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

Welcome to Matters of the Mind now in its 24th 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 else coast to coast you may dial 866- (969) to seven to zero now on a fairly regular basis we're broadcasting live every Monday night from our spectacular PBS Fort Wayne studios and if you have any questions that can answer on the air, you may write me via the Internet at matters of the mind all one word at WFYI Dog and it looks like I have a question right off the bat here it reads Dear Doctor, Father, can you explain what postpartum depression is and how it differs from regular clinical depression?

>> Postpartum depression like the name implies refers to having depression after a woman has baby.

>> Now there's true postpartum depression which is clinically significant where it's causing impairment in the woman's ability to care for herself and to care and care for her baby.

>> Now you have baby blues which occurs in about four out of five women after delivery and baby blues is a mild depression.

>> It's thought not to be highly problematic.

It's just that a woman feels more sad, more moody, might be more tearful during that time but major depression in the form of postpartum depression is where a functional ability is impaired and a woman has difficulty taking care of herself and her child and that's what we call postpartum depression.

>> It occurs in about I've seen five to 10 percent of women after delivery and it occurs particularly the first two months after delivery because during that time that the estrogen and progestin alone that were sky high during pregnancy are plummeting now during that time there's that plummeting of estrogen and progesterone that can cause a lot of depression but also during that time you have this increase this dramatic increase in this chemical by the name of oxytocin.

>> Oxytocin comes from the pituitary gland which is right smack in the middle of the brain.

Oxytocin can go up like 80 times the usual level when a woman delivers a baby and that's the bonding hormone and the question is is postpartum depression also influenced by deficiencies in oxytocin in these women because postpartum depression should lead to increased bonding with the baby.

Postpartum depression is something that often leads to a deficiency in that kind of bonding and it's not uncommon when I see a woman who comes in to my office back when we were able to see people in our offices.

But when I see a woman come into my office she'd often come in with her mother, her mother in law or some other family member and that other family member would be holding the baby and the woman with postpartum depression seemed to have that bit of detachment from the baby.

She didn't seem as interested in the baby as you might expect for a newborn and that's where you realize it's problematic and that's where postpartum depression can be highly dangerous because that lack of bonding, those first few weeks that those first few months after delivery is not only hindering the mother's mental health but it could affect the baby's mental health long term because that bonding is very, very important.

>> Why does it occur?

Well, it's thought to be due to the disturbances and hormonal levels including estrogen, progesterone, possibly oxytocin .

>> But it's more common with women who had prior postpartum depression.

So if a woman had severe postpartum depression after her first after her second after her third delivery and now she's had her fourth baby, she's more likely to have postpartum depression.

So for women like that we will often be proactive and try to give them antidepressant medications even in their third trimesters anticipating that they might have postpartum depression following delivery.

You're also more likely to have postpartum depression if you had a prior history of major depression.

>> So even when you weren't pregnant you had a greater likelihood of depression.

And finally there's a higher likelihood for postpartum depression, especially if you have a family history of depression.

>> So if a woman has a mother or father, brother or sister with depression, that woman will be more likely to have postpartum depression.

Now it's not uncommon that we also see women have more postpartum depression if they had complications add delivery ,if they had a lot of stress going on in their lives.

>> If there's relationship difficulties such as the father of the baby no longer wanting to be a part of of of the family life all sorts of different stresses can bring out the postpartum depression.

But it's highly predictive if a woman has previously experienced postpartum depression.

>> Thanks for your email.

Let's go to our first caller.

Hello Mike.

Welcome to Matters the Mind.

>> Well, Mike, you want to know what is reactive attachment disorder to developmental disturbance where as a child you can have difficulty with attachment and bonding.

And Mike, you might have been listening to my discussing postpartum depression because that's part of the reason that can occur.

>> It's where a baby and a small child just doesn't bond adequately to a parent or especially the mother.

And because that bonding disturbance that can potentially lead to depression later on.

>> Now I'm not a child psychiatrist.

I know a little bit about child psychiatry.

It's something we we we studied in our training as a general psychiatrist but I don't typically see children at this stage of my career.

