Good evening.

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

Welcome to Matters of the Mind Now and 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 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 at a dog that's matters of the mind at FWC Dog and I'll start tonight's program with a question I recently received.

>> It reads Dear Dr. Fauver, I've been sad, depressed and anxious since I was 30.

I'm now over 60 and it's a lot worse.

Would it save time to get a genetic blood test?

Should I see a doctor first?

Well, there's several things you want to do.

I would suggest if you're having trouble with depression and anxiety and sadness that you first see your primary care clinician if you've not yet done so to make sure you get a medical evaluation to make sure you don't have such conditions as diabetes, iron deficiency anemia, thyroid disturbances and maybe sleep apnea.

>> Sleep apnea is where people will snore at night.

They don't have adequate airflow and they don't get enough air into the lungs thereby they don't get enough oxygen to the brain at night time and then they have decreased oxygen at periodic times during the night and they feel really tired and depressed the next day.

So I'd want to make sure there wasn't some particular medical reason for you to have depression.

You're in your 60s now.

You've had depression since your 30s.

Yeah, we'd want to know was it worsened when she went into menopause and how that that affect you?

>> That's the first thing I'd want you to do.

The second thing I'd want you to do is try to examine and do the best you can and get a listing of all the different medications you've tried so far.

That's very important for your clinicians, whether it be a psychiatrist, a primary care doctor or a nurse practitioner or a physician assistant for the purpose of trying to sort out what kind of pattern you've had with various classes of medication.

Now at my office for instance, we track thirty different categories of medications based mechanisms of action or pharmaceutical class and we can often see this pattern of treatment response as we put medications in the different categories that you might have tried.

And we often find that some categories just won't work for you and some of them might work rather well.

It's just that you might need something with it.

So listing your past medications and your treatment responses to those medications with as much detail as possible would be very important for any clinician who you see now genetic testing that is an added piece to the puzzle that's awfully nice to have but it's not mandated.

We have treated patients for decades without genetic testing.

We've had genetic testing readily available for the past ten or fifteen years and it's just an added dimension.

It is not determined if it does not determine which medication we're going to use, it just helps kind of be nudged in one direction or another.

And the main thing about genetic testing will be it helps us understand how quickly you break down certain medications.

Some people will breakdowns specific medications rather quickly and others will break down those same medications rather slowly.

And there's several different enzymes that are examined in genetic testing and these enzymes are coded by genes and if you're a fast metabolism, slow metabolism, it basically tells us how we should dose any medication, whether it should be high or low.

>> A second thing that genetic testing will do for psychiatry is it'll help us determine if you are an adequate metabolism for folic acid to folic acid goes through this particular enzyme called F.R.

at methylene tetrahedral folic reduc days and if far is an enzyme that breaks down folic acid, folic acid is vitamin B nine .

So that's one of the B vitamins and vitamin B nine needs to be broken down to Elmsford folate to adequately be able to allow you to manufacture the chemical serotonin norepinephrine and dopamine.

These are the chemicals that are important for a brain transmission to be able to think be able to concentrate and to maintain an adequate mood without difficulty with stress tolerance.

>> So it's nice to know if you adequately break down folic acid and we do that by looking at the gene your father's two different types.

>> There's twelve ninety nine under six seventy seven.

We will look at both of those particular genes and determine if you tend to breakdown folic acid adequately.

If you don't we give you the in biproduct elmsford folate as a means of giving you something as a vitamin supplement to help you out with that.

A third thing that we'll examine with genetic testing and it has less research behind it but it is helpful will be the so-called pharmacodynamic genes tells us what mechanisms of action might specifically be most helpful for you if we to treat with various medications.

>> So it'll tell us whether you might be more predictive to respond to a serotonin type of medication, a dopamine type of medication and well not just one direction or another they can be the pharmacodynamic genes can be quite predictive if you would do very well with a stimulant medication for instance if you had ADHD.

So we'll look at these different genes and put them all together and it just helps us increase the probability that we're going to be on the right track sooner rather than later.

So it's not mandated but it just helps us nudge our decision making one direction or another.

