Good evening.

I'm psychiatrist Jeff Alver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now and as twenty fourth 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 at PBS Fort Wayne by dialing in the Fort Wayne area (969) 27 two zero or if you're calling a place coast to coast you may dial 866- (969) to seven to zero now in a fairly regular basis where our broadcasting live from our spectacular PBS Fort Wayne studios which lie in the shadows 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 via the Internet at Matters of the Mind at WFB dot org.

>> That's the Internet address matters of the mind at WSW a dog and I'll start tonight's program with an email I recently received.

>> It reads Dear Dr. Fauver I currently take Wellbutrin and Zoloft but I still have some major depressive episodes especially when I'm reminded of my son with whom I can't see should I take a different medication.

>> Wellbutrin and Zoloft do have different mechanisms and I want to be realistic when you're grieving the separation of a child, if you're in a custody battle and you have family conflicts, obviously medications might not be the primary answer for you.

You need to go through counseling and within the courts limitations you need to be able to try to still be able to maintain that good relationship with a child and be the best parent you can be because that will be remembered for decades a lot of adults will talk about what their relationship was like with each of their divorced parents even as they are growing.

So with that being said from a pharmacological standpoint, Wellbutrin works one way, Zoloft works another way.

Wellbutrin primarily will increase the chemicals dopamine and norepinephrine Zoloft increases serotonin and to some degree dopamine transmission but they work in different ways so it's often a good combination.

>> It's a nice balance of chemicals.

But we have to remember that norepinephrine, serotonin and dopamine are just three chemicals that will affect the brain with there's over 80 known chemicals in the brain that will affect the mood, the anxiety levels for people.

So these are just medications that will affect three chemicals a chemical that's being more further studied more recently is a chemical called glutamate.

So you might be hearing over the next year or two about medications that affect glutamate because whereas medications that are affecting serotonin and norepinephrine and dopamine might take four to six weeks to go to work and sometimes can kind of lose their effects medications that affect glutamate work within a matter of minutes if not seconds.

And for many people there can be meaningful changes within a day or two of these other medications, these medications are in development.

They are coming out ketamine IV where they use it intravenously has been used for the past twenty two years without FDA approval.

Ketamine is used as an anesthetic but it's been used without FDA approval for depression for the past twenty two years as ketamine is a nasal spray called bravado.

It's something that can be used and it's something that's affecting glutamate and it's working differently than Zoloft or Wellbutrin.

>> So for some people who have been treatment refractory and they've tried at least two different omnipresence maybe they've tried five they tried ten antidepressants and the traditional antidepressants that are affecting serotonin, norepinephrine and dopamine are just not working for them sometimes we'll go to the next step and use the medications affecting glutamate the medications coming out over the next year or two will be oral formulations of medications that affect glutamate.

So as a psychiatrist that is something that I think could give a lot of people hope because we've had 15 oral antidepressants come out since Prozac came out in nineteen eighty seven.

So we've had these various antidepressants come out over the past twenty five thirty years but they all are primarily affecting dopamine, norepinephrine and serotonin.

The newer medications are going to affect glutamate though predictably work faster and they might hold their effects longer than a traditional medication.

So the next ten or twenty years in psychiatry should be very exciting looking at the different mechanisms that we'll have available to treat people who just couldn't get satisfactory effects on their traditional antidepressant medications.

>> Thanks for your email.

Let's go to next email.

Our next email reads Dear Dr. Fauver, I have been taking Trazodone 50 milligrams to help me sleep.

I also recently stopped taking 10 milligrams escitalopram.

Does triacetone help with anxiety or should I take both?

Can Trazodone also cause weight gain?

Well, 50 milligrams at bedtime is primarily going to help you sleep.

>> It works within twenty minutes.

Gives you a deep nice slow wave.

Sleep in many cases can't suppress to some degree dream sleep which is sometimes overabundant for people with depression but it's affecting serotonin receptors quite selectively.

A little bit of a serotonin riptech inhibitor effect which means it can flood the synapse with serotonin to some degree but for the most part low doses of Trazodone are going to be used for sleep now way back in 1981 I believe Trazodone was approved as an antidepressant.

It doses between 300 and 600 milligrams a day really high doses for the purpose of helping with depression.

It was considered to be an atypical or a second generation antidepressant because it was different from the traditional older and depressants we had even before Prozac and it was popular at that time because it didn't cause as much difficulty with weight gain and it didn't cause the dry mouth that the older medications cause a trazodone rarely will be associated weight gain.

