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>> Good evening.

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

Welcome to Matters of the Mind.

Now as 20 60 year matters, 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 in the Fort Wayne area by dialing (969) 27 two zero or if you're calling coast to coast you may dial toll free at 866- (969) 27 to zero now in 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, you may write me a via the Internet at matters of the mind all one word at WFB Eigg that's matters of the mind of UFW Edgard I'll start tonight's program with an email I received just this past week.

It reads Durant Not offer is a that it is good for both our physical and mental health to carry a little bit of extra weight.

> I know a lot of people are is the deal.

I'm going to try to stay in my lane.

>> I'm a psychiatrist so I'm going to talk about particularly from a mental health perspective of extra fatty tissue.

>> OK, but first let me go outside my lane and talk about from an orthopedic standpint I've orthopedic surgeons say yeah, a little bit extra weight is OK if you fall if you have a little bit extra fat cushion.

>> But on the other hand, if you have extra weight from an orthopedic standpoint you carry more weight on the joints and for every extra pound of weight you have it's an extra six pounds of pressure on the joints themselves.

I've heard that stated over the course of time cardiologists I think would all say that having the extra weight was not probably good for your heart and from a psychiatric standpoint from a psychiatric standpoint, I can tell you that adipose fatty tissues will release inflammatory proteins.

>> Inflammatory proteins can go to the brain and make you feel sluggish, slow down your concentration or make you kind of move a little bit slower.

>> Excessive inflammatory proteins can make you more likely to not enjoy things we call that symptom and the symptom of anhedonia but inflammatory proteins will cause you to not have fun and take pleasure in different things.

>> So from a psychiatric standpoint, having extra fatty tissue is probably not a good idea.

>> Again, going outside of my lane in internal medicine Doctor who is treating you noticing that you might have some recurrent kind of infectious condition, a cardiac condition apartment, a condition where you're sick& for a couple of weeks on end?

Yeah, maybe having an extra five pounds would be OK because if you have recurrent medical conditions that episodically caused you to lose weight having a few extra pounds is OK. >> But again, going back from a psychiatry standpoint, extra adipose tissue can be pro inflammatory which means that it can give you bad effects on the brain overall.

Now what I certainly recommend for people as they get older is to do some weight training also known as resistance training.

ps as we get older because as you get older you tend to lose muscle mass and as you lose muscle mass you typically have less stability in terms of your ability to to maintain the stability of your frame so you have more falls you are able to walk as well.

You trip more easily.

So we need to maintain muscle mass from a mental health standpoint because I'm thinking if you fall you're likely to hit your head and if you break a hip or break a bone that's going to incapacitate you in some ways and that's not good for your mental health either.

>> So from a psychiatric standpoint I'm often recommending to people maintain your body weight as much as you can reasonably possible possibly but also try to increase your muscle mass because you tend to lose it as you get older.

Do some resistance training, do some weight training.

Aerobic exercise is still great but we really got to focus on the weight training to some degree as we get older.

>> Thanks for your email.

Let's go to our next e-mail.

Our next email reads Dear Dr. Fauver, can genetic testing predict what medications a person needs?

>> Genetic testing something that's been around for about 25 years now in psychiatry at least and we've used it over the course of time to help us understand three aspects of a person's well-being.

And number one, we try to understand what genetic testing if somebody adequately breaks down folic acid folic acid is known as vitamin B nine and vitamin B nine or folic acid needs to break down to its active biproduct for it to work.

Now this is kind of like going to this big football stadium we have down Indianapolis called Lucas Oil Lucas Oil Stadium to get in you have to go through a turnstile then once you get in you're able to watch the game.

Well, the turnstile is like this enzyme that's called far methylene tetrahedral redoes reduc tastes long word there but methylene tetra tetra hydro folate reduc taste that's an enzyme that breaks down folic acid to its byproduct called elemental folate.

So elmsford folate is what gets inside the stadium or gets inside your brain and actually goes to work.

>> So if you don't have a well functioning inside of farm you tend to not break down folic acid adequately and you don't make the type of chemicals you need such as serotonin, norepinephrine and dopamine.

So what do you do?

You have to replace the folic acid with a supplement of elemental folate 10 or 15 milligrams depending on what kind of genetic mutation you might might be experiencing.

