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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 10th year, Matters of the Mind is a live call in program where you have the chance to choose the topic for discussion.

So if you have any questions concerning mental health issues, give me a call here in the Fort an area by (969) 27 two zero or four calling any place else coast to coast you may dial toll free at 866- (969) to seven to zero now and a fairly regular basis we are broadcasting live every 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 via the Internet at matters of the mind all one word at Wadongo that's matters of the mind at www vague and I'll start tonight's program with an email I recently received.

>> It reads Due to the fovea how would a person do on Prozac if that person does not have depression?

Prozac came out in 1987.

>> Its generic chemical name is Fluoxetine.

When it came out it was thought to be a miracle medication and the reason it was thought to be a miracle medication is because it was the first antidepressant that was actually highly tolerable.

>> It didn't work any better than the prior antidepressants.

You know, the prior antidepressants all affected serotonin, norepinephrine, somewhat dopamine, Prozac or Fluoxetine was very, very specific on increasing serotonin and was so specific on increasing serotonin it did not cause dry mouth weight gain lightheadedness cardioverter vascular problems like the other medications could.

So it was very tolerable medication and people could take it day by day and if they missed dosage they could actually make up for it because fluoxetine of Prozac would stay in your system for several days .

>> So way back in the late 1980s other people were asking the same question as are you?

>> And they were asking why don't we just have everybody take Prozac because it seems to help so many people and there was actually a psychologist out in Washington state proposing seriously that they put Fluoxetine or Prozac in the water supply.

Well, here's what happened when they actually studied Flugtag Prozac in people who didn't have depression and then they studied it in a related group with people with placebo and then they crisscrossed what they found with the flu vaccine people for the Prozac, people who didn't have depression was that they would have an emotional dulling effect.

>> It wasn't necessarily a horrible effect but they felt emotionally numb.

They felt not good.

They did not bad.

They just kind of felt blah and what Prozac or Fluoxetine will do, it increases serotonin and it gives you is this blissful calming effect and it's kind of an emotional numbing.

>> So if you're having difficulty with a natural crying or extreme anxiety, Fluoxetine or Prozac can dampen that down and you got to find just the right amount for it to work but it'll dampen down excessive emotions.

>> Now what if you have what we'd call normal emotions where you don't have anxiety to an abnormal degree, you don't have depression for that matter?

Well, it'll probably make you feel kind of blah.

And that's what I did for a lot of people and many people who took Prozac if they didn't have depression, felt some sexual side effects.

They had some diarrhea, gastrointestinal problems, some headache.

>> We now know that a serotonin toxicity words they're just getting too much serotonin in their system.

So if you don't need Fluoxetine, it's kind of like putting on somebody else's eyeglasses you put on somebody else's eyeglasses and you'll just find the your is actually worse.

>> If anything, if you take Prozac and you're not depressed or you don't have that much anxiety, you'll just feel a little bit emotional dulling effect and you might be able to put up with stuff a little bit better to some degree.

>> But most people wouldn't like how they felt if they took Prozac, if they didn't have what we consider to be pathological depression or anxiety.

>> Thanks for your call.

Let's go to our first caller for tonight.

Hello Jan.

Welcome to Mastermind Jan. You heard me say normal.

So what is normal?

How do you know if a treatment's working or not?

Well, normal basically Jan is where you don't have significant functional impairment to have a psychiatric condition by definition you have to have impairment with social work or school functioning.

>> You have had to have a hard time getting along in life .

So basically normal is where you can pursue happiness.

You can live relatively independently and be self-sufficient and you can get along with other people and you can have interpersonal relationships that are there to a meaningful degree.

So normalcy basically is where you can be all you can be and you're not having anything from an emotional standpoint impair your ability getting there so people will have mood and anxiety disturbances.

They'll have difficulty with thinking due to mental health disturbances if we can treat those mental health disturbances the idea would be that you'd be able to have those meaningful relationships you'd be able to pursue a job or school opportunities as you would intend to do so and you'd be able to stay active physically within your within your level of physical abilities based on your age and your overall physical health .

So you're able to be all you can be to use an old term in the United States Army.

They always talked about you know, you can be well that's what it's all about normalcy from a mental health standpoint means that you can be all you can be and you don't have that degree of functional impairment.

