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

Wayne, Indiana.

Welcome to Matters of the Mind now as 23 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 any place coast to coast you may dial 866- (969) 27 two zero now on a fairly regular basis I am broadcasting live every Monday night from those spectacular PBS 14 PBS Fort Wayne studios which lie in the shadows of the Purdue University 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 a dot org that's matters of the mind at WFA beeg and I'll start tonight's program with an email I received over the past month or so and it reads Dear Dr. Farber I am taking 30 milligrams of Cymbalta that's also known as Do Occitan for anxiety.

>> But since taking it I'm experiencing moments of anger and lack of patience with others.

Does this mean that I'm not taking enough or is Cymbalta just not compatible with me?

This is one of the drugs recommended by genetic testing.

Well, there's a lot of different questions within that question.

This genetic testing on one hand gives us an idea on what direction to go.

>> It kind of tips the scales in determining which medication we should use.

However, it's not definitive.

>> We call genetic testing more probabilistic but it's not definitive.

In other words, you need to look at somebody's symptoms, look at their past track record of medications.

We like to look at the patient's family history of medication responses.

We look at the whole picture overall and determine if Cymbalta is going to be the best fit or not.

>> Cymbalta is known as Dellucci and it's a medication that when used at higher doses for some people can make them more irritable.

Now that can be a tip off that you're having more difficulty with mood swings and highs and lows.

>> So if you notice that you're more irritable, more impatient and also you're all getting more hyper and you're not needing to sleep as much, those factors can be contributing to the possibility that you might have a bipolar spectrum condition where you're not just having lows or anxiety for that matter but you're having highs and lows.

You did mention you're using it primarily for anxiety and typically Cymbalta for anxiety does fine at lower doses.

But for you that little surge of norepinephrine that's giving you might be causing you to have some irritability in relationship with anxiety.

Now we use it for depression and anxiety for depression.

Sometimes people need that increased transmission of serotonin and norepinephrine and that's what Cymbalta does.

>> But for anxiety many times people will get adequate effects with an increase in serotonin and maybe a little bit of norepinephrine effect and perhaps in your case you're getting some irritability either because it's just not a good genetic fit for you.

>> But you mentioned it was or perhaps you actually have mood swings mean highs and lows.

>> But thirdly, getting too high of a dose is Cymbalta can sometimes make a person irritable.

Why shouldn't we all take a medication like Cymbalta for this very reason?

If you take Cymbalta and you don't typically really need it instead of giving you the good effects you're trying to expect, do you actually feel a little bit agitated and irritable?

>> So if you take Cymbalta and you don't have adequate an adequate degree of anxiety depression it just makes you feel worse and maybe you're getting a bit too high of a dosage on as it is right now.

>> But I'd have your clinician take a look at not only the genetic testing because that could be a tip off.

>> Genetic testing looks at how well you metabolize the medication.

How will you break down the medication?

And in the case of Cymbalta, if you're a normal metabolism on these two different enzymes, one's called to desex and one's called one a four if you're a normal metabolize on that, the genetic test is going to say you're good fit for Cymbalta but it doesn't take all these other factors involved.

We consider this one enzyme that's a gene called C OMT chemical or methyl transferee and C OMT if it has the code of Memet we find that Cymbalta does better for those people but I doubt the genetic testing made the recommendation based on that particular ISO enzyme.

But the genetic testing to which you referred does look at C OMT so take a look at your see OMT.

>> If it's Memet you're a better fit for Cymbalta compared to some other medications so that might be a factor but it doesn't make any more irritable.

>> I bet you if you went to higher dosage it's going to make you feel worse.

>> Typically it means you need to go to a lower dosage and that often takes care of it for a lot of people.

>> Thanks for your email.

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

Our next e-mail question reads Durata Fauver I am on forty milligrams of Cymbalta.

This is a different person but also on Cymbalta.

Forty milligrams of Cymbalta and need to take ten milligrams more.

>> Is it OK to split one of the twenty milligram capsules and take it in this manner?

Are there any side effects I can expect?

