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>> Good evening.

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

Welcome to Matters of the Mind now in its twenty fourth year matters 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 toll free at 866- (969) 27 two zero now on a fairly regular basis where our broadcasting live every Monday night from our spectacular Fort Wayne studios which lie in the shadows of the Purdue Fort Wayne campus.

And if you'd like to contact me with an email question that I can answer on the air, you may write me a via the Internet at matters of the mind all one word at the morgue that's matters of the mind at WFYI a dog.

>> I'll start tonight's program with one of us few emails that I recently received.

It reads Dear over this past winter with increased snow in Fort Wayne I was sinking into depression.

>> The sight of snow piling up makes me feel anxious and agitated.

The gray cloudy sky blends into the snow and on the ground and makes me feel claustrophobic as well.

Somebody told me that I have snow depression.

How do I deal with this?

Well, snow depression is different from seasonal affective disorder which is one of the other questions seasonal affective disorder is also known as winter depression is where the skies get darker and with less light and with less stimuli on your retina every day from the light you get depressed, you get to the point where you don't care.

You get fatigue, you get tired, you want to eat more, you don't want to socialize.

You just feel more depressed with a dark days of winter that's a seasonal affective disorder.

That's a winter depression you're describing snow depression where the piling up of snow keeps you from getting out.

>> So some of that's a safety issue.

>> So I understand why you might have some difficulty with feeling somewhat anxious and agitated because you see the snow and you have difficulty getting out and about.

>> I think the best thing for you to do would be to number one, try to socialize the best you can find friends, family who can get you out in their four wheel vehicles who can help you shovel out, who can allow you to get out and about despite the snow.

The good thing about Indiana as we get some pretty hard snows occasionally but after a few days things get cleared up.

Now by contrast in Minnesota and Wisconsin they embrace the snow during the winter.

>> They really need to adapt to do so.

But they'll have festivals, they'll have events week by week.

>> They're socializing.

They have sporting events in the snow.

So they embrace their winters and they do that because they maintain their socialization that way.

>> But they're also exercising and physically active.

>> They're getting out and about in the fresh air during that time.

So one of the ways to get over a winter depression where you're dealing with the dark days of winter will be to try to exercise to get yourself some exposure to bright lights, for instance with light therapy where somebody sits in front of a bright light for twenty minutes every morning.

You'd mentioned Prozac being used in the past for you Prozac also known as Fluoxetine has been used for people with winter depression although preferably we're seeing bupropion or Wellbutrin used as an antidepressant for winter depression.

>> That's for the people who get tired and depressed during the wintertime.

>> You're talking about social isolation.

You're talking about the apprehension and anxiety related to seeing that snow piling up and knowing that you have difficulty getting out.

I think from your perspective the best approach would be to reassure yourself that it's going to be gone after a few days.

>> So you know, we haven't had the blizzard of 78 type of depth for for quite a while now.

>> So I think the kind of snows we get give it a couple of days, give yourself some reassurance, have something planned on days where will snow heavily and do something that you could find that would be pleasurable inside the house just during those days and have that arranged ahead of time perhaps do some kind of book study what's have some movies ready, have some kind of indoor activities preplanned for those snow days.

And again in Indiana it's usually two or three days in a row that you'll have some bad snow and then then they tend to subside and now we're getting into spring so that should get better.

>> Thanks for your question.

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

Our next e-mail question reads Dear Dr. Farber, I'm sixty seven years old and I have taken one hundred milligrams of nor tripling that bedtime for thirty five years and the occasional low dose of Xanax I've been told that nor Tripoli can damage my heart.

Is this true and how do I taper it?

How long do I wait before trying another antidepressant and which antidepressants would you choose?

>> Well nor tripling is a medication that back in nineteen eighty six was the number one antidepressant available.

The reason being of the various antidepressants available up in nineteen eighty six it was the one that caused the least toxicity and a unique feature about nor tripling is it has a therapeutic window on blood levels.

>> You can get a blood level being on near Tripoli in twelve hours after the prior dosage.

>> So if you take a dosage of nine p.m. about nine a.m. the next morning you can get a blood level that blood level should be between roughly 50 and one hundred and fifty so we know exactly where the blood level should be.

So we know if we've overshot or if we've undershot on the dosage and that's kind of unique within our Tripoli.

>> It's easy to do that.

Their plane doesn't cause as much difficulty with cardiac conditions compared to a lot of other medications in its class.

If you have a preexisting cardiac condition such as second degree block congestive heart failure, you have some problem with your heart already.

