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good evening.

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

Welcome to Matters of the Mind now in as 26 year 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 in the Fort Wayne area by dialing (969) 27 two zero and if you're calling any place else coast to coast you may dial toll free at 866- (969) 27 to zero.

Now on a fairly regular basis I am broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which Lylea Chateaux of the Purdue 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 WSW Edgar that's matters of the mind at a dog and I'll start today's program with an email I recently received.

It reads Dear Dr. Oliver how could three hundred milligrams of Wellbutrin and 20 milligrams of acetone that's also known as LATU to interact if taken together for depression is there anything that could be added to that to help with a little anxiety?

I have taken Lauriston in the past and it causes agitation and spells of sadness.

Well the first question I would have for you would be OK you've taken lucid in the past.

>> You are taking a very small dosage now 20 milligrams again the president is also known as La Tuta.

>> I would wonder in the past if you took 40 or even 60 milligrams of Lura Sedona LUCCHITTA because that higher amount could have given you agitation and I'm thinking OK, I'm hoping your clinician is now considering that lower dosage to avoid the agitation Larissa Down or Latona as a medication that can make your restless and have caused you difficulty sitting still and ponce in a while give you a tremor at higher doses.

>> Lower doses can kind of tweak the serotonin and dopamine and dopamine transmission and to some degree norepinephrine transmission that can sometimes help give you a little bit of added benefit on top of Wellbutrin.

Now they do have some offsetting effects.

Wellbutrin is trying to increase dopamine Laryssa down lattitude is trying to it's going to in some cases decreased dopamine so they can have some opposin effects in that way.

Can something be added to help with anxiety?

There are many, many, many different things that can be had that can be added for anxiety.

But the first question I'd want to know is OK, what what are we looking at from a diagnostic standpoint?

Anxiety can be related directly to depression.

>> Many people will worry and that leads to in commonly insomnia and that leads to depression and you become despondent because of that.

>> Some people have anxiety due to having social anxiety or particular fears and anxieties when they encounter certain situations people can have anxiety about their job, their marriage, their friendships, their social interactions.

There can be different types of anxiety that we'd want to You could have anxiety related to post-traumatic stress where you've had some terrible things happen in the past giving you some problems with being able to cope with certain situations because cause you too much anxiety now.

So I'd want to know what kind of anxiety is underneath all that because we would treat that type of anxiety in different ways.

Now Laryssa Down or Lietuva is a medication that's often used for people having bipolar depression.

>> Other words they have highs and lows and the highs might be little highs but then they have big lows.

>> LA can be a good medication to stabilize out the moods.

They don't have highs or lows so it can be used in a low dosage in that way.

So we always want to know what the diagnosis might be in the type of symptoms you're having.

>> That's the first thing we always want to consider.

Secondly, we'd want to know how you did on past medications in general you had mentioned that with Saddam you had some anxiety with it before.

I would hope your clinician would take that consideration and upon resuming it you resuming at a lower dosage as popposed to using the same dosage that caused agitation previously I'd want to know what kind of medications gave you really good effects and maybe not so good effects in the past because you want to kind of balance that out and use that as a guide on what direction to go.

We always want to know when choosing a medication for anxiety what kind of medications, if any your family members have taken.

So if your family members have done good or poorly on different medications for anxiety, we want to know that we want to know if you have an ongoing medical conditions sleep apnea for instance, where people are not getting adequate airflow to the lungs at night because they're snoring or they're pausing their breathing.

Sleep apnea can give you anxiety the next day.

More commonly sleep apnea will give you difficulty with fatigue, sleepiness, poor concentration and just feeling kind of blah and it's very subtle but people with sleep apnea will have a lot of physical and psychiatricpsymd can be a factor in terms of making people depressed and sometimes anxious for that matter.

>> We always want to look at glucose disturbance is high or low glucose can make you sometimes anxious.

So we'd want to look at all the medical conditions that might be going on.

I'd want to make sure that you're not using alcohol or marijuana as a means of self medicating.

People will sometimes insist that alcohol and marijuana make them feel better but they keep using more and more and more of it at higher and higher amounts to get the same effect.

So alcohol and marijuana might help for a while but in the long run they can actually make anxiety worse.

And finally, just to mention how we would choose a medication for anxiety, we do genetic testing sometimes for people.

Genetic testing is not going to be a deterministic it's not going to determine exactly what you need and what dosage you need but it will help us kind of tip the scales if we're thinking about going one way or another.

