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>> Good evening.

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

Welcome to Matters of the Mind now in its 26th year matters the mind is a live call in program where you have the chance to choose a topic for discussion.

So if you have any questions about mental health issues, give me a call in the here in the Fort Wayne area by dialing (969) 27 two zero or if you're calling any place around the country coast to coast you may dial 866- (969) 27 to zero now on a fairly regular basis we are broadcasting live every Monday night from our spectacular 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 via the Internet at matters of the mind all one word WFYI Egg Thoughts Matters of the Mind at WFA Egg Roll starts tonight's program with an email I received this week.

It reads during a favor I'm 70 years old.

I have been taking medication for depression, anxiety and ADHD for the past 15 years.

Could there be side effects from taking would Avenal also known as Provigil Bupropion also known as Wellbutrin Savani which is the trade name for Llamosa Gene Vele acetone which is the chemical name for hybrid elemental folate and gabapentin that could mimic symptoms of Parkinson's disease.

Interestingly enough, when you put that combination of medications together, I'm not seeing anything there that would mimic the symptoms of Parkinson's disease.

>> There's a slight chance vol acetone which is known as Vibert possibly could because if you increase serotonin excessively, sometimes indirectly you could dampen down the dopamine transmission Parkinson's symptoms are symptoms such as a tremor, a shuffling gait no swing to your arms.

You're walking difficulty with facial expressions.

Sometimes people get a runny nose with Parkinson's disease and it's a condition that's a neurological condition where you're basically not getting enough dopamine outflow from this middle part of your brain called the substantia Negroes right here in the middle part of the brain and nigra striatum is another term for the but the striatum is a part of the brain that shrinks down to and maybe 30 or 40 percent of its usual size when somebody has Parkinson's disease and you're not getting enough dopamine adequate amounts of dopamine in the motor cortex where you move is necessary to be able to have these these smooth movements.

So if you increase serotonin excessively sometimes you can get and offsetting where you decrease dopamine.

However, you mentioned you're on BiPAP RIM a good medication for ADHD and depression.

It's increasing dopamine.

>> You're also on modafinil.

Modafinil is an interesting medication known as Provigil .

>> It's been around for a long time and it's a medication that increases histamine in the front part of the brain and that's what keeps you awake.

So you might have heard of antihistamines blocking histamine making you sleepy and tired.

>> Well, Provigil or Modafinil increases histamine and keeps you awake.

It also will slightly increase dopamine as well.

So you have a couple of medications there primarily be appropriate and secondarily Modafinil that can actually increase dopamine and offset any side effects that you could get from Vlas AdOne in terms of causing any Parkinson's symptoms.

Elmdale folate is a nice medication because it will offset any bit inhibition of the suburbanite causing a dampening down of the enzyme methylene tetra hydrophilic reduc tace F.R.

Lamotrigine or 078 will make that particular enzyme not work so well and in doing so can kind of stall the conversion of folic acid to methyl folate.

Methyl folate is the active byproduct of folic acid.

That's the byproduct that you need to be able to manufacture serotonin and norepinephrine and dopamine.

So elmsford for folate is kind of like jumping the turnstile at a football stadium where the turnstile itself is F.R.

the enzyme that helps break it down and Llamosa Gene or I'm sorry folic acid is on the outside trying to get in Lamotrigine and will basically make that turnstile not work so well so that's why it's helpful to have Elmsford folate as a vitamin supplement overall gabapentin had mentioned that that's often used for anxiety and difficulty with sleep.

Really nice medication for sleep especially as we all get older because as we get older Gabapentin is a medication that will deepen sleep, give you a more efficient sleep, it'll give you a lengthening of your dreams and it will also give you a deeper so-called slow wave sleep that recharges the body.

>> So by improving dream sleep, by giving you more of a recharging sleep for your body that actually can help with longevity and decrease the likelihood of getting dementia.

A lot of dementia researchers right now actually recommend in gabapentin for people for sleep because it tends to normalize the sleep architecture and doing so can actually give you an improved sleep overall.

