Good evening.

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

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

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

That's MattersOfTheMind@wfwa.org.

And if you're able to do so, you may call or text me while I'm on the air.

So let's begin tonight's program with an email question that I got just recently.

It reads, are there hidden symptoms when you're struggling with depression or anxiety?

Things like nervous pacing, overeating, headaches, feeling tired?

Yeah, when you have depression and anxiety and they often go hand in hand, b y the way.

You will often have a myriad of physical symptoms, and it's difficult to separate the mind from the body.

So the mind body interaction is true.

So you might have gastrointestinal problems, body aches, low back pain.

People can have difficulty with headache.

They can have difficulty with concentration.

Many people, when they have depression, for instance, will wonder if they have adult onset attention deficit disorder because all of a sudden they can't think clearly and they can't process thoughts.

So depression and anxiety often will go hand in hand.

And how that often works will people will be that people will initially worry on the job of anxiety and anxiety and worry will lead to insomnia.

When you have difficulty sleeping, you don't recharge the front part of your brain adequately, and that thereby can give you difficulty with coping abilities and what we call in psychiatry stress resilience.

In other words, you have difficulty putting up with stuff.

You have difficulty dealing with new stresses.

So the whole spectrum of depression, anxiety and insomnia, it'll often go hand in hand and it will affect the entire body itself.

When I was coming out of medical school, I considered going into primary care, family medicine or internal medicine, and I found that in primary care, a lot of people, the patients who were being treated had difficulty depression, anxiety, insomnia, and they're being treated for all these other medical conditions that were stress-related in some cases, such as peptic ulcer disease, tension headaches, we'd see people with type two diabetes who had been under stress for a long time, and I found that sometimes it's best to try to look at the core symptoms of depression anxiety, to try to address those kinds of symptoms the best we can.

Thanks for your email.

Let's go to our first caller.

Hello, Judy, welcome to Matters of the Mind.

Judy, you had mentioned you've heard me talk about progesterone in women's mental health.

How does it affect a woman on who's going through menopause?

Progesterone is a hormone that will rise and fall before you go into menopause, Judy.

And what you'll notice is that as you go into menopause, progesterone will fall, as will estrogen.

As estrogen falls, you'll have an increase in this particular hormone called follicular stimulating hormone, or FSH, that goes up and up and up.

And that's somewhat from a chemical standpoint, diagnostic of menopause.

So when progesterone goes down, progesterone goes down its active byproduct called allopregnanolone.

Allopregnanolone will also go down alone in the brain is like the brain's natural Xanax.

So imagine all of a sudden going into Xanax withdrawal or benzodiazepine withdrawal, you can feel more anxious.

You have difficulty sleeping, you'll feel more irritable, more moody.

To a mild degree, that can happen the 5 to 7 days prior to a woman's monthly menstrual cycle.

But to a more dramatic degree, gradually, it will occur well following childbirth during delivery, and it will also occur during menopause.

So what will often be done will be bioidentical hormones involving progesterone will be given.

I know following delivery we can give a medication called zuranolone, also known as Zurzuvae, which is a chemical mimic of alloprenanolone.

In other words, it looks like alloprenanolone in the brain.

So the brain's fooled thinking alloprenanolone still hanging around.

But progesterone breaks down into alloprenanolone.

When progesterone is no longer around, you don't have as much alloprenanolone.

And that's what causes a lot of symptoms that women will notice during during menopause, as well as following delivery with postpartum depression and to a more minor degree during the premenstrual time the week before a woman's monthly menstrual cycle.

Judy, thanks for your call.

Let's go to our next caller.

Hello, Andy.

Welcome to Matters of the Mind.

Andy, you want to know how do you cope with the lack of support from your family over your depression diagnosis?

Andy, usually depression does not occur from a familial standpoint in a vacuum.

Depression is about 35% genetic.

So it does run in families.

And I'd wonder if other family members might have experienced depression, but they manifested it in different ways.

In other words, some people with depression will drink alcohol as a means of self-medicating.

Other people will use cannabis.

Other people will just be irritable and nasty and mean.

So people can show depressive symptoms in different ways, but they can also try to treat it in different ways.

And these same people are treating their depression with alcohol, marijuana, opiates for that matter.

They're the same people that might say, you don't need to be treated for depression when they're doing so themselves by their own means.