The nice thing about genetic testing will be it can give us a little bit better insight on what might really work for you and at what dosage we should use, whether we should use a high dosage of certain medications or lower dosage certain medications.

>> Thanks for your call.

Let's go to next caller.

Hello Marie.

Welcome to Matters of Mind.

Marie had mentioned that you noticed a change in your appetite and fatigue as the winter months approach.

>> Is that normal?

It's kind of a hibernation effect, Marie, as the winter months approach, the days get darker and darker as the days get darker and darker, the sun's coming up a little bit later.

It's going down a little bit earlier.

It's lower all day long.

It's more prominent up in Alaska, less prominent down there in Sarasota, Florida.

as examples.

But what happens the light rays will hit the back of the retina at the back.

The retina will then transmit a signal on light to this area in the middle of the brain called the pineal gland the pineal body of the binding pineal gland that's the front front of the brain there.

Pineal bodies right smack in the middle of brains, little p shaped gland that will secrete melatonin and as it's getting darker melatonin will go up and up.

So melatonin is known as the vampire hormone because it rises when it gets darker.

>> So with melatonin going higher and higher it can make you more tired, can make you more depressed, make you less socially motivated to be around people just make you feel kind of blah, make you want to eat more especially carbohydrates.

And what do you do about it?

Well the first thing you have to do is try to get outside in the early morning hours especially a sunny day where it's nine a.m. 10 a.m. go outside for about twenty or thirty minutes.

Many people will indeed use a light box in the winter months between October and about March or every morning they sit in front of a bright light box.

Now this is not a light that would be transmitted from a lamp or something that you'd have from your usual indoor indoor appliances.

We're talking about a light box that has the light intensity of what's called ten thousand Lux one Lux is the light intensity of a international candle which is one meter away from your ten thousand lux is very bright.

It's the light intensty that ou'd normally h0 a.m. on a bright sunny summer morning.

So the light intensity first in the morning of ten thousand lux for about twenty or thirty minutes about a foot or two away from you can wake up your brain and allow you to kind of get through the winter depression months.

>> How do you get a light box?

You can always talk to your primary care clinician about that.

They should have different places where you could order a light box but again it's a specific light box.

It has a certain intensity of light.

It used to be thought that oh gee, should you have red light blue light?

Should you have full spectrum light full spectrum light appears to be adequate right now for winter depressions.

It's the brightness of the light as opposed to the type of the light that seems to be the most important.

So when you get bright light hitting your retina, it goes to the pineal body right in the middle of the brain and tells the pineal to decrease the melatonin transmission.

Wake up the brain off you go now when the brain wakes up what happens?

>> Histamine gets released.

Histamine release makes your brain awake and alert and it's often a consider to be a very good antidepressant if you block histamine with antihistamines such as Benadryl and some of those sleep medications that makes you sleepy.

>> So what you want to do is try to increase histamine release during the daytime to make you more awake and alert and people will often ask me well OK, so what about coffee ?

Should I drink coffee first thing in the morning?

It's always debatable whether you should drink coffee for the caffeine content first thing in the morning because quite frankly your brain might not need it that much first thing in the morning when your brain might really need the coffee is later in the morning and especially mid-afternoon because as the day goes on you have this chemical in the brain called adenosine.

Adenosine is kind of like the exhaust fumes in your brain and the exhaust fumes build up and build up and build up adenosine goes a little adenosine receptors and they make it that'll make you tired.

So as adenosine goes a little catcher's mitts which are a little receptors and adenosine gets those receptors makes you tired as the day goes on.

What caffeine does is it mimics adenosine because it's structurally similar to adenosine fuels the brain into thinking it's adenosine caffeine goes to adenosine receptors knocks off the adenosine receptor from the receptors.

But unlike adenosine, caffeine does not make you tired it just knocks off the adenosine.

So the way that caffeine works is by knocking off the adenosine and in doing so it can increase histamine in the brain.

>> Caffeine lasts about an hour or two so it's not a really good treatment overall for keeping you awake one way or another.

But increasing histamine, increasing dopamine those are the kind of neurotransmitters we're often considering increasing when people are kind of tired and sleepy.

But in the winter months what can you do naturally get some sunlight, get in front of a light box exercise you don't want to exercise in the winter months.

That's the last thing you want to do but you need to exercise.

So go to a gym or go to some kind of exercise facility where you can exercise 30 minutes three or four times a week is ideal so thirty minutes there are four times a week is great socializing in the winter time is very, very important.