Well Cymbalta does indeed come in twenty milligram forty milligram and sixty milligram capsules and if you and your clinician decide fifty milligrams might be the sweet spot for you it's kind of awkward to get there but there are ways on one hand you could take forty milligrams one day and sixty milligrams the next day and alternate back and forth there would be a slight chance a little bit of withdrawal going from 60 to 40 each to each time you do that but that's sometimes your suggestion of splitting the capsules in half can be done believe it or not Cymbalta is actually studied long time ago by Lilly down in Indianapolis for people who had bariatric surgery and with bariatric surgery you have to be very careful about slow release products because they don't get absorbed very well.

But Cymbalta was studied on applesauce or yogurt where the capsules were indeed taken apart and the entire amount of the capsule all the beads were poured out over some over applesauce or yogurt.

>> It was found to be adequately absorbed that way theoretically you could take that capsule apart, pour out half the beads.

The question I would have is how do you know you have half the beads?

You're not going to count them one by one.

It would be a rough estimate of half the beads.

>> Perhaps you'd use one half one day and the other half the next day.

But your question is could you do?

>> Yeah, you could.

And if you poured out the beads on applesauce or yogurt they would get absorbed CYMBALTA as the chemical do fluoxetine and do Fluoxetine doesn't get very well absorbed when it gets exposure to the acid, the acidity of the stomach so for that reason they put this little coating around the Cymbalta drug and those are the little BJC That coating allows Cymbalta to go through the stomach and it gets released and absorbed in the small intestine.

>> But if Cymbalta gets exposed to the acidity of the stomach, the molecule gets destroyed.

That's why it's in Bede's like that.

>> But those beads can be broken apart, put on applesauce or yogurt.

The estimating of the half the half the caps would be your biggest challenge there.

But like I said, the other option would be going forty one day 60 the next day and going back and forth like that and that's what a lot of people would do when they go to 50 mg but the usual incrementing incremental change will be 20, 40 and 60 for a lot of people.

>> Thanks for email.

>> Let's go to our first caller.

Hello Tyler.

Welcome to Matters of Mind.

Tyler, you're wondering about the best medication to control a depression you've had for over five years.

You can't even put your finger on it on why you're depressed and just want to feel better.

>> One of my suggestions, Tyler, the first thing you need to do is go to a mental health clinician or perhaps a counselor and sort out that you do indeed have depression related to a chemical disturbance in the brain because when you have depression as we call a clinically significant depression as a major depression, it's it's where you have difficulty with sadness, lack of enjoyment and things you might not have motivation, energy get up and go.

You might have sleep disturbances, appetite disturbances.

>> You don't feel good about yourself and all these symptoms Tylor are causing you day by day by day for at least two weeks to have what we call functional impairment.

>> In other words you're having a hard time getting stuff done because of the functional impairment itself.

And with that being said the first thing we want to do is make sure you don't have a medical condition that's contributing to these kind of symptoms because those are often overlooked.

>> We have to address them.

>> We need to make sure you don't have low thyroid for instance, diabetes, low iron and very commonly sleep apnea where people snore at night and because they snore they don't get adequate air flow to the lungs and thereby less oxygen in the brain and with less oxygen to the brain that gives people difficulty with feeling tired.

They have trouble concentrating the next day and they often come across as having depression.

But let's say you do have depression.

Where should you start the first place you should start Tyler is talking to family members asking if any family members had any similar symptoms and very importantly how were they treated if they were with medication the what medications help them?

What medications did not help them?

What side effects did they have?

>> I mentioned genetic testing earlier with an email question in the case of genetic testing that gives you an idea of kind of how you might respond to different medications but very importantly will be how your family members have responded, especially a first degree relative such as a mother, father, brother, sister.

They can be very, very helpful in helping you understand what might work for you.

So the first thing I would do is make sure that you truly have depression is not due to a medical condition if it is depression, OK, sometimes there's reasons, sometimes there's not.

>> But back in the old days we always kind of assumed back in the 1980s we always assumed there must have been a reason why people got depressed nowadays we just realized you might have a genetic predisposition.

>> Stuff happens you can have covered for that matter can set people off in depression when they might not have previously had depression.

So there can be triggers for the depression themselves and that can sometimes set people off.

