good evening, I'm psychiatrist Jeff Alver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now in its 10th 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 here at PBS Fort Wayne by dialing in the Fort Wayne area nine by dialing (969) 270 zero or if you're calling any place coast to coast you may dial toll free at 866- nine seven (969) to seven to zero now on a fairly regular basis I am broadcasting live every Monday night from our spectacular PBS Fort Wayne studios 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 all one word at WFA Egg that's matters of the mind at WSW a dot org.

>> And let's start tonight's program with one or two emails I just received this week.

>> One reads during Evolver I've recently heard some people saying that nicotine patches may be beneficial for some mental health issues.

>> Is this true nicotine patches would forego the aromatic hydrocarbons that are toxic to the lungs and much of the rest of the body nicotine itself goes to this little part of the brain called the nucleus accumbens right inside the middle part of the brain here and also fires up these nicotine receptors in the temporal lobe which is responsible for concentration.

>> So the bottom line in nicotine as a drug can help with motivation, energy and concentration.

>> That's why a lot of people use nicotine in the form vaping in cigarets and cigars and you name it.

>> But nicotine has some drawbacks.

No one and the biggest drawback I would say is that it loses its effect over the course of time and like a lot of drugs of abuse, you need a higher and higher amount to get the same effect.

That's the biggest concern I would have about it where it doesn't give a sustained effect at the same dosage over the course of time.

>> Secondly, it tends to not last very long and only lasts for a few hours and that's why people when they smoke cigarets have to smoke more and more and more frequently as a means to get the same effect.

>> And you know, it's one thing if you smoke three or four cigarets recreationally once in a while but if you're smoking a pack a day, two packs a day usually with cigarets you need to keep smoking more and more to get the same effect.

>> Otherwise you go into withdrawal and that's a problem with nicotine.

So if you use nicotine patches good thing about patches they'll be slow release but you still can have some difficulty with a little bit of withdrawal the times that you don't have the patches from a medical standpoint I'd be concerned about nicotine possibly increase the likelihood of you having hypertension and possibly cardiovascular or heart problems so not the best drug.

>> You know, 60 years ago before we had all these antidepressants in which we are using now nicotine was obviously a drug of choice back in the 1930s or so cocaine was as well.

>> So we had other treatments back in those days before a twenty nine oral antidepressants became available over the past six years, 60 years.

>> But they just didn't have a safety track record.

>> So I wouldn't recommend nicotine patches necessarily as a means of treating underlying conditions because I think we just have so many other things that are much better.

I would certainly recommend nicotine patches over cigaret smoking or even vaping for that matter.

Vaping has some toxicity itself with the device so nicotine patches are probably safer than either of those.

But as a treatment I wouldn't recommend nicotine itself.

>> Thanks for your email.

Let's go to our next email our next email reads Dear dear father, I have osteoarthritis and osteoporosis.

I mean you have thinning of the bones and recent muscle stiffness that's impacting my sleep and quality of life.

My doctor has prescribed Cymbalta but I'm concerned over research that indicates that it may increase bone density loss.

>> Is there another medication I could recommend for muscle pain based on the type of muscle pain you're having?

>> If it's Nierop theme, if it's from fibromyalgia pain, if it's pain related to possibly some nerve ending pain, there are medications you could use that are in the class of anti seizure medications called the gabapentin noise.

Two of them would be pregabalin and gabapentin.

Pregabalin is Lyrica and Gabapentin is Neurontin.

So those are medications that affect the calcium channel.

Bottom line is when you're in pain often it's your little nerve endings firing too much they get an easy trigger finger .

So when your nerve endings are firing excessively, what can slow them down where you can kind of modify calcium channel and slow down the influx of calcium and decrease the likelihood you're going to have all this firing the nerve cells and that's what the gabapentin always will do.

>> So those are options.

Why does Cymbalta have an effect on bone density while Cymbalta basically will increase serotonin and norepinephrine which are based in the brainstem down here kind of in a stalk of the brain, it's the brain looking at you in the stock of the brain.

>> It's where norepinephrine and serotonin are originating.

Cymbalta will increase both serotonin and norepinephrine.

>> In doing so they will go to the spinal cord and decrease the intensity of the pain coming up the spinal cord.

So the pain that you have you won't notice as much.

And for many people they'll say that Cymbalta also known Fluoxetine.

They'll say it's life saving because it allows them to function in a much greater level.

They're not sedated like they would be under a narcotic but yet they're not feeling as much pain coming up the spinal cord.

So what's going on with the bone density?

What's that all about?

