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good evening time psychiatrist Jay Fawver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind Now in his twenty sixth 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.

>> The Fort Wayne area by dialing (969) 27 two zero or if you'd like to call coast to coast you may dial toll free at 866- (969) to seven 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 or you may write me via the Internet at matters of the mind all one word at WFYI Vague that's matters of the mind at WFYI ECG and start tonight's program with an email question I recently received reads Dear Doctor Favorite Thirty five years of age I suddenly developed a panic disorder after having several panic attacks while driving two years later I'm still struggling with it.

How do I get out of this SSRI and Snorri's have only made me feel worse and never help me with my panic.

>> Anxiety is authorized.

This second essay on those is serotonin the first as selective so selective serotonin reuptake inhibitor or serotonin norepinephrine replicative inhibitor they both are enhancing serotonin and serotonin can sometimes dial down the anxiety baseline to a bit where you're not as not as anxious and not as prone to having panic attacks.

They don't work for everybody though.

So in your case I'd want to know are you still having panic attacks associated with driving or are you still having panic attacks associated with specific type of circumstances because those in turn might be related to more difficulty with a phobic or a phobia type of phenomenon where when you get into a closed environment, when you're driving, when you're doing something, it creates a lot of anxiety and I bet you you're having a fast heart rate, maybe some sweatiness, some tremulousness when that's all happening.

>> If the serotonin medications are not working as long as you don't have asthma I'd certainly consider a beta blocker.

A beta blocker is basically a medication that blocks adrenaline and in blocking adrenaline you'll be less prone to having the physiological type of effects of the panic while you're doing a certain situation.

Now if you're still having panic specifically while driving for instance, you want to keep driving and you want to drive short short periods of time and for a short distances because the last thing you want to do when you're having panic attacks due situation.

>> It convinces the brain that avoiding that situation will prevent you from having panic attacks.

>> So it's important for you to try to get out there and encounter your fears and actually participate in the things that might cause you to have anxiety.

Now that's where psychotherapist can come in a talk therapist can teach you relaxation exercises and to help you go step by step by step in desensitizing you from that panicky situation itself.

>> So from a medication standpoint the serotonin medications are more often people will start because enhancing serotonin will dial down the anxiety baseline and the condyle dial down that degree of panic that you're prone to experiencing.

>> There's anticipatory panic where you are going to always be fearing having a panic attack and then there's the actual panic attacks themselves.

But I don't know I think you might be able to get some benefit from something like a beta blocker considering serotonin medications did not help and again, beta blockers or something you can't use if you have asthma because asthmatic attacks or any kind of respiratory disturbance will with a beta blocker by blocking adrenaline can make the bronchioles the airway passages not expand as easily so that can aggravate conditions like asthma itself.

>> Thanks for your email question.

Let's go to our first caller.

Hello Janet.

Welcome to Mariza Mind Janet, you want to know if you should see a psychiatrist to help you with mood swings from early menopause maybe Janet early menopause is sometimes called perimenopause is where you're not having periods as regularly and you're starting to decrease the frequency of periods that might go on for a couple of years known commonly and during that time your estrogen is coming down, your progesterone is coming down.

>> The good news is if you're prone to having premenstrual symptoms prior to that time eventually as you go into menopause, which is the full cessation of having periods and a decrease in estrogen and progesterone to a certain level you won't have the premenstrual symptoms in menopause.

That's the good news.

The problem will be in early menopause and perimenopause you might have hot flashes, you might have difficulty with sleep hot flashes and difficulty with sleep during perimenopause will be predictive of having more depression and mood swings.

>> So it's a phenomenon, Janet, where you're decreasing estrogen.

Estrogen is very prone to go these little estrogen receptors here in the hippocampus and the limbic system of the brain that's a side part of the brain.

That's the emotional volume control basically and in the limbic system in the hippocampus that's the emotional center of the brain.

That's the hippocampus is the memory center of the brain.

That's why a lot of women will notice having difficulty with memory during that time specifically now what can we do about it?