>> Now we do know, Tyler, that typical guidelines for the treatment of depression will be to start with a medication that enhances serotonin and you'll often hear about people starting with a medication like Prozac, Zoloft, Lexapro, Celexa or maybe Paxil.

>> These are all medications that selectively and specifically increase serotonin.

The problem with that will be if you've had what we call adverse childhood experiences, if you've had some trauma before the age of eight years of age where you had some tough stuff going on in the household, your parents were divorcing a parent went to jail, you had some physical or emotional abuse.

You were knocked up against the wall if you had some kind of emotional physical or sexual trauma especially prior to the eight years of age that can be a predictor that you will not respond so well to the serotonin medication.

So that's why we will often complete this questionnaire and it's free online by the way, called the Adverse Childhood Experiences Questionnaire that goes by a key adverse childhood experiences questionnaire.

>> It's ten questions and if you score roughly four or more it might be suggestive that an SSRI or a serotonin antidepressant will not work for you.

>> So in those cases we often start with a medication like Cymbalta or Wellbutrin or even Raymarine for that matter based on your symptoms.

Now those symptoms are called a phenotype a phenotype basically will describe what your symptoms might be.

>> So we put all that together.

We look at your current symptoms.

>> We look at your past childhood experiences if they were a factor, we look at how your family members have responded.

>> We make sure that you haven't had any medical conditions that might be contributing to your current symptoms and if we choose a medication we try to consider all of that and at any time you're always welcome to have talk therapy or counseling as a means of trying to sort through some contributing factors that might have led to your getting some depression.

But nowadays we consider depression to be a condition where you can in some cases have a full body inflammatory inflammatory reaction and with a full body inflammation you can actually feel tired and don't have much motivation and you just feel like all the air has been taken out of your sails so we have to consider those factors as well when we choose an antidepressant.

>> Well, thanks for your thanks for your call, Tyler.

>> Let's go to our next caller.

Hello Mickey.

Welcome to Matters of Mind.

Well, Mickey, you had said that you have a four year old who's exhibiting symptoms of hyperactivity and lack of focus.

Should you just tell the four year old to write it out and maybe outgrow it or consider a medication?

>> Well, when you have a four year old who has hyperactivity and lack of focus, you have to consider how that compares to other so-called normal four year olds and many times it requires an astute pediatrician or a child psychiatrist to kind of sort through that or perhaps a child psychologist, somebody who specializes in really evaluating four year olds.

Now there are some things you can do, Mickey, in terms of trying to figure out if this is early the early symptoms of ADHD Attention Deficit Hyperactivity Disorder is where you will indeed have difficulty with focus and hyperactivity.

>> Part of that is from the lack of adequate development of front part of the brain.

The brain slowly develops on its front part of the brain that's responsible for focus and impulse control that actually grows last so that doesn't fully grow into your twenty four .

>> So a four year old has a very undeveloped front part of the brain.

>> That's why we need to be very, very patient with two year olds, three year olds, four year olds because they truly don't have adequate brain development and that's why they will have to have a fit every now and then.

>> So with that being said, you don't want to medicate a four year old unless that four year old is so out of control that behavioral techniques have not been effective and it's significantly affecting that four year old's ability to go into preschool and be able to interact with peers and that's where you often draw the line.

There's a lot of behavioral techniques that could be done.

You have to have the the parenting skills that are taught.

I would strongly recommend you go that route in terms of determining what kind of things you can do to try to help your four year old get through those spells of hyperactivity and even be able to focus.

>> But if your four year olds going into preschool and it's so disruptive they can't have your four year old in the class, that's where you might want to consider going the next step for a medication.

But especially for four year olds.

>> We might hold off on that if you're six, seven and eight years of age and you're getting behind in school because of lack of focus and hyperactivity and so forth, that's where we want to be careful not to allow that child to fall behind in school now with ADHD, yeah, we have symptoms of ADHD we'll examine but we'll also look at family members that might have similar symptoms so if you have family members especially a mother, father, brother or sister who have similar symptoms of ADHD and they were successfully medicated with this medication or that medication maybe this or that medication might be helpful for this person you might be considering treating so we have to take that in consideration.