>> So the first reason to do genetic testing I think is to determine if you have an alpha methyl folate deficiency based on this GFR mutation because that could not only give you difficulty with depression and difficulty concentration but it could also increase your likelihood of heart attack and stroke.

And if you're a pregnant mom and you got the baby in the, you're more likely to miscarry if you have an empty GFR mutation that's not being supplemented with methyl folate.

So that's the first reason we'll do genetic testing the second reason would be to determine how quickly your breakdown medications over 90 percent of all medications are broken down by certain liver enzymes.

We call them Cytochrome before these enzymes and these particular enzymes break down medications, some medications are broken down quickly by certain enzymes.

>> Other medications are broken down slowly by certain enzymes and you need to understand if you're prone to quickly break down a medication meaning that you need a higher dosage or if you're prone to more slowly break down certain medications meaning that you need a lower dosage.

>> So that's one reason we find genetic testing to be helpful.

But a third reason why we'll do genetic testing and this is often get misinterpreted is from a pharmacodynamic standpoint to determine if the medication is right for you from a mechanism of action standpoint.

>> In other words, is the medication going to work for you now we can determine if you need elements of folate.

>> We can determine what dosage you might need of the medication high or low.

But we also want to kind of know if it's going to work for you.

Now here's where it gets tricky gets tricky because these genes are wrapped up in these little histones and the histones.

>> I used to call them pigs in a blanket but you know, pigs in a blanket have that nice fluffy pastry on the outside the taste really good.

>> Then you got the hot dog on the inside.

I'd rather compare the genes to a candy bar wrapped in paper.

All right.

So you got a candy bar that's wrapped in paper on the outside of the package on a candy bar on the package it says the name of the candy and it says the ingredients but you don't taste and under and appreciate the attributes of the candy bar until you open up the wrapper and actually taste the candy bar.

>> That's the way our genes are.

>> Our genes are wrapped up in this lining and they don't express themselves unless you open that lining.

And again it's kind of like the wrapper on the jeans what opens up the wrapper on the jeans?

Well, it can be life stresses it can be things that happen to you in the past.

It can be you're exercising or not exercising can be smoking, it can be drinking alcohol.

>> All these different factors can open up the wrapper for genes that you have simmering there.

They're there but they might not be they might not be expressd unless you have stuff that happens in your life or stuff that you've done.

>> So that's why for instance, when we talk about medications that affect serotonin, right.

We've got these selective serotonin reuptake inhibitors and the SSRI or Prozac, Lexapro, Zoloft, Celexa, Paxil flu vaccine also known as Luvox.

>> These are the SSRI.

The SSRI don't help people with depression so much if you've had a lot of early childhood trauma.

>> So if you've had a lot of early childhood trauma you can unwrap the genes that are underlying the mechanism of action for serotonin.

If you've had a lot of early childhood trauma, the serotonin medications might not work for you and it's a predictor for the medications not working for you later on now it's not deterministic.

>> It's not going to say not going to say yes or no.

They're going to work.

It's just that it's a factor that we'll consider so when we look at genetic testing we call it the genetic testing probabilistic but not deterministic.

In other words, it increase the probability that we're going to be swayed in the right direction in our treatment choices but it's not going to determine do this, do this, do this and that's where people often get confused with some genetic testing.

It's out there.

They'll have different proprietary brands on the front page.

It just says these are good medications or bad medications.

>> It's not that simple.

It depends on what how you've responded to medications in the past.

>> It depends on what stuff has happened to you in the past.

It depends on how your family members have done on various medications.

>> We have to look at all those different factors and then add the genetic testing results on top of it and that will sometimes tip the scales.

But one of the biggest factors to predict how somebody is going to do on a medication is simply by asking how a family member has done on a particular medication for similar symptoms as you.

>> So if you've had anxiety and you have family members who have similar types of anxiety hey, how are they done on medications poorly or in a good matter?

>> I mean have they done have they had poor responses to medications of a good response to medications?

>> We want to know the good and bad in terms of how they've done with past medications because that's a huge predictor on how somebody is going to do with our medication choices.

But genetic testing can be helpful if it was at no cost, if it was free I would certainly want to do it on every single person I'd see.

But there is a cost prohibitive aspect of it and it always comes down to is it worth the cost at this point we often reserve genetic testing for people who might have failed two or three different treatments in the past and we always allow the patient to determine if they choose to to accept the cost of the genetic testing based on what it might be for them.