Hormone replacement therapy use very conscientious lead by a gynecologist can be helpful sometimes endocrinologist will treat people with hormone replacement therapy as a means of trying to decrease the intensity of the menopausal symptoms.

>> We do use some medications based on your specif symptoms you might be encountering.

For instance, if you are indeed having mood swings you're extremely irritable.

>> You're having difficulty with moodiness during the perimenopausal time sometimes we'll use the medication stabilizes a chemical called glutamate because excesses excessive excesses of glutamate can cause you to be more irritable and more angry and moody itself.

So a medication like Lamotrigine can be helpful in those cases other women will notice that they are having a lot of trouble with memory concentration.

They have a hard time processing information for those women.

>> We're using a lot of intellects nowadays Tronox is known Vaud Occitan but Trantor is a medication has been around for about ten years now and it's very good for helping you with your speed of processing of information that often is a problem during the menopausal years itself.

Some people are having good luck in using a newer medication called All Veloute which is a combination of Wellbutrin also known as bupropion and as well as dextromethorphan which is cough suppressant when used at high levels in the blood level it can be used for depression and anxiety itself it's relatively new has been out for a little over a year now so it's something we're starting to use to help with irritability, anxiety and depression but we're not using it routinely for a lot of menopausal symptoms.

>> If you're having trouble specifically with hot flashes and sleep not uncommonly we might use a low dosage of clonidine.

>> Clonidine is a medication has been around for a long time for blood pressure.

It's been around for decades for blood pressure.

But Clonidine has an effect on the norepinephrine surges that people get causing the menopausal hot flashes that it can decrease those significantly clonidine at low doses especially in the evening can be useful.

So we use various medications for menopausal hot flashes and for mood swings.

The gynecologists will sometimes use the hormone replacement therapy so there's a lot of different options there.

I would start with the gynecologist or at least your primary care clinician to see what kind of options you might have.

>> They'll test you for some blood levels of SS FSA follicular stimulating hormone Lutin rising hormone which is L.H.

They'll look for blood levels on those to determine if you're going into menopause and if you are then they can address that accordingly.

Janet, thanks for your call.

Let's go next email question.

>> Our next email question reads Dear Doctor Father my husband has anxiety and it's affecting his mood and sleep.->a psychiatrist for this or could our family physician prescribe something?

Would medicine help anxiety and difficulty with mood and sleep?

>> However, here's the cascade People often start worrying and ruminating about something and they'll brood about something that will cause them to have difficulty with sleeping because they have a hard time going to sleep and if they happen to briefly awaken at 1:00 or 2:00 in the morning they can't go back to sleep because they start thinking about things.

>> So worry often leads to difficulty with sleep, difficulty with sleep will affect the front part of your brain which is the reasoning part of the brain.

The first part of the brain needs to rest at night.

>> The thinking part of your brain, the decisive part of the brain needs to rest at night and if it does not you don't make good decisions the next day and you can't concentrate and can't pay attention to things.

So if the front part of brain has not adequately rested at night in the form of getting deep sleep and dream sleep you'll have more trouble with concentrate and coping skills the next day.

>> So lack of sleep is a key reason why some people will get depressed and if you get that cascade going, the first thing we always want to address is try to first and foremost try to help with a sleep.

>> I saw a lady earlier today who that's exactly what we did .

>> She was doing kind of OK with her antidepressant medication for depression but she wasn't sleeping so well .

>> Insomnia is a psychiatric vital sign for us.

Sleep is something we should always be asking about.

How well are you sleeping?

Are you having trouble getting sleep, staying asleep?

Are you a hard time a waking up in the morning?

>> We have to ask those specific questions with every visit for our patients so we we need to see how people are sleeping because lack of sleep will have a significant impact on your mental health .

>> So with this lady earlier today she was doing OK with her antidepressant mood was better but she wasn't sleeping so well.

Got her to sleep a little bit better at night time.

>> That made a dramatic difference for her.

It got her from about 60 percent better all the way up to what she perceives as being 100 percent better.

>> So lack of sleep can be a big factor so the family clinician can indeed address some of those issues by giving him medication for sleep anxiety medications.

