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

>> Welcome to Matters of the Mind now in its 24th year are Matters of the Mind is a live call in program where you have a chance to choose the topic for discussion.

>> So if you have any questions concerning mental health issues, give me a call here at PBS for 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 toll free at 866- (969) 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 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 ad WSW Egg That's Matters of the mind at WSW Edgard.

>> I'll start tonight's program with an email I received this past week.

It reads Dear Dr. Farber I took Prozac and beuse Spyro and that's also known as beuse are for depression and generalized anxiety disorder for 20 years now I take Prozac 80 milligrams and alprazolam is also known as Xanax point five milligrams and you'd also mentioned by the way abuse Spyro had a brief period of time 15 years ago when it was taken off the market because of supply issues.

>> It's back on the market now.

So to finish up the question there is now take the Prozac at a higher dosage.

>> You take a little bit of alprazolam.

You're wondering at this point if you should go back on the Bu Spyro Antabuse bar because you're now having some anxiety again since BU's Spierer is back on the market and it's easier to obtain now and it's very inexpensive.

You may indeed do so Prozac or Fluoxetine at twenty milligrams, 60 milligrams, 80 milligrams the higher and higher doses will give you more and more blockage of the uptake in the present haptic neuron and that's all fancy terminology for meaning that the firing neuron is called the present haptic neuron that's firing out serotonin like a shotgun.

So the firing neuron fires out serotonin like a shotgun and the serotonin goes to one of 14 different receptors out in the periphery.

>> All these different receptors do different things now to keep the serotonin out in the periphery and stimulating different targets again and again and again you have what's called a reuptake pump because the serotonin naturally will be vacuumed back in to the firing neuron allowing you to preserve your bullets so to speak.

And if you block the vacuuming of serotonin back into the firing neuron, you can get them firing up or bouncing around for a longer period of time.

That's how Prozac works.

And the bottom line is if you increase the dosage of Prozac, you can only block so many of those little reuptake pumps and you can only get so much effect from that if you go higher and higher on Prozac sometimes it might do you more harm than good.

So you always have to consider is it really worth to go higher?

I saw a person today who went higher on their Prozac a while back and I asked, you know, did it help you going from twenty milligrams to forty milligrams?

Did you notice that much of a difference because if you don't you go back down to twenty milligrams and then reassess to what degree that's helping you.

So Prozac is a good place to start for increased serotonin transmission.

>> Xanax or alprazolam will affect this part of the brain right here called the amygdala basically turns down the volume control on anxiety, fear and anger and by doing so it makes you just calm down and does so very quickly.

>> The problem with Xanax is that it can cause you to have difficulty with memory and processing information and it's kind of like taking your computer speed in your brain and slowing it down.

>> So if you have a slow computer it's very frustrating and that's what happens to the brain when you're on a medication like Xanax it just slows down the processing speed so Xanax wouldn't be highly recommended but spirit is good for worry, Bew Spirent abuse bar can be good for worry and I mentioned those fourteen different serotonin receptors will be Inspiron is affecting one of them is called serotonin receptor one A and by dialing in on that one receptor what it does it acts kind of as a thermostat and and stimulates that receptor.

If you're too low on serotonin it will block the receptor if you too high on serotonin and basically Prozac and boost Biron can be used together and that's how they were used when you had mentioned I treated you twenty years ago or so and it's common combination it basically fine tunes how much serotonin getting to that serotonin one receptor and doing so it can help with anxiety.

So yes your spirit is back on the market now.

It's readily available and we do prescribe it on a regular basis because it's very inexpensive and it's still very effective for what it does.

>> It came out in nineteen eighty six and it was thought of nineteen eighty six to replace a medication like appraisal or Xanax but it was found that alprazolam or Xanax worked more powerfully for anxiety.

Barrone is more for worry rumination dwelling on the what if what if what if and it's good for that round and round type of circular thinking some people can experience.

>> Thanks for your email.

Let's go to our first caller.

>> Hello Artie.

Welcome to Matters of Mind.

>> Ah do you want to know about Lewy body dementia and what are some of the symptoms?

What hope is there for someone with this diagnosis already?