Should you have genetic testing before you come in to see the clinician might be difficult to do because number one you need an order from a physician to get genetic testing and it's not so much a blood test as a mouth swab but you need an order from a physician to get the genetic testing and very importantly the physician or the nurse practitioner for that matter who orders the genetic testing.

>> We'll get the results directly if you get genetic testing on your own, it's important to be able to bring those genetic testing results that were ordered by another clinician into the clinician who you will be seeing.

>> So get a paper copy, make sure to bring them in to the physician you'll be seeing I'm seeing a lot of people by video visits now when I see patients and I just have them hold up the genetic testing results to the camera so I'm able to see them one by one and I write them down and put them in my chart.

But for genetic testing it's nice to have it in a perfect world.

>> I would love to have every single patient.

I see how genetic testing available right up front but I also know that I want to make sure they get the right type of genetic testing.

The type of genetic testing will that will help me the most.

However, I never discourage anybody from getting any types of genetic testing because to me any genetic testing can be helpful.

I can always dissect out certain things from the genetic testing that I find to be useful but any type of genetic testing is helpful.

But there are certain types I prefer more for for what I do as a psychiatrist now should you see a psychiatrist first?

Did you see a nurse practitioner?

>> I would say see who's available first now nurse practitioners and in some cases physician assistants are seeing people as outpatients and they can do a nice job in terms of doing an initial assessment and at least getting you started with treatment in the United States.

From what I'm hearing right now, there's very few psychiatrist now available to see outpatients.

A lot of psychiatrists United States are either supervising nurse practitioners or they're doing more inpatient work or hospital work.

There's fewer and fewer available on the outpatient side to be able to see new patients as opposed to established patients.

They might have been seen for a while so don't be surprised if you see so in the mental health field for medication management that you might see a nurse practitioner right up front and you may or may not see a psychiatrist over the course of time.

But in most treatment facilities psychiatrists are kind of in the background.

Oh, kind of like being the wizard behind the curtain who they're kind of supervising the nurse practitioners.

They're kind of overseeing what's happening from a treatment approach standpoint.

>> But in all cases the clinicians should always be asking not only about symptoms that you might be having but if they're going to consider medication management they need to thoroughly dissect what medications you've taken in the past, how they've done for you and if they don't have it available in their own electronic medical record from the other clinicians in their health care system, it's very important that you provide that information the best you can about what knowledge you might might know about past medication treatment responses.

That's very, very important.

Coming in with your past medical history is very important as well where you can talk to your clinician not only about your current medications for other medical conditions like diabetes, asthma, hypertension but talking about surgeries for instance, if you've had a gastric bypass that's really important because if you've had a gastric bypass surgery in the past it might affect how well certain extended release or long acting medications are able to be absorbed.

Some of them don't get absorbed so well if you've had certain types of gastric bypass.

>> So certainly share that type of information if you are a woman and you had a surgical menopause where you had a bilateral Pinkel refractory cell pingle refractory IBS so where you had your ovaries taken out earlier, that's very important because basically if you went into menopause surgically earlier than you would have done so naturally that kind of gives us an idea that we need to go a certain different direction in our antidepressant treatment for a lot of people.

So having a good medical history available to the clinicians is very important as well as the past.

I could medications that you might have taken will often on the outpatient side whether it's a psychiatrist or nurse practitioner ask a lot of questionnaires in the age of electronic medical records.

The beauty of that is we can ask you the questions even before you come in to see us.

So within a couple days of coming in for your appointment, whether it's a face to face to face appointment or whether it's a video appointment in nowadays and in twenty twenty two you'll often get a lot of questionnaires and these questionnaires are asking you about symptoms of anxiety, depression, your ability to concentrate your overall functioning and these questionnaires are very, very important for us to be guided on what direction we should go in terms of your treatment overall.

So with medication treatment those are very important and with the questionnaires they often will guide us on what kind of psychotherapy or talk therapy they might need as well.

>> Thanks for your question.

Let's go to our first caller.

Hello Joyce.

Welcome to Matters of Mind.