>> Yeah, the medications that increase serotonin can help with anxiety and indirectly sometimes can help with depression.

>> About one out of three people have this type of depression where they will tend to ruminate and they get stuck on things it is a type of depression where the inside part of the brain it's called the default mode network.

It's the part of the brain that you used as to think about things you dread, daydream about things you can be creative during that time you're not really thinking about anything really intensely but a lot of your time is spent in these so-called default mode network.

>> You're just kind of hanging out.

You just kind of thinking about this or that but with some people they can pathologically get stuck in that default mode network where they start ruminating about things from the past and they start going over old memories and they go on and on.

>> There's another network called the Salient Network.

>> The salient network takes you out of that default mode network kind of like a clutch in a car back in the old days we used to have clutches where you'd go between your gears with the clutch.

>> That clutch should take you into the next type of network called the executive function the executive network.

The executive network is the thinking part of the thinking network that's the part of the network that allow you to focus on something, keep your mind on things and get you out of that ruminative funk that you might be about one out of three people will get this ruminative type of depression where they're Salyut network.

>> It just doesn't work.

It's like a clutch that the first gear so you're stuck the default mode network and you're ruminating you're drawing on something you're going on and on about it and next thing you know you can't sleep and you get more depressed for those people they do better with a serotonin antidepressive but about two out of three people don't have that particular problem.

>> They have more trouble with the clutch kicking them into the executive network where they're trying to think through things so they have a hard time with concentration processing informatio.

>> They have a hard time with enjoyment and things.

They just get stuck with not being able to get into that decisive kind of network where they can actually cope with different things.

>> So it's basically the kind of depression you have where we might choose one antidepressant versus another for somebody but a common out and common theme with a lot of will be difficulty with sleeping and enjoying things.

>> People will often ask me what are the two biggest risk factors for having difficulty with depression?

>> Number one, the biggest risk factor could be loneliness.

I just heard the World Health Organization for whatever it's worth has recently said that loneliness is a is an epidemic in itself.

So loneliness is something that's a big risk factor for depression at any time of your life if you're not socially active.

>> But a second risk factor, something we can't change is where you've been physically, emotionally sexually traumatized at an early age.

>> So as a child if you had a lot of traumatic experiences it will increase your likelihood for depression later on.

>> Couple that with loneliness and lack of social activity.

It can be a big, big risk factor for having depression later on.

>> Thanks for your call.

Let's go to our next caller.

>> Hello Justin.

Welcome to Mastermind.

Hi, good evening.

How are you today?

Hi Justin.

I'm doing OK. Good to hear from you.

>> Thank you.

Hey I was on the off the actual so my insurance quit covering it so they put me on turtling generic form of it and now it's just super weird because I cannot sleep at all at night my depression is getting better but now my anxiety is here the hook like I'm actually having anxiety about taking my anxiety meds and they said this exact same pill it's all in my head.

Is it just like an adjustment period to get back to it?

I'm sorry I just been feeling crazy, you know, saying like I used to sleep real well with and now I'm second third shrilling and now I'm not sleeping and I'm just driving myself crazy.

>> So I just saw your on I figured I'd give you a call.

I'd love to answer that Justin just say what's the dosage of searchingly that you're taking.

>> I am at twenty five mg cap where you at 25 milligrams of Zoloft brand name.

>> Yes OK you're very sensitive to the molecule of sertraline.

Sertraline is the actual chemical structure of the molecule.

Zoloft is the brand name.

So you took the brand name Zoloft which meant that when you took 25 milligrams of Zoloft you were getting between twenty four to twenty six milligrams of sertraline.

>> You're right there.

>> But with 25 milligrams of sertraline in a generic form you could be getting 80 percent to 125 percent of the twenty five milligram doses of of the sertraline.

So you could be getting somewhere between let me see if I could do my math here real quickly somewhere between about 20 to 30 milligrams of sertraline itself.

So let's say OK, you are really sensitive to sertraline which increases serotonin and to a lesser degree dopamine but it's mainly increasing serotonin if you increase serotonin in 30 milligrams a certainly is just too much for you.

