a rhythmic disturbances itself.

So the combination of Trazodone ,Lyrica and rhythm all the trade name of the anti arrhythmic medication you mentioned seems to be safe.

>> So it's a medication combination that can be used but always check with your cardiologist your primary care clinicians, the people who are coordinating the oversight of the medications that can often be helpful.

We have electronic medical records now that we typically use and the electronic medical records will typically pick up and give us clues when there's medication interactions now often they go a bit overboard and they tell us that there's interactions in the interactions are not clinically significant but they do give us ideas as clinicians when we're prescribing medications that might interact with one another we often will use medications that intentionally will interact.

For instance, there's a medication for depression now called All Valide and the idea with ability is you add bupropion to a medication called dextromethorphan which is a cough medicine and by adding bupropion or Wellbutrin to dextromethorphan it increases the dextromethorphan level at higher amounts.

That's an intentional drug interaction because we're trying to increase the dextromethorphan levels for the purpose of helping with depression.

So sometimes we intentionally have drug interactions like that and that's called a pharmacokinetic interaction and those are the kind of interactions that will prefer to have usually for the purpose of increasing the blood level of a second medication.

>> Thanks for email.

Let's go to our first caller.

Hello and welcome to Matters of Mind when you want to know about the effectiveness of sunlight therapy boxes for people with seasonal affective disorder.

Sunlight therapy boxes are also known as light boxes weighing and light boxes have a light intensity of what's called ten thousand lux LRU x one lux is a light intensity of an international candle and there are international candles out there which is about one meter away a little bit over a yard away.

>> So an international candle one meter away that's one lux of light intensity with the sunlight boxes or the sun or the light boxes that we'll use for the purpose of treating seasonal affective disorder.

>> We're trying to get a light intensity of ten thousand lux it's controversial whether red light blue light is more important one way or another.

>> Bottom line is it seems like a light intensity is the most important factor and the light intensity is the light intensity that you have about 10 a.m. on a on a summer morning to about 10 a.m. on a sun or some sun on a summer morning.

That's the kind of light intensity you're trying to pursue and you want to sit in front of a light box without looking directly into it for about 20 minutes.

So for about 20 minutes you're kind of reading the paper you're looking at your iPhone, you're reading a book, you're doing something just for about 20 maybe 30 minutes at the most.

>> If you sit in front of a light box too much you might actually get a little bit of a headache and feel a little bit irritable.

>> That means you're getting too much of the dosage of the light intensity.

So first thing every morning and here's the key wane specifically between about October until the end of March for about a six month period.

That's when you want to sit in front of like box more mornings than not if you sit in front of a light box let's say in May or June or July, you might not notice that much of a difference or you can feel more irritable in doing that or you might not just notice because there's plenty of light outside that would be affecting you in a similar manner.

Light boxes are as you mentioned, sunlight therapy boxes tend to be most effective for people who specifically and specifically they will have what's called winter depressions every winter.

Predictably they get more depressed so they start getting depressed around October November when it's getting darker outside they are really depressed December and January when it's when it's really dark and there's very few hours of sunlight.

And then as April comes around ,Azmeh comes around, they start dosing, they feel better and they feel perfectly fine if not a little bit more energized in May, June and July.

>> So that's called seasonal affective disorder.

Seasonal means obviously changing with a seasonal affective within a affective refers to the mood and it's a mood that is specifically changing based on the darkness of of the day and how little light you get.

People sometimes wonder Will is seasonal affective disorder related to the the cold weather?

>> It's not is it related to humidity?

It's not.

It's related to the lack of light intensity in the winter months and that's why in Alaska, for instance, will have a very high rate of seasonal affective disorder and that's where people typically will readily utilize light boxes during the winter months.

But the light boxes should be used more mornings than not typically in the morning because it will wake you up and more mornings than not throughout the throughout the entire winter it works works best for people and how they work is light will hit the retina.

>> I watch the back of the eyeball and the right and I will send a signal that there is light outside to the middle part of the brain called the pineal body.

The pineal body will then suppress the melatonin get gets released because it's thought that with people with seasonal affective disorder they have excessive amounts of serotonin of melatonin that's getting released and that will make them more depressed, more tired people with winter depression or seasonal affective disorder affective disorder will have more trouble with overeating.

They'll socially withdraw.

They don't want to exercise.

They don't want to move around much.

They have trouble with concentration.

It's kind of like a hibernation mode.

So people go into this hibernation mode in the winter time and they get into a funk.

There is one medication that is approved by the food Drug Administration specifically for seasonal affective disorder or winter depression that is Wellbutrin BiPAP and it's an activating energizing antidepressant that increases dopamine and norepinephrine about 20 to 30 percent reuptake a blockade for norepinephrine and dopamine.