>> Joyce, you wondered about people with mental health issues.

Are they more inclined to commit violent crimes?

>> That's a very interesting question, Joyce.

And I'm so glad you brought that up because I was thinking about bringing that up.

>> But I forgot I've heard a lot about gun violence recently and how people who commit gun violence and they have mass shootings, they obviously have mental health issues.

I think we need to be careful about making that quick assumption, Joyce, because there is a component of evil that is behind the gun violence itself.

I don't think it all comes down to mental illness because quite frankly if you look at people with mental illness, whether it be severe mental illness like schizophrenia, bipolar disorder, depression, anxiety disorders, these people aren't more prone than the general population to commit violent acts necessarily.

When you look at the entire population of these people with mental illness.

So I think it does a disservice to people with mental illness to say they are more prone to committing violent acts because if you look at the socio economic and the demographic of these people who are committing these violent crimes, they don't have clear cut mental illness.

They have a lot of life disturbances.

They have a lot of family disruption that goes back.

Can you automatically qualify that as mental illness if that's the case, anybody who engages in criminal activity would be considered to have mental illness.

>> And I've heard people make that argument, Joyce.

And if you think along those lines, OK, if you have disturbed says in your frontal lobe functioning the frontal lobe is what allows you to make good decisions and it makes you think before the act and you know, half the people in the prison systems are thought to have ADHD.

So does that mean that we say that anybody who who commits a criminal act against another person automatically is mentally ill?

I think that's a tough call to make because how would you address the treatment for those particular people?

So with mental illness I believe that the means you have a neurobiological disturbance that can be identified based on symptoms, based on research, based on treatment approaches and I really question if we're really talking about mental illness when we talk about everybody who commits a violent crime because physically for the past several decades there hasn't been a specific cause and effect with somebody having a mental illness and committing a violent crime.

Now granted when somebody's psychotic and they have difficulty with maintaining good judgment during that time they can commit a violent crime.

But it's not more likely that the mental illness itself creates a is a direct cause and effect for violent crime.

And I think that's something that needs to be further studied over the course of time.

But I hear a lot about mental health issues with people committing violent crimes.

I think you have to look a little bit more closely into their backgrounds and what you'll often find is a lot of family disruptions in those backgrounds and it might go beyond just mental illness.

We might have to call it something else but a mental illness to me is a neurobiological disturbance that relates to a mood disturbance, an anxiety disturbance.

I think there's a greater dimension than just mental illness for these people who are committing violent crimes and I'm hoping those lines of communication stay open for people who are talking about means of trying to address violent crimes.

>> I think just saying these people are criminally insane and having them go to a psychiatrist or a mental health professional, I think there's more to it than that for a lot of these people.

So it's something we need to keep in mind when we talk about violent crimes and mental illness illness.

Joyce, Joyce, thanks for your call.

>> Let's go to our next email question.

Our next e-mail question reads your daughter Fauver I've been taking Wellbutrin for about four weeks now and I'm not sure it's working.

How do I know it's doing what it's supposed to do now if you take Wellbutrin for about four weeks, there's a couple of things I'd really want to know.

>> Number one, by saying it's not working, it's not working all the way or it's just not working as well as you like.

>> In about two weeks after taking an antidepressant, you should notice about a 20 percent or more improvement.

Now how do we measure that?

We do questionnaires and one of the questionnaires that we'll use to assess improvement for depression with Wellbutrin will be a questionnaire called the Patient Health Questionnaire Dash nine nine questions Canine and the Conine basically gives you a numerical score for depression.

It's online.

It's free.

It's not copyrighted.

It's something that a lot of clinicians use every time people come in and we'll use a conine to really assess somebody's numerical score on their depression with each visit.

>> So let's say you have a Q nine of of ten when you first come in.

>> If Wellbutrin is working this second time you come in that nine should go down to eight or less so it should have a 20 percent or more improvement on the page conine within two weeks now you always hear with antidepressants oh my goodness they take four to six weeks to work.