Well, basically Cymbalta does have a feature where it's blocking the vacuuming of serotonin into the neurons.

So what it'll do is called a serotonin reuptake inhibitor.

When you fire out serotonin from a firing neuron just like a shotgun serotonin sprays out across brain and central nervous system and goes all these various targets to keep more serotonin in the system.

>> If you block the vacuuming of serotonin back into the firing neuron, you'll have more serotonin bouncing around for a longer period of time.

So that's how Cymbalta, Lexapro, Prozac, Zoloft, Paxil that's how those medications are working.

>> They're basically keeping serotonin in the system longer because they're blocking the vacuuming of serotonin back into the fire neuron.

>> Now why do the neurons vacuum back in serotonin?

>> It's to preserve the serotonin otherwise you'd be making serotonin all the time and you can keep up.

So this is a way of you kind of recycling the serotonin.

It vacuums into the firing neuron so what happens?

>> You got platelets and you got bone platelets and bone also have a means by which they have those vacuum's and in platelets they have a vacuum for serotonin and if you block the vacuum for serotonin and don't let of serotonin come back into the platelets, you're going to bleed more easily.

>> And that's the biggest concern I'd have about an older person for instance, taking any medication that has a serotonin reuptake inhibition such as Cymbalta.

>> It works really well for pain.

>> But I want to make sure you didn't have any gastrointestinal bleeds or any propensity for bleeding such as a history of a hemorrhagic stroke where you've had a bleeding stroke.

>> So in those cases I'd be particularly concerned how about the bone density issue?

>> Well, that little pump that in serotonin also in calcium to the bone.

>> So if you're blocking the pump that's in calcium to the bone that can make your bones a little bit more brittle.

>> Now how much you'll have about an eight to 12 percent higher likelihood of having a broken wrist or maybe a broken hip.

So eight to 12 percent higher risk in taking a medication that's that's inhibiting the uptake of serotonin, serotonin and thereby calcium.

So it's a little bit higher risk especially for menopausal women, menopausal women don't have the estrogen for taking them from having breaks in their bones.

Estrogens very good for the bones, no estrogen and menopause.

You're gonna have more likelihood of having a break at a later age and if you put a medication like Cymbalta on top of that, it can increase the likelihood a bit.

Now how can you mitigate that likelihood?

You can take calcium calcium citrate for instance between 300 and 600 milligrams a day possibly can decrease the likelihood of having the break because what you're doing is you're flooding the body with extra calcium, with extra calcium.

You're going to get more into the into the bone if you're also using a medication that by nature strengthens the bones like Fosamax that might decrease the likelihood as well.

>> So talk about your Clinton talk to your clinician about the pros and cons of using Cymbalta itself, possibly adding a little bit of calcium if you're not already using calcium but if you want to bail out on Cymbalta or Delux entirely and not take a medication, it's going to have that effect on in calcium to the bone.

You don't want to take a serotonin reuptake inhibitor.

You want to take something like a gabapentin noyd such as pregabalin or gabapentin I mentioned previously because they have no effect on serotonin they will decrease aches and pains directly at the nerve site level whereas Cymbalta is decreasing your perception of pain as it's coming up the spinal cord.

>> That's a very, very long answer for a very short question.

So thanks for your question.

Let's go to our next caller.

Hello fellas.

Welcome to Matters of Mind.

>> Also you had mentioned that you had a stroke earlier this year and now you're having a lot of anxiety and fear.

Is that common and should you seek help, Phyllis, if the anxiety and fear is getting to the point where it's problematic in your day to day functioning and you're not able to socialize as much, you're not able to do the things around the house you'd like to do if it's becoming somewhat paralyzing for you.

But go ahead and talk to your neurologist, talk to your primary care clinician, try to get some ideas on what you can do when people have a stroke Phyllis it because it'll cause damage to the brain when you have a stroke you have either decreased blood flow to certain parts of the brain.

You have bleeding in the brain and it causes damage to certain parts of the brain depending on what part of the brain is damaged.

>> It can give you different symptoms but with any type of stroke people can have some anxiety.

>> Why do they have anxiety?

Well, it's because there's this chemical on the outside part the brain, the gray matter part of the brain called glutamate.

>> It's an excitatory chemical and you can see this with a stroke.

>> You can see it with seizures.

You can see it with a concussion.

But when you have any damage to the brain itself you can increase glutamate.

Increasing glutamate gives you an excitatory effect and sometimes can make people unnaturally anxious, fearful and sometimes will give them difficulty the concentration now that can even be worse depending on what part of the brain is affected.

But we'll often hear about people having some unnatural anxieties.

