good evening I'm a psychiatrist Fauver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now on its 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.

>> PBS Fort Wayne by dialing in the Fort Wayne area (969) 27 two zero or if you're calling any place else coast to coast you may dial toll free at eight six nine six nine to seven to zero now on a fairly regular basis we are broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Purdue Fort Wayne campus.

>> And if you'd like to contact me with an email question that I can answer on the air concerning mental health issues, give me an email at matters of the mind all one word at a dot org that's matters of the mind Edgard and I'll start tonight's program with an email I recently received.

>> It reads Dr. Fovea, I know you mentioned that there is a shortage of psychiatrists.

When is it OK to only see your primary care doctor for a prescription for mental health purposes?

This is not uncommon as a practice.

About seventy five percent of all antidepressant medications are written by primary care clinicians and that's out of necessity.

Primary care clinicians can often treat uncomplicated depression anxiety if you're having trouble with sleep which is often a precursor to worsening depression for a lot of people that could be very important.

So primary care clinicians are often on the front lines in treating not only mental health conditions but also cardiac conditions, stomach conditions, lung conditions all sorts of other types of medical illnesses.

>> So there often get things started because they're the gatekeepers in many cases for medical conditions and there are treatments.

So with that being said, psychiatrists were kind of the backup psychiatrists across the country right now are heavily utilizing nurse practitioner as a means of collaborators.

Nurse practitioners and psychiatrists commonly will work together as a means of trying to take care of the medication needs for people in the community.

Now psychotherapy talk therapy still is done but it's often done by master's level and doctorate level individuals who are trained in psychotherapy and counseling whereas the nurse practitioners and the psychiatrists are primarily dealing with the medication management.

When I was in my psychiatric training or in the 1980s our primary means of treatment was talk therapy and psychotherapy.

>> I was a pharmacist at the time and I was told back in nineteen eighty three that I'd be wasting my career and in pharmacy if I went into psychiatry because in psychiatry back in those days not many medications were used.

As it turns out I was trained a lot in psychotherapy back in the nineteen eighties but over the course of the past twenty years psychopharmacology or medication management has in the main role of the psychiatrists in the United States and across the world.

So primary care clinicians do indeed often initiate treatment and if they can help you with anxiety, sleep and to some degree the early stages of depression that can be really, really critical.

Primary care clinicians are getting better educated as well about the different types of depression such that there is a so-called major depression where you mainly just have dips of depression.

>> Then you have bipolar depression where you can have highs and lows and with those kind of depressions you do need mood stabilizers.

In either case it's always important to try to address the anxiety and the difficulty with sleep go along with those conditions.

Primary care clinicians are often doing that now what I also like about you're seeing primary care clinician as a possibility for the treatment of depression will be the primary care clinicians also look at medical conditions that are often overlooked by people in the mental health field for instance.

I think it's very important for anybody with depression, fatigue, poor concentration to be assessed for sleep apnea, diabetes, low iron, low thyroid.

>> These are all conditions that are highly comorbid with psychiatric conditions.

>> So primary care clinicians are often very much aware of those kind of conditions and you need to assess the underlying medical condition that might be problematic.

>> Thanks for your email.

Let's go to our first caller.

Hello Rick.

Welcome to Matters of Mind.

Hello, Rick.

Hi.

>> You're on the air.

Good evening.

OK, I recently went through a lot of life changes a breakup which I feel betrayal and my children's lives not turning out very well and I've had problems with them with one of them moving out and I'm and I got a promotion and I got this new job at work and it's really hard and I'm going to seek help tomorrow.

But I want to know what is affecting my mind that I do this pause, rewind and replay and dwell on stuff and it kind of wakes me up and sleep and what am I going through and what should I look forward to tomorrow?

>> Yeah, it's a cascade of type of things, Rick, and I think it's fantastic that you're looking for the new opportunity and again think of this as a new opportunity and try to focus on the positives.

>> Yeah, you should be anxious.

Anxiety is a normal emotion, sadness, happiness, anxiety, apathy, anger, all normal emotions.

And when you're going into a job situation like that, you're getting interviewed.

>> You're learning new type of skills on a job by all means you should be anxious because anxiety will help fire up your brain to pay better attention.

So anxiety actually helps us in some ways so that's why I'm always emphasizing to people Rick don't have a couple drinks before going in there.