>> Basically Lewy body dementia is where you get these little speckles of what's called Lewy bodies all over the outside part of the brain.

>> Now generally you shouldn't have any more than maybe point five percent of the outside part of the brain having those kind of speckles.

>> But with Lewy body dementia they're much more prominent and under a microscope with a particular red dye.

They look like little pieces of cherry jello all over the brain.

>> These little speckles will give you difficulty with memory impairment and being able to have adequate concentration because the front part of the brain is very, very important for maintaining attention and focusing on different things other other types of aspects of Lewy body dementia, however, will be decreased blood pressure when you stand you can have lowering in blood pressure because with Lewy body dementia you're affecting the brain stem section down here in the middle and with Lewy body dementia you can also have some difficulty with Parkinson's like symptoms and it's thought to sometimes go hand in hand for Parkinson's symptom.

But the most troublesome part of Lewy body dementia won't be the difficulty with concentration won't be the blood pressure disturbances.

>> It will be seeing little people or little animals and nobody understands why people with Lewy body disease or Lewy body dementia have the propensity to see little furry animals commonly and they see little people and they'll often describe babies sitting in the room and what's characteristic of people with Lewy body dementia Lewy body disease will be these people won't be highly disturbed or upset about seeing little people or little animals and they're often furry animals.

They are often described as like rabbits.

They're not thought to be in danger when they see these animals occasionally I have heard about people going to a different room because they just want to get away from them.

But they'll often describe the small child sitting in the room at night or they'll talk about a baby that's in the room.

The baby's not crying, they're not making any noise and they're often not that disruptive occasion the little children will be running around the room but usually they're not loud and they're not disruptive.

But there will be noticeable by the person Lewy body disease.

Now why do people have Lewy body disease where you've got the little speckles of the Lewy bodies all over the grape outside part of the brain but it's also thought is an exceedingly increased amount of what's called serotonin 2A receptors I mentioned earlier there's seven there's fourteen different type of serotonin receptors what is called to a and if you have too many of the two a receptor that can indeed give you difficulty with having Lewy body disease and some of the newer medications that are used for Lewy body dementia can be a good for blocking these particular serotonin 2A receptors and in doing so can decrease the of having Lewy body disease.

So that's actually a treatment that some people will address with with Lewy body disease a particular medication is a strong blocker of 2A receptors will be new plays in and that's a medication that's used particularly for people that have Lewy body disease that's particularly related to Parkinson's disease.

>> So there are treatments out there for it and is getting more steady.

We're getting a better understanding of it.

It used to be thought that people with Lewy body disease would just get antipsychotic medications such as Clozaril, Seroquel and sometimes Zyprexa.

But now it's the real we've realized that the focus of the treatment needs to be on blocking to the serotonin 2A receptors in the front part of the brain and that will thereby decrease the likelihood of having difficulty with the hallucinations which are most bothersome for people with Lewy body disease.

>> Thanks for your call.

Let's go to next caller.

Hello Jim.

Welcome to Matters of Mind.

>> Hi Jim.

Hey, how are you?

I'm doing all right.

How are you?

Good.

Well actually I'm quite miserable.

I've been on antidepressants for about thirteen years now and just recently seriously depressed or I'm having suicidal ideation because I'm just so miserable in my mind that I can't think of any way to stop the way I feel and I'm I'm considering it's ketamine.

I'm a little scared because it sounds like a last ditch attempt to cure this and I'm afraid if it doesn't work that I'm finished.

But I'm I just wondered what kind of success you've had with ketamine treatment and if you could go ahead and maybe just expound upon the how that all works and in particular what kind of success you've had with that, Jim, by all means maintain hope because there's always other treatments for number one, we always want to make sure that somebody doesn't have a medical condition that's very treatable if you have low thyroid sleep apnea, diabetes, low iron, there's all these medical conditions that can contribute to somebody not doing well on traditional antidepressant treatments.

And Jim, as you likely know, we sometimes add other medications with different mechanisms of action to antidepressant medications to help somebody pull out of depression.

So we look at all these different factors.

We might look at your family history.

Anybody in the family done particularly well on various antidepressants.

We'll consider that.

But we look very carefully at your track record looking at the thirty different categories of medications that we use in psychiatry and seeing if there's any kind of pattern to how you respond to different medications.