>> Yeah, nor tripling can affect to some degree the conduction of the heart.

>> But if you don't have that kind of condition already and your heart's doing OK, there wouldn't be a reason you'd have to come off the line from a heart perspective my biggest my biggest concern with nurture blame for somebody who is sixty seven years young would be the possibility that it has anticholinergic effects.

>> That means it blocks this chemical called acetylcholine and it can all your memory a little bit.

>> Secondly, when you're sixty seven years young you can have difficulty with constipation, blurred vision, difficulty seeing things up close which we all have difficulty doing as we get older.

>> Unfortunately you can have a bit of a dry mouth.

You can have dry eyes that can be a factor.

So those are the kind of side effects we're often talking about.

It can lower your blood pressure a little bit upon standing you had mentioned you're on a low dosage of a blood pressure medication.

It could lower your blood pressure just a slight degree upon standing it specifically and fairly selectively will enhance a neurotransmitter called norepinephrine.

Now the neurotransmitters that we often discuss with depression will be norepinephrine, dopamine, serotonin, glutamate.

It's increasing norepinephrine.

So what medication out there specifically will increase norepinephrine and not give you the effects on the heart and not be as anti cholinergic No one niaf asado CyrusOne Nafisa no one's been out since about nineteen eighty eight or so and it's a medication it does increase norepinephrine it's very well tolerated.

It's just that a lot of companies quit manufacturing it and it's on and off in terms of its availability years ago about twenty years ago fifteen years ago there were a few cases in Canada of people on Naficy owner Sarazen who had some liver problems because of that some companies of some manufacturers quit making it but then it came back because they found the liver problems weren't really that problematic.

It was very isolated with those particular people.

>> So nothing was done specifically can increase serotonin.

So it's a well tolerated medication does not cause weight gain, does not cause sexual disturbances, does not cause difficulty with dry mouth or constipation and certainly doesn't cause memory problems.

>> So if I was to choose a medication I'd probably go over to that one now how would you do that?

I would suggest maybe a three or four week criss-Cross.

I mean you can always talk it over with your clinician but basically maybe 100 milligrams of of trapline for a week with something like NFSA Azzedine with it nor tryptophan goes through a particular enzyme called to desex.

>> That's how it gets broken down broken down whereas now Facetune goes through three eight four so they go through different metabolic pathways when you criss-cross on medications you typically want to make sure they go through they go through different pathways.

If they're going through the same pathway to get out of the body they can kind of fight them getting out of the body and it kind of messes up your ability to get off one and start another one.

>> So I'm always looking having medications on board that go through different pathways.

You could very carefully start the medication more commonly used by the name of Cymbalta or Dellucci Cymbalta delux Dean has some very similar effects as Nafez known only Cymbalta or digoxin does increase serotonin as well so it could be a little messier in cross titrating but that would certainly be a possibility.

>> But the Facetune has very little effect on the heart and it's less likely to give you the constipation dry mouth compare to the near Tripoli.

But keep in mind Cymbalta or are Dulux Tene does have some enhancement in norepinephrine and if you increase norepinephrine you can get a dry mouth and constipation.

I just talked to a lady a few days ago who had some constipation on Cymbalta that can be a side effect and that's from the norepinephrine effect not the blocking of the seal coaling watch which is what you can get from your trip lane.

So there are other options in terms of trading over one hundred milligrams isn't that high of a dosage for a lot of people?

>> I'd look more at the blood level if your blood levels on that high side of normal I'd say maybe get back down a little bit on it.

>> We've been on it for thirty five years.

If it was Xanax I'd have more concerns about that low dosage of Xanax that you're taking.

But if it was Xanax and you'd been on Xanax for thirty five years on a regular basis I might take CZI as many as the thirty five weeks to get you off the Xanax might slowly taper you off that because the longer you've been on Xanax on a day to day to day basis the more slowly should back off of that.

>> You had mentioned you don't take the Xanax all the time so that might not be a problem for you but I'd have actually more concerns about you being on Xanax if it was on a daily basis at a higher dosage that can significant affect your concentration and memory processing as you get older overall.

So bottom line is that you could do a criss-Cross with nor trapline with another medication and other medication could be NEFE acetone or Dellucci teen and most people can tolerate that pretty well.

>> You don't have to wait in coming off the north trapline.

A lot of people will do that.

>> They do that in clinical trials and research trials which aren't the real world and research trials you want to research a drug that you created in your basement.

>> You got this brand new drug and you really want to get research right?

So what do you do?