How do you know your treatment's working?

I always suggest to people that they give me the main treatment goals that they have in mind right off the bat.

What kind of treatment goals do you have?

What would you hope any treatment from a medical standpoint would do for you and have the patient identify what their main goals are?

And you as a clinician you're often surprised because you're thinking oh, I thought they might have this goal or that goal based on their symptoms but many people will have different goals than clinician might believe.

So I think it's imperative that the clinician ask the patient what goals he or she is pursuing and then you follow those goals over the course of time and the goals might be something as simple as getting better night's sleep, having more energy during the day, having more motivation, having more enjoyment with the grandchildren.

You can go in a wide range of areas and then kind of track how those goals are doing and the patient will often identify what those goals should be.

So successful treatments should be where somebody is feeling like they can still experience happiness, anger, sadness, apathy, irritability.

>> They can still experience a wide range of emotions.

That's all good.

Otherwise you're going to be an emotional robot.

You don't want that but you should still feel emotions based on life circumstances and you should especially on one hand be able to enjoy your sensory environment around you.

You should be able to enjoy things that are currently in your presence but you should also look forward to enjoying things in the future.

Enjoying things now is called consumer tery enjoyment enjoying things in the future is called anticipatory enjoyment.

You should have both of those aspects where you can look forward to the future and still have hope and even those those things aren't going so well for you now in different areas you realize that as you wait it out over the next few weeks or months for that matter, things will often change and typically for most people things can change for the better and you have to maintain that degree of optimism.

>> Thanks for your call.

Let's go next caller.

Hello Catherine.

Welcome to Mastermind Catherine .

>> You want to know what hypnosis helps someone with communication would help with communication with someone who has autism.

>> So you're asking I believe, Catherine, if you have autism with hypnosis help your ability to communicate and I'd say probably not hypnosis no.

>> One, you have to be extremely suggestible and trusting for the with the clinician for them to be able to hypnotize you and the whole idea would be for you to be able to do self hypnosis so you can practice over the course of time.

So hypnosis is a very good for anxiety.

Hypnosis can be very relaxing and give you a calming effect in social situations.

But with autism basically autism is where the right front part of the brain is underactive to a degree where you don't have as many mirror neurons as you really should have mirror neurons basically are neurons that allow you to mirror the behaviors and the emotions of the people with whom you're communicating.

So we will do this unconsciously, unconsciously as we're talking to somebody we relate to them by sometimes mirroring their mannerisms might be hand gestures, gestures we might even take on the inflection of their voice any accent they might have to a mild degree we might take that on and that's a means of connecting with somebody else.

People with autism have a difficult time doing that.

So it's not an anxiety condition per say and I don't think hypnosis would really help with that.

Thanks for calling.

>> Let's go to our next caller.

Well, let's go to our next email for that matter.

Our next email would read here it is your daughter Fauver.

How do you choose one medication over another and what are the criteria that you use when we choose medications?

>> Number one, we want to get a proper diagnosis so if you have let's say chest pain, if you have chest pain, the first thing you need to sort out is what's causing the chest pain.

Is it a heart attack?

Is it bronchial pneumonia?

Is it bronchitis?

Is it asthma?

Is it gastroesophageal reflux?

>> What's causing the chest pain?

So you're going to have different treatments based on the nature of the condition causing the symptoms.

>> If somebody has let's say depression we need to sort out what's causing that depression itself.

Is it an emotional problem?

We don't want to be too soon too quick to jump.

It's saying well it's because your life circumstances it's this or this or this.

I almost didn't go into psychiatry because I found when I was a medical student back in the 1980s I just found that a lot of psychiatrists were attributing symptoms to specific things happening in people's lives and you know, stuff happens in everybody's life .

You can always identify certain things.

So I always was one to want to look at the underlying problems on why people might have certain symptoms.

So depression for instance, somebody comes in and they say they have depression.

You have to identify what symptoms they're experiencing.

Are they having difficulty with fatigue, poor concentration, low motivation?

>> Those kind of symptoms can be related to so many different things low thyroid, diabetes you can have sleep apnea where you're not getting enough airflow at nighttime and you're snoring.

You can have difficulty with all sorts of different endocrine problems and have difficulty with low motivation and poor concentration.

If you have poor concentration that can be from attention deficit disorder.

