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

Welcome to Matters of the Mind now entering its 25th year, Matters of the Mind is a live call 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 (969) 27 two zero or if you're calling coast to coast you may dial toll free at 866- (969) 27 two 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 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 a via the Internet at matters of the mind all one word Atwar dot org that's matters of the mind at WFA Oregon.

I did receive some email questions this past week.

>> The first one reads Dear Dr. Fauver, what is the difference between bravado and a compounding pharmacy ketamine nasal spray bravado is the left sided piece of ketamine.

>> Ketamine is an anesthetic that was approved by the Food and Drug Administration for anesthesia back in 1970.

So it's been around for over 50 years and ketamine is thought to be a very safe I.V.

anesthetic.

>> It's used in different formulations nowadays but it's not used orally because it doesn't get absorbed very well.

>> So ketamine can be used as an anesthetic in various ways.

>> Well, it's ketamine.

It's bravado is ketamine is the left sided piece of ketamine and if you think about a lot of molecules they have a left sidepiece and a right sidepiece the left sided piece with with ketamine is acetaminophen is four times more potent than the right sided piece in terms of blocking this particular receptor called an NMDA receptor if you block it NMDA receptor bottom line is you can get anesthesia and number two you can get a relief of depression and it's something has been studied IV with ketamine for about the past ten or fifteen years who are patients who just didn't do very well with the traditional oral antidepressant medications that primarily affect norepinephrine serotonin and dopamine.

>> They got ketamine IVI two or three times a week in some cases and they got some very rapid relief.

So for that reason it's ketamine being more potent compound than the right sided piece of ketamine as ketamine was developed as a nasal spray and it was found that it could be used as a nasal spray twice a week for the first month once a week, the second month and then every week or every other week thereafter over the course of time as some people spread out their visits even to every three weeks, every four weeks and even less frequently as time goes on as ketamine ers bravado has been studied over the course of four years or so we have a very good idea about safety issues with it.

>> We do know that with ketamine people are carefully monitored.

It's been approved by the Food and Drug Administration and for that reason it's going to be covered by insurances and malpractise covers of carriers are going to be more prone to be approving of your using as ketamine or also known as bravado versus ketamine IV if you're a clinician who's using those kind of kind of medications.

>> So we're going to be more prone to wanting to use bravado or as ketamine compared to a compounded nasal formulative ketamine because ketamine in the nasal spray just hasn't been studied that much and has not been approved by the Food and Drug Administration.

Yeah, it can be relatively inexpensive to use.

I wouldn't recommend it because we just don't know about the absorption of ketamine as a nasal spray.

We don't have the predictability that we have with ketamine or bravado.

So we've been using bravado now since March of 2009 teen for depression.

>> So we have over a three year track record with it in the general clinical practice.

>> But the research studies go on over four years now so we're going to be more prone to using less bravado or less ketamine as a nasal spray compared to having a pharmacy compound ketamine itself.

So what do we know about bravado?

We know that about one out of six people can get a pretty pretty profound effect after just one treatment.

These are people who hadn't responded very well with various antidepressant medications over the over quite some time and we also know that it's pretty good chance of the course of four or five weeks they can get a a nice response where they feel better such that they're willing and able to stay on this bravado over the course of three months, four months, five months and the longer they stay on it the less likely they're going to have a relapse into depression itself.

Most of the side effects from bravado or ketamine nasal spray will occur the first two hours of treatment where that's during the time they'll have kind of this out of body experience in some cases they'll have a numbness in their hands or feet.

They can sometimes have some nausea but they don't have any vomiting unless they eat or drink something shortly before the treatments themselves.

We do have them continue on their antidepressant medication so they stay on their oral antidepressant medication that are working best for them.

But we use the ketamine's bravado as a means of just kind of adding on to the effect of the oral antidepressant.

Now how does blocking it in the NMDA receptor help you with depression?

Basically when you block NMDA receptors you're affecting this chemical that's not serotonin dorper dopamine and norepinephrine were affecting a chemical called glutamate and whereas norepinephrine dopamine or serotonin they might require four to five to six weeks to give you the full effects if you use those medications that affect those particular chemicals with glutamate.