>> Thanks for your email.

>> Let's go to next email.

Our next email reads We have the third email tonight.

It reads Dear Dr. Bovver, I've been on an antidepressant medication for three years and it's finally working for me.

>> That's fantastic.

Is there a symptom that's most likely to predict if you get depressed again?

>> In other words you're saying that you Petto it sounds like you've been on various other medications over the course of time and here you're finally feeling well.

>> Well, if you're finally feeling well and you're on your third medication for depression ,here's the bad news you might relapse and even though your life is good, things might be going well for you if you previously failed on two medications and now you're on a third medication for depression.

Yeah, there's a chance you might have difficulty with what we call depression relapse within even a year.

So what's the biggest predictor for relapse based on studies that have been done over the past 25 years?

>> There's one symptom that really predicts if somebody's going to just out on their antidepressant in other words there and a person just seems equipped quit working now the technical term there is out.

It's also known as tacky flaks.

>> It just means the medication not working anymore when somebody notices the medication not working anymore, they just out of the blue start getting more depressed.

>> All those old symptoms come back now if you're doing relatively well, what's lingering symptom might predict that you're going to have difficulty with relapse.

>> It's anhedonia.

>> Anhedonia means no fun and means no no hedonism means fun.

So if you're not able to have fun, if you're not taking pleasure in things, if you're not doing things that are enjoyable, if you're not socializing, if you're not getting out and doing the things you like to do when you're not depressed, that will be a predictor that you will get depressed again and it's something we're always monitoring there is a scale now it's a fourteen item scale called the Szeps the Snaith Hamilton pleasure scale.

It's a 14 item scale and it's not copyrighted.

>> So it's available for clinicians to use but the Szeps is predictive of relapse if you have over for a yesses, if you have over four symptoms on the Szeps out of fourteen showing that you're not enjoying four particular different areas of your life , it can be predictive you're going relapse into depression and we watched that Shapp score.

We only want to see the score go lower and lower and lower as people are getting treated with depression because the sharp score is something we consider now Sharps score will look at your ability to enjoy things from a sensory standpoint, from a social standpoint and from cognitive standpoint.

>> So it looks at different dimensions of enjoyment in your daily life .

So it asked you Joy smelling the flowers do you enjoy a nice sunset?

Do you enjoy socializing and receiving a compliment?

>> Simple things like that.

But those are predictors that people will either stay well or relapse and the higher the score the more likely something somebody is going to relapse.

We have found over the course of time I mentioned earlier the serotonin medications but we found over the course of time the serotonin medications don't help that much with the SAT scores that serotonin medications might not help that much with being able to enjoy things, especially if you tried a lot of different medications over the course of time.

>> So we're now taking a really good look at what specific medication might really help with that underlying difficulty with enjoyment or pleasure and the medication we're finding to be most likely to help with that particular symptom will be ketamine which is being used off label as an IV medication has been used without food Drug Administration approval for depression for the past 25 years or so.

Ketamine certainly helps with that as ketamine also known as bravado which is a nasal spray is particularly good for the symptom of anhedonia.

We have Wellbutrin which is a medication doesn't affect serotonin.

It affects more dopamine and norepinephrine and now we have all veloute which is a medication that is affecting glutamate in a whole different way compared to other medications that are available in an oral form.

>> So we have these different medications that are out there now that we didn't have a few years ago that are helping with that symptom of anhedonia which is a lingering symptom that often predicts relapse and often compare it to a simmering ember on a on a campfire if you have a simmering ember on the campfire you didn't put the campfire out.

>> You leave that simmering ember with a puff of smoke which is kind of like a stress in your life that puff of smoke can just flare up the flames and off you go and next thing you know you have a big forest fire.

>> So a simmering ember on a campfire can predict a forest fire, a simmering symptom such as anhedonia with depression even though you're pretty well put the depression out a little bit of stress can bring out and you can have difficulty with the depression recurring.

So it's something we've talked about for a long time.

We noticed a way back in 1987 1988 when Prozac or Fluoxetine first came out and that was a medication.

>> It worked wonderfully for a lot of people.

It was tolerable.

>> It was a serotonin medication but it didn't help with that lingering difficulty with being able to take pleasure in things.