ADHD is about sixty five seventy percent genetic it's highly, highly genetic so it does run in families and not uncommonly when you hear about one person in the family with ADHD symptoms you'll hear that.

Oh yeah.

The mother the father had similar symptoms and what's sad about that is if the mother and father had similar symptoms the mother and father might not have had adequate treatment in the past and that could have caused them to kind of lag behind in school.

>> People with ADHD often are free thinking entrepreneurs.

They often have higher IQ compared to people without ADHD.

>> It's just that they can't get things done so they have a hard time reading and comprehending they have a hard time sitting still.

They have a hard time focusing on one conversation because they're thinking about three and four conversations outside of their area of focus so people with ADHD have a difficult time being able to adjust in society and getting things done.

>> So with that being said, it's important that we treat people for ADHD in the elementary school years if they have adequate evidence of ADHD and you have to kind of compare ADHD to needing eyeglasses.

If you have nearsightedness and you have poor vision you put on eyeglasses it can be a life changing experience.

The same can be true in grade school when you have ADHD and you get adequate treatment.

>> Thanks for your thanks for your call there Mickey.

Let's go to our next caller.

Hello Mike.

Welcome to Matters of Mind.

>> Hi Mike.

I called I take the impact of how you spell it.

Yeah 50 mg I take two a day and since I've been taken I've been getting it back and so anything I can do to to suffer should I take less of it?

>> Yeah.

Mike, the purpose of impact is what oh why are you taking them apart from party to hear me ok I can the reason I ask about the purpose of impact Mike will the impact can be used for seizures if using it for seizures you don't want to change the dosage unless you have careful interactions with your clinicians who's prescribing it.

>> So that's very important.

>> Some people take them out for migraine headaches.

If that's the case by all means talk it over the clinician again.

But if your clinician did decrease the dosage that might decrease side effects now Mike, as a as a former pharmacist myself, I always remember in pharmacy school I learned that the first thing we always do in terms of examining side effects from any medication will be to look at when the side effect started and if the side effects started shortly after you change the dosage or started a medication by all means that's probably the medication doing that and you hit the nail on the head decrease the dosage often can help.

However the reason I ask about the purpose of impact is because if you're using vent pad for seizures you need to get that dosage spot on of the vent and you can't arbitrarily lower that dosage because you'll have seizures again.

>> Now some people will use vampyre for other reasons and they can use sub seizure threshold, sub seizure medication, dosage dosages for those cases and they can lower the dosage but talk it over your clinician.

But bottom line is if you notice you started having backaches shortly after starting the vent pad or increasing the dosage that indeed can possibly be related to the out like thanks for your call.

>> Let's go next caller.

Hello Lucy.

Welcome to Matters of Mind.

>> Hello.

Hello Lucy.

You're on the air.

Hi.

Oh I'm sorry I have a I've been following a lot even it was a week ago today that I fell and I look it up my ribs and they hurt so bad it's just not funny and I yeah I have a broken ankle.

Oh my goodness.

Oh no.

You know I've got my revelator and when I need to get around with but I take so many different medicines I just doesn't can't one maybe not agree with the other.

>> It happens sometimes Lucedale keep in mind I'm a psychiatrist so in assessing somebody for falling if I was to see somebody and they were having difficulty falling I am indeed going to look at the medications and also take a look at your blood pressure.

There's a way that you could check for blood pressure somebody lays down for a little while, you check your blood pressure, then they stand up abruptly.

We call that orthostatic changes where they stand up and we compare their blood pressure upon laying down.

Now are there as a psychiatrist I can perhaps mention or comment on those medications.

>> Are you taking any medications for your nerves?

>> Yes.

Which ones are you taking, Lucy?

Flextime.

I had two hundred milligrams of triacetone to sleep and I take 60 milligrams of flextime.

Mm hmm.

And then I also take oh my gosh a second after it's I take two more things Haidara oxen to go to sleep hydroxyl hydrazine now.

>> Yeah and I can tell you the name of the others so I've been taking them forever.

>> If you've been taking them for a long time and you didn't fall before that could be a factor.

The reason people can have difficulty with falling can be dehydration and that's worsened by certain medications of the ones you're taking.