>> Genetic testing will often help us be guided in a little bit different direction sometimes when we see that.

>> So with all that being said, Academi is also known as bravado.

It came out in March of twenty.

Nineteen is as an FDA approval I can personally attest to my office using as ketamine since June twenty nineteen we've treated over one hundred patients with over four thousand treatments.

Now it's a nasal spray Jim.

We've heard of ketamine possibly ketamine was FDA approved approved by the Food and Drug Administration back in nineteen seventy as an anesthetic and then at about 2000 ketamine started being used I.V.

in various clinics for depression.

>> It was found to be particularly effective for depression and even suicidal thinking for the past 20 some years ketamine has been used not approved by the FDA but it's been used off label as we call it IV for the treatment of depression.

>> It's not been regulated.

People could kind of haphazardly use ketamine.

The doctors weren't advised on how to use it.

There were no particular protocol on a regular basis that were assumed.

So what happened is ketamine is the left sided piece of ketamine s ketamine has some greater potency for the target of ketamine and that's why it's it uses a nasal spray as it uses a nasal spray because it gets better absorption through the nose as opposed to the stomach.

So you're getting better absorption through the nose.

It's always done in supervised environment and you get the ketamine treatments twice a week for the first month, once a week for the second month and then after the second month it's once a week or every other week and you can kind of spread out the treatments thereafter.

Some people choose to stay on the medication every week or every other week after that second month for several months thereafter all the time staying on the best antidepressant combination that worked for you so if you're on one or two or three different medications for depression already, you might want to steal those oral medications ongoing.

But what we often find is that people can start chipping away and taking less oral medications as time goes on with this ketamine.

>> So how does that gedmin work?

Basically it blocks this particular receptor called NMDA receptors and when you're doing that you're affecting sodium and calcium ion channels.

>> And if you think about how traditional antidepressant medications work, Jim, traditional antidepressant works to traditional antidepressants work by affecting serotonin, norepinephrine and dopamine and they work by changing the number of little protein receptors that are the targets for these different chemicals.

>> Ketamine is entirely different.

It's not directly affecting dopamine, norepinephrine a serotonin.

>> It's affecting glutamate.

Now glutamate is all over the brain.

It's the excitatory chemical.

It's all over the brain and you want to particularly stimulate these type of glutamate receptors called AMPA receptors AMPA receptors and it's thought that NMDA receptors are overabundant with some people with depression.

>> You want to block those receptors when somebody has depression and allow the glutamate to go around the NMDA receptors and go to the AMPA receptors in doing so that gives you an added boost of fertilizer to the brain increasing these chemicals like what's called Amthor of a million target of rapamycin brain derived neurotrophic factor Abedian aph these are all stimulatory chemicals in the brain that will increase the growth and the fluffiness of the neurons themselves because when people have long term depression they often have less fluffy neurons and when you have less fluffy neurons it's like trees that have fewer branches on them.

>> Your brain just doesn't work so well in and you get more and more depressed.

People often have difficulty with processing speed when they get depressed they have trouble motivation, enjoying things and suicidal thinking goes hand-in-hand with that.

>> So whereas the traditional antidepressants take four to six weeks to give you the beneficial effects on the little receptors on serotonin, norepinephrine and serotonin, serotonin, norepinephrine and dopamine the ketamine can give you effects on these calcium and sodium channels in a matter of seconds.

>> So it's a very quick treatment for many people about one out of six people will get a knock it out the park effect within one or two treatments.

About one of six people will feel phenomenally better.

When I first started seeing this effect, Jim, on people three years ago I thought it was a placebo effect.

I thought nobody can feel that much better from depression that quickly.

But that's what was happening.

>> But most people it takes two , three or maybe four weeks to get a significant effect and then ongoing a few people don't respond until six or seven weeks but most of our patients will have that notable beneficial effect within one month.

Now we're very selective on who we for whom we use as ketamine.

We would want to make sure they don't have sleep apnea, thyroid disturbances, diabetes and so forth.

We want to make sure they're not using marijuana on a regular basis.

We want to make or they're not using drugs of abuse because those will be factors on why people don't get well.