So it's increasing norepinephrine and dopamine some but about half of the intensity of a true stimulant.

That's why Wellbutrin or bupropion is not a controlled medication is not prone to causing addiction because it doesn't increase dopamine and norepinephrine to the amounts that the stimulants do.

But that is a medication that can be used as an activating energizing antidepressant medication for people who are specifically having winter depression now do we have people go off of a medication like Wellbutrin in the springtime?

>> We can if they specifically have seasonal affective disorder where they predictably only get depressed in the wintertime.

>> So there's a few people out there who predictably only get depressed in the wintertime.

Women are about four times more likely to have seasonal affective disorder compared to men, especially if they're premenopausal.

When women get to be menopausal they're likelihoods and the rates of depression tend to mirror that of men.

But before menopause women will typically have four times the amount of winter depression compared to men.

We used to talk about different supplements you can get give during the wintertime.

Sometimes they work, sometimes they don't.

But the B complex vitamin sometimes can help a little bit with winter depression.

But the main vitamin that works during winter depression and I recommend it to people year round and that's vitamin D D and dog.

So vitamin D is a level in which you can obtain and a level for vitamin D ideally ought to be above fifty five when we see the level down there around twenty or fifteen sometimes I see the level in the single digits for vitamin D we know those people need vitamin D supplementation so especially in the wintertime I'm often recommending vitamin D but many times throughout the rest of the year I'm recommending vitamin D as well.

There are a lot of complicating factors with vitamin D concerning its ability to prevent certain medical comorbidities.

>> It's thought that low vitamin is associated with various types of cancers.

Low vitamin D can be associated with higher risk for multiple sclerosis and low vitamin D is certainly associated with more depression and more difficulty with concentration as evidenced by studies that were done over in Denmark and Denmark.

It's pretty far north so people in Denmark were found that if they had low vitamin D levels which they often did, they had more propensities to having these kind of conditions.

So I'm frequently recommending people to take vitamin D on a on a regular basis at least at a small amount.

>> But always check it out with your primary care clinician to see if it would be a good option for you.

>> But if vitamin D something in which you can get an actual blood level and see what level you really need.

>> Wayne, thanks for your call.

Let's go to our next e-mail question.

Our next e-mail question reads Dear Doctor Father, what are the side effects of propranolol that's also known as the brand name Inderal?

Can it cause nightmares?

>> I take something for panic attacks and it used to help but lately I have been having nightmares.

Could there be a connection?

Propranolol is a so-called beta blocker.

It blocks norepinephrine at night time when you're sleeping and you're not taking any medication at all.

>> Normally what happens the front part of the brain up here it's called the dorsolateral prefrontal cortex.

It kind of shuts down and rests when it's shutting down and resting.

There's a decrease in norepinephrine in that area and it's a way of your brain just having a time for the night to be able to get some rest.

If you use a beta blocker you're further enhancing this blockade of norepinephrine and thereby you can have nightmares.

So a side effect of beta blockers can be nightmares and for that reason people have nightmares.

We give them medications that are somewhat the opposite of beta blockers.

Beta blockers will block norepinephrine will give people experiencing nightmares medications that increase norepinephrine transmission.

That's why medications such as the old tricyclic depressants nor trapline at low doses can help with nightmares clomp remain which is basically imipramine the chloride attachment to it.

That's a great medication for nightmares at bedtime.

There are a couple of medications that are called Alpha two agonists 115 and Clonidine.

They also affect norepinephrine by enhancing the receptor activity and they could decrease nightmare so beta blockers block norepinephrine, they can worsen nightmares and these other medications will actually stimulate the the benefits of the norepinephrine itself and decrease nightmare.

>> So there's ways we can get around that if you're having panic attacks and you're having difficulty with sleep, there are other medications we can use.

We try to stay away from the so-called benzodiazepines Xanax out of an Klonopin Valium.

>> Those medications if used long term can cause you to kind of get used to them and cause you to have trouble with being able to find them beneficial long term.

So we try to stay with those medications after more than a couple of weeks but we might use the medications which I switch to which I referred earlier like gabapentin also known as Neurontin or Lyrica also known as Pregabalin.

These medications can do a really nice job in terms of helping with panic attacks as well as sleep without causing the nightmares.

So there's a lot of other options out there besides propranolol not propranolol has been around for decades and it's a medication that for many people is is well tolerated.

It basically blocks adrenaline, it slows down the heartbeat slows down the the breathing for a lot of people in a good way.

It decreases shakiness of people tend to get really hyped up and anxious before they're doing something.

So we use it for performance anxiety prior to people giving talks, people who are prone to having a very dry mouth before giving a presentation to a group of people those people can often do well with a little bit of propranolol but if you use it on a regular basis especially close to your bedtime dosing sometimes it can indeed cause nightmares.

>> Thanks for your question.