So I think the best thing to do is to always try to maintain the idea that, number one, depression is somewhat genetic, and if you have depression, it's been diagnosed.

Maybe other people should be looking for forms of it themselves in their in the family.

But secondly, look at the medical basis of depression itself.

We now know that depression is not just an attitude problem as we, as many people thought decades ago.

Now we realize there's a lot of strong neurobiological basis behind depression.

The networking the of the brain is disordered when people have clinical depression.

So when you have trouble with concentration, enjoying things, motivation, you have trouble with sadness, suicidal thoughts for that matter, appetite changes, sleep disturbances, self-esteem.

These are all neurobiological issues that occur with depression.

And we now have imaging techniques that can identify that with research with research subjects.

So it's not like it was back in the 1980s where we really didn't understand depression that much.

In the past several decades, we've come to a lot better understanding of the networking of the brain that causes depression itself.

Thanks for your call.

Let's go.

Next caller.

Hello, Bill.

Welcome to Matters of the Mind.

Bill, you mentioned you take gabapentin for anxiety.

How does that affect your brain?

Bill, gabapentin is a medication that has a trade name of Neurontin.

Gabapentin or Neurontin came out as an FDA approved medication for seizures back in the 1980s.

And it readily became obvious that gabapentin was a very good medication for anxiety, for pain, and for sleep.

As a matter of fact, older adults actually do quite nicely with gabapentin because it will not just help them sleep throughout the night from an hour by hour standpoint, but it actually improves the efficiency of their sleep so older adults can actually get a better quality of sleep by enhancing their deep sleep by enhancing their dream sleep.

And it's thought to be one of the more favorable medications for sleep, especially for older adults.

So gabapentin is something that does not go directly to the GABA receptors like the name implies.

It basically will modulate the calcium channels in such a way that it will decrease the excess, the excessive firing of of calcium that will lead to increased anxiety and increased pain for some people, and for that matter, more seizures.

So what it does if you have an itchy trigger finger on the calcium channel, it's firing too much.

Gabapentin will go there and stabilize that trigger finger.

So the the calcium channel is not firing so often and you're not getting as much stimulation.

So it has an inhibitory effect not on GABA itself.

GABA itself will affect chloride channels.

This is working more on calcium channels.

So it's a whole different type of medication compared to Xanax, alcohol, the barbiturates, those type of things.

So it's a whole different type of medication.

Now where should it not be used?

Be careful if you're using gabapentin with opiates.

All right.

Opiates can be amplified in their effects with gabapentin.

Not so much is the benzodiazepines like Xanax, Klonopin, Ativan, Valium.

But gabapentin can amplify the effect of opiate.

So we're going to be really careful in using gabapentin with opiates.

And that's kind of a shame because gabapentin can be helpful for pain.

So you'll hear about gabapentin sometimes being used with opiates trying to address the pain that opiates are also trying to address.

But you always want to be careful about that combination in general.

Some people on gabapentin will have some puffiness in their ankles, so they'll have some swelling, but most people don't have fat accumulation around their abdomen like they will with some medications.

Gabapentin doesn't usually do that.

Gabapentinoids, which are gabapentin, pregabalin also known as Lyrica.

These type of medications, yeah they can give you a little bit of a high.

Its controversial.

Or are they addicting?

Are they not addicting?

When they gave gabapentin to some people who are addicts, they said they felt a little bit of a buzz with a when they got to a higher dosage.

Some states not including my state Indiana, but some states actually have a schedule of of gabapentin being a controlled medication where it's schedule three was a schedule four medication.

In Indiana, it is not.

But Indiana is still monitored.

So people can get a high on it, but not to the degree as many other medications overall.

So it's considered to be a relatively safe medication for people of all ages.

You can't take it necessarily if you have in stage renal problems, because gabapentin is exclusively excreted through the kidneys, it's not damaging on the kidneys.

It's just that's how it gets out of the body.

So if you have poor renal renal function or poor kidney function, you're just not going to get rid of gabapentin.

So that's where we can't use gabapentin overall.

From a drug interaction standpoint it seems to be pretty clean.

It does not seem to inhibit or promote the metabolism of other medications.

So it plays well in the other medications sandbox overall.

So thanks for your call.

Let's go to our next email question.

Our next email question reads when somebody somebody is on the right medication, what's the biggest hindrance to their recovery?