>> So with that combination I wouldn't think that would elicit Parkinson's like symptoms unless you're having a bit of a tremor that's only Parkinson's like symptom I could imagine with all those medications between bupropion and sometimes Valassis donor Vibert you can sometimes get a little tremor from those but Parkinson's symptoms overall is where you have a shuffling gait very little arm movement of masked faces which is where you don't have much facial expression.

It's a whole different phenomenon.

So talk it over with your clinicia and see what kind of options might be available for you overall it looks like you're on a really nice combination of medication that will do a lot of different things we never like to see overlaps of mechanisms of action with medication but what you described is a really nice combination medication where they're all doing different things.

>> Thanks for your email.

Let's go to our first caller.

>> Hello Carlos.

Welcome to Matters of Mind.

Carlos, you have a very important question.

You want to know how to tell the difference between a heart attack and a panic attack?

Well, No one a panic attack can give you a racing heartbeat sweatiness, chest pain, tightness.

But you want to make sure you're not having a heart attack.

So the first thing you want to determine, Carlos, is that you're not having a heart attack.

A heart attack can be diagnosed primarily by cardiac enzymes which get in the bloodstream and electrocardiogram itself.

But they use cardiac enzymes and electrocardiogram as a means of diagnosing a heart attack.

A heart attack is basically where some of the heart is not getting adequate blood flow that will give you chest pain for some women it comes across just as nausea occasionally or achiness sometimes will give achiness up the jaw down the arm.

>> But people can have sweatiness with both heart attack and a panic attack.

>> But a panic attack is basicaly a condition where you've excluded other conditions like a cardiac condition if you're having difficulty with a panic attack such as the sweatiness, the dizziness, the lightheadedness, feeling like you're going to die nausea, diarrhea, abdominal aches and pains, sweatiness, chills or hot flashes either one can come across tremor is a common symptom of a panic attack as well as chest pain and fast heartbeat.

Those are all symptoms of panic attack.

>> You want to make sure you're not having a cardiac issue but you also want to make sure you're not having a thyroid issue, a glucoses you we want to make sure you don't have a condition especially if you're female although you're not Carlos.

>> But if you're female you can have a condition called postural orthostatic tachycardia syndrome known as Potts and young women especially in their 20s sometimes are adolescent years but also in their 20s can have the symptoms and that's where your heart just starts racing really fast.

>> You get lightheaded and you get very weak and with posses something that will often come across as what appears to be a panic attack.

But it's Pott's which is typically thought to be an autoimmune condition and it's treated very specifically with high salt diet and various medications to to alleviate that much more common with women.

But it's something that's very important for us to identify.

So with any kind of panic attacks, Carlos, the first thing we want to identify is OK, what other medical conditions might be bringing this on and then if it is a panic attack, we want to see what might have precipitated the panic attack because many people will have their firstppal like they're backed up in the corner and life circumstances there's no way out.

They are in a situation where they're just stuck and they'll have a panic attack as a means of a of an adrenaline surge and that will give them a lot of those symptoms.

>> Carlos, thanks for your call us to our next caller.

Hello, Patrick.

Welcome to Mars.

The mind.

>> Well, Patrick, you want to know about the difference between obsessive compulsive disorder and just being used to a rigorous routine if you're used to a rigorous routine, let's take it one step further here, Patrick, and say oh, let's say you're kind of a perfectionist.

>> That's really OK.

They used to call him type A personalities but people who are perfectionists just like to in a certain routine.

>> Other people might notice it but overall it's not functionally functionally impairing.

If you're a perfectionist, what do I mean by that means that you're still able to get stuff done, you're getting work done and you're not too much of an annoyance to the people around you.

OCD, obsessive compulsive disorder entirely different phenomenon.

>> OCD is where the front part of the brain gets kind of stuck and it's kind of like the old record players that had the needles on them.

>> It's like the needle getting stuck and you have a thought that comes your mind over and over again and you can't get it off your mind and you know the thought doesn't make any sense and I thought might involve contamination or an immoral type of thought where he just gets stuck.

He can't get it off your mind and sometimes you'll do things as a means of trying to get that thought off your mind by excessive checking of things, repeating things over and over again you might count over and over again you're trying to distract yourself from that particuar thought and what happens that thought goes through a loop right up here in the front part of the brain and you have our time getting off your mind.