Let's go to our next caller.

Hello Amanda.

Welcome to Matters of Mind.

>> Amanda, you want to know why do mood stabilizers cause weight gain?

Most of them do not all of them do.

>> But let's start with lithium.

Lithium is a medication that can give you weight gain primarily due to the fluid retention lithium as a salt.

>> It's very close in the periodic chart to sodium.

So the body looks at sodium and lithium in a similar manner and sodium can cause bloating.

So can lithium.

So lithium weight gain is mainly due to bloating and fluid retention.

>> It can give a change in the metabolism of of your body's biological furnace so to speak so lithium can slow down the thyroid functioning and in doing so can give you weight gain.

But the other medications such as the antiepileptic something particularly Depakote Dove Alperovitz can give you weight gain for reasons that people aren't really sure to dove out of medication.

It's a marvelous mood stabilizer.

It's great for from an anti suicidal effect because it has some specific qualities.

It can decrease suicidality but it changes the metabolism of the body in such a way that it can cause a gradual increase in weight.

We have other medications that are called the so-called second generation antipsychotic medications.

They are used for mood stabilization.

They are used for bipolar disorder very effectively and the ones that cause the most weight gain will be Seroquel Quited.

It's been around for a long time and Zyprexa also known as olanzapine Zyprexa now has a formulation where it's paired with a medication by the name of Sammy Dauphine.

So Olanzapine with Sammy Dauphine will not typically give you the weight gain you might see with olanzapine by itself.

Sammy Dauphine added to Olanzapine tends to decrease the likelihood that really profound weight gain by half and for many people they tend to have very little weight gain at all when they use the addition of Sammy Dauphine to Olanzapine and that's called Liebovich.

>> So we're using that quite a bit for people who got really good benefits from Olanzapine or potentially can get really good benefits from Olanzapine without the weight gain.

So that's why Liebovich is being used.

But it's thought started these medications are affecting serotonin receptors in various ways where they are changing the metabolism of the body and they might change the way insulin is is is seen that the receptors themselves they don't directly contribute to diabetes but it's thought that the weight gain is something that's related to the serotonin receptors.

>> Now weight gain is a risk factor for diabetes and we have always remember that.

But it's not the only risk factor for diabetes having bipolar disorder and schizophrenia for that matter can significantly increase the likelihood of diabetes just by having those conditions.

So we don't like to see the weight gain with people on mood stabilizers in general we use different techniques to help people with weight gain.

For instance, a commonly used medication to actually prevent weight gain with antipsychotic medication will be metformin.

Metformin has been around for decades and metformin is a medication that basically decreases insulin production.

It makes your little insulin receptors more sensitive and it decreases glucose absorption from the gut.

>> So metformin 500 milligrams twice a day, sometimes a thousand milligrams twice a day is commonly used to specifically decrease the weight gain associated with antipsychotic medication.

So that's probably the best means of decrease in weight gain when people are in various mood stabilizers especially there are psychotics we might use some of the newer medications for diabetes that are coming out.

Those are the injectable ones that you might use once a week if you use those kind of medications typically you already have Type two diabetes but they can be very good at tens of in terms of decreasing the weight for a lot of people as well.

>> So there's a lot of strategies will be used but the main mood stabilizers out there or lithium the antiepileptic medications and the so-called second generation antipsychotic medications all of them can contribute to weight gain to some degree within the classes there are some medications that don't cause the weight gain.

For instance, with the anti epileptics Lamotrigine or Lamictal is FDA approved for ABI itself for maintenance of bipolar disorder.

So for the purpose of stabilizing the mood, Lamictal or Limosine typically works better on the lows and the highs but it can stabilize the mood somewhat.

No Wakita so issue with that Tager Tolle's also known as carbamazepine that is also an antiepileptic medication not typically associated with weight gain but it has a lot of drug interactions so we have to be careful that it doesn't cause the increased metabolism of a lot of other medications which it might affect including birth control pills.

So that's Tegretol or carbamazepine.

Trileptal Hox carbamazepine is also an antiepileptic medication no weight gain associated with that.

So that's the nice thing about that.

It does tend to stabilize the the mood for many people of the antipsychotic medications, the ones that don't cause a weight gain.

>> They're usually bipolar disorder are medications such as Carolita Latouche to suppress Geodon.

These are the main medications that might be used for the purpose of not causing weight gain and will often use those for the purpose of mood stabilization with bipolar disorder.

So there's a lot of options out there.

The medications do work differently so be aware that if one medication was not tolerable for you or didn't work for the purpose of mood stabilization, there's many, many other options out there now we like to still use lithium.

>> Lithium has been around since the early 1950s.

It's been around for a long, long time.

Lithium is a salt.

It comes from the dirt and it's in the same periodic table area as you'd see with sodium.