Don't smoke any marijuana, nothing like that because it'll impair your ability to really focus.

Here's what happens, Rick, when you have anxiety this anxiety volume control right here called the amygdala.

>> It's almond shaped about the size of your top your thumb and that's the anxiety and anger and irritability volume control.

It gets turned up a little bit when you get anxious.

>> Now that's OK as long as it doesn't get turned up so high that it dampens down the reasoning part of your brain.

The reasoning part of your brain is this pink front part of your brain that's the part of the brain that helps you think focus, pay attention to things, make good decisions, decide should I do this or should I do that?

That's the front part of the brain happening there now specifically in the front part of the brain you've got this left front part of the brain called the left dorsolateral prefrontal cortex big long word for a front part of the brain there.

But this the part of the brain that helps you pay attention to things, focus on what's being said and keep your mind on something.

Well, this part of the brain when you start getting depressed starts to decrease in its activity.

>> When that decreases in its activity, you have a hard time paying attention to things.

Then you got this front part of the brain over here in the above the eyeball called the orbital lateral prefrontal cortex orbital refers to above the eyeball lateral mean to the outside prefrontal cortex is the front part of the brain the orbital lateral prefrontal cortex actually increases in activity for some people when they get depressed and that causes you to start ruminating on things so you start dwelling on stuff and you can't turn things off and that's what you're describing having difficulty with depression which is associated with a decrease in the dorsolateral part of the brain where you're trying to concentrate on things and an increase in the brooding part of the brain when you start brooding on things you start thinking about the negative, especially if you're prone to depression and then you got this inside part of the brain here called the anterior cingulate gyrus.

>> That's the part of the brain that decides she should I do this or should I do that?

>> And sometimes it gets stuck when you start getting anxious because you can't decide.

So you're trying to figure out what's the best decision for you to make the decision.

Pardon?

Part of the brain is right inside here and that gets stuck when you get really anxious.

>> Here's the deal, Rick.

What I would suggest for you this might sound kind of weird.

You've got a big meeting coming at them up in the morning go for a brisk walk for about 30 minutes.

>> Get on the treadmill for thirty, has got an elliptical for thirty minutes.

>> Do something physically active for thirty minutes before you go to the meetings tomorrow morning.

So if that means you need to get up a little bit earlier than usual, do it go for a brisk walk, get your heart rate going.

It's been shown that if you get your heart rate going in the morning it actually will give you a calming effect.

There's a particular chemical that's a protein is released from the heart when you're exercising and this protein will go to the brain and give your brain a calming effect and over the course of the day it actually slows down the heart rate.

So it's called atrial naturelle hormone and basically it's a atrial naturally peptide A in P is the name of it but it's a particular peptide or it's a protein piece that slows down the heart.

>> It gives your brain a calming effect and it's related to exercising and all often try to do this myself.

Rick, if I have to give a talk later in the day, if I have to go to a meeting that I particularly don't want to attend, I'm going to try to exercise specifically in the morning because it'll give me a calming effect and it does another thing for you, Rick.

It helps focus to help you focus and concentration.

So if you exercise in the morning it actually fires up this front part of the brain and in doing so can help you think more clearly throughout the day and you don't have to do it every day necessarily do it on the days you have these kind of meetings like this.

But a brisk walk no more than thirty minutes.

>> Thirty minutes is fine doing some kind of exercise for thirty minutes that morning where all this is expected on you now back in the old days about twenty thirty years go Rick has always thought that you shouldn't exercise if you're prone to anxiety because there is a misconception that if you exercised your heart rate would increase you'd be sweating during exercise and it would actually make you more anxious and just the opposite has been shown to be the case because atrial naturally peptide increases and actually calm you down when you're prone to anxiety, when you also exercise just chemical called brain derived neurotrophic factor which is the brain's natural fertilizer that fires up the front part of the brain.

>> It's like throwing Miracle-Gro in the front part of your brain.

It actually causes the brain's little branches to sprout more and it's thought that when people have chronic depression related to ongoing anxiety they don't have as fluffy as of neurons and they don't have the sprouts coming off the neurons quite as nicely.

So brain derived neurotrophic factor will help the sprouting of those little neurons allowing you to think more clearly and you can increase brain derived neurotrophic factor by exercising.

