>> Good evening.

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

Welcome to Matters of the Mind Now in its third 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 had 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) 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 Purdue University Fort Wayne campus.

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

>> That's matters of the mind at WFA Edgartown after tonight's program with an email I recently received.

>> It reads Dear Dr. Fauver, I've heard that some antidepressants can make birth control inactive if this is true and what medications would have this effect?

>> The good news is that the most commonly used antidepressants do not make birth control less effective such as the SSRI like Prozac, Zoloft, Lexapro the S in our eyes like effect suppress Deek Cymbalta.

We've got some other antidepressants like Wellbutrin, Trin Telex Vibert.

They don't make antidepressants are they don't make birth control pills any less effect.

Even the birth control pills really have no effect on them of any significant degree.

>> You might have heard about St. John's Wort a very popular herbal AMTA antidepressant that made the cover of Newsweek magazine back in the late 1990s.

I believe and it was very popular back then.

>> What people found is that yes, it did accelerate the enzyme activity of the liver thereby breaking down estrogen and progesterone faster and when that happened the birth control pills became less effective.

>> So a lot of women who took St. John's Wort, which was very popular a couple of decades ago, they got pregnant unexpectedly because they were taking St. John's Wort that made the birth control pills less effective carbamazepine which is a rarely used mood stabilizing medication also known as Tegretol can also enhance the activity of the enzymatic activity in the liver and cause the birth control pills to get broken down faster so those are the main concerns.

But the good news is that antidepressant medications themselves, the ones that are commonly used do not typically have any effect on birth control overall.

Now there have been studies that have been conflicting over the past 20 years saying that women on birth control might be more likely to have depression and anxiety.

Other studies say they don't.

>> And the bottom line is you have to see how you feel individually if you take a birth control pills or woman and you notice you feel more moody or more irritable after you take it, you might want to change to a different birth control pill.

Some women actually get benefits then they feel more stabilized their mood once they get on birth control because they don't have the shifts up and down of estrogen and progestin and some people notice that lessens the premenstrual symptoms and that can be a treatment sometimes for for some women.

>> But if you notice that you're having moodiness and irritability with or without the birth control pills, you can always talk to your clinician.

But there are a lot of different antidepressant medications that can be used even if you are on birth control.

>> Do birth control pills cause menstrual irregularities?

They can if you enhance serotonin especially that can sometimes cause menstrual irregularities but really has no direct effect on the birth control pills themselves.

>> So many irregularities might be noticed.

Some women notice they bleed more heavily on birth control pills.

Some women notice they bleed less.

>> But the contraception is typically still apparent for these women.

Thanks for your email question .

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

Let's go to that one and this next question reads Dear Dr. Varvara, my 11 year old daughter has been diagnosed with anxiety and depression and I'm not sure about putting her on medication at her age.

Are there severe risk in her age group?

>> Eleven year olds they really ought to be assessed and a lot of cases by a child psychiatrist ideally or at least a child psychologist for the purpose of really getting a definitive diagnosis to understand what kind of things going on because eleven year old girls are having hormonal changes and hormonal changes themselves can elicit moodiness and anxiety.

>> So where would you use medication for an 11 year old girl who's having more depression and anxiety?

>> You'd use it no one if there's a strong family history of depression or anxiety, no tool to if this girl at an early age was highly traumatized, that can be a factor because a lot of trauma, emotional trauma, sexual abuse, parental separation or divorce maybe a parent was imprisoned all this stuff that happens especially before the age of seven years old and highly before the age of three years old.

I mean the younger you are with all these traumas are occurring as the brain is still growing, the brain has a difficult time adapting to all these different changes in stress.

So with that being said, if there's a lot of trauma at an early age, yeah, there might be a need for an antidepressant medication for those people.

>> But I'll typically wonder, you know, if a child needs an antidepressant or not, if I if I hear about that or you know, even an adolescent for that matter, I want to know what has worked for the rest of the family members if the rest of the family members have taken this, this or this antidepressant, OK, predictably those different antidepressants might work for the 11 year old girl.