>> First thing you want to do is get everybody off the previous drugs, wait at least a week and they call that a wash out sometimes they wait a month and then you start the new drug.

>> Well that's OK in research settings where people are perhaps getting paid to be in the research trial itself.

>> But in the real world people feel miserable when they do that when people go off of one medication, wait a week and then start another medication during that time they are depressed, they can't sleep, they're anxious.

What we often do in the real world is we criss-cross medications.

We'll have them taper off.

The existing medication are on at the same time start a low dosage of the medication in which they're starting and we do crisscross that way not done in the clinical trials but that's what we do in the real world.

>> Thanks for your email.

Let's go to our next email.

>> I got three emails this past week.

It reads Dear Doctor Father can depression be related to ringy in the ears?

>> I wouldn't say the Depression would cause tinnitus or ringing in the ears.

That's very unlikely but tinnitus ringing in the ears that buzzing annoying sound people can sometimes that can cause depression.

>> That's where I often see people with tinnitus.

I wish I had better treatments for tinnitus.

I do think it's probably a more of an ear, nose and throat or perhaps a neurological condition where there is increased sensitivity at the auditory cortex in the brain itself.

>> So the brain is picking up auditory impulses and perceptions that are just unnatural.

>> So you're hearing all this background noise and it's a ringing.

>> It's a buzzing.

People get anxious because of that and there's various ways to try to cope with it.

Some people will have headphones or wear headphones.

They try to have some outside distractions to try to offset the ringing in the ears.

>> I've seen some people get benefit from Anta Virt also known as mechanizing which is a basically an antihistamine that's used for dizziness or vertigo.

>> But people who have ringing in the ears sometimes will have dizziness or vertigo and along with that they'll have trouble with nausea.

So you have this this cascade of symptoms where you have dizziness and nausea and the ringing in the ears all that and in one extreme is called Moneris Disease Manure's disease is a condition by which people often use this antihistamine called Miklosi Rahnavard as a means of getting some relief back in the old days people used to get high doses of Xanax for ringing in the ears.

>> I think that helped more with the anxiety than ringing the ears.

So I didn't find that to be a lot have been very beneficial for people but I think it's more of an ear, nose and throat condition where I think the ear, nose and throat clinicians will be the ones to step up and try to figure out a treatment for that in the long run.

Ringing the ears can be a precursor to hearing loss in some cases.

So that's why it should be taken seriously.

>> But it doesn't it doesn't in itself.

It does not appear to be caused by depression but it can cause depression or anxiety for some people.

>> Thanks for email.

>> Let's go to our next email.

I thought we had a caller there.

I guess we don't let's go to our next email.

We have another email.

>> Yeah, we do.

Here's one to fall over what's the best antidepressant for anxiety and difficulty with sleep?

>> I've tried Lexapro and Celexa and they haven't helped Lexapro and Celexa both are very specific and selective in enhancing serotonin and for a lot of people they help with anxiety.

>> But if you have difficulty with anxiety and sleep very specifically I'd recommend a couple of medications if you need something for depression.

>> Mirtazapine Raemer on it came out in nineteen ninety five has five different mechanisms of action so it has a lot of different mechanisms of action.

Unfortunately one of them isn't it's in a histamine effect.

>> It blocks histamine type one receptors and in doing so can make you sedated which is good if you have trouble with sleep but also it's it can increase your appetite some so that's always the drawback of mirtazapine or amron.

We do indeed selectively give it to people who have poor appetites, who have nausea.

It's a very good medication for nausea.

So you can imagine mirtazapine could be a great medication for people who are recently having chemotherapy for for cancer treatment.

>> So we will not uncommonly use mirtazapine for people who are having trouble with sleep.

>> They're anxious.

They're depressed because it's very good antidepressive and they specifically are having trouble with nausea or their appetite for that matter.

Now we can as I did earlier today use mirtazapine in combination with a medication like Wellbutrin.

Wellbutrin is also known as bupropion.

Bupropion increases norepinephrine and serotonin norepinephrine dopamine whereas the mortez is increasing serotonin and norepinephrine.

They work together really nicely because mirtazapine can increase your appetite but bupropion decrease your appetite so they tend to balance out any appetite disturbances while giving you a very potent antidepressant effect overall and they go through different metabolic pathways so once again they don't interact with each other that way so we could use that.

>> So Mirtazapine would be one option specifically for depression, anxiety and sleep disturbances if you're having trouble with with anxiety and sleep disturbances predominantly and the anxiety sleep disturbances are causing you to be depressed because that will happen if you don't get enough sleep, you feel depressed and you can't process information very well in your frontal lobe.