Fears for that matter after they've had a stroke might go on for a year or two because it takes the brain about a year or two to repair itself from a stroke.

And yes, the brain can repair itself to some degree following a stroke, especially if you keep the brain active.

That's why occupational therapy and different rehabs will be good for people who've had strokes because they're trying to keep their brains active with an active brain.

You're literally regrowing the branching of the brain so you want to be able to do that.

>> So right now we're using medications that will block excessive excessive glutamate.

>> These are anti seizure medications such as Lamotrigine Valproic.

Those brand names are Lamictal and Depakote respectively but they're blocking excessive glutamate transmission and thereby can decrease anxiety.

The drawback of Depakote especially will be the difficulty that people have with sedation from it and sometimes liver problems lamotrigine a much safer but it's not as sedating and not as calming as Depakote.

So there are options to decrease some of that anxiety you're having following a stroke.

>> What you do not want to take is medication is called a benzodiazepine such as Xanax and Klonopin, Valium.

>> These are medications that have been around for decades but that they make the ability to think now much more impaired especially after a stroke.

>> It sounds like a reasonable thing to do but I've seen a lot of people who have had strokes getting something like Xanax Radovan.

They get extremely confused and they get even delirious where they don't know where they are and they start hallucinating.

>> So we don't want to give those medications for anxiety.

But you can give the so-called anti seizure medications for anxiety related to post stroke.

>> Thanks for your call.

Let's go to next caller.

Hello.

Welcome to Matters of Mind.

>> You had mentioned that your prayer was prescribed area Pipas also known as Abilify for agitation for dementia.

Are there any side effects and this is this a long term fix?

Abilify has been used for dementia.

We have a your medication is kind of a chemical cousin to Erra Pipas I'll call BRICS Brazil Breakfast Brazil is result it is FDA approved officially approved for the treatment of agitation related to dementia.

>> So these are medications that affect serotonin, norepinephrine and dopamine receptors in specific ways and can give a calming effect for some people.

>> What's the main drawback of those medications especially for older adults?

>> It can give people twitches and tics.

They can have hard blinking mouth movements or tongue can move around.

They can have shrugging of the shoulder.

So we need to watch for those kind of symptoms especially for older adults with long term use.

>> But for someone with dementia it can be something that can be substantially improved their quality of life.

So Abilify Rigotti, these can be medications that can be very effective for agitation related to dementia.

Again, back in the old days people sometimes would get Zanuck's out of an Klonopin, Valium, the so-called benzodiazepines for agitation related to dementia and it would make the agitation worse .

So we want to stay away from those medications.

So nowadays we're going to use these so-called medications that we use for psychosis Abilify or faulty.

But we might use the antiepileptic medications as well.

Low doses of gabapentin, low doses of pregabalin which I mentioned before Neurontin and Lyrica respectively.

>> It used to be used used to be common practice for people to get a little bit of Depakote with dementia related agitation but those patients would get way too sedated to have falling risk so we don't use those so much.

So using Abilify using result can be helpful for agitation and one of the best ways to relieve agitation related dementia is to keep the loved one in a familiar environment changing from one environment to another when you have dementia it's very, very confusing.

So with people with dementia it's important to have a very stable structured type of environment around them.

>> So it's very predictable.

Have photographs of the family around or photographs of important events in their lives because they want to have that stability to be able to reminisce and they want to know where things are day to day.

Keep a calendar on the wall, make sure there's a clock in the room.

Let them know when it's morning afternoon, evening and introduce yourself repeatedly as you come in because they might have forgotten who you are even if you're a family member.

So it's important to maintain that kind of structure and stability for somebody agitation related to dementia.

>> Thanks for your call.

Let's go next caller.

Hello Karl.

Welcome to Matters of Mind.

>> Karl, you want to know if seizures run in the family?

Is it safe to take clozapine for schizophrenia and or are there other alternatives?

All of the antipsychotic medications, Karl, do have an increased likelihood for seizure.

It's not guaranteed that you're going to get a seizure if you are taking an antipsychotic medication such as clozapine.

>> But it's it's a possible risk.

So somebody already has seizures.

We're going to keep a close eye on them often with them on an antiepileptic like medication such as Depakote, Tegretol, Trileptal, Lamictal just to name a few and the anti epileptic medication will prevent the seizures and often give a mood stabilizing effect anyway.

>> So having a family member with having a seizure wouldn't necessarily preclude you taking a medication like clozapine unless you developed a seizure even if you did develop a seizure, weigh the benefits versus the risk of clozapine water, other options out there all the psychotic medications can get have a fairly similar risk of having a seizure although I think it could be debated some of these new medications coming out for psychosis such as Koban Fee and Leida would be less likely to cause a seizure.