No I take four to six weeks to give you a more full effect but at two weeks you should start seeing that twenty percent or more improvement at four weeks you should start noticing some type of improvement with your energy level, with your concentration, with depressive symptoms and when will often see somebody on the first time prior to starting an antidepressant medication like Wellbutrin will ask what are your main treatment goals?

>> How would you want to feel better if we can give you any medication?

How would you hope that medication would make you feel better?

Secondly, we'll ask what side effects do you really, really, really want to avoid in the third to try to assess the last time you've you felt in remission and felt well we'll ask when's the last time you felt really good and well for a whole month that kind of gives us a time frame on how long it's been since you were last in so-called remission.

>> So we try to determine all those different factors and looking at the treatment goals will specifically look at the main treatment goals that you identified on the first appointment and then ask how are you doing with those treatment goals at the next visit?

Now we might be asking if you could score your level of how much improvement you've been experiencing zero not all hundred percent.

You feel great.

How much how much improvement have you noticed that's where we're looking for that.

Twenty percent or more improvement as well.

So at two weeks you should have twenty percent or more improvement on a medication.

At four weeks you should be getting around 70 or 80 percent improvement but sometimes it does take six or eight weeks to get full improvement with any medication.

>> So if you're not getting any improvement at all many times we'll ask are you having any side effects?

>> Are you having any problematic difficulties taking the medication?

Do you take the medication every day or do you miss a dosage every three or four days?

If that happens, maybe you're not getting an adequate dosage and sometimes we do increase the dosage.

>> Let's say you're taking 150 fifty milligrams of Wellbutrin every day and it's just not doing much for you.

>> Well, maybe you need 300 milligrams or 450 milligrams and as my first e-mail question cited, is genetic testing worth it?

Should I have genetic testing before seeing my clinician?

>> If you have a if you have a medication like Wellbutrin or bupropion on board, you want to know number one, how quickly you metabolize it.

So are you A to B six B as in boy metabolize or whether you're a slow metabolize or kneading you need a lower dosage area, a fast metabolism meaning meaning that you need a higher doses.

So we want to know that weed also can identify based on genetic testing how you might look on your C OMT chemical or methyl transference enzyme C OMT if it has a particular particular genetic profile we call it a genotype Val Val you might be a really good responder to a medication like Wellbutrin but if it's Memet we want to keep the dosage nice and low so that can indeed affect how well you might respond to medication like Wellbutrin for weeks you should be noticing something otherwise the dosage might need to go up a little bit higher for a lot people.

Mary, I don't know what the jaw syndrome is.

We don't treat it ourselves in psychiatry so I might have to defer your question for you.

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

Our next e-mail question reads Dear not to favor I have some days where I'm very productive and get a lot of things done.

>> However, most days I get very I feel very depressed.

How do I know if I'm bipolar and what can I do about it on the days where you're very productive?

>> My question, you know, is always going to be I love it when people are feeling productive level when people feel good but you know that you're bipolar or you're manic if you're noticing that on those days you don't need to sleep as much.

>> In other words, you're getting by maybe with three or four hours of sleep and that goes on day by day and you don't feel tired the next day.

>> In other words, you don't feel fatigued, you don't feel tired.

You don't feel like you need to take a nap.

The next day you're raring to go and you've just had a few hours of sleep that goes on day by day by day accompanying that you notice that your thoughts more commonly than usual are going very, very quickly.

They're going from one thing to another to another.

You might feel on top of the world you might feel very creative.

You go into grocery stores and you're talking to everybody more so than usual and you're interrupting conversations with strangers perhaps and you're very outgoing and somewhat socially intrusive in that regards.

People who are on the bipolar mania side of things will often say and do things they later might regret.

So you might buy things you might impulsively do things that you later regret and it gets you into trouble and what people will often describe if they have bipolar disorder is they'll have several days like that in a row where they'll be a little bit on the high side might even feel a little bit more snappy and irritable when they're on the highs but then they crash and it's like the wind comes out of sales and then they crash and then the next thing you know, they're sleeping twelve hours a day.

They don't want to be around anybody.

They can get out of bed to go to work and it's not unlike what we hear when we hear about people using cocaine .