On the other hand, it's not a matter of weeks.

It's a matter of just seconds for it to get give its effect on the brain and it's thought that if you affect glutamate you're actually making the brain more fluffy.

It's thought that when people get depression the front part of the brain especially kind of shrinks down a little bit.

It's not as fluffy people have trouble with motivation, enjoying things, enjoyment on a day to day basis.

They have trouble with thinking and concentrate.

They have trouble with initiative and just getting things done and that's because the front part of the brain physically shrinking down a little bit when they get depressed and it's thought that if you stimulate glutamate in various ways this case in which I'm speaking using bravado you can actually enhance the growth of the front part of the brain and thereby bring somebody out of depression.

What we've liked about bravado is it does work fairly quickly and it brings people out of depression quite nicely.

>> Other alternatives can be electroconvulsive therapy.

>> Treatment also works quickly but the issue with ECT is while you're getting ECT treatments often you'll have some memory disturbances during the treatments themselves and for several days after and you often cannot go back to work during those days with bravado or ask edamame you can't drive a day of treatment but many times people go back to work as long as they're not tired and they're not operating machinery bravado does not seem to cause difficulty with concentration, focus and memory at least a couple hours after you've had the treatment themselves with bravado we want to make sure somebody doesn't have high blood pressure prior to treatments because during the treatments they not unlike people who exercise they can have an increase in blood pressure about 40 minutes after the treatment itself that often comes back down at about a one hour mark.

So the main side effects from bravado can be that dissociation where they have that out of body experience.

They can have a little bit of tiredness, sometimes some nausea but not uncommonly they'll have that blood pressure spike at about forty minutes but that comes back down by that by an hour and at the two hour mark when they're ready to leave and and either go back to work or go back home while somebody else is driving them, they'll often have the blood pressure coming back down and they might have a little bit of tiredness the first two or three treatments.

But after that time they tend to have less fatigue overall people often ask me is there an oral version of bravado or are ketamine IV that we can use for depression that might be coming on down the line?

>> There is a combination treatment of bupropion and dextromethorphan.

Bupropion came out as an antidepressant way back in nineteen eighty nine and it increases dopamine and norepinephrine will be and will increase the blood levels of dextromethorphan.

>> Dextromethorphan is a cough medicine.

It's an Robitussin D.M.

for instance the D.M.

means dextromethorphan and you'll hear about dextromethorphan formulations as cough suppressants and as a cough suppressant.

Dextromethorphan does block Inamed NMDA receptors not unlike ketamine or ketamine.

>> So the question is what to be a rising over this next year or two ?

>> How will this combination of appropriate and dextromethorphan upon it being utilized extensively?

How will that combination orally which is twice a day dosing how will that compare to somebody who's using bravado as a nasal spray?

So we're excited to see what's going to happen there.

What's nice is oh since nineteen eighty seven or so we've had about sixteen different oral and depressant medications become available so we've had all these different antidepressants become available and many people have benefited from them but there are some people who just don't get well using the traditional newer and a presence that increased serotonin dopamine and norepinephrine bravado whereas ketamine is an is an enhancing and selectively targeting the direction of glutamate.

>> So we're hoping that that's that direction might help some people who previously didn't get adequate benefits.

>> Thanks for your email question.

Let's go to our next question.

Our next question reads Dear Dr. Fauver, I'm forty seven years old, love reading and I have struggled with depression for twenty five years.

>> Why has depression changed my personality from being a bibliophile to someone who lacks reading interest?

>> Should I force myself to read or donate all my books?

>> This is a fairly common phenomenon.

You're 47 years of age.

You've always enjoyed reading and when people get depressed part of the vicious cycle will be depression will cause you to start to start to give up pleasurable activities.

>> And it's it's a question we often ask people who are depressed are you no longer participating or engaging in previously enjoyed activities?