But that's from a theoretical standpoint.

But I think over the course of time will have ideas for people who have seizures who need an antipsychotic medication in terms of alternatives.

But right now if you look at the pros and cons of using clozapine, having a family member with a seizure wouldn't necessarily put you at that kind of risk.

>> Thanks for your call.

Let's go next caller.

Hello, Rita.

Welcome to Matters of Mind.

>> Rita, you want to know is bravado an effective treatment in child for childhood trauma?

If you're the adult and you've had childhood trauma often it can give you symptoms of post-traumatic stress disorder.

>> It's provided as a medication Food Drug Administration approved for individuals who have failed on two or more antidepressant medications so they have what's called treatment refractory depression.

>> I don't like that term because bottom line is I just think people haven't succeeded on the traditional antidepressants that are primarily increasing serotonin, norepinephrine and dopamine that mean more treatment for refractory just means we need to go another direction.

It's bravado as a medication it's a nasal spray and under supervised setting twice a week the first month, once a week, the second month and then every other week or every week thereafter for a while with bravado.

>> It's done in a supervised setting but it's increasing very, very quickly that chemical called glutamate in the brain and if you increase glutamate in the face of depression it can within a matter of days give you significant relief with the depression.

Well over the course of the years my clinic started using bravado back in 2019 for patients we did over 5000 treatments and we found that if people had major depressive disorder it was treatment resistant to the older antidepressant medications and if they had additional post-traumatic stress from childhood trauma it was helpful for the childhood trauma.

Now you might have heard about some of the hallucinogenics coming out that are very effective for childhood trauma and for PTSD time will tell to see how they do for people.

>> But I think right now bravado would be a very nice option if somebody had depression with a history of post-traumatic stress disorder due to childhood trauma.

>> I think the bravado could be a nice option for those people.

Rita, thanks for your call.

Let's go to next caller.

Hello, Maria.

>> Welcome to Mariza Mind.

Maria, you want to know about the symptoms of seasonal affective disorder, seasonal affective disorder is a fancy term for what we typically would call winter depression.

>> In other words, between October and April I saw a lady earlier today that had this very phenomenon going for the past years from October until April she gets dreadfully depressed very predictably every year it starts when the days are getting a bit shorter of daylight and days are darker.

Sun's lower on the horizon.

She notices that she's more socially withdrawn.

She has less motivation.

She doesn't care to do anything.

She overeat a lot of carbohydrates over sleeps and she just feels like she's in a funk for the whole winters.

>> How do you get around it ?

>> You get around it by exercising no one socializing the people up in Wisconsin, Minnesota, North Dakota they tend to embrace the winter of staying active with winter festivals and socializing.

Socializing and exercising are two very, very important means to try to keep out of winter depression.

>> Watch we'd be go easy on the carbohydrates.

You know we get the holidays coming up in the wintertime and it's so easy to continue eating a high carbohydrate diet even when you're not in those social events but that will often make people even more depressed and more fatigued.

It's thought that winter depression by logically a somewhat similar to hibernation we see animals hibernating in the winter.

>> It's kind of like what some people will do in the winter time because with less light in the environment there's less light coming into your retina.

>> You're in the back of your eyeballs.

The retina will give a signal to the pineal gland which is right in the middle of the brain here the pineal gland is the size of a pea and the pineal gland will increase the production of melatonin.

So if you have more darkness there's more melatonin with more brightness there's less melatonin.

So it's thought that the pineal gland has something to do with why some people have winter depression now women are about four times more likely to have winter depression than men don't know why might have something to do with the estrogen and progesterone fluctuations oppressed especially for premenopausal women.

>> So what can you do about it outside of socializing, exercising, watching your diet there is a medication it's of specifically use for winter depression called bupropion Wellbutrin bupropion has been out for a long time nineteen eighty nine it came and the only reason you couldn't use bupropion or Wellbutrin would be if you have a history of seizures or if you have recently had difficulty with binge eating and vomiting.

>> So those are two reasons why a person couldn't take a medication like Wellbutrin.

But Wellbutrin is an activating energizing antidepressant medication that increases the transmission of norepinephrine and dopamine and in doing so it can help people get out of a funk in the wintertime some of my patients will just take the Wellbutrin over the winter months and that's a very important treatment for winter depression will indeed be using a light box.

>> A light box is a very bright light.

You said about a foot or two away from it first thing every morning from October till about April and you use it for about twenty or thirty minutes.