>> So if somebody still had anhedonia as a symptom and they couldn't take pleasure in different activities, they were more likely to have what we called Prozac out and it just didn't work for them over the course of a year or two and they wondered why I quit working now I was a consultant at the time with Lilly who who created Prozac and Lilly at the time their top researchers were saying well you just need to increase the dosage.

>> Well, as we found out that didn't help because it was a serotonin issue where if you increase serotonin you indirectly decrease dopamine.

If you indirectly decrease dopamine, you can have more difficulty with enjoyment, pleasure and trying to get back to where you wanted to be before.

>> Thanks for your email.

>> Let's go to our next caller.

Hello Sharon.

Welcome to Mastermind or Sharon.

You want to know is selective hearing a sign of a mental health disorder?

>> I think we need to first kind of look back Sharon, take a step back.

>> What is a mental health disorder?

A mental health disorder is where due to certain clusters of symptoms you are having difficulty getting things done in your life and you're having trouble socializing.

>> You're having trouble go to work, going to work or having trouble with relationships.

You're having trouble concentrate and you're having trouble getting things done that you want to get done.

>> And I would add to all of that being able to take pleasure in your life .

>> So if you have a cluster of symptoms that will cause you to have what we call functional impairment, that's a mental health conition.

So in that case, Sharon, if selective hearing is a component of a condition is causing you difficulty with getting things done that you'd like to do every day?

Yeah, that could be an issue.

For instance, if you have selective hearing at the workplace and you're not listening to your boss, that's a problem if you're having selective hearing in school and you're not hearing the assignments and you're not following the instructor that's a problem.

>> So if it's selective hearing, we want to see what's the nature of the selective hearing.

So on top of the list could be a condition such as ADHD.

>> People with attention deficit hyperactivity disorder also are also attention deficit disorder without hyperactivity with those kind of symptoms you basically by nature have decreased activity in the front part of the brain, the thinking part of the brain, the part of the brain it allows you to focus and the left front part of the brain called the dorsolateral prefrontal cortex allows you to pay attention to things that aren't that interesting.

>> So hey, if you kind of tune out from various conversations because they're not that interesting or your left prefrontal cortex here might not be working so well and that could be a symptom of ADHD.

We treat ADHD by basically firing up the front part of the brain using medications not uncommonly such as the stimulant medications or maybe some of the non stimulant medications that are now available because they also can indirectly increased dopamine transmission.

So if you increase dopamine transmisson in this left prefrontal cortex also known as the left dorsolateral prefrontal cortex that can help with focus and concentration so that could help a selective hearing.

>> Now there's another phenomenon that occurs out there and that phenomenon is where men tend to have about twenty five percent less norepinephrine projections coming from their local serialist which is down here on the brainstem right down here.

>> So the locus serialist will fire out all these little projections and men tend to have about 20 to 25 percent less projections of norepinephrine.

>> So symptom asymptomatically that means that men will not notice things to the detail that women might.

So there are differences between the brains of men and women and that's one of them where men might not pay attention to simple subtle details in the environment and social cues that women might notice.

And that's because just from a physical standpoint men don't have the norepinephrine projections that women might might have.

So that's why men might not be as prone to paying attention in some social situations especially and in various environmental situations and that's at all ages.

It does not make a difference whether it's younger men or older men that could be a factor in itself.

>> Thanks for your call, Sharon.

Let's go to our next caller.

Hello Roger.

Welcome to Matters of Mind.

Roger, you mentioned hello Roger.

Yes, I have some questions about my yeah.

Is several people in our family I've tried taking have nightmares with it, several on anxiety medications also is there a good substitute over the counter or prescription that would fill in for the melatonin?

>> Yeah, Roger, I would recommend melatonin mainly for one type of sleep problem and that's where you're having trouble going to sleep or you're you're jet lagged and you're trying to get to sleep and you've gone from the East Coast to the West Coast and you're I'm sorry you're going the other direction again from West Coast to East Coast.

>> You're trying to get to sleep at a different time and you you're just not tired and we see a lot of time with adolescents where adolescents will just have our time going to sleep.

The adolescent brain naturally wants to stay up later and get up later the next morning.

That's normal factor with adolescents.