>> Cocaine will make people feel extremely energetic for a day or two when they're using it and then they have this horrible, horrific crash and as you can imagine with somebody has bipolar disorder, they've gone to the mountaintop.

>> Another having a significant drop in their mood and that drop in the mood is where they have severe depression.

So they've been to the mountaintop and they get this really bad depression.

People with bipolar disorder are more likely when they're depressed to commit suicide because they've had this gradient of mood from a really big high all the way down to a low more so than people who have a normal mood and then they get depressed.

So I talk to a person a day who said every now and then they just feel pretty good for a few days and they get more done during those days.

However, during those days they felt happy.

They didn't feel like there are more talkative than they would expect to be.

>> They are not having less need for sleep.

>> They are not doing anything impulsively.

They don't do anything they later regret.

They didn't feel happy on those days but then they feel depressed after that and they wondered if this person wonder if if that was bipolar disorder.

It's not bipolar disorder if you have a normal mood is perfectly fine to have normal mood and to feel happy and to get things done on certain days it's where you have this unusual increase in your mood where you have this sense of feeling higher than a kite.

You're talking really, really fast.

You're going from topic to topic to topic.

That type of phenomenon is bipolar two friends a very, very important that we separate out bipolar disorder versus normal mood with depression because with bipolar disorder you need a cruise control for your mood.

Something is going to level out and keep you from feeling unnaturally high and unnaturally low.

>> You should still have normal emotions.

You could still have that normal vicissitude of mood as we often describe where you have happiness, anger, irritability, sadness, apathy as as the situation is would expect you to have.

>> So you should have these normal gradients of mood based on your environment day by day.

>> That's OK. You want to have those normal moods but what you don't want to have or these unnatural unusual highs it just come on out of the blue now sometimes stress can bring on the highs or the lows.

>> For instance, let's say you had a few days where you had to stay up later than usual and you were you had nighttime obligations and that kept you from sleeping and that will sometimes bring out mood disturbances that people would often have lack of sleep will often significantly affect the brain chemistry and lack of sleep will often throw fuel in the fire for somebody for mood disturbance.

I had a person ask me earlier this morning if I have ongoing depression it seems like I get more anxious than when I get more anxious I get more depressed.

That's often a cascade often I often hear about people feeling really anxious about their life circumstances.

That's how the cascade starts.

So you have certain circumstances going on.

You feel anxious and worried about those life circumstances you start to ruminate about them and you start to worry about them.

That leads to you're having difficulty with sleep because you're sacrificing your sleep because you're worrying about what's happening during the day when you start sacrifice the sleep it affects this judgment center the brain up on the front and this is the part of the brain that starts to go a little haywire when you get depressed.

So the front part of the brain does not work adequately when you get depressed and as you might imagine judgment part of the brain, the thinking part of the brain, the part of the brain that makes you think before you act on things it doesn't work so well when you're depressed and that leads to having those bad ruminative thoughts about death or suicide or thinking that you're a failure and nobody else likes you.

That all comes from the front part of the brain.

We do treat that kind of condition with medication as well as counseling because the idea of counseling is to try to help you rethink those automatic thoughts that you're a failure and nobody else likes you and that's because the front part of the brain isn't working so well.

>> But there's often a cascade between oh you're under stress, you're trying to cope with different things that leads to anxiety and worry.

The anxiety and worry leads to you're having difficulty with sleep and that thereby leads to you having difficulty depression on down the line.

And that's why a psychiatric vital sign that will often examine will be lack of sleep.

>> We actually use a particular questionnaire called Insomnia Severity Index.

It's eight questions that basically asked about your sleeping and the specifics about your sleep and it's a very, very important sign for us to be able to to follow in psychiatry.

Thanks for your question.

Unfortunately I'm out of time for this evening.

I'm psychiatrist Jay Fawver and you've been watching Matters the Mind on PBS Fort Wayne.

If you have any questions concerning mental health issues that I can answer on the air on the air Yamashiro write me via the Internet at matters of the mind all one word at a dot org God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching.

Have a good night