You don't have to worry about that so much as the years progressed in the late 1980s after Trazodone had been used for quite some time, a lot of psychiatrists have started using Trazodone for sleep disturbances and it became one of the more popular medications for sleep because it was not addicting.

It was something that worked within twenty minutes it got in your system by morning typically and it did not cause you to go to higher and higher doses over the course of time you didn't get used to it.

>> So some people have been taken Trazodone as needed or on a regular basis for literally decades now and not had any difficulty with taking it for long.

Here's a time about one out of nineteen people can get a stuffy nose with it so you can hear about that at higher doses men and about one out of five thousand cases can have prolonged.

But you know that's the kind situation where you're typically using a really high dosage so it's very uncommonly seen with the doses that we use for sleep which will be between twenty five up to about one hundred maybe 200 milligrams bed bedtime will be used for sleep.

Will it help with anxiety at that dosage?

Probably not because at the lower doses it's going to primarily help with sleep.

>> Keeping in mind however if you sleep better the front part of your brain will work better when we sleep the front part of the brain gets a rest.

>> The thinking part of the brain, the logical part of the brain gets more rest while you're sleeping and that's why you have dreams because dreams are very logical but your logical part of your brain needs to get arrested night and that's what happens when you sleep and you get into deep sleep and you get to dream of sleep.

The front part of your brain is resting and if your front part of the brain is resting during the day you should have better ability to logically think through difficulties.

So your anxiety volume control which is down here in the temporal lobe of the brain that's called the amygdala that shouldn't hijack your logical thinking part of your brain and that's what happens when people have anxiety disturbances, their anxiety center, their brain hijacks their logical part of their brain so they can't think through difficulties adequately.

>> Lack of sleep will contribute to that.

So if you don't sleep well, you're not going to be able to think clearly.

You're not going to have logical thought and it's going to cause you difficulties is why people need to get adequate sleep at night for some people they can get by on six or seven hours at night.

>> That's great if they can do that and they can function very well during the day some people will sleep deeply at night, maybe get a 30 minute to a one hour power nap during the day and that works for them.

>> But the key is don't get to the point where you're lacking sleep because you're having obligations that can wait till the next day.

Certainly don't sleep with the television on at night because you'll be waking up periodically.

>> You're not going to get deep sleep if you have distractions like that in the room.

So sleep is very important for the US for the purpose of decreasing anxiety and helping us think logically through our difficult.

>> So with that being said, President can help us sleep and indirectly it can help with anxiety but directly it won't help with anxiety to a great deal at the doses of fifty to up to 200 milligrams of bedtime which are commonly used for sleep.

>> That's where Citalopram comes in.

Citalopram is also known as Celexa.

It came out in a early 2000 about twenty two years ago so it's been along out for a long time and basically it's increasing serotonin all over the brain and the areas of serotonin effects and if you think about how Citalopram works, it works in a similar manner as does Prozac, Zoloft, Lexapro and Paxil.

>> These are all the chemical cousins of Citalopram that all are basically called serotonin reuptake inhibitors.

And what that means if you think about your serotonin nerve cell as being like a serotonin shotgun and it's firing up serotonin bullets spraying out serotonin bullets all over the brain, well there's 14 different serotonin targets in the brain.

>> Some of them you want to stimulate, some you don't but you'll stimulate all 14 different receptors by increasing serotonin in the brain and to some degree people with depression.

>> And if you're genetically prone to having a favorable effect to a serotonin reuptake inhibitor, you can feel better, you can feel calmer, you can put up with things better.

>> You don't cry as much so it can dampen down a lot of the unsnapped feelings you might be having and in doing so it can dampen down unnatural anxiety.

So if you increase serotonin transmission by decreasing the vacuuming of serotonin bullets back into the firing neuron, that's exactly what Citalopram and the selective serotonin reuptake inhibitors do.

They will inhibit the vacuuming of serotonin back into the firing neuron and getting them out of the so-called synapse and keep them away from their targets that way.

So if you keep the serotonin out in the in the brain bouncing around and hitting the targets again and again and again, you're more likely to get the effects when those 14 different targets and some of those targets will make you less anxious if stimulated.

So that's what you're trying to do by giving somebody Citalopram or Celexa Citalopram dose between ten and forty milligrams a day over forty milligrams a day can give people some difficulty with heart conduction and disturbances.

>> And as you go higher on Citalopram it can make you feel emotionally numb.

I mentioned there's fourteen different serotonin targets out there.