I saw a lady earlier this morning who had attention deficit disorder who also had trouble with motivation and get up and go and she said she didn't feel depressed but her clinicians who she had seen in the past were always telling her she must be depressed because she has low motivation or poor concentration.

>> It I believe that she was having trouble with motivation and and being able to get things done because she had AIDS symptoms.

So you treat the 8D those underlying symptoms that we might think of as depression might be mitigated.

So I think it's important that we try to look at the underlying conditions that are there you know, low iron women who were heavily menstruating or people who are vegetarians sometimes have low iron and low iron can contribute to feeling blah and feeling kind of down the dumps.

So no one it's important that we identify what the underlying problem is and treat that particular condition.

Is it bipolar depression for instance, were there intermittently having highs for several days and then they crash in the lows you're to treat those people with a mood stabilizer.

Is it depression?

It's their day by day by day.

How is the depression affecting people?

So we're going to look at the symptoms they're experiencing then second thing I think I'd suggest in terms of determining what medication somebody needs is look at their past medication responses.

It's a very simple thing to do but it's often overlooked.

>> Just simply ask them what medications have you tried in the past and it's ideal to try to categorize those past medications based on their mechanisms of action.

I've seen a lot of people who have for instance been on four and five different serotonin antidepressants and they all fail.

Well if you fail with a couple serotonin the medications you probably not going to be successful in the third one.

So it's important that we very specifically categorize what medication trials people have had in the past, what good effects they've had, what bad effects of have they had if you have a 50 percent or more improvement with a certain medication you might want to try to stick with that one and add on the things to if necessary.

Third thing we'll do after looking at diagnosis after ruling out medical problems and looking at past medication responses very importantly look at what family members have responded to or not responded to.

So in other words, look at the treatment responses for family members.

If you have a mother, father, brother or sister who have who's done really well on a particular medication for similar symptoms as you are experiencing, you might want to consider that kind of medication and that's not only for psychiatric conditions but if you have diabetes, asthma, high cholesterol, if you have a family member who's doing really well with any medications for those conditions and you have those conditions you might want to consider being on that kind of medication we sometimes will indeed look at genetic testing but genetic testing will look at how quickly you metabolize medications and determine if you need a low dose of your high dosage.

So that can be helpful and there are certain aspects of genetic testings that will tell you which mechanism of action might work better for you.

And the focus of genetic testing has an on serotonin, norepinephrine and dopamine and those chemicals kind of sit in the in the passenger seat while the driver is pushing on the brake affecting glutamate or I'm sorry pushing on the brake affecting GABA or pushing on the accelerator affecting glutamate.

So any more we're talking more about glutamate and GABA as a means of trying to regulate depression.

So when we're talking about medications affecting glutamate and GABA they might have a faster onset of action.

So as opposed to starting with something that might affect serotonin, norepinephrine and dopamine especially if you failed on this kind of medications we might think about something like bravado which is a nasal spray that can be used by itself now in a supervised setting we're talking about now a variety of which can be used day by day that's affecting glutamate.

We have a lot of other medications coming out on down the pike that will primarily affect glutamate into a secondary degree GABA So there's a lot of different options out there but there are there's a systematic way of really going through how somebody is going to do on a medication or not and it can be somewhat predictive and people ask me all the time what's the role of artificial intelligence in psychiatry?

Psychiatry historically has been very intuitive.

The psychiatrist just kind of talked to somebody for a while and just kind of is intuitive in terms of what might work for that person based on what they've said.

I think it's important for us as psychiatrists to think as our medical colleagues will where you systematically look at how somebody's done on various medications, what their current symptoms are and try to put that so-called phenotype which is a cluster of symptoms together to figure out what medication will work versus another.

And if somebody has failed for instance in one on one class of medication and had horrific side effects, you probably don't want to put them on a similar type of medication in that class.

So there is a way to kind of dissect who's going to be doing well one way or another.

>> Thanks for your call.

Let's go next.

>> Hello, welcome to Matters of Mind.

Pete, you mentioned that you missed a dose of your medication and you want to know you take it twice a day and you want to know if you should double up or wait until next time.

Pete, it depends on which medication you might be taking if you dig in twice a day it probably is a medication is not lasting very long and you might talk to your clinician about it based on that medication.