It's an obsession.

The thought is the obsession or a compulsion is the behavior.

So an obsession is where you're thinking about something over and over and over again.

You can't get it off your mind and then the compulsion is where you're doing things as a means of trying to address you as some relief from that obsession.

>> Now a lot of people have what's called obsessive compulsive personality disorder OCD, obsessive compulsive personality disorder.

It sounds like OCD but it's quite different OCD will be where somebody is a perfectionist and so rigid to a degree that they get on other people's nerves and they have a hard time with their marriages, with social interactions with OCD.

They've got to have things so perfect that they get extremely anxious, irritated and annoyed if anybody kind of gets in their space.

>> Oh, that becomes a psychiatric problem for some people where we have to kind of address that.

But obsessive compulsive thought as somewhat of an anxiety disorder.

Now we look at it as more of a brain networking problem.

Obsessive compulsive personality disorder is what is something where it's actually functionally impairing and causing you to have a difficult time with interpersonal relationships and actually getting things done and then you've got perfectionism where as you had mentioned, you just like things done in a particularly routine way that's not considered to be pathological.

As matter of fact, perfectionism can be somewhat adaptive in a lot of ways.

>> When I was a pharmacist we were always instructed to count the medications and then check the prescription three times before it left the pharmacy.

Well, in a way they were just giving us that routine where you checked the prescription before it left the pharmacy three times and it gave you that methodical recheck, recheck, recheck type of pattern and that's really OK to have that.

>> Thanks for thanks for your call.

Let's go our next e-mail our next e-mail reads Dear Dad , if ever I've been taking medication for depression for about a year now and I feel it's not working anymore, I try to tell my doctor and he said my only option was therapy.

>> Is there a way to know that a prescription might not be the answer anymore?

>> I wouldn't give up on the medication for a lot of people depending on the severity of the depression overall any more than a cardiologist would give on giving me any medication for your heart if your heart wasn't working as well as it should be.

>> So what I often recommend to people is let's take a really good look at your past medications after and I emphasize after verifying the diagnosis maybe you don't have depression if you have major depression.

>> OK, we're going to treat that with certain medications for depression.

But if somebody has what looks like depression and it's more of a bipolar disorder where they have highs but you're only telling us about the lows, maybe you have thyroid or glucose disturbances as I mentioned before, maybe you have sleep apnea.

>> I've seen a lot of people over the course of my career who are tired.

>> They can't think they will just have difficulty with not having motivation and energy and lo and behold they have sleep apnea.

Sleep apnea is where you don't get enough air flow to the lungs at night because you're snoring or you're pausing your breathing and thereby you don't get enough oxygen to the brain.

So sleep apnea could be a factor.

>> So if somebody has depression that we consider to be treatment resistant from the traditional antidepressant medications, we have so many other options now there's been over 20 medications approved by the Food and Drug Administration in the past the past six decades that primarily increase norepinephrine serotonin and dopamine.

But just in the recent years, just in the past five years we've had other medications that will affect it will affect glutamate.

>> Now glutamate is the chemical that predominantly runs the outside part of the brain, the gray matter of the brain.

Eighty five percent of the transmision of the chemicals in the gray matter of the brain on the outside here is run by glutamate.

It's an excitatory neuro transmitter and got serotonin, norepinephrine and Obermaier that are originating down here in the brainstem and they basically are giving advice to how much glutamate should be produced up there.

>> So now we're getting to talk more about glutamate so we have ketamine has been used without FDA approval for the past 25 years.

You might have heard about that.

>> Ketamine is a nasal spray called bravado been around for five years now although it is an oral medication and it does affect glutamate that's been available for about a year and a half.

>> So we have these other medications coming out that can treat depression differently than the other medications did from the past.

>> So if somebody's not getting well from their depression I would want to make sure they're on the right medication if need be they need to be on a medication I want them on a medication is going to least work for them.

Therapy can be fine but therapy is something where it is necessary for your brain to work for the therapy to work.