>> If sleep is the main issue there, you could take one or two medications.

We often use Gabapentin or Neurontin.

It's an old anti seizure medications.

We're using it a lot nowadays for pain.

We're using it for us.

This leg's tightening jaw called bruxism.

We use Gabapentin or Neurontin not uncommonly for people who are having trouble with anxiety and sleep disturbances and it's a medication that helps you get to sleep typically within about twenty minutes gives you an eight hour duration of sleep.

And what I like about Gabapentin also known as Neurontin is that it gives you a deep sleep.

>> In other words, there's different phases of sleep.

>> There's the phase one phase two which is the light sleep.

Then you get into the phase three and four sleep which is really deep sleep and if you get awakened from the three and four sleep stage sleep you're very confused and because you've been in a very deep sleep you're not dreaming.

You're in that sleep.

It's during stage three and four sleep that people will sleepwalk and younger kids especially as their brains are growing will have more stage three and four sleep and that's why younger people will have what's called night terrors where they awaken screaming perhaps they're very confused because they awaken during the Earth Stage three and four sleep that's different from REM sleep a rapid eye movement sleep which is actually increased when somebody has depression.

That's the dream sleep that people not not uncommonly have.

So Gabapentin or Neurontin can be used for anxiety, give you a deeper sleep what we like about it it typically wears out within eight hours so it's has a nice duration of action for sleep.

You do not want to use Gabapentin or Neurontin if you're also using narcotics because they can amplify the effect of narcotics not in a good way and you don't want to use Gabapentin or Neurontin if you're prone to using drugs of abuse because again it can give you a little bit more of a high so a few people out there can get a bit of a high off of gabapentin.

>> So those are the people we don't want to see using it.

Thanks for your question.

Let's go our first caller.

>> Hello Mike.

Welcome to Matters of Mind.

Yeah, hello.

Hi Mike.

Yeah, I've got a question regarding what what are some of the causes of the chemical imbalances that happen?

That's a question I'd love to be able to to answer as accurately as I could, Mike, because what we know in Twenty Twenty to the Brain is run by seven or eight different chemicals predominantly and these chemicals all talk to each other.

>> So we have 70 or 80 chemicals on the brain and they all talk to each other through these little neurons that each have a tenth that each neuron has ten thousand branches on it when it's fluffy enough so you've got these little neurons that fire out these chemicals.

>> The chemicals are all talking to each other.

You increase serotonin, serotonin can go these dopamine neurons shut down the dopamine neurons so too much one chemical offsets another one and then you have all these imbalances that way.

>> So the fine line will always get the chemistry in balance.

>> So what causes the chemical imbalance?

A lot of things like number one you can have the genetics for a chemical imbalance.

So if you have the genetics for chemical imbalance that means for depression for instance, if you have a first degree family member a brother, brother, father, brother, father what we're trying to say here it's late at night father, mother, brother, sister.

>> That's it.

If you have a first degree relative with depression you have a one out of three chance of having depression in a similar manner.

>> If you have that first degree relative with bipolar disorder where they have highs and lows, you have about a 60 percent chance a 60 percent chance of having bipolar disorder yourself.

>> So we know there are some genetic propensity and we do genetic testing, Mike, and we try to figure out who might do better on one medication versus another.

>> But with genetic testing it's interesting we'll find that some people don't do so well if they have certain genetics matched with a lot of childhood trauma.

So one of the things that really messes up your brain chemistry and causes these chemical imbalances will be childhood trauma.

>> We do this particular scale called the adverse childhood experience scale.

It's ten items scale.

>> It's on the on the Internet.

Take it for free.

Generally speaking, if you have four or more of those ten adverse childhood experiences, you're more likely to have difficulty with depression or anxiety as an adult.

Now those childhood experiences have to occur before your eight years of age.

>> So a lot of stuff can go on if you're if you're having a lot of trauma in your life with your parents separating or divorcing a parent goes to jail at an early age.

>> You see you experience bad stuff in your life before the age of eight years of age that can have a huge impact on you later on and it's called it's called epigenetic.

>> It's where your environmental influences the stuff happening around you will influence how your genetics are expressed.

>> And I always refer to genetics as being kind of like pigs in a blanket.

You know, it's a marvelous culinary delicacy.

Pigs in a blanket especially when you put sausage in instead of hot dogs but pigs in a blanket are basically a hot dog or sausage inside a flaky Chryson All right.

>> That's the way DNA is structured in our cells.