So you want to be very, very careful and the high need for 11 year olds as we don't want to medicate normal adolescent behavior.

>> That's where you have to be so careful you're medicating behavior that's causing them to have trouble with social relationships to help them be able to function in school.

You want to be able to medicate them for the purpose of allowing them to have overall better functional outcomes.

But you don't want to medicate normal childhood adolescent behaviors and that's it's a very fine line but that's what clinicians need to determine.

>> Thanks for your question.

>> Let's go to our next caller.

Hello Gail.

Welcome to Matters of Mind.

Hi.

Hello Gail.

Hi.

I have a question regarding recently I received a letter from my insurance company saying that I was taking a duplicate medication from Desk Venlafaxine which is generic for cacique and I'm wondering if that's because the same doctor also prescribed Rexall two point five milligrams and then I have a second part of the question as I am also diagnosed ADHD and for my anxiety I've on Diazepam five milligrams twice a day and I know that there are inherent dangers of taking a benzodiazepine for a long period of time.

So I was wondering since I can't get my doctor to listen to me to change the Diazepam if there is a way to approach that, is there a better way to approach it or another way to taper me off or titrate me down to something else that might work?

>> You bring up several issues, Gail and I think I can address some of those that's Venlafaxine is indeed Stik.

>> It's an antidepressant that will typically 50 to 100 milligrams a day will give you enhancement of serotonin and to some degree norepinephrine.

>> So it works like Effexor its parent compound basically does.

>> Venlafaxine is the breakdown product of its parent compound Effexor and what you'll notice is you'll have fewer side effects on Venlafaxine which is now generic like its parent compound Effexor is.

So we prefer Des's Venlafaxine or Stik for a lot of people who need that class of medication if that's the right medication for you now you'd mentioned anxiety was added.

>> The result is a brand name medication great.

Add on to Presti or Jesslyn Venlafaxine Gaile so exalt he works entirely differently.

Result is a medication that has many different mechanisms of action and for that reason my goodness at higher doses it can actually be used for schizophrenia but low dose we use it for mood stabilization and even a lower dose point five milligrams like you mentioned it can be used as an add on to make an antidepressant work better.

>> So if you think of a Hamburger Helper Iaat Hamburger Helper, how's the hamburger in it?

And that's like the des Venlafaxine or Presti anything you want to make hamburger taste better so you add the Hamburger Helper to it and then you have a casserole.

>> That's what we're doing when we add on Rexall TI we're trying to make the mystique the antidepressant work better and the combination of prestige and low dose of the result can work out really well.

It's not a duplicate in a sense that they have different mechanisms of action.

What you wouldn't want to do obviously clinicians typically know this you wouldn't want to add another serotonin norepinephrine medication to Presti or Desmond live vaccines.

You wouldn't add Cymbalta for instance to Des Venlafaxine .

>> You would need the medications that have duplicate actions but results works entirely differently and it's a it's a very nice add on to the press Staker does venlafaxine I think your insurance company is probably saying they want to try something different than results and many times we have to try Abilify first.

Abilify is a Pipas all result is Breck's Pip Resul so they kind of are chemical cousins.

That Arop result is a little bit cheaper as a result can give people a little bit more restlessness which can be a problem when you already have some depression and anxiety and that's what we often change over to result.

>> But the adding on to an antidepressant can be a very nice strategy to try to help somebody with depression.

Now Gail, you had mentioned you also have ADHD.

You've been on Diazepam, Valium five milligrams twice a day back in nineteen seventy nine when I graduated from pharmacy school a long time ago, Diazepam was the number one medication of all medications prescribed.

>> All right.

So in the United States more people were on Valium or Diazepam than any other medication antihypertensive anti diabetic medications you name it.

>> They were on Valium more than any other medication back in nineteen seventy nine .

>> So these medications have been around for a long time.

It's been a very popular means of helping with anxiety.

>> Why does it help with anxiety?

Diazepam goes to this little part of the brain here called the amygdala dials down the volume control there so you have less anxiety, less anger, less irritability and for some people they just have a calming effect.