>> Some of the serotonin targets will indirectly decrease this other chemical called dopamine.

Dopamine is a feel good happiness motivating energizing type of neurotransmitter and if you decrease dopamine you can feel kind of bloo and you have difficulty with concentration.

>> Decreasing dopamine can contribute to sexual disturbances trouble with concentration.

>> So if you increase any of these serotonin medications too much you're not going to feel better and better.

>> You actually feel worse.

So sometimes we have to pull back and dial down on the serotonin medications Citalopram at ten milligrams a day nice low dosage but it could decrease the excessive emotional reactions that people can sometimes have with anxiety.

>> Thanks for your email.

Let's go our next caller.

Hello Susan.

>> Welcome to Matters of Mind.

Yes, my name is Susan and I'm seven years old and I suffer from anxiety and depression and insomnia and I was on several different antidepressants.

Now I'm on the Flexner's seventy five milligrams and I have very strange vivid dreams and I don't sleep very long and the doctor gave me some Seroquel for 25 milligrams and they seemed to be helping that I still have anxiety and depression and don't fall asleep very easily.

>> Susan, do you notice that your dreams are worse since you've been on the Effexor seventy five milligrams a day or did you already have difficulty with sleep problems and dream vivid dreams even before the Effexor I've been on several antidepressants and all of them seem to give me the vivid dreams and a Flexner's just seems to be like the other ones I've been on.

>> Got you.

What time of the day do you take the Effexor Susan is the first thing in the morning and it's extended release.

>> Has your clinician told you to take the Effexor specifically first thing in the morning?

>> I no.

But since I have weird dreams I thought maybe if I would take it early in the day it wouldn't be so affecting me when I'm sleeping Effexor is a strange medication in that regard.

>> Susan Effexor gets in your system really fast.

The extended release is how we want to have people take it because they have regular immediate release tablets so you have to take three times a day.

Everybody had trouble with those so the extended release capsule will last 24 hours.

>> But here's what's happened happening.

Susan Effectors getting to your system early in the day which is good but then the blood levels get out really quickly toward the end of the day and it's a phenomenon that I've seen in my practice and you can talk to your clinician about it but we've had some people in that kind of scenario actually take Effexor at bedtime.

It's not the effects are causing the bad dreams.

It's the effects are getting out your system that's causing the bad dreams and sometimes we'll even have people take Effexor extended release morning and evening but it's just easier to take it all in the evening.

But if you took the higher blood level in the evening it should suppress the dream the vivid dreams in here's what's going on to some degree, Susan.

Number one, when people have depression they have more vivid dreams.

>> We don't know why that when you have depression this front part of your brain tends to shut down more intensely and when that front part of your brain up here shuts down excessively, you can actually have extremely vivid dreams.

>> Now keep in mind, Suzanne, dreams are fantastic.

You want to have dreams, dreams help your memory center your brain down here in the temporal lobe helps the memory center download memory.

>> So dreaming is good.

>> It's nightmares where you're awakening with a startle you're breathing fast.

Your heart's pounding a mile a minute.

>> Those are the kind of dreams we don't want people to have.

But if they're vivid dreams that are awakening that awakening, that's not good.

>> But dreaming is good.

Dreaming is great for a lot of people.

But when people get depressed in general they tend to have more vivid dreams.

>> Antidepressants typically will decrease dreaming so if you give someone an antidepressant it will decrease dreaming until the antidepressant is wearing out and we don't see the vivid dreams as often with the medication like Prozac because Prozac stays in your system for days.

But the shorter acting antidepressants Effexor being at the top of the list Paxil be a no to those two medications, get in your system and get out very quickly and that's why people have so much difficulty with this continuation on those medications because they're getting out of your system so quickly and I've seen this with dreams when people take their antidepressant at nighttime often the dreams will be a little bit more suppressed.

Seroquel Quartier Pain can suppress vivid dreams to some degree and that will work for a lot of people.

Trazodone which we mentioned before has similar mechanisms of action as does Kittie Pain or Seroquel and the receptors they hit on serotonin but for the vivid dreams themselves a simple solution before I have you do anything else in terms of changing anything up, Susan would be simply to take the Effexor at bedtime.

Now you might think oh my goodness, why would I take an antidepressant at bedtime?

I'm going to be awake all night because and a presence can be awakening, alerting and alerting you can take any nighttime except for Wellbutrin .