The DNA is like the hot dog or sausage that around that is the blanket which we call a histone.

>> The histone opens up periodically and it can acetyl eight which means activate the genes or it can deactivate it by methylated it so you can methylated it.

>> You can ask acetyl to the bottom line is our genes can be expressed by stuff happening in our lives.

>> So if you have all this trauma occurring to you it can be opening up susceptible genes that would cause you to have these metabolic and even neurotransmitter disturbed cells and that's what we call chemical imbalances.

So chemical imbalances you can't measure them.

That's what makes it so challenging to be a psychiatrist in twenty twenty two we can't do blood tests and figure out how somebody's brain brain chemistry is doing because the brain chemistry is encapsulated by this blood brain barrier which is like a sheath all around the brain and it was very selective on letting certain chemicals in letting certain chemicals out so you can't check a blood test and see how somebody's serotonin level is or norepinephrine level is and even he could my question would be so what?

>> You can have a certain serotonin level but how is everything else doing and how are you adapting to those particular symptoms?

We say the same thing with genetic testing.

We'll see some people with the exact same genetics as others but they have different symptoms.

>> Why?

Because they had different stuff happen in their lives.

Some people smoke, some people did and some people exercise more.

>> Some people don't exercise as much.

Some people have better coping skills than others.

>> That will all affect how your genetics will be expressed.

So what we're doing in psychiatry in trying to assess chemical imbalances, we're doing the best we can to sort out what your family history do.

>> You have other family members who have had similar type of symptoms and have they responded or not responded to certain medications?

>> We want to know that off the bat.

Secondly, what are your symptoms overall?

We call that the phenotype.

>> The phenotype will look at what your overall symptoms will be and that's how we come up with a diagnosis.

Why do we need a diagnosis of psychiatry?

>> Well, at some level you've got to figure out what the heck you're treating if you have a call for instance, you could have a cough related to a peanut caught in your throat.

It could be a cough due to asthma, heart disease, gastric reflux.

You could have a cough due to cancer, pneumonia.

You could have a call from all sorts of different reasons but you're going to treat that cough differently based on how you diagnose what's causing the cough.

We're trying to do the same thing when somebody has irritability for instance, we want to know that symptom of irritability.

>> Well, let's look at the other symptoms around it and come up with a diagnosis.

Is the irritability due to attention deficit hyperactivity disorder?

Is it due to a head injury?

>> Is it due to depression?

Is it due to bipolar disorder?

Is it due to post-traumatic stress disorder?

The list goes on and on.

>> So we want to sort out what's what kind of symptoms you have and then direct our treatment toward that.

So we're not at a point where we can actually methodically diagnose chemical imbalance.

>> What we're doing is we're looking at the symptoms.

We're looking at the after effects in a similar matter that you can look at electricity, you don't see electricity occurring.

>> I've got these bright lights all around me.

I can see the bright lights.

I can see the effect of the electricity but I can't see the electricity the same way you can see the effect of the brain chemicals but you can't actually measure them directly from the brain.

>> Mike, thanks for your call.

Let's go to our last caller.

Hello Eric.

>> Welcome to Marisela Mind we've got about a minute or so here left.

So I was wondering if LaRock is a good alternative for Gabapentin and does that help with anxiety at all?

>> You bet.

Eric Lyrica is also known as Pregabalin.

It's a chemical cousin of gabapentin and it works on these little calcium channels that basically modulates or stabilize the calcium channels.

>> It's thought that when somebody has anxiety or pain for that matter, Eric, they have an itchy trigger finger with calcium.

>> Some calcium is firing calcium channels or firing too much.

>> So gabapentin will help some Lyrica meal even more so for a lot of people.

So we find that some people do a bit better on Lyrica than Gabapentin.

Lyrica or Pregabalin is now generic so it's less expensive for a lot of people.

>> So we often use that as an alternative can use it for nightmares who can work OK for nightmares?

>> Some people do better with it because as I mentioned before, Gabal and Gabapentin and Lyrica for that matter do give you increased deep sleep so they can decrease the REM sleep in that matter.

>> Eric, thanks for your call.

>> Reto unforced I'm out of time for this evening.

Give me a call this next week.

I'd love to hear your question at that time.

I'm Jeff or I'm a psychiatrist and I've I am finishing up here on matters of the mind for this evening if you have any questions I can answer.

In the meantime over the next week you may write me via the Internet at matters of the mind at WFYI dot org.

>> Thanks for watching.

Have a good evening.

God willing and PBSC willing to be back again next week.

Good night