It works within twenty minutes, lasts four hours because diazepam or Valium lasts for a long, long, long time and many people can take it just once a day but many people do take a twice a day.

>> Here's the problem with Diazepam Gaile and why we're no longer using that class of medication.

So much for people especially with ADHD because diazepam or Valium Alprazolam also known as Xanax quanties of Hamilton is Klonopin Lorazepam also known as Ativan.

>> These are medications that can immediately give you a calming effect and they can make you feel better but they make you kind of mentally dull.

You don't have the speed of processing that you might like if you have ADHD they typically help with anxiety related to ADHD but they often will impair your ability to think and concentrate.

>> And I've seen patients in my practice who have been on that class of medication for decades and as I slowly taper them off they will feel like they have new brains and the way I'm describing slowly tapering them off is I use a general rule of thumb where for every year somebody's been on these medications I use that number of weeks to get them off the medication.

>> So if they've been on a medication for let's say ten years I might use ten weeks to taper them off and it's just a general rule of thumb we can always stretch out that tapering sometimes we might add another medication to it to help him with the anxiety such as gabapentin also known as Neurontin to try try to dial down the anxiety a little bit as are coming off of the benzodiazepine medication.

But the bottom line is benzodiazepines just give the brain a general overall tranquilized and it can make you not care and if you have ADHD already you're having difficulty with processing speed now what does that mean?

>> Difficulty processing speed is like your computer speed if you've been on the old computers ten, fifteen years ago, you know, kind of took a while to go from screen to screen and that's called speed of processing Valium, Xanax, Klonopin, Ativan they all slow down the speed of processing.

>> So it's like your computer speed and your brain is slower and it gets very frustrating.

>> That can be a problem with ADHD because with ADHD you're having difficulty with processing speed but you're also having trouble distractibility and you put all that together.

>> Benzodiazepines like diazepam can make it a lot worse.

What I'd want to do for you, Gail, take a look at the diazepam or Valium.

>> Look at how long you been on.

It's been five milligrams twice a day a common dosage but the longer you've been on the slower you taper off.

Diazepam is fairly easy to taper off for most people because it stays in the system for a long time.

So we sometimes use Diazepam to help people taper off of their other medications in that class.

>> So very slow tapering on that you'll notice maybe you'll be more awake and alert and then I'd want to look at some help for the ADHD and distractibility because ADHD by nature can cause you anxiety with ADHD Attention Deficit Hyperactivity Disorder people have inattentiveness.

They can only pay attention to things that are highly interesting or highly challenging.

>> But if it's not that interesting, their mind is all over the place and their mind will wander.

They'll often be perceived as very inefficient.

It takes them twelve hours to get eight hours of work done.

They will often procrastinate, put things off.

They don't do the get their priorities done first and what happens while they get more anxious because they worry about what they forgot what they overlook, what they didn't do.

So as you worry about that, that creates anxiety.

So somebody like you Gail might have gotten a Pam because you're anxious about the ADHD.

>> So what we need to do is go back to square one and take a look at OK, the nature of the anxiety, what caused the anxiety if it had to do with childhood trauma, OK, talk therapy counseling can happen.

We can work with that.

But if it had to do primarily with ADHD symptoms my goodness you treat ADHD with several different types of medication it can help secondarily with anxiety.

If your focus and your attention span are improved you'll often notice your anxiety improves.

>> And it's ironic for a lot of people though they'll say that when they take a stimulant for ADHD they'll notice they're calmer because if you take a stimulant for ADHD you're more focused your mind's more on track and you're less anxious about things happening around you.

>> Now here's where people get in trouble with stimulants.

>> If you take a stimulant and you don't have ADHD, it's kind of like wearing somebody else's eyeglasses if you don't have poor vision, you know, eyeglasses correct the vision and the same way stimulant medications can correct the difficulty the focus for ADHD and what people like about the stimulants will be as the name implies the stimulation as a side effect early on people can have increased energy and more get up and go.

>> Sometimes people will have an appetite suppression with a stimulant medications and they like those effects.