So if you give up pleasurable activities, things that used to be fun for you, you get more depressed as you get more depressed you give up pleasurable activity so it becomes a vicious, vicious cycle.

>> So we're always trying to get people to get engaged in things they liked to do previously.

>> So we asked people what did you previously enjoy to do we doing try to gradually get back involved with those.

>> So even though you might not like to read at this point, even though it might not be as interesting for you to try to gradually get back into it if you've previously gave you joy and pleasure.

For some people it's quilting.

For some people it's playing the piano for some people it's socializing.

>> But those are the last things people want to do when they get more and more depressed and as you can imagine, if you're giving up things that used to be fun to do that makes you more depressed and it's a cascade that we often see with depression.

>> So I would suggest you not sell your books.

You keep them on hand but try to gradually get back into reading and as you gradually get back into the reading in the routine, hopefully and find some of that joy again and that can then get the snowball rolling down the hill where you want to read more and more and more.

>> But the last thing you want to do is avoid activities that used to be pleasurable for you because you don't want to do them.

We hear about the same thing with exercise.

Many people were really admit that exercising twenty or thirty minutes at a time makes them feel better but they don't have the motivation to do it and it's a matter of getting out there and doing it.

>> And we often hear with runners for instance that first mile is always the toughest because not only are they warming up but they just don't have the motivation to get out there.

But once they get running a little bit then they feel great and then after two or three miles they feel especially good.

The same thing can happen with exercising.

Once you start exercising for ten, fifteen, twenty minutes you feel pretty good and then after the workout as long you didn't overdo it and you didn't go beyond your abilities yeah you can feel a lot better so we're always trying to get people to exercise but we're always trying to get people to do pleasurable activities things that used to be enjoyable for them because that can help with your mood helping and motivation and help with your overall enjoyment life .

>> Thanks for your email.

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

Our next e-mail question reads Dear Dr. Farber, when faced with difficult situations I feel extremely guilty whenever I try to escape for a little bit like watching a movie.

Is this guilt rational?

Why does this extreme guilt make me feel so immoral or sociopathic?

>> I wouldn't go that far.

What you're saying is that when you're faced with difficult situations sometimes you want to withdraw a bit and sometimes that's OK.

It's all right to withdrawal an arrest with you feel overwhelmed and overwrought with your current situations to kind of step back and rethink what your plan and strategy might be to address it so when you're faced with difficult situations by all means try to address it the best you can try to get wise counsel from friends, from friends, family and coworkers, try to get some ideas from other people, try to address it and tackle it the best you can based on your past knowledge and awareness of how to deal with that particular situation.

>> But when you're just feeling wiped out and you're kind of stuck by all means rest watch a movie, do something entirely unrelated we often tell this to people who are involved I.T.

information technology whether doing software programing sometimes you just have to step back and do something totally different than what you would usually do.

>> There was a reason God instructed us to have a day of rest each week because we need that day of rest where we do something entirely differently than what we usually do.

So a day of rest or a time of rest for you could be stepping back, watching a movie, doing something that you ordinarily wouldn't do and it's totally unrelated to your stressful situation or your dilemma and then get back to it later on.

Now what you don't want to do is avoid the dilemma.

>> You want to avoid the problem.

We don't want to avoid your work environment and just not show up because then you're obviously not addressing it so you want to get back and address it but it's OK to step back and rest and take a breather from your situation and sometimes for some people that could be as simple as watching sitcoms or doing something that doesn't require a lot of brain activity and watching somebody else's dramatic writing or their comedic writing for that matter and do something that is just an entirely unrelated to the problem at hand and that's where recreational activity will come in.

Recreational activity is for the purpose of just sitting back and finding amusement, amusement basically means you're not thinking a means not in use means thinking so amusement means you're just not thinking and you're just giving your brain a little bit of a rest and that's OK. >> If you try to overthink a situation often you'll get stuck and then you become anxious and the next you know you can't sleep because you actually take it to bed with you and you're still thinking about it and you're stuck and that's why some people will say after they have a decent night's rest all of a sudden they have all these ideas for how to solve it, how to solve their problems.