There's this high school outside Chicago called Naperville High School and about about a little over twenty years ago they started this program where they had the high school kids exercise every morning.

>> They weren't competing with each other.

They're just exercising with the intention of getting their heart rates up and they go for a brisk walk.

They go for the long run.

They were getting timed.

They weren't competing with each other and race is nothing like that.

They just exercised first thing in the morning.

Now you might imagine getting adolescents to exercise in the morning pretty unreasonable but it worked very well and their test scores specifically from the morning classes went up quite substantially such that they are number one in the world with science scores and I think there are a number four number six something like that with math scores.

So there's their overall test scores improved dramatically and it was thought to be drug the attributable to their exercising for about 30 minutes or up to an hour first thing in the morning and they did so first thing in the morning and they found that they were less prone to be sleepy in the morning.

They're more awake and that's interesting because in high school your adolescent brain is still growing this front part of the brain continued to grow until you're twenty four and in high school as your brain is still growing by nature you want to go to bed later at night and get up later that next morning and that's why some high schools have pushed back their start times in the morning because I realized adolescents are not early morning people.

>> Well, I find it interesting that Naperville High School had these children and these adolescents exercising first thing in the morning when they weren't entirely awake telling you that a cup of coffee is good for waking you up but exercises too and that can actually help you throughout the rest of your day.

That's a simple exercise to try to get you to that day just on the days when you're going to be learning these new things are interviewing, exercising every day is great.

But on those days in particular you want to try to get some physical activity first thing in the morning to try to give a calming effect, help with anxiety, help with depression.

People ask me all the time what's the best natural thing I can do to help with anxiety and depression?

>> They're often expecting me to recommend some kind of herb or yoga or meditation and those are okay perhaps.

But exercising is the very best natural thing you can do to help with anxiety, to help with sleep and to help with depression.

>> Rick, thanks for your call.

Let's go next caller.

Hello Joe.

Welcome to Mars.

The mind.

Joe, you you wondered how might an amputee exercise to emotionally boost themselves?

I'd certainly defer that kind of response to a physical therapist to the first thing I'd want to do is have you contact a physical therapist if you're an amputee and see to what degree you're able to move around and physical therapist are really good at determining what exercises you can do within your physical abilities.

>> Now when I talk about exercise, Jo, I'm talking about within your physical ability.

I would not expect somebody who's never exercised in their lives in their lives to go out and run a five k you have to start slow and for many people that just going out for a walk maybe one block two blocks around around the area, the neighborhood and gradually building up even marathoners don't start off running 20 mile runs.

They will gradually get into the routine of running three and six mile runs.

So you have to know what you can do within your ability.

But any kind of movement, any kind of exercising even a brisk walk can fire up these very important chemicals that can help with concentration, with anxiety, with sadness and certainly help with sleep.

Now sometimes people ask me should I exercise at a morning or in the evening?

You have to be careful about that sometimes because if you exercise later in the day specifically after 7:00 p.m. sometimes it'll disrupt your sleep and you won't sleep as well.

You have to determine what works best for you now when I was younger my goodness I can go out running when I was in medical school a bunch of us ran in the middle of the night one o'clock two o'clock in the morning after we were in our cadaver labs in the middle of the night and that was just a regular thing for us and we get up the next morning seven or eight o'clock in the morning and go to classes.

I could do that when I was in my 20s but when you get in your 40s or 50s when you start exercising after about seven p.m. it might disrupt your sleep and that's where you know you shouldn't exercise in the evening.

So two things you really shouldn't do in the evening after seven or eight o'clock try not to eat anything because that disrupts your sleep but also be careful about exercising later in the evening.

But if that's the only time you can exercise and quite frankly that's how a lot of these twenty four hour fitness centers got going because some people just can't exercise until they're in until they get in there in the evenings.

Maybe they they work second or even third shift for that matter and that's the best time for them to to work out.

>> That's OK if that's when it works for you and you're still able to sleep.

>> But for most people the best time for them to exercise is in the morning because not only will that have less impairment on your sleep but it also will help you with concentration and focus as the day goes on.

>> Joe, thanks for your call.

Let's go to our next email our next email reads Dear Dr.

Favor, are there any new medications being developed to decrease appetites related to psychiatric medication?

I heard of a medication that sounded like Sammy Davis.