But reactive attachment disorder is where it is best treated with psychotherapy and counseling.

Play therapy is commonly used for and also family therapy as a means of helping that child try to bond with the parents, especially the mother with whom the child often finds difficult to bond and again thought to be due to the mother having difficulty bonding at an early age due to the postpartum depression that's so commonly can occur during that time.

>> Mike, thanks for your call.

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

Our next e-mail question reads Dear Dr. Fauver, what's the effect of a brain injury on personality and mood to all concussions cause permanent damage.

>> A brain injury can include a concussion but it can also include a stroke or some kind of hemorrhage in the brain.

>> And basically if you look at if you look at how the brain sits in the skull, the skull is rock hard but the brain has the consistency of jello inside the inside the skull.

>> So when there is a concussion it means the brain got bounced around inappropriately and when the brain gets bounced around it's almost like you have somewhat of a brain bruise.

>> It doesn't show up on an MRI of the brain.

So when they do scans of the brain after a brain injury they're looking for any evidence of hemorrhage or any evidence of cell loss or specific damage to the brain that can be permanent.

>> But a concussion typically will show up as a normal MRI of the brain thereafter because it basically is the is the squishy brain just getting bounced around inside the hard skull.

>> When that happens you can have a release of certain chemicals, particularly ones called glutamate.

>> When there's an excessive amount of glutamate it can cause you no one to have seizures and that's why some people following a head injury can have seizures.

There's an excessive amount of glutamate released glutamate is important because it helps with your being alert helps with memory, helps with mood.

>> But excessive glutamate can cause you to have difficulty with seizures and over the course of time if there was excessive glutamate released during that head injury you can have irritability and depression because too much glutamate actually makes you depressed enough glutamate can be problematic as well.

Too much glutamate can make people psychotic and that's why people with schizophrenia often respond adequately to some degree to medications that will stabilize glutamate.

But the main glutamate stabilizers out there will be medications that are anti epileptic such as Depakote, Lamictal being the two most prominent to a lesser degree Tegretol and Trileptal but mainly Depakote and Lamictal are the ones that stabilize the glutamate and what we find is when we give those medications to people who have head injuries and then thereafter have problems with irritability, poor stress tolerance where they have trouble putting up with stuff they have in appropriate anger, they kind of fly off the handle if we find that's related to their having a head injury we often find the anti seizure medications do quite nicely for them.

Now people who have had head injuries are often given medications like the serotonin reuptake inhibitors Zoloft, Paxil, Lexapro, Celexa, Prozac.

>> These are medications that increase serotonin and they can help to some degree.

They've been around since the late 1980s, early 1990s and they've been around for a long time and they tend to dampen or dull the emotions but they're primarily increasing serotonin which can dampen the excess excessive emotions.

>> I find that the anti seizure medications typically work a bit bit better for these people in along with those anti seizure medications not in commonly we can add a medication like in Acetylcysteine which is a supplement that still is available 600 milligrams twice a day is is something that can also enhance the glutamate system.

Another medication we're using nowadays that works in a different way on the glutamate system will be as ketamine also known as bravado as ketamine is a left sided piece of ketamine and as the left side of the piece of ketamine it's a nasal spray and we find that it helps a lot of people with treatment resistant depression.

The question is will it also help with head injuries and people who have had traumatic brain injury, concussions, memory disturbances due to stroke that hasn't been studied yet but it's speculative since it's affecting glutamate.

Could you use that in addition to Lamictal we find with a lot of our academy patients or this bravado patients these are people who were treating we're treating their treatment resistant depression.

>> They've tried several different antidepressants.

It didn't work so well.

So we use bravado whereas ketamine we find that often helps with the depression.

But quite frankly we often use a second medication on top of the antidepressant medication that they might be taking and that second medication will often be Lamictal.

About 40 percent of our patients take Lamictal with an antidepressant when they have treatment resistant depression and they're being treated with a of centimeters bravado.

So Lamictal is stabilizing for glutamate and stabilizing glutamate.

It basically helps people tolerate stress better helps them put up with things better and it's particularly helpful for people who have had head injuries so is a concussion permanent?

>> Not necessarily.