>> We take a good look at their medication track record.

We try to optimize and idealize the medications they're already on.

Then we add this ketamine and like I said, it's always done under supervision of a health care professional in the office.

You sit there for two hours the rest the day you can't drive the rest of the day can't operate machinery.

Machinery is not just something with wheels on machinery also includes chain saws so anything is potentially dangerous.

You can't use that for the rest of that day when you are being treated with us ketamine's so like I said is twice a week the first month once a week, the second month and after the second month it's once a week or every other week and then it's often stretched out thereafter while at the same time always staying on an oral antidepressant medication.

Jim, we're not at a point where we're just giving people as ketamine and having them take it at home.

The Food and Drug Administration expects us to monitor people very carefully for no one's sedation, no to dissociation because at the 40 minute mark when the ketamine is peaking in your blood level, you'll feel this kind of spacey feeling.

You feel like perhaps you're floating.

We call dissociation last for about ten or twenty minutes for most people.

Then they start coming out of it the second hour.

Another factor and the reason we monitor people during that two hour period gym will be the blood pressure will increase at the 40 minute mark and then at one hour it starts to come down in a two hours it's often back to baseline so the blood pressure will peak at the 40 minute mark when that blood level of US ketamine is is peaking.

So from our perspective in our practice we've seen over nine out of ten people get a favorable response to US ketamine and these are people who are highly treatment resistant in our practice gym the average number of medication failures prior to using as ketamine was ten.

So we had people that had on the average ten medication failures for depression prior to using US ketamine and we've been using it now for over three years.

There's more and more so ketamine clinics sprouting up around the country right now and that's so favorable type of situation because I think there's more and more people can benefit from it.

There's also transcranial magnetic stimulation.

It's been around for about twenty years now.

Electroconvulsive therapy or ECT is another option.

>> So there's various other options out there.

But you always want somebody to take a good look at your past history and take a full overview on what might have been overlooked because I always remember there are times in the past where I thought before I started looking for sleep apnea 20 years ago for people I always wondered people back in the 1990s or people back in the 1980s when I was first practicing if some of those people actually had sleep apnea and I was missing it because I wasn't looking for it.

Sleep apnea is basically where you're not breathing adequately at nighttime you're snoring.

You might pause and you're breathing at night and you're not getting adequate air flow to the lungs thereby decreasing oxygen to the brain with less oxygen in the brain periodically throughout the night you'll feel depressed, sleepy, tired.

>> You'll have trouble with concentration and you'll have trouble motivation the next day.

So sleep apnea is something we carefully will assess for somebody who is having difficulty with what we call treatment refractory depression.

Jim, I wish you the best and keep in contact with your primary care clinician or your mental health clinician who you're currently seeing because there's a lot of other options coming out now for depression.

>> Thanks for your call, Jim.

Let's go to next caller.

Hello, Wayne.

Welcome to Matters of Mind when you want to know about some causes for memory loss I was just mentioning sleep apnea.

>> I would say the number one factor we always have to consider for memory loss Wayne will be in difficulty with the airflow at night and we call it sleep apnea.

It's characteristic with people who are snoring at night.

They're pausing in their breathing and are often sleepy and tired or in the day.

But that will be a big factor for memory loss.

A second factor across the board for memory loss will be people who are having difficulty with depression because depression a clinically significant depression that's there day by day by day for at least two weeks on end and it's causing you to have difficulty with functional impairment where you have trouble going to work, you have trouble going to school, you have trouble socializing.

The difficulty with functionally impairing depression will often give you difficulty with processing speed of the brain where you can't process information adequately and many people will call this memory loss and it's actually termed as pseudo dementia.

So especially older people will have depression and they'll perceive they have dementia because they're getting up in the years and they wonder if they have trouble with dementia because they're having trouble memory.

Another factor especially as people get older will be inadequate vitamin B 12 absorption vitamin B 12 gets carried to the small intestine by this little bus that's in the stomach that's called intrinsic factor.

Intrinsic factor is released from parietal cells in the stomach.

>> As we get older we tend to have less stomach lining and we have less of an intrinsic factor because you have fewer parietal cells and the intrinsic factor is the bus on which upon which vitamin B 12 needs to get attached and that carries to the small intestine gets absorbed.