Many times people become more socially reclusive in the winter time the weather is not that great.

Try to get around people somehow or another.

>> If you're around people you're less likely to have difficulty with depression.

So in the wintertime it's important to be socially active, be physically active, keep yourself busy doing things and try to get some sunlight the best you can be careful about the carbohydrates in the wintertime people will crave carbohydrates in the wintertime people will go to the holiday festivities and and the parties and they'll lots of carbohydrates that will jack up your jack up your serotonin level indirectly briefly by increasing tryptophan transmission into the brain.

If you increase insulin levels from eating a lot of carbohydrates that increase tryptophan into the brain when the tryptophan gets into the brain it starts to manufacture more serotonin you feel better but in the long run you feel lousy because you crash thereafter.

>> So many people have noticed that carbohydrate crash after having a high carbohydrate meal.

>> They need to back off of that.

Thanks for your call.

Let's go our next caller.

Hello Chris .

Welcome to Bear in mind Chris Ude wondered about genetic testing and you've tried so-called serotonin reuptake inhibitors in the past for panic disorder.

They haven't worked.

What else is there, Chris ?

If somebody is not done well with a serotonin reuptake inhibitors, sometimes we can pick that up on genetics about one of three people do great on serotonin medications such as Zoloft, Paxil, Prozac, Celexa, Lexapro.

>> Those are the serotonin medications that we primarily will use and they're often used line but the problem is about one out of three people do well but two out of three people don't.

>> So who are the people who do well on selective serotonin reuptake inhibitors?

>> Well, from a genetic standpoint these are the people that have a SLAC say for a gene that's coded as Ella Ella you got it.

A gene from your mom, you got an early gene from your dad .

>> That's a great combination for somebody who's often going to do well with necessary if have an SS or a LGC or an LG LG sometimes those are the people who don't do well with the serotonin medication.

So genetically there's a bit of a predictor there that we can sometimes pick up.

Secondly, people who have experiened a lot of trauma in the past if you had trauma prior to eight years of age, what we talked about with trauma we're talking about sexual physical emotional abuse.

>> We're talking about neglect by your parents.

We're talking about a parent having alcohol or drug problems, a parent having a psychiatric condition.

>> Anybody in the household going to jail is a trauma.

People who have noticed that they've they've had a lot of family bickering in the household and there's been a separation or divorce again if you're a child prior to eight years of age and you'v&-py of that, that's going to put you at a greater likelihood of having depression later on.

And secondly, it puts you at a greater likelihood of not responding to a serotonin medication.

For that reason we're always asking people about childhood trauma.

There's a particular test ten question test called an ACIS an adverse childhood experience scale and if you score four or more out of the ten it's highly likely you will not respond to a selective serotonin reuptake inhibitors so trauma can be a factor.

Genetic can be a factor in terms of whether somebody will or will not respond to a selective serotonin reuptake inhibitor.

>> And a third factor will be basically how your brain is networked.

>> And this is something that's more recent, Chris , where somebody might have a tendency to brood and ruminate about different things where somebody else might have trouble when they get depressed with just being able to kick in their brain and concentrate and focus on different things about one third of people out there have this difficulty with their brain tending to ruminate and get stuck and thinking about the past and they can't get off the worry and all that those people are thought to be over connected with these two networks called the Salient Network in the Default Mode Network.

Now there's another type of depression where people are under connected between the salient network and the executive network which is the thinking network.

So about two thirds of the people are interconnected in that network of the brain.

About one third of people are connected.

The people who are over connected and they have difficulty with just getting stuck on things and brooding and ruminating about things those people will be more likely to respond to serotonin reuptake inhibitors.

>> So how do we decide on what medication to give people?

>> Well, we can look at their genetics if we have them.

I'm always a big fan of getting any genetics at all.

If I can see genetics were free I'd order for everybody.

But we look at past treatment responses how you did with different medications we look at maybe childhood traumatic experiences.

If you had several you might not do so well.

The selective serotonin reuptake inhibitor.

But we also look at your so-called phenotype of phenotype is where we're looking at the type of depression, the type of anxiety symptoms you're experiencing.

So what else can we do?

Well, there are other medications out there that might not affect serotonin depending on what other symptoms you might have Chris .

So Clonazepam Klonopin is a medication that you'd mentioned that you're taking.

So that's a medication.

It can be used short term.

We used to use it quite extensively over ten years ago but then we found that over the course of time it makes people kind of emotionally dull and it's significantly impacts your ability to concentrate.