People can have a concussion and recover over the course of a few weeks or a few months.

Where you get into trouble is where you have concussion after concussion after concussion.

>> So people who have experienced a lot of head injuries are more likely at a later date to have Trepp difficulty with Alzheimer's dementia and that's actually a risk factor for Alzheimer's dementia.

A lot of head injuries so we're always trying to get people to limit their number of head injuries so they don't have conditions that can cause a memory problems, personality changes and a lot of irritability and anger at a later date.

And of course you might have heard about the disturbances a lot of football players, the older football players who played in a time were concussions weren't taken that seriously back in the 1960s, 1970s and 1980s.

A lot of them have struggled with depression, personality changes, memory problems later on and that type of what's called chronic traumatic encephalopathy.

Those people can have difficulty with memory disturbances because potentially they've had that surge of glutamate that's increased each time they had the head injury and that caused them the toxicity of the brain.

So too much glutamate can actually be toxic the brain and that's one of the mechanisms by which we will often treat people with head injuries.

Thanks for email.

Let's go to next email question or an email question reads Dear Dr. Fauver, how much difficulty will a person have if they have a folic acid mutation or is there a way to test for this in our genetic testing a folic acid mutation will be one of the genes that will be assessed.

It's called methylene tetra hydro folate reductive F.R.

This is a gene that has two types twelve ninety eight and sixty six seventy seven.

But if you have a mutation at both of those genes you can be very likely to have difficulty with not breaking down folic acid adequately.

>> And here's how that works.

If you think of folic acid as being like a person outside of a turnstile going into a football stadium, folic acid needs to get through the turnstile to get into the football stadium.

Well, folic acid is on the right on the outside l methyl folate the breakdown product is on the inside so that needs to go through the turnstile to get to the inside.

Well, think of the turnstyles be an empty HFA methylene tetrahedral folate reduc d that's the enzyme that breaks down folic acid to allow to get inside the brain and be able to do the good things that it does.

>> It tends to enhance the production of serotonin, norepinephrine, dopamine.

>> It tends to allow for from a whole body perspective decrease the risk of stroke, heart disease even diabetes for that matter.

>> So getting adequate active forms of folic acid is very, very good for our whole body wellness not only our brains but you need to be able to break down folic acid also thought about twenty five.

>> Thirty percent of the population has some form of mutation for folic acid metabolism but you don't see it to be problematic until somebody actually has symptoms.

So you have to have the symptoms that are there to be able to find that that's something that can be treated.

So if you do have a mutation that's identified based on a genetic test, if you do have the mutation and you have sign of depression, anxiety, difficulty with concentration, that could be a reason to take Elmsford willfully a woman who's had a lot of miscarriages I was talking earlier about postpartum depression.

Well, miscarriages can be a factor in terms of causing postpartum depression later on as well.

But if you've had a lot of miscarriages that can be a factor because if you don't adequately metabolize folic acid it could increase a woman's risk for miscarriages.

So that's why I think it's very important to check people as a check people's genetic profiles and one of the reasons to do so would be to look at their F.R.

status for six seventy seven and twelve ninety eight and looking at those two particular genes will tell us whether somebody predictably should get the special form of the end product of folic acid.

Folic acid is one of the B vitamins.

It's vitamin B nine so there's twelve different B vitamins it's vitamin B nine so it is water soluble it goes right through if you get too much of it.

>> But if you take regular old folic acid and you have the mutation, you don't break it down very well.

It actually can be somewhat toxic to you because your body can build up with folic acid unnecessarily and you can make a little bit too much of this chemical called homocysteine and it used to be thought well we could measure homocysteine levels and determine if somebody has a folic acid mutation now we can just look at their genetics and get a little bit better reading on it.

>> Thanks for your email.

Let's go to our next caller.

Hello, welcome to Matters of Mind.

>> Well, Joe, you want to know about the average age someone might show for signs of bipolar disorder?

>> Can life changes impact the impact that the usual age was made to show early symptoms of bipolar disorder would be around 14 to 16 years of age.

>> You're going to hear about people having some kind of mood disturbances in their adolescence that differs a little bit when somebody has what's called a major depression or a clinically significant depression.