I believe you're referring to Sammy Dauphin.

That kind of sounds like Sammy Davis.

But Sammy Dauphin is a medication that is doesn't have a trade name yet but it's a chemical is being added to a medication called Olanzapine and the two of them and in combination are called Leibovici basically olanzapine is a medication has been around for twenty five twenty six years and it's a medication that's very effective for schizophrenia and for bipolar disorders.

We use it for a lot of different conditions.

But the problem with olanzapine historically has been the weight gain that it can occur over the course of three and six months even over the course of a year.

So Sammy Dauphin is a medication.

It's interesting and how it works it blocks these opiate receptors.

Does it stimulate opiate receptors?

It blocks this particular opiate receptor and there's three main opiate receptors.

There's MUE receptors, delta receptors and kapa receptors.

It'll profoundly block the receptionist thought that if you block the receptor it'll decrease your appetite.

>> So on one hands opiates themselves can cause people to have an increased appetite if you block the receptor the opiate receptor it can decrease the appetite or at least decrease the likelihood you're going to gain weight from a medication like Olanzapine.

>> So that's the newest medication.

It's been developed specifically for the purpose of suppressing the appetite related to another medication causing that for a long time we've used topiramate topiramate is an old anti seizure medication that as a side effect in migraine studies when they study for migraine headaches they notice the side effect being that you had a decreased appetite and topiramate as a side effect can decrease a person's appetite.

So that's sometimes a possibility.

Very commonly people are getting a particular type two diabetes medication is very inexpensive called metformin metformin.

The old trade name used to be called Glucophage but you don't hear called that anymore.

>> But metformin is a medication that is typically dosed between five hundred and thousand milligrams twice a day.

>> You take it twice a day sometimes with food, sometimes not.

But it will decrease the amount of glucose being absorbed in the intestine and also decreases the production of insulin and the liver thereby decrease in the insulin surge and the UPS and downs of insulin that can occur and will make insulin receptors more sensitive in that way.

So Metford is active actually affecting glucose metabolism and insulin receptivity and in doing so can possibly decrease the weight for some people who are prone to Type two diabetes.

>> Other medications can to some degree decrease the appetite.

We'll use a medication like Vyvanse for instance.

This medication has been around for a long time.

It's a long acting amphetamine and has a long active amphetamine.

It can suppress the likelihood for people who are prone to binge eating now binge eating is where you keep eating and eating and eating even though you're not hungry and it's kind of also known as emotional eating.

>> But when people are emotionally eating they actually eat to the point where they physically hurt and they'll eat in secret.

They're ashamed of it.

>> Sometimes with binge eating people will turn to bulimia and they'll make themselves vomit and they have this horrible cycle of bingeing then vomiting and they go back and forth.

Well that's binge that's bulimia binge eating disorders where they're only binge eating and they gain more and more weight from doing that.

>> But they're they're not eating because they're hungry.

>> They're eating because they're trying to fill an emotional void.

And when you eat and especially when you Bengie it will increase insulin production but increasing insulin production will increase the transportation of tryptophan into the brain and tryptophan is a building block for serotonin.

>> So briefly when you binge you feel a sense of bliss and happiness and you feel a little bit less anxious.

So binge eating does serve a emotional means.

>> It gives you a little bit of a chemical reward and gives you a calming effect when you binge.

But the problem is that's short lived.

What happens in is going sky high but then it crashes and you have this up and down of insulin in your brain and in the rest of your body and that leads to insulin resistance and that leads to weight gain for a lot of people.

>> So that weight gain insulin resistance gives you type two diabetes which is where your blood sugars will gradually go up and up and up.

So a lot of the newer medications for Type two diabetes are trying to address the weight gain as well as the glucose management as well.

But a real inexpensive one that we use in psychiatry have been well studied with psychiatric medications is a medication called metformin.

>> So metformin twice a day is a means of trying to address the precursors to the to the metabolic syndrome.

>> Metabolic syndrome will be where blood sugars are going up ,blood pressure is going up, your waist circumference is increasing.

>> You have higher triglycerides, metabolic syndrome will we'll include all these different precursors to diabetes, stroke and heart attacks.

>> So we try to get that under better control as soon as we can.

Thanks for your email.

Let's go to our next email our next e-mail reads Dear Dr. Fauver, my wife takes escitalopram.