Trazodone sometimes can give you difficulty falling the next morning it tends to stay in the system longer than eight hours or so for a lot of people.

But you take it 200 milligrams of Trazodone sometimes that'll make you have some difficulty with falling the next morning hydroxyl zeins not so problematic with that hydroxy is an antihistamine but it's a medication that typically will not give you a lot of difficulty with lightheaded.

So you're spot on there are some medications can make you lightheaded and you want your prescribing clinicians to take a really good look at all the medications you're taking to see if any of them could be causing to have lightheadedness.

But yeah, get your blood pressure checked that might be getting a little bit low on you and make sure that you have adequate hydration, drink plenty of water and drink plenty of fluids as a means of keeping your hydration adequate.

>> Lucy, Lucy, thanks for your call.

Let's go our next caller.

Hello, Heidi.

Welcome to Mars The Mind.

>> Hi, Dr. Farber.

Hi, Heidi.

Thanks for taking my call.

Sure.

Thank you so much.

You say your work in the community thank you.

Definitely yes.

Absolutely.

So I just had a question my son and I have both struggled with ADHD mind wasn't diagnosed till I was an adult but his has been I think as a byproduct partly of him having seizures as a young child and he's been seizure free now for ten years.

Great.

But yeah I know I'm so thankful we did the ketogenic diet so that seems to definitely help him and cleared about but again, you know now we've been dealing with more anxiety and ADHD side effects.

He's taken stimulants in the past but those have caused tics and some anxiety as a result.

So we've looked he's also taken things like Satara and on FSN but we we'd really like to try and find something more natural for him as far as you know, vitamins or things like that.

>> Just want to get your feedback.

Natural treatment for ADHD has not been highly successful of all the naturally occurring chemicals that have been beneficial for ADHD.

From my experience and from looking at the literature that's been available it has been caffeine now do you give caffeine tablets to a child?

Probably not.

But adults for instance who have difficulty tolerating various doses of stimulants and constituents as your son has tried, adults will sip on coffee throughout the day.

>> Now there's a possibility it's a little bit less effective than caffeine but green tea has been shown to be effective for concentration and anxiety, especially at higher doses.

>> Now you can get green tea capsules where it's easier to take that way.

Otherwise you have to drink about fifteen or twenty cups of green tea every day.

But green tea is something it can naturally help with that.

>> But in terms of a naturally occurring type of chemicals out there for ADHD, caffeine is probably the best thing that's that's available.

>> I really couldn't responsibly recommend anything else.

St John's Wort for instance could possibly be helpful but that has a lot of side effects at any time you St John's Wort, John's Wort you do have a lot of drug interactions that can affect somebody who's already on anti seizure medication so I wouldn't really recommend that this point Heidi.

>> Heidi, thanks for your call.

Let's go our next caller.

Hello Jonathan.

Welcome to Matters of Mind.

>> Hello Jonathan.

Jonathan, you want to know if I had any advice on dealing with covid panic and fear and being around crowds?

>> That is a that that is an after effect of covid Jonathan.

Now on one hand when people have experienced covid they can have this residual anxiety and it's really because it goes directly to the brain so is going to the brain and in going to the brain it can give you difficulty with after effects for anxiety in the mood itself.

>> So if you've had covered that could be a factor people sometimes with the covid restrictions where they've had to wear a mask, they've had to isolate themselves away from other people getting back out and about with crowds has been somewhat problematic for them.

>> So the key would be to gradually get out of the house, gradually get around small groups of people and desensitize yourself because one of the best ways to get over any fear, Jonathan, is to gradually expose yourself to that fear.

So if it's a fear of being around large crowds get out small crowds for a little while, then get around bigger crowds as time goes on so the more you're exposed to the the things that cause you fear, the less your brain becomes sensitized that it's a dangerous situation.

>> Jonathan, 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 about mental health issues, you are a contact me via email at Matters of the Mind at WFB dot org that's matters of the Mind at WFA ECG.

I'm psychiatrist Ja'far and you've been watching Matters of Mind on PBS for Wayne God willing and PBS willing.

>> I'll be back again next week.

>> Thanks for watching.

Goodnight