Those people might not start showing symptoms of depression maybe until their late adolescence or early adult years.

>> But if you have an earlier age of onset of having depression that might be a predictor for bipolar disorder, a bigger predictor for bipolar disorder quite frankly is if you have a family history of bipolar disorder because bipolar disorder is about 60 percent genetic.

So it's more genetic than clinical depression itself.

Clinical depression itself is thought to be about 35 percent genetic bipolar disorder is about 60 percent genetic so it runs in families.

So if you have a first degree relative, especially a mother, father, brother, sister, son or daughter for that matter with bipolar disorder and it's pretty distinctive.

It's bipolar disorder.

It's been accurately diagnosed.

It's not ADHD which is an entirely different phenomenon if it's truly bipolar disorder, that person has responded well to mood stabilizers.

>> That's the bigger prediction of who's going to have bipolar disorder later on versus age of onset and you can have an earlier age onset with depression obviously if you've had a lot of awful stuff happen to you at an early age, there's tends ten questions that we often ask and as part of the of the Adverse Childhood Experiences questionnaire, the ACE questionnaire AC is available on the Internet.

>> It's totally free but the Adverse Childhood Experiences questionnaire if you have over four out of 10 of those particular findings, it's highly predictive that you're going to have depression later on, especially if you have a lot of other factors going on later in your life .

>> But it's a risk factor for getting depression later on if you've had over four of those ten ace questions if you've answered affirmatively on those over four out of the ten, it increases the likelihood depression later on and that's when we talk about childhood experiences we're talking about under eight years of age.

So your personality is is strongly developing before your eight years of age and what happens to you as a child before eight years of age can significantly impact you later on.

>> I mentioned genetics earlier Gelb if you have that high numerical value on the ace, the adverse childhood experiences scale, you put that together with a genetic mutation at the SLC six a four gene it's called the also known as a serotonin transporter gene if you have a mutation there and a high score on your adverse childhood experiences, that makes it highly likely that you will not respond very well to the commonly used antidepressants that affect serotonin like Lexapro, Celexa, Paxil, Zoloft, Prozac and that's probably why as many as two out of three people don't do really well, especially in their first trial or two of those type of medications.

One of the three people or so do great on them but about to three of them don't.

So can stress bring out bipolar conditions?

It can and that's why you might have a family history of bipolar disorder.

>> You might have a father who might have a mother with bipolar disorder but you don't develop those symptoms.

>> Why?

It's because stuff didn't happen to you to the to the degree that it might with other people.

You don't you tolerated stress adequately.

>> You had coping abilities.

You manage stress.

Now I always tell people that no stress is a stress in itself because if you don't have any stress in your life and you never have anything bad happen to you, it just isn't realistic.

You're not going to learn to overcome those particular bad experiences.

>> Sometimes trauma difficult challenging experiences in our lives.

They can be some of the best things that ever happened to us but we have to learn how to overcome, how to cope , how to manage those kind of stresses.

And that's why people who have endured past stresses are less likely to get post-traumatic stress disorder in the event that something horrible happens to them later in life .

>> The people who tend to tolerate combat experiences, for instance, are the ones who tend to have significant stressors early in their lives because they've to some degree learned how to adapt to very, very challenging situations.

>> So challenging situations is not something that we should avoid.

>> You know, as parents we want to allow our children to have as happy lives as possible.

We want to protect them from bad things that can happen.

But we have to remember that they have to be allowed to endure the challenges and go through the pain and experiences that it's just part of normal development and we we have to learn how to cope with these past challenges and that's part of growing up.

So with that being said, bipolar disorder yeah, it can be brought on by stressful circumstances if you've not learned how to cope with those circumstances because any stressful circumstance from a from a neurobiology standpoint can increase this particular hormone called cortisol when cortisol goes up you can have chemical changes occurring in the brain that can kind of fire off that bipolar phenomenon, a bipolar disorder basically is where you can have unnatural highs and unnatural lows.

>> The highs lasts for several days on the highs can go on for two days, four days in the case of bipolar disorder type one can go on for over a week.