>> It's also known as Lexapro Bupropion that's also known as Wellbutrin and gabapentin also known as Neurontin are adverse sensitivity to touch and loss of libido common with antidepressants?

Will these side effects reverse with time medication or counseling?

>> The ESCs Citalopram also known as Lexapro can to some degree decrease the libido.

It's increasing serotonin and it can decrease sex drive by indirectly decreasing dopamine.

>> So if you increase serotonin you can indirectly decrease dopamine.

>> Now Wellbutrin or bupropion can offset some of that so that's good.

But the other drawback of escitalopram for some strange reason that sometimes will decrease make your sensitivity to touch a little bit different for some people it's excessively sensitive on the people it's decreased has they have decreased sensitivity but that also is a serotonin effect.

Gabapentin not so likely to be a culprit with those particular problems will the difficulty with libido and sensitivity touch decrease over the course of time?

>> Maybe, but more likely if you decrease the dosage under your supervision that might be a better way to go.

So for some people twenty milligrams of escitalopram is too much.

Your wife might be taken 20 milligrams if that's the case going down to ten might help sometimes going down five helps even more but there are other medications that can be used other than escitalopram.

>> They can give that serotonin enhancement and might not cause as much difficulty with libido and sensitivity to touch.

One of them is called Trents also known as Forty Occitan.

Twenty six blood levels will double if you also take it with bupropion or Wellbutrin which you had mentioned your wife is taking.

So you do have to start with a really low dosage of treinta.

But Trent has actually been studied head to head with Lexapro concerning sexual functioning and libido and it's been shown that Taryn talks is much less likely to cause sexual disturbances compared to Lexapro.

Same could probably be to be true for the difficulty with a sense of touch as well.

>> Thanks for your email.

Let's go next caller.

Hello Jerry.

Welcome to Mastermind.

Uh yes.

I was wondering what was cause the increase of myopathy with anxiety I guess currently on Larita in type gabapentin but the gabapentin seems to be only on one hundred milligrams seems to relate to me for a loop the next day one hundred milligrams of Gabapentin Nakatani for a loop you're a very sensitive gabapentin but are you on Lyrica as well Jerry Correct.

>> Those are two chemical cousins now I've seen them use together I wouldn't myself use that combination.

>> Lyrica is also known as pre Abberline and Gabapentin is also known as Neurontin.

So you got gabapentin and Pregabalin, their chemical cousins are both affecting this little calcium channel and I'm wondering if you're so sensitive to Gabapentin because you're also on Lyrica now Lyrica is typically twice a day dosing and not uncommon.

You'll see people go to 225 milligrams twice a day, maybe 300 milligrams twice a day on Lyrica gabapentin if you add that on top of it'll make you really tired.

Luppi So what I'd wonder would be if you could take one or the other to see how they did.

We do have people on Gabapentin who pay itself a hundred milligrams is just too much makes them feel loopy.

>> What do we do that comes there's a gabapentin solution and the Gabapentin Paignton solution is basically 250 milligrams per teaspoonful.

>> A teaspoonful is five milliliters so you could take one milliliter which would be fifty milligrams half the dosage that's in a small associative capsule for gabapentin.

So that's one option take have a solution take one milliliter or even take just a few drops to give you less and less and less.

But if you're really sensitive to gabapentin itself you could get by on a lesser amount.

The cause of neuropathy is partially due to an itchy trigger finger at these calcium channels.

>> A calcium channel when it opens up will make you hurt and sometimes give you an increased sensation of pressure and more sensitive to touch and give you a burning sensation.

So if you have an itchy trigger finger of these calcium channels you'll have more pain and more sensitivity and more burning the idea of gabapentin and pregabalin which Neurontin and Lyrica respectively is that they will modulate and stabilize these little itchy trigger fingers so they're not the channels aren't opening as much.

>> It'll give you less likely to have that kind of pain.

Another means of helping with pain, Jerry and you probably encountered this will be to give Fluoxetine also known as Cymbalta.

It increases serotonin and norepinephrine and will dampen down the pain signal coming up the spinal cord so it puts the brakes on the pain signal.

>> Coming up, the spinal cord itself.

>> 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 WFA a drug God willing and PBSC willing.

>> I'll be back again next week.

Thanks for watching.

Goodnight