Do some people just not want to get well?

Well, let's imagine somebody is symptomatically doing reasonably well on a particular medication.

And they have a severe mental illness, for instance schizophrenia.

They have bipolar disorder.

And they're finally on the right medication where symptomatically they're doing well.

Why do some people just seem not to progress from there?

And am I reminded from gospel reading in the book of John, this is in the gospel, chapter five, verse six.

All right.

This is the story of the crippled man who had been lame for 38 years.

He's lying there at the pool of Bethesda.

All right.

So John, chapter five, verse six, Jesus sees the man knows that he's been lying there for quite some time.

And he he tells the man, do you want to get well?

Do you want to get well?

Why did Jesus ask this man?

Do you want to get well?

What does that mean?

Of course he wants to get well.

He's been lame for 38 years.

When Jesus asked the man, do you want to get well, what he was the context of that was he was saying, you know, your life is going to change once you get symptomatically well.

So once you're able to walk and talk and you're able to get up and around, your life is going to change quite a bit.

Number one, he would need a skill set.

And I'm thinking you got to read between the lines here with what Jesus did.

Yeah.

He symptomatically made him well.

But I imagine supernaturally Jesus also gave this crippled man of 38 years.

He also gave him a skill set so he could at least make a living, because he didnt have a skill set with carpentry.

He didn't have social skills to speak up because he'd been lying there for quite some time.

This is the challenge we see with people with severe mental illness.

All right.

We can symptomatically get people with severe mental illness a lot better where they no longer have hallucinations.

Their awful thoughts are significantly decreased.

They're sleeping, they're able to concentrate better.

But we've got to remember, if somebody had a severe mental illness for several years, they might have a lot of difficulty just going out in public, finding work, socializing, doing simple things they need to do.

And this is one of the beauties of this particular treatment model called the clubhouse model.

It's been around for six decades now, but the clubhouse model actually allows people to come into a treatment setting where there are around other people with similar problems.

They're learning skill sets.

Simple things like cooking, socializing, looking for work, finishing their GED for high school, getting the lives back because the days where we put somebody in the hospital for 3 or 4 days give them medication.

We now have injectable medications in the last three months, so we can give medications.

We can symptomatically get them better.

But just like Jesus healing that man at the Pool of Bethesda, he got up.

But he also needed to have a skill set to be able to function there out thereafter.

And that's often the big challenge we have with mental illness.

So the biggest hindrance in somebody staying well after they are recovering from a mental illness, the symptomatology itself will be having the skill set to be able to get things done in life and getting their lives back.

And it's very important that as mental health clinicians, we don't ignore that.

We always keep an eye on them and make sure they're moving forward.

And they're, you know, it's good to look at their symptoms.

That's part of it.

But one of the biggest predictors for relapse or difficulty with somebody recovering will be if they haven't achieved functional improvement or functional recovery.

That just means they're able to socialize or able to get work.

They're able to be all they can be in their lives.

And it's one thing to get symptomatic relief with the medication.

It's quite another to actually get functional relief.

And I think that's what Jesus was doing for the man at the at Bethesda, the book of John chapter five.

He was saying, yeah, you've been lying here for a long time.

He knew he'd been crippled for 38 years.

He got him up and around on his feet, but then he needed to have the skill set to be able to function thereafter.

That's why Jesus asked him, do you want to be healed?

Well, he was actually asking, are you ready to be healed?

Are you realizing, okay, your life's going to change once you're healed?

That's what often happens with people with severe mental illness.

Why do some people with severe mental illness stop their medication?

Part of it is because they might be struggling with knowing their expectations are are getting kicked up a notch once they have symptomatic recovery.

I think that's a little bit of it, but I think a lot of it is they just lack insight.

They lack awareness and insight that they have any mental illness and they wonder why they have to take medications.

Some people might find the medications aren't that effective anyway and they stop them.

I understand that some people might find some of the side effects of medications are intolerable.

So as clinicians is important for us to find medications that are effective, that they're tolerable, and also that they can acquire the medication and be able thereafter once their symptoms are decreasing quite a bit thereafter, we're hoping they can get out and about and functionally do what they need to do.

And that includes having work activities and being able to socialize and just having that degree of comfort to be around other people.

Thanks for your email.

Let's go to our next email question.

Our next email question reads, dear Dr.