And we found this way back in 1987 when Prozac came out Fluoxetine Prozac became available in nineteen eighty seven and for the first time people able and willing to take a medication for depression because the prior antidepressants before Prozac in nineteen eighty seven the prior antidepressants would cause dry mouth light headedness, weight gain, blurred vision.

>> People didn't want to take the older medications with Prozac at least it was tolerable.

But the only thing Prozac did was increase serotonin which helped you feel somewhat better.

>> But the fact of the matter was if the people felt better on Prozac and they felt a little bit less anxious and they weren't as likely to have crying episodes, they did better in therapy.

>> So whereas I was trained in the early 1980s to always, always, always do the therapy didn't work then you would go to use a medication.

Nowadays we want to optimize the medication treatment to make the brain functioning as well as possible to help with attention span concentration motivation, get the brain functioning as well as possible then go on and deal with the issues in therap that you might need to to deal with such as interpersonal relationships ,challenges you might have at the job and so forth.

>> So now we often will try to optimize the medication first and then go to therapy.

>> So I look for other options that might be available for but first and foremost always make sure that diagnosis is correct because if there's other medical conditions going on that will be a factor for treatment refractory depression.

Thanks for email.

Let's our next caller hello Bev.

>> Welcome to Mars the mind.

>> Bev, you had mentioned that you would wonder if you believe that your spouse was not taking his if you believe that your spouse is not taking the antipsychotics that are prescribed, are you able to put your spouse on a psychiatric hold in a facility?

>> A psychiatric hold is where somebody is admitted to a hospital involuntarily now that you have to have a reason for that, they have to be having some difficulty with being a danger to themselves, danger to somebody else or being gravely disabled and then you go to the spouse's treating clinician and through the treating clinician, the spouse spouse is treating clinician would then initiate that involuntary hold if those criteria were met now gravely disabled means that your spouse would be not eating not taking care of him or herself and basically not doing the kind of things that should be done on a day to day basis due to the mental illness itself.

Greatly gravely disabled is kind of a gray area but it often is used as a means as a rationale for hospitalizing somebody against their will if they're just not able to take care of themselves.

>> But more commonly people are on an involuntary hold if they're a danger to themselves or somebody else and that would be the usual criteria for getting somebody into a hospital against their will merely having non adherence to medication wouldn't be a reason to have somebody in the hospital against their will unless it's causing them significant difficulties with caring for themselves.

>> Beth, thanks for your call.

Let's go to next caller.

Hello Dustin.

Welcome to Mastermind Dustin.

>> You had mentioned that your adolescent is leaving for college this fall.

Any advice on how to find a new therapist or help with the transition in providers?

Doesn't I recommend that you have your adolescent look into some possibility for counseling and medication treatment right there on the college campus?

Many, many college campuses have their own psychiatrist or nurse practitioners, sometimes physicians assistants.

They have prescribed burns on campus and they frequently have therapists.

A lot of therapists will work on college campuses and nice thing about the prescribers and the therapists right there on the college campuses they are readily available to the adolescent and they are they have a lot of expertize in taking care of the issues that are so prevalent among that age group.

So it's nice to get them set up with somebody right there on campus and to have somebody locally where the college is located now we are doing a lot of video health nowadays so with video help I see for instance a lot of adolescents and young adults who are attending college I'll see them as a clinician by video health so that way we don't lose track of them.

Now with video health you can occasionally see somebody out of state if you don't have a state license in that particular state on an emergency basis.

But more often than not we need to have the person to be seen in the same state where we are licensed so the patient needs to be in the state where I have a license for instance.

So with video help that's sometimes an option to to maintain contact with the therapist or the prescriber if the therapist or prescriber has a license in the state where your adolescent is attending college doesn't.

Thanks for your call.

Let's go to our next email our next e-mail read your daughter Fauver.

Is it possible that depression can be caused by inflammation chicken or the egg?

There is inflammation causing depression is depression causing inflammation but there is a correlation there one way or another we've got these little cells in our brains called microglia and they're the white blood cells of the brain basically in essence they release all lot of these inflammatory proteins and when they release them in the brain they will fry these little helper cells around the neurons called glial cells also known as astrocytes.