We call that delayed circadian rhythm disturbance and when that occurs you can use melatonin safely for an adolescent no more than three to five milligrams I often recommend now for sleep medicine specialist tells you to take ten or fifteen milligrams at bedtime.

Hey, go ahead and do it.

But generally three to five milligrams is plenty for a lot of people.

>> But the thing about melatonin, Roger, is it's like a puff of smoke.

It's there for about 30 minutes and it gives you a brain the chemical signal to go to sleep.

Then it's gone.

>> Melatonin naturally does come from the pineal gland which is right smack in the middle of the brain here and it's basically known as the vampire hormone because it goes up when it gets dark and goes down when it gets light.

So if you have the darkness of the night melatonin will go up and give your brain the chemical signal to go to sleep and then it kind of kind of will hook up with our circadian rhythms to try to get us to go to sleep the same time every night.

>> So the best thing you can do to get your melatonin regulated naturally Roger would be to try to go to bed the same time every night and try to get up about the same time every morning.

>> That's what your brain wants to do.

OK, melatonin is not working for you and melatonin you bet.

Can give you nightmares if you take higher doses.

>> That's why I don't recommend going up to ten or fifteen milligrams of melatonin because it can give you nightmares and actually worse in your sleep.

>> So I'm always warning people don't take more and more melatonin.

It's not helping you if it might not be helping me because it's not giving you the quality of sleep you want at that at the dosage you've been taking and three to five milligrams at bedtime is usually plenty for a lot of people.

>> So what are other options?

Well, if you take diphenhydramine also known as Benadryl and diphenhydramine is an ingredient that's in a lot of sleep medication is an antihistamine that does tend to knock people out, makes them sleepy but it gives them a dry mouth and it makes their their memory kind of foggy until noon the next day, especially if you're over fifty five years young.

>> So if you're old and an older adult you can more trouble Benadryl or diphenhydramine.

>> I do not recommend that for especially for older folks younger people, maybe adolescents they can kind of get by with diphenhydramine or Benadryl but that's not usually a highly recommended agent for people.

UNISOM is a trade name of a medication that contains docs El-Amine another antihistamine again kind of OK if you do going to use an antihistamine be very careful using it as an older model.

If I'm treating an older adult with specific difficulty with getting to sleep and staying asleep I'd probably want to go with a prescription medication.

>> There are some over-the-counter agents Valerian Root is over-the-counter as an herb and it's really OK very, very safe.

You could try that but in terms of something that works I'm going to typically go with one of three things not in commonly gabapentin be in one gabapentin doesn't work for everybody but it's a good medication for a lot of people.

What I like about Gabapentin it's something that typically is not addictive unless you're using it with a narcotic it will amplify the effect of a narcotic as much as Xanax, Klonopin or Ativan but don't use it with a narcotic basically it's what I recommend .

I like Gabapentin because it gives you a greater depth of sleep so it gives you a deeper, better quality of sleep.

It helps you dream in a good way without giving you nightmares and it gets out of your system after about eight hours works more than twenty minutes, gets out of your system within within eight hours.

It's an old anti seizure medication that affects these little overactive calcium channels that supposedly keep you awake.

A second medication to be Trazodone been around since nineteen eighty two .

>> Trazodone has been around for a long time.

It's a medication that specifically will affect the serotonin receptors called serotonin 2A receptors by blocking them again gives you a greater depth of sleep, helps give you a good quality of sleep about one out nineteen people will get a stuffy nose on it so they don't like it for that reason.

>> But 18 out COVID 19 people don't get that effect and a third treatment that we'll use as a prescription medication will be Liquid Dock's appen Konstanty it comes in a tablet form called Silane or but it's three three to six milligrams of docs and a tiny dose of which used to be used as an antidepressant medication.

>> Talk it over with your primary care clinician.

There's a lot of options out there.

Lack of sleep over the course of time is not a good symptom to experience.

It can give you difficulty with high blood pressure, higher risk for diabetes and even heart disease.

>> Roger, thanks for your call.

Unfortunately I'm out of time for this evening.

>> If you have any questions that I can answer on the air you can write me via the Internet at matters of the mind all one word at WSW a drug I'm Psychiatrist Ja'far and you've been watching Matters of the Mind on PBS Fort Wayne now on YouTube God willing and PBS willing.

I'll be back again next week.

>> Thanks for watching.

Goodnight