So the body processes lithium very similar as it does for sodium but lithium will still do some things that no other medication will do.

For instance, it does a nice job in decreasing this particular chemical in the brain that is associated with inflammation.

So if you have a particular chemical in the brain called one hundred it goes sky high when you get manic.

So if a person gets manic and they're not sleeping they're talking a mile a minute, they're going from topic to topic.

They're impulsive, they're saying things and doing things they later regret.

These people are have been shown to have this higher chemical in the brain called one hundred lithium fairly specifically can decrease as one hundred and it has some antiinflammatory effects on the brain and it's thought that when people get manic and they get depressed on top of that and they get really irritable, it's thought that that inflammation can increase the risk of suicidal thinking.

And we've seen patients with very, very low doses of lithium do wonderfully with suicidal thinking.

I've seen some patients that had chronic suicidal thinking for years.

>> Every day they wake up and they just start thinking about ways of killing themselves.

We seem a little bit of lithium, 150, 200 milligrams of lithium carbonate.

It's often all they need and a very small amount of lithium can often within a week decrease of suicidal thinking for people.

Now we might still check blood levels to make sure they're not getting too high on the blood level.

We tell them to keep eating the same salt intake we don't want them eating more salt or eating less salt.

You can still eat salt.

Just don't eat more or less than what you're usually accustomed to eating because salt if if you take in increased sodium intake it'll decrease lithium levels if you all of a sudden go on a low salt diet while you're taking lithium, lithium can go sky high.

You also really shouldn't take lithium if you're taking a so-called INSEAD for pain and nonsteroidal antiinflammatory agent like Advil, Motrin, any kind of medication it can sometimes be used for pain in that manner can increase the lithium blood levels but typically for suicidal thinking we're using very low amounts of lithium for bipolar mood stabilization we'll often use a higher amount but lithium has been around for a long time ,still commonly used but yeah, you might see the weight gain with it occasionally.

One thing will often examine if they're having more bloating and the way you get around it many times will be to no one use the controlled release formulation.

Don't give lithium three times a day which is what you always see in the textbooks with the immediate release formulation just give lithium in the controlled release formulation and give it all at bedtime.

No one that decreases the side effects from lithium a number two it's over on the kidneys but number three it's easy to take and number four it helps with sleep.

So lithium does a lot of good things if you take it all at bedtime for the purpose of helping with the mood decrease in sort suicidal thinking and for some people it will be something that they'll notice will make them less irritable.

Lithium is a classic medication has been on for a long time that will decrease irritability.

>> Amanda, thanks for your call.

Let's go to our next e-mail question.

Our next e-mail question reads Dear Dr. Fauver, I have seen something on the Internet about people with OCD that's obsessive compulsive disorder getting caught in a loop.

What is this?

Well, OCD obsessive compulsive disorder is where you have thoughts called obsessions that you can't get off your mind and they don't make any sense.

We're not talking about worries here.

We're not talking about things that you're worrying about in the future and you're ruminating about we're talking about obsessions which don't make any sense to you but you can't get them off your mind usually a thought like that should be like a puff of smoke.

It's there for a moment and you think I stupid thought and you think and you move on and obsession is an irrational thought that just you just can't get it off your mind and that's the loop we're talking about here because the obsessions have their origins in this little part of the brain right above the eyeball called the orbital lateral prefrontal cortex.

>> That part of the brain is the brooding part of the brain when you start brooding and thinking about stuff over and over again and that's where the ruminative worry part does occur when people have depression that's increased in its activity but with obsessive compulsive disorder that's dramatically increased and that has a loop around a circuit here in the middle part of the brain and it goes round and round the limbic system and then back around and you have this loop of thoughts and obsessions.

You just can't get off your mind and sometimes that will lead you to start performing compulsions.

Compulsions are irrational behaviors you keep doing over and over again.

Some people will check things over and over again.

Some people will count over and over again but they will try to perform these compulsions repeatedly and it's causing them to be late for work and late to get out the door.

But they just can't stop themselves from doing it because if they try to stop it makes them more anxious.

So obsessive compulsive disorder in its classic sense is where you have these obsessions with this loop of irrational thoughts is going round and round and round that leads to compulsions or behaviors and it makes it late for things as occurring day by day and it's the type of condition that can be treated with counseling or talk therapy but it's often treated with medications that specifically at high doses will enhance serotonin with the different serotonin reuptake medications.

>> Thanks for email.

Let's well we're out of time for this evening so unfortunately we're out of time.

I'm psychiatrist Jeff Aubrey.

You've been watching matters of mine on PBS Fort Wayne God willing on PBS willing.

I'll be back again next week if you have any questions concerning mental health issues that I can answer on the air, you may write me via the Internet at matters of mind all one word at a dog.

>> Thanks for watching.

Have a good evening.

Good night