>> So it's because your brain got refreshed when you sleep at night the thinking part of your brain which is the left front part of the brain, the thinking part of the brain is allowed to recharge.

It goes into rest.

That's why you have dreams the left front part of your brain is decreasing in its activity and when you're dreaming your brain is resting.

You're not dreaming about rational type of things.

That's why dreams don't make a lot of sense to people and allowing your brain to recharge and you need all these phases of sleep to be able to recharge.

You need the dream sleep.

You need the deep sleep to be able to recharge the rest of your body.

You need to go through all these phases of sleep to be able to be able to recharge for the next day and sometimes that's why resting is probably the best thing you can do to be able to think through different dilemmas.

>> So I wouldn't think necessarily unless you're totally withdrawing the problem to the point where you're avoiding it, I wouldn't think you're having any sociopathic tendencies or moral dilemmas for that matter.

>> You just need to get away every now and then but you get to get back at it and try to figure out other ways to address it.

As I mentioned though before, feel free as your addressing a difficult situation to rely on.

Other people were naturally sociable creatures we need to talk to other people.

We need to interact and get other people's ideas on how we can address different situations.

Social media can be a marvelous tool in helping that social media can be disastrous for some individuals because with social media they might be comparing themselves inappropriately to others and they can be the subject of bullying with social media.

So social media has some downsides but it has some tremendous abilities to be able to connect with other people.

But going one step further, connecting face to face seems to have that extra bit of benefit for a lot of people.

>> We saw this with the covid restrictions with Akufo-Addo restrictions where people couldn't interact with one another, where they had to wear masks.

It was very difficult for some people to maintain that social connectivity with others it wasn't the same when they saw people on video and we're just now finding that out after two and a half years and we're seeing some people in our practice as a psychiatrist, we're seeing some people in psychiatric practice who are having a lot of anxieties getting back out and they're having difficulties they didn't have prior to the COLA restrictions.

We didn't see it so much the first six months and in fact people asked me the first six months of the code restrictions are you hearing about any problems from a psychological standpoint?

I wasn't I wasn't hearing about any increase in suicide the first six months covid restrictions.

I wasn't hearing about people having more anxiety.

It was after about a year, year and a half and especially now two years after all the restrictions we're hearing about all the people who were having such tremendous difficulty with depression, anxiety, many people are self medicating with narcotics and alcohol as a means of overcoming that so we're just now seeing a lot of the after effects of the code restrictions we just didn't see a year and a half or so ago .

So it's important we try to maintain that social networking with people the face to face contact is great.

Yeah, there are some hazards out there with some people still being contagious with the newer variants of the covid virus.

But at the same time it's important we try to get our allies back, we interact with each other and we do the things that used to we used to find pleasurable and get around people once again.

>> But going back to your original question about engaging in a problem at stake and taking a step back from a feeling guilty when you step back from a it's important to get back involved with it and sometimes doing so means getting some other ideas and doing some social networking to get some other perspectives on things because chances are other people have dealt with the same kind of problems that you've encountered and as we all find out, we're not the first ones in history to have to deal with some of the problems that we've had to encounter so other people can often be a blessing to us all.

>> Thanks for your email.

Let's go to next e-mail question.

Our next e-mail question reads during a favor How can I tell what kind of things trigger my anxiety sometimes at the end of the day I feel like I can't face another day.

>> Do people keep journals?

Is it helpful to know exactly what triggers anxiety?

Answer one of your questions there.

Yeah, journals are very, very important because you'll notice that if you journal you'll be able to look back on your journal entries three months later, six months later, a year later and you'll find out that the things that were bothering you today.

>> Yeah.

You figured out how to deal with them.

They kind of resolved themselves and are no longer that big of an issue for you.

So journaling can be remarkable for people who struggle with mood and anxiety disturbances and I strongly recommend it for a lot of people.

There's actually some three and five year journals out there where you can actually journal based on the dates year by year and you can actually look at what you were doing a year ago two years ago three years ago and kind of compare notes on where you were at that time because what seems to be overwhelming force today chances are another few months you'll look on down the line and you realize you know, I was able to overcome that that kind of took care of itself.