So we don't like to use Clonazepam long term now we did again before about 2010.

We did all the time.

Then we realized that for many, many people and a lot of different studies it was actually causing to have difficulty focus, concentration, keeping their mind on things the next day.

So we try to get away from the benzodiazepines such as clinical Pam Gabapentin you bet is an option for a lot more people.

Gabapentin is a medication that can be used if you are not taking an opiate or a narcotic.

So gabapentin is a medication that we do use extensively for anxiety.

It will affect indirectly gabb which is the brakes on the brain about 70 percent of the brain's neurotransmission is Gabb and the rest on the gray matter outside matter for that matter is glutamate.

So glutamates the accelerator gabb is the brakes gabapentin will indirectly affect Gabb by affecting the so-called calcium channels which are the trigger fingers for the purpose of opening up the channels and releasing Gabb for that matter.

So Gabapentin is used for that purpose.

We will use Gabapentin in psychiatry as needed now you think wait a minute Gabapentin if you look at the package insert that was created twenty five years ago it says you should take it every day because it's used for seizures in the package insert.

Well for the past twenty five years we've been using gabapentin much more extensively for sleep anxiety.

We've been using it for bruxism where you have a tight jaw and your clamping down.

We use gabapentin extensively for restless legs so we use gabapentin for a lot of different purposes.

>> If you're using it for a seizure disorder you bet you have to take it every single day on a very consistent basis if you an arrest for four restless legs you might you want to use a long acting formulation such as Grealy to give you an example that lasts a little bit longer and it's a little bit smoother in its release.

You might want to use something night by night by a night for restless legs but for anxiety will often use gabapentin on an as basis at a lower dosage.

Now again, Chris , if you take it a narcotic, if you're taking an opiate medication you don't want to use gabapentin.

>> That's where it gets abused because people will use gabapentin as a means of amplifying the narcotic effect.

It's not as much as what Clonazepam or Xanax or alprazolam also does alprazolam will do the benzodiazepines will significantly amplify the effect of the opiates gabapentin to some degree.

So if you're taking an opiate or a narcotic we don't like it on the gabapentin but by itself Gabapentin can be used for anxiety as an alternative Clonazepam.

Now you'd like to you'd sometimes want to take something day by day by day for you.

It might not be a serotonin related medication.

>> There's other medications that could be used depending on the nature of your anxiety and if you have any other type of any type of depressive symptoms going along with it, we might go a little bit different direction.

>> Chris , thanks for your call .

Let's go to next caller.

Hello Don.

Welcome to Mastermind Don.

You want to know if it was possible for medications like hydroxyl and certainly to run their course?

If so, what other options are there?

>> Don, hydrocortisone isn't antihistamine medication as an antihistamine medication.

It's main mechanism is to make you tired.

That's what it comes down to.

I mentioned earlier that histamine is a chemical that primarily affects the front part of the brain.

>> It wakes you up so increasing in histamine during the day is great and wakes you up hydroxyl zem would basically block histamine if you think about its mechanism it's just mainly making you tired.

>> I don't think that's a really good means by which we should treat anxiety but that's my opinion.

I know hydroxide is used extensively as needed by many, many clinicians out there and it's fairly effective because it'll make you tired.

It also gives you a dry mouth, makes you a little bit fuzzy from a concentration standpoint it doesn't affect the concentration as much as a medication like diphenhydramine or Benadryl will at bedtime.

Diven Hydrometer Drome at bedtime will make people really sleepy and there's been studies on it showing the next day you're going to have trouble with driving up until noon if you took a diphenhydramine at bedtime.

Hydroxyl is less sedating since it'll kind of calm you down but my preference will be to not block histamine if you are having anxiety I'd rather go to the core of anxiety itself affecting Gabb and that's exactly what a medication like I mentioned I gabapentin will do.

>> Pregabalin is also known as Lyrica that will do a similar type of have a similar type of effect on the calcium channels.

>> Sertraline can run its course.

Yeah certainly is a medication known as Zoloft.

If you increase serotonin which is the mechanism of action of Zoloft or really if you increase serotonin you can indirectly decrease dopamine transmission and what that does it'll make you feel kind of blaw you'll not care might have some trouble with concentration.

Now the great thing about sertraline is it will increase dopamine a little bit by a totally separate mechanism of action so it will increase serotonin but a little bit of dopamine.