>> So glial cells are a type um called astrocytes basically nourish each individual neuron .

You have about ten astrocytes around each individual neuron and these Astroglide astrocytes are like a pit crew with you look at a NASCAR race or an Indy 500 race, you'll see this pit crew around the car run the car when they come in for a pit stop.

>> I think there's are like six of them six pit crew members in this pit crew works in a very coordinated way and those change for tires and load up eighteen and a half gallons of gasoline within a matter of six or seven seconds very, very efficiently.

Well, that's what we have in our brains.

We have glial cells also known as astrocytes that are nourishing each individual neuron if you have inflammation, the inflammation being caused by the microglia, you can have sick astrocytes and any more you know, we're not talking about individual neurons dying.

We're talking about the glial cells around the neurons dying off and being very sick themselves.

>> So a lot of the new research in psychiatry has to do with how do we keep the astrocytes more healthy and how do we keep the pit crew around the neurons working more efficiently because that seems to be a factor in and seen a lot of these psychiatric disturbances.

around an automobile is not functioning very well.

You got tires that aren't getting changed and you get a bunch of gas.

It's getting a bunch of fuel that's getting spilled alongside the car if they're not working efficiently and you're not going to have a very good pit stop and that's what's happening in our brain with our neurons if those glial cells just aren't clicking on all cylinders and not they're not working efficiently, you're going to have trouble with neurological problems now each individual neuron has anywhere between ten thousand and fifty thousand connections to other neurons.

So as the neurons get sicker and they become inflamed, you get less branching on the individual neurons.

>> Now some areas of the brain like the hippocampus here, the memory center of the brain, the library center of the brain, that area the brain is always turning over and it has fifty thousand connections per neuron so it has all these different connections there and if it gets sick it shrivels up very quickly.

>> So that's why a lot of people when they get depressed and they get they have inflammatory effects overall they will have trouble their memory and concentration but the specific symptoms that you might have inflammation associated depression will not only be sadness but also difficulty enjoying things we call it anhedonia.

>> You feel really slowed down if you're really tired and many people will have a slow process sensing speed of their brain.

So it's like their brain has a slow Internet speed so those are symptoms that appear to be very characteristic of inflammation associated depression.

>> Now we're not yet giving people antiinflammatory medications for depression or prophylactically or as a means of trying to head off earlier.

>> But many of our medications indirectly will have antiinflammatory effects and we're finding that we're talking about circuitry disruptions, the brain that might be partially related in some cases to inflammation.

>> Thanks for your call.

Let's our next caller.

>> Hello, Brian.

Welcome to the mind.

Brian, you want to know if CalSTRS or psychiatrists are required to report stalking to the police if no physical harm has been done?

Brian, it's kind of a it's a case by case situation if a psychiatrist knows that their individual patient is threatening to harm somebody else if their individual patient has expressed to the clinician that they are going to be stalking somebody and threatening somebody in that case the psychiatrist based on this law called the Tarasov law, they are obligated to report that to law enforcement and ideally to the person who's the target.

But our main obligation is to report that to law enforcement if they hear about somebody else stalking what we might advise that particular patient to do is if they're being stalked that they should contact the law enforcement as a means of getting a restraining order or whatever it needs to be done.

>> Brian, thanks for your call.

Do we have another email?

I don't know if we have another email or not.

I don't think we do well with that in mind I'm saying there is another email.

>> Let's try to get this in about 30 seconds.

I just started working with my family doctor and she prescribed Wellbutrin.

What if I start feeling worse?

>> I'm not seeing a difference yet.

About one out of four people on Wellbutrin or bupropion can feel worse right up from three out of four people don't usually that's a dose relationship issue.

>> Usually it's a genetic issue.

Some people just aren't fit more Wellbutrin and sometimes you just not have they don't have the right diagnosis for Wellbutrin.

>> So if you do feel worse early on, make sure to talk to your clinician.

Thanks for your call.

Unfortunately I'm out of time for this evening.

I'm psychiatrist Jeff Alver and you've been watching matters of the Mind on PBS for way now available on YouTube God willing of PBS willing.

I'll be back again next week.

Thanks for watching.

Goodnight