>> But the problem is to get those side effects of energy and appetite suppression you have to go higher and higher and higher on the dosage and the next thing you know somebody is no longer on Adderall 20 milligrams a day they're on sixty and one hundred milligrams a day and off they go and then they're taking medication like Diazepam or Valium to calm them down and it just gets to be a big mess.

>> So as with any kind of condition jail No one we want to look at the underlying type of issues going on.

>> If it's depression, if it's anxiety, if it's ADHD we want to knock down as many birds with as few stones as possible and to do that we try to use as few medications that we need but we want medications that will work for two or three different conditions.

For instance, there's an antidepressant out there although you might have taken by the name of Wellbutrin, Wellbutrin has been around since nineteen eighty nine and it's a medication it increases dopamine and norepinephrine and in doing so it can not only help with depression but it helps with focus and concentration.

>> Now not everybody tolerates it.

About one out of four people just are not a good genetic fit for Wellbutrin so those people will get more agitated, more anxious with us so we go a different direction for those people.

>> But a lot of times we'll use Wellbutrin for the purpose of helping with depression and focus.

There's a bedtime medication people use for blood pressure but they also use it for distractibility and it helps with focus in a whole different way than Wellbutrin or stimulants do.

It's called Gwon Forseen.

So Gwon Forseen in the brand name is called Tenex.

It's a long acting formulation is called intuitive but that's a medication that can help with distractibility and focus.

But people take it at bedtime because it will help with the depth of sleep with which many people with ADHD will lack.

>> There's a lot of different type of things that can be done out there Gail.

But I agree with you no one result is a brand name medication.

That's why your insurance probably denied that particular medication in combination with Venlafaxine and other two diazepam always a good idea to try to taper off of that very slowly but it's always a good idea to taper off of that to preserve your brain functioning if you're over sixty five years of age and it looks like it looks like those kind of medications will increase the likelihood of your having memory impairment.

>> So especially as we get older, it's always best to be off of that class of medication.

Gail, thanks for your call.

>> Let's go to our next caller.

Hello John.

Welcome to Matters of Mind.

>> Hi, John.

Hi.

We have a family member with a narcissistic borderline personality disorder.

There's often abuse to self medicate has had a profound influence on our family.

>> Is there any support group to help cope with this individual to help you cope with that individual?

>> Correct.

Yeah, the best support group would be in your area looking for an Al Anon group if you've ever heard of those.

>> It's a support group for family members with individuals with alcohol dependance but it also can be used for individuals with narcotic dependance as well.

The bottom line is family members do need the support for loved ones who are going through those different type of things.

There's a real good support group for mental health issues in general and this is where having a family member with narcissistic personality disorder and borderline personality disorder is where it can be helpful.

It's the National Alliance on Mental Illness.

The National Alliance on Mental Illness often goes by the name NAMI and by far it's been the best support group we've seen for family members getting together and just educating each other on taking care of their needs because nobody understands what a family is going through more than another family member who's going through the same thing.

And this is exactly what we see with mental health issues.

>> NAMI does a wonderful job of that and most areas do have a NAMI group and in the area you can always talk to your mental health clinician to see where you can get a referral for our local NAMI chapter.

But I know Fort Wayne we've had a marvelous NAMI chapter here for oh boy about thirty years now I believe it's twenty years ago it was named the top NAMI chapter in the entire country.

So we've had a very good support group and I've been fortunate to be part of this community that has such a good support group that does so many good things.

The NAMI chapter in Fort Wayne helped start the carriage house which is a half which is the carriage house is a type of a place where people with chronic mental illness can go on a day to day basis and in doing so they have meaningful activities.

>> They get to socialize, they're able to be around people and with many of these type of places family members can meet there on a regular basis with their NAMI chapters and are often allowed to do so.

So the carriage house in Fort Wayne has been a great place for people with chronic mental illnesses to go and sometimes people will find that that's beneficial for them John ,thanks for your call.

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

Our next e-mail question reads Dear Dr. Farber, how does ketamine work?

>> I've been on many different antidepressants and none of them seem to work.

>> I've heard that ketamine can be an option.