Fawver, if I think a medication is causing side effects, how long should I wait to report something to my provider?

Should I give it a few days to see if things resolve?

Well, that's always a judgment call.

If the symptoms that you're experiencing have to do with a rash or you're having trouble breathing if they're serious, by all means we want to know sooner rather than later.

So if the symptoms are really serious, we want to know as soon as possible if they're kind of annoying.

Yeah, give it a few days with many, many medications.

The symptoms, the side effects you get with medications will resolve on their own after a week or two.

Now, if you feel like you can't make it a week or two, that's understandable.

That's okay.

But in that case, what will often do is clinicians is will assess, can you simply decrease the dosage a little bit.

You want to do that under your clinicians supervision, or do you need to stop the medication and let it wash out for a little while?

How early are you in treatment if you're having side effects from medication the first week or two?

Yeah, we might have you try to fight through that and hang in there.

We might change the dosing from morning to evening.

In some cases we might have you take a with food as opposed to without food.

So there's little tricks we could do once in a while.

We don't like to do it, but we'll add another medication to the first medication as a means of offsetting the side effects.

There's a lot of little tricks we can do, but I think it all comes down to how bothered and how annoyed are you with the symptoms overall, and do you feel like you could hang in there day by day?

So generally, the rule of thumb is within a week or two, if you're having side effects, the side effects should start to mitigate and dampen down some.

Thanks for your call.

Let's go to the next caller.

Hello, Ted.

Welcome to Matters of the Mind.

Ted, you had mentioned that you recently came off of duloxetine that's also known as Cymbalta, and you've switched to fluoxetine, also known as Prozac, since you've been since that time.

Going from duloxetine to fluoxetine, you've been constantly tired.

Is that normal?

Yeah.

Duloxetine has two mechanisms of action.

Number one it's going to enhance serotonin.

And number two is going to increase norepinephrine.

And it's called an SNRI serotonin norepinephrine reuptake inhibitor.

And what that means is enhancing the transmission all over the brain of serotonin and norepinephrine.

Norepinephrine is more activating and energizing.

You can think of norepinephrine as kind of like being a chemical cousin to adrenaline.

So it gives you more energy, more get up and go.

And it can be helpful for being alert if you change from duloxetine over to fluoxetine.

Fluoxetine exclusively primarily just does one thing.

It increases serotonin has some minor secondary effects, but it's mainly increasing serotonin transmission.

Serotonin has a very calming effect.

Now fluoxetine or Prozac does have some secondary effects that can allow it to be somewhat energizing in its effects on a particular serotonin receptor called serotonin receptor two C, and sometimes people will notice they get a little bit more energy, a little bit more get up and go from that.

So for some people that's adequate.

But for other people, they notice that change from duloxetine to phlox teen can cause them feel a little bit more tired.

And that's probably from your lacking the norepinephrine effect from the duloxetine itself.

So that can happen.

So I imagine there was a reason why you're a change from duloxetine over to fluoxetine.

Duloxetine, yeah.

It works in a different way than fluoxetine.

But primarily duloxetine will be more useful for a lot of people with pain, energy, concentration.

Fluoxetine, on the other hand, is often better for binge eating.

It's often better for a lot of people, and it does last a long time.

The drawback of duloxetine is if you miss a dosage or two, you can feel like you're having a stroke.

I mean, you can feel you can have a tingling in your hands and feet.

You can have a dizzy feeling.

Some people don't like that effect.

Fluoxetine, you're typically not going to have that effect because fluoxetine stays in your body for days, and it's not going to get out of your system quite so quickly.

So there's a reason why clinicians might prescribe one versus another.

Thanks for your call.

Let's go to our next text.

Hello, Joe from Hicksville.

You had asked, how do I know when it's time to retire?

Financially, I'm in good shape.

I am worried about how things are going to go socially for me.

Joe, you're on the right path there because okay, financially you're in good shape.

You've lived your life.

You've worked your entire life for retirement to be able to acquire the finances.

Here's what often hear about from people.

Joe, after they've retired, they'll say the first 2 or 3 weeks are fantastic.

They might sleep in a little bit every day.

They stay up late at night, they watch the ball games, they watch movies in the evenings, and it's wonderful.

And then after 2 or 3 weeks, they kind of feel like their sails just went flat, and they just feel like they feel more discouraged.