So that's why we favored a certain Lenar Zoloft among the serotonin medications for quite some time but with certainly any time you increase serotonin you can indirectly decrease dopamine.

Serotonin has some other effects on the brain.

It'll make you feel emotionally blunted.

So emotionally blunted means you don't feel happy but you don't feel sad.

You just kind of feel neutral and kind of flatlined and you might think oh that doesn't sound so bad.

It actually bothers a lot of people.

>> So a lot of people who are emotionaly blunted don't like how they feel so increasing serotonin can make you kind of feel emotionally blunted increases.

Serotonin can also affect your concentration a little bit and finally can cause you to have a little bit less joy overall.

So sertraline Zoloft and decrease crying again, decrease agitation it can make you feel calmer but in doing so it has the side effects of the joy, happiness, emotional blunting and just making you not care about a lot of different things increasing serotonin can indirectly also decrease sexual functioning which bothers a lot of people.

So what else do you do?

Well, you can increase serotonin in different ways and some examples will be increasing serotonin with the medication like Trin Telex also known as Very Occitan it will enhance serotonin but it also will affect very specifically five of the 14 different receptors that are out there for serotonin and in doing so doesn't give you the side effects that you might see with certainly in itself.

So it would not give you emotional blunting.

You'll still be able to feel joy and happiness and it does not typically cause sexual disturbances.

So you can use a serotonin, a medication that works differently than sertraline.

Another option would be to use one of the newer options that are available out there for anxiety and depression such as ketamine which is an IV injection is ketamine which is an international spray.

There's all Valide which is a medication it came out about a year ago for the purpose of helping with depression but it also gives people a& calming effect.

These are medications that work more on glutamate.

So in working more in glutamate these medications can wake up the brain, help with concentrate and help with energy, help with enjoyment with things but not cause not do so at the cost of emotional blunting like you might see a certain things.

So if when you think about certain lean if it's just not working so much anymore, sometimes we're going to think outside the box and think about another type of neurotransmitter combination.

>> You know it's commonly I commonly see people will go from certainly an overdue Dellucci team or Cymbalta or maybe over to Venlafaxine also known as Effexor.

That's OK.

But they're primarily increasing serotonin.

They give you a little bit of a dopamine are a little bit of a norepinephrine boost which can help a little bit with energy but it's not usually dramatic now what else do we do if you're doing somewhat better on searching, I want to know how much better on sertraline you're doing if you notice that you're feeling a little bit better.

So if you're somewhere north keep you on sertraline and add a medication like Wellbutrin or Bupropion to the virtually because the Wellbutrin would be increasing dopamine and to some degree norepinephrine itself and that's kind of been an old school way of helping with all three neurotransmitters over the course of time by enhancing serotonin, norepinephrine and dopamine so you can add something to the search within my rule of thumb is if somebody is doing 50 percent or more better on a medication, I'll probably leave that medication alone.

Now if they're doing twenty five to thirty percent better I might look at their past treatment history and consider OK do we keep them on some Trelane and add other things so you always have to balance that out.

But that's why it's very, very important that as clinicians we have a very clear understanding and a clear tracking of what medications have worked, what haven't worked, what kind of side effects you have for different medications.

We need to track those very, very methodically not only for you as the patient but also for the family members because we really want to know how the family members have done on different medications.

I think I have another email in the hopper there or what other email do I have there?

I have one that reads Dear dear father, what are the main reasons why people get depressed?

>> I kind of alluded to that earlier couple main reasons people get depressed will be number one, they'll have trouble with depression due to lack of socialization.

That's a big factor.

A lack of socialization can increase depression and secondly early childhood trauma .

So if you've had early childhood trauma you're much more likely to have depression later on in life .

Can't do anything about that.

If you had early childhood trauma, that's something that did happen.

You don't want to go through life being feeling like you're a victim.

But the bottom line is it did happen in the past.

What you want to do is try to address it the best way possible either through psychotherapy.

But the second big factor for depression that is correctable will be socialization.

>> So socializing and is very, very important to keep your depression loneliness is very, very impactful for so many people out there.

>> Thanks for your call.

Unfortunately I'm out of time for this evening.

>> If you have any questions concerning mental health issues you may go ahead and e-mail me at matters of the mind at Debu FWC Dorgan.

I'll see if I can get to those questions on the air God willing and be willing.

I'll be back again next week.

Thanks for watching.

You've been watching Matters the mine on PBS for Wayne God willing and PBS willing.

>> I'll be back again next week.

Have a good evening tonight