But if you take a medication twice a day I'm going to give you an example here abuse bapi byroade these spareribs Byron is typically given twice a day if you miss the dosage in the evening.

>> Yeah, I don't want to double up on it.

Just wait till the next day.

Shouldn't be a big issue.

There's the old immediate acting venlafaxine.

If you miss that second dosage you're going to feel pretty badly within an hour or two of missing the second dosage if it's immediate release Venlafaxine or Effexor.

So you might want to take the dosage later on but generally you don't want to double up on doses but that's always to be left your clinician.

It's best to let it go and if you miss the dosage and you wake up at 2:00 in the morning and think Oh I think I missed my bedtime dosage for this or that, typically you don't want to take the dosage unless it's the kind of medication that you can take at that time of night.

But talk it over with your clinician concerning the type of medication you're taking.

But typically we don't recommend people double up on their medication because you get walloped with a very high blood level very quickly if you do so.

>> Pete, thanks for your call.

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

>> Our next e-mail question reads Dear Dr. Farber, what are the long term concerns of a mental illness remains untreated?

I have a teenager who has some struggles.

There is a temptation to see if things run their course.

Would you approach is differently if it was an adult?

I'll ask the second part of that question first.

Yeah, I would approach it differently as an adult because with teenagers their brains are still growing and they tend to be very resilient in a lot of ways because teenagers their brains are growing so quickly that they might not be bothered by something three or four months from now that they are now because the front part of the brain is the part of the brain that you use for judgment ,impulse control, even focus for that matter and it continues to grow into your twenty four years old.

And that's why I'm always preaching to adolescents and young adults don't use cannabis or marijuana because it actually slows the progress and I'd certainly say boy, don't use alcohol because your brain still growing and alcohol just fries the memory center of the brain especially for children adolescent and young adults for that matter.

>> So you and TI get to be twenty four years of age.

You want your brain your brain to grow to its full capacity so you don't want to do anything that's going to hinder its ability to continue to grow and grow and grow.

>> So with an adult I'd suggest that if you're having what's called functional impairment and you're having difficulty getting along with people having trouble the job, you're having trouble in school, you're having trouble getting things done to the extent that you expect to be able to get things done and you have a hard time finding joy in your life if you're having trouble with the pursuit of happiness and you're just not able to get things done to a reasonable degree, you bet you might want to get treatment if it's going on over two weeks.

So as an adult, if you have a long extended period of depression or anxiety it can be considered to be toxic to the brain.

What's that mean?

Well, it means your little neurons that have all these billions of little connections or millions of connections on them, they're shriveling up and as the neurons are shriveling up that will cause you to have trouble with the communication from one neuron to another giving you trouble with concentra focus.

And actually there's a study on people over 65 years of age if they have chronic untreated depression, it goes on week after week after week.

They are four to five times more likely to have Alzheimer's dementia because with Alzheimer's dementia the part of the brain that is shriveling up is this part of the brain called the hippocampus.

The hippocampus is over here and the yellow part of the brain on the top of that yellow part is kind of shaped like a boxing oven.

It's at the top of the thumb hippocampus of the memory center of the brain and shriveled up if you have depression so shrivels up especially for women if they drink heavily they drink alcohol heavily.

So that's a part of the brain you don't want to see shriveling up over the course of time.

Chronic depression can do that.

So chronic depression itself is toxic to the brain even more toxic the brain will be psychosis where somebody is losing touch with reality that's highly toxic to the brain because with psychosis there's an excessive amount of this excitatory chemical called glutamate.

It's similar to what you'd see with a seizure.

Too much glutamate will give you a seizure too.

But if you have excessive glutamate you can have seizures, psychosis and neurodegenerative conditions like Alzheimer's dementia.

>> So excessive glutamate is like putting too much fertilizer on your lawn.

You know, you might think well gee, lawns tend to grow more robustly with fertilizer.

>> They're nice and green and thick.

Why shouldn't I dump a whole bunch more fertilizer on there?

Well, if you do, you're going to fry your lawn and the same will happen with your brain if you get too much glutamate.

So there's always that nice balance in the brain between glutamate and gabber glutamate being the accelerator, Gabbar being the brake.

You want that nice balance going on there but you don't want excessive glutamate and that's what happens sometimes when people get depressed and anxious and they have neurodegenerative conditions.