>> Twenty five was just right.

Thirty milligrams might be too much for you're getting extra serotonin that way and getting that extra serotonin.

Some people will get serotonin toxicity which is manifested by restlessness where they can't sit still.

>> They have to feel like they have to pace they feel like they're coming out of their skin and they can't sleep sometimes they'll get headaches, nausea, a little bit of diarrhea.

>> It's simply due to your being excessively sensitive to serotonin.

>> Now most time most of the times when people go from a brand name to a generic they're going from usually the dosage down to eighty percent of what they got in the brand name.

But in your case you could you could be going the other direction and getting 125 percent of that 25 mg dosage.

>> Do some of those symptoms sound familiar to you, Justin?

Yeah, like I said, it feels weird.

It feels like I am actually moving faster than my body is.

Yeah, that makes sense.

Yeah, that sounds like it's my biggest problem I have.

I'm just not sleeping and I feel like my whole body is moving fast and I'm just like doped up.

>> Yeah yeah.

And it's a valid kind of concern you you're having because brand name Zoloft you're not going to probably get that covered nowadays.

Zoloft came out in 1992 so it's been around for a long time and comes of a generic version but sometimes you have to kind of tweak the dosage of those generic sertraline that you're taking take into account that the symptoms you're having are not related to anxiety undoubtably it's probably due to serotonin toxicity from what you're describing.

Is there a blood test for that?

No, but your symptoms are suggestive that so you can talk to your clinician about the possibility of shaving down the search lane.

>> Who knows with generic sertraline could you get by on twelve point five milligrams?

It's a small doses.

You're sensitive to it.

And many times when people take sertraline or Zoloft for anxiety, they don't need that high of a dosage now for depression people need fifty hundred sometimes 200 milligrams a day.

>> But for anxiety many people can get by on a very, very small amount.

>> But if you get too much serotonin in your system related to too much sertraline ,you know sometimes you can have all those serotonin toxicity side effects and it can make you feel really lousy .

>> I think a simple solution would be to talk to your clinician about either taking a half tablet of certainly which would be twelve point five milligrams of the twenty five milligram dose of your taking or even taken three quarter you can cut it in half and cut it in half again so you could get three quarters of a tablet that way and in doing so I think you'll have a lot of those symptoms subside that you're describing.

But again serotonin toxicity is related to feeling like you're kind of an out of body kind of experience sometimes difficulty with sleep is very, very common restlessness.

We call it a Cathy show where you have a hard time sitting still and again headache, diarrhea, nausea those are all symptoms that many people will have when they get excessive serotonin effects.

>> Twitching sometimes is notable for some people.

So you know, bottom line is for first thing we do is decrease the dosage.

>> I mean, yeah, we can get creative and add up and specific medication the block serotonin toxicity called Cypress Hebridean.

>> But why start another medication if the simple solution would be to decrease the one you're on?

>> But it's a real valid concern you're having chest and because brand name medications you're getting a right about between ninety eight to one hundred and two percent of the dosage that you're known to get.

>> So brand name medication will be very precise with the milligram strength whereas generic medications is between 80 percent and 25 percent you just might be about 25 percent more of the sertraline than you would have had when you took brand names off.

So it's a valid concern.

Justin, talk to your clinician about that and see what kind of options can be available for you.

Thanks for your call, Justin.

>> Let's go to next caller.

Hello, Doug.

Welcome to Matters of Mind.

Doug, you want to know if there's anything you can do to stop lucid dream some medication you take for your neurodegenerative disease the lucid dreams from a neurodegenerative disease?

>> A lot of different factors could be depends on what medications you are taking.

But if you're having the lucid dreams, vivid dreams, sometimes it can be related to norepinephrine serotonin transmission and if you're getting excessive amounts of certain medication effects from that you can have very vivid lucid dream.

>> Sure we have medications that we use to dampen down the intensity of dreams of these medications do affect norepinephrine clonidine being one gwon forseen be another medication prazosn will also affect your dreams.