I've had what people on Wellbutrin even take it at bedtime but usually with Wellbutrin and Bupropion you want to take it first in the morning because it's very alerting and it's chemically structured similar to a stimulant.

So ideally you want to take Wellbutrin in the morning but the rest of them especially if you're having vivid dreams after taking the antidepressants you might want to try the depressants for about a week or so at bedtime to see if it makes much of a difference in your dreaming if the dreaming is intensive and if it's excessive.

>> But talk to your clinician about that as a possibility.

Now we always look at OK, when the dreams start if the dream started right when you started taking an antidepressant it's due to the depressant in all likelihood getting out of your system.

>> But on the other hand, if you had vivid dreams even before you took the antidepressant, that could be part of the condition of depression itself.

People with clinically significant depression as part of their depression will often dream more and when they take an antidepressant especially at bedtime or a longer acting out depressant, they will actually the antidepressants will suppress the dreams to some degree.

So that's a lot of times a bit of a strategy that will use giving the antidepressants at bedtime with the exception I would say of Wellbutrin.

But like I said, some people have taken Wellbutrin nightime and they've done OK.

But talk that over with your clinician Susan and see if that's an option, if that's a possibility.

>> The main hope I would have for you is if the Effexor is working for you it's seventy five milligrams.

>> That's fantastic.

If it's working for you, your moods better your anxieties under better control.

You feeling pretty good.

I'd want you to stay on the Effexor but maybe just take it at bedtime or keep everything else as it is.

>> Susan, thanks for your call.

Let's go to next caller.

Hello Joanne.

Welcome to Mary's Mind.

>> Joanne, you want to know what medications I'd recommend for a restful sleep?

Well, several Joanne I'll start with the ones I wouldn't recommend off the bat.

>> I don't recommend for anybody over sixty five years of age they're taking an over-the-counter sleeping medication which usually will be the antihistamine medications they have dock's el-amine in them which is UNISOM and Nyquil or they have diphenhydramine in them which would be Benadryl in those kind of products melatonin.

>> OK melatonin though is like a puff of smoke and for a lot of people they'll say it doesn't work and they go higher and higher on the doses.

I saw a lady today who is taken ten or fifteen milligrams of melatonin and she's saying she's sleeping throughout the night.

She's a little bit tired the next morning.

But the main thing for her as she got she's getting more intense dreams and even nightmares.

>> Well, if you take melatonin at really high doses, sometimes it can give you nightmares.

I like to use melatonin for people who are mainly having trouble shutting their brains off at night and they're having trouble getting to sleep .

>> Our brain naturally secretes melatonin when it gets dark from the pineal gland which is right smack in the brain here a little pea shaped gland, the pineal gland or the pineal body secretes melatonin which goes up at night as we're trying to get to sleep.

>> So when we're trying to get to sleep melatonin goes up and it's like a puff of smoke .

>> It lasts for about 30 minutes to an hour and it gives your brain the chemical signal to go to sleep so melatonin can be good over the counter if it's something that you want to use just to get you to sleep.

>> But I would not use the antihistamines, the over-the-counter medications if they don't have melatonin is a primary ingredient.

>> So what prescription medications are there?

There are several Ambien Lunesta Senada.

These are medications have been around for a long time.

They work exceptionally well but you only want to use less than two weeks a very brief period of time they will knock you out and we used to use medication called a Restoril Temazepam don't see that use so much anymore but again it's going to knock you out.

Any of these medications can cause you to become somewhat tolerant to them but they do not give you a good quality of sleep.

That's the problem that I have of those kind of medications.

So you don't want to have the medications in the benzodiazepine class.

You don't want to have the medications that are the So Gabb a receptor class they're safer than the benzodiazepines but ambulance's Ambien and Lunesta are medications that for a lot of people they they just get to the point where they get used to them and they don't give them long term benefits.

So we have some other medications coming out that can help with sleep in an entirely different way.

>> They've gobal Samarrah.

These are medications that are affecting Eareckson.

So basically by affecting this chemical called or Rexon also known as Hypocretin, it'll help your brain get to a nice deep sleep very good quality of sleep for many people.

They have to take those medications two or three weeks to get the good quality.

But Dave Go or Bill Samarrah can be very good medications for sleep and then we have the traditional medications for sleep and I can think about the bad of three of them.

We commonly use Trazodone I mentioned earlier between 50 and 200 milligrams at bedtime.