As I mentioned to Gail earlier, the first thing you want to do is make sure you have the right diagnosis and you've had treatment addressing that diagnosis and the old analogy is going back to a cough.

If you have a cough that just won't go away, you have to sort out what's causing that cough as a cough from pneumonia, bronchitis from allergies is it from gastroesophageal reflux?

People with heart conditions will sometimes have a cough because the fluids backing up in their lungs.

>> Is there some reason for the cough that's causing it to just go on and on?

>> Don't give don't just keep taking a cough suppressant.

Try to figure out what's what's causing the cough and then the same true can be the case for depression, for anxiety.

>> Don't treat the symptoms.

Let's treat what's going on.

I mean is it due to sleep apnea?

Many people with unremitting depression have sleep apnea where they don't breathe adequately at night while they're sleeping and they snore and they don't get enough airflow and that decreases the oxygen to the brain.

>> Some people have low thyroid, some people have diabetes.

Some people have low iron.

These can all be medical reasons for depression.

We need to take a look at the nature of the depression itself.

If it's bipolar disorder, we're going to treat it entirely differently than we would if somebody just had straight depression.

Does somebody also have post-traumatic stress on top of the depression?

So we have to sort out what the diagnosis is first and then we need to take a thorough assessment of what past medications somebody has taken .

So we want to go class by class of all these different medications out there, how these medications have worked, how they've not worked so well and try to get a good understanding of some of these past like medication history.

>> It's very, very advantageous for us to understand what medications family members have taken and what's worked and what hasn't worked.

And we do genetic testing where genetic testing just gives us an extra dimension on understanding how somebody breaks down medications and which ones might work for them.

>> So I bring all of this up because before you start talking about ketamine treatment you want to make sure that you're been getting the proper treatment.

So if we've ruled out all those other issues and you're on the right medication, you're doing the best you can with that medication as we know him.

>> That's where ketamine comes in.

Ketamine is I.V.

Ketamine was approved by the Food and Drug Administration back in 1970 as an anesthetic and worldwide wide is the most popular anesthetic out there.

I've it's very safe and very tolerable.

It's ketamine is the left sided piece of ketamine.

So a lot of molecules they have the left side and right sided pieces of ketamine as the left side piece of ketamine, the left side of a piece of ketamine is four times more potent than the right side part of ketamine on this particular receptor called an NMDA a receptor and an NMDA receptor is something you want to block if you have depression because it's thought that people with depression have increased budding out of NMDA receptors.

So if you think about a basketball analogy, I live in Indiana so we know all about basketball here a basketball analogy would be where ketamine or s ketamine it's left sided piece sets the pick on NMDA receptors when you set the pick on the NMDA receptor, the glutamate which stimulates the NMDA receptor goes around the NMDA receptor and goes to a different receptor called the AMPA receptor.

That appx receptor now if you stimulate the AMPA receptor you'll tend to get a better outcome for depression and you get more growth and the fuzziness of your neurons and it makes this kind of like fertilizer for the brain.

So if you think about miracle growth for the brain, that's what ketamine and ketamine are trying to do for the brain.

They're making it more fluffy because when people have long term depression they lose the fluffiness of their brains and that causes them to have more trouble with different parts of the brain communicating with each other and that makes for more depression and difficulty with reasoning itself.

>> So if you stimulate the AMPA receptors with glutamate that can give people nice outcomes overall.

So when you think about ketamine and ketamine it's always added on to an antidepressant medication.

So you add in the ketamine or ketamine to an antidepressant medication ongoing and it basically helps them work.

>> So it's something that can be an option for you.

Ketamine is given IV.

>> It's not covered by insurance as ketamine also known as bravado as a nasal spray that is covered by insurance.

And at my office we've done over 3500 treatments.

Now with that we found very nice outcomes with ketamine over the course of time.

Thanks for your email.

Unfortunately I'm out of time for this evening.

>> If you have any questions that I can answer on the air you may write me a via the Internet at matters of the mind all one word at a dog.

I'm psychiatrist Jeff Oliver and 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.

Goodnight