>> So these are medications used for post-traumatic stress disorder when people are having nightmares related to PTSD but they can also be used for lucid dreams depending on what medications you're taking for the neurodegenerative conditions and how sometimes people will take medications to increase dopamine.

>> Increasing dopamine can sometimes offset tremors and neuroligin of conditions like Parkinson's disease and if you are increasing dopamine in in that matter sometimes you can take a long acting formulation.

>> You could change the time of the day when you're taking the medication and obviously decreasing the dosage with your clinicians oversight trying to determine what dosage works the best for you for the neurodegenerative condition but yet doesn't give as many side effects.

So there's different things that can be done about that.

What we don't like to do is give you medications that would block dopamine which could help with the vivid dreams but in blocking dopamine it could make neurodegenerative conditions worse.

>> So we don't like to do that.

So we'd like to fiddle with the dosage, change the formulation from a short acting to a long acting and sometimes looked for other options like that.

>> Doug, thanks your call.

Let's go to our next caller.

Hello Clark.

Welcome to Matters of the Mind.

>> Clark, you had mentioned you attended a retreat or they had they did group trauma bonding.

Is that a healthy way to form relationships?

It depends on trauma bonding, the type of trauma bonding to which you're referring to when Clark when you have trauma in the past, it's it's helpful to be in group therapy as a means of understanding that you're not alone and other people have endured this group therapy is marvelous because you share your experiences on how you've coped and how you've been able to overcome a lot of the different symptoms you've been enduring.

So that's where the whole concept of group therapy can come and now the trauma bonding I'm not familiar with that so much but I do know group therapy when used in kind of situations like dialectic behavioral therapy which is used for borderline personality disorder, many people with borderline personality disorder have been traumatized in the past and they do well with good behavioral therapy because therapy is a type of therapy where you deal with the here and now and you deal with coping mechanisms themselves.

So that could be done in a group therapy type of setting which could be helpful for a lot of people.

>> Clark, thanks for your call.

Let's go to our next caller.

Let's go to our next e-mail.

Our next e-mail reads Dear to the father Can a good psychiatric assessmnt and treatment be achieved with telehealth?

How does it differ from a regular office visit?

Telehealth basically is where you're seeing a clinician either a prescriber such as myself or a therapist on line and it's high definition video.

>> You've got to go to audio going there and it's something that's become much more popular and much more utilized since the covid pandemic restrictions that occurred three years ago.

And we have found that it can be very effective for many,-mant for everybody?

>> No, but you'll get about 95 96 percent of people say they actually prefer telehealth because it's more accessible.

I see people by telehealth myself.

I see them at the workplace.

I see them when they're at home, when they have a difficult time finding babysitters to come to the office.

They don't want to come to the office because of the time and the effort that it takes to come to the office.

We can often do a very good assessment by telehealth in office visits.

You know, we we would try to do some questionnaires before people would come in.

But with the telehealth is it a questionnaire is expected where within two days before people come him they complete these questionnaires such that by the time we see them on telehealth the questionnaires have already been entered into the electronic medical record system so we can kind of see how somebody is doing before they come in.

But a lot of people will say they prefer telehealth.

It gives increased access.

They don't have to make the one or two hour drive to our office.

So with telehealth we can often do a very good job for a lot of people out there.

Again, not for everybody of five to six percent of the population might not do well with telehealth but for the vast majority of people it does.

>> Thanks for email question.

Richard, you had a quick question here.

What part of the brain does Parkinson's disease take place in here in the basal ganglia?

It's thought that the basal ganglia kind of a section called the the straddle area the straddle area will decrease by about 70 percent with Parkinson's disease.

>> That will decrease the projections of dopamine and give you the difficulty with movement conditions where you're kind of freezing sensations.

>> You have a hard time with moving the arms, you have a hard time with shuffling gait.

>> You don't swing your arms as much when you walk and so forth.

>> Richard, thank you for your call.

Unfortunately 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 a via the Internet at matters of the mind all one word at WFB Reorgs God William PBS willing I'll be back next week.

Thanks for watching.

Have a good evening.

Good night