So you have these manic highs where you can have difficulty with not sleeping or not needing to sleep for that matter.

>> You're wide awake the next day you're impulsive during the highs you talk really fast and you go from topic to topic to topic during the highs you just want to talk to everybody so you intruded on conversations.

You just walk up to everybody in grocery stores and in places where you ordinarily wouldn't go and you start talking to people that's a manic high and along with that many manic high people sometimes can spend money without discrimination.

They can become involved in sexual encounters indiscriminately.

They do all these things that they later regret that's a manic high and then you can crash into these terrible lows where it's just the opposite.

>> You're depressed, you're sleeping all the time.

You're very fatigued.

You don't want to be around anybody.

So that's bipolar disorder go in real high and real low and you can have typically the low start first and then you have the highs later on.

That's why a lot of people aren't recognized as having bipolar disorder until they've had several years perhaps of depression.

They might have had little subtle highs maybe for one or two days but there wasn't really thought to be really significant to even mention.

But sometimes as mental health clinicians we have to kind of fish out of them when they had those highs because some people will perceive those highs as being very productive.

They get a lot a lot of stuff done.

>> They get all their laundry done during those days.

They clean the house, they remodel the kitchen.

I mean they do all these different things when they're on the high end for them compared to lows those were great.

>> The problem is when you have unnatural highs not just talking about happiness here we're talking about unnatural top of the world highs that unfortunately can get you into trouble and they predict your likelihood of crashing into a low because when you go to the mountaintop you can just kind of use up all the chemicals in your brain and then you can crash into this terrible low and it goes back and forth for those people.

We often will give them mood stabilizers and that's where we'll often treat people with medications like lithium the anti seizure medications which are often very effective for that and the so-called second generation antipsychotic medications which don't just treat psychosis, they treat a lot of their conditions including mood stabilization.

>> Thanks for your call.

Let's go next caller.

Hello Jane.

Welcome the mind Jane you want to know can constantly low blood pressure caused depression?

Jane it can it can contribute to feeling really depressed and that's an interesting observation there because low blood pressure as you can imagine.

What's it do?

It makes you tired.

It makes you lightheaded upon standing low blood pressure can give you trouble with concentration and thinking and by all means low blood pressure can make you less likely to want to exercise and move around.

>> So low blood pressure can make you feel depressed and tired and contribute to your lack of activity which then in a vicious cycle can in the long run make you depressed.

So low low blood pressure is a factor in causing you to be tired and eventually very depressed and have giving you difficulty with concentration.

We look at other medical conditions that will commonly look like depression so we have to always support those type of things out.

We'll look at people there's likelihood of having sleep apnea where they're not adequately moving air into their lungs and thereby not getting oxygen to the brain.

Sleep apnea can give you fatigue and poor concentration and depressive terms.

You can have diabetes with blood sugar disturbances that will certainly make you very depressed in the long run.

Low iron is very common.

People with low iron will frequently have depression.

We often see this with young women who are heavily menstruating or people who are really limiting their iron intake because they're not eating red meat or not eating green leafy vegetables.

>> We'll often hear about people with thyroid disturbances.

If you have low thyroid you'll be tired.

You can't think you'll feel kind of puffy.

You'll be constipated and you get depressed.

>> So we have to consider all those medical conditions when we treat depression.

So you know, I'm not one to think well, gee, I'm a psychiatrist.

I'm only going to treat people from the neck up if somebody tells me they're depressed.

I want to make sure I'm looking at the whole body because there's a lot of conditions like you mentioned with low blood pressure.

Yeah, that can be a factor in terms of causing somebody to be depressed and fatigued.

Jane, thanks for your call.

Unfortunate I'm out of time for this evening if you have any questions that I can answer on the air concerning mental health issues, give me a call here.

>> PBS Fort Wayne by daily (969) 27 to zero during the hours that were on the air seven thirty on Monday nights where you can just write me via the Internet at matters of mind all one word at eight dot org I'm psychiatrist favorite.

You've been watching Matters of the mind on PBS Fort Wayne God willing and PBS willing.

I'll be back again next week.

>> Thanks for watching.

Have a good evening