So if you have low vitamin B 12 especially as you get older you can reverse that with injections or tablets that you put into the tongue for adequate absorption.

Occasionally people will have trouble with memory disturbances if they have low thyroid.

A common common scenario with people with low thyroid will be they'll feel tired, they'll have trouble unexpected weight gain.

They might be a bit constipated.

They'll have dry skin but they'll have memory disturbances and they'll have trouble with keeping their mind on things and focusing and a big factor for memory problems .

>> Wayne will be ongoing lifelong disturbance with attention deficit hyperactivity disorder or attention deficit disorder called ADD or ADHD or ADHD is a condition word day by day by day.

Your mind is going so fast and your thoughts are racing to such an extent that you have trouble processing information.

You get readily distracted and you don't remember things that people said to you and you can't process information.

So it's kind of like the brain needing eyeglasses to be able to focus.

You know when you have nearsightedness and you can't say things at a distance you were eyeglasses so you can focus with ADHD and that's how you treat the brain.

Just allow the brain to be able to focus more adequately as a general rule, Wayne, if you want to have better concentration, better memory, the one thing you ought to do is exercise for about 30 minutes every morning.

That's one of the best ways to really fire up the concentration and memory.

I hear this all the time from people.

How can I focus better during the day?

How I concentrate better during the day.

They've actually done a study with high school kids up at Naperville High School over twenty years ago where they exercised for thirty minutes to an hour every morning at the start of the school day on a regular basis and they had better test scores.

They had better concentration during the day and it was considered to be a national benchmark for how you can help high school children do better in their academics.

Wayne, thanks for your call.

Let's go our next caller.

Hello Susan.

Welcome to Matters of Mind.

Susan, you want to know about the symptoms of bipolar disorder?

I mentioned that briefly.

And what are the treatment options?

Bipolar disorder is basically as the name implies by means to an poller means one way or another.

So you have extremes of the mood high or low people with bipolar disorder have episodic every now and then periods where they will have racing thoughts they won't need to sleep.

They'll be impulsive, they'll be intrusive in conversations.

They will do things and say things they later regret.

That's the manic high.

The manic high can last a matter of a day or two and that's often called depression with mixed features it can occur four to six days if you have a manic high with depression for at least two weeks that's called bipolar disorder type two or you can have seven or more days of mania with or without depression.

It's called bipolar disorder type one.

We treat those conditions differently.

Some of them manic highs will be accompanied by depression but not all of them.

Most of them are, however, So if you have at least two weeks of depression with one to three days of manic highs, that's major depression with mixed features.

>> We'll treat that with an antidepressant and may add a little bit of a mood stabilizer motor regime maybe carbamazepine, carbamazepine can be another type of option.

>> So there are mood stabilizers can be used with major depression, with mixed features when you have the four to six weeks of mania with two weeks of depression that's called bipolar disorder type two typically will be treated with a mood stabilizers just as a second generation antipsychotic medication.

Lamotrigine can be used Depakote is great but it can cause a lot of difficulty with weight gain for a lot of people lithium is very good if they if somebody has bipolar disorder type one where they have one week or more of distinctive manic episodes, they get themselves in all sorts of trouble.

>> Lithium and to some degree Depakote are very distinctive in a sense they have an antiinflammatory effect on the brain.

There's a particular protein in the brain called Ascione that goes sky high while somebody's manic lithium has a really nice track record of suppressing as one hundred and it decreases inflammation in the brain that appears to be present during mania itself.

So bipolar disorder could be considered to be an inflammatory condition where you're having unnatural highs and lows about sixty five percent genetic it does indeed run in the family is very treatable but you need to get on the mood stabilizing medications not unlike if you have epilepsy you need to be on an anti seizure medication to prevent the seizures from occurring with bipolar disorder you want to quit the unstable unpredictable mood swings that are occurring that are often unprovoked even by stress they just come on out of the blue.

Susan, thanks 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 may write me via the Internet at matters of the mind all one word at WFB a dot org.

I'm J I'm psychiatrist J forever and God willing and PBSC willing.

I'll be back again next week.

>> Thanks for watching.

Have a good evening.

Good night