Very safe medication to use if it works for you if you have a lot of trouble with anxiety and you're dwelling on a lot of stuff and you're worrying about things at nighttime we tend to use this anti seizure medications again hasn't been FDA approved for sleep but we use a lot of medications off label for sleep and that would be Gabapentin or Neurontin.

Neurontin been around for a long time.

>> It helps basically calm the brain down, lasts for about eight hours but unlike some of the older medications for sleep it's not thought to be really addictive.

>> People rarely go higher and higher and higher on their doses of Gabb Paignton and then you have Doc Sipan docs happen at just tiny little doses of of doses of three to six milligrams at bedtime can interestingly enough decrease the firing of histamine and in doing so helps you go to sleep.

Histamine is what we have in our brains when we're wide awake histamine skyhigh so there are some medications such as Provigil Nuvigil that actually increase histamine in our brains and it makes us more awake.

Well if you decrease systemis in the brain it can make you more sleepy and that's what the antihistamines over the counter will do.

>> Doxa or a dock's el-amine Benadryl unisom diphenhydramine these are all medications dual block histamine but they do so in such a way that they can make you foggy and give you difficulty with concentration and memory the next day.

Doc pain doesn't seem to do that doc pain only decreases the firing of histamine.

It doesn't affect the histo and receptors.

It doesn't affect the calling receptors at low doses.

Now back in the old days in the 1960s and 1970s and some of these 1980s dock's been used as an antidepressant.

It was called atropine or Synacthen and it was used a dose is between 150 and 200 milligrams a day for sleep anxiety, stomach problems and depression great medication but it caused a lot of weight gain.

It gave people difficulty.

They're horrifically dry mouth made them constipated, give dry eyes, made them lightheaded standing.

A lot of people did not want to take it for depression.

So we're talking about 150 to 200 milligrams a day for depression and now we're talking about three to six milligrams at bedtime for sleep because of those tiny little doses you don't have all those side effects the higher doses of pain will have and you'll get the nice effect for sleep gives you a nice good quality of sleep basically simply shutting down the histamine without affecting the histamine receptors and giving you all those side effects that the older and older older antihistamines will give you now some people will use various other medications for sleep you can use as I mentioned before, melatonin Rosero has been around for a long time.

>> Rosero is more of a melatonin specific receptor stimulator or agonist in such a way that it's a little bit more selective in what we'll do similar to melatonin won't work for everybody.

>> It'll help you get to sleep but it might not help you stay asleep.

So I think the first thing you always have to consider Joanne and something we'll ask everybody who in our in our practice who is having difficulty asleep how long have you been having sleep problems and what are your sleep problems like?

Is it always having difficulty getting sleep?

>> Is it trouble staying asleep?

Do you wake up early in the morning where you need to sleep longer but you just can't do you have trouble with frequent awakening throughout the night?

>> And I'm also going to wonder, you know, have you ever been told that you snore or your pause and your breathing at nighttime because sleep apnea is a huge reason why people have difficulty with sleep disturbances because if you're having pauses and you're breathing and you're literally suffocating at night because you're snoring and you can't get the adequate airflow, yeah, your brain's going to set off an alarm that you're suffocating and you wake up frequently throughout the night and the following morning you're going to have headaches.

You can have nausea all sorts of these weird symptoms the following morning it's because you had a terrible night's sleep because you were snoring and you weren't getting an adequate airflow.

>> So if you're having difficulty with sleep due to snoring or pausing your breathing, that can be a factor .

>> Some people will have difficulty with sleeping because they have restless legs and for those people we will use specific medication that increased dopamine such as such as Perama Paxil that will increase dopamine transmission .

Gabapentin can work for that as well.

We use Horizon as a long acting gabapentin if you're having restless legs so that can be a factor if you're having sleep difficulties because you're specifically having intense dreams or nightmares, especially if you've had post-traumatic stress experiences in the past we might use a medication like Gwon farseeing Clonidine or maybe Prazosin.

These are all medications that can give you a deeper night's sleep and suppress nightmares.

>> So Joanne, it all comes down to what kind of difficulties you're having with sleep in terms of identifying the best things we can do.

As always, we're always going to recommend to people try to go to bed the same time every night, try to get the same time every morning, don't watch television late into the night hours, try to get good sleep hygiene and getting good routine going.

Joanne, thanks for your call.

Unfortunately I'm out 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 via the Internet at matters of the mind all one word at a dog.

>> I'm psychiatrist Jeff Alver and you've been watching Matters the Mind on PBS Fort Wayne God willing on PBS .

Well I'll be back again next week.

Thanks for watching.

Good night