And what's happening in those cases, Joe, will be that they don't have anything to do.

When you have a work life activity, you have a schedule.

You got to get up a certain time.

You have expectations during the day.

You have things to do.

You have purposeful, meaningful activity, which is what people with any with a chronic mental illness also need as well.

But when you retire, you need purposeful, meaningful activity on a day to day basis.

Work gives you that.

So when you retire, think of it as a new chapter in your life where you need a schedule.

You need to have things to do every day.

Now, it does not have to be as intense as when you were employed, but you need to have a reason to get up every morning.

And very, very, very importantly, you need to be around people.

The worst thing you can do in retirement is to isolate.

Now, some people, inadvertently and unfortunately will isolate because of their medical condition.

But even in a medical condition, try to figure out ways to socialize somehow, someway, because social isolation is a big predictor, number one for depression after you retire.

And actually social isolation and depression will predict a greater likelihood of dementia.

So in retirement, what I'd suggest is stay socially active, number one.

Number two, keep a schedule.

Number three, this would be a good time to do things you might not have done before, but start getting yourself in physical in physical shape.

Now, what that means is what a lot of people don't like to hear.

But doing strength training, resistance training, doing weight work.

And now many people haven't done weight work since they were in high school.

But you know, get a coach, get a trainer and start doing weight work because as we get older, weight work activity resistance training is a huge predictor for maintaining your physical health, maintaining your mental health, and decreasing likelihood of dementia.

A lot of studies or study out of Harvard just showed that more recently, showing that resistance training specifically, especially when it was combined, a little bit of aerobic activity when you increase your heart rate.

But that was a big, big predictor in decrease in the likelihood of dementia.

So socializing, keeping a calendar, keeping a schedule on a regular basis, resistance training and doing some physical activity.

Those are the biggest recommendations I could give anybody as they go into retirement.

But congratulations, you've achieved that level in your life where you financially are able to retire.

Okay now you're able to to do the things that you might have wanted to do before that you didn't have time.

But it's important not to sit back and and kind of be inert.

Keep yourself busy.

Thanks for your text.

Let's go to our next text.

Hello, Pat from Fort Wayne.

You had asked, is there a better medication than divalproex sodium?

I've tried Oxcarbazepine and Zoloft.

Don't like the 14 pages with the divalproex sodium to even start taking.

It sounds dangerous and can cause anxiety to go up.

Yeah, divalproex sodium is Depakote.

Been around since the 1960s, I believe around for a long time, and it's a very effective medication based on its mechanism of action, but it does have a lot of toxicity associated with it.

That's why we have to check blood levels with it.

And you have to check liver tests and CBCs.

So it does have some toxicity.

It works, but got some drawbacks.

Carbamazepine is also known as Trileptal.

It has drug interactions where it can decrease the effectiveness of other medications because it enhances or stimulates the metabolism of many other medications that go through various pathways.

So that's the biggest drawback of that.

So what will often use alternative for anxiety in the same class?

Staying in the anti-epileptic class which is often used for anxiety.

You've got divalproex Depakote.

You've got oxcarbazepine and carbazepine, chemical cousins.

They will both help with anxiety to different degrees.

We also have lamotrigine or Lamictal, which works on blocking excessive glutamate, which goes up when people get under stress.

Lamotrigine or Lamictal can sometimes be used in that class.

We have a topamax, which a lot of people don't care to take because it makes them kind of mentally dull.

I don't care for topamax for a lot of people, but it does dull dull the appetite in a good way.

Sometimes we prefer gabapentin, which I mentioned earlier.

That's also known as Neurontin, and its chemical cousin, pregabalin, known as Lyrica, can also be used for anxiety.

But it all comes down to what kind of symptoms are you treating.

It sounds like you're treating anxiety symptoms, and in those cases, you know a different type of antiepileptic could be beneficial for you.

I'd certainly advise those over the so-called benzodiazepines like Xanax, Ativan, Klonopin, Valium.

They can kind of make you feel mentally dull and affect your memory in some cases.

Thanks for your email us a lot of time for this evening.

If you have any questions that I can answer on the air, you can write me a via the internet at MattersoftheMind - all one word - @wfwa.org That's MattersoftheMind@wfwa.org.

God willing and PBS winning.

I'll be back again next week.

Thanks for watching.

Good night.