>> A light box is so bright that if you look right into it it'll actually hurt your eyes so you don't look right into it.

You read you look at your iPhone or your tablet or something.

We have lightbox sitting right there first thing in the morning for twenty or thirty minutes throughout the winter months.

It has a dramatic impact for people who are prone to having winter depression so we often recommend a lightbox Wellbutrin or bupropion for many people and then socializing, exercising and watching your diet.

>> Those are the main things we often recommend for winter depression and even though you might be tempted to do so, try not to sleep nine or ten hours, set the alarm, get up at seven or eight hours even though you might not want to try to get up and try to get outside especially in the sun's first coming up now in the first if the sun is first coming up it's very important to try to get some light.

Fresh air is good but it's more about the light itself getting some natural light.

The light box itself gives you the light intensity that you'd get in the summertime at about 10:00 a.m.

So at 10 a.m. in summertime the sun's really bright.

>> Getting in front of a light box will often help with that.

In Denmark they found that people who are more prone to winter depression had lower levels of vitamin D in Denmark they have extensor of medical records on their whole population.

>> They follow everybody in terms of their hospitalizations and their various conditions and vitamin D deficiencies can be a factor.

>> So I often recommend people to do as I do and take about five thousand units of vitamin D throughout the winter time talk your clinician about that first to see if there's any reasons you shouldn't take vitamin D but taking vitamin D in the wintertime can be very helpful.

>> Vitamin D is what's called a pro hormone.

A pro hormone is a hormone that gets manufactured in your skin upon some kind of stimulation so vitamin D gets stimulated in vitamin D gets produced in the skin upon stimulation with ultraviolet light that produces vitamin and that has a lot of good effects on the mood.

My goodness higher levels of vitamin D have actually been associated with lower levels of cancer so there's a lot of good benefits for vitamin D You don't want to get too much because it gets stored in the liver but it can be measured in the bloodstream and you can talk to your clinician about that.

>> Thanks for your call.

Let's our next caller hello Larry.

>> Welcome to Mariza Mind Larry.

>> You want to know if there's any medications that can make you stutter the medication and to medication I can think of Larry, you're off the bat here.

>> They can cause you to stutter would be medications that do increase dopamine and one of them is Wellbutrin bupropion.

>> As I mentioned before, if you are prone to stuttering and stuttering is a neurological condition, Larry, where your basal ganglia this middle part of the brain in here gets a little disrupted and you have a hard time getting your words out and you stutter because of the basal ganglia disturbance Oza neurological disturbance if you stimulate that basal ganglia excessively with dopamine such as you can with Wellbutrin that could cause you to stutter second medication that can cause you to stutter would be any kind of stimulant maitham that mean any amphetamines for ADHD for instance Ritalin products methylphenidate products can cause you to stutter if you're prone to having stuttering and then we've known for years now that people use using cocaine will be more prone to stuttering too.

So stimulant medications, any medications that increase dopamine like the bupropion or Wellbutrin they can cause you to stutter and often look back to see OK, did you start stuttering when you started this medication or this medication?

>> We try to look at the time frame in terms of when the starting stuttering might have started.

>> Thanks for your call, Larry.

Let's go to our last caller.

Hello Joy.

Welcome to Mary's Mind, Joy.

You want to know about what things you can do to lower your stress this time of year?

Joy, you need to basically be able to say no to different activities and different obligations.

Many people feel obligated to attend every activity that people are asked.

>> So that's one thing.

Secondly, try to get your sleep.

I mentioned earlier with winter depression will often sleep excessively but it's important to try to get enough sleep to this time of year even though you might have a lot of obligations Joy in the wintertime more people than not don't like to exercise try to get some kind of physical activity and exercising even on cold days go out for a walk for maybe 15, 20 minutes, just get some kind of physical activity because physical activity can substantially lower your stress levels and finally be around people with whom you have meaningful relationships.

>> We should have we should have less stress in the holidays if we're around people with meaningful relationships.

>> But unfortunately sometimes family interactions can provoke anxiety.

You need to keep your distance from some of that and stay objective but try to stay sociable with people who meet a lot in their lives and try to maintain the whole purpose of the season.

>> Joy, thanks for your call.

Unfortunately, while I'm out of time for this evening, if you have any questions concerning mental health issues that I can answer on the air, you may write me via the Internet at matters of the mind all one word at a dog.

>> I'm psychiatrist Jeff.

All right.

You've been watching Matters of mind on PBS right wing God willing on PBS willing.

>> I'll be back again next week.

Thanks for watching.

Good night