I resolve that and different things happen and I especially recommend journaling for people who tend to have a hopeless negative Ristic pessimistic type of attitude where they always expect the worst to happen.

They don't expect much positivity in their future.

I encourage them to journal because it will give them encouragement that as they look back on their journaling they'll realize things worked out OK.

So journaling is something that I recommend to people of all ages.

It's interesting as you journal as an adolescent for instance, keep those journals over the course of your young adult years and later as an adult and you can actually show your child for instance or even grandchildren what you were thinking when you were their age.

>> And that's pretty enlightening because it allows them to have some comfort in realizing that, you know, is that front part of your brain is developing until you're twenty four years of age you start to be able to have a degree of wisdom as you get older.

The front part of your brain is your reasoning.

Part of your brain is the part of the brain that makes you think before you do things to think before you say things and you can look at different life circumstances with people and different type of activities when you're an adolescent and just feel overwhelmed and think that you can never overcome them was because the front part of your brain is not fully developed as your front part of your brain fully develops and it grows and grows and grows.

>> You're able to think through a lot of those those what were thought to be overwhelming type of circumstances.

>> So the social pressure, the expectations, what am I going to do with my life ?

All those kind of questions come to mind when you're going through those very vulnerable adolescent years and you'll find that well as your brain grows many times with experience and with the brain development, you can kind of figure out all of those different things.

>> So with that being said, let's go to our next caller.

>> Hello Fondo.

Welcome to Matters of the Mind.

Do you wanna know about my opinion on Haldol or Haloperidol?

>> Haloperidol came out in the nineteen fifties.

I think it's an antipsychotic medication that strongly blocks a chemical by the name of dopamine and by blocking dopamine it can have life changing improvement and hallucinations and delusions fixed false beliefs, agitation.

>> It works very fast.

It's not highly sedating and it doesn't decrease the blood pressure like some other medications do you typically will not hear about Haldol or Haloperidol being used long term nowadays because we have about twenty newer antipsychotic medications that appear to give you less side effects, less side effects such as tightening Haldol or how Parador can cause people to get very tight.

>> It's called dystonia and they can get an arching other back that's really tight.

It's called up the Tonys don't get to see that very often but is a tightening of the back that makes them arched her back.

They can get a tremulousness.

There can be possibly a higher risk for tardive dyskinesia if they have these different side effects tardive dyskinesia which will be where they have long term neurological disturbances such as hard blinking and mouth movements and tongue movements.

>> So we don't use Haloperidol that much on an ongoing basis nowadays it can be used for instance in the hospital setting where it can be used as an intramuscular agent just to calm somebody down very, very quickly and when somebody's suffering from psychosis, they're highly agitated.

They're not thinking properly.

They're having difficulty with being able to maintain good judgment.

>> They're impulsive, they can be aggressive, they can do things and say things they ordinarily just wouldn't do and say it's so Haloperidol can settle them down very, very quickly.

Why was it used so much historically?

It was used because it didn't cause as much sedation.

It didn't make people overly sleepy to the degree that Thorazine did you know Thorazine was used Corporal Klau Barazan it was used for years and years as a knockout medication to make people very, very sleepy.

>> So it was Haloperidol or Haldol was used as a alternative to Thorazine for that reason Thorazine also caused people to have a lowering of their blood pressure and they'd have a hard time standing up.

So it was very sedating but they had trouble standing up.

>> So that's why Thorazine didn't get used so much.

Haldol or Haloperidol became an alternative.

Thank you for your call.

Unfortunate I'm at a time for this evening if you have any questions concerning mental health issues that I can answer on the air you may write me that matters the mind all one word at a dot org that's on the Internet.

>> Unfortunately I'm out of time for this evening.

I'm psychiatrist favorite.

You've been watching Matters of the mind on PBS Fort Wayne God willing on PBS willing.

>> I'll be back again next week.

Thanks for watching.

Good night Telos October .