>> If you have excessive glutamate it will not get cleared from the system so much with each individual neuron there's these other little cells called glial cells that tend to clean up the excessive glutamate and if the glial cells are sick they don't clean up the glutamate.

So it's kind of like having a pit crew at the Indy 500 at the pit crew of Indy 500 think they have nine pit members around each car when they come into the pits.

Well, in our brains there's roughly eight to ten glial cells around each individual neurons.

If those glial cells are sick and they're not cleaning up the glutamate so much it'll actually fry the neurons themselves.

That's the problem with long term problems.

So with an adult yeah, long term depression, anxiety, psychosis, mood disturbances of any type like bipolar disorder can actually be toxic to the brain with an adolescent going back to your original question with an adolescent it's a judgment call if it's causing the problem in school with socialization with getting things done and it's not clearing up as you would expect, you can always talk to your primary care clinician, the pediatrician or whoever might be involved in that person's medical care to give a give a judgment call if they do need any medication treatment, if they need counseling or what direction you might want to go.

>> Thanks for your call.

Let's go next caller.

Hello Jerry.

Welcome to Mastermind.

>> Hello, Larry.

Hello, Jerry.

Uh, yes, I was wondering about this lack of sleep contribute to agoraphobia and a good medication for that lack of sleep can contribute to a lot of problems.

>> Jerry, lack of sleep basically doesn't allow your coping part of the brain the left front part of the brain that allows you to cope with different life circumstances allows you to think through your problems if you don't get good sleep.

Jerry, it's kind of a vicious cycle because lack of sleep well thereby give you trouble with depression and concentration difficulties and anxiety disturbances.

You'd mentioned agoraphobia.

You have a hard time getting out.

Agoraphobia is often preceded by panic attacks and there might be a reason or having trouble getting out and that sometimes will go along with social anxiety as well.

So if you have any difficulty with sleep disturbances it can cascade and cause a lot of mental health problems.

That's why as psychiatrist we will often look at sleep disturbances as being like a psychiatric vital sign.

We're always asking people about their abilities to get to sleep, stay asleep, waking up to early, feeling refreshed the next day, needing to take prolonged naps the next day.

>> These are all symptoms of impairment and sleep and if you have impaired sleep it's like your cell phone charger, your cell phone not getting adequate charge on it because the Chargers bad.

So you want to get that brain charged up at night time with non REM sleep which is a deep sleep and REM sleep which is a dream sleep and that will refresh the front of the brain again which is the thinking part of the brain.

So if you're not thinking through clearly on your life circumstances you can misinterpret the world around you including a fear of getting around other people getting out in open spaces and having the symptoms of agoraphobia.

So what medications would you use?

You know, I try to stay away from the so-called Z drugs, the Ambien Lunesta popular or used.

>> They work exceptionally well for a few weeks but often they will fade and their effects long term.

I'm getting away from using a lot of those type of medications and a simple medication for getting somebody into a deep sleep and getting somebody into REM sleep normally would be a medication like Gabapentin also known as Neurontin that was originally used for seizures and got used a lot for pain and psychiatry were using it a lot for sleep anxiety disturbances because it gives you a good officiants sleep.

>> It gives you a good recharging of the brain so doses no more than 100, 200, 300 milligrams bedtime is what often will be effective.

Trazodone as a medication has been around since the 1990s for depression.

We do indeed use that for the purpose of helping people sleep it to get you good eight hours of sleep give you a deep sleep one way or another.

So Trazodone is a medication that will often use doxa in three to six milligrams at low doses it's an old antidepressants but a tiny little dose goes by the trade name Solander but at tiny little doses it can be a medication that will not only decrease the release of histamine but block histamine histamine decreases or what allows this will allow us to sleep so Doxiadis actually decrease in the transmission of the histamine itself.

There's a lot of good medications out there.

Talk to your clinician about that and look for the possibility.

Jerry, thanks for your call.

Unfortunately I'm out of time for this evening if you have any questions concerning mental health issues that I can answer on the air you may write me via the Internet at matters of the mind all one word at WSW ECG.

I'm psychiatrist Jeff and you've been watching Matters of Mind on PBS Fort Wayne now on YouTube.

Thanks for watching.

>> Have a good night.

Good night